Role of men in women’s health service utilisation in northern Nigeria: a qualitative study of women, men and provider perspectives

Abstract

Background

The 2018 Nigeria Demographic and Health Survey shows poor maternal health in northern Nigeria. Contraceptive use remains low and maternal mortality high. Studies show that cultural norms related to men’s decision-making role in the family significantly contribute to this phenomenon.

Objectives

The assessment was designed to identify barriers to service delivery and utilisation of maternal-health and family-planning services in three northern Nigerian states, focusing on aspects of service delivery affected by husband involvement.

Design

Qualitative design included 16 focus group discussions and 12 in-depth interviews with facility clients, and 16 in-depth interviews with healthcare providers, in each of the three states.

Setting

Primary healthcare facilities in three northern Nigeria states: Bauchi, Kebbi and Sokoto.

Participants

Women who came to the facility for family-planning services (n=233 in 24 focus groups); women who came for antenatal care (n=97 in 12 focus groups); men married to women who either received antenatal care or delivered in a facility (n=96 in 12 focus groups); mothers of newborns who delivered in a facility (n=36) and healthcare providers (n=48).

Results

We found gender barriers to contraceptive use and to obtaining maternal healthcare, with some women requiring their husband’s permission to use services, even in emergencies. Several supply-side barriers exacerbate the situation. Many healthcare providers would not provide women with a family-planning method without their husbands’ presence or approval; some male providers would not admit a woman to deliver in a facility if her husband objected to her being treated by a man and there was no female provider present and some facilities do not have the infrastructure to accommodate men.

Conclusion

Despite years of programming, barriers to women’s family-planning and maternal-health service utilisation persist. State governments in northern Nigeria should invest in additional provider training, improving infrastructure and hiring more female healthcare providers.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Findings may not be representative of primary healthcare in northern Nigeria, as this was a qualitative study using a convenience sample.

• We selected respondents who received care in health facilities, excluding those who chose not to attend antenatal care in a facility, deliver in a facility or obtain a family-planning method there.

• Data were collected for a different purpose—to inform improvements to health-service programming—so that some themes relevant to the current paper were not followed in sufficient detail in the interviews.

Introduction

High levels of maternal mortality continue to plague several countries in sub-Saharan Africa, despite continued efforts to address the underlying issues and reduce the incidence of maternal death.^{1 2} In 2017, sub-Saharan African countries accounted for about two-thirds of global maternal deaths.³ A major contributor to the statistic was Nigeria, especially northern Nigeria, where maternal health indicators are among the poorest in the world. Maternal mortality is high in the region, with ratios higher than 1000 per 100 000 live births estimated in some states.^{4 5}

Table 1 shows data from the Nigeria Demographic and Health Survey (2018).⁶ On several key maternal health indicators in the three northern Nigerian states that are the focus of this assessment: Bauchi, Kebbi and Sokoto, as well as Nigeria overall. Compared with the rest of the country, contraceptive prevalence is very low and most women, especially in Kebbi and Sokoto, do not receive antenatal care and do not deliver in a health facility, contributing to the high levels of maternal mortality in the region.

Table 1. Maternal health indicators in Bauchi, Kebbi and Sokoto states.

	Bauchi	Kebbi	Sokoto	Nigeria
% married women age 15–49 currently using a modern contraceptive method	5.2	3.2	2.1	12.0
% married women age 15–49 who gave birth in the past 5 years, who received antenatal care from a skilled provider in their last pregnancy	51.6	14.7	24.3	67.0
% births in the past 5 years that were in a health facility	21.8	7.4	7.8	39.4

The literature shows that male involvement plays an important role in women’s utilisation of reproductive and maternal health services and contributes to improved health outcomes.⁷,⁹ Male involvement is especially important in patriarchal societies that invest men with social and economic powers, enabling them to have significant control over their spouses, particularly health-seeking behaviours and their access to, and utilisation of, available healthcare services.^{10 11} Men in these communities often consider pregnancy to be the woman’s domain, yet, women do not have agency to make their own health decisions. Men often make health-related decisions for their wives without educating themselves on such issues.¹² In northern Nigeria, men are considered leaders and the ultimate decision-makers within their family. Women believe that this is how it should be.¹³,¹⁶ Many healthcare providers accept this cultural practice and require men’s approval before providing some services.¹⁷

