Effect of a community based social marketing strategy on the uptake of clean delivery kits in peri-urban communities of Karachi, Pakistan

This study was conducted from October 2009 to March 2010 in four peri-urban communities, Rehri Goth, Ibrahim Hyderi, Bilal colony and Bhains colony in Karachi, Pakistan [29] (Fig. 1). These are low socioeconomic fishing communities and semi urban settlements.. The total population at the time of study was 212,294. Major occupations in this area are fishing, subsistence farming and small businesses. Most of the pregnant women deliver at home-in the presence of a traditional birth attendant (TBA), a close relative, or a skilled birth attendant (midwife or a nurse).

This was an explanatory sequential mixed method study with a quantitative component followed by a qualitative component. The quantitative study consisted of a prospective intervention arm in which a cohort of pregnant women received the social marketing intervention. All women who were at least 24 weeks pregnant and were planning to deliver in the catchment area were eligible to be enrolled in the intervention arm. These were identified from an ongoing pregnancy surveillance at the study sites. Pregnant women in the intervention arm received two social marketing visits during the third trimester of the pregnancy. The target audience were the pregnant woman, her husband, and any other decision maker of the family. The 4 Ps of social marketing (Price, Place, Promotion, Product) were kept in view [30]. During the home visits, locally resident trained CHWs having at least 10 years of education, fluent in local languages and well-accepted by the community, provided information and education on the use and importance of CDKs. The time and date of sessions were scheduled as per the participants’ convenience. Pre-assembled CDKs were made available at convenient and accessible spots in the community (the Place). The contents of the kit, it's availability at the nearest kiryana (local store), its method of use, and cost effectiveness in preventing both maternal and newborn complications were discussed (the Product and the Price). Visual illustrations were used for explaining many of the concepts (the Promotion). Women were followed till the end of the pregnancy to record outcome of the pregnancy. Primary outcome was use of CDK’s in women who delivered at home. The control arm consisted of a retrospective cohort of pregnant women, selected from a pregnancy registry maintained at the sites and who had delivered in previous three months. They did not receive the social marketing intervention. They were visited during the study period to collect information on their pregnancy and use of CDKs.

The qualitative component consisted of separate focused group discussions (FGDs) with three distinct groups: women who bought CDKs and used in their home deliveries, women who did not buy CDKs and the birth attendants.

Data was collected during home visits by trained CHWs. In the intervention arm data was collected over a baseline enrolment visit, two additional visits during the pregnancy and one after the delivery. In the retrospective control arm, data was collected through one enrollment visit and covered all the information about the preceding pregnancy and its outcome. In both intervention and control arm, questions were asked on sociodemographic characteristics, past medical and obstetric history of the mother, use of CDKs and information on events around the peri-partum period. Specific questions were asked about the place of delivery, person assisting the delivery and key decision makers in the family for seeking care during and after pregnancy. If CDKs were used, women were asked about the items that were most used. If CDKs were not used, mothers were inquired about the reasons for not using them.

A total of 6 FGD’s were planned. Two were conducted with mothers in the intervention arm who used the CDK, two with mothers in the intervention arm who did not use the CDK and two FGDs were conducted with the birth attendants. Each FGD had around 5–7 participants and was conducted by the principal investigator herself along with a sociologist. Audio recording were made, and detailed notes were taken.

Data was collected on paper forms and subsequently dual entered by two independent data entry operators using a customized program developed on Epi info version 6.04 (CDC, USA). Consistency and range checks were built in. A dual entry validation check was performed, and disagreements were resolved by going back to the paper forms.

Based on unpublished data from the ongoing surveillance at the study sites, we took baseline uptake of CDKs to be 10% in deliveries taking place at home (65% of the total deliveries). We calculated the sample size for a 15% absolute increase in proportion of women using the kits enrolled in the intervention arm and delivering at home, at 90% power and alpha of 0.05. Inflating for 15% lost to follow up in the intervention arm, we needed a minimum of 600 outcomes in the intervention and control arm.

