Prost A.,University College London |
Colbourn T.,University College London |
Seward N.,University College London |
Azad K.,Perinatal Care Project |
And 29 more authors.
The Lancet | Year: 2013
Background: Maternal and neonatal mortality rates remain high in many low-income and middle-income countries. Different approaches for the improvement of birth outcomes have been used in community-based interventions, with heterogeneous effects on survival. We assessed the effects of women's groups practising participatory learning and action, compared with usual care, on birth outcomes in low-resource settings. Methods: We did a systematic review and meta-analysis of randomised controlled trials undertaken in Bangladesh, India, Malawi, and Nepal in which the effects of women's groups practising participatory learning and action were assessed to identify population-level predictors of effect on maternal mortality, neonatal mortality, and stillbirths. We also reviewed the cost-effectiveness of the women's group intervention and estimated its potential effect at scale in Countdown countries. Findings: Seven trials (119 428 births) met the inclusion criteria. Meta-analyses of all trials showed that exposure to women's groups was associated with a 37% reduction in maternal mortality (odds ratio 0·63, 95% CI 0·32-0·94), a 23% reduction in neonatal mortality (0·77, 0·65-0·90), and a 9% non-significant reduction in stillbirths (0·91, 0·79- 1·03), with high heterogeneity for maternal (I2=58·8%, p=0·024) and neonatal results (I2=64·7%, p=0·009). In the meta-regression analyses, the proportion of pregnant women in groups was linearly associated with reduction in both maternal and neonatal mortality (p=0·026 and p=0·011, respectively). A subgroup analysis of the four studies in which at least 30% of pregnant women participated in groups showed a 55% reduction in maternal mortality (0·45, 0·17-0·73) and a 33% reduction in neonatal mortality (0·67, 0·59-0·74). The intervention was cost effective by WHO standards and could save an estimated 283 000 newborn infants and 41 100 mothers per year if implemented in rural areas of 74 Countdown countries. Interpretation: With the participation of at least a third of pregnant women and adequate population coverage, women's groups practising participatory learning and action are a cost-effective strategy to improve maternal and neonatal survival in low-resource settings. © 2013. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved.
Intracluster correlation coefficients and coefficients of variation for perinatal outcomes from five cluster-randomised controlled trials in low and middle-income countries: Results and methodological implications
Pagel C.,University College London |
Prost A.,University College London |
Lewycka S.,University College London |
Das S.,Education and Health Action SNEHA |
And 5 more authors.
Trials | Year: 2011
Background: Public health interventions are increasingly evaluated using cluster-randomised trials in which groups rather than individuals are allocated randomly to treatment and control arms. Outcomes for individuals within the same cluster are often more correlated than outcomes for individuals in different clusters. This needs to be taken into account in sample size estimations for planned trials, but most estimates of intracluster correlation for perinatal health outcomes come from hospital-based studies and may therefore not reflect outcomes in the community. In this study we report estimates for perinatal health outcomes from community-based trials to help researchers plan future evaluations.Methods: We estimated the intracluster correlation and the coefficient of variation for a range of outcomes using data from five community-based cluster randomised controlled trials in three low-income countries: India, Bangladesh and Malawi. We also performed a simulation exercise to investigate the impact of cluster size and number of clusters on the reliability of estimates of the coefficient of variation for rare outcomes.Results: Estimates of intracluster correlation for mortality outcomes were lower than those for process outcomes, with narrower confidence intervals throughout for trials with larger numbers of clusters. Estimates of intracluster correlation for maternal mortality were particularly variable with large confidence intervals. Stratified randomisation had the effect of reducing estimates of intracluster correlation. The simulation exercise showed that estimates of intracluster correlation are much less reliable for rare outcomes such as maternal mortality. The size of the cluster had a greater impact than the number of clusters on the reliability of estimates for rare outcomes.Conclusions: The breadth of intracluster correlation estimates reported here in terms of outcomes and contexts will help researchers plan future community-based public health interventions around maternal and newborn health. Our study confirms previous work finding that estimates of intracluster correlation are associated with the prevalence of the outcome of interest, the nature of the outcome of interest (mortality or behavioural) and the size and number of clusters. Estimates of intracluster correlation for maternal mortality need to be treated with caution and a range of estimates should be used in planning future trials. © 2011 Pagel et al; licensee BioMed Central Ltd.
