Background
Methods
Setting and study design
Intervention design
Maternal | |
Screening criteria
|
Health education
|
• Maternal infection (e.g. fever, mastitis) • Secondary postnatal hemorrhage • Postnatal Pre-eclampsia • Anemia | • Danger signs for postnatal care-seeking • Maternal nutrition • Postnatal family planning |
Newborn | |
Screening criteria
|
Health Education
|
• Insufficient breastfeeding/dehydration • Jaundice (palms, soles, and eyes) • Local infection (umbilical cord, eyes, and skin) • Breathing difficulties • Fever • Hypothermia | • Breastfeeding • Danger signs for newborn care-seeking • Umbilical cord care • Thermal care • Hand hygiene |
Data collection
Outcomes
Outcome measure
|
Definition
|
Outcomes measured at 3 days postpartum
| |
Maternal complication detected and referred | CHWs documented any observed or reported maternal complications detected through administration of the checklist; data collected for study participants assigned to CHW treatment by phone or home visit |
Newborn complication detected and referred | CHWs documented any observed or reported complications detected through administration of the checklist; data collected for study participants assigned to CHW treatment by phone or home visit |
Outcomes reported at 10 days postpartum
| |
Maternal referral acted upon | Binary variable indicating CHW referral was made (from programmatic data) and respondent reporting seeking facility-based care based on referral advice |
Newborn referral made and acted upon | Binary variable indicating CHW referral was made (from programmatic data) and respondent reporting seeking facility-based care based on referral advice |
Facility-based maternal postpartum care sought | Binary variable indicating whether respondent reported going to a health facility for her health since delivery |
Days postpartum maternal care sought, among maternal care-seekers | Continuous variable indicating days after delivery maternal care was sought, for those who report seeking facility-based maternal care |
Facility-based newborn postpartum care sought | Binary variable indicating whether respondent reported bringing her baby for a child wellness clinic visit |
Days postpartum newborn care sought, among maternal care-seekers | Continuous variable indicating days after delivery newborn wellness care was sought, for those who report seeking facility-based newborn wellness care |
Any maternal health problem reported | Binary variable indicating respondent reported yes to the question, “Are you having any problems with your health, related to your delivery, since you delivered?” |
Maternal problem reported and action taken | Binary variable indicating respondent reported yes to the question, “Did you do anything as a response to this problem?”, administered to respondents who reported a newborn health problem. |
Any newborn health problem reported | Binary variable indicating respondent reported yes to the question, “Is your baby having any problems with his/her health since you delivered?” |
Newborn problem reported and action taken | Binary variable indicating respondent reported yes to the question, “Did you do anything as a response to this problem?”, administered to respondents who reported a newborn health problem. |
Number of maternal danger signs named | Accurate identification of maternal danger signs defined as ability to name any of the following 11 predefined signs: fever/chills, foul-smelling vaginal discharge, convulsions/loss of consciousness, heavy vaginal bleeding (defined as soaking through a pad every hour), severe headaches, dizziness or faintness, visual disturbance (blurry vision or unusual difficulty seeing), increased cramping or abdominal pain, increased perineal pain, swelling, redness or discharge, difficulty passing urine, difficulty breathing, breast redness or hot to the touch, and pain or lump in the breast. |
