Table Of ContentScaling up community mobilisation through
women's groups for maternal and neonatal
health: experiences from rural Bangladesh
Nahar et al.
Naharetal.BMCPregnancyandChildbirth2012,12:5
http://www.biomedcentral.com/1471-2393/12/5(24January2012)
Naharetal.BMCPregnancyandChildbirth2012,12:5
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RESEARCH ARTICLE Open Access
Scaling up community mobilisation through
’
women s groups for maternal and neonatal
health: experiences from rural Bangladesh
Tasmin Nahar1, Kishwar Azad1, Bedowra Haq Aumon1, Layla Younes2, Sanjit Shaha1, Abdul Kuddus1, Audrey Prost2,
Tanja AJ Houweling2,3, Anthony Costello2 and Edward Fottrell2*
Abstract
Background: Program coverage is likely to be an important determinant of the effectiveness of community
interventions to reduce neonatal mortality. Rigorous examination and documentation of methods to scale-up
interventions and measure coverage are scarce, however. To address this knowledge gap, this paper describes the
process and measurement of scaling-up coverage of a community mobilisation intervention for maternal, child and
neonatal health in rural Bangladesh and critiques this real-life experience in relation to available literature on
scaling-up.
Methods: Scale-up activities took place in nine unions in rural Bangladesh. Recruitment and training of those who
deliver the intervention, communication and engagement with the community and other stakeholders and active
dissemination of intervention activities are described. Process evaluation and population survey data are presented
and used to measure coverage and the success of scale-up.
Results: The intervention was scaled-up from 162 women’s groups to 810, representing a five-fold increase in
population coverage. The proportion of women of reproductive age and pregnant women who were engaged in
the intervention increased from 9% and 3%, respectively, to 23% and 29%.
Conclusions: Examination and documentation of how scaling-up was successfully initiated, led, managed and
monitored in rural Bangladesh provide a deeper knowledge base and valuable lessons.
Strong operational capabilities and institutional knowledge of the implementing organisation were critical to the
success of scale-up. It was possible to increase community engagement with the intervention without financial
incentives and without an increase in managerial staff. Monitoring and feedback systems that allow for periodic
programme corrections and continued innovation are central to successful scale-up and require programmatic and
operational flexibility.
Background proportion of all under-five deaths [2-5]. In Bangladesh,
In line with Millennium Development Goal (MDG) 4, around 85% of births occur at home, 57% of all under-
many countries are on track to reduce under-five mor- five deaths are in the first month of life and the neona-
tality by two thirds from 1990 levels by 2015 [1]. This tal mortality rate remains high at 37 per 1000 live births
progress has not been uniform for all under-five age [6].
groups, however. Neonatal mortality has been relatively Tackling the burden of neonatal deaths, particularly
resistant to change and the 3.7 million neonatal deaths deaths in the first twenty-four hours of life, requires
that occur annually worldwide account for an increasing community-based interventions to improve the supply
and demand for maternal and neonatal health care and
*Correspondence:[email protected] the use of safe home-delivery and newborn care prac-
2UCLCentreforInternationalHealthandDevelopment,InstituteofChild tices that can prevent neonatal deaths [7-9]. Several stu-
Health,UniversityCollegeLondon,30GuilfordStreet,London,WC1N1EH,
dies provide encouraging evidence on how home visits
UK
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AttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,andreproductionin
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or community mobilisation with concurrent health ser- unions (the lowest-level administrative level in rural
vices strengthening can improve maternal and neonatal Bangladesh). These unions are located within three dis-
health in South Asia [10,11]. Sustaining and scaling-up tricts of Bangladesh (Bogra, Molavibazar and Faridpur)
interventions to increase coverage remain critical which were selected on the basis of having active Dia-
challenges. betic Association of Bangladesh (BADAS) offices. The
Low-cost, participatory, community-based approaches majority of the population in the selected areas is Mus-
involvingwomen’sgroupsareeffectiveatimprovinghome lim (> 80%), with most of the remainder being Hindu
delivery practices and birth outcomes in a range of set- [7]. Most women deliver at home (> 90%) and approxi-
tings. The women’s group method significantly reduced mately 50% of mothers in the selected areas have no
neonatal mortality by 30% and 45% in Nepal and India, formal education or only primary education [7]. Physical
respectively, and improved hygienic home delivery prac- geography in the three intervention districts, including
tices and newborn care in Bangladesh, though it did not vulnerability to flooding, contributes to poor communi-
have an impact on neonatal mortality overall [7,12,13]. cations and limited access to good quality health care.
