Ampim et al. Reprod Health (2021) 18:106 https://doi.org/10.1186/s12978-021-01152-5 RESEARCH Open Access “I came to escort someone”: Men’s experiences of antenatal care services in urban Ghana—a qualitative study Gloria Abena Ampim1* , Astrid Blystad2 , Albert Kpoor3 and Haldis Haukanes1 Abstract Background: Male involvement in maternal healthcare has been widely recognized as essential for positive health outcomes for expectant mothers and their unborn babies. However, few studies have explored men’s experiences of maternal health services. The purpose of this paper is to explore men’s involvement in antenatal care in urban Ghana and to discuss how men navigate their roles in a space that has been constructed as feminine. The study draws upon theories of space, place, and gender. Methods: A qualitative exploratory study using semistructured interviews, focus group discussion, and observation was conducted in Accra, Ghana. Expectant fathers and health workers were interviewed, and observation was con- ducted at a selected public hospital in Accra. Results: The findings suggest that the few men who attend antenatal care with their expecting partners become involved to a limited extent in the clinic’s activities. Beyond a few who take an active role, most men stay on the outskirts of the hospital grounds and rarely participate in consultations with their partner and midwife. Men still view their presence as necessary to acquire knowledge and as sources of emotional, financial, and physical support for their partners. On the health workers’ side, the study found no clear agenda for engaging men at the clinic, and nurses/midwives felt there was a lack of staff who could engage more directly with the men. Conclusion: The study indicates that most expecting fathers feel too shy and uncomfortable to locate themselves in the female space that makes up antenatal care/maternity wards. Health workers do not feel they have the necessary resources to involve men fruitfully. Thus, men do not engage in the activity as hoped but rather remain on the out- skirts of the maternity clinic. However, if men continue to negotiate their involvement at the clinic and become more assertive in their roles, the maternity clinic as a female space could, with time, be transformed into a space in which both expecting mothers and fathers can actively participate and be engaged to the benefit of all. Plain Language Summary This article discusses men’s roles and involvement in health workers’ activities when they accompany their preg- nant partners to the maternity clinic. Health workers organize antenatal care services (ANCs) for expectant mothers *Correspondence: Gloria.Ampim@uib.no 1 Department of Health Promotion and Development, University of Bergen, Bergen, Norway Full list of author information is available at the end of the article © The Author(s) 2021. 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The Creative Commons Public Domain Dedication waiver (http://c reati veco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Ampim et al. Reprod Health (2021) 18:106 Page 2 of 12 to receive regular check-ups during pregnancy. Since pregnancy and childbirth are generally viewed as women’s domains, men have not traditionally been expected to attend antenatal care with their partners. However, recent national and global agendas have recognized men’s inclusion in maternal healthcare as central to improving moth- ers’ and unborn babies’ health. Men are being encouraged to play an active role in supporting their partners during pregnancy, and as part of this role, they are encouraged to attend antenatal care services. In the health facility where this study was conducted, we found that the few men who attended antenatal care most of the time stayed outside the maternity clinic under trees or in other empty spaces around the clinic. They opted to remain in the outside areas because they felt shy sitting among women who were a substantial majority at the clinic. We also found that health workers rarely involved men in ANC activities because of a lack of staff to engage men in separate sessions. Although the fathers attending antenatal care were disappointed that they were not engaged in activities, they still found it necessary to attend to give their partners emotional, physical, and financial support. Without the consideration of how ANC activities are structured and the appropriate resources for health workers, men’s active participation in ANCs will remain minimal. Keywords: Men’s involvement, Antenatal care, Space and gender, Ghana Background to the study knowledge but felt fearful, embarrassed, and helpless In sub-Saharan Africa, men have, to a large extent, been when witnessing their partners in labor [32]. viewed as the leading decision-makers in the household Studies on male involvement in reproductive health in responsible for the financial resources of the family [1–4]. Ghana have primarily focused on family planning [5, 9, Men’s ideal roles as leaders and providers in the house- 33, 34]. Other research in the field has discussed factors hold have implications for women’s access to quality that prevent men from attending maternal healthcare healthcare during pregnancy and childbirth. When and clinics and has identified expected gender norms, lack where to seek healthcare and how much to spend on of time and low formal educational status as the causes healthcare, as well as decisions about the number of chil- of low male attendance [2, 4, 8, 35–42]. Hence, the expe- dren in a family largely depend on male partners [4–9]. riences of men who try to participate in maternity care Positive health outcomes for women and children have services have remained undocumented in the Ghanaian been associated with male involvement in both devel- research-based literature. This article focuses on men oped and developing countries [10–12]. Consequently, who attend antenatal care (ANC) with their partners, and male involvement in maternal and infant healthcare has it attempts to enhance the knowledge about and under- been encouraged to improve women’s and