Male Involvement and Accommodation During Obstetric Emergencies in Rural Ghana: A Qualitative Analysis

Cultural barriers to male partners' involvement in antenatal care in Limpopo province

Background

Participation of male partners in antenatal care (ANC) is a complicated process that involves social and behavioural transformation. It necessitates that males take a more active part in reproductive health. Men's participation in prenatal care has been linked to beneficial health outcomes such as enhanced maternal health outcomes across the world. However, culture has been identified as a barrier to male partners' participation in prenatal care.

Aim

The aim of the study was to explore and describe the cultural barriers to male partner involvement in ANC.

Setting

The study focussed on selected clinics and hospitals under Vhembe District, Limpopo province.

Methods

Qualitative, exploratory, descriptive, and contextual research design was used in this study. Qualitative data were collected through individual semi-structured interviews and Focus Group Discussions (FGDs). A thematic analysis approach was used to analyse the collected data from semi-structured interviews and FGDs.

Results

The findings revealed three themes: cultural beliefs and practices that affect male partners' involvement in ANC; gender-related barriers that affect male partners' involvement in ANC; and socioeconomic barriers to male partners' involvement in ANC.

Conclusion

The study's findings revealed that certain cultural beliefs and practices are a stumbling block to male partners' involvement in antenatal healthcare.

Contribution

Culturally based developed strategy might help in improving the knowledge and practices of male partners in ANC.

"At Least Somebody Sees You as a Hero": Fatherhood Stress and Well-Being in Ghana

Fathers' mental health and behaviors influence child development and partner well-being, yet paternal stress and well-being are frequently overlooked; especially in non-Western settings. The aim of this mixed-methods study was to quantitatively assess the impact of parenting stress on fathers' overall well-being in Ghana, West Africa; while qualitatively delving into their lived experiences as fathers. We used a qual/quant mixed-methods approach in this study. The study was conducted in three distinct locations in Ghana (a) Ada, a rural community on the Southeastern coast; (b) Kumasi, an urban setting in upper Southern Ghana; and (c) Sunyani, a peri-urban setting in West-central Ghana. Paternal stress was measured with the Aggravation in Parenting Scale (APS) and well-being was assessed using the Secure Flourishing Index (SFI). Textual data from focus group interviews were sorted using inductive coding and aggregated into overarching themes. Thirty-eight Ghanaian fathers ages 21 to 74 years participated in the study, average age 43 (±12.12 SD), median 39.5. Correlation analyses showed a strong, negative association between paternal stress and well-being (R = -0.63; p < .0001), which was supported in linear regression models (β = -1.04; 95% CI: -1.62, -0.45; p<.0001). Emergent themes of fatherhood stress included financial (employment, food, education, and health care), social (norms and expectations), and psychological (mental work, discipline, relationships, and coping strategies) stressors. A fourth overarching theme of pride and joy in parenting permeated the interviews. Ghanaian fathers with higher parenting stress experience lower overall well-being. Identified stressors could guide interventions that bolster the well-being of fathers and their families.

Men's involvement in women's abortion-related care: a scoping review of evidence from low- and middle-income countries

Men’s involvement in abortion is significant, intersecting across the individual, community and macro factors that shape abortion-related care pathways. This scoping review maps the evidence from low- and middle-income countries relating to male involvement in abortion trajectories. Five databases were searched, using search terms, to yield 7493 items published in English between 01.01.2010 and 20.12.2019. 37 items met the inclusion criteria for items relating to male involvement in women’s abortion trajectories and were synthesised using an abortion-related care-seeking framework. The majority of studies were conducted in sub-Saharan Africa and were qualitative. Evidence indicated that male involvement was significant, shaping the ability for a woman or girl to disclose her pregnancy or abortion decision. Men as partners were particularly influential, controlling resources necessary for abortion access and providing or withdrawing support for abortions. Denial or rejection of paternity was a critical juncture in many women’s abortion trajectories. Men’s involvement in abortion trajectories can be both direct and indirect. Contextual realities can make involving men in abortions a necessity, rather than a choice. The impact of male (lack of) involvement undermines the autonomy of a woman or girl to seek an abortion and shapes the conditions under which abortion-seekers are able to access care. This scoping review demonstrates the need for better understanding of the mechanisms, causes and intensions behind male involvement, centring the abortion seeker within this.

