striving to promote male involvement

7/30/2019 Striving to Promote Male Involvement

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Striving to promote maleinvolvement in

maternal health care in rural andurban settings

in Malawi - a qualitative study

Lucy I Kululanga1,2*, JohanneSundby1, Address Malata3 and EllenChirwa3AbstractBackground: Understanding thestrategies that health care providersemploy in order to invite men toparticipatein maternal health care is very vitalespecially in todays dynamic culturalenvironment. Effective utilization of

suchstrategies is dependent on uncoveringthe salient issues that facilitate maleparticipation in maternal health care.This paper examines and describesthe strategies that were used bydifferent health care facilities to invitehusbands to participate in maternalhealth care in rural and urban settingsof southern Malawi.Methods: The data was collectedthrough in-depth interviews fromsixteen of the twenty health careprovidersfrom five different health facilities inrural and urban settings of Malawi. Thehealth facilities comprised two healthcentres, one district hospital, onemission hospital, one private hospitaland one central hospital. A semi-structured

interview guide was used to collectdata from health care providers withthe aim of understanding strategiestheyused to invite men to participate inmaternal health care.Results: Four main strategies wereused to invite men to participate inmaternal health care. The strategieswere;health care provider initiative, partner

notification, couple initiative and

community mobilization. The healthcareprovider initiative and partnernotification were at health facility level,while the couple initiative was at family

leveland community mobilization was atvillage (community) level. Thecommunity mobilization had three sub-themesnamely; male peer initiative, use ofincentives and communitysensitization. The sustainability ofeach strategy tosignificantly influence behaviourchange for male participation in

maternal health care is discussed.Conclusion: Strategies to invite men toparticipate in maternal health carewere at health facility, family andcommunity levels. The couple strategywas most appropriate but was mostlyused by educated and city residents.The male peer strategy was effectiveand sustainable at community level.There is need for creation ofawarenessin men so that they sustain theirparticipation in maternal health careactivities of their female partners evenin theabsence of incentives, coercion orinvitation.Keywords: Malawi, male involvement,strategies, maternal health, careBackgroundTraditionally, maternal health issues

have predominantlybeen seen and treated as a purelyfeminine matter [1].This was because women getpregnant and give birth.Although mens participation inmaternal and childhealth (MCH) care services is low,they play a vital rolein the safety of their female partnerspregnancy and

childbirth. The exclusion of men fromMCH services


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reinforced the erroneous notion thatpregnancy andchildbirth was uniquely feminine [2,3]and maternityunits as exclusively meant for women

[2]. It has howeverbeen discovered that some womensaccess and utilizationof MCH services depend upon theirpartners[4].A number of studies have highlightedthe importantrole played by men in makingdecisions pertaining tomaternal health issues and called for

male involvementin MCH [4,5]. However, the men lackknowledge on* Correspondence:[email protected] of International Health,Section for Health and Society, Facultyof Medicine, University of Oslo, P.O.Box 1130, Blindern, Oslo 0318,NorwayFull list of author information isavailable at the end of the articleKululanga et al. Reproductive Health2011, 8:36http://www.reproductive-health-journal.com/content/8/1/36 2011 Kululanga et al; licenseeBioMed Central Ltd. This is an OpenAccess article distributed under theterms of the CreativeCommons Attribution License

(http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,distribution, andreproduction in any medium, providedthe original work is properly cited.maternal health issues that limitswomens access to lifesaving treatment [6-8]. On the otherhand, interventionstudies have shown that maternalhealth education

interventions targeting both men andwomen have

proved to increase knowledge in bothmen and women[9-11]; increase health seekingbehaviour among pregnantwomen [9,11]; raise awareness and

use of familyplanning (FP) in the postpartumperiod, and alsoincrease awareness of dual protectionfor STIs [12].Effective strategies to reach men andengage them insexual and reproductive healthprogrammes are healthfacility, couple and community based.These strategies

encourage men to attend antenataland postnatal consultationswhere information on maternal healthis providedto couples [9-12]. Mens participationin antenataleducation programmes has positiveeffects includingincrease in mens reproductive healthand child healthknowledge, high utilization of antenatalcare services bywomen.In Malawi, pregnancy and childbirthhas beenwomens domain and maternal healthcare services havefocused on women, with very littlemale involvement.Literature has shown that attempts toinvolve men in

maternal health care especially ANC,have managed toattract only few husbands [13-15].Strategies that areused to invite husbands to participatein maternal healthcare by health care providers indifferent settings areseldom understood. Therefore, there isneed to understandstrategies that are used to invite men

to participate


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in MCH. This information is importanttoformulate policies that remove barriersto male participation.This study investigated strategies that

are usedto invite men to participate in maternalhealth care indifferent health facilities in rural andurban settings insouthern region of Malawi. While mostmale involvementstudies targeted communities in ruraland urbansettings, this study has focused on theoften-neglected

strategies used by health careproviders to invite meninto the facilities. The aim of this studywas to exploreand describe strategies that are usedto invite men intodifferent health care facilities toparticipate in maternalhealth care of their female partners.MethodsDesignThe design of the study wasdescriptive non-experimentalthat utilized qualitative method. Thedata was collectedusing in-depth interviews that allowedin-depthexploration of the under-researchedarea of the perspectivesof health care providers on strategiesthat are used

to invite men to participate in maternalhealth care [16].The study was part of a major projectthat is focusingon male involvement in maternalhealth care in ruraland urban settings in Malawi.SettingsData was collected from five differenthealth facilities inthe southern region of Malawi. The

sampled health

facilities comprised two health centres,one district hospitaland one central hospital owned bygovernment.Two more health facilities, one

belonging to the ChristianHealthcare Association of Malawi(CHAM) and oneprivately owned were also included inthe sample. Thehealth care facilities were purposivelychosen in order tocapture views from health careproviders from differenthealth care settings. The governmentowned facilities

were Zomba Central Hospital (ZCH),Mwanza DistrictHospital (MDH) and its affiliated healthcentres (Kunenekudeand Tulonkhondo). The CHAM facilitywasMlambe Mission Hospital (MMH) andthe privatelyowned facility was Blantyre AdventistHospital (BAH).Zomba Central Hospital is situated 65kilometreseast of the city of Blantyre. It is ateaching hospital andoffers tertiary level services. Inaddition, it is a referralhospital for 4 surrounding districts and28 health centres.Zomba city has a university campus,but no districthospital and all referrals from health

centres comestraight to the central hospital. It is an800 bedded hospitaland provides specialized obstetric andgynecologicalservices. The obstetric part ismanaged byobstetricians, and general practitioners(medical doctorsand clinical officers), State RegisteredNurse Midwives

