Effectiveness of participatory women's groups scaled up by the public health system to improve birth outcomes in Jharkhand, eastern India: A pragmatic cluster non-randomised controlled trial

Nirmala Nair, Prasanta K. Tripathy, Rajkumar Gope, Shibanand Rath, Hemanta Pradhan, Suchitra Rath, Amit Kumar, Vikash Nath, Parabita Basu, Amit Ojha, Andrew Copas, Tanja A.J. Houweling, Hassan Haghparast-Bidgoli, Akay Minz, Pradeep Baskey, Manir Ahmed, Vasudha Chakravarthy, Riza Mahanta, Audrey Prost*

*Corresponding author for this work

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Introduction The WHO recommends community mobilisation with women's groups practising participatory learning and action (PLA) to improve neonatal survival in high-mortality settings. This intervention has not been evaluated at scale with government frontline workers. Methods We did a pragmatic cluster non-randomised controlled trial of women's groups practising PLA scaled up by government front-line workers in Jharkhand, eastern India. Groups prioritised maternal and newborn health problems, identified strategies to address them, implemented the strategies and evaluated progress. Intervention coverage and quality were tracked state-wide. Births and deaths to women of reproductive age were monitored in six of Jharkhand's 24 districts: Three purposively allocated to an early intervention start (2017) and three to a delayed start (2019). We monitored vital events prospectively in 100 purposively selected units of 10 000 population each, during baseline (1 March 2017-31 August 2017) and evaluation periods (1 September 2017-31 August 2019). The primary outcome was neonatal mortality. Results We identified 51 949 deliveries and conducted interviews for 48 589 (93.5%). At baseline, neonatal mortality rates (NMR) were 36.9 per 1000 livebirths in the early arm and 39.2 in the delayed arm. Over 24 months of intervention, the NMR was 29.1 in the early arm and 39.2 in the delayed arm, corresponding to a 24% reduction in neonatal mortality (adjusted OR (AOR) 0.76, 95% CI 0.59 to 0.98), including 26% among the most deprived (AOR 0.74, 95% CI 0.57 to 0.95). Twenty of Jharkhand's 24 districts achieved adequate meeting coverage and quality. In these 20 districts, the intervention saved an estimated 11 803 newborn lives (min: 1026-max: 20 527) over 42 months, and cost 41 international dollars per life year saved. Conclusion Participatory women's groups scaled up by the Indian public health system reduced neonatal mortality equitably in a largely rural state and were highly cost-effective, warranting scale-up in other high-mortality rural settings. Trial registration ISRCTN99422435.

Original languageEnglish
Article numbere005066
JournalBMJ Global Health
Issue number11
Publication statusPublished - 3 Nov 2021

Bibliographical note

Funding Information:
Acknowledgements We thank women’s group members, mothers and their family members who gave their time to be interviewed and all members of the partnering communities. We thank the Accredited Social Health Activists (ASHA) facilitators and ASHAs of Jharkhand, who led the intervention. We thank Dr Suranjeen Pallipamula, Professor Joanna Schellenberg and Dr Rajani Ved for acting as members of the advisory group for this study. We are grateful to the National Health System Resource Centre and Community Mobilisation Cell of National Health Mission, Jharkhand, for their inputs. We also thank Vishal Chandra, Smita Todkar, Prabas Kumar Sahoo, Sarfraz Ali, Sanjay Kumar, Enem Aind, Vijay Singh, Nirakar Panda, Sumitra Gagrai, Nibha Das, all district managers and training team members including Priyanka Banerjee, Vikas Kumar, Nawab Parvez, Jyoti Mundri, Poonam Devi and Ravi Das for support in the field. We thank the state and block training teams of the National Health Mission, Jharkhand, for supporting the intervention and study. We thank Erin McCarthy, Manjula Singh, Hemang Shah and Mihretab Salasibew for supporting the evaluation at the Children’s Investment Fund Foundation. Contributors AP conceptualised the study and developed its methods with HP, NN, ShR, SuR, PKT, VN, RG, and AK. HP, AP, TH and AC carried out the analyses. ShR and HP led the quantitative data collection and cleaning. SuR led the analysis of the qualitative data. VC and RM collected and analysed data for the third-party evaluation by Development Solutions used to estimate effects of the intervention at scale. PBasu analysed data from the Monitoring and Information System. AO and HH-B led the collation and analysis of cost data. AP wrote the first draft of the article and collated subsequent inputs. All authors, including AM, PBask and MA, commented on drafts of the manuscript. AP acquired the funding and oversaw the grant that funded the study. AP, HP and TH had access to all underlying data. AP acts as guarantor. Funding The study was funded by the Children’s Investment Fund Foundation (grant number G160100937). The funder had no role in designing the study, data collection and analysis, the decision to publish or the preparation of this manuscript. Competing interests AM, PBask and MA are employed by Jharkhand’s State Health Mission. Other authors declare that they have no conflicts of interest. Patient consent for publication Not applicable. Ethics approval The study was approved by an independent ethics research committee linked to Ekjut in Ranchi on 19 August 2016 and by University College London’s Research Ethics Committee (reference: 1881/003). We sought individual informed consent from all individual participants and recorded it through signature or thumbprint.

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© 2021 Author(s). Published by BMJ.


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