University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA COLLEGE OF HUMANITIES DEPARTMENT OF SOCIAL WORK THE PERCEPTIONS AND EXPERIENCES OF MEN’S INVOLVEMENT IN ANTENATAL AND POSTNATAL CARE: A STUDY OF GREENHILL COMMUNITY AT OYARIFA IN GHANA BY FRANKLIN KONADU ADDO AGYEMAN (ID. NO. 10273798) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL SOCIAL WORK DEGREE JULY, 2016 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Franklin Konadu Addo Agyeman, hereby declare that this thesis is the result of an original research conducted by me under the supervision of Dr. Cynthia A. Sottie and Dr. Kwabena Frimpong-Manso of the Department of Social Work, University of Ghana, Legon. No part of it has been submitted anywhere for any other degree. All references cited have been duly acknowledged. Signature: ……………………………… Date: ……………………… Franklin Konadu Addo Agyeman (Student) Signature……………………………. Signature: ……………………………… Date………………………. Date………………………. Dr. Cynthia A. Sottie Dr. Kwabena Frimpong-Manso (Supervisor) (Supervisor) i University of Ghana http://ugspace.ug.edu.gh DEDICATION This dissertation is dedicated to family who have been very supportive over the years. ii University of Ghana http://ugspace.ug.edu.gh ABSTRACT Men’s participation in antenatal and postnatal care issues is critical to the health of mothers and their children. However, issues of maternal health have exclusively been regarded as affairs of women with less focus on men’s involvement which is generally low. In Ghana, men are seen as the primary decision makers in the home, hence their participation in maternal health issues is considered to be very essential. Antenatal and postnatal care has been considered by the World Health Organisation as important phases in ensuring the survival of both the mother and the baby. Men’s participation in antenatal and postnatal in Ghana is becoming recognised, as they are seen to play key role in providing their spouses with the needed support thereby impacting the well-being of the mother and baby. This is a strategy to minimise maternal mortality in Ghana, however, little studies have been embarked on in this area. Therefore, this study was conducted to explore the perceptions and experiences of men’s involvement in antenatal and postnatal care in the Greenhill community at Oyarifa. Qualitative research design was employed using in-depth interviews and focus group discussion to collect data from 29 participants. Participants included 10 married couples, 6 unmarried community members and 3 health workers who were purposively selected form households and work places for the study. Data was transcribed and analysed thematically using the six steps of thematic analysis by Braun and Clarke. The results showed that, majority of the participants saw the need for men’s involvement during the antenatal and the postnatal periods. Some participants perceived that men who involved themselves understood the importance of intimate relationship. Also, the study revealed that, mostly women attend antenatal and postnatal sessions alone. But, men who went with their spouses to the sessions were given preferential treatment as they accessed quicker services at the clinic. Men gave support to their spouses in various ways as most support was financial with a few domestic support. However, culture has greater influence on men’s involvement both at home and outside the home. Participants revealed that men’s involvement could strengthen bonds, enhance relationships, and have the potential to reduce maternal and child mortality. The study recommends that workshops and seminars should be organised in various communities to encourage more men involvement. Gender inequity should be addressed through education and sensitisation as well as advocating for policies to encourage male participation in maternal health issues. iii University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS Content Page DECLARATION............................................................................................................... i DEDICATION................................................................................................................... ii ABSTRACT...................................................................................................................... iii TABLE OF CONTENTS.................................................................................................. iv LIST OF FIGURES…………......................................................................................... viii LIST OF ABBREVIATIONS........................................................................................... ix ACKNOWLEDGEMENT................................................................................................ x CHAPTER ONE................................................................................................................ 1 INTRODUCTION............................................................................................................. 1 1.1 Background of the study............................................................................................... 1 1.2 Problem Statement….................................................................................................... 4 1.3 Objectives of the study.................................................................................................. 5 1.4 Research Questions....................................................................................................... 5 1.5 Significance of the Study.............................................................................................. 5 1.6 Operational definition………………………………………………………………... 6 1.7 Organisation of the Study............................................................................................. 6 CHAPTER TWO.............................................................................................................. 8 THEORETICAL FRAMEWORK AND LITERATURE REVIEW.......................... 8 2.0 Introduction …............................................................................................................. 8 2.1 Theoretical Framework................................................................................................ 8 2.2 Literature Review ……………………………………………................................... 10 2.2.1 Antenatal Care ………………………………………................................................... 10 2.2.2 Postnatal Care …………………………........................................................................ 15 iv University of Ghana http://ugspace.ug.edu.gh 2.2.3 Gender issues in Ghana……………....................................................................... 16 2.2.4 Male Involvement in Maternity Care...................................................................... 19 2.2.5 Factors that Affect Male Involvement...................................................................... 22 2.2.6 Benefits of Men’s Involvement …………............................................................... 26 2.3 Conclusion ……………………………...................................................................... 27 CHAPTER THREE........................................................................................................ 28 METHODOLOGY.......................................................................................................... 28 3.0 Introduction ……........................................................................................................ 28 3.1 Study Area................................................................................................................... 28 3.2 General Research Strategy........................................................................................... 29 3.3 Sources of Data ……................................................................................................... 29 3.4 Study Population …..................................................................................................... 29 3.5 Sample Size.................................................................................................................. 30 3.6 Sampling Technique …................................................................................................ 30 3.7 Data Collection Tools/Methods.................................................................................... 31 3.8 Data Management and Analysis................................................................................... 32 3.9 Ethical Consideration.................................................................................................... 33 3.10 Limitations of the study.............................................................................................. 34 3.11 Measures to ensure trustworthiness of the work………………………………..... 34 CHAPTER FOUR............................................................................................................ 36 FINDINGS AND DISCUSSIONS………....................................................................... 36 4.0 Introduction.................................................................................................................. 36 4.1 Demographic background of participants.................................................................... 36 4.2 Perceptions of participants and perceived barriers on men’s involvement.................. 37 v University of Ghana http://ugspace.ug.edu.gh 4.2.1 Men’s involvement as a necessity……………………………………….... 37 4.2.2 Involvement of men as an act of love……………………………….…...... 39 4.2.3 Cultural influence on men’s involvement…………………………….…... 40 4.2.4 Perceived barriers to men’s involvement…………………………….….... 43 4.3 Experiences of couples on men’s involvement …………………………….............. 46 4.3.1 Clinic Attendance…………………………………………………………. 46 4.3.2 Men’s involvement expedite services for women….................................... 47 4.3.3 Support at home …………………………………..…………………........ 47 4.3.4 Reactions from People on men’s support to their partners ...…………...... 50 4.3.5 Problems couples encounter when men support………………………….. 51 4.4 Couples’ Perceptions and experiences of the benefit of men’s involvement................... 52 4.4.1 Psychological wellbeing and enhanced relationship................................... 52 4.4.2 Knowledge upgrade and potential for reduction in maternal and child mortality………………………………………………………….…......... 54 4.5 Participants’ reflection on men’s involvement in the Future..................................... 54 4.6 Discussion of findings….……………….................................................................. 56 CHAPTER FIVE........................................................................................................... 63 SUMMARY, CONCLUSION AND RECOMMENDATION……………………... 63 5.0 Introduction ……………………………….............................................................. 63 5.1 Summary of findings................................................................................................. 63 5.2 Conclusion………..................................................................................................... 65 5.3 Recommendation ………………………………………………………………….. 65 5.3.1 Recommendation for the Health Sector .…………………………...…..... 65 5.3.2 Recommendation for Social Workers .……………………………..……. 66 5.3.3 Recommendation for Future Studies …………………………….………. 66 vi University of Ghana http://ugspace.ug.edu.gh REFERENCES.................................................................................................................. 67 APPENDICES................................................................................................................... 78 Appendix 1 Introductory letter to Danfa Health Centre…………………………............ 78 Appendix 2 Interview guide for female partners.................................................................... 79 Appendix 3 Interview guide for male partners………………............................................. 81 Appendix 4 Interview guide for health workers................................................................ 83 Appendix 5 Focus group discussion guide for unmarried community members.............. 84 vii University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1 Theory of Reasoned Action/Planned Behaviour………………………... 12 Figure 2 Factors that affect male involvement in maternity care………................. 25 viii University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS ANC Antenatal Care FANC Focused Antenatal Care FGD Focus Group Discussion GDHS Ghana Demographic and Health Survey GHS Ghana Health Service GMDG Ghana Millennium Development Goal GSS Ghana Statistical Service HCWs Health Care Workers ICPD International Conference on Population and Development MDG Millennium Development Goal MoH Ministry of Health NHIS National Health Insurance Scheme NDPC National Development Planning Commission PNC Postnatal Care QA Quality Assurance TRA Theory of Reasoned Action UN United Nations UNICEF United Nation Children’s Fund USAID United States Agency for International Development WHO World Health Organisation ix University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I first want to give thanks to the Almighty who sees to the needs and wants of those who look up to Him. To my supervisors, Dr. Cynthia Sottie and Dr. Kwabena Frimpong-Manso, thank you for being with me from the beginning of this project to the very end of my work, encouraging and guiding me to successfully complete this project. My gratitude also goes to my respondents for availing themselves during data collection and to Aunty Felicia of the Family Planning Unit at the Danfa Health Centre for her hospitality, friendship and making it easier to gather data at the health centre. My thanks also goes to my best of heart, Simonia Afia Bemah for her support, understanding, encouragement and care during this programme and to Francisca Oforiwaa Doku, her mum Francisca Asamoah Doku and Daniel Desire Oppong for their support and prayers. To all my 2015 course mates and Vida Dede Kartey who has been a good friend to me, I say thank you for your support and keeping me on the edge to finish the work. To Enoch Adade, a good friend of mine who helped in giving me directions towards my work, to Conrad Kakraba and Elizabeth Nunoo who helped in proof reading my work, I say thank you. And finally to Mr. Charles Arthur, Mr. Abloso and Miss Catherine Tukpe all of Ghana International School, I say a big thank you for the pieces of advice you gave to me. x University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 Background of the Study Male involvement in maternal health is an approach that is being encouraged by the World Health Organization (WHO) in Ghana and Africa as a whole to make pregnancy safe. Male involvement is seen as men playing responsible roles in maternal health to ensure the well- being of women and children (Bhatta, 2013). It includes men participating actively and supporting their partners in antenatal and postnatal care attendance. Men’s support also includes providing financial support, assisting in domestic activities like washing, cooking among others, to reduce the work load of women. Men can also provide emotional support, ensure good communication between them and their spouses, assist in birth preparations, care for the baby after delivery (changing diapers, carrying baby) and provide additional nutritional supplement for the mother and the baby (Kwambai, Dellicour, Desai, Ameh, Perso, Achieny & Kuile, 2013). Antenatal and postnatal care are important sessions in the lives of mothers. Antenatal care involves preparation for birth and parenthood as well as prevent, detect, alleviate or manage problems that affect mothers and babies (Ortiz, 2007). It includes identifying and managing obstetric complications such as pre-eclampsia, tetanus identification and management of infections such as syphilis, HIV and other sexually transmitted infections (STIs) (Lincetto, Mothebesoane-Anoh, Gomez & Munjanja, n.d.). Postnatal care is also a critical phase in the lives of mothers and their babies, and yet, it is the most neglected period for provision of quality care services (WHO, 2013). Postnatal care period begins with the delivery of the baby and the placenta and it is also known as puerperium (Arthur-Arko, 2013). According to Arthur-Arko, postnatal care basically looks at providing an environment that is supportive, 1 University of Ghana http://ugspace.ug.edu.gh where there is a new beginning for the mother and the new born infant together with the whole family. Traditionally, maternal health issues, according to Kululanga, Sundby and Chirwa (2011), have been perceived and addressed as a purely feminine matter. Pregnancy and child birth in Africa have been seen as the domain of women and maternal health care services have focused on women with less involvement of males (Kululanga et al., 2011). The presence of a husband at an antenatal clinic is uncommon in many communities in Africa and it is rare to find men accompanying their partners during antenatal care (ANC) and delivery (Bhatta, 2013). The role of men in women’s reproductive health is becoming more recognised globally. Doe (2013) in her study on male involvement in Ablekuma District in the Greater Accra region of Ghana noted that, when men are educated on the importance of health care for the family, there is promotion of some health-seeking behaviours such as antenatal and postnatal care. Also, there is enhancement in support of female spouses when men are provided with education on maternal health (Mullany, Becker, & Hindin, 2007). The actions of men can, therefore, have direct bearing on the health of their partners and children. Within the African social and cultural environment, men possess considerable power, making it difficult for women to have autonomy and decision-making powers (Bhatta, 2013). Men usually make decisions on timing and conditions of sexual relations, family size and sometimes, women’s access to maternal health may depend on the male. Involving males in antenatal and postnatal care, and men and women jointly making decisions on healthcare therefore, could result in better maternal outcome through the utilisation of health care services (Story & Burgard, 2012). Kululanga, Sundby, Malata and Chirwa (2012) observed that, men in the United Kingdom have been participating in maternal health since the 1970’s. Sweden also values the involvement of fathers in pregnancy education, childbirth and the 2 University of Ghana http://ugspace.ug.edu.gh care of the new born baby. Both Sweden and Norway have laid emphasis on men’s involvement in legislation regarding parent education, pregnancy, childbirth and the care of the new born baby (Kululanga et al., 2012). Involving men enables them to give support to their spouses to utilise obstetric services and both will be prepared adequately for birth complications. Men can play an important role in developing countries and impact birth outcomes, according to Bhatta (2013). Maternal mortality rate in developing countries is estimated at about 480 deaths per 100,000 live births with over half a million women having to die from pregnancy complications and childbirth complications. Ghana’s current maternal mortality is 358 per 100,000 live births (National Development Planning Commission [NDPC] & United Nations [UN], 2015). It is critical for a mother to receive health care during and after delivery because, they get screened and treated during antenatal visits for possible complications during pregnancy. Women gain access to good health care that are vital to their health and future children when they have regular contact with a doctor, mid-wife or nurse during their pregnancy (Centre for Disease Control and Prevention, n.d.). There are often delays that affect access to maternal health care. These involve delay in deciding to receive care, delay in reaching the service delivery point and delay in receiving care at the facility. Male involvement can have great influence on the decision to receive care and accessing service delivery points, since the decision to seek care in some homes or cultures needs the approval of the man. Therefore, since the contribution of men towards the health concerns of women is important, the perceptions and experiences of people towards men’s involvement in antenatal and postnatal care are explored in this study. 