The Impact of Including Husbands in Antenatal Health Education Services on Maternal Health Practices in Urban Nepal: Results from a Randomized Controlled Trial

This paper reports on a research intervention designed to test one strategy for meeting the fifth United Nations Millennium Development Goal of reducing maternal mortality in developing countries: involving men in reproductive health education. As evidence cited here shows, education and health services provided during the antenatal period can reduce pregnancy and delivery complications and improve birth outcomes in resource-poor settings; however, these benefits are contingent upon user compliance. At the same time, women's ability to seek health care or implement lessons learned from health education interventions is often determined by the household head, usually the husband.

A randomised controlled trial was designed to test the impact of involving male partners in antenatal health education on maternal health care utilisation and birth preparedness in urban Nepal. In total, 442 currently married women aged 18 years or over attending their first antenatal care (ANC) visit at Prashuti Griha Maternity Hospital (PGMH), Kathmandu, during the second trimester of pregnancy were randomised into three groups: women who received education with their husbands, women who received education alone, and women who received no education.

The health education intervention consisted of two 35-min health education sessions administered in a private room in the hospital. Participants in the intervention groups received the first session on the day of enrollment and were asked to return to PGMH for the second session 4–6 weeks later. In addition, one detailed health education flier that reviewed main curriculum points was made for each session for the two intervention groups. A brief flier was designed for women in the control group, made to resemble and standardise the limited health education messages that regular ANC patients (may) receive at PGMH. The intervention was based on principles from the theory of reasoned action, which stipulates that an individual's intention to perform an action (or behaviour) is essentially a function of that individual's attitude toward that action and of that individual's perceptions of social subjective norms, as well as the health belief model, which describes how health beliefs interact with modifying factors (e.g., perceived seriousness of problem) to determine health behaviours. The curriculum covered a number of maternal health topics, and the information was delivered in ways that recognised factors such as the impact of knowledge levels on attitudes and the influence of partners, other family members, and peer groups. Female study nurses and male auxiliary health workers summarised health information in the form of talking points supplemented with what were designed to be culturally adapted, easy-to-follow graphic materials. All health educators received a standardised training course including education and counselling techniques and role-playing, and structured intervention protocols were followed. For delivery of the intervention, individual couples received a face-to-face education session administered jointly by one male and one female worker. Women in the woman-alone group received an individual face-to-face education session with a female worker.

Women in the couples group were nearly twice as likely as control group women to report making >3 birth preparations. Among women who did not live with their mothers-in-law, those who received education with their husbands were more likely to be highly prepared for birth than control group women [23 versus 4%, risk ratio (RR) = 5.19, 95% confidence interval (CI) = (1.86, 14.53)]. In addition, women who received education alone (and lived separately from their mothers-in-law) were significantly more likely to make >3 birth preparations as compared with control group women [RR = 4.44, 95% CI = (1.56, 12.69)]. None of the birth preparedness outcomes was different between women in the couples group versus women in the woman-alone group.

Study groups were similar with respect to attending the minimum number of ANC checkups, delivering in a health institution, or having a skilled provider at birth. Women assigned to the couples group were more likely to attend the postpartum visit than participants assigned either to the control group [61 versus 47%, RR = 1.29, 95% CI = (1.04, 1.60)] or to the woman-alone group [61 versus 49%, RR = 1.25, 95% CI = (1.01, 1.54)]. There was no evidence that complication status or co-residence with mother-in-law modified the relationship between study group and these health care utilisation outcomes.

These data provide evidence that educating pregnant women and their male partners yields a greater net impact on maternal health behaviours compared with educating women alone.