MIDDLES
The effect of maternal and child health and family planning services on mortality: Is prevention enough? Vincent Fauveau, Bogdan Wojtyniak, Jyotsnamoy Chakraborty, Abdul Majid Sarder, Andre Briend Abstract Objective-To examine the impact on mortality of a child survival strategy, mostly based on preventive interventions. Design-Cross sectional comparison of cause specific mortality in two communities differing in the type, coverage, and quality of maternal and child health and family planning services. In the intervention area the services were mainly preventive, community based, and home delivered. Subjects-Neonates, infants, children, and mothers in two contiguous areas ofrural Bangladesh. Interventions-In the intervention area community health workers provided advice on contraception and on feeding and weaning babies; distributed oral rehydration solution, vitamin A tablets for children under 5, and ferrous fumarate and folic acid during pregnancy; immunised children; trained birth attendants in safe delivery and when to refer; treated minor ailments; and referred seriously ill people and malnourished children to a central clinic. Main outcome measures-Overall and age and cause specific death rates, obtained by a multiple step "verbal autopsy" process. Results-During the two years covered by the study overali mortality was 17% lower among neonates, 9% lower among infants aged 1-5 months, 30% lower among children aged 6-35 months, and 19% lower among women living in the study area than in those living in the control area. These differences were mainly due to fewer deaths from neonatal tetanus, measles, persistent diarrhoea with severe malnutrition among children, and fewer abortions among women. Conclusions-The programme was effective in preventing some deaths. In addition to preventive components such as tetanus and measles immunisation, health and nutrition education, and family planning, curative services are needed to reduce mortality further.
International Centre for Diarrhoeal Disease Research, Bangladesh Vincent Fauveau, MD,
physician Bogdan Wojtyniak, PHD, demographer Jyotsnamoy Chakraborty, manager, health services Abdul Majid Sarder, manager, demographic surveillance system Andre Briend, MD, nutritionist Correspondence and requests for reprints to: Dr V Fauveau, ICDDR,B, GPO Box 128, Dhaka 1000, Bangladesh.
BrMedJf 1990;301:103-7 BMJ VOLUME 301
14
Introduction Approaches towards defining priorities and establishing the balance between preventive and curative services, particularly in developing countries, are still debated.`17 Few data are available to allow approaches to be compared, and strategies are often recommended without adequate data to support the choices made. A review of several primary health care projects in the developing world showed that cause specific mortality could not be used to evaluate the projects because the sample populations were too small, the death rates were too low, there was no control population, or thqre was no precise assessment of the cause of death.5 Matlab, the field station of the International Centre for Diarrhoeal Disease Research, Bangladesh, is well JULY
1990
equipped to overcome these problems. It has a population of 196 000 under demographic surveillance, it includes a control area, and the causes of death are carefully documented. In this study cause specific death rates among infants, children, and women in two neighbouring areas receiving different levels of services were compared and evaluated to help to define priorities for future service development.
Subjects and methods Matlab lies in the Ganges delta, 45 km south east of Dhaka, the capital of Bangladesh. Most people live by subsistence farming and travel by waterways. In 1986 the area had a population density of 700 per km2, an adult literacy rate of 30%, a total fertility rate of 6 per woman, and an infant mortality of 95/1000 live births. Fewer than 5% of the children who died in the whole study area during 1986-7 had sought care from a hospital. The research centre has operated a diarrhoea treatment centre in the middle of the study area since 1963 and demographic surveillance since 1966: every household is visited twice a month by one of 110 female community health workers, who record births, deaths, migrations and marriages.8 In 1978 a maternal and child health and family planning services programme was introduced in half of the area.9 Most ofthe services were preventive and delivered at home by the community health workers. They were implemented gradually and included: (a) a wide range of contraceptive methods, accompanied by measures to encourage motivation and take care of side effects; this service resulted in a contraceptive use rate among married couples of 48% in 1986-7; (b) an oral rehydration therapy programme, including the placement of stocks of oral rehydration solution packets in every cluster of households, resulting in a 90% coverage rate; (c) an immunisation programme, resulting in coverage rates of 82% for measles, 58% for three doses of diphtheriatetanus-pertussis-polio, and 88% for two doses of tetanus toxoid among married women in 1986-7; (d) distribution of ferrous fumarate and folic acid tablets during the last four months of pregnancy; (e) training of traditional birth attendants to use safe delivery kits and to refer complicated deliveries; (f) nutritional advice about using colostrum, early introduction of energy rich weaning foods, the need for green leafy vegetables, and the need to breast feed beyond the age of 6 months, particularly during illnesses; (g) treatment of minor ailments such as helminthiasis and skin problems by female paramedics in four decentralised maternal and child health clinics; (h) six monthly distribution of vitamin A capsules to children aged under 5 (96% coverage); and (i) referral of severely ill people and malnourished children to a central clinic staffed by two women doctors with a 10 bed nutrition rehabilitation unit. 103
