A Controlled Before-and-After Perspective on the Improving Maternal, Neonatal, and Child Survival Program in Rural Bangladesh: An Impact Analysis

Interventions addressing routine childhood immunization and its behavioral and social drivers

Introduction

Despite the advances in vaccination, there are still several challenges in reaching millions of children in low- and middle-income countries (LMICs). In this review, we present an extensive summary of the various strategies used for improving routine immunization in LMICs to aid program implementers in designing vaccination interventions.

Methods

Experimental and quasi-experimental impact evaluations conducted in LMICs evaluating the effectiveness of interventions in improving routine immunization of children aged 0-5 years or the intermediate outcomes were included from 3ie's review of systematic reviews. Some additional impact evaluation studies published in recent years in select LMICs with large number of unvaccinated children were also included. Studies were coded to identify interventions and the barriers in the study context using the intervention framework developed in 3ie's Evidence Gap Map and the WHO's Behavioral and Social Drivers (BeSD) of vaccination framework, respectively. Qualitative analysis of the content was conducted to analyze the intervention strategies and the vaccination barriers that they addressed.

Results and conclusion

One hundred and forty-two impact evaluations were included to summarize the interventions. To address attitudinal and knowledge related barriers to vaccination and to motivate caregivers, sensitization and educational programs, media campaigns, and monetary or non-monetary incentives to caregivers, that may or may not be conditional upon certain health behaviors, have been used across contexts. To improve knowledge of vaccination, its place, time, and schedule, automated voice messages and written or pictorial messages have been used as standalone or multicomponent strategies. Interventions used to improve service quality included training and education of health workers and providing monetary or non-monetary perks to them or sending reminders to them on different aspects of provision of vaccination services. Interventions like effective planning or outreach activities, follow-up of children, tracking of children that have missed vaccinations, pay-for-performance schemes and health system strengthening have also been used to improve service access and quality. Interventions aimed at mobilizing and collaborating with the community to impact social norms, attitudes, and empower communities to make health decisions have also been widely implemented.

Assessing the relationship of maternal short stature with coexisting forms of malnutrition among neonates, infants, and young children of Pakistan

Evidence from previous studies suggests a strong association between pediatric undernutrition and maternal stature. However, there's a scarcity of evidence regarding the relationship between maternal stature and pediatric coexisting forms of malnutrition (CFM). This study examined the prevalence and trends of CFM at the individual, household, and community levels, using data from the Demographic & Health Surveys (DHS) of Pakistan. Furthermore, this study assessed the association between pediatric CFM and short maternal stature while adjusting for multiple covariates. A panel cross-sectional analysis was conducted using data from the 2012-2013 and 2017-2018 Pakistan Demographic & Health Survey (PDHS). We included data from 6194 mother-child dyads aged 15-49 years and 0-59 months, respectively, while excluding data from pregnant mothers and dyads with incomplete anthropometric variables and anthropometric outliers. Across the two survey periods, our findings reveal a significant decline in pediatric malnutrition, including CFM, alongside a concurrent increase in maternal overweight/obesity. Three out of four households had either a malnourished mother, and/or a malnourished child, and/or both. Our study demonstrates that short maternal stature increased the odds of various forms of pediatric undernutrition by two-to-threefolds (p < .041), but we did not find an association with wasting, overweight/obesity, and nutritional paradox. This underscores the heightened vulnerability of children born to short-stature mothers to various forms of pediatric undernutrition. Addressing the high prevalence of pediatric undernutrition among children of short-stature mothers necessitates a comprehensive approach that considers an individual's nutritional status throughout their entire life cycle.

Use of community engagement interventions to improve child immunisation in low-income and middle-income countries: a systematic review and meta-analysis

OBJECTIVE

To support evidence informed decision-making, we systematically examine the effectiveness and cost-effectiveness of community engagement interventions on routine childhood immunisation outcomes in low-income and middle-income countries (LMICs) and identify contextual, design and implementation features associated with effectiveness.

DESIGN

Mixed-methods systematic review and meta-analysis.

