Acceptability of couple antenatal education: A qualitative study of expectant couples attending antenatal clinics in Blantyre, Malawi.

Background: Few studies have assessed the effectiveness and acceptability of male partner involvement in antenatal education. Yet, male involvement in antenatal care including antenatal education has been proposed as a strategy to improve maternal and neonatal outcomes. We conducted this study to add to the body of knowledge on acceptability of male partner involvement in antenatal education following an intervention.
Methods: This was a cross sectional qualitative study using 18 in-depth interviews with 10 couples, 5 women from the couples group and 3 nurse-midwife technicians. Participants were purposively selected and interviewed between July and November, 2017. The study setting was South Lunzu and Mpemba Health Centres and their catchment areas. All interviews were audiotaped, transcribed verbatim and translated from Chichewa into English. Data were coded in Nvivo 10.0 and analyzed thematically. Findings: We identified three themes: benefit of content received; organization of couple antenatal education appropriate for male partner involvement; and delivery of couple antenatal education incentive for male involvement and learning. However, some improvements were suggested regarding content, organization and delivery of the education sessions.
Conclusion: Couple antenatal education was acceptable to the couples and the facilitators in terms of content received, organization and delivery. Nevertheless, adding naming the baby to the list of topics, creating a special day for couples to attend antenatal education and providing a readable leaflet are likely to make couple antenatal education more user friendly.

Background

Male involvement in maternal health services, including antenatal education, has been advocated for internationally with the understanding that men are likely to fulfill their supportive roles as partners if they are made to know about parenthood1. This has seen establishment of couple health programmes in western countries such as antenatal classes for expectant parents2,3. The classes are geared towards providing information to prospective parents on childbirth and parenting skills with the aim of improving maternal and neonatal outcomes. However, the classes have often not been male friendly, ultimately negatively affecting participation of male partners1,4,5. Studies have documented factors which can facilitate male partner participation in antenatal education. Some of the reported factors include: conducting expected fathers' antenatal classes facilitated by a fellow man6,7; providing antenatal education to a mixed gender class8; conducting the education in evening hours and weekends9,10; and use of drama11. These studies have documented improved male partner participation in antenatal education and acceptability of male partner involvement in antenatal education. However, many of these studies have been conducted in high income countries with a few in Africa, where male involvement in maternal health is an emerging practice12,13. Researchers have argued that for initiatives and interventions to meet intended purposes, needs of the beneficiaries and later on acceptability of the intervention should be determined14,15. Acceptability is the extent to which people delivering or receiving a healthcare intervention consider it to adequately satisfy a need or standard14. In this study, we describe acceptability as the extent to which the education is perceived to have met the learning needs of couples from the perspectives of facilitators of the couple antenatal education and couples themselves. While acceptability can be determined at different stages of the intervention, participants' attitudes towards intervention, perceived relevance and suitability of the intervention can be best assessed post intervention14. Intervention studies on male involvement and the acceptability of interventions in antenatal care, particularly antenatal education, are scarce in Africa16,17,18. Therefore, this study aims to assess acceptability of couple antenatal education in Malawi following an intervention.

This study is part of a randomized control trial (RCT), registration number PACTR 201710002636253. The RCT was informed by an exploratory qualitative baseline study whose focus was to identify learning needs of couples to determine acceptability, feasibility and effectiveness of couple antenatal education. The baseline study led to the development of a tailor-made curriculum and a leaflet which were used during the intervention. The intervention involved providing two antenatal education sessions to two groups. The groups were couples who belonged to the intervention arm and married women who belonged to the standard of care arm. The education was conducted during two consecutive antenatal visits in the second trimester. The areas which were covered during the first session were on pregnancy and childbirth while the last session focused on postnatal care. We conducted this study to assess the acceptability of couple antenatal education after the participants had received the education sessions.

Methodology

Study design

We conducted an exploratory cross sectional qualitative study from July to November 2017, among couples and nurse-midwife technicians to explore and describe their perceptions towards couple antenatal education sessions. The design enabled us to have a deeper understanding of the acceptability of couple antenatal education19.

Study setting

The study was conducted in Blantyre district in the southern region of Malawi. The sites selected were Mpemba and south Lunzu (SL) because this is where we had piloted specifically-designed couple antenatal education sessions. The sites were chosen as they were semi-urban sites representing rural and urban populations. Additionally, the sites were likely to have less mobile population for the intervention and had adequate clientele.

