Home-based counselling strategies alone may not improve neonatal survival in rural Africa
Implementing a home-based volunteer counselling strategy during pregnancy and the first few days of an infant's life in rural Africa may not be enough to improve neonatal survival, despite improvements in childbirth in health facilities and newborn care practices, according to new research by Claudia Hanson, from the London School of Hygiene & Tropical Medicine, UK, and colleagues, published this week in PLOS Medicine.
The authors conducted a large cluster-randomized trial in rural Tanzania which aimed to test whether improvements in neonatal mortality could be achieved by training 824 female volunteers to deliver key counselling messages during three home visits, including messages about hand washing with soap before delivery, and early and exclusive breast feeding, and supporting messages such as the importance of childbirth in a health care facility. The study was conducted between 2007 and 2013 in six districts in rural southern Tanzania that covered a population of 1.2 million people.
The authors found that neonatal mortality decreased from 35 to 31 deaths per 1,000 live births in areas where the volunteers were active, with 59% of women receiving at least one volunteer visit during pregnancy and 41% received at least one visit postpartum. However, in control wards where volunteers were not making visits neonatal mortality also decreased, from 35 to 30 deaths per 1,000 live births during the study. Given similar reduction in both arms of the trial there was no evidence of an impact of the intervention on neonatal survival.
Although the study did not find that the intervention had an effect on the study's primary outcome, the newborn care practices reported by mothers were better in intervention compared to comparison areas, including immediate breastfeeding (42% vs 35%), feeding only breast milk for the first 3 days (90% vs 79%), and having clean hands for home delivery (92% vs 88%). Facility delivery improved dramatically in both groups from 41% at baseline to 82% and 75% in intervention and comparison wards, respectively, at the end of the study.
The authors note, "[d]espite moderate increases in newborn care behaviours associated with the intervention, neonatal mortality was similar in intervention and comparison areas, questioning the evidence base in support of home-based counselling."
The authors conclude, "[o]ur findings also give a stark reminder that demand and supply side strengthening should go hand in hand". The lack of effect of home-based counselling on neonatal mortality despite improvements in newborn care practices suggests that improvement in the quality of facility care is of highest relevance in this setting. "Our results thus support the recent shift to prioritize improvement in quality of facility-based care in Tanzania ... and internationally."