Measuring What Works: Evaluating Women's Groups on Maternal Health Uptake in Rural Nepal

Measuring What Works: Evaluating Women's Groups on Maternal Health Uptake in Rural Nepal
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with Edwin van Teijlingen, Professor of Maternal & Perinatal Health Research at Bournemouth University.

Last month Women's Deliver Conference in Copenhagen was a turning point for the future of the Sustainable Development Goals (SDGs) with regards to women and girls' rights -The SDGs will only be achieved if women and girls are put at the centre of development and the key message from the conference was that there is a need to focus on solutions.

In order to obtain solutions for maternal health, we need to evaluate interventions to take the guesswork out of policy-making by determining what works, what does not work, when and why. For there are still too many programmes where the impact is not known - such as programmes that sadly lack any comparison, whether in time (before-and-after research) or with a control area, or are not evaluated at all due to lack of resources. If organisations do not evaluate we may never know the medium- to longer-term effects of their projects.

Health Promotion Groups
We would like to highlight an example of a well-designed evaluation of a medium-sized programme run on a low budget in Nepal. In 2007, Green Tara Nepal (GTN), a non-governmental organization (NGO), designed and implemented a five-year intervention to improve maternal health uptake in rural Nepal using health promotion groups. GTN aims to improve women's health and their rights. It addresses issues around sexual and reproductive health, tackling social issues that include sexual violence. GTN's work was all the more interesting as it started shortly after the Maoist rebellion (1996-2006) in Nepal, which was still ongoing at the time the intervention was designed (2005/2006). It is worth remembering that Nepal like many countries has inequitable access of health services due to finances, geography (the time it takes to reach a clinic), caste, ethnicity, religion and corruption. Sometimes it is simply women not knowing about maternity care or in Nepal's case - their mothers-in-law influence their decision to attend maternity clinics. Women have it tough there, some may not finish school, and they do most of the work in the house and fields. Especially poor rural women married young; by 18 or 19 they are a mother of two children. Typically, on marriage a young woman moves into their husband's home and becomes part of his family and the mother-in-law decides everything - When she eats, when she works, when to go to the hospital, when to seek care and where to give birth.

To address this dynamic, GTN recruited two local Nepali health promoters to create groups of women and mothers-in-law to empower women to seek care; as women and mother-in-law groups encouraged the whole community to negotiate their own solutions and improve access to maternal health. It used health promotion groups and participatory action approaches (for example using role-play), health promotion techniques and offered women in the groups small incentives. Yet, it was hard to engage the men to take part in similar groups. The GTN curriculum for the women's groups each with 24 sessions of health promotion. The content of the intervention and the health promotion sessions include visual card description, a facilitator guide/modules if possible, or an outline of the session topics and related participatory activities. The GTN model is similar to that of social mobilisation groups in India and the Aga Khan Foundation Rural Support Programmes (AKRPs). All founded on the principles that communities can take ownership of their development through village groups. GTN and similar groups work with the community to implement and resource activities in support of that plan, often in partnership with local government.

With our colleagues at GTN, Faculty of Health and Social Sciences, Bournemouth University, UK, Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina, Centre for Public Health, Liverpool John Moores University, UK and ISGlobal, Barcelona Centre for International Health Research - Spain, we evaluated the intervention. Two elements are important in evaluation: choosing your outcomes (what changed) and the method (tool to measure). Here the following outcomes: antenatal care (ANC), skilled birth attendance (SBA), institutional delivery and postnatal care (PNC) were chosen because they are indirectly correlated with maternal mortality. The tool to measure change - to measure the effect of the intervention on the selected outcomes - was Difference-in-Difference (DiD) analysis.

2016-06-07-1465303399-7229319-_DSC0969.JPG
One of the GTN women's groups.

What did we find?
Our paper 'Measuring What Works: An impact evaluation of women's groups on maternal health uptake in rural Nepal's provides insight into women's group interventions why they work and sometimes do not. We concluded that GTN's activities in community-based health promotion using groups have a greater effect on the uptake of ANC, including taking iron and folic acid, attending postnatal care and less so on delivery care. What is impressive is that only two locally recruited and trained health promoters, established and supported women's groups with enrolment running between 2006 and 2012. Mobilising close to 1000 women including a wide-range of castes and empowering lower castes to attend. What GTN did was exploiting existing monthly women's group meetings, which were originally savings or literacy-based. Using such existing social capital has a potential for scaling-up within existing social systems, where community and health institutions are collaborating to improve access to quality maternal and newborn health services.

The evaluation has implications for policy and practice in public health
- Programs aiming to improve uptake of services may benefit from maternal health promotion using women's groups that include women and their mothers-in law. Yet, health promotion cannot solve everything. We must remember that other factors that are not easily resolved through health promotion interventions may influence these outcomes, such as costs or geographical constraints.This paper discusses how to implement and evaluate what works best in low-income countries. We advocate that the evaluation should be designed early even before the implementation of the fieldwork and that the evaluation research is setting appropriate, with a well-designed methodology (DiD) and analysis plan.

To those attempting to evaluate we caution that measuring the effect of a community-based intervention is not straightforward because of confounding social and environmental factors. Therefore, the most-suited evaluation design is needed to ascertain whether the changes or improvements are due to the intervention or to external factors, yet often randomised controlled trials, the gold standard methodology for measuring effectiveness are difficult to organise, expensive and often setting-inappropriate. Finally, to achieve long-term change you have to build slowly and not expect to see massive change overnight, and not give up.

Where next?
We need more data on women to continue to contribute to programmes' impact, accountability and efficacy. We need more projects such as GTN that use groups to improve awareness: This implies increasing and improving accountability and measurement mechanisms at country and global levels. As Melinda Gates elaborated, one of the tools to find and take further these solutions is more and better data, "make the invisible visible".

Our paper can be read here:
Sharma, S., van Teijlingen, E., Belizán, J.M., Hundley, V., Simkhada, P., Sicuri, E. (2016) Measuring What Works: An impact evaluation of women's groups on maternal health uptake in rural Nepal, PLOS One 11(5): e0155144

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