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Meta-Analysis
. 2021 Jul 21;7(7):CD009326.
doi: 10.1002/14651858.CD009326.pub4.

Schedules for home visits in the early postpartum period

Naohiro Yonemoto  1 , Shuko Nagai  2 , Rintaro Mori  3
Affiliations
Meta-Analysis

Schedules for home visits in the early postpartum period

Naohiro Yonemoto et al. Cochrane Database Syst Rev. .

Abstract

Background: Maternal complications, including psychological/mental health problems and neonatal morbidity, have commonly been observed in the postpartum period. Home visits by health professionals or lay supporters in the weeks following birth may prevent health problems from becoming chronic, with long-term effects. This is an update of a review last published in 2017.

Objectives: The primary objective of this review is to assess the effects of different home-visiting schedules on maternal and newborn mortality during the early postpartum period. The review focuses on the frequency of home visits (how many home visits in total), the timing (when visits started, e.g. within 48 hours of the birth), duration (when visits ended), intensity (how many visits per week), and different types of home-visiting interventions.

Search methods: For this update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (19 May 2021), and checked reference lists of retrieved studies.

Selection criteria: Randomised controlled trials (RCTs) (including cluster-, quasi-RCTs and studies available only as abstracts) comparing different home-visiting interventions that enrolled participants in the early postpartum period (up to 42 days after birth) were eligible for inclusion. We excluded studies in which women were enrolled and received an intervention during the antenatal period (even if the intervention continued into the postnatal period), and studies recruiting only women from specific high-risk groups (e.g. women with alcohol or drug problems).

Data collection and analysis: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We used the GRADE approach to assess the certainty of the evidence.

Main results: We included 16 randomised trials with data for 12,080 women. The trials were carried out in countries across the world, in both high- and low-resource settings. In low-resource settings, women receiving usual care may have received no additional postnatal care after early hospital discharge. The interventions and controls varied considerably across studies. Trials focused on three broad types of comparisons, as detailed below. In all but four of the included studies, postnatal care at home was delivered by healthcare professionals. The aim of all interventions was broadly to assess the well-being of mothers and babies, and to provide education and support. However, some interventions had more specific aims, such as to encourage breastfeeding, or to provide practical support. For most of our outcomes, only one or two studies provided data, and results were inconsistent overall. All studies had several domains with high or unclear risk of bias. More versus fewer home visits (five studies, 2102 women) The evidence is very uncertain about whether home visits have any effect on maternal and neonatal mortality (very low-certainty evidence). Mean postnatal depression scores as measured with the Edinburgh Postnatal Depression Scale (EPDS) may be slightly higher (worse) with more home visits, though the difference in scores was not clinically meaningful (mean difference (MD) 1.02, 95% confidence interval (CI) 0.25 to 1.79; two studies, 767 women; low-certainty evidence). Two separate analyses indicated conflicting results for maternal satisfaction (both low-certainty evidence); one indicated that there may be benefit with fewer visits, though the 95% CI just crossed the line of no effect (risk ratio (RR) 0.96, 95% CI 0.90 to 1.02; two studies, 862 women). However, in another study, the additional support provided by health visitors was associated with increased mean satisfaction scores (MD 14.70, 95% CI 8.43 to 20.97; one study, 280 women; low-certainty evidence). Infant healthcare utilisation may be decreased with more home visits (RR 0.48, 95% CI 0.36 to 0.64; four studies, 1365 infants) and exclusive breastfeeding at six weeks may be increased (RR 1.17, 95% CI 1.01 to 1.36; three studies, 960 women; low-certainty evidence). Serious neonatal morbidity up to six months was not reported in any trial. Different models of postnatal care (three studies, 4394 women) In a cluster-RCT comparing usual care with individualised care by midwives, extended up to three months after the birth, there may be little or no difference in neonatal mortality (RR 0.97, 95% CI 0.85 to 1.12; one study, 696 infants). The proportion of women with EPDS scores ≥ 13 at four months is probably reduced with individualised care (RR 0.68, 95% CI 0.53 to 0.86; one study, 1295 women). One study suggests there may be little to no difference between home visits and telephone screening in neonatal morbidity up to 28 days (RR 0.97, 95% CI 0.85 to 1.12; one study, 696 women). In a different study, there was no difference between breastfeeding promotion and routine visits in exclusive breastfeeding rates at six months (RR 1.47, 95% CI 0.81 to 2.69; one study, 656 women). Home versus facility-based postnatal care (eight studies, 5179 women) The evidence suggests there may be little to no difference in postnatal depression rates at 42 days postpartum and also as measured on an EPDS scale at 60 days. Maternal satisfaction with postnatal care may be better with home visits (RR 1.36, 95% CI 1.14 to 1.62; three studies, 2368 women). There may be little to no difference in infant emergency health care visits or infant hospital readmissions (RR 1.15, 95% CI 0.95 to 1.38; three studies, 3257 women) or in exclusive breastfeeding at two weeks (RR 1.05, 95% CI 0.93 to 1.18; 1 study, 513 women).

