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Background: Rwanda has raised gender equality on the political agenda and is, among other things, striving for involving men in reproductive health matters. With these structural changes taking place, traditional gender norms in this setting are challenged. Deeper understanding is needed of men’s perceptions about their gendered roles in the maternal health system. Objective: To explore recent fathers’ perspectives about their roles during childbearing and maternal care-seeking within the context of Rwanda’s political agenda for gender equality. Design: Semi-structured interviews were conducted with 32 men in Kigali, Rwanda, between March 2013 and April 2014. A framework of naturalistic inquiry guided the overall study design and analysis. In order to conceptualize male involvement and understand any gendered social mechanisms, the analysis is inspired by the central principles from relational gender theory. Results: The participants in this study appeared to disrupt traditional masculinities and presented ideals of an engaged and caring partner during pregnancy and maternal care-seeking. They wished to carry responsibilities beyond the traditional aspects of being the financial provider. They also demonstrated willingness to negotiate their involvement according to their partners’ wishes, external expectations, and perceived cultural norms. While the men perceived themselves as obliged to accompany their partner at first antenatal care (ANC) visit, they experienced several points of resistance from the maternal health system for becoming further engaged. Conclusions: These men perceived both maternal health system policy and care providers as resistant toward their increased engagement in childbearing. Importantly, perceiving themselves as estranged may consequently limit their engagement with the expectant partner. Our findings therefore recommend maternity care to be more responsive to male partners. Given the number of men already taking part in ANC, this is an opportunity to embrace men’s presence and promote behavior in favor of women’s health during pregnancy and childbirth–and may also function as a cornerstone in promoting gender-equitable attitudes.
Because of the context of Rwanda with increased focus toward gender equality and involvement of men in ANC, we use Connell’s relational theory of gender to conceptualize the participant’s perspectives about their experiences (26, 27). This theory posits gender as socially constructed, and that men are gendered beings, having power as a central aspect of their relations, actions, and expectations. Gendered expectations are formed both under the influence and expectations of society, as well as by individual interactions, both between and among women and men. The additional concept of hegemonic masculinity embodies what is ‘currently accepted’ of a man in a certain context. Even though an individual’s behavior is complex, and each individual will cope differently with the social setting, Connell argues that gendered structures produce a narrow arena for individuals. The construct of gender is thus multidimensional and arranged simultaneously on intrapersonal, interpersonal, institutional, and society-wide levels (26, 27). The pattern in gender structures on these different levels can be called gender regimes. Institutions, such as a health system, follow the logics of the gender regime within its specific context, and policies are simultaneously constructing and deconstructing the gendered order of a society. Ethics approval for the project was obtained from the Rwanda National Health Research Committee, Kigali (NHRC/2012/PROT/0045), as well as the Institutional Review Board of Kigali University Teaching Hospital. Permission to recruit participants was sought and obtained separately from each hospital. All participants were approached and included in this study following our precise adherence to the ethics approval, including informed consent for participation, and strict handling and storage of the recorded and transcribed interviews. This study took place in Kigali, the capital of Rwanda, having 1.2 million inhabitants and vast socioeconomic differences (28). The average inhabitant generates an income from farming or service-related industries, such as driving a motorbike or taxi. The literacy rate is 80% for men and 77% for women (19). Kigali provides public and private health centers, three district hospitals, and three tertiary referral hospitals. Data were collected between March 2013 and April 2014 at three public hospitals in Kigali and this work is part of a project focusing on maternal near-miss (MNM) in the context of Rwanda. MNM refers to women who survive a severe, life-threatening obstetric complication during childbearing (29), and this approach is appropriate for identifying underlying factors to mortality, both including care-seeking delays and inadequate provision of care (30–32). Some participants were recruited purposively with the help of health care workers and others via snowball sampling within the community (33) with assistance from a Rwandan interpreter, fluent in both Kinyarwanda and English. The research team was composed of three female