Intervention coverage was one women’s group per 756
population and one per 468 population in Nepal and Intervention
India,respectively[7].Thepercentageofwomenwhogave The intervention is a cycle of monthly women’s group
birthandreportedattendingwomen’sgroupswasaround meetings on maternal and newborn health and, subse-
30% to 45% inIndia and 50% inNepal [12,13]. Coverage quently, on under-5 and women’s health. A salaried
inBangladeshwasmuchloweratonewomen’sgroupper facilitator guides the women’s groups through a partici-
1414populationandtheproportionofwomenwhodeliv- patory learning and action cycle [20], in which she leads
eredandreportedattendingwomen’sgroupswas3%,with and supports the groups to identify and prioritise their
just9%ofwomenofreproductiveagebecomingwomen’s health problems, plan strategies to address them, and
groupmembers[7]. implement and evaluate these strategies (Figure 1). All
Program coverage has been observed to be an inde- meetings are facilitated with the use of picture cards
pendent determinant of neonatal mortality, even when and flip charts that convey simple health messages and
adjusted for type of intervention and baseline mortality preventative strategies. This intervention content was
levels [14]. For community-based interventions to have derived from successful trials in Nepal [12] and India
a substantial impact on birth outcomes, therefore, it is [13] as well as key health issues in Bangladesh. Details
necessary to have a large enough population coverage of the content and delivery of the intervention are pro-
over a sustained period [14-16]. We hypothesise that the vided elsewhere [21]. Community meetings encourage
women’s group intervention in Bangladesh did not show the participation and support of the wider community
an impact on neonatal mortality because of its relatively in the development and implementation of strategies.
low coverage relative to that used in India and Nepal. Day-to-day implementation of the intervention is decen-
For this reason, we increased the coverage in the same tralised from Dhaka headquarters to district offices. The
geographical areas and the percentage of women in approximate direct costs of each meeting (i.e. the facili-
reproductive age and pregnant women exposed to the tator, travel and meeting materials) is between 500 and
intervention. The impact of this scaled-up delivery of 1000 Bangladeshi Taka (approximately USD 6 to 13 on
the intervention is the subject of an ongoing cluster ran- 16th December 2011).
domised controlled trial detailed elsewhere [17].
Scaling-up is frequently discussed but seldom analysed Recruitment and training
or rigorously studied [18] yet examination and docu- Figure 1 illustrates the scale-up process. With nine facil-
mentation of how scaling-up experiences are initiated, itators already active in the intervention areas, a further
led, managed and monitored provide a deeper knowl- 36 facilitators were recruited in 2008 to increase popula-
edge base and valuable lessons [19]. This paper details tion coverage and intensity in the same areas. In recog-
experiences in our expansion of women’s groups in Ban- nition of cultural norms thought to be essential for the
gladesh. We emphasise the importance of monitoring effective delivery of the intervention, recruitment criteria
and evaluating the success of scale-up in relation to spe- specified that facilitators should be married women with
cific targets, with practical examples of how this may be at least one and a half years of experience in community
done in resource-poor settings. work and a minimum of 12 years of schooling. To
enhance acceptance in the community, facilitators had
Methods to live in the local area and be familiar with local cul-
Setting and context ture and customs.
Following from a previous cluster randomised trial [7], Facilitators received seven days of training in facilita-
scale-up activities were based in nine previously selected tion techniques, community mobilisation and
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Figure1Schematicillustrationofthescale-upprocess,theparticipatoryactioncycleinterventionandcomponentsofmonitoringand
evaluatingthesuccessofscale-up.
participatory and communication skills. They were also Community orientation
trained in the use of picture cards and flip charts to Followingmapping,informalmeetingswereheldbetween
convey simple messages and stimulate discussion. Based project staff and community members to build rapport
on field observations and facilitators’ requests, refresher andtomotivatelocalleaderstosupporttheintervention.
training was given six months after initial training. Fre- Thesemeetingsexplainedtheinterventionobjectives, the
quent supervision by senior project staff provided on- role of facilitators and how the women’s groups might
going feedback and opportunities to review the status of work alongside local resources to improve maternal and
facilitators’ work and intervention delivery. Particular neonatal health. The orientation meetings were also an
emphasis was given to facilitators to motivate and opportunitytoidentifywomeninterestedinparticipation
involve newly pregnant and reproductive-aged women in the women’s group meetings. A subsequent round of
in the women’s group intervention. householdvisitswasconductedtoensurethatallwomen
Under the supervision of nine coordinators, the 45 ofreproductiveageandpregnant womeninthecommu-
facilitators catalysed community mobilisation, each run- nitywereinformedaboutthewomen’sgroupintervention.
ning 18 women’s groups in a month. They also liaised Newly formed women’s groups met for the first time in
with community leaders, non-governmental organisa- January 2009andbegan a 30-monthparticipatory action
tions and other community based organisations and cycleonmaternalandneonatalhealth.
health care providers.
