Progress toward the Millennium Development Goals has been uneven, especially in maternal and child health. One third of global childhood deaths are attributable to inequalities in socioeconomic mortality within countries. Even though effective interventions are known, they are rarely available to those who desperately need them. Community-based interventions are critical to improve neonatal survival, but the equity impact of these endeavors is unclear. The cluster-randomized controlled Ekjut trial involving a participatory women’s group intervention in India provided an opportunity to assess the effect of community interventions on equity and found a strong effect of women’s groups on the neonatal mortality rate (NMR). The present secondary analysis was undertaken to determine whether the strong effects of the intervention on NMR were also observed among lower socioeconomic groups and whether differences in the effect of the intervention on mortality were present in the most and less socioeconomically marginalized groups.
The study areas were located in 2 extremely poor Indian states. Thirty-six poor clusters with a predominantly tribal population were randomly assigned to an intervention or control group. The intervention arm received an intervention with participatory women’s groups. During the 3-year study period, they met monthly and were led by a facilitator. Maternal and newborn health problems were identified and prioritized. Strategies to address these problems were developed, implemented, and evaluated, with the support of the entire community. All live births and neonatal deaths in the study areas were recorded. At 6-week postpartum, the mother was interviewed and asked about socioeconomic and sociodemographic background characteristics, home care practices, use of health care services, and her and the baby’s condition. The primary outcome was the equity impact of the intervention for NMRs among lower and higher socioeconomic groups. The main analyses were done for years 2 and 3 combined. About 30% of the study population belonged to the most socioeconomically marginalized groups.
In the intervention arm, the NMR declined by greater than 50% and by 71% between the 9-month baseline and year 3 among lower socioeconomic and the most marginalized groups, respectively. Among higher socioeconomic groups in the intervention arm, the NMR also declined, but less strongly. The difference in mortality trend between the most and less marginalized groups indicated that the mortality disadvantage of the most marginalized disappeared and was even reversed in year 3 (odds ratio for the most/less marginalized in year 3, 0.54 [95% confidence interval, 0.33–0.90]). In the control areas, the NMR remained stable or increased among all social groups. A large effect was seen among lower socioeconomic and the most marginalized groups. An estimated 59% effect was seen in years 2 and 3 (70% in year 3) among the most marginalized compared with an estimated 36% effect (35% in year 3) among the less marginalized (P for difference: 0.028 for years 2–3; 0.009 for year 3). The stronger effect of the intervention among the most marginalized groups was concentrated in early NMR (days 1–7). In year 3, this was complemented by an effect on the late NMR (days 8–28). The intervention may have influenced food intake, thermal care, and breast-feeding among the most and the less marginalized along with hygienic practices for home deliveries. These effects were comparable among the most and the less marginalized groups. No effect was seen for the overall use of health care among the most and less marginalized. Attendance at the women’s groups increased from 11% and 15% of deliveries among the most and the less marginalized, respectively, in year 1 to 59% and 52%, respectively, in year 3.
The women’s group intervention strongly reduced the NMR among lower socioeconomic groups. These findings are important because of the paucity of evidence for effective means for reducing socioeconomic inequalities in mortality. The results show that a low-cost participatory community intervention can contribute to a lowering of neonatal mortality and a lowering of socioeconomic inequalities in this area.
Institute for Global Health (T.A.J.H., A.C., A.P.), University College London, London, UK; Department of Public Health (T.A.J.H., C.W.L.), Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands; and Ekjut (P.T., N.N., Sh. Rath, Su. Rath, R.G., R.S.), Chakradharpur, Jharkhand, India