Community intervention through women’s groups improves maternal and newborn survival and health in low-resource settings
Submitting InstitutionUniversity College London
Unit of AssessmentPublic Health, Health Services and Primary Care
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Summary of the impact
UCL researchers and overseas partners have developed a successful
community intervention to improve maternal and newborn health, which is
now saving lives in India's poorest communities and is being taken up in
other low- and middle-income countries. The intervention involves village
women's groups working together to identify, prioritise and address common
problems during and after pregnancy using local resources. The process was
tested successfully in Nepal, led to a 45% reduction in newborn mortality
in an award-winning trial in rural India, demonstrated an impact on
maternal mortality in a meta-analysis of seven trials across four
countries, and has already been scaled up to a population of over 1.5
million in rural India's poorest communities.
Nearly ninety-nine per cent of the world's maternal and newborn deaths
occur in low- and middle- income countries. South Asian and African
nations shoulder a substantial proportion of this burden.
From 2000 to 2004, Professor Anthony Costello and Dr David Osrin at the
UCL Institute for Global Health (IGH) worked with MIRA, an NGO in Nepal,
to develop and test a community intervention, which involved women's
groups in identifying, prioritising, and addressing common problems during
the perinatal period using participatory methods. The intervention was
tested in a large community cluster-randomised controlled trial (RCT) in
Nepal, where it led to a 30% reduction in neonatal mortality .
The intervention increased care-seeking during pregnancy and institutional
deliveries, and was also linked to improved newborn care practices in the
From 2005 to 2012, Costello and Osrin, along with Dr Tim Colbourn, Dr
Edward Fottrell (both IGH) and Dr Audrey Prost (UCL Institute of Child
Health) worked with partner organisations in India, Malawi, Nepal and
Bangladesh to test the impact of the women's group intervention on
maternal and newborn health in other under-served communities.
In rural India, the trial of the women's group intervention led by our
partner, Ekjut, resulted in a 45% reduction in newborn deaths over two
years in rural, largely indigenous communities among the poorest in India
. Further research also found that, in this rural trial,
mortality reduction was greatest among the poorest mothers, suggesting
that women's groups can be an effective way of targeting inequalities .
The intervention's evaluation won the Society for Clinical Trials' 2011 Trial
of the Year award.
The intervention was also tested in slum communities in Mumbai, India, in
a project led by local organisation SNEHA (Society for Nutrition,
Education & Health Action) in collaboration with Osrin. In this
setting, the effects were not as great as for the rural population. One
reason for this was that newborn survival was already better than in the
other settings in which groups were implemented .
Research in Malawi has been ongoing since 2003, when the MaiMwana project
was set-up by UCL researchers Sonia Lewycka and Mikey Rosato to test the
effect of the women's group intervention in Africa for the first time. The
results of the MaiMwana women's group intervention were impressive: a 74%
reduction in maternal mortality, and a 41% reduction in newborn mortality
. In 2007 another less-intensive women's group intervention,
MaiKhanda, was tested, also by cluster randomised trial, by UCL
researchers Tim Colbourn and Bejoy Nambiar. MaiKhanda also achieved
significant results: a 16% reduction in perinatal mortality (stillbirths
and deaths in the first week of life) and a 23% reduction in newborn
mortality in areas where the women's group intervention was combined with
a health facility quality improvement intervention .
The intervention did not have the same impact on mortality as observed in
Nepal and rural India when applied to a population of around 500,000 in
rural Bangladesh with partners BADAS-PCP between 2005 and 2007. This
caused us to question why the intervention had been so successful in some
settings but not in others and we concluded that population coverage of
the intervention was likely to be key (i.e. the ratio of community women's
group per population). We therefore decided to test the intervention at a
higher population coverage, increasing the number of groups from a
coverage of one per 1,400 to one per 300 population. The results showed
that when delivered at this higher population coverage and with greater
participation or pregnant women and women of reproductive age, the
intervention reduced newborn mortality by more than one third and was
highly cost-effective .
