SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
March, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
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.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
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.
| Review objectives: To 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. | ||
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
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.
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Women's groups practicing participatory learning and action compared to usual care |
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People: Women of reproductive age |
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| Outcome |
Absolute effect* |
Relative effect (95% CI) | Certainty of the evidence (GRADE) | |||
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Without Women's groups |
With Women's groups |
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Maternal mortality Settings with higher maternal mortality |
678 per 100,000 |
428 per 100,000 |
OR 0.77 (95% CI 0.48 to 1.23) |
Low |
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Difference: 155 fewer per 100,000 (Margin of error: 351 fewer to 155 more per 100,000) |
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Settings with lower maternal mortality |
242 per 100,000 |
153 per 100,000 |
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Difference: 56 fewer per 100,000 (Margin of error: 126 fewer to 55 more per 100,000) |
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Neonatal mortality High risk |
5913 per 100,000 |
4616 per 100,000 |
OR 0.77 (95% CI 0.65 to 0.90)
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Moderate |
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Difference: 1297 fewer per 100,000 (Margin of error: 1988 to 560 fewer per 100,000) |
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Low risk
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3026 per 100,000 |
2346 per 100,000 |
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Difference: 680 fewer per 100,000 (Margin of error: 1038 to 294 fewer per 100,000) |
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Stillbirths |
2659 per 100,000 |
2477 per 100,000 |
OR 0.93 (95% CI 0.82 to 1.05) |
Low |
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Difference: 182 fewer per 100,000 (Margin of error: 468 fewer to 129 more per 100,000) |
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Margin of error and 95% CI = 95% confidence interval OR: Odds ratio GRADE: GRADE Working Group grades of evidence (see above and last page) * The risk WITHOUT the intervention is based on control groups in the trials. The corresponding risk WITH the intervention (and the 95% confidence interval for the difference) is based on the overall odds ratio (and its 95% confidence interval). |
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| 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. |
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*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 |
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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
