Efectos del estrés crónico y del condicionamiento del miedo al contexto sobre

Although men exert a strong influence on key behaviours that affect RH, they do not routinely participate in maternity care in many parts of the world. Most studies from Sub-Saharan Africa report that a third or less of male partners have ever accompanied their spouses to ANC or PNC, though the proportion who actually took part in the consultations is likely to be lower (Ganle and Dery, 2015, Iliyasu et al., 2010, Van den Berg (editor), 2015, Nkuoh et al., 2010). In urban Burkina Faso, observations of routine maternity care in facilities in the cities of Bobo-Dioulasso and Ouagadougou have shown that men are not usually involved in maternity care, rarely accompany their wives to antenatal and postnatal care appointments, and have scarcely any contact with health workers (Rossier and Hellen, 2014, Daniele, 2014). However, there is evidence that ANC attendance by men may be higher in settings where it has in effect become compulsory, a problematic local interpretation of national policy in certain countries (see General Discussion, Subchapter 11.6) (Påfs et al., 2015, Vermeulen et al., 2016). In some settings, particularly private hospitals where labour wards are sufficiently spacious, male presence at the birth appears to be becoming more common (Kululanga et al., 2012b). A survey of multiparous female ANC attendees in Nigeria has shown that only 44% had ever been accompanied by their male partner to ANC, but 64% reported that their partner was present last time they gave birth (Olayemi et al., 2009).

Most surveys suggest that formal education, marriage, employment and city residence are predictors of male involvement in ANC (Iliyasu et al., 2010, Kariuki and Seruwagi, 2016, Katz et al., 2009). Male education was associated with presence at birth in a survey from Nigeria (Olayemi et al., 2009) and a qualitative study from Malawi (Kululanga et al., 2011). However, whereas ANC attendance was associated with older age among Ugandan men (Kariuki and Seruwagi, 2016), younger men were more likely to participate in Nigeria (Iliyasu et al., 2010) and to opt for couple voluntary counselling and testing for HIV (VCT) rather than individual VCT in Kenya (Katz et al., 2009). Factors limiting participation in Uganda also included the presence of other family members in the household, and the strength of peer influence (Kariuki and Seruwagi, 2016). Monogamy is associated with higher involvement in most studies

(Ditekemena et al., 2012, Olayemi et al., 2009). In Burkina Faso, women’s empowerment, including economic empowerment, is associated with higher levels of male accompaniment to ANC (Jennings et al., 2014).

Men’s attitudes towards their own involvement vary. Several studies show that men are

theoretically willing to participate in maternity care, but that they generally do not do so, except in the case of complications (Adelekan et al., 2014, Ganle and Dery, 2015, Aarnio et al., 2013, Kwambai et al., 2013, Nkuoh et al., 2010). Surveys show that the majority of women are willing to be accompanied by their male partners (Vermeulen et al., 2016, Nanjala and Wamalwa,

36 2012), except where there is a concern about HIV status disclosure, domestic violence or

alcohol abuse (Ditekemena et al., 2012).

There are several reasons why men do not take part in maternity care, including a range of social or cultural barriers (Ditekemena et al., 2012). There is evidence from various parts of Sub-Saharan Africa suggesting that many men perceive pregnancy and maternity care to be a women’s affair, or that they think pregnancy support is a female role, and that their participation is therefore not required or is “not in our culture” (Ganle and Dery, 2015, Nanjala and

Wamalwa, 2012, Nkuoh et al., 2010). Qualitative research conducted as part of the PopDev study has shown that these beliefs are also prevalent in Burkina Faso (internal communication). Men’s role is often perceived to be that of financial provider, paying for care bills and transport, and sometimes looking after the home or other children if there is no female relative to do so (Adelekan et al., 2014, Kwambai et al., 2013, Kululanga et al., 2012b, Olayemi et al., 2009). Men may think that accompanying women is a sign of weakness, that they may not be seen as total men (Onyango et al., 2010), or that it would be inappropriate for them to take part given that pregnancy is the equivalent of an initiation process for women (Mohlala et al., 2012). Another reason commonly reported by men for not participating is that they are too busy or cannot take time off from work to spend long hours at the clinic waiting to be seen (Adelekan et al., 2014, Singh et al., 2014, Nkuoh et al., 2010, Onyango et al., 2010).

