“Even things they won’t share with their sisters-in-law” – Assessing an integrated Community Health Worker intervention on person-centered postpartum contraception in rural Nepal

Postpartum contraceptive counseling and access are challenging in Nepal’s remote, hilly areas, driving a disproportionately higher unmet need for contraception. Community health workers (CHWs) play an important role in delivering healthcare in difficult to reach places in Nepal, but there is limited evidence on the ideal CHW model and its impact over time. We implemented a pilot program in two rural districts in Nepal where full-time, salaried, and supervised CHWs delivered a bundled reproductive, maternal, newborn, and child health (RMNCH) intervention. This included a person-centered contraceptive counseling component adapted from the Balanced Counseling Strategy. Applying a type 2 hybrid effectiveness-implementation study approach, we conducted a non-randomized pre-post study with repeated measurements and nested qualitative data collection to assess the intervention’s reach, effectiveness, adoption, implementation, and maintenance. This paper describes the postpartum contraceptive outcomes associated with the integrated RMNCH intervention over a five-year period. Compared to the pre-intervention period, we observed a higher ward-level post-intervention postpartum contraceptive prevalence stratified by early postpartum (RR: 2.20; 95% CI: 1.96, 2.48) and late postpartum (RR: 1.70; 95% CI: 1.50, 1.93) periods, after adjusting for district and intervention site. Although we observed high rates of lactational amenorrhea method (LAM) in most intervention sites, the proportion of women who switched from LAM to another effective method was relatively low. Qualitative data indicate that CHWs’ longitudinal engagement enabled them to build trust with participants in their community, which likely contributed to the uptake of modern contraceptive methods. Barriers to modern contraceptive use included fear of side effects, limited autonomy for women, peer influence, and contraceptive unavailability. Implementation barriers included distance, challenging physical terrain, and increased travel times during the rainy season. This study contributes to the implementation research literature on community-based interventions to improve postpartum contraception use and may inform other CHW programs in similar contexts. ### Competing Interest Statement NC is a PhD student at a private university (NYU Grossman School of Medicine), and was employed by the non-profit Possible and a private medical school (Icahn School of Medicine at Mount Sinai) when most of this work was completed. WW, SM, and DM are employed by, and WW, SM, DC, DM, and S. Sapkota are faculty members at a private medical school (Icahn School of Medicine at Mount Sinai). NC, WW, SM, DC and SH serve as advisors to the US-based non-profit organization Possible, for which they receive no compensation. S. Sapkota is employed by a Nepal-based non-governmental organization, Possible that operates with support from US-based Possible. RK, A. Tiwari, A. Thapa, VB, AB, BB, LDB, DC, SH, SK, YKBK, LBK, KRM, NM, IN, R. Paudel, S. Saud, R. Shrestha, PT, HJR were employed by the non-profit organizations Nyaya Health Nepal/Possible at the time of this work. S. Saud is employed by a government hospital of Nepal (Civil Service Hospital). R. Shrestha is a student at the School of Health and Allied Sciences, Pokhara University. IB is a board chair of Nepal-based Possible. DC is a faculty member at the University of Washington and SH is employed by the Washington State Department of Children, Youth & Families (Olympia, WA). R. Schwarz is employed at an academic medical center (Brigham and Women?s Hospital) and is a faculty member at a private medical school (Harvard Medical School) and an academic medical center (Massachusetts General Hospital). SA is a faculty member at a private medical school (NYU Grossman School of Medicine). LBK is employed by a non-profit (Medic). PT is currently a postdoctoral fellow at School of Population and Global Health, McGill University, Quebec, Canada. KRM is employed by Transcultural Psychosocial Organization Nepal (TPO Nepal). DS is employed by Possible Nepal. GNS is director of and BR is Senior Hospital Nursing Administrator Chief of the Nursing and Social Security Division under the Government of Nepal Ministry of Health and Population. All authors declare that we have no competing financial interests. ### Clinical Trial NCT03371186 ### Clinical Protocols ### Funding Statement This work was supported by Grand Challenges Canada [GCC Grant Number 1808-17775 and TTS-2009-35989], United States Agency for International Development via a Partnerships for Enhanced Engagement in Research award [sponsor grant number AID-OAA-A11-00012, National Academy of Science subaward letter 2000007780] and the Office of the Director, National Institutes of Health under an Early Independence Award [DP5OD019894] to DM (the Eunice Kennedy Shriver National Institute Of Child Health & Human Development (NICHD) and the National Institute Of Dental & Craniofacial Research (NIDCR)). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Any findings, conclusions, or recommendations expressed in this article are those of the authors alone and do not necessarily reflect the views of the Grand Challenges Canada, United States Agency for International Development, National Institutes of Health or the National Academy of Science. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Nepal Health Research Council (461/2016), the Brigham and Women’s Hospital institutional review board (2017P000709/PHS), and Mount Sinai institutional review board (MSSM IRB-18-01091) gave human subjects approval for the study. The Boston Medical Center (H-38196) institutional review board exempted the study. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes De-identified, ward-level data used for the primary analysis are publicly available at: https://osf.io/24smk/. Requests for participant level (human subjects) data can be sent to the corresponding author.