Co-responsibility: Male Involvement in Antenatal Care in Zika Prevention

Elga Salvador

WI-HER/ Senior Gender Advisor

Tisa Barrios Wilson

WI-HER/Gender Specialist

In many low and middle-income countries (LMICs), men are the primary providers and key decision-makers in the family, often determining women's access to economic resources and restricting women’s ability to make choices about their health and children’s health.1 Since many health systems require out-of-pocket payments, this practice can limit women's access to maternal health services and obstetric care, which are essential to Zika prevention and overall maternal, newborn, and child health (MNCH) (1). In addition, women’s decreased decision-making power may interfere with their ability to engage in safe prevention practices, such as wearing a condom to prevent Zika and other STIs, and in important activities critical to child development, such as adequate maternal nutrition during pregnancy, breastfeeding practices, and caring for a sick or disabled child (2). Engaging men during pregnancy through antenatal care (ANC) visits is a critical entry-point for Zika prevention, to improve MNCH, and to address couples’ decision-making dynamics (3). Men’s greater involvement can also open opportunities to improve men’s own sexual and reproductive health, disrupt intergenerational cycles of violence, and promote men’s roles as advocates for MNCH (3).

ANC visits increase men's knowledge about the importance of maternal, postnatal, and child health services which can make them more invested in the health of their partners and children (4,5). This knowledge can translate into the provision of resources for accessing maternal services such as transportation to the hospital for delivery and payment of user fees, but also as long-term investments such as early father involvement in the infant’s life which is beneficial for child development (6).

Several studies in LMICs report positive benefits of male involvement in ANC visits, including: increased maternal access to antenatal and postnatal services, use of a skilled birth attendant, discouragement of unhealthy maternal practices such as smoking and alcohol consumption, improved maternal mental health, reduced postpartum depression, improved maternal nutritional status, reduction of stress, pain, and anxiety during delivery, and higher rates of breastfeeding and in general has a long-lasting, positive impacts in the development of children (1,3,5,7). All of these practices are crucial to reduce overall maternal and infant mortality. Some studies have also shown that increased paternal investment in the pregnancy is correlated with increased infant attachment and bonding with their child which is beneficial for child development (6,8,9).

Male participation in ANC visits can also provide opportunities for providers to counsel pregnant couples and has been shown to increase likelihood of contraception usage, uptake of HIV testing, and adoption of preventive interventions for vertical and sexual transmissions of HIV.  Since Zika is also sexually transmitted, ANC visits are a key window of opportunity to counsel pregnant couples to promote condom usage (2) Finally, several studies have reported that male presence at ANC visits are correlated with an improvement in couple communication, an increase in joint decision-making, and an impact in identifying and reducing gender-based violence (1,10).

While the benefits are well documented, it is also important to understand that male involvement in ANC does not work for every situation. In relationships with intimate partner violence (IPV) or other unhealthy controlling behaviors, the woman may not want her partner to be involved. Therefore, its critical to seek the woman’s consent before involving her partner. In addition, providers should be sensitive that not all pregnant woman have partners, and to be wary of programs and policies that prioritize women with partners present at the expense of further isolating single mothers.

Under USAID’s Applying Science to Strengthen and Improve Systems (ASSIST) Project, WI-HER is helping countries in the Latin America and Caribbean region uncover barriers to male participation in ANC, strengthen existing male engagement initiatives, and help health providers and facilities plan new initiatives.

Working alongside ASSIST staff, we conducted gender analyses in Honduras, Guatemala, and the Dominican Republic and identified three primary barriers that prevent men from engaging in antenatal care visits. The first is the idea that pregnancy and childcare is considered the responsibility of women, which is reflected in the “machismo” cultural idea that men are not expected to be involved in seeking care for their wives and children, especially during pregnancy, childbirth, and the postpartum period (11).

We want to promote awareness that men can take care of a baby, that it’s not just the woman’s role. But this is not the custom here, there are many cultural barriers and there is a lot of machismo. We want to free this stigma and change these roles.” (Health Provider, Tela, Honduras)

The second barrier, is that men often perceive the health system, including the attitudes of maternity healthcare workers, as unwelcoming, intimidating and unsupportive of male participation (12,13). While it is of the utmost importance to focus on the needs of the woman, providers should also engage and include the partner in the conversation or even let them in the room with the woman’s consent. In addition, men often complain that the health system is too slow, are unwilling to endure long wait times, and generally avoid the health system unless it is an emergency or for work clearance.

"In the Guatemalan culture the health center is used practically only by women and children, the men prefer to pay for a private consultation, and only for the health check they need for work, but not for personal consultation. "(Man, Teculután, Guatemala)

The third and most commonly cited barrier is logistical, as ANC appointments take place during work hours and men have difficulty obtaining permission to leave work, or they cannot afford to forgo a day’s wages. Cost is also an issue and paying for food and transportation for two people can be outside a family’s budget.

It is costly here in Guatemala to get permission to accompany the woman. If I can get the money, sometimes it’s just enough for my partner to go, for her exams and her food. We do not earn enough to pay for the tickets for both of us and for the food." (Man, Llano de Animas, Guatemala)

In our most recent trip to Honduras, we learned about the initiatives that the ASSIST team in Honduras and their partners working in health facilities have been implementing to increase male involvement in Zika response. One strategy some health facilities use is to ask women to invite their partners to the ANC appointment by extending a written or verbal invitation. Some hospitals issue certified letters so that men can present them to their employers and can obtain permission to leave work for the appointment. Some health facilities run workshops or presentations with couples, and one even has an agreement with the municipality that couples who apply for a marriage license must attend a mandatory session at the hospital to learn about Zika prevention, family planning, and condom use. Some facilities target men separately, with individual counseling sessions with condom distribution and others target groups of men through health presentations, or presentations in the waiting room. While some of these initiatives are starting small and are still being tested out, many teams are optimistic and proud of their work.

Some of the changes we’ve seen in men who participated [with their partners in our workshops] is increased condom use, closer family ties, and more co-responsibility when caring for their children.” (Health Provider, El Progreso, Honduras)

These teams are working tirelessly to create a change of attitude and practices on the community level, encouraging men who participated to talk to and invite their friends, family, and neighbors to participate and become more involved.

In short, it is critical for providers to engage men as part of the solution. Promoting partner involvement through ANC visits, or other avenues, is a critical opportunity to help prevent Zika and advance overall MNCH in this region. To support our partners in this work, WI-HER applies iDARE, an innovative approach based on the science of improvement, to help country teams identify gender gaps and opportunities, train and sensitize health providers in gender integration, and provide support to improve program implementation, measurement, and evaluation.


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