Background
Public accountability of healthcare institutions
Maternal and newborn health in Nepal
Engaging citizens and communities in Nepal
Methods
Setting
Trial design
Participants
Allocation
Outcomes
Primary
Secondary
The intervention
Process evaluation methods
Sample size
Surveillance and data management
Analysis
Ethical concerns
Health service strengthening
Results
Process evaluation: HMC intervention
Dream | HMC dreams | HMC dreams achieved |
---|---|---|
Keep the HMC active | 18 | 14 |
Increase health awareness in the community | 18 | 12 |
Improve physical infrastructure | 16 | 7 |
Procure equipment for maternal and newborn care | 12 | 4 |
Upgrade the health facility (for example make an SHP an HP) | 11 | 2 |
Provide 24-h/effective delivery services | 10 | 9 |
Recruit an Auxiliary Nurse Midwife | 10 | 8 |
Maintain a user friendly environment in the health facility | 8 | 3 |
Start providing delivery services | 8 | 5 |
Fill vacant posts | 6 | 1 |
Buy an ambulance | 8 | 1 |
Improve cleanliness and the physical environment of the health facility | 6 | 2 |
Monitor and reward personnel and co-ordinate with other organisations | 6 | 2 |
Ensure the mobilisation of the FCHV | 5 | 3 |
Increase quality of health services | 5 | 1 |
Monitor and maintain regular attendance of staff and maintain opening hours | 4 | 2 |
Improve maternal and newborn health | 4 | 2 |
Register land in the name of the health institution | 3 | 0 |
Provide more services | 3 | 2 |
Conduct a family planning campaign | 2 | 2 |
Team building training for HMCs and health personnel | 2 | 1 |
Increase financial transparency | 1 | 1 |
Put up a notice board to track numbers of institutional deliveries | 1 | 1 |
Process evaluation: Women’s group intervention
Barriers to institutional delivery | Groups (n = 203) |
---|---|
Lack of money | 104 |
Embarrassment and fear | 98 |
Lack of knowledge | 89 |
Belief in traditional healers | 81 |
Lack of family support | 75 |
Lack of 24-h service | 71 |
Lack of transportation | 62 |
Geographic difficulties | 52 |
Absence of health workers | 20 |
Strategy to address barriers | No. groups that suggested this strategy | No. groups that implemented this strategy | No. of groups that evaluated this strategy |
---|---|---|---|
First action-learning cyclea | |||
Awareness programme | 71 | 172 | 172 |
Counselling of pregnant women & family | 143 | 123 | 123 |
Mutual fund | 93 | 163 | 163 |
Information about AMA programme & danger signs | 75 | 60 | 60 |
Stretcher scheme | 73 | 113 | 113 |
Interaction with traditional healers | 70 | 19 | 19 |
Advocacy at the local health institution | 9 | 10 | 10 |
Second cyclea | |||
Referral card | 167 | 167 | n/ab |
Invitation card to pregnant women & household head | 159 | 159 | n/ab |
Mobile meeting | 95 | 95 | n/ab |
Process evaluation: context
Baseline | Endline | |||
---|---|---|---|---|
Intervention n (%) | Control n (%) | Intervention n (%) | Control n (%) | |
Community based organisation activities | ||||
Pregnant women’s group (Centre for Community Development Nepal (CCDN)) | 16 | 25 | 78 | 81 |
Women’s group (District government Women and Children Office) | 11 | 34 | 60 | 124 |
Health Management Committee strengthening (CCDN) | 0 | 0 | 3 | 6 |
FCHV status | ||||
18–35 | 66 (46) | 110 (54) | 100 (52) | 103 (50) |
36–55 | 85 (49) | 102 (36) | 88 (46) | 86 (42) |
55 and above | 9 (5) | 21 (10) | 4 (2) | 17 (8) |
Illiterate | 48 (28) | 59 (29) | 42 (22) | 18 (9) |
Functioning FCHV women’s group | 133 (65) | 160 (78) | 191 (94) | 159 (77) |
HMC status | ||||