Authors' conclusions: The evidence is very uncertain about the effect of home visits on maternal and neonatal mortality. Individualised care as part of a package of home visits probably improves depression scores at four months and increasing the frequency of home visits may improve exclusive breastfeeding rates and infant healthcare utilisation. Maternal satisfaction may also be better with home visits compared to hospital check-ups. Overall, the certainty of evidence was found to be low and findings were not consistent among studies and comparisons. Further well designed RCTs evaluating this complex intervention will be required to formulate the optimal package.

Trial registration: ClinicalTrials.gov NCT00298311 NCT01620723 NCT02769676 NCT03165838 NCT03448289 NCT03715218 NCT03880032 NCT03887910 NCT00996528 NCT04084275.

PubMed Disclaimer

Conflict of interest statement

Naohiro Yonemoto: none known.

Shuko Nagai: none known.

Rintaro Mori: none known.

Figures

1
1
Study flow diagram.
2
2
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 1: Maternal mortality within 42 days post‐birth
1.2
1.2. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 2: Neonatal mortality
1.3
1.3. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 3: Severe maternal morbidity
1.4
1.4. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 4: Secondary postpartum haemorrhage
1.5
1.5. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 5: Abdominal pain up to 42 days postpartum
1.6
1.6. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 6: Back pain up to 42 days postpartum
1.7
1.7. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 7: Urinary tract complications up to 42 days postpartum
1.8
1.8. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 8: Maternal fever up to 42 days postpartum
1.9
1.9. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 9: Dyspareunia
1.10
1.10. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 10: Maternal perception of general health at 6 weeks (mean SF36)
1.11
1.11. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 11: Mean postnatal depression score (last assessment up to 42 days postpartum)
1.12
1.12. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 12: Mean maternal anxiety score (last assessment up to 42 days postpartum)
1.13
1.13. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 13: Maternal satisfaction with postnatal care
1.14
1.14. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 14: Mean satisfaction score with postnatal care
1.15
1.15. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 15: Infant jaundice
1.16
1.16. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 16: Infant respiratory tract infection within 42 days
1.17
1.17. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 17: Infant diarrhoea up to 42 days postpartum
1.18
1.18. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 18: Exclusive breastfeeding (last assessment up to 6 weeks)
1.19
1.19. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 19: Exclusive breastfeeding (last assessment up to 6 months)
1.20
1.20. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 20: Any breastfeeding (up to 6 weeks)
1.21
1.21. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 21: Any breastfeeding (last assessment up to 6 months)
