Men's and women's knowledge of danger signs relevant to postnatal and neonatal care-seeking: A cross sectional study from Bungoma County, Kenya.

BACKGROUND: Neonatal and maternal mortality rates remain high in Kenya. Knowledge of neonatal danger signs may reduce delay in deciding to seek care. Evidence is emerging on the influential role of male partners in improving maternal and newborn health. This study analysed the factors that determine men's and women's knowledge and practices in postnatal and neonatal care-seeking, in order to inform design of future interventions.
METHODS: A quantitative, cross-sectional study was undertaken in Bungoma County, Kenya. Women who had recently given birth (n = 348) and men whose wives had recently given birth (n = 82) completed questionnaires on knowledge and care-seeking practices relating to the postnatal period. Univariate and multivariate logistic regression analyses were performed to investigate associations with key maternal and newborn health outcomes.
RESULTS: 51.2% of women and 50.0% of men knew at least one neonatal danger sign, however women knew more individual danger signs than men. In the univariate model, women's knowledge of a least one neonatal danger sign was associated with attending antenatal care ≥4 times (OR 4.46, 95%CI 2.73-7.29, p<0.001), facility birth (OR 3.26, 95%CI 1.89-5.72, p<0.001), and having a male partner accompany them to antenatal care (OR 3.34, 95%CI 1.35-8.27, p = 0.009). Higher monthly household income (≥10,000KSh, approximately US$100) was associated with facility delivery (AOR 11.99, 95%CI 1.59-90.40, p = 0.009).
CONCLUSION: Knowledge of neonatal danger signs was low, however there was an association between knowledge of danger signs and increased healthcare service use, including male partner involvement in antenatal care. Future interventions should consider the extra costs of facility delivery and the barriers to men participating in antenatal and postnatal care.

Introduction

The 2030 Agenda for Sustainable Development emphasises the need to reduce preventable newborn deaths and the maternal mortality ratio [1]. Kenya’s neonatal mortality rate (NMR) is 22 deaths per 1,000 live births, and Kenya’s maternal mortality ratio (MMR) is 510 deaths per 100,000 live births [2]. This represents a major challenge if the Sustainable Development Goal targets of a NMR of 12 per 1,000 live births or lower, and an MMR of less than 70 per 100,000 live births [3], are to be met. Moreover, whilst worldwide under-5 child mortality has been declining, NMR has been reducing at a much slower rate, highlighting the need for urgent attention [4].

Low knowledge of obstetric and neonatal danger signs is widely reported throughout low- and middle-income countries [5-8]. JHPIEGO’s birth preparedness and complication readiness framework proposes that increasing knowledge and awareness of these danger signs will improve problem identification, and thus will reduce the delay in deciding to seek care [9, 10]. Furthermore, caregivers’ ability to recognise danger signs has been linked with use of antenatal care (ANC) and skilled birth attendance [7, 11, 12].

The importance of skilled birth attendance at every childbirth is widely recognised [11, 13], and has been described as the most significant single factor in averting maternal deaths [14]. Most maternal deaths occur at the time of labour, delivery and the immediate postpartum period [15], with 46% of all maternal deaths and 40% of all stillbirths and neonatal deaths occurring during the period of labour and the day of birth [16]. The importance of ANC during pregnancy is recognised in the World Health Organization’s (WHO) revision of global ANC standards; from 2016 recommending eight ANC contacts throughout pregnancy [17]. However, in low-resource settings often less than half of women attend the pre-2016 recommendation of at least four ANC visits [8, 12, 18]. ANC is a crucial intervention in improving birth outcomes and reducing neonatal mortality [19], and is associated with increased likelihood of skilled delivery [20].

The Kenyan Government’s commitment to improving maternal and newborn health outcomes is demonstrated by the 2013 Free Maternity Services Policy [21, 22], whereby maternal health services are delivered at no cost throughout the primary, secondary and tertiary government health sector [23]. Analysis of this policy shows that it has successfully started to increase facility deliveries, however challenges including knowledge and physical accessibility of the facilities still remain: it is clear that additional factors beyond cost affect uptake of facility-based care for pregnancy and childbirth [24]. Our research therefore seeks to understand the additional determinants of ANC use and childbirth occurring in a facility, especially those relating to women’s and men’s perspectives.

Male involvement

Since the 1994 International Conference on Population and Development, there has been increasing recognition of the shared rights and responsibilities of women and men in sexual and reproductive health, including the critical role of male partners in maternal and child health [3]. The WHO has listed male involvement as a key health promotion intervention for maternal and newborn health [25, 26]. It is recommended that men are engaged in health services and optimal home practices during pregnancy, childbirth and also after birth, however the level of evidence for interventions is low; resulting in calls for further research into the impacts of male involvement strategies on health outcomes [25, 27].

Strict definitions of what male involvement entails are not yet broadly agreed [27-29], however one elementary indicator is whether men participate in antenatal care visits [28]. The WHO recommendations stipulate that male involvement interventions ought to be culturally specific and thus may differ depending on the context [25, 26]. An important factor, however, is ensuring that male involvement interventions continue to promote, or at least not detract from, female autonomy and decision-making [25, 26, 30]. Pregnancy and childbirth are especially complex because these topics are often considered to be women’s business [30], but men are often household decision makers in relation to care-seeking [27, 28].

