Elsevier

Seminars in Perinatology

Volume 34, Issue 6, December 2010, Pages 477-485
Seminars in Perinatology

Why Is Continuum of Care from Home to Health Facilities Essential to Improve Perinatal Survival?

https://doi.org/10.1053/j.semperi.2010.09.001Get rights and content

The period around the time of delivery is extremely hazardous for infants in developing countries. After the first week the risk drops sharply, and survival improves markedly. To reduce perinatal mortality, a continuum of care between the home and the various facilities is essential during pregnancy, childbirth and the newborn period. This paper reviews strategies to promote the establishment of this continuum: providing health care within or close to home by frontline workers and increasing the use of services in health facilities through community mobilization and financing strategies. As perinatal care and care for seriously sick children face common challenges and lessons could be learned from successful strategies for management of other illnesses, this paper also reviews intervention models involving community health workers (CHWs) to improve case management of sick children at the household and community levels. Available evidence suggests that the community strategy with the greatest impact on neonatal mortality is home visits by CHWs combined with community mobilization. The same strategy appears to be effective in increasing health facility utilization. An equally effective strategy for increasing health facility utilization seems to be financing health care to remove financial access barriers, particularly using conditional cash transfers or vouchers. Although the availability of information on the effect of community interventions to improve newborn health has increased in the recent past, significant gaps remain. Information on the effectiveness of strategies in different settings, particularly in sub-Saharan Africa, cost-effectiveness and sustainability are particularly needed and should be gathered in future studies.

Section snippets

Search Strategy and Studies

We searched PubMed and the Cochrane Controlled Trials Register in the Cochrane Library for randomized controlled trials (RCTs), systematic reviews, meta-analyses, and qualitative reviews. The search strategy included the following groups of keywords connected by “and”: (i) newborn OR neonate OR neonatal OR stillbirth OR stillborn; (ii) community OR home; and (iii) health center OR health facility OR Hospital. We included only studies that had been conducted in countries with a low or middle

Strategies to Improve Linkages Between Homes and Health Facilities

Several community-intervention strategies have the potential to improve the links between home and the health facility. In subsequent sections, we briefly review the evidence for the following 3 approaches:

  • 1

    home-based care by traditional birth attendants (TBAs) and CHWs;

  • 2

    community mobilization, particularly a participatory intervention strategy involving women's group meetings; and

  • 3

    financing strategies to increase demand for health services

Impact of Community-Based Strategies on Neonatal Mortality

There is a growing body of evidence that community-based interventions can reduce neonatal mortality in high-mortality settings with very low access to facility based care.13, 14 The authors of a systematic review identified 60 studies that evaluated training of TBAs, of which 32 had a postcomparison design and 21 had a pre-post design.15 We added the results of a subsequently published RCT of effectiveness of training TBAs conducted in Pakistan to those of the meta-analysis.16 Another

Impact of Community-Based Strategies on Health Facility Utilization

There are 3 possible mechanisms of effect of community-based strategies on neonatal survival. First, the intervention strategy may result in optimal newborn care practices which prevent illness and promote healthy growth and development.13 Second, provision of timely and appropriate care and treatment at or near home could reduce severity of illness. Finally, the impact on mortality could be a result of improved linkages between the homes and health facilities and increased use of health

Lessons from Other Health Programs

The community-facility continuum of care for other childhood illnesses, such as pneumonia, diarrhea and malaria also follows the same pattern, ie, home care, care seeking for illness, management of illness at community or health facility, and emergency triage assessment and treatment, and appropriate management of severely ill children in hospitals. These are part of Integrated Management of Childhood Illness (IMCI), where referral of seriously sick children is important for survival. Children

Gaps in Evidence

The availability of information on the effect of community interventions to improve newborn health has increased significantly in the recent past. As part of this new evidence base are the findings from studies that explored how interventions might increase the use of health care at the facility level. Still, important information gaps remain. Particularly noticeable is the need for data on cost-effectiveness and effectiveness in different settings, particularly in sub-Saharan Africa. Also

Conclusions

Currently, available evidence suggests that the community strategy with the greatest impact on neonatal mortality is home visits by CHWs combined with community mobilization strategies. The same intervention strategy appears to be one of the most effective in increasing health facility use. An equally effective strategy for increasing health facility use seems to be financing health care to remove financial access barriers, particularly using conditional cash transfers or vouchers.

Acknowledgments

We thank Paulson Amibor for his assistance in the literature search.

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    RB, SQ, and JM are staff members of the World Health Organization. The views expressed in this publication are authors' own and they do not necessarily represent the decisions or the stated policy of the World Health Organization.

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