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

"Participatory groups have the advantage of helping the poorest, being scalable at low cost, and producing potentially wide-ranging and long-lasting effects."

Neonatal mortality rates remain high in low- and middle-income countries. Maternal depression is also a key public health concern because of its high prevalence and wide-ranging implications for the health of the mother and infant. Indigenous communities have higher mortality rates and poorer access to health services than the non-indigenous populations. Carried out in three rural districts in eastern India with largely tribal, underserved, and economically poor populations, this cluster-randomised controlled trial (RCT) tested whether community mobilisation through participatory women's groups might reduce neonatal mortality and maternal depression.

From 36 clusters in Jharkhand and Orissa, with an estimated population of 228,186, the researchers assigned 18 clusters to intervention or control groups. Women were eligible to participate if they were aged 15-49 years, residing in the project area, and had given birth during the study.

In the 18 intervention clusters, the researchers used a participatory action cycle with 172 existing women's groups, who were involved in savings and credit activities, and created an additional 72 groups. Every group met monthly for a total of 20 meetings, and a local woman, selected on the basis of criteria (including speaking the local language and having the ability to travel to meetings) identified by the community, facilitated the meetings. Information about clean delivery practices and care-seeking behaviour was shared through stories and picture-card games, rather than presented as key messages. By discussion of case studies imparted through contextually appropriate stories, group members identified and prioritised maternal and newborn health problems in the community, collectively selected relevant strategies to address these problems, implemented the strategies, and assessed the results. Community members who were not regular group members were also encouraged to participate in discussions. The idea is that, "By addressing critical consciousness,...groups have the potential to create improved capability in communities to deal with the health and development difficulties arising from poverty and social inequalities."

In addition, the researchers formed health committees in all intervention and control clusters so that community members would have the opportunity to express their opinions about the design and management of local health services. They also provided workshops for appreciative inquiry with frontline government health staff from seven clusters per district in Jharkhand.

After baseline surveillance of 4,692 births, the researchers monitored outcomes for 19,030 births from 2005 to 2008. Neonatal mortality rates (NMRs) per 1,000 were 55.6, 37.1, and 36.3 during the first, second, and third years, respectively, in intervention clusters, and 53.4, 59.6, and 64.3, respectively, in control clusters. NMR was 32% lower in intervention clusters adjusted for clustering, stratification, and baseline differences (odds ratio 0.68, 95% confidence interval (CI) 0.59-0.78) during the 3 years and 45% lower in years 2 and 3 (0.55, 0.46-0.66).

The most likely mechanism of mortality reduction was through improved hygiene and care practices: Home-care practices showed substantial improvements in intervention clusters - birth attendants were more likely to wash their hands, use a safe delivery kit and a plastic sheet, and boil the thread used to tie the cord than were those in the control clusters. The proportion of infants exclusively breastfed at 6 weeks was higher in intervention areas in adjusted analyses for years 2 and 3.

The researchers explain that, while availability of safe delivery kits increased in both control and intervention areas, women's groups seemed to generate more demand in intervention clusters than in control clusters. In places where kits were not provided, group members made them and provided information about their contents to mothers, then visited pregnant women during the eighth month of pregnancy to ensure they had received kits and would use them. Birth outcomes might have been affected by the fact that these community members attended the groups or were advised by group members, thus generating increased social awareness and support for clean delivery practices.

Although there was no significant effect on maternal depression overall, reduction in moderate depression was 57% in year 3 (0.43, 0.23-0.80). The researchers hypothesise that this reduction could be due to improvements in social support and problem-solving skills of the women's groups. Furthermore, the maternal mortality ratio was generally lower in intervention than in control clusters, although the study was not powered to detect significant differences. Qualitative evidence from the assessment of the trial's process showed that community mobilisation through women's groups might have contributed to avoidance of some maternal deaths.

The researchers point out that costs for participatory women's group interventions are lower than for most other primary healthcare interventions and can complement existing self-help groups in the community. They conclude by asking: "Could such a participatory intervention support and strengthen the National Rural Health Mission's mandate of communitisation of health and the Accredited Social Health Activist programme?....Further assessments of this approach will involve a scale-up in large populations with little access to health services, and different delivery mechanisms of the intervention will need to be tested in partnership with government and non-government organisations."