Research Article: Community health workers to improve uptake of maternal healthcare services: A cluster-randomized pragmatic trial in Dar es Salaam, Tanzania

Date Published: March 29, 2019

Publisher: Public Library of Science

Author(s): Pascal Geldsetzer, Eric Mboggo, Elysia Larson, Irene Andrew Lema, Lucy Magesa, Lameck Machumi, Nzovu Ulenga, David Sando, Mary Mwanyika-Sando, Donna Spiegelman, Ester Mungure, Nan Li, Hellen Siril, Phares Mujinja, Helga Naburi, Guerino Chalamilla, Charles Kilewo, Anna Mia Ekström, Dawn Foster, Wafaie Fawzi, Till Bärnighausen, Elvin H. Geng

Abstract: BackgroundHome delivery and late and infrequent attendance at antenatal care (ANC) are responsible for substantial avoidable maternal and pediatric morbidity and mortality in sub-Saharan Africa. This cluster-randomized trial aimed to determine the impact of a community health worker (CHW) intervention on the proportion of women who (i) visit ANC fewer than 4 times during their pregnancy and (ii) deliver at home.Methods and findingsAs part of a 2-by-2 factorial design, we conducted a cluster-randomized trial of a home-based CHW intervention in 2 of 3 districts of Dar es Salaam from 18 June 2012 to 15 January 2014. Thirty-six wards (geographical areas) in the 2 districts were randomized to the CHW intervention, and 24 wards to the standard of care. In the standard-of-care arm, CHWs visited women enrolled in prevention of mother-to-child HIV transmission (PMTCT) care and provided information and counseling. The intervention arm included additional CHW supervision and the following additional CHW tasks, which were targeted at all pregnant women regardless of HIV status: (i) conducting home visits to identify pregnant women and refer them to ANC, (ii) counseling pregnant women on maternal health, and (iii) providing home visits to women who missed an ANC or PMTCT appointment. The primary endpoints of this trial were the proportion of pregnant women (i) not making at least 4 ANC visits and (ii) delivering at home. The outcomes were assessed through a population-based household survey at the end of the trial period. We did not collect data on adverse events. A random sample of 2,329 pregnant women and new mothers living in the study area were interviewed during home visits. At the time of the survey, the mean age of participants was 27.3 years, and 34.5% (804/2,329) were pregnant. The proportion of women who reported having attended fewer than 4 ANC visits did not differ significantly between the intervention and standard-of-care arms (59.1% versus 60.7%, respectively; risk ratio [RR]: 0.97; 95% CI: 0.82–1.15; p = 0.754). Similarly, the proportion reporting that they had attended ANC in the first trimester did not differ significantly between study arms. However, women in intervention wards were significantly less likely to report having delivered at home (3.9% versus 7.3%; RR: 0.54; 95% CI: 0.30–0.95; p = 0.034). Mixed-methods analyses of additional data collected as part of this trial suggest that an important reason for the lack of effect on ANC outcomes was the perceived high economic burden and inconvenience of attending ANC. The main limitations of this trial were that (i) the outcomes were ascertained through self-report, (ii) the study was stopped 4 months early due to a change in the standard of care in the other trial that was part of the 2-by-2 factorial design, and (iii) the sample size of the household survey was not prespecified.ConclusionsA home-based CHW intervention in urban Tanzania significantly reduced the proportion of women who reported having delivered at home, in an area that already has very high uptake of facility-based delivery. The intervention did not affect self-reported ANC attendance. Policy makers should consider piloting, evaluating, and scaling interventions to lessen the economic burden and inconvenience of ANC.Trial NCT01932138

Partial Text: The World Health Organization (WHO) recommends frequent antenatal care (ANC) visits spaced at regular intervals during pregnancy [1]. A minimum of 4 ANC visits was recommended until 2016 [2], after which WHO changed its recommendation to a minimum of 8 visits [1], with the first visit taking place as early as possible and no later than the end of the first trimester. However, while almost all women in sub-Saharan Africa attend at least 1 ANC visit, few attend 4 or more visits, and few have their first visit within the first trimester [3]. This pattern is also true for Tanzania, where, according to the latest (2015–2016) Demographic and Health Survey, 98% of women had attended at least 1 ANC visit for their most recent live birth [4], but only 51% attended 4 ANC visits or more, and only 24% made their first visit during the first 3 months of pregnancy. Late and inconsistent ANC attendance may mean that health problems existing prior to pregnancy (e.g., sexually transmitted infections or anemia) or conditions arising during pregnancy (e.g., gestational diabetes or pre-eclampsia) are detected late, increasing the risk of adverse health outcomes for the mother and newborn [5]. In addition, the routine HIV testing conducted during ANC in sub-Saharan Africa generally serves as the entry point to prevention of mother-to-child HIV transmission (PMTCT) services [1,6]. In settings with high HIV prevalence, such as Tanzania [7], late and inconsistent ANC attendance is therefore likely to result in late initiation of antiretroviral therapy (ART) and poor ART adherence for pregnant women with HIV [6]. Improving the uptake of ANC is thus crucial to maximize the benefits of ART for both the mother and the newborn.

A total of 7,320 and 3,480 households were visited, and 1,784 and 758 women contacted, in the household survey in the intervention and standard-of-care wards, respectively (Fig 1). In all, 1,664 women in the intervention wards and 665 women in the standard-of-care wards were interviewed, which is similar to our projected sample size (1,464 and 696 women, respectively). The mean age of the participants was 27.3 (SD: 5.9) years, and 34.5% (804/2,329) of the women were pregnant at the time of the household visit. For 59 (8.9%) and 114 (6.9%) participants in the standard-of-care and intervention wards, respectively, we could not ascertain from the questionnaire data whether the participant was currently pregnant or had recently delivered. These participants were included in all analyses; we provide results in S4 Table for analyses excluding these participants. The participant characteristics were well balanced across the 2 study arms (Table 1).

In this cluster-randomized trial implemented directly in the public-sector health system in urban Tanzania, we investigated the impact of a large-scale community intervention—consisting of additional CHW supervision, CHW-led identification of newly pregnant women, and CHW follow-up at home of those who missed an ANC appointment—on ANC attendance and uptake of facility-based delivery. We found that the intervention had no effect on reducing self-reported late or infrequent ANC attendance. However, results suggest that the intervention was effective in reducing self-reported delivery at home. The CHW intervention almost halved the probability of self-reported home delivery, moving the already very high proportion of facility-based delivery in this population even closer to universal coverage.



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