Open Access Research article

Reduced perinatal mortality following enhanced training of birth attendants in the Democratic Republic of Congo: a time-dependent effect

Richard Matendo1*, Cyril Engmann2, John Ditekemena1, Justin Gado1, Antoinette Tshefu1, Rinko Kinoshita2, Elizabeth M McClure3, Janet Moore3, Dennis Wallace3, Waldemar A Carlo4, Linda L Wright5 and Carl Bose2

Author Affiliations

1 Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo

2 Division of Neonatal-Perinatal Medicine, CB#7596, University of North Carolina at Chapel Hill, North Carolina 27599-7596, USA

3 Research Triangle Institute, PO Box 12194, Research Triangle Park, NC 27709, USA

4 Women & Infants Center, University of Alabama at Birmingham, 1700 6th Ave South, Birmingham, AL 35233, USA

5 Eunice Kennedy Shriver National Institute of Child Health and Human Development, Building 31, Room 2A32, MSC 2425, 31 Center Drive, Bethesda, Maryland 20892-2425, USA

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BMC Medicine 2011, 9:93  doi:10.1186/1741-7015-9-93

Published: 4 August 2011



In many developing countries, the majority of births are attended by traditional birth attendants, who lack formal training in neonatal resuscitation and other essential care required by the newly born infant. In these countries, the major causes of neonatal mortality are birth asphyxia, infection, and low-birth-weight/prematurity. Death from these causes is potentially modifiable using low-cost interventions, including neonatal resuscitation training. The purpose of this study was to evaluate the effect on perinatal mortality of training birth attendants in a rural area of the Democratic Republic of Congo (DRC) using two established programs.


This study, a secondary analysis of DRC-specific data collected during a multi-country study, was conducted in two phases. The effect of training using the WHO Essential Newborn Care (ENC) program was evaluated using an active baseline design, followed by a cluster randomized trial of training using an adaptation of a neonatal resuscitation program (NRP). The perinatal mortality rates before ENC, after ENC training, and after randomization to additional NRP training or continued care were compared. In addition, the influence of time following resuscitation training was investigated by examining change in perinatal mortality during sequential three-month increments following ENC training.


More than two-thirds of deliveries were attended by traditional birth attendants and occurred in homes; these proportions decreased after ENC training. There was no apparent decline in perinatal mortality when the outcome of all deliveries prior to ENC training was compared to those after ENC but before NRP training. However, there was a gradual but significant decline in perinatal mortality during the year following ENC training (RR 0.73; 95% CI: 0.56-0.96), which was independently associated with time following training. The decline was attributable to a decline in early neonatal mortality. NRP training had no demonstrable effect on early neonatal mortality.


Training DRC birth attendants using the ENC program reduces perinatal mortality. However, a period of utilization and re-enforcement of training may be necessary before a decline in mortality occurs. ENC training has the potential to be a low cost, high impact intervention in developing countries.

Trial registration

This trial has been registered at webcite (identifier NCT00136708).