Tripathy P.,Ekjut |
Nair N.,Ekjut |
Barnett S.,University College London |
Mahapatra R.,Ekjut |
And 10 more authors.
The Lancet | Year: 2010
Background: Community mobilisation through participatory women's groups might improve birth outcomes in poor rural communities. We therefore assessed this approach in a largely tribal and rural population in three districts in eastern India. Methods: From 36 clusters in Jharkhand and Orissa, with an estimated population of 228 186, we assigned 18 clusters to intervention or control using stratified randomisation. Women were eligible to participate if they were aged 15-49 years, residing in the project area, and had given birth during the study. In intervention clusters, a facilitator convened 13 groups every month to support participatory action and learning for women, and facilitated the development and implementation of strategies to address maternal and newborn health problems. The primary outcomes were reductions in neonatal mortality rate (NMR) and maternal depression scores. Analysis was by intention to treat. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN21817853. Findings: After baseline surveillance of 4692 births, we monitored outcomes for 19 030 births during 3 years (2005-08). NMRs per 1000 were 55·6, 37·1, and 36·3 during the first, second, and third years, respectively, in intervention clusters, and 53·4, 59·6, and 64·3, respectively, in control clusters. NMR was 32% lower in intervention clusters adjusted for clustering, stratification, and baseline differences (odds ratio 0·68, 95% CI 0·59-0·78) during the 3 years, and 45% lower in years 2 and 3 (0·55, 0·46-0·66). Although we did not note a significant effect on maternal depression overall, reduction in moderate depression was 57% in year 3 (0·43, 0·23-0·80). Interpretation: This intervention could be used with or as a potential alternative to health-worker-led interventions, and presents new opportunities for policy makers to improve maternal and newborn health outcomes in poor populations. Funding: Health Foundation, UK Department for International Development, Wellcome Trust, and the Big Lottery Fund (UK). © 2010 Elsevier Ltd. All rights reserved.
PubMed | Sitaram Bhartia Institute of Science and Research, Sector 44 Institutional Area, Ekjut and Guilford College
Type: | Journal: BMC public health | Year: 2016
In India, Village Health Sanitation and Nutrition Committees (VHSNCs) are participatory community health forums, but there is little information about their composition, functioning and effectiveness. Our study examined VHSNCs as enablers of participatory action for community health in two rural districts in two states of eastern India - West Singhbhum in Jharkhand and Kendujhar, in Odisha.We conducted a cross-sectional survey of 169 VHSNCs and ten qualitative focus group discussions with purposively selected better and poorer performing committees, across the two states. We analysed the quantitative data using descriptive statistics and the qualitative data using a Framework approach.We found that VHSNCs comprised equitable representation from vulnerable groups when they were formed. More than 75 % members were women. Almost all members belonged to socially disadvantaged classes. Less than 1 % members had received any training. Supervision of committees by district or block officials was rare. Their work focused largely on strengthening village sanitation, conducting health awareness activities, and supporting medical treatment for ill or malnourished children and pregnant mothers. In reality, 62 % committees monitored community health workers, 6.5 % checked sub-centres and 2.4 % monitored drug availability with community health workers. Virtually none monitored data on malnutrition. Community health and nutrition workers acted as conveners and record keepers. Links with the community involved awareness generation and community monitoring of VHSNC activities. Key challenges included irregular meetings, members limited understanding of their roles and responsibilities, restrictions on planning and fund utilisation, and weak linkages with the broader health system.Our study suggests that VHSNCs perform few of their specified functions for decentralized planning and action. If VHSNCs are to be instrumental in improving community health, sanitation and nutrition, they need education, mobilisation and monitoring for formal links with the wider health system.
Houweling T.A.J.,University College London |
Houweling T.A.J.,Erasmus University Rotterdam |
Tripathy P.,Ekjut |
Nair N.,Ekjut |
And 6 more authors.
