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

Abstract

BackgroundReducing 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.MethodsThe 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.ResultsAt 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....

“Taking Care of Your Pregnancy”: A Mixed-Methods Study of Group Antenatal Care in Kakamega County, Kenya

“…We hypothesize that non-use of family planning in our sample may be due to a low perceived risk of pregnancy before a return of menses, as a systematic review found [38]. Like the study in Nepal [31], we found no quantitative data showing an increase in facility delivery; the use of facilities for delivery at baseline was high (89%), making changes harder to see. In contrast, through our qualitative data, health providers, CHVs, and county staff reported that GANC led to a perceived increase in rates of facility delivery at project sites.…”

“…This contradicts what is generally found in the literature [17,23,34,35], which has reported improvements in all aspects of knowledge. A recent study in Nepal [31] also found that knowledge of danger signs signi cantly improved, but knowledge of birth preparation decreased, from baseline to endline. Our qualitative data revealed that participating women identi ed learning as the aspect they most valued in GANC; they appreciated the tips and information and an understanding of the "why" in addition to the "what."…”

“…The only quantitative study to date assessing the effect of GANC on women's empowerment [25] had mixed results: in Malawi, women in GANC had higher empowerment scores, while there was no statistically signi cant difference in Tanzania. We found only one qualitative study [31] assessing empowerment as a result of GANC, where women reported feeling empowered to speak up in a group setting. In our qualitative data women, most notably among adolescents, reported feelings of empowerment and self-e cacy to do things they felt they could not before they attended GANC.…”

“…We found no statistically signi cant changes in ANC retention or early initiation of ANC. To date, few studies have assessed the effects of GANC on retention: studies in Malawi, Tanzania, Nigeria and Kenya [24,25,29] reported ANC4+ retention was higher in GANC than individual ANC; a study in Nepal [31], however, also found no change in ANC completion. No previous studies have examined the effect of GANC on early ANC initiation, and only one qualitative study has examined the role of the patient-provider relationship in seeking early ANC [39].…”

“…Evidence on social support is also limited, although research shows that continuous social and emotional support in childbirth affects outcomes for the mother and the newborn, including reductions in cesarean sections, antenatal hospital admissions, and mean number of hospitalization episodes [28], and is protective against postpartum depression [30]. Finally, only one recent study [31] has provided a theory of change to explain how GANC led to the expected effects.…”