Assessment of the uptake of neonatal and young infant referrals by community health workers to public health facilities in an urban informal settlement, KwaZulu-Natal, South Africa

Duduzile Nsibande,Debra Jackson,David Sanders,Mark Tomlinson,Joy Lawn,Tanya Doherty,Petrida Ijumba

doi:10.1186/1472-6963-13-47

Abstract

BackgroundGlobally, 40% of the 7.6 million deaths of children under five every year occur in the neonatal period (first 28 days after birth). Increased and earlier recognition of illness facilitated by community health workers (CHWs), coupled with effective referral systems can result in better child health outcomes. This model has not been tested in a peri-urban poor setting in Africa, or in a high HIV context.MethodsThe Good Start Saving Newborn Lives (SNL) study (ISRCTN41046462) conducted in Umlazi, KwaZulu-Natal, was a community randomized trial to assess the effect of an integrated home visit package delivered to mothers by CHWs during pregnancy and post-delivery on uptake of PMTCT interventions and appropriate newborn care practices. CHWs were trained to refer babies with illnesses or identified danger signs. The aim of this sub-study was to assess the effectiveness of this referral system by describing CHW referral completion rates as well as mothers’ health-care seeking practices. Interviews were conducted using a structured questionnaire with all mothers whose babies had been referred by a CHW since the start of the SNL trial. Descriptive analysis was conducted to describe referral completion and health seeking behaviour of mothers.ResultsOf the 2423 women enrolled in the SNL study, 148 sick infants were referred between June 2008 and June 2010. 62% of referrals occurred during the first 4 weeks of life and 22% between birth and 2 weeks of age. Almost all mothers (95%) completed the referral as advised by CHWs. Difficulty breathing, rash and redness/discharge around the cord accounted for the highest number of referrals (26%, 19% and 17% respectively). Only16% of health workers gave written feedback on the outcome of the referral to the referring CHW.ConclusionsWe found high compliance with CHW referral of sick babies in an urban South African township. This suggests that CHWs can play a significant role, within community outreach teams, to improve newborn health and reduce child mortality. This supports the current primary health care re-engineering process being undertaken by the South African National Department of Health which involves the establishment of family health worker teams including CHWs.Trial registration numberISRCTN41046462

Highlights

40% of the 7.6 million deaths of children under five every year occur in the neonatal period
The main objective of this paper is to report on the uptake of community health workers (CHWs) referrals within a peri-urban settlement, to describe the referral process and health seeking behaviour of mothers
This referral study was a sub-study of a cluster randomized controlled trial known as Good Start Saving Newborn Lives (SNL) which was implemented in KwaZulu-Natal province between 2008 and 2011 (ISRCTN41046462)

Summary

Introduction

40% of the 7.6 million deaths of children under five every year occur in the neonatal period (first 28 days after birth). Increased and earlier recognition of illness facilitated by community health workers (CHWs), coupled with effective referral systems can result in better child health outcomes. This model has not been tested in a peri-urban poor setting in Africa, or in a high HIV context. Across South Africa many childhood deaths occur outside the health system, and at least 25% of those included in mortality audits were related to delayed recognition of illness or late arrival at facilities. Of those deaths that occurred in facilities, over half were related to poor care or care received too late [2,4]. Recognition by the mother or other caregivers and rapid reaction are critical to reducing deaths [5]

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