1. UCL DEPARTMENT OF GEOGRAPHY UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Improving maternal & newborn health outcomes among tribal communities in Eastern India: THE EKJUT TRIAL ekjut

2. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT BACKGROUND METHODS RESULTS DISCUSSION ekjut

3. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT BACKGROUND METHODS RESULTS DISCUSSION ekjut

4. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Community mobilisation through womens groups can improve maternal and newborn health outcomes at low cost Makwanpur trial, Nepal: 30% reduction in neonatal mortality 80 % reduction in maternal mortality Manandhar et al. Lancet 2004

5. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Is this approach scaleable & replicable? Four randomised controlled trials: Rural Malawi Mumbai, India Jharkhand & Orissa, India - the Ekjut trial Bangladesh (three rural districts) ekjut

6. Ekjut trial study areas Jharkhand & Orissa - eastern India (combined population ~ 66 million) Tribal people (adivasi) ~ around a quarter of the population in both states Jharkhand: poorest state in India at its creation in 2000 Around 40% of population in both states live below the poverty line. ekjut

7. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Maternal & newborn health indicators (2006) JHARKHANDORISSAINDIA Neonatal Mortality Rate (per 1000 livebirths) 494539 Maternal Mortality Ratio (per 100,000 livebirths) 471458407 JHARKHANDORISSAINDIA Antenatal Care (%)3850.7 Institutional delivery (%) 1941 (DLHS -3 & NFHS - 3) 48 36 ekjut

8. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Tribal communities: worse socio-economic / health indicators compared with non-indigenous people. NMR and MMR considerably worse than in general population. ekjut

9. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Baseline survey findings in the study areas NMR: 58 per 1000 live births MMR: 557 per 100,000 live births 40% of women did not have any ANC 15% had 4+ ANC visits 85% of deliveries took place at home ekjut

10. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT TRIAL OBJECTIVES & OUTCOMES To measure the impact of working through womens groups on maternal health, newborn health, and maternal depression through a cluster randomised controlled trial. - 35% in neonatal mortality rate - 55% in maternal mortality ratio - 50% in maternal depression + improved home care practices & care-seeking ekjut

11. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Study design 36 clusters (~ 6300 population) in 3 districts randomised to intervention & control arms ekjut 18 CONTROL CLUSTERS Womens groups 36 CLUSTERS Health Service Strengthening 18 INTERVENTION CLUSTERS Womens groups ++

12. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT INCLUSION CRITERIA & TIMELINE All women of reproductive age (15-49) Residing in the project area Who gave birth between 31 st July 2005 – 30 th July 2008 Who gave consent for involvement in the project Timeline: Baseline surveyYear 1Year 2Year 3 Nov 04- Jul 05Jul 05- Jul 06Jul 06- Jul 07Jul 07- Jul 08 ekjut

13. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Monitoring births & deaths ekjut

14. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT ekjut EXISTING GROUPS = 203 EKJUT WOMENS GROUPS =244 CONTROL CLUSTERSINTERVENTION CLUSTERS WOMENS GROUP CYCLE

15. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT The womens group participatory cycle ekjut

17. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT BACKGROUND METHODS RESULTS DISCUSSION ekjut

18. 18829 Pregnancies* 23 Died during pregnancy due to maternal causes 18806 Deliveries 19030 Births 581 Stillbirths 18449 Live births 937 Died within 28 days Early NND = 635 Late NND = 302 17511 Alive at one month 55 Died during labour / childbirth due to maternal causes 31 Died after childbirth (42 days-1 yr) due to maternal causes * System designed to identify births and deaths not pregnancies - 01/09 EKJUT TRIAL ekjut

19. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Intervention Clusters Control Clusters Adjusted odds ratios (95% CI) Births Livebirths 9770 9469 9260 8980 - Stillbirths Neonatal deaths Maternal deaths 301 406 49 280 531 60 - Stillbirth rate (per 1000 livebirths) Neonatal mortality rate (per 1000 livebirths) Maternal mortality ratio (per 100,000 livebirths) 30.7 43 517.9 30.2 59 668.2 1.06 (0.86 - 1.30) 0.69 (0.59 - 0.81) 0.775 ekjut

20. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Reduction in newborn mortality Intervention Clusters Control Clusters Adjusted odds ratios (95% CI) Neonatal deaths In years 2 & 3 Neonatal deaths In Year 3 259 109 390 188 0.58 (0.48 - 0.71) 0.54 (0.42 - 0.70) ekjut

21. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT

22. Early Neonatal Mortality Rate in Intervention and Control Areas ekjut

23. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Late Neonatal Mortality Rate in Intervention and Control Areas ekjut

24. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT ekjut

25. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT ekjut

26. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT ekjut

27. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Perinatal Mortality Rate in Intervention and Control Areas ekjut

28. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Maternal Mortality Ratio in Intervention and Control Areas InterventionControlAll Baseline680321.8608 Year 1651.91012.1828.9 Year 2669.5593.3632.9 Year 3224.7402.5311.7 Y1,2 &3517.5668.2590.8 ekjut

29. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT In her 8 th month of pregnancy Rajani Juang and her mother-in-law attended a womens group meeting where she participated in a drill based on what to do in case of postpartum bleeding. After a month when she delivered at home and had severe bleeding, her mother- in-law remembered the meeting and without wasting time asked Rajani to breast feed her baby, while she rushed to get money from the group and asked her son to get a vehicle. She was immediately taken to the district hospital, where she was given medicines, IV fluid, two pints of blood, and was discharged after fifteen days. ekjut Ref Case study no.25 Case study - a maternal death avoided

30. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Maternal depression in intervention & control clusters At Year 3 (using K10 scale): OR (95% CI)p Moderate depression0.40 (0.17- 0.93)0.034 High / Severe depression0.68 (0.09 - 4.95)0.708 ekjut

31. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Improved home Care Practices Median (%)InterventionControlp Birth attendants washed hands 44.518.30.01 Used safe delivery kit29.318.70.008 Used plastic sheet26.67.1<0.001 Boiled thread29.810.80.04 Infant exclusively breastfed for first 6 weeks 79.470.70.04 ekjut

32. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Service utilisation Median (%)InterventionControlp Any care in pregnancy83.182.10.974 4 + ANC18.722.70.194 Institutional delivery1314.20.154 Any postpartum care1515.70.506 Mother had check-up in 1st 6 weeks 6.27.80.194 ekjut

33. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT BACKGROUND METHODS RESULTS DISCUSSION ekjut

34. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Mechanisms for change ? High population coverage (1 group per 460 pop) Quality of intervention delivery Targeting the most marginalised High proportion of pregnant women in groups ekjut

35. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT ekjut Targeting the most marginalised: adivasis District% in district % in clusters % in meeting 1 % in meeting 25 Saraikela - Karshwan 36586867 Keonjhar48697377 West Singhbum 55708285

36. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Men, adolescents and elderly women Tribal, Marginalized & Underserved communities Where health services are inaccessible Families living in hamlets, inaccessible, remote, hilly regions Mechanisms: targeting ekjut

37. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Belief that together they can bring about change Involvement of men, adolescents and elderly women Increase in family support during pregnancy, delivery and postpartum period Process indicators: intervention quality ekjut

38. Community Womens Group PREGNANT WOMEN IN GROUPS - YEAR 1 Pregnant women Other women 17.5 % ekjut

39. Community Womens Group Pregnant women Other women 17.5%38.4% PREGNANT WOMEN IN GROUPS - YEAR 2 ekjut

40. Community Womens Group Pregnant women Other women 17.5% 38.4%55 % PREGNANT WOMEN IN GROUPS - YEAR 3 ekjut

41. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT We could not do much as individuals but as a group we could find a way to solve each others problems. It was easy to understand the causes and effects of maternal and newborn problems through picture card stories. The involvement of both women and men in choosing strategies was very encouraging. We are proud that to some extent we have helped in changing the behaviour of our group members and others who do not attend the meetings. ekjut Feedback from group members

42. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT Summary 42% reduction in newborn mortality (Y2&3) 60% reduction in moderate depression in Y3 Improved home care practices NMR reduction is higher than in Makwanpur trial Ekjut is working towards scale-up in 3 more districts ekjut

43. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT STUDY COLLABORATION: EKJUT Dr Prasanta Tripathy & Dr Nirmala Nair Suchitra Rath Shibanand Rath Raj Kumar Gope Rajendra Mahapatra Deepnath Mahto CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT (UCL) Prof Anthony Costello Dr Sarah Barnett Dr Audrey Prost Funded by: THE HEALTH FOUNDATION (UK) & BIG LOTTERY FUND (UK) ekjut

44. UCL CENTRE FOR INTERNATIONAL HEALTH & DEVELOPMENT