S
Birth Preparedness and Complication Readiness
in Improving Skilled Birth Attendance
Population Foundation of India
MCH STAR
Ms. Arti Bhanot
Systematic Review of
Birth Preparedness and Complication Readiness (BP/CR) Interventions
Improving Skilled Birth Attendance in South Asia
Study Report
Submitted by
Population Foundation of India
February 2011
STUDY TEAM
Population Foundation
of India
Dr. Shalini Verma
Ms. Kirti Mishra
South Asian Cochrane
Network & Centre
Dr.Prathap Tharyan
i
nterventions
in South Asia
South Asian Cochrane
Network & Centre
Dr.Prathap Tharyan
Foundation of India Population
TABLE OF CONTENTS
List of abbreviations ......................................................................................... PAGE i
Executive Summary ........................................................................................ PAGE ii
1. INTRODUCTION ................................................................................... PAGE 1-4
1.1 BACKGROUND Burden of Maternal Mortality Proximate Causes of Maternal Mortality
Skilled Birth Attendants
Birth Preparedness and Complication Readiness (BP/CR)
1.2 RATIONALE FOR THE SYSTEMATIC REVIEW
1.3 OBJECTIVE Specific Study Questions
2. METHODS ............................................................................................. PAGE 5-9
2.1 STUDY ELIGIBILITY CRITERIA Study Protocol
2.2 INFORMATION SOURCES Search
2.3 STUDY SELECTION
2.4 DATA COLLECTION PROCESS
2.5 DATA ITEMS
2.6 RISK OF BIAS IN INDIVIDUAL STUDIES
2.7 SUMMARY MEASURES AND SYNTHESIS OF RESULTS
2.8 RISK OF BIAS ACROSS STUDIES
3. RESULTS .......................................................................................... PAGE 10-23
3.1 STUDY SELECTION FOR SYSTEMATIC REVIEW
3.2 STUDY CHARACTERISTICS Geographical Distribution
Type of Studies Participants
Interventions (Intervention Planning, Intervention Coverage, Intervention Components,
Intervention Approach, Intervention Agents & Intervention Monitoring)
Controls
Outcomes
3.3 RISK OF BIAS WITHIN STUDIES
3.4 RESULTS OF INDIVIDUAL STUDIES
3.5 SYNTHESIS OF RESULTS Analysis of Individual Studies
Odds Ratios
3.6 RISK OF BIAS ACROSS STUDIES
Foundation of India Population
4. DISCUSSION ......................................................................................... PAGE 24-
4.1 SUMMARY OF EVIDENCES
4.2 LIMITATIONS
4.3 CONCLUSIONS
4.4 FUNDING
5. RECOMMENDATIONS ........................................................................ PAGE 25
ANNEXURE I: SEARCH STRINGS ....................................... ANNEXURE PAGE 1-2
SEARCH STRING USED IN GOOGLE SCHOLAR
SEARCH STRING USED IN PUBMED
SEARCH STRING USED IN POPLINE
ANNEXURE II: RESULTS OF INDIVIDUAL STUDIES ... ANNEXURE PAGE 3-13
STUDY CHARACTERISTICS TABLE 1: MCPHERSON (2006)
STUDY CHARACTERISTICS TABLE 2: HODGINS (2010)
STUDY CHARACTERISTICS TABLE 3: DARMSTADT (2010)
STUDY CHARACTERISTICS TABLE 4: HOSSAIN (2006)
STUDY CHARACTERISTICS TABLE 5: BAQUI (2008)
STUDY CHARACTERISTICS TABLE 6: KUMAR (2008)
STUDY CHARACTERISTICS TABLE 7: CURRIE 2009)
ANNEXURE III: LIST OF EXCLUDED STUDIES ........... ANNEXURE PAGE 14-19
LIST OF BOXES, FIGURES AND TABLES
Box 1 PICO PROTOCOL ............................................................................... PAGE 6
Box 2 INFORMATION SOURCES .................................................................... PAGE 7
Box 3 QUALITY ASSESSMENT CRITERIA ....................................................... PAGE 9
Box 4 FLOW CHART OF STUDY SELECTION ................................................. PAGE 11
Box 5 POTENTIAL SOURCES OF BIASES IN THE SELECTED STUDIES .............. PAGE 18
Figure 1 GEOGRAPHICAL DISTRIBUTION OF THE SELECTED STUDIES ............... PAGE 12
Table 1 COMPARISON OF THE INTERVENTION PACKAGE ACROSS STUDIES ...... PAGE 15
Table 2 EFFECTIVENESS OF BP/CR INTERVENTION ........................................ PAGE 20
Table 3 ODDS OF USING SKILLED BIRTH ATTENDANT.................................... PAGE 23
i
LIST OF ABBREVIATIONS
ANM Auxiliary Nurse Midwife
ASHA Accredited Social Health Activist
AWW Anganwadi Workers
BP/CR Birth Preparedness and Complication Readiness
CHW Community Health Worker
EmOC Emergency Obstetric Care
FRU First Referral Unit
GoI Government of India
HIV Human Immuno Virus
ICDS Integrated Child Development Services
JSY Janani Suraksha Yojana
MCH-STAR Maternal Child Health-Sustainable Technical Assistance and Research
MMR Maternal Mortality Ratio
NGO Non Governmental Organization
NRHM National Rural Health Mission
PFI Population Foundation of India
PICO Participants Intervention Control Outcome
PMTCT Prevention of Mother To Child Transmission
PPES Probability Proportional to Estimated Size
RCT Randomized Controlled Trials
RHL Reproductive Health Library
SBA Skilled Birth Attendant
SLI Standard of Living Index
TAG Technical Advisory Group
UNICEF United Nations Children’s’ Fund
UP Uttar Pradesh
USAID United States Agency for International Development
WHO World Health Organization
WRAI White Ribbon Alliance India
ii
ABSTRACT
Background
South Asian countries account for one third of maternal deaths globally. Apart from the bio-medical
causes of maternal deaths, there are a number of underlying factors at the household and community
levels that may undermine the health and survival of mothers. It is also well-recognized that most of
these deaths can be prevented. Receiving timely care from a skilled provider during childbirth is
regarded as the single most important intervention in safe motherhood. Birth preparedness and
complication readiness (BP/CR) is a strategy to promote timely use of skilled maternal care.
There was a need to review the efficacy of community based BP/CR interventions at scale in
improving skilled birth attendance and thus reducing maternal mortality. The Population Foundation
of India (PFI), with technical and financial assistance from MCH-STAR/USAID conducted a systematic review of studies on BP/CR interventions and their impact on improving skilled birth
attendance.
Objectives
The objective of the study was to conduct a systematic review of community based evidence at scale
from South Asian countries (India, Nepal, Bangladesh, Pakistan and Sri Lanka) to assess the
effectiveness of birth preparedness and complication readiness in improving skilled birth attendance,
knowledge and preparedness for delivery.
Methods
Data sources Electronic search was done through, Google Scholar, PubMed, Popline, WHO
Reproductive Health Library (RHL) and the Cochrane Library (EPOC Group). List serve calls were
made through WRAI, CORE and Solution exchange. Reference list of identified papers were scanned
and leading authors, experts and agencies were contacted. Study eligibility criteria Eligible studies were community based RCTs or case-control studies or pre-
post evaluations. Studies available in the English language, irrespective of publication status and year
were searched. Participants Study participants were women of childbearing age (15-49 years) who have given birth
within 24 months prior to the study.
Interventions Large scale community based intervention on birth preparedness and complication
readiness.
Study appraisal and synthesis methods Two authors independently assessed the studies and extracted
the data. Risk of bias, within studies and across studies were assessed. Due to the heterogeneity in
selected studies, a narrative synthesis has been done.
Results
Seven studies, four RCTs and three before and after studies were included in the systematic review. The systematic review found that BP/CR interventions at scale have proven to be effective in South
Asian countries in improving knowledge and preparedness for delivery. BP/CR intervention could
also lead to significant improvement in SBA use, if health service delivery is also strengthened along
with it. The most successful components of the BP/CR package are education to improve knowledge
on danger signs, financial preparedness for the delivery/emergency and preparedness for transport. BP/CR interventions with a strong component of community mobilisation are found to be more
effective.
Conclusions and implications
BP/CR interventions along with community mobilisation and supply side strengthening could lead to
improved and timely utilisation of skilled birth attendance in the South Asian settings. This intervention could lead to reduction in maternal mortality by addressing all the delays to prevent
maternal deaths in resource-poor settings. This establishes a need for strengthening BP/CR
interventions in public health service delivery.
Population Foundation of India Page 1
1.1 INTRODUCTION
1.1 BACKGROUND
Burden of Maternal Mortality
During the year 2008, there were an estimated 358,000 maternal deaths in the world, or a
maternal mortality ratio (MMR) of 260 maternal deaths per 100,000 live births1. Most of
these deaths occurred in developing countries, and most were avoidable. Improving maternal
health is one of the eight Millennium Development Goals adopted by the international
community at the United Nations Millennium Summit in 2000. In Millennium Development
Goal 5 (MDG5), countries have committed to reducing the maternal mortality ratio by three
quarters between 1990 and 20152.
There are stark differences in the maternal mortality ratio between developed regions (14
maternal deaths per 100,000 live births) and developing regions (290 maternal deaths per
100,000 live births). The high incidence of maternal death is one of the signs of major
inequity spread across the world, reflecting the gap between rich and poor.
Developing countries continued to account for 99% (355,000) of the maternal deaths
globally. South Asia alone accounted for one third of these deaths. In addition to the
differences between countries, there are also large disparities within countries between people
with high and low income and between rural and urban populations31.
Proximate Causes of Maternal Mortality
Most maternal deaths could be avoided. The timing and causes of maternal mortality are well
known and they have not changed over time. Haemorrhage and hypertensive disorders
together account for the largest proportion of maternal deaths in developing countries4. Most
maternal deaths, barring those related to abortion occur from the third trimester to the first
week after delivery. It is also well-recognized that most of these deaths can be prevented if
skilled delivery care backed by emergency obstetric care (EmoC) is available along with
necessary drugs, equipment and a referral system for obstetric emergencies, i.e. a well-
functioning health system. In fact, receiving care from a skilled provider during childbirth is
regarded as the single most important intervention in safe motherhood5.
Apart from the bio-medical causes for maternal deaths, there are a number of underlying
factors at the household and community levels that may undermine the health and survival of
1 WHO. 2010. Trends in Maternal Mortality: 1990 to 2008. estimates developed by WHO, UNICEF, UNFPA
and the World Bank. Geneva, World Health Organization.
(http://whqlibdoc.who.int/publications/2010/9789241500265_eng.pdf accessed 29 Nov 2010). 2 WHO. 2008. Maternal Mortality Fact Sheet.
(http://www.who.int/making_pregnancy_safer/events/2008/mdg5/factsheet_maternal_mortality.pdf , accessed
29 Nov 2010). 3 WHO. 2010. op. cit., 1 4 Khan. 2006. WHO analysis of causes of maternal death: a systematic review. Lancet, 2006, 367:1066–1074.
http://www.who.int/reproductivehealth/topics/maternal_perinatal/progress_71.pdf, accessed 29 Nov 2010). 5 Starrs. 1997. The safe motherhood action agenda: Priorities for the next decade. Report on the Safe
Motherhood Technical Consultation, 18-23 October 1997 Colombo, Sri Lanka. New York, NY: Family Care
International, 1997. Page.94.
Population Foundation of India Page 2
mothers and their newborns6. The Delays model put forth by Thaddeus (1994)
7 is well
established in explaining the immediate causes of maternal deaths. It provides an explanatory
framework in terms of the following delays that influence provision and use of obstetric
services to prevent maternal deaths in resource-poor settings:
• the first delay is in recognizing complications
• the second delay is in deciding to seek care for an obstetric emergency
• the third delay is in reaching appropriate care
• the fourth delay is in receiving adequate care once a service facility has been reached
Skilled birth attendants
In developing countries, deliveries largely occur at home and when complications arise, they
may or may not be recognized and women may or may not be taken to a facility where care is
available. TBAs, including those who are trained, are not defined by the World Health
Organization as skilled attendants and TBAs are not an acceptable substitute for skilled
attendance at birth.8
WHO defines a skilled attendant as “an accredited health professional – such as a midwife,
doctor or nurse – who has been educated and trained to proficiency in the skills needed to
manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period,
and in the identification, management and referral of complications in women and
newborns”9.
Large disparities exist in providing pregnant women with antenatal care and skilled assistance
during delivery. All women and babies need maternity care in pregnancy, childbirth and after
delivery to ensure optimal pregnancy outcomes. Around the world, only 65.7% of births were
attended by a skilled health worker. Although nearly all births were attended by skilled health
personnel in developed country settings, this proportion is 61.9% in less developed countries
and only 35.3% in the least developed countries10. WHO strongly advocates for “skilled care
at every birth” to reduce the global burden of maternal deaths.
Historical and observational evidence indicates that skilled care at birth reduces the risk of
maternal mortality. Industrialized countries halved their maternal mortality ratios in the early
20th century by providing professional midwifery care at childbirth. Malaysia, Sri Lanka and
Thailand halved their maternal mortality ratios within 10 years by increasing the number of
midwives in the 1950s and 1960s. Over a further 15-year period, Thailand reduced its
maternal mortality ratio from 200 to 50 maternal deaths per 100,000 live births by deploying
even more midwives and by increasing the capacity of hospitals at the district level. Between
6 UNICEF. 2008. The State of the World’s Children 2009: Maternal and Newborn Health. 7 Thaddeus. 1994. Too far to walk: maternal mortality in context. Social Science and Medicine. 38:1091-1110. 8 WHO. 2008. Skilled birth attendants.
http://www.who.int/making_pregnancy_safer/topics/skilled_birth/en/index.html accessed 29 Nov 2010) 9 WHO. 2004. Making pregnancy safer: the critical role of the skilled attendant. A joint statement by WHO,
ICM and FIGO. Geneva, World Health Organization.
http://whqlibdoc.who.int/publications/2004/9241591692.pdf accessed 29 Nov 2010). 10 WHO. 2008. Proportion of births attended by a skilled health worker – 2008 updates. Geneva, World Health
Organization.
(http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/2008_skilled_attendant.pdf
accessed 29 Nov 2010).
Population Foundation of India Page 3
1983 and 2000, Egypt doubled the proportion of deliveries assisted by skilled birth attendants
and reduced its maternal mortality ratio by 50%11.
Birth Preparedness and Complication Readiness (BP/CR)
Birth preparedness and complication readiness (BP/CR) is a strategy to promote timely use of
skilled maternal care. BP/CR has been described as “an overarching program approach to
improve the use and effectiveness of key maternal and newborn health services, based on the
premise that preparing for birth and being ready for complications reduces delays in
recognizing complications and obtaining care, thereby saving needless deaths”12. BP/CR is
one strategy that has the potential to address delays.
WHO recommends to assist women and their partners and families to be adequately prepared
for childbirth by making plans on how to respond if complications or unexpected adverse
events occur to the woman and/or the baby at any time during pregnancy, childbirth or the
early postnatal period13.
