Background Ninety-eight percent of the 3.7 million neonatal deaths and 3.3 million stillbirths per year occur in developing countries, and evaluation of community-based interventions is needed. Methods Using a train-the-trainer model, local instructors trained birth attendants from rural communities in six countries (Argentina, Democratic Republic of Congo, Guatemala, India, Pakistan, and Zambia) in the World Health Organization Essential Newborn Care course (routine neonatal care, resuscitation, thermoregulation, breastfeeding, kangaroo care, care of the small baby, and common illnesses), and in a modified version of the American Academy of Pediatrics Neonatal Resuscitation Program (in depth basic resuscitation), except in Argentina. The Essential Newborn Care intervention was assessed with a before and after design (N=57, 643). The Neonatal Resuscitation Program intervention was assessed as a cluster randomized controlled trial (N=62,366). The primary outcome was 7-day neonatal mortality. Results The 7-day follow-up rate was 99.2%. Following Essential Newborn Care training, there was no significant reduction from baseline in all-cause 7-day neonatal (RR 0.99; CI 0.81, 1.22) or perinatal mortality; there was a significant reduction in the stillbirth rate (RR 0.69; CI 0.54, 0.88; p<0.01). Seven-day neonatal mortality, stillbirth, and perinatal mortality were not reduced in clusters randomized to Neonatal Resuscitation Program training as compared with control clusters. Conclusions Seven-day neonatal mortality did not decrease following the introduction of Essential Newborn Care training of community-based birth attendants, although the rate of stillbirths was reduced following this intervention. Subsequent training in the Neonatal Resuscitation Program did not significantly reduce the mortality rates. (clinicaltrials.gov number, NCT00136708).

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A high percentage of women at 20 to 26 weeks of pregnancy had mild to moderate anemia. Pica, tea consumption, and low intake of eggs and red meat were associated with anemia. Women of childbearing age should be provided nutritional education regarding food sources of iron, especially prior to becoming pregnant, and taught how food choices can either enhance or interfere with iron absorption.

WHAT'S KNOWN ON THIS SUBJECT:The majority of infant deaths occur during the neonatal period. Educational programs available to train neonatal health care workers are effective in improving knowledge and skills, but there are limited data on their effects on neonatal mortality rates. WHAT THIS STUDY ADDS:Training midwives in neonatal care reduces early neonatal mortality rates for infants born in lowrisk, first-level facilities. abstract + OBJECTIVE: This study was designed to test the hypothesis that 2 training programs would reduce incrementally 7-day neonatal mortality rates for low-risk institutional deliveries. METHODS:Using a train-the-trainer model, certified research midwives sequentially trained the midwives who performed deliveries in low-risk, first-level, urban, community health clinics in 2 cities in Zambia in the protocol and data collection, in the World Health Organization Essential Newborn Care (ENC) course (universal precautions and cleanliness, routine neonatal care, resuscitation, thermoregulation, breastfeeding, kangaroo care, care of small infants, and common illnesses), and in the American Academy of Pediatrics Neonatal Resuscitation Program (in-depth basic resuscitation). Data were collected during 3 periods, after implementation of each training course. RESULTS:A total of 71 689 neonates were enrolled in the 3 study periods. All-cause, 7-day neonatal mortality rates decreased from 11.5 deaths per 1000 live births to 6.8 deaths per 1000 live births after ENC training (relative risk: 0.59 [95% confidence interval: 0.48 -0.77]; P Ͻ .001), because of decreases in rates of deaths attributable to birth asphyxia and infection. Perinatal mortality rates but not stillbirth rates decreased. The 7-day neonatal mortality rate was decreased further after Neonatal Resuscitation Program training, after correction for loss to follow-up monitoring.CONCLUSIONS: ENC training for midwives reduced 7-day neonatal mortality rates in low-risk clinics. Additional in-depth basic training in neonatal resuscitation may reduce mortality rates further. Pediatrics

