Review question
Is community health educational intervention for newborn care effective in improving neonatal health and survival in low- and middle-income countries?
Background
In low- and middle-income countries (LMICs), health service utilisation is low and neonatal mortality and morbidity are high. However, improvements in neonatal outcomes have been documented in several studies with simple health educational interventions. This review assessed the effectiveness of health education strategies imparted to mothers or their family members in community settings of LMICs. It also assessed the impact of health education strategies on neonatal mortality, neonatal morbidity, access to health care, and cost.
Study characteristics
A total of 33 experimental studies were conducted across Africa and Central and South America, with most reported from Asia, specifically India, Pakistan, and Bangladesh. Of the 33 community educational interventions, 16 required involvement of family members, most frequently the mother-in-law or the expectant father. Most studies (n = 14) involved one-to-one counselling between a range of community healthcare workers and mothers, and 12 involved group counselling consisting predominantly of mothers, with family members included occasionally; the remaining seven had components of both one-to-one and group counselling.
Key results
This review found that community health educational interventions significantly reduced newborn death, early newborn mortality, and late newborn mortality, as well as perinatal mortality. These interventions also positively impacted utilisation of any before birth (antenatal), care during pregnancy, and initiation of breastfeeding within an hour after birth. The review shows that educational interventions delivered to both mothers and other family members in a group setting had a greater impact on these outcomes. Educational interventions delivered during antenatal care were more effective for reducing early neonatal deaths, and those delivered during both antenatal and postnatal (after birth) periods were effective for reducing late neonatal deaths and perinatal deaths. Educational interventions during the postnatal period were most effective for improving breastfeeding practices.
Quality of evidence
The quality of evidence is low for newborn mortality outcomes and very low for early, late, and perinatal mortality. This reflects concerns of bias, inconsistency (unexplained variability of results), and imprecision (variation in studies presenting both benefit and harm from the intervention) of the included randomised controlled trials.
This review offers encouraging evidence on the value of integrating packages of interventions with educational components delivered by a range of community workers in group settings in LMICs, with groups consisting of mothers, and additional education for family members, for improved neonatal survival, especially early and late neonatal survival.
In low- and middle-income countries (LMICs), health services are under-utilised, and several studies have reported improvements in neonatal outcomes following health education imparted to mothers in homes, at health units, or in hospitals. However, evaluating health educational strategy to deliver newborn care, such as one-to-one counselling or group counselling via peer or support groups, or delivered by health professionals, requires rigorous assessment of methodological design and quality, as well as assessment of cost-effectiveness, affordability, sustainability, and reproducibility in diverse health systems.
To compare a community health educational strategy versus no strategy or the existing approach to health education on maternal and newborn care in LMICs, as imparted to mothers or their family members specifically in community settings during the antenatal and/or postnatal period, in terms of effectiveness for improving neonatal health and survival (i.e. neonatal mortality, neonatal morbidity, access to health care, and cost).
We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 4), in the Cochrane Library, MEDLINE via PubMed (1966 to 2 May 2017), Embase (1980 to 2 May 2017), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 2 May 2017). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.
Community-based randomised controlled, cluster-randomised, or quasi-randomised controlled trials.
Two review authors independently assessed trial quality and extracted the data. We assessed the quality of evidence using the GRADE method and prepared 'Summary of findings' tables.
We included in this review 33 original trials (reported in 62 separate articles), which were conducted across Africa and Central and South America, with most reported from Asia, specifically India, Pakistan, and Bangladesh. Of the 33 community educational interventions provided, 16 included family members in educational counselling, most frequently the mother-in-law or the expectant father. Most studies (n = 14) required one-to-one counselling between a healthcare worker and a mother, and 12 interventions involved group counselling for mothers and occasionally family members; the remaining seven incorporated components of both counselling methods.
Our analyses show that community health educational interventions had a significant impact on reducing overall neonatal mortality (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.78 to 0.96; random-effects model; 26 studies; n = 553,111; I² = 88%; very low-quality evidence), early neonatal mortality (RR 0.74, 95% CI 0.66 to 0.84; random-effects model; 15 studies that included 3 subsets from 3 studies; n = 321,588; I² = 86%; very low-quality evidence), late neonatal mortality (RR 0.54, 95% CI 0.40 to 0.74; random-effects model; 11 studies; n = 186,643; I² = 88%; very low-quality evidence), and perinatal mortality (RR 0.83, 95% CI 0.75 to 0.91; random-effects model; 15 studies; n = 262,613; I² = 81%; very low-quality evidence). Moreover, community health educational interventions increased utilisation of any antenatal care (RR 1.16, 95% CI 1.11 to 1.22; random-effects model; 18 studies; n = 307,528; I² = 96%) and initiation of breastfeeding (RR 1.56, 95% CI 1.37 to 1.77; random-effects model; 19 studies; n = 126,375; I² = 99%). In contrast, community health educational interventions were found to have a non-significant impact on use of modern contraceptives (RR 1.10, 95% CI 0.86 to 1.41; random-effects model; 3 studies; n = 22,237; I² = 80%); presence of skilled birth attendance at birth (RR 1.09, 95% CI 0.94 to 1.25; random-effects model; 10 studies; n = 117,870; I² = 97%); utilisation of clean delivery kits (RR 4.44, 95% CI 0.71 to 27.76; random-effects model; 2 studies; n = 17,087; I² = 98%); and care-seeking (RR 1.11, 95% CI 0.97 to 1.27; random-effects model; 7 studies; n = 46,154; I² = 93%).
Cost-effectiveness analysis conducted in seven studies demonstrated that the cost-effectiveness for intervention packages ranged between USD 910 and USD 11,975 for newborn lives saved and newborn deaths averted. For averted disability-adjusted life-year, costs ranged from USD 79 to USD 146, depending on the intervention strategy; for cost per year of lost lives averted, the most effective strategy was peer counsellors, and the cost was USD 33.