Final Assignment: Dissertation B/
Project
Student Name:.Tibanyendera ..Deogratias
Module/Unit and Semester Name:.
Dissertation 15a
Date of submission: 23.10.2014
First submission
By submitting this assignment I am
certifying that it is all my own work and that I have quoted and referenced all
the sources used in the answer.
Project title:
Home visits
by Community Health Care Workers (CHCW) to promote Antenatal care (ANC) as a
preventive intervention to improve Maternal and child health (MCH) in Uganda,
Bushenyi District.
Research Question
Do
home visits by CHCW to promote antenatal care lead to increase in ANC adherence
and improvement in maternal and new born health in Bushenyi district, Uganda
A
PROJECT PROPOSAL
SUBMITTED
IN PARTIAL FULFILMENT OF REQUIREMENTS FOR THE AWARD OF
A
MASTERS IN PUBLIC HEALTH FROM PEOPLES OPEN EDUCATION INITIATIVE –PEOPLES UNI,
MANCHESTER UK.
Table of
contents
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section
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Content
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Page
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1
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Introduction
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3
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2
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Background
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3
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3
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Literature search
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4
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3.1 Hypothesis
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5
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3.2 Literature search process
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6
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3.3 search results
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6
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3.4 table of the search process
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7
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4
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Literature review
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8
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4.1 literature review
limitations
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10
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5
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Research question
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10
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6
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Study objectives
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11
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7
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Study design
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11
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7.1 methodology
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12
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7.2 study setting
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14
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7.3 intervention plan
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15
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7.4 outcome measures
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18
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8
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Qualitative performance
evaluation
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18
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8.1 Assessment
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18
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8.2 sample selection
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18
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9
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Data collection
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18
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9.1 data analysis
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19
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10
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Time frame
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19
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11
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Ethical considerations
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22
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12
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Limitations of the study
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22
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13
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Implications for future research
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23
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References
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23
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Appendix 1- summary of
references
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27
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1.
Introduction
One of the gaps
identified in the literature study was that the roles of CHCW were scanty and
not specific in different countries hence giving varying results in terms of
achievements towards MCH. Therefore this project will assign one specific role
of preventive intervention to CHCW and find out their contribution in the area
of maternal and child health at the community level. By conducting home visits to
promote ANC as a preventive measure anticipating an ANC adherence and improvement
in maternal and new born health.
Antenatal care
(ANC) is one of the recommended interventions to reduce maternal mortality and
neonatal mortality. Though there are high rates of ANC in most Sub-Saharan
African countries, high rates of ANC coverage coexist with high maternal and
neonatal mortality (WHO 2014). This precipitates a focus on the quality of ANC
services especially provided that in most countries pregnant mothers attend ANC
once than the recommended four ANC visits by the WHO. However, little empirical
study exists on the home visits by CHCW to promote ANC in low-income countries
and in particular Uganda. Most of the policies to promote the mother’s
health focus on improving economic and
physical accessibility to increase the number of ANC visits to at least four
times ( Finlayson and Downe 2013).
There is
generally limited evidence on the effects of home visits by CHCW on ANC. In
Northern Uganda a community intervention used CHCW to track mothers who had
missed ANC appointments. Though the program led to increase in ANC attendance,
it is not clear if this was as a result of CHCW intervention or other
activities in the program like community sensitization and male partner access
clubs to promote ANC (Le Roux I, M et al 2013)
Knowledge gaps
exist in defining how to sustainably implement home visits by community-based
interventions for maternal, newborn health, and how these interventions not
only improve home care practices but also create demand for healthcare services
in the broader health system
Cluster randomized
control trial (cluster RCT) shall be used to measure the impact of CHCW home visits
to promote ANC and the outcome on maternal and child health.
Such a study is
beneficial to public health because, information on the effectiveness of these
complementary community-based approaches for reducing neonatal mortality is necessary
to frame policy for their inclusion in public health programs. Further, the
relative value of preventive or promotive and treatment interventions are
unclear especially if carried out by CHCW. Therefore this study is for the
purpose of determining whether home visits to promote ANC by community health
workers can reduce infant and neonatal deaths and stillbirths in
resource-limited settings with poor access to health facility-based care.
2.
Background
Antenatal care
(ANC) is one of the recommended measures by the WHO in reducing maternal as
well as child deaths. The WHO further urges that every woman should at least
adhere to four ANC visits including screening, detection and treatment of
infections and warning signs during pregnancy. However in most rural developing
world where health centers are rare, only 46% of women attend ANC for at least
four visits with 23 % having no ANC at all. Though a substantial percentage of
women in developing countries attend ANC visit, it is normally during the late
stages of the pregnancy when it may be too late to rectify any complications
(WHO, 2013). Every day, approximately 800 women die from preventable causes
related to pregnancy and childbirth. In 2008 over 300,000 maternal deaths
occurred worldwide and almost all of these in low- and middle-income countries (WHO et al 2010). It is also estimated
that every year 3 million newborn babies die within the first month of life and between 2.1 to 3.8 million babies are stillborn (Lawn JE et al
2011).
ANC is essential
in saving the lives of the mothers and babies since it acts as a remedy before
child births and early post natal period. ANC gives an opportunity to the
mother to detect any ailments during pregnancy as well as promoting healthy
home practices, good health seeking behaviors and all these influence the women
to give birth at a health facility (UNICEF 2013)
Effects on
mothers
An estimated 25 percent
of maternal deaths in developing countries occur during pregnancy. This varies
between countries where there is unsafe abortion, violence and diseases. Other
causes include hypertension and ante partum hemorrhage which are all attributed
to inadequate care during pregnancy. Malaria, anemia, HIV/AIDs and malnutrition
are responsible for maternal and newborn morbidity and mortality where
prevalence of these conditions are high (WHO, 2014b)
Effects on
babies:
In sub-Saharan
Africa there are almost 900,000 still births during the last trimester during
pregnancy. Babies who die immediately after birth account for two –thirds of
all still births in the developing countries where mortality rate is 22 per
1000 births. Nearly six out of seven still births are caused by maternal
infections, and new born are usually affected by illnesses during pregnancy
including preterm birth and restricted fetal growth fetal alcohol syndrome and
congenital infections (WHO et al 2010)
In Uganda, women
who had at least four ANC visits between
2008 to 2012 was 47% and one ANC visit
was 93.3% , and neonatal mortality at 45/1000 live births (UNICEF, 2013) which
indicates that mothers attend ANC once and they visit again the hospital when
they are ready to deliver. This poses a high risk to pregnant women or risk to
the baby may be detected late at the time of delivery when it is late to
provide any remedy. Hence this project wants to fill that gap and ensure that
pregnant mothers fulfill the WHO recommendation of four ANC visits. The late
and inconsistent ANC attendance pose a public health problem. Late detection of
pregnancy related illnesses increases the rate of adverse outcomes to the
mother and the baby (WHO, 2003)
Community health
workers (CHCW) can successfully perform a variety of services and activities,
including the delivery of basic health care, health education, and promoting
uptake of facility-based health care and preventive education for example
promote ANC. ( Ahorlu, C,K. et al 2009)
Literature
review demonstrate that CHCW community based programs can be essential in
reducing maternal and new born health in
low income settings if a variety of interventions were channeled through CHCW
community based program though the information is scanty.
3.
Literature search
P - pregnant
women between 17 to 35 years in Bushenyi district, Uganda
I - Home visits to promote ANC visits to at least four
C- Households of pregnant women that received ANC Home visits by CHCW versus households of pregnant women that did not receive home visits by CHCW
O – Adherence to ANC - percentage of mothers who had at least 4 or more ANC visits at a health center in the last 6 months and Reduction in Neonatal mortality- percentage reduction in neonatal mortality by 10% from 45/1000 live births to 40.5/1000 live births.
Research Question: Do home visits by CHCW to promote antenatal care lead to increase in ANC adherence and improvement in maternal and new born health in Bushenyi district, Uganda
I - Home visits to promote ANC visits to at least four
C- Households of pregnant women that received ANC Home visits by CHCW versus households of pregnant women that did not receive home visits by CHCW
O – Adherence to ANC - percentage of mothers who had at least 4 or more ANC visits at a health center in the last 6 months and Reduction in Neonatal mortality- percentage reduction in neonatal mortality by 10% from 45/1000 live births to 40.5/1000 live births.