Group membership and participation
Mapping Women’s group members are registered volunteers who
Using structured guidelines, local youth volunteers car- should be ever-married women of reproductive age and
ried out village mapping. This included identification of are expected to directly participate in the women’s
existing women’s groups and maternal and neonatal group’s activities and lead the implementation of strate-
health projects run by other organisations in the inter- gies. There is a maximum of around 25 members per
vention unions, health care providers, trained and un- women’s group. However, every women’s group meeting
trained traditional birth attendants and non-governmen- is open to participation by non-members from the com-
tal organisations. Mapping also identified key local lea- munity, including men, who are interested in the meet-
ders for intervention initiatives. The facilitators ing content but are unwilling or unable to volunteer as
conducted initial household visits to identify women of women’s group members. These non-member partici-
reproductive age and pregnant women, explained the pants are considered crucial to the community-wide
intervention objectives to them and encouraged them to acceptance, dissemination and broad participatory nat-
participate in women’s group activities. ure of the intervention.
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Targeted participation and dissemination groups’ members to gather data on their age and back-
Participation among women of reproductive age and ground characteristics. All household, surveillance and
pregnant women in women’s groups is a crucial factor process evaluation data were subject to field quality con-
for an effect on health and healthy practices, yet house- trol procedures before being entered, verified and stored
hold responsibilities and cultural restrictions on in electronic databases.
women’s ability to freely attend meetings are a barrier Data from the community-based surveillance and pro-
in many areas. As such, explicit strategies were cess evaluation systems collected between January 2009
employed to attract women of reproductive age, preg- and June 2010 as well as data from the household-listing
nant or newly married women to groups. These strate- survey conducted in 2009 were used to calculate inter-
gies included asking women at meetings to volunteer vention coverage. Total population coverage was calcu-
their pregnancy status and to identify anybody who they lated by dividing the total population in the intervention
knew to be pregnant or newly married in the commu- areas from the household listing by the total number of
nity. Traditional birth attendants, community health women’s groups. Similarly, the intervention’s coverage
workers and community nutrition workers were also of reproductive-aged women is calculated by dividing
asked to inform facilitators if they were aware of women the number of women of reproductive age in the inter-
who might benefit from the intervention. Facilitators vention areas from the household listing by the number
then visited these women in their homes and explained of women’s groups.
to them and influential family members (e.g. mothers- To calculate the proportion of women of reproductive
in-law, elders and husbands) the nature and objectives age who are women’s group members, the number of
of the women’s groups, encouraging them to participate. ever-married women’s group members in reproductive
Women who remained unable or unwilling to partici- age from the 2009 process evaluation socio-economic
pate were offered home visits by women’s group mem- survey was divided by the number of ever-married
bers or facilitators to share key health messages and women of reproductive age in the intervention areas
discussion topics raised during the meetings, which from the household listing. The intervention’s coverage
allowed diffusion of information. of pregnant women was estimated using the commu-
Participation of young, newly married or pregnant nity-surveillance data by dividing the number of deliv-
women in the women’s groups was difficult in some eries to women that attend women groups by the
areas where traditional and conservative attitudes prevail number of deliveries in intervention areas.
or where there was resistance among influential com- Intervention dosage received at the population level
munity and religious leaders to the concept of women’s was calculated by dividing the number of meetings actu-
groups. Several meetings between senior project staff ally attended by each group member by the total num-
and these community and religious leaders gradually ber of meetings implemented as part of the participatory
broke down barriers, to some extent, with one particular action cycle intervention.
success resulting in recommendations from a local
Imam during religious services that people in the com- Ethical approval
munity should attend the groups. Scale-up and the evaluation of its impact was approved
by the University College London Research Ethics Com-
Measuring scale-up mittee (ID Number: 1488/001) and by the Ethical
An annual household listing is conducted in all study Review Committee of the Diabetic Association of Ban-
areas to provide information on the total population gladesh. Informed verbal consent from the interviewee
and age and sex distributions. In addition, a prospective was obtained before any data were collected.
