Themes emerging from analysis related to current socio-cultural perceptions of male involvement as well as the potential for and possible challenges of increasing male involvement. Participant responses reflected strict gender-based divisions of work and space that relegated certain knowledge, practices and abilities to one gender only. Gendered divisions, including cultural constructs of masculinity and generational dynamics, inform each of the identified sub-themes related to the role men played and could potentially play in newborn care. Men were not involved in physically carrying out care tasks however men did involve themselves in other ways and some showed a desire to increase their involvement.
Perceptions of male involvement
Areas inaccessible to men
Certain areas – physical spaces or spheres of influence – were closed to men and male influence entirely with men playing a very limited or no role in performing care tasks. Men designated the delivery room and the immediate care of the baby after birth as “women’s affair” (Male, 50), a space completely under female influence and control. Men were usually sent from the delivery room by attending women during the most active parts of labour and not called back to see mother and child until immediate newborn care tasks were completed:
He knows nothing about that [cleanliness of delivery room] because men are not supposed to be present when their wife is delivering. ... he said the women there would even ask you to go out and wait (Male, 42).
When his wife is giving birth he doesn’t enter the delivery room so he doesn’t know what happens to the baby and it has never occurred to him to think about it (Male, 37).
Only two participants recounted men’s involvement in labour and delivery and only in unexpected or quickly progressing births. One participant repeatedly resisted her husband’s attempts to fetch a traditional birth attendant. In these instances men were present for labour and followed some instructions to fetch water, for example, but women still described delivering on their own without physically involving their husbands:
Although the husband was there when she was delivering…he could not help her (Female, unknown).
Finally she delivered on her own at 7 am. Her husband went to stand outside when she started pushing. He went to the room when he heard the child crying (Female, 33).
Gendered divisions of labour place both genders in particular physical spaces: men at work, women at home. Although some women farm or trade they are still responsible for completing household duties and the household is perceived as their main domain. Women are seen as “naturally” closer to children, both physically and as a result of their gender:
Decisions concerning how newborns are cared for are mostly taken by women since they are closer to the babies than men (Male, 37).
He wouldn’t like to sit in such [newborn care home visits] because he sees that as ‘Woman/child and the worker’s affair’ (Male, 28).
Both men and women believe that men are less able than women to assume a caretaking role and women know more about birth and childrearing by nature of their gender. Interviews revealed the dismissive attitudes of some women towards a man’s ability to be involved in newborn care:
[Immediate newborn care] is done by the women who assist with the delivery. ‘They do everything and if the man says something they would ignore it and laugh at you (Male,39).
Men do not know anything about labour that is why we consult our mothers or anybody who has experience in childcare. If you rely on the men, you would die! (Female, age unknown).
In areas that were not entirely inaccessible to men, men were still not directly involved in performing newborn care tasks. Many men reported little to no physical contact with the newborn. Women and their mothers were responsible for physically carrying out tasks such as breastfeeding, cord care, bathing and keeping the baby warm. The potential for male involvement in encouraging or understanding breastfeeding was seen as inherently limited by biology:
He laughed [at the suggestion that he assist with breastfeeding]…He said men do not have breasts so the women decide when to breastfeed…‘I don’t get myself involved in these things’ (Male, 39).
For other care tasks gendered divisions of labour combined with some men’s perceived lack of knowledge resulted in little physical involvement of men with their newborn babies:
When the baby is very fresh [new], ‘I don’t hold it, because I wouldn’t know how to do that. So, I allow my wife alone to carry the baby’ (Male, 50).
The small number of men who did provide physical assistance participated in cord care under the instruction of a woman or carried the newborn while the mother completed other tasks:
He only assists with applying [methylated] ‘spirit’…on the cord if his wife asks him to (Male, 39).
He assists his wife in bathing the babies by carrying one of them while the woman baths the other (Male, 44, father of twins).