Several studies suggest that up to half of men fear that if they accompanied their partners to ANC or to give birth they would be perceived as being dominated by or taking orders from their wives, and thus be ridiculed by their peers (Adelekan et al., 2014, Ganle and Dery, 2015, Nanjala and Wamalwa, 2012, Onyango et al., 2010). A study from Cameroon suggests instead that men fear they’d be perceived as jealous by the community if they attended the clinic with their pregnant spouse (Nkuoh et al., 2010). Qualitative studies focused on the experiences of men who attended their partners’ births have shown that these men are willing to support their spouses, but often experience difficulties in navigating the contradictory roles dictated by tradition and by the modern expectation of being a supportive companion (Kaye et al., 2014, Mbekenga et al., 2011).

However, there is also ample evidence of service-level barriers to male partner participation (Ditekemena et al., 2012). Traditionally, reproductive health (RH) services are female-oriented, ignoring the influence that men exercise over women’s choices (Mbizvo and Bassett, 1996). In some cases, men are actually excluded or prevented from entering the consultation room and “made to wait outside in the sun” (Mohlala et al., 2012, Kululanga et al., 2012b). Clinic infrastructure is often not couple-friendly, and men’s presence may not be possible due to congestion and concerns for privacy (Kwambai et al., 2013, Kaye et al., 2014). Opening hours may not be favourable to men who work (Ganle and Dery, 2015). However, staff attitude is also

37 sometimes a problem. Men report negative experiences, being treated rudely, and being

ridiculed by staff and “asked if they have also gone to hospital to deliver” (Nanjala and Wamalwa, 2012, Vermeulen et al., 2016).

Health workers may be overworked or not have the inclination to encourage men to attend. They may not tell women that their husbands are welcome, and women may not share the invitation with their partners for fear of a negative reaction (Vermeulen et al., 2016). My qualitative findings from Bobo-Dioulasso suggest that some health workers believe that involving male partners is important, however during my observations they made no effort to encourage women to invite them, while at the same time blaming men for not wanting to attend (Daniele, 2014). Where men are invited, this is usually only in the context of prevention of mother-to-child transmission of HIV (PMTCT) and specifically for HIV testing. Men may not be given any other health information about other topics, such as the importance of SBA or birth preparedness (Magoma et al., 2010). In Rwanda, once HIV testing is complete men are not allowed to participate in the actual health consultation (Påfs et al., 2015). The impression is that even where men’s presence is tolerated, they are not given much attention, and that services are often not ready to welcome men who want to act as supportive partners (Mullick et al., 2005). Men who attended their partners’ births felt excluded, helpless, unprepared and unsupported, and reported tensions with health workers who perceived them as excessively demanding (Kululanga et al., 2012b). Men’s negative experiences have also included witnessing health workers behaving abusively towards their female partners (Ganle and Dery, 2015, Vermeulen et al., 2016).

Other concerns limiting men’s participation include staff asking them for money, including informal payments (Ganle and Dery, 2015, Adelekan et al., 2014, Vermeulen et al., 2016, Nanjala and Wamalwa, 2012). Up to half of men may be reluctant to attend for fear that they will be forced into testing for HIV or disclosing their status (Nanjala and Wamalwa, 2012, Mukobi, 2012), but some also fear being pressurised into vasectomies or disclosing extramarital sexual activity (Withers et al., 2015, Onyango et al., 2010). Having multiple partners may itself be a reason to not attend for men who fear being seen accompanying a different woman

(Mohlala et al., 2012). In general, some men feel embarrassed or uncomfortable about openly discussing sexual matters in front of or with their female partners (Withers et al., 2015).