Research Question: Do home visits by CHCW to promote antenatal care lead to increase in ANC adherence and improvement in maternal and new born health in Bushenyi district, Uganda
3.1 Hypothesis
Complex interventions,
such as a CHCW program, need to be supported by a convincing theory of change
describing the hypothesized mechanisms linking the intervention to outcomes.(Van
Belle, S,B et al. 2010) I postulate that
the home visits by CHCW while promoting ANC will lead to increase in ANC visits and impact on newborn health
through the following pathways.
First, the sensitization
on ANC benefits by CHCW raises awareness of ANC and can also provide a source of
motivation for attending ANC.CHCW counseling may also increase ANC attendance
by simply informing women of the location of the nearest ANC clinic. This could
be a particularly relevant factor in the study areas where women may have moved
to the location recently from other parts of the country and may not yet be
familiar with the location of ANC clinics. This is further supported by a
randomized controlled trial in Canada which showed that counseling by CHCW can
improve uptake of different antenatal and community services (Tough, S,C. et al.
2006)
Second, the CHCW
visit itself may serve as a reminder to women who were already planning to
attend ANC at the time of the CHCW visit. This can be similar to a study that
investigated the use of CHCW for improving adherence to medications by patients
with acute coronary syndrome that was successful in reminding people of the
need. (O'Riordan M 2014)
Third, CHCW visits may also be a source of
normative social influence. In order to be liked and accepted, people tend to
conform to social expectation, such as the expectation that pregnant women
should attend ANC (Satterfield, D, et al. 2002)
3.2 Literature search process
Key words
included: maternal and child health, community health workers, antenatal care,
CHCW performance evaluation, home visits, MCH preventive interventions,
developing countries,
The MESH terms
included MCH preventive intervention, ANC adherence , CHCW Case Management;
Community Health Nursing; Infant, Newborn; Medicaid; Outcome Assessment (Health
Care); Pregnancy Outcome; Pregnancy, High-Risk; Prenatal Care /utilization. To
increase on the articles CHCW and ANC, CHCW preventive intervention and
developing countries were added
The literature search
included: Pub Med, the Cochrane Controlled Trials Register in the Cochrane
Library, Excerpta Medica Database (EMBASE), Health Services Technology,
Administration, and Research (HealthSTAR), the ISI Web of Science, the
Cumulative Index to Nursing and Allied Health Literature (CINAHL), PLOS and
clinical trials web sites. Included were articles in English published from the
beginning of each database up to 2015. For all included articles, a lateral
search in Pub Med by using the “related articles” link. Also the searched articles included reviews
and for conference proceedings/abstracts.
Since antenatal
care practice indicators were not a primary outcome and were examined only as
explanatory variables for any effect on mortality, I did not search for them independently.
I did not employ any filter to limit the search to developing country
(resource-limited) settings. However, I included only trials that had been
conducted in countries with a low or middle level of human development.
Inclusion criteria included
·
comparing groups that received
different experimental interventions, including home visits for antenatal care
by community health workers, with a control group that did not receive any
home-based intervention by community health workers during the antenatal period
·
The trial population had to be
composed of pregnant mothers in resource-limited settings with poor access to
health-facility-based care.
·
Trials were required to include
home-based experimental interventions by community health workers in the antenatal
period.
·
Interventions during pregnancy
could comprise one or more of the following: (i) promotion of antenatal
care; (ii) health education and/or counseling of the mother regarding
desirable practices during pregnancy; (iii) promotion of delivery in a
hospital or at home by a skilled birth attendant; and (iv) education about
safe and/or clean delivery practices.
·
Interventions were required to
be preventive and have been delivered at the household
level by Community Health Workers
·
Only studies conducted in low-
and middle-income countries, as described by The World Bank at time of study
initiation, and only those articles published from 1990 to present were
included. This time period was chosen to coincide with the re-emergence of the
popularity of CHCW programs(Lehmann U, Sanders D. 2007),
Exclusion criteria
·
Articles were excluded if they
did not meet the inclusion criteria or:
·
If interventions were not clear
or in studies with multiple intervention techniques where it was not possible
to separate out specific preventive intervention outcomes.
·
If the description of CHCWs was
insufficient or their role in the intervention was ill-defined.
·
If multiple health cadres were
responsible for the intervention’s implementation and the CHCW’s specific role
could not be differentiated.
·
studies with the home visit ANC
was conducted by other health administrators
other than CHCW
·
articles not in English were
excluded since there was not funds and time for translation
3.3 Search results
A total of 190
studies were initially identified and through the screening process a total of
14 articles were included in the review. Studies came from ten different
countries, like Bangladesh, India, Asia, Uganda, Malawi, Tanzania, Pakistan, Ethiopia,
Ghana, and Nigeria. Studies consisted of
randomized controlled trials, cluster randomized controlled trials, ,systematic
reviews, field trials , impact surveys and other, case control and cross
sectional studies. Overall quality of evidence was found to be moderate. Five
main preventive intervention categories emerged: health education, ANC
promotion, breastfeeding promotion, essential newborn care and psychosocial
support. All categories showed some evidence for the effectiveness of CHCW in ANC,
however they were found to be especially effective in promoting mother and
newborn health.
3.4 Table search process
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Potential relevant references
identified and screened for
retrieval #190
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potentially appropriate references #137
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Finalreferences considered # 14
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obviously irrelevant
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excluded material not
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connected to the
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study #53
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references
excluded due to , Not
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intervention by CHCW,
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language
not English, not
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related to ANC, outcomes not
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related to MCH mortality and
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morbidity , no Home visits,
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abstracts #117
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references satisfying the
criteria
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for inclusion appropriate
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references # 20
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excluded because of - abstracts
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and not detailed and with no
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research related study
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= 6
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3.5 Literature search flow
chat
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Study design
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Number of studies
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1
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Cluster
randomized trial
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5
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2
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Cluster
randomized controlled trial
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4
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3
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Meta-analysis
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1
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4
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Impact
evaluation survey
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1
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5
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Systematic review
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1
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6
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Repeated cross sectional study
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1
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7
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Field
trial
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1
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Total 14
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4.
Literature review
The New hints
cluster–randomized trial in Ghana showed the effects of home visits by trained
community–based surveillance volunteers (CBSVs) on neonatal mortality and home
care practices The CBSVs in the study zones were trained to identify pregnant
women in their community and to make two home visits during pregnancy and
promote safe motherhood, ANC adherence and make referrals. As a result, there was a reduction in overall
neonatal mortality by 8% (Kirkwood, B, R, et al. 2013)
A repeated
cross-sectional study to identify the connection between ANC visits by CHCW and
facility based delivery was carried out in Tanzania. The study measured the
relationship between the number of home visits – up to four and facility based
delivery. A higher proportion of home visits was realized in the urban areas
(from two to four home visits) and increase in facility based delivery. However there was no significant relationship
of the CHCW home visits and increased facility based delivery in the rural
areas (Seung-Ah Choe, et al. 2015)
In Tanzania a
cluster randomized controlled trial investigated the effect of home based counseling
by CHCW on new born care practices. The CHCW were tasked to make home visits
and identify pregnant women and counsel them on newborn care practices, as well
as promote post natal care. In one trial a relative decline in infant mortality
was documented. (Penfold, S, et al. 2014).
In an evaluation
of a cluster – randomized controlled trial
in Bangladesh for community based new born interventions, CHCW were
tasked to identify pregnant women and
encourage them to make at least two ANC visits , sensitize mothers on
preventive care practices , access newborn illness and carry out at least four
post natal visits and make referrals . The study realized high coverage of ANC visits
(two visits) by 91%, postnatal visits by 69%. Though there was no impact on
neonatal mortality, improvements in newborn care practices were evident.
