Trained Village Health Workers Research Articles

Acceptability and uptake of oral HIV self-testing among rural community members in Tanzania: a pilot study

ABSTRACT New strategies are needed to improve HIV testing rates in Tanzania, particularly among adult men. We sought to investigate if HIV oral self-testing would increase HIV testing uptake in Tanzanian rural community homes. The study design was a prospective community-randomized pilot study, in two matched villages with similar characteristics (intervention and control villages) Before data collection, we trained village health workers and research assistants for one week. We recruited male and female adults from 50 representative households in each of two villages in eastern Tanzania. We collected data at baseline and we followed-up the enrolled households after a one-month period. There was a high interest in testing for HIV, with all participants from both arms (100%; n = 259) reporting that they would like to test for HIV. After the one-month follow-up, overall, 66.1% (162/245) of study participants reported to have tested for HIV in both arms. In the intervention arm, 97.6% (124/127) reported that they tested for HIV versus in the control arm, 32.2% (38/118) tested for HIV, p-value < 0.001. In Tanzania, we found that availability of HIV self-testing was associated with an enormous increase in HIV testing uptake in a rural population.

Decline in the Incidence of Neonatal Sepsis in Rural Gadchiroli, India During the Twenty-one Years (1998-2019) Following the Home-based Neonatal Care Field-trial.

Sepsis is a leading cause of neonatal mortality globally. The home-based neonatal care (HBNC) field trial (1995-1998) in rural Gadchiroli demonstrated a reduction in the incidence of neonatal sepsis. The current study examines the trend of neonatal sepsis during the twenty-one years (1998-2019) following the trial's completion. We conducted a retrospective cohort study based on the HBNC program data in rural Gadchiroli, India, from April 1998 to March 2019. All live-born neonates who spent all or part of the neonatal period in the 39 study villages and received HBNC were eligible for inclusion. Sepsis was diagnosed during regular home visits by trained village health workers if pre-specified clinical criteria were present. Sepsis incidence was computed for seven 3-year periods. Trend analyses were conducted using the Mann-Kendall test. Of the total 17,289 live births, 16,339 (94.5%) home visited were included. In this cohort, 1069 (65 per 1000 live births) neonates were diagnosed with sepsis. The incidence of neonatal sepsis declined from 111 per 1000 live births in 1998 to 2001 to 19 per 1000 live births in 2016 to 2019, an 82.9% decrease (P < 0.0001), mean 4% decrease per year. The incidence of neonatal sepsis declined for early-onset sepsis (P < 0.0001), late-onset sepsis (P < 0.0001), home births (P = 0.006), facility births (P < 0.0001), preterm neonates (P < 0.0001) and full-term neonates (P < 0.0001). The incidence of neonatal sepsis in rural Gadchiroli has continued to decline during the past twenty-one years. We hypothesize that the decline is due to the ongoing practice of HBNC, improved socioeconomic conditions, and new governmental health policies.

Reactive, self-administered malaria treatment against asymptomatic malaria infection: results of a cluster randomized controlled trial in The Gambia

BackgroundSelectively targeting and treating malaria-infected individuals may further decrease parasite carriage in low-burden settings. Using a trans-disciplinary approach, a reactive treatment strategy to reduce Plasmodium falciparum prevalence in participating communities was co-developed and tested.MethodsThis is a 2-arm, open-label, cluster-randomized trial involving villages in Central Gambia during the 2017 and 2018 malaria transmission season. Villages were randomized in a 1:1 ratio using a minimizing algorithm. In the intervention arm, trained village health workers delivered a full course of pre-packed dihydroartemisinin-piperaquine to all residents of compounds where clinical cases were reported while in the control arm, compound residents were screened for infection at the time of the index case reporting. All index cases were treated following national guidelines. The primary endpoint was malaria prevalence, determined by molecular methods, at the end of the intervention period.ResultsThe trial was carried out in 50 villages: 34 in 2017 and 16 additional villages in 2018. At the end of the 2018 transmission season, malaria prevalence was 0.8% (16/1924, range 0–4%) and 1.1% (20/1814, range 0–17%) in the intervention and control arms, respectively. The odds of malaria infection were 29% lower in the intervention than in the control arm after adjustment for age (OR 0.71, 95% CI 0.27–1.84, p = 0.48). Adherence to treatment was high, with 98% (964/979) of those treated completing the 3-day treatment.Over the course of the study, only 37 villages, 20 in the intervention and 17 in the control arm, reported at least one clinical case. The distribution of clinical cases by month in both transmission seasons was similar and the odds of new clinical malaria cases during the trial period did not vary between arms (OR 1.04, 95% CI 0.57–1.91, p = 0.893). All adverse events were classified as mild to moderate and resolved completely.ConclusionThe systematic and timely administration of an anti-malarial treatment to residents of compounds with confirmed malaria cases did not significantly decrease malaria prevalence and incidence in communities where malaria prevalence was already low. Treatment coverage and adherence was very high. Results were strongly influenced by the lower-than-expected malaria prevalence, and by no clinical cases in villages with asymptomatic malaria-infected individuals.Trial registration:This study is registered with ClinicalTrials.gov, NCT02878200. Registered 25 August 2016.https://clinicaltrials.gov/ct2/show/NCT02878200.

