Overall, the study had 42 participants, 18 men and 24 women (Figure 1). Participation was notably higher among women 57% (24/42) (Figure 5) than men who were eligible partly because male partners were reached via the women (Figure 1). . Men were older with median age of 28.5 years (interquartile range [IQR]: 25-31) while median age for women was 23.5 (IQR: 19-29). There was generally equal representation of female participation from the three clinics although in Bangwe there were fewer men: 2 vs 8 each in Ndirande and Zingwangwa. More women than men reported lower level of formal education with 70% of the women having completed primary school only compared to only 30% of the male partners. All six participants who said they were paid employees were men with none of the 24 women reporting being in any form of paid employment. Overall, 90.5% (38/42) of the participants reported that they were married. Of the participants who did not previously test for HIV, 33.3% (5/15) were men and 66.7% (10/15) were women. Social desirability bias may explain this finding as women are consistently found to have higher HIV testing percentage in the literature (4).
Factors influencing men’s decision-making process to attend or not attend ANC with their pregnant partners and testing for HIV have been organised into two broad themes namely: barriers and facilitators to male partner involvement. Five sub-themes emerged under the barriers to male partners of ANC attending women, while four sub-themes emerge as facilitators to male involvement.
Barriers of male partner’s decision to attend ANC and test for HIV
The five key factors that influenced male partner’s decision not to attend ANC with a pregnant partner and test for HIV in ANC clinics were community norms and beliefs, peer influence, risk of attending ANC and opportunity cost associated with attending ANC services. These are briefly discussed next.
Community norms and beliefs
Views of the societal norms and long held traditional beliefs regarding the roles and responsibilities of women and men seemed to play a major role in the decision making regarding male partner ANC attendance and testing for HIV at ANC clinic during a scheduled clinic visit for a female partner. ANC was traditionally considered to be spaces restricted to women and therefore not suitable for male partners because the focus of the services in these clinics were mainly directed to benefit pregnant women.
“Some people (in the community) say such men have nothing to do that is why they go there (to antenatal care), explaining that if they had some work to do they would not be wasting time going there”. Ndirande PHC-Female FGD.
The quote demonstrates how community norms fuel the perception that a mnn should not attend ANC together with his pregnant partner. It also highlights how men who attend such clinics are perceived to have nothing productive to do.
Male partner’s peers and social networks seemed to influence their decision to either attend or ignore attending ANC even at the request of their pregnant partners. Male partners frequently reported that their peers would not consider attending ANC with their partners. Male partner’s ability to conform to the ideals and values of their social networks was visibly determined by how they conducted themselves within the network. The following quotes demonstrate how opinions of peers could alter male partner’s perspectives and eventually the decision about attending ANC and test for HIV:
“My friends were just laughing at me, for example two days ago before I came here, I told them my wife wants to start going to ANC. I want to go with her to see how the process is like. My friends said, ‘you are stupid because ANC is for women only, not for men’”. Ndirande PHC-Male FGD.
The above quote demonstrates how peers ridicule and demean other men simply for attending ANC with their partner and how a circle of friendships influences men’s attitude and behaviour towards attending ANC. It also vividly illustrates real life experiences of men emasculated or perceived as not being a man enough just because they chose to attend ANC clinic. One participant described how opinions from friends about ANC are taken into consideration during decision-making processes to eventually deter male partners who may have not been totally against attending ANC initially:
“As someone already said, most men talk about discouraging things. So, when you pay so much attention to them, you tend to follow your friends – ‘… the way my friends talked, I can’t be going there with my wife.’ So, when you take those things seriously, and you were also doubting in the first place then that’s it”. Zingwangwa FGD Male.
The influence of male network members on male partner’s decision to attend ANC was also described by female participants, who narrated that women often find it challenging to convince their partner to attend ANC. Female participants were aware that most male partners are discouraged from attending ANC by their close friends as illustrated by the following quote:
“It’s mostly men themselves who discourage each other. For us women, we may be encouraging the men to be coming with us to antenatal clinic but you find that their friends are the ones who make them lazy by telling them ‘how can you let a woman lie to you? How can you go to the hospital with a woman? Don’t accept that, you are stupid to do that.’ With such discouragement if the man had thoughts of going to the hospital, he becomes lazy as well because of what his friends said”. Zingwangwa FGD Female.