Sampling and selection of study participants

A purposive sample of ten couples, 5 women from the couple group and 3 nurse-midwife technicians who had direct experience with couple education were recruited. The couples and the women participated as learners while the nurse-midwife technicians were facilitators of the education sessions. Variations such as age, gravidity and educational level were considered during the recruitment of couples in both sites in order to obtain diverse views and experiences. The eligibility of the participants depended on willingness to participate in the interviews; ability to provide informed consent, having attended the antenatal education sessions twice as couples or having facilitated couple antenatal education sessions almost the entire period of the RCT which was from January to November 2017, in case of the nurse-midwife technicians.

Data collection

In-depth interviews were conducted using the pretested, semi-structured interview guides containing open ended questions. All in-depth interviews were conducted in Chichewa except for three in English. Each interview lasted 30 to 60 minutes.

One broad question guided the interviews: “What would you say about the couple antenatal education sessions you attended/facilitated?” We probed further based on the three domains which constitute learning needs which are content, organization and delivery of the education20. Probes were on relevance of the content received, how the participants felt about the organization and delivery of the education and how the sessions could be made better. We conducted interviews among the following groups: couples who had received two antenatal education sessions and women from the couple group. These women were interviewed separately to allow them to express their views freely in the absence of their male partners17. The final group comprised nurse-midwife technicians who were facilitators of the couple education.

After each interview, main issues arising were noted and summarized to the participants for data verification. Data were triangulated across the three data sources which were couples, women and nurse-midwife technicians to minimize biases21

Data management and analysis

The audiotaped recordings were transcribed verbatim. Transcripts in Chichewa were translated into English and were verified by the co-investigators. Another researcher fluent in both languages helped the translation in order to preserve the meaning of the content. The transcripts were managed in NVivo 10.0. The data were analyzed using thematic analysis framework which allows the data to be coded deductively and inductively22 in order to gather information related to acceptability of couple antenatal education. We read all the transcripts against the recorded data and selected significant issues. One transcript was then deductively and inductively coded and was then reviewed by co-investigators and an independent researcher. Next, we agreed that the codes be used for indexing the rest of the transcripts while paying attention to emerging codes. The codes were then organized into various categories centering on the domains of the learning needs. Additionally, the codes were further categorized based on their similarities, differences and recurrence across the data set and were then brought together as overarching themes. The themes were presented as results after the verification process where the themes were checked against the recorded information.

Ethical considerations

The study received ethical approval from the College of Medicine Research Ethics Committee (COMREC) (Certificate No P.11/151821). The Blantyre District Health Office, which is responsible for the management of health services for Mpemba and SL Health Centres, also granted permission. We explained the purpose of the study to the potential participants and none of the participants refused participation. We obtained informed consent, or witnessed consent with a thumb print if illiterate, prior the interviews from all the participants who met the criteria. All the participants accepted the interviews to be digitally recorded.

Results

Participant characteristics

In total, we conducted 3 interviews with nurse-midwife technicians (1 male and 2 females), 10 with couples and 5 separate interviews with women from the couple group. The mean age for the women in the couple group was 29 years and 33 for men. Most of men and women attended primary education with 2 couples who attended secondary education and 1 couple attended tertiary education. There were 4 primigravida, 2 multigravida and 2 grand multigravida. All women except 1 were housewives by occupation. Most of the men ran small scale businesses and some were casual labourers; 2 men were formally employed. The ages of the nurse-midwife technicians were 30, 35 and 43 years. Years of experience in antenatal care for the nurse-midwife technicians ranged from 4 to 10 years.

We identified the themes based on the three domains related to learning needs which are content, organization and delivery of antenatal education. The themes are presented with subthemes as follows:

Benefits of content received

There was a general feeling among the participants and facilitators of couple antenatal education that the content covers all maternal health essentials.

“The sessions were good … all the things an expectant couple has to know were there … at the end of the sessions most men would come and say how good sessions were because most of them thought that it would just be a waste of time. They were even feeling sorry for those who did not come…” (Facilitator 1)

Participants further felt that providing couple antenatal education sessions was beneficial to both men and women for various reasons.

A. Couple antenatal education enhances communication, decision making and male partner support.

Participants expressed that because couples received the education together, both partners became knowledgeable. Additionally, it was easier to communicate and make decisions together; ultimately, the number of misunderstandings declined. Furthermore, male partners were able to provide the needed support. All men, women and facilitators were of the view that men were able to provide such support as the men trusted the information.

“I heard everything for myself … I was therefore making an effort to follow and do whatever we were taught because I knew it was true. I therefore decided to take part in the preparations for the birth of our child and also supported my partner in any way possible.” (Husband 9)

“It [couple education] helped us because we received the education together … we used to discuss and agree on what to do.” (Wife 1)

Additionally, couples felt that the information gathered enabled the participants to dispel some traditional myths associated with pregnancy.

