Papel de los glucocorticoides

The degree to which men engage in issues related to RMNH and the role that they play are influenced by deeply rooted social norms regarding gender roles. Gender norms are socially constructed rather than biologically driven, and shape individual expectations and experiences related to reproduction and parenting (World Health Organization, 2007a, McAllister et al., 2012). In many societies, the subordination of women to men is maintained and legitimised through a range of established ideas, cultural values and private life arrangements that reward women’s compliance (Connell and Messerschmidt, 2005). In South Africa, for example, this means that men are expected to have priority in SRH decision-making (Jewkes and Morrell,

43 2010). In addition, violence may be used against women to reinforce social norms (Barker et al., 2011).

Incorporating a gender perspective into reflections on male involvement shows that there are specific situations in which involving men in RH care may not be in the best interest of women. For example, in contexts with high lifetime prevalence of intimate partner violence (IPV), HIV- status disclosure to male partners entails justifiable fears of a partner’s violent reaction (Visser et al., 2008). Women who have experienced or been threatened with violence also

understandably fear partner involvement during pregnancy and the postpartum period (Maman et al., 2011). More generally, however, there is a risk that involving men can entail a shift in the locus of control from women to men in domains that were previously women’s territory (Frye Helzner, 2006). Although male engagement can be beneficial, “involving men without acknowledging and addressing gender biases may result in interventions that inadvertently consolidate male power over reproductive and sexual decision-making” (Greene et al., 2006).

Instead, the integration of gender and health goals can result in positive synergies. Promoting women’s empowerment and gender equity can itself contribute to achieving RH goals. There is evidence that dimensions of women’s autonomy are associated with the use of health services, such as the use of ANC and SBA in Nepal (Haque et al., 2012). In Burkina Faso, women’s participation in decision-making within the household is associated with the uptake of postnatal care (Fort et al., 2006). An association has been shown between women’s financial autonomy’s and longer breastfeeding in India (Shroff et al., 2011), and gender-equity in decision-making is linked to lower fertility in Nigeria (Fadeyi, 2010). Women’s empowerment and men’s

engagement, however, are not mutually exclusive, and male involvement programmes should not replace efforts to empower girls and women. On the contrary, if interventions are designed to transform, rather than reinforce, inequitable gender norms, this will also make their health objectives more achievable (Yinger et al., 2002). At the same time, there is evidence that the effect of women’s empowerment programmes, such as microcredit initiatives, can be enhanced by the addition of components that engage with male partners (Edstrom et al., 2015).

In order to draw attention to the importance of incorporating a gender perspective into RH promotion and HIV prevention activities, the Interagency Gender Working Group (IGWG) has developed a framework for evaluating programmes based on the way in which they engage with gender equity issues (see Figure 1) (Interagency Gender Working Group (USAID)). This illustrates how programmes can either ignore gender inequalities (gender blind), or engage with them (gender aware).

It is possible for gender-aware programmes to engage with gender norms in an exploitative way (gender exploitative) by taking advantage of inequalities or even reinforcing them. One example involved a campaign, launched in Virginia (USA) in 2012, to increase the number of men tested

44 for sexually transmitted infections (STIs). The messaging was based on the reinforcement of aggressive masculinity notions such as “hitting it” (Fleming and Lee 2014). Another example would be a hypothetical PMTCT programme that includes messaging such as “what kind of mother would give HIV to her baby?”, thus reinforcing harmful norms that increase women’s vulnerability (Kraft et al., 2014).

Other programmes may work around existing gender differences, without seeking to challenge them (gender accommodating). Programmes that engage with “men as partners”, rather than as “agents of positive change” (Greene et al., 2006), may fall into this category. An example is a randomised controlled trial (RCT) conducted in Ethiopia, involving a home-based couple- counselling programme on contraception (Terefe and Larson, 1993). While the experimental condition involved providing health education to the woman and her husband together, there was no discussion of men’s role or emphasis on improving gender relations. While these programmes can improve health outcomes in the short run, they too may risk reinforcing gender inequities, albeit inadvertently. The classic example is a nationwide social marketing campaign conducted in Zimbabwe in the early ‘90s, which used messages and images derived from competitive sports in order to appeal to men and encourage their involvement in FP. However, one effect was that men exposed to the campaign were more likely to consider themselves the primary decision makers on family planning and parity (Piotrow et al., 1992).

Finally, programmes may engage critically with inequitable gender norms and actively seek to change them and promote greater equality (gender transformative). Strategies focused on “men as agents of positive change” fall under this category (Greene et al., 2006). One successful example is the Male Motivator intervention in Malawi, which used peer educators to talk to men about FP, but also to challenge rigid gender norms such as the notion that a large family is a sign of virility (Shattuck et al., 2011).

It is clear from these examples that male involvement strategies that take an instrumental approach towards inequitable gender norms may replicate the same structures that perpetuate women’s subordination and ill health (Comrie-Thomson et al., 2015b). However, there is also evidence that they are less effective in achieving RH goals. A review of interventions to engage men and boys to improve RH, conducted by the WHO, classified these based on their level of engagement with gender issues (World Health Organization, 2007a). Based on ranking criteria including evaluation design and level of impact, the authors concluded that gender-

transformative programmes were more effective, compared to gender-sensitive or

accommodating interventions, in increasing condom and contraceptive use, promoting spousal communication, and decreasing gender-based violence (GBV). Similarly, in a review of 23 reproductive, maternal, newborn and child health (RMNCH) behaviour change interventions

45 from low- or middle-income countries, Kraft found that the evidence of effect was more

compelling for the gender-transformative interventions (Kraft et al., 2014).

In order to develop male involvement interventions that incorporate a gender perspective and include, among their objectives, the transformation of inequitable gender dynamics, attention to proper design is therefore essential. One basic principle is the inclusion of mechanisms to ensure “women’s permission, consent and perspective on male involvement before inviting men to be involved” (World Health Organization, 2015c). In terms of content, it is important to address egalitarian decision-making within couples and “to avoid reinforcing gendered stereotypes of men as the decision-makers” (World Health Organization, 2015c). Therefore, organization-wide training on gender equality needs to be included in order to equip health workers or facilitators with these skills (Jansson, 2014). There is also a need to ensure that programme evaluations routinely include measures to assess the intervention’s impact on gender norms or empowerment (Sternberg and Hubley, 2004).

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2.6.

Conclusion

Women’s peer and family networks, and in particular their male partners, exert considerable influence on their decisions related to reproductive health, and may thus facilitate or hinder their adherence to recommended practices such as attending postnatal care, exclusively breastfeeding, or using family planning. However, in many parts of Sub-Saharan Africa, including Burkina Faso, it is rare for men to participate in facility-based maternity care because of a variety of institutional and socio-cultural barriers.

In the last couple of decades, strategies to increase male involvement in maternity services have received considerable international attention, because they provide opportunities to enhance men’s role as supportive and informed partners to women, with an equal interest in family health. However, male involvement programmes must avoid engaging with men’s dominant social role in an instrumental way, in order to achieve specific health goals. On the contrary, they should work together with men and explicitly involve them in challenging inequitable gender norms, while at the same time seeking greater empowerment of women. Such gender- transformative interventions have the potential to achieve greater and more sustainable health gains.

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