Recommendation

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.

(Context-specific recommendation)

 

Publication history

First published: November 2016

Updated: No update planned

Assessed as up-to-date: November 2016

 

Remarks

• Part of this recommendation was integrated from WHO recommendations on community mobilization through facilitated participatory learning and action cycles with women’s groups for maternal and newborn health (2014) (1).
• The pathways of influence of this multifaceted, context-specific intervention on maternal and newborn outcomes are difficult to assess. Women meeting to identify their needs and seek solutions plays an important role; mechanisms related to additional activities that are organized based on the solutions identified at the meetings may also play a role.
• Detailed information and guidance related to the recommendation, including important implementation considerations, can be found in the 2014 WHO recommendations on PLA cycles (1), available at:   http://www.who.int/maternal_child_adolescent/documents/community-mobiliz...

 

Background

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.

 

Methods

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.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

• Should community-based interventions that increase communication with, and support for, pregnant women be recommended to improve ANC coverage and pregnancy outcomes?

 

Evidence summary

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.

Maternal outcomes

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).

Coverage outcomes

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).

Additional considerations

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:

http://apps.who.int/iris/bitstream/10665/250796/8/9789241549912-websupplement- eng.pdf?ua=1

 

Implementation considerations

• The successful introduction of evidence-based policies related to antenatal care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
• The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
• An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
• Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
• Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Taking this as a foundation, the GDG reviewed how ANC should be delivered in terms of both the timing and content of each of the ANC contacts, and arrived at a new model – the 2016 WHO ANC model – which replaces the previous four-visit focused ANC (FANC) model. For the purpose of developing this new ANC model, the ANC recommendations were mapped to the eight contacts based on the evidence supporting each recommendation and the optimal timing of delivery of the recommended interventions to achieve maximal impact.

 

Research implications

The GDG identified this priority question related to this recommendation:

• How acceptable and feasible are mixed-gender community mobilization groups? What are the optimal methods for community-based interventions to improve communication and support for pregnant women and adolescent girls; to improve integration of community-based mobilization efforts with health systems; and to ensure continuity of care with home visits? What are the mechanisms of effect of these interventions?

 

Related links

WHO recommendations on antenatal care for a positive pregnancy experience

(2016) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health

 

 

References

1. WHO recommendations 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/ community-mobilization-maternal-newborn/ en/, accessed 29 September 2016).
2. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. What matters to women: a scoping review to identify the processes and outcomes of antenatal care provision that WHO recommendations on antenatal care for a positive pregnancy experience 124 are important to healthy pregnant women. BJOG. 2016;123(4):529–39. doi:10.1111/1471- 0528.13819.
3. Office of the United Nations High Commissioner for Human Rights (OHCHR). Technical guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce preventable maternal morbidity and mortality. Human Rights Council, twentieth session. New York (NY): United Nations General Assembly; 2012 (A/ HRC/21/22; http://www2.ohchr.org/english/ issues/women/docs/A.HRC.21.22_en.pdf, accessed 28 September 2016).
4. WHO handbook for guideline development, 2nd edition. Geneva: World Health Organization; 2014 (http://www.who.int/kms/handbook_2nd_ ed.pdf, accessed 6 October 2016).
5. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
6. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016).
7. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).
8. Baqui AH, El-Arifeen S, Darmstadt GL, Ahmed S, Williams EK, Seraji HR et al.; Projahnmo Study Group. Effect of community-based newborncare intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: a cluster-randomised controlled trial. Lancet. 2008;371(9628):1936–44. doi:10.1016/S0140-6736(08)60835-1.
9. Azad K, Barnett S, Banerjee B, Shaha S, Khan K, Rego AR et al. Effect of scaling up women’s groups on birth outcomes in three rural districts in Bangladesh: a cluster-randomised controlled trial. Lancet. 2010;375(9721):1193–202. doi:10.1016/S0140-6736(10)60142-0.
10. Colbourn T, Nambiar B, Bondo A, Makwenda C, Tsetekani E, Makonda-Ridley 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;5(3):180–95. doi:10.1093/inthealth/iht011.
11. Fottrell E, Azad K, Kuddus A, Younes L, Shaha S, Nahar T et al. The effect of increased coverage of participatory women’s groups on neonatal mortality in Bangladesh: a cluster randomized trial. JAMA Pediatr. 2013;167(9):816–25. doi:10.1001/jamapediatrics.2013.2534.
12. Lewycka S, Mwansambo C, Rosato M, Kazembe P, Phiri T, Mganga A 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;381(9879):1721–35. doi:10.1016/S0140-6736(12)61959-X.
13. Manandhar DS, Osrin D, Shrestha BP, Mesko N, Morrison J, Tumbahangphe KM et al. Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet. 2004;364:970–9.
14. More NS, Bapat U, Das S, Alcock G, Patil S, Porel M et al. Community mobilization in Mumbai slums to improve perinatal care and outcomes: a cluster randomized controlled trial. PLoS Med. 2012;9(7):e1001257. doi:10.1371/journal. pmed.1001257.
15. Tripathy P, Nair N, Barnett S, Mahapatra R, Borghi J, Rath 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;375(9721):1182–92. doi:10.1016/S0140-6736(09)62042-0.
16. Prost A, Colbourn T, Seward N, Azad K, Coomarasamy A, Copas A 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;381(9879):1736–46.

 

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.