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

Abstract

Objective 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. Design Prospective, cluster randomised and controlled effectiveness study. Setting 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. Participants 127 traditional birth attendants and mothers and their newborns (3559 infants delivered regardless of vital status) from Lufwanyama district. Interventions 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). Main outcome measures 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. Results 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. Conclusions 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.

Thermal protection of the newborn in resource-limited environments

“…65 In Zambia, we recently showed that training traditional birth attendants in newborn care with special emphasis on resuscitation and simple thermal protection (wiping the newborn dry and wrapping the dried infant in a separate piece of cloth) along with an intervention to provide early treatment of possible sepsis reduced mortality rates at day 28 after birth by 45%. 66 Low-cost, low-tech treatment of newborn hypothermia The use of incubators for thermal protection of newborns has been reported for more than 150 years, since the Parisian obstetrician Jean Louis Paul Denucé in 1857 engineered his couveuse, a device Thermal protection of the newborn K Lunze and DH Hamer for the care of a premature infant. In 1878, his local colleague Stéphane Tarnier, using a modified warming chamber for the rearing of poultry, found a decrease in neonatal death rate from 66 to 38% among infants with birth weights <2000 g. 67 Today, postnatal care devices (isolettes or infant warmers) combine the features of incubators and radiant warmer beds and have evolved with many features, including automated temperature and humidity regulations, 68 oxygen supplementation and light therapy.…”

A Cluster Randomized Controlled Community Based Trial Utilizing a Continuum of care Among Pregnant Women: Outcomes in the Women

“…More newborn deaths occur at home among the rural poor. Consistent with global trends almost 50% of all deliveries in Zambia take place at home or rely on traditional birth attendants as the nearest available source of maternity and delivery healthcare (4,7,9,10) . History has taught us that we do not need expensive technologies to facilitate the reductions of either maternal or newborn deaths (10) .…”

“…The role of community health workers in child survival is under debate as to the acceptability, level, function, type of incentives (12,13) . Traditional birth attendants and other CBAs continue to be the nearest source of care within the community (4,7,9,10,14,15,16,17,18,19) . This article describes cluster randomized community based trial in Zambia, with deliberate interventions in the pregnant mother.…”

Engagement of the Community, Traditional Leaders, and Public Health System in the Design and Implementation of a Large Community-Based, Cluster-Randomized Trial of Umbilical Cord Care in Zambia

“…This low rate compares favorably to chlorhexidine application trials conducted in south Asia (5% lost to follow-up in Bangladesh, and 2.5% lost to follow-up in Nepal) and newborn health trials in Africa. 7,8,22,23 Structural barriers. In Zambia, like many African countries, rural communities are widely dispersed, and families often travel great distances to reach primary health centers.…”