ABSTRACT
Background:
Male involvement is crucial in spouse health care, especially during childbirth. Male involvement in maternal health has been linked to positive health outcomes for women and children as they control household resources and make significant decisions, which influence maternal health. Despite the important role they play in maternal health care, their actual involvement remains low in developing countries.
Objective:
This study investigates the level of male involvement in maternal health care among women and their spouse.
Materials and Methods:
A cross-sectional study was conducted among 336 participants (168 women, 168 husband) from two tertiary care hospitals at Rishikesh selected through convenient sampling technique. The data were gathered using a dichotomous questionnaire for male involvement. The collected data were analyzed using descriptive and inferential statistics.
Results:
The mean age of women is 24.62, husbands 24.16, and midwives 28.57 years. Most women and husbands were Hindus and reside in urban areas. 97% of women reported that their husbands were highly involved in maternal health care, particularly during the antenatal period. No significant association was found between the levels of male involvement in maternal health care among women. The level of male involvement, education, occupation, and income among husbands were found to have significant associations.
Conclusion:
Women stated that their husbands played a major role in providing maternal health care, especially during the antenatal period.
Keywords: Husband, male involvement, maternal health care, women
Introduction
Maternal and child health care (MCH) has been viewed as one of the most vital components of a nation’s health. The word “maternal health care” defines a care of women during their pregnancy, delivery, and postpartum period. “The services for women during their pregnancies, during labor, and after delivery are included in maternal health care (MHC)”.[1] World Health Organization (WHO) says that maternal mortality is high and about 287,000 women die during pregnancy and childbirth in 2020. Almost 95% of all maternal deaths occurred in low and lower middle-income countries, and most could have been prevented. Overall, the maternal mortality ratio (MMR) in least-developed countries declined by just under 50%.[2]
According to national Sample Registration system (SRS), the total estimated annual maternal deaths declined from 33,800 maternal deaths in 2016 to 25,220 deaths in 2020 in India.[3] The year 1994 marked an important turning point internationally regarding the roles and responsibilities of men in reproductive, maternal, newborn, and child health.[4] The Cairo International Conference on Population and Development (ICPD), held in 1994, was the first global initiative in switching the focus beyond women and emphasized the shared responsibility of men in reproductive, maternal, newborn, and child health.[5]
The Report of the ICPD, Cairo, 5-13 September 1994 specifically states: “Special efforts should be made to emphasize men’s shared responsibility and promote their active involvement in responsible parenthood, sexual and reproductive behavior, including family planning.”[6] Furthermore, the report of the 1995 United Nations (UNs) Fourth World Conference on Women (FWCW) held in Beijing encouraged men to take steps toward achieving gender equality and better reproductive health. The United Nations Population Fund (UNFPA), as one of the leading organizations in this respect, published its first Technical Report in 1995 on male involvement in reproductive health, including family planning and sexual health.[7]
However, males’ support is often curtailed by hospital and employment policies as well as lack of communication with their partners. Thus, UNFPA recommended projects such as the “Pati Sampark” in India which give pregnancy and childbirth information to husbands and point out specific roles that they can fill, including providing household help during pregnancy and making plans involving transportation.[8] In 2007, the theme for the World Population Day was “Men as Partners in Maternal Health” as partnering with men promotes the right of every woman, man, and child to enjoy a life of health and equal opportunity.[9]
The first meta-analysis and systematic review to examine the effect of male involvement on maternal health outcomes in developing countries has shown that male involvement has statistically significant positive effects on mother health, including lower likelihood of maternal depression and higher use of maternal health care. Although the results were inconsistently significant, male involvement was also linked to a lower risk of birthing problems. There was little evidence that a husband’s presence in the delivery room improved the health of the mother.[10]
Additionally, the results of research indicate that male participation in pregnancy and the postpartum period appears to provide statistically significant benefits for maternal health compared to male involvement during delivery.[11] Historically, maternal health care has been considered primarily a woman’s domain, with men playing a limited role.[12]
According to India’s National Health and Family Survey (2019–21), 68.2% of men were present with their wives during any Antenatal care (ANC) visit and 17.8% men were not present during any ANC visit. In Uttarakhand, 66.5% of men accompanied their wives on any ANC visit.[13] The results of several researches on male partners’ participation in the ANC in India ranged from 22 to 75.9%.[6] So, this study assesses the understand of male involvement in maternal health care.