A qualitative assessment of factors influencing implementation and sustainability of evidence-based tobacco use treatment in Vietnam health centers

BackgroundEffective strategies are needed to increase implementation and sustainability of evidence-based tobacco dependence treatment (TDT) in public health systems in low- and middle-income countries (LMICs). Our two-arm cluster randomized controlled trial (VQuit) found that a multicomponent implementation strategy was effective in increasing provider adherence to TDT guidelines in commune health center (CHCs) in Vietnam. In this paper, we present findings from a post-implementation qualitative assessment of factors influencing effective implementation and program sustainability.MethodsWe conducted semi-structured qualitative interviews (n = 52) with 13 CHC medical directors (i.e., physicians), 25 CHC health care providers (e.g., nurses), and 14 village health workers (VHWs) in 13 study sites. Interviews were transcribed and translated into English. Two qualitative researchers used both deductive (guided by the Consolidated Framework for Implementation Research) and inductive approaches to analysis.ResultsFacilitators of effective implementing of TDT included training and point-of-service tools (e.g., desktop chart with prompts for offering brief counseling) that increased knowledge and self-efficacy, patient demand for TDT, and a referral system, available in arm 2, which reduced the provider burden by shifting more intensive cessation counseling to a trained VHW. The primary challenges to sustainability were competing priorities that are driven by the Ministry of Health and may result in fewer resources for TDT compared with other health programs. However, providers and VHWs suggested several options for adapting the intervention and implementation strategies to address challenges and increasing engagement of local government committees and other sectors to sustain gains.ConclusionOur findings offer insights into how a multicomponent implementation strategy influenced changes in the delivery of evidence-based TDT. In addition, the results illustrate the dynamic interplay between barriers and facilitators for sustaining TDT at the policy and community/practice level, particularly in the context of centralized public health systems like Vietnam’s. Sustaining gains in practice improvement and clinical outcomes will require strategies that include ongoing engagement with policymakers and other stakeholders at the national and local level, and planning for adaptations and subsequent resource allocations in order to meet the World Health Organization’s goals promoting access to effective treatment for all tobacco users.Trial registrationNCT02564653, registered September 2015

Validation of DPOAE screening conducted by village health workers in a rural community with real-time click evoked tele-auditory brainstem response

Objective: This study assessed the validity of DPOAE screening conducted by village health workers (VHWs) in a rural community. Real-time click evoked tele-auditory brainstem response (tele-ABR) was used as the gold standard to establish validity. Design: A cross-sectional design was utilised to compare the results of screening by VHWs to those obtained via tele-ABR. Study samples: One hundred and nineteen subjects (0 to 5 years) were selected randomly from a sample of 2880 infants and young children who received DPOAE screening by VHWs. Method: Real time tele-ABR was conducted by using satellite or broadband internet connectivity at the village. An audiologist located at the tertiary care hospital conducted tele-ABR testing through a remote computing paradigm. Tele-ABR was recorded using standard recording parameters recommended for infants and young children. Wave morphology, repeatability and peak latency data were used for ABR analysis. Results: Tele-ABR and DPOAE findings were compared for 197 ears. The sensitivity of DPOAE screening conducted by the VHW was 75%, and specificity was 91%. The negative and positive predictive values were 98.8% and 27.2%, respectively. Conclusions: The validity of DPOAE screening conducted by trained VHW was acceptable. This study supports the engagement of grass-root workers in community-based hearing health care provision.

