The association between male involvement in institutional delivery and women's use of institutional delivery in Debre Tabor town, North West Ethiopia: Community based survey.

BACKGROUND: Maternal deaths remain high in Ethiopia mainly due to poor maternal health service utilization. Despite men are the chief decision-makers and economically dominant in Ethiopia, the impact of their involvement on maternal health services utilization is not clear. This study aimed to assess the association between male involvement and women's use of institutional delivery, and factors influencing male partners' involvement in institutional delivery.
METHODS: A community based cross-sectional study was conducted between March and May, 2019. A total of 477 married men who have children less than one year of age were interviewed. Face-to-face interviews using a pre-tested and structured questionnaire were used for data collection. Bivariate and multiple logistic regressions were carried out. SPSS version 23 was used for data analysis.
RESULTS: Overall 181 (37.9%) husbands/partners were involved in institutional delivery for the most recent child birth. Male partners involvement in institutional delivery was strongly associated with an increased odds of attending institutional delivery by spouse [AOR: 66.2, 95% CI: 24.8, 177.0]. Education [AOR: 0.33, 95% CI: 0.18-0.59], knowledge on maternal health [AOR: 1.67, 95% CI: 1.11-2.50], favourable attitude towards institutional delivery [AOR: 1.83, 95% CI: 1.23-2.71], and no fear while supporting spouse [AOR: 2.65, 95% CI: 1.28-5.50] were positively associated with male partners involvement in institutional delivery.
CONCLUSION: Male partner's involvement in institutional delivery was inadequate. This study reported a significant beneficial impact of male involvement on maternal health through improved utilisation of institutional delivery. Therefore, maternal health interventions should target husbands as consumers of maternal health services, and healthcare/government policies that isolate or discourage men from having active engagement in maternal health should be improved.

Introduction

Maternal and newborn health is still major concerns worldwide. Globally, approximately 800 women die every day due to pregnancy or childbirth related complications, and almost all maternal deaths (99%) occur in developing countries [1]. In Africa and South Asia, it is the leading cause of death for women of reproductive age [1]. The risk of a woman dying in sub-Saharan Africa as a result of pregnancy or childbirth is 1 in 39, as compared to 1 in 4,700 in industrialized countries [1, 2]. Ethiopia, as a sub-Saharan African country, is characterized by high maternal mortality (412 per 100,000 live births) [3], and direct obstetric complications account for 85% of maternal deaths [4]. These complications could be prevented or treated by skilled care during pregnancy, childbirth, and postpartum period [5]. Despite these proven interventions, maternal health service utilization in Ethiopian is one of the lowest in the world. Institutional delivery (26%) and PNC (Post Natal Care) service use (17%) has remained very low, while the ANC (Antenatal Care) coverage has shown an increment (27% in 2000 to 62% in 2016) but it is still below the desired [3]. This poor maternal health services utilization highlights the challenges to further improve maternal and child health [6].

Reduction of maternal mortality is a global priority and skilled care before, during and after childbirth is the key to save the lives of women and newborn babies [7, 8]. However, maternal deaths continuing to be significant in developing countries due to limited maternal health service utilization [9, 10]. This clearly indicate that the potential for improving maternal health through increasing utilisation of these key services has not been fully addressed, and remains one of the key areas for research and subsequent intervention [6]. Globally, the big challenge of the effort to improve maternal health is male attendance of skilled ANC and delivery care [11]. In sub-Saharan Africa absence of support from the husband is one of the main reasons for many pregnant women not to seek maternity services [12]. This indicates that the characteristics of health delivery system, economic and geographic accessibility, and socio-demographic factors are not the only factors affecting the uptake of maternal health care [13]. Therefore, the concept of male involvement in maternal health is now being promoted as a new essential element of World Health Organization (WHO) initiative for improving maternal and child health [14]. International Conference on Population and Development recommend that special efforts should be made for involving men in maternal and child health [15]. However, the term ‘male involvement’ is subjective and very multifaceted [16]. Most studies defined male involvement as the active participation of men in maternal health services/care (attending maternal health service and support/help); while others defined it as providing financial support for pregnancy and childbirth related expenses. The remaining studies defined male involvement as shared decision-making on maternal health with wife [17]. In this study male involvement in institutional delivery is operationalized as the active participation of men in: accompanying for ANC, birth preparedness, encouraging for institutional delivery, and discussion with spouse, relatives and health professionals on place of delivery.

