INTRODUCTION

Unpredictable complications may be associated with the sensitive period of pregnancy and during childbirth.1 Globally, about 830 women die every day from preventable causes of pregnancy and childbirth.2 The lifetime risk of a woman dying as a result of pregnancy or delivery is nearly 1 in 220 in India, compared to 1 in 4900 in developed countries.3

To reduce maternal mortality, one of the key interventions is birth preparedness and complication readiness (BPCR).4 Due to a wide range of factors at multiple levels, we need to engage women, families, communities, providers, facilities and policy-makers in actions related to BPCR.4

To prevent maternal deaths and to minimize complications, exploring the role of men in BPCR would be of value5 as men act as gatekeepers to women’s health.1 In familial and societal matters, men are the decision-makers and economic resource providers in many patriarchal societies.6 Husbands were also responsible for maintaining the nutrition of their pregnant wives.7 Women who were supported by their husbands were found to be more empowered and they tolerated the pressures of pregnancy and labour much better than the women who did not have the support of their husbands.8 Reluctance of some husbands to attend antenatal classes conducted at our clinic was the motivation for this study. If information was provided to men, they would understand the proven benefits of attending antenatal care and would support their partners.9 Therefore, we aimed to study the role of male partners in BPCR of pregnant women attending an antenatal clinic in Kerala.

METHODS

This qualitative study was based on the grounded theory approach. Data were collected through 29 in-depth interviews conducted among husbands (n=8), mothers (n=8), mothers-inlaw (n=8), health professionals (n=5) and focus group discussions (FGDs) with pregnant women (FGD, n=3) till data saturation was reached. The study was conducted at the antenatal clinics of the rural community health centre in Njarakkal, Kerala. Pregnant women attending these antenatal clinics were purposively selected for the FGDs, with each group having 8– 12 participants and each session lasting for 40–45 minutes. During the FGDs, antenatal mothers who were found to be resourceful and those with and without husband involvement in pregnancy care were noted. It was ensured that women were from different socioeconomic and geographical strata. Their mothers, mothers-in-law and husbands were invited to participate in an in-depth interview to get a holistic perspective. Those who accompanied them to the hospital were interviewed at the clinic while the non-accompanying mothers, husbands and mothers-in-law were contacted via phone and an appointment was fixed at a place and time convenient for them. The healthcare professionals who closely interacted with the antenatal mothers were also interviewed. Each of these interviews lasted for 20–30 minutes.

Both interviews and FGDs were conducted using guides prepared after extensive formative research for interviews. Informed consent was obtained. The interview was audio recorded in the local language (Malayalam) and field notes were taken. The audio-recorded data were transcribed verbatim and translated into English. Manually coded transcripts were further categorized into different domains to identify emerging themes and sub-themes. To enhance the validity of the findings, they were verified independently by another researcher. The inconsistencies that emerged were overcome through discussions and a consensus was reached. Data were triangulated to draw inferences.

RESULTS

Among the husbands, mothers and mothers-in-law interviewed, a majority had an education up to high school or less, and the pregnant women were educated up to higher secondary school or graduation. The majority of husbands were occupied in skilled jobs, while most of the pregnant women, mothers and mothers-in-law were home-makers. Most of the pregnant women were primigravida in their third trimester. The key domains identified in the qualitative study are mentioned below.

Role of men in birth preparedness

It was observed that husbands were much concerned and involved in the selection and provision of nutritious food for their wives. They also motivated them to take their food on time. However, pregnant women felt and believed that, due to their years of experience, their mothers or mothers-in-law were more knowledgeable in this regard compared to their husbands. Mothers and mothers-in-law had views similar to those of the pregnant women and they opined that husbands should be involved only in the provision of food.

He will buy whatever food I want or need, but my mother gives meal-related advice—25-year-old pregnant woman

It was interesting to observe that none of the pregnant women, husbands, mothers and mothers-in-law were concerned about exercising and did not motivate them to do so. They felt that routine household chores were more than enough.

Exercise does not seem especially important as she does household work herself—50-year-old mother

Most husbands emphasized that their pregnant wives required a lot of emotional support. They were constantly reassuring them and building their confidence. The pregnant women felt that their husbands understood their feelings better than their parents. They were able to share their concerns openly with their husbands rather than their parents or in-laws. However, both mothers and mothers-in-law continually reminded the husbands not to share their worries with their pregnant wives because this might create panic among them.

