Reducing maternal mortality in low- and middle-income countries: the Nepalese approach of helicopter retrieval.

Ninety-four percent of global maternal deaths occur in low- and middle-income countries (LMICs). The UN has a goal of reducing maternal deaths to <70 per 100,000 live births by 2030, but progress is minimal. Maternal deaths in LMICs are associated with 3 delays in the care of women with obstetrical emergencies: 1) in the family of the woman realizing that her life is at risk, 2) in the transport of the woman to a hospital, and 3) in providing care after arrival at the hospital. These 3 delays function like links in a chain, and failure of any link leads to maternal death. LMICs have characteristics that make it likely that the chain will break. Women in LMICs frequently have low standing, and cultural beliefs often lead to delay in the recognition of obstetrical emergencies. LMICs are characterized by poor roads and long distances to hospitals leading to transport delays. Cultural and other factors also lead to treatment delays when a woman reaches a suitably-equipped and staffed hospital. Nepal has addressed these delays and reduced maternal mortality. Firstly, we have reported in the Journal the use of culturally acceptable approaches to improving the knowledge about antenatal care in remote villages. In the case of Nepal, singing songs related to maternal care proved to be a highly effective strategy. We now report that the government of Nepal has repurposed military helicopters to overcome the tyranny of poor roads to allow rapid transport of women with obstetrical emergencies to a small number of fully-equipped and staffed hospitals. As of June 2023, this service has successfully retrieved 625 women in four and half years. The Nepalese government has included questions on maternal mortality in the 2021 national census, followed by a verbal autopsy. These data indicate a fall in the maternal mortality ratio from 239 in 2016 to 151 in 2021. The efficiency of the triage service continues to improve, suggesting that maternal mortality will continue to fall. This may provide a model that can be implemented in other LMICs and highlights factors that may be responsible for recent increases in the US maternal mortality ratio.

A first step to improving maternal mortality in a low-literacy setting; the successful use of singing to improve knowledge regarding antenatal care.

BACKGROUND: Preventable maternal mortality is related to delays in recognizing the problem, transport to a facility, and receiving appropriate care on arrival. Reducing maternal mortality in low-literacy settings is particularly challenging. In the rural villages of Nepal, the maternal mortality rate is among the highest in the world; the reasons include illiteracy and lack of knowledge of the needs of pregnant women. Culturally, singing and dancing are part of Nepalese daily life and present an opportunity to transmit knowledge of antenatal care and care at birth with a view to reducing the first 2 delays. OBJECTIVE: We hypothesized that health messages regarding the importance of antenatal care and skilled birth assistance would be effectively transmitted by songs in the limited literacy environment of rural Nepal. STUDY DESIGN: We randomly grouped 4 rural village development committees comprising 36 villages into 2 (intervention and control) clusters. In the intervention group, local groups were invited to write song lyrics incorporating key health messages regarding antenatal care to accompany popular melodies. The groups presented their songs and dances in a festival organized and judged by the community. The winning songs were performed by the local people in a song and dance progression through the villages, houses, and fields. A wall chart with the key health messages was also provided to each household. Knowledge of household decision makers (senior men and women) was assessed before and after the intervention and at 12 months using a structured questionnaire in all households that also assessed behavior change. RESULTS: Structured interviews were conducted at baseline, immediately postintervention in the control and intervention areas (intervention n = 735 interviews, control n = 775), and at 12 months in the intervention area only (n = 867). Knowledge scores were recorded as the number of correct items out of 36 questions at baseline and postintervention, and of 21 questions at follow-up. Postintervention, test score doubled in the intervention group from a mean of 11.60/36-22.33/36 (P < .001), with no practically significant change in the control population (17.48/36-18.26/36). Improvement was greatest among the most illiterate members of the community (6.8/36-19.8/36, P < .001). At 12 months follow-up, a majority of the participants (63.9%) indicated that they provided information learned from the songs to their neighbors and friends, and 41.3% reported still singing the songs from the intervention. CONCLUSION: The use of songs bypassed the limitations of literacy in communicating health messages that are key to improving maternal care in this low-literacy rural setting within a developing country. The improvements were maintained without further intervention for 12 months. With appropriate sociocultural adaptation to local contexts, this low-cost method of community education may be applicable to improving maternal health knowledge and behavior change in other low-resource and limited literacy settings that may lead to reductions in maternal mortality.

Systematic review of community participation interventions to improve maternal health outcomes in rural South Asia.

BACKGROUND: This is a systematic review on the effectiveness of community interventions in improving maternal health care outcomes in South Asia. METHODS: We searched electronic databases to June 2017. Randomised or cluster randomised studies in communities within rural/remote areas of Nepal, Bangladesh, India and Pakistan were included. Data were analysed as risk ratios (RR) or odds ratios (OR), and effects were adjusted for clustering. Meta-analyses were performed using random-effects and evidence quality was assessed. RESULTS: Eleven randomised trials were included from 5440 citations. Meta-analysis of all community interventions combined compared with control showed a small improvement in the number of women attending at least one antenatal care visit (RR 1.19, 95% CI 1.06 to 1.33). Two community mobilisation sub groups: home care using both male and female mobilisers, and education by community mobilisers, improved the number of women attending at least one antenatal visit. There was no difference in the number of women attending at least one antenatal visit for any other subgroup. There was no difference in the number of women attending 3 or more antenatal visits for all community interventions combined, or any community subgroup. Likewise, there was no difference in attendance at birth between all community interventions combined and control. Health care facility births were modestly increased in women's education groups (adjusted RR (1.15, 95% CI 1.11 to 1.20; 2 studies)). Risk of maternal deaths after 2 years (RR 0.63, 95% CI 0.24 to 1.64; 5 studies), and 3 years (RR 1.11, 95% CI 0.52 to 2.36; 2 studies), were no different between women's education groups and control. Community level mobilisation rather than health care messages at district level improved the numbers of women giving birth at health care facilities (RR1.09 (95%CI 1.06 to 1.13; 1 study)). Maternal health care knowledge scores improved in two community-based interventions, one involving education of male community members. CONCLUSION: Women's education interventions may improve the number of women seeking birth at a health care facility, but the evidence is of low quality. No impact on maternal mortality was observed Future research should explore the effectiveness of including male mobilisers. TRIAL REGISTRATION: This systematic review is registered with PROSPERO CRD42016033201 .