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Four million babies die each year in their first four weeks of life. Better neonatal survival requires cost-effective action at the community level and good links with the healthcare system. Trained community health workers could spot the danger signs that signal a baby’s need for hospital treatment.

Research led by Johns Hopkins University, in the USA, and ICDDR, in Bangladesh, tests the ability of community health workers (CHWs) to recognise neonatal illnesses during routine household visits in Mirzapur, Bangladesh. Globally, neonatal deaths make up an estimated 41 percent of under-five mortality. Almost all occur in low and middle-income countries and more than half happen at home. Trained CHWs can promote good newborn care practices at home by teaching parents about the signs of illness and the need to seek care, and by assessing babies directly.

The researchers assess the validity of a clinical algorithm, or process, used by CHWs. This includes a list of seven severe conditions requiring referral as well as five minor conditions needing home care and a follow-up visit, plus problems with breastfeeding. In the study, CHWs visited 395 babies at 0, 2, 5 and 8 days old. They referred any newborn babies with 1 or more of 11 clinical signs of very severe disease (VSD) to a community hospital. Physicians verified these assessments within 12 hours.

The classification of VSD by CHWs shows good agreement with that of physicians:

• CHWs correctly identified 73 percent of all babies with VSD (sensitivity) and 98 percent of those who do not have VSD (specificity).
• Of the babies classified as having VSD by a CHW, physicians confirmed 57 percent as very severely ill and needing referral (positive predictive value).
• When CHWs decided that babies are not severely ill, they were correct in 99 percent of cases (negative predictive value).
• If mothers tell physicians their baby has a feeding problem, it is highly likely a visiting CHW has identified a severe feeding problem (especially a lack of ability to suckle).
• However, clinical signs such as fast breathing and ‘weak, abnormal or absent cry’ are not good indicators of severe disease.

These results show that home-based illness recognition, care and referral by CHWs could improve neonatal health and survival in low-resource settings. They also suggest that doctors can rely on maternal reports of feeding problems without the need for complex, time-consuming and culturally difficult direct assessments of breastfeeding.

To maximise the health impact of this approach, health researchers and decision-makers should strive to:

• test CHWs performance in assessing neonatal illnesses in other settings with different rates and types of illness, such as high HIV and malaria prevalence
• minimise the loss of trained CHWs and ensure that all new recruits learn how to use the clinical algorithm
• train CHWs to care for sick newborn babies in areas with poor access to quality health facilities.

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