Dear HIFA and CHIFA colleagues,
Longtime members of HIFA will recall that we had long discussions about the role of traditional birth attendants. Our discussions were even published as a BMC paper: https://link.springer.com/article/10.1186/1471-2393-14-118
This new paper finds (inter alia) that 'TBA training played an important role in improving home-based essential newborn care (ENC) and did not compromise uptake of facility care'.
CITATION: Health Policy & Planning: Pathways of change for essential newborn care practices and health care seeking: a process evaluation of Mamás del Río, a community-based, maternal and neonatal health intervention in the Peruvian Amazon Open Access
Stefan Reinders , Magaly M Blas , Angela Alva , Luis Huicho , Carine Ronsmans , Isabelle L Lange
Health Policy and Planning, Volume 41, Issue 3, March 2026, Pages 376–394, https://doi.org/10.1093/heapol/czag004
ABSTRACT
In rural Indigenous communities in the Peruvian Amazon, access to quality care is difficult, home births are frequent, and neonatal mortality remains high. Peru has a large cadre of Community health workers (CHW), yet their potential is not harnessed. A recent outcome evaluation of a community-based intervention showed improvements in essential newborn care (ENC) for home births and small increases in facility births. To explain these findings, elucidate the pathways of change, and derive policy recommendations, we conducted a mixed-methods process evaluation. Implementation strength, mechanisms of change, and influence of contextual factors were assessed using data collected from women, CHW, traditional birth attendants (TBA), supervisors, and community members. We calculated programme coverage and intervention exposure and explored experiences, perceptions, and birth stories through interviews, focus group discussions, and participant observation using content analysis. Triangulated findings were narratively synthesized and contrasted to hypothesized intervention mechanisms. The programme achieved high coverage of well-trained CHW and TBA supported by intensive supervision. Multiple pathways of change were identified: Trained TBA as main providers of home-based birth care implementing ENC; CHW home visits sensitizing women through educational videos and provision of delivery kits, albeit with less reach and counselling than expected; and supervisor-led, women-only educational meetings. Some CHW proactively facilitated access to facility care, while promotion alone to increase demand appeared insufficient. Pathways of change identified support a causal link between the intervention and observed behaviour changes in the outcome evaluation. Our findings demonstrate the potential of community-based approaches involving CHW and TBA which should be given greater importance in national health policy. To improve impact and sustainability of the Peruvian CHW programme, we provide several context-specific recommendations.
KEY MESSAGES
Community health worker (CHW) home visit interventions are effective in reducing neonatal mortality, particularly in settings with difficult access to quality care. Community-based interventions are typically complex, and while their effect is well documented, little is known about their mechanisms of change, both internationally and for the Peruvian setting
This study is the first process evaluation of a community-based maternal-neonatal intervention in Peru, identifying multiple pathways of change that link intervention components with observed effects. CHW represented the central intervention axis, but their promotional home visits contributed less to change than expected. TBA training played an important role in improving home-based essential newborn care (ENC) and did not compromise uptake of facility care
To optimize impact and sustainability of the Peruvian CHW programme, we recommend the selection of female CHW to increase reach, financial and non-financial incentives to improve retainment, focus on alternative communication strategies, and strengthen CHWs’ roles as facilitators of access to care. TBA training should be considered for settings where deficiencies in facility care persist and TBA remains a key providers of birth care
Our experience demonstrates the potential of community-based approaches involving structured CHW home visits, training of TBA, and close supervision to achieve behaviour change. It also reiterates that sustained uptake in facility care not only requires promotion to foster demand but also simultaneous addressing of structural access barriers and quality of care
Best wishes, Neil
HIFA profile: Neil Pakenham-Walsh is coordinator of HIFA (Healthcare Information For All), a global health community that brings all stakeholders together around the shared goal of universal access to reliable healthcare information. HIFA has 20,000 members in 180 countries, interacting in four languages and representing all parts of the global evidence ecosystem. HIFA is administered by Global Healthcare Information Network, a UK-based nonprofit in official relations with the World Health Organization. Email: neil@hifa.org