Heterogeneity in intervention designs and outcomes made quantitative methods, including meta-analysis and effect size for synthesis impossible and inappropriate. Studies were therefore categorised and described as reported in the following narrative synethesis.
Health education interventions
Three studies covering interventions on food safety, immunization promotion and overall child health and safety were found. A before and after study by Sheth and Obran [
28] in an urban Indian slum promoted food safety education to mothers of underprivileged children between 6 and 24 months. This intervention involved CHWs conducting home visits using visual educational materials, to 200 low-income households purposely selected across 8 randomly chosen Anganwai centre catchment areas. Pre and post intervention analysis found a 52.5% reduction in child diarrhoea, 65% and 10% reduction in mother’s and children’s microbial load, respectively, indicating improved hand-washing behaviour. Inappropriate environmental sanitation and mother’s poor hygiene practices decreased by 36.5% and 8.5%, respectively. As well, there was significant improvement in mother’s knowledge, attitude and practice regarding diarrhoea etiology and sanitation and hygiene.
Owasis and colleagues [
31] conducted a randomized controlled trial in Karachi, Pakistan with mothers who had children less than or equal to 6 weeks of age. The intervention (n=183) consisted of DPT-3/HepB immunization promotion via a 5 -minute presentation using visual displays by a CHW. Pictorial aids addressing the importance of DPT-3/HepB, logistical information on the immunization clinics, and the importance of retaining immunization cards were then left with the mothers. The control group of 183 mothers received a 10–15 minute verbal presentation on general health education, which included basic information on vaccines. After adjusting for immunization status at time of enrollment, which was significantly associated with outcome, the intervention group’s full immunization rate was 32% higher than that of the control four months post intervention.
In southwest Uganda, Brenner et al. [
33] conducted a controlled before and after study to assess the impact of CHWs in child under-5 household health promotion following the IMCI strategy. Post-intervention data showed a statistically significant decrease in diarrhoea prevalence of 10.2% and 5.8% in malaria and/or fever in the intervention group, consisting of 606 households. The control group (n=486), which received no household intervention, had non-significant results. As reported by CHWs, after 18 months of the intervention, a decline in underweight children of 5.1% was seen as well as a reduction of under-5 mortality of 53 per cent.
Breastfeeding interventions
Five articles, comprising seven different studies relating to breastfeeding, were identified. All interventions involved CHWs promoting approved breastfeeding practices to mothers in their homes, though they differed on timing and intensity of visits and outcomes assessed (Table
2). Of these seven studies, six were randomized controlled trials.
Table 2
Visit timing, EBF and diarrhoea rates for cRCT and RCT breastfeeding interventions
Asrasda
| | | | x | | x | x | | x | x | x | x | x | 32% vs. 0% | 15% vs. 30.5% |
Haider
| | xx | x | | x | | x | | xx | xx | xx | xx | xx | 70% vs. 6% | NR |
Morrow 1
| x | x | | x | | x | x | | x | | | | | 50% vs. 12% | NR |
Morrow 2
| | x | | x | | x | | | | | | | | 38% vs. 12% | NR |
Tylleskar 1*
| | x | | x | | x | | x | x | | x | x | | 71% vs. 9% | NR |
Tylleskar 2*
| | x | | x | | | | x | x | x | | | | 51% vs. 11% | NR |
Tyllesker 3*
| | x | | x | | | | x | x | x | | | | 2% vs. <1% | NR |
In Manila, Philippines Agrasada et al. [
38] recruited first time mothers who recently gave birth to Low Birth Weight (LBW) babies in hospital for a 3-armed randomized controlled trial. In the first intervention arm CHWs with personal breastfeeding experience educated women (n=68) on exclusive breastfeeding (EBF) and aided in prevention and management of common breastfeeding problems once between days 3–5 and 7–10, and on day 21 and 1.5 months, then once monthly until 5.5 months. In the second intervention, peer counselors using the same visiting schedule as the EBF arm educated 67 mothers on basic child-care practices with some breastfeeding attention. The control (n=69) arm received no household visits. Physicians collected data at hospitals during 7 scheduled appointments for all study arms. Women in the EBF arm were 6.3 times more likely to practice exclusive breastfeeding from two weeks to six months than participants from the basic childhood health intervention and control, with EBF rates of 32%, 3% and 0%, respectfully. Complementary feeding at six months was also significantly higher in the EBF arm, compared to the basic child health arm and control arm (63.2% vs. 31.1% vs. 29.0%). At six months, there was no significant difference in child weight for age between intervention groups, however diarrhoea rates were significantly lower in the EBF arm compared to basic child heath and control groups, 15% vs. 28.3% vs. 30.5%, respectively.
Haider et al. [
23] conducted a RCT in the city Dhaka of Bangladesh, to promote EBF through 15 home visits by paid peer counselors with personal breastfeeding experience. Women (n=363) were assigned to both the intervention group and the control group (who received no household visits). In the intervention arm, two visits occurred in the last trimester of pregnancy, three within the early postpartum period and then every two weeks from months 2 to 5. Visits lasted from 20 to 40 minutes and included topics of EBF for 5 months including early newborn holding, and initiation of feeding and discouragement of pre-lacteal and post-lacteal feeding. All measured breastfeeding practices were significantly more prevalent in the intervention group compared to the control with: first hour initiation; 64% vs. 15%, feeding pre-lacteal; 31% vs. 89%, feeding post-lacteals; 23% vs. 47%; EBF during first four days, 56% vs. 9%; EBF on day four, 84% vs. 30%; and EBF to five months, 70% vs. 6 percent.
