systematic review of birth preparedness and complication readiness interventions

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


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


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.


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).


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.


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.


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).


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


• 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


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.


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.


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.


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.


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


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


• 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.


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


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.


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


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


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


“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


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.


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


only in intervention

Not Apparent

Duration of exposure to the


NA

Darmstadt

2010

Not Apparent

Randomization was achieved and

groups were similar in socio-

economic characteristics.

Not apparent



Not Apparent

Duration of exposure to


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


Not Apparent Duration of exposure to the


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


study area.

Not Apparent Duration of exposure to


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


study area.

Apparent

Baseline and post intervention

survey tools were different. This

affected the analysis on

secondary outcomes.

Duration of exposure to


NA


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).


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


− 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


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.


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


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.


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.


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.


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


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


AND danger signs


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


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"


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.


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)


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.


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.


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.


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


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


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


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.


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).


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


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)


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


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)



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


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


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


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.


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.


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


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


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


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


35. Paxton, 2005, International Journal of Gynaecology and Obstetrics The evidence for emergency obstetric care


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?


38. Gogia, 2010, Bulletin of the World Health Organization


Home visits by community health workers to prevent neonatal deaths in developing countries:

a 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?


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


41. Gülmezoglu, 2004, Bio Med Central - Medical Research Methodology WHO systematic review of maternal mortality and morbidity: methodological issues and

challenges


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


45. Acharya, 2000, Health Policy and Planning

Maternal and child health services in rural Nepal: does access or quality matter more?


46. Annigeri, 2004, Poptech An assessment of Public Private Partnership opportunities in India


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


49. Paul, 2004, BMJ Health systems and the community: Community participation holds the key to health gains


50. Nair,2010, PLoS Medicine


Improving Newborn Survival in Low-Income Countries: Community based Approaches and

Lessons from South Asia


51. Canavan, 2009, KIT Working Papers Series, Review of global literature on maternal health interventions and outcomes related to provision

of skilled birth attendance


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



62. Pembe, 2010, BMC Pregnancy and Childbirth Quality of antenatal care in rural Tanzania: counselling on pregnancy danger signs


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

systematic review of birth preparedness and complication readiness interventions

Documents