Involving men to improve maternal and newborn health: A systematic review of the effectiveness of interventions

Improving Treatment Adherence and Retention of HIV-Positive Women Through Behavioral Change Interventions Aimed at Their Male Partners: Protocol for a Prospective, Controlled Before-and-After Study

BACKGROUND

According to the World Health Organization, in 2018, 37.9 million people were living with HIV globally. More than two-thirds were residing in sub-Saharan Africa, where the HIV prevalence in the adult population (aged 15-49 years) was 3.9%. This population included 1.3 million pregnant women, of whom 82% had received antiretroviral therapy (ART) for the prevention of HIV mother-to-child transmission. In these countries, one challenge is an insufficient level of treatment adherence, particularly in HIV-positive pregnant women. Among the causes, the lack of involvement from a male partner is a significant contributor to the problem. This issue has strongly emerged in Malawi, one of the countries with the highest HIV prevalence in the world: 9.2% of its adult population were living with HIV in 2018.

OBJECTIVE

This study aims to assess 3 interventions that are aimed at improving ART adherence and retention among HIV-positive women through engagement with their male partners in 4 Malawian health care centers.

METHODS

The prospective, controlled before-and-after study is conducted in 3 phases (total duration: 24 months): preintervention, intervention, and postintervention analyses. The number of selected clusters (clinical centers) is limited to 4: one for each intervention, plus a cluster where no intervention is performed (control arm). The interventions are as follows: opening the facility on one Saturday per month only for men, defined as a special day; testing peer-to-peer counseling among men, male champions; and providing a noneconomic incentive to all women who are accompanied by their partners to the facility, nudge. The primary outcome of the study is to evaluate the differences in retention in care and adherence to therapeutic protocols among women; the intermediate outcome is the assessment of differences in male involvement. The level of male involvement in the health of their partners (intermediate outcome) will be evaluated through a dedicated questionnaire administered at baseline and in the postintervention phase. Data will be collected at the clinical centers and stored in 2 electronic databases managed using 2 different types of software.

RESULTS

The analysis of data collected in the 4 centers during the preintervention phase is ongoing, as enrollment ended on March 31, 2020. The total number of patients enrolled was 452 (Namandanje: 133; Kapeni: 78; Kapire: 75; and Balaka: 166). Meanwhile, several meetings have been conducted to organize the intervention phase.

CONCLUSIONS

The study will identify the best intervention that enhances the involvement of male partners in women's health, using an approach that considers a broad spectrum of behaviors. An important aspect is the use of educational tools focused on messages, thereby initiating a reflective discussion of stereotypes and false beliefs related to the idea of masculinity present in the Malawian culture.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/19384.

Anything New about Paternal Contribution to Reproductive Outcomes? A Review of the Evidence

Paternal health and behavioral lifestyles affect reproductive and neonatal outcomes and yet the magnitude of these effects remain underestimated. Even though these impacts have been formally recognized as a central aspect of reproductive health, health care services in Europe often neglect the involvement of fathers in their reproductive programs. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for systematic reviews, a literature search was carried out to assess the possible impact of paternal health on reproductive outcomes. The comprehensive strategy included cohort studies and meta-analysis available on PubMed, Web of Science, CINAHL, and Google scholar. Cross-referencing of bibliographies of the selected papers ensured wider study capture. Paternal factors were grouped into two categories respectively identified with the terms "Biological Paternal Factors" and "Lifestyle Paternal Factors". Advanced age may impair male fertility and affect early pregnancy stages. Increased body mass index, smoking, alcohol and recreational drugs, all alter seminal fluid parameters. Hazardous alcohol use correlates with low birthweight in pregnancy and harmful behavioral lifestyles have been linked to congenital heart defects, metabolic and neurodevelopmental disorders in the offspring. Measures targeting paternal health and lifestyle within the first 1,000 days' timeframe need to be implemented in couples undergoing reproductive decisions. Health professionals, as well as future fathers, must be aware of the benefits for the offspring associated with correct paternal behaviors. More research is needed to build guidelines and to implement specific programs aiming at reproductive health promotion.

Factors contributing to men's grief following pregnancy loss and neonatal death: further development of an emerging model in an Australian sample

Background

Historically, men’s experiences of grief following pregnancy loss and neonatal death have been under-explored in comparison to women. However, investigating men’s perspectives is important, given potential gendered differences concerning grief styles, help-seeking and service access. Few studies have comprehensively examined the various individual, interpersonal, community and system/policy-level factors which may contribute to the intensity of grief in bereaved parents, particularly for men.

Methods

Men (N = 228) aged at least 18 years whose partner had experienced an ectopic pregnancy, miscarriage, stillbirth, termination of pregnancy for foetal anomaly, or neonatal death within the last 20 years responded to an online survey exploring their experiences of grief. Multiple linear regression analyses were used to examine the factors associated with men’s grief intensity and style.

Results

Men experienced significant grief across all loss types, with the average score sitting above the minimum cut-off considered to be a high degree of grief. Men’s total grief scores were associated with loss history, marital satisfaction, availability of social support, acknowledgement of their grief from family/friends, time spent bonding with the baby during pregnancy, and feeling as though their role of ‘supporter’ conflicted with their ability to process grief. Factors contributing to grief also differed depending on grief style. Intuitive (emotion-focused) grief was associated with support received from healthcare professionals. Instrumental (activity-focused) grief was associated with time and quality of attachment to the baby during pregnancy, availability of social support, acknowledgement of men’s grief from their female partner, supporter role interfering with their grief, and tendencies toward self-reliance.

Conclusions

Following pregnancy loss and neonatal death, men can experience high levels of grief, requiring acknowledgement and validation from all healthcare professionals, family/friends, community networks and workplaces. Addressing male-specific needs, such as balancing a desire to both support and be supported, requires tailored information and support. Strategies to support men should consider grief styles and draw upon father-inclusive practice recommendations. Further research is required to explore the underlying causal mechanisms of associations found.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-020-03514-6.

"We wish to have good medical care": findings from a qualitative study on reproductive and maternal health of internally displaced women in India

Internally displaced women are underserved by health schemes and policies, even as they may face greater risk of violence and unplanned pregnancies, among other burdens. There are an estimated 450,000 internally displaced persons in India, but they are not formally recognised as a group. Displacement has been a common feature in India's northeast region. This paper examines reproductive and maternal health (RMH) care-seeking among Bru displaced women in India. The study employed qualitative methodology: four focus group discussions (FGDs) were held with 49 displaced Bru women aged 18-45 between June and July 2018; three follow-up interviews with FGD participants and five in-depth interviews with community health workers (Accredited Social Health Activists - ASHAs) in camps for Bru displaced people in the Indian state of Tripura. All interviewees gave written or verbal informed consent; discussions were conducted in the local dialect, recorded, and transcribed. Data were indexed deductively from a dataset coded using grounded approaches. Most women were unaware of many of the RMH services provided by health facilities; very few accessed such care. ASHAs had helped increase institutional deliveries over the years. Women were aware of temporary contraceptive methods as well as medical abortion, but lacked awareness of the full range of contraceptive options. Challenges in accessing RMH services included distance of facilities from camps, and multiple costs (for transport, medicines, and informal payments to facility staff). The study highlighted a need for comprehensive intervention to improve RMH knowledge, attitudes, and practices among displaced women and to reduce access barriers.

Access to maternal-child health and HIV services for women in North-Central Nigeria: A qualitative exploration of the male partner perspective

BACKGROUND

In much of sub-Saharan Africa, male partners play influential roles in women's access to maternal-child healthcare, including prevention of mother-to-child transmission of HIV services. We explored male partner perspectives on women's access to maternal-child healthcare in North-Central Nigeria.

METHODS

Three focus groups were conducted with 30 men, purposefully-selected on the basis of being married, and rural or urban residence. Major themes explored were men's maternal-child health knowledge, gender power dynamics in women's access to healthcare, and peer support for pregnant and postpartum women. Data were manually analyzed using Grounded Theory, which involves constructing theories out of data collected, rather than applying pre-formed theories.

RESULTS

Mean participant age was 48.3 years, with 36.7% aged <40 years, 46.7% between 41 and 60 years, and 16.6% over 60 years old. Religious affiliation was self-reported; 60% of participants were Muslim and 40% were Christian. There was consensus on the acceptability of maternal-child health services and their importance for optimal maternal-infant outcomes. Citing underlying patriarchal norms, participants acknowledged that men had more influence in family health decision-making than women. However, positive interpersonal couple relationships were thought to facilitate equitable decision-making among couples. Financial constraints, male-unfriendly clinics and poor healthcare worker attitudes were major barriers to women's access and male partner involvement. The provision of psychosocial and maternal peer support from trained women was deemed highly acceptable for both HIV-positive and HIV-negative women.

CONCLUSIONS

Strategic engagement of community leaders, including traditional and religious leaders, is needed to address harmful norms and practices underlying gender inequity in health decision-making. Gender mainstreaming, where the needs and concerns of both men and women are considered, should be applied in maternal-child healthcare education and delivery. Clinic fee reductions or elimination can facilitate service access. Finally, professional organizations can do more to reinforce respectful maternity care among healthcare workers.

Social determinants of male partner attendance in women's prevention-of mother-to-child transmission program in Malawi

BACKGROUND

Male partners are rarely present during PMTCT (Prevention-Mother-To-Child-Transmission) services in Sub-Saharan Africa (SSA). Male involvement is increasingly recognised as an important element of women's access to care. This study aims to identify the socio-demographic characteristics, HIV-Knowledge, Attitude and Practice (KAP) among women accompanied and not accompanied by their male partners.

