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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 2019

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

In the beginning of 2019, Possible executed several activities as part of its planned community health expansion activities across Dolakha and Achham districts. This included: the expansion of activities in Bhimeswor (Dolakha); the continuation of the baseline survey; conducting refresher training on mental health programs to all CHWs and new CHNs; the continuation of Group ANC services; the expansion in Tamakoshi (Dolakha) which includes the hiring of staff, and getting the continuous surveillance system (CSS) and pregnancy surveillance system (PSS) up and running; and finally, the team in Achham conducted meetings with the Mangalsen municipality chief and ward chairpersons regarding the planned expansion to the region.

Over the next 3-6 months, the team plans to expand program activities in existing hubs, and initiate program to additional hubs. In parallel, they will publish additional interim studies pertaining to the work and continue conversations with the Ministry of Health leadership around CHW policy strategy.

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