Impact of Home Visits to Pregnant Women and Their Spouses on Gender Norms and Dynamics in Bauchi State, Nigeria: Narratives from Visited Men and Women

"He [husband] forbade me from taking our children to the health facility for immunization. I had to obey his order because he is the head of my family. Things changed for us last year....A male worker engaged my husband in discussions and gave him awareness. Alhamdulillah! My husband accepted his advice. Now he allows our children to be immunized." (40-year-old woman)

Maternal and newborn child health are priority concerns in Bauchi State, northern Nigeria. From 2015 to 2019, the research group authoring this paper, including a local non-governmental organisation (NGO), implemented a cluster randomised controlled trial (RCT) of universal home visits to improve maternal and early childhood health outcomes in the Toro local government authority (LGA) of Bauchi State. Increasing male involvement was an important element of the programme. In addition to the quantitative measurement of the impact of the home visits, the researchers collected narratives of change from women and men in visited households to understand what the visits meant to them. This paper offers an analysis of the stories, exploring the impact of the home visits on gender roles and decision-making and evaluating to what extent the intervention was gender-transformative.

As part of the programme, female and male home visitors visited pregnant women and their spouses during pregnancy and after delivery, sharing and discussing with them the same local evidence about risk factors for maternal health, actionable at the household level: heavy work during pregnancy, domestic violence, lack of spousal communication about pregnancy and childbirth, and lack of knowledge of danger signs in pregnancy and childbirth. Quantitative analysis of the trial (see Related Summaries, below) found that women in the visited areas had significantly fewer complications in pregnancy and after birth than women in non-visited areas, as well as improvements in the four identified risk factors; child outcomes also improved in the visited areas, and male knowledge and attitudes about maternal and child health improved.

The home visits programme had the potential to be gender-transformative because it addressed maternal health risk factors strongly related to gender norms and dynamics. Reducing heavy work during pregnancy questions the traditional division of labour, increasing spousal communication impacts shared decision-making, and preventing from gender violence is a fundamental aspect of women's dignity and rights. The home visitors invited pregnant women and their spouses to think about their behaviours and about social and cultural norms that could be harmful. That is, the approach in the home visits was not to prescribe actions; the households themselves chose what changes they made in the light of the local evidence shared by the home visitors.

Drawing on the most significant change technique, 4 trained fieldworkers (2 women and 2 men) collected stories of change from 23 women who had been visited during their pregnancies and 21 men who had been visited during their wives' pregnancies. The analysis indicated that the visits: improved men's support for antenatal care, immunisation, 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 change 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 - one reflected in the language used: "I allow my wife to..." Such views are likely to be deeply ingrained and not questioned by either women or men.

In conclusion: "Few studies have examined the gender-transformative potential of interventions to promote male involvement in reproductive health"; the stories analysed here provide some initial insights about how the visits affected shared decision-making, women's autonomy, and gender roles.