A Type II hybrid effectiveness-implementation study of an integrated CHW intervention to address maternal healthcare in rural Nepal

Abstract

Skilled care during pregnancy, childbirth, and postpartum is essential to prevent adverse maternal health outcomes, yet utilization of care remains low in many resource-limited countries, including Nepal. Community health workers (CHWs) can mitigate health system challenges and geographical barriers to achieving universal health coverage. Gaps remain, however, in understanding whether evidence-based interventions delivered by CHWs, closely aligned with WHO recommendations, are effective in Nepal’s context. We conducted a type II hybrid effectiveness-implementation, mixed-methods study in two rural districts in Nepal to evaluate the effectiveness and the implementation of an evidence-based integrated maternal and child health intervention delivered by CHWs, using a mobile application. The intervention was implemented stepwise over four years (2014–2018), with 65 CHWs enrolling 30,785 families. We performed a mixed-effects Poisson regression to assess institutional birth rate (IBR) pre-and post-intervention. We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to evaluate the implementation during and after the study completion. There was an average 30% increase in IBR post-intervention, adjusting for confounding variables (p<0.0001). Study enrollment showed 35% of families identified as dalit, janjati, or other castes. About 78–89% of postpartum women received at least one CHW-counseled home visit within 60 days of childbirth. Ten (53% of planned) municipalities adopted the intervention during the study period. Implementation fidelity, measured by median counseled home visits, improved with intervention time. The intervention was institutionalized beyond the study period and expanded to four additional hubs, albeit with adjustments in management and supervision. Mechanisms of intervention impact include increased knowledge, timely referrals, and longitudinal CHW interaction. Full-time, supervised, and trained CHWs delivering evidence-based integrated care appears to be effective in improving maternal healthcare in rural Nepal. This study contributes to the growing body of evidence on the role of community health workers in achieving universal health coverage.

“Even things they won’t share with their sisters-in-law”– Assessing an integrated Community Health Worker intervention on person-centered postpartum contraception in rural Nepal

“…Stable electricity and therefore, mobile phone service and communication with the participants was less reliable during the rainy season. These barriers are also described further in detail elsewhere (26).…”

“…CHWs delivered this bundled intervention using CommCare, an open-source, mobile platform that guided counseling, provided decision support, and allowed for offline data collection. The full details of the intervention and its implementation, and sociodemographic characteristics of the study site are published elsewhere (25, 26, 29).…”

“…The intervention, delivered by CHWs, sought to reach an estimated population of 300,000 in two rural districts. In line with WHO recommendations (24), CHWs were local, full-time, salaried, trained and supervised employees, and used a mobile platform that facilitated counseling support and longitudinal data collection to deliver the intervention (25,26).…”

“…The intervention, delivered by CHWs, sought to reach an estimated population of 300,000 in two rural districts. In line with WHO recommendations (24), CHWs were local, full-time, salaried, trained and supervised employees, and used a mobile platform that facilitated counseling support and longitudinal data collection to deliver the intervention (25, 26). Contraceptive counseling was integrated into this bundled intervention based on evidence supporting the effectiveness of integrated contraception interventions over stand-alone ones (8, 27, 28).…”

“…(31, 32). We have previously reported the bundled intervention’s outcomes on antenatal and postnatal care (26). In this paper, we focus on postpartum contraceptive outcomes associated with the integrated RMNCH intervention over a five-year period in two districts.…”