'I can't leave everything in the hands of my husband': Economic constraints and gender roles in care-seeking in post-Ebola Guinea

The 2014-2016 Ebola epidemic in West Africa had enduring effects on health systems and healthcare utilisation. This study explores the intersection of economic constraints and gender roles in Guinea to understand delays in care-seeking post-Ebola. In-depth interviews (n = 45) and focus group discussions (n = 24) were conducted with mothers, male heads of household, grandmothers, and health workers in rural and urban areas in Basse-Guinée and Guinée Forestière. A thematic analysis identified salient themes related to gender and economic constraints on health care-seeking. Participants, particularly men, emphasised the high cost of seeking care, which led to delays as women secured funds. Men's engagement in care-seeking included providing funds and permission, picking up medication, and giving appointment reminders. As principal actors when 'navigating' the healthcare system, women were intimately involved in economic decisions and responsible for securing funds for services - even when lacking direct financial control. Essentialist descriptions of men as 'providers' and women as 'navigators', therefore, masked nuances in care-seeking and economic responsibilities. Programmes must acknowledge men's engagement in care-seeking and address both the economic barriers women face when seeking care and their economic roles. Greater attention to the complex intersection of economic constraints and gender roles could address care-seeking delays.

"I came to escort someone": Men's experiences of antenatal care services in urban Ghana-a qualitative study

BACKGROUND

Male involvement in maternal healthcare has been widely recognized as essential for positive health outcomes for expectant mothers and their unborn babies. However, few studies have explored men's experiences of maternal health services. The purpose of this paper is to explore men's involvement in antenatal care in urban Ghana and to discuss how men navigate their roles in a space that has been constructed as feminine. The study draws upon theories of space, place, and gender.

METHODS

A qualitative exploratory study using semistructured interviews, focus group discussion, and observation was conducted in Accra, Ghana. Expectant fathers and health workers were interviewed, and observation was conducted at a selected public hospital in Accra.

RESULTS

The findings suggest that the few men who attend antenatal care with their expecting partners become involved to a limited extent in the clinic's activities. Beyond a few who take an active role, most men stay on the outskirts of the hospital grounds and rarely participate in consultations with their partner and midwife. Men still view their presence as necessary to acquire knowledge and as sources of emotional, financial, and physical support for their partners. On the health workers' side, the study found no clear agenda for engaging men at the clinic, and nurses/midwives felt there was a lack of staff who could engage more directly with the men.

CONCLUSION

The study indicates that most expecting fathers feel too shy and uncomfortable to locate themselves in the female space that makes up antenatal care/maternity wards. Health workers do not feel they have the necessary resources to involve men fruitfully. Thus, men do not engage in the activity as hoped but rather remain on the outskirts of the maternity clinic. However, if men continue to negotiate their involvement at the clinic and become more assertive in their roles, the maternity clinic as a female space could, with time, be transformed into a space in which both expecting mothers and fathers can actively participate and be engaged to the benefit of all.

Labour companionship and women's experiences of mistreatment during childbirth: results from a multi-country community-based survey

Background

Evidence has shown the benefits of labour companions during childbirth. Few studies have documented the relationship between the absence of labour companions and mistreatment of women during childbirth in low-income and middle-income countries using a standardised tool.

Methods

We conducted a secondary analysis of the WHO multi-country study on how women are treated during childbirth, where a cross-sectional community survey was conducted with women up to 8 weeks after childbirth in Ghana, Guinea, Nigeria and Myanmar. Descriptive analysis and multivariable logistic regression were used to examine whether labour companionship was associated with various types of mistreatment.