community-based surveillance system of all births and
maternal and neonatal deaths has been operational in Results
study areas since 2004 [7,22]; all women who deliver in Recruitment and training were considered successful
the study areas are interviewed about their pregnancy and facilitators’ skills in leading women’s group meet-
and delivery experiences, including any participation in ings generally improved over time. There were some dif-
women’s groups. Simultaneously, a process evaluation ficulties in meeting education and marital status criteria
system gathered information on the delivery and receipt for recruitment due in part to household responsibilities,
of the women’s group intervention. Structured forms and the lack of availability of educated women, who
were used in the process evaluation by facilitators to were often engaged in better-paid jobs or positions
prospectively capture information on attendance at offering greater benefits. Staff turnover was reasonably
women’s group meetings and the pregnancy status of all high, with 18 out of the 36 recruited facilitators resign-
participants. In 2009, a one-off socio-economic and ing. Turnover mainly occurred in the first three months
demographic survey was conducted with women’s following recruitment and was primarily due to issues of
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family constraints on freedom of movement or offers of
(cid:1007)(cid:1004)
more competitive employment opportunities. This led
to a revision of recruitment strategies, in that shortlisted (cid:1006)(cid:1009)
cseanvednidadteasyswobrkeefodrien tohfeficfiiealldlyonbeainvoglunaptaproyinbatesids foasr (cid:374)(cid:282)(cid:286)(cid:396)(cid:400)(cid:1006)(cid:1004)
facilitators. (cid:381)(cid:296)(cid:3)(cid:258)(cid:410)(cid:410)(cid:286)(cid:1005)(cid:1009) (cid:68)(cid:381)(cid:437)(cid:367)(cid:258)(cid:448)(cid:349)(cid:271)(cid:258)(cid:460)(cid:258)(cid:396)
In a population of 243,341 people in the nine inter- (cid:271)(cid:286)(cid:396)(cid:3)(cid:271) (cid:17)(cid:381)(cid:336)(cid:336)(cid:396)(cid:258)
vention unions, 648 new women’s groups were added (cid:69)(cid:437)(cid:373)(cid:1005)(cid:1004) (cid:38)(cid:258)(cid:396)(cid:349)(cid:282)(cid:393)(cid:437)(cid:396)(cid:3)
to the pre-scale-up 162 groups. All 810 groups con- (cid:1009)
tinue to run to date. The population coverage is esti-
mated at one women’s group per 300 population (cid:1004)
(cid:1005) (cid:1006) (cid:1007) (cid:1008) (cid:1009) (cid:1010) (cid:1011) (cid:1012) (cid:1013) (cid:1005)(cid:1004) (cid:1005)(cid:1005) (cid:1005)(cid:1006) (cid:1005)(cid:1007) (cid:1005)(cid:1008) (cid:1005)(cid:1009) (cid:1005)(cid:1010) (cid:1005)(cid:1011) (cid:1005)(cid:1012)
(Table 1), an approximately five-fold increase in cover- (cid:116)(cid:381)(cid:373)(cid:286)(cid:374)(cid:918)(cid:400)(cid:3)(cid:39)(cid:396)(cid:381)(cid:437)(cid:393)(cid:3)(cid:68)(cid:286)(cid:286)(cid:410)(cid:349)(cid:374)(cid:336)(cid:3)(cid:894)(cid:373)(cid:381)(cid:374)(cid:410)(cid:346)(cid:895)
age relative to pre-scale-up levels. Following scale up, Figure 2 Average attendance of participants (members and
there is approximately one women’s group per 57 non-members)atwomen’sgroupmeetingsbydistrictin
interventionareas.
ever-married women of reproductive age, compared to
one group per 283 prior to scale-up and 23% of the
45,820 ever-married women in reproductive age living We showed an approximately five-fold increase in popu-
in the intervention areas are women’s group members. lation coverage, a 2.5-fold increase in the women’s
Approximately 29% of women who gave birth and group membership among women of reproductive age
were interviewed as part of the community-surveillance and a 10-fold increase in the proportion of women who
system during the period January 2009 to June 2010 gave birth and reported attending a women’s group.
reported attending women’s groups, compared to 3% Scale-up was achieved without financial incentives for
prior to scale-up. Average attendance at each women’s women and without any increase in managerial staff.
group meeting in the newly-formed groups is shown in Nevertheless, enhancement of already strong operational
Figure 2. capabilities and institutional knowledge within our Peri-
Intensity of the exposure to the intervention among natal Care Project (PCP) was crucial for the success of
women’s group members in 2009 was estimated at 70%, scale-up. Furthermore, PCP works under the auspices of
meaning that, on average, women’s group members BADAS, whose positive reputation as the largest non-
were exposed to 70% of the intended dosage for 2009, i. governmental healthcare provider in Bangladesh facili-
e. an average of 8 out of 12 meetings were attended. tated acceptance of the intervention.
