Group Antenatal Care: The Power of Peers for Increasing Skilled Birth Attendance in Achham, Nepal

In rural Nepal, the major drivers of underutilization of skilled birth attendance are poverty, poor social support and inadequate birth planning. Drawing from similar programs that have been shown to improve maternal and neonatal outcomes, we have designed a group antenatal care program that uses a participatory learning and action process to engage women in identifying and solving problems accessing maternity care services and create a supportive social network. We plan to test a group antenatal care program that will change antenatal care in three major ways: 1) conduct care in a group setting with women matched by gestational age, 2) incorporate participatory learning and action, and 3) provide expert and facilitated peer counseling.

Study Overview

• Status: Completed
• Conditions: Prenatal Care
• Intervention / Treatment: Other: Group Antenatal Care; Other: Individual Antenatal Care

Detailed Description

The group antenatal care intervention aims to improve rates of institutional birth and ANC care completion via improving acceptability of group care, maternal and neonatal health knowledge, self-efficacy, social support, and birth planning.

Objective 1: Assess the effect of group antenatal care on institutional birth rates through a prospective study using community household census data. Secondary outcomes will be completion of basic ANC package; neonatal mortality rate; percentage of preterm births; percentage of stillbirths; and percentage of small-for-gestational age (SGA) births.

• Hypothesis 1: Group ANC will increase institutional birth rates by 5% over one year.
• Hypothesis 2: Group ANC will increase completion of 4 ANC visits by 5% over one year.
• Hypothesis 3: Group ANC will reduce infant mortality rate by 5% over one year.
• Hypothesis 4: Group ANC will reduce the postpartum contraceptive prevalence rate by 5% over one year.
• Hypothesis 5: Group ANC will reduce the stillbirth rate by 5% over one year.
• Hypothesis 6: Group ANC will reduce the perinatal mortality rate 5% over one year.
• Hypothesis 7: Group ANC will reduce the combined infant mortality and stillbirth rate by 5% over one year.

Objective 2: Assess the mechanisms of implementation of group antenatal care through quantitative participant survey measures, qualitative focus group discussions and key informant interviews.

• Hypothesis 1: Group antenatal care will be acceptable to participants and providers, and preferred to individual care.
• Hypothesis 2: Group antenatal care will increase pregnant patients' access to and utilization of delivery services through improved knowledge, self-efficacy, social support and birth planning.

Objective 3: Report on key aspects of the implementation process: costs, human resources, logistics, and fidelity of the group antenatal program to model content and participatory processes.

• Study Type: Interventional
• Enrollment (Actual): 2184
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Nepal
  • Achham
    • Bayaplata, Achham, Nepal
      • Bayalpata Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 15 years to 49 years (Child, Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: Female

Description

Inclusion Criteria:

• Female
• Age 15-49 years old
• Resident of 14 village clusters in study site
• Intervention cohort: less than 24 weeks' gestation prior to first group antenatal care session.

Exclusion Criteria:

• Intervention cohort: more than 24 weeks' gestation prior to first group antenatal care session.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Non-Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Intervention Cohort; We will use a cohort of 60 women from intervention village clusters for the group antenatal care intervention.	Other: Group Antenatal Care; The group antenatal care intervention will match pregnant women by gestational age in the intervention village clusters and assign them to peer group sessions facilitated by local healthcare clinic staff.
Active Comparator: Control Cohort; We will use a cohort of 60 women from control village clusters as an active comparison.	Other: Individual Antenatal Care; Pregnant women in control village clusters will have individual antenatal care sessions with their healthcare provider.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Institutional Birth Rate	We expect the number of pregnant women from intervention village clusters who give birth at a healthcare facility to increase by 5% compared to control.	1 year

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Infant Mortality Rate	We expect the infant mortality rate to be 5% lower among the babies from the intervention cohort women compared to control.	1 year
Postpartum contraceptive prevalence rates	We expect the postpartum contraceptive prevalence rate to be 5% higher among the intervention cohort women compared to control.	1 year
Completion percentage of 4 antenatal care visits	We expect that 5% more women in the intervention cohort will complete all 4 antenatal care visits compared to the control.	1 year
Stillbirth rate	We expect that the stillbirth rate will be 5% lower among the intervention cohort compared to control.	1 year
Perinatal mortality rate	We expect that the perinatal mortality rate will be 5% lower among the intervention cohort compared to control.	1 year
Combined infant mortality and stillbirth rate	We expect that the combined infant mortality and stillbirth rate will be 5% lower among the intervention cohort compared to control	1 year

Collaborators and Investigators

• Sponsor: Possible
• Collaborators: Brigham and Women's Hospital
• Investigators: Study Director: David Citrin, PhD, MPH, Possible; Study Chair: Biraj Karmacharya, MBBS, Msc, University of Washington; Principal Investigator: Duncan Maru, MD, PhD, Possible

Publications and helpful links

General Publications

• Harsha Bangura A, Nirola I, Thapa P, Citrin D, Belbase B, Bogati B, B K N, Khadka S, Kunwar L, Halliday S, Choudhury N, Schwarz R, Adhikari M, Kalaunee SP, Rising S, Maru D, Maru S. Measuring fidelity, feasibility, costs: an implementation evaluation of a cluster-controlled trial of group antenatal care in rural Nepal. Reprod Health. 2020 Jan 17;17(1):5. doi: 10.1186/s12978-019-0840-4.
• Thapa P, Bangura AH, Nirola I, Citrin D, Belbase B, Bogati B, Nirmala BK, Khadka S, Kunwar L, Halliday S, Choudhury N, Ozonoff A, Tenpa J, Schwarz R, Adhikari M, Kalaunee SP, Rising S, Maru D, Maru S. The power of peers: an effectiveness evaluation of a cluster-controlled trial of group antenatal care in rural Nepal. Reprod Health. 2019 Oct 22;16(1):150. doi: 10.1186/s12978-019-0820-8.

Helpful Links

• Possible
• Healthcare Systems Design Group

Study record dates

Study Major Dates

• Study Start (Actual): August 1, 2014
• Primary Completion (Actual): July 10, 2016
• Study Completion (Actual): July 10, 2016

Study Registration Dates

• First Submitted: December 31, 2014
• First Submitted That Met QC Criteria: December 31, 2014
• First Posted (Estimate): January 5, 2015

Study Record Updates

• Last Update Posted (Actual): June 25, 2021
• Last Update Submitted That Met QC Criteria: June 22, 2021
• Last Verified: June 1, 2021

More Information

Terms related to this study

• Keywords: Nepal; Global Health; Implementation Research; Preterm Birth; Maternal Mortality; Stillbirth; Infant, Small for Gestational Age; Institutional Birth Rate; Neonatal Mortality Rate
• Other Study ID Numbers: GroupANCnyaya