3 University of Ghana http://ugspace.ug.edu.gh 1.2 Problem Statement Male involvement is an essential factor in improving maternal health (United States Agency for International Development [USAID], 2010). However, research has shown that, the involvement of men during antenatal and postnatal periods in Ghana is very low (Mitchel, 2012). This could be a contributing factor to maternal and child mortality because, men in Ghana are key decision makers in families. They are usually seen in the home as providers of resources for women during pregnancy, as well as wielding substantial power in making decisions in all matters at all levels (Narang & Singhal, 2013). For instance, for a woman to have access to good health care services, sometimes depend on the male spouse. Moreover, involvement of men in maternal health has been perceived as women losing their rights to make decisions regarding issues of pregnancy, such as when and where to seek health care, how to seek health care, where to give birth among others (Kululanga, Sundby, Malata & Chirwa, 2012). Statistics from the Ghana Millennium Development Goal (GMDG) report show that, maternal mortality still remains high in Ghana, with 358 per 100,000 live births as against the Millennium Development Goal five to reduce it to 185 per 100,000 live births by 2015 (National Development Planning Commission [NDPC] & United Nations[UN], 2015). Sablah (2011) indicates that, 25 percent of maternal deaths occur during pregnancy. In Ghana, work has been done on male involvement in maternal health care with regard to decision making and partner involvement in maternity care (Bruce, 2013; Coffie, 2011; Doe, 2013; Mitchel, 2012). However, there is the need to understand how Ghanaians perceive the involvement of men with regard to antenatal and postnatal care, and the experiences couples go through with men’s involvement in antenatal and postnatal care. Understanding the perceptions of Ghanaians on the involvement of men, is important to anticipate how men will involve themselves in the near future, taking into consideration gender roles related to culture, social norms, beliefs and values. Therefore, the researcher conducted this study to 4 University of Ghana http://ugspace.ug.edu.gh explore the perceptions and experiences of couples and community members on the involvement of men in antenatal and postnatal care in the Greenhill community at Oyarifa. 1.3 Objectives of the Study Generally, the study sought to explore the perceptions and experiences of men’s involvement in antenatal and postnatal care in Greenhill Community, Oyarifa. Specifically, the study sought to: 1. Describe participants’ perceptions on men’s involvement during antenatal and postnatal periods. 2. Describe experiences of couples on men’s involvement during antenatal and postnatal periods. 3. Explore couples’ perceptions and experiences of the benefits of men’s involvement during antenatal and postnatal periods. 1.4 Research Questions 1. What are the perceptions of participants on men’s involvement during antenatal and postnatal periods? 2. What are the experiences of couples on men’s involvement during antenatal and postnatal periods? 3. What are couples’ perceptions and experiences of the benefits of men’s involvement during antenatal and postnatal periods? 1.5 Significance of the Study The findings will add to the Ghanaian literature to provide information on how people perceive men’s involvement in antenatal and postnatal care. Information about these perceptions is important, since it will inform policy makers to formulate policies that will encourage more male involvement in issues of antenatal and postnatal care. The results from 5 University of Ghana http://ugspace.ug.edu.gh the study highlights what couples go through during the period of antenatal and postnatal. Based on the information, care providers will be able to provide measures that will include more male participation in their activities and how to address experiences couples go through at these stages. Also, social workers who wish to work in hospitals, have the knowledge to assist in counselling to motivate men to play active roles in maternal health issues and address issues of gender inequity. 1.6 Operational Definition of Concepts Antenatal care: The care received from health care professionals during pregnancy. Men’s involvement: Refers to active participation of men in all areas of antenatal and postnatal care. It includes actions taken by men to support and protect the health of the woman and the child. Such actions are attending antenatal and postnatal care and participating during such visits, providing financial support, assisting partners in domestic activities such as washing, cooking and cleaning to reduce the work load of the women, providing emotional support, ensuring good communication between them and their partner, assisting in birth preparations, caring for the baby after delivery (changing diapers, carrying baby to allow the woman to function in other areas) and providing additional nutritional supplement for the mother and the baby. Postnatal care: The care a mother and the baby receive from health care professionals after birth of the child. 1.7 Organisation of the Study The study has been presented in five chapters. Chapter one introduces the study, by providing background information on antenatal and postnatal care and male involvement. The chapter discusses the problem the study sought to investigate, and outlines the objectives of the study, and questions the study sought to find answers to. The chapter further provides information 6 University of Ghana http://ugspace.ug.edu.gh on how significant the study is to people and what the results of the study could be used to provide alternative interventions to assist couples. Finally, the chapter defined some operational terms that will guide readers in understanding what the study is investigating. Chapter two explains the theoretical framework within which the study was carried out and reviews literature on antenatal care, postnatal care, gender issues in Ghana, male involvement in antenatal and postnatal care, factors that affect male involvement, benefits of men’s involvement. Chapter three focuses on the research methods, which describe the procedure in which the data was collected and gives a brief description on the area where data was collected. The chapter explains the technique used in drawing a sample from the target population and describes the tools used to collect the data from the sample. The chapter further provides detailed explanation on how the data collected was to be managed and analysed. Ethical consideration and limitations to the study were also outlined in the chapter. Chapter four presents and discusses the findings of the study. Finally, Chapter five summarises the findings, draws conclusions based on the findings and makes recommendations for more male involvement in antenatal and postnatal care. 7 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO THEORETICAL FRAMEWORK AND LITERATURE REVIEW 2.0 Introduction This chapter is divided into two sections. The first section discusses the theoretical framework within which the study was situated and the second section reviews literature on antenatal care, postnatal care, gender issues in Ghana, male involvement in antenatal and postnatal care, factors that affect male involvement, and the benefits of men’s involvement in antenatal and postnatal. 2.1 Theoretical Framework This section explains the theory of reasoned action/planned behaviour within which the study is carried out. The theory of reasoned action/planned behaviour was chosen to understand attitudes of men towards their female spouses, and the reasons for supporting and not supporting their spouses. The Theory of Reasoned Action was first introduced by Fishbein in 1967 to understand the relationship between attitude and behaviour (Ajzen & Fishbein, 1980). The theory attempts to explain the relationship between beliefs, attitudes, intentions and behaviour. Southey (2011) asserted that, the Theory of Reasoned Action (TRA) provides a model that helps in predicting the intention to perform a behaviour based on an individual’s behavioural, normative and control beliefs. According to the theory, the most precise determinant of behaviour is behavioural intention. The direct determinant of people’s behavioural intentions is their attitudes towards performing the behaviour, the subjective norms associated with the behaviour and the control beliefs (Tlou, 2009; Vallerand, Pelletier, Deshaies, Cuerrier & Mongeau, 1992). The behavioural beliefs comprises of the belief that, a particular behaviour leads to a certain outcome and an evaluation of the outcome of that behaviour. Thus, if a person beliefs that 8 University of Ghana http://ugspace.ug.edu.gh behaviour is good, he or she will show positive attitude towards performing the behaviour. Once the person shows positive attitude towards the behaviour, there is the likelihood of the individual engaging in the behaviour. Likewise, if the individual beliefs that behaviour is bad, he or she will show negative attitude towards performing the behaviour and will eventually disengage himself/herself from that behaviour. Also, included in one’s attitude towards a particular behaviour, is the person’s concept of the subjective norm (Ajzen & Fishbein, 1980). The subjective norm is a person’s perception of what others around them believe that the individual should do. Thus, the subjective norm of a person is determined by whether important referents (those who are important to the person) approve or disapprove of the performance of a behaviour (normative beliefs), weighted by the person’s motivation to comply with those referents (Ajzen & Fishbein, 1980). An individual is most likely to perform a behaviour, if appropriate persons in the life of the individual see the behaviour as good and the individual is willing to act in accordance of the appropriate persons. Ajzen (1991) introduced the theory of planned behaviour by adding perceived behavioural control to explain behaviour in situations where volitional control of the individual is low. The perceived behavioural control looks at the factors that are outside the individual’s volitional control and may affect the person’s intentions and behaviour. The addition was included on the idea that, performing a behaviour is influenced by motivation (intention) and ability (behavioural control). Thus, an individual will have a high perceived control if the individual strongly holds control beliefs that make it easier to perform the said behaviour. So, an individual making a decision after reflecting on the consequences of a particular behaviour, and his/her beliefs about what others expect from him regarding the behaviour, as well as the individual having the ability to perform the behaviour in the presence or absence of facilitators and barriers, would lead to increased intention to perform the behaviour. 9 University of Ghana http://ugspace.ug.edu.gh Involving men in maternal health issues will depend on how men perceive the benefit of carrying out those roles and the influence of others around them. If the outcome of their involvement is not pleasant, they will retreat from that behaviour. However, if the outcome of their involvement is pleasant, they will continuously play more productive roles in supporting their female partners. Men play specific roles because, men by nature do not want to defile their reputation and be seen as demonstrating weakness with regard to particular roles they perform, especially those that are not considered to be male roles (Kululanga et al., 2012). 2.2 Literature Review This section reviews literature on antenatal care, postnatal care, gender issues in Ghana, male involvement in antenatal and postnatal care, factors that affect male involvement, benefits of men’s involvement. 2.2.1 Antenatal Care Antenatal care has positive impact on pregnancy and birth outcomes, as it facilitates early diagnosis and treatment of complications as well as promotes the health of the pregnant woman. When women go through a sequence of care that is accessible and of high quality before and during pregnancy, complications during child birth and during the postnatal period are likely to be avoided. Antenatal care can aid a woman’s preparation for delivery and understand warning signs during pregnancy and childbirth (UNICEF, n.d.). Pathmanathan et al. (2003) assert that, there have been accumulation of knowledge and experience to increase quality health care over the years globally, however, due to lack of resources in low income countries, there are still challenges in achieving perfect antenatal care system. Degley’s (2012) study on quality antenatal care services in Nkwanta South District in the Volta Region of Ghana showed that, the success of antenatal care (ANC) is dependent on the perception of client on the quality of health services. The client’s perception 10 University of Ghana http://ugspace.ug.edu.gh according to Degley, also re-enforces continuous utilisation of the health facilities such as delivery and postnatal care services. Ghana Health Service (GHS) in 1999, began the implementation of Quality Assurance (QA) programme, which focuses on client-centred care and is measured by client satisfaction at antenatal care units to show its operation. Antenatal care services create opportunity for service providers to establish contact with the woman to identify and manage current and potential risks and problems during pregnancy (Sablah, 2011). The WHO has established a new model of antenatal care based on four goal oriented visits by pregnant women to the clinics, now called Focused Antenatal Care (FANC) (Owoo & Lambon-Quayefio, 2013; Sablah, 2011; UNICEF, n.d.). However, statistics of UNICEF indicates that, only about half of pregnant women receive the recommended amount of care globally. According to Sablah (2011), the first visit should be made immediately signs of pregnancy are detected or between 8-12 weeks of pregnancy. The WHO (2011) postulated that, when the first visit is made, the pregnancy will be confirmed and the woman is classified for basic antenatal care (i.e. four visits or more), depending on whether the pregnancy is classified as complicated or not. Second visit takes place between 24-26 weeks where assessment of maternal and foetal well-being is done together with modification or review of birth and emergency plan. Third and fourth visits are scheduled in 32 weeks and between 36-38 weeks, respectively to again assess maternal and foetal well-being as well as birth and emergency review. Antenatal care is needed for diagnosing and treating complications that could pose danger to the lives of the mother and child. The Ghana Demographic and Health Survey (GDHS), (2008) report indicates that, it is crucial for a mother to receive health care before, during and soon after delivery, to ensure her survival and well-being as well as that of her child. Women get information that are of necessity to their diet and other overall safety practices for mother and child. 11 University of Ghana http://ugspace.ug.edu.gh Behavioural beliefs (Belief towards an outcome) Attitude Outcome Evaluation Behavioural Behaviour Normative Beliefs Intention (Beliefs of what others think or what experts think) Subjective Perceived Norms behavioural control Motivation to comply with others Control Perceived beliefs power Figure 1. Theory of Reasoned Action/Planned Behaviour Source: Ajzen & Fishbein, 1980 The diagram indicates that, our attitudes are guided by our belief about a behaviour with evaluation of that behaviour, whiles our subjective norms associated with the behaviour are guided by approval or disapproval of behaviour from important referents, weighted by our motivation to comply with those referents. Our perceived behavioural control is guided by our ability to perform a behaviour with or without barriers and facilitators. When our attitudes and subjective norms come together as well our ability to perform the behaviour, they determine our behavioural intentions and our behavioural intentions further determine our behaviour. 12 University of Ghana http://ugspace.ug.edu.gh With regard to antenatal care in Ghana, the GDHS report found that, 90% of women saw a health professional at least once during pregnancy for the most recent birth in the five-year period before the survey. In Ghana, access to health care depends on availability of money. This implies that, income has an impact on the use of antenatal care in Ghana. Antenatal care involves consultation cost, recommended drugs to be purchased and treatment of possible pregnancy complications alongside transportation cost, among others (Abor & Abekah-Nkrumah, 2013). In Ghana, it is more likely for women who are rich to use antenatal services than women who are poor as indicated by Abor and Abekah-Nkrumah (2013). This assertion was attested by Ortiz (2007) in his study in Colombia, concluding that, mothers who are wealthy have better chance of receiving antenatal care for all required visits than mothers who are poor. It is expected that, the higher the wealth of the woman, the more likely she will use antenatal care due to her affordability of usage of health care services (Arthur, 2012). Furthermore, the GDHS in 2008 reported that, women who are more educated are likely to access antenatal care than women with no education. Overbosch et al. (2004) indicated that, in Ghana, the attitude of women towards antenatal care is influenced by their education. This is the case because, when a pregnant woman is educated, she is able to make informed choices about her health needs. A Study by Nyarko et al. (2006) indicates that, a significant proportion (45%) of pregnant women wait until the second or third trimester to seek antenatal care, which delay preventive measures when complications like anaemia occur. Failure to receive antenatal care during pregnancy, can result in unwanted outcomes in pregnancy such as low birth weight for the baby, maternal morbidity, or worse maternal mortality (Magadi, Madise & Rodrigues, 2000). 