METHODS

We included pregnant women enrolled in PMTCT programme between August 2018 and November 2019 in the Southern Region of Malawi. Eligible women were aged 18 years or older, living with a male partner, enrolled for the first time in one of the four selected facilities. We provided a KAP survey to women and their partners attending the facilities. Our primary objective was to assess and analyse the proportion of women who were accompanied by their partner at least once. We applied descriptive statistics and logistic regressions to study the association between being accompanied and explanatory variables.

RESULTS

We enrolled 128 HIV-positive women: 82 (64.1%) were accompanied by their male partners and 46 (35.9%) were alone. In the multivariable model, women's unemployment and owning a means of transport are negatively associated with male attendance (respectively adjusted OR 0.32 [95% CI, 0.11-0.82] and 0.23 [95% CI, 0.07-0.77]), whereas, in the univariable model, high women's level of knowledge of HIV is positively associated with male attendance (OR 2.17 [95% CI, 1.03-4.58]). Level of attitude and practice toward HIV were not significantly associated to our study variable.

CONCLUSIONS

Our study shows a high male attendance in Malawi compared to other studies performed in SSA. This study highlights that women's level of knowledge on HIV and their economic condition (employment and owning a means of transport) affects male attendance. Moreover, the study points out that gender power relationships and stringent gender norms play a crucial role thus they should be considered to enhance male involvement.

Expectant Fathers' Social Determinants of Health in Early Pregnancy

This cross-sectional, descriptive study examined unmet social and economic needs and health information requests of low-income, expecting fathers who participated in the First 1000 Days program. The First 1000 Days is a systems-level intervention aiming to prevent obesity among low-income mothers and infants across 3 community health centers in Greater Boston, MA, USA. Fathers who attended their partner's first prenatal care visit were invited to complete a program survey during early pregnancy. Among 131 fathers surveyed, 45% were white, 21% were Hispanic/Latino, 55% were foreign-born, and 69% reported an annual income under $50 000. Fathers reported elevated levels of food insecurity (18%) and 33% were unaware of someone that could provide a $50 loan; however, over 85% of fathers knew someone that could provide non-financial social support. Fathers requested information about pregnancy, birth preparation, and fatherhood. Findings support addressing fathers' unmet needs during pregnancy and providing father-specific perinatal information.

Quality and women's satisfaction with maternal referral practices in sub-Saharan African low and lower-middle income countries: a systematic review

Background

sub-Saharan African Low and Lower-Middle Income Countries (sSA LLMICs) have the highest burden of maternal and perinatal morbidity and mortality in the world. Timely and appropriate maternal referral to a suitable health facility is an indicator of effective health systems. In this systematic review we aimed to identify which referral practices are delivered according to accepted standards for pregnant women and newborns in sSA LLMICs by competent healthcare providers in line with the needs of pregnant women.

Methods

Six electronic databases were systematically searched for primary data studies (2009–2018) in English reporting on maternal referral practices and their effectiveness. We conducted a content analysis guided by a framework for assessing the quality of maternal referral. Quality referral was defined as: timely identification of signal functions, established guidelines or standards, adequate documentation, staff accompaniment and prompt care by competent healthcare providers in the receiving facility.

Results

Seventeen articles were included in the study. Most studies were quantitative (n = 11). Two studies reported that women were dissatisfied due to delays in referral processes that affected their health. Most articles (10) reported that women were not accompanied to higher levels of care, delays in referral processes, transport challenges and poor referral documentation. Some healthcare providers administered essential drugs such as misoprostol prior to referral.

Conclusions

Efforts to improve maternal health in LLMICs should aim to enhance maternity care providers’ ability to identify conditions that demand referral. Low cost transport is needed to mitigate barriers of referral. To ensure quality maternal referral, district level health managers should be trained and equipped with the skills needed to monitor and evaluate referral documentation, including quality and efficiency of maternal referrals.

Trial registration

Systematic review registration: PROSPERO registration CRD42018114261.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12884-020-03339-3.

Maternal and newborn healthcare practices: assessment of the uptake of lifesaving services in Hoima District, Uganda

BACKGROUND

The current maternal mortality ratio in Uganda is 336 maternal deaths per 100,000 live births. Infant mortality is 43 deaths per 1000 live births, with 42% of the mortality occurring during the neonatal period. This might be related to a weak health system in the country. This study aimed at assessing the uptake of lifesaving services during pregnancy and childbirth in Hoima District, Uganda.

METHODS

The study used a cross-sectional quantitative design among 691 women with a child under 5 years. Households were randomly sampled from a list of all the villages in the district with the ENA for SMART software using the EPI methodology. Pre-coded questionnaires uploaded in the Open Data Kit were used for data collection. The data was cleaned and analysed using MS Excel and SPSS software. Descriptive results are presented.

RESULTS

Of the 55.1% women attending at least four antenatal care (ANC) visits, only 24.3% had the first ANC within the first trimester. Moreover, ANC services generally was of poor quality, with only 0.4% meeting all the requirements for quality of ANC service. The highest contributors to this poor quality included poor uptake of iron-folic acid (adherence 28.8%), the six-required birth preparedness and complication readiness items (13.2%), and recognition of the seven danger signs of pregnancy (3.0%). Adherence to the seven essential newborn care actions was very low (0.5%), mainly caused by three practices: initiating breastfeeding within 1 h (59.9%), lack of postnatal care within 24 h (20.1%), and failure to recognize the 6 danger signs of the newborn (2.4%). Only 11.1% of the males participated in all maternal and newborn care requirements, by encouraging women to seek healthcare (39.9%), accompanying them to healthcare (36.9%), and HIV counselling and support services (26.2%).

CONCLUSION

The study reveals poor maternal and newborn practices throughout the continuum of care, from ANC and skilled birth attendance to newborn care during childbirth. With such poor results, it is not surprising that Hoima is sixth of 10 districts that have the highest numbers of deaths due to maternal mortality in Uganda.

Parental concerns and uptake of childhood vaccines in rural Tanzania - a mixed methods study

BACKGROUND

Vaccine hesitancy has been recognized as an important barrier to timely vaccinations around the world, including in sub-Saharan Africa. In Tanzania, 1 in 4 children is not fully vaccinated. The objective of this mixed methods study was to describe and contextualize parental concerns towards vaccines in Tanzania.

METHODS

Between 2016 and 2017, we conducted a cross-sectional survey (n = 134) and four focus group discussions (FGDs, n = 38) with mothers of children under 2 years of age residing in Mtwara region in Southern Tanzania. The survey and FGDs assessed vaccination knowledge and concerns and barriers to timely vaccinations. Vaccination information was obtained from government-issued vaccination cards.

RESULTS

In the cross-sectional survey, 72% of mothers reported missed or delayed receipt of vaccines for their child. Although vaccine coverage was high, timeliness of vaccinations was lower and varied by vaccine. Rural mothers reported more vaccine-related concerns compared to urban mothers; literacy and access to information were identified as key drivers of the difference. Mothers participating in FGDs indicated high perceived risk of vaccine-preventable illnesses, but expressed concerns related to poor geographic accessibility, unreliability of services, and missed opportunities for vaccinations resulting from provider efforts to minimize vaccine wastage.

CONCLUSIONS

Findings from our cross-sectional survey indicate the presence of vaccination delays and maternal concerns related to childhood vaccines in Tanzania. In FGDs, mothers raised issues related to convenience more often than issues related to vaccine confidence or complacency. Further research is necessary to understand how these issues may contribute to the emergence and persistence of vaccine hesitancy and to identify effective mitigation strategies.

Effectiveness of a family-centered behavioral and educational counselling approach to improve periodontal health of pregnant women: a randomized controlled trial

BACKGROUND

Poor oral hygiene and high hormone levels during pregnancy can lead to a deterioration in periodontal health. This study assessed the effectiveness of a family-centered behavioral and educational counselling program on improving the periodontal health of women during pregnancy and postpartum.

METHODS

A randomized controlled trial was conducted among pregnant women (10th-22nd gestational week) and their husbands. Participating families were randomized into test and control groups. Intervention in the test group included explanation of oral health education (OHE) pamphlets, oral hygiene instruction, individualized feedback, and proposed solutions to overcome barriers in self-care. Reinforcements were implemented in the 3rd trimester of pregnancy and six months postpartum. In the control group, only OHE pamphlets were distributed. The assessed outcomes were bleeding on probing (BOP), periodontal pocket (Poc), loss of clinical attachment (LoA), and Visible Plaque Index (VPI). The data collection was carried out at baseline (T₀), in the 32nd gestational week (T₁), and 12 months postpartum (T₂).

RESULTS

Altogether 589 pregnant women were recruited, and 369 attended all three visits (test:188; control:181). In the test group, the mean VPI score at T₀ was 0.19, which decreased to 0.14 at T₁ and 0.15 at T₂. In the control group, the mean VPI decreased from 0.19 at T₀ to 0.16 at T₁, but increased to 0.22 at T₂. A main effect of time and intervention and an interaction between time and intervention were detected (all p < 0.05), indicating that the intervention effect differed between T₁ and T₂. The test group showed a significantly greater decrease over time than the control group did. Similarly, the mean BOP% decreased more significantly over time in the test group (T₀:57%, T₁:46%, T₂:35%) than in the control group (T₀:58%, T₁:52%, T₂:46%). For Poc and LoA, there were improvements in both study groups at 12 months postpartum, compared with during pregnancy (p < 0.001).

