Estimation of potential effects of improved community-based drug provision, to augment health-facility strengthening, on maternal mortality due to post-partum haemorrhage and sepsis in sub-Saharan Africa: an equity-effectiveness model

  • The Lancet, Volume 374, No. 9699, Year 2009

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Study Justification:
The study aimed to assess whether improved community-based access to life-saving drugs, in addition to health-facility strengthening, could reduce maternal mortality due to post-partum hemorrhage and sepsis in sub-Saharan Africa. This is important because maternal mortality rates in Africa have not significantly improved since 1990.
Highlights:
– The study developed a mathematical model to estimate the potential effects of different intervention packages.
– Three potential packages of interventions were considered: health-facility strengthening, health-facility strengthening combined with improved drug provision through antenatal care appointments and community health workers, and all interventions in package two combined with improved community-based drug provision through female volunteers in villages.
– The model was applied to Malawi and sub-Saharan Africa.
– The study estimated that the intervention packages could prevent a significant number of maternal deaths from post-partum hemorrhage and sepsis.
– The estimated effect of community-based drug provision was greatest for the poorest women.
Recommendations:
– The study recommends the implementation of community provision of misoprostol and antibiotics to reduce maternal deaths from post-partum hemorrhage and sepsis.
– It suggests that this community-based drug provision could be a highly effective addition to health-facility strengthening in Africa.
– The study emphasizes the need for further investigation to establish the risks, benefits, and challenges of widespread implementation of these interventions.
Key Role Players:
– Health facility staff
– Antenatal care providers
– Community health workers
– Female volunteers in villages
Cost Items for Planning Recommendations:
– Training and capacity building for health facility staff, antenatal care providers, community health workers, and female volunteers
– Procurement and distribution of misoprostol and antibiotics
– Monitoring and evaluation of the intervention
– Communication and awareness campaigns
– Infrastructure and equipment for health facilities and community-based drug provision

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Background: Maternal mortality in Africa has changed little since 1990. We developed a mathematical model with the aim to assess whether improved community-based access to life-saving drugs, to augment a core programme of health-facility strengthening, could reduce maternal mortality due to post-partum haemorrhage or sepsis. Methods: We developed a mathematical model by considering the key events leading to maternal death from post-partum haemorrhage or sepsis after delivery. With parameter estimates from published work of occurrence of post-partum haemorrhage and sepsis, case fatality, and the effectiveness of drugs, we used this model to estimate the effect of three potential packages of interventions: 1) health-facility strengthening; 2) health-facility strengthening combined with improved drug provision via antenatal-care appointments and community health workers; and 3) all interventions in package two combined with improved community-based drug provision via female volunteers in villages. The model was applied to Malawi and sub-Saharan Africa. Findings: In the implementation of the model, the lowest risk deliveries were those in health facilities. With the model we estimated that of 2860 maternal deaths from post-partum haemorrhage or sepsis per year in Malawi, intervention package one could prevent 210 (7%) deaths, package two 720 (25%) deaths, and package three 1020 (36%) deaths. In sub-Saharan Africa, we estimated that of 182 000 of such maternal deaths per year, these three packages could prevent 21 300 (12%), 43 800 (24%), and 59 000 (32%) deaths, respectively. The estimated effect of community-based drug provision was greatest for the poorest women. Interpretation: Community provision of misoprostol and antibiotics to reduce maternal deaths from post-partum haemorrhage and sepsis could be a highly effective addition to health-facility strengthening in Africa. Investigation of such interventions is urgently needed to establish the risks, benefits, and challenges of widespread implementation. Funding: Institute of Child Health and Faculty of Mathematical and Physical Sciences, University College London, and a donation from John and Ann-Margaret Walton. © 2009 Elsevier Ltd. All rights reserved.

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The publication titled “Estimation of potential effects of improved community-based drug provision, to augment health-facility strengthening, on maternal mortality due to post-partum haemorrhage and sepsis in sub-Saharan Africa: an equity-effectiveness model” recommends improving access to life-saving drugs for maternal health in sub-Saharan Africa. The study suggests that community-based provision of drugs, such as misoprostol and antibiotics, in addition to strengthening health facilities, could significantly reduce maternal mortality due to post-partum hemorrhage and sepsis.

