The United Nation’s fourth and fifth Millennium Development Goals set targets for reducing child and maternal mortality by 2015.1 Child survival has shown some improvement globally, but progress has been slow for maternal, perinatal and neonatal health.2,3 Better monitoring and management of labour, delivery and the immediate postpartum period are thought to be critical to reducing rates of maternal mortality and perinatal mortality (i.e. a stillbirth or early neonatal death).2–6 Ensuring that labour and the first 24 hours postpartum are managed by a skilled care provider is one of the keys to achieving this aim.4,5
There have been few rigorous studies of the effects on maternal or perinatal mortality of various levels and configurations of skilled care or of the size of the effect on maternal or perinatal mortality that could be achieved by such care.4,7–9 Ecological studies have shown that populations with a greater per cent of births attended by a skilled professional also have higher maternal and perinatal mortality,9–12 but causal inferences cannot be robustly drawn.13 Few studies have assessed whether the use of a skilled provider reduces the risk of maternal or perinatal death for individual women and their offspring.13,14
This paper examines whether skilled attendance around the time of birth is associated with the risk of maternal and perinatal death for individual women and neonates. The Matlab study area in rural Bangladesh offers a unique opportunity to examine this relationship because the uptake of skilled care at birth improved dramatically over the study period and prospective surveillance through the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) ensures high-quality data on maternal and perinatal mortality.15–17 By separating basic from comprehensive obstetric care and by examining the outcomes for both mother and neonate, we provide insights into the nature of the relationship between skilled birth attendance and health outcomes around the time of birth.