Of the women for whom information regarding a previous pregnancy had been recorded, 4929 had one further pregnancy during the trial surveillance period, 228 had 2 pregnancies and 5 had 3 pregnancies. Hence, there were a total of 5400 within-trial pregnancies from women with retrospectively recorded information.
Most women delivered at home (93%), without a trained attendant (92%) or any government health personnel present (90%), in either the preceding or study pregnancy. The sentinel care practices of antenatal care uptake, use of a clean blade to cut the umbilical cord, appropriate dressing of the cord and feeding of colostrum to the baby were more variably followed. Table shows the demographic breakdown of the women and the extent to which good practice was being followed prior to commencement of the study.
Practices in pre-trial pregnancies according to demographic variables
Approximately three quarters of the women were appropriately dressing the cord initially and this proportion was fairly constant across demographic subgroups. Attendance at antenatal care, boiling of the blade and not discarding colostrum were all more prevalent amongst the more highly educated and literate women from wealthier households.
The effect of being in an intervention VDC
Table shows the percentages of pregnancy pairings falling into each of the 4 categories (BETTER, GOOD, BAD, WORSE) for the 4 outcomes for women in intervention and control arms of the trial.
Behaviour change over time between pre-trial and trial pregnancies for four perinatal care practices.
The percentage of women who were following good practice during their trial pregnancies can be obtained by adding together the percentages falling into the BETTER and GOOD categories. For each of the 4 outcomes a greater percentage of the women in the intervention clusters followed good practice during the trial.
Combining the BETTER and BAD categories gives the percentage of women who were following bad practice pre-trial (and hence had the capacity to change for the better). For all outcomes apart from the discarding of colostrum, control clusters had more women with that capacity than intervention clusters. The percentages of women who recalled discarding colostrum in their preceding births were approximately equal between control and intervention clusters. The percentages lying within the BAD category represent missed opportunities for positive change and there were consistently fewer women within intervention clusters falling into this category for each of the 4 outcomes.
Women who changed their practice between preceding and study pregnancies fell into the BETTER and WORSE categories. The percentage of women in the intervention clusters falling into the BETTER category was greater than the percentage in the WORSE category, showing that women were more likely to make a positive, as opposed to detrimental, change for all outcomes. Women in the control clusters were more likely to stop, as opposed to start, appropriate dressing of the cord, but otherwise their changes were similarly more likely to be in a positive direction.
The differences between women in the intervention and control VDCs are further quantified by the fitting of multinomial models to the 4 outcomes with intervention status as a predictor. The coefficients and confidence intervals are given for the BETTER/BAD and BETTER/WORSE ratios. These are all significantly different to 1. For all four practices women who were initially following bad practice were significantly more likely to change to good practice if they lived in an intervention VDC (BETTER/BAD ratios). For example, women who did not attend antenatal care in preceding pregnancies were more than twice as likely to do so during the study period if they lived in an intervention area (odds ratio 2.04 95% ci (1.82, 2.27 times)). Of the women who changed practice these changes were significantly more likely to be in a positive direction for all outcomes except antenatal care attendance (BETTER/WORSE ratio).
Women attending antenatal care and/or using a boiled blade to cut the cord in pregnancies falling within the study period were significantly less likely to be doing so as a result of a positive change in practice if they lived in an intervention VDC (BETTER/GOOD ratios). These results are not unexpected given the larger percentages of women within the intervention VDCs following good practice for these outcomes pre-trial.
The independent effect of attending a women's group
About one in twelve married women of reproductive age, and about one third of newly pregnant women in intervention clusters attended the women's groups. There were few differences between the percentages of women who did and did not attend women's groups falling into each of the 4 categories.
The effect of attending a group over and above the improvements attributable to living within an intervention area was greatest for antenatal care attendance. The percentages of women who attended the groups falling into the BETTER, GOOD, BAD and WORSE categories were 22.3, 37.3, 33.7 and 6.7 respectively, compared to 17.8, 34.9, 38.9 and 9.1 of those within intervention VDCs who did not attend groups. Hence, a larger percentage of those attending the women's groups improved their practice (22.3 vs 17.8%) or maintained previous good practice (37.3 vs 34.9%). The significantly lower odds of making a positive as opposed to negative change (BETTER/WORSE ratio) in the intervention VDCs were counter-acted in the subgroup who attended the women's groups. The women who attended the groups were significantly more likely to make positive changes than non-attending women within intervention VDCs (BETTER/WORSE ratio 1.77 (1.30, 2.40)). Similarly, the women within intervention VDCs who attended the groups but did not attend antenatal care in their previous pregnancies were significantly more likely to start doing so than the women within those same VDCs who did not attend (BETTER/BAD ratio 1.51 (1.28, 1.79)). This difference was additional to the 2.04 fold increase seen in the intervention VDCs overall. The BETTER/GOOD ratio for attenders vs non-attenders was also significant (1.22 (1.04, 1.45)). Women attending the groups were significantly more likely to make positive changes compared to non-attending women in the same VDCs with respect to discarding colostrum (BETTER/WORSE ratio 1.03 (1.01, 1.06)) and there was some evidence that if they were discarding colostrum previously they were more likely to stop doing so (BETTER/BAD ratio 1.02 (1.00, 1.04)). There were no other significant differences.
Were specific subgroups of women with the capacity for positive change more likely to respond to intervention?
Table shows the increase in the BETTER/BAD ratios for the intervention group compared to the women in control areas. Values greater than 1 indicate that the intervention was more successful in those subgroups of women relative to the baseline demographic category. Significant differences in the effects of intervention on the four process outcomes were not consistent across demographic subgroups.
Table 3 Coefficients and 95% confidence intervals for the extent to which women in the intervention VDCs, relative to women in the control VDCs, within different demographic subgroups were more (or less) likely to make a positive change, relative to those in (more ...)
Were women who changed practice more likely to do so positively if they were from specific subgroups?
The extent to which women made positive, as opposed to negative, changes in practice is quantified by the BETTER/WORSE model coefficients. Patterns were not consistent (Table ) but they were based on the smallest groups (Table ). Women from households with more assets within intervention VDCs were significantly more likely to make a positive change to dressing the cord but a negative change with respect to the treatment of colostrum. It was the older women, those who were less literate and the less well educated who were significantly more likely to have stopped, as opposed to started, discarding colostrum if they lived in intervention, as opposed to control, VDCs.
Table 4 Coefficients and 95% confidence intervals for the extent to which women in the intervention VDCs, relative to women in the control VDCs, within different demographic subgroups were more (or less) likely to make positive as opposed to negative changes, (more ...)
Were women from specific subgroups who followed good practice during the trial more likely to be doing so as a result of a positive change?
These differences are quantified in Table (BETTER/GOOD ratios). This table is presented for completeness. However, it is of the least clinical interest due to the dependence on the variability between groups of the percentages who show no changes but continue good practice throughout.
Table 5 Coefficients and 95% confidence intervals for the extent to which women in the intervention VDCs, relative to women in the control VDCs, within different demographic subgroups who were following good practice during the study period were more (or less) (more ...)