Community-Based Intervention Packages to Reduce Maternal and Neonatal Mortality
This is an interim intervention report. We have spent limited time to form an initial view of this program and, at this point, our views are preliminary. We plan to consider undertaking additional work on this program in the future.
Summary
- What is the program? Community-based intervention package programs are designed to prevent maternal and neonatal mortality by providing evidence-based care to women and newborns via community outreach workers.
- What is the evidence of effectiveness? A meta-analysis of 26 studies finds that on average, these types of interventions reduce maternal mortality, neonatal mortality, and stillbirths. However, heterogeneity in program design and setting underlying these findings prevents us from using this aggregate evidence to endorse any specific program design.
- How cost-effective is it? A review that we have not yet vetted indicates that these types of programs may be in the range of cost-effectiveness of programs that we would consider as potential top charities.
- Is there room for more funding? We expect that there is likely room for more funding in this area, particularly in Sub-Saharan Africa and South Asia, where neonatal mortality and maternal mortality rates remain high.
- Bottom line: Packages of interventions provided to mothers and newborns in the community can prevent maternal and neonatal death. However, given substantial heterogeneity underlying the current body of evidence, we would need to investigate cost-effectiveness in the context of the work that specific charities are undertaking in this area in order to assess specific opportunities.
Published: January 2020
What is the problem?
In 2018, 2.5 million infants died in the first 28 days of life.1 Sub-Saharan Africa and South Asia comprise 79% of global neonatal mortality.2 In 2017, 295,000 women and girls died from complications arising from pregnancy and childbirth,3 and 86% of those deaths occurred in Sub-Saharan Africa and South Asia.4
What is the program?
A range of preconception, antenatal, and neonatal interventions have shown individual effectiveness in preventing neonatal mortality.5 These interventions are typically packaged according to their delivery mode and target populations.6 In this review, we focus on universal intervention packages delivered in the community setting that involve training of community outreach workers who deliver maternal and newborn care interventions.7 Intervention packages are heterogeneous in terms of which interventions are included and how they are delivered (via home visits or women’s groups).8
Intervention packages included in this evidence assessment may include some combination of:9
- Basic antenatal, natal and postnatal care
- Preventive essential newborn care including: ensuring warmth, immediate skin-to-skin care, early breastfeeding, umbilical cord care, eye care, Vitamin K administration, and immunization
- Breastfeeding counselling
- Management and referral of sick newborns
- Skills development in behavior change communication
- Community mobilization strategies to promote birth and newborn care preparedness.
Does the program have strong evidence of effectiveness?
A 2015 Cochrane Collaboration systematic review and meta-analysis of community-based intervention packages aimed at reducing maternal and neonatal morbidity and mortality included 26 randomized and quasi-randomized trials with a low to moderate risk of bias.10 The review found that on average, these packages are associated with the following statistically significant (p<0.05) effects:
- 25% reduction in neonatal mortality11
- 19% reduction in stillbirths12
- 25% reduction in maternal morbidity13
- 20% reduction in maternal mortality (marginally significant, p=0.05)14
This evidence is suggestive that as evaluated, these interventions resulted in reduced maternal and neonatal mortality.15
However, heterogeneity in program design and setting underlying these data prevents us from using this aggregate evidence to endorse any specific program design. This concern is corroborated by moderate to high heterogeneity in neonatal outcomes across studies.16 This and other meta-analyses have attempted to model how intervention impact varies according to the characteristics of the intervention or setting, but we have not vetted this work.17 We might revisit these subgroup findings and conduct additional modeling of expected mortality and morbidity benefits if we decide to move forward with the evaluation of a specific program.
Beyond interventions included in the 2015 meta-analysis, we are aware of two new studies: One study in India found a significant 32% reduction in neonatal mortality,18 and the other in Tanzania did not find a significant reduction in neonatal mortality.19 We have not yet added these to the meta-analysis, but we do not expect that these studies will change the bottom line.
Are there any potential negative impacts of the program?
There may be adverse effects associated with a given component of the intervention package. We will take adverse events into account if we identify a promising charity delivering a specific intervention package.
How cost-effective is it?
