Background

Since the 1994 International Conference on Population Development in Cairo, the importance of male involvement in reproductive health programs, including maternal health, has come into focus [1], however there are not many studies.

In India in most of the families, men take decisions for most of the matters of the family, including the place of birth, especially in villages, because of low female literacy, lack of awareness, lack of resources and communities’ norms. It is essential to understand the perceptions, opinions and practices of men about birth place, birth attendant for safe birth, at safe place to reduce maternal, neonatal mortality, morbidity.

Objective

Objectives of the present pilot study were to know men’s, practices as well as perceptions in relation to place of birth, accompanying person.

Materials and Methods

The protocol for the study was developed in adherence to international norms involving human respondents for research. Approval of the institute’s ethics committee was taken. Study was done in 65 villages (20% of the villages of Melghat region in Amravati district of Maharashtra, India, hilly forestry region with tribal population), 50% of villages of Dharni Block, one of the 3 blocks of Melghat region, looking at feasibility and future attempts of providing help. Study eligibility was limited to married men whose wife had a birth within last 5 years; wife may or may not have been pregnant at the time of interview. As per inclusion criteria, men from every 10th house were interviewed. However if there was no such man in 10th house, next family was approached for inclusion. Minimum 10% families were approached in each village and the total study subjects of each village depended on the population of a particular village and availability of men as per inclusion criteria. Informed consent of the respondent was taken prior to participation in the research. These men were willing to provide the desired information as per the questionnaire. Study was done by doing interviews through a predesigned and pretested questionnaire in local language. Information collected was about staying around wife during child birth after accompanying her, not exactly with women which is almost nonexistent in such places. Also their perceptions about who should accompany, stay nearby the birth place, and presence of person with wife during birth (Table 1). Questions were open and closed-ended. Information was recorded on the questionnaire by the interviewer assigned. No study subject was given the questionnaire to fill. Further focus group discussions were also conducted by the field worker who did interviews and a doctor who was briefed about the objectives of the study to have over all relevant information. In the FGD the same tool which was for the interview was used, however the age of study subjects and birth interval were relaxed. All men willing to join were invited, keeping the numbers around 10-15 at a time. Analysis of the information collected and recorded at the same time not leaving anything to memory.

Table 1: Accompanied during birth.

Most of study subjects were of 25-29 years (512/1000), 26.50% (265/1000) of 30-34 years, 7.1% (71/1000) of 35-39 years and only 15.2% (152/1000) were of 20-24 years. Education status revealed 34.10% (341/1000) had primary school educated. 34.5% (345/1000) had secondary school education, 17.0% (170/1000) higher secondary, 14.1% (141/1000) were illiterate and only 3 were graduates. Majority (99.6%), of the men belonged to low socio-economic status (996/1000), only one participant was of upper lower class, two middle class and one of upper middle class. Majority (98.62%) were wage earners, daily wager or on yearly basis.

Results

Irrespective of age of the participant, only 46.7% (467/1000) had accompanied their wives, when they went to the place of delivery (Table 2). Only 57/141 (40.43%) illiterate men, 135/341 (39.59%) men with primary education, 175/345 (50.72%) men with secondary education, 95/170 (55.88%) men having higher secondary education and 2 out of 3 graduate men accompanied their wives for delivery with significant relationship between education of men and accompanying wife during delivery, 464/996 (46.59%) men from lower SES accompanied their wives during delivery, however almost all were from lower SES status. In FGD only 20% said that they had accompanied their wives, when they went for birth (Table 3).

Table 2: Opinion about place of delivery.

Table 3: Perception about person to accompany during delivery.

Of all 1000 men interviewed, 59.30% (593/1000) said last births were at home, 27.70% (277/1000) at public health facility and 13.00% (130/1000) at private health facilities. It was interesting to know that 98.98% (586/592) men whose wives had delivered at home were satisfied with home births and said it is good to have birth at home. But only 101/277 (36.46%) men whose wives delivered at public hospitals reported that they were satisfied with care given at hospital, rest were not. Highly significantly more men whose wives delivered at home with the help of local traditional birth attendants (TBA) were satisfied than women who delivered at health facility (P value 0.001).

