Participants' demographic characteristics
The participants' age ranged from 21 to above 50 years and four of the participants were male. Professional qualifications included SRNM (2), NMT (13) and clinical officer (1). Furthermore, their experience in MCH ranged from 1 to 25 years. Of the 16 participants, 3 were from Blantyre Adventist Hospital, 5 from Mwanza District Hospital, 1 each from the two health centres, 4 from Mlambe Mission Hospital and the other 4 from Zomba Central Hospital.
The participants' responses generated four main strategies that were used to invite men to participate in maternal health care services. The strategies were health provider initiative and partner notification that were at health facility level, while the couple initiative was at family level and community mobilization at village (community) level. The community mobilization had three sub-themes namely; male peer initiative, use of incentives and community sensitization.
Health care provider initiative
In this strategy, the health care provider asked the pregnant woman to bring her husband next time she comes for ANC services. The woman decided whether to invite the husband or not. On the other hand, when the woman invited her husband to participate in her care at the ANC, the husband decided whether to participate or not. When the husband decided to participate, he accompanied the wife during the subsequent ANC visits. This strategy was also used to solicit husband participation in the PMTCT programme. The health care providers further explained that couple counseling and HIV testing is encouraged in order to promote women's adherence to PMTCT interventions. Mandatory HIV test is part of the routine antenatal care in Malawi. Hence, the health care providers encouraged couple counseling because it was noted that many women were not disclosing their HIV status to their spouses out of fear of their partners' reaction. The health providers were of the view that inviting men to the ANC clinic where HIV testing is part of the routine has its own challenges. The coming of the husband to the clinic depended upon the wife's freedom of choice and her perception of the benefits of having a husband participate in the facility based maternal care. The social association of HIV positive status and infidelity hindered many women from inviting their husbands to the ANC.
"When a woman comes to the clinic for the first ANC, we ask her to come with a husband during the next visit. The husband is needed so that we can counsel the couple on how to prepare for the baby and on HIV testing and prevention of mother to child transmission of HIV (PMTCT). Some men do come during the next visit." (Jane)
Another provider initiative at facility level involved giving first and fast service to women that attended ANC with their couples. The heath care provider interviews showed that men as main family breadwinners could not manage to postpone or stop working so that they participate in maternal health care of their partners. Husbands/partners who were employed needed to ask for some hours off duty to accompany a wife for antenatal care. Those husbands, who earned a living by small-scale business like selling vegetables, felt that they wasted time by being at ANC instead of attending to personal business that brought money to the family. To attract men to participate in maternal health care, the providers introduced the first and fast service for couples so that the husbands/partners should not waste time on the queue at the facility. First and fast service strategy was used in all the health facilities where this study was conducted except BAH.
"Another thing is that most men are busy, so when they come I think it can be a good thing if we attend to those who come with their husbands first, so that next time they can come knowing that they will be helped fast and they won't be late for work or any of the activities that help them to earn a living." (Mable)
Women were encouraged to come with their husbands to the clinic and were assured of a fast and first service. This initiative also worked well for the women because they did not spend much time at the clinic and they went back home in good time to do other activities. The health providers perceived the use of this type of initiative as unsustainable.
"It is attractive now because few men are attending ANC. It may not be applicable when almost all women would be accompanied by husbands."(John)
Partner notification
Partner notification is another provider-initiated strategy, which is used to solicit male participation when a woman has a sexually transmitted infection (STI). The main purpose for this strategy is to have the husband/partner treated for STI in order to control the infection. Some of the STIs, such as syphilis do have adverse effects on the foetus as well. In partner notification, the provider explained to the woman the importance of having a husband/partner treated for the infection. Then, the woman was given a notification card to give to the husband. The notification card had the woman's identification number and the husband/partner had to present this card to the health care provider at the clinic. The husband could come alone to the ANC or with the wife. However, the health care providers preferred that the couple be together for further counseling. The view that men were being invited in maternal health care portrayed them as second level clients who could only attend the clinic when there was pathology. On the other hand, pregnancy justified women's use of the services.
"Sometimes we do call for the husband/partner when the woman has problems that require counseling to both of them, for example when a woman has sexually transmitted infection. The treatment requires that the man be treated as well and they should abstain from sex until they have finished the treatment. In such cases we call for the man if he was not coming for antenatal care together with the wife." (Jane)
The providers noted that almost all men who were invited to the clinic through partner notification came for the treatment. However, they did not come back to the clinic when they have finished the treatment. The majority of the health care providers acknowledged that husbands were being invited to participate in specific maternal health interventions such as HIV testing and STI treatment. They viewed that using this strategy limited male participation to specific maternal health services as such husbands did not see the need to accompany the wives to the clinic when there was no agenda for them. Partner notification strategy was used in all the health facilities where this study was conducted.
