Benefits of and Barriers to Male Involvement in Maternal Health Care in Ibanda District, Southwestern, Uganda ()
1. Introduction
There is evidence that male involvement in antenatal, delivery and postnatal care has benefits to men, women, the family, the community and the Heath care system [1]. There has been a number of global initiatives to increase male partner involvement in reproductive and newborn care. These include the International Conférences on Population and Development in Cairo and Beijing of 1994 and 1995 respectively and a number of other initiatives. According to Sakala et al. [1], men’s reproductive health and their behavior may impact positively and/or negatively on women’s reproductive health outcomes and children’s well-being in society. Research shows that men not only act to restrict women and children from health care seeking but if involved may lead to better healthcare-seeking behavior and better utilization of antenatal, delivery, and postnatal care services [2] - [7]. It is known that male involvement in antenatal, delivery and postnatal improves utilization and uptake of skilled antenatal, delivery, and postnatal services and this ultimately improves maternal and newborn outcomes [3] [8] - [16]. When the men are involved in antenatal care and learn the likely pregnancy risks early directly from the health worker they are likely to be better prepared for any eventuality. The men are even more likely to ensure compliance with instructions that are given if they are present during health care provision. The Ministry of Health in Uganda implements a policy of attending to mothers who come for antenatal with the male partner first as a strategy to encourage male partner involvement in antenatal care. Men who are involved in health of their families may also enjoy better health and closer relationships with family members [17] [18] [19] [20] [21].
The factors that hinder male involvement in antenatal, delivery and postnatal care are attributed to the health system, gender and social norms, cultural values, economic status, lack of or limited health information, level of education, women empowerment and religious factors [1] [17] [18] [22] - [27]. The family dynamics and communication and the extended family may also be a hindrance of male involvement in reproductive care [22] [28] [29] [30]. Men however report that they do not feel welcome and comfortable in prenatal clinics, the health workers have negative attitudes towards them and there are no services targeting men; in some settings, there are policies that intentionally restrict men’s access to clinics or the labor wards and these discourage male involvement [20] [21] [22] [25] [26] [28]. There are also perceptions that pregnancy and delivery care is a female role; in some cultures, men who go with their wives for antenatal or other care are perceived to be dominated by their wives [20] [21]. Although couple testing for HIV during antenatal care has widespread benefits in the control of HIV transmission for the couple and the newborn, it has been shown to be one of those factors that hinder male involvement, as some men fear to test for fear that the results will be known by their partners. Other male partners may completely not be involved in antenatal care hence the prevention of Mother to Child Transmission of HIV is interrupted. [1] [24]. This provides challenges with reproductive health care and HIV prevention intervention services.
There is limited documentation of benefits of and barriers to male partner involvement in antenatal delivery and postnatal care in Ibanda district in Uganda. The aim of this study was to explore and describe the benefits of and barriers to male involvement in antenatal, delivery and postnatal care from the perspective of the local context.
2. Methods
The study was carried out in the Ibanda district which is located in southwestern Uganda. The district is bordered by Kamwenge district in the north and northwest, Kiruhura district in the east, Buhweju, and Mbarara in the south, and Rubirizi district in the west. It has predominantly tropical vegetation and climate with some hilly and mountainous areas. It consists of 11 sub-counties, 4 town councils, 54 parishes and 577 villages. The total population is 206,905 of which 112,590 (54.4%) are female and 11,346 (5%) women are estimated to be pregnant annually. The population growth rate is 2.54% per annum which is slightly lower than the national rate of 3.04. The larger proportions of the population are farmers and live in the rural area with the smaller proportion living in the four semi-urban town councils.