International Journal of Epidemiology | Year: 2013
Progress towards the Millennium Development Goals (MDGs) has been uneven. Inequalities in child health are large and effective interventions rarely reach the most in need. Little is known about howto reduce these inequalities. We describe and explain the equity impact of a women's group intervention in India that strongly reduced the neonatal mortality rate (NMR) in a cluster-randomised trial. Weconducted secondary analyses of the trial data, obtained through prospective surveillance of a population of 228 186. The intervention effects were estimated separately, through random effects logistic regression, for the most and less socio-economically marginalised groups. Among the most marginalised, the NMR was 59% lower in intervention than in control clusters in years 2 and 3 (70%, year 3); among the less marginalised, the NMR was 36% lower (35%, year 3). The intervention effect was stronger among the most than among the less marginalised (P-value for difference1/40.028, years 2-3; P-value for difference1/40.009, year 3). The stronger effect was concentrated in winter, particularly for early NMR.There was no effect on the use of health-care services in either group, and improvements in home care were comparable. Participatory community interventions can substantially reduce socio-economic inequalities in neonatal mortality and contribute to an equitable achievement of the unfinished MDG agenda. © The Author 2013; all rights reserved.
Nair N.,Ekjut |
Tripathy P.,Ekjut |
Prost A.,University College London |
Costello A.,University College London |
Osrin D.,University College London
PLoS Medicine | Year: 2010
Reducing global neonatal mortality is crucial. In low-income countries, most births and deaths occur at home. Obstacles to improving survival include: many newborn infants are invisible to health services; care-seeking for maternal and newborn ailments is limited; health workers are often not skilled and confident in caring for newborn infants; and there are inequalities across all these factors. The best community-based approach is a combination of community mobilization and home visits by community-based workers. Both timing of visits and treatment interventions are critical. It is not clear how community-based approaches should be balanced, and whether they are effective outside South Asia and when introduced into public sector systems. Operational challenges include integrating community-based activities into public health systems, and questions of how to achieve coverage at scale. The possibility of partnership between the public and nongovernment sectors should be explored, particularly in terms of novel large-scale collaborations. © 2010 Nair et al.
Nair N.,Ekjut |
Tripathy P.,Ekjut |
Costello A.,University College London |
Prost A.,University College London
International Journal of Gynecology and Obstetrics | Year: 2012
Research conducted over the past decade has shown that community-based interventions can improve the survival and health of mothers and newborns in low- and middle-income countries. Interventions engaging women's groups in participatory learning and action meetings and other group activities, for example, have led to substantial increases in neonatal survival in high-mortality settings. Participatory interventions with women's groups work by providing a forum for communities to develop a common understanding of maternal and neonatal problems, as well as locally acceptable and sustainable strategies to address these. Potential partners for scaling up interventions with women's groups include government community health workers and volunteers, as well as organizations working with self-help groups. It is important to tailor scale-up efforts to local contexts, while retaining fidelity to the intervention, by ensuring that the mobilization of women's groups complements other local programs (e.g. home visits), and by providing capacity building for participatory learning and action methods across a range of nongovernmental organizations and government stakeholders. Research into scale-up mechanisms and effectiveness is needed to inform further implementation, and prospective surveillance of maternal and neonatal mortality in key scale-up sites can provide valuable data for measuring impact and for advocacy. There is a need for further research into the role of participatory interventions with women's groups to improve the quality of health services, health, and nutrition beyond the perinatal period, as well as the role of groups in influencing non-health issues, such as women's decision-making power. © 2012 International Federation of Gynecology and Obstetrics.
Seward N.,Institute of Child Health |
Osrin D.,Institute of Child Health |
Li L.,Institute of Child Health |
Costello A.,Institute of Child Health |
And 8 more authors.
PLoS Medicine | Year: 2012
Background: Sepsis accounts for up to 15% of an estimated 3.3 million annual neonatal deaths globally. We used data collected from the control arms of three previously conducted cluster-randomised controlled trials in rural Bangladesh, India, and Nepal to examine the association between clean delivery kit use or clean delivery practices and neonatal mortality among home births. Methods and Findings: Hierarchical, logistic regression models were used to explore the association between neonatal mortality and clean delivery kit use or clean delivery practices in 19,754 home births, controlling for confounders common to all study sites. We tested the association between kit use and neonatal mortality using a pooled dataset from all three sites and separately for each site. We then examined the association between individual clean delivery practices addressed in the contents of the kit (boiled blade and thread, plastic sheet, gloves, hand washing, and appropriate cord care) and neonatal mortality. Finally, we examined the combined association between mortality and four specific clean delivery practices (boiled blade and thread, hand washing, and plastic sheet). Using the pooled dataset, we found that kit use was associated with a relative reduction in neonatal mortality (adjusted odds ratio 0.52, 95% CI 0.39-0.68). While use of a clean delivery kit was not always accompanied by clean delivery practices, using a plastic sheet during delivery, a boiled blade to cut the cord, a boiled thread to tie the cord, and antiseptic to clean the umbilicus were each significantly associated with relative reductions in mortality, independently of kit use. Each additional clean delivery practice used was associated with a 16% relative reduction in neonatal mortality (odds ratio 0.84, 95% CI 0.77-0.92). Conclusions: The appropriate use of a clean delivery kit or clean delivery practices is associated with relative reductions in neonatal mortality among home births in underserved, rural populations. Please see later in the article for the Editors' Summary. © 2012 Seward et al.