(Bhandari, N et al. 2012)
A study by
Bhutta et al (2008) in Pakistan investigated the feasibility of using CHCW and
traditional birth attendants in improving antenatal care. Training on essential
maternal and newborn care was provided to the CHCW and they were supposed to
liaise with the traditional birth attendants. The intervention realized a
reduction in neonatal mortality from 57.3 to 41.3 per 1000 live births.
Facility based deliveries increased from 18% to 30% and a significant increase
in new born care practices.
A feasibility
study on the effect of CHCW on neonatal mortality within areas with weak health
systems, or low utilization showed positive results in reduction of neonatal
mortality and increase in utilization of health services in trials and
demonstration projects in Asia (Kumar, V, et al. 2008). In cluster randomized trials conducted in Uganda,
home visits by CHCW for preventive care as well as curative care was able to
reduce neonatal mortality by 30% (Waiswa, P, et al. 2012)
Studies in
Bangladesh, India and Pakistan on showed that home visits can reduce new born
deaths in developing settings by 30% (Bang, A, T, et al. 1999). The visits led
to improvement in new born care practices, skin to skin contact, delayed
bathing, improved hygiene, and initiation of breastfeeding and code care.
In sub Saharan
Africa, evidence is still limited. In a multi-country study involving Burkina
Faso, South Africa and Uganda antenatal peer counseling by CHCWs improved
prevalence of exclusive breastfeeding (Tylleskar, T, et
al. 2011). In western Uganda, home visits by CHCWs targeting children less than
five years reportedly reduced prevalence of diarrheal diseases and fever as
well as improved use of child health services (Brenner,
J,L, et al . 2011).
A systematic
review by Gogia S, and Sachdev, H,S.( 2010).in the developing countries ,
discovered that home visits by CHCW led to increase in ANC visits, immunization coverage, breast feeding
and code care (Gogia S, and Sachdev,
H,S. 2010). A reduction in newborn deaths in areas of universal coverage of
CHCW has potential to reduce maternal and child mortality especially in
communities well served by primary health facilities. (Darmstadt, G. etal, 2005)
In Malawi, a
study using cluster randomized control design evaluated the effect of home
based counseling on maternal and child health outcomes. Areas receiving home
base counseling reported increase in exclusive breastfeeding in the first six
months by 20% as opposed to the control areas. However there was no conclusive
evidence on any reduction in neonatal mortality (Lewycka, S ET al.2013)
A cluster –
randomized /quasi randomized trials consisting of 18 clusters to identify the
impact of CHCW on neonatal mortality in developing countries as a result of
using community based intervention care packages, discovered that, there was
not any reduction in maternal mortality though there was substantial reduction
in maternal morbidity 28%, neonatal mortality 69%, still births 66% and
prenatal deaths by 82%. The study also led to increase in pregnancy related referrals
by 40% as well as increase initiation of breast feeding by 94% (Lassi, Z, S. et
al. 2010)
All reviews
except one (Bhandari N, et al.2012) reported CHCW home visits specific outcomes,
increasing number of home visits. Other most reported outcomes as a result of
CHCW include maternal, newborn morbidity and mortality, immunization rates,
breast feeding, referral, ANC and PNC utilization.
In conclusion
therefore, most reviews included several outcomes as a result of CHCW home
visit interventions but this study seeks to analyze and deduce strong evidence
on the value of CHCW in promoting ANC as an intervention. While the evidences
presents good results as a result of CHCW and ANC , evidence still lacks on
whether CHCW home visits while promoting ANC may lead to adherence to at least
4 home visits and improved neonatal outcomes
which hence will be the basis for the study.
4.1 Limitations
The data may not
be conclusive due to the fact that the pregnant women residing in the
intervention areas could have sought
care outside the study area and the studies do not present any control measures
on the issue(Bang, A,T, et al.1999).
Moreover, the neonatal
mortality, may have improved without increase in ANC visits, this can be
possible to the pregnant educated mothers who are aware of the new born care
practices prior to the intervention. (Kirkwood, BR, et al. 2013)
More to that the
review was basically to identify studies where CHCW performed prevention only
activities, this means that other
evidence to show their effectiveness in this area may be been omitted in particular
where there were multiple intervention programs. (Perry, H, et al. 2009). But
authors Perry and Zullinger (2009) compiled a list of other interventions areas
for CHCW for further reading.
There is limited
knowledge and research on antenatal visits,
though with some studies carried out on postnatal care by CHCW and neonatal
care in eastern Uganda(Waiswa, P, et al . 2012)
, this lack in study calls for
the proposed project on the antenatal care visits and its implications on neonatal
health.
Some studies Bhutta
et al (2008), (Bhandari, N, et al. 2012) have multiple outcome focus like neonatal
mortality, hospital based deliveries, PMTCT and breastfeeding outcomes which
may not conform to the study area in particular and the outcomes may be
different.
Although the
study in Tanzania (Penfold, S, et al, 2014) may have covered a large number of pregnant
women to improve their ANC and MTCT, however it is very difficult to measure if
the increase in ANC visits was because of the need for ANC purposes or to know
their HIV status.
.
5.
Research question
Do home visits
by CHCW to promote antenatal care (ANC) lead to an increase in ANC adherence
and improve maternal and new born health in the Bushenyi district, Uganda
The study hypotheses
that there will be at least an increase in ANC visits from the present 30% to
50% after an 11 months intervention of this project. The interventions hopes to
improve the ANC adherence from a mean of 1 visit to 4or more as recommended
visits by the WHO. Nationally, the average one ANC visit is97% and for Bushenyi
district the study intervention area is 30%. While nationally the average women
who have four or more ANC coverage is 47% (UNICEF 2013). A cross section
baseline study was conducted to increase birth preparedness in three districts
in eastern Uganda (LigaT et al 2015) was able to realize a 34% increase of one
ANC visits over 12 months hence 20%
increase in ANC visits in three sub countries of one district is a realistic
target over 11 months.
The study also
hypotheses that there will be an improvement in neonatal mortality rates by 10%;
a reduction from 45 per 1000 live births to 40.5 per 1000 live births. (UNICEF
2013). A similar study in western Uganda by Bremmer,J (2011) the intervention
let to a relative decline of 53% in child deaths over an 18 months period,
hence an 11 months intervention can achieve 10% reduction in neonatal deaths
Definitions
Home visits according to the Segens Medical
dictionary (2012) is a visit conducted by a health personnel to a patient’s
home. The visits have to be face to face contact with the patient with the aim
to offer domiciliary consultations and counseling.
Antenatal care
visit as a preventive health care type is where pregnant mothers attend regular
checkups to allow health personnel to treat and prevent potential pregnancy
related complications during the pregnancy. The services include advice on
lifestyle and detection of problems in pregnancy such as edema and preeclampsia.
A newborn
infant, or neonate, is a child under 28 days of age. During these first 28 days
of life, the child is at highest risk of dying. It is thus crucial that
appropriate feeding and care are provided during this period, both to improve
the child’s chances of survival and to lay the foundations for a healthy life.
6.
Study objectives
Primary objective:
The primary
objective of the study is to test whether home visits by CHCW can lead to increase
in ANC visits during the 11 months project intervention, from 30% to 50%, the
hypothesis is that regular home visits reminding the pregnant mothers of the
ANC will impel others to adhere to the regular ANC visits as recommended by
WHO.
Secondary objective is
that the regular home visits will reduce neonatal morbidity and mortality,
because ANC and other advice on sanitation and immunization should improve
newborn health.
7. Study design
7.1 Methodology
Cluster randomized
control trial(C-RCT) shall be used for this study. Three of the six health
centers that offer ANC in the district shall be randomly selected as the intervention
sites, where the women in the three randomized villages shall be asked to attend
the ANC, this is because the same ANC health personnel shall be part of the
study hence it is important to designate specific health centers for this study.
Women shall be clustered by places of origin and their proximity to the health
center. Cluster -RCT was a preferred choice because it is able to compare the
intervention group and the control group and it ensures equal side groups for
easy comparison of statistics.
For the start
all women in the 6 villages shall be sensitized on the benefits of ANC and will
be explained about the study objectives, thereafter only the women in the three
intervention villages shall benefit from the home visits. Hence this means that
the study will not ignore completely the control group.
