Maternal and perinatal mortality by place of delivery in sub-Saharan Africa: a meta-analysis of population-based cohort studies

Jobiba Chinkhumba, Manuela De Allegri, Adamson S Muula, Bjarne Robberstad, Jobiba Chinkhumba, Manuela De Allegri, Adamson S Muula, Bjarne Robberstad

Abstract

Background: Facility-based delivery has gained traction as a key strategy for reducing maternal and perinatal mortality in developing countries. However, robust evidence of impact of place of delivery on maternal and perinatal mortality is lacking. We aimed to estimate the risk of maternal and perinatal mortality by place of delivery in sub-Saharan Africa.

Methods: We conducted a systematic review of population-based cohort studies reporting on risk of maternal or perinatal mortality at the individual level by place of delivery in sub-Saharan Africa. Newcastle-Ottawa Scale was used to assess study quality. Outcomes were summarized in pooled analyses using fixed and random effects models. We calculated attributable risk percentage reduction in mortality to estimate exposure effect. We report mortality ratios, crude odds ratios and associated 95% confidence intervals.

Results: We found 9 population-based cohort studies: 6 reporting on perinatal and 3 on maternal mortality. The mean study quality score was 10 out of 15 points. Control for confounders varied between the studies. A total of 36,772 pregnancy episodes were included in the analyses. Overall, perinatal mortality is 21% higher for home compared to facility-based deliveries, but the difference is only significant when produced with a fixed effects model (OR 1.21, 95% CI: 1.02-1.46) and not when produced by a random effects model (OR 1.21, 95% CI: 0.79-1.84). Under best settings, up to 14 perinatal deaths might be averted per 1000 births if the women delivered at facilities instead of homes. We found significantly increased risk of maternal mortality for facility-based compared to home deliveries (OR 2.29, 95% CI: 1.58-3.31), precluding estimates of attributable risk fraction.

Conclusion: Evaluating the impact of facility-based delivery strategy on maternal and perinatal mortality using population-based studies is complicated by selection bias and poor control of confounders. Studies that pool data at an individual level may overcome some of these problems and provide better estimates of relative effectiveness of place of delivery in the region.

Figures

Figure 1
Figure 1
Flow chart showing identification, screening and inclusion of studies for meta-analysis of maternal and perinatal mortality by place of delivery in sub-Saharan Africa, 1990–2013.
Figure 2
Figure 2
Pooled analysis of perinatal mortality by place of delivery in sub-Saharan Africa.
Figure 3
Figure 3
Pooled analysis of maternal mortality by place of delivery in sub-Saharan Africa.

