‘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

Background: The importance of men’s involvement in facilitating women’s access to skilled maternal healthcare in patriarchal societies such as Ghana is increasingly being recognised. However, few studies have been conducted to examine men’s involvement in issues of maternal healthcare, the barriers to men’s involvement, and how best to actively involve men. The purpose of this paper is to explore the barriers to and opportunities for men’s involvement in maternal healthcare in the Upper West Region of Ghana. Methods: Qualitative focus group discussions, in-depth interviews and key informant interviews were conducted with adult men and women aged 20-50 in a total of seven communities in two geographic districts and across urban and rural areas in the Upper West Region of Ghana. Attride-Stirling’s thematic network analysis framework was used to analyse and present the qualitative data. Results: Findings suggest that although many men recognise the importance of skilled care during pregnancy and childbirth, and the benefits of their involvement, most did not actively involve themselves in issues of maternal healthcare unless complications set in during pregnancy or labour. Less than a quarter of male participants had ever accompanied their wives for antenatal care or postnatal care in a health facility. Four main barriers to men’s involvement were identified: perceptions that pregnancy care is a female role while men are family providers; negative cultural beliefs such as the belief that men who accompany their wives to receive ANC services are being dominated by their wives; health services factors such as unfavourable opening hours of services, poor attitudes of healthcare providers such as maltreatment of women and their spouses and lack of space to accommodate male partners in health facilities; and the high cost associated with accompanying women to seek maternity care. Suggestions for addressing these barriers include community mobilisation programmes to promote greater male involvement, health education, effective leadership, and respectful and patient-centred care training for healthcare providers. Conclusions: The findings in this paper highlight the need to address the barriers to men’s involvement, engage men and women on issues of maternal health, and improve the healthcare systems – both in terms of facilities and attitudes of health staff – so that couples who wish to be together when accessing care can truly do so.

This paper forms part of a larger study that the authors conducted between January and August 2014 to examine men’s involvement in maternity care in Ghana. The study employed a qualitative research design. A qualitative research approach is useful as it rests on the idea that social reality and experiences are complex and dynamic. It has been argued that the quantitative research method fails to fully comprehend the dynamics of social life and, in particular, ignores local people’s perspectives and understanding [27]. Since this research aimed to explore the barriers to, and opportunities for, men’s involvement in maternal healthcare, the use of a qualitative approach was ideal [28]. The qualitative design provided a detailed description of men’s perceptions, attitudes and involvement in maternal healthcare and uncovered how women navigate their maternal healthcare needs in Ghana’s Upper West Region. The study was conducted in seven communities across two districts (Wa West and Lambussie-Karni districts) of the Upper West Region (UWR) of Ghana. The UWR is located on the northwestern part of Ghana, and covers a geographical area of 18,478 square km. The region has a population of 702,110, comprising 51.4 % females and 48.6 % males [29]. The region is the second poorest region in Ghana, with 82.5 % of the total population characterised as rural [19]. The primary economic activity is agriculture, with approximately 72 % of the active labour force engaged in agriculture [29]. Women constitute the majority of the farm labour-force. Women also make up the majority of contributors in the informal sector in the region. In the UWR, only 12.5 % of roads are tarred, with most in poor and deplorable condition, becoming impassable in the rainy season [30]. In terms of healthcare, there is almost no healthcare coverage in the remote rural areas of the region except Community-based Health Planning and Services (CHPS) zones, a primary healthcare facility dedicated to providing basic curative care, and usually manned by a trained community health nurse at best, or a community volunteer, at worst. Chronic shortages of equipment, medical supplies, and healthcare staff often worsen the situation. Currently, statistics suggest that there is one doctor for every 11,649 patient population and one nurse to 1,172 patient population in the region [22]. This situation is made worse by the refusal of Ghana’s highly trained medical doctors and nurses to accept posting to the region [22]. Like most parts of Ghana, the region is one of the areas where maternal mortality is still a worrying concern. The maternal mortality ratio as at 2013 stood at 161 deaths per 100,000 live births [22]. This is far higher than many regions in the southern part of Ghana. Only 55 % of births are attended by skilled birth attendants despite the fact that skilled maternal healthcare services, since 2003, have supposedly been provided free-of-charge at the point of delivery in health facilities [22]. In the UWR as in most parts of Ghana, gender-based role differentiation and male domination are entrenched and pervasive [31]. Men are in charge of decision-making and are seen as the breadwinners and women have less decision-making power both at the domestic sphere and the public realm [31]. It is within this context that this paper aims to examine the involvement of men in maternal healthcare. The main research