Introduction: Near-term and intrapartum care play pivotal roles in ensuring a safe childbirth experience and are essential components of a comprehensive approach to maternal and neonatal health. Methods: The following interventions were identified: antibiotics for preterm premature rupture of membrane, antenatal corticosteroids for fetal lung maturation, partograph use during labor and delivery, induction of labor at or post-term, skilled birth care and safe childbirth checklist during labor and delivery. A scoping exercise was conducted to ascertain the most up-to-date evidence, and reviews of topics of interest were updated in case the evidence was not recent, with a focus on low- and middle-income countries (LMICs). Results: Antibiotics reduced the overall risk of neonatal infection including pneumonia (RR 0.67 [0.52 to 0.85]). LMIC evidence showed a significant effect of antenatal steroids on the risk of neonatal mortality (RR 0.64 [0.43 to 0.97]) and respiratory distress syndrome (RR 0.65 [0.44 to 0.96]). Induction of labor practices at term or post-term reduced the risk of meconium aspiration syndrome (RR 0.51 [0.34 to 0.76]). The use of the WHO childbirth checklist significantly raised the standard of preeclampsia care (OR 8.09 [2.55 to 25.63]) as well as of maternal infection management (OR 25.44 [4.09 to 158.08]). LMIC-specific evidence also demonstrated a significant reduction in the risk of stillbirth (OR 0.92 [0.87 to 0.96]). Conclusion: Further research initiatives pertaining to health interventions delivered to expectant mothers near-term or during the intrapartum period can contribute to a more inclusive understanding of health challenges in LMICs.

Near-term and intrapartum care comprises of safe and supportive measures given to pregnant women during pregnancy and childbirth to curb adverse maternal and neonatal health outcomes. It involves an interdisciplinary team of healthcare workers (HCWs), including obstetricians, anesthesiologists, midwives, nurses, and neonatologists, as well as family members and caretakers of the babies [1], working together in conjunction to ensure a safe and positive childbirth experience for the mother as well as adequate care for the neonates.

In 2020, 287,000 women lost their lives during and following pregnancy and childbirth, and 95% of all maternal deaths took place in low and lower-middle-income countries (LMICs). The maternal mortality ratio in high-income countries was 13 per 100,000 live births, compared to 430 per 100,000 live births in low-income countries, highlighting the stark disparity between the provision of health care in high- and low-resource settings. And while there has been a 34% decrease in the maternal mortality ratio in the last 20 years, the improvement has been much too sluggish [2].

The first 24 h of life is critical for screening, detecting, and managing health complications, and the first month of life collectively represents the most vulnerable time for a newborn. In 2022, 2.3 million neonates died within the first 20 days of life, and evidence suggests that approximately 75% of neonates die in the first week of life, and a million die within the first 24 h of life, with most of these deaths occurring in LMICs [3]. In high-resource settings, access to advanced health systems, including the presence of trained skilled birth attendants at birth, contributes to improved maternal and neonatal health outcomes. Factors such as poor infrastructure, economic restrictions, poverty, gender equality, and limited access to education prevent women in low and LMICs from receiving proper health care during the perinatal period [2].

Preterm birth is a significant public health concern worldwide and can lead to various health complications for an inadequately developed baby. Low socioeconomic status, maternal age under 20 years, hypertensive disorders, severe antenatal hemorrhage, nulliparity, and less than four antenatal visits are associated with a higher risk of preterm birth and low birthweight [4], and babies born prematurely are at a greater risk of neonatal death, stillbirth, necrotizing enterocolitis (NEC), cerebral palsy, and maternal and neonatal infections [5].

Near-term and intrapartum care collectively includes regular prenatal check-ups, appropriate treatment of preterm premature rupture of membrane (PPROM) and assessment of fetal lung maturity, monitoring the progress of labor and taking timely action if needed, and the attendance of skilled birth attendants during delivery. Effective implementation of interventions to optimize maternal and neonatal health outcomes as well as the capacity to correctly and competently employ those measures during potential complications occurring near-term or during delivery, especially in preterm deliveries, needs to be prioritized.

The objective of this paper was to summarize current literature on essential near-term and intrapartum care interventions. The paper aimed to meticulously streamline the gaps in the continuum of care within LMICs and propose evidence-based strategies and recommendations to bridge these gaps to improve maternal and neonatal health outcomes not only in high- and upper-middle-income countries, but also in LMICs.

The Lancet Every Newborn series published in 2014 highlighted interventions aimed at improving the health of mothers and newborns. The evidence from the series was updated, new evidence relevant to the topic of interest was identified, and subgroup analysis of LMICs was conducted where applicable. This paper is a part of a supplement that offers a comprehensive synthesis of interventions implemented near-term and during the intrapartum period. A range of methodological approaches was used to synthesize the overall and LMIC-specific evidence, and while the detailed methodology is published elsewhere [6], below is the brief methodology for this paper.

Analysis and Update of Existing Systematic Reviews

Search and Selection of Reviews

We conducted a search to identify all the recent relevant systematic reviews that focused on the interventions in the near-term and intrapartum period and focused on outcomes for the mothers and their fetuses. The specific interventions were finalized after reviewing the previous Lancet Series and the consultation of the technical advisory group. The following interventions were included in this paper.

