ABSTRACT

CORRESPONDING AUTHOR:
Dr. T.P. Jayanthi
Flat No: 201,
Manikandan Block,
Chitra Avenue,
No. 9 Choolaimedu High Road,
Chennai-600094
Tamilnadu, India.
E-mail: jayanthipandian@yahoo.co.in

ABSTRACT: BACKGROUND: Male participation in maternal and newborn care has gained importance over the last two decades. Despite the fact that men being the decision makers and could contribute a lot towards safe motherhood and newborn survival, men do not involve themselves to the desired level. Knowledge and views of men and factors contributing to poor male participation, needs to be understood for effective planning of programme strategies involving men. MATERIALS AND METHODS: This qualitative study was designed to get a comprehensive understanding of the knowledge, attitude and involvement of men in maternal and newborn care and barriers in male participation. In-depth interviews and focus group discussions were conducted with women and spouses of recently delivered women. RESULTS: Men considered pregnancy and childbirth as domain of women, yet were willing to take care of their spouses and share domestic work. Men feel that their role is to provide emotional and financial support for the family. Men lacked knowledge on care of women during pregnancy, their nutritional needs and identification of warning signs. Men had limited knowledge on contraceptive methods and preferred tubectomy. They totally lacked knowledge on breast feeding, immunization and danger signs in newborn. Long waiting time in public health facilities, non-availability of waiting area for men and poor communication of health care providers were barriers for male participation. CONCLUSION: In spite of inadequate knowledge on maternal and newborn care, men show interest and are concerned about their spouses and newborns and are willing to share responsibilities. This attitude of men should be best used by health care services, which should provide space for men, offer counseling sessions and develop focused health education messages designed for men. Health care providers also need a change in attitude and accept men as care givers of their spouses and newborn. Involving men in safe motherhood services will improve the quality of reproductive health of women.

KEYWORDS: Male participation, Male involvement, maternal care, Newborn care.

INTRODUCTION: Over years, Reproductive health (RH) programmes across the globe have always been focussing on women as they are biologically responsible for child bearing. The International conference on Population and Development in Cairo in 1994 threw light on the need to involve men more in RH.¹ In India, which is predominantly a patriarchal society, decisions on maternal health, contraceptive usage and health seeking behaviour of women are decided by men.² Lack of knowledge and low prioritization of health issues of the mother and new born can lead to increased maternal and neonatal mortality and morbidity.

Male participation in RH has been highlighted by the programme planners over the last two decades, yet very little is visible. Studies from many countries have shown that male involvement has a positive influence on the health of the mother and newborn.^1,3,4 In India, few studies have been done on male participation, but the main focus has been only on sexual behaviour and family planning and least on maternal and newborn care(M&NBC).^5-7 This present study was therefore designed to get a comprehensive understanding of the knowledge, attitude and participation of men in M&NBC which is essential to formulate programme strategies involving men.

This present study was conducted in Chennai, a separate district and the capital city of Tamil Nadu, whose population is entirely urban. Tamil Nadu is one of most urbanized state in India, which has made great advances in providing quality health care to its people. It is fast emerging as a good public health model for the rest of the country, especially for maternal and child care.

MATERIALS AND METHODS: The parliamentary constituency of Chennai district has three major divisions North, Central and South. Maternal and child health services are provided through a network of 12 Emergency Obstetric Care centres and 109 health posts (HPs) administered by Chennai Corporation. More than 75% of women access the HPs for Antenatal (AN), postnatal and newborn care. One HP was randomly selected from each division. Pulianthope HP from North, Vadapalani HP from the south and Shenoy Nagar HP from the central division. The geographical area allocated to all the three HPs were the study area. This method of selection of study area was adopted to get holistic picture of the entire district. Men and women residing in the study area were the study subjects.

A qualitative study design was chosen as done in similar studies.^2,8 In-depth interviews (IDIs) with recently delivered women and spouses of recently delivered women were conducted as it is considered as an ideal technique to get a clear understanding of knowledge, attitude, and involvement of men in M&NBC and barriers in male participation. FGDs with men were conducted to understand group and community norms and also for triangulating information with more than one type of data collection technique.