13 University of Ghana http://ugspace.ug.edu.gh According to Arthur (2012), antenatal care services in Ghana are provided free of charge in all government owned hospitals and in some accredited private hospitals. However, some private hospitals also provide antenatal care services, but at a fee. In a qualitative study in Kosovo by UNICEF (2009), using Focus Group Discussion (FGD) with health care professionals, revealed that majority of women access antenatal services of gynaecologists as compared to other health care professionals. The study also showed that, institutions that were visited mostly by women during pregnancy were private institutions. The increase in use of antenatal services in private institutions was as a result of higher level of education and income of the household (UNICEF, 2009). AbuBakar and Jegasoth (2006) also in their study on assessment of quality antenatal care services in Tanzania showed that, inadequate resources such as shortage of supplies (drugs), inadequate skilled staff and inadequate stationary affected the quality of antenatal care. Degley (2012) further revealed that, provision of antenatal care in Nkwanta South in Ghana was of good quality and in line with the national standards. Quality of antenatal was measured by client satisfaction with the six (6) dimensions of quality such as empathy, communication, competence, resource availability, tangibles and responsiveness. Results showed that, most participants were satisfied with services received from health care providers. However, in areas such as long waiting time, limited time to ask questions which were aspects of responsiveness and communication, as well as erratic supply of some essential medicines at the health centres, participants showed dissatisfaction. Similar studies have been conducted to assess the level of satisfaction of patients (Mawajdeh et al., 1996; Pitaloka & Rizal, 2006). Mawajdeh et al. (1996) in their study showed that, 65% out of 289 of pregnant women were dissatisfied with the patient-provider relationship and with the extent of information exchange between their care providers and themselves. Results from Pitaloka & Rizal also 14 University of Ghana http://ugspace.ug.edu.gh showed that, more than half of the patients, constituting 56.7% were satisfied with services they had received, while a few patients constituting 43.3% showed dissatisfaction with services. 2.2.2 Postnatal Care The postnatal period, which begins at delivery and extends through the first six weeks of life, is seen as a critical period for the mother and the new born, as services at the postnatal stage enables health care providers to identify post-delivery problems and provide immediate treatment (Titaley, Hunter, Heywood & Dibley, 2010; WHO, 2013). Nevertheless, the postnatal period is the most neglected, as mortality occurs frequently during this period. This is confirmed by Abou-Zahr and Wardlow (2003), who found that, most neonatal deaths take place during the first seven days of life, and maternal deaths occur during the postnatal period. Abor and Abeka-Nkrumah (2013) also posit that, most maternal mortality deaths occur during the postnatal period, hence, it is considered one of the most important periods in maternal health care. The Ghana Statistical Service (GSS), Ghana Health Service (GHS) and ICF Macro (2009) reported that, 45% of all maternal deaths occur within one day of delivery and 65% occur within the first week. In Ghana, the first postnatal check-up is preferred to be done within the first three days of delivery and subsequent check-ups should be made as appropriate (GSS, 2011; GSS, GHS & ICF Macro, 2009). Research findings by Arthur-Arko (2013) indicated that, women who had given birth for the first time did not seek postnatal care (PNC) services due to lack of knowledge of the service. This was also as a result of the failure of health care providers to provide sufficient information on the benefits involved and the risk of not receiving PNC services. Her study further showed that, services provided by health care workers were not of good quality, as some aspects of PNC service were completely left out. 15 University of Ghana http://ugspace.ug.edu.gh Unavailability of health facilities and professional health workers, cost of transportation, distance as well as unfriendly attitudes of health care providers were factors that prevented postnatal mothers from utilising PNC services (Arthur-Arko, 2013). This finding is in line with the 2008 GDHS report on utilisation of PNC services. Studies have shown that, meeting the Millennium Development Goal (MDG) 5, which was targeted at reducing maternal and child mortality by 2015, was a challenge and will not be met because, neonatal deaths account for as high as 40% of under-five mortality in Ghana (Ministry of Health [MoH], 2014). 2.2.3 Gender issues in Ghana Gender related issues in sexual reproductive health have been hashed out for years. Gender encompasses the belief of society regarding roles, responsibilities, duties among others on the basis of the sex of an individual (Singh, Bloom & Brodish, 2011). Hangman (2013) in his study indicated that, gender inequalities exist in any society contributing to the subordination of women relative to men in most contexts. Influence of gender inequality according to Singh, Bloom and Brodish (2011) on health status correlates with gender stratification in a given place. Gendered structures place barriers to women’s access to paid labour, education and health services which could provide them with life-saving care (Hagman, 2013). In many communities, leadership roles are reserved for the men as the women are often viewed as child bearers, with the duty to produce. Women’s roles as housewives and household organisers including the role of reproduction further creates problems to their health. According to Hagman (2013), there is a barrier to women’s empowerment in societies that are dominated by patriarchal structures. Women tend to lose their freedom as men hold superior position and this can increase risk of violence against women. Men take the role as 16 University of Ghana http://ugspace.ug.edu.gh decision makers in every aspects of life, including reproductive health and the female body issues (Greene, Mehta, Pulerwitz, Wulf, Bankole & Singh, n.d.). In Ghana, there is substantial evidence showing that women preferred to live with mothers during pregnancy, childbirth and the postpartum period, thereby limiting the men to roles such as provision of money for medical bills and other material needs including naming of the child (Ampim, 2013; Jansen, 2006). Improving maternal health as the MDG 5 seeks to achieve, would be impossible without the involvement of the men who are seen as partners, fathers, husbands and brothers to women (The United Nations Fund for Population Activities, 2007). The UNFPA (2011) also indicates that, to promote gender equality, especially in areas of sexual and reproductive health, it is appropriate to include men as they usually have strong reproductive decision-making power in relation to the number of children and the use and choice of contraceptives. The 1992 constitution of Ghana gives provision of protection for all persons who are before the law. Article 15 of the constitution of Ghana spells out the inviolability of the dignity of all persons. The constitution in section 17, commands against discrimination on the basis of gender, race, colour, ethnic origin, religion, creed or social or economic status. Also included in the constitution, section 27, sub-section 3, is the guarantee for equal rights for women without any impediments from any person (Constitution of Ghana, 1992; Ministry of Health, 2009; Venkatesh, 2010). Discrimination and inequality faced by women in the Ghanaian society according to Sossou (2006), is still ongoing, decades after the women’s international conference in 1975 and the United Nations Convention on the Elimination of all Forms of Discrimination against Women, as well as the constitutional provision of Ghana concerning the right and equality of women. Ghana’s representative to the United Nations, on an international conference in 2011 stated that, there were measures to address the existing gaps 17 University of Ghana http://ugspace.ug.edu.gh in ensuring women’s full participation in decision-making process (UN General Assembly, 2011). Despite the constitutional provisions and other international conventions, there is little changes in the lives of women in Ghana (Sossou, 2006). Gender issues continues to spread in the health needs of both men and women. Roles and responsibilities are prescribed by society in different social context as well as differences in opportunities and resources available for women and men, and in their ability to make decisions and exercise their human rights, including those related to protecting health and seeking care in case of ill health (Ministry of Health, 2009). According to the Ministry of Health, Ghana’s policy commitments to gender equality promotion with implications on health are also enshrined in the National Plan of Action on Girls Education (1995); the Ghana Poverty Reduction Strategy 1 (2002); Growth and Poverty Reduction Strategy II (2005); National Gender and Children’s Policy (2004); The National Plan of Action for Women; the National Gender and Children’s Strategy (2004); The Early Childhood Care and Development Policy (2004); the Three Year Strategic Implementation Plan of the Ministry of Women and Children (2005-2008) and the Domestic Violence Law, 2007. Ghana in achieving gender and health provisions also signed on to a series of key international development targets such as the MDGs, the Growth and Poverty Reduction Strategy II, and the National Policy in 2007. Women tend to delay in seeking healthcare which results in high maternal mortality because, travelling to health facilities gives additional burden to their heavy domestic schedules (MoH, 2009). Also as a contributing factor to maternal mortality is, higher levels of poverty among women, lower literacy levels, and ignorance as compared to men. 18 University of Ghana http://ugspace.ug.edu.gh 2.2.4 Male Involvement in Maternity Care Male involvement in maternity care has been emphasised since the 1994 International Conference on Population and Development (ICPD) in Cairo and there is growing awareness to encourage more male involvement (Davis, Luchters & Holmes, 2012; Narang & Singhal, 2013). Male involvement in maternity care is seen as men acting together with women as partners and supporting decisions and activities that will improve women’s health (Akinpelu & Oluwaseyi, 2014; Mullany et al., 2005). Male involvement is crucial to ensure the safety of the mother and the baby as well. Men are able to see to it that, the child’s development is monitored during antenatal care, proper screening is done and partake in health advices given by health care providers (Overbosch, Nsowah-Nuamah, Van Den Boom & Damnyag, 2004). Male involvement provides encouragement in communication and negotiation among couples. Davis et al. (2012) posit that, men can influence the health of the mother and the child in so many ways. They noted that, men can support and encourage antenatal care (ANC) attendance, ensure good nutrition and reduced workload during pregnancy, assist with birth preparations, and provide emotional support. Men can also encourage and support good infant nutrition, including early and exclusive breastfeeding, and childhood immunisation. This was observed in a qualitative study by Kwambai et al. (2013) on the perspectives of men in antenatal and delivery care service utilisation in Kenya. In the study, some of the men were seen to participate in taking on some of their partners’ domestic duties, such as fetching water, splitting firewood and cultivating land, which were thought to have detrimental effects on the health of both the mother and the their unborn child. Men partaking in antenatal and postnatal care services receive education at the clinic. This increases their knowledge and appreciation of the need for these services. Kwambai et al. (2013) also indicated that, participants saw the need to accompany their partners to antenatal 19 University of Ghana http://ugspace.ug.edu.gh care to get first-hand information about the health of their partners and unborn babies. Few participants from the study were able to remind their partners to follow instructions given by doctors. According to Mullany (2006), when women are educated with their partners, they are able to take up information acquired and comply with the information apart from the men also learning. Mullany et al. (2005) noted that, both males and their female partners including health care providers were in support of a more male friendly maternity care services that will encourage more men to involve themselves. In Africa, most cultures regard pregnancy and other maternal issue as female domain (Kululanga et al., 2012). Men, therefore, are not often expected to accompany their female partners to antenatal care and postnatal care clinics. Men are usually seen as decision makers with regard to when, where and even if a woman should have access to healthcare (Kwambai et al., 2013). This gives an indication that, men are considered to have critical role to play during pregnancy and at child birth. Their support ensure the progress of their partners in the process of pregnancy and child birth as men’s decisions can have direct impact on the wellbeing of the pregnant wife and the child as well (Mitchel, 2012). According to Bloom, Wypij and Das Gupta (2001), seeing to it that pregnancy is safe and delivery is successful, may not be in the control of the woman, but rather in the control of the husband since he is the head of the household. According to Kululanga et al. (2012), practices in Malawi indicated that, women who come with their male partners are attended to first before attending to mothers who attend alone. Attending to couples first, was a way of getting more men to be actively involved and follow their partners to antenatal and postnatal clinics. In Malawi, when a man accompanies his partner to the clinic, it is publicly viewed as an indication of the level of love and affection the man has for his partner. 20 University of Ghana http://ugspace.ug.edu.gh A systematic review by Ditekemena et al. (2012) showed that, targeted interventions such as tailored messages, specific health educations, and innovative strategies in identification of male friendly venues would be of great benefit to increase male involvement. These interventions were drawn out based on a study conducted by Ditekemena et al. (2012) in the Democratic Republic of Congo, to invite men for voluntary counselling and testing in three venues: a bar, a health centre or a church. Their results showed that, male involvement was higher in the bar and church than in the health centre, suggesting that more friendly and convenient venues for men are needed. They further noted that, gender specific services to address uniquely male issues do not exist because clinics are not able to accommodate pregnant women and their partners concurrently due to lack of space. Also, study by Kululanga et al. (2012) have shown that, women access quick service at the clinic when they go with their partners. This is done to increase male involvement, however, its effectiveness is still not achieved. Women have to wait frequently for longer periods before receiving ANC services due to burdensome administrative procedures, resulting in poor patient/client through-put in health facilities. And with this, men who are also frequently in paid workforce are more often not in a position to spend virtually the entire day participating in ANC services (Ditekemena et al., 2012). Similarly, Ayebare et al. (2015) in their systematic review of interventions for male involvement in pregnancy and labour noted that, several interventions have been suggested to support male involvement in reproductive health and maternity care. However, no assessment has been done in terms of their effectiveness. Two interventions were identified in their review: facility-based couple health education and workplace-based health education. Isichei et al. (2015) postulated that, peer sensitisation and the establishment of male-friendly areas in antenatal facilities are intervention that can give rise to male involvement. This was testified in Uganda as male partner testing increased from 5.9 percent to 76 percent over the last 21 University of Ghana http://ugspace.ug.edu.gh decade. They also indicated that, for male involvement to be more effective, there is the need for antenatal clinics to be accessible to men and messaging around HIV testing during pregnancy needs to be equally targeted at men. Some possible ways suggested to increase male participation included hand delivered invitations and routine testing for men who accompany their partners. They concluded, it is usually far from easy to persuade men to attend when they regard women’s clinics dealing with women’s issues. 