In a peri-urban area of Mexico, San Pedro Martir, Morrow and colleagues [
37] used a 3-arm cRCT with pregnant women and their influential family members. In the first intervention arm participants (n=44) received six home visits from mid pregnancy to eight weeks postpartum by peer counselors to promote healthy breastfeeding practices. In the second intervention arm, 52 women received three household visits, one in late pregnancy and one in the first and one in the second week postpartum. The control population (n=34) received no home visits though all study arms were encouraged to seek standard pregnancy and child facility care. Significant differences in EBF at 2 weeks and 3 months were seen between intervention arms compared to the control, as well as between the two control arms with the 6 visit arm having higher rates than the 3 visit arm. At 2 weeks and 3 months, rates were 80.0% and 67% for 6 visits, 62% and 50% for 3 visits, and 24% and 12% for the control. The intervention had no significant effect on duration of any breastfeeding greater than three months or six months or on diarrhoea incidence in infants between birth and three months.
Tylleskar et al. [
22] used the same study design and intervention across three countries, Burkina Faso, Uganda and South Africa. At all sites, a cRCT was arranged using CHWs with similar training and supervision schedules to conduct a behavioural intervention to promote EBF for six months and provide breastfeeding support and education. Women at least seven months or visibly pregnant were recruited and assigned to either the intervention arm consisting of home visits, or the control arm in which women only received existing regular health services. Data was collected based on 24 hour and 7-day recall from the participants.
In Banfora, a rural area in southwest Burkina Faso, 392 women received seven household visits, one in the third trimester, then one in weeks 1,2,4,8,16 and 20 post-partum. Exclusive breastfeeding rates at 12 weeks for intervention and control (n=402) using 7-day recall were significant at 77% and 23%, respectively. At time 24 weeks, EBF rates were reported as 71% for the intervention and 9% for control. At both 12 weeks and 24 weeks there was no significant difference in prevalence of infant diarrhoea for intervention and control arms.
The study in Uganda took place in rural Mbale District, with 396 women in the intervention and 369 in the control cluster. Five household visits by community health workers took place, one in late pregnancy and one each in weeks 1,4,7 and 10 post-partum. Using 7-day recall, EBF at 12 weeks was significantly higher in the intervention than control, with rates of 77% and 34%, respectively. At 24 weeks, 51% of intervention participants compared to 11% of control participants practiced exclusive breastfeeding. As with the study in Burkina Faso, there was no significant difference in infant diarrhoea rates between clusters.
In two peri-urban regions of South Africa, Paarl and Umlazi, and one rural region, Rietvlei, women in the intervention cluster (n=535) received the same home visit schedule as that in Uganda, with 5 visits between the third trimester and week ten. However, in the control cluster peer counselors conforming to the same schedule as that of the intervention, conducted visits to assist mothers in obtaining birth certificates and government grants. Differences in breastfeeding rates between intervention and control were significant at both 12 weeks and 24 weeks (8% vs. 4% and 2% vs. <1%, respectively), though they were remarkably lower than those in the other study sites. The difference in prevalence of infant diarrhoea between clusters at was not significant.
The final study on breastfeeding was a cross-sectional analysis of the intervention arm of a cRCT in rural Sylhet, Bangladesh by Mannan et al. [
24]. This study sought to examine breastfeeding problem rates associated with different intervention timings, mostly early visits (within 3 days) compared to non-early visits. Home visits were to be made between postpartum days 1–3, 4–5 and 6–7 to promote newborn care and breastfeeding education and assistance. Only 6% of women who received early CHW visits (between days 1–3) had difficulty breastfeeding compared to 34% of women receiving late visits having difficulties. Pre-lacteal feeding was 2.9 times more common, and the likelihood of having breastfeeding problems was 7.7 times higher in women who did not receive an early visit.
Newborn care interventions
Five of the included studies target birth and newborn care preparedness (BNCP) and/or newborn care practices. Bari and colleagues’ [
25] intervention aimed to increase appropriate newborn care seeking practices in Tangail, Bangladesh. This cRCT had pregnant women and their families receiving two BNCP home visits at 3 and 8 months prenatal, and postnatal visits on days 0,3,6 and 9 for newborn care education and potential referrals. Controls received no home visits. In the intervention group newborn care seeking from qualified professionals increased significantly compared to the control group, with the intervention group increasing from 31.2% to 60.4% compared to the control group increase from 29.6% to 33.9%. Hospital care also increased significantly and care from an unqualified professionals decreased significantly from 66.7% to 36.7% for the intervention group compared to a minimal reduction from 67.9% to 65% in the control group.
The remainder of the newborn care interventions promote essential newborn care (ENC), specifically the use of skin-to-skin (STS) care to prevent hypothermia and other neonatal morbidities. Two of these studies examined the acceptability and trends in STS care by mothers after a household promotion by community health workers.
