Male involvement

Since the 1994 International Conference on Population and Development, there has been increasing recognition of the shared rights and responsibilities of women and men in sexual and reproductive health, including the critical role of male partners in maternal and child health [3]. The WHO has listed male involvement as a key health promotion intervention for maternal and newborn health [25, 26]. It is recommended that men are engaged in health services and optimal home practices during pregnancy, childbirth and also after birth, however the level of evidence for interventions is low; resulting in calls for further research into the impacts of male involvement strategies on health outcomes [25, 27].

Strict definitions of what male involvement entails are not yet broadly agreed [27–29], however one elementary indicator is whether men participate in antenatal care visits [28]. The WHO recommendations stipulate that male involvement interventions ought to be culturally specific and thus may differ depending on the context [25, 26]. An important factor, however, is ensuring that male involvement interventions continue to promote, or at least not detract from, female autonomy and decision-making [25, 26, 30]. Pregnancy and childbirth are especially complex because these topics are often considered to be women’s business [30], but men are often household decision makers in relation to care-seeking [27, 28].

Collaborative Newborn Support Project

The ‘Collaborative Newborn Support Project’ has been implemented in Bungoma County, Kenya in order to reduce maternal and neonatal mortality from October 2015 to April 2019. It is an intervention of quasi-experimental design, involving newborn special care units, telehealth, call centre establishment, neonatology training, and community awareness programs [31]. The cross-sectional study reported here forms part of the ‘Collaborative Newborn Support Project’ and aimed to inform interventions through an assessment of men’s and women’s knowledge and practices relating to pregnancy and postnatal care.

Study design

This is a descriptive cross-sectional survey of women and men involved in the ‘Collaborative Newborn Support Project’, Kenya [31].

Study setting

The study was undertaken in Bungoma County, Kenya. Bungoma County is located in Western Kenya, bordering Uganda, and has a population of 1.67 million people [32], mostly subsistence farmers [31], with only 11.3% of the population live in urban areas (2019 census) [33]. The project team believed it important to assess knowledge attitudes and practices of rural populations who were potential users of the hospitals in the broader project.

Study population

Women and men from the same geographic area were recruited independently, meaning that the responses to each questionnaire are not linked as mother-father dyads. In total, 82 men and 348 women participated in the study, based on the data collection resources available to the project team. Men whose female partners had delivered within the previous one year (between April 2016 and April 2017) were recruited through convenience sampling, from those accompanying their female partners to healthcare clinics, and from men in market centres that fell within the regular catchment area of the facilities involved in the ‘Collaborative Newborn Support Project’, Kenya [31]. Women who had recently delivered were recruited at antenatal and postnatal reproductive care units, and in maternal and child health clinics at two health facilities: Bungoma and Webuye hospitals. These facilities were purposively sampled, based on the fact that they are County and Sub-County referral hospitals respectively, and involved in the broader project intervention.

Data collection

Two questionnaires were administered, one to the women’s sample and the other to the men’s sample. These were adapted and abridged from the JHPIEGO birth preparedness and complication readiness tool sample questionnaires [9]. Both questionnaires covered basic socio-demographic factors and asked similar questions about knowledge, attitudes and practices relating to maternal and newborn health; however, these weren’t identical between the two surveys. Specific questions on danger signs in the postnatal period for woman or newborn classified these as Vaginal bleeding, Neo-natal sepsis, Jaundice, Convulsions, Asphyxia, High fever, Congenital problems, Difficulty breathing, Severe weakness, Changed activity, Bleeding umbilical cord, Poor breastfeeding, and free-text fields for other options. Data were collected by research assistants over a three-month period in 2017. The questionnaires were in English and Kiswahili. Research assistants translated the questions into local dialect whenever necessary. Following collection, the data were transferred to an Access database and archived in Mount Kenya University servers within the Directorate of Research and Innovation.

Data analysis

The data were cleaned and analysed using Stata 13 [34] to find summary statistics and to undertake univariate and multivariate logistic regression analyses. Complete case analysis was used in regression analyses. Some variables were grouped to dichotomous responses, based on analysis team consensus, to ensure no group was too small for regression analysis. The common approach of interpreting a p-value of less than 0.05 as indicating statistical significance was taken.

Although questions were not completely uniform across the two questionnaires, where possible we used similar variables across both data sets in the analysis to allow the contrast of women’s and men’s knowledge and practices. Outcome variables examined in the logistic regression analysis covered both knowledge and practices. There was insufficient variability in the data to include attitudes in the final analysis.

