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Can community-based intervention packages reduce maternal and neonatal morbidity and mortality?

In the last three decades, rates of neonatal mortality in low-income countries have declined much more slowly than the rates of infant and maternal mortality. A significant proportion of these deaths could potentially be addressed by community-based intervention packages, which are defined as delivering more than one intervention via different sets of strategies that include additional training of outreach workers, building community-support, community mobilization, antenatal and postnatal home visitation, training of traditional birth attendants, antenatal and delivery home visitation, and home-based neonatal care and treatment; usually supplemented by strengthening linkages with local health systems.

Key messages

Community mobilisation and antenatal and postnatal home visitation decreases neonatal mortality.

The following community-based intervention packages probably reduce neonatal mortality:

 

  • Community-support groups or women’s groups
  • Community mobilisation and home-based neonatal treatment

The following community-based intervention packages may reduce neonatal mortality:

 

  • Training traditional birth attendants who make antenatal and intrapartum home visits
  • Home-based neonatal care and treatment
  • Education of mothers and antenatal and postnatal visitation

The following community-based intervention packages may reduce maternal mortality:

 

  • Community mobilisation and antenatal and postnatal home visitation
  • Community-support groups or women’s groups
  • Community mobilisation and home-based neonatal treatment
  • Training traditional birth attendants who make antenatal and intrapartum home visits

 

Background

Maternal and neonatal mortality remain high in low-income countries. Strategies to improve maternal and newborn survival include a variety of community-based intervention packages that can have multiple components, including:

• Additional training of outreach workers

• Building community support

• Community mobilization

• Antenatal and intrapartum home visitation

• Home-based care

 

Additional training of outreach workers can include training of lay health workers, traditional birth attendants, or community midwives in maternal care during pregnancy, delivery and the postpartum period, and routine newborn care. Training sessions can comprise lectures, supervised hands-on training in a healthcare facility or within the community.



About the systematic review underlying this summary

Review objectives: To assess the effectiveness of community-based intervention packages in reducing maternal and neonatal morbidity and mortality
Type of What the review authors searched for What the review authors found
Study designs & interventions Randomised or nonrandomised trials evaluating the effectiveness of community-based intervention packages in reducing maternal and neonatal mortality
24 randomised and 2 nonrandomised trials of intervention packages, including mainly: building community-support or women’s groups (9 studies), community mobilisation and antenatal and postnatal home visitation (7), community mobilisation and home-based neonatal treatment (1), training traditional birth attendants who made antenatal and intrapartum home visits (2), home-based neonatal care and treatment (2), and education of mothers and antenatal and postnatal visitation (2)
Participants Women of reproductive age, pregnant women at any period of gestation
Women of reproductive age, newborns and other family members, support groups, traditional birth attendants, community health workers, and midwives
Settings Communities
Bangladesh (6 studies), India (6), Pakistan (4), Malawi (2), Tanzania (1), Ghana (1), Nepal (1), Zambia (1), China (1), South Africa (1), Vietnam (1), and Greece (1)
Outcomes Primary: maternal mortality, neonatal mortality, early neonatal mortality, and late neonatal mortality. Secondary outcomes included: perinatal mortality, stillbirths, measures of morbidity, quality of care, and institutional deliveries
Maternal mortality (11 studies), neonatal mortality (21), early (11) and late (11) neonatal mortality, perinatal mortality (17), stillbirths (15), institutional deliveries (16), and measures of morbidity, and quality of care
Date of most recent search: May 2014
Limitations: This is a well-conducted systematic review with only minor limitations.

Lassi ZS, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD007754. DOI.

Summary of findings

Sixteen of the 26 included studies were conducted in low and middle-income countries.

1) Intervention packages consisting mainly of building community-support or women’s groups

Interventions consisted of monthly meetings of mothers’ groups to identify maternal and neonatal health problems, prioritization of problems and implementation and monitoring strategies. Some also implemented a participatory learning cycle, where they identified and prioritised maternal and newborn health problems in their community, selected relevant strategies to address these problems, implemented the strategies, and evaluated the results.