1.22
1.22. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 22: Mean duration of any breastfeeding (months)
1.23
1.23. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 23: Infant immunisation took place
1.24
1.24. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 24: Non prespecified ‐ Contraceptive use
1.25
1.25. Analysis
Comparison 1: Schedules involving more versus fewer home visits, Outcome 25: Non prespecified ‐ Infant health care utilisation
2.1
2.1. Analysis
Comparison 2: Schedules comparing different models of postnatal care at home, Outcome 1: Neonatal mortality
2.2
2.2. Analysis
Comparison 2: Schedules comparing different models of postnatal care at home, Outcome 2: Postnatal depression (EPDS ≥ 13 at 4 months postpartum)
2.3
2.3. Analysis
Comparison 2: Schedules comparing different models of postnatal care at home, Outcome 3: Neonatal morbidity up to 28 days
2.4
2.4. Analysis
Comparison 2: Schedules comparing different models of postnatal care at home, Outcome 4: Stopped exclusive breastfeeding (last assessment up to 6 weeks)
2.5
2.5. Analysis
Comparison 2: Schedules comparing different models of postnatal care at home, Outcome 5: Exclusive breastfeeding (last assessment up to 6 months)
2.6
2.6. Analysis
Comparison 2: Schedules comparing different models of postnatal care at home, Outcome 6: Any breastfeeding (up to 6 weeks)
3.1
3.1. Analysis
Comparison 3: Home versus facility postnatal care, Outcome 1: Severe maternal morbidity (emergency health care visits)
3.2
3.2. Analysis
Comparison 3: Home versus facility postnatal care, Outcome 2: Severe maternal morbidity (hospital readmissions)
3.3
3.3. Analysis
Comparison 3: Home versus facility postnatal care, Outcome 3: Postnatal depression (last assessment up to 42 days postpartum)
3.4
3.4. Analysis
Comparison 3: Home versus facility postnatal care, Outcome 4: Postpartum depression based EPDS at 60 days
3.5
3.5. Analysis
Comparison 3: Home versus facility postnatal care, Outcome 5: Mean maternal anxiety score (last assessment up to 42 days postpartum)
3.6
3.6. Analysis
Comparison 3: Home versus facility postnatal care, Outcome 6: Maternal anxiety and depression (HADS score)
3.7
3.7. Analysis
Comparison 3: Home versus facility postnatal care, Outcome 7: Maternal satisfaction with postnatal care
3.8
3.8. Analysis
Comparison 3: Home versus facility postnatal care, Outcome 8: Mean satisfaction score with postnatal care
3.9
3.9. Analysis
Comparison 3: Home versus facility postnatal care, Outcome 9: Exclusive breastfeeding (last assessment up to 6 weeks)
3.10
3.10. Analysis
Comparison 3: Home versus facility postnatal care, Outcome 10: Discontinued breastfeeding (up to 6 weeks)
3.11
3.11. Analysis
Comparison 3: Home versus facility postnatal care, Outcome 11: Any breastfeeding (last assessment up to 6 months)
3.12
3.12. Analysis
Comparison 3: Home versus facility postnatal care, Outcome 12: Discontinuation breastfeeding (up to 30 days)
3.13
3.13. Analysis
Comparison 3: Home versus facility postnatal care, Outcome 13: Non prespecified ‐ Infant emergency health care visits
3.14
3.14. Analysis
Comparison 3: Home versus facility postnatal care, Outcome 14: Non prespecified ‐ Infant hospital readmissions
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References

