The Impact of Universal Home Visits with Pregnant Women and Their Spouses on Maternal Outcomes: A Cluster Randomised Controlled Trial in Bauchi State, Nigeria

"Home visits reduced upstream maternal risks, improving maternal outcomes without increased use of health services."

Maternal mortality in Nigeria is extremely high. Maternal mortality and lack of antenatal care (ANC) are related to structural factors in many developing countries: extreme poverty, powerful gender disparities, social marginalisation, and low levels of education. Knocking on the door of the home of every pregnant woman to discuss pregnancy risks with her and her spouse can be a structural intervention. It reduces the isolation of individual women and provides a strong message about the value of every pregnant woman. Conducted in Nigeria's north-eastern Bauchi State, this cluster randomised controlled trial (RCT) tested the impact of universal home visits that discussed risk factors with pregnant women and their spouses to precipitate household actions protecting pregnant women.

All women of childbearing age (14-49 years) in all households in the intervention wards were eligible for the study. Each ward included urban, rural, and rural remote communities. Among these women, all those who became pregnant during the study period were visited at home several times during their pregnancies; their husbands were also visited during the pregnancies. Each home visit team of one woman and one man covered around 300 households and visited every household every 2 months. The researchers recruited the home visitors mostly from the intervention communities, and they trained and evaluated them before they began the work. Female visitors followed those registered as pregnant with a surveillance questionnaire and discussion about the four issues related to pregnancy risk in a previous study in the state: heavy work in pregnancy, experience of domestic violence, lack of communication with the spouse, and lack of knowledge about pregnancy danger signs. Male visitors separately interviewed and held discussions with the partners of the pregnant women. The intention was to provoke household discussion and action on the risk factors.

The home visitors entered interview responses directly into global positioning system (GPS)-enabled android handsets preloaded with information for the home visitors to share with pregnant women and their spouses, along with instructions for referring pregnant women who reported danger signs to a local clinic. They uploaded records to a central server after each visit.

There were 1,837 women in intervention group and 1,853 women in the control (delayed) group. Primary outcomes were pregnancy, delivery, and postnatal complications, analysed with intention to treat using a cluster t-test.

The study found that the intervention reduced problems in pregnancy and postpartum: raised blood pressure (relative risk reduction (RRR) 0.120, cluster-adjusted 95% confidence interval (CIca) 0.045 to 0.194; risk difference (RD) 0.116, 95% CIca 0.042 to 0.190) and swelling of face or hands (RRR 0.271, 95% CIca 0.201 to 0.340; RD 0.264, 95% CIca 0.194 to 0.333) and postpartum sepsis (RRR 0.399, 95% CIca 0.220 to 0.577; RD 0.324, 95% CIca 0.155 to 0.493).

There were also statistically significant improvements in the risk behaviours. Compared with women in the pre-intervention wards, women in the intervention wards reported less heavy work in pregnancy (0.948 intervention vs. control 0.726) and less physical domestic violence in pregnancy (0.974 vs 0.909); they reported more communication with partners about pregnancy and delivery (0.899 vs 0.695), and they had better knowledge of danger signs during pregnancy and delivery (0.704 vs 0.287). The intervention did not increase use of antenatal care, institutional delivery, or skilled birth attendance.

Thus, the study identified "a clear advantage in the intervention wards. Universal home visits to pregnant women and their husbands reduced nearly all the reported complications in pregnancy that we examined and reduced reported postpartum sepsis. They also reduced reported domestic violence during pregnancy and improved the other targeted risk factors (heavy work in pregnancy, lack of spousal communication and lack of knowledge about danger signs). The improvement in outcomes was not due to increased use of health services." That is, baseline differences or differences in use of health services did not explain the impact detected on the outcomes.

The researchers suggest that the findings are "relevant to other parts of Bauchi and Nigeria, and probably also to other countries with high levels of maternal mortality and underfunded health services. Since the intervention did not address facilities or healthcare practices, any impact will be limited to upstream determinants [in light of underfunded and low-quality services]. Universal home visits should result in more referrals of those who need the extra attention to survive, so they could increase the demand on services."

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