Trainers' perception of the learning environment and student competency: A qualitative investigation of midwifery and anesthesia training programs in Ethiopia.

BACKGROUND: Ethiopia has successfully expanded training for midwives and anesthetists in public institutions. This study explored the perceptions of trainers (instructors, clinical lab assistants and preceptors) towards the adequacy of students' learning experience and implications for achieving mastery of core competencies. METHODS: In-depth interviews with 96 trainers at 9 public universities and 17 regional health science colleges across Ethiopia were conducted to elicit their opinions about available resources, program curriculum suitability, and competence of graduating students. Using Dedoose, data were thematically analyzed using grounded theory. RESULTS: Perceptions of anesthesia and midwifery programs were similar. Common challenges included unpreparedness and poor motivation of students, shortages of skills lab space and equipment, difficulties ensuring students' exposure to sufficient and varied enough cases to develop competence, and lack of coordination between academic training institutions and clinical attachment sites. Additional logistical barriers included lack of student transport to clinical sites. Informants recommended improved recruitment strategies, curriculum adjustments, increased time in skills labs, and better communication across academic and clinical sites. CONCLUSIONS: An adequate learning environment ensures that graduating midwives and anesthetists are competent to provide quality services. Minimizing the human resource, infrastructural and logistical gaps identified in this study requires continued, targeted investment in health systems strengthening.

Reducing stillbirths: behavioural and nutritional interventions before and during pregnancy.

BACKGROUND: The vast majority of global stillbirths occur in low- and middle-income countries, and in many settings, the majority of stillbirths occur antenatally, prior to the onset of labour. Poor nutritional status, lack of antenatal care and a number of behaviours increase women's risk of stillbirth in many resource-poor settings. Interventions to reduce these risks could reduce the resulting burden of stillbirths, but the evidence for the impact of such interventions has not yet been comprehensively evaluated. METHODS: This second paper of a systematic review of interventions that could plausibly impact stillbirth rates covers 12 different interventions relating to behavioural and socially mediated risk factors, including exposures to harmful practices and substances, antenatal care utilisation and quality, and maternal nutrition before and during pregnancy. The search strategy reviewed indexed medical journals on PubMed and the Cochrane Library. If any eligible randomised controlled trials were identified that were published after the most recent Cochrane review, they were added to generate new meta-analyses. Interventions covered in this paper have a focus on low- and middle-income countries, both because of the large burden of stillbirths and because of the high prevalence of risk factors including maternal malnutrition and harmful environmental exposures. The reviews and studies belonging to these interventions were graded and conclusions derived about the evidence of benefit of these interventions. RESULTS: From a programmatic perspective, none of the interventions achieved clear evidence of benefit. Evidence for some socially mediated risk factors were identified, such as exposure to indoor air pollution and birth spacing, but still require the development of appropriate interventions. There is a need for additional studies on culturally appropriate behavioural interventions and clinical trials to increase smoking cessation and reduce exposure to smokeless tobacco. Balanced protein-energy supplementation was associated with reduced stillbirth rates, but larger well-designed trials are required to confirm findings. Peri-conceptional folic acid supplementation significantly reduces neural tube defects, yet no significant associated reductions in stillbirth rates have been documented. Evidence for other nutritional interventions including multiple micronutrient and Vitamin A supplementation is weak, suggesting the need for further research to assess potential of nutritional interventions to reduce stillbirths. CONCLUSION: Antenatal care is widely used in low- and middle-income countries, and provides a natural facility-based contact through which to provide or educate about many of the interventions we reviewed. The impact of broader socially mediated behaviors, such as fertility decision-making, access to antenatal care, and maternal diet and exposures like tobacco and indoor air pollution during pregnancy, are poorly understood, and further research and appropriate interventions are needed to test the association of these behaviours with stillbirth outcomes. For most nutritional interventions, larger randomised controlled trials are needed which report stillbirths disaggregated from composite perinatal mortality. Many antepartum stillbirths are potentially preventable in low- and middle-income countries, particularly through dietary and environmental improvement, and through improving the quality of antenatal care - particularly including diagnosis and management of high-risk pregnancies - that pregnant women receive.

Reducing stillbirths: prevention and management of medical disorders and infections during pregnancy.

