March, 2017 - SUPPORT Summary of a systematic review | print this article |

What is the impact of women’s groups practising participatory learning and action on maternal and newborn health outcomes in low-resource settings?

Women’s groups are one strategy to help improve maternal and newborn health outcomes. They aim to do this by increasing appropriate home prevention and care practices for mothers and newborns, and by increasing appropriate care-seeking (including antenatal care and skilled birth attendance).

Key messages

 Women’s groups practising participatory learning and action probably improve newborn survival, may improve maternal survival, and may be a cost-effective strategy in rural areas in low- and middle-income countries.

  The effectiveness of women’s groups may depend on participation of a substantial proportion of pregnant women, adequate supervision and support, home visits, access to care, improving the quality of care, and adequate resources.

 

Background

Maternal and neonatal mortality are major health priorities in many rural areas in low-income countries. Women’s groups aim to improve appropriate care-seeking (including antenatal care and skilled birth attendance) and appropriate home prevention and care practices for mothers and newborns . Women’s groups practising participatory learning and action cycles could play an important role in improving maternal and neonatal outcomes in comparison to usual care.

Action cycles include four phases: (i) identifyining and prioritising problems during pregnancy, delivery, and post partum; (ii) planning; (iii) implementing locally feasible strategies to address the priority problems; and (iv) assessing the group’s activities.



About the systematic review underlying this summary

 

Review objectivesTo assess the impact of women’s groups practising participatory learning and action cycles on birth outcomes in low- and middle-income countries.
 
Type of What the review authors searched for What the review authors found
Study designs & interventions Randomised trials of participatory women’s groups in low- and middle-in- come countries
7 cluster-randomised trials of participatory women’s groups in low- and middle-income countries
Participants Women's groups in which most of the participants are of reproductive age (15–49 years)
7 studies that included a total of 111 women’s groups and 119,428 births
Settings Low- and middle-income countries
Rural areas in Bangladesh (2), India (2), Malawi (2), and Nepal (1)
Outcomes Maternal mortality, neonatal mortality, and stillbirths
Maternal mortality (7 studies), neonatal mortality (7), and stillbirths (7)
Date of most recent search:October 2012
Limitations: This is a well-conducted systematic review with only minor limitations.

Summary of findings

The review included 7 randomised trials with a total of 111 women’s groups and a total of 119,428 births. The studies were conducted in rural areas in low- and middle-income countries. All of the studies compared women’s groups practising participatory learning and action compared to usual care.

  • Women’s groups practising participatory learning and action may improve survival in mothers. The certainty of this evidence is low.
  • Women’s groups practising participatory learning and action probably improve survival in newborn babies. The certainty of this evidence is moderate.
  • Women’s groups practising participatory learning and action may slightly reduce stillbirths. The certainty of this evidence is low.
  • Women’s groups practising participatory learning and action may be cost-effective.
  • These outcomes depended on participation of at least one third of pregnant women in the targeted areas.

    Impact on HIV test uptake levels of providing VCT at a local clinic only compared to providing VCT at an alternative location

    People:  Male and female household members aged ≥15 years
    Settings
    :  Community setting in Lusaka, Zambia
    Intervention
    : VCT at an optional location, including a person’s home, a clinic or another location
    Comparison
    : VCT at a local clinic only

    Outcome

    Absolute effect*

    Relative effect (95% CI) Certainty of the evidence (GRADE)

    Without choice of location

    With choice of alternative location

    Acceptance of HIV pre-test counselling

    133 per 1000

    614 per 1000

    RR 4.6
    (3.58 to 5.91)

    Low

    Difference: HIV pre-test councelling accepted 481 more times per 1000 household members ≥15 years

    (Margin of error: 344 more to 655 more)

    Acceptance of HIV pre-test counselling

    133 per 1000

    614 per 1000

    Difference: HIV pre-test councelling accepted 481 more times per 1000 household members ≥15 years

    (Margin of error: 344 more to 655 more)

    Acceptance of HIV pre-test counselling and HIV testing

    124 per 1000

    572 per 1000

    RR 4.6

    (3.51 to 5.92)

    Low

    Difference: HIV pre-test councelling and HIV testing accepted 448 more times per 1000 household members ≥15 years

    (Margin of error: 312 more to 612 more)

    Acceptance of HIV pre-test counselling and HIV testing

    124 per 1000

    572 per 1000

    Difference: HIV pre-test councelling and HIV testing accepted 448 more times per 1000 household members ≥15 years

    (Margin of error: 312 more to 612 more)

    HIV post-test counselling and test results received by those tested

    118 per 1000

    553 per 1000

    RR 4.7

    (3.62 to 6.21)

    Low

    Difference: HIV post-test counselling and test results received by those tested accepted 435 more times per 1000 household members ≥15 years

    (Margin of error: 308 more to 613 more)

    Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page)

    * The risk WITHOUT the intervention is based on the provision of VCT at a local clinic only. The corresponding risk WITH the intervention (and the 95% confidence interval for the difference) is based on the overall relative effect (and its 95% confidence interval).