The study was conducted during the last quarter of 2014. Ethical clearance was obtained from the Institutional Review Board of Government Kilpauk Medical College, Chennai. Informed written consent was obtained from all the study participants. Eight IDIs with men and another eight IDIs with women were conducted in each of the study site totaling to 24 men and 24 women. Men and women interviewed had representation from different levels of literacy and socioeconomic status. Three FGDs were conducted in each of the three study site with 8 to 10 men whose spouses had delivered babies in the last six months. Men were in the age group of 20 to 35 yrs and had representation from all levels of socio economic status. IDIs and FGDs were conducted in common places, convenient to the participants, ensuring privacy and confidentiality. Guides were developed separately for men and women to ensure consistency. Probes were built into the guide to allow for a thorough understanding of the topic.

IDIs and FGDs conducted by the authors were audio recorded and notes were made on non-verbal behaviour. A frame work analytical approach was used for data analysis. Audio recorded IDIs and FGDs were transcribed, translated into English and then coded. Segments of text that were related to a common theme were put together and emergent themes were identified.

RESULTS: Information shared by men and women were based on their personal experiences during the recent and previous child birth. Information obtained from women was complementary to data obtained from men

Men’s Knowledge on M & NBC: Men knew that AN checkups are important for assessing the health status of the women and to monitor the growth of the baby, yet very few knew about registering pregnancy by 12 weeks. Among the investigations done for pregnant woman, all men knew about testing for HIV since it is mandatory for the couple while knew very little about the others investigations except for Ultrasonogram. Men knew that anaemia was a common problem in pregnancy but did not know that Iron and folic acid (IFA) tablets given for correcting anaemia. Few of the educated participants knew that pregnant women should take calcium, iron and vitamin tablets. Tetanus toxoid injection was referred as “Thaduppuvusi”, and was thought to protect the baby from all infections. Men knew that pregnant women should take nutritious food, take rest and should not carry weight. Nutritious food, in the context of men, was mainly fruit juices while a few mentioned “Keerai” (greens).

Men believe that pregnant women should do all household work after 5 months to have an easy delivery. Most of the men had no knowledge of danger signs in pregnancy except few who knew about headache, bleeding and high blood pressure. Men knew that rupture of the bag of membranes (Panikudum) and abdominal pain was a sign of initiation of labour. Men were aware that cash assistance was provided through the maternity benefit schemes (MBS) - Rs. 600/- and 12, 000/-. Details of the source, time of disbursement and its purpose were not known. Most of the interviewees had not received even the first instalment of the state funded MBS.

The family planning method adopted was mostly a joint decision of the couple. Cu T for spacing and tubectomy for permanent sterilization were the most popular methods. Few preferred condoms but oral pills were known to none. Both men and women were reluctant to opt for vasectomy as they did not know much about it. One participant said “Vasectomy no. Because men cannot carry heavy weight, I have seen men getting hospitalized with severe pain following vasectomy. ” Women are also responsible for increased preference of tubectomy and poor adoption of vasectomy. Couples felt that tubectomy following delivery was the best as the woman would anyway take rest after delivery. One woman said “it is better that i get operated, it’s a waste using other contraceptives, I told him not to go for male operation, though he was willing.”

Many men did not know about the danger signs in the newborn, few mentioned about vomiting, diarrhoea, difficulty in breathing and continuous crying. Men knew that bottle feeds are harmful and breast feeding is essential for the growth of the baby, but had no knowledge on exclusive breast feeding (EBF) , importance of colostrum and complementary feeding. For men, duration of EBF ranged from 45days to one year. Men knew that babies have to be vaccinated, but did not when and why it should be given.