PubMed | Sitaram Bhartia Institute of Science and Research, Ekjut, Public Health Foundation of India and University College London
Type: Journal Article | Journal: BMJ open | Year: 2016
Undernutrition affects 165 million children globally and contributes up to 45% of all child deaths. India has the highest proportion of global undernutrition-related morbidity and mortality. This protocol describes the planned economic evaluation of a community-based intervention to improve growth in children under 2years of age in two rural districts of eastern India. The intervention is being evaluated through a cluster-randomised controlled trial (cRCT, the CARING trial).A cost-effectiveness and cost-utility analysis nested within a cRCT will be conducted from a societal perspective, measuring programme, provider, household and societal costs. Programme costs will be collected prospectively from project accounts using a standardised tool. These will be supplemented with time sheets and key informant interviews to inform the allocation of joint costs. Direct and indirect costs incurred by providers will be collected using key informant interviews and time use surveys. Direct and indirect household costs will be collected prospectively, using time use and consumption surveys. Incremental cost-effectiveness ratios (ICERs) will be calculated for the primary outcome measure, that is, cases of stunting prevented, and other outcomes such as cases of wasting prevented, cases of infant mortality averted, life years saved and disability-adjusted life years (DALYs) averted. Sensitivity analyses will be conducted to assess the robustness of results.There is a shortage of robust evidence regarding the cost-effectiveness of strategies to improve early child growth. As this economic evaluation is nested within a large scale, cRCT, it will contribute to understanding the fiscal space for investment in early child growth, and the relative (in)efficiency of prioritising resources to this intervention over others to prevent stunting in this and other comparable contexts. The protocol has all necessary ethical approvals and the findings will be disseminated within academia and the wider policy sphere.ISRCTN51505201; pre-results.
PubMed | Erasmus University Rotterdam, Ekjut and University College London
Type: Journal Article | Journal: The Lancet. Global health | Year: 2016
A quarter of the worlds neonatal deaths and 15% of maternal deaths happen in India. Few community-based strategies to improve maternal and newborn health have been tested through the countrys government-approved Accredited Social Health Activists (ASHAs). We aimed to test the effect of participatory womens groups facilitated by ASHAs on birth outcomes, including neonatal mortality.In this cluster-randomised controlled trial of a community intervention to improve maternal and newborn health, we randomly assigned (1:1) geographical clusters in rural Jharkhand and Odisha, eastern India to intervention (participatory womens groups) or control (no womens groups). Study participants were women of reproductive age (15-49 years) who gave birth between Sept 1, 2009, and Dec 31, 2012. In the intervention group, ASHAs supported womens groups through a participatory learning and action meeting cycle. Groups discussed and prioritised maternal and newborn health problems, identified strategies to address them, implemented the strategies, and assessed their progress. We identified births, stillbirths, and neonatal deaths, and interviewed mothers 6 weeks after delivery. The primary outcome was neonatal mortality over a 2 year follow up. Analyses were by intention to treat. This trial is registered with ISRCTN, number ISRCTN31567106.Between September, 2009, and December, 2012, we randomly assigned 30 clusters (estimated population 156519) to intervention (15 clusters, estimated population n=82702) or control (15 clusters, n=73817). During the follow-up period (Jan 1, 2011, to Dec 31, 2012), we identified 3700 births in the intervention group and 3519 in the control group. One intervention cluster was lost to follow up. The neonatal mortality rate during this period was 30 per 1000 livebirths in the intervention group and 44 per 1000 livebirths in the control group (odds ratio [OR] 0.69, 95% CI 053-089).ASHAs can successfully reduce neonatal mortality through participatory meetings with womens groups. This is a scalable community-based approach to improving neonatal survival in rural, underserved areas of India.Big Lottery Fund (UK).