References

    1. Filippi V, Ronsmans C, Campbell OMR, Graham WJ, Mills A, Borghi J, Koblinsky M, Osrin D. Maternal health in poor countries: the broader context and a call for action. Lancet. 2006;368:1535–1541. doi: 10.1016/S0140-6736(06)69384-7.
    1. Bhutta ZA, Darmstadt GL, Hasan BS, Haws RA. Community-Based Interventions for Improving Perinatal and Neonatal Health Outcomes in Developing Countries: A Review of the Evidence. Pediatrics. 2005;115(2 suppl):519–617.
    1. Kerber JK, de Graft-Johnson EJ, Bhutta AZ, Okong P, Starrs A, Lawn J. Continuum of care for maternal, neonatal, and child health: from slogan to service delivery. Lancet. 2007;370:1358–1369. doi: 10.1016/S0140-6736(07)61578-5.
    1. Ronsmans C, Graham WJ. Maternal mortality: who, when, where, and why. Lancet. 2006;368:1189–1200. doi: 10.1016/S0140-6736(06)69380-X.
    1. WHO . The World Health Report 2005: make every mother and child count. Geneva: World Health Organization; 2005.
    1. United Nations . Millennium Development Goals Report. New York: United Nations; 2008.
    1. Starrs A. Delivering for Women. Lancet. 2007;370:1285–1287. doi: 10.1016/S0140-6736(07)61549-9.
    1. Paxton A, Maine D, Freddman L, Fry D, Lobis S. The evidence for emergency obstetric care. Int J Gynaecol Obstet. 2005;88:181–193. doi: 10.1016/j.ijgo.2004.11.026.
    1. Montagu D, Yarney G, Visconti A, Harding A, Yoong J. Where do poor women in developing countries give birth? A multi-country analysis of demographic and health survey data. PLoS One. 2011;6:e17155. doi: 10.1371/journal.pone.0017155.
    1. Prata N, Passano P, Sreenivas A, Gerdts CE. Maternal mortality in developing countries: challenges in scaling-up priority interventions. Womens Health (Lond Engl) 2010;6:311–327. doi: 10.2217/whe.10.8.
    1. Jacobs B, Ir P, Bigdeli M, Annear PL, Van DW. Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries. Health Policy Plan. 2012;27:288–300. doi: 10.1093/heapol/czr038.
    1. Prata N, Passano P, Rowen T, Bell S, Walsh J, Potts M. Where there are (few) skilled attendants. J Health Popul Nutr. 2011;29:81–91. doi: 10.3329/jhpn.v29i2.7812.
    1. McNamee P, Ternent L, Hussein J. Barriers in accessing maternal healthcare: evidence from low and middle-income countries. Expert Rev Pharmacoecon Outcomes Res. 2009;9:41–48. doi: 10.1586/14737167.9.1.41.
    1. Parkhurst JO, Rahman SA, Ssengooba F. Overcoming access barriers for facility-based delivery in low-income settings: insights from Bangladesh and Uganda. J Health Popul Nutr. 2006;24:438–445.
    1. Diaz-Granados N, Pitzul KB, Dorado LM, Wang F, McDermott S, Rondon MB, Posada-Villa J, Saavedra J, Torres Y, Des Meules M, Stewart DE. Monitoring gender equity in health using gender-sensitive indicators: A cross-national study. J Women’s Health. 2011;20:145–153. doi: 10.1089/jwh.2010.2057.
    1. Borghi J, Ensor T, Somanathan A, Lissner C, Mills A. Mobilizing financial resources for maternal health. Lancet. 2006;368:1457–1465. doi: 10.1016/S0140-6736(06)69383-5.
    1. WHO . Trends in Maternal Mortality: 1990 to 2010. WHO, UNICEF, UNFPA and The World Bank estimates. Geneva: World Health Organization; 2012. pp. 25–26.
    1. WHO . Neonatal and perinatal mortality, 2004: country, regional and global estimates. Geneva: World Health Organization; 2007.
    1. Kruk ME, Paczkowski M, Mbaruku G, de Pinho H, Galea S. Women's Preferences for Place of Delivery in Rural Tanzania: A Population-Based Discrete Choice Experiment. Am J Public Health. 2009;99:1666–1672. doi: 10.2105/AJPH.2008.146209.
    1. Gorter AC, Ir P, Meessen B. Evidence Review, Results-Based Financing of Maternal and Newborn Health Care in Low- and Lower-middle-Income Countries, February 2013, study commissioned and funded by the German Federal Ministry for Economic Cooperation and Development (BMZ) through the sector project PROFILE at GIZ – Deutsche Gesellschaft für Internationale Zusammenarbeit. 2013.
    1. Meessen B, Soucat A, Sekabaraga C. Performance-based financing: just a donor fad or a catalyst towards comprehensive health-care reform? Bull World Health Organ. 2011;89:153–156. doi: 10.2471/BLT.10.077339.
    1. De Allegri M, Ridde V, Louis VR, Sarker M, Tiendrebéogo J, Yé M, Müller O, Jahn A. Determinants of utilization of maternal care services after the reduction of user fees: a case study from rural Burkina Faso. Health Policy Plan. 2011;99(3):210–218. doi: 10.1016/j.healthpol.2010.10.010.
