The fear of social stigma experienced by men: A barrier to male involvement in maternal services in Misungwi District, rural Tanzania

Background: Evidence have shown that male involvement is associated with improved maternal health outcomes. In rural Tanzania, men are the main decision makers and may determine women’s access to health services and ultimately their health outcomes. Despite efforts geared towards enhancing male participation in maternal health care, participation remains low; one barrier that impacts men’s participation is the fear and experience of social stigma. This study, built on previous ndings about men’s perspectives in attending antenatal care appointments in Misungwi district in Tanzania, more closely examines the fear of social stigma among men attending maternal health services. Methods: A secondary analysis was conducted on data collected for a broader research study on male involvement in maternal services. We conducted twelve focus group discussions with males of reproductive age, and six in depth interviews with health care workers and village leaders. Interviews were audiotaped and transcripts were transcribed and translated to English. Transcripts were organized in NVivo V.12 then analyzed using thematic approach. Results: Three main themes were found to create fear of social stigma for men: 1. Fear of HIV testing; 2. Traditional Gender Norms and 3. Financial and material insecurity. Conclusion: Respondent’s experiences reveal that fear of social stigma is a major barrier to attend maternal services with their partners. Attention must be given to the complex sociocultural norms and social context that underly this issue at the community level. Strategies to address fear of social stigma require an understanding of the real reasons some men do not attend maternal services and require community engagement of community health workers (CHWs), government ocials and other stakeholders who understand the local context.


Introduction
Maternal mortality is a critical health issue in Low-and Middle-income countries (LMICs) such as Tanzania. In Tanzania, maternal mortality ratio has remained high, at about 566 per 100,000 live births [1], despite several interventions at the health facility and community levels. Over the decades, research has shown that addressing gender equity issues in LMICs is an integral part of the efforts to reduce maternal and perinatal mortality and morbidities [2,3]. Men are often decision makers at family level in terms of when and how women access and utilize antenatal care (ANC) & delivery services and ultimately maternal and child health outcomes [4,5].
Enhanced male participation in ANC and delivery services, can increase shared decision making in impactful health choices such as parenting, health care-seeking for delivery and illness, contraception, and family planning. Increased male involvement during pregnancy has several advantages such as in reducing maternal stress through emotional, logistical, and nancial support. Furthermore, male participation during maternal services is associated with increased use of health facility delivery and use of postnatal health services and reduced postpartum complications [3,6]. Although men play a key role as the main decision makers in the family, interventions and programs to improve access and utilization of maternal services, often target women, and despite efforts to include and encourage men's attendance, their involvement in maternal health matters remains low [5].
Studies in Nigeria and Gambia, patriarchal countries similar to Tanzania, revealed that social stigma is one factor that contributes to men's low attendance to maternal services. In many communities, community members look down on men who escort their wives to ANC and delivery services [5,7,8]. In a study in Kenya, men reported that they would be perceived as being "ruled" by their wives, "ridiculed" and not seen as "men" if seen taking part in maternal services [9]. Further, economics and material insecurity have been found in other studies to be a barrier to male attendance. A study in Geita region of Tanzania found that community members may feel stigmatized for not having good attire at the health facility and is a barrier for ANC and delivery seeking [10].
The social stigma related with HIV infection and testing at health facilities can prevent male attendance for maternal services [11,12]. While men fear being tested, they also fear that their results will not be kept con dential; healthcare worker's (HCWs) who broke con dentiality has been found in South Africa [13].
Such experiences can create mistrust, fear and resistance for men to attend maternal services [8,10,14,15].
Men are clearly impacted by various cultural practices and gender roles and these may negatively impact seeking maternal services. In our recent study [2] we examined perceptions of males in Misungwi district that impact attendance to ANC services and described two themes: 1. Perceived exclusion during ANC visits among men and 2) Traditional gender norms resulting to low attendance among men, with subthemes of (a)shame and (b) secrecy. In this study, we sought to more closely examine and better understand the genesis of social stigma, which appeared in our subtheme of shame, and how the fear of social stigma impacts male attendance to ANC and delivery services.

