Reducing Maternal, Newborn and Child Deaths in the Asia Pacific: Strategies that Work

Published by World Vision and The Nossal Institute for Global Health, this 32-page report explores strategies that have been proven to be effective in reducing maternal, newborn, and child deaths as part of the effort to meet Millennium Development Goals (MDGs) 4 and 5 by 2015. This investigation was motivated by figures cited here indicating that 18 of the 29 developing countries in the Asia-Pacific region are currently off track to achieve Goal 4 (reduce child deaths by two-thirds) and 23 are off track to achieve Goal 5 (reduce maternal deaths by three-quarters).

The first portion of the document presents evidence that low-income countries could indeed substantially reduce the number of maternal, newborn, and child deaths by implementing a limited number of cost-effective interventions at specific points in time. A key theme characterising successful maternal, neonatal, and child health (MNCH) interventions is provision of a continuum of care during the period before and during pregnancy, through birth and the neonatal stage, and then through early childhood (up to 5 years of age). Other directives include developing systematic approaches to planning and monitoring, training and retaining sufficient health staff to provide effective services at the community and district level, reducing inequalities, and actively engaging communities in programmes. The Countdown to 2015 group identifies the critical evidence-based components to an effective continuum of care for mothers; these are summarised in Table 2 (Tables 3 and 4 share similar models for neonatal and child health, respectively). The authors estimate that universal implementation of all of the evidence-based care packages detailed here could prevent approximately 370,000 of the 500,000 maternal deaths each year, approximately 2.4 million of the 4 million neonatal deaths each year, and 4 million of the 6 million post-neonatal child deaths each year.

The authors stress that this type of progress requires not just effective clinical strategies, but approaches which also take account of the local situation and which local people accept. This, they stress, cannot be achieved without the active engagement of civil society. Other key components are better integration of vertical programme funding, the expansion of health systems, and stronger health information and reporting systems. To illustrate these points in a concrete way, the document next presents 8 case studies of low-cost projects that have resulted in improvements in MNCH in the Asia-Pacific region. Each study delineates the "target group", problem, approach, results, sustainability, cost, and main lessons/features of success. The projects detailed are summarised here, with a focus on the communication-related aspects of the treatment approach in each case, and a brief presentation of selected results:

1. Myanmar Nutritional Anaemia Initiative Project - Activities included: development of key anaemia prevention and control messages; social mobilisation activities which included meetings with local stakeholders and decision makers and training sessions for health workers, teachers, and volunteers based on the information found in the baseline survey; and development and distribution of information, education and communication (IEC) materials on nutritional foods, iron supplements, and other health practices, as well as promotional activities such as calendars for each household, posters, street banners, announcements for start of supplement taking, school and community competitions, cooking demonstrations, cartoons, bags, and T shirts for mobilisers. A year after the start of the project, anaemia prevalence declined substantially in the treatment areas (from 60.8% to 42.1%). The evaluators also reported "a big change in people's attitudes".
2. Participatory women's birthing groups - Makwanpur district, Nepal - In each of 12 village development committees (VDCs), a local female facilitator was recruited who convened local women's group meetings on a monthly basis over 10 months. The facilitators received training on perinatal health services following a training session and manual. Information was conveyed using picture card games and other methods that addressed prevention and treatment in maternal and child health (MCH), and a locally made film was screened to raise awareness. Treatment areas experienced significantly lower maternal and neonatal maternity rates compared to the control areas, with 30% lower neonatal mortality and 80% lower maternal mortality.
3. Northeast Cambodia Child Survival Program, Kratie Province - Village Health Volunteers (VHVs), which included traditional birth attendants (TBAs) and their supervisors from health centres, were trained to be the main promoters of change. The programme focused on breastfeeding promotion, immunisation, nutrition and micro-nutrition, and management of diarrhoeal diseases, and was delivered during visits to households and group health education meetings. Participatory methods used to select VHVs in Chhlong district meant those chosen were already key community leaders, which lent credibility to the behaviour change messages communicated throughout the project. Feedback from the VHVs was also used to improve services. The end-line evaluation found substantial improvements across most indicators.
4. Pragati Child Survival Project - Uttar Pradesh, India - The project used "timed counselling" to encourage the use of effective family planning and MNCH approaches and services using the "continuum of care" model. Project volunteers (who were skilled and knowledgeable providers) delivered the messages/counselling sessions through home visits. Mothers' use of contraception, vitamin A supplementation, and timely initiation of semisolid foods to children improved during the project period. The project also achieved modest success in increasing coverage of pregnant women with tetanus toxoid and reducing drop-out among children between the first and third doses of diphtheria, whooping cough, and tetanus vaccines. There were also improvements in overall child immunisation coverage in 2 of the 3 areas.
5. Chiranjeevi Scheme - Gujarat, India - The scheme allowed eligible families (those below the poverty line in 5 of the most remote districts with the highest maternal mortality) to access private doctors during pregnancy and delivery without the need for cash, and covered all direct and indirect costs of accessing facility-based care. Institutional deliveries increased from 38% at baseline to 59% during the pilot. Around 80% of the deliveries of below-poverty-line women were covered under the scheme, and 94% of those who benefited from the scheme earned less than US$1 a day. Eighty-two percent of beneficiaries indicated that they had been informed about the scheme through community health workers. This suggests that community health workers can be effectively used to build health promoting behaviour and as an effective link with health facilities.
6. Improving neonatal care at Goroka Base Hospital - Papua New Guinea - The changes were based on international evidence of effective neonatal interventions and on the use of appropriate strategies and technology within this particular setting. It was not a vertical programme dependent on external funding but was integrated into the existing infrastructure and health system. It was not a single intervention but a package of interventions. A review indicated that neonatal mortality was 41% lower during the intervention period, with 82 neonatal deaths avoided during the post-intervention period.
7. Sayaboury Primary Health Care Project, Sayaboury Province - Lao PDR - Dispensary staff make quarterly visits to each village to supervise village health volunteers (VHVs) and traditional birth attendants (TBAs) and to collect record forms. For zones without dispensaries, district mobile teams make 6-monthly visits to each village to: screen educational videos; provide clinical services, antenatal care, growth monitoring and family planning; and offer on-the-job training and supervision to TBAs and VHVs. Ninety-four percent of the population in Sayaboury is now within 5 kms of a fixed health facility, and there has been district-level training in the Integrated Management of Childhood Illnesses (IMCI) approach down to the dispensary level. Purpose-built MNCH centres at district hospitals have led to a large increase in births attended by a trained health worker. The placement of female health staff at dispensaries has improved MNCH service utilisation rates. Trained VHVs and TBAs have been placed in virtually every village, which has led to a large decrease in cases of neonatal tetanus and improved health behaviours, especially infant feeding.
8. Rebuilding hospital services for children in the Solomon Islands - Paediatricians from the Solomon Islands expressed interest in a plan to rebuild and improve the quality of child health services, so they engaged in an assessment and planning process that led the Ministry of Health (MoH) to: revise and reintroduce standard treatment and hospital guidelines; introduce training courses to enable a more systematic approach to childhood illnesses; and introduce a national system to report on child mortality. In 2007 the Solomon Islands' first national Child Health Summit met to discuss the Child Health Plan and mechanisms for scaling up across all provinces. At the summit, healthcare staff from national and provincial levels discussed technical components, reviewed availability of technical resources, developed a strategy for resource allocation and training, and established a system for monitoring and data collection.