presented in Delhi conference

1. Importance of social and behavior change
in improving child survival
Impact of Participatory women’s
groups on maternal and neonatal
health: Experience from Nepal
JR Shrestha MPH
Research Program Coordinator
Mother and Infant Research
Activities (MIRA) 1

2. Supply Demand
2

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. Impact of Health Education
The effects of postnatal
health education for
mothers on infant care
and family planning
practices in Nepal: a
randomised controlled
Trial
Showed no effects after 6
months of standard health
education
Bolam et al BMJ, 1998 4

5. How to change behaviour?
• Telling people what to
do? NO
• Communication for
social change:
dialogue not
monologue
5

6. MIRA Makwanpur
Mother and Newborn Care Study
- a cluster randomised trial using
participatory women’s groups
implemented in collaboration with the
Institute of Child Health, London
One 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. Two strategies
Facilitation
a participatory community action
cycle
in the intervention area
Health service strengthening
in both control and intervention
areas
7

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. Primary outcome
Neonatal mortality rate
Secondary outcomes
Stillbirth rate
Maternal mortality ratio
Home care practices
Health care seeking 9

10. The intervention
1 local woman facilitator per cluster
Not a health worker
7000 population, 60 sq km
9 monthly women’s groups
Only 8% coverage of MWRA
10

11. The participatory action cycle
Problem
Identification
Participatory Planning
evaluation together
Implementation
11

12. The first ten meetings
How women approach maternal and neonatal issues
Common local maternal and neonatal problems
Why mothers and newborns die
Strategies to gather information in the community
Information sharing
Identification of key problems
Strategies to address these problems
Wider presentation of problems and
strategies
Adoption of community strategies
12

13. Developing
strategies
Problem
Identification
Participatory Planning
evaluation together
Implementation 13

14. Health Service Strengthening in both
study areas
Training of the health staff
and TBAs and FCHVs
Supply
•Some essential equipment
• Some essential drugs
14

15. 15

16. 30% reduction in neonatal mortality!
Major impact on maternal mortality!
Lancet 2005
16

17. How do the groups work?
SDK Hand washing Family support
Postnatal care Use of Nets Funds Breastfeeding
Empowerment
Critical consciousness
Decision-making
Communication Political action Solidarity 17

18. Cost Effectiveness
• The average provider cost of the women's
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. Expansion of the Trial
Similar intervention trials with some local
modifications have been undertaken in :
• Rest of Makwanpur district
• Dhanusha in Nepal
• Mumbai and Jharkhand in India
• Bangladesh
• Malawi
Results from other studies also showed positive effect
on reduction of neonatal mortality particularly from Ek
Jut trial
Recently a systematic review and meta analysis of
participatory women’s groups on maternal and neonatal
mortality has been submitted to the Lancet 19

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. Thank You
21