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Emphasis to community participation in Alma Ata declaration
Participation in health care was a key principle in the Alma-Ata Declaration. In developing countries, antenatal, delivery, and postnatal experiences for women usually take place in communities rather than health facilities. Strategies to improve maternal and child health should therefore involve the community as a complement to any facility-based component.
The fourth article of the Declaration stated that, "people have the right and duty to participate individually and collectively in the planning and implementation of their health care", and the seventh article stated that primary health care "requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care".

Status of women in the world
Over half a million women die each year due to complications during pregnancy and birth. In 2000, the estimated number of maternal deaths worldwide was 529,000. 95 per cent of these deaths occurred in Africa and Asia. In several countries the lifetime risk is greater than 1 in 10. For every woman who dies from obstetric complications, approximately 30 more suffer injuries, infection and disabilities. In 1999, for example, WHO estimated that over 2 million women living in developing countries remain untreated for obstetric fistula, a devastating injury of childbirth. There is no single cause of death and disability for men between the ages of 15 and 44 that is close to the magnitude of maternal death and disability.
Women living in poverty and in rural areas, and women belonging to ethnic minorities or indigenous populations, are among those particularly at risk. Globally, around 80 per cent of maternal deaths are due to obstetric complications; mainly haemorrhage, sepsis, unsafe abortion, pre-eclampsia and eclampsia, and prolonged or obstructed labour. Almost all cases of maternal mortality are preventable. An estimated 74 per cent of maternal deaths could be averted if all women had access to the interventions for preventing or treating pregnancy and birth complications, in particular emergency obstetric care.

Community participation
Participation in general sense is the involvement of the members of a particular community in the formulation of public policy and its implementation and usage. That is, it is the involvement of the local people in the development process of the community as a whole. (green 1986 and huff and kline, 1999). Participation means in its broadest sense, to mobilize people and thus, their willingness to respond to development programs, as well as to encourage local initiatives. Community participation involves organized effort to increase control over resources and regulate institutions in given social institutions on the part of groups or movements of those hither to exclusion from such control. (Huff and Kline, 1999) Quite often it is forgotten that community participation is more than the mere contribution of money, material or labor to a developmental program by the target group. It is even more than people getting involved in the planning, monitoring and implementation of programs, or sharing the benefits of such programs.

Community mobilization
It has long been advocated that communities should come together to make lasting improvements to their health and have a right to access high quality healthcare, as recognized by the Alma Ata Declaration made at the International Conference on Primary Health Care in 1978: “The people have the right and duty to participate individually and collectively in the planning and implementation of their health care”.
Local communities can be strengthened by coming together to plan, carry out, and evaluate activities to make sustained improvements to their health. This strengthening process is often referred to as community mobilization, which can make deep and lasting improvements to the health and well-being of communities. Communities can achieve improved health through increased knowledge to identify and address important healthcare needs.

Why community participation?
In Nepal, the main cause of maternal mortality is the three delays:
• Delay in seeking appropriate medical help for an obstetric emergency for reasons of cost, lack of recognition of an emergency, poor education, lack of access to information and gender inequality.
• Delay in reaching an appropriate facility for reasons of distance, infrastructure and transport.
• Delay in receiving adequate care when a facility is reached because there are shortages in staff, or because electricity, water or medical supplies are not available
Community participation is crucial because community people can work to duly cut down these delays. In rural areas, there is no proper transportation facility and a pregnant woman is manually carried off by the community people to the service center. If the community is able to help the family prepare for the delivery in advance, and take pregnant mother to the service center in time, the mortality can be reduced to a great extent. If community do not help any family to carry women to the center, it is more likely that the women will not reach the center.
In rural community, due to various reasons, women deliver in the home itself. This should be discouraged, and if it is not possible, should be conducted in the presence of skilled attendant.
Community participation can bring about various community based initiatives too. Maternal health has its relation directly with the society, and such initiatives can mean a lot to women. Pregnancy and delivery is a special situation and a family needs a lot of support. Thus community participation is always necessary, but more important to crucial stage like pregnancy and delivery to strengthen maternal health.