The Pregnant
women in the 3 control villages will not be considered for the study home
visits , as any project that is implemented in a particular area , but that
does not mean they will be prohibited from ANC services or other government programs
that are aimed at increasing ANC visits. They will continue accessing any
health center for any ANC needs thought their data will not be taken.
To prevent contamination,
proximity shall be considered and women will be asked where they prefer to go
for ANC visit , probably to the nearest health center and its where they will
be asked to attend the ANC , hence it will not make visits increase because
they will have gone to the same health center in absence of the intervention. Cluster
RCT was preferred against simple RCT where pregnant women are randomized. This option allows a bigger number of women
in the same geographical areas to be considered for the study. The option also allows
direct and indirect effects of the study to be evaluated.
Advantages of
Cluster RCT
·
It is easy to administer and
manage since data from designated health centers is easily collected
·
If at all the study proves ineffective , the control
group is saved from the wasteful intervention
·
When seeking consent it becomes
easier to choose a population, define a cluster in which a trial will take
place and then seek consent. This conforms to Zelens M (1990) approach to individuals
select clusters and consent is sought after randomization, but to individual
clusters you need to inform the selected seek consent to the study participants
before they are considered for the study.
·
It is easy to prevent
contamination across individuals in this
situation because women in the same village (three villages) shall be part of
the study hence any cross discussion or sharing of information does not
contaminate the study as would have been the case if women were individually
selected across villages.
·
It is easy to measure the study
outcomes at the clustered health centers because women shall have ANC visit at
the selected health centers hence it is easier to collect statistics.
·
With the cluster RCT it gives
room for comparison purposes and it is easy to tell if the study made a difference
or not. By comparing the women in the central study who received home visits
than those who did not.
Disadvantages
·
It deprives the pregnant women in
the control study of the essential education and sensitization of the home
visits and ANC education which may have made a difference in their lives – but
as said as any project, it cannot be applied in the whole country and It is a trial
hence with its success other villages will also benefit.
·
This study as compared to
individual randomization needs more participants to get greater statistical
power hence the need to get 210 women participants if better statistics are to
be of substance.
·
Individuals consent is in this
case ignored but pregnant women who opt not to be part of the study will be
allowed their consent freedom or respect of individual consent is paramount
·
The level of education and
literacy may be different across villages hence giving varying results. Because
if in one village more women are educated they tend to take on the messages positively
than the uneducated
·
The ANC health personnel may
give more attention to pregnant women under trial, because of the close
attention and individual data required which may not go down well with other
women under the study. However they will be asked to render the same time and
care as all women in the village.
7.1. Target population and
sample selection
The target
population shall be the pregnant women in, the Bushenyi district, Uganda. The
mean age of women to be included in the study will be ranging from 17 to 34
years. None of the studies will be limited to women in the first trimester of
pregnancy but also women in the second trimester who have not had any ANC visit
or those who have not had 4 ANCs visits and who still have time to be able to
complete at least four ANC visits. The Study will report the number and
duration of prenatal home visits per woman. Prenatal care utilization will be
measured with a scale for adequacy of care use or by number of visits.
All the six
health centers are classified as health center three (111) according to the
ministry of health Uganda. Health Center III (HCIII) are at Sub-county level serving an estimated
population of 2000 peoples ,the standard level staffing for HCIII is 1 Senior
Clinical Officer, 1 Clinical Officer, 2 Mid-wives, 1 Nursing Officer Nursing, 3
Enrolled Nurses, 1 Laboratory Technician, 1 Laboratory Assistant, 3 Nursing
Assistants, and 1 Health Assistant. HCIIIs provide basic preventative,
promotive and curative care and provides support supervision of the community
and HCIIs under its jurisdiction. There are provisions for laboratory services
for diagnosis, maternity care and first referral cover for the sub-county. (MUIPH/HAP
2012)
The six villages are in geographical proximity to each other. The terrain is a mountainous nature and with poor infrastructure which poses a risk for women to access ANC visits. The literacy level in the areas is 55% .The region is known for agriculture with over 95 % of the population dependent on agriculture. Fertility in this area is around 6.6 children per women which is among the highest in Uganda, the total average population in the six sub-counties of the intervention is 253,621(UBOS 2014).
The six villages are in geographical proximity to each other. The terrain is a mountainous nature and with poor infrastructure which poses a risk for women to access ANC visits. The literacy level in the areas is 55% .The region is known for agriculture with over 95 % of the population dependent on agriculture. Fertility in this area is around 6.6 children per women which is among the highest in Uganda, the total average population in the six sub-counties of the intervention is 253,621(UBOS 2014).
Study participants
will be selected from the three of the six counties and clustered according to
their counties or villages and other 3 as control sites where the women shall
not receive home visits. The pregnant women who shall be identified shall be
allocated sites where they are supposed to attend their ANCs.
As part of the study, the three
intervention health centers that offer ANC shall be randomly selected, the
stratified health centers shall be categorized in terms of location, and the
capability and capacity to handle ANC before randomization. Of the three study villages with ANC health centers each village
randomly selected for the study will be allocated CHCW and they will randomly
identify pregnant mothers at least 210shall be identified , 70 from each
village .
Sample size calculation based on expected
difference in ANC uptake from 30% to 50%: Group sample sizes of 94 in group one
and 94 in group two achieve 80% power to detect a difference between the group
proportions of 20%. The proportion in group one (the treatment group) is
assumed to be 30% under the null hypothesis and 50% under the alternative
hypothesis. The proportion in group two (the control group) is 30%. The test statistic
used is the two-sided Z test with pooled variance. The significance level of
the test was targeted at 0.0500. (Hintze J. 2008).
However this sample size calculation
assumes randomization of the women and not cluster-RCT. For the sample size
calculation of the cluster-RCT, I need the intra-class correlation coefficient
which measures how more similar women in one village behave compared to the
other villages. Hence, I need to increase the sample size because of the
cluster-RCT and because of loss to follow-up to 210 women in intervention and 210
women in the control group (70 women per village).
Pregnant women
in their first trimester or women in the second trimester who have not had 4
ANC visits at the time of the study will be eligible for inclusion. Studies
will be required to report prenatal care utilization, pre-term birth (as
defined in the primary study), gestational age at birth, and/or birth weight.
The study intervention will be a standalone ANC program though does not
interfere with the preexisting ANC government program.
Inclusion
criteria of pregnant women for the study
·
Pregnant women in their first
and second trimester who have not as yet
attended any ANC or have not completed four ANC visits
·
Pregnant women who give consent
to participate in the study
·
Pregnant women between 17 and 35 years of age
Exclusion
criteria
·
Pregnant women who will not provide
consent to participate in the study
·
Women in the third trimester –
since they may not be able to complete the 4 or more ANC visits
·
Pregnant women who have
benefited from the same study 6 months prior to the study or any similar study
that may be targeting same women
·
Pregnant women who have already
completed four or more ANC visits
·
Pregnant women with disability
shall also be excluded because they receive domiciliary care (Home based ANC by
health professionals), and since they don’t visits hospitals but benefit from
home based care they are excluded.
7.2 Study Setting
Uganda is a
land-locked country located in East Africa, and lies to the north along the
equator. Uganda has a projected population of 32.4 million people. Landmass is
about 241,038 km2 in size and the country has a population density
of about 137/km2. An estimated 86% of the population live in rural
areas, and practice mainly peasant farming. Nationally about 97 % of
pregnant women make at least one antenatal care consultation and 52 % make
four antenatal consultations, but less than 50 % deliver with the help of
a skilled attendant, and deliveries at health facilities have remained low
(42%), (MangwiAyiasi,R et al. 2014).
