Beyond Mortality Statistics: A Detailed Look at the Community Mobilization Process of the Emergency Obstetric and Neonatal Care Trial in Nagpur, India

Abstract

In many countries a high percentage of women still die during childbirth, and many children do not survive past the neonatal period. The NIH-funded Emergency Obstetric and Neonatal Care (EmONC) trial was a multi-site randomized control trial aimed at reducing maternal and neonatal mortality and morbidity by improving access to quality services. In order to achieve this goal, community facilitators in intervention groups received trainings on approaches for increasing local engagement with these issues. These facilitators were then responsible for carrying out phase-wise meetings with local stakeholders to help them strategize about how to address the most pressing maternal and neonatal health concerns of their communities. Nagpur region, in central India, was the most active of the trial sites. Although no statistically significant improvements in mortality and morbidity were observed in any of the trial sites, Nagpur serves as an excellent foundation for understanding the broader role of community mobilization in health behavior. To that end, this study used a combination of existing qualitative meeting data from 800 community meeting logs and 211 strategic plans across the 10 EmONC intervention clusters in the Nagpur region, data collected through key informant interviews with EmONC program staff, and data collected through focus group discussions with community facilitators and community health workers in five of the ten EmONC intervention clusters to take a more nuanced look at the community mobilization component of the EmONC trial, and to understand the ways in which participation in the EmONC trial impacted those who participated. In Nagpur, 1095 core community groups were formed, and 12,204 meetings were held, which were facilitated by 211 community health facilitators (CHFs). Overall, the community meetings were well attended, with anywhere between 6 to 20+ participants, but male participation was low (3% of all participants). The major maternal problems prioritized by the communities were postpartum and antepartum hemorrhage (85%), pre-eclampsia/eclapmsia (65%) and obstructed labor (10%), while the major neonatal problems prioritized were respiratory distress/asphyxia (37%), seizures (26%), and low birth-weight/prematurity (30%). The majority of communities felt that financial, educational and cultural barriers were the primary barriers to improving conditions, and that increased community savings through the creation of pooled emergency transport funds and awareness-raising about the value of individual savings, improved earlier recognition of problems through education, and increased provision of emergency transportation via contracting of private vehicles and provision of driver’s contact information were key tactics to decreasing maternal and neonatal mortality. While the strategies devised by the communities were often broad, predominantly focused on awareness-raising, and not directly linked to the problems or goals articulated, it was clear from these meetings that the community was attuned to their problems, engaged with them, and capable of thinking strategically about how to mobilize their own resources to solve them. These preliminary findings indicate that many of the community groups were successful empowered to meet the goals of the community mobilization process as articulated by the EmONC research team. Future research will be necessary to explore the full extent to which the community strategies were actualized, and the impact that the community meetings may have had on both those who did and did not participate directly in them.