Improving maternity care through women’s groups: The Green Tara project
Green Tara Trust, UK- Dr. Jane Stephens (Karunamati), Collette Fanning (Padmadharini), Dr. Maria Antoniou,
Green Tara Nepal- Dr. Bibha Simkhada, Sarita Khadka, Ram Chandra Silwal
University of Sheffield- Dr. Padam Simkhada
University of Bournemouth- Dr. Sheetal Sharma, Prof. Dr. Edwin van Teijlingen
Green Tara Trust is a UK-based Buddhist non-governmental organisation (NGO). In rural Nepal, via its ‘sister’ NGO, Green Tara Nepal aims to deliver a range of programmes, using different health promotion methods. Appropriate interventions are trialled and evaluated within rural communities to help determine what works best for whom and contribute to evidence-base health implementation in Nepal. Green Tara realised two-decades ago that countries of the South are dependent on aid first Northern hemisphere countries with dictates how programmes are run. This situation requires political change. Secondly, Green Tara is aware that such a change is not likely to occur in the near future, hence the immediate aim to improve the lives of people within the current global structure. Therefore, Green Tara designed an intervention that aimed to: (a) empower women to make their own health decisions; (b) improve neonatal care practices; and (c) improve maternal care practices (for more details see Table 1).1
Table 1: Underlying philosophy of the Green Tara programme
|1. Community-based intervention/ programme.
2. Culturally appropriate.
3. Women-centred, but work with mothers in law/husbands who can be barriers.
6. Make best use of existing resources, both from government and NGOs locally.
7. Low cost.
8. Involve stakeholders at all stages to maximise chances of sustainability.
The intervention focused on two rural Village Development Committee (VDCs), 20 km south-west from Kathmandu. These were typical VDCs in Kathmandu Valley, which are relatively under-developed but slightly more developed than the average VDC in rural Nepal. A control community with similarly- matched indicators (caste distribution and socio-economic status) was chosen to the northeast of Kathmandu, and both communities were evaluated in 2008, 2010 and 2012.
The Green Tara health promotion intervention included the involvement and mobilisation of the local community. Local Green Tara staff participated in nine mass health education events on days of religious festivals and helped organise street drama. Health promotion activities were was implemented in 60 groups (reaching over 2000 people) and visited 134 households to support women in need who were unable to attend groups About 32 group meetings were conducted each month. Annually, on average 600 women benefited each year. In addition, staff regularly provided technical assistance, support and training to PHC/ORC in four localities.
The intervention started with a community-based needs assessment, social mapping and consultation with local stakeholders and policy makers and participatory activity.1 The local needs assessment included several postgraduate research projects supervised by the authors.2-3 These UK-university projects offered the Green Tara project high quality local research (provided strategies, based on the evidence of the locally conducted research), which was largely unfunded. In this case both the students and the community benefitted from the research. Where possible throughout the life of the programme, Green Tara incorporated the diverse/changing needs of the local communities and made best use of the existing resources whether these were delivered by the government or by NGOs. Helping to improve the local maternity service provision and advocate its uptake makes it much more likely that the intervention becomes sustainable compared to the introduction of an expensive external intervention which is new to the community.
Local traditional healers were trained as they were key decision-makers and often the first point of contact in case of any illness among in women and children. To promote essential newborn care baby blankets were distributed to pregnant women in their 9th month if they had attended 4 or more antenatal check- ups. Local health facilities were closely supported by Green Tara health promoters (also trained to ANM level of above) to deliver antenatal outreach clinics on the back of immunization clinics to run primary health care outreach clinics (PHC/ORCs) to encourage pregnant women those who have difficulties visiting the sub-health posts every month due to the distance and time away from house and field chores.
Working with Government agencies
Green Tara worked with local government agencies and well as with the national government. At the local and regional level it made the commitment to keep its stakeholders informed throughout the project duration. Prior to starting any work, we arranged meetings with community groups, the local health post staff, the District Public Health Office, the chairs of the relevant VDCs and other active local organisations. This was then common practice to conduct a number of focus group discussions across different community groups prior to a more in depth qualitative and quantitative assessment. We had regular formal and informal meetings with various local stakeholders throughout the programme to assess impact, problems and to adjust the programme delivery where necessary, as well as to encourage participation.4This pro-active approach helped to establish whether key staff members were still in place or had changed, and what their priorities were.
At the national level, Green Tara advocates health promotion. It facilitated a national network and as part of the bigger picture raised the idea of running the first ever National Health Promotion Conference in Nepal (March 2013 with 29 partners and more than 250 participants). It was a great success, with the Ministry of Health in consideration of incorporating health promotion into their activities with discussion of 4 key note speeches, 12 plenary papers, 76 scientific papers and skill building session. This has helped to highlight the key players in health promotion in Nepal and where the gaps are.
Manju KC, Female Community Health Volunteer (FCHV), Daxinkali VDC-6
Manju K.C., 31 years, has been an FCHV for 11 years. She is engaged at gathering people together and in communicating with them on many health issues, including women and children’s health. As an FCHV she also distributes medicine for diarrhoea, and fever so on to the community.
