Feasibility of community neonatal death audits in rural Uttar Pradesh, India

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Journal of Perinatology (2007) 27, 556–564 r 2007 Nature Publishing Group All rights reserved. 0743-8346/07 $30 www.nature.com/jp


Feasibility of community neonatal death audits in rural Uttar Pradesh, India Z Patel1, V Kumar1,2, P Singh2, V Singh2, R Yadav2, AH Baqui1, M Santosham1, S Awasthi3, JV Singh4 and GL Darmstadt1, for the Saksham Study Group5 1

Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; 2Institute of Clinical Epidemiology, King George Medical University, Lucknow, India; 3Department of Pediatrics, King George Medical University, Lucknow, India and 4Department of Social and Preventive Medicine, King George Medical University, Lucknow, India

Objective: Medical audit is a widely promoted strategy in hospitals, but experience within community settings is scant. Community neonatal death audit is a form of audit, which involves a systematic analysis of the quality of care provided in the home, danger sign recognition and care seeking decision making for neonatal illness. This research was conducted in Uttar Pradesh, India, to investigate the feasibility and cultural acceptability of community neonatal death audits.

Study Design: During November–December 2004, we conducted three in-depth interviews with family members of deceased neonates, and six focus group discussions with family and community members. Three approaches were evaluated: in-depth interview with the family before engaging them in an audit with the community; preliminary meeting to build rapport with the family and community before conducting an audit; and audit with the family and community in a single focus group. Approaches were interactive processes, involving the community, to identify avoidable factors in a particular death and discuss solutions. Result: Carried out in a culturally sensitive and non-punitive manner, community neonatal death audit was found to be acceptable and feasible. All approaches provoked formal investigation by community members, and stimulated sharing of views, leading to the self-discovery that community perception was a cumulatively amplified effect of individual perceptions. Presence of an educated/experienced community member or health worker served as a catalyst. No one optimal approach was identified. Conclusion: Community neonatal audit is an acceptable approach that shows promise as an effective intervention for improving neonatal health outcomes. Journal of Perinatology (2007) 27, 556–564; doi:10.1038/sj.jp.7211788; published online 19 July 2007

Correspondence: Dr GL Darmstadt, Department of International Health, E8153, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA. E-mail: [email protected] 5 Saksham Study Group: RC Ahuja, S Awasthi, AH Baqui, M Bhandari, N Bharti, GL Darmstadt, A Gupta, S Gupta, V Kumar, RP Misra, S Mohanty, MK Mitra, M Santosham, JV Singh, P Singh, V Singh, PJ Winch, R Yadav. Received 14 December 2006; revised 2 May 2007; accepted 29 May 2007; published online 19 July 2007

Keywords: audit; cause of death; community; India; mortality; neonatal

Introduction Medical audit is a widely promoted strategy for improving obstetric and other health care in industrialized countries. The audit process seeks to improve the current level of care by comparing existing practices against standards of care and defined criteria.1 When avoidable factors in deaths are identified during this process, related either to delays in care-seeking or substandard provision of care, mechanisms for improvements in care are sought and possible actions are proposed, implemented and monitored.2 Improvements are also brought about through promoting teamwork and increasing the skills, motivation and accountability of health workers. Thus, the principal aim of audit is ‘to improve the quality of care’.1,3–5 A death audit cycle consists of the following steps: identify deaths, ascertain the causes of death, identify avoidable factors, discuss the findings and propose solutions, implement improvements in care and evaluate impact.6 Studies from health facilities in developing countries evaluating Perinatal Death Audits (PNDA) have shown reductions of upto 40% in perinatal mortality (stillbirths after 28 weeks gestation and early neonatal deaths in the first week of life).7 Avoidable factors accounted for up to 19% of perinatal deaths and fell to 0% over the course of one study in the Hlabisa Health District of KwaZulu/Natal, South Africa. Most research on maternal and PNDA has been performed at the facility level in controlled settings, and experience in developing countries, especially within community settings and applied to neonatal deaths, is scant. There is increasing interest, however, in the potential of audit to improve the quality of both domiciliary and facility-based health care in developing countries.8 The objective of this study was to investigate the feasibility and cultural acceptability of conducting neonatal death audits at the

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community level in rural Uttar Pradesh, India. The ideal method to facilitate approaching the community to discuss the death of a particular neonate, the number and characteristics of participants needed during discussions to ensure maximum participation, and the duration of the discussion were explored. Community members’ ability to identify avoidable factors leading to the death of the neonate and to suggest possible solutions, as well as their acceptance of the process was observed.

