The Lancet



The Lancet, Volume 375, Issue 9721, Pages 1142 - 1144, 3 April 2010



Original Text


Zulfiqar A Bhutta a, Zohra S Lassi a


Maternal and child deaths represent two of the most resilient targets among the Millennium Development Goals (MDGs).1 At current trends, a large proportion of the high-burden countries will be unable to meet reduction targets by 2015.2 Achieving the MDG 4 target of reducing newborn and child mortality will require concerted efforts to scale up evidence-based interventions, especially community-based preventive and therapeutic strategies in primary care.3 To improve maternal survival, we need to scale up facility-based services,4 as well as availability of commodities and health workers in primary care.5 A major challenge is the appropriate mix of strategies for demand creation as well as provision of services.


In The Lancet today, investigators led by Anthony Costello present contrasting findings from two large studies of community-based women's support groups in rural Bangladesh6 and in two rural areas in India (Jharkhand and Orissa),7 and their effects on maternal and newborn health outcomes. The intervention did not have much effect in rural Bangladesh, where only 2% coverage of newly pregnant women being enrolled into the women's groups was achieved, which raises the question of ineffective implementation of this intervention. By contrast, in Jharkhand and Orissa, the intervention was more successful, with 55% of all pregnant women joining women's support groups by year 3 of the study and a 32% reduction in neonatal mortality rate. The latter finding is consistent with the finding of reduced neonatal mortality (adjusted odds ratio 070, 95% CI 053094) previously observed in rural Nepal.8 The investigators from today's studies have also evaluated the role of community-support groups in rural Malawi,9 although final results of the trial are not yet available.


Several contextual factors must be underscored to understand these diverse results. Unlike the situation in rural Bangladesh, most villages in rural Jharkhand and Orissa had a lower proportion of births in the hands of birth attendants, and cluster allocation took pre-existing local committees into account. Other factors confounding the interpretation of these analyses include the post-hoc exclusion of certain population segments, such as tea-garden residents, and the assumption that training birth attendants in neonatal resuscitation could not plausibly affect neonatal outcomes. A recent large multicounty study10 of training birth attendants in basic resuscitation was associated with a statistically significant reduction in stillbirths, although these were probably misclassified as very early neonatal deaths.


Several other large-scale trials in south Asia have also evaluated the role of community support and advocacy groups in combination with the delivery of domiciliary preventive and therapeutic care through community health workers.1113 Although the precise mechanisms of effect and direction of effect through such interventions are unclear, there seems to be an effect on family awareness, domiciliary care practices (such as the use of clean delivery kits), breastfeeding practices, and care-seeking for newborn illnesses. We did a pooled analysis of all recent randomised trials in which community-support groups and group-advocacy sessions that targeted women were used as part of the intervention. As is evident, these strategies are associated with significant reduction in neonatal mortality rate and a range of benefits on domiciliary practices, such as early initiation of breastfeeding and a fairly strong suggestion that care seeking for illness improved (figure). There might also be benefits of such interventions on female empowerment and family relationships, but these outcomes are difficult to objectively evaluate in such settings.


Although the benefits of community-support strategies on neonatal outcomes are well established,3 benefits on maternal morbidity and mortality are less clear. None of the recent studies of community strategies were powered for maternal mortality outcomes but at least one8 indicated benefits. Today's Jharkhand and Orissa trial also indicates the same direction of effect and suggests that such women's groups also promote maternal uptake of antenatal care and care-seeking for effective care during childbirth and complications. In a trial in Hala, Pakistan,12 which used community mobilisation through group sessions as well as domiciliary visits by community health workers, significantly increased rates of skilled birth attendance and facility-based care were observed during the pilot phase,12 as well as in the scaled-up effectiveness trial.

These recent studies greatly add to the global evidence base of intervention and delivery strategies that might improve maternal and newborn outcomes. Although improved maternal emergency obstetric care and health-system interventions to improve access and quality of care remain crucial to improving maternal survival,14 future strategies to improve maternal and newborn survival need to integrate community-based strategies and facility-based care. The deployment of women's groups or community-support groups through trained community health workers offers a cost-effective mechanism for reaching populations at risk and linking appropriate domiciliary and care-seeking practices. These strategies also offer a unique opportunity to move beyond survival. As the evidence from Jharkhand and Orissa and rural Pakistan14 indicates, such interventions also have great potential to improve maternal mental health outcomes, reduce rates of postnatal depression, and improve household practices for maternal and newborn care.


We declare that we have no conflicts of interest.


1 UN Secretary-General. The Millennium Development Goals Report 2009. http://www.unhcr.org/refworld/docid/4a534f722.html. (accessed Feb 21, 2010).

2 Countdown Coverage Writing Group. Countdown to 2015 for maternal, newborn, and child survival: the 2008 report on tracking coverage of interventions. Lancet 2008; 371: 1247-1258. Summary | Full Text | PDF(488KB) | CrossRef | PubMed

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5 Pagel C, Lewycka S, Colbourn T, et al. Estimation of potential effects of improved community-based drug provision, to augment health-facility strengthening, on maternal mortality due to post-partum haemorrhage and sepsis in sub-Saharan Africa: an equity-effectiveness model. Lancet 2009; 374: 1441-1448. Summary | Full Text | PDF(183KB) | CrossRef | PubMed

6 Azad K, Barnett S, Banerjee B, et al. Effect of scaling up women's groups on birth outcomes in three rural districts in Bangladesh: a cluster-randomised controlled trial. Lancet 2010; 375: 1193-1202. Summary | Full Text | PDF(276KB) | PubMed

7 Tripathy P, Nair N, Barnett S, et al. Effect of a participatory intervention with women's groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster-randomised controlled trial. Lancet 2010; 375: 1182-1192. Summary | Full Text | PDF(914KB) | PubMed

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9 Rosato M, Mwansambo CW, Kazembe PN, et al. Women's groups' perceptions of maternal health issues in rural Malawi. Lancet 2006; 368: 1180-1188. Summary | Full Text | PDF(169KB) | CrossRef | PubMed

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13 Baqui AH, El-Arifeen S, Darmstadt GL, et alfor the Projahnmo Study Group. Effect of community-based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: a cluster-randomised controlled trial. Lancet 2008; 371: 1936-1944. Summary | Full Text | PDF(307KB) | CrossRef | PubMed

14 Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet 2008; 372: 902-909. Summary | Full Text | PDF(146KB) | CrossRef | PubMed

a Women and Child Health Division, Aga Khan University, Karachi 74800, Pakistan

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