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1.  Emollient therapy for preterm newborn infants – evidence from the developing world 
BMC Public Health  2013;13(Suppl 3):S31.
Introduction
Application of emollients is a widespread traditional newborn care practice in many low and middle-income countries (LMICs) and may have the potential to decrease infection and consequent mortality in preterm neonates.
Methods
We systematically reviewed literature published up to December 2012 to identify studies describing the effectiveness of emollient therapy. We used a standardized abstraction and grading format to estimate the effect of emollient therapy by applying the standard Child Health Epidemiology Reference Group (CHERG) rules.
Results
We included seven studies and one unpublished trial in this review. Topical emollient therapy significantly reduced neonatal mortality by 27% (RR: 0.73, 95% CI: 0.56, 0.94) and hospital acquired infection by 50% (RR: 0.50, 95% CI: 0.36, 0.71). There were significant increases in weight (g) (MD: 98.04, 95% CI: 42.64, 153.45) and weight gain (g/kg/day) (MD: 1.57, 95% CI: 0.79, 2.36), whereas the impacts were non-significant for length and head circumference.
Conclusion
Emollient therapy is associated with improved weight gain, reduced risk of infection and associated newborn mortality in preterm neonates and is a potentially promising intervention for use in low resource settings. Large scale effectiveness trials are required to further assess the impact of this intervention.
doi:10.1186/1471-2458-13-S3-S31
PMCID: PMC3878124  PMID: 24564550
2.  A strategy for reducing maternal and newborn deaths by 2015 and beyond 
Background
Achievement of Millennium Development Goal (MDG) 4 for child survival requires acceleration of gains in newborn survival, and current trends in improving maternal health will also fall short of reaching MDG 5 without more strategic actions. We present a Maternal Newborn and Child Health (MNCH) strategy for accelerating progress on MDGs 4 and 5, sustaining the gains beyond 2015, and further bringing down maternal and child mortality by two thirds by 2030.
Discussion
The strategy takes into account current trends in coverage and cause-specific mortality, builds on lessons learned about what works in large-scale implementation programs, and charts a course to reach those who do not yet access services. A central hypothesis of this strategy is that enhancing interactions between frontline workers and mothers and families is critical for increasing the effective coverage of life-saving interventions. We describe a framework for measuring and evaluating progress which enables continuous course correction and improvement in program performance and impact.
Summary
Evidence for the hypothesis and impact of this strategy is being gathered and will be synthesized and disseminated in order to advance global learning and to maximise the potential to improve maternal and neonatal survival.
doi:10.1186/1471-2393-13-216
PMCID: PMC3866510  PMID: 24261785
3.  Home Care Practices for Newborns in Rural Southern Nepal During the First 2 weeks of Life 
Journal of Tropical Pediatrics  2011;58(3):200-207.
The provision of essential newborn care through integrated packages is essential to improving survival. We analyzed data on newborn care practices collected among infants who participated in a community-based trial in rural Nepal. Analysis focused on feeding, hygienic, skin/cord care and thermal care practices. Data were analyzed for 23 356 and 22 766 newborns on Days 1 and 14, respectively. About 56.6% of the babies were breastfed within 24 h and 80.4% received pre-lacteal feeds within the first 2 weeks of life. Only 13.3% of the caretakers always washed their hands before caring for their infant. Massage with mustard oil was near universal, 82.2% of the babies slept in a warmed room and skin-to-skin contact was rare (4.5%). Many of these commonly practiced behaviors are detrimental to the health and survival of newborns. Key areas to be addressed when designing a community-endorsed care package were identified.
doi:10.1093/tropej/fmr057
PMCID: PMC3530276  PMID: 21705765
essential newborn care; neonatal; hygiene; feeding; thermal; Nepal
4.  Extended-interval Dosing of Gentamicin for Treatment of Neonatal Sepsis in Developed and Developing Countries 
Serious bacterial infections are the single most important cause of neonatal mortality in developing countries. Case-fatality rates for neonatal sepsis in developing countries are high, partly because of inadequate administration of necessary antibiotics. For the treatment of neonatal sepsis in resource-poor, high-mortality settings in developing countries where most neonatal deaths occur, simplified treatment regimens are needed. Recommended therapy for neonatal sepsis includes gentamicin, a parenteral aminoglycoside antibiotic, which has excellent activity against gram-negative bacteria, in combination with an antimicrobial with potent gram-positive activity. Traditionally, gentamicin has been administered 2–3 times daily. However, recent evidence suggests that extended-interval (i.e. ≥24 hours) dosing may be applicable to neonates. This review examines the available data from randomized and non-randomized studies of extended-interval dosing of gentamicin in neonates from both developed and developing countries. Available data on the use of gentamicin among neonates suggest that extended dosing intervals and higher doses (>4 mg/kg) confer a favourable pharmacokinetic profile, the potential for enhanced clinical efficacy and decreased toxicity at reduced cost. In conclusion, the following simplified weight-based dosing regimen for the treatment of serious neonatal infections in developing countries is recommended: 13.5 mg (absolute dose) every 24 hours for neonates of ≥2,500 g, 10 mg every 24 hours for neonates of 2,000–2,499 g, and 10 mg every 48 hours for neonates of <2,000 g.
