Husbands’ Experience and Perception of support during labour and childbirth in Tanzania

Background: A key strategy for reducing the number of women dying from delivery complications is birth preparedness and prevention of maternal complications such as haemorrhages and infections. Involving husbands who are decision makers in the house holds may play role in reducing maternal mortality which is still unacceptably high despite the targeted goal to reduce this mortality up to three quarters as targeted in the MDGs by 2015.This is still addressed in the Sustainable Development Goals (SDGs) of 2015/30 Methodology: Qualitative descriptive study design was employed; involving men aged between 24-63years. Participants under this study were selected purposefully at the clinic and in labour ward of SRRH. The in-depth interview, guided by semi structured interview guide was used to collect the audio recorded and hand written information. Data were analyzed using qualitative content analysis Results; Nine (9) semi-structured interviews conducted with husbands of women attended for antenatal care and those came for deliveries. Four themes emerged; Demonstrating love and affection, Men’s adoption with modern life style, Observing women’s right and Meeting social economic difficulties.

importance of male involvement in reproductive and child health issues. Further research is recommended to focus on exploring on how educations, urbanization and globalization variations affect male involvement in maternal and child health specifically in urban communities.

Introduction
Male companion during ANC and child birth is rare in Tanzania and in many African countries communities. It is very uncommon to find a husband accompanying a woman for delivery. However, husbands as head of families, control resources and Men decide for their wives on where and when pregnant women should seek medical care (1) even when their wives are economically well-off (2). Husbands are also social and economic powerful and they are traditionally seen by the community as facilitators of their wives' access to reproductive health services (3) Studies in many countries have shown that involving men in reproductive health interventions can help improve maternal outcomes (4), (5), (6) (7).
Male involvement in maternal and child health has been promoted for over a decade since the International Conference on Population and Development held in Cairo in 1994.
However, many cultures in Africa and Asia have been considering pregnancy and childbirth and child rearing as woman's responsibility (8). Involving men in reproductive and child health issues has been a prominent part of the shift from family planning to the broader reproductive health agenda. Men obviously make up significant new customers for programs (9) In Tanzania, Male involvement in reproductive and child health is the strategy that has been introduced and promoted at the ministerial level to health care facilities since 2008.
In this strategy, women are required to come with their husbands in the health facility during antenatal and postnatal visits and for maternal and child health services (10) This strategy is believed to enable husbands support their wives during labour and delivery and adequately prepare together for birth and birth complications that may arise (3).
Studies have reported some improvement in male involvement in reproductive and child health in issues of PMTCT (11) (12). For example, a health facility based study has reported a prevalence of 70% in Tanzania and 80% in Kenya of women accompanied by someone from their social network to the health facility during their childbirth (13) (14).
In spite of improvement of male involvement in reproductive and child health little is known about the experiences and perceptions of husbands on the support they provide to their wives during labor and deliveries in Tanzania. Understanding experience and perceptions of husbands on support that they provided or though they should provide may improve not only their involvement but also to establish strategies that would foster husbands' active participation during labour and delivery This study explored experiences and perceptions of husbands who accompanied their wives to the health facility during pregnancy, labour and deliveries at Sekoutoure Regional Referral Hospital in Mwanza Region.

Study design and participants
This is a study with a descriptive research design (15) which has been conducted to explore experiences and perceptions of support from husbands who accompanied their wives during pregnancy, labour and deliveries. The study was conducted between April to June 2016 at Sekoutoure regional referral hospital (SRRH) and Teaching Hospital in Mwanza Region. The hospital is the third referral level in the health system pyramid in Tanzania that offers a wide range of health care services including maternal and child health services.
It is a 320 total bed with 71 beds dedicated for maternity services. In the hospital about 30-50 deliveries occur each day Annual hospital report -2015. Participants were selected based on inclusion criteria through purposive sampling among husbands accompanied their wives to the hospital. These criteria included husbands who accompanied their wives for normal antenatal and delivery services, ability to speak Kiswahili and agree to participate in the study. The researcher approached the men who accompanied their wives to the hospital explain about the method and procedures of the study and those who agreed to take part in the study the times of the face to face interviews were set up as desired for the participants. Participants signed the consent form after they were told about issues of confidentiality and the voluntary nature of their participation and that they have the right to participate or to withdraw from the study at any time.