Study Design
The study was conceptualized, planned, and executed as a cross-sectional, exploratory study based on the Grounded Theory research designs because of its complexity in nature. The Grounded Theory also conceptualizes patterns of people’s behavior in order to resolve their concerns. The data collection was done in Ibanda district, Southwestern, Uganda in May of 2020. The participants were purposively through narrative interviews (18) this was done until saturation was achieved when no new ideas were being realized from the interviews. The tool was an open ended narrative interview guide and they included questions like what are the benefits of male involvement to the man, woman, family and community. Then what are the barriers to male involvement in antenatal, postnatal and delivery care in the community. The guide was administered to pregnant females, men with pregnant women, community health workers, unmarried males, elderly females, elderly males, health workers and Village Health Team members. Among those interviewed nine were male and nine were female and they were purposively selected. The selected participants were female who were pregnant at the time and those who had had children before, health workers they were midwives working with maternal health, men who had pregnant wives or who had had children before and community elders and opinion leaders. The recorded qualitative data from the cross-sectional study were transcribed verbatim, read and re-read, coded, and sorted into categories. The analysis was done using the content-based approach for qualitative data and themes of describing benefit of and barriers to male involvement in reproductive health were identified [23]. The limitation of the study is that they cannot be generalized to the general population because communities may have deferent personal, cultural and gender perspectives.
The proposal of the study was approved by the Higher Degree Research Ethics Committee of Makerere University School of Public Health and the Uganda National Council for Science and Technology. Written permission was got from Ibanda district local authority and individual informed consent was obtained from participants at the time of enrollment into the qualitative study.
3. Results
The respondents included nine male and nine female who were purposively selected and these were married (4 male), unmarried (2 male), pregnant (4), previously pregnant women (2), village health team members (3; one female, two male) and health workers (3; one male, two female).
3.1. Benefits
Four thematic areas of benefits emerged from the analysis and they included family wellbeing and health, health care services utilization, health care worker motivation and community improvement and development.
3.1.1. Family Wellbeing and Health
This was the theme with the most benefits and they include having a healthy mother, baby and man, more love, respect and trust between man and wife, peace of mind for the mother, women doing fewer household chores, better joint planning for pregnancy, reduced expenditure on health care for the family and increased family income. These benefits created harmony in the family unit and it was happier, but where they were lacking then the family was less happy and less harmonious.
“If the man is involved, this woman will not have to explain this and that because they will be working together. They can plan together according to the resources they have, the woman might need a lot of things but if she knows the available resources, she will understand and they plan to save up some money in case the woman is about to deliver.” (Respondent 2 male)
“If a man is involved in helping his wife in reproductive care, it brings the family together and the children may become so resourceful in future because if you leave everything to the woman, she may fail to take care of the children and perhaps they may become criminals.” (Respondent 7 male)
“As for the baby, I have the hopes that the baby gets healthy, grows well and becomes intelligent when he or she doesn’t grow well, the baby can’t be intelligent.” (Respondent 4 male)
“When a child and the mother are healthy, the man isn’t going to spend on paying hospital bill and transport, so to me a healthy family is also a benefit to a man.” (Respondent 10 male)
“This can help him give care when he is at home by helping you with the work at home.” (Respondent 15 female)
“When you are taking care of her, you get a healthy baby and you as a family you keep in harmony, and you save money which you would have paid in the hospital.” (Respondent 16 female)
3.1.2. Health Care Services Utilization
In this thematic area when the man is involved he understands the risks and needs of the wife during this period and the importance of having antenatal, delivery and postnatal care at the health facility. The man is then more likely to encourage the partner to attend skilled health care at the health facility which increases utilization of health services and improved maternal and newborn outcomes.
