Impact Evaluation of an Integrated Nutrition and Health Programme on Neonatal

Mortality in rural Northern India: Experience of an Independent Evaluation

Praween K. Agrawal, Ph.D

New Delhi, India

Background • Neonatal period is recognized as a brief, critical time that requires focused

interventions to reach the MDG (two-thirds reduction in child mortality) by 2015.

• In India, there are one million neonatal deaths every year, representing approximately a quarter of all global neonatal deaths.

• To cater the need, Integrated Nutrition and Health Programme (INHP) was launched in 100 districts in India with partnership of an international NGO, CARE-India, together with Government of India (GOI) and local NGOs.

• The programme was implemented through the infrastructure of GOI Ministry of Women and Child Development’s Integrated Child Development Services (ICDS) and the Ministry of Health and Family Welfare.

• The newborn care package aimed to increase the frequency of behaviours during the antenatal, delivery and postnatal periods that have proven benefits for maternal and newborn survival.

Objective

To assess the impact of the newborn health component of a large-scale community-based integrated nutrition and health programme on neonatal mortality.

CARE-India

Planning, coordination and logistical support to integrate and strengthen ICDS and MOHFW programmes with an emphasis on newborn care

Technical support, training of government officials, frontline health workers and community volunteers

Funding to NGOs for BCC and social marketing

Monitoring and evaluation

Ministry of Health and Family Welfare

Infrastructure

One auxiliary nurse-midwife per 5000

Planning, training, supervision, supplies, logistics and monitoring

Programme and policy development

Imp

lem

en

ting

pa

rtne

rs a

nd

th

eir in

pu

ts

Ministry of Women and Child Development’s Integrated Child

Development Services

Infrastructure

One anganwadi worker per1000 (or 1 village)

Planning, training, supervision, supplies, logistics and monitoring

Programme and policy development

Health workers’ knowledge improved Increased programme coverage Improved monitoring systems at the block and district level Volunteer recruited and trained; volunteer women’s groups formed at village level Improved supervision Strengthened supply chain

Pro

ce

ss

Ou

tc

om

e

Imp

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Conceptual model for promotion of newborn care within the INHP

Mothers’ knowledge of maternal and newborn

care increased

Improved preventive care practices for mothers

Improved newborn care practices

Improved use of health-care

services

Reduced neonatal mortality rate

Study location and design

• Although the programme was implemented in eight states, data was collected from Uttar Pradesh state only.

• A quasi-experimental design was used with a baseline and end line surveys (pre-post) with three adequacy surveys in one intervention and one comparison district.

• The evaluation study (design, data collection and analysis) was conducted by a team of independent researchers who were not involved in the implementation of the intervention.

• The sample size was calculated to detect a 20% reduction in neonatal mortality following the intervention with 80% power at a 5% significance level.

Data collection and analysisMothers who had given birth in two years preceding the surveys were interviewed during the baseline (n=14,952) and endline (n =13,826) surveys in 2003 and 2006, respectively.

Data collection was contracted out to an survey agency and a rigorous data quality assurance (DQA) mechanism was in place. A consistent weekly data matching were done to ensure the quality along with spot checks and back checks by the evolution team.

Descriptive statistics were calculated with use of standard methods. Intervention exposure and behaviour change indicators were analyzed using a difference-in-difference test to compare the change from baseline to endline for intervention versus comparison districts.

Neonatal mortality rates (NMR) were also calculated after stratification by antenatal and postnatal home visitation status.

Stata, version 8 was used (StataCorp. LP, College Station, TX, United States of America) for statistical analysis.

Antenatal home visits by any service provider over the study period by intervention and comparison districts

Antenatal Home Visit Coverage

15

39

54 52

62

23 2328 28

20

0

10

20

30

40

50

60

70

Baseline ADQI ADQII ADQIII Endline

(n=15017) (n=1759) (n=1746) (n=1747) (n=6498)

Pro

po

rtio

n o

f R

DW

Intervention Comparison

Postpartum Visit (1 week) Coverage

1

1115 16

26

2 3 3 2 20

10

20

30

40

50

60

70

Baseline ADQI ADQII ADQIII Endline

(n=15017) (n=1759) (n=1746) (n=1747) (n=6498)

Pro

pro

tio

n o

f M

oth

ers

Intervention Comparison

Postpartum home visits within a week by any service provider

over the study period by intervention and comparison districts

Recently delivered women’s (RDW) exposure to promoted

behaviours by intervention and comparison

•P-value for difference of differences test. Adjusted for age, education, parity, religion and wealth.•† At least one of the following: suitable location for delivery, person to deliver baby, hospital/clinic to be attended in case of complication, arrangement for transport, and disposable delivery kit.

