Reducing maternal and neonatal mortality in the poorest communities
http://www.100md.com
《英国医生杂志》
1 International Perinatal Care Unit, Institute of Child Health, University College London, London WC1N 1EH, 2 Mother Infant Research Activities (MIRA), GPO Box 921, Kathmandu, Nepal
Correspondence to: A Costello ipu@ich.ucl.ac.uk
Current programmes are often failing to reach those at highest risk of maternal and neonatal death. The international community needs to learn from community trials in the South
Introduction
Epidemiology has been criticised for concentrating on biomedical rather than social issues, and researchers have been encouraged to tackle the political aspects of public health through community based participatory research.8 Such research is an example of transfer of knowledge from South to North. The philosophy, politics, and praxis of community engagement is at the core of work conducted over the past 50 years by such catalytic figures as Gandhi, Freire, and Chambers. Why not dignify this approach with best practice public health research? Evidence is growing for use of community based interventions to reduce maternal and neonatal mortality, as we describe below.
Interventions based on community participation
Our cluster randomised controlled trial of a community based intervention in Nepal shows the potential of this approach.6 In each intervention cluster, one woman facilitator convened nine, monthly women's group meetings. She supported the groups through an action learning cycle in which they identified local perinatal problems and formulated strategies to overcome them. Women in intervention clusters had more antenatal care, institutional delivery, trained birth attendance, and hygienic care. This social intervention harnessed the creativity, self interest, and self organising activities of poor women, and seems to have had results unpredicted by linear biological models.6
Communities often show an overwhelming preference to seek care locally.w9 Safer motherhood and newborn care programmes must tackle the resulting delays in seeking care—for example, recognition of a problem at home, a decision to seek care, getting transport to a health facility. As well as improving hygiene practices at home, the Nepal intervention probably shortened delays through better awareness of warning signs, less dependence on traditional remedies, and the development of stretcher schemes and funds to allow transport of sick mothers and newborns to health facilities.
Family planning
The importance of family planning in reducing maternal mortality is uncontroversial. As many as 50% of pregnancies are unplanned and 25% are unwanted, and complications of unsafe abortion are responsible for a substantial proportion of deaths.w10 The existing demand for family planning services could reduce maternal deaths in developing countries by 20% or more. Bangladesh, which achieved great success in expanding family planning uptake and reducing fertility rates, reduced maternal mortality from 850/100 000 in 1990 to 380/100 000 in 2000, even though, in 2002, only 12% deliveries had a skilled attendant.w8
Treatment of perinatal sepsis
Semmelweis convincingly showed the contribution of puerperal sepsis to maternal mortality in 1846. Attention to hygiene greatly decreased maternal mortality, but cleanliness in childbirth remained poor in the industrialised world well into the 20th century. Detailed analysis of the fall in maternal mortality in the United Kingdom in the middle of the last century showed that 40% of the reduction followed treatment of infection rather than sophisticated obstetric care; maternal mortality from sepsis fell from 203/100 000 in 1931, when sulphonamides became available, to 58/100 000 just nine years later.9 A recent meta-analysis of community based treatment of acute respiratory infections underlines the potential for reducing neonatal mortality,10 and the results of our Nepal trial seem to reflect prevention or early treatment of sepsis.6
Management of postpartum haemorrhage
Because postpartum haemorrhage can kill within two hours, an effective community based intervention could prevent many of the 140 000 annual deaths.w2 In 1996, it was suggested that misoprostol (a prostaglandin E1 analogue) might be a suitable treatment as it is inexpensive, orally administered, and does not require refrigeration.w11 By 2001, WHO had reported a hospital based trial of misoprostol versus oxytocin. The authors concluded that oxytocin was preferable for clinical use, but the study did not examine whether misoprostol could reduce haemorrhagic death outside hospital in high risk populations.11 Despite numerous clinical evaluations showing misoprostol's safety and effectiveness,w12 no trial has examined this, and a low cost drug that could be carried by community health workers is little used. The failure to evaluate misoprostol properly is a serious omission in international public health. Pharmaceutical and international politics may have played a part, given its use to induce abortion.
Collaboration with traditional birth attendants
Speculation about the cost and effectiveness of programmes to train traditional birth attendants has led to their widespread abandonment, despite an absence of trial evidence.w13 Absence of evidence of effect is not evidence of absence of effect. A recent meta-analysis of 60 studies showed that training traditional birth attendants was associated with significant improvements in performance and mortality.12 Concerns about the cost effectiveness of training traditional birth attendants are legitimate in settings where their coverage or workload is low. Nevertheless, they are often key providers of support and opinion in their communities. We believe that in countries where maternal mortality is high and use of traditional birth attendants common, programmes should collaborate with them to promote reproductive health and hygiene, avoid delays in seeking care for complications, and perhaps to help with vital surveillance.
