• Audrey Prost, Tim Colbourn, Nadine Seward, Kishwar Azad, Arri Coomarasamy, Andrew Copas, Tanja A J Houweling, Edward Fottrell, Abdul Kuddus, Sonia Lewycka, Christine MacArthur, Dharma Manandhar, Joanna Morrison, Charles Mwansambo, Nirmala Nair, Bejoy Nambiar, David Osrin, Christina Pagel, Tambosi Phiri, Anni-Maria Pulkki-Brännström, Mikey Rosato, Jolene Skordis-Worrall, Naomi Saville, Neena Shah More, Bhim Shrestha, Prasanta Tripathy, Amie Wilson, and Anthony Costello.
• Institute for Global Health, University College London, London, UK. audrey.prost@ucl.ac.uk
• Lancet. 2013 May 18; 381 (9879): 1736-46.

BackgroundMaternal 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.MethodsWe 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.FindingsSeven 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.InterpretationWith 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.FundingWellcome Trust, Ammalife, and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Birmingham and the Black Country programme.Copyright © 2013 Elsevier Ltd. All rights reserved.

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