In the other half of the area, the comparison area, the
assessed on a majority rule and coded according to a classification derived from the World Health Organisation's recommended classification.'0 In case of complete disagreement additional information requested by the doctors was collected. Additional structured questionnaires were taken by a specially trained female interviewer to the houses where neonates or women had died to investigate better some difficult histories such as neonatal disorders, obstetric problems, abortion, or violence. In some cases it was not possible to use the death categories recommended by the World Health Organisation. No causal information on diarrhoeal diseases was available, so they were classified according to the clinical type of diarrhoea: acute watery, acute non-watery (combining bloody and mucoid diarrhoea), persistent, and persistent with severe malnutrition. Given that the total population under 5 years was around 30000, it was impossible to get an objective measure of the degree of malnutrition before death." Hence the diagnosis of severe malnutrition was applied when parents or relatives of the dead child had noted a rapid or recent wastage of the child's tissues before death or the recent appearance of tibial oedema. In a subsample of 253 cases in which the mid upper arm circumference had been measured within a month of death the degree of agreement between the assessment
population was served by understaffed government clinics, lacking in supplies and supervision, and grossly underused. Fewer than 3% of the children and mothers were immunised, fewer than 20% of couples used contraceptives, and referral to health centres was minimal. Coverage for oral rehydration solution packets and vitamin A, however, was comparable to that in the study area because these were distributed by the same community health workers, and people were offered the same referral facilities as in the study area for diarrhoea treatment and nutritional rehabilitation at the Matlab hospital. This study reports the deaths of children aged under 3 years and women aged 15-44, which occurred in both areas from January 1986 to December 1987. The cause of death was assessed by a multiple step procedure known as "verbal autopsy." Deaths were detected by community health workers during their biweekly home visits. A health assistant interviewed the family within six weeks to collect sociodemographic information and record the symptoms preceding death. This history, collected in a semistructured mode, was written in the local language, preserving local idioms. The information was reviewed independently by three doctors, who assigned the most likely primary and underlying causes of death. The final cause was then
TABLE i-Cause of death among neonates (
The effect of maternal and child health and family planning services on mortality: Is prevention enough? Vincent Fauveau, Bogdan Wojtyniak, Jyotsnamoy Chakraborty, Abdul Majid Sarder, Andre Briend Abstract Objective-To examine the impact on mortality of a child survival strategy, mostly based on preventive interventions. Design-Cross sectional comparison of cause specific mortality in two communities differing in the type, coverage, and quality of maternal and child health and family planning services. In the intervention area the services were mainly preventive, community based, and home delivered. Subjects-Neonates, infants, children, and mothers in two contiguous areas ofrural Bangladesh. Interventions-In the intervention area community health workers provided advice on contraception and on feeding and weaning babies; distributed oral rehydration solution, vitamin A tablets for children under 5, and ferrous fumarate and folic acid during pregnancy; immunised children; trained birth attendants in safe delivery and when to refer; treated minor ailments; and referred seriously ill people and malnourished children to a central clinic. Main outcome measures-Overall and age and cause specific death rates, obtained by a multiple step "verbal autopsy" process. Results-During the two years covered by the study overali mortality was 17% lower among neonates, 9% lower among infants aged 1-5 months, 30% lower among children aged 6-35 months, and 19% lower among women living in the study area than in those living in the control area. These differences were mainly due to fewer deaths from neonatal tetanus, measles, persistent diarrhoea with severe malnutrition among children, and fewer abortions among women. Conclusions-The programme was effective in preventing some deaths. In addition to preventive components such as tetanus and measles immunisation, health and nutrition education, and family planning, curative services are needed to reduce mortality further.
International Centre for Diarrhoeal Disease Research, Bangladesh Vincent Fauveau, MD,
physician Bogdan Wojtyniak, PHD, demographer Jyotsnamoy Chakraborty, manager, health services Abdul Majid Sarder, manager, demographic surveillance system Andre Briend, MD, nutritionist Correspondence and requests for reprints to: Dr V Fauveau, ICDDR,B, GPO Box 128, Dhaka 1000, Bangladesh.