In most developing countries, the decision to seek care is usually made by male partners [18] and they are the chief providers which often determining women’s access to economic resources [19]. Similarly in Ethiopia, women traditionally enjoy little independent decision making on most individual and family issues, including the option to choose whether to give birth in a health facility or seek the assistance of a trained provider [20]. High male involvement stemming from knowledge of delivery process results in positive perception towards skilled birth care and involvement manifested through such actions as physical and emotional and financial support which will lead to good maternal health outcomes [21]. These practice has implications for maternal health as it determines the nutritional status of women during pregnancy [22]; women’s access to maternal health services since healthcare systems in most developing countries require out-of-pocket payments [23]; and women’s chances of receiving emergency obstetrics care, which is vital in averting maternal mortality [22]. Even though this situation makes husbands a critical partner for the reduction of maternal mortality, in many sub-Saharan Africa countries including Ethiopia, maternal and child health is viewed as a woman’s affair, and many studies on determinants of maternal health service utilization excluded men [18, 24].

Many studies have reported positive benefits of male involvement in maternal and child health including: increased uptake of maternal health care (ANC, institutional delivery, contraception use), decreased mother-to-child transmission of HIV, and improved maternal mental health [25-28]. However, other studies reported that it could occasionally lead to increased male dominance in decision-making, intimate partner violence, disruptions of family relationships and loss of economic support to women [28, 29].

Evidence suggests that male involvement may be beneficial to maternal health; however, the magnitude of the association is not clear and whether involving men in maternal health can improve maternal outcomes remains unclear [17, 30, 31]. There have also been speculations on possible negative impacts of male involvement in maternal health, hence it is necessary to explore the impact of male partner’s involvement on the female partner’s use of maternal health services in developing countries where the greatest burden of global maternal deaths and men’s dominant roles in these countries have been shown to influence health outcomes. In Ethiopia where maternal death, males economic dominance and decision-making power remained high, attempts to examine male partner’s involvement and its role on maternal health service utilization have been very limited, relying largely on socio-demographic and maternal characteristics [32, 33]. Thus, this study aimed to assess the association between male involvement in institutional delivery and women’s use of institutional delivery, and identify factors influencing male involvement in institutional delivery in Debre Tabor town, Ethiopia.

Methods

Study design and area

A community based cross-sectional study was conducted between March and May, 2019 in Debre Tabor town, North West, Ethiopia. It is the city of South Gondar Zone in Amhara Regional State and located 667 kilometres from Addis Ababa, capital of Ethiopia. The town is divided in to six kebeles (small administrative units) with an estimated total population of 65530 in 2018.

Population

The source population was all men in marital union with a women (legal, religious or traditional) having children less than one year of age and permanent residents of Debre Tabor town. All men in marital relationship having children less than one year of age and permanent residents of Debre Tabor town and selected during the study period were our study population.

Sample size and sampling procedure

Firstly, the required sample size was calculated using single population proportion formula based on the prevalence (41.9%) of male involvement in institutional delivery in Ambo town assuming 95% confidence level of Za/2 = 1.96, 5% of absolute precision, and 10% non-response rate [34] which yield sample size of 410. Moreover, sample sizes were calculated using factors associated with male involvement in institutional delivery, such as respondents’ knowledge and perceived cost of health service [34, 35]. Finally, the maximum sample size of 486 was taken to address all objectives of the study (Table 1).

Table 1

Sample size calculation based on factors affecting male partners’ involvement in institutional delivery.

S.no	Factors	Assumptions							Sample size
		Ratio	Power %	CI %	AOR	Involved among exposed	Involved among non-exposed	Design effect
1	Knowledge of respondents	2:1	80	95	2.9	79	56.4	1	173
2	Perceived cost of health service	2:1	80	95	1.79	45.3	31.6	1	441

All 6 kebeles found in Debre Tabor town was included and a total of 2098 households that fulfil the inclusion criteria were selected. The list of households that fulfils the inclusion criteria (households with fathers in marital relationship having children less than one year of age and permanent resident) was obtained from health extension workers. Based on the obtained information, the sample size for each kebeles was proportionally allocated. The sampling interval for each kebeles was calculated by dividing the number of households that fulfil the inclusion criteria for allocated sample size in that kebeles. Finally, the study subjects were selected by systematic random sampling using every kth interval. The first father was selected by lottery method and subsequent fathers were included randomly based on the interval through house to house visit.

Data collection

Data were collected by face to face interview technique using a structured and pre-tested questionnaire adapted from the survey tools developed by African Medical and Research Foundation (AMRF), Child and Reproductive Health Programme which is modified according to local context [36]. The questionnaire was prepared in English and translated into Amharic (the local language), and back into English to ensure consistency (S1 File). Six health extension worker and three BSc nurses was recruited as data collector and supervisors respectively. One day training was given for data collectors and supervisors on the techniques of data collection and purpose of the study prior to data collection.

