Community-based postpartum contraceptive counselling in rural Nepal: a mixed-methods evaluation

Abstract

Unmet need for postpartum contraception in rural Nepal remains high and expanding access to sexual and reproductive healthcare is essential to achieving universal healthcare. We evaluated the impact of an integrated intervention that employed community health workers aided by mobile technology to deliver patient-centred, home-based antenatal and postnatal counselling on postpartum modern contraceptive use. This was a pre–post-intervention study in seven village wards in a single municipality in rural Nepal. The primary outcome was modern contraceptive use among recently postpartum women. We performed a multivariable logistic regression to examine contraceptive use among postpartum women pre- and one-year post-intervention. We conducted qualitative interviews to explore the implementation process. There were 445 postpartum women in the pre-intervention group and 508 in the post-intervention group. Modern contraceptive use increased from 29% pre-intervention to 46% post-intervention (p < 0.0001). Adjusting for age, caste, and household expenditure, time since delivery and sex of child in the index pregnancy, postpartum women one-year post-intervention had twice the odds (OR 2.3; CI 1.7, 3.1; p < 0.0001) of using a modern contraceptive method as compared to pre-intervention. Factors at the individual, family, and systems level influenced women’s contraceptive decisions. The intervention contributed to increasing contraceptive use through knowledge transfer, demand generation, referrals to healthcare facilities, and follow-up. A community-based, patient-centred contraceptive counselling intervention supported by mobile technology and integrated into longitudinal care delivered by community health workers appears to be an effective strategy for improving uptake of modern contraception among postpartum women in rural Nepal.

Résumé

Les besoins insatisfaits en contraception postpartum dans le Népal rural restent élevés et il est essentiel d’élargir l’accès aux soins de santé sexuelle et reproductive pour parvenir à une couverture santé universelle. Nous avons évalué l’impact d’une intervention intégrée qui a employé des agents de santé communautaires secondés par une technologie mobile pour dispenser des conseils prénatals et postnatals à domicile et axés sur les patientes en matière d’utilisation de contraceptifs modernes pendant le postpartum. Il s’agissait d’une étude avant et après l’intervention dans sept villages d’une seule municipalité du Népal rural. Le principal résultat était l’emploi de contraceptifs modernes chez des femmes ayant récemment accouché. Nous avons réalisé une régression logistique multivariable pour examiner l’emploi de contraceptifs chez les jeunes accouchées avant et une année après l’intervention. Nous avons mené des entretiens qualitatifs pour explorer le processus de mise en œuvre. Le groupe pré-intervention comptait 445 femmes en postpartum, contre 508 dans le groupe post-intervention. L’emploi de contraceptifs modernes est passé de 29% avant l’intervention à 46% après l’intervention (p < 0,0001). Après ajustement en fonction de l’âge, de la caste et des dépenses du ménage, du délai écoulé depuis l’accouchement et du sexe de l’enfant dans la grossesse examinée, les femmes en postpartum une année après l’intervention avaient deux fois plus de probabilités (Rc 2,3; IC 1,7, 3,1; p < 0,0001) d’utiliser une méthode contraceptive moderne qu’avant l’intervention. Des facteurs aux niveaux individuel, familial et systémique influaient sur les décisions contraceptives des femmes. L’intervention a contribué à augmenter l’emploi de contraceptifs par le transfert de connaissances, la création de demande, les aiguillages vers les centres de soins de santé et le suivi. Une intervention relative aux conseils contraceptifs axés sur les patientes et à assise communautaire, soutenue par une technologie mobile et intégrée dans les soins longitudinaux dispensés par des agents de santé communautaires, semble être efficace pour améliorer le recours à une contraception moderne parmi les femmes en postpartum dans le Népal rural.

Resumen

La necesidad insatisfecha de anticoncepción posparto en las zonas rurales de Nepal continúa siendo alta y la ampliación del acceso a los servicios de salud sexual y reproductiva es esencial para lograr cobertura médica universal. Evaluamos el impacto de una intervención integrada que empleó a agentes de salud comunitaria ayudados por tecnología móvil para brindar consejería prenatal y posnatal domiciliaria centrada en la paciente sobre el uso de anticonceptivos modernos posparto. Este estudio pre- y post-intervención fue realizado en siete subdivisiones en una sola municipalidad de Nepal rural. El principal resultado fue el uso de anticonceptivos modernos entre mujeres en posparto reciente. Realizamos una regresión logística multivariable para examinar el uso de anticonceptivos entre mujeres posparto antes de la intervención y un año después. Realizamos entrevistas cualitativas para explorar el proceso de ejecución. Había 445 mujeres posparto en el grupo pre-intervención y 508 en el grupo post-intervención. El uso de anticonceptivos modernos aumentó del 29% pre-intervención al 46% post-intervención (p < 0.0001). Ajustando por edad, casta y gastos del hogar, tiempo desde el parto y sexo del niño en el índice de embarazos, las mujeres posparto un año después de la intervención tuvieron el doble de probabilidades (RM 2.3; IC 1.7, 3.1; p < 0.0001) de usar un método anticonceptivo moderno, comparadas con las mujeres en el grupo pre-intervención. Los factores a nivel individual, familiar y sistémico influyeron en las decisiones anticonceptivas de las mujeres. La intervención contribuyó a aumentar el uso de anticonceptivos mediante la transferencia de conocimientos, generación de demanda, referencias a unidades de salud y seguimiento. La intervención comunitaria, centrada en la paciente, para brindar consejería anticonceptiva apoyada por tecnología móvil e integrada en atención longitudinal domiciliaria brindada por agentes de salud comunitaria parece ser una estrategia eficaz para mejorar la aceptación de anticonceptivos modernos entre mujeres posparto en las zonas rurales de Nepal.