PMCID: PMC2740664  PMID: 18686550
Developing countries; Drug therapy; Gentamicin; Infant, Newborn; Pharmacokinetics; Review literature; Sepsis
5.  Practices of Rural Egyptian Birth Attendants During the Antenatal, Intrapartum and Early Neonatal Periods 
Neonatal deaths account for almost two-thirds of infant mortality worldwide; most deaths are preventable. Two-thirds of neonatal deaths occur during the first week of life, usually at home. While previous Egyptian studies have identified provider practices contributing to maternal mortality, none has focused on neonatal care. A survey of reported practices of birth attendants was administered. Chi-square tests were used for measuring the statistical significance of inter-regional differences. In total, 217 recently-delivered mothers in rural areas of three governorates were interviewed about antenatal, intrapartum and postnatal care they received. This study identified antenatal advice of birth attendants to mothers about neonatal care and routine intrapartum and postpartum practices. While mothers usually received antenatal care from physicians, traditional birth attendants (dayas) conducted most deliveries. Advice was rare, except for breastfeeding. Routine practices included hand-washing by attendants, sterile cord-cutting, prompt wrapping of newborns, and postnatal home visits. Suboptimal practices included lack of disinfection of delivery instruments, unhygienic cord care, lack of weighing of newborns, and lack of administration of eye prophylaxis or vitamin K. One-third of complicated deliveries occurred at home, commonly attended by relatives, and the umbilical cord was frequently pulled to hasten delivery of the placenta. In facilities, mothers reported frequent use of forceps, and asphyxiated neonates were often hung upside-down during resuscitation. Consequently, high rates of birth injuries were reported. Priority areas for behaviour change and future research to improve neonatal health outcomes were identified, specific to type of provider (physician, nurse, or daya) and regional variations in practices.
PMCID: PMC2740680  PMID: 18637526
Home care; Community; Daya; Delivery; Newborn; Traditional birth attendant; Egypt
6.  Safety of neonatal skin cleansing in rural Nepal 
Indian pediatrics  2006;43(2):117-124.
Objective
A high proportion of deaths during the neonatal period are attributed to infections. Neonatal skin plays an important role in protecting the newborn from invasive pathogens. In preparation for a study of newborn skin cleansing with chlorhexidine in Nepal, we evaluated the feasibility, acceptability, and safety of the newborn cleansing procedure.
Study Design/Setting
Observational pilot study of full-body cleansing of newborns in rural Nepal.
Methods
Thirty-two newborn infants were wiped with commercially available non-antiseptic baby wipes. Pre- and post-procedure axillary temperatures were recorded to estimate the impact of cleansing on body temperature. Skin aggravation, residual moisture, removal of vernix, and maternal satisfaction were assessed qualitatively.
Results
Body temperature of newborns decreased an average of 0.40 °C (95% CI: 0.31 – 0.49 °C, p<.0001) during the procedure. There was no evidence of skin aggravation, injury or removal of vernix, and mothers expressed satisfaction with the procedure. The procedure was simple and project workers were easily trained.
Conclusions
Care must be taken to promptly wrap infants after skin cleansing procedures as slight temperature decrease was noted after the procedure. These pilot data indicate, however, that gentle cleansing of newborn skin poses minimal risk to infants. This procedure is safe and appropriate precautions can be taken to deliver safe skin antisepsis with chlorhexidine to infants in the community.
PMCID: PMC1402338  PMID: 16528107
Neonatal infections; skin antisepsis; chlorhexidine; Nepal
7.  Review of Domiciliary Newborn-care Practices in Bangladesh 
In Bangladesh, high proportions of infant deaths (two-thirds) and deaths among children aged less than five years (38%) occur in the neonatal period. Although most of these deaths occur at home due to preventable causes, little is known about routine domiciliary newborn-care practices and care-seeking for neonatal illness. As an initial step in strategic planning for the implementation of interventions in Bangladesh to improve neonatal outcomes, a review of the literature of antenatal, intrapartum, and postpartum care practices for mothers and newborns in Bangladeshi communities and homes was conducted. A dearth of information was found and summarized, and priority areas for future formative research were identified. The information gained from this review was used for informing development of a guide to formative research on maternal and neonatal care practices in developing-country communities and forms a cornerstone for formulation of behaviour change-communication strategies and messages to advance neonatal health and survival in Bangladesh.
PMCID: PMC3001142  PMID: 17591335
Obstetric care; Behaviour change; Healthcare-seeking; Review literature; Bangladesh
8.  Effect of knowledge of community health workers on essential newborn health care: a study from rural India 
Health Policy and Planning  2011;27(2):115-126.
Background This study explored the relationship between the knowledge of community health workers (CHWs)—anganwadi workers (AWWs) and auxiliary nurse midwives (ANMs)—and their antenatal home visit coverage and effectiveness of the visits, in terms of essential newborn health care practices at the household level in rural India.
Methods We used data from 302 AWWs and 86 ANMs and data from recently delivered women (RDW) (n = 13 023) who were residents of the CHW catchment areas and gave birth to a singleton live baby during 2004–05. Using principal component analysis, knowledge scores for preventive care and danger signs were computed separately for AWWs and ANMs and merged with RDW data. A multivariate logistic regression model was used to estimate the adjusted effect of knowledge level. A generalized estimating equation (GEE) was used to account for clustering.
