What is the issue?
Health problems for mothers and babies commonly occur or become apparent in the weeks following the birth. For the mothers these include postpartum haemorrhage (substitute excessive blood loss), fever and infection, abdominal and back pain, abnormal discharge (heavy or smelly vaginal discharge), thromboembolism (a blood clot), and urinary tract complications (being unable to control the urge to pee), as well as psychological and mental health problems such as postnatal depression. Mothers may also need support to establish breastfeeding. Babies are at risk of death related to infections (babies may be badly affected by infections), asphyxia (difficulties in breathing, caused by lack of oxygen), and preterm birth (being born prematurely).
Why is this important?
Home visits by health professionals or lay supporters in the early postpartum period may prevent health problems from becoming long-term, with effects on women, their babies, and their families. This review looked at different home-visiting schedules in the weeks following the birth.
What evidence did we find?
We included 16 randomised trials with data for 12,080 women. Some trials focused on physical checks of the mother and newborn, while others provided support for breastfeeding, and one included the provision of practical support with housework and childcare. They were carried out in both high-resource countries and low-resource settings where women receiving usual care may not have received additional postnatal care after early hospital discharge.
The trials focused on three broad types of comparisons: schedules involving more versus fewer postnatal home visits (five studies), schedules involving different models of care (three studies), and home versus facility postnatal check-ups (eight studies). In all but four of the included studies, postnatal care at home was delivered by healthcare professionals. For most of our outcomes, only one or two studies provided data. Overall, our results were inconsistent.
The evidence was very uncertain about whether home visits reduced newborn deaths or serious health problems with the mother. Women's physical and psychological health were not improved with more intensive schedules of home visits although more individualised care improved women's mental health in one study and maternal satisfaction was slightly better in two studies. Overall, babies may be less likely to have additional medical care if their mothers received more postnatal home visits. More home visits may have encouraged more women to exclusively breastfeed their babies and women to be more satisfied with their postnatal care. The different outcomes reported in different studies, how the outcomes were measured, and the considerable variation in the interventions and control conditions across studies were limitations of this review. The certainty of the evidence was generally found to be low or very low according to the GRADE criteria.
What does this mean?
Increasing the number of postnatal home visits may promote infant health and exclusive breastfeeding and more individualised care may improve outcomes for women. More research is needed before any particular schedule of postnatal care can be recommended.
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.
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.
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.
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.
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).
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.
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).