As a data quality assurance measure, a pre-test was conducted on about 10% of the sample that has similar characteristics with the study population other than the sampled households in the study area before actual data collection period. The appropriateness and clarity of questions were checked and necessary modifications were made in terms of clarifying questions and vague terms, and removing items that were not aligned with the study objectives. Each item in the questionnaire was checked by the supervisor and the principal investigator on a daily basis to review the accuracy and completeness of variables. At the completion of data collection, all entered records were inspected for missing or incorrect values and data cleaning and coding was conducted before analysis by the principal investigator.

Measurement

Male involvement in institutional delivery was our primary outcome variable computed based on responses to six items: accompanying spouse for ANC, participating in birth preparedness plan, encouraging spouse for institutional delivery, discussion with health professionals on the place of delivery, discussion with relatives and friends about the place of delivery. Therefore, men who responded “yes” to 3 or more items were categorized as “involved” while those who responded “yes” to less than 3 items were categorized as “not involved”. Moreover, prior studies on male involvement in institutional delivery applied this approach of categorization [34-38]. Furthermore, place of delivery (institutional/home) for the last child was considered as another outcome variable to examine the association between male partners’ involvement in institutional delivery and women’s use of institutional delivery.

Knowledge on maternal health: Participants were asked 13 items on institutional delivery and signs of complication during pregnancy to assess their knowledge on maternal health. Men who responded correctly to 6 or more items were categorized as having “Good knowledge” while those who responded correctly to less than 6 items were categorized as “Poor knowledge” [39].

Attitude towards institutional delivery: Participants were asked to reflect their opinion on serious of six items concerning institutional delivery using likert scale with a score ranging from 1 = strongly disagree to 5 = strongly agree. Using the mean score as the cut-off point, above or equal to 3.0 was categorized as “favourable attitude” and below 3.0 was categorized as having “unfavourable attitude” [39].

Data analysis

Data were entered into Epi-data version 3.1 and exported to Statistical Package for Social Science (SPSS) version 23 for analysis. Descriptive statistics such as frequency mean and standard deviation was computed to describe variables of the study. Bivariate and multiple logistic regression analyses were fitted to assess the existence of association between male partner’s involvement and women’s use of institutional delivery. Another model was fitted to identify factors associated with male partners’ involvement in institutional delivery. For both models explanatory variables on bivariate logistic regression analysis with p<0.2 was entered into multivariable logistic regression analysis and a p-value of less than 0.05 was used to declare statistical significance.

Ethics approval and consent to participate

Ethical clearance was obtained from Institutional Review Board of Bahirdar University (IRB). Official letter of cooperation was obtained from the respective administrators in the study area. Informed written consent was obtained from individual participants before data collection. Confidentiality was strictly maintained throughout the process.

Results

Socio-demographic characteristics

Out of 486 estimated study samples, 477 had a full response and included in the analysis making a response rate of 98%. The mean age of study participants were 33.8 years with Standard Deviation (SD) of ±5.9 years; and the age range lies between 20 and 52 years. Regarding the level of education, 240 (50.3%) had diploma and above and the average monthly income of respondents were 3,241.9 Ethiopian Birr with SD of ± 1756 Birr (Table 2).

Table 2

Socio-demographic characteristics of study participants in Debre Tabor town, North-West Ethiopia, 2019 (n = 477).

Variables	Frequency	Percent
Age (years)
20–29	170	35.6
30–39	249	52.2
≥ 40	58	12.2
Religion
Orthodox	398	83.4
Muslim	52	10.9
Protestant	27	5.7
Ethnicity
Amhara	459	96.2
Oromo	10	2.1
Tigrie	8	1.7
Educational status
Diploma & above	240	50.3
Secondary education	110	23.1
Primary education	86	18.0
No formal education	41	9.0
Monthly income (ETB)
< = 1000	35	7.3
1000–2500	162	34.0
2501–5000	222	46.5
> = 5000	58	12.2
Occupation
Civil servant	246	51.6
Private employ	36	7.5
Business men	124	26.0
Unemployed	71	14.9

ETB = Ethiopian Birr

Health service utilization and accessibility related characteristics

Two hundred ninety (60.8%) men reported that their spouse gave birth in health institutions for their most recent birth. Majority of them (60.4%) made decision on place of delivery with their spouse jointly (Table 3).

