Community-based postpartum contraceptive counselling in rural Nepal: a mixed-methods evaluation

Wu, Wan‐Ju; Tiwari, Aparna; Choudhury, Nandini; Basnett, Indira; R.G.Bhatt,; Citrin, David; Halliday, Scott; Kunwar, Lal; Maru, Duncan; Nirola, Isha; Pandey, Sachit; Rayamazi, Hari Jung; Sapkota, Sabitri; Saud, Sita; Thapa, Aradhana; Goldberg, Alisa B.; Maru, Sheela

doi:10.1080/26410397.2020.1765646

Cited by 12 publications

(24 citation statements)

References 41 publications

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“…In addition, for women and girls in this setting, the comfort and ability to respond to open-ended questions are often challenging despite measures to ensure privacy and confidentiality. 34 The voices of the most vulnerable girls may have been under-sampled. 35 Furthermore, due to resource limitations, we did not formally back-translate the interviews to assess for accuracy of the translations.…”

Section: Discussionmentioning

confidence: 99%

“Our mothers do not tell us”: a qualitative study of adolescent girls’ perspectives on sexual and reproductive health in rural Nepal

Tiwari

Citrin

et al. 2022

Sexual and Reproductive Health Matters

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Adolescent girls in low- and middle-income countries continue to face poor sexual and reproductive health (SRH). In Nepal, early marriage and motherhood, gender-based violence, and unmet need for contraception remain pervasive. Adolescent girls in rural areas bear a disproportionate burden of poor reproductive health outcomes, but there are limited context-specific data. This is a qualitative study to identify factors that impact adolescent girls’ utilisation of and access to SRH services in a rural district of Nepal. We conducted 21 individual interviews with adolescent girls aged 15–19 years, and three focus group discussions with community health workers. We used an inductive analytic approach to identify emergent and recurrent themes and present the themes using the social ecological model. Individual-level factors that contribute to low uptake of services among adolescent girls include lack of knowledge, self-perceived lack of need, low decision-making autonomy, and shyness. Interpersonal factors that impact access include unsupportive family norms, absence of open communication, and need for permission from family members to access care. At the community level, disparate gender norms, son preference, and judgment by community members affect adolescent SRH. Inadequate sex education, far travel distance to facilities, lack of female healthcare providers and teachers, and inability to access abortion services were identified as organisational and systems barriers. Stigma was a factor cross-cutting several levels. Our findings suggest the need for multi-level strategies to address these factors to improve adolescent girls’ SRH.

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Section: Discussionmentioning

confidence: 99%

“Our mothers do not tell us”: a qualitative study of adolescent girls’ perspectives on sexual and reproductive health in rural Nepal

Tiwari

Citrin

et al. 2022

Sexual and Reproductive Health Matters

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“…While our study addressed health literacy, community-based care, social support for women, and linkages between community and facility-based care, other structural and socio-cultural factors, such as facility quality and gender-based violence that also affect health outcomes were beyond the scope of this study. In the long-term, improvements in the healthcare quality coupled with other community efforts to address social determinants of health may also be essential for substantial impact [41][42][43]. The findings from this study could potentially inform community health strategy and scale-up in Nepal and similar settings.…”

Section: Discussionmentioning

confidence: 85%

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

Tiwari

Thapa

Choudhury

et al. 2023

PLOS Glob Public Health

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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.

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“…This could have caused misclassification or underreporting of mortality and stillbirths in the programmatic data as well. However, this limitation may have been partially mitigated since CHWs belong to the same community as the women they serve, and have built trust with them through continued engagement during care delivery [ 38 ]. Future studies should attempt to use a more advanced and in-depth method, such as verbal and social autopsy and participatory analytic methods, and strengthen linkages with government reporting systems, to identify stillbirth and mortality events with greater accuracy [ 8 , 14 ].…”

Section: Discussionmentioning

confidence: 99%

Comparing two data collection methods to track vital events in maternal and child health via community health workers in rural Nepal

Choudhury

Tiwari²,

Wu³

et al. 2022

Popul Health Metrics

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Background Timely tracking of health outcomes is difficult in low- and middle-income countries without comprehensive vital registration systems. Community health workers (CHWs) are increasingly collecting vital events data while delivering routine care in low-resource settings. It is necessary, however, to assess whether routine programmatic data collected by CHWs are sufficiently reliable for timely monitoring and evaluation of health interventions. To study this, we assessed the consistency of vital events data recorded by CHWs using two methodologies—routine data collected while delivering an integrated maternal and child health intervention, and data from a birth history census approach at the same site in rural Nepal. Methods We linked individual records from routine programmatic data from June 2017 to May 2018 with those from census data, both collected by CHWs at the same site using a mobile platform. We categorized each vital event over a one-year period as ‘recorded by both methods,’ ‘census alone,’ or ‘programmatic alone.’ We further assessed whether vital events data recorded by both methods were classified consistently. Results From June 2017 to May 2018, we identified a total of 713 unique births collectively from the census (birth history) and programmatic maternal ‘post-delivery’ data. Three-fourths of these births (n = 526) were identified by both. There was high consistency in birth location classification among the 526 births identified by both methods. Upon including additional programmatic ‘child registry’ data, we identified 746 total births, of which 572 births were identified by both census and programmatic methods. Programmatic data (maternal ‘post-delivery’ and ‘child registry’ combined) captured more births than census data (723 vs. 595). Both methods consistently classified most infants as ‘living,’ while infant deaths and stillbirths were largely classified inconsistently or recorded by only one method. Programmatic data identified five infant deaths and five stillbirths not recorded in census data. Conclusions Our findings suggest that data collected by CHWs from routinely tracking pregnancies, births, and deaths are promising for timely program monitoring and evaluation. Despite some limitations, programmatic data may be more sensitive in detecting vital events than cross-sectional census surveys asking women to recall these events.

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Community-based postpartum contraceptive counselling in rural Nepal: a mixed-methods evaluation

Cited by 12 publications

References 41 publications

“Our mothers do not tell us”: a qualitative study of adolescent girls’ perspectives on sexual and reproductive health in rural Nepal

“Our mothers do not tell us”: a qualitative study of adolescent girls’ perspectives on sexual and reproductive health in rural Nepal

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

Comparing two data collection methods to track vital events in maternal and child health via community health workers in rural Nepal

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