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Article Excerpt
Une traduction en francais de ce resume figure a la fin de l'article. Al final del articulo se facilita una traduccion al espanol.
Introduction
The neonatal period is recognized as a brief, critical time that requires focused interventions to reach the Millennium Development Goal of a two-thirds reduction in child mortality by 2015. In India there are one million neonatal deaths every year, representing approximately a quarter of all global neonatal deaths. (1,2) Neonatal deaths account for about 38% of the annual 10.6 million child deaths recorded worldwide and nearly half of the deaths in children under 5 years in India. (1,3)
In developing countries, the primary causes of neonatal deaths are infections (36%), complications of preterm birth (28%) and birth asphyxia (23%), with low birth weight as the primary contributory cause. (1) High coverage of a few simple and cost-effective interventions would reduce neonatal mortality. (4-7) Interventions at the family and community level can save lives, especially where health systems are weak. (4,8) Several community-based efficacy trials have evaluated service delivery strategies to improve newborn survival. (7,9-16) Those trials were conducted under controlled conditions to ensure high programme coverage and usually employed workers who delivered only the intervention being studied. However, population-level data on the impact of family and community-based neonatal care from large-scale programmes is scarce. A need exists to implement proven interventions at scale, across the continuum of care, without losing impact.
Here, we evaluate the effect of a community-based package of maternal and newborn interventions that was implemented at scale using existing government infrastructure through an integrated nutrition and health programme in eight states of India. This evaluation was conducted in two rural districts of the state of Uttar Pradesh, India.
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Methods
Programme description The Integrated Nutrition and Health Programme (INHP) was a partnership of an international nongovernmental organization (NGO), CARE-India, with the Indian government and local NGOs. The programme was implemented through the infrastructure of the government's Ministry of Women and Child Development's Integrated Child Development Services and the Ministry of Health and Family Welfare (Fig. 1). The newborn care package aimed to increase the frequency of behaviours during the antenatal, delivery and postnatal periods that have proven benefits for maternal and newborn survival (Table 1). The INHP also included interventions to improve immunization rates and the nutritional status of child-bearing women and children under the age of 5 years; these interventions were evaluated separately.
In both the INHP and standard government health services, health education and services are provided by two groups of government functionaries: auxiliary nurse-midwives, and maternal and child health promotion (anganwadi) workers. Auxiliary nurse-midwives work in health centres that serve a rural population of about 5000 people. They make home visits to promote home care and care-seeking, attend deliveries, provide immunization and encourage use of family planning methods. Anganwadi workers serve one village (a population of approximately 1000) and operate a facility called an anganwadi centre. They promote maternal, newborn and child health from fixed sites and through home visits, distribute supplementary food to poor families, and provide preschool education. (17-19) The INHP encouraged anganwadi workers to recruit community volunteers called "change agents" to further improve the reach of programmes. The anganwadi workers, auxiliary nurse-midwives, and change agents in the intervention district received a total of 6 days of training on the care of mothers and newborn babies; as a group, we refer to them as community-based workers. In the INHP, information to encourage behaviour change was usually communicated during antenatal and postnatal home visits by the community-based workers (Table 1).
Study location, population and design
Although the programme was implemented in eight states, we collected data from Uttar Pradesh state only. A quasi-experimental design was used and the study design, data collection and analysis were conducted by a team of independent researchers who were not involved in the implementation of the intervention. Two of the authors of this paper (UK and DP) were involved in programme implementation.
One INHP district, Barabanki, served as the intervention district, while a district receiving standard government health and Integrated Child Development Services, Unnao, was used as a comparison district. From the 15 rural blocks in each district, we used a computer programme to randomly select nine blocks in the intervention district and eight blocks in the comparison district (the difference in the number of blocks selected was due to differences in population size of the blocks in Barabanki and Unnao). One sector, an areawith 15-25 anganwadi centres and an estimated population of 20 000 to 25 000 people, was randomly selected from each of the selected blocks. The sample size was calculated to detect a 20% reduction in neonatal mortality following the intervention with 80% power at a 5% significance level.
A baseline household survey was conducted between January and June 2003 to establish rates of programme coverage, maternal knowledge and practices, and neonatal mortality. The newborn component of INHP began in July 2003. Household surveys were repeated at the end of the project, between January and March 2006. All households in the selected sectors were included in both surveys; respondents were women who had had a live birth or stillbirth within the reference period: calendar years 2001-2002 for baseline and 2004-2005 for endline. Only live births were included in this analysis. Data collection included information on household and maternal characteristics, exposure to the...
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