Transcript Slide 1

NEWHINTS
Testing a community based
intervention to reduce neonatal
deaths in rural Ghana
NEWHINTS Trial: COLLABORATION
KHRC: Alex Manu; Charlotte Tawiah; Seth Owusu-Agyei;
Ben Weobong; Thomas Gyan; Sammy Danso
LSHTM: Betty Kirkwood; Zelee Hill (now ICH); Karen Edmond;
Seyi Soremekun; Guus ten Asbroek
DHMTs: 6 districts
GHS HQ: Isabella Sagoe-Moses; Patrick Aboagye; Frank
Nyonator
Funders: SNL + WHO + DFID
Kintampo Health
Save the Children
London School of
World Health
Department for
Ghana Health
Research Centre
Saving Newborn
Hygiene &
Organication
International
Service
Lives
Tropical Medicine
Development
Newborn Home Intervention Study
- NEWHINTS Cluster randomised
trial to evaluate
impact of routine
home visits by CBSVs
on neonatal mortality
in rural Ghana
Primary objectives




To develop a feasible and sustainable
intervention to improve newborn care
practices through routine home visits in
pregnancy and the first week of life
To evaluate the impact of these home visits
on all cause neonatal mortality
To evaluate their impact on newborn care
practices
To evaluate the cost-effectiveness of the
intervention
Secondary objectives



To assess the coverage and quality of the service
provided and the family and community response
to the service
To evaluate whether the intervention reduces
socio-economic inequalities in neonatal mortality,
and in access to key interventions
To evaluate the impact of the intervention on ageand cause-specific neonatal mortality
Setting: Brong Ahafo Region
Kintampo North
Tain
Kintampo South
Wenchi
Nkoranza
Techiman
Baseline data
• 18,000 pregnancies: 15,000 live births/year
• Stillbirth rate:
34.0 /1000 live and stillbirths
• Perinatal mortality rate:
55.1 /1000 live and stillbirths
• Neonatal mortality rate:
30.3 /1000 live births
• Maternal mortality ratio:
397 /100,000 live births
• Home deliveries:
50.3%
Overall design
•
•
•
•
Formative research
Development of intervention
Development of evaluation plan
Implementation and evaluation of
intervention (cluster randomised trial)
Formative research
• Families, Range of health care providers
– Literature review
– Focus group discussions
– In depth interviews
– Birth narratives
– Participant observation
– Facility surveys
– Quantitative data analysis
Target behaviors
 Attend antenatal care, including in early pregnancy
 Deliver in a health facility
 Prepare for the birth:
 Facility birth: transport, supplies, financial plan
 Home/impromptu birth: clean delivery, extra birth assistant to
vigorous dry and wrap the baby
 Breastfeed as soon as the cord is cut and place baby skinto-skin with mother
 Bath baby quickly, with warm water and dry immediately
 Keep small babies skin-to-skin, do not bath, feed every 2
hours, & wash hands
 Care seeking for pregnancy, delivery, post partum &
neonatal danger signs
Delivery channel
• Home visits from community health workers
(community based surveillance volunteers)
• District health management team supervision
Intervention design
 Focus on prevention
 Give simple messages through a story for
behaviours where knowledge is the key
barrier
 Counsel/problem solve for behaviours
which require negotiation
 Not direct health care
 Refer and facilitate referral
when necessary
Intervention design
An Integrated Intervention Package
TBA
Sensitisation
Materials
Counsel
Women
(& families)
Training
CBSVs
5 HOME
VISITS
Incentives
Community
Sensitisation
Assess
& Refer
Newborns
Health
Facility
Sensitisation
Supervision
Strengthening DHMTs
Hospital
ENC
Strengthening
Ensure
consistent
advice
Five focused home visits
1. Early
pregnancy
Birth preparedness: Promote facility delivery, planning
for delivery, saving for emergencies, bednets, ANC.
2. 3rd trimester Dry, wrap & breastfeed immediately after delivery (plus
2nd assistant during delivery)
3. Day of birth Weigh and assess the baby for danger signs
Refer very LBW & sick babies to hospital
Encourage exclusive BF; Reduce bathing
Special care for LBW babies
4. Day 3
Assess baby for danger signs & Refer sick babies
Reinforce EBF
Teach danger signs & encourage prompt careseeking
5. Day 7
Assess baby for danger signs & Refer sick babies
Reinforce EBF, prompt careseeking
Encourage bednet use, immunisations
Five focused home visits
PLUS
 Follow-up visits for referred babies
 Visit at 14 days for very LBW babies
• Health cards used to assist with each home
visit
Evaluation design:
Cluster randomised trial
 98 “Newhints” zones in the 6 districts:
 Area covered by 1 supervisor (8-10 CBSVs)
 49 Intervention zones: Newhints package
 49 Control zones: CBSVs continue as usual (eg. encouraging
families to attend on child health days)
 18,000 pregnancies/year; 15,000 live births
 80% power to detect 25% reduction in
neonatal mortality
 Analysis: Intention to treat
Evaluation design
 Outcome
 Process
Outcome evaluation design
- How
 Outcomes
 Independent to intervention implementation
 4-weekly home visits of all women in trial districts
(intervention and control)
 Additional visit after all neonatal deaths (for verbal
post mortem)
Outcome evaluation - What
 Mortality outcomes
 All neonatal deaths
 Causes of death
 Timing of death
 Neonatal care practices
 Facility delivery, EBF, Drying, Wrapping, Bathing,
BF, Care seeking, Bednets
 Access / coverage (quantitative)
 No and timing of visits from CBSV
Process monitoring & evaluation
 Sub-samples from Newhints zones
– In-depth interviews with mothers exploring practices in
detail (constraints, facilitating factors & in Newhints zones
role of CBSV)
– Some quantitative data collection (eg. cost data)
 Special sub-samples from Newhints zones to explore
whether mothers carried out advice on:
– Special care for LBW babies inc. SSC
– Referrals
Process monitoring & evaluation
 Delivery channel, CBSVs, Supervisors, DHMTs
 In depth interviews
 Perceptions and feedback, Supervision, Workload,
Referrals
 Data collection
 Log books , Referral outcome, Supervisor reports, Staff
turnover
 Cost effectiveness
Timescale


July 2008: Intervention fully implemented
Evaluation: Babies born 1 July 2008 - 30 June 2009
 18,000 pregnancies/year; 15,000 live births
 80% power to detect 25% reduction in neonatal mortality

Aug 2009: end of data collection

Analysis: Intention to treat

Nov 2009: main results

IF IT WORKS:


Expand to control zones
Scale-up (Region, rest of Ghana, sub-Saharan Africa)
Thank you