Obstetric care in low-resource settings: What, who, and how to overcome challenges to scale up?

Hofmeyr, G. Justus; Haws, Rachel A.; Bergström, Staffan; Lee, Anne CC; Okong, Pius; Darmstadt, Gary L.; Mullany, Luke C.; Oo, Eh Kalu Shwe; Lawn, Joy E.

doi:10.1016/j.ijgo.2009.07.017

« Previous Next »International Journal of Gynecology & Obstetrics
Volume 107, Supplement , Pages S21-S45, October 2009

Obstetric care in low-resource settings: What, who, and how to overcome challenges to scale up?

G. Justus Hofmeyr
- Effective Care Research Unit, Eastern Cape Department of Health, Universities of the Witwatersrand and Fort Hare, South Africa
- Corresponding author. Effective Care Research Unit, East London Hospital Complex, PB X9047, East London 5201, South Africa/University of the Witwatersrand/University of Fort Hare, South Africa. Tel.: +27 83 280 9402; fax: +27 43 708 761158.
Rachel A. Haws
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
Staffan Bergström
- Averting Maternal Death and Disability (AMDD) Program, Columbia University, New York, USA
- Division of Global Health (IHCAR), Karolinska Institute, Stockholm, Sweden
Anne CC Lee
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Saving Newborn Lives, Save the Children-US, Cape Town, South Africa
Pius Okong
- St Raphael of St. Francis Hospital, Nsambya, Uganda
Gary L. Darmstadt
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
Luke C. Mullany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
Eh Kalu Shwe Oo
- Karen Department of Health and Welfare, Mae Sot, Thailand
Joy E. Lawn
- Saving Newborn Lives, Save the Children-US, Cape Town, South Africa
- Health Systems Research Unit, Medical Research Council of South Africa, Cape Town, South Africa

Abstract

Background

Each year, approximately 2million babies die because of complications of childbirth, primarily in settings where effective care at birth, particularly prompt cesarean delivery, is unavailable.

Objective

We reviewed the content, impact, risk-benefit, and feasibility of interventions for obstetric complications with high population attributable risk of intrapartum-related hypoxic injury, as well as human resource, skill development, and technological innovations to improve obstetric care quality and availability.

Results

Despite ecological associations of obstetric care with improved perinatal outcomes, there is limited evidence that intrapartum interventions reduce intrapartum-related neonatal mortality or morbidity. No interventions had high-quality evidence of impact on intrapartum-related outcomes in low-resource settings. While data from high-resource settings support planned cesarean for breech presentation and post-term induction, these interventions may be unavailable or less safe in low-resource settings and require risk-benefit assessment. Promising interventions include use of the partograph, symphysiotomy, amnioinfusion, therapeutic maneuvers for shoulder dystocia, improved management of intra-amniotic infections, and continuous labor support. Obstetric drills, checklists, and innovative low-cost devices could improve care quality. Task-shifting to alternative cadres may increase coverage of care.

Conclusions

While intrapartum care aims to avert intrapartum-related hypoxic injury, rigorous evidence is lacking, especially in the settings where most deaths occur. Effective care at birth could save hundreds of thousands of lives a year, with investment in health infrastructure, personnel, and research—both for innovation and to improve implementation.

Keywords: Birth asphyxia/asphyxia neonatorum, Childbirth care, Emergency obstetric care, Intrapartum care, Intrapartum-related mortality, Low-income countries, Neonatal mortality, Perinatal mortality