Bushenyi
district in South Western Uganda is bordered by Kasese district to the north,
Kamwenge district and Ibanda district to the northeast, Mbarara district to the
east and the south-east, Ntungamo district to the south, Rukungiri district to
the southwest and the Democratic Republic of the Congo to the west. The district
is made up of twelve sub counties of Bushenyi D, Bitooma, Ibaare, Bushenyi E,
Bushenyi C, Kyabugimbi, Bushenyi A, Kyeizooba, and Ruhumuro, together with
central division, Nyakabirizi division and Ishaka division. The district covers
4,292.5 square kilometers (1,657.3 sq. miles) of land, open water, wetland and
protected national forest reserve (UBOS 2007)
In 2010 the
population of Bushenyi was estimated at 916,400 with an annual growth rate of
3%. Only 6 of the 10 medical facilities offer ANC hence it is in these
facilities that the project shall be implemented .Kyeizooba, Bushenyi HC, Kakanju,
Kabushaho, Ishaka Adventist and Bishop Comboni hospital. (Bushenyi district
2012) the district ANC coverage is 30% and neonatal mortality rate is 45/1.000
live births, (UNICEF 2013) this project shall reduce the ANC coverage from 30%
to 40% and reduce neonatal mortality by 10% from 45/1000 live births to
40.5/1000 live births after the intervention.
Since the year
2000, the delivery of health services in Uganda has been decentralized to district
level. The Ministry of Health (MoH) plays a stewardship role, providing
leadership, standards, funding and policies. On the other hand, districts are
responsible for implementation and service delivery. Below the district level
are Health Sub-Districts (HSDs), which are administrative zones with about 10
to 20 lower level health facilities. Therefore the district health office has
the mandate to authorize the study since it is autonomous (MOH/MUSPH. 2012).
7.3 Intervention Plan
CHCWs will be recruited
from the community, based on criteria stipulated in the national Village Health
Team (as referred to by the Uganda Ministry of health guidelines but same as
CHCW): a permanent resident of the community, literate and willing to work as a
volunteer. A preference will be given to mature females already doing some
community health work since pregnant women find it easy to discuss ANC matters
with fellow women .
Selection process: CHCW
posts will be advertised according to criteria set using Ministry of Health
village health team criteria, the community will identify a selection team and
the candidates will be interviewed and CHCW posts filled. The study will need
15 CHCW.
Pregnant women
shall be selected, using systematic sampling. The CHCW shall be allocated
villages and they randomly conduct door to door visits to identify women that
are potentially eligible. This also eliminates selection bias than if women
were self-selected since they may not be a representative of the pregnant women.
CHCW responsibilities:
·
Visit all homes in the neighborhoods
in which they are assigned every months and providing antenatal counseling an
encouraging pregnant mothers to make at least 4 ANC visits and other
information relevant for pregnant mothers like immunization, baby care and mother nutrition.
·
Identify pregnant women during
home visits and refer them to ANC (by providing a referral form to the woman
with a referral identification number and the name of the designated study ANC
health center). All pregnant women who will be
identified during the CHCW home visits and specifically counseled by the
CHCW on the importance of early ANC visits and ANC,.
·
Routinely revisit all
identified pregnant women to verify whether they have visited ANC and to
promote ANC uptake through information and education. CHCW will be instructed
to routinely revisit all pregnant women they identified in the community within
two weeks after the initial visit. Each
CHCW should at least visit each home 4 times before the closure of the project
·
Follow up pregnant women who
will have missed a scheduled ANC. During the weekly routine meeting with the CHCW,
they then requested the CHCW who worked in the neighborhood where a pregnant
woman who had missed a scheduled appointment lived, to specifically follow up
with that woman and to remind and encourage her to return to the ANC facility.
Therefore
the steps involved include 1- identification of families where pregnant women
are located, 2- apply the inclusion and exclusion criteria 3:- offer ANC education,
4 refer the pregnant women for ANC; and 5 follow up.
CHCW training:
·
There will be a five-day
training on preventive and promotive maternal and newborn care and counseling
skills,
·
Teaching methods include
participatory discussion, practical demonstrations and role-playing
·
CHCW will received a five-day
training in the delivery of the intervention plus a two- to three-day training
on the monitoring and evaluation tools used as part of the intervention.
Trainings will be conducted by members of the research team over the course of
two weeks. In addition to specific knowledge about pregnancy and maternal and
child health, the training will include communication and counseling skills,
monitoring and evaluation, and data collection and management.
Home visits during pregnancy
·
First pregnancy visit (Target:
as early as possible up to 2nd trimester )
·
Counsel on and refer for ANC
including tetanus immunization and malaria prevention
·
Counsel on birth preparedness
and clean delivery practices
·
Counsel on and assess danger
signs of pregnancy, refer if present
Second pregnancy visit (Target: in third trimester)
·
Counsel on birth preparedness
and clean delivery practices
·
Counsel on and assess danger
signs of pregnancy, refer if present
·
Counsel on newborn care
practices immediately following delivery (e.g. placing the baby skin-to-skin,
ensuring warmth, initiating breastfeeding, hygienic cord care)
·
.
Management and deployment
CHCWs will be given
a set of materials including a register, picture-based counseling cards on
birth preparedness and maternal and newborn care
For easy
identification they will be given branded t-shirts and identity cards
‘Super’ CHCWs
nominated as leaders will be tasked with mobilizing and encouraging fellow CHCWs
and serving as supervisors where health workers are not available
A CHCW supervisor
will liaise with the district health officer and the health personnel within
ANC designate clinics. In addition, monthly meetings with the CHCW and ANC
clinic based personnel in each of the three study centers shall be necessary.
At these meetings, the CHCW will share and discuss obstacles they are facing in
performing their work and possible approaches to overcome them. In addition,
the coordinator will share with the intervention team the latest data on the
number of pregnant women visited in each cluster.
At the ANC clinic level , ANC health personnel
will be in charge of supervising CHCW activities and referrals and responsible
for the coordination of reporting on the progress at the clinics;, ensure that
pregnant women who missed clinic appointments received CHCW visits, and served
as a conduit between the CHCW, clinic staff, and the trial project team.
The CHCW shall
identify at least 2 pregnant women per day during the selection process which
means that for the first week each CHCW should have recruited 14 women which
makes a total of 210 women for the intervention.
Each pregnant woman
shall be visited 4 times before delivery. This means once every 2 months the
CHCW have to visit their allocated pregnant women. Each CHCW shall be allocated
14pregnantwomen .The allocations shall be based on geographical proximity. This
is also to maintain familiarity and not make outsiders or not familiar persons
within the village be involved in a new location. This promotes friendly
discussion and trust especially for confidentiality. Each CHCW is expected to do
56 home visits which translates to 840home visits on the intervention area and
pregnant women.
Pregnant women
in the control women of about 200 women as said at the start of the project
will also be included in the briefing and sensitization on the importance of
ANC, dangers of missing ANC, and they will also be encouraged at the session to
attend to ANC and no further activities with them and they will not be involved in home visits. This will later make it possible to compare
the results on how home visits may influence ANC visits by comparing the two
groups. The information from the three control villages and health centers
shall be compared to the intervention health centers.
Important data
to be collected
CHCW during home
visits, are supposed to introduce themselves and seek permission whether to go
ahead with record keeping in case the person is not ready for the hem visit a
later date can be arranged.
-
Age of the pregnant women
-
Number of home ANC visits made so far ( because if a women has already
made 4 or more she will be excluded from the study
-
Date of visits
-
Duration of pregnancy
(gestation period)
-
Number of referrals made
-
Geographical location and
marked by code / or house code number
By ANC health personnel
at the health center
-
Age and gestation period
-
Ailments and complications
-
Indicate number of visits and
scheduled visits for easy follow up in case of non-adherence
There
will be personal confounding where individual women data or the intervention
group shall be taken .Hence pregnant women attending ANCs visits shall be the
confounding variable and as said their individual data shall be taken and ANC
visit attended to by a designated ANC health personal at the health center. The
possible confounders include: age of the women, geographical location, Level of
education, history of drug use, previous miscarriages, ethnicity and race,
number of children, number of pregnancy, family composition, marital status, and
social economic status.
