State of the World's Minorities and Indigenous Peoples 2013 - Case study: Power of participation: women's groups dramatically improve health for Adivasi mothers and newborns in eastern India

by Dr Audrey Prost, Dr Prasanta Tripathy and Soumendra Sarangi

Involving Adivasi women in the planning and evaluating of health care has significantly reduced deaths and empowered women among India's Adivasi communities in Jharkhand and Odisha.

Over 84 million Adivasis (original inhabitants) from more than 500 tribal groups live in western, central, eastern and north-eastern India. Today a quarter of all Adivasis reside in the central and eastern states of Jharkhand, Odisha and Chhattisgarh. Traditional Adivasi livelihoods revolved around the use of forest products and cultivation (both shifting and upland). Laws imposed under the British administration led to the widespread nationalization of forests and subsequently large forest areas were contracted to private companies. Adivasi ownership of land and resources has yet to be addressed through government legislation, such as the recently enacted Forest Act. Because of this, and large infrastructure projects such as the construction of dams, Adivasis now constitute over half of India's displaced people. Adivasi homelands also span some of the world's largest mineral reserves, but indigenous communities have yet to reap the social and economic benefits of mining-related development. In eastern India, competing claims over existing natural resources are increasing the risk of conflict.

Amidst this charged political backdrop, Adivasis remain the poorest socio-economic group in India, with low literacy and the highest maternal and child mortality rates in the country. The risk of an Adivasi child dying before the age of five is 25 per cent higher than that of a non-tribal child, and the maternal mortality ratio (MMR) in tribal areas of Jharkhand and Odisha is three times the national MMR.

Although access to quality health services is critical to saving mothers and infants, in tribal areas of Jharkhand and Odisha around half of women still deliver at home, and fewer than 20 per cent access postnatal care. This is because of the remoteness of tribal villages, concerns about the costs of health care and fear of discrimination at the hands of non-Adivasi professionals. There is also a lack of information about simple prevention strategies and care for common problems during pregnancy, childbirth and the postnatal period.

Fortunately, in some areas this is beginning to change through processes led by Adivasi women themselves. Since 2005, the civil society organization, Ekjut (meaning 'coming together'), has worked with women's groups to improve maternal and newborn health in remote tribal areas of Jharkhand and Odisha. Building on a methodology first developed with the indigenous Aymara community of Bolivia, Ekjut selected local female facilitators to support 244 women's groups to meet every month as part of a participatory learning and action process. During these sessions women identified common problems they faced in pregnancy and after giving birth. They also found feasible strategies to address these problems and evaluate the results. The facilitators were not health workers but local women whom others could trust and relate to. They were given training in participatory communication techniques and basic knowledge about maternal and newborn health. The women's groups discussed common problems using role plays, picture cards and storytelling, followed by reflection and analysis. The groups also organized large community meetings to share their priority problems and enlist the support of other community members to implement their chosen strategies. These activities were meant to improve individual and community knowledge of maternal and newborn health, but also foster reflection and the confidence to change existing practices.

The intervention had hugely positive results. The impact of the women's groups was evaluated using a cluster-randomized controlled trial, published in a leading medical journal. An indigenous demographic surveillance system was used, in which local women reported births and deaths among women of reproductive age in their communities. A data collection team interviewed women who had recently delivered to find out about events around the time of birth. The women's groups led to a 32 per cent reduction in neonatal mortality (deaths in the first 28 days of life), significant improvements in hygienic practices at the time of delivery and increases in exclusive breastfeeding.

At the end of the trial, Ekjut decided to introduce the women's group intervention into control areas for ethical reasons. Neonatal mortality fell sharply in the control areas, and an estimated 500 newborn infants have been saved through these interventions since 2005. Further analyses also showed that the groups had succeeded in attracting the poorest mothers and mortality reduction has been greatest among the poorest.

After these early successes, Ekjut is also adapting the participatory learning and action method to address other pressing health issues, including the prevention of childhood illnesses and under-nutrition, and carrying out new evaluations. Ekjut have also supported a scaling up of the intervention through their own facilitators and other actors. The government of India's flagship National Rural Health Mission programme now supports women's groups facilitated by accredited social health activists in several areas of Jharkhand, and other agencies are implementing the participation learning and action cycle with self-help groups in Bihar and Odisha.

There are a number of lessons from this work. First, women can be catalysts for change. Many organizations and governments endorse the right to participate in the planning of health care, but methods to ensure this are rarely evaluated, and tribal women are seldom in control of the process. Using participatory methods to involve Adivasi women in planning and decision-making resulted in substantial reduction in mortality and a significant sense of empowerment among women. In the first local elections held in the areas where Ekjut implemented the programme, several facilitators of the women's groups won seats as people's representatives, testifying to women's increased confidence.

Second, good evaluation pays off. Many organizations do outstanding work to improve health among indigenous communities but low-cost surveillance systems and evaluation methods lend credibility to demands for scaling up. Finally, scaling up interventions is often not – and need not be – a linear process: change happens in many ways, and so efforts to scale up interventions require long-term commitment and flexibility. Today, combined with increased government efforts to strengthen health services and a national conditional cash transfer scheme to increase the uptake of institutional deliveries (Janani Surakjsha Yojana), women's groups from Jharkhand and Odisha are paving the way to a better future for Adivasi mothers and their newborn babies.