Effect of Facilitation of Local Maternal-and-Newborn Stakeholder Groups on Neonatal Mortality: Cluster-Randomized Controlled Trial.
Effect of Facilitation of Local Maternal-and-Newborn Stakeholder Groups on Neonatal Mortality: Cluster-Randomized Controlled Trial.
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DOI：
10.1371/journal.pmed.1001445
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发表时间：
2013
期刊：
影响因子：
15.8
通讯作者：
Ewald U
中科院分区：
文献类型：
--
作者：
Persson LÅ;Nga NT;Målqvist M;Thi Phuong Hoa D;Eriksson L;Wallin L;Selling K;Huy TQ;Duc DM;Tiep TV;Thi Thu Thuy V;Ewald U
Lars Åke Persson 及其同事在越南北部进行了整群随机对照，以分析当地社区孕产妇和新生儿利益相关群体的活动对新生儿死亡率的影响。 请参阅本文后面的编辑摘要 据报道，为当地妇女团体提供便利可能会降低新生儿死亡率。目前尚不清楚由当地卫生保健人员和政治家组成的团体的协助是否可以改善围产期结局。我们假设，为当地利益相关者团体提供便利将降低越南广宁省的新生儿死亡率（主要结果）并改善孕产妇、分娩和新生儿护理指标（次要结果）。在整群随机设计中，44 个公社被分配为干预组，46 个公社被分配为控制组。三年来，非专业妇女主持了由卫生保健人员和公社关键人物组成的小组每月举行的会议。采用了解决问题的方法。对出生和新生儿死亡情况进行监测，并对新生儿死亡家庭和随机选择的幸存婴儿进行访谈。在这种类型的干预中，预计会出现一段潜伏期，但该时间范围并未预先指定。 2008 年 7 月至 2011 年 6 月期间，干预公社的新生儿死亡率 (NMR) 为 16.5/1,000（每 11,818 名活产 195 人死亡），对照公社为 18.4/1,000（每 10,559 名活产 194 人死亡）（调整后比值比 [OR] 0.96 [95% CI] 0.73–1.25]）。在干预公社中，NMR 存在显着的下降时间趋势 (p = 0.003)，但在对照公社中则没有 (p = 0.184)。前两年（2008 年 7 月至 2010 年 6 月）NMR 没有观察到显着差异，而第三年（2010 年 7 月至 2011 年 6 月）干预组的 NMR 显着降低：调整后 OR 0.51（95% CI 0.30-0.89）。干预公社的妇女更频繁地参加产前护理（调整后 OR 2.27 [95% CI 1.07–4.8]）。由初级保健工作人员和当地政治家组成的当地利益相关者团体进行了为期三年的随机促进干预，采用解决围产期问题的方法，提高了产前护理的参与率，并降低了潜伏期后的新生儿死亡率。当前对照试验 ISRCTN44599712 请参阅文章后面的编辑摘要 在过去的几年里，国际社会做出了巨大的努力，以实现千年发展目标 4 设定的目标，即到 2015 年，将五岁以下儿童死亡率比 1990 年的水平分别降低三分之二，将孕产妇死亡人数减少四分之三。根据世界卫生组织的最新数据，已经取得了一些令人鼓舞的进展。该组织称，2011年，5岁以下儿童死亡人数接近700万，比十年前减少了近300万。然而，目前 5 岁以下儿童死亡中 41% 发生在出生前后和出生后 28 天（围产期和新生儿死亡率）。简单的干预措施可以大大减少新生儿死亡，国际、国家和地方已经做出了一些努力来实施有效的护理方案，以帮助减少新生儿死亡人数。为了使这些干预措施最有效，当地社区的参与非常重要。社区动员，特别是通过当地妇女团体进行动员，可以使妇女能够优先考虑具体干预措施，以帮助改善自己和婴儿的健康。另一种策略可能是动员那些已经有责任促进社会健康和福利的人，例如初级保健人员、乡村卫生工作者和民选政治代表。然而，尚不清楚这些利益相关者团体的活动是否会改善新生儿的生存率。因此，在这项来自越南北部的研究中，研究人员分析了当地孕产妇和新生儿利益相关群体的活动对新生儿死亡率的影响。 2008年至2011年间，研究人员在越南东北部广宁省的90个公社进行了整群随机对照试验：44个公社被分配为干预组，46个公社被分配为对照组。当地妇女联盟促进了干预措施、当地利益相关团体（孕产妇和新生儿健康团体）的招募，其中包括初级保健人员、乡村卫生工作者、妇女联盟代表以及公社卫生负责人。这些小组的作用是确定当地围产期健康问题并确定优先顺序，并采取行动帮助克服这些问题。三年期间，44 个干预公社的孕产妇和新生儿健康小组召开了 1,508 次会议。每年都会发现 15-27 个独特问题并解决 94-151 次。问题解决过程每年产生 19-27 项独特的行动，每年应用 297-649 次。这些小组确定的首要问题和行动涉及产前护理、产后检查、怀孕期间的营养和休息、家庭分娩和母乳喂养。干预组的新生儿死亡率在前两年没有变化，但在第三年出现显着改善。死亡的三大原因是早产/低出生体重（36%）、产时相关的新生儿死亡（30%）和感染（15%）。干预组的死产率为每 1,000 名新生儿 7.4 例，对照组的死产率为每 1,000 名新生儿 9.0 例。干预公社有 1 名孕产妇死亡，对照公社有 4 名孕产妇死亡，干预组的产前护理出勤率有了显着改善。然而，干预组和对照组的其他结局没有显着差异，包括破伤风免疫、分娩准备、机构分娩、分娩时温度控制、早期开始母乳喂养或产后第一周助产士家访。这些研究结果表明，由初级保健人员和当地政治家组成的当地利益相关者团体采用解决问题的方法可能有助于在实施三年后降低新生儿死亡率（尽管在试验开始前未指定预期降低新生儿死亡率的时间段），并且还可能提高产前护理就诊率。然而，干预措施对其他重要结果没有影响，例如机构分娩率和母乳喂养率。这项研究采用了一种以社区为基础的活动的新颖方法，该方法以低成本实施到公共部门系统中。通过新生儿复苏培训和对母亲及其婴儿的家访，可以进一步减少分娩期间的新生儿死亡。请通过此摘要的在线版本访问这些网站：http://dx.doi.org/10.1371/journal.pmed.1001445。世界卫生组织提供有关新生儿死亡率的全面统计数据 健康新生儿网络提供有关社区干预措施的信息，以帮助降低世界各地的新生儿死亡率
Lars Åke Persson and colleagues conduct a cluster randomised control in northern Vietnam to analyze the effect of the activity of local community-based maternal-and-newborn stakeholder groups on neonatal mortality. Please see later in the article for the Editors' Summary Facilitation of local women's groups may reportedly reduce neonatal mortality. It is not known whether facilitation of groups composed of local health care staff and politicians can improve perinatal outcomes. We hypothesised that facilitation of local stakeholder groups would reduce neonatal mortality (primary outcome) and improve