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Background: Access to high-quality antenatal care services has been shown to be beneficial for maternal and child health. In 2016, the WHO published evidence-based recommendations for antenatal care that aim to improve utilization, quality of care, and the patient experience. Prior research in Nepal has shown that a lack of social support, birth planning, and resources are barriers to accessing services in rural communities. The success of CenteringPregnancy and participatory action women's groups suggests that group care models may both improve access to care and the quality of care delivered through women's empowerment and the creation of social networks. We present a group antenatal care model in rural Nepal, designed and implemented by the healthcare delivery organization Nyaya Health Nepal, as well as an assessment of implementation outcomes., Methods: The study was conducted at Bayalata Hospital in Achham, Nepal, via a public private partnership between the Nepali non-profit, Nyaya Health Nepal, and the Ministry of Health and Population, with financial and technical assistance from the American non-profit, Possible. We implemented group antenatal care as a prospective non-randomized cluster-controlled, type I hybrid effectiveness-implementation study in six village clusters. The implementation approach allows for iterative improvement in design, making changes to improve the quality of the intervention. Assessments of implementation process and model fidelity were undertaken using a mobile checklist completed by nurse supervisors, and observation forms completed by program leadership. We evaluated data quarterly using descriptive statistics to identify trends. Qualitative interviews and team communications were analyzed through immersion crystallization to identify major themes that evolved during the implementation process., Results: A total of 141 group antenatal sessions were run during the study period. This paper reports on implementation results, whereas we analyze and present patient-level effectiveness outcomes in a complementary paper in this journal. There was high process fidelity to the model, with 85.7% (95% CI 77.1-91.5%) of visits completing all process elements, and high content fidelity, with all village clusters meeting the minimum target frequency for 80% of topics. The annual per capita cost for group antenatal care was 0.50 USD. Qualitative analysis revealed the compromise of stable gestation-matched composition of the group members in order to make the intervention feasible. Major adaptations were made in training, documentation, feedback and logistics., Conclusion: Group antenatal care provided in collaboration with local government clinics has the potential to provide accessible and high quality antenatal care to women in rural Nepal. The intervention is a feasible and affordable alternative to individual antenatal care. Our experience has shown that adaptation from prior models was important for the program to be successful in the local context within the national healthcare system., Trial Registration: ClinicalTrials.gov Identifier: NCT02330887, registered 01/05/2015, retroactively registered.

Background: Persistent inequities in coverage of maternal and newborn health (MNH) services continue to pose a major challenge to the health-care system in Nepal. This paper uses a novel composite indicator of intersectional (dis) advantages to examine how different (in) equity markers intersect to create (in) equities in contact coverage of MNH services across the continuum of care (CoC) in Nepal.Methods: A secondary analysis was conducted among 1978 women aged 15-49 years who had a live birth in the two years preceding the survey. Data were derived from the Nepal Demographic and Health Survey (NDHS) 2016. The three outcome variables included were 1) at least four antenatal care (4ANC) visits, 2) institutional delivery, and 3) postnatal care (PNC) consult for newborns and mothers within 48 h of childbirth. Independent variables were wealth status, education, ethnicity, languages, residence, and marginalisation status. Intersectional (dis) advantages were created using three socioeconomic variables (wealth status, level of education and ethnicity of women). Binomial logistic regression analysis was employed to identify the patterns of (in) equities in contact coverage of MNH services across the CoC.Results: The contact coverage of 4ANC visits, institutional delivery, and PNC visit was 72, 64, and 51% respectively. Relative to women with triple disadvantage, the odds of contact coverage of 4ANC visits was more than five-fold higher (Adjusted Odds Ratio (aOR) = 5.51; 95% CI: 2.85, 10.64) among women with triple forms of advantages (literate and advantaged ethnicity and higher wealth status). Women with triple advantages were seven-fold more likely to give birth in a health institution (aOR = 7.32; 95% CI: 3.66, 14.63). They were also four times more likely (aOR = 4.18; 95% CI: 2.40, 7.28) to receive PNC visit compared to their triple disadvantaged counterparts.Conclusions: The contact coverage of routine MNH visits was low among women with social disadvantages and lowest among women with multiple forms of socioeconomic disadvantages. Tracking health service coverage among women with multiple forms of (dis) advantage can provide crucial information for designing contextual and targeted approaches to actions towards universal coverage of MNH services and improving health equity. [ABSTRACT FROM AUTHOR]