Interventions for Near-Term Care

The following are the interventions for near-term care:

  • Antibiotics for PPROMs

  • Antenatal corticosteroids for fetal lung maturation.

Interventions for Intrapartum Care

Interventions for intrapartum care are as follows:

  • Partograph use during labor and delivery

  • Induction of labor at or post-term

  • Skilled birth care

  • Safe childbirth checklist (SCC) during labor and delivery.

Databases including CENTRAL and PubMed were searched to identify recent systematic reviews for all these interventions. The aims were to conduct de novo reviews if no systematic reviews were determined to be pertinent to the intervention of interest, update existing systematic reviews if the evidence was out-of-date, and employ existing systematic reviews as-is if the evidence was current. For reviews that were updated, we utilized the same methodology including the search strategy and databases as outlined in the original review, and if no search strategy was mentioned in the review, the MeSH terms provided were used to curate a new search strategy and were run on databases such as PubMed, CINAHL, and Embase.

Data Collection and Synthesis

Once the current systematic review was identified, we extracted in duplicate all the relevant information and outcomes with estimates. To conduct a subgroup analysis for all low-income countries and LMICs, we classified the countries according to the World Bank [7] classification based on the year in which the studies were conducted. The data for a particular outcome were categorized as overall if the evidence collectively derived from all studies was from different-income groupings and separately for studies from low-income countries and LMICs. This reanalysis process was done by two authors. We followed the same statistical procedure described in the original review to get the pooled effect estimates.

For reviews that were updated, the search was conducted by two reviewers, and following the inclusion criteria, we included all eligible studies, and extractions were done. We updated all the outcomes where new studies reported those outcomes. Data for new studies were entered in Review Manager 5.4.1, and the existing forest plots were updated, with new estimates reported as RR with 95% CI for dichotomous and mean difference with 95% CI for continuous outcomes.

Maternity care is the care offered to mothers and newborns throughout labor and delivery and is designated to safeguard the health of the mother and the baby. Near-term and intrapartum care are highly individualized and are contingent upon the preferences of the mother, special circumstances surrounding labor and delivery, and availability of proper equipment and healthcare facilities.

We found existing recent systematic reviews for antenatal corticosteroids for fetal lung maturation [8], partograph use during labor and delivery [9], induction of labor at or post-term [10], and SCC during labor and delivery [11]. Systematic reviews identified for antibiotics for PPROMs [12] and skilled birth care [13] were updated.

Findings are summarized in the following paragraphs and are discussed in further detail in Tables 1 and 2. Additional information can be found in online supplementary files 1 and 2 (for all online suppl. material, see https://doi.org/10.1159/000543384).

Table 1.

