Will Rahima's Firstborn Survive Overwhelming Odds? Positive Deviance for Maternal and Newborn Care in Pakistan

From the Positive Deviance Wisdom Series (Number 5), a collaborative venture of the Positive Deviance Initiative at Tufts University (Boston, Massachusetts, United States) and the Social Justice Initiative, Department of Communication, University of Texas (El Paso, TX, USA), this case study explores the use of the Positive Deviance (PD) approach to strive for better maternal and newborn health outcomes in 8 villages of Haripur District in Pakistan's North West Frontier Province (NWFP) from January 2001 to October 2004. PD is based on the observation that in every community there are certain individuals or groups whose uncommon behaviours and strategies enable them to find better solutions to problems than their peers, while having access to the same resources and facing similar or worse challenges.

Initiated by Save the Children as part of their Saving Newborn Lives (SNL) Initiative in Pakistan, the project was carried out in 2 phases. In Phase one, activities were initiated to foster community dialogue about the problem of newborn mortality and morbidity among community members (separately between male and female groups) in order to identify PD newborns and their families, discover what were their demonstrably successful strategies, and develop a plan of action. Phase two was dedicated to community action via community-designed neighbourhood activities undertaken by both male and female groups. The PD process, designed to build strong rapport with the community members, helped the intervention team: learn about the local contexts of understanding with respect to maternal and newborn care; discern household behaviours that increased the chances of newborn survival; and glean insights on messaging strategies used by the positive deviants (PDs) - such as one from a religious leader, whose messages about delaying the bathing rituals of a newborn were given play in mohallah (neighbourhood) sessions and in community Healthy Baby Fairs, thus multiplying its effects.

Due to fact that in the NWFP of Pakistan, safe motherhood, pregnancy, and delivery are highly taboo subjects, a step-by-step approach was employed with various participatory activities such as transect walks, focus group discussions, social network maps, newborn mapping, and in-depth interviews. During the community orientation and feedback sessions, facts and figures about newborn and maternal care were shared, such as through testimonies from family members who had lost a newborn or a wife, daughter-in-law, or niece during labour and delivery.

Next, working with both women's and men's groups, a baseline about newborns in the community was established. A newborn mapping activity was conducted by both groups to determine how many babies had been born the year before, how many had been stillborn or died immediately after birth, after 7 days, after 28 days, and within 40 days. Concurrently, explorations of common practices with women's groups around pregnancy, delivery, and immediate and subsequent post-partum care were explored using stuffed dolls as props. The dolls provided a visual representation of how the newborn was handled during the delivery process and post-delivery, and were used to allow mothers, mothers-in-law, fathers, and dais (traditional birth attendants) to engage in learning by doing.

Based on the above, a PD team was formed. It was composed of village leaders, self-identified volunteers (activists), and Save the Children staff. They identified a PD (misali kirdar) newborn who survived against heavy odds (poverty, prematurity, and maternal health history). In addition to the newborn, family members related to the newborn were identified as PD persons, such as a father who saved money in case of obstetric emergency at delivery, a mother-in-law who prepared a delivery kit for the arriving newborn, and a dai who successfully resuscitated newborns who were not breathing and practiced clean cord cutting and appropriate cord care.

Different channels of communication were then used to repeat and reinforce the PD messages through different media and individuals, including religious and secular leaders and popular, culturally appropriate tools, such as street theatre, to validate the messages given by the PD volunteers. The PD practices that were discovered were openly shared with community members in community-wide meetings, albeit separately, because of cultural mores, with male and female members. The action plan was developed with the consensus of the entire community and displayed in a common social place to ensure transparency of roles and responsibilities to achieve the objectives. This basic plan was further developed or modified by the community-identified activists in a Village Action Team (VAT) workshop. Village health activists participating in the VAT developed a 6-month plan, deciding that in cooperation with the community members, a plethora of activities would be undertaken at the neighbourhood level with regular bi-monthly group interaction mohallah sessions. Each session focused on a newborn and maternal care topic and highlighted certain specific PD behaviours and strategies that had been discovered during recent PD inquiries.

For instance, in response to the fact that the initial community dialogue in intervention villages revealed that male involvement in maternal and newborn care was minimal (in this dominant Pashtun culture of patriarchy, male bonding with infants or caring for one's wife is perceived as not being 'manly'), in one male mohallah session participants set up a mock bazaar where men were asked to buy what they considered a clean delivery kit for pregnant women. Discussion on each participant's purchase followed and resulted in men declaring, some anonymously, that a new razor blade was the best tool for cutting the umbilical cord. According to the authors of this report, the community's respect and open support for the men's contributions and decisions "helped enhance their self and collective efficacy, leading to the emergence of a new and innovative leadership. Scores of new male volunteers signed up to run the mohallah sessions."

A pre-post, interventional control research design pointed to significant gains in maternal and newborn care indicators. In comparison to control villages where the gains were insignificant, in the intervention villages:

• The percentage of mothers giving homemade pre-lactal feeds in the first 3 days decreased from 70% to 25%.
• The percentage of pregnant mothers visiting antenatal clinics increased from 45% to 63%.
• The percentage of newborns whose cords did not receive unhygenic homemade remedies increased from 7% to 19%.
• The percentage of fathers who saved money and arranged for transport to tackle pregnancy emergencies increased from 45% to 62%.
• The percentage of families that used a new blade to cut the baby's cord increased from 19% to 33%.
• The percentage of families that delayed bathing the newborn for the first 24 hours increased from 18% to 32%.

In conclusion, the authors note that, in the NWFP (a highly conservative part of Pakistan), the introduction of the PD approach, which began by building trust with the community's male elders, led to more open household, neighbourhood, and community discussions on "taboo" topics between men and women - i.e., maternal and newborn health. In this place where infant and maternal mortality are couched in fatalistic terms - e.g. "as God's will" - and where women, by tradition, are not allowed to participate in health education meetings. "The odds of survival for the yet-to-be-born in Rahima's village have gone up significantly since the PD approach to maternal and newborn care was implemented."