1 & 2TABEL EVIDENCE MATRIX FOR LITERATUR MODEL PELATIHAN
PEDULI DUKUN BAYI UNTUK MENINGKATKAN POTENSI SEBAGAI AGENT OF
CHANGE PELAKSANAAN INISIASI MENYUSU DINI
LJLead Author, Article Title, Jurnal CitationMETHODOLOGICAL
CHARACTERISTICSCONTENT SPESIFIC FINDINGYear Study DesignStudi
PopulationSampel SizeIntervention
CharacteristicResultsConclusionOther Comments1Pfeiffer dan
Mwaipopo, Menyampaikan di rumah atau di fasilitas kesehatan?
perilaku mencari kesehatan perempuan dan peran dukun bayi di
Tanzania, BMC Kehamilan dan Persalinan 2013, 13:55
http://www.biomedcentral.com/1471-2393/13/552013Menggunakan
pendekatan campuran metode, kuantitatif maupun kualitatifPenelitian
ini difokuskan pada berbagai tingkatan dalam masyarakat dan sistem
kesehatan, yang melibatkan (1) wanita yang telah disampaikan dalam
2 bulan terakhir, (2) dukun bayi, dan (3) anggota masyarakat200
wanita diwawancarai: 100 dari mereka di perkotaan dan 100 di
pedesaan. 14 dukun beranak (10 di Kabupaten Masasi dan 4 di Ward
Ilala, Dar es Salaam), perspektif masyarakat, 8 Focus Group Diskusi
(4 di Ward Ilala dan 4 di Maundo)N / A bukan intervensiHasil dari
perkotaan menunjukkan bahwa prestasi yang signifikan telah dibuat
dalam hal mempromosikan kehamilan dan jasa pengiriman terkait
melalui tenaga kesehatan terampil. Wanita hamil memiliki tingkat
kesadaran yang tinggi dan jelas lebih memilih untuk memberikan di
fasilitas kesehatan. Skenario berbeda di pedesaan (Masasi
District), di mana tenaga kesehatan terlatih dan fasilitas
kesehatan yang lengkap belum nyata, sehingga melahirkani di rumah
dengan bantuan baik TBA atau saudara.Alih-alih berfokus pada sektor
tradisional, ia berpendapat bahwa perhatian lebih harus dibayar
untuk (1) meningkatkan akses serta penguatan sistem kesehatan untuk
menjamin persalinan oleh tenaga kesehatan terlatih; dan (2)
menjembatani kesenjangan antara masyarakat dan sektor kesehatan
formal melalui konseling berbasis masyarakat dan pendidikan
kesehatan, yang disediakan oleh petugas kesehatan desa terlatih dan
diawasi yang menginformasikan warga tentang pelayanan kesehatan
promotif dan preventif, termasuk kesehatan ibu dan bayi.Beberapa
penelitian formatif yang bertujuan mengevaluasi efektivitas dan
biaya strategi scalable sedang dilaksanakan dalam rangka
meningkatkan kesehatan neonatal dan maternal di pedesaan Tanzania
selatan melalui intervensi berbasis masyarakat dan dengan
memperkenalkan tenaga kesehatan masyarakat2"Christopher J Gill, et.
Al" "Pengaruh pelatihan dukun bayi angka kematian bayi baru lahir
(Lufwanyama Neonatal Survival Project):acak terkontrol "" BMJ 2011;
342: d346doi: 10.1136/bmj.d346 "2010Prospektif, klaster acak dan
terkontrol studi efektivitas.Semua kelahiran yang terjadi di rumah
ibu, di daerah pedesaan.127 dukun bayi dan ibu dan bayi mereka
(3559 bayi yang dilahirkan tanpa memandang status vital)Menggunakan
desain unblinded, dukun bayi secara acak untuk kelompok intervensi
atau kelompok kontrol. Intervensi memiliki dua komponen: pelatihan
dalam versi modifikasi dari protokol resusitasi neonatal, dan
amoksisilin dosis tunggal ditambah dengan rujukan yang difasilitasi
bayi ke pusat kesehatan. Kontrol bidan melanjutkan standar yang
sudah ada perawatan (keterampilan kebidanan dasar dan penggunaan
kit persalinan bersih)."Di antara 3497 pengiriman dengan informasi
yang dapat dipercaya, angka kematian pada hari ke 28 setelah
kelahiran adalah 45% lebih rendah di antara bayi lahir hidup
disampaikan oleh intervensi bidan daripada bidan control (rasio
tingkat 0,55, 95% interval kepercayaan 0,33-0,90). Penurunan
terbesarangka kematian berada di 24 jam pertama setelah lahir: 7,8
kematian per 1.000 kelahiran hidup untuk bayi disampaikan oleh
intervensi bidan dibandingkan dengan 19,9 per 1000 untuk bayi yang
dilahirkan oleh kontrol bidan (0,40, 0,19-0,83). Kematian akibat
asfiksia lahir yangdikurangi dengan 63% di antara bayi yang
dilahirkan oleh intervensi bidan (0,37, 0,17-0,81) dan sebesar 81%
dalam dua hari pertama setelah lahir (0,19, 0,07-0,52). Lahir mati
dan kematian akibat infeksi serius terjadi pada tingkat yang sama
pada kedua kelompok."Pelatihan dukun bayi untuk mengelola kondisi
perinatal umum secara signifikan mengurangi kematian neonatal di
pedesaan Afrika.Pendekatan ini memiliki potensi yang tinggi untuk
diterapkan untuk pengaturan yang sama dengan populasi di pedesaan
terpencil.
