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Cycle 5 (2015 Deadline)

Cluster-controlled implementation science trial of integrated maternal newborn child healthcare delivery in group settings

PI: Pushpa Chaudhary (, Nepal Ministry of Health & Possible (formerly known as Nyaya Health)
U.S. Partner: Duncan Maru, Brigham and Women's Hospital
Project Dates: January 2017 - June 2020

Project Overview:

5-17 CHW Checkup
A community health worker conducts a check-up (photo courtesy of Dr. Chaudhary).
This research team will conduct a cluster-controlled, stepped wedge implementation science trial of a bundled maternal healthcare delivery intervention in rural communities in Nepal. Nepal represents an ideal setting to pilot this study based on its robust national community health worker network, progressive national healthcare priorities, and the team's personal experience in delivering healthcare in a district public healthcare setting since 2008. The intervention integrates three evidence-based approaches for maternal, newborn, and child health: (1) group antenatal and postnatal care to improve the institutional birth rate and reduce mortality among children under age two; (2) a Community Health Worker (CHW) model of home-based care to monitor and increase utilization of services, maternal and neonatal health knowledge, self-efficacy, social support, and emergency planning among mothers; and (3) a mentoring approach to quality improvement targeted at government clinic providers in the study population. This intervention will be implemented and tested in the district of Achham, Far-West Nepal, within a district population of 260,000. Achham is one of 20 priority districts under USAID’s development strategy in Nepal.

The study aims to analyze the impact of the integrated care package on institutional birth rates and under-two mortality using community household survey data. The researchers will assess the mechanisms of the impact of group integrated care and assess the efficacy of targeted CHW protocols for a home-based model of care delivery to address maternal, neonatal, and child care, in addition to chronic disease care, continuous surveillance, and mortality assessment. They will describe key aspects of the implementation process, including costs, human resources, logistics, and fidelity of the group integrated care program to model content and processes. Finally, they will produce a cost-effectivness analysis to determine affordability for national government adoption and Possible’s care delivery model. It is expected that the interventions should decrease infant mortality and morbidity, increase the percent of births that occur in a monitored setting, and increase subsequent contraceptive use.

Summary of Recent Activities

Possible successfully conducted its planned community health project activities and engaged with key stakeholders in the last quarter of 2019 across the various municipalities. In Baiteshwor (Dolakha), the community health team continues to continuously provide pregnancy surveillance, first aid, antenatal care, labor, and family planning services, and engaged with stakeholders through meetings with female community health volunteers (FCHVs), health mother's groups, and other stakeholders. Following CHW training, the team plans to rollout postnatal and under-2 services in the remaining wards in the coming months. In the second municipality, Chaurpati (Achham), project CHWs continued to provide comprehensive RMNCH services throughout the region and the team had discussions to introduce additional non-communicable disease (NCD) services through its community health program.

Expansion of the direct enrolled population for the RMNCH intervention will continue but the team is beginning to taper expansion efforts over the remainder of the grant period. Hiring new CHWs and their CHN supervisors will continue, but in parallel, Possible will continue to iteratively refine training materials for existing team members based on learnings to date. Analysis of new expansion area baseline data and ongoing programmatic data is ongoing and the team is looking ahead to potential final research publications. By hiring, growing, and training a robust network of CHWs who have larger reach and capacity, the project team is seeing an improvement in health outcomes and reduced mortality among infants, children, and women in rural communities in Nepal. This evidence will be consolidated into a final report at the end of the funding period.

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