UCL DEPARTMENT OF GEOGRAPHY UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Improving maternal & newborn health outcomes among tribal communities in

UCL DEPARTMENT OF GEOGRAPHYUCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT

Improving maternal & newborn health outcomes among tribal communities in Eastern India:

THE EKJUT TRIAL

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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT

BACKGROUND

METHODS

RESULTS

DISCUSSION

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BACKGROUND

METHODS

RESULTS

DISCUSSION

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Community mobilisation through women’s groupscan improve maternal and newborn health outcomesat low cost

Makwanpur trial, Nepal:

30% reduction in neonatal mortality

80 % reduction in maternal mortality Manandhar et al. Lancet 2004


Is this approach scaleable & replicable?

Four randomised controlled trials:

• Rural Malawi• Mumbai, India• Jharkhand & Orissa, India - the Ekjut trial• Bangladesh (three rural districts)

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Ekjut trial study areas

Jharkhand & Orissa - eastern India

(combined population ~ 66 million)

Tribal people (adivasi) ~ around a quarter of the population in both states

Jharkhand: poorest state in India at its creation in 2000

Around 40% of population in both states live below the poverty line.

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Maternal & newborn health indicators (2006)

JHARKHAND ORISSA INDIA

Neonatal Mortality Rate (per 1000 livebirths)

49 45 39

Maternal Mortality Ratio (per 100,000 livebirths)

471 458 407

JHARKHAND ORISSA INDIA

Antenatal Care (%) 38 50.7

Institutional delivery (%) 19 41

(DLHS -3 & NFHS - 3)

4836

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Tribal communities: worse socio-economic / health indicators compared with non-indigenous people.

NMR and MMR considerably worse than in general population.

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Baseline survey findings in the study areas

• NMR: 58 per 1000 live births• MMR: 557 per 100,000 live births

• 40% of women did not have any ANC • 15% had 4+ ANC visits• 85% of deliveries took place at home

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TRIAL OBJECTIVES & OUTCOMES

To measure the impact of working through women’s groups on maternal health, newborn health, and maternal depression through a cluster randomised controlled trial.

- 35% in neonatal mortality rate

- 55% in maternal mortality ratio

- 50% in maternal depression

+ improved home care practices & care-seeking

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Study design

36 clusters (~ 6300 population) in 3 districts

randomised to intervention & control arms

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18 CONTROL

CLUSTERS

Women’s groups ’

36 CLUSTERS

Health Service Strengthening

18 INTERVENTION

CLUSTERSWomen’s groups ++


INCLUSION CRITERIA & TIMELINE

• All women of reproductive age (15-49)

• Residing in the project area• Who gave birth between 31st July 2005 – 30th July 2008 • Who gave consent for involvement in the project

• Timeline:

Baseline survey Year 1 Year 2 Year 3

Nov 04- Jul 05 Jul 05- Jul 06 Jul 06- Jul 07 Jul 07- Jul 08

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Monitoring births & deaths

Select one key informant per 25O households

Pay informant incentive to identify births &deaths to women of reproductive age

Interviewer visits informant monthly to collect list of identifications

Interviewer verifies identifications and pays informant

Interviewer interviews once at six weeks after delivery

Women who are interviewed are ‘ snowballed ’ for other identifications

Interviewer collects identifications from government records every month

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EXISTING GROUPS = 203 EKJUT WOMEN’S GROUPS =244

CONTROL CLUSTERS INTERVENTION CLUSTERS

WOMEN’S GROUP CYCLE


The women’s group participatory cycle

PHASE 1Identify and

Prioritise Problems

PHASE 2Plan

Strategies

PHASE 3Put strategies Into practice

PHASE 4Assess impact

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Visit Community

IntroduceProject

Explore Current

Practices

Identify MaternalProblems

Identify NewbornProblems

Prioritise Problems

PHASE 1Identify And Prioritise Problems

PHASE 2Plan Strategies

PHASE 3Put Strategies Into Practice

PHASE 4Assess Impact

Discuss Causes

& Solutions

Barriers &Strategies

Prioritise Strategies

Choose Process For

Sharing

Prepare & Practice

COMMUNITY MEETING

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BACKGROUND

METHODS

RESULTS

DISCUSSION

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18829 Pregnancies* 23 Died during pregnancy

due to maternal causes

18806 Deliveries

19030 Births

581 Stillbirths 18449 Live births

937 Died within 28 days Early NND = 635 Late NND = 302

17511 Alive at one month

55 Died during labour / childbirth


31 Died after childbirth (42 days-1 yr)


* System designed to identify births and deaths not pregnancies - 01/09

EKJUT TRIAL

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Intervention Clusters

Control Clusters

Adjusted

odds ratios

(95% CI)

Births

Livebirths

9770

9469

9260

8980-

Stillbirths

Neonatal deaths

Maternal deaths

301

406

49

280

531

60

-

Stillbirth rate (per 1000 livebirths)

