Date Published: February 28, 2019
Publisher: Public Library of Science
Author(s): Ruoyan Gai Tobe, Mohammad Tajul Islam, Yukie Yoshimura, Jahangir Hossain, Jacobus P. van Wouwe.
Although achieved development goals on maternal and child health, in the era of Sustainable Development Goals (SDGs), Bangladesh still needs to promote skilled attendance at birth as well as a continuum of care for mothers and babies. How to implement effective interventions by strengthening the community health system also remains as a crucial policy issue. The objective of the proposed study is to evaluate the impact of a community-based intervention as part of a bilateral development aid project on utilization of maternal and neonatal care provided by skilled providers and qualified facilities.
A cluster randomized trial was conducted in Kalaroa Upazila of Satkhira District. Community Clinics (CCs) in the study setting were randomly allocated to either intervention or control. We recruited all eligible women covered by CC catchment areas who gave a birth during the past 12 months of data collection at the baseline and end-line surveys. In the intervention areas, three Community Support Groups (CSGs) were developed in each of the CC areas. The members of CSG were trained to identify pregnant women, educate community people on pregnancy related danger signs, and encourage them for utilization of skilled services in the community and health facilities. The primary outcomes were the utilization of services for antenatal care, delivery, postnatal care and sick newborns. Difference-in-Difference (DID) analysis was performed to identify the changes by the intervention with adjustment of cluster effects by generalized mixed effects regression models.
The major indicators of the utilization of maternal and neonatal care among pregnant women with different wealth status showed significant improvement after the intervention. The impacts of the intervention were in particular significant among the women of 2nd and 3rd quintiles of household wealth status. The use of CCs increased after the intervention and private hospitals / clinics served as the major health providers. The study also identified increased practices of cesarean section.
The success of the intervention suggests a potential of the government efforts to strengthen the community support system for promotion of safe motherhood. The intervention helps to identify and remove existing and emerging barriers that lie between women and healthcare providers for safe motherhood and continuum of care.
UMIN Clinical Trial Registry UMIN000031789.
Bangladesh has achieved a significant progress on reduction of maternal and child mortality in the Millennium Development Goal (MDG) era, and also left issues and lessons in the era of post-2015 (Fig 1) [1,2]. The government of Bangladesh has taken maternal and neonatal health and underlying accessibility and quality of healthcare into account, with the global targets of the Sustainable Development Goals (SDGs) to reduce the maternal mortality ratio to less than 70 per 100,000 live births and to reduce the neonatal mortality rate to as low as 12 per 1,000 live births by 2030 [3,4].
A total of 2,407 (1102 in baseline and 1305 in end-line) and 2,268 (1237 in baseline and 1031 in end-line) women were enrolled in the intervention group and control group, respectively, meeting the requirement of sample size as planned. Table 2 showed the socio-demographic characteristics of the participants in the two groups. Except husband’s occupation, the distribution of socio-demographic characteristics did not differ significantly between the two groups. On an average, the participants were aged 23.7 years (SD: 4.98 years), with 7.68 years of education (SD: 2.62 years) and 1.69 children (SD: 0.86 children). The enrollment rate did not vary across unions and times.
To our knowledge, this is the first cluster randomized controlled trial to evaluate the CSG intervention of SMPP in rural Bangladesh. Our findings showed that the intervention through development and strengthening of CSGs and community mobilization significantly improved the utilization of antenatal, delivery and postnatal care services, after adjustment of covariates at the individual and cluster levels. In the project, the CSG members built a capacity to coordinate participatory approaches to implement the group activities and persuaded pregnant women for accessing skilled MHC services. CSGs share some similarities with women’s groups, of which effectiveness in reducing neonatal and maternal mortalities has already been proven by several studies as discussed earlier . For example, the functions of CSG such as organizing meetings and developing action plans are grounded in a participatory approach with a critical role played by facilitators. On the other hand, CSGs differ from women’s groups: one of such differences is that a CSG is a key component of the government endorsed and supported community mobilization mechanism to promote the utilization of CCs. As per the government policy, CSGs have already been expanded throughout the country. In this context, our study contributed for the government, by evaluating the effect of CSGs in improving maternal and neonatal health, to determine the future direction of the government run Community Clinic program, specifically on how to engage community people for their own well-beings. Another difference is active participation of male CSG members in the discussions and activities related to maternal and neonatal health. We observed comparative advantages of male members over female counterparts in terms of approaching men for behavior change and mobilizing community resources including fund raising and emergency supports. Nevertheless, the male membership in the group could be challenged by negative opinions: women’s groups can openly discuss women’s issues and concerns with the absence of men in the group while female members of CSGs may feel shy to share their personal feelings and experiences in front of male members. We did not evaluate under this study; yet, the question of influence of male participation in the group activities could be a potential area for future studies.
The integrated community-based strategy combined with health system strengthening as foundation effectively improved the utilization of MHS in rural Bangladesh, with perspectives and outcomes in equity. The success suggested a potential of the government efforts to strengthen community support system for ensuring safe motherhood. To provide better maternal and neonatal care, continuous efforts to promote the demand and to address perception and awareness among local people by engaging communities, together with strengthening the public healthcare and building an innovative public-private partnership are necessary. The intervention helped to identify and remove existing and emerging barriers that lie between women and healthcare providers for safe motherhood and a continuum of care.