European researchers (a medical doctor, a medical anthropologist, and the doctoral student whose foundation is in social work) and two male medical doctors from Kigali (both holding a PhD in international health). The first author (the doctoral student) and a local interpreter conducted individual interviews with the partners of women who had experienced MNM while they were still at the hospital, yet only after the woman gave her consent for their inclusion. These men were also asked to bring one or two friends to join group interviews, which were conducted at a later session in the community, either at a participant’s home or at a conference center. The inclusion criteria for all participants were having a partner who recently experienced MNM or having recently become a father. All except two men consented to take part after learning the aims of the study. No reasons were given for the two men who declined (Table 1). Overview of data collection MNM=maternal near-miss; IDI=individual, semi-structured interview; GD=group discussion; FGD=focus group discussion. The framework of naturalistic inquiry guided the study (34). A hermeneutic dialectical approach was used during the interviews for eliciting a conversation-like experience about how men perceived themselves in this shared context (34). All interviews were transcribed into English for analysis and cross-checked by an external translator, which was done to ensure the validity of the transcription (35). Themes of the semi-structured interview questions included men’s perceived role during pregnancy, how they experienced their partner’s pregnancy outcome – which was sometimes life-threatening, and their attitudes toward fitting in during the care encounter with medical professionals. Naturalistic inquiry guided the emergent analysis (34), which began during initial data collection, where information from one interview helped to guide new questions in later interviews. Topical saturation of new concepts was met upon repetition of participants’ answers. We performed member checks to validate the findings (34), and the necessity for establishing topical saturation was met upon repetition of participants answers. In-depth analysis occurred once all interviews were transcribed via rereading of all interviews and use of AtlasTi (Scientific Software, 2013) for sorting the data. The first and last authors read the sorted data and coded and interpreted overarching categories that best encapsulated the men’s perspectives about their role. These were then sorted into the conceptual framework inspired from Connell (26) and discussed by the full research team. Figure 1 details the outcome of data collection among 32 men, 13 of whom had a partner that experienced MNM. Four of these men’s partners had had a miscarriage and three babies had not survived birth. Among the remaining participants, two had prior experiences of a baby not surviving birth. All of the men expressed their desire for the pregnancy, even if it was not necessarily intended. The men were between 23 and 35 years old, and two were in their 50s. One participant was currently studying at the university, whereas all the others had either primary or secondary level of education. The men had varied occupations, and several of them were either unemployed or were daily wageworkers. The men in this study were among those having the community health insurance Mutuelles, which is available for low-income households not covered by other insurance systems, such as those for employees of government, military, or private companies. Conceptual framework, inspired from Connell (26), mapping recent fathers’ perceived roles during childbearing and maternal care-seeking, illustrated on the different levels. The men openly shared their reflections on their perceived role during their partners’ childbearing. However, the topic of the MNM caused a momentary quietness before the men expressed thoughts of anxiety and frustration over the near loss of their partner and the loss of their coming baby. The event seemed to have brought these men to reflect on their own participation and to be more attentive to flaws in the maternal health system. Men’s perspectives were interpreted on an intrapersonal, interpersonal, institutional, and societal level in Fig. 1 and represented separately for clarity. However, these levels should be understood as interlinked. A pregnancy was perceived as a blessing and embraced with joy, yet also as a responsibility embraced with worries. Men’s main purpose was perceived as being the breadwinner, with the role to provide financially for their partner and coming family member. This role was not experienced as short term: ‘As a man you need to provide for the child until s/he is grown up enough to look after her/himself’ (28 years old, first child, partner to MNM). Nevertheless, it appeared important to be strong and engaged and to not allow anxieties about the new responsibility to affect the partner during pregnancy. When asked to define their role toward a pregnant partner, most men presented ideals of an engaged father, using attributes of caring and benevolence. Although some focused mostly on the financial aspects, several of the men further explained the importance