Exploring the equity impact of a maternal and newborn health intervention: a qualitative study of participatory women’s groups in rural South Asia and Africa

The design was similar for trial sites in Bangladesh, India and Nepal. Research teams agreed that purposive sampling of poor and better-off participants was necessary, but adherence to strict inclusion criteria about socioeconomic status when purposively sampling participants could cause offense. The process of building rapport is key to having an open, honest discussion and this could be jeopardised if participants knew they were being approached because they were ‘poor’. Instead, participants were purposively sampled from three trial intervention clusters that included locally defined poor and better-off areas. Local research team members and health volunteers categorised areas and located participants according to sampling criteria (Table 1). In each cluster, we conducted a key informant interview (KII) with a women’s group facilitator, a focus group discussion (FGD) with women who had attended the group in a poor area, and a FGD with women who had not attended the group in a similar area. This enabled us to explore the effect of the intervention in the general community, as well as within group attenders. Women who had attended a group were asked to identify a woman who had been pregnant during the trial whom they felt had been helped by the intervention. We then conducted a semi-structured interview (SSI) with her. The same data collection occurred in better-off areas in two of the three sampled clusters at each site. We collected more data in poor areas because we felt it was important to understand the experience of the intervention from poor women’s perspectives. Researchers took informed verbal consent from participants and no-one refused to participate.

Researchers used topic guides in interviews and discussions, translated from English and adapted to the local context. These were split into three sections. The first section invited respondents to remember the time and context of the women’s group intervention and discuss specific examples of women who had been pregnant and given birth, including their behaviour and how they were affected by the women’s group. The first section of the topic guide for the SSI asked the woman to discuss her own experience and how she felt the group had affected or not affected her and her family’s behaviour. The second section explored specific care behaviours that we had seen improve, and how poor women and families were particularly enabled to change their behaviour. This allowed site-specific exploration of issues - for example, in India, participants discussed the reasons why poor women showed increased uptake of iron supplementation. The third section summarised the discussion, and invited participants to prioritise how women’s groups had enabled behaviour change, and how they might have particularly affected poor women and families. Prioritisation used participatory voting, putting pebbles on meta-cards which had a short description and symbol for each topic. Emergent topics were added to meta-cards by researchers. Topics covered dissemination and discussion of ideas and knowledge, acceptability of home care behaviours, and community capacity and social support.

In Malawi, the intervention had a similar mortality effect on poor and better-off families, but had no effect on home care practices and health care uptake in either socioeconomic group. To understand these findings, we purposively sampled research team members who had been involved in the trial intervention and monitoring, as well as community and group members. We explored how interventions and monitoring systems might have affected the mortality impacts and reporting of behaviours. The proximity of trial team members to communities throughout the intervention made them key informants. We conducted one FGD with facilitation supervisors, one with monitoring supervisors, one with female group facilitators, one with male trial enumerators from control areas, and one with a mixed gender group of facilitators and trial enumerators. In the community, we categorised areas as previously described, and conducted two FGDs with women’s group attenders from poor and better-off households, and two FGDs with women from poor and better-off households who had not attended the groups. We also conducted four KIIs with community members, four with trial researchers, and four with facilitators in two clusters. A senior qualitative researcher who was an established MaiMwana team member led discussions. This researcher had not been involved in the trial. We took informed verbal consent from participants and no-one refused to participate. Topic guides were developed in English in discussion with JM, and subsequently translated. We explored how the activities and strategies of the women’s groups might have been effective in reducing neonatal mortality among both the poor and better-off.

Group attenders learned how to care for pregnant women, prepare for a delivery, and care for mothers and infants during delivery and postpartum. This included care to prevent and treat illness: “In the women’s group we learned that after the child enters the womb you should go for a check-up straight away, and then once in the seventh month, then in the eighth and ninth months. You need to go for a check-up four times to see whether the child is all right or not, to see whether it is healthy or not. Then you get weighed. See! We’ve learnt all of these things!” (Bangladesh, attender, poor, FGD). Participants at all sites discussed how other non-governmental organisations and government and media campaigns had been useful in disseminating information and increasing knowledge, but some felt that the group enabled a more engaging form of learning: “(community members) also get all this information from the radio and television, but the (women’s group) meeting is giving something that we do not get anywhere else. Even if tribal women watch TV, they do not understand in detail, but they get knowledge about health through this meeting. (The facilitator) sits with us and makes us understand.” (India, attender, poor, changed behaviour, SSI). In Bangladesh, women’s group attenders reported that traditional birth attendants (TBAs) also learned from the group.

