From the analysis of data, 7 major themes were evident (female roles, male roles, healthcare worker attitudes, benefits of facility-based maternity care, benefits of men’s attendance, barriers to men’s attendance, logistics and the role of Traditional Birth Attendants (TBAs)). The subthemes of male dominance, negativity and distrust between spouses, also emerged within the main themes.
Pregnancy support as a female role
Many men reported that primary pregnancy support was most often provided by other women. Overall, men told us that males were often excluded from a supporting role, even as part of a couple. Many mentioned that disclosure of pregnancy was rarely made to them in the first instance, despite some men’s wish to be the first to know. Most men reported that women typically chose to tell their mothers in law, co-wives, friends or trusted female neighbours before their husbands. Some men told us that they thought delayed or even non-disclosure to their husband was often due to women’s ‘shyness’ in discussing ‘female issues’ or fear of the husbands’ reaction to an unplanned pregnancy (which many were).
“she did not tell me but I saw her stomach growing, is when I realised that she is pregnant so when I asked her slowly that what’s happening nowadays that you’re gaining weight, that is when she told me”(FG7, P3).
“She told one of her in- laws about the pregnancy, therefore that is how I got the information. She was scared to tell me because the family planning method failed, so she thought her in law was going to convince me not to beat her up”(FGD 1,P7).
Men as the provider
Men typically reported their role during pregnancy as providers. Many participants believed that a woman should take rest and refrain from too much manual labour during pregnancy and so men took on some of her domestic duties e.g. fetching water, splitting firewood and cultivating land, activities thought to be detrimental to the health of both the mother and her unborn child. Yet, despite this belief, a few men reported assisting their wives only late in their pregnancy.
“for the mother, tough work will give her and the child problems, so you give her light work so that she can have a good life… bringing flour and fetching fire wood are some of the jobs that we help them [with] when they are pregnant” (FGD 2, P8).
Some men also reported purchasing additional food for their wife to supplement her diet, which was considered important for her health and her unborn child. A few men told us that tight fitting clothes could affect the health of the foetus; therefore they bought maternity clothes for their pregnant spouses. Just a few older participants mentioned reminding their wife about clinic appointments and occasionally accompanying them to clinic, but only if they were ill or there was a perceived complication of the pregnancy. Emotional support was mentioned, by some participants in both age groups, but only when the moderator specifically asked about it.
Men as decision maker
The patriarchal role of Luo men was also reflected in their identification of being in charge of household money and thus the decision maker of matters pertaining to maternity care. Few men reported discussing such matters with their wives, and was another example of the male dominant role which emerged during the discussions.
“I think you are the one to choose because you are the husband [and] you are the owner of the money, so when you are looking for a health facility you are the one to choose according to your money…”(FGD 2, P1).
“I will tell her –‘if you refuse to do as I say, go away’…and you know if you tell your wife to go away, tears will roll down, so it will force her to do as I say”(FGD1, P3).
As well as for financial reasons, some men also justified making decisions based on their wives poor health seeking behaviour, due to ignorance and/or laziness. As a result some men occasionally had to ‘force’ their wives to seek care from facility-based services or sometimes, the TBA.
“Even if the clinic is near, you have to force her to go to the clinic. So with laziness they will not make it even if it is free of charge”(FGD 5, P2).
Men’s perceived benefits of health facility ANC and delivery care
Knowledge about the services provided during ANC care included confirmation of pregnancy, detection of complications and testing for HIV. Some men also mentioned “checking the position of the baby in the stomach”. Weight monitoring, malaria tests, blood pressure measurements, temperature and blood group typing were also mentioned by a minority of participants. Most were aware that medication could be issued, but they could neither name the drugs nor their uses. Irrespective of the depth of knowledge of the services provided, there was strong opinion voiced across all FGDs that wives should attend ANC. However, the TBA was also mentioned, though less often, as a source of healthcare during pregnancy – particularly a source of advice because of their experience.
“When she was pregnant I told her to go to clinic or I can tell her to go to the nearest traditional birth attendant who can give her advice on how to take care of herself and the child she is carrying” (FGD 7, P1).
Most men reported that a hospital or health facility was the best place to deliver a baby. The hospital was seen as hygienic and would “prevent infection by any disease like tetanus.” Complications could be better managed because they were staffed by qualified personnel and had the necessary equipment. Hospitals could handle birth complications such as delivery of a big baby, stitching ‘cuts’. Other merits for hospital based deliveries were prevention of HIV transmission from mother to child, and vaccination after delivery.
“At first that is where [hospital] there is a specialized doctor that if you are found having a problem, then he knows what he can do. Secondly that is where there are equipments that can be used on that person in case of any problem…there is also good care and observation” (FGD 2, P4).
“…there are women who can get pregnant and they are HIV positive. If they go for delivery in a health facility and it is discovered, they can find a way to help the child not to get infected with HIV…” (FGD 6, P1).
Logistics and the TBA
However, despite this stated preference of hospital based delivery care a few men reported that using a TBA was sometimes inevitable because whilst delivery care services were affordable in hospital, the flexibility of payment for TBA services made payment easier. TBA charges were negotiable and could be paid in kind or by instalments.
“…she can discuss with the TBA and come to an agreement. Sometimes you will pay her later if you still don’t have money… but you know in hospital when you are being discharged you have to pay the entire amount”(FGD 6, P5).
“There is no [fixed] rate of payment for TBA services; it depends on how you talk to her…. now the day her husband is coming to take her is when he can give something small as gratitude”(FGD1, P1).
