WHO recommendation on community mobilization and antenatal home visits

WHO recommendation on community mobilization and antenatal home visits

 

Recommendation

Packages of interventions that include household and community mobilization and antenatal home visits are recommended to improve antenatal care utilization and perinatal health outcomes, particularly in rural settings with low access to health services.

(Context-specific recommendation)

 

Publication history

First published: November 2016

Updated: No update planned

Assessed as up-to-date: November 2016

 

Remarks

  • The GDG agreed that the extent to which these packages improve communication and support for pregnant women is not clear.
  • As a stand-alone intervention, the evidence does not support the use of antenatal home visits by lay health workers during pregnancy to improve ANC utilization health outcomes. While the quality and effectiveness of communication during home visits, and the extent to which they increase support for women, is not clear, antenatal home visits may be helpful in ensuring continuity of care across the antenatal, intrapartum and postnatal periods and in promoting other healthy behaviour.
  • Stakeholders need to be clear that antenatal home visits by lay health workers do not replace ANC visits.
  • Stakeholders should implement health system strengthening interventions alongside these community-based interventions.
  • Health-care providers need initial and ongoing training in communication with women and their partners. For women’s groups and community mobilization, providers also need training on group facilitation, in the convening of public meetings and in other methods of communication.
  • Information for women and community members should be provided in languages and formats accessible to them and programme planners need to ensure that health-care providers/facilitators have reliable supplies of appropriate information materials.
  • Programme planners should be aware of the potential for additional costs associated with home visits and community mobilization initiatives, including the potential need for extra staff and travel expenses.
  • When considering the use of antenatal home visits, women’s groups, partner involvement or community mobilization, programme planners need to ensure that these can be implemented in a way that respects and facilitates women’s needs for privacy as well as their choices and their autonomy in decision-making. By offering pregnant women a range of opportunities for contact, communication and support, their individual preferences and circumstances should also be addressed.
  • Further research is needed on the acceptability and feasibility of mixed-gender communication, the optimal methods for community mobilization, the best model for integration with health systems, continuity elements of home visits, and the mechanisms of effect of these interventions.

 

Background

The scoping review conducted for the ANC guideline identified communication and support for women as integral components of positive pregnancy experiences. The term “communicate” refers to the act of sharing information, education and communication with women about timely and relevant physiological, biomedical, behavioural and sociocultural issues; “support” refers to social, cultural, emotional and psychological support (1). Having access to appropriate communication and support is a key element of a quality ANC service. A human-rights-based approach recognizes that women are entitled to participate in decisions that affect their sexual and reproductive health (2). In addition, pregnant women have a right to access quality health-care services and, particularly in low-resource settings, may need to be empowered to do so. Interventions that increase the dialogue around awareness of a women’s rights, barriers and facilitators to utilizing ANC services and keeping healthy during pregnancy and beyond (including dialogue around newborn care and postnatal family planning), and providing women and their partners with support in addressing challenges they may face, may lead to improved ANC uptake and quality of care.

 

Methods

The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (3). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (4) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) (5) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (6) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

  • Should community-based interventions that increase communication with, and support for, pregnant women be recommended to improve ANC coverage and pregnancy outcomes?

 

Evidence summary

The evidence on the effects of community mobilization and antenatal home visits was synthesized from data derived from a Cochrane review of health system and community-level interventions for improving ANC coverage and health outcomes (7). Four large cluster-RCTs conducted in rural Bangladesh, India and Pakistan contributed data on packages of interventions involving community mobilization and antenatal home visits versus no intervention (8-11). Health system strengthening occurred in both the intervention and control groups in two of the trials. The focus of these packages was generally to promote maternal health education, ANC attendance and other care-seeking behaviour, tetanus toxoid vaccinations and iron and folic acid supplements, and birth and newborn-care preparedness. Household visits were performed by trained lay health workers and consisted of at least two visits during pregnancy. In two trials, these visits were targeted to occur at 12–16 weeks of gestation and 32–34 weeks; in one trial, these visits both occurred in the third trimester; and in the fourth trial the timing of the visits was not specified. Multilevel community mobilization strategies included advocacy work with community stakeholders (community leaders, teachers, and other respected members), TBAs, husbands or partners, and households (husbands or partners, women, and other family members). Two intervention packages included group education sessions for women focusing on key knowledge and behaviour around pregnancy and early neonatal care, including promotion of ANC and other health education. One intervention package included husband education via booklets and audio cassettes. Training of TBAs to recognize common obstetric and newborn emergencies was a component of three intervention packages. In one trial, telecommunication systems with transport linkages were also set up as part of the intervention package. In another trial, community health committees were encouraged to establish an emergency transport fund and use local vehicles, in addition to advocacy work, household visits and women’s meetings.

