Abstract
BackgroundMaternal, 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.MethodsWe 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.ResultsFor 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.ConclusionsDespite 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.
Highlights
Recent trends show a decline in maternal mortality from 984 per 100 000 live births during 2000 –2004 to 675 per 100 000 live births during 2006 – 2010,1,2 Malawi is offtrack to meet Millennium Development Goal 5.3 Neonatal mortality, at 31 per 1000 live births in 2006 –2010,2 and perinatal mortality, at 40 per 1000 live births in 2006 – 2010,2 are high and lag behind decreases in the number of child deaths but Malawi is on-track to meet Millennium Development Goal 4.3,4The main direct causes of maternal death in Malawi are haemorrhage, sepsis, ruptured uterus and eclampsia; and the main indirect causes are HIV, malaria and anaemia,5 with underlying social causes including poverty, illiteracy and lack of knowledge
Given that observed birth rates in the study matched those expected from the crude birth rate1,27 to within 3%, and that in-migration probably broadly matched out-migration, many of the pregnancies recorded by key informants (KI) as ‘lost to follow-up’ may have been recorded as pregnancies by mistake and true loss-to-follow-up was probably much lower; there was little difference in loss-to-follow-up between arms
There were no significant differences between the percentages of uncategorized stillbirths and neonatal deaths by randomized controlled trial (RCT) arm
Summary
Recent trends show a decline in maternal mortality from 984 per 100 000 live births during 2000 –2004 (just before this trial) to 675 per 100 000 live births during 2006 – 2010,1,2 Malawi is offtrack to meet Millennium Development Goal 5 (a three-quarters reduction in maternal mortality between 1990 and 2015). Neonatal mortality, at 31 per 1000 live births in 2006 –2010,2 and perinatal mortality, at 40 per 1000 live births in 2006 – 2010,2 are high and lag behind decreases in the number of child deaths but Malawi is on-track to meet Millennium Development Goal 4.3,4The main direct causes of maternal death in Malawi are haemorrhage, sepsis, ruptured uterus and eclampsia; and the main indirect causes are HIV, malaria and anaemia, with underlying social causes including poverty, illiteracy and lack of knowledge. Based on the three delays model (delays in deciding to seek care, reaching the place of care and receiving adequate care once there), an international consortium of partner organizations designed supply side (health facility quality improvement; FI) and demand side (community women’s groups; CI) interventions to reduce maternal and newborn mortality.. Based on the three delays model (delays in deciding to seek care, reaching the place of care and receiving adequate care once there), an international consortium of partner organizations designed supply side (health facility quality improvement; FI) and demand side (community women’s groups; CI) interventions to reduce maternal and newborn mortality.8 The impact of both interventions on deaths was evaluated by a two-by-two factorial cluster randomized controlled trial (RCT). We evaluated community and facility-based interventions to reduce deaths in three districts of Malawi
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