Collaborative Newborn Support Project

The ‘Collaborative Newborn Support Project’ has been implemented in Bungoma County, Kenya in order to reduce maternal and neonatal mortality from October 2015 to April 2019. It is an intervention of quasi-experimental design, involving newborn special care units, telehealth, call centre establishment, neonatology training, and community awareness programs [31]. The cross-sectional study reported here forms part of the ‘Collaborative Newborn Support Project’ and aimed to inform interventions through an assessment of men’s and women’s knowledge and practices relating to pregnancy and postnatal care.

Methods

Study design

This is a descriptive cross-sectional survey of women and men involved in the ‘Collaborative Newborn Support Project’, Kenya [31].

Study setting

The study was undertaken in Bungoma County, Kenya. Bungoma County is located in Western Kenya, bordering Uganda, and has a population of 1.67 million people [32], mostly subsistence farmers [31], with only 11.3% of the population live in urban areas (2019 census) [33]. The project team believed it important to assess knowledge attitudes and practices of rural populations who were potential users of the hospitals in the broader project.

Study population

Women and men from the same geographic area were recruited independently, meaning that the responses to each questionnaire are not linked as mother-father dyads. In total, 82 men and 348 women participated in the study, based on the data collection resources available to the project team. Men whose female partners had delivered within the previous one year (between April 2016 and April 2017) were recruited through convenience sampling, from those accompanying their female partners to healthcare clinics, and from men in market centres that fell within the regular catchment area of the facilities involved in the ‘Collaborative Newborn Support Project’, Kenya [31]. Women who had recently delivered were recruited at antenatal and postnatal reproductive care units, and in maternal and child health clinics at two health facilities: Bungoma and Webuye hospitals. These facilities were purposively sampled, based on the fact that they are County and Sub-County referral hospitals respectively, and involved in the broader project intervention.

Data collection

Two questionnaires were administered, one to the women’s sample and the other to the men’s sample. These were adapted and abridged from the JHPIEGO birth preparedness and complication readiness tool sample questionnaires [9]. Both questionnaires covered basic socio-demographic factors and asked similar questions about knowledge, attitudes and practices relating to maternal and newborn health; however, these weren’t identical between the two surveys. Specific questions on danger signs in the postnatal period for woman or newborn classified these as Vaginal bleeding, Neo-natal sepsis, Jaundice, Convulsions, Asphyxia, High fever, Congenital problems, Difficulty breathing, Severe weakness, Changed activity, Bleeding umbilical cord, Poor breastfeeding, and free-text fields for other options. Data were collected by research assistants over a three-month period in 2017. The questionnaires were in English and Kiswahili. Research assistants translated the questions into local dialect whenever necessary. Following collection, the data were transferred to an Access database and archived in Mount Kenya University servers within the Directorate of Research and Innovation.

Data analysis

The data were cleaned and analysed using Stata 13 [34] to find summary statistics and to undertake univariate and multivariate logistic regression analyses. Complete case analysis was used in regression analyses. Some variables were grouped to dichotomous responses, based on analysis team consensus, to ensure no group was too small for regression analysis. The common approach of interpreting a p-value of less than 0.05 as indicating statistical significance was taken.

Although questions were not completely uniform across the two questionnaires, where possible we used similar variables across both data sets in the analysis to allow the contrast of women’s and men’s knowledge and practices. Outcome variables examined in the logistic regression analysis covered both knowledge and practices. There was insufficient variability in the data to include attitudes in the final analysis.

Univariate associations were tested between outcome variables and hypothesised factors of association, as determined by similar studies and the availability of data from the questionnaires. These were then included in a multivariate model to control for the effects of confounding. Potential confounding factors included in the women’s multivariate model were women’s and men’s age and education levels, monthly household income, time to healthcare facility, gravidity, age at first pregnancy and shared decision making for health service seeking between woman and male partner. Potential confounding factors included in the men’s multivariate model were women’s and men’s age and education level, and monthly household income. Outcomes considered to be on the causal pathway between exposure and outcome were included in univariate models, but not in multivariate models.

Ethical considerations

This study was approved by the Mount Kenya University Ethics Review Committee (MKU/ERC/0096). Participants signed informed consent forms after the aims and research process were explained to them, prior to undertaking the questionnaire.

Results

Socio-demographic characteristics

Women’s sample

Half of women were under 25 years of age (49.4%) with most of their husbands at least 30 years of age (67%). Over a third were first time mothers (38.2%) and around half had completed secondary school or higher (54.8%). Women reported their husbands as slightly higher educated, with 68.7% having completed secondary school or higher (at least 12 years of formal school). 63.3% lived in households with a monthly income at or above 10,000 KSh (approximately USD100). More than half (59.1%) lived more than 5 kilometres away from the nearest health facility. Over a third of women reported sharing pregnancy and childbirth decision making with their husband (38.8%), with the rest either making the decision themselves, their husband making the decision without them, or the decision was made by another family member, such as a mother in law (Table 1).

Table 1

Socio-demographic characteristics of the women’s and men’s samples.

	WOMEN		MEN
	n = 348		n = 82
	N	%	N	%
Woman’s age (years)
<25	172	49.4	25	30.5
≥25	176	50.6	57	69.5
Woman’s median age	25 years		28 years
Man’s age (years)
<30	74	33.0	23	28.1
≥30	150	67.0	59	71.9
Man’s median age	30.5 years		33.5 years
Woman’s highest level of education completed
Primary school or less	157	45.2	28	34.2
Secondary school or greater	191	54.8	54	65.8
Man’s highest education level completed
Primary school or less	74	31.3	20	24.4
Secondary school or greater	163	68.7	62	75.6
Monthly household income (KSh)
<10,000	79	36.7	16	19.5
≥10,000	136	63.3	66	80.5
Distance to healthcare facility from home
≤5 kilometres	141	40.9
>5 kilometres	204	59.1
Gravidity
Primigravida	129	38.8
Multigravida	209	61.2
Age at first pregnancy
<18	85	25.0
≥18	255	75.0
Shared decision making for health service seeking between mother and male partner
No	211	61.2
Yes	134	38.8

* Note that the women’s and men’s cohorts were not recruited in the same way and are therefore not entirely comparable.

