“Secret Mothers” & “Organized Diffusion”: Community-level Change Theory in Practice

Theories of action (theories of change) guide the development of interventions. Most of the theories discussed in class were individual level theories of behaviour change; some addressed social and environmental contexts while others did not. Recently, I came across an article in the New York Times Opinion Pages that details “a bold plan to improve maternal care nationwide” in Malawi by implicitly using change theory at the community and population levels. The author also discusses an explicit use of community-level change theory in a similar setting.

Malawi is a country in southern Africa where 85% of the population lives rurally and the lifetime risk of a women dying while giving birth is 1 in 36 (Martin). High maternal mortality in Malawi is largely associated with home births and the attendance of traditional (untrained) birth attendants. Joyce Banda, the Malawian President, is invested in addressing the problem, especially since the national ban on giving birth at home established by her predecessors in 2007 has failed to curb the issue. Clearly, the issue cannot be solved with laws alone, a cultural shift is needed.

Success depends on the “government’s ability to harness the country’s true power brokers, Malawi’s 20,000 village chiefs—and sensitize them to the dangers of women giving birth with [traditional] attendants, while still respecting tribal traditions” (Martin). Chief Kwataine of Ntcheu, in central Malawi, is one of these power brokers. He has overseen the organizational and attitudinal transformation of his villages, largely through the implementation of 48 “safe motherhood committees.” The committees are comprised of 10 community members each, wherein each member has a distinct role, including family planning counselors and growth monitors. The innovative element is the so-called “secret mothers” who are typically elderly women and “serve as liaisons between the expecting mother and the professional health workforce” (Martin).

Traditionally, women avoid prenatal care and give birth with unskilled attendants, because it is inappropriate to share news of one’s pregnancy with anyone other than one’s mother. Now in Ntcheu, women report their pregnancy to a “secret mother,” who is responsible for monitoring the women’s health and ensuring that she accesses skilled care; “secret mothers disrupt the dangerous part of the tradition…while preserving the value of secrecy and inter-generational bonding” (Martin). Since the 48 “safe motherhood” committees have been operating, there hasn’t been a single maternal death in Ntcheu in over 3 years.

The next step is to take the community-level organizational and attitudinal change to the population level. Chief Kwataine chairs the Chiefs Committee for the initiative and has charged other Malawian Chiefs with spreading the word about the importance if maternal health and safer alternatives to traditional birth attendants. Chief Kwataine also hosts a daily radio show, speaking to men about family planning and maternal health issues. Martin relates the attempts to “scale up” the Malawi initiative to Tostan’s work engaging male influencers to catalyze cultural change.

Tostan’s theory is titled “organized diffusion” and begins in the community setting. Their model entails raising awareness though grassroots discussion groups in 3-year holistic education programs by creating community settings where people can comfortably discuss information about health and human rights. It is essential, naturally, that “the influencers—often the men—are engaged both intellectually and emotionally” (Martin). Tostan’s model is based on empowering people to lead social change within their own communities and includes facilitation of a preparation phase, an implementation phase, and a sustainability phase. “Organized diffusion” seeks to spread information throughout social networks through “adopt-a-learner” programs, awareness-raising events, inter-village meetings, radio programs, public declarations, and social mobilization teams.

I like to think of organized diffusion as a combination of social cognitive theory and diffusion of innovations, whereby decisions on whether to adopt are contextualized by social interactions. I believe the theories and models in these health initiatives have been successful because they allow communities to discuss and address the issues themselves, they respect cultural contexts, and they occur at every level: organizational and attitudinal change in the community (led by the community) can lead to beneficial individual behaviour change. Do you think that these community-level models can be effective on a population scale? Can you name other community-led initiatives to change individual behaviour?


Martin, Courtney E. (2013) “Malawi’s Leader Makes Safe Childbirth her Mission”


Tostan: Community-Led Development




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