Expectant fathers’ participation in antenatal care services in Papua New Guinea: A qualitative inquiry

Background: The importance of engaging men in maternal and child health programs is well recognised internationally. In Papua New Guinea (PNG), men’s involvement in maternal and child health services remains limited and barriers and enablers to involving fathers in antenatal care have not been well studied. The purpose of this paper is to explore attitudes to expectant fathers participating in antenatal care, and to identify barriers and enablers to men’s participation in antenatal care with their pregnant partner in PNG. Methods: Twenty-eight focus group discussions were conducted with purposively selected pregnant women, expectant fathers, older men and older women across four provinces of PNG. Fourteen key informant interviews were also conducted with health workers. Qualitative data generated were analysed thematically. Results: While some men accompany their pregnant partners to the antenatal clinic and wait outside, very few men participate in antenatal consultations. Factors supporting fathers’ participation in antenatal consultations included feelings of shared responsibility for the unborn child, concern for the mother’s or baby’s health, the child being a first child, friendly health workers, and male health workers. Sociocultural norms and taboos were the most significant barrier to fathers’ participation in antenatal care, contributing to men feeling ashamed or embarrassed to attend clinic with their partner. Other barriers to men’s participation included fear of HIV or sexually transmitted infection testing, lack of separate waiting spaces for men, rude treatment by health workers, and being in a polygamous relationship. Building community awareness of the benefits of fathers participating in maternal and child health service, inviting fathers to attend antenatal care if their pregnant partner would like them to, and ensuring clinic spaces and staff are welcoming to men were strategies suggested for increasing fathers’ participation in antenatal care. Conclusion: This study identified significant sociocultural and health service barriers to expectant fathers’ participation in antenatal care in PNG. Our findings highlight the need to address these barriers – through health staff training and support, changes to health facility layout and community awareness raising – so that couples in PNG can access the benefits of men’s participation in antenatal care. This paper forms part of a larger study that the authors conducted between June and August 2012 to examine health seeking behaviour for antenatal care, men’s involvement in ANC, and prevention, testing and treatment of STIs and HIV. This study employed a qualitative study design including focus group discussions (FGDs) and key informant interviews (KIIs) using standard question guides. Given the relative dearth of published research into expectant fathers’ involvement in ANC in PNG, this study design was appropriate to explore and build our understanding of this topic. This study was funded by UNICEF PNG and conducted to inform design of the “Haus Man Sambai Long Ol Mama” project, a UNICEF PNG pilot program to increase men’s involvement in ANC and PPTCT. Data were collected across four provinces of PNG. All four provinces had been identified as implementation locations for the Haus Man Sambai Long Ol Mama project, selected for the project due to high rates of parent-to-child transmission of HIV. In each province, one to three clinics providing PPTCT services were purposively selected to represent the range of rural and urban clinical settings operating in that province. Ultimately, a total of seven sites were selected: Port Moresby General Hospital and St. Therese Clinic in National Capital District; Migende St. Joseph Rural Hospital in Chimbu Province; Kumin Headquarters PPTCT Centre and Mendi General Hospital in Southern Highlands Province; and Mt. Hagen General Hospital, Tininga and Rabiamul Clinic in Western Highlands Province. Antenatal care services are provided free of charge in these clinic. The main study participants were adult men and women from communities surrounding the study clinics, including: women who were pregnant or had given birth in the last 12 months (referred to collectively here as ‘pregnant mothers’); men whose female partner was currently pregnant or had given birth in the last 12 months (referred to collectively here as ‘expectant fathers’); older women aged 50 years or over; and older men aged 50 years or over. In PNG, older people often play an important role in community decision-making and information sharing and older women in particular often support younger women throughout pregnancy and childbirth [44]. Older people were therefore an important informant group to understand attitudes and experiences of men’s role in the antenatal period. FGD participants were recruited using convenience sampling via public announcements, flyers, posters, and individual verbal invitations at health centres, community meeting places, churches and other community institutions. A total of 300 community members participated in FGDs, including 78 pregnant mothers, 64 expectant fathers, 77 older women and 81 older men. The average pregnant mother participating in