Men’s Attitude towards M & NBC: Men believe that women are knowledgeable on issues relating to pregnancy and childbirth and therefore seek the help of female relatives. They feel that their role is to provide financial and materialistic support for the family. Considering pregnancy as a simple and normal process, laziness, shyness and lack of knowledge about pregnancy related problems were mentioned by women as reasons for non-involvement of men. Choice of health facility for AN care/ delivery was invariably a joint decision of the couple with consent of the family members. Though public emergency transport system was known to men, birth preparedness was considered as a responsibility of women. The expenditure towards the first delivery is to be met by the parents of the delivering woman, while subsequent deliveries were the responsibility of the spouses.

Women from joint families were supported more by their mothers or their in- laws, while spouses extended more support in nuclear families. Work was mentioned as the main reason for not accompanying their wives to the clinics and by some for not sharing household work. Men at large said that they share household work, buy fruits, insist their wives to take good food and remind them to take medicines. IDIs with women also reflected similar information. Women are contended with such little support from their husbands since men have to concentrate on their job.

Male Participation – Current Status and Barriers: Men who accompany their spouses for AN visit, drop them in the hospital and go for their job or wait outside the hospital for a long time till they come back after the checkup. Many men said “even if we come to the hospital they don’t allow us inside. “ We are allowed only once, that is when they do HIV testing, and they talk to us about HIV”. One of the participants said “I always accompany my wife not once have i seen the doctor”. Another said “we are not allowed into the hospital, we don’t have an opportunity to talk to the doctor or other staff, we get information only from our wives. He added “some women are reluctant to ask their doubts to the doctors, we men cannot help them as we wait outside the hospital.” One of participant said “Sister gets the signature to do Caesarean section, but does not tell us why it is done, if we ask. Sister says doctor said it has to be done”. This was acknowledged by many women also. Men can sit with babies in front of the immunization clinics, but are not provided with any information. One of them said “I am there to just keep the baby, here also they don’t tell us anything”. Many men did not even know that health workers make home visits.

A common suggestion was that doctors should insist all women to come with their spouses for at least 3 AN visits and brief them about the health status of their wives as done in few private hospitals. Some suggested that men should be briefed on M&NBC when they come for HIV testing and health information related to M&NBC may be telecasted in television and displayed in posters.

DISCUSSION: The concept of male involvement in maternal health is now being advocated as an essential element of World Health Organization’s initiative for making pregnancy safer. ⁹ This qualitative study provides insight into the knowledge and attitude of men towards M&NBC and also gives a holistic understanding of issues surrounding male participation. The views of men and women were uniform across the study sites.

Knowledge and Attitude on M & NBC: Pregnancy and childbirth is perceived as a natural and simple process and is considered purely a feminine matter.¹⁰ A male gendered role norm exists and men generally believe that their role is to provide emotional, material and financial support for the family as found in other studies.^8,11 The cultural norms are imbibed into their minds, making the changing process slow. Lack of knowledge regarding pregnancy and shyness are also reasons for poor male participation.¹ Men knew the importance of AN care, but lacked knowledge on early registration of pregnancy, details of investigations and treatment, a finding similar to other studies.^6,8,12 Men did not know about of warning signs in pregnancy and emergency preparedness. It is important to educate men on various components of AN care, specifically pregnancy related complications to avoid delay in seeking care which would lead to maternal mortality and morbidity.^1,13

In spite of IFA supplementation for pregnant women for the last two decades anaemia sill continues to be a major problem and only 42% women had consumed the required dose.¹⁴

Educating men on foods rich in iron and the importance of IFA supplementation could be considered as an approach for reducing the burden of anaemia. Men should be briefed on the diet recommended for pregnant women specifically the locally available foods which are affordable to prevent malnutrition in women. Men knew that cash assistance was provided under MBS, yet knew nothing about the scheme and its purpose. Imparting information about the details of the scheme to the beneficiaries and timely disbursement is crucial, else it defeats the purpose for which it is intended.

