Improving Newborn Survival in Low-Income Countries: Community-Based Approaches and Lessons from South Asia

Published in Public Library of Science (PLoS) Med (Vol. 7, No. 4), this article provides a summary of community-based interventions for improved neonatal survival in low-income countries, where most births and deaths occur at home. From the perspective of the authors, obstacles to improving survival in places like South Asia and East and Southern Africa (where only about 35% of births take place in institutions) include: many newborn infants are invisible to health services; care-seeking for maternal and newborn ailments is limited; health workers are often not skilled and confident in caring for newborn infants; and there are inequalities across all these factors.

Table 1 of the article summarises published controlled trials in which the interventions being tested included 1 or more of 3 broad strategies: community mobilisation initiatives, programmes that involved home visits by community-based workers, and partnerships with traditional birth attendants (TBAs). In short, the authors argue that, in this context, a community-based approach that combines community mobilisation and home visits by community-based workers is most effective, but that timing of visits and treatment interventions is critical. Another key finding is that the possibility of partnership between the public and non-government sectors should be explored, particularly in terms of novel large-scale collaborations.

Specifically,

• On the community mobilisation front, the authors discuss programmes that work with communities to identify problems and solutions as a specific strategy to increase newborn survival. For instance, in rural Nepal, groups moved through a cycle of discussions that encompassed: sharing of experiences, internalising new information, prioritising, strategising, acting, and evaluating. A cluster randomised trial suggested that women's groups facilitated by a local female community worker (trained in facilitation techniques but without a health care background) could reduce neonatal mortality rates through such community mobilisation strategies by about 30%. There were behaviour changes in, for example, hygienic practices and care-seeking for problems. Seventy-five percent of groups remained active 18 months after withdrawal of programme support. The model is being tested with rural groups in Bangladesh, India, and Malawi and in urban slums in India.
• Regarding the strategy of home visits by community workers, the authors cite an idea developed n rural Maharashtra, India, by the non-governmental organisation (NGO) Society for Education, Action and Research in Community Health (SEARCH). This NGO trained community health workers to: conduct group health education; identify pregnant women; make antenatal care visits to their homes; attend deliveries; give vitamin K injections; make several further postnatal home visits; identify and manage infants at risk from birth asphyxia, low birth weight, and sepsis; and encourage appropriate referral. This model gradually reduced neonatal mortality by 70%. The authors note that "the SEARCH approach developed incrementally in the context of a commitment to community development and included a range of activities. The most prominent were regular visits to women and their newborn infants by a cadre of community-based women trained and remunerated by SEARCH. These local nongovernment workers were able to give advice and identify and treat neonatal problems, their skills extending to resuscitation and administration of intramuscular antibiotics." Since then, trials of home-based care have been conducted in North India, Bangladesh, and Pakistan (summarised along with other key work in Table 1). Strategies differed in personnel and content, but all the programmes included community meetings, antenatal and postnatal home visits, and preventive advice. Most of the programmes showed: increased uptake of antenatal care, some increase in institutional delivery (although this was not a primary feature of any programme), and better performance on indicators of essential newborn care.
• Recent reviews suggest that TBAs could have a role in increasing newborn survival, and a controlled trial in rural Pakistan found a 30% reduction in neonatal mortality when they were linked systematically with government community health workers and obstetric services. The authors also cite evidence that infants could be saved if TBAs had some skills in managing birth asphyxia, for example.

The authors next present and discuss "Five Things That We Need to Know" when it comes to community interventions for newborn survival:

1. The correct balance of supply and demand intervention
2. What is needed outside South Asia
3. How to fit components into systems
4. Whether workers can cope with the intensity demanded
5. Coverage at scale

In concluding, the authors suggest that "the key questions are now more about the medium than the message: how effective simplified program designs might be, whether they are relevant in African contexts, whether they will be as effective as they appear, and how they could be rolled out and sustained....For governments the choice of approach should almost certainly focus on defining the roles and responsibilities of existing cadres in reaching out to women who deliver at home....This is not simply a matter of training health workers, since it is the marginalised and hard to reach who are most at risk. Women's groups represent a valuable community resource that already exists in many areas and may have inbuilt sustainability. We see active involvement of individuals and communities as the key to achieving targeted coverage of poor and marginalized families to bring down neonatal mortality, and this is an opportunity for governments to facilitate community mobilization in partnership with civil society organisations."