Can name 3 or more maternal danger signs | Binary variable coded for continuous outcome variable, indicating whether 3 or more maternal dangers signs were named |
Number of newborn danger signs named | Accurate identification of infant danger signs defined as ability to name any of the following eight signs: fever, jaundice, poor feeding, lethargic/unresponsive, umbilical cord redness or discharge, convulsions, abnormal breathing (including panting, fast breathing, grunting, or nasal flaring, and pus from eyes. |
Can name 3 or more newborn danger signs | Binary variable coded for continuous outcome variable, indicating whether 3 or more newborn dangers signs were named |
Can name 2 or more hand washing best practices | Accurate identification of hand washing best practices defined as ability to name any of the following times that are particularly important for a caregiver to wash hands: after using the toilet, before touching/holding baby, after washing or touching nappies |
Can name 2 or more cord care practices | Accurate identification of sources of cord care practices defined as ability to name any of the following best practices to prevent cord infection: keep cord clean and dry, do not apply anything to stump, keep cord outside nappy/diaper |
Can name 3 or more newborn thermal care practices | Accurate identification of sources of dietary protein defined as ability to name any of the following best practices to ensure baby stays warm: keep room where newborn stays warm, dress newborn in several layers of clothes, bathe baby quickly in cold weather using warm water and dry and dress baby quickly, keep newborn’s head covered, practice skin to skin contact |
Can name 3 or more sources of dietary protein | Accurate identification of sources of dietary protein defined as ability to name any of the following: beans, lentils, meat, eggs, chicken, fish, milk |
Applied water or nothing to umbilical stump | Binary variable indicating nothing or water applied to umbilical stump. The checklist and data collection defined best practices in umbilical cord care according to Jacaranda Health’s clinical practice of dry cord care at the time of data collection. While Kenya introduced a change in its newborn care clinical guidelines from dry care to use of topical antiseptic in November 2013, the World Health Organization recommends both dry cord care and topical antiseptic as best practice [33, 34]. |
Appropriate newborn thermal care practiced | Binary variable indicating respondent mentions trying to keep baby warm when asked how she bathes her baby |
Exclusive breastfeeding | Binary variable indicating only newborn consumed only breastmilk since birth |
Breastfed 3 or more times in past 8 hours | Binary variable indicating respondent reports feeding baby 3 or more times in 8 hours prior to the survey |
Outcomes reported at 9 weeks postpartum
| |
At least one dose of polio and pentavalent vaccines | Binary variable indicating that respondent reports infant has received at one or more doses of polio vaccine and one or more doses of pentavalent vaccine when asked which vaccinations the infant has received since delivery |
Use of family planning method | Binary variable indicating respondent reports current use of any family planning method |
Exclusive breastfeeding | Binary variable indicating only newborn consumed only breastmilk since birth |
Breastfed 3 or more times in past 8 hours | Binary variable indicating respondent reports feeding baby 3 or more times in 8 hours prior to the survey |
Index measures
| |