 

  • Community-support groups or women’s groups probably decrease neonatal mortality. The certainty of this evidence is moderate.
  • Community-support groups or women’s groups may decrease maternal mortality. The certainty of this evidence is low.

 

Intervention packages consisting mainly of building community-support groups or women’s groups

People             Pregnant women at any period of gestation

Settings           Communities in low and middle-income countries

Intervention    Building community-support groups or women’s groups

Comparison     Usual maternal and newborn care services provided by local government and non-government facilities

Outcomes

Absolute effect*

Relative effect

(95% CI)

Certainty

of the evidence

(GRADE)

Without
support or women’s groups

With
support or women’s groups

Difference

(Margin of error)

Maternal mortality

239 

per 100 000

198 

per 100 000

RR 0.84

(0.56 to 1.22)

Low

Difference: 41 fewer deaths per 100 000 live births

(Margin of error: 105 fewer to 53 more)

Neonatal mortality

28

per 1000

24

per 1000

RR 0.84

(0.73 to 0.96)

Moderate

Difference: 4 fewer deaths per 1000 newborns

(Margin of error: 8 to 1 fewer)

Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page)

* The risk WITHOUT the intervention is based on maternal mortality rate for developing countries in 2015 ( http://www.who.int/mediacentre/factsheets/fs348/en/ ), neonatal mortality rate for Africa in 2015 ( http://apps.who.int/gho/data/node.wrapper.MORT-1?lang=en&menu=hide ). The corresponding risk WITH the intervention (and the 95% confidence interval for the difference) is based on the overall relative effect (and its 95% confidence interval).

 

2) Intervention packages consisting mainly of community mobilisation and antenatal and postnatal home visitation

These interventions included home visits and promotion of antenatal care, iron and folate use during pregnancy, immediate newborn care, promotion of exclusive breastfeeding, promotion of maternal nutrition and rest, recognition of danger signs and lay health worker visits to pregnant women during pregnancy and in the postnatal month.

 

  • Community mobilisation and antenatal and postnatal home visitation decreases neonatal mortality. The certainty of this evidence is high.
  • Community mobilisation and antenatal and postnatal home visitation may decrease maternal mortality. The certainty of this evidence is low.

 

Intervention package consisting mainly of community mobilisation and antenatal and postnatal home visitation

People             Pregnant women at any period of gestation

Settings           Low and middle-income countries

Intervention    Building community-support or women’s groups

Comparison     Usual maternal and newborn care services provided by local government and non-government facilities

Outcomes

Absolute effect*

Relative effect

(95% CI)

Certainty

of the evidence

(GRADE)

Without
mobilisation & visitation

With
mobilisation & visitation

Difference

(Margin of error)

Maternal mortality

239

per 100 000

172

per 100 000

RR 0.72

(0.49 to 1.06)

Low

Difference: 67 fewer deaths per 100 000 live births

(Margin of error: 122 fewer to 14 more)

Neonatal mortality

28

per 1000

17

per 1000

RR 0.60

(0.49 to 0.72)

High

Difference: 11 fewer deaths per 1000 newborns

(Margin of error: 14 to 8 fewer)

Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page)

* The risk WITHOUT the intervention is based on maternal mortality rate for developing countries in 2015 ( http://www.who.int/mediacentre/factsheets/fs348/en/ ), neonatal mortality rate for Africa in 2015 ( http://apps.who.int/gho/data/node.wrapper.MORT-1?lang=en&menu=hide ). The corresponding risk WITH the intervention (and the 95% confidence interval for the difference) is based on the overall relative effect (and its 95% confidence interval).


3) Other community-based intervention packages

Other community-based intervention packages that were evaluated included training traditional birth attendants who made antenatal and intrapartum home visits (2 studies), home-based neonatal care and treatment (2 studies), education of mothers and antenatal and postnatal visitation (2 studies), and community mobilisation and home-based neonatal treatment (1 study).

