Trained Birth Attendants Research Articles

Validation of a novel tool for assessing newborn resuscitation skills among birth attendants trained by the Helping Babies Breathe program.

To validate a simplified objective structured clinical examination (OSCE) tool for evaluating the competency of birth attendants in low-resource countries who have been trained in neonatal resuscitation by the Helping Babies Breathe (HBB) program. A prospective cross-sectional study of the OSCE tool was conducted among trained birth attendants working at dispensaries, health centers, or hospitals in five regions of Tanzania between October 1, 2013, and May 1, 2014. A 13-item checklist was used to assess clinical competency in a simulated newborn resuscitation scenario. The OSCE tool was simultaneously administered by HBB trainers and experienced external evaluators. Paired results were compared using the Cohen κ value to measure inter-rater reliability. Participant performance was rated by health cadre, region, and facility type. Inter-rater reliability was moderate (κ = 0.41-0.60) or substantial (κ = 0.61-0.80) for eight of the OSCE items; agreement was fair (κ = 0.21-0.41) for the remaining five items. The best OSCE performances were recorded among nurses and providers from facilities with high annual birth volumes. The simplified OSCE tool could facilitate efficient implementation of national-level HBB programs. Limitations in inter-rater reliability might be improved through additional training.

From research to action: Oral Misoprostol for preventing postpartum haemorrhage during home delivery in rural Bangladesh

While Bangladesh has experienced a remarkable 40% decline in maternal mortality over the past ten years, it remains a major health problem. Postpartum haemorrhage (PPH) is one of the most prevalent preventable causes of maternal mortality in the country, accountable for over a quarter of the deaths. In Bangladesh, over 70% of the births take place outside health centres, mostly in poor rural areas. This leads to lack of access to conventional injectable uterotonics (i.e. oxytocin) during the third stage of labour to prevent or treat PPH. The purpose of this paper is to discuss the use of oral misoprostol as an intervention to prevent PPH in rural Bangladesh during home births that take place without trained birth attendants. A review of the existing literature in electronic database, shows robust evidence from Randomised Controlled Trials (RCTs)on the effectiveness of oral misoprostol in preventing PPH. Misoprostol has proved significantly effective (RR 0.58, CI 0.38–0.87) in reducing PPH incidence and to go have a very good safety profile. Furthermore, field trials and operational studies have already proven the feasibility, acceptance and safety of scaling up the use of misoprostol in rural Bangladesh. Therefore, we recommend oral misoprostol to be included in the National Maternal Health Strategy as an intervention to control PPH during home birth in rural Bangladesh.South East Asia Journal of Public Health Vol.4(2) 2014: 2-6

The Role of Trained Birth Attendants in Delivering PMTCT Services

Nigeria was part of an HIV epidemic that once threatened to engulf all of West Africa. The trajectory was altered by the interventions of international donor agencies such as the US President’s Emergency Plan for AIDS Relief (PEPFAR), local organizations, and other agencies who assisted in reducing the threat. Birth Attendants provide an important resource for Prevention of Mother-to-Child Transmission of HIV (PMTCT) as they are more affordable and accessible to most women living in the rural parts of poor developing countries like Nigeria. In March 2004, Faith Alive Foundation (FAF), in collaboration with Global Strategies for HIV Prevention, organized a training workshop for Traditional (trained) Birth Attendants (TBAs) providing services in Plateau State. The workshop curriculum was developed by Global Strategies for HIV Prevention and included HIV Prevention and Care, Voluntary Counseling and Testing (VCT) or HIV Counseling and Testing (HCT), safe delivery practices, and methods for sterilizing instruments. The trained TBAs were followed up by a Faith Alive project coordinator, who was responsible for providing continued oversight, record-keeping, quality assurance, and ongoing education and training. After more than 10 years of implementation and support, a program for PMTCT utilizing TBAs proved to be an important and sustainable tool for HIV Prevention. TBAs were able to provide insight into the lives of women in the community and to use their own experience to help bridge the gap between the clinical setting and the realities of culture and economics that often face women in Africa. Additionally, offering VCT to their clients and referral of HIV-positive women to Faith Alive provided another means whereby women living in remote areas were introduced to the wider healthcare network to access HIV Care and Support as well as other diseases. The role of trained traditional birth attendants should be integrated into PMTCT services in order to ensure that couples receive HCT, women recruited into PMTCT programs receive prophylaxis at the time of delivery, and opportunities are provided to access additional broad health care benefits.

