Globally, an estimated 3.6 million newborns and 360 000 mothers die every year. Of these, maternal health complications contribute to 1.5 million neonatal deaths in the first week of life and 1.4 million stillbirths, suggesting that a major gap of intervention exists around childbirth and in the early postnatal period, a time at which mothers and babies are most at risk.1,2 The main direct causes of neonatal death include birth asphyxia, preterm birth complications and severe infections, including sepsis, pneumonia, diarrhoea and tetanus. In terms of low birthweight, according to the United Nations Children’s Fund (UNICEF) estimates of 2009, sub-Saharan Africa and South Asia bear the greatest burden, with 80% of all neonatal deaths occurring in these two regions alone.3 Global progress in reducing neonatal mortality has been slow, and the burden is particularly marked in poor, rural communities that are the most difficult to reach and among the most disadvantaged, with the lowest access to and utilisation of facility-based services for childbirth and newborn care.
In addition to poverty, several underlying social determinants contribute to the burden of neonatal morbidity and mortality. These include factors such as low literacy and women’s status in society, nutritional status pre-conception and at the time of conception, early marriages and childbearing, high fertility and closely spaced pregnancies. Many harmful neonatal care practices, such as inadequate cord care, discarding the colostrum and feeding pre-lacteals, are deeply rooted in the cultural fabric of societies4 and further increase the risk of neonatal deaths. These risks are greatly compounded by poorly functional health systems and shortages of skilled human resources for health. This is a particular cause for concern in poor populations which are disproportionately affected by the outmigration of health professionals and the inability to provide good-quality primary care services.5
Given the shortage of care providers and functional health facilities, and the deeply entrenched practices, there is much interest in community-based interventions and strategies for care. A growing body of evidence suggests that many direct causes of neonatal deaths can be adequately managed by community health workers (CHWs) employing a range of promotive, preventative and therapeutic interventions at community level. These include the promotion of behavioural change through community counselling on topics related to birth and newborn care preparedness, as well as additional provision of preventative and therapeutic interventions at household level for newborn care. However, it is recognised that functional facilities with around-the-clock provision of emergency obstetric and newborn care, and adequate transport services, are also a critical necessity to reduce maternal morbidity and mortality.
The evidence base of the effectiveness of CHW-delivered packages of care continues to grow.6 CHWs can work across a range of contexts and cultures, religions and beliefs of the communities they serve. It is now well recognised that CHWs, both skilled and semi-skilled, play a major role in community mobilisation and deliver a range of promotive, preventative and curative services. These have been formally evaluated in a large number of efficacy and effectiveness trials in South Asia and Africa, deploying CHWs for a range of community-based interventions.7–13 These interventions have included community mobilisation and advocacy through women’s support groups, in combination with the delivery of domiciliary preventative and therapeutic care through home visits. The context and range of studies vary considerably with many employing a combination of interventions. It is therefore important to analyse the evidence of the impact of community-based interventions systematically with due attention given to actual strategies used for training and implementation.
We undertook a pooled analysis of all recent randomised controlled trials in which community-based strategies were employed as part of the intervention. As suggested previously, these strategies are associated with a significant reduction (27%) in neonatal mortality, particularly when community mobilisation is supplemented with home visitation by CHWs to deliver preventative, promotive and therapeutic care interventions (32%).14 Early neonatal resuscitation, management of neonatal sepsis and usage of a clean delivery kit by a traditional birth attendant during the intrapartum period was also associated with a significant reduction (19%) in neonatal deaths (Table 1).
Several caveats should be considered when using pooled analyses across a range of studies and contexts. Although meta-analyses are widely regarded as extremely useful for the synthesis of information from a range of sources, care must be taken when extrapolating results to a wider range of contexts. Nuances and important co-determinants are rarely captured in forest plots.
Although the process pathways for the effectiveness of many such interventions are uncertain, they seem to influence community awareness and practices, such as the use of clean delivery kits, breastfeeding and care seeking for maternal and newborn illnesses. Analysis from these trials showed that these strategies were also associated with benefits on newborn care practices, such as the early initiation of breastfeeding (within 1 hour of giving birth) and healthcare seeking for neonatal illness (Table 2).
These studies greatly add to the global evidence base of intervention and delivery strategies that may improve neonatal health outcomes. A daunting challenge to improve global neonatal health is the need for appropriate packages of care to be delivered in appropriate circumstances using a range of contextually relevant approaches. These studies imply that, within the community, three categories of individuals and groups have important roles in developing a successful and sustainable community-based neonatal health programme: first, CHWs, who provide primary health care, can mobilise community members and impart knowledge; second, training of and linkages to traditional birth attendants can provide basic prenatal and obstetric care, as well as referrals where skilled birth attendants are absent, and can also promote facility-based births when skilled birth attendants are available in functional referral facilities; third, community support groups, especially women’s groups, can empower communities and help in problem solving and planning to improve opportunities for women’s health, as well as care for mothers and newborns.
To improve maternal and newborn survival, future strategies will require the integration of both community- and facility-based care. The deployment of community-based strategies through CHWs offers a cost-effective, rapid mechanism to reach populations at risk, and to link to appropriate domiciliary and care-seeking practices.