title: Effect of the Uganda Newborn Study on care-seeking and care practices: a cluster-randomised controlled trial.
abstract: BACKGROUND
  Care for women and babies before, during, and after the time of birth is a sensitive measure of the functionality of any health system. Engaging communities in preventing newborn deaths is a promising strategy to achieve further progress in child survival in sub-Saharan Africa.
  
  
  OBJECTIVE
  To assess the effect of a home visit strategy combined with health facility strengthening on uptake of newborn care-seeking, practices and services, and to link the results to national policy and scale-up in Uganda.
  
  
  METHODS
  The Uganda Newborn Study (UNEST) was a two-arm cluster-randomised controlled trial in rural eastern Uganda. In intervention villages volunteer community health workers (CHWs) were trained to identify pregnant women and make five home visits (two during pregnancy and three in the first week after birth) to offer preventive and promotive care and counselling, with extra visits for sick and small newborns to assess and refer. Health facility strengthening was done in all facilities to improve quality of care. Primary outcomes were coverage of key essential newborn care behaviours (breastfeeding, thermal care, and cord care). Analyses were by intention to treat. This study is registered as a clinical trial, number ISRCTN50321130.
  
  
  RESULTS
  The intervention significantly improved essential newborn care practices, although many interventions saw major increases in both arms over the study period. Immediate breastfeeding after birth and exclusive breastfeeding were significantly higher in the intervention arm compared to the control arm (72.6% vs. 66.0%; p=0.016 and 81.8% vs. 75.9%, p=0.042, respectively). Skin-to-skin care immediately after birth and cord cutting with a clean instrument were marginally higher in the intervention arm versus the control arm (80.7% vs. 72.2%; p=0.071 and 88.1% vs. 84.4%; p=0.023, respectively). Half (49.6%) of the mothers in the intervention arm waited more than 24 hours to bathe the baby, compared to 35.5% in the control arm (p<0.001). Dry umbilical cord care was also significantly higher in intervention areas (63.9% vs. 53.1%, p<0.001). There was no difference in care-seeking for newborn illness, which was high (around 95%) in both arms. Skilled attendance at delivery increased in both the intervention (by 21%) and control arms (by 19%) between baseline and endline, but there was no significant difference in coverage across arms at endline (79.6% vs. 78.9%; p=0.717). Home visits were pro-poor, with more women in the poorest quintile visited by a CHW compared to families in the least poor quintile, and more women who delivered at home visited by a CHW after birth (73.6%) compared to those who delivered in a hospital or health facility (59.7%) (p<0.001). CHWs visited 62.8% of women and newborns in the first week after birth, with 40.2% receiving a visit on the critical first day of life.
  