How community participation?
The community participation has helped to reduce maternal mortality and morbidity, especially in the rural community of Nepal, and across the globe. Certain things that have been brought about by community participation are as follows:
• Women’s Groups
The concept of women group has been very effective in addressing maternal health. It supports the group to identify and prioritize problems during pregnancy, childbirth and the newborn period, and to develop and evaluate strategies to overcome these problems. The initial meetings facilitate discussions on why mothers and newborns die in the community, and introduce the concept of ‘learning together’ to encourage the women to discuss problems within the group but also with their neighbors and friends. After each meeting, women return to their community to present their work at a community meeting stimulating wider health discussions. Therefore the impact of a women’s group is not just confined to group members but on the health of the community as a whole.

• Community Emergency funds
Women in rural areas often give birth at home with assistance from family members or a local traditional birth attendant (TBA). When these women face complications during their pregnancy, they often cannot afford transport to a healthcare professional. The community groups have therefore developed an emergency fund in Bangladesh, Nepal and Malawi, which can be used by any member in an emergency.

• Improved healthcare facilities
When women can access healthcare facilities they often lack privacy and comfortable furniture. In response, community people can contact a local forester and order resources to make new furniture and gathered material to make curtains. In this situation women are building links between the health service staff and user.

• Flags in pregnant homes
In many rural communities, people have placed a specific flag in home where pregnant women are living. It helps the community and community based health worker to identify such homes and if required, to take special care of such homes. Community people can consult those homes and ask them if they require any help.

• Stretcher
Women’s groups, in many communities, have managed to collect money to purchase a second hand stretcher for the village to ensure pregnant women can be moved easily to a clean and safe delivery place when they go into labor. In Nepal, where many villages are remote, half the women’s groups ran stretcher schemes. This had an additional benefit for the community because 90 per cent of the time the stretchers were used for other sick people not just mothers in labor.

• Clean home delivery kits
The World Health Organization advocates the use of clean home delivery kits as an effective way of reducing maternal and newborn infections. In Nepal and other developing countries, several examples are seen where the community people with support of the women’s groups developed their own delivery kits comprised of a blade, a bar of soap, three cord ties, a plastic coin for cord cutting, a plastic sheet, and a set of pictorial instructions. The groups then decided on the price and best selling location, and all profits went into the emergency fund.

• White Ribbon Alliance for Safe Motherhood (WRA)
Mali, Futures Group works with religious leaders and uses a “Grandmother Strategy” to encourage pregnant women to get their prenatal visits and for couples to discuss pregnancy openly, plan together for delivery, and use bednets.

• Other initiatives
A community based healthcare organization in Nepal had a short film about maternal and newborn care, but poor communities could not watch it due to a lack of electricity in their homes. Women community group approached those households which were fortunate enough to have electricity and a television, to show the video to members of the community. The women sang health promotion songs from the video at annual women’s festivals and played the songs on local buses.

The role of community can be especially crucial in:
 Increasing socio-cultural acceptance
Certain aspects of motherhood especially the taboos and social stigma have their origin in the society or community. Community can be a crucial matter in changing the attitude of the people on any matter. A women will always feel comfortable to attend a female doctor in her pregnancy, would like to attend a privacy maintained service center etc. These can be made accepted only by changing the attitude of the community. Maternal health is determined by the care a mother receives before and during pregnancy. A well empowered educated family always seeks proper care of the mother. Social discrimination and violence of the women, early marriage, and early age at first birth would contribute to unhealthy mother and child. These are all society and community related taboos.

 Men Involvement
Men are equally liable to a healthy child as is a woman. Male involvement in maternal health has shown to be a great relief to the health status if the mother and child. If a society is male dominating and the culture is such that men are not involved in these aspects, the health cannot be assured.
In Nepal too, until last year, men were not allowed to be present in the delivery ward because of social stigma. But these days, it has started becoming socially acceptable and thus the male involvement is increasing. Post natal care allowance to male is also a social initiative to improve maternal health.
Male involvement is now accepted in the society in urban areas. But in rural community, still, male involvement is not accepted and one involving is terms wife discriminated. However, a society can change the attitude and increase male involvement for maternal health.