COMMUNITY-BASED APPROACH TO IMPROVING

MATERNAL HEALTH IN LOW MIDDLE-INCOME COUNTRIES

A NARRATIVE LITERATURE REVIEW

Monica Utari Mariana

Master Student in Global Health

International Maternal and Child Health Department

INTRODUCTION

Maternal health is explained as the health status of a woman from conception to childbirth and
the postpartum period. Many women perceive maternal life as a positive and enjoyable
experience while the rest link it into something bad such as pain, frustrated, illness, suffering
and even the condition which bring them close to death (1).

Despite the estimated 44% reduction in maternal mortality during the pregnancy and childbirth
between 1990 and 2015, today there are about 830 women still die every day due to
complications in pregnancy and childbirth. The main causes of death are severe bleeding
(mostly hemorrhage after childbirth), high blood pressure (pre-eclampsia and eclampsia),
sepsis, obstructed labor, unsafe abortion and indirect causes such as pre-existing health status.
Almost all the cases happened in Low Middle-Income Countries (LMICs), as the consequences
women in developing countries have a risk 33 times higher than women in the developed
counties (2).

The higher number of maternal mortality has been occurring in rural areas, among the poor
communities with low level of education (2) (3). Having health enhancing investments in
multiple sectors have been identified as one of key success factor for reducing maternal
mortality (4). In order to improve the condition, health care access has to be brought into the
community through community participation and intervention (5). The suitable method of
promoting maternal health in this setting becomes an interesting issue.

Community-Based Approach in Health Program is introduced as one of the ways in working

with communities to achieve their goal through activities that are linked to health services but
taking place in communities. In this concept, community plays an important role as a vital
resource and key partner with health systems (6).

The expert panel review of the effectiveness of community-based primary health care
(CBPHC) in improving maternal, neonatal and child health found that community platform
shows the highest averted number of maternal, neonatal, under five death as well as stillbirth
(around 2.3 million - not the original figure). Followed by Hospital Platform (0.9 million) and
primary health care platform (0.8 million). Community platform refers to all interventions that
can be delivered by a community-based health worker with appropriate training and support
(6).
In addition, a community-based approach can address the issue of equity among the population,
especially for the disadvantaged population. It can help the health system to reach those who
live away from health facilities as well as those who have the lower income that likely not
utilize health facility (7) (8). Moreover, there are many cases of childbirth occurring outside
health facilities and attended by unskilled providers (9) (10). Despite the importance of
community-based approach, building partnership with the community was not widely
appreciated and undervalued. There was no highlighted point of this approach in The Second
International Countdown to 2015 Conference in South Africa, 2008 (11). This literature review
aims to give a view on the importance of community-based approach, the methods that used
and how it affects maternal health in low middle-income countries.

METHOD

In order to have some suitable sources for the literature review, Uppsala University library
portal was utilized to access the full articles. In addition, I used PubMed as the main database.
I sought for studies that reported the analysis, strategy, evaluation, impact, and the challenge
of community-based approach in improving maternal health, especially in low middle-income
settings. In addition, I sought some literature from the United Nation (UN) website including
World Health Organization (WHO) reports, guideline book and publication.

There were some keywords that I used in finding, such as "Maternal Mortality in Low Middle-
Income Countries", “Community empowerment”, “Community and Maternal Health” and
“Improving Maternal Health”. I found 36 sources and selected 20 sources to be used in this
literature review. At the first phase of selection, I did initial title screening and continued with
abstract screening. Inclusion criteria were studies that described the topics, available in English
and published less than 15 years ago. The last date for the search was December 4th, 2017. No
geographic limitations were strictly used especially for UN reports and meta-analysis studies.
However, I still put more attention on resource-limited settings. I also found more interesting
studies from the bibliography of the previously chosen literature.

RESULT

As identified from the main articles, there are many ways that have been addressed by
stakeholders to improve and achieve Millenium Development Goals (MDGs) number 5
(Improve Maternal Health). In addition, the achievement in improving maternal health is
corresponding with MDGs number 4 (Reducing Child Mortality). Some LMICs have shown
outstanding progress to achieve the target and categorized as "fast-track" countries before 2015.
One of the success factors that has been identified by Success Factor Studies for WHO
Women's and Children's Health Study Groups is the partnership. The partnership is a part of
Catalytic Strategies which also emphasized in the design of the Sustainable Development Goals
(SDGs) (4). In addition, one of the key principles on the WHO Global Strategy on human
resources for health is having empowered and engaged communities (12). It shortens the gap
between the formal institution of health services and community toward a sustainable
improvement of the health status.

