title: Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis.
abstract: BACKGROUND
  Maternal and neonatal mortality rates remain high in many low-income and middle-income countries. Different approaches for the improvement of birth outcomes have been used in community-based interventions, with heterogeneous effects on survival. We assessed the effects of women's groups practising participatory learning and action, compared with usual care, on birth outcomes in low-resource settings.
  
  
  METHODS
  We did a systematic review and meta-analysis of randomised controlled trials undertaken in Bangladesh, India, Malawi, and Nepal in which the effects of women's groups practising participatory learning and action were assessed to identify population-level predictors of effect on maternal mortality, neonatal mortality, and stillbirths. We also reviewed the cost-effectiveness of the women's group intervention and estimated its potential effect at scale in Countdown countries.
  
  
  RESULTS
  Seven trials (119,428 births) met the inclusion criteria. Meta-analyses of all trials showed that exposure to women's groups was associated with a 37% reduction in maternal mortality (odds ratio 0.63, 95% CI 0.32-0.94), a 23% reduction in neonatal mortality (0.77, 0.65-0.90), and a 9% non-significant reduction in stillbirths (0.91, 0.79-1.03), with high heterogeneity for maternal (I(2)=58.8%, p=0.024) and neonatal results (I(2)=64.7%, p=0.009). In the meta-regression analyses, the proportion of pregnant women in groups was linearly associated with reduction in both maternal and neonatal mortality (p=0.026 and p=0.011, respectively). A subgroup analysis of the four studies in which at least 30% of pregnant women participated in groups showed a 55% reduction in maternal mortality (0.45, 0.17-0.73) and a 33% reduction in neonatal mortality (0.67, 0.59-0.74). The intervention was cost effective by WHO standards and could save an estimated 283,000 newborn infants and 41,100 mothers per year if implemented in rural areas of 74 Countdown countries.
  
  
  CONCLUSIONS
  With 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.
  
  
  BACKGROUND
  Wellcome Trust, Ammalife, and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Birmingham and the Black Country programme.
authors.affiliation: Institute for Global Health, University College London, London, UK. audrey.prost@ucl.ac.uk
authors.forename: Audrey
authors.initials: A
authors.lastname: Prost
authors.forename: Tim
authors.initials: T
authors.lastname: Colbourn
authors.forename: Nadine
authors.initials: N
authors.lastname: Seward
authors.forename: Kishwar
authors.initials: K
authors.lastname: Azad
authors.forename: Arri
authors.initials: A
authors.lastname: Coomarasamy
authors.forename: Andrew
authors.initials: A
authors.lastname: Copas
authors.forename: Tanja A J
authors.initials: TA
authors.lastname: Houweling
authors.forename: Edward
authors.initials: E
authors.lastname: Fottrell
authors.forename: Abdul
authors.initials: A
authors.lastname: Kuddus
authors.forename: Sonia
authors.initials: S
authors.lastname: Lewycka
authors.forename: Christine
authors.initials: C
authors.lastname: MacArthur
authors.forename: Dharma
authors.initials: D
authors.lastname: Manandhar
authors.forename: Joanna
authors.initials: J
authors.lastname: Morrison
authors.forename: Charles
authors.initials: C
authors.lastname: Mwansambo
authors.forename: Nirmala
authors.initials: N
authors.lastname: Nair
authors.forename: Bejoy
authors.initials: B
authors.lastname: Nambiar
authors.forename: David
authors.initials: D
authors.lastname: Osrin
authors.forename: Christina
authors.initials: C
authors.lastname: Pagel
authors.forename: Tambosi
authors.initials: T
authors.lastname: Phiri
authors.forename: Anni-Maria
authors.initials: AM
authors.lastname: Pulkki-Brännström
authors.forename: Mikey
authors.initials: M
authors.lastname: Rosato
authors.forename: Jolene
authors.initials: J
authors.lastname: Skordis-Worrall
authors.forename: Naomi
authors.initials: N
authors.lastname: Saville
authors.forename: Neena Shah
authors.initials: NS
authors.lastname: More
authors.forename: Bhim
authors.initials: B
authors.lastname: Shrestha
authors.forename: Prasanta
authors.initials: P
authors.lastname: Tripathy
authors.forename: Amie
authors.initials: A
authors.lastname: Wilson
authors.forename: Anthony
authors.initials: A
authors.lastname: Costello
mesh_terms: D000293:Adolescent; D000328:Adult; D003256:Community Participation; D055812:Community-Based Participatory Research; D003362:Cost-Benefit Analysis; D003906:Developing Countries; D005260:Female; D015438:Health Behavior; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D057194:Intention to Treat Analysis; D008428:Maternal Mortality; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic; D050497:Stillbirth / Q000453:epidemiology*; D055815:Young Adult