Evaluation of a community intervention for promotion of safe motherhood in Eritrea

Introduction: We evaluated a community‐based intervention to promote safe motherhood, focusing on knowledge and behaviors that may reduce maternal mortality and birth complications. The intervention aimed to increase women's birth preparedness, knowledge of birth danger signs, use of antenatal care services, and birth at a health care facility. Methods: Volunteers from a remote rural community in Northern Eritrea were trained to lead participatory educational sessions on safe motherhood with women and men. The evaluation used a quasiexperimental design (nonequivalent group pretest‐posttest) including cross‐sectional surveys with postpartum women (pretest n = 466, posttest n = 378) in the intervention area and in a similar remote rural comparison area. Results: Women's knowledge of birth danger signs increased significantly in the intervention area but not in the comparison area. There was a significant increase in the proportion of women who had the recommended 4 or more antenatal care visits during pregnancy in the intervention area (from 18% to 80%, P < .001), although this proportion did not change significantly in the comparison area (from 53% to 47%, P= .194). There was a greater increase in birth in a health care facility in the intervention area. Discussion: Participatory sessions led by community volunteers can increase safe motherhood knowledge and encourage use of essential maternity services.     

Safe motherhood and newborn health: FIGO initiatives 2006-2010

Through international partnerships, FIGO has been delivering safe motherhood and newborn health (SMNH) projects in a number of low-income countries. The projects aim to achieve the objectives set out in the ICPD Programme of Action and the Millennium Development Goals 4 and 5, which are related to child survival and maternal mortality. Each project is developed in response to the needs of the intervention region and can be organized around the following themes: provision of maternal and newborn health care services to underserved and hard-to-reach areas; improvement and provision of quality basic emergency obstetric care; establishment of functional clinical and perinatal audits; development of new maternal and newborn health care protocols; community education and sensitization to women's rights in sexual and reproductive health; and reducing the risk of unsafe abortion.     

Reducing maternal mortality among Afghan refugees in Pakistan

Objective

The International Rescue Committee (IRC) strove to reduce maternal mortality among Afghan refugees in Hangu district of Pakistan by improving access to emergency obstetric care (EmOC), community knowledge of danger signs of pregnancy, and the use of health information.

Methods

IRC established EmOC centers, trained community members on safe motherhood, linked primary health care with education on danger signs of pregnancy and the importance of skilled attendance, and improved the health information system.

Results

The maternal mortality ratio among Afghan refugees in the area improved from 291 per 100 000 live births in 2000 to 102 per 100 000 live births in 2004. The proportion of refugee births attended by skilled staff increased from 5% in 1996 to 67% in 2007. Complete prenatal care coverage increased from 49% in 2000 to 90% in 2006, and postnatal coverage more than trebled from 27% in 2000 to 85% in 2006.

Conclusion

Improved services, community involvement and education, good coordination, and effective systems succeeded in reducing maternal mortality in a traditionally conservative environment.     

Community-driven impact of a newborn-focused behavioral intervention on maternal health in Shivgarh, India

ObjectiveTo assess the effect on maternal health outcomes of a community-based behavior change management intervention for essential newborn care leading to a reduction in neonatal mortality.MethodsA cluster-randomized controlled trial involving 1 control and 2 intervention arms was conducted in Shivgarh, India, between January 2004 and May 2005. Risk-enhancing domiciliary newborn care behaviors, including those posing a concomitant risk to maternal health, were targeted through home visits and community meetings. Secondary outcomes included knowledge of maternal danger signs, self-reported complications, maternal care practices, care-seeking from trained providers, and maternal mortality ratio (MMR). The intervention arms were combined for analysis, which was done by intention to treat.ResultsSignificant improvements were observed in maternal health equity and outcomes including knowledge of danger signs, care practices, self-reported complications, and timely care-seeking from trained providers. The difference in adjusted MMR was not significant (relative risk 0.44; 95% confidence interval, 0.14–1.43; P = 0.11) owing to the inadequate sample size for this outcome, but may suggest a decline in MMR given improvements in other outcomes in the causal pathway to mortality.ConclusionCommunity-based strategies focused on prevention and care-seeking effectively complemented facility-based strategies toward improving maternal health, while synergizing with newborn care interventions.     