Data collection
The semi structured interview guide that was formulated by the researcher through review of literature and based on the experience of the researchers of conducting qualitative studies. The guide was not pilot tested because of its flexibility nature for revision during the course of data collection to allow new emerging issues to be included. The guide had open ended questions and probes related to experiences and perceptions of men who accompanied their partners/wives focusing on support that they provided and challenges encountered.
Nine (9) semi structured interviews with husbands (Table 1) were conducted by the first author at the quiet suitable side room that was located within the maternity ward without the presence on anyone except the participant. The interviews were conducted in Kiswahili using semi structured interview guide and were audio recorded with prior permission from the participants. Interviews were conducted until when no new information was revealed and previous shared information was repeating (15). Each semi-structured interview took approximately 20-35 minutes and field notes were taken. Before the data collection, the Medical Officer In charge of Sekoutoure Referral Regional (SRRH) gave permission to conduct the study.

Data analysis
Data was analyzed based on content analysis (16). The advantage of this analytical framework is that it is a concrete that could be readily applied and its ability to analyze data from the participants directly without imposing any other theoretical views by the researcher. The audio recorded interview voices were transcribed and translated from Kiswahili to English language by the first author. A different person back-translated two transcripts to Kiswahili to ascertain the quality of translation (17), (18) and there were no significant differences between them. Transcripts were read several times and text, phrases and statements that describes husbands experiences when accompanying their wives to the hospital (meaning units) were extracted and condensed by shortening the original text, while maintaining the core meaning (16). Medical Officer Incharge of Sekoutoure Referral Regional (SRRH) gave permission to conduct the study. Participants provided written consent after they were explained the aim of the study, the procedure of data collection, issues of confidentiality, voluntary nature of participation and that they were free to withdraw their participation at any time, the decision that would not affect services to their wives. Further, oral permission was sought from participants on the use of audio-recorder during interview process.

Results
During data analysis a total of four main themes were identified relating to the experiences and perceptions of men who support their partners during pregnancy, labour and delivery. The identified themes are; Demonstrating love and affection, Men's adoption with modern life style, Observing women's right and meeting socioeconomic difficulties during support. These themes together with corresponding categories are presented in Table 2 below.

Demonstrating love and affection
Participants interviewed in this study had different views about support they provide to their partners/wives during pregnancy, labor and delivery. They reported that support they provided to their partners was geared at ensuring the physical wellbeing of both mother and the coming baby.
"…It is in terms of services like to make sure she (the wife) gets proper diet during the daytime and during the night. All what I am doing is for the mother and for the coming baby…" (

PT. No 2)
Other participants shared that the support provided to their wives was seen as the way to appeal to what the couple sworn at the day of marriage. It is a commitment which the two agreed as they married each other.
"…it has relation with the marital oath, though as you swear during marriage you swear to be with the wife for problems and happiness because those were our agreements. So it is also because it was in our agreement that I have to be here to give her support…"(PT.

No.5)
Some participants thought that the support provided based on their religious beliefs of which they have to obey in their denominations; and others thought of the relationship they are having with their partners to be the main reason to provide support; or because he is the one responsible for the pregnancy, hence he has to take care, thus being the meaning of support. This was stated as follows: "…... I see myself as the one who was involved to make her in this condition and if she succeeds it will be fruits to me, that am why I see it is important that we are together…."

(PT. No 4)
Participants' also reported that they provided support to their partners because it was women's human rights to be supported and cared. This concept of support further generated an interesting and stimulating status for women. Among men participated in this study, when asked whether what they are doing is all about women's rights, the majority responded in the positive perspective, one insisted that it is more than women's right it is rather human right.

Men's adoption of the modern lifestyle
Support provided by men was perceived by some participants as a way of conforming to a new life style where it is not uncommon for a man to support their wives when they are pregnant or during delivery. However; some participants reported that for a long time men have been providing support to their partners, though not as it is now where provision of support to their partners make them to be seen as modern men or men who aremoving with current era. This was also stated to have improved with the current increase of educations among men compared to old times. As quoted from one of the informants; "…this was practiced though partially from the past, but because of development with

