Newborn care behaviours and neonatal survival: evidence from sub-Saharan Africa.
OBJECTIVES:To evaluate the effect on neonatal and infant mortality during 10 years (1993 to 2003) in the field trial of home-based neonatal care (HBNC) in Gadchiroli.To estimate the contribution of the individual components in the intervention package on the observed effect.STUDY DESIGN:The field trial of HBNC in Gadchiroli, India, has completed the baseline phase (1993 to 1995), observational phase (1995 to 1996) and the 7 years of intervention (1996 to 2003). We measured the stillbirth rate (SBR), neonatal mortality rate (NMR), perinatal mortality rate (PMR), postneonatal mortality rate (PNMR) and the infant mortality rate (IMR) in the intervention area and the control area. The effect of HBNC on all these rates was estimated by comparing the change from baseline (1993 to 1995) to the last 2 years of intervention (2001 to 2003) in the intervention area vs in the control area. For other estimates, we made a before–after comparison of the rates in the intervention arm in the observation year (1995 to 1996) vs intervention years (1996 to 2003). We evaluated the effect on the cause-specific NMRs. By using the changes in the incidence and case fatality (CF) of the four main morbidities, we estimated the contribution of primary prevention and of the management of sick neonates. The proportion of deaths averted by different components of HBNC was estimated.RESULTS:The baseline population in 39 intervention villages was 39,312 and in 47 control villages it was 42,617, and the population characteristics and vital rates were similar. The total number of live births in 10 years (1993 to 2003) were 8811 and 9990, respectively. The NMR in the control area showed an increase from 58 in 1993 to 1995 to 64 in 2001 to 2003. The NMR in the intervention area declined from 62 to 25; the reduction in comparison to the control area was by 44 points (70%, 95% CI 59 to 81%). Early NMR decreased by 24 points (64%) and late NMR by 20 points (80%). The SBR decreased by 16 points (49%) and the PMR by 38 points (56%). The PNMR did not change, and the IMR decreased by 43 points (57%, 95% CI 46 to 68%). All reductions were highly significant (p<0.001) except for SBR it was <0.05. The cause-specific NMR (1995 to 1996 vs 2001 to 2003) for sepsis decreased by 90%, for asphyxia by 53% and for prematurity by 38%. The total reduction in neonatal mortality during intervention (1996 to 2003) was ascribed to sepsis management, 36%; supportive care of low birth weight (LBW) neonates, 34%; asphyxia management, 19%; primary prevention, 7% and management of other illnesses or unexplained, 4%.CONCLUSIONS:The HBNC package in the Gadchiroli field trial reduced the neonatal and perinatal mortality by large margins, and the gains were sustained at the end of the 7 years of intervention and were carried forward as improved survival through the first year of life. Most of the reduction in mortality was ascribed to sickness management, that is, management of sepsis, supportive care of LBW neonates and management of asphyxia, in that order, and a small portion to primary prevention.