Furthermore, the TBA was viewed by men as local, making access much easier, particularly when transport was not available. Many men mentioned that the health facilities are far and roads are impassable, especially, during the rainy seasons. Other reasons men shared for utilising the TBA appeared to stem from the wives preference and perceived ‘manipulation’ of the situation i.e. they deliberately failed to plan for the delivery, were ignorant of the expected date of delivery, and intentionally left it too late to go to hospital once labour had started, thus the TBA was the only option left. The quotes below also serve to illustrate the subtheme of distrust which commonly emerged from the discussions.
“…most women buy time until they are not able to control [pain] so they just go to the TBA”(FGD 7, P3).
“…there are some who forget their delivery dates and when labour comes they just deliver in their houses or TBA’s…there are some who do that and when you ask…, she tells you that it just came suddenly…”(FGD 8, P1).
Benefits of male attendance to ANC
Interestingly, most participants across all FGDs reported that it was beneficial to accompany their wives for ANC, to get first-hand information about the health of their wives and unborn babies. Some men believed that their wives either distorted or withheld some information after clinic visits; the implication being that this was sometimes a deliberate act. A lack of trust meant they needed to hear it directly from the HCW, and was again another example of the distrust between the men and their wives. A few participants, especially the younger men, also reported they would be able to remind their spouses to follow the doctors’ instructions.
“For me, the benefit that I will get…[is] first-hand information, that is, what she is being told I also hear, not that I wait for a report that can be distorted, she may not tell me others” (FGD 1,P5).
Accompanying a wife to ANC was reported by a few younger men as a way to discover her HIV status, whilst others felt it encouraged disclosure between couples. Receiving counselling on HIV/AIDS and prophylaxis to prevent transmission of HIV to the unborn child was also mentioned as an important reason to visit the clinic by some men in both age groups. However, HIV testing was also perceived as a barrier for ‘other’ men and just occasionally, as a reason for their preventing wives from attending clinic.
“… if we go with her to the clinic, we can be tested and get out of there knowing our status [of HIV]… if one person is positive and another negative then we can be told how to stay together”(FGD 1, P4).
“He is an old man but he doesn’t want his wife to go to clinic because, he says that if she goes then his status (HIV) will be discovered..... He knows that he is infected but he didn’t tell the wife this thing”(FGD 3, P7).
Benefits of male attendance to delivery care
As with ANC care, participants also identified reasons they should accompany their wife during the birth. They could organise transport if referral is required, be available to sign consent for surgery, and make decisions if complications occurred. Some men reported that their wives, in some cases, would or could not, make major decisions in their absence, another example of the dominant male role in the partnership.
“When you are with her it shows contact, you are aware of what is going on there and in case of any complications or even if any referral might be needed, you may decide on what you can do…” (FGD 1, P6).
A few participants pointed out that they would be able to pay for any necessities, and importantly, could also prevent their baby from being exchanged for another.
“… nowadays the world has changed, someone can switch your child… there is a possibility that if someone wanted a baby boy and gives birth to a baby girl, they may exchange for your baby boy”(FGD 7, P1).
Some men reported that their role was to provide love and encouragement during labour.
“…being there [during delivery] gives her courage, so even if she is now pushing the child, she pushes it with happiness since you are there [laughter]…”(FGD 1, P7).
Despite the perceived benefits of accompanying their wives, very few men mentioned that they did this in practice. Indeed they only spoke of going with their wives when there were specific health issues, pregnancy complications, or laboratory tests were necessary. As such this seemed to be a ‘one off’ act not leading to routine accompaniment.
Barriers to attendance at ANC and delivery care
Most participants across the FGDs echoed three issues preventing them from accompanying their wives for either ANC or delivery care. Firstly this was seen as a ‘female’ role and thus the responsibility of mother-in-laws or co-wives rather than the male.
Secondly, as head of household and provider, men’s focus was on economic activity which was more important for them to concentrate on at this time. Interestingly, a couple of participants admitted that they had pretended to be busy so as to avoid accompanying the spouse for ANC. In this vein, some participants reported that they would readily accompany their wives to ANC if they would be given priority in the queue before women who were unaccompanied (by a male partner). This is practiced in some clinics in a neighbouring district, but it is not a Government policy.
“… if you go with your wife, they [should] consider those who have come with their husbands [and] give them the first priority…”(FGD7, P5).
The third barrier stemmed from the negative attitude that HCWs had towards men participating in ANC or delivery care. Most men in all FGDs reported that they had, or had heard anecdotally that other men had been ignored by HCWs, subjected to unfriendly attitude or even abusive language.
“ I have heard others say that if they go to the clinic, the sisters there are harsh to them so they fear going to be harassed because it leaves them in a state that they don’t like’(FG7, P1).
Most men who had accompanied their wives for delivery similarly reported that maternity staff did not allow them to enter the delivery rooms; therefore, they choose to stay away feeling that they were not wanted there.
“… those people [HCW] are so harsh and they don’t want a man to step inside [delivery room]… there is nothing you can do because you cannot see her although you wish to be near her, so it is even better for you to stay away and do some other things that can help her after delivery”(FGD 8, P7).
However, there were exceptions where few men were allowed into the labour ward but chose not to, either because they thought their wife would not like to be seen in labour, or they were afraid of what they would see.
“But when I entered this room I found some women beating walls with their hands and I felt afraid that I am also going to see my wife doing that. I went and stood outside” (FG7 P4).
There were mixed responses when men were asked about witnessing the birth of their babies. Some older men were more likely than the younger men to feel that it was culturally disrespectful for a man to see a woman giving birth.
“seeing the way the child is coming out and that is the same place that you would like to have sex at…it can’t be good because you may lose the urge”(FGD 4, P8).
Interestingly, whilst acknowledging that it was not true, some participants frequently reported that traditionally, Luo people believed that the presence of the husband at the time of delivery delays the birth of the baby.