Management of childhood pneumonia by traditional birth attendants. The SEARCH Team.

In a field trial in Gadchiroli, India, we trained 30 paramedical workers (PMWs), 25 village health workers (VHWs) and 86 traditional birth attendants (TBAs) from 58 villages to diagnose childhood pneumonia and treat it with sulfamethoxazole+trimethoprim. Continued training, the development of a breath counter, and educative supervision progressively reduced errors in case management made by the TBAs. Over the 3.5-year period 1988-91, 2568 attacks of childhood pneumonia were managed and the case fatality rate was 0.9%, compared with a rate of 13.5% in the control area. The case fatality rates for the three types of worker were similar. The TBAs were superior to the other workers in terms of their availability, outreach, access to neonates, and cost. Satisfaction with the VHWs, and PMWs was expressed by 85%, 69% and 18% of users, respectively. In the intervention area the mortality rate attributable to pneumonia among neonates declined by 44% (P < 0.01) while the total neonatal mortality fell by 20%, presumably because of the involvement of TBAs in the control of acute respiratory infections (ARI). If adequately supported by the health system, TBAs can successfully manage childhood pneumonia in villages at the lowest possible cost and with a high degree of community acceptance. TBAs and VHWs are the most suitable community-based health workers for ARI control programmes in developing countries.

Pneumonia in neonates: can it be managed in the community?

Neonatal pneumonia kills about two million children a year worldwide. The World Health Organisation recommends hospitalisation of all cases of pneumonia in the first two months of infancy. In a field trial of community based management of childhood pneumonia in Gadchiroli, India, neonatal pneumonia contributed more than half of the pneumonia deaths. Parents refused referral even when advised therefore community based health workers and traditional birth attendants managed cases of neonatal pneumonia with co-trimoxazole. Case fatality was 15% (10/65) in all cases and 6% (3/52) in cases without high risk or referral indications. Case fatality in 56 babies aged 30-59 days treated for pneumonia was zero. During the two years of the trial, pneumonia specific mortality rate in the intervention area was 40% less in the neonates and about 80% less in the second month and rest of infancy compared with the control area. Pneumonia in the second month of infancy and uncomplicated cases of neonatal pneumonia can be safely and effectively managed in the community using co-trimoxazole.