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Keywords:

  • sub-Saharan Africa;
  • infant;
  • newborn;
  • infant care

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Objective

To review evidence from sub-Saharan Africa for the association between the practice or promotion of essential newborn care behaviours and neonatal survival.

Methods

We searched MEDLINE for English language, peer-reviewed literature published since 2005. The study population was neonates residing in a sub-Saharan Africa country who were not HIV positive. Outcomes were all-cause neonatal or early neonatal mortality or one of the three main causes of neonatal mortality: complications of preterm birth, infections and intrapartum-related neonatal events. Interventions included were the practice or promotion of recommended newborn care behaviours including warmth, hygiene, breastfeeding, resuscitation and management of illness. We included study designs with a concurrent comparison group. Study quality was assessed using the Cochrane EPOC or Newcastle–Ottawa tools and summarised using GRADE.

Results

Eleven papers met the search criteria and most were at low risk of bias. We found evidence that delivering on a clean surface, newborn resuscitation, early initiation and exclusive breastfeeding, Kangaroo Mother Care (KMC) for low-birthweight babies, and distribution of clean delivery kits were associated with reduced risks of neonatal mortality or the main causes of neonatal mortality. There was evidence that training community birth attendants in resuscitation and administering antibiotics, and establishing women's groups can improve neonatal survival.

Conclusion

There is a remarkable lack of robust evidence from sub-Saharan Africa on the association between practice or promotion of newborn care behaviours and newborn survival.

Objectif

Analyser les données d'Afrique subsaharienne sur l'association entre la pratique ou la promotion des comportements de soins essentiels aux nouveau-nés et à la survie néonatale.

Méthodes

Nous avons effectué des recherches sur Medline pour la littérature, évaluée par les pairs, en langue anglaise, publiée depuis 2005. La population de l’étude était les nouveau-nés résidant dans un pays d'Afrique subsaharienne qui n’étaient pas VIH positifs. Les résultats étaient toutes causes de la mortalité néonatale ou néonatale précoce ou l'une des trois principales causes de mortalité néonatale: complications de la prématurité, infections et événements néonatales associés à l'intrapartum. Les interventions consistaient à la pratique ou la promotion des comportements de soins recommandés aux nouveau-nés, y compris la chaleur, l'hygiène, l'allaitement, la réanimation et la prise en charges de la maladie. Nous avons inclus les concepts d’étude incluant un groupe de comparaison simultanée. La qualité des études a été évaluée à l'aide des outils de Cochrane EPOC ou Newcastle-Ottawa, et résumée en utilisant GRADE.

Résultats

11 articles répondaient aux critères et la plupart étaient à faible risque de biais. Nous avons trouvé des preuves que l'accouchement sur une surface propre, des soins propres du cordon, la réanimation du nouveau-né, l'initiation précoce et exclusive de l'allaitement maternel, les soins kangourou pour les bébés de faible poids à la naissance et la distribution de kits d'accouchement propres, étaient associés à une réduction des risques de mortalité néonatale ou des principales causes de la mortalité néonatale. Il y avait des preuves que la formation des accoucheuses communautaires en réanimation et à l'administration d'antibiotiques, et la création de groupes de femmes peuvent améliorer la survie néonatale.

Conclusion

Il y a un manque considérable de preuves solides de l'Afrique subsaharienne sur l'association entre la pratique et la promotion des comportements de soins aux nouveau-nés et la survie néonatale.

Objetivo

Revisar la evidencia de África subsahariana en busca de la asociación entre la práctica o promoción de comportamientos esenciales en los cuidados de neonatos y la supervivencia neonatal.

Métodos

Hemos realizado una búsqueda en Medline de literatura en inglés, con revisión por pares, publicada desde el 2005. La población de estudio eran neonatos residiendo en un país del África subsahariana y que no fuesen VIH positivos. Los resultados a evaluar eran la mortalidad por cualquier causa o la mortalidad neonatal temprana o una de las tres causas principales de mortalidad infantil: complicaciones por nacimiento prematuro, infecciones y eventos neonatales relacionados con el parto. Las intervenciones incluidas eran la práctica o promoción de comportamientos recomendados para el cuidado del neonato, incluyendo el dar calor, la higiene, la lactancia materna, la resucitación y el manejo de la enfermedad. Incluimos estudios que tenían un diseño con grupo de comparación simultáneo. La calidad del estudio se evaluó utilizando las herramientas Cochrane EPOC o Newcastle-Ottawa y se resumió utilizando GRADE.

Resultados

11 publicaciones cumplían los criterios de búsqueda y la mayoría tenían una baja probabilidad de sesgo. Hallamos evidencia de que dar a luz sobre una superficie limpia, los cuidados de limpieza del cordón umbilical, la resucitación del neonato, la iniciación temprana y la exclusividad de la lactancia materna, los cuidados de madre canguro para bebés con bajo peso al nacer y la distribución de kits de limpieza para el parto estaban asociados con una reducción en el riesgo de la mortalidad neonatal o de sus principales causas. Había evidencia de que entrenar a parteras comunitarias en la resucitación y en la administración de antibióticos así como establecer grupos de mujeres pueden mejorar la supervivencia neonatal.

Conclusión

Hay una falta importante de evidencia robusta en África subsahariana sobre las asociaciones entre la práctica y la promoción del comportamiento en la atención al neonato y la supervivencia neonatal.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

In 2005, the Lancet neonatal survival series brought to global attention the issue of neonatal mortality (Deaths in the first 4 weeks of life; The Lancet 2005). Despite successful reductions in child mortality, reductions in neonatal mortality have been small by comparison (Rajaratnam et al. 2010), and the majority of neonatal deaths occur in the first 7 days of life (early neonatal deaths) (Lawn et al. 2005). Thus, the proportion of childhood deaths occurring in the neonatal period is increasing (UNICEF 2012). Of around three million neonatal deaths every year, two-thirds occur in South-East Asia and sub-Saharan Africa (UNICEF 2012). The highest rates and slowest declines in neonatal mortality are observed in sub-Saharan Africa (Lawn et al. 2005; Hill & Choi 2006; UNICEF 2012). In 2010, there were estimated to be 1.07 million neonatal deaths in Africa, comprising 30% of deaths in children below 5 years (Liu et al. 2012). The neonatal mortality rate in the region was estimated to be 34 per thousand live births in 2011 (UNICEF 2012). Improved neonatal survival in sub-Saharan Africa is almost essential to achieve the fourth millennium development goal of reducing mortality in children aged less than five years by two-thirds between 1990 and 2015.

Epidemiology of neonatal mortality

The main causes of neonatal mortality in sub-Saharan Africa are complications of preterm birth (25%), infections (23%) and intrapartum-related neonatal events (20%) (Liu et al. 2012).

Prematurity and low birthweight

Preterm birth is childbirth after fewer than 37 completed weeks of gestation (Goldenberg et al. 2008). Risk factors for spontaneous preterm delivery include individual or family history of preterm birth, young or advanced maternal age, short interpregnancy intervals, low body mass index, multiple pregnancy, pre-existing non-communicable disease, hypertensive disease of pregnancy and infections (Goldenberg et al. 2008; Blencowe et al. 2012). Complications of preterm birth are not only the leading direct cause of neonatal mortality globally but also the dominant risk factor for neonatal mortality by other causes and have risks for long-term impairments to health (Lawn et al. 2005, 2010). Premature babies are at higher risks of neurodevelopmental impairments and respiratory and gastrointestinal complications (Goldenberg et al. 2008). Preterm birth increases the risk of hypothermia because of truncated deposition of subcutaneous fat in the last trimester of pregnancy, which reduces insulation (Kumar et al. 2009). In 2010, 12% of births in sub-Saharan Africa were preterm; only Southern (13%) and south-eastern Asia (14%) had higher rates (Blencowe et al. 2012).

A birthweight of less than 2500 g is classed as low birthweight (LBW), regardless of gestational age (Kramer 1987). LBW may be due to preterm birth or intrauterine growth restriction, or both (Kramer 1987; Katz et al. 2013). In developing countries, LBW most commonly results from intrauterine growth restriction owing to poor maternal health and nutrition, which increases the risk of mortality and complications throughout life (Kramer 1987; Blanc & Wardlaw 2005). It is estimated that 15% of babies in sub-Saharan Africa and 27% of babies in south-central Asia are born with LBW (UNICEF & WHO 2004). LBW is associated with increased risks of neonatal complications including those of prematurity and intrauterine growth restriction (Katz et al. 2013), hypothermia (defined as body temperature <36.5 °C (WHO 1994; Kumar et al. 2009; Byaruhanga et al. 2005) and a low Apgar score (physical condition) (Adam et al. 2007).

Owing to the intrinsic link between birthweight and gestational age, and because of the relative ease of measuring birthweight compared with gestational age in low-resource settings, assessment of the risks associated with prematurity or LBW are often reported together.

In a meta-analysis of four data sets from East Africa, Marchant et al. (2012) analysed risks of mortality from LBW, preterm birth and weight for gestational age. They found increased risks of mortality for each individual condition [LBW odds ratios (OR) 7.6 (95% CI 4.8–12.1), slightly premature (34–36 weeks' gestation) with weight appropriate for gestational age OR 3.2 (95% CI 0.9–10.7)] and small for gestational age OR 2.1 (95% CI 1.3–3.5)), particularly for babies born at <34 weeks' gestation [OR 58.7 (95% CI 28.4–121.4)]. For babies born slightly premature and small for gestational age, the risk of mortality was higher [OR 19.9 (95% CI 8.3–47.4)] compared with the risk of death associated with each condition separately (Marchant et al. 2012).

