Effect of community-based newborn care on cause-specific neonatal mortality in Sylhet district, Bangladesh: findings of a cluster-randomized controlled trial

Acceptability and operational feasibility of community health worker-led home phototherapy treatment for neonatal hyperbilirubinemia in rural Bangladesh

There is an unmet need for phototherapy treatment in low- and middle-income countries (LMICs) to prevent disability and death of newborns with neonatal hyperbilirubinemia. Home phototherapy deployed by community health workers (CHWs) in LMICs may help increase access to essential newborn postnatal care in a more acceptable way for families and lead to an increase in indicated treatment rates for newborns with hyperbilirubinemia. We aimed to investigate the operational feasibility and acceptability of a CHW-led home phototherapy intervention in a rural sub-district of Bangladesh for families and CHWs where home delivery was common and a treatment facility for neonatal hyperbilirubinemia was often more than two hours from households. We enrolled 23 newborns who were ≥ 2 kg in weight and ≥ 35 weeks gestational age, without clinical danger signs, and met the American Academy of Pediatric treatment criteria for phototherapy for hyperbilirubinemia. We employed a mixed-method investigation to evaluate the feasibility and acceptability of home phototherapy through surveys, in-depth interviews and focus group discussions with CHWs, mothers, and grandparents. Mothers and family members found home phototherapy worked well, saved them money, and was convenient and easy to operate. CHWs found it feasible to deploy home phototherapy and identified hands-on training, mHealth job aids, a manageable workload, and prenatal education as facilitating factors for implementation. Feasibility and acceptability concerns were limited amongst parents and included: a lack of confidence in CHWs' skills, fear of putting newborn infants in a phototherapy device, and unreliable home power supply. CHW-led home phototherapy was acceptable to families and CHWs in rural Bangladesh. Further investigation should be done to determine the impact of home phototherapy on treatment rates and on preventing morbidity associated with neonatal hyperbilirubinemia. Clinical Trial (CT) registration ID: NCT03933423, full protocol can be accessed at https://doi.org/10.1186/s13102-024-00824-6 . Name of the trial registry: clinicaltrials.gov. Clinical Trial (CT) registration Date: 01/05/2019.

Community-based newborn care intervention fidelity and its implementation drivers in South Wollo Zone, North-east Ethiopia

Community-based newborn care (CBNC) has been implemented in Ethiopia across the maternal, neonatal, and child health continuum of care with the goal of lowering newborn mortality. However, neonatal mortality rate in Ethiopian is among the highest in the world. Why neonatal mortality remains high in the face of such effective interventions is the issue. As a result, the authors claim that it is unknown whether the planned intervention is carried out effectively or not. The purpose of this study was to investigate the fidelity of community-based newborn care intervention and its implementation drivers. Multicenter community-based mixed method study was employed on 898 postpartum women, 16 health extension workers (HEWs) and 10 health posts to evaluate CBNC intervention fidelity. Structured questionnaire and facility audit checklist was used to collect quantitative data. In-depth interview technique was used to explore lived experiences of HEWs on CBNC implementation. CBNC intervention fidelity was computed as a composite index of the product of program coverage, frequency and contents. Multilevel linear regression model with adjusted β-coefficients at P-value of 0.05 and a 95% confidence interval (CI) were used to declare a significant relation between CBNC intervention fidelity and its implementation drivers. Interpretative phenomenological analysis was employed for qualitative data analysis. CBNC intervention fidelity was found to be 4.5% (95% CI: 3.6-5.4) with only two women received the intervention with full fidelity. The overall CBNC intervention coverage was 38.4% (95% CI: 35.2-41.6). Only 8.1% and 1.5% of women received all CBNC interventions with recommended frequency and content, respectively. HEWs knowledge of danger sign was significant facilitator while lack of: health center's feedback, related short-term training, health development army support, health center staff's technical assistance to HEWs and shortage of medical equipment supply were barriers for CBNC intervention fidelity. In conclusion the CBNC intervention fidelity was too low in this study. This indicates that CBNC intervention package was not implemented as envisioned implying an implementation gap. All implementation drivers were poorly implemented to result in improved fidelity and intervention outcomes.

