Evidence from community level inputs to improve quality of care for maternal and newborn health: interventions and findings

Annually around 40 million mothers give birth at home without any trained health worker [1]. Consequently, most of the maternal, perinatal and neonatal morbidities and mortalities occur at the community level due to lack of good quality care during labour and birth. The poorest and fragile countries have the highest neonatal mortality rates and preventable deaths depicting the existing inequities[1, 2]. The causes are multi-factorial, ranging from socio-economic aspects of poverty; poor health status of women; lack of autonomy and decision making authority; and illiteracy to health system related factors like poor antenatal and obstetric care; absence of trained birth attendant; inadequate referral system; lack of transportation facilities; and poor linkages between health centers and communities [1, 3]. This burden could be averted by achieving universal coverage in skilled birth attendance and providing good quality care for all births. However due to paucity of trained human resource professionals in first-level health services and the reduced awareness of and accessibility to services for the deprived and marginalized populations, these are not accessible to the ones in need [1, 4].

Community based delivery is now widely recognized as an important strategy to deliver key maternal and child survival interventions [5‐10]. It has been instrumental in scaling up coverage of certain interventions, such as immunization, oral rehydration therapy for diarrhea, tuberculosis treatment and family planning initiatives. Interventions delivered at the community level have not only been advocated to improve access and coverage of essential interventions but also to reduce the existing disparities and reaching the hard to reach. Inputs at the community level involve programs based on training and consequent task shifting from healthcare personnel to mid-level health care personnel or lay individuals for local implementation at home, village or any defined community group. They focus on resources such as local knowledge, volunteers’ time, community confidence and trust as channels for delivery. Community platforms can be used to deliver a full spectrum of promotive, preventive, and curative interventions including provision of basic antenatal (ANC), natal and postnatal care (PNC); preventive essential newborn care; breastfeeding counseling; management and referral of sick newborns; skills development in behavior change communication; and community mobilization strategies to promote birth and newborn care preparedness. These programs do not substitute for a formal health system, but provide a channel to reach far flung areas with knowledge, commodities and skills, thus attempting to reduce existing inequities in healthcare access and utilization. In this paper, we have reviewed the effectiveness of care delivered through community level inputs for improving maternal newborn health (MNH) outcomes. For this review, we have broadly categorized these interventions into four categories: outreach services (including home visitation and referrals); task shifting; training; and formation of support groups for community mobilization.

We considered all available systematic reviews published before May 2013 on the pre-defined community level interventions as outlined in our conceptual framework [27]. A separate search strategy was developed for each component using broad keywords, medical subject heading (MeSH), and free text terms: [(Community OR home OR “home visit*” OR outreach OR “task shift*” OR “human resource” OR “in-service” OR training OR mobilization OR “support group*”OR “women’s group” OR “health worker*” OR “community health aides” OR “primary health care” OR “community health worker*” OR “lay health worker*” OR “mid-level health worker*” OR “community based interventions”) AND (health OR maternal OR mother OR child OR newborn OR neonat*)]

Our priority was to select existing systematic reviews of randomized or non-randomized controlled trials, which fully or partly address the a priori defined community delivered interventions for improving quality of care for MNH. We excluded reviews on home visits for prevention or screening for child abuse, maltreatment and childhood injury prevention as these were not included in the scope of our review. Search was conducted in the Cochrane library and PubMed and reviews that met the inclusion criteria were selected and data was abstracted by two authors on a standardized abstraction sheet. Quality assessment of the included reviews was done using Assessment of Multiple Systematic Reviews (AMSTAR) criteria [28] as detailed in paper 1 [27]. Any disagreement between the primary abstractors was resolved by the third author. For the pre-identified interventions, which did not specifically report MNH outcomes, we have reported the impacts on other health outcomes reported by the review authors. Estimates are reported as relative risks (RR), odds ratios (OR), risk differences (RD) or mean differences (MD) with 95% confidence intervals (CI) where available. For detailed methodology please refer to paper 1 of the series [27].

Our search yielded 310 potentially relevant review titles. Further screening of abstracts and full texts resulted in the inclusion of 43 eligible reviews: 17 for outreach services (home visitation and referrals), 6 for task shifting, 18 for human resource training and 2 for community mobilization (Figure 2). The overall quality of the reviews ranged from 3 to 11 with a median of 9 on the AMSTAR criteria.

There is a greater body of existing evidence on the effectiveness of community based inputs for improving MNH outcomes in LMIC compared to district and facility level inputs (discussed in papers 3 and 4) [68, 69]. At community level, home visitation, community mobilization, women’s support groups and training of the CHW and TBA have shown maximum impact on a range of MNH outcomes. Community based generation of funds for transportation has also shown significant impacts in resource limited settings of India and sub-Saharan Africa. Interventions delivered through midwives, CHW and MLHW have not only demonstrated comparable outcomes when compared to routine non-MLHW care delivery but also reported better results for some of the outcomes. Specialized outreach clinics, continuing medical education, problem based learning, clinical practice guideline implementation and critical appraisal showed inconclusive and mixed results.

