Two new reports on research from Ghana conclude that it is important to engage with families – particularly husbands and mothers-in-law – in order to improve use of maternal health facilities. The articles, however, adopt radically different perspectives on the family.
The longer article (Ganle et al. 2015) presents a clear paradigm: pregnant women want to use health facilities; they lack power and so cannot decide for themselves; family members – husbands and mothers-in-law in particular – do not want them to go to health facilities; so they don’t go. The solution is increased autonomy for women.
This argument is questionable on the grounds that the study did not actually interview any fathers or mothers-in-law and cannot, therefore, say what they believe.
The other study from the same country (Cofie et al. 2015) did ask husbands about preferred place of birth and found they were just as likely as their wives to want birth in a health facility. And another study this month from Nepal found the same. Interestingly the Nepal study showed how workers in health facilities had mistaken opinions about what pregnant women wanted in terms of partner involvement, and even the researchers expressed surprise at what fathers actually thought, once asked.
Earlier studies have also shown the influence of the husband over place of birth – e.g. a 2010 study in Tanzania and a 2000 study in Uganda. A 2012 study from Laos found that a driver of a preference for home birth is having family members around.
In one paragraph, however, the Ganle at al. article strongly questions the paradigm present in the rest of the text and homes in on how family decision-making functions: “As illustrated by women’s and healthcare providers’ accounts, communalism and interdependence are still strong binding forces, which frame how decisions, including those concerning maternity care within the household, family and community are taken. This finding suggests the need for further research to interrogate the notion of women’s autonomy for its conceptual adequacy or usefulness as a determinant of women’s reproductive health in contexts such as Ghana.”
If this scenario is closer to reality than the assumption in the rest of the article, then the key to improving maternal health is actively and effectively engaging the community of care, rather than competing with it. And, indeed, Ganle et al. conclude strongly that engagement with family and community is important.
We know from the practice of engaging with fathers in maternity and childcare services that the attitudes of health professionals to men and families is highly important. If these individuals are seen as the problem, and if the service is framed as an “intervention” to “target” them, then the service is likely to get off to a rocky start! Engagement with family members and communities need to start with (i) finding out what their motivations, fears and needs are, by asking them, (ii) engaging with them on the assumption that they want the best for mother and baby and will respond to guidance, and (iii) assisting the conversation in the community about what is best for pregnant women. This is the approach that has been developed by organisations that have developed expertise in father engagement, such as the Fatherhood Institute.
Cofie LE, Barrington C, Singh K, Sodzi-Tetty & Akaligaung A (2015), Birth location preferences of mothers and fathers in rural Ghana: Implications for pregnancy, labor and birth outcomes, BMC Pregnancy and Childbirth
Ganle JK et al. (2015), How intra-familial decision-making affects women’s access to, and use of maternal healthcare services in Ghana: a qualitative study, BMC Pregnancy and Childbirth
Photo: World Bank. Creative Commons.