International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
BMC Public Health. 2013 Nov 7;13:1052. doi: 10.1186/1471-2458-13-1052.
Inequities in both health status and coverage of health services are considered important barriers to achieving Millennium Development Goal 4. Community-based health promotion is a strategy that is believed to reduce inequities in rural low-income settings. This paper examines the contributions of community-based programming to improving the equity of newborn health in three districts in Malawi.
This study is a before-and-after evaluation of Malawi's Community-Based Maternal and Newborn Care (CBMNC) program, a package of facility and community-based interventions to improve newborn health. Health Surveillance Assistants (HSAs) within the catchment area of 14 health facilities were trained to make pregnancy and postnatal home visits to promote healthy behaviors and assess women and newborns for danger signs requiring referral to a facility. "Core groups" of community volunteers were also trained to raise awareness about recommended newborn care practices. Baseline and endline household surveys measured the coverage of the intervention and targeted health behaviors for this before-and-after evaluation. Wealth indices were constructed using household asset data and concentration indices were compared between baseline and endline for each indicator.
The HSAs trained in the intervention reached 36.7% of women with a pregnancy home visit and 10.9% of women with a postnatal home visit within three days of delivery. Coverage of the intervention was slightly inequitable, with richer households more likely to receive one or two pregnancy home visits (concentration indices (CI) of 0.0786 and 0.0960), but not significantly more likely to receive a postnatal visit or know of a core group. Despite modest coverage levels for the intervention, health equity improved significantly over the study period for several indicators. Greater improvements in inequities were observed for knowledge indicators than for coverage of routine health services. At endline, a greater proportion of women from the poorest quintile knew three or more danger signs for pregnancy, delivery, and postpartum mothers than did women from the least poor quintile (change in CI: -0.1704, -0.2464, and -0.4166, respectively; p < 0.05). Equity also significantly improved for coverage of some health behaviors, including delivery at a health facility (change in CI: -0.0591), breastfeeding within the first hour (-0.0379), and delayed bathing (-0.0405).
Although these results indicate promising improvements for newborn health in Malawi, the extent to which the CBMNC program contributed to these improvements in coverage and equity are not known. The strategies through which community-based programs are implemented likely play an important role in their ability to improve equity, and further research and program monitoring are needed to ensure that the poorest households are reached by community-based health programs.
健康状况和卫生服务覆盖方面的不平等被认为是实现千年发展目标 4 的重要障碍。以社区为基础的健康促进被认为是一种能够减少农村低收入环境中不平等现象的策略。本文考察了以社区为基础的方案对改善马拉维三个地区新生儿健康公平状况的贡献。
本研究是对马拉维以社区为基础的母婴保健和新生儿护理（CBMNC）方案的前后评估，该方案是一套改善新生儿健康的设施和以社区为基础的干预措施。在 14 个卫生设施的服务区内，培训卫生监测助理（HSA），以对孕妇进行家访并促进健康行为，对产妇和新生儿进行评估，以发现需要转介到医疗机构的危险信号。还培训了“核心小组”的社区志愿者，以提高对推荐的新生儿护理实践的认识。基线和终线家庭调查衡量了干预措施的覆盖范围和针对该前后评估的目标健康行为。使用家庭资产数据构建了财富指数，并对每个指标的基线和终线之间的集中指数进行了比较。
在干预中接受培训的 HSA 对 36.7%的孕妇进行了妊娠家访，对 10.9%的产妇在分娩后三天内进行了家访。干预措施的覆盖率稍不公平，较富裕的家庭更有可能接受一次或两次妊娠家访（集中指数（CI）分别为 0.0786 和 0.0960），但并不显著更有可能接受产后家访或了解核心小组。尽管干预措施的覆盖范围较低，但在研究期间，几个指标的卫生公平状况显著改善。与常规卫生服务的覆盖范围相比，知识指标的改善幅度更大。在终线时，最贫穷的五分之一的妇女比最不贫穷的五分之一的妇女更了解三个或更多与妊娠、分娩和产后母亲有关的危险信号（变化的 CI：分别为-0.1704、-0.2464 和-0.4166；p<0.05）。一些健康行为的覆盖范围也有显著改善，包括在医疗机构分娩（CI 变化：-0.0591）、产后一小时内母乳喂养（CI 变化：-0.0379）和延迟洗澡（CI 变化：-0.0405）。
尽管这些结果表明马拉维新生儿健康状况有了有希望的改善，但尚不清楚 CBMNC 方案在多大程度上促进了这些覆盖范围和公平性的改善。以社区为基础的方案实施的策略可能在其改善公平性的能力方面发挥着重要作用，需要进一步的研究和方案监测，以确保最贫困的家庭能够受益于以社区为基础的卫生方案。