CONCLUSIONS

Providing family-centered, behavioral, and educational counselling to pregnant women at an early stage of pregnancy and with reinforcements can improve their oral hygiene and reduce gingival inflammation. The effect can be sustained over an extended period and is greater than that of distributing oral health leaflets alone.

TRIAL REGISTRATION

Clinicaltrials.gov , #NCT02937194. Registered 18 October 2016. Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02937194?cond=Family-centered+oral+health+promotion+for+new+parents+and+their+infants&draw=2&rank=1.

A cross-sectional study of the role of men and the knowledge of danger signs during pregnancy in southern Mozambique

Background

The role of the male partner and wider family in maternal health, especially in case of emergencies, has been receiving increasing attention over the last decade. Qualitative research has highlighted that women depend on others to access high quality maternity care. Currently little is known about these factors in relation to maternal health in Mozambique.

Methods

A cross sectional household survey was conducted with men and women in southern Mozambique about decision making, financial support and knowledge of danger signs. A multivariable logistic model was used to identify factors associated with knowledge of danger signs and Cohen’s kappa for agreement among couples.

Results

A total of 775 men and women from Marracuene and Manhica districts were interviewed. Maternal health care decisions were frequently made jointly by the couple (32–49%) and financial support was mainly provided by the man (46–80%). Parental and parent-in-law involvement in decision making and financial support was minimal (0–3%). The average number of danger signs respondents knew was 2.05 and no significant difference (p = 0.294) was found between men and women. Communication with the partner was a significant predictor for higher knowledge of danger signs for both men (p = 0.01) and women (p = 0.03). There was very low agreement within couples regarding decision making (p = 0.04), financial support (p = 0.01) and presence at antenatal care consultations (p = 0.001). Results suggest women and men have a high willingness for more male participation in antenatal care, although their understanding of what constitutes this participation is not clear.

Conclusion

The study findings highlight the important role men play in decision making and financial support for maternal health care issues. Strengthening male involvement in antenatal care services, by investing in counselling and receiving couples, could help accelerate gains in maternal health in Mozambique. Maternal health care studies should collect more data from men directly as men and women often report different views and behavior regarding maternal health care issues and male involvement.

Association between male involvement during antenatal care and use of maternal health services in Mwanza City, Northwestern Tanzania: a cross-sectional study

BACKGROUND

Male involvement in antenatal care (ANC) is among interventions to improve maternal health. Globally male involvement in ANC is low and varies in low-income and middle-income countries including Tanzania where most maternal deaths occur. In Sub-Sahara, men are chief decision makers and highly influence maternal health. In Tanzania information is limited regarding influence of male involvement during ANC on utilisation of maternal health services.

OBJECTIVES

To determine the effect of male involvement during ANC on use of maternal health services in Mwanza, Tanzania.

DESIGN

A cross-sectional study conducted from June to July 2019.

SETTING

This study was conducted at seven randomly selected health facilities providing reproductive, maternal and child health (RCH) services in Mwanza City.

PARTICIPANTS

Included 430 postpartum women who delivered 1 year prior to the study and attending for RCH services (growth monitoring, vaccination, postpartum care).

OUTCOME MEASURES

4 or more ANC visits, skilled birth attendant (SBA) use during childbirth and postnatal care (PNC) utilisation 48 hours after delivery.

METHODS

Interviews and observation of the women's ANC card were used to collect data. Data was entered, cleaned and analysed by SPSS.

RESULTS

The mean age of participants was 25.7 years. Of 430 women, 54.4% reported their partners attended ANC at least once, 69.7% reported they attended for four or more ANC visits during last pregnancy, 95% used SBAs during childbirth and 9.2% attended PNC within 48 hours after delivery. Male involvement during ANC was significantly associated with four or more ANC visits (Crude Odds Ratio (COR): 1.90; 95% CI: 1.08-3.35) but not with SBA use or PNC utilisation.

CONCLUSION

Male involvement in ANC is still low in Mwanza, as 46% of the partners had not attended with partners at ANC. Alternative strategies are needed to improve participation. Studies among men are required to explore the barriers of participation in overall RCH services.

First-Time Fathers' Attitudes Towards, and Experiences With, Parenting Courses in Denmark

Several studies report that men, just like women, go through a complex emotional upheaval when they are about to become parents and that men need support to be able to tackle parenthood in the best way possible. This qualitative study addresses the extent to which parenting courses attended by both the mother and the father constitute an appealing institutional service for first-time fathers and whether they find them useful in tackling the challenges they face during the pregnancy and after the birth. The article explores difficulties with recruiting fathers to such courses and ensuring their continued attendance since men's masculinity dilemmas can affect the extent to which they are willing to seek help and to complete such courses. The findings indicated that fathers' sense of responsibility and awareness of their role as a father in their child's life was strengthened, and overall, they were satisfied both with the topics addressed during the course and with the teaching. Strong networks were formed among some of the parents at the parenting course. Caution is called for when drawing general conclusions about the benefits of such courses for first-time parents, as they are seldom attended by parents with minority ethnic backgrounds or by vulnerable and underprivileged parents.

Promoting equity in maternal, newborn and child health - how does gender factor in? Perceptions of public servants in the Ethiopian health sector

Background: Advancing gender equality and health equity are concurrent priorities of the Ethiopian health sector. While gender is regarded as an important determinant of health, there is a paucity of literature that considers the interface between how these two priorities are pursued.

Objective: This article explores how government stakeholders understand gender issues (gender barriers and roles) in the promotion of maternal, newborn and child health equity in Ethiopia.

Methods: Adopting an exploratory qualitative case study design, we conducted semi-structured interviews with 17 purposively-selected stakeholders working in leadership positions with the Federal Ministry of Health and Federal Ministry of Women and Children Affairs as part of a larger study regarding the promotion of health equity in maternal, newborn and child health. A post hoc content and thematic sub-analysis was done to explore how participants raised gender issues in conversations about health equity.

Results: Efforts to address gender inequalities were synonymous with the promotion of a women’s health agenda, which was largely oriented towards promoting health service use. Men were predominant decision makers with regards to women’s health and health care seeking in both public and private spheres. Participants reported persisting gender-related barriers to health stemming from traditional gender roles, and noted the increased inclusion of women in the health workforce since the introduction of the Health Extension Program.

Conclusions: The framing of gender as a women’s health issue, advanced through patriarchal structures, does little to elevate the status of women, or promote power differentials that contribute to health inequity. Encouraging leadership roles for women as health decision makers and redressing certain gender-based norms, attitudes, practices and discrimination are possible ways forward in re-orienting gender equality efforts to align with the promotion of health equity.

Male involvement in reproductive, maternal, newborn, and child health: evaluating gaps between policy and practice in Uganda

INTRODUCTION

Male involvement in maternal and child health is a practice wherein fathers and male community members actively participate in caring for women and supporting their family to access better health services. There is positive association between male involvement and better maternal and child health outcomes. However, the practice is not always practiced optimally, especially in low- and middle-income countries, where women may not have access to economic resources and decision-making power.

AIM

This study investigates how key stakeholders within the health system in Uganda engage with the 'male involvement' agenda and implement related policies. We also analyzed men's perceptions of male involvement initiatives, and how these are influenced by different political, economic, and organizational factors.

METHODOLOGY

This is a qualitative study utilizing data from 17 in-depth interviews and two focus group discussions conducted in Kasese and Kampala, Uganda. Study participants included men involved in a maternal health project, their wives, and individuals and organizations working to improve male involvement; all purposively selected.

RESULT

Through thematic analysis, four major themes were identified: 'gaps between policy and practice', 'resources and skills', 'inadequate participation by key actors', and 'types of dissemination'. These themes represent the barriers to effective implementation of male involvement policies. Most health workers interviewed have not been adequately trained to provide male-friendly services or to mobilize men. Interventions are highly dependent on external aid and support, which in turn renders them unsustainable. Furthermore, community and religious leaders, and men themselves, are often left out of the design and management of male involvement interventions. Finally, communication and feedback mechanisms were found to be inadequate.

CONCLUSION

To enable sustainable behavior change, we suggest a 'bottom-up' approach to male involvement that emphasizes solutions developed by or in tandem with community members, specifically, fathers and community leaders who are privy to the social norms, structures, and challenges of the community.

Effect of counselling with men on perceived stress and social support of their pregnant wives

BACKGROUND

Given the important role of spouses during pregnancy, this study aimed to determine the effect of counseling with men on stress and social support of their women (primary outcomes), anxiety, depression, weight gain, newborns' anthropometric indicators, frequency of cesarean section and preterm delivery (secondary outcomes).

METHODS

102 pregnant women were randomly assigned to two groups of counseling and control. Four sessions of counseling were held for the spouses of intervention group. Perceived Personal Resource Questionnaire-85-Part2, Perceived Stress Scale, Edinburgh's Postpartum Depression Scale, and Spielberger's State and Trait Anxiety Inventory were completed before and four weeks after intervention. The participants were followed up until delivery, and newborns' anthropometric indicators, delivery type, and preterm delivery were recorded.

RESULTS

The mean score of social support increased significantly 4 weeks after intervention in the counseling group compared to the control group (MD:12.7; 95%CI: 18.5 to 6.9). There was no significant difference between groups in the mean score of stress, anxiety, depression, and weight gain during pregnancy at four weeks after intervention and also frequency of cesarean delivery, preterm delivery, and anthropometric indicators of newborns (p>0.05).

CONCLUSIONS

Counseling with fathers can be recommended as an effective intervention to increase social support of pregnant women.

