An Introduction to Women S Groups

HOW DO WOMEN’S GROUPS IMPROVE MATERNAL AND NEWBORN HEALTH?

A short summary prepared by

Women and Children First (UK) United House North Road London N7 9DP www.wcf-uk.org

January 2007 Adapted September 2008 1. Background

1.1 Maternal and newborn health Every minute one woman dies from a pregnancy related problem and eight newborn babies die, 98 per cent of these deaths are in developing countries while half of all births take place in the home without skilled birth attendance. Many of these deaths can be prevented by improving the health and knowledge of the mother, especially during pregnancy, delivery and the early post-delivery period. The health of a newborn baby is directly linked to the health of its mother during pregnancy and childbirth newborn. A child whose mother dies during childbirth is 3-10 times more likely to die before his or her second birthday.

It is widely recognised that women in developing countries do not have access to healthcare during pregnancy because they face a series of delays in reaching skilled care in a safe and clean environment. The first delay is making a decision to seek care, the second delay is transporting the mother to a health facility and the third delay is receiving good quality care after arrival at the hospital or health centre. Women need help to overcome these barriers to ensure they receive a continuum of care not only during their pregnancy but before pregnancy, and after the birth.

When problems occur during pregnancy, labour or the post-natal period decisions on what to do are often based on advice from family members, neighbours or traditional healers. In addition, the pregnant woman is often too shy to speak out because pregnancy is seen to be an unclean or shameful occurrence, and pain is thought to be normal and so she does not ask anyone for help. Therefore it is not only the pregnant women that need to understand the best form of care but also the wider community.

1.2 Community mobilisation It has long been advocated that communities should come together to make lasting improvements to their health and have a right to access high quality healthcare, as recognised by the Alma Ata Declaration made at the International Conference on Primary Health Care in 1978: “The people have the right and duty to participate individually and collectively in the planning and implementation of their health care”.

Local communities can be strengthened by coming together to plan, carry out, and evaluate activities to make sustained improvements to their health. This strengthening process is often referred to as community mobilisation, which can make deep and lasting improvements to the health and well-being of communities. Communities can achieve improved health through increased knowledge to identify and address important healthcare needs.

Women’s groups help to achieve community mobilisation. In many developing countries women do not have regular contact with other community members, nor an opportunity to voice their opinions. Women’s groups are therefore effective in bringing women together to discuss key issues affecting them during pregnancy and childbirth.

2. Women’s Groups

Women’s groups bring women with similar needs together to discuss topics that are of concern to them, for example a lack of access to high quality healthcare facilities and skilled birth attendants. A group is formed by 15-20 female members, who meet on a

Women and Children First (UK) 1 regular basis, usually monthly. Each group is facilitated by a local woman who has been selected and trained to run the group. The facilitator supports the group to identify and prioritise problems during pregnancy, childbirth and the newborn period, and to develop and evaluate strategies to overcome these problems.

Problem identification

Planning together

Evaluation and Implementation problem identification

Initially the whole community is briefed on what women’s groups are and consent is obtained from village elders, chiefs or leaders to ensure the initiative is supported by the women’s social network, following which women volunteer to become a group member. The initial meetings facilitate discussions on why mothers and newborns die in the community, and introduce the concept of ‘learning together’ to encourage the women to discuss problems within the group but also with their neighbours and friends. The women therefore bring problems faced by the wider community rather than just their own experiences.

The meetings enable women to develop their own knowledge about maternal and newborn health, which is used to educate others and challenge existing power structures. After each meeting, women return to their community to present their work at a community meeting stimulating wider health discussions. Therefore the impact of a women’s group is not just confined to group members but on the health of the community as a whole. Women and Children First estimates that in Bangladesh one woman who regularly attends meetings only has to interact with 2-3 pregnant women in her district to ensure that all women of child-bearing age are being regularly contacted and given the opportunity to benefit from peer learning.

3. Low Cost Strategies

To date women’s groups have developed various low cost strategies to meet their healthcare needs.

3.1 Emergency funds Local women often give birth at home with assistance from family members or a local traditional birth attendant (TBA). When these women face complications during their pregnancy, they often cannot afford transport to a healthcare professional. The groups have therefore developed an emergency fund in Bangladesh, Nepal and Malawi, which can be used by any member in an emergency.

Women and Children First (UK) 2 Improved healthcare facilities When women can access healthcare facilities they often lack privacy and comfortable furniture. In response, groups contacted a local forester and ordered resources to make new furniture and gathered material to make curtains. In this situation women are building links between the health service staff and user.

Video shows A local healthcare organisation in Nepal had a short film about maternal and newborn care, but poor communities could not watch it due to a lack of electricity in their homes. Women from the group approached those households which were fortunate enough to have electricity and a television, to show the video to members of the community. The women sang health promotion songs from the video at annual women’s festivals and played the songs on local buses.

Stretcher Women’s groups have managed to collect money to purchase a second hand stretcher for the village to ensure pregnant women can be moved easily to a clean and safe delivery place when they go into labour. In Nepal, where many villages are remote, half the women’s groups ran stretcher schemes. This had an additional benefit for the community because 90 per cent of the time the stretchers were used for other sick people not just mothers in labour.