The level of Community-Based Essential Newborn Care utilization and associated factors among rural women in Southern Ethiopia, 2020: Based on the updated Community-Based Essential Newborn Care guideline

Background:

A Community-Based Essential Newborn Care is a national initiative that incorporates a newborn care program into the continuum of maternal and child health care through enhancing community participation to reduce child morbidity and mortality and encourage healthy growth and development. This study aimed at assessing the level of Community-Based Essential Newborn Care service uptake and its associated factors among rural women in the Guraghe zone, Southern Ethiopia, 2020.

Methods:

A community-based cross-sectional study was conducted in the rural districts of Southern Ethiopia, from 1 to 31 May 2020. A multistage sampling technique was applied. Using a systematic random sampling technique, a total of 818 respondents were selected. The data collected by a pretested structured questionnaire were entered into EpiData 3.1 and exported to the Statistical Package for Social Sciences (Version 23) for analysis. To identify significant predictors of Community-Based Essential Newborn Care utilization, a multivariable logistic regression analysis was fitted. Adjusted odds ratios with 95% confidence intervals were used to estimate the strength of associations, and statistical significance was declared at a p value <0.05.

Results:

One-third, 269 (33.1%) (95% confidence interval = 30.0–36.2), of women and their newborns got the entire packages of the Community-Based Essential Newborn Care program. Desire on the last pregnancy (adjusted odds ratio = 2.66, 95% confidence interval = 1.56–4.51), birth preparedness and complication readiness plan (adjusted odds ratio = 4.82, 95% confidence interval = 3.26–7.12), timing of the postpartum visit (adjusted odds ratio = 3,56, 95% confidence interval = 2.00–6.34), attending monthly pregnant women conference (adjusted odds ratio = 3.01, 95% confidence interval = 1.99–4.57), and being a certified model household (adjusted odds ratio = 1.88, 95% confidence interval = 1.24–2.85) were identified as key predictors of Community-Based Essential Newborn Care utilization.

Conclusion:

The uptake of the full Community-Based Essential Newborn Care packages in the study area was low. Health care providers at the health institution and community level should give due emphasis to improve contraceptive service delivery. Besides, health extension workers at the community level should work on providing immediate postpartum visits, creating model households, and strengthening pregnant women conferences.

Early Postnatal Care: Exploring Primary Caregivers' Experiences of Continuity of Care After Discharge at Selected Districts in Limpopo Province South Africa

BACKGROUND

Early postnatal discharge is perceived as a factor that contributes to possible maternal, neonatal complications and deaths during the first week of delivery. Continuing with provision of home-based postnatal care by the primary caregivers is crucial to prevent morbidity and mortality.

PURPOSE

The purpose was to explore the experiences of primary caregivers of continuing with the provision of early postnatal care at home.

METHOD

A qualitative research approach, which was explorative, descriptive, and contextual was conducted in the three selected districts of different ethnic groups at Limpopo Province in October 2019. A non-probability, purposive sampling was used to conveniently sample 20 primary caregivers of postnatal women. Data were collected during the first 2 weeks of delivery through in-depth individual semi-structured interviews until data saturation was reached. Data were analysed through a thematic analysis framework applying Tesch's open coding method. The study was done in Limpopo district, South Africa.

FINDINGS

The findings revealed a theme, namely, knowledge and skills of providing community-based postnatal care and three sub-themes; early postnatal care to detect and prevent possible complications to the mother; general postnatal care, and early neonatal care to detect and prevent possible complications.

CONCLUSION

Primary caregivers displayed acceptable indigenous skills and knowledge of providing early postnatal care. However, the skills of detecting potential danger signs were not adequately displayed. It was recommended that midwives need to create awareness to primary caregivers from the antenatal through postnatal care period. Community Health Workers to assist during immediate postnatal check-ups (mother and neonate) which is done within 72hours of delivery. The health education, counseling, and community-based awareness campaigns are to be done with a focus on the detection and prevention of possible complications to mother and baby.

Intervention fidelity and its determinants of focused antenatal care package implementation, in south Wollo zone, Northeast Ethiopia

Background

Focused antenatal care is directed at sustaining maternal health and improving fetal wellbeing to ensure birth of a healthy neonate. Failure to implement focused antenatal care can result in inability to reduce maternal and perinatal morbidity and mortality in low income countries. Due to evidence-practice gaps, however, thousands of maternal, fetal and neonatal lives are still lost every day, mostly from preventable causes. This study aimed to assess focused antenatal care package’s intervention fidelity and its determinant factors in South Wollo Zone, Northeast Ethiopia.

