title: The impact of training non-physician clinicians in Malawi on maternal and perinatal mortality: a cluster randomised controlled evaluation of the enhancing training and appropriate technologies for mothers and babies in Africa (ETATMBA) project.
abstract: BACKGROUND
  Maternal mortality in much of sub-Saharan Africa is very high whereas there has been a steady decline in over the past 60 years in Europe. Perinatal mortality is 12 times higher than maternal mortality accounting for about 7 million neonatal deaths; many of these in sub-Saharan countries. Many of these deaths are preventable. Countries, like Malawi, do not have the resources nor highly trained medical specialists using complex technologies within their healthcare system. Much of the burden falls on healthcare staff other than doctors including non-physician clinicians (NPCs) such as clinical officers, midwives and community health-workers. The aim of this trial is to evaluate a project which is training NPCs as advanced leaders by providing them with skills and knowledge in advanced neonatal and obstetric care. Training that will hopefully be cascaded to their colleagues (other NPCs, midwives, nurses).
  
  
  METHODS
  This is a cluster randomised controlled trial with the unit of randomisation being the 14 districts of central and northern Malawi (one large district was divided into two giving an overall total of 15). Eight districts will be randomly allocated the intervention. Within these eight districts 50 NPCs will be selected and will be enrolled on the training programme (the intervention). Primary outcome will be maternal and perinatal (defined as until discharge from health facility) mortality. Data will be harvested from all facilities in both intervention and control districts for the lifetime of the project (3-4 years) and comparisons made. In addition a process evaluation using both quantitative and qualitative (e.g. interviews) will be undertaken to evaluate the intervention implementation.
  
  
  CONCLUSIONS
  Education and training of NPCs is a key to improving healthcare for mothers and babies in countries like Malawi. Some of the challenges faced are discussed as are the potential limitations. It is hoped that the findings from this trial will lead to a sustainable improvement in healthcare and workforce development and training.
  
  
  BACKGROUND
  ISRCTN63294155.
authors.affiliation: Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK. d.r.ellard@warwick.ac.uk
authors.forename: David
authors.initials: D
authors.lastname: Ellard
authors.forename: Doug
authors.initials: D
authors.lastname: Simkiss
authors.forename: Siobhan
authors.initials: S
authors.lastname: Quenby
authors.forename: David
authors.initials: D
authors.lastname: Davies
authors.forename: Ngianga-bakwin
authors.initials: NB
authors.lastname: Kandala
authors.forename: Francis
authors.initials: F
authors.lastname: Kamwendo
authors.forename: Chisale
authors.initials: C
authors.lastname: Mhango
authors.forename: Joseph Paul
authors.initials: JP
authors.lastname: O'Hare
mesh_terms: D000328:Adult; D003150:Community Health Workers / Q000193:education*; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D008295:Malawi; D008428:Maternal Mortality; D008880:Midwifery / Q000193:education*; D009774:Obstetrics / Q000193:education*; D018743:Perinatal Care; D054238:Perinatal Mortality; D011247:Pregnancy