Intrapartum-related neonatal deaths

During normal labour, the foetus experiences hypoxia but is able to tolerate this remarkably well. Problems occur if there is a severe or sustained lack of oxygen to the foetus, which may happen before, during or after labour. Resulting deaths, called intrapartum-related neonatal deaths (also known as birth asphyxia), are defined as live-born term babies who die in the first 28 days of life from neonatal encephalopathy, or who could not be resuscitated or for whom resuscitation was not available. Almost all intrapartum-related neonatal deaths occur in the first week of life (Lawn et al. 2009).

Not only are the highest numbers of intrapartum-related neonatal deaths in developing countries, but the highest proportions too. Three of the ten countries with the highest rates of intrapartum-related neonatal mortality (Democratic Republic of Congo, Ethiopia and Tanzania) are in sub-Saharan Africa (Lawn et al. 2009). Intrapartum-related mortality is also a leading cause of stillbirths in low- and middle-income countries (Gravett et al. 2010). Improving the health of mothers and access to skilled care at delivery are considered vital to reducing intrapartum-related neonatal deaths (Lawn et al. 2009).

Infections

The most common infections causing death in neonates are sepsis, meningitis and pneumonia; other notable infections are tetanus and diarrhoea (Liu et al. 2012). A review of community-based studies in developing countries reported that infection-specific mortality rate estimates ranged from 3 (95% CI 2–4) in South Africa to 39 (95% CI 17–75) per 1000 live births in Somalia. Overall, a median of 37% (interquartile range, 26–49%) of neonatal deaths were estimated to be due to infections (Thaver & Zaidi 2009). Both intrapartum complications and preterm birth raise the risk of infections (Lawn et al. 2005, 2010; Ojukwu et al. 2006), the latter owing to impaired newborn immune function (Tissieres et al. 2012).

Strategies to reduce newborn death

The health of mothers and newborns is closely linked. Until recently, policies tended to address maternal and child health needs separately, resulting in gaps in care that particularly affected newborns. It is beneficial to both mothers and children that the focus has shifted towards a continuum of care throughout the life cycle (Lawn & Kerber 2006): improving maternal health during pregnancy, delivery and post-partum can improve both maternal and neonatal outcomes (PMNCH 2011). Nevertheless, newborns require specific care needs to be met in order to reduce the main causes of mortality and morbidity.

In 1994, the World Health Organization (WHO) convened a technical working group to define essential newborn care at three levels (home, health centre/first level referral and district hospital), including both prevention and treatment strategies (WHO 1994). Since this report, other publications have continued to develop this list of interventions within the continuum of care approach (WHO 2009; PMNCH 2011; Save the Children 2013). Table 1 lists the original essential interventions recommended by the WHO in 1994, with additions from subsequent key sources as required.

Table 1. Essential newborn care behaviours and interventions
For all babies:
1. Cleanliness: clean delivery and clean cord care for the prevention of newborn infections (namely tetanus and sepsis). This means during labour and delivery attendants must have clean hands, prepare a clean delivery surface, clean the perineum of the woman, introduce nothing unclean into the vagina, cut the cord with a clean instrument and put nothing on the cord after it has been cut (WHO 1994) or apply chlorhexidine (Save the children 2013)
2. Thermal protection: prevention and/or management of neonatal hypothermia and hyperthermia. This means delivering the baby in a warm room, drying the baby immediately after delivery, skin-to-skin contact with the mother as soon as possible after birth, wrapping the baby loosely in warm layers if separated from his/her mother, delaying bathing the baby until his/her temperature is stable (WHO 1994)
3. Early and exclusive breastfeeding (WHO 1994)
4. Check initiation of breathing (WHO 1994)
5. Eye care: prevention and management of ophthalmia neonatorum. This means applying silver nitrate solution, tetracycline or erythromycin ointment to the eyes within one hour of delivery to prevent the transmission of gonorrhoea or chlamydia, the two main causes of ophthalmia neonatorum (WHO 1994)
6. Immunisation, namely BCG, OPV and hepatitis B vaccinations (WHO 1994)
7. Promote sleeping under insecticide-treated bed net (WHO 2009)
If required:
8. Resuscitation with bag and mask (WHO 1994 & PMNCH 2011)
9. Management of newborn illness. This means early recognition of newborn illness by family members, followed by prompt care seeking and the receipt of appropriate care at the health facility. (WHO 1994) These include jaundice, sepsis, meningitis and pneumonia (PMNCH 2011)
10. Care of the preterm and/or low-birthweight (LBW) newborn namely: good thermal protection through skin-to-skin contact with the mother, breast milk (WHO 1994) and extra support for feeding, surfactant to prevent respiratory distress and continuous positive airway pressure to manage babies with respiratory distress syndrome (PMNCH 2012)
11. Steroid injections for women in preterm labour to reduce deaths due to premature babies' breathing problems (Save the children 2013)

Essential newborn care practices can reduce neonatal mortality from the three main causes through reducing the incidence of intrapartum complications, reducing the incidence and improving the treatment of neonatal infections, and improving the management of complications of preterm birth. Strategies to improve newborn survival through improved newborn care can be grouped into two types: improving newborn care practices and training practitioners to promote and practise improved newborn care (Figure 1). To be effective, these interventions require families and the wider community to be willing to change the way they care for their newborns, and a health system that is resourced to provide good quality care to mothers and babies, and to train practitioners where required.

image

Figure 1. Pathway for strategies to improve newborn survival within an enabling environment.

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Aim

Here, we review recent evidence from sub-Saharan Africa for the association between the promotion and practice of recommended newborn care behaviours and interventions, and neonatal mortality, or one of the three major causes of neonatal mortality. Our focus is on evidence published since the Lancet neonatal survival series (The Lancet 2005).

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

We searched MEDLINE for English language, peer-reviewed literature published between January 2005 and May 2013. Medical Subject Headings (MeSH) combined with ‘or’ Boolean operators included Newborn, Premature Birth, Birth Weight, Postnatal Care, Prenatal Care, Infant Care, Infant Mortality. MeSH terms for every low- and middle-income economy country in sub-Saharan Africa according to the World Bank classification (The World Bank 2013) were also combined with an ‘or’ operator. Results of these two searches were combined with an ‘and’ Boolean operator.

Eligibility criteria for papers to be included in the review are shown in Table 2. The study population were neonates residing in a low- or lower-middle-income economy country in sub-Saharan African country who were not known to be HIV positive. The outcomes of interest were all-cause neonatal or early neonatal mortality, or one of the three main causes of neonatal mortality: intrapartum-related neonatal death, infections or complications of preterm delivery. Interventions included were the practice of, or programmes training practitioners in, one or more of the recommended essential newborn care behaviours and interventions, as described in Table 1. Study designs selected included those with a contemporaneous comparison group, that is, individually randomised controlled trials (RCTs), cluster-randomised controlled trials, non-randomised cluster trials, controlled before and after studies, case–control studies and cohort studies.

Table 2. Paper inclusion criteria
1. Study uses one of the following designs:
a. Individually randomised controlled trials
b. Cluster-randomised controlled trials
c. Non-randomised trials
d. Controlled before and after studies
e. Case–control study
f. Cohort study
2. Study set in a low- or lower-middle-income economy country in sub-Saharan Africa
3. Study outcome is all-cause neonatal mortality or one of the 3 main causes of neonatal mortality (intrapartum-related mortality, infections or complications of preterm delivery)
4. Study reports the effect of/association between the promotion or practice of at least one recommended newborn care behaviour on/and the study outcome, specifically risk ratio, odds ratio, rate ratio or hazard ratio or data to calculate these
5. Study does not involve patients known to be HIV positive as the study group

Retrieved references were entered into Endnote version X7 (endnote.com). Titles and abstracts were scanned by two independent researchers (SP and BW) to identify those which met the inclusion criteria, and the resulting list of articles was compared. Articles appearing in both researchers' lists were taken forward for further screening by reading the full article.

The location, intervention, outcome measures, study design, sample size and measure of effect were extracted. Here, we present the results so that the intervention or behaviour being examined represents the reference group; therefore, point estimates of effect measures from the published results have been inverted where necessary.

We did not analyse the effectiveness of interventions to improve neonatal survival using meta-analysis because study designs were too variable (The Cochrane Collaboration 2011). Instead, the quality of the extracted papers was reviewed thematically. For studies using a randomised trial or controlled before-and-after design, quality was assessed using the Cochrane EPOC risk of bias checklist (Cochrane Effective Practice & Organisation of Care Group, 2013). Areas assessed included generation of allocation sequence, concealment of allocation, similarity in baseline outcome measurements and other characteristics, incomplete outcome data, masking, protection against contamination for cluster designs and selective outcome reporting. Each domain was assessed as ‘done’, ‘not done’ or ‘not clear’ suggesting low, high or unclear risk of bias, respectively. For case–control and cohort studies, quality was assessed using Newcastle–Ottawa quality assessment scale (Wells et al. 2011). The scale uses a star system in which a study is judged on three perspectives: the selection of the study groups (one star can be allocated to each item), the comparability of the groups (up to two stars can be allocated) and the ascertainment of either the exposure or outcome of interest for case–control or cohort studies, respectively (one star can be allocated to each item). Thus, scores on this scale range from zero to nine stars. Finally, the quality of the evidence for each outcome was then assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria (Guyatt et al. 2008).

