Background
Maternal mortality is a public health challenge worldwide. In 2015, 303,000 maternal deaths were estimated to have occurred globally [
1]. Nearly all of these deaths occurred in low resources countries [
1]. In Tanzania, the reckoned maternal mortality ratio was 556/100,000 [
2], meaning that for every 1000 live births, about 5 women died due to pregnancy-related causes which amounted to 8000 maternal deaths per year. Therefore, Tanzania was categorized to be among the countries in Africa with the highest maternal mortalities.
Low male involvement in maternal services utilization in low resources countries has been cited as one of the factors contributing to high maternal mortality in these countries [
3]. Male involvement in maternal services utilization has been expressed as a practice of social and behavioral change that is needed for men to take more responsibility in maternal services utilization with the focus of ensuring women’s and children’s health [
4].
There are complex behavioral and cultural factors influencing male partner’s involvement in the care of their expecting wives/partners in Tanzania [
5]. The evidence indicates that efforts that embrace male partners and uphold gender-equitable relationships between men and women are more efficient in producing behavior change than narrowly focused interventions [
6].
The practice of male involvement in developing countries including Tanzania remains unacceptably low [
7‐
9]. The previous study was done by Sokoya Masunmola et al., [
10] has reported that although both men and women are in support of male involvement during pregnancy and childbirth surprisingly very few men were involved in maternal services utilization. The low male involvement practice could be rooted in cultural gender roles where pregnancy care and childbirth are believed to be women’s responsibility [
3] while men’s responsibility is to provide financial support [
5].
The effect of gender roles and responsibilities does matter in actual male involvement in maternal services utilization in low resources settings including Tanzania [
5]. It has been a norm in rural settings that pregnant care, childbirth, and post-delivery care are solemnly responsible for women [
5]. The responsibility of the male partner is to provide financial support [
5]. The trend in low resources settings is now struggling to change from the traditional maternal services delivery from addressing a pregnant woman to addressing couples. If pregnant women understand and accept positively on involving their male partners in maternal services utilization, the state of male involvement in maternal services utilization will improve dramatically.
As well, pregnant women’s negative attitude towards male involvement [
8] is among the barriers towards male involvement. The negative attitude is due to three aspects, the perception that pregnancy and childbirth are the responsibility of women [
5,
8], avoiding negative stereotyping [
8], and fear male involvement may decrease their superior power and end up being insecure like women [
8].
Studies have also reported unfair reproductive health programmes for women without partners as a contributing factor for low male involvement in maternal services utilization [
9]. This means the struggle to bring male partners in maternal health services utilization must go hand in hand with creating male-centered services. It should go beyond physical presence. Although the center of care is a pregnant woman, a man should feel involved by either his vital signs taken or given health education specifically for him. Tanzania is among the countries with low male involvement in maternal health services especially the rural communities [
10]. There is a direct relationship between male involvement and cultural beliefs which means that the societal perception and beliefs about male involvement do affect male involvement [
11]. When there is a cultural belief that disapproves of the involvement of male partners in maternal services utilization, there is low male involvement despite educational interventions and mobilizations to improve male involvement.
Male partners may be willing to learn their roles in maternal services utilization but the existing perception that pregnant care issues are solemnly responsibility of women may act as a barrier towards their involvement in maternal services utilization [
12,
13]. This study invested in studying the attitudes perceived subjective norms and perceived behavior control towards male involvement in maternal services utilization among pregnant women.
According to
the Theory of Planned Behavior, behavior intention is influenced by three predictors which are attitude, subjective norms, and perceived behavior control [
14]. Attitude is influenced by individual beliefs and the evaluation of behavioral outcomes. The perceived subjective norms are the way a pregnant woman perceives her society approves of disapproves male involvement in maternal services utilization. If she perceived her society approves for her to be accompanied by her male partner, she will act in favor of male involvement but if she perceives her society disapproves of the act then she will act accordingly. The perceived behavior control is influenced by control beliefs and perceived power.
Therefore, there was a need to determine pregnant women’s attitudes, perceived subjective norms, and perceived behavior control towards male involvement in maternal services utilization. The study also went further to explore factors that are associated with attitudes, subjective norms, and perceived behavior control towards male involvement in maternal services utilization.
Discussion
Male involvement in maternal services utilization has been recognized as an effective strategy for the improvement of birth outcomes [
18]. Many studies have reported male involvement and factors which influence male involvement focusing on males themselves [
8,
9,
19]. Pregnant women’s attitudes, subjective norms, and perceived behavior control towards male involvement in maternal health services is an important behavioral aspect which if well addressed has the potential to improve male involvement. A female partner may act as a barrier towards bringing men to pregnancy care and childbirth. Their attitude, perceived subjective norms, and perceived behavior control matters a lot in their intention to have their male partners with them in maternal services utilization [
5].
The study found that majority of pregnant women had a negative attitude, perceived subjective norms, and perceived behavior control towards male involvement in maternal services utilization. Age at marriage predicted all three domains of intention, attitude, perceived subjective norms, and perceived behavior control. The attitude towards male involvement in maternal services utilization was also influenced by pregnant women’s level of education and her economic status. In addition to age at marriage, the perceived behavior control was also influenced by pregnant women’s intention to be accompanied by her male partner. These findings are discussed hereunder.
The high proportion of pregnant women with negative attitudes towards the involvement of male partners in maternal health services utilization could be rooted in cultural beliefs and traditions and customs [
5,
19]. Traditions and customs in most African cultures have assigned the role of pregnancy care and childbirth to women (Antenatal women and their mother and mother in law). In with accordance to
Theory of Planned Behavior, the attitude towards a certain behavior can be influenced by the belief an individual has on the behavior and the way an individual evaluates the outcome of the behavior [
13]. When pregnant women evaluate the outcome of male partner’s involvement in maternal health services utilization to have no contribution to the desired outcome, their attitude disregards male involvement in maternal health services utilization. Innovative interventions are highly recommended in this low resource setting to sensitize pregnant women on the benefits of male involvement in maternal health services utilization.
Likewise, the majority of pregnant women had negative perceived subjective norms towards male involvement in maternal health services utilization. This means that majority perceived that their community disregarded the accompaniment of their male partners in maternal health services. This perception is also stemmed from community beliefs and traditional gender roles [
5,
19]. It sends a signal that insisting pregnant women come with their male partners during maternal services utilization alone without addressing their norms may delay male involvement in maternal services in our context. The effect of societal pressure on male involvement in maternal services utilization may act as a barrier towards male involvement in maternal services utilization. Innovative interventions are recommended to sensitize the community on the benefits of male involvement in maternal services utilization.
Similarly, the majority of pregnant women had negative perceived behavior control towards male involvement in the utilization of maternal health services. They perceive that they cannot bring their male partners in maternal health services utilization. Based on the
Theory of Planned Behavior, perceived behavior control is influenced by control beliefs and perceived power [
13]. Perceived behavior control could be affected by the low socio-economic status of the study community where a male partner has to engage in work to earn money for family sustainability.
The study found that factors which influence pregnant women’s attitude towards male involvement were age at marriage, education status, and economic status. Pregnant women who were married at the elder age were more likely to have a positive attitude towards male involvement in maternal health services than those who were married at a younger age. The possible reason for this finding could be that women who were married at a younger age did not have the opportunity to be exposed to formal education as compared to those who were married at an older age. Exposure to formal education can dilute the cultural beliefs of a woman which may influence power relations between men and women [
20].
Pregnant women who had primary education were 1.7 times more likely to have a positive attitude towards male involvement than pregnant women who had no formal education. The finding is in line with a previous study which has reported a direct relationship between education and male involvement in maternal services utilization [
20].
The study further noted that pregnant women who earned at least one dollar per day were 1.5 times more likely to have a positive attitude towards male involvement than pregnant women who earned less than one dollar per day. This could be poor women are concerned about their husbands engaging in earning work to sustain their living rather than participating in pregnancy care. A similar finding is reported by a previous study which reported that family earning do influence male involvement [23].
Age at marriage predicted the perceived subjective norms towards male involvement in maternal services utilization. Women who were married at the elder age were more likely to have a positive perception of societal approval for male involvement than women who were married at a young age. This finding could be women who are married at a younger age are less likely to have exposure to other societal cultural practices as they grow in the same culture. Those married at the elder age could have exposure to both education and travels to different places.
The age at marriage also influenced the perceived behavior control towards male involvement in maternal services utilization. Similarly, pregnant women who were married at the elder age, perceived to be able to be accompanied by their male partners for maternal services utilization. This could be because pregnant women who were married at a younger age could have stronger cultural attachment than those married at an elder age.
It was also found that pregnant women with the intention to be accompanied by their male partners were more likely to have positive perceived behavior control than those without the intention to be accompanied by their male partners.
This study used baseline data from an intervention study where control and intervention were compared. The two samples were treated as one sample after comparing the outcome variables (attitudes, subjective norms and perceived behavior control) and found no significant difference existed between the two groups. Intervention group participants were matched with control in a ratio of one to two. Even though in both cases random sampling was employed, our analysis may have suffered bias from differences in sampling probabilities in the two groups. There is a chance that some group is over represented than the other so may limit the generalizability of findings. To minimize the effect of this limitation, the participants were matched (5 years age groups and parity). The study also included robust of background information (ethnicity, economic status, exposure to media, education level, covered with health insurance, religion) in the data collection tool and were included in the analysis to adjust for the confounders.
Both groups came from rural districts of Rukwa region. Because rural Rukwa districts share similar cultural and social economic status, our findings can be generalized within rural Rukwa and other rural settings within Tanzania with similar characteristics.
Conclusion
The study indicated that aged women are more likely to have a positive attitude, subjective norms, and perceived behavior control towards male involvement in maternal services than young pregnant women. Pregnant women with primary education, who earned more than a dollar per day were more likely to have positive attitudes towards male involvement than their counterparts. The intention to attend maternal services with their male partners significantly influenced positively the perceived behavior control. The study recommends a community based interventional study to address the community beliefs and traditional gender roles in maternal services utilization to improve pregnant women’s attitudes, subjective norms, and perceived behavior control towards male involvement in maternal services utilization. Behavior theory integrated interventions to address deep-seated predictors of male involvement and health-seeking behaviors have not been well explored in the existing literature. To understand and address such factors there is a need for innovative high-impact interventions that utilize theories, to address modifiable predictors of intention to engage in a behavior (Attitude, subjective norms, and perceived behavior control. The findings from such studies can be useful in shaping antenatal care interventions such as male involvement in maternal services utilization.
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