Low involvement of men in women's Reproductive Health in Maekel Region In Eritrea
ANC Antenatal Care
EDHS Eritrea Demographic Health Survey
FGD Focus Group Discussion
FP Family Planning
MCH Mother and Child Health
MDGs Millennium Development Goals
PPC Post Partum Care
RH Reproductive Health
WHO World Health Organization
1. Introduction and problem statement
Men can help in improving the lives and health of women as they become more involved in the women's reproductive health. Worldwide, around 536,000 women die yearly from complications during pregnancy, childbirth, or the postpartum period and nearly all of these deaths can be preventable. Almost all the deaths which is 99% occur in developing countries and 900 maternal deaths per 100,000 live births are from Sub Saharan Africa (WHO, 2005). Eritrea is one of the countries with high maternal mortality. Delays in seeking care is one of the factors that contributes to high maternal mortality in the country. Delay also contributes to maternal deaths when complications arise during pregnancy, delivery and after delivery. Three types of delay position mothers' health at danger—delay on decision making to seek care; delay in reaching the health facility; and delay in receiving sufficient care at the facility (Thaddeus S, Maine D.1994). Men and other family members can play an essential roles in assuring timely care. Men are often the ones who decide when a woman's condition is serious enough to look for medical services care. They are also the ones who decide how a woman will transport to the health center or hospital and also they are the ones who pays for transportation. Therefore, the first two delays can be avoided if men are involved and learn the symptoms of imminent complications of pregnancy and delivery.
Maternal mortality is the most serious problem in Eritrea. The Maternal Mortality Ratio is estimated at 450 per 100,000 Live Births (WHO, 2007). Female illiteracy rate of about 55%, high fertility rate of 4.8 children per mother, low percentage of service utilization for skilled attendance during delivery (28%), and low contraceptive prevalence rate (8% for all methods in 2002) are underling factors that contribute significantly to the poor health status of women, young people and children in Eritrea (EDHS, 2002)
Women of reproductive age and children constitute about 60 % of the total population in the country, thus improving the health status of these groups' means improving the health status of the majority of the people. In Eritrea, maternal health services are often described as women's responsibilities as well as all the maternal health services: ANC, Delivery, Postpartum and Family planning are all women focused. Health services fail to address or include men in reproductive health services in general and in ANC, delivery, PPC and FP in particular. In the Road Map Conference that was held in (2004), it was stated that most men do not accompany their partners to family planning or antenatal care consultations, during labor and delivery.
2. Literature Review
The role of men and women in the society is defined by the cultural, social, gender and socio-economic factors. This could impede men from participating in the critical aspects of pregnancy, child birth and postpartum care. A study concerning male involvement in maternity care in south Africa states that family planning, pregnancy and childbirth is considered as women's concern. Men do not go along with their partners to the ANC, FP, delivery and post natal care clinics. on the other hand, male social dominance and sexual behavior puts women at high risk of unwanted pregnancy and poor outcome of the mother and baby due to infections (Mullick et al, 2005).
Men are rarely visited health facilities which provide reproductive health services. The logistic and cultural problems prevent men from accessing the reproductive health services. In addition, the reproductive health services are unfriendly for men due to the exclusive use of health services by women (Mullick et al, 2005).
Involving men in reproductive health is a challenge in some countries, especially if the culture has a big role in defining the gender role of men and women. In countries where communication between couples is limited, it is very difficult to address the reproductive health of the wives and the family. Therefore, offering a service that includes couples may provide an opportunity for breaking the ice and encouraging the couples to discuss health issues freely (Walston, N. 2005).
A study concerning male involvement in antenatal care stated that there is increasing recognition that men's attitude and behaviors during partner's pregnancy influences the outcome of the pregnancy (Marindo, R. 2001). The role of antenatal care services foster couples to communicate importance of providing emotional support and engage in financial support to mother and baby. Additionally, in the study women suggested that men involvement would strengthen the bond with in the family, additionally, men would notice the changes in their pregnant partner's body and be available to help at home.
The attainment of the MDGs which is reduction of maternal mortality by 75 percent by 2015 might be possible through the involvement of men in supporting women during pregnancy, labor, delivery, and postpartum care. High fertility rate, low contraceptive prevalence and increased risk of STI & HIV/AIDs could be avoided by involving men in women's reproductive health care services. Involving men as partners, fathers, husbands, policy makers and community members have an important role to play in safeguarding the maternal health and addressing the socio-cultural factors that affect reproductive health.
Studies from Katmandu, Nepal described so many reasons that hinder men from involving in the reproductive health. Some of the reasons that has given are low knowledge of men, unfavorable social and cultural environment such as social stigma, shyness/embarrassment and job responsibilities and lack of health services that involves men (Mullany, B. 2005). However, specific research which is related to low involvement of men in women's reproductive health both in decision making and service utilization in the country has not been done yet and therefore we cannot conclude that the studies that has found in other countries are also applicable and relevant in Eritrea.
