Measuring fidelity, feasibility, costs: an implementation evaluation of a cluster-controlled trial of group antenatal care in rural Nepal

Abstract

Background: Access to high-quality antenatal care services has been shown to be beneficial for maternal and child health. In 2016, the WHO published evidence-based recommendations for antenatal care that aim to improve utilization, quality of care, and the patient experience. Prior research in Nepal has shown that a lack of social support, birth planning, and resources are barriers to accessing services in rural communities. The success of CenteringPregnancy and participatory action women's groups suggests that group care models may both improve access to care and the quality of care delivered through women's empowerment and the creation of social networks. We present a group antenatal care model in rural Nepal, designed and implemented by the healthcare delivery organization Nyaya Health Nepal, as well as an assessment of implementation outcomes.

Methods: The study was conducted at Bayalata Hospital in Achham, Nepal, via a public private partnership between the Nepali non-profit, Nyaya Health Nepal, and the Ministry of Health and Population, with financial and technical assistance from the American non-profit, Possible. We implemented group antenatal care as a prospective non-randomized cluster-controlled, type I hybrid effectiveness-implementation study in six village clusters. The implementation approach allows for iterative improvement in design, making changes to improve the quality of the intervention. Assessments of implementation process and model fidelity were undertaken using a mobile checklist completed by nurse supervisors, and observation forms completed by program leadership. We evaluated data quarterly using descriptive statistics to identify trends. Qualitative interviews and team communications were analyzed through immersion crystallization to identify major themes that evolved during the implementation process.

Results: A total of 141 group antenatal sessions were run during the study period. This paper reports on implementation results, whereas we analyze and present patient-level effectiveness outcomes in a complementary paper in this journal. There was high process fidelity to the model, with 85.7% (95% CI 77.1-91.5%) of visits completing all process elements, and high content fidelity, with all village clusters meeting the minimum target frequency for 80% of topics. The annual per capita cost for group antenatal care was 0.50 USD. Qualitative analysis revealed the compromise of stable gestation-matched composition of the group members in order to make the intervention feasible. Major adaptations were made in training, documentation, feedback and logistics.

Conclusion: Group antenatal care provided in collaboration with local government clinics has the potential to provide accessible and high quality antenatal care to women in rural Nepal. The intervention is a feasible and affordable alternative to individual antenatal care. Our experience has shown that adaptation from prior models was important for the program to be successful in the local context within the national healthcare system.

Trial registration: ClinicalTrials.gov Identifier: NCT02330887, registered 01/05/2015, retroactively registered.

Keywords: CenteringPregnancy; Group antenatal care; Group prenatal care; Implementation science; Institutional birth; Nepal; Quality of care.

Conflict of interest statement

AHB is employed by a private, non-profit corporation (Lakewood Health System) that de- livers healthcare using funds from fee-for-service medical transactions and private foundation support. IN is a student at a private university (Harvard T.H. Chan School of Public Health). PT is a student at a public university (University of New South Wales). DC, BBogati, SKhadka, SH, NC, and SKalaunee are employed by and, DM and SM work in partnership with a nonprofit healthcare company (Nyaya Health Nepal with support from a partner United States-based 501c3 organization Possible) that delivers free healthcare in rural Nepal using funds from the Government of Nepal and other public, philanthropic, and private foundation sources. At the time of program implementation, AHB worked in partnership with and IN, PT, BBelbase, and LK were employed by Nyaya Health Nepal. DC is a faculty member at and both DC and SH are employed part-time by a public university (University of Washington). BBelbase is employed by a non-government organization (Karma Health) that delivers free healthcare in rural Nepal using local municipal and individual philanthropic funds. RS employed at an academic medical center (Brigham and Women’s Hospital) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. RS employed at an academic medical center (Massachusetts General Hospital) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. RS is a faculty member at a private university (Harvard Medical School). MA is a graduate student at a private university (Yale School of Public Health). SKalaunee is a student at a private university (Eastern University). SR is a founding member of a non-profit organization (Group Care Global) that supports implementation of group healthcare programming using revenue from consulting and service training fees, and individual donations. SR and SM (joined after conclusion of the study) are voting members on the Group Care Global Board of Directors, a position for which they receive no compensation. NC and SH are employed by, and DC, DM and SM are faculty members at a private university (Icahn School of Medicine at Mount Sinai). DM is a non-voting member on the Board of Directors with Nyaya Health Nepal, a position for which he receives no compensation. All authors have read and understood Reproductive Health’s policy on declaration of interests, and declare that we have no competing financial interests. The authors do, however, believe strongly that healthcare is a public good, not a private commodity.