DATA SOURCES

21 databases of academic and grey literature and 12 additional websites were searched in May 2019 and May 2020.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included experimental and quasi-experimental impact evaluations of community engagement interventions considering outcomes related to routine child immunisation in LMICs. No language, publication type, or date restrictions were imposed.

DATA EXTRACTION AND SYNTHESIS

Two independent researchers extracted summary data from published reports and appraised quantitative risk of bias using adapted Cochrane tools. Random effects meta-analysis was used to examine effects on the primary outcome, full immunisation coverage.

RESULTS

Our search identified over 43 000 studies and 61 were eligible for analysis. The average pooled effect of community engagement interventions on full immunisation coverage was standardised mean difference 0.14 (95% CI 0.06 to 0.23, I2=94.46). The most common source of risk to the quality of evidence (risk of bias) was outcome reporting bias: most studies used caregiver-reported measures of vaccinations received by a child in the absence or incompleteness of immunisation cards. Reasons consistently cited for intervention success include appropriate intervention design, including building in community engagement features; addressing common contextual barriers of immunisation and leveraging facilitators; and accounting for existing implementation constraints. The median intervention cost per treated child per vaccine dose (excluding the cost of vaccines) to increase absolute immunisation coverage by one percent was US$3.68.

CONCLUSION

Community engagement interventions are successful in improving outcomes related to routine child immunisation. The findings are robust to exclusion of studies assessed as high risk of bias.

Use of community engagement interventions to improve child immunisation in low- and middle-income countries: A systematic review and meta-analysis

Immunisation is one of the most cost-effective interventions to prevent and control life-threatening infectious diseases. Nonetheless, rates of routine vaccination of children in low- and middle-income countries (LMICs) are strikingly low or stagnant. In 2019, an estimated 19.7 million infants did not receive routine immunisations. Community engagement interventions are increasingly being emphasised in international and national policy frameworks as a means to improve immunisation coverage and reach marginalised communities. This systematic review examines the effectiveness and cost-effectiveness of community engagement interventions on outcomes related to childhood immunisation in LMICs and identifies contextual, design and implementation features that may be associated with effectiveness. We identified 61 quantitative and mixed methods impact evaluations and 47 associated qualitative studies related to community engagement interventions for inclusion in the reteview. For cost-effectiveness analysis 14 of the 61 studies had the needed combination of cost and effectiveness data. The 61 included impact evaluations were concentrated in South Asia and Sub-Saharan Africa and spread across 19 LMICs. The review found that community engagement interventions had a small but significant, positive effect on all primary immunisation outcomes related to coverage and their timeliness. The findings are robust to exclusion of studies assessed as high risk of bias. Qualitative evidence indicates appropriate intervention design, including building in community engagement features; addressing common contextual barriers of immunisation and leveraging facilitators; and accounting for existing implementation constraints and practicalities on the ground are consistently cited as reasons for intervention success. Among the studies for which we were able to calculate cost-effectiveness, we find that the median non-vaccine cost per dose of intervention to increase immunisation coverage by 1% was US $3.68. Given the broad scope of the review in terms of interventions and outcomes, there is significant variation in findings. Among the various types of community engagement interventions, those that involve creation of community buy-in or development of new cadres of community-based structures were found to have consistent positive effect on more primary vaccination coverage outcomes than if the engagement is limited to the design or delivery of an intervention or is a combination of the various types. The evidence base for sub-group analysis for female children was sparse (only two studies) and the effect on coverage of both full immunisation and third dose of diphtheria pertussis tetanus for this group was insignificant.

Increasing midwifery capability on maternal health service

OBJECTIVE

This study aimed to determine the differences in midwives' knowledge, attitudes, motivation and abilities regarding maternal health care after an intervention.

METHODS

This was an experimental research study with a quasi-experimental pretest-posttest design with a control group. The sample of this study was 66 midwives in Jeneponto Regency; 33 midwives comprised the control group, and 33 comprised the treatment groups. The sampling technique was purposive. This study was conducted at six primary health care in Jeneponto Regency.

