Can Better Everyday Care During Labour Help More Babies Survive Birth?

What the ALERT study by Hanson and colleagues (Nature Medicine, 2026) learned from training and supporting maternity teams in 16 hospitals in Benin, Malawi, Tanzania and Uganda

A large study in 16 hospitals in Benin, Malawi, Tanzania and Uganda tested whether training midwives, helping staff solve problems together and supporting ward leaders could make birth safer for babies. Once the programme was in place, the odds of a baby being stillborn during labour or dying within 24 hours of birth were 22% lower after accounting for other changes over time, although stillbirths on their own did not clearly fall.

Why the hours around birth matter so much

For most families, labour ends with a healthy baby. But labour and the first day of life are a time of particular risk, and in parts of the world with fewer health resources that risk is much greater. Many of the problems that arise, such as a baby running short of oxygen during a long labour, can be spotted and acted on with simple, well-known steps: listening to the baby's heartbeat regularly, noticing early when labour is not going well, and helping a baby who does not breathe straight away. This article explains a large study that asked whether doing those everyday things better could save babies' lives.

How families and health workers faced this problem before

Researchers have long known that sub-Saharan Africa, the part of Africa south of the Sahara Desert, still has high rates of deaths among mothers and babies around birth [1][2]. Worldwide, deaths of mothers, stillbirths (babies who die before birth) and deaths of newborns add up to almost 5 million each year, and they share many of the same causes [2]. Lack of oxygen during labour can also injure a baby's brain: in 2010 an estimated 1.15 million babies developed this kind of brain injury, nearly all of them in lower-income countries [3].

For many years, the main goal was simply to get more women to give birth in a health facility rather than at home, and today more than 60% of women in sub-Saharan Africa do so [1]. Arriving at a hospital, however, does not guarantee good care. A worldwide analysis estimated that in 2016 about 5 million deaths in lower-income countries happened because people received poor-quality care, even though they had reached the health system [4]. Experts also pointed out that maternity care can go wrong in two opposite ways, offering "too little, too late" for some women and "too much, too soon" for others [5]. In 2018 the World Health Organization (WHO) published a single set of recommendations describing the essential care every woman should receive during labour [6].

Earlier projects tried to improve care in narrower ways. Some focused on emergencies or on particular groups of babies. For example, a programme in 20 health facilities in Kenya and Uganda helped babies born too early or too small [7], and another in 12 hospitals in Nepal, which focused on helping newborns start breathing, was followed by fewer deaths linked to labour [8]. A checklist programme in India helped birth attendants follow good practices more often but did not reduce deaths [9]. What had not yet been tested was a training programme built around the WHO's 2018 recommendations for everyday labour care [1].

How the ALERT study was set up

The study is called ALERT, short for Action Leveraging Evidence to reduce perinatal Mortality and Morbidity. "Perinatal" means the time around birth, "mortality" means deaths and "morbidity" means illness. It took place in 16 busy hospitals, four in each of Benin, Malawi, Tanzania and Uganda; in each country, three were government hospitals and one was run by a faith-based organisation [1]. The study was registered publicly in June 2020, before it began [1], and its detailed plan was published in 2021 [10], which helps keep researchers honest about what they set out to measure.

Instead of choosing which hospitals got the programme, the researchers used a fair draw to decide the order in which hospitals would start it. Every hospital began with its usual care, and then, every six months, more hospitals switched over until all 16 had the programme. This is called a "stepped-wedge" design, because the switch-overs form a staircase pattern [11]. It allowed each hospital to be compared with itself before and after starting. Between July 2021 and December 2023 the study included 134,630 women who gave birth to 139,300 babies, and about 4,000 mothers were interviewed before going home about how they had been treated [1].

What the programme involved

The ALERT programme had four parts. First, mothers, families and midwives worked together to decide what most needed to change, a process called co-design. Second, midwives and other maternity staff took part in three days of practical training in their own hospital, practising on simple, low-cost birth models. The training covered checking women carefully on arrival, monitoring labour, being ready for emergencies, treating women with respect, birth positions, and teamwork. Third, staff used a step-by-step method of testing small improvements and checking the results, guided by information collected on every birth. Fourth, the leaders of the maternity wards received mentoring, both in person and by phone [1]. These topics were chosen partly because an earlier assessment in the same hospitals had found gaps in how often staff checked babies' heartbeats during labour and how they assessed women on arrival [12]. In total, 484 staff were trained [1].

What the researchers found

The main result concerned babies who were stillborn during labour or who died within 24 hours of birth. After taking into account changes that happened over time anyway, the odds of this happening were 22% lower once a hospital had started the programme. Stillbirths during labour, looked at on their own, did not fall by a clear amount [1].

It helps to see the raw numbers. In both the "before" and "after" periods, about 3 in every 100 babies were stillborn during labour or died in their first day. The 22% figure comes from a more careful comparison that looked at each hospital against itself while accounting for changes over time that could affect all hospitals, whether or not they had started the programme. That is why the overall numbers look similar even though the adjusted comparison shows a benefit [1].

There were other encouraging signs. Using the same careful comparison, the odds of a baby having a low Apgar score were 19% lower. The Apgar score is a quick check of how well a newborn is doing just after birth; here it was measured five minutes after birth, and a score below 7 suggests the baby had a difficult start. More women also had their baby's heartbeat checked when they arrived in labour, rising from about 89 to 95 in every 100 women. Caesarean births became a little more common, rising from about 27 to 29 in every 100 babies, mostly in Tanzania. The researchers believe this reflects better care rather than unnecessary operations, although the reasons for each operation were not recorded. Mothers' views of how respectfully they were treated did not change [1].

What this means for families

If you are expecting a baby, or have recently had one, the main message is reassuring: simple, everyday care during labour matters, and hospitals can improve it with training, teamwork and support for their leaders, without expensive new machines [1]. A similar programme in 30 facilities in Tanzania also found fewer babies dying around birth [13].

It is fine to ask your care team how often they will listen to your baby's heartbeat, who will help your baby if they need support to breathe, and whether a companion can stay with you. Being treated with dignity is part of good care, too; a study that watched births in Ghana, Guinea and Nigeria found that about 4 in every 10 women experienced mistreatment, such as physical or verbal abuse [14], and the ALERT programme did not yet change how mothers rated their treatment.

Some honest limits

The results differed a great deal from hospital to hospital, and only 16 hospitals took part. In 13 of the 16 hospitals the estimate pointed towards fewer early deaths, but in the others it did not. Staff and mothers knew when the programme had started, and the information came from routine hospital records, which are not always complete. Babies were followed only for their first 24 hours, so we do not know how they did later. The low Apgar score is a useful warning sign but is not the same as lasting brain injury, and some of the study's extra checks gave less clear results than the main analysis. The researchers also estimated that the programme cost between about US$760 and US$3,188 for each death around birth that it prevented, depending on the country [1].

What researchers are working on next

Researchers want to know which parts of the programme matter most, whether the improvements last once outside mentors leave, how babies do after their first day, and how to measure respectful care more sensitively. The trial's experience with staff moving between wards also raises the question of how to keep training going [1].

In summary

The ALERT study showed that improving ordinary, everyday care during labour, by training staff, working with families, using information to solve problems and supporting ward leaders, was linked to fewer babies dying during labour or in their first day of life across 16 hospitals in four African countries. It did not clearly reduce stillbirths on their own, and results varied between hospitals. Still, it offers hope that better everyday care, delivered by well-supported midwives, can help more babies have a safe start.

References

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