“Now that they come to our doorsteps to teach us these things…” – Postpartum contraception outcomes from a pre-post effectiveness-implementation study of an integrated community health worker intervention in rural Nepal

Postpartum contraceptive counseling and access are challenging in Nepal’s remote, hilly areas, driving a disproportionately high unmet need for contraception. Community health workers (CHWs) play an important role in delivering healthcare in difficult to reach places, but there is limited evidence from professionalized CHW models and their impact over time in Nepal. 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 contraceptive counseling adapted from the Balanced Counseling Strategy. Here we describe postpartum contraceptive outcomes associated with the integrated RMNCH intervention over a five-year period. Applying a type 2 hybrid effectiveness-implementation approach, we conducted a non-randomized pre-post study with repeated measurements and nested qualitative data collection to study the intervention’s reach, effectiveness, adoption, implementation, and maintenance. Compared to the pre-intervention period, we observed 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), after adjusting for district and intervention site. Lactational amenorrhea method (LAM) was the most common method during early postpartum in most intervention sites. The proportion of women who switched to other effective methods after LAM was relatively low. Qualitative data indicated that CHWs’ longitudinal engagement with participants helped facilitate contraceptive counseling and uptake despite challenges such as participants’ fear of side effects, limited autonomy for women, and peer influence. Our findings suggest the integrated RMNCH intervention’s potential to increase modern contraceptive uptake in low-resource community settings and underscore CHWs’ ability to help drive longer-term change in their communities, especially around sensitive topics. 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. ClinicalTrials.gov Identifier: NCT03371186, registered 04 December 2017, retrospectively registered. Women in Nepal’s remote, hilly areas often lack access to contraceptive counseling despite not wanting another pregnancy soon after giving birth. Community health workers (CHWs) play a key role in delivering healthcare in difficult to reach places. We tested out a program in two rural districts in Nepal where CHWs visited women in their homes to offer reproductive, maternal, newborn, and child health (RMNCH) care. The program included counseling individuals on contraception based on their family planning needs and values. We studied how modern contraception use changed in the area after this RMNCH program was introduced, compared to before. We found that, on average, the proportion of women who used a modern method of contraception increased in the local areas where CHWs visited women to provide RMNCH care. We also learned through conversations with CHWs, others involved in the program, and those who received care from CHWs, that CHWs’ regular visits helped them build relationships within their community, which likely helped women feel more comfortable being counseled and choose contraceptive methods. Women in the community hesitated to use modern contraceptives because they were afraid of side effects, were often unable to make decisions for themselves without their partners or families’ approval, or because the contraceptives they wanted were not available. We found that CHWs can help drive longer-term change in their communities, especially around sensitive topics like contraception.