Introduction
Increasing women’s and children’s encounters with effective health services can greatly reduce maternal and child morbidity and mortality in low-resource settings [
1]. According to the three delays model, a seminal framework describing maternal care seeking for obstetric emergencies, there are three types of barriers that can hinder care seeking: 1) a delay in deciding to seek care (affected by perceptions of illness severity or cause, the status of women, distance, ease of transportation, cost, and the quality of care available); 2) a delay in reaching care (affected by distance, road conditions, travel time, and transportation cost or availability); and 3) a delay in receiving care once at the facility (affected by shortages of well-trained staff, drugs, supplies, and equipment, and the ability of the referral system to respond to patients’ needs) [
2]. Men are often implicated in delays seeking emergency or other types of care given that decisions related to seeking care outside the home are often based on the opinion of men and male household heads [
3‐
5]. This level of decision-making authority means that men’s incorrect judgment regarding danger signs, when to depart for a facility, or the need for a facility delivery or referral can delay care seeking and endanger mothers and newborns [
6‐
8].
However, as Davis, Luchters and Holmes described in their 2013 review, engaging men in maternal and newborn health and providing them with knowledge for informed decision-making can contribute positively to the health of their families by decreasing maternal workload, increasing emotional support for women during pregnancy, improving birth preparedness, increasing use of health services during the postnatal period, and improving couple communication [
5]. Furthermore, male accompaniment during antenatal care specifically can positively affect facility-based deliveries and skilled attendance at birth, women’s knowledge about danger signs, and utilization of postnatal services [
6,
9]. Male participation during pregnancy and after childbirth can also lead to a decreased likelihood of maternal postpartum depression [
9]. The positive impact of male involvement is not unique to low-resource settings. In high-resource settings such as the United States, Israel, Great Britain, and Sweden, male involvement has been shown to positively affect children’s cognitive development [
10‐
12].
Men who want to be positively involved in maternal and newborn health can face substantial barriers related to local expectations of male roles. A number of terms for these expectations are found in the literature, including gender ideology [
13], socialization ideology [
14] gender norms, and male role norms [
15], and can manifest in numerous ways. In Nepal [
16,
17] and Tanzania [
18], for example, men reported experiencing social stigma against male involvement. In Malawi, men expressed feeling ignored by facility staff [
19]. Men also described encountering actual or perceived policies restricting their movement and presence where women’s health services are delivered in Nepal [
17], Kenya [
20], Rwanda [
21], and Ghana [
8]. Encountering barriers that limit men’s interactions with their partners and providers can cause men to feel ineffective and uninformed [
22,
23].
The global public health community has recognized the importance of male involvement in maternal and newborn health for decades. Among the most explicit calls for male involvement was a mandate issued at the 1994 International Conference on Population and Development, which had a stated objective “to encourage and enable men to take responsibility for their sexual and reproductive behaviour and their social and family roles” [
24]. More recently, in its 2015 recommendations on interventions for maternal and newborn health, the World Health Organization called specifically for interventions that “promote the positive role that men can play as partners and fathers” [
25].
Despite evidence and calls for action, implementers have struggled to enact programs to increase male involvement due, in large part, to perceptions and implications of gender norms [
5,
26]. Implementation challenges are also linked to a lack of research directly involving men on the prenatal, labor, delivery, and postpartum periods [
20]. Instead, research involving men has focused on HIV prevention and treatment [
27‐
29] and family planning [
30‐
33]. In addition, studies often rely primarily on women’s reports of assumed male perspectives, although relying on women to serve as proxies for their husbands can be misleading; women do not always accurately report their husbands’ opinions about health-related topics [
33‐
35] and husband-wife pairs may report divergent accounts of the same events [
7].
This study draws on interviews with men in Morogoro Region, Tanzania to describe their role in maternal and newborn health care seeking. Data analysis revealed insights from men that align with the three delays model, which has been applied extensively in the maternal health literature, but has received less attention in literature focusing on male perspectives [
36]. We present our findings according to this framework, adding a male-partner perspective on how men can contribute to overcoming each of the delays, and the barriers they face in doing so. In our discussion, we situate our findings relative to the literature on male participation in care seeking, focusing on men’s roles as decision maker, financial provider, and patient advocate. Lastly, drawing from respondent recommendations and conversations in the literature on gender inequity, we provide insights on how to bolster male involvement in maternal and newborn health services.
