Respectful maternity care and the role of male partners in Mozambique : practices, obstacles and conceptualisation

Maternal health is a constant concern in Mozambique, as the nation’s maternal mortality rate (MMR) is still one of the highest in the world. The latest numbers from 2017 indicate a MMR of 289 maternal deaths per 100 000 livebirths[130].On a more positive note, significant progress has been made in the country in encouraging women to deliver in health facilities, with a nationwide institutional delivery rate of 70% [113]. In line with global strategies, efforts in Mozambiquehave largely focused on increasing antenatal care (ANC) coverage and facilitybased childbirth together with improving access to family planning services during the Millennium Development Goals era as key mechanisms to reduce perinatal and maternal mortality [10, 11]. More recently, maternal health efforts are shifting from an emphasis on boosting service utilisation to improving quality of care, because poor quality of care in health care settings seem to compromise the expected health gains of the increased antenatal care coverage and institutional deliveryrates[274]. Quality issues have shown to be aggravated by inequities and evidence suggests that especially poor and marginalized women (e.g. adolescents and single women) may encounter disrespectful or abusive care, affecting the overall quality of care [14, 15]. In addition men’s important role in improving maternal health care utilisation has been receiving more attention over the last decade, in the belief that male involvement in maternal health can contribute to the reduction of maternal and infant mortality[54, 47]. Also in Mozambique men have been encouraged to be involved in maternal health care by different interventions, such as sending invitation letters to attend antenatal care, giving priority to couples and different community campaigns[144, 275]. Nevertheless evidence on the role of men in maternal health and effective interventions for increasing male involvement remains scarce in Mozambique.Within this context this dissertation overall aim was to examine the role of the male partner in southern Mozambique during pregnancy and childbirth and assess barriers and facilitators for the successful involvement of men. However, this assessment could not be done without also examining the broader context of maternal health care provision in Mozambique. Preliminary findings demonstrated how quality of care issues and the occurrence of disrespectful treatment hampered the engagement of men in maternal health. As a consequence the objectives of this doctoral thesis were expanded by also assessing the implementation of respectful maternity care in southern Mozambique. Lastly the concept of male involvement in maternal health was also examined from a global perspective, based on the perceivedgap in the literature regarding a clear definition and operationalisation of the concept.The first aim of this thesis was to assess the implementation of respectful maternity care in southern Mozambique, including the role of the male partner. Our second aim was to assess the role of the male partner during pregnancy and childbirth in southern Mozambique and explore barriers for male involvement. As third aim I explored the conceptualisation of male involvement in maternal health from a global perspective. To answer the research questions and study objectives of this dissertation, several data-collection methods and data sources were used, namelyquantitative surveys, in depth individual interviews, focus group discussions, a systematic review of the literature and a Delphi study. Every aim of our research was explored by a mix of qualitative and quantitative data and examined by a mixed method approach. Findings of this doctoral dissertation have been published in six peer-reviewed articles.The first paper , \Disrespect and abuse during facility-based childbirth in Southern Mozambique: a cross-sectional study." , showed that the occurrence of disrespectful treatment is common in southern Mozambique, although the prevalence of certain forms of abuse such a physical violence and bribing were rather low compared to the neighbouring countries. I also found that the occurrence of disrespect and abuse was much higher in the district hospitals compared to the referral hospitals, emphasizing the high need for tailored interventions according to the severity of the problem and specific context. While male birth companions are not allowed in public facilities, women seem in favour of involving their partners. With the ideal conditions (such as infrastructure allowing privacy and trained providers) the invitation of male birth companions could be explored in the future, with the potential of improving women and their partners’ experience of care.The second paper, \A qualitative study on midwives’ identity and perspectives on the occurrence of disrespect and abuse in Maputo city.", revealed midwives are struggling with their low position in the health system hierarchy, which might be a trigger for disrespectful treatment of women during childbirth. In addition midwives did not seem adequately trained to handle stressful emergency situations and risk to conduct disrespectful behaviour when an obstetric emergency occurs. However, in my study I could not identify an intentional abuse by providers, making terms such as obstetric violence and abuse misplaced in this context. Supportive