The study proposes three intervention packages:
1) Health-facility strengthening alone
2) Health-facility strengthening combined with improved drug provision through antenatal care appointments and community health workers
3) All interventions in package two combined with improved community-based drug provision through female volunteers in villages.

The findings of the study indicate that implementing these intervention packages could prevent a significant number of maternal deaths. In Malawi, package one could prevent 7% of deaths, package two could prevent 25% of deaths, and package three could prevent 36% of deaths from post-partum hemorrhage and sepsis. In sub-Saharan Africa, these packages could prevent 12%, 24%, and 32% of maternal deaths, respectively.

The study emphasizes the importance of community-based drug provision, particularly for the poorest women, as it could be a highly effective addition to health-facility strengthening efforts in Africa. However, further investigation is needed to determine the risks, benefits, and challenges of implementing these interventions on a wider scale.

This publication was published in The Lancet in 2009 and was funded by the Institute of Child Health and Faculty of Mathematical and Physical Sciences, University College London, as well as a donation from John and Ann-Margaret Walton.
AI Innovations Description
The recommendation proposed in the publication titled “Estimation of potential effects of improved community-based drug provision, to augment health-facility strengthening, on maternal mortality due to post-partum haemorrhage and sepsis in sub-Saharan Africa: an equity-effectiveness model” is to improve access to life-saving drugs for maternal health in sub-Saharan Africa. The study suggests that community-based provision of drugs, such as misoprostol and antibiotics, in addition to strengthening health facilities, could significantly reduce maternal mortality due to post-partum hemorrhage and sepsis.

The study developed a mathematical model to estimate the potential impact of different intervention packages. The three packages considered were: 1) health-facility strengthening alone, 2) health-facility strengthening combined with improved drug provision through antenatal care appointments and community health workers, and 3) all interventions in package two combined with improved community-based drug provision through female volunteers in villages.

The findings of the study indicate that the implementation of these intervention packages could prevent a significant number of maternal deaths. In Malawi, package one could prevent 7% of deaths, package two could prevent 25% of deaths, and package three could prevent 36% of deaths from post-partum hemorrhage and sepsis. In sub-Saharan Africa, these packages could prevent 12%, 24%, and 32% of maternal deaths, respectively.

The study highlights the importance of community-based drug provision, particularly for the poorest women, as it could be a highly effective addition to health-facility strengthening efforts in Africa. However, further investigation is needed to establish the risks, benefits, and challenges of implementing these interventions on a wider scale.

This publication was published in The Lancet in 2009 and was funded by the Institute of Child Health and Faculty of Mathematical and Physical Sciences, University College London, as well as a donation from John and Ann-Margaret Walton.
AI Innovations Methodology
The methodology used in the study to simulate the impact of the recommendations on improving access to maternal health involved developing a mathematical model. The model considered key events leading to maternal death from post-partum hemorrhage or sepsis after delivery.

To estimate the effect of different intervention packages, the model used parameter estimates from published work on the occurrence of post-partum hemorrhage and sepsis, case fatality rates, and the effectiveness of drugs.

The three intervention packages considered were:
1) Health-facility strengthening alone.
2) Health-facility strengthening combined with improved drug provision through antenatal care appointments and community health workers.
3) All interventions in package two combined with improved community-based drug provision through female volunteers in villages.

The model was applied to both Malawi and sub-Saharan Africa. It estimated the number of maternal deaths from post-partum hemorrhage and sepsis that could be prevented by each intervention package.

The findings of the study showed that the implementation of these intervention packages could prevent a significant number of maternal deaths. The impact was greatest for the third package, which included improved community-based drug provision.

The study concluded that community provision of drugs, such as misoprostol and antibiotics, could be a highly effective addition to health-facility strengthening efforts in Africa. However, further investigation is needed to understand the risks, benefits, and challenges of implementing these interventions on a wider scale.


Statistics:
Citations: 48
Identifiers:
DOI: 10.1016/S0140-6736(09)61566-X
ISSN: 01406736
Research Areas:
Community Interventions, Health System and Policy, Maternal and Child Health, Quality of Care, Workforce
Study Countries:
Malawi
Study Design:
randomised-control-trial
Participants Gender:
Female
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