***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Maternal and newborn mortality rates remain unacceptably high , especially where the majority of births occur in home setting s or in facilities with inadequate re sources . The introduction of emergency obstetric and newborn care services has been proposed by several organizations in order to improve pregnancy outcomes . However , the effectiveness of emergency obstetric and neonatal care services has never been proven . Also unproven is the effectiveness of community mobilization and community birth attendant training to improve pregnancy outcomes . Methods / Design We have developed a cluster-r and omized controlled trial to evaluate the impact of a comprehensive intervention of community mobilization , birth attendant training and improvement of quality of care in health facilities on perinatal mortality in low and middle-income countries where the majority of births take place in homes or first level care facilities . This trial will take place in 106 clusters ( 300 - 500 deliveries per year each ) across 7 sites of the Global Network for Women 's and Children 's Health Research in Argentina , Guatemala , India , Kenya , Pakistan and Zambia . The trial intervention has three key elements , community mobilization , home-based life saving skills for communities and birth attendants , and training of providers at obstetric facilities to improve quality of care . The primary outcome of the trial is perinatal mortality . Secondary outcomes include rates of stillbirth , 7-day neonatal mortality , maternal death or severe morbidity ( including obstetric fistula , eclampsia and obstetrical sepsis ) and 28-day neonatal mortality . Discussion In this trial , we are evaluating a combination of interventions including community mobilization and facility training in an attempt to improve pregnancy outcomes . If successful , the results of this trial will provide important information for policy makers and clinicians as they attempt to improve delivery services for pregnant women and newborns in low-income countries . Trial Registration Clinical Trials.gov OBJECTIVE : Changes in the ability of midwives to perform practical skills , after completion of the Maternal Care Manual of the Perinatal Education Program , were determined . STUDY DESIGN : A prospect i ve , controlled trial in a study town and two control towns . The practical skills of  midwives  caring for pregnant women in the towns were determined . Subsequently , the Maternal Care Manual was studied by midwives in the study town , and the skills of all midwives were subsequently evaluated . RESULTS : A total of 34 midwives in the study town and 39 midwives in the two control towns were studied . The marks showed a significant ( p ≤ 0.000 ) improvement in the study town when comparing the pre- and postintervention marks . The mean improvement in the study town was 36.6 % . DISCUSSION : The practical skills of midwives improved significantly . The Perinatal Education Program can be implemented with confidence as a distance learning program that is especially suited to the needs of health workers in remote regions The potential for  traditional birth attendants ( TBAs )  to improve  neonatal health outcomes has largely been overlooked during the current debate regarding the role of TBAs in improving maternal health . R and omly-selected TBAs ( n=93 ) were interviewed to gain a more thorough underst and ing of their knowledge , attitudes , and practice s regarding maternal and newborn care . Practice s , such as using a  clean cord-cutting instrument  ( 89 % ) and h and -washing  before delivery ( 74 % ) , were common . Other beneficial practice s , such as thermal care , were low . Trained TBAs were more likely to wash h and s with soap before delivery , use a clean delivery-kit , and advise feeding colostrum . Although mustard oil massage was a universal practice , 52 % of the TBAs indicated their willingness to consider alternative oils . Low-cost , evidence -based interventions for improving neonatal outcomes might be implemented by TBAs in this setting where most births take place in the home and neonatal mortality risk is high . Continuing efforts to define the role of TBAs may benefit from an emphasis on their potential as active promoters of essential newborn care BACKGROUND Two recent trials have shown that women 's groups can reduce neonatal mortality in poor communities . We assessed the effectiveness of a scaled-up development programme with women 's groups to address maternal and neonatal care in three rural districts of Bangladesh . METHODS 18 clusters ( with a mean population of 27 953 [ SD 5953 ] ) in three districts were r and omly assigned to either intervention or control ( nine clusters each ) by use of stratified r and omisation . For each district , cluster names were written on pieces of paper , which were folded and placed in a bottle . The first three cluster names drawn from the bottle were allocated to the intervention group