‘What men don’t know can hurt women’s health’: a qualitative study of the barriers to and opportunities for men’s involvement in maternal healthcare in Ghana

The research participants’ views on men’s involvement in maternal healthcare, and
the challenges of, and opportunities for, involving men converged on the following
themes.

Men’s perceptions of the importance of skilled maternal healthcare

Several of the men interviewed acknowledged the importance of women accessing and
using skilled maternal healthcare services, especially ANC and skilled delivery. However,
younger men and men in urban communities, perhaps because their levels of formal education
were relatively higher than their rural and older counterparts, demonstrated greater
awareness about the significance of women accessing and using skilled birthing services.

I think it is important for every woman to go to hospital for check-up when they are
pregnant. That way, the doctors can examine the pregnancy to make sure that everything
is fine with the woman and her unborn child (Young Man, FGD).

Nearly all women, in both rural and urban areas, also acknowledged the need for skilled
care during pregnancy and at childbirth.

I believe it is very important for every pregnant woman to seek proper care…I mean
it is good to go to the doctor to check whether everything is fine with their pregnancy
(Female Participant, IDI).

Despite men’s awareness of the importance of women seeking skilled care during pregnancy
or delivery, most of them reported that they do not usually accompany their wives
to seek care neither do they encourage their wives to seek care, especially ANC during
the first trimester of pregnancy and delivery in a health facility. Less than a quarter
of male participants reported ever accompanying their wives for antenatal care or
postnatal care check-up in a health facility. Most of the men who reported ever accompanying
their wives to seek skilled maternal healthcare were, either younger (20-30years),
educated or resident in urban towns. Focus discussions with men and in-depth interviews
with women and community health nurses revealed several factors that limited men’s
active involvement in maternity care.

Men’s involvement in maternal healthcare

Information was collected through FGDs, in-depth and key informant interviews about
several aspects of men’s involvement in maternal healthcare. In particular, men were
asked whether their wives had any ANC checkups during the last pregnancy, whether
they accompanied their partners to these checkups and the reasons why they did or
did not accompany their wives to any ANC checkups and other maternal healthcare services.
The results are presented in the next two sub-sections.

Barriers to men’s involvement

Most participants in the study reported four main barriers hindering men’s involvement
in maternal healthcare. These barriers include 1) masculinity and male role conflicts;
2) Cultural beliefs and practices; 3) health services factors such as unfavourable
opening hours of services, poor attitudes of healthcare providers and lack of space
to accommodate male partners in health facilities; and 4) high cost associated with
accompanying women to seek maternity care.

Masculinity and male role conflicts

A major barrier to men’s involvement in maternal healthcare is the conflict between
traditional definitions of men’s roles as breadwinners and their involvement in maternity
care. In both FGDs and IDIs with men and women, it was reported that traditionally,
men are seen as heads of households and breadwinners hence men’s focus is largely
on economic activities. Maternal healthcare is usually seen as a ‘feminine’ domain
and thus the responsibility of women’s.

For me, I think it is the responsibility of my wife to go for ANC as I get busy with
my farming activities. You know as a man, I am expected to provide food for my family…so
if I spend time accompanying my wife to seek ANC, how would I be able to provide my
family needs? Society and even my wife will mock me (Male participant, FGD).

Men’s role as family providers not only conflicts with modern demands for them to
be involved in maternity care, but also acts as a barrier to accompanying their wives
for maternal healthcare. Some men reported they were too busy for such tasks as accompanying
their wives to seek ANC or PNC. In this regard, most men especially from rural communities
felt it was time wasting to accompany their wives to seek care during pregnancy. This
was often exacerbated by the fact that majority of the study’s participants are predominantly
smallholder farmers, and therefore too many demands on men’s time especially during
the rainy season compel them [men] to forgo accompanying their wives for maternal
healthcare. Interviews with women largely corroborated the relatively low involvement
of men in maternal healthcare.

In this community, which man will stop his work and accompany you to go and check
your pregnancy? My husband has never done it and most men don’t involve themselves
with matters of pregnancy care…they say it is women’s affair (Female Participant,
IDI).

Some however said that they only got involved in situations where there are clinical
complications such as protracted labour or delivery by caesarean section. Interviews
with community health nurses suggested that men in urban areas were more willing to
accompany or encourage their wives to seek skilled care than their rural counterparts.
This was partly attributed to the fact that many urban men had relatively higher educational
levels than their rural counterparts, and were therefore likely to be more aware of
the importance of skilled care than rural men. Interviews with some urban men also
suggested that they accompanied their wives to seek care because the health facility
was not too distant. This notwithstanding, there was still a general consensus that
most men are dissuaded from active participation in maternity care because of perceptions
that caring for pregnancy and children is the preserve of women.

