Haws Rachel A, Thomas Abigail L, Bhutta Zulfiqar A, Darmstadt Gary L
Department of International Health, E8153, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD 21205, USA.
Health Policy Plan. 2007 Jul;22(4):193-215. doi: 10.1093/heapol/czm009. Epub 2007 May 25.
A disproportionate burden of infant and under-five childhood mortality occurs during the neonatal period, usually within a few days of birth and against a backdrop of socio-economic deprivation in developing countries. To guide programmes aimed at averting these 4 million annual deaths, recent reviews have evaluated the efficacy and cost-effectiveness of individual interventions during the antenatal, intrapartum and postnatal periods in reducing neonatal mortality, and packages of interventions have been proposed for wide-scale implementation. However, no systematic review of the empirical data on packages of interventions, including consideration of community-based intervention packages, has yet been performed. To address this gap, we reviewed peer-reviewed journals and grey literature to evaluate the content, impact, efficacy (implementation under ideal circumstances), effectiveness (implementation within health systems), type of provider, and cost of packages of interventions reporting neonatal health outcomes. Studies employing more than one biologically plausible neonatal health intervention (i.e. package) and reporting neonatal morbidity or mortality outcomes were included. Studies were ordered by study design and mortality stratum, and their component interventions classified by time period of delivery and service delivery mode. We found 41 studies that implemented packages of interventions and reported neonatal health outcomes, including 19 randomized controlled trials. True effectiveness trials conducted at scale in health systems were completely lacking. No study targeted women prior to conception, antenatal interventions were largely micronutrient supplementation studies, and intrapartum interventions were limited principally to clean delivery. Few studies approximated complete packages recommended in The Lancet's Neonatal Survival Series. Interventions appeared largely bundled out of convenience or funding requirements, rather than based on anticipated synergistic effects, like service delivery mode or cost-effectiveness. Only two studies reported cost-effectiveness data. The evidence base for the impact of neonatal health intervention packages is a weak foundation for guiding effective implementation of public health programmes addressing neonatal health. Significant investment in effectiveness trials carefully tailored to local health needs and conducted at scale in developing countries is required.
在新生儿期，即通常在出生后的几天内，婴儿和五岁以下儿童死亡率过高，这一现象发生在发展中国家社会经济贫困的背景下。为指导旨在避免每年这400万例死亡的项目，近期的综述评估了产前、产时和产后各阶段个体干预措施在降低新生儿死亡率方面的效果和成本效益，并提出了一系列干预措施以供大规模实施。然而，尚未对包括基于社区的干预措施组合在内的干预措施组合的实证数据进行系统综述。为填补这一空白，我们查阅了同行评审期刊和灰色文献，以评估报告新生儿健康结果的干预措施组合的内容、影响、效果（在理想情况下的实施情况）、效力（在卫生系统内的实施情况）、提供者类型和成本。纳入了采用一种以上具有生物学合理性的新生儿健康干预措施（即组合）并报告新生儿发病率或死亡率结果的研究。研究按研究设计和死亡率分层排序，其组成干预措施按分娩时间和服务提供模式分类。我们发现41项实施干预措施组合并报告新生儿健康结果的研究，其中包括19项随机对照试验。完全缺乏在卫生系统中大规模开展的真实效力试验。没有研究针对受孕前的妇女，产前干预措施主要是微量营养素补充研究，产时干预措施主要限于清洁分娩。很少有研究接近《柳叶刀》新生儿生存系列中推荐的完整组合。干预措施似乎大多是出于便利或资金需求而捆绑在一起，而不是基于预期的协同效应，如服务提供模式或成本效益。只有两项研究报告了成本效益数据。新生儿健康干预措施组合影响的证据基础薄弱，难以指导有效实施解决新生儿健康问题的公共卫生项目。需要对根据当地卫生需求精心定制并在发展中国家大规模开展的效力试验进行大量投资。
