1.1 What the is problem?
Child mortality is closely linked to fourth Millennium Development Goal (MDG) of the eight goals and can be defined as the death of children under the age of five (WHO, 2015). Since the MDGs were set in 2000 a number of reports have been released to assess and evaluate the progress made (Moucheraud, Owen, Singh, Requejo, Lawn, & Berman, 2016). Child mortality reports show that there has been a significant decrease in the number of deaths in children under the age of five Worldwide. According to UNICEF child mortality rate fell by 62% from the year 1990 to the 2000’s (Hug, Sharrow, ; You, 2017). In 1990 it was reported that over 12.7 million children under the age of five had died, globally (Hug, Sharrow, ; You, 2017). However, once MDG interventions had been put into place this number had decreased to about 6.3 million in 2013 (WHO, 2015) and by the year 2016 about 5.6 million deaths had been reported. With this remarkable achievement the lives of over 50 million children had been saved around the world since the beginning of 2000, which would have not been the case had the situation remained the same as that of 1990 (Hug, Sharrow, ; You, 2017).
All the same, despite this significant progress, child mortality is still a health burden in some parts of the world, with some countries showing slower progress in reducing this burden than others. This trend has been more apparent in developing countries, 2016 reports showed that the highest under-five deaths occurred in developing countries, with 39% in south of Asia and 38% in Sub-Saharan countries (Hug, Sharrow, ; You, 2017). A country such as Malawi was not spared from the high rates of child and infant mortality. Located in Sub-Saharan Africa, a region with 14 times a higher risk for children to die before their fifth birthday compared to developed countries, the country experienced a mortality rate of 112 deaths per 1, 000 births among children under the age of five from the year 2005 to the year 2010 (Lewycka, Mwansambo, Rosato, Kazembe, Phiri, Mganga, ; Pulkki-Brännström, 2013). Most of these deaths can be attributed to preventable diseases such as malaria, malnutrition and pneumonia (WHO, 2017)
With the introduction of the MDGs and the different interventions implemented across the country, Malawi had seen a tremendous change in child health and mortality rates (Doherty, Zembe, Ngandu, Kinney, Manda, Besada ; Sanders, 2015). With this said, Malawi was noted to be one of the first and few Sub-Saharan African countries to achieve MDG 4, despite its low gross national incomes per capita (World Bank, 2015). Interventions such as the MaiMwana Project contributed to the reduction of child mortality rates within the country.
1.2. Why is it a problem?
According to O’Hare, Makuta, Chiwaula and Bar-Zeev (2013) there is a negative relationship between high child mortality and the health status of a country. Meaning, if a country has high rates of child mortality it is most likely to have a poor health status, therefore, child mortality is essentially a good measure for a country’s health status (O’Hare, Makuta, Chiwaula and Bar-Zeev, 2013). Health status can be linked to the economic development of a country, therefore it is fair to say that child mortality may directly or indirectly affect the economy of a country and vice versa. How? It has already been established that “wealthier people are healthier” and high income countries are more likely have better health outcomes, which would be measured by looking at different indicators such as life expectancy and child mortality rates (Hague, Gottschalk & Martins, 2008). But what does child mortality have to do with a country’s income? Following a study done Amiria and Gerdthamb (2013), the improvement of health in children together with the increase in the survival rates of infants would provide a larger population in the future that would bring in a variety of skills into the country. These skills are fundamental for high productivity of labour to bring about a nation’s development and economic growth (Amiria & Gerdthamb, 2013). Therefore, investments made in health and child mortality, such as increasing the GDP percent spent on health, could provide returns of an even higher GDP in the future (Amiria & Gerdthamb, 2013). This information could be useful for influencing stakeholders, such as ministers of finance, policy makers, potential donors, the private sector, to make an investment in improving the health of people and improving service delivery within the health sector (Buckley, Lange & Peterson, 2014).
2. MaiMwana project Malawi
The MaiMwana Project was established in 2003 as a research and development collaboration between The Malawi Ministry of Health and the UCL Centre for International Health and Development in the United Kingdom (Rosato, Mwansambo, Lewycka, Kazembe, Phiri, Malamba, & Costello, 2010). The community mobilization randomised trial was the first of its kind to be implemented in a rural African context (Rosato et al., 2010). The intervention was a 2×2 factorial cluster-randomised trial that looked at two main interventions; women’s groups and volunteer counsellor health education. The 2×2 factorial design was appropriate for this project because it is able to efficiently test two different interventions within one sample population (Stevens, 2012).
The MaiMwana project took place in the Mchinji district of Malawi, with a study population of 185 888 people, divided into 48 equal-sized clusters (Rosato et al., 2010). 12 separate clusters received the women’s group intervention only, another 12 clusters received the community counselling intervention only, another 12 clusters received both the women’s group intervention and the community intervention and the last 12 clusters received none of the interventions.
The project mainly targeted females between the age 15-49, however other members of the community were also included in the project, such as girls younger than 15 who were not of the child bearing age but because it was very likely that they could become pregnant in the future and use the information they obtained from the project (Rosato et al., 2010). Elderly women were included because they had experience that they could share with the rest of the community that could be useful to the intervention. Lastly, men and boys were included because they had an important role to play in the health of both mothers and children.