Management of Third Stage of Labour with Per Rectal Administration of 400 MCG of Tablet Misoprostol Before Delivery of Placenta - Protocol for 3rd Stage of Labour - A Pilot Study

Post partum haemorrhage (PPH) is the single most significant and preventable cause of maternal death worldwide. More than half of all maternal deaths occur within 24 hours of delivery, mostly due to excessive bleeding. Aims: The aim of the study was to evaluate the efficiency of tablet misoprostol 400 mcg administered per rectum within one minute of delivery of the baby in preventing postpartum haemorrhage and to study any side effect due to this. Materials and Methods: A prospective pilot study was carried out in a peripheral hospital from 01 Jun 2014 to 10 Oct 2015 110 patients were included in the study. Results: 110 patients of term pregnancy with singleton foetus were evaluated. 24 were primiparas and 86 were multiparas. The mean blood loss of all the patients evaluated was 163.41 ml with SD of 59.97 ml. That of primiparas 163.83 ml with SD of42.78 ml and that of multiparas was 166.93 ml with SD of 63.35 ml. Conclusion: The third stage of labour poses potentially life threatening risks and several severe complications to a mother who has just delivered. The patients in rural and peripheral setups are more vulnerable given their poor nutritional status, rare health care facilities, non availability of trained birth attendants and distance to a tertiary care centre. In larger centres also ,avoidance of post partum haemorrhage adds to maternal well being and saves on hospital resources in terms of man and material. The mean blood loss of 163.41 ml during third stage of labour is an encouraging result especially when no significant side effects were noted.

Handling postpartum haemorrhage- obstetrics between tradition and modernity in post-war Sierra Leone.

How traditional birth attendants (TBAs) in post-war Sierra Leone explain, handle and prevent postpartum haemorrhage (PPH) and their potential role in a better management of PPH to reduce maternal mortality in this low resource setting. Semi-quantitative interviews about knowledge and measures in PPH and participant observation with 140 Sierra Leonean birth attendants, divided in three groups: (A) TBAs who never attended any official training course (n = 82); (B) TBAs who attended at least one official training course (n = 48); and (C) officially trained birth attendants (n = 10). There are several observable gaps in the knowledge of TBAs about PPH compared to modern obstetrics, however similar procedures exist. Herbal medicine is applied; metaphysical convictions about PPH remain present. Training courses show an impact. Officially trained birth attendants demonstrate knowledge deficiencies and lack resources and infrastructure to manage PPH adequately. Morbidity and mortality of PPH in Sierra Leone is related to several factors and not solely to the ignorance of TBAs. TBAs still play an important role for many women there. Hence improvement of the formal health sector should be combined with life-saving programmes integrating TBAs in the care for the pregnant, delivering and breastfeeding mothers.

Provider perspectives on the enabling environment required for skilled birth attendance: a qualitative study in western Nepal.

In Nepal, where difficult geography and an under-resourced health system contribute to poor health care access, the government has increased the number of trained skilled birth attendants (SBAs) and posted them in newly constructed birthing centres attached to peripheral health facilities that are available to women 24h a day. This study describes their views on their enabling environment. Qualitative methods included semi-structured interviews with 22 SBAs within Palpa district, a hill district in the Western Region of Nepal; a focus group discussion with ten SBA trainees, and in-depth interviews with five key informants. Participants identified the essential components of an enabling environment as: relevant training; ongoing professional support; adequate infrastructure, equipment and drugs; and timely referral pathways. All SBAs who practised alone felt unable to manage obstetric complications because quality management of life-threatening complications requires the attention of more than one SBA. Maternal health guidelines should account for the provision of an enabling environment in addition to the deployment of SBAs. In Nepal, referral systems require strengthening, and the policy of posting SBAs alone, in remote clinics, needs to be reconsidered to achieve the goal of reducing maternal deaths through timely management of obstetric complications.

