PMNCH Knowledge Summary #26 Engaging Men and Boys in RMNCH
Publisher: The Partnership for Maternal, Newborn and Child Health
Publication date: 2013
Language: English only
Historically, male involvement in Reproductive, Maternal, Newborn and Child Health (RMNCH) policy has not been given the attention that it deserves. However, the evidence shows that men who are well-informed about their sexual and reproductive health are more likely to make better health choices for themselves, their partners, and their families than men who lack this knowledge.1
Health policy should seek to involve, educate and invite men to make well-informed sexual and reproductive health decisions that can protect their lives as well as the lives of their partners and families.1
Men have a clear role in decision making about contraception, family planning and use of health services. In spite of this, male involvement in RMNCH policy has not been given the attention that it deserves. This is due to several factors that include the following:2
- Emphasis on clinical service delivery to women of reproductive age and on women’s barriers to contraceptive use.
- Assumptions about open communication and evenly shared reproductive decisions between men and women.
- Lack of research on men’s attitudes and behaviors and gaps in evaluation data for interventions on men.
The role of men in Reproductive, Maternal, Newborn and Child Health (RMNCH) - A broader perspective3
Increased engagement of men in RMNCH is consistent with several global instruments that promote human rights and gender equity. These include the 1979 Convention on the Elimination of All Forms of Discrimination against Women that emphasises the responsibility of both men and women in raising children, and the 1994 Programme of Action at the International Conference on Population and Development which stated that a full partnership between men and women is required in both productive and reproductive life.
In recognition of this, the 2010 Global Strategy for Women’s and Children’s Health4 calls for organizations which work with men and boys to coordinate their educational and advocacy programming to increase their effectiveness.
Gender Transformative Programming
WHO-Promundo research confirmed that a “Gender Transformative”5 approach that confrontsand transforms gender norms is more likely to change health behaviour.
Male roles in RMNCH that can be reinforced via gender transformative programming include6 shared responsibility for family planning, contraception and prevention of STIs; helping pregnant women stay healthy and deliver their babies safely and engaging in responsible fatherhood and caregiving of children.
A UNFPA literature review of men’s roles in gender equality7 described two strategies that such gender transformative programmes could use to increase male involvement in RMNCH:
- Engaging men as partners in reproductive health
- Engaging men as agents of change in RMNCH
Engaging Men as Partners in Reproductive Health
Involving men in prevention of mother to child transmission (PMTCT) of HIV
Recent studies8 reinforce that establishing consistent participation of male partners (in this case husbands) for PMTCT activities is a determinant for success fulimplementation of PMTCT guidelines. Specifically:
- Women with supportive partners will be more motivated to undergo HIV testing, to return for test results and to disclose the HIV result to their partner.
- Couples well informed about HIV prevention and PMTCT may be more likely to adopt low risk behaviours and increase mutual support, regardless of the test result.
Studies also show that low male participation in PMTCT services increases the risk of maternal transmission of HIV to exposed infants.9,10 Further, women whose male partners came to antenatal clinic visits had less MTCT compared with women with uninvolved partners. In short, male involvement in PMTCT improves ARV prophylaxis uptake, and is a key factor in PMTCT of HIV.
Involving Fathers in Prenatal Care
Prenatal care visits are a key point within the RMNCH continuum where fathers can learn about nutrition in pregnancy, recognition of pregnancy complications, breastfeeding, postpartum family planning and the negative consequences of STIs during pregnancy (to name a few).
Several11,12,13 observational studies have shown that educating men about the importance of family health care enhances communication between men and their female partners about topics such as the health of pregnant mothers and child immunizations14,15
The Role of Service Providers16
A study of determinants of male involvement in MCH services in sub-Saharan Africa10 showed that health providers played a key role in affecting male involvement in PMTCT and ostensibly for broader RMNCH issues.
- Harsh behaviour from service providers: Harsh, critical behaviour and language from skilled health professionals is a barrier to male participation and discourages men from returning or participating in PMTCT activities.
- Quality of care: Health services providers are often overworked, stressed, and have to work in an infrastructure with severely limited resources. In such context, the quality of services is compromised and taking care of participating male partners is considered an additional burden.10
- Lack of space/resources: Clinics are often unable to concurrently accommodate pregnant women and their partners because of a lack of space.10 When there is limited physical space to accommodate male partner they are not comfortable and this can add to the burden and stress of the providers.
The staffing and financial situations in many health care systems in sub-Saharan Africa are unlikely to improve overnight. Alternative models of care targeted at men, are imperative if men are to participate in MCH activities. Alternatives include:
- Using an appointment system and/or letter of invitation by the health provider.
- Broadening services to evenings and weekends.