Need for large scale community public health trials
Haines A, Cassels A. Can the millennium development goals be attained? BMJ 2004;329: 394-7.
Maine D, Rosenfield A. The Safe Motherhood initiative: why has it stalled? Am J Public Health 1999;89: 480-2.
Maine D, Rosenfield A. The AMDD program: history, focus and structure. Int J Gynecol Obstet 2001;74: 99-103.
Committee on Improving Birth Outcomes, Board on Global Health. Improving birth outcomes. Meeting the challenge in the developing world. Washington, DC: National Academies Press, 2003.
Bang A, Bang R, Baitule S, Reddy M, Deshmukh M. Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lancet 1999;354: 1955-61.
Manandhar D, Osrin D, Shrestha B, Mesko N, Morrison J, Tumbahangphe K, et al. The effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster randomized controlled trial. Lancet 2004;364: 970-9.
Koblinsky M, Campbell O, Heichelheim J. Organising delivery care: what works for safe motherhood? Bull WHO 1999;77: 399-406.
Shy C. The failure of academic epidemiology: witness for the prosecution. Am J Epidemiol 1997;145: 479-84.
Tew M. Safer childbirth? A critical history of maternity care. London: Chapman and Hall, 1990.
Sazawal S, Black R, Pneumonia Case Management Trials Group. Effect of pneumonia case management on mortality in neonates, infants, and pre-school children: a meta-analysis of community-based trials. Lancet Infect Dis 2003;3: 547-56.
Gulmezoglu A, Villar J, Ngoc N, Piaggio G, Carroli G, Adetoro L, et al. WHO multicentre randomised trial of misoprostol in the management of the third stage of labour. Lancet 2001;358: 689-95.
Sibley L, Sipe T. What can a meta-analysis tell us about traditional birth attendant training and pregnancy outcomes? Midwifery 2004;20: 51-60.
West K, Katz J, Khatry S, LeClerq S, Pradhan E, Shrestha S, et al. Double blind, cluster randomised trial of low dose supplementation with vitamin A or beta carotene on mortality related to pregnancy in Nepal. BMJ 1999;318: 570-5.(Anthony Costello, directo)
Correspondence to: A Costello ipu@ich.ucl.ac.uk
Current programmes are often failing to reach those at highest risk of maternal and neonatal death. The international community needs to learn from community trials in the South
Introduction
Epidemiology has been criticised for concentrating on biomedical rather than social issues, and researchers have been encouraged to tackle the political aspects of public health through community based participatory research.8 Such research is an example of transfer of knowledge from South to North. The philosophy, politics, and praxis of community engagement is at the core of work conducted over the past 50 years by such catalytic figures as Gandhi, Freire, and Chambers. Why not dignify this approach with best practice public health research? Evidence is growing for use of community based interventions to reduce maternal and neonatal mortality, as we describe below.
Interventions based on community participation
Our cluster randomised controlled trial of a community based intervention in Nepal shows the potential of this approach.6 In each intervention cluster, one woman facilitator convened nine, monthly women's group meetings. She supported the groups through an action learning cycle in which they identified local perinatal problems and formulated strategies to overcome them. Women in intervention clusters had more antenatal care, institutional delivery, trained birth attendance, and hygienic care. This social intervention harnessed the creativity, self interest, and self organising activities of poor women, and seems to have had results unpredicted by linear biological models.6
Communities often show an overwhelming preference to seek care locally.w9 Safer motherhood and newborn care programmes must tackle the resulting delays in seeking care—for example, recognition of a problem at home, a decision to seek care, getting transport to a health facility. As well as improving hygiene practices at home, the Nepal intervention probably shortened delays through better awareness of warning signs, less dependence on traditional remedies, and the development of stretcher schemes and funds to allow transport of sick mothers and newborns to health facilities.
