title: Care during labor and birth for the prevention of intrapartum-related neonatal deaths: a systematic review and Delphi estimation of mortality effect.
abstract: BACKGROUND
  Our objective was to estimate the effect of various childbirth care packages on neonatal mortality due to intrapartum-related events ("birth asphyxia") in term babies for use in the Lives Saved Tool (LiST).
  
  
  METHODS
  We conducted a systematic literature review to identify studies or reviews of childbirth care packages as defined by United Nations norms (basic and comprehensive emergency obstetric care, skilled care at birth). We also reviewed Traditional Birth Attendant (TBA) training. Data were abstracted into standard tables and quality assessed by adapted GRADE criteria. For interventions with low quality evidence, but strong GRADE recommendation for implementation, an expert Delphi consensus process was conducted to estimate cause-specific mortality effects.
  
  
  RESULTS
  We identified evidence for the effect on perinatal/neonatal mortality of emergency obstetric care packages: 9 studies (8 observational, 1 quasi-experimental), and for skilled childbirth care: 10 studies (8 observational, 2 quasi-experimental). Studies were of low quality, but the GRADE recommendation for implementation is strong. Our Delphi process included 21 experts representing all WHO regions and achieved consensus on the reduction of intrapartum-related neonatal deaths by comprehensive emergency obstetric care (85%), basic emergency obstetric care (40%), and skilled birth care (25%). For TBA training we identified 2 meta-analyses and 9 studies reporting mortality effects (3 cRCT, 1 quasi-experimental, 5 observational). There was substantial between-study heterogeneity and the overall quality of evidence was low. Because the GRADE recommendation for TBA training is conditional on the context and region, the effect was not estimated through a Delphi or included in the LiST tool.
  
  
  CONCLUSIONS
  Evidence quality is rated low, partly because of challenges in undertaking RCTs for obstetric interventions, which are considered standard of care. Additional challenges for evidence interpretation include varying definitions of obstetric packages and inconsistent measurement of mortality outcomes. Thus, the LiST effect estimates for skilled birth and emergency obstetric care were based on expert opinion. Using LiST modelling, universal coverage of comprehensive obstetric care could avert 591,000 intrapartum-related neonatal deaths each year. Investment in childbirth care packages should be a priority and accompanied by implementation research and further evaluation of intervention impact and cost.
  
  
  BACKGROUND
  This work was supported by the Bill and Melinda Gates Foundation through a grant to the US Fund for UNICEF, and to Saving Newborn Lives Save the Children, through Save the Children US.
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. aclee@jhsph.edu
authors.forename: Anne C C
authors.initials: AC
authors.lastname: Lee
authors.forename: Simon
authors.initials: S
authors.lastname: Cousens
authors.forename: Gary L
authors.initials: GL
authors.lastname: Darmstadt
authors.forename: Hannah
authors.initials: H
authors.lastname: Blencowe
authors.forename: Robert
authors.initials: R
authors.lastname: Pattinson
authors.forename: Neil F
authors.initials: NF
authors.lastname: Moran
authors.forename: G Justus
authors.initials: GJ
authors.lastname: Hofmeyr
authors.forename: Rachel A
authors.initials: RA
authors.lastname: Haws
authors.forename: Shereen Zulfiqar
authors.initials: SZ
authors.lastname: Bhutta
authors.forename: Joy E
authors.initials: JE
authors.lastname: Lawn
mesh_terms: D001238:Asphyxia Neonatorum / Q000401:mortality / Q000517:prevention & control*; D036861:Delivery, Obstetric; D003697:Delphi Technique; D005260:Female; D006801:Humans; D007226:Infant Mortality; D007231:Infant, Newborn; D018743:Perinatal Care; D011247:Pregnancy