Most safe motherhood programs use BP/CR as a strategy for reducing maternal mortality by
seeking to address the first three delays. Components such as arrangements for a skilled birth
attendant, plan for where to give births, knowledge of danger signs of pregnancy and
delivery, transportation plan and calculation of anticipated expenses and possible sources of
funds are the most common components of BP/CR advised globally. The BP/CR strategy
suggested by JHPIEGO has gone a step further to also address the fourth delay in receiving
adequate care after reaching the service facility. The JHPIEGO Matrix of Shared
Responsibility13 identifies the role of service providers, health facilities and policymakers for
ensuring availability of quality maternal healthcare services.
1.2 RATIONALE FOR THE SYSTEMATIC REVIEW
Many countries and organizations have used the BP/CR concept. There is a need to review
the efficacy of community based BP/CR interventions at scale in improving skilled birth
attendance and thus reducing maternal mortality. Some of the previously done research has
found affirmative as well as negative responses on this association, as mentioned below:
• Although, Moran (2006)14 has highlighted that birth-preparedness and complication
readiness may be useful in increasing the use of skilled providers at birth, it expresses
the need for additional research to further explore these relationships.
• The study by Rosecrans (2008)15 on "Is emergency birth preparedness associated with
increased skilled care at birth?" concluded that promoting emergency birth
11 WHO. 2005. Make every mother and child count. Geneva, World Health Organization.
(http://www.who.int/whr/2005/whr2005_en.pdf accessed 29 Nov 2010). 12 Jhpeigo. 2004. “Monitoring Birth Preparedness and Complication Readiness: Tools and Indicators for
Maternal and Newborn Health.” JHPIEGO, USA. Page 1-6.
(http://www.jhpiego.jhu.edu/resources/pubs/mnh/BP/CRtoolkit.pdf accessed 29 Nov 2010). 13 WHO. 2007. Tool 1.9 - 'Birth and emergency preparedness in antenatal care'. Integrated management of
pregnancy and childbirth. Standards for maternal and newborn health. World Health Organization, Geneva.
(http://whqlibdoc.who.int/hq/2007/a91272.pdf accessed 29 Nov 2010) . 14 Moran. 2006. Birth-Preparedness for Maternal Health: Findings from Koupéla District, Burkina Faso.
Journal of Health, Population and Nutrition, Vol. 24, No. 4, Dec, 2006, pp. 489 - 497 15 Rosecrans. 2008. Is emergency birth preparedness associated with increased skilled care at birth? Evidence
from rural Uttar Pradesh, India. Journal of Neonatal-Perinatal Medicine; Volume 1(3): 145-152.
Population Foundation of India Page 4
preparedness in community based maternal and newborn care programs may increase
the utilization of skilled birth attendants.
• While assessing the effectiveness of birth-preparedness programmes, McPherson
(2006)16 found that these programmes do not impact skilled birth attendants.
With this background, it is planned to conduct a systematic review of studies on BP/CR
interventions and their impact on improving skilled birth attendance.
Advocacy for BP/CR was identified as a key priority during a stakeholder consultation
organized by the White Ribbon Alliance for Safe Motherhood, India, an alliance of
individuals and organizations striving for improving maternal and neonatal health in the
country. As a member of WRAI, the Population Foundation of India proposed to conduct a
systematic review to identify key interventions and the evidence base for advocating with the
government of India.
The larger goal of the proposed systematic review is to provide evidence-based
recommendations to the government of India for programs that focus on BP/CR, such as the
Janani Suraksha Yojana, as well as to civil-society organizations that support implementation
of BP/CR interventions.
For the purpose of advocacy with the government of India, the geographical coverage of
systematic review has been limited to South Asian countries (India, Nepal, Bangladesh,
Pakistan and Sri Lanka) with similar socio cultural background.
1.3 OBJECTIVE
The objective of the study is to conduct a systematic review of community based evidences,
at scale17, from South Asian countries (India, Nepal, Bangladesh, Pakistan and Sri Lanka), to
assess the effectiveness of birth preparedness and complication readiness, in improving
skilled birth attendance, knowledge and preparedness for delivery.
Specific Study Questions
• Are Birth Preparedness and Complication Readiness (BP/CR) interventions at scale
effective in South Asian countries in improving skilled birth attendance, knowledge
and preparedness for delivery.
• What are the components or combination of components of BP/CR proven to be
effective at scale?
• Which approach/es for implementing BP/CR have proven to be successful?
• What BP/CR components and approaches do not work at scale?
16 McPherson. 2006. Are Birth-preparedness Programmes Effective? Results From a Field Trial in Siraha
District, Nepal. Journal of Health and Population Nutrition. Dec;24(4):479-488 17 A study was considered at scale if it covers a minimum population size of a 100,000. As the South Asian
countries have huge differences in population size, this cut-off holds different meaning across these
countries. In the Indian context, which is the largest country of the region, 100,000 is the average population
of an administrative block, which is ideal for planning and implementing a program.
Population Foundation of India Page 5
2. METHODS
For preparation of this systematic review report, PRISMA guideline
18 on preferred reporting
items for systematic reviews were followed.
2.1 STUDY ELIGIBILITY CRITERIA
Before starting the search for studies, the following inclusion criteria was determined. It was
prepared on the basis of information needed to fulfil the study objective.
Inclusion Criteria:
• Eligible study should be a community based study
• Eligible study should be a randomised control trial (RCT / cluster RCT / quasi RCT / case-control study / pre-post evaluation)
• Eligible study should be available in the English language, irrespective of publication status and year
• Eligible study participants should be women of childbearing ages (15-49 years) who have given birth within 24 months prior to the study
• Eligible study should be based on any community based intervention at scale (population coverage more than 100,000) on birth preparedness and complication
readiness
• Eligible study should report on change in skilled attendance and possibly on other indicators of knowledge and preparedness.
• Eligible study should have controls of concurrent comparable populations experiencing either ‘usual care’ or other community interventions.
Exclusion criteria:
• Exclude one point study (without impact evaluation)
• Exclude study based on secondary data
Study Protocol
For collecting relevant studies for systematic review to assess the effectiveness of BP/CR a
PICO (Population, Intervention, Comparison and Output) protocol was developed and
presented in Box 1.
18 Moher 2009. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement
http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000097, accessed 29
November, 2010).
Population Foundation of India Page 6
2.2 INFORMATION SOURCES
Following sources were used to identify relevant studies, available in English language,
irrespective of publication status and year.
Web-based sources - Electronic databases such as Google Scholar, PubMed and Popline
were searched for information. WHO Reproductive Health Library (RHL) and the Cochrane
Library for studies produced by EPOC Group (Effective Practice and Organisation of Care)
were searched
List Serve Calls - A call for published/
unpublished reports and studies were
made through the following maternal
health related list serves:
• White Ribbon Alliance
• CORE Group Community Listserv
• Solution Exchange-Maternal and Child Health Community
Box 2: Information sources
Web based sources
• Google Scholar
• PubMed
• Popline
• WHO Reproductive Health Library (RHL)
• Cochrane Library
List Serve Calls
• Solution exchange
• White Ribbon Alliance
• CORE Group
Manual Search
• Cross references
• Contacting experts
Box 1: PICO Protocol
Type of participants:
• Women of childbearing age (15-49 years) who have given birth within 24 months prior to the study
Interventions
Any large scale (population coverage more than 100,000) community based
intervention involving birth preparedness and complication readiness. The intervention
may include any of the following components-
• Education to improve knowledge Knowledge of danger signs for the mother, when to seek help, expected date of
delivery, importance of early registration and obstetric services/antenatal care,
individualised birth planning, etc.
• Preparedness for delivery Where to give birth and go in case of complications, identification of a skilled birth
attendant, preparations for clean childbirth, identification of possible sources of
funds, plan for saving money, plan for transportation, identification of a person to
accompany the mother, prior identification of a blood donor, etc.
Comparison
Community or women who did not receive the intervention
• The control group in RCTs or case-control studies
• The baseline evaluation in pre-post evaluations
Outcomes
Primary
• Increased use of skilled birth attendants Secondary
• Increased knowledge of danger signs of pregnancy and delivery
• Increased preparedness for delivery
Population Foundation of India Page 7
Manual Search - Reference list of identified papers was scanned to identify other relevant
studies. Leading authors, experts and agencies that have been involved in implementing
BP/CR packages were identified and contacted to obtain unpublished materials and program
reports.
Search
Key search terms and search strings were finalised for web based search and search was
conducted. Relevant studies were separated out as identified resources. List serve calls were
made. Leading authors, experts and agencies were contacted. Reference list of identified
resources were scanned. Identified reports/studies were added to the earlier pool of web-
based resources.
The following search terms were used to develop search strings. Moreover, specific search
was conducted for terms 'janani suraksha yojana' and 'micro birth plan' in the Indian context.
A set of search strings used in Google Scholar, PubMed and Popline are given in annexure I.
• pregnant / pregnancy / maternal / birth / childbirth / delivery / labour / labour
• birth preparedness (prepare / preparedness / readiness / ready / plan / planning)
• complication readiness
• skilled birth attendant / attendance /assistance
• knowledge / information / awareness
• clean / safe delivery
• transport / vehicle / ambulance
• save / saving / money / fund / funding / finance / resource
• danger signs
• emergency
• EMoC
• health-facility / hospital / institution
2.3 STUDY SELECTION
For the purpose of the study selection, study titles were assessed at the primary stage. At the
second stage, abstracts of studies with suitable titles were reviewed. In case of uncertainty the
original papers were obtained to reach a decision about eligibility.
For qualified abstracts, the full text papers were retrieved at the third stage. Selected full text
articles were independently assessed by two authors on the basis of the study eligibility
criteria (inclusion and exclusion criterion) to be included in the systematic review. In case of
uncertainty the third reviewer was involved.
2.4 DATA COLLECTION PROCESS
All selected studies for systematic review were reviewed by two authors and data was
extracted in duplicate. In case of uncertainty, original authors were contacted for obtaining
and confirming data.
Population Foundation of India Page 8
2.5 DATA ITEMS
Two authors independently assessed the studies and extracted the data. For data extraction,
STROBE checklist19 was referred for observational studies and CONSORT checklist
20 for
RCTs. For the data extraction, information was broadly sought on the following variables:
• Name of the study
• Type of study
• Characteristics of the study participants
• Description of the intervention
• Description of the comparison
• Results utilized for this review
• Results not utilized for this review
• Program description (setting, target population, strategy, implementer and funder and project duration)
• Any additional information that may potentially influence interpretation of the quality of the evidence
2.6 RISK OF BIAS IN INDIVIDUAL STUDIES
Studies were assessed to estimate the extent to which design, methods, execution and analysis
minimizes the bias in assessment of effectiveness, focusing on internal validity21. Studies
were classified with respect to selection, performance, measurement and attrition biases22 as
described in Box 3.
Box 3: Quality Assessment Criteria
Type of BIAS No Yes
Selection
Bias
Studies with randomization, allocation
concealment and similarity of groups at base-line or studies with some deficiencies in
randomization (e.g. lack of allocation conceal-
ment), or nonrandomized studies with either similarities at baseline or use of statistical
methods to adjust for any baseline differences
Non randomised, with obvious
differences at baseline, and without analytical adjustment for these
differences
Performance
Bias
Differed only in intervention, which was
adhered to without contamination, groups were
similar for co interventions or statistical
adjustment was made for any differences.
Intervention was not easily
ascertained or groups were treated
unequally other than for intervention
or there was non-adherence,
contamination or dissimilarities in
groups and no adjustments made
Measurement
Bias
Outcome measured equally in both groups,
with adequate length of follow up, direct
verification of outcome with data to allow calculation of precision estimates.
Inadequate length of follow up or
length not given. Inadequate
reporting or differences in measurement in both groups
Attrition
Bias
No systematic differences in withdrawals between groups and with appropriate
imputation for missing
Incomplete follow-up data, not intention-to-treat analysis or lacking
reporting on attrition
19 Elm. 2007. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)
Statement: Guidelines for Reporting Observational Studies.
http://download.journals.elsevierhealth.com/pdfs/journals/0895-356/PIIS0895435607004362.pdf, accessed
29 November, 2010). 20 Campbell. 2004. CONSORT statement: Extension to cluster randomised trials.
http://www.consort-statement.org/extensions/designs/cluster-trials/, accessed 29 November, 2010). 21 Kidney. 2009. “Systematic review of effect of community level interventions to reduce maternal mortality”
BMC Pregnancy and Childbirth. 9:2. 22 Cochrane collaboration. 2006. Tool for assessing the risk of bias. Cochrane handbook for systematic review
of interventions 4.2.6 updated in September 2006.
Population Foundation of India Page 9
2.7 SUMMARY MEASURES AND SYNTHESIS OF RESULTS
The primary outcome of interest was increased SBA use, therefore the intent was to calculate
(if not available in the published paper) and combine odd ratio (OR) estimates on use of SBA
in intervention and control arms of selected studies in a meta-analysis. The Review Manager
(RevMan5) software23 developed by the Cochrane Collaboration was planned to be used for
this synthesis.
One problem with pooling results of studies is the problem of heterogeneity (or inconsistency
in the study results), wherein a true ‘average’ effect across studies cannot be assumed, unlike
when homogenous study results are pooled in a meta-analysis. Heterogeneity can arise if the
studies included in a meta-analysis differ in designs, the risk of bias, population
characteristics, intervention characteristics, methods used in delivery of interventions and in
the definition or detection of outcomes. Heterogeneity can also arise due to chance and it
would be important to first detect the presence of heterogeneity that precludes the effects of
chance (random errors), and if heterogeneity is present, determine the amount of
heterogeneity due to true inter-study variability in results rather than due to chance.
It was therefore also planned that significant statistical heterogeneity would be sought for and
detected by the chi-squared test (using a p value of <0.1 to denote significant heterogeneity
and not p <0.05, due to the low power of the test to detect significant heterogeneity when
there are few studies). In addition, the amount of inconsistency between study outcomes due
to true differences between studies than due to chance would be determined using the I2
value, with I2 values of 25% or less denoting low inconsistency, values between 26% to 50%
denoting moderate inconsistency and values above 75% denoting substantial heterogeneity.
It was also planned that if I2 values denoted substantial heterogeneity, then data would not be
pooled but would be presented with OR and 95% confidence intervals (CI) along with the
Number Needed to Treat (NNT; an estimate of how many mothers would need to be
approached with BPCR intervention to increase SBA use in one mother compared to no
BPCR interventions) and their 95% CI. We intended to pool the results of RCTs and those
that used other study designs separately. These approaches are the standard recommendations
in the Cochrane Collaboration’s “Cochrane Handbook for Systematic Reviews of
Interventions”24.
2.8 RISK OF BIAS ACROSS STUDIES
All the selected studies will be assessed for risk of bias that may affect the cumulative
evidence. The systematic review will attempt to assess the selective reporting within studies.
With regard to publication bias and to overcome it, this study will attempt to access
unpublished material from where lessons on what did not work could be sought.
23 http://ims.cochrane.org/revman, accessed 29 November, 2010).
24 Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.2
[updated September 2009]. The Cochrane Collaboration, 2009. Available from www.cochrane-
handbook.org.
