Community Perspective of Male Involvement in Maternal Health Care in Uttarakhand, India: A Qualitative Study

Pawna Kaushal¹· Meenakshi Khapre¹· Amity Das¹ · Ranjeeta Kumari¹ · Megha Sharma¹

Pawna Kaushal BDS, MPH Student, Department of Community and Family Medicine All India Institute of Medical Sciences, Rishikesh; Meenakshi Khapre MD, Associate Professor, Department of Community and Family Medicine All India Institute of Medical Sciences, Rishikesh; Amity Das BDS, MPH Student, Department of Community and Family Medicine All India Institute of Medical Sciences, Rishikesh; Ranjeeta Kumari MD, Additional Professor, Department of Community and Family Medicine All India Institute of Medical Sciences, Rishikesh; Megha Sharma BDS, MPH Student, Department of Community and Family Medicine All India Institute of Medical Sciences, Rishikesh.

Pawna Kaushal pawnakaushal@gmail.com

1 Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, India

Background
Due to the significant role of male in decision making in India, they may decide if, when and where a woman may access antenatal, delivery and postnatal care; and whether or not to provide financial resources to travel to these services. Men's involvement in maternity care is recognized as a key strategy in improving maternal health and accelerating the reduction of maternal mortality. This study explores key components and challenges to male involvement in maternal health care (MHC).

Methods
Focus group discussions (FGDs) were conducted with a purposive sample of the community key stakeholders from the field practice area of All India Institute of Medical Sciences, (AIIMS) Rishikesh from October 2020 to January 2021. Manual thematic analysis with a semantic approach was used for the data analysis. Themes were prioritized using Participatory rural appraisal (PRA) technique.

Results
Twenty-three participants represented the heterogeneous group of key stakeholders. Stakeholders identified the need for improved awareness regarding MHC services among men. Husband involvement is affected by availability (work stations at different places), literacy, gender-based work domain and social cultures, finances and health facility environment.

Four major themes were identified: Male involvement in antenatal, intranatal; postnatal care; and barriers to male involvement in MHC. Sub-themes under male involvement in antenatal care; intranatal care; and postnatal care were further prioritized via PRA as ‘very important’; ‘important’ and ‘not so important’ and scores were given as 3, 2 and 1 respectively.

Conclusions
Male involvement is a key strategy to improve pregnancy outcome; however, different challenges exist in their involvement in the maternal health care. Current study helped to contextualize the perception regarding importance of male involvement in MHC; and the situation of study area in order to understand social and cultural factors that shape the behavior and practices of men in relation to their involvement.

Keywords : Perception · Male involvement · Maternal health care · Husbands’ involvement · MHC

Abbreviations
ANC Antenatal care

ANM Auxiliary Nurse Midwife

ASHA Accredited Social Health Activist

AWW Anganwadi worker

FGD Focus group discussion

MHC Maternal health care

MMR Maternal mortality ratio

PNC Postnatal care

PRA Participatory rural appraisal

WHO World Health Organization

The survival and well-being of mothers are not only important in their own right but also an important aspect of the development of any country in terms of increasing equity and reducing poverty; and solving large broader, economic, social and developmental challenges. To ensure safe motherhood, strengthening MHC services is very important at every stage [1, 2]. Maternal Mortality Ratio (MMR) is one of the important indicators of the quality of MHC services. According to the global estimate of the World Health Organization (WHO) in 2017, MMR was 211 per 100,000 live births [1], and in India, MMR was 113 per 100,000 live births in indices 2016–18 [1, 3].
Male involvement in MHC has been recognized as a key strategy in improving maternal health and accelerating reduction of maternal mortality globally [4–6]. In a meta-analysis of Yargawa J, male involvement is associated with improved maternal health outcomes in developing countries [7]. But maternal health-related problems have largely been perceived and treated purely as a women's role, and men have been exclusively excluded from MHC services. Husband has a decisive role in, when and where a woman may access MHC services and to provide financial resources to travel for these services [8, 9].

According to India’s National Health and Family Survey- IV, 68.2% of men were present with their wives during any ANC visit and 17.8% men were not present during any ANC visit [10]. In Uttarakhand, 66.5% of men accompanied their wives on any ANC visit [11]. Several studies concerning male partners' involvement in the ANC in India showed varied results ranging from 22 to 75.9% [12–15]. Men who were not present during ANC visits thought that their attendance was unnecessary [10].

Low (35%, 44%, and 20%) male involvement is reported during antenatal care, delivery, and postnatal care services, respectively, in a study of Ghana [8]. In a Nigerian study, 53.2% of the male respondents had good knowledge of emergency obstetric conditions (danger signs), and 97.4% encouraged their wives to attend antenatal clinic [16]. In Central Tanzania study, 53.9% men were involved in ANC visits [9]. Inconsistent results were reported by other studies [17–20].

Till now in India, the main focus has only been given to men’s involvement in ANC services utilization. Other components like the husband's role at home, during delivery, and how women feel during pregnancy are understudied in India. Males themselves are not clear about the importance of their role in MHC. To best of our knowledge, in India, no scale is available to measure male involvement in MHC. Also, there is a need to understand cultural, socio-economic, and facility-based barriers to male involvement and how it can help to improve male involvement in MHC. This study aimed to 1. Explore the community perspective of key components and challenges; 2. Develop a scale to measure male involvement in MHC in Dehradun district, Uttarakhand, India.

Declarations

Competing Interests All authors declare that they have no competing interest.
Ethical Approval Ethical approval from Institutional Ethics Committee, All India Institute of Medical Sciences, Rishikesh (AIIMS/IEC/20/808) was sought before the conduct of study. Written consent from the participants was obtained after informing them purpose of study; voluntary participation; and no harm to the participant. All methods were performed in accordance with the relevant guidelines and regulations. To protect the confidentiality of participants no names or positions have been reported in the manuscript.

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