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International Health

Lancet 2008 Paper of the Year
On the effect of a community-based newborn-care intervention; Lead author Abdullah Baqui

It’s fitting that during the 30th anniversary of the signing of the Alma-Ata Declaration, The Lancet awarded Top Paper of the Year to an article evaluating a community-based intervention in rural Bangladesh. The award not only acknowledges innovative research that can address health inequities in populations most at risk, but it also highlights how communities can effectively participate in their own primary health care.

Dr. BaquiWhile Associate Professor Abdullah Baqui, Health Systems, was first author, local researchers were integral in every aspect of the evaluation, from data collection to writing the article. The Project for Advancing Health of Newborns and Mothers (Projahnmo, which means generation in Bangla) conducted the study in three rural sub-districts of Sylhet district. The Projahnmo Study Group included researchers from the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), the Bangladesh Ministry of Health and Family Welfare, the Bloomberg School of Public Health, and non-governmental organizations in Bangladesh, including Shimantik, Dhaka Shishu Hospital, and the Institute of Child and Mother Health. Several Department faculty were also co-authors: Research Associate Emma Williams, Associate Ishtiaq Mannan, Associate Rasheduzzaman Shah, Associate Professor Peter Winch, Research Associate Amnesty Lefevre, Professor Mathuram Santosham, and Department Chair Robert Black.

Community Ownership
One of Alma-Ata’s main principles is community ownership and participation. In this intervention, community health workers (CHWs) with little or no health-care background were trained to promote a package of antenatal and postpartum interventions during home visits in rural areas with high neonatal mortality rates. CHWs identified and managed newborns with infections using a simple diagnostic approach. This home-based care, provided by community members who received only 6 weeks of training, reduced neonatal mortality by 34 percent compared to women who received the usual care.

Evidence-Based Programming
The fourth Millennium Development Goal is a reduction by two-thirds in mortality by 2015 for children under 5. The Lancet’s Alma-Ata Series, which commemorates the Declaration’s 30th anniversary, observes that implementation and assessment must be a priority for primary health care in order to reach this goal. Policymakers need to know that interventions are based on solid evidence so they feel confident scaling up programs.

This study is one of the first to use a randomized controlled trial to evaluate a community-based intervention. It was heralded in a Lancet editorial by Don Thea of Boston University and Shamim Qazi of the World Health Organization. These experts noted that because this scientifically rigorous large study was implemented using existing NGO and government health service delivery programs, the findings have significant “generalizability and program relevance.”

Scaling Up
According to Dr. Baqui, “Scaling up of this evidence-based intervention package could significantly improve access to essential and sick newborn care in developing countries, saving millions of newborn lives every year and taking pressure off of strained health care systems.” In fact, based in part on this study, USAID and the government of Bangladesh are planning a large-scale community-based project to improve newborn health in Bangladesh.

Dr. Baqui does warn, however, “There are a lot of good studies out there showing impact. But when we take them into larger programs, we lose the effectiveness. We need research on how you take an intervention from half a million people to the millions of people living in poor communities of Asia and Africa without losing effectiveness.”

Paper of the Year
Six papers were short-listed by The Lancet, and, thanks to voters here at Hopkins and across the globe, the paper was one of three to share this year’s honor. “Top paper of the year is certainly an honor for all of us at Projahnmo project in Bangladesh. We hope that the recognition of our work will influence policies and programs around the world that will prevent many unnecessary newborn deaths,” said Dr. Baqui. The Lancet has awarded this honor since 2003, but this is the first time a Johns Hopkins faculty member, from any school, has been the first author of a winning paper.

Also see the Lancet profile of Dr Baqui.

--Brandon Howard, March 2009