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Background Men have traditionally not been fully involved in reproductive health care of their partners, and yet, they play a crucial role in family decision-making and therefore crucial key players in preventing poor pregnancy outcomes. This study aimed to assess prevalence and determinants of male participation in maternal health care and explore male partners’ perspective of their involvement in antenatal care at an urban tertiary referral facility. Methods A mixed-methods study was conducted from October 2018 to January 2019 at Muhimbili National Hospital. A cross-sectional survey of 428 nursing mothers and two focus group discussions of male partners (n = 7 and n = 11) of women attending antenatal clinic and nursing mothers in the post-natal ward were performed. Using SPSS Ver. 23 (IBM, Chicago, IL), frequency distribution tables summarized demographic data and categories of male partners’ involvement in antenatal care. Focus group discussions included male partners of age from 24 to 55 years at their first to fifth experience of pregnancy and childbirth. Interviews were audio-recorded, and then transcribed and coded. Thematic analysis was applied. Results The prevalence of male involvement in antenatal care was 69%. More than two-thirds of nursing mothers received physical, psychological and financial support from partners (76%) and attended four or more antenatal visits (85%). Five themes of male perspective of their involvement in antenatal care were generated, including: a) cultural norms and gender roles, b) ignorance of reproductive health service, c) factors outside their control, d) couple interaction and conflicts, and e) institutional obstacles. Conclusion The prevalence of male partners’ involvement in antenatal care was relatively high. Men’s involvement in antenatal care depended on access to antenatal care education, standards of structure and process of antenatal service and how well their role was defined in the maternal health care system. Interactions and practice in society, employment sector and government health system should complement strategies to promote men’s involvement in maternal health.
A mixed-methods study was conducted at Muhimbili National Hospital (MNH) [25] using a cross-sectional survey of nursing mothers during the postnatal period of the first 24 hours after childbirth, from October 2018 to January 2019. During the period of the study, qualitative exploration of opinion of male partners was also performed using two focus group discussions (FGD), one of male partners of nursing mothers admitted in post-natal ward and another of male partners of women attending antenatal clinics at MNH. MNH is a tertiary referral health facility serving the city of Dar es Salaam and neighboring regions including Lindi, Mtwara, Pwani, Zanzibar and Morogoro. As a teaching university hospital, MNH also serves as a medical training facility for numerous universities in Tanzania [25]. Like other public health facilities, the cost of RCH service at MNH has user-fee exemption and cost sharing modalities [26, 27] for clients who were referred from public-referral hospitals. Self-referred clients are received as private clients (either health-insured or paying services in cash) under Intramural Private Practice Management (IPPM). Approximately 9,000 deliveries are conducted per year for both public (60%) and private (40%) clients at a caesarean section rate of 54%. RCH services are provided in two separate maternity buildings—Maternity ‘One’ and ‘Two’, which are in close proximity. The ground floor of the Maternity Two building accommodates outpatient RCH services including a registration counter and a waiting hall for 60 to 80 people, eight antenatal and postnatal clinic consultation rooms, two privately-secured rooms for HIV/AIDS counselling and testing, two rooms for family planning counselling and provision of contraceptives, a room equipped for minor procedures and a laboratory for routine test (such as haemoglobin, urine analysis, random blood glucose and rapid testing for malaria, syphilis and hepatitis B surface antigen). Outpatient RCH services are provided five times a week from Monday to Friday, from 9 a.m. to 5 p.m. Public outpatients are registered from 9 a.m. while private outpatients start the registration process at 12 p.m. RCH services for public and private clients are comparable, except that private clients have a privilege of choosing specialist service and receiving more comfortable in-patient accommodation in dedicated private wards. Other floors of Maternity Two constitute inpatient wards for antenatal and postnatal mothers under IPPM and nursing mothers performing Kangaroo Mother Care. Maternity One is mostly for antenatal and postnatal inpatients care for cost-sharing and user fee -excepted clients. Other functions in Maternity One include sonographic imaging services, pharmacy services, cashiers’ counter and inpatient registration counter for both maternity buildings. Tanzania is a low-middle income country divided into 30 regions, among which Dar es Salaam is the largest business city with a population of over 6 million people living in four municipalities (Kinondoni, Ubungo, Temeke and Kigamboni) and one city–Ilala City, where MNH is located. The health system pyramid puts MNH at the apex of an inclusive network of mainly government-owned health facilities organized in such a way that dispensaries and health centers serve most of the population as primary health care facilities, while district, regional and specialized/consultant hospitals serve as referral health facilities. MNH is the highest referral health facility in the eastern and coastal zone health system, as well as supervising and mentoring other referral health facilities in western and northern lake zone, northern zone and southern zone. All levels of public and some private health facilities provide RCH services, including antenatal and postnatal care, under-five care, family planning counselling and provision of contraception, essential vaccinations services, HIV/AIDS counselling and testing, and Emergency Obstetric and Newborn Care (EmONC). All nursing mothers in the postnatal wards were assessed for eligibility for recruitment including antenatal care attendance at MNH. Women who delivered within 24 hours, those who were either too sick to be interviewed or those who refused to participate in the study, were excluded. Using Kish Leslie’s formula, n = (z^2 p(100-p))/ε^2 by assuming that the proportion of male involvement in maternal healthcare in Tanzania (p) was 40% [28] at a maximum error (ε) of 5%, z value at 95% level of confidence of 1.96 and 10% non-response rate, the minimum required sample size was 413. The first author and research assistants (trained nurses) identified women from postnatal ward using inpatient registers and ward round records. Inclusion criteria was applied by assessing the antenatal cards. Eligible participants were listed and gave written consent. A simple random sampling