Neonatal mortality rate (per 1000 livebirths)

Maternal mortality ratio(per 100,000 livebirths)

30.7

43

517.9

30.2

59

668.2

1.06 (0.86 - 1.30)

0.69 (0.59 - 0.81)

0.775

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Reduction in newborn mortality

Intervention Clusters

Control Clusters

Adjusted

odds ratios

(95% CI)

Neonatal deaths

In years 2 & 3

Neonatal deaths

In Year 3

259

109

390

188

0.58 (0.48 - 0.71)

0.54 (0.42 - 0.70)

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Early Neonatal Mortality Rate in Intervention and Control Areas

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Late Neonatal Mortality Rate in Intervention and Control Areas

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Perinatal Mortality Rate in Intervention and Control Areas

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Maternal Mortality Ratio in Intervention and Control Areas

Intervention Control All

Baseline 680 321.8 608

Year 1 651.9 1012.1 828.9

Year 2 669.5 593.3 632.9

Year 3 224.7 402.5 311.7

Y1,2 &3 517.5 668.2 590.8

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In her 8th month of pregnancy Rajani Juang and her mother-in-law attended a women’s group meeting where she participated in a drill based on “what to do in case of postpartum bleeding”.

After a month when she delivered at home and had severe bleeding, her mother-in-law remembered the meeting and without wasting time asked Rajani to breast feed her baby, while she rushed to get money from the group and asked her son to get a vehicle.

She was immediately taken to the district hospital, where she was given medicines, IV fluid, two pints of blood, and was discharged after fifteen days.

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Ref Case study no.25

Case study - a maternal death avoided


Maternal depression in intervention & control clusters

At Year 3 (using K10 scale):

OR (95% CI) p

Moderate depression 0.40 (0.17- 0.93) 0.034

High / Severe depression 0.68 (0.09 - 4.95) 0.708

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Improved home Care Practices

Median (%) Intervention Control p

Birth attendants washed hands

44.5 18.3 0.01

Used safe delivery kit 29.3 18.7 0.008

Used plastic sheet 26.6 7.1 <0.001

Boiled thread 29.8 10.8 0.04

Infant exclusively breastfed for first 6 weeks

79.4 70.7 0.04

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Service utilisation

Median (%) Intervention Control p

Any care in pregnancy 83.1 82.1 0.974

4 + ANC 18.7 22.7 0.194

Institutional delivery 13 14.2 0.154

Any postpartum care 15 15.7 0.506

Mother had check-up

in 1st 6 weeks

6.2 7.8 0.194

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BACKGROUND

METHODS

RESULTS

DISCUSSION

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Mechanisms for change ?

• High population coverage (1 group per 460 pop)• Quality of intervention delivery • Targeting the most marginalised • High proportion of pregnant women in groups

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Targeting the most marginalised: adivasis

District %

in district

% in clusters

% in meeting 1

% in

meeting 25

Saraikela - Karshwan

36 58 68 67

Keonjhar 48 69 73 77

West Singhbum

55 70 82 85


Men, adolescents and elderly women

Tribal, Marginalized & Underserved communities

Where health services

are inaccessible

Families living in hamlets, inaccessible, remote, hilly regions

Mechanisms: targeting

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Belief that together they can bring about change

Involvement of men, adolescents and elderly women

Increase in family support during pregnancy, delivery and postpartum

period

Process indicators: intervention quality

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Community Women’s Group

PREGNANT WOMEN IN GROUPS - YEAR 1

Pregnant women

Other women

17.5 %

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Community Women’s GroupPregnant women

Other women

17.5% 38.4%


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Community Women’s GroupPregnant women

Other women

17.5% 38.4% 55 %


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“We could not do much as individuals but as a group we could find a way to solve each other’s problems”.

“It was easy to understand the causes and effects of maternal and newborn problems through picture card stories”.

“The involvement of both women and men in choosing strategies was very encouraging”.

“We are proud that to some extent we have helped in changing the behaviour of our group members and others who do not attend the meetings”.

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Feedback from group members


Summary

• 42% reduction in newborn mortality (Y2&3)• 60% reduction in moderate depression in Y3• Improved home care practices

• NMR reduction is higher than in Makwanpur trial• Ekjut is working towards scale-up in 3 more districts

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STUDY COLLABORATION:

EKJUT

Dr Prasanta Tripathy & Dr Nirmala Nair

Suchitra Rath

Shibanand Rath

Raj Kumar Gope

Rajendra Mahapatra

Deepnath Mahto

CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT (UCL)

Prof Anthony Costello

Dr Sarah Barnett

Dr Audrey Prost

Funded by: THE HEALTH FOUNDATION (UK) & BIG LOTTERY FUND (UK) ekjutekjut



Documents

UCL DEPARTMENT OF GEOGRAPHY UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Improving maternal & newborn health outcomes among tribal communities in