BACKGROUND: Maternal, perinatal and neonatal mortality remains high in low-income countries. We evaluated community and facility-based interventions to reduce deaths in three districts of Malawi.
METHODS: We evaluated a rural participatory women's group community intervention (CI) and a quality improvement intervention at health centres (FI) via a two-by-two factorial cluster randomized controlled trial. Consenting pregnant women were followed-up to 2 months after birth using key informants. Primary outcomes were maternal, perinatal and neonatal mortality. Clusters were health centre catchment areas assigned using stratified computer-generated randomization. Following exclusions, including non-birthing facilities, 61 clusters were analysed: control (17 clusters, 4912 births), FI (15, 5335), CI (15, 5080) and FI + CI (14, 5249). This trial was registered as International Standard Randomised Controlled Trial [ISRCTN18073903]. Outcomes for 14,576 and 20,576 births were recorded during baseline (June 2007-September 2008) and intervention (October 2008-December 2010) periods.
RESULTS: For control, FI, CI and FI + CI clusters neonatal mortality rates were 34.0, 28.3, 29.9 and 27.0 neonatal deaths per 1000 live births and perinatal mortality rates were 56.2, 55.1, 48.0 and 48.4 per 1000 births, during the intervention period. Adjusting for clustering and stratification, the neonatal mortality rate was 22% lower in FI + CI than control clusters (OR = 0.78, 95% CI 0.60-1.01), and the perinatal mortality rate was 16% lower in CI clusters (OR = 0.84, 95% CI 0.72-0.97). We did not observe any intervention effects on maternal mortality.
CONCLUSIONS: Despite implementation problems, a combined community and facility approach using participatory women's groups and quality improvement at health centres reduced newborn mortality in rural Malawi.
EXECUTIVE SUMMARY: Maternal, perinatal and neonatal mortality remain high in Malawi and throughout subSaharan Africa. The Health Foundation funded community and facility interventions aimed at reducing this burden. MaiKhanda was set up as an independent NGO in Malawi to deliver both interventions with technical support from IHI and WCF. The community intervention involved mobilisation of rural communities through women’s groups, and later, maternal and neonatal health task forces. 729 women’s groups completed a participatory learning and action cycle to identify and prioritise maternal and neonatal health problems, decide upon local solutions/advocate and lobby for alternatives, and, implement and evaluate such strategies. The facility intervention involved coaching of health facility staff in quality improvement methodology, including Plan-Do-Study-Act cycles, change ideas, bundles and packages and death reviews to improve obstetric and newborn care at 29 health centres (randomised) and 9 hospitals (not randomised). The community and facility interventions were evaluated via a two-by-two factorial cluster randomised controlled trial. All pregnant women in surveillance areas were eligible to take part and consenting women were followed-up to two months after birth via a low-cost community surveillance system using village-based key informants. Primary outcomes were maternal, perinatal and neonatal mortality. A separate non-controlled time-series evaluation of the quality improvement work at the 9 hospitals was under-taken with maternal and neonatal case-fatality rates as primary outcomes. Parallel process evaluations seeking to understand the processes, mechanisms, and intermediate outcomes of the interventions and the context within which they succeeded or failed were also undertaken and are reported in full. A preliminary cost-effectiveness analysis was also undertaken. Both the interventions underwent changes throughout the evaluation period (2007-2010) and could have had sub-optimal dosages. Implementation could also have been improved. There were also political, management and resource challenges in the three districts (Lilongwe, Salima and Kasungu), and at the health facilities, which may have accounted for the lower impact of the interventions than hoped for. Our 21 main findings are as follows. Each of these is extensively discussed with respect to its implications, precision, potential bias, and relevant literature, in chapter 5.
Maternal, perinatal and neonatal mortality remains high in low-income countries. We evaluated community and facility-based interventions to reduce deaths in three districts of Malawi.
METHODS:
We evaluated a rural participatory women's group community intervention (CI) and a quality improvement intervention at health centres (FI) via a two-by-two factorial cluster randomized controlled trial. Consenting pregnant women were followed-up to 2 months after birth using key informants. Primary outcomes were maternal, perinatal and neonatal mortality. Clusters were health centre catchment areas assigned using stratified computer-generated randomization. Following exclusions, including non-birthing facilities, 61 clusters were analysed: control (17 clusters, 4912 births), FI (15, 5335), CI (15, 5080) and FI + CI (14, 5249). This trial was registered as International Standard Randomised Controlled Trial [ISRCTN18073903]. Outcomes for 14,576 and 20,576 births were recorded during baseline (June 2007-September 2008) and intervention (October 2008-December 2010) periods.
RESULTS:
For control, FI, CI and FI + CI clusters neonatal mortality rates were 34.0, 28.3, 29.9 and 27.0 neonatal deaths per 1000 live births and perinatal mortality rates were 56.2, 55.1, 48.0 and 48.4 per 1000 births, during the intervention period. Adjusting for clustering and stratification, the neonatal mortality rate was 22% lower in FI + CI than control clusters (OR = 0.78, 95% CI 0.60-1.01), and the perinatal mortality rate was 16% lower in CI clusters (OR = 0.84, 95% CI 0.72-0.97). We did not observe any intervention effects on maternal mortality.
CONCLUSIONS:
Despite implementation problems, a combined community and facility approach using participatory women's groups and quality improvement at health centres reduced newborn mortality in rural Malawi.
