|Year : 2014 | Volume
| Issue : 1 | Page : 20-27
Effect of a behavioral intervention on male involvement in birth preparedness in a rural community in Northern Nigerian
Muhammed Sani Ibrahim, Mu'awiyyah Bambale Sufiyan, Suleman Hadejia Idris, Sunday Asuke, Shamsuddeen Suleiman Yahaya, Abdulhakeem Abayomi Olorukooba, Kabir Sabitu
Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria
|Date of Web Publication||18-Sep-2014|
Muhammed Sani Ibrahim
Department of Community Medicine, Ahmadu Bello University, Zaria
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Delays in care seeking for obstetric emergencies are major determinants of maternal death in Nigeria. Birth preparedness has been found to be effective in reducing these delays. Male involvement is necessary for improving birth preparedness because of patriarchy which allows men to control women's access to and utilization of maternal health care.
Aim: To assess the effect of a health promotion intervention on male involvement in birth preparedness in a rural community in northern Nigeria.
Materials and Method: A quasi-experimental study in which 205 and 206 married men were enrolled into study and control groups respectively. Pre-intervention, data were collected from both groups. Thereafter, a three-component health promotion intervention was carried out among the study group. Six months after, a post-intervention survey was carried out among both groups. Quantitative data was analyzed using SPSS Statistics 17.0, and statistical significance of difference between pre- and post-intervention levels of birth preparedness was determined using Chi-square test at P < 0.05. Qualitative data was analyzed manually according to themes.
Results: Post-intervention, both study and control groups did not show statistically significant increase in the practice of birth preparedness. Analysis of qualitative data revealed that their religious beliefs were not in favour of the practice of birth preparedness.
Conclusion: The intervention did not increase male involvement in birth preparedness likely due to religious misconceptions. Therefore, future studies should consider assessing the effect of interventions that employ religious approaches on birth preparedness.
Keywords: Birth preparedness, health promotion intervention, male involvement, married men, Northern Nigeria
|How to cite this article:|
Ibrahim MS, Sufiyan MB, Idris SH, Asuke S, Yahaya SS, Olorukooba AA, Sabitu K. Effect of a behavioral intervention on male involvement in birth preparedness in a rural community in Northern Nigerian. Ann Nigerian Med 2014;8:20-7
|How to cite this URL:|
Ibrahim MS, Sufiyan MB, Idris SH, Asuke S, Yahaya SS, Olorukooba AA, Sabitu K. Effect of a behavioral intervention on male involvement in birth preparedness in a rural community in Northern Nigerian. Ann Nigerian Med [serial online] 2014 [cited 2017 Dec 12];8:20-7. Available from: http://www.anmjournal.com/text.asp?2014/8/1/20/141025
| Introduction|| |
Male involvement in pregnancy care refers to all the care and support that men give to their partners who are pregnant or experiencing the outcome of pregnancy in order to avoid death or disability from complications of pregnancy and child birth.  Because patriarchy invests men with the power to determine what their wives do or fail to do, men often have control over women's access to and utilization of maternal health services. 
Birth preparedness by a couple ensures that appropriate care is received during delivery and also reduces the delays that commonly lead to maternal mortality.  Internationally, the realization of the need to promote the involvement of men in birth preparedness has seen many efforts geared toward achieving it. For example, an attempt was made to examine the level of involvement of husbands in birth preparedness in Nepal using the data drawn from Nepal Demographic Health Survey of 2006.  A similar attempt had also been made in a smaller study carried out in a Nepalese community.  The Nigeria Demographic and Health Survey,  however, does not assess the practice of birth preparedness.
In exploring the effect of various interventions on improving birth preparedness, a study conducted in Nepal found that joint health education of women and their husbands improved birth preparedness practice among them.  In Zimbabwe, the Mira Newako Project engaged pregnant women and their husbands through a number of interventions, including community outreach, clinic-based education and couple-oriented counseling.  The project reported improvement in male involvement behaviors among men who received couple-oriented counseling and/or community outreach and were given the Information, Education and Communication (IEC) materials, unlike among men who only received IEC materials.
