Improving essential newborn care in the Peruvian Amazon: Outcome and process evaluation of a community-based, maternal and neonatal health intervention

Background: Despite remarkable progress in maternal and neonatal health, regional inequalities persist in Peru. In remote indigenous communities in the Amazon, access to quality care is difficult, home births are frequent, and neonatal mortality remains high. Essential newborn care (ENC), a set of hygienic cord care, thermal care, and optimal breastfeeding practices, are recommended to be received by every newborn. Global evidence suggests that community health worker (CHW) home visit interventions are effective in reducing neonatal mortality and have a critical role in reaching underserved populations. Rigorous setting-specific evidence on effect and mechanisms of change, however, is lacking for Peru. In this PhD, I aim to: 1) estimate the prevalence of ENC; 2) assess if a community-based, maternal-neonatal health intervention can improve ENC over time; and 3) understand how and why the intervention can achieve effect in the Peruvian Amazon.

Methods: Mamás del Río consists of tablet-enhanced educational home visits by CHW to pregnant women, mothers, and newborns to promote ENC and uptake of facility care, with supportive ENC training of traditional birth attendants and facility staff, as well as supervision and community sensitization. I conducted a before-and-after study in three districts in Loreto with repeated community censuses and women questionnaires to measure ENC in home births (primary outcomes) at baseline, and at year 2 and 3 after intervention implementation. A nested, theory-based, mixed-methods process evaluation was conducted to assess implementation strength, mechanisms of change, and influence of contextual factors using data from all community-based stakeholders.

Results: At baseline, all 79 rural communities with a population of 14,474 were censused, finding a high proportion of home births (70%) and low prevalence of ENC in home births; ENC in facility births was also not universal. Following implementation of the intervention in early 2019, coverage of trained CHW volunteers, mostly middle-aged and predominantly male, was high (97%). At year 2 follow-up, most women received a CHW visit during pregnancy (63%, 322/530). Seven out of nine ENC indicators among home births improved, with largest adjusted prevalence differences (PD) in immediate skin-to-skin contact (50% [95% CI: 42–58], p<0.0001), colostrum feeding (45% [35–54], p<0.0001), and cord care (19% [10–28], p=0.0001). Improvements were maintained at year 3, except for cord care. Proportion of facility births increased from 35 to 46% (adjusted PD 8% [14–1], p=0.021) at year 2. Process evaluation revealed strong implementation with intensive supervision. I identified multiple pathways of change: Trained middle-aged female TBA as main providers of home-based birth care adopting ENC; CHW sensitizing women through educational videos and providing delivery kits during home visits, albeit with less reach and counselling than expected; and supervisor-led, women-only educational meetings. Some CHW proactively facilitated access to care, while promotion alone to create demand appeared insufficient to increase uptake of facility care.

Conclusions: A community-based approach can achieve behaviour change in home-based newborn care and has the potential to increase uptake of facility care. Identified pathways of change support the causal link between the intervention and observed outcomes. To improve impact and sustainability of similar interventions and to optimize the Peruvian CHW programme, I recommend preferential selection of female CHW, financial and non-financial incentives for CHW, and strengthening CHWs’ roles in facilitating access to facility care. In remote and indigenous settings with persisting access barriers and poor facility care, TBA or equivalent cadre training should be considered. To achieve a sustainable shift towards facility births, however, structural barriers need to be addressed to enable access to high quality and respectful facility care.