As a result of these gender dynamics, many women cannot use reproductive and maternal health services without their husband’s explicit permission. Women’s demand for, and utilisation of these services is directly impacted. Men do not always give their permission for their wives to seek healthcare, for a variety of reasons, including, for example, fear of costs of services, mistrust of the healthcare system and lack of understanding of the need for care.¹⁰¹⁸,²⁰ And yet there is some evidence that things are beginning to change. A 2019 study on unmet need for family planning in Kaduna state, for example, found that while women still do not feel empowered to make contraceptive decisions, there is a growing preference for smaller families and decreased stigmatisation of contracepting women, suggesting that the state may be on the cusp of social change.¹⁷

The Integrated Health Programme (IHP), a 5-year project funded by the United States Agency for International Development, aims to contribute to state-level reductions in child and maternal morbidity and mortality and to increase the capacity of health systems (public and private) to sustainably support quality primary healthcare (PHC) services for reproductive health/family planning, maternal, newborn, child and adolescent health, nutrition and malaria. To identify barriers to service delivery and utilisation, IHP conducted a comprehensive assessment of the current state of service delivery in the states in which it works. The assessment had quantitative and qualitative components. We report on findings from the qualitative elements in three of IHP’s states: Bauchi, Kebbi and Sokoto. The broader assessment assisted IHP to evaluate each state health system holistically, starting from the community and ward, the facility, the local government area (LGA) through to the state level. The qualitative element of the assessment presented here was designed to assess services provided in primary health facilities from the perspectives of women, men and healthcare providers.

We present findings relevant specifically to reproductive and maternal health, including family planning, antenatal care and delivery services, with a focus on men’s involvement in women’s healthcare utilisation, and the interaction between the prevalent cultural norms and service delivery. Overall, we respond to the following research question: What are male involvement-related barriers to utilisation of maternal health and family-planning services in northern Nigeria?

Methods

Study design

This was a phenomenological qualitative assessment that included focus group discussions and in-depth interviews to explore provider and client perceptions of the capacity of healthcare providers, the experience of clients and quality of care; and to understand and document key facilitators and barriers to the provision and utilisation of effective, integrated healthcare services. Given the importance of men in women’s health decisions in northern Nigeria, the assessment included a component about men’s involvement, which is our focus. Descriptive phenomenology allowed us to gain a deep understanding of how clients perceive their facility experiences, and how providers perceive their experience in providing services. Study procedures in the three states were identical.

Assessment population and sample selection

Data were collected in two states in North-West Nigeria (Kebbi and Sokoto) and one in North-East (Bauchi). We conducted focus group discussions with women who came to healthcare facilities for family-planning services and antenatal care, and husbands of women who either came to the facility for antenatal care or delivered in the facility. We also conducted in-depth interviews with mothers of newborns (age 4–8 weeks) about their experience delivering in the facility, as focus group discussions with them were not practical, and with healthcare providers. The distribution of clients is shown in table 2. The reason there were twice as many focus groups with family-planning clients, compared with the other client types, was to allow us to separate participants into groups of women younger than 25 and groups of older women. This was necessary because younger women would often feel uncomfortable talking freely in front of older women. Table 2 also shows which relevant topical areas each group of participants contributed to.

Table 2. Distribution of focus group discussions and in-depth interviews.