Recognition of and response to postpartum hemorrhage in rural northern India

This study describes the results of a Morbidity and Performance Assessment (MAP) conducted to provide insight into the medical factors contributing to maternal and newborn morbidity and mortality in a rural district of northern India, and to use these insights to develop a locally appropriate, community-based safe motherhood program The MAP study was based on verbal autopsy method. Five hundred ninety-nine women (or in the case of 9 maternal deaths, a family member) participated in the study. This article describes a subsample of women who reported signs or symptoms suggesting excessive bleeding (n = 159). Findings include a poor knowledge of danger signs; poor problem recognition during labor, birth, and the immediate postpartum period; and a low level of health seeking that was consistent with poor recognition. Maternal sociodemographic characteristics, antenatal care use, and knowledge of danger signs were generally not associated with problem recognition and health seeking. The case fatality rate was 4%. These findings suggest an urgent need to understand the phenomenon of problem recognition and to integrate this into the design of interventions to reduce delays in health seeking.     

A framework for a new approach to antenatal care.

A framework for a new approach to antenatal care (ANC) is presented to improve maternal health. Based on evaluations of ANC, safe motherhood programs, gender and social theory, it suggests that managers should draw upon existing family and community support systems, and develop partnerships beyond the health service. Policy and program changes are required in: professional mandates for ANC providers, organization of ANC services, service protocols, training programs, policy towards TBAs, referral care, and service support systems.     

Household knowledge and practices of newborn and maternal health in Haripur district, Pakistan.

OBJECTIVE: To learn about household maternal and newborn health knowledge and practices to aid the design of newborn programming within Save the Children's Haripur Program. STUDY DESIGN: In April, we conducted 43 semi-structured interviews (SSIs) and 34 focus group discussions among men, women of reproductive age and health service providers; in September, we added 21 SSIs among new mothers, new fathers and dais. Two investigators analyzed the findings according to themes within six care types: antenatal, delivery, immediate newborn, routine postpartum, special maternal and special newborn. RESULT: Findings indicated poor maternal diet and antenatal care-seeking. Home delivery with an untrained dai was the norm. Respondents knew about benefits of clean delivery, but rarely put knowledge into practice. Knowledge and practices for maintaining the newborn's warmth were good. Delayed initiation of breastfeeding, avoidance of colostrum and prelacteal feeding were almost universal. Unhygienic cord care, including an unclean cut and application of ghee on the cord-stump, was the norm. After delivery, mothers often maintained low fluid intake but otherwise reported healthy nutritional practices. Knowledge of some danger signs in newborns was common, but timely action upon recognition was not. CONCLUSION: Although the findings illustrate some beneficial practices, many reported practices are harmful to the newborn. These findings, consistent with the sparse existing data in Pakistan, inform program interventions for household-level behavioral change.     

Effects of a community-based data for decision-making intervention on maternal and newborn health care practices in Ethiopia: a dose-response study

Background

Community participation and community health volunteer programs are an essential part of the health system so that health services are responsive and accountable to community needs. Information systems are necessary for community health volunteer programs to be effective, yet effectiveness evaluations of such information systems implemented at scale are rare. In October 2010, a network of female volunteers with little or no literacy, the Women’s Development Army (WDA), was added to extend Ethiopia’s Health Extension Program services to every household in the community. Between July 2013 and January 2015, a health management information system for the WDA’s Community-Based Data for Decision-Making (CBDDM) strategy was implemented in 115 rural districts to improve the demand for and utilization of maternal and newborn health services. Using the CBDDM strategy, Health Extension Workers (HEWs) fostered the WDA and community leaders to inform, lead, own, plan, and monitor the maternal and newborn health interventions in their kebeles (communities). This paper examines the effectiveness of the CBDDM strategy.

