February 17, 2010

BIRMINGHAM, Ala - New findings in a study led by the director of the University of Alabama at Birmingham (UAB) Division of Neonatology show that that training birth attendants in essential newborn-care techniques reduced stillbirths by more than 30 percent - and potentially could save as many as 1 million lives worldwide each year.

Ninety-eight percent of the 3.7 million neonatal deaths and 3.3 million stillbirths each year occur in developing countries. This project, spearheaded by UAB's Waldemar A. Carlo, M.D., was designed to train birth attendants, including doctors, midwives, nurses and traditional birth attendants, in communities and hospitals in 96 communities worldwide. The findings were published in the Feb. 18 edition of the New England Journal of Medicine.

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"The birth attendants were trained to do several easy steps that are critical for babies to survive at birth and be kept alive through the first week of life," said Carlo, the lead author who worked with a large group of American and international colleagues. "We selected the World Health Organization course on essential newborn care because it contains what we believed are the essential interventions necessary to sustain life in many infants and created an educational package that included interventions that could be used by any birth attendant anywhere in the world."

Using the train-the-trainer model, local instructors trained birth attendants from rural communities in Argentina, Democratic Republic of Congo, Guatemala, India, Pakistan and Zambia. They used the World Health Organization (WHO) newborn-care course (routine neonatal care, resuscitation, thermoregulation, breastfeeding, kangaroo care, care of the small baby and common illnesses) and a modified version of the American Academy of Pediatrics Neonatal Resuscitation Program (in-depth basic resuscitation).

The goal was to see if training birth attendants to use these interventions would reduce perinatal and neonatal mortality in the first week of life in infants weighing at least 1500 grams in rural communities in developing countries.

"Major global causes of perinatal mortality are birth asphyxia and low birth weight/prematurity," Carlo said. "We wanted to find out if these low-cost interventions, including neonatal resuscitation training and kangaroo care, effectively reduced deaths from these causes worldwide. A preliminary smaller study in Zambia has shown that improved skill and knowledge in birth attendants in perinatal care reduced neonatal mortality."

Kangaroo care is a technique used on a newborn, usually a preterm infant, wherein the infant is held, skin-to-skin, with an adult. It is used to provide closeness of the newborn with mother and/or father to ensure physiological and psychological warmth and bonding. The kangaroo position also provides ready access to nourishment. The mother's body responds to the needs of the infant directly, helping regulate the infant's body temperature more smoothly than an incubator; her milk adjusts to the nutritional and immunological needs of her fragile infant, and the baby sleeps more soundly.

The train-the-trainer program used various teaching methods, including clinical practice sessions and demonstrations for the trainers. Carlo and his colleagues also developed instructions on the essential techniques with visual cues to assist birth attendants who could not read. The essential newborn-care intervention was assessed with a before-and-after design. The neonatal resuscitation program intervention was assessed as a cluster randomized control trial.

The stillbirth rate decreased significantly for nurses/midwives and traditional birth attendants following essential newborn care training. The stillbirth rate also decreased among home deliveries. There was not a significant decrease in all-cause first week mortality or stillbirth for those using the in-depth neonatal resuscitation program.

Carlo said it is plausible that the observed reduction in stillbirths may be due to essential newborn-care training. Live-born infants without obvious signs of life may have been misidentified as stillbirths before this training; such misclassifications have been reported in the literature. After training, resuscitation was more likely, and stillbirths decreased.

Carlo added that though the data show that training in basic neonatal care has an important role in improving perinatal outcomes in the developing world, more scaled-up research is needed to prove that the training reduces mortality in other health-care systems.

"A package of essential newborn-care interventions, if implemented worldwide, might decrease perinatal deaths by about 1 million per year," he said.

About the UAB Department of Pediatrics and Division of Neonatology

The UAB Department of Pediatrics and UAB Division of Neonatology, together with Children's Hospital of Alabama, operate the state's only Level IIIC Regional Neonatal Intensive Care Unit (RNICU) and provide the state's highest level and most comprehensive care for well newborns and preterm and term babies with medical conditions. In addition to the RNICU, UAB also is home to a Continuing Care Nursery (CCN), providing extended step-down care for premature infants and infants with medical conditions. UAB is one of the original eight National Institute of Child Health and Human Development (NICHD) research sites commissioned in 1986 and is the only facility in the country that is involved in all three of the NIH research initiatives for maternal, child and family health, the Neonatal Research Network, Maternal-Fetal Medicine Units Network and the Global Network for Women and Children Research.