In low‐ and middle‐income countries (LMICs), health services are under‐utilised, and
several studies have reported improvements in neonatal outcomes following health education
imparted to mothers in homes, at health units, or in hospitals. However, evaluating
health educational strategy to deliver newborn care, such as one‐to‐one counselling
or group counselling via peer or support groups, or delivered by health professionals,
requires rigorous assessment of methodological design and quality, as well as assessment
of cost‐effectiveness, affordability, sustainability, and reproducibility in diverse
health systems. To compare a community health educational strategy versus no strategy
or the existing approach to health education on maternal and newborn care in LMICs,
as imparted to mothers or their family members specifically in community settings
during the antenatal and/or postnatal period, in terms of effectiveness for improving
neonatal health and survival (i.e. neonatal mortality, neonatal morbidity, access
to health care, and cost). We used the standard search strategy of Cochrane Neonatal
to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue
4), in the Cochrane Library, MEDLINE via PubMed (1966 to 2 May 2017), Embase (1980
to 2 May 2017), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL)
(1982 to 2 May 2017). We also searched clinical trials databases, conference proceedings,
and the reference lists of retrieved articles for randomised controlled trials and
quasi‐randomised trials. Community‐based randomised controlled, cluster‐randomised,
or quasi‐randomised controlled trials. Two review authors independently assessed trial
quality and extracted the data. We assessed the quality of evidence using the GRADE
method and prepared 'Summary of findings' tables. We included in this review 33 original
trials (reported in 62 separate articles), which were conducted across Africa and
Central and South America, with most reported from Asia, specifically India, Pakistan,
and Bangladesh. Of the 33 community educational interventions provided, 16 included
family members in educational counselling, most frequently the mother‐in‐law or the
expectant father. Most studies (n = 14) required one‐to‐one counselling between a
healthcare worker and a mother, and 12 interventions involved group counselling for
mothers and occasionally family members; the remaining seven incorporated components
of both counselling methods. Our analyses show that community health educational interventions
had a significant impact on reducing overall neonatal mortality (risk ratio (RR) 0.87,
95% confidence interval (CI) 0.78 to 0.96; random‐effects model; 26 studies; n = 553,111;
I² = 88%; very low‐quality evidence), early neonatal mortality (RR 0.74, 95% CI 0.66
to 0.84; random‐effects model; 15 studies that included 3 subsets from 3 studies;
n = 321,588; I² = 86%; very low‐quality evidence), late neonatal mortality (RR 0.54,
95% CI 0.40 to 0.74; random‐effects model; 11 studies; n = 186,643; I² = 88%; very
low‐quality evidence), and perinatal mortality (RR 0.83, 95% CI 0.75 to 0.91; random‐effects
model; 15 studies; n = 262,613; I² = 81%; very low‐quality evidence). Moreover, community
health educational interventions increased utilisation of any antenatal care (RR 1.16,
95% CI 1.11 to 1.22; random‐effects model; 18 studies; n = 307,528; I² = 96%) and
initiation of breastfeeding (RR 1.56, 95% CI 1.37 to 1.77; random‐effects model; 19
studies; n = 126,375; I² = 99%). In contrast, community health educational interventions
were found to have a non‐significant impact on use of modern contraceptives (RR 1.10,
95% CI 0.86 to 1.41; random‐effects model; 3 studies; n = 22,237; I² = 80%); presence
of skilled birth attendance at birth (RR 1.09, 95% CI 0.94 to 1.25; random‐effects
model; 10 studies; n = 117,870; I² = 97%); utilisation of clean delivery kits (RR
4.44, 95% CI 0.71 to 27.76; random‐effects model; 2 studies; n = 17,087; I² = 98%);
and care‐seeking (RR 1.11, 95% CI 0.97 to 1.27; random‐effects model; 7 studies; n
= 46,154; I² = 93%). Cost‐effectiveness analysis conducted in seven studies demonstrated
that the cost‐effectiveness for intervention packages ranged between USD 910 and USD
11,975 for newborn lives saved and newborn deaths averted. For averted disability‐adjusted
life‐year, costs ranged from USD 79 to USD 146, depending on the intervention strategy;
for cost per year of lost lives averted, the most effective strategy was peer counsellors,
and the cost was USD 33. This review offers encouraging evidence on the value of integrating
packages of interventions with educational components delivered by a range of community
workers in group settings in LMICs, with groups consisting of mothers, and additional
education for family members, for improved neonatal survival, especially early and
late neonatal survival. Community‐based maternal and newborn educational care packages
for improving neonatal health and survival in low‐ and middle‐income countries Review
question Is community health educational intervention for newborn care effective in
improving neonatal health and survival in low‐ and middle‐income countries? Background
In low‐ and middle‐income countries (LMICs), health service utilisation is low and
neonatal mortality and morbidity are high. However, improvements in neonatal outcomes
have been documented in several studies with simple health educational interventions.
This review assessed the effectiveness of health education strategies imparted to
mothers or their family members in community settings of LMICs. It also assessed the
impact of health education strategies on neonatal mortality, neonatal morbidity, access
to health care, and cost. Study characteristics A total of 33 experimental studies
were conducted across Africa and Central and South America, with most reported from
Asia, specifically India, Pakistan, and Bangladesh. Of the 33 community educational
interventions, 16 required involvement of family members, most frequently the mother‐in‐law
or the expectant father. Most studies (n = 14) involved one‐to‐one counselling between
a range of community healthcare workers and mothers, and 12 involved group counselling
consisting predominantly of mothers, with family members included occasionally; the
remaining seven had components of both one‐to‐one and group counselling. Key results
This review found that community health educational interventions significantly reduced
newborn death, early newborn mortality, and late newborn mortality, as well as perinatal
mortality. These interventions also positively impacted utilisation of any before
birth (antenatal), care during pregnancy, and initiation of breastfeeding within an
hour after birth. The review shows that educational interventions delivered to both
mothers and other family members in a group setting had a greater impact on these
outcomes. Educational interventions delivered during antenatal care were more effective
for reducing early neonatal deaths, and those delivered during both antenatal and
postnatal (after birth) periods were effective for reducing late neonatal deaths and
perinatal deaths. Educational interventions during the postnatal period were most
effective for improving breastfeeding practices. Quality of evidence The quality of
evidence is low for newborn mortality outcomes and very low for early, late, and perinatal
mortality. This reflects concerns of bias, inconsistency (unexplained variability
of results), and imprecision (variation in studies presenting both benefit and harm
from the intervention) of the included randomised controlled trials.