WHO recommendation on birth preparedness and complication readiness

Pregnant woman sweeping the floor

WHO recommendation on birth preparedness and complication readiness

 

Recommendation

Birth preparedness and complication readiness (BPCR) interventions are recommended to increase the use of skilled care at birth and to increase the timely use of facility care for obstetric and newborn complications.

 (Strong recommendation, very low quality of evidence)

 

Publication history

First published: May 2015

Updated: No update planned

Assessed as up-to-date: May 2015

 

Remarks

  • Additional research is required

 

Background

In 2003 the World Health Organization (WHO) published “Working with individuals, families and communities to improve maternal and newborn health”, (1) the IFC framework that promotes integrating the health promotion approach set out in the Ottawa Charter (2) into national maternal and newborn health (MNH) strategies.

The IFC Framework was developed in response to analysis and global statements indicating that as well as strengthening services, MNH strategies need to improve the capacity of individuals, families and communities to provide appropriate care for pregnant women, mothers, and newborns in the home. It also addresses the reasons – over and above what happens in clinical services – why women do not reach good quality skilled care during pregnancy, childbirth and after birth. The Ottawa Charter’s health promotion components(2) were translated into MNH programme language and 12 promising interventions – identified through reviews of country experiences and the literature – were categorized into four priority areas. Community and intersectoral participation was recommended to guide implementation. Exact interventions to be adapted by country programmes were to be identified through local assessment; however, the framework highlighted the need for interventions to address all four priority areas at the same time. All six WHO Regions integrated this guidance into the regional maternal mortality reduction strategies.

Birth Preparedness and Complication Readiness (BPCR) is an intervention included by WHO as an essential element of the antenatal care package. (3) It is often delivered to the pregnant woman by the health care provider in antenatal care or initiated or followed up through a visit to the home of the pregnant woman by a community health worker. In addition to working with an individual pregnant woman, programmes often address efforts to her family and to the broader community to increase awareness on BPCR or to improve health workers’ skills to provide BPCR as part of ANC. Programmes often provide education materials or other visual aids with BPCR information, or may implement mass media campaigns with BPCR messages.

A birth and complications preparedness plan contains the following elements: the desired place of birth; the preferred birth attendant; the location of the closest facility for birth and in case of a complication; funds for any expenses related to birth and in case of complications; supplies and materials necessary to bring to the facility; an identified labour and birth companion; an identified support to look after the home and other children while the woman is away; transport to a facility for birth or in the case of a complication; and the identification of compatible blood donors in case of emergency.(4)

To be able to be prepared for birth and possible complications, women, families and communities need to know about signs of onset of labour as well as danger signs during pregnancy and after birth for the woman and newborn. BPCR interventions have evolved and while originally programmes focused largely on careseeking for the woman, in recent years, programmes have recognized the value of discussing care-seeking for newborn complications.

This recommendation was published within the 2015 WHO guideline “WHO Recommendations on Health Promotion Interventions for Maternal and Newborn Health.”(5)

 

Methods

The recommendation was developed using standardized operating procedures in accordance with the process described in the “WHO handbook for guideline development”, guided by the GRADE approach.(6) Outcomes used for this recommendation were aligned with the prioritized outcomes from the WHO recommendations on health promotion interventions for maternal and newborn health (2015).(5)

A systematic review was conducted on birth and complications readiness.(7) In the review, randomized controlled trials relevant to the key question were screened by review authors, and data on relevant outcomes and comparisons were extracted. Evidence profiles (in the form of GRADE tables) were prepared for comparisons of interest, including the assessment and judgments for each outcome, and the estimated risks.

WHO convened a Guideline Development Group (GDG) meeting on recommendations on health promotion interventions for maternal and newborn health where this recommendation was developed. The GDG comprised of a group of independent experts, who used the evidence profiles to assess evidence on effects on the pre-specified outcomes. GDG members discussed the balance between desirable and undesirable effects, overall quality of supporting evidence, values and preferences of stakeholders, resource requirements, cost-effectiveness, acceptability, feasibility and equity, to formulate the recommendation. Remarks were added to clarify the recommendation, and aid implementation.

