1. Testing the Gateway Behavior Strategy: Spouse Communication and Antenatal Counseling Catalyze a Lifetime of Family Health Douglas Storey, Grace Awantang, Bamidele Moyosola, & Olumide Adefioye Social & Behavior Change Communication Summit Addis Ababa, Ethiopia 10 February 2016

2. Managing diverse RMNCH objectives AIM: Investigate ways to improve the efficiency and long-term impact of RMNCH interventions. Gateway Behaviors Positive behaviors that catalyze multiple subsequent health behaviors Gateway Moments Transitional moments in life when people are receptive to new information and behaviors.

3. Gateway Behaviors at Gateway Moments

4. Study design Phase 1 Validated concept, identified potential Gateway Behaviors Literature review Secondary analysis of family health data from Nigeria (NDHS, NURHI MLE) and Egypt Communication for Healthy Living Two potential Gateway Behaviors identified Interpersonal communication (IPC) with spouse/partner Receiving at least four quality antenatal care (ANC) visits during a pregnancy.

5. Study design Phase 2 Tested Gateway Behavior approach in two LGAs in Nigeria Arm 1: Facility-based – Exit interviews with pregnant ANC clients, aged 18-30 – Sampled proportional to client volume Arm 2: Community-based (in catchment area of same facilities) – Household interviews with women, aged 18-30 – EAs & HHs sampled in catchment areas around facilities in Arm 1 – Pre-post cohort design: late 2012-early 2015 Baseline data collected December 2012—January 2013 Endline data collected January—February 2015

6. Table 1: Quasi-experimental design —Eight facilities audited/selected in each LGA

7. Gateways Intervention in Ilorin South April 2013-March 2015 Community based advocacy with leaders Door to door mobilization & referrals Community signage Key life events Happy Couple events Parades & performances Community dialogue sessions SMS blasts & follow-up to clinic visits Training for doctors, nurses, midwives

8. Figure 1: Percent of panel women recalling specific community- based message topics at endline in Ilorin South (Intervention) and Ilorin West (Control) Source: NURHI Gateway Behaviors Panel Survey (2013 & 2015) with WRA, aged 15-30 in Ilorin South (n=515) and Ilorin West (n=464).

9. Figure 2: Percent of panel women having 4 or more visits at last pregnancy in Ilorin South (Intervention) and Ilorin West (Control) Results only for women who have had two or more pregnancies. Source: NURHI Gateway Behaviors Panel Survey (2013 & 2015) with WRA, aged 18-30 in Ilorin South (n=515) and Ilorin West (n=464). P-value <0.05*, <0.01**, <0.001***

10. Results only for women who have had two or more pregnancies. Source: NURHI Gateway Behaviors Panel Survey (2013 & 2015) with WRA, aged 18-30 in Ilorin South (n=515) and Ilorin West (n=464). * p<.05, **p<0.001 Figure 3: Percent of panel women reporting discussion of family planning with ANC Provider at last birth in Ilorin South (Intervention) and Ilorin West (Control)

11. Figure 4: Percent of panel women reporting communication about family planning by local government authorities in Ilorin South (Intervention) and Ilorin West (Control) All increases were significant (p <0.05). Source: NURHI Gateway Behaviors Panel Survey (2013 & 2015) with WRA, aged 18-30 in Ilorin South (n=515) and Ilorin West (n=464).

12. Figure 5: Changes in percent of women reporting spousal communication, by topic in Ilorin South (Intervention) and Ilorin West (Control) Source: NURHI Gateway Behaviors Panel Survey (2013 & 2015) with WRA, aged 18-30 in Ilorin South (n=515) and Ilorin West (n=464). * p<.001 Taking your child for health care Getting your child vaccinated Going for antenatal care Worries or concerns about FP method Use of an FP method Number of children you desire Family financial situation

13. Figure 6: Percent of panel women reporting ANC-related behaviors by level of Gateways message exposure at endline

14. Subsequent outcome behaviors Self-reported behaviors at Time 2 1.Facility-based delivery of the most recent birth 2.Medically assisted delivery of the most recent birth, 3.Initiation of breastfeeding within 24 hours of delivery for the most recent birth, 4.Adoption or re-initiation of FP after the most recent birth, 5.Immunization of the most recently born child and 6.Having received an HIV test

15. Figure 7: Number of desired outcome behaviors at endline by level of Gateways message exposure

16. Figure 8: Number of self-reported outcome behaviors at endline as a function of Gateway Behaviors prior to endline

17. Summary Exposure to community-based intervention activities and messages was correlated with earlier registration for antenatal care earlier initiation of ANC in the first trimester of pregnancy discussion of MCH issues with one’s spouse number of reported MCH health behaviors. Women who reported optimum ANC service utilization (four or more ANC visits) during first pregnancy and discussion of family health issues with their spouse/partner reported a higher number of later MCH behaviors, controlling for LGA, time and household characteristics.

18. Implications 1.Spousal communication has long been recognized as an important predictor of contraceptive practice, but this research indicates that it may be a critical facilitator of multiple other behaviors across the family health lifestage spectrum. 2.Antenatal care, particularly during a woman’s first pregnancy, can set the stage for good behavior in a number of health domains including family planning, maternal health, and child care.

19. Thank you