2.2.5 Factors that affect Male Involvement Male involvement in maternity care may be affected by a number of factors. These factors may include socio-demographic factors, normative beliefs, economic factors, religious factors, programme factors and health facility factors. Socio-demographic characteristics include age, educational level, occupation and religion (Doe, 2013). Other factors include the type of marital union (formally married, unmarried or cohabitating), whether or not they live together (Coffie, 2011). Cultural norms that differentiate gender roles may not encourage men to get involved in activities considered as feminine. Kwambai et al. (2013) from their study in Kenya indicated that, one major barrier to attending antenatal care for men is the fact that, it is seen as a female role. Males are often excluded from playing a supporting role because, the primary pregnancy support is usually provided by other women. This is so because, in many African cultures women typically choose to tell their mothers-in-law, or co- wives or trusted female neighbours about issues concerning their pregnancies rather than the male (Kwambai et al., 2013). In some cultures, men are prohibited and it is considered a taboo for a man to be involved in issues related to maternity care (Doe, 2013). Factors within the health facility may or may not encourage male involvement in areas of antenatal and postnatal. Men could actively participate when there is readiness of health facilities to accommodate them when they accompany their partners. When the facilities are not male friendly and restrict men to areas in the facility they can access, it may also have 22 University of Ghana http://ugspace.ug.edu.gh influence on men involvement. Some men do not accompany their female partners due to negative attitudes portrayed by Health Care Workers (HCWs) towards men participating in ANC or delivery care. They are sometimes subjected to unfriendly attitudes or even abusive language from HCWs (Kwambai et al., 2013). Involving males could lead to improvement in maternal health outcomes by increasing women’s utilisation of health services. According to Mullick, Kunene and Wanjiru (2005), issues of family planning, pregnancy and child birth have exclusively been regarded as women’s affairs in South Africa and most parts in Africa. This is because, men are generally not seen to accompany their female partners to antenatal and postnatal care services. In addition, men are not expected to be present during delivery of their children. This notion deter men from involving themselves as they often have the perception that, getting actively involved will be seen as showing weakness. They noted further that, men’s inability to fully participate and give support to their partner, is an indication of them not getting any benefit from information given by health care providers. Studies indicate that, male involvement is not encouraged in many African countries (Nanjala & Wamalwa, 2012; Nkuoh, Meyer, Tih, & Nkfusai, 2010). Nkuoh et al. (2010) indicated that, it was shameful for a man to attend clinic with the woman. Kinanee and Ezekiel-Hart (2009) also posited in their study that, roles played by men and women in the family and the community as a whole, have been made known through the traditional system. Traditionally, boys are expected to grow up with the expectant knowledge of being hardworking and the stronger ones to care for their wives. On the other hand, girls are to focus on domestic activities in the home as well as be submissive to find good husbands. Their study showed that, the patriarchal system has negatively affected maternal health in Nigeria, particularly, in River State and in order to achieve significant improvement in maternal health, men have to be actively involved. Apart from the cultural barrier, Nkuoh 23 University of Ghana http://ugspace.ug.edu.gh et al. (2010) further noted in their study that, men find it difficult to accompany their wives to antenatal clinics due to their occupation. More often than not, there are demands at their work places, which leave them with little time to accompany their wives to antenatal and postnatal clinic. This is affirmed by the findings of Bhatta (2013) that, men often use their preoccupation at the work place as an excuse to avoid accompanying their partners to antenatal care. Narang and Singhal (2013) highlighted in their study on analysis of male awareness and attitudes in maternal health that, the most prominent barriers to male involvement in maternal health include low levels of knowledge, shyness and job responsibilities. According to their findings, men did not see themselves as part of antenatal care processes and thought it was not their concern to accompany their wives as they saw it to be a ‘woman’s affair’. The men who accompanied their wives to antenatal sessions had the feeling of not been accommodated in the system, as joint consultations were not allowed by the health care providers. Advice given to the women was not made known to husbands who accompanied their wives. This was backed by the findings from the study of Awasthi, Nandan, Mehrotra and Shanker (2008). Despite the cultural and other barriers to men’s participation in antenatal and postnatal care, Kululanga et al. (2012) from their study noted that, it will be possible to involve men in maternal health issues if the causal factors of the barriers to men’s involvement are addressed. 24 University of Ghana http://ugspace.ug.edu.gh Socio-Demographic factors  Age Improved maternal  Educational level health outcomes  Occupation  Number of children  Marital status  Living together  Religion Male Involvement in maternity care  Accompanying partner to Normative beliefs health facility  Differentiation of  Discuss maternal issues gender roles with partner  Role of other family  Discuss maternal issues members with her health care  Taboos providers  Provide financial and physical support  Plan for emergency delivery and post care Health facility factors  Staff attitude  Waiting time  Provision made for men at antenatal and postnatal clinics  Men allowed in labour and delivery rooms Figure 2: Factors that affect male involvement in maternity care Source: Doe (2013) 25 University of Ghana http://ugspace.ug.edu.gh 2.2.6 Benefits of Men’s Involvement in Maternal Health Nuraini and Parker (2005) from their study found that, the key strategy for reducing maternal mortality and ensuring safe delivery is antenatal care, and involving the men in antenatal care would help achieve reduction in maternal mortality. Mullick et al. (2005) in their study indicated that, behaviours of men can put the lives of women at serious risk, which further can affect the health outcomes of the mother as well as the baby. Mitchell (2012) in her study on male involvement in maternal health decision-making in Nkwanta South District in Ghana supported the idea that, men’s decisions to a greater extent can have an impact on the well- being of both the mother and the child. Olugbenga-Bello, Asekun-Olarinmoye, Adewole, Adeomi and Olarewaju (2013) in their study noted that, when men participate and make joint decisions, there is some reduction in maternal morbidity and mortality. This is because, women receive good health care services when men are actively involved, as they are seen as the main decision makers in most of our communities in Africa. This is supported by the study by Bloom et al. (2001) on the dimensions of women’s autonomy and influence on maternal health care utilisation in North India and indicated that, safe and successful delivery may be in the control of the husband as the head of the family other than in the control of the woman. Awasthi et al. (2008) added to the assertion of Bloom et al that, women’s health care seeking behaviour may not only depend on their own perceptions, but also on the perception of their male partners. According to McNamara, Martin, Bloch and Hair (2007), women who feel emotionally supported by their partners experience lower emotional distress. In addition, male involvement encourages more communication and negotiation among couples. Men receive education given at the clinic when they participate in antenatal and postnatal care. They tend to learn from health care providers and this increases their knowledge (Mullany, 2006). 26 University of Ghana http://ugspace.ug.edu.gh 2.3 Conclusion This chapter reviewed the theoretical framework within which the study was carried out. The chapter also reviewed existing literature on antenatal care, postnatal care, gender issues in Ghana, male involvement in antenatal and postnatal care, factors affecting male involvement and the benefits of male involvement. From the review it was seen that, men’s involvement in antenatal and postnatal is important as it ensures the safety of the mother and the child. It was also seen that, men are encouraged to give support to their partners as they see it to be of good benefit to them and their partners as well as their children. The next chapter focuses on the method and procedures employed to gather information from participants to aid in the study. 27 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY 3.0 Introduction This chapter focuses on the methods used in collecting data to address the objectives of the study. It outlines the general research strategy adopted, discusses how participants were selected for interviews, the methods and tools used in collecting data from participants. There was also focus on how data was managed and analysed. The chapter concludes with ethical issues considered during the study and limitations to the study. 3.1 Study Area The study was conducted in the Greenhill Community, near Oyarifa. The Greenhill community is located within an area known as Ghana Flag, off the Adenta-Aburi highway. The Greenhill community consists of middle and low income groups of people. The majority of the people fall within the low income bracket. The community comprises squatters, landlords and land owners. Most of the residents are self-employed. Many of the male inhabitants are masons and the women engage in trading. Some inhabitants are tailors/seamstresses, beauticians, welders, mechanics and food vendors with others selling in their own containers. The closest hospital to the community is the Danfa government health centre which is about three kilometres from the community. The Danfa health centre provides general services to nearest communities around and is NHIS (National Health Insurance Scheme) accredited. The Greenhill community was chosen based on convenience and familiarisation with the community which made it easier to undertake the study. 28 University of Ghana http://ugspace.ug.edu.gh 3.2 General Research Strategy Qualitative research method was used to conduct the study. Qualitative research methods involve interpretive, naturalistic approach to the world. Qualitative research consists of studying things in their natural settings, attempting to make sense of or interpret phenomena in terms of the meanings people bring to them and clarify any ambiguity (Denzin & Lincoln, 2011, p.3). Qualitative approach to research also gives the researcher an opportunity to elicit and capture feelings, emotions which the researcher will not be able to capture using a quantitative approach (Mack, Woodsong, MacQueen, Guest & Namey, 2005). Qualitative design was used in this study because, the researcher aimed at capturing the lived experiences of participants with regard to men’s involvement during antenatal and postnatal periods. It allowed participants to express themselves and gave their thoughts on the issue under study. Additionally, the choice of a qualitative method was not to generalise the findings to the entire population of the Greenhill community. 3.3 Sources of Data Data was collected from primary sources to aid in the study. Primary data was collected through in-depth interviews with couples and health workers, and a focus group discussion with community members. 3.4 Study Population The study population were men and women of Greenhill community who were living together as married couples and had had a child within the past one to four years. This was to gather information from those who had experiences as regard antenatal and postnatal care. Residents who were 18 years and above were included in the study to gain information on their general perceptions on male involvement in antenatal and postnatal care. Also included in the study population were key informants, specifically, health workers who had worked in Danfa health centre specifically in the maternity care unit (Family planning unit and 29 University of Ghana http://ugspace.ug.edu.gh ANC/PNC unit) for a year or more. Key informants were included because they provide services for pregnant women. 3.5 Sample Size Twenty-nine (29) participants were sampled by the researcher for the study. Twenty (20) participants from Greenhill community, consisting of 10 female partners and 10 male partners (ten couples) were interviewed. Three health workers from Danfa health centre who were all females and married were also interviewed. Six (6) residents consisting of three females and three males took part in the focus group discussion. The couples from the community were men and women, who were staying together as husbands and wives, who had had a child within the past one to four years, whilst the six were community members who were not married. Women were involved in the study to give better understanding on the issues under study because they are affected. Involving the couples gave a clearer picture of how they viewed their participation in antenatal and postnatal care. The community members also gave a general view on how they perceived men’s involvement in antenatal and postnatal care. Three key informants, namely health workers who worked at the Danfa maternity care unit were interviewed as part of the study. The sample size was chosen because, qualitative study does not aim at generalising, and moreover, the researcher reached saturation with these numbers. Data saturation according to Fusch (2015), is reached when there is enough information to replicate the study when the ability to obtain additional new information has been attained, and when further coding is no longer feasible. 3.6 Sampling Technique Purposive sampling was employed in selecting participants for the study. Participants were purposively selected based on their availability and willingness to participate in the study. The researcher purposively selected households with both couples who had children within the past one to four years, because the researcher was interested in getting the views and 30 University of Ghana http://ugspace.ug.edu.gh experiences of both couples. Regarding the couples, the researcher spoke to husbands who were at home to inform them about the study and selected them. Those who were not available at home were called on mobile phones to inform them about the study and fix a favourable date to participate or go to their work places. The researcher also went to households and work places to select community members to participate in the study. Finally, the researcher went to the Danfa health centre to select health workers at the maternity care unit who were married (worked for a year or more) and were willing to participate in the study. Purposive sampling helps to select information-rich cases whose study will illuminate the question under study. 3.7 Data Collection Tools/Methods The researcher engaged in in-depth interviews and a focus group discussion with participants. In-depth interviews enabled the researcher to get understanding and capture the points of view of participants without predetermining those points of view through selection of questionnaire categories (Patton, 2002). In-depth interviews consist of one-on-one interviews with prospects to better understand. Couples and health workers were interviewed individually. The researcher also engaged in one focus group discussion with community members. Focus group discussion brings a group of people together into one setting and a moderator facilitates a group discussion about a topic. The group dynamic leads to brainstorming, generating ideas, and a deepening of the discussion because of the variety of participants and their experiences. Pilot interviews were undertaken to guide the researcher on the needed information for the study before actual interviews were conducted. Data collection was undertaken for two weeks on the field. During the in-depth interviews and the focus group discussion, responses from participants were recorded using a voice recorder upon seeking their permission and complemented with notes taking. The interviews were conducted in the homes and work places of participants 31 University of Ghana http://ugspace.ug.edu.gh and the focus group discussion was conducted in Greenhill Preparatory School. Interview questions were designed in English, but interviews were either conducted in English, Twi or Ewe depending on the preference of the interviewee. An interpreter was sought to assist in cases where participants spoke Ewe. All participants agreed to participate in the study. Interviews lasted between 25 to 30 minutes and the focus group lasted for close to an hour. The focus group discussion was facilitated by the researcher. The focus group discussion comprised of six (6) community members (3 males and 3 females). The size of the focus group was chosen because literature indicates that an adequate group size is between four and twelve participants, with an optimal size being between five and ten individuals (Beyea & Nicoll, 2000; Kululanga et al, 2012). 3.8 Data Management and Analysis The researcher transcribed the data collected from the field into text format after consecutively listening to the recordings from participants on a computer. Data was then cleaned by reading each transcript thoroughly, whilst editing alongside and stored on drive to serve as backup. Thematic analysis was used to analyse the transcribed data from the field, using the six steps of analysis by Braun and Clarke (2006). The researcher first of all, familiarised himself with the data, thus, the depth and breadth of the content through repeated reading of the data. Familiarisation was done to search the meanings, patterns and information that will be needed to make the data rich. The second phase was to generate initial codes that will help the researcher identify features that were interesting to analyse. The researcher achieved this by colour coding sections that sounded interesting to be analysed based on the objectives outlined. Coloured sections were grouped under each objective to make identification and analysis easier. After coding was successfully done, there was the need to search for themes from the data. Themes were identified in the transcripts in line with the objectives and research questions 32 University of Ghana http://ugspace.ug.edu.gh outlined. Furthermore, the researcher reviewed the various themes listed and identified the key themes to be discussed under each objectives to address the research questions outlined. After key themes were identified, they were then defined and refined to know what each theme stood for and what aspects of data will be captured under each theme. This was to make the analysis look more presentable. Finally, the report was produced. In explaining the findings from the study, the researcher developed patterns from the themes that had been identified from the content analysis (Guest, MacQueen & Namey, 2012). Findings were discussed in detail under selected themes and supported with quotes from participants. According to Patton (2002), data interpretation and analysis involve making sense out of what people have said on the matter under study, looking for patterns, putting together what is said in one place with what is said at another place and integrating what different people have said. Follow up was made as soon as possible to seek clarification on things that were unclear. Patton (2002) notes that people who are interviewed appreciate such a follow-up because it shows how serious the researcher or interviewer is in taking their responses. Data was coded, cross-checked and analysed only by the researcher without the presence of an assistance. 3.9 Ethical Considerations Information gathered was properly acknowledged with the right sources. Also, consent was sought form participants to partake in the study and the researcher made participants aware of their participation as voluntary, including their right to withdraw anytime in the course of the interview. Denzin and Lincoln (2002) noted that, participants have the right to be informed about the nature and consequences of their participation and they must voluntarily agree to be part of the study. 