Home visits by community workers in South Africa improve maternal and child outcomes

A cluster randomised controlled effectiveness trial evaluating perinatal home visiting among South African mothers/infants.

Rotheram-Borus MJ, Tomlinson M, le Roux IM, Harwood JM, Comulada S, O'Connor MJ, Weiss RE, Worthman CM. PLoS One. 2014 Oct 23;9(10):e105934. doi: 10.1371/journal.pone.0105934. eCollection 2014.

Background: Interventions are needed to reduce poor perinatal health. We trained community health workers (CHWs) as home visitors to address maternal/infant risks.

Methods: In a cluster randomised controlled trial in Cape Town townships, neighbourhoods were randomised within matched pairs to 1) the control, healthcare at clinics (n = 12 neighbourhoods; n = 594 women), or 2) a home visiting intervention by CBW trained in cognitive-behavioural strategies to address health risks (by the Philani Maternal, Child Health and Nutrition Programme), in addition to clinic care (n = 12 neighbourhoods; n = 644 women). Participants were assessed during pregnancy (2% refusal) and 92% were reassessed at two weeks post-birth, 88% at six months and 84% at 18 months later. We analysed 32 measures of maternal/infant well-being over the 18 month follow-up period using longitudinal random effects regressions. A binomial test for correlated outcomes evaluated overall effectiveness over time. The 18 month post-birth assessment outcomes also were examined alone and as a function of the number of home visits received.

Results: Benefits were found on 7 of 32 measures of outcomes, resulting in significant overall benefits for the intervention compared to the control when using the binomial test (p = 0.008); nevertheless, no effects were observed when only the 18 month outcomes were analyzed. Benefits on individual outcomes were related to the number of home visits received. Among women living with HIV, intervention mothers were more likely to implement the PMTCT regimens, use condoms during all sexual episodes (OR = 1.25; p = 0.014), have infants with healthy weight-for-age measurements (OR = 1.42; p = 0.045), height-for-age measurements (OR = 1.13, p<0.001), breastfeed exclusively for six months (OR = 3.59; p<0.001), and breastfeed longer (OR = 3.08; p<0.001). Number of visits was positively associated with infant birth weight ≥2500 grams (OR = 1.07; p = 0.012), healthy head-circumference-for-age measurements at 6 months (OR = 1.09, p = 0.017), and improved cognitive development at 18 months (OR = 1.02, p = 0.048).

Conclusions: Home visits to neighbourhood mothers by CHWs may be a feasible strategy for enhancing maternal/child outcomes. However, visits likely must extend over several years for persistent benefits.

Abstract  Full-text [free] access

Editor’s notes: This trial combines two major trends in the delivery of health care. These include the shift of HIV services from specialist to generalist providers, and task-sharing between generalist and community providers. Community-based workers (CBW) from the Philani Maternal, Child Health and Nutrition Programme in Cape Town, South Africa were recruited to provide and apply health information about maternal and child health, HIV, alcohol use and nutrition to 644 perinatal women in the programme communities. The CBWs complemented the standard of care for health services, which were also available to 594 perinatal women in the control communities. About a quarter of participants were living with HIV. This study is notable for its real-world applicability through its trial design, provision of services to the entire population of eligible perinatal women, range of behavioural and clinical outcomes and rigorous analytic methods. At six months post-partum, women living with HIV in the programme arm were more likely to implement the prevention of mother-to-child regimen and to use condoms with their sex partners. Additionally, the children of these women had improved growth characteristics. Future research must determine whether CBWs can improve the other outcomes assessed in this trial, the cost-effectiveness of the CBWs, and how these gains can be extended to 18 months post-partum.

South Africa
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