  
  CONCLUSIONS
  Consistent with results from other community newborn care studies, volunteer CHWs can be effective in changing long-standing practices around newborn care. The home visit strategy may provide greater benefit to poorer families. However, CHW strategies require strong linkages with and concurrent improvement of quality through health system strengthening, especially in settings with high and increasing demand for facility-based services.
authors.affiliation: Department of Health Policy, Planning and Management, School of Public Health, College of Health Science, Makerere University, Kampala, Uganda.|Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.|Iganga-Mayuge Health and Demographic Surveillance Site, Iganga-Mayuge, Uganda; pwaiswa@musph.ac.ug.
authors.forename: Peter
authors.initials: P
authors.lastname: Waiswa
authors.affiliation: Department of Health Policy, Planning and Management, School of Public Health, College of Health Science, Makerere University, Kampala, Uganda.|Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
authors.forename: George
authors.initials: G
authors.lastname: Pariyo
authors.affiliation: Department of Health Policy, Planning and Management, School of Public Health, College of Health Science, Makerere University, Kampala, Uganda.|Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.|Malaria Consortium, London, UK.
authors.forename: Karin
authors.initials: K
authors.lastname: Kallander
authors.affiliation: Department of Health Policy, Planning and Management, School of Public Health, College of Health Science, Makerere University, Kampala, Uganda.
authors.forename: Joseph
authors.initials: J
authors.lastname: Akuze
authors.affiliation: Department of Health Policy, Planning and Management, School of Public Health, College of Health Science, Makerere University, Kampala, Uganda.
authors.forename: Gertrude
authors.initials: G
authors.lastname: Namazzi
authors.affiliation: Department of Health Policy, Planning and Management, School of Public Health, College of Health Science, Makerere University, Kampala, Uganda.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Ekirapa-Kiracho
authors.affiliation: Save the Children, Cape Town, South Africa.
authors.forename: Kate
authors.initials: K
authors.lastname: Kerber
authors.affiliation: Save the Children, Cape Town, South Africa.
authors.forename: Hanifah
authors.initials: H
authors.lastname: Sengendo
authors.affiliation: Save the Children, Cape Town, South Africa.
authors.forename: Patrick
authors.initials: P
authors.lastname: Aliganyira
authors.affiliation: MARCH Unit, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Joy E
authors.initials: JE
authors.lastname: Lawn
authors.affiliation: Department of Health Policy, Planning and Management, School of Public Health, College of Health Science, Makerere University, Kampala, Uganda.|Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.|International Maternal and Child Health Unit, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
authors.forename: Stefan
authors.initials: S
authors.lastname: Peterson
mesh_terms: D000293:Adolescent; D000328:Adult; D002662:Child Health Services / Q000458:organization & administration*; D016000:Cluster Analysis; D003153:Community Health Services / Q000458:organization & administration*; D003906:Developing Countries; D005260:Female; D006792:House Calls; D006801:Humans; D007223:Infant; D007224:Infant Care / Q000458:organization & administration*; D007231:Infant, Newborn; D008297:Male; D008427:Maternal Health Services / Q000458:organization & administration*; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011247:Pregnancy; D019035:Rural Health Services / Q000458:organization & administration*; D012424:Rural Population; D012959:Socioeconomic Factors; D014454:Uganda; D055815:Young Adult
keywords: Uganda; community health workers; health system strengthening; kangaroo mother care; maternal care; neonatal mortality; newborn care; randomised controlled trial
references.citation: Glob Health Action. 2015 Mar 31;8:24251
references.pmid: 25843495
references.citation: Trials. 2012 Nov 15;13:213
references.pmid: 23153395
references.citation: Glob Health Action. 2015 Mar 31;8:24386
references.pmid: 25843497
references.citation: Lancet. 2007 Oct 13;370(9595):1358-69
references.pmid: 17933651
references.citation: BMC Pregnancy Childbirth. 2010 Feb 23;10:9
references.pmid: 20178626
references.citation: Lancet. 2011 Apr 16;377(9774):1319-30
references.pmid: 21496917
references.citation: Trop Med Int Health. 2014 Mar;19(3):256-266
references.pmid: 24433230
references.citation: Glob Health Sci Pract. 2013 Mar 21;1(1):5-10
references.pmid: 25276511
references.citation: AIDS. 2009 Sep 10;23(14):1924-6
references.pmid: 19710561
references.citation: Lancet. 2013 Jun 22;381(9884):2184-92
references.pmid: 23578528
references.citation: Glob Health Action. 2015 Mar 31;8:23968
references.pmid: 25843491
references.citation: BMC Pregnancy Childbirth. 2008 Jun 21;8:21
references.pmid: 18570672
references.citation: Health Policy Plan. 2012 Jul;27 Suppl 3:iii104-117
references.pmid: 22692413
references.citation: Lancet. 2011 Jan 29;377(9763):403-12
references.pmid: 21239052
references.citation: Trop Med Int Health. 2013 Jul;18(7):898-906
references.pmid: 23551394
references.citation: PLoS One. 2013 Nov 29;8(11):e81610
references.pmid: 24312326
references.citation: Health Policy Plan. 2012 Jul;27 Suppl 3:iii6-28
references.pmid: 22692417
references.citation: Glob Health Action. 2017;10(1):1356641
references.pmid: 28799450
references.citation: Glob Health Action. 2015 Mar 31;8:24271
references.pmid: 25843496
references.citation: PLoS One. 2010 Mar 24;5(3):e9696
references.pmid: 20352087
references.citation: Pediatr Infect Dis J. 2009 Apr;28(4):304-10
references.pmid: 19289979
references.citation: Lancet. 2013 May 18;381(9879):1736-46
references.pmid: 23683640
references.citation: Am J Trop Med Hyg. 2012 Nov;87(5 Suppl):46-53
references.pmid: 23136277
references.citation: Trop Med Int Health. 2010 Aug;15(8):964-72
references.pmid: 20636527
references.citation: Trop Med Int Health. 2010 Oct;15(10):1140-7
references.pmid: 20723185
references.citation: Glob Health Action. 2015 Mar 31;8:24250
references.pmid: 25843494
references.citation: Lancet. 2008 Sep 27;372(9644):1151-62
references.pmid: 18926277
references.citation: J Perinatol. 2005 Mar;25 Suppl 1:S92-107
references.pmid: 15791283
references.citation: Child Care Health Dev. 2013 Jan;39(1):20-6
references.pmid: 22680250