 

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

  • What interventions used to implement BPCR are effective for increasing use of skilled birth attendants and for improving other maternal and newborn health outcomes?

 

Evidence summary

Evidence on birth and complications readiness was extracted from a systematic review conducted by Solnes Miltenburg et al. (7) of 33 studies which summarized the findings from 21 different programmes. The study designs reported in the studies included one RCT, three cluster RCTs, seven pre and post comparative studies with a control group, three pre and post studies, seven one group before and after evaluations of which two had a qualitative component, and one qualitative study. The 21 programmes were implemented in Bangladesh, Burkina Faso, Cambodia, Eritrea, Guatemala, India, Indonesia, Kenya, Nepal, Pakistan and Tanzania. The BPCR interventions largely focused on promoting birth with a skilled birth attendant (SBA), with the exception of seven, which were primarily aimed to increase use of skilled care for obstetric complications.(8-14)

The programmes implemented different strategies including house visits by volunteers who provided education on BPCR, training of health workers in facilities to provide BPCR as part of ANC, provision of education materials or other visual aids with BPCR information, community mobilization activities to increase awareness on BPCR and mass media campaigns with BPCR messages. There was not sufficient evidence to determine which of these strategies or which combination of strategies were most effective.

 

For the outcome of birth with a skilled birth attendant or facility birth, the quality of the evidence ranged from very low to low.

-One RCT (Mullany, Becker and Hindin, 2007) of a single BPCR intervention using facility education sessions with poor women and husbands in a maternity hospital in urban Nepal reported a non-significant increase in the use of a skilled birth attendant at birth in both intervention groups (the husband and wife or wife alone received health education) compared with control (the wife receives no education). Low-quality evidence.(15)

-13 studies reported on this outcome, including four quasi-experimental studies (FCI Kenya, 2007; FCI Tanzania, 2007; Hounton et al., 2008; Turan, Tesfagiorghis and Polan, 2011) and one pre and post study with a control group (Sood et al., 2004 Indonesia); seven were one group before and after evaluations (Fonseca-Becker and Schenck-Yglesias, 2004; Hodgins et al., 2010; McPherson et al., 2006; Moran et al., 2006; Mushi, Mpembeni and Jahn, 2010; Sinha, 2008; Sood et al., 2004 Nepal); and one qualitative feasibility study (Skinner and Rathavy, 2009).(16-25) Three quasi-experimental studies (FCI Tanzania, 2007; Hounton et al., 2008; Turan, Tesfagiorghis and Polan, 2011) and one pre and post study with a control group (Sood et al., 2004 Indonesia) report significant improvements in the primary outcome in the intervention area (SBA or facility births); the other quasi-experimental study reports a higher increase in SBA in the control area (FCI Kenya, 2007). Four of the one group before and after studies report significant improvements in SBA or facility birth (Fonseca-Becker and Schenck-Yglesias, 2004; Moran et al., 2006; Mushi, Mpembeni and Jahn, 2010; Sinha, 2008); the other three report slight improvements from baseline (Hodgins et al., 2010; McPherson et al., 2006) and greater improvement in SBA in the unexposed group at endline (Sood et al., 2004 Nepal). The qualitative feasibility study which includes pre- and post-facility data indicates an increase in the number of women giving birth with a midwife, but this is based on data from all villages linked to 10 health centres and not just the villages where the intervention occurred (Skinner and Rathavy, 2009). Very low-quality evidence.(26)

-For those studies whose focus was increasing access to skilled care for complications:

  • Two cluster RCTs (Darmstadt et al., 2010; Midhet and Becker, 2010) report the percentage of women giving birth at a facility was significantly higher in the intervention arms compared to the control. In another cluster RCT (Kumar et al., 2010), facility births were higher and more women gave birth with a qualified attendant in the intervention arm, but these were not significant differences. Very low-quality evidence.(11, 13)
  • A quasi-experimental study (Hossain and Ross, 2006) reports significant increases in facility birth in the intervention and the comparison areas baseline to follow-up, but not in the control area. Another quasi-experimental study (Baqui et al., 2008) reports significant improvement in use of skilled birth attendants in a health facility or at home from baseline to endline in the intervention district. In the pre-post study (Ahluwalia et al., 2003), there was a reduction in births assisted by a health provider. Very low-quality evidence.(8, 10, 12)

 

For the outcome of care with a skilled birth attendant or in a facility in case of complications/illness in women and newborns, the quality of the evidence was rated as very low.

-Four studies report on this outcome. The before and after studies report more women seeking skilled care for complications between baseline and followup (Fonseca-Becker and Schenck-Yglesias, 2004; McPherson et al., 2006) and increases between baseline and endline in percentage of respondents seeking care following recognitions of danger signs in newborns, in pregnancy and at delivery (Hodgins et al., 2010). One quasi-experimental pre and post study with a control group (FCI Tanzania, 2007) reports a significant increase in women with complications seeking treatment at a facility in the intervention group. Very low-quality evidence.(19-21)

-For those studies whose focus was increasing access to skilled care for complications:

  • Three cluster RCTs report on this outcome. One cluster RCT (Midhet and Becker, 2010) reports significant increases in women with complications seeking care in pregnancy and after birth, but no significant difference between study arms for care-seeking for birth complications. Another cluster RCT (Kumar et al., 2012) reports that significantly fewer women with complications went to unqualified practitioners; and the other RCT (Darmstadt et al., 2010) reports that careseeking from a qualified provider for neonates with complications increased significantly more in the intervention arm than comparison. Very low-quality evidence.(11, 13, 14)
  • A quasi-experimental study (Hossain and Ross, 2006) reports a significant increase in women seeking care for complications in the intervention and comparison groups but not control. Both the pre and post study (Ahluwalia, 2003) and the follow-up evaluation (Ahluwalia, 2010) report increases in number of women with complications seeking hospital care but only the follow-up study (Ahluwalia, 2010) estimates what percentage this represents (based on old surveillance data). There is no comparable data from a control group of women who did not receive the intervention. Very low-quality evidence.(8, 9, 12)

 

For the outcome of maternal mortality, the quality of the evidence ranged from very low to moderate.

-One quasi-experimental study (Hounton et al., 2008) reports a lower mortality risk in the intervention group and a decline over time but this is not significantly different to the non-intervention area or control area. Very low-quality evidence.(16)

-For those studies whose focus was increasing access to skilled care for complications:

  • One RCT (Kumar et al., 2012) reports a non-significant downward trend in maternal mortality ratio (MMR) in the intervention arm compared to control. Low-quality evidence.(13)

 

For the outcome of neonatal mortality, the quality of the evidence was rated as very low to low.

-The pre and post evaluation (Hodgins et al., 2010) showed fewer neonatal deaths over time but there was no separate comparison group. Low-quality evidence.(20)

 

-For those studies whose focus was increasing access to skilled care for complications:

  • One cluster RCT (Kumar et al., 2012) reports significantly lower neonatal mortality in the BP intervention group. The other two cluster RCTs (Darmstadt et al., 2010; Midhet and Becker, 2010) report no significant difference in neonatal mortality by study arm. Very low-quality evidence.(11, 13, 14)
  • The quasi-experimental study (Baqui et al., 2008) showed no difference in neonatal mortality rates between the intervention and comparison groups or from the baseline and endline. Low-quality evidence.(10)

 

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:

http://apps.who.int/iris/bitstream/10665/172427/2/9789241508742_tables_eng.pdf?ua=1

 