Results Coverage of antenatal home visits and newborn care practices were positively correlated with the knowledge level of AWWs and ANMs. Initiation of breastfeeding in the first hour of life (odds ratio 1.97; 95% confidence interval (CI): 1.55–2.49 for AWW, and odds ratio 1.62; 95% CI: 1.25–2.09 for ANM), clean cord care (odds ratio 2.03; 95% CI: 1.64–2.52 for AWW, and odds ratio 1.43; 95% CI: 1.17–1.75 for ANM) and thermal care (odds ratio 2.16; 95% CI: 1.64–2.85 for AWW and odds ratio 1.88; 95% CI: 1.43–2.48 for ANM) were significantly higher among women visited by AWWs or ANMs who had better knowledge compared with those with poor knowledge.
Conclusion CHWs’ knowledge is one of the crucial aspects of health systems to improve the coverage of community-based newborn health care programmes as well as adherence to essential newborn care practices at the household level.
doi:10.1093/heapol/czr018
PMCID: PMC3606030  PMID: 21385799
Knowledge level; community health workers; essential newborn health care practices; principal component analysis; logistic regression; generalized estimating equation
9.  Incidence of and Risk Factors for Neonatal Respiratory Depression and Encephalopathy in Rural Sarlahi, Nepal 
Pediatrics  2011;128(4):e915-e924.
OBJECTIVES:
To characterize the incidence of, risk factors for, and neonatal morbidity and mortality associated with respiratory depression at birth and neonatal encephalopathy (NE) among term infants in a developing country.
METHODS:
Data were collected prospectively in 2002–2006 during a community-based trial that enrolled 23 662 newborns in rural Nepal and evaluated the impact of umbilical-cord and skin cleansing on neonatal morbidity and mortality rates. Respiratory depression at birth and NE were defined on the basis of symptoms from maternal reports and study-worker observations during home visits.
RESULTS:
Respiratory depression at birth was reported for 19.7% of live births, and 79% of cases involved term infants without congenital anomalies. Among newborns with probable intrapartum-related respiratory depression (N = 3465), 112 (3%) died before their first home visit (presumed severe NE), and 178 (5%) eventually developed symptoms of NE. Overall, 629 term infants developed NE (28.1 cases per 1000 live births); 2% of cases were associated with congenital anomalies, 25% with infections, and 28% with a potential intrapartum event. The incidence of intrapartum-related NE was 13.0 cases per 1000 live births; the neonatal case fatality rate was 46%. Infants with NE more frequently experienced birth complications and were male, of multiple gestation, or born to nulliparous mothers.
CONCLUSIONS:
In Sarlahi, the incidence of neonatal respiratory depression and NE, associated neonatal case fatality, and morbidity prevalence are high. Action is required to increase coverage of skilled obstetric/neonatal care in this setting and to evaluate long-term impairments.
doi:10.1542/peds.2010-3590
PMCID: PMC3182846  PMID: 21949140
neonatal encephalopathy; neonatal respiratory depression; birth asphyxia; Nepal; developing country; neurodevelopment; intrapartum
10.  60 million non-facility births: Who can deliver in community settings to reduce intrapartum-related deaths? 
Background
For the world’s 60 million non-facility births, addressing who is currently attending these births and what effect they have on birth outcomes is a key starting point toward improving care during childbirth.
Objective
We present a systematic review of evidence for the effect of community-based cadres–community-based skilled birth attendants (SBAs), trained traditional birth attendants (TBAs), and community health workers (CHWs)–in improving perinatal and intrapartum-related outcomes.
Results
The evidence for providing skilled birth attendance in the community is low quality, consisting of primarily before-and-after and quasi-experimental studies, with a pooled 12% reduction in all cause perinatal mortality (PMR) and a 22%–47% reduction in intrapartum-related neonatal mortality (IPR-NMR). Low/moderate quality evidence suggests that TBA training may improve linkages with facilities and improve perinatal outcomes. A randomized controlled trial (RCT) of TBA training showed a 30% reduction in PMR, and a meta-analysis demonstrated an 11% reduction in IPR-NMR. There is moderate evidence that CHWs have a positive impact on perinatal-neonatal outcomes. Meta-analysis of CHW packages (2 cluster randomized controlled trials, 2 quasi-experimental studies) showed a 28% reduction in PMR and a 36% reduction in early neonatal mortality rate; one quasi-experimental study showed a 42% reduction in IPR-NMR.
Conclusion
Skilled childbirth care is recommended for all pregnant women, and community strategies need to be linked to prompt, high-quality emergency obstetric care. CHWs may play a promising role in providing pregnancy and childbirth care, mobilizing communities, and improving perinatal outcomes in low-income settings. While the role of the TBA is still controversial, strategies emphasizing partnerships with the health system should be further considered. Innovative community-based strategies combined with health systems strengthening may improve childbirth care for the rural poor, help reduce gross inequities in maternal and newborn survival and stillbirth rates, and provide an effective transition to higher coverage for facility births.
doi:10.1016/j.ijgo.2009.07.010
PMCID: PMC3428830  PMID: 19815200
Birth asphyxia; Community health worker; Community midwife; Hypoxia; Intrapartum; Neonatal mortality; Stillbirth; Traditional birth attendant
11.  Linking families and facilities for care at birth: What works to avert intrapartum-related deaths? 
Background
Delays in receiving effective care during labor and at birth may be fatal for the mother and fetus, contributing to 2 million annual intrapartum stillbirths and intrapartum-related neonatal deaths each year.