Knowledge, Attitude and Practice of Mothers about Perinatal Care

Background: Infant Mortality Rate (IMR), the most sensitive indicator of health is reflected by female literacy, health education and nutrition of mother and infant. The present study is aimed to assess the Knowledge, Attitude and Practice of mothers regarding perinatal care, nutrition in pregnancy, place and method of delivery, breast feeding, prelacteal feeds, care of newborn, vaccination and red flag signs in newborn. Methods: The study was conducted to determine the Knowledge, Attitude, Practices amongst mothers (250 families), regarding perinatal care and to study the effect of health education. A pretested questionnaire was adopted after a short pilot study. Proportions were calculated for all observations and Z-test was applied for comparison between observations. Results: The majority of the respondents had correct knowledge regarding antenatal care, hospital delivery (88%), selection of clean place for delivery, delivery to be conducted by doctors, nurses or trained birth attendants (97.2%), cord cutting (83.6%), cord care(52.4%), rooming in (88%), hypothermia prevention (72.4%) and physiological jaundice of newborn (81.2%). Most had incorrect knowledge regarding type of diet and time of initiation of nutritious diet after delivery, infant feeding in relation to initiation of first feed (58%), colostrum being beneficial and giving prelacteal feeds (52.4%), kajal application (68.4%) and oil instillation in ears (72%). Conclusions: Successful maternal and child health depends largely on perinatal care viz. pregnancy, antenatal care, nutrition, spacing between pregnancies, basic hygiene, domiciliary delivery, care of the newborn and prevention from infection. Thus, health education regarding perinatal care is important for both mother and child.

Competence of birth attendants at providing emergency obstetric care under India's JSY conditional cash transfer program for institutional delivery: an assessment using case vignettes in Madhya Pradesh province.

BackgroundAccess to emergency obstetric care by competent staff can reduce maternal mortality. India has launched the Janani Suraksha Yojana (JSY) conditional cash transfer program to promote institutional births. During implementation of the JSY, India witnessed a steep increase in the proportion of institutional deliveries-from 40% in 2004 to 73% in 2012. However, maternal mortality reduction follows a secular trend. Competent management of complications, when women deliver in facilities under the JSY, is essential for reduction in maternal mortality and therefore to a successful program outcome. We investigate, using clinical vignettes, whether birth attendants at institutions under the program are competent at providing appropriate care for obstetric complications.MethodsA facility based cross-sectional study was conducted in three districts of Madhya Pradesh (MP) province. Written case vignettes for two obstetric complications, hemorrhage and eclampsia, were administered to 233 birth attendant nurses at 73 JSY facilities. Their competence at (a) initial assessment, (b) diagnosis, and (c) making decisions on appropriate first-line care for these complications was scored.ResultsThe mean emergency obstetric care (EmOC) competence score was 5.4 (median = 5) on a total score of 20, and 75% of participants scored below 35% of the maximum score. The overall score, although poor, was marginally higher in respondents with Skilled Birth Attendant (SBA) training, those with general nursing and midwifery qualifications, those at higher facility levels, and those conducting >30 deliveries a month. In all, 14% of respondents were competent at assessment, 58% were competent at making a correct clinical diagnosis, and 20% were competent at providing first-line care.ConclusionsBirth attendants in the JSY facilities have low competence at EmOC provision. Hence, births in the JSY program cannot be considered to have access to competent EmOC. Urgent efforts are required to effectively increase the competence of birth attendants at managing obstetric complications in order to translate large gains in coverage of institutional delivery services under JSY into reductions in maternal mortality in Madhya Pradesh, India.

Disabled women׳s maternal and newborn health care in rural Nepal: A qualitative study

Objectivethere is little evidence about disabled women׳s access to maternal and newborn health services in low-income countries and few studies consult disabled women themselves to understand their experience of care and care seeking. Our study explores disabled women׳s experiences of maternal and newborn care in rural Nepal. Designwe used a qualitative methodology, using semi-structured interviews. Settingrural Makwanpur District of central Nepal. Participantswe purposively sampled married women with different impairments who had delivered a baby in the past 10 years from different topographical areas of the district. We also interviewed maternal health workers. We compared our findings with a recent qualitative study of non-disabled women in the same district to explore the differences between disabled and non-disabled women. Findingsmarried disabled women considered pregnancy and childbirth to be normal and preferred to deliver at home. Issues of quality, cost and lack of family support were as pertinent for disabled women as they were for their non-disabled peers. Health workers felt unprepared to meet the maternal health needs of disabled women. Key conclusions and implications for practiceintegration of disability into existing Skilled Birth Attendant training curricula may improve maternal health care for disabled women. There is a need to monitor progress of interventions that encourage institutional delivery through the use of disaggregated data, to check that disabled women are benefiting equally in efforts to improve access to maternal health care.

