Effect of Participatory Women's Groups Facilitated by Accredited Social Health Activists on Birth Outcomes in Rural Eastern India: A Cluster-Randomised Controlled Trial

"ASHAs can successfully reduce neonatal mortality through participatory meetings with women's groups. This is a scalable community-based approach to improving neonatal survival in rural, underserved areas of India."

India's government-approved Accredited Social Health Activists (ASHAs), a group of more than 900,000 trained and incentivised female community volunteers, work to improve maternal and newborn health in India by encouraging women to access antenatal care and give birth in health facilities, conducting postnatal home visits, and providing health education with local women's groups. This cluster-randomised controlled trial (RCT) aimed to test the effect of participatory women's groups facilitated by ASHAs on birth outcomes, including neonatal mortality, in rural Jharkhand and Odisha, eastern India.

The study took place in 30 geographical clusters covering 5 rural districts of Jharkhand and Odisha. About half of the residents in these 5 districts belong to indigenous (adivasi) or Scheduled Tribe communities, and 70% of the ASHAs who took part in the study were adivasi. The researchers randomly assigned (1:1) geographical clusters to intervention (participatory women's groups: 15 clusters, estimated population n=82,702) or control (no women's groups: 15 clusters, n=73,817). Study participants were women who gave birth between September 1 2009 and December 31 2012.

The 31-month intervention was a cycle of women's group meetings led by ASHAs that were held fortnightly for the first 4 months and every month thereafter. These ASHAs had received 11 days of training by Ekjut, a local non-governmental organisation, in addition to their own government training. The meeting cycle followed rules of participatory learning and action and had a 4-phase structure:

1. ASHAs helped the groups identify and prioritise maternal and newborn health problems using picture cards and a participatory voting game.
2. Groups listened to stories with local motifs featuring the causes of their prioritised problems and potential solutions. They discussed these stories, identified and prioritised feasible strategies, and held a community meeting in which they talked about their problems and strategies with other community members and sought their support.
3. Groups implemented their chosen strategies and learned about other practical actions to improve maternal and newborn health (e.g., how to prepare for emergencies in pregnancy).
4. Groups evaluated the meeting cycle and progress against their strategies.

Specific adaptations from previous women's group interventions included actively encouraging pregnant women to join the groups, and ensuring that meetings about thermal care for newborn infants were held during winter starting from the first year.

During the follow-up period (January 1 2011 to December 31 2012), the researchers identified 3,700 births in the intervention group and 3,519 in the control group. One intervention cluster was lost to follow up. The neonatal mortality rate during this period was 30 per 1,000 livebirths in the intervention group and 44 per 1,000 livebirths in the control group (odds ratio [OR] 0.69, 95% confidence interval [CI] 0.53-0.89). The researchers recorded no differences in stillbirths, perinatal deaths, or maternal deaths between intervention and control groups, and most care practices improved over time in both intervention and control groups.

In short: "ASHAs successfully supported women's groups through a cycle of participatory learning and action meetings at high coverage, achieving a 31% reduction in neonatal mortality rate during 2 years, and with especially strong reductions among the most marginalised mothers." The latter finding could be due to the fact that participatory group meetings enable "soft-targeting" of the economically poorest women because they are open to all, occur at a time decided by women themselves, and take place in remote hamlets. These factors "could have enabled ASHAs to better promote birth preparedness and facility births among those who needed it the most, thereby contributing to mortality reduction."

Process evaluation data collected by the researchers suggest that the recognition given to ASHAs by their communities for facilitating meetings was a strong incentive for them to continue the intervention.

India's flagship National Health Mission programme has recommended scaling up participatory learning and action with ASHAs in rural areas and co-developed a facilitation manual [PDF] with Ekjut.

"Participatory learning and action with women's groups could be used to address problems beyond the perinatal period, and further research is needed to examine its potential to improve women, children and adolescent's health across the lifecourse."