7.4 Outcome measures
The specific
outcomes are: Increase in ANC visits from 1 to 4 or more and improved newborn
health
Indicators will include:
·
proportion of pregnant women
who have attended antenatal care four or more times;
·
proportion of neonates who
survive after the 28th day after birth with no complications
Hypothesis testing
The hypotheses is
that: the intervention will lead to
1. % increase of
pregnant women attending ANC at least four times (from 30% to 50%)
2. % reduction
in neonatal mortality from 45/1000 live births to 40.5/1000 live births (10%
reduction)
8.0 Quantitative Performance Evaluation
This study will
focus on the content of the intervention, how and to what extent it will be
implemented, and what it will achieve. A performance evaluation can complement
an evaluation of causal impact in several important ways, (Stern, E et al 2012)
it can (1) elucidate how and why an intervention works, (2) distinguish between
design and implementation failure if an intervention does not lead to the
anticipated effects, (3) provide information for intervention replication in
other settings through detailed description of implementation processes and
context (Khagram S, Thomas C 2010)
8.1 Quality assessment
The quality of
the identified trials centers will be assessed on the basis of the methods used
for sampling and for allocation into intervention and control groups. (Higgins
JPT, Green S, Eds 2006) Randomization will be classified as: (a) adequate,
(b) unclear, (c) inadequate and (d) not used; allocation
concealment as: (a) adequate, (b) unclear, (c) inadequate and (d) not
used.
9. Data collection
Data will be quantitative, and collected at each visit
that is after 2 months. And the data required during home visits and ANC visits
include
Important data
to be collected at household level include
i.
Geographical location
ii.
Age
iii.
Number of home visits made
iv.
Type of intervention carried
out – counseling or referrals etc.
Data collected
at the health centers
v.
Screening results
vi.
Geographical location /
origin/age
vii.
Number of visits made and
scheduled next visits
viii.
Estimated gestation period
ix.
Risk assessment
9.1 Data analysis
Baseline
characteristics of villages and of participating women will be described using
counts and percentages for categorical data and mean and standard deviation
(symmetrical distribution) or median and inter-quartile range (skewed
distribution) for numerical data. Baseline data will be compared between
intervention and control groups to identify potential confounders.
The main outcome
measures (% women with 4 ANC visits; newborn mortality) will be compared between
intervention and control groups using Chi-square and Fisher’s exact test. In
case confounding is detected, multiple logistic regression analyses will be
used to adjust for confounders. Data analysis will be adjusted for the cluster
sampling approach.
For quantitative
data analysis, SPSS (statistical package for social scientists) shall be used
to analyze data. Important information like number of visits shall be analyzed
to see to what extent the home visits helped to increase the ANC visits in the
intervention area compared to the control areas. Again the data on the
intervention area shall be kept to monitor newborn health to see if there are
no further complications .This helps to collate whether the number of ANC
visits have a bearing influence on the newborn health.
Statistics will
hence help to ascertain if home visits to promote ANC can lead to increase in
ANC visits up to four or more and further lead to newborn health.
The following
will be the independent variables: district,
number of household members, sequence of pregnancy, marital status, mother's
age group , number of ANC visits, trimester during which the first ANC visit
was undertaken, receiving care from a healthcare provider during the
pregnancy,.
10. Time frame
The recruitment
of pregnant women will take one week. Each CHCW shall be tasked with
identifying 14 pregnant women in one week and that means during the week, they
need to identify at least 2 pregnant women per day. The same pregnant women
identified after applying the inclusion and exclusion criteria shall then be
followed up till the eleventh months of the project duration. Then data
collection will be from the fifth week till the end of the project.
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Finalize
project and submit
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Obtain
ethical clearance
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Design
data collection tools
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Secure
funds for the project
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Printing
of data collection tools
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Identification
and selection of CHCW
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Training
of CHCW
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Pretest
of data collection tools
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Identify
study participants
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Deploying
of CHCW for data collection
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Home
visits / data collection
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Data
collection at health centers
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Post-delivery
assessment of newborn health
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Data
entry and screaming
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Data
analysis
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Report
writing and preliminary feedback
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Dissemination
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11. Ethical considerations
A written consent shall be secured at the time of enrolment of
prenatal women into the community intervention study. The pre-enrolment consent
detailed, home visits by CHCW and women’s participation in subsequent
interviews. During this study women will be reminded of their prior consent to
participate in the study and verbal consent to be obtained before conducting
interviews. Should any participant opt
to discontinue being part of the intervention at any stage, reasons should be
taken and the CHCW reports to the supervisory at the ANC health center. All pregnant
women that will be approached for the interviews shall have to first accept to
participate and if a pregnant woman decides not to participate in the study her
decision should be respected and CHCW shall not include her in the study and
for confidentiality the matter remains there and not to be reported or recorded
as having refused . Confidentiality also applies to the data and interaction of
the pregnant women and CHCW and the ANC personnel. All CHCW will provide verbal
consent to participate in this study. Confidentiality will be maintained
throughout the interviews and results will be anonymous to protect identity.
This study will also seek approval from the Higher Degrees, Research and Ethics
Committee of Makerere University School of Public Health, College of Health
Sciences and the National Council of Science and Technology in Uganda. The Bushenyi
district Health officer will be approached to offer approval of the study in
the area.
12. Limitations of the study
Pregnancy,
childbirth and the newborn period is surrounded by many cultural beliefs and
traditional practices that could serve as a barrier to CHCW work. For example women who are pregnant are always
skeptical of being identified in early stages hence they tend to hide till the
pregnancy comes out, this is because of the fear of witchcraft. However, they
will be sensitized on the benefits and this could impel mothers to come and
participate in the study. The lack of success in identifying pregnancies among
high-risk groups of older and younger women points to the need for CHCWs to not
only rely on house to house visits, but on other forms of community
mobilization and awareness on services available for families expecting a
newborn.
The project area
is mountainous hence transport may be a problem which may leave many women UN
identified for the study. Therefore the home visits may be a problem and the
CHCW may not be able to offer at least 4 home visits to a family with a
pregnant women. However selecting CHCW from their home villages can reduce on
this problem.
These interventions, that use community
members as volunteers, have different implementation frameworks and support
mechanisms for volunteers and ways of engaging communities. As a result, CHCWs
may be faced with demands for material support from families which may have received
such support from previous studies. But clarity on the objectives of the study
to the community members should be able to curb on this.
In addition, CHCWs may be viewed as fellow
community members with limited expertise to teach about health matters.
Specific households in the community regarded as having high status, such as
politicians, rich households, and homes of health personnel, may under look the
CHCW home visits.
The study relies on the knowledge,
attitudes, and perceptions of CHCWs, mothers, health workers, and key
stakeholders because it is difficult to monitor the content of the care and
information provided by CHCW since not all of them can be supervised during
home visits, but the training provided should be enough to make all CHCW at the
same level of expertise.
Selection bias
may also be a limitation because the western region where Bushenyi is located
has a higher fertility rate than the eastern and northern hence the study
outcomes may not be similar if applied to the other parts of the country.
The study relies
on the accuracy of the information collected by the CHCW during home visits and
the quality of ANC provided by the health centers designated. because poor ANC
services may not result in positive newborn health even if all the four ANC
visits or more are completed putting into consideration that most health
centers that offer ANC have problems with ANC related care and drugs which are
either insufficient or not present . Moses T (2012) observed that in Uganda,”
the ANC services are characterized by poor attendance, poor counseling services
and poor client-provider relations, with the quality being worse in rural areas
“
The main confounders
the pregnant women may not adhere to the home visits if at all its may be a
planting season. Hence home visits and ANC may be compromised for their usual
livelihood means. However this shall be communicated and a better time before
or after their routine daily activities can be designated for home visits.
Confounders identified will be adjusted during multivariable analysis.
13. Implications for future
research
The following
gaps in the study , there is need to further ascertain the roles of CHCW home
visits and their (i) the
effectiveness of the intervention package in low-mortality settings in other
regions, particularly sub-Saharan Africa; (ii) the effectiveness of the
intervention package in settings with lower neonatal mortality rates (15–29
deaths per 1000 live births (iii) the benefit of adding a curative
component (especially the treatment of neonatal sepsis) to preventive or
promotive neonatal care; (iv) the relative efficacy of home visits of a
certain number and timing (e.g. 1 versus 2–3 in the first week of life); and
(v) ways to achieve high coverage and an intervention of high quality in
program settings.