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Mohd Shukri 2019 {published data only}
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NCT00298311 2006 {published data only}
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NCT01620723 2012 {published data only}
    1. NCT01620723. Evaluation of breastfeeding support after short time hospitalization [Effect evaluation of a theory and evidence based programme for establishing effective breastfeeding after short time hospitalization post partum]. Available from: clinicaltrials.gov/show/NCT01620723 (first received 2012 June 15). [CENTRAL: CN-01595738]
NCT02069782 2014 {published data only}
    1. NCT02069782. Mother and infant home visiting program evaluation. Available from: clinicaltrials.gov/show/NCT02069782 (first received 2014 February 24).
NCT02769676 2016 {published data only}
    1. NCT02769676. A comparison of short interval vs. routine postpartum visit on contraceptive initiation. Available from: clinicaltrials.gov/show/NCT02769676 (first received 2016 May 11). [CENTRAL: CN-01558193]
NCT03165838 2017 {published data only}
    1. NCT03165838. Effectiveness of shortened time interval to postpartum visit in Iiproving postpartum attendance. Available from: clinicaltrials.gov/show/NCT03165838 (first received 2017 May 24). [CENTRAL: CN-01575281]
NCT03448289 2018 {published data only}
    1. NCT03448289. Use of a reproductive life planning tool at the pediatric well-baby visit with postpartum women. Available from: clinicaltrials.gov/show/NCT03448289 (first received 2018 February 28). [CENTRAL: CN-01483511]
NCT03715218 2018 {published data only}
    1. NCT03715218. Impact of mothers touch program to improve maternal health after birth [Indian postpartum care: a randomised trial to improve maternal health six weeks after birth]. Available from: clinicaltrials.gov/show/NCT03715218 (first received 2018 October 23). [CENTRAL: CN-01664337]
NCT03880032 2019 {published data only}
    1. NCT03880032. Happy Mother-Healthy Baby: an anxiety-focused early prenatal intervention [Happy Mother-Healthy Baby: an anxiety-focused early prenatal intervention for the prevention of common mental disorders in Pakistan]. Available from: clinicaltrials.gov/show/NCT03880032 (first received 2019 March 19). [CENTRAL: CN-01930983]
NCT03887910 2019 {published data only}
    1. NCT03887910. Northwell health visits: a Family Connects Pilot implementation at Northwell Health. Available from: clinicaltrials.gov/show/NCT03887910 (first received 2019 March 25). [CENTRAL: CN-01931053]
Olds 2002 {published data only}
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Park Himes 2017 {published data only}
    1. Park Himes K, Donovan H, Wang S, Weaver C, Grove JR, Facco FL. Healthy beyond pregnancy, a web-based intervention to improve adherence to postpartum care: randomized controlled feasibility trial. JMIR Human Factors 2017;4(4):e26. [CENTRAL: CN-02004118] - PMC - PubMed
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Pluym 2021 {published data only}
    1. NCT03733405. Postpartum care timing: a randomized trial [Randomized control trial of postpartum visits at two or six weeks to evaluate clinic attendance and emergency department usage]. Available from: clinicaltrials.gov/show/NCT03733405 (first received 2018 November 07). [CENTRAL: CN-01918332]
    1. Pluym ID, Mok T, Holliman K, Afshar Y, Rao R, Tandel MD, et al. Randomized Control Trial of Postpartum Visits at Two and Six Weeks. American Journal of Obstetrics & Gynecology MFM 2021:100363. [CENTRAL: CN-02257474] [EMBASE: 634692347] - PubMed
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    1. Pluym ID, Tandel M, Kwan L, Mok T, Holliman K, Afshar Y, et al. 57 Randomized Control Trial of Postpartum Visits at 2 weeks and 6 weeks. American Journal of Obstetrics and Gynecology 2021;224(2):S40. [CENTRAL: CN-02247498] [EMBASE: 2010868436] - PubMed
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Rotheram‐Borus 2017 {published data only}
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Tandon 2018 {published data only}
    1. Tandon SD, Ward EA, Hamil JL, Jimenez C, Carter M. Perinatal depression prevention through home visitation: a cluster randomized trial of mothers and babies 1-on-1. Journal of Behavioral Medicine 2018;41(5):641-52. [CENTRAL: CN-01915399] [EMBASE: 626711953] [PMID: ] - PubMed
Tomlinson 2016 {published data only}
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Var 2015 {published data only}
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References to studies awaiting assessment