TRIAL REGISTRATION

IRCT2017042910324N38. Registered 25 June 2017, http://en.irct.ir/trial/10813.

"When I got the news": Aboriginal fathers in the Kimberley region yarning about their experience of the antenatal period

Issue addressed

Paternal involvement during the antenatal period is recognised as a positive contributor to a child's health and developmental outcomes. Little is known about Aboriginal Australian men's experiences and perceptions during their partner's antenatal period.

Methods

A qualitative yarning methodology was used to explore the experiences of ten Aboriginal Australian fathers during their partner's antenatal period, in a remote Northern Australian town.

Results

The study found the participants valued supporting their partners through pregnancy, making positive changes to their lifestyles, and having access to information on pregnancy. Participants described experiencing multiple stressors during the antenatal period that impacted on their social and emotional wellbeing. This is despite the range of protective factors identified by them. Participants had diverse experiences with health care providers during the antenatal period.

Conclusions

This study demonstrated that these Aboriginal men valued engagement with antenatal care (ANC) services and highlighted strategies to improve Aboriginal paternal involvement with ANC services.

So what?

Enhancing ANC to be inclusive of fathers, through a local co‐design process, could strengthen and support Aboriginal families to achieve improved health and wellbeing outcomes across the family system.

Perception of pregnant women on barriers to male involvement in antenatal care in Sekondi, Ghana

Getting men to be actively involved in Antenatal Care (ANC) has been acknowledged by the World Health Organisation as a key indicator for better maternal health outcomes. We investigated the perception of women about barriers to male involvement in ANC in Sekondi, Ghana. Dwelling on cross-sectional design, we used a sample of 300 pregnant women (adolescents excluded) who had ever attended ANC in five fishing communities in Sekondi. The study was underpinned by a conceptual framework adapted from Doe's conceptual framework of male partner involvement in maternity care. We used questionnaire for the data collection. Both descriptive-frequencies and percentages; and inferential-binary logistic regression analyses were carried out. Seven out of ten (70%) participants indicated high male involvement in ANC. Respondents whose partners were aged 50-59 were less likely to report high male involvement in ANC compared to those whose partners were aged 20-29 years (OR = 0.47, 95% CI = [0.35-0.86], p = 0.03). Those living together with their partners were about two times more likely to report high male involvement in ANC compared to those who did not live with their partners (OR = 1.63, 95% CI = [1.18-3.19], p = 0.01). Participants who identified long waiting time at the health facility as a determinant of male involvement in ANC were less likely to report high male involvement in ANC compared to those who disagreed (OR = 0.57, 95% CI = [0.38-0.85], p = 0.01). The outcome of our study calls for male partner friendly policy driven environment at the various ANC visit points that would make men more comfortable to accompany their partners in accessing ANC services.

Male participation in antenatal care and its influence on their pregnant partners' reproductive health care utilization: insight from the 2015 Afghanistan Demographic and Health Survey

Afghanistan has made remarkable progress in reducing maternal mortality over the past few decades, and male participation in their pregnant partner's reproductive health care is crucial for further improvement. This study aimed to examine whether male attendance at antenatal care (ANC) with their pregnant partners might be beneficially associated with the degree of utilization of reproductive health care by the pregnant partners. Data for 2660 couples (women aged 16-49 years) were taken from the 2015 Afghanistan Demographic and Health Survey (AfDHS). Bivariate and multivariate logistic regression models were employed to explore the association between male attendance at ANC with their pregnant partners and reproductive health care utilization outcomes, including adequate utilization (four or more visits) of ANC services, ANC visits during the first trimester (up to 12 weeks) of pregnancy, rate of blood and urine testing during pregnancy, rate of institutional delivery and utilization of postnatal check-up services. The results indicated that the rate of male attendance at ANC with their pregnant partners was 69.4%. After controlling for covariates, pregnant partners who were accompanied to ANC by their male partners were more likely to adequately utilize ANC services (AOR=1.42; 95% CI: 1.18-1.71), commence ANC visits even during the first trimester (AOR=1.21; 95% CI: 1.03-1.42), give birth at a health facility (AOR=1.23; 95% CI: 1.03-1.47) and present themselves for postnatal check-ups (AOR=1.24; 95% CI: 1.04-1.47) than those who were not accompanied by them. The study demonstrated that participation of male partners in ANC was positively associated with their pregnant partners' utilization of reproductive health care services in Afghanistan. The findings suggest that, to improve maternal and child health outcomes in the country, it would be worthwhile implementing interventions to encourage male partners to become more engaged in the ANC of their pregnant partners.

Do male engagement and couples' communication influence maternal health care-seeking? Findings from a household survey in Mozambique

Background

This study explored effects of couples’ communication and male participation in birth preparedness and complication readiness (BPCR) on delivery in a health facility (“institutional delivery”). A cross-sectional, baseline household survey was conducted in November 2016 prior to an integrated maternal and child health project in Nampula and Sofala Provinces in Mozambique.

Methods

The study used the Knowledge, Practices and Coverage survey tool, a condensed version of the Demographic and Health Survey and other tools. The sample included 1422 women. Multivariable logit regression models tested the association of institutional delivery with couples’ communication and four elements of BPCR both with and without male partners: 1) saving money, 2) arranging transport, 3) choosing a birth companion, and 4) choosing a delivery site; controlling for partners’ attendance in antenatal care and social and demographic determinants (education, wealth, urban/rural location, and province).

Results

The odds that women would deliver in a health facility were 46% greater (adjusted odds ratio (aOR) = 1.46, 95% confidence interval (CI) = 1.02–2.10, p = 0.04) amongst women who discussed family planning with their partners than those who did not. Approximately half of this effect was mediated through BPCR. When a woman arranged transport on her own, there was no significant increase in institutional delivery, but with partner involvement, there was a larger, significant association (aOR = 4.31, 2.64–7.02). Similarly, when a woman chose a delivery site on her own, there was no significant association with institutional delivery (aOR 1.52,0.81–2.83), but with her partner, there was a larger and significant association (aOR 1.98, 1.16–3.36). Neither saving money nor choosing a birth companion showed a significant association with institutional delivery—with or without partner involvement. The odds of delivering in a facility were 28% less amongst poor women whose partners did not participate in BPCR than wealthy women, but when partners helped choose a place of delivery and arrange transport, this gap was nearly eliminated.

Conclusions

Our findings add to growing global evidence that men play an important role in improving maternal and newborn health, particularly through BPCR, and that couples’ communication is a key approach for promoting high-impact health behaviors.

'If he sees it with his own eyes, he will understand': how gender informed the content and delivery of a maternal nutrition intervention in Burkina Faso

A growing body of literature urges policymakers, practitioners and scientists to consider gender in the design and evaluation of health interventions. We report findings from formative research to develop and refine an mHealth maternal nutrition intervention in Nouna, Burkina Faso, one of the world's most resource-poor settings. Gender was not an initial research focus, but emerged as highly salient during data collection, and thus guided lines of inquiry as the study progressed. We collected data in two stages, first using focus group discussions (FGD; n = 8) and later using FGDs (n = 2), interviews (n = 30) and observations of intervention delivery (n = 30). Respondents included pregnant women, breastfeeding mothers and Close-to-Community (CTC) providers, who execute preventative and curative tasks at the community level. We applied Morgan et al.'s gender framework to examine intervention content (what a gender-sensitive nutrition programme should entail) and delivery (how a gender-sensitive programme should be administered). Mothers emphasized that although they are often the focus of nutrition interventions, they are not empowered to make nutrition-based decisions that incur costs. They do, however, wield some control over nutrition-related tasks such as farming and cooking. Mothers described how difficult it is to consider only one's own children during meal preparation (which is communal), and all respondents described how nutrition-related requests can spark marital strife. Many respondents agreed that involving men in nutrition interventions is vital, despite men's perceived disinterest. CTC providers and others described how social norms and gender roles underpin perceptions of CTC providers and dictate with whom they can speak within homes. Mothers often prefer female CTC providers, but these health workers require spousal permission to work and need to balance professional and domestic demands. We recommend involving male partners in maternal nutrition interventions and engaging and supporting a broader cadre of female CTC providers in Burkina Faso.

Educating men about vaginal microbicides: considerations from Kenya

Men desire to be involved in their partner's decision-making about vaginal microbicide use. This coincides with women's desire to inform male partners about their microbicide use. Educating men about microbicides may enhance acceptability and generate critical support for the female participants of microbicide trials. In this multiphase mixed-methods study, we adapted an educational intervention on vaginal microbicides and tested it among men (n = 45) to determine its effect on men's knowledge regarding HIV/STI, vaginal microbicides and microbicide trials. We also conducted focus group discussions (FGDs) with the female partners (K = 3, n = 43) of the study participants and community representatives (K = 2, n = 24) to obtain their views on male partner microbicide education. We analysed FGD data for key themes using content analysis. HIV and vaginal microbicide knowledge scores increased significantly among men after the educational intervention. Both women and men highly supported male partner microbicide education, in the context of existing gender relations, to increase men's understanding about microbicides, promote adherence and help women gain their partners' trust. Complex gender dynamics should be considered when designing male partner educational interventions to improve acceptability and the use of microbicides and other female-initiated HIV prevention methods.