Couple initiative
In this strategy, the couple agreed to jointly participate in maternal health care. Most husbands participated in maternal health care when a wife conceived after a long waiting time. In this case, the pregnancy was precious and the husband was anxious about the well-being of the foetus and the mother. As such, the husband was very interested to know the progress of the pregnancy and the health of the wife. The health care providers described such husbands as very inquisitive, wanting to know what was happening to the foetus and the wife. They asked about the results of every test done on the wife and about the resultant treatment. The participants also mentioned that young educated couples used this strategy regardless of whether it was a low or high-risk pregnancy. In addition, the health care participants described the couples who used this strategy as educated, exposed to male involvement information through the mass media, internet and had travelled abroad. The participants described that the couples who used couple initiative strategy attended all ANC visits together and the husband was present during labour and delivery. The husband also accompanied the wife during postnatal care consultations. This strategy was commonly used at BAH and Mlambe Mission Hospital (private wing) due to the fact that the labour wards in these facilities offered some privacy and that the facilities were accessed by educated and city residents.
"Most of our clients are educated and well to do. They are used to men being allowed in ANC consultations, labour and delivery wards and postnatal consultations. Previously, non-Malawian men were the ones that used to accompany their wives for maternal health care services. But nowadays, we are seeing a lot of Malawian men coming to the clinic with their wives, and some even assisting the wife in the labour ward." (Martha)
"Nowadays most men are participating in maternal health care. Last month [October 2010] there was a woman who was in labour and admitted in the private labour ward. The husband was present throughout labour and delivery supporting the wife. There was a time when the woman was in early labour and was asked to be walking around. I saw the couple holding hands walking around the hospital. For me this is male involvement."(John)
However, at Zomba Central Hospital there were also a few couples who used this strategy. The husbands participated in all ANC and postnatal consultations but not in labour and delivery care due to privacy issues. The hospital had one big labour and delivery room with 10 delivery beds that were demarcated by curtains. Most often than not, women labour naked, as the hospital did not have hospital gowns and women had to spare their home clothes to be put on after delivery. The lack of privacy in the labour room hindered birthing women to have a spouse or family member present in labour ward for emotional support.
Community mobilization strategy
Male peer initiative
Men who had participated in maternal health care inform their peers about their experiences. The other men become motivated and discussed with their wives. When they agreed, the couple visited the ANC together. The husbands would decide whether to be present during labour and delivery.
"....another man told me that he learnt about male involvement from a friend. He came to the clinic with his wife just to see what was there for men. At the end of the clinic, he said that he had learnt a lot about pregnancy issues. He also appreciated the way he was welcomed at the clinic." (Jane)
The health care providers were of the view that male peer approach should be emphasized, as men would want to identify with fellow men. So the men that are influential among their peers should be targeted with male involvement information in order for them to be role models for their peers.
Community sensitization
The health care providers at Mwanza District Hospital and its affiliated health centres mainly used community sensitization strategy. The health care providers felt the need to involve men in maternal health care. They approached the traditional authorities and chiefs, who are highly respected community leaders in Malawi, and were informed about the maternal health problems in the district. The health care providers in collaboration with the community leaders developed plans on how to involve men. Different methods were used such as community outreach, public meetings, use of incentives, and launching of male involvement. The collaboration with the community leaders also enabled the health care providers to access the communities and households with male involvement information.
"We involved the village chiefs to disseminate the information about male involvement in safe motherhood. Firstly, we talked with the chiefs about maternal health problems that women in the area are facing such as poor health and maternal deaths. Then, we would discuss with the chiefs on strategies that can be used to prevent maternal deaths and improve maternal and child health. Then we would introduce male championship as one of the strategies and encourage the chiefs to motivate the men to accompany their wives for antenatal care, especially the first visit."(Ruth)
Health surveillance assistants (HSA) who are the community health care workers in Malawi mainly conducted community outreach. The HSAs spread the male involvement messages in the villages. They collaborate with the community leaders on how to approach the men. The villagers do identify with the HSAs because they live in the same villages and the communities respect them. Due to the nature of the work of the HSAs, they do interact with the villagers and do know the socio-cultural norms of the communities in which they work. This enables them to disseminate the male involvement information in a socio-culturally acceptable manner. The community members felt free to ask them for clarification on any information to do with maternal health and male involvement.
