Background
The importance of involving men in reproductive, maternal and child health programs has gained increasing recognition since the mid-1990s when key international conferences in Cairo and Beijing highlighted the tremendous benefits that actively engaging men can have for the health of men, women and children [
1‐
7]. In many contexts worldwide, men tend to be the decision makers within families and heavily influence decisions regarding contraception and STI prevention; the allocation of money, transport and time for women to attend a health centre for antenatal care or to give birth; nutrition and workload during pregnancy; and health care for children [
6,
8,
9]. Yet men are often unable to make informed choices in such matters because they have been excluded from reproductive, maternal and child health services and education. Research suggests that efforts to engage men can positively influence birth spacing and use of contraceptives [
10‐
14], maternal workload during pregnancy [
15,
16], birth preparedness [
17,
18], postnatal care attendance [
19], and couple communication and emotional support for women during pregnancy [
10,
14,
15,
20]. In addition, research into the influence of husbands and fathers on health-related behaviours suggest that building men’s knowledge regarding maternal and child health may be beneficial in terms of care-seeking for pregnancy and birth [
21‐
31], infant feeding practices [
32‐
36], childhood immunisation [
37], and care seeking for childhood illness [
24,
34,
38].
In the Pacific region, many countries have made significant progress on improving reproductive, maternal, newborn and child health in the past decade [
39]. However, the burden of poor maternal and child health remains heavy. The Millennium Development Goal (MDG) Region of Oceania, which includes Pacific Island countries such as Fiji, Kiribati, Papua New Guinea (PNG), Samoa, Solomon Islands, Tonga and Vanuatu, has the second highest maternal mortality ratio by region in the world, with 187 deaths per 100,000 live births [
40]. This region has an under 5 mortality rate of 51 per 1000 live births, more than double the regional MDG target for 2015 [
41]. In line with growing international recognition of the important role of men in maternal and child health (MCH), some Pacific national MCH policies now highlight the importance of engaging men – particularly fathers and male partners – in health education and clinical services related to MCH [
42‐
44]. However, literature regarding MCH service provision in the Pacific rarely mentions men or fathers, and the scant research focusing on men’s involvement in MCH suggests that, in practice, expectant fathers and fathers of young children are rarely engaged in MCH-related services [
45,
46]. While several studies have explored community and health worker perceptions of male involvement in MCH in the Pacific [
45‐
48], less is known about the views of senior MCH policymakers and practitioners (referred to here collectively as ‘MCH officials’). This paper explores the attitudes and beliefs of senior MCH officials regarding the benefits, challenges, risks and approaches to increasing men’s involvement in MCH in the Pacific region.
Methods
Semi-structured, in-depth interviews were conducted with senior MCH policymakers and practitioners working in the Pacific, between September 2011 and March 2012. The Pacific region is defined here in line with the MDG region of Oceania [
49], which includes the Cook Islands, Fiji, Kiribati, Marshall Islands, Federated States of Micronesia, Nauru, Niue, PNG, Samoa, Solomon Islands, Tokelau, Tonga, Tuvalu, and Vanuatu. The knowledge, attitudes and beliefs of senior MCH officials about men’s involvement in MCH in the Pacific are likely to influence practice in MCH services. Given the dearth of information currently available, a qualitative study design employing in-depth interviews using standard question guides was employed to build our understanding of this topic.
Study participants
We sought to include senior MCH officials working in the Pacific region [
49]. Senior MCH officials were defined as any senior policymakers working within national health departments and working on national MCH policies or plans, senior public hospital staff specialising in MCH, senior university staff involved in health worker education and training, or representatives of regional or national non-government organisations working on MCH issues. Participants were identified using ‘snowballing’ techniques: the first round of contacts (seeds) were identified by searching attendee lists of regional maternal and child health conferences and personal contacts of authors, and then by asking interviewed contacts to nominate other appropriate senior MCH policymakers and practitioners for interview.
We sent email invitations to 33 individuals to participate in this research. Of these, 18 participants responded to invitations and agreed to be interviewed, including: four senior staff members at departments of health, five participants from UN agencies (WHO and UNFPA), five senior hospital staff, two senior university staff, one from a regional NGO and one from a regional network. Participants and their organisations represented the region (4), or a specific country in the Pacific, including Cook Island (1), Fiji (1), PNG (8), Solomon Island (3) and Vanuatu (1).
Data collection
Three interviewers conducted in-depth interviews with participants using a standard question guide. Interviews were conducted via telephone or, where possible, in person. Sixteen individuals participated in verbal interviews, and two participants providing written responses to interview questions. Of the verbal interviews, 14 interviews were conducted individually with just one participant present, while two participants from the same organisation preferred to be interviewed together. Interviews took between 30 and 60 min and addressed i) potential benefits, ii) challenges, iii) risks and iv) opportunities for increasing men’s involvement in MCH clinical and education services in the Pacific region. All interviews were conducted in English and key points and quotations recorded by hand.
