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: 17.45). 02/2011; 342(feb03 2):d346. DOI: 10.1136/bmj.d346
Source: PubMed


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.

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Available from: Davidson H Hamer
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    • "Therefore, the newborn is often just dried after birth and wrapped if something to wrap is available, and then put next to the mother or into a corner of the room without receiving attention until the mother is cared for. In a previous prospective, cluster-randomized, controlled effectiveness trial, we showed that a combination of interventions including immediate simple thermal care, i.e. drying and wrapping the baby, together with neonatal resuscitation could be done by trained TBAs and reduced neonatal mortality almost by half (45%) [30]. Educational messages to promote thermal care in rural areas such as Lufwanyama need to reinforce the importance of immediate thermal care after birth and need to address various potential delays. "
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    ABSTRACT: Neonatal hypothermia is increasingly recognized as a risk factor for newborn survival. The World Health Organization recommends maintaining a warm chain and skin-to-skin care for thermoprotection of newborn children. Since little is known about practices related to newborn hypothermia in rural Africa, this study's goal was to characterize relevant practices, attitudes, and beliefs in rural Zambia. We conducted 14 focus group discussions with mothers and grandmothers and 31 in-depth interviews with community leaders and health officers in Lufwanyama District, a rural area in the Copperbelt Province, Zambia, enrolling a total of 171 participants. We analyzed data using domain analysis. In rural Lufwanyama, community members were aware of the danger of neonatal hypothermia. Caregivers' and health workers' knowledge of thermoprotective practices included birthplace warming, drying and wrapping of the newborn, delayed bathing, and immediate and exclusive breastfeeding. However, this warm chain was not consistently maintained in the first hours postpartum, when newborns are at greatest risk. Skin-to-skin care was not practiced in the study area. Having to assume household and agricultural labor responsibilities in the immediate postnatal period was a challenge for mothers to provide continuous thermal care to their newborns. Understanding and addressing community-based practices on hypothermia prevention and management might help improve newborn survival in resource-limited settings. Possible interventions include the implementation of skin-to-skin care in rural areas and the use of appropriate, low-cost newborn warmers to prevent hypothermia and support families in their provision of newborn thermal protection. Training family members to support mothers in the provision of thermoprotection for their newborns could facilitate these practices.
    Full-text · Article · Apr 2014 · PLoS ONE
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    • "Qualitative studies have identified a number of reasons for this ongoing use of TBAs, including poor access to health facilities, infrastructure and clinical staff; deeply rooted sociocultural practices [14]; the cost hospital care for women [15]; and the poor quality of interpersonal care in locations where healthcare is accessible [16,17]. Many women, as Gill et al. [18] reason, will continue to give birth without the supervision of a skilled birth attendant for the foreseeable future. The disjuncture between healthcare recommendations and the reality of implementing local skilled birth attendant coverage is therefore likely to persist. "
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    ABSTRACT: Health workforce shortages are key obstacles to the achievement of the health-related Millennium Development Goals. Task shifting is seen as a way to improve access to pregnancy and childbirth care. However, the role of traditional birth attendants (TBAs) within task shifting initiatives remains contested. The objective of this study was to explore stakeholder views and justifications regarding the incorporation of TBAs into formal health systems. Data were drawn from messages submitted to the HIFA2015 and CHILD2015 email discussion forums. The forums focus on the healthcare information needs of frontline health workers and citizens in low - and middle-income countries, and how these needs can be met, and also include discussion of diverse aspects of health systems. Messages about TBAs submitted between 2007-2011 were analysed thematically. We identified 658 messages about TBAs from a total of 193 participants. Most participants supported the incorporation of trained TBAs into primary care systems to some degree, although their justifications for doing so varied. Participant viewpoints were influenced by the degree to which TBA involvement was seen as a long-term or short-term solution and by the tasks undertaken by TBAs. Many forum members indicated that they were supportive of trained TBAs being involved in the provision of pregnancy care. Members noted that TBAs were already frequently used by women and that alternative options were lacking. However, a substantial minority regarded doing so as a threat to the quality and equity of healthcare. The extent of TBA involvement needs to be context-specific and should be based on evidence on effectiveness as well as evidence on need, acceptability and feasibility.
    Full-text · Article · Mar 2014 · BMC Pregnancy and Childbirth
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    • "Distance, cost of health-care and performance of HCWs are the contributing barriers.[89] However, facility-based births are increasing in many resources limited countries and therefore a call for improving the performance of HCW at these hospital settings is vital.[1011121314] "
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    ABSTRACT: There is a higher neonatal mortality rate while the adherence to the existing guidelines is rarely studied in Tanzania. The aim of this study is to assess the performance of health workers for neonatal health-care. Settings - Peripheral health facilities (regional referral, district hospitals and health centers) and a tertiary referral hospital of Kilimanjaro region, Tanzania. Fourteen hospital facilities within all seven districts of the Kilimanjaro region wer involved in this cross-sectional descriptive study. Data were collected for 5 months from 26(th) November, 2010 to 25(th) April, 2011. We analyzed our quantitative data by using STATA v10 (StataCorp, TX, USA) for statistical comparison using Chi-square test to test the difference between the categories and odds ratio (OR) for association between independent and dependent variables. Birth asphyxia was the most recalled health problem requiring critical care, reported by 27.5% (33/120) of health-care workers (HCWs) at peripheral hospitals and at 46.4% (13/28) in a tertiary referral centers. Majority of HCWs commented on their own performance 47.5% (67/140). In the periphery (40), first comment was on management and follow-up of neonatal cases 47.5% (19/40), second on a need of skills 45% (18/40) and third on timely referrals 7.5% (18/40). Shortage of proper equipment was reported at 26.4% (37/140), shortage of staff was reported at 12.0% (17/140), lack of organization of care 11.4% (16/140) and poor hygiene at 2.9% (4/140). It was hard to judge the impact of training on the sufficiency of knowledge (OR: 2.1; 95% confidence interval: [0.9 - 4.8]; P = 0.08) although levels of knowledge for critical neonatal care were higher at the tertiary referral hospital (Pearson χ(2) [2] = 53.8; P < 0.001). Performance of HCWs in early neonatal care is suboptimal and requires frequent systematic evaluation.
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