Systematic review of effect of community-level interventions to reduce maternal mortality

Elaine Kidney¹ , Heather R Winter^{^ 1}, Khalid S Khan² , A Metin Gülmezoglu³ , Catherine A Meads¹ ,Jonathan J Deeks¹ and Christine MacArthur¹

¹Dept of Public Health and Epidemiology, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK

²Academic Unit, Birmingham Women's Hospital, University of Birmingham, Birmingham, UK

³UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Geneva, Switzerland

author email corresponding author email^Deceased

BMC Pregnancy and Childbirth 2009, 9:2doi:10.1186/1471-2393-9-2

The electronic version of this article is the complete one and can be found online at:http://www.biomedcentral.com/1471-2393/9/2

Received:	18 July 2008
Accepted:	20 January 2009
Published:	20 January 2009

© 2009 Kidney et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

The objective was to provide a systematic review of the effectiveness of community-level interventions to reduce maternal mortality.

Methods

We searched published papers using Medline, Embase, Cochrane library, CINAHL, BNI, CAB ABSTRACTS, IBSS, Web of Science, LILACS and African Index Medicus from inception or at least 1982 to June 2006; searched unpublished works using National Research Register website, metaRegister and the WHO International Trial Registry portal. We hand searched major references.

Selection criteria were maternity or childbearing age women, comparative study designs with concurrent controls, community-level interventions and maternal death as an outcome. We carried out study selection, data abstraction and quality assessment independently in duplicate.

Results

We found five cluster randomised controlled trials (RCT) and eight cohort studies of community-level interventions. We summarised results as odds ratios (OR) and confidence intervals (CI), combined using the Peto method for meta-analysis. Two high quality cluster RCTs, aimed at improving perinatal care practices, showed a reduction in maternal mortality reaching statistical significance (OR 0.62, 95% CI 0.39 to 0.98). Three equivalence RCTs of minimal goal-oriented versus usual antenatal care showed no difference in maternal mortality (1.09, 95% CI 0.53 to 2.25). The cohort studies were of low quality and did not contribute further evidence.

Conclusion

Community-level interventions of improved perinatal care practices can bring about a reduction in maternal mortality. This challenges the view that investment in such interventions is not worthwhile. Programmes to improve maternal mortality should be evaluated using randomised controlled techniques to generate further evidence.