Methods

Using data from cross-sectional surveys in 2010–11 and 2014–15 from 177 kebeles, we estimated self-reported maternal and newborn care practices from women with children aged 0 to 11 months (2124 at baseline and 2113 at follow-up), and a CBDDM implementation strength score in each kebele. Using kebele-level random-effects models, we assessed dose-response relationships between changes over time in implementation strength score and changes in maternal and newborn care practices between the two surveys.

Results

Kebeles with relatively high increases in CBDDM implementation strength score had larger improvements in the coverage of neonatal tetanus-protected childbirths, institutional deliveries, clean cord care for newborns, thermal care for newborns, and immediate initiation of breastfeeding. However, there was no evidence of any effect of the intervention on postnatal care within 2 days of childbirth.

Conclusions

This study shows the extent to which an information system for community health volunteers with low literacy was implemented at scale, and evidence of effectiveness at scale in improving maternal and newborn health care behaviors and practices.

     

Maternal survival in developing countries: what has been done, what can be achieved in the next decade.

Every year, approximately 600000 women die of pregnancy-related causes - 98% of these deaths occur in developing countries. For every woman who dies, at least 30 suffer injuries and often, permanent disability. The challenge today is to re-orient programmes on priority interventions, and to mobilize sufficient resources for their implementation. More resources have been put into antenatal care than into delivery care and the management of complications of births and unsafe abortions. This article describes the effective strategies for reducing maternal death, their policy requirements and programmatic implications, and provides examples of successful developing country programmes. Priority interventions include: (1) improving availability and use of essential obstetric care for the management of complications; (2) strengthening family planning services; (3) ensuring skilled attendance at birth; (4) promoting women-friendly health services; (5) increasing district-level planning with community participation; and (6) monitoring process with process indicators. Finally, the promotion of safe motherhood as a right is of crucial importance. Needed now is political commitment as well as coordinated action for the implementation of large-scale programmes in low-income countries.     

Preparation for Discharge,Maternal Satisfaction,and Newborn Readmission for Jaundice: Comparing Postpartum Models of Care

ABSTRACT: Background: Physiological jaundice generally appears between the third and fifth days of life. The danger of hyperbilirubinemia is therefore a major challenge when postpartum hospital stays are short, and part of the responsibility for screening for signs of jaundice is assumed by the mother. The objective of this study was to identify the model of postnatal continuity of care most likely to prepare mothers for discharge, to reduce newborn readmission for jaundice, and to enhance maternal satisfaction. Methods: An epidemiological study was conducted in regions operating under 3 different models of postnatal continuity of care. Eligible mothers were those who had spent less than 60 hours in hospital after an uncomplicated vaginal delivery. Of this group, 70.8 percent participated in telephone interviews conducted 1 month after their deliveries (n = 1,096). Newborns who had presented with signs of jaundice were identified through statements from their mothers. Results: Of the participating newborns, 45.5 percent presented with signs of jaundice, and 3.2 percent were readmitted for jaundice during the first week of life. The follow‐up procedures used in regions operating under a community‐based model most closely followed the recommendations of health authorities and featured a high level of mothers’ satisfaction. In the region operating under a mixed hospital model, mothers reported signs of jaundice significantly more often, and postdischarge services received by mothers were less effective at allaying their fears compared with other models. Phototherapy was offered in the home only in the region operating under a mixed ambulatory model, and no readmissions for jaundice were recorded in this region. Conclusions: An effective coordination between community‐based perinatal services and hospital‐linked home phototherapy in the form of an integrated network appears to be an essential condition for improved monitoring of newborns’ health since it fosters a follow‐up that is focused not only on jaundice but also on mothers’ and newborns’ needs while reducing the costs generated by newborn readmissions. (BIRTH 34:2 June 2007)     

All Our Babies Cohort Study: recruitment of a cohort to predict women at risk of preterm birth through the examination of gene expression profiles and the environment

Background

In Tanzania, maternal mortality ratio remains unacceptably high at 578/100,000 live births. Despite a high coverage of antenatal care (96%), only 44% of deliveries take place within the formal health services. Still, "Ensure skilled attendant at birth" is acknowledged as one of the most effective interventions to reduce maternal deaths. Exploring the potential of community-based interventions in increasing the utilization of obstetric care, the study aimed at developing, testing and assessing a community-based safe motherhood intervention in Mtwara rural District of Tanzania.

