Effect on mortality of community-based maternity-care programme in rural Bangladesh

Abstract

Various community-based interventions have been proposed to improve maternity care, but hardly any studies have reported the effect of these measures on maternal mortality. In this study, the efficacy of a maternity-care programme to reduce maternal mortality has been evaluated in the context of a primary health-care project in rural Bangladesh. Trained midwives were posted in villages, and asked to attend as many home-deliveries as possible, detect and manage obstetric complications at onset, and accompany patients requiring referral for higher-level care to the project central maternity clinic. The effect of the programme was evaluated by comparison of direct obstetric maternal mortality ratios between the programme area and a neighbouring control area without midwives. Random assignment of the intervention was not possible but potentially confounding characteristics, including coverage and use of other health and family planning services, were similar in both areas. Maternal mortality ratios due to obstetric complications were similar in both areas during the 3 years preceding the start of the programme. By contrast, during the following 3 years, the ratio was significantly lower in the programme than in the control area (1.4 vs 3.8 per 1000 live births, p = 0.02). The findings suggest that maternal survival can be improved by the posting of midwives at village level, if they are given proper training, means, supervision, and back-up. The inputs for such a programme to succeed and the constraints of its replication on a large scale should not be underestimated.

PIP: This study considers the effects of a maternity care program within a community based maternal and child health and family planning program (MCH--FP) in rural Bangladesh (Matlab subdistrict). The area is rural and poor, with literacy rates of 30% for men and 17% for women; total fertility rates range from 5.5 to 4.3/woman and infant mortality from 110/1000 live births to 75/1000 in 1989. A demographic surveillance system was begun in 1966, and in 1977, MCH-FP was set up as a special treatment area separate from a comparable area with only Government health services. There are 80 community health workers (CHWs) who visit and collect data on each household of every village every 2 weeks. Maternal mortality is established by protocol. Maternal mortality in this study is defined as deaths occurring during pregnancy, delivery, or 6 weeks postpartum and attributable to obstetric complications but not conditions aggravated by the pregnancy or postpartum status (diarrhea, hepatitis, respiratory tract infections). Maternity care and referral is provided by the CHWs. Up to 1986, contraceptive use prevalence rates increased but maternal mortality remained at 5.5/1000 live births. Interventions based on a retrospective study of causes and conditions of maternal mortality were instituted in 1987. These consisted of posting professional midwives equipped to treat immediately obstetric complications in villages and a backup referral system. The intervention program was set up in 50% of the MCH--FP area and consisted of 48,000 people living in 39 villages. There were 1600 pregnancies a year in the program area, or an average of 33 a month/midwife (4 midwives in 2 outposts). Backup included a new maternity clinic without surgical, radiological or modern laboratory facilities, but staff available to stabilize patients for transfer to a regional hospital. Data was collected by the midwives, including the ratio of deaths/1000 live births as the best measure of the risk of dying during pregnancy. The results of the comparison between the intervention area, which also had a higher infant and adult female mortality rate, and the control area for 1987-89 showed that the odds ratio of obstetric death in the pre and post period was .31 (95% CI .11-.81, p=.007); there was no significant change in the control area. The principal causes of death reduced by the program and ranked in decreasing order were abortion complications, postpartum hemorrhage, postpartum sepsis, obstructed labor and eclampsia. It is likely that the intervention was the significant factor in the mortality reduction since the areas were similar sociodemographically. Another method for reducing maternal mortality has been implemented and being evaluated: the use of female paramedical field workers to detect high risk pregnancies.