The quote demonstrates how male partners, influenced by their peers, attempt to enact their masculine roles by avoiding being associated with ANC which is traditionally considered to be associated with women. Accepting to attend ANC clinic with a female partner would implicitly be relinquishing one’s masculine power and control in submission to demands of a female partner.
Perceived social risks associated with male partners ANC attendance In a cultural context of reward and sanctions, male partners anticipated that they would encounter certain negative consequences from their social networks because they opted to attend ANC clinic with their pregnant partner and this would damagingly affect their social image and position. The perceived negative reactions from their social network that male partner’s expected included weakening their male friendship bonds, being perceived as fearing and subordinate to one’s partner, and being disrespected by their male friends as captured in this quote:
“Even the relationship or friendship one had with his friends gets affected. When you go to ANC, it’s more like you will just be chatting with your wife only rather than chatting on our own as men.” Zingwangwa FGD Male.
Thus, men were afraid to lose their social identity in the community but also the social capital that they have built by merely choosing to visit ANC clinic with a pregnant partner. Another participant described the perception that men who attend ANC are either afraid of their partner or that the woman cast a magic spell on the man through witchcraft to coerce him to attend ANC which he would have otherwise not accepted in his normal self.
“Others say ‘the man is stupid and he is scared of his wife. That’s why he has gone to ANC for testing.’ They say ‘the woman has forced him to go get tested’ while others say that ‘he is scared of his wife or maybe the wife used traditional medicine’.” Ndirande Mixed FGD Male.
In the quote above, a male partner’s choice to attend ANC is interpreted as either being foolish or as a sign of subordination to the demands of a wife or simply lack of power in the relationship. Furthermore, supernatural forces are sometimes used to explain this kind of behaviour which is perceived as being unnatural for the male gender identity. The risk of losing respect in one’s network is a concern for some male partners who attend ANC, with one participant reporting that he witnessed men disrespecting male partners of pregnant women who had attended ANC:
“I have been seeing other men looking down upon or saying rude things to other men who have escorted their wives to the hospital at ANC. They say things like ‘he is stupid’ or maybe ‘I cannot participate in escorting my loved one to ANC’, or maybe ‘I am busy’.” Bangwe IDI, Male.
Opportunity cost/time conflict/food Insecurity
The amount of time required for male partners of pregnant women to be at ANC clinic was a challenge as most male partners who felt that visiting a clinic would keep them away from potential employment or economic opportunities that could help them provide for their families. This concern was amplified for poor men who were experiencing food insecurity and living in a precarious economic environment. Thus, the choice to go to an ANC clinic with a female partner conflicted with the male gender role to provide for the family as illustrated in this quote:
“It is true that many people say that a man who goes to ANC has nothing to keep him busy with. They say ‘if both a man and a woman go to ANC, who will go look for food? Will the family eat ANC?’” Zingwangwa IDI Male.
The quote above suggests seemingly clear food insecurity which often places men at the forefront of fending for the household. It also depicts stigmatisation associated with failure to provide for the family by men. For an employed male partner, their decision to attend ANC clinic with their pregnant partner was further compromised where the employer failed to allow them to leave their workplaces. Male study participants mentioned that it was difficult for employed men to be excused from work to attend ANC with their partner:
“I work at someone’s house and I have come here. So, another day comes I should tell them I am going to ANC again, they will say are you the one pregnant or what? You were supposed to go the first day of registration only, so most times you try to protect your job” Zingwangwa FGD Male.
The quote above clearly demonstrates that men may not have sufficient grounds to justify attending ANC clinics because biologically, they do not carry the pregnancy. However, there is a recognition by employers that men can attend the first ANC visit only.