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Included studies

Eleven papers met the inclusion criteria; the search results are summarised in Figure 2. Of the 27 full-text articles extracted, 16 were excluded as they did not meet the study inclusion criteria, leaving 11 papers to be reviewed. We viewed the evidence for the effectiveness of the recommended newborn care behaviours on neonatal health to fall into two groups: practice of and training practitioners in the practice or promotion of recommended behaviours (Figure 1). The results are presented by these three groups and subsequently grouped by the recommended behaviour as described in Table 1.

image

Figure 2. PRISMA flow chart.

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The 11 papers reviewed represent 9 unique studies from community and facility settings, published between 2005 and 2013, from eight countries in sub-Saharan Africa. In Table 3, we describe the context of each study, and in Table 4, we summarise the main analysis and results. Five of the papers reported the association between practice of newborn care behaviours and neonatal outcomes (Mosha et al. 2005; Edmond et al. 2006, 2007, 2008; Gitta et al. 2006). Of these five, four were observational studies examining the associations between reported newborn care behaviours and mortality (one case–control study of cleanliness during delivery and three reports on a cohort study of breastfeeding practices) and one was a cluster RCT of clean delivery kits. The remaining six papers reported findings of trials involving training others to promote and practise essential newborn care behaviours (Worku & Kassie 2005; Nagai et al. 2010; Gill et al. 2011; Matendo et al. 2011; Kirkwood et al. 2013; Lewycka et al. 2013). Of these six, two were RCTs examining the effect of the timing of implementing Kangaroo Mother Care (KMC, see further explanation below) on neonatal mortality for LBW babies. Four were cluster RCTs of the effect of training practitioners to promote and practise a combination of essential newborn care behaviours on neonatal and early neonatal mortality. No papers were found that examined the impact of practicing or practitioners undertaking training in thermal care, resuscitation, eye care, immunisation or management of illness, although these care elements are included in some of the combined interventions. No studies were found of the impact of sleeping under a bed net or the use or steroids during preterm labour on neonatal survival. Study sample sizes ranged from 73 (Nagai et al. 2010) to 18 744 live births (Lewycka et al. 2013).

Table 3. Outline of studies included
First author, yearCountry, settingBehaviour/interventionOutcomes of interestStudy designSample size
Practice of behaviours
Gitta 2006Uganda, communityClean deliveryNeonatal tetanusCase–control24 cases who could be traced and 96 matched controls
Mosha 2005Tanzania, community

Use of clean delivery kit (primary analysis)

Applying substances to the cord (secondary analysis)

Neonatal infection – cord infectionCluster RCT3262 women
Edmond 2006Ghana, communityEarly and exclusive breastfeedingNeonatal mortalityProspective observational cohort10 947 singleton babies surviving to day 2, including 145 neonatal deaths from days 2–28
Edmond 2007Ghana, communityEarly and exclusive breastfeedingNeonatal mortality – infectionProspective observational cohort10 942 breastfed singleton babies who survived to day 2
Edmond 2008Ghana, communityEarly and exclusive breastfeedingNeonatal mortality – LBWProspective observational cohort3411 babies with weight measured within 2 days, of which 296 (8.7%) were <2.5 kg. (Therefore, deaths on day 1 and non-breastfeeders excluded.) 15 LBW babies died
Training in promotion and practice of behaviours
Nagai 2009Madagascar, facilityEarlier (within 24 h delivery) vs. later (at least 48–72 h after delivery) KMC for LBW babiesNeonatal mortality for LBWRCT37 cases (earlier KMC), 36 control (later KMC)
Worku 2005Ethiopia, facilityKMC for LBW babiesNeonatal mortality for LBWRCT62 cases (received KMC), 61 control (conventional care)
Gill 2011Zambia, communityTBA Training in neonatal resuscitation and recognition of signs of sepsis and provision of antibiotics and resuscitator mask with facilitated referral for ill neonates vs. basic newborn care and clean delivery training. Intervention and control received clean delivery kitsNeonatal mortalityCluster RCT60 TBAs received training, 60 TBAs did not (controls). TBAs attended 3559 mothers/babies (2007 intervention and 1552 control) of which 3497 had reliable data for analysis
Matendo 2011Democratic Republic of Congo, facility and communityEssential newborn care training followed by neonatal resuscitation programme training of birth attendants (traditional birth attendants, nurses and nurse midwives)Early neonatal mortalityCluster RCT of neonatal resuscitation programme with active baseline of essential newborn care training. Before and after essential newborn care training also analysed

1867 births at baseline.

5528 births after essential newborn care training (active baseline). 2928 births were in intervention group (neonatal resuscitation programme training)

3365 births were in control group

Kirkwood 2013Ghana, communityCommunity volunteers trained to visit women at home during pregnancy and the early post-natal period to promote essential newborn care practices, weigh and assess babies for danger signs and refer as necessaryNeonatal mortalityCluster RCTMore than 800 volunteers were trained. 16168 live births (7977 in intervention areas and 8191 in control areas) occurred during the study period; the status of 15619 (97%) were known at 1 month
Lewycka 2013Malawi, communityTwo interventions: a) women's groups to identify and tackle maternal and child health priorities and b) volunteer peer counsellors conducting home visits during pregnancy, neonatal and infant periodNeonatal mortality2 × 2 factorial cluster RCT207 women's groups were established and 72 volunteer counsellors made home visits. The study involved 18 744 live births
Table 4. Outline of study findings
First author, yearComparison groupIntervention groupEstimate of effectIf multivariate analysis, adjusted for which variablesComments
Practice of behaviours
Gitta 2006Neonates with tetanusNeonates without tetanusTetanus vs. born on clean surface, OR 38.8 (95% CI 2.9–518.1)Parity, birth attendant, use of intravaginal substances, type of cord tie used, 1 or 2 doses of tetanus toxoid during pregnancy 
Mosha 2005

Non-users of clean delivery kit

Babies with substances applied to the cord

Users of clean delivery kit

Babies with nothing applied to the cord

Neonatal infection vs. clean kit use, OR 12.6 (95% CI 5.0–32.1).

Risk of cord infection vs. putting nothing on the cord, OR 1.6 (95% CI 0.8–3.3)

Applying substances to the cord, bathing before delivery, shaving before delivery and place of delivery

Use of delivery kit, bathing before delivery, shaving before delivery and place of delivery

