How many child deaths can we prevent this year

Evidence-based, cost-effective interventions: how many newborn babies can we save?

Background. Infant and under-5 childhood mortality rates in developing countries have declined significantly in the past 2 to 3 decades. However, 2 critical indicators, maternal and newborn mortality, have hardly changed. World leaders at the United Nations Millennium Summit in September 2000 agreed on a critical goal to reduce deaths of children Objective. This review of community-based antenatal, intrapartum, and postnatal intervention trials in developing countries aimed to identify (1) key behaviors and interventions for which the weight of evidence is sufficient to recommend their inclusion in community-based neonatal care programs and (2) key gaps in knowledge and priority areas for future research and program learning. Methods. Available published and unpublished data on the impact of community-based strategies and interventions on perinatal and neonatal health status outcomes were reviewed. Evidence was summarized systematically and categorized into 4 levels of evidence based on study size, location, design, and reported impact, particularly on perinatal or neonatal mortality. The evidence was placed in the context of biological plausibility of the intervention; evidence from relevant developed-country studies; health care program experience in implementation; and recommendations from the World Health Organization and other leading agencies. Results. A paucity of community-based data was found from developing-country studies on health status impact for many interventions currently being considered for inclusion in neonatal health programs. However, review of the evidence and consideration of the broader context of knowledge, experience, and recommendations regarding these interventions enabled us to categorize them according to the strength of the evidence base and confidence regarding their inclusion now in programs. This article identifies a package of priority interventions to include in programs and formulates research priorities for advancing the state of the art in neonatal health care. Conclusions. This review emphasizes some new findings while recommending an integrated approach to safe motherhood and newborn health. The results of this study provide a foundation for policies and programs related to maternal and newborn health and emphasizes the importance of health systems research and evaluation of interventions. The review offers compelling support for using research to identify the most effective measures to save newborn lives. It also may facilitate dialogue with policy makers about the importance of investing in neonatal health.

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Community-Based Interventions for Improving Perinatal and Neonatal Health Outcomes in Developing Countries: A Review of the Evidence

This paper analyzes the importance of strengthening the relationship of accountability between health service providers and citizens for improving access to and quality of health care. How this is to be achieved, and whether it works, however, remain open questions. The paper presents a randomized field experiment on increasing community-based monitoring. As communities began to more extensively monitor the provider, both the quality and quantity of health service provision improved. One year into the program, there are large increases in utilization, significant weight-for-age z-score gains of infants, and markedly lowerdeaths among children. The findings on staff behavior suggest that the improvements in quality and quantity of health service delivery resulted from an increased effort by the staff to serve the community. Overall, the results suggest that community monitoring can play an important role in improving service delivery when traditional top-down supervision is ineffective.

https://papers.ssrn.com/sol3/Delivery.cfm/4268.pdf?abstractid=996174&mirid=1

Power to the People: Evidence from a Randomized Field Experiment of a Community-Based Monitoring Project in Uganda

This brief summarizes the results of a gender impact evaluation study, entitled Power to the people : evidence from a randomized field experiment on community-based monitoring in Uganda, intervention started in 2004 and consisted of a training and a six month follow up in Uganda. The study observed that localized nongovernmental organizations encouraged communities to be more involved with the state of health service provision and strengthened their capacity to hold their local health providers to account for performance. The community based monitoring project increased the quality and quantity of primary health care provision. The program led to a significant increase in the weight of infants by .14 z scores and a significant decrease in child mortality by 33. Utilization of outpatient services was significantly higher (20 percent) in the treatment group and the overall effect across utilization measures is large and significant. Funding for the study derived from Bank-Netherlands Partnership Program, World Bank Research Committee, World Bank Africa Region division, Swedish International Development Agency, Department for Research Cooperation.