Methods
This study was a secondary analysis of qualitative data collected for a broader research study of perceptions of male involvement in maternal services in Misungwi District located in Tanzania. The full methods for the broader research study are outlined in detail elsewhere https://doi.org/10.1186/s12884-021-03585-z [2]. Upon completion of our study [2], we returned to the data to more fully examine the data for stories of shame, stigma or fear, which was touched upon in our broader study.

Data analysis:
Data collected were in Swahili language, then transcribed and translated in English. The transcripts were reviewed by the technical team from CUHAS and BMC to ensure accuracy of participant interviews. The secondary thematic analysis was in uenced by our analysis and ndings of our rst paper https://doi.org/10.1186/s12884-021-03585-z [2] and we used sensitizing concepts such as fear, social stigma and gender norms to more fully explore the experience of social stigma. We used NVivo version Page 4/12 12 to organize qualitative data. Transcripts were read line by line and chunks of data were assigned a code. The codes were organized in NVivo and code books were generated and reviewed and agreed upon by external mentors from University of Calgary (UoC) and CUHAS. Codes were organized and collapsed into themes.

Results
The table below shows demographic characteristics of respondents whose age ranged from 25-60 years and the majority were above 35 years and were married (80%) as described in the Table 1 below. The three themes found in this study include: 1. Fear of HIV testing, 2. Gendered male norms and roles and 3. Financial and material insecurity.

Theme 1: Fear of HIV testing
Respondents revealed that men fear taking the HIV test and the social stigma that accompanies having a test, testing positive and compromised con dentiality about test results. The fear of HIV is a collective fear, accompanied by social stigma in the community; however, respondents share that women may be disproportionately bearing the responsibility of being tested. Respondents shared that men may prefer their partner to attend ANC, take the HIV test and as a result many men will assume that their result is the same.
One respondent explains, "Men are unwilling to be tested for HIV. They just tell their women, you go alone, if you are HIV negative, I am also negative" (Father with one child). Given that HIV testing is mandatory during ANC visits, male involvement in this portion of maternal care is subsequently impacted more than other aspects of maternal and newborn care.
The fear of HIV testing is augmented by the fear that others will overhear their diagnosis or that healthcare workers breach con dentiality and may reveal a positive HIV test in front of others or share it with others without consent. Several respondents shared experiences that increase their fear of being stigmatized. One participant noted that con dentiality was not honored in the clinic: "Some community members noticed that I was seated somewhere privately with a healthcare worker. To my surprise they asked the nurse about the conversation and this nurse revealed to him about my result.
Next time I will not tell her a thing" (Father with more than one child).
"Help us with the treatment we receive from our healthcare providers, health providers should not reveal the secrets of the patients because when they do that, that person won't tell them a thing when they meet her/him again, even if she has some illnesses, she/he won't tell them because they are not trustworthy" (Father with one child).
Another respondent shared that community members may know the results of a man's HIV test, and they assert that healthcare workers are sharing this information and breaching con dentiality. Some individuals noted that the physical space is often not conducive to private conversations, increasing the risk of men experiencing discomfort in taking the HIV test and desire better spaces at health facilities. One respondent explained: "The Government should create more privacy so that there can be space to accommodate people to talk freely with a health provider so that what you tell her remains there and you do not hear about it elsewhere." (Expectant father).

