A multi-faceted hospital-based intervention for intrapartum care in sub-Saharan Africa: a stepped-wedge cluster-randomized trial
Around three million babies are stillborn or die shortly after birth each year worldwide, underscoring a persistent and unacceptable burden on families and health systems. To help address this challenge, we developed the facility-based, multi-faceted Action Leveraging Evidence to reduce perinatal Mortality and Morbidity (ALERT) intervention. ALERT promoted essential practices of intrapartum childbirth using (i) co-design, (ii) training, (iii) quality improvement and (iv) leadership mentoring. We evaluated ALERT using a stepped-wedge cluster-randomized trial with five 6-month periods across 16 hospitals in Benin, Malawi, Tanzania and Uganda. Among 134,630 women (including 139,300 neonates), the intervention was associated with 22% lower odds of the composite co-primary outcome, early perinatal mortality, defined as fresh stillbirth and 24 h neonatal mortality (adjusted odds ratio 0.78, 95% confidence interval 0.65-0.94), but not with the co-primary outcome, fresh stillbirth (adjusted odds ratio 0.88, 95% confidence interval 0.68-1.13). Despite the limitation of only including 16 hospitals, the diversity of settings across four sub-Saharan African countries supports the finding that early perinatal mortality and morbidity could be reduced through implementation of multi-faceted, context-specific strategies to build maternity provider capacities. Pan African Clinical Trial Registry: 202006793783148 .
Authors
- Rian Snijders (ORCID: https://orcid.org/0000-0002-2432-9818)
- Philip Wanduru
- Jean‐Paul Dossou (ORCID: https://orcid.org/0000-0003-1681-2604)
- Josephine Babirye
- Christelle Boyi Metogni
- Manuela Straneo (ORCID: https://orcid.org/0000-0002-2464-1633)
- Andrea B. Pembe (ORCID: https://orcid.org/0000-0002-8090-3298)
- Antoinette Sognonvi
- Thérèse Delvaux (ORCID: https://orcid.org/0000-0001-6299-2648)
- Jil Molenaar (ORCID: https://orcid.org/0000-0002-4154-6478)
- Claudia Hanson (ORCID: https://orcid.org/0000-0001-8066-7873)
- Bianca Kandeya (ORCID: https://orcid.org/0000-0002-8829-4618)
- Gertrude Namazzi (ORCID: https://orcid.org/0000-0003-1239-8311)
- Fadhlun M. Alwy Al‐beity (ORCID: https://orcid.org/0000-0003-2416-6876)
- Gisèle Houngbo
- Anastasia Månsson (ORCID: https://orcid.org/0000-0003-0612-1631)
- Regine Unkels (ORCID: https://orcid.org/0000-0001-6348-1620)
- Helle Mølsted Alvesson (ORCID: https://orcid.org/0000-0001-6109-7203)
- Yesaya Z. Nyirenda
- Virginia Castellano Pleguezuelo (ORCID: https://orcid.org/0000-0003-0866-2319)
- Veronika Tirado (ORCID: https://orcid.org/0000-0002-2006-6539)
- Lenka Beňová (ORCID: https://orcid.org/0000-0001-8595-365X)
- Nicola Orsini (ORCID: https://orcid.org/0000-0002-2210-5634)
- Maria Del Rosario Alsina
- Ann-Beth Nygaard Moller
- Soha El Halabi
- Hussein Kidanto
- Sunjuri Sun
- Andrea B. Pembe
- Tumbwene Mwansisya
- Dickson Mkoka
- Effie Chipeta
- Joanne Welsh
- Gorrette Nalwadda
- Muzdalifat Abeid
- William Stones
- Lilian T. Mselle
- Joseph Akuze
- Christian Agossou
- Peter Waiswa
- Beatrice Mwilike
- Zamoyoni Julius
- Samuel Meja
- Armelle Vigan
- Kristi Sidney Annerstedt
- Mechthild M. Gross
- Elizabeth O. Ayebare
- Gottfried Agballa
- Bruno Marchal
- Sibylle Herzig van Wees
- Hussein Kidanto
Institutions
- University of London (GB)
- Muhimbili University of Health and Allied Sciences (TZ)
- Kamuzu Central Hospital (MW)
- Karolinska Institutet (SE)
- Medizinische Hochschule Hannover (DE)
- London School of Hygiene & Tropical Medicine (GB)
- Aga Khan University (TZ)
- Makerere University (UG)
- Instituut voor Tropische Geneeskunde (BE)
Publication Details
- Journal
- Nature Medicine
- Published
- 2026-08-26
- DOI
- https://doi.org/10.1038/s41591-026-04599-w
- Primary Topic
- Global Maternal and Child Health
- Type
- article
- Field-Weighted Citation Impact
- 0.00
Funders
- Vetenskapsrådet
- Horizon 2020 Framework Programme