Methods Setting and subjects The study was conducted in the rural development block of Shivgarh in Raebareli District of Uttar Pradesh, India. The block consists of 39 villages (gram sabhas) with a total population of 104 000. The study was part of an ongoing block-wide communitybased program to promote essential newborn care practices through community mobilization and behavior change communication. The study site for the parent trial was selected on the basis of its rural characteristics, poor socio-demographic indicators, predominantly home deliveries, high neonatal mortality and limited access to formal health care. The community death audits were conducted in four villages during the months of November and December 2004 to inform further the community mobilization strategy. The cases for neonatal death audit were chosen purposefully from among the neonatal deaths that had taken place in these villages during the past 1 year. The parent study had a surveillance system to identify and register vital events, including pregnancies, births, and neonatal deaths and was utilized to identify potential cases for audit. The cases of neonatal deaths that became the subject of community death audit were chosen using the following criteria: (1) the neonatal death had occurred at least 3 months before the audit in an intervention area of the parent project, (2) the neonatal death did not occur under extraordinary circumstances and the baby did not have a gross congenital abnormality and (3) willingness of the family of the deceased newborn to discuss the circumstances leading to the death. Study design Approaches to death audit. Three different approaches to community neonatal death audit were assessed using a mix of indepth narrative style interviews with family members of the deceased, and focus group discussions (FGDs) with family members and neighbors. Each approach was designed to be interactive and build rapport, to identify possible causes of the death and factors that may have contributed to the death, as well as possible steps community members could take in the future to prevent a death from occurring under similar circumstances. Approach I (family audit followed by community audit): This approach consisted of two phases. The family audit phase consisted

of an in-depth interview with family members to gain their confidence and explore their perceptions of the death of their newborn. This was followed by the community audit phase in which a FGD was held at a later date with family members, immediate neighbors and other village residents to explore the issue further. Approach II (community pre-audit followed by community audit): This approach also consisted of two phases. The community preaudit phase entailed a preliminary group meeting to build rapport and confidence with members of the community, including the family of the deceased newborn. During a subsequent meeting at a later date, the community audit was held, similar to the second phase (community audit) of Approach I in all respects. Approach III (community audit): This approach consisted of condensing Approach II into a single meeting, utilizing the first half as a preparatory phase for building rapport, and the second half for conducting the neonatal death audit. Once the cases were identified, each case was assigned to a particular approach, informed by discussions with field staff of the parent study. The assignment of cases to each approach was made based on the level of rapport the parent study field staff had already developed with the community. Approaches I and II were considered to be more conservative as compared to Approach III, where after obtaining consent from the family, the audit was conducted with the community without any prior interaction with the family or the community regarding the death of the neonate. Thus, Approach III was conducted in communities where rapport with the community was relatively well-established. Follow-up visits, in the form of in-depth semi-structured interviews were conducted in March 2007 to understand community reactions to the process.

Data collection. Three open-ended, semi-structured in-depth interviews were conducted with families (mother, mother-in-law, father and father-in-law) centered around perceptions of antenatal care and the actual care that the mother had received, narration of the events during delivery, perceived maternal and neonatal morbidities and post-natal preventive and curative care administered in the home or sought outside of the home (formal or informal). Care was taken to avoid and diffuse any blame. Interviews were conducted in the presence of family members to gain a sense of how the household, as a unit, thought about and reacted to the neonatal death and the events leading to the death. The purpose of the interview was to initiate an in-depth thought process, surrounding the death of the neonate, among not only the immediate caregivers of the neonate, but also including and drawing upon the combined knowledge and strengths of all household members. Additionally, this meeting was utilized to gain the family’s consent and co-operation to allow the community members to deliberate with them on the death of the newborn. Journal of Perinatology

