In Uganda, child mortality rates are improving, but progress is slower for deaths occurring in the first four weeks of life, or the newborn period, and for stillbirths. But recent evidence from local researchers show that a cost-effective package of care linking families, government-mandated village health teams (a form of community health workers), and health facilities can improve life-saving practices during pregnancy, childbirth and in the first weeks of life; and benefit poorest families the most. This new evidence was published as a special issue of the peer-reviewed journal Global Health Action.
The nine-article special issue, titled Newborn Health in Uganda, details results of a community randomized trial, the Uganda Newborn Study (UNEST), which evaluated an integrated care package linking homes, clinics and hospitals and involving visits during pregnancy and the postnatal period at home by a designated member of the village health team. The study was carried out in rural eastern Uganda by Ugandan researchers using existing health system structures and in partnership with national policy-makers and district leaders.
The UNEST results demonstrate that these home visits in pregnancy and soon after delivery were possible to achieve, and that life-saving behaviors could be improved by this interaction. Breastfeeding practices, skin-to-skin care immediately after birth, delaying a baby's first bath, and hygienic care of the baby's umbilical cord stump were higher amongst the families receiving home visits compared to those that did not receive them. Importantly, these home visits were pro-poor, with more women in the poorest households, who are at most risk of encountering difficulties in access to care, receiving an early home visit after delivery when compared to the wealthiest families.
According to the editorial published as part of the special issue, UNEST was influenced by the previously published neonatal survival series in the Lancet which identified cost-effective interventions that could prevent the majority of deaths in the newborn period.
It was this series that initially prompted Ugandan officials to act, organizing the nation's first stakeholder meeting on newborn survival and setting up the National Newborn Steering Committee which has proactively served as the country's lead advisory group on newborn care since 2009. UNEST, designed to address important gaps for care around the time of birth at community and facility level, was adapted from similar trials conducted in South Asia, and carried out concurrently with five other country trials conducted through the Africa Newborn Network.
Prof. Joy Lawn Director of the MARCH Centre at the London School of Hygiene, was involved in the trial from the outset. In the editorial, she and her co-authors identify four key learnings from UNEST:
- While community care is pro-poor in this rural African context, scalability depends on recognition of community care as a part of the health system with consistent funding and supervision. UNEST results proved that harmful behaviors can be altered as a result of the interactions between mothers and the village health team members, even if behaviors are strongly held. But researchers warn inadequate funding at district level could impede expansion efforts and further integration between community programs and health facility care.
- Quality care at facilities is crucial for ending preventable deaths amongst mothers and their babies. Care at the time of birth is highlighted as a sensitive marker of any health system. Improved quality of care at clinic and hospital level through management and procurement support were associated with increases in women delivering at health facilities instead of at home in both study intervention arms. However, systemic challenges related to staff shortages and attrition, and supply chain failures for drugs and equipment affect all healthcare users and babies are the most vulnerable.
- Innovations can address key challenges. UNEST tested a number of novel solutions to address the realities of operating in a low resource setting. Innovative solutions included a foot length card that village health workers can use, in the absence of a scale, to identify and refer small babies to the health facility for extra care.
- Local leadership is key and requires intentional strategies. UNEST provides a model for local capacity building intended to inform national policy. More leaders are needed, particularly at district level, to shine light on the burden of stillbirths and neonatal deaths on families, communities and the health system, and to champion the cause of improving care at birth and ending these preventable deaths.
The study, supported by funding from The Bill & Melinda Gates Foundation through Save the Children's Saving Newborn Lives program and the Swedish International Development Agency, was the first of its kind to be led and carried out by local researchers in Uganda.
Professor Stefan Peterson, co-Principal Investigator of the study says, "We are especially happy to have graduated three Ugandan PhDs from this study who are experts in newborn health research. Capacity development should be part of all studies and that is how we will build national cadres of researchers."
Among those leading the study was Dr. Peter Waiswa, from Makerere University School of Public Health and senior lecturer at Karolinska Institutet in Sweden. Dr. Waiswa explains, "I grew up around this region and know how important community is. As a medical doctor working within the rural health system before becoming a researcher, I felt there was more we could do to understand and address the gaps between households and health facilities that are keeping women from accessing quality care for themselves and their newborns."