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David R, Evans R, Fraser HS. Modelling Prenatal Care Pathways at a Central Hospital in Zimbabwe. Health Serv Insights 2021; 14:11786329211062742. [PMID: 34880627 PMCID: PMC8647229 DOI: 10.1177/11786329211062742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 11/05/2021] [Indexed: 11/19/2022] Open
Abstract
Background: Maternal mortality remains a problem in low-income countries (LICs). In
Zimbabwe, there has been an unprecedented increase in maternal mortality in
the last 2.5 decades. Effective prenatal care delivery, particularly early
visits, appropriate number of visits, and receiving recommended care is
viewed as key to reducing fatal care outcomes. Aims: This study sought to model and identify gaps requiring service and care
delivery improvement in prenatal care pathways for pregnant women visiting
Mpilo Central Hospital in Bulawayo, Zimbabwe. Methods: This was a case study of the services offered by an antenatal care department
at Mpilo Central Hospital in Bulawayo, Zimbabwe. Evidence from literature in
low-income countries was used to develop prenatal care pathway guidelines as
a tool to guide care delivery and identify gaps in care and service
delivery. One hundred cases of prenatal care records were reviewed to
determine the prenatal care pathway and care delivered to pregnant women.
This data was complemented by interviews with 20 maternity care
clinicians. Results: In 100 maternity case records studied, 53% booked for prenatal care. Of the
53% (n = 53) pregnant women who booked, their first visit on their pregnancy
was late at an average gestational age of 27.1 weeks with extremes of 30 to
40 weeks in 38% (n = 20) cases. Missing scheduled prenatal care appointments
was prevalent, with only 11% (n = 6) having attended all the expected 5
visits, whilst 60% (n = 32) missed 3 or more. There were inadequacies in the
care delivered to women in each visit compared to that expected in such
areas as obstetrics, physical examinations and haematological tests.
Maternity care clinicians attributed the cost of prenatal booking fees in
the background of poverty and poor family support systems as key factors
hindering women’s access to prenatal services. Conclusions: The current prenatal care pathway at MCH requires improvement in the areas of
referral, adherence to appointment by pregnant women and visiting prenatal
care early. Clinicians also need to adhere to standard clinical tests
recommended for each specific pregnant woman’s visit. In the Zimbabwean
setting with limited resources, where the number of visits is already low,
pathways with reduced visits may not be appropriate. An investment into
prenatal care by the government is recommended to enable the utilisation of
interventions such as e-health technologies that may improve care delivery
as well as adherence to best practices. E-health and mobile health
technologies involving e-referrals, e-booking, decision support, and
reminder systems are recommended for clinicians to manage and deliver
appropriate care to patients as well as pregnant women to adhere to
scheduled visits.
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Affiliation(s)
- Rodreck David
- School of Information Management, Victoria University of Wellington, Wellington, New Zealand
| | - Ruth Evans
- Division of Health Services Research, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Hamish Sf Fraser
- Brown Center for Biomedical Informatics, Brown University, Providence, RI, USA
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Gelano TF, Assefa N, Bacha YD, Mahamed AA, Roba KT, Hambisa MT. Effect of Mobile-health on maternal health care service utilization in Eastern Ethiopia: study protocol for a randomized controlled trial. Trials 2018; 19:102. [PMID: 29433537 PMCID: PMC5809837 DOI: 10.1186/s13063-018-2446-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 01/03/2018] [Indexed: 11/28/2022] Open
Abstract
Background Globally, the rapid development of mobile technology has created new ways of addressing public health challenges and shifted the paradigm of health care access and delivery. The primary aim of this study is to examine the effectiveness of Mobile-health on maternal health care service utilization in Eastern Ethiopia. Methods/design Through, a cluster-randomized controlled trial, 640 participants will be selected based on their districts and respective health centers as the unit of randomization. All pregnant mothers who fulfill the inclusion criteria will be allocated to a mobile-phone-based intervention and existing standard of care or control with a 1:1 allocation ratio. The intervention consists of a series of 24 voice messages which will be sent every 2 weeks from the date of enrollment until the close-out time. The control group will receive existing standard of care without voice messages. Data related to outcome variables will be assessed at three phases of the data collection periods. The primary outcome measures will be the proportion of antenatal care visits and institutional delivery, whereas the secondary outcome measures will consist of the proportion of postnatal care visits and pregnancy outcomes. Risk ratios will be used to a measure the effect of intervention on the outcomes which will be estimated with 95% confidence interval and all the analyses will be done with consideration of clustering effect. Discussions This study should generate evidence on the effectiveness of mobile-phone-based voice messages for the early initiation of maternal health care service use and its uptake. It has been carefully designed with the assumption of obtaining higher levels of maternal health care service use among the treatment group as compared to the control. Trial registration Pan African Clinical Trial Registry, www.panctr.org, ID: PACTR201704002216259. Registered on 28 April 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2446-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tilayie Feto Gelano
- Department of Pediatrics and Neonatal Nursing, School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, PO Box 235, Ethiopia.
| | - Nega Assefa
- School of Nursing and Midwifery, Department of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Yadeta Dessie Bacha
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Afendi Abdi Mahamed
- Department of Computer and Information Sciences, College of Sciences and Technology, Haramaya University, Harar, Ethiopia
| | - Kedir Teji Roba
- Department of Nursing, School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Mitiku Teshome Hambisa
- Research Centre for Generational Health and Ageing, University of Newcastle, P.O. Box 2308, Callghan, New Castle, NSW, Australia
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Solnes Miltenburg A, van der Eem L, Nyanza EC, van Pelt S, Ndaki P, Basinda N, Sundby J. Antenatal care and opportunities for quality improvement of service provision in resource limited settings: A mixed methods study. PLoS One 2017; 12:e0188279. [PMID: 29236699 PMCID: PMC5728494 DOI: 10.1371/journal.pone.0188279] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 11/04/2017] [Indexed: 12/01/2022] Open
Abstract
Antenatal care is essential to improve maternal and newborn health and wellbeing. The majority of pregnant women in Tanzania attend at least one visit. Since implementation of the focused antenatal care model, quality of care assessments have mostly focused on utilization and coverage of routine interventions for antenatal care. This study aims to assess the quality of antenatal care provision from a holistic perspective in a rural district in Tanzania. Structure, process and outcome components of quality are explored. This paper reports on data collected over several periods from 2012 to 2015 through facility audits of supplies and services, ANC observations and exit interviews with pregnant women. Additional qualitative methods were used such as interviews, focus group observations and participant observations. Findings indicate variable performance of routine ANC services, partly explained by insufficient resources. Poor performance was also observed for appropriate history taking, attention for client's wellbeing, basic physical examination and adequate counseling and education. Achieving quality improvement for ANC requires increased attention for the process of care provision beyond coverage, including attention for response-based services, which should be assessed based on locally determined criteria.