“People believe a woman with swollen feet is expecting a male child. After receiving the education, I realized that swollen feet is a danger sign.” (Husband 10)

Although the content taught was adequate, a facilitator of the education expressed that name of the baby should be added to birth preparedness content.

“The information that needs to be included on birth preparedness should be the name of a child, which should aid in registration and preparation of birth certificates.” (Facilitator 3)

Furthermore, another facilitator observed that couples did not pay much attention to postnatal topics during the sessions.

“Things to do with the postnatal period … most people did not show interest, more especially on how to care for the woman and the baby after delivery.” (Facilitator 1)

Organization of couple antenatal education, realistic for male partner involvement

Participants gave their opinions about the day couple education was conducted, the number of sessions and the length of each session.

A. Friday, a suitable day for couple antenatal education

Couples, women and the facilitators expressed that Friday was a good day for education as it was near the weekend and it was easier for men to escort their spouse and attend the sessions.

“Friday was a good day because he (partner) was able to get time off from work. It was probably easy for him to be allowed time off because it was towards weekend.” (Wife 5)

“Friday was a very good day … because one can do things that can support his family during the other days…” (Husband 3)

“Friday was ideal because most men can find time on this day as they would have completed most of the work they had to do that week” (Facilitator 1)

Frequency of antenatal education for a male partner

Participants reported that the two sessions were adequate because couples managed to receive the needed information and it was more realistic for men to attend two sessions.

“They [two sessions] were enough because men are busy most of the time.” (Wife 6)

“I also believe that by assigning four sessions for the women and two for men they had also considered this as well.” (Husband 6)

However one of the facilitators felt that in order to increase participation of men in antenatal education, the number of sessions should be reduced from two to one and the duration of the session should be long enough to allow the couples have all the necessary information.

“…..maybe it could just be one session because men are busy and should be long enough to cover everything.” (Facilitator 3)

Duration for couple antenatal education appropriate for couples

Couples, women and facilitators expressed gratification with the duration for the first and second sessions which took approximately sixty and thirty minutes respectively. Participants felt that the duration was reasonable and men could accompany their spouses.

“The length of each session was adequate … Some people came from far and they were able to return home in good time.” (Husband 2)

However, all participants felt that while the sessions themselves were not time consuming, waiting times were.

“The time was alright but the problem is people come at different times while you have come here early and you had to wait for others.” Wife 8

Delivery of couple antenatal education incentive for male involvement

Participants also expressed their views on how the couple education was delivered.

A. Leaflet encouraged male partner's participation in antenatal education

Facilitators, couples and women accepted the leaflet provided and stated that it reminded them of what they learnt. Additionally, male participants reported that the leaflet motivated them to accompany their spouses for antenatal care.

“The leaflet reminded people what was discussed at the antenatal clinic…” (Facilitator 3)

“I was encouraged to attend the education sessions with my wife after reading the leaflet … If she didn't bring the leaflet … I could have refused to accompany her to the clinic.” (Husband 2)

Despite the leaflet's benefits, facilitators felt that that for it to be more user friendly for both literate and illiterate people, it should be in colour with large font sizes and graphics.

“The leaflet needs to be in colour … and should have drawings to help people who can't read understand the messages … the letters should be bigger for people who didn't go far with education to read easily.” (Facilitator 3)

Group couple learning facilitates learning

Women, couples and facilitators explained that group learning was a source of strength and it encouraged participation and learning. Furthermore, 1 male participant reported that group learning was interactive, stimulating and exciting and provided opportunities to create social networks which facilitated learning among male partners beyond the scheduled antenatal education sessions.

“I also feel that it is good to have couple group education. It encourages unity among couples and people understand better … A couple may be scared if invited to attend the education session alone … we formed some sort of friendship and we were able to discuss … (outside) the group whenever we met as friends.” (Husband 5)

“There was a difference between teaching a group of couples and a single couple. A couple that was taught as a unit was not free and open as compared to teaching a group of couples.” (Facilitator 2)

Despite the merits associated with group learning, all the participants observed that generally men were more open than women. A male participant observed that women were not actively participating when issues to do with sex were discussed.

