This is an overview of evidence of the effectiveness of antenatal care in relation to maternal mortality and serious morbidity, focused in particular on developing countries. It concentrates on the major causes of maternal mortality, and traces their antecedent morbidities and risk factors in pregnancy. It also includes interventions aimed at preventing, detecting or treating any stage along this pathway during pregnancy. This is an updated and expanded version of a review first published by the World Health Organization (WHO) in 1992. The scientific evidence from randomised controlled trials and other types of intervention or observational study on the effectiveness of these interventions is reviewed critically. The sources and quality of available data, and possible biases in their collection or interpretation are considered. As in other areas of maternal health, good-quality evidence is scarce and, just as in many aspects of health care generally, there are interventions in current practice that have not been subjected to rigorous evaluation. A table of antenatal interventions of proven effectiveness in conditions that can lead to maternal mortality or serious morbidity is presented. Interventions for which there is some promising evidence, short of proof, of effectiveness are explored, and the outstanding questions formulated. These are presented in a series of tables with suggestions about the types of study needed to answer them.

https://onlinelibrary.wiley.com/doi/pdf/10.1046/j.1365-3016.2001.0150s1001.x

How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence

Background
While maternal, infant and under-five child mortality rates in developing countries have declined significantly in the past two to three decades, newborn mortality rates have reduced much more slowly. While it is recognised that almost half of the newborn deaths can be prevented by scaling up evidence-based available interventions such as tetanus toxoid immunisation to mothers; clean and skilled care at delivery; newborn resuscitation; exclusive breastfeeding; clean umbilical cord care; management of infections in newborns, many require facility based and outreach services. It has also been stated that a significant proportion of these mortalities and morbidities could also be potentially addressed by developing community-based packages interventions which should also be supplemented by developing and strengthening linkages with the local health systems. Some of the recent community-based studies of interventions targeting women of reproductive age have shown variable impacts on maternal outcomes and hence it is uncertain if these strategies have consistent benefit across the continuum of maternal and newborn care.
The objective of this review is to assess the effectiveness of community-based intervention packages in reducing maternal and neonatal morbidity and mortality; and improving neonatal outcomes.

/pdf/community-based-intervention-packages-for-reducing-maternal-3qa2rmi564.pdf

Community‐based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes

Summary This paper explores the scientific justification for the key action message “ensure skilled attendance at delivery.” Many governments and other provider agencies in poor countries will need to commit additional health resources in order to respond to this message, and opportunity costs will be incurred. Achieving targets will take time, and benefits in terms of maternal mortality may not be detected for several years. It is therefore crucial to review the basis for prioritising skilled attendance. This paper examines the historical and epidemiological evidence at both the individual and population levels of analysis. The lack of a clear definition has been, and continues to be, the cause of much confusion over the role, and thus the potential, of skilled attendants. Recent initiatives to specify minimum and additional skills have improved understanding not only of training requirements but also of the wider environment which is required for skilled attendants to function effectively. This paper proposes that skilled attendance be conceived as encompassing 1) a partnership of skilled attendants (health professionals with the skills to provide care for normal and/or complicated deliveries), AND 2) an enabling environment of equipment, supplies, drugs and transport for referral. At the individual level, there are sound clinical reasons for believing that the risk of maternal death can be reduced by skilled attendance, particularly as the causal pathways can be specified. However, this theory of how skilled attendance could work has not been rigorously tested, and the available empirical evidence – both historical and epidemiological, is flawed, either owing to weak study designs which fail to control for key confounding factors and/or inadequate power. Insights from modeling can be used to complement an empirical approach and in this paper a preliminary model is pre

/pdf/can-skilled-attendance-at-delivery-reduce-maternal-mortality-220d28bwfk.pdf

Can skilled attendance at delivery reduce maternal mortality in developing countries

https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1016/j.ijgo.2004.11.026

The evidence for emergency obstetric care

Safe motherhood strategies: a review of the evidence

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(97)08012-4.pdf

Anne Marie Vanneste

Papers

Decline in maternal mortality in Matlab Bangladesh: a cautionary tale.