maternal, delivery, and newborn care indicators (secondary outcomes) in Quang Ninh province, Vietnam. In a cluster-randomized design 44 communes were allocated to intervention and 46 to control. Laywomen facilitated monthly meetings during 3 years in groups composed of health care staff and key persons in the communes. A problem-solving approach was employed. Births and neonatal deaths were monitored, and interviews were performed in households of neonatal deaths and of randomly selected surviving infants. A latent period before effect is expected in this type of intervention, but this timeframe was not pre-specified. Neonatal mortality rate (NMR) from July 2008 to June 2011 was 16.5/1,000 (195 deaths per 11,818 live births) in the intervention communes and 18.4/1,000 (194 per 10,559 live births) in control communes (adjusted odds ratio [OR] 0.96 [95% CI 0.73–1.25]). There was a significant downward time trend of NMR in intervention communes (p = 0.003) but not in control communes (p = 0.184). No significant difference in NMR was observed during the first two years (July 2008 to June 2010) while the third year (July 2010 to June 2011) had significantly lower NMR in intervention arm: adjusted OR 0.51 (95% CI 0.30–0.89). Women in intervention communes more frequently attended antenatal care (adjusted OR 2.27 [95% CI 1.07–4.8]). A randomized facilitation intervention with local stakeholder groups composed of primary care staff and local politicians working for three years with a perinatal problem-solving approach resulted in increased attendance to antenatal care and reduced neonatal mortality after a latent period. Current Controlled Trials ISRCTN44599712 Please see later in the article for the Editors' Summary Over the past few years, there has been enormous international effort to meet the target set by Millennium Development Goal 4 to reduce the under-five child mortality rate by two-thirds and to reduce the number of maternal deaths by three-quarters, respectively, from the 1990 level by 2015. There has been some encouraging progress and according to the latest figures from the World Health Organization, in 2011, just under 7 million children aged under 5 years died, a fall of almost 3 million from a decade ago. However, currently, 41% of all deaths among children under the age of 5 years occur around birth and the first 28 days of life (perinatal and neonatal mortality). Simple interventions can substantially reduce neonatal deaths and there have been several international, national, and local efforts to implement effective care packages to help reduce the number of neonatal deaths. In order for these interventions to be most effective, it is important that the local community becomes involved. Community mobilization, especially through local women's groups, can empower women to prioritize specific interventions to help improve their own health and that of their baby. An alternative strategy might be to mobilize people who already have responsibility to promote health and welfare in society, such as primary care staff, village health workers, and elected political representatives. However, it is unclear if the activities of such stakeholder groups result in improved neonatal survival. So in this study from northern Vietnam, the researchers analyzed the effect of the activity of local maternal-and-newborn stakeholder groups on neonatal mortality. Between 2008 and 2011, the researchers conducted a cluster-randomized