(SRNMs) and Nurse MidwifeTechnicians (NMTs). The


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hospital also offers routine MCHservices to the peoplearound its catchment area. Maleinvolvement in maternalhealth care is encouraged especially in

ANC, postnatal,family planning and prevention ofmother to childtransmission (PMTCT) of HIV services.Mwanza District Hospital is located100 kilometresnorth of Blantyre City. The hospitalserves a populationof 93, 000, with an annual growth of4.1%. The districthospital serves as a referral hospital to

the three healthcentres and dispensaries within itscatchment area. Thedistrict hospital also receives referralsfrom health facilitiesin Chikwawa district with which itshares boundary.Furthermore, it receives aconsiderable number ofpatients from border villages ofMozambique and referralsfrom health centres in Mozambique. Italso collaborateswith non-governmental organizations(NGOs)within the district. The district hospitalprovides comprehensiveemergency obstetric care (CEmOC).Generalpractitioners, SRNMs and NMTsprovide maternal

health care services.Data for this paper were also collectedfrom two ofthe districts health centres namelyKunenekude andTulonkhondo. Kunenekude healthcentre is 19 km northof the district hospital and it serves anestimated populationof 15,800, while Tulonkhondo healthcentre

which is 17 km south of the districthospital serves an

Kululanga et al. Reproductive Health2011, 8:36http://www.reproductive-health-journal.com/content/8/1/36Page 2 of 12

estimated population of 14,500. Thehealth centres providebasic emergency obstetric care(BEmOC). TwoNMTs at each health centre providedmaternal healthcare services.Male involvement in reproductivehealth was initiatedin Mwanza district by Ministry of Healthwith the support

from UNICEF in 2004. UNICEFpioneered a projectcalled Male Champion Initiative andthe aim of theproject was to involve more men intheir partnersreproductive health. Men wereencouraged to accompanytheir wives to antenatal clinics whereservices suchas PMTCT are offered.Mlambe Mission Hospital is situated 30kilometresnorth of Blantyre city. It is a 254-bedfacility run by theRoman Catholic Church. The hospitalis one of theChristian Hospital Association ofMalawi (CHAM) facilities.CHAM is an ecumenical, not for profitnon-governmental

umbrella organization of Christianownedhealth facilities. CHAM offers about37% of health careservices in Malawi [17]. Ninety percentof CHAM healthfacilities are located in the ruralsettings of the countrywhere, in most cases, there are nogovernment facilities.Thus, Ministry of Health signed a

contract with CHAM


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to provide free maternal healthcarethrough ServiceLevel Agreements (SLAs). MlambeMission Hospitalsigned a SLA contract with Blantyre

District HealthOffice to enable it provide maternalhealth care servicesto the people around its catchmentarea. In addition,the hospital receives obstetric referralsfrom six governmenthealth centres. The hospital offersANC, labourand delivery and postnatal care. Itdoes not offer family

planning services due to this churchsguiding principles.Family planning clients are referred togovernment andother non-governmental facilities thatoffer the services.An obstetrician, general practitioners,clinical officers,SRNMs and NMTs, offer the MCHservices. The hospitalpolicy also encourages maleinvolvement in maternalhealth care.Blantyre Adventist Hospital is locatedat the centreof Blantyre city. The Americanmissionary doctors ofthe Seventh-Day Adventist Churchestablished the hospitalin 1957. It is a forty bedded private-for-profit hospital.

It offers specialized obstetric care andoperated byan obstetrician, SRNMs and NMTs.Since its inception,the hospital encourages men toparticipate in maternalcare of their wives/partners, includingattendance atdelivery.Participants and recruitmentTwenty health care providers were

approached to participate

in the study. However, the final samplecomprisedsixteen health care providers becausefour refused toparticipate. The reasons for refusal

given by health careproviders included being busy withtheir work and didnot want to use their free time for theinterviews; andbeing tired of participating in studentsresearch. Theparticipants were purposively selectedamong the healthcare providers. Health care providerswho expressed

willingness to participate in the studywere Malawiansworking in the MCH department for notless than 6months. Thus, the selection ofparticipants with individualexperience in MCH and maleinvolvement waspurposeful in order to ensure credibilityof results. Writteninformed consent was obtained andthe health careproviders were guaranteed of theirconfidentiality andfreedom to withdraw from the study atanytime. Theywere also informed that they were freenot to answerany question that they felt notcomfortable to answer.The participants age ranged from 21

to above 50 yearsand four of the participants were male.Professional qualificationsincluded SRNM, NMT and clinicalofficers.Furthermore, their experience in MCHranged from 1to 25 years. Of the 16 participants, 3were from BlantyreAdventist Hospital, 5 from MwanzaDistrict Hospital, 4

from Mlambe Mission Hospital and theother 4 from


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Zomba Central Hospital. Recruitmentstopped afterachieving data saturation [18].Ethical considerationMalawi College of Medicine Research

