Dharma Manandhar

Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial

BACKGROUND Neonatal deaths in developing countries make the largest contribution to global mortality in children younger than 5 years. 90% of deliveries in the poorest quintile of households happen at home. We postulated that a community-based participatory intervention could significantly reduce neonatal mortality rates. METHODS We pair-matched 42 geopolitical clusters in Makwanpur district, Nepal, selected 12 pairs randomly, and randomly assigned one of each pair to intervention or control. In each intervention cluster (average population 7000), a female facilitator convened nine womens group meetings every month. The facilitator supported groups through an action-learning cycle in which they identified local perinatal problems and formulated strategies to address them. We monitored birth outcomes in a cohort of 28?931 women, of whom 8% joined the groups. The primary outcome was neonatal mortality rate. Other outcomes included stillbirths and maternal deaths, uptake of antenatal and delivery services, home care practices, infant morbidity, and health-care seeking. Analysis was by intention to treat. The study is registered as an International Standard Randomised Controlled Trial, number ISRCTN31137309. FINDINGS From 2001 to 2003, the neonatal mortality rate was 26.2 per 1000 (76 deaths per 2899 livebirths) in intervention clusters compared with 36.9 per 1000 (119 deaths per 3226 livebirths) in controls (adjusted odds ratio 0.70 [95% CI 0.53-0.94]). Stillbirth rates were similar in both groups. The maternal mortality ratio was 69 per 100000 (two deaths per 2899 livebirths) in intervention clusters compared with 341 per 100000 (11 deaths per 3226 livebirths) in control clusters (0.22 [0.05-0.90]). Women in intervention clusters were more likely to have antenatal care, institutional delivery, trained birth attendance, and hygienic care than were controls. INTERPRETATION Birth outcomes in a poor rural population improved greatly through a low cost, potentially sustainable and scalable, participatory intervention with womens groups.

Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis

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 womens 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 womens 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 womens 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 womens 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 (I(2)=58.8%, p=0.024) and neonatal results (I(2)=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, womens groups practising participatory learning and action are a cost-effective strategy to improve maternal and neonatal survival in low-resource settings. FUNDING Wellcome Trust, Ammalife, and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Birmingham and the Black Country programme.

Cross sectional community based study of care of newborn infants in Nepal.

Abstract Objective: To determine home based newborn care practices in rural Nepal in order to inform strategies to improve neonatal outcome. Design: Cross sectional, retrospective study using structured interviews. Setting: Makwanpur district, Nepal. Participants: 5411 married women aged 15 to 49 years who had given birth to a live baby in the past year. Main outcome measures: Attendance at delivery, hygiene, thermal care, and early feeding practices. Results: 4893 (90%) women gave birth at home. Attendance at delivery by skilled government health workers was low (334, 6%), as was attendance by traditional birth attendants (267, 5%). Only 461 (8%) women had used a clean home delivery kit, and about half of attendants had washed their hands. Only 3482 (64%) newborn infants had been wrapped within half an hour of birth, and 4992 (92%) had been bathed within the first hour. 99% (5362) of babies were breast fed, 91% (4939) within six hours of birth. Practices with respect to colostrum and prelacteals were not a cause for anxiety. Conclusions: Health promotion interventions most likely to improve newborn health in this setting include increasing attendance at delivery by skilled service providers, improving information for families about basic perinatal care, promotion of clean delivery practices, early cord cutting and wrapping of the baby, and avoidance of early bathing. What is already known on this topic Most births in rural south Asia occur at home Neonatal mortality has remained fairly constant in developing countries despite falling infant mortality What this paper adds Only 6% of births in rural Nepal took place in the presence of a skilled attendant Cord cutting implements were often unclean and drying and wrapping of newborn infants was usually delayed 99% of babies were breast fed, 92% of them within six hours of birth, and colostrum was generally given Interventions need to focus on educating women about hygiene, encouraging early wrapping, and delaying bathing of newborn babies

The effects of postnatal health education for mothers on infant care and family planning practices in Nepal: a randomised controlled trial