	Bauchi	Kebbi	Sokoto	Total	Number of participants	Family planning	Antenatal care	Delivery
Focus group discussions
Family-planning clients	8	8	8	24	233	X
Pregnant antenatal care clients	4	4	4	12	97		X
Men married to antenatal/delivery clients	4	4	4	12	96		X	X
In-depth interviews
Delivery services clients	12	12	12	36	36			X
Healthcare providers	16	16	16	48	48	X	X	X
Total number of participants					510

Participant selection started with the choosing of facilities. The sample frame was the list of IHP-prioritised facilities in each of the three states. Facilities were selected from the list using a stratified purposive approach, where facilities were categorised as urban or rural based on the LGA and ward they were in. Facilities were then conveniently selected so that half of the focus groups and half of the interviews were in urban facilities and the other half in rural. A total of 16 facilities were selected from each state. One provider was interviewed per facility, purposefully selected from among all healthcare providers available on the day the study team was there, such that half the interviewed providers were female and half male. Focus group participants were recruited either in the facility or in the community near the facility. Postpartum women were identified for interviews when they exited immunisation services in the facility with their newborn. Respondents and participants were not compensated for their time.

Field work

Data were collected in September and October 2020, by a team of recruiters, moderators, interviewers, note-takers and supervisors. All data collectors were residents of the respective state in which they worked and grounded in local culture.

Participants were recruited in the facilities and in the surrounding communities. Potential participants were told about the study, and if they expressed interest in participation, were invited to a specific focus group and informed of the location and time. All participants signed a written informed consent (see the ‘Ethical approval section’).

Data collection occurred during the COVID-19 pandemic. The assessment team followed all federal and state COVID-19 guidelines, to ensure the safety of study participants and the assessment team. The study team used face masks, gloves and antibacterial soap throughout fieldwork. They used audio equipment during focus group discussions so that participants were able to hear each other while maintaining social distancing. All participants were provided with face masks.

Group discussions and interviews were undertaken in Hausa, the most commonly used language in the three assessment states. They were audio recorded then transcribed directly to English for analysis. Interviews and discussions varied greatly in length but lasted no more than 90 min.

Instruments and analysis

Question guides, designed to obtain in-depth perspectives on barriers and enablers to service utilisation, were developed by the research team and used to guide the conversations. The guides were pretested by the data collectors immediately following their training, in facilities in Abuja, the capital. The instruments were fine-tuned based on lessons learnt from this exercise before the start of data collection. Client question guides are in online supplemental file 1; provider question guides are in online supplemental file 2. Male involvement was not the focus of the question guides, as the assessment was meant to identify barriers to service utilisation writ large, but each guide included a component related to male involvement:

• Women who attended family-planning services were asked whether they were required to obtain their husband’s permission to get services.

• Women who attended antenatal care services and those who delivered in the facility were asked about their husband’s involvement in their facility experience.

• Men married to women who attended antenatal care and delivery services were asked about their wives’ facility experience, and their own perceptions of facility care.

• Healthcare providers were read a series of vignettes and asked how they would attend to the situation described. Box 1 shows the two vignettes relevant to husband’s involvement in their wives’ care.

Box 1. Vignettes administered to healthcare providers.

Family-planning vignette (asked of all providers)

Amina* is 19 years old. She got married at the age of 15 and she is the second of two wives. She has three children, the youngest is 6 months old. Amina does not want to have another child until her youngest baby is 2 years old. She is afraid to talk about this with her husband. She comes to you for advice.

• How would you counsel Amina?

• Do you think Amina needs her husband’s approval if she wishes to use a method to space her children? Why?

• If it was evident that Amina is seeking birth-spacing without her husband’s knowledge or permission, how would you handle the situation?

• What do you think about women who use family planning without their husband’s knowledge?

Delivery vignette (asked only of male providers)

Nafisa* is in labor and was brought to your facility by her husband. You are the only skilled attendant available in the facility to assist with the delivery. Nafisa’s husband insists that Nafisa be attended by a female provider. Nafisa is almost fully dilated, is in a lot of pain, and does not mind a male provider.

• What would you do?

Amina and Nafisa are fictitious characters.