Table 3

Health service utilization and accessibility related characteristics of respondents in Debre Tabor town, North-West Ethiopia, 2019 (n = 477).

Variables	Frequency	Percent
Frequency of ANC visit by spouse (for the youngest child)
Zero	282	59.1
One	116	24.3
Two	62	13.0
Three	11	2.3
Four	6	1.2
Place of delivery (for the youngest child)
Health institution	290	60.8
Home	187	39.2
Decision on place of delivery
Jointly with spouse	288	60.4
Spouse	156	32.7
Male partner	30	6.3
Other	3	0.6
Distance from health facility (reachable in 30 minutes)
Yes	364	76.3
No	94	19.7
I am not sure	19	4.0
Perceived cost of health service
Absolutely free	381	79.8
Affordable	74	15.5
Expensive	22	4.6

Knowledge on maternal health

More than one third (34.6%) of respondents were knowledgeable, while others (65.4%) have poor knowledge on maternal health. Majority of respondents know the signs of pregnancy complications (87.4%) and the importance of institutional delivery (69.4%) (S1 Table).

Attitude towards institutional delivery

In this study about 234 (49.1%) male partners had favourable attitude towards institutional delivery, while the rest 243 (50.9%) had unfavourable attitude (S2 Table).

Socio-cultural barriers for male involvement

This study identified several socio-cultural barriers that hinder male partners’ involvement in supporting their spouses to access institutional delivery. One third (33.5%) of respondents believed that child birth is a natural phenomenon that should not be given much attention and about 30% reported that it’s not our culture to discuss with wife about place of delivery (S1 Fig).

Male partners involvement in institutional delivery

Overall 181 (37.9%) husbands/partners were involved in institutional delivery for the most recent child birth (95% CI = 34%–42%). Discussion with relatives on the place of delivery (77%) and encouraging spouse for institutional delivery (76.5%) were the most common activities while discussion with health worker on place of delivery (36.9%) was the least common activity of involvement (Table 4).

Table 4

Male partners involvement in institutional delivery in Debre Tabor town, North-West Ethiopia, 2019 (n = 477).

Variables	Frequency	Percent
Accompany spouse for ANC follow-up
Yes	195	40.9
No	282	59.1
Birth preparedness support by male partners
Yes	330	69.2
No	147	30.8
Encourages institutional delivery
Yes	166	76.5
No	51	23.5
Discuss with health provider about the place of delivery
Yes	176	36.9
No	301	63.1
Discuss with relatives about the place of delivery
Yes	187	77
No	56	23
Discuss with friends about the place of delivery
Yes	165	67.9
No	78	32.1

The association between male involvement and women’s use of institutional delivery

Table 5 shows the association between male involvement in institutional delivery and women’s use of institutional delivery in Debre Tabor town. The bivariate logistic regression analysis identified age, education, occupation, income, fear of being seen by others, knowledge and attitude of male partners, and male partners involvement as a significant variable. However, in multiple logistic regression analysis, male involvement and knowledge on maternal health was significantly associated with women’s use of institutional delivery for the most recent birth.

Table 5

The association between male involvement and women’s use of institutional delivery in Debre Tabor town, 2019 (n = 477).

Variable	Institutional delivery		COR(95% CI)	AOR(95% CI)	P-value
	Yes	No
Knowledge on maternal health care
Poor	156(53.8)	156(83.4)	1	1	0.0000
Good	134(46.2)	31(16.6)	4.32(2.76–6.77)	5.854(3.18–10.78)
Male partner involved in institutional delivery
No	114(39.3)	182(97.3)	1	1	0.0000
Yes	176(60.7)	5(2.7)	56.2(22.4–140.1)	66.26(24.8–177.0)

COR = Crude odd ratio, AOR = Adjusted odd ratio, CI = Confidence interval

Male partners involvement in institutional delivery appeared to be strongly associated with an increased odds of attending institutional delivery by spouse [AOR: 66.2, 95% CI: 24.8, 177.0] as compared to those men not involved. Moreover, women with knowledgeable male partners had about 6 times [AOR: 5.8, 95% CI: 3.18, 10.78] more odds of using institutional delivery when compared to women whose partner had poor knowledge on maternal health (Table 5).

Factors associated with male involvement in institutional delivery

Table 6 shows factors associated with male partner’s involvement in institutional delivery at Debre Tabor town. Age, education, occupation, income, fear of being seen by others, knowledge and attitude of male partners towards maternal health were significant variables on bivariate logistic regression. After adjusting for the effect of confounding variables in the multivariate analysis, educational status, knowledge on maternal health, attitude towards institutional delivery and socio-cultural barriers (fear of being seen by others) were significantly associated with male’s involvement in institutional delivery.

