Impact Evaluation of an Integrated Nutrition and Health Programme on Neonatal Mortality in rural Northern India: Experience of an Independent Evaluation Praween K. Agrawal, Ph.D New Delhi, India Background • Neonatal period is recognized as a brief, critical time that requires focused interventions to reach the MDG (two-thirds reduction in child mortality) by 2015. • In India, there are one million neonatal deaths every year, representing approximately a quarter of all global neonatal deaths. • To cater the need, Integrated Nutrition and Health Programme (INHP) was launched in 100 districts in India with partnership of an international NGO, CARE-India, together with Government of India (GOI) and local NGOs. • The programme was implemented through the infrastructure of GOI Ministry of Women and Child Development’s Integrated Child Development Services (ICDS) and the Ministry of Health and Family Welfare. • The newborn care package aimed to increase the frequency of behaviours during the antenatal, delivery and postnatal periods that have proven benefits for maternal and newborn survival. Objective To assess the impact of the newborn health component of a large-scale community-based integrated nutrition and health programme on neonatal mortality. Conceptual model for promotion of newborn care within the INHP Implementing partners and their inputs Pro ces s Out co me Imp act Ministry of Health and Family Welfare CARE-India Planning, coordination and logistical support to integrate and strengthen ICDS and MOHFW programmes with an emphasis on newborn care Infrastructure One auxiliary nurse-midwife per 5000 Planning, training, supervision, supplies, logistics and monitoring Technical support, training of government officials, frontline health workers and community volunteers Ministry of Women and Child Development’s Integrated Child Development Services Infrastructure One anganwadi worker per1000 (or 1 village) Funding to NGOs for BCC and social marketing Planning, training, supervision, supplies, logistics and monitoring Monitoring and evaluation Programme and policy development Programme and policy development Health workers’ knowledge improved Increased programme coverage Improved monitoring systems at the block and district level Volunteer recruited and trained; volunteer women’s groups formed at village level Improved supervision Strengthened supply chain Mothers’ knowledge of maternal and newborn care increased Improved preventive care practices for mothers Improved newborn care practices Reduced neonatal mortality rate Improved use of healthcare services Study location and design • Although the programme was implemented in eight states, data was collected from Uttar Pradesh state only. • A quasi-experimental design was used with a baseline and end line surveys (pre-post) with three adequacy surveys in one intervention and one comparison district. • The evaluation study (design, data collection and analysis) was conducted by a team of independent researchers who were not involved in the implementation of the intervention. • The sample size was calculated to detect a 20% reduction in neonatal mortality following the intervention with 80% power at a 5% significance level. Data collection and analysis Mothers who had given birth in two years preceding the surveys were interviewed during the baseline (n=14,952) and endline (n =13,826) surveys in 2003 and 2006, respectively. Data collection was contracted out to an survey agency and a rigorous data quality assurance (DQA) mechanism was in place. A consistent weekly data matching were done to ensure the quality along with spot checks and back checks by the evolution team. Descriptive statistics were calculated with use of standard methods. Intervention exposure and behaviour change indicators were analyzed using a difference-in-difference test to compare the change from baseline to endline for intervention versus comparison districts. Neonatal mortality rates (NMR) were also calculated after stratification by antenatal and postnatal home visitation status. Stata, version 8 was used (StataCorp. LP, College Station, TX, United States of America) for statistical analysis. Antenatal home visits by any service provider over the study period by intervention and comparison districts Proportion of RDW 70 Antenatal Home Visit Coverage 62 60 50 40 30 20 10 54 52 28 28 39 23 15 23 20 0 Baseline ADQI ADQII ADQIII Endline (n=15017) (n=1759) (n=1746) (n=1747) (n=6498) Intervention Comparison Postpartum home visits within a week by any service provider Proprotion of Mothers over the study period by intervention and comparison districts 70 Postpartum Visit (1 week) Coverage 60 50 40 30 26 20 10 0 2 1 11 3 15 16 3 2 2 Baseline ADQI ADQII ADQIII Endline (n=15017) (n=1759) (n=1746) (n=1747) (n=6498) Intervention Comparison Recently delivered women’s (RDW) exposure to promoted behaviours by intervention and comparison Advice received during pregnancy Tetanus toxoid immunization Iron-folate supplementation Saving money for birth † Any other birth planning Maternal and/or newborn danger signs Five cleans of delivery Breastfeeding Drying and wrapping of the newborn COMPARISON Baseline Endline INTERVENTION Baseline Endline (2001-02) (2004-05) (2001-02) (2004-05) 41.0 37.8 5.0 13.2 7.7 6.3 9.2 