The first month of a newborn’s life can be the most joyous. But it can also be the most dangerous, especially if a serious illness or infection goes untreated. Globally, 2.8 million babies die during this vulnerable period each year, with 99% of deaths occurring in low-resource settings like Kenya. Neonatal infections–including sepsis, meningitis, pneumonia, and diarrhea–are a leading cause of death. Though the majority of these deaths are preventable, too often families don’t have access to lifesaving care for their children. Lwala and partners are working to change trends in infant mortality by mobilizing the community health system as a first point of care.
Jane, a new mother, knew something was wrong with her month-old son. He wouldn’t stop crying, and it seemed he was struggling to breathe. While Jane was pregnant, she had attended a parenting class led by community health workers (CHWs), and she remembered these as danger signs of illness in infants. Jane spoke with her mother, who agreed it was best to call their CHW, Rose. “We live far from a hospital,” Jane says, “but I trusted Rose to come quickly and advise me on what to do.”
Like Jane’s son, 1 in 10 newborns under two months old develop signs and symptoms of a possible serious bacterial infection (PSBI), such as pneumonia or sepsis. For years, the gold standard for treating these newborns was referral to a hospital and 7 to 10 days of injectable antibiotics. But in some cases, especially in rural settings, hospitals are out of reach and week-long stays are not possible. Fortunately, emerging evidence shows that many cases of PSBI can be addressed through coordination between CHWs and primary health care facilities.
It’s already standard practice for CHWs to visit newborns in the first 2 days after birth–but without training on PSBI, we miss an opportunity to identify and treat infections before they become life threatening. In 2020, we launched a pilot to fill this gap, in partnership with the Bill & Melinda Gates Foundation, Living Goods, Population Council, and Northwestern University. Across Migori and Busia Counties, we trained 727 CHWs, 104 CHW supervisors, and 104 facility-based staff on PSBI management.
Through the pilot, CHWs counsel families on newborn care, recognition of danger signs, and the importance of prompt care-seeking during household visits. CHWs also assess newborns for symptoms of PSBI and refer sick newborns to nearby primary health care facilities. Here, trained providers confirm the CHW’s assessment and make a diagnosis. In some cases, newborns are treated with injectable or oral antibiotics. In the case of critical illness, newborns are given an initial injection and then referred to a hospital.
This training enabled Rose’s swift response when she visited Jane and her baby. Rose first assessed the newborn, taking his temperature and counting how many breaths he took in a minute. “I observed that he was breathing very fast, so I knew I needed to refer him to a health facility,” Rose says. She even helped organize transportation. At the health facility, the baby was diagnosed with pneumonia and treated with amoxicillin. Health workers kept Rose updated on progress, and when Jane and her baby returned home, Rose continued to visit the family to ensure he completed his course of antibiotics.
Rose’s follow-up visits represent a key component of PSBI management. After newborns are treated at a health facility, CHWs conduct follow-up visits to encourage completion of their medication, as well as return to the facility if needed (e.g. for additional injections). This requires significant coordination between CHWs and health facilities, and throughout the pilot, we tested ways to strengthen these linkages. We updated referral slips, for example, to improve the flow of information from CHWs, to facilities, then back to CHWs. Additionally, more than half (53%) of facilities decided to station CHWs at a desk to receive sick infants, review their referral slip, and ensure they see a provider. These “CHW desks” improved both community linkages and families’ experience. “Some clients feel more comfortable in the presence of CHWs who are familiar with them,” said one health provider in Migori.
Results from the pilot are promising: they confirm that CHWs and primary health care facilities can manage PSBI in infants when hospital-level care is not feasible. During the pilot, CHWs identified danger signs in 1,119 newborns under two months and referred them to a primary health care facility. 83% of these newborns were taken to a facility and treated, and 92% were visited by a CHW two days later to confirm their recovery. There were, however, some caregivers that declined or delayed visiting a health facility because of distance or financial barriers. We learned that CHWs can reduce these delays by physically escorting mothers and newborns to the facility. Other family members declined care because of cultural beliefs that newborns should not be taken from the home in the first months of life–we are addressing this belief through community forums, where health providers and religious leaders highlight the dangers of delayed care.
“As a young mother, I was concerned about making the wrong choice for my baby’s health. That’s why CHWs are so important–because of the health messages they spread and the care they give. They offer solutions that are possible for my family.”
- Jane, a new mother in East Kamagambo
Community-based PSBI management was endorsed by new World Health Organization (WHO) guidelines released in 2015, but it’s far from being fully integrated into national health systems and leading global priorities on neonatal health. In Kenya, PSBI management has been incorporated into newborn care guidelines for health providers, while guidelines for community management of newborn care for CHWs is underway. Yet significant action and government commitment is needed to scale up this essential newborn care, including training all health workers, improving supply of commodities, and strengthening linkages between CHWs and facilities. Globally, PSBI must be prioritized in the Every Newborn Action Plan and the Primary Health Care agenda.
Without concerted effort to integrate newborn care into health systems, neonatal mortality will continue to lag behind other improvements in health outcomes. This pilot strengthens the case for community-based PSBI management to save newborn lives, and we will continue working with our partners to pursue a pathway to scale in Kenya.
Jane and her baby offer us hope for the care CHWs can provide–he is now fully recovered from pneumonia. “As a young mother, I was concerned about making the wrong choice for my baby’s health,” Jane says. “That’s why CHWs are so important–because of the health messages they spread and the care they give. They offer solutions that are possible for my family.”