Abstract
BackgroundAround a quarter of the world's neonatal and maternal deaths occur in India. Morbidity and mortality are highest in rural areas and among the poorest wealth quintiles. Few interventions to improve maternal and newborn health outcomes with government-mandated community health workers have been rigorously evaluated at scale in this setting.The study aims to assess the impact of a community mobilisation intervention with women's groups facilitated by ASHAs to improve maternal and newborn health outcomes among rural tribal communities of Jharkhand and Orissa.Methods/designThe study is a cluster-randomised controlled trial and will be implemented in five districts, three in Jharkhand and two in Orissa. The unit of randomisation is a rural cluster of approximately 5000 population. We identified villages within rural, tribal areas of five districts, approached them for participation in the study and enrolled them into 30 clusters, with approximately 10 ASHAs per cluster. Within each district, 6 clusters were randomly allocated to receive the community intervention or to the control group, resulting in 15 intervention and 15 control clusters. Randomisation was carried out in the presence of local stakeholders who selected the cluster numbers and allocated them to intervention or control using a pre-generated random number sequence. The intervention is a participatory learning and action cycle where ASHAs support community women's groups through a four-phase process in which they identify and prioritise local maternal and newborn health problems, implement strategies to address these and evaluate the result. The cycle is designed to fit with the ASHAs' mandate to mobilise communities for health and to complement their other tasks, including increasing institutional delivery rates and providing home visits to mothers and newborns. The trial's primary endpoint is neonatal mortality during 24 months of intervention. Additional endpoints include home care practices and health care-seeking in the antenatal, delivery and postnatal period. The impact of the intervention will be measured through a prospective surveillance system implemented by the project team, through which mothers will be interviewed around six weeks after delivery. Cost data and qualitative data are collected for cost-effectiveness and process evaluations.Study registrationISRCTN: ISRCTN31567106
Highlights
Introduction to the projectIdentifying & prioritizing maternal problems in the communityIdentifying & prioritizing neonatal problems in the communityPhase II: StrategiesThermal care for newbornsUnderstanding causes and solutions for prioritized problemsIdentifying and prioritising strategies for implementationChoosing a method & preparing for sharing at the community meetingPreparing for a community meetingCOMMUNITY MEETING 1 AND Accredited Social Health Activists (ASHAs) TRAINING 3Phase III: Meeting Implementation
19 of 68 priority countries are on track to achieve MDG4, which calls for a two-thirds reduction in underfive mortality rates from 1990 levels [1]
Because neonatal deaths account for 41% of under-5 deaths, achieving Millennium Development Goals (MDGs) 4 requires scaling up strategies to reduce neonatal mortality [2]
Summary
Introduction to the projectIdentifying & prioritizing maternal problems in the communityIdentifying & prioritizing neonatal problems in the communityPhase II: StrategiesThermal care for newborns (story on preventing winter deaths)Understanding causes and solutions for prioritized problems (story focusing on causes, effects and management)Identifying and prioritising strategies for implementationChoosing a method & preparing for sharing at the community meetingPreparing for a community meetingCOMMUNITY MEETING 1 AND ASHA TRAINING 3Phase III: Meeting Implementation. Identifying & prioritizing maternal problems in the community. Identifying & prioritizing neonatal problems in the community. Effective interventions have long been identified, and key questions concern the best ways to increase their coverage in an equitable manner, in countries and communities with high mortality rates [3,4,5]. Neonatal mortality rates vary widely between states, ranging from 11 in Kerala to 48 in Uttar Pradesh [9] They vary within states and between social groups: the NMR in rural areas is about one and a half times that of urban areas, and rates among the poorest wealth quintile are more than double those among the richest [10]. Socio-economically disadvantaged communities such as indigenous or adivasi groups (defined in India’s demographic surveys as Scheduled Tribes) have high mortality rates: adivasi children have a 25% increased risk of dying before the age of five compared to non-adivasi children [11]
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