title: Household surveillance of severe neonatal illness by community health workers in Mirzapur, Bangladesh: coverage and compliance with referral.
abstract: BACKGROUND
  Effective and scalable community-based strategies are needed for identification and management of serious neonatal illness.
  
  
  METHODS
  As part of a community-based, cluster-randomized controlled trial of the impact of a package of maternal-neonatal health care, community health workers (CHWs) were trained to conduct household surveillance and to identify and refer sick newborns according to a clinical algorithm. Assessments of newborns by CHWs at home were linked to hospital-based assessments by physicians, and factors impacting referral, referral compliance and outcome were evaluated.
  
  
  RESULTS
  Seventy-three per cent (7310/10,006) of live-born neonates enrolled in the study were assessed by CHWs at least once; 54% were assessed within 2 days of birth, but only 15% were attended at delivery. Among assessments for which referral was recommended, compliance was verified in 54% (495/919). Referrals recommended to young neonates 0-6 days old were 30% less likely to be complied with compared to older neonates. Compliance was positively associated with having very severe disease and selected clinical signs, including respiratory rate > or = 70/minute; weak, abnormal or absent cry; lethargic or less than normal movement; and feeding problem. Among 239 neonates who died, only 38% were assessed by a CHW before death.
  
  
  CONCLUSIONS
  Despite rigorous programmatic effort, reaching neonates within the first 2 days after birth remained a challenge, and parental compliance with referral recommendation was limited, particularly among young neonates. To optimize potential impact, community postnatal surveillance must be coupled with skilled attendance at delivery, and/or a worker skilled in recognition of neonatal illness must be placed in close proximity to the community to allow for rapid case management to avert early deaths.
authors.affiliation: Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA. gdarmsta@jhsph.edu
authors.forename: Gary L
authors.initials: GL
authors.lastname: Darmstadt
authors.forename: Shams
authors.initials: S
authors.lastname: El Arifeen
authors.forename: Yoonjoung
authors.initials: Y
authors.lastname: Choi
authors.forename: Sanwarul
authors.initials: S
authors.lastname: Bari
authors.forename: Syed M
authors.initials: SM
authors.lastname: Rahman
authors.forename: Ishtiaq
authors.initials: I
authors.lastname: Mannan
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Winch
authors.forename: A S M Nawshad Uddin
authors.initials: AS
authors.lastname: Ahmed
authors.forename: Habibur Rahman
authors.initials: HR
authors.lastname: Seraji
authors.forename: Nazma
authors.initials: N
authors.lastname: Begum
authors.forename: Robert E
authors.initials: RE
authors.lastname: Black
authors.forename: Mathuram
authors.initials: M
authors.lastname: Santosham
authors.forename: Abdullah H
authors.initials: AH
authors.lastname: Baqui
mesh_terms: D000328:Adult; D001459:Bangladesh; D003153:Community Health Services; D003150:Community Health Workers; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D008427:Maternal Health Services; D015997:Neonatal Screening; D015397:Program Evaluation; D019035:Rural Health Services; D012720:Severity of Illness Index; D055815:Young Adult