Mira nepal presentation
- 1. Importance of social and behavior change in improving child survival Impact of Participatory women’s groups on maternal and neonatal health: Experience from Nepal JR Shrestha MPH Research Program Coordinator Mother and Infant Research Activities (MIRA) 1
- 2. Supply Demand 2
- 3. Improving the Demand Side • Bringing awareness in the family – avoiding harmful practices and promoting good practices, promoting delivery by a SBA or in a health facility • Recognising danger signs and seeking help from health workers or at appropriate health facilities • Developing strategies in the community to manage the problems 3
- 4. Impact of Health Education The effects of postnatal health education for mothers on infant care and family planning practices in Nepal: a randomised controlled Trial Showed no effects after 6 months of standard health education Bolam et al BMJ, 1998 4
- 5. How to change behaviour? • Telling people what to do? NO • Communication for social change: dialogue not monologue 5
- 6. MIRA Makwanpur Mother and Newborn Care Study - a cluster randomised trial using participatory women’s groups implemented in collaboration with the Institute of Child Health, London One of the largest such studies in the world involving 30,000 married women of reproductive age in 24 V.D.Cs of Makwanpur district 6
- 7. Two strategies Facilitation a participatory community action cycle in the intervention area Health service strengthening in both control and intervention areas 7
- 8. Trial design 24 clusters in 12 matched pairs 1600 sq km population 170,000 Surveillance of pregnancies 28,931 women Supply side Health service activities 12 intervention clusters 12 control clusters Demand side Women’s groups No women’s groups 8
- 9. Primary outcome Neonatal mortality rate Secondary outcomes Stillbirth rate Maternal mortality ratio Home care practices Health care seeking 9
- 10. The intervention 1 local woman facilitator per cluster Not a health worker 7000 population, 60 sq km 9 monthly women’s groups Only 8% coverage of MWRA 10
- 11. The participatory action cycle Problem Identification Participatory Planning evaluation together Implementation 11
- 12. The first ten meetings How women approach maternal and neonatal issues Common local maternal and neonatal problems Why mothers and newborns die Strategies to gather information in the community Information sharing Identification of key problems Strategies to address these problems Wider presentation of problems and strategies Adoption of community strategies 12
- 13. Developing strategies Problem Identification Participatory Planning evaluation together Implementation 13
- 14. Health Service Strengthening in both study areas Training of the health staff and TBAs and FCHVs Supply •Some essential equipment • Some essential drugs 14
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- 16. 30% reduction in neonatal mortality! Major impact on maternal mortality! Lancet 2005 16
- 17. How do the groups work? SDK Hand washing Family support Postnatal care Use of Nets Funds Breastfeeding Empowerment Critical consciousness Decision-making Communication Political action Solidarity 17
- 18. Cost Effectiveness • The average provider cost of the women's group intervention was USD 0.75 dollars per person per year (0.90 dollars with health- service strengthening) in a population of 86,704. • The incremental cost per life-year saved (LYS) was 211 dollars • Expansion could rationalize on start-up costs and technical assistance, reducing the cost per LYS to 138 dollars . • Sensitivity analysis showed a variation from 83 dollars to 263 dollars per LYS for most variables. • This intervention could provide a cost- effective way of reducing neonatal deaths. BorgJoJhi et al Lancet 2005 18
- 19. Expansion of the Trial Similar intervention trials with some local modifications have been undertaken in : • Rest of Makwanpur district • Dhanusha in Nepal • Mumbai and Jharkhand in India • Bangladesh • Malawi Results from other studies also showed positive effect on reduction of neonatal mortality particularly from Ek Jut trial Recently a systematic review and meta analysis of participatory women’s groups on maternal and neonatal mortality has been submitted to the Lancet 19
- 20. Conclusions & Recommendations • Participatory women’s groups have been found to be effective in reducing NMR and (MMR) and thus helping Child survival. • This method has been found successful in high mortality situations in rural areas and but not that effective in high institutional delivery areas with low mortality rates . • For effectiveness of this process, a facilitator should be available for about 800 population • This strategy should be scaled up in above situations 20
- 21. Thank You 21