Choice of health facility for AN checkup and delivery has been a joint decision by the couple This is a positive trend as RH decisions taken jointly by the couples are more likely to be implemented.² As seen in few studies, there is an attitudinal change and men express interest in taking care of their spouses.^4,15 Though many men lacked knowledge about the medical components, they were found to share the house hold work and insisted that their wives to take good food and medicines as seen in some studies.¹³ Rapid urbanisation and a move towards the culture of nuclear families have made men more supportive to their spouses. Women are contended with this support and do not expect more as profession is considered as the main responsibility of men.¹⁵

As seen in other parts of the country, couples opted for tubectomy, preferably during the puerperium as they have examples of many healthy women following tubectomy. CuT and condoms were less preferred.⁶ Misconceptions prevailed about vasectomy and use of oral pills.^2,16 The views of men correspond with the findings of the DLHS- 4 report for Chennai district. Among couples adopting contraception, 96% had undergone tubectomy, 1.5% Cu T and other methods were less than 0.5%.¹⁷ This is because the HCPs focus only on tubectomy and Cu T and fail to provide adequate information about other methods as seen in other studies.² Men being the decision makers should be counselled along with their spouses on contraception right from the AN period.³ More emphasis should be laid on spacing methods since the unmet need for contraception is still high (18%).¹⁷

Regarding newborn care, men had no knowledge on breast feeding and complementary feeding practices. Inspite of 98% institutional deliveries in the state, DLHS -4 reports shows that only 71% initiated breast feeding within an hour and only 52% of the babies were exclusively breast fed for five months. Men had no knowledge on when and why the vaccines are given. DLHS - 4 report shows that only 72% of the children in Chennai are fully immunised and Vitamin A supplementation for children up to 3 years showed a declining trend from 92% to 52%.¹⁷ Men lack knowledge on the various aspects of new born care mainly because HCPs talk about it to women only. Men should be briefed on the importance of breast feeding, details of vaccination and warning signs in newborn to enable them to support their spouses and to take appropriate and timely action to reduce neonatal mortality and morbidity.

Male Participation – Current Status and Barriers: As men are not allowed inside the hospital and provided with information about the health status of the mother and the baby, they lose interest and do not choose to come for subsequent visits considering it a waste of time. Lack of agenda for men at the health facilities seems to be a major barrier for poor participation of men.^2,8 Men coming for HIV testing are provided with information on HIV only. This window of opportunity could be used by HCPs to educate men on M&NBC care also. HCPs talk to men only at times when their wives have some complication or to get consent for doing a caesarean section and that too without explaining the indication placing the families under stress. HCPs are so much attached to the idea that M&NBC is an area for women and don’t accept men as care givers and many do not have the initiative to involve the men.⁸ Another factor could be that HCPs giving maternal care are mainly women. HCPs need a change in attitude and look for avenues to involve men as they are the decision makers and women are mostly financially dependent on them.^1,2,8

HCPs should insist that women should be accompanied by their spouses for registering for pregnancy and for at least 3-4 AN visits. Briefing men on the health status of the mother and baby would enhance more participation of men. Men should have access to clear their doubts especially when their spouses are not communicative. Lack of space to accommodate the spouses in AN clinics are found to adversely affect the involvement of men.¹⁸ Focussed services to address men do not exist. Provision of a male friendly ambience, specific health education sessions with tailored messages through mass media and encouragement from health staff are essential to enhance male participation.^2,5,18 HCPs should be provided with written guidelines for involving men M&NBC. Involving men has shown beneficial outcomes.^15,19

CONCLUSION: The traditional ways in which M&NBC services are implemented play a crucial role in influencing male participation as well as knowledge of men on maternal and newborn health issues.⁸ Men lacked knowledge on M & NBC, and the attitude that it is a domain of women still exists. However men realise their roles and responsibility and are keen to know about the health status of their spouse and newborn. This attitude of men should be capitalized to improve male participation breaking down the barriers from the side of the service delivery. HCPs also need a change in attitude and involve men right from the beginning, educate them on M&NBC instead of talking to them only at times of complication. Health care services should provide adequate space, offer counselling sessions and develop health education messages tailored for men.²⁰ A separate study has been taken up as views of HCPs regarding male participation in M&NBC, is equally important to design programme strategies to suit men for improving newborn survival and making pregnancy safer for women.²

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