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The Lancet
The
Lancet, Volume
375, Issue 9721, Pages 1142 - 1144, 3 April 2010
EMPOWERING COMMUNITIES FOR MATERNAL
& NEWBORN HEALTH
Maternal
and child deaths represent two of the most resilient targets among the
Millennium Development Goals (MDGs).1
At current trends, a large proportion of the high-burden countries will be
unable to meet reduction targets by 2015.2
Achieving the MDG 4 target of reducing newborn and child mortality will require
concerted efforts to scale up evidence-based interventions, especially community-based
preventive and therapeutic strategies in primary care.3 To improve maternal survival, we
need to scale up facility-based services,4
as well as availability of commodities and health workers in primary care.5
A major challenge is the appropriate mix of strategies for demand creation as
well as provision of services.
In The
Lancet today, investigators led by Anthony Costello present contrasting
findings from two large studies of community-based women's support groups in
rural Bangladesh6
and in two rural areas in India (Jharkhand and Orissa),7
and their effects on maternal and newborn health outcomes. The intervention did
not have much effect in rural Bangladesh, where only 2% coverage of newly
pregnant women being enrolled into the women's groups was achieved, which
raises the question of ineffective implementation of this intervention. By
contrast, in Jharkhand and Orissa, the intervention was more successful, with
55% of all pregnant women joining women's support groups by year 3 of the study
and a 32% reduction in neonatal mortality rate. The latter finding is consistent
with the finding of reduced neonatal mortality (adjusted odds ratio 0·70, 95%
CI 0·53—0·94) previously observed in rural Nepal.8 The investigators from today's
studies have also evaluated the role of community-support groups in rural
Malawi,9
although final results of the trial are not yet available.
Several
contextual factors must be underscored to understand these diverse results.
Unlike the situation in rural Bangladesh, most villages in rural Jharkhand and
Orissa had a lower proportion of births in the hands of birth attendants, and
cluster allocation took pre-existing local committees into account. Other
factors confounding the interpretation of these analyses include the post-hoc
exclusion of certain population segments, such as tea-garden residents, and the
assumption that training birth attendants in neonatal resuscitation could not
plausibly affect neonatal outcomes. A recent large multicounty study10
of training birth attendants in basic resuscitation was associated with a
statistically significant reduction in stillbirths, although these were
probably misclassified as very early neonatal deaths.
Several
other large-scale trials in south Asia have also evaluated the role of
community support and advocacy groups in combination with the delivery of
domiciliary preventive and therapeutic care through community health workers.11—13
Although the precise mechanisms of effect and direction of effect through such
interventions are unclear, there seems to be an effect on family awareness,
domiciliary care practices (such as the use of clean delivery kits),
breastfeeding practices, and care-seeking for newborn illnesses. We did a
pooled analysis of all recent randomised trials in which community-support
groups and group-advocacy sessions that targeted women were used as part of the
intervention. As is evident, these strategies are associated with significant
reduction in neonatal mortality rate and a range of benefits on domiciliary
practices, such as early initiation of breastfeeding and a fairly strong suggestion
that care seeking for illness improved (figure).
There might also be benefits of such interventions on female empowerment and
family relationships, but these outcomes are difficult to objectively evaluate
in such settings.
Figure
Full-size image (53K) Download
to PowerPoint
Although
the benefits of community-support strategies on neonatal outcomes are well
established,3
benefits on maternal morbidity and mortality are less clear. None of the recent
studies of community strategies were powered for maternal mortality outcomes
but at least one8
indicated benefits. Today's Jharkhand and Orissa trial also indicates the same
direction of effect and suggests that such women's groups also promote maternal
uptake of antenatal care and care-seeking for effective care during childbirth
and complications. In a trial in Hala, Pakistan,12 which used community
mobilisation through group sessions as well as domiciliary visits by community
health workers, significantly increased rates of skilled birth attendance and
facility-based care were observed during the pilot phase,12
as well as in the scaled-up effectiveness trial.
