Reduced perinatal mortality following enhanced training of birth attendants in the Democratic Republic of Congo: a time-dependent effect

Richard Matendo, Cyril Engmann, John Ditekemena, Justin Gado, Antoinette Tshefu, Rinko Kinoshita, Elizabeth M McClure, Janet Moore, Dennis Wallace, Waldemar A Carlo, Linda L Wright, Carl Bose, Richard Matendo, Cyril Engmann, John Ditekemena, Justin Gado, Antoinette Tshefu, Rinko Kinoshita, Elizabeth M McClure, Janet Moore, Dennis Wallace, Waldemar A Carlo, Linda L Wright, Carl Bose

Abstract

Background: In many developing countries, the majority of births are attended by traditional birth attendants, who lack formal training in neonatal resuscitation and other essential care required by the newly born infant. In these countries, the major causes of neonatal mortality are birth asphyxia, infection, and low-birth-weight/prematurity. Death from these causes is potentially modifiable using low-cost interventions, including neonatal resuscitation training. The purpose of this study was to evaluate the effect on perinatal mortality of training birth attendants in a rural area of the Democratic Republic of Congo (DRC) using two established programs.

Methods: This study, a secondary analysis of DRC-specific data collected during a multi-country study, was conducted in two phases. The effect of training using the WHO Essential Newborn Care (ENC) program was evaluated using an active baseline design, followed by a cluster randomized trial of training using an adaptation of a neonatal resuscitation program (NRP). The perinatal mortality rates before ENC, after ENC training, and after randomization to additional NRP training or continued care were compared. In addition, the influence of time following resuscitation training was investigated by examining change in perinatal mortality during sequential three-month increments following ENC training.

Results: More than two-thirds of deliveries were attended by traditional birth attendants and occurred in homes; these proportions decreased after ENC training. There was no apparent decline in perinatal mortality when the outcome of all deliveries prior to ENC training was compared to those after ENC but before NRP training. However, there was a gradual but significant decline in perinatal mortality during the year following ENC training (RR 0.73; 95% CI: 0.56-0.96), which was independently associated with time following training. The decline was attributable to a decline in early neonatal mortality. NRP training had no demonstrable effect on early neonatal mortality.

Conclusion: Training DRC birth attendants using the ENC program reduces perinatal mortality. However, a period of utilization and re-enforcement of training may be necessary before a decline in mortality occurs. ENC training has the potential to be a low cost, high impact intervention in developing countries.

Trial registration: This trial has been registered at http://www.clinicaltrials.gov (identifier NCT00136708).

Figures

Figure 1
Figure 1
Derivation of the study population.
Figure 2
Figure 2
Change in rates of stillbirth, and neonatal and perinatal mortality as a function of time during the study period. Each time point represents the rates for the preceding three month period of time. The vertical lines indicate the time of ENC () and NRP training (). There was a significant decline in perinatal mortality during the year following ENC training, after adjustment for type of birth attendant and location of birth.

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