Data analysis
Interview notes were initially reviewed based on broad themes of interest, namely: potential benefits of greater involvement of fathers in MCH clinical and education services; challenges in engaging more with fathers; possible risks associated with greater father involvement in MCH; and opportunities for involving fathers in MCH. Subsequent analysis of interview notes involved inductive data-driven coding of the text to identify and synthesise recurrent issues in the data. Data was coded manually by two authors (WH and JD), and all coding reviewed by a third author (JV), with any differences in coding resolved through discussion. Relevant quotations have been used to illustrate themes in the presentation of study findings.
Discussion
Understanding the views of senior MCH policymakers and practitioners is important in designing and implementing context-specific, appropriate strategies to increase male involvement in maternal and child health in the Pacific. This research revealed strong agreement amongst policymakers regarding the benefits of involving men in MCH, including increased use of clinic services by women and children, increased use of family planning, and allowing men to support practices that promote MCH and challenge those behaviours that are detrimental to MCH. Such findings are in keeping with international findings regarding the greater decision-making power [
24,
50] and low health knowledge of men [
3,
24,
50], and their greater openness to new information about their role as husband and father during significant life events such as pregnancy and the birth of a child [
47,
51,
52].
Participants in this study also reported beliefs that including men in MCH services may have benefits for men’s own health. In many settings, men have very little contact with the formal health system, particularly for preventative services, and prefer to seek curative services from a traditional healer or pharmacy [
53]. For men, as for women, pregnancy and early childhood provides an opportunity to link parents to the health system. Efforts to engage men in MCH education and clinical services should therefore seize opportunities to provide men with information and services related to their own health. Health workers and educators providing men or couples with information on health during pregnancy and postpartum should routinely provide men with information about healthy behaviours to reduce the risk of both communicable and non-communicable diseases. Men accompanying their female partner to antenatal or postnatal clinics should also be offered testing and treatment for STIs and other infections. In all cases, men should routinely be provided with information on men’s health services available locally.
While all MCH officials participating in this research described clear benefits of greater male involvement in MCH in terms of health outcomes for women and children, many participants identified substantial barriers to engaging fathers in MCH education and clinical services. Barriers to father participation in MCH highlighted by MCH official in this research, including the belief that it is inappropriate for men to actively participate or take an active interest in MCH, and men feeling embarrassed or uncomfortable attending clinical services with their partner or child, are similar to findings from male involvement research with community members and health workers elsewhere in the world [
37,
47,
50,
52,
54‐
61]. Importantly, participants in this study tended to conceptualise interventions to engage men in MCH as requiring men to attend clinical services with their female partner. However, promising findings from the international literature, that may be applied in Pacific contexts, suggest that men can be encouraged to take a more active, positive role in MCH using alternative strategies such as men-only group talks or one-on-one peer-education [
10,
62‐
65], community meetings [
66‐
68], distribution of information, education and communication materials [
13,
16], or mass-media campaigns [
18,
64,
65,
67,
69,
70]. These types of community-based interventions, as well as school-based programs, may also be appropriate in Pacific contexts in which many first pregnancies are unplanned and where first pregnancies are often the first point of health education for couples, a challenge highlighted in this study.
Despite these sociocultural challenges to male involvement in MCH, MCH officials consulted in this study tended to report beliefs that many men in the Pacific would welcome greater involvement in MCH education and clinical services. This finding is in line with the results of other qualitative research in Laos [
52], South Africa [
71], Uganda [
72], and PNG [
47]. In other contexts where MCH education and services are considered ‘women’s business’, simply inviting male partners to attend antenatal clinics, via a written letter, has been effective in making men feel more welcome and increasing couple attendance [
73], particularly when invitations are tailored to local health concerns [
74]. Our findings that the attitudes of some staff, inadequate numbers of male staff and lack of training for all staff on how to engage men in MCH, also suggest that engaging men needs to feature in health worker recruitment and training. While the attitudes and capacity of health workers has been identified as a barrier to male involvement in other research [
45,
47,
50,
52,
58], training and support to all health workers, and recruiting male staff, can facilitate engagement of men in maternal and child health [
4,
6,
59,
75]. In clinics, providing waiting areas and consultation spaces that men feel comfortable in, or separate spaces for men, was recommended by many of our participants and has proven effective in other contexts [
76,
77]. Changes such as providing a separate entrance or waiting area for men, or displaying posters, magazines or educational DVDs that target men can make clinics less daunting and more educational for men.
Some of the changes suggested here to make clinics more ‘father-friendly’ require health service providers to have a more welcoming attitude towards fathers attending the clinic and to be mindful of the needs of fathers, but will require minimal additional resources. Other initiatives, such as changes to recruitment and training of health workers or changes to clinic infrastructure are likely to have more substantial resource implications. Considerations of resource constraints is particularly important given that many participants in this study expressed concerns regarding the ability of already over-stretched health staff and infrastructure to cater to expectant or new fathers, a perceived barrier found elsewhere [
50]. Health service providers are unlikely to embrace new approaches, regardless of effectiveness, if they present an added burden that exceeds capacity. These findings underscore the need for holistic approaches to men’s involvement in MCH, that build awareness regarding the benefits of engaging fathers in MCH, while also building health system capacity to engage and serve men.
