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Review
. 2009 Oct;107 Suppl 1(Suppl 1):S89-112.
doi: 10.1016/j.ijgo.2009.07.010.

60 Million non-facility births: who can deliver in community settings to reduce intrapartum-related deaths?

Gary L Darmstadt  1 , Anne C C Lee, Simon Cousens, Lynn Sibley, Zulfiqar A Bhutta, France Donnay, Dave Osrin, Abhay Bang, Vishwajeet Kumar, Steven N Wall, Abdullah Baqui, Joy E Lawn
Affiliations
Review

60 Million non-facility births: who can deliver in community settings to reduce intrapartum-related deaths?

Gary L Darmstadt et al. Int J Gynaecol Obstet. 2009 Oct.

Abstract

Background: For the world's 60 million non-facility births, addressing who is currently attending these births and what effect they have on birth outcomes is a key starting point toward improving care during childbirth.

Objective: We present a systematic review of evidence for the effect of community-based cadres-community-based skilled birth attendants (SBAs), trained traditional birth attendants (TBAs), and community health workers (CHWs)-in improving perinatal and intrapartum-related outcomes.

Results: The evidence for providing skilled birth attendance in the community is low quality, consisting of primarily before-and-after and quasi-experimental studies, with a pooled 12% reduction in all cause perinatal mortality (PMR) and a 22%-47% reduction in intrapartum-related neonatal mortality (IPR-NMR). Low/moderate quality evidence suggests that TBA training may improve linkages with facilities and improve perinatal outcomes. A randomized controlled trial (RCT) of TBA training showed a 30% reduction in PMR, and a meta-analysis demonstrated an 11% reduction in IPR-NMR. There is moderate evidence that CHWs have a positive impact on perinatal-neonatal outcomes. Meta-analysis of CHW packages (2 cluster randomized controlled trials, 2 quasi-experimental studies) showed a 28% reduction in PMR and a 36% reduction in early neonatal mortality rate; one quasi-experimental study showed a 42% reduction in IPR-NMR.

Conclusion: Skilled childbirth care is recommended for all pregnant women, and community strategies need to be linked to prompt, high-quality emergency obstetric care. CHWs may play a promising role in providing pregnancy and childbirth care, mobilizing communities, and improving perinatal outcomes in low-income settings. While the role of the TBA is still controversial, strategies emphasizing partnerships with the health system should be further considered. Innovative community-based strategies combined with health systems strengthening may improve childbirth care for the rural poor, help reduce gross inequities in maternal and newborn survival and stillbirth rates, and provide an effective transition to higher coverage for facility births.

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Figures

Fig. 1
Fig. 1
Coverage of care for facility and home births according to birth attendant. Source: New analysis based on data from UNICEF [1] 2009 and Demographic Health Surveys (2000–2007). Percentages are the weighted averages for countries with data on facility birth, skilled birth attendance, and TBA attendance at deliveries. Facility births presume skilled attendant at birth. Coverage of skilled birth attendance outside of facility is the difference between skilled attendant and facility birth coverage. * The regional data shown is higher than actual regional averages for home births because we are using weighted averages for countries with information by country from DHS, which are not administered in all countries. Thus, this information is not representative of these regions. ** Traditional birth attendant includes both trained and untrained TBAs for 4 countries that have DHS data on trained TBAs: Ghana, Niger, Tanzania, and Zimbabwe.
Fig. 2
Fig. 2
Meta-analysis of mortality effect with before/after evaluations of community-based skilled birth attendants. (A) Perinatal mortality. (B) Early neonatal mortality rate.
Fig. 3
Fig. 3
Meta-analysis of mortality effect of community health worker packages. (A) Perinatal mortality. (B) Early neonatal death.
Fig. 4
Fig. 4
Community level care: Tools, technologies, and further development innovations required.
See this image and copyright information in PMC

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References

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