RESULTS

This study shows that there were differences between the midwives in the treatment and control groups in mean knowledge, motivation, attitude and ability regarding health care for pregnant women before and after health education (p<0.005); the increase in the service abilities of midwives after the Ammuntuli Bija intervention models indicates that the intervention is truly working. The components that showed significant changes (p<0.05) were knowledge (p=0.024), motivation (p=0.046) and ability (p=0.017).

CONCLUSION

The models and modules provided were capable of increasing the knowledge, motivation and ability of midwives in maternal health care. Comprehensive efforts, cross-sector support and supporting regulations are needed.

Scoping Review of Intervention Strategies for Improving Coverage and Uptake of Maternal Nutrition Services in Southeast Asia

Maternal undernutrition can lead to protein-energy malnutrition, micronutrient deficiencies, or anemia during pregnancy or after birth. It remains a major problem, despite evidence-based maternal-nutrition interventions happening on ground. We conducted a scoping review to understand different strategies and delivery mechanisms to improve maternal nutrition, as well as how interventions have improved coverage and uptake of services. An electronic search was conducted in PubMed and Google Scholar for published studies reporting on the effectiveness of maternal-nutrition interventions in terms of access or coverage, health outcomes, compliance, and barriers to intervention utilization. The search was limited to studies published within ten years before the initial search date, 8 November 2019; later, it was updated to 17 February 2021. Of 31 studies identified following screening and data extraction, 22 studies were included for narrative synthesis. Twelve studies were reported from India and eleven from Bangladesh, three from Nepal, two from both Pakistan and Thailand (Myanmar), and one from Indonesia. Nutrition education and counselling, home visits, directly observed supplement intake, community mobilization, food, and conditional cash transfer by community health workers were found to be effective. There is a need to incorporate diverse strategies, including various health education approaches, supplementation, as well as strengthening of community participation and the response of the health system in order to achieve impactful maternal nutrition programs.

Determinants of maternal low mid-upper arm circumference and its association with child nutritional status among poor and very poor households in rural Bangladesh

Malnutrition among women is a long-standing public health concern that has significant adverse consequences on the survival and healthy development of children. Maternal mid-upper arm circumference (MUAC) could potentially represent a simpler alternative to traditional nutritional indicators. This study aimed to investigate the factors associated with low maternal MUAC (as an indicator of being underweight) and address the research question of whether maternal MUAC is significantly associated with children's nutritional status among poor and very poor households in rural Bangladesh. Data on 5,069 households were extracted from the Suchana programme baseline survey, which was carried out in 80 randomly selected unions (the lowest administrative unit of Bangladesh) in Sylhet and Moulvibazar districts between November 2016 and February 2017. The outcome variables were three child nutritional status indicators: wasting, stunting and underweight. Mothers were classified as underweight if their MUAC was less than 23 cm. Separate multiple logistic regression analyses were used to determine the factors potentially associated with maternal underweight status and explore whether maternal underweight status is significantly associated with children's nutritional status. The prevalence of maternal underweight status was 46.7%, and the prevalence of wasting, stunting and underweight among children under two were 10.5%, 44.4% and 31.9%, respectively. After controlling for various socio-economic and demographic characteristics, maternal MUAC was significantly associated with children's nutritional status in rural Bangladesh.

Modifiable Factors and Delays Associated with Neonatal Deaths and Stillbirths in Jordan: Findings from Facility-Based Neonatal Death and Stillbirth Audits

OBJECTIVE

 This study employed the "three-delay" model to investigate the types of critical delays and modifiable factors that contribute to the neonatal deaths and stillbirths in Jordan.

STUDY DESIGN

 A triangulation research method was followed in this study to present the findings of death review committees (DRCs), which were formally established in five major hospitals across Jordan. The DRCs used a specific death summary form to facilitate identifying the type of delay, if any, and to plan specific actions to prevent future similar deaths. A death case review form with key details was also filled immediately after each death. Moreover, data were collected from patient notes and medical records, and further information about a specific cause of death or the contributing factors, if needed, were collected.

