Strengthening Migrant Access to Reproductive Healthcare in Thailand: observation of fixed and outreach service-based models of antenatal care for Karen and Myanmar migrants in Thailand, 2021-2024.

Background: Evidence to guide reproductive healthcare provision for undocumented migrants is limited. This study reports on the Strengthening Migrant Access to Reproductive Healthcare in Thailand (SMARH-T) initiative. Methods: This prospective observational study presents indicators of antenatal care (ANC), birth outcomes, and contraceptive uptake classified by the clinic of registration- standard (fixed clinic) or intervention (outreach clinic) -over a 3.5-year period from March 2021 to August 2024, including the initial 6-month pilot phase. Results: In total, 5,391 pregnant women (2,649 fixed and 2,742 outreach) registered over the 3.5 years, with the outreach team averaging 31 site visits per month. Seven of the nine WHO framework indicators for a positive pregnancy experience were reported for the two service-based models of antenatal care (ANC): the standard fixed clinic model and a new outreach model. Among women who delivered (2,280 fixed, 2,148 outreach), five of the seven indicators improved. The most improved measure by proportional increase from year one (baseline) to three, were eight ANC contacts (107.6% fixed, 81.7% outreach) and first ANC contact at <12 weeks (43.2% fixed, 31.0% outreach). First ANC contact at <12 weeks was the lowest-performing indicator overall (<30% of women). In contrast, syphilis screening, blood pressure monitoring, and fetal heartbeat measurement achieved >97.5% among all women. Homebirth without a skilled birth attendant was 2-fold higher in the outreach group (11.6% outreach, 5.3% fixed). Within 100 days of birth, 58.6% of women (1,945 of 3,318) opted for contraception; of these, the majority chose an implant (1,305 of 1,945, 67.1%), mostly (860 of 1,305, 65.9%) within 7 days postpartum. Completion of the 4-component delivery package (≥2 tetanus vaccinations, skilled birth attendance, health insurance and contraception within 100 days of birth) was achieved by 48.6% of women in total, with a greater proportional increase (year one to three) in the outreach group, including for health insurance. There were three maternal deaths (giving a maternal mortality ratio of 91 [95%CI: 31-267] per 100,000 live births [3 of 3,290]) and the maternal near-miss rate was 33 per 1,000 live births (95% CI: 28-40; 110 of 3,290), primarily due to postpartum hemorrhage. Conclusion: In total, five of seven quality indicators of care defined by the WHO framework for a positive pregnancy experience improved, with the outreach model of care nearly meeting the standards achieved by the fixed model. While the outreach model performed well, its sustainability remains a significant concern.