Barriers to involvement of men in ANC and VCT in Khayelitsha, South Africa.

We used qualitative methods to assess pregnant women and men's attitudes, feelings, beliefs, experiences and reactions to male partners' involvement in antenatal clinic (ANC) in Khayelitsha, Cape Town, South Africa. The aims of these studies were to determine barriers to male partners' attendance of ANC with their pregnant female partners and to identify possible strategies to overcome these barriers. Findings from the qualitative studies demonstrated that pregnant women were keen to invite their male sexual partners and that men would attend if invited. The main barrier to male participation was lack of awareness and the healthcare facility environment. The findings of these studies emphasized the need to increase awareness among men in Khayelitsha of the need for male attendance of ANC and the need to address the barriers to male attendance of ANC. It was clear that community sensitization programmes coupled with improvement of the health facility environment to be receptive to men are essential for increasing male attendance of ANC.

Introduction

To improve compliance with treatment and reduce stigmatization of pregnant women infected with HIV, it has been suggested that approaches that involve male sexual partners in prevention of parent to child transmission of HIV (PPTCT) interventions should be developed, evaluated and implemented (Allen et al., 2003; Maman, Mbwambo, Hogan, Kilonzo, & Sweat, 2001; Pool, Nyanzi, & Whitworth, 2001; Semrau et al., 2005; Van der Straten, King, Grinstead, Serufilira, & Allen, 1995). In sub-Saharan Africa, involvement of male sexual partners in maternity care is a thorny and problematic issue; traditionally men do not attend maternity clinics with their women and maternity is seen as a woman's business. We undertook qualitative studies in Khayelitsha Township, Cape Town, South Africa to determine barriers to male partners’ attendance of antenatal clinic (ANC) with their women and to identify possible strategies to overcome these barriers.

Methods

Rationale for focus group discussions

Focus group discussions (FGD) were used as the method of data collection because our main aim was to draw on pregnant women and men's attitudes, feelings, beliefs, experiences and reactions to male partners’ involvement in ANC (Powell & Single, 1996). The social gathering and interaction provided in FGDs can enhance the likelihood of revealing attitudes, feelings and beliefs, whereas, on the other hand, FGDs help to elicit a multiplicity of views and emotional processes within a group context and generate a huge amount of information in a short period (Kitzinger, 1995; Munodawafa, Gwede, & Mubayira, 1995).

FGD participants

The key attributes to seek in participants were identified based on the research objectives. We were interested in pregnant women and men who use public sector maternity facilities in Khayelitsha and made sure that we got diverse groups of participants to stimulate the discussions. Three weeks before the FGDs, participants were selected using purposive nonprobability sampling strategy and invited to attend. Women were recruited from the two maternity units in Khayelitsha, Site B (SB) and Michael Mapongwane (MM) during ANC. Men were recruited through existing social networks by word of mouth and through the use of key informants, and by advertising. The message was written in the local language isiXhosa inviting men to discuss male involvement in ANC. Six groups were recruited – three each of female and male participants. Ten participants were included in each group to allow sufficient diversity in the group, without compromising control due to larger group size. Also, to ensure that, if some participants did not attend, we could still have enough participants to continue with the discussion. Compensation in the form of reimbursement for transport costs was offered to all participants at the rate of 50 Rand per person. A day before each FGD, participants were phoned up and reminded about the meeting.

Conduct of FGD

All the FGDs were organized in a setting that accommodated the participants, the moderator and the note-taker. They sat in a circle and they could all view each other. The women focus groups met at the maternity units because it was thought that women would feel comfortable expressing their opinions about male involvement at these locations; men met at their work place. Two sessions were organized per focus group. The first session was used to explore participants’ attitudes and perceptions about male involvement in ANC. The second session focused on designing community sensitization activities aimed at overcoming barriers to male involvement in ANC.

