Community mobilisation through participatory women’s groups Anthony Costello, UCL Institute for Global health

Photo credit: MaiMwana, 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 Randive et al. PLoS ONE. 2013

Bangladesh and 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, 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