of providing care so the woman could rest. Pressuring the partner for sex during pregnancy was seen as selfish, and referred to as something happening earlier, during traditional times, before men’s understanding of the need to show respect toward a pregnant partner. The men were thoughtful about such attentiveness, but also toward consequences to the coming child: [During pregnancy] you should listen to whatever your wife tells you, and stop thinking that accepting her ideas or the advice she gives you is some sort of unmanly attitude. You also have to avoid being rude towards her or frightening toward her, because if she gets angry it will affect the baby, too. And then you risk losing both of them because you were a jerk. (FGD 3) Several men regarded their roles as dynamic, emphasized on shared decision-making, concluding that, ‘A man should stop thinking that he is the king of the home’ (FGD 2). Participants felt constrained by their limited insights into maternal health matters, yet perceived themselves as responsible to ensure a woman received maternal care. This was particularly apparent for ANC because the men perceived their presence as mandatory during the first ANC visit. Attendance was understood as required for HIV testing, and ensuring the expectant partner would be received for consultation. The men described attendance at the first ANC as a ‘government rule’ requiring ‘obligatory involvement’. However, complaints were raised about how long wait times actually made men have to take 1 day free from work, which created a liability to their role as breadwinner. This was especially true among those who worked far from home, reflecting that their limited presence had delayed their partner’s initial maternal care-seeking. The requirement for a man’s attendance at the first visit was perceived as non-flexible at public clinics, which motivated some to ensure their partner went instead to a private clinic. The men perceived new responsibilities during pregnancy. Their reflections about changed family dynamics were discussed through the lens of changing traditions. Many lived far away from family members after moving to Kigali to find employment, or they had few role models after having lost extended relatives in the 1994 Genocide. The men were particularly aware of the loss of their partner’s mother or their own, that is, women who would have otherwise provided support for the pregnant partner. Men described their attempts to become involved, often consulting with relatives and friends to be able to assist: ‘You try to play a role in her pregnancy and you do all you can to make sure she is taken care of’ (33 years old, second child, partner to MNM). However, consulting with others was not always self-evident because pregnancy was esteemed a strictly private matter, shared between a man and woman. One man reflected, ‘Everybody manages their problems. You cannot tell the secrets of the family to other people’ (35 years old, second child, partner to MNM). At most, the couple could share with closest family or people considered trustworthy. Obtaining information on maternal health was generally perceived as challenging and identified as posing potential difficulties on the intimate relationship. Only a few had been present when their partner received maternal health information from a care provider. Not being present at such times seemed to consequently prevent some from absorbing information, for example: ‘When she comes home and tells you what they have told her, you just listen [to her] but do not care, because you were not there’ (GD: 34 years old, third child). Although pregnancy was considered a private matter, a pregnant woman was seen as respected in the community, and men perceived themselves to be under external pressure to fulfill expectations about becoming a father. There was the need to be caring and attentive to a partner’s needs, and making sure she attends ANC. A man not attending to these responsibilities risks being publicly referred to as either negligent or cowardly. Most men considered being involved and affectionate in parallel, saying, ‘If you cannot cope with your wife’s troubles, then you do not love her’ (FGD 3). Nearly all men perceived limited exposure to pregnancy information, as this was not provided at all facilities. They also had different experiences with ANC. Only a few had been included in a group information session conducted at the care facility, covering pregnancy and health risks. None of the men were welcomed during the actual pregnancy consultation, wondering aloud why they could not participate and receive direct, first-hand information from the care provider. For example, ‘[Health care workers] are more interested in talking to the women, but they do not consider informing the men, as well. It would be better if we all could understand more about those symptoms’ (GD: 27 years old, second child). Participants were strongly in favor of facility-based childbirth. They viewed it as their responsibility to bring a woman to a health facility where she would be taken care of by professionals, but also wished to avoid the imposed fine if she delivered at home. The latter was perceived as a bother that required strategizing: You have