33 University of Ghana http://ugspace.ug.edu.gh Furthermore, anonymity and confidentiality was ensured, in that, identities of participants were substituted with pseudonyms and other sensitive information of participants was not included in the interview. The researcher also ensured that, all surroundings were cleared of interferences and safe to conduct the interview to prevent people from listening to the conversation between the researcher and the participants. 3.10 Limitations to the Study First of all, the study could have taken into account quantitative method to cover more areas by the researcher. Since it was a qualitative study, the researcher was unable to get wide range information from other hospitals to verify whether some of policies were available at the national level. Example of policy was the fact that women who attend antenatal and postnatal sessions with their husbands were immediately cared for before women who came alone. Also, the some interviews were conducted in Twi or Eve and as such, some data would be lost during the transcription phase since some expressions would not have a direct meaning in English, thereby, not making the information rich. Furthermore, throughout the study, community members from ages 50 to 70 years were not identified. Including them could have projected some interesting quotes which would have made the study richer as those of older generations would have different perceptions compared to the newer generations. In addition, the researcher translated the interviews by himself without the help of others to cross-check what has been transcribed. As such the quality of the translation might not be obtained to make the data richer. 3.11 Measures to ensure Trustworthiness of the Work The researcher engaged in data triangulation, where individual interviews and focus group discussion was employed to collect data from participants. This helped to verify view points and experiences of participants against others from the study. Furthermore, the researcher did 34 University of Ghana http://ugspace.ug.edu.gh member checking, where transcripts were given to participants to verify whether or not they said what has been transcribed into text format, and also to get clarification on some things spoken by participants. This was done to ensure that, data used for the study were accurate as well as understood. 35 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR FINDINGS AND DISCUSSIONS 4.0 Introduction This chapter presents and discusses the findings of the study in line with the research objectives. The main goal of the study was to explore the perceptions and experiences of men’s involvement in antenatal and postnatal care in the Greenhill Community, Oyarifa. In line with the goal of the study, this chapter is presented under three main sections namely perceptions of participants on men’s involvement; experiences of couples on men’s involvement; and perceived effects of men’s involvement. Quotes from participants were selected as they best suit the themes and gave better understanding of the findings. 4.1 Demographic Background of Participants Twenty-nine (29) participants took part in the study comprising of 10 male partners, 10 female partners, six community members and three health workers. The age range of the male partners was 35 to 45 years and 30 to 38 for the female partners. Educational level ranged from Form four (middle level school certificate) to tertiary and most of them were self-employed, except for two men who were employed by others: a professional teacher and a building supervisor. The number of children of couples ranged from one to five. The age range of the key informants was 36-57 and all three were married women. All three had tertiary level education; one was at the family planning unit and the other two at the antenatal and postnatal care units. Six community members, three females and three males, participated in the Focus Group Discussion. The age range of the community members was 20 to 26. Their educational level ranged from Senior High to Tertiary. 36 University of Ghana http://ugspace.ug.edu.gh 4.2 Perceptions on Men’s Involvement Participants’ perceptions on men’s involvement in antenatal and postnatal care ranged from involvement as a necessity to being perceived as an act of love. Participants also believed that, cultural influence affects the involvement of men and may serve as barrier to men’s involvement in pre-natal and post-natal care. These findings are presented and discussed in more detail below. 4.2.1 Men’s Involvement as a Necessity The data showed that, men should take up as responsibility to attend antenatal and postnatal sessions with their wives to understand various things related to pregnancy and child birth, through the education and talks given at the clinic by the nurses. Some of the participants reasoned that, men attending antenatal and postnatal gave them the opportunity to have a clearer understanding of how to prepare for the birth of the child. Some female participants expressed feeling of doubt by the men sometimes, regarding what they learn and are told at the clinic. The doubt from the men was due to their perception that, their wives are not being truthful to them. Hence, there is the need for men to attend antenatal and postnatal sessions with them: Yes, it is necessary because, certain advice are given by doctors to get deeper understanding and know how to help. Sometimes, they think you are not being truthful to them on what transpired at the hospital or maybe, you are giving false information. So I think it is good they go with us to hear from the person’s own mouth. - (Madam Meena, 38 years, five children) It is not everything the woman will remember and the man must also have knowledge on some things said by the nurses to help her and the baby enjoy good health…So I think the man, not always, but sometimes, needs to accompany her to the clinic. (FGD Female participant) The men similarly were in favour of them accompanying their wives to antenatal and postnatal clinics: Anytime a pregnant woman goes to the clinic, the man should be there with her to listen to the immediate information or advice given at the time because, advice given may differ. So it is wise the man be there with her to also know and understand what is said. (Mr. kwaapia, 40 years, three children) 37 University of Ghana http://ugspace.ug.edu.gh The data also showed that, men who are very much involved in attending antenatal and postnatal sessions with their wives, give reports to the nurses on the behaviour of their wives with respect to following instructions given. As such, the nurses at the unit encouraged the women to bring their husbands to the antenatal and postnatal clinic. This practice enabled the nurses to get feedback on what the women do at home. The nurses further reasoned that, the men should accompany their wives to the clinic so as to remind them on what they are being told, be it their medication or their next visit to the clinic. This could ensure the women follow instructions given at the clinic and be prompted when they act contrary to medical advice. One nurse explained how: It is very necessary, as some men are able to alert the nurses to stress on certain aspects when they come with their wives because, their wives have not been doing it. So it helps us to also get information on what goes on at home. (Nurse 3, ANC & PNC unit) Another nurse from the Family planning unit similarly explained: I will say it is very important that, the men accompany their wives to antenatal and postnatal. Some women are absent-minded when we are talking to them because, they have multiple challenges. But when they come with their husbands, they feel confident and the man also listens to whatever we say. When they get home and the woman is going against what he has been told, the man will be in support to say that “this was what the nurse told you to do, so why not do that”. (Nurse 1, Family Planning Unit) Some men will not have the interest in going to the clinics with their partners as they limit themselves to roles they play. From the data, arguments were raised on the fact that pregnancy and child birth are considered to be the portion of women in the family, hence, it is not a must for men to accompany their wives to antenatal and postnatal clinic. With this, some men do not find the need to be at antenatal and postnatal clinics all the time: Hmmm, anyway it’s not compulsory…you don’t need to accompany her always because she also has her own way of doing things, though she is your wife. But it is nice the man accompanies her anytime she goes and assists her in case of any problem that may be encountered. (Mr. Jo, 35 years, two children) When men begin to have such notions, not to support their partners by accompanying them to clinics, it will inform their intentions and they will at all times, be unconcerned with issues 38 University of Ghana http://ugspace.ug.edu.gh that occurs at the clinic. This could be facilitated by discouragement from peers and possibly, the society they are in. On the other hand, when they are motivated enough when they accompany their partners to the clinics, they will be more willing to repeat such behaviour which will be of good benefit to their partners. 4.2.2 Involvement of Men as an Act of Love Giving support to one’s partner during pregnancy and childbirth has been linked to a husband’s love and affection for his wife. The data showed that, men giving support to their wives during antenatal and postnatal periods, was perceived by some participants as an understanding of the importance of having intimate relationship. Some female and male partners mentioned that, men will see helping as their responsibility once they get deeper understanding of what marriage is about. If men have this mind set, supporting the wife during pregnancy and childbirth will not be a problem, as they will be of assistance in all situations both at home and outside the home. Mr. Kwaapia, a 40 year old man with three children relates: Honestly, I don’t think the youth of today understand the word agape love in a woman and a man’s relationship. But if there is love and understanding, nothing will prevent the man from caring for his wife. In fact, love covers everything…. (Mr. Kwaapia) Madam Ayongo, a 34 year old woman with two young children similarly explained: For a man to help his wife, will depend on the love he has for her. He will not help if he has no love for the woman. Some men don’t know what they want and end up not making the right choices in choosing a woman. When such happens, they end up not showing love to the woman as well as not helping because they think they have made a wrong choice. (Madam Ayongo) As humans, we tend to be supportive to those we share connections with. Without the feeling of love, support will be minimum which could be a burden to one party. However, when there is love, things get easily done. 39 University of Ghana http://ugspace.ug.edu.gh 4.2.3 Cultural Influence on Men’s Involvement Culture has diverse ways of defining how things are done in every community and since we all belong to one culture or another, our behaviour is influenced by our culture. All participants stated that culture plays a major role in grooming men and influencing what they should do or not do. From participants’ point of view, the cultural perception of men not doing house hold chores has been there since time immemorial, and still continues to have influence on the current generation of men. In the past, it was often believed that a man needed to do all the hard work to earn money for the home and the woman’s work was to manage the home, thus, doing the house chores which included cooking, sweeping, taking care of children, washing among others. In some cultures, according to some participants, men who are seen doing work considered to be the preserve of women are branded or given funny names or worse are seen as showing weakness as the head of the family. Men are normally seen as the decision makers in the home and are therefore not to be found getting involved in things considered to be for women and since pregnancy and childbirth are seen to be a woman’s job, men have the mind-set that it is a forbidden area for them: I think culture is the main reason why men do not involve themselves. It is culture that defines the role of a man and a woman. And with men, nothing was said about doing house chores. Culture expects the man to work hard and earn money to support the woman and the woman takes care of house chores. (FGD Male participant) In time past, house chores were considered the preserve of women but, has now been changed as men are also seen to engage in house chores as a way of supporting the women. Some men these days are joining hands to help domestically: When we refer to scripture, it says that a woman is a man’s helper and this very statement makes the man aware that, the [woman] came to help [the man] and not to serve him. Unlike in the past where we see women going to the farm, men sitting under big trees (‘kwankwaannuase’) playing draft, and the women will prepare ‘fufu’ for them to eat and in the night too they will not let the women sleep. No! We are not at that level now, that is olden days era where women were made to feel useless (“bagyimeebr3”). (Mr. Kwaapia, 40 years, three children). 40 University of Ghana http://ugspace.ug.edu.gh Despite some men demonstrating their support domestically, others find it difficult to assist their wives in doing house chores as a result of their perceptions that, women are in charge of house chores: I can see that, many men do not understand the need to help their partners during pregnancy and childbirth. Some still have the perception that, pregnancy and child birth is a woman’s affair... (FGD Male participant) Some men still have the mind-set that, house work is for the women so they do not engage themselves in housework and they carry the same attitude to marriage…How will he help you if he thinks he is not supposed to do house work?… some think after all, they are the heads, why should they involve themselves in cooking or fetching water or anything that women do. (Nurse 2, ANC & PNC Unit) In communities where men have the belief that, everything will be left on them should they decide to get involved in supporting their partners, there is the possibility that such men would not want to get involved: One problem which a lot of men face is that, some women take advantage of them helping. So at times, they won’t do it, thereby leaving everything down which I think it is very bad. This deters some men to help. (Mr. Kay, 40 years, two children). Societies vary from place to place and have different views on what role a man and a woman should play. According to some participants, the society has influence on your involvement in activities done. There are societies which may frown on men doing house work and in such societies, men do not get involved with house chores for fear of being mocked or losing respect from others. On the contrary, when a society approves men’s support at home, the men will not have difficulty helping their wives at home. Some men are trained not to do domestic work and they take this same behaviour to marriage making it difficult to help in their marital home. Those who are brought up to do house works end up helping their wives at home. A FGD male participant said: The society you find yourself in can influence your behaviour because if the society does not value men’s involvement and you will be mocked if seen, you will withdraw yourself. There are rigid societies that are not used to certain things thereby giving you labels when spotted. (FGD male participants) 41 University of Ghana http://ugspace.ug.edu.gh In some communities, mothers of couples cater for the women during pregnancy and at birth with the assumption that it is a woman’s affair. With this, some men have feelings of withdrawal from their wives and as a result may lose interest in helping with house work and giving other support. Some men may want to be involved but are restrained from doing so. It is normally the mothers and mothers-in-law who virtually do everything when the women are pregnant and when the women give birth. This was explained by a male participant: It is the women who are making the men withdraw themselves. When the women give birth, their mothers are the ones coming to fight over the child and the man will be left somewhere. The mother of the woman wants to bathe the baby’s head while the man’s mother too wants to do same. What are you the man going to do? They do not consider the man to be the one to help the woman when she gives birth. All these discourage the man to get involved…they need to allow the man to come and help because he doesn’t get to bond with the child. When he comes, the baby is with the mother, the baby has to be fed, the baby is asleep and when he tries to hold the baby, they will say he should stop and not to disturb the baby…When you go to the western countries, the man is allowed to bathe the baby. Sometimes, there are workshops where people will go and sit down and the men will be taught how to bath the baby. This tells you that, culture is one of the biggest factor that prevents the man from extending support when the baby is born. (FGD Male participant) Some participants agreed that, some aspects of culture are changing and the current generation of men are now embracing the need to help their wives in all aspects of antenatal and postnatal care though, some still hold on to the old cultural perceptions. Boys are trained on how to help at home and they eventually portray those attitudes and behaviours when they marry. According to some participants, it is the same culture that once said a man should not play certain roles, that now talks about the positive aspects of culture with respect to men supporting their wives during pregnancy and childbirth. Participants believe that many of our cultures have started making changes and are making way to engage the men to give more 42 University of Ghana http://ugspace.ug.edu.gh support. Participants showed optimism of those cultural biases being dealt with, though at some point, they think culture is hard to modify: You know the way we bring boys up in our culture who virtually become men, they begin to think certain things are solely for women to do. I think this generation is doing things right because people are now training their boys to cook and do other house chores…eventually it will change. (Madam Meena, 38 years, five children) The cultural influence to men’s involvement complements other factors that impede on the active participation of men during antenatal and postnatal periods. 