Women’s empowerment and male involvement in antenatal care: analyses of Demographic and Health Surveys (DHS) in selected African countries

Empowering women and increasing male involvement in maternal health care-seeking are both viewed as important strategies to reduce preventable maternal morbidity and mortality worldwide [1‐3]. Each year, roughly a third of maternal deaths worldwide are directly related to inadequate care during pregnancy [1], and complications during pregnancy can result in acute and chronic maternal morbidity [4, 5]. Focused antenatal care, including identification and management of infections and obstetric complications, connects a woman and her household to formal health services and increases the likelihood of her giving birth with a skilled attendant [1, 6]. Antenatal care visits are an ideal time to advise mothers and families on essential pregnancy care to reduce stillbirths and neonatal deaths, and develop a birth preparedness plan [1]. In sub-Saharan Africa, approximately 69% of pregnant women receive at least one antenatal care (ANC) visit, and 44% receive at least four ANC visits and the full package of key interventions [1]. In addition to physical and health systems barriers, in many settings, women’s low status negatively impacts utilization of antenatal care services. As compared to men, women often lack decision-making power to allocate resources for health-care seeking [7, 8], particularly in contexts where men determine whether and under what conditions their spouses will use health services [9, 10]. This can prove problematic particularly in households where men underestimate the importance of antenatal care [1, 11]. Even following ANC consultation, women’s limited means and authority to implement healthy home practices have hindered development goals.

Global efforts to empower women have aimed to redress gender-based inequalities by implementing programs to increase opportunity, control, and inclusion for women [12]. Empowered women, particularly those who are more autonomous, have increased pregnancy health care-seeking [13, 14], are more likely to have skilled delivery attendance [13, 15], utilize modern contraceptive methods [16, 17], and have lower infant mortality [18]. At the same time, there has been increasing emphasis on encouraging greater male participation in women’s health [19, 20]. Inviting men to accompany women to ANC is considered an important strategy for reducing maternal morbidity and mortality by enabling them to sufficiently prepare for birth and avoid care-seeking delays for obstetric emergencies [21‐23]. Men’s involvement in ANC is also intended to encourage husbands to support women’s care from pregnancy, to delivery, and throughout the postnatal period [1]. Research suggests that men’s presence during ANC can improve uptake of institutional deliveries [23], postnatal service utilization [24], and spousal communication [25]. However, socio-cultural norms that define pregnancy as a woman’s domain as well as health systems factors such as poor health worker communication and low male representation among staff have been shown to discourage men’s participation [11, 26].

Although in theory the two strategies can work synergistically, in practice they may result in opposing processes and outcomes. Women’s empowerment initiatives typically involve raising the status of women and shifting the gender balances of power [12, 27], while male involvement programs are meant to result in shared decision-making and the adoption of new male norms for constructive engagement [28]. However, in some cases, such programs have been criticized for inadvertently bypassing efforts to empower women and taking advantage of men’s superior status to achieve program goals [29]. Tensions exist, and there is little empirical evidence on the relationship between women’s empowerment and male involvement. Researchers describe a range of possible scenarios [30]. One constitutes the ideal situation where women’s autonomy and male involvement reinforce one another [30]. Less ideal situations occur when empowering women excludes male partners or involving men undermines women’s preferences [31].

No study to-date has examined links between women’s empowerment and male antenatal involvement in sub-Saharan Africa. In some communities, male partner attendance to ANC is rare, and empowering women may result in even fewer instances of engaging spouses [21, 32, 33]. In contrast, given that male social norms often discourage accompanying spouses to ANC [34], more empowered women may be better equipped to persuade spousal participation during pregnancy [3, 34, 35], or such behaviors may reflect emerging norms among couples exposed to recent health campaigns [9, 36, 37]. Understanding differences in male involvement by levels of women’s empowerment can help inform strategies aiming to address poor maternal health outcomes resulting from women’s unequal status and low spousal engagement.

To our knowledge, this study is the first to-date to examine the relationship between women’s empowerment and male antenatal accompaniment in sub-Saharan Africa. We build upon prior analyses by including a composite empowerment measure in addition to examining the direct contribution of three dimensions (economic, socio-familial, and legal), using analytical methods that account for differences in individual, partner and household characteristics. Most studies examining women’s empowerment have focused on a single country or up to four countries. However, this analysis provides a more geographically diverse sample of eight countries using country-specific estimates to inform our understanding across the region. Key findings indicated that male ANC accompaniment was not uncommon. However, we observed mixed results regarding the association between women’s empowerment and male accompaniment to ANC. In some settings, women’s empowerment was positively and significantly associated with increased odds of male attendance, predominately in the economic and legal domain. However, this relationship was not universal. In several cases, no associations were observed or negatively associated in which more empowered women were significantly less likely to have their spouse’s presence at ANC. The analysis’ mixed results of positive, negative, and null associations reveal several important programmatic and research implications.

First, the significant positive association of women’s empowerment with male involvement is encouraging as it suggests increasing women’s participation in economic and legal domains works synergistically with male involvement strategies meant to enhance shared decision-making. Positive associations were found in overall empowerment in Uganda and Burkina Faso, and in the economic empowerment dimension in Burkina Faso. In these countries, women who had a say in more decisions on use of household resources were more likely to be accompanied to ANC by their spouses as compared to women who were less often included in these decisions. This pattern is similar to those observed by Mullany et al., [30] in Nepal where joint-decision making among women was significantly associated with greater male participation during pregnancy. Reasons for this positive association in our study may be that more empowered women were more likely to negotiate and involve their male partners in prenatal care-seeking. It is also possible that couples accustomed to shared decision-making in other life domains were more likely to view pregnancy care as a shared domain. In addition, women who were sole decision-makers may also be more capable of soliciting spousal antenatal assistance than women excluded from participating in other aspects of family life. Conversely, women with limited say or participation may select not to invite spouses who may otherwise restrict their care-seeking choices. In a recent review, Ditekemena et al., [34] found that some African women feared violence from spouses who accompanied them to ANC, particularly as a result of antenatal HIV testing. The significant positive observations imply that male involvement efforts may benefit from both empowerment initiatives that promote women’s participation in social and economic spheres and male-centered approaches that focus on new male norms. In addition, increased male involvement in ANC may spur changes in social norms for women and men. Such efforts may be most impactful in settings where women’s empowerment scores are lowest, as was the case in Burkina Faso.

A second implication relates to the significant negative relationship between empowerment and antenatal accompaniment in Malawi. The negative trends in Malawi were observed among all empowerment dimensions, although the relationship was only significant for the combined and economic empowerment scores. Thapa & Niehof [31] also found in Nepal that increased women’s autonomy was associated with lower likelihoods of husband’s presence at ANC. In our analysis, one explanation for the reverse relationship could be that women with greater participation in health care and household decisions, including asset ownership, saw less of a need to invite spouses to ANC. It may be also that such an invitation was viewed as unnecessarily overlapping with women’s roles. Kululanga et al., [55] found in Malawi that some women viewed male involvement in pregnancy as a “foreign concept” and synonymous with an infringement on “territory they did not want men to invade”. Thus, women with more influence in household matters may also be more likely to voice and achieve their preferences. This suggests that enabling women and their partners to identify potentially beneficial and acceptable norms of male participation during pregnancy may assist in implementing approaches that do not undermine women’s autonomy. Alternatively, higher empowerment scores could indicate male partner absence, such as a spouse who works abroad, where women alone bear the burden of decision-making out of necessity – which is not the aim of empowerment approaches. Kululanga et al., [55] also found in Malawi that male involvement programs were sometimes perceived as unfair to unmarried or otherwise single women and perpetuated cultural norms that men were superior. In this regard, male involvement strategies may more appropriately empower women by identifying other peers or relatives who can assist in preparing for birth and support women’s continuity of care throughout the postpartum period.

A final implication relates to the lack of significant findings in Burundi, Mozambique, Rwanda, Senegal, and Zimbabwe. In Rwanda, an overwhelming majority of men reported accompanying their wives to ANC – the highest male attendance rate compared to other countries, while Burundi had the lowest accompaniment rate. Our findings suggest that the pervasive male norms in these settings are not substantially impacted by women’s empowerment status. Another possible explanation for the null findings may be that Rwanda and Zimbabwe also had the highest total women’s empowerment scores compared to other selected countries. For example, while empowerment scores were highest in Zimbabwe (6.3 out of 9), only a third of men reported attending at least one antenatal check-up with their spouse. Zimbabwe also had the highest proportion of women receiving all four recommended ANC visits as compared to other selected countries, which could indicate a stronger cultural norm that defines pregnancy as a woman’s domain. Male involvement in these countries may reflect other social and health systems factors not captured in the DHS empowerment measure.

Additional qualitative research may provide more in-depth understanding of the contexts driving the different associations between women’s empowerment and male antenatal accompaniment. Qualitative methods could also assist in examining whether there is indeed no association between women’s empowerment and joint antenatal care-seeking, or whether women’s empowerment aspects which are linked to male involvement were unmeasured in this analysis. Measuring a latent construct such as empowerment across a range of contexts is inherently challenging, and it is possible that different meanings and manifestations of empowerment were unable to be captured by the DHS. Some researchers have increasingly questioned the adequacy of DHS empowerment measures for use in sub-Saharan Africa, particularly since the items were developed based on experiences and conceptual models drawn from Asia [35, 49]. It is worth noting that in our analysis none of the socio-familial empowerment items were associated with male ANC accompaniment. Do & Kurimoto [35] also found that DHS sociocultural empowerment measures did not predict contraceptive use in the study’s four African countries [35]. This suggests that such indicators, as measured, may not signify empowerment or are not related to male partner engagement in African settings. Rather, supplemental qualitative research could inform the development of more culturally relevant and sensitive measures of women’s empowerment and its dimensions in African settings that often have less restrictive gender norms. Future research might also examine the extent to which male antenatal accompaniment mediates or modifies the relationship between women’s empowerment status and improved reproductive health outcomes.

This study is the first to-date to examine the relationship between women’s empowerment and male antenatal accompaniment in sub-Saharan Africa. Our findings contribute to the existing literature by providing positive and negative empirical evidence on the relationship of potentially synergistic and opposing women’s empowerment and male antenatal accompaniment. However, results were mixed. Several null associations suggest that more qualitative and longitudinal research is needed to inform the development of locally relevant measures of women’s empowerment and its dimensions in African settings.