Interventions for near-term care

OutcomeOverallLMICs
studies (participants), neffect estimate (95% CI)studies (participants), neffect estimate (95% CI)
Comparison: any antibiotic versus placebo for PROM (13) 
Cesarean section 11 (6,317) RR 0.96 (0.88 to 1.05) 1 (88)a RR 1.04 (0.67 to 1.63) 
Chorioamnionitis 11 (1,559) RR 0.66 (0.46 to 0.96)b 1 (87)a RR 0.19 (0.05 to 0.83)b 
Preterm birth 3 (4,931)c RR 1.00 (0.98 to 1.03) 
LBW 2 (4,876)c RR 1.00 (0.96 to 1.04) 
Positive neonatal blood culture 3 (4,961)c RR 0.79 (0.63 to 0.99)b 
Neonatal infection including pneumonia 12 (1,680) RR 0.67 (0.52 to 0.85)b 1 (85)a RR 1.02 (0.39 to 2.67) 
Perinatal death/death before discharge 12 (6,301) RR 0.93 (0.76 to 1.14) 1 (84)a RR 1.17 (0.43 to 3.18) 
Neonatal NEC 11 (6,229) RR 1.09 (0.65 to 1.83) 1 (85)a RR 0.34 (0.01 to 8.14) 
Neonatal respiratory distress syndrome 12 (6,287) RR 0.95 (0.83 to 1.09) 1 (85)a RR 0.32 (0.11 to 0.89)b 
Comparison: corticosteroids versus placebo or no treatment (9) 
Maternal mortality 6 (6,244) RR 1.19 (0.36 to 3.89) 2 (3,052) RR 1.24 (0.33 to 4.63) 
Respiratory distress syndrome 26 (11,183) RR 0.71 (0.65 to 0.78)b 6 (3,890) RR 0.65 (0.44 to 0.96)b 
Moderate/severe respiratory distress syndrome 7 (4,874) RR 0.70 (0.59 to 0.83)b 2 (3,201) RR 0.30 (0.03 to 3.22) 
Fetal death 14 (9,833) RR 1.01 (0.83 to 1.22) 3 (3,519) RR 1.01 (0.79 to 1.30) 
Perinatal death 14 (9,833) RR 0.85 (0.77 to 0.93)b 3 (3,519) RR 0.70 (0.40 to 1.23) 
Neonatal mortality 22 (10,609) RR 0.78 (0.70 to 0.87)b 5 (3,070) RR 0.64 (0.43 to 0.97)b 
OutcomeOverallLMICs
studies (participants), neffect estimate (95% CI)studies (participants), neffect estimate (95% CI)
Comparison: any antibiotic versus placebo for PROM (13) 
Cesarean section 11 (6,317) RR 0.96 (0.88 to 1.05) 1 (88)a RR 1.04 (0.67 to 1.63) 
Chorioamnionitis 11 (1,559) RR 0.66 (0.46 to 0.96)b 1 (87)a RR 0.19 (0.05 to 0.83)b 
Preterm birth 3 (4,931)c RR 1.00 (0.98 to 1.03) 
LBW 2 (4,876)c RR 1.00 (0.96 to 1.04) 
Positive neonatal blood culture 3 (4,961)c RR 0.79 (0.63 to 0.99)b 
Neonatal infection including pneumonia 12 (1,680) RR 0.67 (0.52 to 0.85)b 1 (85)a RR 1.02 (0.39 to 2.67) 
Perinatal death/death before discharge 12 (6,301) RR 0.93 (0.76 to 1.14) 1 (84)a RR 1.17 (0.43 to 3.18) 
Neonatal NEC 11 (6,229) RR 1.09 (0.65 to 1.83) 1 (85)a RR 0.34 (0.01 to 8.14) 
Neonatal respiratory distress syndrome 12 (6,287) RR 0.95 (0.83 to 1.09) 1 (85)a RR 0.32 (0.11 to 0.89)b 
Comparison: corticosteroids versus placebo or no treatment (9) 
Maternal mortality 6 (6,244) RR 1.19 (0.36 to 3.89) 2 (3,052) RR 1.24 (0.33 to 4.63) 
Respiratory distress syndrome 26 (11,183) RR 0.71 (0.65 to 0.78)b 6 (3,890) RR 0.65 (0.44 to 0.96)b 
Moderate/severe respiratory distress syndrome 7 (4,874) RR 0.70 (0.59 to 0.83)b 2 (3,201) RR 0.30 (0.03 to 3.22) 
Fetal death 14 (9,833) RR 1.01 (0.83 to 1.22) 3 (3,519) RR 1.01 (0.79 to 1.30) 
Perinatal death 14 (9,833) RR 0.85 (0.77 to 0.93)b 3 (3,519) RR 0.70 (0.40 to 1.23) 
Neonatal mortality 22 (10,609) RR 0.78 (0.70 to 0.87)b 5 (3,070) RR 0.64 (0.43 to 0.97)b 

LMICs, low- and middle-income country; PROMs, preterm rupture of membranes.

aMulticountry data.

bEffect size is significant.

cHIC data: high-income country.

Table 2.