BrMedJf 1990;301:103-7 BMJ VOLUME 301
14
Introduction Approaches towards defining priorities and establishing the balance between preventive and curative services, particularly in developing countries, are still debated.`17 Few data are available to allow approaches to be compared, and strategies are often recommended without adequate data to support the choices made. A review of several primary health care projects in the developing world showed that cause specific mortality could not be used to evaluate the projects because the sample populations were too small, the death rates were too low, there was no control population, or thqre was no precise assessment of the cause of death.5 Matlab, the field station of the International Centre for Diarrhoeal Disease Research, Bangladesh, is well JULY
1990
equipped to overcome these problems. It has a population of 196 000 under demographic surveillance, it includes a control area, and the causes of death are carefully documented. In this study cause specific death rates among infants, children, and women in two neighbouring areas receiving different levels of services were compared and evaluated to help to define priorities for future service development.
Subjects and methods Matlab lies in the Ganges delta, 45 km south east of Dhaka, the capital of Bangladesh. Most people live by subsistence farming and travel by waterways. In 1986 the area had a population density of 700 per km2, an adult literacy rate of 30%, a total fertility rate of 6 per woman, and an infant mortality of 95/1000 live births. Fewer than 5% of the children who died in the whole study area during 1986-7 had sought care from a hospital. The research centre has operated a diarrhoea treatment centre in the middle of the study area since 1963 and demographic surveillance since 1966: every household is visited twice a month by one of 110 female community health workers, who record births, deaths, migrations and marriages.8 In 1978 a maternal and child health and family planning services programme was introduced in half of the area.9 Most ofthe services were preventive and delivered at home by the community health workers. They were implemented gradually and included: (a) a wide range of contraceptive methods, accompanied by measures to encourage motivation and take care of side effects; this service resulted in a contraceptive use rate among married couples of 48% in 1986-7; (b) an oral rehydration therapy programme, including the placement of stocks of oral rehydration solution packets in every cluster of households, resulting in a 90% coverage rate; (c) an immunisation programme, resulting in coverage rates of 82% for measles, 58% for three doses of diphtheriatetanus-pertussis-polio, and 88% for two doses of tetanus toxoid among married women in 1986-7; (d) distribution of ferrous fumarate and folic acid tablets during the last four months of pregnancy; (e) training of traditional birth attendants to use safe delivery kits and to refer complicated deliveries; (f) nutritional advice about using colostrum, early introduction of energy rich weaning foods, the need for green leafy vegetables, and the need to breast feed beyond the age of 6 months, particularly during illnesses; (g) treatment of minor ailments such as helminthiasis and skin problems by female paramedics in four decentralised maternal and child health clinics; (h) six monthly distribution of vitamin A capsules to children aged under 5 (96% coverage); and (i) referral of severely ill people and malnourished children to a central clinic staffed by two women doctors with a 10 bed nutrition rehabilitation unit. 103
In the other half of the area, the comparison area, the
assessed on a majority rule and coded according to a classification derived from the World Health Organisation's recommended classification.'0 In case of complete disagreement additional information requested by the doctors was collected. Additional structured questionnaires were taken by a specially trained female interviewer to the houses where neonates or women had died to investigate better some difficult histories such as neonatal disorders, obstetric problems, abortion, or violence. In some cases it was not possible to use the death categories recommended by the World Health Organisation. No causal information on diarrhoeal diseases was available, so they were classified according to the clinical type of diarrhoea: acute watery, acute non-watery (combining bloody and mucoid diarrhoea), persistent, and persistent with severe malnutrition. Given that the total population under 5 years was around 30000, it was impossible to get an objective measure of the degree of malnutrition before death." Hence the diagnosis of severe malnutrition was applied when parents or relatives of the dead child had noted a rapid or recent wastage of the child's tissues before death or the recent appearance of tibial oedema. In a subsample of 253 cases in which the mid upper arm circumference had been measured within a month of death the degree of agreement between the assessment
population was served by understaffed government clinics, lacking in supplies and supervision, and grossly underused. Fewer than 3% of the children and mothers were immunised, fewer than 20% of couples used contraceptives, and referral to health centres was minimal. Coverage for oral rehydration solution packets and vitamin A, however, was comparable to that in the study area because these were distributed by the same community health workers, and people were offered the same referral facilities as in the study area for diarrhoea treatment and nutritional rehabilitation at the Matlab hospital. This study reports the deaths of children aged under 3 years and women aged 15-44, which occurred in both areas from January 1986 to December 1987. The cause of death was assessed by a multiple step procedure known as "verbal autopsy." Deaths were detected by community health workers during their biweekly home visits. A health assistant interviewed the family within six weeks to collect sociodemographic information and record the symptoms preceding death. This history, collected in a semistructured mode, was written in the local language, preserving local idioms. The information was reviewed independently by three doctors, who assigned the most likely primary and underlying causes of death. The final cause was then
TABLE i-Cause of death among neonates (