A codebook was developed a priori based on the question guides. At the end of each day of data collection facilitators and interviewers in each state met to share their initial reactions and themes that stood out, leading to refinements to the a priori codebook. Data were then coded by individuals who did not participate in data collection using the Atlas.Ti qualitative data analysis software, to identify themes and subthemes that emerged from the responses, focusing on perceptions of participants of their lived experiences. Several transcripts were coded by more than one coder to ensure that there was consensus on themes. The codebook became a living document and was revised as analysis progressed. The themes and subthemes were then synthesised to respond to the assessment objectives, triangulating data from the various respondent types. We did not compare the three states, urban and rural facilities, or male and female providers because we did not reach saturation for any of the subgroups. Analysis was done separately for each state. In the Results section, we synthesise findings from the three states to a coherent whole.

Patient and public involvement

The study was conducted to obtain information needed to improve services provided in public health facilities in the study states. Facility patients were not involved in the development of the study. Rather, the study was a venue for the team to learn about patient priorities, experiences and preferences, to inform programming.

Results

Findings were fairly consistent across the three states. After we describe the participants, we present results by service area: family planning, antenatal care and delivery.

All but five female clients had at least one child (maximum seven children). All male clients had at least one child by definition, as this was an inclusion criterion. The majority of clients were Hausa/Fulani, the remainder came from various ethnic groups. Table 3 shows participant profile.

Table 3. Participant profile.

	Bauchi	Kebbi	Sokoto
Family-planning clients
Mean age	25.8	27.0	28.3
Mean number of children	2.7	2.6	4.4
% Hausa/Fulani	57.8	75.0	100
Antenatal care clients
Mean age	29.9	27.6	28.5
Mean number of children	2.4	3.0	2.7
% Hausa/Fulani	48.2	84.3	100
Delivery clients
Mean age	27.2	28.3	27.7
Mean number of children including infant	2.8	3.4	3.0
Male clients
Mean age	34.3	31.0	37.6
Mean number of children	3.3	3.8	4.5
% Hausa/Fulani	52.0	100	100
Healthcare providers
Type of provider*
% CHEW	50.0	50.0	50.0
% CHO	0	25.0	43.8
% Midwife or nurse	50.0	25.0	6.3
% female	50.0	50.0	50.0
Mean years’ experience	5.4	15.2	7.3

^*The community health extension worker (CHEW) is a member of the health team for primary healthcare (PHC). CHEWs are expected to spend 50% of their time in the clinic; they supervise the junior community health extension workers (JCHEW), the community health extension worker in training, the Vvolunteer Vvillage Hhealth Wworkers and the Ttraditional Bbirth Aattendants. CHEWs are supervised by the community health officer (CHO).

Providers represent the prevalent cadres in northern Nigeria. Equal numbers of male and female providers were selected. Their experience ranged from just a few months to over 30 years.

Family planning services

Women perspectives

When we asked women whether their husbands knew that they came to the facility for child-spacing services, many participants volunteered information about conversations they had with their husbands, and how the decision to use contraception was made. Given that there was no direct question on couple communications, we cannot report on the experience of women whose husbands did not approve or women who did not discuss contraceptive use with their husbands.

At first my husband was not in support but after explaining it to him, he agreed, and we went for it. (age 25–29, first wife, two children, Bauchi)

Many family-planning clients said that their husband’s presence or consent was required for them to obtain family-planning services.

Honestly, your husband is required. If it is your first time, you will be together with your husband. Subsequently, he will wait for you outside. (age 20–24, first wife, five children, Sokoto)

They have ever asked him, and when he came in, they explained it to him there. It is with his permission I am doing it, and they asked some questions. He agreed and they explained everything, and he said no problem. They now asked him to go and sit outside, and they continued with me (age 35–39, second wife, four children, Kebbi)

Women explained that when their husband came with them, they were often counselled together; however, sometimes there would be no space for the husband in the consultation rooms, and often there would be no waiting areas for men.

We will go into the room together, but he doesn't have a place to sit, but we are advised together. (unidentified participant, Kebbi)

When asked for their recommendations for service improvements, some participants recommended that men would be better educated about the advantages of planning their families because having many children is difficult for women, and men often do not recognise that.

