Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial
Abstract
Background
Neonatal deaths in developing countries make the largest contribution
to global mortality in children younger than 5 years. 90% of deliveries
in the poorest quintile of households happen at home. We postulated that
a community-based participatory intervention could significantly reduce
neonatal mortality rates.
Methods
We pair-matched 42 geopolitical clusters in Makwanpur district, Nepal,
selected 12 pairs randomly, and randomly assigned one of each pair to
intervention or control. In each intervention cluster (average
population 7000), a female facilitator convened nine women's group
meetings every month. The facilitator supported groups through an
action-learning cycle in which they identified local perinatal problems
and formulated strategies to address them. We monitored birth outcomes
in a cohort of 28931 women, of whom 8% joined the groups. The primary
outcome was neonatal mortality rate. Other outcomes included stillbirths
and maternal deaths, uptake of antenatal and delivery services, home
care practices, infant morbidity, and health-care seeking. Analysis was
by intention to treat. The study is registered as an International
Standard Randomised Controlled Trial, number ISRCTN31137309.
Findings
From 2001 to 2003, the neonatal mortality rate was 26·2 per 1000 (76
deaths per 2899 livebirths) in intervention clusters compared with 36·9
per 1000 (119 deaths per 3226 livebirths) in controls (adjusted odds
ratio 0·70 [95% CI 0·53–0·94]). Stillbirth rates were similar in both
groups. The maternal mortality ratio was 69 per 100000 (two deaths per
2899 livebirths) in intervention clusters compared with 341 per 100000
(11 deaths per 3226 livebirths) in control clusters (0·22
[0·05–0·90]). Women in intervention clusters were more likely to have
antenatal care, institutional delivery, trained birth attendance, and
hygienic care than were controls.
Interpretation
Birth outcomes in a poor rural population improved greatly through a
low cost, potentially sustainable and scalable, participatory
intervention with women's groups.
Citation
Manandhar, D.S.; Osrin, D.; Shrestha, D.P.; Mesko, N.; Morrison, J.; Tumbahangphe, K.M.; Tamang, S.; Thapa, S.; Shrestha, D.; Thapa, B.; Shrestha, J.R.; Wade, A.; Borghi, J.; Standing, H.; Manandhar, M.; Costello, A.M de L. Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet (2004) 364 (9438) 970-979. [DOI: 10.1016/S0140-6736(04)17021-9]