Implementation considerations

  • Implementation of BPCR should include preparedness for birth and complications for mother and newborn; as opposed to focusing either only on planning for birth, only on planning for complications or only on the mother.
  • Use of a skilled birth attendant during childbirth or facility birth increased primarily under circumstances where BPCR interventions were part of a multiple package of interventions. Co-interventions which seemed to have a positive impact include community participation, the involvement of male partner and of other household decision-makers in discussions (with the woman’s consent) and concurrent efforts to improve the quality of service delivery.
  • Factors that limited the impact of the interventions include health system barriers such as shortage of health professionals, lack of resources and poor quality of care; cultural factors that affected the use of care, including perceptions of what skilled care is; and high costs for seeking care which relate to out-ofpocket expenditures.
  • In settings with extremely low use of SBA for birth and where facility birth is not feasible, BPCR should include the following actions: choosing an SBA to attend the birth in the home; preparing the place of birth at home; preparing for clean birth with essential materials and supplies such as a birth kit; planning for emergency transportation; essential newborn care preparedness (delayed first bathing, drying of newborn before the delivery of the placenta, initiation of breastfeeding within one hour after birth, safe cord care); and a companion who will stay with the woman for at least 24 hours after birth.

 

 

Research implications

The GDG identified that further research on the following high-priority questions is needed:

  • Agreement on priority BPCR actions and/or which combination of essential actions should be further tested.
  • Whether BPCR interventions that include careseeking for the newborn in case of complications have had an impact on this outcome.
  • Studies that better measure the effect on careseeking outcomes for pregnant women and newborns of including men and other key decision-makers at the household level in the discussions on preparations and in the corresponding decisions.
  • Both quantitative and qualitative enquiries are needed.

 

 

Related links

WHO recommendations on health promotion interventions for maternal and newborn health (2015)full document and evidence tables

 

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health

Newborn Health

 

Supporting systematic reviews:

Solnes Miltenburg A, Roggeveen Y, Shields L, van Elteren M, van Roosmalen J, Stekelenburg J, et al. Impact of Birth Preparedness and Complication Readiness Interventions on Birth with a Skilled Attendant: A Systematic Review. PloS one. 2015;10(11):e0143382.

 

References

  1. Working with individuals, families, and communities to improve maternal and newborn health. Geneva: World Health Organization; 2010. [26 November 2014] http://wwwwhoint/maternal_child_adolescent/documents/who_fch_rhr_0311/en/.

2.   The Ottawa Charter for Health Promotion [website]. Geneva: World Health Organization; 1986. [30 March 2014] http://wwwwhoint/healthpromotion/conferences/previous/ottawa/en/.

3.   Carroli G, Villar J, Piaggio G, Khan-Neelofur D, Gulmezoglu M, Mugford M, et al. WHO systematic review of randomised controlled trials of routine antenatal care. Lancet (London, England). 2001;357(9268):1565-70.

4.   Counselling for maternal and newborn health care: a handbook for building skills. Geneva: World Health Organization; 2013. [8 January 2015] http://appswhoint/iris/bitstream/10665/44016/1/9789241547628_engpdf?ua=1 [PubMed].

5.   Organization WH. WHO recommendations on health promotion interventions for maternal and newborn health 2015: World Health Organization; 2015.

6.   WHO Handbook for Guideline Development - 2nd edition. Geneva: World Health Organization; 2014. World Health Organization. 2014.

7.   Solnes Miltenburg A, Roggeveen Y, Shields L, van Elteren M, van Roosmalen J, Stekelenburg J, et al. Impact of Birth Preparedness and Complication Readiness Interventions on Birth with a Skilled Attendant: A Systematic Review. PloS one. 2015;10(11):e0143382.

8.   Ahluwalia IB, Schmid T, Kouletio M, Kanenda O. An evaluation of a community-based approach to safe motherhood in northwestern Tanzania. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2003;82(2):231-40.

9.   Ahluwalia IB, Robinson D, Vallely L, Gieseker KE, Kabakama A. Sustainability of community-capacity to promote safer motherhood in northwestern Tanzania: what remains? Global health promotion. 2010;17(1):39-49.