Objective-Our goal was to determine stillbirth rates in a multi-site population-based study in community settings in the developing world.Study Design-Outcomes of all community deliveries in five resource-poor countries (Democratic Republic of Congo, Guatemala, India, Zambia and Pakistan) and in one mid-level country (Argentina) were prospectively evaluated over an 18-month period. Births >1000g with no signs of life were defined as stillbirth. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. NIH Public AccessAuthor Manuscript Am J Obstet Gynecol. Author manuscript; available in PMC 2007 December 20. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author ManuscriptResults-Outcomes of 60,324 deliveries were included. Stillbirth rates ranged from 34 per 1000 in Pakistan to 9 per 1000 births in Argentina. Increased stillbirth rates were significantly associated with lower skilled providers, out-of-hospital births, and low cesarean section rates. Maceration was present in 17.2% of stillbirths.Conclusions-The stillbirth rates among births ≥ 1000g in these developing countries were substantially higher than reported stillbirth rates in developed countries (3-5/1000). Since most developed countries define a stillbirth as ≥20 weeks or ≥500g and since nearly half of all stillbirths are <1000g, the developing/developed country difference is actually larger than apparent from this study. Maceration was uncommon, indicating that most of the deaths probably occurred during labor. The low rates of physician attendance, hospital delivery, and cesarean sections suggest that stillbirth rates could be reduced by access to higher quality institutional deliveries.

Objective-To evaluate the effectiveness of the American Academy of Pediatrics Neonatal Resuscitation Program (NRP) in improving knowledge, skills, and self-efficacy of nurse midwives in low-risk delivery clinics in a developing country.Study design-We used the content specifications of the NRP material applicable to collegeeducated nurse midwives working in low-risk clinics in Zambia to develop performance and selfefficacy evaluations focused on principles of resuscitation, initial steps, ventilation, and chest compressions. These evaluations were administered to 127 nurse midwives before and after NRP training and 6-months later.Results-After training, written scores (knowledge evaluation) improved from 57% ± 14% to 80% ± 12% (mean ± SD; P < .0001); performance scores (skills evaluation) improved the most from 43% ± 21% to 88% ± 9% (P < .0001); self-efficacy scores improved from 74% ± 14% to 90% ± 10% (P < .0001). Written and performance scores decreased significantly 6 months after training, but self-efficacy scores remained high.Conclusions-As conducted, the NRP training improved educational outcomes in collegeeducated practicing nurse midwives. Pre-training knowledge and skills scores were relatively low despite the advanced formal education and experience of the participants, whereas the selfefficacy scores were high. NRP training has the potential to substantially improve knowledge and skills of neonatal resuscitation.Birth asphyxia is one of the most frequent causes of early deaths, accounting for approximately 23% of 4 million neonatal deaths worldwide. 1 Neonatal resuscitation is a simple, inexpensive, readily available, and cost-effective intervention that can prevent many of the deaths and reduce disabilities in survivors from birth asphyxia. 2,3 However, the World Health Organization has concluded that resuscitation is often not initiated or the methods used are inadequate or wrong. 4 This is especially true in the developing world, which accounts for 98% of the 4 million neonatal deaths and could benefit dramatically from effective neonatal resuscitation training of birth attendants. 42%, 5,6 although this improvement cannot be ascribed to NRP alone. Although controlled non-randomized studies in China, India, and Africa suggest that training in resuscitation with the NRP or other programs may reduce neonatal mortality caused by birth asphyxia, 2,3,7-9 studies do not show a consistent decrease in mortality and a meta-analysis is inconclusive on all-cause neonatal mortality. 10 The NRP has been widely adopted for use throughout many highly developed and lesser-developed countries.The NRP course improved healthcare providers' knowledge, skills, and attitudes in developed countries 10 ; however, there has been no rigorous evaluation of its educational impact and retention in developing countries. Furthermore, the evaluation of the educational impact of other resuscitation training in developing countries has been limited. 11,12 Evaluation of the educational effectiveness of NRP training in low...

Background-99% of the 4 million neonatal deaths per year occur in developing countries. The WHO Essential Newborn Care (ENC) course sets the minimum accepted standard for training midwives on aspects of infant care (neonatal resuscitation, breastfeeding, kangaroo-care, small baby care and thermoregulation), many of which are provided by the mother.

Objective-To determine stillbirth risk factors and gestational age at delivery in a prospective developing country birth cohort.Study Design-1369 Pakistani women were prospectively enrolled at 20 -26 weeks, the gestational age determined by ultrasound, and risk factors and pregnancy outcomes assessed.Results-The stillbirth rate was 33.6/1000 births despite 96% of women receiving prenatal care, 83% attended by skilled providers in hospital and a 20% cesarean section rate. 51% of stillbirths occurred ≥ 37 weeks and 19% from 34-36 weeks. Only 4% had congenital anomalies. Hemoglobin < 8 g/dL, vaginal bleeding and preeclampsia were associated with increased stillbirth risk.Conclusions-In this developing country with reasonable technical resources defined by hospital delivery and a high cesarean section rate, stillbirth rates were much higher than US rates. That most of the stillbirths were term, did not have congenital anomalies and the demise appeared to be recent, suggests that many Pakistani stillbirths may be preventable with higher quality obstetric care.