In 2013, a meta-analysis led by Prost and Colbourn collated data from
seven trials testing the impact of women's groups, and found that the
intervention reduced maternal mortality by around a third, or, in trials
where the groups had greater than 30% of pregnant women as members, by 55%
. This is the first time that a community intervention other
than training Traditional Birth Attendants has demonstrated an impact on
maternal mortality at a population level.
References to the research
 Manandhar DS, Osrin D, Shrestha BP, et al.; Members of the MIRA
Makwanpur trial team. Effect of a participatory intervention with women's
groups on birth outcomes in Nepal: cluster- randomised controlled trial.
Lancet. 2004 Sep 11-17;364(9438):970-9. http://doi.org/fntgkw
 Tripathy P, Nair N, Barnett S, et al. Effect of a participatory
intervention with women's groups on birth outcomes and maternal depression
in Jharkhand and Orissa, India: a cluster- randomised controlled trial.
Lancet. 2010 Apr 3;375(9721):1182-92. http://doi.org/bs583j
 Houweling TA, Tripathy P, Nair N, et al. The equity impact of
participatory women's groups to reduce neonatal mortality in India:
secondary analysis of a cluster-randomised trial. Int J Epidemiol. 2013
 More NS, Bapat U, Das S, et al. Community mobilization in Mumbai
slums to improve perinatal care and outcomes: a cluster randomized
controlled trial. PLoS Med. 2012;9(7):e1001257. http://doi.org/p5w
 Lewycka S, Mwansambo C, Rosato M, et al. Effect of women's groups and
volunteer peer counselling on rates of mortality, morbidity, and health
behaviours in mothers and children in rural Malawi (MaiMwana): a
factorial, cluster-randomised controlled trial. Lancet. 2013 May
 Colbourn T, Nambiar B, Bondo A, et al. Effects of quality improvement
in health facilities and community mobilization through women's groups on
maternal, neonatal and perinatal mortality in three districts of Malawi:
MaiKhanda, a cluster randomized controlled effectiveness trial. Int
Health. 2013 Sep;5(3):180-95. http://dx.doi.org/10.1093/inthealth/iht011.
 Fottrell E, Azad K, Kuddus A, et al. The effect of increased coverage
of participatory women's groups on neonatal mortality in Bangladesh: A
cluster randomized trial. JAMA Pediatr. 2013 Sep;167(9):816-25. http://dx.doi.org/10.1001/jamapediatrics.2013.2534.
 Prost A, Colbourn T, Seward N, et al. Women's groups practising
participatory learning and action to improve maternal and newborn health
in low-resource settings: a systematic review and meta-analysis. Lancet.
2013 May 18;381(9879):1736-46. http://doi.org/f2m7hq
Society for Clinical Trials, Trial of the Year Awards 2011:
Details of the impact
As a result of the underpinning research described above, scale-up of
participatory women's groups has begun in various parts of India. Our work
has also begun to influence policy in other low and middle-income
countries. The results of our meta-analysis influenced WHO's decision to
develop a training module on the intervention for global dissemination.
From 2008-13, UCL and Ekjut worked to scale up the intervention in the
high-mortality eastern Indian states of Jharkhand and Odisha. In total,
the project led to work with 4,676 women's groups across 17 districts in
four states, covering a population of over two million people [a].
In 2012, the Department of Health and Family Welfare in Jharkhand
incorporated the intervention into the curriculum of the Accredited Social
Health Activist, a cadre of community health volunteers working in the
country's poorest areas, and rolled out the intervention across the state
[b]. In 2013, the intervention was rolled out in the state of
Odisha in a collaboration between the Departments of Health, Women and
Child Development, and Rural Development, together with the UK Department
for International Development (DFID). DFID India made the decision to
promote the women's group intervention as a cost-effective strategy to
improve maternal and newborn health and to test its application to other
health issues, including maternal and child under-nutrition [c].
The roll-out in Odisha covers a population of over one million women [d].
The results of our work have received vast media coverage in India and
internationally. An article in The Hindu in 2010 interviewed
mothers who had benefited from the programme. One described the impact of
the programme as follows: "Earlier, we didn't clean our hands before
cooking and eating. We'd just leave the baby and go off to work. Now we
clean and grow vegetables ourselves. We keep the water clean in the
house. Women in the village help one another and sometimes pool money to
transport someone to hospital for delivery and visits to the doctor."
