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NEWHINTS

Testing a community based intervention to reduce neonatal deaths in rural Ghana. NEWHINTS. NEWHINTS Trial: COLLABORATION. KHRC: Alex Manu; Charlotte Tawiah; Seth Owusu-Agyei; Ben Weobong; Thomas Gyan; Sammy Danso

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NEWHINTS

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  1. Testing a community based intervention to reduce neonatal deaths in rural Ghana NEWHINTS

  2. NEWHINTS Trial: COLLABORATION KHRC: Alex Manu; Charlotte Tawiah; Seth Owusu-Agyei; Ben Weobong; Thomas Gyan; Sammy Danso LSHTM: Betty Kirkwood; Zelee Hill (now ICH); Karen Edmond; Seyi Soremekun; Guus ten Asbroek DHMTs: 6 districts GHS HQ: Isabella Sagoe-Moses; Patrick Aboagye; Frank Nyonator Funders:SNL + WHO + DFID

  3. Newborn Home Intervention Study- NEWHINTS - Cluster randomised trial to evaluate impact of routine home visits by CBSVs on neonatal mortality in rural Ghana

  4. Primary objectives • To develop a feasible and sustainable intervention to improve newborn care practices through routine home visits in pregnancy and the first week of life • To evaluate the impact of these home visits on all cause neonatal mortality • To evaluate their impact on newborn care practices • To evaluate the cost-effectiveness of the intervention

  5. Secondary objectives • To assess the coverage and quality of the service provided and the family and community response to the service • To evaluate whether the intervention reduces socio-economic inequalities in neonatal mortality, and in access to key interventions • To evaluate the impact of the intervention on age- and cause-specific neonatal mortality

  6. Kintampo North Tain Kintampo South Wenchi Nkoranza Techiman Setting: BrongAhafo Region

  7. Baseline data • 18,000 pregnancies: 15,000 live births/year • Stillbirth rate: 34.0 /1000 live and stillbirths • Perinatal mortality rate: 55.1 /1000 live and stillbirths • Neonatal mortality rate: 30.3 /1000 live births • Maternal mortality ratio: 397 /100,000 live births • Home deliveries: 50.3%

  8. Overalldesign • Formative research • Development of intervention • Development of evaluation plan • Implementation and evaluation of intervention (cluster randomised trial)

  9. Formative research • Families, Range of health care providers • Literature review • Focus group discussions • In depth interviews • Birth narratives • Participant observation • Facility surveys • Quantitative data analysis

  10. Target behaviors • Attend antenatal care, including in early pregnancy • Deliver in a health facility • Prepare for the birth: • Facility birth: transport, supplies, financial plan • Home/impromptu birth: clean delivery, extra birth assistant to vigorous dry and wrap the baby • Breastfeed as soon as the cord is cut and place baby skin-to-skin with mother • Bath baby quickly, with warm water and dry immediately • Keep small babies skin-to-skin, do not bath, feed every 2 hours, & wash hands • Care seeking for pregnancy, delivery, post partum & neonatal danger signs

  11. Delivery channel • Home visits from community health workers (community based surveillance volunteers) • District health management team supervision

  12. Intervention design • Focus on prevention • Give simple messages through a story for behaviours where knowledge is the key barrier • Counsel/problem solve for behaviours which require negotiation • Not direct health care • Refer and facilitate referral when necessary

  13. TBA Sensitisation Materials Training Counsel Women (& families) CBSVs Community Sensitisation 5 HOME VISITS Incentives Assess & Refer Newborns Supervision Health Facility Sensitisation Hospital ENC Strengthening Ensure consistent advice Intervention designAn Integrated Intervention Package Strengthening DHMTs

  14. Five focused home visits

  15. Five focused home visitsPLUS • Follow-up visits for referred babies • Visit at 14 days for very LBW babies

  16. Health cards used to assist with each home visit

  17. Evaluation design:Cluster randomised trial • 98 “Newhints” zones in the 6 districts: • Area covered by 1 supervisor (8-10 CBSVs) • 49 Intervention zones: Newhints package • 49 Control zones: CBSVs continue as usual (eg. encouraging families to attend on child health days) • 18,000 pregnancies/year; 15,000 live births • 80% power to detect 25% reduction in neonatal mortality • Analysis: Intention to treat

  18. Evaluation design • Outcome • Process

  19. Outcome evaluation design - How • Outcomes • Independent to intervention implementation • 4-weekly home visits of all women in trial districts (intervention and control) • Additional visit after all neonatal deaths (for verbal post mortem)

  20. Outcome evaluation - What • Mortality outcomes • All neonatal deaths • Causes of death • Timing of death • Neonatal care practices • Facility delivery, EBF, Drying, Wrapping, Bathing, BF, Care seeking, Bednets • Access / coverage (quantitative) • No and timing of visits from CBSV

  21. Process monitoring & evaluation • Sub-samples from Newhints zones • In-depth interviews with mothers exploring practices in detail (constraints, facilitating factors & in Newhints zones role of CBSV) • Some quantitative data collection (eg. cost data) • Special sub-samplesfrom Newhints zones to explore whether mothers carried out advice on: • Special care for LBW babies inc. SSC • Referrals

  22. Process monitoring & evaluation • Delivery channel, CBSVs, Supervisors, DHMTs • In depth interviews • Perceptions and feedback, Supervision, Workload, Referrals • Data collection • Log books , Referral outcome, Supervisor reports, Staff turnover • Cost effectiveness

  23. Timescale • July 2008: Intervention fully implemented • Evaluation: Babies born 1 July 2008 - 30 June 2009 • 18,000 pregnancies/year; 15,000 live births • 80% power to detect 25% reduction in neonatal mortality • Aug 2009: end of data collection • Analysis: Intention to treat • Nov 2009: main results • IF IT WORKS: • Expand to control zones • Scale-up (Region, rest of Ghana, sub-Saharan Africa)

  24. Thank you

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