Is Community Intervention Effective for Improving Maternal, Newborn and Child Health Care in Hard-to-Reach Areas of Chin State, Myanmar?
Myo Myo Mon, Kyaw Min Htut, Aung Ye Naung Win,Myo Win Tin, Khin Zaw, Nyi Nyi Zayar & Phyo Aung Naing
Myanmar Health Sciences Research Journal, Vol. 32, No. 1, 2020Abstract
To tackle the maternal, newborn and child health (MNCH) care needs is a challenging situation in remote and hard-to-reach areas. Intervention activities focusing on strengthening community health care network through community participation and supporting Basic Health Staffs for MNCH services have been implemented in Kanpetlet and Paletwa townships since 2014. A community-based, pre-test, post-test study was done in 2017 to compare the knowledge and practices of mothers on MNCH care after the community intervention and the challenges during the intervention. Face-to-face interviews with mothers of children under 2 years and key informant interviews with responsible providers and in-depth interviews with volunteers were conducted. A total of 291 mothers participated in the end-line assessment. Higher proportions of mothers from end-line than baseline had correct knowledge on number of ante-natal care needed (44.9% vs. 67.3%, p<0.01), knew more than 2 danger signs regarding ante-natal (47.5% vs. 94.9%, p<0.001) and post-natal (40.2% vs. 55.1%, p<0.05). More mothers received their first ante-natal care within first trimester (38% vs. 74%, p<0.01), received delivery with skilled birth attendants (50% vs. 85.5%, p<0.01), post-partum and newborn care services (14.1% vs. 74.2%, p<0.01). Considerably higher proportion of mothers from end-line used contraception (43.2% vs. 55.3%, p<0.05) and many of them received contraceptive service from voluntary health workers (7.7% vs. 51.9%, p<0.01). More than 77% of mothers were aware of village health committee (VHC) and 65.6% had received health education from them. Responsible township health officers acknowledged the improvement in immunization coverage and increased referral from the villages because of community intervention.Go to : Goto
Globally, the health of women, mothers and children is fundamental to development of the country. Hence, under 3MDG’s (3 Millennium Development Goals) activities, maternal, newborn and child health (MNCH) is the largest component covering maternal, newborn health, child health, immunization, nutrition and health promotion. The focus of investment was to support township health planning and service delivery aiming to scale-up and strengthen access to health services. The maternal mortality ratio (MMR) in Myanmar is 282 deaths per 100,000 live births which is the second highest among ASEAN countries. According to 2014 census, around 2,800 women die during pregnancy or childbirth every year. Infant mortality rate is 62 per 1,000 live births,compared to 25 in Cambodia and 11 in Thailand. Among different States and Regions of Myanmar, highest MMR of 357 is seen in Chin State showing geographic disparity in maternal mortality when comparing to national average.1 Furthermore, according to Public Health Statistics Report (2014-2016), Kanpetlet and Paletwa Townships were included in the twenty townships needed for maternal health intervention.2
To tackle the MCH care needs of communities in hard-to-reach areas of Chin State, with the support of 3 MDG, International Rescue Committee (IRC) has designed a maternal and child health program in partnership with Township Health Department and local NGO. Working in partnership with State and Region Health Departments under the Ministry of Health and Sports, the program is supporting the work of Basic Health Staff (BHS). Besides support to facility-based healthcare services, the fund is also providing significant financing for community-based health care work by supporting Community Health Workers (CHW) and Auxiliary Midwives (AMW) for identifying the need for an emergency referral.
Strengthening local capacities to improve MNCH was launched in 2010 across 100 villages in Southern Chin State up to 2013 by European Union fund. Starting from 2014, with support of 3 MDG fund, it was expanded to the whole townships of Paletwa and Kanpetlet in Southern Chin State. Project interventions were supporting BHS for MNCH activities, training of CHWs, AMWs and Village Health Committee (VHC) for raising awareness of community and emergency referral. Implementation of community health prevention and behaviour change communication (BCC) activities was done in collaboration with BHS.
Previous community intervention studies have documented the successful application of various strategies including BCC in promoting maternal, newborn and child health care.3-7 The BCC strategy has been used to implement advocacy, communication and social mobilization activities in order to increase knowledge and utilization of health services for improved maternal and child health outcomes of the target population.
According to the project design, midwives (MWs) and supportive staff have to conduct individual support supervision visits to each village focusing on early detection and timely referral of MCH cases, health education and community mobilization for health promotion. CHWs/AMWs are also participating in MW outreach and health education actions not only as part of hands-on training but also for strengthening the linkages between CHWs/AMWs/VHCs and MWs, and health facilities. BHS and IRC programme staff carried out continuous support activities for CHW/AMWs, which foster sustainable capacity and improve the quality of services. With the aim of determining progress of the project in the communities by comparing with the baseline assessment which was carried out in 2015,8 an end-line assessment was carried out during September and December 2017.Go to : Goto
MATERIALS AND METHODS
MATERIALS AND METHODS
Study design and study population
A community-based, pre- and post-inter-vention study was conducted applying both quantitative and qualitative methods at Kanpetlet Township and Paletwa Township, Southern Chin State. Baseline assessment was carried out in 2015 and end-line assess-ment was conducted during September-December 2017. Study population included mothers of less than 2 years old children and health care providers.
