Stillbirths drop dramatically after newborn-care training in developing countries

February 17, 2010

The rate of stillbirths in rural areas of six developing countries fell more than 30 percent following a basic training program in newborn care for birth attendants, according to a study funded by the National Institutes of Health and the Bill and Melinda Gates Foundation. The study tracked more than 120,000 births.

The study tested the efficacy of a three-day Essential Newborn Care training regimen that covers basic newborn care techniques, the importance of early breastfeeding, how to keep infants warm and dry, and signs of serious health problems.

The study, the largest of its kind, is one of the first to track the rate of infant deaths following the implementation of such a regimen. The World Health Organization (WHO) estimates that, in addition to more than 3 million stillbirths worldwide each year, nearly 4 million infants die in their first month of life.

The results appear in the Feb. 21 issue of The New England Journal of Medicine.

"These findings suggest that a low-cost instructional regimen for birth attendants can be effective in reducing stillbirths in parts of the world where most births are not attended by a physician," said Alan E. Guttmacher, M.D., acting director of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the NIH institute, that, along with the Bill and Melinda Gates Foundation, funded the study.

The research was conducted at study sites in Argentina, the Democratic Republic of Congo, Guatemala, India, Pakistan, and Zambia as part of the Global Network for Women's and Children's Health Research. The network is a partnership of the NICHD and the Bill and Melinda Gates Foundation.

Waldemar A. Carlo, M.D., of the University of Alabama at Birmingham, led the research team. The study's senior author was Linda L. Wright, M.D., scientific director of the NICHD Global Network for Women's and Children's Health Research.

Before data collection on births began, research staff taught local health care workers how to collect data, assess infant health, and diagnose stillbirth and other conditions. In addition, the researchers provided local health care workers with scales to accurately measure birth weight, hand-held pumps and masks to fill babies' lungs with air, and clean-delivery kits to prevent infection.

One health care worker from each of the participating countries traveled to the United States to learn essential newborn care techniques. That person returned home to train other trainers, with the training ultimately reaching 3,600 health care workers in rural communities--physicians, nurses, midwives, and birth attendants with no formal training.

Coordinators and attendants collected data on the births in their communities. In 99.2 percent of cases, they also documented whether babies were alive after one week. The researchers then compared statistics before and after the emergency newborn care training.

The study authors found that the overall rate of infant death during the first 7 days of life did not change among infants who had been administered the essential newborn care regimen. However, the rate of stillbirths dropped sharply--from 23 per 1,000 deliveries to 15.9 per 1,000. The researchers believe these improvements were seen in infants who had not drawn a breath on their own and would have been considered to have been born dead by birth attendants who had not received the early newborn care training.

"The reduction in stillbirth is extremely encouraging," Dr. Carlo said. "Stillbirths among births attended by midwives and traditional birth attendants declined to nearly the same levels seen among births attended by physicians."

Dr. Carlo explained that many infants do not take a breath when they are first born. In the majority of these cases, some kind of stimulation--rubbing the back or tapping the soles of the feet--will start the baby breathing on its own. Other infants need air pushed into their lungs. Birth attendants without training in recognizing and resuscitating newborns who do not breathe at birth may consider the babies to be stillborn and not attempt to revive them. The researchers found a decrease in the rates of fresh stillbirth--or death immediately before or at the moment of birth. The study did not find a decrease in macerated stillbirths--those assumed to have died before the beginning of labor.

The study authors concluded that the essential newborn care training was most effective in providing attendants needed skills and expertise in newborn resuscitation. The greatest decrease in stillbirth rates was among deliveries attended by nurses, midwives, and traditional attendants, all of whom, the researchers believe, would likely not have received such training.

"Our results show that training in essential newborn care can play a role in improving birth outcomes in the developing world," Dr. Wright said.

In a subsequent phase of the study, trainers led in-depth sessions focused exclusively on neonatal resuscitation techniques in 88 randomly selected communities, where attendants had already undergone the ENC program. The researchers found this additional training did not further reduce infant mortality from stillbirth or other causes.
The NICHD sponsors research on development, before and after birth; maternal, child, and family health; reproductive biology and population issues; and medical rehabilitation. For more information, visit the Institute's Web site at

The National Institutes of Health (NIH) -- The Nation's Medical Research Agency -- includes 27 Institutes and Centers and is a component of the U. S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical, and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit

NIH/Eunice Kennedy Shriver National Institute of Child Health and Human Development

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