***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Various community-based interventions have been proposed to improve maternity care , but hardly any studies have reported the effect of these measures on maternal mortality . In this study , the efficacy of a maternity-care programme to reduce  maternal mortality has been evaluated in the context of a primary health-care project in rural Bangladesh .  Trained midwives were posted in villages , and asked to attend as many home-deliveries as possible , detect and manage obstetric complications at onset , and accompany patients requiring referral for higher-level care to the project central maternity clinic . The effect of the programme was evaluated by comparison of direct obstetric maternal mortality ratios between the programme area and a neighbouring control area  without midwives . R and om assignment of the intervention was not possible but potentially confounding characteristics , including coverage and use of other health and family planning services , were similar in both areas . Maternal mortality ratios due to obstetric complications were similar in both areas during the 3 years preceding the start of the programme . By contrast , during the following 3 years , the ratio was significantly lower in the programme than in the control area ( 1.4 vs 3.8 per 1000 live births , p = 0.02 ) . The findings suggest that maternal survival can be improved by the posting of midwives at village level , if they are given proper training , means , supervision , and back-up . The inputs for such a programme to succeed and the constraints of its replication on a large scale should not be underestimated BACKGROUND Neonatal deaths in developing countries make the largest contribution to global mortality in children younger than 5 years . 90 % of deliveries in the poorest quintile of households happen at home . We postulated that a community-based participatory intervention could significantly reduce neonatal mortality rates . METHODS We pair-matched 42 geopolitical clusters in Makwanpur district , Nepal , selected 12 pairs r and omly , and r and omly assigned one of each pair to intervention or control . In each intervention cluster ( average population 7000 ) , a female facilitator convened nine women 's group meetings every month . The facilitator supported groups through an action-learning cycle in which they identified local perinatal problems and formulated strategies to address them . We monitored birth outcomes in a cohort of 28?931 women , of whom 8 % joined the groups . The primary outcome was neonatal mortality rate . Other outcomes included stillbirths and maternal deaths , uptake of antenatal and delivery services , home care practice s , infant morbidity , and health-care seeking . Analysis was by intention to treat . The study is registered as an International St and ard R and omised Controlled Trial , number IS RCT N31137309 . FINDINGS From 2001 to 2003 , the neonatal mortality rate was 26.2 per 1000 ( 76 deaths per 2899 livebirths ) in intervention clusters compared with 36.9 per 1000 ( 119 deaths per 3226 livebirths ) in controls ( adjusted odds ratio 0.70 [ 95 % CI 0.53 - 0.94 ] ) . Stillbirth rates were similar in both groups . The maternal mortality ratio was 69 per 100000 ( two deaths per 2899 livebirths ) in intervention clusters compared with 341 per 100000 ( 11 deaths per 3226 livebirths ) in control clusters ( 0.22 [ 0.05 - 0.90 ] ) . Women in intervention clusters were more likely to have antenatal care , institutional delivery , trained birth attendance , and hygienic care than were controls . INTERPRETATION Birth outcomes in a poor rural population improved greatly through a low cost , potentially sustainable and scalable , participatory intervention with women 's groups OBJECTIVES In their efforts to reduce maternal and neonatal morbidity and mortality , many national and international agencies make considerable investments in training traditional birth attendants ( TBAs ) . The value of TBA training is controversial , and plausible arguments are made both for and against . Numerous process evaluations are reported in the literature and the results are mixed , though generally positive . Outcome evaluations , however , are scarce . This article describes an outcome evaluation of  TBA training conducted in two districts of Brong-Ahafo Region , Ghana , during 1996 . DESIGN AND METHODS Data from a r and om sample survey of 1961 clients of TBAs were subjected to logistic regression modelling to determine the effect of training on maternal outcomes , controlling for other independent variables . RESULTS Of eight outcomes modelled , three were associated with training and five were not . Three additional outcomes were not modelled , primarily due to low prevalence . CONCLUSIONS Despite some inherent design limitations , this study found that the evidence for a beneficial impact of TBA training was not compelling . Training sponsors should consider alternative health investments and , where TBA training remains the intervention of choice , be realistic about expectations of impact 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-r and omized 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 . Assessment s of newborns by CHWs at home were linked to hospital-based assessment s 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 assessment s 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 > or = 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 OBJECTIVE : We found a high burden of morbidities in a cohort of neonates observed in rural Gadchiroli , India . We hypothesised that interventions would reduce the incidence of neonatal morbidities , including the seasonal increase observed in many of them . This article reports the effect of home-based neonatal care on neonatal morbidities in the intervention arm of the field trial by comparing the early vs late periods , and the possible explanation for this effect . METHODS : During 3 years ( 1995 to 1998 ) ,  trained village-health-workers ( VHWs ) in 39 villages prospect ively collected data by making home visits during pregnancy , home-delivery and during neonatal period . We estimated the incidence and burden of neonatal morbidities over the 3 years from these data . In the first year , the VHWs made home visits only to observe . From the second year , they assisted mothers in neonatal care and managed the sick neonates