Home-based counselling strategies alone may not improve neonatal survival in rural Africa

Home visits by volunteers trained to deliver important health messages to women during pregnancy and in the first days of a baby's life did not appear to improve newborn survival in rural Tanzania, according to new research published in PLOS Medicine. This is despite the study showing improvements in newborn care practices and childbirth in health facilities.

The study was led by researchers at the London School of Hygiene & Tropical Medicine and Ifakara Health Institute in Tanzania, who conducted a large cluster-randomised trial to test whether a home-based counselling strategy would improve survival rates in Tanzania, where neonatal (up to 28 days after birth) mortality remains high.

District health staff trained 824 female volunteers to deliver key health information (including messages about hygiene during childbirth, early breast feeding, and extra care for low birthweight babies such as skin-to-skin care) as well as supporting messages such as the importance of giving birth in a healthcare facility. The volunteers were trained to make three home visits in pregnancy and two in the first few days of a baby's life in 65 randomly selected areas in six districts of rural southern Tanzania that covered a population of 1.2 million people. The study was conducted between 2007 and 2013.

The researchers found that neonatal mortality reduced from 35 to 31 deaths per 1,000 live births in the areas where the trained volunteers were making home visits. 59% of women received at least one volunteer visit during pregnancy and 41% received at least one visit in the days following childbirth. However, in the comparison areas where volunteers were not making visits, neonatal mortality also reduced from 35 to 30 deaths per 1,000 live births during the study period.

Lead author Dr Claudia Hanson from the London School of Hygiene & Tropical Medicine said: "Our findings show very similar numbers of newborn deaths in the group of mothers that received home visits and the group that did not. Contrary to what we had expected based on previous studies, there was no evidence that the home-counselling intervention had an impact on newborn survival. We believe this is the largest randomised study in Africa of a community-based intervention addressing newborn health."

Although the study did not find that the counselling strategy had an effect on survival, the newborn care practices reported by mothers were better in areas with home visits compared to those without. Improvements included breastfeeding immediately after birth (42% in intervention areas vs 35% in comparison areas), feeding only breast milk for the first three days (90% vs 79%), and birth attendants having clean hands for home delivery (92% vs 88%). The proportion of women giving birth in a health care facility improved dramatically in both groups from 41% at the beginning of the study to 82% in intervention areas and 75% in comparison areas when the study finished.

Professor Joanna Schellenberg, study principal investigator from the London School of Hygiene & Tropical Medicine, said: "The home visit strategy we evaluated was based on evidence published in the Lancet Newborn Series in 2005. It was expected to improve newborn survival on the basis of previous studies, all but one of which was in Asia rather than Africa.

"Our results from Tanzania suggest that a home based strategy alone, when designed and implemented at scale, was not sufficient to yield major reductions in newborn mortality in this high-mortality African setting."

Dr Fatuma Manzi, study co-principal investigator from Ifakara Health Institute in Tanzania, added: "This underlines the need to invest in the quality of care in health care facilities in Tanzania and internationally in order to improve newborn survival."

The authors note some study limitations including the possibility of some spill over between comparison and intervention areas, and response bias for newborn care behaviours.

The Improving Newborn Survival in Southern Tanzania (INSIST) study was led by the London School of Hygiene & Tropical Medicine in collaboration with Ifakara Health Institute in Tanzania, Swiss TPH, and Institute of Child Health at UCL. It received funding from the Bill & Melinda Gates Foundation through Saving Newborn Lives (Save the Children), UNICEF Tanzania, the Batchworth Trust, and the Laerdal Foundation.


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