Methods

A cross-sectional study design was employed and a total of 898 women who gave birth in the last 6 months prior to data collection were included. Also 16 health extension workers, working in ten selected health posts, were included. Interviews and self-administered questionnaires were used to collect data from mothers and health extension workers. Ten [10] health posts were audited to assess availability and functionality of drugs and supplies to provide focused antenatal care. Mothers were asked whether or not the required level of care was provided. Health extension workers were provided with self-administered questionnaires to assess socio-demographic characteristics, reception of training, facilitation strategies for the implementation of focused antenatal care and ability to classify danger signs. Multilevel linear regression analysis was performed to identify individual and organizational level’s factors influencing focused antenatal care package intervention fidelity.

Results

Overall weighted average focused antenatal care package intervention fidelity (implemented as intended/planned) was 49.8% (95% CI: 47.7–51.8), which means the average number of focused antenatal care package interventions women received is 49.8%. Health extension workers implemented 55.1% and skilled providers (nurses, midwives, health officers or medical doctors) 44.9% of focused antenatal care package interventions. Overall antenatal care coverage, irrespective of frequency (at least one visit), was 752/898 women (83.7%; 95% CI: 81.3–86.1); 263/752 women (35.0%; 95% CI: 31.6–38.4) received at least four antenatal visits and only 46/752 women (6.1%; 95% CI: 4.4–7.8) received all recommended components of focused antenatal care. Previous pregnancy-related problems, paternal education and implementation of facilitation strategies were found to be significant factors enhancing focused antenatal care package intervention fidelity.

Conclusion

Focused antenatal care package intervention fidelity in the study area was low; this may imply that the current level of maternal, perinatal and neonatal mortality might be partly due to the low level of focused antenatal care intervention fidelity. Improving implementation of facilitation strategies is highly required to contribute to the reduction of those mortalities.

Provider performance and facility readiness for managing infections in young infants in primary care facilities in rural Bangladesh

BACKGROUND

Neonatal infections remain a leading cause of newborn deaths globally. In 2015, WHO issued guidelines for managing possible serious bacterial infection (PSBI) in young infants (0-59 days) using simplified antibiotic regimens when compliance with hospital referral is not feasible. Bangladesh was one of the first countries to adopt WHO's guidelines for implementation. We report results of an implementation research study that assessed facility readiness and provider performance in three rural sub-districts of Bangladesh during August 2015-August 2016.

METHODS

This study took place in 19 primary health centers. Facility readiness was assessed using checklists completed by study staff at three time points. To assess provider performance, we extracted data for all infection cases from facility registers and compared providers' diagnosis and treatment against the guidelines. We plotted classification and dosage errors across the study period and superimposed a locally weighted smoothed (LOWESS) curve to analyze changes in performance over time. Focus group discussions (N = 2) and in-depth interviews (N = 28) with providers were conducted to identify barriers and facilitators for facility readiness and provider performance.

RESULTS

At baseline, none of the facilities had adequate supply of antibiotics. During the 10-month period, 606 sick infants with signs of infection presented at the study facilities. Classification errors were identified in 14.9% (N = 90/606) of records. For infants receiving the first dose(s) of antibiotic treatment (N = 551), dosage errors were identified in 22.9% (N = 126/551) of the records. Distribution of errors varied by facility (35.7% [IQR: 24.7-57.4%]) and infection severity. Errors were highest at the beginning of the study period and decreased over time. Qualitative data suggest errors in early implementation were due to changes in providers' assessment and treatment practices, including confusion about classifying an infant with multiple signs of infection, and some providers' concerns about the efficacy of simplified antibiotic regimens.

CONCLUSIONS

Strategies to monitor early performance and targeted supports are important for enhancing implementation fidelity when introducing complex guidelines in new settings. Future research should examine providers' assessment of effectiveness of simplified treatment and address misconceptions about superiority of broader spectrum antibiotics for treating community-acquired neonatal infections in this context.

Caregiver acceptability of the guidelines for managing young infants with possible serious bacterial infections (PSBI) in primary care facilities in rural Bangladesh

INTRODUCTION

Many infants with possible serious bacterial infections (PSBI) do not receive inpatient treatment because hospital care may not be affordable, accessible, or acceptable for families. In 2015, WHO issued guidelines for managing PSBI in young infants (0-59 days) with simpler antibiotic regimens when hospital care is not feasible. Bangladesh adopted WHO's guidelines for implementation in outpatient primary health centers. We report results of an implementation research study that assessed caregiver acceptability of the guidelines in three rural sub-districts of Bangladesh during early implementation (October 2015-August 2016).

