Effect of a Participatory Intervention with Women's Groups on Birth Outcomes in Nepal

"If participation is a key element of primary health care then few controlled studies have been done of its effect on health outcomes. Participation is typically seen as an adjunct to implementation rather than as a primary intervention, and the distinction between a didactic approach to health education at community level and a participatory approach to developing strategies is blurred."

Motivated by this observation, a team from Mother and Infant Research Activities (MIRA) in Kathmandu, Nepal undertook a low-cost, community-based participatory intervention with women's groups to test the impact of peer education on birth outcomes in an economically poor rural population. Funded by the UK Department for International Development (DFID), the study itself was approved by the Nepal Health Research Council and the ethics committee of the Institute of Child Health and Great Ormond Street Hospital for Children, and was conducted in collaboration with His Majesty's Government Ministry of Health, Nepal. This 10-page report, published in The Lancet (Vol. 364, No. 9438) describes the implementation and results of this internationally registered, cluster-randomised controlled trial of community-based strategies to reduce neonatal mortality (ISRCTN31137309).

To provide some context and motivation for the project, the authors indicate that the estimated infant mortality rate in Nepal is 64 per 1000 livebirths, the neonatal mortality rate 39 per 1000 livebirths, and the perinatal mortality rate 47 per 1000 births. In rural areas, 94% of babies are born at home, and only 13% of births are attended by trained health workers. In the mountainous and rural Makwanpur district, the research site, the district hospital has facilities for antenatal care and delivery, but there are 7852 people for every 1 hospital bed.

The intervention evaluated here focused on the participation of local women of reproductive age. The communication approach emphasised participatory learning, rather than instruction. In each intervention cluster (average population 7000), a facilitator - a literate locally resident woman - convened 9 women's group meetings every month. This woman needed to have "abilities and training in participatory communication techniques. She needed to have a grasp of perinatal health issues and some knowledge of potential interventions so she could act as a broker of information and a catalyst for change...One supervisor provided support for every three facilitators by attending group meetings and making regular community visits. The first step of the intervention was to discuss issues around childbirth and care behaviours in the community, which allowed facilitators to develop participatory learning skills and generated information on pregnancy and childbirth, covering beliefs and practices in both uncomplicated and complicated pregnancies." Over a yearlong period, the facilitator supported groups through an action-learning cycle in which they identified local perinatal problems and formulated strategies to address them.

"One result of the process was that women sought more information about perinatal health. This information was provided through the iterative design and playing of a picture card game that addressed prevention, treatment, and consultation for typical problems in mothers and babies."

The MIRA team had already taken action to remedy various weaknesses in the provision of antenatal, delivery, and newborn care (in both intervention and control areas, for ethical reasons). For example, in partnership with the District Public Health Office, the team organised training in essential newborn care for government health staff and for female community health volunteers and traditional birth attendants. Community-based workers received a basic newborn care kit that featured medical tools and a pictorial manual.

The intervention was found to be very effective; it reduced neonatal mortality by 30%. Maternal mortality, although not a primary outcome of the trial, was also significantly lower (78%) in intervention areas. Women in intervention clusters were more likely to have antenatal care, institutional delivery, trained birth attendance, and hygienic care than were controls. The intervention also seemed to be acceptable: 95% of groups remained active at the end of the trial despite no financial incentives and the opportunity costs incurred by women spending time away from other tasks.

The authors assert that this intervention could be scaled up rapidly with strong political commitment and the involvement of both government and nongovernment organisations. "Local rather than central government might be preferable to lead the process for reasons of participation, accountability, and sustainability." They conclude that "Progress towards the Millennium Development Goals for maternal and child mortality reduction has faltered. Our findings suggest that a demand-side intervention can achieve great reductions in neonatal and maternal mortality in poor and remote communities."