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Author Notes:

Corresponding author. Integrated Health Solutions Development, Global Health Program, Bill & Melinda Gates Foundation, PO Box 23350, Seattle, WA 98102, USA. Gary.darmstadt@gatesfoundation.org.

We would like to thank Mary Kinney for her extraordinary assistance with referencing and coverage figures.

We thank Saifuddin Ahmed, Emma Williams, and Yoonjoung Choi for their assistance with the preparation of the Projahnmo data for the meta-analysis.

We also thank Robert Goldenberg, Department of Obstetrics and Gynecology, Drexel University; Rajiv Bahl, Department of Child and Adolescent Health and Development, WHO; and Leslie Elder, Save the Children-US for serving as expert reviewers of the paper.

All authors have no conflicts of interest to declare.



  • Science & Technology
  • Life Sciences & Biomedicine
  • Obstetrics & Gynecology
  • Birth asphyxia
  • Community health worker
  • Community midwife
  • Hypoxia
  • Intrapartum
  • Neonatal mortality
  • Stillbirth
  • Traditional birth attendant

60 million non-facility births: Who can deliver in community settings to reduce intrapartum-related deaths?

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Journal Title:

International Journal of Gynecology and Obstetrics


Volume 107, Number SUPPL.


, Pages S89-S112

Type of Work:

Article | Post-print: After Peer Review


Background: For the world's 60 million non-facility births, addressing who is currently attending these births and what effect they have on birth outcomes is a key starting point toward improving care during childbirth. Objective: We present a systematic review of evidence for the effect of community-based cadres-community-based skilled birth attendants (SBAs), trained traditional birth attendants (TBAs), and community health workers (CHWs)-in improving perinatal and intrapartum-related outcomes. Results: The evidence for providing skilled birth attendance in the community is low quality, consisting of primarily before-and-after and quasi-experimental studies, with a pooled 12% reduction in all cause perinatal mortality (PMR) and a 22%-47% reduction in intrapartum-related neonatal mortality (IPR-NMR). Low/moderate quality evidence suggests that TBA training may improve linkages with facilities and improve perinatal outcomes. A randomized controlled trial (RCT) of TBA training showed a 30% reduction in PMR, and a metaanalysis demonstrated an 11% reduction in IPR-NMR. There is moderate evidence that CHWs have a positive impact on perinatal-neonatal outcomes. Meta-analysis of CHW packages (2 cluster randomized controlled trials, 2 quasi-experimental studies) showed a 28% reduction in PMR and a 36% reduction in early neonatal mortality rate; one quasi-experimental study showed a 42% reduction in IPR-NMR. Conclusion: Skilled childbirth care is recommended for all pregnant women, and community strategies need to be linked to prompt, high-quality emergency obstetric care. CHWs may play a promising role in providing pregnancy and childbirth care, mobilizing communities, and improving perinatal outcomes in low-income settings. While the role of the TBA is still controversial, strategies emphasizing partnerships with the health system should be further considered. Innovative community-based strategies combined with health systems strengthening may improve childbirth care for the rural poor, help reduce gross inequities in maternal and newborn survival and stillbirth rates, and provide an effective transition to higher coverage for facility births.

Copyright information:

© 2009 Published by Elsevier Ireland Ltd.

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