Training Village Health Workers in Detection and Monitoring of Noncommunicable Diseases: A Low Cost Option for Rural Areas Facing the Emerging Health Epidemic.

Noncommunicable diseases account for 53% of deaths and 44% of disability-adjusted life years lost in India. Village health workers (VHWs) were trained in blood pressure (BP) and blood sugar (BS) measurement and assessed using a checklist. A total of 38 VHWs with a mean age of 44.8 years, schooling of 9.9 years, scored 10.0 (76.9%) for BP and 9.74 (69.6%) for BS. There was no difference in scores for education and age. It is possible to train VHWs in BP and BS measurement and utilize them for screening and monitoring of hypertension and diabetes in a noncommunicable disease care program.

Using mHealth for HIV/TB Treatment Support in Lesotho: Enhancing Patient-Provider Communication in the START Study.

Background:mHealth is a promising means of supporting adherence to treatment. The Start TB patients on ART and Retain on Treatment (START) study included real-time adherence support using short-text messaging service (SMS) text messaging and trained village health workers (VHWs). We describe the use and acceptability of mHealth by patients with HIV/tuberculosis and health care providers.Methods:Patients and treatment supporters received automated, coded medication and appointment reminders at their preferred time and frequency, using their own phones, and $3.70 in monthly airtime. Facility-based VHWs were trained to log patient information and text message preferences into a mobile application and were given a password-protected mobile phone and airtime to communicate with community-based VHWs. The use of mHealth tools was analyzed from process data over the study course. Acceptability was evaluated during monthly follow-up interviews with all participants and during qualitative interviews with a subset of 30 patients and 30 health care providers at intervention sites. Use and acceptability were contextualized by monthly adherence data.Findings:From April 2013 to August 2015, the automated SMS system successfully delivered 39,528 messages to 835 individuals, including 633 patients and 202 treatment supporters. Uptake of the SMS intervention was high, with 92.1% of 713 eligible patients choosing to receive SMS messages. Patient and provider interviews yielded insight into barriers and facilitators to mHealth utilization. The intervention improved the quality of health communication between patients, treatment supporters, and providers. HIV-related stigma and technical challenges were identified as potential barriers.Conclusions:The mHealth intervention for HIV/tuberculosis treatment support in Lesotho was found to be a low-tech, user-friendly intervention, which was acceptable to patients and health care providers.

Acceptability of malaria rapid diagnostic tests administered by village health workers in Pangani District, North eastern Tanzania.

BackgroundMalaria continues to top the list of the ten most threatening diseases to child survival in Tanzania. The country has a functional policy for appropriate case management of malaria with rapid diagnostic tests (RDTs) from hospital level all the way to dispensaries, which are the first points of healthcare services in the national referral system. However, access to these health services in Tanzania is limited, especially in rural areas. Formalization of trained village health workers (VHWs) can strengthen and extend the scope of public health services, including diagnosis and management of uncomplicated malaria in resource-constrained settings. Despite long experience with VHWs in various health interventions, Tanzania has not yet formalized its involvement in malaria case management. This study presents evidence on acceptability of RDTs used by VHWs in rural northeastern Tanzania.MethodsA cross-sectional study using quantitative and qualitative approaches was conducted between March and May 2012 in Pangani district, northeastern Tanzania, on community perceptions, practices and acceptance of RDTs used by VHWs.ResultsAmong 346 caregivers of children under 5 years old, no evidence was found of differences in awareness of HIV rapid diagnostic tests and RDTs (54 vs. 46 %, p = 0.134). Of all respondents, 92 % expressed trust in RDT results, 96 % reported readiness to accept RDTs by VHWs, while 92 % expressed willingness to contribute towards the cost of RDTs used by VHWs. Qualitative results matched positive perceptions, attitudes and acceptance of mothers towards the use of RDTs by VHWs reported in the household surveys. Appropriate training, reliable supplies, affordability and close supervision emerged as important recommendations for implementation of RDTs by VHWs.ConclusionRDTs implemented by VHWs are acceptable to rural communities in northeastern Tanzania. While families are willing to contribute towards costs of sustaining these services, policy decisions for scaling-up will need to consider the available and innovative lessons for successful universally accessible and acceptable services in keeping with national health policy and sustainable development goals.