Maternal outcomes

Moderate-certainty evidence indicates that intervention packages with community mobilization and antenatal home visits probably have little or no effect on maternal mortality (2 trials; RR: 0.76, 95% CI: 0.44–1.31).

Fetal and neonatal outcomes

Moderate-certainty evidence indicates that intervention packages with community mobilization and antenatal home visits probably reduce perinatal mortality (3 trials; RR: 0.65, 95% CI: 0.48–0.88).

Coverage outcomes

High-certainty evidence shows that intervention packages with community mobilization and antenatal home visits improve ANC coverage of at least one visit (4 trials; RR: 1.76, 95% CI: 1.43–2.16). However, moderate-certainty evidence indicates that they probably have little or no effect on ANC coverage of at least four visits (1 trial; RR: 1.51, 95% CI: 0.50– 4.59) or facility-based birth (3 trials; RR: 1.46, 95% CI: 0.87–2.46).

Additional considerations

The GDG also considered evidence on antenatal home visits as a stand-alone intervention, but did not make a separate recommendation on this intervention due to the lack of evidence of benefits related to the ANC guideline outcomes. In brief, evidence of moderate- to high-certainty suggests that stand-alone antenatal home visits have little or no effect on ANC visit coverage of at least four visits (4 trials; RR: 1.09, 95% CI: 0.99–1.22), facility-based birth (4 trials; RR: 1.08, 95% CI: 0.87–1.35), perinatal mortality (4 trials; RR: 0.91, 95% CI: 0.79–1.05) and preterm birth (1 trial; RR: 0.88, 95% CI: 0.54–1.44).

The 2013 WHO recommendations on postnatal care of the mother and newborn include the following recommendation: “Home visits in the first week after birth are recommended for care of the mother and newborn (strong recommendation based on high-quality evidence for newborns and low-quality evidence for mothers).” This recommendation is accompanied by the remark “Depending on the existing health system in different settings, these home visits can be made by midwives, other skilled providers or well trained and supervised CHWs [community health workers]” (12). The 2011 WHO guidelines on Preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries strongly recommend the following in relation to the outcome “Increase use of skilled antenatal, childbirth and postnatal care among adolescents”: – “Provide information to all pregnant adolescents and other stakeholders about the importance of utilizing skilled antenatal care.” – “Provide information to all pregnant adolescents and other stakeholders about the importance of utilizing skilled childbirth care.” – “Promote birth and emergency preparedness in antenatal care strategies for pregnant adolescents (in household, community and health facility settings)” (12). Several WHO recommendations included in the 2015 WHO recommendations on health promotion interventions for maternal and newborn health are relevant to community-based interventions to improve communication and support for women during pregnancy. (13)

Resources

A systematic review of the cost–effectiveness of strategies to improve the utilization and provision of maternal and newborn health care in low- and lower-middle-income countries reported that there was reasonably strong evidence for the cost–effectiveness of the use of PLA cycles (14). Estimated costs per life saved for PLA cycle interventions alone was US$ 268 and for community mobilization combined with home visits during pregnancy and/or health system strengthening, costs ranged from US$ 707 to US$ 1489 per death averted. However, costs of these interventions are difficult to estimate and depend on context. Costing must also take into account the facilitators’ time, training and supervision; these elements are considered key to the quality of implementation and the success of the intervention.

Equity

Interventions such as PLA cycles, community mobilization and home visits during pregnancy are a way of facilitating dialogue and action with, and empowering, disadvantaged populations to engage in efforts to improve health and to strengthen broader community support. The women’s groups PLA cycles, in particular, were conducted in marginalized areas where other support mechanisms often do not exist. Interventions to engage male partners/husbands and others in the community to support women to make healthy choices for themselves and their children may help to address inequalities. However, when engaging men, it is important to consider women’s preferences, as including male partners could also have a negative effect for women who would prefer to discuss pregnancy-related and other matters without their partner’s involvement.