Background: Women's role has been a priority area not only for sustainable development, but also in reproductive health since ICPD 1994. However, very little empirical evidence is available about women's role on maternal health service utilization in Nepal. This paper explores dimensions of women's autonomy and their relationship to utilization of maternal health services.Methods: The analysis uses data from the Nepal Demographic and Health Survey, 2011. The analysis is confined to women who had given birth in the 5 years preceding the survey (n = 4,148). Women's autonomy related variables are taken from the standard DHS questionnaire and measured based on decision in household about obtaining health care, large household purchases and visit to family or relative. The net effect of women's autonomy on utilization of maternal health services after controlling for the effect of other predictors has been measured through multivariate logistic regression analysis.Results: The findings indicate only about a half of the women who had given birth in the past 5 years preceding the survey had 4 or more ANC check up for their last birth. Similarly, 40 % of the women had delivered their last child in the health facilities. Furthermore, slightly higher than two-fifth women (43 %) had postnatal check up for their last child. Only slightly higher than a fourth woman (27 %) had utilized all the services (adequate ANC visit, delivered at health institution and post natal check up) for their last child. This study found that many socio-demographic variables such as age of women, number of children born, level of education, ethnicity, place of residence and wealth index are predicators of utilizing the maternal health services of recent child. Notably, higher level autonomy was associated with higher use of maternal health services [adjusted odds ratio (aOR) =1.40; CI 1.18-1.65].Conclusions: Utilization of maternal health services for the recent child among women is very low. The study results suggest that policy actions that increase women's autonomy at home could be effective in helping assure good maternal health. [ABSTRACT FROM AUTHOR]

Background: Maternal health affects the lives of many women and children globally every year and it is one of the high priority programs of the Government of Nepal (GoN). Different evidence articulate that the equity gap in accessing and using maternal health services at national level is decreasing over 2001-2016. This study aimed to assess whether the equity gap in using maternal health services is also decreasing at subnational level over this period given the geography of Nepal has already been identified as one of the predictors of accessibility and utilization of maternal health services.Methods: The study used wealth index scores for each household and calculated the concentration curves and indexes in their relative formulation, with no corrections. Concentration curve was used to identify whether socioeconomic inequality in maternity services exists and whether it was more pronounced at one point in time than another or in one province than another. The changes between 2001 and 2016 were also disaggregated across the provinces. Test of significance of changes in Concentration Index was performed by calculating pooled standard errors. We used R software for statistical analysis.Results: The study observed a progressive and statistically significant decrease in concentration index for at least four antenatal care (ANC) visit and institutional delivery at national level over 2001-2016. The changes were not statistically significant for Cesarean Section delivery. Regarding inequality in four-ANC all provinces except Karnali showed significant decreases at least between 2011 and 2016. Similarly, all provinces, except Karnali, showed a statistically significant decrease in concentration index for institutional delivery between 2011 and 2016.Conclusion: Despite appreciable progress at national level, the study found that the progress in reducing equity gap in use of maternal health services is not uniform across seven provinces. Tailored investment to address barriers in utilization of maternal health services across provinces is urgent to make further progress in achieving equitable distribution in use of maternal health services. There is an opportunity now that the country is federalized, and provincial governments can make a need-based improvement by addressing specific barriers. [ABSTRACT FROM AUTHOR]

Background: In resource-poor settings, the provision of basic maternity care within health centres is often a challenge. Despite the difficulties, Nepal reduced its maternal mortality ratio by 80% from 850 to an estimated 170 per 100,000 live births between 1991 and 2011 to achieve Millennium Development Goal Five. One group that has been credited for this is community health workers, known as Female Community Health Volunteers (FCHVs), who form an integral part of the government healthcare system. This qualitative study explores the role of FCHVs in maternal healthcare provision in two regions: the Hill and Terai.Methods: Between May 2014 and September 2014, 20 FCHVs, 11 health workers and 26 service users were purposefully selected and interviewed using semi-structured topic guides. In addition, four focus group discussions were held with 19 FCHVs. Data were analysed using thematic analysis.Results: All study participants acknowledged the contribution of FCHVs in maternity care. All FCHVs reported that they shared key health messages through regularly held mothers' group meetings and referred women for health checks. The main difference between the two study regions was the support available to FCHVs from the local health centres. With regular training and access to medical supplies, FCHVs in the hill villages reported activities such as assisting with childbirth, distributing medicines and administering pregnancy tests. They also reported use of innovative approaches to educate mothers. Such activities were not reported in Terai. In both regions, a lack of monetary incentives was reported as a major challenge for already overburdened volunteers followed by a lack of education for FCHVs.Conclusions: Our findings suggest that the role of FCHVs varies according to the context in which they work. FCHVs, supported by government health centres with emphasis on the use of local approaches, have the potential to deliver basic maternity care and promote health-seeking behaviour so that serious delays in receiving healthcare can be minimised. However, FCHVs need to be reimbursed and provided with educational training to ensure that they can work effectively. The study underlines the relevance of community health workers in resource-poor settings. [ABSTRACT FROM AUTHOR]

