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Meta-Analysis
. 2015 Mar 23;2015(3):CD007754.
doi: 10.1002/14651858.CD007754.pub3.

Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes

Zohra S Lassi  1 , Zulfiqar A Bhutta
Affiliations
Meta-Analysis

Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes

Zohra S Lassi et al. Cochrane Database Syst Rev. .

Abstract

Background: While maternal, infant and under-five child mortality rates in developing countries have declined significantly in the past two to three decades, newborn mortality rates have reduced much more slowly. While it is recognised that almost half of the newborn deaths can be prevented by scaling up evidence-based available interventions (such as tetanus toxoid immunisation to mothers, clean and skilled care at delivery, newborn resuscitation, exclusive breastfeeding, clean umbilical cord care, and/or management of infections in newborns), many require facility-based and outreach services. It has also been stated that a significant proportion of these mortalities and morbidities could also be potentially addressed by developing community-based packaged interventions which should also be supplemented by developing and strengthening linkages with the local health systems. Some of the recent community-based studies of interventions targeting women of reproductive age have shown variable impacts on maternal outcomes and hence it is uncertain if these strategies have consistent benefit across the continuum of maternal and newborn care.

Objectives: To assess the effectiveness of community-based intervention packages in reducing maternal and neonatal morbidity and mortality; and improving neonatal outcomes.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2014), World Bank's JOLIS (25 May 2014), BLDS at IDS and IDEAS database of unpublished working papers (25 May 2014), Google and Google Scholar (25 May 2014).

Selection criteria: All prospective randomised, cluster-randomised and quasi-randomised trials evaluating the effectiveness of community-based intervention packages in reducing maternal and neonatal mortality and morbidities, and improving neonatal outcomes.

Data collection and analysis: Two review authors independently assessed trials for inclusion, assessed trial quality and extracted the data. Data were checked for accuracy.

Main results: The review included 26 cluster-randomised/quasi-randomised trials, covering a wide range of interventional packages, including two subsets from three trials. Assessment of risk of bias in these studies suggests concerns regarding insufficient information on sequence generation and regarding failure to adequately address incomplete outcome data, particularly from randomised controlled trials. We incorporated data from these trials using generic inverse variance method in which logarithms of risk ratio (RR) estimates were used along with the standard error of the logarithms of RR estimates.Our review showed a possible effect in terms of a reduction in maternal mortality (RR 0.80; 95% confidence interval (CI) 0.64 to 1.00, random-effects (11 studies, n = 167,311; random-effects, Tau² = 0.03, I² 20%). However, significant reduction was observed in maternal morbidity (average RR 0.75; 95% CI 0.61 to 0.92; four studies, n = 138,290; random-effects, Tau² = 0.02, I² = 28%); neonatal mortality (average RR 0.75; 95% CI 0.67 to 0.83; 21 studies, n = 302,646; random-effects, Tau² = 0.06, I² = 85%) including both early and late mortality; stillbirths (average RR 0.81; 95% CI 0.73 to 0.91; 15 studies, n = 201,181; random-effects, Tau² = 0.03, I² = 66%); and perinatal mortality (average RR 0.78; 95% CI 0.70 to 0.86; 17 studies, n = 282,327; random-effects Tau² = 0.04, I² = 88%) as a consequence of implementation of community-based interventional care packages.Community-based intervention packages also increased the uptake of tetanus immunisation by 5% (average RR 1.05; 95% CI 1.02 to 1.09; seven studies, n = 71,622; random-effects Tau² = 0.00, I² = 52%); use of clean delivery kits by 82% (average RR 1.82; 95% CI 1.10 to 3.02; four studies, n = 54,254; random-effects, Tau² = 0.23, I² = 90%); rates of institutional deliveries by 20% (average RR 1.20; 95% CI 1.04 to 1.39; 14 studies, n = 147,890; random-effects, Tau² = 0.05, I² = 80%); rates of early breastfeeding by 93% (average RR 1.93; 95% CI 1.55 to 2.39; 11 studies, n = 72,464; random-effects, Tau² = 0.14, I² = 98%), and healthcare seeking for neonatal morbidities by 42% (average RR 1.42; 95% CI 1.14 to 1.77, nine studies, n = 66,935, random-effects, Tau² = 0.09, I² = 92%). The review also showed a possible effect on increasing the uptake of iron/folic acid supplementation during pregnancy (average RR 1.47; 95% CI 0.99 to 2.17; six studies, n = 71,622; random-effects, Tau² = 0.26; I² = 99%).It has no impact on improving referrals for maternal morbidities, healthcare seeking for maternal morbidities, iron/folate supplementation, attendance of skilled birth attendance on delivery, and other neonatal care-related outcomes. We did not find studies that reported the impact of community-based intervention package on improving exclusive breastfeeding rates at six months of age. We assessed our primary outcomes for publication bias and observed slight asymmetry on the funnel plot for maternal mortality.