and Ethical Committeeand the Regional Committee forMedical andHealth Research Ethics in Norwayapproved the study.In addition, permission to collect datawas obtainedfrom the directors of the sampledfacilities and writteninformed consent was obtained fromindividual

participants.Data collectionA semi-structured questionnaire wasadministered to 16individuals that consented toparticipate in the study.The structured part collectedparticipants demographicdata and the open-ended partcaptured qualitative data.The interviews were held in Chichewaand lastedbetween 40 to 60 minutes. The healthfacility managementprovided a private office for theinterviews. Allinterviews were audio-recorded exceptfor two participantswho refused to have their responsesaudio-taped.For these two participants, hand

written notes wereused to record responses. Fieldrecords were taken forall participants responses and thehand written noteswere expanded into transcripts.Data AnalysisData analysis was undertakensimultaneously with datacollection in order to identify andcorrect errors during

next interviews. The taped informationwas transcribed

verbatim and translated fromvernacular language intoEnglish. Thematic content analysisguided data analysisKululanga et al. Reproductive Health

2011, 8:36http://www.reproductive-health-journal.com/content/8/1/36Page 3 of 12[19]. The transcripts were readrepeatedly and wordswith similar meanings were groupedinto categoriesusing Nvivo 9 software. Similarcategories were groupedinto themes and sub-themes that are

presented asresults. The results contain directquotes from participantsand narrations are reported as spokenby participantswithout editing the grammar to avoidlosingmeaning. Expressions in vernacularlanguage are presentedin parentheses and fictitious namesare used inquotes to maintain confidentiality of theparticipants.ResultsParticipants demographiccharacteristicsThe participants age ranged from 21to above 50 yearsand four of the participants were male.Professional qualificationsincluded SRNM (2), NMT (13) and

clinicalofficer (1). Furthermore, theirexperience in MCH rangedfrom 1 to 25 years. Of the 16participants, 3 werefrom Blantyre Adventist Hospital, 5from Mwanza DistrictHospital, 1 each from the two healthcentres, 4from Mlambe Mission Hospital and theother 4 from

Zomba Central Hospital.


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The participants responses generatedfour main strategiesthat were used to invite men toparticipate inmaternal health care services. The

strategies were healthprovider initiative and partnernotification that were athealth facility level, while the coupleinitiative was atfamily level and communitymobilization at village(community) level. The communitymobilization hadthree sub-themes namely; male peerinitiative, use of

incentives and communitysensitization.Health care provider initiativeIn this strategy, the health careprovider asked the pregnantwoman to bring her husband next timeshe comesfor ANC services. The woman decidedwhether to invitethe husband or not. On the other hand,when thewoman invited her husband toparticipate in her care atthe ANC, the husband decidedwhether to participate ornot. When the husband decided toparticipate, heaccompanied the wife during thesubsequent ANC visits.This strategy was also used to solicithusband participation

in the PMTCT programme. The healthcare providersfurther explained that couplecounseling and HIVtesting is encouraged in order topromote womensadherence to PMTCT interventions.Mandatory HIVtest is part of the routine antenatalcare in Malawi.Hence, the health care providers

encouraged couple

counseling because it was noted thatmany women werenot disclosing their HIV status to theirspouses out offear of their partners reaction. The

health providerswere of the view that inviting men tothe ANC clinicwhere HIV testing is part of the routinehas its ownchallenges. The coming of thehusband to the clinicdepended upon the wifes freedom ofchoice and herperception of the benefits of having ahusband participate

in the facility based maternal care. Thesocial associationof HIV positive status and infidelityhinderedmany women from inviting theirhusbands to the ANC.When a woman comes to the clinic forthe firstANC, we ask her to come with ahusband during thenext visit. The husband is needed sothat we cancounsel the couple on how to preparefor the babyand on HIV testing and prevention ofmother tochild transmission of HIV (PMTCT).Some men docome during the next visit. (Jane)Another provider initiative at facilitylevel involved

giving first and fast service to womenthat attendedANC with their couples. The heathcare provider interviewsshowed that men as main familybreadwinnerscould not manage to postpone or stopworking so thatthey participate in maternal health careof their partners.Husbands/partners who were

employed needed to ask


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for some hours off duty to accompanya wife for antenatalcare. Those husbands, who earned aliving by smallscalebusiness like selling vegetables, felt

that theywasted time by being at ANC insteadof attending topersonal business that brought moneyto the family. Toattract men to participate in maternalhealth care, theproviders introduced the first and fastservice for couplesso that the husbands/partners shouldnot waste

time on the queue at the facility. Firstand fast servicestrategy was used in all the healthfacilities where thisstudy was conducted except BAH.Another thing is that most men arebusy, so whenthey come I think it can be a goodthing if we attendto those who come with their husbandsfirst, so thatnext time they can come knowing thatthey will behelped fast and they wont be late forwork or any ofthe activities that help them to earn aliving. (Mable)Women were encouraged to comewith their husbandsto the clinic and were assured of a fastand first

service. This initiative also worked wellfor the womenbecause they did not spend much timeat the clinic andthey went back home in good time todo other activities.The health providers perceived the useof this type ofinitiative as unsustainable.It is attractive now because few menare attending

ANC. It may not be applicable whenalmost all women

would be accompanied byhusbands."(John)Partner notificationPartner notification is another provider-initiated strategy,

which is used to solicit maleparticipation when aKululanga et al. Reproductive Health2011, 8:36http://www.reproductive-health-journal.com/content/8/1/36Page 4 of 12woman has a sexually transmittedinfection (STI). Themain purpose for this strategy is tohave the husband/

partner treated for STI in order tocontrol the infection.Some of the STIs, such as syphilis dohave adverseeffects on the foetus as well. In partnernotification, theprovider explained to the woman theimportance of havinga husband/partner treated for theinfection. Then,the woman was given a notificationcard to give to thehusband. The notification card had thewomans identificationnumber and the husband/partner hadto presentthis card to the health care provider atthe clinic. Thehusband could come alone to the ANCor with the wife.However, the health care providers

preferred that thecouple be together for furthercounseling. The view thatmen were being invited in maternalhealth care portrayedthem as second level clients who couldonlyattend the clinic when there waspathology. On theother hand, pregnancy justifiedwomens use of the services.

