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Research
Up-skilling associate clinicians in Malawi in emergency obstetric, neonatal care and clinical leadership: the ETATMBA cluster randomised controlled trial
  1. David R Ellard1,
  2. Wanangwa Chimwaza2,
  3. David Davies3,
  4. Doug Simkiss4,
  5. Francis Kamwendo5,
  6. Chisale Mhango6,
  7. Siobhan Quenby7,
  8. Ngianga-bakwin Kandala8,
  9. Joseph Paul O'Hare9
  10. on behalf of The ETATMBA Study Group
    1. 1Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK
    2. 2Malawi University, College of Medicine, Blantyre, Malawi
    3. 3Educational Development & Research Team, Warwick Medical School, The University of Warwick, Coventry, UK
    4. 4Division of Mental Health & Wellbeing, Warwick Medical School, The University of Warwick, Coventry, UK
    5. 5Obstetrics and Gynaecology Department, Malawi University, College of Medicine, Blantyre, Malawi
    6. 6College of Medicine, University of Malawi, Blantyre, Malawi
    7. 7Division of Reproductive Health, Warwick Medical School, The University of Warwick, Coventry, UK
    8. 8Faculty of Engineering and Environment, Department of Mathematics and Information sciences, Northumbria University, Newcastle upon Tyne, UK
    9. 9Division of Metabolic & Vascular Health, Warwick Medical School, The University of Warwick, Coventry, UK
    1. Correspondence to Dr David R Ellard; d.r.ellard{at}warwick.ac.uk

    Abstract

    Background The ETATMBA (Enhancing Training And Technology for Mothers and Babies in Africa) project-trained associate clinicians (ACs/clinical officers) as advanced clinical leaders in emergency obstetric and neonatal care. This trial aimed to evaluate the impact of training on obstetric health outcomes in Malawi.

    Method A cluster randomised controlled trial with 14 districts of Malawi (8 intervention, 6 control) as units of randomisation. Intervention districts housed the 46 ACs who received the training programme. The primary outcome was district (health facility-based) perinatal mortality rates. Secondary outcomes included maternal mortality ratios, neonatal mortality rate, obstetric and birth variables. The study period was 2011–2013. Mortality rates/ratios were examined using an interrupted time series (ITS) to identify trends over time.

    Results The ITS reveals an improving trend in perinatal mortality across both groups, but better in the control group (intervention, effect −3.58, SE 2.65, CI (−9.85 to 2.69), p=0.20; control, effect −17.79, SE 6.83, CI (−33.95 to −1.64), p=0.03). Maternal mortality ratios are seen to have improved in intervention districts while worsening in the control districts (intervention, effect −38.11, SE 50.30, CI (−157.06 to 80.84), p=0.47; control, effect 11.55, SE 87.72, CI (−195.87 to 218.98), p=0.90). There was a 31% drop in neonatal mortality rate in intervention districts while in control districts, the rate rises by 2%. There are no significant differences in the other secondary outcomes.

    Conclusions This is one of the first randomised studies looking at the effect of structured training on health outcomes in this setting. Notwithstanding a number of limitations, this study suggests that up-skilling this cadre is possible, and could impact positively on health outcomes.

    Trial registration number ISRCTN63294155; Results.

    This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

    https://doi.org/10.1136/bmjgh-2015-000020

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