ArticlesEffect of the Newhints home-visits intervention on neonatal mortality rate and care practices in Ghana: a cluster randomised controlled trial
Introduction
Every year 3·3 million babies die within the first 28 days of life (the newborn or neonatal period); newborn deaths account for 41% of all child deaths in developing countries.1, 2 Another 3·2 million babies are stillborn.3 Effective interventions could prevent most of these deaths.4 The challenge is to identify strategies that can be implemented feasibly in the short term to ensure that newborn babies have access to these life-saving interventions. In 2009, WHO and UNICEF issued a joint statement calling on all governments in low-income and middle-income countries to implement home visits for newborn babies.5 In particular, they recommend three visits during the first week of life to promote essential newborn care, examine newborn babies for danger signs and treat or refer them as appropriate, and counsel the family about danger signs and the importance of prompt care-seeking for the newborn baby.
This strategy was based on results from four proof-of-principle studies in south Asia (appendix pp 1–2) showing that home visits for promotion of essential newborn-care practices and treatment or referral of sick babies can reduce the neonatal mortality rate (NMR) by 30–60%. These studies were a non-randomised comparison in Gadchiroli, India,6, 7 cluster randomised controlled trials in Shivgarh, India,8 and Sylhet, Bangladesh,9 and a pilot study in Hala, Pakistan.10 Since the joint statement was issued, effects on NMR have been reported in three cluster randomised controlled trials of interventions delivered in a programme setting that included home visits (appendix pp 1–2). The results of these trials in south Asia showed substantially lower reductions in NMR than did the proof-of principle trials: Projahnmo2 in Mirzapur, Bangladesh11 (13% reduction), Hala, Pakistan12 (15% reduction), and an assessment of the integrated management of the newborn and childhood illnesses programme in Haryana, India13 (9% reduction).
We present findings from the Newhints14 cluster randomised controlled trial, which was designed to test the effect of the home-visits strategy in Ghana delivered by the existing community-based surveillance volunteers (CBSVs). The underlying hypotheses were that CBSVs could be trained to make home visits during pregnancy and the first week of life to promote essential newborn-care practices and assess and refer sick newborn babies, they would achieve a high coverage of the Newhints home visits, these visits would lead to improved essential newborn-care practices and increased access to care for sick newborn babies, and this strategy would save newborn lives. The primary objectives were therefore to assess the effect of the Newhints intervention on all-cause NMR, and essential newborn-care practices including care-seeking.
Section snippets
Methods
Newhints was a cluster randomised controlled trial; the clusters were CBSV supervisory zones. It was undertaken in seven predominantly rural districts in the Brong Ahafo Region, Ghana: Kintampo North, Kintampo South, Nkoranza North, Nkoranza South, Tain, Techiman, and Wenchi. The trial area comprised 98 supervisory zones, each with eight to 12 CBSVs; 49 zones were randomly assigned to the Newhints intervention and 49 to the control group (appendix p 3). Detailed information about the methods
Results
Figure 2 shows the trial profile. 98 zones were randomly assigned to Newhints and control. 19 981 women were identified as being pregnant from Nov 1, 2008, the start of the trial, and 1372 of these were still pregnant at the end of the study on Dec 31, 2009. There were 18 609 eligible pregnancies, 9435 in the 49 control zones and 9174 in the 49 Newhints zones. Three groups of pregnancies were not included in the analysis of NMR: 908 (5%) women were lost to follow-up during pregnancy; 1216 (7%)
Discussion
Newhints achieved an 8% reduction (95% CI −12 to 25; p=0·405) in overall NMR (table 3). Figure 4 and the panel show this finding in context with other evidence. Figure 4 shows that this small reduction is similar to the small reductions in NMR achieved in the other three trials to test the effect of the home visit strategy delivered in a programme setting. The summary estimate represents an overall reduction in NMR of 12% (5 to 18; figure 4). Because there is no suggestion of any heterogeneity
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