Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
BMC Public Health. 2011 Apr 13;11 Suppl 3(Suppl 3):S10. doi: 10.1186/1471-2458-11-S3-S10.
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).
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.
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.
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.
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.
我们的目标是估计各种分娩护理包对足月婴儿因分娩期相关事件（“产时窒息”）导致的新生儿死亡的影响，以便用于生命救助工具（LiST）。
我们进行了系统文献综述，以确定联合国规范（基本和综合产科急救护理、熟练分娩护理）定义的分娩护理包的研究或综述。我们还审查了传统助产妇（TBA）培训。数据被抽象到标准表格中，并根据改编的 GRADE 标准进行质量评估。对于低质量证据但强烈推荐实施的干预措施，我们进行了专家德尔菲共识过程，以估计特定病因死亡率的影响。
我们确定了紧急产科护理包对围产期/新生儿死亡率影响的证据：9 项研究（8 项观察性研究，1 项准实验性研究），熟练分娩护理的证据为 10 项研究（8 项观察性研究，2 项准实验性研究）。研究质量较低，但实施的 GRADE 推荐是强有力的。我们的德尔菲过程包括 21 名代表所有世卫组织区域的专家，就全面产科急救护理（85%）、基本产科急救护理（40%）和熟练分娩护理（25%）降低分娩相关新生儿死亡达成共识。对于 TBA 培训，我们确定了 2 项荟萃分析和 9 项报告死亡率影响的研究（3 项 cRCT、1 项准实验性研究、5 项观察性研究）。研究间存在很大的异质性，证据质量总体较低。由于 TBA 培训的 GRADE 推荐取决于背景和地区，因此未通过德尔菲或纳入 LiST 工具来估计效果。
证据质量评级较低，部分原因是产科干预措施进行 RCT 存在挑战，这些干预措施被认为是标准护理。证据解释的额外挑战包括产科包的不同定义和死亡率结果的不一致衡量。因此，熟练分娩和紧急产科护理的 LiST 效应估计是基于专家意见。使用 LiST 模型，普及全面的产科护理可以每年避免 591,000 例分娩相关的新生儿死亡。投资于分娩护理包应该是优先事项，并伴随着实施研究以及进一步评估干预措施的影响和成本。
这项工作得到了比尔和梅林达·盖茨基金会的支持，通过向美国儿基会的联合国儿童基金会基金和拯救儿童会美国分会的 Saving Newborn Lives 捐款。