RESULTS

 During the study period (August 1, 2019-February 1, 2020), 10,726 births, 156 neonatal deaths, and 108 stillbirths were registered. A delay in recognizing the need for care and in the decision to seek care (delay 1) was believed to be responsible for 118 (44.6%) deaths. Most common factors included were poor awareness of when to seek care, not recognizing the problem or the danger signs, no or late antenatal care, and financial constraints and concern about the cost of care. Delay 2 (delay in seeking care or reaching care) was responsible for nine (3.4%) cases. Delay 3 (delay in receiving care) was responsible for 81 (30.7%) deaths. The most common modifiable factors were the poor or lack of training that followed by heavy workload, insufficient staff members, and no antenatal documentation. Effective actions were initiated across all the five hospitals in response to the delays to reduce preventable deaths.

CONCLUSION

 The formation of the facility-based DRCs was vital in identifying critical delays and modifiable factors, as well as developing initiatives and actions to address modifiable factors.

KEY POINTS

· Death review committees play key roles in identifying critical delays and modifiable factors.. · The "three-delay" model was successful in identifying preventable neonatal deaths and stillbirths.. · Death review committees are central in developing actions to reduce preventable deaths..

Integrated community case management of childhood illness in low- and middle-income countries

BACKGROUND

The leading causes of mortality globally in children younger than five years of age (under-fives), and particularly in the regions of sub-Saharan Africa (SSA) and Southern Asia, in 2018 were infectious diseases, including pneumonia (15%), diarrhoea (8%), malaria (5%) and newborn sepsis (7%) (UNICEF 2019). Nutrition-related factors contributed to 45% of under-five deaths (UNICEF 2019). World Health Organization (WHO) and United Nations Children's Fund (UNICEF), in collaboration with other development partners, have developed an approach - now known as integrated community case management (iCCM) - to bring treatment services for children 'closer to home'. The iCCM approach provides integrated case management services for two or more illnesses - including diarrhoea, pneumonia, malaria, severe acute malnutrition or neonatal sepsis - among under-fives at community level (i.e. outside of healthcare facilities) by lay health workers where there is limited access to health facility-based case management services (WHO/UNICEF 2012).

OBJECTIVES

To assess the effects of the integrated community case management (iCCM) strategy on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for children younger than five years of age in low- and middle-income countries.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL on 7 November 2019, Virtual Health Library on 8 November 2019, and Popline on 5 December 2018, three other databases on 22 March 2019 and two trial registers on 8 November 2019. We performed reference checking, and citation searching, and contacted study authors to identify additional studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs), cluster-RCTs, controlled before-after studies (CBAs), interrupted time series (ITS) studies and repeated measures studies comparing generic WHO/UNICEF iCCM (or local adaptation thereof) for at least two iCCM diseases with usual facility services (facility treatment services) with or without single disease community case management (CCM). We included studies reporting on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for under-fives in low- and middle-income countries.

DATA COLLECTION AND ANALYSIS

At least two review authors independently screened abstracts, screened full texts and extracted data using a standardised data collection form adapted from the EPOC Good Practice Data Collection Form. We resolved any disagreements through discussion or, if required, we consulted a third review author not involved in the original screening. We contacted study authors for clarification or additional details when necessary. We reported risk ratios (RR) for dichotomous outcomes and hazard ratios (HR) for time to event outcomes, with 95% confidence intervals (CI), adjusted for clustering, where possible. We used estimates of effect from the primary analysis reported by the investigators, where possible. We analysed the effects of randomized trials and other study types separately. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included seven studies, of which three were cluster RCTs and four were CBAs. Six of the seven studies were in SSA and one study was in Southern Asia. The iCCM components and inputs were fairly consistent across the seven studies with notable variation for the training and deployment component (e.g. on payment of iCCM providers) and the system component (e.g. on improving information systems). When compared to usual facility services, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (RR 0.96, 95% CI 0.77 to 1.19; 2 CBA studies, 5898 children; very low-certainty evidence). iCCM may have little to no effect on neonatal mortality (HR 1.01, 95% 0.73 to 1.28; 2 trials, 65,209 children; low-certainty evidence). We are uncertain of the effect of iCCM on infant mortality (HR 1.02, 95% CI 0.83 to 1.26; 2 trials, 60,480 children; very low-certainty evidence) and under-five mortality (HR 1.18, 95% CI 1.01 to 1.37; 1 trial, 4729 children; very low-certainty evidence). iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness by 68% (RR 1.68, 95% CI 1.24 to 2.27; 2 trials, 9853 children; moderate-certainty evidence). None of the studies reported quality of care, severity of illness or adverse events for this comparison. When compared to usual facility services plus CCM for malaria, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (very low-certainty evidence) and iCCM may have little or no effect on careseeking to an appropriate provider for any iCCM illness (RR 1.06, 95% CI 0.97 to 1.17; 1 trial, 811 children; low-certainty evidence). None of the studies reported quality of care, case load or severity of illness at health facilities, mortality or adverse events for this comparison.

