Email updates

Keep up to date with the latest news and content from BMC Public Health and BioMed Central.

This article is part of the supplement: Technical inputs, enhancements and applications of the Lives Saved Tool (LiST)

Open Access Review

Care during labor and birth for the prevention of intrapartum-related neonatal deaths: a systematic review and Delphi estimation of mortality effect

Anne CC Lee12*, Simon Cousens3, Gary L Darmstadt14, Hannah Blencowe3, Robert Pattinson5, Neil F Moran6, G Justus Hofmeyr7, Rachel A Haws1, Shereen Zulfiqar Bhutta8 and Joy E Lawn9

Author Affiliations

1 Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore MD, USA

2 Department of Newborn Medicine, Brigham and Women’s Hospital, Boston, MA, USA

3 London School of Tropical Medicine and Hygiene, London, UK

4 Family Health Division, Global Health Program, Bill and Melinda Gates Foundation, Seattle WA, USA

5 MRC Maternal and Infant Health Care Strategies Research unit, University of Pretoria, South Africa

6 Grey’s Hospital, KwaZulu-Natal, South Africa

7 University of the Witwatersrand and East London Hospital Complex, South Africa

8 Jinnah Postgraduate Medical Center and the Aga Khan University, Karachi, Pakistan

9 Saving Newborn Lives/Save the Children

For all author emails, please log on.

BMC Public Health 2011, 11(Suppl 3):S10  doi:10.1186/1471-2458-11-S3-S10

Published: 13 April 2011



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.