UNEDITED/Tomas/2013/Aug

SUMMARY Background: While maternal, infant and under-five child mortality rates in developing countries have declined significantly in the past two to three decades, newborn mortality rates have reduced much more slowly. It is recognized that almost half of the newborn deaths can be prevented by scaling up evidence-based available interventions such as tetanus toxoid immunisation to mothers, clean and skilled care at delivery, newborn resuscitation, exclusive breastfeeding, clean umbilical cord care and management of infections in newborns. However, many of these require facility based and outreach services. It has also been stated that a significant proportion of these mortalities and morbidities could potentially be addressed by developing community-based packages of interventions which should be supplemented by developing and strengthening linkages with the local health systems. Some of the recent community based studies of interventions targeting women of reproductive age have shown variable impacts on maternal outcomes and hence it is uncertain if these strategies have consistent benefit across the continuum of maternal and newborn care. Objectives: To assess the effectiveness of community-based intervention packages in reducing maternal and neonatal morbidity and mortality; and improving neonatal outcomes. Methods: A comprehensive search was conducted of published and unpublished materials. Studies were identified for inclusion which employed rigorous impact evaluation techniques, using experimental ( randomised assignment) and quasiexperimental methods, and which evaluated the effectiveness of community-based intervention packages in reducing maternal and neonatal mortality and morbidities and improving neonatal outcomes. Two review authors independently assessed trial quality and extracted the data. The review has been conducted to Campbell/Cochrane Collaboration standards of systematic review, as well as drawing on a programme theory in the analysis. Results: The review included 27 experimental and quasi-experimental trials, covering a wide range of interventional packages in which health workers received additional training in maternal and newborn care. The data from these trials were incorporated using generic inverse variance method in which logarithms of risk ratio estimates were used along with the standard error of the logarithms of risk ratio estimates. Our review did not show any significant reduction in maternal mortality (RR 0.77; 95% CI: 0.59 to 1.02). However, significant reduction was observed in maternal morbidity (RR 0.75; 95% CI 0.61 to 0.92), neonatal mortality (RR 0.73; 95% CI 0.65 to 0.82), stillbirths (RR 0.89; 95% CI 0.78 to 1.02) and perinatal mortality (RR 0.82; 95% CI 0.72 to 0.93) as a consequence of implementation of community-based interventional care packages. The interventions also increased the referrals to health facility for pregnancy related complication by 41 per cent (RR 1.41; 95% CI 1.24 to 1.62), and improved the rates of early breastfeeding by 83 per cent (RR 1.83; 95% CI 1.20 to 2.77). We assessed our primary outcomes for publication bias, but no such asymmetry was observed on the funnel plot. Conclusions: Our review offers encouraging evidence of the value of integrating maternal and newborn care in community settings through a range of interventions which can be packaged effectively for delivery through a range of community health workers and health promotion groups. While the importance of skilled delivery and facility based services for maternal and newborn care cannot be denied, there is sufficient evidence to scale up community-based care through packages which can be delivered by a range of community-based workers.

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