“If men do what they are supposed to do in helping their wives during pregnancy, delivery and after delivery, they plan together and communicate, then the woman can have a healthy mind and body which will lead to delivery of healthy babies at the health Centre.” (Respondent 10 male)
“It helps in having planned children which can reduce abortions and loss of lives because sometimes we can have unplanned pregnancies.” (Respondent 9 female)
“Pregnancy period isn’t easy, so if your husband escorts you to ante natal, he can be advised by the doctors, he also sees what the women go through even during delivery, it’s important for them to respect the women.” (Respondent 15 female)
“Usually we think that a safe delivery is when you deliver in the hands of a health worker but male involvement leads to a safe delivery because these are the guys that are controlling budgets at home, they will provide the funds like transport so that the woman attends antenatal and delivery when it is early and complications will be minimal.” (Respondent 10 male)
3.1.3. Health Worker Motivation
Here the health workers are happy, have a good reputation and are motivated because the men are participating as recommended and this means that complications are identified early and dealt with hence better outcomes for the mother and baby. The demand for the health care services will also increase.
“If we men involve ourselves in taking care of our wives, it means that the health workers have done their part well, that is through education the men have grasped what was taught and hence the health workers are thanked.” (Respondent 4 male)
“They “Health workers” become happy knowing that mothers and children in their society are healthy.” (Respondent 5 female)
“They become proud if the people in their community are healthy and the health workers in that community get good reputation, the hospital even gets market from other clients.” (Respondent 6 female)
“When I get a good report from my village, and the sub-county knows whatever happens because they got records, for me as a VHT, it adds me some rank, this shows I taught people very well and they understood.” (Respondent 7 male)
3.1.4. Community Improvement and Prosperity
When men are involved and take care of their wives, the pregnancy risks reduce, and if present are taken care of early. This will result in reduced expenses on health hence other development will occur in the community.
“If all men involve themselves in taking care of their wives, our community develops and income may increase. Because, if we got peace you can start up a small retail shop and perhaps buy a car for my family which can be resourceful to my fellow people in the village.” (Respondent 4 male)
“If a man sees some another man’s wife is looking good and healthy after giving birth, he may have a thought of going to take care of his own wife. This can act as a good example to other men who don’t take care about their wives.” (Respondent 5 female)
“Your husband becomes proud of you and he can’t spend a lot because after a woman has given birth, she might fall sick due to child birth if he doesn’t care for you well.” (Respondent 6 female)
“It shows that he has accepted his responsibilities as the head of the family, this gives reputation and respect in his family and community. That community can develop, if a woman is well taken care of, she gets to the time of delivery when healthy.” (Respondent 7 male)
“It is beneficial in a way that you can be an example to the community hence inspiring the young ones to give birth in future.” (Respondent 15 female)
3.2. Barriers
In the barriers 4 themes emerged and these were individual factors and behavior, family and extended family factors, environment, cultural and gender factors and health care services factors.
3.2.1. Individual Factors and Behavior
The individual factors and behavior include ignorance/knowledge, responsibility, excessive alcohol consumption, laziness, lack of money and personal attitudes towards antenatal, delivery and postnatal care.
“Maybe you may find when the man has other women that distract him from his pregnant wife.” (Respondent 5 female)
“Being lazy also makes men not care about their wives, they neglect their responsibilities as men, they take pregnancy to be a simple joke because they find making a woman pregnant easy, so they think pregnancy and delivery are also easy.” (Respondent 6 female)
Respondent 8: “And meanwhile others, fear going to the hospital with their wives because they don’t want to be tested for HIV.”
“To me it is knowledge because if someone is aware of what they will benefit by going with the wife for antenatal, escorting the wife during the time of delivery or taking the child for immunization.” (Respondent 9 female)
“Most of the men are drunkards, these drunkard men cannot secure money for their pregnant women and they neglect their wives.” Respondent 11 male
“Most of the times, it’s because men don’t have enough money to take care of their wives, men sometimes don’t have money to purchase essentials for the wife and baby.” (Respondent 18 female)
3.2.2. Family and Extended Family Factors
The family factors include trust and cooperation within the couple, fidelity issues, domestic violence, family planning and the extended family attitudes and perceptions.