Sometimes we do call for thehusband/partner when


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the woman has problems that requirecounseling toboth of them, for example when awoman has sexuallytransmitted infection. The treatment

requires that theman be treated as well and theyshould abstain fromsex until they have finished thetreatment. In suchcases we call for the man if he was notcoming forantenatal care together with the wife.(Jane)The providers noted that almost allmen who were

invited to the clinic through partnernotification camefor the treatment. However, they didnot come back tothe clinic when they have finished thetreatment. Themajority of the health care providersacknowledged thathusbands were being invited toparticipate in specificmaternal health interventions such asHIV testing andSTI treatment. They viewed that usingthis strategy limitedmale participation to specific maternalhealth servicesas such husbands did not see theneed toaccompany the wives to the clinicwhen there was noagenda for them. Partner notification

strategy was usedin all the health facilities where thisstudy was conducted.Couple initiativeIn this strategy, the couple agreed tojointly participatein maternal health care. Mosthusbands participated inmaternal health care when a wifeconceived after a longwaiting time. In this case, the

pregnancy was precious

and the husband was anxious aboutthe well-being ofthe foetus and the mother. As such,the husband wasvery interested to know the progress of

the pregnancyand the health of the wife. The healthcare providersdescribed such husbands as veryinquisitive, wanting toknow what was happening to thefoetus and the wife.They asked about the results of everytest done on thewife and about the resultant treatment.The participants

also mentioned that young educatedcouples used thisstrategy regardless of whether it was alow or high-riskpregnancy. In addition, the health careparticipantsdescribed the couples who used thisstrategy as educated,exposed to male involvementinformation throughthe mass media, internet and hadtravelled abroad. Theparticipants described that the coupleswho used coupleinitiative strategy attended all ANCvisits together andthe husband was present during labourand delivery.The husband also accompanied thewife during postnatalcare consultations. This strategy was

commonly usedat BAH and Mlambe Mission Hospital(private wing)due to the fact that the labour wards inthese facilitiesoffered some privacy and that thefacilities wereaccessed by educated and cityresidents.Most of our clients are educated andwell to do.

They are used to men being allowed inANC consultations,


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labour and delivery wards andpostnatalconsultations. Previously, non-Malawian men werethe ones that used to accompany their

wives formaternal health care services. Butnowadays, we areseeing a lot of Malawian men comingto the clinicwith their wives, and some evenassisting the wife inthe labour ward. (Martha)Nowadays most men are participatingin maternalhealth care. Last month [October

2010] there was awoman who was in labour andadmitted in the privatelabour ward. The husband was presentthroughoutlabour and delivery supporting thewife. Therewas a time when the woman was inearly labourand was asked to be walking around. Isaw the coupleholding hands walking around thehospital. Forme this is male involvement."(John)However, at Zomba Central Hospitalthere were also afew couples who used this strategy.The husbands participatedin all ANC and postnatal consultationsbut notin labour and delivery care due to

privacy issues. Thehospital had one big labour anddelivery room with 10delivery beds that were demarcated bycurtains. Mostoften than not, women labour naked,as the hospital didnot have hospital gowns and womenhad to spare theirhome clothes to be put on afterdelivery. The lack of

privacy in the labour room hinderedbirthing women to

have a spouse or family memberpresent in labour wardfor emotional support.Community mobilization strategyMale peer initiative

Men who had participated in maternalhealth careinform their peers about theirexperiences. The otherKululanga et al. Reproductive Health2011, 8:36http://www.reproductive-health-journal.com/content/8/1/36Page 5 of 12men become motivated and discussedwith their wives.

When they agreed, the couple visitedthe ANC together.The husbands would decide whetherto be present duringlabour and delivery.....another man told me that he learntabout maleinvolvement from a friend. He came tothe clinicwith his wife just to see what was therefor men. Atthe end of the clinic, he said that hehad learnt a lotabout pregnancy issues. He alsoappreciated the wayhe was welcomed at the clinic. (Jane)The health care providers were of theview that malepeer approach should be emphasized,as men wouldwant to identify with fellow men. So the

men that areinfluential among their peers should betargeted withmale involvement information in orderfor them to berole models for their peers.Community sensitizationThe health care providers at MwanzaDistrict Hospitaland its affiliated health centres mainlyused community

sensitization strategy. The health careproviders felt the


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need to involve men in maternal healthcare. Theyapproached the traditional authoritiesand chiefs, whoare highly respected community

leaders in Malawi, andwere informed about the maternalhealth problems inthe district. The health care providersin collaborationwith the community leaders developedplans on how toinvolve men. Different methods wereused such as communityoutreach, public meetings, use ofincentives, and

launching of male involvement. Thecollaboration withthe community leaders also enabledthe health care providersto access the communities andhouseholds withmale involvement information.We involved the village chiefs todisseminate theinformation about male involvement insafe motherhood.Firstly, we talked with the chiefs aboutmaternalhealth problems that women in thearea arefacing such as poor health andmaternal deaths.Then, we would discuss with the chiefson strategiesthat can be used to prevent maternaldeaths and

improve maternal and child health.Then we wouldintroduce male championship as oneof the strategiesand encourage the chiefs to motivatethe men toaccompany their wives for antenatalcare, especiallythe first visit."(Ruth)Health surveillance assistants (HSA)who are the community

health care workers in Malawi mainlyconducted

community outreach. The HSAsspread the male involvementmessages in the villages. Theycollaborate withthe community leaders on how to

approach the men.The villagers do identify with the HSAsbecause theylive in the same villages and thecommunities respectthem. Due to the nature of the work ofthe HSAs, theydo interact with the villagers and doknow the socio-culturalnorms of the communities in whichthey work.

