Community Mobilization in Mumbai Slums to Improve Perinatal Care and Outcomes: A Cluster Randomized Controlled Trial

"Significant municipal initiatives in the trial period included some improvement in outreach services by community health volunteers, birth registration and pulse polio campaigns, and infectious disease surveillance."

Improving maternal and newborn health in low-income settings requires both health service and community action, according to a study that tested an intervention in which urban slum-dweller women's groups worked to improve local perinatal health.

Researchers carried out a cluster randomised controlled trial in 24 intervention and 24 control settlements, covering a population of 283,000. In each intervention cluster, a facilitator supported women's groups through an action learning cycle. SNEHA recruited one full-time facilitator in each intervention cluster of about 1,000 households. This sakhi (friend) participated in training, profiled her settlement, and worked to build rapport with local stakeholders. Over about 6 months, she set up ten women's groups, which met fortnightly. There was no set point at which women had to join a group, and women of all ages, pregnant and non-pregnant, were welcome to participate. The intervention took a participatory approach, with an emphasis on sharing and peer learning, rather than on the sakhi as an expert resource and used the change methodology of Appreciative Inquiry to focus on the positive and to build energy for action through identification of the strengths of participants, their families, and neighbourhoods. Each step was simulated in sakhis' weekly meetings and supported by supervisors. The emphasis was on knowing what services were available, choosing appropriate perinatal health care, understanding best practice, and negotiating optimal care with family and providers.

Researchers monitored births, stillbirths, and neonatal deaths, and interviewed mothers at 6 weeks postpartum. The primary outcomes described perinatal care, maternal morbidity, and extended perinatal mortality. During the 3-year trial (2006-2009), there were 18,197 births in the participating settlements. The women in the intervention clusters were enthusiastic about acquiring new knowledge and made substantial efforts to reach out to other women but were less successful in undertaking collective action such as negotiations with civic authorities for more amenities. There were no differences between the intervention and control communities in the uptake of antenatal care, reported work, rest, and diet in late pregnancy, institutional delivery, or in breastfeeding and care-seeking behaviour. Finally, the combined rate of stillbirths and neonatal deaths (the extended perinatal mortality rate) was the same in both arms of the trial, as was maternal mortality.

The researchers explain that their question "was not whether women's groups were beneficial to their members. Members valued the groups and their opportunities for peer learning, showed behaviour change, and helped other women in their communities. Exchange of knowledge about health and health services, rights, social networks, and increased confidence are public goods, although there are challenges in quantifying such outcomes in public health terms. Rather, the question was about the added value of women's groups - over and above activities to improve health care quality - in terms of measurable changes in perinatal health at population level. While acknowledging the possibility that others might be able to achieve this through more intensive community activities in higher mortality settings, our own programme did not show effect. Community groups will feature in our subsequent interventions, as they must in any participatory initiative. We will, however, attempt to integrate them more strongly with pro-poorest targeting, service provision at household level, strengthening of links between communities and service providers, and partnerships with public and private sector providers to improve quality of care."