10. Baqui AH, Williams EK, Rosecrans AM, Agrawal PK, Ahmed S, Darmstadt GL, et al. Impact of an integrated nutrition and health programme on neonatal mortality in rural northern India. Bulletin of the World Health Organization. 2008;86(10):796-804.

11. Darmstadt GL, Choi Y, Arifeen SE, Bari S, Rahman SM, Mannan I, et al. Evaluation of a cluster-randomized controlled trial of a package of community-based maternal and newborn interventions in Mirzapur, Bangladesh. PloS one. 2010;5(3):e9696.

12. Hossain J, Ross SR. The effect of addressing demand for as well as supply of emergency obstetric care in Dinajpur, Bangladesh. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2006;92(3):320-8.

13. Kumar V, Mohanty S, Kumar A, Misra RP, Santosham M, Awasthi S, et al. Effect of community-based behaviour change management on neonatal mortality in Shivgarh, Uttar Pradesh, India: a cluster-randomised controlled trial. Lancet (London, England). 2008;372(9644):1151-62.

14. Midhet F, Becker S. Impact of community-based interventions on maternal and neonatal health indicators: Results from a community randomized trial in rural Balochistan, Pakistan. Reproductive Health. 2010;7:30.

15. Mullany LC, Lee TJ, Yone L, Lee CI, Teela KC, Paw P, et al. Impact of community-based maternal health workers on coverage of essential maternal health interventions among internally displaced communities in eastern Burma: the MOM project. PLoS medicine. 2010;7(8):e1000317.

16. Hounton S, Menten J, Ouedraogo M, Dubourg D, Meda N, Ronsmans C, et al. Effects of a Skilled Care Initiative on pregnancy-related mortality in rural Burkina Faso. Tropical medicine & international health : TM & IH. 2008;13 Suppl 1:53-60.

17. Turan JM, Tesfagiorghis M, Polan ML. Evaluation of a community intervention for promotion of safe motherhood in Eritrea. Journal of midwifery & women's health. 2011;56(1):8-17.

18. Sood S, Chandra U, Palmer A, Molyneux I. Measuring the effects of the SIAGA behavior change campaign in Indonesia with population-based survey results. 2004.

19. Schenck-Yglesias. F-BFa. Measuring the effects of behavior change and service delivery interventions in Guatemala with population-based survey results. Baltimore: JHPIEGO;. 2004.

20. Hodgins S, McPherson R, Suvedi BK, Shrestha RB, Silwal RC, Ban B, et al. Testing a scalable community-based approach to improve maternal and neonatal health in rural Nepal. Journal of Perinatology. 2010;30(6):388-95.

21. McPherson RA, Khadka N, Moore JM, Sharma M. Are birth-preparedness programmes effective? Results from a field trial in Siraha district, Nepal. Journal of health, population, and nutrition. 2006;24(4):479-88.

22. Moran AC, Sangli G, Dineen R, Rawlins B, Yameogo M, Baya B. Birth-preparedness for maternal health: findings from Koupela District, Burkina Faso. Journal of health, population, and nutrition. 2006;24(4):489-97.

23. Mushi D, Mpembeni R, Jahn A. Effectiveness of community based Safe Motherhood promoters in improving the utilization of obstetric care. The case of Mtwara Rural District in Tanzania. BMC pregnancy and childbirth. 2010;10:14.

24. Sinha D. Empowering communities to make pregnancy safer: an intervention in rural Andhra Pradesh: Population Council; 2008.

25. Sood S, Chandra U, Mishra P, Neupane S. Measuring the effects of behavior change interventions in Nepal with population-based survey results. 2004.

26. Skinner J, Rathavy T. Design and evaluation of a community participatory, birth preparedness project in Cambodia. Midwifery. 2009;25(6):738-43.

 

Citation: WHO recommendation on birth preparedness and complication readiness interventions (2015). WHO Reproductive Health Library; Geneva: World Health Organization.