If she finds a pregnant woman then she invites her to attend a new mother’s group meeting. She says, “At first it was very difficult to invite the mothers in to the meeting and nobody used to come. Pregnant women also did not want to go for antenatal care (ANC) check-up. The community women’s behaviour in seeking health services has changed after Green Tara started to work in this VDC. The women are very positive toward us now, they are regularly coming to meetings, going for ANC service check-ups and institutional delivery has also increased.” So Manju feels that Green Tara has played a vital role in improving the health seeking behaviour of people in this community.
Ratnamaya Participates in Group
Ratnamaya Waiba of Chhaimale VDC-5 is now 24 years old and has 2 children; a 6 yrs. old daughter and 1 yr. old son. She had no ANC check-up in her last pregnancy as she did not know the importance. In her second pregnancy she joined the group, and this resulted in her going for ANC check-ups and she obtained a safe delivery kit. She says “as a result of joining the group, I have learned a lot about how to care for my child, and it was much easier for me than the last pregnancy.”She says she is very enthusiastic to learn new things and has been attending the group meeting regularly for the last 19 months.
Seeking Prompt Care Saves Sabitri’s Life
Sabitri is a 34 year old woman from Chhaimale. She has a 17-year-old son and recently decided to have a second child. She had been attending Green Tara Trust’s health promotion group monthly for 4 years, and during her pregnancy, followed the advice suggested by the health promoters e.g. avoiding heavy work, taking iron folic acid, and having antenatal checks. However, two weeks before her delivery date, Sabitri began experiencing pain. She felt the baby was not moving and so visited a doctor at the community hospital. As a result of her participation in the health group, Sabitri was aware of the danger signs in pregnancy and had got some money together in case there was an emergency; in Nepal, families have to pay costs associated with visits to hospital, and this is often why pregnant women don’t receive the urgent care they need. Visiting hospital is a significant change for women in these communities, since Green Tara Trust began working there. As her pain increased, Sabitri was taken to another hospital where comprehensive emergency obstetric care services were available. There, it was discovered that the condition of the baby was critical and she was admitted for close observation. Over the next 4 days, Sabitri’s health deteriorated and became life-threatening. Doctors performed an emergency cesarean section. Unfortunately, the baby did not live, but Sabtiri survived and is doing well. If she had not accessed care, Sabitiri would inevitably have died in childbirth. She says “Because of the information in the group, and the preparation of money for emergency, I received a new life. If I had not done this, I would have died.” She is grateful to Green Tara staff and supporters.
How is the Green Tara project different?
Our project was thoroughly planned. It used a combination of health promotion theory to help design the intervention, whilst at the same time ensuring that we involved the local stakeholders to ensure that whatever we came up with as the intervention ingredient was acceptable to the local community, especially the women and their families. If what we tried was unsuccessful it was easy to change things quickly. This may be harder to do in a larger organisation or if an organisation, due to pressure from funders, is required to deliver a programme in a set way.
Many health promotion interventions conduct small-scale process evaluations, or compare their own results to national level data. Table 2 gives an example of some of the key changes in behavioural outcomes. The Green Tara programme is more rigorous and used a control before-and-after-study design.5 This design enabled us to be more certain that the improvements we detected through the research are real rather that some of these would have happened over time anyway. As you can see form the table below, all behaviours improved significantly more in the intervention area compared to the control area, apart from tetanus toxoid vaccination. The latter was a national health programme rolled out by central Government, and so we can assume the increase in both areas is due to this. This also shows the benefit of having a control area.
Table 2: Major changes in Maternal, Neonatal & Child Health behaviours
|Women took iron during pregnancy||86.5%||95.5%||76%||79.3%|
|Seeking health care during pregnancy||84.6%||98%||80.4%||88.7%|
|Receiving post natal care||51.4%||85.4%||42.6%||72.3%|
|Receiving essential newborn care (properly wrapping babies)||4.9%||32.4%||11%||9.3%|
|Use of contraception||4.3%||24.6%||6.4%||16.9%|
- van Teijlingen E, Simkhada P, Stephen J, Simkhada B, Woodes Rogers S, Sharma S (2012) Making the best use of all resources: developing a health promotion intervention in rural Nepal. Health Renaissance 10(3): 229-35.
- Dhakal S, van Teijlingen E,Simkhada P, Dhakal KB, Stephens J, Chapman G, Raja AE (2011) Antenatal care among women in rural Nepal: A community-based study. Online J Rural Nurs Health Care 11(2): 76-87.
- Simkhada B, Porter M, van Teijlingen E (2010) The role of mothers-in-law in antenatal care decision-making in Nepal: A qualitative study. BMC Pregnancy & Childbirth 10(34).
- van Teijlingen E, Simkhada P, Stephen J (2013) Doing focus groups in the health field: Some lessons from Nepal, Health Prospect 12(1): 15-7.
- Sharma S, van Teijlingen E, Hundley V, Stephens J, Simkhada P, Angell C,Sicuri E, Belizan JM (2013) Mixed-methods evaluation of a maternity care intervention in rural Nepal: measuring what works, Poster P.2.3.004 (A), Trop Med Int Health 18(Suppl. 1): 183-4.