METHODS

We included 19 outpatient primary health centers involved in the initial rollout of the infection management guidelines. We extracted data for all PSBI cases (N = 192) from facility registers to identify gaps in referral feasibility, simplified antibiotic treatment, and follow-up. Focus group discussions (FGD) and in-depth interviews (IDI) were conducted with both caregivers (6 FGDs; 23 IDIs) and providers (2 FGDs; 28 IDIs) to assess caregiver acceptability of the guidelines.

RESULTS

Referral to the hospital was not feasible for many families (83.3%; N = 160/192) and acceptance varied by infection severity. Barriers to referral feasibility included economic and household factors, and previous experiences with poor quality of care at the sub-district hospital. Conversely, providers and caregivers indicated high acceptability of simplified antibiotic treatment. 80% (N = 96/120) of infants with clinical severe infection for whom referral was not feasible returned to the facility for the second antibiotic injection. Some providers reported developing local solutions-including engaging informal providers in treatment of the infant-to address organizational barriers and promote treatment compliance. Follow-up of young infants receiving simplified treatment is critical, but only 67.4% (N = 87/129) of infants received fourth day follow-up. Some providers' reported deviations from the guidelines that shifted responsibility of follow-up to the caregiver, which may have contributed to lapses.

CONCLUSION

Caregivers' perception of trust and communication with providers were influential in caregiver acceptability of care. Few caregivers accepted referral to the sub-district hospital, suggesting low acceptability of this option. When referral was not feasible, many caregivers reported satisfaction with simplified antibiotic treatment. Local solutions described by providers require further examination in this context to assess the safety and potential value of these strategies in outpatient treatment. Our findings suggest strengthening providers' interpersonal skills could improve caregiver acceptability of the guidelines.

A Linked Community and Health Facility Intervention to Improve Newborn Health in Cambodia: the NICCI Stepped-Wedge Cluster-Randomized Controlled Trial

Background: Newborn mortality in Cambodia remains high, with sepsis and complications of delayed care-seeking important contributing factors. Intervention study objectives were to improve infection control behavior by staff in health centers; improve referral of sick newborns; increase recognition of danger signs, and prompt care-seeking at an appropriate health facility; and appropriate referral for sick newborns by mothers and families of newborn infants. Methods: The stepped-wedge cluster-randomized controlled trial took place in rural Cambodia from February 2015 to November 2016. Sixteen clusters consisted of public health center catchment areas serving the community. The intervention included health center staff training and home visits to mothers by community health volunteers within 24 h of birth and on days 3 and 7 after delivery, including assessment of newborns for danger signs and counselling mothers. The trial participants included women who had recently delivered a newborn who were visited in their homes in the first week, as well as health center staff and community volunteers who were trained in newborn care. Women in their last trimester of pregnancy greater than 18 years of age were recruited and were blinded to their group assignment. Mothers and caregivers (2494) received counseling on handwashing practices, breastfeeding, newborn danger signs, and prompt, appropriate referral to facilities. Results: Health center staff in the intervention group had increased likelihood of hand washing at recommended key moments when compared with the control group, increased knowledge of danger signs, and higher recall of at least three hygiene messages. Of mother/caregiver participants at 14 days after delivery, women in the intervention group were much more likely to know at least three danger signs and to have received messages on care-seeking compared with controls. Conclusions: The intervention improved factors understood to be associated with newborn survival and health. Well-designed training, followed by regular supervision, enhanced the knowledge and self-reported behavior of health staff and health volunteers, as well as mothers’ own knowledge of newborn danger signs. However, further improvement in newborn care, including care-seeking for illness and handwashing among mothers and families, will require additional involvement from broader stakeholders in the community.

Effectiveness and cost-effectiveness of home-based postpartum care on neonatal mortality and exclusive breastfeeding practice in low-and-middle-income countries: a systematic review and meta-analysis

Background

Early postpartum facility discharge negatively impacts mothers’ proper and effective use postnatal care. Cognizant of these facts, home-based postnatal care practices have been promoted to complement facility-based care to reduce neonatal mortality. This systematic review evaluated the effectiveness and cost-effectiveness of home-based postnatal care on exclusive breastfeeding practice and neonatal mortality in low-and-middle-income countries.