This enables them to disseminate themale involvementinformation in a socio-culturallyacceptable manner.The community members felt free toask them for clarificationon any information to do with maternalhealthand male involvement.Probably the campaign on safemotherhood hasmade a difference. Here at MwanzaDistrict Hospitalthere is a safe motherhood team. Thisteam goes intothe villages encouraging men andwomen on theimportance of antenatal care, hospitaldelivery, andfamily planning. They also emphasizethe importance

of male involvement in these issues.Since the initiationof male championship in this district,we haveseen a change in health care seekingbehaviour of thepeople. Most women are deliveringhere at the hospital.In addition, we have also seen a dropin maternaldeaths. (Pamela)

Public meetings were another avenuethat community


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leaders use to disseminate informationabout maleinvolvement in maternal health care.The informationwas disseminated during political

meetings, funeralsand social gatherings. The health careproviders wereof the view that the community leaderswere motivatedto do this due to the incentives theywere getting andthe perceived benefits for women,families and thecommunity in general. However, thehealth care providers

explained that during public meetings,the communitymembers could not ask questions tothetraditional leaders. In this community, itis regarded aslack of respect to ask a leader or anelderly personquestions in public. However, thehealth care providersfelt that the information that wasreceived during publicmeetings stimulated much debate aswell as communicationbetween couples and households. Thiswasevident when some men sought formore informationfrom the health care providers aboutmale involvementbecause of such meetings.

The group village headman here isvery much intoit. He takes opportunity of every publicmeeting, be itpolitical, religious or even at a funeral,to talk aboutmale involvement. He tells the peoplethat it is one ofthe important strategies to reducematernal andchild deaths. (Peter)

Use of incentives

At community level, Mwanza DistrictHospital usedcompetition among villages toencourage maleKululanga et al. Reproductive Health

2011, 8:36http://www.reproductive-health-journal.com/content/8/1/36Page 6 of 12involvement in maternal health care.UNICEF organizedthe competition in 2008. A traditionalauthority and villagechief that had high proportion ofcouples attendingantenatal clinic received a prize. The

use of the incentivesmotivated village chiefs to becomevigilant in promotingmale involvement. The village chiefsadvisedhealth care providers not to attend toany woman whocame to the antenatal clinic without ahusband in orderfor them to get a prize.In this competition, the organizerswere looking atthe number of couple against the totalnumber ofmothers who came for antenatalvisit..... The villageheadman for that particular village(with a high proportionof couples would) receive a bicycle. Inaddition,the Traditional Authority with high

proportionof couples would receive a bicycle anda trophy.These incentives motivated the chiefsto disseminatethe male championship messages tothe villagers.Some chiefs went to the extent ofadvising the healthcare providers not to attend to anywoman who

came for antenatal care without ahusband. If the


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husband is away, the woman wassupposed to get aletter from the chief. (Ruth)However, the health care providersrecognized that

sending women back who did notcome to the antenatalclinic with a husband was notprofessionally acceptable.They did it out of respect for thetraditional authorities,importance of the initiative and savinga collaborativerelationship with the communities.The health care providers explainedfurther that when

the competition came to an end therewas a decline inthe number of couples attending ANCservices. Thehealth care workers viewed that thecompetition was amotivating factor for the men toparticipate in maternalhealth care. However, the strategyfailed to induce behaviouralchange towards male participation infacilitybased maternal health care.In fact this practice was only effectivein 2008because of the competition. Now thereare no longermaterial rewards but still the peopleare used to theprinciples of the initiative. However,few men do

accompany their wives for antenatalcare. (Ruth)Women were encouraged to comewith their husbandsto the clinic and were assured of a fastand firstservice. This incentive also workedwell for the womenbecause they do not spend much timeat the clinic andthey went back home in good time to

do other activities.

The health care providers perceivedthe use of this typeof incentive unsustainable.It is attractive now that few men doattend the

ANC. It may not be the case whenalmost all womenwould be accompanied by husbands.(John)The only hospital that did not useincentives to motivatemale participation was BAH. Theclients bookedfor antenatal consultation and weregiven a specific timewhen to see the doctor. In the other

study sites, theyuse the first come first served kind ofmodel. Hence,women queued for the services, andwomen that wereaccompanied by their spouses wereattended to immediatelywithout queuing.Sensitization campaignsSensitization campaigns helped inMwanza district toencourage men to participate inmaternal health care.The health providers used a number ofstrategies to sensitizethe communities about maleinvolvement such aslaunching the programme andcommunity outreach.The male involvement programme waslaunched publically

in the district. During the launch,people wereentertained with drama and traditionaldances that conveyedmale involvement and maternal healthmessages.The District Health Officer and one ofthe TraditionalAuthorities for the district madespeeches to emphasizethe importance of the programme. The

presence of the


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traditional authorities at the functionsignaled the leadersapproval and commanded anobligation from thepart of the community members.