Results

Of 2672 women, about half (50.4%) reported the presence of a labour companion. Approximately half (49.6%) of these women reported that the timing of support was during labour and after childbirth and most of the labour companions (47.0%) were their family members. Across Ghana, Guinea and Nigeria, women without a labour companion were more likely to report physical abuse, non-consented medical procedures and poor communication compared with women with a labour companion. However, there were country-level variations. In Guinea, the absence of labour companionship was associated with any physical abuse, verbal abuse, or stigma or discrimination (adjusted OR (AOR) 3.6, 1.9–6.9) and non-consented vaginal examinations (AOR 3.2, 1.6–6.4). In Ghana, it was associated with non-consented vaginal examinations (AOR 2.3, 1.7–3.1) and poor communication (AOR 2.0, 1.3–3.2). In Nigeria, it was associated with longer wait times (AOR 0.6, 0.3–0.9).

Conclusion

Labour companionship is associated with lower levels of some forms of mistreatment that women experience during childbirth, depending on the setting. Further work is needed to ascertain how best to implement context-specific labour companionship to ensure benefits while maintaining women’s choices and autonomy.

Male partner involvement in birth preparedness, complication readiness and obstetric emergencies in Sub-Saharan Africa: a scoping review

Background

Maternal mortality remains a pressing concern across Sub-Sahara Africa. The ‘Three Delays Model’ suggests that maternal deaths are a consequence of delays in: seeking care, reaching medical care and receiving care. Birth Preparedness and Complication Readiness (BPCR) refers to a plan organised during pregnancy in preparation for a normal birth and in case of complications. Male partners in many Sub-Saharan African communities could play a pivotal role in a woman’s ability to prepare for birth and respond to obstetric complications. This review aimed identify: the extent and quality of research performed on the topic of male partner involvement in BPCR in Sub-Saharan Africa; the degree to which populations and geographic areas are represented; how male partner involvement has been conceptualized; how male partners response to obstetric complications has been conceptualised; how the variation in male partners involvement has been measured and if any interventions have been performed.

Methods

In this scoping review, articles were identified through a systematic search of databases MEDLINE, EMBASE and Maternity and Infant Care and a manual scan of relevant papers, journals and websites. All authors contributed to the screening process and a quality assessment using the Kmet checklist. The PRISMA checking list for Scoping Reviews was used to guide the search, data charting and reporting of the review The protocol was registered with PROSPERO (ID: CRD42019126263).

Results

Thirty-five articles met inclusion criteria, reporting: 13 qualitative, 13 cross-sectional, 5 mixed method and 4 intervention studies. Data were contributed by approximately 14,550 participants (numbers were not always reported for focus groups) including: women who were pregnant or who had experienced pregnancy or childbirth within the previous 3 years, their male partners and key informants such as health workers and community leaders.

Conclusions

The diversity of study designs, aims and source countries in this body of literature reflects an emerging stage of research; as a result, the review yielded strong evidence in some areas and gaps in others. Male partner’s involvement in BPCR and responding to obstetric emergencies can be conceptualised as being centrally involved in responding to complications and having some role in preparing for birth through their position in the chain of decisions and provision of logistic support. However, their knowledge of pregnancy complications and level of preparation for birth is low, suggesting they are making decisions without being fully informed. There is limited evidence on interventions to improve their knowledge. Future research efforts should be focused on producing standardised, culturally appropriate, higher level evidence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03606-x.

Using Qualitative Research to Study the Profession of Rural Surgery

This is a systematic review of original research articles that use qualitative methods to investigate rural surgery over the last decade (2010-2019). This review found that interviews and focus groups were common, most often engaging with patients and health care professionals. Thematic analysis and grounded theory were data analysis methods most frequently used among these qualitative rural surgery studies. Studies in this review often pertained to obstetrics or the provision of other other surgical services. Areas for future qualitative research on rural surgery are surgical teamwork, scope of practice, workforce shortages, and issues related to the aging rural patient.

