Malawian fathers’ views and experiences of attending the birth of their children: a qualitative study.

Exploring the experiences and views of men who had attended the birth of their children is very vital, especially in a setting where traditionally only women accord women support during labour and childbirth. The insights drawn from the male partners’ views and experiences could enhance the current woman-centred midwifery model that encompasses the needs of the baby, the woman’s family and other people important to the woman, as defined and negotiated by the woman herself. This paper explored the views and experiences of men who attended the birth of their children from two private hospitals in an urban setting in southern Malawi. This study used an exploratory descriptive qualitative approach. The data were collected through in-depth interviews from 20 men from Blantyre, a city in the southern part of Malawi, who consented to participate in the study. These men attended the birth of their children at Blantyre Adventist and Mlambe Mission Hospitals within the past two years prior to data collection in August 2010. A semi-structure interview guide was used to collect data. Qualitative content analysis was used to analyse the data set. Four themes were identified to explain the experiences and views of men about attending childbirth. The themes were motivation; positive experiences; negative experiences; reflection and resolutions. The negative experiences had four sub-themes namely shame and embarrassment, helplessness and unprepared, health care provider–male partner tension, and exclusion from decision-making process. The findings showed that with proper motivational information, enabling environment, positive midwives’ attitude and spouse willingness, it is possible to involve male partners during childbirth in Malawi. Midwives, women and male peers are vital in the promotion of male involvement during childbirth. In addition, midwives have a duty to ensure that men are well prepared for the labour and childbirth processes for the experience to be a positive one. The design of the study was an exploratory descriptive approach that utilized qualitative methods. The data were collected using in-depth interviews. Data for this study were collected from men whose partners gave birth to their babies at Blantyre Adventist and Mlambe Mission hospitals in Blantyre city, Malawi. The two hospitals were purposively chosen because they allowed male partner’s presence during labour and birth. Blantyre Adventist Hospital (BAH) is located at the centre of Blantyre city in southern Malawi. The American missionary doctors of the Seventh-Day Adventist (SDA) Church established the hospital in 1957. It is a forty-bed private-for-profit hospital. Although the hospital belongs to the SDA church, it is completely self-financed, receiving no church subsidies. Almost all of the clients of BAH have an insurance medical scheme, pay cash, or are part of a firm or organization that covers the account on their behalf. The BAH offers specialized obstetric care operated by an obstetrician, state registered nurse/midwives (SRNMs) and nurse/midwives technicians (NMTs). Maternal care services that are offered at the hospital include antenatal care that includes ultra-sound scanning, childbirth classes, labour and childbirth services, postnatal care of mother and baby, 2 weeks post-normal birth and 1-week post caesarean section. Antenatal and postnatal care services are offered by an obstetrician at the outpatient department. Clients have to book an appointment in order to be seen by their obstetrician. The number of antenatal care visits depends on individual obstetric needs. Optional childbirth classes are also offered by a midwife at the outpatient department. During childbirth, the clients choose whom they would want to assist the birth of their baby, a midwife, a general doctor or an obstetrician. The cost of childbirth depends on who conducts the birth and the mode of birthing, for example, normal or caesarean section. The cost of childbirth conducted by a midwife is lower than a birthing conducted by an obstetrician. Mlambe Mission Hospital (MMH) is situated 30 kilometres north of Blantyre city. It is a 254-bed facility that is run by the Roman Catholic Church. The hospital is one of the Christian Hospital Association of Malawi (CHAM) facilities. CHAM is an ecumenical, not-for-profit non-governmental umbrella organization of Christian-owned health facilities. CHAM offers about 37% of health care services in Malawi [21]. Ninety percent of CHAM health facilities are located in the rural settings of the country where, in most cases, there are no government facilities. Therefore, through Service Level Agreement (SLA) CHAM signed contract with Ministry of Health (MoH) to provide free maternal health care. Mlambe Mission Hospital signed a SLA contract with Blantyre District Health Office that enables it provide maternal health care services to the people around its catchment area. In addition, the hospital receives obstetric referrals from six government health centres. The hospital offers antenatal care (ANC), labour, birth, and postnatal care services. An obstetrician, general practitioners, clinical officers, SRNMs and NMTs offer the MCH services. Mlambe Mission Hospital offers two levels of maternity care services, low cost care and private care. The low-cost maternity care services cater to poor women who cannot access government hospitals. The private maternity care services are similar to that of BAH except for the childbirth classes. However, the cost of private maternity care at MMH is lower than that of BAH because of the financial support from the Roman Catholic Church and CHAM. For instance, a normal vaginal birth would cost around MWK 100,000, an equivalent of 333USD, and a caesarean section would cost MWK 250, 000 (833USD) at BAH. At MMH, a normal birth costs around MWK 50,000.00 (166USD) and caesarean section costs around MWK 100,000 (333USD). However, in the government hospitals these services are free. Twenty indigenous Malawian men were purposively selected to participate in this study. Purposive sampling strategy was used because the participants could provide relevant, insightful information on the phenomenon being explored. In addition, variation in sample with regard to educational background, age, social economic status and parity was sought in order to include a range of perspectives. Some of the participants were recruited from the health facilities as they came with their female partners for postnatal check up or family