Acceptability

Qualitative evidence suggests that women in a variety of settings and contexts readily engage with interventions designed to increase communication and support, provided they are delivered in a caring and respectful manner (high confidence in the evidence) (15). The use of women’s groups is likely to fulfil two key requirements of ANC from a woman’s perspective – the opportunity to receive and share relevant information and the opportunity to develop supportive relationships with other women and health-care providers (high confidence in the evidence). Evidence from women and providers in LMICs also highlighted the importance of active community engagement in the design and delivery of informational-based services, especially in communities where traditional beliefs may differ from conventional understandings (moderate confidence in the evidence). Qualitative evidence from providers suggests that there is a willingness to supply pregnancy-related information and offer psychological/emotional support to women provided that resources are available (high confidence in the evidence) and the services are delivered in a coordinated, organized manner with appropriate managerial support (moderate confidence in the evidence) (16)

Feasibility

Qualitative evidence suggests that, where health-care providers are involved in facilitating women’s groups, they may need additional training to help with the facilitative components and this may be a barrier in some resource-poor settings (high confidence in the evidence). Similarly, the extra costs associated with home visits in terms of additional staff and extra resources may limit implementation in some LMICs (high confidence in the evidence) (16). It has been suggested that community-based interventions introduced through existing public sector health workers and local health systems may be more feasible and more likely to succeed than project-based interventions. (200)

 

Relevant recommendations from the 2015 WHO recommendations on health promotion interventions for maternal and newborn health

Recommendation 1: Birth preparedness and complication readiness interventions are recommended to increase the use of skilled care at birth and to increase the timely use of facility care for obstetric and newborn complications. (Strong recommendation, very low-quality evidence)

Recommendation 2: Interventions to promote the involvement of men during pregnancy, childbirth and after birth are recommended to facilitate and support improved self-care of women, improved home care practices for women and newborns, and improved use of skilled care during pregnancy, childbirth and the postnatal period for women and newborns. (Strong recommendation, very low-quality evidence) These interventions are recommended provided that they are implemented in a way that respects, promotes and facilitates women’s choices and their autonomy in decision-making, and supports women in taking care of themselves and their newborns. In order to ensure this, rigorous monitoring and evaluation of implementation is recommended.

Recommendation 3 on interventions to promote awareness of human, sexual and reproductive rights and the right to access quality skilled care: Because of the paucity of evidence available, additional research is recommended. The GDG supports, as a matter of principle, the importance for MNH programmes to inform women about their right to health and to access quality skilled care, and to continue to empower them to access such care.

Recommendation 6 on partnership with traditional birth attendants (TBAs): Where TBAs remain the main providers of care at birth, dialogue with TBAs, women, families, communities and service providers is recommended in order to define and agree on alternative roles for TBAs, recognizing the important role they can play in supporting the health of women and newborns. (Strong recommendation, very low-quality evidence)

Recommendation 7: Ongoing dialogue with communities is recommended as an essential component in defining the characteristics of culturally appropriate, quality maternity care services that address the needs of women and newborns and incorporate their cultural preferences. Mechanisms that ensure women’s voices are meaningfully included in these dialogues are also recommended. (Strong recommendation, very low-quality evidence)

Recommendation 11: Community participation in quality-improvement processes for maternity care services is recommended to improve quality of care from the perspectives of women, communities and health-care providers. Communities should be involved in jointly defining and assessing quality. Mechanisms that ensure women’s voices are meaningfully included are also recommended. (Strong recommendation, very low-quality evidence)

Recommendation 12: Community participation in programme planning, implementation and monitoring is recommended to improve use of skilled care during pregnancy, childbirth and the postnatal period for women and newborns, increase the timely use of facility care for obstetric and newborn complications and improve maternal and newborn health. Mechanisms that ensure women’s voices are meaningfully included are also recommended. (Strong recommendation, very low-quality evidence)

Source: WHO, 2015 (13).

 

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:

http://apps.who.int/iris/bitstream/10665/250796/8/9789241549912-websupplement- eng.pdf?ua=1

 

Implementation considerations

  • The successful introduction of evidence-based policies related to antenatal care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
  • An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
  • Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
  • Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Taking this as a foundation, the GDG reviewed how ANC should be delivered in terms of both the timing and content of each of the ANC contacts, and arrived at a new model – the 2016 WHO ANC model – which replaces the previous four-visit focused ANC (FANC) model. For the purpose of developing this new ANC model, the ANC recommendations were mapped to the eight contacts based on the evidence supporting each recommendation and the optimal timing of delivery of the recommended interventions to achieve maximal impact.

