Levels of adherence to the intervention

As described in Chapter 6, the intervention 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).}

We defined high protocol adherence as attendance at at least two sessions out of three.

Components A and B were delivered between February and July 2015. Component C was delivered from when the first participant in the intervention group gave birth, in March 2015, to when the last gave birth in November of the same year.

Figure 6 illustrates the details of which Components/sessions were attended by study

participants assigned to the intervention arm. Out of 583 men/couples in the intervention group, 216 (37%) attended all three components, 216 (37%) attended any two, 98 (17%) attended any one, and 53 (9%) attended none. In other words, 74% attended at least two sessions, and can therefore be regarded as highly protocol-adherent.

Overall, component A was attended by 447 male partners (corresponding to 82% of the intervention group), B was attended by 373 couples (64%), and C by 328 (56%). This means that component A was followed by a certain level of drop-out, including by some who didn’t attend any further sessions (9% of couples in the intervention group). A further 12% attended A, did not attend B, but after birth attended C.

Component A was designed to be the starting point of the intervention, both chronologically and in terms of content. However, some people attended other components, but not A. For example, 3% of couples in the intervention group attended B without having attended A. These were

137 couples in which the man was unavailable for the group session, and, following negotiation of an appointment, the couple were received directly for component B.

In addition, there were also a certain number of men/couples (6% of the total) who had not attended any prior sessions, but in the end attended C. This can be explained by the fact that these men were present in the health centre around the time of birth, or attended when called, as this is a time when men may be available to pay for fees or medication (see Subchapter 6.1.3). The inclusion of component C in the intervention therefore provided a unique opportunity to involve men who had been unable or reluctant to attend during pregnancy.

Figure 6: Intervention components attended

Figure produced using www.sankeymatic.com

Although more than half of the group attended C, it was the least-attended component. The most likely reason for this can be found by comparing attendance with follow-up data on place of delivery, which is available for 96% of intervention-group study participants. Among these women, 379 (68%) delivered in one of the 5 participating facilities, and 181 (32%) delivered in elsewhere (mostly in referral hospitals, see Subchapter 9.1). As already mentioned, Component C was not offered in other facilities, but only in the 5 PHCs participating in the study.

As can be seen from Table 18, there was a stark difference in attendance at Component C by place of delivery: 78% of those who gave birth in a study facility received this component, versus 14% who gave birth elsewhere. This also means that overall those who gave birth

138 elsewhere were less likely to attend at least two sessions or be highly protocol-adherent (61% versus 81%), and very few attended all three (8%).

Table 18: Intervention components attended by place of birth Components attended: Birth in a study PHC: n [%] Birth elsewhere: n [%] A 314 [82.9] 145 [80.1] B 249 [65.7] 112 [61.9] C 294 [77.6] 25 [13.8] At least 2 306 [80.7] 111 [61.3] All three 194 [91.9] 17 [8.1] TOTAL 379 [100] 181 [100]

The reason why 14% of those who gave birth elsewhere nevertheless received Component C is that in these cases particularly zealous health workers asked the couple to return for Component C once they were discharged from the hospital. In other cases, they provided the counselling session to the couple at the time of the 6th _{day PNC appointment. Although they were probably}

counselled later than 6 hours after birth, I classified these couples as having received Component C.

Among those who did give birth in a study facility and did not receive Component C, this was probably due to the lack of availability of the male partner, or the staff’s failure to provide the consultation (see qualitative evaluation results in Subchapter 10.2.1).

8.1.1. High adherence by recruitment PHC

There was considerable variation in the levels of high adherence to the intervention depending on the health centre where women were first recruited into the study. As shown in Table 19, the proportions attending at least 2 sessions varied from a maximum of 87% for Guimbi, to a minimum of 64% for Ouezzinville (p=0.001, Chi square).

Table 19: High adherence to the intervention by recruitment PHC

Bolomakote Guimbi O’ville Sarfalao Sect 24

Attended 0-1 session: n [%] 21 [23.6] 13 [12.9] 58 [35.6] 25 [21.0] 34 [30.6] Attended at least 2 sessions: n [%] 68 [76.4] 88 [87.1] 105 [64.4] 94 [79.0] 77 [69.4] TOTAL 89 [100] 101 [100] 163 [100] 119 [100] 111 [100]

This difference could be explained by a combination of factors, but place of delivery appears to play a major part. As discussed, the likelihood that participants would attend the 3rd

intervention component (C) differed by place of delivery. As shown in Table 20, the proportion of women who delivered in a study facility varied substantially depending on recruitment PHC,

139 from a maximum of 83% of women from Sarfalao, to 53% of those from Ouezzinville

(p<0.001, Chi square). Although the Table presents data on the intervention arm only, almost identical proportions were observed in the control arm.

The variation in place of delivery by recruitment PHC could be due to population-based factors, or to factors related to the PHC itself. We believe that the geographical location of the health centres played an important role, as can be seen from the map of Bobo-Dioulasso in Subchapter 5.1.2). The proportion of births taking place elsewhere was highest for women recruited at the PHCs that were geographically closest to the referral hospitals (Ouezzinville, and to a lesser extent Guimbi and Bolomakote).

Table 20: Birth in a study PHC in the intervention arm

Bolomakote Guimbi O’ville Sarfalao Secteur 24 Birth in a study PHC: n [%] 60 [67.6] 61 [64.2] 81 [52.9] 95 [82.6] 82 [75.9] Birth elsewhere: n [%] 29 [32.6] 34 [35.8] 72 [47.1] 20 [17.4] 26 [24.1]

TOTAL 89 [100] 95 [100] 153 [100] 115 [100] 108 [100]