In rural Uttar Pradesh, India, Darmstadt et al. [
29] examine the acceptability of STS by conducting a before and after study nested within a 3-arm RCT promoting essential newborn care (ENC) practices. Two intervention groups received the same home visits, but differed in that the intervention used a device for measuring body temperature, whereas the control group only had the usual government health services offered to all. Volunteer CHWs, made both antenatal and postnatal home visits to pregnant women and influential family members. Acceptability of STSC taught for home deliveries was high in the two intervention groups with 74.5% of Normal Birth Weight (NBW) and 76% of Low Birth Weight (LBW) receiving the care from their mothers.
Similar to Darmstadt et al., Quasem and colleagues [
26] did a case series study on a pilot programme in Sylhet, northeast Bangladesh, for Community Kangaroo Mother Care (CKMC). Essential newborn care and KMC was taught to women seven months pregnant to newly (within 7 days) postpartum using demonstrations and visual aids. One month post intervention women were surveyed for their experiences and findings indicated that 77% initiated KMC, with 85% of LBW babies and 73% of non-LBW babies being given the care. More female neonates than males were exposed to STSC (83% vs. 74%, respectfully). Also mothers providing STSC had more positive exclusive breastfeeding practices and delayed the common, unadvised, practice of immersion bathing.
In rural Uttar Pradesh, India, Kumar et al. [
30] conducted a 3-arm cRCT using CHWs to deliver BCC to expectant women and individuals that may have an influence on their health care, argeting positive ENC practices. The two intervention arms received two antenatal and two postnatal home visits from CHWs with one arm utilizing a hypothermia-indicating tool. Neonatal mortality was significantly reduced in both intervention arms compared to the control arm, with a 54% reduction in the ENC only arm, and a 52% in the ENC plus hypothermia measuring tool arm. The intervention had no effect on use of ANC, place of delivery, use of a skilled attendant and immediate umbilical cord care (tying and cutting within thirty minutes), but positively influenced breastfeeding practices with both intervention arms having significantly higher rates of feeding within first hour and lower pre-lacteal feeding. All birth preparedness indicators were significantly enhanced in both intervention arms, with the exception of the pre-identification of a birth attendant. Three newborn thermal practices were significantly more positive in the intervention arms than control: Skin-to-skin (84.9% and 85.5% vs. 10%), bathing within the first day (18.3% and 20.6% vs. 68.1%) and the clothing of baby during massage (5.6% and 5.9% vs. 2.4%).
Similar to Kumar et al. [
30] Sloan and colleagues [
27] used a BCC intervention to promote CKMC and ENC to expectant and postpartum women and their families in Dhaka and Sylhet, Bangladesh. Using a cRCT, CHWs delivered the programme to the intervention cluster and were responsible for weighing infants during specified visits. Weight measurements within 7 days of birth were collected for 59.0% of the intervention group and 54.2% of the control group. Results from the intervention group show 77.4% ever practicing KMC, with a significantly higher rate for those with home deliveries vs., elsewhere, 85.9% vs. 59.9%, respectively. Women in the intervention group breastfed on average 3.4 hours earlier than those in the control, and 29.3% practiced immersion bathing compared to 72.3% in the control. Infant diarrhoea was significantly reduced in the intervention group (43.6% vs. 39.3%); however, no growth or mortality differences were observed.
Mother psychosocial well-being interventions
Two studies were identified that used CHWs to provide social support or therapy to pregnant women to affect positive health outcomes for both mother and child.
Cooper and colleagues [
34] identified women in their last trimester of pregnancy in Khayelitsha, South Africa for a RCT to provide support and guidance for parenting. Two hundred and twenty women in the intervention group received 16 home visits (2 antenatal visits, weekly visits for 8 weeks postpartum, followed by bi-weekly visits for two months) lasting approximately an hour each, for promotion of sensitive and responsive interactions with infants. Women in the control group (n=229) received their normal local services with no additional home visits. Women in the intervention group had significantly more sensitive and less intrusive mother-infant interactions at both 6 and 12 months. Secure infant attachment was also significantly higher in the intervention (74%) than the control (63%). Though maternal
depressed mood at 6 months was lower in the intervention group there was no effect on maternal
depressive disorder.
In rural Pakistan, Rahman et al. [
32] conducted a cRCT with women in their third trimester of pregnancy with perinatal depression following DSM-IV criteria. The “Thinking Healthy Programme”, a cognitive behavioural therapy, was used by CHWs during 4 visits in the last month of pregnancy, 3 in first month postnatal followed by 1 session per month for the succeeding 9 months. A CHW visited the women in control clusters following the same schedule but without administering the Thinking Healthy Programme. Outcomes were measured at 6 and 12 months for both mother and child. At both 6 and 12 months maternal depression was significantly lower in intervention clusters compared to control clusters, 23% vs. 53%, and 27% vs. 59%, respectively. Also, disability function scores and perceived social support were all significantly improved in the intervention clusters. However, there were no significant differences in child weight-for-age or height-for-age at 6 and 12 months between groups.