children’s standing of expectant fathers’ experiences of the ser- health and promote gender equality in reproductive vice. Given the premise that men’s involvement in ANC health responsibilities [13–16]. strengthens reproductive health, knowledge about their Research has shown that male involvement is sig- experiences at clinics is important to indicate what may nificant in women’s use of maternal health services [13, be productive or achievable. This study presents the vary- 17–19]. In addition to providing material resources to ing forms of expectant fathers’ involvement in ANC and facilitate attendance, men can use their influence to how the organization of the activities and space at the demand respectful care and act as patient advocates maternity clinic shape what fathers do while there. We [20–22]. However, a number of factors, such as the fear draw upon theories of space, place and gender to aug- of having to be HIV tested, long waiting hours, the atti- ment the understanding of the material [43]. tude of health workers toward men and the idea that pregnancy is a woman’s responsibility, have been found Conceptual framework to prevent men from visiting maternity clinics with Following Doreen Massey [43], we understand space their partners [7, 23–30]. Among the limited research to comprise social relations, while a place is where conducted on the experiences of men who attend ante- these relations are performed, constructed, contested natal care (ANC), a study from Rwanda indicates that and renewed. The formation and identity of a place, its even when men accompanied their partners for antena- social structure, political character and local culture are tal services, midwives prevented them from participat- all products of interactions [[43], p. 120]. Both spaces ing in private consultations to protect their professional and places are therefore formulated in terms of social domains and maintain the maternity clinic as a space for practices. Gender is influential in defining the kind of women [31]. A study from Malawi on men’s labor and relations that are played out in particular places and in birth experiences found that men experienced increased shaping the way that men and women relate in a place. A mpim et al. Reprod Health (2021) 18:106 Page 3 of 12 Massey [43] noted that the dominant image of a place in Ghana, unlike private facilities that are likely to have and space will often be contested and subject to gradual wealthier clients. transformation. The place under discussion in this context is a mater- Participants nity clinic where expectant mothers gather as a group led Participants contributing to the data illustrated in this by health workers. The maternity clinic can be described article are expectant fathers, midwives and community as an example of a “third place”. Third place has been health nurses.1 Purposive sampling was used to recruit defined as “physical locations outside the home (first men and health workers. The recruitment proceeded as place), or workplace (second place) that facilitate social follows: the first author (GAA) started out by observ- interaction, community building and social support” ing expectant mothers and fathers as they came to the [[44], p. 1] [45]. The maternity clinic is a physical loca- maternity clinic. She also joined the antenatal education tion where women and their caregivers share reproduc- sessions and took note of the men present, their level of tive health information and a place where women form involvement in activities, their body language, and their social relationships with other expectant mothers. In this interaction with service providers and other men and way, the clinic supports and sustains women’s social life women. She then approached these men after the edu- during pregnancy. cational sessions had ended and informed them about The continuous interaction of pregnant women and the project individually. Observations and recruitment their caregivers at the maternity clinic, discussing repro- continued over a seven-month period at the maternity ductive health matters, has constructed the maternity clinic. The inclusion criteria for the men were first-time clinic as a female space where masculine presence and expectant fathers who were regular attendees at ANC. domination have been rather peripheral. However, when Because expectant mothers are required to attend at least men visit the maternity clinic, it is expected that they four antenatal visits, one inclusion criterion of expectant share the same space with their partners, a space where fathers was that they had attended ANC at least twice their defined hegemonic roles [46] as heads of the house- before the interview. All men were recruited at the hos- hold are of little or no significance. In this regard, we seek pital and followed up on with phone calls to schedule to discuss how the maternity clinic as a physical place and interviews. Follow-ups presented an opportunity for the socially constructed space is being potentially reshaped researcher to establish rapport with the participants and to include men and how men negotiate their authority gather more background information before the actual and masculinity within this space. interview took place. Not all men contacted were able to participate in the interviews; some did not meet the Methods inclusion criteria, while others could not find time to par- Study design ticipate. Ten men were interviewed. All except one were This article forms part of a broader study that the authors first-time expectant fathers. One father had a child from conducted between June 2017 and May 2019 to explore a previous relationship, but this was revealed only after the nexus of male involvement in maternal healthcare the interview. and gender relations in Ghana. The study used an explor- atory qualitative research approach to present detailed Topic guides descriptions of people’s own understanding of events and GAA conducted all interviews and the focus group dis- experiences [47]. Semistructured interviews, focus group cussion using three different open-ended