Interventions for intrapartum care

OutcomeOverallLMICs
studies (participants), neffect estimate (95% CI)studies (participants), neffect estimate (95% CI)
Comparison: partograph use with no partograph (10) 
Instrumental vaginal birth 3 (1,813) RR 0.99 (0.84 to 1.15) 2 (657) RR 1.05 (0.75 to 1.48) 
Cesarean section 3 (1,813) RR 0.77 (0.40 to 1.46) 2 (657) RR 0.65 (0.22 to 1.91) 
Low APGAR score (<7 at 5 min) 2 (1,596) RR 0.76 (0.29 to 2.03) 1 (440) RR 0.46 (0.04 to 5.00) 
Comparison: labor induction versus expectant management (11) 
Cesarean section 31 (21,030) RR 0.90 (0.85 to 0.95)a 7 (1,600) RR 0.97 (0.81 to 1.15) 
Cesarean section <40 weeks 8 (8,537) RR 0.87 (0.80 to 0.95)a 
Cesarean section 40–41 weeks 6 (1,189) RR 1.12 (0.88 to 1.43) 2 (480) RR 1.34 (0.96 to 1.87) 
Cesarean section ≥41 weeks 17 (11,304) RR 0.90 (0.83 to 0.97)a 5 (1,120) RR 0.85 (0.69 to 1.04) 
Perineal trauma 5 (11,589)b RR 1.04 (0.85 to 1.26) 
Perineal trauma <40 weeks 2 (6,714)b RR 1.18 (0.90 to 1.55) 
Perineal trauma ≥41 weeks 3 (4,875)b RR 0.89 (0.66 to 1.19) 
Stillbirth 22 (18,785) RR 0.30 (0.12 to 0.75)a 6 (1,369) RR 0.33 (0.03 to 3.18) 
Stillbirth <40 weeks 4 (7,126)b RR 0.51 (0.09 to 2.76) 
Stillbirth 40–41 weeks 3 (760) RR 0.31 (0.01 to 7.45) 1 (149) Non-estimable 
Stillbirth ≥41 weeks 15 (10,909) RR 0.24 (0.08 to 0.78)a 5 (1,120) RR 0.33 (0.03 to 3.18) 
MAS 13 (16,622) RR 0.75 (0.62 to 0.92)a 4 (1,012) RR 0.51 (0.34 to 0.76)a 
Asphyxia 4 (1,456) RR 1.66 (0.61 to 4.55) 1 (249) RR 3.02 (0.12 to 73.52) 
Perinatal mortality 22 (18,795) RR 0.31 (0.15 to 0.64)a 6 (1,369) RR 0.38 (0.09 to 1.60) 
Perinatal mortality <40 weeks 4 (7,126)b RR 0.50 (0.13 to 2.01) 
Perinatal mortality 40–41 weeks 3 (760) RR 0.31 (0.01 to 7.45) 1 (149) Non-estimable 
Perinatal mortality ≥41 weeks 15 (10,909) RR 0.26 (0.11 to 0.64)a 5 (1,120) RR 0.38 (0.09 to 1.60) 
Neonatal mortality 21 (18,611) RR 0.39 (0.13 to 1.14) 6 (1,369) RR 0.41 (0.06 to 2.73) 
Comparison: WHO childbirth checklist versus none (12) 
Preeclampsia management 7 (5,667) OR 7.05 (2.34 to 21.29)a 6 (5,428) OR 8.09 (2.55 to 25.63)a 
Maternal infection management 7 (5,667) OR 17.46 (3.62 to 84.24)a 6 (5,428) OR 25.44 (4.09 to 158.08)a 
Partograph 6 (5,316) OR 3.79 (1.71 to 8.40)a 5 (5,077) OR 3.07 (1.36 to 6.94)a 
Maternal mortality 3 (159,936) OR 1.06 (0.77 to 1.45) 
Stillbirth 5 (299,952) OR 0.92 (0.87 to 0.96)a 
Early neonatal mortality 5 (293,467) OR 1.07 (0.01 to 1.13) 
Breastfeeding started within 1 h 5 (4,050) OR 17.06 (7.63 to 38.17)a 
Postpartum counseling 4 (1,876) RR 132.51 (49.27 to 356.36)a 
Comparison: skilled birth care versus standard care 
Stillbirth 8 (185,848) RR 0.96 (0.91 to 1.02) 6 (69,136) RR 0.90 (0.82 to 0.97)a 
Intervention-control   2 (116,712)c RR 1.03 (0.95 to 1.12)c 
Stillbirth 7 (239,020) RR 0.73 (0.61 to 0.87)a 6 (181,467) RR 0.69 (0.53 to 0.90)a 
Before-after   1 (57,553)c RR 0.81 (0.58 to 1.14)c 
Perinatal mortality 8 (185,626) RR 0.90 (0.82 to 0.99)a 6 (69,407) RR 0.85 (0.79 to 0.90)a 
Intervention-control   2 (116,219)c RR 0.99 (0.93 to 1.05)c 
Perinatal mortality 4 (148,599) RR 0.81 (0.71 to 0.92)a 3 (91,492) RR 0.79 (0.64 to 0.98)a 
Before-after   1 (57,107)c RR 0.85 (0.78 to 0.92)a,c 
Neonatal mortality 7 (127,643) RR 0.82 (0.76 to 0.89)a 6 (66,290) RR 0.81 (0.74 to 0.88)a 
Intervention-control   1 (61,353)c RR 0.88 (0.73 to 1.06)b 
Neonatal mortality 5 (553,502) RR 0.80 (0.60 to 1.07) 3 (79,426) RR 0.68 (0.38 to 1.21) 
Before-after   1 (56,247)c RR 0.88 (0.53 to 1.47) 
OutcomeOverallLMICs
studies (participants), neffect estimate (95% CI)studies (participants), neffect estimate (95% CI)
Comparison: partograph use with no partograph (10) 
Instrumental vaginal birth 3 (1,813) RR 0.99 (0.84 to 1.15) 2 (657) RR 1.05 (0.75 to 1.48) 
Cesarean section 3 (1,813) RR 0.77 (0.40 to 1.46) 2 (657) RR 0.65 (0.22 to 1.91) 
Low APGAR score (<7 at 5 min) 2 (1,596) RR 0.76 (0.29 to 2.03) 1 (440) RR 0.46 (0.04 to 5.00) 
Comparison: labor induction versus expectant management (11) 
Cesarean section 31 (21,030) RR 0.90 (0.85 to 0.95)a 7 (1,600) RR 0.97 (0.81 to 1.15) 
Cesarean section <40 weeks 8 (8,537) RR 0.87 (0.80 to 0.95)a 
Cesarean section 40–41 weeks 6 (1,189) RR 1.12 (0.88 to 1.43) 2 (480) RR 1.34 (0.96 to 1.87) 
Cesarean section ≥41 weeks 17 (11,304) RR 0.90 (0.83 to 0.97)a 5 (1,120) RR 0.85 (0.69 to 1.04) 
Perineal trauma 5 (11,589)b RR 1.04 (0.85 to 1.26) 
Perineal trauma <40 weeks 2 (6,714)b RR 1.18 (0.90 to 1.55) 
Perineal trauma ≥41 weeks 3 (4,875)b RR 0.89 (0.66 to 1.19) 
Stillbirth 22 (18,785) RR 0.30 (0.12 to 0.75)a 6 (1,369) RR 0.33 (0.03 to 3.18) 
Stillbirth <40 weeks 4 (7,126)b RR 0.51 (0.09 to 2.76) 
Stillbirth 40–41 weeks 3 (760) RR 0.31 (0.01 to 7.45) 1 (149) Non-estimable 
Stillbirth ≥41 weeks 15 (10,909) RR 0.24 (0.08 to 0.78)a 5 (1,120) RR 0.33 (0.03 to 3.18) 
MAS 13 (16,622) RR 0.75 (0.62 to 0.92)a 4 (1,012) RR 0.51 (0.34 to 0.76)a 
Asphyxia 4 (1,456) RR 1.66 (0.61 to 4.55) 1 (249) RR 3.02 (0.12 to 73.52) 
Perinatal mortality 22 (18,795) RR 0.31 (0.15 to 0.64)a 6 (1,369) RR 0.38 (0.09 to 1.60) 
Perinatal mortality <40 weeks 4 (7,126)b RR 0.50 (0.13 to 2.01) 
Perinatal mortality 40–41 weeks 3 (760) RR 0.31 (0.01 to 7.45) 1 (149) Non-estimable 
Perinatal mortality ≥41 weeks 15 (10,909) RR 0.26 (0.11 to 0.64)a 5 (1,120) RR 0.38 (0.09 to 1.60) 
Neonatal mortality 21 (18,611) RR 0.39 (0.13 to 1.14) 6 (1,369) RR 0.41 (0.06 to 2.73) 
Comparison: WHO childbirth checklist versus none (12) 
Preeclampsia management 7 (5,667) OR 7.05 (2.34 to 21.29)a 6 (5,428) OR 8.09 (2.55 to 25.63)a 
Maternal infection management 7 (5,667) OR 17.46 (3.62 to 84.24)a 6 (5,428) OR 25.44 (4.09 to 158.08)a 
Partograph 6 (5,316) OR 3.79 (1.71 to 8.40)a 5 (5,077) OR 3.07 (1.36 to 6.94)a 
Maternal mortality 3 (159,936) OR 1.06 (0.77 to 1.45) 
Stillbirth 5 (299,952) OR 0.92 (0.87 to 0.96)a 
Early neonatal mortality 5 (293,467) OR 1.07 (0.01 to 1.13) 
Breastfeeding started within 1 h 5 (4,050) OR 17.06 (7.63 to 38.17)a 
Postpartum counseling 4 (1,876) RR 132.51 (49.27 to 356.36)a 
Comparison: skilled birth care versus standard care 
Stillbirth 8 (185,848) RR 0.96 (0.91 to 1.02) 6 (69,136) RR 0.90 (0.82 to 0.97)a 
Intervention-control   2 (116,712)c RR 1.03 (0.95 to 1.12)c 
Stillbirth 7 (239,020) RR 0.73 (0.61 to 0.87)a 6 (181,467) RR 0.69 (0.53 to 0.90)a 
Before-after   1 (57,553)c RR 0.81 (0.58 to 1.14)c 
Perinatal mortality 8 (185,626) RR 0.90 (0.82 to 0.99)a 6 (69,407) RR 0.85 (0.79 to 0.90)a 
Intervention-control   2 (116,219)c RR 0.99 (0.93 to 1.05)c 
Perinatal mortality 4 (148,599) RR 0.81 (0.71 to 0.92)a 3 (91,492) RR 0.79 (0.64 to 0.98)a 
Before-after   1 (57,107)c RR 0.85 (0.78 to 0.92)a,c 
Neonatal mortality 7 (127,643) RR 0.82 (0.76 to 0.89)a 6 (66,290) RR 0.81 (0.74 to 0.88)a 
Intervention-control   1 (61,353)c RR 0.88 (0.73 to 1.06)b 
Neonatal mortality 5 (553,502) RR 0.80 (0.60 to 1.07) 3 (79,426) RR 0.68 (0.38 to 1.21) 
Before-after   1 (56,247)c RR 0.88 (0.53 to 1.47) 