Men's roles in care seeking for maternal and newborn health: a qualitative study applying the three delays model to male involvement in Morogoro Region, Tanzania

Background

Increasing the utilization of facility-based care for women and newborns in low-resource settings can reduce maternal and newborn morbidity and mortality. Men influence whether women and newborns receive care because they often control financial resources and household decisions. This influence can have negative effects if men misjudge or ignore danger signs or are unwilling or unable to pay for care. Men can also positively affect their families’ health by helping plan for delivery, supplementing women’s knowledge about danger signs, and supporting the use of facility-based care. Because of these positive implications, researchers have called for increased male involvement in maternal and newborn health. However, data gathered directly from men to inform programs are lacking.

Methods

This study draws on in-depth interviews with 27 men in Morogoro Region, Tanzania whose partners delivered in the previous 14 months. Debriefings took place throughout data collection. Interview transcripts were analyzed inductively to identify relevant themes and devise an analysis questionnaire, subsequently applied deductively to all transcripts.

Results

Study findings add a partner-focused dimension to the three delays model of maternal care seeking. Men in the study often, though not universally, described facilitating access to care for women and newborns at each point along this care-seeking continuum (deciding to seek care, reaching a facility, and receiving care). Specifically, men reported taking ownership of their role as decision makers and described themselves as supportive of facility-based care. Men described arranging transport and accompanying their partners to facilities, especially for non-routine care. Men also discussed purchasing supplies and medications, acting as patient advocates, and registering complaints about health services. In addition, men described barriers to their involvement including a lack of knowledge, the need to focus on income-generating activities, the cost of care, and policies limiting male involvement at facilities.

Conclusion

Men can leverage their influence over household resources and decision making to facilitate care seeking and navigate challenges accessing care for women and newborns. Examining these findings from men and understanding the barriers they face can help inform interventions that encourage men to be positively and proactively involved in maternal and newborn health.

Female perspectives on male involvement in a human-papillomavirus-based cervical cancer-screening program in western Kenya

BACKGROUND

To be effective, population-based cervical cancer prevention programs must be tailored to meet the needs of the target population. One important factor in cervical cancer screening may include male involvement. To iteratively improve a screening program employing self-collected vaginal swabs for human-papillomavirus (HPV) testing in western Kenya, we examined the role of male partners and community leaders in decision-making and accessing screening services.

METHODS

We carried out 604 semi-structured, in-depth interviews (IDIs) with women and community health volunteers who took part in a multiphase trial of implementation strategies for HPV-based cervical cancer screening. IDIs were coded and themes related to decision-making, screening and treatment barriers, and influence of male partners and community leaders were identified and analyzed.

RESULTS

Women experienced both support and opposition from their male partners. Partner support took the form of financial support for transportation and emotional support and encouragement, while opposition ranged from anticipated negative reactions to lack of permission, isolation, and abandonment. Though most women described their own partners as supportive, many felt that other male partners would not be supportive. Most participants believed that increased HPV and cervical cancer knowledge would increase partner support. Women reported a general acceptance of involvement of community leaders in education and screening campaigns, in a setting where such leaders may hold influence over men in the community.

CONCLUSION

There was a clear interest in involving male partners in the cervical cancer prevention process, specifically in increasing knowledge and awareness. Future research should explore the feasibility and effectiveness of engaging male partners in cervical cancer screening and prevention programs.

Key Decision Makers and Actors in Selected Newborn Care Practices: A Community-Based Survey in Northern Uganda

Knowledge of key decision makers and actors in newborn care is necessary to ensure that health interventions are targeted at the right people. This was a cross-sectional study carried out in Lira district, Northern Uganda. Multivariable logistic regression was used to determine factors associated with mothers being the key decision maker regarding where to give birth from and when to initiate breastfeeding. Fathers were the key decision makers on the place of birth (54.3%, n = 505) and on whether to seek care for a sick newborn child (47.7%, n = 92). Grandmothers most commonly bathed the baby immediately after birth (55.5%, n = 516), whereas mothers and health workers were common decision makers regarding breastfeeding initiation. Predictors for a mother being the key decision maker on the place of birth included: Mother having a secondary education (AOR 1.9: 95% C.I (1.0–3.6)) and mother being formally employed (AOR 2.0: 95% (1.5–2.9)). Mothers, fathers, grandmothers, health-workers, and traditional birth attendants were the most influential in the selected newborn care practices. Programs that aim to promote newborn care need to involve husbands, grandmothers, and health workers in addition to mothers.