In developed countries, where access to healthcare services is generally higher and cultural norms may be more conducive to male involvement, the percentage of male involvement in maternal health care tends to be relatively higher compared to developing nations. But in India, approximately 72.5% of antenatal visits were attended; that percentage dropped to 27.5% during labor and 20.3% during vaccinations.[14] So, it is clear that husband involvement in maternal healthcare is quite low in developing countries. So, there is no empirical evidence on the level of male involvement in maternal health. The participation of males in the broader perspective of maternal health care is still inadequate. It is evident that in developing countries, husbands’ involvement in maternal health care is particularly very low.[15,16,17]
Objectives
The present study aims to investigate the level of male involvement in maternal health care in Rishikesh, Uttarakhand.
Materials and Methods
Study design and setting
This cross-sectional study was conducted among women and husbands from December 26 to January 20 in two settings at AIIMS Rishikesh and SPS Rishikesh, Uttarakhand.
Study participants and sampling
Participants were selected through convenience sampling. Women ≥19 years of age and who gave birth within 6 weeks and husbands present during the data collection were included. Widowed or separated women and husbands who stay away from their wives during data collection were excluded. After explaining the objectives, we obtained written consent. The data were collected through a self-reported structured interview technique. It took about 15 minutes for each participant to collect the data tool.
Data collection tool and technique
The study comprised four sections; the first section of personal characteristics of women contains seven items including age, marital status, religion, habitat, parity, education, and occupation; husbands comprised five items including age, religion, education, and occupation; and midwives comprised four items including age, education, designation, and experience. The second section includes a dichotomous questionnaire of 28 items regarding level of male involvement in maternal health care, rated as Yes or No. The scoring was given: Yes, 1; No, 0. The respondent’s involvement was categorized as highly involved (>21), moderately involved (15–21), and less involved (<15).
Seven experts validated the tool (five nursing faculty, two clinicians) to assess the readability, clarity, relevance, and acceptability. Modifications were made for a better understanding before the final survey. The data received were coded and entered in a microsoft excel spreadsheet and analyzed using statistical package for the social sciences for windows version 26. Descriptive statistics (frequency, mean, and standard deviation) and inferential statistics were used in the study.
Ethical considerations
Written permission was taken from Institutional Ethics Committee (AIIMS/IEC/23/379- 06/10/2023) of AIIMS Rishikesh. Written informed consent was obtained from study participants. Written permission was taken from authority of selected hospitals. No invasive procedure was performed during the study. The anonymity of the participants and confidentiality of the information were preserved.
Results
Participant characteristics
A total of 336 participated, and the mean age of the women was 24.61 ± 1.59 and that of husbands was 24.16 ± 1.77. Almost 79% of women and 57% of husbands were aged between 20 and 30 years. 66% were Hindus, and 61% resided in urban areas; 43% of them had second parity. Both women and husbands of the head of the family had 24% middle school certificates; almost 45% belonged to the Upper Lower IV socioeconomic strata [Table 1].
Table 1.
Personal characteristics of participants (women and husband) n=336
| Variables | Women n=168 f (%) | Husband n=168 f (%) |
|---|---|---|
| Age (in years) Mean±SD | 24.61±1.59 | 24.16±1.77 |
| Religion | ||
| Hindu | 110 (66) | |
| Muslim | 58 (34) | |
| Habitat | ||
| Rural | 66 (39) | |
| Urban | 102 (61) | |
| Parity | ||
| 1 | 38 (23) | - |
| 2 | 73 (43) | - |
| 3 | 44 (26) | - |
| 4 | 13 (8) | - |
| Education* | ||
| Professional or Honours | - | 01 (01) |
| Graduate | 16 (10) | 25 (15) |
| Intermediate or diploma | 17 (10) | 22 (13) |
| High school certificate | 25 (15) | 39 (23) |
| Middle school certificate | 38 (23) | 41 (24) |
| Primary school certificate | 54 (32) | 29 (17) |
| Illiterate | 18 (11) | 11 (6) |
| Occupation* | ||
| Professionals | - | 03 (02) |
| Technicians and Associate professionals | - | 27 (16) |
| Clerks | - | 20 (12) |
| Skilled workers and Shop and Market Sales Workers | - | 18 (11) |
| Skilled Agricultural and Fishery Workers | 37 (22) | 33 (20) |
| Craft and related trade workers | 32 (19) | 26 (15) |
| Plant and Machine Operators and Assemblers | - | 35 (21) |
| Elementary Occupation | 53 (32) | 04 (02) |
| Unemployed | 46 (27) | 02 (01) |
| Total monthly income of the family* | ||
| Upper I | 05 (03) | |
| Upper middle II | 17 (10) | |
| Lower Middle III | 48 (29) | |
| Upper Lower IV | 75 (45) | |
| Lower V | 23 (14) |
*Based on socioeconomic status scale, (-) No participants found in particular category
Women reported that their husbands were highly involved in maternal health care (97%). Husbands also agreed that they were highly involved (94%) in maternal health care [Table 2].