Sheet2TABEL EVIDENCE MATRIX FOR LITERATUR MODEL PELATIHAN PEDULI
DUKUN BAYI UNTUK MENINGKATKAN POTENSI SEBAGAI AGENT OF CHANGE
PELAKSANAAN INISIASI MENYUSU DINI
NOLead Author, Article Title, Jurnal CitationMETHODOLOGICAL
CHARACTERISTICSCONTENT SPESIFIC FINDINGYear Study DesignStudi
PopulationSampel SizeIntervention
CharacteristicResultsConclusionOther Comments1Pfeiffer and
Mwaipopo, Delivering at home or in a health facility?
health-seeking behaviour of women and the role of traditional birth
attendants in Tanzania, BMC Pregnancy and Childbirth 2013, 13:55
http://www.biomedcentral.com/1471-2393/13/552013Using a
mixed-methods approach, quantitative as well as qualitativeThe
study focused on various levels within the society and the health
system, involving (1) women who had delivered in the past 2 months,
(2) TBAs, and (3) community members200 women were interviewed: 100
of them in urban and 100 in rural sites. 14 TBAs (10 in Masasi
District and 4 in Ward Ilala, Dar es Salaam), the community
perspective, 8 Focus-Group Discussions (4 in Ward Ilala and 4 in
Maundo)N/A not an interventionThe results from the urban site show
that significant achievements have been made in terms of promoting
pregnancy- and delivery-related services through skilled health
workers. Pregnant women have a high level of awareness and clearly
prefer to deliver at a health facility. The scenario is different
in the rural site (Masasi District), where an adequately trained
health workforce and well-equipped health facilities are not yet a
reality, resulting in home deliveries with the assistance of either
a TBA or a relative.Instead of focusing on the traditional sector,
it is argued that more attention should be paid towards (1)
improving access to as well as strengthening the health system to
guarantee delivery by skilled health personnel; and (2) bridging
the gaps between communities and the formal health sector through
communitybased counselling and health education, which is provided
by well-trained and supervised village health workers who inform
villagers about promotive and preventive health services, including
maternal and neonatal health.Several formative research studies
that aim at evaluating the effectiveness and cost of scaleable
strategies are being implemented in order to improve neonatal and
maternal health in rural southern Tanzania through community-based
interventions and by introducing community health
workers2Christopher J Gill, et. Al "Effect of training traditional
birth attendants on neonatalmortality (Lufwanyama Neonatal Survival
Project):randomised controlled study" BMJ 2011;
342:d346doi:10.1136/bmj.d3462010Prospective, cluster randomised and
controlled effectiveness study.All births carried out by study
birth attendants occurred at mothers homes, in rural village
settings.127 traditional birth attendants and mothers and their
newborns (3559 infants delivered regardless of vital status)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).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
reductionsin 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 werereduced 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.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.3Ebuehi and Akintujoye, Perception and utilization of
traditional birth attendants by pregnant women attending primary
health care clinics in a rural Local Government Area in Ogun State,
Nigeria. Dove Press Journals; International Journal of Womens
Health 3 Februari 20122012A quantitative design ; a descriptive
cross-sectional studyThe study was carried out among registered
pregnant women attending the antenatal clinics of selected PHCs
inIfo LGA.250 pregnant women attending four randomly selected
primary health care clinics in the LGA..N/A not an
interventionAlmost half (48.8%) of the respondents were in the age
group 2635 years, with a mean age of 29.4 kurang lebih7.33 years.
