Background Annually, 2.6 million stillbirths occur worldwide, 98% in developing countries. It is crucial that we understand causes and contributing factors. Methods We conducted a systematic review of studies reporting factors associated with and cause(s) of stillbirth in low‐ and middle‐income countries (2000–13). Narrative synthesis to compare similarities and differences between studies with similar outcome categories. Main results A total of 142 studies with 2.1% from low‐income settings were investigated; most report on stillbirths occurring at health facility level. Definition of stillbirth varied; 10.6% of studies (mainly upper middle‐income countries) used a cut‐off point of ≥22 weeks of gestation and 32.4% (mainly lower income countries) used ≥28 weeks of gestation. Factors reported to be associated with stillbirth include poverty and lack of education, maternal age (>35 or <20 years), parity (1, ≥5), lack of antenatal care, prematurity, low birthweight, and previous stillbirth. The most frequently reported cause of stillbirth was maternal factors (8–50%) including syphilis, positive HIV status with low CD4 count, malaria and diabetes. Congenital anomalies are reported to account for 2.1–33.3% of stillbirths, placental causes (7.4–42%), asphyxia and birth trauma (3.1–25%), umbilical problems (2.9–33.3%), and amniotic and uterine factors (6.5–10.7%). Seven different classification systems were identified but applied in only 22% of studies that could have used a classification system. A high percentage of stillbirths remain ‘unclassified’ (3.8–57.4%). Conclusion To build capacity for perinatal death audit, clear guidelines and a suitable classification system to assign cause of death must be developed. Existing classification systems may need to be adapted. Better data and more data are urgently needed.

BackgroundHealthcare provider training in Emergency Obstetric and Newborn Care (EmOC&NC) is a component of 65% of intervention programs aimed at reducing maternal and newborn mortality and morbidity. It is important to evaluate the effectiveness of this.MethodsWe evaluated knowledge and skills among 5,939 healthcare providers before and after 3–5 days ‘skills and drills’ training in emergency obstetric and newborn care (EmOC&NC) conducted in 7 sub-Saharan Africa countries (Ghana, Kenya, Malawi, Nigeria, Sierra Leone, Tanzania, Zimbabwe) and 2 Asian countries (Bangladesh, Pakistan). Standardised assessments using multiple choice questions and objective structured clinical examination (OSCE) were used to measure change in knowledge and skills and the Improvement Ratio (IR) by cadre and by country. Linear regression was performed to identify variables associated with pre-training score and IR.Results99.7% of healthcare providers improved their overall score with a median (IQR) increase of 10.0% (5.0% - 15.0%) for knowledge and 28.8% (23.1% - 35.1%) for skill. There were significant improvements in knowledge and skills for each cadre of healthcare provider and for each country (p<0.05). The mean IR was 56% for doctors, 50% for mid-level staff and nurse-midwives and 38% for nursing-aides. A teaching job, previous in-service training, and higher percentage of work-time spent providing maternity care were each associated with a higher pre-training score. Those with more than 11 years of experience in obstetrics had the lowest scores prior to training, with mean IRs 1.4% lower than for those with no more than 2 years of experience. The largest IR was for recognition and management of obstetric haemorrhage (49–70%) and the smallest for recognition and management of obstructed labour and use of the partograph (6–15%).ConclusionsShort in-service EmOC&NC training was associated with improved knowledge and skills for all cadres of healthcare providers working in maternity wards in both sub-Saharan Africa and Asia. Additional support and training is needed for use of the partograph as a tool to monitor progress in labour. Further research is needed to assess if this is translated into improved service delivery.

Providing quality emergency obstetric care (EmOC) reduces the risk of maternal and newborn mortality and morbidity. There is evidence that over 50% of maternal health programmes that result in improving access to EmOC and reduce maternal mortality have an EmOC training component. The objective was to review the evidence for the effectiveness of training in EmOC. Eleven databases and websites were searched for publications describing EmOC training evaluations between 1997 and 2017. Effectiveness was assessed at four levels: (1) participant reaction, (2) knowledge and skills, (3) change in behaviour and clinical practice and (4) availability of EmOC and health outcomes. Weighted means for change in knowledge and skills obtained, narrative synthesis of results for other levels. One hundred and one studies including before–after studies (n = 44) and randomized controlled trials (RCTs) (n = 15). Level 1 and/or 2 was assessed in 68 studies; Level 3 in 51, Level 4 in 21 studies. Only three studies assessed effectiveness at all four levels. Weighted mean scores pre-training, and change after training were 67.0% and 10.6% for knowledge (7750 participants) and 53.1% and 29.8% for skills (6054 participants; 13 studies). There is strong evidence for improved clinical practice (adherence to protocols, resuscitation technique, communication and team work) and improved neonatal outcomes (reduced trauma after shoulder dystocia, reduced number of babies with hypothermia and hypoxia). Evidence for a reduction in the number of cases of post-partum haemorrhage, case fatality rates, stillbirths and institutional maternal mortality is less strong. Short competency-based training in EmOC results in significant improvements in healthcare provider knowledge/skills and change in clinical practice. There is emerging evidence that this results in improved health outcomes.

ObjectiveTo determine retention of knowledge and skills after standardised “skills and drills” training in Emergency Obstetric Care.DesignLongitudinal cohort study.SettingGhana, Malawi, Nigeria, Kenya, Tanzania and Sierra Leone.Population609 maternity care providers, of whom 455 were nurse/midwives (NMWs)MethodsKnowledge and skills assessed before and after training, and, at 3, 6, 9 and 12 months. Analysis of variance to explore differences in scores by country and level of healthcare facility for each cadre. Mixed effects regression analysis to account for potential explanatory factors including; facility type, years of experience providing maternity care, months since training and number of repeat assessments.Main outcome measuresChange in knowledge and skills.ResultsBefore training the overall mean (SD) score for skills was 48.8% (11.6%) and 65.6% (10.7%). for knowledge. After training the mean (95% CI) relative improvement in knowledge was 30.8% (29.1% - 32.6%) and 59.8% (58.6%– 60.9%) for skills. Mean scores for knowledge and skills at each subsequent assessment remained between those immediately post-training and those at 3 months. NMWs who attended all four assessments demonstrated statistically better retention of skills (14.9%, 95% CI 7.8%, 22.0% p<0.001) but not knowledge (8.6%, 95% CI -0.3%, 17.4%. p = 0.06) compared to those who attended one or two assessments only. Health care facility level or experience were not determinants of retention.ConclusionsAfter training, healthcare providers retain knowledge and skills for up to 12 months. This effect can likely be enhanced by short repeat skills-training sessions, or, ‘fire drills’.

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