Projahnmo I Sub-study: Maternal Behaviors and Morbidity during Pregnancy, Delivery, and the Early Postpartum Period in Rural Bangladesh

This 36-page report details a study nested in a project entitled "Projahnmo: Community-Based Interventions to Reduce Neonatal Mortality in Bangladesh". The United Stages Agency for International Development (USAID) and the Saving Newborn Lives Initiative (SNL) of Save the Children-US (through a grant from the Bill and Melinda Gates Foundation) embarked on this communication-based investigative research in response to the following observation: In Bangladesh, almost all births take place at home without assistance from medically trained providers - even though women's perceived complications and morbidity are high. The study area consisted of a population of 480,000 in 3 rural sub-districts (Beanibazar, Zakiganj, and Kanaighat) of Sylhet district, which has the highest rates of neonatal mortality (63 per 1,000 births) and maternal mortality ratio (471 per 100,000 live births) in Bangladesh.

In order to foster behaviour change, Projahnmo drew largely on interpersonal communication (IPC) in or near the household level, with an emphasis on involving the entire range of decision-makers in the lives of pregnant women. The interventions included behaviour change communication (BCC) to improve maternal knowledge and practices, promotion of services focusing on birth and newborn care preparedness (BNCP), safe and clean delivery, essential newborn care, and management of serious neonatal illness. For example, community mobilisers (CMs) work with women's and men's groups in the community to encourage and educate them on appropriate home care techniques for both mother and newborn, the need for a birth and newborn preparedness plan for every expectant mother, and their rights as a community to adequate health care.

The study was comprised of 3 arms: home care (HC), community care (CC), and comparison (the latter received existing care from government and non-governmental organisation (NGO) health workers and facilities). While the content of the intervention was virtually the same in both the HC and CC arms, in the HC arm, the group-based meetings described above were supplemented by one-on-one counselling with pregnant women and their families. Resident literate women were trained as community health workers (CHWs). During the visits in pregnancy, CHWs emphasised BCC messages, encouraged women to seek antenatal care at the health centre or satellite clinic, and negotiated maternal and newborn care practices with the family. During the postpartum visits, the CHWs assessed the health of mother and baby and encourage use of postpartum care.

Researchers conducted semi-structured interviews with women who had given birth 6-12 months prior as well as several surveys in an effort to provide descriptive information on self-reported maternal morbidities and care-seeking behaviours among the following 3 groups: women with perceived complications/morbidities, women who received life-saving surgery, and women who died from a maternal cause. Their secondary objective was to measure the effect of the intervention package described above by comparing differences on maternal behaviours as well as selected maternal morbidities (anaemia).

The following excerpts illustrate some of the key results and lessons learned from the experience:

"Objective I: Perceptions of morbidity and "care seeking"
...In our study, care seeking inside the home was prevalent. Home-based treatments included spiritual water and/or oil, homeopathic medicines, and allopathic medicines provided by an untrained pharmacist or a medically trained doctor....From the perspective of study participants, there are several advantages to home-based care. First, families have the ability to control costs of treatment....Further, families have control over the type of treatment provided. Some women preferred homeopathic treatments...

These findings have important implications for safe motherhood programs. First, safe motherhood programs work under the assumption that recognition of "serious" complications will prompt care seeking from basic or comprehensive obstetric care facilities....The concept of "care seeking" often has been defined in narrow terms in maternal health, with "care" denoting services provided by professionals with appropriate life-saving skills, and "seeking" denoting transfer of the woman from the home to a health facility. Local definitions of care seeking can differ considerably from definitions used by programs, making it difficult both to plan interventions to promote care seeking, and to accurately measure the impact of these interventions. These definitions need to be incorporated in the design of household surveys to track progress toward achieving the MDG for maternal mortality, and taken into account in the design of interventions to promote care seeking.

Objective II: Maternal behaviors and morbidity across study arms
The results indicate that the Projahnmo intervention was effective at reaching women in the HC and CC arms, with 97% and 46% of women respectively reporting at least one contact with a community worker. Although care seeking from medically trained providers for perceived complications did not differ significantly across study arms, there was an effect of the intervention on knowledge of danger signs, using a clean delivery kit, and taking iron during pregnancy. Anemia rates did not differ significantly between HC and comparison arms, but there was a significant difference between the CC and comparison group.

Although three-quarters of women reported preparing for birth in the HC arm and half of women reported preparing for birth in the CC and comparison arms, few women mentioned specific birth preparedness actions taken....Moreover, birth preparedness actions require complex behaviors. Unlike knowledge of danger signs, using a clean delivery kit, and taking iron/folate during pregnancy which are within the control of the woman, birth preparedness behaviors involve input and approval of the woman's family. In Bangladesh, where women have limited decision-making power and mobility outside the household..., these types of behaviors may require more intensive interventions at the family and community levels...

In the literature, there is much debate on the usefulness of community-based interventions to improve maternal morbidity and mortality. These interventions are effective at decreasing neonatal mortality, but evidence is less clear for maternal outcomes....In this study, the community-based interventions had little effect on primary maternal outcomes, but did have some effect on intermediate outcomes. This may have been the result of the emphasis of the project which was to decrease neonatal mortality. Program messages focused on newborn resuscitation, community-based administration of antibiotics, and referring sick newborns to facilities, and messages on maternal health may have been diluted, especially given the workloads of the CMs and CHWs..."