Population Foundation of India Page 10
3. RESULTS
3.1 STUDY SELECTION FOR SYSTEMATIC REVIEW
The web search through Google scholar, Cochrane library, PubMed, Popline and WHO RH
Library for studies and reports available in the English language, irrespective of publication
status and year, returned 3382 hits. After initial screening of titles, 930 titles were found
relevant to the present study (refer to the flow chart of study selection given in Box 4). The
first round of search was conducted through Google scholar followed by PubMed and then
Popline. After searching Google scholar, many studies were found in duplicate in PubMed
and Popline and they have not been counted.
After initial screening of abstracts, 210 relevant abstracts were identified. Keeping in view
the study (PICO) protocol, all these abstracts were re-reviewed and during final selection of
abstracts 76 studies were included in the study.
Simultaneously, through manual search, 3 more relevant studies were found and added to the
pool of finally selected abstracts. For all these 79 studies, full text articles were retrieved
and reviewed.
After final screening of full text articles, the following seven studies have been included in
the systematic review following the strict inclusion and exclusion criteria. Details of 72
excluded studies are given in annexure III:
1. McPherson (2006)25
2. Hodgins (2010)26
3. Hossain (2006)27
4. Baqui (2008)28
5. Darmstadt (2010)29
6. Currie (2009)30
7. Kumar (2008)31
25 McPherson. 2006. Are Birth-preparedness Programmes Effective? Results From a Field Trial in Siraha
District, Nepal. Journal of Health and Population Nutrition. Dec;24(4):479-488 26 Hodgins. 2010. Testing a scalable community based approach to improve maternal and neonatal health in
rural Nepal. Journal of Perinatology. 30:388-395 27 Hossain.2005. The effect of addressing demand for as well as supply of emergency obstetric care in
Dinajpur,Bangladesh. International Journal of Gynecology and Obstetrics. 92, 320—328 28 Baqui. 2008. Impact of an integrated nutrition and health programme on neonatal mortality in rural northern
India. Bulletin of the World Health Organization. 86 (10) 29 Darmstadt. 2010. Evaluation of a Cluster-Randomized Controlled Trial of a Package of Community-Based
Maternal and Newborn Interventions in Mirzapur, Bangladesh. PLoS ONE Vol 5 Issue 3 30 Currie. 2009. Increasing use of skilled attendance at birth in Dumka, India. Paper presented at IUSSP
Conference, Morocco. 31 Kumar. 2008. Eff ect of community-based behaviour change management on neonatal mortality in Shivgarh,
Uttar Pradesh, India: a cluster-randomised controlled trial. Lancet. 372: 1151–62
Population Foundation of India Page 11
Reasons for Exclusion
Not fulf ill PICO criterion
• Intervention not being at scale (population coverage < 100,000) (2)
• Does not fulf ill participants / intervention/outcome criterion (20)
• Cross-sectional / one point study (3)
• Secondary data based or qualitative studies (7)
Utilized for reference
• Systematic review s / review articles on maternal health issues (21)
• Geographical coverage other than South Asia (15)
• Manuals / guidelines / policy briefs around BP/CR (4)
Excluded Studies
72
Initial Screening of Abstracts
Box 4: Flow Chart of Study Selection
Studies Included in Systematic review
7
• RCT’s
• 3 before and after studies
Final Selection of Abstracts
Full text
accessed
49
Full text
accessed
20
Full text
accessed
7
Full text
accessed
3
Total Full Text Reviewed
Relevant
Abstracts
0
Relevant
Abstracts
160
Relevant
Abstracts
35
Relevant
Abstracts
15
Manual Search
Cochrane
Library
425
Google Scholar
1949
PubMed
307
Popline
551
WHO RH
Library
150
List Serve Calls
• Solution exchange
• White Ribbon Alliance
• Core
Manual Search
• Cross references
• Contacting experts
Screening of Titles
Relevant Titles
20
Relevant Titles
540
Relevant Titles
210
Relevant Titles
160
Relevant Titles
0
Web Based Search
3.2 STUDY CHARACTERISTICS
Geographical distribution
Among the selected studies, three studies were from India, from the states of Uttar Pradesh
(Baqui 2008 and Kumar 2008) and Jharkhand (Currie 2009), two from Nepal (McPherson
2006 and Hodgins 2010) and two from Bangladesh (Darmstadt 2010 and Hossain 2006). No
relevant studies were available from Pakistan and Sri Lanka despite attempts to access these
through the web and personal communication with key maternal health experts in the region.
Figure 1 provides geographical distribution of the studies on the map of South Asian
countries.
Population Foundation of India Page 12
Figure 1: Geographical Distribution of the Selected Studies
Type of Studies
The studies were heterogeneous with respect to study design, sampling, sample size, program
setting, BP/CR components and other interventions.
In terms of study design, there were three experimental studies (Kumar 2008, Darmstadt
2010 and Baqui 2008) and four observational studies (Currie 2009, Hossain 2006, McPherson
2006 and Hodgins 2010). The experimental studies were all RCTs, while the observational
studies were of a before and after intervention design with or without a control or comparison
group.
• Kumar (2008) and Darmstadt (2010) were 'Cluster-Randomized Controlled Trial'32
• Baqui (2008) was a 'Quasi-Randomized Controlled Trial'33
• Currie (2009) and Hossain (2006) were 'Controlled Clinical Trial (Before and After)'34
• Hodgins (2010) and McPherson (2006) had 'Before and After' study design35 with no
control arm.
32 A cluster randomised controlled trial is a type of randomised controlled trial in which groups of subjects (as
opposed to individual subjects) are randomised 33 The design of a quasi-experiment relates to the setting up a particular type of study in which one has little or
no control over the allocation of the treatments or other factors being studied. 34 In a controlled clinical trial, least one group of participants is given a test intervention, while at least one other
group concurrently receives a control intervention. 35 In before and after study, characteristics of a population are compared before versus after a particular intervention
Population Foundation of India Page 13
The investigation period for all studies was within the last decade even though we did not
use any limits to exclude on the basis of chronology. This can be explained by the fact that
though evidence had been accumulating, implementation of policy on skilled attendance for
delivery is a recent phenomenon in South Asian countries.
The sample sizes ranged from 300 to over 15,000 varying with the primary outcome of the
study. Three of the seven studies examining the effect of the maternal and neonatal health
intervention on neonatal mortality (Baqui 2008, Kumar 2008, Darmstadt 2010) had a sample
size of over 14,000, while those investigating changes in maternal and newborn care
behaviours and practices had a smaller sample size ranging from 300 to 1,800. The study by
Hossain (2006) was focused on availing Emergency Obstetric Services(EMoC) at facility.
All studies were of adequate power to detect changes in the primary outcome of interest.
Among the three before and after studies only Hodgins (2010) explained the criteria for
sample selection. Two of the RCTs estimated sample size assuming 40% reduction in
neonatal mortality (Kumar 2008, Darmstadt 2010), while Baqui 2008 assumed 20% reduction
in neonatal mortality for approximately the same duration of intervention.
Detailed information on sampling and randomization techniques was available for two of the
four RCTs. Darmstadt et al 2010, used computer-generated pseudo random number sequence
for randomization. Stratified cluster randomization using Standard of Living Index (SLI) and
religion as stratification covariates was used in Kumar (2008) and random allocation was
based on STATA 7 generated sequence. Masking was not feasible in these RCTs due to the
nature of the intervention but Kumar (2008), closely monitored study arms to prevent
contamination.
Information on sampling was available for only two of the observational studies (McPherson
2006 and Hodgins 2010) and both used the multi-stage 30 cluster sampling approach with
random selection of study units using probability proportional to estimated size (PPES) at
each stage. The smallest sampling unit was the household.
In the study by Hossain (2006), a sample was taken from three randomly selected wards from
each union of Upazila. Starting from a random point of a selected ward every alternate
household was visited to see if an eligible ever married woman who had given birth in the
last one year would respond to the survey.
Participants
In all the studies, which qualified for final analysis, the participant group included mothers
who had delivered within the last 12 months of data collection. The only exception was Baqui
(2008), in which the participant group included mothers who had delivered within the last 24
months of data collection.
In six of these studies, mothers who had a still birth were either excluded at the time of
sampling or during data analysis thus limiting information on outcome measures to mothers
who had a live birth. The intervention reported in Hossain (2006) is primarily focused on
utilization of EMoC services and birth outcomes were considered.
Population Foundation of India Page 14
Interventions
Intervention Planning
Interventions in Darmstadt (2010), Currie (2009) and Hossain (2006) and Kumar (2008) were
designed on the basis of well defined formative research on women’s need to identify
barriers and facilitators to practicing optimum maternal and newborn care practices before
designing the intervention and mode of delivering the intervention. McPherson (2006),
Hodgins (2010) and Baqui (2008) have not reported any such information in their paper.
Intervention Coverage
For the purpose of measuring exposure around BP/CR, this systematic review focused on
intervention coverage for ANC visits/counselling, as opportunity for providing BP/CR
messages. The coverage of the intervention varied across studies from 54% to 90%.
The highest intervention coverage (90%) was reported in Darmstadt (2010), which may be
attributed to the adequacy surveys conducted every eight months during the course of the trial
and utilising the results for taking corrective action, unlike any other trials. In Hodgins
(2010), Kumar (2008) and Baqui (2008), intervention coverage was measured as 82%, 60%
and 56% respectively.
In McPherson (2006), intervention coverage (54%) was defined as respondents exposed to
information on BP/CR. Data on intervention coverage was not available for Hossain (2006)
and Currie (2009). However, Currie (2009) stated that coverage was closely monitored and
can be assumed to be high.
Intervention Components
Table 1 summarises the selected studies by their components of BP/CR package and
implementation strategy. The interventions ranged from providing education to individualised
birth-planning and some also include supply-side interventions. It is notable that though this
study investigated only BP/CR components of interventions, these trials had a wider range of
components spanning around antenatal, delivery, postnatal and neonatal care.
As presented in table 1 the components of the BP/CR package across the studies had some
common elements. Education to improve knowledge on danger signs of pregnancy and
delivery and importance of saving money for emergencies and delivery was provided in all
the seven interventions. The other components pertaining to education to improve knowledge
for arranging transport, identification of SBA, clean birth at home, identification of blood
donor and identification of escort were observed in order of decreasing frequency across the
studies. It is clearly noticeable from the table that identification of danger signs, saving
money in advance for the delivery or for any emergency, prior arrangement of transportation
facility and identification of skilled birth attendance were the most commonly suggested
components of BP/CR. Preparation for clean birth at home was suggested in the interventions
by Baqui (2008), Darmstadt (2010), Kumar (2008) and Hossain (2006).
In both the interventions from Bangladesh, traditional birth attendants were promoted. In the
intervention captured by Darmstadt (2010), women were primarily advised to go for facility
delivery, otherwise identify a trained birth attendant from the community. However, in
Population Foundation of India Page 15
Hossain (2006) women were advised to identify a trained birth attendant in the community
and a health facility to approach if some complication arises.
An Individualised Birth Planning meant that a pregnant woman and/or her family was
helped to prepare for delivery and more specifically for complications by having an
actionable plan on whom to contact, where to go, and how to go there. Individualised birth
planning was reported in Darmstadt (2010), Currie (2009), Kumar (2008), Hodgins (2010)
and Hossain (2006) through developing community funds, arranging for transportation and
providing support to pregnant women to comply with the individualized plan.
Table 1: Comparison of the intervention package across studies STUDY DETAILS STUDIES
Authors McPhers
on 2006
(Nepal)
Hodgins
2010
(Nepal)
Hossain
2006
(Bangl-
adesh)
Baqui
2008
(India)
Darmstadt
2010
(Bangl-
adesh)
Currie
2009
(India)
Kumar
2008
(India)
COMPONENTS OF BP/CR INTERVENTION
Education to improve knowledge on
• Danger signs Yes Yes Yes Yes Yes Yes Yes
• Saving money Yes Yes Yes Yes Yes Yes Yes
• Arranging transport Yes Yes Yes Yes Yes Yes No
• Identification of SBA Yes Yes No Yes No Yes Yes
• Clean birth at home No No Yes Yes Yes No Yes
• Identification of blood donor No No Yes Yes No Yes No
• Identification of escort No No Yes Yes No No No
Individualised birth planning No Yes No Yes Yes Yes
'
Supply side interventions
• Facility up gradation No No Yes No No No No
• SBA training No No No No No Yes No
INTERVENTION APPROACH BP/CR message delivery
• At ANC visit (home/facility) Yes Yes Yes Yes Yes Yes Yes
• At Community meetings Yes No Yes No No Yes* Yes
BP/CR message target
• Pregnant women Yes Yes Yes Yes Yes Yes Yes
• Family members Yes Yes Yes Yes No No Yes
• Community Yes No Yes No No Yes* Yes
Community mobilisation No No Yes** No No Yes** Yes
* The published paper does not report on organising community meetings however, considering the high focus
of the intervention on community mobilization, it is very likely that community meetings were organised
**Community support to adhere to birth plan
Only two interventions covered supply side strengthening. Currie (2009) has reported on an
exhaustive 12 weeks SBA training to increase the number of community and facility based
midwives along with promotion of BP/CR. Hossain (2006) captured on facility up-gradation
Population Foundation of India Page 16
for providing Emergency Obstetric Services (EMoC). It is notable that in some of the other
trials in particular Darmstadt (2010) and Kumar (2008) the study area were well served by
public and private health care providers.
Intervention Approach
Another consideration to assess these interventions across the studies is the implementation
strategy of the BP/CR intervention. Table 1 further reveals that in all trials the mode of
BP/CR message delivery / counselling / birth planning was through two antenatal visits by
community workers. An additional effort to promote BP/CR through community meetings
was reported by McPherson (2006), Hossain (2006), and Kumar (2008). Currie (2009) does
not report on organising community meetings, however, considering the high focus of the
intervention on community mobilization, it is very likely that community meetings were
organised.
The BP/CR messages in all the selected studies were targeted at pregnant women. Five
interventions (Hodgins 2010, McPherson 2006, Kumar 2008, Baqui 2008, and Hossain 2006)
have further involved family members in their communication strategy. McPherson (2006),
Hossain (2006), Currie (2009) and Kumar (2008) have also involved the community for
targeting BP/CR messages. These studies have reported on showing the pictorial handouts,
flash cards, birth planning cards, brochures, performing folk songs, distributing the key
chains, poster to convey the messages to the community.
Studies by Currie (2009), Kumar (2008) and Hossain (2006) had reported on community
mobilisation activities. Kumar (2008) and Hossain (2006) had worked through formation of
stakeholder committees involving influential community members from the different fields
of the community so as to generate the consensus on the issue. Intervention by Currie (2009)
reported on the involvement of a local level NGO and the setting up of Mahila Mandal (Self
Help Group) to promote BP/CR messages. Individualised birth planning in Currie (2009) and
Hossain (2006) were supported by developing community funds.
Intervention Agents
The primary agents for the behaviour change in all studies were individuals identified
from the community. These intervention agents were either
− CHWs from the government health system; or
− Trained Birth Attendants (TBA), Registered Medical Practitioners (RMP) or other
volunteers from the community
Darmstadt (2010), Curry (2009) and Hodgins (2010), utilised the intervention agents from
the government system. Baqui (2008) and Kumar (2008) have separately recruited these
intervention agents from outside the government system. Hossain (2006) and McPherson
(2006) utilised the intervention agents both from within the government system as well as
from outside the system.