Mothers of under 2 years old children who are staying at least 2 years at the study township
Mothers of under 2 years old children who were moving into the study township after delivery of the index child. Participants included in the qualitative assessment were responsible providers from public sector, focal persons from international and local non-governmental organizations, volunteers and VHC members.
Intervention components and process
Program intervention activities were supporting BHS for MNCH activities such as providing travel expenses to attend monthly meeting, financial support for meeting with VHC, outreach and supervision support; revitalizing village health committee, and training of CHWs, AMWs and VHC for raising awareness of community and emergency referral. In particular, CHWs, AMWs and VHCs were trained under the leadership of Township Health Officer and BHS regarding the danger signs and need of emergency referral to implement community health prevention and behavior change communication (BCC) activities in colla-boration with BHS.
A process called Accountability, Equity, and Inclusion (AEI) practice cycle was also conducted as a series of meetings between BHS, VHC and local NGO. It is applied to identify the gaps in MNCH care after discussions have been made between local NGO, BHS and VHC thereby aiming for improving MNCH care. AEI cycle was carried out as the step-by-step approach aiming to recognize challenges, search for the solutions and make final decision after discussion with focal person from public sector.
Sample size and sampling
Sample size was
a difference in proportions of mothers on knowledge about danger signs before and after the intervention as 25% (50% before intervention and 75% after intervention). Therefore, total number of mothers needed in each township would become 140 for 95% confidence level, power of 80%, design effect of 2, and non-response rate 5%. Cluster sampling was applied to recruit the required sample size. At each township, seven villages were randomly chosen considering to include from different geographical areas and after excluding the no-go zones and conflict areas. At each selected village, a total of 20-25 eligible participants were recruited. A total of 12 qualitative interviews were done by using purposive sampling.
interviewers was done at Department of Medical Research before field data
collection. Using a
pre-tested, structured questionnaire, face-to-face interviews were conducted
with mothers of under two years old children by well-trained interviewers.
In some villages, interviews were done with the help of trained translators. Outcome measures for quantitative assessment were knowledge and practice of mothers on antenatal, delivery and post-natal period. Key informant interviews (KIIs) with responsible service providers and in-depth interviews (IDIs) with volunteers and VHC members were also carried out using the guidelines. Confidentiality of the participants’ information was ensured.
Data management and analysis
Data entry was done using EpiData-3.1 and analyses were conducted using SPSS version 20. Descriptive statistics were shown as frequency and percentage for categorical variables and as mean or median for continuous variables. Comparison of out- come measures was done using Chi square test. Manual thematic analysis was applied for qualitative information. Triangulation of the research results was done from both quantitative and qualitative information to capture the comprehensive understanding of the program.
consent was taken from all the participants after thorough explanation about
the assessment. Anonymity and confi-dentiality of the information were ensured
using the code numbers and only inves-tigators have accessed to the
The study was approved by the Ethics Review Committee of Department of Medical Research, Myanmar (Ethics/DMR/ 2017/ 159).
Community intervention approach signi-ficantly improved the knowledge and practice of mothers on maternal and newborn health care as well as strengthened the community health care network through community participation. Furthermore, revi-talization of village health committee and using volunteer health workers was bene-ficial and suitable especially in hard-to-reach areas. Applying Accountability, Equity, and Inclusion (AEI) practice cycle could also identify the gaps in MNCH care and able to recognize the challenges and search for the solutions. Such kind of approach seems effective since all concerned people included in the process which could enhance the community participation and ownership.
Application of different intervention strate-gies have
been documented in previous studies showing improvements in MNCH care as well
as challenges faced by the implementers.3-7,9,10 In Vietnam,
assessment on MCH handbook intervention was done and challenges were
identified. Although MCH outcomes were improved, weakness
in recording handbook by mothers as well
as provider was seen as a challenge.4 In
Kenya, assessment was done to see the
MNCH outcomes after using monitoring
and tracking tool for community health volunteers. After using the tool, volunteers could able to plan their activities and workloads, identify requirements of bene-ficiaries for MNCH care. Voluntary health workers acknowledged the usefulness of the tool and MNCH outcomes were also improved.9 A community-based randomized controlled trial conducted in rural Ethiopia documented the role of mobile health intervention. The study showed that improved MCH outcomes were achieved with the use of mobile phone equipped with short message service linking community health workers to health centers.10
In achieving reduction of maternal mortality, improved
knowledge and practice of mothers is essential since most maternal deaths
occurred during delivery and immediate post-natal period. Successful outcomes
in current study were improvement in knowledge as well as practice of mothers regarding MNCH. Specifically, knowledge of mothers on AN care, danger signs during pregnancy, delivery and postpartum were improved at end-line. In addition, more mothers from end-line received AN, delivery and PN care services than baseline. These showed the positive outcomes from community intervention at the townships which need maternal health intervention.