Methods in Community Based Approach

There are some methods that rise up in community-based approach, as follow: home visitation;
community case management including danger sign, case identification, and treated cases;
formation of participatory women’s groups and provision of community-based services by
mobile teams based a peripheral health facilities (6) (13). Other methods used within the
community-based aproach are sharing stories about common maternal or infant problem, how
they seek care or treatment; using picture and games as a tool for understanding the message;
conducting a discussion about proper intervention. This approach can raise the demand for
antenatal care and birth skilled attendance (14). One of the innovative methods that have been
introduced is sharing histories. It can be used both for having outstanding community health
worker (CHW) or used by CHW to empower mothers for behavior change. It uses narrative
communication with autobiographical memories (13).

There are some critical aspects which have to be considered while doing the community-based
approach such as the engagement with community leaders; existing and/or formation of new
women’s groups; innovative tools and methods to deliver the message; involvement of
community in the planning, implementation and evaluation as well as improving the capacity
of CHW through training, assistance and supervision (6) (14) (10)
The Impact of Community Based Approach

A case-control study about community engagement in improving Maternal, Neonatal, Child

Health (MNCH) was implemented from 2009 to 2013 in Northern Nigeria. The result showed
that the estimated MMR declined from 1271 to 1057 per 100,000 live births in intervention
communities whereas the MMR was 1262 per 100,000 live births (quite stagnant) in control
communities. The intervention communities had completed community engagement (CE-
Complete) whereas the control communities had not completed community engagement. In
addition, more women had 4 or more ANC visits in the intervention community (80%)
compared with control community (74.6%), P < 0.001. Moreover, women who have
knowledge about maternal danger signs significantly increased from 10.2% to 24% in
intervention community compared with 12.6% in the control communities, P<0.001 (10).

In Ethiopia, Health Extension Workers (HEWs) do a home visit, community outreach and
become first point contacts of the community to the health system. They focus on maternal and
child health from preventive, promotive and curative services. The visit of HEWs was
significantly correlated with ANC [OR 3.46 (95% CI 3,07-3,91)]. On the other side, this
approach was not significantly associated with the increase of skilled birth attendance during
delivery [OR 0.87 (95% CI 0.25-2.96)] (9). In addition, there was a Community Based Health
Insurance (CBHI) scheme implemented in some West Africa Countries (Senegal, Mali, and
Ghana). This voluntary health insurance at the community level has risen the demand for
maternal health services especially in the area where the utilization rate was very low and more
expensive delivery related care (15).

Another example is in Ayacucho district, Peru. There was a partnership between communities
and service providers in Life for Mother (LFM) program. The community was encouraged to
move pregnant women who live far away from health services to go to a medical facility before
labor. Over the last five years, Ayacucho district has cut its maternal death rate in half (16).
Moreover, the retrospective evaluation using narrative communication with autobiographical
memory among CHW was conducted in Afghanistan, which showed a 46% reduction in child
mortality, scaled up the training in 13 provinces and achieving an increase of health coverage
by 77% (17) (18).
DISCUSSION

The community-based approach is one of the strategies to increase demand for maternal health
services in resource-limited settings. It includes the participation of community especially
women in participatory learning and action on maternal health (19). According to the research
that has been conducted, community-based approach successfully makes people seek care and
make the health as a need.

As mentioned in the result, there is an association between community-based approach and

maternal health improvement. However, community-based approach is not a single factor that
affects maternal health. As an example, there was no statistical association between
community-based approach (in form of HEWs visit) and delivery in health facility but adjusted
for other factors, HEWs visit positively and significantly associated with health facility
delivery [Adjusted OR 1.96 (95% CI 1.25-3.06)] which might be caused by the place of
residence. Mothers who live in urban have higher access than in rural area (9).

In addition, a cross-sectional study in 29 countries showed that high coverage of essential

interventions in health center did not automatically reduce maternal mortality (20). I strongly
agree with this view since it shows that multiple factors play a significant role in improving
maternal health. We can not only rely on one factor. It has to be comprehensive from increasing
the demand side until providing the best services in normal and emergency situation both in
the community and health center. It is also about improving the quality not only the availability
of the services. I personally found some limitation in finding literature such as limited research
about the engagement of community which not only focuses on women participation; the
variance of methods and their effectiveness. Besides that, I found that it might be a bias of the
community-based impact evaluation since the intervention usually not only single approach.

This review does however clearly show the importance of community-based approach, the
methods which mainly used and the impact in improving maternal health. Still, there are many
initiatives, partnerships and quality improvements needed to have a better condition of maternal
health, especially in low middle-income countries.
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