UCL DEPARTMENT OF GEOGRAPHY UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Improving maternal & newborn health outcomes among tribal communities in Eastern India: THE EKJUT TRIAL ekjut
Mar 26, 2015
UCL DEPARTMENT OF GEOGRAPHYUCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
Improving maternal & newborn health outcomes among tribal communities in Eastern India:
THE EKJUT TRIAL
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
BACKGROUND
METHODS
RESULTS
DISCUSSION
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
BACKGROUND
METHODS
RESULTS
DISCUSSION
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
Community mobilisation through women’s groupscan improve maternal and newborn health outcomesat low cost
Makwanpur trial, Nepal:
30% reduction in neonatal mortality
80 % reduction in maternal mortality Manandhar et al. Lancet 2004
UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
Is this approach scaleable & replicable?
Four randomised controlled trials:
• Rural Malawi• Mumbai, India• Jharkhand & Orissa, India - the Ekjut trial• Bangladesh (three rural districts)
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Ekjut trial study areas
Jharkhand & Orissa - eastern India
(combined population ~ 66 million)
Tribal people (adivasi) ~ around a quarter of the population in both states
Jharkhand: poorest state in India at its creation in 2000
Around 40% of population in both states live below the poverty line.
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
Maternal & newborn health indicators (2006)
JHARKHAND ORISSA INDIA
Neonatal Mortality Rate (per 1000 livebirths)
49 45 39
Maternal Mortality Ratio (per 100,000 livebirths)
471 458 407
JHARKHAND ORISSA INDIA
Antenatal Care (%) 38 50.7
Institutional delivery (%) 19 41
(DLHS -3 & NFHS - 3)
4836
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
Tribal communities: worse socio-economic / health indicators compared with non-indigenous people.
NMR and MMR considerably worse than in general population.
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
Baseline survey findings in the study areas
• NMR: 58 per 1000 live births• MMR: 557 per 100,000 live births
• 40% of women did not have any ANC • 15% had 4+ ANC visits• 85% of deliveries took place at home
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
TRIAL OBJECTIVES & OUTCOMES
To measure the impact of working through women’s groups on maternal health, newborn health, and maternal depression through a cluster randomised controlled trial.
- 35% in neonatal mortality rate
- 55% in maternal mortality ratio
- 50% in maternal depression
+ improved home care practices & care-seeking
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
Study design
36 clusters (~ 6300 population) in 3 districts
randomised to intervention & control arms
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18 CONTROL
CLUSTERS
Women’s groups ’
36 CLUSTERS
Health Service Strengthening
18 INTERVENTION
CLUSTERSWomen’s groups ++
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INCLUSION CRITERIA & TIMELINE
• All women of reproductive age (15-49)
• Residing in the project area• Who gave birth between 31st July 2005 – 30th July 2008 • Who gave consent for involvement in the project
• Timeline:
Baseline survey Year 1 Year 2 Year 3
Nov 04- Jul 05 Jul 05- Jul 06 Jul 06- Jul 07 Jul 07- Jul 08
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
Monitoring births & deaths
Select one key informant per 25O households
Pay informant incentive to identify births &deaths to women of reproductive age
Interviewer visits informant monthly to collect list of identifications
Interviewer verifies identifications and pays informant
Interviewer interviews once at six weeks after delivery
Women who are interviewed are ‘ snowballed ’ for other identifications
Interviewer collects identifications from government records every month
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
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EXISTING GROUPS = 203 EKJUT WOMEN’S GROUPS =244
CONTROL CLUSTERS INTERVENTION CLUSTERS
WOMEN’S GROUP CYCLE
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The women’s group participatory cycle
PHASE 1Identify and
Prioritise Problems
PHASE 2Plan
Strategies
PHASE 3Put strategies Into practice
PHASE 4Assess impact
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Visit Community
IntroduceProject
Explore Current
Practices
Identify MaternalProblems
Identify NewbornProblems
Prioritise Problems
PHASE 1Identify And Prioritise Problems
PHASE 2Plan Strategies
PHASE 3Put Strategies Into Practice
PHASE 4Assess Impact
Discuss Causes
& Solutions
Barriers &Strategies
Prioritise Strategies
Choose Process For
Sharing
Prepare & Practice
COMMUNITY MEETING
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
BACKGROUND
METHODS
RESULTS
DISCUSSION
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18829 Pregnancies* 23 Died during pregnancy
due to maternal causes
18806 Deliveries
19030 Births
581 Stillbirths 18449 Live births
937 Died within 28 days Early NND = 635 Late NND = 302
17511 Alive at one month
55 Died during labour / childbirth
due to maternal causes
31 Died after childbirth (42 days-1 yr)
due to maternal causes
* System designed to identify births and deaths not pregnancies - 01/09
EKJUT TRIAL
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
Intervention Clusters
Control Clusters
Adjusted
odds ratios
(95% CI)
Births
Livebirths
9770
9469
9260
8980-
Stillbirths
Neonatal deaths
Maternal deaths
301
406
49
280
531
60
-
Stillbirth rate (per 1000 livebirths)
Neonatal mortality rate (per 1000 livebirths)
Maternal mortality ratio(per 100,000 livebirths)
30.7
43
517.9
30.2
59
668.2
1.06 (0.86 - 1.30)
0.69 (0.59 - 0.81)
0.775
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
Reduction in newborn mortality
Intervention Clusters
Control Clusters
Adjusted
odds ratios
(95% CI)
Neonatal deaths
In years 2 & 3
Neonatal deaths
In Year 3
259
109
390
188
0.58 (0.48 - 0.71)
0.54 (0.42 - 0.70)
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
Early Neonatal Mortality Rate in Intervention and Control Areas
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
Late Neonatal Mortality Rate in Intervention and Control Areas
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
Perinatal Mortality Rate in Intervention and Control Areas
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
Maternal Mortality Ratio in Intervention and Control Areas
Intervention Control All
Baseline 680 321.8 608
Year 1 651.9 1012.1 828.9
Year 2 669.5 593.3 632.9
Year 3 224.7 402.5 311.7
Y1,2 &3 517.5 668.2 590.8
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
In her 8th month of pregnancy Rajani Juang and her mother-in-law attended a women’s group meeting where she participated in a drill based on “what to do in case of postpartum bleeding”.