Table 6

Factors associated with male partner’s involvement in institutional delivery at Debre Tabor town North-West Ethiopia, 2019 (n = 477).

Variable	Male involvement		COR(95% CI)	AOR(95% CI)	P-value
	Yes (n = 181)	No (n = 296)
Education
Diploma and above	116(64.1)	122(41.2)	1	1	1
Secondary education	30(16.6)	80(27.1)	0.39(0.24–0.64)	0.44 (0.27–0.73)	0.001***
Primary education	19(10.5)	67(22.6)	0.30(0.17–0.53)	0.33 (0.18–0.59)	<0.001***
No formal education	16(8.8)	27(9.1)	0.62(0.32–1.22)	0.62 (0.31–1.23)	0.171
Knowledge on maternal health
Good	79(44)	86(29.1)	1.89(1.29–2.78)	1.67(1.11–2.50)	0.014*
Poor	102(56)	210(70.9)	1	1
Attitude on institutional delivery
Favourable	112(61.9)	131(44.3)	2.04(1.40–2.98)	1.83(1.23–2.71)	0.003**
Unfavourable	69 (38.1)	165(55.7)	1	1
Fear of being seen by others
Yes	24(13.3)	14(4.7.)	1	1
No	157(86.7)	282(95.3)	3.08(1.55–6.12)	2.65(1.28–5.50)	0.009**

COR crudes odds ratio, AOR adjusted odds ratio,

* Significant at P<0.02;

** Significant at P<0.01;

*** Significant at P≤0.001

Male partners who attend primary [AOR: 0.33, 95% CI: 0.18–0.59] and secondary education [AOR: 0.44, 95% CI: 0.27–0.73] had lower odds of involvement in institutional delivery as compared to those partners who had diploma and above.

Male partners with good knowledge on maternal health [AOR: 1.67, 95% CI: 1.11–2.50] and favourable attitude towards institutional delivery [AOR: 1.83, 95% CI: 1.23–2.71] had a higher odds of involvement in institutional delivery as compared to those partners who had poor knowledge and unfavourable attitude. Furthermore, male partners who did not fear others while supporting spouse had more than 2 times [AOR: 2.65, 95% CI: 1.28–5.50] odds of involvement in institutional delivery than those who fears while supporting spouse (Table 6).

Discussion

This study investigated the association between male involvement in institutional delivery and women’s use of institutional delivery, and identified factors associated with male involvement in institutional delivery among fathers who have children less than one year of age in Debre Tabor town, Ethiopia. In this study male involvement in institutional delivery was considered as the active participation of men in: accompanying spouse for ANC, birth preparedness, encouraging for institutional delivery and discussion with spouse, relatives and health professionals on place of delivery. Based on this we found that 37.9% of male partners were involved in at least half of total six activities of involvement for institutional delivery and studies which defined male involvement similarly reported closer level of involvement in Lemo woreda (38.2%) [35] and Ambo town (41.9%) [34], Ethiopia. This low level of involvement could result from low knowledge (34.6%), unfavourable attitude towards institutional delivery (50.9%), and socio-cultural barriers reported by this study. Generally, this inadequate male involvement in a country like Ethiopia with poor maternal health services utilization highlights the challenges to further improve maternal and child health.

Regarding the specific activities of involvement, the current and previous studies shows that substantial proportion of male partners were involved in accompanying spouse for ANC and supporting birth preparedness, suggesting similar pattern of involvement by males partners across different setting in Ethiopia. In contrary, discussion with relatives on place of delivery was the most common activity of involvement in this study (77%) while it is the least common activity of involvement in Lemo woreda (15%) [35] and Ambo town (34.8%) [34]. This might be due to socio-cultural variation and rural setting of Lemo woreda which implies that priority should be given for improving awareness of male partner’s on institutional delivery through community based health education in these settings.

