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

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 <5 years by two thirds, but this may be unattainable without halving newborn deaths, which now comprise 40% of all under-5 deaths. Greater emphasis on wide-scale implementation of proven, cost-effective measures is required to save women’s and newborns’ lives. Approximately 99% of neonatal deaths take place in developing countries, mostly in homes and communities. A comprehensive review of the evidence base for impact of interventions on neonatal health and survival in developingcountry communities has not been reported. 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 communitybased 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 Available published and unpublished data on the impact of community-based strategies and interventions on perinatal and neonatal health status outcomes were reviewed.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. Pediatrics 2005;115:519–617. ABBREVIATIONS. ARI, acute respiratory infection; CCS, casecontrol study; CHW, community health worker; CI, confidence interval; CKMC, community-based application of kangaroo mother care; CQ, chloroquine; DBRCT, double-blind, randomized, controlled trial; DBRPCT, double-blind, randomized, placebocontrolled trial; EFA, essential fatty acid; EPI, Expanded Programme on Immunization; FHW, family health worker; Hb, hemoglobin; HBeAg, hepatitis B virus “e” antigen; HBsAg, hepatitis B surface antigen; HBV, hepatitis B virus; HDN, hemorrhagic disease of the newborn; IM, intramuscular; IMR, infant mortality rate; IPT, intermittent presumptive treatment; ITN, insecticidetreated bed net; IUGR, intrauterine growth restriction; IV, intravenous; IVH, intraventricular hemorrhage; KMC, kangaroo mother care; LBW, low birth weight; NIB, untreated bed net; NIH, National Institutes of Health; NMR, neonatal mortality rate; NTD, neural tube defect; OR, odds ratio; PCS, prospective cohort study; PMR, perinatal mortality rate; PROG, proguanil; PPROM, preterm premature rupture of membranes; PROM, premature rupture of membranes; QT, quasi-experimental trial; RCS, retrospective cohort study; RCT, randomized, controlled trial; RDA, recommended dietary allowance; RPCT, randomized, placebo-controlled trial; RPR, rapid plasma reagin; RR, relative risk; SEARCH, Society for Education, Action and Research in Community Health; SGA, small for gestational age; SP, sulfadoxine-pyrimethamine; STD, sexually transmitted disease; TBA, traditional birth attendant; TEWL, transepidermal water loss; TT, tetanus toxoid; UNICEF, United Nations Children’s Fund; UTI, urinary tract infection; VLBW, very low birth weight; WHO, World Health Organization; WIC, Women, Infants, and Children Supplemental Nutrition Program; VHW, village health worker. From the *Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan; ‡Saving Newborn Lives Initiative, Office of Health, Save the Children/USA, Washington, DC; and §Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Accepted for publication Aug 10, 2004. doi:10.1542/peds.2004-1441 No conflict of interest declared. Reprint requests to (Z.A.B.) Department of Pediatrics and Child Health, Aga Khan University, Stadium Road, Karachi 74800, Pakistan. E-mail: zulfiqar.bhutta@aku.edu; or Gary L. Darmstadt, MD, Department of International Health, E8153, Bloomberg School of Public Health, Johns Hopkins University, 615 N Wolfe St, Baltimore, MD, 21205. E-mail: gdarmsta@ jhsph.edu PEDIATRICS (ISSN 0031 4005). Copyright © 2005 by the American Academy of Pediatrics. PEDIATRICS Vol. 115 No. 2 February 2005 519 by on October 26, 2010 www.pediatrics. org Downloaded from