Home visits versus fixed-site care by community health workers and child survival: a cluster-randomized trial, Mali

Abstract

Objective To test the effect of proactive home visits by trained community health workers (CHWs) on child survival. Methods We conducted a two arm, parallel, unmasked cluster-randomized trial in 137 village-clusters in rural Mali. From February 2017 to January 2020, 31 761 children enrolled at the trial start or at birth. Village-clusters received either primary care services by CHWs providing regular home visits (intervention) or by CHWs providing care at a fixed site (control). In both arms, user fees were removed and primary health centres received staffing and infrastructure improvements before trial start. Using lifetime birth histories from women aged 15–49 years surveyed annually, we estimated incidence rate ratios (IRR) for intention-to-treat and per-protocol effects on under-five mortality using Poisson regression models. Findings Over three years, we observed 52 970 person-years (27 332 in intervention arm; 25 638 in control arm). During the trial, 909 children in the intervention arm and 827 children in the control arm died. The under-five mortality rate declined from 142.8 (95% CI: 133.3–152.9) to 56.7 (95% CI: 48.5–66.4) deaths per 1000 live births in the intervention arm; and from 154.3 (95% CI: 144.3–164.9) to 54.9 (95% CI: 45.2–64.5) deaths per 1000 live births in the control arm. Intention-to-treat (IRR: 1.02; 95% CI: 0.88–1.19) and per-protocol estimates (IRR: 1.01; 95% CI: 0.87–1.18) showed no difference between study arms. Conclusion Though proactive home visits did not reduce under-five mortality, system-strengthening measures may have contributed to the decline in under-five mortality in both arms.