These intervention agents are referred variedly across the studies. McPherson (2006) and
Darmstadt (2010) referred to them as community health workers (CHWs). Hodgins (2010)
utilised the Female community health volunteers (FCHVs) as intervention agents. Baqui
(2008) referred to them as change agents. Kumar (2008) referred to paid change agents as
Population Foundation of India Page 17
“Saksham Sahayak” and volunteer change agents as “Saksham Karta”. Currie (2009) utilised
the Anganwadi Workers and Sahiyas as change agents.
The training of intervention agents varied across studies. The most extensive training to
intervention agents was reported in Darmstadt (2010), where they were trained for 36 days on
pregnancy surveillance, counselling and negotiation skills, etc. Routine monitoring and
refresher training were provided each fortnight.
In contrast, shorter trainings were given to intervention agents in Kumar (2008) (7 days),
Baqui (2008) (6 days) and McPherson (2006) (2-3 days). Hodgins (2010) and Currie (2009)
have not reported on trainings of intervention agents.
Intervention Monitoring
In terms of monitoring and supervision, all these studies report on a well defined
supervision mechanism. As compared to other interventions two adequacy surveys were
conducted in Darmstadt (2010) to monitor the coverage and adequacy of the intervention,
while Kumar (2008) and Currie (2009) reported close monitoring at regular intervals at every
stage of implementation. Kumar (2008) reports an additional effort of spot quality check of
the change agents during home visits and community meetings so as to improve the quality of
data collection, while in Currie (2009) training of ANM’s was monitored by the training
coordinator. Hossain (2006) reported on monthly meetings of service providers to discuss the
progress and issues of implementation of the program and development of stakeholder
committees and sub-committees to monitor Urban Health Centre (UHC) cleanliness.
Controls
In all the RCTs, the intervention and control groups were similar in selected socio-
economic factors such as maternal age, parity, literacy and economic status.
Among the three before and after studies, Hodgins (2010) reports no significant difference in
the socio-economic profile at baseline and end-line. However, McPherson (2006) reported on
significant differences in the ethnicity of the participants in the program and comparison area.
Hossain (2006) reported differences in education and caste of the respondents in the
intervention group as compared to the comparison and control groups.
In Currie 2007, Kumar 2008 and Hossain (2006), there were three study arms wherein two
arms received two types of interventions and the third served as a control.
The other two RCTs (Baqui 2008, Darmstadt 2010) had an intervention and a control arm
each. The control arm received usual public and private health care services while the study
arm received well planned BP/CR intervention.
Outcomes
Across the studies, the primary outcome of 'SBA use' were defined and measured variedly. In
terms of SBA use, Hodgins (2010), Darmstadt (2010) and Hossain (2006) reported only on
Population Foundation of India Page 18
facility based deliveries36. Kumar (2008) and Baqui (2008) refers to SBA deliveries as
'deliveries conducted by ANM/doctor/trained nurse' either at health facility or at home. Currie
(2009) refers to SBA deliveries 'deliveries conducted by skilled birth attendant (ANM) at
health facility or at home'. McPherson (2006) has not defined the 'SBA use'.
3.3 Risk of Bias Within Studies
The selected seven studies varied significantly in study design, intervention and reporting
quality. By virtue of design the RCTs offer robust evidence as compared to the before and
after study. However, there are various considerations in the randomization process that need
to be investigated before conclusive estimates are drawn from an RCT. In addition the
implementation of the intervention package, measurement of exposure and outcome and the
analysis affect the level of confidence in the results. Box 5 provides a summary of some of
the potential sources of biases in the selected studies
Selection bias
Randomization was achieved in three of the four RCTs and two of the before and after studies.
For Currie (2009) and Hossain (2006) published reports do not provide any information on
randomization. McPherson (2006) and Hossain (2006) reported significant differences in the
socio-economic profile of respondents at two points of comparison. Details of random number
sequence generation were available for only two RCTs (Darmstadt 2010 and Kumar 2008).
Socio-economic profile of the study arms was similar in Darmstadt (2010) and Kumar (2008).
Information on the same was not available for Currie (2009) while Baqui (2008) made
statistical adjustments to address difference in the socio-economic profile of the study arms.
Such differences were expected in the latter as the intervention and control arms were two
different districts in UP, India.
Performance bias
Reportedly in all the studies difference in the study arms/endline was solely the intervention.
therefore performance bias was not apperent. None of the studies reported co-existence of
another donor funded program in the intervention or control areas during the course of the
study.
Measurement bias
There was consistency within the studies in definition of skilled attendance at delivery.
Duration of exposure to intervention was uniform and measurement tools were consistent
across study arms in most of the studies.
In the intervention covered by McPherson (2006), counselling was given by various
providers (FCHVs, members of mothers’ groups, trained TBAs and facility-based CHWs)
and was not uniform. The intervention also provided varied exposure to birth preparedness
packages such as provision of a key chain on BPP, exposure to BPP messages and
counselling.
36 For these study locations (Bangladesh and Nepal), deliveries outside facility were assisted by TBAs and not
by SBAs.
Population Foundation of India Page 19
Hossain (2006) reported changes in the survey design between baseline and post-intervention.
This affected the analysis on secondary outcomes. Knowledge of BP messages was measured
only post-intervention.
Attrition bias
Attrition bias was applicable to only one of the trials (Kumar 2008) where pregnant women
were followed-up through the intervention phase. Loss to follow-up was not considerable
The quality assessments would need to be reported as unclear for all components assessed,
and this can be highlighted in the results and discussion. Since the results for all 7 seven
studies can be expressed in increase in percentage of use of SBA (however defined)
Box 5: Potential Sources of Biases in the Selected Studies
Study Selection
bias
Performance
bias
Measurement
bias
Attrition
bias
Baqui
2008
Not Apparent
The sample was not distributed
uniformly. However, statistical
adjustments were made for
controlling socio-demographic
characteristics.
Not Apparent
Groups were differed
only in intervention.
Not Apparent
Duration of exposure to the
intervention was uniform.
NA
There
was no
follow-
up
Currie
2009 Unclear
No information on sampling
including randomization.
Not Apparent
Groups were differed
only in intervention
Not Apparent
Duration of exposure to the
intervention was uniform.
NA
Darmstadt
2010
Not Apparent
Randomization was achieved and
groups were similar in socio-
economic characteristics.
Not apparent
Groups were differed
only in intervention
Not Apparent
Duration of exposure to
intervention was uniform.
End-line survey conducted before
trial ended to ensure trial closure
does not affect responses.
NA
Kumar
2008
Not Apparent Randomization was achieved
and groups were similar in
socio-economic characteristics.
Not Apparent Groups were differed
only in intervention
Not Apparent Duration of exposure to the
intervention was uniform.
Not
Apparent
McPherson
2006
Apparent
Randomization was achieved but
there were significant differences
in caste/ethnicity of respondents
at baseline and end-line.
Not Apparent
No reported maternal
health program in the
study area.
Apparent
Not all women received the
same form of counselling.
Varied exposure to birth
preparedness package.
NA
Hodgins
2010
Not Apparent Randomization was achieved
and groups were similar in
socio-economic characteristics
Not Apparent No reported maternal
health program in the
study area.
Not Apparent Duration of exposure to
intervention was uniform.
NA
Hossain
2006
Apparent
No information on randomization
and there were significant
differences in caste & education
in the intervention, comparison
and control area.
Not Apparent
No reported maternal
health program in the
study area.
Apparent
Baseline and post intervention
survey tools were different. This
affected the analysis on
secondary outcomes.
Duration of exposure to
intervention was uniform.
NA
Population Foundation of India Page 20
3.4 RESULTS OF INDIVIDUAL STUDIES
Results from each of the selected study along with data extracted from them are provided in
annexure II.
3.5 SYNTHESIS OF RESULTS
Due to the heterogeneity in study designs (even among RCTs), the intervention strategies and
measurement of outcomes as well as other sources of differences, the I2 value for the pooled
effect estimate (OR) for the RCTs (Kumar 2008, Darmstadt 2010 and Baqui 2008) was 86%;
indicating that 86% of the inconsistency in the results of the meta-analysis was due to true
inter-study variability, rather than chance. Hence a meta-analysis could not be done. Thus, a
combined estimate of the effect of BP/CR intervention and SBA use is not available in this
review.
In order to review the increase in SBA use in the individual studies included in this review,
the percentage of SBA use in each arm of controlled trials and RCTs at baseline and at the
endpoint (and before and after in uncontrolled studies) were calculated and the difference in
the change in percentage SBA use between study arms (or before and after interventions in
un-controlled studies) was determined and are presented along with their 95%CI. In addition,
and a narrative synthesis was also done. In the realm of public health reviews this is a valid
synthesis as has been commonly done by many authors faced with the challenge of pooling
estimates due to heterogeneity37.
The selected BP/CR intervention and their impact on primary outcome (increase in SBA use)
are summarised in Table 2. The impact of BP/CR interventions on secondary outcomes
(increased knowledge on danger signs and increased preparedness for delivery) are
summarised in Table 3.
To capture the effect of BP/CR intervention on increase in SBA use, Table 2, summarises the
change between baseline and endpoint percentage use of Skilled Birth Attendants (or facility
deliveries) between interventions. The 95% confidence interval (CI) for the change in
percentage use of Skilled Birth Attendants, is also presented in the table. All the studies were
sub-grouped by study design and intensity of intervention.
The overall rates of SBA use in all studies even after the interventions (BPCR) are found to
be low. The baseline SBA use ranges between 2.4 to 24.0 per cent and the end point SBA use
ranges between 5.0 to 28.4 per cent.
The difference in increase of SBA use between intervention and control areas has been small.
These differences are also found to be statistically significant as their confidence intervals
(CIs) do not overlap, for Kumar (2008), Baqui (20080, Currie (2009) and Hossain (2006, in
case of full intervention vs. no intervention). These differences are not found to be significant
for Hossain (2006, in case of full intervention vs. facility upgrade).
37 Bravata. 200. Challenges in Systematic Reviews: Synthesis of Topics Related to the Delivery, Organization,
and Financing of Health Care. Ann Intern Med, 142;12 Part 2:1056-1065.
http://www.annals.org/content/142/12_Part_2/1056.full, accessed 29 November, 2010).
Population Foundation of India Page 21
Among the two before and after studies, proportion of SBA use has found to increase
significantly in Hodgins (2010) and no change was reported in McPherson (2006).
Analysis of increase in % SBA use demonstrate that, intensity of interventions increases the
% SBA use after intervention.
Table 2: Change between baseline and endpoint percentage use of Skilled Birth Attendants (or
facility deliveries) between interventions
Study
Intervention Control Change in SBA use %
from baseline [95% CI] Baseline
SBA use
%
Endpoint
SBA use
%
Baseline
SBA use
%
Endpoint
SBA use
% Intervention Control Difference
1. Study Design: Cluster-Randomized Controlled Trial
a) BPCR with individualized birth plan
Darmstadt 2010 12.1 20.2 12.5 16.5 8.1 4.0 4.1
[7.3-8.9] [3.4-4.6] [3.1-5.0]
b) BPCR with individualized birth plan + community mobilization
Kumar 2008 NA 27.2 NA 18.9 NA NA 8.3
[4.8-11.6]*
2. Study Design: Quasi-Randomized Controlled Trial
c) BPCR
Baqui 2008 16.3 22.2 17.5 21.8 5.9 4.3 1.6
[5.5-6.2] [3.9-4.6] [1.0-2.1]
3. Study Design: Controlled Clinical Trial (Before And After) d) BPCR + SBA training + community mobilization
Currie 2009 5.0 13.2 4.0 6.8 8.2 2.8 5.3
[6.5-10.2] [1.8-4.5] [3.0-7.6]
e) BPCR + Individualized Birth plan+ community mobilization + facility upgrade (based on
deficiencies)
Hossain 2006 2.4 10.5 4.5 5.0 8.1 0.5 7.6
[6.4-10.2] [0.4-1.2] [5.8-9.7]
f) BPCR + Individualized Birth plan+ community mobilization + facility upgrade (based on
deficiencies) versus facility upgrade alone
Hossain 2006 2.4 10.5 7.2 12.1 8.1 5.3 2.8
[6.4-10.2] [3.4-7.8] [2.4-8.1]
4. Study Design: Before And After (no control arm) g) BPCR + individualized birth plan
Hodgins 2010 24.0 28.4 - - - -
4.4** [3.7-5.1]
h) BPCR
McPherson 2006 16.0 16.0 - - - - 0.0
*Kumar 2008: change in SBA use % at endpoint between interventions
** Difference found to be significant at 5% level (Z-test)
Table 3 summarises the selected BP/CR interventions and their impact on the secondary
outcome of increased knowledge on danger signs and increased preparedness for delivery.
Impact of interventions on increased preparedness for delivery was broken down by various
components of preparedness such as-
− Financial preparedness
− Preparedness for transport
− Identification of SBA
− Preparedness for clean birth at home
− Identification of blood donor
Population Foundation of India Page 22
− Identification of escort
In all the interventions, participants were educated on identification of danger signs (Table
1). Knowledge of danger signs has reported to be increased in five interventions. Two
interventions (Baqui 2008 and Kumar 2008) do not report on the status of knowledge of
danger signs.
To save money in advance for delivery or for some emergency was advised in all the
interventions. Table 2 shows that six of seven studies reported that financial preparedness
has increased. Darmstadt (2010) has not reported on status of financial preparedness. Hossain
(2006) has not measured the improvement in financial preparedness at end-line. However the
intervention had established community support systems. These community support systems
had established bank accounts to maintain emergency funds. Among women who
experienced an obstetric emergency during the study period, one third of them used these
community based funds. Therefore, the study description strongly indicates that the
intervention resulted in increased financial preparedness.
Table 2: Impact of BP/CR intervention on secondary outcomes
STUDIES Impact on secondary outcomes
Increased
knowledge
on danger
signs
Increased preparedness for delivery
Financial
preparedness
Preparedness
for transport
Identification
of SBA
Preparedness
for clean birth
at home
Identification
of blood donor
Identification
of escort
Darmstadt 2010 Yes -- -- NA - NA NA
Kumar 2008 -- Yes NA -- -- NA NA
Baqui 2008 -- Yes -- -- -- -- --
Currie 2009 Yes Yes Yes* -- NA -- NA
Hossain 2006 Yes Yes* Yes* NA -- -- --
Hodgins 2010 Yes Yes -- -- NA NA NA
McPherson 2006 Yes Yes Yes -- NA NA NA
* : The published paper does not report on increased preparedness. However, the study
description strongly indicates that the intervention resulted in increased preparedness.
- - : Not reported in the study
NA : Not applicable as the intervention has not focused on these components
Arranging for transport facility in advance was advised in six of the seven studies. Three
studies (Hodgins 2010, Baqui 2008 Darmstadt 2010) have not reported separately on the status
of transport preparedness. Hossain (2006) and Currie (2009) have not measured improvement
in financial preparedness. Currie (2009) mentioned that in all the intervention villages, the
project was successful in setting up functional emergency transport system for birth
preparedness and complication readiness during pregnancy and childbirth through community
mobilization. Therefore, it can be strongly inferred that the intervention resulted in increased
preparedness for transport. Hossain (2006) reported on establishment of community support
systems and purchase of a rickshaw-van to transport women during obstetric emergencies by
some of them. Among women who experienced an obstetric emergency during the study
period, nearly 15 percent of them used these rickshaw-vans. The study description indicates
Population Foundation of India Page 23
that the intervention resulted in increased transport preparedness. McPherson (2006) has
clearly reported that preparedness for transport has increased by 19 percentage points between
baseline and end-line.