About two-thirds (65.6%) of the respondents had been pregnant 24
times before. TBA functions, as identified by respondents, were:
taking normal delivery (56.7%), providing antenatal services
(16.5%), performing caesarean section (13.0%), providing family
planning services (8.2%), and performing gynaecological surgeries
(5.6%). About 6/10 (61.0%) respondents believed that TBAs have
adequate knowledge and skills to care for them, however,
approximately 7/10 (69.7%) respondents acknowledged that
complications could arise from TBA care. Services obtained from
TBAs were: routine antenatal care (81.1%), normal delivery (36.1%),
special maternal bath to ward off evil spirits (1.9%), concoctions
for mothers to drink to make baby strong (15.1%), and family
planning services (1.9%). Reasons for using TBA services were: TBA
services are cheaper (50.9%), TBA services are more culturally
acceptable in my environment (34.0%), TBA services are closer to my
house than hospital services (13.2%), TBAs provide more
compassionate care than orthodox health workers (43.4%), and TBA
service is the only maternity service that I know (1.9%).
Approximately 8/10 (79.2%) of the users (past or current) opined
that TBA services are effective but could be improved with some
form of training (78.3%). More than three-quarters (77.1%) opposed
the banning of TBA services. Almost 7/10 (74.8%) users were
satisfied with TBA services.Study findings revealed a positive
perception and use of TBA services by the respondents. This
underlines the necessity for TBAs knowledge and skills to be
improved within permissible standards through sustained partnership
between TBAs and health systems. It is hoped that such partnership
will foster a healthy collaboration between providers of orthodox
and traditional maternity services that will translate into
improved maternal and neonatal health outcomes in relevant
settings.4Administration of misoprostol by trained traditional
birth attendants to prevent postpartum haemorrhage in homebirths in
Pakistan: a randomised placebo-controlled trial, N Mobeen,a J
Durocher at. Al; 2010 Gynuity Health Projects Journal compilation
RCOG 2010 BJOG An International Journal of Obstetrics and
Gynaecology2010A randomised, double-blind, placebo-controlled triaA
total of 1119 women giving birth at home.intervention=534 women and
control=585 womenconsenting women were randomised to receive 600 lg
oral misoprostol (n = 534) or placebo (n = 585) after delivery to
determine whether misoprostol reduced the incidence of PPH (500
ml)Oral misoprostol was associated with a significant reduction in
the rate of PPH (500 ml) (16.5 versus 21.9%; relative risk 0.76,
95% CI 0.590.97). There were no measurable differences between
study groups for drop in haemoglobin >2 g/dl (relative risk
0.79, 95% CI 0.621.02); but significantly fewer women receiving
misoprostol had a drop in haemoglobin >3 g/dl, compared with
placebo (5.1 versus 9.6%; relative risk 0.53, 95% CI 0.340.83).
Shivering and chills were significantly more common with
misoprostol. There were no maternal deaths among
participants.Postpartum administration of 600 lg oral misoprostol
by trained TBAs at home deliveries reduces the rate of PPH by 24%.
