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.

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.