A prospective study on the incidence of dog bites and management in a rural Cambodian, rabies-endemic setting

Rabies circulates intensely in Cambodia, mainly affecting rural populations. We conducted a prospective study to estimate the baseline incidence of potentially infective dog bites in rural villages of Siem Reap province, Cambodia. The study was conducted in a convenience sample of 844 families totaling 1779 persons in four villages. The study collected data in a total of 802.3 person-years.Trained village health workers (VHW) exhaustively documented consecutive dog bites at the end of each month. Between May 15th and November 15th, 2011, a total of 40 attacks (43 bites; 1.07 bites per attack) were notified by 39 persons (50% female; one suffered two distinct incidents) to VHW. The all-age attack rate for bites over this 6-month period was 2.3% (CI95%: 1.7–3.1%), with a global incidence rate estimated at 4.84 bites/100 person-years (CI95%: 3.5–6.6). The mean age in bite victims was 20.8±18.9years (median 12.5; interquartile range 6–36; range 1–63). The dog was identified in 39 (97.5%) of cases, being the household dog in 9 (22.5%) of cases. Bites were classified as severe (WHO Category III—broken skin with bleeding) in 33 (82.5%) of cases with a severe dog bites incidence estimated at 4/100 person-years (CI95%: 2.8–5.6). The bites involved the hand or face in 1 (2.5%) case each (both Category III). In 20 incidents (50%), only rice was applied to the wounds. There were no suspected or confirmed human rabies deaths during the study period but one dog died after biting (2 others were lost to follow-up and 14 were put down by their owner). Our study documented an extremely high incidence of dog bites in of rural Cambodian adults and children. Adapted control policies for canine vaccination are urgently needed.

Systematic Medical Appraisal, Referral and Treatment (SMART) Mental Health Programme for providing innovative mental health care in rural communities in India.

India has few mental health professionals to treat the large number of people suffering from mental disorders. Rural areas are particularly disadvantaged due to lack of trained health workers. Ways to improve care could be by training village health workers in basic mental health care, and by using innovative methods of service delivery. The ongoing Systematic Medical Appraisal, Referral and Treatment Mental Health Programme will assess the acceptability, feasibility and preliminary effectiveness of a task-shifting mobile-based intervention using mixed methods, in rural Andhra Pradesh, India. The key components of the study are an anti-stigma campaign followed by a mobile-based mental health services intervention. The study will be done across two sites in rural areas, with intervention periods of 1 year and 3 months, respectively. The programme uses a mobile-based clinical decision support tool to be used by non-physician health workers and primary care physicians to screen, diagnose and manage individuals suffering from depression, suicidal risk and emotional stress. The key aim of the study will be to assess any changes in mental health services use among those screened positive following the intervention. A number of other outcomes will also be assessed using mixed methods, specifically focussed on reduction of stigma, increase in mental health awareness and other process indicators. This project addresses a number of objectives as outlined in the Mental Health Action Plan of World Health Organization and India's National Mental Health Programme and Policy. If successful, the next phase will involve design and conduct of a cluster randomised controlled trial.

Burden of Self-Reported Noncommunicable Diseases in 26 Villages of Anand District of Gujarat, India

Introduction. Noncommunicable diseases (NCDs) account for 53% of deaths and 44% of disability adjusted life years lost in India. A survey was undertaken to measure the prevalence of tobacco and alcohol use and self-reported NCDs in a rural community in western part of India. Methodology. Trained Village Health Workers did the survey in the years 2012-13 under supervision. The data was collected for five NCDs, namely, hypertension, diabetes mellitus, cancer, heart disease, and mental illnesses. Results. 18,269 households with a population of 89755 were covered. Prevalence of any form of tobacco use in the age group of >20 years was 34.5 and 52.7% and 15.2% in males and females, respectively. Prevalence of any NCD was 5.3% with a slightly higher prevalence in females (5.4%) than males (5.2%) in the age group of 20–69 years. Prevalence of NCD multimorbidity (≥2 NCDs) was 0.7% in the age group of 20–69 years. 80.7% of hypertensives and 94.9% of diabetics were taking treatment. More females than males were taking antihypertensive treatment. Conclusion. Tobacco use was high. Prevalence of NCDs was less than that reported in other studies. Data generated from this study can be useful in planning a community based NCD programme.