Implementation and evaluation of the Helping Babies Breathe curriculum in three resource limited settings: does Helping Babies Breathe save lives? A study protocol

BackgroundNeonatal deaths account for over 40% of all under-5 year deaths; their reduction is increasingly critical for achieving Millennium Development Goal 4. An estimated 3 million newborns die annually during their first month of life; half of these deaths occur during delivery or within 24 hours. Every year, 6 million babies require help to breathe immediately after birth. Resuscitation training to help babies breathe and prevent/manage birth asphyxia is not routine in low-middle income facility settings. Helping Babies Breathe (HBB), a simulation-training program for babies wherever they are born, was developed for use in low-middle income countries. We evaluated whether HBB training of facility birth attendants reduces perinatal mortality in the Eunice Kennedy Shriver National Institute of Child Health and Human Development’s Global Network research sites.Methods/designWe hypothesize that a two-year prospective pre-post study to evaluate the impact of a facility-based training package, including HBB and essential newborn care, will reduce all perinatal mortality (fresh stillbirth or neonatal death prior to 7 days) among the Global Network’s Maternal Neonatal Health Registry births ≥1500 grams in the study clusters served by the facilities. We will also evaluate the effectiveness of the HBB training program changing on facility-based perinatal mortality and resuscitation practices. Seventy-one health facilities serving 52 geographically-defined study clusters in Belgaum and Nagpur, India, and Eldoret, Kenya, and 30,000 women will be included. Primary outcome data will be collected by staff not involved in the HBB intervention. Additional data on resuscitations, resuscitation debriefings, death audits, quality monitoring and improvement will be collected. HBB training will include training of MTs, facility level birth attendants, and quality monitoring and improvement activities.DiscussionOur study will evaluate the effect of a HBB/ENC training and quality monitoring and improvement package on perinatal mortality using a large multicenter design and approach in 71 resource-limited health facilities, leveraging an existing birth registry to provide neonatal outcomes through day 7. The study will provide the evidence base, lessons learned, and best practices that will be essential to guiding future policy and investment in neonatal resuscitation.Trial registrationTrial registration ClinicalTrials.gov Identifier: NCT01681017

Reducing high maternal mortality rates in western China: a novel approach

Among the Millennium Development Goals, maternal mortality reduction has proven especially difficult to achieve. Unlike many countries, China is on track to meeting these goals on a national level, through a programme of institutionalizing deliveries. Nonetheless, in rural, disadvantaged, and ethnically diverse areas of western China, maternal mortality rates remain high. To reduce maternal mortality in western China, we developed and implemented a three-level approach as part of a collaboration between a regional university, a non-profit organization, and local health authorities. Through formative research, we identified seven barriers to hospital delivery in a rural Tibetan county of Qinghai Province: (1) difficulty in travel to hospitals; (2) hospitals lack accommodation for accompanying families; (3) the cost of hospital delivery; (4) language and cultural barriers; (5) little confidence in western medicine; (6) discrepancy in views of childbirth; and (7) few trained community birth attendants. We implemented a three-level intervention: (a) an innovative Tibetan birth centre, (b) a community midwife programme, and (c) peer education of women. The programme appears to be reaching a broad cross-section of rural women. Multilevel, locally-tailored approaches may be essential to reduce maternal mortality in rural areas of western China and other countries with substantial regional, socioeconomic, and ethnic diversity.

Randomized Control Trial to Evaluate the effectiveness of Helping Babies Breathe Programme on Knowledge and Skills Regarding Neonatal Resuscitation among Auxiliary Nurse Midwives Students

Helping Babies Breathe is a simple, evidence-based training for birth attendants that delivers the skills needed to help. Helping Babies Breathe coordinates with the Neonatal Resuscitation Program, which includes techniques of advanced care. Effective resuscitation of the newborn requires adequate training and preparation of staff involved in the care of women in labour. Hence the present study intends to evaluate the effectiveness of helping Babies Breathe Programme on knowledge and skills regarding neonatal resuscitation among Auxiliary Nurse Midwives students.

