Introduction
Antenatal care (ANC) is important for the health of the mother and the development of foetus because it links the woman and her family with the health care system which may increase the chance of using a skilled attendant atbirth and contributes to good health through the life cycle [
1]. Men’s involvement in ANC has potential to reduce delays in decisions to utilize antenatal health care services. In African countries, men’s involvement in ANC has been shown to increase utilization of maternal health services [
2‐
6]. Before the 1994 International Conference on Population and Development in Cairo, reproductive health programmes were focused on women’s health viewing men as non-actors whose role was irrelevant [
7]. Recently, however, there has been increasing attention on the role of male participation in women’s reproductive health after recognizing that men’s attitudes, knowledge, and behavior can strongly influence women’s health choices [
8‐
12].
Despite the call for men’s involvement in maternal care, men are rarelyinvolved in their partners’ care during pregnancy [
13]. The main reason for this lack of involvement is that reproductive health has largely been viewed as a women’s concern [
14‐
16]. Recent scholars have raised the point that many men may not be prepared to participate in antenatal care [
17] and that ANCsettings create barriersfor male involvement [
18‐
22]. Inadequate male involvement in ANC can lead to persistent increases in maternal morbidity and mortality [
23], because men hold the decision making power on where and when women should seek health care services, particularly in African settings [
5,
10,
24].
Sub-Saharan Africa has the highest maternal mortality ratio of about 510 maternal deaths per 100,000 live births [
25].In Tanzania, 2014 estimates indicated7,900 maternal deaths and a maternal mortality ratio (MMR) of 410 per 100,000 live births, which is a decline by 55% between 1990 and 2013 [
25]. Although Tanzania has madeprogress in reducing MMR, the rate was far from the target of the fifth Millennium Development Goal of reducing MMR to 230 per 100,000 live births by 2015 [
26]. As the Millennium Development Goals have now changed to Sustainable Development Goals [
27], more efforts are needed to achieve the target of reducing MMR to less than 70 per 100,000 live births by 2030 [
28].
Causes of maternal deaths have been well studied [
29]. In Africa, South of Sahara these causes can be closely linked with low female socio-economic status as well as lack of decision making opportunity among women about their health care and over household budget [
30]. Men’s involvement can potentially impact the first two delays in maternal care. First, the delay in making a decision to seek health care which may be caused by under-estimation of the severity of the problem and the need for male partners’ approval to seek care, commonly reported among women in developing countries [
24,
31,
32]. The delay in reaching a health care facility may be associated with a lack of money for transport as well as other health care related costs in which women depend on a male partner. An earlier report showed that 42% of women in Dodoma Region reported that lack of money for transport was a barrier for timely access of health care services [
31].
Awareness among men on pregnancy related problemsand their complicationsis very low [
33], this may consequently limit their scope of involvement in maternal care. In Tanzania, men rarely help their wives/partners in infant care and household chores during the maternity period and those who do are culturally portrayed as being effeminate and weak [
34]. Little has been documented in Tanzania, particularly in Dodoma Region regarding the level of men’s involvement in ANC. This study aimed at assessing the level and the factors influencing men’s involvement in maternity care during antenatal period in Dodoma Region.
Discussion
Generally, more than half (53.9%) of men had high level of involvement in ANC. The level of involvement in this study is higher than findings from other studies [
6,
41]. The difference observed could be due to a difference in methods employed to construct the involvement level as well as study setting. For example, previous studies were hospital based while the current study was community based. The high level of men’s involvement in ANC in this study implies the effectiveness in implementing safe motherhood initiatives which emphasizes on male involvement in the region [
29]. The initiative integrates men’s involvement in maternal health particularly in individual birth preparedness, and prevention of mother to child transmission of HIV [
29]. The multivariate analysis revealed that exposure to information regarding men’s involvement in ANC was the strongest factor influencing men’s involvement in ANC, as it has been described in other studies [
37,
41‐
43]. It is more likely that, exposure to ANC information has a great potential in addressing misconceptions and myths that hinders men from being involved in maternal care. Other scholars suggested that men who know the danger signs of pregnancy are more likely to act fast to save the lives of their wives when complications arise [
44].
By and large, more than half (63.4%) of the men reported to accompany their partners, at least once, to an antenatal clinic visit. This is consistent with previous studies in Uganda and Nigeria where the proportion of male involvement in ANC was 65.4 and 63% respectively [
45,
46]. Shared cultural values on gender roles among African societies could explain the observed similarities in these findings [
14‐
16].In this study more than half of respondents who accompanied their partners to an ANC visit reported to spend more than one hour in health care facility waiting for services. This is likely to discourage men from coming to ANC in subsequent visits. Studies done in other parts of Africa show that the longer the time spent waiting for services, the less the chances are for men to be involved in ANC services [
4,
47,
48]. Time spent in accompanying spouses to ANC services could have more implications to male involvement in ANC among employed men. Findings from the current study showed that having employment was negatively associated with the level of men’s involvement in ANC. Men who are in the paid workforce, are often not in a position to spend virtually the entire day participating in ANC services [
41].
