- Email: [email protected]
Influencing birth outcomes in Nepal
Comment
Meta-analyses of epidemiological data from multiple countries and modelled estimates of their total healtheffects have advanced our understanding of important health-risks and their geographical distributions worldwide. INTERHEART provides the next important step in this process through coordinated collection of primary data. The findings should motivate future coordinated research on complex exposures, their social and behavioural determinants, and their interventions where cross-population differences will prove as informative as similarities.
Majid Ezzati Harvard School of Public Health, Boston, MA 02115, USA [email protected]
8
9
10 11
12
13
14
I thank Stephen Vander Hoorn for comments. I am supported by the National Institute on Aging Grant PO1-AG17625. I declare that I have no conflict of interest. 1 2 3
4 5 6
7
Preston SH. Mortality patterns in national populations: with special reference to recorded causes of death. New York: Academic Press, 1976. Peto R, Lopez AD, Boreham J, Thun M, Heath C Jr. Mortality from tobacco in developed countries. Lancet 1992; 339: 1268–78. Ezzati M, Lopez AD, Rodgers A, et al, for the Comparative Risk Assessment Collaborative Group. Selected major risk factors and global and regional burden of disease. Lancet 2002; 360: 1347–60. Yusuf S. Two decades of progress in preventing vascular disease. Lancet 2002; 360: 2–3. Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80%. BMJ 2003; 326: 1419. Ezzati M, Vander Hoorn S, Rodgers A, et al. Estimates of global and regional potential health gains from reducing multiple major risk factors. Lancet 2003; 362: 271–80. Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360: 1903–13.
15
16
17 18 19
20
Calle EE, Thun MJ, Petrelli JM, Rodriguez C, Heath CW Jr. Body-mass index and mortality in a prospective cohort of US adults. N Engl J Med 1999; 341: 1097–105. Law MR, Wald NJ, Thompson SG. By how much and how quickly does reduction in serum cholesterol concentration lower risk of ischaemic heart disease? BMJ 1994; 308: 367–73. Zhang X, Patel A, Horibe H, et al. Cholesterol, coronary heart disease, and stroke in the Asia Pacific region. Int J Epidemiol 2003; 32: 563–72. Lawes CM, Rodgers A, Bennett DA, et al. Blood pressure and cardiovascular disease in the Asia Pacific region. J Hypertens 2003; 21: 707–16. Jee SH, Suh I, Kim IS, Appel LJ. Smoking and atherosclerotic cardiovascular disease in men with low levels of serum cholesterol: the Korea Medical Insurance Corporation Study. JAMA 1999; 282: 2149–55. Murray CJL, Lauer JA, Hutubessy RC, et al. Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular-disease risk. Lancet 2003; 361: 717–25. Rehm J, Room R, Monteiro M, et al. Alcohol use. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: WHO, 2004: 959–1108. Lock K, Pomerleau J, Causer L, McKee M. Low fruit and vegetable consumption. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: WHO, 2004: 597–728. Bull FC, Armstrong TP, Dixon T, Ham S, Neiman A, Pratt M. Physical inactivity. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: WHO, 2004: 729–881. Evans AS. Causation and disease: the Henle-Koch postulates revisited. Yale J Biol Med 1976; 49: 175–95. McEwen BS. Protective and damaging effects of stress mediators. N Engl J Med 1998; 338: 171–79. Stampfer MJ, Hu FB, Manson JE, Rimm EB, Willett WC. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med 2000; 343: 16–22. Magnus P, Beaglehole R. The real contribution of the major risk factors to the coronary epidemics: time to end the “only-50%” myth. Arch Intern Med 2001; 161: 2657–60.
Influencing birth outcomes in Nepal See Articles page 970
914
In this issue of The Lancet, Dharma Manandhar and colleagues report a cluster-randomised trial of the effect of women’s groups on birth outcomes in Nepal. They studied 12 matched pairs of geopolitical clusters in the Makwanpur district—a poor rural population—with random assignment of one cluster in each pair to participate in the intervention. During the 2-year study, control clusters had 37 neonatal deaths per 1000 livebirths. With a low-cost participatory intervention, Manandhar and colleagues showed a 30% reduction in neonatal mortality, the primary outcome, and an even more substantial reduction in maternal mortality, a secondary outcome of this study. This improvement is likely to have occurred because women's group activities in the intervention clusters influenced women to have more antenatal care, institutional delivery, trained birth-attendance, and hygienic care. The most common causes of neonatal death were complications of preterm birth, presumptive birthasphyxia, and infection. Infection-related deaths were less common in intervention clusters than in control clusters.
