Birth Preparedness and Complication Readiness (BPCR) Interventions to Reduce Maternal and Neonatal Mortality in Developing Countries: Systematic Review and Meta-analysis

"Neonatal and maternal risks can be significantly reduced if home visits and/or women's group sessions reach a high proportion of pregnant women."

Developing countries have invested in behaviour change and community mobilisation interventions to reduce maternal and neonatal risks following the concept of birth preparedness and complication readiness (BPCR), which comprises elements of antenatal, intrapartum, postpartum, and neonatal care. This systematic review sought to evaluate the impact of BPCR interventions involving women, families, and communities during the prenatal, postnatal and neonatal periods to reduce maternal and neonatal mortality in developing countries. It also examined intervention impact on a variety of intermediate outcomes important for maternal and child survival.

BPCR programmes generally include counselling for women and their families to: (i) encourage them to take decisions before the onset of labour and potential occurrence of obstetric complications; (ii) inform them about the signs of complications so they will know and be able to react promptly if needed; (iii) inform them about the locations of emergency services to make the care-seeking process more efficient; and (iv) encourage them to save the money needed to pay for services and to plan their transportation to a health facility during labour and in case of emergency. In most cases, BPCR requires making effective use of community health workers and health promotion groups or women's groups and often involves community mobilisation activities.

The researchers searched for relevant randomised trials on December 17 2012, updated December 5 2013. Electronic and manual searches identified 654 potentially useful reports; 38 reports were retained for full text review, and 14 randomised studies were retained. Two of the studies used individual randomised units; the other 12 were cluster trials with geographic entities (villages, administrative unions, or neighbourhoods) as the randomisation units. Study settings were India, Nepal, Bangladesh, Ghana, Malawi, Pakistan, and 4 Latin American cities.

The 12 randomised cluster studies evaluated a series of interventions including prenatal and postnatal components; only in the 2 individual trials were the interventions purely prenatal. Three studies considered a home visit strategy. Seven studies involved participation in women's groups engaged in action-learning cycles (identifying and prioritising problems, planning strategies, implementing strategies, and evaluating the effects). Two studies combined community mobilisation with home visits. In addition to pregnant women, studies included husbands, persons close to the women, other women of reproductive age in the community, or community leaders.

Meta-analyses of the 14 studies (292,256 live births) showed that exposure to BPCR interventions was associated with a statistically significant reduction of 18% in neonatal mortality risk (12 studies, relative risk (RR) = 0.82; 95% confidence interval (CI): 0.74, 0.91) and a non-significant reduction of 28% in maternal mortality risk (7 studies, RR = 0.72; 95% CI: 0.46, 1.13). Subgroup analyses of studies in which at least 30% of priority women participated in interventions showed a 24% significant reduction of neonatal mortality risk (9 studies, RR = 0.76; 95% CI: 0.69, 0.85) and a 53% significant reduction in maternal mortality risk (4 studies, RR = 0.47; 95% CI: 0.26, 0.87).

Subgroup analyses also suggested that combining home visits and community-based women's group sessions would have a greater impact than would either one alone. Home-based individual counselling is more personalised and appropriate for developing mothers' personal skills related to sanitary care practices. Community-based activities are still needed to support decision-making, because in traditional settings, decisions are more often made by the community than by the individual. In practice, the choice of one strategy or another will depend on the social context and resource availability.

Significant improvements in some process outcomes associated with child survival (i.e., use of care in the event of newborn illness, clean cutting of the umbilical cord, and breastfeeding within the first hour after birth) were also shown. In addition, 2 trials reported improvements in knowledge about danger signs, and 2 others indicated that women in intervention groups were more likely to carry out birth preparedness and complication readiness activities than were their peers in the control groups.

While calling for additional primary studies, based on the review herein, the researchers conclude that decision-makers could support BPCR approaches "in settings where healthcare facilities are inadequate, where healthcare utilization is low, and where the burden of neonatal mortality is high. Sufficient resources should be mobilized for widespread implementation of these interventions and to ensure their quality, through ongoing training of educators/facilitators, provision of practice guidelines, and regular field supervision."