BACKGROUND: An estimated two-thirds of the world's 3.2 million stillbirths occur antenatally, prior to labour, and are often overlooked in policy and programs. Poorly recognised, untreated or inadequately treated maternal infections such as syphilis and malaria, and maternal conditions including hypertensive disorders, are known risk factors for stillbirth. METHODS: We undertook a systematic review of the evidence for 16 antenatal interventions with the potential to prevent stillbirths. We searched a range of sources including PubMed and the Cochrane Library. For interventions with prior Cochrane reviews, we conducted additional meta-analyses including eligible newer randomised controlled trials following the Cochrane protocol. We focused on interventions deliverable at the community level in low-/middle-income countries, where the burden of stillbirths is greatest. RESULTS: Few of the studies we included reported stillbirth as an outcome; most that did were underpowered to assess this outcome. While Cochrane reviews or meta-analyses were available for many interventions, few focused on stillbirth or perinatal mortality as outcomes, and evidence was frequently conflicting. Several interventions showed clear evidence of impact on stillbirths, including heparin therapy for certain maternal indications; syphilis screening and treatment; and insecticide-treated bed nets for prevention of malaria. Other interventions, such as management of obstetric intrahepatic cholestasis, maternal anti-helminthic treatment, and intermittent preventive treatment of malaria, showed promising impact on stillbirth rates but require confirmatory studies. Several interventions reduced known risk factors for stillbirth (e.g., anti-hypertensive drugs for chronic hypertension), yet failed to show statistically significant impact on stillbirth or perinatal mortality rates. Periodontal disease emerged as a clear risk factor for stillbirth but no interventions have reduced stillbirth rates. CONCLUSION: Evidence for some newly recognised risk factors for stillbirth, including periodontal disease, suggests the need for large, appropriately designed randomised trials to test whether intervention can minimise these risks and prevent stillbirths. Existing evidence strongly supports infection control measures, including syphilis screening and treatment and malaria prophylaxis in endemic areas, for preventing antepartum stillbirths. These interventions should be incorporated into antenatal care programs based on attributable risks and burden of disease.

Practices of rural Egyptian birth attendants during the antenatal, intrapartum and early neonatal periods.

Neonatal deaths account for almost two-thirds of infant mortality worldwide; most deaths are preventable. Two-thirds of neonatal deaths occur during the first week of life, usually at home. While previous Egyptian studies have identified provider practices contributing to maternal mortality, none has focused on neonatal care. A survey of reported practices of birth attendants was administered. Chi-square tests were used for measuring the statistical significance of inter-regional differences. In total, 217 recently-delivered mothers in rural areas of three governorates were interviewed about antenatal, intrapartum and postnatal care they received. This study identified antenatal advice of birth attendants to mothers about neonatal care and routine intrapartum and postpartum practices. While mothers usually received antenatal care from physicians, traditional birth attendants (dayas) conducted most deliveries. Advice was rare, except for breastfeeding. Routine practices included hand-washing by attendants, sterile cord-cutting, prompt wrapping of newborns, and postnatal home visits. Suboptimal practices included lack of disinfection of delivery instruments, unhygienic cord care, lack of weighing of newborns, and lack of administration of eye prophylaxis or vitamin K. One-third of complicated deliveries occurred at home, commonly attended by relatives, and the umbilical cord was frequently pulled to hasten delivery of the placenta. In facilities, mothers reported frequent use of forceps, and asphyxiated neonates were often hung upside-down during resuscitation. Consequently, high rates of birth injuries were reported. Priority areas for behaviour change and future research to improve neonatal health outcomes were identified, specific to type of provider (physician, nurse, or daya) and regional variations in practices.

Impact of packaged interventions on neonatal health: a review of the evidence.

A disproportionate burden of infant and under-five childhood mortality occurs during the neonatal period, usually within a few days of birth and against a backdrop of socio-economic deprivation in developing countries. To guide programmes aimed at averting these 4 million annual deaths, recent reviews have evaluated the efficacy and cost-effectiveness of individual interventions during the antenatal, intrapartum and postnatal periods in reducing neonatal mortality, and packages of interventions have been proposed for wide-scale implementation. However, no systematic review of the empirical data on packages of interventions, including consideration of community-based intervention packages, has yet been performed. To address this gap, we reviewed peer-reviewed journals and grey literature to evaluate the content, impact, efficacy (implementation under ideal circumstances), effectiveness (implementation within health systems), type of provider, and cost of packages of interventions reporting neonatal health outcomes. Studies employing more than one biologically plausible neonatal health intervention (i.e. package) and reporting neonatal morbidity or mortality outcomes were included. Studies were ordered by study design and mortality stratum, and their component interventions classified by time period of delivery and service delivery mode. We found 41 studies that implemented packages of interventions and reported neonatal health outcomes, including 19 randomized controlled trials. True effectiveness trials conducted at scale in health systems were completely lacking. No study targeted women prior to conception, antenatal interventions were largely micronutrient supplementation studies, and intrapartum interventions were limited principally to clean delivery. Few studies approximated complete packages recommended in The Lancet's Neonatal Survival Series. Interventions appeared largely bundled out of convenience or funding requirements, rather than based on anticipated synergistic effects, like service delivery mode or cost-effectiveness. Only two studies reported cost-effectiveness data. The evidence base for the impact of neonatal health intervention packages is a weak foundation for guiding effective implementation of public health programmes addressing neonatal health. Significant investment in effectiveness trials carefully tailored to local health needs and conducted at scale in developing countries is required.