controlled trial in 90 communes within the Quang Ninh province of northeast of Vietnam: 44 communes were allocated to intervention and 46 to the control. The local women's union facilitated recruitment to the intervention, local stakeholder groups (Maternal and Newborn Health Groups), which comprised primary care staff, village health workers, women's union representatives, and the person with responsibility for health in the commune. The groups' role was to identify and prioritize local perinatal health problems and implement actions to help overcome these problems. Over the three-year period, the Maternal and Newborn Health Groups in the 44 intervention communes had 1,508 meetings. Every year 15–27 unique problems were identified and addressed 94–151 times. The problem-solving processes resulted in an annual number of 19–27 unique actions that were applied 297–649 times per year. The top priority problems and actions identified by these groups dealt with antenatal care attendance, post-natal visits, nutrition and rest during pregnancy, home deliveries, and breast feeding. Neonatal mortality in the intervention group did not change over the first two years but showed a significant improvement in the third year. The three leading causes of death were prematurity/low birth-weight (36%), intrapartum-related neonatal deaths (30%), and infections (15%). Stillbirth rates were 7.4 per 1,000 births in the intervention arm and 9.0 per 1,000 births in the control arm. There was one maternal death in the intervention communes and four in the control communes and there was a significant improvement in antenatal care attendance in the intervention arm. However, there were no significant differences between the intervention and control groups of other outcomes, including tetanus immunization, delivery preparedness, institutional delivery, temperature control at delivery, early initiation of breastfeeding, or home visit of a midwife during the first week after delivery. These findings suggest that local stakeholder groups comprised of primary care staff and local politicians using a problem-solving approach may help to reduce the neonatal mortality rate after three years of implementation (although the time period for an expected reduction in neonatal mortality was not specified before the trial started) and may also increase the rate of antenatal care attendance. However, the intervention had no effect on other important outcomes such as the rate of institutional delivery and breast feeding. This study used a novel approach of community-based activity that was implemented into the public sector system at low cost. A further reduction in neonatal deaths around delivery might be achieved by neonatal resuscitation training and home visits to the mother and her baby. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001445. The World Health Organization provides comprehensive statistics on neonatal mortality The Healthy Newborn Network has information on community interventions to help reduce neonatal mortality from around the world
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影响因子：
5.2
作者：
Osrin D;Prost A
通讯作者：
Prost A
影响因子：
4.5
作者：
Eriksson L;Nga NT;Målqvist M;Persson LA;Ewald U;Wallin L
通讯作者：
Wallin L
影响因子：
158.5
作者：
Jokhio, AH;Winter, HR;Cheng, KK
通讯作者：
Cheng, KK
影响因子：
3.8
作者：
Hoa, Dinh P.;Nga, Nguyen T.;Persson, Lars Ake
通讯作者：
Persson, Lars Ake
影响因子：
3
作者：
Malqvist, Mats;Eriksson, Leif;Persson, Lars-Ake
通讯作者：
Persson, Lars-Ake