participants were adult men. To gain multiple views on the involvement of men in maternal healthcare, however, the wives/partners of some of the men who participated in the study were interviewed. Also other key informants such as community leaders (chiefs, women’s leaders, and assembly members), community health nurses, community health officers (CHOs), and mother-to-mother support group leaders, were also interviewed. In general, the ages of the participants, including those interviewed in key informants, ranged from 20 to 50 years. Majority of the participants had no formal education. Majority of the participants were also smallholder farmers with few others being professional teachers and community health nurses. All the participants, except some of the community health nurses, were married and had at least one child at the time of this study. The seven study communities (four in Wa West and three in Lambussie-Karni districts) were purposively selected to capture a diversity of social and health situations that were largely representative of the region. In each of the study district, one urban community (i.e. community with a population of 5000 people or above), one rural community with at least one health facility, and one rural community without any health facility were selected. This was done after lists of all urban communities with a health facility, all rural communities with a health facility, and all rural communities without a health facility, were compiled in each district. From each of these categories, we purposively selected the community with the highest population. A mix of purposive and convenient sampling techniques was however used to select individual research participants. Initially, we applied purposive sampling to select men whose spouses were either pregnant or lactating at the time of the research. Later on in the selection process, however, other men who expressed a desire to participate in the study were conveniently selected. The entire selection process was however based on a number of pre-set inclusion criteria: ease of recruitment, participant’s availability, participant’s willingness to participate in the study, and ability/capacity of a participant to consent to participate in the research. The actual recruitment process involved advertising the study at vantage points (local community markets, churches and mosques) via community and religious leaders and CHOs, in addition to public announcement using the local community gong gong beaters (i.e. local community announcers). We acknowledge that the way in which the study was advertised could have introduced some bias in the selection of participants. For example, men who did not go to church or mosque were more likely not to hear about the study. However, we believe the diverse media we used to advertise the study such as beating the gong gong ensured that the majority of potential research participants heard about the study. Besides, the invitation was extended to all adult men and their spouses who met the essential inclusion criteria. The CHOs then helped the researchers to recruit interested individual participants for interviewing. Having grown up in the study communities, the CHOs were very conversant with the local cultural nuances and were therefore in a good position to advice the researchers on the selection and recruitment of participants, and arrange interview meetings. Focus group discussions (FGDs) were the main data collection methods. This data collection technique was adopted partly because of its practical relevance in helping to reproduce men and women’s opinions on men’s involvement in issues of maternal healthcare in a normal peer-group interpersonal exchange [2, 3]. Other researchers have suggested that group setting often works well for generating talk about health, and that FGDs provide broader views about health and illness meanings [32]. In fact because FGDs were interactive, participants were able to query and challenge each other as well as explain themselves; hence offering validated data on the extent of consensus or diversity [33]. In all, 12 FGDs were completed with men. Groups were segmented by age (i.e. 20–30 years, and 31–50 years). We did this because initial discussions with CHOs suggested that there were age hierarchy conflicts in the study communities. In other words, younger men (20-30years) were unlikely to freely express their views in the presence of older men (31-50years) because of cultural norms, which require young people to listen to their elders. Segmenting discussants by similar age groups therefore ensured that each participant was comfortable expressing their opinions on all the issues as well as sharing their experiences within the group context with minimal hindrance. Groups consisted of 7–12 participants. Discussions in the FGDs lasted 1.30 to 2 hours, and ended when a point of saturation was reached i.e. when no new issues seemed to arise. All FGDs were held in the study communities. FGDs were held at locations convenient to both the participants and the researchers, and all the discussions were held in the local dialect – Dagaari. This was done because the literacy [written or spoken English] rates are low among the study participants. The researchers were all conversant and fluent in Dagaari and English. In the view of Grewal and Ritchie, a shared dialect could facilitate communication between the researched and the researcher [27]. The researchers’ ability to conduct interviews using a shared language with informants fostered rapport and social conversation with participants. The shared dialect also facilitated and smoothened the communication between the researchers and participants, as there was no need for a translator. To complement the FGDs, in-depth interviews were also conducted with some of the men who participated in the FGDs and their spouses. These in-depth interviews were