4.2.4 Perceived Barriers to Men’s Involvement The barriers that emerged from the study include work which encompasses socio-economic barrier. Barriers to men’s involvement are lack of knowledge, shyness, laziness, women not showing appreciation, disrespect on the part of the women are discussed in detail below. Majority of the participants echoed that, work can prevent a man from involving himself in any way. There are instances where demands from work may not permit the man to support at home and the only support that could be given will be the financial aspect. According to some male and female partners, there is very little involvement on the part of the men as they get occupied by work. Mr. Yaw, a 34 year old man with a child said: I always have to leave early for work, other than that, I would have gone to the clinic with her. (Mr. Yaw) When you look at men with professions, they would not have time for their wives because, they go early morning and come back late. (Mr. EK, 45 years, five children) This was also confirmed by a female couple: You see, he is a worker so, he will not be with me all the time... (Madam Ayongo, 34 years, two children) When men are financially constrained, it will be difficult to seek proper health care for their wives. And when proper health care is not received, there could be complications during delivery: 43 University of Ghana http://ugspace.ug.edu.gh I see work to be a barrier because if the man is not working to provide money, he will tend to neglect his responsibilities. Sometimes too, the level of education becomes a factor. If you want to compare educated and less educated people, the educated ones will be more likely to get involved and support than less educated ones. (FGD Female participant) When it comes to the socio-economic aspect, many presume when I go to the hospital I am going to spend this much. For example, a lady was admitted here four good days, nobody not even the man visited her. I called the man and he ended up insulting me. He later told his friend he was scared, about what, I did not know so some men just don’t want to come and spend money because they are not financially sound. (Nurse 1, Family Planning Unit) Mr AB, a 43 year old man with three children similarly explained: I think the main focus is on job. If you are working you will be able to support your wife but if you don’t have a job or you are not wealthy, it will be difficult to support your wife and the family. – (Mr AB). Having the opportunity to learn new things gives you an advantage in knowledge over one who does not learn. Education is key for improvement in our social lives. According to participants, lack of knowledge on how to help the women to stay healthy and have a safe delivery makes it difficult for men to offer support to their wives during the time of pregnancy and child birth. They do not know the importance of giving support to a partner and they tend to be irresponsible in all aspects of the woman’s life right from pregnancy to the time the baby is born. Men assume they will be mocked when they are seen to be supporting their partners as such, they tend to withdraw from responsibilities. Mr. Dee, a 42 year old man with three young children explained: Some men do not have knowledge on childbirth and caring for the new born. Some may feel they will be laughed at when seen doing house chores and they need to gain respect of people around them as men so with that, they will not help…At times, when the men are not ready to have children and such happens, they are disappointed making them not to give support to the women. (Mr. Dee) Some men are given labels when seen. I don’t know if you have heard of “antenatal man” meaning, a man who follows his partner to the hospital is jobless…he does not have anything to do and that the woman is the breadwinner of the family who tells him what to do and he does it. (FGD Male participant) 44 University of Ghana http://ugspace.ug.edu.gh A female partner also contributed by saying: Others feel shy to help with the thought of what people will say when they see them or maybe it could be that they are not ready to be called fathers. (Madam Ayongo, 34 years, two children) Responses from participants showed that, there are instances where a man finds himself with a woman who does not appreciate the role of the man in supporting nor give him needed respect. Such women, according to participants tend to lose the opportunity of the men helping: If a man’s wife does not respect him or does not appreciate him helping, he will stop doing them. (Madam Akua, 36 years, three children) I will say disrespect from the woman can deter the man from supporting. Also, for a man to help will depend on the love he has for the woman. He will not help if he has no love for the woman. (Madam Ayongo, 34 years, two children) Showing appreciation for one’s work done provides motivation for the individual to continue to do more. Alternatively, if appreciations are not seen, the individual is demotivated in what he does best and this affects outcome of things. 4.3 Experiences of Couples on Men’s Involvement Responses from participants with regard to their experiences centred on clinic attendance, involvement expediting services for women, home support, reactions from people and problems encountered. These are discussed in more details in the sub-sections below. 4.3.1 Clinic Attendance The data revealed that, in most cases, it was only the women who attended antenatal and postnatal sessions without the men accompanying them. More often than not, men used their jobs as reasons for not attending antenatal and postnatal clinics with their partners. The men usually left home early in the morning and returned home late. Some male participants shared their sentiments of having the edge to accompany their partners to antenatal and postnatal 45 University of Ghana http://ugspace.ug.edu.gh clinics, however, they were always restricted by their work. Mr. E.K., a 45 year old man with five children explained: I am a professional teacher so when she goes I wouldn’t have the time to go with her. With that, she will go alone. (MR. E.K.) The women also shared similar view: Left to him alone, he would go but his work is not allowing him. If he had time he would have loved to go with me. (Madam Adwoa, 32 years, one child). The data also showed that, some men did not attend due to shyness. The men could not stand the humiliation of being seen attending such clinics with their partners, which they felt was a place for only women: He is a shy type so he does not like to be in the midst of people. When he sees you, he won’t look at you twice, his head remains faced down so for him, he will never follow you to the clinic (laughs aloud). (Madam Abena, 38 years, three children). From the data, few men who went to the clinic appreciated the importance of being involved in antenatal and postnatal. According to participants, they get the opportunity to be engaged in education on things concerning pregnancy and health related issues that could impede the woman’s safe delivery during labour. They further got advice on how to support their partners at home: I go with her to the clinic because, I get to understand some of the things the nurses tell her and prepare in case of complications. (Mr. Dee, 42 years, three children) When I go with her to the clinic, I normally get advice from the nurses and ensure I heed to the advice of the nurses to help her follow instructions given….some people can learn and within some few moments forget what has been said to them. (Mr. Kwaapia, 40 years, three children) Men who were able to attend antenatal and postnatal sessions with their wives gave the advantage to their wives to go through the sessions quickly without waiting for long. This was adopted to enable more men to come to the antenatal and postnatal clinic. 46 University of Ghana http://ugspace.ug.edu.gh 4.3.2 Men’s Involvement Expedites Services for Women Results from the study showed that, women had quicker access to antenatal and postnatal services when they were accompanied by their husbands. This was a policy at the antenatal and postnatal unit and have been made known to every pregnant woman who visits the unit. Some couples and key informants revealed that, although women who come alone may come very early, those with their male partners do not join the normal queue. They are immediately taken care of on the assumption that, the man needs to be at work and his time must not be wasted. In view of this, some women are only interested in their husbands going with them so they can be attended to as quickly as possible and return home to attend to other things. Madam Pat, a 30 year old woman with two young children shared her experience: At times, when I don’t feel very well and go to the hospital with him, they take care of me faster. Sometimes, when you have something to do at home and there is a queue at the clinic, you will have to wait till it gets to your turn. So when you go with your husband, it makes it easier and faster for you. (Madam Pat) Sometimes, the nurses say that when you come with your husband, they will take care of you quickly so you can go home because your husband may go to work. (Madam Abena, 38 years, three children) Women who come with their husbands are given preferential treatment. We take care of them quickly and they do understand because we let them know if you come with your husband, you won’t wait. (Nurse 3, ANC & PNC Unit) The data shows favouritism of men who accompany their partners to the clinic. This could make some women resent as they do not get such opportunities or are not given that attention. This policy also, might not be a nationwide intervention to make more men get involved. As such its effectiveness cannot be measured. 4.3.3 Support at Home From the data, it was found that, all men provided financial support to the women. The men usually saw to it that drugs needed or recommended by nurses were provided to enable the women stay healthy and go through safe deliveries. The men ensured that, the women sought proper healthcare as they funded such care. According one of the nurses, the National Health 47 University of Ghana http://ugspace.ug.edu.gh Insurance Scheme does not cover some aspects of antenatal care so, it is the duty of the men to ensure that what is needed for the pregnant women are provided. When the baby is delivered, necessary things to be used by both the mothers and the new born are also provided by the men: Well I support her financially. If there is something that she needs to buy or care to be taken, I help her to do them. (Mr E.K, 45 years, five children) The women gave similar expression: When I am pregnant, he provides money to purchase all that the nurses recommend but he usually makes me aware when he doesn’t have the money. (Madame Pat, 30 years, two children) Some men also provide additional nutritious food for their wives to serve as additional supplement to their diets to keep their health in good shape. A male partner explained how: When my wife is pregnant, she mostly takes in fruits and beverages as her major food apart from the normal food she takes, so I make sure I get it for her. (Mr Kwaapia, 40 years, three children) Physical support is also provided to the women by some of the male couples. The male partners indicated that, they helped in doing household chores apart from giving out money. They usually help in cooking, fetching water, sweeping, bathing, and carrying the baby. A few men had difficulty performing such chores even though they were able to give some support in the home. Mr Yaw, a 34 year old man with a single child shared his experience: I sometimes cook and help her with washing because she wouldn’t get the strength to undertake hard activities. When the baby is born, I try to change diapers but I was not getting it well so I stopped changing but I usually hold the baby when she is doing something. (Mr. Yaw) ..With house hold activities, I sometimes help her cook, wash clothes and at other times I go outside to fetch some water for her when we don’t have water. (Mr E.K, 45 years, five children) I am not really good in cooking but I try to help since she directs me. I fetch water for her to bath and sometimes wash the clothes. I help her in carrying the bag or the baby when we are both going out and I try to remind her to take her drugs and her next appointment to the clinic. (Mr. Dee, 42 years, two children) 48 University of Ghana http://ugspace.ug.edu.gh The women confirmed the expressions of the men as they gave similar views: ..He helps me to cook and I’m saying this for a fact, when I was pregnant I never cleaned the bathroom. He was the one doing all that. He doesn’t allow me to bend down to clean the bathroom and at times he washes the clothes for me. (Madam Pat, 30 years, two children) He supports me sometimes with few house chores because he is not used to it. As you can see he is now learning how to change diapers (laughs). (Madam Jane, 37 years, three children) From the data, some participants revealed that, some men leave the women to do all the house chores without the men extending a hand to assist. Some female participants indicated, they were able to do house chores when the men did not help because they looked very healthy during pregnancy though they were not comfortable with the situation: When it comes to housework hmmmmm, like a woman is pregnant and a man should help her in washing and other things, oh no it won’t happen. The day he will do it, will result in anger. A lady came to stay in our house, when she got pregnant her husband took care of everything in the house, washing, cooking and went to work too. He makes sure he wakes up early and do them before going to work but for my husband he won’t do it. (Madam Abena, 38 years, three children). Apart from giving money, he will only pray for me but the rest I do it alone. You see, `when I am pregnant I’m strong so I do everything on my own. (Madam Vero, 30 years, one child). Some men also gave their reasons for not helping their wives with house chores: When it comes to house chores, I do not do it because, I am not used to it. All I am concerned is to bring money home. (Mr. AB, 43 years, three children) Furthermore, as part of the physical support given by the men, they served as reminders to the women, by ensuring their medications were taken at regular time intervals and also reminded the women on the next appointments. This was because many of the women forgot to take their medications due to the changes they were experiencing daily and the stress they went 49 University of Ghana http://ugspace.ug.edu.gh through. Some women intentionally did not follow the time table given them when their husbands were not around: If I am at home doing something and he is around, he helps me so I take my rest. He reminds me on the scheduled time given for taking my medication. (Madam Adwoa, 32 years, one child) Sometimes I forget my medication so he reminds me to take them. (Madam Akosua, 38 years, three children) The men also expressed similar thought: I try to remind her to take her drugs and of the time to visit the clinic. (Mr. Dee, 42 years, three children) 4.3.4 Reactions from People on Men’s Support to their Partners Some male couples noted that, they normally got commendations from people who observed the help they provided to their partners. People appreciate the fact that, men are seen doing household chores and showing more love and attention to their partners. Such expressions are given by people because, a man is seldom seen doing house chores perceived by many people as women’s work. Observers got excited upon seeing such events and they expressed their commendations and appreciations: I get commendations from the neighbours when they see me assisting my wife and they praise me for not engaging in any quarrel with her during the period of pregnancy and childbirth. (Mr. AB, 43 years, three children) Also, some people were envious of the support some of the men gave to their wives at home. When men were noticed doing house chores, it sometimes brought about jealousy among women around. According to some participants, people expressed jealousy because they did not experience such opportunities. Men with these qualities were considered a blessing to the family and needed by others who did not experience such supports: There was an instance when he was cleaning the room and my friend visited me…her response was “eeeei you are enjoying oo, I wish I were you” (laughs). So I see that people get jealous when they see all these. (Madam Pat, 30 years, two children) 50 University of Ghana http://ugspace.ug.edu.gh I only realise it when he sweeps the house because his friends will say “eeii, today pastor is sweeping the house” and he will also respond “angels will be visiting the house today” (laughs). (Madam Vero, 30 years, one child) Furthermore, few couples expressed they had not experienced any form of reactions from people concerning how the men helped at home. Some just did not want to listen to what others may say to discourage them. They believed it was their family affair and therefore did not want interference from others: Observers are always worried especially when they see you washing your wife’s clothes “oh this man is a stupid fool (“kwaadonto”), his wife has overcome him. So if you the observer criticize or praise me, it is your personal problem. - (Mr Kwaapia, 40 years, three children) When people do not get the opportunity to receive support from their partners as others do, it creates instability in their relationships with their partners and may lead to further problems. 4.3.5 Problems Couples Encounter when Men Support Some couples who experienced problems with regard to the men supporting indicated that, they usually had misunderstandings with their partners. Some partners believed that, during pregnancy, women get easily angered by the little mistake done due to the conditions they find themselves in. The findings indicated that, because of differences in how couples think, there were always disagreements and quarrels on things that needed to be done. Men portrayed themselves as the head of the family and did not want to be controlled, whilst women on the other hand saw themselves as “the perfectionists” who wanted things to be done to their expectation. This resulted quarrels: I will say as humans, our views are different. Also, my education is a bit higher than his so sometimes there are arguments because I think this should be done this way and he thinks otherwise. (Madam Jane, 37 years, three children) Sometimes we quarrel and when this happens he leaves home (laughs a little) (Madam Pat, 30 years, two children) 51 University of Ghana http://ugspace.ug.edu.gh The men also shared their experiences of problems they encounter: Sometimes she gets upset when I am not doing the house chores right and we quarrel over it for some few minutes and we are done. (Mr. Dee, 42 years, three children). According to some male participants, they have some knowledge of changes the women experience both physical and psychological during such stages, therefore, caution is taken not to escalate matters that will end up affecting both the mother and the child. Likewise, some female partners were aware of the anger they experienced when they were pregnant so they tried as much as possible not to encourage problems between them and their husbands: …we sometimes disagree when she expects more from me at home but I try to supress it because of her condition. (Mr. Yaw, 34 years, two children) The women added to the views of the men: …we have been told at antenatal that, when you are pregnant you get angry easily so knowing that I try not to create any problem. (Madam Akua, 36 years, three children) 4.4 Couples’ Perceptions and Experiences of the Benefit of Men’s Involvement From participants, the consequences of men’s involvement in antenatal and postnatal were psychological wellbeing and enhanced marital relationships. It also led to knowledge upgrade on maternal and infant wellbeing which has consequences for reducing maternal and child mortality. Findings of these benefits are discussed in detail below. 