AUTHORS' CONCLUSIONS

iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness. However, the evidence presented here underscores the importance of moving beyond training and deployment to valuing iCCM providers, strengthening health systems and engaging community systems.

The Effects of Community Home Visit and Peer Group Nutrition Intervention Delivery Platforms on Nutrition Outcomes in Low and Middle-Income Countries: A Systematic Review and Meta-Analysis

Weak delivery systems reduce the potential of evidence-supp orted interventions to improve nutrition. We synthesized the evidence for the effectiveness of nutrition-specific intervention delivery platforms for improving nutrition outcomes in low and middle-income countries (LMIC). A systematic literature search for studies published from 1997 to June 2018 resulted in the inclusion of 83 randomized controlled trials (RCTs), quasi-randomized, and controlled before-after studies across a variety of delivery platforms. In this paper, we report on meta-analysed outcomes for community health worker (CHW) home visits and mother/peer group delivery platforms. Compared to care as usual, CHW home visits increased early initiation of breastfeeding (EIBF) (OR: 1.50; 95% CI: 1.12, 1.99; n = 10 RCTs) and exclusive breastfeeding (EBF) (OR: 4.42; 95% CI: 2.28, 8.56; n = 9 RCTs) and mother/peer groups were effective for improving children's minimum dietary diversity (OR: 2.34; 95% CI: 1.17, 4.70; n = 4) and minimum meal frequency (OR: 2.31; 95% CI: 1.61, 3.31; n = 3). Pooled estimates from studies using both home visit and group platforms showed positive results for EIBF (OR: 2.13; 95% CI: 1.12, 4.05; n = 9), EBF (OR: 2.43; 95% CI: 1.70, 3.46; n = 12), and < 5 wasting (OR: 0.77; 95% CI: 0.67, 0.89; n = 4). Our findings underscore the importance of interpersonal community platforms for improving infant and young child feeding practices and children's nutritional status in LMICs.

Maternal nutrition intervention and maternal complications in 4 districts of Bangladesh: A nested cross-sectional study

BACKGROUND

Maternal morbidity is common in Bangladesh, where the maternal mortality rate has plateaued over the last 6 years. Maternal undernutrition and micronutrient deficiencies contribute to morbidity, but few interventions have measured maternal outcomes. We compared reported prevalence of antepartum, intrapartum, and postpartum complications among recently delivered women between maternal nutrition intervention and control areas in Bangladesh.

