Components of interventions and key features of controlled trials of community-based approaches to improve newborn survival.

a<p>Intervention 2 added liquid crystal thermometry by community health workers.</p>b<p>Rate ratio.</p>c<p>Comparison was pre-post intervention, not intervention-control.</p><p>CI, confidence interval; RCT, randomised controlled trial.</p

Maternity as a life event, components of care with potential effects on newborn survival, and 11 possible delivery strategies.

<p>Maternity as a life event, components of care with potential effects on newborn survival, and 11 possible delivery strategies.</p

Characteristics of the studies and populations included in the analysis.

a<p>Neonatal mortality rate from cRCT baseline data.</p>b<p>Neonatal mortality rate from district health survey data.</p><p>OBC, other backward class.</p

Generating Insights from Trends in Newborn Care Practices from Prospective Population-Based Studies: Examples from India, Bangladesh and Nepal

<div><p>Background</p><p>Delivery of essential newborn care is key to reducing neonatal mortality rates, yet coverage of protective birth practices remains incomplete and variable, with or without skilled attendance. Evidence of changes over time in newborn care provision, disaggregated by care practice and delivery type, can be used by policymakers to review efforts to reduce mortality. We examine such trends in four areas using control arm trial data.</p><p>Methods and Findings</p><p>We analysed data from the control arms of cluster randomised controlled trials in Bangladesh (27 553 births), eastern India (8 939), Dhanusha, Nepal (15 344) and Makwanpur, Nepal (6 765) over the period 2001–2011. For each trial, we calculated the observed proportion of attended births and the coverage of WHO essential newborn care practices by year, adjusted for clustering and stratification. To explore factors contributing to the observed trends, we then analysed expected trends due only to observed shifts in birth attendance, accounted for stratification, delivery type and statistically significant interaction terms, and examined disaggregated trends in care practice coverage by delivery type. Attended births increased over the study periods in all areas from very low rates, reaching a maximum of only 30% of deliveries. Newborn care practice trends showed marked heterogeneity within and between areas. Adjustment for stratification, birth attendance and interaction revealed that care practices could change in opposite directions over time and/or between delivery types – e.g. in Bangladesh hygienic cord-cutting and skin-to-skin contact fell in attended deliveries but not home deliveries, whereas in India birth attendant hand-washing rose for institutional deliveries but fell for home deliveries.</p><p>Conclusions</p><p>Coverage of many essential newborn care practices is improving, albeit slowly and unevenly across sites and delivery type. Time trend analyses of birth patterns and essential newborn care practices can inform policy-makers about effective intervention strategies.</p></div

Analysis study periods.

<p>The study periods used in the analysis, for each site. “Year” refers to the study year, i.e. the 12-month period from the start of the study (see text).</p

Comparison of deliveries with and without clean delivery kit use.

<p>*Differences between clean delivery kit use and non-use tested using chi-square statistic and significant at <i>p</i><0.05.</p>a<p>Not applicable: data were not collected in the study.</p>b<p>Standard terms used in Indian demographic surveys.</p>c<p>Doctor, nurse, or trained midwife.</p><p>na, not available.</p

Adjusted odds ratios for the association between clean delivery kit use and clean delivery practices with neonatal mortality.

a<p>Adjusted for clustering, maternal age, maternal education, maternal reading ability, household assets, bleeding in pregnancy, excessive bleeding during delivery, preterm delivery, exclusive breastfeeding for the first 6 wk of life, season, number of antenatal care visits, malpresentation at delivery, fever 3 d prior to delivery, and, for the pooled analysis, study site.</p>b<p>Data available from India, Bangladesh, and Nepal, <i>n</i> = 19,754.</p>c<p>Adjusted for the indicators above and the use of a clean delivery kit.</p>d<p>It was not possible to obtain estimates for this model because of low numbers of cases where antiseptic was used; however, it was possible to include Nepal data in the pooled analysis.</p>e<p>Adjusted for the indicators above, and for delivery by a TBA, cord wrapped around infant's neck at delivery, infant condition at 5 min, parity, delivery by a skilled birth attendant (doctor, nurse, trained midwife).</p>f<p>Data available from India and Bangladesh, <i>n</i> = 13,882.</p>g<p>Not applicable: data were not collected in the study.</p

Trends in birth attendance.

<p>Proportion of births taking place in an institution or at home with a skilled birth attendant by year, in each study area (with 95% confidence intervals). Note that for Makwanpur there are very few observations in the control arm in 2008 and so the 95% confidence intervals become very large (2.9%, 68%), hence this data point was considered meaningless and is not shown. Note also that for eastern India, 2005 only contained five months of data including an anomalously high first month.</p

Schematic diagram of analysis.

<p>The analysis conducted to address the three key research questions posed is shown schematically.</p

Illustrative application: Bangladesh.

<p>Interesting analysis findings for Bangladesh, highlighting the sorts of potential learning and questions for further inquiry that would be of most relevance to researchers and policy-makers in these areas.</p