These findings are also
a review done in 2015 to assess the effectiveness of community-based inter-vention packages in reducing maternal and neonatal morbidity and mortality. According to the review, community-based intervention packages had provided the encouraging evidences of the interventions in reducing morbidity for women, morbidity and mortality for babies through a range
of community health workers and health promotion groups. It was also shown
that community-based interventions also improved the uptake of immunization and other health care seeking practices.11
Another major achievement of the current MNCH project was increased immunization coverage in both townships as mentioned by the responsible public providers. Supporting midwives to attend the monthly meeting could enable them to carry back the immunization boxes thereby increasing the immunization coverage at remote areas where routine immunization was impossible. All the focal persons from public sector and local NGO acknowledged the success of immunization coverage after initiation of the project although it was still lower than national average.
Successful MNCH outcomes were achieved along with the
improvement in community participation. It was also linked with the
revitalization of village health committees (VHC) and establishment of
“emergency fund” at the villages. As part of community intervention, village
health committees were strengthened to help mothers for emergency referral,
nutrition promotion, emergency fund raising and health education. However,
sustainability of these VHCs and their activities after the project remained as
There were certain limitations which should be acknowledged. First of all, at the time of data collection, the survey team could not get access to some villages from conflict and very hard to reach areas and we could not know the situation of mothers from these areas. Therefore, findings from current assessment reflect only to the areas which are free from these constraints. Secondly, there was a limitation in communication at some areas due to language barrier though trained translators were used to help for interviewing the participants. However, these limitations were overcome by including villages from different geographical areas and providing detailed explanation about the questionnaire to the translators.
Besides achievements, there were challenges in
different stages of the program imple-mentation. Limited human resource in
public sector, presence of restricted areas, com-munication difficulty
hindering the pre-paration of activities and language barriers were the major
challenges as identified by the local implementing partners. Practical and
sustained ways should be identified and implemented for maintaining achievement
in immunization coverage. Ways and means for the sustainability of the village health committees, volunteers, emergency referral fund and community mobilization should be considered as to maintain the achievements in MNCH care. Strengthening of the
linkage between BHS and VHC is also recommended.
Funding support for this study was provided by the International Rescue Committee in Myanmar. We sincerely acknowledged the Director Generals of the Department of Medical Research and Department of Public Health for allowing us to conduct the study and the Township Medical Officers from the study townships for their kind coordination. We are also grateful to all the participants who participated in the study.Go to : Goto
CONFLICT OF INTEREST
CONFLICT OF INTEREST
The authors declare that they have no competing interestsGo to : Goto
1. Ministry of Health and Sports, Myanmar National Health Plan 2017-2021. Naypitaw, MOHS, 2016.
2. Department of Public Health. Public Health Statistics (2014-2016). Naypitaw, MOH, 2017.
3. Horii N, Habi O, Dangana A, Maina A, Alzouma
S & Charbit Y. Community-based behavior change promoting child health
care: A response to socio-economic disparity. Journal of Health, Population, and Nutrition 2016; 35:12. Available from: [doi:10. 1186/ s41043-016-0048-y]
4. Aiga H, Nguyen VD, Nguyen CD, Nguyen TTT & Nguyen LTP. Knowledge, attitude and practices: Assessing maternal and child health care handbook intervention in Vietnam. BMC Public Health 2016; 16: 129. Available from: [doi:10.1186/s 12889-016-2788-4]
5. Department of Medical Research & Burnet Institute. End-line report on “Male participation in maternal and newborn health: community-based intervention”. Yangon, DMR, 2014.
6. Cofie LE, Barrington C, Akaligaung A, et al. Integrating community outreach
into a quality improvement project to promote maternal
and child health in Ghana. Global Public
Health 2014; 9(10): 1184-1197. Available from: [doi:10.1080/ 17441692. 2014. 952656]
7. Perry H, Morrow M, Borger S, et al. Care Groups I: An Innovative community-based
strategy for improving maternal, neonatal,
and child health in resource-constrained settings. Global Health: Science and Practice 2015; 3(3): 358-369. Available from: [doi:10.9745/ GHSP-D-15-00051]
8. Kyaw Oo, Thida, Yadana Aung, Kyaw Thu Soe & Nyein Nyein Thaung. Baseline report on “Knowledge, attitude, practices and coverage of maternal, newborn and child health care at selected townships in southern Chin State.” Yangon, DMR, 2016.
9. Avery LS, Du Plessis E, Shaw SY, et al. Enhancing the capacity and effectiveness of community health volunteers to improve maternal, newborn and child health: Exp-erience from Kenya. Canadian Journal of Public Health 2017; 108(4): e427-e434. Available from: [doi: 10.17269/cjph.108.5578]
10. Atnafu A, Otto K & Herbst CH. The role of Health intervention on maternal and child health service delivery: Findings from a randomized controlled field trial in rural Ethiopia. Mobile Health 2017; 3: 39 Available from: [doi: 10.21037/mhealth.2017.08.04]
11. Lassi ZS, Haider BA & Bhutta ZA. Community-based intervention packages
for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Systematic Reviews 2010; (11): CD007754. Available from: [doi: 10.1002/ 14651858. CD007 754]