Observing women's right
Responses indicated that men commonly reported to feel their involvement in favor of their partner's rights. These are the men's concern and attentiveness over women's rights, they are being supported by the community; and also are men's expectations of their partners.
Providing support to partners during pregnancy and during laboring process is perceived by the community as a normal event and also as something that needs to be promoted among many other men. It was also established that other men are ready to assist in taking the woman to the hospital even when the owner of the wife is not around. The following was quoted from two informants during the interview. "……Every person has his own perspective; others may ignore or may see as a normal issue according to his own culture……" (PT. No 8) It came out from the participants that all the efforts men put on the support they provide to their partners has aim to gain profit. This is either in the perspective of increasing number of children as making worth of, or believing that after recovering, the partner will produce more for the family. Others went further to say that their support prevents the partners from getting psychological problems and predicting the good health status of the unborn baby. This is according to what was quoted from some participants as follows; at home including the partner who has no job. This was mentioned to be their foremost constraint especially to those introduced as wage earners (kibarua) and the entrepreneurs (wajasiliamali) i.e. all whose income is of middle and low scale. These informants also had a concern with time spent during ANC services in conjunction with being at the hospital during delivery process. In this they were thinking of how to compensate in days which has been spent either at the clinic or at the hospital during delivery process, this is according to how the following participants were quoted; " …… I usually have many activities, those days which I am required to go to the clinic it is the market day, therefore when I go to the clinic, the market issues goes down….."( PT.

No 1)
In the su pport provided by men, they are faced by various barriers perceived as challenges from the early stages of pregnancy until they reach the place for delivery. These are in terms of infrastructures which facilitate transport to the health care facility, the general environment at the heath care facility and the attitude of the care providers after reaching the facility. Again because the issues of pregnancy were taken as for women only from previously, it is an attitude which will take time to dissolve though it is advantageous to women who are escorted by their partners as they are given priority of services antenatal at the clinic. The following are some responses from informants of this study. In the other aspect, men wanted to be informed of what was going on onto their partners after leaving them to enter inside the labour ward. This was narrated by some informants who were complaining of why they are not informed; instead they just stay outside with tension and sometimes they are chased out. They are not allowed to be in the ward until the visiting hours which may take many hours before any feedback concerning their In accordance to informants under this study, each individual man is unique and therefore just encouraging other men will facilitate more men in the community to provide adequate support to their partners/wives, although education is still important to men in taking care of their partners.
"…….Advices to other men is that, they should be left free without interference; but they should be educated more on how they can care for their wives, just to encourage them.
Because each family has their protocols, so I cannot interfere with others decision….."(

Discussion
In this study men's support has been referred to as any care provided by a man to a pregnant woman and during delivery, including his physical presence either at home or at the health care facility. The study focused on men as their voice is overlooked in maternal health care also this is under research globally. Studies in Tanzania's maternal health issues has been in the perspectives of either family planning issues or during maternal to child transmission (MTCT) of HIV as their main focuses, (19) & (20). This study may have opened the door for other studies by involving men in the perspective beyond MTCT and family planning. Therefore the perspective of this study probably may change to focus on men's support to their partners/wives during pregnancy and the laboring process.