Keywords:

• family planning
• postpartum contraception
• Nepal
• implementation science
• reproductive health
• community health workers
• contraceptive counselling

Acknowledgements

We wish to express our appreciation to the Nepal Ministry of Health and Population for their continued efforts to improve the public sector healthcare system in rural Nepal. We wish to give our thanks to the Population Council for developing the Balanced Counselling Strategy, to Dr Deeb Shrestha Dangol and colleagues at Ipas for input in adapting the intervention, and to our technology partners ThoughtWorks and Dimagi. Lastly, we are indebted to the community health workers and community health nurses whose commitment to serving our patients and dedication to improving reproductive, maternal, newborn, and child health outcomes in rural Nepal continue to inspire us.

Author contributions

WW conceived the study and serves as guarantor for the work. The study grew out of discussions between WW, SM, IB, IN, AG, A. Thapa, DC, DM, SH, and S. Sapkota. RB, S. Saud, HJR, SP, and LK assisted with implementation of the intervention. A. Tiwari conducted the qualitative data collection and assisted with data analysis. SM, NC, DM, DB also assisted with data analysis. WW, SM, and A. Tiwari drafted the manuscript. All authors have reviewed and approved the manuscript.

Disclosure statement

WW is employed at an academic medical centre (Boston Medical Center) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. WW is a faculty member at a private university (Boston University School of Medicine). A Tiwari, RB, DC, HJR, S. Sapkota, S. Saud, and A Thapa are employed by and WW, NC, SH, DM, and SM work in partnership with a non-profit healthcare organisation (Nyaya Health Nepal with support from a partner United States-based 501c3 Possible) that delivers free healthcare in rural Nepal using funds from the Government of Nepal and other public, philanthropic, and private foundation sources. DC is a faculty member at and employed part-time by a public university (University of Washington). At the time of programme implementation, IN, IB, LK, and SP were employed by Nyaya Health Nepal. NC is employed full-time and SH is employed part-time at a private university (Icahn School of Medicine at Mount Sinai). IB is employed by the Government of Nepal. IN is a student at a private university (Harvard TH Chan School of Public Health) and a member on the Board of Directors with Possible, a position for which she receives no compensation. DM and SM are faculty members at a private university (Icahn School of Medicine at Mount Sinai). DM is a non-voting member on the Board of Directors with Nyaya Health Nepal, a position for which he receives no compensation. AG is employed at an academic medical centre (Brigham and Women’s Hospital) and a non-profit organisation (Planned Parenthood League of Massachusetts) that provides reproductive healthcare in the United States and globally using public, philanthropic, and private foundation sources. All authors have read and understood Sexual and Reproductive Health Matters policy on declaration of interests, and declare that we have no competing financial interests. The authors do, however, believe strongly that healthcare is a public good, not a private commodity.

Data availability statement

De-identified quantitative data are available on request by emailing: [email protected] and will be posted in a publicly-accessible data repository. Full transcripts of qualitative data are not available as they contain quotes and identifiable information that could compromise the identity of participants.

Notes

* Brahmin and Chhetri people are at the top of the social hierarchy. Historically, they have had more opportunities for education, held more respected occupations, and enjoyed higher socioeconomic status, than socially excluded “lower” castes. Although the caste system is not formally enforced in modern Nepal, Brahmins and Chhetris still disproportionately hold senior positions, usually have higher socioeconomic status, and in some studies have better health outcomes.

Additional information

Funding

The research study is funded by the United States Agency for International Development (US) via a Partnerships for Enhanced Engagement in Research award (sponsor grant number AID-OAA-A-11-00012, National Academy of Science sub-award letter 2000007780). WW received support through a combined Global Women’s Health and Family Planning Fellowship that is funded by the Society of Family Planning Research Fund (grant number SFPRF17-10). The funders played no role in research design, data collection, data analysis, manuscript write-up, or decision to publish. Any opinions, findings, conclusions, or recommendations expressed in this article are those of the authors alone, and do not necessarily reflect the views of the United States Agency for International Development or the National Academy of Science.