  • Community mobilisation and home-based neonatal treatment probably reduces neonatal mortality. The certainty of this evidence is moderate.
  • Training traditional birth attendants who make antenatal and intrapartum home visits may decrease neonatal and maternal mortality. The certainty of this evidence is low.
  • Home-based neonatal care and treatment may decrease neonatal mortality. The certainty of this evidence is low.
  • Education of mothers and antenatal and postnatal visitation may decrease neonatal mortality. The certainty of this evidence is low.

 

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY

All but one of the studies were conducted in low- and middle-income countries.

The study populations included women in urban and rural areas with diverse socioeconomic conditions.


The effects of community-based intervention packages might vary in different low-income countries due to the availability of trained health professionals and health system infrastructure.
EQUITY
The review did not provide data about differential effects of the interventions in disadvantaged populations.

To the extent that community-based intervention packages are targeted at disadvantaged populations, they are likely to decrease inequities.

Community-based intervention packages might require more resources to implement in underserviced areas. Interventions that are targeted at populations with different levels of access to health services could increase inequities, if additional resources are not invested in underserviced areas.


ECONOMIC CONSIDERATIONS
The review did not provide data about costs.

Resources available for implementing the packages and training health workers, supervision and support need to be considered when assessing whether the interventions can be implemented.

Resources for increased use of healthcare resources also need to be considered, including resources for transportation, social services, human resources (time), and facility admissions.


MONITORING & EVALUATION

Although the certainty of the evidence is moderate to high for neonatal mortality for some community-based intervention packages, there is uncertainty about the effects for other important outcomes and for some intervention packages. There may also be uncertainty about the transferability of the findings to some settings.

 


Process measures (quality of care), outcomes and costs should be monitored if community-based intervention packages are implemented, due to uncertainty about the effects and costs of different packages across different settings.

Consideration should be given to conducting randomized trials and economic studies to evaluate the effects and cost-effectiveness of packages of interventions for which there is important uncertainty.


*Judgments made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgments were made see:
www.supportsummaries.org/methods


 

Additional information

Related literature

Sibley LM, Sipe TA, Barry D. Traditional birth attendant training for improving health behaviours and pregnancy outcomes. Cochrane Database of Systematic Reviews 2012; 8:CD005460.

 

Lewin S, Munabi-Babigumira S, Glenton C, et al. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database of Systematic Reviews 2010 Mar 17; 3:CD004015.

 

Bhutta ZA, Darmstadt GL, Haws RA, et al. Delivering interventions to reduce the global burden of stillbirths: improving service supply and community demand. BMC Pregnancy Childbirth 2009; 9 Suppl 1:S7.

 

This summary was prepared by

Natalia Zamorano and Cristian A. Herrera. Unit for Health Policy and Systems Research, Evidence Based Healthcare Program. Faculty of Medicine, Pontificia Universidad Católica de Chile. Santiago, Chile.

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Josh Vogel and Zohra Lassi.

SUPPORT collaborators:

The Cochrane Effective Practice and Organisation of Care Group (EPOC) is part of the Cochrane Collaboration.  The Norwegian EPOC satellite supports the production of Cochrane reviews relevant to health systems in low- and middle-income countries . www.epocoslo.cochrane.org

 

The Evidence-Informed Policy Network (EVIPNet) is an initiative to promote the use of health research in policymaking in low- and middle-income countries. www.evipnet.org

 

The Alliance for Health Policy and Systems Research (HPSR) is an international collaboration that promotes the generation and use of health policy and systems research in low- and middle-income countries. www.who.int/alliance-hpsr

 

Norad, the Norwegian Agency for Development Cooperation, supports the Norwegian EPOC satellite and the production of SUPPORT Summaries. www.norad.no

 

The Effective Health Care Research Consortium is an international partnership that prepares Cochrane reviews relevant to low-income countries. www.evidence4health.org

 

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This review should be cited as

Lassi ZS, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD007754. DOI.

 

The summary should be cited as

Zamorano N, Herrera CA. Can community-based intervention packages reduce maternal and neonatal morbidity and mortality? A SUPPORT Summary of a systematic review. January 2017. www.supportsummaries.org

 

Keywords

evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care, maternal mortality, neonatal mortality, perinatal mortality, stillbirths, community-based interventions



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