1. Introduction

Male involvement in pregnancy and childbirth has been found to influence and improve pregnancy outcomes [1-3]. Studies have shown that involvement of men contributed positively to improving birth preparedness, use of health services for antenatal care services, facility-based deliveries, and utilization of postnatal services [4-6]. The need for improved men engagement in reproductive and maternal care to promote human rights and gender equity has been consistent with many global agreements. These include the 1994 International Conference on Popula-tion and Development in Cairo and the 1995 Fourth World Conference on Women in Beijing. The outcome of the conferences acknowledged that women’s empowerment requires the engagement of men to promote improvement in reproductive, maternal, newborn and child health outcomes [7]. The World Health Organization report in 2015 on recommendations on health promotion interventions for maternal and newborn health called for inter-ventions that “promote the positive role that men can play as partners and fathers” [8]. The 1979 Conven-tion on the Elimination of All Forms of Discrimi-nation against Women (CEDAW) emphasizes the responsibility of both men and women in raising children [9].

Male involvement or engagement refers to various ways in which male relate to reproductive health problems and programs, reproductive rights and reproductive behavior considers as strategy for imp-roving maternal health and many factors have been found to affect men’s involvement or engagement [10-12]. Somali region of Ethiopia is a patriarchal community like most African settings where the influence of men is very profound, and they control households’ financial resources and hold decision-making power that affect maternal health including the choice of health services [10]. The study aimed to explore men’s perception, experience and the factors that affect the involvement of men in pregnancy and childbirth.

2. Methods

2.1 Study design and population

The study was a cross-sectional descriptive survey using qualitative method. The study was conducted in rural population in Awbare district in Somali region, site for an intervention project. The study was part of baseline assessment for a community-based inter-vention project to improve utilization of maternal and child health services in the region. The study popu-lation were religious and traditional leaders and young men who were married, and their wives have delivered at least once. They were selected because they are key members of the communities who have understanding and familiar with issues of male involvement in pregnancy and childbirth in their communities. Participants were recruited through purposeful sampling and respondents were identified and approached through snowball sampling.

2.2 Data collection and analysis

Data was collected through in-depth interviews using semi structured open-ended interview guide. Key Informant Interview (KII) was conducted among 25 participants which included 10 religious’ leaders,10 traditional leaders and 5 young men. The interview aimed at getting deeper understanding of the involve-ment of men and barriers to supporting their wives during pregnancy and childbirth. The study was conducted in September 2021. The KII data were triangulated and transcribed verbatim to produce transcripts of narrative text for thematic analysis. The data were coded according to the types of themes and issues and thematic analysis was used and comprised a mix of inductive and deductive coding. Male involvement in this study refers to active partici-pation of men during pregnancy and childbirth. Involvement was assessed in terms of accompany-ying their wives to health facilities for antenatal visits and delivery, helping out with the house chores, helping out in taking care of the other children, giving emotional support throughout the pregnancy, reminding wives of medication and antenatal visits, and making arrangement for skilled birth delivery.

3. Results

The results are organized in two major themes: knowledge of men about pregnancy and childbirth and the expected role of men; and barriers to men’s involvement in pregnancy and childbirth. Four subthemes were generated from barriers to invol-vement in pregnancy and childbirth: socio-cultural practices, financial constraints, unavailability due to economic reasons, and social habits.

3.1 Theme 1: Knowledge of pregnancy and child-birth and expected role of men

The participants demonstrated good knowledge of the benefits of pregnant women visiting the health faci-lities during pregnancy, childbirth and the possible complications that can occur when pregnant and during childbirth. Some of the respondents were quoted below:

1. Religious leader 1: Pregnant women are to go to health centre so the doctor or midwife can check them and their babies so that they don’t develop medical complications later and to deliver safely with no complications.
2. Traditional leader 1: Pregnant women can develop many problems like high blood pressure and during delivery they can bleed. There could be cases where the mothers breasts become swollen making it difficult to breastfeed their babies. So it is good for the mother to go to the clinic for checkup after delivery to monitor the progress of the mother and the baby’
3. Young male 1: During labor pregnant woman can develop medical complications which will be a risk to her life as well as the baby so to avoid that she should be taken to the health center for delivery by the midwife.

