Participatory Women’s Groups to Reduce Neonatal Mortality in Rural South Asia

Evidence Rating:

Top Tier

Highlights

Program:

A program that has been implemented in rural India, Bangladesh, and Nepal, which aims to reduce neonatal mortality by engaging community women in participatory groups. In a four-phased cycle, a female facilitator guides women in community meetings to identify local maternal and infant health problems, develop strategies to address them, implement the strategies, and evaluate them. The communities also receive health system strengthening activities, including the provision of basic birthing equipment. (The control group areas also received these strengthening activities in the studies described below.) One study estimated the program’s cost per women’s group – comprising 33 group meetings – to be about $800, not including the health system strengthening activities.
Evaluation Methods:

Five high-quality randomized controlled trials (RCTs)[1] have been conducted in rural areas of India (2), Nepal (1) and Bangladesh (2), each of which randomly assigned between 18 to 36 geographical areas to treatment and control groups and had observation periods of two or three years.[2] The number of live births in those periods ranged across studies from 6,125 to 43,717.
Key Findings:

Across four of the five RCTs, the women’s group were found to reduce neonatal mortality by a range of approximately 30 to 35% from control group levels that ranged from 30 to 59 deaths per 1,000 births.[3] These effects were all statistically significant and represent reductions in infant deaths ranging from 10 to 19 per 1,000 live births.

One of the RCTs – in Bangladesh – failed to find statistically significant reductions in neonatal mortality. The researchers hypothesized that this was a result of the very low rate of group attendance (about 3%) by pregnant women in the community. A second Bangladesh RCT was conducted in the same treatment and control areas, with the number of women’s groups increased fivefold. As a result, about 37% of pregnant women in the treatment areas participated in the groups. The second RCT found a statistically significant 33% reduction in neonatal mortality.
Other:

This program was designed for rural areas with high rates of neonatal mortality. An adaptation of the program for urban settings was evaluated in an RCT in Mumbai, India. The adapted program failed to achieve substantial group attendance by pregnant women or to produce a reduction in neonatal mortality. The study found an increase in neonatal mortality that was statistically significant under one analytical approach and not under another. These statistically ambiguous results, along with the low level of group attendance, suggest the finding of increased mortality could be due to chance rather than a true effect. In any case, the study’s failure to find a reduction in neonatal mortality in Mumbai implies that the program’s positive impacts apply only to rural areas.

Arnold Ventures’ Evidence-Based Policy team continuously monitors and reviews the evaluation literature in international development, as we do in domestic U.S. social policy, to identify programs with credible RCT evidence of important effects on people’s lives. However, given our organization’s focus on U.S. social policy, we only provide “highlights” of our evidence reviews for most international development programs (as shown above), without the accompanying detailed PDF summaries that we provide for U.S. programs.

Top Tier

Programs shown in well-conducted RCTs, carried out in typical community settings, to produce sizable, sustained effects on important outcomes. Top Tier evidence includes a requirement for replication – specifically, the demonstration of such effects in two or more RCTs conducted in different implementation sites, or, alternatively, in one large multi-site RCT. Such evidence provides confidence that the program would produce important effects if implemented faithfully in settings and populations similar to those in the original studies.

Near Top Tier

Programs shown to meet almost all elements of the Top Tier standard, and which only need one additional step to qualify. This category primarily includes programs that meet all elements of the Top Tier standard in a single study site, but need a replication RCT to confirm the initial findings and establish that they generalize to other sites. This is best viewed as tentative evidence that the program would produce important effects if implemented faithfully in settings and populations similar to those in the original study.

Suggestive Tier

Programs that have been evaluated in one or more well-conducted RCTs (or studies that closely approximate random assignment) and found to produce sizable positive effects, but whose evidence is limited by only short-term follow-up, effects that fall short of statistical significance, or other factors. Such evidence suggests the program may be an especially strong candidate for further research, but does not yet provide confidence that the program would produce important effects if implemented in new settings.

References

[1] For example, the studies had successful random assignment (as evidenced by highly similar treatment and control groups), used systematic surveillance systems involving key informants to identify all live births and infant deaths in the study areas, and conducted analyses that appropriately accounted for the fact that geographic areas rather than individual households were randomly assigned.

[2] There have been three other RCTs of participatory women’s groups in rural areas – two in Malawi and one in Nepal (they are cited in the references below). A report on the Nepal RCT is forthcoming. The Malawi RCTs fall outside our website’s criteria due to limitations that reduce confidence in the findings, such as the use of study design and analysis methods that may generate false-positive results.

[3] The primary outcome for all studies was the neonatal mortality rate, defined as deaths within the first 28 days of life per 1,000 live births.

Manandhar D.S., Osrin D., Shrestha B.P., et al, (2004). Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: cluster randomized controlled trial. The Lancet 364: 970–79.

Azad K., Barnett S., Banerjee B., et al. (2010). Effect of scaling up women’s groups on birth outcomes in three rural districts in Bangladesh: a cluster-randomised controlled trial. The Lancet 375: 1193–202.

Tripathy P., Nair N., Barnett S., et al. (2010). Effect of a participatory intervention with women’s groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster-randomised controlled trial. The Lancet 375: 1182–92.

Shrestha, B.P., Bhandari, B., Manandhar, D.S., Osrin, D., Costello, A., & Saville, N. (2011). Community interventions to reduce child mortality in Dhanusha, Nepal: study protocol for a cluster randomized controlled trial. Trials 12:136.

More, N.S., Bapat U., Das S., et al. (2012). Community mobilization in Mumbai slums to improve perinatal care and outcomes: a cluster randomised controlled trial. PLoS Medicine 9(7): e1001257.

Fottrell E., Azad K., Kuddus A., Younes L., Shaha S., & Nahar T. (2013). The effect of increased coverage of participatory women’s groups on neonatal mortality in Bangladesh: a cluster-randomised trial. JAMA Pediatrics 167(9):816-0.

Colbourn T., Nambiar B., Bondo A., et al. (2013). Effects of quality improvement in health facilities and community mobilization through women’s groups on maternal, neonatal and perinatal mortality in three districts of Malawi: MaiKhanda, a cluster randomised controlled effectiveness trial. International Health 5: 180-195.

Lewycka S., Mwansambo C., Rosato M., et al. (2013). Effect of women’s groups and volunteer peer counselling on rates of mortality, morbidity, and health behaviours in mothers and children in rural Malawi (MaiMwana): a factorial, cluster randomised controlled trial. The Lancet 381: 1721–35.

Tripathy, P., Nair, N., Sinha, R., et al. (2016). Effect of participatory women’s groups facilitated by Accredited Social Health Activists on birth outcomes in rural eastern India: a cluster-randomised controlled trial. Lancet Global Health 4:e119-28.

Sinha, R.K., Haghparast-Bidgoli, H., Tripathy, P.K., Nair, N., Gope, R., Rath, S., & Prost, A. (2017). Economic evaluation of participatory learning and action with women’s groups facilitated by Accredited Social Health Activists to improve birth outcomes in rural eastern India. Cost Effectiveness and Resource Allocation 15:2.

Highlights

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Evaluation Methods:

Key Findings:

Other:

References

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