Reducing one million child deaths from birth asphyxia--a survey of health systems gaps and priorities.

BACKGROUND: Millions of child deaths and stillbirths are attributable to birth asphyxia, yet limited information is available to guide policy and practice, particularly at the community level. We surveyed selected policymakers, programme implementers and researchers to compile insights on policies, programmes, and research to reduce asphyxia-related deaths. METHOD: A questionnaire was developed and pretested based on an extensive literature review, then sent by email (or airmail or fax, when necessary) to 453 policymakers, programme implementers, and researchers active in child health, particularly at the community level. The survey was available in French and English and employed 5-point scales for respondents to rate effectiveness and feasibility of interventions and indicators. Open-ended questions permitted respondents to furnish additional details based on their experience. Significance testing was carried out using chi-square, F-test and Fisher's exact probability tests as appropriate. RESULTS: 173 individuals from 32 countries responded (44%). National newborn survival policies were reported to exist in 20 of 27 (74%) developing countries represented, but respondents' answers were occasionally contradictory and revealed uncertainty about policy content, which may hinder policy implementation. Respondents emphasized confusing terminology and a lack of valid measurement indicators at community level as barriers to obtaining accurate data for decision making. Regarding interventions, birth preparedness and essential newborn care were considered both effective and feasible, while resuscitation at community level was considered less feasible. Respondents emphasized health systems strengthening for both supply and demand factors as programme priorities, particularly ensuring wide availability of skilled birth attendants, promotion of birth preparedness, and promotion of essential newborn care. Research priorities included operationalising birth preparedness, effectively evaluating pregnancy risk in the community, ensuring roles for traditional birth attendants (TBAs) that link them with the health system, testing the cost-effectiveness of various community cadres for resuscitation, and developing a clear case definition for case management and population monitoring. CONCLUSION: Without more attention to improve care and advance birth asphyxia research, the 2 million deaths related to asphyxia, plus associated maternal deaths, will remain out of reach of effective care, either skilled or community level, for many years to come.

Community-based interventions for improving perinatal and neonatal health outcomes in developing countries: a review of the evidence.

BACKGROUND: Infant and under-5 childhood mortality rates in developing countries have declined significantly in the past 2 to 3 decades. However, 2 critical indicators, maternal and newborn mortality, have hardly changed. World leaders at the United Nations Millennium Summit in September 2000 agreed on a critical goal to reduce deaths of children <5 years by two thirds, but this may be unattainable without halving newborn deaths, which now comprise 40% of all under-5 deaths. Greater emphasis on wide-scale implementation of proven, cost-effective measures is required to save women's and newborns' lives. Approximately 99% of neonatal deaths take place in developing countries, mostly in homes and communities. A comprehensive review of the evidence base for impact of interventions on neonatal health and survival in developing-country communities has not been reported. OBJECTIVE: This review of community-based antenatal, intrapartum, and postnatal intervention trials in developing countries aimed to identify (1) key behaviors and interventions for which the weight of evidence is sufficient to recommend their inclusion in community-based neonatal care programs and (2) key gaps in knowledge and priority areas for future research and program learning. METHODS: Available published and unpublished data on the impact of community-based strategies and interventions on perinatal and neonatal health status outcomes were reviewed. Evidence was summarized systematically and categorized into 4 levels of evidence based on study size, location, design, and reported impact, particularly on perinatal or neonatal mortality. The evidence was placed in the context of biological plausibility of the intervention; evidence from relevant developed-country studies; health care program experience in implementation; and recommendations from the World Health Organization and other leading agencies. RESULTS: A paucity of community-based data was found from developing-country studies on health status impact for many interventions currently being considered for inclusion in neonatal health programs. However, review of the evidence and consideration of the broader context of knowledge, experience, and recommendations regarding these interventions enabled us to categorize them according to the strength of the evidence base and confidence regarding their inclusion now in programs. This article identifies a package of priority interventions to include in programs and formulates research priorities for advancing the state of the art in neonatal health care. CONCLUSIONS: This review emphasizes some new findings while recommending an integrated approach to safe motherhood and newborn health. The results of this study provide a foundation for policies and programs related to maternal and newborn health and emphasizes the importance of health systems research and evaluation of interventions. The review offers compelling support for using research to identify the most effective measures to save newborn lives. It also may facilitate dialogue with policy makers about the importance of investing in neonatal health.