Thus, health care providers and program implementers should take appropriate action to advocate and encourage men’s involvement in ANC. During ANC, pregnant women and their partners are given health education. This may result in a greater outcome on maternal health behaviors compared to when women receive this education alone [
5]. It is understood that education and health services provided during the antenatal period have the potential to reduce pregnancy and delivery complications and improve birth outcomes [
49]. Thus if men and women miss this opportunity during ANC, it is not surprising that Sustainable Development Goal number three is not achieved.
Surprisingly, our study has revealed a negative association between the perception of participants on the attitude of health care providers toward men who accompany their partners to ANC and the level of men’s involvement in ANC. Participants who perceived positive attitude of providers had low odds of involvement compared with those who had a negative perception. This finding was not expected but could be explained in terms of the protective nature of men towards their partners whereby those who had a negative perception may accompany their partners as a way of protecting them from providers with a negative attitude. However, further studies are needed to explore in depth the perception of men on provider’s attitude towards men’s involvement with ANC in settings where gender roles are still highly observed in caring for pregnant mothers.
This study found that the majority of men (89.0%) reported that they made joint decision with their partners regarding ANC. This finding differs significantly from previous studies where joint decision making within couples was reported as low as 9% in Nigeria () and 28.6% in India [
50]. The reason for this variation could be due to the effect of cultural differences and limited exposure to safe motherhood initiative programs. In this study, 63% of men reported to have accompanied their partners to ANC visit at least once. Continued health education given to both women and men at RCH clinics coupled with the influence of safe motherhood initiatives including ongoing media campaigns such as the
WazaziNipendeni Project may have further contributed to high male involvement which ultimately increased couple’s joint decision making on ANC issues. This could further explain the high proportion (77.3%) of men who reported to offer support to their partners including relieving them from some of the household chores during pregnancy. Previous studies have reported low proportion of men offering such support to their partners [
7,
50‐
53]. It has been observed that involving partners in maternal health care and encouraging joint decision-making among couples may provide an important strategy in improving men’s involvement and couples empowerment [
39]. This study therefore, stresses the need for health care providers, voluntary groups, religious and community leaders, to encourage inter-spousal communication during sensitization of the community on the importance of men’s involvement in ANC.
This study revealed that religion was an important factor for men’s involvement where men of the Christian faith reported relatively higher involvement in ANC than their Muslim counterparts. Studies conducted in Nigeria and Cameroon had similar findings [
15,
47]. Future intervention should address religion as an important platform for implementation. Factors such as male user friendly ANC services should be emphasized, to address some of the religious values including having a separate space for men accompanying their spouses to ANC clinics [
15,
47] to minimize risk of intermingling between clinic attending non-spousal men and women.
Providers need to be trained on culturally sensitive provision of care to men accompanying their spouses to ANC clinic. In this study only 23.5% of men accompanying their partners reported getting a chance to discuss maternal health issues with the providers. These findings imply that majority of men who accompanied their partners to ANC (63.4%) did not have contact with health care providers of their partners. Apart from infrastructural barriers including shortage of providers and limited space in the consultation rooms, providers may have limited competence to provide culturally sensitive care to accompanying male partners [
37,
38,
41,
54].
This study provided some important information on men’s involvement from a large group of participants in four districts of the Dodoma Region. Therefore, it may be possible to generalize the findings to the whole region. However, there are a few limitations that need to be mentioned. The study assessed only four variables for men’s involvement in ANC, while the variable men’s involvement is complex. It needs to be assessed by a combination of several variables. The combination of other variables such as financial support for ANC, arranging transportation for delivery, planning for a potential blood donor, involvement in decision making of the location for delivery, accompaniment to the place of deliverycould improve the accuracy of the measure. Although the study included men with children aged less than two years, the issue of recall bias and the fact that pregnancy issues may not have as much importance to the male partners as they do to the female may limit the study findings. Additionally there are chances that, social desirability could have played a negative influence on men to disclose their involvement in maternal care issues especially given the cultural context of gender roles in the study area.
Future research should explore men’s expectations of ANC services and test ways to meaningfully integrate them in couple friendly ANC services. Also there is a need to assess the cultural competency of care providers in attending male partners accompanying their spouses for ANC services. Factors such as religion were observed to significantly influence men’s involvement in ANC. Therefore, there is a need for studies to explore potential barriers that are strongly connected to religious beliefs and see how religion could be effectively used as an avenue for testing health promotion interventions including appropriate media messages targeting men’s involvement in ANC and other reproductive health services.