Effect of provision of home-based curative health services by public sector health-care providers on neonatal survival: a community-based cluster-randomised trial in rural Pakistan

Abstract

SummaryBackgroundAlthough the effectiveness of community mobilisation and promotive care delivered by community health workers in reducing perinatal and neonatal mortality is well established, evidence in support of home-based neonatal resuscitation and infection management is mixed. We assessed the effectiveness of adding training in neonatal bag and mask resuscitation and oral antibiotic therapy for suspected neonatal infections to a basic preventive and promotive interventions package delivered by public sector community-based lady health workers (LHWs) in rural Pakistan.MethodsWe did a cluster-randomised controlled trial in two subdistricts of Naushahro Feroze in rural Sindh, Pakistan, between April 15, 2009, and Dec 10, 2012. LHWs, trained in basic newborn resuscitation and in recognition and treatment (with oral amoxicillin) of suspected neonatal respiratory infections, were linked with traditional birth attendants and encouraged to attend home births. Control clusters received routine care through the existing national programme. The primary outcome was all-cause neonatal mortality. Independent data collection teams recorded data for all pregnancies and their outcomes, morbidity, mortality, and household practices related to maternal and newborn care.FindingsOf the 27 randomised clusters with functional LHW programmes, 13 were allocated to the intervention group (n=242 749) and 14 to the control group (n=256 985). In the intervention group, LHWs did 80% of the planned community mobilisation sessions, but were able to attend only 1184 (14%) of 8425 deliveries and 4318 (25%) of 17 288 neonatal visits within 72 h of birth (p<0·0001 for both variables compared with the control group). The neonatal mortality rate was 42 deaths per 1000 livebirths in intervention clusters compared with 55 per 1000 in the control group (risk ratio 0·80, 95% CI 0·68–0·93; p=0·005).InterpretationThe reduction in neonatal mortality in intervention clusters occurred against a background of improvements in domiciliary practices for maternal and newborn care. However, the poor reach of LHWs in accessing newborn infants at birth and in the early postnatal period underscores the limitations of tasking community health workers in public sector programmes working in similar circumstances with such complex interventions. Such community-based interventions in health systems should be accompanied by concerted efforts to improve quality of care in facilities and referral systems.FundingSaving Newborn Lives, Save the Children USA.

Bringing Greater Precision to Interactions Between Community Health Workers and Households to Improve Maternal and Newborn Health Outcomes in India

“…These findings from UP add to a substantial body of evidence across the developing world suggesting that CHWs can play an important role in safeguarding the health of women and their newborns, 4,6,20,21,[31][32][33] especially those in the poorest parts of society. 22 Their position on the frontlines provides a bridge especially for the rural poor into the formal healthcare system.…”

Logistical, cultural, and structural barriers to immediate neonatal care and neonatal resuscitation in Bihar, India

“…Although not explicitly mentioned by mentors in interviews, a recent systematic review identified workload as a strong contributor to provider burn out and emotional fatigue in LMICs [ 29 ], which undoubtedly effects quality of care. While, training more ANMs and GNMs should remain a long-term goal [ 30 ], a more immediate solution may be thoughtful task shifting within PHCs to less skilled providers including community health workers known as Ashas [ 31 ]. Approximately 10% of neonates require only the initial steps of NR (drying, warming, and stimulating) whereas 3–6% require further intervention including bag-mask ventilation [ 32 ].…”

Effect of an integrated neonatal care kit on neonatal health outcomes: a cluster randomised controlled trial in rural Pakistan

“…The integration of evidence-based interventions for implementation by caregivers has long been considered a promising means to improve neonatal survival 11. We demonstrated that, while the idea of integrating interventions, delivering packages by LHWs and engaging caregivers as implementers, has several advantages, it did not translate into improved neonatal survival.…”

“…One notable exception was the training and evaluation of traditional birth attendants in rural Zambia in the management of common perinatal conditions that led to significant reductions in newborn morality, especially those in the first 24 hours of life 10. Given that multiple barriers prevent CHWs from accessing a newborn soon after birth,11 efforts are needed to engage pregnant women and families as implementers of newborn interventions 5. The delivery of newborn intervention packages by CHWs for implementation by women and families has potential to sustainably reduce neonatal mortality 4…”