/pdf/power-to-the-people-evidence-from-a-randomized-field-3yp8a031cr.pdf

Power to the people : evidence from a randomized field experiment on community-based monitoring in Uganda

PIP: 1 approach to the prevention of tetanus neonatorum (a leading cause of infant death throughout the world) is improving the quality of prenatal, obstetric, and postnatal maternal and child health services. Another complementary approach is the active immunization of women before or during pregnancy with tetanus toxoid. Work in progress at the Matlab field station of the International Center for Diarrheal Disease Research in Bangladesh (ICDDR,B) provided a unique opportunity to study the effectiveness of certain aspects of these 2 strategies. In 1974, during a field trial of cholera toxoid vaccine, 2 injections of an aluminum phosphate tetanus-diphtheria toxoid were provided as a control to a randomly assigned group of nonpregnant women. Beginning in June 1978, a program of immunizing women during pregnancy with aluminum phosphate-absorbed tetanus toxoid was initiated in conjunction with the implementation of a village based maternal and child health and family planning program in half of the same Matlab surveillance area. Throughout the period of these 2 programs, the ICDDR,B maintained an independent, longitudinal, vital registration system, identifying all births and deaths in the study area. In this analysis, all live births registered in the Maternal and Child Health-Family Planning and comparison areas during the September 1, 1978 until December 31, 1979 period were identified. These records were linked with any deaths recorded within 28 days of birth. The acceptance of tetanus vaccination during the 1974 cholera vaccine trial, by the mothers of these live births, was ascertained from the 1974 vaccine registers. The acceptance of vaccination during the 1978-1979 program was obtained from the field registers. For infants whose mothers had received 2 tetanus injections 48-64 months prior to delivery, the neonatal mortality rate was 63.8/l000 live births compared with 78.3/1000 for infants whose mothers did not receive tetanus immunization. Immunization of women with 2 tetanus injections during pregnancy reduced neonatal mortality rates to 42.8/1000, a reduction of 35.5/1000. Mortality on days 4-14 was reduced by about 70%. 1 injection during pregnancy did not appear to provide protection against tetanus neonatorum.

Use of tetanus toxoid for the prevention of neonatal tetanus. 1. Reduction of neonatal mortality by immunization of non-pregnant and pregnant women in rural Bangladesh.

2 studies have been conducted in Matlab Thana of Rural Bangladesh over the 1975 to 1981 period to test the hypothesis that contraceptive services can reduce fertility in rural Bangladesh. This paper reviews the designs of the 2 studies and analyzes their demographic effects. The 1st study tested a pill and condom household contraceptive distribution approach; the 2nd augmented that strategy with better training of workers a wider battery of methods more intensive follow-up and referral services and ancillary health care. Both projects had an impact on fertility. Contraceptive distribution had a modest impact in its 1st year and no effect subsequently. The initial impact of the comprehensive health and contraceptive care approach was at least double the initial impact of the contraceptive distribution approach. Moreover the effects of the 2nd study were sustained over time. Policy implications of the findings of the studies are reviewed. (authors)

The demographic impact of 2 contraceptive service projects in Matlab Thana of Bangladesh: a compendium of findings for the 1975-1980 period.

Sucrose-electrolyte oral therapy packets (1 liter) were distributed to a rural Bangladesh population of 157000 by community-based workers and this effort was evaluated. A similar population of 134000 served as a comparison group. The locally-produced packets showed satisfactory chemical composition with a shelf-life of up to 3 months and a cost of U.S. $.05. After 4 months the workers were distributing an average of 70 packets/1000 population/month. Most patients used 1 packet/diarrheal episode; 13% of children used 2 packets and 15% and 8% of adults used respectively 2 and 3 packets. The electrolyte composition of the oral fluids prepared by fieldworkers and mothers showed substantial variation but no hyperconcentrated solutions were noted. When comparing the hospitalization rate from the 2 study areas it appears that there was a 29% reduction in hospital stays for diarrhea during the 4-month distribution period. (Authors modified)

Bhatia S

Papers

Use of tetanus toxoid for the prevention of neonatal tetanus. 1. Reduction of neonatal mortality by immunization of non-pregnant and pregnant women in rural Bangladesh.

The demographic impact of 2 contraceptive service projects in Matlab Thana of Bangladesh: a compendium of findings for the 1975-1980 period.

Village-based distribution of oral rehydration packets in Bangladesh.