[…] please let the men in Bauchi especially be enlightened about this system. Even as to stop thinking that the women don’t want to give birth. (age 20–24, first wife, two children, Bauchi)

Provider perspectives

Some providers in all three states recognised that women have a right to use family planning, even without their husband’s consent or knowledge.

I don’t think she needs her husband’s approval since he is not in support of her in spacing their children, so I will help her in child spacing so as to make sure she spaces her children in the absence of her husband. (Nurse, seven years of work experience, Bauchi)

[…] before now the woman needed the consent of her husband, but the current approach now is that you can give the family planning even without the consent of the husband. So, based on this, I can give Amina what she deserves. (CHEW, 13 years of work experience, Bauchi)

You can’t blame the women. It’s not easy because they are the ones who carry the pregnancy. (Nurse, 5 years of work experience, Kebbi)

An interesting response was from a provider in Sokoto who suggested that sometimes in the first few months of marriage, a bride’s family may want her to use a method without her husband’s knowledge, in case the marriage does not work out. This was not because of concern for Amina (the fictitious woman in the vignette), but because of the wishes of the family, since Amina is young.

There are some who do it secretly without the concern of their husband, especially in Amina’s situation. When a woman wants to get married for the first time, her family members will come ask if their child will be given family planning, reason being that the rate of divorce here is very high, they may fear for their daughter, so they will request the method for like three months to ascertain if the marriage will last long before their daughter gets pregnant. (CHO, 3 years of work experience, Sokoto)

However, most providers in all three states said they would not provide a family-planning method without the husband’s consent.

Yes, she needs his approval, if chance permits, they should even come together. Because only with his approval that is when we are going to do it for her. (CHO, 5 years of work experience, Kebbi)

What we normally did when most women come is that we ask for consent letter from their husbands (CHO, 8 years of work experience, Sokoto)

Some providers explained that they would not provide a method without husband consent because that would cause marital difficulties.

Seriously, it is not a good thing because family planning is between husband and wife, and to have a good understanding and agree to do it, because there are issues that may follow if not. (CHO, 6 years of work experience, Sokoto)

Many of the providers who would require husband approval recognised women’s plight and would counsel them on how to talk to their husband, to convince him to provide consent. One even suggested that he would go to Amina’s home to talk to her husband himself.

I would counsel her on […] what to tell her husband so they wouldn’t have issues at home. I will remind her of how important husband’s consent is. (Nurse, 5 years of work experience, Kebbi)

But I believe that won’t be a challenge because even if it means me going to his house to explain that, I will do just that for him to understand. (Nurse, 5 years of work experience, Bauchi)

Antenatal care services

Women perspectives

Some women said their husbands had a good understanding of issues related to pregnancy, but many women in all three states would like for their husband to accompany them for antenatal care visits, so that they have a better understanding of what they are going through in pregnancy.

He is really supporting me, because he will go and boil the water for me while I am in bed [laughter]. Honestly, he is really taking good care of me. There is no problem. He is really trying. (age 35–39, second wife, four children, five months pregnant)

I want them to tell the husbands they don’t know the pains you are passing through, they should inform to follow their wives for antenatal visit to hear what doctors are telling us, because when you told them the doctor said I should eat egg today and I should drink malt tomorrow […] the husband will say you are just saying for your enjoyment. (age 25–29 first wife, three children, Bauchi)

Sometimes there is something they will require of you, and your husband will not assist in that area. He will be thinking you are just doing what you feel like doing. We want them to know the importance and risk attached to pregnancy (age 25–29, third wife, three children, Kebbi)

Some women said that their husbands never accompanied them to facility visits, but others said their husbands did come with them, or that they had seen men accompany their wives for antenatal care visits. Some women seemed surprised by the idea of men accompanying their wives, and one woman said the suggestion was absurd.