Men’s sample

Since the women’s and men’s cohorts were not recruited in the same way, they represent comparable, but not matched, populations. Sampled male respondents, along with their wives, tended to be slightly older, more educated and in higher income households than those in the women’s sample. Most men were 30 years of age or older (71.9%), with most of their wives at least 25 years of age (69.5%). Three quarters of the men had completed secondary school or higher (75.6%), while 65.8% of their wives had completed secondary school or higher. Most households had a monthly income of over 10,000 KSh (80.5%) (Table 1).

Women’s and men’s knowledge and practices relating to pregnancy and postnatal care

Just over half of the women (51.2%) knew at least one neonatal danger sign, with over a third of women reporting that their newborn had experienced problems after childbirth (39.1%). Half of those women who had experienced a problem sought care within an hour of noticing the newborn was ill (53.2%), however, 30.6% waited for more than six hours before seeking care. Regarding antenatal care, 39.1% of women attended at least four times during the last pregnancy. Most women delivered in a healthcare facility (79.2%), be that a government hospital or a private clinic. In the men’s sample, 40.2% of the men knew at least one postpartum danger sign and half (50.0%) knew at least one neonatal danger sign. 51.2% of men accompanied their wife to antenatal care during her most recent pregnancy, either always, most of the time or sometimes. Almost all men reported that their wife’s last childbirth was in a healthcare facility (90.1%), with two thirds accompanying their wife to health facility for delivery (66.2%). Most deliveries occurred in a government hospital (79.0%) and were attended by a nurse or midwife (73.8%) (S1 Table).

Identification of neonatal danger signs

Fig 1 illustrates that overall the sample of women could identify a larger number of danger signs than the men, although a similar proportion of women and men were not able to identify any neonatal danger signs (48.8% of women, compared to 50.0% of men). Each individual danger sign was identified by a greater percentage of women than men. Some danger signs were identified approximately twice as frequently by women than by men, such as poor breastfeeding or not able to breastfeed, fast breathing, fever, and difficult to wake, lethargic or unconscious.

Fig 1

Identification of neonatal danger signs: Women and men*.

Characteristics associated with knowledge of neonatal danger signs

Characteristics associated with women’s knowledge

Higher levels of woman’s education (AOR: 5.65, 95% CI: 1.88–17.04, p = 0.002), higher household income (AOR: 4.35, 95% CI: 1.74–10.88, p = 0.002), multigravidity (AOR: 4.66, 95% CI: 1.52–14.36, p = 0.007), and older age at first pregnancy (AOR: 3.24, 95% CI: 1.00–10.52, p = 0.05) were all significantly associated with woman’s knowledge of at least one neonatal danger sign, after adjusting for confounding (S2 Table).

Characteristics associated with men’s knowledge

Higher household income, at or above KShs 10,000 per month, was significantly associated with men’s knowledge of at least one neonatal danger sign (AOR: 4.09, 95%CI: 1.00–16.64, p = 0.049) (S3 Table).

Characteristics associated with health care-seeking practices

Characteristics associated with women’s care-seeking

Women who shared care-seeking decision making with their husband had increased odds of attending antenatal care at least four times throughout their most recent pregnancy (AOR: 2.27, 95% CI: 1.10–4.67, p = 0.027). Women who knew at least one neonatal danger sign had increased odds of attending four or more antenatal visits during their last pregnancy, compared with those who did not know any neonatal danger signs (unadjusted OR: 4.46, 95% CI: 2.73–7.29, p<0.001) (S4 Table).

Women who completed secondary school or higher had increased odds of birth in a healthcare facility, compared with those who had completed primary school or less, after adjusting for confounding (AOR: 4.24, 95% CI: 1.35–13.30, p = 0.013). The univariate analysis for those factors on the causal pathway also demonstrated that there was a significant increase in the odds of the most recent birth occurring in a healthcare facility both for women who knew at least one neonatal danger sign (OR: 3.26, 95% CI: 1.89–5.72, p<0.001), and for women who attended antenatal care at least four times during their last pregnancy (OR: 5.20, 95% CI: 2.38–11.39, p<0.001) (S4 Table).

Characteristics associated with men’s practices

In the men’s sample, both male partner’s and woman’s education was associated with men accompanying their wife to antenatal care during her most recent pregnancy. However, these associations were in opposing directions. Men who completed secondary school or higher had an odds ratio of 0.25 (95% CI: 0.07–0.95, p = 0.042), meaning they had a 75% decrease in odds of accompanying their wife to antenatal care, compared with counterparts who had completed primary school only. Conversely, men whose wife had completed secondary school or higher had increased odds of accompanying their wife to antenatal care (AOR: 3.45, 95% CI: 1.09–11.28, p = 0.036). In univariate analysis, men who knew at least one neonatal danger sign showed increased odds of accompanying their wife to antenatal care during her most recent pregnancy (AOR: 3.34, 95% CI: 1.35–8.27, p = 0.009) (S5 Table).

