Community mobilisation through participatory women’s groups Anthony Costello, UCL Institute for Global health
Photo credit: MaiMwana, Malawi Secular trend in NMR Secular trend in NMR The policy challenge
How will mortality change under alternative policies?
Which policies will we recommend?
Costs and benefits? Secular trend in NMR The policy challenge
Proposition: community groups, especially women using PLA cycles, are highly effective in accelerating NMR decline in poor communities both directly and indirectly through effects on equity, care-seeking, quality and counting. RECOMMENDATION “Implementation of community mobilization through facilitated participatory learning and action cycles with women’s groups to improve maternal and newborn health is recommended, particularly in rural settings with low access to services”. STRONG for newborn health
RECOMMENDATION “should focus on creating a space for discussion where women...identify priority problems and advocate local solutions for MNH”
“more research is needed…on effects…of other outcomes…in different contexts” Some challenges 1. Delivery care
Relationship between Institutional delivery and MMR in India Randive et al. PLoS ONE. 2013
Bangladesh and Nepal will achieve MDGs with only ~20% institutional delivery Some challenges 2. Quality care
BUT “disrespect and abuse….runs wide and deep within the maternity services of many countries” Freedman and Kruk, Lancet 2014
AND risks of perinatal disability? Some challenges 3. Equity
Median levels of health care use across 45 low and middle income countries: poorest 20% and richest 20% DHS data Houweling, 2009 Communities can be powerful to address inequity
Photo credit: Perinatal Care Project, Bangladesh 4. Family/community
Poverty Gender Literacy
History Power Economy
Decision-making Nutrition Caste Security Culture and practices Community health workers
The effect of home visits on neonatal mortality rate (Kirkwood, Lancet 2013)
Impact at scale is attenuate d Some challenges 5. Count every newborn Is information enough ?
Photo credit: MIRA, Nepal A traditional response: healthBolam et al.education BMJ 1998 The Warmi Project, Bolivia
Photo credit: Save the Children Fund
Howard-Grabman L et al. 1992 The community action cycle
PHASE 4 PHASE 1 EVALUATE IDENTIFY & PRIORITISE PROBLEMS TOGETHER
PHASE 3 PHASE 2 PUT STRATEGIES INTO PLAN STRATEGIES PRACTICE
http://vimeo.com/15751446 PHASE 1 Understand current practices IDENTIFY & PRIORITISE PROBLEMS
Identify maternal & newborn problems
Prioritise problems Understand causes and effects Identifying strategies: bridge First community meeting: share with pictorial stories and but game strategies why game
PHASE 2 PLAN STRATEGIES Assign responsibilities Measure progress Learn from others
PHASE 3 PUT STRATEGIES INTO PRACTICE
Transport to seek care PHASE 4 EVALUATE TOGETHER
Participatory evaluation
Second community meeting
http://vimeo.com/15751446 Makwanpur Trial, Nepal cRCT, 180,000
1 local woman facilitator per cluster Not a health worker
Problem Identification
Participatory Planning evaluation together
Implementation
2004 Photo credit: Tom Kelly Ekjut Trial, Jharkhand & Odisha, India
Photo credit: S Olwe for Ekjut 2010 cRCT in 38 geographic clusters
32% reduction in across 3 districts: 19030 births NMR 32% reduction in NMR OR: 0.68 (95% CI: 0.58 – 0.78) (OR: 0.68, 0.59-0.78)
Care-seeking during perinatal period for mother Care-seeking for newborn Clean delivery practices during home births Improved newborn care practices at home
Tripathy et al. Lancet 2010 IMPACT ON MOST MARGINALISED
59% reduction in NMR in most marginalised
36% reduction in NMR in less marginalised
Houweling et al. Int J Epi 2013 Perinatal Care Project Trials I and 2, Bangladesh
2010 and… 2013
Photo credit: Perinatal Care Project City Initiative For Newborn Health, Mumbai
Photo credit: SNEHA 2012 MaiMwana Project, Mchinji district, Malawi
Photo credit: MaiMwana Project
Factorial cRCT Women’s group intervention (180 000) Peer infant feeding counselling intervention Photo credit: MaiKhanda
MaiKhanda, Malawi Factorial cRCT in Kasungu, Lilongwe and Salima districts > 700 women’s groups Quality improvement in health facilities
Colbourn et al. International Health 2013 OVERALL EFFECT OF WOMEN’S GROUPSNeonatal ON NEONATAL MORTALITY mortality
Heterogeneity
0·80 (0·67–0·96) 20 % reduction in neonatal mortality
Prost et al. Lancet 2013. corrected EFFECT ON NEONATAL MORTALITY WITH 30% OF WOMEN ATTENDING GROUPS
0·67 (0·60–0·75) 33 % reduction in neonatal mortality Prost et al. Lancet 2013. corrected EFFECT ON MATERNAL MORTALITY WITH 30% OF WOMEN ATTENDING GROUPS
0·51 (0·29–0·89) 49 % reduction in maternal mortality
Prost et al. Lancet 2013. corrected How do groups empower to cut deaths? It’s about the social determinants of heal Mechanisms 1. Knowledge sharing and individual behaviour
Clean delivery Handwashing kits
Breastfeeding Use of and thermal Nets care Mechanisms 2. Social support
Postnatal care Family and Funds village support
Fewer obstetric complications? Mechanisms 2. Social support
Bicycle ambulance
Small business
Loans It’s about community action… Mechanisms 3. Decision-making and political advocacy
Communication
Empowerment and critical Advocacy skills consciousnes Solidarity Representation s Asking why
Broader benefits: mental health
YEAR 3 57% reduction in maternal depression OR: 0.43(95% CI:0.23- 0.80)
Tripathy et al, Lancet 2010, 228 000 tribal population 19 030 births roader benefits: gender equality
40 Men are involved Broader benefits: services
SNEHA Slum communities Mumbai, India Broader benefits: water, food, farms, environment
43 Evidence for scale-up…
India’s Accredited Social Health Activists conducted home visits and facilitated a monthly women’s group
Reduced NMR by a third Greatest impact among poorest
Ekjut, forthcoming, 2014 Photo credit: S Olwe for Ekjut Orissa scale-up…from 2012 Study leaders: Kishwar Azad, Charles Mwansambo, Neena Shah More Prasanta Tripathy, Nirmala Nair, Dharma Manandhar, Anthony Costello
Photo credit: SNEHA
Photo credit: SNEHA, Mumbai, India Women’s groups using PLA are the most evidence- based strategy to tackle newborn deaths in poor, rural areas It’s not a drug, it’s not a vaccine, it’s not a device. It’s women, solving problems, saving lives. Richard Horton, May 2013
Follow my twitter @globalhlthtwit Learn more, download intervention materials and watch our films: http://www.ucl.ac.uk/igh/womens-groups