Basically, like our husbands don’t normally go the facilities with us, at best they give us transport fare to go by ourselves, they don’t follow us to the hospital. (age 20–24, first wife, one child, Bauchi)

Our husbands do come, because they know it is very important, so they bring us here and take us back home as well. (unidentified participant, Kebbi)

My husband doesn’t come so it never occurred to me to ask [him] (age 35–39, first wife, three children, Sokoto)

Typically, providers do not require husbands to come with their wives for antenatal care, but a few participants in Bauchi said they were required to bring their husbands with them.

It is required that we bring our husbands to the facility in case there are complications, they won’t have to look for him since he is already available. (age 30–34, first wife, four children, Bauchi)

A few women said that when their husband accompanies them to the facility, he can join them in the consultation room, but most said this is not the case. Husbands had to wait outside, and in some facilities, there were no waiting areas for them.

A man is supposed to accompany his pregnant wife unless he is inexcusably busy. He is supposed to, because she will be more comfortable and feel loved if he goes with her. (age 35–39, first wife, one child, Sokoto)

There is no place for men to seat down and wait. We will appreciate it if a place will be provided for them to also seat down and rest. (age 25–29 first wife, four children, Bauchi)

Men perspectives

Most men in Kebbi, about half in Bauchi, and some in Sokoto indicated that they accompany their wives to antenatal care at least some of the time. They provided various reasons for accompanying their wives, such as worry for their wives it being her first pregnancy, to help reduce cost of transportation, loving their wives, receiving information from providers and fearing her use of public transportation on her own.

The reason why I do take her to the facility and bring her back myself is because of time, and also it is an oath that I have already made when I was getting married to her that her responsibility and care is on me. And lastly, I am the jealous type and I do wait for her to finish all the checkups before I accompany her back home. (age 35–39, one wife, two children, Bauchi)

We give our wives the privilege to visit healthcare facility […] We accompany them sometimes because the counselling is also helpful to us. That is the reason why we accompany them to the healthcare facility so that we will also get counselled with them, and it is helpful to them, us and our children. (age 20–24, one wife, one child, Kebbi)

I am the one who accompanies her to the antenatal care service, because giving her transportation fee is an additional expense for me. (age 35–39, one wife, two children, Bauchi)

Men who did not accompany their wives to facility visits either saw no need or could not come because of their work schedules.

I am a laborer and I can’t leave my job because my job requires me to be at the field always. (age 35–39, two wives, three children, Bauchi)

I don’t accompany her to the facility, and the doctors gives her good care. (age 25–29, one wife, one child, Bauchi)

No, I wait outside because it’s women stuff, so is not proper for me as a man to be there, so I wait outside. (age 40–45, two wives, four children, Sokoto)

Several men added that men are discouraged from accompanying their wives to the facility because of long waiting time and insufficient waiting areas.

I wait outside. It is the place that has been sectioned for all the men to sit down […] not a big place because the majority of the men don't come always […] seats are lacking there. (age 40–45, two wives, four children, Sokoto)

[…] but I don’t follow her for tests and it’s because I do go for work and I heard they are taking much time at the facility, if you go there you will meet pregnant women, over 50 of them waiting, so you will waste time there and be late at work so you have to go to work. (age 45–49, two wives, nine children, Bauchi)

Some men reported that the providers let them in the room for their wives’ consultation, and their questions were answered; others were asked to wait outside.

When I accompanied my wife […] the healthcare provider told me that I should take care of my wife and allow her to do some chores to serve as a form of exercise. That helps them to deliver easily. (age 20–24, one wife, one child, Kebbi)

[…] they would usually send the man to go far away to stand and wait for his wife. (Age 25-29, one wife, six children, Sokoto)

No man has ever been invited to see the doctor. They don’t allow men in the counseling room. (age 20–24, first wife, one child, Bauchi)

Delivery services

Women perspectives

Some women said their husbands accompanied them to the facility for delivery, others said their husband did not. Without exception, their husbands were not allowed in the delivery room with them, but many women would have liked them to.

He’d wanted coming inside but they tell him he cannot do that. No, they don’t. We did not meet, it was later after I get cleaned up that I see him (age 20–24, only wife, two children, Sokoto)

I would wish for him to be there so that he will know that giving birth is not that easy the way they think it is. They would usually joke to say that it is just about going there to ‘push the thing out (Age 30-34, third wife, two children, Bauchi)

While some men could wait in the facility, others had to wait outside because there was no waiting area for them inside.