Some participants felt that both poor and better-off women held traditional beliefs and lacked knowledge about healthy behaviours, and that community members from all socioeconomic strata were able to learn and be convinced by the intervention. Group attenders and non-attenders emphasised that knowledge was useful for all socioeconomic strata: “Rich families have money, but that doesn’t mean to say they know everything. Money is not worth anything if there is a lack of education or ideas. If there was no women’s group then how would better-off women and poor families know about good home care behaviour?” (Nepal, non-attender, poor, changed behaviour, SSI). At the same time, knowledge provided by the groups on how to prevent problems was considered particularly relevant for poor women. While better-off women could go to a private clinic for delivery or treatment, preventing health problems was more important for poor women: “People from poor communities are getting more benefit in comparison to the better-off because the better-off are able to go to hospital… poor people depend on and benefit from the meetings more than the better-off. The better-off have other options.” (India, non-attender, poor, changed behaviour, SSI). Recommendations for low-cost home care behaviours to prevent illness were particularly well received by poor families.

Facilitators in Malawi said that messages were “shared equally” among better-off and poor families and that there was no discrimination in implementing strategies, visiting homes of non-attenders or having discussions. Groups in Nepal and India had focused on poor families, while not neglecting the better-off: “Group attenders gave priority to poor families and counselled them that good care behaviours were important.” (Nepal, non-attender, poor, FGD).

Attenders and non-attenders at all sites described the group facilitator as a respected source of information and knowledge: “The facilitator gave health information about everything women didn’t know before and then all the women knew about good home care behaviours. They realized what they should do for themselves to improve their health.” (Nepal, non-attender, poor, FGD). The format of the meetings was accessible to illiterate women, as “messages were shared by word of mouth, not by reading and writing.” (India, facilitator, FGD). “Some women who were not actively participating in the discussion in the beginning started to participate little by little, knowing how to address others. We also used participatory tools to guide our discussions.” (Malawi, facilitator, KII). The facilitator was also influential in maintaining the relevance of the group discussions and strategies for both better-off and poor women. For example, awareness-raising strategies and home visits to give advice and information were low-cost and something that poor women could participate in and learn from. Facilitators reminded group members that they should recommend locally relevant actions that could be undertaken by all types of families, and often focused more on poor families: “I think that the women’s group showed an interest in poor families. Poor families were the worst-off and they did not have correct knowledge about good home care practices. Poverty makes poor families weak and makes their mentality weak. In that situation, I saw that facilitators went to poor families and provided them suggestions about good home care practice.” (Nepal, non-attender, better-off, FGD).

Women learned from the facilitator, but at all sites they said that they also learned from each other: “The discussion was like educating each other.” (Malawi, facilitator, KII). Sharing of ideas in the group was discussed as the first step to behaviour change. The group was open to all women and enabled both poor and better-off women to get together, share ideas, and learn from each other: “There is one proverb we have that either people gain knowledge through reading or through experience. Poor families changed their behaviour by seeing whatever others did. The women’s group encouraged them to do good home care practices.” (Nepal, non-attender, KII).

All participants felt that increasing knowledge and awareness stimulated behaviour change in group attenders and non-attenders: “Women were interested and asked, what do you do in the women’s group? What do you discuss? So as time went by, they were learning from their friends.” (Malawi, facilitator, KII). “If I learned something, I would not only apply it to myself, but I would also tell others who did not attend the meeting. In this way if someone did not come to the meeting she could know from me or others who attended.” (India, attender, poor, FGD). Group attenders interacted informally with family members, friends and neighbours about how to improve maternal and newborn care behaviours in their daily lives. More formal interactions occurred through implementing strategies to disseminate information about the group and knowledge about good care behaviours. For example, in Malawi, home visits were a strategy implemented by the groups to address water and sanitation concerns: “Because women’s group members were visiting households, things changed and there was good sanitation in the whole village…We noted that if we were to reduce deaths, after going to the toilet we had to wash our hands with soap before we breastfeed the baby. When we wanted to cook food in the kitchen, we washed our hands, washed plates and swept the kitchen. This helped to prevent diseases in our households and all children would not get infected.” (Facilitators, FGD).

Home visits were a popular strategy and had the benefit of being able to reach beyond the immediate networks of women’s group attenders and include poor and better-off families: “The door-to-door visits have helped so much because women did not choose who is a group member and who is not; they visited everyone.” (Malawi, facilitators, FGD). Some participants felt that facilitators and attenders had responded to a need and reached parts of the population not usually accessed: “Previously, due to the lack of proper education, awareness campaigns didn’t reach people. But, later on, health workers, facilitators, and staff from MIRA came to them and made suggestions. It helped to spread awareness everywhere. This is the reason there was behaviour change and women started to accept (recommended) home care practices.” (Nepal, non-attender, poor, changed behaviour). Group attenders felt that this type of dissemination would not have been possible without developing an awareness of how best to support mothers and babies: “Women hardly took iron tablets because they tasted bad or their in-laws did not allow them, but at group meetings we have been told that it is good for us and for our child too. Then our in-laws realised that whatever is told in the group it is good for mothers.”(India, attender, poor, FGD).