Kumar (2008) had reported that large improvements were seen in multiple aspects of birth
preparedness. McPherson (2006) developed a composite index of birth preparedness package
and reported 21 percentage points increase by the end-line. Baqui (2008) has reported 23.9
percentage points increase in a pooled indicator 'took any other birth planning step'. This
indicator is based on at least one of the following: suitable location for delivery, person to
deliver baby, hospital/clinic to be attended in case of complication, arrangement for transport
and disposable delivery kit. These studies have not separately reported on the status of the
remaining BP/CR components such as identification of SBA, clean birth at home,
identification of blood donor and identification of escort, wherever applicable. Darmstadt
(2010), Hodgins (2010), Hossain (2006) and Currie (2009) have not reported on the outcomes
of other BP/CR components covered in their intervention.
Odds Ratios
An analysis of the odds of using skilled birth attendants, between those receiving intervention
versus controls was undertaken and presented in Table 4.
To estimate the effect of BP/CR intervention in increasing the SBA use, Table 4, summarises
the Odds Ratio and Number Needed to Treat (NNT) which implies that the number needed to
be reached with the intervention to ensure one pregnant woman uses an SBA. The 95%
confidence interval (CI) is also presented in the table. All the studies were sub-grouped by
study design and intensity of intervention.
Participants exposed to the intervention in Darmstadt (2010) were 1.27 times more likely to
use SBAs compared to controls. However, the clinical significance of the difference is
questionable since the lower limits of the 95% confidence intervals do not indicate a
clinically appreciable benefit.
Participants exposed to the intervention in Kumar (2008), Currie (2009) and Hossain (2006,
in case of full intervention vs. no intervention) have shown a clear improvement in SBA use
compared to controls.
In At 95% confidence level there was nearly no difference in SBA use in intervention versus
comparison arms in Baqui (2008). Moreover, McPherson (2008) found no difference in SBA
use after the intervention.
Analysis of odds demonstrate that, intensity of interventions increases odds of SBA use after
intervention.
The Number Needed to Treat (NNT) implies that the Hossain (2006) is the most effective
intervention. In case this BP/CR intervention reaches 12 pregnant woman then it ensures that
one pregnant woman uses an SBA. The NNT could not be calculated for McPherson (2008)
as their odds ratio was exactly one.
Population Foundation of India Page 24
Table 4: Effect estimates with 95% confidence intervals (CI) of BPCR interventions in
increasing the use of Skilled Birth Attendants (or facility deliveries) among mothers
with live births: Studies sub-grouped by study design and intensity of intervention
Study Intervention Control Odds
ratio
Number
needed to treat SBA use Total SBA use Total
1. Study Design: Cluster RCT
a) BPCR with individualized birth plan
Darmstadt 2010 355 1759 286 1732
1.27 27
[1.0-1.5] [16-91]
b) BPCR with individualized birth plan + community mobilization
Kumar 2008 372 1364 188 992
1.6 12
[1.3-1.9] [9-20]
2. Study Design: Quasi- Randomized Controlled Trial c) BPCR
Baqui 2008 1758 7812 1311 6014
1.0 141
[0.9-1.1] [48-144]
3. Study Design: Controlled Clinical Trial (Before And After)
d) BPCR + SBA training + community mobilization
Currie 2009 54 410 20 291
2.0 15
[1.2-3.5] [9-58]
e) BPCR + Individualized Birth plan+ community mobilization + facility upgrade
Hossain 2006 43 410 10 400
4.5 12 [2.2-9.2] [9-21]
f) BPCR + Individualized Birth plan+ community mobilization + facility upgrade versus
facility upgrade alone
Hossain 2006 43 410 48 400
0.9
[0.6-1.3]
66
[35-117]
4. Study Design: Before And After (no control arm) g) BPCR + individualized birth plan
Hodgins 2010 412 1716 489 1723
1.2 22
[1.0-1.4] [14-70]
h) BPCR
McPherson 2006 48 300 48 300
1.0 Not estimable
[0.6-1.5]
*Analysis from cluster RCTs are not adjusted for clustering
Analysis of Individual Studies
The intervention covered in McPherson (2006), focused on promoting BP/CR to increase
SBA use, but it could not show any change from baseline to end-line. However, the program
positively improved certain birth planning practices like financial preparedness and
arrangement for transportation. There was a significant increase of 26 percentage points in
danger sign recognition among participants. Financial and transport preparation increased
significantly by 27 and 19 percentage points respectively. Although programme beneficiaries
have reported that SBA use is ‘important’, but they did not find it ‘necessary’. The cost to
avail services was found to be a determining factor for not using SBA and thus community
utilizes SBA only for emergencies.
Hodgins (2010) reported significant but only 4.4 percentage points increase in SBA use. The
focus of this intervention was promoting multiple maternal and neonatal health practices and
BP/CR was one of the many components of it. Though the program could not achieve
substantial increase in SBA use, there was a significant increase of 47.1 percentage points in
Population Foundation of India Page 25
financial preparation for delivery. The study additionally reported on significant increase of
8.4 percentage points for making arrangement of health facility delivery in advance.
Baqui (2008) showed significant increase of 5.9 percentage points in SBA use. The study was
based on Integrated Nutrition and Health Project (INHP), which focused primarily to reduce
neonatal mortality by promoting better practices for women as well as neonates. Though the
program could not bring substantial changes in SBA use, saving money for emergencies
increased significantly by 35 percentage points in intervention from baseline to end-line.
The 'Project for Advancing the Health of Newborns and Mothers' (Projahnmo) in Mirzapur,
Bangladesh covered by Darmstadt (2010) showed significant increase of 8.1 percentage
points in SBA. Projahnmo was focused on improving maternal and neonatal health care
practices for reducing neonatal mortality. Pregnant women were counselled on attaining
facility deliveries and were closely followed by CHWs. Study area was served by good
private health facilities. There was a significant increase in the facility deliveries from
baseline to end-line in the intervention as compared to control. The study has not reported on
any of the secondary outcomes other than limited increase in knowledge of danger signs.
Hossain (2006) reported on Dinajpur Safe Motherhood Initiative by CARE Bangladesh. The
intervention was focused to improve utilisation of EMoC services. The project purposely
chose the areas that have been upgraded by UNICEF and government of Bangladsh (GoB) to
provide EMoC services. The study showed significant increase of 8.1 percentage points in
facility deliveries. The study has not reported on any of the secondary outcomes. This study
has demonstrated the establishment of community support systems in villages and its positive
impact on improving behaviour (such as arranging for emergency funds, emergency
transportation, ready list of volunteers to accompany women and blood donors). The study
concluded that the best results are achieved through a combination of facility improvement,
quality of care activities and targeted community mobilization activities. The study also
found that the facility upgrade (based on identified deficiencies) alone had a significant
impact on increasing SBA use, without any BP/CR interventions.
The intervention captured by Currie (2009) was a part of the global program (ACCESS) with
technical support from many partners. The intervention not only covered the community level
BP/CR initiative but also worked on health system strengthening through ANM training.
Currie (2009) reported significant increase of 8.2 percentage points in SBA use. The study
has also reported on a significant increase of 19 percentage points in knowledge of BP/CR
and a significant increase of 31 percentage points in financial preparedness. The intervention
had also made improvement in intentions to deliver at a health facility. Moreover, the
program could mobilize communities in terms of development of community funds and
stakeholder committees.
Increase of 10.2 percentage points in SBA use is reported by Kumar (2008) from Shivgarh,
U.P. India, but the increase was not significant. The paper also reported 6.7 percentage points
increase in SBA use in the control area as well. Further There is insufficiency of reporting
around BP/CR components and SBA use in the reported paper.
Population Foundation of India Page 26
3.6 Risk of Bias Across Studies
Risk of bias across studies
• Participants: Studies under review have excluded mothers who had a still birth either at
the time of sampling or during data analysis. This has limited the information on outcome
measures only to mothers who had a live birth. Since there is a socio-economic gradient
in child mortality it is likely that these mothers were more vulnerable and less likely to
adopt new care-seeking practices.
• Intervention: In most of the selected studies, BP/CR was only one of the multiple
components of interventions. Interventions covered in Hodgins (2010) and Darmstadt
(2010) were focused on multiple aspects of maternal and neonatal health. Reduction in
neonatal mortality was focused in interventions of Kumar (2008) and Baqui (2008).
Hossain (2006) and Currie (2009) largely focused on supply side strengthening. The only
intervention focused on measuring the effectiveness of birth preparedness programmes
was McPherson (2006).
Neither BP/CR was the prime focus of these interventions nor increasing SBA use was
the key outcome. This could have affected the efforts to promote BP/CR in these
interventions. It could also result in selective reporting on components other than BP/CR.
• Primary Outcome: Studies under review have defined and measured the primary
outcome of 'SBA use' variedly. Some studies are considering only facility based
deliveries and others are taking deliveries both at health facilities or at home. However,
home deliveries were rarely attended by SBA and thus this should not affect the outcomes
reported in the trial.
The other variation is that a few studies refer to SBA deliveries as 'deliveries conducted
by skilled birth attendant (ANM)' but other studies define them as 'deliveries conducted
by ANM/doctor/trained nurse'.
The overall rates of SBA use in all studies even after the interventions (BPCR) are low, in
spite of some increase in the knowledge of the advantages of using SBAs.
• Secondary Outcome: Most of the selected studies have not (separately) reported on the
status of BP/CR components other than knowledge on danger signs, financial preparedness
and transport preparedness. The selective outcome reporting, excludes results on other
BP/CR components on identification of SBA, clean birth at home, identification of blood
donor and identification of escort.
Risk of bias for the review as a whole
• Publication Bias: In-spite of various attempts to access unpublished material, very few
such reports were found. This systematic review may be affected by publication bias.
• Reporting Bias: Most of the selected studies have not reported or separately reported on
the status of many BP/CR components such as identification of SBA, clean birth at home,
identification of blood donor and identification of escort. This could be attributed to
reporting bias.
Population Foundation of India Page 27
4. DISCUSSION
4.1 SUMMARY OF EVIDENCES
Study Question 1. Are Birth Preparedness and Complication Readiness (BP/CR)
interventions at scale effective in South Asian countries in improving skilled birth
attendance, knowledge and preparedness for delivery.
Answer 1. The systematic review of Birth Preparedness and Complication Readiness
(BP/CR) interventions at scale has found that these interventions can lead to small but
significant increase in the use of SBA.
The BP/CR interventions seems to be more effective in improving knowledge and
preparedness for delivery. The large improvements in knowledge and preparedness were
found, even in studies where no change was observed in SBA use. This indicates that, only
promoting the concept of BP/CR may not be fruitful to motivate the women to avail services
from skilled birth attendance.
Available evidence suggests that community based BP/CR intervention could lead to
improvement in SBA use, only if health service delivery is also strengthened (such as facility
up-gradation, training of service providers, etc.), either prior to or along with BP/CR
programs and if the intervention is backed by community support mechanism.
Study Question 2. What are the components or combination of components of BP/CR proven
to be effective at scale?
Answer 2. Among the various components of BP/CR package at scale, 'education to improve
knowledge on danger signs' and 'financial preparedness' for the delivery/emergency seems to
be most effective. Subsequent to these, the BP/CR component of 'preparedness for transport'
also seems to be effective.
Study Question 3. Which approach/es for implementing BP/CR have proven to be
successful?
Answer 3. Following approach/es for implementing BP/CR interventions appear to be
successful:
• BP/CR interventions designed on the basis of formative research on women’s need to identify barriers and facilitators to maternal care practices.
• BP/CR interventions with the component of supply side strengthening such as facility up-gradation, training of service providers, etc. Otherwise, the interventions area
should be well served by pre-existing public/private health care facility.
• The key intervention agents from the government system, supported with extensive training and refresher trainings.
• The BP/CR intervention monitored closely and regularly.
• BP/CR messages not only targeting pregnant women but also involving family members and community.
• BP/CR interventions with a strong component of community mobilisation. The community establishing mechanisms to support pregnant women and their families to
comply with the individualised plan.
Population Foundation of India Page 28
Study Question 4. What BP/CR components and approaches do not work at scale?
Answer 4. Only education to improve knowledge on BP/CR without supply side
strengthening and without community mobilisation does not work at scale. However, there is
no evidence to suggest that this does not work in settings where supply-side is secured.
Caution needs to be exercised in arriving at any conclusions on what does not work at scale
as there were only two studies from which this could be assessed.
4.2 LIMITATIONS
Various limitations of this systematic review were discussed in previous sections (3.3 & 3.6)
on risk of bias. Moreover, the review is not representative of the South Asian region due to
limited evidence from some countries as well as the intra-country cultural variations, which
cannot be captured by one or two studies from each of these countries-namely India,
Bangladesh and Nepal. Despite these variations, the significant socio-economic indicators
bearing relevance to maternal and child health are similar across these countries. Thus, these
findings may be applicable to settings with similar socio-economic profiles.
4.3 CONCLUSIONS
Available evidence indicates that birth preparedness and complication readiness (BP/CR)
interventions with a component of strengthening health service delivery and community
mobilisation, are effective in improving knowledge and preparedness for delivery.
Fullerton (2005)38 and CASP (2003)
39also confirms similar results of significant increase in
financial preparedness and transport preparedness. Fullerton (2005) also reports on
community involvement in generating funds and arranging for transport through the
formation of Village Health Committees (VHC). Similarly, CASP (2003) reported on the
establishment of a Group Saving Scheme for obstetric emergencies. Increase in facility based
deliveries was reported in two separate interventions from Pakistan and from India. In both,
transportation of obstetric emergencies was facilitated40&41
.
Studies on strengthening health facilities suggest that availability of EMoC facilities with
regular up gradation and maintenance of drugs and supplies contributes in increasing the
proportion of facility deliveries42. There are various schemes going on in targeted countries
that provide financial support for facility delivery, either through conditional cash transfer or
by mobilising community funds. Though these schemes are helpful in improving facility
based deliveries but results shows that they are unable to reach the poorest of the poor43,44,45
.
38 Fullerton 2005. Outcomes of a Community- and Home Based Intervention for Safe Motherhood and
Newborn Care. Health Care for Women International. 26:561-576. 39 CASP. 2003. Expanding the role of CBD workers & advocates in safe motherhood in India. Unpublished report.
40 Midhet. 2010. Impact of Community-based Interventions on Maternal and Neonatal Health Indicators:
Results from a Community Randomized Trial in Rural Balochistan, Pakistan. Reproductive Health.7:30 41 De Costa. 2009. Financial Incentives to influence maternal mortality in a low-income setting: making
available ‘Money to Transport’- experiences from Amaprpatan, India. Global Health Action, V.2. 42 Islam. 2005. improvement of coverage and utilization of EMoC services in southwestern Bangladesh.