There is a place for them to sit, arranged with bench where they sit. (age 35–39, second wife, six children, Bauchi)

That he had to wait outside, and there was no seat for him to sit on, and they had to go back to the car to sit. When they later decided to attend to me, they wanted to get something and came back to ask me of my husband’s whereabouts. I told them that he was outside, and they said that they did not see him. They had to call him to come back before they told him what to go and get. He was angry at them and told them that there were supposed to be seats nearby, in case of emergency. (age 25–29, only wife, one child, Sokoto)

Men perspectives

Men confirmed women’s observations. Some wanted to be with their wives in the delivery room but could not, and there was not always sufficient waiting room for them in the facility.

[…] by that time, I wanted to follow my wife in because of the pity I had on her, but I was not allowed […] (age 40–44, one wife, four children, Bauchi)

I tried to enter the delivery room and I was allowed to. They considered how sympathetic I was. I did not spend up to 10 minutes inside the delivery room because another woman was brought in. She delivered successfully and I was called to see my wife and newborn child. (age 20–24, one wife, one child, Kebbi)

Provider perspectives

One of the vignettes included in the assessment was only asked of male providers. State records show that about 30% of healthcare providers in Bauchi, and 68% in both Kebbi and Sokoto are male. It was about a husband who brought his wife (Nafisa) to the facility for delivery. The husband refuses to have his wife attended to by a male provider, even though she is very close to delivery and there is no female provider available.

All interviewed male providers agreed that Nafisa’s situation is critical. Most would start by trying to convince the husband to let them attend Nafisa, and two (one in Bauchi and one in Kebbi) said they would invite the husband to the delivery room so that he could observe.

I explain to the husband or the couple that the woman is in a stage that needs to be assisted because there is a possibility of her having problems if not attended to. (CHEW, 13 years of work experience, Bauchi)

I will explain everything relating to her situation to him and even religion permit it. (CHO, two years of work experience, Sokoto)

To make it easy for him I’ll invite him to the labor room so he can observe the process. I want to believe if he doesn’t trust the facility, he wouldn’t even bring her in the first place. (CHEW, 13 years of work experience, Bauchi)

Opinions differed, however, about what to do if the husband continues to refuse his wife’s treatment by a male provider. Some providers said that the decision should be Nafisa’s, since she is the one in danger, and that they would simply obtain her consent. Others, however, insisted that the husband has the ultimate right to make the decision.

She too has the right to give us the go ahead to check her […] Since she is the one in a critical condition then I think she has more right than the husband. (Nurse, six months of work experience, Kebbi)

It cannot be done without the consent of her husband; even if you start the husband can follow you inside and stop you. (CHO, two years of work experience, Sokoto)

[…] because if you proceed and attend to her and something went wrong along the line, then you can be sued. (CHEW, five years of work experience, Sokoto)

Discussion

This qualitative assessment considered the perspectives of women, men and healthcare providers in northern Nigeria of their experiences receiving and providing maternal and reproductive health services. The focus was men’s role in the uptake and provision of family-planning, antenatal care and delivery services in primary care facilities. Results were fairly consistent between participant types and states and highlight several ongoing barriers to service utilisation, which are also consistent with the literature.

First, many healthcare providers would not give women a family-planning method without their husband’s consent. They ask that he accompanies his wife to the facility or provide her with written consent. This was reported by women, as well as healthcare providers, who believe that covert use of family planning would result in marital difficulties. Therefore, there are women who come to health facilities for family-planning services and are denied services because they do not have their husband’s permission. In a region with such a low contraceptive prevalence, this is a significant barrier. This phenomenon has been reported in previous studies in northern Nigeria.²¹

Studies show that couple-friendly family planning and maternal health services are instrumental in facilitating male involvement in their wives’ healthcare.²² In our study, some women want their husbands to accompany them to antenatal care, and some husbands want to join their wives. However, many healthcare facilities cannot accommodate husbands. There are no, or insufficient, waiting areas for them and often men cannot accompany their wives to the consultation rooms.