The powerful position of the mother-in-law and other family members in overseeing the behaviour of daughters-in-law - particularly newlyweds - was emphasised at Asian sites. In Bangladesh, restrictions preventing women from going outside the home were discussed as significant barriers to accessing information that would be beneficial for their health and the health of their baby. Daughters-in-law felt that they learned a lot if they were allowed to go to the group: “We did not know anything (about maternal and newborn health). We are daughters-in-law; if we had been able to go outside before, we might have known something. But now daughters-in-law can know these things from the comfort of their home. The women’s group came and taught us things, and showed us things would be better if we did these things. So now we know, and we are willing to do them.”(Bangladesh, attender, poor, FGD). Participants in Bangladesh felt that women from better-off families were more restricted in visiting public places and were equally able to learn from groups.

In-laws often preferred traditional ways of caring for women and babies: “Family members would think that if I took iron tablets then the baby would grow big, and if my child grows big then I wouldn’t have a normal delivery. I would have a caesarean section. Now these things have changed.” (Bangladesh, facilitator, KII). Women reported feeling able to challenge or convince their own family members and those of others to behave differently after they had been to the group: “(Traditional) practices are diminishing because now we are conscious, we have seen and heard a lot of things. Sometimes we might even engage in disagreements with in-laws. If a mother-in-law suggests something then we suggest a different way of doing things. Like when the mother-in-law still has faith in traditional healers and we opt for a doctor.” (Bangladesh, attender, poor, changed behaviour, SSI). Community support for harmful practices also diminished: “There was the belief that pregnant women should drink traditional medicine to induce labour pains, but this was causing complications. This practice has been reduced in some areas, and in others it has stopped completely.” (Malawi, facilitator, KII).

In Nepal, Bangladesh, and India, the practice of immediate bathing after birth was particularly challenging to address. Cultural beliefs about birth pollution were related to the practice of bathing with water: “Because the child has ‘dirt’ attached to it, if anyone takes the baby on their lap then that person wouldn’t be able to perform Namaz (Islamic prayers). Communities have many superstitions.” (Bangladesh, facilitator, KII). Despite this, study participants felt that behaviour change had occurred through increasing understanding about the effect of bathing on the baby: “When a child is in the mothers’ womb it is warm inside, but when it comes out, the environment is different and the baby may catch cold. Therefore everyone stopped bathing their newborn. This was told at the meeting.” (India, non-attender, better-off, FGD).

In Nepal and Bangladesh, there was some evidence of social prestige in practising behaviours recommended by the group: “Now people follow what they are taught in the meetings. And if someone follows the old superstitions in the village, we tell them to leave those practices as they are from an old era.” (Bangladesh, non-attender, poor, changed behaviour, SSI). Families who practised recommended care behaviours were seen as educated about health issues and forward-thinking: “Because of social prestige, they care about their infants.” (Nepal, attender, poor, FGD).

In the Asian sites, groups promoted kits to enable clean delivery care. When we discussed increased access to them, participants tended to focus on how the group had increased their knowledge of the need to prevent infection and the benefits of using a kit: “Using a safe delivery kit is safe as mothers will not get an infection” (India, attender, better-off, changed behaviour SSI). With this increase in knowledge there was an increase in demand: “In previous days, different kinds of tools were used to cut a baby’s umbilical cord. Because of those tools, we lost many mothers and babies. But later on, women realized that a kit must be used during delivery. The women’s group made people aware by visiting door-to-door. There was only an increase in the use of kits after the women’s group did that.” (Nepal, non-attender, changed behaviour, SSI). Participants reported an increased demand for kits at the Asian sites, particularly among group attenders: “Those women who had attended the meeting regularly understood the importance of the kit and therefore they demanded it from Auxiliary Nurse Midwives while delivering their child.” (India, facilitator, KII). The availability of kits was particularly beneficial to women who were restricted from going outside their homes. In Bangladesh, group attenders “took the kits from facilitators and gave them to pregnant women.” (Bangladesh, attender, poor, FGD). Participants in Bangladesh and India felt that the increased demand and utilisation of kits was indicative of advance preparation for a delivery: “Now people have become cautious these days, they keep the kit at home in advance.” (Bangladesh, non-attender, better-off, FGD). Groups in Nepal made and sold kits at lower cost than available brands and poor women in India and Nepal made the kits themselves: “If poor women couldn’t buy the kit, they made it by themselves by boiling the blade in water, using clean clothes and bringing thread and soap etc.” (Nepal, non-attender, better-off, FGD). Participants felt that the role of a kit in preventing illness was particularly important for poor women: “Poor people know that in case of any emergency they don’t have enough resources to deal with it. Therefore they prefer to be prepared for these things. Preparing safe delivery kits is one example of this.” (India, attender, better-off, changed behaviour, SSI). Women in Malawi did not use or promote clean delivery kits, but participants elsewhere felt there had been increased demand for health services as a result of the group intervention.