Men in households with a monthly income at or above KShs 10,000 had increased odds of their wives delivering in a healthcare facility (AOR: 11.99, 95% CI: 1.59–90.40, p = 0.016), compared with those who were in households with monthly incomes below 10,000 KSh, after adjusting for confounding factors (S6 Table).

Discussion

Overall, knowledge of neonatal danger signs was low, a finding mirrored in similar studies in other low- and middle-income settings, as well as elsewhere in Kenya [6, 7, 35, 36]. Women were better able than men to identify danger signs, especially when asked to name specific danger signs, even though the men’s sample tended to be older, more educated, and from higher income households. In general, knowledge of danger signs was associated with wealth and education, as others have also found [7, 35–37]. If men are to be actively involved in decision making and healthcare seeking in maternal and newborn health, improving their knowledge of key issues such as danger signs is a necessary starting point. Our regression models show strong associations between women’s and men’s knowledge of neonatal danger signs and positive healthcare seeking behaviours in pregnancy and postnatal care. Whilst the cross-sectional study design of this research cannot show causation, these associations suggest a correlation between danger signs knowledge and healthcare seeking practices during pregnancy and childbirth.

The results show that knowledge is not adequate in explaining delays in health care seeking among mothers of newborns: 30% of women waited over 6 hours after recognising that their newborn was ill before seeking care. Other factors observed to influence health care-seeking in our results echo the findings of others in suggesting that education and wealth are key determining factors in use of antenatal care [18], and skilled delivery [12, 21, 35]. In both the men’s and women’s samples, higher income was associated with both higher knowledge and healthier practices, such as a woman’s most recent childbirth occurring in a facility, even after adjusting for confounding factors. Given that Kenya now has free maternity health services [22, 23], there may be other cost barriers, aside from cost of care itself, at play in the decision to seek care. Future programs may need to consider, for example, the cost of transport, accommodation, and the opportunity cost of missing employment. Our age and parity findings also suggest that health promotion interventions and health communication initiatives should target first time and/or young mothers; this may also present an opportunity for peer-based community learning, such as through group antenatal care [38], whereby more experienced and older mothers are able to assist in the teaching of danger signs.

This study has highlighted the low proportion of men accompanying their wives to antenatal care, as seen elsewhere [39]. The conflicting findings whereby more educated women had healthier practices, but more educated male partners (in the men’s sample) seemed less likely to accompany their wives to antenatal care warrants consideration. It may be that better educated men are more likely to be in formal employment, and programs aiming to increase male involvement may need to consider clinic scheduling that better enables men (and women) to balance parental responsibilities with paid work requirements, for example by offering ANC sessions on weekends, outside office hours, or close to the workplace. Shifting gender norms and attitudes among men, women, health providers and employers can also be expected to contribute to men’s increasing participation in antenatal care, for example by reducing stigma, normalising men’s leave from work or flexible working, and providing inclusive antenatal health services that address both parents’ reproductive health needs. Further research, particularly qualitative research, on the challenges and barriers men face in attending antenatal care in Bungoma County would prove useful for informing future program design. For example, other studies in different locations comment on the ridicule men can face upon their arrival at maternal and child health services [35, 40], and also the lack of infrastructure to accommodate men’s presence, such as privacy curtains in clinics [41]. Additionally, there is opportunity in enhancing utility of the Mother Child Handbook that details pregnancy and neonatal danger signs by targeting communication to men on using the handbook to increase their knowledge on the danger signs. Presently the handbook is more mother focussed.

Limitations and strengths

A key limitation of this research is the small sample size of the men’s sample, at 82 participants. This meant that confidence intervals were wide and there was often weak evidence of associations since the small sample size reduced the power of the study to detect smaller differences. As a convenience sample, these results must be taken as indicative of potential knowledge patterns rather than being representative of the general male population. Due to limitations in the project’s data collection resources, women and men were also administered different questionnaires and were sampled in different ways. This limits the potential for direct comparison between the two groups, and because some questions were worded slightly differently for men and women, no statistical analysis of knowledge differences was possible. We estimated that we were going to get less biased cohort of men in market places than the few motivated ones who accompany their partners in the ante natal clinics. Additionally, due to cultural barriers, men who accompany their partners to ANC are really outliers. Relying exclusively on this catchment may have denied the study representativeness of the general population. The regression analysis undertaken used similar outcomes and exposures in order to smooth the differences between the two cohorts.

The primary strength of this research is that it was conceived and led by local Kenyan researchers and thus addressed local priorities. Additionally, this research has combined data from both women and men in one study, which is not widely seen in the existing literature, thus enabling a level of comparison between these two interconnected groups.

Conclusion

Overall, knowledge of neonatal danger signs in this particular population within Bungoma County, Kenya is low among both women and men. Whilst it is suggested that improving knowledge of the neonatal danger signs can reduce the delay in deciding to seek care [9, 10], there still exists a certain disconnect between knowledge translating into practice for some women in Bungoma County who did not immediately seek care once realising their newborn was ill.

The key determining factors in men’s and women’s knowledge and practices relating to pregnancy and postnatal care were education level, income, gravidity and age at first pregnancy. Future interventions, including those in the ‘Collaborative Newborn Support Project’, must thus consider the extra costs of childbirth occurring in a facility. Furthermore, interventions should address the barriers to men participating in antenatal care, including work commitments and pervasive social and gender norms around pregnancy and child-rearing. Target groups for knowledge-based interventions should focus on primiparous mothers and mothers under the age of 18 at their first pregnancy. These findings have important implications those working in maternal and newborn health in Bungoma County, as well as the overall reduction of maternal and neonatal mortality in Kenya.

