A combined community- and facility-based approach to improve pregnancy outcomes in low-resource settings: a Global Network cluster randomized trial

Omrana Pasha, Elizabeth M McClure, Linda L Wright, Sarah Saleem, Shivaprasad S Goudar, Elwyn Chomba, Archana Patel, Fabian Esamai, Ana Garces, Fernando Althabe, Bhala Kodkany, Hillary Mabeya, Albert Manasyan, Waldemar A Carlo, Richard J Derman, Patricia L Hibberd, Edward K Liechty, Nancy Krebs, K Michael Hambidge, Pierre Buekens, Janet Moore, Alan H Jobe, Marion Koso-Thomas, Dennis D Wallace, Suzanne Stalls, Robert L Goldenberg, EMONC Trial Investigators, Agustina Mazzoni, Marina Laski, Ariel Karolinski, Mabel Berrueta, Christine Kaseba, Melody Miselo Kunda Chiwila, Evelyn Morales, N S Mahantshetti, N V Honnungar, Kamal Patil, M K Swamy, Sadiah Ahsan, Khadim Hussain, Azra Ahsan, Manju Waikar, Nivedita Kulkarni, Sushama Thakre, Manoj Bhatnagar, Betsy Rono, Peter Gisore, Hillary Mbeya, Omrana Pasha, Elizabeth M McClure, Linda L Wright, Sarah Saleem, Shivaprasad S Goudar, Elwyn Chomba, Archana Patel, Fabian Esamai, Ana Garces, Fernando Althabe, Bhala Kodkany, Hillary Mabeya, Albert Manasyan, Waldemar A Carlo, Richard J Derman, Patricia L Hibberd, Edward K Liechty, Nancy Krebs, K Michael Hambidge, Pierre Buekens, Janet Moore, Alan H Jobe, Marion Koso-Thomas, Dennis D Wallace, Suzanne Stalls, Robert L Goldenberg, EMONC Trial Investigators, Agustina Mazzoni, Marina Laski, Ariel Karolinski, Mabel Berrueta, Christine Kaseba, Melody Miselo Kunda Chiwila, Evelyn Morales, N S Mahantshetti, N V Honnungar, Kamal Patil, M K Swamy, Sadiah Ahsan, Khadim Hussain, Azra Ahsan, Manju Waikar, Nivedita Kulkarni, Sushama Thakre, Manoj Bhatnagar, Betsy Rono, Peter Gisore, Hillary Mbeya

Abstract

Background: Fetal and neonatal mortality rates in low-income countries are at least 10-fold greater than in high-income countries. These differences have been related to poor access to and poor quality of obstetric and neonatal care.

Methods: This trial tested the hypothesis that teams of health care providers, administrators and local residents can address the problem of limited access to quality obstetric and neonatal care and lead to a reduction in perinatal mortality in intervention compared to control locations. In seven geographic areas in five low-income and one middle-income country, most with high perinatal mortality rates and substantial numbers of home deliveries, we performed a cluster randomized non-masked trial of a package of interventions that included community mobilization focusing on birth planning and hospital transport, community birth attendant training in problem recognition, and facility staff training in the management of obstetric and neonatal emergencies. The primary outcome was perinatal mortality at ≥28 weeks gestation or birth weight ≥1000 g.

Results: Despite extensive effort in all sites in each of the three intervention areas, no differences emerged in the primary or any secondary outcome between the intervention and control clusters. In both groups, the mean perinatal mortality was 40.1/1,000 births (P = 0.9996). Neither were there differences between the two groups in outcomes in the last six months of the project, in the year following intervention cessation, nor in the clusters that best implemented the intervention.

Conclusions: This cluster randomized comprehensive, large-scale, multi-sector intervention did not result in detectable impact on the proposed outcomes. While this does not negate the importance of these interventions, we expect that achieving improvement in pregnancy outcomes in these settings will require substantially more obstetric and neonatal care infrastructure than was available at the sites during this trial, and without them provider training and community mobilization will not be sufficient. Our results highlight the critical importance of evaluating outcomes in randomized trials, as interventions that should be effective may not be.

Trial registration: ClinicalTrials.gov NCT01073488.

Figures

Figure 1
Figure 1
EmONC Study Organization.
Figure 2
Figure 2
Consort diagram.

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