Understanding how women's groups improve maternal and newborn health in Makwanpur, Nepal: a qualitative study.

Women's groups, working through participatory learning and action, can improve maternal and newborn survival. We describe how they stimulated change in rural Nepal and the factors influencing their effectiveness. We collected data from 19 women's group members, 2 group facilitators, 16 health volunteers, 2 community leaders, 21 local men, and 23 women not attending the women's groups, through semi-structured interviews, group interviews, focus group discussions and unstructured observation of groups. Participants took photographs of their locality for discussion in focus groups using photoelicitation methods. Framework analysis procedures were used, and data fed back to respondents. When group members were compared with 11 184 women who had recently delivered, we found that they were of similar socioeconomic status, despite the context of poverty, and caste inequalities. Four mechanisms explain the women's group impact on health outcomes: the groups learned about health, developed confidence, disseminated information in their communities, and built community capacity to take action. Women's groups enable the development of a broader understanding of health problems, and build community capacity to bring health and development benefit.

The impact of Nepal's national incentive programme to promote safe delivery in the district of Makwanpur.

OBJECTIVE: Nepal's Safe Delivery Incentive Programme (SDIP) was introduced nationwide in 2005 with the aim of encouraging greater use of professional care at childbirth. It provided cash to women giving birth in a public health facility and an incentive to the health provider for each delivery attended, either at home or in the facility. We aimed to assess the impact of the programme on neonatal mortality and health care seeking behaviour at childbirth in one district of Nepal. METHODS: Impacts were identified using an interrupted time series approach, applied to houSehold data. We estimated a model linking the level of each outcome at a point in time to the start of the programme, demographic controls, a vector of time variables and community-level fixed effects. FINDINGS: The recipients of the cash transfer in the programme's first two years were disproportionately wealthier households, reflecting existing inequality in the use of government maternity services. In places with women's groups--where information about the policy was widely disseminated--the SDIP substantially increased skilled birth attendance, but failed to impact on either neonatal mortality or the caesarean section rate. In places with no women's groups, the SDIP had no impact on utilisation outcomes or neonatal mortality. IMPLICATIONS FOR POLICY: The lack of any impact on neonatal mortality suggests that greater increases in utilisation or better quality of care are needed to improve health outcomes. The SDIP changed health care seeking behaviour only in those areas with women's groups highlighting the importance of effective communication of the policy to the wider public.

How did formative research inform the development of a women's group intervention in rural Nepal?

Inability to reduce neonatal and maternal mortality in poor countries is sometimes blamed on a lack of contextual knowledge about care practices and care-seeking behavior. There is a lack of knowledge about how to translate formative research into effective interventions to improve maternal and newborn health. We describe the findings of formative research and how they were used to inform the development of such an intervention in rural Nepal. Formative research was carried out in four parts. Part 1 involved familiarization with the study area and literature review, and parts 2, 3 and 4 involved community mapping, audit of health services, and qualitative and quantitative studies of perinatal care behaviors. Participatory approaches have been successful at reducing neonatal mortality and may be suitable in our context. Community mapping and profiling helped to describe the community context, and we found that community-based organizations often sought to involve the Female Community Health Volunteer in community mobilization. She was not routinely conducting monthly meetings and found them difficult to sustain without support and supervision. In health facilities, most primary care staff were in post, but doctors and staff nurses were absent from referral centers. Mortality estimates reflected under-reporting of deaths and hygiene and infection control strategies had low coverage. The majority of women give birth at home with their mother-in-law, friends and neighbors. Care during perinatal illness was usually sought from traditional healers. Cultural issues of shyness, fear and normalcy restricted women's behavior during pregnancy, birth and the postpartum period, and decisions about her health were usually made after communications with the family and community. The formative research indicated the type of intervention that could be successful. It should be community-based and should not be exclusively for pregnant women. It should address negotiations within families, and should tailor information to the needs of local groups and particular stakeholders such as mothers-in-law and traditional healers. The intervention should not only accept cultural constructs but also be a forum in which to discuss ideas of pollution, shame and seclusion. We used these guidelines to develop a participatory, community-based women's group intervention, facilitated through a community action cycle. The success of our intervention may be because of its acceptability at the community level and its sensitivity to the needs and beliefs of families and communities.