Can we reduce maternal mortality with community-based interventions?
Every 90 seconds one woman dies in pregnancy or childbirth, with rural women living in resource-poor countries particularly vulnerable. Poor, rural women are the least likely to have access to family planning and the most likely to deliver without a skilled birth attendant. In countries with high maternal mortality, access to quality and affordable medical care is in short supply, thus leaving most of the women to rely on the help of existing community members such as traditional birth attendants (TBAs), health extension workers (HEWs), community-based reproductive health agents (CBRHAs), rural chemical sellers, and others. What is the best approach to reaching these vulnerable women? Community-based interventions.
Community-based interventions are those interventions that can be implemented at home, via community health posts(extension of health clinics in rural communities), or delivered by the lowest level cadre of the health care system including HEWs or equivalent, drug sellers/ keepers, TBAs, CBRHAs, or any other outreach community health worker (CHW).
In poor countries, the direct causes of maternal mortality are concentrated in 3 major areas: postpartum hemorrhage, unsafe abortion, and eclampsia. There are powerful examples of community-based interventions reaching rural woman and reducing their risk of maternal mortality by addressing these causes. In 2003 and 2004 in Kigoma, Tanzania, the Bixby Center and its partners demonstrated that trained TBAs could safely and effectively diagnose postpartum hemorrhage and treat it with misoprostol. In Tigrai, Ethiopia, Bixby research showed that CBRHAs, a group of community volunteers distributing condoms and pills, could be trained to provide injectable contraceptives, expanding family planning access for rural women.
Other community based interventions are also possible. For example, early pregnancy termination and treatment of uncomplicated incomplete abortion can be provided at the community level using HEWs and CHWs. To increase the chances of survival of women with eclampsia and severe pre-eclampsia, a loading dose of mangnesium sulphate can be administered at the community level by a HEW or CHW with remarkable results. In addition, the availability of the non-pneumatic anti shock garment in communities could further ensure that postpartum hemorrhage deaths are curtailed.
It is possible to reduce maternal mortality with community interventions, but it will entail shifts in strategies and policies. Successful community-based interventions require demedicalization and task shifting to empower local health workers, and a focus on interventions that maximize existing health infrastructure and human capacity. We must be pragmatic prioritizing feasible and scalable interventions that address the greatest burden of maternal health. By designing interventions that can reach marginalized populations in places where care by skilled providers will continue to be a long term goal we can ensure the survival of the women and their babies who are often not reached by health facility services.
References and further reading:
Shamsuddin L, Nahar K, Nasrin B, Nahar S, Tamanna S, Kabir RM, Alis MJ, Anwary SA. (2005). Use of parenteral magnesium sulphate in eclampsia and severe pre-eclampsia cases in a rural set up of Bangladesh.Bangladesh Med Res Counc Bull. 2005 Aug;31(2):75-82.
Stanback, J; Mbonye, AK; Bekiita, M. Contraceptive injections by community health workers in Uganda: a nonrandomized community trial. Bulletin of the world health organization (85) 768-773, 2007.