Women’s and men’s knowledge and practices relating to pregnancy and postnatal care.

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Factors associated with women’s knowledge of at least one neonatal danger sign.

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Factors associated with men’s knowledge of at least one neonatal danger sign.

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Factors associated with women’s healthy care-seeking practices.

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Factors associated with male partners accompanying women to antenatal care during her most recent pregnancy.

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Factors associated with a woman’s most recent birth occurring in a healthcare facility, as reported by the male partner.

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5 May 2020

PONE-D-20-06532

Men’s and women’s knowledge and practices relating to pregnancy and postnatal care: a cross sectional study from Bungoma County, Kenya

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Editor Comments:

Thank you for your revisions. However, there are still many comments from reviewers to address, but we are confident they will make the article stronger.

In addition to those from the reviewer:

-There is inconsistency is the statement of the objective. The title states knowledge, but the paper suggests knowledge, attitudes and practices, and also at times says "determinants of ANC use and facility based childbirth. Please clarify.

-Further, the link between knowledge and male involvement isn't very clear.

-The data presented are not very in-depth and it is not clear what this adds to previous literature on this topic, even from Kenya, since there are existing studies. Some of the more nuanced analysis may be in supplemental tables and the authors may want to consider including those info in the main paper.

-There is some inconsistency in language about the questionnaire - in some places it is referred to as an interview

-I wouldn't say that fathers being influential in maternal and child health is new

-"recently" delivered needs to be defined (was it deliveries within a year?); also, how were recently delivered women recruited from ANC??

-the association between knowledge of danger signs and ANC is presented as if knowledge is a factor related to ANC, when it is likely that the association is the other way (those who attend ANC or deliver in a facility learn the danger signs)

-low knowledge of danger signs is not only in low income countries, but also among those who are disadvantaged/uneducated in high income settings

-if the authors refer to the "first delay" then the 3 delays model has to be explained

-how many danger signs were included in the questionnaire? what were they?

-For the languages, it if was expected to need other languages besides English and Kiswahili, why not translate ahead of time? it is atypical to use ad hoc translation, as the terminology is then not consistent.

-there is redundant demographic info in the descriptions of the male and female samples

-there should not be new findings presented in the discussion. The results around how long it took to seek care once identifying an illness should be in the results.

-the limitations allude to confidence intervals but these are not presented

-why were the women's and men's cohorts not recruited the same way? Needs to be explained in the limitations.

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review this manuscript, which tackles the important problem of parents knowledge about neonatal danger signs using a cross sectional study from Bungoma County, Kenya.

Is the title reflective of the main message: Men’s and women’s knowledge and practices relating to pregnancy and postnatal care—isn’t it really focused on neonatal danger signs?

This is a strikingly well written manuscript which has been meticulously copy edited and is easy to read and follow. It makes clear points.

I have a few comments which I will hope to strengthen the manuscript further:

1. In the abstract, why are unadjusted models of mothers’ knowledge presented instead of adjusted ones like for the men?

2. Similarly, in the body of the manuscript in the results section please focus only on the adjusted odds ratio’s and remove the unadjusted ones. Flipping back-and-forth between adjusted and unadjusted ones is confusing to the reader

3. Why do the conclusions in the abstract only refer to the mothers’ knowledge?

4. Please clarify in the introduction when ANC is used whether you mean all of antenatal care or antenatal and intrapartum and postpartum care e.g. particularly in lines 81 - 89, but also elsewhere.

5. Another key limitation is that we do not know the response rate

6. In the limitations or strengths could you please mention the degree to which your sample is reflective of the general population in terms of education, age, etc.

7. For your tables, rather than putting the 1.00 in each of the cells indicating the reference, would you consider decluttering the table by putting (Reference) in the first column only? eg Less than 25 years (Reference)

8. Similarly, since you were 95% confidence intervals indicate significance you could delete the P values and just bold the odds ratio’s and 95% confidence intervals instead which would decrease clutter within the table and make it easier for your readers to see the main points

9. Throughout the tables, figures, and manuscript rather than using “father“ please replace with “men” as you do in figure 1 for example. Why? We know from genetics research that 10% of male partners are not actually the father of the child

10. Please comment on missing data for each question

11. Please clarify how missing data was handled e.g. ?complete case analysis

Minor points:

Please do not start sentences with numbers e.g. line 190

When you print off your figures in black-and-white, are the two colours easily distinguishable?

Reviewer #2: I have made separate comments that need to be addressed. These are scattered through the document so can not be displayed here. The attachment will show the areas needing review by the authors. It is a worthwhile papers that shows where health workers need to focuss on

Reviewer #3: The methodology used should be justified. For example, why is it that male partners of female participants were not enrolled, instead men we conveniently enrolled from the market place. What was the basis of sample size calculation? Why the difference in sample size? What is the role of the collaborative intervention in this study? The clarity of the methodology will help in the clarity of the results, discussion and conclusions. More comments are in the document.

**********

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Reviewer #1: Yes: Sarah McDonald

Reviewer #2: No

Reviewer #3: No

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Submitted filename: PONE-D-20-06532_reviewer.pdf

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Submitted filename: PONE-D-20-06532_reviewer.doc

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1 Nov 2020

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When submitting your revision, we need you to address these additional requirements.

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Done

2. In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants for both the womens and mens samples. Please ensure you have provided sufficient details to replicate the analyses such as: a) the recruitment date range (month and year), b) a description of any inclusion/exclusion criteria that were applied to participant recruitment, c) a table of relevant demographic details, d) a statement as to whether your sample can be considered representative of a larger population, e) a description of how participants were recruited, and f) descriptions of where participants were recruited and where the research took place."

