This month the Government of India (GOI) made a landmark decision to provide an incentive payment to accredited social health activists (ASHAs) to conduct routine home-based newborn care.
Until now, the National Rural Health Mission (NRHM), the flagship national primary healthcare program of the GOI, has paid ASHAs, the key frontline, village-based workers of this system, to provide other select, high-priority services. The focus has been primarily on promoting hospital- or clinic-based childbirth care through a conditional cash transfer scheme called Janani Suraksha Yojana (JSY), by providing women an incentive to deliver in the hospital and giving ASHAs an incentive to get women there.
The JSY program has driven tremendous social norm change by substantially increasing the number of women who give birth in health facilities in India, and there is early evidence of an impact on reducing newborn mortality. A criticism of the program, however, is that the focus on facility delivery has distorted healthcare provision by neglecting other key aspects of maternal and newborn care, particularly quality postnatal care.
This week’s landmark decision to promote newborn care at home recognizes a body of evidence that has developed over the past 15 years—evidence that suggests that this new policy has the potential to make a game-changing impact on neonatal as well as maternal mortality.
To understand how impactful the decision may be, it’s important to detail some of what this body of evidence has uncovered about the link between home-based visits and newborn mortality. In fact, the studies from which the evidence comes were instrumental in informing the UNICEF and WHO Joint Statement on home-based care of newborns, released in July 2009, which recommends home visits on days one and three of a newborn's life, and if possible, a third visit before the end of the first week of life.
In 1999, Dr. Abhay Bang and his team at a local Indian NGO in Maharastra state of India, called the Society for Education, Action and Research in Community (SEARCH), demonstrated a 62-percent reduction in neonatal mortality through multiple home visits—generally three prenatal visits and eight postnatal visits. Trained village health workers visited women in their homes and promoted preventive care, as well as provided identification and case management of key conditions—particularly serious neonatal infections and low birth weight.
The GOI’s decision is a tribute to the pioneering work of Dr. Abhay Bang and his team. This landmark, home-based intervention was developed in response to a lack of care-seeking for newborn care, including lack of compliance with going to a health facility for care of a sick newborn even when recommended by a healthcare provider. Since that time, SEARCH has expanded its approach through partnership with NGOs and governments, and has inspired newborn care programs in sub-Saharan Africa and in other Indian states.
To replicate and extend the SEARCH findings, Johns Hopkins University investigators teamed up with an international research center, the International Center for Diarrhoeal Disease Research Bangladesh (ICDDR,B), Shimantik (an NGO), Dhaka Shishu Hospital, and the Government of Bangladesh. The study demonstrated a 34-percent reduction in neonatal mortality through a reduced number of home-based visits—in this case, two prenatal and three postnatal visits, by trained community health workers in Sylhet district, Bangladesh.
The study confirmed and uncovered some fascinating results. First, the study confirmed that community-based workers are capable of identifying and managing newborns with serious infections, including the administration of injectable antibiotics at home in instances where the family refuses to go to a health facility for care.
Another critical finding was that if the first postnatal visit occurred within 48 hours of birth, there was a significant (64-percent) reduction in neonatal mortality. If the first visit occurred after 48 hours, however, there was no impact on neonatal mortality rates. This pointed out just how important these home visits are to saving newborn lives, immediately after birth.
In Shivgarh block in Uttar Pradesh state, India, Johns Hopkins University and local investigators of the Community Empowerment Lab in Lucknow worked together to implement a package of preventive care focused on newborn thermal care, including skin-to-skin care, and prevention of neonatal infections, promoted through community meetings and a limited number of antenatal (two) and postnatal (two) visits. Through this package of care, investigators documented a 54-percent reduction in neonatal mortality, corroborating the analyses of the Lancet Neonatal Survival Series and demonstrating conclusively that preventive interventions at home can make a substantial impact on reducing neonatal mortality.
Evidence clearly suggests, then, along with the WHO and UNICEF recommendations, that a program of home-based newborn care can avert 30 to 60 percent of all newborn deaths. It is recommended that skilled health workers specifically promote and support early (within the first hour after birth) and exclusive breastfeeding; skin-to-skin contact between mother and infant; hygienic umbilical cord and skin care. The health workers should also assess the baby for signs of serious health problems; advise referral for prompt medical care if necessary; and encourage timely vaccination according to national schedules.
Finally, during home visits, the WHO and UNICEF joint statement emphasizes that the mother should also be asked whether she has any of a variety of danger signs signaling the presence of critical conditions such as hemorrhage, infection, or hypertensive disease; or difficulties with breastfeeding. She should be counseled about seeking care for problems, and about postpartum family planning and nutrition. Estimates suggest that about one-third of maternal deaths can also be addressed through such home visits with facilitated referral of women with problems to an appropriate health facility.
This month’s decision, then, on the part of the Government of India, to encourage ASHAs to provide routine, home-based care for mothers and their newborns, is a milestone in the effort to prevent maternal and newborn deaths in a country where about a quarter of all the world’s maternal and newborn deaths currently occur each year.