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Six FGDs were conducted with community members living in the immediate vicinity of the household whose neonate was to be the topic of discussion. Villages in Shivgarh are generally organized in a manner in which people of similar social class, caste and economic status reside together in well-defined geographical units. Therefore, a certain level of homogeneity was maintained within each focus group. All family members, male and female, were invited to participate. Additionally, experienced women from the community, who were respected for the advice they provide to mothers on pregnancy-related health-care seeking and delivery practices, were invited to participate. FGDs were designed to begin as a general conversation on health, and then purposefully narrow down to focus on neonatal health, eventually leading into a discussion on the actual death. Family members and caregivers of the deceased newborn were encouraged to share their perception of the sequence of events leading to the death, avoiding blame and to engage with the community members in identifying potential avoidable factors and proposing solutions and preventive measures to be taken. The purpose of this process was to explore the feasibility and use of an adverse event, such as a neonatal death, in encouraging the community to think collectively about and harness already existing community resources in developing, and publicly sanctioning, remedial actions to be taken at the household and the community level. Thus, emphasis was placed on viewing the death as an opportunity for the community to come together to generate solutions that would be relevant to the care of all newborns in the community. The members of the parent project intervention team conducted the in-depth interviews and FGDs in Hindi. Each interviewer was trained and briefed on the concept of community neonatal death audits. Special attention was given to avoiding any blame and to keeping the process neutral and conducive to open discussion. In-depth interviews were conducted by two team members. While one conducted the interview the other took detailed field notes. FGDs were conducted by three team members. Two members conducted the interview and helped build rapport among the participants, while the third team member took detailed field notes. Participant’s reactions were closely observed during the FDGs. Verbal consent was obtained from all participants, which explained the steps involved in the audit process and the logic behind its objectives. Each session was tape recorded, and field notes were updated and expanded with the help of the recorded tapes. Non-verbal communications and reactions were recorded and included in the analysis process. Discussion sessions with all team members were held within 24 h after each interview and FGD. Data were organized and analyzed based on the following themes that were defined a priori: (1) community perception and response toward neonatal death, (2) feasibility and acceptability of audit and (3) identification of avoidable factors and possible solutions mentioned by the participants. Journal of Perinatology

The study was approved by the Committee on Human Research of the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, and the Ethical Review Committee of King George Medical University, Lucknow, Uttar Pradesh, India. The study was registered, under the parent trial, at clinicaltrials.gov #H.

Results The study team conducted three in-depth interviews and six focus group discussions across four villages: Jodhawarkheda, Raipur Murtimata, Aimapur and Padariya (Table 1). Of the five neonatal deaths reviewed (in Jodhawarkheda the process involved twin baby boys), three were male and two were female. Community perception and response towards neonatal deaths There was a general feeling of discomfort during the initial part of the in-depth interviews with families and during FGDs with the community on newborn deaths. The common phrase heard was ‘bhagwan ki marji thi; jo hona tha so hogaya, ab uspe baat karne se kya fayeda?’ (‘It was the will of God. What had to happen has happened. Is there any use talking about it?’) However, this phase of initial resistance was gradually overcome and replaced by an increased willingness to discuss the issue of death of the newborn. From the discussions, it could be surmised that practices during the antenatal, intra-partum and newborn periods are predominantly shaped by traditions long-followed and approved by the community. It was apparent that measures such as modification of the diet during pregnancy; confinement of the mother and newborn for the first 1 week, or in some cases for the first few weeks postpartum in a special room (Saur) fortified against evil spirits; and special regimens for the mother and the baby, were all directed at improving chances of survival of the mother and the newborn. In the event the family recognized signs that they perceived as dangerous for the baby, they followed a sequence of steps consistent with community norms that they believed would best serve the health of the newborn. They utilize their own taxonomy of disease conditions and the probable associated causes and cures, and this combined with limited access to health care and financial constraints usually guide their careseeking behaviors and referral patterns. In the event of death of the baby despite their best efforts, they tend to evoke a set of justifications that usually center on the sovereign role of God and the supernatural, which serves to hasten the process of recovery of the mother and family members from this catastrophic event. Several practices identified (for example, not naming the baby or buying new clothes for the baby before delivery or during the first few days after birth, avoidance of elaborate rituals for newborn deaths in contrast to deaths in adults and resignation to the notion that the mother can produce more babies later) appear to reflect the high risk of newborn death that

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Table 1 Findings from neonatal community death audits Approach

