Area and population:
The field trial of HBNC was conducted in the Gadchiroli district in Maharashtra state in India during 1993-98 by SEARCH (Society for Education, Action, and Research in Community Health) (9). The area (Fig. 1), population characteristics, available healthcare, the background work of SEARCH, the methods of data collection, the quality and the validation of the data, the definitions, and the incidence of maternal health condition during the first year of the intervention (1995-96) have all been extensively reported (6, 7, 10). Here we shall only describe the maternal interventions.
Since Traditional Birth Attendants (TBAs) used to conduct most of the deliveries in rural Gadchiroli at home, in 1988-89 SEARCH had trained the TBAs in the area, including those in the 39 intervention villages. They were trained to distribute iron-folic acid and calcium tablets during pregnancy, to provide vitamin A supplements if a woman complained of night blindness in the last trimester, and to use gentian violet for treating vaginal discharge. They were also trained in hand washing, using gloves, antiseptic lotion, clean blade and thread during delivery, and in the importance of antenatal checkup and of early referral when certain danger signs were present (11).
The sources of maternal health care were the SEARCH clinic located outside the intervention area, run by an obstetrician (RB), the government district hospital located in the centre of the intervention area and few private doctors. The families used to call on unqualified private practitioners to inject oxytocin to quicken home deliveries.
The field trial of HBNC was conducted in this area. In the first year of the intervention phase (1995-96) 39 female community health workers (CHWs) were introduced, one in each intervention village. These were married women resident of the village with 5 to 10 years of schooling. Their training and job description in the first year of the field trial (1995-96) have been described in detail (7, 9, 10, 12, 13, 14).
After the maternal and neonatal conditions were prospectively observed and recorded in the first year of the field trial (6, 12), the CHWs were trained and home-based newborn care interventions were incrementally introduced (7). In the third and the final year of the trial (1997-98), as well as subsequently during the service program (1998–2008), CHWs made the interventions described in Panel 1.
CHWs worked in close collaboration with the family, TBA and supervisory physician (SB), and later with the two CHWs upgraded as Field Supervisors. The Supervisors visited each village once every 15 days to check the findings and the interventions of the CHW, but who themselves did not treat. The CHWs were part-time workers of SEARCH, and their payment was based on a mix of fixed payment (1/3) and performance based evaluation (2/3).
The medical clinic of SEARCH, located outside the intervention area, provided the facilities for antenatal checkup, management of anemia, medical illnesses, reproductive tract infections, detection of risk factors and, when necessary, advising hospital delivery, usually at the government district hospital which was the only source of caesarian section delivery and blood transfusion. The government hospital as well as SEARCH provided free or subsidized ambulance service.
Maternal Knowledge and Practices:
We had studied maternal knowledge and practices by qualitative methods, key informant interviews (with TBAs) and focused group discussions with mothers and grandmothers, during the pre-intervention period (15). These had revealed the following harmful beliefs and behaviors: 1) A mother should not eat adequately during pregnancy or consume iron tablets, lest a large fetus would lead to difficult delivery. 2) Pregnant women should not consume meat, milk, eggs, (‘hot foods’) or certain leafy vegetables or fruits (‘papaya’ may cause abortion, guava or banana may cause ‘cough’). 3) Pregnancy and delivery are natural events, hence there is no need for medical checkups or interventions. 4) Breast feeding was often not started before the third day. The colostrum was considered impure milk, and hence discarded. 5) Delivery rooms were dirty and without toilet facilities. 6) A mother could not step out of the delivery room for five to seven days after delivery. 7) To minimize their toilet needs during this period, mothers reduced their food and fluid intake.
The insights gained were used to design the health education messages. CHWs imparted health education at home with a flip chart, twice during pregnancy and once during the neonatal / post-partum period. Additionally, group health education for pregnant women and mothers-in-law was organized in the village every four months. Fifteen days after the group health education session, the CHW interviewed the mothers, using a questionnaire, to assess their knowledge. CHW also observed mothers’ health behaviors and had recorded the same in a printed mother- newborn record during her home visits.
The definitions used to diagnose maternal health conditions in this field setting are in Panel 2 and have also been published earlier (6).
Some women used to temporarily move to their parents’ home for delivery. We included the events in the village where they actually occurred (‘de-facto method’) irrespective of where the women came from. The total number of deliveries, still births (completed 28 weeks of gestation) and child deaths in the study and control villages were regularly recorded by an independent system of vital statistics collection using male community health workers functional since 1988. Recording of deaths in adults including maternal deaths was not part of vital statistics collection system. This system had been assessed to be 98% complete (12). The proportion of mothers and deliveries observed by female CHW and included in this study (coverage) was estimated by comparing them with these vital statistics data on total deliveries in the area. Percent difference was calculated by dividing the absolute difference for that variable by percent incidence of that variable in the first year.
In table 2 (interventions), the mean percent coverage was calculated by taking the mean of coverage of all eight indicators for each year. In table 3, 4 and 5, the data collection for some conditions was started at a later period than the baseline and the denominator was taken accordingly. Data collection on prolonged rupture of membranes and abnormal behavior was stopped in the years 1998–2002, and was restarted immediately after. Abnormal presentation was recorded in home deliveries only when the CHW was present at the time of delivery.
Data of two successive years were combined to increase the robustness of the data except for the 1st year of the data collection (1995–96) which was considered the baseline period for this analysis. Analysis was done using statistical package R (version 3.6.2). Significance was calculated on the basis of percent reduction. P value for overall change from 1995 to 2008 was calculated using Chi square test.