Researchers say they've found a way to keep more newborns alive in the poorest corners of eastern India: Get their mothers talking. A report published in The Lancet medical journal last month suggests that gathering women together for monthly chats on sound pregnancy practices and reproductive health may drastically cut neonatal mortality rates in rural communities. "Too many people in the health community think that health is about delivering little magic bullets to passive poor people," says Anthony Costello of University College London's Institute of Child Health, which spearheaded the project. "What that doesn't do is tap into the solidarity, the collective memory, the sharing, the supporting." Where the Indian government has largely focused on improving access to treatment in far-flung areas, the Institute has aimed at prevention. And as it turns out, collective conversation is a powerful safety measure.
India could use a few fresh ideas when it comes to neonatal care. Behind the screen of its phenomenal economic growth, the country continues to struggle with abysmally high rates of newborn deaths. According to national estimates, for every 1,000 live births, 39 babies die in their first month; a third of these don't survive their first day. In Jharkhand and Orissa, two of east India's most impoverished and underserved states, the numbers are worse still 49 and 45 deaths per 1,000 live births, respectively. The neonatal mortality rate in China, by comparison, lingers under 15. "Just improving health services will not do," says Dr. Prasanta Tripathy, who founded the Indian social welfare NGO Ekjut with his wife Dr. Nirmala Nair. "Communities need to be made aware of what it is in their own power to accomplish."
Ekjut and the Institute of Child Health teamed up to stage a regional intervention that would show moms how they could themselves reduce this risk. Their plan was to mobilize a few thousand women from a clutch of villages in one Orissa and two Jharkhand districts as part of a three-year trial (2005 to 2008). A similar project in the mountainous Makwanpur region of Nepal, where health facilities can easily be a six-hour walk away, required the Institute to organize local women into groups. In east India, it rallied an existing structure of "self-help groups," a national network of rural microfinance intermediaries typically composed of 10 to 15 women who contribute small savings to a common fund until they have enough to begin lending. As part of the trial, the groups were asked to replace talk of business with babies, and open meetings to the general public.
With the help of village headmen, Ekjut handpicked women who were paid and trained to facilitate the discussions or gather data on community births and neonatal deaths. Facilitators were required to be mobile and speak two or more local languages prepared, in other words, to bicycle from village to village and sit in on sessions. Group meetings are informal, and usually open with village gossip. Goats tied with rope to trees bleat in frustration; children squirm in their mothers' sari-covered laps. The facilitator begins with a story related to a local concern, perhaps about a pregnant girl with malaria. Participants work with picture cards, identifying the problems depicted and collectively venturing causes (e.g., stagnant water) and solutions (e.g., insect repellent, mosquito nets). The women also hold emergency drills and keep a fund that allows for those in labor to be transported swiftly to hospital.
The results of the trial's first stage in India have been a testament to the influence of the easy, intimate get-together, more intuitive to many young mothers-to-be than one-on-one encounters with unfamiliar healthcare professionals. The neonatal mortality rate in the intervention areas, according to the data collected, dropped by a whopping 47% by the project's end in 2008. The entire three years cost organizers just $300,000, and participation rates increased from one in six women of childbearing age in the first year to more than half in the third. Sebati Thakur, a 23-year-old from Keonjhar district in Orissa, lost her first baby to a bacterial infection. She began attending the meetings with her mother-in-law, learning, she says, to "go for checkups, take iron and get a Tetanus shot." Last year she gave birth to a healthy girl.
UNICEF India's Chief of Health, Henri van den Hombergh, points out that local women's groups should not be taken as a substitute for institutions where professional care is available to sick newborns. But, he says, "peer influencing" of the type that goes on at these meetings relating to commonsensical practices, like hand washing and good hygiene certainly helps. "The neonate is too cold because the baby isn't wrapped well; the baby isn't getting enough breast milk; the baby is showing signs of infection. These three simple things are the underlying causes of the majority of all the neonatal deaths in India," says van den Hombergh. Interestingly, during the Ekjut Trial, as it is called, attendance at natal clinics and other health facilities did not rise by much. What changed was behavior in the home.
In Nepal, where neonatal mortality in participating groups dropped by 30%, the benefits of the trial have endured. Recent estimates indicate that the neonatal mortality rate has now dipped under 30 per 1,000 live births, thanks also to the work of other NGOs and governmental organizations in the region. Two years ago, the Institute of Child Health withdrew funds and left, but the women kept on going. When Costello returned to visit recently, 75% of the groups were still active. "It's really impressive that our groups are still running," he recalls telling a cluster of women. "They're not 'your' groups," one answered. "They're our groups."
And while women's autonomy is one of the project's goals, organizers recognize that it can't hurt to get the government on their side. The Ekjut Trial in India has expanded to five other districts in the two states; according to the NGO, 20,000 village women are meeting every month. Now the team is looking to collaborate with the Indian government's five-year-old National Rural Health Mission to take advantage of its female Accredited Social Health Activists, or ASHAs. These frontline workers, trained in neonatal care, have already been stationed throughout rural India. Incorporating them as facilitators into the Ekjut Trial, says the Institute, would give them a more focused role in village communities. UNICEF's van den Hombergh calls the ASHAs the key to "cooperation between the women's groups and the government." He adds: "They will keep things localized and realistic."
Teaming up with the government should also help keep the neonatal death rate in participating districts down. But since the release of the results, no one seems very concerned about numbers. Health workers come and go; now that these women have a hold on the basics, they aren't likely to forget them fast. "Once the numbers go down," Costello says, "they don't come back up again."