Slide 1

Report
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.

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