Impact of intrapartum quality improvement interventions on stillbirths: a systematic review and meta-analysis.

Abstract

<h4>Background</h4>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.<h4>Objectives</h4>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.<h4>Design</h4>A systematic review and meta-analysis of experimental and analytical studies.<h4>Data sources and methods</h4>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 <i>Q</i> test, tau-squared (<i>τ</i> ²) and quantified using the <i>I</i> ² statistic followed by exploration through sensitivity analysis, subgroup analysis and meta-regression.<h4>Results</h4>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.<h4>Conclusion</h4>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.<h4>Review registration</h4>PROSPERO CRD42024503854.