supervision and avoiding a blaming culture seems key for mitigating disrespect in health facilities, together with an increased respect for midwives (both by societyand within the health system). The positive views of midwives on continuous labour companionship and inviting male partners as birth companions are promising for future quality improvements initiatives in that aspect of care.The third paper, \Policymaker, health provider and community perspectives on male involvement during pregnancy in southern Mozambique: a qualitative study." , showed men are willing to take up a supportive role during pregnancy and childbirth and consider it as their responsibility to \take care" . However, persistent gender inequality in- and outside the health facility hamper successful implementation of male involvement programs. In addition I observed a long standingassociation of men attending ANC services with being HIV positive, which was a serious barrier for male presence at ANC in southern Mozambique. Overall an increased focus on supply side barriers (by more male friendly services and gender sensitive consultations) might be needed for improving male involvement in maternal health in southern Mozambique. Lastly I found that male involvement programs should also focus on other aspects of men’s role during pregnancy and childbirth than ANC presence and HIV testing, for avoiding HIV stigmatisation and improving not only maternal health outcomes but also broader outcomes such as gender equality.The fourth paper, \A cross-sectional study of the role of men and the knowledge of danger signs during pregnancy in southern Mozambique." showed men take part in decisions concerning maternal health and are often providing financial support related to maternal health care issues. I found that maternal health care knowledge was equally low among men and women and that male attendance at ANC (at least once in the last pregnancy) was reported to be 30% . However, the latter should be interpreted with caution as male attendance at ANC is interpreted differently by different actors (waiting at the gate is often also considered as male attendance). Surprisingly, communication with the partner was associated with higher maternal health knowledge among men and women, while presence at ANC was not. These findings let me conclude that the quality of ANC should be improved for optimising maternal health care provision, whereby counselling of men and women regarding birth preparedness and knowledge of danger signs takes a central place. In addition improving and facilitating communication between men and women about maternal health care issues might be an important intervention strategy to improve male involvement and maternal health outcomes. The fifth paper, \A systematic review of the concept \male involvement in maternal health" by natural language processing and descriptive analysis." showed that the conceptualisation of male involvement in maternal health in the literature isdone by focusing on either the psychosocial aspects of support or men’s role in maternal health care utilisation. Overall male involvement was most often measured by instrumental actions such as presence at health services, financial support or providing transport. Other aspects of male involvement, such as communication, emotional support and shared decision making have received little attention, especially in low- and middle-income countries. Based on those findings I recommend more research into those neglected aspects of male involvement (such as the subjectivefeeling of perceived support and shared decision making) to broaden the potential of male involvement programs and also reveal and minimize potential negative side-effects of male involvement interventions. In the last paper, \Towards a global framework for assessing male involvement in maternal health: results of an international Delphi study\, a team of global experts reached a consensus regarding a global male involvement framework, consisting of five categories: involvement in communication, involvement in decision making, practical involvement, physical involvement and emotional involvement. The strong consensus reached in this study around a global framework for assessingmale involvement in maternal health provides a platform for further optimisation of the proposed indicators (based on pilot testing in different countries) and an opportunity for improved monitoring and reporting of effectiveness of male involvement interventions at a global level. However, further research is needed to explore how couple dynamics (such as shared decision making, women’s empowerment and gender equality) can be optimally assessed within male involvement interventions.In conclusion, this dissertation has revealed the complexity of involving men in maternal health care, together with the challenges of providing respectful maternity care in a low-income setting. I found that the provision of respectful maternity care and the involvement of men seem to be hampered by mainly the same challenges, being privacy issues, limited training of health providers and a high workload. In addition there is a persistent gender inequality within society and the health system, negatively affecting how midwives are treated in the health system hierarchy, but also negatively affecting women’s role in the consultation when they are accompanied by a partner. My findings suggest a \one fits all" approach for involving men into maternal health will hardly work, and that every strategy will have his limitations. The promotion of gender-equitable relationships into every male involvement strategy is key for limiting negative side-effects of male involvement. Unintended (negative) side-effects of male involvement programs are hardly documented in the literature and should be assessed and explored more often. Based on these findings I made some key recommendations for policy and practice in Mozambique:-The practice of giving priority to couples should be revised to avoid the reinforcement of gender inequality at the health system level.