Discussion
To our knowledge, this study is the first cluster randomized controlled
trial to assess the effect of the MCH program enhanced by mobile
platform This is also the first cluster randomized design for HBR to
improve CoC for mothers and babies in Bangladesh. Our findings indicated
that the application of MCH improved uptake of multiple healthcare
services, including antenatal care and postnatal/neonatal care, among
rural pregnant women. The interventions increased ANC visits, from 1.48
visits in the control group to 1.97 times and 2.01 times in the
intervention groups by using MCH and combining MCH and mobile platform,
respectively. Although the overall proportion of at least four visits of
ANC as recommended was relevantly low in the study settings, the figure
in the two intervention groups, especially in the combined intervention,
were better. A similar tendency was also observed in PNC. The combined
intervention further improved facility-based delivery and utilization of
healthcare facility for complications during pregnancy and delivery. The
multilevel GEE models identified statistical significance of these
intervention effects, after adjusting potential confounders.
Compared to the monitoring data of UNICEF which targeted the overall
population during the study period in Bangladesh 29,
our study which targeted pregnant women living in rural areas identified
higher NMR of 29.7 per 1,000 (95% CI: 21.6 - 37.8 per 1,000). Although
the estimated figure was lower in the two intervention groups, no
statistical significance on the immediate efforts to reduce mortality
and morbidities was identified. A possible reason for this could be the
calculation of the study sample size was based on an NMR of 24.4 per
1,000 (derived from the final MDG report), while the indicator has been
substantially reduced since then. We also acknowledged that unlike
obstetric care practices, MCH does not have an immediate life-saving
effect and that the universal access to good-quality obstetric and
neonatal healthcare plays a key role in reducing NMR based on the
success observed in Bangladesh and other developing settings30,31. On the other hand, consistent with the findings
of a systematic review, 32 our analysis confirmed that
a crucial determinant in reducing NMR was CoC; both interventions showed
a significant improvement. This suggests that MCH has a potential to
improve neonatal survival through the promotion of utilization of CoC
for mothers and the newborn,.
In our study, MCH brought upon several benefits, such as health
education, promotion of daily care awareness and practices, involvement
of husband and family members and boosting communication between
pregnant women and healthcare providers, especially CHWs, leading to
better healthcare utilization during pregnancy, at birth and after
birth. This was compatible to previous studies on MCH16-20. The interventions involved primary healthcare
at the community as an inevitable aspect. In the intervention settings,
and the local residents, including pregnant women and their families,
were organized and networked, and community meetings aiming to
strengthen participatory learning and action on preventive and
care-seeking behaviors were also implemented regularly. Similar
empowerment practices have proven to be effective in improving key
behaviors and neonatal survival outcomes, although its mechanism may
depend on local practices, capabilities and the responsiveness of health
services 33. In our study, during this empowerment
process, MCH or MCH combined with the mobile platform were the key
instruments. CHWs were mobilized to reinforce the linkage, deliver
knowledge and primary care, organize the community meeting and bridge
pregnant women and healthcare facilities, in order to accomplish the
proposed interventions. To this end, the results suggested that MCH can
be a useful tool to strengthen primary healthcare delivery in rural
Bangladesh. The interventions largely filled the gap of health education
during pregnancy and routine primary healthcare at the community level,
and the (potential) usefulness of these interventions were definitely
recognized among most participants.
Compared to MCH alone, the combined intervention achieved better
utilization of CoC, especially in terms of facility-based delivery and
care seeking for complications during pregnancy and delivery, as well as
lower rate of cesarean section (CS) delivery. What works for this
intervention were likely to be effective contacts and more frequent
interactions between pregnant women and CHWs, such as sharing
information and advising daily home-based care, together with seeking
relevant healthcare based on individual needs and requirement. Text and
voice messages complemented MCH in knowledge dissemination and deepening
the understanding of the key contents of MCH. The high mobile coverage
and the low costs in the study settings facilitated the intervention.
The results added relevant evidence on the effectiveness of mHealth on
improvement of maternal and neonatal outcomes and related care seeking
by the high-quality study design, which were of lack in low- and
middle-income countries 34, and suggested the value to
apply these effective tools in primary healthcare at the community
level.
Our study revealed the latest status of universal health coverage for
mothers and neonates in rural Bangladesh. We identified the proportion
of ANC4, FBD and PNC to be 11.06% (95% CI: 9.90% - 12.22%), 61.23%
(95% CI: 59.99% - 62.47%) and 42.36% (95% CI: 40.73% - 43.99%),
respectively, and the proportion of CoC throughout prepartum,
intrapartum and postpartum/neonatal period to be 8.03% (95% CI: 7.04%
- 9.03%) as the consequence. The uptake of ANC4 among rural pregnant
women living in the study settings was considerably lower than that of
the overall population identified by BDHS 2014 35,36,
but was comparable to that of community-based studies conducted in a
rural area 37,38. This can be explained by a
substantial rural-urban gap in the uptake of maternal healthcare
services 39. Contrary to the stagnant progress in ANC
uptake, our results suggested a fairly progressive uptake of PNC and FBD
compared to previous surveys and estimates 40,41. The
overall low uptake of these maternal and neonatal services suggested a
big room for improvement through strengthening primary healthcare as the
frontline of health system 42, particularly in rural
areas.
Meanwhile, we confirmed that the improved FBD led to a marked increase
in CS delivery in Bangladesh. The incidence of CS identified in our
study was much higher compared to that in BDHS 201443, and largely exceeded the optimal rate ranging from
5% to 20% 44. Although it is a life-saving measure
in obstetric care, a high level of CS indicates a substantial proportion
of the practice without medical indication, leading to wasting of scarce
healthcare resources and a high health and economic burden, especially
in low- and middle-income countries 45-47. The
mechanism of the high-level CS tended to be complicated, mixing
motivations of both the supply and demand sides, and the decision of the
mothers and their family may largely affected by doctors due to poorly
informed healthcare needs 43,48. Our results suggested
that this alarming phenomenon is emerging in not only urban areas, but
also in rural areas recently, and an intervention by applying MCH and
mobile platform had the potential to reduce the misuse. The emerging
issues on CS in MCH for implementing health promotion/health education
programs at community level are expected to be covered.
In interpreting these major findings, several issues should be carefully
considered. The enrollment of the target pregnant women relied on
self-report. Because of the variation in identifying pregnancy among the
participants, gestational age at enrollment was diversified, causing
differences in the participation duration. Moreover, our study was
likely to be inevitably contaminated somehow, because the interventions
and the outcomes cannot be masked, and there had been some previous
NGO-driven health promotion campaigns and activities targeting the rural
community in the study settings. However, there was no differences
regarding these factors across the study settings and groups. Finally,
because of the limited follow-up duration, our study did not observe the
outcomes posterior to the neonatal period, potentially missing the
overall effects of the target tools on maternal and child health.
In summary, our study indicated the effectiveness of the interventions
by leveraging MCH and a mobile platform to promote uptake of CoC
throughout prepartum, intrapartum and postpartum/neonatal periods,
potentially bringing long-lasting benefits to mothers and their
offspring. These tools coordinated the interactions of pregnant women,
their families and CHWs and their active engagement in primary
healthcare at the community level, potentially contributing to better
health outcomes. It is worth including these tools in primary healthcare
to achieve universal health coverage for mothers and babies in rural
Bangladesh.