“Lack of cooperation and trust between the couple and domestic violence in a family also stops men from taking care of their wives.” Respondent 3 male
“I think it all begins with how you start your family, how you handle each other and understand each other, otherwise nothing should stop a man from taking care of his wife.” (Respondent 10 male)
“Sometimes a man can refuse to take care of his wife in suspicion of thinking that the pregnancy is not his and this makes him neglect you.” (Respondent 14 female)
“The first maybe when you conceived when he wasn’t willing, maybe he gave you money for family planning and you conceived, this stops him from being involved.”
“When the family has conflicts, it may also prevent this man from taking care, if the relatives don’t like the woman so he is also forced not to care.” (Respondent 15 female)
3.2.3. Cultural and Gender Factors
These included community perspectives and mis-perceptions of male involvement, the cultural beliefs about the role of men involvement in reproductive issues of their wives and the gender norms of the community for what men are expected to do in reproductive care.
“Others it is culture, in some cultures, you find a man isn’t supposed to appear when the woman is delivering and they think it is the woman’s business.” (Respondent 2 male)
“Others, it’s not actually that they aren’t involved but the nature of their work they do limits them however much they would want to.” (Respondent 2 male)
“In most cases men find it embarrassing for them to cook, wash and do all the things for the wife, they fear public judgment of thinking maybe he was bewitched by the wife.” (Respondent 8 female)
“And usually men also don’t have time; they are usually never in their homes but rather at work.” (Respondent 8 female)
3.2.4. Health Services Care Factors
These include the way services are delivered the timing of the services the attitude of the health workers and the availability and access to the health care services.
“Men also usually say that when they come to the hospital with their wives, the health workers are usually rude to them.” (Respondent 8 female)
“The rudeness of some health workers, sometimes due to heavy work load, may lead to some men not coming to the health facility with their partners.” (Respondent 9 female)
4. Discussion
4.1. Benefits
The study explored the perceived benefits of male involvement in antenatal, delivery and postnatal care and themes include family wellbeing and health, health care services utilization, health worker motivation and community improvement and prosperity. Under family health and wellbeing similar findings in Tanzania [22], Kenya [2], Nigeria [31], Uganda [32] & Ghana [20] conquered with our findings which suggested that the child, mother, man and family had better health and overall wellbeing in the event of male involvement in maternal health care. Some of the specific benefits included having a healthy mother, baby and man, more love, respect and trust between man and wife, peace of mind for the mother, women doing fewer household chores, better joint planning for pregnancy, reduced expenditure on health care for the family and increased family income The study also found that utilization of antenatal, delivery, postnatal and even the vaccination services increased with male involvement. This is consistent with other findings in: Ethiopia [3] [8] [33], Kenya [2] [15], Nepal [34], Myanmar [35], Nigeria [31] and South Asia [29]. These also reported a strong association between male partner involvement although still low and utilization of reproductive services across all the reproductive services. The men if involved and were aware on any risks and required resources were more likely to encourage their spouses to attend the scheduled appointments hence overall increase in the utilization of the maternal health services [2] [35]. This work also revealed that health workers were motivated if women came with their partners because they got them involved and they helped their spouses to go for services and to follow other scheduled interventions. The health workers felt that they were relevant when they saw the couples implementing the health advice they had given them. This is consistent with work done in Tanzania by Peneza [36] where health workers first tracked women who came with their male partners. However this was not the same for other literature who did not in most cases investigate health worker motivation specifically [2] [3] [8] [31]. This study has demonstrated among others that health workers are also motivated and happier if the male partners are involved this is probably because it augments their health care service outcomes.
4.2. Barriers
The study also explored the barriers to male involvement in antenatal, delivery and postnatal care and the themes included individual factors and behavior, family and extended family factors, environment, cultural and gender factors and Health care services factors.
The individual’s characteristics and specific behavior of the man will determine whether he will be involved in reproductive care for the partner. These may include ignorance or knowledge about reproductive issues, responsibility, age of male partner, excessive alcohol consumption, laziness, lack of money and personal attitudes of men towards antenatal, delivery and postnatal care. The findings in my studies are similar to work done in Ghana [28] [39], India [26], Kenya [21], Malawi [1], Myanmar [27], Nigeria [24] [25], Tanzania [22], and USA [37]. However some other work in Mozambique [30] [38] and Ghana [19] considered other factors other than individual ones and was not consistent with my findings.