Community’s perception of cause of death

Identified preventable factors

Proposed solutions

Plans to implement solutions

Identified constraints to implementation

Approach I

Breach delivery, asphyxia

Non-identification of high-risk pregnancy

Attend ANC regularly

Village is very far from the primary health care center

Poor quality of ANC services being offered by the government

Seek skilled care for ANC and delivery

Collect money through the course of the pregnancy to prepare for delivery and transport costs Early identification and notification of skilled birth attendant for home delivery

Family audit, then community audit; female baby; Aimapur village

Home delivery

Approach II

Community preaudit, then community audit; twin male babies; Jodawarkheda village

Malnourished/ weak Babies were born small, ‘kamjor’, that mother is, weak and premature Lack of proper nutrition for babies due to lack of breast milk (caused by malnourishment of mother)

Local auxiliary nurse midwife (ANM) does not provide quality ANC

Inability to identify other quality health services Lack of knowledge about maternal and newborn danger signs Increase intake of green leafy vegetables and dal (lentil soup) during pregnancy Consume at least three meals a day during pregnancy

Educate pregnant women and new mothers on the importance of maternal nutrition

Economic constraints

Seasonality of vegetables

Feed baby cow’s milk in case of lack of breast milk

Limited access to the markets/ transport No cows in the village If pregnant women eat too much, there will be less space for the baby to grow Loss of appetite during pregnancy If women eat too much, they cannot work in the fields Elderly women did not want to get involved in family matters as young couples react defensively

Approach III

Community audit (single session); female baby; Raipur Murtimata Village

Delayed care seeking Malnourished/weak for qualified health mother care

Birth spacing

Delay in recognition of danger signs

ANC attendance

Delay in seeking qualified care Close birth order

Maternal nutrition

Speak about personal experiences, whether positive or negative, with the community

Deeply embedded cultural beliefs in, and fear of, supernatural forces

Strong belief in traditional healers

Keep the baby clean at all times

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Table 1 Continued Approach

Community’s perception of cause of death

Identified preventable factors

Proposed solutions

Plans to implement solutions

Identified constraints to implementation

Ensure good maternal nutrition

Learn how to cut the cord

Domin has limited access to transportation, especially after sunset

Approach qualified practitioner if mother is sick during pregnancy

Ensure speedy arrival of the domin

Other community members will look down upon them for cutting the cord, as it is unclean and therefore the job of only the lower caste domin Vernix is unclean and baby may get a rash if not washed with soap and water

Use a new and boiled blade to cut the cord Keep the baby warm Seek care from a qualified practitioner

Community audit (single session); male baby Padariya Village

Baby was born small Improper medical treatment for the mother and the body was during pregnancy cold to the touch (hypothermia) Delayed arrival of the domin

Attend ANC Baby lay in the ‘soop’ (rice cleaning device made of straw), inadequately wrapped for several hours Bathing of the baby even Cut the cord in case of when the body felt cold delayed arrival of the to the touch domin Delay bathing Immediate wrapping Keep baby in close contact with the caretaker

Hold a community meeting with the domin to reassure her of the need of her other services, that is, clean the delivery room, and disposal of the placenta Wipe the baby with a clean damp cloth instead of bathing

Abbreviation: ANC, antenatal care.

the family and community experiences on one hand, and the need to overcome the loss and minimize feelings of guilt or ineptitude on the other. Feasibility and acceptability of death audit All three approaches to the death audit process produced rich discussion and contributions from participants. Each approach demonstrated that newborn death audits within the rural community of Shivgarh were acceptable, as evidenced by the number of willing participants, their level of involvement, ensuing dialog and potential strategies conceived for improving survival of future newborns in the community. Discussions during the audit process on the vulnerability of newborns in contrast to that of adults, and on factors and practices that unintentionally increase the risk of death, induced active participation and dialog and led to initial dismay at their lack of awareness of critical aspects of newborn care. The participants themselves identified the imperative Journal of Perinatology

for ‘new knowledge’ and constant and continuous care for the newborn, which incorporates the ‘new knowledge’. Establishing rapport was observed to be a necessary precursor to conducting a participatory community death audit in all three approaches. Enquiry by facilitators on agriculture and current topics of the day was very useful in creating the necessary environment to encourage discussion of the issue of newborn death. It was also observed that composition of the groups in terms of caste, gender, age, inter-personal relationships, previous experience of living in the city and level of education influenced the participatory process. In Jodhawarkheda village, the participants were comfortable discussing the death of a newborn whose family was not at the meeting, or a death that had occurred many years ago, but were wary to discuss the recent death of a newborn in a family present at the meeting. This was attributed to the strained relations of the immediate family of the newborn with the extended family, which made the participants