Manandhar and colleagues’ study is seminal and deserves widespread attention for many reasons. To our knowledge, the study is the first randomised trial of a community-based strategy to reduce neonatal mortality and of women’s groups to improve health outcomes. The lack of such trials is unfortunate and indicates insufficient attention to neonatal mortality, participatory interventions, and to research necessary to generate a strong foundation for population-based primary prevention. The lack of such trials is, however, understandable. Intervention trials are much needed, but are multidimensional and challenging. The behavioural intervention studied by Manandhar and the research infrastructure needed to do it took many years to develop, was shaped from the lessons learnt from previous demonstration projects in several countries, involved substantial human resources, depended on political will and stability, and required a high degree of international, national, and local cooperation.1–3 This important study contributes to a growing body of experience and peerwww.thelancet.com Vol 364 September 11, 2004
Comment
Pakistan China Nepal Bhutan
Bangladesh
India
Survival pointed to this inequity and issued a compelling call to leaders, governments, and citizens to translate knowledge into action.11,12 In many ways, the study by Manandhar and colleagues powerfully resounds that call, and provides a model of how multisectoral collaborations can work to ensure the dissemination and use of simple affordable interventions to improve the health of mothers and children, and in the process, achieve more vibrant communities. But to achieve the millennium goals, this study is not the end; it is only part of the beginning. We now need to assess factors affecting neonatal intervention effectiveness and sustainability. The intervention described by Manandhar and colleagues, and other successful population-based participatory approaches, especially breastfeeding interventions, must be adapted to the circumstances of each country and culture, integrated with primary-care systems, and taken to scale worldwide to prevent the tragedy of millions of unnecessary maternal and child deaths each year.
*Ardythe L Morrow, Adekunle Dawodu Children's Hospital Medical Center, Center for Epidemiology and Biostatistics, Cincinnati, OH 45229, USA [email protected] Sri Lanka
We declare that we have no conflict of interest.
reviewed publications that show successful mobilisation of communities through motivated and well-trained lay helpers to achieve improved health-care delivery and behaviour, resulting in improved health outcomes.1,2,4,5 The empowerment approach was low cost, seems sustainable and scalable, and shows the potential of welltargeted demand-side interventions.6,7 Key to success was the remarkable capacity and altruism of the lay women who facilitated the women’s group activities and moved each group through a purposeful cycle of assessment, sharing experiences, planning, action, and reassessment. The development goals adopted at the Millennium Summit of the United Nations in September, 2000, call for a dramatic reduction in poverty and marked improvements in the health of the poor. In 2002, as part of the Millennium Development Goals, nations pledged to ensure a two-third’s reduction in child mortality by 2015 compared with 1990.8,9 The global estimate of deaths in children under 5 years of age is 10·8 million, with about 4 million deaths being neonatal.9 Thus substantial progress in child survival requires a focus on reducing neonatal mortality. The millennium goal for child survival, although it might seem ambitious, could be achieved with known interventions.10 Thus the most fundamental constraint in improving child survival is the failure of delivery. About a year ago in The Lancet, the Bellagio Study Group on Child www.thelancet.com Vol 364 September 11, 2004
1
Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD. Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lancet 1999; 354: 1955–61. 2 Howard-Grabman L, Seoane G, Davenport C, MotherCare and Save the Children. The Warmi Project: a participatory approach to improve maternal and neonatal health, an implementor’s manual. Westport: John Snow International, Mothercare Project, Save the Children, 2002. 3 Pradhan EK, Katz J, LeClerq SC, West KP Jr. Data management for large community trials in Nepal. Control Clin Trials 1994; 15: 220–34. 4 Bhandari N, Bahl R, Mazumdar S, et al. Effect of community-based promotion of exclusive breast-feeding on diarrhoeal illness and growth: a cluster randomised controlled trial. Lancet 2003; 361: 1418–23. 5 Morrow AL, Guerrero ML, Shults J, et al. Efficacy of home-based peer counselling to promote exclusive breastfeeding: a randomised controlled trial. Lancet 1999; 353: 1226–31. 6 Morgan LM. Community participation in health: perpetual allure, persistent challenge. Health Pol Plan 2001; 16: 221–30. 7 Ensor T, Cooper S. Overcoming barriers to health service access: influencing the demand side. Health Pol Plan 2004; 19: 69—79. 8 UN. General assembly, 56th session. Road map towards the implementation of the United Nations millennium declaration: report of the Secretary-General (UN document no. A/56/326). New York: United Nations, 2001. 9 Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003; 361: 2226–34. 10 Jones G, Steketee RW, Black RE, and the Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003; 362: 65–71. 11 Victora CG, Wagstaff A, Schellenberg JA, Gwatkin D, Claeson M, Habicht JP. Applying an equity lens to child health and mortality: more of the same is not enough. Lancet 2003; 362: 233–41. 12 The Bellagio Study Group on Child Survival. Knowledge into action for child survival. Lancet 2003; 362: 323–27.
