Ninety-eight percent of the 3.7 million neonatal deaths and 3.3 million stillbirths each year occur in developing countries. In a study published in the Feb. 19 edition of the New England Journal of Medicine, a University of Alabama at Birmingham (UAB) neonatologist working with a large group of U.S. and international colleagues found that training birth attendants in essential newborn care reduced stillbirths by over 30 percent, a potential of saving up to one million lives worldwide each year.

"This project was designed to train birth attendants including doctors, midwives, nurses and traditional birth attendants in communities and hospitals in 96 communities worldwide. The birth attendants were trained to do several easy steps that are critical for babies to survive at birth and kept alive through the first week of life," said lead author Waldemar A. Carlo, M.D., director of the UAB Division of Neonatology. "We selected the World Health Organization course on essential newborn care because it contains what we believed were the essential interventions necessary to sustain life in many infants and created an educational package that included interventions that could be used by any birth attendant anywhere in the world."

Using the train-the-trainer model, local instructors trained birth attendants from rural communities in Argentina, Democratic Republic of Congo, Guatemala, India, Pakistan and Zambia, using the World Health Organization (WHO) newborn care course (routine neonatal care, resuscitation, thermoregulation, breastfeeding, kangaroo care, care of the small baby, and common illnesses) and in a modified version of the American Academy of Pediatrics Neonatal Resuscitation Program (in-depth basic resuscitation). The goal was to see if training birth attendants to use these interventions would reduce perinatal and neonatal mortality in the first week of life in infants weighing at least 1500 grams in rural communities in developing countries.

"Major global causes of perinatal mortality are birth asphyxia and low birth weight/prematurity" Carlo said. "We wanted to find out if these low-cost interventions, including neonatal resuscitation training and kangaroo care, effectively reduced deaths from these causes worldwide. A preliminary smaller study in Zambia has shown that improved skill and knowledge in birth attendants in perinatal care reduced neonatal mortality".

The train-the-trainer program utilized various teaching methods for participant learning, including clinical practice session and demonstrations for the trainers. Carlo and his colleagues also developed instructions on the essential techniques with visual cues to assist birth attendants who could not read. The essential newborn care intervention was assessed with a before and after design. The neonatal resuscitation program intervention was assessed as a cluster randomized control trial.

The stillbirth rate decreased significantly for nurses/midwives and traditional birth attendants following essential newborn care training. The stillbirth rate also decreased among home deliveries. There was not a significant decease in all-cause first week mortality or stillbirth for those using the in-depth NRP neonatal resuscitation program.

Carlo said it is plausible that the observed reduction in stillbirths may be due to  essential newborn care training. Live-born infants without obvious signs of life may have been misidentified as stillbirths before this training; such misclassifications have been reported in the literature. After training, resuscitation was more likely, and stillbirths decreased.

Carlo added that though the data show that training in basic neonatal care has an important role in improving perinatal outcomes in the developing world, more scale up research is needed to prove that the training reduces mortality in other health care systems. He said "A package of essential newborn care interventions if implemented   worldwide might decrease perinatal deaths by about 1 million per year."


NIH Press Release - February 17,2010


Feb. 17, 2010

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