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uncomfortable to discuss or comment on the events surrounding the death. Approach I (family audit followed by community audit) led to greater participation and acceptance of the process by the family, and facilitated the death audit process with the community. Here, the family seemed better prepared for the discussion as compared to Approach III (community audit) where the audit was conducted in a single meeting without previous discussion with the family. While Approach III was potentially less time-consuming, the need for a skilled facilitator, good group dynamics and presence of a key participant (that is, educated/experienced community member who may have lived in a bigger town or city, or a local health worker) was heightened. It was observed that the degree of involvement of community members was a function of the willingness of the family of the deceased newborn to enter into the dialog themselves. The community members seemed to sense when the family members were comfortable and open to discussing the death, and thus felt they had permission to express their own thoughts and opinions more freely. An ideal size for a death audit meeting that facilitated maximum participation and helped maintain a level of comfort among the participants ranged between 8 and 10 people. The average duration of a constructive FGD was between 1 and 1.5 h. Identification of avoidable factors and solutions Table 1 gives a description of results of FGDs, including the cause of death as perceived by the participants, their recognition of avoidable factors, proposed solutions, plans to implement solutions and identification of constraints to implementation. During FGDs, once the family members or caretakers described the events leading up to the death of the neonate, other participants were able to suggest possible causes of death and identify preventable factors leading to the death. As a by-product of the exercise of recalling the sequence of events leading to the death of the neonate and the support and contribution of key participants, community members entered spontaneously into a process of identifying the main components of maternal and essential newborn care which they had learned through the parent trial or had prior knowledge of, including the need for regular attendance at antenatal care, good maternal nutrition, birth spacing, warmth for the baby immediately after birth, delayed bathing, immediate and hygienic cutting of the cord and skilled attendance at birth. Cultural beliefs, economic constraints and limited access to qualified health care were identified as major constraints. Throughout this process, no differences in recollection, or variation in participant enthusiasm were found, based on the gender of the deceased neonate. When asked about cultural beliefs, key participants explained that the community had followed certain traditions for generations and individual members of the community were reluctant to venture away from time-tested practices that they perceived had served them reasonably well. As noted in Table 1, participants of

the FGD in Padariya, due to community support, were willing to discuss possible ways to overcome the constraint of cultural traditions. The family identified that one of the factors leading to the death of the neonate was the delayed cutting of the cord and inadequate wrapping of the baby. The cause of this was determined to be the late arrival of the domin (lady belonging to the lower caste who has the job of cutting the cord and cleaning the baby and the mother after delivery). The proposed solution was to hold a community meeting with the domin to discuss the problems arising due to her late arrival after delivery, and the possibility of the family members cutting the cord in case of late arrival. The domin would also be ensured of the need for her other services and the receipt of compensation for them. Once it was recognized that the community would not look down upon the family for cutting the cord, the participants felt that the proposed solution was more feasible. The presence of key participants greatly facilitated and catalyzed the process of identifying avoidable factors leading to the death of the neonate and the discussion of possible solutions. FGDs in Raipur Murtimata, Aimapur and Padariya were more constructive in terms of better identification of avoidable factors and possible solutions as compared to the FGD held in Jodhawarkheda. Other than strained family and social relations in Jodhawarkheda, one of the important reasons for this appeared to be the lack of presence of key participants in the FGD held there (Table 1). In all approaches, the male/female mix proved to be an enriching exercise for all participants. Older male members of the family, like the father-in-law or the deceased neonate’s uncle, took great interest in this process. It was noted that, traditionally, male members were not allowed into the delivery room, and were only consulted after the women in the household recognized there was a health issue needing external or professional help. However, based upon their responses, older male members were found to have considerable knowledge about maternal and neonatal danger signs and expressed the immediate need to seek health care, outside the home, for the mother and/or the sick neonate upon presentation of the signs. They were found to offer actively possible suggestions and solutions to various issues that were being brought up by the women. Thus, new solutions were entertained. Reflections on the audit process in follow-up Follow-up visits with the families of the deceased neonates were conducted to further understand community reaction to and acceptance of the audit process. Although, the process of discussing avoidable factors and possible solutions was well accepted, in situations where resources are limited and conditions difficult, targeting of negative aspects without offering concrete support for implementation of recommended solutions was found to be discouraging and overwhelming. However, participants expressed their willingness to initiate, along with the support of local health Journal of Perinatology