Family and extended family factors like trust and cooperation within the couple, fidelity issues, domestic violence, family planning and the extended family attitudes and perceptions were also important barriers to male involvement. Where the relationships were good the male partner was more likely to be involved and where they were not getting on well the male was not usually involved. Similar finding were also documented in Ghana [28], where if couples were not living together the male partner was less likely to be involved in antenatal care. Other studies in Bangladesh [13], Mozambique [38] and Tanzania [22] also documented family factors as barriers to male involvement in antenatal, delivery and postnatal which is also consistent with this work.
The environmental, cultural and gender norms were also identified as barriers to male involvement in antenatal, delivery and postnatal care. Where the environmental, cultural and gender norms discourage male partner involvement in antenatal, delivery or postnatal care the men did not get involved. For example in some area of this community the business of pregnancy and delivery is for the women. The findings of this study are not isolated but similar other documentation in Bangladesh [13], Kenya [21], Ghana [20], India [26], Malawi [1], Mozambique [30], Nigeria [25], Tanzania [22] and Uganda [32]. If these community, cultural and social norms are addressed male involvement in antenatal, delivery and postnatal care can be improved.
Health care services factors that emerged included the way services are delivered, the timing of the services, attitude of the health workers and the availability and access to the health care services. These factors are fundamental because the recommendation by WHO and Uganda Ministry of health is that if antenatal, delivery and postnatal should be got from skilled care providers at the health facilities. This will likely give better outcomes for the mother and newborn baby. My findings were similar to other work done in Kenya [21], Ghana [28], Nigeria [24], Tanzania [22], Myanmar [27] and Ghana [39]. The factors demonstrated in this study may be similar in many communities but they may not be necessarily generic and applicable to other communities in an entire manner.
5. Conclusions and Recommendation
The benefits of male involvement in antenatal, delivery and postnatal care include family wellbeing and health, health care services utilization, health worker motivation and community improvement and prosperity. Therefore interventions that encourage family wellbeing, male and community involvement are encouraged and will likely have a positive impact on maternal reproductive and newborn child health outcomes.
The barriers to male involvement in antenatal, delivery and postnatal care include individual factors and behavior, family and extended family factors, environment, cultural and gender factors and health care services factors. Therefore interventions to improve male involvement should focus on the individual, family, environment or community, cultural, gender and health care services factors.
Acknowledgements
Special thanks were sending to the School of Public Health, Makerere University; Department of Community Health, Mbarara University of Science and Technology, Ibanda District Health workers, Data collectors, Village Health Teams, and the community members that participated.
Author’s Contributions
FB was involved in the conception and design of the study, its implementation, analysis of the data, interpretation of the findings, and drafting of the paper. VB participated in the conception of the study and review of the paper. CGO participated in the conception of the study and review of the paper. EN was involved in the conception of the study and review of the paper. LA was involved in the conception and design of the study and review of the paper. All the authors of this manuscript have read and approved it.
Funding
The funding is by the Swedish International Development Agency (SIDA) as a Ph.D. scholarship through the Makerere-Sweden Bilateral Research Programme.
Availability of Data
All the data including the audio recording are available with the corresponding author Fred Bagenda, Department of Community Health, Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda, email: bagendaf@gmail.com, Tel: + 256772452506.
Ethical Approval
The study was approved by the Higher Degree Research Ethics Committee of Makerere University School of Public Health and the Uganda National Council for Science and Technology. Written permission was got from Ibanda local district authority and informed consent from the individual participants.
Abbreviations
ANC Antenatal Care
HIV Human Immunodeficiency Virus
KI Key Informant
PNC Postnatal Care
WHO World Health Organization.