A combined community- and facility-based approach to improve pregnancy outcomes in low-resource settings: a Global Network cluster randomized trial

BackgroundFetal and neonatal mortality rates in low-income countries are at least 10-fold greater than in high-income countries. These differences have been related to poor access to and poor quality of obstetric and neonatal care.MethodsThis trial tested the hypothesis that teams of health care providers, administrators and local residents can address the problem of limited access to quality obstetric and neonatal care and lead to a reduction in perinatal mortality in intervention compared to control locations. In seven geographic areas in five low-income and one middle-income country, most with high perinatal mortality rates and substantial numbers of home deliveries, we performed a cluster randomized non-masked trial of a package of interventions that included community mobilization focusing on birth planning and hospital transport, community birth attendant training in problem recognition, and facility staff training in the management of obstetric and neonatal emergencies. The primary outcome was perinatal mortality at ≥28 weeks gestation or birth weight ≥1000 g.ResultsDespite extensive effort in all sites in each of the three intervention areas, no differences emerged in the primary or any secondary outcome between the intervention and control clusters. In both groups, the mean perinatal mortality was 40.1/1,000 births (P = 0.9996). Neither were there differences between the two groups in outcomes in the last six months of the project, in the year following intervention cessation, nor in the clusters that best implemented the intervention.ConclusionsThis cluster randomized comprehensive, large-scale, multi-sector intervention did not result in detectable impact on the proposed outcomes. While this does not negate the importance of these interventions, we expect that achieving improvement in pregnancy outcomes in these settings will require substantially more obstetric and neonatal care infrastructure than was available at the sites during this trial, and without them provider training and community mobilization will not be sufficient. Our results highlight the critical importance of evaluating outcomes in randomized trials, as interventions that should be effective may not be.Trial registrationClinicalTrials.gov NCT01073488

English

BACKGROUND: An observation study was conducted at the Gynaecological and Obstetric Department ,Medical College and Hospital, Kolkata, of maternal deaths from 1st July 2009 to 30thJune 2010. AIMS: To analyze from data of maternal mortality how variables like sociodemographic factors, incidents surrounding maternal mortality, causes of it and time of death to admission interval affect maternal mortality. DESIGN: Observational secondary data based study MATERIALS AND METHODS: Maternal deaths between 1st July 2009 to 30th June 2010 were studied at the department of Gynaecology and Obstetrics, Medical College and Hospital, Kolkata. Data regarding detailed case history, routine antenatal investigations, time of detection of deteriorating patient status with treatment instituted along with referral card, if any, was collected. Data was collected and analysed using MS Excel and Stat cal. RESULTS: 48 maternal deaths were studied. Maternal deaths were notably more among rural ladies. Deaths were more due to direct causes and more among vaginal deliveries than instrumental deliveries and caesarean sections. Maximum number of deaths was within 24 hours of admission. CONCLUSION: Early registration, immunization, regular antenatal visits, trained birth attendants along with institutional deliveries, prompt referral and timely interventions go a long way in bringing down maternal mortality in a developing country like India.

Stillbirth and Newborn Mortality in India After Helping Babies Breathe Training

This study evaluated the effectiveness of Helping Babies Breathe (HBB) newborn care and resuscitation training for birth attendants in reducing stillbirth (SB), and predischarge and neonatal mortality (NMR). India contributes to a large proportion of the worlds annual 3.1 million neonatal deaths and 2.6 million SBs. This prospective study included 4187 births at >28 weeks' gestation before and 5411 births after HBB training in Karnataka. A total of 599 birth attendants from rural primary health centers and district and urban hospitals received HBB training developed by the American Academy of Pediatrics, using a train-the-trainer cascade. Pre-post written trainee knowledge, posttraining provider performance and skills, SB, predischarge mortality, and NMR before and after HBB training were assessed by using χ(2) and t-tests for categorical and continuous variables, respectively. Backward stepwise logistic regression analysis adjusted for potential confounding. Provider knowledge and performance systematically improved with HBB training. HBB training reduced resuscitation but increased assisted bag and mask ventilation incidence. SB declined from 3.0% to 2.3% (odds ratio [OR] 0.76, 95% confidence interval [CI] 0.59-0.98) and fresh SB from 1.7% to 0.9% (OR 0.54, 95% CI 0.37-0.78) after HBB training. Predischarge mortality was 0.1% in both periods. NMR was 1.8% before and 1.9% after HBB training (OR 1.09, 95% CI 0.80-1.47, P = .59) but unknown status at 28 days was 2% greater after HBB training (P = .007). HBB training reduced SB without increasing NMR, indicating that resuscitated infants survived the neonatal period. Monitoring and community-based assessment are recommended.