Prevalence of under nutrition in under-five tribal children of Melghat: A community based cross sectional study in Central India

ObjectiveUnder nutrition has chronically remained a major public health problem among tribal children population in India. The present study aimed to estimate the prevalence of various forms of under nutrition in ‘under five’ children in Melghat – a difficult to reach, hilly, forest area of Maharashtra in Central India using different standards. MethodsA community based cross-sectional study was conducted in Dharni & Chikhaldara blocks in tribal area of Melghat over a period of two months. A representative sample of 2926 under-five children from randomly chosen 33 villages in two blocks was selected with cluster sampling. Information on various demographic and anthropometric characteristics (e.g. age, sex, height, weight) of study subjects was collected in a pre-designed proforma by trained tribal female village health workers (VHWs). Under nutrition was assessed by using Standard WHO criteria like stunting, underweight, wasting, and IAP grades; alone and in combination. Crude and adjusted prevalence estimates accounting for clustering effect were obtained along with 95% Confidence Intervals. ResultsOut of total 2926 U5 children, 1006 (34.4%) were severely stunted, 547 (18.7%) were SUW and 209 (7.1%) were SAM, and 199 (6.8%) were severely under nourished (grade III–IV) according to IAP standards. However, when various WHO criteria & IAP gradations were applied in combination, more number 2241 i.e. (76.59%) of the U5 children in Melghat were found to be severely or moderately under nourished. by one or more standards. ConclusionVery high prevalence of severe stunting, severe underweight and severe acute malnutrition was found in tribal U5 children population in Melghat. A combination of more than one criteria may be useful in tracking more number of under nourished children in tribal communities, which otherwise would be missed by any single criterion alone. The study findings will be helpful in planning prevention and planning of programmes that would focus more on populations most affected.

Providing Tele ABR in Rural India

This paper discusses the challenges in conducting real time diagnostic Tele-Auditory Brainstem Response (ABR) testing in remote rural locations, based on our experience with testing over 100 infants and young children in a community based hearing screening program. Two methods of tele-ABR, one using satellite connectivity in a mobile tele-van and other using broadband internet connectivity in a non-government organization at the remote location is used in the program. Advantages and disadvantages related to the two methods, challenges with respect to training technicians for telepractice, training village health workers for remote assistance, and other practical and logistic considerations in conducting tele-ABR in remote site is detailed.

389 Home Based Child Care for Reducing Child Malnutrition in Melghat

Background: Melghat is tribal area in India with very high child mortality & malnutrition. One of the major causes of mortality & morbidity are protein energy malnutrition(PEM). We developed Home Based Child Care (HBCC) model for tribal population to reduce children mortality and malnutrition. Objectives: Methods: Study-design was Randomised Control Trial. We selected 16 intervention (population 14,888) and 18 control (population 16,310) villages. Trained village health workers in intervention area treated post-neonatal diseases such as malnutrition, diarrhoea, ARI, malaria and neonatal diseases like LBW, etc. Behaviour Change Communication programs were conducted. Results: Baseline mortality indices and prevalence of severe malnutrition in control versus intervention areas were: IMR- 72.97 vs 94.9, & U5MR- 102.56 vs 143.52 and severe malnutrition-9.6% vs.9.8 %. After intervention IMR, U5MR & prevalence of severe malnutrition were significantly decreased in intervention area to 24.79, 37.19 & 4.4% respectively(p< 0.05). The prevalence, number of deaths & case fatality rates due to malnutrition in intervention area were reduced significantly (p< 0.05). Conclusions: HBCC resulted in significant decrease in children mortality especially due to malnutrition & prevalence of severe malnutrition. Our model is replicable for reducing children mortality due to malnutrition.