4.4.1 Psychological Wellbeing and Enhanced Relationships The data showed that, when men actively participate in supporting their partners during pregnancy and child birth, both partners are happier. Men are happy giving support to the women and likewise, the women are also happy when they receive support. According to couples, when there is joy in the home, the mind is set free from all pressures surrounding the individual and ensures positive thinking. The most important thing couples hoped for was to 52 University of Ghana http://ugspace.ug.edu.gh have a happy home and to accomplish their heartfelt desires. According to them, without joy, nothing productive to their benefit can be accomplished: (Laughs)…I feel very happy. I remember there was a time I didn’t know how to prepare “kokonte” so he asked me to put on the fire for him to prepare though he has no taste for the food. I laughed at him after he finished but we all ate together. (Madam Akosua, 38 years, three children). …It makes you feel very good (laughs aloud) because when a woman is pregnant, she needs to be pampered so that she will not be filled with pain when her time for delivery is due. (Madam Adwoa, 32 years, one child) The men also shared similar sentiments: Ooh, I feel happy because, I am the one who put her in that condition, so I do not find it difficult when am helping her, I do not feel anything at all. (Mr. Jo, 35 years, two children) The findings indicate that, the bond between couples becomes stronger if the man gives support to the woman. The woman always has a positive feeling that the man will be there for her. Both couples are able to share common ideas to ensure the safety of both the mother and the child. Women on the other hand will have the confidence to share things with their partners without the fear of negative outcomes. According to some couples, when there was stronger bonding, communication improved and there was better understanding of each other. With some participants, when the child was born, the men were able to connect with the child as they got closer to the child and helped in caring for him or her. Thus, the more a husband helped his wife to care for the child, the better the bond between father the child. Madam Meena, a 38 year old woman with five children explained how: It’s a kind of bonding with your child. You see, these days they say when it is father’s day nothing is heard and we only hear that of mother’s day. It is all part of it, when you care for the child you become connected to each other. (Madam Meena) 53 University of Ghana http://ugspace.ug.edu.gh 4.4.2 Knowledge Upgrade and Potential for Reduction in Maternal and Child Mortality According to participants, when men attend antenatal and postnatal with their partners, they get deeper understanding of a lot of things surrounding pregnancy and childbirth. They get to learn and know terms used at the clinic by health workers and are able to identify complications when it happens due to the education given by health workers: I get the chance to understand some of the things they tell the woman and prepare in case of any complication or problem. (Mr. Dee, 42 years, two children) If I am able to go to the clinic with my wife, I get to learn from what the nurses tell her. (Mr E.K., 45 years, five children) Involvement of men according to one male couple has an impact on the health of the mother and the child as well. According to him, when men provide support to the women, it stabilises the thoughts of the women, reduces the work load of the women which can have effect on the baby and the mother as well, the woman’s health improves due to proper health care and proper monitoring of the man with regard to taking medication and attending appointments. All these result in safe delivery of the baby and reduces maternal and infant mortality: Eemmmm, if there is support from the men I feel that many women will be safe from maternal mortality and child mortality will also reduce. (Mr. Kwaapia, 40 years, three children). Men supporting their partners during antenatal and postal periods has been seen to be beneficial, enlightening more men to get involved during these periods in a woman’s life. 4.5 Participants’ Reflection on Men’s Involvement in the Future Participants revealed that, in the future men are going to help their partners with the reason that, culture is now changing and more men are beginning to see and understand the need to help. Some participants reasoned that, if the right education and strategy are used, men will 54 University of Ghana http://ugspace.ug.edu.gh help. They believe that, this generation of men are not doing things as done in the past, which provides hope of men getting involved in areas of pregnancy and child birth: In future, it is going to be fantastic. It is going to change many negative things and even help the nation as a whole. We see men as the land lords, the heads of the women in the house. For us to be successful, it’s just like getting into a community without seeing the chief, you cannot do anything. So we see the men as the chiefs of the house. When the men are sensitised to understand issues I think it will be very fantastic. (Nurse 1, Family Planning Unit) I think in future we will have many men supporting their wives during antenatal and postnatal periods. I have seen many young couples helping so I believe that in years to come we will not have much of that problem. (Madam Meena, 38 years, five children) The men had more to say: I think we will have more men supporting in the future if our mothers and wives can train the men to help at home. Once the person knows it, he will do it and I think looking at modern Ghana more men will be very supportive in that aspect because a lot of education is going on to make more men understand. - (Mr Yaw, 34 years, one child) Some participants were not confident in men involving themselves in the future. Some reasoned that men still have the old perception of pregnancy and childbirth as areas of women whiles some were not certain of men’s support in the future. Also one male raised concern about the millennium development goals, specifically goal five with regard to its achievement in mortality reduction by 2015. We may have men to help if the right measure will be taken because some still have it in mind that pregnancy is an area of women. (Mr. Dee, 42 years, three children) When it comes to future involvement, I am not sure if men will be involved to support during pregnancy and childbirth. (FGD Male participant) Hmmmm, you see Millennium Development Goal 5 on maternal health was set to reduce mortality rate by 2015, men will be involved, and they themselves have accepted they have not achieved that so the future is blur. (FGD Male participant) 55 University of Ghana http://ugspace.ug.edu.gh Some women shared similar views to the men: I think men will not be helping their wives in the future. It will be difficult to find a man sweeping and doing other house works nowadays, so I don’t think they will help. They are all focusing on the money they will bring, maybe one or two men will do it but not all men. (Madam Vero, 30 years, one child) 4.6 Discussion of Findings Results from the data showed that, involving men is a critical factor to safeguard the mother and the baby as well. During antenatal periods, the development of the child needs to be monitored, health hazards screened and health advices given (Overbosch et al., 2004), so it is therefore important the man be present to learn from what is being done and know how to provide help in case of complications. If the man participates actively, it will help reduce risk of maternal complication and enhance the health of both the mother and the child. According to Mitchell (2012), behaviours of men have a high impact on women’s reproductive health and the well-being of children. This indicates the critical role of men in ensuring that, their partners receive proper care during pregnancy, delivery and the postnatal period. The Theory of Reasoned Action explains a person’s ‘Attitude’ as comprising of the belief that, a particular behaviour leads to an outcome and an evaluation of the outcome of the performed behaviour. From the findings, when men see their involvement as being beneficial, hence giving a pleasant outcome, they will be more willing to give support to their spouses. A pleasant outcome will inform the intentions of the men to exhibit such supportive behaviours. The performance of the behaviour is complemented with the ability of the men and willingness to give support to the spouses with or without facilitators or barriers. This was seen from Mr. Kwaapia and Mr. Dee who benefited from education given when they went to the clinic with their spouses and always wants to be part of the sessions at the clinic. Moreover, from the findings, participants believed that, a man will attend antenatal and postnatal clinic with his partner if he loves his partner. Similarly, failure on the part of the 56 University of Ghana http://ugspace.ug.edu.gh man to attend pre-natal and postnatal clinics with the partner, is regarded as absence of love. Kululanga et al. (2012) in their study showed that, men accompanying their wives to such clinics, was associated with the existence of a degree of intimacy in their relationship. This association was constructed from the ratio of men who attend to men who do not attend. Men usually do not attend because, they think it is not their usual role as the head of the family. Traditionally, in African cultural environment, the roles men play are quite different from the roles women play. In Ghanaian societies, men are seen as the breadwinners of the family and the decision makers at home. They are also the providers for the family. Women on the other hand, are seen as the care takers in the home and the supporting partners to the men. These roles have been clearly defined, so it is uncommon to find men playing the roles of women. It has become a challenging endeavour to incorporate the men in areas of antenatal and postnatal care because, cultural perceptions have greater influence on men with regard to support in all areas of antenatal and postnatal care. As postulated by Mitchell (2012), it is difficult for men to involve themselves in countries where gender roles have been culturally defined. Cultural perceptions become a hindrance for men to participate in areas of pregnancy and childbirth. People generally portray certain behaviours because of their culture. However, there has been some changes over the years in some aspects of the Ghanaian culture as men’s involvement are being embraced in many African countries. Sensitisation of men is still in progress to educate men on their support for partners to improve on the well-being of the mother and unborn child. Nanjala and Wamalwa (2012) noted that, men generally do not attend family planning, antenatal, or postnatal care services because it was considered to be women’s affair and men were not expected to attend. A study by Nkuoh et al. (2010) also indicated that accompanying a woman to antenatal care was shameful to a man. The Theory of reasoned action/planned behaviour shows that, a person’s ‘Subjective’ norm is determined by approval or disapproval 57 University of Ghana http://ugspace.ug.edu.gh of the performed behaviour and the person’s motivation to comply. This affirms the findings, where culture is seen to define roles for men and women. From the findings, when culture frowns on certain roles done by men, it becomes difficult for men to be seen taking up such roles. Once this is established together with the motivation of the men not to take up such roles, their intentions of not giving support in such areas will be informed and finally show unsupportive behaviours. Although more men are being sensitised to involve themselves in antenatal and postnatal care, barriers continue to exist that prevent them from giving support to their partners in such areas. In most cases, the work demands of the man or unemployment may prevent him from taking up responsibilities in the home. Nkuoh et al. (2010) in their study on barriers to men’s participation in antenatal and prevention of mother-to-child HIV transmission care in Cameroon posited that, occupations of men place a barrier on accompanying their wives to the clinic for antenatal care. This is complemented with African cultural perception that, certain roles or activities are considered feminine. Mothers and mothers-in-law in some communities cater for the women during pregnancy and childbirth. This is consistent with the findings of Kwambai et al. (2013) that, support during pregnancy and after birth were usually provided by women, in that, the women preferred telling their mothers, mothers-in-law, co-wives or trusted female neighbours about their conditions during pregnancy and after birth than telling the man. This often keeps the men from involving themselves and giving support. Some cultures consider it a taboo and therefore prohibit the men from involving themselves. This was also supported by the findings of Bhatta (2013) that, men attributed their failure to attend antenatal clinics to the belief that, it is a woman’s duty and being preoccupied by work. The theory explains a person’s ‘Subjective norm’ where important referents approve or disapprove of the performed behaviour. This supports the finding by showing how mothers and mothers-in-law 58 University of Ghana http://ugspace.ug.edu.gh often do not encourage the men to assist during childbirth because, it is considered as areas of women. Mothers are often seen as the right candidates to offer assistance when the child is born. Since they are also important in our lives, they can approve or disapprove of the man’s assistance during this stage and this will inform the behavioural intention of the man to show supportive or unsupportive behaviour. From the study it was found that, most of the women went to antenatal and postnatal clinics without the escort of the men. However, Bhatta (2013) noted that when men are provided with information about attending antenatal care, it might increase their level of involvement. Olugbenga-Bello et al. (2013) also indicated that, the presence of men at the health centre and their involvement in antenatal session can serve as a morale booster for their wives and result in better improvement in the health of the mother and the baby. This was supported by the findings of Mullick et al. (2005). Results from the data indicated that, normally, women who attend antenatal and postnatal clinics with their partners are attended to much faster as compared to mothers who attend alone. This initiative was made in order to get more men attending clinic with their spouses. Kululanga et al. (2012) described a similar practice in Malawi, where couples were immediately taken care of before mothers who attended the hospital alone. It was based on the belief that, men needed to be at work and their time must not be wasted. This was done to encourage more men to follow their partners to antenatal and postnatal sessions. As indicated by Kululanga et al. (2012), this practice showed that, issues of maternal health in the past have mostly focused on women with less involvement of men, in that, women where mostly seen to attend clinics alone and men are now being encouraged to accompany their partners to antenatal and postnatal sessions. Also from the theory, key informants such as health care providers who served as important referents (‘Subjective norm’ determined by whether 59 University of Ghana http://ugspace.ug.edu.gh important people approve or disapprove of the behaviour), were able to influence some men to provide support to their partners which has been of significant benefit to the men as they get education when they attend antenatal and postnatal care with their partners. The quick access intervention enjoyed by women whose partners accompany them might not be a general policy that cuts across all hospitals and clinics in the country. With this, its effectiveness will not be known as knowledge on it is limited. Again, women who attend the clinic alone may feel singled out from such benefit and may show dissatisfaction on equitable service delivery. Findings indicated that, men provide financial support and other support at home, though their involvement in attending antenatal and postnatal sessions was low. From the study, it was revealed by participants that, men are the main providers when it comes to funding to cater for medications and other care services. The results showed that, majority of the men help their partners at home in terms of doing household chores, reminding their partners of medications and appointments at the clinic among others. However, most research have focussed on male involvement in areas of accompanying their partners to the clinic (Kululanga et al., 2012; Nkuoh et al., 2010; Olugbenga-Bello et al., 2013) indicating that, interest in promoting male involvement has been centred on men attending clinic with their wives. Measures to encourage men’s involvement and support of their partners should look beyond attending clinics and factor support in the home as well. The theory of reasoned action, explaining one’s ‘Attitude’ (belief that a behaviour leads to an outcome and evaluation of the outcome), affirms the findings from the study where men were seen to be supporting their spouses at home with house chores and attending antenatal and postnatal sessions with their spouses. The men gave support in such areas with the belief of lessening the work load of the women to enhance their health as well as the health of the baby. Therefore, supportive behaviour will be shown because evaluation of the outcome of the 60 University of Ghana http://ugspace.ug.edu.gh performed behaviour was seen to be pleasant. Men tend to exhibit these attitudes with respect to how they were groomed and how society also value their involvement. Participants from the study were of the view that, maternal and child mortality can be minimised when men are involved. Men usually ensure their partners receive good health care which reduces the risk of losing the mother and the baby. From the study, it was also evident that, men reduced the burden of women as they helped at home to do the chores, reducing the risk of causing harm to either the mother or the baby, thereby increasing the tendency to have a safe delivery. Complications may arrive, according to health workers from the study, if men do not give all the needed support to their wives. According to Doe (2013), there is better outcome for both the mother and the baby when men are involved because, men see to it that women get access to and utilise good health care services. Also, the study indicates that, men increase their knowledge when they get involved. This is as a result of education given when they attend the clinic. According to Mitchell (2012), decisions of men can have a great impact on the well-being of the mother and the child and Bloom et al. (2001) specifically stated that, safe and successful delivery may be in the control of the husband as the head of the family rather than in the control of the woman. This clearly gives an indication that, men can impact positively to a large extent the well-being of their partners. Finally, the findings indicated that, men’s involvement could increase the bond between the mother and the father, the father and the baby as well as bring about increased communication between the two partners. As communication is enhanced, there is suppression of the tendency for disagreements. Olugbenga-Bello et al. (2013) in their study on perception, attitude and involvement of men in maternal health care in a Nigerian 61 University of Ghana http://ugspace.ug.edu.gh community observed that, when men participate in attaining good health care for the women and make joint decisions with their partners, it could lead to reduction in maternal mortality and morbidity, since the woman will receive the necessary care. The theory of reasoned action, which explains one’s ‘Attitude’ (belief that a behaviour leads to an outcome and evaluation of the outcome), supports the finding by showing that, some men were willing to support their partners because of their realisation of the importance, benefit and the effect of giving support to their partners. 