No information on essential aspects of study, including the number of women in intervention and control arms, the number of women provided with or using kits or number of cases of cord infection
Edmond 2006Babies who had been breastfed after first day of birthBabies who had been breastfed within first day of birthNeonatal mortality vs. initiation <1 day OR 2.9 (95% CI 1.8–4.4). Effect sizes were similar when analyses repeated to exclude babies at higher risk of death and ill health, and deaths during first week. Also risk increased with increasing delay of breastfeeding.Gender, birth size, gestational age, presence of a congenital anomaly, health on the day of birth, health at the time of interview, mother's health at the time of delivery, age of mother, parity, educational level of mother, mother having cash income, household water supply, place of defecation, number of antenatal visits, place of birth, birth attendant and established breastfeeding pattern 
Babies who had been partially breastfedBabies who had been exclusively breastfedNeonatal mortality vs. exclusively breastfed babies OR 3.8 (95% CI 2.0–7.3)
Babies who had been fed pre-lacteal feeds on day of birthBabies who had not been given pre-lacteal feedsNeonatal mortality vs. no pre-lacteal feeding OR 1.6 (95% CI 1.1–2.5)
Edmond 2007Babies who had been breastfed after first day of birthBabies who had been breastfed within first day of birthInfection-specific neonatal mortality vs. initiation of breastfeeding <1 day OR 2.6 (95% CI 1.7–4.0). Also risk increased with increasing delayMaternal educational level, maternal cash income, water supply, sanitation, overcrowding, antenatal care, delivery attendant, site of delivery, maternal ethnicity, maternal age, parity, maternal perinatal health, neonate sex, congenital abnormalities, gestational age, neonate size at birth, neonate perinatal, health and other breastfeeding practices. 
Babies who had been partially breastfedBabies who had been breastfed exclusively breastfedInfection-specific neonatal mortality vs. exclusively breastfed babies, OR 5.7 (95% CI 2.8–11.9)
Babies who had been fed pre-lacteal feeds on day of birthBabies who had not been given pre-lacteal feedsInfection-specific neonatal mortality vs. no pre-lacteal feeding, OR 1.1 (95% CI 0.7–1.9)
Edmond 2008Babies who had been breastfed after first day of birthBabies who had been breastfed within first day of birthNeonatal mortality in LBW babies vs. initiation <1 day, OR 3.2 (95% CI 1.1–9.8). Also risk increased with increasing delay (P = 0.02)Maternal educational level, sanitation, site of delivery, maternal age, maternal perinatal health, parity, multiple births, infant gender and infant perinatal health 
Babies who had been partially breastfedBabies who had been breastfed exclusively breastfedSample size too small to assess risk
Babies who had been fed pre-lacteal feeds on day of birthBabies who had not been given pre-lacteal feedsNeonatal mortality for LBW babies vs. no pre-lacteal feeds, OR 3.1 (95% CI 1.2–8.2)
Training in promotion and practice of behaviours
Nagai 2009Later KMC (after 24 h post-birth)Earlier KMC (within 24 h post-birth)Neonatal mortality vs. earlier KMC, risk ratio 0.5 (95% CI 0.1–5.6)  
Worku 2005Conventional care (generally includes: an artificial warming system (heated room overhead lamp warmers), oxygen therapy, breast, tube, cup or mixed feeding.Earlier KMC (within 24 h post-birth)Neonatal mortality 22.5% for early KMC vs. 38% for conventional care, P < 0.05  
Gill 2011Traditional birth attendants used existing standard of care (basic obstetric skills and clean delivery kits)Training traditional birth attendants in modified version of the neonatal resuscitation protocol, and single-dose amoxicillin coupled with facilitated referral of infants to a health centre.Neonatal mortality vs. babies born to intervention traditional birth attendants, rate ratio 1.8 (95% CI 1.1–3.0)ClusteringMost reduction in deaths seems to be from reduced intrapartum-related mortality (down by 70% in intervention areas), despite common use of antibiotics and increased referrals in intervention areas
Matendo 2011Birth attendants not trained in neonatal resuscitationBirth attendants trained in neonatal resuscitationPost-neonatal resuscitation programme training early neonatal mortality rates: intervention = 16, control = 17 rate ratio comparison vs. intervention 1.1 (95% CI 0.6–2.1) A two-step intervention, the second step implemented using a design included in this review. Outcome measured after completion of training in each intervention, also outcome measured every 3 months in year following initial training. Data collected by birth attendants. Although not an outcome of interest to this review, it is notable that there was significant decline in perinatal mortality in the year after essential newborn care training, after adjustment for birth attendant and place of birth (before vs. after relative risk 1.37 (95% CI 1.04–1.79).
Kirkwood 2013Routine maternal and child careRoutine care plus community volunteers made home visit to women during pregnancy and early neonatal periodNeonatal mortality vs. infants born in intervention areas, relative risk 1.1 (95% CI 0.9–1.3)Clustering 
Lewycka 2013  Neonatal mortality at years 2 and 3:Cluster-level baseline values, socioeconomic quintile and parityStudy aims included improving maternal and infant health outcomes, as well as neonatal health
No intervention or peer counsellingWomen's groups to identify and implement maternal and child health improvementsNeonatal mortality in comparison areas vs. Women's groups areas only, adjusted OR 1.7 (95% CI 1.0–2.8)
No intervention or women's groupsVolunteer peer counsellors conducting home visits during pregnancy and post-deliveryNeonatal mortality in comparison areas vs. peer counselling only, adjusted OR 1.3 (95% CI 0.8–2.1)
No interventionBoth interventionsNeonatal mortality in comparison areas vs. women's groups and peer counselling, adjusted OR 1.0 (0.7–1.6)

Risk of bias

We assessed the risk of bias in every paper (Tables 5-7). For the seven papers assessed using EPOC (Table 5), four were considered to be at low risk of bias for the majority of domains (Nagai et al. 2010; Gill et al. 2011; Kirkwood et al. 2013; Lewycka et al. 2013). Only one study was considered to be at high risk of bias in several domains (Mosha et al. 2005), and key information missing in this paper was found in another publication from the same study that did not meet the search criteria for this review (Winani et al. 2007). Worku & Kassie 2005 did not report the adherence of participants to the intervention in their RCTs. Matendo et al. (2011) did not report newborn care behaviours so it is unclear whether the lack of impact on mortality was due to a lack of behaviour change by the birth attendants or family members. Only two of the RCTs reported baseline outcome measurements (Kirkwood et al. 2013; Lewycka et al. 2013). The five papers assessed using the Newcastle–Ottawa scale scored between six and eight stars, thus appeared to be at low risk of bias (Table 6). Overall, evidence for the practice of recommended newborn care behaviours reducing neonatal mortality and early neonatal mortality was of high quality, but for infections and mortality in LBW babies was of mixed quality (Table 7). The three papers on the large cohort study examining the effects of breastfeeding practices were upgraded from moderate to high quality owing to the large effect sizes and dose responses seen. The RCT of clean delivery kits was considered to be low quality. The two RCTs of KMC were small and had few mortality cases, so were reduced from high to moderate quality. The cluster RCTs of interventions training practitioners to promote or practise recommended newborn care behaviours were all considered to be of high quality.

Table 5. Risk of bias according to EPOC checklist for individually randomised controlled trials, cluster randomised controlled trials, non-randomised cluster trials and controlled before and after studies
EPOC CriterionRisk of biasa
Nagai 2009Worku 2005Mosha 2005Gill 2011Matendo 2011bKirkwood 2013Lewycka 2013
  1. a

    Author's judgement, rated as high low or unclear.

  2. b

    Resuscitation training component only. Carlo et al. (2010) also examined for further details of study.

Allocation generationLowLowUnclearLowUnclearLowLow
Allocation concealmentLowUnclearUnclearLowUnclearLowLow
Baseline outcome measurementUnclearUnclearUnclearUnclearUnclearLowLow
Baseline characteristics measurementLowLowHighLowHighLowLow
Follow-up of patients/address incomplete outcome dataLowUnclearUnclearLowLowLowLow
Prevention of knowledge of allocated interventionUnclearUnclearHighUnclearUnclearUnclearUnclear
Protection against contaminationLowLowLowLowLowLowLow
Non-selective outcome reportingLowHighHighLowHighLowLow
Free from other biasesLowUnclearHighLowLowLowLow
Table 6. Newcastle–Ottawa quality assessment of cohort and case–control studies
Study typeFirst author, yearDimension ItemAssessmentRating of assessmenta
  1. a

    The scale judges a study on three perspectives: the selection of the study groups (one star can be allocated to each item), the comparability of the groups (up to two stars can be allocated) and the ascertainment of either the exposure or outcome of interest for case–control or cohort studies, respectively (one star can be allocated to each item). Thus, total scores can range from zero (high risk of bias) to nine stars (low risk of bias).

Case–control studies
 Gitta 2006Selection
  Adequate case definitionYes, independently validated*
  Cases representativeConsecutive or obviously representative series of cases*
  Selection of controlsCommunity controls*
  Definition of controlsControls not necessarily without history of disease 
  Comparability
   Comparability of cases and controls on the basis of design or analysisStudy controls for known risk factors for neonatal tetanus, delivery characteristics and demographic variables**
  Exposure
  Ascertainment of exposureInterview not blind to case–control status 
  Same method of ascertainment for cases and controlsYes*
  Non-response rateNot described for controls 
  Total Score 6
Cohort Studies
 Edmond 2006Selection
  Representativeness of the exposed cohortTruly representative of all the singleton infants born in the study area between 01 July 2003 and 30 June 2004, who initiated breastfeeding, and survived to day 2, and whose mothers were visited by the research team in the neonatal period*
  Selection of the non-exposed cohortDrawn from the same community as the exposed cohort*
  Ascertainment of exposureStructured interview*
  Demonstration that outcome of interest was not present at start of studyYes*
  Comparability
  Comparability of cohorts on the basis of design or analysisStudy controls for demographic, socioeconomic, health, antenatal, delivery and other breastfeeding factors.**
  Outcome
  Assessment of outcomeSelf-report 
  Long enough follow-up for outcomes to occurYes*
  Adequacy of follow-up of cohortsSubjects lost to follow-up unlikely to introduce bias – small number lost – Data were captured for 11 316 (82%) of the 13 860 singleton births within 28 days of delivery. 106 (0.9%) of the day-2 singleton survivors were excluded as either they did not initiate breastfeeding or started then stopped, plus 154 (1.4%) whose mothers moved out of the study area before the second interview conducted within month 2. Overall follow-up rate >95%*
  Total Score 8
 Edmond 2007Selection 
  Representativeness of the exposed cohortTruly representative of all the singleton infants born in the study area between 01 July 2003 and 30 June 2004, who initiated breastfeeding, and survived to day 2, and whose mothers were visited by the research team in the neonatal period*
  Selection of the non-exposed cohortDrawn from the same community as the exposed cohort*
  Ascertainment of exposureStructured interview*
  Demonstration that outcome of interest was not present at start of studyYes*
  Comparability
  Comparability of cohorts on the basis of design or analysisStudy controls for demographic, socioeconomic, health, antenatal, delivery and other breastfeeding factors.**
  Outcome
  Assessment of outcomeSelf-report 
  Long enough follow-up for outcomes to occurYes*
  Adequacy of follow-up of cohortsSubjects lost to follow-up unlikely to introduce bias – small number lost – Data were captured for 11 316 (82%) of the 13 860 singleton births within 28 days of delivery. 106 (0.9%) of the day-2 singleton survivors were excluded as either they did not initiate breastfeeding or started then stopped, plus 154 (1.4%) whose mothers moved out of the study area before the second interview conducted within month 2, plus 5 babies who died but for whom a verbal autopsy was not conducted. Overall follow-up rate >95%*
  Total Score 8
Edmond 2008Selection 
  Representativeness of the exposed cohortTruly representative of all the low-birthweight singleton infants born in the study area between 01 July 2003 and 30 June 2004, who initiated breastfeeding, and survived to day 2, and whose mothers were visited by the research team in the neonatal period*
  Selection of the non-exposed cohortDrawn from the same community as the exposed cohort*
  Ascertainment of exposureStructured interview*
  Demonstration that outcome of interest was not present at start of studyYes*
  Comparability
  Comparability of cohorts on the basis of design or analysisStudy controls for demographic, socioeconomic, health, antenatal, delivery and other breastfeeding factors.**
  Outcome
  Assessment of outcomeSelf-report 
  Long enough follow-up for outcomes to occurYes*
  Adequacy of follow-up of cohorts

Of 11 344 breastfed infants who survived to day 2 and for whom data collected within neonatal period, 70% did not have recorded birthweight.

