Barriers to and attitudes towards promoting husbands’ involvement in maternal health in Katmandu, Nepal

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Abstract

Couple-friendly reproductive health services and male partner involvement in women's reproductive health have recently garnered considerable attention. Given the sensitive nature of gender roles and relations in many cultures, understanding the context of a particular setting, potential barriers, and attitudes towards a new intervention are necessary first steps in designing services that include men. In preparation for a male involvement in antenatal care intervention, this qualitative study specifically aims to: (a) understand the barriers to male involvement in maternal health and (b) explore men's, women's, and providers’ attitudes towards the promotion of male involvement in antenatal care and maternal health. In-depth interviews were conducted with fourteen couples and eight maternal health care providers at a public maternity hospital in Katmandu, Nepal. Additionally, seventeen couples participated in focus group discussions. The most prominent barriers to male involvement in maternal health included low levels of knowledge, social stigma, shyness/embarrassment and job responsibilities. Though providers also foresaw some obstacles, primarily in the forms of hospital policy, manpower and space problems, providers unanimously felt the option of couples-friendly maternal health services would enhance the quality of care and understanding of health information given to pregnant women, echoing attitudes expressed by most pregnant women and their husbands. Accordingly, a major shift in hospital policy was seen as an important first step in introducing couple-friendly antenatal or delivery services. The predominantly favorable attitudes of pregnant women, husbands, and providers towards encouraging greater male involvement in maternal health in this study imply that the introduction of an option for such services would be both feasible and well accepted.

Introduction

Couple-friendly reproductive health services and male partner involvement in women's reproductive health have attracted considerable attention in recent years. The promotion of such services, however, is complex and highly sensitive. Among the most prominent concerns are the imposition of Western standards on gender roles and ideals, the reinforcement or perpetuation of patriarchal domination, the safety and confidentiality of women, and the resource diversion from women's reproductive health programs. To understand better the complexities surrounding the endorsement of male involvement, this qualitative study specifically aims to: (a) understand the barriers to male involvement in maternal health; and (b) explore men's, women's, and providers’ attitudes towards the promotion of male involvement in maternal health, particularly during pregnancy and childbirth.

In an extensive review of men's roles in women's reproductive health, Dudgeon and Inhorn (2004) examined studies in the fields of medical anthropology and public health and reported that the influence of men in decision-making and positive impact of including men in health services have been seen in the fields of family planning, sexually transmitted infections and HIV, abortion, and infertility. The authors pointed out the relative scarcity, however, of information on men's intentions and practices as they relate to pregnancy and childbirth, stating that, “more qualitative research…is needed to include men as a major part of women's social environments in both pre- and post-natal health” (Dudgeon & Inhorn, 2004, p. 1388). One of the few in-depth investigations of the roles of male partners in maternal health was conducted in rural Guatemala. Carter (2002) found that, contrary to negative stereotypes about husbands’ roles in maternal health, male involvement in maternal health in Guatemala was both relatively high and desirable. Some of the most commonly cited reasons for this involvement included the provision of love and support for wives and husbands’ paternalistic tendencies, while factors such as low knowledge levels, work demands, and barriers imposed by midwives were important obstacles to male involvement. Little is known regarding barriers to and attitudes towards male involvement in maternal health in other settings, including South Asia.

A wide array of castes and ethnicities, as represented by over 70 languages and dialects, make Nepal's population of 23 million people extremely diverse. This heterogeneity manifests itself in varying gender norms and customs throughout the country, particularly as the experience of gender has been suggested to differ by caste group (Cameron, 1998). Generally, women in Nepal have a low social status that often directly and indirectly manifests itself in women's poor health outcomes. The 2001 Nepal Demographic and Health Survey (DHS) indicates that 36% of women in urban Nepal have no formal education, considerably higher than the 14% of men lacking such education. Women experience low decision-making power, particularly in regards to decisions that directly impact their own health. In urban Nepal, 60% of women have no say in making decisions about their own health care. These decisions are instead dominated by their husbands (Nepal 2001 DHS), a pattern confirmed in several studies of Katmandu Valley populations (Matsuyama, 2002; Mullany, Hindin, & Becker, 2005).