Abstract Objectives: To evaluate impact of postnatal health education for mothers on infant care and postnatal family planning practices in Nepal. Design: Randomised controlled trial with community follow up at 3 and 6 months post partum by interview. Initial household survey of study areas to identify all pregnant women to facilitate follow up. Setting: Main maternity hospital in Kathmandu, Nepal. Follow up in urban Kathmandu and a periurban area southwest of the city. Subjects: 540 mothers randomly allocated to one of four groups: health education immediately after birth and three months later (group A), at birth only (group B), at three months only (group C), or none (group D). Interventions: Structured baseline household questionnaire; 20 minute, one to one health education at birth and three months later. Main outcome measures: Duration of exclusive breast feeding, appropriate immunisation of infant, knowledge of oral rehydration solution and need to continue breast feeding in diarrhoea, knowledge of infant signs suggesting pneumonia, uptake of postnatal family planning. Results: Mothers in groups A and B (received health education at birth) were slightly more likely to use contraception at six months after birth compared with mothers in groups C and D (no health education at birth) (odds ratio 1.62, 95% confidence interval 1.06 to 2.5). There were no other significant differences between groups with regards to infant feeding, infant care, or immunisation. Conclusions: Our findings suggest that the recommended practice of individual health education for postnatal mothers in poor communities has no impact on infant feeding, care, or immunisation, although uptake of family planning may be slightly enhanced. Key messages Health education is widely promoted in primary care, but there have been few rigorous evaluations of its impact, especially in developing countries A randomised controlled trial of postnatal individual health education for mothers given by trained female health workers showed no significant impact on maternal knowledge and practices of child care or on infant health outcomes, but there was a small improvement in uptake of family planning at six months after birth The efficacy of health education interventions that rely solely on giving people information to bring about a change in health behaviour is unproved; interventions should be evaluated before being implemented on a large scale Alternative strategies for health promotion in developing countries such as interactions within families, peer groups, or communities may be more effective but are costly and difficult to implement on a large scale

Risk Factors for neonatal encephalopathy in Kathmandu,Nepal, a developing country: unmatched case-control study

Abstract Objective: To determine the risk factors for neonatal encephalopathy among term infants in a developing country. Design: Unmatched case-control study. Setting: Principal maternity hospital of Kathmandu, Nepal. Subjects: All 131 infants with neonatal encephalopathy from a population of 21 609 infants born over an 18 month period, and 635 unmatched infants systematically recruited over 12 months. Main outcome measures: Adjusted odds ratio estimates for antepartum and intrapartum risk factors. Results: The prevalence of neonatal encephalopathy was 6.1 per 1000 live births of which 63% were infants with moderate or severe encephalopathy. The risk of death from neonatal encephalopathy was 31%. The risk of neonatal encephalopathy increased with increasing maternal age and decreasing maternal height. Antepartum risk factors included primiparity (odds ratio 2.0) and non-attendance for antenatal care (2.1). Multiple births were at greatly increased risk (22). Intrapartum risk factors included non-cephalic presentation (3.4), prolonged rupture of membranes (3.8), and various other complications. Particulate meconium was strongly associated with encephalopathy (18). Induction of labour with oxytocin was associated with encephalopathy in 12 of 41 deliveries (5.7). Overall, 78 affected infants (60%) compared with 36 controls (6%) either had evidence of intrapartum compromise or were born after an intrapartum difficulty likely to result in fetal compromise. A concentration of maternal haemoglobin of less than 8.0 g/dl in the puerperium was significantly associated with encephalopathy (2.5) as was a maternal thyroid stimulating hormone concentration greater than 5 mIU/l (2.1). Conclusions: Intrapartum risk factors remain important for neonatal encephalopathy in developing countries. There is some evidence of a protective effect from antenatal care. The use of oxytocin in low income countries where intrapartum monitoring is suboptimal presents a major risk to the fetus. More work is required to explore the association between maternal deficiency states and neonatal encephalopathy.

Reducing maternal and neonatal mortality in the poorest communities

Current programmes are often failing to reach those at highest risk of maternal and neonatal death. The international community needs to learn from community trials in the South

Women's health groups to improve perinatal care in rural Nepal

BackgroundNeonatal mortality rates are high in rural Nepal where more than 90% of deliveries are in the home. Evidence suggests that death rates can be reduced by interventions at community level. We describe an intervention which aimed to harness the power of community planning and decision making to improve maternal and newborn care in rural Nepal.MethodsThe development of 111 womens groups in a population of 86 704 in Makwanpur district, Nepal is described. The groups, facilitated by local women, were the intervention component of a randomized controlled trial to reduce perinatal and neonatal mortality rates. Through participant observation and analysis of reports, we describe the implementation of this intervention: the community entry process, the facilitation of monthly meetings through a participatory action cycle of problem identification, community planning, and implementation and evaluation of strategies to tackle the identified problems.ResultsIn response to the needs of the group, participatory health education was added to the intervention and the womens groups developed varied strategies to tackle problems of maternal and newborn care: establishing mother and child health funds, producing clean home delivery kits and operating stretcher schemes. Close linkages with community leaders and community health workers improved strategy implementation. There were also indications of positive effects on group members and health services, and most groups remained active after 30 months.ConclusionA large scale and potentially sustainable participatory intervention with womens groups, which focused on pregnancy, childbirth and the newborn period, resulted in innovative strategies identified by local communities to tackle perinatal care problems.

