Abstract
BackgroundEngaging citizens and communities to make services accountable is vital to achieving health development goals. Community participation in health management committees can increase public accountability of health services. We conducted a cluster randomised controlled trial to test the impact of strengthened health management committees (HMCs) and community mobilisation through women’s groups on institutional deliveries and deliveries by trained health workers in rural Nepal.MethodsThe study was conducted in all Village Development Committee clusters in the hills district of Makwanpur (population of 420,500). In 21 intervention clusters, we conducted three-day workshops with HMCs to improve their capacity for planning and action and supported female community health volunteers to run women’s groups. These groups met once a month and mobilised communities to address barriers to institutional delivery through participatory learning and action cycles. We compared this intervention with 22 control clusters. Prospective surveillance from October 2010 to the end of September 2012 captured complete data on 13,721 deliveries in intervention and control areas. Analysis was by intention to treat.ResultsThe women’s group intervention was implemented as intended, but we were unable to support HMCs as planned because many did not meet regularly. The activities of community based organisations were systematically targeted at control clusters, which meant that there were no true ‘control’ clusters. 39% (5403) of deliveries were in health institutions and trained health workers attended most of them. There were no differences between trial arms in institutional delivery uptake (1.45, 0.76–2.78) or attendance by trained health workers (OR 1.43, 95% CI 0.74–2.74).ConclusionsThe absence of a true counterfactual and inadequate coverage of the HMC strengthening intervention impedes our ability to draw conclusions. Further research is needed to test the effectiveness of strengthening public accountability mechanisms on increased utilisation of services at delivery.Trial registrationCurrent Controlled Trials ISRCTN99834806.Date of registration:28/09/10.
Highlights
Engaging citizens and communities to make services accountable is vital to achieving health development goals
Further research is needed to test the effectiveness of strengthening public accountability mechanisms on increased utilisation of services at delivery
Maternal and newborn health in Nepal Nepal’s maternal and neonatal health indicators are improving, yet many women still deliver at home, in rural areas, without access to a trained health worker at delivery [6]
Summary
Setting The study was implemented in the hill district of Makwanpur in central Nepal. From 2005 to 2008, the women’s group intervention was implemented in all 24 VDCs 12 intervention and 12 previous control VDCs - and birth outcomes were monitored in six additional VDCs. Within each stratification, equal numbers of clusters were randomly allocated to receive the intervention using a lottery method. We described context through baseline and endline surveys of the status and activities of health facilities, HMCs, active women’s groups, community based organisations (CBOs), and FCHVs. We conducted two qualitative studies, one exploring reasons for home delivery [27], and one exploring perceptions about quality of care in intervention and control areas. Surveillance and data management We ran a surveillance system that incentivised local women to identify births, newborn deaths, infant deaths, under five deaths, and deaths of women between 12 and 49 years These women reported events at a monthly meeting with cluster interviewers, who verified them and administered a paper questionnaire.
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