Institute for Global Health Participation, women’s groups and going to scale Anthony Costello 50 150 Active network Affinity band Sympathy 15 group Survival clique 5 Reasons for caution on ‘behaviour change’ Impact of health education: Kathmandu RCT, Bolam et al, BMJ 1990s Warmi Project, Bolivia 1990s HIGH PARTICIPATION LOW PARTICIPATION ‘A student is an empty vessel to be filled with a teacher’s knowledge.’ ‘People are experts about their own worlds. They require more than just information: respect and a space to develop their own solutions.’ Community action cycle PHASE 4 PHASE 1 IDENTIFY & PRIORITISE EVALUATE PROBLEMS TOGETHER PHASE 3 PHASE 2 PUT STRATEGIES INTO PLAN STRATEGIES PRACTICE Makwanpur, Nepal 2004 Photovoice in Makwanpur: Work Birth Health MAKWANPUR TRIAL, NEPAL 1 local woman facilitator per cluster Not a health worker 7000 population, 60 sq km 9 monthly women’s groups Problem Identification Participatory Planning evaluation together Implementation 2004 Photo credit: Tom Kelly, Save the Children Fund cRCT – 24 clusters: 6275 births 30% reduction in neonatal mortality (OR: 0.70, 0.53-0.94) Care-seeking during perinatal period for mother Care-seeking for newborn Clean delivery practices during home births Improved newborn care practices at home Manandhar et al. Lancet 2004 SEVEN CLUSTER RANDOMISED CONTROLLED TRIALS IN NEPAL, INDIA, BANGLADESH AND MALAWI Ekjut trial: rural eastern India MaiMwana and Maikhanda: rural Malawi Makwanpur trial, rural Nepal Perinatal Care Project I & II: rural City Initiative for Newborn Health, Ekjut, Jharkhand & Odisha, India Tripathy et al, Lancet 2010 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 Bangladesh 2010 AND… TRIPLED COVERAGE 2013 Azad et al, Lancet 2010 and Fottrell et al, JAMA 2013 Bangladesh (BADAS) study areas Photo credit: Perinatal Care Project First cRCT (2005-8) : 36 113 births No detectable impact on mortality or practices? Why? Azad et al. Lancet 2010 Gender barriers ? Lack of financial incentives ? Coverage too low ? Not the right kind ? 1 group per 1414 population 1 per 468 (India) 1 per 756 (Nepal) Only 3% of pregnant women Photo credit: Perinatal Care Project were in a group Second cRCT (2009-11) triple coverage: 19301 births 38% reduction in NMR (RR: 0.62: 0.43-0.89) Care-seeking during perinatal period for mother Care-seeking for newborn Clean delivery practices during home births Photo credit: Sanjit Shaha, Perinatal Care Improved newborn Project care practices at home Fottrell et al. JAMA Pediatrics 2013 / MaiMwana and Maikhanda, Malawi Lewycka et al, Lancet 2013, Colbourn et al Int 2013 Health 2013 Photo credit: MaiMwana Project MaiMwana, Mchinji district, Malawi (200 Factorial cRCT Women’s group intervention Peer infant feeding counselling intervention MaiMwana Project, Mchinji district, Malawi Photo credit: MaiMwana Project Overall: 26,262 births Care-seeking during perinatal period for No detectable impact of women’s mother groups Care-seeking for newborn in factorial analysis: (OR: 0·93, Clean delivery N/A 0·64–1·35) practices during home births In women’s group versus control Improved newborn care practices at areas: Lewycka et al. Lancet 2013 home 41% reduction in NMR and 74% Photo credit: MaiKhanda MaiKhanda, Malawi (2008-10) Factorial cRCT in Kasungu, Lilongwe and Salima districts > 700 women’s groups Quality improvement in health facilities through 400 task forces Colbourn et al. International Health 2013 Dharavi, Mumba Shah More et al, PLOS Med 2012 Dharavi, Mumba Photo credit: SNEHA 2012 cRCT in 48 slum areas: 18197 births No detectable impact on mortality or practices Learning from failure PNMR (OR: 1.19, 0.90– 1.57) Shah More et al. PLoS Med 2012 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 It’s not just about the mother and infant… EMPOWERMENT It’s about community action… Its about an active voice Poverty Gender Literacy History Power Economy Decision-making Nutrition Caste Security Culture and practices WHAT DO THESE SUCCESSFUL TRIALS HAVE IN COMMON? Rural Rural Rural Rural Rural settings Nepal India Bangladesh Malawi MM 1I Care-seeking High baseline during perinatal neonatal mortality period for (>30 /1000) mother Care-seeking for newborn More than 30% of illness Clean pregnant women in delivery N/A groups practices during home births Around one group Improved newborn care per 500 population practices at + + + ? home 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? Oxytocin The ‘ormone of lerve’ Michel Odent The ecology of the womb and childbirth Mechanisms 2. Social support Bicycle ambulance Small business Loans 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 47 Men are involved Broader benefits: services SNEHA Slum communities Mumbai, India Broader benefits: water, food, farms, environment 50 Shocks Groups and consumption smoothing Potential impact at Assumingscale a 30% loss of effectiveness when implemented at scale (a conservative lower bound): Annually in 74 Countdown countries 41,100 maternal deaths and 283,000 neonatal deaths averted Five countries where the Five countries where the most neonatal deaths could most maternal deaths could be averted (% of total) be averted (% of total) India: 116 000 (10%) India: 9370 (17%) Nigeria: 27 200 (10%) Nigeria: 5980 (15%) Ethiopia: 23 800 (19%) Ethiopia: 3320 (36%) Bangladesh: 13 700 (13%) Sudan: 2 120 (20%) Niger: 5800 (18%) Bangladesh: 2 050 (28%) Orissa scale-up…from 2012 NOT HOME VISITS VS GROUPS India’s Accredited Social Health Activists conducted home visits and facilitated a monthly women’s group 32% reduction in NMR OR: 0.68 (0.52-0.88) Greatest impact among poorest OR: 0.58 (0.35-0.95) Ekjut, forthcoming, 2014 Photo credit: S Olwe for Ekjut Culture eats strategy for breakfast • Deming • Quality improvement • Immunisation • PHC • Community mobilisation • Ebola 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 But are there risks from participatory women’s groups? • Social exclusion? • Gender violence? • Delayed referral? • Persistence of traditional harmful practices? • Political conflict? How to marry the Technical and the Social? Five principles 1. Coalitions: leverage groups with a shared vision 2. Focus on a few strategies and interventions 3. Build ownership at grassroots level 4. Continually innovate to maximise resources 5. Reinforce accountability by continuously measuring what matters Technophiles profess to agree… “Often women’s groups are very powerful to get the word about best practices, and those are kind of grass root, organised at the village level, without the government having to play much of a role at all.” (Bill Gates, in India with Aamir Khan, July 2013) The science of sympathy groups THE GROUP Funding acknowledgements: The Wellcome Trust, The Health Foundation (UK), The Big Lottery Fund, DFID, Saving Newborn Lives and ICICI Foundation, W d Child Fi t 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 www.ucl.ac.uk/igh UCLGlobal Health interviews on You Tube .