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The HBNC package in the Gadchiroli field trial reduced the neonatal and perinatal mortality by large margins, and the gains were sustained at the end of the 7 years of intervention and were carried forward as improved survival through the first year of life. Most of the reduction in mortality was ascribed to sickness management, that is, management of sepsis, supportive care of LBW neonates and management of asphyxia, in that order, and a small portion to primary prevention.

Objectives To estimate the incidence of maternal morbidity during labour and the puerperium in rural homes, the association with perinatal outcome and the proportion of women needing medical attention. Design Prospective observational study nested in a neonatal care trial.Setting Thirty-nine villages in the Gadchiroli district, Maharashtra, India.Sample Seven hundred and seventy-two women recruited over a one year period (1995 -1996) and followed up from the seventh month in pregnancy to 28 days postpartum (up to 10 visits in total). Methods Observations at home by trained village health workers, validated by a physician. Diagnosis of morbidities by computer program. Main outcomes Direct obstetric complications during labour and the puerperium, breast problems, psychiatric problems and need for medical attention. Results The incidence of maternal morbidity was 52.6%, 17.7% during labour and 42.9% during puerperium.The most common intrapartum morbidities were prolonged labour (10.1%), prolonged rupture of membranes (5.7%), abnormal presentation (4.0%) and primary postpartum haemorrhage (3.2%). The postpartum morbidities included breast problems (18.4%), secondary postpartum haemorrhage (15.2%), puerperal genital infections (10.2%) and insomnia (7.4%). Abnormal presentation and some puerperal complications (infection, fits, psychosis and breast problems) were significantly associated with adverse perinatal outcomes, but prolonged labour was not. A third of the mothers were in need of medical attention: 15.3% required emergency obstetric care and 24.0% required non-emergency medical attention. Conclusions Nearly 15% of women who deliver in rural homes potentially need emergency obstetric care.Frequent (43%) postpartum morbidity, and its association with adverse perinatal outcome, suggests the need for home-based postpartum care in developing countries for both mother and baby.

High levels of neonatal mortality and lack of access to neonatal health care are widespread problems in developing countries. A field trial of home-based neonatal care (HBNC) was conducted in rural Gadchiroli, India to develop and test the feasibility of a low-cost approach of delivering primary neonatal care by using the human potential available in villages, and to evaluate its effect on neonatal mortality. In the first half of this article we summarize various aspects of the field trial, presented in the previous 11 articles in this issue of the journal supplement. The background, objectives, study design and interventions in the field trial and the results over 10 years (1993 to 2003) are presented. Based on these results, the hypotheses are tested and conclusions presented. In the second half, we discuss the next questions: Can it be replicated? Can this intervention become a part of primary healthcare services? What is the cost and the cost-effectiveness of HBNC? The limitations of the approach, the settings where HBNC might be relevant and the management pre-requisites for its scaling up are also discussed. The need to develop an integrated approach is emphasized. A case for newborn care in the community is made for achieving equity in health care.

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OBJECTIVES:To evaluate the effect of home-based neonatal care on birth asphyxia and to compare the effectiveness of two types of workers and three methods of resuscitation in home delivery. STUDY DESIGN:In a field trial of home-based neonatal care in rural Gadchiroli, India, birth asphyxia in home deliveries was managed differently during different phases. Trained traditional birth attendants (TBA) used mouthto-mouth resuscitation in the baseline years (1993 to 1995). Additional village health workers (VHWs) only observed in 1995 to 1996. In the intervention years (1996 to 2003), they used tube-mask (1996 to 1999) and bag-mask (1999 to 2003). The incidence, case fatality (CF) and asphyxia-specific mortality rate (ASMR) during different phases were compared. RESULTS:During the intervention years, 5033 home deliveries occurred. VHWs were present during 84% home deliveries. The incidence of mild birth asphyxia decreased by 60%, from 14% in the observation year (1995 to 1996) to 6% in the intervention years (p<0.0001). The incidence of severe asphyxia did not change significantly, but the CF in neonates with severe asphyxia decreased by 47.5%, from 39 to 20% (p<0.07) and ASMR by 65%, from 11 to 4% (p<0.02). Mouth-to-mouth resuscitation reduced the ASMR by 12%, tube-mask further reduced the CF by 27% and the ASMR by 67%. The bag-mask showed an additional decrease in CF of 39% and in the fresh stillbirth rate of 33% in comparison to tube-mask (not significant). The cost of bag and mask was $13 per averted death. Oxytocic injection administered by unqualified doctors showed an odds ratio of three for the occurrence of severe asphyxia or fresh stillbirth. CONCLUSIONS:Home-based interventions delivered by a team of TBA and a semiskilled VHW reduced the asphyxia-related neonatal mortality by 65% compared to only TBA. The bag-mask appears to be superior to tube-mask or mouth-to-mouth resuscitation, with an estimated equipment cost of $13 per death averted.

Home-based management of LBW and the preterm neonates is feasible and effective. It remarkably improved survival by preventing comorbidities, by supportive care, and by treating infections.