- Considered use of alternative, more “male friendly” venues not traditionally associated with health care provision such as bars, bus stops and churches.
The Bhoruka public welfare trust
In this initiative, health care providers were sensitised to the reproductive health needs of male clients. Specifically, the Trust developed gender specific services that delivered targeted interventions, tailored messages, specific health education sessions, and strategies for male friendly venues (health centres located at strategic terminal points in Eastern India specifically for truck drivers).17
These centres provided diagnostic and therapeutic interventions and counselling in a receptive and private space. Clinic staff were trained to avoid the judgemental approach that the truck drivers reported was a barrier to seeking sexual and reproductive health services. In 2003 alone, over 5,500 STI cases were treated in Bhoruka’s five clinic sites and mobile camps and the male truck drivers started to bring their families to the centres.
Men as Agents of Change in RMNCH
Male Health Workers for Accessible Care18
Community-based Accredited Social Health Activists (ASHA) in Orissa, India, are mostly women and often have difficulty communicating with men about reproductive and sexual health issues. Social norms limit their ability to talk with men on these matters. However, as heads of households, men often decide if a mother or child can seek health care but have limited knowledge about the importance of maternal and child health services.
In addition, security concerns limit the ASHA’s ability to tend to emergencies at night and their heavy workload poses limits to the coverage of MNCH interventions in Orissa.
To address these gaps, a pilot programme utilising a cadre of Male Health Activists (MHA) was established to target men more effectively, and increase coverage to areas that can be difficult for women to access.
A key hypothesis driving the pilot is that increased contact between community health workers and appropriately informed male household decision makers will increase access to and demand for key MNCH clinical services. The programme is testing this hypothesis via:
- Organising and conducting Purusha Swasthya Vahini (male health group/force) meetings where they disseminate information on relevant topics to the male members (especially husbands) in the community they serve.
- Escorting women in labour to facilities at night (with and without an ASHA).
- Increasing male attendance at Village Health and Nutrition Days where pregnant women go for antenatal care and children receive immunization.
- Volunteering for activities such as mobilizing members of the community during intensified immunization campaigns or malaria control efforts.
This pilot is currently being evaluated for its effectiveness.
Men as support for women suffering with mental health issues
According to WHO,19 maternal mental health problems can have negative effects on both maternal and child health. Depression and anxiety are approximately twice as common globally in women as in men, and are at their highest rates in the lifecycle during the childbearing years, from puberty to menopause.
Research20 in the UK also shows that today, 70% of new mothers turn to their partners for emotional support, compared with only 47% in the 1960s. Moreover a strong correlation is reported between perceived support by the baby’s father and lower rates of depression21 in a sample of young and highly disadvantaged mothers.
Most of the research and interventions cited in this area is done in developed countries. However, the universal nature of maternal mental health challenges lends itself to a reasonable expectation that men can play an important role in managing maternal mental health within various social contexts internationally.
Movement towards multisectoral and integrated programmes
A landmark WHO 2007 report, Engaging Men and Boys in Changing Gender-Based Inequity in Health22 found that there has been a general move from single-focus or single-issue interventions and that multi-theme programmes seem to show the highest rates and levels of effectiveness. Further, the evidence reviewed suggests that integrated programmes, particularly those that combine community outreach, mobilization and mass-media campaigns with group education, are the most effective in changing behaviour.
WHO is working with several partnerships including the MenEngage Alliance23 and the MenCare campaign to enhance their efforts to engage men as caregiver partners, promote the exchange of lessons learned, and develop evidence-based policies and programme interventions.
These partnerships seek to develop a unified voice through:
- Long-term investment in reaching boys and young men in their formative years;
- Policy initiatives in which gender equality is established as a new social norm;
- Ensuring that new programme and finance initiatives recognise the importance of routinely involving men in RMNCH.
All men and women would benefit from critical health information and services that can preserve and protect their health. With appropriate support and information most men will seek reproductive health care services and proactively participate in informed sexual and reproductive health decision-making to the benefit of their partners, children and themselves.
If men’s roles in sexual and reproductive health are recognised, understood and well addressed, men will be enabled to make informed choices that have the potential to have positive implications beyond reproductive health.