These
recent studies greatly add to the global evidence base of intervention and
delivery strategies that might improve maternal and newborn outcomes. Although
improved maternal emergency obstetric care and health-system interventions to
improve access and quality of care remain crucial to improving maternal
survival,14 future strategies to improve
maternal and newborn survival need to integrate community-based strategies and
facility-based care. The deployment of women's groups or community-support
groups through trained community health workers offers a cost-effective
mechanism for reaching populations at risk and linking appropriate domiciliary
and care-seeking practices. These strategies also offer a unique opportunity to
move beyond survival. As the evidence from Jharkhand and Orissa and rural
Pakistan14
indicates, such interventions also have great potential to improve maternal
mental health outcomes, reduce rates of postnatal depression, and improve
household practices for maternal and newborn care.
We
declare that we have no conflicts of interest.
1
UN Secretary-General. The
Millennium Development Goals Report 2009. http://www.unhcr.org/refworld/docid/4a534f722.html.
(accessed Feb 21, 2010).
2
Countdown Coverage Writing Group. Countdown to
2015 for maternal, newborn, and child survival: the 2008 report on tracking
coverage of interventions. Lancet 2008; 371: 1247-1258. Summary | Full
Text | PDF(488KB) | CrossRef | PubMed
3
BhuttaZAAliSCousensS. Interventions
to address maternal, newborn, and child survival: what difference can
integrated primary health care strategies make?. Lancet 2008; 372: 972-989. Summary | Full
Text | PDF(340KB) | CrossRef | PubMed
4
CampbellOMGrahamWJon behalf
of The Lancet Maternal Survival Series steering group. Strategies
for reducing maternal mortality: getting on with what works. Lancet 2006; 368: 1284-1299. Summary | Full
Text | PDF(296KB) | CrossRef | PubMed
5
PagelCLewyckaSColbournT. Estimation of
potential effects of improved community-based drug provision, to augment
health-facility strengthening, on maternal mortality due to post-partum
haemorrhage and sepsis in sub-Saharan Africa: an equity-effectiveness model.
Lancet 2009; 374: 1441-1448. Summary | Full
Text | PDF(183KB) | CrossRef | PubMed
6
AzadKBarnettSBanerjeeB. Effect of
scaling up women's groups on birth outcomes in three rural districts in
Bangladesh: a cluster-randomised controlled trial. Lancet 2010; 375: 1193-1202. Summary | Full
Text | PDF(276KB) | PubMed
7
TripathyPNairNBarnettS. Effect of a
participatory intervention with women's groups on birth outcomes and maternal
depression in Jharkhand and Orissa, India: a cluster-randomised controlled
trial. Lancet 2010; 375: 1182-1192. Summary | Full
Text | PDF(914KB) | PubMed
8
ManandharDSOsrinDShresthaBPand members of the MIRA Makwanpur trial team. Effect of
participatory intervention with women's groups on birth outcomes in Nepal:
cluster-randomised controlled trial. Lancet 2004; 364: 970-979. Summary | Full
Text | PDF(465KB) | CrossRef | PubMed
9
RosatoMMwansamboCWKazembePN. Women's
groups' perceptions of maternal health issues in rural Malawi. Lancet 2006; 368: 1180-1188. Summary | Full
Text | PDF(169KB) | CrossRef | PubMed
10
CarloWAGoudarSSJehanIthe First
Breath Study Group. Newborn-care training and perinatal mortality in
developing countries. N Engl J Med 2010; 362: 614-623. CrossRef | PubMed
11
KumarVMohantySKumarAfor the Saksham Study Group. Effect of
community-based behaviour change management on neonatal mortality in Shivgarh,
Uttar Pradesh, India: a cluster-randomised controlled trial. Lancet 2008; 372: 1151-1162. Summary | Full
Text | PDF(186KB) | CrossRef | PubMed
12
BhuttaZAMemonZASoofiSSalatMSCousensSMartinesJ. Implementing community-based perinatal care: results
from a pilot study in rural Pakistan. Bull
World Health Organ 2008; 86: 452-459. PubMed
13
BaquiAHEl-ArifeenSDarmstadtGLfor the Projahnmo Study Group. Effect of
community-based newborn-care intervention package implemented through two
service-delivery strategies in Sylhet district, Bangladesh: a
cluster-randomised controlled trial. Lancet 2008; 371: 1936-1944. Summary | Full
Text | PDF(307KB) | CrossRef | PubMed
a Women and
Child Health Division, Aga Khan University, Karachi 74800, Pakistan
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