Substantial variations in social, cultural, policy and resource environments across the Pacific mean that there is unlikely to be one approach to engaging men in MCH appropriate to all communities or countries. Rather, a range of strategies is required. While Pacific actors can draw on the global evidence regarding effective approaches to engaging men in MCH, our finding suggest that concerted, policy-level efforts to increase men’s engagement in MCH clinical and education services is unlikely to occur in this region, until Pacific-specific, context- and resource-appropriate strategies for engaging men have been pilot-tested and proven feasible, acceptable and effective. Several MCH officials participating in this research expressed support for program strategies that work within or build upon cultural norms that support maternal and child health. Building on cultural norms such as men’s role in caring for their family, can be an effective strategy for encouraging improved health behaviours. For example, research shows that men socialised to be the providers and protectors of the family can be encouraged to share decision-making more equitably with their female partner when the benefits of doing so to the health of their families are clear [
11,
13,
14,
17]. Furthermore, if supported adequately, many men will challenge traditional practices that might endanger their partner’s health [
71,
78]. Importantly, a systematic review of interventions to improve gender-based inequality and equity in health conducted by WHO found that programs that seek to address gender-inequalities that lead to poor health outcomes are often more successful than those that simply accommodate or work around gender inequalities [
67]. In Pacific contexts, initiatives that work with both men and women in examining prevailing gender norms and roles and the impact these have on health, while also engaging men to play a positive role in supporting the health of their female partners and children, may therefore be most effective in improving MCH outcomes. In most settings, initiatives to address underlying gender-inequalities that lead to poor health are unlikely to be implemented through the formal health system, requiring partnership with non-government organisations working to improve MCH and gender equality.
When asked about potential risks associated with involving men more in MCH, some participants spoke of the potential for some men to use their involvement in MCH services to exert control over choices and information usually controlled by women, a concern highlighted elsewhere in the world [
6,
67,
79]. Additional risks of including men in clinical services include women feeling less free to discuss confidential information with health workers, the risk of violence or divorce when men learn information about their partners’ STI, HIV, contraceptive or other health status, or unintentionally dissuading women from attending services when they cannot bring a male partner [
53,
79‐
82]. Programs that seek to increase men’s engagement with MCH should therefore explicitly delineate men’s rights to information and services verses women’s rights to privacy and autonomy. Men have a right to information and services that will affect their own health and that will enable them to avoid behaviors that may pose a risk to the health of their partners and children. However, men should not automatically be allowed to participate in maternal health consultations or be given access to the personal health information of their female partner, unless their partner consents to this. Efforts to engage men in MCH – whether through community-based or clinical services – should also carefully avoid unintentionally giving the impression that men should be the sole decision-maker regarding issues related to MCH. Findings of this study and the international literature underscore the need to involve women in program design, to pilot test communication materials and strategies, and explicitly promote equitable couple communication and decision-making for health [
6,
67]. Programs to engage men in MCH clinical services must also allow women to choose how and when male partners are present and involved in maternal health clinical services. Health workers providing MCH care should routinely ask women if they would like their male partner to join the consultation, or in the case of antenatal care, give pregnant women an invitation that they have the option of passing on to their male partner to attend subsequent antenatal visits.
This study has some important limitations. Only 17 out of 33 people invited to participate did so, while the remainder of invitees did not respond to our invitation. This may be a source of selection bias because those self-selecting to participate may be more supportive of male involvement in MCH than those who declined to participate. Non-respondents did not give reasons for not participating, therefore we are unable to further examine this possible source of selection bias. Use of ‘snowballing’ as a selection strategy may have led to bias because participants might be more likely to recommend additional participants that they know are supportive of engaging men in MCH. Finally, the researchers have previously advocated publically for greater health service engagement with fathers and this may have influenced both participant recruitment and induced participants to provide socially desirable responses.
Further research and dissemination
Most senior MCH policymakers and practitioners participating in this research articulated a range of benefits that would result from greater male involvement in MCH. This suggests that evidence-based, context-specific strategies that have been pilot-tested for feasibility and acceptability are likely to be well received by senior MCH officials and that, provided these strategies are resource-appropriate, advocacy to increase men’s engagement with MCH education and clinical services may gain traction at least at the senior levels. A search of the published literature reveals no rigorously evaluated male involvement intervention in this region and no quantitative studies of the health benefits of male involvement for mothers and babies. These findings indicate that (1) better dissemination of known impacts of male involvement is needed and (2) rigorously evaluated Pacific-specific male involvement pilot projects or trials which measure the impact on health outcomes may be valuable in encouraging action at the policy level. Policymakers and planners consulted in this research consistently highlighted the importance of locally appropriate strategies for increasing male involvement, designed on a strong understanding of local cultural and social norms. Program design is therefore likely to benefit from sound formative research into the knowledge, attitudes and practices of local communities and health workers, and from formative research to test the feasibility of strategies prior to implementation.