ACTRN12618000491268 {published data only}
    1. ACTRN12618000491268. Understanding your Newborn and Adapting to parenthood (UNA): a randomised clinical effectiveness trial of the Newborn Behavioural Observations (NBO) for new families [Understanding your Newborn and Adapting to parenthood (UNA): A randomised clinical effectiveness trial of the Newborn Behavioural Observations (NBO) on mother-infant relationship, and maternal postnatal depression and stress in new families at-risk of postnatal depression]. Http://www.who.int/trialsearch/Trial2.aspx?TrialID=ACTRN12618000491268 (first received 2018). [CENTRAL: CN-01905765]
Baghersad 2020 {published data only}
    1. Baghersad Z, Mokhtari F, Bahadoran P. Effect of postpartum home care on mothers' health [Effect of postpartum home care on mothers' health]. Iranian Journal of Obstetrics, Gynecology and Infertility 2020;23(4):45-53. [CENTRAL: CN-02250307] [EMBASE: 2004921923]
IRCT201403152324N14 {published data only}
    1. IRCT201403152324N14. Quality of Life in Postpartum [Effect of Training Based on Continuous Care Model on Quality of Life and Quality of Sleep in the Postpartum Period]. Http://www.who.int/trialsearch/Trial2.aspx?TrialID=IRCT201403152324N14 (first received 2014). [CENTRAL: CN-01809101]
IRCT2016092529965N1 {published data only}
    1. IRCT2016092529965N1. The effect of Educational Counseling on parental expectations and postpartum stress [The effect of home-based Supportive Educational Counseling on parental expectations and postpartum stress in primiparous women]. Http://www.who.int/trialsearch/Trial2.aspx?TrialID=IRCT2016092529965N1 2016. [CENTRAL: CN-01878137]
IRCT2016121431416N1 {published data only}
    1. IRCT2016121431416N1. Effect Postpartum care at home on postpartum outcome [Aimed to investigate the effect of Postpartum care at home on postpartum outcome]. Http://www.who.int/trialsearch/Trial2.aspx?TrialID=IRCT2016121431416N1 (first received 2017). [CENTRAL: CN-01889935]
IRCT20200108046055N1 {published data only}
    1. IRCT20200108046055N1. The effect of postpartum home visit on mothers' knowledge and attitude about exclusive breastfeeding, incidence of some breastfeeding complications [The effect of postpartum home visit on mothers' knowledge and attitude about exclusive breastfeeding, incidence of some complications of lactation and physiological jaundice in neonates in hospital]. Http://www.who.int/trialsearch/Trial2.aspx?TrialID=IRCT20200108046055N1 (first received 2020). [CENTRAL: CN-02171268]
ISRCTN45202278 {published data only}
    1. ISRCTN45202278. Web-based and home-based postnatal psychoeducational interventions for first-time mothers [The effectiveness and cost-effectiveness of web-based and home-based postnatal psychoeducational interventions for first-time mothers: A randomized controlled trial]. Http://www.who.int/trialsearch/Trial2.aspx?TrialID=ISRCTN45202278 (first received 2016). [CENTRAL: CN-01804044]
Liu 2020 {published data only}
    1. Liu Y, Hu J, Chen X, Yu Y, Bai J. Effects of a health education program targeted to Chinese women adhering to their cultural practice of doing the month: a randomized controlled trial. Midwifery 2020 Jul 18;90:102796. [CENTRAL: CN-02160376] [EMBASE: 632485916] [PMID: ] - PubMed
NCT04084275 {published data only}
    1. NCT04084275. The effect of care given using Levine's Conservation Model on postpartum quality of life in primiparas. Available from: clinicaltrials.gov/show/NCT04084275 (first received 2019 September 10). [CENTRAL: CN-01984172]
TCTR20190206004 {published data only}
    1. TCTR20190206004. The effectiveness of a nurse-led social support program to prevent postpartum depression among adolescent mothers: a randomized controlled trial. Http://www.who.int/trialsearch/Trial2.aspx?TrialID=TCTR20190206004 (first received 2019). [CENTRAL: CN-01993127]

References to ongoing studies

Kristensen 2018 {unpublished data only}
    1. Kristensen IH, Kronborg H. What are the effects of supporting early parenting by enhancing parents' understanding of the infant? Study protocol for a cluster-randomized community-based trial of the Newborn Behavioral Observation (NBO) method. BMC Public Health 2018;18(1):832. [CENTRAL: CN-01935208] [EMBASE: 627710416] [PMID: ] - PMC - PubMed
NCT04226807 {published data only}
    1. NCT04226807. Impact of Earlier Postpartum Contact on Postpartum Visit Compliance and Maternal Wellbeing [Re-imagining the Postpartum Process: The Impact of Earlier Postpartum Contact on Attendance at Postpartum Visits and Maternal Wellbeing]. Https://clinicaltrials.gov/show/NCT04226807 (first received 2020 Jan 13). [CENTRAL: CN-02079327]
NCT04257552 {published data only}
    1. NCT04257552. Care After Pregnancy Study (CAPS): Engaging Women in Postpartum Care [Care After Pregnancy Study (CAPS): Randomized Controlled Trial of Patient Engagement After Pregnancy]. Https://clinicaltrials.gov/show/NCT04257552 (first received 2020 February 06). [CENTRAL: CN-02080137]

Additional references

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References to other published versions of this review

Yonemoto 2011
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Publication types

Associated data