title: A systematic review of community-to-facility neonatal referral completion rates in Africa and Asia.
abstract: BACKGROUND
  An estimated 2.8 million neonatal deaths occur annually worldwide. The vulnerability of newborns makes the timeliness of seeking and receiving care critical for neonatal survival and prevention of long-term sequelae. To better understand the role active referrals by community health workers play in neonatal careseeking, we synthesize data on referral completion rates for neonates with danger signs predictive of mortality or major morbidity in low- and middle-income countries.
  
  
  METHODS
  A systematic review was conducted in May 2014 of the following databases: Medline-PubMed, Embase, and WHO databases. We also searched grey literature. In addition, an investigator group was established to identify unpublished data on newborn referral and completion rates. Inquiries were made to the network of research groups supported by Save the Children's Saving Newborn Lives project and other relevant research groups.
  
  
  RESULTS
  Three Sub-Saharan African and five South Asian studies reported data on community-to-facility referral completion rates. The studies varied on factors such as referral rates, the assessed danger signs, frequency of home visits in the neonatal period, and what was done to facilitate referrals. Neonatal referral completion rates ranged from 34 to 97 %, with the median rate of 74 %. Four studies reported data on the early neonatal period; early neonatal completion rates ranged from 46 to 97 %, with a median of 70 %. The definition of referral completion differed by studies, in aspects such as where the newborns were referred to and what was considered timely completion.
  
  
  CONCLUSIONS
  Existing literature reports a wide range of neonatal referral completion rates in Sub-Saharan Africa and South Asia following active illness surveillance. Interpreting these referral completion rates is challenging due to the great variation in study design and context. Often, what qualifies as referral and/or referral completion is poorly defined, which makes it difficult to aggregate existing data to draw appropriate conclusions that can inform programs. Further research is necessary to continue highlighting ways for programs, governments, and policymakers to best aid families in low-resource settings in protecting their newborns from major health consequences.
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St. W5019, Baltimore, MD, 21205, USA. nkozuki@jhu.edu.
authors.forename: Naoko
authors.initials: N
authors.lastname: Kozuki
authors.affiliation: Save the Children, 2000 L Street NW, Suite 500, Washington, DC, 20036, USA. TGuenther@savechildren.org.
authors.forename: Tanya
authors.initials: T
authors.lastname: Guenther
authors.affiliation: Save the Children, 2000 L Street NW, Suite 500, Washington, DC, 20036, USA. LVaz@savechildren.org.
authors.forename: Lara
authors.initials: L
authors.lastname: Vaz
authors.affiliation: Save the Children, 2000 L Street NW, Suite 500, Washington, DC, 20036, USA. allisynmoran@gmail.com.
authors.forename: Allisyn
authors.initials: A
authors.lastname: Moran
authors.affiliation: Aga Khan University, Karachi, Pakistan. sajid.soofi@aku.edu.
authors.forename: Sajid B
authors.initials: SB
authors.lastname: Soofi
authors.affiliation: Makerere University College of Health Sciences School of Public Health, Kampala, Uganda. cnalwadda@musph.ac.ug.
authors.forename: Christine Nalwadda
authors.initials: CN
authors.lastname: Kayemba
authors.affiliation: Makerere University College of Health Sciences School of Public Health, Kampala, Uganda. stefan.peterson@kbh.uu.se.|International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden. stefan.peterson@kbh.uu.se.|Karolinska Institutet, Department of Public Health Sciences, Stockholm, Sweden. stefan.peterson@kbh.uu.se.
authors.forename: Stefan S
authors.initials: SS
authors.lastname: Peterson
authors.affiliation: Center of Excellence in Women and Child Health, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan. zulfiqar.bhutta@aku.edu.|Center for Global Child Health, Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G A04, Canada. zulfiqar.bhutta@aku.edu.
authors.forename: Zulfiqar A
authors.initials: ZA
authors.lastname: Bhutta
authors.affiliation: Morang Innovative Neonatal Intervention/John Snow Inc. Research and Training Institute, Kathmandu, Nepal. sudhirkhanal@hotmail.com.
authors.forename: Sudhir
authors.initials: S
authors.lastname: Khanal
authors.affiliation: Department of Global Health, George Washington University Milken Institute School of Public Health, 950 New Hampshire Ave., NW, Suite 400, Washington, DC, 20052, USA. jtielsch@email.gwu.edu.
authors.forename: James M
authors.initials: JM
authors.lastname: Tielsch
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, Francie van Zijl Drive, Parow, Cape Town, South Africa. tanya.doherty@mrc.ac.za.|School of Public Health, University of the Western Cape, Bellville, Cape Town, South Africa. tanya.doherty@mrc.ac.za.
authors.forename: Tanya
authors.initials: T
authors.lastname: Doherty
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, 491 Ridge Road, Durban, South Africa. Duduzile.Nsibande@mrc.ac.za.
authors.forename: Duduzile
authors.initials: D
authors.lastname: Nsibande
authors.affiliation: Save the Children, 2000 L Street NW, Suite 500, Washington, DC, 20036, USA. joy.lawn@lshtm.ac.uk.|Maternal Reproductive and Child Health (MARCH) Center, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. joy.lawn@lshtm.ac.uk.|Research and Evidence Division, UK AID, 22 Whitehall, London, SW1A 2EG, UK. joy.lawn@lshtm.ac.uk.
authors.forename: Joy E
authors.initials: JE
authors.lastname: Lawn
authors.affiliation: Save the Children, 2000 L Street NW, Suite 500, Washington, DC, 20036, USA. swall@savechildren.org.
authors.forename: Stephen
authors.initials: S
authors.lastname: Wall
mesh_terms: D017954:Africa South of the Sahara; D001208:Asia; D003153:Community Health Services; D003150:Community Health Workers; D006268:Health Facilities; D006792:House Calls; D006801:Humans; D007231:Infant, Newborn; D009017:Morbidity; D066087:Perinatal Death / Q000517:prevention & control*; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012111:Residence Characteristics