Mixed-Methods Systematic Review of Behavioral Interventions in Low- and Middle-Income Countries to Increase Family Support for Maternal, Infant, and Young Child Nutrition during the First 1000 Days

Fathers, grandmothers, and other family members' influence on maternal, infant, and young child nutrition (MIYCN) is widely recognized, yet synthesis of the effectiveness of engaging them to improve nutrition practices during the first 1000 d is lacking. We examined the impact of behavioral interventions to engage family members in MIYCN in low- and middle-income countries through a mixed-methods systematic review. We screened 5733 abstracts and included 35 peer-reviewed articles on 25 studies (16 with quantitative and 13 with qualitative data). Most quantitative studies focused on early breastfeeding, primarily engaging fathers or, less often, grandmothers. Most found positive impacts on exclusive breastfeeding rates and family members' knowledge and support. The few quantitative studies on complementary feeding, maternal nutrition, and multiple outcomes also suggested benefits. Qualitative themes included improved nutrition behaviors, enhanced relationships, and challenges due to social norms. Interventions engaging family members can increase awareness and build support for MIYCN, but more rigorous study designs are needed. This systematic review is registered at PROSPERO as CRD42018090273, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=90273.

Male involvement interventions and improved couples' emotional relationships in Tanzania and Zimbabwe: 'When we are walking together, I feel happy'

Male involvement in maternal and child health is recognised as a valuable strategy to improve care-seeking and uptake of optimal home care practices for women and children in low- and middle-income settings. However, the specific mechanisms by which involving men can lead to observed behaviour change are not well substantiated. A qualitative study conducted to explore men's and women's experiences of male involvement interventions in Tanzania and Zimbabwe found that, for some women and men, the interventions had fostered more loving partner relationships. Both male and female participants identified these changes as profoundly meaningful and highly valued. Our findings illustrate key pathways by which male involvement interventions were able to improve couples' emotional relationships. Findings also indicate that these positive impacts on couple relationships can motivate and support men's behaviour change, to improve care-seeking and home care practices. Men's and women's subjective experiences of partner relationships following male involvement interventions have not been well documented to date. Findings highlight the importance of increased love, happiness and emotional intimacy in couple relationships - both as a wellbeing outcome valued by men and women, and as a contributor to the effectiveness of male involvement interventions.

Mothers' satisfaction with health extension services and the associated factors in Gamo Goffa zone, Southern Ethiopia

BACKGROUND

Providing compassionate and respectful maternity services in order to bring satisfaction to service users is one of the health extension services packages in Ethiopia. Though the service utilization and its associated factors have been well documented so far, yet there is a dearth of information on client satisfaction; particularly among rural women who are mostly the target groups of health extension services within the Ethiopia. Thus, this study aimed to assess mothers' satisfaction with health extension services and the associated factors in the Gamo Goffa Zone, of Southern Ethiopia.

METHODS

A community based cross sectional study was conducted among 478 women from February 1st to February 28th of 2018. A pre-tested and interviewer administered questionnaire was used to collect the data. The study participants were selected using a systematic random sampling technique by allocating a proportion to each rural kebeles. Both bivariate and multivariate logistic regression analysis were performed to identify associated factors. Odds ratio with its 95% confidence interval was used to determine the degree of association. Level of statistical significance was set at a p-value of less than 0.05.

RESULT

The overall proportion of mothers who were satisfied with health extension services was 37.4% with 95% CI (33-44%). Mothers who had good family monthly income [AOR = 4.66 (95% CI: 1.1, 20.6)], whose husbands participated in the health extension program [AOR = 4.02 (95% CI: 2.0, 8.1)], who had recent participation in planning of health extension programs [AOR = 5.75 (95% CI: 2.0, 16.5)], who were recognized as a model family [AOR = 2.23 (95% CI: 1.1, 4.6)] had higher odds of satisfaction with health extension services.

CONCLUSION

Satisfaction with the health extension services was low among women in the study area. A better household monthly income, women's and their husbands' participation in health extension services and being a member of a model family were positively associated with their satisfaction. Interventions to enhance women's satisfaction in the health extension service need to focus on household-based involvement of them and their husbands in planning and implementing the services. Likewise, expansion of experiences of model families in the community would raise satisfaction levels.

Exploring the Gender-Specific Impact of Educational Film on Maternal and Child Health Knowledge and Behavior: A Qualitative Study in Serenje District, Zambia

Background

Educational film is a communication tool that helps to present complex information simply and clearly, keeping audiences interested for longer and helping to reinforce important learning. Medical Aid Films produces educational films targeted at communities and health workers, with a focus on maternal and child health (MCH) content. Pilot work suggests that film screenings have attracted male as well as female viewers and have started to increase male involvement in MCH care. We explored stakeholder perspectives and gender-specific responses to educational films screened in a rural district of Serenje, Zambia.

Methods

A qualitative study using focus group discussions and in-depth interviews with men and women who had viewed the films at least once, and key informant interviews with health workers who helped deliver the film screenings. Thematic framework analysis was used to derive themes and subthemes, and illustrative quotes are used to substantiate interpretation of the findings.

Results

Men’s and women’s perspectives are clustered around the influence of the films on knowledge and behavior in relation to MCH topics and male involvement and overall community responses to the films. The three themes summarizing key informant perspectives relate to their impressions of the influence of the films on male involvement in MCH and their views on using film to deliver heath information.

Conclusion

Educational films have the potential to improve women’s and men’s knowledge and awareness of MCH topics, including healthy nutrition and welfare of women during pregnancy, the need to seek skilled care during pregnancy and for childbirth, and the importance of male involvement in supporting the care of women and children. Before widespread implementation, decisions must be made about whether and how to integrate the films with community health education programs, the needs, values, and preferences of men and women and how to present and deliver the film content in a way that maximizes participation of men and women in MCH but does not undermine women’s rights, autonomy, or safety.

Desire to delay the first childbirth among young, married women in India: a cross-sectional study based on national survey data

BACKGROUND

Young women in India continue to face diverse challenges that threaten their health and wellbeing. The reproductive health and rights of newly married women, who are often expected to begin childbearing soon after marriage, are often neglected. The present study aims to understand some of the factors associated with the desire to delay the first childbirth in young, married women in India.

METHODS

The study utilised the data from the most recent National Family Health Survey 2015-16 in India. Our study sample was restricted to married women who were 15-24 years of age and who had never been pregnant at the time of the survey. Chi-squared tests, independent t-tests and multivariable logistic regression analyses were performed to measure associations between multiple independent factors and the reported preferred waiting time for the first childbirth.

RESULTS

Among never pregnant, married women aged 15-24, 21.49% reported a preferred waiting time for their first childbirth of 2 years or more. Belonging to an other backward class, or OBC, (ORadjusted 1.55, 95%CI 1.14-2.10), having completed higher education (ORadjusted 2.04, 95%CI 1.11-3.76), marrying after the age of 18 (ORadjusted 1.57, 95%CI 1.10-2.24), a husband's higher education level (ORadjusted 2.42, 95%CI 1.27-4.64), a younger husband (ORadjusted 0.75, 95%CI 0.66-0.84) and non-exposure to physical violence (ORadjusted 1.84, 95%CI 1.09-3.11) were significantly associated with a longer preferred waiting time for the first childbirth.

CONCLUSION

Intimate partner violence and partner characteristics play a role in the childbearing intentions of young women after marriage. Delaying the first childbirth could improve women's educational and economic opportunities, their health, and the health of their future and properly planned children. To achieve this, it is crucial to promote and respect women's right to decide who and when to marry, when to have children, and to promote relationships free of gender-based violence.

Identifying barriers to post-placental intrauterine device placement: male partners' views

Objective: The use of post-placental intrauterine devices (IUDs) has potential to address the health issues of suboptimal breastfeeding rates and short inter-pregnancy intervals. An understudied factor that may influence choice of breastfeeding-compatible contraception among postpartum women is their romantic partner. We aimed to identify male partner influences on women's postpartum breastfeeding-compatible contraception choices.Methods: Questionnaires were administered to 75 men in Cleveland, OH, USA. Data on partner priorities, opinions and knowledge about breastfeeding and contraception, and barriers to partner IUD receipt were collected. Survey data were summarised using frequencies and percentages, and univariate logistic regression models were used to explore associations between responses.Results: Participants were predominantly African American, unmarried and had at least one child. Twenty-six participants (36%) reported using contraception with their current partner; men who had discussions and agreed about contraception with their partner were more likely to use it. Thirty-nine men (54%) intended for a future child to breastfeed; this intention was more likely for men who had a child that was breastfed previously and for those with knowledge of breastfeeding benefits. Only 25 (35%) thought a post-placental IUD was safe for breastfeeding mothers; correct IUD knowledge and a partner's positive IUD experience were significantly associated with this response.Conclusion: Our findings suggest that knowledge about breastfeeding and contraception as well as experiential learning regarding breastfeeding and contraception within a partnered relationship are important and that minimal prior experience and low knowledge in these areas may be a male partner barrier to post-placental IUD placement for breastfeeding mothers.

"The midwife helped me ... otherwise I could have died": women's experience of professional midwifery services in rural Afghanistan - a qualitative study in the provinces Kunar and Laghman

Background

Afghanistan has one of the world’s highest maternal mortality ratios, with more than 60% of women having no access to a skilled birth attendant in some areas. The main challenges for childbearing Afghan women are access to skilled birth attendance, emergency obstetric care and reliable contraception. The NGO-based project Advancing Maternal and Newborn Health in Afghanistan has supported education of midwives since 2002, in accordance with the national plan for midwifery education.

The aim of this study is to explore women’s experiences of professional midwifery care in four villages in Afghanistan covered by the project, so as to reveal challenges and improve services in rural and conflict-affected areas of the country.

