Scaling up community mobilisation through women's groups for maternal and neonatal health: experiences from rural Bangladesh

Nahar et al. BMC Pregnancy and Childbirth 0 UCL Centre for International Health and Development, Institute of Child Health, University College London , 30 Guilford Street, London, WC1N 1EH , UK 1 Department of Public Health, ErasmusMC University Medical Center Rotterdam , Dr. Molewaterplein 50, 3015 GE Rotterdam , The Netherlands 2 Perinatal Care Project, Diabetic Association of Bangladesh (BADAS), BIRDEM 122 Kazi Nazrul Islam Avenue Shahbagh , Dhaka-1000 , Bangladesh - Scaling up community mobilisation through women's groups for maternal and neonatal health: experiences from rural Bangladesh Nahar et al. Open Access Scaling up community mobilisation through womens groups for maternal and neonatal health: experiences from rural Bangladesh Tasmin Nahar1, Kishwar Azad1, Bedowra Haq Aumon1, Layla Younes2, Sanjit Shaha1, Abdul Kuddus1, Audrey Prost2, Tanja AJ Houweling2,3, Anthony Costello2 and Edward Fottrell2* Background: Program coverage is likely to be an important determinant of the effectiveness of community interventions to reduce neonatal mortality. Rigorous examination and documentation of methods to scale-up interventions and measure coverage are scarce, however. To address this knowledge gap, this paper describes the process and measurement of scaling-up coverage of a community mobilisation intervention for maternal, child and neonatal health in rural Bangladesh and critiques this real-life experience in relation to available literature on scaling-up. Methods: Scale-up activities took place in nine unions in rural Bangladesh. Recruitment and training of those who deliver the intervention, communication and engagement with the community and other stakeholders and active dissemination of intervention activities are described. Process evaluation and population survey data are presented and used to measure coverage and the success of scale-up. Results: The intervention was scaled-up from 162 womens groups to 810, representing a five-fold increase in population coverage. The proportion of women of reproductive age and pregnant women who were engaged in the intervention increased from 9% and 3%, respectively, to 23% and 29%. Conclusions: Examination and documentation of how scaling-up was successfully initiated, led, managed and monitored in rural Bangladesh provide a deeper knowledge base and valuable lessons. Strong operational capabilities and institutional knowledge of the implementing organisation were critical to the success of scale-up. It was possible to increase community engagement with the intervention without financial incentives and without an increase in managerial staff. Monitoring and feedback systems that allow for periodic programme corrections and continued innovation are central to successful scale-up and require programmatic and operational flexibility. Background In line with Millennium Development Goal (MDG) 4, many countries are on track to reduce under-five mortality by two thirds from 1990 levels by 2015 [1]. This progress has not been uniform for all under-five age groups, however. Neonatal mortality has been relatively resistant to change and the 3.7 million neonatal deaths that occur annually worldwide account for an increasing proportion of all under-five deaths [2-5]. In Bangladesh, around 85% of births occur at home, 57% of all underfive deaths are in the first month of life and the neonatal mortality rate remains high at 37 per 1000 live births [6]. Tackling the burden of neonatal deaths, particularly deaths in the first twenty-four hours of life, requires community-based interventions to improve the supply and demand for maternal and neonatal health care and the use of safe home-delivery and newborn care practices that can prevent neonatal deaths [7-9]. Several studies provide encouraging evidence on how home visits or community mobilisation with concurrent health services strengthening can improve maternal and neonatal health in South Asia [10,11]. Sustaining and scaling-up interventions to increase coverage remain critical challenges. Low-cost, participatory, community-based approaches involving womens groups are effective at improving home delivery practices and birth outcomes in a range of settings. The womens group method significantly reduced neonatal mortality by 30% and 45% in Nepal and India, respectively, and improved hygienic home delivery practices and newborn care in Bangladesh, though it did not have an impact on neonatal mortality overall [7,12,13]. Intervention coverage was one womens group per 756 population and one per 468 population in Nepal and India, respectively [7]. The percentage of women who gave birth and reported attending womens groups was around 30% to 45% in India and 50% in Nepal [12,13]. Coverage in Bangladesh was much lower at one womens group per 1414 population and the proportion of women who delivered and reported attending womens groups was 3%, with just 9% of women of reproductive age becoming womens group members [7]. Program coverage has been observed to be an independent determinant of neonatal mortality, even when adjusted for type of intervention and baseline mortality levels [14]. For community-based interventions to have a substantial impact on birth outcomes, therefore, it is necessary to have a large enough population coverage over a sustained period [14-16]. We hypothesise that the womens group intervention in Bangladesh did not show an impact on neonatal mortality because of its relatively low coverage relative to that used in India and Nepal. For this reason, we increased the coverage in the same geographical areas and the percentage of women in reproductive age and pregnant women exposed to the intervention. The impact of this scaled-up delivery of the intervention is the subject of an ongoing cluster randomised controlled trial detailed elsewhere [17]. Scaling-up is frequently discussed but seldom analysed or rigorously studied [18] yet examination and documentation of how scaling-up experiences are initiated, led, managed and monitored provide a deeper knowledge base and valuable lessons [19]. This paper details experiences in our expansion of womens groups in Bangladesh. We emphasise the importance of monitoring and evaluating the success of scale-up in relation to specific targets, with practical examples of how this may be done in resource-poor settings. unions (the lowest-level administrative level in rural Bangladesh). These unions are located within three districts of Bangladesh (Bogra, Molavibazar and Faridpur) which were selected on the basis of having active Diabetic Association of Bangladesh (BADAS) offices. The majority of the population in the selected areas is Muslim (> 80%), with most of the remainder being Hindu [7]. Most women deliver at home (> 90%) and approximately 50% of mothers in the selected areas have no formal education or only primary education [7]. Physical geography in the three intervention districts, including vulnerability to flooding, (...truncated)