Increasing access to care for sick newborns: Evidence from the Ghana Newhints cluster-randomised controlled trial

Objectives To evaluate the impact of Newhints community-based surveillance volunteer (CBSV) assessments and referrals on access to care for sick newborns and on existing inequities in access. Design We evaluated a prospective cohort nested within the Newhints cluster-randomised controlled trial. Setting Community-based intervention involving more than 750 000, predominantly rural, population in seven contiguous districts in the Brong-Ahafo Region, Ghana. Participants Participants were recently delivered women (from more than 120 000 women under surveillance) and their 16 168 liveborn babies. Qualitative in-depth interviews with referral narratives (IDIs) were conducted with 92 mothers, CBSVs and health facility front-desk and maternity/paediatrics ward staff. Interventions Newhints trained and effectively supervised 475 CBSVs (existing within the Ghana Health Service) in 49 of 98 supervisory zones (clusters) to assess and refer newborns with any of the 10-key-danger signs to health facilities within the first week after birth; promote independent care seeking for sick newborns and problem-solve around barriers between November 2008 and December 2009. Primary outcomes The main evaluation outcomes were rates of compliance with referrals and independent care seeking for newborn illnesses. Results Of 4006 sampled, 2795 (69.8%) recently delivered women received CBSV assessment visits and 279 (10.0%) newborns were referred with danger signs. Compliance with referrals was unprecedentedly high (86.0%) with women in the poorest quintile (Q1) complying better than the least poor (Q5):87.5%(Q1) vs 69.7%(Q5); p=0.038. Three-quarters went to hospitals; 18% were admitted and 58% received outpatient treatment. Some (24%) mothers were turned away at facilities and follow-on IDIs showed that some of these untreated babies subsequently died. Independent care seeking for severe newborn illness increased from 55.4% in control to 77.3% in Newhints zones, especially among Q1 where care seeking almost doubled (95.0% vs 48.6%; RR=1.94 (1.32, 2.84); p=0.001). Rates were the highest among rural residents but urban residents complied quicker. Conclusions Home visits are feasible and a potentially pro-poor approach to link sick newborns to facilities. Its effectiveness in improving survival hinges on matched improvement in facility quality of care.

