Academic journal article Bulletin of the World Health Organization

Comparison of Two Training Strategies for Essential Newborn Care in Brazil. (Research)

Academic journal article Bulletin of the World Health Organization

Comparison of Two Training Strategies for Essential Newborn Care in Brazil. (Research)

Article excerpt


More than 7.5 million perinatal deaths occurred in 1995, 98% of which were in developing countries (1).

Perinatal mortality is an indicator not only of social and economic development, but also of access to, coverage of, and the use and quality of perinatal care (2, 3). Perinatal mortality is high in the state of Pernambuco, in north-east Brazil. The rate of stillbirths is unknown and so there is no reliable estimate of perinatal mortality. Neonatal mortality in 1997 was around 30/1000 live births, but this was probably an underestimate, and there were wide variations among districts (4). Early neonatal mortality is probably about half that figure, or 15/ 1000 live births. Perinatal mortality may be more than twice that of early neonatal mortality, as it has been estimated that in 1988 about 50% of perinatal deaths had not been registered (5); registration might be improving but it is far from complete. From census data, infant mortality in 1997 was estimated to be 52/1000 live births and believed to range from 12/1000 to 69/1000 in different districts (6).

In 1997, the government of Pernambuco developed interventions to reduce maternal and perinatal mortality, targeting them at maternity units. These interventions were an attempt to improve the quality of care: it was presumed that the majority of perinatal deaths could be prevented by providing good obstetric and neonatal care. The plan was to carry out an initial survey and then provide essential equipment and supplies to all maternity units and to train doctors and nurses in essential obstetric care and essential newborn care. The training focused on simple, effective interventions that would be relevant to the majority of deliveries in all maternity units. The programme also included an evaluation component, which was completed for a sample of the units. The objective of the evaluation was to determine which training strategy was more effective and whether it could be extended to include non-professional staff. Unfortunately, complete and reliable data were gathered only for the component on essential newborn care; data on essential obstetric care are not presented in this paper.


The instrument used for training health professionals in essential newborn care was a manual published by the WHO Regional Office for Europe (7), which was translated into Portuguese. The section on counselling women about breastfeeding was taken from a WHO manual (8) and integrated into the instrument.

Given the lack of evidence on the effectiveness of short in-service training courses and the need to identify the most feasible training strategy, it was decided to test two options in two groups of hospitals. The first training option was a conventional 5-day course taught by two trainers and two or three facilitators for around 20 participants in each hospital (Group 1). The second option was a self-directed learning course which was offered in the remaining hospitals (Group 2).

The self-directed course was offered to all doctors and nurses in a particular hospital by a supervisor and two or three facilitators. It took about 5 weeks to complete. Pernambuco's Department of Health provided the trainers and the supervisors; the facilitators were selected from the senior clinicians in each hospital. Each self-directed course started with a half-day meeting to explain the objectives and methods and to distribute the first part of the manual, corresponding to one day of the taught course offered to Group 1. Weekly meetings were then organized to allow participants to: discuss the study materials with supervisors and facilitators, resolve any queries, verify the level of learning by questions and answers, conduct practical sessions as described in the manual, and hand out the subsequent parts of the manual. The facilitators were accessible to the participants between weekly meetings to address any queries. The participants worked at their own pace during the week. …

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