COMPARISON INTERVENTION

Baseline (2001-02)

Endline (2004-05)

Change Baseline (2001-02)

Endline (2004-05)

Change Adjusted P-value*

Advice received during pregnancy Tetanus toxoid immunization 41.0 69.0 28.0 15.7 76.6 60.9 <0.000 Iron-folate supplementation 37.8 57.9 20.1 14.3 72.3 58.0 <0.000 Saving money for birth 5.0 24.2 19.2 3.5 57.5 54.0 <0.000 Any other birth planning † 13.2 29.7 16.5 6.7 63.8 57.1 <0.000 Maternal and/or newborn danger signs 7.7 7.5 -0.2 3.5 18.1 14.6 <0.000 Five cleans of delivery 6.3 12.9 6.6 3.3 49.3 46.0 <0.000 Breastfeeding 9.2 24.7 15.5 5.1 61.7 56.6 <0.000 Drying and wrapping of the newborn 7.1 17.1 10.0 4.1 51.0 46.9 <0.000

Recently delivered women’s (RDW) adherence to promoted behaviours by intervention and comparison

COMPARISON INTERVENTION

Baseline (2001-02)

Endline (2004-05)

Change Baseline (2001-02)

Endline (2004-05)

Change Adjusted P-value*

Antenatal Care

Proportion of RDW that: Received one or more antenatal check-ups from a qualified provider ‡

24.6 27.7 3.1 16.5 35.4 18.9 <0.000

Received three or more antenatal check-ups from a qualified provider ‡

7.0 8.8 1.8 3.6 12.1 8.5 <0.000

Received 2+ tetanus immunizations 58.0 62.6 4.6 47.8 70.0 22.2 <0.000 Consumed 100+ iron-folic acid tablets 6.6 8.3 1.7 5.0 20.8 15.8 <0.000 Saved money for childbirth 12.2 29.7 17.5 14.8 50.0 35.2 <0.000 Took any other birth planning step † 20.0 17.6 -2.4 10.7 34.4 23.7 <0.000

Recently delivered women’s (RDW) adherence to promoted behaviours by intervention and comparison

COMPARISON INTERVENTION

Baseline (2001-02)

Endline (2004-05)

Change Baseline (2001-02)

Endline (2004-05)

Change Adjusted P-value*

Delivery and newborn care Proportion of RDW that:

Delivered in a health facility or at home with a skilled birth attendant ‡

17.9 22.1 4.2 16.7 22.6 5.9 <0.008

Practiced clean cord care § 35.8 41.8 6.0 32.2 68.4 36.2 <0.000 Practiced newborn thermal care in the first 6 hours ||

0.7 0.6 -0.1 3.8 23.8 20.0 <0.000

Initiated breastfeeding on first day 11.7 23.6 11.9 16.8 68.0 51.2 <0.000 Newborns with complications who received care from a qualified provider ‡ ¶

35.5 30.2 -5.3 20.3 30.3 10.0 <0.000

Total number of participant mothers 5861 5710 8264 7503 * P-value for difference of differences test. Adjusted for age, education, parity, religion and wealth. ‡ Medically qualified doctor, nurse, lady health visitor or auxiliary nurse midwife. § Umbilical cord cut with boiled blade and tied with sterile thread. || Newborn dried and wrapped immediately after delivery and first bath delayed for six hours or more. ¶ Only newborns with complications included. Comparison baseline n=3066, endline n=2210; Intervention baseline n=4899, endline n=2931.

Impact on neonatal mortality rates

Baseline survey Endline survey Baseline survey Endline survey

Live births 8 756 7 812 6 196 6 014

Deaths 431 393 296 299

Unadjusted NMR (95% CI) 49.2 (44.8–54.0) 50.3 (45.6–55.4) 47.8 (42.6–53.4) 49.7 (44.4–55.5)

Adjusted NMR (95% CI) 46.4 (42.0–50.8) 52.1 (47.2–57.0) 45.8 (40.6–51.0) 48.6 (42.9–54.2)Adjusted for age, education, parity, religion and standard-of-living scores using direct standardization.

Intervention district Comparison district

0 10 20 30 40 50 60 70 80 90 100

Using coefficients from adjusted logistic regression, the marginal changes in neonatal

mortality were estimated for various levels of coverage of antenatal and postnatal home

visits; the effect of antenatal visits was assessed by varying the antenatal coverage levels

from 0% to 100% assuming no postnatal visitation. Coverage of postnatal visitation within

28 days was varied between 0% and 100% keeping antenatal coverage at the same level.

For example, if postnatal coverage was estimated at 50%, antenatal was also estimated

at 50%.

Findings• In the intervention district, the frequency of home visits by community based workers

increased 4 times during the antenatal (from 15% to 60%) and also postnatal visits within a week significantly increased (from 4% to 26%) and resulted into better maternal and newborn care practices.

• In the comparison district, no improvement in antenatal or postnatal home visits was observed and limited improvements maternal and newborn care practices.

• Neonatal mortality rates remained unchanged in both districts. However, neonates who received a postnatal home visit within 28 days of birth had 34% lower neonatal mortality (35.7 deaths per 1000 live births) than those who received no postnatal visit (53.8 deaths per 1000 live births), after adjusting for socio-demographic variables.

• Three-quarters of the mortality reduction was seen in those who were visited within the first 3 days after birth.

Conclusion• The limited programmme coverage did not enable an effect on

neonatal mortality to be observed at the population level.

• A reduction in neonatal mortality rates in those receiving postnatal home visits shows potential for the programme to have an effect on neonatal deaths.

• Reaching newborn babies at the community level is crucial in settings where the availability and utilization of facility-based care is low.

• While the training of multipurpose health and nutrition workers in essential newborn care is necessary, systems must also be put in place to ensure that these workers visit neonates at home during the first hours and days after birth and that they can provide a link to competent health services.