Authors' conclusions: Our review offers encouraging evidence that community-based intervention packages reduce morbidity for women, mortality and morbidity for babies, and improves care-related outcomes particularly in low- and middle-income countries. It has highlighted the value of integrating maternal and newborn care in community settings through a range of interventions, which can be packaged effectively for delivery through a range of community health workers and health promotion groups. While the importance of skilled delivery and facility-based services for maternal and newborn care cannot be denied, there is sufficient evidence to scale up community-based care through packages which can be delivered by a range of community-based workers.

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Conflict of interest statement

Dr Zulfiqar A Bhutta is the principal investigator of two included studies evaluating community care perinatal care package in Pakistan (Bhutta 2008; Bhutta 2011) but he was not involved in assessing these trials for inclusion in this review, assessing trial quality, or data extraction. These tasks were carried out by other members of the review team who were not involved with the original studies (ZSL and BAH).

Figures

1
1
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
2
2
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
3
3
Funnel plot of comparison: 1 Community‐based intervention versus control, outcome: 1.1 Maternal mortality.
4
4
Funnel plot of comparison: 1 Community‐based intervention versus control, outcome: 1.2 Neonatal mortality.
1.1
1.1. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 1 Maternal mortality.
1.2
1.2. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 2 Neonatal mortality.
1.3
1.3. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 3 Early neonatal mortality.
1.4
1.4. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 4 Late neonatal mortality.
1.5
1.5. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 5 Perinatal mortality.
1.6
1.6. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 6 Stillbirths.
1.7
1.7. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 7 Mean birthweight (kg).
1.8
1.8. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 8 Maternal morbidity.
1.9
1.9. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 9 Complication of pregnancy: haemorrhage.
1.10
1.10. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 10 Complication of pregnancy: obstructed labour.
1.11
1.11. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 11 Complication of pregnancy: puerperal sepsis.
1.12
1.12. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 12 Complication of pregnancy: eclampsia.
1.13
1.13. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 13 Complication of pregnancy: spontaneous abortion.
1.14
1.14. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 14 Referal to health facility for any complication during pregnancy.
1.15
1.15. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 15 Iron/folate supplementation (not pre‐specified).
1.16
1.16. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 16 Any Tetanus toxoid immunisation (not pre‐specified).
1.17
1.17. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 17 Institutional deliveries.
1.18
1.18. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 18 Birth attended by healthcare provider.
1.19
1.19. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 19 Use of clean delivery kits (not pre‐specified).
1.20
1.20. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 20 Baby wrapped within 30 minutes (not pre‐specified).
1.21
1.21. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 21 Initiation of breastfeeding within 1 hour of birth.
1.22
1.22. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 22 Delayed bathing for up to 6 hours (not pre‐specified).
1.23
1.23. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 23 Clean cord care (not pre‐specified).
1.24
1.24. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 24 Healthcare seeking for maternal morbidities.
1.25
1.25. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 25 Healthcare seeking for neonatal morbidities.
1.26
1.26. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 26 Maternal mortality: low risk of bias studies.
1.27
1.27. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 27 Neonatal mortality: low risk of bias studies.
1.28
1.28. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 28 Perinatal mortality: low risk of bias studies.
1.29
1.29. Analysis
Comparison 1 Community‐based intervention versus control, Outcome 29 Stillbirths: low risk of bias studies.
See this image and copyright information in PMC

Update of

References

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Joseph 2006 {published data only}
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Joseph 2009 {published data only}
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Koniak‐Griffin 1991 {published data only}
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Lumley 2006 {published data only}
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References to studies awaiting assessment