With respect to delivering in the facilities, some male providers will not allow a woman to deliver in the facility if her husband does not give his permission. Some husbands in northern Nigeria object to their wives being attended to by a male provider, and many male providers believe that the ultimate decision is the husband’s, not the wife’s, even when the wife’s life is at risk. This is exacerbated by the fact that usually men cannot join their wives in the delivery room, as being there with her might ease the men’s mind so that he allows her to deliver with a male attending. While two male providers said that if they needed to convince the husband to allow his wife to be attended by them, they would ask him to join her in the delivery room, this was not confirmed by clients. All women and all men participants agreed that men are not allowed in the delivery room, to protect the privacy of other women who may be there at the same time, as most public PHC facility have only one delivery room.

The literature is clear that supportive (not enforced) male involvement in their wives’ healthcare decisions is fundamental to improving women’s health outcomes and that educating men to promote this is crucial.⁷,¹¹ Our findings, however, show cultural barriers to men’s involvement, exacerbated by supply-side issues, such as infrastructure and provider attitudes.

Despite years of programming designed to improve service provision and utilisation, there are still significant barriers at the facility level.

Our data are biased, as only clients who had received services in the facility were included in our sample. These are women and men who overcame these and other barriers, including demand-side barriers and came to the facility for services. This makes it even more significant that they were met with these difficulties.

The governments of northern-Nigerian states can mitigate the impact of these facility-level barriers on female service utilisation. Facilities should be equipped with waiting rooms for male partners, and providers trained to enable greater involvement of husbands in their wives’ antenatal care and the labour and delivery process. Providers should be trained to respect women’s agency in making contraception decisions and should be accountable for failure to do so. Given the reluctance of clients and their husbands to be seen by male providers, the states should ensure a higher proportion of female physicians and healthcare providers recruited and deployed to PHC facilities. In remote areas where it is difficult to hire and retain female physicians and nurses/midwives, the states should expedite implementation of their task shifting and task sharing policy to ensure greater availability of female healthcare providers.

The study has several limitations. First, as it is a qualitative study using a convenience sample, the findings may not be representative of PHC in northern Nigeria. However, given consistent findings across three states and different types of clients, we believe our findings offer a good representation of perceptions and practices at public PHC facilities in the region. Second, we selected respondents who received care in health facilities, excluding those who chose not to attend antenatal care in a facility, deliver in a facility, or obtain a family-planning method there. Finally, data were collected for a different purpose—to inform improvements to health-service programming. As a result, some themes relevant to the current paper were not followed in sufficient details in the interviews and discussions.

Conclusion

This qualitative assessment examined client and provider perceptions of family planning, maternal care and delivery services in PHC facilities in three northern Nigerian states, with a focus on male involvement. Our findings show that despite years of programming, women still face significant barriers to quality care because of cultural conventions that limit women’s agency, exacerbated by limitations of infrastructure and human resources. We recommend that northern Nigeria state government actively work to mitigate these issues.

Additional required information

Original protocol

The study was a segment of a larger comprehensive study designed to support the design of comprehensive health-service programming in each state. Therefore, the full protocol is not submitted. The comprehensive study included several quantitative components, including a full service-readiness facility assessment, client exit interviews, capacity assessments of various levels of governance and assessments of achievements of performance indices. It was conducted in two additional states—we excluded Ebonyi state from the current manuscript because it is not a northern state; we also excluded the Federal Capital Territory because of the capital city, Abuja, with its political and socioeconomic context different from other Northern States. The qualitative work in each state also included focus groups with mothers of children aged 6 months to 5 years about child health services, and separately about nutrition services, as well as focus groups with men and women (separately) about malaria services they received. No other publications are available on any segment of the comprehensive study, and there are no plans for additional publications.

Data availability statement

No data are available.