Given its ease of use and low cost, misoprostol could reduce the
burden of PPH in community settings where universal oxytocin
prophylaxis is not feasible. Continual training and skill-building
for TBAs, along with monitoring and evaluation of programme
effectiveness, should accompany any widespread introduction of this
drug. Misoprostol may be the only feasible PPH prevention option,
it should be endorsed as a safe and effective alternative
intervention for use at home deliveries.5Georgina Msemo, Augustine
Massawe et.al, Newborn Mortality and Fresh Stillbirth Rates in
Tanzania After Helping Babies Breathe Training, Pediatrics
2013;131;e353; originally published online January 21, 2013; DOI:
10.1542/peds.2012-1795,
http://pediatrics.aappublications.org/content/131/2/e353.full.html2012design
was used for implementationHBB was implemented in 8 hospitals
designated as study sites. Master trainers from the 3 major
referral hospitals, 4 associated regional hospitals, and 1 district
hospital were trained in the HBB program to serve as trainers for
national disseminationA before(n = 8124) and after (n = 78
500)Implementation of HBB Training ProgramImplementation was
associated with a significant reduction in neonatal deaths
(relative risk [RR] with training 0.53; 95% confidence interval
[CI] 0.430.65; P =.0001) and rates of FSB (RR with training0.76;
95% CI 0.640.90; P = .001). The use of stimulation increased from
47% to 88% (RR 1.87; 95% CI 1.821.90; P =.0001) and suctioning from
15% to 22% (RR 1.40; 95% CI 1.331.46; P =.0001) whereas face mask
ventilation decreased from 8.2% to 5.2% (RR 0.65; 95% CI 0.600.72;
P = .0001).HBB implementation was associated with a significant
reduction in both early neonatal deaths within 24 hours and rates
of FSB. HBB uses a basic intervention approach readily applicable
at all deliveries. These findings should serve as a call to action
for other resource-limited countries striving to meet Millennium
Development Goal 46Gary L. Darmstadt, Anne CC Lee et.al,
INTRAPARTUM-RELATED DEATHS: EVIDENCE FOR ACTION 5; 60 million
non-facility births: Who can deliver in community settings to
reduce intrapartum-related deaths?, International Journal of
Gynecology and Obstetrics 107 (2009) S89S112, journal homepage:
www.elsevier.com/locate/ijgo2009review the evidence for the effect
of care by different community cadres during pregnancy and
childbirth. we use GRADE criteria to assess the quality of evidence
for the mortality-effect of these community-based providers on
outcomes related to acute intrapartum hypoxiaSearches of the
following databases of the medical literature were conducted:
PubMed, Popline, EMBASE, LILACS, IMEM, African Index Medicus,
Cochrane, and World Health Organization (WHO) documents.The initial
search was conducted in November 2002, and was updated May 2009.
Keyword searches relevant for this paper included birth
asphyxia/asphyxia neonatorum, hypoxic ischaemic
encephalopathy/hypoxic ischemic encephalopathy, neonatal
encephalopathy, or neonatal mortality, and a combination of
TBA/trained TBA/traditional birth attendant, community health
worker/village health workers/community health aides, birthing
center, skilled birth attendant/skilled attendant, or community
midwives OR midwifery.N/A not an interventionThe evidence for
providing skilled birth attendance in the community is low quality,
consisting of primarily before-and-after and quasi-experimental
studies, with a pooled 12% reduction in all cause perinatal
mortality (PMR) and a 22%47% reduction in intrapartum-related
neonatal mortality (IPR-NMR). Low/moderate quality evidence
suggests that TBA training may improve linkages with facilities and
improve perinatal outcomes. A randomized controlled trial (RCT) of
TBA training showed a 30% reduction in PMR, and a metaanalysis
demonstrated an 11% reduction in IPR-NMR. There is moderate
evidence that CHWs have a positive impact on perinatal-neonatal
outcomes. Meta-analysis of CHW packages (2 cluster randomized
controlled trials, 2 quasi-experimental studies) showed a 28%
reduction in PMR and a 36% reduction in early neonatal mortality
rate; one quasi-experimental study showed a 42% reduction in
IPR-NMR.Skilled childbirth care is recommended for all pregnant
women, and community strategies need to be linked to prompt,
high-quality emergency obstetric care. CHWs may play a promising
role in providing pregnancy and childbirth care, mobilizing
communities, and improving perinatal outcomes in low-income
settings. Whilethe role of the TBA is still controversial,
strategies emphasizing partnerships with the health system shouldbe
further considered. Innovative community-based strategies combined
with health systems strengthening may improve childbirth care for
the rural poor, help reduce gross inequities in maternal and
newborn survival and stillbirth rates, and provide an effective
transition to higher coverage for facility births.More research is
needed to determine the cost- effectiveness, sustainability,
scalability and long-term impact, including neurodevelopmental
outcomes, of such approaches. While the goal is to have a skilled
attendant at every birth, innovative community strategies with
health systems strengtheningmay provide childbirth care to the
poor, help reduce the gross inequities in maternal and newborn
survival and stillbirth rates, and provide an effective transition
to higher coverage for facility births.7Sabin LL, Knapp AB, MacLeod
WB, Phiri-Mazala G, Kasimba J, et al. (2012) Costs and
Cost-Effectiveness of Training Traditional Birth Attendants to
Reduce Neonatal Mortality in the Lufwanyama Neonatal Survival Study
(LUNESP). PLoS ONE 7(4): e35560.
doi:10.1371/journal.pone.0035560.2012LUNESP was a
cluster-randomized trialAll TBAs and mothers who participated in
the LUNESP trial, in an impoverished rural district in
north-central Zambia among a population with limited access to
health careA total of 120 TBAs were initially randomized to receive
the intervention trainings and equipment, or to continue their
existing standard of careAll TBAs received one clean delivery kit
per birth for their regular TBA duties, which included a delivery
sheet, cord cutter, cotton cord ties, latex gloves, and soap.