topic guides. discussions (FGDs) and observations were used to gather The topic guide for the qualitative interviews with the in-depth knowledge about how activities are organized fathers focused on four main topics: fatherhood and at the maternity clinic of a key government hospital in masculine norms within the Ghanaian social context; Accra. fathers’ roles during pregnancy and childbirth; the role of the extended family during pregnancy and child- Study setting birth; and the experiences of fathers at service points, The study was conducted in Accra, Ghana’s capital. All including the maternity clinic. The second topic guide participants were recruited through one of the fully gov- for midwives focused on perceptions about fatherhood ernment-operated hospitals in the Accra metropolis. The norms, benefits of male involvement in service delivery, particular hospital was selected as the main facility in the study, as it is a key government hospital in Accra and provides services through National Health Insurance. Moreover, a government facility was selected because 1 As part of the broader study, interviews were also conducted with expectant its clients represent people of different social statuses mothers in Accra, and health workers and expectant parents in rural areas, but these interviews do not form part of the data used for this article. Ampim et al. Reprod Health (2021) 18:106 Page 4 of 12 ways of engaging men at the clinic, and the potential Results challenges of male involvement at the clinic. The third This section presents a description of the maternity topic guide used in a focus group discussion with com- clinic, how ANC activities were organized, and where munity health nurses (CHNs) focused on perceptions men were located during the clinic’s proceedings. It will about fatherhood norms, benefits of male involvement then continue with a discussion of the varying forms of as observed in the community and at the health facility, male involvement found in the study, including men’s ways of engaging men in maternal health at the clinic as own agendas at the clinic. It ends with a presentation of well as in the community, and the potential challenges health workers’ engagement of men at the clinic. of securing male engagement at the community level and at the clinic. Because the instruments were open- The maternity clinic and male partners ended, GAA could adjust the questioning to suit the The maternity clinic was managed by a midwife and individual participants’ situation. She also engaged in a offers three fairly distinct services: antenatal care, labor continuous review and rephrasing of the questions to and delivery care, and postnatal care. The antenatal care ensure that they were clear and comprehensible to the (ANC) division had one gynecologist and approximately research participants. four midwives per work shift. The clinic operates between 8 am and 5 pm from Monday to Friday. Mothers began to arrive as early as 6 am to form a queue, sometimes com- Data analysis ing in the company of other mothers or partners. By 8 The data were analyzed using Braun & Clarke’s [48] am, when sessions started, the seats in the waiting area approach to thematic analysis. Data analysis began with where ANC takes place were usually fully occupied by the writing of an analytic memo, which was updated expectant mothers. The sessions commenced with a mid- periodically during fieldwork. Key concepts that par- wife leading the expectant mothers in the waiting area ticipants mentioned were recorded in an analytic memo in a Christian worship session lasting approximately ten and later used to generate codes. Soon after gathering minutes. She then led the group in a short exercise ses- the data, all the tape-recorded audio was transcribed and sion before giving an educational talk on topics such as anonymized to protect the identity of the study partici- nutrition, birth preparedness, and signs of labor, among pants. Upon transcription, a few interviews were printed others. More mothers arrived as the educational ses- out and coded on paper to develop a coding manual. sion proceeded. On average, approximately 200 women All transcripts were later transferred into QSR NVivo attended ANC at the hospital per day. software, where more codes were generated. Themes During the session, mothers talked among themselves were generated from the codes, and some themes were and with health workers, asked questions, and shared merged with other themes upon consultation with the jokes. When the educational session ended, individual research team. Themes were continuously refined by the mothers were called upon, and their folders were sorted coauthors. according to their assigned midwives. At this point, women waited for a one-on-one consultation with their assigned midwives in a separate room. This is a crucial Ethics service provided during ANC. Although the waiting area The study is guided by the protocols of the Norwegian was largely congested during the educational session, Institute for Data Protection (53,570/3/ASF). Ethical the space began to open up as the educational sessions approval was granted by the University of Ghana, Col- closed and women continuously moved in and out of the lege of Health Sciences (CHS-Et/M.6–P1.12/2017–2018). clinic. It was common to find expectant mothers moving Permission was also sought from the administration around in pairs or more to the canteen, washroom, and and the maternity clinic of the hospital before the study laboratory. Women who attended the clinic with their began. Written or oral informed consent was obtained partners walked around with them. from all participants after thoroughly explaining the Men who accompanied their partners to the clinic purpose of the study [49]. Moreover, interviews and dis- were encountered mostly at three different locations. cussions were recorded only upon the acceptance of the Some sat among the expectant mothers in the waiting participants. The participants were informed that they area during the educational sessions. From observation, could withdraw their