Mwanza District Hospital had a safemotherhood teamthat went out into the villages todisseminate informationand provided reproductive healthservices. One ofthe messages that were disseminatedwas male involvement.The health team focused on providinginformationabout male involvement in relation to

HIV testingand PMTCT interventions. Coupleswere encouraged togo to the health facilities for couplecounseling and HIVtesting. Men were told that they wereonly needed atthe ANC during the first visit when theHIV test wasdone. The health care workers saidthat they had noteda difference in health care seekingbehaviour of the menin the areas they had visited. Inaddition, they also saidthat they had noted an increase inhospital deliveriesand reduction in maternal deaths.Probably the campaign on safemotherhood hasmade a difference. Here at Mwanza

District Hospitalthere is a safe motherhood team. Thisteam goes intothe villages encouraging men andwomen on theimportance of antenatal care, hospitaldelivery, andfamily planning. They also emphasizethe importanceof male involvement in these issues.Since the initiation

of male championship in this district,we have

seen a change in health care seekingbehaviour of theKululanga et al. Reproductive Health2011, 8:36http://www.reproductive-health-

journal.com/content/8/1/36Page 7 of 12people. Most women are deliveringhere at the hospital.In addition, we have also seen a dropin maternaldeaths. (Pamela)DiscussionHealth care provider initiativeHealth care provider initiative strategydepended on the

health care provider to initiate theinvitation of husbandsto participate in maternal health care.This strategywas used in all the five study sites.Legitimate poweris provided to the women with thisstrategy. Thewomen exercise freedom of choice ofwhether to invitethe husband/partner or not. Kabeerdescribes power interms of the ability to make choices[20]. By givingwomen the freedom to invite theirhusbands/partners,the health care provider seemingly,allow for a degree ofautonomy on behalf of the women.However, in orderfor the women to be truly empowered,

there is need foran ability to formulate ones ownpreferences and tolook for alternatives. Thus, health careproviders havethe responsibility of explaining thereasons for invitingthe husbands to the clinic and theimpact that it willhave on the womans health care. Thisinformation is

important for the woman to make aninformed decision.


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Unless the pregnant women areempowered with a realinformed opportunity to make choices,they may notinvite their spouses for a variety of

reasons deeplyembedded in their own culture. Otherstudies done inMalawi describe lack of knowledge onthe importanceof ANC and that some of the womenattend ANC toget a card to avoid being scolded byhealth care providersduring labour [21]. For such women itmay be difficult

to understand the importance for maleinvolvementand let alone inviting them toparticipate in the care.Furthermore, for men who may viewmaternal healthcare services as feminine may decidenot to accompanythe wife in order to maintain theirmasculine powerdespite being invited. The invitation isstill seen as arecommendation from the side ofpublic services, not asa deeply felt choice that is eventuallyeffectuated.The health care providers indicatedthat the routineantenatal care of the women is notaffected if the husband/partner is not present. They further

expressed thatmale participation is very lowcompared to the numberof women that attend antenatal care inthe respectivehealth facilities. However, the healthcare providersattributed low male participation tomens commitmentto income generating activities for theirfamilies and

lack of knowledge of male involvementprogramme.

Theuring also found similar results inthe study done inMbeya Region, Tanzania [22]. Menslack of knowledgeabout male involvement programmes,

and a lack ofpriority for such activities whencompeting with otherchallenges, could be attributed to thestrategies used todisseminate the information.Health care provider initiative strategyis also dependenton the attitudes of the health careprovider towardsmale involvement. The health care

providers that havepositive attitude towards theprogramme would encouragethe women to invite their partners.They wouldtake time to explain to the women thebenefits of havinga husband/partner involved in theircare. Furthermore,when the husband accompanied thewoman the providerwould do her best to attend to thecouple and makethe visit worthwhile to both the womanand the man.However, poor health care providersattitudes havebeen attributed to low maleparticipation in Malawi[23].Partner notification

The fact that partner notification wasused when awoman was diagnosed with an STIcould mean that thisstrategy was not male involvementper se, nevertheless,draws men into the services. However,inviting men toparticipate in maternal health careservices throughpartner notification portrays them as

second level clients


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who could only benefit directly from itsservices whenthere is pathology. On the other hand,pregnancy justifieswomens use of the services. Aarnio

and friends [13]report similar findings.Partner notification has been used inSTIs control butits effectiveness in male involvement inthe whole menuof services has not been explored inMalawi. However,evidence shows that there is loweffectiveness of partnernotification with STIs [24,25]; and that

partner notificationalone without community mobilizationdoes notsuffice to attract men [26,27].Nevertheless, anecdotalreport from Mulago hospital staff inUganda indicatethat use of invitation letters hasincreased male participationduring antenatal and postnatal care ofwomenfrom the national average of 7% to15% [28]. At MulagoHospital in Uganda, all mothers visitingANC, regardlessof HIV status, were given invitationletters for theirspouses [28].The dependency on women to invitemen for maleinvolvement in maternal health care

indicates lack ofreadiness by the health care sector toinvest in communitybased approaches that have provedsuccessful elsewhere[29]. In this study, the health careproviders inthe MCH department were oftenoverburdened withtheir work. Some of the health careproviders expressed

that it was not possible for them toengage in active

male involvement campaigns. TheZomba Central Hospitalhealth care providers alluded to thatfact that thehospital is a referral facility.

Community based activitieswere supposed to be done by ZombaDistrict HealthOffice. The only strategy they coulduse was toKululanga et al. Reproductive Health2011, 8:36http://www.reproductive-health-journal.com/content/8/1/36Page 8 of 12encourage male participation through

the women whocame for services at the hospital.However, it was notedthat there was lack of coordinationbetween the twohealth departments. The ZombaCentral Hospital healthcare providers were not aware of maleinvolvementactivities that the District Health Officeengaged in. Thehealth care providers at BlantyreAdventist Hospitalindicated that they encouraged maleparticipation butdid not conduct community-basedcampaigns. It wasthe responsibility of Blantyre DistrictHealth Office.However, the health care providersindicated that they

could conduct outreach services whenfunds were available.Similar sentiments were expressed byMlambeMission Hospital Staff. On thecontrary, Mwanza DistrictHospital had health care providersconducted communitybased male involvement campaigns.However,the results of such campaigns have

brought much


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impact at health centre level than atdistrict hospitallevel. The positive impact at healthcentre level could beattributed to the fact that most of the

men that livewithin the catchment area of the healthcentres werepeasant farmers who could easily bemobilized.Couple initiativeCouple initiative strategy was found tobe a strategycommonly used by couples who visitedBAH andMlambe Mission Hospital private

sections. Most of theclients who used these facilities werefrom the affluentsector of the society. Feyisetan foundsimilar results inNigeria where by education played asignificant role inspouse communication [30]. Theyfound that spousecommunication about contraceptiveuse was greatlyenhanced when both spouses hadsimilar levels of education(or close to one another). Thesignificance ofeducation was much more pronouncedwhen none ofthe partners had below secondaryeducation and at leastone of them had a post- secondaryeducation [30]. It

should be noted that such type ofcouples have accessto mass media, internet and exposureto the outsideworld, factors that influence behaviorchange. Thisstrategy was most efficient andsustainable but unfortunatelyonly confined to the few educated andurbandwellers.

