Group Antenatal Care: The Power of Peers for Increasing Skilled Birth Attendance in Achham, Nepal

Overview

In rural Nepal, the major drivers of underutilization of skilled birth attendance are poverty, poor social support and inadequate birth planning. Drawing from similar programs that have been shown to improve maternal and neonatal outcomes, we have designed a group antenatal care program that uses a participatory learning and action process to engage women in identifying and solving problems accessing maternity care services and create a supportive social network. We plan to test a group antenatal care program that will change antenatal care in three major ways: 1) conduct care in a group setting with women matched by gestational age, 2) incorporate participatory learning and action, and 3) provide expert and facilitated peer counseling.

The group antenatal care intervention aims to improve rates of institutional birth and ANC care completion via improving acceptability of group care, maternal and neonatal health knowledge, self-efficacy, social support, and birth planning. Objective 1: Assess the effect of group antenatal care on institutional birth rates through a prospective study using community household census data. Secondary outcomes will be completion of basic ANC package; neonatal mortality rate; percentage of preterm births; percentage of stillbirths; and percentage of small-for-gestational age (SGA) births. * Hypothesis 1: Group ANC will increase institutional birth rates by 5% over one year. * Hypothesis 2: Group ANC will increase completion of 4 ANC visits by 5% over one year. * Hypothesis 3: Group ANC will reduce infant mortality rate by 5% over one year. * Hypothesis 4: Group ANC will reduce the postpartum contraceptive prevalence rate by 5% over one year. * Hypothesis 5: Group ANC will reduce the stillbirth rate by 5% over one year. * Hypothesis 6: Group ANC will reduce the perinatal mortality rate 5% over one year. * Hypothesis 7: Group ANC will reduce the combined infant mortality and stillbirth rate by 5% over one year. Objective 2: Assess the mechanisms of implementation of group antenatal care through quantitative participant survey measures, qualitative focus group discussions and key informant interviews. * Hypothesis 1: Group antenatal care will be acceptable to participants and providers, and preferred to individual care. * Hypothesis 2: Group antenatal care will increase pregnant patients' access to and utilization of delivery services through improved knowledge, self-efficacy, social support and birth planning. Objective 3: Report on key aspects of the implementation process: costs, human resources, logistics, and fidelity of the group antenatal program to model content and participatory processes.