Table 2.
Level of male involvement in maternal health among women and husbands n=336
| Level of Involvement | Women n=168 f (%) | Husband n=168 f (%) | Range | Mean±SD |
|---|---|---|---|---|
| Moderately involved | 5 (3) | 11 (6) | 15-21 | 20.44±0.62 |
| Highly involved | 163 (97) | 157 (94) | 22-28 | 24.59±1.47 |
Range of score: (0-28) (No participants were in less involved category)
During the antenatal period, the mean percentage of male involvement was 92%, indicating strong participation and support from their husbands. The mean percentage increased to 88% during the postnatal phase, although it declined slightly to 74% during the intranatal period. Overall, the findings show that men are frequently and actively involved in all phases of maternal healthcare [Table 3].
Table 3.
Period of level of male involvement in maternal health among women and husbands n=336
| Period | Mean±SD | Range | Mean % | |
|---|---|---|---|---|
|
| ||||
| Women n=168 | Husband n=168 | |||
| Antenatal | 14.68±1.12 | 14.51±1.13 | 0-16 | 92 |
| Intranatal | 3.72±0.45 | 3.55±0.59 | 0-05 | 74 |
| Postnatal | 6.20±0.77 | 6.10±0.78 | 0-07 | 88 |
Antenatal: Both wives and husbands highly prioritize joint planning for pregnancy, financial support, and arranging transport for antenatal visits. Husband often reminds wife to take antenatal medications, while husbands are more likely to assist with household works and cooking. Although husbands may not always accompany wives to all antenatal visits, they are generally supportive and share excitement about the pregnancy.
Intranatal: Both wives and husbands usually plan together for the place of delivery and arrange transport. Husbands save money for delivery expenses and are aware of potential complications, though not always present during labor process.
Postnatal: Husbands actively participate in caring for both the mother and child after birth, ensuring doctor visits, nutrition, and child immunizations. While they may discuss maternal health issues with health workers, this aspect could use more attention from both husband and wife [Table 4].
Table 4.
Item-wise ranking of level of male involvement in maternal health care among women and husbands n=336
| Items | Women n=168 | Husband n=168 | ||
|---|---|---|---|---|
|
|
|
|||
| Mean% | Rank | Mean% | Rank | |
| Antenatal period | ||||
| Joint Planning of pregnancy. | 100 | 1 | 92 | 7 |
| Joint Planning about the time and place of ANC visits. | 100 | 1 | 94 | 5 |
| ANC Planning for upcoming financial necessities throughout the care. | 100 | 1 | 100 | 1 |
| Financial support during antenatal period. | 100 | 1 | 100 | 1 |
| Arranged transport for wife while visiting ANC visits. | 100 | 1 | 90 | 8 |
| Accompanied wife to ANC visits. | 79 | 7 | 92 | 7 |
| Reminded for taking antenatal medications. | 94 | 3 | 99 | 2 |
| Accompanied wife for morning and evening walk. | 84 | 6 | 78 | 10 |
| Helped in doing exercise. | 93 | 4 | 95 | 4 |
| Collected videos for care during pregnancy and discussed. | 43 | 8 | 43 | 12 |
| Took care of wife’s extra nutrition requirement. | 100 | 1 | 99 | 2 |
| Discussed with health care providers regarding antenatal care. | 100 | 1 | 93 | 6 |
| Helped in household work. | 96 | 2 | 92 | 7 |
| Cooked her favorite dishes. | 93 | 4 | 86 | 9 |
| Spent extra time with wife as compared to usual. | 100 | 1 | 99 | 2 |
| Shared excitement regarding the pregnancy. | 87 | 5 | 98 | 3 |
| Intranatal period | ||||
| Joint planning of place for delivery. | 100 | 1 | 92 | 3 |