Since they are going through the pregnancy together, partners are emotionally attached and they understand the feelings of each other well— 38-year-old health professional

With regard to financial support, it was observed that local customs played a big role. It was customary that the woman be sent to her own home at 7 months of her pregnancy. The expenses of the first delivery were taken care of by the woman’s family, while the second delivery and beyond were taken care of by the husband’s family. Therefore, most of the husbands had saved up enough money only for the first 7 months of the pregnancy and not for the delivery. In certain cases, treatment of infertility before the pregnancy was also taken care of by the husband. Therefore, the woman’s family was often found to save money for the delivery expenses. Even though some of them had difficulty in meeting the expenses, most mothers of pregnant women considered it their duty to do so. In some instances, husbands and mothers-in-law overlooked these customs and took care of the delivery expenses if the pregnant woman’s family was unable to do so.

According to our tradition, a pregnant woman is sent to her mother’s place by 7 months during her first delivery and brought back only after 56 days of delivery. But we didn’t give importance to customs and we took care of the delivery expenses since her mother was unable to take care of her— 36-year-old husband

Men were found to support their pregnant wives in various ways in their day-to-day activities. Some of them took care of the needs of the elder child/children such as preparing and taking them to school while the pregnant women took rest. Most of them regularly helped their pregnant wives with daily household chores. Some even ensured that the women were drinking plenty of water and were taking their medicines regularly. Pregnant women feel good when their husbands help them. Mothers and mothers-in-law had varying opinions, that husbands should help only in their absence as they cannot always be with women.

Since she needs to go to the washroom often, my wife is reluctant to drink water. However, to prevent her suffering from urinary tract infections, I keep reminding her to drink enough water—29-year-old husband

Husbands were found to play a major role in deciding the hospital where the women would go for antenatal check-ups and delivery. The other members of the family also offered suggestions in this regard. Health professionals considered the participation of husbands in the antenatal class as an important requisite for BPCR. The majority of pregnant women, mothers and mothers-in-law considered the husband’s participation in antenatal classes to be crucial because they are often the decision-makers. Husbands felt that it was important to keep themselves updated and well informed. It was observed that most men accompanied their wives to the hospitals and this was supported by the mothers, mothers-in-law and the health professionals. They felt that men can do all the enrolment procedures during hospital admission, while the mothers assisted the pregnant women to settle in without tiring them out. Women whose husbands accompanied them were found to be more confident. However, in situations where the husbands could not make it due to their jobs, the woman’s mother/mother-in-law was often found to accompany her.

Twice I accompanied her. Rest all the time she was accompanied by my mother as I work in Thiruvananthapuram, which is more than 200 km away—28-year-old husband

Role in complication readiness

With regard to complication readiness, most women in the last trimester had kept their hospital luggage packed in advance fearing last minute complications. Their mothers and mothers-in-law helped them keep it ready because the men had no clue what was to be taken to the hospital. The role of the husbands in complication readiness according to pregnant women, mothers and mothers-in-law was to arrange a vehicle for transportation to the hospital and to identify blood donors. None of the husbands knew that they needed to identify possible blood donors beforehand. They somehow did not realize its importance.

I didn’t know we should identify blood donors. For the first delivery, we didn’t need anyone. If an emergency comes someone will come by—32-year-old husband

The majority of husbands and pregnant women were interested in the concept of birth companionship. Husbands wanted to support their partners and wanted to know the difficulties they faced. At the same time, some of them openly admitted that they were afraid of the birthing procedure. Most mothers and mothers-in-law were against the idea of birth companionship at the time of delivery because they felt husbands have no role in delivery. Pregnant women and health professionals felt birth companionship would increase respect, understanding and bonding between the couples. It also relieved pain, gave mental strength to the women and improved spacing practices. However, this facility was available only in some hospitals in Kerala.

If the management decides we can easily arrange birth suits, as this being a private hospital. But in government hospitals due to lack of facilities and lack of health professionals, it is difficult—38-year-old health professional

Motivators for male participation in birth preparedness and complication readiness

Both pregnant women and their husbands were of the opinion that the key motivation for the men’s participation in BPCR was that they felt responsible for the pregnancy. They wanted to be aware of the entire process and wanted to prevent any complication from happening as best as they could. In some cases, pregnant mothers had no one other than their husbands to support them as the mothers and mothers-in-law were either too old or unwell to do so. Another factor was previous bad obstetric history such as abortion, which was also a key factor that led to participation of the husbands in BPCR. According to health professionals, mothers and mothers-in-law felt the shift towards a nuclear family was the major reason for increasing the involvement of the husbands.