A progressive declining in the burden of malaria in north-eastern Tanzania

BackgroundThe planning and assessment of malaria interventions is complicated due to fluctuations in the burden of malaria over time. Recently, it has been reported that the burden of malaria in some parts of Africa has declined. However, community-based longitudinal data are sparse and the reasons for the apparent decline are not well understood.MethodsMalaria prevalence and morbidity have been monitored in two villages in north-eastern Tanzania; a lowland village and a highland village from 2003 to 2008. Trained village health workers treated presumptive malaria with the Tanzanian first-line anti-malarial drug and collected blood smears that were examined later. The prevalence of malaria parasitaemia across years was monitored through cross-sectional surveys.ResultsThe prevalence of malaria parasitaemia in the lowland village decreased from 78.4% in 2003 to 13.0% in 2008, whereas in the highland village, the prevalence of parasitaemia dropped from 24.7% to 3.1% in the same period. Similarly, the incidence of febrile malaria episodes in the two villages dropped by almost 85% during the same period and there was a marked reduction in the number of young children who suffered from anaemia in the lowland village.ConclusionThere has been a marked decline in malaria in the study villages during the past few years. This decline is likely to be due to a combination of factors that include improved access to malaria treatment provided by the trained village helpers, protection from mosquitoes by increased availability of insecticide-impregnated bed nets and a reduced vector density. If this decline in malaria morbidity is sustained, it will have a marked effect on the disease burden in this part of Tanzania.

Out of the Ordinary: Nursing in Peru

A high school friendship inspired a love of other cultures and a desire to pursue missionary nursing in South America. As a parish nurse in a remote village in Peru, the author trained village health workers in the basics of hygiene, first aid, and disease prevention.

Is Home-Based Diagnosis and Treatment of Neonatal Sepsis Feasible and Effective? Seven Years of Intervention in the Gadchiroli Field Trial (1996 to 2003)

To further evaluate our earlier findings on the feasibility and effectiveness of home-based management of neonatal sepsis by analysing 7 years data (1996 to 2003) from the field trial in Gadchiroli, India. Neonates in 39 villages were monitored by trained village health workers (VHWs) from 1995 onwards. In 1996, we trained VHWs to diagnose sepsis by using a clinical algorithm and provide domiciliary treatment using intramuscular gentamicin and oral co-trimoxazole. Health records for all neonates were kept by the VHWs, checked by field supervisors, and computerized. Live births and neonatal deaths were recorded by an independent vital statistics collection system. We evaluated the feasibility and effectiveness of this approach. During September 1996 to March 2003, VHWs monitored 93% of all neonates in 39 villages (N=5268). As compared to 552 cases of sepsis diagnosed by computer algorithm, VHWs correctly diagnosed 492 cases (89%). Parents agreed to home-based treatment for the majority of infants (448, 91%), refused treatment in 31 (6.4%) cases, and hospitalized 13 infants (2.6%). VHWs treated 470 neonates with antibiotics, that is, 8.9% of all neonates in community. Of 552 cases diagnosed by computer, VHWs correctly treated 448 (81.2%) and gave unnecessary treatment to 22/470 (4.7%) of treated neonates. The case fatality (CF) was 6.9% in treated cases vs 22% in untreated or 16.6% in the pre-intervention period (p<0.001). Home-based treatment resulted in 67.2% reduction in %CF among preterm and a 72% reduction among LBW neonates. Home-based management of neonates with suspected sepsis is acceptable to most parents, safe, and effective in reducing sepsis case fatality by nearly 60%. With proper selection, training, and supervision of health workers, this method may be applicable in areas in developing countries where access to hospital care is limited.