Index of health knowledge at 10 days post-delivery | Summative index with a maximum of 6 points and a minimum of 0 points, where each point represents knowledge of the following 6 postnatal health topics: 1) ability to name 3 or more maternal danger signs; 2) ability to name 3 or more infant danger signs; 3) ability to name 2 or more hand washing best practices; 4) ability to name 2 or more; 5) ability to name 3 or more recognized newborn thermal care practices; 6) and ability to name 3 or more sources of maternal dietary protein |
Index of health practices at 10 days and 9 weeks post-delivery | Summative index with a maximum of 8 points and a minimum of 0 points, where 4 points represent 4 key health practices reported at 10 day (exclusive breastfeeding, breastfed 3 or more times in the past 8 hours, appropriate newborn thermal care practices, and water or nothing applied to umbilical cord stump) and 4 points represent 4 key health practices reported at 9 weeks (exclusive breastfeeding, breastfed 3 or more times in the past 8 hours, use of postnatal contraception, infant has received at least one dose of polio and pentavalent vaccines). |
Ethical approval trial registration
Statistical power
Data analysis
Results
Panel A. Participant demographic and household characteristics | |||||||||
Standard of care | CHW call | CHW visit |
p-values | ||||||
n
| % / mean |
n
| % / mean |
n
| % / mean | CHW call vs. Standard of care | CHW visit vs. Standard of care | ||
Women | |||||||||
Age | 31 | 26.7 | 40 | 25.6 | 31 | 25.9 | 0.23 | 0.38 | |
Education | |||||||||
Primary | 4 | 14 % | 8 | 21 % | 4 | 15 % | 0.59 | 0.49 | |
Secondary | 15 | 52 % | 18 | 47 % | 16 | 59 % | |||
Post-Secondary | 10 | 35 % | 12 | 32 % | 7 | 26 % | |||
n | 19 | 38 | 27 | ||||||
Marital Status | |||||||||
Married | 30 | 97 % | 35 | 85 % | 30 | 97 % | 0.08 | >0.99 | |
Single | 1 | 3 % | 6 | 15 % | 1 | 3 % | |||
n | 31 | 41 | 31 | ||||||
Parity | |||||||||
Primiparous | 9 | 29 % | 8 | 20 % | 9 | 30 % | 0.36 | 0.94 | |
Multiparous | 22 | 71 % | 33 | 81 % | 21 | 70 % | |||
n | 31 | 41 | 31 | ||||||
Employed in Past 12 Months | 16 | 70 % | 21 | 66 % | 11 | 41 % | 0.76 | 0.04 | |
n | 23 | 32 | 27 | ||||||
Assigned to postnatal contraception subsidy treatment through concurrent randomized trial | 6 | 19 % | 14 | 34 % | 7 | 22 % | 0.16 | 0.81 | |
n | 31 | 41 | 32 | ||||||
Husband | |||||||||
Husband Education | |||||||||
Primary | 0 | 0 % | 4 | 14 % | 2 | 8 % | 0.12 | 0.11 | |
Secondary | 15 | 65 % | 13 | 45 % | 10 | 39 % | |||
Post-Secondary | 8 | 35 % | 12 | 41 % | 14 | 54 % | |||
n | 23 | 29 | 26 | ||||||
Household | |||||||||
Improved toilet facility | 24 | 92 % | 34 | 97 % | 24 | 86 % | 0.43 | 0.45 | |
n | 26 | 35 | 28 | ||||||
Toilet shared among more than one house | 9 | 39 % | 15 | 47 % | 10 | 39 % | 0.58 | 0.96 | |
n | 23 | 32 | 26 | ||||||
Improved drinking water source | 18 | 90 % | 27 | 96 % | 23 | 92 % | 0.41 | 0.82 | |
n | 20 | 28 | 25 | ||||||
Panel B. Primary outcomes | |||||||||
Standard of Care | CHW call | CHW visit | p-values | ||||||
n | % / mean | n | % / mean | n | % / mean | CHW call vs. Standard of care | CHW visit vs. Standard of care | ||
Complications detected and referred, collected through programmatic CHW data | |||||||||
Maternal or newborn complications detected and referred by CHW | 4 | 10 % | 3 | 9 % | |||||
n | 41 | 32 | |||||||
Postpartum care-seeking practices for mother and newborn, reported during day 10 survey | |||||||||
Referrals made and acted upon | 1 | 4 % | 2 | 11 % | |||||
n | 23 | 18 | |||||||
Facility-based maternal postpartum care sought | 2 | 8 % | 4 | 13 % | 6 | 22 % | 0.62 | 0.17 | |
n | 24 | 32 | 27 | ||||||
Days postpartum maternal care sought, among maternal care-seekers | 2 | 8.5 | 4 | 7.5 | 6 | 5.8 | 0.57 | 0.09 | |
Facility-based newborn postpartum care sought | 23 | 96 % | 30 | 94 % | 26 | 96 % | 0.73 | 0.93 | |
n | 24 | 32 | 27 | ||||||
Days postpartum newborn care sought, among newborn care-seekers | 23 | 5.9 | 30 | 3.8 | 26 | 4.1 | 0.02 | 0.04 | |
Postnatal health problems and responses at day 10 post-delivery | |||||||||