The participants demonstrated adequate knowledge of the type of support men are expected to give to their wives during pregnancy and childbirth. How-ever, they reported that these roles are not usually played by most men in their communities because of so many barriers which prevent men from translating the expectations into practice. Some of the respondents were quoted below:

1. Traditional leader 2: We men are supposed to support our wives with the enough money that they need during pregnancy and during labor which is the most critical time, we are to take our wives to the nearest health center so that they are attended to by the midwives and give birth safe and sound.
2. Religious leader 2: Our religion says that the men have responsibility to protect and care for women, therefore the man should take his wife to the health center during childbirth, and the man must be around his wife until she gives birth and while she is recovering

3.2 Theme 2: Barriers to men’s involvement in pregnancy and childbirth

The barriers to men’s involvement in pregnancy and childbirth as reported by the participants are catego-rized into four areas: socio-cultural practices, fina-ncial constraints, unavailability, and social habits.

3.2.1 Subtheme 1: Socio -cultural practices: This is the major barrier reported by the participants because of the stereotyping and feminization of maternal health issues which are held strongly in the study area. The culture doesn’t support male involvement during pregnancy and delivery other than to provide money. Men are not expected to be involved espe-cially to be seeing following their wives to go to the health facilities and those who attempt to do so are usually stigmatized by their peers. The peer pressure hinders a lot who want to get involved in doing so. Some of the respondents were quoted below:

1. Young male 2: In our culture, when a woman is pregnant and gives birth, the man has nothing to do with it, because the woman’s relatives come to help her until she recovers and, is able to do her job.
2. Traditional leader 3: In the Somali culture, women are always considered self-sufficient and do not need any support or help, all Somali men have now inherited this culture from their parents and that is why they don't help their wives when pregnant.
3. Young male 3: When a man tries to help his wife during pregnancy or follow her to go to the clinic , he is subjected to insults and abuse in the community, which causes him to stop helping his wife.
4. Religious leader 3: The reason that men are not involved in helping their wives during pregnancy and after childbirth is related to Somali tradition, which expect that when a woman becomes pregnant or giving birth, she gets help from other women such as, her sister, her mother or her husband's mother.

The participants expressed the issue of conflict between religion and culture as related to the role expected by men in maternal health issues especially when their wives are pregnant in the society. While the religious teaching encourages and expects men to be involved in supporting their wives when pregnant, the deep-seated culture prevents a lot of men from doing so. Some of the respondents were quoted below:

1. Religious leader 4: Some men who do not understand the religion very well or ignore it and prefer to neglect what religion has told us about women and their rights and instead support the bad culture in our community.
2. Religious leader 5: The main reason men do not help women is because men do not know the religion too much, because if they know the religion well, they would never neglect their wives when they are
3. Religious leader 6: We Somali men are getting more awareness nowadays on the roles which we are to play even though we are told in our religion that we should help our wives when pregnant but then the culture becomes a problem which tells us that when the wife gives birth, the man doesn’t even look at them or come close. But today there is a lot aware-ness that the we religious leaders are presen-ting using the Islamic law that the man has a lot of responsibility when it comes to his wife and his family particularly when the wife gives birth he should give a helping hand.

3.2.2 Subtheme 2: Financial barrier: The partici-pants also identified lack of money by men as another barrier that prevents them in supporting their wives especially when there is need for the wives to access health care services. In most communities in the region' it is the husbands who determine the household expenditure and provide the fund that will be required by the women to access health services. This is because most women especially in the rural population generally do not have financial autonomy and they rely solely on their husbands to provide money. When the man is unable to provide fund, it will be impossible for the wives to seek health care services at the health facilities.

1. Traditional leader 4: To my understanding why some men don’t help their wives is because of lack of money since the women will need money either for transportation or to buy drugs in the clinics and any other things she needs especially since most of women do not work and rely on their husbands for money.
2. Young male 5: If the man lacks money it would be difficult for him to give what the pregnant wife needs and will ask the wife to go to traditional birth attendants or other women in the community when she has prob-lem or about to deliver since they do not cost a lot like going to health centre.

