title: A cluster randomized implementation trial to measure the effectiveness of an intervention package aiming to increase the utilization of skilled birth attendants by women for childbirth: study protocol.
abstract: BACKGROUND
  Nepal is on track to achieve MDG 5 but there is a huge sub-national disparity with existing high maternal mortality in western and hilly regions. The national priority is to reduce this disparity to achieve the goal at sub-national level. Evidences from developing countries show that increasing utilization of skilled attendant at birth is an important indicator for reducing maternal death. Further, there is a very low utilization during childbirth in western and hilly regions of Nepal which clearly depicts the barriers in utilization of skilled birth attendants. So, there is a need to overcome the identified barriers to increase the utilization thereby decreasing the maternal mortality. The hypothesis of this study is that through a package of interventions the utilization of skilled birth attendants will be increased and hence improve maternal health in Nepal.
  
  
  METHODS
  This study involves a cluster randomized controlled trial involving approximately 5000 pregnant women in 36 clusters. The 18 intervention clusters will receive the following interventions: i) mobilization of family support for pregnant women to reach the health facility, ii) availability of emergency funds for institutional childbirth, iii) availability of transport options to reach a health facility for childbirth, iv) training to health workers on communication skills, v) security provisions for SBAs to reach services 24/24 through community mobilization; 18 control clusters will not receive the intervention package. The final evaluation of the intervention is planned to be completed by October 2014. Primary study output of this study is utilization of SBA services. Secondary study outputs measure the uptake of antenatal care, post natal checkup for mother and baby, availability of transportation for childbirth, operation of emergency fund, improved reception of women at health services, and improved physical security of SBAs.
  
  
  CONCLUSIONS
  The intervention package is designed to increase the utilization of skilled birth attendants by overcoming the barriers related to awareness, finance, transport, security etc. If proven effective, the Ministry of Health has committed to scale up the intervention package throughout the country.
  
  
  BACKGROUND
  ISRCTN78892490.
authors.affiliation: Nepal Public Health Foundation, Post Box 4004, Kathmandu, Nepal. gpbhandari@gmail.com.
authors.forename: Gajananda P
authors.initials: GP
authors.lastname: Bhandari
authors.forename: Narayan
authors.initials: N
authors.lastname: Subedi
authors.forename: Janak
authors.initials: J
authors.lastname: Thapa
authors.forename: Bishnu
authors.initials: B
authors.lastname: Choulagai
authors.forename: Mahesh K
authors.initials: MK
authors.lastname: Maskey
authors.forename: Sharad R
authors.initials: SR
authors.lastname: Onta
mesh_terms: D000328:Adult; D000488:Allied Health Personnel / Q000592:standards*; D016000:Cluster Analysis; D005260:Female; D006268:Health Facilities / Q000592:standards*; D006297:Health Services Accessibility; D006700:Home Childbirth / Q000706:statistics & numerical data*; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D008880:Midwifery / Q000458:organization & administration*; D009390:Nepal; D011247:Pregnancy; D012189:Retrospective Studies; D019035:Rural Health Services