Improvement of perinatal and newborn care in rural Pakistan through community-based strategies: a cluster-randomised effectiveness trial
Improvement of perinatal and newborn care in rural Pakistan through community-based strategies: a cluster-randomised effectiveness trial
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DOI：
10.1016/s0140-6736(10)62274-x
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发表时间：
2011-01-01
期刊：
影响因子：
168.9
通讯作者：
Martines, Jose
中科院分区：
文献类型：
--
作者：
Bhutta, Zulfiqar A.;Soofi, Sajid;Martines, Jose
背景在巴基斯坦，新生儿死亡占5岁以下儿童死亡的57%。尽管有大量训练有素的女保健工作者(LHW)方案，但这种培训对新生儿结局的有效性尚未得到研究。我们的目的是评估以社区为基础的干预方案的有效性，该方案主要通过LHW与传统接生员和社区卫生委员会合作，在巴基斯坦农村地区降低围产儿和新生儿死亡率。方法2006年2月至2008年3月，我们在巴基斯坦Hala和Matiari分区进行了一项整群随机试验。初级保健机构和所有附属LHW的集水区被用来定义集群，这些集群通过限制性分层随机分配给干预组和对照组。LHW通过小组会议提供的干预方案包括推广产前保健和孕产妇健康教育、使用清洁分娩工具包、设施分娩、新生儿立即护理、识别危险征兆和促进抚摸；对照组群接受常规护理。独立数据收集者进行了季度家庭监测，以获取出生、死亡和与产妇和新生儿护理有关的家庭做法的数据。数据收集者被屏蔽到集群分配中；而那些分析数据的人则没有。主要结果是围产期和各种原因造成的新生儿死亡率。分析采用意向治疗。本试验登记为ISRCTN16247511，共16组，分为干预组(23353户，总出生数12391人)和对照组(23768户，总出生数11443人)。干预组中的低保健妇女能够参加7084次计划小组会议中的4428次(63%)，但只能访问其集水区村庄12028名活产中的2943名新生儿(24%)。与对照组(48.7/1000；风险比[RR]0.79，95%可信区间0.68-0.92；p=0.006)相比，干预组死产减少(每1000名新生儿中有39.1名死产)。干预组新生儿死亡率为每1000活产43.0例死亡，而对照组为每1000活产49.1例(相对危险度0.85，0.76-0.96；p=0.02)。解释我们的结果支持通过社区卫生工作者扩大预防性和促进性孕产妇和新生儿干预的规模，并强调需要注意方案管理和此类倡议的覆盖面问题，以发挥最大潜力。
Background Newborn deaths account for 57% of deaths in children younger than 5 years in Pakistan. Although a large programme of trained lady health workers (LHWs) exists, the effectiveness of this training on newborn outcomes has not been studied. We aimed to evaluate the effectiveness of a community-based intervention package, principally delivered through LHWs working with traditional birth attendants and community health committees, for reduction of perinatal and neonatal mortality in a rural district of Pakistan.Methods We undertook a cluster randomised trial between February, 2006, and March, 2008, in Hala and Matiari subdistricts, Pakistan. Catchment areas of primary care facilities and all affiliated LHWs were used to define clusters, which were allocated to intervention and control groups by restricted, stratified randomisation. The intervention package delivered by LHWs through group sessions consisted of promotion of antenatal care and maternal health education, use of clean delivery kits, facility births, immediate newborn care, identification of danger signs, and promotion of careseeking; control clusters received routine care. Independent data collectors undertook quarterly household surveillance to capture data for births, deaths, and household practices related to maternal and newborn care. Data collectors were masked to cluster allocation; those analysing data were not. The primary outcome was perinatal and all-cause neonatal mortality. Analysis was by intention to treat. This trial is registered, ISRCTN16247511.Findings 16 clusters were assigned to intervention (23 353 households, 12 391 total births) and control groups (23 768 households, 11 443 total births). LHWs in the intervention clusters were able to undertake 4428 (63%) of 7084 planned group sessions, but were only able to visit 2943 neonates (24%) of a total 12 028 livebirths in their catchment villages. Stillbirths were reduced in intervention clusters (39.1 stillbirths per 1000 total births) compared with control (48.7 per 1000; risk ratio [RR] 0.79, 95% CI 0.68-0.92; p=0.006). The neonatal mortality rate was 43.0 deaths per 1000 livebirths in intervention clusters compared with 49.1 per 1000 in control groups (RR 0.85, 0.76-0.96; p=0.02).Interpretation Our results support the scale-up of preventive and promotive maternal and newborn interventions through community health workers and emphasise the need for attention to issues of programme management and coverage for such initiatives to achieve maximum potential.