Fear to test for HIV
Almost all participants mentioned that because of stigma, male partners of ANC attending women were scared to test for HIV publicly at ANC. It was frequently mentioned that male partners would rather go for HIV testing by themselves first to see the outcome alone before going for the second time with their partners when they are confident about the test outcome. The quote below illustrates the need for male partners to have a separate initial HIV test before agreeing to attend ANC with their partner.
“It’s better to go behind her back or maybe go to Banja Lamtsogolo (HIV testing centre) or health centre to get tested and see the outcome by yourself first.” Ndirande PHC-Male FGD.
It seems that fear of learning one’s HIV sero-status for the first-time with a sexual partner was intimidating to most male partners especially if the test results came out HIV-positive. Male partners were also worried about the negative consequences associated with taking an HIV test together with a partner. Importantly, the fear of learning about HIV-discordant results together was perceived to lead to marriage breakup and inadvertently revealing infidelity especially of the male partner:
“The part that I feel like is tough is if my wife or let’s just say when two people want to get tested, the first thought is if one is found negative the other positive then that’s the end of the marriage.” Ndirande PHC-Male FGD.
The quote above highlights the lack of information on the part of the general population about managing HIV discordant couples and the role of treatment as prevention. As such, a default response to HIV sero-discordant result is to think about the incompatibility of sexual partners based on their divergent HIV serostatus resulting into marriage breakups.
Facilitators of men’s decision to attend ANC
Several factors were identified to encourage male partners to decide to attend ANC with their female partners. These included an arrangement that give priority to couples during consultations, health education targeting male partners, the benefit of couples testing and availability of a male friendly space within the ANC clinic.
Priority consultation for couples
Study participants recognized that male partners would be encouraged to attend ANC where couples are given priority when undergoing formalities at ANC clinic and if they understood that their attendance at the clinic would mean that their female partner would receive prompt medical attention than the rest of women who present without a male partner. A quote below illustrates this:
“The ones [pregnant women] who come with their male partners are the first to be assisted so that the man should go back in good time to continue with his work. They both leave early that’s the good part of it.” Ndirande IDI, Female.
In the quote above, a female participant demonstrates that male partner’s knowledge that they would spend less time at a facility might encourage them to accept attending ANC with their female partner. However, it was not clear from the data whether the ANC clinics currently provided preferential treatment to couples and whether male partners are aware about this provision.
Health education for benefit of male partners
Another important factor that facilitated male involvement in ANC was a prospect of learning new things through the regular health talks at facilities before service provision starts. With a male partner in attendance, both partners get to hear about the health of the woman and the baby.
“I have learnt a lot here, they educated us on the right types of food to eat, the right sides to sleep and how much exercise and work the woman can do which is very helpful because I was not aware of all this information.” Ndirande PHC-Male FGD.
In the quote above, a man expresses excitement for learning new things about how to manage the gestation period for wife to ensure smooth delivery of the baby.
Value of testing together
It was also highlighted by participants that testing together for HIV helps them to know each other’s status cementing their relationship. In general, women saw greater value in testing together while male partners seemed to view testing together as a concern.
“It’s good because you get to know each other’s status and since you are also counselled together, you are able to remind each other on what you were told to do so it’s helpful.” Ndirande PHC-Female IDI.
“With the fear of testing together as expressed by FGD participant number 1, actually the main fear [with testing together] is that maybe my [HIV positive] status will be known by everyone.” Zingwangwa Male FGD.
Male friendly clinics
Most participants said having a male friendly clinic within ANC would allow male partners of ANC attending pregnant women to feel comfortable to visit a space that is traditionally associated with women and children:
“Having a male friendly clinic can help if it can be aside [away from the main clinic]. Most men would go since they won’t have to be shy anymore knowing they will not have to sit amongst women. And if I am found [HIV] positive everything will be discussed right there.” Zingwangwa IDI female
The quote above suggests that the current arrangement of ANC services is not conducive to the male partners who feel outnumbered and uncomfortable to sit among women. However, having a male friendly clinic would provide a safe sanctuary for male partners.