Kamm 2012 {published data only}
    1. Kamm KB, Nasreen S, Vujcic J, Arifeen S, Zaman K, Luby SP, et al. Impact of a brief in‐home neonatal health promotion on self‐reported birth and neonatal care practices among primiparous women in the third trimester in rural Bangladesh. American Journal of Tropical Medicine and Hygiene 2012;87(5 Suppl 1):450.
Kestler 2013 {published data only}
    1. Kestler E, Walker D, Bonvecchio A, Saenz de Tejada S, Donner A. A matched pair cluster randomized implementation trial to measure the effectiveness of an intervention package aiming to decrease perinatal mortality and increase institution‐based obstetric care among indigenous women in Guatemala: study protocol. BMC Pregnancy and Childbirth 2013;13(1):73. - PMC - PubMed
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Khan 2012 {published data only}
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    1. Morrison J, Tumbahangphe KM, Budhathoki B, Neupane R, Sen A, Dahal K, et al. Community mobilisation and health management committee strengthening to increase birth attendance by trained health workers in ruralMakwanpur, Nepal: study protocol for a cluster randomised controlled trial. Trials 2011;12:128. - PMC - PubMed
Rodriguez‐Angulo 2012 {published data only}
    1. Rodriguez‐Angulo E, Andueza‐Pech G, Rosado‐Alcocer L, Ortiz‐Panozo E, Hernandez‐Prado B. Effect of a community‐based intervention to improve the knowledge on the warning signs of maternal complications among Mayan women from Yucatan randomized controlled trial [Spanish] [Efecto de una intervencion comunitaria para mejorar conocimientos sobre signos de alarma de complicaciones maternas en mujeres mayas de Yucatan, ensayo controlado, aleatorizado]. Revista de Investigacion Clinica 2012;64(2):154‐63. - PubMed
Rotheram‐Borus 2011b {published data only}
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Tripathy 2011 {published data only}
    1. ISRCTN31567106. The effect of womens' groups facilitated by Accredited Social Health Activists (ASHAs) on birth outcomes in Eastern India. http://www.controlled‐trials.com/ISRCTN31567106 [accessed 12 December 2011].
    1. Tripathy P, Nair N, Mahapatra R, Rath S, Gope RK, Rath S, et al. Community mobilisation with women’s groups facilitated by Accredited Social Health Activists(ASHAs) to improve maternal and newborn health in underserved areas of Jharkhand and Orissa: study protocol for a cluster‐randomised controlled trial. Trials 2011;12:182. - PMC - PubMed
Waiswa 2012 {published data only}
    1. ISRCTN50321130. Uganda Newborn Survival Study: improving newborn health and survival through a community based intervention linked to health facilities. http://www.controlled‐trials.com/ISRCTN50321130 Accessed 12 December 2011.
    1. Waiswa P, Peterson SS, Namazzi G, Ekirapa EK, Naikoba S, Byaruhanga R, et al. The Uganda Newborn Study (UNEST): an effectiveness study on improving newborn health and survival in rural Uganda through a community‐based intervention linked to health facilities ‐ study protocol for a cluster randomized controlled trial. Trials 2012;13(1):213. - PMC - PubMed
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References to ongoing studies

Bhandari 2014 {published data only}
    1. Bhandari GP, Subedi N, Thapa J, Choulagai B, Maskey MK, Onta SR. A cluster randomized implementation trial to measure the effectiveness of an intervention package aiming to increase the utilization of skilled birth attendants by women for childbirth: study protocol. BMC Pregnancy and Childbirth 2014;14(1):109. - PMC - PubMed
ISRCTN63294155 {published data only}
    1. Ellard D, Simkiss D, Quenby S, Davies D, Kandala NB, Kamwendo F, et al. The impact of training non‐physician clinicians in Malawi on maternal and perinatal mortality: a cluster randomised controlled evaluation of the enhancing training and appropriate technologies for mothers and babies in Africa (ETATMBA) project. BMC Pregnancy and Childbirth 2012;12:116. - PMC - PubMed
    1. ISRCTN63294155. Does training non‐physician clinicians, in Malawi, have an impact on new‐born baby and maternal survival?. http://www.controlled‐trials.com/ISRCTN63294155 [accessed 6 Sept 2013].
NCT01022788 {published data only}
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NCT01073488 {published data only}
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    1. Pasha O, Goldenberg RL, McClure EM, Saleem S, Goudar SS, Althabe F, et al. Communities, birth attendants and health facilities: a continuum of emergency maternal and newborn care (the Global Network's EmONC trial). BMC Pregnancy and Childbirth 2010;10:82. - PMC - PubMed
NCT01350765 {published data only}
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NCT01751945 {published data only}
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NCT01941264 {published data only}
    1. NCT01941264. Community‐based scheduled screening and treatment of malaria in pregnancy for improved maternal and infant health: a cluster‐randomized trial in The Gambia, Burkina Faso and Benin. https://clinicaltrials.gov/ct2/show/NCT01941264 [accessed 5 February 2014] 2013. - PMC - PubMed

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