This study is a prospective study nested within the Newhints cluster-randomised controlled trial. Details of the Newhints trial design have already been published.24 25 In brief, it was a CRT with 49 of 98 supervisory zones randomised for Newhints implementation and 49 acting as controls receiving routine Ghana Health Service (GHS) programmes. In addition, ENC training was conducted in the main health facilities covering both intervention and control zones. The trial covered seven contiguous districts (figure 1) in the Brong-Ahafo Region in central Ghana; an area of ∼12 000 km2 with a multiethnic and predominantly (80%) rural population of more than 700 000,26 engaged primarily in subsistence agriculture. Educational levels were low and communities, mostly served by unpaved roads, lacked modern infrastructure. The four main hospitals located in the relatively urban district capital towns of Techiman, Kintampo, Nkoranza and Wenchi (figure 1) provided comprehensive emergency obstetric and newborn care services and were referral destinations for subdistrict and community-based facilities. Distances between families and hospitals vary from a few metres for urban residents to more than 80 km from some villages. Map of Ghana showing Newhints trial districts. Newhints was fully implemented by end of October 2008. Data for impact and process evaluations were obtained through an on-going surveillance system24 27 covering 120 000 women of child-bearing age. Trial participants were women with babies born between November, 2008 and December, 2009. Newhints was an integrated intervention package25 which included a three-pronged approach to increasing access to care for sick newborns (figure 2). The core components of Newhints were training more than 450 CBSVs, over 9 days, to identify pregnant women and conduct five focused home visits (two during pregnancy and three on days 1, 3 and 7 in the first week after birth) to promote ENC practices, weigh and assess newborns and refer to health facilities if any of the 10 danger signs was present (table 1). To reach babies timely after birth CBSVs left their contact details with families to be contacted whenever women delivered. In addition, they increased the frequency of home visits to women who were in their late pregnancy. CBSVs were provided with portable weighing scales with colour-coded bands: red for weights <1.5 kg identifying very low birthweight (vLBW) babies; yellow for weights of 1.5–2.4 kg identifying LBW babies; and green for weights of 2.5 kg and above; a digital thermometer; and a timer. Danger signs for neonatal illness used in Newhints Newhints algorithm for increasing access to care using three-pronged assessment, referral and counselling approach. CBSV, community-based surveillance volunteer. CBSV training involved interactive discussions, group exercises and practical newborn assessment video exercises using the WHO's Integrated Management of Childhood Illnesses (IMCI) Computerized Adaptation and Training Tool (ICATT). Two training days were dedicated for clinical assessments within hospitals where each CBSV assessed at least two babies. When CBSVs identified babies with any danger sign, they referred them to health facilities issuing them with a referral card to take along, and counselled on the importance of keeping the baby warm and frequent breastfeeding on the way to the facility. They dialogued and problem-solved around barriers to compliance, followed-up within 24 hours to check compliance and discussed continued ENC (figure 2). If families had not complied, CBSVs re-assessed and referred again when danger signs persisted. At the second and third postnatal visits, CBSVs additionally promoted the importance of prompt care seeking, and discussed five key illness signs: if the baby has stopped to feed or is not feeding well; if baby is too hot or too cold to touch (fever or hypothermia); if the baby is having difficult or fast breathing (dyspnoea); if the baby has become yellow all over the body (jaundice); and if the baby has become less active (lethargy). CBSVs were supervised by two trained district-based project supervisors (illness) in each district. DiPS carried out monthly visits to pay CBSV incentives, replenish their stocks and provide supportive supervision by accompanying them into communities and directly observing them carry out home visits; in some of these visits they also carried out repeat assessments of babies. DiPS completed structured performance records for these directly observed supervision (DOS) visits and gave supportive feedback to reinforce CBSV skills. The DiPS were supervised by Newhints research fellows. Two main indicators were used to measure newborn access to care: referral compliance defined as the percentage of families who took their babies to health facilities after CBSV referrals and overall care seeking defined as the percentage of newborns taken to a hospital/clinic among those reported by the mother in the first surveillance visit (usually up to 56 days) after birth as having had severe illness. The evaluation of compliance achieved in Newhints and assessing whether Newhints has reduced inequities in care seeking for severely ill newborns was based on four types of data (the details are provided in the following sections): surveillance, process evaluation, assessment quality checks (of CBSVs and DiPS) and in-depth interviews with mothers, CBSVs and health professionals. Individual informed consent was obtained from all women under surveillance, recently delivered mothers selected for process interviews and the in-depth interviews; CBSVs and their supervisors and health professionals. Interviewers read an information sheet to potential participants in the local language or in English, checked their understanding and answered any questions before consent was requested. Consent forms were read to them and agreement for participation was indicated with a signature or a thumbprint. Participants were assured of confidentiality and their rights to withdraw from the study at any point without prejudice to their position, participation in the main Newhints study or health services received in any facility. They were not required to provide reasons for such decisions. Trained resident-fieldworkers identified pregnancies, births and deaths through 4-weekly home visits to all women of reproductive age. They collected data on sociodemographic characteristics for all pregnancies, including an assets inventory, newborn care practices, morbidity and mortality in the first visit after the birth was identified. From July 2009, this was amended to 8-weekly visits to follow-up pregnant women and their infants. From March 2009, trained field supervisors visited a random subsample of 64 recently delivered women (within 8 weeks of delivery) per week to collect process data on CBSV visits including coverage, assessments, referrals and compliance with referrals including its timing, facilities used and care received. From August 2009, these data were collected from all women at the first surveillance visit after birth. In total, 4006 women in the Newhints zones were interviewed within 8 weeks after the birth. With the DOS form, the supervisors (DiPS) recorded the findings of the CBSVs' newborn assessment and their own independent findings during the observation of the CBSV home visits. In July 2009, the DiPS validated the results by comparing outcome of each DiPS' assessment of four babies to an independent assessment conducted by the study clinician (AM) and this took place in the four main hospitals in Kintampo, Nkoranza, Techiman and Wenchi. In-depth interviews on perceptions and experiences with CBSV assessments, referrals and treatment at the health facility were conducted by the lead author (AM) with 55 recently delivered women whose babies were referred (up to 4 months after birth); purposively selected from the surveillance database to reflect balance with respect to maternal age, rural/urban residence, ethnicity and parity. IDIs on similar topics were also conducted with 21 CBSVs who referred babies, purposively selected to obtain balance on age, gender and place of residence and 15 health facility staff (2 front-desk staff, 10 nurses/midwives, 3 doctors including a paediatrician) from the 4 main hospitals. IDIs were either in the local (Akan) language (women and CBSVs) or English (facility staff). They lasted 60–90 min and were digitally recorded; notes on interview settings were also made. Statistical analyses were carried out using Stata V.11.2 (StataCorp. Stata Statistical Software: Release 11.2. College Station, Texas, USA: StataCorp; 2009). Principal components analysis was conducted on the assets inventory to generate a wealth index, which was used to divide mothers into socioeconomic status quintiles (SEQs). Simple tabulations and cross tabulations were carried out for the outcomes by key maternal (education, place of residence, SEQ), newborn (sex) and other factors (visited by the 2nd day after delivery, issuance of referral card) specific to Newhints. Percentage agreements and κ statistics were estimated for agreement between CBSVs and DiPS and between DiPS and clinician assessments. Generalised estimating equations with a log link function were used to estimate the risk ratios of care seeking by SEQs adjusted for clustering, together with 95% CIs. Recordings from the IDIs together with the field notes were transcribed into English and exported into NVIVO V.9.2 (QSR International Pty Ltd. NVivo qualitative data analysis software: Version 9; 2010) for analysis. Analysis involved multiple reading of the transcripts to familiarise with the data, generation of themes (codes), systematic coding and interpretation of text, language, trends and relationships. Newhints and this evaluation received ethical approvals from London School of Hygiene & Tropical Medicine and Kintampo Health Research Centre. Newhints is registered at clinicaltrials.gov(number={"type":"clinical-trial","attrs":{"text":"NCT00623337","term_id":"NCT00623337"}}NCT00623337).

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• Dima Health