Training for intervention TBAs commenced with 4-day sessions for
each group of 30 TBAs, followed by 12 day refresher trainings
approximately every 34 months for the duration of the trial. The
trainings were conducted collaboratively by a US-based
neonatologist and a local master trainer (a Zambian nurse-midwife),
assisted by 68 Zambian facilitators. To demonstrate competency,
intervention TBAs indicated skills retention at each retraining
session. Each intervention TBA received one resuscitator mask, a
polypropylene bottle with chlorinated water, and a laminated
reference card summarizing NRP and trigger conditions for AFR. They
also received each of the following per delivery: two flannel
receiving blankets, a soft rubber bulb syringe, two 250 mg
amoxicillin capsules, one 2-ounce mixing cup and spoon, and a 3 ml
oral syringe. A more detailed description of the design, training,
and analytic methods used in LUNESP has been published elsewhereWe
calculated LUNESPs financial and economic costs and the economic
cost of implementation for a forecasted ten-year program
(20112020). In each case, we calculated the incremental cost per
death avoided and disability-adjusted life years (DALYs) averted in
real 2011 US dollars. The forecasted 10-year program analysis
included a base case as well as conservative and optimistic
scenarios. Uncertainty was characterized using one-way sensitivity
analyses and a multivariate probabilistic sensitivity analysis. The
estimated financial and economic costs of LUNESP were $118,574 and
$127,756, respectively, or $49,469 and $53,550 per year. Fixed
costs accounted for nearly 90% of total costs. For the 10-year
program, discounted total and annual program costs were $256,455
and $26,834 respectively; for the base case, optimistic, and
conservative scenarios, the estimated cost per death avoided was
$1,866, $591, and $3,024, and cost per DALY averted was $74, $24,
and $120, respectively. Outcomes were robust to variations in local
costs, but sensitive to variations in intervention effect size,
number of births attended by TBAs, and the extent of foreign
consultants participation.Based on established guidelines, the
strategy of using trained TBAs to reduce neonatal mortality was
highly cost effective. We strongly recommend consideration of this
approach for other remote rural populations with limited access to
health care. Moreover, it shows that the cost-effectiveness of this
strategy can likely be improved if implemented programmatically
over a longer time horizon and with deliberate cost-saving
measures. These results further strengthen the rationale for
implementing programs similar to LUNESP in other disadvantaged
communities with extremely limited access to health
care.8Christopher J. Gilla,b, Nicholas G. Guerinac, et. Al.,
Training Zambian traditional birth attendants to reduce neonatal
mortality in the Lufwanyama Neonatal Survival Project (LUNESP), Int
J Gynaecol Obstet. 2012 July ; 118(1): 7782.
doi:10.1016/j.ijgo.2012.02.0122012design was used for
implementationpregnant women, their husbands, clinic staff, and
TBAs; local village headmen and religious leaders98% of the TBAs
considered farming as their primary vocation. Their educational
level was low: 17% had never attended school and only 13% had
progressed beyond primary school. The TBAs were members of the
communitiesthey served, used clean delivery kits for every birth,
and were registered, supported, and tracked by the Lufwanyama DHMT.