The Incidence of Morbidities in a Cohort of Neonates in Rural Gadchiroli, India: Seasonal and Temporal Variation and a Hypothesis About Prevention

The incidence of morbidities among home-cared neonates in rural areas has not been studied. To estimate the incidence of various neonatal morbidities and the associated risk of death in home-cared neonates in rural setting. To estimate the variation in the incidence of neonatal morbidities by season and by day of life. To identify the scope for prevention of morbidities and suggest a hypothesis. A prospective observational study nested in the first year of the field trial in rural Gadchiroli, India. Trained village health workers in 39 villages observed neonates at the time of birth and in subsequent eight home visits up to 28 days. We diagnosed 20 neonatal morbidities by using clinical definitions. The data were analyzed for the incidence, case fatality, and relative risk of death and for the seasonal and day-wise variation in the incidence of morbidities. We observed total 763 neonates in 1 year. The incidence of morbidities was a mean of 2.2 morbidities per neonate. The case fatality in 13 morbidities was >10%. Only 2.6% neonates were seen or treated by a physician, and 0.4% were hospitalized. Hypothermia, fever, upper respiratory symptoms, umbilical and skin infections, and conjunctivitis showed statistically significant seasonal variation. Although the morbidities were concentrated in the first week of life, new cases continued to appear throughout the neonatal period. Various morbidities showed different distribution of incidence during 1 to 28 days. A large burden of disease occurs in rural home-cared neonates, and many morbidities are associated with high case fatality. Some morbidities show strong seasonal and day-wise variation in incidence, indicating poor care at home. We hypothesize that changes in practices and better home-based care will prevent the seasonal and temporal increase in morbidities. Some morbidities may not be preventable and will need early detection and treatment. Therefore, frequent home visits by a health worker are necessary to identify sick neonates.

Why Do Neonates Die in Rural Gadchiroli, India? (Part I): Primary Causes of Death Assigned by Neonatologist Based on Prospectively Observed Records

To determine the primary causes of death in home-cared rural neonates by using prospectively kept health records of neonates and a neonatologist's clinical judgment. In the first year (1995 to 1996) of the field trial in Gadchiroli, India, trained village health workers observed neonates in 39 villages by attending home deliveries and making eight home visits during days 0 to 28. The recorded data were validated in the field by a physician. An independent neonatologist assigned the most probable single primary cause of death based on these recorded data. A total of 763 neonates were observed, of whom 40 died (NMR 52.4/1000). The primary causes of death were sepsis/pneumonia 21 (52.5%), asphyxia 8 (20%), prematurity <32 weeks 6 (15%), hypothermia 1 (2.5%), and other/not known 4 (10%). Most of the prematurity or asphyxia deaths occurred during the first 3 days of life. All 21 sepsis/pneumonia deaths occurred during days 4 to 28. A similar picture existed in England before the antibiotic era. Sepsis/pneumonia is the primary cause in half the deaths in rural neonates cared for at home in Gadchiroli, followed by asphyxia and prematurity. Infections cause a larger proportion of deaths in neonates in the community compared to the reported proportion in hospital-based studies.

Maternal morbidity during labour and the puerperium in rural homes and the need for medical attention: A prospective observational study in Gadchiroli, India.

To estimate the incidence of maternal morbidity during labour and the puerperium in rural homes, the association with perinatal outcome and the proportion of women needing medical attention. Prospective observational study nested in a neonatal care trial. Thirty-nine villages in the Gadchiroli district, Maharashtra, India. Seven hundred and seventy-two women recruited over a one year period (1995-1996) and followed up from the seventh month in pregnancy to 28 days postpartum (up to 10 visits in total). Observations at home by trained village health workers, validated by a physician. Diagnosis of morbidities by computer program. Direct obstetric complications during labour and the puerperium, breast problems, psychiatric problems and need for medical attention. The incidence of maternal morbidity was 52.6%, 17.7% during labour and 42.9% during puerperium. The most common intrapartum morbidities were prolonged labour (10.1%), prolonged rupture of membranes (5.7%), abnormal presentation (4.0%) and primary postpartum haemorrhage (3.2%). The postpartum morbidities included breast problems (18.4%), secondary postpartum haemorrhage (15.2%), puerperal genital infections (10.2%) and insomnia (7.4%). Abnormal presentation and some puerperal complications (infection, fits, psychosis and breast problems) were significantly associated with adverse perinatal outcomes, but prolonged labour was not. A third of the mothers were in need of medical attention: 15.3% required emergency obstetric care and 24.0% required non-emergency medical attention. Nearly 15% of women who deliver in rural homes potentially need emergency obstetric care. Frequent (43%) postpartum morbidity, and its association with adverse perinatal outcome, suggests the need for home-based postpartum care in developing countries for both mother and baby.