Co-designed and co-delivered place-based community interventions to reduce inequity in early initiation of antenatal care: findings from the cluster randomised controlled community REACH trial

Background Early initiation of antenatal care provides timely screening, advice and support. Inequities in early care initiation exist in high-income countries, but there is scant evidence on effective interventions. The community REACH (Research for Equitable Antenatal Care and Health) trial aimed to assess the effectiveness of co-produced place-based interventions to strengthen community support for early care initiation. Methods Matched-pair cluster randomised trial in socially disadvantaged and ethnically diverse areas in England. Electoral wards with low rates of early care initiation were matched and randomly allocated to intervention or control (usual care) (n=10 pairs). Following a 3-month co-design phase, community organisations and volunteers in intervention sites conducted targeted outreach activities over 6 months. The primary outcome was initiation of antenatal care by the 12th completed week of pregnancy. Results There was no evidence of a difference in the primary outcome (OR 1.07, 95% CI 0.89 to 1.28). There were also no statistically significant differences in rates of emergency caesarean, preterm birth, low birth weight, smoking or breastfeeding. There was a higher rate of care initiation by 10 weeks and fewer antenatal admissions in the intervention arm during the intervention period, although differences were not sustained after it finished. Conclusion This rigorous evaluation found a limited impact of short-term place-based interventions to strengthen community support for early initiation of antenatal care. Future initiatives may benefit from embedding in integrated health and care structures to ensure sufficient time and resources for mobilisation of community assets and focusing on smaller ‘hyper-local’ neighbourhoods. Actions to tackle wider structural and organisational barriers are also needed. Trial registration number ISRCTN registry: registration number 63066975. Registered on 18 August 2015.