The specific impact of the scale-up on mortality rates
Discussion
is yet to be determined through an ongoing cluster-ran-
For both women’s groups and community health worker domised trial [17], which includes detailed analysis of
interventions, coverage is thought to be a critical factor process indicators of delivery and receipt of the inter-
for a positive impact on neonatal mortality rates [14]. vention. Nevertheless, documenting the process and suc-
Simple quantitative data indicate considerable success in cess of scale-up is itself important if development
the scale-up of the women’s groups in rural Bangladesh. initiatives are to foster participation and remain
Table 1Population coverage ofthe women’sgroup intervention
CoverageIndicator TOTAL
NumberofWomen’sGroups Pre-scale-up 162
Newlyformed 648
Total 810
Populationin2009 243,341
Ever-marriedwomeninreproductiveagein2009 45,820
PopulationCoverage(Totalpopulation/numberofwomen’sgroups) 300
(2009pre-scale-upvalue) (1502)
Coverageofreproductive-agedwomen(Totalpopulationofever-marriedwomeninreproductiveage/numberofwomen’sgroups) 57
(2009pre-scale-upvalue) (283)
%ofreproductiveaged-womenwhoarewomen’sgroupmembers 23
(2009pre-scale-upvalue) (9)
%deliveriestowomenattendingwomen’sgroups 29
(2009pre-scale-upvalue) (3)
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accountable to communities, and to avoid cumbersome study area and an initial lack of appreciation by project
organisational structures that are detached from their managers for the need for family understanding of facili-
grassroots bases [23]. This paper does not presume to tators’ roles increased vulnerability to staff turnover at
provide the ultimate solution to such challenges, but the beginning of scale-up. This necessitated greater flex-
rather shares experiences of a single intervention in a ibility in recruitment criteria and processes, including a
resource-poor setting. Though limited to just nine probationary period of field exposure, which ultimately
unions in rural Bangladesh, these experiences and the minimised disruption caused by staff turnover. Effective
described principles and processes of scale-up and its systems of supervision, review and refresher training of
measurement are likely to be relevant to the wider project staff are likely to enhance delivery and sustain-
development community, notwithstanding the need for ability of any intervention and therefore the success of
intervention- and context-specific alterations and for any scale-up initiatives.
programme flexibility. Various definitions of scaling-up exist, relating to
Experience of delivery of the intervention on a smaller complexity, impact and interactions with other organisa-
scale enabled PCP to meet the majority of requirements tions, but the concept of scaling-up as expansion of cov-
for successful scale-up as described by Simmons et al. erage is the most common [15,23]. Geographical
(2006)[24] and summarised by Gilson and Schneider expansion is associated with particular challenges such
(2010)[19]. For example, clear messages about the objec- as increasing distance from project headquarters, and
tives and advantages of women’s groups were communi- larger areas and organisational structures to manage.
cated to the community, while mapping exercises, Notwithstanding the introduction of groups into new
household visits and community orientation meetings villages in the existing unions, we did not expand geo-
ensured early involvement through personal contact. graphically. Rather, our experience was an increase in
Similarly, recognition of the importance of locally the intensity of intervention in the same areas to
recruited and trained facilitators to manage groups, the increase population coverage. Some of the issues around
participatory nature of the intervention, and active diffu- effective geographical expansion and increased intensifi-
sion of key messages through household visits and com- cation are the same, however. In each case, scale-up
munity, governmental and non-governmental networks does not mean exact duplication of pre-existing strate-
were central to the scale-up process. Concurrent sys- gies. In our scale-up, lessons were learned from the pre-
tematic monitoring of the process and outcomes of scal- vious, smaller-scale implementation of women’s groups
ing up further met Simmons et al’s (2006)[24] and but existing structures and procedures were not always
Gilson and Schneider’s (2010)[19] recommendations to copied. For example, the schedule of group meetings
use evidence to guide and evaluate scale-up. and content were revised before scale-up to emphasise
The scaling-up process described is a logical sequence participation of women of reproductive age, and espe-
and represents more or less the order in which various cially pregnant women. As a flexible replication of simi-
stages were initiated. In practice, however, the linear lar women’s groups interventions in Nepal and India we
presentation is artificial and it is important to recognise endorse the recommendation that replication as a path
that scaling-up is a dynamic, non-linear, iterative pro- for scaling up is only likely to work if done flexibly [23].
cess whereby the various phases may occur simulta- Strategies to measure the success of scale-up depend
neously, in different orders, have feedback loops and on specific objectives and anticipated outcomes. In rela-
may have to be repeated or revisited [18]. Feedback sys- tion to population coverage or intervention expansion,
tems that allow for periodic programme corrections and specific indicators of success, and how they are mea-
continued innovation are central to successful scale-up sured, are essential. There is no one-size-fits-all strategy
and require managerial flexibility and strategic flair for monitoring and evaluation and different methods
[19,25]. have differing degrees of complexity and resource
Training and capacity building of staff is crucial for a demands [26,27]. Data from three different sources were
thorough understanding of the group process and a used to measure the success of our scale-up, a particular
sense of ownership at the grassroots level. Recruitment strength of this initiative.