Family planning
The importance of family planning in reducing maternal mortality is uncontroversial. As many as 50% of pregnancies are unplanned and 25% are unwanted, and complications of unsafe abortion are responsible for a substantial proportion of deaths.w10 The existing demand for family planning services could reduce maternal deaths in developing countries by 20% or more. Bangladesh, which achieved great success in expanding family planning uptake and reducing fertility rates, reduced maternal mortality from 850/100 000 in 1990 to 380/100 000 in 2000, even though, in 2002, only 12% deliveries had a skilled attendant.w8
Treatment of perinatal sepsis
Semmelweis convincingly showed the contribution of puerperal sepsis to maternal mortality in 1846. Attention to hygiene greatly decreased maternal mortality, but cleanliness in childbirth remained poor in the industrialised world well into the 20th century. Detailed analysis of the fall in maternal mortality in the United Kingdom in the middle of the last century showed that 40% of the reduction followed treatment of infection rather than sophisticated obstetric care; maternal mortality from sepsis fell from 203/100 000 in 1931, when sulphonamides became available, to 58/100 000 just nine years later.9 A recent meta-analysis of community based treatment of acute respiratory infections underlines the potential for reducing neonatal mortality,10 and the results of our Nepal trial seem to reflect prevention or early treatment of sepsis.6
Management of postpartum haemorrhage
Because postpartum haemorrhage can kill within two hours, an effective community based intervention could prevent many of the 140 000 annual deaths.w2 In 1996, it was suggested that misoprostol (a prostaglandin E1 analogue) might be a suitable treatment as it is inexpensive, orally administered, and does not require refrigeration.w11 By 2001, WHO had reported a hospital based trial of misoprostol versus oxytocin. The authors concluded that oxytocin was preferable for clinical use, but the study did not examine whether misoprostol could reduce haemorrhagic death outside hospital in high risk populations.11 Despite numerous clinical evaluations showing misoprostol's safety and effectiveness,w12 no trial has examined this, and a low cost drug that could be carried by community health workers is little used. The failure to evaluate misoprostol properly is a serious omission in international public health. Pharmaceutical and international politics may have played a part, given its use to induce abortion.
Collaboration with traditional birth attendants
Speculation about the cost and effectiveness of programmes to train traditional birth attendants has led to their widespread abandonment, despite an absence of trial evidence.w13 Absence of evidence of effect is not evidence of absence of effect. A recent meta-analysis of 60 studies showed that training traditional birth attendants was associated with significant improvements in performance and mortality.12 Concerns about the cost effectiveness of training traditional birth attendants are legitimate in settings where their coverage or workload is low. Nevertheless, they are often key providers of support and opinion in their communities. We believe that in countries where maternal mortality is high and use of traditional birth attendants common, programmes should collaborate with them to promote reproductive health and hygiene, avoid delays in seeking care for complications, and perhaps to help with vital surveillance.
Need for large scale community public health trials
Haines A, Cassels A. Can the millennium development goals be attained? BMJ 2004;329: 394-7.
Maine D, Rosenfield A. The Safe Motherhood initiative: why has it stalled? Am J Public Health 1999;89: 480-2.
Maine D, Rosenfield A. The AMDD program: history, focus and structure. Int J Gynecol Obstet 2001;74: 99-103.
Committee on Improving Birth Outcomes, Board on Global Health. Improving birth outcomes. Meeting the challenge in the developing world. Washington, DC: National Academies Press, 2003.
Bang A, Bang R, Baitule S, Reddy M, Deshmukh M. Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lancet 1999;354: 1955-61.
Manandhar D, Osrin D, Shrestha B, Mesko N, Morrison J, Tumbahangphe K, et al. The effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster randomized controlled trial. Lancet 2004;364: 970-9.
Koblinsky M, Campbell O, Heichelheim J. Organising delivery care: what works for safe motherhood? Bull WHO 1999;77: 399-406.
Shy C. The failure of academic epidemiology: witness for the prosecution. Am J Epidemiol 1997;145: 479-84.
Tew M. Safer childbirth? A critical history of maternity care. London: Chapman and Hall, 1990.
Sazawal S, Black R, Pneumonia Case Management Trials Group. Effect of pneumonia case management on mortality in neonates, infants, and pre-school children: a meta-analysis of community-based trials. Lancet Infect Dis 2003;3: 547-56.
Gulmezoglu A, Villar J, Ngoc N, Piaggio G, Carroli G, Adetoro L, et al. WHO multicentre randomised trial of misoprostol in the management of the third stage of labour. Lancet 2001;358: 689-95.
Sibley L, Sipe T. What can a meta-analysis tell us about traditional birth attendant training and pregnancy outcomes? Midwifery 2004;20: 51-60.
West K, Katz J, Khatry S, LeClerq S, Pradhan E, Shrestha S, et al. Double blind, cluster randomised trial of low dose supplementation with vitamin A or beta carotene on mortality related to pregnancy in Nepal. BMJ 1999;318: 570-5.(Anthony Costello, directo)