Follow-up rate 30% and no description of those lost

 
  Total Score 7
Table 7. Summary of findings and evidence quality
InterventionImpactN studiesQuality of the evidence (GRADE)
  1. a

    The evidence of the three analyses (two individual interventions and one combined intervention) from Lewycka et al. (2013) is listed separately.

Outcome: Neonatal mortality
Early and exclusive breastfeedingEarly and exclusive breastfeeding is associated with lower neonatal mortality compared with later initiation, giving pre-lacteal feeds or mixed feeding1High
Training TBAs in resuscitationNeonatal mortality rate was lower following TBA training1High
Training volunteers to undertake home visits during pregnancy and after deliveryNeither study showed evidence of an impact of trained volunteers conducting home visits to promote recommended newborn care on neonatal mortality2aHigh
Women' groups established to tackle maternal and child health issuesNeonatal mortality was lower following the establishment of women's groups1aHigh
Trained volunteers conducting home visits plus women's groupsNo reduction in neonatal mortality in areas receiving volunteer home visits and where women's groups established1aHigh
Outcome: Early neonatal mortality
Birth attendants trained to conduct newborn resuscitationNo change in mortality following birth attendant training1High
Outcome: Neonatal infection or infection-specific neonatal mortality
CleanlinessClean delivery and cord care are associated with a lower risk of neonatal infection2Low
Early and exclusive breastfeedingEarly and exclusive breastfeeding is associated with lower infection-specific neonatal mortality compared with later initiation, giving pre-lacteal feeds or mixed feeding1High
Outcome: Neonatal mortality in LBW babies
Early and exclusive breastfeedingEarly and exclusive breastfeeding is associated with lower neonatal mortality in LBW babies compared with later initiation or giving pre-lacteal feeds1High
Kangaroo mother careOne study found early KMC for LBW babies was associated with a lower risk of neonatal mortality compared with conventional care, but another study comparing early and late initiation of KMC found no impact of early initiation. Both RCTs were limited by small sample sizes and few mortality cases2Moderate

Practice of recommended behaviours

Cleanliness

A case–control study from Uganda identified several risk factors for neonatal tetanus, including two that related to cleanliness during delivery (Gitta et al. 2006). Mothers of neonates with tetanus were more likely to have delivered on an unclean surface [OR 6.7 (95% CI 2.1–21.3)] or their birth attendant not to have worn gloves [OR 3.8 (95% CI 1.1–13.1)]. After accounting for parity, birth attendant, type of cord tie and number of tetanus toxoid injections, babies whose mothers delivered on an unclean surface were almost 40 times more likely to have tetanus than babies of mothers who delivered on a clean surface [OR 38.8 (95% CI 2.9–518.1)]. Conversely to what had been found in other studies, the use of substances intravaginally (here, most commonly herbs or burnt snake skin or snail shells) was associated with a reduced risk of neonatal tetanus in both bivariate and multivariate analyses. The authors postulate that the substances commonly used might have antibacterial properties (Gitta et al. 2006).

A paper by Mosha et al. (2005) described a cluster RCT in Tanzania of the distribution of clean delivery kits (including a plastic sheet, clean razor blade, string to tie the umbilical cord, bar of soap and information on neonatal and maternal infections) alongside health education, looking at the effect on cord infection and puerperal sepsis rates. The results suggested babies of non-users of delivery kits were more like to have had a cord infection [OR 12.6 (95% CI 5.0–32.1)], and babies who had had substances applied to the cord were no more likely to get a cord infection than babies who had had nothing applied to the cord [OR 1.6 (95% CI 0.8–3.3)].

However, there was no information on or reference to essential aspects of the study, including the number of women in intervention and comparison arms, what care women in comparison arms received, the number of women provided with or using kits or number of cases of cord infection; therefore, the evidence from this study was considered to be at high risk of bias (Table 5) (Mosha et al. 2005). However, a paper published later from the same study by Winani et al. (2007), which was identified in the review process but did not meet the search criteria, provided some of the key information needed to allow more reliable interpretation of the study by Mosha et al. (2005). According to Winani et al. (2007), a total of 3262 women were enrolled in the study and were given a delivery kit, of whom 59% used the full kit or at least one part of the kit. There were 56 cases (1.7%) of cord infection. Here, not using a clean delivery kit [OR 13.1 (95% CI 5.16–33.53)] was both associated with a higher risk of neonatal cord infection in multivariate analyses (adjusted for place of delivery and other hygiene practices) and associated with reduced risk of puerperal sepsis for the mothers (Winani et al. 2007).

Early and exclusive breastfeeding

Edmond et al. published three papers on the association between early and exclusive breastfeeding and neonatal mortality. Each paper was secondary analysis of data from a cohort of participants from one large RCT of maternal vitamin A supplementation in rural Ghana involving all women of childbearing age and their children.

The first paper reported the association between timing and type of breastfeeding on neonatal mortality as a whole in a cohort of 10 947 breastfed singleton babies who survived to day two and whose mothers were visited in the neonatal period (Edmond et al. 2006). Type of breastfeeding was classified into ‘exclusive’, meaning feeding of only breast milk and nothing else except for vitamin supplements and prescribed medicines, ‘predominant’, meaning feeding of breast milk along with other non-milk fluids, or ‘partial’, meaning infants were offered breast milk and animal milk, infant formula or solids. In addition, the effect of pre-lacteal feeding, meaning feeding any non-human milk food or fluids on the first day of life, was examined. There were 145 neonatal deaths between day 2 and day 28. Breastfeeding was initiated within one day of birth in 71% of infants and by the end of day 3 in all but 1.3% of them; 70% of babies were exclusively breastfed during the neonatal period. The risk of neonatal mortality was higher for babies who were partially breastfed compared with those exclusively breastfed [OR 3.8 (95% CI 2.0–7.3)] and for babies whose breastfeeding initiation was delayed (initiation more than one day after delivery OR 2.9 (95% CI 1.9–4.4) and a dose response of increasing risk of neonatal mortality with increasing delay in initiation of breastfeeding from one hour to day seven). Infants who were given pre-lacteal feeds also had a higher neonatal mortality [OR: 1.6; 95% CI: 1.1–2.5)], although the authors do not report the number of babies given pre-lacteal feeds. Analyses were adjusted for demographic, socioeconomic, antenatal, delivery and health factors (Edmond et al. 2006).

The second paper used the same cohort of babies, this time looking at the association between timing or type of breastfeeding and infection-specific mortality, to try to understand the relationship seen in the earlier study and to propose a causal pathway (Edmond et al. 2007). Using verbal autopsies, of the 140 neonatal deaths, 93 were classified as dying from infections. The risk of death as a result of infection increased with increasing delay in initiation of breastfeeding after birth from 1 h to day seven. Compared with initiating breastfeeding within one day, the OR of infection-specific neonatal mortality after day one was 2.6 (95% CI 1.7–4.0) after adjusting for demographic, socioeconomic, antenatal, delivery, neonatal and other breastfeeding factors. Partial breastfeeding was associated with a large increased risk of death from infectious disease compared with exclusive breastfeeding [OR 5.7 (95% CI 2.8–11.9)]. No obvious associations were observed between these feeding practices and non-infection-specific mortality. There was no evidence of association between pre-lacteal feeding and either infection- or non-infection-specific mortality (Edmond et al. 2007).

The third paper reported the risk of neonatal mortality in LBW babies in relation to timing of, type of and pre-lacteal breastfeeding (Edmond et al. 2008). Of the 11 787 breastfed babies (including non-singleton babies), there were 296 babies of birthweight less than 2.5 kg, of whom 15 died between day 2 and 28. Compared with initiation within one day, initiation of breastfeeding after day one and pre-lacteal feeding were found to be both associated with a threefold increased mortality risk (late feeding initiation OR 3.2 (95% CI 1.1–9.8), pre-lacteal feeding OR 3.1 (95% CI 1.2–8.2). There was no evidence of association with predominant breastfeeding and no modifications of effects by birthweight. The sample size was insufficient to allow assessment of the impact of partial breastfeeding (Edmond et al. 2008).

Training in promotion and practice of recommended behaviours

Care of preterm or LBW baby

Care of the preterm or LBW baby includes good thermal protection and breastfeeding. Therefore, the evidence from the sections on thermal care and breastfeeding already described may also contribute evidence to this section, although the studies described do not exclusively include preterm or LBW babies. Here, we describe additional evidence that comes from studies including only preterm or LBW babies.

