title: Reduced perinatal mortality following enhanced training of birth attendants in the Democratic Republic of Congo: a time-dependent effect.
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.
  
  
  CONCLUSIONS
  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.
  
  
  BACKGROUND
  This trial has been registered at http://www.clinicaltrials.gov (identifier NCT00136708).
authors.affiliation: Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo. rmatendo@yahoo.fr
authors.forename: Richard
authors.initials: R
authors.lastname: Matendo
authors.forename: Cyril
authors.initials: C
authors.lastname: Engmann
authors.forename: John
authors.initials: J
authors.lastname: Ditekemena
authors.forename: Justin
authors.initials: J
authors.lastname: Gado
authors.forename: Antoinette
authors.initials: A
authors.lastname: Tshefu
authors.forename: Rinko
authors.initials: R
authors.lastname: Kinoshita
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: McClure
authors.forename: Janet
authors.initials: J
authors.lastname: Moore
authors.forename: Dennis
authors.initials: D
authors.lastname: Wallace
authors.forename: Waldemar A
authors.initials: WA
authors.lastname: Carlo
authors.forename: Linda L
authors.initials: LL
authors.lastname: Wright
authors.forename: Carl
authors.initials: C
authors.lastname: Bose
mesh_terms: D001238:Asphyxia Neonatorum / Q000517:prevention & control; D015023:Democratic Republic of the Congo / Q000453:epidemiology; D004501:Education, Medical / Q000379:methods*; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007231:Infant, Newborn; D017053:Infection Control; D008297:Male; D008880:Midwifery / Q000193:education*; D054238:Perinatal Mortality / Q000639:trends*; D011247:Pregnancy; D011446:Prospective Studies; D013997:Time Factors