Increasing access to care for sick newborns: evidence from the Ghana Newhints cluster-randomised controlled trial.
To evaluate the impact of Newhints community-based surveillance volunteer (CBSV) assessments and referrals on access to care for sick newborns and on existing inequities in access.



We evaluated a prospective cohort nested within the Newhints cluster-randomised controlled trial.



Community-based intervention involving more than 750 000, predominantly rural, population in seven contiguous districts in the Brong-Ahafo Region, Ghana.



Participants were recently delivered women (from more than 120 000 women under surveillance) and their 16 168 liveborn babies. Qualitative in-depth interviews with referral narratives (IDIs) were conducted with 92 mothers, CBSVs and health facility front-desk and maternity/paediatrics ward staff.



Newhints trained and effectively supervised 475 CBSVs (existing within the Ghana Health Service) in 49 of 98 supervisory zones (clusters) to assess and refer newborns with any of the 10-key-danger signs to health facilities within the first week after birth; promote independent care seeking for sick newborns and problem-solve around barriers between November 2008 and December 2009.



The main evaluation outcomes were rates of compliance with referrals and independent care seeking for newborn illnesses.



Of 4006 sampled, 2795 (69.8%) recently delivered women received CBSV assessment visits and 279 (10.0%) newborns were referred with danger signs. Compliance with referrals was unprecedentedly high (86.0%) with women in the poorest quintile (Q1) complying better than the least poor (Q5):87.5%(Q1) vs 69.7%(Q5); p=0.038. Three-quarters went to hospitals; 18% were admitted and 58% received outpatient treatment. Some (24%) mothers were turned away at facilities and follow-on IDIs showed that some of these untreated babies subsequently died. Independent care seeking for severe newborn illness increased from 55.4% in control to 77.3% in Newhints zones, especially among Q1 where care seeking almost doubled (95.0% vs 48.6%; RR=1.94 (1.32, 2.84); p=0.001). Rates were the highest among rural residents but urban residents complied quicker.



Home visits are feasible and a potentially pro-poor approach to link sick newborns to facilities. Its effectiveness in improving survival hinges on matched improvement in facility quality of care.



NCT00623337.
Department of Maternal, Newborn and Adolescent Health cluster, Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.
Alexander
A
Manu
Faculty of Population Health Sciences, Institute of Global Health, University College London, London, UK.
Zelee
Z
Hill
Department of Global Health, Academic Medical Centre, Amsterdam, The Netherlands.
Augustinus Ha
AH
Ten Asbroek
Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.
Seyi
S
Soremekun
Department of Maternal, Newborn and Adolescent Health cluster, Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana.
Benedict
B
Weobong
Department of Maternal, Newborn and Adolescent Health cluster, Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana.
Thomas
T
Gyan
Department of Maternal, Newborn and Adolescent Health cluster, Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana.
Charlotte
C
Tawiah-Agyemang
Department of Maternal, Newborn and Adolescent Health cluster, Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana.
Samuel
S
Danso
Department of Maternal, Newborn and Adolescent Health cluster, Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana.
Seeba
S
Amenga-Etego
Department of Maternal, Newborn and Adolescent Health cluster, Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.
Seth
S
Owusu-Agyei
Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.
Betty R
BR
Kirkwood
D003150:Community Health Workers; D005260:Female; D005869:Ghana; D006268:Health Facilities / Q000706:statistics & numerical data*; D006792:House Calls / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007226:Infant Mortality / Q000639:trends*; D007231:Infant, Newborn; D007407:Interviews as Topic; D008297:Male; D010349:Patient Compliance / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012424:Rural Population; D014505:Urban Population
EPIDEMIOLOGY; PREVENTIVE MEDICINE; PRIMARY CARE