Antenatal care in rural Bangladesh: Gaps in adequate coverage and content

INTRODUCTION

Antenatal care (ANC) has long been considered a critical component of the continuum of care during pregnancy, with the potential to contribute to the survival and thriving of women and newborns. Although ANC utilization has increased in over the past decades, adequate coverage and content of ANC contacts have fallen under increased scrutiny. The objectives of this article are to describe the coverage and content of ANC contacts in the context of rural Bangladesh.

METHODS

A community-based, cross-sectional household survey was conducted in two sub-districts of Netrokona district, Bangladesh in 2016. A total of 737 women with a recent birth outcome were interviewed. Respondents reported on the ANC contacts and the content of these contacts. Descriptive statistics were used to report coverage and content of ANC contacts stratified by covariates. Chi-square tests were performed to explore whether the estimates are different among different categories and significant differences were reported at p<0.05.

RESULTS

Around 25% of women attended at least four ANC contacts, with only 11% initiating ANC in the first trimester of pregnancy. Blood pressure was measured in almost all of the ANC contacts (92%), and abdominal examination performed in 80% and weight measured in 85% of ANC contacts. Urine tests were conducted in less than half of the ANC contacts, whereas blood screening tests and ultrasound were conducted in 45% contacts. Health care providers counselled women on danger signs in only 66% of the ANC contacts. Overall, the content of facility-based ANC contacts were better than home-based ANC contacts across all components.

CONCLUSIONS

Adequate coverage of ANC remains poor in Netrokona, Bangladesh and important gaps remain in the content of ANC contacts when women attend these services.

Barriers to access and utilization of emergency obstetric care at health facilities in sub-Saharan Africa: a systematic review of literature

BACKGROUND

Nearly 15% of pregnancies end in fatal perinatal obstetric complications including bleeding, infections, hypertension, obstructed labour and complications of abortion. Globally, an estimated 10.7 million women have died due to obstetric complications in the last two decades, and two thirds of these deaths occurred in sub-Saharan Africa. Though the majority of maternal mortalities can be prevented, different factors can hinder women's access to emergency obstetric services. Therefore, this review is aimed at synthesizing current evidence on barriers to access and utilization of emergency obstetric care in sub-Saharan Africa.

METHODS

Articles were searched from MEDLINE, CINAHL, EMBASE, and Maternity and Infant Care databases using predefined search terms and strategies. Articles published in English, between 2010 and 2017, were included. Two reviewers (AG and AM) independently screened the articles, and data extraction was conducted using the Joanna Briggs Institute data extraction format. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. The identified barriers were qualitatively synthesized and reported using the Three Delays analytical framework. The PRISMA checklist was employed to present the findings.

RESULT

The search of the selected databases returned 3534 articles. After duplicates were removed and further screening undertaken, 37 studies fulfilled the inclusion criteria. The identified key barriers related to the first delay included younger age, illiteracy, lower income, unemployment, poor health service utilization, a lower level of assertiveness among women, poor knowledge about obstetric danger signs, and cultural beliefs. Poorly designed roads, lack of vehicles, transportation costs, and distance from facilities led to the second delay. Barriers related to the third delay included lack of emergency obstetric care services and supplies, shortage of trained staff, poor management of emergency obstetric care provision, cost of services, long waiting times, poor referral practices, and poor coordination among staff.

CONCLUSIONS

A number of factors were found to hamper access to and utilization of emergency obstetric care among women in sub-Saharan Africa. These barriers are inter-dependent and occurred at multiple levels either at home, on the way to health facilities, or at the facilities. Therefore, country-specific holistic strategies including improvements to healthcare systems and the socio-economic status of women need to be strengthened. Further research should focus on the assessment of the third delay, as little is known about facility-readiness.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017074102.