-The infrastructure of the facilities and skills of the health providers need to be improved in order to minimise supply-side barriers for male involvement in maternal health. Offering high quality antenatal care for both the woman and partner is key for the successful involvement of men in maternal health.-Improving midwives’ working environment in terms of constructive supervision and promoting positive gender equal relationships with patients, colleagues and superiors has the potential of improving overall maternal health care and reducing disrespectful treatment towards women during childbirth.-Integration of gender equality interventions into male involvement programming is key for improving maternal health together with broader outcomes on the long term.At a global level I believe a broader holistic scope, involving a multidimensional assessment in male involvement interventions, might give more sustainable results on maternal health and broader health outcomes than narrowly focused interventions. In addition more realist evaluations of male involvement programs are needed , especially in LMICs were the conditions of intervention programs can often not be replicated over the whole country due to limited resources. The global framework for assessing male involvement in maternal health provides an opportunityfor improved monitoring and reporting of male involvement interventions at a global level and can facilitate ongoing efforts to broaden the evidence base regarding male involvement in maternal health.Public defense: 2021-09-03Maternal health is a constant concern in Mozambique, as the nation’s maternal mortality rate (MMR) is still one of the highest in the world. The latest numbers from 2017 indicate a MMR of 289 maternal deaths per 100 000 livebirths[130].On a more positive note, significant progress has been made in the country in encouraging women to deliver in health facilities, with a nationwide institutional delivery rate of 70% [113]. In line with global strategies, efforts in Mozambiquehave largely focused on increasing antenatal care (ANC) coverage and facilitybased childbirth together with improving access to family planning services during the Millennium Development Goals era as key mechanisms to reduce perinatal and maternal mortality [10, 11]. More recently, maternal health efforts are shifting from an emphasis on boosting service utilisation to improving quality of care, because poor quality of care in health care settings seem to compromise the expected health gains of the increased antenatal care coverage and institutional deliveryrates[274]. Quality issues have shown to be aggravated by inequities and evidence suggests that especially poor and marginalized women (e.g. adolescents and single women) may encounter disrespectful or abusive care, affecting the overall quality of care [14, 15]. In addition men’s important role in improving maternal health care utilisation has been receiving more attention over the last decade, in the belief that male involvement in maternal health can contribute to the reduction of maternal and infant mortality[54, 47]. Also in Mozambique men have been encouraged to be involved in maternal health care by different interventions, such as sending invitation letters to attend antenatal care, giving priority to couples and different community campaigns[144, 275]. Nevertheless evidence on the role of men in maternal health and effective interventions for increasing male involvement remains scarce in Mozambique.Within this context this dissertation overall aim was to examine the role of the male partner in southern Mozambique during pregnancy and childbirth and assess barriers and facilitators for the successful involvement of men. However, this assessment could not be done without also examining the broader context of maternal health care provision in Mozambique. Preliminary findings demonstrated how quality of care issues and the occurrence of disrespectful treatment hampered the engagement of men in maternal health. As a consequence the objectives of this doctoral thesis were expanded by also assessing the implementation of respectful maternity care in southern Mozambique. Lastly the concept of male involvement in maternal health was also examined from a global perspective, based on the perceivedgap in the literature regarding a clear definition and operationalisation of the concept.The first aim of this thesis was to assess the implementation of respectful maternity care in southern Mozambique, including the role of the male partner. Our second aim was to assess the role of the male partner during pregnancy and childbirth in southern Mozambique and explore barriers for male involvement. As third aim I explored the conceptualisation of male involvement in maternal health from a global perspective. To answer the