van den Broek Nynke, Ameh Charles, Madaj Barbara, Makin Jennifer, White Sarah, Hemming Karla, Moodley J, Pattinson Robert
Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK.
Department of Obstetrics & Gynaecology, University of Pretoria, Pretoria, South Africa.
BMJ Glob Health. 2019 Nov 10;4(6):e001670. doi: 10.1136/bmjgh-2019-001670. eCollection 2019.
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.
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.
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).
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.
ISRCTN11224105.
据认为，三分之二的孕产妇死亡以及40%的与分娩相关的新生儿死亡可通过紧急产科和新生儿护理（EmOC&NC）预防。对产科工作人员进行EmOC&NC的“技能与演练”培训的效果进行了评估。
采用阶梯式楔形整群随机试验进行实施研究，纳入了南非孕产妇死亡率最高的11个区129家医疗保健机构（HCFs）中的127家。所有区接受EmOC&NC培训的顺序是随机的，但无法设盲。培训时间安排使得10个区在EmOC&NC培训前提供数据，10个区在培训后提供数据。为HCFs得出的主要结局指标如下：死产率（SBR）、早期新生儿死亡率（ENND）、机构孕产妇死亡率（iMMR）和直接产科病死率（CFR）、识别并处理的并发症数量以及按并发症分类的CFR。
在基线时，SBR中位数（每1000例分娩）和ENND率（每1000例活产）分别为9（四分位间距0 - 28）和0（四分位间距0 - 9）。对于任何所述结局，在EmOC&NC培训后均未检测到显著变化：SBR（调整发病率比（aIRR）0.97，95%CI 0.91至1.05）、iMMR（aIRR 1.23，95%CI 0.80至1.90）、ENND率（aIRR 1.04，95%CI 0.92至1.17）和直接产科CFR（aIRR 1.15，95%CI 0.66至2.02）。总体上，被识别为需要并接受EmOC的女性数量显著增加（aIRR 1.14, 95%CI 1.02至1.27），对于出血（aIRR 1.31, 95%CI 1.13至1.52）和产后败血症（aIRR 1.86, 95%CI 1.17至2.95）也是如此。
经过EmOC&NC培训后，医疗保健提供者在分娩时更有能力识别并处理并发症。本试验未提供证据表明该干预措施在降低不良临床结局方面有效，但表明随机评估在实施研究中是可行的。
ISRCTN11224105。