technique (lottery) was performed by asking eligible participants to randomly choose a piece of paper from an envelope (A4 size) filled with similarly folded and mixed-up pieces of paper, according to number of eligible participants in a particular ward. Each piece of paper was either written “YES” (70%) or ‘NO” (30%). Participants who picked papers that were written “YES” were included in the study and subsequently filled out the questionnaires. those who picked papers written “NO” were excluded from the study. The same procedure was instituted in all postnatal wards until the sample size of 428 participants was reached. Data collection was conducted using a structured questionnaire adapted from previous study [28]. The questionnaire covered these topics: a) Demographic parameters such as age, marital status, religion, level of education, occupation, duration of relationship (physical, social or financial) and number of children; b) information on barriers of male involvement in ANC of which women were to choose one or more possible barriers [11, 12, 29] such as ‘being too busy with work’, ‘thinking its women’s’ affairs’, ‘lack of maternal health knowledge’ and health service related factors such as ‘comfortability to be in antenatal clinic’, ‘prohibitions to participate during care’, ‘poorly perceived quality of care’, ‘staff attitudes’, ‘inhibitive facility infrastructure’ and /or, ‘long waiting time’. Questionnaires were screened for completeness and missing information was inquired before data entry, which was concomitantly performed with data collection. The study conducted a purposeful sampling of male partners of women attending postnatal clinics and others who were nursing mothers in postnatal wards. The male partners were simultaneously selected during a cross-section survey, and their selection was independent of their female partners’ participation in the study. Eligible participants who agreed to be interviewed signed a written consent for participation. Two FGDs were performed. The first FGD was of male partners of nursing mothers in the postnatal ward (n = 7). Male participants were between 24 to 52 years of age, and they had experienced one to four pregnancies with their spouses. Three out of seven participants were self-employed, two were employed in private organizations, and the rest were government employees. The second FGD was of male partners of women attending postnatal clinic (n = 11). Participants’ ages were between 30 and 55 years and they had experienced one to five pregnancies with their spouses. Seven out of eleven participants were self-employed, while the rest were employed in private organizations. Each FGD was conducted in a closed–door session for about 1 hour. The first author was a passive member of the group. All FGDs were audio recorded and transcribed verbatim by the first author on the same day. The transcriptions were in Kiswahili and later translated to English.by the first author with and later verified by other researchers. Participants used Kiswahili during the FGDs. All researchers were Kiswahili speakers, as the first language, which is also the language normally spoken by clients and service providers in the hospital. The questions posed during the FGDs were open-ended and focused on these topics: a) general understanding of being a father and biological father, b) benefits of male partner’s involvement, c) barriers of male partner’s involvement, d) whether health service related factors such as facility infrastructure, long waiting time, staff attitudes and quality of care affect their antenatal clinic attendance, and e) recommendations on how to tackle those barriers. Follow-up questions were put forward regarding staff interaction with male partners and quality of customer care. The first FGD transcript was read and areas that needed in depth inquiry and further exploration were identified and introduced in the second FGD. Saturation was reached at a point where no new information was gathered from the FGDs. The participants were given soft drinks during the discussions as a gesture of appreciation for participating [30]. Quantitative data was entered into SPSS ver. 23 (IBM SPSS, Chicago, IL). Data entry and cleaning included amending information that was incomplete or suspected of being incorrect by cross-checking with women before discharge. Typographic errors and duplicated information were removed. Simple descriptive statistical analysis was used to obtain percentage distribution of main outcome measure associated with male involvement in ANC. Male involvement was defined using a composite scoring system based on five factors that were weighted a score of ‘1’ when present or ‘0’, when not. These factors included a) Did your husband attend antenatal clinic at least once? b) Was he available during scheduled days and times of antenatal care appointments? c) Did he participate in decision-making regarding pregnancy and childbirth? d) Did he provide emotional, physical or financial support during antenatal clinic? and e) Did he take part in any maternal healthcare education programs? Demographic, socioeconomic and maternal factors were tested for association with male involvement in antenatal care using chi-squire and bivariate logistic regression. Odds ratio with 95% confidence intervals of p < 0.05 was considered as significant for association. For qualitative data, transcripts from the FGDs were translated in English prior to analysis to enable report-writing and dissemination for non-Kiswahili-speaking audience and readers. Thematic content analysis [31] was used to describe the themes within the FGD findings in stepwise manner by familiarizing with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes and producing a report. Naturalistic inquiry guided the emergent analysis [32] from the initial data collection, where information from one FGD was used to generate new questions in the other. Topical saturation of new concepts was met upon repetition of participants’ answers. Qualitative data analysis Nvivo 10 computer software was used in managing and organizing data. Triangulation was performed to compare and contrast reported findings. Ethical approval was obtained from Research and Publication Committee of Muhimbili University of Health and Allied Sciences (MUHAS) Senate (Ref. No. DA.287/298/01A). Approval to conduct the study at MNH was granted by MNH Research Ethics Review Board. All methods were performed in accordance with the relevant guidelines and regulations under MNH research policy. A written informed consent was obtained from all participants in Kiswahili. Participants were informed of their right to withdraw from the study at any point and that the information obtained was confidential. All recordings and transcripts were made anonymous before being discussed within the research group. Patients’ names or hospital registration numbers were not used to ensure confidentiality, and access to participants’ information was given to researchers only.
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