This study examined the role of male partner involvement in institutional delivery as a determinant factor for female partners’ utilization of institutional delivery from father’s perspective. We found a statistically significant beneficial impact of male involvement on maternal health through improved utilisation of institutional delivery. Women whose husband involved in institutional delivery had more odds of attending institutional delivery than those whose husband were not involved; which implies the need to consider men as part of the solution and also to improve healthcare/government policies that isolate/discourage men from having active engagement in maternal health programs [23]. It is consistent with the findings of several studies in sub-Saharan Africa and elsewhere [17, 40–43], which suggested male partners’ involvement in maternal health care during pregnancy has benefits on maternal health care services access and utilization. Other studies also have linked male partners’ attendance to ANC with increased maternal health service utilization [17, 42]. This could be explained by the fact that the active involvement of male partners makes them more aware of the significance of maternal health care services which in turn makes them more likely to encourage and support their wives to use them [17, 40, 44]. In a developing country setting, this acquired knowledge could also translate into the husbands’ grant of permission and provision of resources for accessing maternal services such as financial support for maternal health care services. On the other hand, the observed (60.4%) joint decision making with spouse on place of delivery in this study may contribute for the above strong association between male involvement and women’s use of institutional delivery as shared decision-making on maternal health with wife is considered one features of male involvement.

Furthermore, the current study investigated factors affecting male partners’ involvement in institutional delivery. We found that education, knowledge and attitude on maternal health and socio-cultural barriers have a significant influence on male involvement. Male partners’ involvement in institutional delivery was shown to increases with increase in educational level of male partners, which reinforces the significant role that education plays in improving utilization of maternal health service. This finding is similar to the studies carried out in in Ethiopia [34, 45], Keyna [46] and Nigeria [47]. This is due to the fact that education leads to better health awareness, and may contribute for timely health care seeking and economic capability required.

This study showed that male partners who had good knowledge on maternal heath were more likely involved in institutional delivery than those who had poor knowledge which is consistent with other studies conducted in Lemo woreda [35], Ambo town [34] and Mareka woreda, southern, Ethiopia [45]. Those with good knowledge may understand well the possible birth complications; so that they encourage their spouses to give birth in health institutions. Similarly, male involvement was significantly higher among men’s who showed favourable attitude towards maternal health service utilization. This was in line with other studies conducted in Ethiopia and Nigeria [35, 48]. The fact that husbands’ positive perception on benefit of maternity care might lead to higher level male partners’ participation. These findings point to the important roles of partner’s knowledge and attitude in influencing their involvement in institutional delivery which suggest a need to recognize husbands as clients of maternal care services and to understand possible complications related to pregnancy and childbirth.

Cultural norms shape the perception of individuals and subsequently engaging in positive health behaviour like male involvement in institutional delivery. This study showed that male partners who didn’t fear others while accompanying their spouse to health facilities had more odds of getting involved in institutional delivery than those who fear others. This finding was supported by other studies in Africa which reported that existing cultural norms result in undesirable reactions from family and peers of male partners, which precludes them from participating in maternal processes including skilled birth care [46, 49]. It could be related to the findings of this study which reported the most frequently mentioned socio-cultural barriers for male involvement were: considering child birth as a natural phenomenon that should not be given much attention and their culture did not allow them to discuss with wife about place of delivery. Therefore, it could be due to a reason that many societies and cultures treat pregnancy and child-birth as solely a women’s issue and this may have contributed to men not being invited to learn about and engage in matters related to women’s and children’s health [50].

Previous studies mostly focused on the positive benefits of male involvement in maternal and child health; however, the magnitude of the association is not clear. This study assesses the impact of male partner’s involvement on the female partner’s use of institutional delivery. Our findings showed that active participation of men appeared to have more impact on women’s utilisation of institutional delivery. This study also reinforces the findings on the significant influence of education, knowledge and attitude on maternal health and socio-cultural barriers on male involvement in institutional delivery. The impact of male partner’s involvement on maternal and childbirth outcomes, how men could have better involvement and the time of involvement (during pregnancy, delivery and postpartum period) merit further investigations.

The findings of this study need to be interpreted in the light of some limitations. It was difficult to explore the contextual and social factors that may limit male partner involvement as it is quantitative in design. We relied on verbal reports of fathers in relation to male involvement in institutional delivery. This has the tendency for the respondents to over report good behaviour as participants may want to provide socially desirable responses. Also, recall bias could have been present as pregnancy may not represent as much significance to the male partner as it does to the female.

Conclusion

Male partner’s involvement in institutional delivery was inadequate. This study reported a significant beneficial impact of male involvement on maternal health through improved utilisation of institutional delivery. It implies the need to shift from women-only maternal health services to ‘male-friendly’, couple services, and also to improve healthcare/government policies that isolate/discourage men from having active engagement in maternal health. Education, knowledge and attitude on maternal health and socio-cultural beliefs were factors associated with male partner’s involvement in institutional delivery.

Therefore, maternal health interventions should target husbands as consumers of maternal health services and efforts should be made to improve awareness of the male partner’s on institutional delivery through community based health education.

Socio-cultural barriers for male partners’ involvement in institutional delivery in Debre Tabor town, North-West Ethiopia, 2019.

