Browsing by Author "GABIDA, Meggie"

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    Effect of Institutionalising Community Health System Vital Signs on Preventable Neonatal Deaths in Mashonaland West Province, Zimbabwe, 2020 - 2021: A Mixed Methods Approach
    (2026) GABIDA, Meggie
    Preventable neonatal mortality remains a critical public-health challenge in Zimbabwe despite relatively high coverage of antenatal care and facility-based childbirth. This study evaluated whether institutionalising three core “vital signs” of the community health system (i) a trained and supported Village Health Worker (VHW) workforce, (ii) functional community governance through Village Health Committees, and (iii) modified Women’s and Men’s Learning and Action (WLA/MLA) groups could reduce neonatal mortality in rural communities in Mashonaland West Province, Zimbabwe. An embedded quantitative–qualitative mixed-methods design was undertaken within a two-arm pragmatic cluster-randomised controlled trial comprising 52 ward-level clusters. Intervention clusters received an institutionalised package integrating the three community health-system vital signs, while control clusters continued standard Ministry of Health and Child Care community health service delivery. A total of 984 pregnant women were enrolled, with live-born infants followed through 28 days of life. The primary outcome was neonatal death from 0–28 days, used as the measurable outcome for preventable neonatal mortality. Deaths were identified through household surveillance and confirmed using verbal autopsy or facility records. The primary analysis followed the intention-to-treat principle and used a three-level mixed-effects log-binomial regression model, incorporating random intercepts for cluster and VHW catchment, to estimate adjusted risk ratios (ARRs) with 95% confidence intervals. A concurrent qualitative process evaluation, comprising in-depth interviews, focus group discussions and observation, explored implementation pathways and was analysed thematically before integration with the quantitative findings. Among 973 mother–infant pairs included in the analysis, 882 live births were recorded, including 446 in intervention clusters and 436 in control clusters. Neonatal mortality was 4.5% (20/446; 44.8 per 1,000 live births) in intervention clusters compared with 11.0% (48/436; 110.1 per 1,000 live births) in control clusters. The intervention package was associated with a substantially lower risk of neonatal death (ARR 0.43, 95% CI 0.26–0.70; p < 0.001), corresponding to a 57% relative reduction and a number needed to treat of 16 mother–infant pairs (95% CI 11–29). Low birthweight (<2,500 g) and lower levels of community women's literacy were the strongest baseline risk factors for neonatal death. Qualitative findings suggested that the intervention strengthened recognition of neonatal danger signs, timely care-seeking, referral and community-level support for maternal and newborn health. Institutionalising three community health-system vital signs as an integrated package was associated with a substantial reduction in neonatal mortality in rural Mashonaland West Province during 2020–2021. The findings provide experimental evidence that strengthening community health-system capacity, governance and participatory action concurrently can improve neonatal survival. Because the components were delivered as a combined intervention, the trial establishes the effect of the package rather than individual components; component-specific estimates are therefore adjusted associations. These findings support consideration of the integrated package within Zimbabwe’s National Community Health Strategy and comparable resource constrained rural settings. Interpretation is constrained by the 12-month follow-up period, relatively small number of neonatal deaths, disruption associated with the COVID-19 pandemic, potential contamination from concurrent national community-health programmes, and the single-province study setting, which may limit precision and external generalisability. Keywords: Neonatal mortality; Community health systems; Village Health Workers; Community governance; Mixed-methods research