and the remaining three to control . All clusters received health services strengthening and basic training of traditional birth attendants . In intervention clusters , a facilitator convened 18 groups every month to support participatory action and learning for women , and to develop and implement strategies to address maternal and neonatal health problems . Women were eligible to participate if they were aged 15 - 49 years , residing in the project area , and had given birth during the study period ( Feb 1 , 2005 , to Dec 31 , 2007 ) . Neither study investigators nor participants were masked to treatment assignment . In a population of 229 195 people ( intervention clusters only ) , 162 women 's groups provided coverage of one group per 1414 population . The primary outcome was neonatal mortality rate ( NMR ) . Analysis was by intention to treat . This trial is registered as an International St and ard R and omised Controlled Trial , number IS RCT N54792066 . FINDINGS We monitored outcomes for 36 113 births ( intervention clusters , n=17 514 ; control clusters , n=18 599 ) in a population of 503 163 over 3 years . From 2005 to 2007 , there were 570 neonatal deaths in the intervention clusters and 656 in the control clusters . Cluster-level mean NMR ( adjusted for stratification and clustering ) was 33.9 deaths per 1000 livebirths in the intervention clusters compared with 36.5 per 1000 in the control clusters ( risk ratio 0.93 , 95 % CI 0.80 - 1.09 ) . INTERPRETATION For participatory women 's groups to have a significant effect on neonatal mortality in rural Bangladesh , detailed attention to programme design and context ual factors , enhanced population coverage , and increased enrolment of newly pregnant women might be needed . FUNDING Women and Children First , the UK Big Lottery Fund , Saving Newborn Lives , and the UK Department for International Development We compared the effects of lecture-style ( L ) and interactive problem-based ( I ) educational programs on knowledge , attitude , and practice s ( KAP ) of traditional birth attendants in the Philippines . Participants in two cities were r and omized to L and I teaching groups and completed a question naire pre- , immediately post- , and 6 months after education . Mothers reported practice s of the attendants . There was significant improvement in mean knowledge scores ( L 16.8 to 17.9 and I 16.4 to 19.3 ) in group I. Group I scores continued to improve 6 months later . Attitude scores significantly improved in both groups and decreased 6 months later , indicating a need for reinforcement . Certain undesirable practice s such as late cord clamping and holding the baby upside down following birth were changed in both groups . Actual practice s reported by mothers were carried out less frequently than indicated by providers , indicating a need for further education and possibly provision of adequate re sources . Interactive ( I ) learning is a preferred method for education of traditional birth attendants Background Birth attendance by trained health workers is low in rural Nepal . Local participation in improving health services and increased interaction between health systems and communities may stimulate dem and for health services . Significant increases in birth attendance by trained health workers may be affected through community mobilisation by local women 's groups and health management committee strengthening . We will test the effect of community mobilisation through women 's groups , and health management committee strengthening , on institutional deliveries and home deliveries attended by trained health workers in Makwanpur District . Design Cluster r and omised controlled trial involving 43 village development committee clusters . 21 clusters will receive the intervention and 22 clusters will serve as control areas . In intervention areas , Female Community Health Volunteers are supported in convening monthly women 's groups . The groups work through an action research cycle in which they consider barriers to institutional delivery , plan and implement strategies to address these barriers with their communities , and evaluate their progress . Health management committees participate in three-day workshops that use appreciative inquiry methods to explore and plan ways to improve maternal and newborn health services . Follow-up meetings are conducted every three months to review progress . Primary outcomes are institutional deliveries and home deliveries conducted by trained health workers . Secondary outcome measures include uptake of antenatal and postnatal care , neonatal mortality and stillbirth rates , and maternal morbidity . Trial registration numberIS RCT BACKGROUND Newborn deaths account for 57 % of deaths in children younger than 5 years in Pakistan . Although a large programme of trained lady health workers ( LHWs ) exists , the effectiveness of this training on newborn outcomes has not been studied . We aim ed to evaluate the effectiveness of a community-based intervention