915
Meta-analyses of epidemiological data from multiple countries and modelled estimates of their total healtheffects have advanced our understanding of important health-risks and their geographical distributions worldwide. INTERHEART provides the next important step in this process through coordinated collection of primary data. The findings should motivate future coordinated research on complex exposures, their social and behavioural determinants, and their interventions where cross-population differences will prove as informative as similarities.
Majid Ezzati Harvard School of Public Health, Boston, MA 02115, USA [email protected]
8
9
10 11
12
13
14
I thank Stephen Vander Hoorn for comments. I am supported by the National Institute on Aging Grant PO1-AG17625. I declare that I have no conflict of interest. 1 2 3
4 5 6
7
Preston SH. Mortality patterns in national populations: with special reference to recorded causes of death. New York: Academic Press, 1976. Peto R, Lopez AD, Boreham J, Thun M, Heath C Jr. Mortality from tobacco in developed countries. Lancet 1992; 339: 1268–78. Ezzati M, Lopez AD, Rodgers A, et al, for the Comparative Risk Assessment Collaborative Group. Selected major risk factors and global and regional burden of disease. Lancet 2002; 360: 1347–60. Yusuf S. Two decades of progress in preventing vascular disease. Lancet 2002; 360: 2–3. Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80%. BMJ 2003; 326: 1419. Ezzati M, Vander Hoorn S, Rodgers A, et al. Estimates of global and regional potential health gains from reducing multiple major risk factors. Lancet 2003; 362: 271–80. Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360: 1903–13.
15
16
17 18 19
20
Calle EE, Thun MJ, Petrelli JM, Rodriguez C, Heath CW Jr. Body-mass index and mortality in a prospective cohort of US adults. N Engl J Med 1999; 341: 1097–105. Law MR, Wald NJ, Thompson SG. By how much and how quickly does reduction in serum cholesterol concentration lower risk of ischaemic heart disease? BMJ 1994; 308: 367–73. Zhang X, Patel A, Horibe H, et al. Cholesterol, coronary heart disease, and stroke in the Asia Pacific region. Int J Epidemiol 2003; 32: 563–72. Lawes CM, Rodgers A, Bennett DA, et al. Blood pressure and cardiovascular disease in the Asia Pacific region. J Hypertens 2003; 21: 707–16. Jee SH, Suh I, Kim IS, Appel LJ. Smoking and atherosclerotic cardiovascular disease in men with low levels of serum cholesterol: the Korea Medical Insurance Corporation Study. JAMA 1999; 282: 2149–55. Murray CJL, Lauer JA, Hutubessy RC, et al. Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular-disease risk. Lancet 2003; 361: 717–25. Rehm J, Room R, Monteiro M, et al. Alcohol use. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: WHO, 2004: 959–1108. Lock K, Pomerleau J, Causer L, McKee M. Low fruit and vegetable consumption. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: WHO, 2004: 597–728. Bull FC, Armstrong TP, Dixon T, Ham S, Neiman A, Pratt M. Physical inactivity. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: WHO, 2004: 729–881. Evans AS. Causation and disease: the Henle-Koch postulates revisited. Yale J Biol Med 1976; 49: 175–95. McEwen BS. Protective and damaging effects of stress mediators. N Engl J Med 1998; 338: 171–79. Stampfer MJ, Hu FB, Manson JE, Rimm EB, Willett WC. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med 2000; 343: 16–22. Magnus P, Beaglehole R. The real contribution of the major risk factors to the coronary epidemics: time to end the “only-50%” myth. Arch Intern Med 2001; 161: 2657–60.
Influencing birth outcomes in Nepal See Articles page 970
914
In this issue of The Lancet, Dharma Manandhar and colleagues report a cluster-randomised trial of the effect of women’s groups on birth outcomes in Nepal. They studied 12 matched pairs of geopolitical clusters in the Makwanpur district—a poor rural population—with random assignment of one cluster in each pair to participate in the intervention. During the 2-year study, control clusters had 37 neonatal deaths per 1000 livebirths. With a low-cost participatory intervention, Manandhar and colleagues showed a 30% reduction in neonatal mortality, the primary outcome, and an even more substantial reduction in maternal mortality, a secondary outcome of this study. This improvement is likely to have occurred because women's group activities in the intervention clusters influenced women to have more antenatal care, institutional delivery, trained birth-attendance, and hygienic care. The most common causes of neonatal death were complications of preterm birth, presumptive birthasphyxia, and infection. Infection-related deaths were less common in intervention clusters than in control clusters.
