Health Policy and Planning Advance Access published online on November 16, 2009
Health Policy and Planning, doi:10.1093/heapol/czp048
Household surveillance of severe neonatal illness by community health workers in Mirzapur, Bangladesh: coverage and compliance with referral
1Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA, 2Public Health Sciences Division, ICDDR,B, Dhaka, Bangladesh, 3Department of Pediatrics, Kumudini Women's Medical College, Mirzapur, Tangail, Bangladesh, 4The Projahnmo-2 Study Group includes (in alphabetical order): ASM Nawshad Uddin Ahmed, Saifuddin Ahmed, Nabeel Ashraf Ali, Abdullah H Baqui, Nazma Begum, Robert E Black, Sanwarul Bari, Atique Iqbal Chowdhury, Gary L Darmstadt, Shams El-Arifeen, AKM Fazlul Haque, Zahid Hasan, Amnesty LeFevre, Ishtiaq Mannan, Anisur Rahman, Radwanur Rahman, Syed Moshfiqur Rahman, Taufiqur Rahman, Samir K Saha, Mathuram Santosham, Habibur Rahman Seraji, Ashrafuddin Siddik, Hugh Waters, Peter J Winch and K Zaman
*Corresponding author. International Center for Advancing Neonatal Health, Department of International Health E8153, Bloomberg School of Public Health, Johns Hopkins University, 615 North Wolfe Street, Baltimore, MD 21205, USA. Tel: +1 443 287-3003. Fax: +1 410 614-1419. E-mail: gdarmsta{at}jhsph.edu
Background Effective and scalable community-based strategies are needed for identification and management of serious neonatal illness.
Methods As part of a community-based, cluster-randomized controlled trial of the impact of a package of maternal-neonatal health care, community health workers (CHWs) were trained to conduct household surveillance and to identify and refer sick newborns according to a clinical algorithm. Assessments of newborns by CHWs at home were linked to hospital-based assessments by physicians, and factors impacting referral, referral compliance and outcome were evaluated.
Results Seventy-three per cent (7310/10 006) of live-born neonates enrolled in the study were assessed by CHWs at least once; 54% were assessed within 2 days of birth, but only 15% were attended at delivery. Among assessments for which referral was recommended, compliance was verified in 54% (495/919). Referrals recommended to young neonates 0–6 days old were 30% less likely to be complied with compared to older neonates. Compliance was positively associated with having very severe disease and selected clinical signs, including respiratory rate 
70/minute; weak, abnormal or absent cry; lethargic or less than normal movement; and feeding problem. Among 239 neonates who died, only 38% were assessed by a CHW before death.
Conclusions Despite rigorous programmatic effort, reaching neonates within the first 2 days after birth remained a challenge, and parental compliance with referral recommendation was limited, particularly among young neonates. To optimize potential impact, community postnatal surveillance must be coupled with skilled attendance at delivery, and/or a worker skilled in recognition of neonatal illness must be placed in close proximity to the community to allow for rapid case management to avert early deaths.
Key Words: Community health worker, neonatal illness, referral, surveillance, care seeking
Current address: Integrated Health Solutions Development, Global Health Program, Bill & Melinda Gates Foundation, PO Box 23350, Seattle, WA 98102, USA. E-mail: gary.darmstadt{at}gatesfoundation.org
Accepted for publication 27 July 2009.