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY
All seven studies were conducted in low- and middle-income countries (LMICs); including Bangladesh, Malawi, India, and Nepal.

The use of women's groups practicing participatory learning and action probably decreases newborn mortality and may reduce maternal mortality in rural areas in low-income countries. However, its effectiveness may depend on participation of a substantial proportion of pregnant women. It might also depend on adequate supervision and support, home visits, access to care, improving the quality of care, and adequate resources.

The intervention might be less effective in urban areas if there is less community cohesion and interaction among women included in women's groups, and higher baseline use of health services.


EQUITY
The studies were primarily conducted among disadvantaged populations, particularly women in rural areas.

Women’s groups promote gender equality through empowerment of women, especially in rural areas.

Women’s groups probably reduce inequities by improving health service utilisation and health outcomes in underserved areas.


ECONOMIC CONSIDERATIONS
Four of the seven studies assessed the cost-effectiveness of the intervention.

Required resources include training and capacity building, especially for birth attendants for antenatal, intrapartum, and post-partum home visits; equipment, including delivery kits for home deliveries; and increasing capacity for referrals and transportation to trained health professionals and well-equipped facilities, if needed.

The intervention may be cost-effective according to the WHO standards.


MONITORING & EVALUATION
Costs linked to health-service strengthening, monitoring, and evaluation were not included in the cost-effectiveness analyses.

The effects and costs of implementing women's groups should be monitored, including maternal and perinatal mortality, health service utilisation, the quality of care, operational costs, participation in women’s groups, and the sustainability and functioning of the women's groups.

The impact of women’s groups in urban areas should be evaluated in randomised trials.


*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods

 

Additional information

Related literature

Mbuagbaw L, Medley N, Darzi AJ, et al. Health system and community level interventions for improving antenatal care coverage and health outcomes. Cochrane Database Syst Rev 2015; (12): CD010994.

 

Lassi ZS, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal mor-bidity and mortality and improving neonatal outcomes. Cochrane Database Syst Rev 2015; (3): CD007754.

 

Mangham-Jefferies L , Pitt C , Cousens S, et al. Cost-effectiveness of strategies to improve the utilization and provision of maternal and newborn health care in low-income and lower-middle-income countries: a systematic review. BMC Pregnancy Childbirth 2014; 14:243.

 

Nyamtema AS, Urassa DP, van Roosmalen J. Maternal health interventions in resource limited countries: a systematic review of packages, impacts and factors for change. BMC Pregnancy Childbirth 2011; 11:30.

 

Lewin S, Munabi-Babigumira S, Glenton C, et al. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD004015.

 

World Health Organization. WHO recommendation on community mobilization through facilitated participatory learning and action cycles with women’s groups for maternal and newborn health. Geneva: World Health Organization, 2014. http://www.who.int/maternal_child_adolescent/documents/health-promotion-interventions/en/

 

World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. Geneva: World Health Organization, 2016. http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en/

 

This summary was prepared by

Primus Che Chi, Faculty of Medicine, University of Oslo, Oslo, Norway; and Yasser Sami Amer, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia.

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Audrey Prost and Tess Lawrie.

This review should be cited as

Prost A, Colbourn T, Seward N, et al. Women's groups practicing participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis. Lancet 2013; 381:1736-46.

The summary should be cited as

Chi PC, Amer YS. What is the impact of women’s groups practising participatory learning and action on maternal and newborn health outcomes in low-resource settings? A SUPPORT Summary of a systematic review. March 2017. www.supportsummaries.org

Keywords

evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care, maternal and newborn health, women's groups 

This summary was prepared with additional support from:

Cochrane South Africa, the only centre of the global, independent Cochrane network in Africa, aims to ensure that health care decision making within Africa is informed by high-quality, timely and relevant research evidence. www.mrc.ac.za/cochrane/cochrane.htm

 

 

 

 

 

 



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