| Arranged transport for wife during delivery. | 100 | 1 | 99 | 1 |
| Accompanied partner during delivery. | 0 | 3 | 0 | 5 |
| Saved extra money for delivery. | 100 | 1 | 98 | 2 |
| Was aware of complication during delivery. | 72 | 2 | 67 | 4 |
| Postnatal period | ||||
| Helped in visiting the doctor during the postnatal care. | 90 | 2 | 89 | 6 |
| Took care of mother’s nutrition and rest during postnatal care. | 100 | 1 | 100 | 1 |
| Discussed with the health worker about reproductive health and maternal health issues during postnatal care. | 52 | 4 | 40 | 7 |
| Was involved in careful vigilance on partner’s and child’s physical health. | 100 | 1 | 99 | 2 |
| Took care of child nutrition. | 100 | 1 | 98 | 3 |
| Accompanied partner for child immunization. | 88 | 3 | 92 | 4 |
| Helped in household work. | 90 | 2 | 91 | 5 |
There was no significant association seen between level, perception, and barriers in male involvement in maternal health care with women characteristics. The level of male involvement was significantly associated with their education status (P = 0.023), occupation (P = 0.023), and family income (P = 0.049), whereas there was no significant association seen between level, perception, and barriers in male involvement in maternal health care with husband characteristics [Table 5].
Table 5.
Association between male involvement in maternal health care among women n=336
| Variables f (%) | Women | f (%) | Husband | |||||
|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||
| Mean±SD | F | P | Mean±SD | F | P | |||
| Age (in years) | ||||||||
| 20-30 | 133 (79) | 24.52±1.64 | 2.253 | 0.135 | 96 (57) | 23.92±1.81 | 2.268 | 0.107 |
| 31-40 | 35 (21) | 4.97±1.33 | 68 (41) | 24.50±1.63 | ||||
| >40 | - | - | 04 (02) | 24.50±2.38 | ||||
| Religion | ||||||||
| Hindu | 110 (66) | 24.69±1.63 | 0.759 | 0.385 | 110 (66) | 24.22±1.82 | 0.269 | 0.605 |
| Muslim | 58 (34) | 24.47±1.52 | 58 (34) | 24.07±1.67 | ||||
| Habitat | ||||||||
| Rural | 66 (39) | 24.36±1.73 | 2.692 | 0.103 | 66 (39) | 24.36±1.73 | 2.692 | 0.103 |
| Urban | 102 (61) | 24.77±1.48 | 102 (61) | 24.77±1.48 | ||||
| Parity | ||||||||
| 1 | 38 (23) | 24.45±1.67 | 1.133 | 0.337 | - | |||
| 2 | 73 (43) | 24.86±1.56 | ||||||
| 3 | 44 (26) | 24.45±1.54 | ||||||
| 4 | 13 (08) | 24.23±1.64 | ||||||
| Education | ||||||||
| Professional or honors | 2.030 | 0.077 | 01 (01) | 27.00±0.00 | 2.696 | 0.016* | ||
| Graduate | 16 (10) | 24.81±1.16 | 25 (15) | 24.64±1.91 | ||||
| Intermediate or diploma | 17 (10) | 23.76±1.20 | 22 (13) | 25.09±1.34 | ||||
| High school | 25 (15) | 24.44±1.47 | 39 (23) | 24.10±1.86 | ||||
| Middle school | 38 (23 | 25.0±1.45 | 41 (24) | 23.80±1.56 | ||||
| Primary school | 54 (32) | 24.46±1.86 | 29 (17) | 23.59±1.88 | ||||
| Illiterate | 18 (10) | 25.11±1.56 | 11 (07) | 24.09±1.44 | ||||
| Total monthly income | ||||||||
| 68967-92185 | 5 (03) | 24.60±1.67 | 2.445 | 0.049* | ||||
| 46095-68961 | 17 (10) | 24.18±2.00 | ||||||
| 27654-46089 | 48 (28) | 24.77±1.74 | ||||||
| 9232-27648 | 75 (45) | 23.91±1.63 | ||||||
| <9226 | 23 (14) | 23.65±1.87 | ||||||
P≤0.005*
Women who studied up to high school had favorable perception of male involvement in maternal health care. Furthermore, whoever is educated above primary school could expressed their barriers. However, other variables of women do not affect the level of male involvement. It is estimated that whoever has studies above primary education has good involvement. However, the husband variables do not affect the perception and barriers of male involvement.