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Male partners knowledge on maternal health in Debre Tabor town, North-West Ethiopia, 2019 (n = 477).

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Male partners attitude towards institutional delivery in Debre Tabor town, North-West Ethiopia, 2019 (n = 477).

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Questionnaire.

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Dataset.

(SAV)

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29 Jan 2021

PONE-D-20-32675

Male partners’ involvement in promoting institutional delivery and its effect on the actual place of delivery in Debre Tabor town, North West Ethiopia: community based survey

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #2: No

Reviewer #3: No

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5. Review Comments to the Author

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Reviewer #1: Thank you for the opportunity to review this manuscript

An interesting study drawing on the views of local participants to understand why men do not regularly participant in MCH care. It's strengths are a clear presentation of findings, however it lacks clarity and detail in relation to the rationale for the study, methods used and implications of the findings. There are minor grammatical errors and typos throughout.

Introduction:

More detail needed on the possible impact of increased male partner involvement. Are there studies which show the impact that increased male involvement can have? What does male involvement look like (e.g. attending appointments, births etc)?

The necessity of the study is in question. Still feel like the background does not provide for a clear problem statement. Together, I would suggest the authors during their write up to consider using recent references especially those from countries with similar maternal mortality rates to Ethiopia.

Why is a study in Debre Tabor town important? Can the authors tell us about maternal and child morbidity/mortality rates there? How might the findings be relevant to the international audience? This is referred to later but a line or two at the end of the introduction would clarify the importance of the study and allow the reader to determine whether the paper is relevant to them.

Methods:

Please clarify how was male involvement defined?

The description of the outcome variable is not clear. It would be important to clarify that the variable was computed based on responses to [number of items] items: as listed and having at least 6 times [provide a comprehensive list]. It would also be important to clearly state that men who responded yes to n or more items were classified as being “? involved” while those who respondent yes to n-1 or fewer items were classified as being “less ? involved”. If there is a citation to support the coding of the variable in this way, it should be provided.

Results:

Needs to be re-written as it's extremely long, check language issues in the tables as well as avoid replicating results into the discussion section. Revisions In the tables, the total N should be included in each table. In all tables, are multiple responses included? Some editing is required

Discussion

Their interpretation of the implications of this finding is also flawed – the discussion seems a bit repetitive with more focus on restating the findings rather than discussing implications for the findings or possible future directions related research could take based on the findings. If the authors can be clearer about the added value of their study, or the importance for their setting. It would help to have a clear idea of the purpose behind the current objectives. The similarities and differences of this study needs to be brought out more clearly so that the reader can see how it adds to the current evidence. The discussion section should also include methodological issues or limitations.

The study does not give clear implications in the conclusion or recommendations. If the study provides similar findings as other studies, where is the problem? What is the explanation for this? What should be done about this situation? What should be the next logical step to address this issue? Recommendations for practice and future research should be included.

I noted that you used different reference styles so kindly use only PLOS ONE reference style through out the entire manuscript

Please provide a copy of the interview questionnaire used in this study as an additional file.

Reviewer #2: This paper seems to be a fair summary of literature on Male partners’ involvement in promoting institutional delivery and its effect on the

actual place of delivery in Debre Tabor town, North West Ethiopia: community based survey Methods of identifying relevant studies for review are thoroughly explained. My only concerns are as follows;

An English editorial correction is needed

No scientific concern noted in then article.

Reviewer #3: Comments to the Author

Thank you for the opportunity to review this article, which addresses an important and under-researched topic: namely, the role that male partners play in promoting institutional delivery, and by extension, female reproductive health outcomes. The study found that in North West Ethiopia, male spouses’ involvement in promoting institutional delivery was a strong predictor of institutional delivery, and that factors such as education, maternal heath knowledge, and favorable attitudes toward institutional delivery and spousal support were significantly associated with their involvement. As the authors note, many studies on maternal healthcare utilization exclude men, and I find this piece novel and refreshing for its attention to men’s perspectives and experiences. That said, I have several suggestions the authors might consider in order to strengthen the manuscript.

