Effect of community-based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: a cluster-randomised controlled trial

doi:10.1016/S0140-6736(08)60835-1

The Lancet

Volume 371, Issue 9628, 7–13 June 2008, Pages 1936-1944

https://doi.org/10.1016/S0140-6736(08)60835-1 Get rights and content

Summary

Background

Neonatal mortality accounts for a high proportion of deaths in children under the age of 5 years in Bangladesh. Therefore the project for advancing the health of newborns and mothers (Projahnmo) implemented a community-based intervention package through government and non-government organisation infrastructures to reduce neonatal mortality.

Methods

In Sylhet district, 24 clusters (with a population of about 20 000 each) were randomly assigned in equal numbers to one of two intervention arms or to the comparison arm. Because of the study design, masking was not feasible. All married women of reproductive age (15–49 years) were eligible to participate. In the home-care arm, female community health workers (one per 4000 population) identified pregnant women, made two antenatal home visits to promote birth and newborn-care preparedness, made postnatal home visits to assess newborns on the first, third, and seventh days of birth, and referred or treated sick neonates. In the community-care arm, birth and newborn-care preparedness and careseeking from qualified providers were promoted solely through group sessions held by female and male community mobilisers. The primary outcome was reduction in neonatal mortality. Analysis was by intention to treat. The study is registered with ClinicalTrials.gov, number 00198705.

Findings

The number of clusters per arm was eight. The number of participants was 36059, 40159, and 37598 in the home-care, community-care, and comparison arms, respectively, with 14 769, 16 325, and 15 350 livebirths, respectively. In the last 6 months of the 30-month intervention, neonatal mortality rates were 29·2 per 1000, 45·2 per 1000, and 43·5 per 1000 in the home-care, community-care, and comparison arms, respectively. Neonatal mortality was reduced in the home-care arm by 34% (adjusted relative risk 0·66; 95% CI 0·47–0·93) during the last 6 months versus that in the comparison arm. No mortality reduction was noted in the community-care arm (0·95; 0·69–1·31).

Interpretation

A home-care strategy to promote an integrated package of preventive and curative newborn care is effective in reducing neonatal mortality in communities with a weak health system, low health-care use, and high neonatal mortality.

Funding

United States Agency for International Development and saving newborn lives programme by Save the Children (US) with a grant from Bill and Melinda Gates Foundation.

Introduction

Although many developing countries have had reductions in both postneonatal and 1–4-year-old child mortalities, neonatal mortality has remained constant, with an estimated 4 million deaths per year worldwide.1, 2, 3 In Bangladesh, neonatal mortality accounts for 63% of deaths in infants and 45% in children aged less than 5 years.⁴

Although reductions in neonatal or perinatal mortality were noted in community-based effectiveness trials of maternal and neonatal care packages,5, 6, 7 few large-scale community-based studies have tested strategies to deliver neonatal interventions with the existing health infrastructures and neonatal mortality as an outcome.2, 8, 9 The best method for delivery of neonatal intervention packages at population scale in low-resource settings remains to be identified.8, 9

Health services in Bangladesh are provided by the government's Ministry of Health and Family Welfare, non-government organisations, and private providers. In the government sector, two community-based workers—a family welfare assistant and a health assistant—together serve a population of 6000–7000. First-level outpatient clinics—eg, Union Health and Family Welfare Centre—serve a population of about 20 000. Sub-district hospitals with both inpatient and outpatient facilities serve a population of about 200 000. For study-area residents, the closest emergency obstetric-care facility is outside the study area at the Medical College Hospital in Sylhet city (figure 1).

We developed two service-delivery strategies—a home-care model and a community-care model—to promote neonatal health in rural Bangladesh. We postulated that both intervention strategies would result in a 40% reduction in the neonatal mortality rate versus that in the comparison arm. We report here the effect of the intervention on key health-care behaviours and neonatal mortality.

Section snippets

Study design and participants

The project for advancing the health of newborns and mothers (Projahnmo, which means generation in Bangla) did the study in three rural sub-districts (upazilas; Beanibazar, Zakiganj, and Kanaighat) of Sylhet district (figure 1), which has the highest neonatal mortality rate among Bangladesh's six divisions.⁴ This area was selected because it has poor access to health care, about 15 000 livebirths per year, and the presence of non-government organisations with the ability to scale-up the

Results

Mother's age and education, birth order, child's sex, and household wealth were similar at baseline across study arms for a sample of all women who had a livebirth during 2002 (table 2). Figure 2 shows the trial profile. Among the 24 clusters, the endline survey identified 47 158 women with 58 588 pregnancies, 7160 (15%) of whom declined to participate or were absent during data collection. Survey participants reported a total of 46 444 livebirths, of which 44 380 survived the neonatal period.