Spouse communication wasassociated with the

empowerment of women within themarital union. Anumber of factors indicate theempowerment of womenand the increase of their status within

the householdand the marital union. Feyisetan positsthat at higherlevels of education and with littledifference in educationalattainment, partners appear to feelmore comfortablediscussing issues which aretraditionally thought tobe under the control of men [30]. Thus,education and

exposure to the western cultureinfluence couples attitudesand behaviour towards increasedgender equity,expressed as shared responsibility forthe pregnancy andthe baby.Male peer initiativeThe results of this study have shownthat informal peerinformation giving is one of thestrategies that are usedto invite men to participate in maternalhealth care.Men who have participated in maternalhealth careinform peers about their experiencesand encouragethem to participate. Zulu asserts thatmen in Malawi,whether in a patrilineal or matrilineal

social system, arebrought up to believe that they areinherently superiorto females and therefore tend todownplay the importanceof new ideas originating from females,especiallyissues of reproduction which affect amans social status[31]. Thus, men may be morereceptive to maternal

health information originating fromfellow men than


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women. Similar finding are reported byAarnio andfriends in a study done in Malawi onmale involvementin antenatal HIV counseling and

testing; Elizabeth GlaserPediatric AIDS Foundation in a studydone in arural community in Tanzania thatexplored the role ofmale participation in PMTCTprograms; and Onyangoand friends in Kenya [13,28,32]. Inaddition, Avogo andfriends found that men and womensdiscussions in gendered

networks are significantly associatedwith subsequentspouse communication about familyplanning[33]. They further posit that socialinfluence is directlyreflected when informal socialnetworks exchange informationon childbearing [33].It is worthy noting that in some Malawisocieties, boysand girls are socialized into manhoodand womanhoodthrough separate initiation ceremoniesthat are conductedin separate huts and are encouragedto keepsecret from the opposite sex and theuninitiated.Furthermore, men have their ownplace where they

spend their leisure time after the dayswork where theydo discuss mens issues. Similarly,women have theirown designated place where theyspend their leisuretime socializing. Either places, mensor womens are nogo areas for the opposite sex. If eithersex is found inthe other sex place are ridiculed called

names such as

Chili pa akazi (feminine) or Chili paamuna (tomboy)[34]. It is in these gendered spacesthat informal educationof boys and girls, men and women

takes place.Such gendered social norms make anyother form ofinformation sharing a deviant form,that is, an attemptto break strong social gender barriers -and may at thisstage be counter-productive as theyask for somethingthat the community is not ready for yet.Community mobilization

Community mobilization strategy wasmainly used bythe health care providers at MwanzaDistrict HospitalKululanga et al. Reproductive Health2011, 8:36http://www.reproductive-health-journal.com/content/8/1/36Page 9 of 12and its affiliated health centres. Thehealth care providersin collaboration with traditional andcommunity leadersmobilize the community in general andmen in particular,for male involvement. The communityleaders aregatekeepers of their communities. Thecooperation ofcommunity leaders is very crucial inthe advancement of

any public health initiative in Malawi.The effectivenessof collaboration with traditionalauthorities has been evidentin reducing maternal mortality in somedistrict ofMalawi [35]. In rural areas of MwanzaDistrict, communityoutreach is mainly conducted by HSAswho are theprimary community workers in Malawi

and they do


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reside in the same communities. Thehealth care providersin Mwanza District pointed out that thecommunityapproach is feasible in rural areas

where the communitymembers can easily be mobilized bythe traditional leaders.Working with traditional leaders can bevery fundamentalbecause of their power position withinthecommunity. In communities where thetraditional leaderis a man, he can be the agent ofchange among men, as

he may act as a role model.Sensitization campaignSensitization campaigns were anotherstrategy that targetedcommunities at Mwanza DistrictHospital. Thedistrict used educational messagescombined with entertainmentas they were launching the maleinvolvementprogramme. The power ofentertainment-education toeffectively promote change in healthrelated beliefs andbehaviour is well-documented [36].The sensitizationcampaigns raised awareness,stimulated discussionamong peers and couples about maleinvolvement leadingto the desired action. The health care

providerexpressed that some of the communitymembers soughtfor more information about maleinvolvement followingthe sensitization campaigns. Thedilemma is that campaignsare often short lived, and may notinitiate enoughchange to enhance a long-termbehaviour change.

Use of incentives

Fast and first service is the incentivethat is being used inall antenatal and postnatal clinics inthe study sites but forBAH. Similar findings were also cited

by Elizabeth GlaserPediatric AIDS Foundation [28]. Itshould be noted that atBAH, women had to book for anappointment with anobstetrician and were given a specifictime for the appointment.Thus, there was no need forpreferential treatmentwhether one has come with a spouseor not. On the other

hand, the other health facilities had atradition of havingall the women congregating at 07:30hours (the officialtime to start work in Malawi). The cliniccommenced witha group health educational talk, whichcould last 30 to 60minutes depending on the topic underdiscussion and theperson giving the talk. It was duringthis group healtheducational session that maleinvolvement promotionaltalk was also given. Then, the clientswent for HIV counselingand testing if it was the first visit. Thewomenqueued for blood pressure and weightcheck, and physicalexamination. Thereafter, they had to

queue for medication(malarial prophylaxis and iron tablets).Depending on thenumber of the clients that wereavailable on that particularday and the processes that a womanhad to undergo, shecould spend 2 to 4 hours at the clinic.Consequently, firstand fast services were an incentivewhen women came

with their spouses.