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Affiliation(s)
- Andrea Solnes Miltenburg
- Institute of Health and Society, Section for International Health, Faculty of Medicine, University of Oslo, Oslo, Norway
- Women Centered Care Project, a project of the African Woman Foundation, Magu District, Mwanza Region, Tanzania
| | - Lisette van der Eem
- Women Centered Care Project, a project of the African Woman Foundation, Magu District, Mwanza Region, Tanzania
- Department of Work and Social Psychology, Maastricht University, Maastricht, the Netherlands
| | - Elias C. Nyanza
- School of Public Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Sandra van Pelt
- Women Centered Care Project, a project of the African Woman Foundation, Magu District, Mwanza Region, Tanzania
| | - Pendo Ndaki
- School of Public Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Namanya Basinda
- School of Public Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Johanne Sundby
- Institute of Health and Society, Section for International Health, Faculty of Medicine, University of Oslo, Oslo, Norway
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Symon A, Pringle J, Downe S, Hundley V, Lee E, Lynn F, McFadden A, McNeill J, Renfrew MJ, Ross-Davie M, van Teijlingen E, Whitford H, Alderdice F. Antenatal care trial interventions: a systematic scoping review and taxonomy development of care models. BMC Pregnancy Childbirth 2017; 17:8. [PMID: 28056877 PMCID: PMC5216531 DOI: 10.1186/s12884-016-1186-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 12/07/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antenatal care models vary widely around the world, reflecting local contexts, drivers and resources. Randomised controlled trials (RCTs) have tested the impact of multi-component antenatal care interventions on service delivery and outcomes in many countries since the 1980s. Some have applied entirely new schemes, while others have modified existing care delivery approaches. Systematic reviews (SRs) indicate that some specific antenatal interventions are more effective than others; however the causal mechanisms leading to better outcomes are poorly understood, limiting implementation and future research. As a first step in identifying what might be making the difference we conducted a scoping review of interventions tested in RCTs in order to establish a taxonomy of antenatal care models. METHODS A protocol-driven systematic search was undertaken of databases for RCTs and SRs reporting antenatal care interventions. Results were unrestricted by time or locality, but limited to English language. Key characteristics of both experimental and control interventions in the included trials were mapped using SPIO (Study design; Population; Intervention; Outcomes) criteria and the intervention and principal outcome measures were described. Commonalities and differences between the components that were being tested in each study were identified by consensus, resulting in a comprehensive description of emergent models for antenatal care interventions. RESULTS Of 13,050 articles retrieved, we identified 153 eligible articles including 130 RCTs in 34 countries. The interventions tested in these trials varied from the number of visits to the location of care provision, and from the content of care to the professional/lay group providing that care. In most studies neither intervention nor control arm was well described. Our analysis of the identified trials of antenatal care interventions produced the following taxonomy: Universal provision model (for all women irrespective of health state or complications); Restricted 'lower-risk'-based provision model (midwifery-led or reduced/flexible visit approach for healthy women); Augmented provision model (antenatal care as in Universal provision above but augmented by clinical, educational or behavioural intervention); Targeted 'higher-risk'-based provision model (for woman with defined clinical or socio-demographic risk factors). The first category was most commonly tested in low-income countries (i.e. resource-poor settings), particularly in Asia. The other categories were tested around the world. The trials included a range of care providers, including midwives, nurses, doctors, and lay workers. CONCLUSIONS Interventions can be defined and described in many ways. The intended antenatal care population group proved the simplest and most clinically relevant way of distinguishing trials which might otherwise be categorised together. Since our review excluded non-trial interventions, the taxonomy does not represent antenatal care provision worldwide. It offers a stable and reproducible approach to describing the purpose and content of models of antenatal care which have been tested in a trial. It highlights a lack of reported detail of trial interventions and usual care processes. It provides a baseline for future work to examine and test the salient characteristics of the most effective models, and could also help decision-makers and service planners in planning implementation.
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Affiliation(s)
- Andrew Symon
- Mother & Infant Research Unit, University of Dundee, DD1 4HJ Dundee, UK
| | - Jan Pringle
- School of Nursing & Health Sciences, University of Dundee, DD1 4HJ Dundee, UK
| | - Soo Downe
- School of Health, Brook Building, University of Central Lancashire, Preston, PR1 2HE UK
| | - Vanora Hundley
- Centre for Midwifery, Maternal & Perinatal Health, Faculty of Health & Social Sciences, Bournemouth University, BU1 3LH Poole, UK
| | - Elaine Lee
- Mother & Infant Research Unit, University of Dundee, DD1 4HJ Dundee, UK
| | - Fiona Lynn
- School of Nursing & Midwifery, Queens University, Belfast, BT9 7BL UK
| | - Alison McFadden
- Mother & Infant Research Unit, University of Dundee, DD1 4HJ Dundee, UK
| | - Jenny McNeill
- School of Nursing & Midwifery, Queens University, Belfast, BT9 7BL UK
| | - Mary J Renfrew
- Mother & Infant Research Unit, University of Dundee, DD1 4HJ Dundee, UK
| | - Mary Ross-Davie
- Maternal & Child Health, NHS Education for Scotland, Edinburgh, EH3 9DN UK
| | - Edwin van Teijlingen
- Centre for Midwifery, Maternal & Perinatal Health, Faculty of Health & Social Sciences, Bournemouth University, BU1 3LH Poole, UK
| | - Heather Whitford
- Mother & Infant Research Unit, University of Dundee, DD1 4HJ Dundee, UK
| | - Fiona Alderdice
- School of Nursing & Midwifery, Queens University, Belfast, BT9 7BL UK
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Villadsen SF, Negussie D, GebreMariam A, Tilahun A, Girma T, Friis H, Rasch V. Antenatal care strengthening for improved health behaviours in Jimma, Ethiopia, 2009-2011: An effectiveness study. Midwifery 2016; 40:87-94. [PMID: 27428103 DOI: 10.1016/j.midw.2016.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 05/06/2016] [Accepted: 06/06/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION health systems in low-income settings are not sufficiently reaching the poor, and global disparities in reproductive health persist. The frequency and quality of health education during antenatal care is often low. Further studies are needed on how to improve the performance of health systems in low income settings to improve maternal and child health. OBJECTIVES to assess the effectiveness of a participatory antenatal care intervention on health behaviours and to illuminate how the different socioeconomic groups responded to the intervention in Jimma, Ethiopia. SETTING, INTERVENTION AND MEASUREMENTS: an intervention was designed participatorily and comprised trainings, supervisions, equipment, health education material, and adaption of guidelines. It was implemented at public facilities. Household surveys, before (2008) and after (2010) intervention, were conducted amongst all women who had given birth within the previous 12 months. The effect of the intervention was assessed by comparing the change in health behaviours (number of antenatal visits, health facility delivery, breast feeding, preventive infant health check, and infant immunisation) from before to after the intervention period at intervention sites, relative to control sites, using logistic mixed effect regression. RESULTS on the basis of 1357 women included before and 2262 after the intervention, there were positive effects of the intervention on breast feeding practices (OR 3.0, 95% CI: 1.4; 3.6) and preventive infant health check (OR 2.4, 95% CI: 1.5; 3.5). There was no effect on infant immunisation coverage and negative effect on number of antenatal visits. The effect on various outcomes was modified by maternal education, and results indicate increased health facility delivery (OR 2.4, 95% CI: 0.8; 6.9) and breast feeding practices (OR 18.2, 95% CI: 5.2;63.6) among women with no education. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE the facility based intervention improved some, but not all health behaviours. The improvements indicated amongst the most disadvantaged antenatal care attendants in breast feeding and health facility delivery are encouraging and underline the need to scale up priority of antenatal care in the effort to reduce maternal and child health inequity.
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Affiliation(s)
- Sarah Fredsted Villadsen
- Department of Nutrition, Exercise and Sport, Faculty of Science, University of Copenhagen, Rolighedsvej 25, 1958 Frb. C, Denmark; Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Oester Farimagsgade 5, Post box 2099, 1014 Copenhagen K, Denmark.