Care for perinatal illness in rural Nepal: a descriptive study with cross-sectional and qualitative components

BackgroundMaternal, perinatal and neonatal mortality rates remain high in rural areas of developing countries. Most deliveries take place at home and care-seeking behaviour is often delayed. We report on a combined quantitative and qualitative study of care seeking obstacles and practices relating to perinatal illness in rural Makwanpur district, Nepal, with particular emphasis on consultation strategies.MethodsThe analysis included a survey of 8798 women who reported a birth in the previous two years [of whom 3557 reported illness in their pregnancy], on 30 case studies of perinatal morbidity and mortality, and on 43 focus group discussions with mothers, other family members and health workers.ResultsEarly pregnancy was often concealed, preparation for birth was minimal and trained attendance at birth was uncommon. Family members were favoured attendants, particularly mothers-in-law. The most common recalled maternal complications were prolonged labour, postpartum haemorrhage and retained placenta. Neonatal death, though less definable, was often associated with cessation of suckling and shortness of breath. Many home-based care practices for maternal and neonatal illness were described. Self-medication was common.There were delays in recognising and acting on danger signs, and in seeking care beyond the household, in which the cultural requirement for maternal seclusion, and the perceived expense of care, played a part. Of the 760 women who sought care at a government facility, 70% took more than 12 hours from the decision to seek help to actual consultation. Consultation was primarily with traditional healers, who were key actors in the ascription of causation. Use of the government primary health care system was limited: the most common source of allopathic care was the district hospital.ConclusionsMajor obstacles to seeking care were: a limited capacity to recognise danger signs; the need to watch and wait; and an overwhelming preference to treat illness within the community. Safer motherhood and newborn care programmes in rural communities, must address both community and health facility care to have an impact on morbidity and mortality. The roles of community actors such as mothers-in-law, husbands, local healers and pharmacies, and increased access to properly trained birth attendants need to be addressed if delays in reaching health facilities are to be shortened.

Economic assessment of a women's group intervention to improve birth outcomes in rural Nepal

We did a cost-effectiveness analysis alongside a cluster-randomised controlled trial of a participatory intervention with womens groups to improve birth outcomes in rural Nepal. The average provider cost of the womens group intervention was US0.75 dollars per person per year (0.90 dollars with health-service strengthening) in a population of 86,704. The incremental cost per life-year saved (LYS) was 211 dollars (251 dollars), and expansion could rationalise on start-up costs and technical assistance, reducing the cost per LYS to 138 dollars (179 dollars). Sensitivity analysis showed a variation from 83 dollars to 263 dollars per LYS for most variables. This intervention could provide a cost-effective way of reducing neonatal deaths.

Airborne endotoxin concentrations in homes burning biomass fuel

Background About half of the world’s population is exposed to smoke from burning biomass fuels at home. The high airborne particulate levels in these homes and the health burden of exposure to this smoke are well described. Burning unprocessed biological material such as wood and dried animal dung may also produce high indoor endotoxin concentrations. Objective In this study we measured airborne endotoxin levels in homes burning different biomass fuels. Methods Air sampling was carried out in homes burning wood or dried animal dung in Nepal (n = 31) and wood, charcoal, or crop residues in Malawi (n = 38). Filters were analyzed for endotoxin content expressed as airborne endotoxin concentration and endotoxin per mass of airborne particulate. Results Airborne endotoxin concentrations were high. Averaged over 24 hr in Malawian homes, median concentrations of total inhalable endotoxin were 24 endotoxin units (EU)/m3 in charcoal-burning homes and 40 EU/m3 in wood-burning homes. Short cooking-time samples collected in Nepal produced median values of 43 EU/m3 in wood-burning homes and 365 EU/m3 in dung-burning homes, suggesting increasing endotoxin levels with decreasing energy levels in unprocessed solid fuels. Conclusions Airborne endotoxin concentrations in homes burning biomass fuels are orders of magnitude higher than those found in homes in developed countries where endotoxin exposure has been linked to respiratory illness in children. There is a need for work to identify the determinants of these high concentrations, interventions to reduce exposure, and health studies to examine the effects of these sustained, near-occupational levels of exposure experienced from early life.