The methodology for assembling a database of 548 assessments of the effectiveness of CBPHC in improving child health, including the search strategy, has been described elsewhere in this series [10]. In brief, we considered CBPHC to be any activity in which one or more health–related interventions were carried out in the community outside of a health facility. There could also be associated activities that took place in health facilities. The larger study conducted a search of published documents in PubMed, personal sources, and the grey literature for documents that described the implementation of CBPHC and assessed the effect of these projects, programs, or field research studies (described collectively as projects) on mortality, morbidity, nutritional status, or population coverage of an evidence–based intervention. Of 4276 articles identified for screening via PubMed, 433 qualified for the review. In addition, 115 reports were identified from the grey literature and elsewhere, yielding a total of 548 neonatal and child health assessments included in the review. Two reviewers independently extracted information about the assessment and a third independent reviewer resolved any differences. The data were transferred to an electronic database using EPI INFO version 3.5.4 (US Centers for Disease Control and Prevention, Atlanta, Georgia, USA).

Starting with the child health data set, assessments were selected for the analysis of neonatal health in a three–stage process ( Figure 1 ). In the first stage, articles were selected that had been coded with relevant interventions pertaining to neonates. These interventions, as defined on the data extraction form, were: neonatal/perinatal health; breastfeeding; child weight/height (including birth weight); immunizations; diarrhea treatment; pneumonia treatment; malaria prevention; malaria treatment; Integrated Management of Childhood Illness (IMCI); prevention of mother–to–child transmission of HIV; neonatal tetanus prevention; neonatal tetanus treatment; congenital syphilis prevention; congenital syphilis treatment; and primary health care. This yielded 380 articles.

Figure 1.  Selection of assessments for inclusion in the neonatal health review.

In the second stage, titles and abstracts of these 380 articles were reviewed. Articles were then excluded if the target population was not infants under age one. This yielded 108 articles. Further exclusions were made if the article did not have an outcome directly related to neonatal health (knowledge about newborn illness, care seeking for newborn illness, utilization of postnatal care, or a neonatal health outcome related to nutritional status, morbidity or mortality). The final database for this sub–analysis included 93 articles. Articles were coded by the primary and secondary health condition addressed, the outcome variables, and categorized by the type and strength of study design.

All study designs were included, but were separated into three categories: randomized controlled trials (RCTs); non–randomized controlled trials; and observational and other non–experimental designs. We conducted descriptive analyses on the data set to present the proportion of beneficial health outcomes within each category. A table of only the RCTs is presented in Table S1 of Online Supplementary Document(Online Supplementary Document) .

In this paper, when assessments selected for this analysis are specifically cited, we cite them with the first author’s last name and year of publication, with the reference number in brackets with a prefix S. The full reference can be obtained from Appendix S2 in Online Supplementary Document(Online Supplementary Document) where the full references for all the 93 assessments selected for the analysis in this paper can be located.

The term community health worker (CHW) is used here to refer to any community–level actor who receives training from the project or the broader health system/health program to assist in the activities of the project. We do not provide any further specification here regarding length of training, level of compensation (if any), formal recognition by the ministry of health, or other descriptive characteristics of CHWs, as they varied widely among the included assessments, although we recognize that this is an important dimension of these projects.

Our analysis provides strong evidence that CBPHC can improve neonatal health in low–income settings. Of the studies with strong experimental research designs, over 70% showed a positive neonatal health impact. Although many of these studies were smaller scale pilots or efficacy studies, it demonstrates that CBPHC can be an essential tool where access to facilities is limited and many births take place at home. In these settings, access to antenatal care is often limited; for example, only 49% of pregnant women in sub–Saharan Africa obtain four antenatal care visits [1]. Furthermore, among the 75 countries with the greatest burden of neonatal mortality, the median national coverage of interventions that are important for improving neonatal mortality is quite low: 65% for skilled attendant at delivery, 28% for postnatal visits for newborns, and 50% for early initiation of breastfeeding [14]. Community–based approaches will be essential for the near term in order to achieve universal coverage of health services for these mothers during their delivery and immediately following birth. Even if primary health care services are better developed and facility coverage of antenatal, delivery, and postnatal care increases, CBPHC can continue to make a contribution to improved neonatal health through promotion of healthy household practices and awareness of danger signs for which facility–based care should be sought.

The most common outcome indicators used in the assessments included in our analysis were related to population coverage of postnatal care and exclusive breastfeeding during the neonatal period; mortality was also relatively well–studied. While our review did not include assessments of the quality of implemented interventions or the degree to which projects were implemented under ideal vs more routine conditions (to assess to what degree the assessments were of CBPHC efficacy as opposed to effectiveness), we did summarize the findings by the rigor of the study design and demonstrated that for all levels of methodological rigor, CBPHC approaches appeared to produce favorable outcomes on neonatal health. It is worth noting the importance of assessing and improving the quality of care provided at the time of health contacts between patients and providers, whether they take place in facilities or in homes; however, information on this topic was missing in almost all of the assessments included in our analysis. Further, many of the studies with the strongest designs also had the most intensive support in carrying out the intervention, making it more difficult to judge the effectiveness if scaled up without focused attention or resources.

