Women's Groups Practising Participatory Learning and Action to Improve Maternal and Newborn Health in Low-resource Settings: A Systematic Review and Meta-analysis

"Women's groups practising participatory learning and action led to substantial reductions in neonatal mortality in rural, low-resource settings."

Maternal and neonatal mortality rates remain high in many low- and middle-income countries (LMICs). Among the approaches for the improvement of birth outcomes used in community-based interventions is women's groups meeting in a 4-phase participatory learning and action cycle. Women's groups have the potential to increase appropriate care-seeking (including antenatal care and institutional delivery) and appropriate home prevention and care practices for mothers and newborns. This systematic review of randomised controlled trials (RCTs) sought to ascertain the effects of these groups, compared with usual care, on maternal mortality, neonatal mortality, and stillbirths in low-resource settings.

The women's group approach was inspired by a commitment to the participation of people in health care after the Alma-Ata Declaration of 1978, which identified primary health care as the key to the attainment of the goal of Health for All. It also draws on Paolo Freire's work, which provided insights applicable to health: Many health problems are rooted in powerlessness and could be addressed by social and political empowerment; health education is more empowering if it involves dialogue and problem solving, rather than message giving; and communities can develop critical consciousness to recognise and address the underlying social and political determinants of health.

The participatory learning and action cycle used by many of these groups involves: Phase 1 to identify and prioritise problems during pregnancy, delivery, and post partum; phase 2 to plan and phase 3 to implement locally feasible strategies to address the priority problems; and phase 4 to assess their activities.

Seven RCTs (119,428 births) undertaken in Bangladesh, India, Malawi, and Nepal met the inclusion criteria. Table 1 in the paper summarises the characteristics of these trials, which were carried out between 1999 and 2011. The studies were found to be of good quality and had low risk of bias. In all trials, variants of a participatory learning and action cycle were tested.

Meta-analyses of all trials showed that exposure to women's groups was associated with a 23% non-significant reduction in maternal mortality (odds ratio 0.77, 95% confidence interval (CI) 0.48-1.23), a 20% reduction in neonatal mortality (0.80, 0.67-0.96), and a 7% non-significant reduction in stillbirths (0.93, 0.82-1.05), with high heterogeneity for maternal and neonatal results. In the meta-regression analyses, the proportion of pregnant women in groups was linearly associated with reduction in both maternal and neonatal mortality (p=0.019 and p=0.009, respectively). A subgroup analysis of the four studies in which at least 30% of pregnant women participated in groups showed a 49% reduction in maternal mortality (0.51, 0.29-0.89) and a 33% reduction in neonatal mortality (0.67, 0.60-0.75). Thus: "The proportion of pregnant women participating in groups and the population coverage of groups were key predictors of the effect."

Table 2 in the paper shows the behavioural mechanisms, based on reported data, through which the interventions might have affected birth outcomes. In three of four south Asian trials in which the behavioural mechanisms were reported, women's groups showed strong (including significant and non-significant) effects on clean delivery practices for home deliveries (especially handwashing and use of clean delivery kits) and noticeable effects on breastfeeding. Use of women's groups resulted in significant increases in the uptake of any antenatal care in two studies and institutional deliveries in one study.

Each study had a process evaluation for the interventions, evidence from which enabled the researchers to develop a working hypothesis about the way in which the women's groups bring about improvements in birth outcomes: The intervention builds the capacities of communities to organise and mobilise to take individual, group, and community action to address the structural and intermediary determinants of health. Data showed that groups discussed danger signs, raised community-wide support for maternal health, organised transport for pregnant women, and contributed to emergency funds for transport and healthcare costs.

In reflecting on the findings, the researchers point to the question of whether participatory learning and action have a role in maternal and newborn health in urban contexts. In cities, there is an argument for focusing on improved links between communities and facilities and on the quality of clinical care. Collective action could be instrumental in achieving these objectives but might require moving beyond women's groups as the main agents of change if urban women are more isolated and reluctant to commit to group action. It is also important, per the researchers, to consider how community strategies that were shown to be effective in small-to-medium-sized trials, including home visits and collective action through women's groups, could be combined at scale.

In conclusion: "With the participation of at least a third of pregnant women and population coverage of 450-750 per group, women's groups practising participatory learning and action are a cost-effective strategy to improve maternal and neonatal survival in resource-poor settings. Their implementation in rural areas...could save many lives."

Full list of authors, with institutional affiliations: Audrey Prost, University College London; Tim Colbourn, University College London; Nadine Seward, University College London; Kishwar Azad, Diabetic Association of Bangladesh; Arri Coomarasamy, University of Birmingham; Andrew Copas, University College London; Tanja A J Houweling, University College London and Erasmus MC University Medical Center Rotterdam; Edward Fottrell, University College London; Abdul Kuddus, Diabetic Association of Bangladesh; Sonia Lewycka, University College London and MaiMwana Project; Christine MacArthur, University of Birmingham; Dharma Manandhar, Mother Infant Research Activities; Joanna Morrison, University College London and Mother Infant Research Activities; Charles Mwansambo, Government of Malawi, Ministry of Health; Nirmala Nair, Ekjut; Bejoy Nambiar, University College London and Parent and Child Health Initiative; David Osrin, University College London and Society for Nutrition, Education and Health Action; Christina Pagel, University College London; Tambosi Phiri, MaiMwana Project; Anni-Maria Pulkki-Brännström, University College London; Mikey Rosato, University College London and MaiMwana Project; Jolene Skordis-Worrall, University College London; Naomi Saville, University College London and Mother Infant Research Activities; Neena Shah More, Society for Nutrition, Education and Health Action; Bhim Shrestha, Mother Infant Research Activities; Prasanta Tripathy, Ekjut; Amie Wilson, University of Birmingham; Anthony Costello, University College London