“Women were open when topics on nutrition in pregnancy and swollen feet were discussed and were shy and quiet when topics on sex were discussed.” (Husband 10)

Discussion

The study has demonstrated that couple antenatal education was acceptable as it brought awareness and improved communication among couples, which led to male partners' support on safe motherhood practices such as birth preparedness and complication readiness (BP/CR). The findings are comparable with other studies which have demonstrated that male partners' knowledge of maternal health issues translated into joint decision making and male partners' support in maternal health practices23–25. Although adding name of a baby to the existing content on BP/CR would be good practice, this should be done with caution. Birth preparedness and complication readiness aim at reducing delays which contribute to poor access to maternal health services among women, ultimately reducing maternal mortality26,27. Adding the baby's name to the strategy may not assist in achieving the purpose of the strategy. We propose that the content for BP/CR should be split into two areas which should be birth and emergency preparation during maternity period. The former should cover preconception care including HIV testing and counselling, material for birth/birth kit, companion identification and naming the baby. The latter should focus on issues which can directly promote handling obstetrics emergencies, such as identifying a facility for delivery, keeping money and identifying a mode of transport28,29. We have omitted identifying blood donors because the Malawi Blood Transfusion Service is responsible for that.

In our study, participants were not interested in postpartum topics. This is contrary to findings from western countries where men and women wanted to learn postnatal issues during antenatal classes such as baby care skills, breastfeeding problems and relationships25,30,31. This lack of interest could be because, during pregnancy, people might only be interested in the pregnancy, delivery and its outcomes and might not see the significance of learning postnatal issues during pregnancy. Evidence suggests that postnatal services are almost nonexistent32,33 and that a substantial number of women and neonates are likely to die during the postpartum period in low income countries34, including Malawi. We therefore suggest that postnatal services need to be revived and strengthened in Malawi and additional sessions on postnatal issues should be provided to couples, a practice which exists in some high-income countries25,35.

In this study, Friday was recommended as the best day for couple antenatal education. This is congruent to findings from other studies which have reported men wanting to participate in antenatal education on weekends10,20. Another reason for the participants to prefer the education to be conducted on Fridays could have stemmed from the fact that antenatal clinics in our study settings conduct HIV tests on Mondays and Tuesdays which were booking days for the study sites respectively. Therefore, conducting the sessions on Fridays would not be associated with HIV testing, which has been reported widely as a factor hindering men from participating in antenatal care4,36,37. Participants felt that the duration of the sessions was adequate in the sense that they received relevant information in a short period of time. Conversely, some studies have reported sessions lasting less than one hour in sub-Saharan Africa38–41. Spending less time on antenatal education may have affected delivery of relevant topics during antenatal education thereby defeating one of the core aims of focused antenatal care strategy which promotes provision of health education and counselling to improve outcomes38,42. However, participants felt that waiting time for the other study participants and other antenatal services made them stay long periods at the facility. Time has been reported in several studies as a factor in deterring male partner involvement in antenatal care4,36,43. We suggest that couple antenatal education sessions should be scheduled on a determined day, which should be solely for this purpose. Antenatal sessions are usually conducted during morning hours. We suggest that the services be available all day in order to spread the flow of clients and prevent delays. Couples recommended group education; this coincides with other studies as it facilitates learning, creation of relationships and normalizes the presence of men in an environment traditionally dominated by women44–46.

In the study, women were not as interactive as men, especially when issues to do with sexuality were discussed; a finding which was also documented by Davis17. The reason for men being more active could be that they had little knowledge of childbirth and they wanted to learn more or verify what they knew. The compared lack of active female participation could also have arisen from the fact that women felt that they had escorted men and the messages were meant for men. Another reason could be that women did not want to talk to avoid embarrassing and disrespecting their spouses47. However, even in women-only groups, women have been reported to be ashamed and reserved when issues about sexuality are discussed during antenatal education48. This could be associated with power relations between the providers and clients who assume roles of health information giver and health information recipient respectively. We propose that providers should induce interaction during antenatal education sessions by creating relevant scenarios which can stimulate participation rather than focusing on giving of information in a didactic manner, as is the case in some African countries49. The leaflets distributed during education sessions facilitated learning as evidenced in other studies which have reported print material as a reliable source to facilitate learning50,51. Additionally, the leaflets might have acted as an invitation letter, which is known to encourage male partner participation in antenatal care52.

Strengths and limitations of the study

Men, women and facilitators were included in the study which allowed the researchers to have diverse views of the acceptability of couple antenatal education. Furthermore, the interviews were conducted with couples and some women from the couple group participated in separate interviews in order to enrich our data and to reduce bias. However, one limitation was that participants may have given biased responses since they were beneficiaries of the interventions and that the interviewer (MC) also participated in the intervention.

Conclusion

Couple antenatal education was acceptable among the couples and the facilitators in terms of content received, organization and delivery of the education sessions. Nevertheless, adding a discussion of the name of the baby on the list of topics, creating a special day for antenatal education and provision of a readable leaflet are likely to make couple antenatal education user friendly.