Abstract
Background: The maternal continuum of care (CoC) (antenatal care, facility-based delivery, postnatal care) is critical to maternal and neonatal health and reducing mortality, but completion in rural areas of low- and middle-income countries is often limited. We used repeated cross-sectional household surveys from a rural Liberian county to explore changes in rates of completion of all steps and no steps in the maternal CoC after implementation of the National Community Health Assistant Program (NCHAP), a community health worker (CHW) intervention designed to increase care uptake for families over five kilometers from a facility. Methods: We analyzed repeated cross-sectional household surveys of women aged 18–49 served by NCHAP in Rivercess County, Liberia. We measured survey-weighted, before-to-after implementation difference in completion of all steps and no steps in the maternal CoC. We used multivariable regression to explore covariates associated with completion rates before and after NCHAP implementation. Results: Data from surveys conducted at three timepoints (2015, n = 354; 2018, n = 312; 2021, n = 302) were analyzed. A significant increase in completing the full maternal CoC (2015:23.6%, 2018:53.4%, change:29.7% points (pp), 95% confidence interval (CI) [21.0,38.4]) and a decrease in completing no steps in the CoC (2015:17.6%, 2018:4.0%, change: -12.4pp [-17.6, -7.2]) after implementation of NCHAP were observed from 2015 to 2018, with rates maintained from 2018 to 2021. Living farther from a facility was consistently associated with less care across the continuum. Following implementation, living in a motorbike accessible community was associated with completing the CoC while living in a mining community was negatively associated with omitting the CoC. Household wealth was associated with differences in rates pre-NCHAP but not post-NCHAP. Conclusions: Following NCHAP implementation, completion rate of the full maternal CoC in Rivercess County more than doubled while the rate of completing no steps in the continuum fell below 5%. These rates were sustained over time including during COVID-19 with reduced differences across wealth groups, although far distances remained a risk for less care. CHW programs providing active outreach to remote communities can be important tools for improving uptake of interventions and reducing risk of no formal care during and after pregnancy.
| Original language | English (US) |
|---|---|
| Article number | 841 |
| Journal | BMC Pregnancy and Childbirth |
| Volume | 23 |
| Issue number | 1 |
| DOIs | |
| State | Published - Dec 2023 |
Funding
The study was completed in Rivercess County, in which the National CHA Program implementation is supported by Last Mile Health. Rivercess is a majority-rural county located along Liberia’s central coast with population estimate of 71,000, divided into six health districts []. The CHA program in Rivercess County was implemented simultaneously across the districts in August of 2015. Implementation included recruitment, training, and deployment of CHAs back into their communities utilizing a five S’s approach: selection, skills, supervision, salary, and supplies []. CHAs are trained in facilitating access to and receipt of maternal and newborn health services through a number of methods including home-based education, scheduling of facility-based deliveries, partnerships with trained traditional midwives, and regular screenings and referrals to higher levels of care as necessary. They also receive practical and behavioral training on and provide care regarding family planning (condoms, contraceptive pills, and natural family planning), pregnancy (identifying and treating common problems and warning signs, promoting health care services), and postnatal care (initiation of breastfeeding, care of normal babies, and identification of danger signs). LMH also provides food and transport incentives to pregnant mothers supported by the program. Currently, CHAs are paid $70 per month without compensation for referrals to health facilities, as previously true prior to 2016. In 2016, a coalition of community health stakeholders and partners developed revised the Revised National Community Health Services Policy, which introduced new renumeration plans for CHAs, a standardized approved Ministry of Health training package, supervision by a health profession cadre of Community Health Services Supervisors (CHSSs), refresher trainings for CHAs, and provision of community level supplies and commodities. Since then, a systems-level approach has been utilized to standardize data collection and improve implementation practices to best achieve target outcomes. Following NCHAP implementation, all rural communities in Rivercess were receiving the program. In 2018, the average number of CHAs in Rivercess County was 246 with 22 supervisors; in 2021 there were on average 271 CHAs and 31 supervisors. Full details are located in Luckow, et al. [].
Keywords
- Community health worker
- Liberia
- Maternal continuum of care
- Rural
ASJC Scopus subject areas
- Obstetrics and Gynecology
