The provision of home-based neonatal care by village health workers reduced the infant mortality rate in a rural population in India by almost 50%. Data collected during a three-year field trial indicate that the intervention reduced deaths of newborns from bacterial infections by 76%.¹ One year of neonatal care cost US$5.30 per newborn and averted one death per 18 newborns who received the care.

The study was conducted in the Gadchiroli district of India, an extremely underdeveloped region with high rates of malnutrition and female illiteracy. From April 1993 to March 1995, male health workers collected baseline data from the villages, including the number of live births, neonatal deaths and infant deaths and information about traditional neonatal care in the villages.

The intervention area comprised 39 villages in which a local woman with 5-10 years of education was willing to act as a health worker. An additional 47 villages made up the control area. The two groups of villages were similar in their demographic and characteristics and in their access to government health services.

The female health workers in the 39 intervention villages received six months of training in taking histories of pregnant women, observing the process of labor, examining newborns, recording data and managing cases of pneumonia in children, including newborns.

The researchers introduced the intervention in the 39 villages in steps over a three-year period. During the first year, the female health workers identified pregnant women in the village, collected data during home visits in the women's third trimester, observed labor and examined babies at birth. The health workers also visited the home to gather information and examine the mother and child on days one, two, three, five, seven, 14, 21 and 28 after the birth, as well as on any other day when the family called. They weighed the child each week and managed minor illnesses and pneumonia in the children. The health workers followed up with the children for 28 days after birth, until the mother left the village or until the baby died, whichever happened first.

The researchers used the health workers' data to estimate the natural incidence of death among newborns and assess health care needs in the villages. Because these data indicated that septicemia, meningitis and severe pneumonia--collectively called sepsis--were the most common cause of neonatal death in the area, the intervention was adapted to emphasize early detection and treatment of those infections.

In the second year, the village health workers began providing home-based management of neonatal illnesses to newborns whose parents sought their care. Five months later, the health workers added management of neonatal sepsis to their duties.

In the third year, the village health workers began offering mothers and grandmothers health education about providing appropriate care and nutrition during pregnancy, preventing infection, recognizing symptoms in newborns and seeking immediate help from a health worker. The health workers stressed the importance of early initiation of breastfeeding and exclusive breastfeeding, temperature maintenance and infant weight gain.

Data collection independent of that conducted by the female health workers continued throughout the study. Health workers recorded data on births and child deaths from both the intervention and control villages and conducted a door-to-door survey once every six months in both areas to detect any missed events. In addition, a physician visited each village in the intervention area once every two weeks to verify the village health workers' data, provide feedback and continuing education to the workers, and independently record observations of a sample of 119 newborns. The physician did not provide treatment but advised hospital admission to parents whose newborn was seriously ill.

In the 39 intervention villages, the infant mortality rate decreased from its 1993-1995 baseline rate of 75.5 per 1,000 live births to a rate of 38.8 per 1,000 in 1998--a 49% reduction. Over the same period, the infant mortality rate for the 47 control villages decreased by only 3%, from 77.1 to 74.9 per 1,000 live births.

The neonatal mortality rate in the intervention area decreased by 59%, from 62.0 per 1,000 live births to 25.5 per 1,000 in 1998. In contrast, the neonatal mortality rate in the control area increased by 3%, from 57.7 per 1,000 live births to 59.6 per 1,000.

In 1995-1996, before village health workers received training in management of sepsis, village health workers visited 763 newborns. Among these, 40 died, 21 because of sepsis. The rate of neonatal death from sepsis was 27.5 per 1,000 live births. In 1997-1998, after village health workers began managing cases of sepsis, there were 22 deaths among the 913 newborns they attended. Six of these deaths were caused by sepsis, for a mortality rate of 6.6 per 1,000 live births. This decrease of 76% in the neonatal mortality from sepsis accounted for 74% of the total reduction in neonatal mortality.

To determine the number of deaths averted by the intervention in the third year of the field trial, the researchers used the number of neonatal deaths in the control villages as the approximate number of neonatal deaths that would have been expected in the intervention villages and subtracted from that number the actual number of neonatal deaths in the intervention villages. They estimated that 51 deaths were averted among the 913 newborns who received care from the health workers. Thus, the intervention averted one death among every 18 newborns receiving care from the village health workers in the third year of the field trial.

The study data indicate that expenditures for home-based neonatal care per newborn in 1997-1998 included $1.50 in nonrecurring costs and $3.80 in recurring costs, for a total of $5.30 per newborn. The researchers point out that this outlay is much lower than the cost of hospital-based neonatal care reported in earlier studies in urban India, which ranged from $17.30-44.20 per neonate per day in Chennai (with a mean hospital stay of 8.8 days) to $17.00 per newborn in Vellore in 1992 for newborns similar to those in this field trial. They conclude that "even in populations with poor economic and nutritional status and low female literacy, the infant mortality rate can be reduced by nearly half through health education and home-based neonatal care."--B. Brown

REFERENCE

1. Bang AT et al., Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India, Lancet, 1999, 354(9194):1955-1961.