consent at any point during the we found only two to three men sitting among the more session without any consequences and that informa- than 100 women. Others stayed in an open space out- tion gathered from the study would remain anonymous. side the maternity clinic, while others again were seen All participants were given pseudonyms to enhance under trees on the broader compound of the hospital. anonymity. Although men may not be present in the waiting area, A mpim et al. Reprod Health (2021) 18:106 Page 5 of 12 they were still sometimes called by their partners to (Derrick, 32 years old, Truck Driver). join them for the one-on-one consultation. Statistics from the hospital show that between 2016 and 2019, Some men revealed that they were only shy during male attendance at the maternity clinic had a ratio of the first visit and later became more comfortable sitting approximately ten mothers to one father. These num- among the expectant mothers in the waiting area: bers include men who came for antenatal, labor and When you come for the first time, you would be delivery care and postnatal care. Labor and delivery shy because you would meet many women, and the care have the most sizeable male attendants, according reaction from their faces would be like: “Ah, is your to health workers. Thus, very few men attended ANC wife the only pregnant woman?” Well, fortunately, sessions with their partners. From the few men who I do not take notice of such things because I know came for ANC, we found different ways and levels of my purpose there. So I just sit quietly and mind my involvement. business (Joseph, 32 years old, Sales Manager). Although the seats in the waiting area were mostly fully occupied by expectant mothers, none of the men inter- Varying involvement of men in antenatal care The first question that we asked men after greeting viewed mentioned a lack of seating space as the reason them at the maternity clinic was, “What brought you they waited outside. Instead, as we have shown above, here today?” Most men responded by saying, “I came they related their staying away from the waiting area to to escort someone”. This response was also clear in the experiencing shyness and discomfort. Some expectant ways that men and women occupied space at the hos- fathers were unhappy with a limited level of involvement pital. While women usually gathered in the waiting at the clinic and felt that activities should be tailored to area, most men were, in contrast, found waiting under include them, especially in the individual consultations: trees and in isolated spaces behind the clinic. Expect- The only time you will see the nurses is when they ant fathers who remained outside during the gen- come to mention the names of those whose cards eral session said that they were uncomfortable inside they have. So when they are calling the names, and the maternity clinic. One man, Ibrahim, for example, you are also following, you know the nurses are rude said that he was surprised to see so few men when he at times. They ask where you are going and all sorts attended the clinic with his wife for the first time, and of questions. In addition, even seeing some of the this made him feel uncomfortable. Another expectant men around, even though most men do not come, at father specifically mentioned that he was uncomfort- least they should come and ask what we came to do able sitting among the women: or who we came with and all that. They just move I would not like to be among the ladies. That place back to the rooms after mentioning the (women’s) is only meant for the women. So if I come with names (Eric, 30 years old, Sales Executive). someone, I would not like to sit among the ladies Like Eric, some of these men seemed not to be aware (Elorm, 30 years old, Artist). that men were allowed to participate in the consultations. Other expectant fathers decided to make themselves Derrick also said he would participate if it were allowed. invisible at the clinic, saying it was because they felt Ibrahim similarly said: shy. When we interviewed one man, Derrick, for the We came together, we even went down there, but I first time, his wife was eight months pregnant. He had am currently sitting here because she is going for a attended the ANC since they received a positive preg- scan, and she is the only one expected to be present nancy test. However, sometimes the midwives did not there. After the scan, the next is the lab and a whole even see him because he was mostly hanging around lot before seeing the midwife. That is why I am wait- under the trees surrounding the facility. He did not par- ing for her here (Ibrahim, 32 years old, Trader). ticipate in either the educational or the consultation sessions because he did not see other men doing so. He When asked whether he would join his wife in the con- nonetheless concluded by saying that if he is invited, he sultation with the midwife, he answered, “If I am permit- will join the educational session. He explained: ted, why not?”. Interaction at the clinic was, for most men, limited I feel shy. Well, I do not go into the room with her to interacting with their partners. There was hardly any unless I am invited. The only time I went inside communication between the men themselves or between was when I was called to donate blood. I have men and women. Most men played on their mobile not been there since then. If it is allowed, I will go phones and tablets in their idleness. They explained that Ampim et al. Reprod Health (2021) 18:106 Page 6 of 12 it was better to focus on their purpose at the clinic rather ache, and you would not know what that means, than chatting with other men. but when you come here, and they teach, you would The men who kept a distance and did not involve them- know how to treat such things. It helps me to take selves in activities at the clinic were a substantial majority good care of her. Sometimes she forgets the things among our study participants. However, there were also they teach there as well, so when I go there, I take a few who were more assertive and actively participated