The most common intervention reported for the care of preterm or LBW babies is KMC. This is defined as early, prolonged and continuous skin-to-skin contact between a carer, primarily mother, and newborn LBW infant, both in hospital and after early discharge, until at least equivalent to the 40th week of gestational age. The mother keeps her newborn infant between the breasts, in close contact with her body and covered with her clothes day and night. The baby wears only a nappy and a bonnet or hat. Breastfeeding is the standard feeding method. However, as some premature babies are unable to suck, the mother can also feed her baby with milk using a tube or cup if needed. KMC enables care to be provided for preterm or LBW babies where incubators are not available. It also reduces the cost of care and increases the likelihood of survival as a result of better thermal control, promotion of breastfeeding and protection from cross- and hospital infections. Lastly, it can result in a lower risk of apnoea episodes due to continuous skin-to-skin stimulation, improved well-being of the baby and improved bonding (WHO 2003; Worku & Kassie 2005).

An RCT of early KMC (KMC initiated within 24 h of birth) vs. conventional care (artificial warming system (heated room with overhead lamp warmers), oxygen therapy, and breast, tube, cup or mixed feeding) for LBW infants in Ethiopia included 123 babies (47.5% of the LBW babies admitted to the neonatal unit of the hospital in a 1-year period), 62 randomised to receive KMC and 61 to receive conventional care (Worku & Kassie 2005). Significantly fewer babies died who received KMC (22.5%) compared with conventional care (38%).

Nagai et al. (2010) added further to the evidence, looking at the effect of KMC timing on mortality in LBW neonates. A total of 73 LBW infants (37 receiving early KMC (within 24 h of birth) and 36 receiving later KMC (conventional care followed by KMC after 24 h after birth) were included in a facility-based RCT (Nagai et al. 2010). There was no evidence of a higher risk of mortality for infants receiving early KMC [risk ratio, 2.0 (95% CI 0.2–20.5)]. This was probably due to the low number of deaths recorded in this small sample size (two deaths in the early KMC group and one in the later KMC group), which limited the analyses and interpretation possible.

In both studies, the eligibility criteria meant a large proportion of LBW babies were excluded, even when non-stable babies were included (Worku & Kassie 2005), and the vast majority of deaths occurred in the excluded babies. This limited the analyses undertaken, but it would not have been possible to include more babies as many were severely ill and could not have undertaken KMC.

Combined interventions

Matendo et al. (2011) reported the findings of a study conducted in the Democratic Republic of Congo to assess the impact of birth attendants (traditional birth attendants and midwives) undertaking the Essential Newborn Care course followed by the Neonatal Resuscitation Programme (American Academy of Pediatrics 2012) on several outcomes, including early neonatal mortality. The WHO Essential Newborn Care course covers universal precautions and cleanliness, routine neonatal care, resuscitation, thermoregulation, breastfeeding, KMC, care of small infants and common illnesses (WHO 2010). The impact of the Essential Newborn Care course was assessed using a before and after design, and the impact of training in Neonatal Resuscitation was assessed using a cluster RCT design. There was no evidence of association between early neonatal mortality and either Essential Newborn Care training [rate ratio pre vs. post 1.0 (95% CI 0.7–1.3)] or Neonatal Resuscitation Programme training [rate ratio comparison vs. intervention 1.1 (95% CI 0.6–2.1)]. The authors did not report the frequency of family members or birth attendants practising any newborn care behaviours during the intervention period (Matendo et al. 2011).

Gill et al. (2011) reported the findings of a cluster RCT of training traditional birth attendants (TBAs) in a modified version of the neonatal resuscitation programme, identifying potential cases of neonatal sepsis and administering single-dose amoxicillin coupled with facilitated referral for suspected cases to a health centre vs. standard care (basic obstetric skills and clean delivery kits). Trained TBAs (n = 60) attended 1920 deliveries and reported drying the baby and swaddling in a fresh dry blanket and clearing airways in nearly all cases. 215 babies were referred to a health centre by intervention TBAs and 85 babies in the comparison group (rate ratio of being referred by intervention compared with comparison birth attendant 2.0, 95% CI 1.6–2.5). Intervention TBAs administered amoxicillin on 202 occasions. Neonatal mortality was 45% lower in intervention areas [rate ratio comparison TBAs vs. intervention TBAs 1.8 (95% CI 1.1–3.0)], mainly owing to reduced deaths from intrapartum-related mortality (Gill et al. 2011).

Kirkwood et al. (2013) reported the findings of a cluster RCT in Ghana where community volunteers were trained to visit pregnant women during pregnancy and the early neonatal period to promote essential newborn care practices, weigh and assess babies for danger signs and refer babies to health facilities as necessary. More than 400 volunteers were trained and visited 4358 women (72% of women for whom coverage data were available) at least once during pregnancy and 3815 women (63% of women for whom coverage data were available) at least once during the neonatal period. The intervention increased ten of the twelve essential newborn care behaviours reported. Care seeking for newborn babies had the greatest increase with 102 (77%) of 132 sick babies in intervention zones taken to a hospital or clinic compared with 77 (55%) of 139 in control zones (relative risk (RR) 1.4, 1.2–1.8). Other behaviours occurred more frequently in intervention areas included money saved for delivery or emergency [5730 (86%) of 6681 vs. 5525 (80%) of 6941, respectively; RR 1.1 (95% CI 1.1–1.1)], birth assistant for home delivery washed hands with soap [1853 (93%) of 1992 vs. 1817 (87%) of 2091, respectively; RR 1.1 (95% CI 1.0–1.1)], initiation of breastfeeding in less than 1 h of birth [3743 (49%) of 7673 vs. 3280 (41%) of 7921, respectively; RR 1.2 (95% CI 1.1–1.4)], skin-to-skin contact [3355 (44%) vs. 1931 (24%), respectively; RR 2.30 (95% CI 1.9–2.9)] and first bath delayed for longer than 6 h [3131 (41%) vs. 2269 (29%), respectively; RR 1.7 (95% CI 1.3–2.1)]. Only the coverage of only four or more antenatal-care visits and delivery in a facility were not higher in intervention areas. There was little evidence of an effect on neonatal mortality [neonatal mortality rates were 29.8 and 31.9 per 1000 live births, respectively RR 0.9 (95% CI 0.8–1.1)] (Kirkwood et al. 2013).

Lewycka et al. (2013) reported findings of a 2 × 2 factorial, cluster RCT of two interventions in rural Malawi to improve maternal and child health, including neonatal mortality. The first intervention was the establishment of women's groups which, under the guide of trained facilitators, met to identify and prioritise maternal and child health problems, identified strategies to implement, and implemented and assessed the strategies. The second intervention was the training of volunteer peer counsellors to identify and visit women at home five times during pregnancy, early after delivery and up to five months after delivery. Volunteers counselled women on breastfeeding, infant care, immunisations, prevention of mother to child transmission of HIV and family planning. They also supported women with breast problems and raised awareness of timely care seeking. During the intervention, 207 women's groups were established and 72 volunteer counsellors made home visits. The study involved 18 744 live births. Looking at outcomes from years two and three of the intervention (i.e. excluding the first year when interventions were established), after adjusting for cluster-level baseline outcomes, socioeconomic quintile and parity, neonatal mortality rates were lower in areas with the women's group only [OR 0.6 (95% CI 0.4–0.9)] than in other areas. However, rates were not lower in areas with peer counselling only [OR 0.8 (95% CI 0.5–1.3)] or areas with both women's groups and peer counsellors [OR 1.0 (95% CI 0.6–1.5)]. A number of newborn care behaviours were examined. Comparing each individual intervention with comparison areas, there were no improvements in the recommended neonatal care practices of interest in this review, including birth attendant washing hands or wearing gloves, wrapping the baby within 30 min of delivery and immunisation (Lewycka et al. 2013).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Although 1.1 million African babies die each year before reaching the age of 28 days (Liu et al. 2012), and evidence-based best practices are known, we found just 11 papers published since 2005 reporting the association between the practice or promotion of newborn care behaviours and newborn survival or one of the main causes of neonatal mortality in the region. Observational and intervention studies showed evidence that clean delivery practices, early and exclusive breastfeeding, implementation of women's groups to facilitate local improvements in maternal and child health and training birth attendants in neonatal resuscitation coupled with antibiotic provision are associated with a reduced risk of neonatal mortality, early neonatal or the main causes of neonatal mortality in sub-Saharan African settings. In addition, there is some evidence that KMC and early initiation of breastfeeding can reduce deaths in LBW babies. These studies found a range of effect sizes. Non-early and exclusive breastfeeding was associated with an increased likelihood of neonatal mortality of between 1.6 and 5.7 times. Early KMC was associated with a 15.5 percentage point reduction in neonatal mortality rate in LBW babies compared with conventional care. Compared with areas where birth attendants had been trained in neonatal resuscitation and equipped with antibiotics, the rate of neonatal mortality was 1.8 times higher. Compared with areas without women's groups identifying and implementing maternal and child health improvements, the likelihood of neonatal mortality was 1.7 times higher. In addition, unclean newborn care practices were associated with between 1.6 and 38.8 times higher likelihood of neonatal infections.

There was no evidence that training birth attendants in neonatal resuscitation or community volunteers to promote recommended newborn care behaviours and check for newborn danger signs reduced neonatal mortality. With just six randomised trials, two of which were hospital based, there is a striking need for more evidence to guide policy.

