Trials of participation to improve maternal and newborn health – Authors' reply

I want to commend Audrey Prost and colleagues on their study of the contribution of participatory women’s groups to improve birth outcomes in poor communities in low-income and middle-income countries (May 18, p 1736). Their work is an important contribution to highlight the crucial importance of participation in health care improvement. I would be remiss, however, if I did not challenge the analytical framework in which these data are presented. To frame participation in women’s groups underpinned by Participation Learning and Action (PLA) as the intervention limits the understanding of participation. PLA, the most recent manifestation of Participatory Action Research, is an approach that involves the intended benefi ciaries in all aspects of the intervention design. It values the learning outcomes equal to the material outcomes. The value of PLA lies in the examination of outcomes that also lead to the empowerment, eventual ownership, and sustainability of that intervention. Participation, it has been argued, is better understood in both theory and practice as a process. To present participatory women groups as an intervention with a direct causal relationship to improved health outcomes is simplistic. The interpretation of data would be more robust if the process of participation was disaggregated, and issues around the transformation of attitudes and behaviours, power and control, and sustainability of health outcomes were addressed. Although such an investigation is complicated, the validity of these findings and the generalisability of what appears to be a panacea for a crucial global health problem are questionable.