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Background 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. Methods 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. Results 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. Conclusions 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. Trial registration ClinicalTrials.gov Identifier: NCT03371186, registered 04 December 2017, retrospectively registered. Plain English Summary 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.

Adolescent girls in low- and middle-income countries continue to face poor sexual and reproductive health (SRH). In Nepal, early marriage and motherhood, gender-based violence, and unmet need for contraception remain pervasive. Adolescent girls in rural areas bear a disproportionate burden of poor reproductive health outcomes, but there are limited context-specific data. This is a qualitative study to identify factors that impact adolescent girls' utilisation of and access to SRH services in a rural district of Nepal. We conducted 21 individual interviews with adolescent girls aged 15-19 years, and three focus group discussions with community health workers. We used an inductive analytic approach to identify emergent and recurrent themes and present the themes using the social ecological model. Individual-level factors that contribute to low uptake of services among adolescent girls include lack of knowledge, self-perceived lack of need, low decision-making autonomy, and shyness. Interpersonal factors that impact access include unsupportive family norms, absence of open communication, and need for permission from family members to access care. At the community level, disparate gender norms, son preference, and judgment by community members affect adolescent SRH. Inadequate sex education, far travel distance to facilities, lack of female healthcare providers and teachers, and inability to access abortion services were identified as organisational and systems barriers. Stigma was a factor cross-cutting several levels. Our findings suggest the need for multi-level strategies to address these factors to improve adolescent girls' SRH.

Unmet need for postpartum contraception in rural Nepal remains high and expanding access to sexual and reproductive healthcare is essential to achieving universal healthcare. We evaluated the impact of an integrated intervention that employed community health workers aided by mobile technology to deliver patient-centred, home-based antenatal and postnatal counselling on postpartum modern contraceptive use. This was a pre-post-intervention study in seven village wards in a single municipality in rural Nepal. The primary outcome was modern contraceptive use among recently postpartum women. We performed a multivariable logistic regression to examine contraceptive use among postpartum women pre- and one-year post-intervention. We conducted qualitative interviews to explore the implementation process. There were 445 postpartum women in the pre-intervention group and 508 in the post-intervention group. Modern contraceptive use increased from 29% pre-intervention to 46% post-intervention (p < 0.0001). Adjusting for age, caste, and household expenditure, time since delivery and sex of child in the index pregnancy, postpartum women one-year post-intervention had twice the odds (OR 2.3; CI 1.7, 3.1; p < 0.0001) of using a modern contraceptive method as compared to pre-intervention. Factors at the individual, family, and systems level influenced women's contraceptive decisions. The intervention contributed to increasing contraceptive use through knowledge transfer, demand generation, referrals to healthcare facilities, and follow-up. A community-based, patient-centred contraceptive counselling intervention supported by mobile technology and integrated into longitudinal care delivered by community health workers appears to be an effective strategy for improving uptake of modern contraception among postpartum women in rural Nepal.

