DOI: http://dx.doi.org/10.18203/2394-6040.ijcmph20195040

Evaluation of a maternal, neonatal and child health intervention package in a rural district of Pakistan: a quasi-experimental study

Muhammad Atif Habib, Kirsten I. Black, Camille Raynes Greenow, Mushtaq Mirani, Sajid Muhammad, Fariha Shaheen, Monika Christofori Khadka, Annette Vondeling, Shabina Ariff, Sajid Bashir Soofi

Abstract


Background: Pakistan is among the countries which have the highest maternal, neonatal and child mortality rates. Immediate efforts are required to enable Pakistan to achieve the health related sustainable development goals. The continuum of care interventions can substantially reduce the mortality burden, however local evidence to implement them is lacking in Pakistan. We implemented the maternal, neonatal and child health intervention package comprised of health facility strengthening, capacity building, continuum of care interventions and community mobilization and evaluated its effectiveness on maternal, neonatal and child health care practices and neonatal mortality.

Methods: The intervention package was delivered through existing public health system in a rural district of Pakistan. We used a quasi-experimental design to assess the impact of interventions. Baseline and end line surveys were conducted and neonatal mortality was considered as the primary outcome measure. Data were analysed using bivariate and difference and difference analysis techniques.

Results: We found a reduced risk of neonatal mortality (RR 0.704; 95% CI 0.557-0.889; p=0.0033), in intervention areas compared to control area. For secondary outcomes; including mortality for infants and under five children, antenatal care, skilled birth attendance, institutional deliveries, postnatal care, delayed bathing, inappropriate cord care practices, birth asphyxia, exclusive breastfeeding and immunization a significant difference (p<0.001) was observed in the intervention area compared to control area.

Conclusions: This study provides local evidence from Pakistan that effective methods for delivering MNCH interventions within the existing health infrastructure can improve the MNCH outcomes especially in the rural areas.


Keywords


Maternal, Neonatal and child health, Intervention package, Quasi experimental study, Rural Pakistan

Full Text:

PDF

References


World Health Organization. Trends in maternal mortality: 1990 to 2015. Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. 2015. Available at http://apps.who.int/iris/bitstream/ 10665/194254/1/9789241565141_eng.pdf. Accessed on 3 July 2019.

Bhutta ZA, Hafeez A, Rizvi A, Ali N, Khan A, Ahmad F, et al. Reproductive, maternal, newborn, and child health in Pakistan: challenges and opportunities. The Lancet. 2013;381(9884):2207-18.

National Institute of Population Studies (NIPS) [Pakistan] and ICF. 2018. Pakistan Demographic and Health Survey 2017-18. Islamabad, Pakistan, and Rockville, Maryland, USA: NIPS and ICF. Available at https://www.nips.org.pk/abstract_ files/PDHS%20-%202017-18%20Key%20indicator %20Report%20Aug%202018.pdf. Accessed on 3 July 2019.

Requejo JH, Bryce J, Barros AJ, Berman P, Bhutta Z, Chopra M, et al. Countdown to 2015 and beyond: fulfilling the health agenda for women and children. The Lancet. 2015;385(9966):466-76.

Soofi SB, Ariff S, Khan U, Turab A, Khan GN, Habib A, et al. Diagnostic accuracy of WHO verbal autopsy tool for ascertaining causes of neonatal deaths in the urban setting of Pakistan: a hospital-based prospective study. BMC Pediatrics. 2015;15(1):1.

World Health Organization. WHO recommended interventions for improving maternal and newborn health: integrated management of pregnancy and childbirth. Available at http://apps.who.int/iris/ bitstream/10665/69509/1/WHO_MPS_07.05_eng.pdf. Accessed on 3 July 2019.

Regional Health Systems Observatory- WHO EMRO. Health Systems Profile- Pakistan 2007. Available at http://apps.who.int/medicinedocs/ documents/s17305e/s17305e.pdf. Accessed on 8 July 2019.

Word Health Organization. Pakistan’s lady health worker programme 2007. Available at http://www.who.int/workforcealliance/knowledge/case_studies/CS_Pakistan_web_en.pdf. Accessed on 12 July 2019.

Mumtaz Z, Levay A, Bhatti A, Salway S. Good on paper: the gap between programme theory and real world context in Pakistan’s Community Midwife programme. Br J Obstet Gynaecol. 2015;122(2):249.

Lassi ZS, Haider BA, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Systematic Review. 2010;11:CD007754.

Lassi ZS, Middleton PF, Crowther C, Bhutta ZA. Interventions to improve neonatal health and later survival: an overview of systematic reviews. EBioMedicine. 2015;2(8):985-1000.

Gülmezoglu AM, Lawrie TA, Hezelgrave N, Oladapo OT, Souza JP, Gielen M, et al. Interventions to Reduce Maternal and Newborn Morbidity and Mortality. Reproductive, Maternal, Newborn, and Child Health. 2016:115.

Jokhio AH, Winter HR, Cheng KK. An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan. New England J Med. 2005;352(20):2091-9.

Midhet F, Becker S. Impact of community-based interventions on maternal and neonatal health indicators: Results from a community randomized trial in rural Balochistan, Pakistan. Reproductive Health. 2010;7(1):1.

