Around three million babies are stillborn or die shortly after birth each year globally. To address this persistent burden, the facility‑based, multi‑faceted Action Leveraging Evidence to reduce perinatal Mortality and Morbidity (ALERT) intervention was developed to promote essential intrapartum childbirth practices. ALERT combined co‑design, training, quality improvement and leadership mentoring. The intervention was evaluated in a stepped‑wedge cluster‑randomized trial conducted in 16 hospitals across Benin, Malawi, Tanzania and Uganda. Among 134,630 women (including 139,300 neonates), ALERT was associated with lower odds of the composite co‑primary outcome, early perinatal mortality (fresh stillbirth plus 24‑hour neonatal mortality; adjusted odds ratio 0.78, 95% CI 0.65–0.94), but not with the co‑primary outcome of fresh stillbirth alone (adjusted odds ratio 0.88, 95% CI 0.68–1.13). The trial is registered in the Pan African Clinical Trial Registry (202006793783148).
High maternal and perinatal mortality and morbidity rates persist in sub‑Saharan Africa (SSA). Nearly half of the global stillbirths and neonatal deaths occur in SSA, with stillbirth and neonatal mortality rates reported above 20 per 1,000 births in the region. Poorly managed labour and childbirth care contributes substantially to morbidity, including conditions such as cerebral palsy and neonatal encephalopathy associated with intrapartum oxygen deprivation.
Following increases in facility births over recent decades, attention has shifted from increasing access to improving the quality of intrapartum care. The World Health Organization published a framework for quality pregnancy and childbirth care (2015) and intrapartum care recommendations (2018). Despite this guidance, few training programs have operationalized the WHO 2018 intrapartum care guideline comprehensively; previous efforts often tested single tools or focused on specific components such as neonatal resuscitation.
The ALERT intervention was assessed using a stepped‑wedge cluster‑randomized trial spanning five 6‑month periods. Sixteen hospitals across four SSA countries—Benin, Malawi, Tanzania and Uganda—participated. The trial enrolled 134,630 women delivering in these hospitals, accounting for 139,300 neonates. The authors emphasize the multi‑country, multi‑hospital design as supportive of applicability across diverse settings, while also acknowledging sample size limitations in terms of number of clusters.
ALERT was a facility‑based, multi‑component package aiming to strengthen routine intrapartum practice and readiness to manage complications. The intervention combined four interrelated elements:
These elements were intended to work together to improve provider capacity across multi‑professional maternity teams and to operationalize evidence‑based intrapartum care recommendations.
The trial included 16 hospitals from Benin, Malawi, Tanzania and Uganda. Across the trial periods the study population comprised 134,630 women and 139,300 neonates. The settings represented a range of hospitals within four SSA countries, which the authors cite as enhancing the relevance of findings to diverse contexts despite the modest number of clusters.
The trial had co‑primary outcomes. The composite co‑primary outcome, early perinatal mortality, combined fresh stillbirth and 24‑hour neonatal mortality. ALERT was associated with a reduction in this composite outcome: adjusted odds ratio (aOR) 0.78, 95% confidence interval (CI) 0.65–0.94, indicating a 22% lower odds compared with the control periods.
When assessed separately, the co‑primary outcome of fresh stillbirth alone did not show a statistically significant reduction: aOR 0.88, 95% CI 0.68–1.13.
The trial results indicate that implementation of a multi‑faceted, context‑specific intervention in hospital maternity settings can reduce early perinatal mortality. The authors highlight that improving routine intrapartum care requires more than single‑component training or tools; coordinated strategies that include co‑design, training, quality improvement and leadership mentoring may produce measurable gains.
A key limitation noted by the authors is the inclusion of only 16 hospitals, which constrains the number of clusters and may affect precision and external validity. Nevertheless, the diversity of settings across four countries is presented as supportive evidence that such multi‑component interventions can be effective in varied SSA hospital contexts.
The trial was registered in the Pan African Clinical Trial Registry under number 202006793783148. Full trial methods, additional analyses and contextual details are reported in the main article.