| | - Dereje Negussie
- Department of Obstetrics and Gynaecology, Jimma University Specialized Hospital, Post Box 480, Jimma, Ethiopia
| | - Abebe GebreMariam
- Department of Population and Family Health, Jimma University, Post Box 480, Jimma, Ethiopia
| | - Abebech Tilahun
- JUCAN Research Collaboration, Jimma University, Post Box 480, Jimma, Ethiopia
| | - Tsinuel Girma
- Department of Paediatrics, Jimma University Specialized Hospital, Jimma, Ethiopia
| | - Henrik Friis
- Department of Nutrition, Exercise and Sport, Faculty of Science, University of Copenhagen, Rolighedsvej 25, 1958 Frb. C, Denmark
| | - Vibeke Rasch
- Department of Obstetrics and Gynaecology, Odense University Hospital, Soendre Boulevard 29, Odense, Denmark
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Mbuagbaw L, Medley N, Darzi AJ, Richardson M, Habiba Garga K, Ongolo‐Zogo P. Health system and community level interventions for improving antenatal care coverage and health outcomes. Cochrane Database Syst Rev 2015; 2015:CD010994. [PMID: 26621223 PMCID: PMC4676908 DOI: 10.1002/14651858.cd010994.pub2] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The World Health Organization (WHO) recommends at least four antenatal care (ANC) visits for all pregnant women. Almost half of pregnant women worldwide, and especially in developing countries do not receive this amount of care. Poor attendance of ANC is associated with delivery of low birthweight babies and more neonatal deaths. ANC may include education on nutrition, potential problems with pregnancy or childbirth, child care and prevention or detection of disease during pregnancy.This review focused on community-based interventions and health systems-related interventions. OBJECTIVES To assess the effects of health system and community interventions for improving coverage of antenatal care and other perinatal health outcomes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 June 2015) and reference lists of retrieved studies. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi-randomised trials and cluster-randomised trials. Trials of any interventions to improve ANC coverage were eligible for inclusion. Trials were also eligible if they targeted specific and related outcomes, such as maternal or perinatal death, but also reported ANC coverage. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS We included 34 trials involving approximately 400,000 women. Some trials tested community-based interventions to improve uptake of antenatal care (media campaigns, education or financial incentives for pregnant women), while other trials looked at health systems interventions (home visits for pregnant women or equipment for clinics). Most trials took place in low- and middle-income countries, and 29 of the 34 trials used a cluster-randomised design. We assessed 30 of the 34 trials as of low or unclear overall risk of bias. Comparison 1: One intervention versus no interventionWe found marginal improvements in ANC coverage of at least four visits (average odds ratio (OR) 1.11, 95% confidence interval (CI) 1.01 to 1.22; participants = 45,022; studies = 10; Heterogeneity: Tau² = 0.01; I² = 52%; high quality evidence). Sensitivity analysis with a more conservative intra-cluster correlation co-efficient (ICC) gave similar marginal results. Excluding one study at high risk of bias shifted the marginal pooled estimate towards no effect. There was no effect on pregnancy-related deaths (average OR 0.69, 95% CI 0.45 to 1.08; participants = 114,930; studies = 10; Heterogeneity: Tau² = 0.00; I² = 0%; low quality evidence), perinatal mortality (average OR 0.98, 95% CI 0.90 to 1.07; studies = 15; Heterogeneity: Tau² = 0.01; I² = 58%; moderate quality evidence) or low birthweight (average OR 0.94, 95% CI 0.82 to 1.06; studies = five; Heterogeneity: Tau² = 0.00; I² = 5%; high quality evidence). Single interventions led to marginal improvements in the number of women who delivered in health facilities (average OR 1.08, 95% CI 1.02 to 1.15; studies = 10; Heterogeneity: Tau² = 0.00; I² = 0%; high quality evidence), and in the proportion of women who had at least one ANC visit (average OR 1.68, 95% CI 1.02 to 2.79; studies = six; Heterogeneity: Tau² = 0.24; I² = 76%; moderate quality evidence). Results for ANC coverage (at least four and at least one visit) and for perinatal mortality had substantial statistical heterogeneity. Single interventions did not improve the proportion of women receiving tetanus protection (average OR 1.03, 95% CI 0.92 to 1.15; studies = 8; Heterogeneity: Tau² = 0.01; I² = 57%). No study reported onintermittent prophylactic treatment for malaria. Comparison 2: Two or more interventions versus no interventionWe found no improvements in ANC coverage of four or more visits (average OR 1.48, 95% CI 0.99 to 2.21; participants = 7840; studies = six; Heterogeneity: Tau² = 0.10; I² = 48%; low quality evidence) or pregnancy-related deaths (average OR 0.70, 95% CI 0.39 to 1.26; participants = 13,756; studies = three; Heterogeneity: Tau² = 0.00; I² = 0%; moderate quality evidence). However, combined interventions led to improvements in ANC coverage of at least one visit (average OR 1.79, 95% CI 1.47 to 2.17; studies = five; Heterogeneity: Tau² = 0.00; I² = 0%; moderate quality evidence), perinatal mortality (average OR 0.74, 95% CI 0.57 to 0.95; studies = five; Heterogeneity: Tau² = 0.06; I² = 83%; moderate quality evidence) and low birthweight (average OR 0.61, 95% CI 0.46 to 0.80; studies = two; Heterogeneity: Tau² = 0.00; I² = 0%; moderate quality evidence). Meta-analyses for both ANC coverage four or more visits and perinatal mortality had substantial statistical heterogeneity. Combined interventions improved the proportion of women who had tetanus protection (average OR 1.48, 95% CI 1.18 to 1.87; studies = 3; Heterogeneity: Tau² = 0.01; I² = 33%). No trial in this comparison reported on intermittent prophylactic treatment for malaria. Comparison 3: Two interventions compared head to head. No trials found. Comparison 4: One intervention versus a combination of interventionsThere was no difference in ANC coverage (four or more visits and at least one visit), pregnancy-related deaths, deliveries in a health facility or perinatal mortality. No trials in this comparison reported on low birthweight orintermittent prophylactic treatment of malaria. AUTHORS' CONCLUSIONS Implications for practice - Single interventions may improve ANC coverage (at least one visit and four or more visits) and deliveries in health facilities. Combined interventions may improve ANC coverage (at least one visit), reduce perinatal mortality and reduce the occurrence of low birthweight. The effects of the interventions are unrelated to whether they are community or health system interventions. Implications for research - More details should be provided in reporting numbers of events, group totals and the ICCs used to adjust for cluster effects. Outcomes should be reported uniformly so that they are comparable to commonly-used population indicators. We recommend further cluster-RCTs of pregnant women and women in their reproductive years, using combinations of interventions and looking at outcomes that are important to pregnant women, such as maternal and perinatal morbidity and mortality, alongside the explanatory outcomes along the pathway of care: ANC coverage, the services provided during ANC and deliveries in health facilities.
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Affiliation(s)
- Lawrence Mbuagbaw
- Yaoundé Central HospitalCentre for the Development of Best Practices in Health (CDBPH)Henri Dunant AvenuePO Box 87YaoundéCameroon
- South African Medical Research CouncilSouth African Cochrane CentreTygerbergSouth Africa
| | - Nancy Medley
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Andrea J Darzi
- Clinical Research Institute (American University of Beirut Medical Center)Clinical Epidemiological UnitGefinor 4th FloorHamraBeirutLebanon
| | - Marty Richardson
- Liverpool School of Tropical MedicineCochrane Infectious Diseases GroupPembroke PlaceLiverpoolUKL3 5QA
| | - Kesso Habiba Garga
- Yaoundé Central HospitalCentre for the Development of Best Practices in Health (CDBPH)Henri Dunant AvenuePO Box 87YaoundéCameroon
| | - Pierre Ongolo‐Zogo
- Yaoundé Central HospitalCentre for the Development of Best Practices in Health (CDBPH)Henri Dunant AvenuePO Box 87YaoundéCameroon
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Kikuchi K, Ansah EK, Okawa S, Enuameh Y, Yasuoka J, Nanishi K, Shibanuma A, Gyapong M, Owusu-Agyei S, Oduro AR, Asare GQ, Hodgson A, Jimba M. Effective Linkages of Continuum of Care for Improving Neonatal, Perinatal, and Maternal Mortality: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0139288. [PMID: 26422685 PMCID: PMC4589290 DOI: 10.1371/journal.pone.0139288] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 09/09/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Continuum of care has the potential to improve maternal, newborn, and child health (MNCH) by ensuring care for mothers and children. Continuum of care in MNCH is widely accepted as comprising sequential time (from pre-pregnancy to motherhood and childhood) and space dimensions (from community-family care to clinical care). However, it is unclear which linkages of care could have a greater effect on MNCH outcomes. The objective of the present study is to assess the effectiveness of different continuum of care linkages for reducing neonatal, perinatal, and maternal mortality in low- and middle-income countries. METHODS We searched for randomized and quasi-randomized controlled trials that addressed two or more linkages of continuum of care and attempted to increase mothers' uptake of antenatal care, skilled birth attendance, and postnatal care. The outcome variables were neonatal, perinatal, and maternal mortality. RESULTS Out of the 7,142 retrieved articles, we selected 19 as eligible for the final analysis. Of these studies, 13 used packages of intervention that linked antenatal care, skilled birth attendance, and postnatal care. One study each used packages that linked antenatal care and skilled birth attendance or skilled birth attendance and postnatal care. Four studies used an intervention package that linked antenatal care and postnatal care. Among the packages that linked antenatal care, skilled birth attendance, and postnatal care, a significant reduction was observed in combined neonatal, perinatal, and maternal mortality risks (RR 0.83; 95% CI 0.77 to 0.89, I2 79%). Furthermore, this linkage reduced combined neonatal, perinatal, and maternal mortality when integrating the continuum of care space dimension (RR 0.85; 95% CI 0.77 to 0.93, I2 81%). CONCLUSIONS Our review suggests that continuous uptake of antenatal care, skilled birth attendance, and postnatal care is necessary to improve MNCH outcomes in low- and middle-income countries. The review was conclusive for the reduction of neonatal and perinatal deaths. Although maternal deaths were not significantly reduced, composite measures of all mortality were. Thus, the evidence is sufficient to scale up this intervention package for the improvement of MNCH outcomes.
