摘要：Objectives. We evaluated the effectiveness of the Sure Start project, which was implemented in 7 districts of Uttar Pradesh, India, to improve maternal and newborn health. Methods. Interventions were implemented at 2 randomly assigned levels of intensity. Forty percent of the areas received a more intense intervention, including community-level meetings with expectant mothers. A baseline survey consisted of 12 000 women who completed pregnancy in 2007; a follow-up survey was conducted for women in 2010 in the same villages. Our quantitative analyses provide an account of the project’s impact. Results. We observed significant health improvements in both intervention areas over time; in the more intensive intervention areas, we found greater improvements in care-seeking and healthy behaviors. The more intensive intervention areas did not experience a significantly greater decline in neonatal mortality. Conclusions. This study demonstrates that community-based efforts, especially mothers’ group meetings designed to increase care-seeking and healthy behaviors, are effective and can be implemented at large scale. Uttar Pradesh is the most populous state in India and among the poorest, with a per capita gross domestic product of about half the national average. 1 Health indicators in Uttar Pradesh reflect the poor economic conditions: at 63 deaths per 1000 live births in 2009, the state’s infant mortality rate is 25% higher than the country’s. 1 The Sure Start project was designed to improve health outcomes for mothers and newborns by mobilizing communities to practice healthy behaviors and use public health services. The launching of the project was preceded by the National Rural Health Mission (NRHM), introduced in 2005, which placed community health workers, called accredited social health activists (ASHAs), in villages at a ratio of 1 ASHA per 1000 villagers. The project’s main goals were as follows: To raise awareness of essential maternal and newborn health care through communication and advocacy activities to promote safe pregnancy and neonatal care, directly at the village level and through mass campaigns at a district level. To support households and communities to practice healthy behaviors, through mobilization techniques such as mentoring ASHAs to hold mothers’ group (MG) meetings as well as to improve their skills at promoting institutional delivery. To strengthen village health and sanitation committees and linkages with other structures of the Panchayati Raj Institution (a 3-tiered decentralized governance system; its lowest level of governance is the rural panchayat , our unit of intervention, which in Uttar Pradesh usually consists of a main village and surrounding smaller hamlets). With the cooperation of the Uttar Pradesh government, Sure Start implemented interventions in tandem with planned activities of the NRHM to accelerate the improvement of health in rural areas. The program affected a population of 23 million (> 0.6 million pregnancies) 2 in 7 districts covering 7112 panchayats. Spanning the end of 2007 to the end of 2011, the project promoted implementation of key NRHM policies related to maternal and newborn health and sought to improve accountability related to the supply of funds, facilities, commodities, and services. Through the NRHM, the government launched several important initiatives to improve maternal and newborn health. The most important was a conditional cash transfer scheme—known as Janani Suraksha Yojana —that incentivizes both ASHAs and families to promote and use health facilities for delivery. The motivation for this project came from growing evidence—shown in small-scale randomized control trials (< 500 000 people), many of which were in South Asia—that a significant decrease in neonatal mortality and morbidity can be achieved through community-level interventions to promote care-seeking and encourage healthy maternal and newborn health behaviors by mothers and family members. 3–7 A randomized control trial in Nepal achieved a 30% reduction in neonatal mortality (intention-to-treat impact: odds ratio = 0.70) 4 by a participatory learning action cycle approach first developed in Bolivia. Local female facilitators assisted women’s groups (with mostly pregnant women) to discuss the problems leading to maternal and newborn deaths, develop practical interventions, and implement as well as evaluate their outcomes. Several other rigorous studies followed, and they provide evidence that effective community-based strategies can deliver a range of preventative and behavior change management messages targeting mothers and household maternal and newborn care practices. 3–8 To date, we have not found any reports from similar programs with large-scale, randomized implementation. We examined the overall impact of the high-intensity Sure Start intervention (level 2, or L2), implemented at the village or panchayat level, on pregnancy, delivery, postpartum care, and newborn survival compared with the low-intensity intervention (level 1, or L1) that was implemented through district-level campaigns. We also specifically examined the impact of participating in MG meetings, a central feature of the L2 intervention. We examined the health and behavioral impact of the project’s direct contact with women (L2).