to keep the umbilical cord uncut and just rush to the hospital, because if you cut it, you will have some issues with the doctors. They are going to fine you. You just need to explain to them that the contractions were sudden and took her by surprise. (GD: 28 years old, first child) Several had accompanied their partner to the health facility at time of delivery, whereas others gave the responsibility to a female relative. Among the men who had accompanied their partners, some emphasized the importance of being there because ‘as a man, you will be listened to’ (FGD2). Many expressed bottlenecks at admission, doubt in the quality of maternal care provided and questioned care provider attitudes. For example, ‘[My wife] told me that when a woman is still in the waiting room and starts shouting, the [health care workers] will not even glance at her. They say that, “if you can still shout, it means you definitely still have strength”’ (33 years old, third child, one died during birth, partner to MNM). Another said his wife had been left alone in the ward and she had given birth while unattended. He explained, ‘I think that the medical staff should be trained in giving better care to their patients’ (GD: 31 years old, third child). One man contemplated that he, as the partner and man, might have been listened to by the care provider, in the case where his partner felt uncomfortable about expressing her needs: ‘There are some women who do not like to scream when they are in pain, which the doctor will interpret as if she is not suffering. But if you, who is closest to her, are there, then she can tell you to advise the doctor’ (26 years old, second child, first died, partner to MNM). The idea of not being heard during the care encounter triggered a lack of trust and a wish to be present during labor. Yet, such presence at a public health care facility was perceived as non-negotiable and only allowed at private facilities. Some had not even questioned being barred from attendance during the birth, perceiving it as ‘not allowing men in is a law at the hospital, and so we have just gotten used to it’ (GD: 31 years old, third child). Other men reasoned their exclusion for logistical causes and the limited privacy found in the labor ward: ‘[Health care workers] do not want to violate the privacy of other women in the shared room’ (FGD 2). Even though the men were unable to surveil the actual procedure, they were held to a sense of responsibility. In one case, where a man was asked to sign a consent form for cesarean section, he raised this paradox: They ask you to give your ID number and sign that you are there to make sure she is safe. But, then, after you sign, they turn around and lock you out of the delivery room. So, how am I supposed to ensure that my wife and kid are safe if am locked out of that room? (29 years old, first child, partner to MNM) Despite having limited accessibility on the institutional level, the participants knew of supportive policy guidelines, particularly regarding men’s presence for the first ANC visit. Yet, a man’s actual right for being present at the consultation and childbirth remained unclear and seemed undefined. This presented strong reasons for why men were hesitant to demand increased involvement as it also clashed with cultural norms, as one man explained: In our culture, they say that if the husband sees his wife giving birth, he is never going feel attracted to her again sexually. We are saying that we should be there, but in the Rwandan culture, it is taboo to see your wife giving birth. Some women would not even accept to have their husbands there. So we are kind of on the fence. (26 years old, second child, first died, partner to MNM) Several participants discussed the cultural aspects of women not wanting the partner to be present during consultation. More than simple tradition of preferring female attendants, in particular, men perceived women as not wanting their partners to witness them in the condition of giving birth. Most men also reflected and were in support of the idea that their presence should always be based on the consent of the expectant mother. A father of three children expressed a clear wish to participate, yet highlighted: ‘I think the decision should come from her. If she is comfortable with it, then [the health care workers] should accept her choice to allow whoever she came with to be there and to watch the entire procedure’ (GD: 34 years old). The men’s clear motivation was a wish to surveil the birth procedure, especially among the men whose baby had not survived. One explained, ‘I should have been allowed in there so that I could be sure that whatever happened was nobody’s fault’ (33 years old, third child, one died during birth, partner to MNM). A number of men from the public facilities reflected about not having the same access to the childbirth as was possible at private care facilities. They highlighted a wish to be financially able to seek private care. Moreover, men expressed a wish to challenge restrictions at public care facilities, but felt limited in their ability to negotiate and instead blamed the unclear execution of guidelines at these institutions.
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