Men of 20-24 years gave mixed response regarding person who should accompany the woman when they went to the health facilities for delivery. Many said men were not needed. Only 122 of 512 (23.83%) men of 25-29 years and 35 of 265 (13.21%) of 30-34 years said husband should be present around 11 of 71 (15.49%) men of 35-39 years said woman’s mother should be present with the birthing women at the time of delivery. Interestingly 35 of 512 (6.84%) men of 25-29 years and 131 of 265 (49.43%) men of 30-34 years said TBA should be present during delivery with the woman at the healthy facility. 54 of 341 (45.84%) men with primary education, 57 of 345 (16.52%) men with secondary education, 61 of 170 (35.88%) men with higher secondary education and none of the graduate men said husband should accompany the wife during delivery, only 28 of 141 (19.86%) illiterate said husband should go.

A total of 35 of 141 (24.82%) illiterate men, 94 of 341 (27.57%) men with primary education, 113 of 345 (32.75%) men with secondary education, 34 of 170 (20.00%) men with higher secondary education and one (33.33%) of the three graduates said mother should accompany wife during delivery, 12 of 141 (8.51%) illiterate men, 35 of 341 (10.26%) men with primary education, 50 of 345 (14.49%) men with secondary education, 15 of 170 (8.82%) men with higher secondary education and 2 of 3 of the three graduates said that mother in law should accompany their wives during delivery. During FGD, majority of men said that it should be the woman’s mother who should accompany the woman during delivery, not the mother-in-law.

While 39 of 141 (27.66%) illiterate men, 84 of 341 (24.63%) men with primary education and 55 of 345 (15.94%) men with secondary education, said that TBA be present during delivery, irrespective of place of birth, only 39 of 170 (22.94%) men with higher secondary education and none of graduates did so.

Almost all men were of low SES, so no comments can be made about relation to economic status. Overall 199 of 996 (19.98%) said husband, 276 of 996 (27.71%) men said mother, 191 of 996 (19.18%) men said doctor, 113 of 996 (11.34%) men said mother in law and 217 of 996 (21.79%) said TBA should be with the woman during delivery. One from upper lower class said doctor, of 2 from middle lower, one said husband and other said mother in law, one from upper middle class said mother should be with the woman during delivery.

Discussion

Present study revealed that only 57 of 141 (40.43%) illiterate men, 135 of 341 (39.59%) men with primary education, 175 of 345 (50.72%) men with secondary school education, 95 of 170 (55.88%) men with higher secondary education and two of three graduate men had accompanied their wives during delivery. Men going with the wife to the health facility increased with educational status of men but they were not with the women. According to Chatopadhyay [2], if men do not accompany their wives to health care units, it negatively affected the well-being of women and on the other hand if they were present, it helped women about the care to be taken. Education plays major role in increasing men’s participation in maternal care. NFHS-III revealed that 38% men in rural India knew importance of delivering in health facility.

In the present study 407 of 1000 (40.7%) reported health facility delivery, rest around 60% had home births. It is interesting to know that 98.98% (586/592) men whose wives had delivered at home were satisfied with delivery and said care was better at home. This may be due to their faith in traditional delivery practices and presence of family around.292 of 407 (71.74%) men whose wives had facility delivery reported that they were satisfied with care at hospital, rest were not satisfied because of various reasons including long distance and high cost of health facility care. It is known that because of various reasons there is increase in the number of women delivering in health facilities but the quality of obstetric and neonatal care continues to be poor which contributes to high maternal and neonatal mortality. When men were asked about who should accompany wife during delivery only 200 of 1000 (20%) men’s choice was husband, 277 of 1000 (27.70%) men said woman’s mother needs to be around, only 114/1000 (11.40%) said it should be mother in law, however 192/1000 (19.20%) men’s said doctor at the place of delivery suffices. It’s interesting to know that 217/1000 (21.70%) men said TBA be present during delivery even at the health facility. Faith in TBA is deep rooted. In the study by Vellakkal et al. [3] trust in the skills of traditional birth attendants and the notion of childbirth as a 'natural event' that required no healthcare were the most prevalent impeding factors. The belief that a healthcare facility would be needed only in cases of birth complications was also highly prevalent. The awareness among pregnant women and family members about the value of institutional delivery care facilities for safe childbirth helped. Kuhlen [4] reported that despite the indisputable support that the traditional birth attendant provided and the great responsibility they assumed for maternal health, they were still not adequately valued, promoted or supported by the Ministry of Health. However attitudes were slowly changing with slight changes in policy over the years. In the present study men wanted that their wives’ mothers be present rather than mother in law, understanding the deep rooted culture of someone on whom the birthing woman felt comfortable and could confide. Men do understand the culture in the society. Women remain more comfortable with their mothers, rather than mother in laws.

