In Madagascar—where women face a 1 in 43 lifetime risk of maternal death—community mobilisation can improve maternal health outcomes. In rural areas, clinics and hospitals are located far from many villages, which means that transport in emergency situations is vital for reducing delays in getting women the care they urgently need. Simple community-led initiatives tackling such problems can have a great impact, as evidenced by the recent efforts of a women’s group in the village of Andalambezo on Madagascar’s remote southwest coast.
Following a devastating series of maternal and newborn deaths in Andalambezo, the local community health worker, who distributes contraceptives and provides antenatal and postnatal educational home visits, felt moved to mobilise her peers to take action to address this problem.
Two questions were asked at the first women’s group session that Veleriny convened:
- Do you know a woman who’s died in pregnancy or delivery?
- Do you know a baby who died at a very young age?
Sadly, all hands went up for both of these questions. Of the nine women who had given birth in recent months, four had ended in a stillbirth.
Andalambezo is an isolated coastal community eight kilometres from the nearest healthcare facility, which is located in the neighbouring village of Tampolove. Transport options are limited to either sailing canoes or cattle carts, but even these depend on women’s ability to pay and may also mean forgoing significant income-generating opportunities – as sailing canoes are typically used for fishing and cattle carts are typically used for transporting produce or passengers for a fee.
The women’s group in Andalambezo decided to tackle the challenge of providing emergency transport for women by creating a communal savings fund, and collecting individual contributions of 200 Ariary (equivalent to 5 US¢) every week. However, following widespread eagerness in the first week, fewer and fewer women continued paying into the fund as time went on.
At this stage, Blue Ventures’ community outreach team helped facilitate a meeting with 30 women, from adolescents to elders. Frustrations, challenges, barriers, concerns, ideas and possible solutions were shared openly. They were frustrated by broken dreams of change. They were challenged by a perceived lack of alternative income-generating options as a barrier to paying for emergency transport. They were concerned about not being able to recognise essential danger signs indicating that urgent healthcare was needed. Nevertheless, they were also full of ideas and possible solutions! In sharing these, they became animated and motivated to take action together.
The solution that appealed most to the women’s group was to produce honey to sell to Blue Ventures’ volunteers. Within two weeks honey was in abundant supply, and the revenues from honey sales are now feeding straight into their communal savings fund.
The women decided that their revenue could be used for transport to attend routine antenatal check-ups, emergency transport for pregnant women or babies needing urgent medical attention, and products for making their own clean delivery kits. However, women still have concerns about giving birth en route to the healthcare facility, arriving too late, or being able to afford day-to-day living costs while away from their home village. One potential solution being considered by the women to address these problems is to use their money to build a small house next to the healthcare facility in Tampolove, where pregnant women from Andalambezo can wait to ensure facility delivery.
While the women decide how to proceed, the communal money made from selling honey has been used to pay for cattle carts to send groups of 4-6 pregnant women from Andalambezo to Tampolove for routine anti-tetanus vaccines! This marks a real change from the situation before, when families were unable to save adequate funds on their own. In this way, we’re seeing the community reap the benefits of their hard work with greater access to formal healthcare, improved maternal and child health outcomes, and diversified livelihood options.
The enthusiasm of the women’s group in Andalambezo has also proven to be contagious; inspiring other community health workers to initiate similar projects in their own villages, and reshaping local attitudes previously set against the sharing of wealth between families and clans. Three more women’s groups have now been established in other villages, selling jam and honey to create their own communal savings funds. What’s more, after the men in one village heard about what the women were up to, they too decided to form a group!
This exciting ripple effect demonstrates that community groups can form spontaneously around local insights and ingenuity, with little support from an outside organisation. We’re allowing these groups to develop and evolve with maximum community ownership, while also beginning to explore how we might add value by building the confidence of our community health workers to facilitate group meetings and acquainting them with Participatory Learning Action cycles* as a potentially useful tool for advancing further community-led initiatives.
*Found to be associated with significant reductions in maternal and neonatal mortality when used by women’s groups (Prost et al, 2013).