at home . Health education of mothers and family members , individually and in group , was added in the third year . We measured the coverage of interventions over the 3 years and evaluated maternal knowledge and practice s on 21 indicators in the third year . The effect on 17 morbidities was estimated by comparing the incidence in the first year with the third year . RESULTS : The VHWs observed 763 neonates in the first year , 685 in the second and 913 in the third year . The change in the percent incidence of morbidities was ( i ) infections , from 61.6 to 27.5 ( −55 % ; p<0.001 ) , ( ii ) care-related morbidities ( asphyxia , hypothermia , feeding problems ) from 48.2 to 26.3 ( −45 % ; p<0.001 ) ; ( iii ) low birth weight from 41.9 to 35.2 ( −16 % ; p<0.05 ) ; ( iv ) preterm birth and congenital anomalies remained unchanged . The mean number of morbidities/100 neonates in the 3 years was 228 , 170 and 115 ( a reduction of 49.6 % ; p<0.001 ) . These reductions accompanied an increasing percent score of interventions during 3 years : 37.9 , 58.4 and 81.3 , thus showing a dose – response relationship . In the third year , the proportion of correct maternal knowledge was 78.7 % and behaviours was 69.7 % . The significant seasonal increase earlier observed in the incidence of five morbidities reduced in the third year . CONCLUSION : The home-based care and health education reduced the incidence and burden of neonatal morbidities by nearly half . The effect was broad , but was especially pronounced on infections , care-related morbidities and on the seasonal increase in morbidities BACKGROUND In rural India , most births take place in the home , where high-risk care practice s are common . We developed an intervention of behaviour change management , with a focus on prevention of hypothermia , aim ed at modifying practice s and reducing neonatal mortality . METHODS We did a cluster-r and omised controlled efficacy trial in Shivgarh , a rural area in Uttar Pradesh . 39 village administrative units ( population 104,123 ) were allocated to one of three groups : a control group , which received the usual services of governmental and non-governmental organisations in the area ; an intervention group , which received a preventive package of interventions for essential newborn care ( birth preparedness , clean delivery and cord care , thermal care [ including skin-to-skin care ] , breastfeeding promotion , and danger sign recognition ) ; or another intervention group , which received the package of essential newborn care plus use of a liquid crystal hypothermia indicator ( ThermoSpot ) . In the intervention clusters , community health workers delivered the packages via collective meetings and two antenatal and two postnatal household visitations . Outcome measures included changes in newborn-care practice s and neonatal mortality rate compared with the control group . Analysis was by intention to treat . This study is registered as International St and ard R and omised Control Trial , number NCT00198653 . FINDINGS Improvements in birth preparedness , hygienic delivery , thermal care ( including skin-to-skin care ) , umbilical cord care , skin care , and breastfeeding were seen in intervention arms . There was little change in care-seeking . Compared with controls , neonatal mortality rate was reduced by 54 % in the essential newborn-care intervention ( rate ratio 0.46 [ 95 % CI 0.35 - 0.60 ] , p<0.0001 ) and by 52 % in the essential newborn care plus ThermoSpot arm ( 0.48 [ 95 % CI 0.35 - 0.66 ] , p<0.0001 ) . INTERPRETATION A socioculturally context ualised , community-based intervention , targeted at high-risk newborn-care practice s , can lead to substantial behavioural modification and reduction in neonatal mortality . This approach can be applied to behaviour change along the continuum of care , harmonise vertical interventions , and build community capacity for sustained development . FUNDING USAID and Save the Children-US through a grant from the Bill & Melinda Gates Foundation This analysis identifies salient features of team management that were critical to the efficiency of program implementation and the effectiveness of behavior change management to promote essential newborn care practice s in Uttar Pradesh , India . In May 2003 , the Johns Hopkins Bloomberg School of Public Health and King George Medical University initiated a cluster-r and omized , controlled neonatal health research program . In less than 2 years , the trial demonstrated rapid adoption of several evidence -based newborn care practice s and a substantial reduction in neonatal mortality in intervention clusters . Existing literature involving research program management in re source -constrained areas of developing countries is limited and fails to provide models for team organization and empowerment . The neonatal research project examined in this paper developed a unique management strategy that provides an effective blueprint for future projects . Transferable learning points from the project include emphasizing a common vision , utilizing a live-in field site office , prioritizing character and potential in the hiring process , implementing a learning-by-doing training program , creating tiers of staff recognition , encouraging staff autonomy , ensuring a broad staff knowledge base to seamlessly h and le absences , and maintaining the flexibility to change partnerships or strategies OBJECTIVE : To assess the ability of midwives to interpret antenatal cards and partograms correctly following completion of the Maternal Care Manual of the Perinatal Education Programme . STUDY DESIGN : We conducted a prospect i ve , controlled trial in a study town and two control towns in the Eastern Cape Province of South Africa . All 93 midwives caring for pregnant women in the three towns were included in the study . Sample s were compared using the two-tailed Student ’s t-test . RESULTS : The marks achieved by the study group for questions from the antenatal card and the partogram improved by 33.0 % ( p < 0.001 ) and 17.5 % ( p = 0.001 ) , respectively . No changes were observed in the 
    Output:
    
Innovative community-based strategies combined with health systems strengthening may improve childbirth care for the rural poor , help reduce gross inequities in maternal and newborn survival and stillbirth rates , and provide an effective transition to higher coverage for facility births