Effect of community-level intervention on antenatal care attendance: a quasi-experimental study among postpartum women in Eastern Uganda

Background Early Initiation of antenatal care (ANC) and at least four visits during pregnancy allow screening and support for a healthy lifestyle and self-care during pregnancy however, community-directed interventions to improve access to these services are rarely explored. Objective To assess the effect of community health worker (CHW) involvement on utilisation of antenatal services during pregnancy in resource-constrained rural settings in Uganda. Methods We conducted a quasi-experimental evaluation study among mothers from Eastern Uganda. We used Difference in Differences (DiD) analysis to assess the effect of CHW intervention on ANC attendance. Components of the intervention included community dialogues and empowering CHWs to educate pregnant women about using maternal health services. The primary endpoints were early initiation of ANC and completion of at least 4 ANC visits. Results Overall, the intervention significantly improved attendance of >= 4 ANC visits (DiD = 5.5%). The increase was significant in both intervention and comparison areas (46.2-64.4% vs. 54.1-66.8%, respectively), with slightly greater gains in the intervention area. Other elements that predicted >= 4 ANC attendance besides the intervention were post-primary education (PR1.14, 95%CI 1.02-1.30), higher wealth quintile (PR1.17, 95%CI 1.06-1.30), and early initiation of ANC (PR1.58, 95%CI 1.49-1.68). The intervention did not significantly improve early initiation of ANC (DiD =-1.3%). Instead, early initiation of ANC was associated with higher husband education (PR1.19,95%CI 1.02-1.39), larger household size (PR = 0.81, 95%CI 0.70-0.95), and higher wealth index (PR1.19,95%CI 1.03-1.37). Conclusions The CHW intervention improved attendance of at least 4 ANC visits but not early initiation of ANC. There is need to promote CHW-led health education to increase attendance at 4+ ANC visits, but other approaches to promote early initiation are urgently required.