Knowledge and involvement of husbands in maternal and newborn health in rural Bangladesh

BACKGROUND

Access to skilled health services during pregnancy, childbirth and postnatal period for obstetric care is one of the strongest determinants of maternal and newborn health (MNH) outcomes. In many countries, husbands are key decision-makers in households, effectively determining women's access to health services. We examined husbands' knowledge and involvement regarding MNH issues in rural Bangladesh, and how their involvement is related to women receiving MNH services from trained providers.

METHODS

We conducted a cross-sectional survey in two rural sub-districts of Bangladesh in 2014 adopting a stratified cluster sampling technique. Women with a recent birth history and their husbands were interviewed separately with a structured questionnaire. A total of 317 wife-husband dyads were interviewed. The associations between husbands accompanying their wives as explanatory variables and utilization of skilled services as outcome variables were assessed using multiple logistic regression analyses.

RESULTS

In terms of MNH knowledge, two-thirds of husbands were aware that women have special rights related to pregnancy and childbirth and one-quarter could mention three or more pregnancy-, birth- and postpartum-related danger signs. With regard to MNH practice, approximately three-quarters of husbands discussed birth preparedness and complication readiness with their wives. Only 12% and 21% were involved in identifying a potential blood donor and arranging transportation, respectively. Among women who attended antenatal care (ANC), 47% were accompanied by their husbands. Around half of the husbands were present at the birthplace during birth. Of the 22% women who received postpartum care (PNC), 67% were accompanied by their husbands. Husbands accompanying their wives was positively associated with women receiving ANC from a medically trained provider (AOR 4.5, p < .01), birth at a health facility (AOR 1.5, p < .05), receiving PNC from a medically trained provider (AOR 48.8, p < .01) and seeking care from medically trained providers for obstetric complications (AOR 3.0, p < 0.5).

CONCLUSION

Husbands accompanying women when receiving health services is positively correlated with women's use of skilled MNH services. Special initiatives should be taken for encouraging husbands to accompany their wives while availing MNH services. These initiatives should aim to increase men's awareness regarding MNH issues, but should not be limited to this.

Changing times? Gender roles and relationships in maternal, newborn and child health in Malawi

Background

For years, Malawi remained at the bottom of league tables on maternal, neonatal and child health. Although maternal mortality ratios have reduced and significant progress has been made in reducing neonatal morality, many challenges in achieving universal access to maternal, newborn and child health care still exist in Malawi. In Malawi, there is still minimal, though increasing, male involvement in ANC/PMTCT/MNCH services, but little understanding of why this is the case. The aim of this paper is to explore the role and involvement of men in MNCH services, as part of the broader understanding of those community system factors.

Methods

This paper draws on the qualitative data collected in two districts in Malawi to explore the role and involvement of men across the MNCH continuum of care, with a focus on understanding the community systems barriers and enablers to male involvement. A total of 85 IDIs and 20 FGDs were conducted from August 2014 to January 2015. Semi-structure interview guides were used to guide the discussion and a thematic analysis approach was used for data analysis.

Results

Policy changes and community and health care provider initiatives stimulated men to get involved in the health of their female partners and children. The informal bylaws, the health care provider strategies and NGO initiatives created an enabling environment to support ANC and delivery service utilisation in Malawi. However, traditional gender roles in the home and the male ‘unfriendly’ health facility environments still present challenges to male involvement.

Conclusion

Traditional notions of men as decision makers and socio-cultural views on maternal health present challenges to male involvement in MNCH programs. Health care provider initiatives need to be sensitive and mindful of gender roles and relations by, for example, creating gender inclusive programs and spaces that aim at reducing perceptions of barriers to male involvement in MNCH services so that programs and spaces that are aimed at involving men are designed to welcome men as full partners in the overall goals for improving maternal, neonatal and child health outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1523-1) contains supplementary material, which is available to authorized users.