After a month when she delivered at home and had severe bleeding, her mother-in-law remembered the meeting and without wasting time asked Rajani to breast feed her baby, while she rushed to get money from the group and asked her son to get a vehicle.
She was immediately taken to the district hospital, where she was given medicines, IV fluid, two pints of blood, and was discharged after fifteen days.
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Ref Case study no.25
Case study - a maternal death avoided
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Maternal depression in intervention & control clusters
At Year 3 (using K10 scale):
OR (95% CI) p
Moderate depression 0.40 (0.17- 0.93) 0.034
High / Severe depression 0.68 (0.09 - 4.95) 0.708
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
Improved home Care Practices
Median (%) Intervention Control p
Birth attendants washed hands
44.5 18.3 0.01
Used safe delivery kit 29.3 18.7 0.008
Used plastic sheet 26.6 7.1 <0.001
Boiled thread 29.8 10.8 0.04
Infant exclusively breastfed for first 6 weeks
79.4 70.7 0.04
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
Service utilisation
Median (%) Intervention Control p
Any care in pregnancy 83.1 82.1 0.974
4 + ANC 18.7 22.7 0.194
Institutional delivery 13 14.2 0.154
Any postpartum care 15 15.7 0.506
Mother had check-up
in 1st 6 weeks
6.2 7.8 0.194
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
BACKGROUND
METHODS
RESULTS
DISCUSSION
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
Mechanisms for change ?
• High population coverage (1 group per 460 pop)• Quality of intervention delivery • Targeting the most marginalised • High proportion of pregnant women in groups
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Targeting the most marginalised: adivasis
District %
in district
% in clusters
% in meeting 1
% in
meeting 25
Saraikela - Karshwan
36 58 68 67
Keonjhar 48 69 73 77
West Singhbum
55 70 82 85
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Men, adolescents and elderly women
Tribal, Marginalized & Underserved communities
Where health services
are inaccessible
Families living in hamlets, inaccessible, remote, hilly regions
Mechanisms: targeting
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Belief that together they can bring about change
Involvement of men, adolescents and elderly women
Increase in family support during pregnancy, delivery and postpartum
period
Process indicators: intervention quality
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Community Women’s Group
PREGNANT WOMEN IN GROUPS - YEAR 1
Pregnant women
Other women
17.5 %
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Community Women’s GroupPregnant women
Other women
17.5% 38.4%
PREGNANT WOMEN IN GROUPS - YEAR 2
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Community Women’s GroupPregnant women
Other women
17.5% 38.4% 55 %
PREGNANT WOMEN IN GROUPS - YEAR 3
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
“We could not do much as individuals but as a group we could find a way to solve each other’s problems”.
“It was easy to understand the causes and effects of maternal and newborn problems through picture card stories”.
“The involvement of both women and men in choosing strategies was very encouraging”.
“We are proud that to some extent we have helped in changing the behaviour of our group members and others who do not attend the meetings”.
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Feedback from group members
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Summary
• 42% reduction in newborn mortality (Y2&3)• 60% reduction in moderate depression in Y3• Improved home care practices
• NMR reduction is higher than in Makwanpur trial• Ekjut is working towards scale-up in 3 more districts
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UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
STUDY COLLABORATION:
EKJUT
Dr Prasanta Tripathy & Dr Nirmala Nair
Suchitra Rath
Shibanand Rath
Raj Kumar Gope
Rajendra Mahapatra
Deepnath Mahto
CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT (UCL)
Prof Anthony Costello
Dr Sarah Barnett
Dr Audrey Prost
Funded by: THE HEALTH FOUNDATION (UK) & BIG LOTTERY FUND (UK) ekjutekjut
UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT
UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT