(Mis)measuring men’s involvement in global health: the case of expectant fathers in Dakar, Senegal

In 2010, Lu and colleagues asked, “Where is the F in MCH?” [1] referring to research on father involvement in Maternal and Child Health (MCH). More than ten years later, there is much research about the influences that fathers have on child health and development [2]. Researchers have found that fathers have positive impacts on children’s cognitive development [3‐5], peer relationships, risky behaviors, and decreased odds of incarceration [6‐11]. In 2019, the National Home Visiting Resource Center (NHVRC) noted that father involvement supports attachment and promotes children’s emotional regulation [12]. With respect to male involvement in home visiting programs, fathers self-report “improved knowledge of child development and positive parenting,” “better anger management,” and “greater connects to employment, educational opportunities, and other community services” [12]. In a systematic review, Tokhi and colleagues found that men’s involvement interventions have mostly positive effects on care-seeking, couple relationship dynamics, and home care practices [13]. The authors point out that while interventions may produce these positive effects, it remains to be seen whether these effects are mechanisms of reducing maternal morbidity or mortality.

In 2018, the United States Agency for International Development (USAID) released a report titled “Does Men’s Involvement Improve the Health Outcomes of their Partners and Children?” (henceforth “DHS 64”). In order answer their question, Assaf and Davis, the authors, draw on a well-known model from health promotion, “knowledge-attitude-behavior” [14] (Table 1). In the report, “men’s involvement” is defined using three independent variables: “correct knowledge, positive attitudes, and supportive behaviors toward the health of their partners and children” [15]. While the authors do not define knowledge, attitudes, or behaviors, the variables are operationalized and derived from the most recently available Demographic and Health Surveys (DHS) data from 33 countries as follows:

These independent variables were compared to the following outcome variables:

Overall, with respect to Senegal, Assaf and Davis found the following: In the case of correct knowledge, 39.1% of surveyed Senegalese men knew to give water to a child with diarrhea while only 10.7% had correct knowledge of women’s fertile period. In the case of the positive attitudes, Senegalese men do not generally agree that contraception is only a woman’s business (88.9%), nor that using contraception leads one to become promiscuous (67.5%). In the case of supportive behaviors, Senegalese men were among the least likely to be present during an ANC check-up (20.6%) or discuss family planning with health workers (5.6%). Senegalese men ranked fairly low (27^th) among those who decide with their partners how to spend men’s earnings (19.3%). The implication of these findings is that Senegalese men are uninvolved in women’s health, although DHS 64 was not conclusive that men’s involvement was causative of women’s and children’s health outcomes.

In this article, I argue that Assaf and Davis’ findings (i.e., that Senegalese men are uninvolved) are both true and deeply flawed. My long-term ethnographic study demonstrates that Senegalese men are in fact a key component of antenatal care, and that Assaf and Davis’ findings are limited by the operationalization of “men’s involvement” using a Eurocentric, biomedicalized set of indicators that privilege positivist measurement. After a brief explanation of how long-term, ethnographic methods provide a unique window into the lives of Senegalese expectant parents, I will discuss the cultural context of the entourage and gendered expectations therein. I will then explain what it is Senegalese men are expected to do and what they are not expected to do. In the discussion, I build on the work of Luis Avilés’ 2001 critical discourse analysis [16] of a 1994 USAID report, Epidemiological Profile of El Salvador to argue that development discourse which emphasizes Eurocentric metrics are still present almost 25 years later. I will highlight that the care and support activities men are expected by their families and communities to do are unseen by instruments like the DHS, while the things they are not expected to do are measured by those same instruments. This occlusion of local contexts results in studies such as DHS 64 which find men to be uninvolved when, in actuality, they are involved. I will argue that such formulations of family dynamics and, in particular, masculinities only serve to perpetuate harmful stereotypes of men in LMIC. I conclude that this case is yet another example of the urgent need for global and public health engagement with local stakeholders and ethnographic researchers who can assist in the development of context-dependent and culturally appropriate metrics, program objectives, and goals.

The findings of this article come from an ethnographic study conducted in Dakar, Senegal over 12 months in 2018. The purpose of the study was to examine the ways that expectant fathers involve themselves in antenatal care, what they are expected or encouraged to do by their partners, families, social networks, and the State, and how they navigate these activities in light of the social expectations of masculinity. The findings of this study come from data collection methods including semi-structured interviews [17, 18] and participant-observation [19]. All interviews were conducted in Wolof, Peul, or French, transcribed in French by the author or the two research assistants, and thematically team-coded using MAXQDA12 [20].

In his critical discourse analysis of a USAID Epidemiological Profile of El Salvador [26], Luis Avilés writes,

“These implicit rules [of discourse] are based on the notion that knowledge and power implicate each other. The exercise of power requires the production of certain types of knowledge, while the production of knowledge requires the exercise of power to validate its assertions” [16].

The implicit rules of discourse, knowledge, and power are interlaced into the design and execution of DHS as well as the limitations it places upon the possibilities for operational definitions in reports like DHS 64. Discourse is also mobilized when the inherent values of such a report are reproduced by its dissemination. In DHS 64, the purportedly global values placed on family are heterosexist, monogamous, nuclear, and fully dependent on a specific set of gender stereotypes that make no room for the generative and creative possibilities of non-European networks of kinship and care. Avilés writes of the Eurocentricity that is deeply interwoven into development discourse such that, simply put, “Europe is the model to emulate” [16]. So too do such globalized formulations, not just of family but of masculinity, perpetuate longstanding deficit-based discourses of Black and Brown men in LMIC [27, 28]. Furthermore, they ultimately do nothing to address or bring attention to the historical and political determinants of women’s and children’s health [29].

USAID’s characterization of men as “uninvolved” was a surprising revelation to the Senegalese physicians, midwives, mothers, fathers, and Ministry of Health officials in this study who unanimously viewed men as an integral part of women’s and children’s health. It was apparent to many that the authors of DHS 64 had never been to Senegal to examine the topic of their report. One physician remarked that USAID could not see the deep level of men’s engagement that I was seeing. One midwife noted with irony that there were men who went above and beyond and wished they could do even more for their pregnant partners. The key findings of this article demonstrate why Assaf and Davis’ operationalization of “men’s involvement” is not sufficient for understanding the full picture of how (or whether) Senegalese men are involved in contributing support and care for women’s and children’s health. Further, without a holistic view of what Senegalese men are expected to do or are actually doing, there can therefore be no reliable analysis of whether local expectations have a positive effect on health outcomes.

I speculate that an intervention based on findings like those in DHS 64 would have harmful downstream effects on both women’s and children’s health, as well as future public health research and practice. Such interventions would likely fail by attempting to address issues that are not only not viewed as problems locally, but are accepted as assets of local gender and kin norms. As Lucia Guerra-Reyes’ work [30] demonstrates, global health interventions that ignore local contexts in favor of culturally inappropriate global metrics can be a source of physical and emotional coercion of pregnant women and their families, as well as overwork or redundancy for care providers, all in an effort to meet project goals. Such interventions, frustratingly, would also fail to address the issues that local stakeholders agree are harmful determinants of women’s and children’s health, such as a lack of hospital resources and fair wages for staff. These political determinants, as Avilés writes, are beyond the purview of development organizations like USAID [16], and it therefore makes sense why the authors are disincentivized from considering historical contexts of poor health. This study reveals an urgent need (though by no means new [31‐33]) for global and public health engagement with local stakeholders and ethnographic researchers who can finely-tune context-specific operational definitions and program objectives and goals in line with local needs.

As it relates directly to this study, Assaf and Davis report in DHS 64 that men are not likely to be present during ANC visits or discuss family planning with a healthcare worker. While my ethnographic data support both of these findings, they do not support the implicit conclusions of such global health logics that Senegalese men are therefore uninvolved in women and children’s health. Senegalese men are involved in women and children’s health in ways that the DHS does not track. The numbers simply do not tell the whole story.

In this article, I have demonstrated that in Senegal, antenatal care roles and responsibilities are distributed among a small network of kin-relations called the entourage. As a part of this entourage, expectant fathers are relied upon to find money to pay for the added expenses of pregnancy and to provide emotional support – often the two overlap. Pregnant women, their mothers-in-law, and midwives all agree that these responsibilities are critical to the health and wellbeing of women and children, and yet almost none of them serve as indicators of “men’s involvement” in global health literature, nor can they be measured by current indicators in the DHS.

I have also demonstrated that Senegalese men do not undertake the forms of care and support that Assaf and Davis call “involvement” because those responsibilities are not theirs to act upon, nor would it be financially feasible for most Senegalese.

Finally, I have demonstrated that Eurocentric measures of men’s involvement, while ostensibly universal, are so narrow as to be impractical for intervention. The assumption that, because men aren’t accompanying their pregnant partners to ANC visits, no one is accompanying her reveals deeply entrenched ethnocentric and limited conceptions of masculinity, of family dynamics, and of care. Narrow conceptions of what a father “should” know or do as forms of maternal support are also tied to equally myopic assumptions of nuclear households that presume men are solely responsible for women’s and children’s care. These measures tell us nothing about the relationship between men’s actions and women and children’s health when men are not the only people involved in their care. Like “culture,” kinship is not fixed nor bounded—even in nuclear families (which is a rare occurrence in Dakar). It is important to widen the scope of interrogation to include all meaningful relationships in someone’s life, perhaps approximating what I’ve described here as an entourage or Janzen’s TMG. Measures of men’s involvement can only be meaningful in locally specific, context dependent analysis and practice.