A qualitative research will be used in order to identify the main reasons that deter men from participating on women's reproductive health. In this study, the socio-cultural factors that prevents men to be involved in maternal health, problems related to the health service that deters men from participating and the attitude of men, women and health providers on reproductive health services will be explored and suggestions will be made to the policy makers, program implementers and other relevant stakeholders. Therefore, identifying the problems will provide the family and reproductive health program to come with different interventions and better outcomes towards reduction of maternal mortality.
4. Research objectives
4.1. General objectives
To assess the extent and explore factors that affects the involvement of men in the process of utilization of reproductive health services of their spouses in Maekel region in Eritrea
4.2. Specific Objectives
* To assess the level of involvement of men in women's RH service utilization and their support
* To assess the knowledge of men on reproductive health
* To explore factors that affects involvement of men on women's RH
* To explore the perception of community members towards men involvement in women's reproductive health
* To recommend strategies for involvement and participation of men in to programs aimed at improving RH services
5.1. Study type
A qualitative exploratory study type will be used to explore the reasons that influences men from involving in women's reproductive health.
5.2. variables and issues See annex 2: Research Table
5.3. Structure of the Research organization
The principal investigator will work in collaboration with the Family and Reproductive Health program in the Ministry of Health throughout the data collection and analysis time.
5.4. Sampling method and recruitment of study population
The study will be conducted in Maekel region in Eritrea. There are four districts in the Maekel region i.e. Asmara city, Berik, Gala Nefhi and Serejeka. The study sampling method will be purposeful. Two villages from each district will be selected. Moreover, the study population from the chosen villages will be selected according to characteristics like age, religion, education, socio-economic status, rural and urban settings. The study population will be men and women of reproductive age group who have children under five years, health workers and community leaders.
Homogeneous grouping will be used for the FGD of women in reproductive age from the health facility, to motivate participants to discuss unreservedly on the area of the study. In the group, 8 mothers' who experienced labor and delivery, and recently attending antenatal care and family planning clinics will be participated. In addition, FGD composed of 8 people will also be conducted from the community members to identify the social and cultural factors that hinders and enables men from involving in their partners RH issues.
In-depth interviews for women and health workers will be conducted. After making an in-depth interview with the women, the level of involvement of their husbands will be estimated. Then, the husbands will be traced back to make an in-depth interview using the snowball sampling method.
5.5. Data collection techniques
In-depth Interview: Open-ended topic guide will be used to interview men, women and health workers in the selected villages and health facilities. Trained interviewers will carry out the interview. Interviewing men, women and health workers will continue until the research committee agree that ideas are saturating. Tape recorder will also be used.
Focus group discussion: An estimated minimum number of 2 FGDs per village will be used, each encompassing eight participants will be conducted among women of reproductive age and community members both in the urban and rural setting. Topic guide and tape recorder will be used to verify all the information is documented. The FGD will also be carried out by trained data collectors.
An interview to key informants: An interview to health workers(nurses or nurse midwives) from the ANC, FP and delivery service programs, community leaders and some stakeholders who are actively working in the reproductive health program will be conducted. And this will be done to obtain in depth information on the current role of male involvement in reproductive health and how men could be involved in reproductive health.
5.6. Data processing and analysis
The data will be checked in the field area by the supervisor from the beginning of data collection up to the end in order to ensure that all the information has been collected and recorded. During data processing, information will be checked again for completeness and data's will be transcribed by the interviewers with the help of the supervisor every day during the data collection period. In addition, analysis committee will be selected from the data collectors and supervisors for compiling and analyzing the individual and focus group discussion interviews. All the data's will be coded and analyzed using the content analysis method through spreadsheet prepared in excel for this purpose.
5.7. Ethical considerations
A supportive letter from the ministry of health, family and reproductive health program will be used for the permission of the study in that region. This is done to receive a permission from the health facility, community or local leader before the study has began.
In ethical consideration of the respondents that will participate in the interview and in the focus group discussion, the issue of respect towards the participants ideas and attitude, cultural sensitivity, justice will be considered. A consent form will be used and the purpose of the study will be explained to the respondents. For the purpose of confidentiality the interviewer will tell the respondents that the information that is gathered will be kept securely. An informed consent will be obtained from all the participants. See Annex 4
5.8. Quality Assurance
Training of data collectors and supervisors: This training will be carried out prior to the data collection of the study. The interviewers will be trained in how to facilitate a FGD through role play method during the training. And in order to master the subject area, interviewers will make a practice among themselves. All the ethical considerations will also be discussed during the training.
Pre-test: Pretesting the topic guide for the in-depth interview and FGDs will be carried out outside the study districts before starting the field work with the whole research team in order to have a clear understanding as well as applicability of the material. Problems that are faced during the pretest will be discussed with all the data collectors and supervisors as well as improvement will be made to the topic guide.
Language: The interview will be conducted using local language. Interviewers must be fluent in the local language of the selected areas. In addition, interviewers will be trained to use simple, clear and understandable language for the respondents.
Triangulation: In order to have a broad and reasonable perspective on the involvement of men in RH, women of reproductive age, health workers, community members and key community informants like religious leaders, local administrators and other will be consulted.