Determinants of Institutional Delivery in Rural Uttar Pradesh: Choice of Delivery Location

Access to quality care during pregnancy and especially at delivery seems to be the crucial factor in explaining the disparity in maternal health status. The choice of place of delivery has consistently been found to be associated with maternal and neonatal outcomes. The objective of the present paper is to understand the determinants of delivery location-institutional (public or private) and home; and reasons for non-utilization of facility for delivery care. The District Level Household Survey (2002-04) data for Rural Uttar Pradesh have been used, adopting the conceptual framework of Andersen Behavioural Model. A multinomial Logistic regression analysis was conducted to assess the determinants of home, public and private facilities for delivery. Most of the delivery had taken place at home, with public and private sector accounting for only seven percent and nine percent respectively. Women with higher birth order and those residing far from Primary health centres had greater odds of delivering at home than public facility, while maternal education, Antenatal care visits, regions and pregnancy complications are the significant predictor of institutional delivery. The results indicate that, after controlling for other variables access to health facilities do not have much effect on choice of public facility over home/private. Regional analysis showed significant differentials in reasons for not delivering at health facility. Given the predominance of home deliveries in the rural Uttar Pradesh, every attempt should be made to ensure that these are attended by trained birth attendants.

Three ‘Delays’ as a Framework for Critical Analysis of Maternal Near Miss and Maternal Mortality

ABSTRACT Objective The aim of the study was to assess the magnitude and causes of three delays and their possible implications for safe motherhood. Methods The cross-sectional prospective study was carried out over a period of 1 year from January to December 2010. All patients who fulfill the WHO criteria for maternal near miss and all cases of maternal death during this period were included in the study. The various factors responsible for the delays in accessing obstetrics care facilities at all the three levels were analyzed. Results During 1 year period there were 10,553 emergency admissions in labor room and there were 4538 deliveries, out of these 123 patients who fulfilled the WHO criteria for near miss were included in the study. 83% of patients (102) reported first delay in seeking care and the most common reason for delay was inability to judge the graveness of situation. After initial care there was a delay in reaching a facility with comprehensive obstetric care in 62% of cases (76 patients) and this delay was of around 6 to 8 hours. Once the patients reached Jinnah Hospital there was a delay in about 15 (12%) patients. There were 13 maternal deaths during this period of 1 year and there was a delay both at seeking initial care and referral by the initial care providers. Conclusion Delay in deciding to seek care (1st delay) was the major factors responsible for high maternal mortality and morbidity. So the role of community actors such as mothers in law, husbands, local healers and pharmacies and increased access to properly trained birth attendants need to be addressed if delays in reaching health facilities are to be shortened. How to cite this article Yunus S, Kauser S, Ali S. Three ‘Delays’ as a Framework for Critical Analysis of Maternal Near Miss and Maternal Mortality. J South Asian Feder Obst Gynae 2013;5(2):57-59.

Traditional birth attendant training for improving health behaviours and pregnancy outcomes