Discussion

The home-care strategy reduced neonatal mortality by more than a third in the last 6 months of the 30-month trial and improved key maternal and newborn-care practices. Community health workers successfully referred about a third of neonatal infection cases and treated more than a third of cases with injectable antibiotics in the homes (figure 3). Improvements in care practices, but no mortality reduction, were noted in the community-care arm.

Each community health worker was responsible for a

References (30)

J Bryce et al.
WHO estimates of the causes of death in children
Lancet
(2005)
JE Lawn et al.
4 million neonatal deaths: when? where? why?
Lancet
(2005)
DS Manandhar et al.
Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial
Lancet
(2004)
JE Lawn et al.
1 year after The Lancet Neonatal Survival Series–was the call for action heard?
Lancet
(2006)
MK Campbell et al.
Sample size calculator for cluster randomized trials
Comput Biol Med
(2004)
A Donner et al.
Confidence interval construction for effect measures arising from cluster randomization trials
J Clin Epidemiol
(1993)
A Haines et al.
Achieving child survival goals: potential contribution of community health workers
Lancet
(2007)
AT Bang et al.
Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India
Lancet
(1999)
PJ Winch et al.
Local understandings of vulnerability and protection during the neonatal period in Sylhet District, Bangladesh: a qualitative study
Lancet
(2005)
I de Zoysa et al.
Careseeking for illness in young infants in an urban slum in India
Soc Sci Med
(1998)

J Borghi et al.

Economic assessment of a women's group intervention to improve birth outcomes in rural Nepal

Lancet

(2005)

OB Ahmad et al.

The decline in child mortality: a reappraisal

Bull World Health Organ

(2000)

Bangladesh Demographic and Health Survey, 1999–2000

(2001)

AT Bang et al.

Neonatal and infant mortality in the ten years (1993 to 2003) of the Gadchiroli field trial: effect of home-based neonatal care

J Perinatol

(2005)

AH Jokhio et al.

An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan

N Engl J Med

(2005)

Cited by (482)