this study was 27 years old (range 17 to 45 years), with two or three children (range zero to 8) and 5.6 years of schooling (range zero to 16). The average expectant father was 31 years old (range 19 to 46 years), had two or three children (range zero to 10 children), and had 6.6 years of schooling (range zero to 12 years). Most pregnant mothers and expectant fathers lived with their partner (94% of mothers and 89% of fathers) and were unemployed (88% of mothers and 64% of fathers). A substantial proportion of all participants were in a polygamous marriage, including 13% of pregnant mothers and 5% of expectant fathers. Older men and women were all believed to be aged over 50 years, although many could not recall their exact age. Older women had an average of four children (range zero to eight) and older men an average of between five and six children (range zero to 15). The average older woman had 3.9 years of schooling (range zero to 14 years) while the average older man had 3.6 years of schooling (range zero to 12 years). Health workers (nurses and midwives) involved in ANC or PPTCT service provision in local hospitals, health centres or clinics were also eligible to participate in KIIs. Two health workers were purposively recruited at each site by trained data collectors in conversation with health service management. A total of 28 FGDs (four per site) were conducted. At each site, separate FGDs were conducted with pregnant mothers, expectant fathers, older men and older women. Trained FGD facilitators used open-ended question guides developed and pilot-tested for each specific participant group (refer to Additional files 1, 2, 3, 4, and 5). FGDs were led by a facilitator of the same gender as the participants, supported by a note taker, and explored attitudes to expectant fathers’ participation in ANC, and barriers, enablers and potential strategies to promote men’s participation in ANC. FGDs were held in private rooms in community buildings or health facilities, involved between four and 11 participants, lasted approximately 1.5 h and were conducted in Tok Pisin in combination with other local languages. Basic demographic data were collected from FGD participants regarding number of children, marital status and age. We also undertook 14 KIIs (two per site) with health workers to explore attitudes and behaviours relevant to expectant fathers’ participation in ANC, health system factors influencing expectant fathers’ participation and opportunities to promote fathers’ participation in ANC. KIIs were conducted face-to-face in a private space in the health facility by one facilitator and one note taker, lasted approximately one hour and were conducted in Tok Pisin or English, depending on the participant’s preference. This study used different data collection personnel in each province. Provincial teams were supervised by a team leader who managed and participated in data collection across all sites. This approach was adopted to develop research capacity in each location, to minimise security risks to study personnel, and to ensure data collectors were fluent in local languages. Provincial data collectors were community HIV educators sourced from local non-government organisations. Most had limited prior experience of qualitative research. All data collectors participated in a five day training workshop on qualitative research and participated in field-testing study tools. Two digital recorders were used during data collection and data collectors took detailed written notes. However, substantial background noise and softly spoken participants compromised the usefulness of some digital recordings. Detailed notes taken by note-takers in each FGD and KII were compared to voice recordings and amended where possible and if required, before being checked by the FGD or KII facilitator. These written records were then translated into English. Translated written records were reviewed based on broad themes of interest, namely: support that fathers currently provide to pregnant partners; attitudes to fathers participating in ANC; barriers to expectant fathers attending ANC; enablers to fathers participating in ANC; and potential strategies for increasing fathers’ participation in ANC. Subsequent analysis of written records involved inductive data-driven coding of the text to identify and synthesise recurrent issues in the data. The software package NVivo 10 was used for data management. Provincial research teams provided feedback on initial interpretation of the data, the recurrent issues identified during analysis, and provided assistance with interpretation of findings at a two-day workshop in Port Moresby. This research was approved by the Research Advisory Council of the National AIDS Council Secretariat in Papua New Guinea and the Alfred Health Human Research Ethics Committee in Australia. Written or verbal consent to participate was obtained from all participants after data collectors had explained study objectives and procedures and checked that participants understood this information. To protect participant confidentiality, quotes are attributed to the participant group and the province, but without reference to individual sites. Because of the small number of health worker participants, health worker quotes are not attributed to a province.