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• W2123455864 abstract "A major concern raised by Peter Waiswa and Stefan Peterson is whether we were being overly pessimistic with the suggestion that large-scale programmes introducing home visits on average achieved a 12% reduction in neonatal mortality.1Kirkwood BR Manu A Ten Asbroek AHA et al.Effect of the Newhints home-visits intervention on neonatal mortality rate and care practices in Ghana: a cluster randomised controlled trial.Lancet. 2013; 381: 2184-2192Summary Full Text Full Text PDF PubMed Scopus (143) Google Scholar We consider this suggestion to be an accurate reflection of the evidence to date. It is based on a meta-analysis of four trials, including the Newhints trial in Ghana, the findings of which are remarkably consistent: the p value for the test of heterogeneity is 0·85 suggesting any differences in observed effect between the trials are almost certainly due to chance. Importantly, first day deaths were not excluded in the Newhints estimate. A 12% reduction in neonatal mortality translates into a substantial saving of 396 000 newborn lives from the total of 3·3 million deaths a year.2Oestergaard MZ Inoue M Yoshida S et al.Neonatal mortality levels for 193 countries in 2009 with trends since 1990: a systematic analysis of progress, projections, and priorities.PLoS Med. 2011; 8: e1001080Crossref PubMed Scopus (343) Google Scholar This result compares extremely favourably with many accepted child survival interventions—eg, promotion of breastfeeding (121 000 lives), zinc supplementation (124 000 lives), or management of severe acute malnutrition (348 000 lives)3Bhutta ZA Das JK Rizvi A et al.Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?.Lancet. 2013; 382: 452-477Summary Full Text Full Text PDF PubMed Scopus (1715) Google Scholar—and impotantly, it is based on what can actually be achieved and has been achieved in four settings. In this regard, we would like to point out that the coverage in Newhints over the duration of the trial was high: 63% of babies received a postnatal visit and coverage was 75% in the second half of the trial after improved implementation strategies. It would be totally unrealistic to expect any programme to achieve 100% coverage or to base estimates on it doing so. As Rakesh Gupta and colleagues point out, the rates of institutional deliveries were not increased by Newhints, which was due to a stronger concurrent intervention influencing this variable—namely, the introduction of free registration in the national health insurance scheme for pregnant women and newborn babies.4Dzakpasu S Soremekun S Manu A et al.Impact of free delivery care on health facility delivery and insurance coverage in Ghana's Brong Ahafo Region.PLoS One. 2012; 7: e49430Crossref PubMed Scopus (105) Google Scholar We agree that it is disappointing that improvements in key newborn behaviours achieved by Newhints at all levels did not translate into a more substantial reduction in mortality. We believe that this finding is largely because the behaviour change that had potentially the largest effect—care-seeking for sick babies—was hampered by poor quality of care in facilities. The appendix1Kirkwood BR Manu A Ten Asbroek AHA et al.Effect of the Newhints home-visits intervention on neonatal mortality rate and care practices in Ghana: a cluster randomised controlled trial.Lancet. 2013; 381: 2184-2192Summary Full Text Full Text PDF PubMed Scopus (143) Google Scholar includes additional information, such as sociodemographic comparability of mothers in the intervention and control groups and shows that the education levels were broadly similar in the two groups. We would like to emphasise that more substantial mortality reductions might be achieved if the Newhints home visits were accompanied by parallel improvements in the quality of delivery and neonatal care in health facilities and development of innovative and effective strategies to increase coverage of home visits on the day of birth for babies born at home. The latter is essential if community-based interventions are to realise the potential of skin-to-skin care in mitigation against the high risk of death in premature and low-birth-weight babies.5Vesel L ten Asbroek AH Manu A et al.Promoting skin-to-skin care for low birthweight babies: findings from the Ghana Newhints cluster-randomised trial.Trop Med Int Health. 2013; 18: 952-961Crossref PubMed Scopus (17) Google Scholar However, we strongly believe that the present evidence alone merits promotion of home visits as an essential part of the package to save newborn lives. We declare that we have no conflicts of interest. Home visits: a strategy to improve newborn survivalBetty Kirkwood and colleagues (June 22, p 2184)1 report the effect of the Newhints home-visits intervention on neonatal mortality rate and care practices in Ghana. Overall, the authors reported a non-significant reduction in overall neonatal mortality and a small but significant effect in a pooled analysis. We are running a similar trial in Uganda,2 and would like to raise a few concerns. Full-Text PDF Home visits: a strategy to improve newborn survivalBetty Kirkwood and colleagues' meticulously designed study1 addresses a very relevant topic—improving neonatal mortality. However, a few points need clarification. First, although substantial improvements were noted (ie, care seeking for sick babies, bednet use during pregnancy, birth assistants washing hands with soap, initiation of breastfeeding within 1 h, exclusive breastfeeding, skin-to-skin contact, first bath delayed for longer than 6 h), all these noble measures could not translate into significant improvement in neonatal mortality. Full-Text PDF Effect of the Newhints home-visits intervention on neonatal mortality rate and care practices in Ghana: a cluster randomised controlled trialThe reduction in NMR with Newhints is consistent with the reductions achieved in three trials undertaken in programme settings in south Asia. Because there is no suggestion of any heterogeneity (p=0·850) between these trials and Newhints, the meta-analysis summary estimate of a reduction of 12% (95% CI 5–18) provides the best evidence for the likely effect of the home-visits strategy delivered within programmes in sub-Saharan Africa and in south Asia. Improvements in the quality of delivery and neonatal care in health facilities and development of innovative, effective strategies to increase coverage of home visits on the day of birth could lead to the achievement of more substantial reductions. Full-Text PDF" @default.
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• W2123455864 title "Home visits: a strategy to improve newborn survival – Authors' reply" @default.
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