Abstract:
INTRODUCTION : Two-thirds
of maternal deaths and 40%
of intrapartum-related
neonatal deaths are thought to be
preventable through emergency obstetric and newborn
care (EmOC&NC). The effectiveness of ‘skills and drills’
training of maternity staff in EmOC&NC was evaluated.
METHODS : Implementation research using a stepped wedge
cluster randomised trial including 127 of 129 healthcare
facilities (HCFs) across the 11 districts in South Africa with
the highest maternal mortality. The sequence in which all
districts received EmOC&NC training was randomised but
could not be blinded. The timing of training resulted in 10
districts providing data before and 10 providing data after
EmOC&NC training. Primary outcome measures derived
for HCFs are as follows: stillbirth rate (SBR), early neonatal
death (ENND) rate, institutional maternal mortality ratio
(iMMR) and direct obstetric case fatality rate (CFR), number
of complications recognised and managed and CFR by
complication.
RESULTS : At baseline, median SBR (per 1000 births) and
ENND rate (per 1000 live births) were 9 (IQR 0–28) and
0 (IQR 0–9). No significant changes following training in
EmOC&NC were detected for any of the stated outcomes:
SBR (adjusted incidence rate ratio (aIRR) 0.97, 95% CI 0.91
to 1.05), iMMR (aIRR 1.23, 95% CI 0.80 to 1.90), ENND rate (aIRR 1.04, 95% CI 0.92 to 1.17) and direct obstetric CFR
(aIRR 1.15, 95% CI 0.66 to 2.02). The number of women
who were recognised to need and received EmOC was
significantly increased overall (aIRR 1.14, 95% CI 1.02 to
1.27), for haemorrhage (aIRR 1.31, 95% CI 1.13 to 1.52) and
for postpartum sepsis (aIRR 1.86, 95% CI 1.17 to 2.95)
CONCLUSION : Following EmOC&NC training, healthcare
providers are more able to recognise and manage
complications at time of birth. This trial did not provide
evidence that the intervention was effective in reducing
adverse clinical outcomes, but demonstrates randomised
evaluations are feasible in implementation research.
Trial registration number ISRCTN11224105.