LMIC, low- and middle-income country; MAS, meconium aspiration syndrome.

aEffect size is significant.

bHIC data: high-income country.

cMulticountry data.

Interventions for Near-Term Care

Antibiotics for PROMs

For PPROMs, the original review [12] was updated, as the last date of the search of studies in the review was from September 2013. We initially identified 1,236 records; after assessing 141 full texts, only three trials met the inclusion criteria (online suppl. Fig. 1). However, additional trials found compared different regimens of the same antibiotics only, and therefore, the data could not be pooled for a meta-analysis for a comparison against a placebo.

Kenyon et al. [12] investigated the effect of antibiotic for PPROM and compared it against placebo. The review included sixteen trials involving over 6,300 participants. All trials were from high-income countries, and one was a multicentered trial conducted in Chile and USA, in 88 participants. For most of the studies, the overall risk of bias ranged from unclear to low.

Overall, antibiotic use when compared to placebo suggested a 34% (RR 0.66 [95% CI: 0.46 to 0.96]; 11 studies) and a 33% (RR 0.67 [95% CI: 0.52 to 0.85]; 12 studies) reduction in the risk of chorioamnionitis and neonatal infection including pneumonia, respectively, but had no effect on the risk of caesarian sections, perinatal death, NEC, or respiratory distress syndrome. Further information is given in Table 1. The evidence from a multicountry setting suggested a reduction in the risk of chorioamnionitis (RR 0.19 [95% CI 0.05 to 0.83]; 1 study) and respiratory distress syndrome (RR 0.32 [95% CI 0.11 to 0.89]; 1 study), but no effect was noted in the risk of caesarian sections, neonatal infection including pneumonia, perinatal death, or NEC.