Cultural beliefs and practices

Apart from the fact that men felt their roles conflicted with the demands to be involved
in maternal healthcare, other cultural factors inhibited men’s effective participation
in maternity care. In several instances cultural standards were identified as barriers
to men’s involvement. Several participants reported negative perceptions towards men
attending ANC, DC and PNC services. For instance, men who accompanied their wives
to ANC services were perceived as being dominated by their wives.

The reason why some men do not involve themselves much in pregnancy care is because
they do not want their peers to say that their wives are controlling them. You know
in this community, there is the belief that if a man follows his wife to places like
ANC then he is under the control of his wife (Female Participant, IDI).

Also, women and healthcare providers reported that often men view ANCs and other maternity
care services as designed and reserved for women. Men are thus embarrassed to find
themselves in such “female” places. Interestingly, some of the women reported that
they do not like to be seen with their male partner attending ANC.

Personally, I would not like my husband to accompany me to seek care…normally when
you go with your husband people in the community say you have used witchcraft to control
your husband. The other thing is that when you go to the hospital with your husband,
you cannot talk a lot with other women…you know men, they are always in a hurry. So
I prefer to go alone in the company of other women (Female Participant, IDI).

It was also reported in both FGDs and IDIs that some men do not encourage their women
to seek skilled care due to various other reasons such as adherence to cultural and
superstitious beliefs. Specifically, it was reported that when one discloses being
pregnant within the first trimester, there is the possibility of losing the pregnancy
through witchcraft. Both men and women also reported that attending ANC within the
first trimester traditionally shows that the pregnant woman in question is not physically
strong. One woman said:

When I was pregnant for the first time and decided to attend ANC for the first trimester,
my husband insulted me very well and told me that I was a lazy woman and that I could
not resist the least pain. My mother-in-law also told me that these days ladies are
just lazy because during her days, women could carry a whole nine-month pregnancy
and would deliver successfully without attending ANC or seeing a doctor (Female Participant,
IDI).

The discussions here suggested that men sometimes draw on local cultural beliefs and
practices to justify not only why they [men] should not be involved in maternal healthcare
but also why their wives or partners should not seek skilled care during pregnancy
or delivery.

Health services factors

Another key barrier to men’s involvement in maternal healthcare stemmed from alleged
negative attitudes of health workers to men’s participation in maternity care, which
to some extent appear to reinforce the marginalisation of men and the notion that
pregnancy care is a female domain. Many participants reported that harsh and critical
language directed at women and their husbands from skilled health professionals was
a barrier to male participation. Harsh treatment of women by health providers was
reported to discourage men from returning or accompanying their wives to seek care.

I think one reason why men in this community do not involve themselves much in maternal
healthcare is the attitude of the healthcare providers…I mean the nurses. I say this
because I had a very bad experience three years ago when I went with my wife to see
the midwife. The nurses were asking me what I wanted in the maternity ward…some even
shouted at me to keep quiet when I wanted to tell the midwife how my wife behaved
the night before our visit. Since that experience, I have told myself that I will
not accompany my wife again to see the midwife (Male participant, FGD).

Interviews with healthcare providers found that explanations for provider harshness
and lack of respectful care to both women and men are often related to work overload
resulting from chronic shortage of healthcare providers, lack of a functioning health
infrastructure, poor supervision, and poor working conditions including lack of motivation
and low salaries of care providers.

Also long waiting time was reported as a major barrier to men’s involvement. Frequently
women have to wait for a long time before receiving care because of burdensome administrative
procedures and a lack of appointment system, which result in poor patient/client care
in healthcare facilities. Men, who frequently are in the paid workforce, are often
not in a position to spend virtually the entire day waiting for their wives to receive
care. As a result, some male participants reported that they would readily accompany
their wives for maternity care if they would be given priority in the queue before
women who were unaccompanied by their husbands.

Male participants also argued that a major obstacle to their involvement in maternal
healthcare stems from the maternal healthcare services delivery system itself, which
is almost exclusively oriented to women and often provide little or no information
about male involvement in maternal healthcare. The lack of space to accommodate male
partners in clinics was further reported to adversely impact male involvement. Clinics
are often unable to concurrently accommodate pregnant women and their partners because
of a lack of space, and gender specific services to address uniquely male issues do
not exist. Husbands who accompany their wives for such care are often given poor reception,
made to stand or sit outside the maternity ward and worse still, are usually not given
explanations on the treatment their wives receive. One male participant narrated his
experience thus:

One day, I followed my wife to a health facility. Upon entering the labour ward, the
nurse ordered me to go out in a way as if I was not a human being. She continually
shouted at me and pointed at the door for me to go and wait outside. After this experience,
I have never escorted my wife again for maternal care (IDI).