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Affiliation(s)
- Kimiyo Kikuchi
- Department of Community and Global Health, Graduate School of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113–0033, Tokyo, Japan
| | | | - Sumiyo Okawa
- Department of Community and Global Health, Graduate School of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113–0033, Tokyo, Japan
| | - Yeetey Enuameh
- Kintampo Health Research Centre, Kintampo, Brong-Ahafo, Ghana
| | - Junko Yasuoka
- Department of Community and Global Health, Graduate School of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113–0033, Tokyo, Japan
| | - Keiko Nanishi
- Department of Community and Global Health, Graduate School of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113–0033, Tokyo, Japan
| | - Akira Shibanuma
- Department of Community and Global Health, Graduate School of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113–0033, Tokyo, Japan
| | | | | | | | | | - Abraham Hodgson
- Research and Development Division, Ghana Health Service, Accra, Ghana
| | - Masamine Jimba
- Department of Community and Global Health, Graduate School of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113–0033, Tokyo, Japan
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8
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Dowswell T, Carroli G, Duley L, Gates S, Gülmezoglu AM, Khan‐Neelofur D, Piaggio G. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database Syst Rev 2015; 2015:CD000934. [PMID: 26184394 PMCID: PMC7061257 DOI: 10.1002/14651858.cd000934.pub3] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The number of visits for antenatal (prenatal) care developed without evidence of how many visits are necessary. The content of each visit also needs evaluation. OBJECTIVES To compare the effects of antenatal care programmes with reduced visits for low-risk women with standard care. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 March 2015), reference lists of articles and contacted researchers in the field. SELECTION CRITERIA Randomised trials comparing a reduced number of antenatal visits, with or without goal-oriented care, versus standard care. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked for accuracy. We assessed studies for risk of bias and graded the quality of the evidence. MAIN RESULTS We included seven trials (more than 60,000 women): four in high-income countries with individual randomisation; three in low- and middle-income countries with cluster randomisation (clinics as the unit of randomisation). Most of the data included in the review came from the three large, well-designed cluster-randomised trials that took place in Argentina, Cuba, Saudi Arabia, Thailand and Zimbabwe. All results have been adjusted for the cluster design effect. All of the trials were at some risk of bias as blinding of women and staff was not feasible with this type of intervention. For primary outcomes, evidence was graded as being of moderate or low quality, with downgrading decisions due to risks of bias and imprecision of effects.The number of visits for standard care varied, with fewer visits in low- and middle- income country trials. In studies in high-income countries, women in the reduced visits groups, on average, attended between 8.2 and 12 times. In low- and middle- income country trials, many women in the reduced visits group attended on fewer than five occasions, although in these trials the content as well as the number of visits was changed, so as to be more 'goal-oriented'.Perinatal mortality was increased for those randomised to reduced visits rather than standard care, and this difference was borderline for statistical significance (risk ratio (RR) 1.14; 95% confidence interval (CI) 1.00 to 1.31; five trials, 56,431 babies; moderate-quality evidence). In the subgroup analysis, for high-income countries the number of deaths was small (32/5108), and there was no clear difference between the groups (RR 0.90; 95% CI 0.45 to 1.80, two trials); for low- and middle-income countries perinatal mortality was significantly higher in the reduced visits group (RR 1.15; 95% CI 1.01 to 1.32, three trials).There was no clear difference between groups for our other primary outcomes: maternal death (RR 1.13, 95%CI 0.50 to 2.57, three cluster-randomised trials, 51,504 women, low-quality evidence); hypertensive disorders of pregnancy (various definitions including pre-eclampsia) (RR 0.95, 95% CI 0.80 to 1.12, six studies, 54,108 women, low-quality evidence); preterm birth (RR 1.02, 95% CI 0.94 to 1.11; seven studies, 53,661 women, moderate-quality evidence); and small-for-gestational age (RR 0.99, 95% CI 0.91 to 1.09, four studies 43,045 babies, moderate-quality evidence).Reduced visits were associated with a reduction in admission to neonatal intensive care that was borderline for significance (RR 0.89; 95% CI 0.79 to 1.02, five studies, 43,048 babies, moderate quality evidence). There were no clear differences between the groups for the other secondary clinical outcomes.Women in all settings were less satisfied with the reduced visits schedule and perceived the gap between visits as too long. Reduced visits may be associated with lower costs. AUTHORS' CONCLUSIONS In settings with limited resources where the number of visits is already low, reduced visits programmes of antenatal care are associated with an increase in perinatal mortality compared to standard care, although admission to neonatal intensive care may be reduced. Women prefer the standard visits schedule. Where the standard number of visits is low, visits should not be reduced without close monitoring of fetal and neonatal outcome.
