Increasing access to care for sick newborns: evidence from the Ghana Newhints cluster-randomised controlled trial

Abstract

ObjectivesTo evaluate the impact of Newhints community-based surveillance volunteer (CBSV) assessments and referrals on access to care for sick newborns and on existing inequities in access.DesignWe evaluated a prospective cohort nested within the Newhints cluster-randomised controlled trial.SettingCommunity-based intervention involving more than 750 000, predominantly rural, population in seven contiguous districts in the Brong-Ahafo Region, Ghana.ParticipantsParticipants were recently delivered women (from more than 120 000 women under surveillance) and their 16 168 liveborn babies. Qualitative in-depth interviews with referral narratives (IDIs) were conducted with 92 mothers, CBSVs and health facility front-desk and maternity/paediatrics ward staff.InterventionsNewhints trained and effectively supervised 475 CBSVs (existing within the Ghana Health Service) in 49 of 98 supervisory zones (clusters) to assess and refer newborns with any of the 10-key-danger signs to health facilities within the first week after birth; promote independent care seeking for sick newborns and problem-solve around barriers between November 2008 and December 2009.Primary outcomesThe main evaluation outcomes were rates of compliance with referrals and independent care seeking for newborn illnesses.ResultsOf 4006 sampled, 2795 (69.8%) recently delivered women received CBSV assessment visits and 279 (10.0%) newborns were referred with danger signs. Compliance with referrals was unprecedentedly high (86.0%) with women in the poorest quintile (Q1) complying better than the least poor (Q5):87.5%(Q1) vs 69.7%(Q5); p=0.038. Three-quarters went to hospitals; 18% were admitted and 58% received outpatient treatment. Some (24%) mothers were turned away at facilities and follow-on IDIs showed that some of these untreated babies subsequently died. Independent care seeking for severe newborn illness increased from 55.4% in control to 77.3% in Newhints zones, especially among Q1 where care seeking almost doubled (95.0% vs 48.6%; RR=1.94 (1.32, 2.84); p=0.001). Rates were the highest among rural residents but urban residents complied quicker.ConclusionsHome visits are feasible and a potentially pro-poor approach to link sick newborns to facilities. Its effectiveness in improving survival hinges on matched improvement in facility quality of care.Trial registration numberNCT00623337.

How do low‐birthweight neonates fare 2 years after discharge from a low‐technology neonatal care unit in a rural district hospital in Burundi?

“…Only two of the six infants who died (one death occurred only 10 days after discharge) were taken to a health facility; four stayed at home because their caretaker underestimated the severity of the problem or because the health facility was too far away. These reasons together with cultural practices and/or believing in traditional remedies are well described in the literature [19].…”

A systematic review of community-to-facility neonatal referral completion rates in Africa and Asia

“…From these, 58 publications were extracted for further review after examining titles and abstracts. Six studies were identified with relevant data [ 8 – 14 ]. The investigators of these studies were contacted for additional unpublished data, and responses were received from four research groups.…”

“… 63 % within seven days of birth, 97 % for two-month follow-up visit No facilitation Female Community Health Volunteers to Facility Based – CHWs Care sought within 28 days of life Morang Innovative Neonatal Intervention (MINI) a [ 11 ] Pakistan 2011 Rural Pakistan Study on identification of etiologies of newborn sepsis Days 2, 6, 13, 20, 27, 34, 41, 48, 59 90 % of enrolled newborns were followed at scheduled visits Provided transport for referral to health facility. Follow-up visit within 24 h for those who did not complete referral Study staff (CHW) to facility, study physicians at facility to tertiary facility No timing indicated Aetiology of Neonatal Infection in South Asia (ANISA) (unpublished) a Africa Ghana 2008 Rural Ghana (2008–2009) RCT on improving neonatal health by training existing community-based surveillance volunteers to identify and conduct ANC/PNC visits Days 1, 3, 7 63 % with at least one postnatal visit, 53 % in representative subsample had first visit on day of delivery or day after Training and incentives for volunteers, materials and supervision for hospital newborn care strengthening and sensitization activities, referral card, counselled on keeping baby warm and frequent bf, dialoged and problem-solved around barriers, 24-h follow-up to check compliance, counselling at 2nd and 3rd PNC visits on five illness signs (stopped or poor feeding, too hot or too cold, difficult or fast breathing, jaundice, less active/lethargy) Community-based surveillance volunteers to hospital or clinic, urban residents tended to comply to hospitals/clinics, rural residents to health center No timing indicated Newhints a [ 8 , 34 ] South Africa 2008 Urban South Africa (2008–2011) RCT on home visit package to improve essential maternal/newborn care and PMTCT First 24–48 h, day 3/4, day 10–14, within 3–4 weeks, after 6 weeks. 59 % received the first post-natal visit and of these 73 % within 48 h after discharge from hospital following delivery Training and incentives referral slips, Partner Defined Quality approach to improve facility quality Pre-existing CHW cadre to local PHC clinic Care sought within 28 days of life Good Start a [ 9 ] Uganda 2009 Rural Uganda (2009–2011) …”

“…Three Sub-Saharan African [ 8 – 10 ] and five South Asian studies [ 11 – 15 ] (one unpublished) reported data on community-to-facility referral completion rates. No datasets from the Americas were identified.…”

“…73 % of the mothers perceived the cards as a confirmation that the baby is severely ill. Some families also reported that the card assured them the treatment would be sped up [ 8 ]. South Africa 2008 also provided referral slips, and improved quality of care at the referral facility via the Partnership Defined Quality approach [ 9 ].…”