Neonatal and perinatal mortality has been declining as a result of socioeconomic development, improved education and the implementation of various health programmes, yet worldwide 2.9 million newborn infants still die in the first 4 weeks of life each year.1 Of these, 2.2 million deaths occur in early neonatal period (0–6 days), with only 0.7 million occurring in the late neonatal period (7–28 days), signifying the major burden of mortality in perinatal period.1 In low-income settings, most babies are born at home, and more than half of those who die do so at home. Thus, the highest neonatal mortality rates and rates of stillbirth are seen in sub-Saharan Africa, followed by Asia and Latin America, where most deliveries take place at home. In countries with the highest infant mortality rates, almost 10% of infants do not survive longer than 1 month. However, globally, more than 7.2 million infants die before their fifth birthday, and almost 5 million before 12 months of age.2 Although mortality has been falling in recent years (Figure 1), many countries are failing to make progress towards the Millennium Development Goals (MDGs) – the most far-reaching goals in history aimed at addressing global poverty and ill health. As the prevalence of human immunodeficiency virus (HIV) infections/acquired immunodeficiency syndrome (AIDS) and poverty has increased, and with the addition the global human resource crisis, it was at one time thought that the MDGs might never be reached.3 Despite limited resources and multiple challenges including lack of resources, competing priorities and lack of consensus on what needs to be done, there is much effort afoot to achieve these goals.4
The growing evidence of burden and evidence-based interventions for newborn care
The last decade has seen concerted effort to address the evidence base for what needs to be done to reduce newborn and child deaths. The landmark Lancet series on child survival evaluated the burden and epidemiology of child mortality as well as the opportunities for interventions using existing evidence.5 The evidence review recognized the importance of newborn mortality as well as potential interventions but did not consider these in depth. A clear possibility, given the distribution of a large proportion of these deaths in domiciliary settings, was that innovative interventions and approaches would be needed to address the burden of newborn deaths. In order to define the potential interventions and the evidence base for action, a comprehensive systematic review of the evidence for a range of strategies to address perinatal and newborn outcomes was undertaken and published as a supplement to Pediatrics in 2005.6 This particular review also paved the way for the landmark publication as part of the Lancet series on newborn care, which emphasized that available solutions, including community-based strategies and platforms, have the potential to prevent over half of all newborn deaths globally and to improve quality of care. The Lancet newborn series paper ‘Evidence based, cost effective interventions: how many newborn infants can we save?’ remains one of the most cited and influential papers on newborn care over the last decade and the basis for many subsequent efforts at defining intervention platforms and packages of care.7 The evidence synthesized at the time recognized 16 cost-effective and feasible interventions with the potential to save lives on a large scale. The article also hypothesized that almost three-quarters of all neonatal deaths could be prevented each year if high coverage was achieved for packages of proven, cost-effective interventions that are delivered through three service delivery models (outreach, family–community and facility-based clinical care) at different points along the continuum of care (preconception, antenatal care, intrapartum care, etc.).8 However, the challenge of implementation was described as the key next step.9
The appearance of these benchmark reviews and evidence syntheses galvanized the international community to commit to addressing the issues of newborn death. The challenge of translating research into policy and, importantly, developing delivery platforms remained. Several different strategies or combinations were investigated to formulate effective packages and the core contents thereof. These approaches included developing community support groups to play an informational role, disseminating simple and low-cost health practices; introducing home visits by trained traditional birth attendants (TBAs) and community health workers (CHWs) to deliver preventative and curative amenities; and combined strategies in which preventative, promotional and therapeutic interventions are delivered to improve maternal and newborn health outcomes. While the promising results of these community-based intervention trials were changing the dimension of global learning and raising the possibility of meeting the MDGs, increased efforts were directed to the inclusion of newborn health in global guidelines and national strategies and programmes.
The inclusion of young neonates (< 7 days old) in the Integrated Management of Childhood Illnesses (IMCI),9 the development of verbal autopsy instruments for measurement of causes of neonatal and perinatal deaths and training community-based care providers in neonatal resuscitation techniques and the recognition and management of infections are an integral part of these new strategies.