Ours was a love marriage. There is no one else other than me to take care of her needs—25-year-old husband

Barriers for male participation in BPCR

The major barrier for male participation identified by the husbands, pregnant women and health professionals was lack of time due to their work commitments. This prevented them from accompanying their wives for check-ups. In addition, some husbands were living abroad and were unable to get leave to be with their pregnant wives. Lack of appropriate knowledge regarding pregnancy care was another barrier identified by the husbands especially those who did not have an elderly woman in the family to brief them about it. According to the mothers and mothers-in-law they felt that men did not have the knack or experience in pregnancy and related matters.

Pregnancy care should be done by women as they are more experienced. Men can’t lend help as they don’t know much about pregnancy and child care—52-year-old mother-in-law

Change over generations in male participation

Male participation in BPCR has improved over generations. In earlier days, decisions regarding BPCR were taken by elders in the family especially women. Husbands had no say in the matter and were not even allowed to stay by their wives at the time of delivery or be with them after it. According to the mothers and mothers-in-law, institutionalized deliveries have improved the participation of husbands. They and health professionals were of the opinion that the shift from the joint family system to the nuclear family system encouraged men being more participatory in the whole birthing process.

In the olden days, husbands never needed to get involved as there were mother, aunts and sisters. But the husband needs to support his wife in a nuclear family—64-year-old mother-in-law

Pregnant women felt that this change occurred as a result of globalization and the influence of the West. While the husbands felt that the gender differences have been mitigated due to better awareness and men have realized that they should play an important role in BPCR.

DISCUSSION

This study highlights the role of men in BPCR. Men play a major role in the provision of food. Lewis et al.7 stated that women were dependent on their husbands not only for financial support but men were also responsible for maintaining the nutrition of their pregnant wives. This was the finding in our study as well. However, pregnant women preferred the advice of elderly women regarding nutrition since they were more experienced.

Provision of emotional support was another role played by the husbands throughout the process of pregnancy and delivery. Other family members also recognized this role of men. Akbarzadeh et al.8 had a similar finding where women who were supported by their husbands were found to be more empowered and they tolerated the pressures of pregnancy and labour much better than those who did not have the support of their husbands. Mortazavi et al.10 and Simbar et al.11 showed that the most critical aspect of the father’s role in perinatal care was to provide emotional support to the mother by showering her with love and affection. This was found to reduce postpartum depression among the women.

In their review, Singh et al. stated that men were responsible for taking care of the financial needs of the family including expenses for delivery.12 In contrast, our study showed that most of the husbands had saved up enough money only for the first 7 months of the pregnancy and not for the delivery.

As in all patriarchal societies,13 men are major decision-makers in the family. We observed that even though other family members gave their suggestions regarding their choice of the hospital, the final decision was made by the husband who was the head of the household.

The men in our study accompanied the women during visits to the health facility, which was similar to the findings of Swain.14 As noted in MIMS India Research Evaluation of Intervention, men who accompanied their wives to the hospitals were more knowledgeable and the communication between them on reproductive health and child care was higher than those who did not accompany their wives. It was also found to improve their BPCR.5 The major barrier for men to accompany women to the hospital in our study was their work timings, which was similar to the barrier stated by Obi15 where the work timings clashed with the timings of the antenatal care clinics. In the present study, the participation of the husband in the antenatal class was emphasized as an important requisite for BPCR. Singh et al. identified that if information was provided to men, they would understand the proven benefits of attending antenatal care and would support their partners.12

The majority of husbands and pregnant women were interested in the concept of birth companionship in our study and, as pointed out by Mullany et al., the companionship provided the women with better support and enhanced the learning of men. The desire for male involvement is common, therefore approaches need to take into account the women’s concerns and desires for male involvement.9 This is in contrast to the findings of Swain who stated that cultural factors prevented men from becoming birth companions.14 However, younger educated men were found to be more ‘adventurous’ and likely to challenge the cultural norms.16

In many societies, men have been rarely involved in BPCR. The reason as stated by Iliyasu et al. was that in the past, childbirth was mainly the responsibility of women and the role of men was not clearly defined.17 Singh et al. state that cultural norms can appear to be obstacles for male involvement, when in reality culture is fluid and changes over time.12 In our study we were able to notice a cultural change, where husbands have started to overlook their customs and support their wives in the birthing process. However, they have a long way to go. As rightly pointed by Sternberg and Hubley that, ‘although perhaps no longer considered part of the problem, men have yet to be seen as part of the solution’.18

Thus, we observed that men had a major role to play in BPCR. They supported their pregnant wives by maintaining their health, providing financial support and helping them in the decision-making process regarding treatment. They also provided complication readiness support by arranging transportation and facilitating the process of hospital admission. Our findings emphasize how changes have occurred in the attitudes and practices over generations regarding men’s role in birth preparedness and their participation during delivery. However, there is still a long way to go for which transference of knowledge and cultural transformation have become necessities.