Introduction

Every year 530 000 women die from maternal causes, four million infants die in the neonatal period, and a similar number are stillborn.^{w1 w2} Despite a plethora of newly validated interventions, the millennium development goals to reduce maternal mortality by three quarters and child mortality by two thirds are unlikely to be achieved.1 One of the reasons for this is that current safer motherhood and newborn care programmes emphasise interventions that do not reach the poorest households. Community based interventions have been neglected and undervalued. In this article, we argue that large scale community effectiveness trials are both necessary and feasible if we are to make further progress with reducing maternal and child mortality.

Peer education is the best method of changing behaviour

Problems with current interventions

The fact that poor people are both more likely to become ill and less likely to get appropriate treatment has not changed since Tudor Hart articulated it in the 1970s.^w3 This fact also underlies the fallacy of the assumption that interventions to tackle conditions concentrated primarily among poor people will benefit primarily their poor victims.^w4 The highest maternal and neonatal death rates occur in poor populations. In north India, three fifths of rural women do not have any antenatal care;^w5 in Indonesia, a third of maternal deaths occur in the poorest quintile;^w6 and in 44 countries mothers from the richest quintile are three times more likely to have a birth attendant than those in the poorest quintile.

Most maternal and neonatal deaths take place at home, beyond the reach of health facilities. Current international policy emphasises the provision of skilled birth attendants and …