 

Research implications

The GDG identified this priority question related to this recommendation:

  • How acceptable and feasible are mixed-gender community mobilization groups? What are the optimal methods for community-based interventions to improve communication and support for pregnant women and adolescent girls; to improve integration of community-based mobilization efforts with health systems; and to ensure continuity of care with home visits? What are the mechanisms of effect of these interventions?

 

Related links

WHO recommendations on antenatal care for a positive pregnancy experience

(2016) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health

 

 

References

  1. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. What matters to women: a scoping review to identify the processes and outcomes of antenatal care provision that WHO recommendations on antenatal care for a positive pregnancy experience 124 are important to healthy pregnant women. BJOG. 2016;123(4):529–39. doi:10.1111/1471- 0528.13819.
  2. Office of the United Nations High Commissioner for Human Rights (OHCHR). Technical guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce preventable maternal morbidity and mortality. Human Rights Council, twentieth session. New York (NY): United Nations General Assembly; 2012 (A/ HRC/21/22; http://www2.ohchr.org/english/ issues/women/docs/A.HRC.21.22_en.pdf, accessed 28 September 2016).
  3. WHO handbook for guideline development, 2nd edition. Geneva: World Health Organization; 2014 (http://www.who.int/kms/handbook_2nd_ ed.pdf, accessed 6 October 2016).
  4. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
  5. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016).
  6. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).
  7. Baqui AH, El-Arifeen S, Darmstadt GL, Ahmed S, Williams EK, Seraji HR et al.; Projahnmo Study Group. Effect of community-based newborncare intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: a cluster-randomised controlled trial. Lancet. 2008;371(9628):1936–44. doi:10.1016/S0140-6736(08)60835-1.
  8. Bhutta ZA, Soofi S, Cousens S, Mohammad S, Memon ZA, Ali I et al. Improvement of perinatal and newborn care in rural Pakistan through community-based strategies: a cluster-randomised effectiveness trial. Lancet. 2011;377(9763):403–12. doi:10.1016/S0140- 6736(10)62274-X.
  9. Kumar V, Mohanty S, Kumar A, Misra RP, Santosham M, Awasthi S et al.; Saksham Study Group. Effect of community-based behavior change management on neonatal mortality in Shivgarh, Uttar Pradesh, India: a cluster-randomised controlled trial. Lancet. 2008;372(9644):1151–62. doi:10.1016/S0140- 6736(08)61483-X.
  10. Midhet F, Becker S. Impact of community-based intervention on maternal and neonatal health indicators: results from a community randomized trial in rural Balochistan, Pakistan. Reprod Health. 2010;7:30. doi:10.1186/1742-4755-7-30.
  11. WHO recommendations on postnatal care of the mother and newborn. Geneva: World Health Organization; 2014 (http://apps.who.int/iris/ bitstream/10665/97603/1/9789241506649_ eng.pdf, accessed 28 September 2016).
  12. WHO guidelines on preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries. Geneva: World Health Organization; 2011 (http://apps.who.int/iris/ bitstream/10665/44691/1/9789241502214_ eng.pdf, accessed 28 September 2016).
  13. WHO recommendations on health promotion interventions for maternal and newborn health. Geneva: World Health Organization; 2015 (http://apps.who.int//iris/ bitstream/10665/172427/1/9789241508742_ report_eng.pdf, accessed 28 September 2016).
  14. Mangham-Jefferies L, Pitt C, Cousens S, Mills A, Schellenberg J. Cost-effectiveness of strategies to improve the utilization and provision of maternal and newborn health care in lowincome and lower-middle-income countries: a systematic review. BMC Pregnancy Childbirth. 2014;14:243. doi:10.1186/1471-2393-14-243.
  15. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the use of routine antenatal services by pregnant women: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016;(10):CD012392
  16. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the provision of good quality routine antenatal care services by health staff: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016

 

 

Citation: WHO Reproductive Health Library. WHO recommendation on community mobilization and antenatal home visits. (November 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.