The Nigerian National Reproductive Health Strategic Framework and Plan of 2002-2006 called for the establishment of elements of birth preparedness,  and the Federal Ministry of Health launched a birth preparedness plan in 2005. ,, Hence far, a number of studies have found low level of male involvement in birth preparedness. ,, In addition, there is relatively limited program experience and research on how male involvement in birth preparedness can be improved in Nigeria. Between 1990 and 1995, a project was implemented in Kebbi, northern Nigeria to mobilize a community through participatory methods, to improve pregnancy and delivery outcomes and to prevent maternal deaths.  At the end of this project, delays that were due to husband being away or lack of prior permission, transport, money, or awareness of danger signs had reduced significantly.
The above represent the relatively limited program experience and research that have been conducted on male involvement in birth preparedness in northern Nigeria. This shows that there are only few tested interventions to improve male involvement in reproductive health, and they are concentrated in particular areas of reproductive health, mostly family planning. Therefore, this study was conducted to determine the effect of a behavioral intervention on male involvement in birth preparedness among married men in Dinya, a rural community in North-Western Nigeria.
| Materials and Methods|| |
The study was carried out in Dinya and Garu, both rural communities with populations of 6206 and 4842 respectively,  and located in Soba and Kudan Local Government Areas of Kaduna State in North-Western Nigeria. Each of them is about 30 km from Zaria, the former capital of the Hausa kingdom of Zazzau, and they are about 43 km apart. They are inhabited predominantly by Hausa-Fulani Muslims; and governed by a local government council and a strong traditional institution commanding greater respect from the people.
Both communities have access to mobile telephone network, radio and television services, and there are few individuals in the communities who either owned satellite television or had access to watching it. There are untarred access roads leading into the two communities, and their referral health centers are general hospitals; the one for Garu is about 10-12 km away while the one for Dinya is about 45 km away. The major maternal health services rendered by the primary health care centers within each facility are antenatal care and patient referral. In addition, they offered occasional normal delivery and family services, the latter on demand.
The design was quasi-experimental, with pre- and post-intervention components. The study population included all married men who were presently living in the same home with their wives, and who had lived in Dinya (the study community), and Garu (the control community) in the past 3 years. Any man whose wife had not been pregnant in the last 3 years preceding the pre-intervention survey was excluded from the study.
In each community, multi-stage sampling technique was used to select 208 participants. In the first stage, 16 unguwa were selected from a list of all the unguwa in each community using balloting (Dinya had 23 unguwa while Garu had 18). The second stage entailed selection of 13 houses within each selected unguwa. On arrival at a selected unguwa, a list of all the streets/paths in it was made and one street was selected as the first to be visited using balloting. Then, the first house to be visited on the streee/path was selected from among the houses on the street/path using balloting. In this selected house, the household with an eligible respondent was identified. Where there was more than 1 eligible household in a house, balloting was used to select one household for the interview. In the final stage, one respondent was selected from the selected household using balloting. On completion of the interview in the house, the interviewer exited that house and moved to the house that is to the right of it. This process continued until the required sample size of 13 respondents from each of the 16 selected unguwa was reached, giving a total of 208 respondents.
The participants were interviewed using a structured and coded interviewer-administered questionnaire adopted from the questionnaire for the Nepal Demographic and Health Survey.  The questionnaire was pretested in Bomo another rural community located about 25 km away from Garu, the nearer of the two communities and in a different local government. Adjustments were made accordingly. The questionnaires were administered by a team of ten male research assistants; six junior resident doctors and four community health officers.
In addition, information was obtained through qualitative data collection; focus group discussion (FGD) and key informant interview (KII). In each community, there were two FGDs, each conducted with a group of eight married men purposively selected according to their ages to ensure some homogeneity in each group; 18-35 years in one group, and 36 years and above in another. Similarly, there were two KIIs in each community, with one participant in each KII purposively selected based on his position in the community; community head and leader of community development association. The FGDs and KIIs were conducted in the local language, Hausa, by the researcher (as the moderator) and one of the research assistants (as the note taker), both of whom were trained qualitative data collectors.