While 54 of 341 (15.84%) men with primary education, 57 of 345 (16.52%) men with secondary education, 61 of 170 (35.88%) men with higher secondary education and none of the 3 graduate men said that husband should accompany wife during delivery and only 28 of 141 (19.86%) illiterate husbands thought so however, more educated the husband was more likely to be present at the time of delivery at place. In FGD only around 20% men had said that they had accompanied their wives and only 10% said husband should accompany. Since majority (99.60%) of men were of lower SES (996/1000) and 98.62% wage laborer, it’s not possible to comment in respect to SES.

At the health delivery level, challenges are health providers’ attitudes, staff numbers, waiting times, regulations in health care facilities, cultural and gender norms and men’s knowledge regarding maternal and child health which negatively affects women and their families specially husbands. Bohren [5] reported that continuous support during labour may improve outcomes for women and infants, including increased spontaneous vaginal birth, shorter duration of labour and decreased caesarean birth, instrumental vaginal birth, use of any analgesia, use of regional analgesia, low five-minute Apgar score and negative feelings about childbirth experiences. Also improvements in technical quality of care, and in human resource and commodities availability, should accompany efforts to humanize care to address persistently high rates of maternal and newborn deaths in health facilities in many low-resource settings [6]. Further even if men or family members accompany their wives they can’t be with women because of privacy of other women and overall health delivery system and attitude of health providers. There is a significant need to scale up men’s participation in maternal health and to provide them with the sufficient information to help them make decisions and support their partners [7]. In addition to measures taken to encourage and motivate men to participate, special attention has to be paid to the obstacles they face and complex approaches to overcome them [1]. More rigorous understanding of male involvement initiatives and closer collaboration between different sectors are needed in order to have better maternal and newborn health outcome and well-being [1]. A study revealed that the involvement of men in pregnancy and child birth in the Gambia was restricted by myriad of socio-economic and cultural factors including men's limited knowledge on danger signs, as well as health service and structural factors and finally advocated for men’s education on their reproductive responsibilities [8]. Another review revealed that deliveries were more likely to take place in medical institutions if the husband was aware of various pregnancy and delivery complications. Therefore, the data suggested an urgent need to involve men in the maternal health programs as it has positive health benefits [9]. Male involvement was associated with improved maternal health outcomes in developing countries. Contrary to reports from developed countries, there was little evidence of positive impacts of husbands' presence in delivery rooms. However, more rigorous studies were needed to improve this area's evidence base [10].

While from Millennium Development Goals (MDGs) to Sustainable Development Goals (SDGs) are taking shape, prioritizing issues related to maternal health are going to be critical for progress of women and newborns in the post 2015 era [11]. Over the last several years, research on male involvement in reproductive and maternal health care has shown incredible impacts on the health outcomes of women and newborns. They also exposed the insidiousness risk posed by not keeping scope of gender sensitive policies wide open to interpretation [12]. Millar [13] reported that some, and indeed many, of the vulnerable women were denied the right to access care because they failed to convince their partners to attend. An additional barrier to integration may be societal discrimination. “Ultimately maternal mortality is the culmination of layers of structural, and discrimination, and exclusion that women face in society”.

Conclusion

There are many challenges in male involvement/participation in maternal care. Awareness programs should be carried out by governmental, non-governmental organizations and other civil society to stress the involvement of men in promoting maternal health care and also, being agent of change in improving the quality of life of women as it relates to maternal health, thereby bringing about healthy families and indeed healthy nation. The health system also needs to ensure the health facilities are welcome places for men, keeping social issues in mind.

References

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