title: Systematic review of effect of community-level interventions to reduce maternal mortality.
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IBSS, Web of Science, LILACS and African Index Medicus from inception or at least 1982 to June 2006; searched unpublished works using National Research Register website, metaRegister and the WHO International Trial Registry portal.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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Dept of Public Health and Epidemiology, University of Birmingham, Edgbaston, Birmingham, UK. e.kidney@bham.ac.uk
authors.forename: Elaine
authors.initials: E
authors.lastname: Kidney
authors.forename: Heather R
authors.initials: HR
authors.lastname: Winter
authors.forename: Khalid S
authors.initials: KS
authors.lastname: Khan
authors.forename: A Metin
authors.initials: AM
authors.lastname: Gülmezoglu
authors.forename: Catherine A
authors.initials: CA
authors.lastname: Meads
authors.forename: Jonathan J
authors.initials: JJ
authors.lastname: Deeks
authors.forename: Christine
authors.initials: C
authors.lastname: Macarthur
mesh_terms: D003153:Community Health Services; D003906:Developing Countries; D005260:Female; D006801:Humans; D008428:Maternal Mortality; D011247:Pregnancy; D011295:Prenatal Care