Done. See the methods and results sections as well as the supplementary tables.

3. Please provide a sample size and power calculation in the Methods, or discuss the reasons for not performing one before study initiation."

Women and men from the same geographic area were recruited independently, meaning that the responses to each questionnaire are not linked as mother-father dyads. In total, 82 men and 348 women participated in the study. Men whose female partners had recently delivered were recruited through convenience sampling, from those accompanying their female partners to healthcare clinics, and from men in market centres. Women who had recently delivered were recruited at antenatal and postnatal reproductive care units, and in maternal and child health clinics at two health facilities of Webuye level 5 hospital and Bungoma Referral hospital

4. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

Copies provided

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We have shared de-identified data at https://doi.org/10.6084/m9.figshare.13048718. Contact information for Mount Kenya University Ethics Review Committee is research@mku.ac.ke.

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We have uploaded the 2 datasets at https://doi.org/10.6084/m9.figshare.13048718.

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Done

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Done

Editor Comments:

Thank you for your revisions. However, there are still many comments from reviewers to address, but we are confident they will make the article stronger.

In addition to those from the reviewer:

-There is inconsistency is the statement of the objective. The title states knowledge, but the paper suggests knowledge, attitudes and practices, and also at times says "determinants of ANC use and facility based childbirth. Please clarify.

The new title captures the attitudes as well.

-Further, the link between knowledge and male involvement isn't very clear.

Indeed this forms part of our research question; what is the best way to address male involvement? What are the knowledge gaps for male involvement?

-The data presented are not very in-depth and it is not clear what this adds to previous literature on this topic, even from Kenya, since there are existing studies. Some of the more nuanced analysis may be in supplemental tables and the authors may want to consider including those info in the main paper.

We have included more tables to deepen the analyses. Our study is unique in that we address contextual issues in a high burden setting.

-There is some inconsistency in language about the questionnaire - in some places it is referred to as an interview.

Corrected.

-I wouldn't say that fathers being influential in maternal and child health is new.

Indeed, this is not new. However we aimed at understanding contextual issues around male involvement in knowledge and practice. In the study context, men have traditionally left child care to women. This perception has been so pervasive that men have been left out in the design of maternal and child health programs and policies. This study hoped to establish a scientific basis for either supporting or refuting these perceptions.

-"recently" delivered needs to be defined (was it deliveries within a year?); also, how were recently delivered women recruited from ANC??

Recently delivered means deliveries within a year. Yes, these were recruited from the ANC.

-the association between knowledge of danger signs and ANC is presented as if knowledge is a factor related to ANC, when it is likely that the association is the other way (those who attend ANC or deliver in a facility learn the danger signs)

This is well understood. However, in our setting, the extended family is also an important source of knowledge on danger signs.

-low knowledge of danger signs is not only in low income countries, but also among those who are disadvantaged/uneducated in high income settings

This is true, but also outside of the scope of this paper, which focuses on Kenya.

-if the authors refer to the "first delay" then the 3 delays model has to be explained

We have taken out the word “first” so as to not complicate things with long explanations of a well-known concept.

-how many danger signs were included in the questionnaire? what were they?

Vaginal bleeding

Neo-natal sepsis

Jaundice

Convulsions

Asphyxia

High fever

Congenital problems

Difficulty breathing

Severe weakness

Accelerated/reduced foetal movement

Water breaks without labour

Bleeding umbilical cord

Poor breastfeeding

Other- open ended.

-For the languages, it if was expected to need other languages besides English and Kiswahili, why not translate ahead of time? it is atypical to use ad hoc translation, as the terminology is then not consistent.

Most of the participants understand Kiswahili, and hence we estimated that there was minimal need to translate to Kibukusu or kisabaoti.

-there is redundant demographic info in the descriptions of the male and female samples

Corrected.

-there should not be new findings presented in the discussion. The results around how long it took to seek care once identifying an illness should be in the results.

This information is presented in both the results table S1 and the body of the text (currently line 289)

-the limitations allude to confidence intervals but these are not presented.

These are in the supplementary tables.

-why were the women's and men's cohorts not recruited the same way? Needs to be explained in the limitations.

Done.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: Thank you for the opportunity to review this manuscript, which tackles the important problem of parents knowledge about neonatal danger signs using a cross sectional study from Bungoma County, Kenya.

Is the title reflective of the main message: Men’s and women’s knowledge and practices relating to pregnancy and postnatal care—isn’t it really focused on neonatal danger signs?

Well noted and corrected.

This is a strikingly well written manuscript which has been meticulously copy edited and is easy to read and follow. It makes clear points.

I have a few comments which I will hope to strengthen the manuscript further:

1. In the abstract, why are unadjusted models of mothers’ knowledge presented instead of adjusted ones like for the men?

2. Similarly, in the body of the manuscript in the results section please focus only on the adjusted odds ratio’s and remove the unadjusted ones. Flipping back-and-forth between adjusted and unadjusted ones is confusing to the reader.

We reported on unadjusted odds ratios when the variable was considered to be on the causal pathway, and therefore not included in the multivariate model. This was explained in the methods and is noted in the relevant tables. If we take out the unadjusted ORs, we will lose a big chunk of the data/paper content.

3. Why do the conclusions in the abstract only refer to the mothers’ knowledge?

We have states that “knowledge of neonatal danger signs was low”, which was true for both mothers and men.

