title: Obstetric care in low-resource settings: what, who, and how to overcome challenges to scale up?
abstract: BACKGROUND
  Each year, approximately 2 million 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.
authors.affiliation: Effective Care Research Unit, Eastern Cape Department of Health, Universities of the Witwatersrand and Fort Hare, South Africa. gjh@global.co.za
authors.forename: G Justus
authors.initials: GJ
authors.lastname: Hofmeyr
authors.forename: Rachel A
authors.initials: RA
authors.lastname: Haws
authors.forename: Staffan
authors.initials: S
authors.lastname: Bergström
authors.forename: Anne C C
authors.initials: AC
authors.lastname: Lee
authors.forename: Pius
authors.initials: P
authors.lastname: Okong
authors.forename: Gary L
authors.initials: GL
authors.lastname: Darmstadt
authors.forename: Luke C
authors.initials: LC
authors.lastname: Mullany
authors.forename: Eh Kalu Shwe
authors.initials: EK
authors.lastname: Oo
authors.forename: Joy E
authors.initials: JE
authors.lastname: Lawn
mesh_terms: D036861:Delivery, Obstetric; D003906:Developing Countries; D005260:Female; D005313:Fetal Death / Q000453:epidemiology / Q000517:prevention & control*; D006801:Humans; D007744:Obstetric Labor Complications / Q000453:epidemiology / Q000517:prevention & control*; D011247:Pregnancy; D011295:Prenatal Care / Q000458:organization & administration*; D012959:Socioeconomic Factors