A recent paper from the University of Sheffield in UK analyses things that determine the role of fathers during pregnancy, childbirth and babycare in a remote rural area in Nepal.

Nepal has the highest maternal mortality rate in Asia, 281/100,000. The researchers interviewed 17 fathers, 15 mothers, 3 mothers-in-law and 7 health workers.

The paper notes that in this far-flung community, the trend is for fathers to be present at the birth more frequently and to be more involved. Fathers seek medical help, help decide the place of birth, manage the finances and are involved directly in caring activities in a variety of different ways. Like everywhere else in the world, there is diversity and change and a degree of confusion!

What determines involvement of husbands in Nepal?

The article draws attention to a variety of factors that determine how fathers participate in maternal health and childbirth:

• Geography. Health facilities can be inaccessible particularly in winter.
• The cost of attending a clinic.
• The availability of the father in relation to work (he may work away from home).
• Gendered role specialisation within families.
• Lack of knowledge of some fathers and lack of confidence resulting from that.

Attitudes of professionals

A close reading of the article, however, reveals another key factor that is not drawn out fully in the paper, namely the attitudes of health professionals. We know from work in other countries that these attitudes play a key role in determining the role of men in maternal health and childbirth. Indeed, programmes that facilitate father inclusivity, such as those developed by the Fatherhood Institute, focus exclusively on the beliefs and actions of professionals, and take it as given that most fathers, when supported, will respond.

The article quotes a health worker saying “mostly women don’t want their husband to be there”, but then finds that the majority of women do want him to be there. This health professional holds a belief that is wrong. Such beliefs are common across the world and families are highly sensitive to the signals that professionals give out, often unconsciously. So, in this case, the perception may be that the professional does not ask what the family really wants, sending a message that it does not matter what they want. Mothers and fathers are unlikely to challenge this, given the experiences they are going through at that time.

The article notes that in some birth settings men are not allowed into the delivery room, but in one place they are. In this setting, the health professional justified it thus: “so that witnessing the pain of childbirth could facilitate future family planning”. This rather punitive reasoning shows no understanding of the biological and emotional processes that are triggered in men by closeness to pregnant women, childbirth and babies. As I argue elsewhere [article in preparation], it matters greatly how a father is prepared to attend a birth. It is difficult to see how a father could be well prepared if the professionals regard the reason for his attending the birth to be to ‘teach him a lesson’!

The researchers themselves say it is “surprising” that both husbands and wives want more male involvement. This suggests a low expectation on the part of the observers as to what families want. The researchers propose an explanation for this desire: “exposure to foreign ideologies”. There is undoubtedly an exposure through global communications to worldwide trends, but what is happening is not an ideological response, but a realisation that a specialisation of roles that shuts men out of closeness to caring is neither desirable nor necessary and goes against the instincts that have evolved within men. The exposure is triggering a global aspiration in both mothers and fathers, one that is highly beneficial to child and maternal welfare.

The researchers are also surprised that “husbands were aware of their lack of knowledge and voiced a sense of helplessness in learning how to care for their wives”. But this feeling of helplessness and the anxiety of being badly informed is a universal phenomenon across the world, and it is a key factor behind fathers not fulfilling the role they could in caring for mother and baby.

The power of love

The article boldly refers to “love” and suggests that there is a difference between the husband and other family members in the cases where the mother and father love each other – it creates a profound bond and a place of safety and security for the mother through pregnancy, childbirth and baby care. “Love” is not talked about a lot in this context and yet it is self-evidently a core asset for the welfare of mother and baby. The article quotes a 2010 study from Guatemala, ‘Because he loves me’: Husbands’ involvement in maternal health in Guatemala.

The article concludes with a strong recommendation that there should be more education for fathers and proposes group work. This approach is strongly corroborated by the successful experiment with group work in Uganda which we have just reported on Family Included.

The article concludes on a strong and up-beat note: “Maternal health initiatives that focus solely on women may be flawed as they ignore the social context that they live in.” The next posts on Family Included will discuss the reasons why engaging with social context brings better outcomes.

Sarah Lewis et al. (2015), The role of husbands in maternal health and safe childbirth in rural Nepal: a qualitative study, BMC Pregnancy & Childbirth 15

Photo: Jordi Boixareu. Creative Commons.