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.