Method

This community-based intervention was designed as a pre-post comparison study, covering 4 villages with a total population of 8300. Intervention activities were implemented by 50 trained safe motherhood promoters (SMPs). Their tasks focused on promoting early and complete antenatal care visits and delivery with a skilled attendant. Data on all 512 deliveries taking place from October 2004 to November 2006 were collected by the SMPs and cross-checked with health service records. In addition 242 respondents were interviewed with respect to knowledge on safe motherhood issues and their perception of the SMP's performance. Skilled delivery attendance was our primary outcome; secondary outcomes included antenatal care attendance and knowledge on Safe Motherhood issues.

Results

Deliveries with skilled attendant significantly increased from 34.1% to 51.4% (ρ < 0.05). Early ANC booking (4 to 16 weeks) rose significantly from 18.7% at baseline to 37.7% in 2005 and 56.9% (ρ < 0.001) at final assessment. After two years 44 (88%) of the SMPs were still active, 79% of pregnant women were visited. Further benefits included the enhancement of male involvement in safe motherhood issues.

Conclusion

The study has demonstrated the effectiveness of community-based safe motherhood intervention in promoting the utilization of obstetric care and a skilled attendant at delivery. This improvement is attributed to the SMPs' home visits and the close collaboration with existing community structures as well as health services.     

Effects of a participatory community quality improvement strategy on improving household and provider health care behaviors and practices: a propensity score analysis

Background

Maternal and newborn health care intervention coverage has increased in many low-income countries over the last decade, yet poor quality of care remains a challenge, limiting health gains. The World Health Organization envisions community engagement as a critical component of health care delivery systems to ensure quality services, responsive to community needs. Aligned with this, a Participatory Community Quality Improvement (PCQI) strategy was introduced in Ethiopia, in 14 of 91 rural woredas (districts) where the Last Ten Kilometers Project (L10 K) Platform activities were supporting national Basic Emergency Obstetric and Newborn Care (BEmONC) strengthening strategies. This paper examines the effects of the PCQI strategy in improving maternal and newborn care behaviors, and providers’ and households’ practices.

Methods

PCQI engages communities in identifying barriers to access and quality of services, and developing, implementing and monitoring solutions. Thirty-four intervention kebeles (communities), which included the L10 K Platform, BEmONC, and PCQI, and 82 comparison kebeles, which included the L10 K Platform and BEmONC, were visited in December 2010–January 2011 and again 48 months later. Twelve women with children aged 0 to 11 months were interviewed in each kebele. Propensity score matching was used to estimate the program’s average treatment effects (ATEs) on women’s care seeking behavior, providers’ service provision behavior and households’ newborn care practices.

Results

The ATEs of PCQI were statistically significant (p?<?0.05) for two care seeking behaviors — four or more antenatal care (ANC) visits and institutional deliveries at 14% (95% CI: 6, 21) and 11% (95% CI: 4, 17), respectively — and one service provision behavior — complete ANC at 17% (95% CI: 11, 24). We found no evidence of an effect on remaining outcomes relating to household newborn care practices, and postnatal care performed by the provider.

Conclusions

National BEmONC strengthening and government initiatives to improve access and quality of maternal and newborn health services, together with L10 K Platform activities, appeared to work better for some care practices where communities were engaged in the PCQI strategy. Additional research with more robust measure of impact and cost-effectiveness analysis would be useful to establish effectiveness for a wider set of outcomes.

     

Correlates of the Women’s Development Army strategy implementation strength with household reproductive,maternal, newborn and child healthcare practices: a cross-sectional study in four regions of Ethiopia

Background

To address the shortfall in human resources for health, Ethiopia launched the Health Extension Program (HEP) in 2004, establishing a health post with two female health extension workers (HEWs) in every kebele (community). In 2011, the Women’s Development Army (WDA) strategy was added, using networks of neighboring women to increase the efficiency of HEWs in reaching every household, with one WDA team leader for every 30 households. Through the strategy, women in the community, in partnership with HEWs, share and learn about health practices and empower one another. This study assessed the association between the WDA strategy implementation strength and household reproductive, maternal, newborn and child health care behaviors and practices.