Another participant reported:

Sometimes, the nurses are always so harsh and they don’t want to see a man (husband)
inside the maternity ward. There is nothing you can do because you cannot see her
(wife) although you wish to be near her, so it is better for you the husband to stay
away (at home) and do some other things that can help her after delivery (Male Participant,
FGD).

Consequently, it was reported that most men choose to stay away from accompanying
their spouses to seek maternity care, feeling that they are not needed at the health
facilities where their women go to receive care.

High costs

Several participants also reported the high cost associated with seeking skilled maternal
healthcare services as a disincentive to men’s involvement in maternity care. According
to this account, although maternal healthcare is supposedly free at the point of delivery,
clients often have to pay illegal fees to the staff in order to receive care. Also
the cost involved in arranging appropriate transportation to travel to receive the
free services was reported to be very high. This is often compounded by poor road
network and the lack of appropriate transportation particularly in many rural areas.
Men who had no means of transport and who did not want to go through this stress of
travelling long distances on foot to seek maternal healthcare often resort to the
use of local options such as unskilled traditional birth attendants in their community.
One male participant narrated his experience:

We live in a place where transport is hard to come by. When your wife is in labour
and you need to send her to the health facility, you find it difficult to get one.
When you get a motorcycle, the owner will request that you buy fuel which some of
us cannot get. The worse thing is that the motorbikes and tricycles are not common
here; only the rich have them (Male Participant, FGD).

Thus the costs of transportation to and from health facilities and the opportunity
cost of time can be very high enough to deter men from involving in issues of maternal
healthcare. It was however acknowledged by most participants that the issue of high
transport costs and difficulties with getting appropriate transportation is largely
a rural problem. This is due to the fact that large proportions of the rural population
live in poverty and have difficulty paying for such services. But even in urban settings
where public and private transport services are mostly available, it was reported
that urban public transport presents a number of challenges. For instance, it was
reported that sometimes a pregnant woman still has to walk or be hand-carried from
home to bus terminus or from bus terminus to the healthcare facility when public transport
is used. Also, delays associated with the operations of these transport services often
cause further delays in reaching a health facility. It was also reported that expectant
mothers often endure traffic jams on the way, and this results in delays in getting
to healthcare centres.

Facilitators of men’s involvement

Despite the low level of men’s involvement in maternal healthcare in the study communities
and the challenges to men’s involvement, few of the men thought they had a role to
play when their wives are pregnant. Indeed, some men reported defying gender stereotypes
to accompanying their wives to seek care and to providing support and encouragement
to their wives during and after pregnancy and childbirth.

Me I was with my wife during all her ANC visits and even during her delivery. My friends
made fun of it but you know I did not mind them. My involvement gave my wife support
and encouragement so that when she was pushing the child, she pushed it with happiness
and comfort since she knew her husband was by her (Male Participant, IDI).

One male participant also said:

Me…I followed my wife to the health centre where she was going to deliver. After all,
she is carrying my pregnancy and the expectant child belongs to both of us. Truly,
I cannot share the pain of pregnancy but I have to support my wife during pregnancy,
childbirth and even in child rearing and caring. It is the responsibility of both
of us (Male Participant, IDI).

In FGDs, IDIs and KIIs, participants identified a number of factors that could facilitate
men’s involvement in maternity care. These include 1) community mobilisation and engagement
to promote greater male involvement in maternity care; 2) promotion of respectful
and patient-centred care; and 3) health education.

Community mobilisation and engagement to promote male involvement

In both focus groups and interviews, it was reported that maternal health issues in
many communities were still largely treated as women’s business, and maternity wards
as spaces exclusively meant for women. Consequently, there has been very little focus
on men and their involvement in helping women access care. However, several men and
women reported that not only do husbands influence women’s healthcare-seeking decisions
through for example financing, but also they exercise considerable power in either
permitting or restricting women’s access to, and use of services. Several participants
therefore called for community mobilisation and engagement initiatives and programmes
that promote men’s involvement in maternal healthcare.

