A systematic review of community-to-facility neonatal referral completion rates in Africa and Asia

Authors: Naoko Kozuki, Tanya Guenther, Lara Vaz, Allisyn Moran, Sajid B. Soofi, Christine Nalwadda Kayemba, Stefan S. Peterson, Zulfiqar A. Bhutta, Sudhir Khanal, James M. Tielsch, Tanya Doherty, Duduzile Nsibande, Joy E. Lawn, Stephen Wall

An estimated 2.8 million neonatal deaths occur annually worldwide, three-quarters in Africa and Asia. These deaths are due largely to preventable causes, with neonatal infection accounting for 24% of all neonatal deaths. In low-resource community-based settings, care-seeking for neonatal illnesses can be triggered through two paths. One is through household self-identification of potentially life-threatening illness and subsequent self- referral.The second path is via community-based health workers detecting danger signs during home visits, and referring the newborn for care at an appropriately equipped facility. For this purpose, the WHO and UNICEF recommend community health workers (CHW) make a minimum of two home visits for home births, the first occurring within 24 h of birth and the second occurring on day 3.

There is a gap in the literature in understanding how sick newborns are identified, treated, and referred, especially in programs that have CHWs conducting active surveillance for neonatal illness through home visits. There is also less information on neonatal referrals when compared to the more robust literature on infant or under-five referral, many arising from research on Integrated Management of Childhood Illness (IMCI). This paper focuses on the role active referrals by CHWs play in neonatal care-seeking The authors examine referral completion rates for neonates with danger signs predictive of mortality or major morbidity in LMICs. The authors reviewed existing literature with information on referral completion rates following active home-based surveillance of neonatal illness, and also unpublished literature identified through a working group. The authors assess factors that may contribute to high or low completion rates, including infant sex, the danger signs assessed for referral, the overall referral rate, the ways in which referrals were facilitated, and other contextual issues.