Abstract
BackgroundSocioeconomic inequalities in neonatal mortality are substantial in many developing countries. Little is known about how to address this problem. Trials in Asia and Africa have shown strong impacts on neonatal mortality of a participatory learning and action intervention with women’s groups. Whether this intervention also reduces mortality inequalities remains unknown. We describe the equity impact of this women’s groups intervention on the neonatal mortality rate (NMR) across socioeconomic strata.MethodsWe conducted a meta-analysis of all four participatory women’s group interventions that were shown to be highly effective in cluster randomized trials in India, Nepal, Bangladesh and Malawi. We estimated intervention effects on NMR and health behaviours for lower and higher socioeconomic strata using random effects logistic regression analysis. Differences in effect between strata were tested.ResultsAnalysis of 69120 live births and 2505 neonatal deaths shows that the intervention strongly reduced the NMR in lower (50–63% reduction depending on the measure of socioeconomic position used) and higher (35–44%) socioeconomic strata. The intervention did not show evidence of ‘elite-capture’: among the most marginalized populations, the NMR in intervention areas was 63% lower [95% confidence interval (CI) 48–74%] than in control areas, compared with 35% (95% CI: 15–50%) lower among the less marginalized in the last trial year (P-value for difference between most/less marginalized: 0.009). The intervention strongly improved home care practices, with no systematic socioeconomic differences in effect.ConclusionsParticipatory women’s groups with high population coverage benefit the survival chances of newborns from all socioeconomic strata, and perhaps especially those born into the most deprived households.
Highlights
A world without preventable newborn deaths, as envisaged in the Every Newborn Action Plan led by WHO and UNICEF, is only achievable when strategies are available to close the gap in newborn mortality between socioeconomic groups.[1,2] The odds of surviving the first month of life are grossly unequal between infants born in poor and rich households and to higher and less educated mothers within the same country.[3,4,5] little is known about what works to close these mortality gaps.The strongest evidence on intervention effects comes from randomized controlled trials (RCT)
Based on a meta-analysis of four cluster randomized controlled trials, including 69120 live births and 2505 neonatal deaths, we find that community-based women’s groups reduced neonatal mortality equitably and substantially across socioeconomic strata
Whereas communitybased interventions run the risk of elite capture, in which the best-off reap more benefits,[7,8,9,10,11] there are indications that community-based women’s groups can reduce mortality inequalities by reaching all socioeconomic strata through their soft-targeting approach.[12,13]
Summary
A world without preventable newborn deaths, as envisaged in the Every Newborn Action Plan led by WHO and UNICEF, is only achievable when strategies are available to close the gap in newborn mortality between socioeconomic groups.[1,2] The odds of surviving the first month of life are grossly unequal between infants born in poor and rich households and to higher and less educated mothers within the same country.[3,4,5] little is known about what works to close these mortality gaps.The strongest evidence on intervention effects comes from randomized controlled trials (RCT). Four cluster randomized controlled trials, in Asia and Africa, have shown that community-based women’s groups can substantially reduce neonatal mortality, perhaps especially through improved home care practices, provided that coverage of the women’s groups in the population is sufficiently high Trials in Asia and Africa have shown strong impacts on neonatal mortality of a participatory learning and action intervention with women’s groups. Whether this intervention reduces mortality inequalities remains unknown. The intervention did not show evidence of ‘elite-capture’: among the most marginalized populations, the NMR in intervention areas was 63% lower [95% confidence interval (CI) 48–74%] than in control areas, compared with 35% (95% CI: 15–50%) lower among the less
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