Role of Community Engagement in Maternal Health in Rural Pakistan: Findings from the CLIP Randomized Trial

"The CLIP Trial successfully demonstrated that engagement of male and female community stakeholders with the proposed strategy is a practical model to have an impact on pre-eclampsia knowledge in low-resource settings."

Community engagement (CE) ensures community participation in social change. For instance, CE projects have demonstrated that systematic involvement of communities has potential to improve maternal and child health in low-resource settings by facilitating change in socio-environmental risk factors, increasing female empowerment due to greater decision-making power, and promoting health-seeking behaviours. The objective of this study was to assess change in birth preparedness and complication readiness (BPCR) and pregnant women's knowledge about pre-eclampsia as part of CE activities in rural Pakistan during the Community Level Interventions for Pre-eclampsia (CLIP) trial.

The CLIP Pakistan trial was one of three cluster randomised controlled trials (RCTs) conducted with pregnant women in Pakistan, India, and Mozambique (2014-2016). The principles of engagement included understanding local perceptions and building community trust, explaining the purpose of the current work, and continuous evaluation of the CE strategies. In Pakistan, the trial was conducted in 20 clusters (10 in each arm) in Matiari and Hyderabad, Sindh Province. In the intervention clusters, interactive CE activities were conducted at two levels: (i) male stakeholder sessions were conducted by a dedicated research team at community meeting places, and (ii) sessions with pregnant women and their families were held by government-deployed, female community health workers known as lady health workers (LHWs) in the pregnant women's homes using educational aides developed for the study. The content of messages delivered by LHWs were the same as those for male CE sessions and covered pregnancy complications, particularly pre-eclampsia/eclampsia, BPCR, and details of the CLIP intervention package.

Women in control clusters received the standard of care, including routine LHW home visits where health promotion messages focused on antenatal care seeking, danger signs during pregnancy, skilled attendance at delivery, dietary advice, and basic neonatal care.

BPCR was assessed using questions related to transport arrangement, permission for care, emergency funds, and choice of facility birth attendant for delivery during quarterly household surveys. Outcomes were assessed via multilevel logistic regression with adjustment for relevant confounders with effects summarised as odds ratios (ORs) and 95% confidence intervals (CIs).

There were 15,137 home-based CE sessions with pregnant women and families (n = 46,614) and 695 village meetings with male stakeholders (n = 7,784) over two years. The composite outcomes for BPCR and pre-eclampsia knowledge did not differ significantly between trial arms. However, CE activities were associated with improved pre-eclampsia knowledge in some areas. Specifically, pregnant women in the intervention clusters were twice as likely to know that seizures could be a complication of pregnancy (OR = 2.17, 95% CI = 1.11, 4.23) and 2.5 times more likely to know that high blood pressure is potentially life-threatening during pregnancy (OR = 2.52, 95% CI = 1.31, 4.83) vs control clusters.

The fact that the CE approach adopted in the CLIP Pakistan Trial did not result in a statistically significant improvement in BPCR outcomes may be due to low (<30%) coverage of LHWs in certain areas, as was noted in the primary trial findings. Other plausible reasons for the findings may include poor literacy among pregnant women, financial constraints, community factors such as perceptions about BPCR, and health systems factors such as distance from or prior experience at the health facility. It has been demonstrated that the status of women in the community, employment status, and autonomy for decision making are key drivers for maternal care seeking. These factors require systemic action on individual, social, and economic dimensions of role of women in the community. "CE may help increase health-related knowledge, but cultural and environmental changes on these dimensions may require a multi-pronged approach to address inequities and translate into behavior change."

The CE strategy for the CLIP Trial was designed for the specific cultural context of Sindh Province, Pakistan, and some notable strategies included:

• CE sessions were planned and delivered in a manner that was meant to be feasible according to the communities' values and attitudes. This was reflected in the preparation, conduct, and delivery of separate sessions for men and pregnant women.
• The strategy of addressing men at common gathering places, regardless of age, marital status, or their wife's pregnancy status, as well as the presence of their peers, helped disseminate the messages throughout the broader community.
• Conducting CE sessions with pregnant women in their homes and in the presence of their female relatives and friends increased acceptability. Also, LHWs are residents of the area and have a mandate to deliver preventive and promotive health messages in the community. Therefore, this cadre was ideal to deliver CE messages to pregnant women, both for acceptability from the community and sustainability of the process.

Reflecting on those strategies, the researchers stress that "Effective community partnerships need to be built upon trust, shared vision for improving the health of the community, and pooling of physical and social capital resources....The CE sessions were a medium to build rapport, impart knowledge regarding pregnancy complications in general and pre-eclampsia specifically and to emphasize the importance of birth preparedness."

In conclusion, the findings suggested that a CE strategy for male and female community stakeholders increased some measures of knowledge regarding complications of pre-eclampsia in low-resource settings. However, the effect of this intervention on long-term health outcomes needs further study.