Male Engagement and Couples Communication in Reproductive, Maternal and Child Health in Nampula and Sofala Provinces of Mozambique

"Interventions to transform gender norms and behaviors require participatory approaches that occur consistently over time, reinforcing key messaging."

This qualitative male engagement study by the United States Agency for International Development (USAID)'s Maternal and Child Survival Program (MCSP) evaluates the feasibility and acceptability of male engagement interventions designed to improve reproductive, maternal, newborn and child health (RMNCH) in Nampula and Sofala, Mozambique. For the purposes of this study, male engagement and male participation were defined as men taking an active role in protecting and promoting the health and wellbeing of themselves, their partners, and children within households, communities, or health facilities.

In October-November 2016, MCSP conducted a quantitative baseline assessment that included a gender module; among the findings was that women who discussed RH with partners, measured by communication about family planning (FP), were 46% more likely to deliver in a facility (adjusted odds ratio [aOR]=1.46, 95% confidence interval [CI]=1.02-2.10, p=0.04).

Taking account of these findings, MCSP refined gender-focused social behaviour change (SBC) interventions during two years of project implementation, in partnership with the Mozambique Ministry of Health (MOH) and other partners. Messaging at the community level focused on couples jointly making a birth preparedness plan, couples discussing FP together, male participation in RMNCH services, and prevention of gender-based violence (GBV). These messages were delivered through participatory group dialogues called "palestras", using song, role play, dance, and discussion. At the health facility level, MCSP provided training and mentorship for health workers to conduct couples counseling to facilitate dialogue and education about RMNCH, while also encouraging women to bring their male partners to services if they chose to. Providers were encouraged to address inequitable decision-making power between couples that limit women's ability to seek care in a timely fashion.

In November-December 2018, MCSP Mozambique conducted endline studies, which included a qualitative male engagement study involving 197 participants taking part in focus group discussions (FGDs) and in-depth interviews (IDIs). Key findings included clients' (female and male parents of children under 2 years old), health providers', and facilities managers' perspectives regarding the following: male participation in family planning, antenatal care (ANC), and labour and delivery (L&D) services; decision-making about having children; and decision-making about care-seeking. In brief, FGDs and IDIs revealed that:

• Men still make most decisions about fertility and family size: Respondents reported that deeply patriarchal gender norms limit women's agency and participation in decision-making in both provinces.
• The main barriers to male participation included: fears that women only bring their partners for health services when they have tuberculosis (TB) or HIV and that they will therefore be stigmatised; that men who accompany their partners are bewitched or drugged by them; or that the health providers will be male and would see their female partners' nude bodies.
• Women reported that, because men do not usually go to couples' FP counseling visits, there is a missed opportunity for healthcare providers to understand and shift male partners' attitudes and to prevent GBV.
• Community dialogues were effective at increasing male support for healthy RMNCH behaviours, such as desire to limit the number of births and to support their pregnant partners.
• After palestras and capacity-building of health providers on effective male engagement and couples counseling, community members' knowledge, attitudes, and practices changed. For example, men reported they no longer feared being turned away from facilities when accompanying their partners to ANC visits.
• Beliefs about facility births differ, and men experience barriers (e.g., cultural taboos) to participating in L&D.
• Despite MCSP's capacity-building efforts to ensure single women are not discriminated against in health services, there is a persistent practice of deprioritising unaccompanied women.

Facilitators to male engagement within Sofala Province included public presentations at health facilities about FP or RMNCH knowledge imparted through counseling by health providers and during palestras, and the close proximity of health facilities. Within Nampula Province, facilitators to male engagement included previous negative experiences because of a lack of men's engagement encouraging women to bring their partners, men obtaining knowledge from health providers, and men obtaining knowledge and accessing services for their own health.

The study team offers the following recommendations:

• Continue, improve, and scale up palestras: For example, more comprehensive gender-focused content should be integrated into palestras, including:
  • Examination of gender norms and roles, and debunking of harmful norms or myths around RH;
  • Education about the harmful impacts of GBV, awareness raising about rights and the availability of post-GBV services, linkage of GBV survivors to appropriate services, and promotion of non-violent conflict resolution and couples' communication; and
  • Messaging on the potential benefits of male engagement (e.g., improved nutrition, breastfeeding, and immunisation rates)
• Address couples' decision-making and women's autonomy, taking care to ensure that a woman has the right to decide whether she wants her partner involved in her RH.
• Implement evidence-based group education to transform gender norms: For example, the MenCare and Promundo Bandebereho Curriculum in Rwanda engaged men and their partners in participatory, small group sessions of critical reflection and dialogue. Bandebereho found value in having some sessions for men or women alone during which they can discuss private or sensitive issues; however, for other sessions, it is important to hear the other gender's perspectives.
• Engage men as allies and champions: Facilitators can amplify the voices of men who support gender equity and those who are positively changing their behaviours. Providers should be prepared to receive men in a welcoming manner and should consider offering services in locations where men congregate in the community.
• Clarify policies around male participation in health services and address discrimination against unaccompanied women: Efforts to engage men should not come at the expense of women's agency, and providers should only ask women when they are alone whether or not they want their partner to participate, respecting their wishes.
• Invest in increasing privacy: The MOH and implementing partners should continue to support health facilities to offer private consultation rooms, doors, screens, and curtains, which can help overcome physical barriers that prevent men from participating in services and L&D.
• Invest in programmes that empower women economically and increase their employment, which can make women more capable to seek health services and can be important in changing gender norms regarding women's status in society.
• Support multisector gender efforts: The MOH should work closely with other ministries, sectors, and implementing partners to ensure that changing gender norms is a priority across all sectors.

Community members who participated in the study also suggested that health providers and Community Health Committee (CHCs):

• organise community debates, following a similar model to the FGDs, to enlighten and clarify women and men's questions regarding RMNCH services.
• provide further information about health and diseases in schools and communities on an ongoing basis;
• work with local partners to disseminate daily health information via popular and accessible local radio programmes in local languages on diseases, nutrition (with a focus on local food products available), and RMNCH services, using practical examples;
• meet with religious leaders to raise awareness about the importance of male engagement and couples' communication; and
• improve the transportation network to local health facilities.