The participants, moderator and note-taker were allowed to interact informally briefly before the formal discussion. At the beginning of the FGD, the moderator introduced the participants, and the purpose and context of the meeting. The moderator facilitated open and uninhibited dialog, while the note-taker noted verbal and non-verbal gestures and tape-recorded the discussion. All the discussions were conducted in isiXhosa, the local language. In the first session, participants discussed the following four topics: (1) their understanding of male involvement in ANC (2) why is it important to involve men in ANC? (3) why men are not involved in ANC? and (4) how to involve men in ANC? The information obtained in the first session was confirmed by the participants in the second meeting before designing the community sensitization activities.

FGD data analysis

We used the framework approach developed by the National Centre for Social Research in the United Kingdom in analyzing the FGD data (White & Thomson, 1995). We started the analysis deductively from the aims and objectives and proceeded inductively based on the original accounts and observations (Goss & Leinbach, 1996; Holbrook & Jackson, 1996; MacIntosh, 1981; Smith, Scammon, & Beck, 1995). We transcribed the tapes and familiarized ourselves with the data. Thereafter we systematically searched for recurring themes and items of interest based on our original research questions and objectives. We then identified themes that related to each of the study objectives and answers to the research questions.

Results

Study site

The study was carried out in Khayelitsha, between 1 December 2004 and 31 May 2005. Khayelitsha is home to one million Xhosa-speaking Africans. There were two public sector facilities offering ANC in Khayelitsha: MM and SB Midwives and Obstetrician Units (MOUs). The characteristics of the MM and SB are shown in Table 1. There were no facilities for men at MM; men were not allowed on the premises, rather they were asked to wait outside the clinic yard. Although there were neither waiting rooms nor rest rooms for men at SB, there were facilities for couple counselling and men accompanying their women were allowed on the premises.

Table 1.

Michael Mapongwane and Site B MOUs.

Name of MOU	Site B	MM
Location (Khayelitsha)	Site B	Site C
Level	Primary	Primary
Female staff	30	18
Male staff member	1	0
Opening time	7.00 hrs	7.00 hrs
Closing time	16.30 hrs	16.00 hrs
Average booking gestation	24 weeks	22 weeks
How many have regular partners	Unknown Unknown
Number of male partners attending ANC	0	0
Facilities for couple interviewing	Available	None
Group HIV information	Yes	Yes
Type of VCT	Opt in	Opt in
Who provides the counseling	Lay	Lay
Number of bookings per day	30	20
Women who book and deliver at the facility	100%	100%
HIV prevalence	30%	30%
VCT uptake	97%	97%
HIV + mothers taking ARV	95%	98%
Babies of HIV positive mothers taking ARV	96%	97%
HIV + mothers exclusively breast feeding	1%	2%
HIV + mothers mixed feeding	0	0
HIV + mothers formula feeding	99%	98%
MTCT of HIV rate	Unknown	Unknown
Male rest rooms	None	None
Male waiting rooms	None	None

Participants

The sample included 30 pregnant women, aged between 18 and 37 years, and 30 men aged between 19 and 49 years. The pregnant women were at different gestational ages and were all booked at SB or MM; 20% were staying with their partners, 9% were employed and 21% had tertiary education. Only 15% of the men lived with their partners, 40% were employed and 22% had tertiary education.

Male sexual partners’ ANC involvement

Women understood male involvement in ANC to mean that their partners would accompany them to the clinic and be present during the medical consultation. They did not consider a man accompanying a woman to the clinic and staying outside the clinic as involvement. According to them, the situation at MM, where men were only allowed to wait outside the clinic, did not constitute male involvement. As some women eloquently put it:

If a man is not present during the medical consultation, he is not involved in ANC. [22 year-old, unemployed, unmarried mother of two, living with partner, SB]

Involvement means receiving the information provided by the clinic together and taking decisions about the pregnancy as a couple. You cannot be at the gate and say that you are involved in ANC; to be involved you have to be in there with the woman. [31 year-old, unemployed, married mother of two, living with husband, MM]

The importance of male ANC attendance

All women focus groups felt that it was necessary for men to attend ANC to support their partners. As one woman stated:

