Trials of participation to improve maternal and newborn health – Authors' reply

Abstract

Susan Rifkin raises three important issues in relation to participatory women's groups to improve maternal and newborn health.1Prost A Colbourn T Seward N et al.Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis.Lancet. 2013; 381: 1736-1746Summary Full Text Full Text PDF PubMed Scopus (361) Google Scholar The first is that supporting participation in women's groups does not in itself make an intervention participatory. Instead, being true to Participatory Learning and Action would require involvement of the intended beneficiaries in all aspects of the intervention, and valuing of the process of participation as much as its practical outcomes. On this matter we agree. The women's group studies tread a fine line between valuing participation as a bottom-up, long-term, locally owned transformational process to redress inequities, and strategically engineering top-down health promotion approaches to improve health outcomes within the time constraints of trials.2Labonte R Laverack G Capacity building in health promotion, Part 1: for whom? And for what purpose?.Crit Public Health. 2001; 11: 111-128Crossref Scopus (203) Google Scholar The tension of integrating bottom-up and top-down approaches is at the heart of many health interventions. The women's group interventions examined in our meta-analysis, by necessity, sit within a range of participation, and do not claim to encompass all, or the purest forms, of participation.3Howard-Grabman L Snetro G How to mobilise communities for health and social change. Health Communication Partnership/USAID, Baltimore, MD2003Google Scholar Rifkin's second criticism is that presenting participatory women's groups as an intervention with a direct causal relationship to improved health is simplistic. The meta-analysis does support a causal relationship between participatory groups and reduced maternal and neonatal deaths. Several mechanisms, acting through both proximal (eg, improved behaviours) and distal (eg, women's empowerment) outcomes, are likely to be implicated. Our meta-analysis has gone some way towards identifying changes in behaviours linked to reduced mortality. Opening the black box further involves generation and testing of hypotheses about more distal mechanisms, which was beyond the scope of the meta-analysis. Finally, Rifkin argues that the generalisability of our findings is questionable. Participatory women's groups did reduce mortality in many settings. Further exploration of mechanisms can only help to increase the validity of the findings and transferability of the intervention to new settings. Cesar Victora commented that people who study empowerment are rarely those who do trials.4Victora CG Participatory interventions reduce maternal and child mortality among the poorest, but how do they work?.Int J Epidemiol. 2013; 42: 503-505Crossref PubMed Scopus (10) Google Scholar Indeed, reviews have denounced the absence of studies measuring the effect of participatory approaches on health outcomes.5Marston C Renedo A McGowan CR Portela A Effects of community participation on improving uptake of skilled care for maternal and newborn health: a systematic review.PLoS One. 2013; 8: e55012Crossref PubMed Scopus (63) Google Scholar We chose to measure this effect. Trials are vehicles to deploy a range of approaches to understanding change. In this sense, they are only reductionist if we allow them to be so. We invite Rifkin and others who promote participation not to shy away from trials, and to propose new methods for integrating process and impact assessments. We declare that we have no conflicts of interest. Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysisWith the participation of at least a third of pregnant women and adequate population coverage, women's groups practising participatory learning and action are a cost-effective strategy to improve maternal and neonatal survival in low-resource settings. Full-Text PDF Open AccessTrials of participation to improve maternal and newborn healthI want to commend Audrey Prost and colleagues on their study of the contribution of participatory women's groups to improve birth outcomes in poor communities in low-income and middle-income countries (May 18, p 1736).1 Their work is an important contribution to highlight the crucial importance of participation in health care improvement. Full-Text PDF