Young Infant Mortality Associated with Preterm and Small-for-Gestational-Age Births in Rural Bangladesh: A Prospective Cohort Study
2024, Journal of Pediatrics
To assess the relative risk of mortality in infants born preterm and small for gestational age (SGA) during the first and second months of life in rural Bangladesh.
We analyzed data from a cohort of pregnant women and their babies in Sylhet, Bangladesh, assembled between 2011 and 2014. Community health workers visited enrolled babies up to 10 times from birth to age 59 days. Survival status was recorded at each visit. Gestational age was estimated from mother’s reported last menstrual period. Birth weights were measured within 72 hours of delivery. SGA was defined using the INTERGROWTH-21st standard. We estimated unadjusted and adjusted hazard ratios (HRs) and corresponding 95% CIs for babies born preterm and SGA separately for the first and second month of life using bivariate and multivariable weighted Cox regression models.
The analysis included 17 643 singleton live birth babies. Compared with infants born at term-appropriate for gestational age, in both unadjusted and adjusted analyses, infants born preterm-SGA had the greatest risk of death in the first (HR 13.25, 95% CI 8.65-20.31; adjusted HR 12.05, 95% CI 7.82-18.57) and second month of life (HR 4.65, 95% CI 1.93-11.23; adjusted HR 4.1, 95% CI 1.66-10.15), followed by infants born preterm-appropriate for gestational age and term-SGA.
The risk of mortality in infants born preterm and/or SGA is increased and extends through the second month of life. Appropriate interventions to prevent and manage complications caused by prematurity and SGA could improve survival during and beyond the neonatal period.
Effect of the Mamás del Río programme on essential newborn care: a three-year before-and-after outcome evaluation of a community-based, maternal and neonatal health intervention in the Peruvian Amazon
2023, The Lancet Regional Health - Americas
Despite remarkable progress in maternal and neonatal health, regional inequalities persist in Peru. In rural areas of Amazonian Loreto, access to quality care is difficult, home births are frequent, and neonatal mortality is high. We conducted a prospective before-and-after study to assess the effect after implementation and over time of a community-based intervention on essential newborn care (ENC).
Mamás del Río consists of tablet-enhanced educational home visits by Community health workers (CHW) to pregnant women and mothers of newborns, with supportive training on ENC of traditional birth attendants and facility staff. The study area comprised 79 rural communities of three districts in Loreto. Primary outcomes were ENC practices in home births, secondary outcomes were ENC in facility births as well as healthcare seeking, measured at baseline before and at year 2 and year 3 after intervention implementation. Community censuses included questionnaires to women aged 15–49 years with a live birth. We calculated prevalence of outcomes at each time point and estimated adjusted prevalence differences (PD) between time points using post-estimation based on logistic regression.
Following implementation early 2019, 97% of communities had a trained CHW. At year 2 follow-up, 63% (322/530) of women received a CHW visit during pregnancy. Seven out of nine ENC indicators among home births improved, with largest adjusted prevalence differences in immediate skin-to-skin contact (50% [95% CI: 42–58], p < 0.0001), colostrum feeding (45% [35–54], p < 0.0001), and cord care (19% [10–28], p = 0.0001). Improvements were maintained at year 3, except for cord care. At year 2, among facility births only three ENC indicators improved, while more women gave birth in a facility. Sensitivity analyses showed ENC prevalence was similar before compared to after onset of Covid-19 lockdown.
ENC practices in home births improved consistently and changes were sustained over time, despite the onset of the Covid-19 pandemic. A community-based approach for behaviour-change in home-based newborn care appears effective. Process evaluation of mechanisms will help to explain observed effects and understand transferability of findings.
Grand Challenges Canada and Peruvian National Council of Science and Technology.
Effectiveness of a continuum of care in maternal health services on the reduction of maternal and neonatal mortality: Systematic review and meta-analysis
2023, Heliyon
Sustainable Development Goals −3 (SDG – 3) were to ensure healthy live and promote well-being by reducing global maternal and neonatal deaths. These were to be implemented through the concept of continuum of care in maternal health program framework to improve health outcomes. There is a paucity of published evidences; as such, this review is designed to assess the effectiveness of the concept of continuum of care in maternal and neonatal health services on the reduction of maternal and neonatal mortality.
A search was conducted using the key words; maternal and neonatal, health services, continuum of care, maternal and neonatal mortality. Search focused on PubMed, Cochrane, MEDLINE and Google Scholar. Extractions of articles were done based on predetermine criteria. Data were compiled, and screened, entered and analysis was done using STATA 13 and Rev. Man. software. Effects of the intervention package were determined and the result was interpreted in random effect RR with 95%CI. The publication bias was determined by using funnel plot, Egger and Bagger test, heterogeneity, and sensitivity test.
A total of 4685 articles were retrieved of these 20 articles reviewed. Articles on 631,975 live births (LBs) were analyzed. Results showed the distribution as follows; 23,126 newborns died within 28 days resulting [NMR = 35/1000LBs among the intervention group whereas NMR = 39/1000LBs among the control group]. The pooled effect of the intervention was significantly reduced neonatal mortality (RR = 0.84; 95%CI: 0.77–0.91). Similarly, 1268 women died during the pregnancy period up to 42 days after childbirth that resulted [MMR = 330/100,000LBs among the intervention group whereas MMR = 460/100,000LBs among the control group]. The pooled effect of the intervention was not a statistically significant association with maternal mortality (RR = 0.64; 95%CI: 0.41–1.00).
Adoption of continuum of care concepts in maternal health services reduced maternal and neonatal mortality. We recommend strengthening and effective implementation of a continuum of care in maternal health services to improve maternal and neonatal health care outcomes.
Testing theory of change assumptions of health behavior change interventions: A blended approach exploring local contexts
2023, Evaluation and Program Planning