Objective
We present a systematic review of strategies to link families and facilities, including community mobilization, financial incentives, emergency referral and transport systems, prenatal risk screening, and maternity waiting homes.
Results
There is moderate quality evidence that community mobilization with high levels of community engagement can increase institutional births and significantly reduce perinatal and early neonatal mortality. Meta-analysis showed a doubling of skilled birth attendance and a 35% reduction in early neonatal mortality. However, no data are available on intrapartum-specific outcomes. Evidence is limited, but promising, that financial incentive schemes and community referral/transport systems may increase rates of skilled birth attendance and emergency obstetric care utilization; however, impact on mortality is unknown. Current evidence for maternity waiting homes and risk screening is low quality.
Conclusions
Empowering communities is an important strategy to reduce the large burden of intrapartum complications. Innovations are needed to bring the poor closer to obstetric care, such as financial incentives and cell phone technology. New questions need to be asked of “old” strategies such as risk screening and maternity waiting homes. The effect of all of these strategies on maternal and perinatal mortality, particularly intrapartum-related outcomes, requires further evaluation.
doi:10.1016/j.ijgo.2009.07.012
PMCID: PMC3428847  PMID: 19815201
Asphyxia neonatorum; Birth asphyxia; Cash transfers; Community-based health insurance; Community mobilization; Community transport system; Demand for obstetric care; Hypoxia; Maternity waiting homes stillbirth; Neonatal mortality; Risk screening; Vouchers
12.  Streptococcus pneumoniae Serotype-2 Childhood Meningitis in Bangladesh: A Newly Recognized Pneumococcal Infection Threat 
PLoS ONE  2012;7(3):e32134.
Background
Streptococcus pneumoniae is a leading cause of meningitis in countries where pneumococcal conjugate vaccines (PCV) targeting commonly occurring serotypes are not routinely used. However, effectiveness of PCV would be jeopardized by emergence of invasive pneumococcal diseases (IPD) caused by serotypes which are not included in PCV. Systematic hospital based surveillance in Bangladesh was established and progressively improved to determine the pathogens causing childhood sepsis and meningitis. This also provided the foundation for determining the spectrum of serotypes causing IPD. This article reports an unprecedented upsurge of serotype 2, an uncommon pneumococcal serotype, without any known intervention.
Methods and Findings
Cases with suspected IPD had blood or cerebrospinal fluid (CSF) collected from the beginning of 2001 till 2009. Pneumococcal serotypes were determined by capsular swelling of isolates or PCR of culture-negative CSF specimens. Multicenter national surveillance, expanded from 2004, identified 45,437 patients with suspected bacteremia who were blood cultured and 10,618 suspected meningitis cases who had a lumber puncture. Pneumococcus accounted for 230 culture positive cases of meningitis in children <5 years. Serotype-2 was the leading cause of pneumococcal meningitis, accounting for 20.4% (45/221; 95% CI 15%–26%) of cases. Ninety eight percent (45/46) of these serotype-2 strains were isolated from meningitis cases, yielding the highest serotype-specific odds ratio for meningitis (29.6; 95% CI 3.4–256.3). The serotype-2 strains had three closely related pulsed field gel electrophoresis types.
Conclusions
S. pneumoniae serotype-2 was found to possess an unusually high potential for causing meningitis and was the leading serotype-specific cause of childhood meningitis in Bangladesh over the past decade. Persisting disease occurrence or progressive spread would represent a major potential infection threat since serotype-2 is not included in PCVs currently licensed or under development.
doi:10.1371/journal.pone.0032134
PMCID: PMC3316528  PMID: 22479314
13.  Vulnerability of Newborns to Environmental Factors: Findings from Community Based Surveillance Data in Bangladesh 
Infection is the major cause of neonatal deaths. Home born newborns in rural Bangladeshi communities are exposed to environmental factors increasing their vulnerability to a number of disease agents that may compromise their health. The current analysis was conducted to assess the association of very severe disease (VSD) in newborns in rural communities with temperature, rainfall, and humidity. A total of 12,836 newborns from rural Sylhet and Mirzapur communities were assessed by trained community health workers using a sign based algorithm. Records of temperature, humidity, and rainfall were collected from the nearest meteorological stations. Associations between VSD and environmental factors were estimated. Incidence of VSD was found to be associated with higher temperatures (odds ratios: 1.14, 95% CI: 1.08 to 1.21 in Sylhet and 1.06, 95% CI: 1.04 to 1.07 in Mirzapur) and heat humidity index (odds ratios: 1.06, 95% CI: 1.04 to 1.08 in Sylhet and, 1.03, 95% CI: 1.01 to 1.04 in Mirzapur). Four months (June–September) in Sylhet, and six months in Mirzapur (April–September) had higher odds ratios of incidence of VSD as compared to the remainder of the year (odds ratios: 1.72, 95% CI: 1.32 to 2.23 in Sylhet and, 1.62, 95% CI: 1.33 to 1.96 in Mirzapur). Prevention of VSD in neonates can be enhanced if these interactions are considered in health intervention strategies.
doi:10.3390/ijerph8083437
PMCID: PMC3166752  PMID: 21909316
neonatal; infection; sepsis; community health workers; environment; heat humidity index; Bangladesh
14.  Care during labor and birth for the prevention of intrapartum-related neonatal deaths: a systematic review and Delphi estimation of mortality effect 
BMC Public Health  2011;11(Suppl 3):S10.