Our analysis reveals that many of the leading causes of death among children during the first month of life – especially those caused by infection – can be effectively addressed at the community level by CHWs if they have proper training and support. Home–based neonatal care includes promotion of immediate and exclusive breastfeeding, promotion of cleanliness, application of a topical antiseptic (chlorhexidine) to the umbilical cord, prevention of hypothermia, and early diagnosis and referral for treatment of neonatal sepsis. Strong evidence was found for the capacity of CHWs to promote clean delivery, especially in settings where births occur at home and hygiene is poor, to improve neonatal care practices at home, and to identify sick neonates in need of further care and treatment for certain conditions.

Given that many neonatal care projects utilize community health workers (CHWs), it is expected that many interventions can be provided close to or in the home, especially if CHWs live near their patients. Key community–based intervention strategies that were demonstrated to be successful in our analysis include home visitation by CHWs to educate mothers about healthy household practices, danger signs, the importance of early referral and treatment of neonates with danger signs, and outreach by mobile teams from health facilities (especially to provide maternal immunization against neonatal tetanus). Additionally, our analysis identifies the capacity of participatory women’s groups to raise awareness about healthy practices during pregnancy and the postpartum/postnatal period, and to educate about of danger signs for which facility–based care should be sought and the favorable effects of this approach for reducing neonatal mortality. Our equity analysis shows that almost all of the CBPHC interventions for improving newborn health benefit more disadvantaged groups to a greater degree than others.

This study had a number of limitations. The evidence is derived from projects mostly in rural South Asia. Most projects had a relatively short timeline and so we are unable to ascertain if they were successful in the long term. Furthermore, many (but not all) of the projects were implemented in relatively small populations under relatively ideal circumstances in which high–quality training, supervision, and logistical support were assured. So whether similar results can be achieved under more routine condition in larger populations over long periods of time is not known at present.

The large proportion of positive outcomes could be partially due to publication bias. Especially given that all study types were included (such as gray literature reports), there may have been a tendency by organizations to promote their successful work and only publish studies which had a beneficial impact. This study was further limited by the wide range of definitions, indicators and measurements used, which made standardization impossible. We aimed to provide useful categories and definitions, but the variation is wide. For example, it is known that the capacity and competence of CHWs varies widely; further analysis of the details regarding how CHWs were trained and deployed in the projects included in our review were limited. The context in which projects were carried out is also wide: details regarding exactly how the intervention strategies were carried out, and the specific conditions required for them to be effective at scale, go beyond the scope of this analysis. Finally, while this is intended to be a comprehensive review, the field is vast and some studies may not have been included.

The need to accelerate declines in neonatal mortality is readily apparent. In order to achieve universal health coverage and to end preventable neonatal deaths by the year 2030, basic and essential evidence–based neonatal health care interventions will need to reach all mothers and their newborns. Since many countries will not be able to provide universal coverage of essential newborn services by 2030 through facility–based services, progress in reducing neonatal mortality in high–mortality, resource–constrained settings will have to partially depend for the foreseeable future upon strengthening the types of interventions and approaches described here, and on improving timely referral to facilities for newborns with complications. The next step in this process is to test the types of interventions and approaches described here at scale using rigorous operations research methodologies. Further research is also needed in a wider variety of geographic areas, in urban and peri–urban settings, and for longer–term programs.

According to one recently published analysis based on modeling tools [2], immediately scaling up the currently available community–based interventions with evidence of effectiveness for reducing neonatal mortality to reach 90% population coverage would avert an estimated 740 000 neonatal deaths annually (27.4% of the total of 2.7 million neonatal deaths currently occurring each year). Similarly, a separate analysis [15] estimates that 700 000 newborn lives that would be saved if all of the community–based interventions gradually achieved a coverage of 90% over a 5–year period. While CBPHC approaches for reducing the number of stillbirths were not included in this review, there is growing evidence that community–based efforts to improve antenatal care, especially nutrition and malaria prevention, will have effects on the prevalence of stillbirth worldwide [15]. If the interventions that can be provided at primary health care centers and at hospitals but not in the community (eg, full supportive care for preterm newborns or treatment if very serious infection) were able to reach 90% of the neonates who need them, an additional 760 00 neonatal deaths could be averted (170 000 at primary health care centers and 0.59 million at hospitals) [2]. Thus, even though facility–based care is important for improving neonatal health, expanding the coverage of community–based services will also be essential in order to quickly accelerate the decline of neonatal mortality in high–burden countries.

The evidence regarding the potential of CBPHC to improve neonatal health in resource–constrained settings is strong. Now there is a need to begin to assemble evidence regarding the effectiveness of implementation of these interventions and strategies at scale. The scaling up of effective community–based interventions will be essential for accelerating progress in reducing neonatal mortality in the near term and for reaching universal coverage of evidence–based interventions for improving neonatal health. Based upon the current evidence, this will require the development and strengthening of a community–based platform involving (1) training and deployment of CHWs to visit homes frequently to promote healthy household behaviors, identification of neonates in need of referral, and utilization of health facilities appropriately, (2) formation and support of participatory women’s groups, and (3) strengthening of outreach services provided by mobile health teams for provision of antenatal and postnatal care. Identifying ways for all newborns to receive the highest quality of care that can be provided in the home will have a sizable impact on neonatal mortality and morbidity worldwide.