Univariate associations were tested between outcome variables and hypothesised factors of association, as determined by similar studies and the availability of data from the questionnaires. These were then included in a multivariate model to control for the effects of confounding. Potential confounding factors included in the women’s multivariate model were women’s and men’s age and education levels, monthly household income, time to healthcare facility, gravidity, age at first pregnancy and shared decision making for health service seeking between woman and male partner. Potential confounding factors included in the men’s multivariate model were women’s and men’s age and education level, and monthly household income. Outcomes considered to be on the causal pathway between exposure and outcome were included in univariate models, but not in multivariate models.

Ethical considerations

This study was approved by the Mount Kenya University Ethics Review Committee (MKU/ERC/0096). Participants signed informed consent forms after the aims and research process were explained to them, prior to undertaking the questionnaire.

Socio-demographic characteristics

Women’s sample.

Half of women were under 25 years of age (49.4%) with most of their husbands at least 30 years of age (67%). Over a third were first time mothers (38.2%) and around half had completed secondary school or higher (54.8%). Women reported their husbands as slightly higher educated, with 68.7% having completed secondary school or higher (at least 12 years of formal school). 63.3% lived in households with a monthly income at or above 10,000 KSh (approximately USD100). More than half (59.1%) lived more than 5 kilometres away from the nearest health facility. Over a third of women reported sharing pregnancy and childbirth decision making with their husband (38.8%), with the rest either making the decision themselves, their husband making the decision without them, or the decision was made by another family member, such as a mother in law (Table 1).

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Table 1. Socio-demographic characteristics of the women’s and men’s samples.

https://doi.org/10.1371/journal.pone.0251543.t001

Women’s and men’s knowledge and practices relating to pregnancy and postnatal care

Just over half of the women (51.2%) knew at least one neonatal danger sign, with over a third of women reporting that their newborn had experienced problems after childbirth (39.1%). Half of those women who had experienced a problem sought care within an hour of noticing the newborn was ill (53.2%), however, 30.6% waited for more than six hours before seeking care. Regarding antenatal care, 39.1% of women attended at least four times during the last pregnancy. Most women delivered in a healthcare facility (79.2%), be that a government hospital or a private clinic. In the men’s sample, 40.2% of the men knew at least one postpartum danger sign and half (50.0%) knew at least one neonatal danger sign. 51.2% of men accompanied their wife to antenatal care during her most recent pregnancy, either always, most of the time or sometimes. Almost all men reported that their wife’s last childbirth was in a healthcare facility (90.1%), with two thirds accompanying their wife to health facility for delivery (66.2%). Most deliveries occurred in a government hospital (79.0%) and were attended by a nurse or midwife (73.8%) (S1 Table).

Identification of neonatal danger signs.

Fig 1 illustrates that overall the sample of women could identify a larger number of danger signs than the men, although a similar proportion of women and men were not able to identify any neonatal danger signs (48.8% of women, compared to 50.0% of men). Each individual danger sign was identified by a greater percentage of women than men. Some danger signs were identified approximately twice as frequently by women than by men, such as poor breastfeeding or not able to breastfeed, fast breathing, fever, and difficult to wake, lethargic or unconscious.

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Fig 1. Identification of neonatal danger signs: Women and men*.

https://doi.org/10.1371/journal.pone.0251543.g001

Characteristics associated with knowledge of neonatal danger signs

Characteristics associated with health care-seeking practices

Limitations and strengths

A key limitation of this research is the small sample size of the men’s sample, at 82 participants. This meant that confidence intervals were wide and there was often weak evidence of associations since the small sample size reduced the power of the study to detect smaller differences. As a convenience sample, these results must be taken as indicative of potential knowledge patterns rather than being representative of the general male population. Due to limitations in the project’s data collection resources, women and men were also administered different questionnaires and were sampled in different ways. This limits the potential for direct comparison between the two groups, and because some questions were worded slightly differently for men and women, no statistical analysis of knowledge differences was possible. We estimated that we were going to get less biased cohort of men in market places than the few motivated ones who accompany their partners in the ante natal clinics. Additionally, due to cultural barriers, men who accompany their partners to ANC are really outliers. Relying exclusively on this catchment may have denied the study representativeness of the general population. The regression analysis undertaken used similar outcomes and exposures in order to smooth the differences between the two cohorts.

The primary strength of this research is that it was conceived and led by local Kenyan researchers and thus addressed local priorities. Additionally, this research has combined data from both women and men in one study, which is not widely seen in the existing literature, thus enabling a level of comparison between these two interconnected groups.