Measuring what works: a mixed-methods evaluation of women’s groups on maternal health uptake in rural Nepal.

Abstract

Background: There is a need for more studies that analyse evaluation methods in the context of maternal health promotion. These should assess the effectiveness of health promotion interventions on health outcomes, factors contributing to impact, and transferability. This thesis reports on an evaluation of one such intervention in Nepal targeting rural women to promote maternal health. Methods: A mixed-methods approach was used where, first, a Difference-in- Difference (DiD) estimation assessed the effects of the intervention on selected outcome variables while controlling for: 1) a constructed wealth index; and 2) women’s socio-economic characteristics in a five-year controlled, non-randomised, repeated cross-sectional study of a community-based health promotion intervention targeting maternal health in Nepal. Second, the qualitative data were analysed to explore the knowledge, attitudes, and beliefs of women post-intervention. Finally, the financial data were analysed to identify resources needed and estimate the cost of the health promotion intervention. Results: After five years, women in the intervention area were more likely to seek antenatal care at least once, to take iron/folic acid, and to attend postnatal care. The intervention did not influence women’s place of birth or likelihood of receiving care from a skilled birth attendant. However, it did improve attendance for the recommended four antenatal visits for the first two and a half years. The qualitative findings helped explain some of the changes or lack thereof, where in the intervention area women were perceived, by the researcher, as empowered, confident, and the family as supportive. The cost of providing the health promotion intervention per group/woman and the evaluation process consisted of only 10% of the total programme cost. Conclusion: This is the first community-based health promotion intervention that has demonstrated a greater impact during pregnancy (i.e., uptake of antenatal care) than around birth (i.e., changes in delivery care). Other factors, not easily resolved through health promotion interventions, may influence birth outcomes, such as financial liquidity or geographical constraints. The evaluation showed that using mixed methods provided valuable information that would not have been extracted through one method alone. While DiD is a precise tool for measurement, the qualitative research provided insight into why the intervention had an impact in pregnancy but not at birth.