Received an orientation of their roles and responsibilities | 8 (38) | 7 (31) | 20 (95) | 16 (72) |
The VDC secretary was chairperson | 11 (52) | 10 (46) | 9 (43) | 14 (64) |
Conducted regular meetings | 7 (33) | 8 (36) | 13 (62) | 11 (50) |
HMC had conducted a community interaction programme | 1 (5.6) | 0 (0) | 12 (57) | 6 (27) |
Initiated at least four activities in the past year | 10 (48) | 8 (36) | 17 (80) | 16 (72) |
HMC meetings not run because of absent members | – | – | 4 (19) | 7 (32) |
Absence of all or some members from HMC meeting due to personal workload | 8 (38) | 8 (36) | 13 (62) | 13 (59) |
Health workers involved in delivery services | ||||
Doctor | 2 | 2 | 2 | 2 |
Staff nurse | 1 | 2 | 1 | 2 |
ANM | 17 | 20 | 33 | 33 |
MCHW | 16 | 15 | 14 | 12 |
Health workers with SBA training | ||||
Staff nurse | – | – | – | 1 |
ANM | 1 | 1 | 8 | 7 |
MCHW | – | – | 2 | 1 |
Vacant Posts | ||||
Staff nurse | – | 1 | 1 | – |
ANM | 1 | 1 | 2 | – |
MCHW | – | 2 | – | 1 |
Nurses on short term contracts | ||||
ANM (DHO recruited) | 4 | 3 | 13 | 14 |
ANM (HMC recruited) | 7 | 10 | 9 | 6 |
Health facilities providing 24 h delivery care | 6 | 7 | 17 | 15 |
Inj Magnesium Sulphate 2 cc/1 g (for eclampsia treatment) | 8 | 6 | 13 | 13 |
Placenta pit | 0 | 0 | 7 | 9 |
Private clinic or medical shop | 38 | 63 | 55 | 68 |
Baseline data
Control n (%) | Intervention n (%) | All n (%) | |
---|---|---|---|
Households | 3468 (100) | 2818 (100) | 6286 (100) |
Agricultural livelihood | 3093 (89.2) | 2612 (92.7) | 5705 (90.8) |
Own land | 3261 (94.0) | 2706 (96.0) | 5967 (94.9) |
Own home | 3349 (96.6) | 2716 (96.4) | 6065 (96.5) |
Mud and stone walls | 1939 (55.9) | 1641 (58.2) | 3580 (57.0) |
Zinc roof | 1512 (43.6) | 1117 (39.6) | 2629 (41.8) |
Mud floor | 3021 (87.1) | 2625 (93.2) | 5646 (89.8) |
Electric light | 1707 (49.2) | 1600 (56.8) | 3307 (52.6) |
Woodburning stove | 3359 (96.9) | 2739 (97.2) | 6098 (97.0) |
Public wellwater | 2275 (65.6) | 1881 (66.7) | 4156 (66.1) |
Bush toilet | 2230 (64.3) | 1890 (67.1) | 4120 (65.5) |
Ethnic identity | |||
Tamang | 2283 (65.8) | 1609 (57.1) | 3892 (61.9) |
Brahmin-Chhetri | 383 (11.0) | 382 (13.6) | 765 (12.2) |
Praja | 306 (8.8) | 274 (9.7) | 580 (9.2) |
Magar | 138 (4.0) | 93 (3.3) | 231 (3.7) |
Other | 358 (10.3) | 460 (16.3) | 818 (13.0) |
Socioeconomic position | |||
Asset quintile 1 | 975 (28.1) | 754 (26.8) | 1729 (27.5) |
Asset quintile 2 | 628 (18.1) | 602 (21.4) | 1230 (19.6) |
Asset quintile 3 | 455 (13.1) | 384 (13.6) | 839 (13.3) |
Asset quintile 4 | 661 (19.1) | 570 (20.2) | 1231 (19.6) |
Asset quintile 5 | 749 (21.6) | 508 (18.0) | 1257 (20.0) |
Women who delivered* | 3521 (100) | 2853 (100) | 6374 (100) |
Age | |||
< = 19 y | 585 (16.6) | 499 (17.5) | 1084 (17.0) |
20–29 y | 2273 (64.6) | 1813 (63.5) | 4086 (64.1) |
> =30 y | 663 (18.8) | 541 (19.0) | 1204 (18.9) |
Primiparous | 1118 (31.7) | 872 (30.6) | 1990 (31.2) |
Schooling | |||
None | 1698 (48.2) | 1426 (50.0) | 3124 (49.0) |
Primary | 1008 (28.6) | 800 (28.0) | 1808 (28.4) |
Secondary or higher | 815 (23.2) | 627 (22.0) | 1442 (22.6) |
Reading | |||
Cannot read | 1457 (41.4) | 1217 (42.6) | 2674 (42.0) |
Reads with difficulty | 640 (18.2) | 490 (17.2) | 1130 (17.7) |
Reads with ease | 1424 (40.4) | 1146 (40.2) | 2570 (40.3) |
Primary outcomes** | 3524 (100) | 2853 (100) | 6737 (100) |
Institutional delivery | 1069 (30.3) | 848 (29.7) | 1917 (30.1) |
Home delivery | 2455 (69.7) | 2005 (70.3) | 4460 (69.9) |
Institutional delivery conducted by doctor, nurse or auxiliary nurse midwife | 1031 (29.3) | 819 (28.7) | 1850 (27.5) |