Pregnancy is not a woman-only thing. It is both a man's and a woman's thing. [29 year-old casual worker, mother of two, unmarried and not living with partner, SB]

The role of men is seen as supportive. All women felt that it was important for a man to know what was happening during pregnancy to his partner and baby; and that he should be responsible and supportive of his partner. In the words of one woman:

Men should stop thinking that their duty is only to make babies, they should grow up and support their pregnant partners. [23 year-old, unemployed, first pregnancy, unmarried and not living with pregnant partner, MM]

In contrast to the women, men did not think that ANC attendance by men was important. As one father stated:

I don't think it is necessary for men to go, I don't see my role there. [26 year-old, casual worker, father of two, unmarried and living with pregnant partner, MM]

All men thought that maternity was a special place for women and should be respected. Men felt that women were not allowed to attend male initiation and men should not be allowed to attend ANC because it was women's initiation process. As in the words of some fathers:

Women must be allowed to do their thing without interference from men. [32 year-old, unemployed, father of two, married and living with wife, SB]

There are lots of things happening during birth that male partners shouldn't see. It is just the same like women aren't allowed to go to the ‘bush’ (male initiation). Labour ward is the ‘bush’ for women. [45 year-old, priest, father of four, married and living with wife, SB]

The male partner shouldn't be allowed during birth because he will bring ‘bad spirits’ to the mother and baby if he has been with other women. [37 year-old, bricklayer, father of three, married and living with wife, SB]

Men were not aware of the male sexual partner's role in ANC and alleged that their noninvolvement was for the benefit of their pregnant partners. However, it is important to note that women did not express any concern about male sexual partner's involvement in ANC. In fact, women wanted partners to be involved in ANC.

All the men in the FGDs had children and none had attended ANC or the birth of their children. All were unaware of any need for men to attend ANC with their partner and did not see any need why they should attend. However, they all agreed that, if asked to attend, men should do so. Furthermore, when things go wrong, men should be informed and requested to attend. They stated that:

ANC is for the nurses to check if the baby is fine. [24 year-old, cleaner, father of one, unmarried and living with pregnant partner, SB]

If all is well, it isn't necessary for men to attend. [27 year-old, shopkeeper, father of two, married and living with wife, MM]

If invited, men must go because there might be something wrong with the baby. [39 year-old, labourer, father of three, married and living with wife, SB]

I have never been asked to attend and I always thought I am not needed, if they invite me I will go. [32 year-old, mechanic, father of two, married and living with wife, MM]

There was never a reason for me to attend my wife had a normal baby.[23 year-old, casual worker, father of one, married and living with wife, MM]

Men thought they were not needed and saw the ANC as a place for women to find out if all is well with the baby and the mother. They were not aware of the sexually transmitted infection (STI)/HIV screening that takes place in ANC as part of PPTCT. They are prepared to attend if invited, but, according to them, they should be invited only if there is a problem. Although the PPTCT programmes are well established in both MOUs in Khayelitsha, pregnant women and men in this community did not associate partner ANC attendance with STI/HIV screening, or as a place where potential fathers could find out about their HIV status. The role of fathers in parent-to-child transmission of HIV was not recognized. The role of men in ANC was seen by pregnant women as mere support of women, not as an active role for men to know their STI/HIV status so that they can protect their unborn children from infection.

Barriers to partner ANC attendance

Men unaware of their role

None of the men in the FGDs had attended ANC with their pregnant partners. Men were not aware of their role in ANC and did not attend because they thought that it was not important. They felt that the ANC is for women to check the baby's status. The term used for ANC in isiXhosa is equivalent to “palpate” in English. Men pointed out that ANC is meant for pregnant women to undergo abdominal palpation as a means of assessing the baby's health.

Employment

Most of the men in the FGDs were breadwinners and most of the pregnant women were unemployed. The majority of the men were casual workers and were not allowed paternity and/or family responsibility leave, and, as such, these men naturally would prefer to be at work than attend ANC with their partner. Economic activities were seen as a major barrier to men attending ANC.