Discussion
In the current study, more than half of participants were between 20 and 30 years of age, 41% of respondents had middle school certificate, and 43% of them had second parity.
This was similar to the study conducted by Craymah et al.[10] where 17% were in the age group of 20–29 years, 55% of the respondents had elementary education, and in terms of parity, 45% of the respondents had less than three children. In contrast to this study, a study conducted by Olajubu et al.[18] reports respondents of age group 18–66 years old with a mean age of 38.8 ± 9.9 years and 74.8% had tertiary education.
The result of the present study shows that there was a high level of male involvement in maternal health care, 91% husbands actively participated during the antenatal period, 74% during the intranatal period, and 84% in the postnatal period. The findings of the current study are similar to those of the study conducted by Dutta et al.,[19] which revealed 35%, 44%, and 20% of men involvement in antenatal, inranatal, and postnatal care services, respectively. Another study conducted by Craymah et al.[10] reported similar findings that showed approximately 85% of women had their male partners who accompany them to antenatal care. This finding is in contrast to the study conducted by Zakaria et al.,[20] which found that almost all men (~90%) had never accessed services related to reproductive and maternal health, indicating a much lower level of male involvement compared to the current study.
This study reveals that more than 90% of women, husbands, and midwives perceive that males have to participate in the care of the newborn and attend antenatal and postnatal clinics with their wife. These findings are similar with the study conducted by Zakaria et al.,[20,21] which revealed 59.8% of respondents perceived that husbands provided a high-level support in wives’ antenatal care. Furthermore, 44% of respondents had a perception that husbands provided a high level of assistance in their wives’ delivery care, while 35.8% provided a high level of participation in postnatal care. Similarly, a study conducted in low-resource settings by Tanzania, Gibore et al.[22] supported the findings of the current study which reported that male involvement was high in terms of accompanying partners to ANC, providing physical support during pregnancy and making joint decisions for ANC.
Similarly, Mapunda et al.[23] found a significant prevalence of male involvement in antenatal care (69%) but highlighted the diverse perspectives men hold regarding their participation. These findings collectively emphasize the multifaceted nature of male engagement in maternal health and its importance in promoting comprehensive care.
In the present study, it was found that lack of education was identified as one of the most significant barriers, with percentages ranging from 76% to 86%. Conversely, in another study, the primary reason cited for the lack of male involvement was reported to be a deficiency in knowledge regarding maternal healthcare, with 41% of women indicating this as the main obstacle, Mapunda et al.[23] In one study, participants were more likely to report higher levels of male involvement if they disagreed with the perception that male involvement in ANC is influenced by distance to health facilities (OR = 2.13, 95% CI = [1.19-6.36], P = 0.04).
Limitations and Recommendations
A self-structured questionnaire was used. The study is limited to a specific geographic area (selected hospitals in Rishikesh), which may restrict the generalizability of findings to other regions. Further investigation using qualitative methods such as in-depth interviews or focus group discussions can provide deeper insights into the degree of perceptions and barriers related to male involvement.
Conclusion
Women reported that their husbands were highly involved in maternal health care specially during antenatal period. Notably, while midwives’ qualifications significantly influence their perceptions, there is no significant association between barriers to male involvement and their personal characteristics. Conversely, education status, occupation, and family income demonstrate a statistically significant association with the level of male involvement among respondents, underscoring the need for targeted interventions to address these disparities.
Conflicts of interest
There are no conflicts of interest.
Acknowledgement
The authors thank all the respondents involved in this study for their cooperation and support.
Funding Statement
Nil.
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