Article Text

Health economics
Provision of essential newborn care training to midwives in Zambia is a low-cost intervention that reduces neonatal mortality
  1. Linda F Samson
  1. College of Health and Human Services, Governors State University, University Park, Illinois, USA
  1. Correspondence to Linda F Samson
    College of Health and Human Services, Governors State University, 1 University Parkway, University Park, IL 60484, USA; lsamson{at}


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  • Training of clinic midwives in essential neonatal care (ENC) reduced infant mortality and morbidity in urban areas of Zambia.

  • The training provided was found to be a low-cost intervention to reduce death and disability in infants.

  • Although the training proved to be cost effective in urban areas, the researchers question the cost effectiveness in remote areas where the number of care providers available for training is limited.


In an effort to reduce early neonatal mortality in developing countries, the WHO developed a curriculum entitled ENC. Early neonatal mortality rates (ENM), defined as death in the first 7 days of life, are significantly higher in developing countries than in the industrialised world with 2004 rates that ranged from 15 to 35 per 1000 live births compared with rates below 5 per 1000 live births.1 Manasyan and colleagues explored whether the use of the ENC curriculum and training of midwives in first-level facilities in two large urban areas in Zambia (Lusaka and Ndola) would reduce ENM and be a cost-effective strategy. Prior to the training, reported ENM was 11.5 per 1000, a rate lower than the aggregate for developing countries but higher than the rates reported in developed countries.


Eighteen college-educated midwives (3 year minimum education) were trained as ENC instructors, one for each of the 18 largest low-risk first-level delivery clinics in the two urban areas. The 5-day training included universal precautions, routine neonatal care, resuscitation, prevention of hypothermia, early and exclusive breastfeeding, kangaroo care, small infant management, danger signs and recognition of illness. These midwives then trained clinic midwives. A total of 123 midwives were trained in the 18 facilities. The effect of training was calculated by comparing ENM rates pre-ENC (October 2004–October 2005) to post-ENC rates (December 2005–November 2006).

In this multicentre population-based study, data were collected on neonates (n=40.615) during the two study periods from registries maintained by the clinic midwives. The intervention and data collection was overseen by a half-time nurse in each centre. The cost of the intervention was US$20,223.83. The researchers then calculated the intervention costs per life saved and per disability adjusted life year (DALY) averted.


ENM rates were reduced from the preintervention 11.5 per 1000 live births to 6.8 per 1000 live births after the intervention. The researchers calculated that this was indicative of 97 lives being saved. With Zambian gross domestic product $1500, the intervention was calculated to cost $208 per life gained or $5.24 per averted DALY. These data were calculated based on an average life expectancy of 39.7 years.


This study hypothesises that training is a cost-effective intervention to reduce early neonatal mortality in developing countries. Basics of newborn care using the ENC curriculum have been shown to reduce neonatal complications and death in a number of developing countries.2,,4 Despite some reduction of early neonatal mortality reported in these studies, another large multicountry study using the same ENC curriculum and before-and-after design failed to find any change in early neonatal deaths in the 57 643 infants included, even with the inclusion of formal neonatal resuscitation training.5

The primary differences between these studies were the types of birth attendant and the delivery settings. With over 50% of births in Zambia occurring in rural communities with traditional birth attendants at health centres or at home – populations excluded because of the costs of training – combined data may not have validated reduction in mortality or cost savings. In order to more fully understand the impact of ENC on ENM in developing countries, future studies should address the role and current training of midwives and nurses in urban settings including key job competencies and educational preparation for the role, the impact of educational preparation on intervention effect and approaches to training traditional birth attendants who deliver the majority of infants.



  • Competing interests None.

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