Academic journal article Bulletin of the World Health Organization

Improved Neonatal Survival after Participatory Learning and Action with Women's Groups: A Prospective Study in Rural Eastern India/Amelioration De la Survie Neonatale Suite a Des Activites D'apprentissage et Des Actions Participatives Avec Des Groupes Feminins: Une Etude Prospective Dans l'Inde De l'Est Rurale

Academic journal article Bulletin of the World Health Organization

Improved Neonatal Survival after Participatory Learning and Action with Women's Groups: A Prospective Study in Rural Eastern India/Amelioration De la Survie Neonatale Suite a Des Activites D'apprentissage et Des Actions Participatives Avec Des Groupes Feminins: Une Etude Prospective Dans l'Inde De l'Est Rurale

Article excerpt

Introduction

Of the world's 2.9 million neonates who die in the first month of life each year, (1) around 30% (i.e. approximately 876000) are born in India. (2) Meeting the United Nations' Millennium Development Goal for reducing child mortality (MDG 4) requires a focus on India's poorest communities and, as neonatal deaths account for 52% of deaths in children aged under 5 years in the country, on the survival of neonates. (2,3)

The National Rural Health Mission, which was established by the Government of India, has introduced two initiatives for improving maternal and neonatal health: (i) a conditional, cash transfer scheme to increase the number of institutional deliveries, known as the Janani Suraksha Yojana; and (ii) the deployment of over 820 000 community-based, volunteer, Accredited Social Health Activists. The health activists help mothers access antenatal care, encourage delivery in a health-care institution, offer home-based neonatal care during the first 7 days of life and provide counselling on community health and nutrition through home visits and community meetings. (4,5) While these initiatives should help improve neonatal survival, achieving adequate and equitable coverage is difficult. (6,7) Recent evaluations found that the poorest mothers did not always receive payments under the Janani Suraksha Yojana, that institutional delivery was not necessarily synonymous with good obstetric care and that the Janani Suraksha Yojana had not yet resulted in a large reduction in neonatal mortality. (8) Moreover, little evidence is available about the coverage of the home-based interventions delivered by Accredited Social Health Activists or about their effect on neonatal survival on a large scale.

The success and sustainability of community-based programmes for improving maternal and neonatal health require the active involvement of women, families and community health-care workers, yet the strategies used to engage these groups are often externally driven and top-down. Community mobilization, which is defined here as a process through which communities plan and act together to address health problems, is generally viewed as an essential component of programmes for improving maternal and child health. (9-11) Can community mobilization help reduce the number of preventable deaths in the poorest communities at a time when initiatives to strengthen health services and interventions such as home-based neonatal care are being scaled up?

Since 2005, the Indian nongovernmental organization known as Ekjut has helped women's groups to improve maternal and neonatal health in tribal areas of the Indian states of Jharkhand and Odisha (formerly Orissa). Local female facilitators guide women's groups through a cycle of activities involving participatory learning and action, during which women identify, prioritize and analyse local maternal and neonatal health problems and subsequently devise and implement strategies to address them. The Ekjut intervention was initially evaluated in a cluster-randomized, controlled trial carried out between 2005 and 2008 in 36 largely tribal clusters of three contiguous districts of Jharkhand and Odisha. When the trial started, the estimated neonatal mortality rate was 48.6 per 1000 live births in Jharkhand and 45.4 per 1000 live births in Odisha. However, the rate in Scheduled Tribes, as recognized by the Indian Constitution, was higher: more than 60 per 1000 live births. (12-14)

The present study involved the areas included in the original cluster-randomized, controlled trial, which we divided into two zones: zone 1 comprised the clusters in which the original intervention was implemented; and zone 2, the control clusters in the original trial. In 2004, before the original intervention, the neonatal mortality rate was high in both zone 1 and zone 2:61.4 and 54.1 per 1000 live births, respectively. Access to health services was poor in zone 1, where only 34 of 193 villages (17. …

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