Methods

Randomized trials and quasi-experimental studies were searched from electronic databases including PubMed, Popline, Cochrane Central Register of Controlled Trials and National Health Service Economic Evaluation databases. Random-effects meta-analysis model was used to pool the estimates of the outcomes accounting for the variability among studies.

Results

We identified 14 trials implementing intervention packages that included preventive and promotive newborn care services, home-based treatment for sick neonates, and community mobilization activities. The pooled analysis indicates that home-based postpartum care reduced neonatal mortally by 24% (risk ratio 0.76; 95% confidence interval 0.62–0.92; 9 trials; n = 93,083; heterogeneity p < .01) with no evidence of publication bias (Egger’s test: Coef. = − 1.263; p = .130). The subgroup analysis suggested that frequent home visits, home visits by community health workers, and community mobilization efforts with home visits, to had better neonatal survival. Likewise, the odds of mothers who exclusively breastfed from the home visit group were about three times higher than the mothers who were in the routine care group (odds ratio: 2.88; 95% confidence interval: 1.57–5.29; 6 trials; n = 20,624 mothers; heterogeneity p < .01), with low possibility of publication bias (Coef. = − 7.870; p = .164).

According to the World Health Organization’s Choosing Interventions that are Cost-Effective project recommendations, home-based neonatal care strategy was found to be cost-effective.

Conclusions

Home visits and community mobilization activities to promote neonatal care practices by community health workers is associated with reduced neonatal mortality, increased practice of exclusive breastfeeding, and cost-effective in improving newborn health outcomes for low-and-middle-income countries. However, a well-designed evaluation study is required to formulate the optimal package and optimal timing of home visits to standardize home-based postnatal interventions.

Implementation research to support Bangladesh Ministry of Health and Family Welfare to implement its national guidelines for management of infections in young infants in two rural districts

BACKGROUND

World Health Organization revised the global guidelines for management of possible serious bacterial infection (PSBI) in young infants to recommend the use of simplified antibiotic therapy in settings where access to hospital care is not possible. The Bangladesh Ministry of Health and Family Welfare (MoHFW), Government of Bangladesh (GOB) adopted these guidelines, allowing treatment at first-level facilities. During the first year of implementation, the Projahnmo Study Group and USAID/MaMoni Health Systems Strengthening (HSS) Project supported the MoHFW to operationalize the new guidelines and conducted an implementation research study in selected districts to assess challenges and identify solutions to facilitate scale-up across the country.

IMPLEMENTATION SUPPORT

Projahnmo and MaMoni HSS teams supported implementation in three areas: building capacity, strengthening service delivery, and mobilizing communities. Capacity building focused on training paramedics to conduct outpatient management of PSBI cases and developing monitoring and supervision systems. The teams also filled gaps in government supply of essential drugs, equipment, and logistics. Community mobilization strategies to promote care-seeking and referrals to facilities varied across districts; in one district community, health workers made home visits while in another district, the promotion was carried out through community volunteers, village doctors, and through existing community structures.

METHODS

We followed a plan-do-study-act (PDSA) cycle to identify and address implementation challenges. Three cycles-1 every 4 months-were conducted. We collected data utilizing quantitative and qualitative methods in both the community and facilities. The total sample size for this study was 13,590.

DISCUSSION

This article provides implementation research design details for program managers intending to implement new guidelines on management of young infant infections. Results of this research will be reported in the forthcoming papers. Preliminary findings indicate that the management of PSBI cases at the UH&FWCs is feasible. However, MoHFW, GOB needs to address the implementation challenges before scale-up of this policy to the national level.

Advancing the health of women and newborns: predictors of patient satisfaction among women attending antenatal and maternity care in rural Rwanda

Objective

Identify predictors of patient satisfaction with antenatal care (ANC) and maternity services in rural Rwanda.

Design

Cross-sectional.

Setting

Twenty-six health facilities in Southern Kayonza (SK) and Kirehe districts.

Participants

Sample of women ≥ 16 years old receiving antenatal and delivery care between November and December 2013.

Intervention

Survey of patient satisfaction with antenatal and delivery care to inform quality improvement (QI) initiatives aimed at reducing neonatal mortality.

Main Outcome Measure

Overall satisfaction with antenatal and delivery care (reported as excellent or very good).