Background
Our objective was to estimate the effect of various childbirth care packages on neonatal mortality due to intrapartum-related events (“birth asphyxia”) in term babies for use in the Lives Saved Tool (LiST).
Methods
We conducted a systematic literature review to identify studies or reviews of childbirth care packages as defined by United Nations norms (basic and comprehensive emergency obstetric care, skilled care at birth). We also reviewed Traditional Birth Attendant (TBA) training. Data were abstracted into standard tables and quality assessed by adapted GRADE criteria. For interventions with low quality evidence, but strong GRADE recommendation for implementation, an expert Delphi consensus process was conducted to estimate cause-specific mortality effects.
Results
We identified evidence for the effect on perinatal/neonatal mortality of emergency obstetric care packages: 9 studies (8 observational, 1 quasi-experimental), and for skilled childbirth care: 10 studies (8 observational, 2 quasi-experimental). Studies were of low quality, but the GRADE recommendation for implementation is strong. Our Delphi process included 21 experts representing all WHO regions and achieved consensus on the reduction of intrapartum-related neonatal deaths by comprehensive emergency obstetric care (85%), basic emergency obstetric care (40%), and skilled birth care (25%). For TBA training we identified 2 meta-analyses and 9 studies reporting mortality effects (3 cRCT, 1 quasi-experimental, 5 observational). There was substantial between-study heterogeneity and the overall quality of evidence was low. Because the GRADE recommendation for TBA training is conditional on the context and region, the effect was not estimated through a Delphi or included in the LiST tool.
Conclusion
Evidence quality is rated low, partly because of challenges in undertaking RCTs for obstetric interventions, which are considered standard of care. Additional challenges for evidence interpretation include varying definitions of obstetric packages and inconsistent measurement of mortality outcomes. Thus, the LiST effect estimates for skilled birth and emergency obstetric care were based on expert opinion. Using LiST modelling, universal coverage of comprehensive obstetric care could avert 591,000 intrapartum-related neonatal deaths each year. Investment in childbirth care packages should be a priority and accompanied by implementation research and further evaluation of intervention impact and cost.
Funding
This work was supported by the Bill and Melinda Gates Foundation through a grant to the US Fund for UNICEF, and to Saving Newborn Lives Save the Children, through Save the Children US.
doi:10.1186/1471-2458-11-S3-S10
PMCID: PMC3231883  PMID: 21501427
15.  Neonatal resuscitation and immediate newborn assessment and stimulation for the prevention of neonatal deaths: a systematic review, meta-analysis and Delphi estimation of mortality effect 
BMC Public Health  2011;11(Suppl 3):S12.
Background
Of 136 million babies born annually, around 10 million require assistance to breathe. Each year 814,000 neonatal deaths result from intrapartum-related events in term babies (previously “birth asphyxia”) and 1.03 million from complications of prematurity. No systematic assessment of mortality reduction from tactile stimulation or resuscitation has been published.
Objective
To estimate the mortality effect of immediate newborn assessment and stimulation, and basic resuscitation on neonatal deaths due to term intrapartum-related events or preterm birth, for facility and home births.
Methods
We conducted systematic reviews for studies reporting relevant mortality or morbidity outcomes. Evidence was assessed using GRADE criteria adapted to provide a systematic approach to mortality effect estimates for the Lives Saved Tool (LiST). Meta-analysis was performed if appropriate. For interventions with low quality evidence but strong recommendation for implementation, a Delphi panel was convened to estimate effect size.
Results
We identified 24 studies of neonatal resuscitation reporting mortality outcomes (20 observational, 2 quasi-experimental, 2 cluster randomized controlled trials), but none of immediate newborn assessment and stimulation alone. A meta-analysis of three facility-based studies examined the effect of resuscitation training on intrapartum-related neonatal deaths (RR= 0.70, 95%CI 0.59-0.84); this estimate was used for the effect of facility-based basic neonatal resuscitation (additional to stimulation). The evidence for preterm mortality effect was low quality and thus expert opinion was sought. In community-based studies, resuscitation training was part of packages with multiple concurrent interventions, and/or studies did not distinguish term intrapartum-related from preterm deaths, hence no meta-analysis was conducted. Our Delphi panel of 18 experts estimated that immediate newborn assessment and stimulation would reduce both intrapartum-related and preterm deaths by 10%, facility-based resuscitation would prevent a further 10% of preterm deaths, and community-based resuscitation would prevent further 20% of intrapartum-related and 5% of preterm deaths.
Conclusion
Neonatal resuscitation training in facilities reduces term intrapartum-related deaths by 30%. Yet, coverage of this intervention remains low in countries where most neonatal deaths occur and is a missed opportunity to save lives. Expert opinion supports smaller effects of neonatal resuscitation on preterm mortality in facilities and of basic resuscitation and newborn assessment and stimulation at community level. Further evaluation is required for impact, cost and implementation strategies in various contexts.