4. Please clarify in the introduction when ANC is used whether you mean all of antenatal care or antenatal and intrapartum and postpartum care e.g. particularly in lines 81 - 89, but also elsewhere.

We have clarified that this is during pregnancy.

5. Another key limitation is that we do not know the response rate

The response rate was 88%.

6. In the limitations or strengths could you please mention the degree to which your sample is reflective of the general population in terms of education, age, etc.

Done.

7. For your tables, rather than putting the 1.00 in each of the cells indicating the reference, would you consider decluttering the table by putting (Reference) in the first column only? eg Less than 25 years (Reference)

Done.

8. Similarly, since you were 95% confidence intervals indicate significance you could delete the P values and just bold the odds ratio’s and 95% confidence intervals instead which would decrease clutter within the table and make it easier for your readers to see the main points

We wish to maintain as is, as these complement each other and is the practice generally.

9. Throughout the tables, figures, and manuscript rather than using “father“ please replace with “men” as you do in figure 1 for example. Why? We know from genetics research that 10% of male partners are not actually the father of the child

Done.

10. Please comment on missing data for each question.

We had very few missing data which were treated automatically under regression analyses in stata.

11. Please clarify how missing data was handled e.g. ?complete case analysis

Done.

Minor points:

Please do not start sentences with numbers e.g. line 190

Well noted and corrected.

When you print off your figures in black-and-white, are the two colours easily distinguishable?

Yes.

Reviewer #2: I have made separate comments that need to be addressed. These are scattered through the document so can not be displayed here. The attachment will show the areas needing review by the authors. It is a worthwhile papers that shows where health workers need to focuss on

Reviewer #3: The methodology used should be justified. For example, why is it that male partners of female participants were not enrolled, instead men we conveniently enrolled from the market place. What was the basis of sample size calculation? Why the difference in sample size? What is the role of the collaborative intervention in this study? The clarity of the methodology will help in the clarity of the results, discussion and conclusions. More comments are in the document.

Done. See methods section.

Reviewer 2 extended comments:

Comment: The report is centred on knowledge of newborn danger sign. This should be reflected in the title ie replace “relating to pregnancy and postnatal care”. There are no results on postnatal care

Well noted and done.

ABSTRACT: The authors studied knowledge rather than costs of care. Further studied should address knowledge

Agreed and corrected. Thank you.

INTRODUCTION

Lines 87-89 & 116-117

“Our research therefore seeks to understand the additional determinants of ANC use and childbirth occurring in a facility, especially those relating to mothers’ and fathers’ perspectives.

The cross-sectional study reported here forms part of the ‘Collaborative Newborn Support Project’ and aimed to inform interventions through an assessment of men’s and women’s knowledge and practices relating to pregnancy and postnatal care.”

Comment: It’s difficult to correlate ‘additional determinants of ANC use and childbirth’ ‘through an assessment of men’s and women’s knowledge and practices’

Indeed the current study there is little information on actual determinant of use but the authors mostly report on determinants of knowledge.

ANC use is a practice, so we are not being contradictory here. We look at determinants of knowledge and then if knowledge is a determinant of use/practice.

Also give the readers a brief on the broader ‘Collaborative Newborn Support Project’ how long has been going and at stage was the current done.

The Collaborative Newborn Support Project ran from October 2015 to April 2019 and the current study was undertaken July to December 2017.

METHODS

Study setting does not include the hospitals (for women & men) and the type of markets (for men) where the participants were recruited from.

What was their definition of 1. “recently delivered” 2. “delay in seeking health care for the baby?

1. Recently delivered- means had a delivery in the last 1 year.

2. Delay in seeking health care for the baby- Time taken after recognition for need to seek care. We classified this in 3 time bands <1 hour, 1-6 hours and >6 hours.

RESULTS

Socio-demographic characteristics &

Table 1

• To avoid confusion in the column for each characteristic, use men or women instead of husband’s or mother’s.

Done

• Give median ages for the women & their partners in both columns.

Done

Do analyses for all the observations to show if there was any significant statistical differences

We intentionally did not do this because the data are actually not the same.

Men’s sample: In the narrative give the proportion of men who had accompanied their partners in the sample

This is already included under the heading ‘women’s and men’s knowledge and practices relating to pregnancy and postnatal care’ (currently line 292-293)

Supplementary materials

Table S1

Knowledge of at least one postpartum danger sign – which one?

‘’At least one danger sign” refers to respondents listing one or more of the danger signs in their response and does not limit them to a particular one.

The authors need to explain why for women data was not reported on the following:

1. Knowledge of at least one postpartum danger sign

2. Accompanied by partner to ANC

3. Accompanied by partner to delivery

These weren’t questions in the women’s questionnaire. We do say in the methods that the questionnaires were similar. We have added in slightly more explanation to hopefully make this clearer.

DISCUSSION

Kenya has a “Mother Child Health Handbook” which is given for each pregnancy and is in taken home by the mother. This handbook has nearly all the information these authors were looking for in the current study, but it is not mentioned at all in the discussion of this paper

The Mother Child Handbook captures most of the information we sought, however, in our study we aimed at studying the knowledge, attitudes and practices in our setting in Bungoma County where maternal and newborn indicators are among the worst in Kenya. In revision, we have highlighted the need to enhance utility of the Mother Child Handbook as a source of information on danger signs for families.

Submitted filename: Response to reviewers.docx

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7 Dec 2020

PONE-D-20-06532R1

Men’s and women’s knowledge, attitudes and practices relating to pregnancy and neonatal care: a cross sectional study from Bungoma County, Kenya

PLOS ONE

Dear Dr. Gitaka,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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We look forward to receiving your revised manuscript.