Given issues
around CHCW confidence, the optimal duration of training and intervals for
refresher training and/or on-the-job mentorship needs to be further established.
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Appendix 1.Summary of the
articles identified for review
|
Author
and year
|
Article
|
Purpose
|
Sample
setting
|
Research
methods
|
Key
findings
|
Conclusions
|
Quality
/ limitations
|
|
Kirkwood
BR, Manu A, ten Asbroek AH(2013)
|
Effect
of the Newhints home–visits intervention on neonatal mortality rate and care
practices in Ghana: a cluster randomized controlled trial
|
Identify
the effects of home visits by CHCW on Neonatal mortality
|
The
CBSVs in the study zones were trained to identify pregnant women in their
community and to make two home visits during pregnancy.
|
a
cluster randomized controlled trial.
|
The
intervention achieved a reduction of 8% in the overall neonatal mortality
rate
|
CHCW
ANC home visits can reduce neonatal mortality
|
Other
preventive measures like breast feeding and warming the baby may contribute to reduction in neonatal mortality.
|
|
Seung-Ah
Choe, Jinseob Kim, Saerom Kim, et al 2015
|
Do
antenatal care visits always contribute to facility-based delivery in
Tanzania?
|
conducted
in to explore the relationship between antenatal care (ANC) visits by CHCW ,
facility-based delivery and the reasons for home births in women who had made
ANC visits
|
data
from RCS Demographic and Health
Surveys
spanning 20 years and a cluster sample of 30 830 women from
52 districts
of Tanzania.
T
|
repeated
cross-sectional study (RCS) data from
Tanzania to explore the
relationship
between antenatal care (ANC) visits, facility-based delivery and the reasons
for home
births
in women who had made ANC visits.
|
Between
1991 and 2010, the national proportion of women who
had
more than four ANC visits during their last pregnancy had
decreased
from 56.1% to 33.3
. In
the same
period,
there was a decreasing trend in facility delivery followed by
a
relatively modest increase in the latter timeframe (50.3% in 1991–
92,
38.4% in 1999 and 45.1% in 2009–10
|
Increase
of ANC visits
>
2–4
times was associated with higher facility delivery rate only in urban area.
The
proportion
of at least four ANC visits was not related to facility de-
livery
rates at the district level in rural Tanzania.
|
The ANC
visits and increase in home deliveries may be applicable in Urban areas but
not in Rural areas
|
|
Penfold
S, Manzi F, MkumboE at al 2014
|
Effect
of home–based counseling on newborn care practices in southern Tanzania
|
to
improve newborn care practices and survival.
|
All 132
wards in the 6-district study area were randomized to intervention or
comparison groups. Starting in 2010, in intervention areas trained volunteers
made home visits. In 2011, in a representative sample of 5,240 households,
|
a
cluster-randomized trial in six districts of Southern Tanzania. Baseline data
collected in five of those six districts in 2007 estimated the neonatal
mortality rate at 34 per 1,000 live births (unpublished data).
|
Four of
14 newborn care practices were more commonly reported in intervention than
comparison areas: delaying the baby’s first bath by at least six hours (81%
versus 68%, OR 2.0 (95% CI 1.2-3.4)), exclusive breastfeeding in the three
days after birth (83% versus 71%, OR 1.9 (95% CI 1.3-2.9)), putting nothing
on the cord (87% versus 70%, OR 2.8 (95% CI 1.7-4.6)), and, for home births,
tying the cord with a clean thread (69% versus 39%, OR 3.4 (95% CI 1.5-7.5)).
For other behaviors there was little evidence of differences in reported
practices between intervention and comparison
|
A
home-based counseling strategy using volunteers and designed for scale-up can
improve newborn care behaviors in rural communities of southern Tanzania.
|
Further
research is needed to evaluate if, and at what cost, these gains will lead to
improved newborn survival. . the length of the study may have led to
interference of other factors or players in improving neonatal care practices
|
|
Bhandari
N, Mazumder S, Taneja et al 2012
|
.
Effect of implementation of Integrated Management of Neonatal and Childhood
Illness (IMNCI) programme on neonatal and infant mortality
|
To
evaluate the Indian Integrated Management of Neonatal and Childhood Illness
(IMNCI) programme, which integrates improved treatment of illness for
children with home visits for newborn care, to inform its scale-up?
|
8
clusters (population 1.1 million) in Haryana, India. 29,667 births in
intervention clusters and 30,813 in control clusters.
|
Randomized
control trial in 8 clusters to evaluate management of neonatal illness by
Home visits
|
The
infant mortality rate and the neonatal mortality rate were significantly
lower in the intervention clusters than in control clusters.
|
Implementation
of the IMNCI resulted in substantial improvement in infant survival and in
neonatal survival in those born at home. The IMNCI should be a part of
India's strategy to achieve the millennium development goal on child survival
|
Depending
on the population of India , and other high risk areas where literacy may be
low , the results could be different
|
|
Bhutta
ZA, Memon ZA, Soofi S et al 2008
|
Implementing
community–based perinatal care: results from a pilot study in rural Pakistan.
Bull World Health Organ.
|
This
pilot study investigated the feasibility of delivering a package of
community-based interventions for improving perinatal care using lady health
workers (LHWs) and traditional birth attendants (Dais) in rural Pakistan.
|
The
intervention was implemented in four of eight village clusters (315 villages,
total population 138 600), while four served as a comparison group
|
Cluster
randomized trial
|
In
intervention villages, there were significant reductions from baseline in
stillbirth (from 65.9 to 43.1 per 1000 births, P < 0.001) and neonatal
mortality rates (from 57.3 to 41.3 per 1000 live births, P < 0.001). The
proportion of deliveries conducted by skilled attendants at public sector
facilities also increased, from 18% at baseline to 30%, while the proportion
of home births decreased from 79% to 65%.
|
The
improved stillbirth and neonatal mortality rates observed indicate that
community health workers (i.e. LHWs and Dais) can be effective in
implementing a community and outreach package that leads to improved home
care practices by families, increased care-seeking behavior and greater
utilization of skilled care providers
|
The use
of CHCW and traditional birth attendants may interfere in the results and one
cannot determine which group contributed to the neonatal rates
|
|
Kumar
V, Mohanty S, Kumar A, Misra RP, Santosham M, Awasthi S, et al 2008
|
Effect
of community-based behavior change management on neonatal mortality in
Shivgarh, Uttar Pradesh, India
|
aimed
at modifying practices and reducing neonatal mortality
|
39
village administrative units (population 104,123) were allocated to one of
three groups: a control group, which received the usual services of
governmental and non-governmental organizations in the area; an intervention
group, which received a preventive package of interventions for essential
newborn care
|
a
cluster-randomized controlled efficacy trial in Shivgarh, a rural area in
Uttar Pradesh clusters, community health workers delivered the packages via
collective meetings and two antenatal and two postnatal household visitation
|
neonatal
mortality rate was reduced by 54% in the essential newborn-care intervention)
and by 52% in the essential newborn care
|
A socio-culturally
contextualized, community-based intervention, targeted at high-risk
newborn-care practices, can lead to substantial behavioral modification and
reduction in neonatal mortality. This approach can be applied to behavior
change along the continuum of care, harmonies vertical interventions, and
build community capacity
|
There
was little change in care-seeking. Compared with controls, which may mean the
two arms may not have been well controlled in the study
|
|
Waiswa
P, Peterson SS, Namazzi G, et al 2012
|
The
Uganda Newborn Study (UNEST): an effectiveness study on improving newborn
health and survival in rural Uganda through a community-based intervention
linked to health facilities – study
|
To
adapt, develop and cost an integrated maternal-newborn care package that
links community and facility care, and to evaluate its effect on maternal and
neonatal practices in order to inform policy and scale-up in Uganda.
|
in 31
intervention and 32 control areas (villages). The comparison parishes receive
the standard care already being provided by the district, but to the
intervention villages are added a system for CHCWs to visit the mother five
times in her home during pregnancy and the neonatal period
|
a
two-arm cluster randomized controlled design with both areas benefit from a
standardized strengthening of facility care for mothers and neonates.