Funding
This work was supported by the Bill & Melinda Gates Foundation through a grant to the US Fund for UNICEF, and to the Saving Newborn Lives program of Save the Children, through Save the Children US.
doi:10.1186/1471-2458-11-S3-S12
PMCID: PMC3231885  PMID: 21501429
16.  Levels, timing, and etiology of stillbirths in Sylhet district of Bangladesh 
Background
Lack of data is a critical barrier to addressing the problem of stillbirth in countries with the highest stillbirth burden. Our study objective was to estimate the levels, types, and causes of stillbirth in rural Sylhet district of Bangladesh.
Methods
A complete pregnancy history was taken from all women (n = 39 998) who had pregnancy outcomes during 2003-2005 in the study area. Verbal autopsy data were obtained for all identified stillbirths during the period. We used pre-defined case definitions and computer programs to assign causes of stillbirth for selected causes containing specific signs and symptoms. Both non-hierarchical and hierarchical approaches were used to assign causes of stillbirths.
Results
A total of 1748 stillbirths were recorded during 2003-2005 from 48,192 births (stillbirth rate: 36.3 per 1000 total births). About 60% and 40% of stillbirths were categorized as antepartum and intrapartum, respectively. Maternal conditions, including infections, hypertensive disorders, and anemia, contributed to about 29% of total antepartum stillbirths. About 50% of intrapartum stillbirths were attributed to obstetric complications. Maternal infections and hypertensive disorders contributed to another 11% of stillbirths. A cause could not be assigned in nearly half (49%) of stillbirths.
Conclusion
The stillbirth rate is high in rural Bangladesh. Based on algorithmic approaches using verbal autopsy data, a substantial portion of stillbirths is attributable to maternal conditions and obstetric complications. Programs need to deliver community-level interventions to prevent and manage maternal complications, and to develop strategies to improve access to emergency obstetric care. Improvements in care to avert stillbirth can be accomplished in the context of existing maternal and child health programs. Methodological improvements in the measurement of stillbirths, especially causes of stillbirths, are also needed to better define the burden of stillbirths in low-resource settings.
doi:10.1186/1471-2393-11-25
PMCID: PMC3088895  PMID: 21453544
17.  Nosocomial Sepsis Risk Score for Preterm Infants in Low-resource Settings 
Journal of Tropical Pediatrics  2009;56(2):82-89.
Sepsis is a leading cause of mortality for neonates in developing countries; however, little research has focused on clinical predictors of nosocomial infection of preterm neonates in the low-resource setting. We sought to validate the only existing feasible score introduced by Singh et al. in 2003 and to create an improved score. In a secondary analysis of daily evaluations of 497 neonates ≤33 weeks gestational age admitted to a tertiary care NICU in Dhaka, Bangladesh, we tested the Singh score and then constructed and internally validated our own bedside predictive score. The Singh score had low sensitivity of 56.6% but good positive predictive value (PPV) of 78.1% in our sample. Our five-sign model requiring at least one clinical sign of infection (apnea, hepatomegaly, jaundice, lethargy and pallor) had an area under the receiver operating characteristic of 0.70, sensitivity of 77.1%, and PPV of 64.9%. Our clinical sepsis score is the first bedside clinical screen exclusively for hospitalized, very premature neonates in a low-resource setting, and warrants external validation.
doi:10.1093/tropej/fmp061
PMCID: PMC3115678  PMID: 19622712
neonate; sepsis; prematurity; very low birth-weight; developing countries; nosocomial
18.  Household surveillance of severe neonatal illness by community health workers in Mirzapur, Bangladesh: coverage and compliance with referral 
Health Policy and Planning  2009;25(2):112-124.
Background Effective and scalable community-based strategies are needed for identification and management of serious neonatal illness.
Methods As part of a community-based, cluster-randomized controlled trial of the impact of a package of maternal-neonatal health care, community health workers (CHWs) were trained to conduct household surveillance and to identify and refer sick newborns according to a clinical algorithm. Assessments of newborns by CHWs at home were linked to hospital-based assessments by physicians, and factors impacting referral, referral compliance and outcome were evaluated.
Results Seventy-three per cent (7310/10 006) of live-born neonates enrolled in the study were assessed by CHWs at least once; 54% were assessed within 2 days of birth, but only 15% were attended at delivery. Among assessments for which referral was recommended, compliance was verified in 54% (495/919). Referrals recommended to young neonates 0–6 days old were 30% less likely to be complied with compared to older neonates. Compliance was positively associated with having very severe disease and selected clinical signs, including respiratory rate ≥70/minute; weak, abnormal or absent cry; lethargic or less than normal movement; and feeding problem. Among 239 neonates who died, only 38% were assessed by a CHW before death.
Conclusions Despite rigorous programmatic effort, reaching neonates within the first 2 days after birth remained a challenge, and parental compliance with referral recommendation was limited, particularly among young neonates. To optimize potential impact, community postnatal surveillance must be coupled with skilled attendance at delivery, and/or a worker skilled in recognition of neonatal illness must be placed in close proximity to the community to allow for rapid case management to avert early deaths.
doi:10.1093/heapol/czp048
PMCID: PMC2912547  PMID: 19917652
Community health worker; neonatal illness; referral; surveillance; care seeking
19.  Setting Research Priorities to Reduce Almost One Million Deaths from Birth Asphyxia by 2015 
PLoS Medicine  2011;8(1):e1000389.