and selection of appropriate staff is critical, as are The capacity needed for such monitoring and evalua-
planned strategies to cope with staff turnover. Local tion systems should not be underestimated, however.
recruitment was vital in maintaining effective relation- Complex systems add to the cost of interventions con-
ships with the local community through familiarity with siderably and are vulnerable to the limitations of popu-
local customs, knowledge and beliefs. Recruitment cri- lation survey methods, such as recall and reporting
teria, however, cannot be rigid in areas of low literacy, biases [18,27]. Furthermore, direct measurements of cer-
low education and where there are gender barriers to tain phenomena are not always straightforward or possi-
employment. The resource-poor, rural context of our ble. For example, intervention coverage among pregnant
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women in the women’s group intervention could not be objectively assess the success of wider stakeholder
measured directly as it was not possible to accurately engagement in terms of bridging gaps and influencing
measure the pregnancy status of all reproductive-aged policies, but these efforts are undoubtedly important
women. The proportion of births that occur to women for the acceptability and long-term sustainability of
who report attendance at a women’s group was there- scale-up.
fore used as a proxy measure of coverage among preg-
nant women. This estimation depends on accurate Conclusion
reporting of women’s group attendance and on all preg- Strong operational capabilities, clarity of scale-up and
nancies ending in delivery, which is unlikely to be true. intervention objectives and wide stakeholder engage-
Nevertheless, provided that limitations are acknowl- ment were critical to the successful scaling-up of the
edged and measurement methods are consistent pre- women’s group intervention in rural Bangladesh. It was
and post-scale-up, utilising proxy measures and actual possible to increase community engagement with the
data are more informative than entirely modelled esti- intervention without financial incentives and without an
mates. Alternative methods for estimating coverage of increase in managerial staff. Monitoring and feedback
an intervention among pregnant women with varying systems that allowed periodic programme corrections
degrees of complexity, cost and data demands are and continued innovation were central to successful
described and discussed elsewhere [28]. scale-up and required programmatic and operational
Although the sustainability of women’s groups is yet flexibility.
to be formally evaluated, unpublished data suggest that
a high proportion of groups in Nepal and Malawi are Endnotes
running long after withdrawal of project financial sup- i The definition of ever-married used in this paper
port. Successful delivery of the intervention as planned includes married or divorced but not widowed women.
during the first 18 women’s group meetings may be ii Community nutrition workers have a minimum of 8
considered indicative of institutional sustainability in years of basic schooling and have received 21 days train-
terms of ongoing capacity to lead training, maintain the ing on nutrition and counselling.
infrastructure, equipment and supplies and provide the iii A Good Practice Guide [21] to delivering the
necessary inputs and environment for implementation. women’s group intervention, which may facilitate further
Similarly, fairly consistent attendance levels at the replication and scale-up, is available at: http://www.wcf-
women’s groups (Figure 2) and reasonable population uk.org/knowledge/wcf-publications/45-wcf-publications/
exposure estimates indicate programmatic sustainability 363-good-practice-guide.
from a community participatory perspective. Continued
capacity building of women’s group members, perhaps
ListofAbbreviations
with a focus on facilitation methods for example, may
BADAS:DiabeticAssociationofBangladesh;PCP:PerinatalCareProject;MDG:
obviate the need for paid facilitators and thus enhance MillenniumDevelopmentGoal.
the long-term financial sustainability of the intervention,
Acknowledgements
whilst political sustainability can only be achieved
Scale-upandmonitoringactivitiesarefundedbyaBigLotteryFund
through enhanced communication and advocacy efforts InternationalStrategicGrant.Theauthorswouldalsoliketoacknowledge
at local, national and global levels. contributionstothescale-upprocessandmonitoringactivitiesfromJames
Beard,BiplopBanerjee,SarahBarnett,Md.RezaulAlamChowdhury,Md.
The ability to influence national policy from local
GolamAzamandBeniMadhabChakraborty.
initiatives is therefore a final determinant and indicator
of successful scale-up [23,25]. Before the women’s Authordetails
1PerinatalCareProject,DiabeticAssociationofBangladesh(BADAS),BIRDEM
groups became active, considerable time was spent
122KaziNazrulIslamAvenueShahbagh,Dhaka-1000,Bangladesh.2UCL
identifying available services and other governmental CentreforInternationalHealthandDevelopment,InstituteofChildHealth,
and non-governmental organisations in the selected UniversityCollegeLondon,30GuilfordStreet,London,WC1N1EH,UK.
