K Afsana and J E Rohde raise several important issues of relevance to perinatal and newborn care in developing countries.
In many countries with rapid demographic transition and population shifts, the health situation in urban slums is alarming and neonatal mortality rates quite high.1
Not only are such slum populations outside the remit of health services, but people living therein suffer from a combination of poverty, social exclusion, and high rates of crime and drug abuse.2
Widespread fatalism and lack of female empowerment are important barriers towards care-seeking for maternal and neonatal problems. In the absence of stable public sector services, much of the care is in the hands of the private sector, much of it unregulated and informal.
There is growing interest in community-based delivery platforms for maternal and newborn care and the evidence base is growing in varied settings.3
Afsana and Rohde's observation that coordinated activities by BRAC volunteers and urban attendants led to a substantial increase in referrals for facility births is consistent with our findings from rural Sindh, and suggests that such health workers can break social barriers to effect change. Similar findings have also been reported from other cross-sectional assessments in urban slums in Bangladesh.4
Community health workers have considerable potential to address maternal and newborn care in such circumstances, and the reported findings of the Manoshi programme on maternal and fetal outcomes are encouraging. These are also plausible platforms on which to develop additional interventions to support families and children after birth.
Notwithstanding the above, to add to the global evidence base, such interventions must be implemented by means of plausible experimental designs and verified through robust independent assessment. Given the rapidity of secular and economic change, and the frequently complex nature of multiple interventions, caution must be exercised in interpreting findings from observational studies and attributing effects to specific inputs. Although well designed cluster randomised trials of urban newborn care are underway,5
a strong case can also be made for alternative designs such as step-wedge scale-up, which would still allow sound effect attribution.
Given the enormous contribution by BRAC to community-based health care in diverse settings, we would strongly encourage greater investment in community-based trials of innovative interventions and delivery strategies for scaling up maternal and newborn care.
We declare that we have no conflicts of interest.