First, I wonder if the authors could ground their study a bit more in the existing literature on the topic of male partner involvement in promoting female reproductive health. To start, it would be helpful for them to define what is mean by the term “male partner involvement” in this context. How are men expected to ensure women’s and children’s health? Does it refer to men attending ANC appointments, being present at time of delivery, arranging transport and payment of clinic fees, etc., or does “involvement” go beyond this rather narrow, biomedical framing? Second, could you be clearer as to why and how male involvement/support is so important for female reproductive health? You mention the role of men in decision-making regarding healthcare seeking, but could you say more? The article you cite stating the lack of evidence on this theme is from 2012 and I think you’ll see that since this time, quite a bit has been published on the topic of male partner involvement, including a number of intervention studies and those assessing factors that either encourage/discourage men from becoming involved in this arena. I would also recommend that you contextualize the issue within Ethiopia a bit more. What is the burden of maternal and child morbidity/mortality in this context? What factors influence poor reproductive health outcomes, including low rates of institutional delivery?

As for your methods section, there are some important details that are missing and/or unclear. For instance, in your abstract you mention that the study included married men who have children less than one year of age, but in the Population section of your Methods, you just indicate “all male partners.” How are you defining “male partner”? This is an important distinction to make, as I would imagine marital status would influence the extent of men’s involvement/influence on women’s reproductive health. Additionally, I am wondering why you chose only to include men with children one year of age and below? Does this have to do with recall bias?

Where were data collected – i.e. were participants interviewed in their homes or within a health facility? What was the specific random sampling technique utilized (how did you choose where to start) and what kind of systematic technique was used thereafter? When you mention that data were collected using a questionnaire adopted from previous studies (pg. 6, line 79) can you cite these previous studies or say more about them? Also, how were they adapted? Did adaptation go beyond simple translation, and if so, how?

I also think there is much room for your discussion section to be strengthened. As currently written, it contains much repetition of your findings, and also mostly focuses on how your findings are similar to those of other studies. I would like to see you emphasize more that which differentiates your study. What new knowledge does it add to the literature? And going a step further, I think you could speak more specifically to the implications of your findings for policy and programming. Clearly, you can conclude that interventions promoting greater institutional delivery would do well to involve men, but you could also speak to why and how men could be better involved. Your findings regarding joint decision making by couples seem really important here; perhaps interventions should strive to be more gender inclusive? Further, how might policies be enacted to help address some of the barriers to men’s participation that you’ve identified in this study? Do you think other barriers – beyond knowledge and attitude – might need to be addressed? What about time and cost-related factors that may prevent men from becoming more involved in the biomedical encounter? Again, I think this comes back to the question of defining what “involvement” means, as I mentioned earlier.

On a smaller note, you say that men’s involvement in maternal health is “culturally discouraged and remains an important barrier” (pg. 17, line 246) but then you cite a study from Nepal. Can you speak to what current literature from sub-Saharan Africa suggests, and particularly those studies conducted in Ethiopia? Why is men’s participation socially discouraged in this context? Around line 282 you mention men may fear “being ruled” by their wives. Where does this explanation come from, can you cite this? Further, I would encourage you to consider how gender norms are not static but constantly changing. Is there any evidence to suggest that gender norms around male participation in the female reproductive sphere are shifting? And if so, in light of what factors?

Finally, there are a substantial number of issues relating to grammar or awkward wording that require editing. I would highly recommend careful editing during the revision process, perhaps in conjunction with a professional copyeditor. This is needed, as it’s disrupting the flow of what is otherwise an important study.

Minor comments

Pg. 3, line 2 (Introduction) – the first sentence does not make grammatical sense. Try “in which many women are exposed”

The next two sentences of the Introduction need citations.

Pg. 3, line 10 – I would specify that you mean 85% of *maternal deaths

Pg. 7, lines 95-97: I would recommend referring your readers to Table 4 here in case they are wondering how you’re measuring “knowledge about maternal health.” The same goes for “partner attitude” with respect to Table 5.

Pg. 8, line 124: Could you contextualize respondents’ average monthly income for those of us unfamiliar with Ethiopian currency? Are participants able to meet their daily needs with this level of income? How does it compare to the rest of the country?

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Reviewer #1: Yes: Richard KALISA MD, PhD

Reviewer #2: Yes: Brian Barasa Masaba

Reviewer #3: No

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Submitted filename: PONE-D-20-32675.docx

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Submitted filename: ethiopia-male.docx

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12 Mar 2021

All comments raised by academic editor and reviewers were incorporated.

Submitted filename: Response to Reviewers.docx

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29 Mar 2021

The association between male involvement in institutional delivery and women's use of institutional delivery in Debre Tabor town, North West Ethiopia: community based survey

PONE-D-20-32675R1

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Reviewers' comments:

1 Apr 2021

PONE-D-20-32675R1

The association between male involvement in institutional delivery and women’s use of institutional delivery in Debre Tabor town, North West Ethiopia: community based survey

Dear Dr. Wondie:

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