Jokhio Abdul Hakeem, Winter Heather R, Cheng Kar Keung
Liaquat University of Medical and Health Sciences, Jamshoro, Sindh, Pakistan.
N Engl J Med. 2005 May 19;352(20):2091-9. doi: 10.1056/NEJMsa042830.
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.
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.
Of the estimated number of eligible women in the seven talukas, 10,114 (84.3 percent) were recruited in the three intervention talukas, and 9443 (78.7 percent) in the four control talukas. In the intervention group, 9184 women (90.8 percent) received antenatal care by trained traditional birth attendants, 1634 women (16.2 percent) were seen antenatally at least once by the obstetrical teams, and 8172 safe-delivery kits were used. As compared with the control talukas, the intervention talukas had a cluster-adjusted odds ratio for perinatal death of 0.70 (95 percent confidence interval, 0.59 to 0.82) and for maternal mortality of 0.74 (95 percent confidence interval, 0.45 to 1.23).
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.
全球每年约有400万新生儿死亡以及50万孕产妇死亡。来自临床试验的证据有限，难以指导发展中国家有效孕产妇服务的发展。
我们在巴基斯坦一个农村地区的七个分区（乡）开展了一项整群随机对照试验。在随机分配至干预组的三个乡中，对传统接生员进行培训并发放一次性分娩包；女性卫生工作者将传统接生员与现有服务联系起来，并记录过程和结果；产科团队提供产前保健外展诊所。四个对照乡的妇女接受常规护理。主要结局指标为围产期和孕产妇死亡率。
在七个乡估计的 eligible 妇女数量中，三个干预乡招募了10114名（84.3%），四个对照乡招募了9443名（78.7%）。在干预组中，9184名妇女（90.8%）接受了经过培训的传统接生员的产前护理，1634名妇女（16.2%）至少接受过一次产科团队的产前检查，使用了8172个安全分娩包。与对照乡相比，干预乡围产期死亡的整群调整比值比为0.70（95%置信区间为0.59至0.82），孕产妇死亡的整群调整比值比为0.74（95%置信区间为0.45至1.23）。
培训传统接生员并将他们纳入改进的医疗保健系统是可行的，并且在降低围产期死亡率方面是有效的。这种模式可使发展中国家的围产期和孕产妇健康状况得到大幅改善。