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The waiting time was an issue when itcame to dealingwith men. The health care providersexpressed thatthey offered this kind of incentive in

order to release theman to go back to his work. It mightimply that for mentime is money and women have all thetime to spend atthe clinic. This practice reflects thetraditional genderrole norm that men are breadwinnersand that theyshould not spend a lot of time at theclinic. This strategy

may not be sustained in the nearfuture when moremen accompany their wives andqueuing becomes inevitable.However, the strategy has managed tostimulatemen to accompany their wives tofacilities.CompetitionsMwanza District Hospital usedcompetitions amongcommunities in different traditionalauthorities toadvance the male involvementprogramme. The healthcare providers alluded to the fact thatthere were morecouples attending the ANC during thecompetition periodand the numbers dropped when thecompetition

ended. There are several possiblereasons for the declinein couple ANC attendance after thecompetition. Firstly,couples may have been pressurized toattend ANCbecause of the competition. Thecompetition was thedriving force. When the force wasremoved, the mendid not have the will to continue.

Secondly, the main

emphasis of the competition was maleinvolvement inHIV testing and PMTCT. When themen knew theirHIV status, there was no need for

them to go to theclinic even for subsequentpregnancies. This was equallytrue with men in a polygamousmarriage. The men feltno need to accompany the other wiveswhen they knewalready their HIV status. Thirdly, afterthe competition,the health care providers did not feelobliged to force

women to come to the clinic withhusbands. Havingmen at the clinic implied additionalworkload for thehealth care providers. Therefore,competitions like otherincentives were not sustainable in thelong run to promotemale involvement in maternal healthcare services.Limitations of the studyThe main limitation of this study isreporting bias arisingfrom participants wanting to providesociallyKululanga et al. Reproductive Health2011, 8:36http://www.reproductive-health-journal.com/content/8/1/36Page 10 of 12desirable responses rather than true

reflection of the reallife situation. The participants wereaware that the interviewerwas a nurse-midwife and that mayhave influencedthe information given.Furthermore, in this study four healthcare providersdeclined to participate as provided forin the consentform. It may be postulated that had

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further items on strategies to invitemen to participatein maternal health care could havebeen identified.However, it might have also been not

so from theposition that providers were using thesame methodsand any one group could haveprovided the sameinformation.ConclusionsThis study shows that it is possible toinvolve men inmaternal health care. Participants inthis study used

facility, family and community basedstrategies toinvolve men in maternal health care. Atfacility level,the strategies used were notsustainable although theyincreased male participation in theshort run. A majorconstraint was the fact that maleparticipation dependedupon the wifes willingness to deliverthe invitation fromthe health care providers and thehusbands willingnessto participate.Couple based initiative was moreeffective and sustainablebecause it originated from the coupleitself that felta need to jointly get involved inmaternal health care

services. This strategy however, wasmostly adopted bythe educated and city residents.Community mobilization strategieswere more effectiveto rural settings in terms of coverage.The malepeer strategy was both effective andsustainable, shouldhence be encouraged, and promoted.Other communitybased

strategies worked well where therewere incentives.

The incentives were however donordriven, thusthey only worked well during theproject lifetime. It istherefore recommended that while all

the strategies areencouraged, more emphasis should bemade on coupleand male peer strategies to sustainmale participation inmaternal health care. There is also aneed for long-termstrategies targeting a whole generationin order to bringthe desired behaviour change in maleinvolvement

towards maternal health care.List of abbreviations usedANC: Antenatal care; BAH: BlantyreAdventist Hospital; BEmOC: Basicemergency obstetric care; CEmOC:Comprehensive emergency obstetriccare; CHAM: Christian HospitalAssociation of Malawi; FP: Familyplanning;HIV: Human immunodeficiency virus;HSAs: Health surveillance assistants;MCH: Maternal and child health; MDH:Mwanza District Hospital; MDHS:Malawi Demographic and HealthSurvey; MMH: Mlambe MissionHospital;NGOs: Non GovernmentalOrganizations; NMTs: Nurse-MidwifeTechnicians;PMTCT: Prevention of mother-to-childtransmission; SLAs: Service Level

Agreements; SRNMs: StateRegistered Nurse-Midwives; STI:SexuallyTransmitted Infections; UNICEF:United Nations Childrens Fund; ZCH:ZombaCentral Hospital.AcknowledgementsThe Norwegian government throughthe NUFU project funded this study.The findings and conclusions of this

article are those of the authors and do


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not necessarily represent the views ofthe funders. We are grateful to Dr.Alfred Maluwa for critically editing themanuscript.Author details

1Department of International Health,Section for Health and Society, Facultyof Medicine, University of Oslo, P.O.Box 1130, Blindern, Oslo 0318,Norway.2Department of Community andMental Health, Kamuzu College ofNursing,University of Malawi, P.O. Box 415Blantyre, Malawi. 3Department ofMaternal

and Child Health, Kamuzu College ofNursing, University of Malawi, PrivateBag 1 Lilongwe, Malawi.Authors contributionsLIK conceptualized the study, collectedthe data, led the analysis, and wrotethe text of the paper. JS, AM and ECadvised on the conceptualization ofthe study, analysis of the data, andpresentation of the results, review andedited the text. All authors read andapproved the final manuscript.Competing interestsThe authors declare that they have nocompeting interests.Received: 13 October 2011 Accepted:2 December 2011Published: 2 December 2011

striving to promote male involvement

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