Methods

An exploratory case-study approach was adopted. Fourteen in-depth interviews and four focus-group discussions were conducted. A total of 39 women participated – 25 who had given birth during the last six months, 11 mothers-in-law and three community midwives in the provinces of Kunar and Laghman. Data generated by the interviews and observations was analysed using thematic content analysis.

Findings

Many of the women greatly valued the trained midwives’ life-saving experience, skills and care, and the latter were important reasons for choosing to give birth in a clinic. Women further appreciated midwives’ promotion of immediate skin-to-skin contact and breastfeeding. However, some women experienced rudeness, discrimination and negligence on the part of the midwives. Moreover, relatives’ disapproval, shame and problems with transport and security were important obstacles to women giving birth in the clinics.

Conclusions

Local recruitment and professional education of midwives as promoted by Afghan authorities and applied in the project seem successful in promoting utilisation and satisfaction with maternal and neonatal health services in rural Afghanistan. Nevertheless, the quality of the services is still lacking, with some women complaining of disrespectful care. There seems to be a need to focus more on communication issues during the education of midwives. An increased focus on in-service training and factors promoting quality care and respectful communication is necessary and should be prioritised.

Paternal Involvement and Maternal Perinatal Behaviors: Pregnancy Risk Assessment Monitoring System, 2012-2015

OBJECTIVES

Paternal involvement is associated with improved infant and maternal outcomes. We compared maternal behaviors associated with infant morbidity and mortality among married women, unmarried women with an acknowledgment of paternity (AOP; a proxy for paternal involvement) signed in the hospital, and unmarried women without an AOP in a representative sample of mothers in the United States from 32 sites.

METHODS

We analyzed 2012-2015 data from the Pregnancy Risk Assessment Monitoring System, which collects site-specific, population-based data on preconception, prenatal and postpartum behaviors, and experiences from women with a recent live birth. We calculated adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) to examine associations between level of paternal involvement and maternal perinatal behaviors.

RESULTS

Of 113 020 respondents (weighted N = 6 159 027), 61.5% were married, 27.4% were unmarried with an AOP, and 11.1% were unmarried without an AOP. Compared with married women and unmarried women with an AOP, unmarried women without an AOP were less likely to initiate prenatal care during the first trimester (married, aPR [95% CI], 0.94 [0.92-0.95]; unmarried with AOP, 0.97 [0.95-0.98]), ever breastfeed (married, 0.89 [0.87-0.90]; unmarried with AOP, 0.95 [0.94-0.97]), and breastfeed at least 8 weeks (married, 0.76 [0.74-0.79]; unmarried with AOP, 0.93 [0.90-0.96]) and were more likely to use alcohol during pregnancy (married, 1.20 [1.05-1.37]; unmarried with AOP, 1.21 [1.06-1.39]) and smoke during pregnancy (married, 3.18 [2.90-3.49]; unmarried with AOP, 1.23 [1.15-1.32]) and after pregnancy (married, 2.93 [2.72-3.15]; unmarried with AOP, 1.17 [1.10-1.23]).

CONCLUSIONS

Use of information on the AOP in addition to marital status provides a better understanding of factors that affect maternal behaviors.

What about the men? Perinatal experiences of men of color whose partners were at risk for preterm birth, a qualitative study

BACKGROUND

Preterm birth in the United States is associated with maternal clinical factors such as diabetes, hypertension and social factors including race, ethnicity, and socioeconomic status. In California, 8.7% of all live births are preterm, with African American and Black families experiencing the greatest burden. The impact of paternal factors on birth outcomes has been studied, but little is known about the experience of men of color (MOC). The purpose of this study was to explore the experiences of MOC who are partners to women at medical and social risk for preterm birth.

METHODS

This study used a qualitative research design and focus group methods. The research was embedded within an existing study exploring experiences of women of color at risk for preterm birth conducted by the California Preterm Birth Initiative.

RESULTS

Twelve MOC participated in the study and among them had 9 preterm children. Four themes emerged from thematic analysis of men's experiences: (1) "Being the Rock": Providing comfort and security; (2) "It's a blessing all the way around": Keeping faith during uncertainty; (3) "Tell me EVERYTHING": Unmet needs during pregnancy and delivery; (4) "Like a guinea pig": Frustration with the healthcare system. Participants identified many barriers to having a healthy pregnancy and birth including inadequate support for decision making, differential treatment, and discrimination.

CONCLUSIONS

This study shows novel and shared narratives regarding MOC experiences during pregnancy, birth, and postpartum periods. Healthcare providers have an essential role to acknowledge MOC, their experience of discrimination and mistrust, and to assess needs for support that can improve birth outcomes. As MOC and their families are at especially high social and medical risk for preterm birth, their voice and experience should be central in all future research on this topic.

Implementing a healthy postpartum lifestyle after gestational diabetes or preeclampsia: a qualitative study of the partner's role

Background

Women with preeclampsia (PE) and gestational diabetes mellitus (GDM) are at increased risk for later cardiovascular disease, and lifestyle measures are recommended to prevent subsequent disease. Partner support has been shown to be important in lifestyle modification in other diseases, but there is a lack of knowledge of partner involvement in PE and GDM. The aim of this study was to explore the partner’s experiences and knowledge of gestational diseases, and how the partner wishes to contribute to lifestyle change.

Methods

A qualitative study with one focus group interview and seven in-depth individual interviews, involving eleven partners of women with a pregnancy complicated by GDM or PE. The interview data were inductively analysed using four-step systematic text condensation, supported by interdependence theory.

Results

Partners experienced a strong “we-feeling” and wanted to support the woman in lifestyle changes. At the same time, they felt insecure, worried, foolish and left out and they missed information from clinicians. The partners felt that their involvement was crucial to lasting lifestyle changes and expected that the clinicians would routinely invite them to discuss lifestyle change.

Conclusions

Partners considered themselves an important resource for lifestyle changes for women with PE and GDM, but missed being more directly invited, informed and included in maternity care and wanted to participate in the care that followed the gestational disease. This study can help health professionals to realize that partners are an overlooked resource that can make important contributions to improve the health of the whole family if they are involved and supported by health services.

Development of a Novel Scale to Measure Male Partner Involvement in the Prevention of Mother-to-Child Transmission of HIV in Kenya

Male partner involvement is an important factor in prevention of mother-to-child transmission (PMTCT). Yet, poor conceptualization has hindered optimal assessment of male involvement. We created and evaluated a brief 10-item male partner involvement scale using principal components analysis and scree plots, Cronbach's alpha, and linear regression with survey data from postpartum women with HIV (n = 200) in Kenya. The scale had a two-factor structure: male encouragement/reminders and active participation. The overall scale and the encouragement/reminders sub-scale displayed strong internal reliability. In the multivariable models, the scales were positively associated with constructive relationship dynamics, HIV status disclosure, and couple HIV testing and counseling, and negatively associated with internalized HIV stigma. The encouragements/reminders sub-scale was also negatively associated with a new HIV diagnosis during pregnancy. This work furthers the conceptualization of male partner involvement in PMTCT and provides a valid measure to assess male involvement as a pathway to better PMTCT outcomes.

The effectiveness of interventions to involve men living with HIV positive pregnant women in low-income countries: a systematic review of the literature

BACKGROUND

Male involvement (MI) along the continuum of HIV healthcare services has been promoted as a critical intervention in low-income countries and represents one of the reasons for dropout and low retention of women along the cascade of care. The present review aims to identify interventions adopted to improve MI across Antenatal Clinics (ANCs).

METHODS

For this systematic review, we searched electronic databases, including Scopus, PubMed, Web of Science (from 2008 to 2018) in English language. We included all interventions explicitly aimed at involving partners in pregnant women's HIV continuum of care and we excluded studies performed in developed countries, not involving pregnant women. We followed the PRISMA checklist.

RESULTS

We identified a total of 1694 records and excluded 1651 after duplicates were removed and abstract eligibility assessments were performed. Forty-three full-text articles were screened, but only 12 studies were included. Recurrent intermediate outcomes were antenatal partner attendance rate and male HIV testing. We subdivided articles according to the type of intervention: single intervention (7) and multiple interventions (5). Among single interventions, two studies evaluated the use of an invitation letter sent via women to encourage male attendance to the ANC. Four Randomized Controlled Trials (RCTs) compared the invitation card (standard of care, SC) to word of mouth, information letter, home visit and invitation card plus partner tracing. The partner attendance rate was lower in SC than in the intervention arm in three RCTs: information letter (14.2% vs 16.2%), home-visit (39% vs 87%) and invitation card plus partner tracing (52% vs 74%). Home visit strategies seemed the most effective. One study evaluated words of encouragement adopted to trigger women to invite their partners. Among multiple interventions, the most effective strategies in terms of male attendance included health promotion through education and healthcare worker development. These interventions were more likely to be effective in promoting MI than single interventions.

CONCLUSIONS

From the review emerges the importance of male involvement in HIV cascade for pregnant women in countries with a significant HIV incidence and the need to define more precise indicators for measuring MI.

Information = equity? How increased access to information can enhance equity and improve health outcomes for pregnant women in Peru

Background

The Peruvian health system provides care through numerous, disconnected health establishments and information systems. Our objective was to explore information use and needs of pregnant women to improve quality of care.

Methods

We carried out a mixed methods study in the Lima capital metropolitan area in 15 health centers. This included four focus groups with 34 pregnant women and surveys with 403 pregnant women.

