Effect of community health worker home visits on antenatal care and institutional delivery: an analysis of secondary outcomes from a cluster randomised trial in Mali

Abstract

IntroductionThough community health workers (CHWs) have improved access to antenatal care (ANC) and institutional delivery in different settings, it is unclear what package and delivery strategy maximises impact.MethodsThis study reports a secondary aim of the Proactive Community Case Management cluster randomised trial, conducted between December 2016 and April 2020 in Mali. It evaluated whether proactive home visits can improve ANC access at a population level compared with passive site-based care. 137 unique village clusters, covering the entire study area, were stratified by health catchment area and distance to the nearest primary health centre. Within each stratum, clusters were randomly assigned to intervention or control arm. CHWs in intervention clusters proactively visited all homes to provide care. In the control clusters, CHWs provided the same services at their fixed community health post to care-seeking patients. Pregnant women 15–49 years old were enrolled in a series of community-based and facility-based visits. We analysed individual-level annual survey data from baseline and 24-month and 36-month follow-up for the secondary outcomes of ANC and institutional delivery, complemented with CHW monitoring data during the trial period. We compared outcomes between: (1) the intervention and control arms, and (2) the intervention period and baseline.ResultsWith 2576 and 2536 pregnancies from 66 and 65 clusters in the intervention and control arms, respectively, the estimated risk ratios for receiving any ANC was 1.05 (95% CI 1.02 to 1.07), four or more ANC visits was 1.25 (95% CI 1.08 to 1.43) and ANC initiated in the first trimester was 1.11 (95% CI 1.02 to 1.19), relative to the controls; no differences in institutional delivery were found. However, both arms achieved large improvements in institutional delivery, compared with baseline. Monitoring data show that 19% and 2% of registered pregnancies received at least eight ANC contacts in the intervention and control arms, respectively. Six clusters, three from each arm had to be dropped in the last 2 years of the trial.ConclusionsProactive home visits increased ANC and the number of antenatal contacts at the clinic and community levels. ANC and institutional delivery can be increased when provided without fees from professional CHWs in upgraded primary care clinics.Trial registration numberNCT02694055.

Effects of proactive vs fixed community health care delivery on child health and access to care: a cluster randomised trial secondary endpoint analysis

“…For maternal health care, our analysis of other secondary trial endpoints (reported elsewhere) [ 35 ] found that proactive CHW home visits increased the likelihood of first trimester antenatal care (ANC) by 11% (risk ratio (RR) = 1.11; 95% CI = 1.02, 1.19) and of four or more ANC visits by 25% (RR = 1.25; 95% CI = 1.08, 1.43), but had no effect on institutional delivery (RR=1.06; 95% CI = 0.91, 1.20). Across trial arms relative to baseline, any ANC attendance increased by 83% (RR = 1.83; 95% CI = 1.78, 1.86), first trimester ANC by 15% (RR = 1.15; 95% CI = 1.06, 1.25), four or more ANC visits by 2.6 times (RR = 2.59; 95% CI = 2.28, 2.91), and institutional delivery by 54% (RR = 1.54; 95% CI = 1.41, 1.66) [ 35 ]. These maternal care results are consistent with the child health care utilisation results insomuch that the bulk of the improvements occurred across both arms, with the proactive service delivery intervention yielding modest incremental benefits, which are nonetheless important for achieving timely, universal health coverage.…”

Effectiveness of a Community Health Worker-Driven Intervention in Improving the Quality of Life of Caregivers of Children With Disability in Rural Karnataka, India

“…The CHW-driven intervention is being used extensively across the globe for varying health services, from addressing post-partum depression [13], for support in diabetes for immigrants [14], care for childhood diseases in Liberia [15], increasing healthcare access in marginalized communities of New York [16], improve access to cancer care [17], increasing antenatal contacts and promoting institutional deliveries [18], and addressing unmet needs among children with asthma [19]. The CHW-driven intervention is cost-effective and can benefit the unreached population of healthcare [20].…”