Supervision: Supervisors will monitor the progress and quality of work during the field
6. Work plan: See Annex 3
7. Dissemination of results
Final Reports will be duplicated and disseminated to different programs in the Ministry of Health, all partners, NGOs working in RH, MOH Maekel region, and other key stakeholders.
A brief presentation on the findings of the study will be organized and carried out to the Director General of the Health Services, to the Family and Reproductive Health Program, key stakeholders and local administrators of the study areas.
8. Annex 1: Problem tree
9. Annex 2: Research table
General Objective: To assess the extent and explore factors that affect the involvement of men in the process of utilization of reproductive health services of their spouses in two districts in Eritrea
Data collection techniques
To assess the knowledge of men on reproductive health
Back ground information on :
- Educational status
- Marital status
Level of knowledge on:
Sources of information
Perceived benefit of utilizing the RH service
To assess the level of involvement of men in women's RH service utilization
Level of involvement on:
Support during pregnancy, Delivery and after delivery
Birth preparedness plan
Encourage partner to take FP
Participate on contraceptive use
Communication b/n partners
Accompany their partners to the HF
Attended counseling on FP, ANC
To explore factors that affects involvement of men
Perceived quality of services
Attitude of h/workers
Lack of awareness and information
Limited program that involves men
Work demand/job responsibility
Accessibility and availability of services
Rumors and misconceptions
Perceived RH as women's issue
To explore the attitude of the community towards men involvement in women's reproductive health service utilization
Social Perceptions and attitudes
In depth interview
Key community members
To recommend strategies for involvement and participation of men in to programs aimed at improving RH services
Reproductive health program
Regional office of MOH
Community members(Local administration)
10. Annex 3: Work Plan
(April 6-12, 2009)
(April 13-19, 2009)
Finalize the research paper and Clearance from ethical committee, national and funding authorities
Development of topic guide for the interview and FGD
Enrollment of data collectors and supervisors, and preparation for the training
Principal investigator with the RH program members
Training of research teams on the skills of interviewing and FGD
Principal investigator with the RH program members
Pre-testing of the topic guide and refinement (Interview and FGD in field work)
Principal investigator and study team members
Reviewing the feedback from pretest in the field work for the topic guide and finalize it
Principal investigator and study team members
Duplication of topic guide and procurement of essential supplies for the research study
Principal investigator with the RH program members
Field mission to conduct the research study in Maekel Region
Data collectors and supervisors
Data entry, clean up and analysis of the interview and FGD
Selected study team members and principal investigator
Compiling of the analyzed data and writing a final report
Briefing and Feedback to the ministry of health, stakeholders and community
Dissemination of report
11. Annex 4: Consent Form
Letter Head: Ministry of Health Family and Reproductive Health program, Address, Telephone Number and Fax Number
I am …………… from the Ministry of Health, Family and Reproductive Health Program. The Ministry of Health, RH program is conducting a study on low involvement of men on women's Reproductive Health. The purpose of the study is to assess the extent and explore factors that affect the involvement of men in the process of utilization of reproductive health services of their spouses in Maekel region in Eritrea If you agree to participate, you will be asked about the involvement of men and the factors that enables and disables men to involve on RH. This information will be used to determine the most effective ways to involve men in the issue of RH.
Your answers to the questions will be written down by the interviewer, but your name will not be recorded. Your name or address will not appear in the reports or presentations based on these data. The discussion will be tape-recorded. What you have said will be kept confidential in this study. The interview will take about 45 minutes.
We cannot promise that you will directly receive any benefits from this study but your inputs are very important on development of strategies towards men involvement. You will not receive any payment for your participation.
Your participation is voluntary and you have a right to withdraw your consent or discontinue the participation at any time. You have the right to refuse to answer particular questions.
If you have any questions, concerns or complaints about this research study, you should ask the Family and Reproductive Health Program and contact at the above mention address.
Participant's Signature _____________________________ Date ____________
Interviewer's Signature _______________________________
Marindo, R. et al (2001) Male Involvement in Antenatal Care: Opportunity for HIV Risk Reduction; population Studies Center, University of Zimbabwe
Ministry of Health Eritrea (2004) Road Map to Improve Maternal and Newborn Health In Eritrea: Family and Reproductive Health Program, Asmara
Mullany, B. (2005) Barriers to and attitudes towards promoting husband's involvement in maternal health in Katmandu, Nepal. Available from: http://paa2006.princeton.edu [Accessed: 15 February 2010]
Mullick, S. et al (2005) Involving Men in Maternity Care: Health Service Delivery Issues. Available from: www.popcouncil.org/pdfs/frontiers/journals/Agenda_Mullick05.pdf [Accessed:15 February 2010]
National Statistics and Evaluation Office (2002) Eritrea Demographic Health Survey: Asmara: Sabur Printing Press
Thaddeus S, Maine D.(1994) Too far to walk: maternal mortality in context. Soc Sci Med; 38:1091-1110.
Walston, N.(2005) Challenges and Opportunities for Male Involvement in Reproductive Health in Cambodia, USAID. Available from: www.policyproject.com/pubs/.../MaleInvolv_Cam.pdf [Accessed:16 February 2010]
WHO (2007) Maternal mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva, World Health Organization