This thesis builds on a previous cluster-randomised controlled trial of a community mobilisation intervention with women’s groups to reduce neonatal mortality and maternal psychological distress (July 2005-2008) (Tripathy et al. 2010). The trial was implemented by an Indian NGO called Ekjut working in collaboration with the UCL Institute for Global Health.
Community mobilisation with women’s groups to reduce neonatal mortality
The trial included 36 clusters of villages and hamlets (of approximately 6000 people each) from three contiguous districts of Jharkhand and Orissa. The majority of the population were from rural, tribal communities. Clusters were randomised to the intervention group (community mobilisation with women’s groups and health-service strengthening) or to health service strengthening only, stratified by district. Intervention and control clusters were separated by a geographical ‘buffer’ region to minimise the risk of contamination (Tripathy et al. 2010). Health-service strengthening involved setting up cluster-level ‘village health committees’, in line with National Rural Health Mission objectives. Committees consisted of 10 village
82 representatives per cluster who met every two months to discuss the design and management of local health services, and health entitlements for women and new born infants. In addition, frontline healthcare staff from seven clusters in Jharkhand took part in ‘appreciative inquiry’ workshops to enable committees to qualitatively assess service quality (Tripathy et al. 2010). Gaining consent from community members to carry out the study began 10 months prior to the start of the intervention, in accordance with the preliminary phase of community mobilisation (Howard-Grabman 2007). Ekjut field staff met with gram sabhas (village councils), village headmen, and locally elected panchayat representatives in all districts to build trust and cooperation, raise awareness of maternal and neonatal health issues and ultimately to gain permission to work with women’s groups and begin surveillance of births and deaths in the study areas (Tripathy et al. 2010).
The intervention capitalised on the presence of existing women’s groups in some clusters, set up by the NGO PRADAN for micro-credit activities (n=172), as well as creating new women’s groups where necessary (n=72). There was one women’s group per 468 population and attendance by newly pregnant women rose from 18% to 55% over the three-year study period. New births, maternal and neonatal deaths or deaths of women of reproductive age were identified using key informants (ANMs or active community members; 1 per 250 households). Mothers of infants were interviewed 6 weeks postnatally to gather data on background characteristics, care-seeking and homecare practices, and antenatal, perinatal and postnatal information. Maternal psychological distress was identified as a primary outcome in year 2 of the study, and whilst not directly addressed, women identified by interviewers as severely distressed were referred to tertiary mental health services. The women’s group cohort remained open for the duration of the study to women 15-49 who had given birth during the study period, although other community members were allowed to attend meetings (Tripathy et al. 2010).
The process of community mobilisation with women’s groups
Women’s group facilitators (living locally, and trained by Ekjut) carried out monthly meetings with 13 groups each. They facilitated discussions about common maternal and newborn care problems using story-telling, games and picture cards; materials were adapted from a similar trial in Nepal (Manandhar et al. 2004). This process followed a community participatory learning
83 and action cycle including four distinct sequential phases (illustrated in figure 3.1).
Figure 3.1 The Women’s Group Participatory Learning and Action Cycle
In early meetings of phase 1, facilitators sought to engage with participants and clarify the nature of the relationship between Ekjut and the women’s group. In the facilitator manual this is described as one of partnership and minimal dependency: ‘to help communities to help themselves and at the same time to learn from them…where the organisation and the community walk together’. Women then discussed local practices around maternal and newborn health, before moving on to prioritising particular issues for intervention through voting (Tripathy et al. 2010).
After prioritisation, story-telling became central. This allowed group members to develop an in- depth understanding of the health issue. Facilitators were given the core elements of a story relating to causes and effects of a particular health problem, and then made it into a complete narrative, adding local elements. Facilitators supplemented the story with their own drawings to illustrate the important points linking cause and effect, and then asked participants to re-tell the stories. Cause and effect were further explored with the ‘but why’ approach to each component of the problem, starting with the outcome (e.g. still-births) and working backwards to identify each precipitating cause. Causes included immediate medical causes as well as
84 underlying and basic causes. Meetings in this phase also included awareness-raising about recognising danger signs and when formal emergency healthcare assistance was required, and advice to rectify obviously harmful practices emerging from group discussion (Rath et al. 2010). In phase 2 women developed local strategies to tackle the priority problems and presented their ideas to the wider community to gain support. Initially, the concept of strategy development was communicated through the ‘bridge game’. Here groups used local props to symbolise the building of a bridge made up of local actions that enabled access to improved maternal and child health. As women suggested strategies to build the bridge the facilitator helped the group decide if it was feasible by asking how it could be achieved. The best ideas were shortlisted and a small number were eventually chosen, including assignment of tasks to individuals (Nirmala Nair, personal communication, January 2010). Phase 3 involved implementing the chosen strategies, and in the final phase groups evaluated their activities. Some examples of strategies used by the groups include saving for an emergency fund to allow transportation to hospital, emergency drills in the event of post-partum bleeding, and lobbying for an Anganwadi Worker to cover their hamlet (Tripathy et al. 2010) (Suchitra Rath, personal communication, January 2010).
Results of the neonatal mortality trial
Over the three-year study period, neonatal mortality was 32% lower in the intervention group than the comparison group, and 45% lower in the final year of the trial. Maternal psychological distress scores were not significantly different between groups overall, but moderate distress was reduced by 57% in the intervention areas compared to the comparison areas in the final year of the trial (Tripathy et al. 2010). A process evaluation identified six factors instrumental to the success of the intervention: high population coverage, targeting of marginalised communities, on-going and active recruitment of pregnant women, high acceptability of the intervention, mobilisation of community members outside the groups, and increased skills, knowledge and the development of Freire’s ‘critical consciousness’ (Rath et al. 2010). Critical consciousness refers to the outcome of a pedagogical process that seeks to educate underserved groups about the wider societal structures that maintain their position in society; this new awareness is intended to be empowering and stimulate positive social change; the process is termed ‘conscientization’ (Freire 2005).
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