A gender transformative approach is needed to improve access to maternal healthcare (Uganda) – part 2

uganda gender

Researchers in Ghana and Uganda have developed principles for a very different way of engaging fathers in maternal and newborn health – a peer led gender transformative approach.

The Ugandan researchers concluded: “in order to effectively address gendered inequities affecting women’s lack of maternal health care access and utilisation, gender must be integrated into the design, implementation, and evaluation of interventions.” They recommended “gender transformative” approaches that directly address gender norms, addressing both the supply side (service delivery) and demand side (working in the community).

Based on analysis from both Uganda and Ghana, we propose four principles for a new approach.

Principle 1: work with the early adopters of a new social norm

A gender transformative approach needs to work with men who already engage in maternal and newborn health. Their story holds the key to change. What motivates them? What barriers do they encounter? What rewards do they experience?

These men represent a different social norm that is spreading across the globe. There are men in all countries, including in poor rural areas covered by the Ugandan research, who already actively support maternal and newborn health.

Earlier research from Ghana observed the same. ““Many men embrace the importance of newborn care and some already go against deeply entrenched cultural norms to carry out healthy practices such as exclusive breastfeeding, institutional delivery and joint decision-making with their partners.”

There is a tendency, globally, to focus on the negative behaviours of men in relation to woman and child health and to consider ways of fixing this; this approach has a very poor record of success. The research article from Uganda reports in some detail on the problems of men’s behaviours, but within the text are passing references to more positive behaviours.

One woman said men don’t usually help with the housework, implying that some do. There is reference to some men providing the resources for women to attend health facilities. Some men attend health facilities in person. These men are the key to change.

Principle 2: engage fathers via other fathers

The best communicators to fathers about change are fathers who already actively support maternal health and well-being. It is possible to build a network of fathers outside of services and then invite maternal health services in to communicate with fathers on fathers’ own territory. Such an approach would relieve health services of the need to sustain and manage the facility.

The researchers from Ghana put it thus. “Men’s already-existing positive behaviours and attitudes should be built upon as entry points for supporting and increasing involvement along the entire continuum of maternal and child care.” They proposed that “alternative masculinities that include increased involvement can be encouraged through peer networks.”

This contrasts with the approach that is normally proposed: that maternal and newborn health services should engage with fathers. We have reported on dozens of these projects on Family Included and our team has been working on such approaches for 20 years. But they remain stubbornly limited in reach.

This is not just a local problem; it exists at every level of maternal and newborn health and in all countries. The World Health Organisation declared in 2015 that engaging with fathers is important, based on the evidence that this improves maternal and newborn health, but little has resulted from this. The tension between what the evidence says about a family approach to birth and what maternal and newborn health services deliver is a permanent feature of the sector. A gender transformative approach must find new ways around this.

Principle 3: build around the father’s relationship with the child

If the father-baby relationship is nurtured, maternal and newborn health improves. For example, it has been found that father-infant bonding improves breastfeeding rates in Taiwan and Vietnam.

When fathers hold and care for their babies, hormonal changes are triggered, leading to changed behaviours and permanent neurobiological changes that tune men into the needs of the infant. The more fathers are directly connected to their babies, the more their innate capacities to care are switched on.  (See our review of recent research on the biology and neurobiology of fatherhood.)

Patriarchal societies discourage father-child attachment; maternal and newborn health services do not prioritise it.

Principle 4: engage mothers and fathers as coparents

If fathers change their roles, then this has significant implications for mothers, particularly mothers with limited opportunities to develop a social role outside of caring. Ultimately for change to happen, mothers and fathers have to do it together.

The Ghana researchers wrote: “Wives and senior women with influence over newborn care should also be engaged in exercises in gender transformation so they better understand the benefits of male involvement and can support men in expanding their role as fathers.”

A gender transformative approach needs to address how mothers and fathers develop a new way of working together around maternal and newborn health. Useful in this regard is the concept of coparenting. Programmes to support coparenting work with both parents and focus not only on individual parenting activities, but on how mothers and fathers can support each other’s parenting. We have reported on Family Included how a coparenting approach improves breastfeeding rates, Breastfeeding as family teamwork: a research to practice briefing.


Dumbaugh M, Tawiah-Agyemang C, Manu A, ten Asbroek GHA, Kirkwood B & Hill Z (2014), Perceptions of, attitudes towards and barriers to male involvement in newborn care in rural Ghana, West Africa: a qualitative analysis, BMC Pregnancy and Childbirth 14

Morgan R, Tetui M, Kananura RM, Ekirapa-Kiracho E & George AS (2017), Gender dynamics affecting maternal health and health care access and use in Uganda, Health Policy and Planning 32

Photo: Susan Hunt. Creative Commons.