Results

In multivariate logistic regression analysis, high perceived quality [odds ratio (OR) = 3.03, 95% confidence intervals (CI): 1.565.88], respect [OR = 4.13, 95% CI: 2.16-7.89], and confidentiality [SK: OR = 7.50, 95% CI: 2.16-26.01], [Kirehe: OR = 1.54, 95% CI: 0.60-3.94] were associated with higher overall satisfaction with ANC, while having ≥1 child compared to none [OR = 0.46, 95% CI: 0.25-0.84] was associated with lower satisfaction. For maternity services, <5 years of school versus ≥5 years [OR = 0.13, 95% CI: 0.026-0.69] and higher cleanliness [OR = 19.23, 95% CI: 2.22-166.83], self-reported quality [OR = 10.52, 95% CI: 1.81-61.22], communication [OR = 8.78, 95%CI: 1.95-39.59], and confidentiality [OR = 8.66, 95% CI: 1.20-62.64] were all positively associated with high satisfaction. Higher comfort [OR: 0.050, 95% CI: 0.0034-0.71] and Kirehe vs. SK district [OR: 0.21, 95% CI: 0.042-1.01] were associated with lower satisfaction.

Conclusions

Patient-centeredness (including interpersonal relationships), organizational factors, and location are important individual determinants of satisfaction for women seeking maternal care at study facilities. Understanding variation in these factors should inform QI efforts in maternal and newborn health programs.

In search of a primary outcome for community-based newborn infection trials in Eastern Uganda: a nested cohort study within the BabyGel pilot trial

Background

Due to their immature immune system, neonates are at high risk of infection. This vulnerability when combined with limited resources and health education in developing countries can lead to sepsis, resulting in high global neonatal mortality rates. Many of these deaths are preventable. The BabyGel pilot trial tested the feasibility of conducting the main randomised trial, with the provision of alcohol handgel to postpartum mothers for prevention of neonatal infective morbidity in the rural community. This secondary analysis sought to evaluate the methods of detecting infections in babies up to 3 months of age.

Methods

The pilot two-arm cluster randomised controlled trial took place in 10 villages around Mbale, Eastern Uganda. Women were eligible and recruited antenatally if their gestation was ≥ 34 weeks. All infants of mothers participating in the BabyGel pilot trial were followed up for the first 3 months of life. Evidence for infant infection was collected using five different methods: clinician diagnosed infection, microbiologically confirmed infection, maternally reported infection, a positive infection screen using the World Health Organization (WHO) Integrated Management of Childhood Illness (IMCI) screening criteria, and reported antibiotic use identified during home and clinic visits. These methods were assessed quantitatively regarding the detection rates of suspected infections and qualitatively by exploring the challenges collecting data in the rural community setting.

Results

A total of 103 eligible women participated in the BabyGel pilot trial, with 1 woman delivering twins. Of the 99 mother-infant pairs who consented to participate in the study, 55 infants were identified with infection in total. Maternal report of illness provided the highest estimate, with mothers reporting suspected illness for 45 infants (81.8% of the total suspected infections identified). The WHO IMCI screening criteria identified 30 infants with suspected infection (54.5%), and evidence for antibiotic use was established in 22 infants (40%). Finally, clinician-diagnosed infection identified 19 cases (34.5%), which were also microbiologically confirmed in 5 cases (9.1%). Data collection in the rural setting was hindered by poor communication between mothers and the research team, limited staff awareness of the study in health centres resulting in reduced safeguarding of clinical notes, and widespread use of antibiotics prior to notification and clinical review. Furthermore, identification of suspected infection may not have been limited to severe infections, with ambiguity and no official clinical diagnosis being given to those identified solely by maternal report of infection.

Conclusions

A high rate of suspected infection was identified spanning the five sources of data collection, but no ideal method was found for detection of community neonatal infection. Although maternal self-reports of infant infection provided the highest detection rate, data collection via each source was limited and may have identified minor rather than major infections. Future studies could utilise the IMCI screening tool to detect severe community infection leading to referral for clinical confirmation. This should be combined with weekly contact with mothers to detect maternally suspected illness. Obtaining more details of the symptoms and timescale will improve the accuracy when detecting the total burden of suspected disease, and advising participants to retain medication packaging and prescriptions will improve identification of antibiotic use.

Trial registration

Babygel pilot trial - trial registration: ISCRCTN 67852437. Registered 02/03/2015.