Results

Pregnant women’s information needs depend on their age, number of pregnancies and environment. Women relied on their social networks for pregnancy-related advice and valued high-quality, timely and targeted information from the health system. Participants’ information needs include access to reliable information and responses to their questions in a warm, caring and safe environment. These needs can be met during prenatal check-ups and in group settings through informational talks and visual displays in waiting areas, as well as through appropriate digital technologies such as SMS messages and electronic health records.

Conclusions

Pregnant women need individualized health information in an understandable, secure and friendly manner to maximize their understanding of their pregnancy, follow recommendations and optimize health outcomes. Customizing e-Health programs that reach many pregnant women has greater potential for more equitable health outcomes.

Policymaker, health provider and community perspectives on male involvement during pregnancy in southern Mozambique: a qualitative study

BACKGROUND

Increasing male involvement during pregnancy is considered an important, but often overlooked intervention for improving maternal health in sub-Saharan Africa. Intervention studies aimed at improving maternal health mostly target mothers hereby ignoring the crucial role their partners play in their ability to access antenatal care (ANC) and to prevent and treat infectious diseases like HIV and malaria. Very little is known about the current level of male involvement and barriers at different levels. This study explores the attitudes and beliefs of health policymakers, health care providers and local communities regarding men's involvement in maternal health in southern Mozambique.

METHODS

Ten key informant interviews with stakeholders were carried out to assess their attitudes and perspectives regarding male involvement in programmes addressing maternal health, followed by 11 days of semi structured observations in health care centers. Subsequently 16 focus group discussions were conducted in the community and at provider level, followed by three in depth couple interviews. Analysis was done by applying a socio-ecological systems theory in thematic analysis.

RESULTS

Results show a lack of strategy and coherence at policy level to stimulate male involvement in maternal health programmes. Invitation cards for men are used as an isolated intervention in health facilities but these have not lead to the expected success. Providers have a rather passive attitude towards male involvement initiatives. In the community however, male attendance at ANC is considered important and men are willing to take a more participating role. Main barriers are the association of male attendance at ANC with being HIV infected and strong social norms and gender roles. On the one hand men are seen as caretakers of the family by providing money and making the decisions. On the other hand, men supporting their wife by showing interest in their health or sharing household tasks are seen as weak or as a manifestation of HIV seropositivity.

CONCLUSION

A clear strategy at policy level and a multi-level approach is needed. Gender-equitable relationships between men and women should be encouraged in all maternal health interventions and providers should be trained to involve men in ANC.

Perceived barriers to utilization of antenatal care services in northern Uganda: A qualitative study

OBJECTIVE

Antenatal care (ANC) utilization remains a challenge in efforts to reduce maternal mortality and improve maternal health in Uganda. This study aimed to identify perceived barriers to utilization of ANC services in a rural post-conflict area in northern Uganda.

METHODS

A qualitative study using in-depth interviews and focus group discussions of seventeen participants (pregnant women, health workers and a traditional birth attendant). The study was informed through a phenomenological approach to capture perceived barriers to utilization of ANC. The study was carried out in post-conflict Awach sub-county, Gulu District, northern Uganda. Data was analyzed using inductive conventional content analysis.

RESULTS

The main perceived barriers to ANC utilization were identified as: poor quality of care, including poor attitude of health workers; socio-cultural practices not being successfully aligned to ANC; and lack of support from the husband, including difficulties in encouraging him to attend ANC. Additionally, institutional structures and procedures at the health centers in terms of compulsory HIV testing and material requirements and transportation were perceived to prevent some pregnant women from attending ANC.

CONCLUSIONS

Identifying local barriers to ANC utilization are important and should be considered when planning ANC programs. We propose that future efforts should focus on how to ensure a good patient-provider relationship and perceived quality of care, and further how to improve inter-spousal communication and sensitization of husbands for increased involvement in ANC. We recommend more research on how socio-cultural context can meaningfully be aligned to ANC to improve maternal health and reduce maternal mortality.

Engagement of Fathers in Parent Group Interventions for Children with Congenital Zika Syndrome: A Qualitative Study

We aimed to explore the engagement of fathers in a community-based group intervention (Juntos) for children with congenital Zika syndrome (CZS) and their caregivers in Brazil. Six Juntos groups were facilitated from August 2017 to May 2018. We conducted a qualitative study to evaluate the feasibility and acceptability of the intervention for fathers of children with CZS. Methods included participant observation, focus group discussions, and semi-structured interviews of fathers with a child enrolled in the program. Data collected were transcribed, coded and thematically analyzed to explore father preference for, and beliefs about the intervention and to assess potential barriers and enablers to their involvement. Forty-nine families (61 participants) enrolled, of whom 20% (12/61) were fathers. Seven (58%) fathers attended more than 7 out of 10 sessions. The content of Juntos was found to be acceptable to those fathers who attended. Participation in the group offered fathers the opportunity to share experiences of caring for their child and demonstrate their importance as care agents. Work commitments, and the view of mothers as primary caregivers were barriers to engagement of fathers. Facilitators to engagement included a presentation of clear objectives for fathers’ involvement and the opportunity to learn a practical skill related to caring for their child. A better understanding of the perspectives of fathers is crucial to help increase their involvement in parenting interventions.

"That's a woman's problem": a qualitative analysis to understand male involvement in maternal and newborn health in Jigawa state, northern Nigeria

Background

Maternal and newborn mortality continue to be major challenges in Nigeria. While greater participation of men in maternal and newborn health has been associated with positive outcomes in many settings, male involvement remains low. The objective of this analysis was to investigate male involvement in maternal and newborn health in Jigawa state, northern Nigeria.

Methods

This qualitative study included 40 event narratives conducted with families who had experienced a maternal or newborn complication or death, in-depth interviews with 10 husbands and four community leaders, and four focus group discussions with community health workers. The interviews focused on understanding illness recognition and care seeking as well as the role of husbands at each stage on the continuum of maternal and newborn health. Data were transcribed, translated to English, and coded and analyzed using Dedoose software and a codebook developed a priori.

Results

This paper reports low levels of knowledge of obstetric and newborn complications among men and limited male involvement during pregnancy, childbirth and the post-partum period in Jigawa state. Men are key decision-makers around the location of the delivery and other decisions linked to maternal and newborn health, and they provide crucial resources including nutritious foods and transportation. However, they generally do not accompany their wives to antenatal visits, are rarely present for deliveries, and do not make decisions about complications arising during delivery and the immediate post-partum period. These gendered roles are deeply ingrained, and men are often ridiculed for stepping outside of them. Additional barriers for male involvement include minimal engagement with health programs and challenges at health facilities including a poor attitude of health providers towards men and accompanying family members.

Conclusion

These findings suggest that male involvement is limited by low knowledge and barriers related to social norms and within health systems. Interventions engaging men in maternal and newborn health must take into account these obstacles while protecting women’s autonomy and avoiding reinforcement of gender inequitable roles and behaviors.

Interventions addressing men, masculinities and gender equality in sexual and reproductive health and rights: an evidence and gap map and systematic review of reviews

OBJECTIVES

Working with men/boys, in addition to women/girls, through gender-transformative programming that challenges gender inequalities is recognised as important for improving sexual and reproductive health and rights (SRHR) for all. The aim of this paper was to generate an interactive evidence and gap map (EGM) of the total review evidence on interventions engaging men/boys across the full range of WHO SRHR outcomes and report a systematic review of the quantity, quality and effect of gender-transformative interventions with men/boys to improve SRHR for all.

METHODS

For this EGM and systematic review, academic and non-academic databases (CINAHL, Medline, PsycINFO, Social Science Citation Index-expanded, Cochrane Library, Campbell Collaboration, Embase, Global Health Library and Scopus) were searched using terms related to SRHR, males/masculinities, systematic reviews and trials (January 2007-July 2018) with no language restrictions for review articles of SRHR interventions engaging men/boys. Data were extracted from included reviews, and AMSTAR2 was used to assess quality. Outcomes were based on WHO reproductive health strategy.

RESULTS

From the 3658 non-duplicate records screened, the total systematic reviews of interventions engaging men/boys in SRHR was mapped through an EGM (n=462 reviews) showing that such interventions were relatively evenly spread across low-income (24.5%), middle-income (37.8%) and high-income countries (37.8%). The proportion of reviews that included gender-transformative interventions engaging men/boys was low (8.4%, 39/462), the majority was in relation to violence against women/girls (n=18/39, 46.2%) and conducted in lower and middle-income countries (n=25/39, 64%). Reviews of gender-transformative interventions were generally low/critically low quality (n=34/39, 97.1%), and findings inconclusive (n=23/39, 59%), but 38.5% (n=15/39) found positive results.

CONCLUSION

Research and programming must be strengthened in engagement of men/boys; it should be intentional in promoting a gender-transformative approach, explicit in the intervention logic models, with more robust experimental designs and measures, and supported with qualitative evaluations.

"The role of the man is to look for food": Lessons from men's involvement in maternal and child health programmes in rural Central Malawi

Many studies purport that in low-income countries, women are often responsible for producing, preparing and purchasing food. Consequently, policies related to food and nutrition overemphasise the role of women, underestimating the potential for cooperation and complementarity between men and women. This focus on women does not account for socially constructed expectations of women that undermine their decision-making in resource allocation. Using desk reviews, in-depth interviews and focus group discussions, our case study in Malawi sought to understand the complementary role of men in maternal and child nutrition. International agreements and Malawi’s policies were reviewed to understand how men’s involvement emerged on the nutrition policy agenda. Policymakers, stakeholders and men and women from rural Central Malawi were interviewed, sharing their experiences of men’s role in maternal and child health. The study found that men’s involvement in maternal and child health has been on the development agenda since as early as 1995. Malawi has made efforts to involve men in these areas through several policy actions and programmes. Contrary to literature suggesting that women are the main producers, procurers and preparers of food, this study found that men in rural Central Malawi are increasingly becoming responsible for providing and purchasing food. Men also play a supportive role in food preparation, helping women access diverse diets during and after pregnancy. They also take up a supportive role in household activities, providing women with assistance in housework and looking after children. The positive change in men’s roles presents an opportunity for exploring how men can contribute to food security and nutrition. Opportunities exist for designing inclusive food and agriculture policies that promote cooperation between men and women in food and nutrition. These policies can challenge misinterpretations of women’s role in food security and the underlying systems that reinforce gender inequalities.