The strategies developed by women’s groups also enabled some financial support to women. The vegetable gardens in Malawi helped them to eat better during pregnancy, and any surplus was sold and the income put in a fund: “This strategy really helped because a baby needs to eat a variety of food to grow. People used this money to assist pregnant women so that they could eat what they felt like eating. They could take the money and buy anything, which made the women and unborn baby happy.” (Malawi, facilitator KII). Funds created by groups in Bangladesh, Malawi, and Nepal were used to lend money to women. Both poor and better-off women accessed them: “If we are not able to pay for nutritious foods in the period of pregnancy and delivery we sometimes use money from the women’s group fund, and give money back later when we can. We use the fund turn by turn.” (Nepal, non-attender, better-off, FGD). Although the funds were meant to have a maternal and newborn health focus, they were also used for other small expenses, and women could repay at very low interest when they were able. “In the past someone might have a shortage of money, but now we have overcome even that, now that our group has an emergency fund. We can take money from there.” (Bangladesh, attender, poor, FGD). Some groups raised money for non-attenders who had not invested but required help. One non-attender told us: “Although I am not involved in the group, I can get lots of support from it. Other women have also received up to 5000 rupees from the women’s group.” (Nepal, non-attender, poor, FGD). The women’s group network was a source of social and financial support for women, irrespective of attendance, in all sites: "If someone has a problem we could discuss it as a group and give her part of the money to help. When someone is sick we can agree among ourselves to go and see her in the hospital using the group fund (Malawi, facilitator, FGD). At all sites, funds helped group attenders feel more confident: “We can all make decisions. We have money so we have a different kind of strength.” (Bangladesh, attender, better-off, FGD).

Our findings support theories that emphasise the mediating role of social-cognitive factors (behavioural beliefs, perceived behavioural control, social norms) in the relationship between socioeconomic position and health behaviour [31, 32]. Knowledge deficits and constraining community and family norms were significant barriers to healthy behaviours across socioeconomic strata in our study population. The intervention was able to influence behavioural beliefs and social norms so that recommended practices became more acceptable. The PLA process gave women confidence to change their behaviour and influence others to do the same. Bandura’s social learning theory emphasises the importance of social interaction for behaviour change. We found that the facilitator and intervention design shaped the process of social interaction in such a way that the intervention was inclusive of all socioeconomic strata.

The PLA process increased group attenders’ confidence to challenge powerful norms and convince community members about the benefits of healthy practices. These findings support theories that emphasise the importance of social change for improvements in maternal and newborn health. Our findings suggest that the women’s group intervention addresses some structural and agency constraints to reducing health inequalities. Power structures were similar in poor and better-off households, with the exception of Bangladesh where better-off women were perhaps more constrained. The development literature suggests that the PLA approach facilitates dialogue and exchange of ideas and experiences, which enable groups and communities to become critically consciousness of the constraints to health improvement, and this motivates them to change their situation [11, 14]. This process enables communities and individuals to engage with power structures and recognises the role of agency.

Despite obvious contextual differences, for example the restrictions on women in South Asian sites as compared to Malawi, the mechanisms stimulating behaviour change in the four research sites were similar. The participatory nature of the intervention allowed adaption to context, with women and communities identifying local problems and ways to address them.

We found that women’s groups were effective in strengthening or creating social networks, which enabled women to access a broader basis of social support. Strengthened reciprocity and social networks between group attenders and within communities enabled behaviour change in maternal and newborn health.

Although study contexts were culturally different, studies were all conducted in rural areas. Neighbours knew one another and communities arguably had a strong sense of social control. The women’s group intervention took advantage of this to create community pressure for behaviour change. In poor, urban, and perhaps more anonymous communities, the intervention has not been as effective at changing behaviours [33].

Finally, the intervention was implemented in a context where families reported a lack of knowledge about healthy practices. Our findings suggest that the PLA approach is most likely to be equally effective across socioeconomic strata for issues about which there is a knowledge deficit and for which simple changes in the home can be implemented. Facilitators and group attenders were able to offer advice about affordable actions that were contextually relevant and acceptable. This advice, combined with increased social support, confidence and acceptability of healthy behaviours, enabled families to change their behaviour. If healthy behaviours had incurred financial costs to families, the intervention might not have been so effective across socioeconomic strata.