Any maternal health problem reported | 3 | 13 % | 2 | 6 % | 9 | 33 % | 0.48 | 0.08 | |
n | 24 | 32 | 27 | ||||||
Maternal problem reported and action taken | 2 | 8 % | 2 | 6 % | 3 | 11 % | 0.77 | 0.74 | |
n | 24 | 32 | 27 | ||||||
Any newborn health problem reported | 5 | 21 % | 8 | 25 % | 13 | 48 % | 0.72 | 0.04 | |
n | 24 | 32 | 27 | ||||||
Newborn problem reported and action taken | 3 | 13 % | 5 | 16 % | 8 | 30 % | 0.74 | 0.14 | |
n | 24 | 32 | 27 | ||||||
Self-reported knowledge of postnatal danger signs and health practices at day 10 | |||||||||
Number of maternal danger signs named | 24 | 3.8 | 32 | 4.1 | 27 | 4.3 | 0.46 | 0.23 | |
Can name 3 or more maternal danger signs | 19 | 79 % | 26 | 81 % | 23 | 85 % | 0.85 | 0.56 | |
n | 24 | 32 | 27 | ||||||
Number of newborn danger signs named | 24 | 3.3 | 32 | 3.7 | 27 | 3.6 | 0.41 | 0.47 | |
Can name 3 or more newborn danger signs | 19 | 79 % | 26 | 81 % | 23 | 85 % | 0.36 | 0.13 | |
n | 24 | 32 | 27 | ||||||
Can name 2 or more hand washing best practices | 10 | 42 % | 19 | 59 % | 10 | 37 % | 0.20 | 0.74 | |
n | 24 | 32 | 27 | ||||||
Can name 2 or more cord care practices | 7 | 29 % | 13 | 41 % | 5 | 19 % | 0.38 | 0.39 | |
n | 24 | 32 | 27 | ||||||
Can name 3 or more newborn thermal care practices | 7 | 29 % | 11 | 34 % | 8 | 30 % | 0.68 | 0.97 | |
n | 24 | 32 | 27 | ||||||
Can name 3 or more sources of dietary protein | 7 | 29 % | 12 | 38 % | 11 | 41 % | 0.52 | 0.40 | |
n | 24 | 32 | 27 | ||||||
Self-reported postnatal health practices at day 10 | |||||||||
Applied water or nothing to umbilical stump | 17 | 71 % | 26 | 81 % | 23 | 85 % | 0.38 | 0.23 | |
n | 24 | 32 | 27 | ||||||
Appropriate newborn thermal care practiced | 17 | 71 % | 26 | 81 % | 23 | 85 % | 0.84 | 0.93 | |
n | 24 | 32 | 27 | ||||||
Exclusive breastfeeding | 24 | 100 % | 32 | 100 % | 27 | 100 % | -- | -- | |
n | 24 | 32 | 27 | ||||||
Breastfed 3 or more times in past 8 hours | 23 | 96 % | 27 | 84 % | 25 | 93 % | 0.14 | 0.63 | |
n | 24 | 32 | 27 | ||||||
Self-reported postnatal health practices at 9 weeks post-delivery | |||||||||
At least 1 dose of polio and pentavalent vaccines | 15 | 88 % | 22 | 96 % | 18 | 95 % | 0.43 | 0.50 | |
n | 17 | 23 | 19 | ||||||
Use of family planning method | 5 | 29 % | 14 | 61 % | 8 | 42 % | 0.05 | 0.44 | |
n | 17 | 23 | 19 | ||||||
Exclusive breastfeeding | 17 | 100 % | 21 | 91 % | 19 | 100 % | 0.16 | -- | |
n | 17 | 23 | 19 | ||||||
Breastfed 3 or more times in past 8 hours | 15 | 88 % | 22 | 96 % | 18 | 95 % | 0.43 | 0.50 | |
n | 17 | 23 | 19 | ||||||
Indices of postnatal health knowledge and practices at 10 days and 9 weeks post-delivery | |||||||||
Index of health knowledge at 10 days post-delivery | 24 | 3.17 | 32 | 3.56 | 27 | 3.15 | 0.37 | 0.96 | |
Index of health practices at 10 days and 9 weeks post-delivery | 15 | 6.6 | 20 | 7.1 | 17 | 7.2 | 0.16 | 0.06 |
Postnatal complication detection and referral at 3 days after delivery
Care-seeking practices at 10 days after delivery
Panel A. Maternal postnatal care seeking | ||||
(1) | (2) | (3) | (4) | |
Facility-based maternal postnatal care sought | Facility-based maternal postnatal care sought | Days postnatal maternal care sought, among maternal care-seekers | Days postnatal maternal care sought, among maternal care-seekers‡
| |
Unadjusted
|
Adjusted
|
Unadjusted
|
Adjusted
| |
Estimation Type
|
Logistic
|
Logistic
|
OLS
|
OLS
|
CHW phone call | 1.57 | 1.63 | −1 | −1.05 |
(0.26 - 9.49) | (0.23 - 11.8) | (−4.52 - 2.52) | (−10.3 - 8.23) | |
CHW home visit | 3.14 | 7.44* | −2.67* | −2.27 |
(0.56 - 17.5) | (0.77 - 71.5) | (−5.66 - 0.33) | (−14.2 - 9.65) | |
Standard of care arm mean | 0.08 | 0.08 | 8.5 | 8.5 |
p-value for test of call = visit | 0.330 | 0.105 | 0.417 | 0.769 |
p-value for test of joint significance of call and visit | 0.366 | 0.161 | 0.173 | 0.833 |
Controls? | N | Y | N | Y |