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Affiliation(s)
- Therese Dowswell
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Guillermo Carroli
- Centro Rosarino de Estudios Perinatales (CREP)Moreno 878 piso 6RosarioSanta FeArgentina2000
| | - Lelia Duley
- Nottingham Health Science PartnersNottingham Clinical Trials UnitC Floor, South BlockQueen's Medical CentreNottinghamUKNG7 2UH
| | - Simon Gates
- Division of Health Sciences, Warwick Medical School, The University of WarwickWarwick Clinical Trials UnitGibbet Hill RoadCoventryUKCV4 7AL
| | - A Metin Gülmezoglu
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | | | - Gilda Piaggio
- London School of Hygiene and Tropical MedicineMedical Statistics DepartmentLondonUK
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Moreno R, Nababan HY, Ota E, Wariki WMV, Ezoe S, Gilmour S, Shibuya K. Structural and community-level interventions for increasing condom use to prevent the transmission of HIV and other sexually transmitted infections. Cochrane Database Syst Rev 2014:CD003363. [PMID: 25072817 DOI: 10.1002/14651858.cd003363.pub3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Community interventions to promote condom use are considered to be a valuable tool to reduce the transmission of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). In particular, special emphasis has been placed on implementing such interventions through structural changes, a concept that implies public health actions that aim to improve society's health through modifications in the context wherein health-related risk behavior takes place. This strategy attempts to increase condom use and in turn lower the transmission of HIV and other STIs. OBJECTIVES To assess the effects of structural and community-level interventions for increasing condom use in both general and high-risk populations to reduce the incidence of HIV and STI transmission by comparing alternative strategies, or by assessing the effects of a strategy compared with a control. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, from 2007, Issue 1), as well as MEDLINE, EMBASE, AEGIS and ClinicalTrials.gov, from January 1980 to April 2014. We also handsearched proceedings of international acquired immunodeficiency syndrome (AIDS) conferences, as well as major behavioral studies conferences focusing on HIV/AIDS and STIs. SELECTION CRITERIA Randomized control trials (RCTs) featuring all of the following.1. Community interventions ('community' defined as a geographical entity, such as cities, counties, villages).2. One or more structural interventions whose objective was to promote condom use. These type of interventions can be defined as those actions improving accessibility, availability and acceptability of any given health program/technology.3. Trials that confirmed biological outcomes using laboratory testing. DATA COLLECTION AND ANALYSIS Two authors independently screened and selected relevant studies, and conducted further risk of bias assessment. We assessed the effect of treatment by pooling trials with comparable characteristics and quantified its effect size using risk ratio. The effect of clustering at the community level was addressed through intra-cluster correlation coefficients (ICCs), and sensitivity analysis was carried out with different design effect values. MAIN RESULTS We included nine trials (plus one study that was a subanalysis) for quantitative assessment. The studies were conducted in Tanzania, Zimbabwe, South Africa, Uganda, Kenya, Peru, China, India and Russia, comprising 75,891 participants, mostly including the general population (not the high-risk population). The main intervention was condom promotion, or distribution, or both. In general, control groups did not receive any active intervention. The main risk of bias was incomplete outcome data.In the meta-analysis, there was no clear evidence that the intervention had an effect on either HIV seroprevalence or HIV seroincidence when compared to controls: HIV incidence (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.69 to 1.19) and HIV prevalence (RR 1.02, 95% CI 0.79 to 1.32). The estimated effect of the intervention on other outcomes was similarly uncertain: Herpes simplex virus 2 (HSV-2) incidence (RR 0.76, 95% CI 0.55 to 1.04); HSV-2 prevalence (RR 1.01, 95% CI 0.85 to 1.20); syphilis prevalence (RR 0.91, 95% CI 0.71 to 1.17); gonorrhoea prevalence (RR 1.16, 95% CI 0.67 to 2.02); chlamydia prevalence (RR 0.94, 95% CI 0.75 to 1.18); and trichomonas prevalence (RR 1.00, 95% CI 0.77 to 1.30). Reported condom use increased in the experimental arm (RR 1.20, 95% CI 1.03 to 1.40). In the intervention groups, the number of people reporting two or more sexual partners in the past year did not show a clear decrease when compared with control groups (RR 0.90, 95% CI 0.78 to 1.04), but knowledge about HIV and other STIs improved (RR 1.15, 95% CI 1.04 to 1.28, and RR 1.23, 95% CI 1.07 to 1.41, respectively). The quality of the evidence was deemed to be moderate for nearly all key outcomes. AUTHORS' CONCLUSIONS There is no clear evidence that structural interventions at the community level to increase condom use prevent the transmission of HIV and other STIs. However, this conclusion should be interpreted with caution since our results have wide confidence intervals and the results for prevalence may be affected by attrition bias. In addition, it was not possible to find RCTs in which extended changes to policies were conducted and the results only apply to general populations in developing nations, particularly to Sub-Saharan Africa, a region which in turn is widely diverse.
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Affiliation(s)
- Ralfh Moreno
- Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Lund S, Rasch V, Hemed M, Boas IM, Said A, Said K, Makundu MH, Nielsen BB. Mobile phone intervention reduces perinatal mortality in zanzibar: secondary outcomes of a cluster randomized controlled trial. JMIR Mhealth Uhealth 2014; 2:e15. [PMID: 25098184 PMCID: PMC4114456 DOI: 10.2196/mhealth.2941] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 01/17/2014] [Accepted: 02/05/2014] [Indexed: 12/19/2022] Open
Abstract
Background Mobile phones are increasingly used in health systems in developing countries and innovative technical solutions have great potential to overcome barriers of access to reproductive and child health care. However, despite widespread support for the use of mobile health technologies, evidence for its role in health care is sparse. Objective We aimed to evaluate the association between a mobile phone intervention and perinatal mortality in a resource-limited setting. Methods This study was a pragmatic, cluster-randomized, controlled trial with primary health care facilities in Zanzibar as the unit of randomization. At their first antenatal care visit, 2550 pregnant women (1311 interventions and 1239 controls) who attended antenatal care at selected primary health care facilities were included in this study and followed until 42 days after delivery. Twenty-four primary health care facilities in six districts were randomized to either mobile phone intervention or standard care. The intervention consisted of a mobile phone text message and voucher component. Secondary outcome measures included stillbirth, perinatal mortality, and death of a child within 42 days after birth as a proxy of neonatal mortality. Results Within the first 42 days of life, 2482 children were born alive, 54 were stillborn, and 36 died. The overall perinatal mortality rate in the study was 27 per 1000 total births. The rate was lower in the intervention clusters, 19 per 1000 births, than in the control clusters, 36 per 1000 births. The intervention was associated with a significant reduction in perinatal mortality with an odds ratio (OR) of 0.50 (95% CI 0.27-0.93). Other secondary outcomes showed an insignificant reduction in stillbirth (OR 0.65, 95% CI 0.34-1.24) and an insignificant reduction in death within the first 42 days of life (OR 0.79, 95% CI 0.36-1.74). Conclusions Mobile phone applications may contribute to improved health of the newborn and should be considered by policy makers in resource-limited settings. Trial Registration ClinicalTrials.gov NCT01821222; http://www.clinicaltrials.gov/ct2/show/NCT01821222 (Archived by WebCite at http://www.webcitation.org/6NqxnxYn0).
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Affiliation(s)
- Stine Lund
- Department of International Health, Immunology and Microbiology, University of Copenhagen, Copenhagen N, Denmark.
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Lund S, Nielsen BB, Hemed M, Boas IM, Said A, Said K, Makungu MH, Rasch V. Mobile phones improve antenatal care attendance in Zanzibar: a cluster randomized controlled trial. BMC Pregnancy Childbirth 2014; 14:29. [PMID: 24438517 PMCID: PMC3898378 DOI: 10.1186/1471-2393-14-29] [Citation(s) in RCA: 158] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 01/07/2014] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Applying mobile phones in healthcare is increasingly prioritized to strengthen healthcare systems. Antenatal care has the potential to reduce maternal morbidity and improve newborns' survival but this benefit may not be realized in sub-Saharan Africa where the attendance and quality of care is declining. We evaluated the association between a mobile phone intervention and antenatal care in a resource-limited setting. We aimed to assess antenatal care in a comprehensive way taking into consideration utilisation of antenatal care as well as content and timing of interventions during pregnancy. METHODS This study was an open label pragmatic cluster-randomised controlled trial with primary healthcare facilities in Zanzibar as the unit of randomisation. 2550 pregnant women (1311 interventions and 1239 controls) who attended antenatal care at selected primary healthcare facilities were included at their first antenatal care visit and followed until 42 days after delivery. 24 primary health care facilities in six districts were randomized to either mobile phone intervention or standard care. The intervention consisted of a mobile phone text-message and voucher component. Primary outcome measure was four or more antenatal care visits during pregnancy. Secondary outcome measures were tetanus vaccination, preventive treatment for malaria, gestational age at last antenatal care visit, and antepartum referral. RESULTS The mobile phone intervention was associated with an increase in antenatal care attendance. In the intervention group 44% of the women received four or more antenatal care visits versus 31% in the control group (OR, 2.39; 95% CI, 1.03-5.55). There was a trend towards improved timing and quality of antenatal care services across all secondary outcome measures although not statistically significant. CONCLUSIONS The wired mothers' mobile phone intervention significantly increased the proportion of women receiving the recommended four antenatal care visits during pregnancy and there was a trend towards improved quality of care with more women receiving preventive health services, more women attending antenatal care late in pregnancy and more women with antepartum complications identified and referred. Mobile phone applications may contribute towards improved maternal and newborn health and should be considered by policy makers in resource-limited settings.