Methods

Using cross-sectional household surveys and community-level contextual data from 423 kebeles representing 145 rural districts, an internal comparison group design was applied to assess whether HEP outreach activity and household-level care practices were better in kebeles with a higher WDA density. The density of active WDA leaders was considered as WDA strategy implementation strength; higher WDA density in a kebele indicating relatively high implementation strength. Based on this, kebeles were classified as higher, moderate, or lower. Multilevel logit models, adjusted for respondents’ individual, household and contextual characteristics, were used to assess the associations of WDA strategy implementation strength with outcome indicators of interest.

Results

Average numbers of households per active WDA team leader in the 25th, 50th and 75th percentiles of the kebeles studied were respectively 41, 50 and 73. WDA density was associated with better service for six of 13 indicators considered (p < 0.05). For example, kebeles with one active WDA team leader for up to 40 households (higher category) had respectively 7 (95% CI, 2, 13), 11 (5, 17) and 9 (1, 17) percentage-points higher contraceptive prevalence rate, coverage of four or more antenatal care visits, and coverage of institutional deliveries respectively, compared with kebeles with one active WDA team leader for 60 or more households (lower category).

Conclusion

Higher WDA strategy implementation strength was associated with better health care behaviors and practices, suggesting that the WDA strategy supported HEWs in improving health care services delivery.

     

Childbirth traditions and cultural perceptions of safety in Nepal: Critical spaces to ensure the survival of mothers and newborns in remote mountain villages

Objective

to uncover local beliefs regarding pregnancy and birth in remote mountainous villages of Nepal in order to understand the factors which impact on women's experiences of pregnancy and childbirth and the related interplay of tradition, spiritual beliefs, risk and safety which impact on those experiences.

Design

this study used a qualitative methodological approach with in-depth interviews framework within social constructionist and feminist critical theories.

Setting

the setting comprised two remote Nepalese mountain villages where women have high rates of illiteracy, poverty, disadvantage, maternal and newborn mortality, and low life expectancy. Interviews were conducted between February and June, 2010.

Participants

twenty five pregnant/postnatal women, five husbands, five mothers-in-law, one father-in-law, five service providers and five community stakeholders from the local communities were involved.

Findings

Nepalese women, their families and most of their community strongly value their childbirth traditions and associated spiritual beliefs and they profoundly shape women's views of safety and risk during pregnancy and childbirth, influencing how birth and new motherhood fit into daily life. These intense culturally-based views of childbirth safety and risk conflict starkly with the medical view of childbirth safety and risk.

Key conclusions and implications for practice

if maternity services are to improve maternal and neonatal survival rates in Nepal, maternity care providers must genuinely partner with local women inclusive of their cultural beliefs, and provide locally based primary maternity care. Women will then be more likely to attend maternity care services, and benefit from feeling culturally safe and culturally respected within their spiritual traditions of birth supported by the reduction of risk provided by informed and reverent medicalised care.     

A safe motherhood education and counselling programme in Istanbul

Objective?Evaluation of an education/counselling programme intended for pregnant/puerperal women in a secondary health care facility.

Methods?The education/counselling programme was launched in September 2004, following the preparation of environmental and material components. Evaluation of the two-year project was achieved by means of satisfaction surveys of service receivers and service providers, an information survey of service receivers and focus group discussions (FGDs) for both groups.

Results?Forty percent of the pregnant women who attended antenatal visits and 90% of those who had recently delivered were given education/counselling in accordance with the project. The information survey showed that 92.5% of the pregnant women knew that they should take an iron supplement during pregnancy and the puerperium; 72% of the puerperal women knew of the danger signs postpartum and concerning the newborn, and 70% were aware of the methods of effective breastfeeding. The FGDs showed improved competence of the applicants in pre-delivery, pregnancy and puerperal care as well as in newborn nutrition. Feedback from service providers confirmed the patients' improved active participation in their self-care.