With one of the highest maternal mortality rates in the world (539/100,000 live births) (UNDP, 2004), Nepal's maternal health situation is in great need of improvement. Although approximately one in two women in the country and 82% of women in urban areas receive antenatal care (ANC) from a health professional (Nepal 2001 DHS), 89% of deliveries nationally (Nepal 2001 DHS) and 20–40% of deliveries in metropolitan Katmandu take place in the home (Bolam et al., 1998). Nutritional disparities and heavy workloads of women are important indicators of the role that gender plays in determining maternal health outcomes. According to traditional Nepalese cultural norms, “women have to cook and serve food to all other household members before eating themselves, and then eat only whatever is left…even during pregnancy” (Gender Workshop Report, 1994, as cited in Shakya & McMurray, 2001). Gittelsohn (1991) observed that the intra-household food allocation patterns among Nepalese families put females (especially pregnant and lactating women) at particularly high-risk of low intake of energy and micronutrients. Similarly, the expected physical work activities for women are considerably more extensive than for men, including numerous family and household responsibilities from which the man is exempt, and certain chores are culturally viewed as strictly ‘feminine,’ such as fetching water (Matsuyama, 2002).

According to a recent report in Nepal, “addressing men's roles in supporting safe motherhood through behavior change communication activities” is a top priority in reproductive health programming (Engender Health, 2003, p. vii). Such programming cannot move forward unless a greater understanding is achieved regarding potential barriers to positive male involvement in maternal health and about women's and men's attitudes towards the promotion of male involvement, particularly whether and how women want male partners playing roles in their pregnancy, labor and delivery. Finally, the attitudes of health service providers must be assessed in order to engage in effective dialogue about the implementation of services that include men.

This qualitative study, conducted in preparation for an intervention trial of male involvement in antenatal care, describes barriers to and attitudes towards male involvement in maternal health in urban Nepal, as described by pregnant women, husbands, and maternal health care providers. Given that out of wedlock birth is rare in urban Nepal (Nepal 2001 DHS) and this study's particular focus on male partners of pregnant women, we use the terms ‘husband’ and ‘male’ interchangeably.

Section snippets

Methods

In-depth-interviews (IDIs) and focus group discussions (FGDs) were conducted with married, second-trimester pregnant women receiving antenatal services at Prasuti Griha Maternity Hospital (PGMH) between May and June, 2003. PGMH, the largest maternal health care center in Nepal and predominant maternal health provider in Katmandu Valley, is a government-funded hospital with a total catchment population estimated at 1.1 million people and 16,000 annual deliveries (MIRA/UNICEF, 2000). Over 98% of

Results

Fourteen couples and three additional women (whose husbands could not be located at home) participated in the IDIs, and 17 couples and six additional women (whose husbands were unavailable to participate due to job constraints) participated in the FGDs. At the time of the interviews and discussion groups, female participants were on average 23 years old and at 27 weeks gestational age, while their husbands were on average 27 years old. The majority of women described themselves as housewives

Discussion

Understanding the context-specific barriers to and attitudes towards the introduction of a new health or behavior change activity is a crucial step in designing appropriate and applicable interventions. The findings presented in this paper provide important new information regarding barriers that, until now, have prevented men from providing more positive support and involvement during their wives’ pregnancies. The results also suggest that education services could mitigate these obstacles by

Acknowledgements

This project was made possible through a Hopkins Population Center Dissertation Fieldwork Grant, awarded by the Andrew Mellon Foundation, and a grant awarded by the Bill and Melinda Gates Institute for Population and Reproductive Health. I extend my gratitude to Dr. Stan Becker and Dr. Michelle Hindin of Johns Hopkins Bloomberg School of Public Health for their guidance; Dr. Bimala Lakhey of Prasuti Griha Maternity Hospital for her collaboration and invaluable insight; Mrs. Darshana Shrestha

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