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Background: Gender inequities remain critical determinants influencing maternal health. Harmful gender norms and gender-based violence adversely affect maternal health. Gendered division of labour, lack of access to and control of resources, and limited women's decision-making autonomy impede women's access to maternal healthcare services. We undertook a cluster randomized controlled trial of universal home visits to pregnant women and their spouses in one local government area in Bauchi State, North-Eastern Nigeria. The trial demonstrated a significant improvement in maternal and child health outcomes and male knowledge, attitudes and behaviours. This paper qualitatively evaluates gender equity in the home visits programme., Methods: The research team explored participants' views about gender equity in the home visits programme. We conducted nine key informant interviews with policymakers and 14 gender and age-stratified focus group discussions with men and women from visited households, with women and men home visitors and supervisors, and with men and women community leaders. Analysis used an adapted conceptual framework exploring gender equity in mainstream health. A deductive thematic analysis of interviews and focus group reports looked for patterns and meanings., Results: All respondents considered the home visits programme to have a positive impact on gender equity, as they perceived gender equity. Visited women and men and home visitors reported increased male support for household chores, with men doing heavy work traditionally pre-assigned to women. Men increased their support for women's maternal health by paying for healthcare and providing nutritious food. Households and community members confirmed that women no longer needed their spouses' permission to use health services for their own healthcare. Households and home visitors reported an improvement in spousal communication. They perceived a significant reduction in domestic violence, which they attributed to the changing attitudes of both women and men due to the home visits. All stakeholder groups stressed the importance of engaging male spouses in the home visits programme., Conclusion: The home visits programme, as implemented, contributed to gender equity., (© 2024. The Author(s).)

Background: The World Health Organization recommends increased male involvement to improve maternal and newborn health in low- and middle-income countries, but few studies have measured the impact of male-engagement interventions on targeted men. A trial of universal home visits to pregnant women and their spouses in Nigeria improved maternal and child health outcomes. This analysis examines the impact of the visits on male spouses., Methods: In Toro Local Government Area in Bauchi State, Nigeria, we randomly allocated eight wards into four waves, beginning the intervention at one-year intervals. The intervention comprised two-monthly evidence-based home visits to discuss local risk factors for maternal and child health with all pregnant women and their male spouses. 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 compared outcomes between men in visited wards (intervention group) and pre-intervention wards (control group), using a cluster t test. Generalised linear mixed modelling accounted for the effect of socio-economic differences on the measured impact., Results: The analysis included 6931 men in the intervention group and 9434 in the control group. More men in the intervention group knew four or more danger signs in pregnancy (risk difference (RD) = 0.186, 95% confidence interval (CI)  = 0.044 to 0.327), and three 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., Conclusion: Universal home visits improved knowledge of male spouses about maternal and child health, which could contribute to improved maternal and child outcomes., Trial Registration: ISRCTN, ISRCTN82954580. 11 August 2017. Retrospectively registered. http://www.isrctn.com/ISRCTN82954580., Competing Interests: Competing interests: The authors completed the ICMJE Unified Competing Interest Form (available upon request from the corresponding author), and declare no conflicts of interest., (Copyright © 2022 by the Journal of Global Health. All rights reserved.)

Background: Nigeria is the second biggest contributor to global child mortality. Infectious diseases continue to be major killers. In Bauchi State, Nigeria, a stepped wedge cluster randomised controlled trial tested the health impacts of universal home visits to pregnant women and their spouses. We present here the findings related to early child health., Methods: The home visits took place in eight wards in Toro Local Government Authority, randomly allocated into four waves with a delay of 1 year between waves. Female and male home visitors visited all pregnant women and their spouses every 2 months during pregnancy, with a follow up visit 12-18 months after the birth. They presented and discussed evidence about household prevention and management of diarrhoea and immunisation. We compared outcomes among children 12-18 months old born to mothers visited during the first year of intervention in each wave (intervention group) with those among children 12-18 months old pre-intervention in subsequent waves (control group). Primary outcomes included prevalence and management of childhood diarrhoea and immunisation status, with intermediate outcomes of household knowledge and actions. Generalised Estimating Equations (GEE), with an exchangeable correlation matrix and ward as cluster, tested the significance of differences in outcomes., Results: The analysis included 1796 intervention and 5109 control children. In GEE models including other characteristics of the children, intervention children were less likely to have suffered diarrhoea in the last 15 days (Odds Ratio (OR) 0.40, 95% confidence interval (CI) 0.30-0.53) and more likely to have received increased fluids and continued feeding in their last episode of diarrhoea (OR 6.06, 95% CI 2.58-14.20). Mothers of intervention children were more likely to identify lack of hygiene as a cause of diarrhoea (OR 2.24, 95% CI 1.27-3.95) and their households had better observed hygiene (OR 3.29, 95% CI 1.45-7.45). Intervention children were only slightly more likely to be fully immunised (OR 1.67, 95% CI 0.78-3.57)., Conclusions: Evidence-based home visits to both parents stimulated household actions that improved prevention and management of childhood diarrhoea. Such visits could help to improve child health even in settings with poor access to quality health services., Trial Registration: ISRCTN82954580 . Date: 11/08/2017. Retrospectively registered., (© 2021. The Author(s).)

