Results
Between August 22, 2013 and August 30, 2014, a total of 130 (74%) of 176 midwives and health extension workers at two hospitals, 13 health centers and 58 health posts were included in the study. Of these, 46 dropped out during the study, mainly because of transfers to other duty stations (n = 24). Two went for educational upgrade, while one was jailed accused of malpractice. A total of 130 (74%) health workers (32 midwives, 88 health extension workers, 8 unknown) completed the 6- and 12 months follow up, 65 in each arm, and are included in the following analysis (Fig. Flow chartBackground parameters for the participants (Table Background parameters participantsThe baseline scores for skills were not normally distributed, with a median of 12/100 in the intervention group (range 0–72, SD 18.2) and 12/100 for the control group (range 0–66, SD 21.1). The increase in skills scores from baseline to 6 and 12 months and from 6 to 12 months were normally distributed with significant improvements for all three time periods. After 6 months, the increase in mean score was 29.6/100 with a further significant increase during the following 6 months of 13.3/100. The control group did not significantly increase skills for the first 6 months while there was a significant improvement of 4.9/100 from baseline to 12 months. The difference in increase in scores between the intervention and the control group was significant for all the time periods assessed, indicating an effect of the SDA of a more than doubling of the skills scores from baseline (Table Skills and knowledge scores at 0, 6, and 12 monthsMaximum score = 100%Adjusted for within-cluster effect and significant variables associated with outcomeKnowledge scores were normally distributed with an adjusted mean score at 12 month follow-up of 39.1/100 (95% c.i. 34.8–43.4) in the intervention group and 32.1/100 (95% c.i. 28.5–35.7) in the control group. This difference was significant with a mean difference of 7.0 (95% c.i. 1.3–12.8). In the intervention group there was a significant improvement in knowledge scores from baseline to 6 months that was sustained after 12 months, while there was no significant change from 6 to 12 months. There was no significant change for any of the time periods for the control group. The difference in change between the groups was significant (Table 