The DCP-3 volume on reproductive, maternal, child, and newborn health indicates that "home-based and community-based neonatal care" interventions cost between roughly $500 and $6,000 per life saved.20 This may put certain intervention package programs in the range of cost-effectiveness of programs we would consider as potential top charities. We have not vetted these estimates. In the future, we may estimate the cost-effectiveness of specific intervention packages as implemented by identified charities.
Does the program have room for more funding?
We have not yet systematically assessed whether these types of packages have room for more funding. However, we expect that there is likely room for more funding in this area, particularly in Sub-Saharan Africa and South Asia, where neonatal mortality and maternal mortality rates remain high.21
Organizations that implement this program
We are currently investigating whether there are any organizations that are implementing a version of these types of intervention packages. If we identify any such organizations, we will reassess the evidence for that program type in particular.
Key questions for further investigation
- Add studies conducted since 2015 to the Cochrane Collaboration meta-analysis.
- Which charities are currently implementing these types of intervention packages, and which interventions are included in those packages?
- Can we use available empirical evidence to model the expected cost-effectiveness of an intervention package as delivered by a charity?
Sources
- 1
“Globally, 2.5 million children died in the first month of life in 2018– approximately 7,000 neonatal deaths every day.” UNICEF, Neonatal mortality, 2019.
- 2
“In 2017, the annual NMR was highest in west and central Africa, at 30.2 deaths per 1000 livebirths (90% uncertainty interval 25.7–37.2), and in south Asia, at 26.9 deaths per 1000 livebirths (24.1–30.3; figure 1; table). The annual NMR in these regions was more than 9 times higher than the average NMR in high-income countries, which was 3.0 deaths per 1000 livebirths (3.0–3.5). Together, south Asia and sub-Saharan Africa accounted for 79% of the total burden of neonatal deaths.” Hug et al. 2019, Pg. e713
- 3
“The number of women and girls who died each year from complications of pregnancy and childbirth declined from 451,000 in 2000 to 295,000 in 2017.” UNICEF, Maternal mortality, 2019.
- 4
“Two regions, sub-Saharan Africa and South Asia, account for 86 per cent of maternal deaths worldwide. Sub-Saharan Africans suffer from the highest maternal mortality ratio – 533 maternal deaths per 100,000 live births, or 200,000 maternal deaths a year. This is over two thirds (68 per cent) of all maternal deaths per year worldwide. South Asia follows, with a maternal mortality ratio of 163, or 57,000 maternal deaths a year, accounting for 19 per cent of the global total.” UNICEF, Maternal mortality, 2019.
- 5
Table 1, Bhutta et al. 2014. Note that we have not vetted the evidence supporting this list, but rather expect to vet the evidence supporting the suite of interventions being delivered by a specific charity if one is identified.
- 6
Table 2, “Family Care Package,” Darmstadt et al. 2005
- 7
“Types of interventions: Intervention packages that included additional training of outreach workers (residents from the community who are trained and supervised to deliver maternal and newborn care interventions to her target population) namely, lady health workers/visitors, community midwives, community/village health workers, facilitators or TBAs in maternal care during pregnancy, delivery and in the postpartum period; and routine newborn care.” Lassi & Bhutta 2015, Pg. 5
- 8
For example, see Table 3, Pgs. 202-204 in Haws et al. 2007 for a list of all evaluated intervention packages by service delivery mode as of 2006.