My view is that if the healthcare providers want every woman in this community to
attend antenatal clinic or deliver their babies at the hospital, then they need to
talk to we the men too and involve us more to understand why it is important. I say
this because we the men are often responsible for the pregnancy and therefore we have
a lot of say in terms of how the pregnancy is cared for or how the baby should be
born. (Male Participant, FGD).

Another participant said:

You know many of us men still think that it is only the duty of the women to care
for the pregnancy. Some of us also do not still understand the importance of skilled
attendance at birth… and you know what we men do not know can actually hurt women’s
health. So the health people must engage we the men more (Male Participant, FGD).

Many of the healthcare providers and community leaders interviewed in this study agreed
that programmes directed towards improving women’s access and use of skilled maternity
care services must involve men. For these participants, many communities in Ghana
are still characterised by patriarchy and machismo such that men, especially husbands,
are usually the most influential household decision-makers, including regulating women’s
mobility and autonomy in accessing and using skilled care services.

I believe one problem is the failure of the healthcare system to actively engage men
on issues of maternal health. But you see, we still live in a country where men have
more control over household decisions, including decisions like how many children
to have and whether a woman should give birth in the hospital. So I think that if
we want to ensure that all women have access to or use skilled maternal healthcare
services, then we the healthcare providers must also engage the men in the process (Female Healthcare Provider, KII).

Where there has been involvement, it was reported that men’s involvement is often
defined to only mean accompanying or paying for care of pregnant women. However, these
measures were said to provide little information about how else a husband may be involved
in his wife’s pregnancy experience, and how engaged a husband may or may not be when
he accompanies his wife for care. The accounts of several women and key informants
in the study suggested that actively engaging men on issues of maternal health will
make men feel a sense of partnership and collective ownership of the maternal health
services that are being offered at health facilities, and address issues of socio-cultural
barriers and resolve conflicts between men and healthcare providers.

Promoting respectful and patient-centred care

Poor relationships between healthcare providers and women and their spouses is one
reason why some men are reluctant to accompany their wives to seek maternity care.
To reverse this and to involve men in maternity care, many participants proposed the
promotion of a regime of care that is respectful and patient-centred.

One problem is that the health facilities and the workers are supposed to serve our
needs. Unfortunately, you will go to the hospital and the workers will treat you very
badly. I think if they really want men to be involved, then they the healthcare providers
have to change the way they treat us…they should be more friendly, compassionate and
treat us well (Male Participant, FGD).

Another participant said:

For us men to be more involved, I think the health workers need to learn how to treat
us when we visit the clinic. I say this because of my past experience …at one of the
health centres there used to be one midwife…she was very nice to all the men and women
who visited the health centre …she talked nicely to people especially men. Even when
you make a mistake, she will not shout at you; she will take her time to talk to you.
So a time came that all the pregnant women wanted only that midwife to attend to them.
Men were also very willing to take their wives to see that midwife. But now, she has
been sent to a different place, and most of the new people are not friendly at all.
That is why many men are not accompanying their wives to seek care (Male Participant, IDI).

Many of the healthcare providers interviewed also suggested that improving the doctor-patient
relationship at healthcare facilities is an important approach to involving men in
maternal healthcare.

To get many men involved, I think we the healthcare providers need to focus on how
we treat the men and women who come to us for help. We must focus on making all our
facilities and especially labour wards patient-friendly (Male Healthcare Provider, KII).

One mother-to-mother support group leader also said:

I think the healthcare providers need to focus on improving the relationship between
caregivers and women and their spouses. They need to provide more patient-centred
care that is able to address the needs of women, accord the men who accompany them
to the health facilities respect and assure dignity anytime they visit a health facility (Female Participant, KII).

Health education

Several participants also proposed more health education as a strategy to encourage
men to be more involved in maternal healthcare. According to this account, involving
more men on issues of maternal healthcare must be preceded and/ or accompanied by
a very aggressive education of men.

There is still ignorance on the part of many men about health issues including maternal
health. I believe the way to make progress is to increase health education campaigns
using the radio and community durbars to educate men about the need for them to encourage
their wives to seek proper care during pregnancy (Male Participant, IDI).

One male participant also said:

The problem is that there are many men…especially in rural areas who have no formal
education. Such men do not always understand the risks involved in getting pregnant
and giving birth…they also have funny cultural beliefs about hospital births. So if
the health people want we the men to be actively involved then they must intensify
their health education campaigns to educate men to understand the importance of their
involvement in seeking care during pregnancy or childbirth and to do away with traditional
and cultural beliefs that prevent them from actively taking part in issues of maternity
care (Male Participant, FGD).