follow-up interviews. This was necessary because these men declined to discuss certain issues they considered personal and private in the group context. Instead, they expressed a desire to speak to the researchers alone. The selection of men for these individual in-depth interviews was therefore purposive, and was based on each participant expressing a desire to speak with the researchers alone. Indeed, in the literature, there are arguments that people may not necessarily tell the truth in any objective sense when it comes to sensitive issues such as health within a group context [34]. For this reason, the FGDs data were triangulated with individual interviews. A major advantage of this method was that it addressed sensitive issues such as personal experiences of childbirth and barriers to men’s involvement in maternity care. In total, 50 in-depth interviews – 25 with men and 25 with their spouses – were completed. We interviewed these women because we wanted to triangulate the information men gave in relation to their involvement in issues of maternal healthcare. Each interview lasted 30 to 40 min. Interviews were conducted in both Dagaari and English. Lastly, key informant interviews (KIIs) were conducted with six chiefs, five women leaders, six assemblymen, five community health nurses, six community health officers, and two mother-to-mother support group leaders. Thus a total of 30 KIIs were completed. Generally, these KIIs sought to explore the views of other relevant stakeholders on the topic of male involvement in maternal healthcare. In this sense, the aims of the KIIs were not totally different from the other study participants. Rather, these KIIs complemented the FGDs and in-depth interviews with men and their spouses. In many instances, the findings from these KIIs gave further detail and nuance to the views and experiences of men and women. Interviews were conducted in both Dagaari and English, and lasted between 20 to 30 min. Three open-ended thematic topic guides were designed and used. The first instrument was used in the FGDs with men. This instrument focused on exploring men’s understanding of the importance of skilled birth attendance during pregnancy and labour, men’s involvement in maternity care, and the barriers to, and enablers of, men’s involvement in maternal healthcare. The second instrument was used for in-depth interviews with women. This instrument focused on women’s own perceptions about, and experiences with, men’s involvement in maternal healthcare. The last instrument was used to conduct interviews with key informants. This instrument focused on exploring the views of key informants on the topic of male involvement in maternal healthcare, and the challenges of, and opportunities for, involving men in maternal healthcare. All the instruments however had built-in flexibility that allowed for any pertinent but unexpected issues that arose during the discussion or interview process to be further probed. To ensure reliability, the instruments were pre-tested in one of the study communities. This helped to reframe questions, clarify and use more appropriate or easily understandable concepts. As the actual data collection progressed, the researchers also engaged in a continuous review of the questions and interview process to make sure that the questions were appropriate and rightly asked, and that the questions were understandable to research participants. All discussions and interviews were tape-recorded alongside hand-written field notes with the verbal consent of participants. Qualitative data were analysed using Attride-Stirling’s thematic network analysis framework [35]. The Attride-Stirling thematic network analysis framework is a method for conducting thematic analysis of qualitative or textual data, which allows for open and methodical discovery of emergent concepts, themes and relationships through the application of principles of inductive reasoning to generating themes while also employing predetermined (deductive) code types to guide data analysis and interpretation [35]. This involved several steps. Following the completion of interviews, all tape-recorded interviews were transcribed and all non-English transcripts translated into English. All transcripts and interview notes were then read and reviewed for overall understanding. This first step was completed with separate summaries for each transcript outlining the key points participants made. All transcripts were then exported into NVivo 9 qualitative data analysis software, where the data was both deductively and inductively coded. Data coding continued until theoretical saturation was reached (i.e. when no new concepts emerged from successive coding of data). The completed code structure was applied to develop and report themes. Themes simply represented some level of patterned response or meaning within the data set [36]. To ensure that the themes reflected the data, the data segments related to each theme were thoroughly examined. Where necessary, refinements were made. Where appropriate, verbatim quotations from interview transcripts were used to illustrate relevant themes. Ethical approval for the study was obtained from the Ghana Health Service Ethical Review Committee (Protocol ID NO: GHS-ERC 18/11/13). In addition, informed written and verbal consents were obtained from all research participants. Individual participants were requested to sign or tomb print a written informed consent form. Participants (and there were only nine) who did not feel comfortable signing or tomb printing the written consent form were permitted to give verbal consent. Each verbal consent was witnessed by at least one family member or friend. To protect the identities and anonymity of participants, only pseudonyms have been used in the analysis and presentation of data.

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• ganle, john kuumuori
• dery, isaac