Background
Since the declaration of Millennium Development Goals, there has been an increased attention on women’s health in healthcare research and policymaking. As a key indicator of international development, MDG 5 was dedicated to the reduction of the maternal mortality rate by 75% by 2015. However, progress towards achievement of this goal has been inadequate, a mere 34% decline since 1990, and yet uneven across different world regions [
1]. According to WHO, the developing countries, especially those in Sub Saharan Africa and Asia share a discriminate burden of maternal mortality (respectively 900 and 450 against 9 in developed regions in 2005), which remains the second largest cause of mortality among women of reproductive age in these countries. With about 85% of global population, developing countries altogether account for about 99% all maternal mortality cases [
2]. Moreover, about 97% of all unsafe abortions occur in LMICs which contributes to about 15% of total maternal mortality in these countries [
3]. Statistics on the utilisation of maternal health services (MHS) is equally disheartening. In the developed world about 98% women receive adequate number of ANC services, and skilled birth attendants supervising 94% of the deliveries [
4]. In the LMICs in contrast, about half of all women remain deprived of adequate ANC services [
5]. Two broad perspectives from which researchers attempt to explain this stark difference include the efficacy of healthcare systems such as quality, access and infrastructural barriers [
6,
7], and proximate determinants such as economic, gender, health behaviour and sociocultural barriers [
8,
9]. Among the themes that commonly emerge in the sociocultural context of reproductive health, violence against women (VAW) [
10], and male involvement [
11] have been two very important and challenging ones. In this study, we focus on male involvement and aim to explore the factors associative factors among men in Bangladesh.
The issue of male involvement in reproductive care was first pronounced officially in a conference on Population Development in Cairo held in 1994 [
1]. Since then the number of empirical studies and demand for contextual evidence on sexual and reproductive health seeking behaviour and their determinants have also grown considerably. Research evidence from other South Asian countries suggests that men’s involvement in women’s reproductive care has a crucial role to play to increase the uptake of maternal health services and reduce maternal and infant mortality [
12‐
14]. Reproductive health seeking behaviour of an individual has shown to be a psychological construct affected by various proximal/individual (perception of health, self-efficacy, motivation) [
12,
14,
15] and distal/social influences (social norms and values, belief systems, degree of openness about personal matters) [
16,
17]. There is also lot to accomplish especially in the areas of universal access to reproductive health services, increasing the rate of institutional delivery and adoption of family planning which have shown to be more effective in active presence of male counterparts [
15,
18]. In addition to the rate of utilisation of maternal healthcare service, male participation is also positively associated with pregnancy outcomes. Prior studies have shown that male involvement was significantly associated with reduced odds of postpartum depression and improved utilisation of maternal health services [
6]. In the predominantly patriarchal society as seen across the South Asian region, women in Bangladesh are generally dependent on male counterparts for making decisions on matters as general as their own and children’s healthcare, household purchases and visiting relatives [
15]. Being faced with household power imbalance and having minimized control over resources would generally necessitate for even greater involvement of men in women’s health issues. Apart from that, the longstanding sociocultural view on sexual and reproductive health (SRH) is directed in a way that negatively affects reproductive health communication between partners and understanding each other’s positions regarding such matters [
19,
20]. The depth of perception of reproductive health needs among men and women and their SRH seeking behavior are strongly influenced by the established meanings of reproduction embedded in the society in which they live [
21]. In a qualitative study conducted on a group of Bangladeshi men, participants reported feeling uneasy to discuss reproductive health and STDs related issues with their wives, accompany them to healthcare centres and avoided dealing with reproductive health related complications with service providers [
20]. Similar studies conducted in other countries have suggested in-depth population based studies to explore the underlying causes of inadequate participation of men in reproductive health. However, studies on this topic in the context of Bangladesh is remarkably scare. To this end, we conducted this research with the intention to enrich the literature and facilitate policy making aimed at promoting male involvement in maternal health in the country.
Discussion and policy recommendations
Results of this study showed that only 40% of the men had active involvement in reproductive care, and knowledge and awareness regarding reproductive health was remarkably low. Though most participants knew that women need institutional care during pregnancy, knowledge about timing for pregnancy checkup, contraception and awareness about utilisation of MHS by wife and rate of physical presence in service utilisation was meagre (Table
1). This result is not surprising given the result that one-fifth of the participants had no formal education and only 14.5% attained secondary or higher level education (Table
2). Previous studies have reflected on the importance of husbands’ education on positive reproductive health behaviour [
11,
22,
27]. Poor knowledge concerning SRH is also shown to be associated inadequate communication about reproductive matters among family members and grow a virtual barrier for cross-gender cooperation thereby [
28]. Conversely, better communication on SRH has positive impacts on reproductive health awareness [
29]. Findings of our study suggest that literacy has a crucial role to play in ensuring male involvement in reproductive care which is consistent with prior studies conducted in other south Asian countries [
27,
30,
31]. In Bangladesh, the reserved view towards SRH matters exist largely because there is not enough political incentive and civil society motivation to create room for the subject in the tradition health belief systems. Programs aimed at promoting male participation in reproductive must focus on systematically addressing the social barriers in a culture friendly way to ensure effectiveness and long-term success.
Type of residency also appeared to be a significant determinant of male involvement in reproductive care. The urban-rural divide regarding reproductive health behaviour is explainable by the fact that people in urban areas tend to have higher literacy and socioeconomic status, enjoy better access to healthcare service and receives greater media exposure, all of which are likely to improve health behaviour in general [
32,
33]. In our study, men who reported having the habit of reading newspaper occasionally or regularly had higher participation in reproductive care. Therefore, newspaper coverage of reproductive health information is likely to generate potential benefits. However unexpectedly, we didn’t find any association between electronic media exposure such as TV and radio. This may be due to the increasing number of mobile phone subscribers, rapid expansion of internet and social networking sites, which made the traditional media less interesting especially among urban residents. Despite that, TV and radio programs remain a source of entertainment and pastime for many. In China, watching television was found to be strongly associated with adoption of modern contraceptive methods and the number of children desired [
33]. As the population in Bangladesh is predominantly rural, the media sector should take innovative actions to design TV/radio entertainments more interesting and effective by incorporating health messages into age specific programs to encourage positive attitude towards reproductive health.
Another important contribution of our study is that it found a positive correlation between communication with CHWs about FP programs and male involvement in reproductive care. In Bangladesh, CHWs occupy a crucial position in the continuum of healthcare providers especially in remote areas as the country faces huge human resource deficit in healthcare and poses challenges to meet the population health needs [
34]. Involvement of CHWs has proven the potential for cost-effective services in areas as critical as maternal and neonatal care [
35] and DOTS for tuberculosis [
36]. However, their potential remains far from being fully developed and exploited especially in the domain of reproductive care services. Apart from providing direct healthcare services, CHWs can play a vital role in implementing strategies for changing attitude towards reproductive health in both men and women. Feeing of confusion and embarrassment in physician-patient communication is a common thing while discussing confidential matters among young patients. CHWs can bridge the gap substantially since they are usually recruited from the same environment. As they already have some degree of understanding and intimacy with the local populace, people have the advantage of expressing themselves more easily and thus creating the climate for positive attitude and behaviour towards reproductive health [
29].
Results also indicate that men who learned about FP from CHWs are more likely to be involved in reproductive care which is consistent with the prior studies showing the association between SRH education and positive attitude towards reproductive health behaviour [
20,
37]. Bangladesh government has made several programmatic efforts to enhance community-based educational intervention programs to promote maternal and infant health. However, such programs to enhance reproductive health knowledge would require a different approach to ensure participation of both men and women. Educational programs targeting women’s health education were found to be effective in improving their knowledge and reproductive health behaviour [
38,
39]. Studies have found that SRH educational programs had greater impact on maternal health behaviors when both spouses are involved compared to when only women participated the program [
40]. This finding is supported by the fact that SRH behaviour is actually shaped more effectively by social and institutional interactions instead of individual learning [
14] warrants for increased focus on improving learning by interaction and sharing of information through community based health events. Community programs bear special significance for Bangladesh since school-based reproductive health education program is not yet developed. The consequence runs at household level as parents with inadequate knowledge regarding reproductive health also show reservations towards communicating reproductive issues with children [
28] which presents major constraints towards improving reproductive health knowledge and communication among peers. Community based programs has to be tailored in a way to tackle such obstacles that are not yet implemented in schools e.g. creating positive attitude among parents.
Besides its contribution to the current literature, this study has few mentionworthy limitations. Firstly, we used secondary data, which meant that we had no control in selecting the variables and the way they were measured. Secondly, male involvement was measured in terms of performance on knowledge, awareness and practice levels which are subjective matters and prone to misreporting by the participant and hence may not represent the actual scenario. The DHS survey was conducted in 2011, and prevalence of several factors (literacy rate, level of knowledge and awareness, media use status) might have changed since then.
Acknowledgements
We are sincerely thankful to the DHS Program for providing the dataset which made this study possible.