Landmark Research Trial in Mali Shows Dramatic Reduction in Under-Five Mortality Rates in Conflict Zones

Read the original article at the Population Studies Center — Community health workers– trained laypersons who provide rapid, critical front-line public health services to rural and underserved populations– are dramatically impacting newborn, infant, and child mortality rates in Mali, according to a landmark research study published in the Bulletin of the World Health Organization (WHO). The results could inform how we protect children in areas of poverty, healthcare access challenges, and active conflict.

The cluster-randomized Proactive Community Case Management (ProCCM) Trial conducted by a consortium of researchers, the global health organization Muso, and the Malian government saw under-five child mortality rates plummet from 148 to 55 per 1,000 births – despite active regional conflict– as patients in the study received free care from community health workers and at upgraded primary health clinics.

To test the impact of home visits on under-five mortality, the study was conducted in two arms, where one set of patients received care from trained, paid, and supervised community health workers at a fixed site in their village, and others received care from trained, paid, and supervised community health workers conducting regular home visits.

The trial, which followed 135,149 individuals from 2017 to 2020 across 137 rural sites, found home visits did not affect child survival, but significantly improved early and complete prenatal care. Results from the trial on maternal health published last year showed that those receiving home visits were 25% more likely to accrue 4 or more prenatal visits and 8 times more likely to reach 8 or more prenatal care contacts, compared to the control arm.

“Addressing cost, distance, and clinical capacity, which are key determinants of health care utilization and under-five mortality, may have been particularly important in the context of armed conflict,” said Emily Treleaven, an affiliate of the Population Studies Center at the Institute for Social Research and the Center for Global Health Equity at the University of Michigan, who was co-first-author of the study with Jenny Liu of UCSF.

—By Tevah Platt 

According to Muso, the trial communities achieved the largest and fastest improvement in child survival ever recorded in an active conflict zone.

The overall mortality rate decline in both arms suggests that measures to strengthen community health worker systems could be key factors for child survival, Treleaven said.

The trial saw additional positive health outcomes for patients in both arms of the study: Significantly reduced odds of malnutrition for children under 5, for example, and higher odds that mothers took malaria prophylaxis during pregnancy.

The study area, once a peaceful UNESCO World Heritage Site, became a center of a regional conflict a year into the trial. With global implications, the onset of conflict during the trial provided a window to understand how to better serve nearly one in six children who live in or near conflict zones today.

“The achievement of these communities [in reducing under-five mortality rates] highlights that we can and must do much more for children and communities in conflict settings, investing more in care from community providers and quality clinics, provided with zero copays,” Principal Investigator Kassoum Kayentao from the University of Bamako and Muso Senior Scientist said, in a press release issued by Muso.

Despite global declines, under-five mortality remains high in many of the world’s poorest countries. Today, more than half the countries in sub-Saharan Africa are working to expand community and primary care as part of their work towards achieving Universal Health Care. Barriers to timely, quality care– including fees, distance to facilities, and the availability of trained health workers and medical supplies– hinder progress in reducing morbidity and mortality.

More than 3,000 community health workers in Mali and more than a million across sub-Saharan Africa provide frontline services to community members, including family planning services, immunizations, and treatments for malaria, pneumonia, and diarrhea, according to the United Nations.

“These findings offer a roadmap for addressing global challenges in child survival,” said Treleaven. “They also provide rigorous evidence of the life-saving work conducted by community health workers, who reduce barriers to healthcare and provide essential services for maternal and child health.”