notes like a student so that I do not forget the lessons in the consultation with their partners, as shown below: (Joseph, 32 years old, Sales Manager). As for the consulting room, I always make sure I am The quote above indicates two motivational elements there with her because I want to see if everything is of men attending ANC: to acquire knowledge and remind in place. So if there is any lab test, I would like to their partners of information relayed at the clinic. Some know its result and what to do about it. We went expectant fathers understood antenatal visits as an exten- there together yesterday when the time was due for sion of their role as the head and protector of their family: the test they conducted. That was when she (mid- wife) told us what to buy for the child and other This is her first time she has been pregnant, and her things needed for the pregnancy (Eddie, 28 years old, family members are not here. So I am supposed to Self-employed). support and help her out during this time. I have some questions to ask the midwife. She alone will Eddie usually joined his partner for the educational not be able to ask all those questions, you know. How session and would after that drop out and wait outside will she do all that because she is a young girl and until it was time for her consultation with her assigned does not know anything about pregnancy (Elorm, midwife when he would be called to join in. Charles was 32 years old, Artist). another man who said that he regularly participated in the consultation with the midwife. When observed at Men also claimed that spousal love and affection were the clinic, Charles appeared to be in control and aware a key motivation for their involvement in ANC with of his rights and privileges, leading his wife through the their partners. When asked why he continued to attend various proceedings, carrying her folder and handbag ANC with his partner, Charles answered, “The woman, while she followed behind. Men such as Derrick became she is good”. Similarly, men emphasized that attending more involved in activities toward the end of pregnancy. ANC was an expression of love for their partners. They His wife developed complications in the third trimester, explained that experiencing the process of pregnancy which required that she attended frequent check-ups. with their partners will promote respect for women, as Upon the request of his wife’s assigned midwife, Derrick indicated in the two quotes below: joined the consultations when his wife’s due date was I am happy that I came here with her because she drawing closer. knows that I support her. Just staying away from work for a day for her will not affect anything. Just Men’s agenda at the maternity clinic knowing that I support her in the pregnancy gives Irrespective of the varying forms of involvement at the me joy as well (Martin, 38 years old, Mechanic). clinic, expectant fathers seemed to have their agenda for It is good for every man to go through that process to attending ANC with their partners. Observations showed have some respect for every woman they see. Some that most men at the clinic made payments on behalf of men do not respect women. All they care about is, their partners, bought them food, and carried their hand- hey, after all, she is just my girlfriend. They do not see bags and folders. One expectant father, Eric, for example, them as their fellow human beings and treat them as was observed at the clinic sitting in an empty space, hold- such. I believe after they go through this experience, ing his partner’s handbag and folder. Although Eric was their respect and care for women would increase. So disappointed that health workers did not involve men I think when you are always there with her through- in the ANC activities, he found a way to make himself out the process, there would be a change of mind- useful. Our study participants also shared that they per- set on how to treat women. It has truly changed my formed some roles in the form of seeking knowledge and mind and mentality about women (Joseph, 32 years providing emotional and physical support for their part- old, Sales Manager). ners at the clinic. I always want to come here to know more about Health workers engagement of men at ANC pregnancy, so I do not take anything for granted. In general, health workers seemed happy to see men Sometimes, the woman may complain of a head- at the clinic, although they had divergent opinions on A mpim et al. Reprod Health (2021) 18:106 Page 7 of 12 including men in the procedures. Apart from giving pref- about issues relating to the queue and about people they erential treatment to women whose partners attended suspected of cheating. Consequently, health workers gave ANC, health workers had no clear agenda about facili- this preferential treatment silently, and only men and tating male involvement in maternity services. Irrespec- women who were already aware of the privilege were able tive of what midwives viewed as the appropriate way to to take advantage of it. involve men in ANC, their primary concern was how male attendance demanded an increase in their already Challenges of male involvement substantial workload. They held that it would be more Health workers shared different views on how men convenient for health workers if ANC focused mainly or should be involved in the activities at the clinic and the only on women. challenges involved. Community health nurses talked about inadequate physical space for men at the clinic, Jumping the queue while midwives talked about whether men’s inclusion Health workers mentioned that there is a recommenda- should be prioritized: tion to motivate men who attend ANC by allowing their partners to move more quickly up the line.2 This princi- The women at antenatal care are usually very ple is justified by the idea that men have to go to work as plenty. Sometimes they (men) enter there, and they providers for their families, and therefore, their partners see plenty of women there, and they will go back. We should be allowed to move more quickly up the queue do not even have