Background: There is ample evidence of associations between short birth interval and adverse maternal and child health outcomes, including infant and maternal mortality. Short birth interval is more common among women in low-and middle-income countries. Identifying actionable aspects of short birth interval is necessary to address the problem. To our knowledge, this is the first systematic review to systematize evidence on risk factors for short birth interval in low-and middle-income countries. Methods: A systematic mixed studies review searched PubMed, Embase, LILACS, and Popline databases for empirical studies on the topic. We included documents in English, Spanish, French, Italian, and Portuguese, without date restriction. Two independent reviewers screened the articles and extracted the data. We used the Mixed Methods Appraisal Tool to conduct a quality appraisal of the included studies. To accommodate variable definition of factors and outcomes, we present only a narrative synthesis of the findings. Results: Forty-three of an initial 2802 documents met inclusion criteria, 30 of them observational studies and 14 published after 2010. Twenty-one studies came from Africa, 18 from Asia, and four from Latin America. Thirty-two reported quantitative studies (16 studies reported odds ratio or relative risk, 16 studies reported hazard ratio), 10 qualitative studies, and one a mixed-methods study. Studies most commonly explored education and age of the mother, previous pregnancy outcome, breastfeeding, contraception, socioeconomic level, parity, and sex of the preceding child. For most factors, studies reported both positive and negative associations with short birth interval. Shorter breastfeeding and female sex of the previous child were the only factors consistently associated with short birth interval. The quantitative and qualitative studies reported largely non-overlapping results.

BackgroundMaternal mortality in Nigeria is one of the highest in the world. Access to antenatal care is limited and the quality of services is poor in much of the country. Previous research in Bauchi State found associations between maternal morbidity and domestic violence, heavy work in pregnancy, lack of knowledge about danger signs, and lack of spousal communication about pregnancy and childbirth. This cluster randomized controlled stepped-wedge trial will test the impact of universal home visits to pregnant women and their partners, and the added value of video edutainment.MethodsThe trial will take place in six wards of Toro Local Government Area in Bauchi State, Nigeria, randomly allocated into three waves of two wards each. Home visits will begin in wave 1 wards immediately; in wave 2 wards after one year; and in wave 3 wards after a further year. In each wave, one ward, randomly allocated, will receive video edutainment during the home visits. Female home visitors will contact all households in their catchment areas of about 300 households, register all pregnant women, and visit them every two months during pregnancy, after delivery and one year later. They will use android handsets to collect information on pregnancy progress, send this to a central server, and discuss with the women the evidence about household factors associated with higher maternal risks, using video clips in the edutainment wards. Male home visitors will contact the partners of the pregnant women and discuss with them the same evidence. We will compare outcomes between wave 1 and wave 2 wards at about one year, between wave 2 and wave 3 wards at about two years, and finally between wards with and without added edutainment. Primary outcomes will be complications in pregnancy and delivery, and child health at one year. Secondary outcomes include knowledge and attitudes, use of health services, knowledge of danger signs, and household care of pregnant women.DiscussionDemonstrating an impact of home visits and understanding potential mechanisms could have important implications for reducing maternal morbidity and mortality in other settings with poor access to quality antenatal care services.Trial registrationRegistration number: ISRCTN82954580. Registry: ISRCTN. Date of registration: 11 August 2017. Retrospectively registered.

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

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. Plain English summary 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 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.