Although the process pathways for the effectiveness of community delivered interventions are uncertain, they seem to influence community awareness, behavior change and practices, such as accessing skilled birth, use of clean delivery kits, breastfeeding and care seeking for maternal and newborn illnesses. Our overview findings greatly add to the global evidence base of intervention and delivery strategies that may improve MNH outcomes. It implies that within the community level inputs, three interventions have unparalleled significance: first, CHW who provide primary health care, can mobilize community members and impart knowledge; second, training of and linkages to TBA can provide basic prenatal and obstetric care, as well as referrals where skilled birth attendants are absent; third, community support groups, especially women’s groups, can empower communities and help in problem solving and planning to improve opportunities for women’s health, as well as care for mothers and newborns.

Countries in Asia and sub-Saharan Africa are facing critical shortages of healthcare workers despite of bearing 25% of the world’s diseases burden [20]. Reasons behind the migration of professional healthcare force to richer countries is suggested to be lack of incentive, poor working conditions and fewer opportunities for promotions [70]. There is also an existing pull from HIC to recruit health workers from LMIC. Given the shortage of care providers and functional health facilities, and the deeply entrenched practices, there is much interest in community-based interventions and strategies for care. Increasing the number of skilled health workers, training and educating them, providing them with incentives and improving the infrastructure is what needs to be done in all the LMIC to make progress towards achieving the Millennium Development Goals (MDG) 4 and 5.The findings from this overview testifies that increasing the availability and training of the skilled health workers including TBA and CHW for adequately recognizing and managing obstetric complications can significantly reduce maternal and neonatal morbidity and mortality especially in the resource limited settings of Asia and Africa where the highest maternal mortality burden exists with limited resources to mobilize. The challenge is to incentivize these programs and link them with formal health systems to increase retention. In many countries CHW are not linked to national health systems and are expected to work as volunteers which is a major drawback. Another existing challenge is the variation in prerequisites, recruitment, training, supervision and workload of various cadres of community workers including CHW, TBA and midwives. There is a need to streamline their functioning and delegate the activities to achieve efficient implementation and maximum impact.

With the established effectiveness of task shifting and training of CHW, future studies should focus on the factors affecting the sustainability and cost effectiveness of these interventions when scaled up [46]. There is a dearth of information on costs and equity aspects of community based programs as only a few studies have reported the actual costs incurred for saving lives or averting deaths with the use of these strategies. Researchers should now facilitate cost-effectiveness studies and consequent meta-analysis by collecting and reporting cost effectiveness data in a standardized format [39]. Further work is also needed on nurse- based care delivery models including length and frequency of contact, type of approach (e.g. individual or group, behavioral therapy or instructional techniques), level of training of practitioner, patient satisfaction and initial characteristics of patients to establish equivalence in care with the physician- based model and also for program replication [50]. Formal monitoring and evaluation of programs especially referral interventions are also necessary to develop better understanding of how referral interventions work. There is lack of data to establish effectiveness of mass media campaigns and community education as single strategies.

Outreach services may confer the most benefit to access and health outcomes in rural and underprivileged settings hence there is a need for good comparative studies in resource deprived settings rather than in HIC [33]. Among the outreach workers in the LMIC, the role of TBA is pivotal as they remain a major maternity care provider and their services expand from birth attendance to include newborn and post natal care like bathing and massage, domestic chores, and provision of care during postnatal period. Despite of that, TBA training remains controversial in relation to the global 'Safe Motherhood Initiative' as there is insufficient data to provide the evidence base needed to establish training effectiveness [23]. Hence methodologically rigorous evaluations with an adequate sample size are needed to measure the magnitude of the impact of TBA training on maternal and neonatal mortality.

Community based interventions have promising potential to provide range of services throughout the continuum of care and also reach the hard to reach population groups. Current evidence emphasizes that effective community based strategies exist to deliver a range of preventive and promotive interventions to improve the quality of care delivered for MNH and many of these interventions have the potential to reduce maternal, perinatal and neonatal morbidity and mortality. There is now a need to implement them on a larger scale throughout the LMIC. These interventions exist within the current health systems in most of the LMIC and hence policies are needed to integrate and sustain various task shifting and training interventions with the maternal health programs within their health systems. All stakeholders including governments, communities and donors need to work together to form these policies and develop models of health care to suit the needs of their own population. Still more work needs to be done in areas of recruitment, deployment and retention of the community based health care workers in the rural and underprivileged areas and improve the working conditions for them.

All authors contributed to the process and writing of the manuscript.

Peer review reports are included in Additional file 1.