International Journal of Gynecology and obstetrics 91, 298-305 43 Schmidt 2010. Vouchers as demand side financing instruments for health care: A review of the Bangladesh
maternal voucher scheme. Health Policy 96, 98–107 44 Lim 2010. India’s Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation 375: 2009–23
Population Foundation of India Page 29
Promoting birth preparedness and complication readiness (BP/CR) among the marginalised
group could lead to increased SBA use by them.
On the other hand, available skilled professionals are targeted with huge geographical areas
to cover and long distances to facilities constrain women to go for facility. Countries like
Malaysia, Sri Lanka and Thailand had drastically reduced maternal mortality by increasing
the number of midwives at community level46. Promoting birth preparedness may change the
community level behaviour towards attaining better care during pregnancy and child birth but
to ensure skilled care for every women there is need to expand the cadre of skilled
professionals and strengthen the public health delivery system.
4.4 FUNDING
The funding and technical assistance for this study was provided by MCH-STAR/USAID.
5. RECOMMENDATION
Implications for policy
BP/CR interventions along with community mobilisation and supply side strengthening
seems to be effective in improving utilisation of skilled birth attendance in South Asian
settings. This intervention could lead to a reduction in maternal mortality by addressing all
the delays to prevent maternal deaths in resource-poor settings47.
This systematic review found that there are varying components of BP/CR used in selected
studies, it clearly indicate that the BP/CR package needs standardisation. The review also
found that the well trained and well supervised community health workers are key to the
success of BP/CR intervention. This provides evidence in support of adopting/strengthening a
standardised BP/CR policy for provision of care by community health and skilled birth
attendants from the public health system.
Implications for future research
There is a pressing need for more studies that address issues of standardizing the BP/CR
package as well as the mode of delivering this package. The weakest link in the analysis has
been the absence of costing data. There is a need to undertake costing studies (either direct
costing or through modelling) to understand the cost-benefit (or even cost-effectiveness) of
such community based interventions.
It will be informative to investigate the delivery approach for the BP/CR package across areas
with high and low SBA utilisation but similar health infrastructure and resources to truly
understand the challenges and effective means of working at scale.
45 Jackson 2009. The experiences of districts in implementing a national incentive programme to promote safe delivery in Nepal BMC Health Services Research, 9:97
46 WHO. 2005. Make every mother and child count. Geneva, World Health Organization.
(http://www.who.int/whr/2005/whr2005_en.pdf 47 Thaddeus. 1994. op. cit. 7.
Population Foundation of India Annexure Page 1
ANNEXURE I: SEARCH STRINGS
Search string used in Google Scholar
1 “Birth preparedness” “complication readiness”
2 "birth preparedness" "complication readiness" "skilled birth attendance"
3 "birth preparedness" "complication readiness" "clean delivery" OR "safe delivery OR “clean
delivery”
4 Janani Suraksha Yojana
5 birth OR “birth planning” OR “skilled birth attendance”
6 knowledge OR information OR awareness "skilled birth attendance
7 "clean delivery" knowledge OR information OR awareness "safe delivery"
8 “complication readiness" transport OR transportation OR vehicle OR ambulance "birth
preparedness 9 "birth preparedness" save OR saving OR finance OR money OR monetary OR resource OR fund
OR funding "complication readiness
10 EMoC Knowledge OR Information OR awareness “skilled birth attendance”
11 “complication readiness” OR “birth preparedness” “expected-date-of-delivery or time-of-
delivery or delivery-date”
12 “complication readiness” OR “birth preparedness” “blood donor”
13 “complication readiness” OR “birth preparedness” “accompany” 14 “complication readiness” OR “birth preparedness” “escort”
15 "community intervention" AND "safe delivery" AND "south Asia"
16 “janani suraksha yojana”
17 “micro birth plan”
Search string used in PubMed
1 “birth preparedness” OR “complication readiness”
2 “birth preparedness” OR “complication readiness”
3 (“birth preparedness” OR “complication readiness”) AND (skilled AND birth AND (attend* OR
assist*))
4 (“birth preparedness” OR “complication readiness”) AND ((clean OR safe) AND delivery)
5 (“birth preparedness” OR “complication readiness”) AND (transport OR vehicle OR ambulance)
6 (“birth preparedness” OR “complication readiness”) AND (save OR saving OR mone* OR fund
OR funding OR financ* OR resource*)
7 (prepare OR preparedness OR readiness OR ready OR plan OR planning) AND (skilled AND
birth AND (attend* OR assist*))
8 (knowledge OR information OR awareness) AND (skilled AND birth AND (attend* OR assist*))
9 (knowledge OR information OR awareness) AND ("clean delivery" OR "safe delivery")
10 (knowledge OR information OR awareness) AND (skilled AND birth AND (attend* OR assist*)) AND complication
11 (knowledge OR information OR awareness) AND (skilled AND birth AND (attend* OR assist*))
AND danger signs
12 (knowledge OR information OR awareness) AND (skilled AND birth AND (attend* OR assist*))
AND emergency
13 (knowledge OR information OR awareness) AND "EMoC"
14 (pregnan* or maternal or birth or deliver*) and (prepar*) and (danger-sign) 15 (knowledge OR information OR awareness) AND (pregnant OR pregnancy OR maternal OR
birth OR childbirth OR delivery OR labour OR labor) AND (danger-sign OR complication OR
emergency)
16 (knowledge or information or awareness) and (pregnant or pregnancy or maternal or birth or
childbirth or delivery or labour or labor) and (health-facility or hospital or institution)
17 (knowledge or information or awareness) and (pregnant or pregnancy or maternal or birth or
Population Foundation of India Annexure Page 2
childbirth or delivery or labour or labor) and (facility or hospital or institution)
18 (pregnan* or maternal or birth or deliver*) and (prepar*) and (danger-sign)
19 “janani suraksha yojana”
20 “micro birth plan”
Search string used in Popline
1 “Birth preparedness” “complication readiness”
2 Pregnancy complications & danger signs
3 Delivery complications
4 Safe delivery
5 Janani Suraksha Yojana
6 "Birth Planning"
7 Community Intervention
8 "Skilled birth attendance"
9 Financial preparedness / "safe delivery"
10 "Community intervention" & "maternal health"
Population Foundation of India
Annexure Page 3
ANNEXURE II: RESULTS O
F INDIV
IDUAL STUDIE
S
Study Characteristics Table 1: McPherson (2006)
Study
McPherson 2006
Method
Before-after
Multi-stage 30 cluster sampling technique for baseline (B) and end-line (E). Random selection using probability-proportional to
estimated population at each stage.
Participants
Women who had delivered a live baby during the year before the interview date.
Exclusion criteria: Women who had a stillbirth
Estimated sample size: 300 Achieved: 300
Mean age: 24.4 (B) 24.5 (E)
Mean number of births: Not addressed
Literate (%): 25.8(B) 19.7(E)
Economic status (% in lowest quintile): Not addressed
Significant differences in ethnicity of B and E
Intervention
Education to improve knowledge(Danger signs, identification of SBAs, transportation and saving)
Comparison
None
Results utilized
for this review
Intervention coverage: 54% (E)
SBA use: 17.0% (B) to 17.0% (E) (Analysis included women with live births only 1716(B) 1723(E))
Knowledge of danger signs: Prolonged labour 50% (B) 86%(E) Bleeding 29% (B) 56% (E)
Financial preparedness: 45% (B) 72% (E)
Developing birth-plan: Not addressed
Results not
utilized for this
review
Changes in care seeking and service utilization for selected indicators for ante-natal care, post-natal care and delivery complications.
Changes in practices and behaviours during pregnancy and newborn care.
Improvements observed in all indicators.
Notes
Aim: To assess effectiveness of a district-wide BP/CR intervention within existing public health system in Nepal.
Timeline: September 2002 (B) September 2004 (E)
Estimation of sample size: Not provided
Field work and data collection quality checks: Information on size of survey teams, training and quality checks during data collection is
not provided.
Data collection instruments: Not provided.
Program description
Setting
Siraha is a primarily rural district. Majority of the population belongs to indigenous population groups engaged in subsistence farming.
Certain regions (9 of 106 Village development committees) are conflict affected.
Population Foundation of India
Annexure Page 4
12 health posts and 89 sub-health posts provide primary healthcare services to rural communities, while two public hospitals and three
primary healthcare centres provide higher-level services to the general population.
There is no significant donor funded maternal–neonatal health programs in the district.
Target
population
The target populations of the program were 145,000 women, aged 15-49 years, who live in Siraha and their 24,000 newborns.
Strategy
Community health workers within the public health system were trained specifically on counselling techniques for 3-4 days and tasked
to generate awareness about BP/CR through community meetings. No refresher training were mentioned but on site support has been
described in the paper. Multiple media for message delivery were used eg. Keychains, flip-charts.
House-to house visits were expected but not defined in the community health workers job description.
Implementer and
funder
Staff of district public health system with assistance from Saving Newborn Lives initiative funded by Save the Children USA.
Project duration
2002-2004. Full scale implementation initiated in March 2003.
Study Characteristics Table 2: Hodgins (2010)
Study
Hodgins 2010
Method
Before-after
Three stage 30 cluster sampling technique for baseline (B) and end-line (E). Random selection using probability-proportional to
estimated population. First stage-Wards, second stage-geographic segments, third stage-index households.
Participants
Women who had delivered a live or stillborn child during the year before the interview date.
Exclusion criteria: None
Estimated sample size: 1800 (900 per district) Achieved: 1740 (Only 840 could be reached in one district)
Mean age: 25 (B) 24.9 (E)
Mean number of births: 2.73 (B) 2.45 (E)
Literate (%): 43.7(B) 48.5(E)
Economic status (% in lowest quintile): 23.7 (B) 16.6 (E)
Intervention
Education to improve knowledge(exact components of the BP/CR package are not provided) and Individualised planning
Comparison
None
Results
utilized
for this review
Intervention coverage: 81% (E)
SBA use: 24.0% (B) to 28.4% (E) (Analysis included women with live births only 1716(B) 1723(E))
Knowledge of danger signs: Not addressed
Financial preparedness: 34.8% (B) 81.9% (E)
Developing birth-plan: Not addressed
Results not
utilized for this
Changes in care seeking and service utilization for selected indicators for ante-natal care, post-natal care, delivery complications,
neonatal complications.
Population Foundation of India
Annexure Page 5
review
Changes in practices and behaviours during with pregnancy and newborn care.
Improvements observed in all indicators except care seeking after recognition of danger signs during delivery and use of modern
contraceptives.
Notes
Aim: To assess feasibility, coverage and scalability of a maternal neonatal health package implemented through voluntary workers within
existing public health system.
Timeline: June 2005 (B) June 2007 (E)
Estimation of sample size: To detect 10% B to E change in selected indicators assuming B prevalence of 50%, 5% type I error and 20%
type II error, 10% non response and a design effect of two (because of cluster sampling)
Field work and data collection quality checks: 4 member survey teams (including 1 supervisor) trained for 9 days before initiation of data
collection. All interviewers were females. Supervisors checked all filled questionnaires for accuracy, consistency and completeness. Data
entry errors checked. 5% sub-sample of questionnaires re-entered to confirm inconsistencies have been checked.
Data collection instruments: 3 sets used. 1 to identify eligible households, 2 to report household characteristics and 3 to report on
maternal neonatal health behaviours and practices
Program description
Setting
Two rural district of Nepal with different rankings on Human Development Index (HDI), one high and other in the middle range of HDI
ranks in Nepal.
Both districts affected by civil war.
There is no information on number of peripheral health facilities in these districts.
No significant national-level behaviour change communication efforts related to maternal–neonatal health during intervention phase
Target population Entire rural populace. Total population 1 044 000.
Strategy
Home-based antenatal counselling provided by female community health volunteers to pregnant women and other family members
(especially husbands and mothers-in-law). Reinforced with a pictorial handout used for discussion with family members and as reference.
Implementer and
funder
Staff of district public health system with assistance from USAID funded Nepal Family Health Program (NFHP). Major financial
contribution through government.
Project duration
June 2005-June 2007. Full scale implementation initiated in January 2006.
Population Foundation of India
Annexure Page 6
Study Characteristics Table 3: Darmstadt (2010)
Study
Darmstadt 2010
Method
Cluster Randomized Controlled Trial
12 rural union arms randomly allocated to either comparison or intervention arm using a computer-generated pseudo-random number
sequence without stratification or matching. Blinding was unachievable given the nature of the intervention.
Participants
Mothers who delivered within 3 years of the survey. KPC sample consisted of a sub-sample of mothers who delivered in 12 months
preceding the survey.
Exclusion criteria: None
Estimated sample size: 14872 neonates. Achieved: Intervention- 14532 (For KPC - 2644(B) 1759 (E) Comparison - 2371(B) 1732 (E))
Mean age: Not addressed but age distribution pattern was similar in B and E for both arms
Mean number of births: Not addressed
Literate (%): Intervention ~35(B) ~25(E) Control ~39(B) ~28(E) (Women who never attended school)
Economic status (% poor): Intervention 25.7 (B) 14.7 (E) Control 22.7 (B) 15 (E)
Intervention
Education to attain facility delivery and if facility delivery is not feasible-education to improve knowledge on choosing trained birth
attendant, clean child birth, planning for emergency transport and saving money. There was Individualised planning and (Clean birth at
home) community health workers present during or immediately after deliveries)
Comparison
Usual government, NGO and private providers offered maternal and child health services
Results utilized
for this review
Intervention coverage: Above 90% (E)
SBA use: Facility deliveries -Intervention 12.1% (B) to 20.2% (E) Control- 12.5% (B) to 16.5% (E).
Knowledge of danger signs: Significant increase in the intervention arm (Measured as a score)
Financial preparedness: Not addressed
Developing birth-plan: Not addressed
Results not
utilized for this
review
Neonatal mortality
Care seeking and service utilization for neonatal complications. Improved significantly in intervention arm.
Practices and behaviours during pregnancy and for newborn care. Improvement observed in all indicators except 2 doses TT
immunization for pregnant women.
Notes
Aim: To examine the impact of a home-based neonatal care package on knowledge and practice of newborn care and neonatal mortality.
Timeline: April-July 2003 (B) January-May 2006 (E)
Estimation of sample size: Based on a hypothesized 40% reduction in neonatal period, NMR of 28 per 1000 live births, power of 80%
and an estimated design effect of 2.55. At B KPC sub-sample was drawn from the larger sample, At E sample of KPC was randomly
selected within each union, based on a sample size calculation to provide estimates for all KPC indicators assuming 50% prevalence with
66% precision and response rate of 85% for each union.
Field work and data collection quality checks: Information not provided on survey teams, training and monitoring of field activity.
Data collection instruments: Information not provided.
Program description
Population Foundation of India
Annexure Page 7
Setting
Sub-district in Bangladesh (Mirzapur) with good access to health facilities.
750 bedded private hospital is the preferred facility for referral.
Target population All married women in the age group of 15-45 years. Total population of the region 292 000
Strategy
Birth and newborn care preparedness was promoted by Community Health Workers (CHWs) through two antenatal home visits
scheduled at 12–16 and 32–34 weeks of gestation. Each union had six CHW areas, each of which consisted of approximately 4000
population served by one CHW. CHWs were trained for 36 days on pregnancy surveillance, counselling and negotiation skills, essential
newborn care, neonatal illness surveillance and management of illness based on a clinical algorithm adapted from Integrated
Management of Childhood Illness. Routine monitoring and refresher training were provided each fortnight. TBAs were oriented to the
trail and provided basic training on essential newborn care and referral for complication.
