Donna Spiegelman, Pascal Geldsetzer, Dawn W. Foster, Eric Mboggo, Hellen Siril, Nzovu Ulenga, Mary Mwanyika-Sando, Nan Li, Phares G.M. Mujinja, Charles Kilewo, Helga Naburi, Elysia Larson, Ester Mungure, Anna Mia Ekström, Guerino Chalamilla, Lameck Machumi, Till Bärnighausen, Wafaie W. Fawzi, Lucy Magesa, Irene Andrew Lema, and David Sando
Background Home delivery and late and infrequent attendance at antenatal care (ANC) are responsible for substantial avoidable maternal and pediatric morbidity and mortality in sub-Saharan Africa. This cluster-randomized trial aimed to determine the impact of a community health worker (CHW) intervention on the proportion of women who (i) visit ANC fewer than 4 times during their pregnancy and (ii) deliver at home. Methods and findings As part of a 2-by-2 factorial design, we conducted a cluster-randomized trial of a home-based CHW intervention in 2 of 3 districts of Dar es Salaam from 18 June 2012 to 15 January 2014. Thirty-six wards (geographical areas) in the 2 districts were randomized to the CHW intervention, and 24 wards to the standard of care. In the standard-of-care arm, CHWs visited women enrolled in prevention of mother-to-child HIV transmission (PMTCT) care and provided information and counseling. The intervention arm included additional CHW supervision and the following additional CHW tasks, which were targeted at all pregnant women regardless of HIV status: (i) conducting home visits to identify pregnant women and refer them to ANC, (ii) counseling pregnant women on maternal health, and (iii) providing home visits to women who missed an ANC or PMTCT appointment. The primary endpoints of this trial were the proportion of pregnant women (i) not making at least 4 ANC visits and (ii) delivering at home. The outcomes were assessed through a population-based household survey at the end of the trial period. We did not collect data on adverse events. A random sample of 2,329 pregnant women and new mothers living in the study area were interviewed during home visits. At the time of the survey, the mean age of participants was 27.3 years, and 34.5% (804/2,329) were pregnant. The proportion of women who reported having attended fewer than 4 ANC visits did not differ significantly between the intervention and standard-of-care arms (59.1% versus 60.7%, respectively; risk ratio [RR]: 0.97; 95% CI: 0.82–1.15; p = 0.754). Similarly, the proportion reporting that they had attended ANC in the first trimester did not differ significantly between study arms. However, women in intervention wards were significantly less likely to report having delivered at home (3.9% versus 7.3%; RR: 0.54; 95% CI: 0.30–0.95; p = 0.034). Mixed-methods analyses of additional data collected as part of this trial suggest that an important reason for the lack of effect on ANC outcomes was the perceived high economic burden and inconvenience of attending ANC. The main limitations of this trial were that (i) the outcomes were ascertained through self-report, (ii) the study was stopped 4 months early due to a change in the standard of care in the other trial that was part of the 2-by-2 factorial design, and (iii) the sample size of the household survey was not prespecified. Conclusions A home-based CHW intervention in urban Tanzania significantly reduced the proportion of women who reported having delivered at home, in an area that already has very high uptake of facility-based delivery. The intervention did not affect self-reported ANC attendance. Policy makers should consider piloting, evaluating, and scaling interventions to lessen the economic burden and inconvenience of ANC. Trial registration ClinicalTrials.gov NCT01932138, In this cluster-randomized trial in Dar es Salaam, Tanzania, Pascal Geldsetzer & colleagues assessed how a community health worker intervention affected the proportion of women attending antenatal care and delivering their babies at home., Author summary Why was this study done? Along with raising the quality of maternal healthcare services, increasing uptake of antenatal care (ANC) and facility-based delivery is thought to be important to improve both maternal and neonatal health in resource-poor settings. While community health worker (CHW)–led interventions have been proposed to increase uptake of essential maternal care services, there is limited evidence for these interventions from large-scale randomized studies implemented in the routine health system. What did the researchers do and find? We randomized all 60 wards (geographic areas) in 2 of 3 districts of Dar es Salaam, Tanzania, to a CHW intervention—consisting of additional CHW supervision, CHW-led identification of newly pregnant women in the community, and CHW follow-up at home for those who missed an ANC or prevention of mother-to-child HIV transmission (PMTCT) appointment—or to the standard of care (counseling visits by CHWs to PMTCT patients only). We found no difference between study arms in self-reported ANC underutilization (attending ANC fewer than 4 times and not visiting ANC in the first trimester) but the intervention almost halved the probability of women reporting having delivered at home (3.9% in the intervention arm versus 7.3% in the standard-of-care arm). In a nested mixed-methods study, we found that a likely reason for the CHW intervention’s lack of effect on ANC utilization was that provision of information, counseling, and reminders by CHWs was insufficient to change women’s perception that the relatively high transport costs, lost time from work, and inconvenience of earlier and more frequent ANC attendance outweigh its benefits. What do these findings mean? The CHW intervention appears to have been effective in moving towards universal coverage of facility-based delivery in this population that already has high uptake of facility-based delivery. However, the CHW intervention was insufficient to improve the timeliness and frequency of ANC attendance. The main limitation of this study was that the outcomes were assessed through self-report only. Policy makers should consider piloting, evaluating, and scaling CHW interventions aimed at reducing the economic burden and inconvenience of ANC attendance, which could include shifting ANC tasks from nurses at healthcare facilities to CHWs in the community to decrease the number of required healthcare facility visits for ANC.