Behaviour change in perinatal care practices among rural women exposed to a women's group intervention in Nepal [ISRCTN31137309]

BACKGROUND: A randomised controlled trial of participatory women's groups in rural Nepal previously showed reductions in maternal and newborn mortality. In addition to the outcome data we also collected previously unreported information from the subgroup of women who had been pregnant prior to study commencement and conceived during the trial period. To determine the mechanisms via which the intervention worked we here examine the changes in perinatal care of these women. In particular we use the information to study factors affecting positive behaviour change in pregnancy, childbirth and newborn care. METHODS: Women's groups focusing on perinatal care were introduced into 12 of 24 study clusters (average cluster population 7000). A total of 5400 women of reproductive age enrolled in the trial had previously been pregnant and conceived during the trial period. For each of four outcomes (attendance at antenatal care; use of a boiled blade to cut the cord; appropriate dressing of the cord; not discarding colostrum) each of these women was classified as BETTER, GOOD, BAD or WORSE to describe whether and how she changed her pre-trial practice. Multilevel multinomial models were used to identify women most responsive to intervention. RESULTS: Among those not initially following good practice, women in intervention areas were significantly more likely to do so later for all four outcomes (OR 1.92 to 3.13). Within intervention clusters, women who attended groups were more likely to show a positive change than non-group members with regard to antenatal care utilisation and not discarding colostrum, but non-group members also benefited. CONCLUSION: Women's groups promoted significant behaviour change for perinatal care amongst women not previously following good practice. Positive changes attributable to intervention were not restricted to specific demographic subgroups

Cause-specific neonatal mortality: analysis of 3772 neonatal deaths in Nepal, Bangladesh, Malawi and India.

OBJECTIVE: Understanding the causes of death is key to tackling the burden of three million annual neonatal deaths. Resource-poor settings lack effective vital registration systems for births, deaths and causes of death. We set out to describe cause-specific neonatal mortality in rural areas of Malawi, Bangladesh, Nepal and rural and urban India using verbal autopsy (VA) data. DESIGN: We prospectively recorded births, neonatal deaths and stillbirths in seven population surveillance sites. VAs were carried out to ascertain cause of death. We applied descriptive epidemiological techniques and the InterVA method to characterise the burden, timing and causes of neonatal mortality at each site. RESULTS: Analysis included 3772 neonatal deaths and 3256 stillbirths. Between 63% and 82% of neonatal deaths occurred in the first week of life, and males were more likely to die than females. Prematurity, birth asphyxia and infections accounted for most neonatal deaths, but important subnational and regional differences were observed. More than one-third of deaths in urban India were attributed to asphyxia, making it the leading cause of death in this setting. CONCLUSIONS: Population-based VA methods can fill information gaps on the burden and causes of neonatal mortality in resource-poor and data-poor settings. Local data should be used to inform and monitor the implementation of interventions to improve newborn health. High rates of home births demand a particular focus on community interventions to improve hygienic delivery and essential newborn care

Community mobilisation and health management committee strengthening to increase birth attendance by trained health workers in rural Makwanpur, Nepal: study protocol for a cluster randomised controlled trial

Background: Birth attendance by trained health workers is low in rural Nepal. Local participation in improving health services and increased interaction between health systems and communities may stimulate demand for health services. Significant increases in birth attendance by trained health workers may be affected through community mobilisation by local women's groups and health management committee strengthening. We will test the effect of community mobilisation through women's groups, and health management committee strengthening, on institutional deliveries and home deliveries attended by trained health workers in Makwanpur District. Design: Cluster randomised controlled trial involving 43 village development committee clusters. 21 clusters will receive the intervention and 22 clusters will serve as control areas. In intervention areas, Female Community Health Volunteers are supported in convening monthly women's groups. The groups work through an action research cycle in which they consider barriers to institutional delivery, plan and implement strategies to address these barriers with their communities, and evaluate their progress. Health management committees participate in three-day workshops that use appreciative inquiry methods to explore and plan ways to improve maternal and newborn health services. Follow-up meetings are conducted every three months to review progress. Primary outcomes are institutional deliveries and home deliveries conducted by trained health workers. Secondary outcome measures include uptake of antenatal and postnatal care, neonatal mortality and stillbirth rates, and maternal morbidity

Who are dying and why? A case series study of maternal deaths in Nepal

Objectives To identify delays and associated factors for maternal deaths in Nepal.Design A cross-sectional case series study of maternal deaths. An integrated verbal and social autopsy tool was used to collect quantitative and qualitative information regarding three delays. We recorded death accounts and conducted social autopsy by means of community Focus Group Discussions for each maternal death; and analysed data by framework analysis.Setting Sixty-two maternal deaths in six districts in three provinces of Nepal.Results Nearly half of the deceased women (45.2%) were primiparous and one-third had no formal education. About 40% were from Terai/Madhesi and 30.6% from lower caste. The most common place of death was private hospitals (41.9%), followed by public hospitals (29.1%). Nearly three-fourth cases were referred to higher health facilities and median time (IQR) of stay at the lower health facility was 120 (60–180) hours. Nearly half of deaths (43.5%) were attributable to more than one delay while first and third delay each contributed equally (25.8%). Lack of perceived need; perceived cost and low status; traditional beliefs and practices; physically inaccessible facilities and lack of service readiness and quality care were important factors in maternal deaths.Conclusions The first and third delays were the equal contributors of maternal deaths. Interventions related to birth preparedness, economic support and family planning need to be focused on poor and marginalised communities. Community management of quick transportation, early diagnosis of pregnancy risks, accommodation facilities near the referral hospitals and dedicated skilled manpower with adequate medicines, equipment and blood supplies in referral hospitals are needed for further reduction of maternal deaths in Nepal

Utilization and management of maternal and child health funds in rural Nepal.

Maternal and neonatal mortality rates are highest in the poorest countries, and financial barriers impede access to health care. Community loan funds can increase access to cash in rural areas, thereby reducing delays in care seeking. As part of a participatory intervention in rural Nepal, community women's groups initiated and managed local funds. We explore the factors affecting utilization and management of these funds and the role of the funds in the success of the women's group intervention. We conducted a qualitative study using focus group discussions, group interviews and unstructured observations. Funds may increase access to care for members of trusted 'insider' families adjudged as able to repay loans. Sustainability and sufficiency of funds was a concern but funds increased women's independence and enabled timely care seeking. Conversely, the perceived necessity to contribute may have deterred poorer women. While funds were integral to group success and increased women's autonomy, they may not be the most effective way of supporting the poorest, as the risk pool is too small to allow for repayment default