Implementer and
funder
Projahnmo-2 study group. Welcome Trust, USAID (Johns Hopkins Bloomberg School of Public Health). Data analysis and manuscript
preparation support by Bill and Melinda Gates Foundation (Saving Newborn Lives program of Save the Children-US).
Project duration
January 2004-December 2006. Full scale implementation initiated during December 2003– February 2004.
Study Characteristics Table 4: Hossain (2006)
Study
Hossain 2006
Method
Before-after
Paper states a quantitative population based baseline survey in both the areas. For end-line survey, three wards were selected from nine
wards of each union of Upazila (each arm). Starting from the random point of the selected ward, every alternate household was visited.
Participants
Women who had delivered in the last one year proceeding the survey.
Exclusion criteria: None
Estimated sample size: 400 women from each sample area(E) Achieved: 412 women ( intervention) , 400 women (each of comparison
and control arm)
Mean age: 21 years
Mean number of births: Not provided
Literate (%): Not provided
Economic status (% in lowest quintile): Not provided
Intervention
Education to improve knowledge (Danger signs for mother and newborn, identification of SBA, transportation, saving and identification
of blood donor) and individualized planning (community health financing, arrangement for transport)
Supply side interventions - Facility up gradation for providing Emergency obstetric care (EmOC) services and trainings on quality of
care for health service providers.
Comparison
Control
A sub-district of Dinajpur, where only facility up gradation was done
A sub-district of Panchagarh, where no activity was performed.
Results
utilized
for this review
Intervention coverage: Data not provided
SBA use (only facility deliveries): Intervention 2.4% (B) to 10.5% (E) Comparison 7.2% (B) to 12.5% (E) Control 4.5% (B) to 5.0% (E).
Population Foundation of India
Annexure Page 8
Knowledge of danger signs: change in survey design between pre and post intervention, baseline data on knowledge on danger signs
could not be compared to post intervention information.
Developing birth plan: 143 community support systems (CmSS) had been established by the end of the project
− Fifteen CmSS purchased Rickshaw Van to transport the women to facility at the time of emergency
− 13 CmSS established bank account to maintain their funds.
− Out of 150 women who experienced obstetric emergency during the intervention period, 52 women made use of money from the
emergency fund, 23 were accompanied to the health facility and 23 used the transportation system.
Results not
utilized for this
review
Met need for EmOC. Increased in both intervention and comparison area. No change in control area.
Notes
Aim: To increase the utilization of EmOC services from met need for EMoC of 16% to 50% in the intervention area. Timeline: May 1998
(B) - 2001 (E) )
Estimation of sample size: Not provided
Field work and data collection quality checks: Not provided in the paper.
Data collection instruments: 3 sets used. 1 to identify barriers in utilization of EMoC services, 2 to obtain information on quality of care
issues 3 to observe the impact of community mobilization activities focused on BP/CR.
Program description
Setting
Project areas were Dinajpur and Panchagarh district of Bangladesh which have relatively high rates of maternal deaths. The intervention
and comparison area-Birampur and Bochaganj are sub-districts of Dinajpur and control area Debiganj is a sub district of Panchagarh.
There is no information on health infrastructure in these districts
Target population Entire population of Birampur sub-district- 164,000
Strategy
Trained TBA’s, GoB and NGO field workers and doctors disseminated the BP/CR messages during home visits, discussions at village
level satellite clinics and village meetings.
Birth planning cards were distributed to the pregnant women.
Messages were incorporated in the poster, pictorial cards and brochure for literate population.
Family members of pregnant women were also made aware of birth preparedness
A conscious effort was also made to involve community and religious leaders to create awareness
Implementer and
funder
Facility up gradation was provided with technical and financial support from UNFPA and UNICEF. CARE Bangladesh introduced a
community mobilization intervention for care of women with complications. Program was implemented through staff of district public
health system of Bangladesh
Project duration
May 1999-2001
Population Foundation of India
Annexure Page 9
Study Characteristics Table 5: Baqui (2008)
Study
Baqui 2008
Method
Quasi-experimental
Random selection of blocks, sectors (20 000 to 25 000 population) and households.
Participants
Women who had delivered a live or stillborn child during the 24 months before the interview date.
Exclusion criteria: None (But analysis restricted to live born children only)
Estimated sample size: Not provided Achieved: Intervention- 8756 (B) 7812 (E) Comparison- 6196 (B) 6014 (E)
Mean age: Not available but distribution pattern of ages was similar in intervention and comparison arms
Mean number of births: Not available but parity pattern was similar in intervention and comparison arms
Literate (%): Intervention- 23.4%(B) 25.2% (E) Comparison-36.8%(B) 41.3%(E)
Economic status (% in lowest quintile): Not available. By standard of living index low income include: Intervention -46.5% (B) 40.0%
(E) Comparison 53.2% (B) 48.6% (E)
Intervention
Education to improve knowledge(Danger signs, identification of SBAs, transportation and saving)
Comparison
Usual government services
Results
utilized
for this review
Intervention coverage: Intervention-60% (E) Control-20% (E) (Measured as at least one antenatal visit by a community based worker)
SBA use: Intervention- 16.3% (B) 22.5 (E) Comparison- 17.5% (B) to 21.8% (E)
Knowledge of danger signs: Not addressed
Financial preparedness: Intervention- 15% (B) 50% (E) Comparison- 12% (B) 30% (E)
Developing birth plan: Not addressed
Results not
utilized for this
review
Reduction in neonatal mortality. Neonatal mortality remained unchanged in intervention versus control area at approx. 46 per 1000 live
births.
Changes in care seeking and service utilization for selected indicators for ante-natal care and post-natal care.
Changes in practices and behaviours during with pregnancy and newborn care.
Notes
Aim: To assess the impact of the newborn health component of a large-scale community based integrated nutrition and health program.
Timeline: January to June 2003 (B) January to March 2006 (E)
Estimation of sample size: To detect a 20% reduction in neonatal mortality following the intervention with 80% power at a 5%
significance level.
Field work and data collection quality checks: Data collectors with at least a 10th grade education, fluent in the local language and
dialect were selected. The data collectors received 7 days of didactic training and 3 days of field practice and were deployed only if they
qualified in a post-training test. Investigators set up an independent data quality assurance system that included re-interviewing 5% of
households, weekly comparisons of original and re-interview data to identify disagreements, and additional field visits and training to
data collectors to resolve discrepancies.
Data collection instruments: Information not provided
Population Foundation of India
Annexure Page 10
Program description
Setting
Two rural district of Uttar Pradesh, India.
There is no information on number of peripheral health facilities in these districts.
No significant donor assisted maternal–neonatal health program during intervention phase
Target population Entire rural populace. Total population: Not provided.
Strategy
Anganwadi workers encouraged to recruit community volunteers called “change agents” who were additional community based worker
cadre. ANMs, AWWs and change agents received a total of 6 days of training on the care of mothers and newborn babies. Information to
encourage behaviour change was usually communicated during antenatal and postnatal home visits by any of the community based
workers.
Implementer and
funder
Staff of district public health system, ICDS with assistance from USAID funded Integrated Nutrition and Health Project (INHP).
Project duration
2002 to 2007. Full scale implementation initiated in July 2003.
Study Characteristics Table 6: Kumar (2008)
Study
Kumar 2008
Method
Cluster Randomized Control Trial
There were three arms in the intervention. Shivgarh (population 104123) consists of 30 blocks and 13 block to each arm were
randomized
Participants
(Please see these
and update).
Women who had delivered a live or stillborn child.
Exclusion criteria: None ( for BCC analysis was re restricted to singleton live births only)
Estimated sample size: Not provided Achieved: Intervention-
Mean age: Not available
Mean number of births: Not available
Literate (%): Intervention- 39.4%(B) Not available (E) Comparison-38.5%(B) Not available %(E)
Economic status (% in lowest quintile): Intervention- 33.2%(B) Not available (E) Comparison-34.4%(B) Not available (E).
Intervention
Education to improve knowledge(clean child birth, identification of SBAs(identification of delivery supervisor and new born attendant),
identification of health facility and saving for emergencies)
Comparison
Usual government/Non-governmental services
Results
utilized
for this review
Intervention coverage: Intervention-Antenatal visit 60 days before expected date of delivery-60.6%
Antenatal visit 30 days before expected date of delivery-54.2%
Cluster M
eans
Facility Delivery-Intervention-7.9%(B) to19.7%(E) Control-4.8%(B) to14.0%(E)
SBA use: Intervention- 16.6% (B) to 26.7 (E) Control- 13.0% (B) to 19.7% (E)
Knowledge of danger signs: Not addressed
Population Foundation of India
Annexure Page 11
Financial preparedness:
Developing birth plan: Yes
Results
not
utilized for
this
review
Reduction in neonatal mortality. Neonatal and peri-natal mortality rates showed significant reduction in both the intervention arms(i.e.
essential new born care and essential new born care plus thermo Spot)
Changes in care seeking and service utilization for selected indicators for ante-natal care and post-natal care.
Changes in practices and behaviour during pregnancy and newborn care.
Notes
Aim: To assess the efficacy of community based behaviour change management on neonatal mortality
Timeline: May 2002-May 2005
Estimation of sample size: To detect a 40% reduction in neonatal mortality rate in each intervention arm compared with the control arm
over 16 months with 80% power at 5% level of significance
Field work and data collection quality checks: Data collectors were given with at least 7 to 15 days training as per their task. Standard
procedures were established to guide team recruitment, training and supervision. Supervisor to data collector ratio was 1:6 and 15% or
more of households were randomly subjected to back checks, spot checks or truncated re-interviews.
Data collection instruments: semi structured data collection forms were used to gather the information on knowledge, attitude and
practices related to maternal and new born care
House to house survey was done for pregnancy notification. Brief questionnaires were used to collect information on neonatal mortality.
Program description
Setting
Shivgarh districts of Uttar Pradesh which is divided in to 39 village administrative units with 104123 population
Formally Shivgarh is served by one Community Health Centre and two Primary Health Centres operated by physicians and trained Para-
medical staff and 18 Auxiliary Nurse Midwives.
No significant donor assisted maternal–neonatal health program during intervention phase
Target population Entire population: 104123
Strategy
Behaviour change was implemented through two antenatal home visits as well as through community folk songs and community
meetings. The primary behaviour change enablers were community based health workers called as “Saksham Sahayak”. They were
provided with 7 days apprenticeship- based field training on knowledge attitude and practices related to new born care in the society
,behaviour change management and trust building. These were closely monitored and supervised by four regional programme
supervisors. Influential people worked as “community stakeholders”, they were responsible for building trust with the community and
insuring acceptance of the program. “New born care Stakeholders” were traditional birth attendants, unqualified practitioners and new
born care providers, they helped in sustaining target practices. Volunteers within the community (“Saksham Karta”) worked for program
advocacy.
Implementer and
funder
Program was funded by USAID and Save the Children-US through a grant from Bill and Melinda gates foundation.
Project duration
May-2002-May2005
Population Foundation of India
Annexure Page 12
Study Characteristics Table 7: Currie (2009)
Study
Currie (publication status not known)
Method
Quasi Randomized Controlled Trial
Three blocks of Dumka districts were selected for project implementation.
Sampling strategy: not addressed in the paper
Participants
Pregnant women and women who delivered within six months preceding the survey
Exclusion criteria: None
Estimated sample size: not addressed.
Achieved: Intervention:
− pregnant women:Baseline-320 Endline-310
− Recently Delivered Women:Baseline-440 Endline-410
Comparison:
− Pregnant women:Baseline-260 Endline-221
− Recently Delivered Women: Baseline-359 Endline-291
Mean age: Not addressed
Mean number of births: Not addressed
Literate (%):Not Addressed
Economic status (% poor): Not Addressed
Intervention
Education to improve knowledge- on danger signs for mother and when to seek help, identifying SBA’S, plan for saving and
transportation and identification of a blood donor
Individualised birth planning- Facilitated and established systems of health financing and arrangement of transportation
Comparison
Usual government service providers offered maternal and child health services
Results
utilized
for this review
Intervention coverage:
SBA use: -Intervention 5% (B) to 13.2% (E) Control- 4% (B) to 6.8% (E).
Knowledge of danger signs: Significant increase in the intervention arm (Measured as a score)
Financial preparedness:
intervention: pregnant women 17%(B) 32%(E)
RDW 26%(B) 57%(E)
CONTROL: Pregnant women 17%(B) 17%(E)
RDW 31%(B) 38%(E)
All the villages in the intervention area had fully functioning transport system till the end of the intervention period.
Till the completion of intervention all the women delivered at the health facility.
Results not
utilized for this
Post natal Care
Significant increase in the utilization of postpartum care by women in the intervention arm.
Population Foundation of India
Annexure Page 13
review
Planning for institutional delivery increased significantly.
Notes
Aim: To increase the use of quality skilled MNC in communities in Dumka districts of Jharkhand.
Timeline: June 2006- December 2008
Estimation of sample size: Not addressed
Field work and data collection quality checks: survey statistics was collected and reviewed by regular staff on quarterly basis which
indicates that project was closely monitored.
Data collection instruments: data collection was done through semi-structured questionnaires for household and for participants
Program description
Setting
Project was implemented in three blocks i.e. Jarmundi, Shikaripara and Saraiyahat of Dumka is district in Jharkhand.
Target population All married women in the age group of 15-45 years. Total population of three blocks adds up to 372204.
Strategy
Birth preparedness and post partum care was promoted through community mobilization of self help groups, CHW’s and CHV’s and
trained. On the background of baseline research rigorous training of 12 weeks was provided to ANM for performing the deliveries and
for providing the skilled care.
Implementer and
funder
Funded by USAID and implemented by CEDPA, WRAI and Govt. Of Jharkhand
Project duration
June 2006- December 2008. BP/CR was promoted for one year.
Population Foundation of India Annexure Page 14
ANNEXURE III: LIST OF EXCLUDED STUDIES
Excluded for interventions not being at scale
1. Fullerton, 2005, Health Care for Women International 26:561–576 Outcomes of a Community- and Home-Based Intervention for Safe Motherhood and Newborn Care
Reason for exclusion: Intervention not at scale, only covering 20,000-30,000 residents of 42
villages or hamlets of Maitha block, Kanpur.
2. CASP, 2003, Project report, The Enable Project Expanding the role of CBD workers and advocates in Safe Motherhood in India, publication
unknown Reason for exclusion: Intervention not at scale, only covering two slum colonies of Delhi of
55,000 population.
Excluded for not fulfilling the participant / intervention / outcome criterion of PICO protocol
3. More, 2008 , Trials 9:7. BioMedCentral Cluster-randomised controlled trial of community mobilisation in Mumbai slums to improve
care during pregnancy, delivery, postpartum and for the newborn
Reason for exclusion: Non-BP/CR component were dominant in the trial.
4. Islam, 2005, International Journal of Gynaecology and Obstetrics, 91, 298-305
Improvement of coverage and utilization of EmOC services in south-western Bangladesh
Reason for exclusion: Facility based programme focused on improving EMoC facilities,
with less focus on community based efforts.