Joy Lawn and colleagues used a systematic process developed by the Child Health Nutrition Research Initiative (CHNRI) to define and rank research options to reduce mortality from intrapartum-related neonatal deaths (birth asphyxia) by the year 2015.
doi:10.1371/journal.pmed.1000389
PMCID: PMC3019109  PMID: 21305038
20.  Community-based Validation of Assessment of Newborn Illnesses by trained Community Health Workers in Sylhet district of Bangladesh 
Objectives
To validate trained community health workers' (CHWs') recognition of signs and symptoms of newborn illnesses and classification of illnesses using a clinical algorithm during routine home visits in rural Bangladesh.
Methods
Between August 2005 and May 2006, 288 newborns were assessed independently by a CHW and a study physician. Based on a 20-sign algorithm, sick neonates were classified as having very severe disease (VSD), possible very severe disease (PVSD) or no disease. Physician's assessment was considered as the gold standard.
Results
CHWs correctly classified VSD in newborns with a sensitivity of 91%, specificity of 95%, and kappa value of 0.85 (p<0.001) indicating almost perfect agreement with physicians' classification of VSD. CHWs' recognition showed a sensitivity of more than 60% and a specificity of 97–100% for almost all signs and symptoms.
Conclusion
CHWs with minimal training can use a diagnostic algorithm to identify severely ill newborns with high validity.
doi:10.1111/j.1365-3156.2009.02397.x
PMCID: PMC2929169  PMID: 19807901
newborn health; newborn illness; Community Health Workers; validation; Bangladesh; newborn assessment
21.  Population-Based Incidence and Etiology of Community-Acquired Neonatal Bacteremia in Mirzapur, Bangladesh: An Observational Study 
The Journal of infectious diseases  2009;200(6):906-915.
Background
To devise treatment strategies for neonatal infections, the population-level incidence and antibiotic susceptibility of pathogens must be defined.
Methods
Surveillance for suspected neonatal sepsis was conducted in Mirzapur, Bangladesh, from February 2004 through November 2006. Community health workers assessed neonates on postnatal days 0, 2, 5, and 8 and referred sick neonates to a hospital, where blood was collected for culture from neonates with suspected sepsis. We estimated the incidence and pattern of community-acquired neonatal bacteremia and determined the antibiotic susceptibility profile of pathogens.
Results
The incidence rate of community-acquired neonatal bacteremia was 3.0 per 1000 person–neonatal periods. Among the 30 pathogens identified, the most common was Staphylococcus aureus (n = 10); half of all isolates were gram positive. Nine were resistant to ampicillin and gentamicin or to ceftiaxone, and 13 were resistant to cotrimoxazole.
Conclusion
S. aureus was the most common pathogen to cause community-acquired neonatal bacteremia. Nearly 40% of infections were identified on days 0–3, emphasizing the need to address maternal and environmental sources of infection. The combination of parenteral procaine benzyl penicillin and an aminoglycoside is recommended for the first-line treatment of serious community-acquired neonatal infections in rural Bangladesh, which has a moderate level of neonatal mortality. Additional population-based data are needed to further guide national and global strategies.
Trial registration
ClinicalTrials.gov identifier: NCT00198627.
doi:10.1086/605473
PMCID: PMC2841956  PMID: 19671016
22.  Can Early Postpartum Home Visits by Trained Community Health Workers Improve Breastfeeding of Newborns? 
Objectives
Whether postpartum visits by trained community health workers (CHW), reduce newborn breastfeeding problems.
Methods
CHWs made antenatal and postpartum home visits promoting newborn care practices including breastfeeding. CHWs assessed neonates for adequacy of breastfeeding and provided hands on support to mothers to establish breastfeeding. History and observation data of 3,495 neonates were analyzed to assess effects of CHW visitation on feeding problems.
Results
Inappropriate breastfeeding position and attachment were the predominant problems (12% –15%). 6% of newborns who received home visit by CHWs within 3 days had feeding difficulties, compared to 34% of those who did not (OR: 7.66, 95% CI: 6.03–9.71, p=0.00). Latter group was 11.4 times (95% CI: (6.7–19.3, p=0.00) more likely to have feeding problems as late as day 6–7, than the former.
Conclusions
Counselling and hands on support on breastfeeding techniques by trained workers within first 3 days of birth, should be part of community based postpartum interventions.
doi:10.1038/jp.2008.64
PMCID: PMC2929160  PMID: 18596714
Breastfeeding; Community Health Workers; Newborn care; Postpartum visit; Bangladesh
23.  Newborn umbilical cord and skin care in Sylhet District, Bangladesh: Implications for promotion of umbilical cord cleansing with topical chlorhexidine 
Background
Newborn cord care practices may directly contribute to infections, which account for a large proportion of the 4 million annual global neonatal deaths. This formative research study assessed current umbilical and skin care knowledge and practices for neonates in Sylhet, Bangladesh in preparation for a cluster-randomised trial of the impact of topical chlorhexidine cord cleansing on neonatal mortality and omphalitis.
Methodology
Unstructured interviews (n=60), structured observations (n=20), rating and ranking exercises (n=40), and household surveys (n=400) were conducted to elicit specific behaviours regarding newborn cord and skin care practices. These included hand-washing, skin and cord care at the time of birth, persons engaged in cord care, cord cutting practices, topical applications to the cord at the time of birth, wrapping/dressing of the cord stump, and use of skin-to-skin care.