Antenatal Corticosteroids for Fetal Lung Maturation

An existing review was used for antenatal corticosteroids for fetal lung maturation [8], comprising twenty-seven trials, of which only six were from LMICs. Fifteen trials were assessed to be at low risk of bias, two had a high risk of bias in two or more domains, and ten trials had a high risk of bias due to lack of blinding as placebo was not used in the control arm.

Overall, antenatal corticosteroid treatment significantly reduced the risks of respiratory distress syndrome (RR 0.71 [95% CI: 0.65 to 0.78]; 26 studies), perinatal death (RR 0.85 [95% CI: 0.77 to 0.93]; 14 studies), and neonatal mortality (RR 0.78 [95% CI: 0.70 to 0.87]). LMIC-specific evidence indicated a reduction in the risks of respiratory distress syndrome (RR 0.65 [95% CI: 0.44 to 0.96]; 6 studies) (online suppl. Fig. 3.2) and neonatal mortality (RR 0.64 [95% CI: 0.43 to 0.97]; 5 studies) (online suppl. Fig. 3.6). The intervention had no effect on the risks of maternal mortality, perinatal death, or fetal death. For additional information, refer to Table 1.

Interventions for Intrapartum Care

Partograph Use during Labor and Delivery

For this intervention, an existing review was used [9] which evaluated the use of partograph during labor and delivery versus no partograph and included three trials, of which two trials derived evidence from LMICs. As it was infeasible to blind staff or women to the intervention, the risk of bias varied across all studies.

Overall, the use of partograph had no statistical effect on instrumental vaginal birth (RR 0.99 [95% CI: 0.84 to 1.15]; 3 studies) or on caesarian sections (RR 0.77 [95% CI: 0.40 to 1.46]; 3 studies). Evidence from LMICs demonstrated no effect on the risks of instrumental vaginal birth (RR 1.05 [95% CI: 0.75 to 1.48]; 2 studies) or on caesarian sections (RR 0.65 [95% CI: 0.22 to 1.91]; 2 studies). Evidence for outcomes such as oxytocin augmentation, duration of first and second stages of labor, epidural analgesia, antibiotic use, and artificial rupture of membranes was restricted only to high-resource settings. Table 2 offers additional information on the effect estimates.

Induction of Labor at or Post-Term

For this intervention, an existing review was used [10] which included thirty-four trials in its meta-analysis comparing labor induction with expectant management, of which seven trials evaluated evidence from LMICs. The authors gauged the trials to have low-to-moderate risk of bias.

Overall, induction of labor reduced the risks of caesarian sections by 10% (RR 0.90 [95% CI: 0.85 to 0.95]; 31 studies), stillbirth by 70% (RR 0.30 [95% CI: 0.12 to 0.75]; 22 studies), meconium aspiration syndrome by 25% (RR 0.75 [95% CI: 0.62 to 0.92]; 13 studies), and perinatal mortality by 69% (RR 0.31 [95% CI: 0.15 to 0.64]; 22 studies). LMIC-specific evidence for this intervention demonstrated a statistically significant reduction in the risk of meconium aspiration syndrome (RR 0.51 [95% CI: 0.34 to 0.76]; 4 studies) (online suppl. Fig. 4.3). Induction of labor had no effect on cesarean sections, perineal trauma, stillbirth, asphyxia, and perinatal or neonatal mortality. Additional details can be found in Table 2.

SCC during Labor and Delivery

An existing review was used for this intervention [11] and included nine studies in their meta-analysis comparing the use of WHO childbirth checklist with no checklist, of which seven trials were from LMICs. The risk of bias due to allocation concealment was judged to be low (1 study) to high risk (8 studies) where the risk of bias for random allocation was gauged to be low (2 studies) to high (7 studies) risk, respectively. Overall, the intervention improved the management of preeclampsia (OR 7.05 [95% CI: 2.34 to 21.29]; 7 studies), maternal infection (OR 17.46 [95% CI: 3.62 to 84.24]; 7 studies), and increased the likelihood of partograph use (OR 3.79 [95% CI: 1.71 to 8.40]; 6 studies).

Evidence from LMICs suggested a higher standard of preeclampsia care (OR 8.09 [95% CI: 2.55 to 25.63]; 6 studies) (online suppl. Fig. 5.1), maternal infection management (OR 25.44 [95% CI 4.09 to 158.08]; 6 studies) (online suppl. Fig. 5.2), and the use of partograph (OR 3.07 [95% CI 1.36 to 6.94]; 5 studies) (online suppl. Fig. 5.3) on the use of WHO childbirth checklist. The intervention significantly reduced the risk of stillbirth (OR 0.92 [95% CI 0.87 to 0.96]; 5 studies) and improved the likelihood of breastfeeding started within the first hour of life (OR 17.06 [95% CI 7.63 to 38.17]). No effect was gauged on maternal mortality or on early neonatal mortality. Table 2 provides further details.