62 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE SUMMARY OF FINDINGS, CONCLUSION AND RECOMMENDATIONS 5.0 Introduction This chapter gives a summary of the findings, draws conclusion and gives recommendations that are aimed at getting more men involved in areas of antenatal and postnatal care. This study sought to examine the perceptions and experiences of men’s involvement in antenatal and postnatal care. Data was collected from community members, couples and health care providers using qualitative methods. 5.1 Summary of Findings Male involvement is essential to make women’s health better. Men play a key role in seeking the safety of their partners and their new-borns. Their attitudes, behaviours and beliefs affect outcomes of health of women and their babies. Historically, issues of maternal health have been seen as domain of women. Care providers have focused mostly on women. However, the involvement of men is currently being accepted across the globe and has experienced an upsurge of awareness in many communities around the world and Africa as a whole. A lot of emphasis has been placed to get more men involved in issues of maternal health. The study explored the perceptions and experiences of men’s involvement in antenatal and postnatal care. Considering gender roles, with respect to Ghanaian culture, norms and values, it was important to know how people perceive the involvement of men and what couples go through when men are involved. This was to help anticipate how men will be involved in supporting their partners in future and come out with strategies to ensure that more men are involved. Data that emerged from the study showed that, men’s involvement in antenatal and postnatal care was seen to vital. From the findings of the study, men should be readily available to 63 University of Ghana http://ugspace.ug.edu.gh accompany their partners to antenatal and postnatal sessions, as they will ensure that women are given the needed information in service delivery. The study showed that, loving husbands are more likely to accompany their partners to the clinics. Lack of love indicates there is absence of love and involvement. From the study, it was highlighted that, there exist barriers that inhibit men from giving support to their partners. They included demands from work, cultural perception about the issues of pregnancy being a woman’s affair, lack of love or intimate relation, fear of being mocked, shyness, disrespect on the part of women among others. The study also sought to find out couples’ experience on support given by men during antenatal and postnatal periods. The study showed that, most women attended antenatal and postnatal alone without the escort of the men. Women who were accompanied by their husbands to antenatal and postnatal, were given preferential treatment by being provided with quick service than women who attended alone. The results showed that, men gave support to their female partners in various ways. According to the results, men mostly provided financial support to their partners. Men were also seen to give support to their partners by doing domestic work at home, serving as reminders of appointments to antenatal and postnatal sessions and intake of medications among others. From the study, men who usually support their partners at home were commended for their efforts. Some were also envious of the support given to women at home by their husbands. Finally, the study explored the perceptions of community and couples of the benefit of men’s involvement in antenatal and postnatal care. The study showed that, when men support their partners during the periods of pregnancy and childbirth, their relationships are enhanced thereby bring joy in the home, while strengthening their bonds and increasing communication between both couple. Also, the study showed that, there is a potential to reduce maternal and child mortality, when men help in doing the domestic works at home to decrease the burden 64 University of Ghana http://ugspace.ug.edu.gh of the woman and ensure safe delivery. Men also had the opportunity to upgrade their knowledge through education given at the clinics by the nurses. 5.2 Conclusion In the study, men’s role in antenatal and postnatal care was perceived by all participants as being of great importance. The study showed that, men are showing positive behaviours towards providing support to their partners, indicating higher level of involvement in the near future. The need for men to accompany their partners to the clinics during pregnancy and childbirth and also support in various ways at home was stressed by men, women, and health workers, to attain better pregnancy and delivery outcomes, as well as improving maternal and child health, whiles reducing maternal and child mortality. Cultural influence on behaviours of men should be well approached to target more men to actively involve themselves in supporting their partners during pregnancy and childbirth. 5.3 Recommendation Based on the findings of the study, the following recommendations are made: 5.3.1 Recommendations for the Health Sector First of all, nurses at the antenatal and postnatal care unit should encourage and invite husbands of pregnant women to come to the antenatal and postnatal care unit, by engaging the men in the care processes. Men should have a part to play when they accompany their partners to the antenatal and postnatal sessions. This will boost the morale of men to attend antenatal and postnatal visits and avoid the feeling of being mocked or the feeling of unfriendliness at the unit. Also, nurses should engage in communication campaigns using mass media. This can be done through the use of posters at health facilities to portray men giving support in various 65 University of Ghana http://ugspace.ug.edu.gh ways both at home and outside the home during the periods of pregnancy and childbirth to serve as a form of education to those who visit the antenatal and postnatal care unit, community-based workshops and seminars organised by health workers to educate the men and the upcoming youth on the need to support women during antenatal and postnatal periods, radio and television broadcasts to create awareness and educational drama in communities with community members involved. 5.3.2 Recommendation for Social Workers Social workers should assist in counselling to motivate men to support their partners during antenatal and postnatal periods. Also, social workers should address the gender inequity highlighted in this research, through education and sensitisation on male involvement in maternal health issues, as well as advocating for policies that encourage male participation in maternal health issues. In addition, social workers should engage in social marketing to bring about attitudinal change in men to promote male involvement in antenatal and postnatal care. 5.3.3 Recommendation for Future Studies It has been seen that, involvement of men is of great importance and very critical in maternal health. However, focus has been on decisions of men and attendance of men to health centres with less focus on support given at home. Future studies on involvement should be expanded to encompass the support given by men at home. Also, there is the need to for a mixed method study to help quantify the level of male involvement while providing rich qualitative information. 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Africa Journal of Midwifery & Women’s Health. Retrieved from http://b.3cdn.net/glaser/e10cb8378274e8cb86_2tm6bxz7f.pdf 73 University of Ghana http://ugspace.ug.edu.gh Nyarko, P., Birungi, H., Armar-Klemesu, M., Arhinful, D., Deganus, S., Odoi-Agyarko, H. and Brew, G. (2006). Acceptability and feasibility of introducing WHO Focused Antenatal Care Package in Ghana. Retrieved from http://www.hrhresourcecenter.org/node/809 Nuraini, E. and Parker, E. (2005). Improving Knowledge of Antenatal Care (ANC) among Pregnant Women: A Field Trial In Central Java, Indonesia. Asia-Pacific Journal of Public Health, 17(1), 3-8. Olugbenga-Bello, A, Asekun-Olarinmoye, E., Adewole, A., Adeomi, A. & Olarewaju S. (2013). Perception, attitude and involvement of men in maternal health care in a Nigerian community. Journal of Public Health and Epidemiology, 5(6), 262-270. Retrieved from http://www.academicjournals.org/article/article1379689263_Adenike%20et%20al.pdf Ortiz, A. V. (2007). 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Why don’t some women attend antenatal and postnatal care services?: A Qualitative Study Of Community Members’ Perspectives In Garut, Sukabumi And Ciamis Districts Of West Java Province, Indonesia. Pregnancy and Child Birth, 10(61). Retrieved from http://www.biomedcentral.com/1471-2393/10/61 Tlou, E. R. (2009). The application of the theories of reasoned action and planned behaviour to a workplace HIV/AIDS health promotion programme. (Doctoral dissertation, University of South Africa). Retrieved from http://www.worldcat.org/title/application-of-the-theories-of-reasoned-action-and- planned-behaviour-to-a-workplace-hivaids-health-promotion- programme/oclc/520520452 UNFPA. (2007). It takes two: Men As Partners In Maternal Health. Retrieved from http://www.unfpa.org/public/site/global/lan/en/pid/84 UNFPA. (2011). Promoting gender equality. Engaging men and boys. Retrieved from http://www.unfpa.org/gender/men.htm UNICEF (n.d.). Only half of women worldwide receive the recommended amount of care during pregnancy. Retrieved from http://www.data.unicef.org/maternal-health/antenatal-care#sthash.76TFZkWH.dpuf UNICEF (2009). Antenatal care in Kosovo: Quality And Access. Retrieved from http://www.unicef.org/kosovoprogramme/Kujdesi_Antenatal_- _Anglisht(per_Web)02.pdf 76 University of Ghana http://ugspace.ug.edu.gh United Nations General Assembly (2011). With Equal Rights, Empowerment, Women Can Be ‘Agents of Change’ for Sustained Socio-economic Development, Security around World, Third Committee Told. USAID (2010). Men, key to reducing maternal deaths in developing countries. Retrieved from http://transition.usaid.gov/press/frontlines/fl-may10/p08-men 100517.html.on Vallerand, R. J., Pelletier, L. G., Deshaies, P., Cuerrier, J. P. & Mongeau, C. (1992). Ajzen and Fishbein theory of reasoned action as applied to moral behaviour: A Confirmatory Analysis. Journal of Personality and Social Psychology, 62(1), 98-109. Venkatesh, V. (2010). Marital rape- Comparative Legislation In Canada, Ghana, Kenya And Malawi. Retrieved from http://theequalityeffect.org/pdfs/MaritalRapeComparative.pdf World Health Organisation (2011). Antenatal care coverage. WHO Statistical Information System. Retrieved from http//www.who.int/whosis/indicators/compendium/2008/3acf/en World Health Organisation (2013). Recommendations on postnatal care of the mother and new born. Retrieved from http://www.who.int/maternal_child_adolescent/documents/postnatal-care- recommendations/en/ 77 University of Ghana http://ugspace.ug.edu.gh APPENDICES Appendix 1 Introductory letter to Danfa Health Centre DEPARTMENT OF SOCIAL WORK UNIVERSITY OF GHANA P.O. Box LG 419, LEGON-GHANA Tel: 233-21-513051/500300 Ext: 3289 Fax: 233-21-513051 E-mail: socialwk@ug.edu.gh Our Ref…………SC.1(a)………. Your Ref………………………… February 9, 2015. The Hospital Administrator Danfa Health Centre Danfa Dear Sir/Madam, LETTER OF INTRODUCTION – FRANKLIN KONADU ADDO AGYEMAN: STUDENT ID NO. 10273798 This is to certify that the above-named is an M.Phil student of Department of Social Work. He is writing his thesis and needs to collect data on the topic: “Perceptions and experiences of men’s involvement in Antenatal and Postnatal Care” from your outfit. This is purely for academic purpose and should be treated as such. He can be contacted on 0246467308. The department will be grateful for your assistance. Thank you. Yours faithfully, Ms. Esther Korsiwor Yorku (Senior Administrative Asst.) 78 University of Ghana http://ugspace.ug.edu.gh Appendix 2 Interview guide for female partners SAMPLE QUESTIONS TOPIC: PERCEPTIONS AND EXPERIENCES OF MEN’S INVOLVEMENT IN ANTENATAL AND POSTNATAL CARE. Objectives: 1. Find out how people perceive men’s involvement in antenatal and postnatal care. 2. Find out the experiences of couples on men’s involvement in antenatal and postnatal. Female partners 1. How many times do you attend antenatal and postnatal clinics? 2. Who attends the clinic with you? 3. If not your husband why does he not attend? 4. Can you tell me what your husband does when you both attend the clinic? 5. Do you think it’s necessary for your husband to attend antenatal and postnatal with you? Why? 6. Apart from going to the clinic with you, tell me what your husband does to support you during pregnancy and after birth? 7. How do you feel when your husband is assisting you during pregnancy and also after the child is born, including helping in house chores, changing of diapers, assisting in caring for the new born amongst others? 8. What are people’s reactions towards your husband assisting you during pregnancy and after birth? 9. What are some of the problems you encounter in the process of your husband supporting you? 79 University of Ghana http://ugspace.ug.edu.gh 10. Can you tell me in general what you think about men’s involvement in the process of childbirth and the early stages of child up-bring looking at our culture? 11. Do you think culture has a role to play in men assisting during pregnancy and after birth? 12. What do you think can prevent men from being involved in the process of childbirth and caring for new-borns? 13. How do you see men’s involvement in antenatal and postnatal care in the future? 80 University of Ghana http://ugspace.ug.edu.gh Appendix 3 Interview guide for male partners SAMPLE QUESTIONS TOPIC: PERCEPTIONS AND EXPERIENCES OF MEN’S INVOLVEMENT IN ANTENATAL AND POSTNATAL CARE. Objectives: 1. Find out how people perceive men’s involvement in antenatal and postnatal care. 2. Find out the experiences of couples on men’s involvement in antenatal and postnatal. Male partners 1. Do you have any idea on the number of times your wife attends antenatal and postnatal care? 2. Who goes to the Clinic with her? 3. Why don't you attend with her?/Why do you attend with her? 4. Can you tell me what you do when both of you attend the clinic? 5. Do you think it’s necessary for you to attend antenatal and postnatal with your wife? Why? 6. Apart from going to the clinic, what else do you do to support your wife during pregnancy and after birth? 7. How do you feel when you assist your partner during pregnancy and when the child is born, including helping in house chores, changing of diapers, assisting in caring for the new born amongst others? 8. What are people’s reactions towards you assisting your wife during pregnancy and after birth? 9. What are some of the problems you encounter in the process of supporting your wife? 81 University of Ghana http://ugspace.ug.edu.gh 10. Tell me your general view on men’s involvement in the process of childbirth and the early stages of child up-bring looking at our culture? 11. Do you think culture has a role to play in men assisting during pregnancy and after birth? 12. What do you think can prevent men from being involved in the process of childbirth and caring for new-borns? 13. How do you see men’s involvement in antenatal and postnatal care in the future? 82 University of Ghana http://ugspace.ug.edu.gh Appendix 4 Interview guide for health workers SAMPLE QUESTIONS TOPIC: PERCEPTIONS AND EXPERIENCES OF MEN’S INVOLVEMENT IN ANTENATAL AND POSTNATAL CARE. Objective 3: Examine the effects of men’s involvement in antenatal and postnatal care. Health workers 1. How often do men attend antenatal and postnatal clinics with their partners? 2. Tell me what you engage the men in when they come to the clinic? 3. Apart from men attending the clinic what do you think men can do to support their wives during pregnancy and after birth? 4. Do you think it is necessary for men to attend antenatal and postnatal clinics with their wives? 5. What is your view on men supporting their partners in antenatal and postnatal care looking at our culture? 6. Do you think culture has a role to play in men assisting during pregnancy and after birth? Why? 7. What do you think will be the effects if men are involved in antenatal and postnatal care? 8. Tell me the barriers to men’s involvement in antenatal and postnatal care? 9. What will be the way forward to get men involved in the process of childbirth and caring for the new born? 10. How do you see men’s involvement in the future? 83 University of Ghana http://ugspace.ug.edu.gh Appendix 5 Focus group discussion guide for unmarried community members SAMPLE QUESTIONS TOPIC: PERCEPTIONS AND EXPERIENCES OF MEN’S INVOLVEMENT IN ANTENATAL AND POSTNATAL CARE. Focus Group Discussion 1. What do you know about antenatal and postnatal care? 2. What role do men play in antenatal and postnatal care? 3. What are the challenges to men’s involvement in antenatal and postnatal care, the remedial measure if any, and the way forward 84