Results
Ninety percent of deliveries occurred at home. The umbilical cord was almost always (98%) cut after delivery of the placenta, and cut by mothers in more than half the cases (57%). Substances were commonly (52%) applied to the stump after cord cutting; turmeric was the most common application (83%). Umbilical stump care revolved around bathing, skin massage with mustard oil, and heat massage on the umbilical stump. Forty-two percent of newborns were bathed on the day of birth. Mothers were the principal provider for skin and cord care during the neonatal period and 9% reported umbilical infections in their infants.
Discussion
Unhygienic cord care practices are prevalent in the study area. Efforts to promote hand washing, cord cutting with clean instruments, and avoiding unclean home applications to the cord may reduce exposure and improve neonatal outcomes. Such efforts should broadly target a range of caregivers, including mothers and other female household members.
doi:10.1038/jp.2008.164
PMCID: PMC2929163  PMID: 19057570
umbilical cord care; formative research; chlorhexidine; skin care; neonatal health; Bangladesh
24.  Effectiveness of Home-based Management of Newborn Infections by Community Health Workers in Rural Bangladesh 
Background
Infections account for about half of neonatal deaths in low-resource settings. Limited evidence supports home-based treatment of newborn infections by community health workers (CHW).
Methods
In one study arm of a cluster randomized controlled trial, CHWs assessed neonates at home using a 20-sign clinical algorithm and classified sick neonates as having very severe disease or possible very severe disease. Over a two-year period, 10 585 live births were recorded in the study area. CHWs assessed 8474 (80%) of the neonates within the first week of life and referred neonates with signs of severe disease. If referral failed but parents consented to home treatment, CHWs treated neonates with very severe disease or possible very severe disease with multiple signs, using injectable antibiotics.
Results
For very severe disease, referral compliance was 34% (162/478 cases), and home treatment acceptance was 43% (204/478 cases). The case fatality rate was 4.4% (9/204) for CHW treatment, 14.2% (23/162) for treatment by qualified medical providers, and 28.5% (32/112) for those who received no treatment or who were treated by other unqualified providers. After controlling for differences in background characteristics and illness signs among treatment groups, newborns treated by CHWs had a hazard ratio of 0.22 (95% confidence interval 0.07–0.71) for death during the neonatal period and those treated by qualified providers had a hazard ratio of 0.61 (95% confidence interval of 0.37–0.99), compared with newborns who received no treatment or were treated by untrained providers. Significantly increased hazards ratios of death were observed for neonates with convulsions (HR 6.54; 95% CI 3.98–10.76), chest in-drawing (HR 2.38, 95% CI 1.29–4.39), temperature < 35.3°C (HR 3.47, 95% CI 1.30–9.24), unconsciousness (HR 7.92, 95% CI 3.13–20.04).
Conclusions
Home treatment of very severe disease in neonates by CHWs was effective and acceptable in a low-resource setting in Bangladesh.
doi:10.1097/INF.0b013e31819069e8
PMCID: PMC2929171  PMID: 19289979
neonatal; infection; sepsis; community health workers; Bangladesh
25.  Neonatal hypothermia and associated risk factors among newborns of southern Nepal 
BMC Medicine  2010;8:43.
Background
Neonatal hypothermia is associated with an increased mortality risk for 28 days. There are few community-based data on specific risk factors for neonatal hypothermia. Estimates of association between neonatal hypothermia in the community and risk factors are needed to guide the design of interventions to reduce exposure.
Methods
A cohort of 23,240 babies in rural southern Nepal was visited at home by field workers who measured axillary temperatures for 28 days (213,316 temperature measurements). The cumulative incidence of hypothermia (defined as < 35.0°C based on an analysis of the hypothermia-mortality risk relationship) was examined for any association with infant characteristics, care practices and parental, household, socioeconomic and demographic factors. Estimates were adjusted for age and ambient temperature.
Results
Ten percent of the babies (n = 2342) were observed with temperatures of < 35.0°C. Adjusted prevalence ratios (Adj PR) were increased among those who weighed < 2000 g [Adj PR = 4.32 (3.73, 5.00)] or < 1500 g [Adj PR = 11.63 (8.10, 16.70)] compared to those of normal weight (> 2500 g). Risk varied inversely along the entire weight spectrum: for every 100 g decrement hypothermia risk increased by 7.4%, 13.5% and 31.3%% for babies between 3000 g and 2500 g, 2500 g and 2000 g and < 2000 g, respectively. Preterm babies (< 34 weeks), females, those who had been first breastfed after 24 h and those with hypothermic mothers were at an increased risk. In the hot season the risk disparity between smaller and larger babies increased. Hypothermia was not associated with delayed bathing, hat wearing, room warming or skin-to-skin contact: they may have been practiced reactively and thereby obscured any potential benefit.
Conclusions
In addition to season in which the babies were born, weight is an important risk factor for hypothermia. Smaller babies are at higher relative risk of hypothermia during the warm period and do not receive the protective seasonal benefit apparent among larger babies. The need for year-round thermal care, early breastfeeding and maternal thermal care should be emphasized. Further work is needed to quantify the benefits of other simple neonatal thermal care practices.
doi:10.1186/1741-7015-8-43
PMCID: PMC2911389  PMID: 20615216

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