The women’s groups were a community mobilisation strategy that involved a cycle of 20 meeting in 4 phases (Rosato et al., 2010). About 207 women’s groups were formed and were each provided with a trained facilitator who supervised discussion sessions during the meeting. Discussions included topics on health problems most common in children and mothers and were guided using manuals and picture cards (Rosato et al., 2010). The counselling intervention included 72 female volunteers from the community who had been trained and were responsible for finding pregnant women within the community and making home visits (Rosato et al., 2010). The counsellors were to visit during pregnancies and after the birth of the babies. The counsellors educated women on breastfeeding, immunisation, family planning and child care (Rosato et al., 2010).
2.1 Aims and Goals of the project
The main aim of the project was to empower communities in Mchinji district by enabling them to take control of issues relating mortality and morbidity among both women and children, that would improve the survival and health of mothers and their children (Lewycka, Mwansambo, Kazembe, Phiri, Mganga, Rosato, ; Costello, 2010).
2.2 What was achieved?
Analysis of results was mainly done by comparing the four different groups of clusters receiving either only one of the intervention, both the interventions or none of the interventions. A follow up of the project done in 2013 indicates that the women’s groups were able to reduce four mortality categories; prenatal mortality was reduced by 33%, maternal mortality rates by 74%, neonatal mortality by 41% and infant mortality rates by 28% (Lewycka et al., 2013). The peer counsellors had been able to reduce infant mortality by 36% and infant morbidity was reduced by 42% (Lewycka et al., 2013). Essentially the project was aimed benefit the entire communities, however women and children were the key beneficiaries of the project. Women were educated on health care practices and health seeking behaviours that would be give them the ability and kills to take matters into their own hands regarding their health and the health of their children.
2.3 Limitations and gaps
About 90% of the Malawian population lives under the poverty line, that is to say they live on less than $1.9 per day (World Bank, 2010). As a strategy to improve the health of people, the country has always maintained a unique scheme of offering free services in public health care facilities (Yates, 2015). For this reason, critics propose that although the Malawi had been able to achieve MDG 4 by 2015 (Kanyuka, Ndawala, Mleme, Chisesa, Makwemba, Amouzou & Heidkamp, 2016), not all the accomplishments can be attributed to the interventions brought into the country as a result of the MDGs (Yates, 2015). 90% of the residents in Mchinji District live in rural areas and the main source of income is farming (Lewycka et al., 2013). Majority of the health facilities available are government owned or are owned by religious communities. Therefore, an intervention such as the MaiMwana project, that aimed to increase coverage of health services through health promotion would not have been as effective without the strategy of scheme of free public health services. A study done by Yates (2009) proves that countries that do not charge for user fees have a greater chance at improving health care with or without the implementation of health promotion interventions.
Another limitation is the type of design used during the MaiMwana project. The 2×2 factorial design introduced the risks of interactions between the two different interventions implemented within the district (Lewycka et al., 2013). During analysis clusters that received only one of the two interventions showed to be more effective and produced more reliable results than the clusters that received both interventions (Lewycka et al., 2013). The combined delivery in the clusters with both the women’s group and the peer counselling lead to the reduction of efficiency.
Other limitations of the project also included, the risk of loss to follow up in the randomised control trial (Lewycka et al., 2013). Inconsistency in reporting due to the difference in health measurements between that of the project and that of the Malawi Demographic and Health Survey, which resulted in underreporting (Lewycka et al., 2013). Lastly the project was prone to behaviour bias from the participants because they were informed about the project goals and objectives.
4. Other interventions
Studies similar to the MaiMwana project had been implemented in other parts of the world. In Nepal (Manandhar, Osrin, Shrestha, Mesko, Morrison, Tumbahangphe ; Shrestha, 2008) randomised control trials with the use of women’s groups had been implemented in order to reduce the rates of child mortality and to improve maternal health. The interventions were a success and proved to show that the use of women groups in communities is a good initiative to achieving MDG 4. However, in Bangladesh a 2×2 factorial randomised-cluster design was used with two interventions, the first being incorporating women’s groups within the populations and the second being training traditional birth attendants in revival of neonates using the bag-valve breathing mask, results from the intervention showed that Women groups were not as successful in reducing child mortality rates (Azad, K., Barnett, S., Banerjee, Shaha, Khan, Rego, ; Ellis, 2010), as they were in Nepal and Malawi.
The National Vitamin A Program (NVAP) is another intervention that was implemented in Nepal and it looked at distributing Vitamin A capsules to children at least twice a year to at risk communities (Gottlieb, 2008). The program was so successful that it had been able to reduce mortality rates in children under the age of five to about 50% (Gottlieb, 2008). In addition to this the program had also been able to prevent Vitamin A deficiency related illness among children under the age of five.
5. Using women’s Groups in other settings
Chad has been rated the sixth country with the highest rates of child mortality worldwide (Bowden, Braker, Checchi & Wong, 2012). Following a recent article (Kane, 2018), The country is currently experiencing a food emergency which has highly affected the rates of mortality, especially among children under the age of five due to malnutrition. Using women’s groups as proved to be an effective intervention in the past when it comes to improving health and well-being for a whole community. Unlike the factorial design used in MaiMwana project, a randomised control trial could be used to suit the implementation of the intervention in Chad. With two sample groups; one group receiving the intervention and another group not receiving the intervention, this would cross out the risk of interactions between two interventions which would make analysis of results efficient. This design would require a smaller sample group than that of the MaiMwana project, in order to decrease the risks of loss to follow up.