Verbal instruction, support and supervision
Many men claimed involvement in newborn care through verbal instruction, support and/or supervision but often prefaced their comments by stating a lack of knowledge surrounding newborns. Men gave general reminders to complete tasks such as traditional cord care, keeping the baby warm and breastfeeding rather than offering specific advice:
From the little advice I know about child care, I tell her to practice them. For example if he realises that the baby is not covered well or is not wearing a sweater, he tells the wife to do it well or put a sweater on him from catching cold (Male, 20).
Only one male participant encouraged his wife to specifically adopt exclusive breastfeeding:
He learnt that babies should be fed exclusively that is why he insisted that his wife should practice that (Male, 28).
Whereas men’s roles in most care practices were less active or ambiguous, it was common for men to bear a large responsibility in the care seeking and remedy of
asram - a traditionally diagnosed and treated newborn illness widely believed not to respond to hospital treatment [
29]. Men consistently sought out
asram medicine from traditional healers and sometimes supervised the woman’s administration of the medicine:
The man plays a major role and makes sure that wherever that medicine to cure the child is could be found to help the child survive (Male, 39).
If the man brings the [asram] medicine he has to see to it that the woman uses it to treat the child. ‘Some women are lazy so if you don’t supervise them, they would not do the right thing’ (Male, 20).
Men’s active role in asram could be related to the need to purchase medicine which falls into their traditional role of provider described below.
Men also perform a supportive role by accompanying their wife and child in seeking care during or after delivery or running errands during delivery to purchase supplies at the instruction of traditional birth attendants or women’s mothers:
He’d also accompany his wife to send an asram baby to the hospital. Likewise, he’ll accompany his wife and a sick baby to the hospital to ensure that they get a better treatment (Male, 44).
The cord was cut with a new razor blade her mother in law sent her husband to buy when labour progressed (Female, 20).
Provider and decision maker
The most prominent ways in which men were involved in newborn care stem from their role as head of household defined by participants as a “duty” (FGD1) and “traditional responsibility” (FGD2) to ensure the welfare of mothers and children. Involvement as a husband/father was in some cases perceived as an obligation with moralistic undertones:
As a man, your wife and children’s welfare should be very important to you…Making sure proper treatment is given to your sick wife or newborn shows how responsible you are (Male, 37).
Two sub-themes emerged that define the traditional responsibilities of men: decision maker and provider. These intertwined roles are heavily facilitated by money in a mutually reinforcing relationship. Men are expected to provide money for the needs of women and children and at the same time, because men control money as head of household, they also assume the role of ultimate decision maker:In reality this role of decision maker was often symbolic during delivery with women taking many of the decisions and having the power to order husbands to run errands or assist in seeking care at a facility in the case of complications:
Every proper married woman should listen and do accordingly everything her husband tells her to do (Male, 37).
If there were any complications she [the woman giving birth] would take the decision for her to be taken to hospital. The husband will go and look for a car and the cost would be borne by him (Female, age unknown).
Even where women make decisions men are ultimately held responsible for any “problems” and the potential to be blamed or incur monetary cost was a motivator for some men to provide verbal instruction, support and supervision:
Regular antenatal attendance is better than waiting until something happens only for husbands to be blamed or harshly spoken to (FGD1).
He makes sure that the babies are breastfed well when he hears them crying and well-dressed to keep them from catching cold, because ‘If I don’t and they fall sick it’s going to be another wahala [trouble] for me’ (Male, 44).
Decisions that usually fell to men were around care seeking for illness, as this bore a monetary cost, and around asram, as this required leaving the house to seek medicine:
Men are the sole decision makers on [when a sick woman or newborn goes to the clinic] because the man has to look for money to send the woman and the baby to the hospital if they are sick (Male, 20).
The decision to go to the hospital would have been taken by the husband as he would have bared [sic] the cost (Female, age unknown).
