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People, even the illiterate, the poor, and the deprived, do take an interest in their own welfare and are capable of helping themselves. Consider one of the most beautiful, most fascinating, and poorest of countries—Nepal. The average annual income is about £133 (US $240). Most women (57%) are illiterate. They give birth to an average of 4.4 children, and pregnancy complications kill one mother for fewer than 200 livebirths. One in 25 babies born alive is dead within 4 weeks and one in 40 of all babies born after 28 weeks gestation is born dead. Almost all babies are born at home and at few births is there a trained health worker. But the situation is far from hopeless. Researchers there (Dharma S Manandhar and colleagues
, see also comment: ibid: 914–5) have shown the power of organised women’s groups.
The Makwanpur district is southwest of Kathmandu, where the foothills meet the plains. The 400 000 people depend on subsistence farming. The local administrative unit is the “village development committee (VDC)” of which there are 43 in Makwanpur. Twenty-four of these VDCs were allocated into pairs and the members of each pair were randomised—one to intervention and the other to control—by tossing a coin. The average VDC covered an area of 60 square kilometres and had a population of about 7000. In every intervention VDC a local woman was appointed facilitator. She had to be literate but it was considered important that she should not be a health professional. She was given brief training in perinatal health issues. Her task was to set up monthly women’s group meetings in each of nine wards per VDC and to support the women in their discussions of maternal and neonatal problems. The groups were encouraged to identify and prioritise problems, and to develop strategies to address them. This was done over the first ten of the monthly meetings, and in subsequent meetings the women got down to implementing and assessing their strategies. The emphasis throughout was on participatory learning rather than instruction. The women asked for, and were given, more information about perinatal health. No funding was given for group activities but they did things such as collecting money for mother and baby care, organising stretcher schemes, handing out clean delivery kits, and visiting pregnant women. Health centres in both intervention and control VDCs were provided with basic neonatal equipment from research funding. Between 1 November 2001 and 31 October 2003 there were 3190 pregnancies in intervention VDCs and 3524 in control VDCs. The neonatal mortality rate was 26 per 1000 in intervention VDCs and 37 per 1000 in control VDCs. Maternal mortality was 69 vs 341 per 100 000 (2 in 2899 vs 11 in 3226). The stillbirth rate was 24.6 vs 23.3 per 1000 births. The improvements in the intervention VDCs were associated with increases in antenatal care uptake, institutional delivery, presence of a trained attendant at delivery, and hygienic care. Only 8% of married women of reproductive age ever attended the group sessions but their influence clearly spread. The cost per newborn life saved was estimated at somewhat less than £2000.
Puts a new slant on the old cry of “Power to the people”, doesn’t it? The buzz phrase is “demand-side intervention”. To coin a Churchillian phrase, “some demand, some power, some people”!