Husbands, Wives and Malaria: what do we know about male involvement?

A recent article in PLoS One highlights the positive role husbands’ involvement can have in saving the lives of their pregnant wives. A 9-item scale of husband involvement was developed, and although it did not include malaria related content because the Tigre Region of Ethiopia is not malaria endemic, the items relating to support for antenatal care attendance are certainly relevant to malaria elsewhere. Overall, maternal survival was strongly associated with higher levels of husbands’ involvement.

DSCN7129a pregnant women get ITNs when register for ANC RwandaThe importance of male or husband involvement in malaria in pregnancy services is usually assumed. For example, in Rwanda husbands are encouraged to attend at least the first ANC visit with their wives where HIV testing is done and ITNs provided.

Unfortunately the assumption about male involvement is backed by little published literature. In Mali, for example, “health facilities operating under the cost-recovery model strive to provide free IPTp, their own financial constraints often make this impossible.” When costs are connected to this malaria preventive service, “Costs … complicate household budgeting for health care, particularly as women often rely on their husbands for money.”  In Uganda husbands’ encouragement was a significant factors influencing adherence to IPTp with SP.

Use of insecticide treated bednets in prevention of malaria by women in India was indirectly influenced by their husbands. Use was positively associated by women’s decision making power as well as by husband’s educational level, with an implication that husbands are important in understanding women’s decision making.

DSCN7276There is more information about male involvement in antenatal care generally. These studies show positive outcomes in terms of ANC services uptake, and from that one may make the assumption that greater access to and use of these services can help prevent maternal deaths.

In Indonesia, “full family, particularly husband’s, support” is associated with adherence to maternal iron-folic acid (IFA) supplementation during pregnancy. The researchers concluded that husband’s support is especially important for less educated women. A study in Pakistan reported that “restriction from husband or mother-in-law” was a barrier to ANC attendance. Likewise in Uganda lack of support from husband/partner was a barrier to attending ANC and skilled delivery.

A qualitative study in Ghana aptly titled, “What men don’t know can hurt women’s health” showed a reluctance to be involved. Findings suggested that, “Although many men recognize the importance of skilled care during pregnancy and childbirth, and the benefits of their involvement, most did not actively involve themselves in issues of maternal healthcare unless complications set in during pregnancy or labor. Less than a quarter of male participants had ever accompanied their wives for antenatal care or postnatal care in a health facility.” Four barriers to male involvement included –

  1. perceptions that pregnancy care is a female role
  2. belief that men who accompany their wives are being dominated by their wives
  3. unfavorable service factors – hours, staff attitudes
  4. high costs associated with accompanying women to seek maternity care (direct and indirect)

Finally, going back to Rwanda, making male involvement a requirement, might in some cases backfire. The recommendation was seen as “a clear link in the chain of delays and led to severe consequences, especially for women without engaged partners.” Clearly not every pregnancy is the result of a loving mother-father dyad.

Since malaria is a major cause of maternal morbidity and mortality, more work is needed in malaria endemic areas to understand the life-saving role of male/husband involvement. This role will vary by culture, the local economy and the structure of health services, but a better understanding of the male role and practical interventions based on the findings will be valuable investments.

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