This paper used a blended approach that involves multiple techniques to, first, test a set of assumptions around a health behavior change communication intervention theory of change (ToC) and, second, surface some unidentified assumptions involving the local context. The intervention was integrated with women’s self-help groups (SHGs) in Uttar Pradesh, India. The key assumption tested in this paper was the linkage between SHG membership, program exposure, and maternal, newborn, and child health practices. Learnings were substantiated through empirical investigations, including structural equation modeling and mediation analysis, as well as ‘co-learning’ workshops within the community. The workshops aimed to capture and interpret the heterogeneity of local contexts through deep dialogs with the community and program implementers at various levels. Statistical analyses indicated a significant association between the amount of women’s program exposure and their health practices. SHG membership was shown to affect maternal health practices; however, it did not have a direct effect on neonatal or child health practices. The ‘co-learning’ workshops revealed crucial aspects, such as prevailing socio-cultural norms, which prevented pregnant or recently delivered women from participating in SHG meetings. This paper encourages evaluators to work with the community to interpret and co-construct meaning in unpacking the contextual forces that seldom appear in the program ToC.
The effectiveness of prenatal and postnatal home visits by paramedical professionals and women's group meetings in improving maternal and child health outcomes in low and middle-income countries: a systematic review and meta-analysis
2023, Public Health
To assess the effectiveness of prenatal and postnatal home visits (HVs) and women group meetings (WGMs) by paramedical professionals to improve maternal and child health outcomes in low- and middle-income countries (LMICs).
Systematic review and meta-analysis.
We conducted a systematic review of trials published till December 2020, as per registered protocol in The International Prospective Register of Systematic Reviews (PROSPERO) (CRD42018091968). Outcomes were neonatal mortality rate (NMR), maternal mortality ratio (MMR), the incidence of low birth weight, and still birth rate (SBR). The Cochrane Pregnancy and Childbirth Group's Trials Register, Cochrane Central Register of Controlled Trials, PubMed, and Excerpta Medica Database (EMBASE) were searched. Pooled results were estimated using random-effects meta-analysis in RevMan version 5.2.
Twenty-five trials met the inclusion criteria. HVs were the key intervention in 12, WGMs in 11, and both interventions in 2 trials. The pooled estimates have shown that NMR was significantly reduced by HVs (OR 0.77, confidence interval [CI]: 0.67–0.90, P = 0.0007, I² = 77%) and WGMs (OR 0.76, CI: 0.65–0.90, P = 0.001, I² = 71%). SBR was significantly reduced by HVs (OR 0.77, CI: 0.70–0.85; P < 0.001, I² = 0%). Subgroup analysis of studies in which more than 10% of pregnant women participated in the WGMs showed significant reduction in NMR (OR 0.67, CI 0.58–0.77, P = 0.00001, I² = 31%) and MMR (OR 0.55, CI 0.36–0.84, P = 0.005, I² = 27%). Two studies reported improvement in birth weight by HVs.
HVs and WGMs (with >10% pregnant women) by paramedical professionals are effective strategies in reducing the NMR and MMR in LMICs. HVs were also effective in reducing SBR.
Evaluation of existing Home Based Newborn Care (HBNC) services and training for improving performance of Accredited Social Health Activists (ASHA) in rural India: A multiple observation study
2023, Midwifery
One-fourth of global neonatal deaths occur in India alone. Accredited Social Health Activists (ASHA) was launched with the purpose of improving healthcare services, including neonatal survival primarily in rural areas. The aim of this study is to determine the status of ASHA's knowledge, practices, and attitude regarding Home Based Newborn Care (HBNC) services, as well as to provide necessary trainings for improvement of their performance.
For this study, 102 ASHA working in Doiwala were recruited at random, and Quasi Experimental Design - Multiple Observation Method (single group time series design) was adopted. The data were collected using pretested tools consisting of knowledge questionnaires, attitude scale, and practices and skill-based questionnaires on various domains of HBNC. The data from the ASHA were collected 4 times at a regular interval of 30 days. Each time, the assessment of ASHA was accompanied by re-education and training on HBNC.
Even though, about 90% of ASHA had been working for more than 5 years, they possessed average knowledge regarding HBNC before the training. Less than 50% of them were aware of mandatory vaccines and infection care services for newborns. About 70% of them were uninformed about the potential risk of hypothermia in neonates and also lacked knowledge regarding its preventive measures. Their knowledge, practices and attitude regarding HBNC was significantly improved after the training (p˂0.05). About 54% of ASHA became aware of the avoidance of pre-lacteal feeding in newborns. Their practices score regarding prevention of hypothermia was increased from 80% to 95%. The number of ASHA who understood the importance of Kangaroo Mother Care (KMC) was also increased from 56% to 87%. About 95% of the ASHA understood the significance of feeding breast milk to newborns. Moreover, the attitude of ASHA towards the traditional way of newborn care such as early bathing, giving pre-lacteal feed, application of turmeric and ghee to the umbilicus of baby etc. was significant improved.
ASHA must be assessed regularly in order to identify their basic needs, knowledge gaps, challenges and difficulties to quality HBNC services. Proper training on HBNC at regular interval significantly improved their knowledge, practices, and attitude toward their responsibilities, which is crucial for improving newborn health status.

View all citing articles on Scopus

^‡: Other members listed at end of paper

View full text

ArticlesEffect of community-based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: a cluster-randomised controlled trial

Summary

Background

Methods

Findings

Interpretation

Funding

Introduction

Section snippets

Study design and participants

Results

Discussion

Lancet

Lancet

Lancet

Lancet

Comput Biol Med

J Clin Epidemiol

Lancet

Lancet

Lancet

Soc Sci Med

Lancet

The decline in child mortality: a reappraisal

Bull World Health Organ

Bangladesh Demographic and Health Survey, 1999–2000

Neonatal and infant mortality in the ten years (1993 to 2003) of the Gadchiroli field trial: effect of home-based neonatal care

J Perinatol

An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan

N Engl J Med

Articles
Effect of community-based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: a cluster-randomised controlled trial