Social reasons

Traditionally, men do not attend ANC and some felt that men are not attending because they are afraid that they will be the only ones attending and this may be embarrassing. All of the FGDs felt that some men would find it difficult to attend because they have multiple partners and they do not want to be seen with one partner at the clinic. In the words of one pregnant woman:

Some don't want their other girlfriends or wives to see them attending ANC with someone else. [25 year-old, unemployed, mother of two, married and living with husband, SB]

Facility and staff attitudes

All FGDs agreed that staff attitudes could be a barrier to partner attendance of ANC. Maternity facilities are staffed by female nurses and sisters with male staff being scarce in the ANC facilities in Khayelitsha. In the words of pregnant women in the focus groups:

My friend had a baby last year and they chased away her male partner … male partners are not allowed here … men are not allowed; they stay outside in the sun … it is not nice to bring your boyfriend here to stay in the sun … imagine when it is cold in winter the poor man waiting outside. [29 year-old, casual worker, mother of one, unmarried and living with partner, MM]

Cultural reasons

Culture may be a barrier to male sexual partner involvement in maternity care. In Xhosa tradition, men do not enter the room of a woman with a baby of less than 10 days. He should wait until the umbilical cord has fallen down. However, in the FGDs, it was agreed that there are very few people who observe this tradition in Khayelitsha. In any case, this is about a neonate and not ANC. According to the FGD, there was no cultural reason they could think of that would be a barrier to male attendance of ANC.

How to encourage male partners’ involvement

Three ideas for encouraging male partner involvement in PPTCT emerged from the study: (1) making the health/ANC facility environment more “male-friendly”; (2) providing invitations to men to attend ANC visits with pregnant women; and (3) community sensitization activities to support men in attending ANCs by correcting common misconceptions and challenging prevailing social norms.

Facility environment

It was expressed by all the FGDs that, for men to attend, the clinic environment should be inviting to men – men should feel free to attend. Friendly waiting rooms and toilets for men should be created. Clinic staff and counsellors should be trained to ensure that they are comfortable dealing with men. The clinic should introduce an appointment system, flexible opening times and officially invite men.

Invitations to male partners

Some women would invite their partners to ANC if encouraged to do so, as some of the pregnant women stated:

If I am allowed, I will invite my boyfriend to accompany me to the clinic. [22 year-old, unemployed, mother of one, unmarried and not living with partner, MM]

My husband wants to attend, but he is not allowed. If the rules change, I am happy to invite him. [36 year-old, domestic worker, mother of two, married and living with husband, MM]

I always wanted to invite my partner, but I am not sure how to do it. A letter from the clinic would help. [27 year-old, domestic worker, mother of two, unmarried and living with partner, SB]

Husbands who work should be given clinic attendance letters, if they attend [38 year-old, dressmaker, mother of three, married and living with husband, MM]

Community sensitization

All the FGDs agreed that community leaders should be involved in community sensitization programmes. Community meetings should be organized and be used to invite men to attend ANC and to identify and create role models – men who have attended maternity and who feel positive about ANC attendance; who can encourage other men to attend ANC. Posters and flyers advertising male partners’ ANC attendance should be placed around the clinics and in the community where men usually gather – shopping centers, Shebeens (beer halls) and churches.

The FGDs also agreed that advertisements should be placed in local papers informing the community about the importance of men's attendance of ANC. A weekly community radio show and daily radio announcements should be organized. These shows should be interactive and invite community and church leaders to address and allow members of the community to ask questions about HIV, voluntary counselling and testing (VCT) and PPTCT.

Conclusion

Involvement of men in ANC would seem feasible if the barriers to male involvement are removed. For instance, at MM clinic, men are forbidden from attending; thus, for men to attend, the policy has to change. The clinic environment and nursing staff attitudes have to be addressed to ensure that clinics are male-friendly. This would invariably mean addressing nursing work overload and lack of facilities such as male waiting rooms and bathrooms.