3.2.3 Subtheme 3: Unavailability: Another barrier that affects male involvement is unavailability due to economic reason. In order to provide for the family, some men work outside of their homes or some pastoralists during the seasonal movement sometimes leave their wives and little children at home and are always not around when the wives are pregnant. They depend on their relations especially the female relations to take care of their pregnant wives. Some of the respondents quoted below:

1. Young male 3: Some men do not live with their wives and they live somewhere else, like workplace and so they are not always available to support their wives when pregnant.
2. Traditional leader 3: Some pastoralist men during the seasonal movement leave their wives behind at home and so some of their wives when pregnant will be supported by their female members since the man may be far away until he returns back.

3.2.4 Subtheme 4: Social habits: Another barrier that was mentioned by some of the participants is the chewing of Khat (Catha edulis) which is very prevalent and widely practiced by men in the study area. A lot of men are reported to spend their money on the substance with little left for their families. The participants attributed the use to the reason why some men are not being responsible to support their wives especially when pregnant. Some of the respondents were quoted below:

1. Young male 5: Men should stop chewing khat and give back to their wives the money they are spending on the khat. Whenever men chew khat they don’t remember their families.
2. Religious leader 6: In my opinion the reason some men do not usually get involve in suppo-rting their wives when pregnant is the use of Khat which is very addictive and makes them forget their full responsibility to their families.

4. Discussion

The study identified the various barriers that prevent men’s involvement in pregnancy and child birth even though they have good knowledge of issues related to pregnancy and child birth and their expected roles. The participants in the study demonstrated good knowledge of the benefits of pregnant women visiting the health facilities during pregnancy and childbirth and the possible compli-cations that can occur when pregnant. This is unlike findings from other studies on male involvement in reproductive health in Namibia, South Africa, Nepal and India which reported limited knowledge of men and experience regarding maternal health, compli-cations and danger signs during pregnancy and delivery [13-17]. Even though the participants in the study demonstrated adequate knowledge of the type of support men are expected to give to their wives during pregnancy, however the study found that these roles are not usually played my men. This finding is similar to what was reported in the study in a rural region in Ghana which reported that the men demonstrated adequate knowledge of the type of support they ought to give to their partners during pregnancy and claimed to offer but found that the men offer little support to their pregnant partners and the disconnect suggests that men are not necessarily translating their desire to support their partners into actual behavior [18].

The study identified socio-cultural practices, financial constraints, unavailability due to economic reasons and social habits as key barriers to men in supporting their wives in accessing health care service when pregnant. Social cultural practices was reported as the major reason in the study why men do not provide the needed support to their wives because of the stereotyping and feminization of maternal health issues which are held strongly in the region. Men are not expected to get involved when their wives are pregnant and men who try to be involved are stigmatized by their peers. This is similar to the findings in most studies which reported that in many cultures, pregnancy and childbirth are particularly perceived as gendered processes with consequent social stigma that leads to male shyness and embar-rassment with regards with engagement in pregnancy related activities in their communities [14-15, 16, 18-20]. Childbearing and childrearing are primarily seen as the responsibility of women even though reproduc-tive autonomy and decision-making around childbirth are often held by male partners because they control financial resources [10, 21]. Similar to this study men who get involved in care for their pregnant wives are at the risk of social derision and stigma among their peers and name calling where some are deemed shameless for supporting their wives during preg-nancy which discourages men who wish to support their wives during pregnancy [18, 22-25]. However, a study in rural Nepal on the role of husband in maternal health reported that stigma did not emerge to a great extent, with many men not hesitant to dis-cuss their involvement in supporting their wives [19].

The study also identified financial constraints as a barrier to male involvement in pregnancy and child-birth in a region where men determine the household expenditure and provide the fund for women to access health services. Previous study found that most women in the study area especially among the rural population and pastoralist communities do not have financial autonomy and rely solely on their husbands to provide money to access healthcare [10]. When the man is unable to provide money, it will be impossible for their wives to seek health care services at the health facilities. This is similar to findings from other studies which reported that husband determined the method of care his spouse received, which in turn is dependent on his financial status [26, 27]. The use of maternal health services by women was found to be associated with the husband’s income which reinforces the gendered view of men as providers [28, 29]. Another barrier that affects male involvement is non availability as a result of work or during the seasonal movement among the pastoralists who sometimes leave their wives and little children at home and not around to support their wives when pregnantThis is similar to findings from studies where men’s occupation was mentioned as the barrier to their participation as most of them are engaged in works that either take them out of where the family lives or very busy and difficult to set aside enough time to be with their wives or follow them to the clinic [29-31].

The participants in the study identified the social habit of Khat (Catha edulis) chewing as another barrier to men involvement in maternal health. A lot of men are reported to prefer to spend their money on Khat with little left for their families and the participants attributed the use to the reason why some men do not support their wives especially when pregnant Khat chewing is very common and widely practiced among men in Somali region with one of the highest prevalence in the country reported at 35% [32]. A study in Kenya reported that that due to mood changes and withdrawal symptoms when not chewing khat, many respondents used more than half of their domestic budgets on khat and was found to be associated with strain on family relationships and anti-social behavior [33]. A study in the Somali region of Ethiopia also reported that Khat use also contributed to intra-marital conflict as money alloca-ted for household is spent on purchasing khat [34]. A study among Somali communities in Australia which evaluated the possible problem associated with the use of khat reported family breakdown and neglect of social responsibilities among the key problems among identified by the study participants [35]. A similar study in Kenya which assessed the barrier to male involvement in reproductive and maternal and newborn and child health found drunkenness among men referenced as a barrier to male engagement as it created additional challenges to men in being able to provide the required support and right attitude [36]. The study suggested the need to implement sup-ortive programs, such as alcohol abuse prevention and control interventions, in the communities along-side reproductive and maternal newborn and child health programs to ensure the effectiveness of the programs and the creation of enabling family and community environments [36].

The participants in this study didn’t mention any issues related to the health system as barrier to men’s role in supporting their wives. This is unlike most studies on involvement of men in maternal health that reported attitude of the health workers, quality of care, waiting time and restriction of their movement as some of the health system barrier [14-15, 25, 37]. The participants expressed the issue of conflict between religion and culture as related to the role expected by men in maternal health issues especially when their wives are pregnant. While the religious teaching encourages and expect men to be involved in supporting their wives when pregnant, the deep-seated culture was reported to prevent a lot of men from doing so. However, studies have shown the significance of both the religious and community leaders who are the custodian of the cultures in promoting male participation in reproductive and maternal health [38-40]. The studies reported that the leaders were motivated to act as change agents and encouraged other men to assist with maternal health in their community. The studies also noted the preservation of healthful practices, such as breast-feeding, and that traditional leaders negotiated their traditional beliefs regarding gender roles while engagement of religious leaders have been found to increase participation of men in reproductive and maternal health services [38-40].

5. Conclusion

The study identified the barriers to men’s invol-vement in pregnancy and childbirth. Initiatives to promote proactive male involvement should focus on religious and traditional leaders who are community gate-keepers and the custodian of traditional norms as advocates in addressing socio cultural practice and norms that affect men involvement in maternal health. In addition, young men should be engaged as advocates to influence their peers. However, drug prevention and control intervention should be inclu-ded as supportive program in the package of inter-ventions to be provided to the men in the community.

Limitation of the Study

The findings in the study were based on the feedback provided by the respondents which may be subject to various forms of respondent bias. This was however controlled by ensuring the interview guide are open ended questions, administered by trained interviewers and confidentiality of the respondents assured. Whilst this study was limited in its geographical coverage and number of participants, it provided opportunity for better understanding of the role of men in pregnancy and childbirth and in gender-relations more broadly because the participants are key actors in the community.

Acknowledgements and Disclosures

There has been no financial assistance with the project.

Sources of Funding

None

Author Disclosure Statement

The authors report no proprietary or commercial interest in any product mentioned or concept dis-cussed in this manuscript. The views expressed in the manuscript are that of the authors and not the institution they work for.

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