Mira nepal presentation


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Mira nepal presentation

  1. 1. Importance of social and behavior change in improving child survival Impact of Participatory women’sgroups on maternal and neonatal health: Experience from Nepal JR Shrestha MPH Research Program Coordinator Mother and Infant Research Activities (MIRA) 1
  2. 2. Supply Demand 2
  3. 3. Improving the Demand Side• Bringing awareness in the family – avoiding harmful practices and promoting good practices, promoting delivery by a SBA or in a health facility• Recognising danger signs and seeking help from health workers or at appropriate health facilities• Developing strategies in the community to manage the problems 3
  4. 4. Impact of Health EducationThe effects of postnatalhealth education formothers on infant careand family planningpractices in Nepal: arandomised controlledTrialShowed no effects after 6months of standard healtheducation Bolam et al BMJ, 1998 4
  5. 5. How to change behaviour?• Telling people what to do? NO• Communication for social change: dialogue not monologue 5
  6. 6. MIRA MakwanpurMother and Newborn Care Study- a cluster randomised trial usingparticipatory women’s groupsimplemented in collaboration with theInstitute of Child Health, LondonOne of the largest such studies in the world involving 30,000 married women of reproductive age in 24 V.D.Cs of Makwanpur district 6
  7. 7. Two strategies Facilitationa participatory community action cycle in the intervention area Health service strengtheningin both control and intervention areas 7
  8. 8. Trial design 24 clusters in 12 matched pairs 1600 sq km population 170,000 Surveillance of pregnancies 28,931 women Supply side Health service activities 12 intervention clusters 12 control clusters Demand side Women’s groups No women’s groups 8
  9. 9. Primary outcomeNeonatal mortality rateSecondary outcomesStillbirth rateMaternal mortality ratioHome care practicesHealth care seeking 9
  10. 10. The intervention1 local woman facilitator per clusterNot a health worker7000 population, 60 sq km9 monthly women’s groupsOnly 8% coverage of MWRA 10
  11. 11. The participatory action cycle Problem Identification Participatory Planning evaluation together Implementation 11
  12. 12. The first ten meetingsHow women approach maternal and neonatal issues Common local maternal and neonatal problems Why mothers and newborns dieStrategies to gather information in the community Information sharing Identification of key problems Strategies to address these problemsWider presentation of problems and strategies Adoption of community strategies 12
  13. 13. Developingstrategies Problem Identification Participatory Planning evaluation together Implementation 13
  14. 14. Health Service Strengthening in bothstudy areasTraining of the health staffand TBAs and FCHVsSupply•Some essential equipment• Some essential drugs 14
  15. 15. 15
  16. 16. 30% reduction in neonatal mortality!Major impact on maternal mortality! Lancet 2005 16
  17. 17. How do the groups work? SDK Hand washing Family supportPostnatal care Use of Nets Funds Breastfeeding Empowerment Critical consciousness Decision-making Communication Political action Solidarity 17
  18. 18. Cost Effectiveness• The average provider cost of the womens group intervention was USD 0.75 dollars per person per year (0.90 dollars with health- service strengthening) in a population of 86,704.• The incremental cost per life-year saved (LYS) was 211 dollars• Expansion could rationalize on start-up costs and technical assistance, reducing the cost per LYS to 138 dollars .• Sensitivity analysis showed a variation from 83 dollars to 263 dollars per LYS for most variables.• This intervention could provide a cost- effective way of reducing neonatal deaths.BorgJoJhi et al Lancet 2005 18
  19. 19. Expansion of the TrialSimilar intervention trials with some localmodifications have been undertaken in :• Rest of Makwanpur district• Dhanusha in Nepal• Mumbai and Jharkhand in India• Bangladesh• MalawiResults from other studies also showed positive effecton reduction of neonatal mortality particularly from EkJut trialRecently a systematic review and meta analysis ofparticipatory women’s groups on maternal and neonatalmortality has been submitted to the Lancet 19
  20. 20. Conclusions & Recommendations• Participatory women’s groups have been found to be effective in reducing NMR and (MMR) and thus helping Child survival.• This method has been found successful in high mortality situations in rural areas and but not that effective in high institutional delivery areas with low mortality rates .• For effectiveness of this process, a facilitator should be available for about 800 population• This strategy should be scaled up in above situations 20
  21. 21. Thank You 21