Background:

Stillbirths are a major global health concern. Improving intrapartum quality of care could reduce stillbirths, but there is no synthesized evidence on the impact of different intrapartum interventions on stillbirths.

Objectives:

The broad aim was to assess whether intrapartum quality improvement packages and related facility-based clinical, technological and health system interventions at maternity units of health facilities led to a reduction of stillbirths.

Design:

A systematic review and meta-analysis of experimental and analytical studies.

Data sources and methods:

This systematic review is reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Web of Science, Scopus, ProQuest, Cochrane, China National Knowledge Infrastructure (CNKI) databases were searched during July–August 2024. A comprehensive search strategy was developed using Medical Subject Headings (MeSH) terms and keywords. We conducted database scanning, article screening and data extraction and included experimental, cohort or case-control designs. Risk of bias was assessed using Critical Appraisal Skills Programme (CASP), ROBINS-I and RoB 2 checklists. A random-effects model was used to account for between-study variability. Heterogeneity was assessed using Cochran’s Q test, tau-squared (τ²) and quantified using the I² statistic followed by exploration through sensitivity analysis, subgroup analysis and meta-regression.

Results:

The final selection included 24 articles involving 4,647,555 intrapartum women for the systematic review and 17 studies for the meta-analysis. Quality improvement intrapartum interventions of foetal heart rate monitoring, capacity building and mentoring of providers and clinical practice improvement seemed to be beneficial in reducing stillbirths. The pooled estimate on meta-analysis yielded an odds ratio of 0.25 (95% CI: 0.06–1.10), suggesting a 75% reduction in the odds of stillbirth with intrapartum interventions, but not statistically significant. Diverse study settings enhanced the generalizability of findings, but the marked heterogeneity and variable methodological quality of the studies call for caution in making conclusions.

Conclusion:

Comprehensive quality improvement programmes during intrapartum period suggest potential benefits in reduction of stillbirths and can impact intrapartum care practices globally, particularly in low-resource settings. Heterogeneity in study design, study quality and contextual factors underscored the necessity for further research.

Review registration:

PROSPERO CRD42024503854.

Plain language summary

Reducing stillbirths through provision of quality care during labor: a systematic review and meta-analysis

What did we do: We sought to find out whether stillbirths can be reduced by improving quality of care given to women during labour and childbirth. We used a methodology known as systematic review and meta-analysis to address this question. We collected published research studies from large scientific databases through July-August 2024 and selected those studies which assessed the effect of quality improvement programmes implemented during labor on occurrence of stillbirths. The quality improvement programmes included: (1) monitoring the baby’s heartbeat while the mother is in labor, (2) training and mentoring of health providers or birth attendants, (3) improving clinical practices and standards among others. What did we find: Through search strategies, we selected 1356 articles, which came down to 181 after duplicate removals and exclusions. We did full text review of these articles and selected 24 for systematic review. Seventeen articles were selected for meta-analysis; we found that women who delivered in facilities where quality improvement interventions were implemented during labor had lower chances of stillbirths, although statistically, the result was not strong enough to be called conclusive. The studies were from a wide range of settings; hence the findings can be regarded as applicable to diverse backgrounds. However, the studies were not uniform in terms of study design, quality and local contexts. What does this mean: Improving the quality of care of interventions during labor such as monitoring baby’s heart rate as per a protocol and performing immediate caesarean section if needed, capacity building and mentoring of birth attendants, improving standards of care and clinical practices of labour have been found to help reduce the chances of stillbirths (however the result was not strong enough to be confident). While more research is needed, it is noteworthy that improving quality of intrapartum care is worth investing, especially in low resources.