Background: Maternal and newborn child health are priority concerns in Bauchi State, northern Nigeria. Increased male involvement in reproductive health is recommended by the World Health Organization. A trial of a program of universal home visits to pregnant women and their spouses, with an intention to increase male involvement in pregnancy and childbirth, showed improvements in actionable risk factors and in maternal morbidity. We used a narrative technique to explore experiences of the visits and their effect on gender roles and dynamics within the households., Methods: Trained fieldworkers collected narratives of change from 23 visited women and 21 visited men. After translation of the stories into English, we conducted an inductive thematic analysis to examine the impact of the visits on gender norms and dynamics., Results: The analysis indicated that the visits improved men's support for antenatal care, immunization, and seeking help for danger signs, increased spousal communication, and led to changes in perceptions about gender violence and promoted non-violent gender relationships. However, although some stories described increased spousal communication, they did not mention that this translated into shared decision-making or increased autonomy for women. Many of the men's stories described a continuing paternalistic, male-dominant position in decision-making., Conclusions: Few studies have examined the gender-transformative potential of interventions to promote male involvement in reproductive health; our analysis provides some initial insights into this.

Background: Short birth intervals, defined by the World Health Organization as less than 33 months, may damage the health and wellbeing of children, mothers, and their families. People in northern Nigeria recognise many adverse effects of short birth interval (kunika in the Hausa language) but it remains common. We used fuzzy cognitive mapping to systematize local knowledge of causes of kunika to inform the co-design of culturally safe strategies to address it., Methods: Male and female groups in twelve communities built 48 maps of causes and protective factors for kunika, and government officers from the Local Government Area (LGA) and State made four maps. Each map showed causes of kunika or no-kunika, with arrows showing relationships with the outcome and between causes. Participants assigned weights for the perceived strength of relationships between 5 (strongest) and 1 (weakest). We combined maps for each group: men, women, and government officers. Fuzzy transitive closure calculated the maximum influence of each factor on the outcome, taking account of all relationships in the map. To condense the maps, we grouped individual factors into broader categories and calculated the cumulative net influence of each category. We made further summarised maps and presented these to the community mapping groups to review., Results: The community maps identified frequent sex, not using modern or traditional contraception, and family dynamics (such as competition between wives) as the most influential causes of kunika. Women identified forced sex and men highlighted lack of awareness about contraception and fear of side effects as important causes of kunika. Lack of male involvement featured in women's maps of causes and in the maps from LGA and State levels. Maps of protective factors largely mirrored those of the causes. Community groups readily appreciated and approved the summary maps resulting from the analysis., Conclusions: The maps showed how kunika results from a complex network of interacting factors, with culture-specific dynamics. Simply promoting contraception alone is unlikely to be enough to reduce kunika. Outputs from transitive closure analysis can be made accessible to ordinary stakeholders, allowing their meaningful participation in interpretation and use of the findings. For people in Bauchi State, northern Nigeria, kunika describes a short interval between successive births, understood as becoming pregnant again before the previous child is weaned. They recognise it is bad for children, mothers and households. We worked with 12 communities in Bauchi to map their knowledge of the causes and protective factors for kunika. Separate groups of men and women built 48 maps, and government officers at local and state level built four maps. Each group drew two maps showing causes of kunika or of no-kunika with arrows showing the links between causes and the outcome. Participants marked the strength of each link with a number (between 5 for the strongest and 1 for the weakest). We combined maps for women, men and government officers. We grouped similar causes together into broader categories. We calculated the overall influence of each category on kunika or no-kunika and produced summary maps to communicate findings. The maps identified the strongest causes of kunika as frequent sex, not using modern or traditional contraception, and family dynamics. Women indicated forced sex as an important cause, but men focused on lack of awareness about contraception and fear of side effects. The maps of protective factors mirrored those of the causes. The groups who created the maps approved the summary maps. The maps showed the complex causes of kunika in Bauchi. Promoting contraception is unlikely to be enough on its own to reduce kunika. The summary maps will help local stakeholders to co-design culturally safe ways of reducing kunika.