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providers, a problem-solving cycle, ultimately leading to a community wide effort to implement and monitor proposed solutions. A critical finding was the necessity to emphasize that even though one particular neonate was the topic of discussion, the problem of neonatal mortality due to avoidable factors is a common issue applicable to the community at large, and not just limited to any one family. Discussion Community death audit, when implemented as a participatory process, can bring about awareness of factors leading to newborn death, provoke review of current practices and potentially stimulate and empower the community for collective action. Of the three approaches evaluated, no single approach could be identified as optimal, although Approach I (family audit followed by community audit) and Approach II (community preaudit followed by community audit) appeared more promising than Approach III (community audit). Each group was unique and varied in terms of social composition, age, gender, caste, education and level of ease in discussing personal matters in public. If the group is considerably heterogeneous with respect to the above-mentioned characteristics, initial rapport-building would take longer and Approach I or II would then be preferred to Approach III. All approaches had the universal appeal of provoking formal investigation by community members, and by stimulating the sharing of views and concerns, leading to the self-discovery that community perception was a cumulatively amplified effect of individual perceptions. Each approach demonstrated that positive feedback and discussion among community members could foster a learning environment leading to mobilization of the community around the newborn and improved survival through better appreciation of the need for antenatal care, improved birth preparedness, essential maternal and newborn care practices, and appropriate care-seeking. In this way, the audit process served to reinforce the behavior changes promoted by the parent project. Conducting audits that identify both adverse and favorable events, may allow existing strengths in the provision of care to be noted, thereby boosting morale, acknowledging good care and alleviating anxiety and possible defensiveness, while also identifying areas for further improvement. A constant and crucial factor in all the approaches to death audit was the need to include a key participant from within the community to act as a catalyst in speeding up the audit process. The ideal key participant could be an articulate member of the family of the deceased newborn or an educated/experienced member from within the community. Unlike audits in medical facilities that are conducted in relatively more controlled settings, the community death audit did not involve trained medical personnel. Thus, the need for a key participant becomes more Journal of Perinatology

pronounced in community settings. Community health care service providers like the Dai (traditional birth attendant), and the Domin (lower caste woman who traditionally cuts the umbilical cord of the neonate and disposes of the placenta) and local government health care workers like the Auxiliary Nurse Midwife (ANM) and the Aanganwadi Worker (AWW), were intentionally excluded from this process. It was anticipated from previous formative work performed in the area that Dais, Domins, ANMs and AWWs could be viewed negatively by community members as not appropriately fulfilling their expected roles (Table 1). Physical presence of the workers may have inhibited the expression of such concerns by community members. Findings from the study corroborated this. In the future, however, following the initial meetings with family and community members, engagement of these workers could help to generate additional solutions to avoiding neonatal deaths, and for many proposed activities, would require their active participation. Although the neonatal mortality rate in rural Uttar Pradesh is high (56.6 per 1000 live births),9 opportunities for conducting a neonatal death audit appear limited when the number of deaths in a hamlet is one in two years. The large time interval between newborn death events in a given hamlet may presumably affect the efficiency and likely impact of community death audit. This limitation could, however, be utilized to an advantage if community death audit is viewed as the first phase in the process, followed by community neonatal morbidity audit (near misses), and subsequently community newborn health care practices audit. The death audit can set the stage for provoking a dialog, review of risk factors, development of strategies, recommendations for improved practices and call for collective action to prevent subsequent deaths. This could be followed by community morbidity audit that presents more opportunities for discussion and allows more chances for more hamlets and villages to review the recommendations made during community death audits and deliberate on their own cases of moderately to severely sick newborns. This may be particularly advantageous in communities such as Jodarwarkheda, where, for example, strained social relations render discussion of a newborn death too stressful and potentially explosive; in this instance, given the more common occurrence of neonatal morbidity, it may be feasible to identify and discuss a case of neonatal morbidity, thus allowing the audit process to proceed. This phase of morbidity audits could then be followed by regular community newborn health audits that review recommendations made in light of newborn deaths and illnesses, and proposes preventive practices that promote the health of newborns as well as appropriate management of sick newborns. Here, home-based newborn care practices can be reviewed and their advantages or possible harmful consequences discussed, and culturally appropriate options can be put forth in a collective and all-inclusive manner. Resulting from this exercise, there could be a higher uptake of evidence-based newborn home care practices,

