Benefits of and Barriers to Male Involvement in Maternal Health Care in Ibanda District, Southwestern, Uganda

Background: Male involvement in reproductive health care has been shown to have positive outcomes on the maternal and newborn’s health as they provide resources and make crucial decisions. However, male involvement in re-productive/maternal health care in Uganda is still low. The objective of this study was to explore community perspectives on benefits and barriers to men’s involvement in maternity care in southwestern Uganda. Methods: The study was a cross-sectional, exploratory study, in Ibanda district, southwestern Uganda Data collection was collected in May 2020, using qualitative methods, narrative interviews and analyzed using a content-based approach. The sampling was done purposively and 18 narrative interviews were conducted. Results: Eighteen (18) narrative interviews were conducted at house-holds of the participants. The identified benefits of male’s involvement in reproductive care services included family wellbeing and health, health care services utilization, health care worker motivation and community improvement and development. The barriers that emerged included individual and behavioral factors like ignorance/knowledge, responsibility, excessive alcohol consumption, laziness and lack of money. Family and extended family factors included trust and cooperation by the couple, fidelity issues, domestic violence and family perceptions. The environment, cultural and gender factors like mis-perceptions of male involvement, the cultural beliefs about the role of men in reproductive care services utilization, health worker motivation and community improvement and prosperity. The barriers to male involvement in antenatal, delivery and postnatal care include individual and behavioral, family and extended family, environmental, cultural and gender and health care services factors. Therefore interventions to improve male involvement should focus on the individual, family, cultural, gender and health care services factors.


Introduction
There is evidence that male involvement in antenatal, delivery and postnatal care has benefits to men, women, the family, the community and the Heath care system [1]. There has been a number of global initiatives to increase male partner involvement in reproductive and newborn care. These include the International Conférences on Population and Development in Cairo and Beijing of 1994 and 1995 respectively and a number of other initiatives. According to Sakala et al. [1], men's reproductive health and their behavior may impact positively and/or negatively on women's reproductive health outcomes and children's well-being in society. Research shows that men not only act to restrict women and children from health care seeking but if involved may lead to better healthcare-seeking behavior and better utilization of antenatal, delivery, and postnatal care services [2]- [7]. It is known that male involvement in antenatal, delivery and postnatal improves utilization and uptake of skilled antenatal, delivery, and postnatal services and this ultimately improves maternal and newborn outcomes [3] [8]- [16].
When the men are involved in antenatal care and learn the likely pregnancy risks early directly from the health worker they are likely to be better prepared for any eventuality. The men are even more likely to ensure compliance with instructions that are given if they are present during health care provision. The Ministry of Health in Uganda implements a policy of attending to mothers who come for antenatal with the male partner first as a strategy to encourage male partner involvement in antenatal care. Men who are involved in health of their families may also enjoy better health and closer relationships with family members [17] [18] [19] [20] [21].
The factors that hinder male involvement in antenatal, delivery and postnatal care are attributed to the health system, gender and social norms, cultural values, economic status, lack of or limited health information, level of education, women empowerment and religious factors [1] [17] [18] [22]- [27]. The family dynamics and communication and the extended family may also be a hindrance of male involvement in reproductive care [22] [28] [29] [30]. Men however report that they do not feel welcome and comfortable in prenatal clinics, the health There is limited documentation of benefits of and barriers to male partner involvement in antenatal delivery and postnatal care in Ibanda district in Uganda. The aim of this study was to explore and describe the benefits of and barriers to male involvement in antenatal, delivery and postnatal care from the perspective of the local context.

Methods
The study was carried out in the Ibanda district which is located in southwestern

Study Design
The study was conceptualized, planned, and executed as a cross-sectional, exploratory study based on the Grounded Theory research designs because of its complexity in nature. The Grounded Theory also conceptualizes patterns of people's behavior in order to resolve their concerns. The data collection was done in Ibanda district, Southwestern, Uganda in May of 2020. The participants were purposively through narrative interviews (18) this was done until saturation was achieved when no new ideas were being realized from the interviews.
The Team members. Among those interviewed nine were male and nine were female and they were purposively selected. The selected participants were female who were pregnant at the time and those who had had children before, health workers they were midwives working with maternal health, men who had pregnant wives or who had had children before and community elders and opinion leaders. The recorded qualitative data from the cross-sectional study were transcribed verbatim, read and re-read, coded, and sorted into categories. The analysis was done using the content-based approach for qualitative data and themes of describing benefit of and barriers to male involvement in reproductive health were identified [23]. The limitation of the study is that they cannot be genera-

Results
The respondents included nine male and nine female who were purposively selected and these were married (4 male), unmarried (2 male), pregnant (4), previously pregnant women (2), village health team members (3; one female, two male) and health workers (3; one male, two female).

Benefits
Four thematic areas of benefits emerged from the analysis and they included family wellbeing and health, health care services utilization, health care worker motivation and community improvement and development.

Family Wellbeing and Health
This was the theme with the most benefits and they include having a healthy mother, baby and man, more love, respect and trust between man and wife, peace of mind for the mother, women doing fewer household chores, better joint planning for pregnancy, reduced expenditure on health care for the family and increased family income. These benefits created harmony in the family unit and it was happier, but where they were lacking then the family was less happy and less harmonious.
"If the man is involved, this woman will not have to explain this and that because they will be working together. They can plan together according to the resources they have, the woman might need a lot of things but if she "If a man is involved in helping his wife in reproductive care, it brings the family together and the children may become so resourceful in future because if you leave everything to the woman, she may fail to take care of the children and perhaps they may become criminals." (Respondent 7 male) "As for the baby, I have the hopes that the baby gets healthy, grows well and becomes intelligent when he or she doesn't grow well, the baby can't be intelligent." (Respondent 4 male) "When a child and the mother are healthy, the man isn't going to spend on paying hospital bill and transport, so to me a healthy family is also a benefit "Usually we think that a safe delivery is when you deliver in the hands of a health worker but male involvement leads to a safe delivery because these are the guys that are controlling budgets at home, they will provide the funds like transport so that the woman attends antenatal and delivery when it is early and complications will be minimal." (Respondent 10 male)

Health Worker Motivation
Here the health workers are happy, have a good reputation and are motivated Open Journal of Preventive Medicine because the men are participating as recommended and this means that complications are identified early and dealt with hence better outcomes for the mother and baby. The demand for the health care services will also increase.