Background: In Northern Nigeria, short birth interval is common. The word kunika in the Hausa language describes a woman becoming pregnant before weaning her last child. A sizeable literature confirms an association between short birth interval and adverse perinatal and maternal health outcomes. Yet there are few reported studies about how people view short birth interval and its consequences. In support of culturally safe child spacing in Bauchi State, in North East Nigeria, we explored local perspectives about kunika and its consequences., Methods: A qualitative descriptive study included 12 gender-segregated focus groups facilitated by local men and women in six communities from the Toro Local Government Area in Bauchi State. Facilitators conducted the groups in the Hausa language and translated the reports of the discussions into English. After an inductive thematic analysis, the local research team reviewed and agreed the themes in a member-checking exercise., Results: Some 49 women and 48 men participated in the 12 focus groups, with an average of eight people in each group. All participants were married with ages ranging from 15 to 45 years. They explained their understanding of kunika, often in terms of pregnancy while breastfeeding. They described many disadvantages of kunika, including health complications for the mother and children, economic consequences, and adverse impact on men's health and family dynamics. The groups concluded that some people still practise kunika, either intentionally (for example, in order to increase family size or because of competition between co-wives) or unintentionally (for example, because of frequent unprotected sex), and explained the roles of men and women in this., Conclusion: Men and women in our study had a clear understanding of the concept of kunika. They recognized many adverse consequences of kunika beyond the narrow health concerns reported in quantitative studies. Their highlighted impacts of kunika on men's wellbeing can inform initiatives promoting the role of men in addressing kunika.

Background: Nigeria continues to have high rates of maternal morbidity and mortality. This is partly associated with lack of adequate obstetric care, partly with high risks in pregnancy, including heavy work. We examined actionable risk factors and underlying determinants at community level in Bauchi and Cross River States of Nigeria, including several related to male responsibility in pregnancy., Method: In 2009, field teams visited a stratified (urban/rural) last stage random sample of 180 enumeration areas drawn from the most recent censuses in each of Bauchi and Cross River states. A structured questionnaire administered in face-to-face interviews with women aged 15-49 years documented education, income, recent birth history, knowledge and attitudes related to safe birth, and deliveries in the last three years. Closed questions covered female genital mutilation, intimate partner violence (IPV) in the last year, IPV during the last pregnancy, work during the last pregnancy, and support during pregnancy. The outcome was complications in pregnancy and delivery (eclampsia, sepsis, bleeding) among survivors of childbirth in the last three years. We adjusted bivariate and multivariate analysis for clustering., Findings: The most consistent and prominent of 28 candidate risk factors and underlying determinants for non-fatal maternal morbidity was intimate partner violence (IPV) during pregnancy (ORa 2.15, 95%CIca 1.43-3.24 in Bauchi and ORa 1.5, 95%CI 1.20-2.03 in Cross River). Other spouse-related factors in the multivariate model included not discussing pregnancy with the spouse and, independently, IPV in the last year. Shortage of food in the last week was a factor in both Bauchi (ORa 1.66, 95%CIca 1.22-2.26) and Cross River (ORa 1.32, 95%CIca 1.15-1.53). Female genital mutilation was a factor among less well to do Bauchi women (ORa 2.1, 95%CIca 1.39-3.17) and all Cross River women (ORa 1.23, 95%CIca 1.1-1.5)., Interpretation: Enhancing clinical protocols and skills can only benefit women in Nigeria and elsewhere. But the violence women experience throughout their lives--genital mutilation, domestic violence, and steep power gradients--is accentuated through pregnancy and childbirth, when women are most vulnerable. IPV especially in pregnancy, women's fear of husbands or partners and not discussing pregnancy are all within men's capacity to change.