The role of men in promoting women’s reproductive and maternal health in a matrilineal marriage system in Malawi: the case of Ntchisi District

Philosophiae Doctor - PhDThis research explored the role of men in efforts by the Malawi Ministry of Health to promote women’s reproductive and maternal health in accordance with Millennium Development Goal (MDG) number five, i.e. to reduce the maternal mortality ratio by three quarters between 1990 and 2015. The study was conceptualised in 2011 in an effort to contribute to the national strategy to reduce maternal mortality in Malawi, and it was done in the particular cultural context of a matrilineal marriage and kinship system in Ntchisi district, Malawi. At the inception of this study, the highest prevalence of maternal deaths in the country was reported in seven districts, including Ntchisi. A common understanding in public health circles worldwide is that male involvement in reproductive and maternal health activities is an important factor in achieving the above MDG goal. But historically, research on maternal health in Malawi has focused mostly on women and children. Consequently there are only a small number of relevant previous studies or extant literature to draw on for the current investigation. Malawi’s reproductive and maternal health policies largely lack locally-informed research on men and masculinities. My study aimed to explore the relationship between local constructions of masculinity, fatherhood and reproductive health in Malawi among Chichewa speakers who live in Ntchisi. It was guided by the social constructionist theory which recognises the role of the impersonal features of the social world like cultural, personal and group influences in the construction of ideas, knowledge and facts. In this study I adopted an inductive approach to learning in which the participants were the main players in describing and explaining social phenomena as they are constructed and experienced in the research site. I conducted multiple in-depth interviews and focus group discussions with 53 married men, key informant interviews with eight local leaders and traditional birth attendants, as well as focus group discussions with 12 married women who had given birth multiple times. Data analysis involved intensive scrutiny of transcripts to determine prevailing themes. Listening to the tapes and re-reading these transcripts enabled me to detect patterns and categorise different practices and constructions, to find associations between these practices and constructions of concepts. Malawi’s men are considered to be the traditional gatekeepers of maternal and social ideals. Therefore, as elders in a clan or as husbands, their prompt decisions can facilitate the access of their spouses to maternal and reproductive health services. Men as heads of households and decision makers can also support and enable their wives to follow the recommended maternal health counsel. However, men’s “lack of involvement” is not the principal reason why there is increasing maternal challenges among child-bearing women in Ntchisi. Although men are not entirely free of the blame for contributing to the status quo, they already work hard towards ensuring positive pregnancy outcomes for their spouses. The study found that husbands in Ntchisi have long been involved in pregnancy and child care. The study shows that pregnancy is regarded as a liminal state or as a kind of “sickness”. Male involvement in pregnancy means the man should take over the routine household chores of drawing water, fetching firewood and cooking, among other things. However, men construct their involvement in reproductive and maternal health matters in the framework of masculinity and femininity as dictated by the commonly held beliefs of a matrilineal Chewa grouping. The study showed that masculinities are constructed within the context of a matrilineal system, which has nonetheless been changing largely due to the colonial impact of the United Kingdom, the related influences of Christian and westernised social ideals and an education system based on the British model. Men’s gendered practices in reproduction and parenting have foundations in the initiation rites of the secret Nyau societies where the masculine ideals of sexuality and secrecy are inculcated. This research cannot be generally extrapolated to the wider population in Malawi but it is a starting point for understanding the responses of matrilineal Chichewa speaking men to reproductive and maternal health matters. Further and broader research on the construction of fatherhood and masculinity is needed in Malawi to make it possible for public health policy on reproductive and maternal health to be more culturally informed