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Emma Sacks

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Thank you for these edits - the paper is much clearer. The reviewers have only minor additional comments, which are included as comments in the attached PDF (please let our editorial office know if you have trouble accessing these comments).

Additionally:

The abstract and title still need some editing to reflect the actual research questions and findings. I suggest you emphasise knowledge of danger signs and care seeking practices, rather than the very general 'knowledge, attitudes, and practices.' The abstract completely leaves out care seeking for newborns, which seems to me that it would be the most likely variable to be impacted by increased knowledge of newborn danger signs. Currently, the focus is on ANC utilisation, which as I have noted before, is more likely to be a driver than an impact of increased knowledge.

Please add to the limitations the potential bias of only speaking to married man (and not women's unmarried partners). The difference in recruitment methods between men and women is explained well; however, it is still not clear why they completed different questionnaires and what the potential implications are.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Partly

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

**********

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The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

**********

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PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

**********

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Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: (No Response)

Reviewer #3: The authors have addressed most of the comments raised earlier. I have added a few additional comments in areas where there is still need for justification or more specific details.

Otherwise I recommend the article be accepted for publication after the minor corrections.

**********

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Reviewer #2: No

Reviewer #3: No

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Submitted filename: PONE-D-20-06532_R1.pdf

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22 Jan 2021

Second response to reviewers

PONE-D-20-06532R1

Men’s and women’s knowledge, attitudes and practices relating to pregnancy and neonatal care: a cross sectional study from Bungoma County, Kenya

PLOS ONE

Editor’s comments and responses

The abstract and title still need some editing to reflect the actual research questions and findings. I suggest you emphasise knowledge of danger signs and care seeking practices, rather than the very general 'knowledge, attitudes, and practices.' The abstract completely leaves out care seeking for newborns, which seems to me that it would be the most likely variable to be impacted by increased knowledge of newborn danger signs. Currently, the focus is on ANC utilisation, which as I have noted before, is more likely to be a driver than an impact of increased knowledge.

Thank you! The title and abstract have been revised to emphasize the study’s focus on neonatal and postnatal care-seeking, and remove the implication that pregnancy care utilization is an outcome.

Please add to the limitations the potential bias of only speaking to married man (and not women's unmarried partners). The difference in recruitment methods between men and women is explained well; however, it is still not clear why they completed different questionnaires and what the potential implications are.

Thank you. The Limitations section has been revised to also include the bias of only speaking to married men, and to note the study logistics that determined the use of different questionnaires; also noting that this difference constrains comparability between men’s and women’s answers.

Reviewers comments in body of PDF and responses (line numbers refer to PDF)

Line 111: Reviewer comment: “what about attitudes?”

Response: The title has been altered to no longer refer to attitudes.

Line 118: Reviewer comment: “This section should be written to have relevance to the study subject matter. For example, demonstrate how agricultural activities are related to men and women's KAP related to pregnancy and neonatal care. How is the population of the county related to the studied population when this is more of a hospital-based study?”

Response: The text has been revised to note the ecological relevance.

Line 127: Reviewer: how were these sample sizes determined/ calculated?

Response: the convenience sampling has been emphasized in this sentence and below.

Line 128: Reviewer: state clearly the one year period- between which actual months that constitute the year. This must be known to inform how screening/recruitment was done.

Response: the period has been specified more accurately

Line 129: Reviewer: What is the justification for use of this method? this is the poorest method of sampling. it is also inappropriate for sample size and statistical tools are intended for use to determine associations and aimed at generalization.

Response: We have added text to note the sampling was determined by the resources available to the project team. With this disclosure to inform readers, we believe the subsequent analysis and interpretation is proportionate and holds value.

Line 130: Reviewer: Reviewer: specify the market centres where recruitment was done- how many and which ones? what is their vicinity in relation to the hospitals?

Response: Their relationship to the hospitals in the broader study has been specified.

Line 130: Reviewer: be consistent in use of terms- 'women' instead of 'mothers', in line with your study title.

Response: we have changed ‘mother’ to ‘women’ or equivalent, throughout, except where needed to specify the parental role.

Line 130: Reviewer: is it possible that another reason for the selection of these hospitals is because the intervention- the collaborative newborn support project- had taken place at these facilities?

Response: we have added this detail.

Line 338: Reviewer: the sampling procedure used- convenience this is not only the weakest type of procedure, but it is also inappropriate for a study sample that is calculated using methods aimed at representativeness.

Response: we have strengthened our acknowledgement of this limitation

Line 353: Reviewer: The findings can only be generalized to the target population attending ANC, stretching it to the County when it is a hospital-based study, and using convenience sampling method is misleading.

Response: We have reworded to avoid the over-generalisation

Submitted filename: Response to reviewers, second letter v2.docx

Click here for additional data file.

29 Apr 2021

Men’s and women’s knowledge of danger signs relevant to postnatal and neonatal care-seeking: a cross sectional study from Bungoma County, Kenya

PONE-D-20-06532R2

Dear Dr. Gitaka,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Tanya Doherty, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

4 May 2021

PONE-D-20-06532R2

Men’s and women’s knowledge of danger signs relevant to postnatal and neonatal care-seeking: a cross sectional study from Bungoma County, Kenya

Dear Dr. Gitaka:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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PLOS ONE Editorial Office Staff

on behalf of

Professor Tanya Doherty

Academic Editor

PLOS ONE