Another said: "Earlier, when a problem arose, we would pray. Now, I go
to a doctor at the slightest problem. I ate spinach, fish and vegetables
during and after my recent pregnancy. I breast-fed for six months from
the first day" [e]. This story was also covered by the Guardian
and Time, as well as on Indian national television [f].
The New York Times also reported favourably on the publication of
our first Mumbai trial, where the results were less successful, reflecting
on the use of evidence in global policy and the political pressure to show
only positive findings [g].
In Malawi, the intervention has been adopted as a model for improving
maternal and newborn health by the Ministry of Health, UNFPA and the
Uchembere Network. Project team members participated in the development of
the Government of Malawi's plan for community interventions, part of the
Health Sector Strategic Plan (2011-6) and the Malawi Road Map for
Accelerating the Reduction of Maternal and Neonatal Mortality [h].
Further media coverage for MaiKhanda included an interview with Voice of
America in June 2013 [i].
Through the non-governmental organisation Women and Children First, we
are supporting further uptake of the women's group intervention in
Bangladesh, Malawi, Ethiopia and Uganda, using an implementation guide
developed jointly with UCL, the Perinatal Care Project of the Diabetic
Society of Bangladesh and Ekjut India [j]. The organisation aims
to extend the thematic content of the women's groups model to test its
effectiveness for addressing other maternal and child health issues,
including family planning, prevention of mother to child transmission of
HIV, and under- five's health and nutrition.
In December 2012, Costello and Prost participated in a World Health
Organisation (WHO) workshop to design a module on community mobilisation
with women's groups for maternal and newborn health, which will supplement
WHO's existing guidance on Caring for Newborns and Children in the
Community [k]. The results of our meta-analysis were also
presented to WHO in early 2013 and influenced their decision to develop a
training module for community health workers intended for global
dissemination; this will have an impact on developing country health
systems around the world [l]. The meta-analysis results were also
launched at a large event in the Houses of Parliament and at the Women
Deliver International Conference, both in May 2013.
Sources to corroborate the impact
[a] Letter of support from the Funding Officer, Big Lottery Fund, who
provided a grant to support the roll-out. The letter confirms the
population coverage and numbers of groups, and writes that "having
undertaken monitoring visits to project communities in both countries I am
aware of how well the portfolio was received by the project beneficiaries
and stakeholders and how successful it has been". Copy available on
[b] Letter from the Deputy Director of Health Services, Jharkhand Rural
Health Mission Society, Department of Health and Family Welfare,
Jharkhand. Corroborates incorporation into training modules. Copy
available on request. Copies of letters to Chief Medical Officers of
individual regions, confirming the roll-out, are also available.
[c] Corroboration of the influence of UCL and Ekjut's work on DFID in
India can be obtained from the Health Advisor for DFID. Contact details
[d] Odisha CM launches Shakti Varta- empowering women through
participatory learning and action on health, nutrition involving self help
groups". Odisha Diary. April 30, 2013. http://www.orissadiary.com/CurrentNews.asp?id=40992
[e] `Lessons from the Ekjut way.' The Hindu. September 15, 2010.
[f] Further media coverage:
[g] `Learning From Failure.' The New York Times. February 1, 2013
[h] Corroboration of the influence of UCL and MaiMwana's work on
strategies to scale up interventions with community groups in Malawi can
be obtained from the Principal Secretary, Ministry of Health, Government
of the Republic of Malawi. Contact details provided.
[i] `Better Maternal Care Reduces Newborn, Infant Mortality in Malawi.'
Voice of America. June 24, 2013. http://m.voanews.com/a/1688430.html
[k] Film by Mikey Rosato which was presented as evidence: https://vimeo.com/75751099
[l] Corroboration on plans for a WHO module on working with participatory
women's groups to improve maternal and newborn health can be obtained from
Technical Officer, Department of Maternal, Newborn, Child and Adolescent
Health, World Health Organisation. Contact details provided.