Academic journal article Bulletin of the World Health Organization

Community-Based Approaches for Neonatal Survival: Meta-Analyses of Randomized Trial data/Approches Communautaires Pour Ameliorer la Survie Neonatale: Meta-Analyses De Donnees D'essais randomizes/Enfoques De Ambito Comunitario Para la Supervivencia Neonatal: Metaanalisis De Datos De Ensayos Aleatorizados

Academic journal article Bulletin of the World Health Organization

Community-Based Approaches for Neonatal Survival: Meta-Analyses of Randomized Trial data/Approches Communautaires Pour Ameliorer la Survie Neonatale: Meta-Analyses De Donnees D'essais randomizes/Enfoques De Ambito Comunitario Para la Supervivencia Neonatal: Metaanalisis De Datos De Ensayos Aleatorizados

Article excerpt

Introduction

Despite progress in reducing child deaths in the past 25 years, an estimated 2.6 million neonatal deaths occurred globally in 2015. (1) Sustainable development goal (SDG) 3 included the target of no more than 12 deaths per 1000 live births in the first 28 days of life. (2) To reach the target, more effective ways of delivering quality preventive and curative care need to be identified and monitored.

Approaches based on health promotion and on community empowerment and participation have long been promoted as part of formal health-care systems in low--and middle-income countries. (3, 4) Trials to improve maternal and newborn health through community approaches have focused on two approaches: (i) home-based counselling (5) and (ii) participatory women's groups. (6) Both approaches promote appropriate care-seeking as well as improved home practices in newborn care. Home-based counselling focuses on health education and behaviour change to improve newborn care practices by mothers, such as immediate breastfeeding, dry cord care and appropriate health care (e.g. delivering in a health-care facility and seeking care for sick newborns). Women's groups use an empowerment and problem-solving approach aiming similarly to improve care practices and care-seeking by mothers of newborns. The mechanisms of the effect of the home-based counselling strategies are backed by an analysis using the Lives Saved tool. (7)

Previous meta-analyses have reported moderate effects on neonatal mortality of both home-based counselling and women's groups. A meta-analysis of five proof-of-principle trials of home-based counselling in south Asia in 2010 found an almost 40% reduced risk of neonatal death (relative risk, RR: 0.62; 95% confidence interval, CI: 0.44-0.87). (5) In response, the World Health Organization (WHO) recommended home visits to improve neonatal health in high neonatal mortality settings. (8) However, trials of home-based counselling conducted in a larger population and in programme settings (9, 10) showed a smaller risk reduction for neonatal mortality (RR: 0.93; 95% CI: 0.85-1.01). (9) A review of seven trials of women's groups based on participatory learning and action cycles published in 2013 reported a 20% reduction in neonatal mortality (RR: 0.77; 95% CI: 0.65-0.90). (6) The evidence prompted WHO to recommend community mobilization with women's groups to improve maternal and neonatal health. (11)

Factors reported to have the greatest impact on neonatal mortality include how successfully the intervention was implemented, as reflected by the proportion of pregnant women participating in women's groups; (6) the inclusion of injectable antibiotics for treatment of possible severe bacterial infection; (6) and home management of asphyxia. (5) However, it is not clear how the women's group approach works, (12) or what is the interaction between community approaches and contextual factors, such as the characteristics of the healthcare system.

In this paper we updated previous searches and meta-analyses of trials of home-based counselling and women's groups in low-resource countries. The aim was to generate and test hypotheses about which factors may lead to weaker or stronger effects on neonatal survival. We examined associations between reductions in neonatal mortality and the context in which the trial took place or the characteristics of the local health system. We also assessed associations between reductions in mortality and the characteristics of the implementation.

Methods

Inclusion criteria and search methods

We reviewed cluster randomized trials evaluating community approaches to enhancing neonatal survival in low--and middle-income countries in April 2016, covering all studies published to this date. All trials compared neonatal mortality in pregnant women receiving the intervention with those receiving the local standard care (Table 1). We included trials of both home-based counselling and facilitated women's groups delivered during pregnancy. …

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