On average, the intervention TBAs delivered 1.3 infants per month,
or approximately 33 infants per TBA (interquartile range, 1644;
maximum 112) during the study, which was conducted between
September 2006 and November 2008.The study tested 2 interventions:
a simplified version of the American Academy of Pediatrics neonatal
resuscitation protocol (NRP); and antibiotics with facilitated
referral (AFR).The LUNESP study showed that trained TBAs can be
highly effective at reducing neonatal mortality in remote rural
settings. Given how successful this strategy proved to be, it seems
puzzling that TBAs are so rarely included in national health
programs. Key elements that enabled the positive study result were:
focusing on common and correctible causes of mortality; selecting a
study population with high unmet public health need; early
community mobilization to build awareness and support; emphasizing
simplicity in the intervention technology and algorithms; using a
traditional training approach appropriate to students with low
literacy rates; requiring TBAs to demonstrate their competence
before completing each workshop; and minimizing attrition of skills
by retraining and reassessing the TBAs regularly throughout the
study.An effective NRP training model was created that is suitable
for community-based neonatal interventions, in research or
programmatic settings, and by practitioners with limited obstetric
skills and low rates of literacy.The skills and approaches adopted
in LUNESP should be highly generalizable to other remote
populations with limited access to health facilities.9L Keri, D
Kaye, and K Sibylle, Referral practices and perceived barriers to
timely obstetric care among Ugandan traditional birth attendants
(TBA), Journal List Afr Health Sciv.10(1); Mar 20102010Qualitative
methods All focus groups were held in Luganda, the local language
familiar to all research participants.The six focus groups, which
ranged in size from 5 to 12 participantsN/A not an
interventionWhile TBAs, particularly those with previous training,
appear willing to refer problematic pregnancies and labors, more
serious problems exist that could lessen any positive effects of
training. These problems include reported abuse by doctors and
nurses, and seeing fistula as a disease caused by
hospitals.Training of TBAs can be helpful to standardize knowledge
about and encourage timely emergency obstetric referrals, as well
as increase knowledge about the causes and preventions of obstetric
fistula. However, for full efficacy, training must be accompanied
by greater collaboration between biomedical and traditional health
personnel, and increased infrastructure to prevent mistreatment of
pregnant patients by medical staff.10Matendo et al. Reduced
perinatal mortality following enhanced training of birth attendants
in the Democratic Republic of Congo: a time-dependent effect, BMC
Medicine 2011, 9:93
http://www.biomedcentral.com/1741-7015/9/932011That study was a
population-based, prospective interventional study The number of
communities selected from the DRC was determined by the sample size
calculation for the FIRST BREATH Trial, and the number of
deliveries observed was a function of the timing of the study
periods for that trialBaseline data collection=Screened (n =
1,916), Consented (n = 1,893), Births < 1500 grams or missing (n
= 26), Eligible for primary outcome (n = 1,867), Post ENC baseline
data collection=Screened (n = 5,615), Consented (n = 5,612), Births
< 1500 grams or missing (n = 84), Eligible for primary outcome
(n = 5,528). Intervention group (NRP training): Screened (n =
2,930), Consented (n = 2,928), Births < 1500 grams or missing (n
= 45), Eligible for primary outcome (n = 2,883) dan control group
Screened (n = 3,365), Consented (n = 3,365), Births < 1500 grams
or missing (n = 48), Eligible for primary outcome (n = 3,317)study
conducted in two phases. In the first phase, theimpact of training
using the ENC program was evaluated using an active baseline
design. A period of prospective data collection was followed by ENC
training and continuation of data collection. This phase was
followed by a cluster randomized trial of training using an
adaptation of the Neonatal Resuscitation Program (NRP: American
Academy of Pediatrics and American Heart Association; 2000
edition). Communities were randomized to either receive NRP
training (intervention communities) or to continue to provide care
without additional training (control communities).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.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.A
train-thetrainermodel appears to be effective; the use of this
strategymay minimize the impact of the isolation of manyrural
communities and their distance from sites of traditionalmedical
education. Our findings suggest that implementationshould include a
strategy for re-enforcementfollowing the initial training.11Wilson
et.al, Effectiveness of strategies incorporating training and
support of traditional birth attendants on perinatal and maternal
mortality: meta-analysis, BMJ 2011;343:d7102 doi: 10.1136/bmj.d7102
(Published 1 December 2011)2011Systematic review with
meta-analysisMedline, Embase, the Allied and Complementary Medicine
database, British Nursing Index, Cochrane Library, Cumulative Index
to Nursing and Allied Health Literature, BioMed Central, PsycINFO,
Latin American and Caribbean Health Sciences Literature database,
African Index Medicus, Web of Science, Reproductive Health Library,
and Science Citation Index (from inception to April 2011), without
language restrictions. Search terms were birth attend*, traditional
midwife, lay birth attendant, dais, and comadronas.six cluster
randomised controlled trials (n=138 549) and seven non-randomised
controlled studies (n=72 225) that investigated strategies
incorporating training and support of traditional birth
attendants.N/A not an interventionAll six randomised controlled
trials found a reduction in adverse perinatal outcomes; our
meta-analysis showed significant reductions in perinatal death
(relative risk 0.76, 95% confidence interval 0.64 to 0.88, P
