From 2001 to 2003, a team of researchers did a study to see whether participatory workshops would improve birth outcomes in a poor rural area of Nepal.
Problems and Purpose
At the time of the research study, from 2001 to 2003, the neonatal mortality rate in Nepal was 39 per 1000 live births . There has been steady progress made, with UNICEF reporting a neonatal mortality rate of 22 in Nepal in 2015 . This is a large-scale problem that disproportionately affects many developing countries. In 2017, the average infant mortality rate across the globe was 18 per 1000 live births. The rural communities in Nepal, particularly the Makwanpur district, had poor access to hospitals and low birth outcomes. The researchers were interested in finding out how participatory intervention may improve these birth outcomes.
Background History and Context
This was the first study of its kind, using a randomized control study to link participatory planning with improved birth outcomes.  Other studies in Bolivia, conducted between 1990 and 1993,  and India, conducted between 1995 and 1998,  had positive outcomes, but were quasi-experimental designs. Women in rural Nepal often have poor access to health facilities and low levels of education, contributing to poor birth outcomes throughout the Makwanpur district. The researchers believed they could drastically improve birth outcomes through an approach they deemed accessible, inexpensive, and replicable.
Organizing, Supporting, and Funding Entities
As this project was a large-scale research study it was a joint effort of many groups. Some of these were two groups from Kathmandu (Mother and Infant Research Activities (MIRA); Nepal Administrative Staff College), while the two other groups were researchers from the United Kingdom (International Perinatal Care Unit, Centre for Paediatric Epidemiology and Biostatistics, Institute of Child Health, University College London; Institute of Development Studies, Brighton). 
The study was funded by the UK Department for International Development along with support from WHO and the United Nations.
Participant Recruitment and Selection
This was cluster randomized control research. This means that 24 villages of approximately the same size and ethnic make-up were matched: 12 were randomly assigned to be part of a control group (that did not participate in these participatory interventions), while the other 12 were assigned to hold these interventions. Women from both the control and experimental groups totalled 28,931, of which over 2000 took part in participatory interventions. 
The researchers collected data and gained consent from married women in all of the communities who were between the ages of 15 and 49. A local, literate facilitator was nominated by leaders of each of the 12 participating communities. Each of these facilitators was given a brief training on perinatal health. 
Methods and Tools Used
Once a month for ten months, facilitators conducted participatory interventions in nine areas of their communities. When possible, the facilitations were done in conjunction with already existing women’s groups. Each of the ten meetings had a different focus; meetings one and two were an introduction to the study and process, meetings three through five focused on identifying problems, meeting six emphasized prioritizing the problem in the community, while meetings seven through ten focused on participatory planning surrounding the problem.  This was a form of community-based participatory research as well as collaborative planning. This is because community members were involved in all parts of the process, from designing the surveys, to making decisions that would affect their communities. Gamification was also used to increase engagement and make content more accessible, especially to women who were illiterate.
What Went On: Process, Interaction, and Participation
Many participatory interventions occurred over the span of a year. Some communities and individuals were more involved than others. Women led discussions to seek out more information about their health during and after pregnancy. The facilitators utilized a picture card game to demonstrate the prevention and treatment of different conditions. 
During the last four monthly meetings, different groups came up with different community-based solutions, including community funding for care, the creation of clean delivery kits, and home visits to newly pregnant mothers to increase awareness of perinatal health. 
Over the course of this study, interviews were done with each participant. It is important to note that these interviews were created in Nepali and piloted by local teams. This type of community-based participatory research helps create community buy-in and increases the legitimacy of data collected. 
Due to the large-scale nature of this research, as well as the intent as a research study, there is limited information regarding details of what went on during individual participatory convenings.
Influence, Outcomes, and Effects
Only 8% of women in the intervention clusters ever attended the participatory interventions. Their knowledge of healthy birth practices increased, and so did the knowledge of other women in their communities who did not attend these convenings.  Women in these intervention groups, whether they attended a participatory convening or not, were more likely than their peers to receive prenatal care, deliver in a hospital, and participate in best hygiene practices. This suggests that women who participated in these convenings shared their new knowledge with their communities. As a result, there was a 30% decrease in neonatal deaths in the communities with interventions versus the control groups. There was not a significant decrease in stillbirths, but there was a positive unintended result of a significant decrease in mother mortality. These participatory interventions also served to strengthen existing women’s groups on Nepal as well as create new women’s groups in areas that did not have them before. 
Analysis and Lessons Learned
This study, one of the first of its kind, was significant in providing support for the efficacy of participatory interventions in health outcomes, particularly in neonatal care. This is especially important because it is a low-cost, sustainable way to provide information, support, and self-governance in rural, developing areas.  While satisfaction of participants is not mentioned, 95% of the women’s groups continued to meet after the study was over, suggesting that the women were satisfied .
This study appears successful as it lowered negative birth outcomes, specifically neonatal and maternal death rates. The participatory element empowered women to share their new knowledge in their communities and improve outcomes on a larger scale than just those who attended the meetings.  
Participatory Planning in Nepal
Participatory Poverty Assessment in Pakistan
 Manandhar DS, Osrin D, Shrestha B, et al. Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet 2004; 364: 970–79.
 Unicef. (2015). Every newborn action plan: country progress tracking submissions. Every newborn action plan: country progress tracking submissions. https://data.unicef.org › uploads › 2016/11 › 160...[pdf]
 Orourke, K., Howard-Grabman, L., & Seoane, G. (1998). Impact of community organization of women on perinatal outcomes in rural Bolivia. Revista Panamericana De Salud Pública, 3(1). doi: 10.1590/s1020-49891998000100002 https://www.scielosp.org/article/rpsp/1998.v3n1/9-14/en/
 Bang, A. T., Bang, R. A., Baitule, S. B., Reddy, M. H., & Deshmukh, M. D. (1999). Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. The Lancet, 354(9194), 1955–1961. doi: 10.1016/s0140-6736(99)03046-9
The original submission of this case entry was written by Katerina Noori, a Master of Public Service candidate at the University of Arkansas Clinton School of Public Service. The views expressed in the current version are those of the authors, editors, or cited sources, and are not necessarily those of the University of Arkansas Clinton School of Public Service.