Burden of morbidities and the unmet need for health care in rural neonates--a prospective observational study in Gadchiroli, India.

BACKGROUND: Majority of the neonates in developing countries are born and cared for in rural homes but the available information is mostly hospital based. OBJECTIVES: To estimate: (i) the incidence of various neonatal morbidities and associated case fatality in home-cared rural neonates, (ii) proportion of neonates with indications for health care, and (iii) the proportion who actually receive it. DESIGN: Prospective observational study. SETTING: Rural homes. METHODS: Neonates in 39 study villages in the Gadchiroli district (Maharashtra, India) were observed during one year (1995-96) by 39 trained female village health workers at birth and during neonatal period (0-28 days) by making eight home visits. A physician checked the data and the morbidities were diagnosed by a computer program. Vital statistics in these villages was independently collected. RESULTS: Out of 1016 live births, 95% occurred at home and 763 (75&%) neonates were observed. The agreement between observations by health workers and physician was 92%. Total 48.2& neonates suffered high risk morbidities (associated case fatality >10%), 72.2% suffered low risk morbidities, and 17.9% gained inadequate weight (less than 300 g). Seventeen percent neonates developed clinical picture suggestive of sepsis. Though 54.4% neonates had indications for health care and 38 out of total 40 neonatal deaths occurred in these, only 2.6% received medical attention. The neonatal mortality rate was 52.4/1000 live births. CONCLUSION: Nearly half of the neonates in rural homes developed high risk morbidities ten times the neonatal morbidity rate and needed health care but practically none received it. The magnitude of care gap suggests an urgent need for developing home-based neonatal care to reduce neonatal morbidities and mortality

Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India.

BACKGROUND: Neonatal care is not available to most neonates in developing countries because hospitals are inaccessible and costly. We developed a package of home-based neonatal care, including management of sepsis (septicaemia, meningitis, pneumonia), and tested it in the field, with the hypothesis that it would reduce the neonatal mortality rate by at least 25% in 3 years. METHODS: We chose 39 intervention and 47 control villages in the Gadchiroli district in India, collected baseline data for 2 years (1993-95), and then introduced neonatal care in the intervention villages (1995-98). Village health workers trained in neonatal care made home visits and managed birth asphyxia, premature birth or low birthweight, hypothermia, and breast-feeding problems. They diagnosed and treated neonatal sepsis. Assistance by trained traditional birth attendants, health education, and fortnightly supervisory visits were also provided. Other workers recorded all births and deaths in the intervention and the control area (1993-98) to estimate mortality rates. FINDINGS: Population characteristics in the intervention and control areas, and the baseline mortality rates (1993-95) were similar. Baseline (1993-95) neonatal mortality rate in the intervention and the control areas was 62 and 58 per 1000 live births, respectively. In the third year of intervention 93% of neonates received home-based care. Neonatal, infant, and perinatal mortality rates in the intervention area (net percentage reduction) compared with the control area, were 25.5 (62.2%), 38.8 (45.7%), and 47.8 (71.0%), respectively (p<0.001). Case fatality in neonatal sepsis declined from 16.6% (163 cases) before treatment, to 2.8% (71 cases) after treatment by village health workers (p<0.01). Home-based neonatal care cost US$5.3 per neonate, and in 1997-98 such care averted one death (fetal or neonatal) per 18 neonates cared for. INTERPRETATION: Home-based neonatal care, including management of sepsis, is acceptable, feasible, and reduced neonatal and infant mortality by nearly 50% among our malnourished, illiterate, rural study population. Our approach could reduce neonatal mortality substantially in developing countries.

PIP: The article presents the effect of home-based neonatal care and management of sepsis on neonatal mortality in the Gadchiroli district of India. The study responds to the growing need for the reduction of neonatal mortality rate in developing countries. Sample population involved 39 intervention and 47 control villages in the Gadchiroli district. Baseline data for 2 years (1993-95) were collected from these districts. Neonatal care was introduced in the intervention villages in 1995-98, wherein village health workers trained in neonatal care made home visits and managed sepsis and other neonatal problems. Other workers recorded all births and deaths in the intervention and the control area (1993-98) to estimate mortality rates. Findings showed that the net percentage reduction in the third year of intervention for the neonatal mortality rate was 25.5 (62.2%); for the infant mortality rate, 38.8 (45.7%); and for the perinatal mortality rate, 47.8 (71.0%). Case fatality in neonatal sepsis declined from 16.6% before treatment to 2.8% after treatment by village workers (p 0.01). The article concludes that home-based neonatal care, including management of sepsis could reduce neonatal mortality substantially in developing countries.

Management of childhood pneumonia by traditional birth attendants. The SEARCH Team.

In a field trial in Gadchiroli, India, we trained 30 paramedical workers (PMWs), 25 village health workers (VHWs) and 86 traditional birth attendants (TBAs) from 58 villages to diagnose childhood pneumonia and treat it with sulfamethoxazole+trimethoprim. Continued training, the development of a breath counter, and educative supervision progressively reduced errors in case management made by the TBAs. Over the 3.5-year period 1988-91, 2568 attacks of childhood pneumonia were managed and the case fatality rate was 0.9%, compared with a rate of 13.5% in the control area. The case fatality rates for the three types of worker were similar. The TBAs were superior to the other workers in terms of their availability, outreach, access to neonates, and cost. Satisfaction with the VHWs, and PMWs was expressed by 85%, 69% and 18% of users, respectively. In the intervention area the mortality rate attributable to pneumonia among neonates declined by 44% (P < 0.01) while the total neonatal mortality fell by 20%, presumably because of the involvement of TBAs in the control of acute respiratory infections (ARI). If adequately supported by the health system, TBAs can successfully manage childhood pneumonia in villages at the lowest possible cost and with a high degree of community acceptance. TBAs and VHWs are the most suitable community-based health workers for ARI control programmes in developing countries.