3DepartmentofPublicHealth,ErasmusMCUniversityMedicalCenter
unions to communicate and build understanding and
Rotterdam,Dr.Molewaterplein50,3015GERotterdam,TheNetherlands.
trust within the local community. These efforts
enhance the participatory nature of scale-up as Authors’contributions
Allauthorscontributedtodraftingandrevisingthemanuscript.Inaddition:
opposed to being purely driven by the implementing
TN-implementationofwomen’sgroups,substantialcontributiontothe
institutions or experts. In the women’s groups, estab- overallscale-upprocess;KA-overallmanagementofthePCPproject,
lishing links with other key players was beneficial in a includingthescale-upprocess,processevaluationandmonitoringprocesses;
BHA-design,managementandinterpretationofprocessevaluationdata
number of ways, not least by involving traditional birth
systems;LY-scale-upandprocessevaluationprocessesandinterpretation
attendants and community health workers in raising ofdata;SS-capture,managementandreportingofmonitoringand
awareness of the intervention among pregnant women evaluatingdataanddataprocesses;AK,AP,THandAC-technicalsupport
toscale-upactivitiesandcriticaloversighttothedocumentation,
encountered during their routine activities. We cannot
Naharetal.BMCPregnancyandChildbirth2012,12:5 Page8of8
http://www.biomedcentral.com/1471-2393/12/5
interpretationandreportingofscaleupandmonitoringprocesses;EF onbirthoutcomesinBangladesh:doescoveragematter?Acluster
oversawtheconceptualdevelopmentofthemanuscript,interpretationand randomisedtrial.Trials2011,12(208).
presentationofresultsandtheoveralldevelopmentandrevisionofthe 18. KohlR:AnAnalyticalFrameworkforScalingUpPilotsinPublicHealth.In
manuscript.Allauthorshavereadandapprovedthefinalmanuscript. FromOnetoMany:ScalingUpHealthProgramsinLowIncomeCountries.
Editedby:CashRA,ChowdhuryAMR,SmithGB,AhmedF.Dhaka:The
Competinginterests UniversityPressLimited;2011:.
Theauthorsdeclarethattheyhavenocompetinginterests. 19. GilsonL,SchneiderH:Managingscalingup:whatarethekeyissues?
HealthPolicyandPlanning2010,25:97-98.
Received:6October2011 Accepted:24January2012 20. O’RourkeK,Howard-GrabmanL,SeoaneG:Impactofcommunity
Published:24January2012 organizationofwomenonperinataloutcomesinruralBolivia.Rev
PanamSaludPublica1998,3(1):9-14.
References 21. GoodPracticeGuide:CommunityMobilisationthroughWomen’sGroups
1. MillenniumDevelopmentGoals.[http://www.un.org/millenniumgoals/]. toImprovetheHealthofMothersandBabies.[http://www.wcf-uk.org/
2. BlackRE,MorrisSS,BryceJ:Whereandwhyare10millionchildrendying programmes/programme-resources].
everyyear?Lancet2003,361(9376):2226-2234. 22. BarnettS,NairN,TripathyP,BorghiJ,RathS,CostelloA:Aprospectivekey
3. LawnJE,GravettMG,NunesTM,RubensCE,StantonC:Globalreporton informantsurveillancesystemtomeasurematernalmortality-findings
pretermbirthandstillbirth(1of7):definitions,descriptionofthe fromindigenouspopulationsinJharkhandandOrissa,India.BMC
burdenandopportunitiestoimprovedata.BMCPregnancyChildbirth PregnancyandChildbirth2008,8(6).
2010,10(Suppl1):S1. 23. UvinP,MillerD:ScalingUp:ThinkingThroughtheIssues.GlobalPolicy
4. LawnJE,CousensS,ZupanJ:4millionneonataldeaths:when?Where? Forum1994.
Why?Lancet2005,365(9462):891-900. 24. SimmonsR,FajansP,GhironL:ScalingupHealthServiceDelivery:From
5. OestergaardMZ,InoueM,YoshidaS,MahananiWR,GoreFM:Neonatal PilotInnovationstoPoliciesandProgrammes.Geneva:Expandnet&
mortalitylevelsfor193countriesin2009withtrendssince1990:A WorldHealthOrganisation;2006.
systematicanalysisofprogress,prjectionsandpriorities.PLoSMedicine 25. BhandariN,KabirAK,SalamMA:Mainstreamingnutritionintomaternal
2011,8(8):e1001080. andchildhealthprogrammes:scalingupofexclusivebreastfeeding.