research questions and study objectives of this dissertation, several data-collection methods and data sources were used, namelyquantitative surveys, in depth individual interviews, focus group discussions, a systematic review of the literature and a Delphi study. Every aim of our research was explored by a mix of qualitative and quantitative data and examined by a mixed method approach. Findings of this doctoral dissertation have been published in six peer-reviewed articles.The first paper , \Disrespect and abuse during facility-based childbirth in Southern Mozambique: a cross-sectional study." , showed that the occurrence of disrespectful treatment is common in southern Mozambique, although the prevalence of certain forms of abuse such a physical violence and bribing were rather low compared to the neighbouring countries. I also found that the occurrence of disrespect and abuse was much higher in the district hospitals compared to the referral hospitals, emphasizing the high need for tailored interventions according to the severity of the problem and specific context. While male birth companions are not allowed in public facilities, women seem in favour of involving their partners. With the ideal conditions (such as infrastructure allowing privacy and trained providers) the invitation of male birth companions could be explored in the future, with the potential of improving women and their partners’ experience of care.The second paper, \A qualitative study on midwives’ identity and perspectives on the occurrence of disrespect and abuse in Maputo city.", revealed midwives are struggling with their low position in the health system hierarchy, which might be a trigger for disrespectful treatment of women during childbirth. In addition midwives did not seem adequately trained to handle stressful emergency situations and risk to conduct disrespectful behaviour when an obstetric emergency occurs. However, in my study I could not identify an intentional abuse by providers, making terms such as obstetric violence and abuse misplaced in this context. Supportive supervision and avoiding a blaming culture seems key for mitigating disrespect in health facilities, together with an increased respect for midwives (both by societyand within the health system). The positive views of midwives on continuous labour companionship and inviting male partners as birth companions are promising for future quality improvements initiatives in that aspect of care.The third paper, \Policymaker, health provider and community perspectives on male involvement during pregnancy in southern Mozambique: a qualitative study." , showed men are willing to take up a supportive role during pregnancy and childbirth and consider it as their responsibility to \take care" . However, persistent gender inequality in- and outside the health facility hamper successful implementation of male involvement programs. In addition I observed a long standingassociation of men attending ANC services with being HIV positive, which was a serious barrier for male presence at ANC in southern Mozambique. Overall an increased focus on supply side barriers (by more male friendly services and gender sensitive consultations) might be needed for improving male involvement in maternal health in southern Mozambique. Lastly I found that male involvement programs should also focus on other aspects of men’s role during pregnancy and childbirth than ANC presence and HIV testing, for avoiding HIV stigmatisation and improving not only maternal health outcomes but also broader outcomes such as gender equality.The fourth paper, \A cross-sectional study of the role of men and the knowledge of danger signs during pregnancy in southern Mozambique." showed men take part in decisions concerning maternal health and are often providing financial support related to maternal health care issues. I found that maternal health care knowledge was equally low among men and women and that male attendance at ANC (at least once in the last pregnancy) was reported to be 30% . However, the latter should be interpreted with caution as male attendance at ANC is interpreted differently by different actors (waiting at the gate is often also considered as male attendance). Surprisingly, communication with the partner was associated with higher maternal health knowledge among men and women, while presence at ANC was not. These findings let me conclude that the quality of ANC should be improved for optimising maternal health care provision, whereby counselling of men and women regarding birth preparedness and knowledge of danger signs takes a central place. In addition improving and facilitating communication between men and women about maternal health care issues might be an important intervention strategy to improve male involvement and maternal health outcomes. The fifth paper, \A systematic review of the concept \male involvement in maternal health" by natural language processing and descriptive analysis." showed that the conceptualisation of male involvement in maternal health in the literature isdone by focusing on either the psychosocial aspects of support or men’s role in maternal health care utilisation. Overall male involvement was most often measured by instrumental actions such as presence at health services, financial support or providing transport. Other aspects of male involvement, such as communication, emotional support and shared decision making have received little attention,