For many of the individual newborn care behaviours, the study design and sample sizes mean that the evidence for their association with neonatal mortality still needs to be treated with caution. Most studies were found to be at low risk of bias. However, we noted papers often omitted to present a key process measure; only two of the six randomised studies reported baseline outcome measurements, which is one of the EPOC assessment criteria. Some studies were not adequately powered for a mortality outcome (Worku & Kassie 2005; Nagai et al. 2010; Kirkwood et al. 2013). Other studies failed to report frequencies of behaviours following training in recommended newborn care (Matendo et al. 2011). A number of studies were excluded from this review because the design did not include a comparison group or the outcomes were not neonatal mortality, or one its main causes.

Our review of evidence from sub-Saharan Africa supports findings from other geographical regions of the association between several recommended neonatal care behaviours on neonatal mortality, including KMC for low-birthweight babies (Conde-Agudelo et al. 2011), early and exclusive breastfeeding (Mullany et al. 2008), and hygiene during delivery (Rhee et al. 2008).

Gill et al. (2011), Matendo et al. (2011), Kirkwood et al. (2013) and Lewycka et al. (2013) are, to date, the only four published results of trials in sub-Saharan Africa of packaged interventions promoting better newborn care to improve neonatal survival. Two of these interventions resulted in measurable reductions in mortality. In contrast, several large-scale RCTs in South-East Asia report the impact on survival of training community health workers to conduct home visits to promote recommended newborn care and to identify and treat or refer sick newborns (Bang et al. 2005; Baqui et al. 2008a,b; Bhutta et al. 2008, 2011; Kumar et al. 2008; Darmstadt et al. 2010; Bhandari et al. 2012). Kirkwood et al. (2013) highlighted that their report of an estimated 8% reduction in neonatal mortality was compatible with reductions seen in three other trials of comparable interventions conducted in South-East Asia. Individually, these studies were underpowered to detect the reductions seen, and only one showed a statistically significant reduction in neonatal mortality. When combined, the four trials had sufficient power, and the overall summary estimate was less than 1 (OR 0.9 (95% CI 0.8–1.0), representing a significant reduction in neonatal mortality of 12% (95% CI 5–18%).

We identified evidence that non-clinical personnel working outside the health facility setting delivered effective interventions that are conventionally conducted in health facilities (Gill et al. 2011). Given the human resource limitations in many rural health systems in sub-Saharan Africa (Mathauer & Imhoff 2006), and the renewed interest in community health workers (Haines et al. 2007; WHO & UNICEF 2009), our findings support the idea that such a strategy may enable more of those who need such interventions to receive them, which could speed up progress in neonatal survival. However, the sustainability of community health worker strategies has been questioned: they are commonly unpaid or underpaid, multitasking and poorly supervised (Bhutta & Soofi 2008). Yet Gill et al. (2012), in the light of the trial of training traditional birth attendants in Zambia (Gill et al. 2011), suggested that, rather than being excluded from health programmes, such community members should be mainstreamed, including being registered, and receiving training, supplies and supervision. They argued that traditional birth attendants can be trained to deliver interventions that are effective in reducing neonatal mortality, which, along with community mobilisation, can help overcome some of issues associated with accessing skilled attendance for delivery in rural sub-Saharan Africa (Gill et al. 2012).

The evidence reviewed here comes from several countries in sub-Saharan Africa, but for each behaviour, the evidence was generated from no more than two countries. Therefore, the extent to which the results could be generalised, within sub-Saharan Africa as well as beyond, is limited, particularly as many newborn care behaviours have strong cultural influences.

Our search was conducted in only one database. While the database used is comprehensive, it is possible that other studies meeting the search criteria were not listed here. We attempted to reduce bias in the review process by two authors independently identifying articles from the search results that met the review criteria. However, only one author assessed the risk of bias and the findings of the included studies.

Both the demand side, with families and communities willing and able to seek and obtain care and adopt good practices, and the supply side, with a functioning health system, are of key importance for interventions to be effective in improving newborn survival. Furthermore, the continuum of care perspective is important for the health of both mothers and children. It was beyond the scope of this review to include evidence of the effectiveness of many other interventions that may affect neonatal outcomes, such as those to aiming to improve maternal health, delivery outcomes, stillbirth rates, child health more broadly (PMNCH 2011) and overall quality of care.

Our search strategy included randomised trials and observational studies with a comparison group. Although it was not appropriate to conduct meta-analysis on the extracted papers owing to the heterogeneity of the study designs and outcomes, we did review each study thematically and assess the risk of bias using other published tools. However, the validity of the Newcastle–Ottawa scale has been questioned, with the suggestion that some items may be invalid (Stang 2010). We also assessed the quality of evidence for each type of intervention using GRADE. RCTs are often considered the ‘gold-standard’ study design to avoid bias, with non-randomised studies are being prone to selection bias. Yet well-designed cohort and case–control studies have been reported not to overestimate systematically the magnitude of intervention effects compared with RCTs on the same topic (Concato et al. 2000), thus justifying their inclusion in this review. A number of studies were found that explored the behaviours of interest conducted using cross-sectional or uncontrolled before-and-after designs. Such designs were excluded as they did not have a separate comparison group, thus were considered to be at too great a risk of bias, and no tools for assessing bias of these designs were found.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