Data collection was done concurrently in the study and control communities over 5 days; under close supervision, with one supervisor in each community, who checked each completed questionnaire for completeness and consistency.
A behavioral intervention was carried out for all the participants in the study community- Dinya. The intervention lasted a total of 4 weeks, and featured:
- Five interactive workshop sessions with each lasting 3-h.
- A film show and discussion that highlights some reproductive health issues including the role of men in pregnancy care.
- Almanacs that carried messages of male involvement in reproductive health were distributed.
Detailed explanation of each activity is given below.
There were a total of five sessions in 4 weeks; one session on the 1 st day of each week for 4 consecutive weeks, and an extra session held on the 2 nd day of week 1. Each session lasted about 3-h, and was done according to a training module adopted from Training of Traditional Healers; Facilitator's Guide  and adapted to fit the objectives and audience of the workshop. It contained sections on spousal communication, joint decision making, husband's presence at antenatal care, male involvement in household chores, and male involvement in birth preparedness. The module was pretested in Bomo, Sabon Gari Local Government Area, Kaduna State; by simulating the workshop over a period of 2 days.
Participants were divided into three equal groups, and all groups had their separate sessions on the same day, one after the other. This division was to ensure adequate sitting space and ease of interaction. For each session, one of the facilitators (with the support of a co-facilitator) gave an interactive presentation in the local language with the aid of cardboards and public address system. Participants who attempted to attend a session more than once were prevented by keeping a list and identifying all those who already attended.
Film show and discussion
This had four sessions with each session holding on the 3 rd day of week 1 and on the 2 nd days of weeks 2-4. Each session lasted about 3-h: A 1-h Hausa film titled Buri Na (My Desire) was shown to the participants, followed by a 1-h discussion based on a discussion guide that was developed along with the film by Johns Hopkins School of Public Health/Centre for Communication Program. Buri Na! (My Desire!) was a local video that provided maternal health information through an entertaining story that taught the relevance of husband and wife engaging together in various practices of pregnancy care, including birth preparedness.
An almanac of the Islamic calendar of the current year that carried male involvement messages in Hausa language was given as a souvenir to each participant on the 1 st day.
Follow-up of respondents in the study community was achieved through telephone conversations with participants, community leader and leader of the community development associations, and periodic visits to the community to answer questions and clear any doubts on the content of the intervention.
A post-intervention survey was carried out 6 months afterwards on the same population and using the same data collection tools and research team, as the pre-intervention survey.
The quantitative data collected was analyzed using SPSS Statistics 17.0 (SPSS Inc., Chicago, IL, USA). In the interpretation of the outcome variable, practice of birth preparedness, a participant was said to have had good practice if he answered "yes" to at least 3 out of the 6 listed practices. For each community, change in practice of birth preparedness was assessed by comparing its pre-intervention level with its post-intervention level, and testing for the statistical significance of their difference using Chi-square test at P < 0.05.
The qualitative data was analyzed manually. Data collected on tape from the FGDs and KIIs were transcribed, translated and separated according to themes derived from the components of birth preparedness and presented in prose form, with the difference between the pre- and post-intervention responses identified.
Ethical approval was obtained from the Ethical and Scientific Committee of Ahmadu Bello University Teaching Hospital.
| Results|| |
In the study community, 205 married men were successfully interviewed at the pre-intervention survey and 192 at pre-intervention, giving an attrition rate of 93.7%. Similarly, in the control community, 206 were successfully interviewed at pre-intervention and 196 at post-intervention, giving an attrition rate of 95.1%. The mean age of the men was 37.8 ± 11.1 years in the study group and 36.3 ± 10.5 years in the control group. About three-quarter of them had below secondary school education. More than half had five or more children, and about the same proportion had two or more wives. There is no statistically significant difference between the sociodemographic characteristics of men in the study and control groups [Table 1].