6. NationalInstituteofPopulationResearchandTraining(NIPORT),Mitraand MaternChildNutr2008,4(Suppl1):5-23.
Associates,MacroInternational:BangladeshDemographicandHealth 26. BoermaJT,StaneckiKA,NewellML,LuoC,BeusenbergM,GarnettGP,
Survey2007.Dhaka,BangladeshandCalvertonMarylandUSA:National LittleK,CallejaJG,CrowleyS,KimJY,etal:Monitoringthescale-upof
InstituteofPopulationResearchandTraining,MitraandAssociates,and antiretroviraltherapyprogrammes:methodstoestimatecoverage.Bull
MacroInternational;2009. WorldHealthOrgan2006,84(2):145-150.
7. AzadK,BarnettS,BanerjeeB,ShahaS,KhanK,RegoAR,BaruaS, 27. RoweAK:Potentialofintegratedcontinuoussurveysandquality
FlatmanD,PagelC,ProstA,etal:Effectofscalingupwomen’sgroupson managementtosupportmonitoring,evaluation,andthescale-upof
birthoutcomesinthreeruraldistrictsinBangladesh:acluster- healthinterventionsindevelopingcountries.AmJTropMedHyg2009,
randomisedcontrolledtrial.Lancet2010,375(9721):1193-1202. 80(6):971-979.
8. RonsmansC,ChowdhuryME,AlamN,KoblinskyM,ElArifeenS:Trendsin 28. YounesL,HouwelingTA,AzadK,CostelloA,FottrellE:Estimating
stillbirths,earlyandlateneonatalmortalityinruralBangladesh:therole coverageofawomen’sgroupinterventionamongapopulationof
ofpublichealthinterventions.PaediatrPerinatEpidemiol2008, pregnantwomeninruralBangladesh.2011,Manuscript.
22(3):269-279.
9. HouwelingTA,CostelloA,OsrinD:Improvingmaternalandnewborn Pre-publicationhistory
survivalthroughcommunityintervention.InTheRoutledgeInternational Thepre-publicationhistoryforthispapercanbeaccessedhere:
HandbookonGlobalPublicHealth.Editedby:ParkerR,CSommerM.New http://www.biomedcentral.com/1471-2393/12/5/prepub
York:Routledge;2010:354-364.
doi:10.1186/1471-2393-12-5
10. NairN,TripathyP,ProstA,CostelloA,OsrinD:Improvingnewborn
Citethisarticleas:Naharetal.:Scalingupcommunitymobilisation
survivalinlow-incomecountries:community-basedapproachesand throughwomen’sgroupsformaternalandneonatalhealth:experiences
lessonsfromSouthAsia.PLoSMedicine2010,7(4).
fromruralBangladesh.BMCPregnancyandChildbirth201212:5.
11. LassiZS,HaiderBA,BhuttaZA:Community-basedinterventionpackages
forreducingmaternalandneonatalmorbidityandmortalityand
improvingneonataloutcomes.CochraneDatabaseofSystematicReviews
2010,2010(11).
12. ManandharDS,OsrinD,ShresthaBP,MeskoN,MorrisonJ,
TumbahangpheKM,TamangS,ThapaS,ShresthaD,ThapaB,etal:Effect
ofaparticipatoryinterventionwithwomen’sgroupsonbirthoutcomes
inNepal:cluster-randomisedcontrolledtrial.Lancet2004,
364(9438):970-979.
13. TripathyP,NairN,BarnettS,MahapatraR,BorghiJ,RathS,RathS,GopeR,
MahtoD,etal:Effectofaparticipatoryinterventionwithwomen’s
groupsonbirthoutcomesandmaternaldepressioninJharkhandand
Orissa,India:acluster-randomisedcontrolledtrial.Lancet2010,
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375(9721):1182-1192.
14. GogiaS,RamjiS,GuptaP,GeraT,ShahD,MatherJL,MohanP,PandaR: and take full advantage of:
Communitybasednewborncare:Asystematicreviewandmeta-analysis
ofevidence:UNICEF-PHFISeriesonNewbornandChildHealth,India. • Convenient online submission
IndianPediatrics2011,48:537-546.
15. ManghamLJ,HansonK:Scalingupininternationalhealth:whatarethe • Thorough peer review
keyissues?HealthPolicyandPlanning2010,25(2):85-96. • No space constraints or color figure charges
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• Immediate publication on acceptance
Aprocessevaluationofthescaleupofayouth-friendlyhealthservices
initiativeinnorthernTanzania.JIntAIDSSoc2010,13:32. • Inclusion in PubMed, CAS, Scopus and Google Scholar
17. HouwelingTAJ,AzadK,YounesL,KuddusA,ShahaSK,NaharT,BeardJ, • Research which is freely available for redistribution
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