Abstract
BackgroundThe effects of community health worker (CHW) home visiting during the antenatal and postnatal periods in fragile- and conflicted-affected countries such as Afghanistan are not known.MethodsWe conducted a non-randomised population-based intervention study from March 2015 to February 2016. Two intervention and two control districts were selected.All female CHWs in the intervention districts were trained to provide eight home visits and behaviour change communication messages from pregnancy to 28 days postpartum. The primary outcome was the proportion of women who reported delivering in a health facility. Secondary outcomes were the proportion of women who reported attending a health facility for at least one antenatal and one postnatal visit. Outcomes were analysed at 12 months using multivariable difference-in-difference linear regression models adjusted for clustering.ResultsOverall, 289 female CHWs in the intervention districts performed home visits and 1407 eligible women (less than 12 months postpartum) at baseline and 1320 endline women provided outcome data (94% response rate). Facility delivery increased in intervention villages by 8.2% and decreased in the control villages by 6.3% (adjusted mean difference (AMD) 11.0%, 95% confidence interval (CI) 4.0–18.0%, p = 0.002). Attendance for at least one antenatal care visit (AMD 10.5%, 95% CI 4.2–16.9%, p = 0.001) and postnatal care visit (AMD 7.2%, 95% CI 0.2–14.2%, p = 0.040) increased in the intervention compared to the control districts.ConclusionsCHW home visiting during the antenatal and postnatal periods can improve health service use in fragile- and conflict-affected countries. Commitment to scale-up from Ministries and donors is now needed.Trial registrationThis trial was retrospectively registered at the Australian and New Zealand Clinical Trial Registry (ACTRN12618000609257).
Highlights
The effects of community health worker (CHW) home visiting during the antenatal and postnatal periods in fragile- and conflicted-affected countries such as Afghanistan are not known
Studies over the last 5 years in poor communities in south Asia and Africa have conclusively shown that community health worker (CHW) home visiting during the antenatal and postnatal periods can improve both the demand for and use of antenatal care (ANC), delivery and postnatal care (PNC) services, and reduce maternal and newborn mortality by at least 15–20% [8,9,10,11]
Volunteer CHWs have been part of the health system in Afghanistan since 2001, but have not been routinely used for home visiting during the antenatal and postnatal periods [17]
Summary
The effects of community health worker (CHW) home visiting during the antenatal and postnatal periods in fragile- and conflicted-affected countries such as Afghanistan are not known. Afghanistan continues to have a fragile and challenging environment for women wishing to obtain healthcare, with maternal and newborn mortality rates remaining among the highest globally [2,3,4] Reasons for this include persistent levels of violence and conflict, which limit the ability of many mothers and families to leave the home to receive health and social care [5,6,7]. Studies over the last 5 years in poor communities in south Asia and Africa have conclusively shown that community health worker (CHW) home visiting during the antenatal and postnatal periods can improve both the demand for and use of ANC, delivery and PNC services, and reduce maternal and newborn mortality by at least 15–20% [8,9,10,11]. CHWs are increasingly being ‘institutionalised’ in the workforce in south Asia and Africa through enhanced training and incentive packages [12,13,14]
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