Involving Male Partners in Maternity Care in Burkina Faso: A Randomized Controlled Trial

"Involving men as supportive partners in maternity care was associated with better adherence to recommended healthy practices after childbirth."

Burkina Faso has high rates of maternal and infant mortality. Although childbearing and the care of young children are considered female domains, men are usually the ultimate decision-makers on care-seeking. However, male partners are rarely seen in healthcare facilities and have scarcely any contact with health workers. Recognising that ending preventable maternal and perinatal mortality necessarily involves engaging with communities and families, an intervention was designed to involve the male partners of pregnant women in Burkina Faso in facility-based maternity care. This paper reports on a non-blinded, multicentre, parallel-group, superiority trial of the intervention, which sought to influence care-seeking, healthy breastfeeding, and contraceptive practices after childbirth.

The study was conducted in the city of Bobo-Dioulasso, where 1,144 women with low-risk pregnancies were assigned by simple randomisation to 2 study arms: 583 in the intervention arm and 561 in the control arm (routine care only). Women allocated to the intervention group and their male partners were invited to participate in three 1-hour educational sessions at their primary health centre consisting in: (i) an interactive group session during pregnancy with male partners only, to discuss their role; (ii) a counselling session during pregnancy for individual couples; and (iii) a postnatal couple counselling session. Prior to leading these sessions, auxiliary midwives and midwives attended a 1-day training workshop that consisted in discussions, role-playing, and troubleshooting on gender issues, particularly on women's control over their male partner's involvement.

Key findings:

• 3 primary outcomes: The intervention was associated with higher rates (i) of attendance at 2 or more scheduled, outpatient, postnatal care consultations (risk difference (RD): 11.7%; 95% confidence interval (CI): 6.0 to 17.5), (ii) of exclusive breastfeeding 3 months postpartum (RD: 11.4%; 95% CI: 5.8 to 17.2), and (iii) of effective modern contraception use 8 months postpartum (RD: 6.4%; 95% CI: 0.50 to 12.3).
• Secondary outcomes: The intervention had a positive effect on the use of long-acting contraception 8 months postpartum (RD: 8.1%; 95% CI: 2.9 to 13.4), on the use of any contraceptive method both 3 months (RD: 7.7%; 95% CI: 1.2 to 13.6) and 8 months (RD: 6.5%; 95% CI: 1.0 to 12.1) postpartum, and on the timely initiation of effective modern contraception (RD: 7.6%; 95% CI: 0.2 to 15.1). The intervention was also associated with a reduction in unmet need for contraception 8 months postpartum (RD: -4.8%; 95% CI: -9.2 to -0.5). The increase in long-acting, reversible contraception use was almost entirely due to greater implant use; no permanent methods were used.
• Other outcomes: The intervention had a positive effect on the proportion of women with good relationship adjustment (based on the woman's satisfaction with the relationship with her partner and the couple's degree of communication, shared decision-making, and agreement on key reproductive health issues) 8 months postpartum (RD: 8.7%; 95% CI: 2.9 to 14.6). However, the proportion satisfied with routine care was not affected (RD: 0.4%; 95% CI: -4.8 to 5.6).

In short, the proportion of participants who adopted the recommended behaviours increased between 6.4 and 11.7 percentage points for each of the three primary outcomes; for secondary outcomes, the improvement was between 4.8 and 8.7 percentage points. These results were achieved in the context of a high level of adherence to the intervention in an area where men are not traditionally involved in maternity care.

The researchers suggest that the intervention could have worked through several possible mechanisms:

1. Couple counselling may have provided men and women with the opportunity to start conversations about issues they were not used to discussing openly. Moreover, in a context where men are seldom exposed to advice from health workers, the intervention may have enabled them to be better informed when participating in these conversations.
2. The male partner's agreement may have encouraged women to choose long-acting, reversible contraception and removed known barriers, such as financial constraints and the fear that a disapproving husband might discover an implant's insertion site.
3. Men's leverage with their own mothers may have helped some women to continue practicing exclusive breastfeeding and to refuse traditional supplementation with water and herbal infusions.
4. More frequent postnatal contact with health workers probably reinforced the messages on exclusive breastfeeding and family planning.

The researchers caution that policy recommendations for health workers to involve male partners may be interpreted by some as an obligation. Thus, training and supervision during this study ensured that healthcare providers did not pressure women to involve their partners if they did not want to. They urge: "National programmes must include similar safeguards and avoid performance-based incentives. In addition, certain parts of this intervention, notably the group session for men, attempted to stimulate critical reflection on patriarchal norms. Components designed to promote equitable gender relations should be embedded in all future programmes involving men...."