R-squared | 0.159 | 0.438 | ||
Observations | 83 | 79 | 12 | 10 |
Panel B. Newborn postnatal care seeking | ||||
(1) | (2) | (3) | (4) | |
Facility-based newborn postnatal care sought‡‡
| Facility-based newborn postnatal care sought‡
| Days postnatal newborn care sought, among newborn care-seekers | Days postnatal newborn care sought, among newborn care-seekers | |
Unadjusted
|
Adjusted
|
Unadjusted
|
Adjusted
| |
Estimation Type
|
Logistic
|
Logistic
|
OLS
|
OLS
|
CHW phone call | 0.65 | 0.47 | −2.04** | −2.27*** |
(0.055 - 7.76) | (0.054 - 4.10) | (−3.65 - -0.42) | (−3.89 - -0.64) | |
CHW home visit | 1.13 | 0.51 | −1.79** | −1.78* |
(0.066 - 19.4) | (0.022 - 11.8) | (−3.45 - -0.14) | (−3.69 - 0.13) | |
Mean of standard of care arm | 0.96 | 0.96 | 5.86 | 5.86 |
p-value for test of call = visit | 0.663 | 0.942 | 0.714 | 0.537 |
p-value for test of joint significance of call and visit | 0.891 | 0.791 | 0.041 | 0.025 |
Controls? | N | Y | N | Y |
R-squared | 0.098 | 0.195 | ||
Observations | 83 | 40 | 79 | 75 |
Panel A. Maternal health problem reporting and responses | ||||
(1) | (2) | (3) | (4) | |
Any maternal health problem reported | Any maternal health problem reported | Maternal problem reported and action taken | Maternal problem reported and action taken | |
Unadjusted
|
Adjusted
|
Unadjusted
|
Adjusted
| |
Estimation Type
|
Logistic
|
Logistic
|
Logistic
|
Logistic
|
CHW Call | 0.47 | 0.23 | 0.73 | 0.50 |
(0.071 - 3.08) | (0.021 - 2.58) | (0.095 - 5.69) | (0.047 - 5.39) | |
CHW Home Visit | 3.50* | 5.58* | 1.38 | 1.69 |
(0.81 - 15.1) | (0.88 - 35.4) | (0.21 - 9.12) | (0.18 - 15.5) | |
Mean of standard of care arm | 0.13 | 0.13 | 0.83 | 0.83 |
p-value for test of call = visit | 0.017 | 0.004 | 0.512 | 0.371 |
p-value for test of joint significance of call and visit | 0.032 | 0.009 | 0.805 | 0.670 |
Controls? | N | Y | N | Y |
Observations | 83 | 79 | 83 | 53 |
Panel B. Newborn health problem reporting and responses | ||||
(1) | (2) | (3) | (4) | |
Any newborn health problem reported | Any newborn health problem reported | Newborn problem reported and action taken | Newborn problem reported and action taken | |
Unadjusted
|
Adjusted
|
Unadjusted
|
Adjusted
| |
Estimation Type
|
Logistic
|
Logistic
|
Logistic
|
Logistic
|
CHW Call | 1.27 | 1.21 | 1.30 | 0.95 |
(0.35 - 4.54) | (0.33 - 4.46) | (0.28 - 6.11) | (0.20 - 4.57) | |
CHW Home Visit | 3.53** | 3.78* | 2.95 | 3.94* |
(1.01 - 12.3) | (0.95 - 15.1) | (0.68 - 12.9) | (0.80 - 19.4) | |
Mean of standard of care arm | 0.21 | 0.21 | 0.13 | 0.13 |
p-value for test of call = visit | 0.070 | 0.087 | 0.205 | 0.053 |
p-value for test of joint significance of call and visit | 0.078 | 0.120 | 0.260 | 0.104 |
Controls? | N | Y | N | Y |
Observations | 83 | 79 | 83 | 79 |
Postnatal knowledge at 10 days after delivery
Health practices, reported at 10 days and 9 weeks postnatal
(1) | (2) | (3) | (4) | |
Index of postnatal health knowledge, as reported at day 10 post-delivery | Index of postnatal health knowledge, as reported at day 10 post-delivery | Index of postnatal health practices, as reported at day 10 and 9 weeks post-delivery | Index of postnatal health practices, as reported at day 10 and 9 weeks post-delivery | |
Unadjusted
|
Adjusted
|
Unadjusted
|
Adjusted
| |
Estimation Type
|
OLS
|
OLS
|
OLS
|
OLS
|
CHW Call | 0.40 | 0.57 | 0.45 | 0.29 |
(−0.48 - 1.28) | (−0.37 - 1.50) | (−0.18 - 1.08) | (−0.47 - 1.06) | |
CHW Home Visit | −0.019 | 0.11 | 0.58* | 0.45 |
(−0.82 - 0.78) | (−0.75 - 0.97) | (−0.012 - 1.17) | (−0.25 - 1.15) | |
Mean of standard of care arm | 3.2 | 3.2 | 6.6 | 6.6 |
p-value for test of call = visit | 0.323 | 0.331 | 0.649 | 0.650 |
p-value for test of joint significance of call and visit | 0.564 | 0.457 | 0.148 | 0.430 |
Controls? | N | Y | N | Y |
R-squared | 0.016 | 0.045 | 0.073 | 0.158 |
Observations | 83 | 79 | 52 | 49 |