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The impact of traditional birth attendant training on delivery complications in Ghana.
OBJECTIVES: In their efforts to reduce maternal and neonatal morbidity and mortality, many national and international agencies make considerable investments in training traditional birth attendants (TBAs). The value of TBA training is controversial, and plausible arguments are made both for and against. Numerous process evaluations are reported in the literature and the results are mixed, though generally positive. Outcome evaluations, however, are scarce. This article describes an outcome evaluation of TBA training conducted in two districts of Brong-Ahafo Region, Ghana, during 1996. DESIGN AND METHODS: Data from a random sample survey of 1961 clients of TBAs were subjected to logistic regression modelling to determine the effect of training on maternal outcomes, controlling for other independent variables. RESULTS: Of eight outcomes modelled, three were associated with training and five were not. Three additional outcomes were not modelled, primarily due to low prevalence. CONCLUSIONS: Despite some inherent design limitations, this study found that the evidence for a beneficial impact of TBA training was not compelling. Training sponsors should consider alternative health investments and, where TBA training remains the intervention of choice, be realistic about expectations of impact.
Perinatal and infant mortality.
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Care of the low birthweight infant in developing countries.
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Levels and determinants of early neonatal mortality in Natal, northeastern Brazil: results of a surveillance and case-control study.
An institution-based surveillance and nested case-control study was conducted in Natal, Northeastern Brazil to estimate the level and determinants of early neonatal mortality. The early neonatal mortality rate was 25.5 per 1000 live-birth, 75% of early neonatal deaths were premature low birthweight infants, and the mortality rates were 591 and 318 per 1000 respectively, for preterm small for gestational age (PT-SGA) and preterm appropriate for gestational age (PT-AGA) infants. Mortality was 50 per 1000 for term low birthweight, and 8.6 for term normal birthweight AGA infants. In addition to prematurity and low birthweight, the main risk factors associated with early neonatal death were maternal smoking, complications during pregnancy or intrapartum, and inadequate antenatal care. The associations were weaker for prepregnancy factors such as single marital status or low maternal body weight, and no significant associations were observed with socioeconomic status. These findings suggest that in this population, efforts to reduce early neonatal death should focus on improved maternal care and the prevention of prematurity.
Neonatology in the developing world. Part 1.
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Undergraduate training in neonatal resuscitation -- a modified approach.
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Strategies to reduce neonatal mortality.
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Birth kits for safe motherhood in Bangladesh.
Tetanus infection remains the leading cause of high neonatal mortality in Bangladesh. Birth kits which instruct and assist in a clean, safe birth are seen as a key measure in reducing the high incidence of neonatal deaths. A multisectoral programme has developed a simple kit and tested its potential for distribution to pregnant women. Initial results are positive and development is continuing.
Lessons from improved neonatal survival at Chandigarh.
We observed a significant fall in neonatal mortality in babies weighing less than 2 kg during 1986 as compared to 1973 (7.94% vs 12.88%; p less than 0.005), and in preterm babies the mortality fell from 26.88 to 11.5% (p less than 0.001) during 1986. This was achieved despite 2-3 fold increase in the high risk babies and without any increase in the number of neonatal special care beds or nurses. Effective utilisation of the facilities was made possible through: (a) reduction in admissions to neonatal special care unit of babies with birth weight more than 1500 g; (b) early discharge of babies to home from NSCU; (c) involvement of the mothers in the care of their high risk babies: and (d) care of babies with sucking difficulties and asymptomatic birth asphyxia outside NSCU. All babies discharged home at less than 2 kg weight, and living in Chandigarh were followed for 3 months and 98.2% were doing well. This observation highlights the judicious use of neonatal special care facilities and mothers for the care of high risk neonates.
Risk-approach strategy in neonatal care.
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Status of neonatal intensive care units in India.
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Breast-feeding promotes child spacing; delayed ovulation lengthens birth intervals.
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Pediatric mortality: an avoidable tragedy.
The article analyzes the causes of pediatric mortality. One thousand deaths secondary to medical diseases and conditions that occurred at the American University of Beirut Medical Center during 8 years are reviewed. Many deaths could have been avoided. Recommendations are made.
Training and education in perinatal and neonatal care.
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Reduction in pneumonia mortality and total childhood mortality by means of community-based intervention trial in Gadchiroli, India.
In a community-based intervention trial to reduce childhood mortality from pneumonia the intervention area included 58 villages (6176 children aged 0-4 years) and the control area 44 villages (3947 children) in Gadchiroli, India. The interventions included mass education about childhood pneumonia and case-management of pneumonia by paramedics, village health workers, and traditional birth attendants (TBAs) who were trained to recognise childhood pneumonia and treat it with co-trimoxazole. Parents sought treatment, and coverage was 76% without active case-detection efforts. The case-fatality rate among the 612 cases treated by health workers was 0.8%, compared with 13.5% in the control area. After a year of intervention pneumonia-specific childhood mortality was significantly lower in the intervention than in the control area (8.1 vs 17.5 deaths per 1000 children under 5 years); the difference between the areas was greatest in children under 1 year. The differences in infant mortality (89 vs 121 per 1000) and total under-5 mortality (28.5 vs 40.7 per 1000) were highly significant. Mortality from other causes remained similar in the two areas but neonatal mortality due to birth injury and prematurity was significantly lower in the intervention area, presumably owing to the combination of better maternal and neonatal care by the TBAs trained in the project and the availability of treatment for pneumonia. The cost of co-trimoxazole was US $0.025 per child per year ($2.64 per child saved).
Prediction and prevention of pregnancy-induced hypertensive disorders.
Because hypertensive disorders complicating pregnancy are common and constitute a leading cause of maternal, fetal and neonatal morbidity and mortality, prevention attempts appear to be justified. Primary prevention is only possible by avoiding pregnancy. Secondary prevention requires identification of patients at risk. A large number of predictive methods have been published and the majority appear to be of no or limited value. At present only the determination of inactive urinary kallikrein and uteroplacental colour-pulsed Doppler velocimetry show promise and require further assessment. Analysis of the many interventions advocated for prevention of pre-eclampsia reveals that only dietary calcium supplementation and prophylactic low-dose aspirin have shown promise of efficacy in small controlled clinical trials, but the results of large, multicentre trials are disappointing. The disappointing results obtained in large, multicentre trials may be explained, at least in part, by the lack of strict eligibility criteria and end-points and by low patient compliance. Prophylactic low-dose aspirin is recommended in women at high risk because it is associated with a moderate reduction in risk, may reduce the severity of pre-eclampsia if it develops and appears to be safe for mother and infant. The present data do not support any prophylactic intervention in pregnant women at low or medium risk.
Pattern of preventable diseases in Afghanistan: suggestions to reduce the morbidity and mortality at IGICH.
Over nine years period (1354-1362), 1,39,436 children were admitted in Indira Gandhi Institute of Child Health (IGICH), Kabul. Of these 51,212 (46.8%) children were hospitalised with preventable diseases. Seventy four per cent of patients were under five years of age. Among the infectious diseases, gastroenteritis accounted for nearly 70% of admissions. Tuberculosis, measles, diphtheria and typhoid fever were other common infectious diseases. Malnutrition of varying degree was the core problem among the hospitalised children and was seen in nearly two thirds of admissions. Twenty per cent of them had severe protein energy malnutrition which contributed for higher mortality. Gastroenteritis contributed for half (51.5%) of the mortality. Septicemia, tetanus neonatorum and central nervous system infections were associated with high mortality especially among the neonates. Deaths following 6-target preventable diseases accounted for nearly 1/4th of deaths (20.4-24.6%) over these years.