    1. Basinga P, Gertler PJ, Binagwaho A, Soucat AL, Sturdy J, Vermeersch CM. Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation. Lancet. 2011;377:1421–1428. doi: 10.1016/S0140-6736(11)60177-3.
    1. Nove A, Berrington A, Matthews Z. The methodological challenges of attempting to compare the safety of home and hospital birth in terms of the risk of perinatal death. Midwifery. 2012;28:619–626. doi: 10.1016/j.midw.2012.07.009.
    1. Otia SO, Odimegwu C. Perinatal Mortality in Nigeria: Do Place of Delivery and Delivery Assistants Matter? Open Demography J. 2011;4:1–10. doi: 10.2174/1874918601104010001.
    1. Tura G, Fantahun M, Worku A. The effect of health facility delivery on neonatal mortality: systematic review and meta-analysis. BMC Pregnancy Childbirth. 2013;13:18. doi: 10.1186/1471-2393-13-18.
    1. Anker M, Black RE, Coldham C, Kalter HD, Quigley M, Ross D, Snow RW. A Standard Verbal Autopsy Method for Investigating Causes of Death in Infants and Children. Geneva: World Health Organization; 1999.
    1. Darmstadt GL, Yakoob MY, Haws RA, Menezes EV, Soomro T, Bhutta ZA. Reducing stillbirths: interventions during labour. BMC Pregnancy Childbirth. 2009;9(Suppl 1):S6. doi: 10.1186/1471-2393-9-S1-S6.
    1. Stroup DF, Berlin JA, Morton SC, Ingram Olkin G, Williamson D, Rennie D, Moher D, Becker BJ, Sipe TA, Thacker SB. Meta-analysis of Observational Studies in Epidemiology A Proposal for Reporting. JAMA. 2000;283(15):2008–2012. doi: 10.1001/jama.283.15.2008.
    1. Wells GA, Shea B, O'Connell D, Peterson J, Welch V, Losos M, Tugwell P: The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. (Last accessed on 30 November, 2013)
    1. Kirkwood BR, Sterne JAC. Essential Medical Statistics. 2. Oxford: Blackwell Science; 2003.
    1. Haidich AB. Meta-analysis in medical research. HIPPOKRATIA. 2010;14(Suppl 1):29–37.
    1. Harris RJ, Bradburn MJ, Deeks JJ, Harbord RM, Altman DG, Sterne JAC. metan: fixed- and random-effects meta-analysis. The Stata Journal 8. 2008;1:3–28.
    1. Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. Br Med J. 2003;327:557–560. doi: 10.1136/bmj.327.7414.557.
    1. Daly LE, Geoffrey J. Bourke Interpretation and Uses of Medical Statistics. 5. Singapore: Blackwell Science Ltd; 2007.
    1. Bouvier-Colle MH, Ouedraogo C, Dumont A, Vangeenderhuysen C, Salanave B, Decam C, MOMA group Maternal mortality in West Africa. Rates, causes and substandard care from a prospective survey. Acta Obstet Gynecol Scand. 2001;80:113–119.
    1. Aisien AO, Lawson JO, Okolo A. Two years prospective study of perinatal mortality in Jos, Nigeria. Int J Gynecol Obstet. 2000;71:171–173. doi: 10.1016/S0020-7292(00)00214-9.
    1. Chalumeau M, Salanave B, Bouvier-Colle MH, de Bernis L, Prua A, Bréart G. Risk factors for perinatal mortality in West Africa: a population-based study of 20 326 pregnancies. MOMA group. Acta Paediatrica. 2000;89:1115–1121. doi: 10.1111/j.1651-2227.2000.tb03361.x.
    1. Paul W, Moyer CA, Raymond A, Philip A, John W, Welaga P, Moyer CA, Aborigo R, Adongo P, Williams J, Hodgson A, Oduro A, Engmann C. Why Are Babies Dying in the First Month after Birth? A 7- Year Study of Neonatal Mortality in Northern Ghana. PLoS ONE. 2013;8(3):e58924. doi: 10.1371/journal.pone.0058924.
    1. Lawoyin TO, Onadeko MO, Asekun-Olarinmoye EO. Neonatal Mortality and Perinatal Risk Factors in Rural Southwestern Nigeria: A Community-Based Prospective Study. W Afr J Med. 2010;29:19–23.
    1. Kulmala T, Vaahtera M, Rannikko J, Ndekha MD, Cullinan T, Salin ML, Ashorn P. The relationship between antenatal risk characteristics, place of delivery and adverse delivery outcome in rural Malawi. Acta Obstet Gynecol Scand. 2000;79:984–990.
    1. Engmann C, Walega P, Aborigo RA, Adongo P, Moyer CA, Lavasani L, Williams J, Bose C, Binka F, Hodgson A. Stillbirths and early neonatal mortality in rural Northern Ghana. Trop Med Int Health. 2012;17:272–282.
    1. Walraven GE, Mkanje RJ, Roosmalen J, van Dongen PW, Dolmans WM. Perinatal mortality in home births in rural Tanzania. Eur J Obstet Gynecol Reprod Biol. 1995;58:131–134. doi: 10.1016/0028-2243(95)80011-G.
    1. Nankabirwa V, Tumwine JK, Tylleskär T, Nankunda J, Sommerfelt H, PROMISE EBF Research Consortium Perinatal mortality in eastern Uganda: a community based prospective cohort study. PLoS One. 2011;6(5):e19674. doi: 10.1371/journal.pone.0019674.
