Is High-Tech Care in a Middle Income Country Worth It? Evidence from Perinatal Centers in Russia
BACKGROUND Neonatal care is not available to most neonates in developing countries because hospitals are inaccessible and costly. We developed a package of home-based neonatal care, including management of sepsis (septicaemia, meningitis, pneumonia), and tested it in the field, with the hypothesis that it would reduce the neonatal mortality rate by at least 25% in 3 years. METHODS We chose 39 intervention and 47 control villages in the Gadchiroli district in India, collected baseline data for 2 years (1993-95), and then introduced neonatal care in the intervention villages (1995-98). Village health workers trained in neonatal care made home visits and managed birth asphyxia, premature birth or low birthweight, hypothermia, and breast-feeding problems. They diagnosed and treated neonatal sepsis. Assistance by trained traditional birth attendants, health education, and fortnightly supervisory visits were also provided. Other workers recorded all births and deaths in the intervention and the control area (1993-98) to estimate mortality rates. FINDINGS Population characteristics in the intervention and control areas, and the baseline mortality rates (1993-95) were similar. Baseline (1993-95) neonatal mortality rate in the intervention and the control areas was 62 and 58 per 1000 live births, respectively. In the third year of intervention 93% of neonates received home-based care. Neonatal, infant, and perinatal mortality rates in the intervention area (net percentage reduction) compared with the control area, were 25.5 (62.2%), 38.8 (45.7%), and 47.8 (71.0%), respectively (p<0.001). Case fatality in neonatal sepsis declined from 16.6% (163 cases) before treatment, to 2.8% (71 cases) after treatment by village health workers (p<0.01). Home-based neonatal care cost US$5.3 per neonate, and in 1997-98 such care averted one death (fetal or neonatal) per 18 neonates cared for. INTERPRETATION Home-based neonatal care, including management of sepsis, is acceptable, feasible, and reduced neonatal and infant mortality by nearly 50% among our malnourished, illiterate, rural study population. Our approach could reduce neonatal mortality substantially in developing countries.