The Frontiers in Reproductive Health Program (FRONTIERS) carried out this project as part of a coordinated set of operations research (OR) studies, collectively referred to as the "Global Agenda", with U.S. Agency for International Development (USAID) funding. This study explored the feasibility, acceptability, and cost-effectiveness of incorporating men as active partners in the prenatal and postpartum care of their partners. The study investigated the effect of shifting the health care service's focus to couples (as opposed to women alone) on male and female RH and selected infant health indicators. Research was conducted in India and South Africa, with the aim of improving pregnancy outcomes and male and female RH by reducing the prevalence of sexually transmitted infections (STIs), and by increasing family planning (FP) use, 6 months postpartum.

In India the interventions included:

• individual or group counseling session in the antenatal clinic, separately for men and women. Information was provided on: postpartum FP practices and contraceptive methods; STI prevention practices; symptoms of genital ulcer disease and male urethritis; and benefits of immunisations and breastfeeding for infants
• couple counseling sessions during antenatal and postnatal clinics
• screening of all pregnant women for syphilis
• syndromic management of men reporting urethral discharge and men and women reporting genital ulcers.

In South Africa the intervention included:

• improving antenatal care services by strengthening the existing antenatal package and service monitoring and supervision
• introducing couple counseling by training health providers, inviting partners of antenatal women to attend counseling twice during pregnancy and once post-delivery, and providing information to couples using a new antenatal booklet.

The study used a pre-test/post-test design with women attending experimental and control clinics for antenatal visits. In India, the MiM study used a non-equivalent control group study design to examine the effects of the intervention. The study was undertaken with the Employees State Insurance Corporation (ESIC), an insurer of private sector workers. Six of the 34 ESIC dispensaries in Delhi with the highest antenatal clinic attendance and with on-site lab facilities were selected. In South Africa, a randomised cluster, matched pair design was used with 6 clinics implementing the intervention and 6 control clinics providing services following the current practices of the Department of Health. Both rural and urban clinics were included.

Women were recruited into the study when they visited the clinics for a prenatal visit. If they agreed to participate, and were willing to invite their partners' participation, they were interviewed and enrolled in the study. Male partners of control group women were not interviewed, so as to avoid influencing their knowledge, attitudes, or behaviour. Women were contacted for a second interview at approximately 6 months postpartum at their homes. In India, the decision was made to only interview women and men if both partners were available. In South Africa, because so few of the women were married or lived with their partner, all women and men who agreed to the interview were included.

In South Africa, "about one-third of the couples invited for counseling attended, a positive outcome in a community where male participation has been limited, and where domestic arrangements are tenuous. The new antenatal book was given to most women attending the clinics, and many shared it with their partners."

In India, intervention women and men reported more communication on baby's health, breastfeeding, and FP issues. Significantly more men and women from the intervention group reported client-provider discussions during maternity care, and more reported antenatal discussions on FP. However, communication on STIs remained low.

In India,

• Knowledge of condoms for dual protection increased in both intervention women and men, but women's overall knowledge of FP was not significantly different between the intervention and control groups.
• Intervention men and women showed increased knowledge that breastfeeding can prevent pregnancy, but there was no change in knowledge of the 3 conditions of lactational amenorrhea (LAM).
• STI awareness and knowledge did not increase significantly; STI knowledge was lower in women than men. There were few self-reported STI risk behaviours and symptoms.
• Knowledge of pregnancy danger signs was significantly higher among intervention women, but remained low (25%). There was no difference in knowledge of danger signs among men; only 8% knew any symptoms.

In India,

• Postpartum FP use was significantly higher among couples in the intervention group, with the largest increase in condom use.
• The establishment of a universal syphilis screening programme yielded a significant increase in testing pregnant women; more than 90% of intervention women compared with 16% of those in control clinics were tested.
• Husbands' involvement was significantly higher in the intervention group during antenatal and FP consultations, postpartum visits, and during labour and delivery. Presence during physical examination remained low in both groups.

In South Africa, few differences were found between the control and intervention groups to support the hypothesised effects of the intervention, which organisers attribute to "the very weak implementation of the intervention, and to little change in the supervision offered to providers." Significant differences were found only in changing communication, partner assistance during pregnancy emergencies, and knowledge of the condom as a method of dual protection.

In India, intervention group clients who received couple counseling reported satisfaction with services. Qualitative data from focus groups and in-depth interviews revealed that providers were more satisfied with the new package of maternal child health services and would like to continue it.

Emails from FRONTIERS personnel - Susan Adamchak and Laura Raney on April 1 2005, and Nikki Douglas on April 21 2005 - to The Communication Initiative; and "Lessons Learned from the Global Agenda of the Frontiers in Reproductive Health Program" [PDF] [8].