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The Scale of the Problem Home Births and Limited Access to Content of Health Care
Until about twenty years ago, child
Care The three commonest causes of neona-
In low-income settings, most babies are tal deaths are infections (28%), complica-
survival meant the survival of children tions of prematurity (30%), and intrapar-
born at home and more than half of those
rather than newborn infants. With a steady tum-related (‘‘birth asphyxia’’) (24%) [2].
who die do so at home. Three-quarters of
worldwide decline in under-5 deaths— Unfortunately, health workers may lack
neonatal deaths occur in the first week,
most of the lives saved being those of the skills and experience necessary to act
and just under half in the first 24 h [3]. In
infants and children over the age of a appropriately. Basic resuscitation skills and
South Asia and East and Southern Africa,
month—the newborn period has come into knowledge may be limited, and there is a
only about 35% of births take place in
focus as a relatively intransigent source of pervasive idea that intervention needs to
institutions [8]. The newborn infant has
mortality. The ‘‘child survival revolution’’ be highly technical. This is not generally
traditionally occupied a transitional space
increased child survival [1], but newborn true. As early as 1905, Budin recommend-
between potential and actual personhood,
infants went largely unnoticed. Neonatal ed resuscitation, warmth, early and fre-
and seclusion practices add to the likeli-
mortality (0–28 d) now accounts for about quent breastfeeding, keeping the baby
hood that he or she will be invisible to
two-thirds of global infant (0–1 y) mortality with his or her mother, hygiene, and
health professionals. If care is sought, it is
and about 3.8 million of the 8.8 million prompt recognition and treatment of
often in the traditional sector and beset by
annual deaths of children under 5 [2]. Most illness [10]. Contemporary recommenda-
obstacles such as the notion that mother
of these deaths (98%) occur in low- and tions for ‘‘essential newborn care’’ follow
and baby are polluted, which may entail
middle-income countries [3]. this blueprint [11,12]. The Lancet’s series on
seclusion and cause delay in care-seeking.
The last two decades have seen a rise in neonatal survival suggested that between
Access to allopathic (‘‘Western’’ or bio-
advocacy—a call for attention to the 41% and 72% of neonatal deaths could be
medical) health services is limited by lack
newborn infant along with her mother averted if 16 simple, cost-effective inter-
of facilities, human resources, equipment,
and siblings—and an incremental growth ventions were delivered with universal
and consumables.
in the evidence for potential interventions coverage. Among these are adequate
There are four general ways of address-
[4–6]. Reducing neonatal mortality is both nutrition, improved hygiene, antenatal
ing this: improving the provision and
an ethical obligation and a prerequisite to care, skilled birth attendance, emergency
quality of institutional health care, extend-
achieving Millennium Development Goal obstetric and newborn care, and postnatal
ing institutional care through community
4, the target of which is a reduction in visits for mothers and infants [13].
outreach, stimulating demand for appro-
child mortality by two-thirds between
priate health care and institutional deliv-
1990 and 2015. A 2008 report found only Inequity
ery through community engagement and
a quarter of relevant countries on track to
perhaps financial incentives, and changing Newborn survival increases with wealth.
reach this target [7].
ideas and behaviour by working with In India, for example, neonatal mortality
communities. These approaches are far is 56 per 1,000 in the poorest quintile, but
Immediate Challenges from mutually exclusive and should be 25 in the richest [14]. Such inequality is
The main obstacles to improving new- joined up [9]. evident no matter how the population is
born survival are that many babies are
born at home without skilled attendance, Citation: Nair N, Tripathy P, Prost A, Costello A, Osrin D (2010) Improving Newborn Survival in Low-Income
care-seeking for maternal and newborn Countries: Community-Based Approaches and Lessons from South Asia. PLoS Med 7(4): e1000246. doi:10.1371/
journal.pmed.1000246
ailments is limited, health workers are
often not skilled and confident in caring Published April 6, 2010
for newborn infants, and inequalities in all Copyright: ß 2010 Nair et al. This is an open-access article distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,
these factors are felt by those most in need. provided the original author and source are credited.
Funding: DO is supported by The Wellcome Trust (081052/Z/06/Z). The funder played no role in the decision
The Policy Forum allows health policy makers to submit the article or in its preparation.
around the world to discuss challenges and Competing Interests: David Osrin is on the Editorial Board of PLoS Medicine.
opportunities for improving health care in their
societies. * E-mail: d.osrin@ich.ucl.ac.uk
Provenance: Commissioned; externally peer-reviewed.
intensity, was also a feature of other women and make antenatal care visits to based women trained and remunerated by
successful programs [37,38,39]. their homes, attend delivery, give vitamin SEARCH. These local nongovernment
K injections, make several further postna- workers were able to give advice and
Home Visits by Community Workers tal home visits, identify and manage identify and treat neonatal problems, their
Aside from the benefits of group-based infants at risk from birth asphyxia, low skills extending to resuscitation and ad-
discursive approaches, a growing number birth weight and sepsis, and encourage ministration of intramuscular antibiotics.
of programs have shown that targeted appropriate referral. This seminal model Since then, trials of home-based care have
home visits by community-based workers gradually reduced neonatal mortality by been conducted in North India [37],
can help reduce newborn mortality. The 70% [40,41]. Bangladesh [38], and Pakistan [39] (sum-
idea developed over some years in rural Like most successful local initiatives, the marised along with other key work in
Maharashtra, India, where the nongov- SEARCH approach developed incremen- Table 1). Strategies differed in personnel
ernment organisation (NGO), the Society tally in the context of a commitment to and content. All the programs included
for Education, Action and Research in community development and included a community meetings, antenatal and post-
Community Health (SEARCH) trained range of activities. The most prominent natal home visits, and preventive advice.
community health workers to conduct were regular visits to women and their The Hala program included referral [39],
group health education, identify pregnant newborn infants by a cadre of community- as did the Projahnmo program, which also
a
Intervention 2 added liquid crystal thermometry by community health workers.
b
Rate ratio.
c
Comparison was pre-post intervention, not intervention-control.
CI, confidence interval; RCT, randomised controlled trial.
doi:10.1371/journal.pmed.1000246.t001
included curative care [35]. Strategies Health Workers, TBAs, and community underway in South and Southeast Asia
were also implemented by different cadres volunteers. (Bangladesh, India, Nepal, Pakistan, and
of workers. The Shivgarh strategy in- Most of the programs showed improve- Vietnam) and sub-Saharan Africa (Ethio-
volved community health workers re- ments in care: increased uptake of ante- pia, Ghana, Malawi, Mali, Mozambique,
munerated by the program and local natal care, some increase in institutional South Africa, Tanzania, and Uganda), and
volunteers [37]; the Projahnmo stra- delivery (although this was not a primary WHO and UNICEF now recommend
tegy involved NGO community health feature of any program), and better home visits in the first week of life by
workers and mobilisers [38]; and the performance on indicators of essential appropriately trained and supervised
Hala strategy involved government Lady newborn care. Further evaluations are health workers [42].
References
1. Schuftan C (1990) The Child Survival Revolu- resource settings - are we delivering? BJOG 116 neonatal deaths: When? Where? Why? Lancet
tion: a critique. Fam Pract 7: 329–332. (Suppl 1): S49–S59. 365: 891–900.
2. Lawn J, Kerber K, Enweronu-Laryea C, 3. Lawn J, Cousens S, Zupan J, for the Lancet 4. Saving Newborn Lives (2001) State of the world’s
Bateman M (2009) Newborn survival in low Neonatal Survival Steering Team (2005) 4 million newborns. Washington DC: Save the Children.