Pneumonia in neonates: can it be managed in the community?

Neonatal pneumonia kills about two million children a year worldwide. The World Health Organisation recommends hospitalisation of all cases of pneumonia in the first two months of infancy. In a field trial of community based management of childhood pneumonia in Gadchiroli, India, neonatal pneumonia contributed more than half of the pneumonia deaths. Parents refused referral even when advised therefore community based health workers and traditional birth attendants managed cases of neonatal pneumonia with co-trimoxazole. Case fatality was 15% (10/65) in all cases and 6% (3/52) in cases without high risk or referral indications. Case fatality in 56 babies aged 30-59 days treated for pneumonia was zero. During the two years of the trial, pneumonia specific mortality rate in the intervention area was 40% less in the neonates and about 80% less in the second month and rest of infancy compared with the control area. Pneumonia in the second month of infancy and uncomplicated cases of neonatal pneumonia can be safely and effectively managed in the community using co-trimoxazole.

Diagnosis of causes of childhood deaths in developing countries by verbal autopsy: suggested criteria. The SEARCH Team.

In the absence of medical certification of deaths in developing countries, lay reporting and verbal autopsy have emerged as useful alternative methods for collecting data on causes of death. Of these, verbal autopsy offers advantages and is widely used in field studies and child survival programmes. However, because uniform and valid criteria for the diagnosis of common causes of death are lacking, comparison of the results of different studies becomes meaningless. This article proposes such a set of criteria for the cause of death among neonates and for those aged 1-59 months. The criteria are based on the findings of earlier validation studies, a Delphi survey and the experience gained from performing 1000 verbal autopsies in Gadchiroli, India. The emergence of such standardized criteria of causes of death should be of immense value for health planning, monitoring and evaluation purposes and for interregional comparisons.

Breath Counter: a new device for household diagnosis of childhood pneumonia.

Illiterate Traditional Birth Attendants (TBAs) were trained to diagnose pneumonia in children using their visual judgement of tachypnoea. This method resulted in 41% wrong diagnosis in the cases with borderline respiratory rate. A simple device, named 'Breath Counter' was designed and TBAs were trained to diagnose pneumonia in children using this instrument. The agreement of TBAs' diagnosis, with diagnosis using WHO criteria of respiratory rate improved from unaided 60% (30/50) to 82% (41/50) by the use of Breath Counter (p less than 0.05). Breath Counter is simple, cheap, effective and can be used even by illiterate persons to diagnose pneumonia in children. It has the potential of becoming a household diagnostic aid.

Community participation in research and action against alcoholism.

An epidemiological study of sickle cell disease in the Gadchiroli district of India established it as a major problem but resulted in no public initiative or action. In contrast, research and action against alcoholism using the participatory approach resulted in massive community participation and proved highly successful. Public health programmes need community participation, yet most research in this field is self-defeating because it alienates lay people.

Reduction in pneumonia mortality and total childhood mortality by means of community-based intervention trial in Gadchiroli, India.

In a community-based intervention trial to reduce childhood mortality from pneumonia the intervention area included 58 villages (6176 children aged 0-4 years) and the control area 44 villages (3947 children) in Gadchiroli, India. The interventions included mass education about childhood pneumonia and case-management of pneumonia by paramedics, village health workers, and traditional birth attendants (TBAs) who were trained to recognise childhood pneumonia and treat it with co-trimoxazole. Parents sought treatment, and coverage was 76% without active case-detection efforts. The case-fatality rate among the 612 cases treated by health workers was 0.8%, compared with 13.5% in the control area. After a year of intervention pneumonia-specific childhood mortality was significantly lower in the intervention than in the control area (8.1 vs 17.5 deaths per 1000 children under 5 years); the difference between the areas was greatest in children under 1 year. The differences in infant mortality (89 vs 121 per 1000) and total under-5 mortality (28.5 vs 40.7 per 1000) were highly significant. Mortality from other causes remained similar in the two areas but neonatal mortality due to birth injury and prematurity was significantly lower in the intervention area, presumably owing to the combination of better maternal and neonatal care by the TBAs trained in the project and the availability of treatment for pneumonia. The cost of co-trimoxazole was US $0.025 per child per year ($2.64 per child saved).

High prevalence of gynaecological diseases in rural Indian women.

A population-based cross-sectional study of gynaecological and sexual diseases in rural women was done in two Indian villages. Of 650 women who were studied, 55% had gynaecological complaints and 45% were symptom-free. 92% of all women were found to have one or more gynaecological or sexual diseases, and the average number of these diseases per woman was 3.6. Infections of the genital tract contributed half of this morbidity. Only 8% of the women had undergone gynaecological examination and treatment in the past. There was an association between presence of gynaecological diseases and use of female methods of contraception, but this could explain only a small fraction of the morbidity. In the rural areas of developing countries, gynaecological and sexual care should be part of primary health care.