7.1 69.0 57.9 24.2 29.7 7.5 12.9 24.7 17.1 15.7 14.3 3.5 6.7 3.5 3.3 5.1 4.1 76.6 72.3 57.5 63.8 18.1 49.3 61.7 51.0 Change 28.0 20.1 19.2 16.5 -0.2 6.6 15.5 10.0 Change Adjusted P-value* 60.9 58.0 54.0 57.1 14.6 46.0 56.6 46.9 •P-value for difference of differences test. Adjusted for age, education, parity, religion and wealth. •† At least one of the following: suitable location for delivery, person to deliver baby, hospital/clinic to be attended in case of complication, arrangement for transport, and disposable delivery kit. <0.000 <0.000 <0.000 <0.000 <0.000 <0.000 <0.000 <0.000 Recently delivered women’s (RDW) adherence to promoted behaviours by intervention and comparison COMPARISON Baseline Endline Change (2001-02) (2004-05) 24.6 27.7 7.0 58.0 6.6 12.2 20.0 INTERVENTION Baseline Endline Change Adjusted P-value* (2001-02) (2004-05) 3.1 16.5 35.4 18.9 <0.000 8.8 1.8 3.6 12.1 8.5 <0.000 62.6 8.3 29.7 17.6 4.6 1.7 17.5 -2.4 47.8 5.0 14.8 10.7 70.0 20.8 50.0 34.4 22.2 15.8 35.2 23.7 <0.000 <0.000 <0.000 <0.000 Antenatal Care Proportion of RDW that: Received one or more antenatal check-ups from a qualified provider ‡ Received three or more antenatal check-ups from a qualified provider ‡ Received 2+ tetanus immunizations Consumed 100+ iron-folic acid tablets Saved money for childbirth Took any other birth planning step † Recently delivered women’s (RDW) adherence to promoted behaviours by intervention and comparison COMPARISON Baseline Endline Change (2001-02) (2004-05) INTERVENTION Baseline Endline Change (2001-02) (2004-05) Delivery and newborn care Proportion of RDW that: Delivered in a health facility or at 17.9 22.1 4.2 16.7 home with a skilled birth attendant ‡ 35.8 41.8 6.0 32.2 Practiced clean cord care § Practiced newborn thermal care in the 0.7 0.6 -0.1 3.8 first 6 hours || Initiated breastfeeding on first day 11.7 23.6 11.9 16.8 Newborns with complications who received care from a qualified 35.5 30.2 -5.3 20.3 provider ‡ ¶ Total number of participant mothers 5861 5710 8264 * P-value for difference of differences test. Adjusted for age, education, parity, religion and wealth. Adjusted P-value* 22.6 5.9 <0.008 68.4 36.2 <0.000 23.8 20.0 <0.000 68.0 51.2 <0.000 30.3 10.0 <0.000 7503 ‡ Medically qualified doctor, nurse, lady health visitor or auxiliary nurse midwife. § Umbilical cord cut with boiled blade and tied with sterile thread. || Newborn dried and wrapped immediately after delivery and first bath delayed for six hours or more. ¶ Only newborns with complications included. Comparison baseline n=3066, endline n=2210; Intervention baseline n=4899, endline n=2931. Impact on neonatal mortality rates Intervention district Baseline survey Endline survey Live births Deaths Comparison district Baseline survey Endline survey 8 756 7 812 6 196 6 014 431 393 296 299 Unadjusted NMR (95% CI) 49.2 (44.8–54.0) 50.3 (45.6–55.4) 47.8 (42.6–53.4) 49.7 (44.4–55.5) 46.4 (42.0–50.8) 52.1 (47.2–57.0) 45.8 (40.6–51.0) 48.6 (42.9–54.2) Adjusted NMR (95% CI) Adjusted for age, education, parity, religion and standard-of-living scores using direct standardization. 0 10 20 30 40 50 60 70 80 90 100 Using coefficients from adjusted logistic regression, the marginal changes in neonatal mortality were estimated for various levels of coverage of antenatal and postnatal home visits; the effect of antenatal visits was assessed by varying the antenatal coverage levels from 0% to 100% assuming no postnatal visitation. Coverage of postnatal visitation within 28 days was varied between 0% and 100% keeping antenatal coverage at the same level. For example, if postnatal coverage was estimated at 50%, antenatal was also estimated at 50%. Findings • In the intervention district, the frequency of home visits by community based workers increased 4 times during the antenatal (from 15% to 60%) and also postnatal visits within a week significantly increased (from 4% to 26%) and resulted into better maternal and newborn care practices. • In the comparison district, no improvement in antenatal or postnatal home visits was observed and limited improvements maternal and newborn care practices. • Neonatal mortality rates remained unchanged in both districts. However, neonates who received a postnatal home visit within 28 days of birth had 34% lower neonatal mortality (35.7 deaths per 1000 live births) than those who received no postnatal visit (53.8 deaths per 1000 live births), after adjusting for socio-demographic variables. • Three-quarters of the mortality reduction was seen in those who were visited within the first 3 days after birth. Conclusion • The limited programmme coverage did not enable an effect on neonatal mortality to be observed at the population level. • A reduction in neonatal mortality rates in those receiving postnatal home visits shows potential for the programme to have an effect on neonatal deaths. • Reaching newborn babies at the community level is crucial in settings where the availability and utilization of facility-based care is low. • While the training of multipurpose health and nutrition workers in essential newborn care is necessary, systems must also be put in place to ensure that these workers visit neonates at home during the first hours and days after birth and that they can provide a link to competent health services.