title: 60 Million non-facility births: who can deliver in community settings to reduce intrapartum-related deaths?
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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. Gary.darmstadt@gatesfoundation.org
authors.forename: Gary L
authors.initials: GL
authors.lastname: Darmstadt
authors.forename: Anne C C
authors.initials: AC
authors.lastname: Lee
authors.forename: Simon
authors.initials: S
authors.lastname: Cousens
authors.forename: Lynn
authors.initials: L
authors.lastname: Sibley
authors.forename: Zulfiqar A
authors.initials: ZA
authors.lastname: Bhutta
authors.forename: France
authors.initials: F
authors.lastname: Donnay
authors.forename: Dave
authors.initials: D
authors.lastname: Osrin
authors.forename: Abhay
authors.initials: A
authors.lastname: Bang
authors.forename: Vishwajeet
authors.initials: V
authors.lastname: Kumar
authors.forename: Steven N
authors.initials: SN
authors.lastname: Wall
authors.forename: Abdullah
authors.initials: A
authors.lastname: Baqui
authors.forename: Joy E
authors.initials: JE
authors.lastname: Lawn
mesh_terms: D003695:Delivery of Health Care / Q000458:organization & administration*; D003906:Developing Countries; D005260:Female; D005313:Fetal Death / Q000517:prevention & control*; D006700:Home Childbirth / Q000706:statistics & numerical data*; D006801:Humans; D008427:Maternal Health Services / Q000458:organization & administration*; D007744:Obstetric Labor Complications / Q000517:prevention & control*; D011247:Pregnancy