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Care During Labor and Birth 

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More Intervention Effect Estimate Summaries

Lee AC, Cousens S, Darmstadt GL, Blencowe H, Pattinson R, Moran NF, Hofmeyr GJ, Haws RA, Bhutta SZ, Lawn JE Care during labor and birth for the prevention of intrapartum-related neonatal deaths: a systematic review and Delphi estimation of mortality effect. BMC Public Health 2011; 11 (Suppl 3): S10.


  • The decline in neonatal mortality rates in the middle of the 20th century in high income countries has been commonly credited to the advent of hygienic childbirth practices and modern obstetric care. (1)
  • In low income countries, where skilled professionals attend < half of deliveries, and 60 million births occur outside facilities each year (2), neonatal morbidity and mortality related to childbirth remain very high (3).
  • The following definitions are used in this paper:
    • Comprehensive emergency obstetric care (CEmOC) is the standard full package of obstetric care, including Caesarean section and blood transfusion. (4,5)
    • Basic emergency obstetric care (BEmOC) includes the six signal functions (parenteral antibiotics, uterotonics, and anticonvulsants; manual removal of placenta; assisted vaginal delivery, and removal of retained products) that should be available at first-level facilities which provide childbirth care (4-6).
    • Skilled childbirth care is care provided by an accredited health professional, trained to proficiency in the skills needed to manage normal pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications. (4,5)
    • Traditional birth attendant (TBA): a person who assists during childbirth and who initially acquired her skills by delivering babies herself or through an apprenticeship to other TBAs (7)

Intervention Effects

Comprehensive Emergency Obstetric Care (CEmOC) on Intrapartum-related Neonatal Deaths

  • A Delphi panel of 21 experts was convened to estimate effect size, because the quality of evidence is low (8 observation and 1 quasi-experimental study), but GRADE recommendation is strong
  • 85% reduction in intrapartum-related neonatal deaths by comprehensive emergency obstetric care (range 55-96.5%, IQR 67.5-87.5%)

Basic Emergency Obstetric Care (BEmOC) on Intrapartum-related Neonatal Deaths

  • A Delphi panel of 21 experts was convened to estimate effect size, because the quality of evidence was low, but GRADE recommendation is strong
  • 40% reduction in intrapartum-related neonatal deaths by emergency obstetric care (range 15-85%, IQR 40-53%)

Skilled Birth Care on Intrapartum-related Neonatal Deaths

  • A Delphi panel of 21 experts was convened to estimate effect size, because the quality of evidence was low (2 quasi-experimental and 8 observational studies), but GRADE recommendation is strong
  • 25% reduction by skilled birth care alone (range 5-65%, IQR 15-40%) compared with no skilled care

TBA Training on Neonatal Deaths

  • Because the quality of available evidence is low, and the GRADE recommendation for TBA training is conditional on the context and region, the effect was not estimated through a Delphi or included in the LiST tool.

Intervention Recommendation

  • Evidence quality is low, partly because of challenges in undertaking RCTs for obstetric interventions which are considered standard of care.  The effect estimates for skilled birth care and EmOC are based on expert opinion.  
  • Using LiST modeling with the effect estimates above, it is estimated that universal coverage of comprehensive obstetric care could avert 591,000 intrapartum-related neonatal deaths (“birth asphyxia”, 814,000) each year.
  • This estimate is conservative as comprehensive obstetric care would also be expected to reduce deaths from other causes of neonatal deaths as well, notably infections and preterm birth.  

References from Lee Paper Cited Here

  1. Piekkala P, Erkkola R, Kero P, Tenovuo A, Sillanpaa M. Declining perinatal mortality in a region of Finland, 1968-82. Am J Public Health. 1985;75(2):156–160. 
  2. UNICEF. Maternal & Newborn Health. New York, NY: UNICEF; 2009. State of the World's Children 2009.
  3. Lawn JE, Lee AC, Kinney M, Sibley L, Carlo WA, Paul VK, Pattinson R, Darmstadt GL. Two million intrapartum-related stillbirths and neonatal deaths: where, why, and what can be done? Int J Gynaecol Obstet. 2009;107(Suppl 1):S5-18–S19.
  4. Safe Motherhood: Providing Emergency Obstetric and Neonatal Care to All in Need.
  5. WHO DoRHaR, editor. WHO; ICM; FIGO. Making pregnancy safer: the critical role of the skilled attendant. Geneva: World Health Organization; 2004. 
  6. WHO; Unicef; AMDD. Monitoring emergency obstetric care: a handbook. Geneva: WHO; 2009. pp. 1–164.
  7. World Health Organization. Traditional birth attendants: a joint WHO/UNICEF/UNFPA statement. Geneva: World Health Organization; 1992.

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