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Affiliation(s)
- Stine Lund
- Department of International Health, Immunology and Microbiology, University of Copenhagen, Blegdamsvej 3, 2200 Copenhagen, Denmark
| | - Birgitte B Nielsen
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
| | - Maryam Hemed
- Ministry of Health, Revolutionary Government of Zanzibar, Stonetown, Zanzibar, Tanzania
| | - Ida M Boas
- Department of International Health, Immunology and Microbiology, University of Copenhagen, Blegdamsvej 3, 2200 Copenhagen, Denmark
| | - Azzah Said
- Ministry of Health, Revolutionary Government of Zanzibar, Stonetown, Zanzibar, Tanzania
| | - Khadija Said
- Ministry of Health, Revolutionary Government of Zanzibar, Stonetown, Zanzibar, Tanzania
| | - Mkoko H Makungu
- Ministry of Health, Revolutionary Government of Zanzibar, Stonetown, Zanzibar, Tanzania
| | - Vibeke Rasch
- Department of International Health, Immunology and Microbiology, University of Copenhagen, Blegdamsvej 3, 2200 Copenhagen, Denmark
- Department of Obstetrics and Gynaecology, Odense University Hospital, Odense, Denmark
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Soubeiga D, Sia D, Gauvin L. Increasing institutional deliveries among antenatal clients: effect of birth preparedness counselling. Health Policy Plan 2013; 29:1061-70. [PMID: 24270519 DOI: 10.1093/heapol/czt089] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The World Health Organization recommends birth and emergency preparedness (BEP) as essential components of the Focused Antenatal Care model. The purpose of providing BEP messages to women during their antenatal visits is to increase the use of skilled attendance at childbirth. However, the effectiveness of this component has not yet been clearly established in routine contexts. This retrospective cohort study examined the association between exposing women to BEP messages during antenatal visits and the use of the skilled attendance at childbirth in two rural districts of Burkina Faso (Koupela and Dori). The study included 456 antenatal care users in 30 rural health centres in these two districts. Data were collected using modified questionnaires from the Johns Hopkins Program for International Education in Gynecology and Obstetrics and from demographic and health surveys. Logistic regression was performed with a model of generalized estimating equation to adjust for clustered effects. In the Koupela district, where the rate of institutional deliveries (80%) was relatively high, the use of BEP messages was not associated with an increase in institutional deliveries. In contrast, in the district of Dori, where the rate of institutional deliveries (47%) was lower, messages regarding danger signs [Adjusted Odds Ratio (AOR) = 1.93; 95% Confidence Interval (CI): 1.07, 3.49] and cost of care (AOR = 2.13; 95% CI: 1.09, 4.22) were associated with an increased probability of institutional births. Based on these results, it appears that birth and emergency preparedness messages provided during antenatal visits may increase the use of skilled attendance (increase the rate of institutional births) in areas where institutional births are low. Therefore, it is important to adapt the content of the messages to meet the particular needs of the users in each locality. Furthermore, BEP counselling should be implemented in health facilities.
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Affiliation(s)
- Dieudonné Soubeiga
- Department of Health Management, Faculty of Medicine, University of Montreal, Montreal, QC, Canada, Department of Quality and Safety, Sainte Justine University Hospital Center, Montreal, QC, Canada, Institute for Health and Social Policy, McGill University, Montreal, QC, Canada and Department of Social and Preventive Medicine, Faculty of Medicine, University of Montreal, QC, Canada Department of Health Management, Faculty of Medicine, University of Montreal, Montreal, QC, Canada, Department of Quality and Safety, Sainte Justine University Hospital Center, Montreal, QC, Canada, Institute for Health and Social Policy, McGill University, Montreal, QC, Canada and Department of Social and Preventive Medicine, Faculty of Medicine, University of Montreal, QC, Canada
| | - Drissa Sia
- Department of Health Management, Faculty of Medicine, University of Montreal, Montreal, QC, Canada, Department of Quality and Safety, Sainte Justine University Hospital Center, Montreal, QC, Canada, Institute for Health and Social Policy, McGill University, Montreal, QC, Canada and Department of Social and Preventive Medicine, Faculty of Medicine, University of Montreal, QC, Canada
| | - Lise Gauvin
- Department of Health Management, Faculty of Medicine, University of Montreal, Montreal, QC, Canada, Department of Quality and Safety, Sainte Justine University Hospital Center, Montreal, QC, Canada, Institute for Health and Social Policy, McGill University, Montreal, QC, Canada and Department of Social and Preventive Medicine, Faculty of Medicine, University of Montreal, QC, Canada
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Patil CL, Abrams ET, Klima C, Kaponda CP, Leshabari SC, Vonderheid SC, Kamaga M, Norr KF. CenteringPregnancy-Africa: a pilot of group antenatal care to address Millennium Development Goals. Midwifery 2013; 29:1190-8. [PMID: 23871278 PMCID: PMC3786019 DOI: 10.1016/j.midw.2013.05.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 05/21/2013] [Accepted: 05/23/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND severe health worker shortages and resource limitations negatively affect quality of antenatal care (ANC) throughout sub-Saharan Africa. Group ANC, specifically CenteringPregnancy (CP), may offer an innovative approach to enable midwives to offer higher quality ANC. OBJECTIVE our overarching goal was to prepare to conduct a clinical trial of CenteringPregnancy-Africa (CP-Africa) in Malawi and Tanzania. In Phase 1, our goal was to determine the acceptability of CP as a model for ANC in both countries. In Phase 2, our objective was to develop CP-Africa session content consistent with the Essential Elements of CP model and with national standards in both Malawi and Tanzania. In Phase 3, our objective was to pilot CP-Africa in Malawi to determine whether sessions could be conducted with fidelity to the Centering process. SETTING Phases 1 and 2 took place in Malawi and Tanzania. Phase 3, the piloting of two sessions of CP-Africa, occurred at two sites in Malawi: a district hospital and a small clinic. DESIGN we used an Action Research approach to promote partnerships among university researchers, the Centering Healthcare Institute, health care administrators, health professionals and women attending ANC to develop CP-Africa session content and pilot this model of group ANC. PARTICIPANTS for Phases 1 and 2, members of the Ministries of Health, health professionals and pregnant women in Malawi and Tanzania were introduced to and interviewed about CP. In Phase 2, we finalised CP-Africa content and trained 13 health professionals in the Centering Healthcare model. In Phase 3, we conducted a small pilot with 24 pregnant women (12 at each site). MEASUREMENTS AND FINDINGS participants enthusiastically embraced CP-Africa as an acceptable model of ANC health care delivery. The CP-Africa content met both CP and national standards. The pilot established that the CP model could be implemented with process fidelity to the 13 Essential Elements. Several implementation challenges and strategies to address these challenges were identified. KEY CONCLUSIONS preliminary data suggest that CP-Africa is feasible in resource-constrained, low-literacy, high-HIV settings in sub-Saharan Africa. By improving the quality of ANC delivery, midwives have an opportunity to make a contribution towards Millennium Development Goals (MDG) targeting improvements in child, maternal and HIV-related health outcomes (MDGs 4, 5 and 6). A clinical trial is needed to establish efficacy. IMPLICATIONS FOR PRACTICE CP-Africa also has the potential to reduce job-related stress and enhance job satisfaction for midwives in low income countries. If CP can be transferred with fidelity to process in sub-Saharan Africa and retain similar results to those reported in clinical trials, it has the potential to benefit pregnant women and their infants and could make a positive contribution to MGDs 4, 5 and 6.