Skilled Birth Care

For skilled birth care, the review was updated [13] as the last date of search for the review was before 2011. The objective of the review was to ascertain the effect of the provision of skilled birth attendance as well as that of basic and emergency obstetric care on stillbirths. The initial search yielded 452 hits, and after screening and full-text review, only 13 met the inclusion criteria. Therefore, the total number of included studies meta-analyzed was 22, of which 13 new studies were identified in our update and nine studies were included from the original review (online suppl. Fig. 2). The study designs of the included studies were either intervention-control (12 studies) or before-after (10 studies). One study was from an upper-middle-income region, eighteen studies were from LMICs, and three studies were multicentered with participants from Argentina, India, Pakistan, Guatemala, Kenya, Democratic Republic of Congo, and Zambia.

Overall, studies evaluating skilled birth care with intervention-control study design demonstrated a significant reduction in the risk of perinatal mortality (RR 0.90 [0.82 to 0.99]; 8 studies) (online suppl. Fig. 6.2.1) and neonatal mortality (RR 0.82 [0.76–0.89]; 7 studies) (online suppl. Fig. 6.3.1). Evidence from LMICs also showed a reduction in the risk of perinatal mortality (RR 0.85 [0.79 to 0.90]; 6 studies) (online suppl. Fig. 6.2.2) and neonatal mortality (RR 0.81 [0.74 to 0.88]; 6 studies) (online suppl. Fig. 6.3.2).

Overall, skilled birth care (before-after studies) significantly reduced the risk of stillbirth by 27% (RR 0.73 [95% CI 0.61 to 0.87; 7 studies]) (online suppl. Fig. 6.1.4) and perinatal mortality by 19% (RR 0.81 [95% CI 0.71 to 0.92]; 4 studies) (online suppl. Fig. 6.2.4). Evidence from LMICs suggested a 31% reduction in the risk of stillbirth (RR 0.69 [95% CI 0.53 to 0.90]; 6 studies) (online suppl. Fig. 6.1.5) and a 21% reduction in the risk of perinatal mortality (RR 0.79 [95% CI 0.64 to 0.98]; 3 studies) (online suppl. Fig. 6.2.5). For more information, refer to Table 2. Evidence from trials from multicentered settings showed no decrease in the risk of stillbirth or perinatal mortality. Further details are given in Table 2.

A total of six reviews collectively constituting near-term and intrapartum interventions were identified. The evidence suggested that overall, antibiotic administration to women with PPROM reduced some markers of maternal and neonatal morbidity such as chorioamnionitis, positive neonatal blood culture, and neonatal infection including pneumonia, while in the multicentered trial, the intervention had a significant impact on chorioamnionitis and neonatal respiratory distress syndrome. However, evidence for preterm birth, low birthweight, and positive neonatal blood culture only hailed from high-income countries. Evidence from LMICs indicated antenatal corticosteroids prior to anticipated preterm delivery had a significant reduction in the risk of respiratory distress syndrome and neonatal mortality but had no effect on maternal, perinatal, or fetal mortality.

Only three trials compared the use of partograph with no partographs, of which two were from LMICs. The use of partograph had no effect on the rate of caesarian sections, instrumental vaginal birth nor on APGAR scores of less than 7 at 5 min, neither overall nor in LMIC setting. Overall, labor induction practices in pregnant women at or beyond 37 weeks when compared to expectant management had a significant impact on cesarean sections, stillbirth, and perinatal mortality. However, LMIC-specific evidence demonstrated no reduction in the risk of cesarean sections, stillbirth, perinatal mortality, or neonatal mortality. The discrepancy between overall and LMIC-specific estimates could be attributed to poorly equipped obstetrical units, restricted access to skilled birth attendants, and poor infrastructure in LMICs. In high- and upper-middle-income settings, factors such as facility readiness, well-trained obstetrical teams, and prompt interventions contribute toward the effectiveness of interventions such as induction of labor.

Evidence suggested HCWs using the WHO SCC had a seven times higher probability of assessing laboring moms for preeclampsia. The likelihood of HCWs managing maternal infection on use of WHO SCC was high as well. The risk of stillbirth was also reduced by 8%. Skilled birth care showed promising results in overall as well as LMIC settings.

Near-term and intrapartum care are important components of maternal care strategies and focus on ensuring the well-being of both the mother and the newborn. Monitoring the progress of labor, pain management, continuous monitoring of the fetus, availability of well-equipped health facilities, capacity to perform emergency caesarian sections if needed, and expeditious management of neonatal emergencies are among a few key aspects of near-term and intrapartum care.

WHO summarizes its guidelines and recommends the use of antenatal corticosteroids for accelerating fetal lung maturation [14]. An 18-month cluster-randomized, multicentered trial conducted in Pakistan, Guatemala, India, Argentina, Kenya, and Zambia compared with antenatal corticosteroid treatment to standard care suggested no decline in neonatal mortality. Instead, it indicated an increase in the overall population [15]. Moreover, Pettit et al. [16] associated the use of antenatal betamethasone to a significantly greater risk of developing neonatal hypoglycemia (aOR 1.60 [95% CI 1.24 to 2.07]) as well as hyperbilirubinemia (aOR 3.23 [95% CI 2.92 to 3.58]). Evidence from a systematic review [17] involving over 1.25 million children indicated that prenatal corticosteroid administration should be done with caution. Data from the review suggested that children born late-preterm or full-term were significantly more likely to experience negative neurocognitive and/or psychological effects, while children who were born extremely preterm were significantly less likely to experience neurodevelopmental impairment after receiving a single course of antenatal corticosteroids.