|Table 1: Distribution of sociodemographic characteristics of the men in study and control communities|
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At pre-intervention, the levels of birth preparedness in the study and control groups were 12 (5.9%) and 15 (7.3%) respectively, and the difference between them was not statistically significant [Table 2]. At post-intervention, the levels of male involvement in birth preparedness was 12 (6.2%) in the study group, and 16 (8.2%) in the control group, and the increase in levels of birth preparedness in both groups were not statistically significant (P = 0.868 and P = 0.740 respectively) [Table 3].
|Table 2: Pre-intervention levels of birth preparedness among study and control groups|
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|Table 3: Comparison between pre- and post-intervention levels of birth preparedness among study and control groups|
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The study assessed the levels of the individual indices used to assess birth preparedness. Although, all the increases were not marked, the increase was highest in the proportion of men who were saving money (3.9%) and lowest in those who were giving prior permission to their wives to seek care in case of an emergency [Figure 1].
|Figure 1: Comparison between pre- and post-intervention levels of the indices of birth preparedness among the study group|
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Comparison of pre- and post-intervention results of focus group discussion and key informant interview
Participants were asked about the health problems among the women in their communities. Pre-intervention, they listed some general medical problems, and some pregnancy-related problems; prolonged labor, vaginal bleeding, foot swelling, fitting, dizziness, and lack of ready transport to health facility in times of emergency. One participant said, "Bleeding in pregnancy which results to death of pregnant women." At post-intervention, the same range of problems were listed, with high blood pressure and "lack of sufficient blood" as additions.
On the role that husbands play to safe guard their wives' general health, at both pre- and post-intervention, this was said to be best in cases where there was good understanding between a man and his wife, and it was mostly by getting someone to relieve her of household chores, taking care of her upkeep, or by taking her to the hospital and buying the drugs prescribed.
On the role played to safe guard the health of their pregnant women, the roles mentioned included encouraging wife to attend antenatal clinic and accompanying her to the clinic, reducing the household chores that she did, taking care of her basic needs, permitting her to seek health care when ill, taking her to the health facility when ill, donating blood whenever she needed to be transfused, and even providing traditional medicines for her to take regularly. However, one FGD participant said roles that required a husband's presence was usually difficult to play because husbands had to go out to earn a living for the family. At post-intervention, they added that the men bought any drug prescribed for their wives during antenatal visits and also made sure that their pregnant wives ate good diet. In addition, more men were making sure that their wives attended antenatal clinic and accompanying them when time permitted.
Changes in the practice of birth preparedness
Discussions about birth preparedness were uncommon between the men and their wives, because they mostly preferred to "rely on God" for safe delivery of their pregnant wives. It was a common notion that most pregnant women in their communities delivered safely at home, making the practice of birth preparedness unnecessary. One community head during a KII said, "Discussions about birth preparedness is uncommon in my own house. There have been 15 deliveries here and it was the 16 th that had a complication that took her to the hospital." However, few participants agreed that they discussed the need for prior arrangement for transport in case of any obstetric emergencies. At post-intervention, issues concerning birth preparedness were still not commonly discussed, and the only discussions on birth preparedness were related to procuring materials such as new razor blade required for home delivery, mother's and baby's clothing's and the ram for naming ceremony. One post-intervention FGD participant said, "You see, now some of us can discuss certain things with our wives because we know they would not take over our house. However, some things are against our religion, so we cannot do or talk about them." At this, there was no agreement among the participants about which specific issues were against their religion.
Looking at the individual practices under the birth preparedness, most participants agreed that saving money was important. One participant in an FGD said, "For me, I think saving money is the most important preparation", and the rest agreed to this, adding that saving money was a difficult task. At both pre- and post-intervention, most husbands prepared by stocking items like razor blade, cardigan, traditional medicines, firewood, and purchasing ram and food items for naming ceremony. They, however, noted that in times of financial need, these items served as savings because they were sometimes sold to raise money. In addition, most participants said many couples could not afford any arrangement for transportation and had to leave everything to God. Furthermore prior permission for a wife to seek care in times of emergency was not common, so that when an emergency occurs, permission had to be granted by the husband, or in his absence, by his own relatives. However, at post-intervention, more men were said to be making arrangements for emergency transportation and giving prior permission for their wives to seek care in case of emergency. However, at both pre- and post-intervention, they hardly made prior arrangement for blood because it was said to be available for purchase in most hospitals, and because any unused donated blood was never returned to the woman or any member of her family. One participant in a post-intervention FGD said, "All this talk about storing blood and keeping money in anticipation of trouble is against our religion. God does not place a burden on his servant without giving him the means of shouldering it." Most participants agreed with him on this.
