title: The effect of providing skilled birth attendance and emergency obstetric care in preventing stillbirths.
abstract: BACKGROUND
  Of the global burden of 2.6 million stillbirths, around 1.2 million occur during labour i.e. are intrapartum deaths. In low-/middle-income countries, a significant proportion of women give birth at home, usually in the absence of a skilled birth attendant. This review discusses the impact of skilled birth attendance (SBA) and the provision of Emergency Obstetric Care (EOC) on stillbirths and perinatal mortality.
  
  
  METHODS
  A systematic literature search was performed on PubMed/MEDLINE, Cochrane Database and the WHO regional libraries. Data of all eligible studies were extracted into a standardized Excel sheet containing variables such as participants' characteristics, sample size, location, setting, blinding, allocation concealment, intervention and control details and limitations. We undertook a meta-analysis of the impact of SBA on stillbirths. Given the paucity of data from randomized trials or robust quasi-experimental designs, we undertook an expert Delphi consultation to determine impact estimates of provision of Basic and Comprehensive EOC on reducing stillbirths if there would be universal coverage (99%).
  
  
  RESULTS
  The literature search yielded 871 hits. A total of 21 studies were selected for data abstraction. Our meta-analysis on community-based skilled birth attendance based on two before-after studies showed a 23% significant reduction in stillbirths (RR = 0.77; 95% CI: 0.69 - 0.85). The overall quality grade of available evidence for this intervention on stillbirths was 'moderate'. The Delphi process supported the estimated reduction in stillbirths by skilled attendance and experts further suggested that the provision of Basic EOC had the potential to avert intrapartum stillbirths by 45% and with provision of Comprehensive EOC this could be reduced by 75%. These estimates are conservative, consistent with historical trends in maternal and perinatal mortality from both developed and developing countries, and are recommended for inclusion in the Lives Saved Tool (LiST) model.
  
  
  CONCLUSIONS
  Both Skilled Birth Attendance and Emergency/or Essential Obstetric Care have the potential to reduce the number of stillbirths seen globally. Further evidence is needed to be able to calculate an effect size.
authors.affiliation: Division of Women and Child Health, The Aga Khan University, Stadium Road, PO Box 3500, Karachi 74800, Pakistan.
authors.forename: Mohammad Yawar
authors.initials: MY
authors.lastname: Yakoob
authors.forename: Mahrukh Ayesha
authors.initials: MA
authors.lastname: Ali
authors.forename: Mohammad Usman
authors.initials: MU
authors.lastname: Ali
authors.forename: Aamer
authors.initials: A
authors.lastname: Imdad
authors.forename: Joy E
authors.initials: JE
authors.lastname: Lawn
authors.forename: Nynke
authors.initials: N
authors.lastname: Van Den Broek
authors.forename: Zulfiqar A
authors.initials: ZA
authors.lastname: Bhutta
mesh_terms: D002983:Clinical Competence; D036861:Delivery, Obstetric; D004632:Emergency Medical Services; D005260:Female; D005313:Fetal Death / Q000517:prevention & control; D006801:Humans; D009774:Obstetrics; D054238:Perinatal Mortality; D011247:Pregnancy; D016032:Randomized Controlled Trials as Topic; D050497:Stillbirth / Q000453:epidemiology*