title: Effects of quality improvement in health facilities and community mobilization through women's groups on maternal, neonatal and perinatal mortality in three districts of Malawi: MaiKhanda, a cluster randomized controlled effectiveness trial.
abstract: BACKGROUND
  Maternal, perinatal and neonatal mortality remains high in low-income countries. We evaluated community and facility-based interventions to reduce deaths in three districts of Malawi.
  
  
  METHODS
  We evaluated a rural participatory women's group community intervention (CI) and a quality improvement intervention at health centres (FI) via a two-by-two factorial cluster randomized controlled trial. Consenting pregnant women were followed-up to 2 months after birth using key informants. Primary outcomes were maternal, perinatal and neonatal mortality. Clusters were health centre catchment areas assigned using stratified computer-generated randomization. Following exclusions, including non-birthing facilities, 61 clusters were analysed: control (17 clusters, 4912 births), FI (15, 5335), CI (15, 5080) and FI + CI (14, 5249). This trial was registered as International Standard Randomised Controlled Trial [ISRCTN18073903]. Outcomes for 14,576 and 20,576 births were recorded during baseline (June 2007-September 2008) and intervention (October 2008-December 2010) periods.
  
  
  RESULTS
  For control, FI, CI and FI + CI clusters neonatal mortality rates were 34.0, 28.3, 29.9 and 27.0 neonatal deaths per 1000 live births and perinatal mortality rates were 56.2, 55.1, 48.0 and 48.4 per 1000 births, during the intervention period. Adjusting for clustering and stratification, the neonatal mortality rate was 22% lower in FI + CI than control clusters (OR = 0.78, 95% CI 0.60-1.01), and the perinatal mortality rate was 16% lower in CI clusters (OR = 0.84, 95% CI 0.72-0.97). We did not observe any intervention effects on maternal mortality.
  
  
  CONCLUSIONS
  Despite implementation problems, a combined community and facility approach using participatory women's groups and quality improvement at health centres reduced newborn mortality in rural Malawi.
authors.affiliation: UCL Institute for Global Health, 30 Guilford Street, London WC1N 1EH, UK.
authors.forename: Tim
authors.initials: T
authors.lastname: Colbourn
authors.forename: Bejoy
authors.initials: B
authors.lastname: Nambiar
authors.forename: Austin
authors.initials: A
authors.lastname: Bondo
authors.forename: Charles
authors.initials: C
authors.lastname: Makwenda
authors.forename: Eric
authors.initials: E
authors.lastname: Tsetekani
authors.forename: Agnes
authors.initials: A
authors.lastname: Makonda-Ridley
authors.forename: Martin
authors.initials: M
authors.lastname: Msukwa
authors.forename: Pierre
authors.initials: P
authors.lastname: Barker
authors.forename: Uma
authors.initials: U
authors.lastname: Kotagal
authors.forename: Cassie
authors.initials: C
authors.lastname: Williams
authors.forename: Ros
authors.initials: R
authors.lastname: Davies
authors.forename: Dale
authors.initials: D
authors.lastname: Webb
authors.forename: Dorothy
authors.initials: D
authors.lastname: Flatman
authors.forename: Sonia
authors.initials: S
authors.lastname: Lewycka
authors.forename: Mikey
authors.initials: M
authors.lastname: Rosato
authors.forename: Fannie
authors.initials: F
authors.lastname: Kachale
authors.forename: Charles
authors.initials: C
authors.lastname: Mwansambo
authors.forename: Anthony
authors.initials: A
authors.lastname: Costello
mesh_terms: D000328:Adult; D019058:Community Networks; D003256:Community Participation; D005260:Female; D006268:Health Facilities / Q000592:standards*; D006801:Humans; D007226:Infant Mortality; D007231:Infant, Newborn; D008295:Malawi / Q000453:epidemiology; D008427:Maternal Health Services / Q000592:standards*; D008428:Maternal Mortality; D016017:Odds Ratio; D054238:Perinatal Mortality; D011247:Pregnancy; D058996:Quality Improvement; D014930:Women
keywords: Malawi; Maternal mortality; Neonatal mortality; Perinatal mortality; Quality improvement; Women's groups
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