Home delivery conducted by doctor, nurse or auxiliary nurse midwife | 17 (0.005) | 11 (0.004) | 28 (0.004) |
Any delivery conducted by doctor, nurse or auxiliary nurse midwife | 1048 (29.7) | 830 (29.1) | 1878 (29.4) |
Secondary outcomes** | 3524 (100) | 2853 (100) | 6737 (100) |
> =4 antenatal care visits | 2374 (67.4) | 1955 (68.5) | 4329 (67.9) |
Postnatal care visit | 1595 (45.3) | 1497 (52.4) | 3092 (48.5) |
Attended FCHV women’s group | 241 (6.8) | 371 (13.0) | 612 (9.6) |
Impact evaluation: participant flow
Outcomes and estimation
Control n (%) | Intervention n (%) | Odds ratio (95% CI) | All n (%) | |
---|---|---|---|---|
Primary outcomes | 7468 (100) | 6253 (100) | 13,721 (100) | |
Institutional delivery | 2875 (38.5) | 2532 (40.5) | 1.45 (0.76, 2.78) | 5407 (39.4) |
Home delivery | 4590 (61.5) | 3721 (59.5) | Ref | 8311 (60.6) |
Any delivery conducted by doctor, nurse or ANM | 2872 (38.5) | 2498 (40.0) | 1.43 (0.74, 2.74) | 5370 (39.1) |
Any delivery conducted without a doctor, nurse or ANM | 4596 (61.5) | 3755 (60.1) | Ref | 8351 (60.9) |
Institutional delivery conducted by doctor, nurse or ANM | 2826 (37.8) | 2480 (39.7) | 1.43 (0.75, 2.75) | 5306 (38.7) |
Home delivery conducted by doctor, nurse or ANM | 46 (0.6) | 18 (0.3) | 0.49 (0.20, 1.20) | 64 (0.5) |
Stillbirth rate (per 1000 births) | 98 (13.0)** | 88 (14.0)** | 1.06 (0.75, 1.50) | 186 (13.5)** |
NMR (per 1000 live births) | 186 (25.1)¶ | 159 (25.6)¶ | 1.05 (0.75, 1.47) | 345 (25.3)¶ |
Missing data on any primary outcome | 3 | 0 | 3 | |
Secondary outcomes | 7468 (100) | 6253 (100) | 13,721 (100) | |
> =4 antenatal care visits | 5267 (70.5) | 4408 (70.5) | 1.04 (0.80, 1.35) | 9675 (70.5) |
Postnatal care visit | 2982 (39.9) | 2999 (48.0) | 1.77 (0.97, 3.23) | 5981 (43.6) |
Missing data on postnatal care visits | 4 | 1 | 5 | |
Delivery site* | 2875 (100) | 2532 (100) | 5407 (100) | |
Sub-Health Post | 238 (8.3) | 578 (22.8) | 816 (15.0) | |
Health Post | 241 (8.4) | 115 (4.5) | 356 (6.6) | |
Primary Health Centre | 486 (16.9) | 408 (16.1) | 894 (16.5) | |
Government hospital | 1590 (55.3) | 1279 (50.5) | 2869 (53.1) | |
Private hospital | 213 (7.4) | 115 (4.5) | 328 (6.1) | |
Institution in other district | 66 (2.3) | 22 (0.9) | 88 (1.6) | |
Private clinic | 41 (1.4) | 15 (0.6) | 56 (1.0) | |
Free at point of care | 2639 (91.8) | 2388 (94.3) | 5027 (93.0) | |
Received maternity incentive | 2223 (77.3) | 2108 (83.3) | 4331 (80.1) | |
Missing data on costs and incentives | 41 | 16 | 57 | |
Delivery attendant | 7468 (100) | 6253 (100) | 13,721 (100) | |
Doctor | 1165 (15.6) | 816 (13.0) | 1981 (14.4) | |
Nurse | 1982 (26.6) | 1449 (23.2) | 3431 (25.0) | |
Auxiliary Nurse midwife | 1886 (25.3) | 2090 (33.4) | 3976 (29.0) | |
Health Assistant | 12 (0.2) | 25 (0.4) | 37 (0.3) | |
Assistant Health Worker | 127 (1.7) | 196 (3.1) | 323 (2.4) | |
Maternal and Child Health Worker | 88 (1.2) | 150 (2.4) | 238 (1.7) | |
Village Health Worker | 2 (0.0) | 10 (0.2) | 12 (0.1) | |
Female Community Health Volunteer | 120 (1.6) | 159 (2.5) | 279 (2.0) | |
Traditional Birth Attendant | 82 (1.1) | 23 (0.4) | 105 (0.8) | |
Mother-in-law | 1916 (25.7) | 1667 (26.7) | 3583 (26.1) | |
Husband | 807 (10.8) | 1085 (17.4) | 1892 (13.8) | |
Family member | 1096 (14.7) | 1086 (17.4) | 2182 (15.9) | |
Mother | 424 (5.7) | 361 (5.8) | 785 (5.7) | |
Neighbour | 1999 (26.8) | 1671 (26.7) | 3670 (26.8) | |
Natal sister | 117 (1.6) | 134 (2.1) | 251 (1.8) | |
No attendant at all | 265 (3.5) | 231 (3.7) | 496 (3.6) | |
Missing data on delivery attendant | 3 | 0 | 3 | |
Attended FCHV women’s group | 353 (4.7) | 896 (14.3) | 1249 (9.1) |