space (physical) for the men. There- so the men can go back to work. All health workers who fore, we are not making it comfortable for men to participated in this study mentioned this incentive, sum- involve themselves (CHN, FGD). marized in the excerpt below: CHN’s views on sitting/waiting space at ANC seemed When you come with your wife, we give you prior- to support men’s concern that sitting among women ity. We see you first. Because among the lot, approxi- was uncomfortable. Naana, as shown above, argued that mately 200, 300, we have about five men. We treat men who accompanied their partners should be treated you as a special guest for that day. That is what we as unique and served quickly. Nevertheless, she believed have been doing. Even when I am walking around, that men’s presence should not be a priority unless the and I see a man sitting, I ask the wife, which room condition of a pregnant woman demanded her partner’s do you go to? Then, I tell the midwife in that consult- participation in ANC services. She gave the following ing room, do not forget there is a man there. See that example: person first (Naana, Midwife). If your husband is not coming to postnatal with you However, this incentive and practice were not some- or the antenatal, we are not bothered. We are not thing we came across in the interviews with the men or in bothered. We only need the woman if everything is the observation at the clinic. Only one of our study partic- fine, yeah. Unless she comes and there is a problem. ipants, Charles, said that he “helped his wife to jump the Then, we will call the man (Naana, Midwife). queue”. During the follow-up interview after birth, while Rebecca, another midwife, said that men participating Charles and his wife were expecting their second child, in the consultation would increase their workload. There- he still attended ANC to help his wife move more quickly fore, she had suggested to the hospital that the morning up the line. Interviews and observations showed that very sessions should be communicated through videos, which few men at the clinic knew of the incentive to give queue would include videos on what men can do to support privileges to women who were joined by their partners to their partners. Additionally, she emphasized that a sep- ANC. One reason for this might be that health workers arate men’s group would be better than men participat- in practice seemed to keep silent about this privilege and ing in the private consultation. Nonetheless, this should incentive. Naana, one midwife, explained that expectant happen only if and when specific health workers could be mothers waiting for ANC regularly engaged in quarrels assigned to male attendees. Agnes, another midwife, held a slightly different posi- tion and argued that men should participate in the con- sultations because it would make their work much more 2 Health workers spoke about this incentive in the form of a policy that is manageable: implemented in all government health facilities in Ghana. However, we found no documentation to show that the Ghana Health Services has a policy that As I said before it (male inclusion) is something very permits giving preferential treatment to women who attend the ANC with their partners. Another study by Ganle et  al. 2016. “If I go with him, I can- good and makes the work simple for us. When you not talk with other women,” also mentioned a health facility giving preferential tell them what to do and what not to do, the men treatment but not as part of a health sector policy. Ampim et al. Reprod Health (2021) 18:106 Page 8 of 12 remind them (expectant mothers) at home to comply interaction, networking, and support during pregnancy with the instructions. They (men) are always there to [[44], p. 1]. Antenatal care visits provide physical health- check their wives for us (Agnes, Midwife). care and support and sustain women’s social life during Agnes’ claim here reiterates that health workers sup- pregnancy in the form of sharing information and cre- port the men’s agenda for attending ANC to acquire ating long-standing social relationships and networks, knowledge and remind their partners at home of instruc- including mother-to-mother support after childbirth. tions received during the consultation. Unlike Rebecca, Women may be reluctant to include men to protect the Agnes claimed that men’s participation in consultations relationships that they forge at ANC and preserve female would neither prolong nor increase the workload. How- autonomy over pregnancy and childbirth, as indicated in ever, separation of the women and men would require Ghanaian studies [2, 39]. additional caregivers and time, which the hospital may Furthermore, maternity clinics function as safe spaces not have the capacity to provide. She concluded by say- where mothers have reportedly preferred to discuss con- ing that it would be possible to organize a separate infor- traceptive use and other matters in their relationships mation session for expectant fathers only when they start with their peers and health workers without involving coming to the clinic in more significant numbers. their partners, sometimes for fear of intimate partner violence [[2], p. 200]. Spousal violence during pregnancy is quite common, with “prevalence rates of 28–40% for Discussion physical, 3–27% for sexual and 25–49% for emotionally As stated at the onset of the paper, global health research intimate partner violence” among pregnant mothers in has demonstrated that active male participation in Africa according to a WHO report [[51] p. 1]. Women maternal healthcare services improves women’s health who experience violence during pregnancy may be outcomes and promotes gender equality in reproduc- unwilling to attend ANC with their partners. For inten- tive health [14, 15, 50]. Some literature from sub-Saha- tional and unintentional reasons, men have been margin- ran Africa indicates that male partners attending ANC alized in the maternity clinic’s operation and interactions. facilitate quality care for women by demanding respect- Our study suggests that