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Study: An Intervention Involving Traditional Birth Attendants and Perinatal and Maternal Mortality in Pakistan

A study  in the New England Journal of Medicine shows that use of clean birth kits by birth attendants, in conjunction with to antenatal visits, effectively reduced perinatal mortality in Pakistan.

Background.  There are approximately 4 million neonatal deaths and half a million maternal deaths worldwide each year. There is limited evidence from clinical trials to guide the development of effective maternity services in developing countries.
Me thods.  We performed a cluster-randomized, controlled trial involving seven subdistricts (talukas) of a rural district in Pakistan. In three talukas randomly assigned to the intervention group, traditional birth attendants were trained and issued disposable delivery kits; Lady Health Workers linked traditional birth attendants with established services and documented processes and outcomes; and obstetrical teams provided outreach
clinics for antenatal care. Women in the four control talukas received usual care. The primary outcome measures were perinatal and maternal mortality.

Conclus ions

Training traditional birth attendants and integrating them into an improved health care system were achievable and effective in reducing perinatal mortality. This model could result in large improvements in perinatal and maternal health in developing countries.

Research on Maternal and Infant Sepsis

In Maternal and early onset neonatal bacterial sepsis: burden and strategies for prevention in sub-Saharan Africa, Seale et al find gaps in the research on maternal and newborn sepsis.  I just read the summary here http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(09)70172-0/abstract.  Their work seems to substantiates providing clean, antiseptic conditions for birth.

Bolstering the argument for preventing sepsis following birth, they find that:

Although existing published data suggest that sepsis causes about 10% of all maternal deaths and 26% of neonatal deaths, these are likely to be considerable underestimates because of methodological limitations.  Successful intervention strategies in resource-rich settings and early studies in sub-Saharan Africa suggest that the burden of maternal and early onset neonatal bacterial sepsis could be reduced through simple interventions, including antiseptic and antibiotic treatment.

Chlorhexidine Prevents Infection in Newborns

Cord infection is common after homebirths occuring in “low resource settings” .  This study in rural Pakistan finds that the use of  4% chlorhexidine (CHX) solution was effective in reducing the risk of infection.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61877-1/abstract

Topical application of chlorhexidine to neonatal umbilical cords for prevention of omphalitis and neonatal mortality in a rural district of Pakistan: a community-based, cluster-randomised trial
Sajid Soofi FCPS a, Prof Simon Cousens Dip MathsStats a b, Aamer Imdad MBBS a, Naveed Bhutto MBBS a, Nabeela Ali MPH c, ProfZulfiqar A Bhutta PhD a b Corresponding AuthorEmail Address

Summary

Background

Umbilical cord infection (omphalitis) is a risk factor for neonatal sepsis and mortality in low-resource settings where home deliveries are common. We aimed to assess the effect of umbilical-cord cleansing with 4% chlorhexidine (CHX) solution, with or without handwashing with antiseptic soap, on the incidence of omphalitis and neonatal mortality.

Methods

We did a two-by-two factorial, cluster-randomised trial in Dadu, a rural area of Sindh province, Pakistan. Clusters were defined as the population covered by a functional traditional birth attendant (TBA), and were randomly allocated to one of four groups (groups A to D) with a computer-generated random number sequence. Implementation and data collection teams were masked to allocation. Liveborn infants delivered by participating TBAs who received birth kits were eligible for enrolment in the study. One intervention comprised birth kits containing 4% CHX solution for application to the cord at birth by TBAs and once daily by family members for up to 14 days along with soap and educational messages promoting handwashing. One intervention was CHX solution only and another was handwashing only. Standard dry cord care was promoted in the control group. The primary outcomes were incidence of neonatal omphalitis and neonatal mortality. The trial is registered with ClinicalTrials.gov, number NCT00682006.

Findings

187 clusters were randomly allocated to one of the four study groups. Of 9741 newborn babies delivered by participating TBAs, factorial analysis indicated a reduction in risk of omphalitis with CHX application (risk ratio [RR]=0·58, 95% CI 0·41—0·82; p=0·002) but no evidence of an effect of handwashing (RR=0·83, 0·61—1·13; p=0·24). We recorded strong evidence of a reduction in neonatal mortality in neonates who received CHX cleansing (RR=0·62, 95 % CI 0·45—0·85; p=0·003) but no evidence of an effect of handwashing promotion on neonatal mortality (RR=1·08, 0·79—1·48; p=0·62). We recorded no serious adverse events.

Interpretation

Application of 4% CHX to the umbilical cord was effective in reducing the risk of omphalitis and neonatal mortality in rural Pakistan. Provision of CHX in birth kits might be a useful strategy for the prevention of neonatal mortality in high-mortality settings.

Funding

The United States Agency for International Development.

Women and Children First: Good Practice Guide

This Women and Children First Good Practice Guide details a project, focused on community involvement and education to improve the health of mothers and babies.   The project was administered by Ekjut in India and the Perinatal Care Project of the Diabetic Association of Bangladesh (BADAS) in Bangladesh (with the the University College London Centre for International Health and Development and Women and Children First.)

In India, the project resulted in a 45 per cent reduction in newborn deaths and a reduction in maternal deaths, as well as a 57 per cent reduction in moderate maternal depression. In Bangladesh, the project resulted in an increase in uptake of health services. In both India and Bangladesh, the project resulted in a significant improvement in hygienic delivery practices, including use of delivery kits, and an increase in exclusive breastfeeding.

Some effective measures:

Emergency funds to cover transport and medical fees, providing pregnant women with advice and support and, in some Community Mobilisation through Women’s Groups to Improve the Health of Mothers and Babies: Good Practice Guide cases, promoting the use of clean delivery kits for home birth. Women’s groups also held community meetings to raise awareness of maternal and newborn health problems, discuss their proposed strategies and provide feedback to the community on actions and progress.

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