Bhutta ZA, Soofi S, Cousens S, Mohammad S, Memon ZA, Ali I, et al. Improvement of perinatal and newborn care in rural Pakistan through community-based strategies: a cluster-randomised effectiveness trial. The Lancet. 2011;377(9763):403-12.

Memon ZA, Khan GN, Soofi SB, Baig IY, Bhutta ZA. Impact of a community-based perinatal and newborn preventive care package on perinatal and neonatal mortality in a remote mountainous district in Northern Pakistan. BMC Pregnancy Childbirth. 2015;15(1):1.

Bhutta ZA, Hafeez A. What can Pakistan do to address maternal and child health over the next decade? Health Res Policy Systems. 2015;13(1):S49.

World Bank. 2014. 2011 Pakistan floods: preliminary damage and needs assessment. Washington DC; World Bank Group. Available at: http://documents.worldbank.org/curated/en/655781468058769881/2011-Pakistan-floods-preliminary-damage-and-needs-assessment. Accessed on 12 August 2019.

World Health Organization. Priority life saving medicines for women and children. 2012. Available at http://apps.who.int/iris/bitstream/10665/75154/1/ WHO_EMP_MAR_2012.1_eng.pdf. Accessed on 3 August 2019.

Upvall MJ, Sochael S, Gonsalves A. Behind the mud walls: The role and practice of lady health visitors in Pakistan. Health Care Women Int. 2002;23(5):432-41.

Word Health Organization. Maternal, newborn, child and adolescent health, Documents on training. Available at: http://www.who.int/maternal_child_ adolescent/documents/training/en/. Accessed on 3 August 2019.

Masud T, Navaratne KV. The Expanded Program on Immunization in Pakistan: Recommendations for Improving Performance. Health, Nutrition and Population (HNP) discussion paper. 2012. World Bank, Washington, DC. Available at: https://openknowledge.worldbank.org/handle/10986/13579. Accessed on 3 August 2019.

IBM Corp. Released 2010. IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp.

Lechner M. The estimation of causal effects by difference-in-difference methods. Foundations and Trends in Econometrics. 2011;4(3):165-224.

Yeji F, Shibanuma A, Oduro A, Debpuur C, Kikuchi K, Owusu-Agei S, et al. Continuum of care in a maternal, newborn and child health program in Ghana: Low completion rate and multiple obstacle factors. PloS one. 2015;10(12):e0142849.

Owili PO, Muga MA, Chou YJ, Hsu YH, Huang N, Chien LY. Associations in the continuum of care for maternal, newborn and child health: a population-based study of 12 sub-Saharan Africa countries. BMC Public Health. 2016;16(1):1.

Das JK, Lassi ZS, Salam RA, Bhutta ZA: Effect of community based interventions on childhood diarrhea and pneumonia: uptake of treatment modalities and impact on mortality. BMC Public Health. 2013;13(Suppl 3):S29.

Sayem AM, Nury AT, Hossain MD. Achieving the millennium development goal for under-five mortality in Bangladesh: current status and lessons for issues and challenges for further improvements. J Health Population Nutr. 2011:92-102.

World Health Organization: Antenatal Care in Developing Countries: Promises, Achievements and Missed Opportunities. Geneva; 2003.

Mrisho M, Obrist B, Schellenberg JA, Haws RA, Mushi AK, Mshinda H, et al. The use of antenatal and postnatal care: perspectives and experiences of women and health care providers in rural southern Tanzania. BMC Pregnancy Childbirth. 2009;9:10.

Tuladhar H, Dhakal N: Impact of antenatal care on maternal and perinatal outcome: a study at nepal medical college teaching hospital. Nepal J Obstetr Gynaecol. 2011;6(2):37-43.

Swider SM. Outcome effectiveness of community health workers: an integrative literature review. Public Health Nursing. 2002;19(1):11-20.

Nemcek MA, Sabatier R. State of evaluation: community health workers. Public Health Nursing. 2003;20(4):260-70.

Bhutta ZA, Lassi ZS, Pariyo G, Huicho L. Global experience of community health workers for delivery of health related millennium development goals: a systematic review, country case studies, and recommendations for integration into national health systems. Global Health Workforce Alliance. 2010;1:249-61.

Stover J, Ross J. How increased contraceptive use has reduced maternal mortality. Maternal Child Health J. 2010;14(5):687-95.

Ahmed S, Li Q, Liu L, Tsui AO. Maternal deaths averted by contraceptive use: an analysis of 172 countries. The Lancet. 2012;380(9837):111-25.

Tsui AO, Creanga A. Does contraceptive use reduce neonatal and infant mortality? Findings from a multi-country analysis. InAnnual Meeting of the Population Association of America, Detroit, Michigan, April 2009. Available at http://paa2009. princeton.edu/papers/91181. Accessed on 3 July 2019.

Government of Pakistan: Projected trends in CPR 2020. Available at http://www.familyplanning2020. org/entities/97. Accessed on 30 July 2019.

Lassi ZS, Mallick D, Das JK, Mal L, Salam RA, Bhutta ZA. Essential interventions for child health. Reproductive health. 2014;11(1):1.

Imdad A, Yakoob MY, Bhutta Z. Effect of breastfeeding promotion interventions on breastfeeding rates, with special focus on developing countries. BMC Public Health 2011;11(3):24.