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Affiliation(s)
- Crystal L. Patil
- University of Illinois at Chicago, Department of Anthropology, 1007 W. Harrison St (MC 027), Chicago, IL 60607, USA, Phone: (312) 413-3570, Fax: (312) 413-3573,
| | - Elizabeth T. Abrams
- Independent Researcher and Consultant, 2243 Midvale Avenue, Los Angeles, CA 90064, (310) 595-5324,
| | - Carrie Klima
- UIC College of Nursing, 845 South Damen Avenue (MC 802), Chicago, IL 60612-7350, Phone: (312) 996-1863, Fax: (312) 996-8871,
| | | | - Sebalda C. Leshabari
- Department of Community Health Nursing, School of Nursing, Muhimbili University of Health and Allied Sciences, P. O. Box 65001, Dar es Salaam, Tanzania, , (255) 784-287-062
| | - Susan C. Vonderheid
- UIC College of Nursing, 845 South Damen Avenue (MC 802), Chicago, IL 60612-7350, Phone: (312) 996-7982, Fax: (312) 996-8871,
| | - Martha Kamaga
- UIC College of Nursing, 845 South Damen Avenue (MC 802), Chicago, IL 60612-7350, Phone: (312) 996-7940, Fax: (312) 996-8871,
| | - Kathleen F. Norr
- UIC College of Nursing, 845 South Damen Avenue (MC 802), Chicago, IL 60612-7350, Phone: (312) 996-7940, Fax: (312) 996-8871,
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Vogel JP, Habib NA, Souza JP, Gülmezoglu AM, Dowswell T, Carroli G, Baaqeel HS, Lumbiganon P, Piaggio G, Oladapo OT. Antenatal care packages with reduced visits and perinatal mortality: a secondary analysis of the WHO Antenatal Care Trial. Reprod Health 2013; 10:19. [PMID: 23577700 PMCID: PMC3637102 DOI: 10.1186/1742-4755-10-19] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 02/18/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In 2001, the WHO Antenatal Care Trial (WHOACT) concluded that an antenatal care package of evidence-based screening, therapeutic interventions and education across four antenatal visits for low-risk women was not inferior to standard antenatal care and may reduce cost. However, an updated Cochrane review in 2010 identified an increased risk of perinatal mortality of borderline statistical significance in three cluster-randomized trials (including the WHOACT) in developing countries. We conducted a secondary analysis of the WHOACT data to determine the relationship between the reduced visits, goal-oriented antenatal care package and perinatal mortality. METHODS Exploratory analyses were conducted to assess the effect of baseline risk and timing of perinatal death. Women were stratified by baseline risk to assess differences between intervention and control groups. We used linear modeling and Poisson regression to determine the relative risk of fetal death, neonatal death and perinatal mortality by gestational age. RESULTS 12,568 women attended the 27 intervention clinics and 11,958 women attended the 26 control clinics. 6,160 women were high risk and 18,365 women were low risk. There were 161 fetal deaths (1.4%) in the intervention group compared to 119 fetal deaths in the control group (1.1%) with an increased overall adjusted relative risk of fetal death (Adjusted RR 1.27; 95% CI 1.03, 1.58). This was attributable to an increased relative risk of fetal death between 32 and 36 weeks of gestation (Adjusted RR 2.24; 95% CI 1.42, 3.53) which was statistically significant for high and low risk groups. CONCLUSION It is plausible the increased risk of fetal death between 32 and 36 weeks gestation could be due to reduced number of visits, however heterogeneity in study populations or differences in quality of care and timing of visits could also be playing a role. Monitoring maternal, fetal and neonatal outcomes when implementing antenatal care protocols is essential. Implementing reduced visit antenatal care packages demands careful monitoring of maternal and perinatal outcomes, especially fetal death.
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Nyamtema AS, Urassa DP, van Roosmalen J. Maternal health interventions in resource limited countries: a systematic review of packages, impacts and factors for change. BMC Pregnancy Childbirth 2011; 11:30. [PMID: 21496315 PMCID: PMC3090370 DOI: 10.1186/1471-2393-11-30] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Accepted: 04/17/2011] [Indexed: 11/15/2022] Open
Abstract
Background The burden of maternal mortality in resource limited countries is still huge despite being at the top of the global public health agenda for over the last 20 years. We systematically reviewed the impacts of interventions on maternal health and factors for change in these countries. Methods A systematic review was carried out using the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles published in the English language reporting on implementation of interventions, their impacts and underlying factors for maternal health in resource limited countries in the past 23 years were searched from PubMed, Popline, African Index Medicus, internet sources including reproductive health gateway and Google, hand-searching, reference lists and grey literature. Results Out of a total of 5084 articles resulting from the search only 58 qualified for systematic review. Programs integrating multiple interventions were more likely to have significant positive impacts on maternal outcomes. Training in emergency obstetric care (EmOC), placement of care providers, refurbishment of existing health facility infrastructure and improved supply of drugs, consumables and equipment for obstetric care were the most frequent interventions integrated in 52% - 65% of all 54 reviewed programs. Statistically significant reduction of maternal mortality ratio and case fatality rate were reported in 55% and 40% of the programs respectively. Births in EmOC facilities and caesarean section rates increased significantly in 71% - 75% of programs using these indicators. Insufficient implementation of evidence-based interventions in resources limited countries was closely linked to a lack of national resources, leadership skills and end-users factors. Conclusions This article presents a list of evidenced-based packages of interventions for maternal health, their impacts and factors for change in resource limited countries. It indicates that no single magic bullet intervention exists for reduction of maternal mortality and that all interventional programs should be integrated in order to bring significant changes. State leaders and key actors in the health sectors in these countries and the international community are proposed to translate the lessons learnt into actions and intensify efforts in order to achieve the goals set for maternal health.
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Affiliation(s)
- Angelo S Nyamtema
- Tanzanian Training Centre for International Health, Ifakara, Tanzania.
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Dowswell T, Carroli G, Duley L, Gates S, Gülmezoglu AM, Khan-Neelofur D, Piaggio GGP. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database Syst Rev 2010:CD000934. [PMID: 20927721 PMCID: PMC4164448 DOI: 10.1002/14651858.cd000934.pub2] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The number of visits for antenatal (prenatal) care developed without evidence of how many visits are necessary. The content of each visit also needs evaluation. OBJECTIVES To compare the effects of antenatal care programmes with reduced visits for low-risk women with standard care. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2010), reference lists of articles and contacted researchers in the field. SELECTION CRITERIA Randomised trials comparing a reduced number of antenatal visits, with or without goal-oriented care, with standard care. DATA COLLECTION AND ANALYSIS Two authors assessed trial quality and extracted data independently. MAIN RESULTS We included seven trials (more than 60,000 women): four in high-income countries with individual randomisation; three in low- and middle-income countries with cluster randomisation (clinics as the unit of randomisation). The number of visits for standard care varied, with fewer visits in low- and middle- income country trials. In studies in high-income countries, women in the reduced visits groups, on average, attended between 8.2 and 12 times. In low- and middle- income country trials, many women in the reduced visits group attended on fewer than five occasions, although in these trials the content as well as the number of visits was changed, so as to be more 'goal oriented'.Perinatal mortality was increased for those randomised to reduced visits rather than standard care, and this difference was borderline for statistical significance (five trials; risk ratio (RR) 1.14; 95% confidence interval (CI) 1.00 to 1.31). In the subgroup analysis, for high-income countries the number of deaths was small (32/5108), and there was no clear difference between the groups (2 trials; RR 0.90; 95% CI 0.45 to 1.80); for low- and middle-income countries perinatal mortality was significantly higher in the reduced visits group (3 trials RR 1.15; 95% CI 1.01 to 1.32). Reduced visits were associated with a reduction in admission to neonatal intensive care that was borderline for significance (RR 0.89; 95% CI 0.79 to 1.02). There were no clear differences between the groups for the other reported clinical outcomes.Women in all settings were less satisfied with the reduced visits schedule and perceived the gap between visits as too long. Reduced visits may be associated with lower costs. AUTHORS' CONCLUSIONS In settings with limited resources where the number of visits is already low, reduced visits programmes of antenatal care are associated with an increase in perinatal mortality compared to standard care, although admission to neonatal intensive care may be reduced. Women prefer the standard visits schedule. Where the standard number of visits is low, visits should not be reduced without close monitoring of fetal and neonatal outcome.