Implementing integrated strategies for maternal and newborn care in community settings in the developing world
The natural next step after acquiring the aforementioned evidence was to demonstrate that these strategies actually work and could be implemented in public health systems. The case was made that these interventions could be implemented through community-based platforms and by the delivery of domiciliary preventative and therapeutic care by community health workers, which would have the associated benefits of raising family awareness about good care practices (such as the use of clean delivery kits by the health workers which would also help to raise awareness in the family), breastfeeding practices and seeking care for newborn illnesses.10,11 This was further reviewed systematically and in depth with support from the International Initiative for Impact Evaluation (3ie)12 and the Cochrane Collaboration,13 and extensive analysis of findings from 18 trials that evaluated community-based intervention packages.13 The systematic reviews demonstrated that these packages of care could reduce neonatal and perinatal mortality by as much as 24% and 20% respectively. These reviews offered encouraging evidence of the value of integrating in a community setting a range of interventions that can be effectively delivered through by CHWs and health promotion groups. In order to demonstrate that the interventions could make a difference in health systems, Bhutta et al.14,15 undertook a definitive trial of the implementation of a package of basic maternal and newborn care practices and community education through a public sector programme in Pakistan called the Lady Health Workers Program. This large effectiveness cluster randomized trial, commonly called the ‘Hala trial’, was painstakingly conducted in a systematic manner over a period of 6 years in rural Pakistan between 2002 and 2008.14,15 The definitive findings ere published in the Lancet15 and it remains the only effectiveness trial of the implementation of community-based interventions by public sector workers in the developing world. The trial confirmed that, despite limitations and a multitude of problems, community-based interventions delivered in poor and remote rural populations could lead to significant improvements in household practices and care-seeking patterns and reductions in perinatal and neonatal mortality. The work on the Hala trial has received much global attention and led to a series of assessments of the feasibility of implementing these interventions in public sector programmes in other countries, notably in Africa. In addition, Dr Bhutta's team has recently published two landmark studies of community-based evaluations: one of strategies to reduce newborn infections by cord application of chlorhexidine supplied by CHWs and TBAs as part of a clean delivery kit16 and the other management by CHWs of severe pneumonia in young infants and children in domiciliary settings in rural Pakistan.17 These studies have been at scale and have huge implications for policy and the global evidence base for interventions.
In tandem with the aforementioned research, Dr Bhutta's team also assisted the World Health Organization in conducting a definitive in-depth assessment of the typology and characteristics of programmes involving CHWs globally, including eight country case studies.18 This review specifically addressed the issue of health workforce gaps and the potential of utilizing CHWs to provide a variety of services to communities, ranging from preventative health education on safe delivery, breastfeeding, malaria, tuberculosis, HIV/AIDs and non-communicable diseases to the management of neonatal and uncomplicated childhood illnesses and rehabilitation of people suffering from common mental health problems. These services offered by CHWs could potentially help to improve maternal, neonatal and perinatal health but could also help reduce the burden and costs of other infectious and non-communicable diseases. However, the coverage of such programmes is limited, and overall progress towards achieving the MDG targets through community-based and outreach services is very slow. In addition to exploring the role of CHWs in the promotion of care and delivery of services at community level, the critical need to address overall human resources for health (HRH), including maternal health, especially through skilled birth attendants (SBAs), to improve delivery of services at health facility level was also reviewed.19 The application of pragmatic perspective in this review of published HRH interventions offered an opportunity to gain a better understanding of how different HRH interventions can improve the performance of SBAs and reached the desired maternal health goals. The reviewers emphasized the importance of targeting social and developmental features such as education, women empowerment, poverty alleviation, gender equality and provision of infrastructure, drugs and supplies, all of which can further accelerate progress. These issues are now being integrated as an important part of community-based initiatives. The most visible and important components of this are evident in initiatives to address stillbirths as well as initiatives to develop consensus on key evidence-based interventions, relevant commodities and training programmes to address maternal, newborn and child health.18
Addressing stillbirths, especially intrapartum stillbirths, through integrated approaches
The latest efforts in this call for action to address stillbirths have culminated in a sequential body of work on developing the evidence base for interventions that could affect stillbirths.16–32 This work has formed the basis for the recent Lancet stillbirth series33,34 on what needs to be done to address stillbirths in health systems and what the global public health community needs to do to address this issue across health systems. Even now stillbirths, despite accounting for over 3 million deaths annually, mostly in developing countries, are completely excluded from the MDGs. The key point of the stillbirth work is to emphasize that only 10 interventions, if made universally available, have the potential to prevent almost 45% of all stillbirths in the low- and middle-income countries with the highest burden of stillbirths. Many of these interventions have the additional benefit of preventing maternal and newborn deaths and hence provide an ideal basis for recommending integrated interventions across the continuum of care.
The body of work summarized in this review represents a concerted effort to generate evidence, undertake the relevant knowledge synthesis and develop strategies to translate research to policy. However, a lot more needs to be done to scale up interventions and target the poorest and those most in need. In several large Asian countries, as in Africa, groups are now actively working to scale up interventions to improve coverage and health delivery. At the same time, methods of bridging the gap in human resources are being studied in the domain of task shifting and task reallocation by midlevel health providers and to integrate the range of interventions and linkages with other types of health workers and levels in the health system. This is work that will be needed for many years to come to address these global challenges, well beyond the Millennium Development Goals themselves.