METHODS AND FINDINGS

We conducted a cross-sectional assessment nested within a population-based cluster-randomized trial comparing a nutrition counseling and micronutrient supplement intervention integrated within a structured home-based maternal, newborn, and child health (MNCH) program to the MNCH program alone in 10 sub-districts each across 4 Bangladesh districts. Eligible consenting women, delivering within 42-60 days of enrollment and identified by community-level health workers, completed an interviewer-administered questionnaire detailing the index pregnancy and delivery and allowed review of their home-based care register. We compared pooled and specific reported antepartum, intrapartum, and postpartum complications between study groups using hierarchical logistic regression. There were 594 women in the intervention group and 506 in the control group; overall, mean age was 24 years, 31% were primiparas, and 39% reported facility-based delivery, with no significant difference by study group. There were no significant differences between the intervention and control groups in household-level characteristics, including reported mean monthly income (intervention, 6,552 taka, versus control, 6,017 taka; p = 0.48), having electricity (69.6% versus 71.4%, p = 0.84), and television ownership (41.1% versus 38.7%, p = 0.81). Women in the intervention group had higher recorded iron and folic acid and calcium supplement consumption and mean dietary diversity scores, but reported anemia rates were similar between the 2 groups (5.7%, intervention; 6.5%, control; p = 0.83). Reported antepartum (69.4%, intervention; 79.2%, control; p = 0.12) and intrapartum (41.4%, intervention; 48.5%, control; p = 0.18) complication rates were high and not significantly different between groups. Reported postpartum complications were significantly lower among women in the intervention group than the control group (33.5% versus 48.2%, p = 0.02), and this difference persisted in adjusted analysis (adjusted odds ratio [AOR] = 0.51, 95% CI 0.32-0.82; p < 0.001). For specific conditions, odds of retained placenta (AOR = 0.35, 95% CI 0.19-0.67; p = 0.001), postpartum bleeding (AOR = 0.37, 95% CI 0.15-0.92; p = 0.033), and postpartum fever/infection (AOR = 0.27, 95% CI 0.11-0.65; p = 0.001) were significantly lower in the intervention group in adjusted analysis. There were no significant differences in reported hospitalization for antepartum (49.8% versus 45.1%, p = 0.37), intrapartum (69.9% versus 59.8%, p = 0.18), or postpartum (36.1% versus 29.9%, p = 0.49) complications between the intervention and control groups. The main limitations of this study are outcome measures based on participant report, non-probabilistic selection of community-level workers' catchment areas for sampling, some missing data for variables derived from secondary sources (e.g., dietary diversity score), and possible recall bias for reported dietary intake and supplement use.

CONCLUSIONS

Reported overall postpartum and specific intrapartum and postpartum complications were significantly lower for women in intervention areas than control areas, despite similar rates of facility-based delivery and hospitalization for reported complications, in this exploratory analysis. Maternal nutrition interventions providing intensive counseling and micronutrient supplements may reduce some pregnancy complications or impact women's ability to accurately recognize complications, but more rigorous evaluation is needed for these outcomes.

Maternal nutrition counselling is associated with reduced stunting prevalence and improved feeding practices in early childhood: a post-program comparison study

BACKGROUND

Despite progress, suboptimal feeding practices and undernutrition particularly in the form of stunting still remains a major issue among children aged less than 5 years in Bangladesh. Since mothers are the primary caregivers of young children, maternal nutrition counselling can be effective in improving knowledge and practices on child feeding. The Building Resources Across Communities (BRAC) initiated a nutrition counselling intervention using its essential health care (EHC) skeleton in 114 sub-districts of Bangladesh in 2012. This study assessed the role of this intervention on the prevalence of stunting and feeding practices among children aged less than 5 years.

METHODS

The data was collected as part of a nationwide cross-sectional survey, which followed a two-stage cluster random sampling procedure and was conducted between October 2015 and January 2016. The present study analyzed the information of 3009 mother-children dyads from two selected survey areas: i) areas where the EHC package was delivered (comparison; n = 1452), ii) areas with EHC plus nutrition counselling package (intervention; n = 1557) was delivered. The Chi-square test was done to compare the child feeding practices and stunting prevalence between intervention and comparison. The degree of strength of the association of stunting and the intervention was estimated using a mixed-effect logistic regression model.

RESULTS

The study revealed that the prevalence of stunting was significantly lower in areas where the intervention was delivered compared to the comparison areas (29% vs. 37%, P < 0.001). Furthermore, after adjusting for administrative zone, household wealth quintile, child's age, gender, maternal age, education, occupation, cluster disparity, and variation between study groups, it was seen that the risk of stunting was 25% lower in the intervention areas compared to the comparison areas (aOR: 0.75, 95% CI: 0.60-0.94; P = 0.012). Optimal child feeding practices were also more common among mothers from intervention areas than those of the comparison areas (exclusive breastfeeding: 72.7 vs. 59.4%, P = 0.008; feeding 4+ food groups: 42.9 vs. 34.1%, P < 0.001; having minimum acceptable diet: 31.2 vs. 25.3%, P = 0.017; feeding multiple micro-nutrient powder: 16.2 vs. 7.4%, P < 0.001).