Picture card game Picture cards are used to assist women in learning about appropriate care measures when faced with problems during pregnancy and childbirth. Group members then use the cards with other women in the community to share knowledge and promote learning. Cards are developed with inputs from women and community members to accurately depict healthcare messages in a culturally appropriate way, and are designed by local artists. Quiz shows Local women from groups organised a quiz show to educate their communities about maternal and newborn health problems and the correct form of care to use.

Clean home delivery kits The World Health Organisation advocates the use of clean home delivery kits as an effective way of reducing maternal and newborn infections. Women’s groups developed their own delivery kits comprised of a blade, a bar of soap, three cord ties, a plastic coin for cord cutting, a plastic sheet, and a set of pictorial instructions. The groups then decided on the price and best selling location, and all profits went into the emergency fund.

4. Case studies from Bangladesh

Rahatun was pregnant so Shanti and Shajeda, two members of a women’s group and the local TBA, Jobeda, advised her to go to Nandigram hospital for an antenatal check up, which she duly did. Rahatun moved to her parent’s house in preparation for her delivery. When her contractions started she did not tell anyone. On the second day she called Jobeda, who advised her husband to take her to Bogra Mohammad Ali hospital because she had been experiencing contractions for over 12 hours. However, Rahatun’s father did not have enough money to pay for her treatment and so Jobeda arranged for

Women and Children First (UK) 3 him to borrow 500 Taka (£4) from the women’s group emergency fund. Rahatun was admitted to hospital and had a caesarean section. Both mother and baby are now in good health.

Shabana was advised by a member of a local women’s group to go to the hospital for an antenatal check up. She brought picture cards with her and showed her why antenatal care was important, why she should save money in preparation for her delivery, and which danger signs to look for. Shabana, accompanied by a member of the women’s group, visited a nurse at the Nandigram hospital and had an antenatal check up. Soon after she experienced problems and sought further medical help. An emergency caesarean section was required. Within two hours the husband managed to find enough money, a total amount of 1500 Taka (£15), and the caesarean section was performed.

5. What is the evidence behind women’s groups?

There is growing evidence to suggest that women’s groups can significantly improve maternal and newborn health and reduce unnecessary deaths.

5.1 The Warmi Project, Bolivia The Warmi Project, located in a rural area of Bolivia with little health infrastructure and widespread poverty, was the first published account of using women’s groups to improve maternal and newborn care. It developed the use of community action cycles focused on mother and infant care. After three years, the project noted a reduction in perinatal mortality1 of nearly 50 per cent and improved practices related to prenatal care, breastfeeding, immunisation and other behaviours. In addition, women increased their participation in community planning and decision-making processes, and commented that they had never spoken to one another about these types of problems before.

5.2 Makwanpur Study, Nepal To evaluate rigorously the effects of the Warmi women’s group approach, a study was undertaken to improve the health of pregnant mothers and their newborn infants among 170,000 villagers living in rural Makwanpur district, central Nepal. The study was conducted by the International Perinatal Care Unit (IPU) in London and the Mother and Infant Research Activities (MIRA) in Nepal. Building on the Warmi approach and MIRA’s experience, they examined the potential of women’s groups to bring about improvements in perinatal health outcomes in a randomised controlled trial. It demonstrated a 30 per cent reduction in newborn mortality and a three quarters reduction in maternal mortality over a two-year period. Secondary outcomes included changes in care provided for the mother and newborn at home and improved health seeking and referral patterns. Women who attended women’s groups were more likely than non group members to have had antenatal care, given birth in a health facility with a trained attendant or a government health worker, used a clean home delivery kit or a boiled blade to cut the umbilical cord, and for the birth attendant to have washed her hands. In addition, the women were more likely to attend a health facility if they or their infant was ill.

1 The perinatal period starts as the beginning of foetal viability (28 weeks gestation or 1000g) and ends at the end of the 7th day after delivery. Perinatal deaths are the sum of stillbirths plus early neonatal deaths.

Women and Children First (UK) 4 6. Summary

Women’s groups enable women to identify and prioritise maternal and newborn health issues, have the support to find local and low cost solutions and build links with local health services. Women’s groups are a cost effective and evidence based intervention, which have the potential to be scaled up to reach out to all women and make a significant impact on their lives, their babies and the lives of their community members.

7. Further Reading

1. How to mobilise communities for health and social change: A field guide. By Lisa Howard-Grabman and Gail Snetro http://www.hcpartnership.org/Publications/comm_mob/htmlDocs/cac.htm

2. Impact of community organization of women on perinatal outcomes in rural Bolivia. By O'Rourke et al. Rev Panam Salud Publica. 1998 Jan;3(1):9-14

3. Women’s health groups to improve perinatal care in rural Nepal. By Morrison et al. BMC Pregnancy and Childbirth 2005; 5:6

4. Effect of a Participatory Intervention with Women’s Groups on Birth Outcomes in Nepal: Cluster-randomised controlled trial. By Manandhar et al. Lancet 2004; 364: 970- 979

5. Economic assessment of a women’s group intervention to improve birth outcomes in rural Nepal. By Borghi et al. Lancet 2005;366:1882-1884

6. Women’s groups’ perceptions of maternal health issues in rural Malawi. By Rosato et al. Lancet 2006; 368:1180-88

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