title: Effect of women's groups and volunteer peer counselling on rates of mortality, morbidity, and health behaviours in mothers and children in rural Malawi (MaiMwana): a factorial, cluster-randomised controlled trial.
abstract: BACKGROUND
  Women's groups and health education by peer counsellors can improve the health of mothers and children. We assessed their effects on mortality and breastfeeding rates in rural Malawi.
  
  
  METHODS
  We did a 2×2 factorial, cluster-randomised trial in 185,888 people in Mchinji district. 48 equal-sized clusters were randomly allocated to four groups with a computer-generated number sequence. 24 facilitators guided groups through a community action cycle to tackle maternal and child health problems. 72 trained volunteer peer counsellors made home visits at five timepoints during pregnancy and after birth to support breastfeeding and infant care. Primary outcomes for the women's group intervention were maternal, perinatal, neonatal, and infant mortality rates (MMR, PMR, NMR, and IMR, respectively); and for the peer counselling were IMR and exclusive breastfeeding (EBF) rates. Analysis was by intention to treat. The trial is registered as ISRCTN06477126.
  
  
  RESULTS
  We monitored outcomes of 26,262 births between 2005 and 2009. In a factorial model adjusted only for clustering and the volunteer peer counselling intervention, in women's group areas, for years 2 and 3, we noted non-significant decreases in NMR (odds ratio 0.93, 0.64-1.35) and MMR (0.54, 0.28-1.04). After adjustment for parity, socioeconomic quintile, and baseline measures, effects were larger for NMR (0.85, 0.59-1.22) and MMR (0.48, 0.26-0.91). Because of the interaction between the two interventions, a stratified analysis was done. For women's groups, in adjusted analyses, MMR fell by 74% (0.26, 0.10-0.70), and NMR by 41% (0.59, 0.40-0.86) in areas with no peer counsellors, but there was no effect in areas with counsellors (1.09, 0.40-2.98, and 1.38, 0.75-2.54). Factorial analysis for the peer counselling intervention for years 1-3 showed a fall in IMR of 18% (0.82, 0.67-1.00) and an improvement in EBF rates (2.42, 1.48-3.96). The results of the stratified, adjusted analysis showed a 36% reduction in IMR (0.64, 0.48-0.85) but no effect on EBF (1.18, 0.63-2.25) in areas without women's groups, and in areas with women's groups there was no effect on IMR (1.05, 0.82-1.36) and an increase in EBF (5.02, 2.67-9.44). The cost of women's groups was US$114 per year of life lost (YLL) averted and that of peer counsellors was $33 per YLL averted, using stratified data from single intervention comparisons.
  
  
  CONCLUSIONS
  Community mobilisation through women's groups and volunteer peer counsellor health education are methods to improve maternal and child health outcomes in poor rural populations in Africa.
  
  
  BACKGROUND
  Saving Newborn Lives, UK Department for International Development, and Wellcome Trust.
authors.affiliation: Institute for Global Health, University College London, London, UK.
authors.forename: Sonia
authors.initials: S
authors.lastname: Lewycka
authors.forename: Charles
authors.initials: C
authors.lastname: Mwansambo
authors.forename: Mikey
authors.initials: M
authors.lastname: Rosato
authors.forename: Peter
authors.initials: P
authors.lastname: Kazembe
authors.forename: Tambosi
authors.initials: T
authors.lastname: Phiri
authors.forename: Andrew
authors.initials: A
authors.lastname: Mganga
authors.forename: Hilda
authors.initials: H
authors.lastname: Chapota
authors.forename: Florida
authors.initials: F
authors.lastname: Malamba
authors.forename: Esther
authors.initials: E
authors.lastname: Kainja
authors.forename: Marie-Louise
authors.initials: ML
authors.lastname: Newell
authors.forename: Giulia
authors.initials: G
authors.lastname: Greco
authors.forename: Anni-Maria
authors.initials: AM
authors.lastname: Pulkki-Brännström
authors.forename: Jolene
authors.initials: J
authors.lastname: Skordis-Worrall
authors.forename: Stefania
authors.initials: S
authors.lastname: Vergnano
authors.forename: David
authors.initials: D
authors.lastname: Osrin
authors.forename: Anthony
authors.initials: A
authors.lastname: Costello
mesh_terms: D000293:Adolescent; D000328:Adult; D001942:Breast Feeding; D002648:Child; D003256:Community Participation; D003376:Counseling; D005163:Factor Analysis, Statistical; D005260:Female; D015438:Health Behavior; D006293:Health Promotion / Q000458:organization & administration*; D006801:Humans; D007223:Infant; D007224:Infant Care; D007226:Infant Mortality; D057194:Intention to Treat Analysis; D008295:Malawi; D008428:Maternal Mortality; D008875:Middle Aged; D010379:Peer Group; D049590:Postpartum Period; D014838:Volunteers; D055815:Young Adult