Systematic review of community participation interventions to improve maternal health outcomes in rural South Asia

BACKGROUND

This is a systematic review on the effectiveness of community interventions in improving maternal health care outcomes in South Asia.

METHODS

We searched electronic databases to June 2017. Randomised or cluster randomised studies in communities within rural/remote areas of Nepal, Bangladesh, India and Pakistan were included. Data were analysed as risk ratios (RR) or odds ratios (OR), and effects were adjusted for clustering. Meta-analyses were performed using random-effects and evidence quality was assessed.

RESULTS

Eleven randomised trials were included from 5440 citations. Meta-analysis of all community interventions combined compared with control showed a small improvement in the number of women attending at least one antenatal care visit (RR 1.19, 95% CI 1.06 to 1.33). Two community mobilisation sub groups: home care using both male and female mobilisers, and education by community mobilisers, improved the number of women attending at least one antenatal visit. There was no difference in the number of women attending at least one antenatal visit for any other subgroup. There was no difference in the number of women attending 3 or more antenatal visits for all community interventions combined, or any community subgroup. Likewise, there was no difference in attendance at birth between all community interventions combined and control. Health care facility births were modestly increased in women's education groups (adjusted RR (1.15, 95% CI 1.11 to 1.20; 2 studies)). Risk of maternal deaths after 2 years (RR 0.63, 95% CI 0.24 to 1.64; 5 studies), and 3 years (RR 1.11, 95% CI 0.52 to 2.36; 2 studies), were no different between women's education groups and control. Community level mobilisation rather than health care messages at district level improved the numbers of women giving birth at health care facilities (RR1.09 (95%CI 1.06 to 1.13; 1 study)). Maternal health care knowledge scores improved in two community-based interventions, one involving education of male community members.

CONCLUSION

Women's education interventions may improve the number of women seeking birth at a health care facility, but the evidence is of low quality. No impact on maternal mortality was observed Future research should explore the effectiveness of including male mobilisers.

TRIAL REGISTRATION

This systematic review is registered with PROSPERO CRD42016033201 .

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

BACKGROUND

Although 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.

METHODS

We 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.

FINDINGS

Of 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).

INTERPRETATION

The 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.

FUNDING

Saving Newborn Lives, Save the Children USA.

Antepartum complications and perinatal mortality in rural Bangladesh

BACKGROUND

Despite impressive improvements in maternal survival throughout the world, rates of antepartum complications remain high. These conditions also contribute to high rates of perinatal deaths, which include stillbirths and early neonatal deaths, but the extent is not well studied. This study examines patterns of antepartum complications and the risk of perinatal deaths associated with such complications in rural Bangladesh.

METHODS

We used data on self-reported antepartum complications during the last pregnancy and corresponding pregnancy outcomes from a household survey (N = 6,285 women) conducted in Sylhet district, Bangladesh in 2006. We created three binary outcome variables (stillbirths, early neonatal deaths, and perinatal deaths) and three binary exposure variables indicating antepartum complications, which were antepartum hemorrhage (APH), probable infection (PI), and probable pregnancy-induced hypertension (PIH). We then examined patterns of antepartum complications and calculated incidence rate ratios (IRR) to estimate the associated risks of perinatal mortality using Poisson regression analyses. We calculated population attributable fraction (PAF) for the three antepartum complications to estimate potential risk reductions of perinatal mortality associated them.

RESULTS

We identified 356 perinatal deaths (195 stillbirths and 161 early neonatal deaths). The highest risk of perinatal death was associated with APH (IRR = 3.5, 95% CI: 2.4-4.9 for perinatal deaths; IRR = 3.7, 95% CI 2.3-5.9 for stillbirths; IRR = 3.5, 95% CI 2.0-6.1 for early neonatal deaths). Pregnancy-induced hypertension was a significant risk factor for stillbirths (IRR = 1.8, 95% CI 1.3-2.5), while PI was a significant risk factor for early neonatal deaths (IRR = 1.5, 95% CI 1.1-2.2). Population attributable fraction of APH and PIH were 6.8% and 10.4% for perinatal mortality and 7.5% and 14.7% for stillbirths respectively. Population attributable fraction of early neonatal mortality due to APH was 6.2% and for PI was 7.8%.

CONCLUSIONS

Identifying antepartum complications and ensuring access to adequate care for those complications are one of the key strategies in reducing perinatal mortality in settings where most deliveries occur at home.