men felt out of place at the ful care and acting as patient advocates at health facili- maternity clinic. Indeed, at times, they remained almost ties [20–22]. Nevertheless, male experiences of ANC invisible and physically distanced outside the maternity services have not received much research-based atten- clinic. An indication of men’s loss of confidence at the tion. Our study found that only a minority of pregnant maternity clinic is related to their remarks about shyness women’s partners came to the ANC, and those who did that triggered their decision to remain hidden or to stay were actively engaged in the activities at the clinic only to away from the waiting area even when they accompanied a limited extent. While a few men did take an active part their partners. Men conveyed that they were uneasy as even in the individual consultation between their part- a minority in a predominantly female group, a finding ners and the midwives, asked questions and helped to that has also been reported in other studies [36]. Hence, remember instructions, most men attending this particu- they felt more relaxed when they withdrew to a space lar ANC seemed to maintain a relatively distanced role. away from where large numbers of women would often In an attempt to gain in-depth knowledge and under- be gathered, either to the outside of the maternity clinic standing of why men seemed to maintain a distanced role building or to inside areas where the individual consulta- at the maternity clinic, we analyzed the data using the tions took place, where only the man’s wife and the nurse framework of space, place and gender [43]. This frame- would be present in addition to himself. work can elevate our understanding of how a physical Men’s experience of discomfort at the clinic can also place, such as the maternity clinic, can become a site of be related to their potential loss of autonomy in a space gender display and explain why men seemed to be mar- where they feel socially and spatially marginalized. As we ginalized. The identity of the maternity clinic is a product have seen, the clinic is organized in a manner where the of the activities that have been produced and relations focus of the health workers, primarily women, is almost that have been constructed in the location over time [43]. solely on the pregnant women. Thus, men, who in a home As a physical location where women and health workers setting act as heads of the household, find themselves in a (also mainly women) interact and share knowledge on space occupied mainly by women. They feel uninvited to pregnancy and childbirth issues, the place has come to participate and have little to contribute to ongoing activi- exist as a gendered “female” space. ties. In some cases, expectant fathers hoped to partici- The clinic also acts as an essential “third place” for pate in the private consultation to ask questions that they expectant mothers. As a physical place located out- maintained their partners would not properly ask them- side the home and the workplace, it promotes social selves and to remind their partners of important health A mpim et al. Reprod Health (2021) 18:106 Page 9 of 12 instructions. Health workers acknowledged that men men’s disappointment about the lack of facilitation to who participate in private consultations asked questions participate in consultations is similar to the findings from relating to their partners’ health. Participating in the pri- a Rwandan study where men were also reported to be vate consultation demonstrates men’s efforts to share and disappointed that they were not involved beyond attend- contribute to their partners’ maternal health while simul- ing ANC [31]. Nonetheless, our study’s findings indicate taneously presenting them with the opportunity to feel that attendance at the ANC implies a journey where men slightly more in control and reaffirm their masculinity. seemed to gradually become more involved; they become Health workers acknowledged that they have some more accustomed to the setting and activities, and in the structural constraints that reduce their ability to involve process, they become less wary of their own presence in men in ANC activities. Inadequate physical space and a female space. staff to organize separate sessions for expectant fathers As Massey [43] has argued, the identity of places and are a real challenge, as illustrated in our study. This chal- spaces are subject to contestation and change over time. lenge has been documented in other Ghanaian stud- In this line of thinking, could the maternity clinic as a ies, and maternity care services have been criticized as gendered space be transformed to accommodate a male not designed to include men [8]. As part of the Ghana presence with more active participation and inclusion Ministry of Health’s gender policy, health workers are of men? As we have shown, men’s participation is lim- encouraged to engage men to harness their support for ited and involves engaging with health workers only to a appropriate decisions regarding women’s reproductive limited extent. Men felt anxious, invisible or out of place health [52]. The policy also indicates that health work- in the maternity clinic. However, we have also seen that ers should be supported with gender-sensitive training male attendees strived to make themselves useful in a in preservice and in-service education to deliver gen- way that was compatible with their positions as heads der-responsive health services [[52], p. 27]. Although of the household. Typical examples of such involvement undocumented, health workers claimed that there is found among study participants included blood dona- a recommendation of giving preferential treatment to tion, making payments, buying medication, and carrying women who attend maternal health services accompa- their partner’s bags and folders. Men also talked about nied by their partners to motivate men. The reasoning reminding their partners of important health messages behind this incentive has been that men are breadwin- and instructions from the clinic. Moreover, our data