|
home
visits by trained CHCWs to promote preventive care as well as to provide
curative care reduced neonatal mortality by about 30%
|
CHCW
can be effective in improvement of newborn health if home visits are
increased and well supervised
|
Another
limitation is that the study was implemented in a small area where the risk
of contamination is high
|
|
Bang
AT, Bang R, Baitule et al 1999
|
Effect
of home-based neonatal care and management of sepsis on neonatal mortality:
field trial in rural India
|
Investigate
CHCW home visits and the outcome on neonatal mortality
|
3
communities in high mortality areas were identified for Home visits by CHCW
|
Field trial in rural India
|
home
visits can reduce deaths of newborns in high-mortality, developing country
settings by 30 to 61
|
The
visits led to improved coverage of key
newborn care practices such as early initiation of breastfeeding, exclusive
breastfeeding, skin-to-skin contact, delayed bathing and attention to
hygiene, such as hand washing with soap and water, and clean umbilical cord
care.
|
the
limitations are , the study was conducted in high neonatal mortality areas
and results may be different on low neonatal areas . and the two control arms
may have been tampered with
|
|
Tylleskar
T, Jackson D, Meda N et al 2011
|
Exclusive
breastfeeding promotion by peer counselors in sub-Saharan Africa
(PROMISE-EBF):
|
Whether
ANC peer counseling can improve exclusive breast feeding
|
24
communities in Burkina Faso, 24 in Uganda, and 34 in South Africa were
assigned in a 1:1 ratio, by use of a computer-generated randomization
sequence, to the control or intervention clusters. In the intervention group,
one antenatal breastfeeding peer counseling visit and four post-delivery
visits by trained peers
|
Cluster
randomized trial
|
antenatal
peer counseling by CHCWs improved prevalence of exclusive breastfeeding
|
Low-intensity
individual breastfeeding peer counseling is achievable and, although it does
not affect the diarrhoea prevalence, can be used to effectively increase EBF
prevalence in many sub-Saharan African settings.
|
The
study did not first measure the literacy levels of the women selected since
due to their exposure to education , they may already be aware of exclusive
breast feeding . the heterogeneity of the selected people in 3 different
countries was not considered
|
|
Brenner
JL, Kabakyenga J, Kyomuhangi et al 2011
|
Can
volunteer community health workers decrease child morbidity and mortality in
southwestern Uganda
|
to
assess volunteer community health workers' effect on child morbidity,
mortality and to calculate volunteer retention.
|
Two
volunteer community health workers were selected, trained and promoted child
health in each of 116 villages (population ~61,000) during 2006–2009.
|
Impact
evaluations survey
|
Post-intervention
surveys in intervention households revealed absolute reductions of 10.2% in diarrhea prevalence and 5.8% in
fever/malaria; comparative decreases in control households were not
statistically significant. Underweight prevalence was reduced by 5.1% in
intervention households. a relative decline of 53% in child deaths (<5
years old), during the first 18 months of intervention
|
A
low-cost child health promotion model using volunteer community health
workers demonstrated decreased child morbidity, dramatic mortality trend
declines and high volunteer retention.
|
The
sample size may have been too big to monitor and supervision of the home
visits may be difficult .
|
|
Gogia
S, Sachdev HS 2010
|
Home
visits by community health workers to prevent neonatal deaths in developing
countries: a
|
To
determine whether home visits for neonatal care by community health workers
can reduce infant and neonatal deaths and stillbirths in resource-limited
settings.
|
Five
trials, all from south Asia, satisfied the inclusion criteria. The
intervention packages included in them comprised antenatal home visits (all
trials), home visits during the neonatal period (all trials), home-based
treatment for illness (3 trials) and community mobilization efforts (4
trial
|
Meta-analysis
|
Meta-analysis
showed a reduced risk of neonatal death
and stillbirth and a significant improvement in antenatal and neonatal
practice indicators (> 1 antenatal check-up, 2 doses of maternal
tetanus toxoid, clean umbilical cord care, early breastfeeding and delayed
bathing). Only one trial recorded infant deaths
|
Home
visits for antenatal and neonatal care, together with community mobilization
activities, are associated with reduced neonatal mortality and stillbirths in
southern Asian settings with high neonatal mortality and poor access to
facility-based health car
|
data on
stillbirths were limited to three trials, while only one trial had
investigated infant mortality and cause-specific mortality. Second, all
trials were conducted in parts of southern Asia with high baseline neonatal mortality
rates (> 45 deaths per 1000 live births), which impedes generalization to
other regions, particularly to sub-Saharan Africa or to areas with lower
neonatal mortality.
|
|
Darmstadt
GL, Bhutta ZA, Cousens S, et al 2005
|
Evidence-based,
cost-effective interventions: how many newborn babies can we save? World wide
|
Identify
what interventions could avert an
estimated 41-72% of neonatal deaths worldwide.
|
16
interventions with proven efficacy (implementation under ideal conditions)
for neonatal survival and combine them into packages for scaling up in health
systems. three service delivery modes (outreach, family-community, and
facility-based clinical care)
|
Systematic
review
|
Reductions
in neonatal mortality that exceed 50% can be achieved with an integrated,
high-coverage programme of universal outreach and family-community care,
consisting of 12% and 26%, respectively,
|
Early
success in averting neonatal deaths is possible in settings with high
mortality and weak health systems through outreach and family-community care,
including health education to improve home-care practices, to create demand
for skilled care, and to improve care seeking. Simultaneous expansion of
clinical care for babies and mothers is essential to achieve the reduction in
neonatal deaths
|
Reviews
did not test the hypothesis to confirm the results because other factors
other than CHCW and community based interventions may play a part in those
results .
|
|
Lewycka
S, Mwansambo C, Rosato M et al 2013
|
Effect
of women’s groups and volunteer peer counseling on rates of mortality,
morbidity, and health behaviors in mothers and children in rural Malawi
(MaiMwana):
|
Women
were assessed on their effects on
mortality and breastfeeding rates in rural Malawi
|
All
women aged 10–49 years who consented to participate were enrolled. The 48
clusters were allocated randomly to one of four groups 12 were allocated to
the women’s group and volunteer peer counseling, 12 women’s group only, 12
volunteer peer counseling only, and 12 no intervention
|
cluster-randomized
trial in 185 888 people in Mchinjidistrict. 48 equal-sized clusters were
randomly allocated to four groups with a computer-generated
|
results
of the stratified, adjusted analysis showed a 36% reduction in IMR but no effect on EBF in areas without women’s
groups, and in areas with women’s groups there was no effect on IMR and an increase in EBF.
|
Community
mobilization through women’s groups and volunteer peer counselor health
education are methods to improve maternal and child health outcomes in poor rural
populations in Africa
|
The
study limitations were that since 2004 to 2013 changes and influences may
affect the study sample and hence the results . the sample was also too large to control
|
|
Lassi
ZS, Haider BA, Bhutta ZA 2010
|
Community-based
intervention packages for reducing maternal and neonatal morbidity and
mortality and improving neonatal outcomes
|
To
assess the effectiveness of community-based intervention packages in reducing
maternal and neonatal morbidity and mortality; and improving neonatal
outcomes
|
review
included 18 cluster-randomized/quasi-randomized trials, covering a wide range
of interventional packages, including two subsets from one trial.
|
All
prospective randomized and quasi-experimental trials evaluating the
effectiveness of community-based intervention packages in reducing maternal
and neonatal mortality and morbidities; and improving neonatal outcomes
|
The review did not show any reduction in
maternal mortality. However, significant reduction was observed in maternal
morbidity 28%; neonatal mortality 69%, stillbirths 66%, and prenatal 82%, as a consequence of
implementation of community-based interventional care packages. It also
increased the referrals to health facility for pregnancy related complication
by 40% and improved the rates of early breastfeeding by 94% initiation
|
The
study offers encouraging evidence of the value of integrating maternal and
newborn care in community settings through a range of interventions which can
be packaged effectively for delivery through a range of community health
workers and health promotion groups.
|
The
study had multiple outcomes which some do not conform to this study.
|
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