planning services, while other men were recruited through the snowball technique. Snowball sampling, a procedure that relies on referrals from initial informants to generate additional participants who met the eligibility criteria for the study, but are hard-to-reach population [22]. Therefore, men who had been interviewed were asked if they knew other men who attended their children’s birth. The participants represented urban men who were present when their female partners gave birth to their children and the women gave birth at BAH and MMH. In addition, the participants’ infants were 2 years and under at the time of inclusion to the study. Twenty interviews were conducted and were sufficient to achieve data saturation. Green and Thorogood stated that “the experience of most qualitative researchers is that in interview studies little that is ‘new’ comes out of transcripts after you have interviewed 20 or so people” [23], p. 120. Bowen described data saturation as bringing new participants continually into the study until the data set is complete, as indicated by data replication or redundancy [24]. Permission to conduct the study was obtained from Malawi College of Medicine Research and Ethical Committee (protocol number P.05/10/948) and the Regional Committee for Medical and Health Research Ethics in Norway (vår ref. 2009/968a). Permission to access participants was sought from the directors and chief nursing officers of BAH and MMH. All participants were informed about the purpose of the study. The men were also informed that their participation was voluntary and that they were free to withdraw from the interview and the study at any time without giving a reason. The men were further informed that their withdrawal would not affect their entitlements to health services. A written informed consent was obtained from individual participants. Data were elicited between August 2010 and January 2011 in the city of Blantyre. A semi-structured interview guide was administered to 20 individuals that consented to participating in the study. The structured part included participants’ demographic data and the open-ended part captured qualitative data. The semi-structured interview guide was developed basing on a literature review. The questions in the interview guide were broad and open-ended that allowed for both directed questions and freer exploration of unanticipated issues raised by the participants. See Additional file 1: Appendix 1 for the interview guide. The interviews were conducted in Chichewa and lasted between 40 to 60 minutes. The health facility management provided a private office to carry out interviews for participants who opted to be interviewed at the health facility. Ten men were interviewed at the health facilities and six at their place of work. The four remaining participants were interviewed in their respective homes. All interviews were audio-recorded. Hand written notes were taken during the interviews and later expanded into transcripts. At the end of each interview, a summary of the notes were read to the participant in order to verify the data. The participants were given a soft drink and a snack after the interview as a gesture of appreciation. Data analysis was undertaken simultaneously with data collection in order to identify new and important issues that could be addressed during the subsequent interviews. The taped information was transcribed verbatim and translated from vernacular language into English. Observational field notes were incorporated into the data for analysis. General principles of qualitative content analysis by Graneheim and Lundman guided data analysis [25]. The transcribed data were entered in Nvivo 9, software for data storage and management system. The transcripts were read repeatedly and words with similar meanings were grouped into categories. Similar categories were grouped into themes and sub-themes that are presented as findings in this paper. The findings contain direct quotes from participants and the narrations are reported as they were spoken by participants without editing the grammar to avoid losing meaning. Expressions in vernacular language are presented in parentheses and fictitious names are used in the quotes to maintain anonymity of the participants. The process of data verification was carried out according to Lincoln and Guba’s criteria of rigour in qualitative research that includes credibility, transferability, dependability and confirmability [26], 300. They defined credibility as internal validity and relates to “how vivid and faithful the description of the phenomenon is” [27]. In this study, credibility was enhanced by using participants’ actual words in the report. Since the interviews were done in Chichewa, a vernacular language, and translated into English, there was a potential for misrepresenting a participant’s intended meaning of a word. Therefore, the words were supported by quotations from the interviews. In addition, the investigator had frequent discussion sessions with co-authors and impartial colleagues experienced in qualitative methods, which provided a platform for developing ideas and interpretations that represent the correct picture of reality about the phenomenon under study. Transferability corresponds to external validity and the probability that the research findings can be used in other contexts [28], p.316. In this study, the background and methods used were described as much in detail as possible in order to allow readers to assess the applicability in other contexts. Dependability corresponds to reliability of the findings and it occurs when another researcher is able to follow the methods and draw similar conclusions to the original research findings [27]. Dependability requires that the argument is complete, allowing the reader to follow and understand it logically without unexplained leaps from argument to conclusion [26], p.300. In this study, dependability was achieved by the involvement of the experienced researchers (co-authors) in qualitative methods, who followed through the progression of the study. Their independent analysis and evaluation of decisions made and consensus, determined whether comparable conclusions could be reached given the same data and research context. Confirmability is described as objectivity whereby the findings of the study represent the results of the inquiry and not the researcher’s biases [29]. Confirmability was achieved through an audit trail constructed through memos and field notes. The notes allowed the investigator and the co-authors to trace the course of the research systematically.