Between the 1970s and 1990s, the World Health Organization promoted traditional birth attendant (TBA) training as one strategy to reduce maternal and neonatal mortality. To date, evidence in support of TBA training is limited but promising for some mortality outcomes. To assess the effects of TBA training on health behaviours and pregnancy outcomes. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (18 June 2012), citation alerts from our work and reference lists of studies identified in the search. Published and unpublished randomised controlled trials (RCT), comparing trained versus untrained TBAs, additionally trained versus trained TBAs, or women cared for/living in areas served by TBAs. Three authors independently assessed study quality and extracted data in the original and first update review.Three authors and one external reviewer independently assessed study quality and two extracted data in this second update. Six studies involving over 1345 TBAs, more than 32,000 women and approximately 57,000 births that examined the effects of TBA training for trained versus untrained TBAs (one study) and additionally trained TBA training versus trained TBAs (five studies) are included in this review. These studies consist of individual randomised trials (two studies) and cluster-randomised trials (four studies). The primary outcomes across the sample of studies were perinatal deaths, stillbirths and neonatal deaths (early, late and overall).Trained TBAs versus untrained TBAs: one cluster-randomised trial found a significantly lower perinatal death rate in the trained versus untrained TBA clusters (adjusted odds ratio (OR) 0.70, 95% confidence interval (CI) 0.59 to 0.83), lower stillbirth rate (adjusted OR 0.69, 95% CI 0.57 to 0.83) and lower neonatal death rate (adjusted OR 0.71, 95% CI 0.61 to 0.82). This study also found the maternal death rate was lower but not significant (adjusted OR 0.74, 95% CI 0.45 to 1.22).Additionally trained TBAs versus trained TBAs: three large cluster-randomised trials compared TBAs who received additional training in initial steps of resuscitation, including bag-valve-mask ventilation, with TBAs who had received basic training in safe, clean delivery and immediate newborn care. Basic training included mouth-to-mouth resuscitation (two studies) or bag-valve-mask resuscitation (one study). There was no significant difference in the perinatal death rate between the intervention and control clusters (one study, adjusted OR 0.79, 95% CI 0.61 to 1.02) and no significant difference in late neonatal death rate between intervention and control clusters (one study, adjusted risk ratio (RR) 0.47, 95% CI 0.20 to 1.11). The neonatal death rate, however, was 45% lower in intervention compared with the control clusters (one study, 22.8% versus 40.2%, adjusted RR 0.54, 95% CI 0.32 to 0.92).We conducted a meta-analysis on two outcomes: stillbirths and early neonatal death. There was no significant difference between the additionally trained TBAs versus trained TBAs for stillbirths (two studies, mean weighted adjusted RR 0.99, 95% CI 0.76 to 1.28) or early neonatal death rate (three studies, mean weighted adjusted RR 0.83, 95% CI 0.68 to 1.01). The results are promising for some outcomes (perinatal death, stillbirth and neonatal death). However, most outcomes are reported in only one study. A lack of contrast in training in the intervention and control clusters may have contributed to the null result for stillbirths and an insufficient number of studies may have contributed to the failure to achieve significance for early neonatal deaths. Despite the additional studies included in this updated systematic review, there remains insufficient evidence to establish the potential of TBA training to improve peri-neonatal mortality.

Emergency Obstetric Referral in Rural Sierra Leone: What Can Motorbike Ambulances Contribute? A Mixed-Methods Study

Giving birth remains a dangerous endeavour for many of the world's women. Progress to improve this has been slow in sub-Saharan Africa. The second delay, where transport infrastructure is key in allowing a woman to reach care, has been a relatively neglected field of study. Six eRanger motorbike ambulances, specifically engineered for use on poor roads in resource-poor situations were provided in 2006 as part of an emergency referral system in rural Sierra Leone. The aim of this study was to evaluate the implementation of this referral system in terms of its use, acceptability and accessibility. Data were collected from usage records, and a series of semi-structured interviews and focus groups conducted to provide deeper understanding of the service. A total of 130 records of patients being transported to a health facility were found, 1/3 of which were for obstetric cases. The ambulance is being used regularly to transport patients to a health care facility. It is well known to the communities, is acceptable and accessible, and is valued by those it serves. District-wide traditional birth attendant training and the sensitisation activities provided a foundation for the introduction of the ambulance service, creating a high level of awareness of the service and its importance, particularly for women in labour. Motorbike ambulances are suited to remote areas and can function on poor roads inaccessible to other vehicles.

Training traditional birth attendants on the WHO Essential Newborn Care reduces perinatal mortality

To evaluate the impact of birth attendant training using the World Health Organization Essential Newborn Care (ENC) course among traditional birth attendants, with a particular emphasis on the effect of acquisition of skills on perinatal outcomes. Population-based, prospective, interventional pre-post design study. 11 rural clusters in Chimaltenango, Guatemala. Health care providers. This study analyzed the effect of training and implementation of the ENC health care provider training course between September 2005 and December 2006. The primary outcome measure was the rate of death from all causes in the first seven days after birth in fetuses/infants ≥1500g. Secondary outcome measures were overall rate of stillbirth, rate of perinatal death, which included stillbirths plus neonatal deaths in the first seven days in fetuses/infants ≥1500g. Perinatal mortality decreased from 39.5/1000 pre-ENC to 26.4 post-ENC (RR 0.72; 95%CI 0.54-0.97). This reduction was attributable almost entirely to a decrease in the stillbirth rate of 21.4/1000 pre-Essential Newborn Care to 7.9/1000 post-ENC (RR 0.40; 95%CI 0.25-0.64). Seven-day neonatal mortality did not decrease (18.3/1000 to 18.6/1000; RR 1.05; 95%CI 0.70-1.57). Essential Newborn Care training reduced stillbirths in a population-based controlled study with deliveries conducted almost exclusively by traditional birth attendants. Scale-up of this intervention in other settings might help assess reproducibility and sustainability.