We found just 11 papers examining the association between recommended newborn care practices and newborn survival or one of the main causes of neonatal mortality in sub-Saharan Africa, including six RCTs. Improved neonatal outcomes were associated with clean delivery practices, early and exclusive breastfeeding, early KMC, training birth attendants in neonatal resuscitation coupled with antibiotic provision and establishing women's groups in communities. For some recommended practices, no evidence was found. There is a remarkable lack of robust evidence from sub-Saharan Africa on the association between practice or promotion of newborn care behaviours and newborn survival. In this large geographical area with over a million neonatal deaths each year, it is important to increase the evidence base of the effectiveness of practicing or training practitioners in the promotion and practice of recommended newborn care practices from large-scale and adequately powered studies.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References
  • Adam I, Babiker S, Mohmmed A, Salih M, Prins M & Zaki Z (2007) Low body mass index, anaemia and poor perinatal outcome in a rural hospital in eastern Sudan. Journal of Tropical Pediatrics 54, 202204.
  • American Academy of Pediatrics (2012) American Academy of Pediatrics Neonatal Resuscitation Program [Online]. Available at: http://www2.aap.org/nrp/ (accessed 17 October 2012).
  • Bang AT, Reddy HM, Deshmukh MD, Baitule SB & Bang RA (2005) Neonatal and infant mortality in the ten years (1993 to 2003) of the Gadchiroli field trial: effect of home-based neonatal care. Journal of Perinatology 25(Suppl. 1), S92S107.
  • Baqui A, Williams EK, Rosecrans AM et al. (2008a) Impact of an integrated nutrition and health programme on neonatal mortality in rural northern India. Bulletin of the World Health Organization, 86, 796804, A.
  • Baqui AH, El-Arifeen S, Darmstadt GL et al. (2008b) Effect of community-based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: a cluster-randomised controlled trial. Lancet 371, 19361944.
  • Bhandari N, Mazumder S, Taneja S, Sommerfelt H, Strand TA & Group IES (2012) Effect of implementation of Integrated Management of Neonatal and Childhood Illness (IMNCI) programme on neonatal and infant mortality: cluster randomised controlled trial. BMJ 344, e1634.
  • Bhutta ZA & Soofi S (2008) Community-based newborn care: are we there yet? Lancet 372, 11241126.
  • Bhutta ZA, Memon ZA, Soofi S, Salat MS, Cousens S & Martines J (2008) Implementing community-based perinatal care: results from a pilot study in rural Pakistan. Bulletin of the World Health Organization 86, 452459.
  • Bhutta ZA, Soofi S, Cousens S et al. (2011) Improvement of perinatal and newborn care in rural Pakistan through community-based strategies: a cluster-randomised effectiveness trial. Lancet 377, 403412.
  • Blanc AK & Wardlaw T (2005) Monitoring low birth weight: an evaluation of international estimates and an updated estimation procedure. Bulletin of the World Health Organization 83, 178185.
  • Blencowe H, Cousens S, Oestergaard MZ et al. (2012) National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. Lancet, 379, 21622172.
  • Byaruhanga R, Bergstrom A & Okong P (2005) Neonatal hypothermia in Uganda: prevalence and risk factors. Journal of Tropical Pediatrics 51, 212215.
  • Carlo WA, Mcclure EM, Chomba E, et al. (2010) Newborn care training of midwives and neonatal and perinatal mortality rates in a developing country. Pediatrics 126, e1064e1071.
  • Cochrane Effective Practice and Organisation of Care Group (2013) Suggested Risk of Bias Criteria for EPOC Reviews. Available at: http://epoc.cochrane.org/sites/epoc.cochrane.org/files/uploads/14 Suggested risk of bias criteria for EPOC reviews 2013 08 12.pdf (accessed 09 September 2013).
  • Concato J, Shah N & Horwitz RI (2000) Randomized, controlled trials, observational studies, and the hierarchy of research designs. New England Journal of Medicine 342, 18871892.
  • Conde-Agudelo A, Belizan JM & Diaz-Rossello J (2011) Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Systematic Review, 3, CD002771.
  • Darmstadt GL, Choi Y, Arifeen SE et al. (2010) Evaluation of a cluster-randomized controlled trial of a package of community-based maternal and newborn interventions in Mirzapur, Bangladesh. PLoS ONE, 5, e9696.
  • Edmond K, Zandoh C, Quigley MA, Amenga-Etego S, Owusu-Agyei S & Kirkwood B (2006) Delayed breastfeeding initiation increases risk of neonatal mortality. Pediatrics 117, e380e386.
  • Edmond K, Kirkwood B, Amenga-Etego S, Owusu-Agyei S & Hurt LS (2007) Effect of early infant feeding practices on infection-specific neonatal mortality: an investigation of the causal links with observational data from rural Ghana. American Journal of Clinical Nutrition 86, 11261131.
  • Edmond KM, Kirkwood BR, Tawiah CA & Owusu-Agyei S (2008) Impact of early infant feeding practices on mortality in low birth weight infants from rural Ghana. Journal of Perinatology 28, 438444.
  • Gill CJ, Phiri-Mazala G, Guerina NG et al. (2011) Effect of training traditional birth attendants on neonatal mortality (Lufwanyama Neonatal Survival Project): randomised controlled study. BMJ 342, d346.
  • Gill CJ, Guerina NG, Mulenga C, Knapp AB, Mazala G & Hamer DH (2012) Training Zambian traditional birth attendants to reduce neonatal mortality in the Lufwanyama Neonatal Survival Project (LUNESP). International Journal of Gynaecology and Obstetrics 118, 7782.
  • Gitta SN, Wabwire-Mangen F, Kitimbo D & Pariyo G, Centers for Disease, C. & Prevention (2006) Risk factors for neonatal tetanus–Busoga region, Uganda 2002–2003. MMWR. Morbidity and Mortality Weekly Report, 55 (Suppl. 1), 2530.
  • Goldenberg RL, Culhane JF, Iams JD & Romero R (2008) Epidemiology and causes of preterm birth. Lancet 371, 7584.
  • Gravett MG, Rubens CE & Nunes TM (2010) Global report on preterm birth and stillbirth (2 of 7): discovery science. BMC Pregnancy and Childbirth 10(Suppl. 1), S2.
  • Guyatt GH, Oxman AD, Vist GE et al. (2008) GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ, 336, 924926.
  • Haines A, Sanders D, Lehmann U et al. (2007) Achieving child survival goals: potential contribution of community health workers. Lancet 369, 21212131.
  • Hill K & Choi Y (2006) Neonatal mortality in the developing world. Demographic Research 14, 429452.
  • Katz J, Lee AC, Kozuki N et al. (2013) Mortality risk in preterm and small-for-gestational-age infants in low-income and middle-income countries: a pooled country analysis. Lancet 382, 417425.
  • Kirkwood BR, Manu A, ten Asbroek AH et al. (2013) Effect of the Newhints home-visits intervention on neonatal mortality rate and care practices in Ghana: a cluster randomised controlled trial. Lancet 381, 21842192.
  • Kramer MS (1987) Determinants of low birth weight: methodological assessment and meta-analysis. Bulletin of the World Health Organization 65, 663737.
  • Kumar V, Mohanty S, Kumar A et al. (2008) Effect of community-based behaviour change management on neonatal mortality in Shivgarh, Uttar Pradesh, India: a cluster-randomised controlled trial. Lancet 372, 11511162.
  • Kumar V, Shearer JC, Kumar A & Darmstadt GL (2009) Neonatal hypothermia in low resource settings: a review. Journal of Perinatology 29, 401412.
  • Lawn J & Kerber K (2006) Opportunities for Africa's newborns: Practical data, policy and programmatic support for newborn care in Africa. Cape Town.
  • Lawn JE, Cousens S & Zupan J (2005) 4 million neonatal deaths: When? Where? Why? Lancet 365, 891900.
  • Lawn JE, Lee AC, Kinney M et al. (2009) Two million intrapartum-related stillbirths and neonatal deaths: where, why, and what can be done? International Journal of Gynaecology and Obstetrics, 107 (Suppl. 1), S5S18, S19.
  • Lawn JE, Gravett MG, Nunes TM, Rubens CE & Stanton C (2010) Global report on preterm birth and stillbirth (1 of 7): definitions, description of the burden and opportunities to improve data. BMC Pregnancy and Childbirth 10(Suppl. 1), S1.
  • Lewycka S, Mwansambo C, Rosato M et al. (2013) Effect of women's groups and volunteer peer counselling on rates of mortality, morbidity, and health behaviours in mothers and children in rural Malawi (MaiMwana): a factorial, cluster-randomised controlled trial. Lancet 381, 17211735.
  • Liu L, Johnson HL, Cousens S et al. (2012) Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet, 379, 21512161.
  • Marchant T, Willey B, Katz J et al. (2012) Neonatal mortality risk associated with preterm birth in East Africa, adjusted by weight for gestational age: individual participant level meta-analysis. PLoS Med 9, e1001292.
  • Matendo R, Engmann C, Ditekemena J et al. (2011) Reduced perinatal mortality following enhanced training of birth attendants in the Democratic Republic of Congo: a time-dependent effect. BMC Medicine 9, 93.
  • Mathauer I & Imhoff I (2006) Health worker motivation in Africa: the role of non-financial incentives and human resource management tools. Human Resources for Health 4, 24.
  • Mosha F, Winani S, Wood S, Changalucha J & Ngasalla B (2005) Evaluation of the effectiveness of a clean delivery kit intervention in preventing cord infection and puerperal sepsis among neonates and their mothers in rural Mwanza Region, Tanzania. Tanzania Health Research Bulletin 7, 185188.
  • Mullany LC, Katz J, Li YM et al. (2008) Breast-feeding patterns, time to initiation, and mortality risk among newborns in southern Nepal. Journal of Nutrition 138, 599603.
  • Nagai S, Andrianarimanana D, Rabesandratana N, Yonemoto N, Nakayama T & Mori R (2010) Earlier versus later continuous Kangaroo Mother Care (KMC) for stable low-birth-weight infants: a randomized controlled trial. Acta Paediatrica 99, 827835.
  • Ojukwu JU, Abonyi LE, Ugwu J & Orji IK (2006) Neonatal septicemia in high risk babies in South-Eastern Nigeria. Journal of Perinatal Medicine 34, 166172.
  • PMNCH (2011) A Global Review of the Key Interventions Related to Reproductive, Maternal, Newborn and Child Health (RMNCH). PMNCH, Geneva, Switzerland.
  • Rajaratnam JK, Marcus JR, Flaxman AD et al. (2010) Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries 1970-2010: a systematic analysis of progress towards Millennium Development Goal 4. Lancet 375, 19882008.
  • Rhee V, Mullany LC, Khatry SK et al. (2008) Maternal and birth attendant hand washing and neonatal mortality in southern Nepal. Archives of Pediatrics and Adolescent Medicine 162, 603608.
  • Save the Children (2013) Surviving the First Day. State of the World's Mothers 2013. Save the Children, London.
  • Stang A (2010) Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. European Journal of Epidemiology 25, 603605.
  • Thaver D & Zaidi AK (2009) Burden of neonatal infections in developing countries: a review of evidence from community-based studies. The Pediatric Infectious Disease Journal 28, S3S9.
  • The Cochrane Collaboration (2011) Cochrane Handbook for Systematic Reviews of Interventions [Online]. Available at: www.cochrane-handbook.org (accessed 31 May 2013).
  • The Lancet (2005) Neonatal Survival [Online]. The Lancet. Available at: http://www.thelancet.com/series/neonatal-survival (accessed 17 October 2012).
  • The World Bank (2013) Country and Lending Groups [Online]. Available at: http://data.worldbank.org/about/country-classifications/country-and-lending-groups (accessed 09 August 2013).
  • Tissieres P, Ochoda A, Dunn-Siegrist I et al. (2012) Innate Immune Deficiency of Extremely Premature Neonates Can Be Reversed by Interferon-gamma. PLoS ONE, 7, e32863.
  • UNICEF (2012) Level and Trends in Child Mortality Report 2012. UNICEF, New York.
  • UNICEF & WHO (2004) Low Birthweight. Country, Regional and Global Estimates. UNICEF & WHO, New York.
  • Wells GA, Shea B, O'Connell D et al. (2011) The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses [Online]. Available at: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp (accessed 17 December 2012).
  • WHO (1994) Essential Newborn Care. Report of a Technical Working Group. WHO, Trieste.
  • WHO (2003) Kangaroo Mother Care: A Practical Guide. World Health Organization, Geneva.
  • WHO (2009) WHO Recommended Interventions for Improving Maternal and Newborn Health. WHO, Geneva, Switzerland.
  • WHO (2010) Essential Newborn Care Course [Online]. Available at: http://www.who.int/maternal_child_adolescent/documents/newborncare_course/en/ (accessed 17 October 2012).
  • WHO & UNICEF (2009) Home visits for the newborn child: a strategy to improve survival. WHO & UNICEF, Geneva, Switzerland.
  • Winani S, Wood S, Coffey P, Chirwa T, Mosha F & Changalucha J (2007) Use of a clean delivery kit and factors associated with cord infection and puerperal sepsis in Mwanza, Tanzania. Journal of Midwifery & Women's Health, 52, 3743.
  • Worku B & Kassie A (2005) Kangaroo mother care: a randomized controlled trial on effectiveness of early kangaroo mother care for the low birthweight infants in Addis Ababa, Ethiopia. Journal of Tropical Pediatrics, 51, 9397.