1. In Their Own Right: Addressing the Sexual and Reproductive Health Needs of Men Worldwide. Alan Guttmacher Institute April 2004. (Chapter 1) http://www.guttmacher.org/pubs/itor_intl.pdf 2. Involving Men in reproductive health: Contributions to Development (Background paper to the report Public Choices, private Decisions: Sexual and reproductive Health and the Millennium Development Goals). Margaret E. Greene, Manisha Mehta, Julie Pulerwity, Dierdre Wulf, Akinrinola Bankole and Susheela Singh. The Millennium project. 3. Engaging Men and Boys in Gender Equality and Health- A global toolkit for action (Page 45) http://www.unfpa.org/public/home/publications/pid/6815 4. Global Strategy for Women’s and Children’s health (Page9) http://www.who.int/ pmnch/topics/maternal/201009_globalstrategy_wch/en/index.html 5. “ Gender Transformative Programming ” recognises and addresses the individual, institutional and cultural dynamics that influence the behaviours and vulnerabilities of men and women. Engaging Men and Boys in Gender Equality and Health- A global toolkit for action (Page 14) http://www.unfpa.org/webdav/site/global/shared/ documents/publications/2010/Toolkit_menandboys/Introduction.pdf 6. Engaging Men and Boys in Gender Equality and Health- A global toolkit for action (Page 32) http://www.promundo.org.br/en/wp-content/uploads/2010/10/cap-2.pdf 7. Engaging Men and Boys in gender Equity- Vignettes from Asia and Africa (Page 4) http://unfpa.org/public/home/publications/pid/8050 8. Ditekemena J, Koole O et al. Determinants of male involvement in maternal and child health services in sub-Saharan Africa: a review. Reproductive Health 2012, 9:32 http://www.reproductive-health-journal.com/content/9/1/32 9. Kiarie JN, Kreiss JK, Richardson BA, John-Stewart GC: Compliance with antiretroviral regimens to prevent perinatal HIV-1 transmission in Kenya. AIDS 2003, 17:65–71 http://www.ncbi.nlm.nih.gov/pubmed/12478070 10. Delvaux T, Elul B, Ndagije F, Munyana E, Roberfroid D, Asiimwe A: Determinants of nonadherence to a single-dose nevirapine regimen for the prevention of mother- to-child HIV transmission in Rwanda. J Acquir Immune Defic Syndr 2009, 50:223–230. http://journals.lww.com/jaids/Fulltext/2009/02010/Determinants_of_ Nonadherence_to_a_Single_Dose.15.aspx 11. Dev A. Involvement of husbands in the antenatal care: Evaluation of Deepak Charitable Trust’s outreach programme. Kathmandu gender workshop. In: Men as Supportive Partners in Reproductive and Sexual Health. Narrating Experiences. Kathmandu , Nepal: Population Council Workshop, 1998. 12. Khan ME. Involving men in safe motherhood. Journal of Family Welfare 1997; 43: 18–30. 13. Brugha RF, Kevany JP, Swan AV. An investigation of the role of fathers in immunization uptake. International Journal of Epidemiology 1996; 25: 840–5. 14. Varkey LC, Mishra A, Das A et al. Involving Men in Maternity Care in India. Washington, DC: Population Council, 2004. http://pdf.usaid.gov/pdf_docs/PNACX587.pdf 15. Turan JM, Nalbant H, Bulut A et al. Including expectant fathers in antenatal education programmes in Istanbul, Turkey. Reproductive Health Matters 2001; 9: 114–25. 16. Engaging Men and Boys in Gender Equality and Health- A global toolkit for action (Maternal, newborn and Child Health Page 51) http://www.promundo.org.br/en/wp-content/uploads/2010/10/cap-3.pdf 17. U-Turn- Halting AIDS on the Highway- The Bhoruka Public Welfare Trust (BPWT). http://www.bpwt.org/publications/U_turn.pdf 18. Male Health Workers for Accessible Care- A project of CONCERN Worldwide http://innovationsformnch.org/finding-what-works/male-health-workers-for- accessible-health-care 19. WHO: Maternal Mental Health & Child Health and Development http://www.who.int/mental_health/prevention/suicide/MaternalMH/en/ 20. Holopainen D. The experience of seeking help for postnatal depression. Aust.J Adv Nurs 2002;19(3):39-44. 21. Cox JE, Buman M, Valenzuela J, et al. Depression, parenting attributes, and social support among adolescent mothers attending a teen tot program. J Pediatr.Adolesc.Gynecol 2008;21(5):275-81. http://www.sciencedirect.com/science/article/pii/S1083318808000892 22. WHO, Engaging Men and Boys in Changing Gender-Based Inequity in Health: Evidence From Programme Interventions (Geneva: WHO, 2007). http://www.who.int/gender/documents/Engaging_men_boys.pdf 23. For more information see www.menengage.org and www.men-care.org
Drafted by: Stephen Nurse-Findlay. PMNCH Coordinator: Shyama Kuruvilla. Reviewed by: Mario Festin, Paulus Bloem, Joar Svanemyr, Kirsten Vogelsong, Chandra-Mouli Venkatraman, Jane Kato-Wallace, Gary Barker, Vaibhav Gupta, Agnes Becker, Bilal Avan, Veronica Magar. Design by: Roberta Annovi.