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Community mobilization and behavior change communication promotes adoption of evidencebased essential newborn care practices and reduces neonatal mortality in Uttar Pradesh, India
Darmstadt GL,1,2 Kumar V,1,3 Singh P,3 Singh V,3 Yadav R,3 Mohanty S,3 Bharti N,3 Gupta S,3 Mishra RP,3 Baqui AH,1 Gupta A,3 Awasthi S,3,4 Singh JV,3 Ahuja RC,3 Winch PJ,1 Santosham M1
1Department
of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
2Save the Children-US, Washington, DC, USA
3KGMC Institute of Clinical Epidemiology, 4Department of Pediatrics and 5Department of Social and Preventive Medicine, King George Medical University, Lucknow, India
Study Site: Shivgarh
Introduction
Millennium Development Goal-4 for child survival cannot be met
without substantial reductions in neonatal mortality (Lawn JE et al.
Lancet 2005; 365:891-900). Every year an estimated 4 million
infants die in the first 28 days of life. India accounts for 27% of
global neonatal deaths, and 30% of neonatal mortality in India occurs
in the state of Uttar Pradesh (UP). The majority of births and
neonatal deaths take place at home, away from the reach of skilled
providers. Thus, innovative community-based approaches are
urgently needed to bring substantial improvement in newborn
survival in India.
Figure 1. Neonatal
deaths in the state
of UP, India, in
comparison to
other countries
India - UP
Uttar
Pradesh
(UP)
Others
China
Pakistan
Bangladesh
Ethiopia
Nigeria
Objectives
1) To develop and evaluate a community-based, community-driven
program to deliver the Family Package of interventions (Darmstadt
GL, et al. Lancet 2005; 365:977-988).
2) To determine cost and impact on domiciliary care practices, careseeking and neonatal mortality in a low-resource, high-mortality
setting in rural Uttar Pradesh, India, with a poorly functioning health
system.
Study Design
Cluster-randomized controlled trial in a rural development block
(Shivgarh) with 104,000 population; Gram Sabha (cluster of
contiguous villages) as the unit of randomization. 39 Gram Sabhas
were randomly allocated to one of three study arms:
I : Comparison (usual care)
II: CM + BCC
III: CM + BCC + TS
CM = Community Mobilization
BCC = Behavior Change
Communication
TS = ThermoSpot
(hypothermia indicator)
Area I
Area II
Area III
BAHU
DAKHU
RD
BEDA
RU
DEH
LI
BAIN
TI
Findings: Changes in practices
Table 1. Study site characteristics
Findings: Reduced mortality
Table 2. Impact on stillbirths, perinatal and neonatal mortality
(1,2 = per 1000 live births)
Intervention Area I
Control Area
N
1
(c)
(b)
Intervention
The intervention strategy and BCC package was developed
based on formative research and trials of improved practices
(TIPS). The approach adopted was:
•Community mobilization
•Culturally appropriate BCC
•Community-based workers (Saksham Sahayak) to deliver BCC
messages to pregnant women, their family members and key
community stake-holders through home visitations
•Develop and progressively transfer intervention
responsibilities to community volunteers (Saksham Karta)
Still Birth Rate
Perinatal
Mortality Rate1
Early Neonatal
Mortality Rate2
Neonatal
Mortality Rate2
Rate 95% CI
N
Rate 95% CI
N
Rate 95% CI
1149
1149
55.9 (43.3 – 70.9)
1581
114.5 (97.4 – 134.4) 1581
37.3 (28.5 – 47.9)
70.8 (59.2 – 84.6)
1134
1134
41.4 (30.6 – 54.7)
73.2 (59.5 – 90.0)
1080
62.0 (49.2 – 78.2)
1527
34.8 (26.7 – 45.3)
1087
33.1 (24.0 – 45.6)
1080
84.3 (69.2 – 102.5)
1527
42.0 (33.1 – 53.4)
1087
44.2 (33.5 – 58.2)
(a)
Figure 4. Increased acceptance of skin-to-skin care
Figure 7. Survival curves
Panel 1. BCC Package
•Birth preparedness
•Clean delivery
•Immediate breastfeeding
•Skin-to-skin care (STSC)
•Thermal care
•Hygienic cord care and skin care
Conclusion
Figure 5. Increased initiation of breastfeeding on day 0
Community mobilization and behavior change communications
which avoid conflict with deep-rooted social and cultural values
and roles appear to act together to stimulate the adoption of
evidence-based newborn care practices, leading to reduced
neonatal mortality.
Policy Implications
The Saksham Sahayak developed a cadre of volunteers
(Saksham Karta) who complemented their role. The latter
consisted of mothers who benefited from the intervention and
influential members of the community who have a stake in
newborn care and have volunteered to disseminate and support
modification and adoption of evidence-based behaviors by
family members.
In high mortality settings with poorly functioning health systems,
initial emphasis on promotion of evidence-based family and
community essential newborn care can rapidly improve care
practices and substantially lower neonatal mortality, but
community demand requires simultaneous attention to clinical
care for maternal and newborn complications.
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Acknowledgements
REEN
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Community of Shivgarh
Figure 6. Deceased bathing on day 0
Figure 2. View of Shivgarh with
allocated Gram Sabhas
Intervention Area II
Figure 3. Overview of Intervention visits and data collection