Date Published: December 5, 2017
Publisher: Public Library of Science
Author(s): Nadine Seward, Melissa Neuman, Tim Colbourn, David Osrin, Sonia Lewycka, Kishwar Azad, Anthony Costello, Sushmita Das, Edward Fottrell, Abdul Kuddus, Dharma Manandhar, Nirmala Nair, Bejoy Nambiar, Neena Shah More, Tambosi Phiri, Prasanta Tripathy, Audrey Prost, Lars Åke Persson
Abstract: BackgroundThe World Health Organization recommends participatory learning and action (PLA) in women’s groups to improve maternal and newborn health, particularly in rural settings with low access to health services. There have been calls to understand the pathways through which this community intervention may affect neonatal mortality. We examined the effect of women’s groups on key antenatal, delivery, and postnatal behaviours in order to understand pathways to mortality reduction.Methods and findingsWe conducted a meta-analysis using data from 7 cluster-randomised controlled trials that took place between 2001 and 2012 in rural India (2 trials), urban India (1 trial), rural Bangladesh (2 trials), rural Nepal (1 trial), and rural Malawi (1 trial), with the number of participants ranging between 6,125 and 29,901 live births. Behavioural outcomes included appropriate antenatal care, facility delivery, use of a safe delivery kit, hand washing by the birth attendant prior to delivery, use of a sterilised instrument to cut the umbilical cord, immediate wrapping of the newborn after delivery, delayed bathing of the newborn, early initiation of breastfeeding, and exclusive breastfeeding. We used 2-stage meta-analysis techniques to estimate the effect of the women’s group intervention on behavioural outcomes. In the first stage, we used random effects models with individual patient data to assess the effect of groups on outcomes separately for the different trials. In the second stage of the meta-analysis, random effects models were applied using summary-level estimates calculated in the first stage of the analysis. To determine whether behaviour change was related to group attendance, we used random effects models to assess associations between outcomes and the following categories of group attendance and allocation: women attending a group and allocated to the intervention arm; women not attending a group but allocated to the intervention arm; and women allocated to the control arm. Overall, women’s groups practising PLA improved behaviours during and after home deliveries, including the use of safe delivery kits (odds ratio [OR] 2.92, 95% CI 2.02–4.22; I2 = 63.7%, 95% CI 4.4%–86.2%), use of a sterile blade to cut the umbilical cord (1.88, 1.25–2.82; 67.6%, 16.1%–87.5%), birth attendant washing hands prior to delivery (1.87, 1.19–2.95; 79%, 53.8%–90.4%), delayed bathing of the newborn for at least 24 hours (1.47, 1.09–1.99; 68.0%, 29.2%–85.6%), and wrapping the newborn within 10 minutes of delivery (1.27, 1.02–1.60; 0.0%, 0%–79.2%). Effects were partly dependent on the proportion of pregnant women attending groups. We did not find evidence of effects on uptake of antenatal care (OR 1.03, 95% CI 0.77–1.38; I2 = 86.3%, 95% CI 73.8%–92.8%), facility delivery (1.02, 0.93–1.12; 21.4%, 0%–65.8%), initiating breastfeeding within 1 hour (1.08, 0.85–1.39; 76.6%, 50.9%–88.8%), or exclusive breastfeeding for 6 weeks after delivery (1.18, 0.93–1.48; 72.9%, 37.8%–88.2%). The main limitation of our analysis is the high degree of heterogeneity for effects on most behaviours, possibly due to the limited number of trials involving women’s groups and context-specific effects.ConclusionsThis meta-analysis suggests that women’s groups practising PLA improve key behaviours on the pathway to neonatal mortality, with the strongest evidence for home care behaviours and practices during home deliveries. A lack of consistency in improved behaviours across all trials may reflect differences in local priorities, capabilities, and the responsiveness of health services. Future research could address the mechanisms behind how PLA improves survival, in order to adapt this method to improve maternal and newborn health in different contexts, as well as improve other outcomes across the continuum of care for women, children, and adolescents.
Partial Text: Between 1990 and 2015, mortality rates in children aged between 2 months and 5 years declined globally by 58% [1–3]. Neonatal mortality decreased by 47% over the same period, but the proportion of deaths occurring during the neonatal period out of all deaths among children under 5 years of age increased from 37% to 45% . If these trends continue, neonatal mortality will constitute over 50% of deaths among children under 5 years of age by 2030 . Increased coverage of effective interventions is required to improve neonatal survival .
This meta-analysis suggests that women’s groups practising PLA improved home delivery and home care practices during birth and the postnatal period. We found evidence that women’s groups improved clean delivery practices for home deliveries, including the use of safe delivery kits, hand washing with soap by birth attendants prior to delivery, and clean cord cutting. We also found evidence that groups improved home care practices including wrapping newborn infants within 10 minutes of delivery and delaying the bathing of infants for at least 24 hours after delivery. There was no evidence that groups improved the uptake of facility deliveries, antenatal care, early breastfeeding, or exclusive breastfeeding for at least 6 weeks following delivery. Most of the estimates for the separate behaviours had a high degree of heterogeneity. The lack of consistency in improving behaviours across all trials was unsurprising given that groups were involved in a process where women identified, prioritised, and implemented solutions for problems that differed between settings and groups.