The intervention was thus adapted, based on the results of the formative phase. The final version comprised three Components, in addition to routine maternity care:
- A: a group discussion with the male partners of pregnant women, - B: a couple-counselling session during pregnancy, and
- C: male partner participation in the first postnatal consultation, prior to discharge from the health centre (6th hour postpartum).
I will present each Component in detail in this Subchapter, also describing the educational materials used and the strategy used to invite men/couples to take part.
6.3.1. Component A – group discussion for men
Component A was the first intervention session in logical and chronological order. Men were invited to take part in this component through an invitation letter and a phone call. As described in Subchapter 5.3.4, each woman recruited during ANC was visited at home by a research assistant (RA) who completed recruitment, obtained informed consent, conducted the baseline interview and carried out randomisation. If a woman picked an envelope that contained an invitation letter, she was randomised to the intervention group. The letter was addressed to the woman’s male partner and invited him to attend a group discussion for men at the PHC. The
117 letter stated that information and advice on issues related to the health of women and newborns would be given during the session. The RA completed the letter manually with the man’s name, the date and time of the next group, and her own contact number in case of need. The RA asked the woman to give the letter to her partner at the earliest opportunity, and told her that health centre staff would re-iterate the invitation by phone. An example letter from one of the health centres can be found in Appendix 16).
A register of all women/couples assigned to the intervention group, with their contact details, was kept in the PHC in a folder dedicated to the study documentation. Every week, the RA assigned to that facility added the details of most recent intervention group recruits and their partners. Sequential serial numbers were thus assigned, based on the order of entry into the register, and were also reported on the woman’s health booklet together with the pink or yellow mark. This system was set up in order to help health workers to identify each woman/couple whenever she attended, and, if necessary, to easily find the husband’s contact number in the register in order to call him for the 6th hour consultation. ID numbers, because they were
random, could not have served this function. Another aim was to facilitate our identification of participants in all study documentation held in the PHC, and in facility registers (see Subchapter 5.3.5). Providers were asked to report the serial number next to every entry they made for that woman. Every week, health workers used this register to phone the new men and invite them to Component A on the following Saturday.
The group discussions were conducted every Saturday at 8am in each PHC by health workers from the maternity department. Sessions were identical and each participant was expected to attend once. Between 2 and 5 health workers usually conducted the session. Sometimes, one of them would translate into another language, depending on the needs of those present. The groups normally met in an open-air meeting space where several benches were laid out.
Between 3 and 13 men attended each session. Health workers checked their names upon arrival against the list of men who had been invited, and asked to see the invitation letter. Having brought the invitation letter was not a pre-requisite, but the man’s name had to be on the list. This was in order to prevent contamination that could have occurred if other members of the community had attended the session. Meetings were expected to last 30-40 minutes, though in practice they often overran.
During the group sessions, the facilitators read out the stories of three fictional couples having a baby. These were used to stimulate the discussion. In the examples, adverse events happened when men and women lacked adequate health information, and especially when there was no communication and collaboration between them. When adequate information, communication and collaboration were all present, there was a positive ending. Although this was not the main focus of the scenarios, the health issues touched upon in each of them were postnatal care,
118 exclusive breastfeeding, and postpartum family planning. The session ended with a summing up debate in which the key messages emerging from the stories were reinforced. Men were
encouraged to take an interest in their partner’s health and to communicate constructively with them to reach joint decisions, or to respectfully support her choices. I drew up the guide for conducting the group session, with entirely original content. It can be found in Appendix 19.
At the end of the meeting, facilitators asked each participant whether he would be willing to return in the near future for a couple counselling session with his female partner, in order to be receive more information about specific health topics relevant to maternal and infant wellbeing (Component B). If he agreed, he could choose his desired appointment date and time, ideally the following week. Health workers noted all the appointment times on a dedicated calendar sheet. Men were also forewarned that they would be invited for a third meeting after their baby was born (Component C). At the end of the session, participants were given CFA 1000 ($ 1.70) as a one-off contribution for travel expenses.
The documentation sheet for Component A, where the details of expected and actual
participants in the group were recorded, as well as the calendar sheet for scheduling Component B appointments, can be found in Appendix 18.
6.3.2. Component B – couple-counselling during pregnancy
The purpose of both couple counselling sessions (Component B and C) was to provide
information and advice to both partners on a range of topics related to pregnancy, birth, and the postpartum period. Counselling was provided in a private consultation room, with a desk, usually by one or two health workers. The sessions were interactive, and both partners were encouraged to ask questions. Sessions lasted approximately an hour.
Topics covered during Component B included: the importance of ANC and lifestyle adaptations in pregnancy, pregnancy danger signs, birth preparedness and signs of labour, the importance of PNC and the schedule, danger signs for mother and newborn, exclusive breastfeeding, healthy timing and spacing of pregnancies, return to fertility and resumption of intercourse, and postpartum contraception, including the range of methods available. Many women would already have been exposed to this information during the current or previous pregnancies through one-to-one or group education sessions at the health centre (see Subchapter 1.3.4), however, for many men this was likely to be the first time they received full counselling.
For this component, health workers used a counselling flipchart. This contained, for each topic, an illustration on the side facing the participant, and related text on the side facing the health worker. At first, participants were asked to describe what they saw in the picture. Health workers would then clarify and provide additional information based on the notes on the other side. I adapted the flipchart from two existing counselling tools (World Health Organization,
119 2012a, Ministere de la Sante et de la Prevention du Senegal, 2010). It can be found in Appendix 20.
When the conversation moved to family planning, the focus was on each couple’s particular situation and reproductive intentions. Samples of contraceptive methods were made available for the couple to see and touch. If they felt ready, couples were given the opportunity to express their choice of contraceptive method for the postpartum period, and a non-binding plan for initiation was drawn up and documented in the woman’s health booklet for future reference. The plan included information on what method had been chosen, and at what time, and where it would be obtained/commenced.
A specific documentation form was filled out for Component B, which included health workers’ and participants’ details and information about the postpartum contraception plan. This can be found in Appendix 18.
6.3.3. Component C – men’s participation in the 6
thhour postpartum
consultation
Intervention group women who gave birth in the PHC were identified thanks to the pink mark on the inside front cover of their health booklet (see Subchapter 5.3.4). If the woman’s male partner was not in the facility, the woman or health workers phoned him, so that around six hours postpartum the pre-discharge consultation could be conducted with both partners. Usually, the couple were received together after the woman had had a physical examination alone. This third educational component constituted a further opportunity to provide health information and counselling on the topics mentioned for Component B relative to the
postpartum period, and in particular on postnatal care attendance, postpartum family planning, and exclusive breastfeeding. Health workers are supposed to discuss these topics with women on this occasion, according to the national guidelines (see Subchapter 1.3.4). If the couple had not yet made a decision about contraception, they might do so during this session, with the option of immediate initiation of certain methods prior to discharge.
The same flipchart was used as for Component B, and contraceptive samples were used where appropriate. A similar documentation form as for Component B was filled out, and can be found in Appendix 18. This form also included documentation of any immediate postpartum FP method started.