| Discussion|| |
Delays in care seeking for obstetric emergencies are a major contributor to maternal death, and the practice of birth preparedness helps to remove the first three of the four delays. , Overall, the intervention in this study did not produce a significant improvement in the practice of birth preparedness in the study community. The initial low levels of birth preparedness in this study and control communities have been discussed in an earlier publication. 
The slight increase in birth preparedness after intervention noted in this study is at variance with the 21% reported in another intervention study done in Nepal.  Although, the increase recorded in the Nepalese study was not accounted for by birth preparedness practices alone since birth preparedness practices were only a component of a composite indicator that measured knowledge of respondents and use of health services. Therefore, the 21% increase was higher because it included knowledge change which did not necessarily imply a change in practice.
Another explanation for the relatively small change recorded in this study could have been due to the fact that more than 80% of the participants had level of education below secondary school, which could have negatively influenced the extent to which the participants understood and adopted the new behavior (birth preparedness).  The Nepalese study, however, was silent on the educational background of its participants. The lack of increase in the birth preparedness practice observed in this study, could have been due to the extent to which the issue of birth preparedness among this study population was clouded by religious misconception which could have negatively affected the way that participants responded to the messages in the intervention,  considering that the intervention was not religious in its approach. This seems to suggest that religious leaders could have a role to play in improving male involvement in birth preparedness in such communities.
Looking at the changes in the individual indices of birth preparedness, this was least in the proportion of men that gave prior permission, probably because of the culture of patriarchy. ,,, Interestingly, the increase in the proportion that arranged for a birth attendant is slightly higher than the one for those that had identified a place of delivery. The reason for this could be because they preferred home delivery by known identified traditional birth attendants or relations. The change in the proportion that had arranged for means of getting blood was also among the least, probably because the factors influencing this were related to strong religious beliefs and the prevailing blood donation policy, factors which this intervention did not address. Finally, the highest change was in the proportion that saved money, although this must be interpreted with caution because of the reasons given for saving toward delivery. Interestingly, most couples saved money and procured materials mainly as a preparation toward the ceremony that usually follows a safe delivery. The possible advantage of this has already been discussed in the earlier publication mentioned above.
| Conclusion|| |
Prior to the intervention, both study and control groups showed unacceptably low levels of male involvement in birth preparedness. After the intervention, both communities did not show significant increase in the levels of birth preparedness. These observations are most likely because the practice of birth preparedness was negatively influenced by religious misconceptions, and so might require interventions that address them from a religious perspective, rather than ones that sought to appeal to judgment. Further research to improve male involvement in birth preparedness in rural northern Nigerian communities should consider evaluating the effect of interventions that have religious components. A possible approach could be to train religious leaders on how to disseminate messages on male involvement in birth preparedness, in addition to other efforts to improve birth preparedness. Because participants in both communities have reported that the items that they stocked for post-delivery ceremony sometimes served as a form of savings, further studies should also explore the precise role that such stockings could play in assuring that funds are readily available in times of obstetric emergencies.
Nevertheless, we recognize that this study has two limitations. First, the men had been asked questions about issues that were generally considered to be private between a husband and his wife, and the information obtained from them were not independently verified, as such were subject to willful misstatement and recall bias. In second, participants in either of the communities could have received information on birth preparedness through some other means outside the intervention carried out in this study (e.g., radio and television program), which could have increased or decreased the changes observed here.
| Acknowledgment|| |
The authors wish to acknowledge Hadiza Babayaro, the Senior Programme Officer, Johns Hopkins University Centre for Communication Programme KuSaurara Project, Nigeria for the support that she gave through out the period of the research.
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[Table 1], [Table 2], [Table 3]