Background: Reducing the maternal mortality ratio to less than 70 per 100,000 live births globally is one of the Sustainable Development Goals. Approximately 830 women die from pregnancy- or childbirth-related complications every day. Almost 99% of these deaths occur in developing countries. Increasing antenatal care quality and completion, and institutional delivery are key strategies to reduce maternal mortality, however there are many implementation challenges in rural and resource-limited settings. In Nepal, 43% of deliveries do not take place in an institution and 31% of women have insufficient antenatal care. Context-specific and evidence-based strategies are needed to improve antenatal care completion and institutional birth. We present an assessment of effectiveness outcomes for an adaptation of a group antenatal care model delivered by community health workers and midwives in close collaboration with government staff in rural Nepal. Methods: The study was conducted in Achham, Nepal, via a public private partnership between the Nepali non-profit, Nyaya Health Nepal, and the Ministry of Health and Population, with financial and technical assistance from the American non-profit, Possible. We implemented group antenatal care as a prospective non-randomized, cluster-controlled, type I hybrid effectiveness-implementation study in six village clusters. The implementation approach allowed for iterative improvement in design by making changes to improve the quality of the intervention. We evaluated effectiveness through a difference in difference analysis of institutional birth rates between groups prior to implementation of the intervention and 1 year after implementation. Additionally, we assessed the change in knowledge of key danger signs and the acceptability of the group model compared with individual visits in a nested cohort of women receiving home visit care and home visit care plus group antenatal care. Using a directed content and thematic approach, we analyzed qualitative interviews to identify major themes related to implementation. Results: At baseline, there were 457 recently-delivered women in the six village clusters receiving home visit care and 214 in the seven village clusters receiving home visit care plus group antenatal care. At endline, there were 336 and 201, respectively. The difference in difference analysis did not show a significant change in institutional birth rates nor antenatal care visit completion rates between the groups. There was, however, a significant increase in both institutional birth and antenatal care completion in each group from baseline to endline. We enrolled a nested cohort of 52 participants receiving home visit care and 62 participants receiving home visit care plus group antenatal care. There was high acceptability of the group antenatal care intervention and home visit care, with no significant differences between groups. A significantly higher percentage of women who participated in group antenatal care found their visits to be 'very enjoyable' (83.9% vs 59.6%, p = 0.0056). In the nested cohort, knowledge of key danger signs during pregnancy significantly improved from baseline to endline in the intervention clusters only (2 to 31%, p < 0.001), while knowledge of key danger signs related to labor and childbirth, the postpartum period, and the newborn did not in either intervention or control groups. Qualitative analysis revealed that women found that the groups provided an opportunity for learning and discussion, and the groups were a source of social support and empowerment. They also reported an improvement in services available at their village clinic. Providers noted the importance of the community health workers in identifying pregnant women in the community and linking them to the village clinics. Challenges in birth planning were brought up by both participants and providers. Conclusion: While there was no significant change in institutional birth and antenatal care completion at the population level between groups, there was an increase of these outcomes in both groups. This may be secondary to the primary importance of community health worker involvement in both of these groups. Knowledge of key pregnancy danger signs was significantly improved in the home visit plus group antenatal care cohort compared with the home visit care only group. This initial study of Nyaya Health Nepal's adapted group care model demonstrates the potential for impacting women's antenatal care experience and should be studied over a longer period as an intervention embedded within a community health worker program. Trial registration: ClinicalTrials.gov Identifier: NCT02330887, registered 01/05/2015, retroactively registered. [ABSTRACT FROM AUTHOR]