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The impact of implementing the 2016 WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience on perinatal deaths: an interrupted time-series analysis in Mpumalanga province, South Africa
  1. Tina Lavin1,
  2. Robert Clive Pattinson2,
  3. Erin Kelty3,
  4. Yogan Pillay4,
  5. David Brian Preen5
  1. 1School of Population and Global Health, The University of Western Australia Faculty of Medicine, Dentistry and Health Sciences, Perth, Western Australia, Australia
  2. 2MRC Maternal and Infant Health Care Strategies Unit, University of Pretoria, Pretoria, South Africa, Obstetrics and Gynaecology, University of Pretoria, Pretoria, South Africa
  3. 3School of Population and Global Health, The University of Western Australia Faculty of Health and Medical Sciences, Perth, Western Australia, Australia
  4. 4National Department of Health, Pretoria, South Africa
  5. 5School of Population Health, The University of Western Australia, Perth, Western Australia, Australia
  1. Correspondence to Dr Tina Lavin; tina.lavin{at}


Objectives To investigate if the implementation of the 2016 WHO Recommendations for a Positive Pregnancy Experience reduced perinatal mortality in a South African province. The recommendations were implemented which included increasing the number of contacts and also the content of the contacts.

Methods Retrospective interrupted time-series analysis was conducted for all women accessing a minimum of one antenatal care contact from April 2014 to September 2019 in Mpumalanga province, South Africa. Retrospective interrupted time-series analysis of province level perinatal mortality and birth data comparing the pre-implementation period (April 2014–March 2017) and post-implementation period (April 2018–September 2019). The main outcome measure was unadjusted prevalence ratio (PR) for perinatal deaths before and after implementation; interrupted time-series analyses for trends in perinatal mortality before and after implementation; stillbirth risk by gestational age; primary cause of deaths (and maternal condition) before and after implementation.

Results Overall, there was a 5.8% absolute decrease in stillbirths after implementation of the recommendations, however this was not statistically significant (PR 0.95, 95% CI 0.90% to 1.05%; p=0.073). Fresh stillbirths decreased by 16.6% (PR 0.86, 95% CI 0.77% to 0.95%; p=0.003) while macerated stillbirths (p=0.899) and early neonatal deaths remained unchanged (p=0.499). When stratified by weight fresh stillbirths >2500 g decreased by 17.2% (PR 0.81, 95% CI 0.70% to 0.94%; p=0.007) and early neonatal deaths decreased by 12.8% (PR 0.88, 95% CI 0.77% to 0.99%; p=0.041). The interrupted time-series analysis confirmed a trend for decreasing stillbirths at 0.09/1000 births per month (−0.09, 95% CI −1.18 to 0.01; p=0.059), early neonatal deaths (−0.09, 95% CI −0.14 to 0.04; p=<0.001) and perinatal mortality (−1.18, 95% CI −0.27 to −0.09; p<0.001) in the post-implementation period. A decrease in stillbirths, early neonatal deaths or perinatal mortality was not observed in the pre-implementation period. During the period when additional antenatal care contacts were implemented (34–38 weeks), there was a decrease in stillbirths of 18.4% (risk ratio (RR) 0.82, 95% CI 0.73% to 0.91%, p=0.0003). In hypertensive disorders of pregnancy, the risk of stillbirth decreased in the post-period by 15.1% (RR 0.85; 95% CI 0.76% to 0.94%; p=0.002).

Conclusion The implementation of the 2016 WHO Recommendations for a Positive Pregnancy Experience may be an effective public health strategy to reduce stillbirths in South African provinces.

  • obstetrics
  • maternal health
  • epidemiology
  • health policy

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  • Handling editor Seye Abimbola

  • Twitter @tina_lavin, @ygpillay

  • Contributors TL conceptualised idea, conducted data analyses, drafted, reviewed and edited the manuscript. RCP co-conceptualised the idea, provided clinical expertise/input, reviewed and edited the manuscript. EK conducted data analyses and reviewed the manuscript. YP led the implementation recommendations, provided contextual/clinical input to the manuscript and reviewed the manuscript. DBP oversaw data analyses, reviewed and edited the manuscript.

  • Funding TL is supported by an Australian National Health and Medical Research Council Early Career Research Fellowship.

  • Competing interests All authors have completed the ICMJE uniform disclosure form at and declare: RCP is a member of the WHO technical committee that developed the WHO Recommendations for a Positive Pregnancy Experience.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval As de-identified, province-level data were used, an exemption from ethics review was granted by the University of Western Australia (RA/4/1/7955).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon request. Data were obtained from the Perinatal Problem Identification Program (PPIP). PPIP is a database of perinatal births and deaths that can be accessed through a registration process and consent of the sites involved.