Effect of the Uganda Newborn Study on care-seeking and care practices: a cluster-randomised controlled trial

Abstract

BackgroundCare for women and babies before, during, and after the time of birth is a sensitive measure of the functionality of any health system. Engaging communities in preventing newborn deaths is a promising strategy to achieve further progress in child survival in sub-Saharan Africa.ObjectiveTo assess the effect of a home visit strategy combined with health facility strengthening on uptake of newborn care-seeking, practices and services, and to link the results to national policy and scale-up in Uganda.DesignThe Uganda Newborn Study (UNEST) was a two-arm cluster-randomised controlled trial in rural eastern Uganda. In intervention villages volunteer community health workers (CHWs) were trained to identify pregnant women and make five home visits (two during pregnancy and three in the first week after birth) to offer preventive and promotive care and counselling, with extra visits for sick and small newborns to assess and refer. Health facility strengthening was done in all facilities to improve quality of care. Primary outcomes were coverage of key essential newborn care behaviours (breastfeeding, thermal care, and cord care). Analyses were by intention to treat. This study is registered as a clinical trial, number ISRCTN50321130.ResultsThe intervention significantly improved essential newborn care practices, although many interventions saw major increases in both arms over the study period. Immediate breastfeeding after birth and exclusive breastfeeding were significantly higher in the intervention arm compared to the control arm (72.6% vs. 66.0%; p=0.016 and 81.8% vs. 75.9%, p=0.042, respectively). Skin-to-skin care immediately after birth and cord cutting with a clean instrument were marginally higher in the intervention arm versus the control arm (80.7% vs. 72.2%; p=0.071 and 88.1% vs. 84.4%; p=0.023, respectively). Half (49.6%) of the mothers in the intervention arm waited more than 24 hours to bathe the baby, compared to 35.5% in the control arm (p<0.001). Dry umbilical cord care was also significantly higher in intervention areas (63.9% vs. 53.1%, p<0.001). There was no difference in care-seeking for newborn illness, which was high (around 95%) in both arms. Skilled attendance at delivery increased in both the intervention (by 21%) and control arms (by 19%) between baseline and endline, but there was no significant difference in coverage across arms at endline (79.6% vs. 78.9%; p=0.717). Home visits were pro-poor, with more women in the poorest quintile visited by a CHW compared to families in the least poor quintile, and more women who delivered at home visited by a CHW after birth (73.6%) compared to those who delivered in a hospital or health facility (59.7%) (p<0.001). CHWs visited 62.8% of women and newborns in the first week after birth, with 40.2% receiving a visit on the critical first day of life.ConclusionConsistent with results from other community newborn care studies, volunteer CHWs can be effective in changing long-standing practices around newborn care. The home visit strategy may provide...

Effect of a participatory multisectoral maternal and newborn intervention on maternal health service utilization and newborn care practices: a quasi-experimental study in three rural Ugandan districts

“…The major quantifiable outcome of the study used in the calculation of the sample size was the proportion of women who delivered in a health facility with a skilled provider. We therefore assumed that after 3 years (2013–2015) of implementation, skilled deliveries would increase from 38% to 58%, from 62% to 72% and from 68% to 78% in the intervention areas of Kibuku, Pallisa and Kamuli districts, respectively [21]. The assumptions resulted in a sample size of 2293 women.…”

“…Strategies such as home visits by community health workers (CHWs), to increase awareness about the importance of maternal and newborn danger signs and the importance of seeking care at health facilities [16,19–21], have been used to address the first delay. The second delay has been mitigated by two main strategies, which aim to bring the services closer to those in need by providing home-based care, such as the use of CHWs and community midwives [14,20,21], and to improve access to transportation to allow the pregnant women to reach facilities more quickly. The latter includes strategies that provide easier access to cash, through the use of vouchers and conditional cash transfers, and community-based initiatives that improve the transportation itself [22–25].…”

“…Community-based strategies that involve the training of CHWs and traditional birth attendants have resulted in increased awareness of maternal and newborn health and newborn danger signs, increased utilization of antenatal care (ANC) and facility delivery [1,17,20,27,28], and increased newborn care practices such as clean cord care, immediate breastfeeding, thermal care and delayed bathing [19,21]. Community mobilization and the use of community support groups have also resulted in increased awareness and knowledge about maternal and newborn health and increased facility deliveries [6].…”

“…To reduce the above constraints to comprehensive improvements in access to maternal health services, the Makerere University School of Public Health (MakSPH) implemented the Maternal and Neonatal Implementation for Equitable Systems project (MANIFEST) [21]. MANIFEST was a 3 year project (2013–2015) that used a participatory action research approach to tackle both demand- and supply-side constraints.…”

Effect of a participatory multisectoral maternal and newborn intervention on birth preparedness and knowledge of maternal and newborn danger signs among women in Eastern Uganda: a quasi-experiment study

“…The assumption was that after 3 years (2013–2015) of implementation, skilled deliveries in the intervention arms would increase from 38% to 58% in Kibuku, from 62% to 72% in Pallisa, and from 68% to 78% in Kamuli. These targets were informed by the Uganda Newborn study that was implemented in an area with a context similar to the current study [22]. Calculation of sample size based on all these assumptions yielded a sample size of 2,293 women.…”