- 9
- “Additional training was defined as training other than the usual training that health workers received from their governmental or non-governmental organisation (NGO) and could include a combination of training in providing basic antenatal, natal and postnatal care; preventive essential newborn care, breastfeeding counselling; management and referral of sick newborns; skills development in behaviour change communication; and community mobilisation strategies to promote birth and newborn care preparedness.” Lassi & Bhutta 2015, Pg. 5
- “The components of essential newborn care – ensuring warmth, immediate skin-to-skin care, early breastfeeding, umbilical cord care, eye care, Vitamin K administration, and immunization...” Valsangkar et al. 2014
- 10
Lassi & Bhutta 2015, Figure 1, Pg. 11
- 11
“Significant reduction was observed in...neonatal mortality (average RR 0.75; 95% CI 0.67 to 0.83; 21 studies, n = 302,646; random-effects, Tau2 = 0.06, I2 = 85%) including both early and late mortality.” Lassi & Bhutta 2015, Pg. 2
- 12
“Significant reduction was observed in...stillbirths (average RR 0.81; 95% CI 0.73 to 0.91; 15 studies, n = 201,181; random-effects, Tau2 = 0.03, I2= 66%)” Lassi & Bhutta 2015, Pg. 2
- 13
“Significant reduction was observed in…maternal morbidity (average RR 0.75; 95% CI 0.61 to 0.92; four studies, n = 138,290; random-effects, Tau2 = 0.02, I2 = 28%).” Lassi & Bhutta 2015, Pg. 2
- 14
“Our review showed a possible effect in terms of a reduction in maternal mortality (RR 0.80; 95% confidence interval (CI) 0.64 to 1.00, random-effects (11 studies, n = 167,311; random-effects, Tau2 = 0.03, I2 = 20%).” Lassi & Bhutta 2015, Pg. 2
- 15
An additional meta-analysis conducted in 2017 reported on 17 trials, with an overall 14% reduction in neonatal mortality and a 25% reduction in neonatal mortality observed in countries with high baseline neonatal mortality rates (Hanson et al. 2017, Figure 2). This meta-analysis excluded quasi-randomized trials.
- 16
I2 is the percent of variance observed that is due to heterogeneity across studies rather than random variation. From Lassi & Bhutta 2015, Pg. 2:
- Neonatal mortality: I2 = 85%, 21 studies
- Stillbirths: I2 = 66%, 15 studies
- Maternal morbidity: I2 = 28%, 4 studies
- Maternal mortality: I2 = 20%, 11 studies
- 17
For example:
- “When the impact was evaluated separately for packages that built support and advocacy groups, and those that provided home visitation along with community mobilisation, there was a significant impact on reducing average neonatal mortality by 16% (average RR 0.84; 95% CI 0.73 to 0.96; 9 studies, n = 155,509; random-effects, TauO = 0.02, IO = 62% and ChiO P value 0.006)) and 40% (average RR 0.60; 95% CI 0.49 to 0.72, random-effects (five studies, n = 50,052), (TauO = 0.05, IO = 85% and ChiO P value < 0.001)). We found no evidence of reduced neonatal mortality when home-based neonatal care and sepsis management were delivered as a part of a package (average RR 0.63; 95% CI 0.32 to 1.22; two studies, n = 62,567; random- effects); however, significant impact was found when packages provided community mobilisation along with home-based neonatal treatment (RR 0.66; 95% CI 0.47 to 0.93; one study, n = 4248). Conversely, no impact was found when TBAs were trained and asked to make home visits (average RR 0.74; 95% CI 0.48 to 1.16; two studies, n = 22,860; random-effects, TauO = 0.07, IO = 67%), when mothers were given health education at home (average RR 0.80; 95% CI 0.63 to 1.02; two studies, n = 3072; random-effects, TauO = 0.01, IO = 25%), and also when community mobilisation was added with messages in the form of leaflets, and banners (RR 1.44; 95% CI 1.23 to 1.69; one study, n = 4156).” Lassi & Bhutta 2015, Pg. 17
- “A 25% reduction in neonatal mortality (relative risk, RR: 0.75; 95% confidence interval, CI: 0.69–0.80) was found when pooling six studies in settings with 44 or more deaths per 1000 live births. In lower mortality settings (pooling six studies with 32 or fewer deaths per 1000 live births) there was no evidence of an effect. We observed some evidence that community approaches had a stronger effect in south Asia than in sub-Saharan Africa. Community approaches had a lower impact on neonatal mortality in settings where at least 44% of women delivered in a facility.” Hanson et al. 2017, abstract
- 18
“NMR was 32% lower in intervention clusters adjusted for clustering, stratification, and baseline differences (odds ratio 0.68, 95% CI 0.59-0.78)” Tripathy et al. 2010, abstract
- 19
“There was no evidence of an impact of the intervention on neonatal survival (odds ratio [OR] 1.1, 95% confidence interval [CI] 0.9–1.2, p = 0.339).” Hanson et al. 2015, abstract
- 20
Figure 17.2, Pg. 323 of DCP3: Reproductive, Maternal, Newborn, and Child Health, 2016.
- 21
Save The Children told us in direct communication that its “Saving Newborn Lives” intervention program had substantial room for more funding. We have not vetted this claim, however.