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Background As the number of deaths among children younger than 5 years of age continues to decline globally through programs to address the health of older infants, neonatal mortality is becoming an increasingly large proportion of under-5 deaths. Lack of access to safe delivery care, emergency obstetric care and postnatal care continue to be challenges for reducing neonatal mortality. This article reviews the available evidence regarding the effectiveness of community-based primary health care (CBPHC) and common components of programs aiming to improve health during the first 28 days of life. Methods A database comprising evidence of the effectiveness of projects, programs and field research studies (referred to collectively as projects) in improving maternal, neonatal and child health through CBPHC has been assembled and described elsewhere in this series. From this larger database (N = 548), a subset was created from assessments specifically relating to newborn health (N = 93). Assessments were excluded if the primary project beneficiaries were more than 28 days of age, or if the assessment did not identify one of the following outcomes related to neonatal health: changes in knowledge about newborn illness, care seeking for newborn illness, utilization of postnatal care, nutritional status of neonates, neonatal morbidity, or neonatal mortality. Descriptive analyses were conducted based on study type and outcome variables. An equity assessment was also conducted on the articles included in the neonatal subset. Results There is strong evidence that CBPHC can be effective in improving neonatal health, and we present information about the common characteristics shared by effective programs. For projects that reported on health outcomes, twice as many reported an improvement in neonatal health as did those that reported no effect; only one study demonstrated a negative effect. Of those with the strongest experimental study design, almost three-quarters reported beneficial neonatal health outcomes. Many of the neonatal projects assessed in our database utilized community health workers (CHWs), home visits, and participatory women’s groups. Several of the interventions used in these projects focused on health education (recognition of danger signs), and promotion of and support for exclusive breastfeeding (sometimes, but not always, including early breastfeeding). Almost all of the assessments that included a measurable equity component showed that CBPHC produced neonatal health benefits that favored the poorest segment of the project population. However, the studies were quite biased in geographic scope, with more than half conducted in South Asia, and many were pilot studies, rather than projects at scale. Conclusions CBPHC can be effectively employed to improve neonatal health in high- mortality, resource-constrained settings. CBPHC is especially important for education and support for pregnant and postpartum mothers and for establishing community- facility linkages to facilitate referrals for obstetrical emergencies; however, the latter will only produce better health outcomes if facilities offer timely, high-quality care. Further research on this topic is needed in Africa and Latin America, as well as in urban and peri-urban areas. Additionally, more assessments are needed of integrated packages of neonatal interventions and of programs at scale.
The methodology for assembling a database of 548 assessments of the effectiveness of CBPHC in improving child health, including the search strategy, has been described elsewhere in this series [10]. In brief, we considered CBPHC to be any activity in which one or more health–related interventions were carried out in the community outside of a health facility. There could also be associated activities that took place in health facilities. The larger study conducted a search of published documents in PubMed, personal sources, and the grey literature for documents that described the implementation of CBPHC and assessed the effect of these projects, programs, or field research studies (described collectively as projects) on mortality, morbidity, nutritional status, or population coverage of an evidence–based intervention. Of 4276 articles identified for screening via PubMed, 433 qualified for the review. In addition, 115 reports were identified from the grey literature and elsewhere, yielding a total of 548 neonatal and child health assessments included in the review. Two reviewers independently extracted information about the assessment and a third independent reviewer resolved any differences. The data were transferred to an electronic database using EPI INFO version 3.5.4 (US Centers for Disease Control and Prevention, Atlanta, Georgia, USA). Starting with the child health data set, assessments were selected for the analysis of neonatal health in a three–stage process (Figure 1). In the first stage, articles were selected that had been coded with relevant interventions pertaining to neonates. These interventions, as defined on the data extraction form, were: neonatal/perinatal health; breastfeeding; child weight/height (including birth weight); immunizations; diarrhea treatment; pneumonia treatment; malaria prevention; malaria treatment; Integrated Management of Childhood Illness (IMCI); prevention of mother–to–child transmission of HIV; neonatal tetanus prevention; neonatal tetanus treatment; congenital syphilis prevention; congenital syphilis treatment; and primary health care. This yielded 380 articles. Selection of assessments for inclusion in the neonatal health review. In the second stage, titles and abstracts of these 380 articles were reviewed. Articles were then excluded if the target population was not infants under age one. This yielded 108 articles. Further exclusions were made if the article did not have an outcome directly related to neonatal health (knowledge about newborn illness, care seeking for newborn illness, utilization of postnatal care, or a neonatal health outcome related to nutritional status, morbidity or mortality). The final database for this sub–analysis included 93 articles. Articles were coded by the primary and secondary health condition addressed, the outcome variables, and categorized by the type and strength of study design. All study designs were included, but were separated into three categories: randomized controlled trials (RCTs); non–randomized controlled trials; and observational and other non–experimental designs. We conducted descriptive analyses on the data set to present the proportion of beneficial health outcomes within each category. A table of only the RCTs is presented in Table S1 of Online Supplementary Document(Online Supplementary Document). In this paper, when assessments selected for this analysis are specifically cited, we cite them with the first author’s last name and year of publication, with the reference number in brackets with a prefix S. The full reference can be obtained from Appendix S2 in Online Supplementary Document(Online Supplementary Document) where the full references for all the 93 assessments selected for the analysis in this paper can be located. The term community health worker (CHW) is used here to refer to any community–level actor who receives training from the project or the broader health system/health program to assist in the activities of the project. We do not provide any further specification here regarding length of training, level of compensation (if any), formal recognition by the ministry of health, or other descriptive characteristics of CHWs, as they varied widely among the included assessments, although we recognize that this is an important dimension of these projects.
