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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 MPHResearch Program Coordinator

Mother and Infant Research Activities (MIRA)

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Supply Demand

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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

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Impact of Health Education

The 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

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How to change behaviour?

• Telling people what to do? NO

• Communication for social change: dialogue not monologue

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MIRA MakwanpurMother 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

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Two strategies

Facilitationa participatory community

action cyclein the intervention area

Health service strengtheningin both control and intervention areas

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Trial design24 clusters

in 12 matched pairs1600 sq km

population 170,000

Surveillance of pregnancies28,931 women

Supply sideHealth service activities

12 intervention clustersDemand side

Women’s groups

12 control clusters

No women’s groups

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Neonatal mortality rate

Stillbirth rate

Maternal mortality ratio

Home care practices

Health care seeking

Primary outcome

Secondary outcomes

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The intervention1 local woman facilitator per clusterNot a health worker7000 population, 60 sq km9 monthly women’s groupsOnly 8% coverage of MWRA

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The participatory action cycle

Problem Identification

Planning together

Implementation

Participatory evaluation

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Why mothers and newborns die

How women approach maternal and neonatal issues

Common local maternal and neonatal problems

Strategies to gather information in the community

The first ten meetings

Information sharing

Strategies to address these problems

Wider presentation of problems and strategiesAdoption of community strategies

Identification of key problems

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Problem Identification

Planning together

Implementation

Participatory evaluation

Developing strategies

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Health Service Strengthening in both study areas

Training of the health staff

and TBAs and FCHVs

Supply

•Some essential equipment

• Some essential drugs

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30% reduction in neonatal mortality!Major impact on maternal mortality!

Lancet 2005

How do the groups work?

SDK Hand washing Family support

Postnatal care Use of Nets Funds Breastfeeding

Communication Solidarity

EmpowermentCritical consciousnessDecision-making Political action 17

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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

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Expansion of the Trial

Similar 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 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

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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

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