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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 - December 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

The previous quarter's activities were interrupted by the nationwide suspension of activities including CHW-led home-based care visits. Prior to the announcement by the government, all project activities were running smoothly across the project intervention areas. In Ramaroshan municipality (Achham district), the project signed an MOU at the beginning of the year with the municipal government to jointly implement community-based activities including the RMNCH intervention. The agreement incorporated the allocation of municipal funds to support CHW personnel costs. Following the signing of the MOU, the municipality has successfully hired seven CHWs required for the project who will lead the delivery of the home-based package of reproductive, maternal, newborn and child health (RMNCH) services.

The team are also in the process of completing the interim analysis of the bundled intervention and will proceed with dissemination of results once the government re-opens activities and lifts the measures that have been put in place in response to the COVID-19 pandemic.

Analysis of new expansion area baseline data and ongoing programmatic data is ongoing and the team is looking ahead to potential final research publications. Through its robust network of CHWs, the project team has seen 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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