Conclusion?The safe motherhood education/counselling programme was successfully completed. The applicants and health care professionals benefited from the service.     

Process evaluation of a community-based intervention promoting multiple maternal and neonatal care practices in rural Nepal

Background

The challenge of delivering multiple, complex messages to promote maternal and newborn health in the terai region of Nepal was addressed through training Female Community Health Volunteers (FCHVs) to counsel pregnant women and their families using a flipchart and a pictorial booklet that was distributed to clients. The booklet consists of illustrated messages presented on postcard-sized laminated cards that are joined by a ring. Pregnant women were encouraged to discuss booklet content with their families.

Methods

We examined use of the booklet and factors affecting adoption of practices through semi-structured interviews with district and community-level government health personnel, staff from the Nepal Family Health Program, FCHVs, recently delivered women and their husbands and mothers-in-law.

Results

The booklet is shared among household members, promotes discussion, and is referred to when questions arise or during emergencies. Booklet cards on danger signs and nutritious foods are particularly well-received. Cards on family planning and certain aspects of birth preparedness generate less interest. Husbands and mothers-in-law control decision-making for maternal and newborn care-seeking and related household-level behaviors.

Conclusions

Interpersonal peer communication through trusted community-level volunteers is an acceptable primary strategy in Nepal for promotion of household-level behaviors. The content and number of messages should be simplified or streamlined before being scaled-up to minimize intervention complexity and redundant communication.     

Antenatal care in the capital city of Cambodia: current situation and impact on obstetric outcome

AIMS: To analyze the situation of antenatal care (ANC) attendance in the capital of Cambodia, Phnom Penh, and the effect of ANC attendance on delivery and newborn outcome, in order to establish a strategy for ANC in the national reproductive health program in Cambodia. METHODS: This was a health facility-based retrospective cohort study. Background factors (education, household income, and parity) were obtained through interview, and obstetric information (cesarean section, low birth-weight, and maternal complications) were collected from the medical records of women who delivered during 1 month at all the public and private health facilities in Phnom Penh. Relations were analyzed between the number of ANC visits, background factors, and obstetric outcome. RESULTS: A total of 1204 responses were received from Phnom Penh residents, representing 84% of the estimated number of deliveries in the city. Of these, 89% were from public health facilities. Low educational level, low household income, and multiparity were risk factors for ANC attendance. There was no association between the number of ANC attendances and obstetric outcome. CONCLUSIONS: Our study has shown that Phnom Penh residents have good access to ANC and delivery care. Low socioeconomic factors are risk factors to ANC. The number of ANC visits had no association with poor perinatal outcome, but further study on quality of ANC and its impact on obstetric outcome is needed. Within the limited resources, safe motherhood strategies need to be targeted to the rural area and to the poor in order to increase access to ANC and delivery care.     

Approaches to improve the quality of maternal and newborn health care: an overview of the evidence

Despite progress in recent years, an estimated 273,500 women died as a result of maternal causes in 2010. The burden of these deaths is disproportionately bourne by women who reside in low income countries or belong to the poorest sectors of the population of middle or high income ones, and it is particularly acute in regions where access to and utilization of facility-based services for childbirth and newborn care is lowest. Evidence has shown that poor quality of facility-based care for these women and newborns is one of the major contributing factors for their elevated rates of morbidity and mortality. In addition, women who perceive the quality of facilty-based care to be poor,may choose to avoid facility-based deliveries, where life-saving interventions could be availble. In this context, understanding the underlying factors that impact the quality of facility-based services and assessing the effectiveness of interventions to improve the quality of care represent critical inputs for the improvement of maternal and newborn health. This series of five papers assesses and summarizes information from relevant systematic reviews on the impact of various approaches to improve the quality of care for women and newborns. The first paper outlines the conceptual framework that guided this study and the methodology used for selecting the reviews and for the analysis. The results are described in the following three papers, which highlight the evidence of interventions to improve the quality of maternal and newborn care at the community, district, and facility level. In the fifth and final paper of the series, the overall findings of the review are discussed, research gaps are identified, and recommendations proposed to impove the quality of maternal and newborn health care in resource-poor settings.