Manandhar and colleagues’ study is seminal and deserves widespread attention for many reasons. To our knowledge, the study is the first randomised trial of a community-based strategy to reduce neonatal mortality and of women’s groups to improve health outcomes. The lack of such trials is unfortunate and indicates insufficient attention to neonatal mortality, participatory interventions, and to research necessary to generate a strong foundation for population-based primary prevention. The lack of such trials is, however, understandable. Intervention trials are much needed, but are multidimensional and challenging. The behavioural intervention studied by Manandhar and the research infrastructure needed to do it took many years to develop, was shaped from the lessons learnt from previous demonstration projects in several countries, involved substantial human resources, depended on political will and stability, and required a high degree of international, national, and local cooperation.1–3 This important study contributes to a growing body of experience and peerwww.thelancet.com Vol 364 September 11, 2004
Comment
Pakistan China Nepal Bhutan
Bangladesh
India
Survival pointed to this inequity and issued a compelling call to leaders, governments, and citizens to translate knowledge into action.11,12 In many ways, the study by Manandhar and colleagues powerfully resounds that call, and provides a model of how multisectoral collaborations can work to ensure the dissemination and use of simple affordable interventions to improve the health of mothers and children, and in the process, achieve more vibrant communities. But to achieve the millennium goals, this study is not the end; it is only part of the beginning. We now need to assess factors affecting neonatal intervention effectiveness and sustainability. The intervention described by Manandhar and colleagues, and other successful population-based participatory approaches, especially breastfeeding interventions, must be adapted to the circumstances of each country and culture, integrated with primary-care systems, and taken to scale worldwide to prevent the tragedy of millions of unnecessary maternal and child deaths each year.
*Ardythe L Morrow, Adekunle Dawodu Children's Hospital Medical Center, Center for Epidemiology and Biostatistics, Cincinnati, OH 45229, USA [email protected] Sri Lanka
We declare that we have no conflict of interest.
reviewed publications that show successful mobilisation of communities through motivated and well-trained lay helpers to achieve improved health-care delivery and behaviour, resulting in improved health outcomes.1,2,4,5 The empowerment approach was low cost, seems sustainable and scalable, and shows the potential of welltargeted demand-side interventions.6,7 Key to success was the remarkable capacity and altruism of the lay women who facilitated the women’s group activities and moved each group through a purposeful cycle of assessment, sharing experiences, planning, action, and reassessment. The development goals adopted at the Millennium Summit of the United Nations in September, 2000, call for a dramatic reduction in poverty and marked improvements in the health of the poor. In 2002, as part of the Millennium Development Goals, nations pledged to ensure a two-third’s reduction in child mortality by 2015 compared with 1990.8,9 The global estimate of deaths in children under 5 years of age is 10·8 million, with about 4 million deaths being neonatal.9 Thus substantial progress in child survival requires a focus on reducing neonatal mortality. The millennium goal for child survival, although it might seem ambitious, could be achieved with known interventions.10 Thus the most fundamental constraint in improving child survival is the failure of delivery. About a year ago in The Lancet, the Bellagio Study Group on Child www.thelancet.com Vol 364 September 11, 2004
1
Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD. Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lancet 1999; 354: 1955–61. 2 Howard-Grabman L, Seoane G, Davenport C, MotherCare and Save the Children. The Warmi Project: a participatory approach to improve maternal and neonatal health, an implementor’s manual. Westport: John Snow International, Mothercare Project, Save the Children, 2002. 3 Pradhan EK, Katz J, LeClerq SC, West KP Jr. Data management for large community trials in Nepal. Control Clin Trials 1994; 15: 220–34. 4 Bhandari N, Bahl R, Mazumdar S, et al. Effect of community-based promotion of exclusive breast-feeding on diarrhoeal illness and growth: a cluster randomised controlled trial. Lancet 2003; 361: 1418–23. 5 Morrow AL, Guerrero ML, Shults J, et al. Efficacy of home-based peer counselling to promote exclusive breastfeeding: a randomised controlled trial. Lancet 1999; 353: 1226–31. 6 Morgan LM. Community participation in health: perpetual allure, persistent challenge. Health Pol Plan 2001; 16: 221–30. 7 Ensor T, Cooper S. Overcoming barriers to health service access: influencing the demand side. Health Pol Plan 2004; 19: 69—79. 8 UN. General assembly, 56th session. Road map towards the implementation of the United Nations millennium declaration: report of the Secretary-General (UN document no. A/56/326). New York: United Nations, 2001. 9 Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003; 361: 2226–34. 10 Jones G, Steketee RW, Black RE, and the Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003; 362: 65–71. 11 Victora CG, Wagstaff A, Schellenberg JA, Gwatkin D, Claeson M, Habicht JP. Applying an equity lens to child health and mortality: more of the same is not enough. Lancet 2003; 362: 233–41. 12 The Bellagio Study Group on Child Survival. Knowledge into action for child survival. Lancet 2003; 362: 323–27.
915