As providers men were expected to attain money for the needs of women and children. A man’s authority as head of household was preserved and reinforced through his ability to provide for his family:
When a man is unable to meet his wife’s request due to financial constraints, the latter tends to ignore what he tells her (FGD 1).
While a few women used their own savings for some or all of the purchases related to newborn care supplies, the majority of women and all men reported that men alone paid for delivery costs, newborn care supplies and care seeking:
It is the man’s responsibility to start looking for money for the woman immediately after the woman informs him of the pregnancy… (Male, 39).
They [men] said [when a sick woman or newborn goes to the clinic] it is the duty of the husband. They give the women money to go to the hospital. (FGD2).
Potential for increased involvement
Some men already encourage or engage in positive behaviours in collaboration with their wives including exclusive breastfeeding, institutional birth, and joint decision making. For example, one participant and his wife insisted on exclusive breastfeeding even when faced with strong community resistance:
He decided with his wife how the baby should be cared for. He cited the exclusive breastfeeding instance again where he had a lot of resistance from the community members including his mother-in-law but he ignored them because he knew what he was doing (Male, 28).
Many men expressed a desire, some very enthusiastically, to play more of a role in their newborn’s care and health. Increasing involvement in specific care practices was not discussed by male participants but some did mention increasing their handling of newborns because they wanted to “assist” or “give their wife a rest”. A lack of knowledge was frequently cited as the reason for current non-involvement and some men were motivated to learn more about their newborns to enable them to be involved:
He’d like to be involved in visits [by community health workers] himself to learn more about how to handle babies when they’re very small (Male, 50).
He…would want to be taught more…so that he can be able to take much care of his newly born child in order for his wife to have enough time to rest (Male, 45).
Many men also cited work- and money-related reasons for their inability to be involved. These were associated with lack of time, a need to make money and provide for the family as head of household and that involvement itself may have monetary implications:
He would have liked to be involved but because of the nature of his work…he wouldn’t even be at home to decide with them [his wife and mother-in-law]. He has to go and look for money to care for his wife and children because if he stays at home and they fall sick he cannot get money to send them to the clinic (Male, age unknown).
I would like to be more involved if only I have money to do that…if you get yourself involved and the woman asks you to provide money, you can’t say no (Male, 39).
He would not say or suggest anything [about giving birth at a facility] because if he does the woman would ask him for money (Male, age unknown).
Spaces closed to male influence are often reinforced by females, most especially the women’s mothers, highlighting generational power dynamics and the strong influence of elder women which can make it difficult for men to involve themselves in newborn care even if they are motivated. Many women had their mothers stay with them or traveled to their mother’s homes sometime during pregnancy, birth, or the postpartum period. Men expressed frustration with the dominating influence of some mother-in-laws and were discouraged from involving themselves in decision making processes because their contributions were disregarded. Some couples could make decisions together only after the mother-in-law ‘handed over’ authority:
When the baby is very young the woman’s mother would bath him for the first month and later hand him over to the mother. That is when the man can decide with the woman when to bathe the child (Male, 20).
Sometimes we [husband and wife] discuss something together and when [the women] meet their mother they take a different decision and they would not even tell you that this is what they have planned. It is very annoying so we just look at them to do what they like (Male, 39)
Some male participants’ attitudes towards increasing involvement in newborn care were not conducive to forming equitable, male–female partnerships to negotiate power, authority, and decision making. Rather, these attitudes towards increased involvement threatened to reinforce gender hierarchies and suggest negative impacts on women and/or the possible use of force:
The wife always takes his advice. If she doesn’t take it he will divorce her (Male, 27).
‘She would take it [my advice]! Why wouldn’t she take it?’ exclaimed one of the older participants who stressed that as a husband he has authority over his wife, and thus could not imagine why the latter should not take his advice (FGD1).
While a section of participants will use sustained persuasion and education [to get their wives to adopt new practices] other said they will use threats if persuasion fails (Males, FGD2).