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PARTNERSHIPS FOR ENHANCED ENGAGEMENT IN RESEARCH (PEER)
Cycle 5 (2015 Deadline)


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


PI: Pushpa Chaudhary (deopushpa@gmail.com), 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.

Overall Summary of Activities

The primary outcome of this CHW intervention providing comprehensive sexual, reproductive, maternal, newborn and child health services was an increase in the institutional birth rate. With the support of PEER, the project team was able to complete the project including enrollment of 11,416 births in the study, enrolling 55,419 households through an integrated community health worker program. Publications on this work are forthcoming. For the primary outcome, the team observed an average increase from 65% in institutional birth rate at the start of the intervention to 84% at year 1, 93% at year 2, 97% at year 3, and 98% at year 4 following the intervention. This result is significant (p<0.05) for the impact of the intervention. This primary result, coupled with other secondary outcomes, are currently being prepared for publication. The team plans to use these publications along with dissemination efforts to advocate for a professional cadre of CHWs delivering integrated services throughout Nepal.


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