Barriers
In the barriers 4 themes emerged and these were individual factors and behavior, family and extended family factors, environment, cultural and gender factors

Individual Factors and Behavior
The individual factors and behavior include ignorance/knowledge, responsibility, excessive alcohol consumption, laziness, lack of money and personal attitudes towards antenatal, delivery and postnatal care.
"Maybe you may find when the man has other women that distract him from his pregnant wife." (Respondent 5 female) "Being lazy also makes men not care about their wives, they neglect their responsibilities as men, they take pregnancy to be a simple joke because they find making a woman pregnant easy, so they think pregnancy and delivery are also easy." (Respondent 6 female)

Family and Extended Family Factors
The family factors include trust and cooperation within the couple, fidelity is- "When the family has conflicts, it may also prevent this man from taking care, if the relatives don't like the woman so he is also forced not to care." (Respondent 15 female) "Others it is culture, in some cultures, you find a man isn't supposed to appear when the woman is delivering and they think it is the woman's business." (Respondent 2 male) "Others, it's not actually that they aren't involved but the nature of their work they do limits them however much they would want to." (Respondent 2 male) "In most cases men find it embarrassing for them to cook, wash and do all the things for the wife, they fear public judgment of thinking maybe he was bewitched by the wife." (Respondent 8 female) "And usually men also don't have time; they are usually never in their homes but rather at work." (Respondent 8 female)

Health Services Care Factors
These include the way services are delivered the timing of the services the attitude of the health workers and the availability and access to the health care services.
"Men also usually say that when they come to the hospital with their wives, the health workers are usually rude to them." (Respondent 8 female) "The rudeness of some health workers, sometimes due to heavy work load, may lead to some men not coming to the health facility with their partners." (Respondent 9 female)

Benefits
The study explored the perceived benefits of male involvement in antenatal, delivery and postnatal care and themes include family wellbeing and health, health care services utilization, health worker motivation and community improvement and prosperity. Under family health and wellbeing similar findings in Tanzania [22], Kenya [2], Nigeria [31], Uganda [32] & Ghana [20] conquered with our findings which suggested that the child, mother, man and family had better health and overall wellbeing in the event of male involvement in maternal health care. Some of the specific benefits included having a healthy mother, baby and man, more love, respect and trust between man and wife, peace of mind for the mother, women doing fewer household chores, better joint planning for pregnancy, reduced expenditure on health care for the family and increased family income The study also found that utilization of antenatal, delivery, postnatal and even the vaccination services increased with male involvement. This is consistent with other findings in: Ethiopia [3] [8] [33], Kenya [2] [15], Nepal [34], Myanmar [35], Nigeria [31] and South Asia [29]. These also reported a strong association between male partner involvement although still low and utilization of re-
Family and extended family factors like trust and cooperation within the couple, fidelity issues, domestic violence, family planning and the extended family attitudes and perceptions were also important barriers to male involvement.
Where the relationships were good the male partner was more likely to be involved and where they were not getting on well the male was not usually involved. Similar finding were also documented in Ghana [28], where if couples were not living together the male partner was less likely to be involved in antenatal care. Other studies in Bangladesh [13], Mozambique [38] and Tanzania [22] also documented family factors as barriers to male involvement in antenatal, delivery and postnatal which is also consistent with this work.
The environmental, cultural and gender norms were also identified as barriers to male involvement in antenatal, delivery and postnatal care. Where the envi-Open Journal of Preventive Medicine ronmental, cultural and gender norms discourage male partner involvement in antenatal, delivery or postnatal care the men did not get involved. For example in some area of this community the business of pregnancy and delivery is for the women. The findings of this study are not isolated but similar other documentation in Bangladesh [13], Kenya [21], Ghana [20], India [26], Malawi [1], Mozambique [30], Nigeria [25], Tanzania [22] and Uganda [32]. If these community, cultural and social norms are addressed male involvement in antenatal, delivery and postnatal care can be improved.
Health care services factors that emerged included the way services are delivered, the timing of the services, attitude of the health workers and the availability and access to the health care services. These factors are fundamental because the recommendation by WHO and Uganda Ministry of health is that if antenatal, delivery and postnatal should be got from skilled care providers at the health facilities. This will likely give better outcomes for the mother and newborn baby.
My findings were similar to other work done in Kenya [21], Ghana [28], Nigeria [24], Tanzania [22], Myanmar [27] and Ghana [39]. The factors demonstrated in this study may be similar in many communities but they may not be necessarily generic and applicable to other communities in an entire manner.

Conclusions and Recommendation
The benefits of male involvement in antenatal, delivery and postnatal care include family wellbeing and health, health care services utilization, health worker motivation and community improvement and prosperity. Therefore interventions that encourage family wellbeing, male and community involvement are encouraged and will likely have a positive impact on maternal reproductive and newborn child health outcomes.
The barriers to male involvement in antenatal, delivery and postnatal care include individual factors and behavior, family and extended family factors, environment, cultural and gender factors and health care services factors. Therefore interventions to improve male involvement should focus on the individual, family, environment or community, cultural, gender and health care services factors.