Partograph helps dissociate abnormal labor from a normal one, thereby minimizing complications and ensuring safer births and significantly improving the chances of optimal health outcomes for both mothers and newborns. WHO recommends the use of partograph as it enables healthcare providers to make informed decisions, recognize deviations from normal labor, and take timely action when necessary [18]. A study carried out in rural India indicated a significant reduction in the duration of labor, with no cases of labor progressing beyond 12 h [19].

The induction of labor is a valuable technique, playing a crucial role in optimizing maternal and fetal health outcomes by allowing healthcare providers to efficiently manage pregnancies with complications. However, the intervention should be approached with caution, considering the specific indications and the potential risks involved. Common indications of induction of labor include prolonged pregnancy, severe preeclampsia, intrauterine fetal growth restriction, PPROM, and sickle cell disease [20]. A cross-sectional study conducted in Pakistan showed that eighteen percent of pregnant women failed induction of labor and had to undergo caesarian section [21]. Postpartum hemorrhage, placental abruption, precipitated labor, maternal mortality, incomplete uterine ruptures, low APGAR score, and neonatal sepsis are a few of the unfavorable effects of inducing labor [22].

The WHO SCC, created to facilitate the provision of crucial maternal and perinatal care practices and to prevent adverse health outcomes for both the mother and the baby, comprises standard birth protocols that should be provided to all mothers and their infants. Essential childbirth practices include the use of partograph, preeclampsia management, maternal infection management upon admission, active management, the third stage of labor, assessment of maternal postpartum bleeding, starting breastfeeding within 1 h, assessment of newborn feeding upon discharge, counseling of newborn feeding practices as well as counseling on family planning [11]. In low-resource settings, where the burden of maternal and neonatal mortality and morbidity is the highest, a childbirth checklist is essential for improving the quality of care and improving maternal and neonatal outcomes. It provides the healthcare professionals with a methodical approach, boosts adherence to protocols, and ensures that despite scarce resources, mothers and their newborns receive the best possible care. In a cluster-randomized trial conducted in facilities across India, because of WHO SCC program, birth attendants held a greater adherence to essential birth practices but there was no impact on the risk of maternal and perinatal mortality nor on maternal morbidity in the group that utilized the WHO SCC [23].

Skilled birth attendance refers to the presence and assistance of trained healthcare professionals during childbirth to ensure safe and healthy delivery for both the mother and the baby. Ensuring access to skilled birth attendance is a critical component of SDG 3 [24], especially in regions where access to health care is limited.

The provision of quality and timely care during late pregnancy and labor are essential elements in ensuring the well-being of both the mother and the newborn. Improving the standard of care during childbirth and the early postnatal period is key to achieving the 2030 objectives for eliminating preventable maternal and neonatal deaths and hinges on strengthening factors such as governance and leadership, health financing, health workforce, adequate medical equipment and technologies, health service delivery, health information system as well as community ownership and participation [25].

Closing research gap in LMICs is imperative and calls for immediate action to achieve global health equity. Given the disparities in how differently the interventions discussed in this paper impact wealthier and poorer countries, applying guidelines developed in high- and upper-middle-income countries directly to LMICs may not be entirely appropriate, thereby underscoring the need for more inclusive evidence-based care strategies implemented at near-term and during the intrapartum period, that can effectively be applied in low-resource settings.

The dearth of research pertaining to essential interventions delivered near-term or during labor, such as antibiotics for PPROM, antenatal corticosteroids for fetal lung maturation, the use of partograph, and induction of labor in LMICs, is concerning and calls for more stringent data collection in these regions. Addressing health disparities between high- and upper-middle-income countries and LMICs and providing adequate support to at-risk populations are gravitational in preventing adverse maternal and neonatal outcomes. Therefore, it is imperative to amplify efforts in underdeveloped regions to improve the healthcare infrastructure, and educate pregnant women about the importance of identifying the warning signs of maternal and fetal distress during the gestational period, especially at a time as critical as the intrapartum period and childbirth.

We thank the Aga Khan University for providing internal resources.

Ethical approval and consent were not required as this study was based on publicly available data.

The authors have no conflicts of interest to declare.

This study is supported by the Bill and Melinda Gates Foundation Grant (#INV-042789). The funders played no role in the design, data collection, data analysis, and reporting of this study.

R.Y., M.A., H.A.N., and A.A.A. conducted the literature review, extracted data from the reviews/studies, entered data into RevMan, carried out the analysis, and interpreted the results. R.Y. drafted the paper. J.K.D. and Z.A.B. provided supervision for each step and conceptualization, and contributed to the critical revision of the manuscript.

Data used in our paper are publicly available as it was sourced from published reviews. Further inquiries can be directed to the corresponding author.

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