A systematic review and narrative synthesis of antenatal interventions to improve maternal and neonatal health in Nepal

Abstract Background: Maternal and neonatal mortality rates remain high in many less economically developed countries, including Nepal. Good quality antenatal care can reduce adverse pregnancy outcomes; however, identifying how best to improve antenatal care can be challenging. Objectives: Our objective was to identify interventions for maternal or neonatal benefit that have been investigated in in the antenatal period in Nepal. We wanted to understand their scale, location, cost, and effectiveness. Study design: Online bibliographic databases (Cochrane Central, Medline, Embase, CINAHL Plus, British Nursing Index, PsycInfo, Allied and Complementary Medicine) and trial registries (ClinicalTrials.gov and the World Health Organization Clinical Trials Registry Platform) were searched from their inception until 24th May 2020. We included all studies reporting any maternal or neonatal outcome following an intervention in the antenatal period. We screened studies and extracted data in duplicate. Meta-analysis was not possible due to the heterogeneity of interventions and outcomes, so we performed a narrative synthesis of the included studies. Results: Twenty-five studies met our inclusion criteria. These studies showed a variety of approaches to improving antenatal care (e.g. educational programs, incentive schemes, micronutrient supplementation) in different settings (home, community or hospital-based) and with a wide variety of outcomes. Less than a quarter of the studies were randomized controlled trials, and many were single-site or reported only short-term outcomes. All studies reported having made a positive impact on antenatal care in some way but only three provided a cost-benefit analysis to support implementation. None of these studies focused on the most remote communities in Nepal. Conclusions: Our systematic review found good quality evidence that micronutrient supplementation and educational interventions can bring important clinical benefits. Iron folic acid supplementation significantly reduces neonatal mortality and maternal anaemia, while birth preparedness classes increase uptake of antenatal and postnatal care, increase compliance with micronutrient supplementation, and increase awareness of danger signs in pregnancy. Funding: Project funding through University of Bristol Global Challenges Research Fund (GCRF) and salary support from National Institute for Health and Research (NIHR).