indi- ners and therefore need to leave the maternity clinic cated that men were motivated by love for their partners quickly to go to work. to become involved in ANC. As articulated by some studies, a significant problem In summary, our findings suggest that men have with this incentive is that women find the principle unfair actively initiated their participation in ANC more than to those who come to the clinic unaccompanied [2, 53]. health facilities and health workers. The examples of male Health workers in our study have also mentioned that involvement in ANC presented here substantiate the they remain largely silent about giving preferential treat- assertion that men taking joint responsibility for women’s ment to women who are accompanied by their partners workload during pregnancy fosters a less stressful prena- to avoid conflict among expectant mothers in the waiting tal experience for expectant mothers [55]. Our research area. Moreover, this incentive may give the impression material also emphasizes the claim that men become that the male figure is more important than the female exposed to new ways of relating to their partners through figure at the maternity clinic and may reinforce gender their involvement in pregnancy-related care, which could discrimination. If such a recommendation were effec- promote new fatherhood norms [55]. Perhaps with a tively implemented, it could encourage men to attend strategic focus on the clinic’s spatial setup and including the clinics. However, in the long run, it could function men in the general sessions and private consultations, the against the promotion of gender equality in reproductive maternity clinic could, with time, be transformed into healthcare. less of a gendered space, i.e., a space that will accommo- Despite the global and national emphasis on male date both female and male identities. involvement in maternal healthcare services [52, 54], men in this study assumed a minimal participatory role Conclusion in ANC visits. They often remained outside the maternity This study has focused on understanding men’s experi- buildings or even in more distant hospital quarters and ence of ANC services using the conceptual framework primarily accompanied their partners to and from the of space, place and gender. The findings suggest that hospital. A few became disappointed when they found there are differing levels of male involvement in mater- that they were not expected or even allowed to take a nal healthcare services and that active participation of more active and engaged role at the clinic. In this study, men is influenced by socially expected gender norms Ampim et al. Reprod Health (2021) 18:106 Page 10 of 12 and health facilities’ structural factors. Although men Funding seemed to have their own agenda for attending ANC, Field research for this project was funded by the Meltzer Foundation, a research fund attached to the University of Bergen. However, they did not play they felt uncomfortable in a space that was predomi- any role in designing, collecting data, analyzing, interpreting, and writing the nantly occupied by women, and they felt marginalized manuscript. in the services provided by health workers. Availability of data and materials ANC is organized for expectant mothers, and this The datasets used and/or analyzed during this study are available from the core purpose should not be neglected out of an eager- corresponding author on reasonable request. ness to include male partners. Concurrently, the impor- tance of the presence of men who accompany their Declarations partners to ANC for various reasons cannot be over- Ethics approval and consent to participate looked. Active male participation in ANC offers an The study is guided by the protocols of the Norwegian Institute for Data opportunity for the mobilization of men to reflect on Protection (53570/3/ASF). In Ghana ethical approval was granted by the Uni- and nurture new fatherhood norms and new ways of versity of Ghana, College of Health Sciences (CHS-Et/M.6–P1.12/2017–2018). Permission was also sought from the administration of the selected Hospital relating with their partners. Therefore, more research and the maternity clinic of the hospital before the study began. Written or on men’s experiences in ANC services at other gov- oral informed consent were obtained from all participants after thoroughly ernment hospitals in Ghana will facilitate gathering explaining the purpose of the study. Moreover, the participants were asked for the discussion and interviews to be recorded. They were informed that infor- the best evidence for appropriate ways to organize and mation gathered from the study will remain anonymous. All participants were stimulate gender-transformative norms. given pseudonyms to enhance anonymity. The participants were informed An examination of the capacity-building needs of that they could withdraw their consent at any point during the session with- out any consequences. health facilities involving men in pregnancy and child- birth-related care would be beneficial. Considering the Consent for publication often-limited physical space and the limitation of health Not applicable. workers to engage men in separate quarters at ANC, Competing interests health facilities should, at the discretion of health work- The authors declare that they have no conflicting interest. ers, assess what is possible within their capacity and Author details resources to accommodate male attendees. Audio-visual 1 Department of Health Promotion and Development, University of Bergen, materials for broadcasting male activities and respon- Bergen, Norway. 2 Department of Global Public Health and Primary Care, sibilities during pregnancy in maternity clinics’ waiting University of Bergen, Bergen, Norway. 3 Department of Sociology, University of Ghana, Accra, Ghana. areas may be further explored. Furthermore, gender-sen- sitive education in the preservice and in-service training Received: 28 September 2020 Accepted: 11 May 2021 of health workers could be enhanced. 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