Marston, C., Hinton, R., Kean, S., Baral, S., Ahuja, A., Costello, A., & Portela, A. (2016). Community participation for transformative action on women's, children's and adolescents' health. Bulletin Of The World Health Organization,94(5), 376-382. doi:10.2471/BLT.15.168492
Reducing Mortality and Illness Rates Through Counseling
Introduction and Study Type​
In 2003 the Malawi National Health Science Research Committee approved a study of Malawi women, of childbearing age, 10-49 years old. They analyzed the effects of maternal and child health outcomes after receiving health counseling. The counselors were either community mobilizers or peer volunteers. The study (Lewycka et al., 2013) is a cluster-randomized controlled trial, that used a 2x2 factorial analysis and made adjustments “for clustering, stratification by other intervention, and socioeconomic and demographic variables” (p. 1726).
Population and Setting
Purpose and Background
Methods Used
Summary Results
Strengths and Limitations
Use in Professional Practice
The study population included 455,000 Malawi people, 90% living in rural areas. They rely on subsistence farming and live on less than US$2 a day. The cohort included 43719 women of childbearing age that consented to the study, which was approved by the ethics committee from University College of London Institute of Child Health and Great Ormond Street Hospital.
The setting contained 48 clusters of cohort members, based on census enumeration areas. There were four groups developed and contained approximately 3000 people each. The community leaders, district health officer, and district commissioner provided written consent since most participating women were not literate; individual verbal consent was given when data was actively collected. To reduce contamination, a buffer area was defined and excluded, clusters of villages were used, and the urban administrative center was excluded.
Results were positive and complimentary to those seen in Nepal. Teaching from community mobilizers and volunteer peer counselors produce positive effects on initiating breastfeeding, continued breastfeeding up to 6 months, infant immunizations, antenatal and postnatal care, HIV testing, and birth delivery at an institution with skilled providers.
Women’s group results came from 7815 mothers, 53% attended the group, 2457 attended one to five times, 1267 attended six to ten times, and 443 attended more than ten times. Women’s group interventions, only, showed stratified results of Mother mortality rates (MMR) that decreased by 74%, Perinatal Mortality Rate (PMR) that decreased 33%, Neonatal Mortality Rate (NMR) that decreased 41%, Infant Mortality Rate (IMR) that decreased 28% and secondary outcomes show Exclusive breastfeeding (EBF) increased 74 percent. Overall, the women’s group interventions prevented 48.4 maternal deaths and 157.5 infant deaths.
The volunteer peer counselor group results came from 8112 mothers, 55% received counseling and after 6 months, 2328 women received counseling. Primary outcomes for volunteer peer counselor groups showed a 36% reduction in IMR and 42% in infant morbidity. There were secondary outcome improvements for breastfeeding start times; decreased reports of infants with a cough, fever, or diarrhea; and IMR remained lowest in the Volunteer peer counseling group. This group prevented 258.5 infant deaths.
The methods used are in depth. The 48 clusters were divided into four sets. Twelve clusters received women’s group and peer volunteer counseling, 12 received women’s group counseling, 12 received peer volunteer counseling, and 12 received no counseling. During December 2004 to December 2010 participants were randomly sequenced into groups and data was collected monthly, at separate times from interventions. Data collection included questions about “demographic characteristics, maternity history, care and care-seeking behaviors, maternal and infant mortality” (p. 1722).
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This study addresses the Millennium Development Goals (MDG) four and five, to Reduce Child Mortality and Improve Maternal Health. Educating mothers on health, pregnancy, breastfeeding, immunizations, child health, and improved hygiene can improve mother and child mortality and morbidity. The pre-study thought suggested that most African home births will avert infant mortality if mothers are educated. The study design evaluated health outcomes after two types of interventions, teaching by women’s group and volunteer peer counseling, were implemented with four sets of 12 study clusters.
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Strengths of this study come from the extensive research and extended study time. The women’s only group started after the volunteer peer counselors, so the study was extended. The women’s group ran from February 1, 2006, to January 31, 2009. The volunteer peer group ran from July 1, 2005, to June 30, 2008. Demographics were extensive, two kinds of counseling groups were utilized, and paired group analysis was also calculated. Including males in the Women’s group provided some diversity.
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Limitations include using this method on a large scale, considering this study cost $962,003 over a three-year period. Approximately 15,927 mothers reported, 207 women’s group counselors and 72 volunteer peer counselors were activated, and supply costs correlated to this study.
This study supports the Nepal analysis I have presented on the previous pages. Education must start somewhere, and it can be continued through families, school, and local community action. Nepal has done a wonderful job showing other nations how to lower Infant Mortality and increase Maternal Health. My practice takes into account the MDG's and how education can change entire nations. As a community provider, I will utilize this information when planning care, evaluating needed resources or the cost of change.
Nepal's Success Story
Volunteer peer counseling developed 72 female volunteers, aged 23-50 years old, all literate and knowledgeable on breastfeeding. They were trained initially for five days, attended monthly meetings and went to annual refresher courses. The volunteers were supervised by 24 government health surveillance assistants. Teaching contained information about breastfeeding, immunizations, infant care, family planning, and prevention of Maternal-to-child transmission of HIV. Five scheduled home visits were made before and after birth, and informal visits were arranged since everyone was from the same community.
Taken from other community mobilization examples in Nepal and Bolivia, 207 women’s groups were established. Every member was literate, ages 20-49 years old, had at least one child and were selected from the community. The women were provided transportation, supplies and were paid. A cluster facilitator was available for 20 meetings, women were trained for 11 days, received encouragement twice a month from four supervisors and refresher training every four months. Men were included in group membership during the third phase.