29 August 2021
WHO recommendation on facilitated participatory learning and action cycles with women`s groups during pregnancy
The implementation of community mobilization through facilitated participatory learning and action (PLA) cycles with women’s groups is recommended to improve maternal and newborn health, particularly in rural settings with low access to health services. Participatory women’s groups represent an opportunity for women to discuss their needs during pregnancy, including barriers to reaching care, and to increase support to pregnant women.
First published: November 2016
Updated: No update planned
Assessed as up-to-date: November 2016
The scoping review conducted for the ANC guideline identified communication and support for women as integral components of positive pregnancy experiences. The term “communicate” refers to the act of sharing information, education and communication with women about timely and relevant physiological, biomedical, behavioural and sociocultural issues; “support” refers to social, cultural, emotional and psychological support (2). Having access to appropriate communication and support is a key element of a quality ANC service. A human-rights-based approach recognizes that women are entitled to participate in decisions that affect their sexual and reproductive health (3). In addition, pregnant women have a right to access quality health-care services and, particularly in low-resource settings, may need to be empowered to do so. Interventions that increase the dialogue around awareness of a women’s rights, barriers and facilitators to utilizing ANC services and keeping healthy during pregnancy and beyond (including dialogue around newborn care and postnatal family planning), and providing women and their partners with support in addressing challenges they may face, may lead to improved ANC uptake and quality of care.
The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (4). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.
The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (5) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) (6) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (7) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.
To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.
In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.
Further information on procedures for developing this recommendation are available here.
For this recommendation, we aimed to answer the following question:
The evidence on the effects of community mobilization interventions was synthesized for this guideline from data derived from a Cochrane review of health system and community-level interventions for improving ANC coverage and health outcomes (8). Seven cluster-RCTs conducted between 1999 and 2011, involving approximately 116 805 women, contributed data to this comparison. Trials were conducted in Bangladesh (2), India (2), Malawi (2) and Nepal (1), and six out of seven were conducted in low-resource, rural settings (4–15). The intervention consisted of involving women (pregnant and non-pregnant) in PLA cycles facilitated by trained facilitators, with the aim of identifying, prioritizing and addressing problems women face around pregnancy, childbirth and after birth, and empowering women to seek care and choose healthy pregnancy and newborn care behaviours (16). Meetings were usually held on a monthly basis and specific activities were prioritized according to the local context and conditions. Coverage of women’s group meetings ranged from one group per 309 to one group per 1414 people in the population among included trials, with the proportion of pregnant women attending groups ranging from 2% to 51%. Five out of seven trials were conducted against a backdrop of context-specific health system strengthening in both intervention and control arms; these included training of TBAs and provision of basic equipment to TBAs and/or primary care facilities in four trials. Random effects models were used and sensitivity analyses were performed by including only those trials in which pregnant women comprised more than 30% of the women’s groups.
Low-certainty evidence suggests that participatory women’s groups (PWGs) may reduce maternal mortality (7 trials; RR: 0.78, 95% CI: 0.60–1.03). This interpretation is confirmed by the sensitivity analysis that included only those trials in which the women’s groups included more than 30% pregnant women (4 trials; RR: 0.67, 95% CI: 0.47–0.95).
Fetal and neonatal outcomes
Low-certainty evidence suggests that PWGs may reduce perinatal mortality (6 trials; RR: 0.91, 95% CI: 0.82–1.01). This interpretation is confirmed by the sensitivity analysis that included only those trials in which pregnant women comprised more than 30% of the women’s groups (4 trials; RR: 0.85, 95% CI: 0.77–0.94).
Low-certainty evidence suggests that PWGs may have little or no effect on ANC coverage of at least four visits (3 trials; RR: 1.05, 95% CI: 0.78–1.41), facility-based delivery (5 trials; RR: 1.04, 95% CI: 0.89–1.22) and ANC coverage of at least one visit (6 trials; RR: 1.43, 95% CI: 0.81–2.51). However, evidence from the sensitivity analysis, which included only those trials in which pregnant women comprised more than 30% of the women’s groups, suggests that PWGs may increase ANC coverage of at least one visit (3 trials; RR: 1.77, 95% CI: 1.21–2.58).
Findings are consistent with a 2013 review of PWGs (16), which provided low-quality evidence that women’s groups reduced maternal mortality (OR: 0.63, 95% CI: 0.32–0.94) and moderate-quality evidence that women’s groups reduced neonatal mortality (OR: 0.77, 95% CI: 0.65–0.90). The latter review formed the evidence base for the 2014 WHO recommendation on PWGs (1). The existing WHO recommendation on PWGs is as follows: “The implementation of community mobilization through facilitated participatory learning and action cycles with women’s groups is recommended to improve maternal and newborn health, particularly in rural settings with low access to health services (strong recommendation; moderate-quality evidence on neonatal mortality, low-quality evidence for maternal mortality and care-seeking outcomes)” (1). The GDG that developed this recommendation advised that any intervention designed to increase access to health services should be implemented in tandem with strategies to improve the quality of the health services. It also highlighted the need for more research to understand the effects of community mobilization on care-seeking outcomes in different contexts, and recommended the need for close monitoring and evaluation to ensure high quality implementation adapted to the local context.
Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:
The GDG identified this priority question related to this recommendation:
WHO recommendations on antenatal care for a positive pregnancy experience
Citation: WHO Reproductive Health Library. WHO recommendation on facilitated participatory learning and action cycles with women`s groups during pregnancy. (November 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.
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