Using research priority-setting to guide bridging the implementation gap in countries - a case study of the Uganda newborn research priorities in the SDG era.

BACKGROUND: One of the greatest challenges that countries face regarding the achievement of the Sustainable Development Goal (SDG) targets for child health regard the actions required to improve neonatal health; these interventions have to be informed by evidence. In view of the persisting high numbers of newborn deaths in Uganda, we aimed to define a locally contextualised national research agenda for newborn health to guide national investments towards SDG targets. METHODS: We adopted a systematic approach for priority-setting adapted from the Child Health and Nutrition Research Initiative. We identified and listed local newborn researchers and experts in Uganda by reviewing the PubMed database, through a snowballing technique, and engaged the Ministry of Health. Participants were requested to generate at least three research questions. The collated questions were sent to the same expert group to be rated using five criteria, including answerability, scalability, impact, generalisability and speed. FINDINGS: Of the 300 researchers and stakeholders contacted, 104 responded (36%) and generated 304 questions. These questions were collated and duplicates removed giving a condensed list of 41 research questions. These questions were then rated by 82 experts. Of the top 15 research questions, 86.7% (13/15) were in the service delivery and 6.7% (1/15) in the development domain, while only 6.7% (1/15) was in the group 'other'. None of the leading 15 questions was in the discovery domain. Strategies to improve quality of intrapartum care featured high in the responses, while research around care for premature babies was not a perceived focus of research. CONCLUSIONS: The focus of improved evidence to guide and innovate service delivery, foremost intrapartum care, reflects the importance of this area as accelerated improvement is likely to yield fast and sustained survival gains in the neonatal period and beyond in Uganda. We recommend that other countries adapt a similar approach in defining priority reproductive, maternal, newborn and child health areas for investment in order to accelerate progress towards achieving the SDGs.

Effect of the Uganda Newborn Study on care-seeking and care practices: a cluster-randomised controlled trial.

BACKGROUND: Care for women and babies before, during, and after the time of birth is a sensitive measure of the functionality of any health system. Engaging communities in preventing newborn deaths is a promising strategy to achieve further progress in child survival in sub-Saharan Africa. OBJECTIVE: To assess the effect of a home visit strategy combined with health facility strengthening on uptake of newborn care-seeking, practices and services, and to link the results to national policy and scale-up in Uganda. DESIGN: The Uganda Newborn Study (UNEST) was a two-arm cluster-randomised controlled trial in rural eastern Uganda. In intervention villages volunteer community health workers (CHWs) were trained to identify pregnant women and make five home visits (two during pregnancy and three in the first week after birth) to offer preventive and promotive care and counselling, with extra visits for sick and small newborns to assess and refer. Health facility strengthening was done in all facilities to improve quality of care. Primary outcomes were coverage of key essential newborn care behaviours (breastfeeding, thermal care, and cord care). Analyses were by intention to treat. This study is registered as a clinical trial, number ISRCTN50321130. RESULTS: The intervention significantly improved essential newborn care practices, although many interventions saw major increases in both arms over the study period. Immediate breastfeeding after birth and exclusive breastfeeding were significantly higher in the intervention arm compared to the control arm (72.6% vs. 66.0%; p=0.016 and 81.8% vs. 75.9%, p=0.042, respectively). Skin-to-skin care immediately after birth and cord cutting with a clean instrument were marginally higher in the intervention arm versus the control arm (80.7% vs. 72.2%; p=0.071 and 88.1% vs. 84.4%; p=0.023, respectively). Half (49.6%) of the mothers in the intervention arm waited more than 24 hours to bathe the baby, compared to 35.5% in the control arm (p<0.001). Dry umbilical cord care was also significantly higher in intervention areas (63.9% vs. 53.1%, p<0.001). There was no difference in care-seeking for newborn illness, which was high (around 95%) in both arms. Skilled attendance at delivery increased in both the intervention (by 21%) and control arms (by 19%) between baseline and endline, but there was no significant difference in coverage across arms at endline (79.6% vs. 78.9%; p=0.717). Home visits were pro-poor, with more women in the poorest quintile visited by a CHW compared to families in the least poor quintile, and more women who delivered at home visited by a CHW after birth (73.6%) compared to those who delivered in a hospital or health facility (59.7%) (p<0.001). CHWs visited 62.8% of women and newborns in the first week after birth, with 40.2% receiving a visit on the critical first day of life. CONCLUSION: Consistent with results from other community newborn care studies, volunteer CHWs can be effective in changing long-standing practices around newborn care. The home visit strategy may provide greater benefit to poorer families. However, CHW strategies require strong linkages with and concurrent improvement of quality through health system strengthening, especially in settings with high and increasing demand for facility-based services.

Newborn survival in Uganda: a decade of change and future implications.

Each year in Uganda 141 000 children die before reaching their fifth birthday; 26% of these children die in their first month of life. In a setting of persistently high fertility rates, a crisis in human resources for health and a recent history of civil unrest, Uganda has prioritized Millennium Development Goals 4 and 5 for child and maternal survival. As part of a multi-country analysis we examined change for newborn survival over the past decade through mortality and health system coverage indicators as well as national and donor funding for health, and policy and programme change. Between 2000 and 2010 Uganda's neonatal mortality rate reduced by 2.2% per year, which is greater than the regional average rate of decline but slower than national reductions in maternal mortality and under-five mortality after the neonatal period. While existing population-based data are insufficient to measure national changes in coverage and quality of services, national attention for maternal and child health has been clear and authorized from the highest levels. Attention and policy change for newborn health is comparatively recent. This recognized gap has led to a specific focus on newborn health through a national Newborn Steering Committee, which has been given a mandate from the Ministry of Health to advise on newborn survival issues since 2006. This multi-disciplinary and inter-agency network of stakeholders has been able to preside over a number of important policy changes at the level of facility care, education and training, community-based service delivery through Village Health Teams and changes to essential drugs and commodities. The committee's comprehensive reach has enabled rapid policy change and increased attention to newborn survival in a relatively short space of time. Translating this favourable policy environment into district-level implementation and high quality services is now the priority.

Introduction of newborn care within integrated community case management in Uganda.

Uganda's Ministry of Health, together with partners, has introduced integrated community case management (iCCM) for children under 5 years. We assessed how the iCCM program addresses newborn care in three midwestern districts through document reviews, structured interviews, and focus group discussions with village health team (VHT) members trained in iCCM, caregivers, and other stakeholders. Almost all VHT members reported that they refer sick newborns to facilities and could identify at least three newborn danger signs. However, they did not identify the most important clinical indicators of severe illness. The extent of compliance with newborn referral and quality of care for newborns at facilities is not clear. Overall iCCM is perceived as beneficial, but caregivers, VHTs, and health workers want to do more for sick babies at facilities and in communities. Additional research is needed to assess the ability of VHTs to identify newborn danger signs, referral compliance, and quality of newborn treatment at facilities.