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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\u2009h neonatal mortality (adjusted odds ratio 0.78, 95% confidence interval 0.65\u20130.94), but not with the co-primary outcome, fresh stillbirth (adjusted odds ratio 0.88, 95% confidence interval 0.68\u20131.13). 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:\n                    <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" xlink:href=\"http:\/\/clinicaltrials.gov\/ct2\/show\/202006793783148\" ext-link-type=\"uri\">202006793783148<\/jats:ext-link>\n                    .\n                  <\/jats:p>","DOI":"10.1038\/s41591-026-04599-w","type":"journal-article","created":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T09:03:00Z","timestamp":1787734980000},"page":"3832-3841","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["A multi-faceted hospital-based intervention for intrapartum care in sub-Saharan Africa: a stepped-wedge cluster-randomized 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Maternal mortality, stillbirths, and neonatal mortality: a transition model based on analyses of 151 countries. Lancet Glob. Health 11, e1024\u2013e1031 (2023).","journal-title":"Lancet Glob. Health"},{"key":"4599_CR4","doi-asserted-by":"crossref","first-page":"e1275","DOI":"10.1016\/S2214-109X(17)30374-1","volume":"5","author":"A Kakooza-Mwesige","year":"2017","unstructured":"Kakooza-Mwesige, A. et al. Prevalence of cerebral palsy in Uganda: a population-based study. Lancet Glob. Health 5, e1275\u2013e1282 (2017).","journal-title":"Lancet Glob. Health"},{"key":"4599_CR5","doi-asserted-by":"publisher","first-page":"50","DOI":"10.1038\/pr.2013.206","volume":"74","author":"ACC Lee","year":"2013","unstructured":"Lee, A. C. C. et al. Intrapartum-related neonatal encephalopathy incidence and impairment at regional and global levels for 2010 with trends from 1990. Pediatr. Res. 74, 50\u201372 (2013).","journal-title":"Pediatr. 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