An intervention involving participatory women’s groups facilitated by government-approved social workers was associated with reduced neonatal mortality in rural communities in eastern India, according to a cluster-randomized controlled trial conducted between 2009 and 2012.1 Compared with births to women living in control communities, those to women living in intervention communities had 31% lower odds of resulting in death of the infant within the first 28 days of life (odds ratio, 0.7). In addition, the odds of certain home care practices—e.g., birth attendant’s using a safe delivery kit and placing the infant against the mother’s skin within one hour of birth—were greater for births occurring in intervention communities than for those in control communities (odds ratios, 1.4–5.1).
For the study, researchers chose 30 clusters—geographic areas with a population of about 5,000 individuals each—from five rural districts of the Jharkhand and Odisha states of eastern India. Half the clusters were randomly selected to receive an intervention, which was implemented in September 2010 and consisted of a series of women’s group meetings led by village-based accredited social health activists (ASHAs)—female community health workers trained under India’s National Rural Health Mission. ASHAs purposively invited pregnant women and new mothers to participate; however, the meetings were open to all local women. During meetings, women discussed maternal and newborn health problems, strategized about how to solve them, implemented the strategies and assessed their progress. Control clusters did not receive the group meeting intervention; however, in all clusters, the researchers met with village health sanitation and nutrition staff, and with government officials and hospital management to address issues relevant to maternal and newborn health.
Data were collected for a baseline period consisting of the year before the intervention was implemented and for a two-year evaluation period beginning three months after implementation. Monitoring teams attempted to ascertain all births and deaths to women of reproductive age living in study clusters through reports from local key informants and through birth records. Researchers interviewed mothers about six weeks after a delivery to document pregnancy- and birth-related events and practices, and conducted verbal autopsies for deaths among infants and mothers. One intervention cluster was lost to follow-up and was dropped from analyses. Descriptive analyses were used to compare baseline characteristics across groups, and logistic regression analyses were conducted to assess whether the intervention was associated with various outcomes, primarily neonatal mortality (i.e., death of an infant in the first 28 days of life), as well as home care and care-seeking practices.
During the baseline period, 3,244 women (1,635 from intervention clusters and 1,609 controls) experienced 3,304 births. Overall, the mean age of mothers was 24.7 years; 65% could not read, and 58% had not attended school. The socioeconomic characteristics of women were the same across groups, except a greater proportion of women in the control group than of those in the intervention group had a secondary or higher education (33% vs. 24%).
As part of the intervention, ASHAs supported 161 community groups of women and held 4,903 meetings in intervention clusters; on average, 26 women attended each meeting. Two-thirds of women in the intervention group who gave birth to a singleton infant during the evaluation period attended at least one meeting; little contamination of nonintervention clusters occurred, as only 2% of control mothers reported ever attending a meeting.
During the evaluation period, 3,700 births occurred to women in the intervention group and 3,519 to women in the control group. The rates of neonatal mortality in the intervention and control groups were 30 and 44 per 1,000 live births, respectively—which translated to a 31% lower risk for the intervention group (odds ratio, 0.7), after analyses were adjusted for clustering and stratification by district; the reduction in neonatal mortality risk was even greater in analyses that also accounted for baseline differences in maternal mortality (0.5). On closer inspection, the intervention was associated with reduced odds of neonatal death occurring within the first six days of life (0.7), but not of death occurring later. No differences by group were found in regard to stillbirth, perinatal mortality or maternal mortality.
In addition, the intervention was positively associated with a variety of home care practices: Compared with births in the control group, those in the intervention group were more likely to involve a birth attendant who used a safe delivery kit, wiping of the infant within one hour of birth, wrapping of the infant within 10 minutes or one hour of birth and placing of the infant against the mother’s skin within one hour of birth (odds ratios, 1.4–5.1). No differences by group were found in regard to other care-seeking practices, such as having three or more antenatal check-ups by a skilled provider, planning various aspects of delivery and giving birth in a facility.
The investigators note that the findings add to those of a previous randomized trial that also suggested that participatory women’s groups are beneficial in rural eastern India. They speculate that the lower observed risk of neonatal mortality seen in this new trial derived from improvements in thermal care practices, as well as higher levels of birth preparedness and facility births among the most marginalized mothers. According to the investigators, study limitations included lack of full integration of the intervention into the government system and possibly insufficient power to detect differences in some outcomes. "With two positive randomised evaluations of participatory women’s groups in rural eastern India, important equity benefits, and a global [World Health Organization] recommendation, scaling up is justified, particularly in underserved rural areas where neonatal mortality remains high," they conclude.—S. London