SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
March, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
Some 2.6 million stillbirths occur worldwide every year, and almost all of these are in low and middle income countries. A significant proportion of these stillbirths take place at home, usually in the absence of a skilled birth attendant someone with the skills needed to manage normal uncomplicated pregnancies and childbirth.
Key messages
People deciding whether to introduce skilled birth attendance into practice
Yakoob MY, Ali MA, Ali MU, et al. The effect of providing skilled birth attendance and emergency obstetric care in preventing stillbirths. BMC Public Health 2011;11 Suppl 3:S7.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Stillbirths are caused mainly by complications during labour and childbirth, such as prolonged or obstructed labour or umbilical cord accidents. Women and babies need access to appropriate healthcare to improve pregnancy and childbirth outcomes. This care should include skilled birth attendance, and access to emergency obstetric care for women experiencing complications in pregnancy, childbirth, or postpartum.
A skilled attendant is defined as “an accredited health professional – such as a midwife, doctor or nurse – who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns”.
Basic emergency obstetric and newborn care has been defined as including seven “signal functions”: the use of intravenous/intramuscular antibiotics, intravenous/intramuscular
| Review objectives: To determine the effect of provision of skilled birth attendance as well as basic and emergency obstetric care on stillbirths. | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised and non randomised trials; and observational studies evaluating the provision of skilled birth attendance and emergency obstetric care. |
21 studies: 13 for skilled birth attendance (10 before after or non randomised studies and 3 observational studies) and 9 historical or ecological studies for emergency obstetric care |
| Participants | Pregnant women and newborns |
Most women were from rural areas, but some were also from suburbs and mixed areas. |
| Settings | Community based settings in any country |
Most skilled birth attendance studies were from low and middle income countries (Bangladesh, Bolivia, China, Guatemala, Indonesia, Malawi, Mexico, Mozambique, Nigeria, Papua New Guinea, Sudan, and Tanzania). Three studies were from high income countries (Netherlands, Norway, and Sweden). |
| Outcomes | Stillbirths and perinatal mortality |
Two (uncontrolled) before after studies reported stillbirths and four reported perinatal mortality and were included in the primary analysis. |
| Date of most recent search: March 2010 | ||
| Limitations: This is reasonably well conducted systematic review with only minor limitations such as the incomplete reporting of the included studies’ characteristics. | ||
Yakoob MY, Ali MA, Ali MU, et al. The effect of providing skilled birth attendance and emergency obstetric care in preventing stillbirths. BMC Public Health 2011;11 Suppl 3:S7.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
13 studies were included, focusing mainly on training or retraining of staff. Only one controlled before after study and three uncontrolled before after studies reported the specific effects of the training and supervision of skilled birth attendants.
Skilled birth attendance |
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| People: Pregnant women and newborns. Settings: Community based. Intervention: Skilled birth attendance by ‘village midwives’ with 1 year of training (Sudan) and professional midwives (Bangladesh) [for stillbirth outcome] and in addition by trained TBAs and midwives (Indonesia) and professional providers (China) [for perinatal mortality outcome]. Comparison: Usual care |
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| Outcomes |
Relative risk reduction (95% CI) |
Quality of the evidence (GRADE) |
Comments |
| Stillbirths |
23% (15 to 31%) |
Low |
Based on data from 2 uncontrolled before after studies. The data from the studies that could not be pooled showed consistent results |
| Perinatal mortality |
12% (5 to 18%) |
Low |
Based on data from 3 uncontrolled before after studies and 1 controlled before after study. The data from the studies that could not be pooled showed consistent results. |
| GRADE: GRADE Working Group grades of evidence (see above and last page) | |||
The review found little evidence of the effects of alternative ways of providing emergency obstetric care.
Relative risk reduction
| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
| Most studies were conducted in rural areas of low and middle income countries during the last 30 years. |
These findings may be applicable to other low income countries, but the absolute effects of skilled birth attendance and emergency obstetric care will depend on baseline levels of stillbirths and perinatal mortality. Where these baseline levels are high, higher absolute effects can be anticipated. However, good access to these services are needed to optimize these benefits. |
| EQUITY | |
| Most studies included low income and disadvantaged populations but no data were reported regarding differential effects of the interventions for disadvantaged populations. |
The beneficial effects of interventions are expected to be larger for underserved populations, therefore reducing inequalities. |
| ECONOMIC CONSIDERATIONS | |
| The systematic review did not address economic considerations. |
Scaling up skilled birth attendance and access to emergency obstetric care will require considerable resources, particularly in more rural settings. However, the benefits of this may be substantial. |
| MONITORING & EVALUATION | |
| The certainty of the available evidence is low or very low. |
Delivering skilled birth attendance and proper emergency obstetric care are moral imperatives. However, rigorous studies to determine the magnitude of the benefits and the cost effectiveness of different delivery options are needed. |
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low income countries. For additional details about how these judgements were made see:www.supportsummaries.org/methods
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These systematic reviews provide consistent findings and helpful complementary considerations:
Goldenberg RL, McClure EM, Bann CM. The relationship of intrapartum and antepartum stillbirth rates to measures of obstetric care in developed and developing countries. Acta Obstet Gynecol Scand 2007; 86:1303-9.
Darmstadt GL, Lee AC, Cousens S, et al. 60 Million non facility births: who can deliver in community settings to reduce intrapartum related deaths? Int J Gynaecol Obstet 2009; 107(Suppl 1):S89-112.
McClure EM, Goldenberg RL, Bann CM: Maternal mortality, stillbirth and measures of obstetric care in developing and developed countries. Int J Gynaecol Obstet 2007; 96:139-46.
World Health Statistics 2013. World Health Organization, 2013. Available at: http://www.who.int/gho/publications/world_health_statistics/EN_WHS2013_Full.pdf
Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: David Yondo and Mohammad Yakoob.
Yakoob MY, Ali MA, Ali MU, et al. The effect of providing skilled birth attend-ance and emergency obstetric care in preventing stillbirths. BMC Public Health 2011;11 Suppl 3:S7.
Ciapponi A, Do skilled birth attendance and emergency obstetric care prevent stillbirths? A SUPPORT Summary of a systematic review. March 2017. www.supportsummaries.org
All Summaries:
evidence informed health policy, evidence based, systematic review, health systems research, health care, low and middle income countries, developing countries, primary health care, clinical competence, delivery, obstetric, emergency medical services, stillbirth, perinatal mortality, pregnancy, implementation
