Globally the proportion of childhood deaths that occur in the neonatal period is increasing.
Since 1990 there has been a 47% reduction in deaths in children less than five years of age.
However, this rate of reduction has not been seen in infants four weeks of age or younger
(neonates). The reasons why the fall in neonatal mortality has not mirrored that seen in
children mortality, is complex and one that is not well explored in the literature. One
proposed explanation is that interventions that have been successfully employed to reduce
childhood death do not reach the community and it is in the community where most neonates
die. Another pervasive perceived barrier to providing neonatal care, particularly in remote
and rural areas, is the misconception that neonatal care is difficult and expensive.
Many health problems are rooted in powerlessness. Health education that involves community
involvement: dialogue and problem solving, rather than just message giving, is more
empowering. Addressing social needs and empowering communities to make decisions about health
care needs allows for the design of programmes that account for local practices and beliefs.
Up to two-thirds of neonatal deaths could be prevented if neonates were given proper care
during and immediately after birth, because the majority of neonatal deaths occur around the
time of delivery. Training primary level health care workers to deal with emergency
situations that occur around the time of delivery, has been shown to decrease maternal
mortality and neonatal mortality It is reported that 79% of deliveries in Cambodia occur in
healthcare facilities. The majority of these will occur at primary care facilities. Babies
born in primary care facilities who require further care are transferred to the referral
hospital. The majority of referral hospitals in Cambodia do not have the resources or skills
to effectively deal with neonatal complications for babies born either in health centres or
in their on-site maternity wards.
The central hypothesis of this study is that a neonatal healthcare programme that has a
significant impact on neonatal mortality and which spans the healthcare journey from village
to referral hospital can be developed and implemented in a low-resource rural setting.
This study is a five-year cluster-randomised trial, covering the whole of Preah Vihear
province in North-Eastern Cambodia, which is a rural and isolated province. A cluster is
defined as a primary care administrative group, as recognised by the provincial health
department, and includes all primary care facilities, primary care workers, community health
workers, villagers and villages in that geographical area. The study area is divided into 21
clusters. Clusters were pre-assigned to one of two arms: intervention and control. A pilot
sequence has only four clusters, to incorporate a pilot phase into study design.
The intervention of this study is the Saving Babies' Lives programme which is a
comprehensive, contextual and adaptive neonatal healthcare package. The Saving Babies' Lives
Programme will be developed in partnership with the Kingdom of Cambodia Ministry of Health.
The programme will be approved by the Ministry of Health and a memorandum of understanding
signed with the provincial health director of Preah Vihear province. The control is no
intervention; standard government service continues.
The primary care facility intervention component of the Saving Babies' Lives programme
involves course-based training combined with continuous in-situ mentoring to support doctors,
nurses and midwives and other health worker cadres to improve their practical daily skills in
emergency and clinical neonatal care. Essential equipment will be identified and included in
the package.
Meetings attended by community health workers (two from each of the villages) will be held to
identify problems and concerns around neonatal health care in their own village. Monthly
meetings will take place for the group to discuss problems, attempt to arrive at solutions,
and share learning. These meetings will be facilitated by the study team who will use
participatory action research methodology to: identify problems with provision of, and
barriers to seeking, neonatal health care; develop interventions to improve care; implement
these interventions; assess the group's perception of the effectiveness of interventions.
A neonatal healthcare assessment tool will be developed that is quantitative and qualitative
in nature. It will be based on the 'KAP' survey method of analysing Knowledge, Attitudes and
Practice. In addition, two further domains will be added, equipment and staffing, leading to
a 'KAPES' model of assessment.
Data will be collected and used to assess the impact of the programme, its perceived
facilitators and barriers and its successes and failures. This information will be used to
iterate the programme content and structure in order to improve it, with the intention of
creating a scalable blueprint.