Experiences & Perceptions of men who support their partners during pregnancy labour and delivery
Some informants in this study reported to have taken charge in home activities which women could be doing during pregnant state, like the mentioned; cooking, mopping and even washing. Further more in the responsibilities these men mentioned on how they are responsible with reminding their partners according to advices obtained during the clinic visit; Example taking medications or vitamin tablets or Iron supplements, eat well, and some exercises. In all these aspects, taking care of the home duties when the partner is relieved, men have obeyed to theoretical focus of the study and to the notion of masculinities as portrayed by Cornel's (21) hegemonic notion of masculinity.
In a large context of men's responsibilities found in this study, they have reported to be the overseer of everything at their homes, in parallel to this statement, it has been reported that Men tend to be the decision-makers within families and often take the lead in issues regarding the allocation of money, transport, women's workload and access to health services, family planning and use of contraceptives (Ivanova O, 2015) .
Participants in this study also reported to be the overall supervisors in home related issues as their main responsibilities at the family level. For being an overseer to all home activities/affairs, this emphasizes a hegemonic masculinity ideal that men are the major decision makers in the home; therefore seem to carry authority than women (22) Men in this study played their part during antenatal visits as they reported to be with their partners in various occasions. They reported to have been received and handled at the clinics with priority because they were couples. This habit has seen to promote men involvement in maternal health and probably being given a priority, men feel motivated.
When they reach at the labour ward the story changes, because there is no space for men as they come with their partners and the handling is different from that at the clinic. This has been noted in some literatures which have indicated that involving male partners may further increase uptake of antenatal care (ANC) interventions. Focused antenatal care (FANC) encourages partner participation with the recommended approaches as to increase male involvement, formal invitations to attend care "male friendly", improving waiting areas, improving extended time for the services and increased communities outreach.
Despite all these approaches are well known, their implementations can be very difficult Some informants in this study reported to have taken charge in home activities which women could be doing during pregnant state, like the mentioned; cooking, mopping and even washing. Further more in the responsibilities these men mentioned on how they are responsible with reminding their partners according to advices obtained during the clinic visit. Example taking medications or vitamin tablets or Iron supplements, eat well, and some exercises. In all these aspects, despite that he is exercising fatherhood in the context of the ability to impregnate a woman, he is responding to the notion of masculinities. Further more if the teaching at the clinic is effective, he could be seen drawing on hegemonic notion of masculinity (22).
It has been reported in various studies that male support in reproductive health issues, especially during pregnancy and during deliveries is a new concept in African context (9) In this study some men had a wish to witness their partners during the delivery process so that one can do something to their loved ones and probably they could feel the somewhat the same as their partners go through. One participant wanted to be there so that he could save something to eat to his partner. The challenge was that they are not allowed to get inside the delivery room at this setting. One observation of the same, in a study done in Nepal, husbands were invited to attend birth i,e they wanted to be involved throughout pregnancy and birth after attending birth preparation classes. Similar observation was noted in a descriptive review which was looking into experiences of men who support their partners during delivery; it was found that men who had an opportunity to be with their partners during the delivery process expressed that they were happy to be present as their partners were going through pain. Lack of space in the hospital setting and the labour ward in specific, had reduced the morale of the informants under this study towards their efforts on support. This probably is because even the space they used to meet their partners during the process of labour was so small and open in such that privacy of the two could not be observed. Contrary to this, the descriptive review done to evaluate experiences of men who support their partners during deliveries indicated lack of privacy as a concern because of inappropriate infrastructures of labour and birthing rooms. This was because most of the birthing rooms in the third world and low resource countries are built in a traditional style where both audio and visual privacy is a challenge (28)

LIMITATIONS
Because data were collected in the town setting, it was difficult to get deeply into the everyday lives of some informants; two of the informants were interrupted by phone calls from their homes in between the interview, however they were followed afterwards by making a call to make a complete story. The study involved only men, the women's experiences or perceptions would have given similar or different findings hence strengthening the credibility of these results. However the study focused on men as their voice is overlooked and this is under research globally. Also the methodological context of translation in some of the information may have lost/changed its original meaning but the co authors were contacted so as to make a truck maintained. Generalizability of the results may also be difficult as this study has been conducted at a single point of the country and may call a need to quantify the idea in future studies either at the same area or in another setting but basing on the same concept of male involvement in reproductive health

Conclusion And Recommendations
Men have a significant position in providing support in maternal health through the roles identified as lived experiences and perception resulted from this study. Therefore recognizing the value of men's roles will be an important step towards finding the solutions towards the challenges faced maternal health care in these settings.
Because it has been proved through studies that men involvement in maternal health care, especially during pregnancy have positive outcome of labour and probably afterwards (Sapkota et al 2012), with this evidence there is a need to involve men from a pre-conception, also making a follow up probably after pregnancy and delivery more than in the current level. Improving the birthing places to accommodate men who wish to take part in birthing process as evidence has indicated of helpfulness for husbands and hence more respect for women. This has to be initiated early through mass education so as to increase men's knowledge and participation. All this will be for the betterment of their partners, the expected newborn and relief to the health care team.
Hospitals should set friendly environment to accept men as partners during care of pregnant women and also during delivery for positive outcome. Because it has been found as a new phenomenon in resource poor countries like Tanzania, the findings from this study may add up on the bank of information available in this country on men involvement in maternal health. In addition, from the perspective of this study, further research will be needed to focus on exploring on how these variations affect male involvement in maternal and child health specifically in urban communities, and also another study is needed to quantify the level of knowledge among men on support provided to their partners.

Competing interests;
The authors declare that they have no competing interest