May 21, 2019

Engaging communities to build awareness and agency in pre-eclampsia and maternal health

By Pooja Sripad

Engaging women in their communities through group-based maternal health care increases their agency to seek necessary antenatal, childbirth and postnatal care. It stimulates collective learning, promotes involvement of community members and builds social support networks at pivotal points in their lives. Researchers have documented that these groups are effective in improving health literacy, better birth preparedness, improved access to care, better nutrition and health promoting behaviors, and positive outcomes for women and newborns in low- and middle-income countries (LMICs)[1],[2],[3]. These groups vary from group-antenatal care (ANC) models to community-based primary health care strategies to informal local women’s groups. Facilitators include providers from various levels within the health system, including community health and social workers with some supplemental training.

Regardless of the differences, women and care providers agree that community engagement models can overcome health systems deficiencies and empower women to experience better quality care.

Group-based strategies offer unique promise to women and communities to recognize and act upon danger signs and symptoms of maternal complications like hypertensive disorders in pregnancy, including pre-eclampsia and eclampsia (PE/E). Beyond bringing PE/E treatment and referral closer to communities in which women live, studies from Nigeria and Pakistan under the Ending Eclampsia project assess how formal and informal community engagement mechanisms influence PE/E awareness and use of maternal health care. The research explores how community-facility linkages function from the perspectives of women, community-based educators (Lady Health Workers in Pakistan and women’s group leaders in Nigeria), and service providers (community midwives at in Pakistan and community health extension workers and nurses in Nigeria).

Preliminary findings from Cross River State in Nigeria suggest that women’s groups can strengthen awareness around the possible consequences of high blood pressure (BP) during pregnancy. They also show that women’s groups (1) promote early ANC registration and routine and non-routine, symptom driven care-seeking and (2) increase the number of women asking health-related questions during their ANC visits at primary health centers. Training local women leaders transforms existing social groups into educational platforms for women; spreading awareness through these informal peer-networks reaches the broader community that influences Nigerian women’s care-seeking.

Preliminary findings from Sindh, Pakistan show that a formal group-ANC model can link health worker cadres from different tiers of the health system, and gradually increase women’s agency to seek maternal health care, especially in the context of pre-eclampsia. Not only did women find group-ANC to offer social support and encouragement, perspectives of community men reveal greater awareness of the importance of ANC and PNC in intervention areas. Given the gendered household context described by the study sample, in which husbands and mothers-in-law often decide when and where to seek care for maternal complications and/or routine ANC, the acceptability of community-based educators and health providers among men is encouraging.

While community engagement and mobilization activities offer promising and cost-effective solutions[4], qualitative work suggests challenges experienced by the community educators and counselors  – including hostility from some community members, restrictive social norms, and health systems responses need to be considered.

Regardless, engaging women and potentially men through group-based care models, offers an adaptable and promising innovation that can be leveraged by LMICs aspiring to meet the interrelated Sustainable Development Goals of “Good health and Well -being” and “Gender Equality.”

[1] Kearns, A. D., J. M. Caglia, P. Ten Hoope-Bender and A. Langer. 2016. “Antenatal and Postnatal Care: A Review of Innovative Models for Improving Availability, Accessibility, Acceptability and Quality of Services in Low-Resource Settings.” BJOG 123(4):540-8. doi: 10.1111/1471-0528.13818.

[2] Perry, H. B., E. Sacks, M. Schleiff, R. Kumapley, S. Gupta, B. M. Rassekh and P. A. Freeman. 2017. “Comprehensive Review of the Evidence Regarding the Effectiveness of Community-Based Primary Health Care in Improving Maternal, Neonatal and Child Health: 6. Strategies Used by Effective Projects.” J Glob Health 7(1):010906. doi: 10.7189/jogh.07.010906.

[3] Prost, A., T. Colbourn, N. Seward, K. Azad, A. Coomarasamy, A. Copas, T. A. Houweling, E. Fottrell, A. Kuddus, S. Lewycka, C. MacArthur, D. Manandhar, J. Morrison, C. Mwansambo, N. Nair, B. Nambiar, D. Osrin, C. Pagel, T. Phiri, A. M. Pulkki-Brannstrom, M. Rosato, J. Skordis-Worrall, N. Saville, N. S. More, B. Shrestha, P. Tripathy, A. Wilson and A. Costello. 2013. “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 381(9879):1736-46. doi: 10.1016/S0140-6736(13)60685-6.

[4] Mangham-Jefferies, L., C. Pitt, S. Cousens, A. Mills and J. Schellenberg. 2014. “Cost-Effectiveness of Strategies to Improve the Utilization and Provision of Maternal and Newborn Health Care in Low-Income and Lower-Middle-Income Countries: A Systematic Review.” BMC Pregnancy Childbirth 14:243. doi: 10.1186/1471-2393-14-243.