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

Abstract

IntroductionThe 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.MethodsWe 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.ResultsWe 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.ConclusionParticipatory 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 registrationISRCTN99422435.

Economic evaluation of participatory women’s groups scaled up by the public health system to improve birth outcomes in Jharkhand, eastern India

“…Preparation, planning and community sensitisation meetings and recruitment constituted less than 1% of total costs (Table 3 and Figures 2). FLAG's impact evaluation found that the intervention saved 188 neonatal lives over a two years period (min: 16 -max: 327), using lower and higher bound of confidence interval around impact) in the three early intervention districts taking part in the evaluation [19]. Over the 42 months of scale up, we estimated that the intervention saved a total 11,803 neonatal lives across 20 districts (min: 1026 -max: 20,527) [19].…”

“…FLAG’s impact evaluation found that the intervention saved 188 neonatal lives over a two years period (min: 16 – max: 327), using lower and higher bound of confidence interval around impact) in the three early intervention districts taking part in the evaluation[19]. Over the 42 months of scale up, we estimated that the intervention saved a total 11,803 neonatal lives across 20 districts (min: 1026 - max: 20,527) [19]. This translates to an estimated 363,621 (discounted) life years saved, with a range of 31,609 to 632,386 (Table 4).…”

“…Twenty out of 24 districts met these criteria. We estimated the number of neonatal lives saved in rural areas of 20 districts using the following formula: where Pr is rural population in 20 districts, Br is birth rate in crude birth rate in rural area, NMR is neonatal mortality rate in rural areas without intervention, and RR is the Risk Ratio for the intervention in the evaluation districts[19]. We then estimated life years saved by multiplying the number of neonatal deaths averted in 20 districts by 30.81, which corresponds to a standard life expectancy of 86 years, as recommended by Global Burden of Diseases 2010 [25], discounted at 3%.…”

“…The three remaining districts did not receive the intervention until 2019 and were 'comparison' districts for the programme's impact evaluation. A detailed description of the women's group intervention is reported elsewhere [19]. In brief, the intervention comprised monthly women's group meetings (around 36 monthly meetings) following a Participatory Learning and Action (PLA) cycle.…”

“…ASHA Facilitators then provided on-the-job training to all ASHAs in their catchment area (around 20 villages and 20 ASHAs), using an odd-even approach covering 10 villages each month. We described this lowcost training method in detail elsewhere [19]. ASHA Facilitators received an incentive of INR 1,000 (USD 13) to conduct 10 meetings per month, and ASHAs received INR 100 (USD 1.3) per meeting.…”