Discussion
This study highlights men’s descriptions of their engagement along the three delays continuum, including filling the roles of decision maker, financial provider, and patient advocate. As decision makers, men appraise opportunities for their involvement and make financial decisions about care seeking. As financial providers, men evaluate the cost of care versus quality. As patient advocates, men navigate the health system on behalf of their families. We will examine each of these findings relative to the literature, followed by a discussion of the ways in which men’s insights can inform program implementers. We also highlight the importance of considering male-focused program interventions in the context of gender inequity.
Study respondents viewed themselves as accountable for the health of their families, and often highlighted their role as decision makers who draw on available (sometimes inadequate) information. Men described making decisions about their involvement based on the urgency of the situation and on the nature of care sought. They considered routine and non-routine care differently, the latter requiring a higher level of male involvement, which was also found by Kwambai et al. (2013) in Kenya [
20]. Men interviewed also based decisions about their availability for involvement in care seeking on the opportunity cost of leaving income-generating activities. However, our findings show that, when men are not physically present, they nevertheless make essential decisions about care seeking. Similarly, in Ghana and Malawi men outlined plans for birth preparedness, coordinated payment for transportation, arranged financial support from afar, and appointed someone else to help their partner [
8,
39].
Making difficult financial decisions in a context of limited resources emerged as a highly salient issue in this study. Despite challenges, men in Morogoro and across other low-resource settings described removing barriers to access by paying for health services [
53‐
55], procuring or preparing food [
16,
53,
55,
56], arranging and paying for transport to facilities [
16,
19,
20,
53,
56], buying medications [
16,
53,
55], and buying birth kits [
57]. However, similar to men in studies in Ghana, Nepal, and Malawi, men in our study discussed struggling as they gathered and dispensed funds [
8,
16,
19,
56]. A lack of funds, prohibitively expensive care, or inadequate financial preparations meant that men were not always able to fulfill the role of financial provider, a finding documented previously in Tanzania [
7,
18]. Similar to sentiments reported from Malawi, men interviewed in Morogoro were painfully aware that a lack of funds could mean denial of care, and possible death, for a family member [
56].
Findings from this study are consistent with others that highlight the challenges men face regarding the cost of healthcare expenditures and the question of cost relative to quality of care available [
3‐
5,
41,
58]. As financial providers, men are frustrated when they perceive a lack of value in health spending. Respondents often voiced this frustration in relation to having to pay for medications and supplies on top of health service fees and CHF fees, particularly when they understood that a good or a service should be provided for free. This perception of not getting value for healthcare expenditures, especially related to drug and supply availability, can make people less likely to seek care at all, as described in Zambia [
59], or can make men more likely to discourage their wives from using facility-based care, as described in Nigeria [
54].
Dissatisfaction with quality, as appraised through the lens of financial decision making, presents an opportunity for men to also play the role of patient advocate. In our study, men described the need to navigate the health system to find locations that best met their expectations of optimal care. Similar findings in Tanzania presented by Kruk et al. (2008) found that frustration with stock outs at public facilities can drive people to seek care at more expensive but better equipped facilities [
41]. These researchers reported that, of women delivering in a facility, almost half delivered in a mission facility to receive higher quality care, including better availability of supplies, despite having to pay on average four times more on direct medical costs (provider fees, diagnostic tests, supplies, and medications) [
41].
In addition to navigating the health system to locate better quality care, men also help facilitate and advocate for needed care after arriving at facilities. Aarnio, Chipeta, and Kulmala (2013) found that men in Malawi may feel more purposeful during delivery at facilities where they provide financial and other support, compared to home births where they might be less occupied [
56]. However, as described by Kaye et al. (2014) in Uganda and August et al. (2016) in Tanzania, men can still feel ineffective at the facility when their role is not clear [
23,
26]. Men in our study reported taking action by going to pharmacies to buy supplies and medications and being outspoken about problems such as stock outs, long wait times, and quality of care. They tried to enact change by advocating for patients and registering complaints with community and health center officials, a role that can be challenging to assume as shown by men in Rwanda who did not feel empowered to challenge health facility norms and infrastructure limitations [
21]. These findings point to the importance of the active role that male respondents filled when advocating for and facilitating effective care at facilities, especially when we consider that avoiding delays once at facilities is particularly important for reducing maternal deaths [
60]. In fact, though researchers have previously tied male influence to the first two delays of the three delays model [
56], our study explicitly ties the importance of men’s role to avoiding the third delay at the facility level.
Respondent-driven recommendations
Our study reflects others in noting that men would benefit from and be receptive to more education about maternal health, including danger signs and how to prepare for delivery and complications [
54,
56,
57]. This education can be delivered at community and facility levels. At the community level, promising interventions for educating men include peer education, community meetings, and the distribution of educational materials [
5]. Facility-based educational opportunities include promoting and welcoming male involvement throughout the pregnancy, delivery, and postpartum periods and sharing health information with men when they encounter the health system during these care delivery touchpoints [
5,
6,
21,
56,
57]. This promotion of male participation is particularly important considering that a lower level of male involvement in routine services, such as antenatal care (when health messages are often communicated), may be a contributing factor to the lack of health knowledge that men described [
21,
57].
Interventions seeking to shift community norms regarding male participation are also recommended [
18]. As shown by a study in Ghana, when men are seen at the community level as being supportive of facility-based deliveries, women are significantly more likely to deliver at a facility [
61]. Sharing examples from studies like ours of the positive roles men can play in care seeking could thereby contribute to shifting community-level perceptions of male involvement.
At the facility level, our study and others from Ghana and Uganda show that clearly defining supportive roles for men at facilities is important [
8,
23], as is creating male-friendly environments, a finding emerging from research in Ghana, Uganda and Tanzania [
8,
23,
26]. However, for interventions that aim to increase facility-based care through male involvement to have the desired effect of improving maternal and newborn health, confidence in several institutions must be restored. Families need to see that care that is reportedly free is actually free and that savings schemes such as CHFs are honored. Most importantly, the care offered at facilities must be truly effective, affordable, accessible, and of high quality [
54].
Considerations of gender inequity
As a final point, programs implementers should consider interventions that focus on male involvement in the context of gender relations and inequalities. Men’s ability to more quickly address financial or transportation barriers through their control of resources is problematic [
55,
62]. Moving childbirth from the home setting to the more resource-intensive, and therefore more male-dominant, setting of the health facility also has implications for the agency of women during childbirth [
19,
36]. Furthermore, advocating for male involvement can adversely affect women who do not have or are unable to involve their partners because their partners refuse to participate, do not work locally, are abusive, or have passed away. For example, enforcing shorter wait times for couples unfairly disadvantages single women and devalues women’s time compared to men’s [
19,
20,
22]. Even when husbands want to be involved, requirements for their attendance could delay their partners’ receipt of care [
21]. Lastly, women may not want their husbands present during some health services, including physical examinations, delivery, or discussions about sexually transmitted infections [
5,
63].
For these reasons, male involvement should be encouraged alongside efforts to promote women’s autonomy and inter-spousal communication [
16]. Interventions that have not adequately taken gender relations into account have seen negative effects on maternal health care seeking [
26]. It is therefore important that programs engage both men and women in designing and providing feedback about interventions, as well as piloting and revising these interventions as needed [
5].
Study limitations
Response bias and the translation process may limit this study. Social desirability bias could affect our data if respondents provided answers to questions that they thought would be favored by the interviewer. Recall bias could also affect responses when men described events or conversations that occurred in the past. Through probing and rapport building we sought to diminish these biases. In addition, RAs conducted all interviews in Swahili, which were then transcribed, and select quotations translated into English. Though an author re-translated text if discrepancies in translation occurred, it is possible that some nuances were lost during the translation process.
Acknowledgements
The authors would like to acknowledge: the men who gave their time to be interviewed; the data collection team, including Amrad Charles, Emmanuel Massawe, Rozalia Mtaturu, Zaina Sheweji; Ministry of Health and Social Welfare staff, including Georgina Msemo, Neema Rusibamayila and Koheleth Winani; the MUHAS-based team consisting of Switbert Kamazima, Charles Kilewo, Deogratias Maufi, Aisha Omary, and David Urassa; the Jhpiego-Tanzania based team consisting of Dunstan Bishanga, Maryjane Lacoste, Chrisostom Lipingu, Rebecca Mdee, Marya Plotkin; the USAID team consisting of Neal Brandes, Troy Jacobs, Miriam Kombe, Raz Stevenson; the Jhpiego-US team including Eva Bazant, Elaine Charurat, Chelsea Cooper the JHSPH-based team consisting of Jennifer Applegate, Carla Blauvelt, Jennifer Callaghan, Asha George, Shivam Gupta, Amnesty LeFevre, Nicola Martin, Diwakar Mohan. We remember our late friends and colleagues Nicola Martin and Helen Semu with admiration and gratitude.
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