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ekjut. Improving maternal & newborn health outcomes among tribal communities in Eastern India: THE EKJUT TRIAL. BACKGROUND METHODS RESULTS DISCUSSION. ekjut. BACKGROUND METHODS RESULTS DISCUSSION. ekjut. Community mobilisation through women’s groups

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  1. ekjut Improving maternal & newborn health outcomes among tribal communities in Eastern India: THE EKJUT TRIAL

  2. BACKGROUND METHODS RESULTS DISCUSSION ekjut

  3. BACKGROUND METHODS RESULTS DISCUSSION ekjut

  4. Community mobilisation through women’s groups can improve maternal and newborn health outcomes at low cost Makwanpur trial, Nepal: 30% reduction in neonatal mortality 80 % reduction in maternal mortality Manandhar et al. Lancet 2004

  5. Is this approach scaleable & replicable? Four randomised controlled trials: • Rural Malawi • Mumbai, India • Jharkhand & Orissa, India - the Ekjut trial • Bangladesh (three rural districts) ekjut

  6. 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. ekjut

  7. Maternal & newborn health indicators (2006) 48 36 (DLHS -3 & NFHS - 3) ekjut

  8. ekjut Tribal communities: worse socio-economic / health indicators compared with non-indigenous people. NMR and MMR considerably worse than in general population.

  9. 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 ekjut

  10. 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 ekjut

  11. 36 CLUSTERS Health Service Strengthening 18 18 INTERVENTION CONTROL CLUSTERS CLUSTERS Women’s groups ++ Women’s groups ’ Study design 36 clusters (~ 6300 population) in 3 districts randomised to intervention & control arms ekjut

  12. 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 ekjut

  13. Monitoring births & deaths ekjut

  14. CONTROL CLUSTERS INTERVENTION CLUSTERS WOMEN’S GROUP CYCLE EXISTING GROUPS = 203 EKJUT WOMEN’S GROUPS =244 ekjut

  15. The women’s group participatory cycle ekjut

  16. ekjut

  17. BACKGROUND METHODS RESULTS DISCUSSION ekjut

  18. EKJUT TRIAL 23 Died during pregnancy due to maternal causes 18829 Pregnancies* 18806 Deliveries 55 Died during labour / childbirth due to maternal causes 19030 Births 18449 Live births 581 Stillbirths 31 Died after childbirth (42 days-1 yr) due to maternal causes 937 Died within 28 days Early NND = 635 Late NND = 302 17511 Alive at one month ekjut * System designed to identify births and deaths not pregnancies - 01/09

  19. ekjut

  20. Reduction in newborn mortality ekjut

  21. Early Neonatal Mortality Rate in Intervention and Control Areas ekjut

  22. Late Neonatal Mortality Rate in Intervention and Control Areas ekjut

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  26. Perinatal Mortality Rate in Intervention and Control Areas ekjut

  27. Maternal Mortality Ratio in Intervention and Control Areas ekjut

  28. Case study - a maternal death avoided Ref Case study no.25 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. ekjut

  29. Maternal depression in intervention & control clusters At Year 3 (using K10 scale): ekjut

  30. Improved home Care Practices ekjut

  31. Service utilisation ekjut

  32. BACKGROUND METHODS RESULTS DISCUSSION ekjut

  33. 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 ekjut

  34. Targeting the most marginalised: adivasis ekjut

  35. Mechanisms: targeting Tribal, Marginalized & Underserved communities Men, adolescents and elderly women Families living in hamlets, inaccessible, remote, hilly regions Where health services are inaccessible ekjut

  36. Process indicators: intervention quality 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 ekjut

  37. PREGNANT WOMEN IN GROUPS - YEAR 1 17.5 % Pregnant women Women’s Group Community ekjut Other women

  38. PREGNANT WOMEN IN GROUPS - YEAR 2 17.5% 38.4% Pregnant women Women’s Group Community ekjut Other women

  39. PREGNANT WOMEN IN GROUPS - YEAR 3 17.5% 38.4% 55 % Pregnant women Women’s Group Community ekjut Other women

  40. Feedback from group members “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”. ekjut

  41. 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 ekjut

  42. 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) ekjut

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