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Affiliation(s)
- Therese Dowswell
- Cochrane Pregnancy and Childbirth Group, Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK
| | | | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Simon Gates
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - A Metin Gülmezoglu
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Gilda GP Piaggio
- Special Programme of Research Development and Research Training in Human Reproduction, RHR., World Health Organization, Geneva, Switzerland
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Jafari F, Eftekhar H, Fotouhi A, Mohammad K, Hantoushzadeh S. Comparison of Maternal and Neonatal Outcomes of Group Versus Individual Prenatal Care: A New Experience in Iran. Health Care Women Int 2010; 31:571-84. [DOI: 10.1080/07399331003646323] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Handlos LN, Chakraborty H, Sen PK. Evaluation of cluster-randomized trials on maternal and child health research in developing countries. Trop Med Int Health 2009; 14:947-56. [PMID: 19563429 DOI: 10.1111/j.1365-3156.2009.02313.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To summarize and evaluate all publications including cluster-randomized trials used for maternal and child health research in developing countries during the last 10 years. METHODS All cluster-randomized trials published between 1998 and 2008 were reviewed, and those that met our criteria for inclusion were evaluated further. The criteria for inclusion were that the trial should have been conducted in maternal and child health care in a developing country and that the conclusions should have been made on an individual level. Methods of accounting for clustering in design and analysis were evaluated in the eligible trials. RESULTS Thirty-five eligible trials were identified. The majority of them were conducted in Asia, used community as randomization unit, and had less than 10,000 participants. To minimize confounding, 23 of the 35 trials had stratified, blocked, or paired the clusters before they were randomized, while 17 had adjusted for confounding in the analysis. Ten of the 35 trials did not account for clustering in sample size calculations, and seven did not account for the cluster-randomized design in the analysis. The number of cluster-randomized trials increased over time, and the trials generally improved in quality. CONCLUSIONS Shortcomings exist in the sample-size calculations and in the analysis of cluster-randomized trials conducted during maternal and child health research in developing countries. Even though there has been improvement over time, further progress in the way that researchers utilize and analyse cluster-randomized trials in this field is needed.
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Affiliation(s)
- Line Neerup Handlos
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA.
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Yakoob MY, Menezes EV, Soomro T, Haws RA, Darmstadt GL, Bhutta ZA. Reducing stillbirths: behavioural and nutritional interventions before and during pregnancy. BMC Pregnancy Childbirth 2009; 9 Suppl 1:S3. [PMID: 19426466 PMCID: PMC2679409 DOI: 10.1186/1471-2393-9-s1-s3] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The vast majority of global stillbirths occur in low- and middle-income countries, and in many settings, the majority of stillbirths occur antenatally, prior to the onset of labour. Poor nutritional status, lack of antenatal care and a number of behaviours increase women's risk of stillbirth in many resource-poor settings. Interventions to reduce these risks could reduce the resulting burden of stillbirths, but the evidence for the impact of such interventions has not yet been comprehensively evaluated. METHODS This second paper of a systematic review of interventions that could plausibly impact stillbirth rates covers 12 different interventions relating to behavioural and socially mediated risk factors, including exposures to harmful practices and substances, antenatal care utilisation and quality, and maternal nutrition before and during pregnancy. The search strategy reviewed indexed medical journals on PubMed and the Cochrane Library. If any eligible randomised controlled trials were identified that were published after the most recent Cochrane review, they were added to generate new meta-analyses. Interventions covered in this paper have a focus on low- and middle-income countries, both because of the large burden of stillbirths and because of the high prevalence of risk factors including maternal malnutrition and harmful environmental exposures. The reviews and studies belonging to these interventions were graded and conclusions derived about the evidence of benefit of these interventions. RESULTS From a programmatic perspective, none of the interventions achieved clear evidence of benefit. Evidence for some socially mediated risk factors were identified, such as exposure to indoor air pollution and birth spacing, but still require the development of appropriate interventions. There is a need for additional studies on culturally appropriate behavioural interventions and clinical trials to increase smoking cessation and reduce exposure to smokeless tobacco. Balanced protein-energy supplementation was associated with reduced stillbirth rates, but larger well-designed trials are required to confirm findings. Peri-conceptional folic acid supplementation significantly reduces neural tube defects, yet no significant associated reductions in stillbirth rates have been documented. Evidence for other nutritional interventions including multiple micronutrient and Vitamin A supplementation is weak, suggesting the need for further research to assess potential of nutritional interventions to reduce stillbirths. CONCLUSION Antenatal care is widely used in low- and middle-income countries, and provides a natural facility-based contact through which to provide or educate about many of the interventions we reviewed. The impact of broader socially mediated behaviors, such as fertility decision-making, access to antenatal care, and maternal diet and exposures like tobacco and indoor air pollution during pregnancy, are poorly understood, and further research and appropriate interventions are needed to test the association of these behaviours with stillbirth outcomes. For most nutritional interventions, larger randomised controlled trials are needed which report stillbirths disaggregated from composite perinatal mortality. Many antepartum stillbirths are potentially preventable in low- and middle-income countries, particularly through dietary and environmental improvement, and through improving the quality of antenatal care - particularly including diagnosis and management of high-risk pregnancies - that pregnant women receive.
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Affiliation(s)
- Mohammad Yawar Yakoob
- Division of Maternal and Child Health, The Aga Khan University, Karachi 74800, Pakistan
| | - Esme V Menezes
- Division of Maternal and Child Health, The Aga Khan University, Karachi 74800, Pakistan
| | - Tanya Soomro
- Division of Maternal and Child Health, The Aga Khan University, Karachi 74800, Pakistan
| | - Rachel A Haws
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Gary L Darmstadt
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Zulfiqar A Bhutta
- Division of Maternal and Child Health, The Aga Khan University, Karachi 74800, Pakistan
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Kidney E, Winter HR, Khan KS, Gülmezoglu AM, Meads CA, Deeks JJ, MacArthur C. Systematic review of effect of community-level interventions to reduce maternal mortality. BMC Pregnancy Childbirth 2009; 9:2. [PMID: 19154588 PMCID: PMC2637835 DOI: 10.1186/1471-2393-9-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2008] [Accepted: 01/20/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The objective was to provide a systematic review of the effectiveness of community-level interventions to reduce maternal mortality. METHODS We searched published papers using Medline, Embase, Cochrane library, CINAHL, BNI, CAB ABSTRACTS, IBSS, Web of Science, LILACS and African Index Medicus from inception or at least 1982 to June 2006; searched unpublished works using National Research Register website, metaRegister and the WHO International Trial Registry portal. We hand searched major references.Selection criteria were maternity or childbearing age women, comparative study designs with concurrent controls, community-level interventions and maternal death as an outcome. We carried out study selection, data abstraction and quality assessment independently in duplicate. RESULTS We found five cluster randomised controlled trials (RCT) and eight cohort studies of community-level interventions. We summarised results as odds ratios (OR) and confidence intervals (CI), combined using the Peto method for meta-analysis. Two high quality cluster RCTs, aimed at improving perinatal care practices, showed a reduction in maternal mortality reaching statistical significance (OR 0.62, 95% CI 0.39 to 0.98). Three equivalence RCTs of minimal goal-oriented versus usual antenatal care showed no difference in maternal mortality (1.09, 95% CI 0.53 to 2.25). The cohort studies were of low quality and did not contribute further evidence. CONCLUSION Community-level interventions of improved perinatal care practices can bring about a reduction in maternal mortality. This challenges the view that investment in such interventions is not worthwhile. Programmes to improve maternal mortality should be evaluated using randomised controlled techniques to generate further evidence.
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Affiliation(s)
- Elaine Kidney
- Dept of Public Health and Epidemiology, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Heather R Winter
- Dept of Public Health and Epidemiology, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Khalid S Khan
- Academic Unit, Birmingham Women's Hospital, University of Birmingham, Birmingham, UK
| | - A Metin Gülmezoglu
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Geneva, Switzerland
| | - Catherine A Meads
- Dept of Public Health and Epidemiology, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Jonathan J Deeks
- Dept of Public Health and Epidemiology, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Christine MacArthur
- Dept of Public Health and Epidemiology, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
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