A repeated cross-sectional study of the association of community health worker intervention with the maternal continuum of care in rural Liberian communities.

Abstract

Background The maternal continuum of care (CoC) (antenatal care, facility-based delivery, postnatal care) is critical to maternal and neonatal health and reducing mortality, but completion in rural areas of low- and middle-income countries is often limited. We used repeated cross-sectional household surveys from a rural Liberian county to explore changes in rates of completion of all steps and no steps in the maternal CoC after implementation of the National Community Health Assistant Program (NCHAP), a community health worker (CHW) intervention designed to increase care uptake for families over five kilometers from a facility. Methods We analyzed repeated cross-sectional household surveys of women of childbearing age served by NCHAP in Rivercess County, Liberia. We measured survey-weighted, before-to-after implementation difference in completion of all steps and no steps in the maternal CoC. We used multivariable regression to explore covariates associated with completion rates before and after NCHAP implementation. Results Three timepoints (2015, n = 354; 2018, n = 312; 2021, n = 302) were analyzed. A significant increase in completing the full maternal CoC (2015:23.6%, 2018:53.4%, change:29.7 percentage points (pp), 95% confidence interval (CI) [21.0,38.4]) and a decrease in completing no steps in the CoC (2015:17.6%, 2018:4.0%, change: -12.4pp [-17.6, -7.2]) after implementation of NCHAP were observed from 2015 to 2018, with rates maintained from 2018 to 2021. Following the NCHAP implementation, only higher maternal education was negatively associated with completion of the CoC (adjusted odds ratio (aOR:0.57, 95% CI [0.34, 0.93]) and living twenty kilometers or more from a facility was associated with completing no steps (aOR:7.64 [1.87, 31.26]). Wealth was significantly associated with differences in rates pre-NCHAP but not post-NCHAP. Conclusions Following NCHAP implementation, completion rate of the full maternal CoC in Rivercess County more than doubled while the rate of completing no steps in the continuum fell below 5%. These rates were sustained over time including during COVID-19 with reduced differences across wealth groups, although very far distance remained a risk for no steps. CHW programs providing active outreach to pregnant women distant from facilities can be important tools for improving uptake of interventions and reducing risk of no formal care during and after pregnancy.