    1. McDermott J, Steketee VR, Wirima J. Perinatal mortality in rural Malawi. Bull World Health Organ. 1996;74:165–171.
    1. Diallo AH, Meda N, Zabsonré E, Sommerfelt H, Cousens S, Tylleskär T, PROMISE-EBF Study Group Perinatal mortality in rural Burkina Faso: a prospective community-based cohort study. BMC Pregnancy Childbirth. 2010;10:45.
    1. Schmiegelow C, Minja D, Oesterholt M, Pehrson C, Suhrs HE, Boström S, Lemnge M, Magistrado P, Rasch V, Lusingu J, Theander TG, Bruun Nielsen B. Factors associated with and causes of perinatal mortality in northeastern Tanzania. Acta Obstet Gynecol Scand. 2012;91:1061–1068. doi: 10.1111/j.1600-0412.2012.01478.x.
    1. Stanton C, Lawn JE, Rahman H, Wilczynska-Ketende K, Hill K. Stillbirth rates: delivering estimates in 190 countries. Lancet. 2006;367:1487–1494. doi: 10.1016/S0140-6736(06)68586-3.
    1. De Bernis L, Dumont A, Bouillin D, Gueye A, Dompnier PJ, Bouvier-Colle MH. Maternal morbidity and mortality in two different populations of Senegal: a prospective study (MOMA survey) BJOG. 2000;107:68–74. doi: 10.1111/j.1471-0528.2000.tb11581.x.
    1. Høj L, da Silva D, Hedegaard K, Sandstro¨m A, Aaby P. Factors associated with maternal mortality in rural Guinea-Bissau. A longitudinal population-based study. BJOG. 2002;109:792–799.
    1. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7:177–188. doi: 10.1016/0197-2456(86)90046-2.
    1. Matendo MR, Engmann MC, Ditekemena DJ, Gado J, Tshefu A, McClure EM, Moore J, Boelaert M, Carlo WA, Wright LL, Bose CL. Challenge of Reducing Perinatal Mortality in Rural Congo: Findings of a Prospective, Population-based Study. J Health Popul Nutr. 2011;29:532–540. doi: 10.3329/jhpn.v29i5.8908.
    1. Garg AX, Dan H, Marcello T. Systematic Review and Meta-analysis: When One Study Is Just not Enough. Clin J Am Soc Nephrol. 2008;3:253–260. doi: 10.2215/CJN.01430307.
    1. Singh S, Darroch JE, Ashford LS. Adding It Up: The Need for and Cost of Maternal and New- born Care—Estimates for 2012. New York: Guttmacher Institute; 2013.
    1. Lohela TJ, Campbell OMR, Gabrysch S. Distance to Care, Facility Delivery and Early Neonatal Mortality in Malawi and Zambia. PLoS ONE. 2012;7(12):e52110. doi: 10.1371/journal.pone.0052110.
    1. Mcclure EM, Goldenburg RL, Bann CM. Maternal mortality, stillbirth and measures of obstetric care in developing and developed countries. Int J Gynaecol Obstet. 2007;96:139–146. doi: 10.1016/j.ijgo.2006.10.010.
    1. Ronsmans C, Chowdhury ME, Koblinsky M, Ahmed A. Care seeking at time of childbirth, and maternal and perinatal mortality in Matlab, Bangladesh. Bull World Health Organ. 2010;88:289–296. doi: 10.2471/BLT.09.069385.
    1. Scott S, Ronsmans C. The relationship between birth with a health professional and maternal mortality in observational studies: a review of the literature. Trop Med Int Health. 2009;14:1523–1533. doi: 10.1111/j.1365-3156.2009.02402.x.
    1. Blum LS, Sharmin T, Ronsmans C. Attending home vs. clinic-based deliveries: perspectives of skilled birth attendants in Matlab, Bangladesh. Reproductive Health Matters. 2006;14:51–60. doi: 10.1016/S0968-8080(06)27234-3.
    1. Mueller DH, Lungu D, Acharya A, Palmer N. Constraints to implementing the Essential Health Package in Malawi. PloS one. 2011;6:e20741. doi: 10.1371/journal.pone.0020741.
    1. Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: when? Where? Why? Lancet. 2005;365:891–900. doi: 10.1016/S0140-6736(05)71048-5.
    1. Moyer CA, Dako-Gyeke P, Adanu RM. Facility-based Delivery and Maternal and Early Neonatal Mortality in Sub-Saharan Africa: A Regional Review of the Literature. Afr J Reprod Health. 2013;17:30–43.
    1. Graham WJ, Filippi VGA, Ronsmans C. Demonstrating programme impact on maternal mortality. Health Policy Plan. 1996;11:16–20. doi: 10.1093/heapol/11.1.16.
    1. Adeoye AI, Onayade AA, Fatusi OA. Incidence, determinants and perinatal outcomes of near miss maternal morbidity in Ile-Ife Nigeria: a prospective case control study. BMC Pregnancy Childbirth. 2013;13:93. doi: 10.1186/1471-2393-13-93.
    1. Maine D, Rosenfield A. The Safe Motherhood Initiative: why has it stalled? Am J Public Health. 1999;89:480–482. doi: 10.2105/AJPH.89.4.480.
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