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which have community approval and sanction, by individual families. Discussions on delayed cord cutting and its harmful consequences for neonates were reviewed in Padariya where the community was collectively willing to deviate from cultural norms and adopt practices that would lead to better outcomes for their neonates. Thus, the process of participatory audit has the advantage of translating every event of death and sickness into an opportunity to share, learn, explore and act. To reduce neonatal deaths, medical as well as social barriers need to be recognized. There is often a gap between knowledge, risk awareness and actual behavior. Care seeking for newborns is based on a series of decisions resulting in utilization or non-utilization of healthcare services.10,11 Early recognition, followed by prompt and appropriate treatment for neonatal morbidities, is a key to saving newborn lives.12 However, this requires an in-depth understanding of community care seeking practices: how care givers recognize and respond to neonatal illness symptoms, what factors shape their healthcare-seeking behavior and how they choose among available treatment options. Furthermore, the decision process is deeply affected by tradition, culture, religion, socio-economic environment and household demographic characteristics.11,13,14 Sound behavioral research on the health care seeking patterns of the community can provide this information, and aid the development of educational messages that encourage evidence-based care practices, proven to improve newborn health and survival, while discouraging potentially harmful behaviors at the community level. The community death audit can prove to be a powerful tool that utilizes real life situations to address existing barriers through community participation, self-recognition of avoidable risks and audit and reinforcement of improved practices by the community, thus, producing sustainable and culturally acceptable changes. It has been shown that large reductions (up to 50%) in neonatal mortality can be achieved through outreach and familycommunity care, and health education to improve home-based practices, danger sign recognition and health care-seeking behaviors.15–17 In South Africa, it was demonstrated that incorporating a system of identifying, classifying and grading avoidable factors into PNDA enabled the detection of problem areas that could be improved quickly at very low cost.18 Death audits carried out in a culturally sensitive, supportive and non-punitive manner can emphasize support for learning and change. Further analysis is needed, as audits may not always have a positive effect on participants’ attitudes and behavior. It may be perceived as threatening and the critical analysis necessary for constructive case reviews may lead to deterioration in relationships among family and community members. This study was a preliminary exploration of the general feasibility, primary requisites for implementation and the possible scope of community neonatal death audits as a potential community mobilization tool. This study has shown that for the audit to be a success, the participants must have a sense of control and ownership of the

process. Moreover, they must be engaged in an action cycle that leads to constructive use of the information and implementation and monitoring of success of changes in family and community behaviors. Further evaluation of the community audit process should include a range of outcomes, including the impact of the audits on the knowledge and attitudes of the participants, improvements in specific maternal and neonatal health care practices and change in health care seeking behavior for the neonate. Additionally, identification of the appropriate cadre of community based workers, training requirements, appropriate feedback mechanisms and strategies to enhance community processes, based on proposed solutions need to be explored.

Acknowledgments We are grateful to the families and community members in Shivgarh for their willing participation, and to the members of the field team of the parent study in Shivgarh whose experience and dedication made this study possible. This work was supported by, the Office of Health, Infectious Diseases and Nutrition, Global Health Bureau, United States Agency for International Development (USAID) under the terms of Award GHS-A-00-03-00019-00, Global Research Activity Cooperative Agreement; the USAID India (New Delhi) Mission; and the Saving Newborn Lives initiative of Save the Children-US, through a grant from the Bill and Melinda Gates Foundation.

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Supplementary Information accompanies the paper on the Journal of Perinatology website (http://www.nature.com/jp)

Journal of Perinatology

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