CONCLUSIONS

The study highlighted that nutrition counselling of mothers may be effective in reducing childhood stunting with concomitant improvement in optimal feeding practices in children under 5 years of age. The frontline community health workers can be trained to counsel mothers on optimal child feeding practices and this could help reduce the prevalence of stunting.

Effectiveness of programmes and interventions to support optimal breastfeeding among children 0-23 months, South Asia: A scoping review

Most children in South Asia are breastfed at some point in their lives; however, many are not breastfed optimally, including the early initiation of breastfeeding (EIBF) within 1 hr of birth, avoidance of prelacteal feeds (APF), exclusive breastfeeding (EBF) for 6 months, and continued breastfeeding (CBF) up to 2 years of age or beyond. This review identifies and collates evidence on the effectiveness of interventions to support optimal breastfeeding in five countries in South Asia: Afghanistan, Bangladesh, India, Nepal, and Pakistan. A scoping review was conducted of peer‐reviewed and grey literature. The 31 eligible studies included randomized trials and quasi‐experimental designs that were conducted between 1990 and 2015. Data were collated regarding intervention design, characteristics, and effectiveness to support EIBF, APF, EBF, and CBF. Most studies reported a positive impact on breastfeeding outcomes, including 21/25 studies that examined EIBF, 15/19 studies that examined EBF, and 10/10 studies that examined APF. The only study that examined CBF reported no effect. Education, counselling, and maternal, newborn, and child health initiatives were common intervention types with positive effects on breastfeeding outcomes. Interventions were delivered in health facility, community, and home/family environments. Programmes and interventions that reached women and their families with repeated exposure and beginning during pregnancy were more likely to improve EIBF and EBF outcomes. Interventions with no impact on breastfeeding were characterized by short duration, irregular frequency, inappropriate timing, poor coverage, and targeting.

Strengthening the community support group to improve maternal and neonatal health seeking behaviors: A cluster-randomized controlled trial in Satkhira District, Bangladesh

Background

Although achieved development goals on maternal and child health, in the era of Sustainable Development Goals (SDGs), Bangladesh still needs to promote skilled attendance at birth as well as a continuum of care for mothers and babies. How to implement effective interventions by strengthening the community health system also remains as a crucial policy issue. The objective of the proposed study is to evaluate the impact of a community-based intervention as part of a bilateral development aid project on utilization of maternal and neonatal care provided by skilled providers and qualified facilities.

Methods

A cluster randomized trial was conducted in Kalaroa Upazila of Satkhira District. Community Clinics (CCs) in the study setting were randomly allocated to either intervention or control. We recruited all eligible women covered by CC catchment areas who gave a birth during the past 12 months of data collection at the baseline and end-line surveys. In the intervention areas, three Community Support Groups (CSGs) were developed in each of the CC areas. The members of CSG were trained to identify pregnant women, educate community people on pregnancy related danger signs, and encourage them for utilization of skilled services in the community and health facilities. The primary outcomes were the utilization of services for antenatal care, delivery, postnatal care and sick newborns. Difference-in-Difference (DID) analysis was performed to identify the changes by the intervention with adjustment of cluster effects by generalized mixed effects regression models.

Result

The major indicators of the utilization of maternal and neonatal care among pregnant women with different wealth status showed significant improvement after the intervention. The impacts of the intervention were in particular significant among the women of 2^nd and 3^rd quintiles of household wealth status. The use of CCs increased after the intervention and private hospitals / clinics served as the major health providers. The study also identified increased practices of cesarean section.

Conclusion

The success of the intervention suggests a potential of the government efforts to strengthen the community support system for promotion of safe motherhood. The intervention helps to identify and remove existing and emerging barriers that lie between women and healthcare providers for safe motherhood and continuum of care.

Trial registration

UMIN Clinical Trial Registry UMIN000031789.