Men's participation in maternal and child health care in Western Uganda: perspectives from the community

Background

Participation of men in Maternal and Child Health (MCH) is crucial for the reduction of infant and maternal mortality. Men may be influential in making health care decisions that may affect their female partner’s access to health care services, but also as individuals, whose health status has a significant impact on the health of their partners’ and that of their children. However, male involvement is still inadequate due to various reasons. This paper sought to explore the community perspectives towards participation of men in maternal and child health care in Kabale District, Western Uganda.

Methods

The study used a case study approach. Household questionnaires, in-depth interviews, focus group discussions, direct field observation and document review were employed to collect data. One hundred and twenty-four respondents completed a household questionnaire, eight key informants took part in semi-structured interviews and thirty-six community members (two men and two women groups) participated in focus group discussions.

Results

The participation of men in maternal and child health care was found to be low. Patriarchal community values and norms influencing gender roles hindered male involvement in MCH. More so, sensitisation on the importance of male involvement was inadequate.

Conclusion

Men’s participation in MCH is affected by multiple factors emanating from the community and health institutions. Involving men in MCH is critical, and therefore participatory and comprehensive approaches should be applied to encourage participation. Sensitisation of communities is fundamental for increasing awareness of the significance of male involvement in MCH.

Disrupting gender norms in health systems: making the case for change

Restrictive gender norms and gender inequalities are replicated and reinforced in health systems, contributing to gender inequalities in health. In this Series paper, we explore how to address all three through recognition and then with disruptive solutions. We used intersectional feminist theory to guide our systematic reviews, qualitative case studies based on lived experiences, and quantitative analyses based on cross-sectional and evaluation research. We found that health systems reinforce patients' traditional gender roles and neglect gender inequalities in health, health system models and clinic-based programmes are rarely gender responsive, and women have less authority as health workers than men and are often devalued and abused. With regard to potential for disruption, we found that gender equality policies are associated with greater representation of female physicians, which in turn is associated with better health outcomes, but that gender parity is insufficient to achieve gender equality. We found that institutional support and respect of nurses improves quality of care, and that women's empowerment collectives can increase health-care access and provider responsiveness. We see promise from social movements in supporting women's reproductive rights and policies. Our findings suggest we must view gender as a fundamental factor that predetermines and shapes health systems and outcomes. Without addressing the role of restrictive gender norms and gender inequalities within and outside health systems, we will not reach our collective ambitions of universal health coverage and the Sustainable Development Goals. We propose action to systematically identify and address restrictive gender norms and gender inequalities in health systems.

Increasing male engagement in the prevention of vertical transmission of HIV: what works in sub-Saharan Africa?

Muktar Aliyu and colleagues discuss barriers, enablers, and research gaps in engaging male partners in prevention of vertical HIV transmission in sub-Saharan Africa

Factors Associated with Pregnancy Intentions Amongst Postpartum Women Living with HIV in Rural Southwestern Uganda

Comprehensive HIV treatment and care makes it safer for women living with HIV (WLWH) to have the children they desire, partly through provision and appropriate use of effective contraception. However, nearly one third of WLWH in-care in a large Ugandan cohort became pregnant within 3 years of initiating ART and half of these incident pregnancies (45%) were unplanned. We therefore describe future pregnancy plans and associated factors among postpartum WLWH in rural southwestern Uganda in order to inform interventions promoting postpartum contraceptive uptake. This analysis includes baseline data collected from adult WLWH enrolled into a randomized controlled trial to evaluate the effect of family planning support versus standard of care at 12 months postpartum in southwestern Uganda. Enrolled postpartum WLWH completed an interviewer-administered questionnaire at enrolment. Among 320 enrolled women, mean age, CD4 count, and duration on ART was 28.9 (standard deviation [SD] 5.8) years, 395 cells/mm³ (SD = 62) and 4.6 years (SD = 3.9), respectively. One-hundred and eighty nine (59%) of women reported either personal (175, 55%) or partner (186, 58%) desire for more children in the next 2 years. Intentions to have more children was strongly associated with partner’s desire for more children (AOR = 31.36; P < 0.000), referent pregnancy planned (AOR = 2.69; P = 0.050) and higher household income > 150,000 Shs per month (AOR = 1.37; P = 0.010). Previous use of modern contraception (AOR = 0.07; P = 0.001), increasing age (AOR = 0.34; P = 0.012), having > 2 own children living in a household (AOR = 0.42; P = 0.021) and parity > 2 (AOR = 0.59; P = 0.015) were associated with reduced odds of pregnancy intention. Our findings highlight the role male partners play in influencing pregnancy intentions postpartum and the importance of engaging men in sexual and reproductive health counselling about child spacing for the health of women, children, and families. This should be addressed alongside key individual-level social, demographic, economic and structural factors within which couples can understand risks of unplanned pregnancies and access effective contraceptive methods when they need or want them.

Key Decision Makers and Actors in Selected Newborn Care Practices: A Community-Based Survey in Northern Uganda

Knowledge of key decision makers and actors in newborn care is necessary to ensure that health interventions are targeted at the right people. This was a cross-sectional study carried out in Lira district, Northern Uganda. Multivariable logistic regression was used to determine factors associated with mothers being the key decision maker regarding where to give birth from and when to initiate breastfeeding. Fathers were the key decision makers on the place of birth (54.3%, n = 505) and on whether to seek care for a sick newborn child (47.7%, n = 92). Grandmothers most commonly bathed the baby immediately after birth (55.5%, n = 516), whereas mothers and health workers were common decision makers regarding breastfeeding initiation. Predictors for a mother being the key decision maker on the place of birth included: Mother having a secondary education (AOR 1.9: 95% C.I (1.0–3.6)) and mother being formally employed (AOR 2.0: 95% (1.5–2.9)). Mothers, fathers, grandmothers, health-workers, and traditional birth attendants were the most influential in the selected newborn care practices. Programs that aim to promote newborn care need to involve husbands, grandmothers, and health workers in addition to mothers.

Factors associated with knowledge of obstetric danger signs and perceptions of the need for obstetric care among married men in northern Nigeria: a cross-sectional survey

Background

Male involvement in maternal, newborn and child health contributes to better health outcomes for women and their children, especially in restrictive societies. There is evidence that when men have better understanding of women’s health needs, attitudes toward utilization of maternal and child health services, of both women and men, are improved. Given the role of men as the ultimate decision makers in families in northern Nigerian society, this study assessed the determinants of men’s knowledge of danger signs in pregnancy and the continuum of obstetric care, and their perceptions of the importance of antenatal care utilization and health facility delivery.

Methods

This was a cross-sectional descriptive study. Structured questionnaires with close ended questions were administered to 1627 married men who had at least one wife younger than 25 years in communities in Nigeria northern states of Kaduna and Katsina. We use crosstabulations and means to compare characteristics of study respondents in the two states, assessing statistical significance of the differences with χ²-square and Anova tests as appropriate, and logistic regressions to assess the determinants of knowledge and perceptions.

Results

Knowledge of obstetric danger signs, especially during the postpartum period, was poor overall, but respondents were relatively more knowledgeable about danger signs during pregnancy and delivery compared with the postpartum period. Most perceived that antenatal care can reduce the risk of complications. Literate men were twice more likely to have positive health-behaviour perceptions. Wealth was positively associated with the perception that women should deliver in a health facility or hospital but did not have a statistically significant effect on the perception that antenatal care can reduce the risk of complications.

Conclusions

While knowledge of obstetric danger signs was poor, literacy and household wealth significantly influenced knowledge of obstetric danger signs and perceptions that women should deliver at a health facility. Male involvement programmes need to ensure that men are empowered to understand obstetric danger signs along the continuum of obstetric care to improve perception and utilization of maternal health services for better maternal and newborn health outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2271-1) contains supplementary material, which is available to authorized users.

Repositioning traditional birth attendants to provide improved maternal healthcare services in rural Ghana

Following the World Health Organization's recommendation for developing countries to discontinue the use of Traditional Birth Attendants (TBAs) in rural areas, the government of Ghana banned TBAs from offering maternal health care services. Since this ban, community-level conflicts have intensified between TBAs, (who still see themselves as legitimate culturally mandated traditional midwives) and nurses. In this articles, we propose a partnership model for a sustainable resolution of these conflicts. This article emanates from the apparent ideological discontent between people from mainstream medical practice who advocate for the complete elimination of TBAs in the maternal health service space and individuals who argue for the inclusion of TBAs in the health sector given the shortage of skilled birth attendants and continued patronage of their services by rural women even in context where nurses are available. In the context of the longstanding manpower deficit in the health sector in Ghana, improving maternal healthcare in rural communities will require harnessing all locally available human resources. This cannot be achieved by "throwing out" a critical group of actors who have been involved in health-care provision for many decades. We propose a win-win approach that involve retraining of TBAs, partnership with health practitioners, and task shifting.