Unmet need for postpartum contraception in rural Nepal remains high and expanding access to sexual and reproductive healthcare is essential to achieving universal healthcare. We evaluated the impact of an integrated intervention that employed community health workers aided by mobile technology to deliver patient-centred, home-based antenatal and postnatal counselling on postpartum modern contraceptive use. This was a pre–post-intervention study in seven village wards in a single municipality in rural Nepal. The primary outcome was modern contraceptive use among recently postpartum women. We performed a multivariable logistic regression to examine contraceptive use among postpartum women pre-and one-year post-intervention. We conducted qualitative interviews to explore the implementation process. There were 445 postpartum women in the pre-intervention group and 508 in the post-intervention group. Modern contraceptive use increased from 29% pre-intervention to 46% post-intervention (p < 0.0001). Adjusting for age, caste, and household expenditure, time since delivery and sex of child in the index pregnancy, postpartum women one-year post-intervention had twice the odds (OR 2.3; CI 1.7, 3.1; p < 0.0001) of using a modern contraceptive method as compared to pre-intervention. Factors at the individual, family, and systems level influenced women’s contraceptive decisions. The intervention contributed to increasing contraceptive use through knowledge transfer, demand generation, referrals to healthcare facilities, and follow-up. A community-based, patient-centred contraceptive counselling intervention supported by mobile technology and integrated into longitudinal care delivered by community health workers appears to be an effective strategy for improving uptake of modern contraception among postpartum women in rural Nepal. Les besoins insatisfaits en contraception postpartum dans le Népal rural restent élevés et il est essentiel d’élargir l’accès aux soins de santé sexuelle et reproductive pour parvenir à une couverture santé universelle. Nous avons évalué l’impact d’une intervention intégrée qui a employé des agents de santé communautaires secondés par une technologie mobile pour dispenser des conseils prénatals et postnatals à domicile et axés sur les patientes en matière d’utilisation de contraceptifs modernes pendant le postpartum. Il s’agissait d’une étude avant et après l’intervention dans sept villages d’une seule municipalité du Népal rural. Le principal résultat était l’emploi de contraceptifs modernes chez des femmes ayant récemment accouché. Nous avons réalisé une régression logistique multivariable pour examiner l’emploi de contraceptifs chez les jeunes accouchées avant et une année après l’intervention. Nous avons mené des entretiens qualitatifs pour explorer le processus de mise en œuvre. Le groupe pré-intervention comptait 445 femmes en postpartum, contre 508 dans le groupe post-intervention. L’emploi de contraceptifs modernes est passé de 29% avant l’intervention à 46% après l’intervention (p < 0,0001). Après ajustement en fonction de l’âge, de la caste et des dépenses du ménage, du délai écoulé depuis l’accouchement et du sexe de l’enfant dans la grossesse examinée, les femmes en postpartum une année après l’intervention avaient deux fois plus de probabilités (Rc 2,3; IC 1,7, 3,1; p < 0,0001) d’utiliser une méthode contraceptive moderne qu’avant l’intervention. Des facteurs aux niveaux individuel, familial et systémique influaient sur les décisions contraceptives des femmes. L’intervention a contribué à augmenter l’emploi de contraceptifs par le transfert de connaissances, la création de demande, les aiguillages vers les centres de soins de santé et le suivi. Une intervention relative aux conseils contraceptifs axés sur les patientes et à assise communautaire, soutenue par une technologie mobile et intégrée dans les soins longitudinaux dispensés par des agents de santé communautaires, semble être efficace pour améliorer le recours à une contraception moderne parmi les femmes en postpartum dans le Népal rural. La necesidad insatisfecha de anticoncepción posparto en las zonas rurales de Nepal continúa siendo alta y la ampliación del acceso a los servicios de salud sexual y reproductiva es esencial para lograr cobertura médica universal. Evaluamos el impacto de una intervención integrada que empleó a agentes de salud comunitaria ayudados por tecnología móvil para brindar consejería prenatal y posnatal domiciliaria centrada en la paciente sobre el uso de anticonceptivos modernos posparto. Este estudio pre-y post-intervención fue realizado en siete subdivisiones en una sola municipalidad de Nepal rural. El principal resultado fue el uso de anticonceptivos modernos entre mujeres en posparto reciente. Realizamos una regresión logística multivariable para examinar el uso de anticonceptivos entre mujeres posparto antes de la intervención y un año después. Realizamos entrevistas cualitativas para explorar el proceso de ejecución. Había 445 mujeres posparto en el grupo pre-intervención y 508 en el grupo post-intervención. El uso de anticonceptivos modernos aumentó del 29% pre-intervención al 46% post-intervención (p < 0.0001). Ajustando por edad, casta y gastos del hogar, tiempo desde el parto y sexo del niño en el índice de embarazos, las mujeres posparto un año después de la intervención tuvieron el doble de probabilidades (RM 2.3; IC 1.7, 3.1; p < 0.0001) de usar un método anticonceptivo moderno, comparadas con las mujeres en el grupo pre-intervención. Los factores a nivel individual, familiar y sistémico influyeron en las decisiones anticonceptivas de las mujeres. La intervención contribuyó a aumentar el uso de anticonceptivos mediante la transferencia de conocimientos, generación de demanda, referencias a unidades de salud y seguimiento. La intervención comunitaria, centrada en la paciente, para brindar consejería anticonceptiva apoyada por tecnología móvil e integrada en atención longitudinal domiciliaria brindada por agentes de salud comunitaria parece ser una estrategia eficaz para mejorar la aceptación de anticonceptivos modernos entre mujeres posparto en las zonas rurales de Nepal.