The power of peers: an effectiveness evaluation of a cluster-controlled trial of group antenatal care in rural Nepal

Abstract

Background: Reducing the maternal mortality ratio to less than 70 per 100,000 live births globally is one of the Sustainable Development Goals. Approximately 830 women die from pregnancy- or childbirth-related complications every day. Almost 99% of these deaths occur in developing countries. Increasing antenatal care quality and completion, and institutional delivery are key strategies to reduce maternal mortality, however there are many implementation challenges in rural and resource-limited settings. In Nepal, 43% of deliveries do not take place in an institution and 31% of women have insufficient antenatal care. Context-specific and evidence-based strategies are needed to improve antenatal care completion and institutional birth. We present an assessment of effectiveness outcomes for an adaptation of a group antenatal care model delivered by community health workers and midwives in close collaboration with government staff in rural Nepal.

Methods: The study was conducted 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 allowed for iterative improvement in design by making changes to improve the quality of the intervention. We evaluated effectiveness through a difference in difference analysis of institutional birth rates between groups prior to implementation of the intervention and 1 year after implementation. Additionally, we assessed the change in knowledge of key danger signs and the acceptability of the group model compared with individual visits in a nested cohort of women receiving home visit care and home visit care plus group antenatal care. Using a directed content and thematic approach, we analyzed qualitative interviews to identify major themes related to implementation.

Results: At baseline, there were 457 recently-delivered women in the six village clusters receiving home visit care and 214 in the seven village clusters receiving home visit care plus group antenatal care. At endline, there were 336 and 201, respectively. The difference in difference analysis did not show a significant change in institutional birth rates nor antenatal care visit completion rates between the groups. There was, however, a significant increase in both institutional birth and antenatal care completion in each group from baseline to endline. We enrolled a nested cohort of 52 participants receiving home visit care and 62 participants receiving home visit care plus group antenatal care. There was high acceptability of the group antenatal care intervention and home visit care, with no significant differences between groups. A significantly higher percentage of women who participated in group antenatal care found their visits to be 'very enjoyable' (83.9% vs 59.6%, p = 0.0056). In the nested cohort, knowledge of key danger signs during pregnancy significantly improved from baseline to endline in the intervention clusters only (2 to 31%, p < 0.001), while knowledge of key danger signs related to labor and childbirth, the postpartum period, and the newborn did not in either intervention or control groups. Qualitative analysis revealed that women found that the groups provided an opportunity for learning and discussion, and the groups were a source of social support and empowerment. They also reported an improvement in services available at their village clinic. Providers noted the importance of the community health workers in identifying pregnant women in the community and linking them to the village clinics. Challenges in birth planning were brought up by both participants and providers.

Conclusion: While there was no significant change in institutional birth and antenatal care completion at the population level between groups, there was an increase of these outcomes in both groups. This may be secondary to the primary importance of community health worker involvement in both of these groups. Knowledge of key pregnancy danger signs was significantly improved in the home visit plus group antenatal care cohort compared with the home visit care only group. This initial study of Nyaya Health Nepal's adapted group care model demonstrates the potential for impacting women's antenatal care experience and should be studied over a longer period as an intervention embedded within a community health worker program.

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

Keywords: Centering pregnancy; Child health; Group antenatal care; Implementation research; Maternal health; Peer group; Prenatal care.

Conflict of interest statement

PT is a student at a public university (University of New South Wales). AHB is employed by a private, non-profit corporation (Lakewood Health System) that delivers healthcare using funds from fee-for-service medical transactions and private foundation support. IN is a student at a private university (Harvard University). IN is a voting member (joined after conclusion of the study) and DM is a non-voting member on the Board of Directors with Possible, positions for which they receive no compensation. DC, BBogati, NBK, SKhadka, and SKalaunee are employed by and, NC, SH, RS, 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, PT, IN, BBelbase, LK, and JT were employed by and AHB worked in partnership with Nyaya Health Nepal. DC is a faculty member at, SH is a graduate student 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. 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). AO is employed at an academic medical center (Boston Children’s Hospital) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. AO and RS are faculty members at a private university (Harvard Medical School). RS is 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 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. MA is a graduate student at a private university (Yale School of Public Health). SKalaunee is a student at private university (Eastern University). SR is a founding member of a non-profit global healthcare consulting organization (Group Care Global) that supports implementation of group healthcare programming using revenue from consulting and training service fees and individual donations. SR and SM (joined after conclusion of the study) are voting members of Group Care Global’s Board of Directors, positions for which they do not receive 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.

Figures

Fig. 1

Participant enrollment flow diagram

Fig. 2

Group ANC theory of change