Article

Effect of training traditional birth attendants on neonatal mortality (Lufwanyama Neonatal Survival Project): randomised controlled study

Center for Global Health and Development, Boston University, Boston, MA, USA.
BMJ (online) (Impact Factor: 16.38). 02/2011; 342:d346. DOI: 10.1136/bmj.d346
Source: PubMed

ABSTRACT To determine whether training traditional birth attendants to manage several common perinatal conditions could reduce neonatal mortality in the setting of a resource poor country with limited access to healthcare.
Prospective, cluster randomised and controlled effectiveness study.
Lufwanyama, an agrarian, poorly developed district located in the Copperbelt province, Zambia. All births carried out by study birth attendants occurred at mothers' homes, in rural village settings.
127 traditional birth attendants and mothers and their newborns (3559 infants delivered regardless of vital status) from Lufwanyama district.
Using an unblinded design, birth attendants were cluster randomised to intervention or control groups. The intervention had two components: training in a modified version of the neonatal resuscitation protocol, and single dose amoxicillin coupled with facilitated referral of infants to a health centre. Control birth attendants continued their existing standard of care (basic obstetric skills and use of clean delivery kits).
The primary outcome was the proportion of liveborn infants who died by day 28 after birth, with rate ratios statistically adjusted for clustering. Secondary outcomes were mortality at different time points; and comparison of causes of death based on verbal autopsy data.
Among 3497 deliveries with reliable information, mortality at day 28 after birth was 45% lower among liveborn infants delivered by intervention birth attendants than control birth attendants (rate ratio 0.55, 95% confidence interval 0.33 to 0.90). The greatest reductions in mortality were in the first 24 hours after birth: 7.8 deaths per 1000 live births for infants delivered by intervention birth attendants compared with 19.9 per 1000 for infants delivered by control birth attendants (0.40, 0.19 to 0.83). Deaths due to birth asphyxia were reduced by 63% among infants delivered by intervention birth attendants (0.37, 0.17 to 0.81) and by 81% within the first two days after birth (0.19, 0.07 to 0.52). Stillbirths and deaths from serious infection occurred at similar rates in both groups.
Training traditional birth attendants to manage common perinatal conditions significantly reduced neonatal mortality in a rural African setting. This approach has high potential to be applied to similar settings with dispersed rural populations. Trial registration Clinicaltrials.gov NCT00518856.

Download full-text

Full-text

Available from: Davidson H Hamer, Jun 26, 2015
1 Follower
 · 
217 Views
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To review evidence from sub-Saharan Africa for the association between the practice or promotion of essential newborn care behaviours and neonatal survival. We searched MEDLINE for English language, peer-reviewed literature published since 2005. The study population was neonates residing in a sub-Saharan Africa country who were not HIV positive. Outcomes were all-cause neonatal or early neonatal mortality or one of the three main causes of neonatal mortality: complications of preterm birth, infections and intrapartum-related neonatal events. Interventions included were the practice or promotion of recommended newborn care behaviours including warmth, hygiene, breastfeeding, resuscitation and management of illness. We included study designs with a concurrent comparison group. Study quality was assessed using the Cochrane EPOC or Newcastle-Ottawa tools and summarised using GRADE. Eleven papers met the search criteria and most were at low risk of bias. We found evidence that delivering on a clean surface, newborn resuscitation, early initiation and exclusive breastfeeding, Kangaroo Mother Care (KMC) for low-birthweight babies, and distribution of clean delivery kits were associated with reduced risks of neonatal mortality or the main causes of neonatal mortality. There was evidence that training community birth attendants in resuscitation and administering antibiotics, and establishing women's groups can improve neonatal survival. There is a remarkable lack of robust evidence from sub-Saharan Africa on the association between practice or promotion of newborn care behaviours and newborn survival.
    Tropical Medicine & International Health 09/2013; 18(11). DOI:10.1111/tmi.12193 · 2.30 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To provide relevant details on how interventions in the Lufwanyama Neonatal Survival Project (LUNESP) were developed and how Zambian traditional birth attendants (TBAs) were trained to perform them. The study tested 2 interventions: a simplified version of the American Academy of Pediatrics' neonatal resuscitation protocol (NRP); and antibiotics with facilitated referral (AFR). Key elements that enabled the positive study result were: focusing on common and correctible causes of mortality; selecting a study population with high unmet public health need; early community mobilization to build awareness and support; emphasizing simplicity in the intervention technology and algorithms; using a traditional training approach appropriate to students with low literacy rates; requiring TBAs to demonstrate their competence before completing each workshop; and minimizing attrition of skills by retraining and reassessing the TBAs regularly throughout the study. An effective NRP training model was created that is suitable for community-based neonatal interventions, in research or programmatic settings, and by practitioners with limited obstetric skills and low rates of literacy. Clinicaltrials.gov NCT00518856.
    International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 04/2012; 118(1):77-82. DOI:10.1016/j.ijgo.2012.02.012 · 1.56 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Since the 1990s, the TBA training strategy in developing countries has been increasingly seen as ineffective and hence its funding was subsequently reallocated to providing skilled attendants during delivery. The ineffectiveness of training programmes is blamed on TBAs lower literacy, their inability to adapt knowledge from training and certain practices that may cause maternal and infant health problems. However most training impact assessments evaluate post-training TBA practices and do not assess the training strategy. There are serious deficiencies noted in information on TBA training strategy in developing countries. The design and content of the training is vital to the effectiveness of TBA training programmes. We draw on Jordan's concept of 'authoritative knowledge' to assess the extent to which there is a synthesis of both biomedical and locally practiced knowledge in the content and community involvement in the design of TBA a training programme in India. FINDINGS: The implementation of the TBA training programme at the local level overlooks the significance of and need for a baseline study and needs assessment at the local community level from which to build a training programme that is apposite to the local mother's needs and that fits within their 'comfort zone' during an act that, for most, requires a forum in which issues of modesty can be addressed. There was also little scope for the training to be a two way process of learning between the health professionals and the TBAs with hands-on experience and knowledge. The evidence from this study shows that there is an overall 'authority' of biomedical over traditional knowledge in the planning and implementation process of the TBA training programme. Certain vital information was not covered in the training content including advice to delay bathing babies for at least six hours after birth, to refrain from applying oil on the infant, and to wash hands again before directly handling mother or infant. Information on complication management and hypothermia was not adequately covered in the local TBA training programme. KEY CONCLUSIONS: The suggested improvements include the need to include a baseline study, appropriate selection criteria, improve information in the training manual to increase clarity of meaning, and to encourage beneficial traditional practices through training.
    Midwifery 02/2012; 28(1):120-30. DOI:10.1016/j.midw.2011.04.006 · 1.71 Impact Factor