5. Ahmed Tahera, 2009, Reproductive Health Matters, 17(33):45–50 Community based skilled birth attendants in Bangladesh: attending deliveries at home Reason for exclusion: Programme is not focused on promoting BP/CR, it was focused on
training of community based heath workers (with essential midwifery skills) for providing
skilled care at birth. These were TBAs and not SBAs.
6. Ronsmans, 2010, Bulletin of World Health Organization, 88:289–296 Care seeking at time of childbirth, and maternal and peri-natal mortality in Matlab,
Bangladesh
Reason for exclusion: There was no BP/CR component in the paper.
7. Schmidt, 2010, Health Policy, 96: 98–107 Vouchers as demand side financing instruments for health care: A review of the Bangladesh
maternal voucher scheme
Reason for exclusion: This intervention focuses on providing vouchers to women for
availing skilled care at home or at facility. Present paper is a rapid review, impact assessment
is still awaited.
8. Fauveau, 1991, The Lancet, 338: 1183-6 Effect on mortality of community based maternal care programme in rural Bangladesh
Reason for exclusion: The study aims to measure the impact of using trained mid-wives at
the time of birth on maternal mortality.
9. De Costa, 2009, Global Health Action, DOI: 10.3402/gha.v2i0.1866
Population Foundation of India Annexure Page 15
Financial incentives to influence maternal mortality in a low-income setting: making
available ‘money to transport’: Experiences from Amarpatan, India
Reason for exclusion: This intervention of providing transport and financial incentives to
women in one block of Amarpatan, Madhya Pradesh aimed to assess the impact on maternal
mortality.
10. Mavalankar, 2009, International Journal of Gynaecology and Obstetrics, 107: 271–276 Saving mothers and newborns through an innovative partnership with private sector
obstetricians: Chiranjeevi scheme of Gujarat, India
Reason for exclusion: Documentation services utilized under Chiranjeevi Yojana
11. Bang, 2005, The Lancet, 25:S62–S71 Effect of home-based neonatal care and management of sepsis on neonatal mortality: field
trial in rural India
Reason for exclusion: Intervention focused on reduction of neonatal mortality without any
BP/CR component
12. Matthews, 2001, Asia pacific population Journal Antenatal care, Care Seeking and Morbidity in Rural Karnataka, India: Results of a
Prospective study
Reason for exclusion: Intervention focused only on ANC counselling and aimed for
effective service utilization.
13. Tuladhar, 2009, Nepal Medical College Journal Complications of home delivery: Our experience at Nepal Medical College Teaching Hospital
Reason for exclusion: Facility based study among women suffering complications after
delivery on reasons for not using SBA.
14. Manandhar, 2004, Lancet Effect of a participatory intervention with women’s groups on birth outcomes in Nepal:
cluster-randomised controlled trial Reason for exclusion: Intervention focused on reduction of peri-natal mortality without any
BP/CR component.
15. Rath, 2007, Reproductive Health Matters Improving Emergency Obstetric Care in a Context of Very High Maternal Mortality: The
Nepal Safer Motherhood Project 1997–2004
Reason for exclusion: The paper focused on emergency obstetric services.
16. Mullany, 2007, Health Education Research The impact of including husbands in antenatal health education services on maternal health
practices in urban Nepal: results from a randomized controlled trial
Reason for exclusion: The intervention focused on involvement of husband and its impact
on antenatal care services.
17. Wade, 2006, BMC Pregnancy and Childbirth Behaviour change in peri-natal care practices among rural women exposed to a women's
group intervention in Nepal
Reason for exclusion: The intervention focused on use of five cleans and a few peri-natal
care practices without any BP/CR component.
18. MNH programme of JHPIEGO, 2004, Mobilizing for Impact: Key research findings
Building Partnerships to Save Mothers: Nepal’s SUMATA Initiative
Population Foundation of India Annexure Page 16
Reason for exclusion: Study only documents experiences from SUMATA, initiative on
BP/CR in Nepal without any evaluation.
19. Carlough, 2005, International Journal of Gynaecology and Obstetrics Skilled birth attendance: What does it mean and how can it be measured? A clinical skills assessment of maternal and child health workers in Nepal
Reason for exclusion: The study focused on the clinical assessment of capacities of maternal
and child health workers (MCHWs) as skilled birth attendants without any focus on the
BP/CR component.
20. Midhet, 2010, Reproductive Health Impact of community based interventions on maternal and neonatal health indicators:
Results from a community randomized trial in rural Balochistan, Pakistan
Reason for Rejection: The intervention is focused on providing services through TBA’s
21. Bhutta, 2008, Bulletin of the World Health Organization Implementing community based peri-natal care: results from a pilot study in rural Pakistan
Reason for exclusion: The study focused on improving peri-natal care using lady health
workers (LHWs) and traditional birth attendants (Dais) in rural Pakistan without any focus on
the component.
22. Jokhio, 2005, The New England Journal of Medicine An Intervention Involving Traditional Birth Attendants and Peri-natal and Maternal Mortality
in Pakistan
Reason for exclusion: The study focused on improving peri-natal care using lady health workers (LHWs) and traditional birth attendants (Dais) in rural Pakistan without any focus on
the BP/CR component.
Excluded for not fulfilling the type of study criterion of PICO protocol
23. Valley Research Group (VaRG), 2006, Project report Baseline Survey for CB-MNC Program in Kanchanpur District
Reason for exclusion: The study reports only baseline information for the intervention, the
end-line information is not available.
24. Deoki Nandan, 2008-2009, Working paper, Rewa Medical College A Study for Assessing Birth Preparedness and Complication Readiness Intervention in Rewa
District of Madhya Pradesh
Reason for exclusion: Cross sectional study on BP/CR and its impact on utilisation of health
services.
25. Agarwal, 2010, Journal of Health Population and Nutrition Birth Preparedness and Complication Readiness among Slum Women in Indore City, India
Reason for exclusion: Cross sectional study on BP/CR and its impact on utilisation of
health services.
26. Lim, 2010, Lancet India’s Janani Suraksha Yojana, a conditional cash transfer programme to increase births in
health facilities: an impact evaluation Reason for exclusion: The paper is an impact evaluation of JSY under DLHS (2002-04 &
2007-09).
27. Haq, 2009, Journal of Pakistan Medical Association Birth preparedness and the role of the private sector: a community survey
Population Foundation of India Annexure Page 17
Reason for exclusion: A cross-sectional community based survey on birth preparedness and
service utilization.
28. Jackson, 2009, BMC Health Services Research The experiences of districts in implementing a national incentive programme to promote safe delivery in Nepal
Reason for exclusion: Paper reported data from a qualitative study capturing key informant
interviews of service providers.
29. Jafarey, 2009, Journal of Health Population and Nutrition Verbal Autopsy of Maternal Deaths in Two Districts of Pakistan-Filling Information Gaps
Reason for exclusion: Paper reported data from a qualitative study based on verbal autopsy
on reasons for maternal deaths in Pakistan.
30. Singh, 2006, working paper, Achutha Menon Centre for Health Science Studies Relevance of Trained Traditional Birth Attendants in maternal health: case study of Tehri
Garhwal district, Uttaranchal state
Reason for exclusion: Paper focused on use of TBA as birth attendant.
31. Deoki Nandan, 2008, Working paper, National Institute of Health and Family Welfare A Rapid Appraisal on Functioning of Janani Suraksha Yojana in South Orissa
Reason for exclusion: Paper is an appraisal of functioning of Janani Suraksja Yojana in
South Orissa.
32. Deoki Nandan, 2009, Working paper, National Institute of Health and Family Welfare A quality assessment of institutional deliveries in Jaipur
Reason for exclusion: Paper aims at reviewing and comparing deliveries conducted at
facilities before and after JSY
Excluded for being Systematic Reviews / Review Articles
33. Bhutta, 2008, Lancet Alma-Ata: Rebirth and Revision 6: Interventions to address maternal, newborn, and child
survival: what difference can integrated primary health care strategies make?
Reason for exclusion: Systematic Review
34. Haider, 2009 International Initiative for Impact Evaluation (3ie) Community based intervention package for preventing maternal morbidity and mortality and
improving neonatal outcomes
Reason for exclusion: Systematic Review
35. Paxton, 2005, International Journal of Gynaecology and Obstetrics The evidence for emergency obstetric care
Reason for exclusion: Systematic Review
36. Blencowe, 2010, Policy Brief Clean birth kits – potential to deliver? Evidence, experience, estimated lives saved and cost.
Reason for exclusion: Systematic review
37. Health Evidence Network (HEN), 2005, WHO Report
What is the effectiveness of antenatal care, evidence for decision makers?
Reason for exclusion: Systematic Review
38. Gogia, 2010, Bulletin of the World Health Organization
Population Foundation of India Annexure Page 18
Home visits by community health workers to prevent neonatal deaths in developing countries:
a systematic review
Reason for exclusion: Systematic review
39. Darmstadt, 2009, International Journal of Gynecology and Obstetrics 60 million non-facility births: Who can deliver in community settings to reduce intra-partum-
related deaths?
Reason for exclusion: Systematic Review
40. Dogba, 2009, Human Resources for Health Human resources and the quality of emergency obstetric care in developing countries: a
systematic review of the literature
Reason for exclusion: Systematic Review
41. Gülmezoglu, 2004, Bio Med Central - Medical Research Methodology WHO systematic review of maternal mortality and morbidity: methodological issues and
challenges
Reason for exclusion: Systematic review
42. Mavalankar, 2008 Working Paper, Indian Institute of Management The Changing Role of Auxiliary Nurse Midwife (ANM) in India: Implications for Maternal
and Child Health (MCH)
Reason for exclusion: Review Article.
43. Gupta, 2009, Working Paper, Indian Institute of Management A Study of Referral System for EmOC in Gujarat
Reason for exclusion: Review paper on existing delivery referral system in Gujarat
44. Vora, 2009 Journal of Health Population and Nutrition, April;27(2):184-201 Maternal Health Situation in India: A Case Study
Reason for exclusion: Review Article.
45. Acharya, 2000, Health Policy and Planning
Maternal and child health services in rural Nepal: does access or quality matter more?
Reason for exclusion: Review Article.
46. Annigeri, 2004, Poptech An assessment of Public Private Partnership opportunities in India
Reason for exclusion: Review Article.
47. Portela, 2003, British Medical Bulletin Empowerment of women, men, families and communities: true partners for improving
maternal and newborn health
Reason for exclusion: Review Article
48. Sibley, 2003, NGO network for health, at a glance Building Community Partnerships for Safer Motherhood: Home Based Life Saving Skills
Reason for exclusion: Review Article.
49. Paul, 2004, BMJ Health systems and the community: Community participation holds the key to health gains
Reason for exclusion: Review Article.
50. Nair,2010, PLoS Medicine
Population Foundation of India Annexure Page 19
Improving Newborn Survival in Low-Income Countries: Community based Approaches and
Lessons from South Asia
Reason for exclusion: Review Article.
51. Canavan, 2009, KIT Working Papers Series, Review of global literature on maternal health interventions and outcomes related to provision
of skilled birth attendance
Reason for exclusion: Systematic Review
52. Krasovec, 2004, International Journal of Gynaecology and Obstetrics Auxiliary technologies related to transport and communication for obstetric emergencies
Reason for exclusion: Review article
53. UNICEF, 2004, United Nations Children’s Fund, Working Paper Surviving child birth and pregnancy in South Asia
Reason for exclusion: Review article
Excluded for falling outside the geographical coverage
54. Mpembeni, 2007, BMC Pregnancy and Childbirth
Use pattern of maternal health services and determinants of skilled care during delivery in
Southern Tanzania: implications for achievement of MDG-5 targets Reason for exclusion: Study location - Southern Tanzania.
55. Shefner, 2004, Journal of Health Communication Involving Husbands in Safe Motherhood: Effects of the SUAMI SIAGA Campaign in
Indonesia
Reason for exclusion: Study location – Indonesia.
56. Pembe, 2010, Uppsala University, Sweden unpublished dissertation thesis Quality assessment and monitoring of maternal referrals in Rural Tanzania
Reason for exclusion: Study location – Rural Tanzania.
57. Lewycka, 2010,Trials A cluster randomised controlled trial of the community effectiveness of two interventions in
rural Malawi to improve health care and to reduce maternal, newborn and infant mortality
Reason for exclusion: Study location - Malawi.
58. Both, 2006, BMC Pregnancy and Childbirth How much time do health services spend on antenatal care? Implications for the introduction
of the focused antenatal care model in Tanzania
Reason for exclusion: Study location - Tanzania.
59. Birungi, 2006, Frontiers in Reproductive Health Program Acceptability and Sustainability of the WHO Focused Antenatal Care package in Kenya
Reason for exclusion: Study location - Kenya.
60. Mutiso, 2008 East African Medical Journal Birth preparedness among antenatal clients Reason for exclusion: Study location - Kenya.
61. Magoma, 2010, BMC Pregnancy and Childbirth High ANC coverage and low skilled attendance in a rural Tanzanian district: a case for
implementing a birth plan intervention
Population Foundation of India Annexure Page 20
Reason for exclusion: Study location - Tanzania.
62. Pembe, 2010, BMC Pregnancy and Childbirth Quality of antenatal care in rural Tanzania: counselling on pregnancy danger signs
Reason for exclusion: Study location - Tanzania.
63. Hounton, 2008, Tropical Medicine and International Health Effects of a Skilled Care Initiative on pregnancy-related mortality in rural Burkina Faso
Reason for exclusion: Study location - Burkina Faso.
64. Andemichael, 2010, Journal of Eritrean Medical Association JEMA Maternity waiting homes: A panacea for maternal/neonatal conundrums in Eritrea
Reason for exclusion: Study location - Eriteria.
65. Horeman, 2008, Studies in Health Services Organisation & Policy Improving access to safe delivery for poor pregnant women: a case study of vouchers plus
health equity funds in three health districts in Cambodia
Reason for exclusion: Study location - Cambodia.
66. Hiluf, 2008, Ethiopian, Journal of Health and Development Birth preparedness and complication readiness among the women in Adigrtah town, North
Ethiopia
Reason for exclusion: Study location - North Ethiopia.
67. Anya, 2008, BMC Pregnancy and Childbirth Antenatal care in The Gambia: Missed opportunity for information, education and
communication
Reason for exclusion: Study location - Gambia.
68. Moran, 2006, Journal of Health Population and Nutrition Birth-Preparedness for Maternal Health: Findings from Koupéla District, Burkina Faso
Reason for exclusion: Study location - Burkina Faso.
Excluded for being manuals / guidelines / policy briefs around BP/CR
69. Family Care International/ The Skilled Care Initiative, 2000, Facilitator’s guidelines Birth Preparedness: An Essential Part of ANC Counselling:
70. JHPIEGO/Maternal and Neonatal Health Program, 2004, Manual Monitoring birth preparedness and complication readiness: Tools and indicators for maternal
and newborn health
71. JHPIEGO/The Access Programme, 2005, Policy Brief
Household to Hospital continuum of maternal and new born care
72. World Health Organization/Integrated Management of Pregnancy and Child Birth, (IMPAC), 2006, Guidelines. Birth and emergency preparedness in antenatal care