Tanja AJ Houweling, David Osrin, Kishwar Azad, Dharma S Manandhar, Prasanta Tripathy, Tambosi Phiri, Joanna Morrison and Anthony Costello
In low- and middle-income countries, the odds of surviving the first 28 days of life are grossly unequal between infants born in deprived and better-off families, even among children living in the same community. In our study, recently published in the IJE, we have shown that women’s groups are able to address this problem. Under the guidance of a facilitator, women came together every month to discuss problems during pregnancy, delivery and the newborn period, and then designed and implemented strategies to overcome these problems with the help of the entire community.
We combined the data from all randomised controlled trials of these participatory women’s group interventions in India, Nepal, Bangladesh and Malawi and estimated their effects on newborn mortality in children from deprived and better-off households. The analysis included 69,120 live births and 2,505 neonatal deaths.
We found that the intervention strongly reduced newborn mortality across social strata. In infants of the most deprived households, mortality fell by 63%, compared with a 35% reduction in better-off households. Even mortality in the first week of life — usually resistant to decline — reduced substantially, by 40% to 60%, across social strata. While the percentage of women giving birth in a facility had not increased, the use of healthy delivery and newborn care practices at home had improved, again across all social layers.
This equitable distribution of the intervention effects is important because little is known about what works to reduce socioeconomic inequalities in health. Health inequalities are a persistent problem in both poor and rich countries, and few interventions are effective in reducing them. So what lessons can be learned from the women’s group intervention about how to reduce health inequalities?
First, ensure universal coverage — make the intervention open to everyone, so that existing social divisions within the community are not enlarged.
Second, combine universal coverage with soft-targeting — mould the intervention so that it makes uptake easy among those who are most in need. In the case of the women’s groups, this meant meeting in places and at times that were convenient to poor and illiterate women; using methods of engagement that these women found fun and relevant, in language that was easy to understand; and focusing on simple behavioural changes in the home that were affordable for the poor.
Third, focus on behaviours or risk factors that could lead to survival benefits, while also addressing the broader social determinants of health. In the case of the women’s groups, this meant discussing things like thermal care and hygienic delivery practices, while the participatory group process also supported the women’s confidence to make healthy decisions.
Finally, ensure that the prerequisites for effective implementation are well understood. For the women’s groups, this means ensuring sufficient coverage in the population (and knowing in which contexts sufficient coverage will be difficult to achieve, such as in some urban informal settlements) and ensuring the intervention has a sufficient duration, as it takes a while for the women’s groups to mobilise communities and change social norms.
Will this approach also work at scale? Government community health workers in India have implemented the intervention, which led to substantial reductions in newborn mortality, including among infants of the most deprived households. The intervention is currently being rolled out across the entire Indian state of Jharkhand (population of 24 million) through the government system, and we are researching what the effects will be at this large scale. Furthermore, the World Health Organization has now recommended community mobilisation through facilitated participatory learning and action cycles with women’s groups to improve newborn health.
It may be that such community groups will also work for chronic disease prevention and management, and this is currently being evaluated in Bangladesh. Who knows, community mobilisation might even help reduce health inequalities in high-income countries.
Houweling TAJ, Looman CWN, Azad K, et al. The equity impact of community women’s groups to reduce neonatal mortality: a meta-analysis of four cluster randomized trials. International Journal of Epidemiology 2017. doi: https://doi.org/10.1093/ije/dyx160.
Tanja AJ Houweling is Assistant Professor at the Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands. Her research focuses on socioeconomic inequalities in maternal, newborn and child health and early child development. She is Principal Investigator of the ESRC-funded EquiNaM project.
David Osrin is Professor of Global Health and Wellcome Trust Senior Research Fellow in Clinical Science at the Institute for Global Health, University College London (UCL). His current partnership is an urban health research collaboration with the Society for Nutrition, Education and Health Action.
Kishwar Azad is the Project Director of the Diabetic Association of Bangladesh Perinatal Care Project. She is involved in research aimed at creating low-cost, innovative solutions, primarily involving women’s groups, to improve neonatal, child and maternal health. She has led several randomised trials of participatory women’s group interventions.
Dharma S Manandhar is President and Executive Director of Mother and Infant Research Activities, a non-government organisation involved in research, training and advocacy for improving maternal and neonatal health in Nepal and developing countries. He has been involved in several cluster randomised trials related to maternal and newborn health and nutrition in Nepal.
Prasanta Tripathy is Secretary and Director of Ekjut, a non-government organisation in India involved in community-based studies to improve maternal and child health in the under-served districts of India. Ekjut’s collaborative work with the UCL Institute for Global Health won the Trial of the Year from the Society for Clinical Trials in 2011.
Tambosi Phiri is Project Manager for the MaiMwana Project, Mchinji (Malawi), which aims to reduce maternal and child morbidity and mortality using sustainable community interventions. She is an experienced health services administrator with an MSc in International Child Health from UCL.
Joanna Morrison is a Senior Research Associate at the Institute for Global Health, UCL. She is a global health social scientist working with local partners to build research capacity and increase understanding of the issues affecting women’s and children’s health in rural areas. Follow her on Twitter: @morrisontartan
Anthony Costello is Director of the Department of Maternal, Child and Adolescent Health of the World Health Organization. As founder of an international charity, Women and Children First, he helped to spread the results of his research work through mobilisation of women’s groups across Africa and south Asia.