Perinatal Home Visiting By Paraprofessionals Among South African Mothers and Children

Introduction: Home visiting is the preventive intervention with the strongest data generated over the last 30 years, typically implemented by nurses. Yet, in low and middle income countries (LMIC) the workforce will not have a workforce to implement such programs at least for the next 50 years. This study evaluated whether paraprofessional home visiting for township mothers in South Africa buffers mothers and children from the intersecting epidemics of HIV, alcoholism and malnutrition in the first 3 years of life.

Methods: A cluster randomized controlled effectiveness trial was conducted with 24 matched township neighborhoods composed of 450-600 households in Cape Town, South Africa. Neighborhoods were randomized in matched pairs to either: 1) Standard Care (SC) which consists of good clinic care available within 5 km. or 2) the Philani Intervention Program (PIP), a home visiting program delivered by township Mentor Mothers trained as generalist health workers, plus SC. All pregnant women in each neighborhood were recruited (98% enrollment) and mothers were monitored within 2 weeks post-birth (96%), 6 months (94%), 18 months (86%) and 36 months (86%) post birth).  There were typically 16 home visits of about 31 minutes each over 18 months in the PIP condition. Over 36 months, 9.8% of either children or mothers died.

Results:  PIP children had better health measures over 18 months (growth indices of weight and height, % < 2SD below global mean) and at 36 months had significantly higher scores on the Peabody Picture Vocabulary Test and were significantly less likely to be hospitalized, compared to children in the SC condition.  PIP mothers were significantly less depressed at 36 months post-birth, compared to the SC.  At earlier assessments, PIP mothers with HIV were 50% more likely to adhere to the tasks that avoid maternal to child transmission, significantly more likely to stop alcohol use while pregnant, breastfeed longer and were more likely to breastfeed for 6 months compared to SC mothers. 

Conclusions: The benefits of home visiting, while modest at 36 months post-birth, are important. Yet, it is also important to recognize the importance of sustaining home visits for the first 1000 days of life, not tapering at 6 and 18 months post-birth.