Universal Home Visits Improve Male Knowledge and Attitudes about Maternal and Child Health in Bauchi State, Nigeria: Secondary Outcome Analysis of a Stepped Wedge Cluster Randomised Controlled Trial

"Male spouses who received evidence-driven home visits to discuss local risk factors for maternal and child health had significantly better knowledge and attitudes related to maternal and child health than did male spouses in the control group."

Several systematic reviews of studies in low- and middle-income countries (LMICs) conclude that male involvement is associated with increased use of maternal care services, but the impact of interventions to increase male involvement on maternal and newborn morbidity and mortality is not clear. There are also concerns that in some contexts efforts to promote male involvement in reproductive health may cause harm, reinforcing gender stereotypes and increasing gender inequality and male dominance. A trial of universal home visits to pregnant women and their spouses in Nigeria improved maternal and child health outcomes, as detailed at Related Summaries, below. This randomised controlled trial (RCT) examines the impact of the visits on male spouses. It directly measures the impact of the home visits on knowledge and behaviours among participating men.

The study was conducted in Toro local government area (LGA) in Bauchi State, Nigeria. National maternal mortality in Nigeria is among the highest in the world, and rates are even higher in Bauchi. Child immunisation rates (children aged 12-23 months who received all basic vaccinations) are lower in Bauchi (19.6%) than nationally (31.3%), and 2-week diarrhoea prevalence in children under 5 years old is higher in Bauchi (34.1%) than nationally (12.8%). In Toro, the researchers randomly allocated 8 wards into 4 waves, beginning the intervention at 1-year intervals.

The intervention comprised twice-monthly evidence-based home visits to discuss local risk factors for maternal and child health with all pregnant women and their male spouses, with a further visit after the birth and a final visit when the child was aged 12-18 months old. Most of the home visitors worked within their own home communities. They received training over 11 days, including classroom sessions and field practice. Each team of one female and one male home visitor covered a catchment area of about 300 households. They shared with women and men (separately) the same local evidence about actionable upstream risk factors for maternal health: heavy work during pregnancy, domestic violence during pregnancy, lack of spousal discussion about pregnancy and childbirth, and lack of knowledge of danger signs during pregnancy and childbirth. The visitors interacted with the women and their spouses using a surveillance questionnaire and structured discussion guide; in one of each pair of wards, randomly allocated, the home visitors supplemented their discussions with short video clips about risk factors for maternal health.

Measured secondary outcomes of the intervention in the men included knowledge about danger signs in pregnancy and childbirth, beliefs about heavy work in pregnancy, discussion with their wives about pregnancy and childbirth, knowledge about causes and intentions about management of childhood diarrhoea, and views about childhood immunisation.

The analysis included 6,931 men in the intervention group and 9,434 in the control group. More men in the intervention group: knew 4 or more danger signs in pregnancy (risk difference (RD) = 0.186, 95% confidence interval (CI) = 0.044 to 0.327) and 3 danger signs in childbirth (RD = 0.091, 95%CI = 0.013 to 0.170), thought pregnant women should reduce heavy work before the third trimester (RD = 0.088, 95% CI = 0.015 to 0.162), and had discussed pregnancy and childbirth with their spouse (RD = 0.157, 95% CI = 0.026 to 0.288). More knew correct management of childhood diarrhoea with fluids and feeding (RD = 0.300, 95% CI = 0.203 to 0.397) and less would give a child medicine to stop diarrhoea (RD = 0.206, 95% CI = 0.125 to 0.287). Socio-economic differences did not explain the effect of the intervention on any of the outcomes. Future research could focus on understanding which men change as a result of the visits, and which do not; this information could help to tailor the visits to maximise their impact.

This study confirms that visited men were more likely to discuss maternal risk factors with their wives. These researchers have reported in other contexts that sharing information with stakeholders in communities - rather than simply telling them what to do - allows them to decide to take action to change their situation. Here, they hypothesised that sharing information with the male spouses of pregnant women in Toro LGA would increase their knowledge and ability to make changes to support the health of their wives and newborn children; the findings reported here suggest that this was indeed the case.

All visited households had visits to both pregnant women and their male spouses, so the question remains as to whether visiting the male spouses added value to the visits to pregnant women, or even if visiting male spouses could have led to changes in maternal and child outcomes in the absence of visits to pregnant women themselves. Future research could examine which elements of the home visits were most important in improving maternal, child, and male outcomes and measure sustainability of the male knowledge changes associated with the visits.

In conclusion: "Evidence-driven home visits to the male spouses of pregnant women increased their knowledge about maternal, newborn and early child health and associated local risk factors and increased their discussion with their wives about these issues. Together with evidence of impact of the visits on maternal and child health outcomes, this supports the idea that community efforts to improve maternal and child health must involve men."