"Probably the campaign on safe motherhood has made a difference. Here at Mwanza District Hospital there is a safe motherhood team. This team goes into the villages encouraging men and women on the importance of antenatal care, hospital delivery, and family planning. They also emphasize the importance of male involvement in these issues. Since the initiation of male championship in this district, we have seen a change in health care seeking behaviour of the people. Most women are delivering here at the hospital. In addition, we have also seen a drop in maternal deaths." (Pamela)
Public meetings were another avenue that community leaders use to disseminate information about male involvement in maternal health care. The information was disseminated during political meetings, funerals and social gatherings. The health care providers were of the view that the community leaders were motivated to do this due to the incentives they were getting and the perceived benefits for women, families and the community in general. However, the health care providers explained that during public meetings, the community members could not ask questions to the traditional leaders. In this community, it is regarded as lack of respect to ask a leader or an elderly person questions in public. However, the health care providers felt that the information that was received during public meetings stimulated much debate as well as communication between couples and households. This was evident when some men sought for more information from the health care providers about male involvement because of such meetings.
"The group village headman here is very much into it. He takes opportunity of every public meeting, be it political, religious or even at a funeral, to talk about male involvement. He tells the people that it is one of the important strategies to reduce maternal and child deaths." (Peter)
Use of incentives
At community level, Mwanza District Hospital used competition among villages to encourage male involvement in maternal health care. UNICEF organized the competition in 2008. A traditional authority and village chief that had high proportion of couples attending antenatal clinic received a prize. The use of the incentives motivated village chiefs to become vigilant in promoting male involvement. The village chiefs advised health care providers not to attend to any woman who came to the antenatal clinic without a husband in order for them to get a prize.
"In this competition, the organizers were looking at the number of couple against the total number of mothers who came for antenatal visit..... The village headman for that particular village (with a high proportion of couples would) receive a bicycle. In addition, the Traditional Authority with high proportion of couples would receive a bicycle and a trophy. These incentives motivated the chiefs to disseminate the male championship messages to the villagers. Some chiefs went to the extent of advising the health care providers not to attend to any woman who came for antenatal care without a husband. If the husband is away, the woman was supposed to get a letter from the chief." (Ruth)
However, the health care providers recognized that sending women back who did not come to the antenatal clinic with a husband was not professionally acceptable. They did it out of respect for the traditional authorities, importance of the initiative and saving a collaborative relationship with the communities.
The health care providers explained further that when the competition came to an end there was a decline in the number of couples attending ANC services. The health care workers viewed that the competition was a motivating factor for the men to participate in maternal health care. However, the strategy failed to induce behavioural change towards male participation in facility based maternal health care.
"In fact this practice was only effective in 2008 because of the competition. Now there are no longer material rewards but still the people are used to the principles of the initiative. However, few men do accompany their wives for antenatal care." (Ruth)
Women were encouraged to come with their husbands to the clinic and were assured of a fast and first service. This incentive also worked well for the women because they do not spend much time at the clinic and they went back home in good time to do other activities. The health care providers perceived the use of this type of incentive unsustainable.
"It is attractive now that few men do attend the ANC. It may not be the case when almost all women would be accompanied by husbands." (John)
The only hospital that did not use incentives to motivate male participation was BAH. The clients booked for antenatal consultation and were given a specific time when to see the doctor. In the other study sites, they use the first come first served kind of model. Hence, women queued for the services, and women that were accompanied by their spouses were attended to immediately without queuing.
Sensitization campaigns
Sensitization campaigns helped in Mwanza district to encourage men to participate in maternal health care. The health providers used a number of strategies to sensitize the communities about male involvement such as launching the programme and community outreach. The male involvement programme was launched publically in the district. During the launch, people were entertained with drama and traditional dances that conveyed male involvement and maternal health messages. The District Health Officer and one of the Traditional Authorities for the district made speeches to emphasize the importance of the programme. The presence of the traditional authorities at the function signaled the leaders' approval and commanded an obligation from the part of the community members.
Mwanza District Hospital had a safe motherhood team that went out into the villages to disseminate information and provided reproductive health services. One of the messages that were disseminated was male involvement. The health team focused on providing information about male involvement in relation to HIV testing and PMTCT interventions. Couples were encouraged to go to the health facilities for couple counseling and HIV testing. Men were told that they were only needed at the ANC during the first visit when the HIV test was done. The health care workers said that they had noted a difference in health care seeking behaviour of the men in the areas they had visited. In addition, they also said that they had noted an increase in hospital deliveries and reduction in maternal deaths.
"Probably the campaign on safe motherhood has made a difference. Here at Mwanza District Hospital there is a safe motherhood team. This team goes into the villages encouraging men and women on the importance of antenatal care, hospital delivery, and family planning. They also emphasize the importance of male involvement in these issues. Since the initiation of male championship in this district, we have seen a change in health care seeking behaviour of the people. Most women are delivering here at the hospital. In addition, we have also seen a drop in maternal deaths." (Pamela)