We describe distribution of the characteristics of the study participants by the study arm in which they were enrolled. Our primary outcome was proportion of women who used CDKs in the intervention and control arm. To identify predictors of uptake of CDK in the intervention arm, we performed multiple logistic regression. All variables which had a p-value of less than 0.10 in the bivariate analysis were included in the initial model. Backward elimination method was used to derive a parsimonious model with all variables having a p-value ≤ 0.05. Odds ratios with 95% confidence intervals are reported. Hosmer and Lemeshow test was used to assess the final fit of the model. All analysis was done using SPSS version 16.

For the qualitative arm of the study, coding was done for the responses of the participants of the FGDs by the principal investigator. Grounded theory was followed for coding plan. Codes helped summarize, synthesize, and sort observations or statements from the data which provided foundation for data analysis. Themes were identified after reviewing data at least thrice. Reporting was done of selected quotations and analysis of repeated themes.

While the qualitative and quantitative data were analyzed separately, the results were converged to compare and contrast findings during the final interpretation.

Most of the women cited lack of trust in a new product as a main reason for not using CDKs. They were cynical about the strategies applied to promote the kits. One woman said, “We are illiterate; we have been fooled by many marketing campaigns, now we avoid new products.” (ID.3 FGD 1). Another main reason included additional cost associated with purchasing a CDK and a perceived low risk of any complication with not using a CDK. They also mentioned that the money could instead be used for arranging a one-time meal for the family. “We don’t have a regular source of income; we could have bought the kit if we had money; we could have even gone for hospital delivery but at that time we literally had no money.” (ID 1 FGD 2). Some women cited their previous uneventful experience in the absence of using a CDK as reasoning for not using it in their most recent pregnancy. “I gave birth to six kids at home without any such kit why should I use the kit this seventh time?” (ID 4 FGD2). When asked about suggestions to improve the uptake of CDK, their spontaneous answer was to reduce the cost of the kit. Some of the participants were not satisfied with the strategy used as in their view it created a mistrust with the birth attendants. One participant added, “Women should be concerned about pregnancy and delivery as far as diet and rest is concerned; technical things should not be their headache.” (ID 4 FGD 6).

Women who used CDKs in the intervention arm were appreciative of the way intervention was delivered. i.e., CHWs creating awareness among their household including key decision makers like mother-in-law and husband. They thought that these approaches were more useful than passive campaigns like posters or advertisements on electronic media. Many had preexisting concerns about cleanliness during the birthing process and the associated tools used. “We are always trying to keep our home clean, eat clean food and stay healthy but cleanliness during birth is generally neglected and ignored.” (ID 1 FGD3). Women were attracted by the packaging of all the necessary items in one kit which subsidized the cost and was easily available from nearby stores. The packaging in a single kit also made the storage and retrieval of the items at time of need easier in-home settings where single items could be easily misplaced. Although the cost was still substantial for the community, many were willing to bear the cost given the explained benefits of CDKs. “Fifty rupees are nothing if the benefits of the kit are kept in mind” (ID 4 FGD 4).

In all cases, birth attendants reported having no objections to the use of CDKs, had previously used the kits and expressed satisfaction with the content of the kit. They found the sheet in the kit to be extremely useful in providing a clean surface for delivery especially in home surroundings which were very unclean. “If kits are easily available then either woman can buy and keep at homes or we can take along at the time of delivery, it solves a lot of problems” (ID 3 FGD 6). Birth attendants raised concerns about inconsistent distribution strategies deployed for CDKs in the past when they were sometimes provided free of cost to either the woman or birth attendant at a subsidized rate. This in turn affected their dealing with clients. One of the birth attendants said, “I lost one of my clients when I tried to sell the kit. She had seen free distribution in her last delivery” (ID 1 FGD 5).