package , principally delivered through LHWs working with traditional birth attendants and community health committees , for reduction of perinatal and neonatal mortality in a rural district of Pakistan . METHODS We undertook a cluster r and omised trial between February , 2006 , and March , 2008 , in Hala and Matiari subdistricts , Pakistan . Catchment areas of primary care facilities and all affiliated LHWs were used to define clusters , which were allocated to intervention and control groups by restricted , stratified r and omisation . The intervention package delivered by LHWs through group sessions consisted of promotion of antenatal care and maternal health education , use of clean delivery kits , facility births , immediate newborn care , identification of danger signs , and promotion of careseeking ; control clusters received routine care . Independent data collectors undertook quarterly household surveillance to capture data for births , deaths , and household practice s related to maternal and newborn care . Data collectors were masked to cluster allocation ; those analysing data were not . The primary outcome was perinatal and all-cause neonatal mortality . Analysis was by intention to treat . This trial is registered , IS RCT N16247511 . FINDINGS 16 clusters were assigned to intervention ( 23,353 households , 12,391 total births ) and control groups ( 23,768 households , 11,443 total births ) . LHWs in the intervention clusters were able to undertake 4428 ( 63 % ) of 7084 planned group sessions , but were only able to visit 2943 neonates ( 24 % ) of a total 12,028 livebirths in their catchment villages . Stillbirths were reduced in intervention clusters ( 39·1 stillbirths per 1000 total births ) compared with control ( 48·7 per 1000 ; risk ratio [ RR ] 0·79 , 95 % CI 0·68 - 0·92 ; p=0·006 ) . The neonatal mortality rate was 43·0 deaths per 1000 livebirths in intervention clusters compared with 49·1 per 1000 in control groups ( RR 0·85 , 0·76 - 0·96 ; p=0·02 ) . INTERPRETATION Our results support the scale-up of preventive and promotive maternal and newborn interventions through community health workers and emphasise the need for attention to issues of programme management and coverage for such initiatives to achieve maximum potential . FUNDING WHO ; Saving Newborn Lives Program of Save the Children USA , funded by the Bill & Melinda Gates Foundation OBJECTIVES In a community r and omized trial , we aim ed to promote exclusive breastfeeding and appropriate complementary feeding practice s in under-twos to ascertain the feasibility of using available channels for nutrition counselling , their relative performance and the relationship between intensity of counselling and behaviour change . We also assessed whether using multiple opportunities to impart nutrition education adversely affected routine activities . METHODS We conducted a community r and omized , controlled effectiveness trial in rural Haryana , India , with four intervention and four control communities . We trained health and nutrition workers in the intervention communities to counsel mothers at multiple contacts on breastfeeding exclusively for 6 months and on appropriate complementary feeding practice s thereafter . The intervention was not just training health and nutrition workers in counselling but included community and health worker mobilization . FINDINGS In the intervention group , about 32 % of caregivers were counselled by traditional birth attendants at birth . The most frequent sources of counselling from birth to 3 months were immunization sessions ( 45.1 % ) and home visits ( 32.1 % ) , followed closely by weighing sessions ( 25.5 % ) ; from 7 to 12 months , home visits ( 42.6 % ) became more important than the other two . An increase in the number of channels through which caregivers were counselled was positively associated with exclusive breastfeeding prevalence at 3 months ( p = 0.002 ) , consumption of milk/cereal gruel or mix use at 9 months ( p = 0.004 ) and 18 months ( p = 0.003 ) , undiluted milk at 9 months ( p<0.0001 ) and 24 hour non-breast-milk energy intakes at 18 months ( p = 0.023 ) , after controlling for potential confounding factors . Intervention areas , compared with the control , had higher coverage for vitamin A ( 45 % vs. 11.5 % ) and iron folic acid ( 45 % vs. 0.4 % ) supplementation . CONCLUSIONS Using multiple available opportunities and workers for counselling caregivers was feas 
    Output:
    
The results are promising for some outcomes ( perinatal death , stillbirth and neonatal death ) .
A lack of contrast in training in the intervention and control clusters may have contributed to the null result for stillbirths and an insufficient number of studies may have contributed to the failure to achieve significance for early neonatal deaths .
Despite the additional studies included in this up date d systematic review , there remains insufficient evidence to establish the potential of TBA training to improve peri-neonatal mortality