Theme 2. Gendered male norms and roles
Participants shared several impacts of the locally held beliefs about male and female roles in the community that can create a fear of social stigma for men. Attending and being part of ANC is often considered a 'woman's issue' and many men report feeling shame and a fear of being laughed by their fellow men if they escort their partners to the health facility.
A father shared, "we have a shame, shame is upon us we men to attend clinic. The shame comes when we escort our wives, other men will laugh at you…" (Father with more than one child).
The act of men walking together with their partner and attending health facility visits is impacted by cultural beliefs. Sukuma tribe members hold the belief that men are being controlled or charmed by their partners, which con icts with their roles as a man. A man explained: "The community believes that if you're with your wife all the time people will say (heeee) this man has been whipped, set under control of a woman that's why we are not going" (Father of one child).
When couples arrive at the clinic, there are further discomforts for men and women. Culturally, it is not common for men and women to sit together in most gatherings. The father report that.
"sitting together in the waiting spaces or on the same bench is "uncomfortable to sit with many pregnant women…while there are no other men." (Expectant father).
Having multiple sexual partners among men is an accepted norm in the study site. Yet, there is perception among men that while having a concubine is common, it is still done in secrecy. This results in men not attending appointments with women to avoid being seen by others with someone who is not their wife.
You nd most of men have more than one family, so if he escorts a concubine and that man is seen by other people at the clinic, it will be revealed that he escorted another woman, that will become a barrier to escort a woman to ANC. Because men fear family con ict which may arise if he is seen with a concubine at the health facility (Father of one child).
"You nd someone went out of his marriage then the woman faces challenge to come with him to clinic as others will know, that's why they pick other men such as "boda bodas drivers" to satisfy health providers that they came with their husband" (Health care provider).

Theme 3. Financial and material insecurity
Respondents reported several experiences that contribute to insecurity, shame, and fear of being judged by health facility workers or community members. Some respondents disclosed that for Sukuma speakers, not being able to understand or speak Swahili contributed to insecurity and resistance to attend the health facility. One participant described: "In my opinion some men do not escort their partners because they are afraid of being asked questions at the health facility, so they are shy and uncon dent of expressing themselves in Swahili language if the HCW does not communicate tribe language (Sukuma)" (Father with more than one child).
"… other men are afraid to come to our facility because they have not prepared their wives with the requirements for individual birth preparedness, others are afraid to come because of economic status, so mostly those are the reasons" (Healthcare provider).
In the Sukuma community, the family is expected to bring clothes (Khanga) and other materials for the delivery of the baby. For some families who lack the economic means to provide materials or who lack the proper attire, reported shame for being unable to provide the clothes and materials. One of the respondents shared a story about a man who escorted his wife without the required clothes to support the woman after delivery: "Some men do not escort their pregnant woman because rst of all they do not take good care of them in terms of buying nice clothes, so they feel ashamed when they go together with a woman who has no proper attires" (Village Leader).
"I observed in one facility there was one man who came with his wife with one pair of cloth (khanga), and when that woman gave birth that man was asked to give his shirt in order to clean his wife's blood, that man was embarrassed, and he said he will not attend the facility unless he has clothes for her wife" (Community Health Worker).
In Sukuma culture, it is important for men to be the provider and are considered the 'head of the household' and being perceived as unable to provide for their wife and baby is a large barrier in attendance to ANC and delivery services.

Discussion
We found several experiences about the fear of social stigma that serve as a barrier to men's attendance and involvement to maternal services in rural Tanzania. There is a social stigma surrounding HIV testing and testing positive for HIV, which is augmented by fears of a lack of con dentiality around test results. Engrained gender norms impact men's attendance, such as gendered roles (e.g., pregnancy is a woman's issue; sitting with women at the clinic), social stigma related to appearing "charmed" by one's partner or shame about being judged as being of a lower economic status (e.g., being unable to provide clothes/materials for their partner). While extramarital affairs are culturally common among men, they likewise are done in secret and men fear being seen by others should they escort a woman who is not their wife to the health facility. To maximize male attendance, efforts must work with communities to understand and address deep-rooted cultural and gender-based norms that create fears for men and seek local solutions to encourage meaningful participation during pregnancy in locally appropriate ways.
While men attending maternal services with their pregnant partners is increasingly being endorsed as a standard to promote optimal family-centered care, its achievement in many communities in rural Sub-Saharan Africa, has been hard to accomplish [2,6]. While our study presents fears of social stigma which may be unique to the Sukuma tribe, our themes are consistent with other countries which have identi ed similar barriers to maternal services [10,16]. Similar to other traditional gender normed communities, pregnancy is perceived as a woman's issue [14,17] and the social stigma against men who partake in "women's work," such as ANC visits, or who appear controlled by their partner [17] hinders male engagement in maternal health in Misungwi district. Moreover, in Misungwi culture, it is not common for men and women to sit together at gathering, and as such there is discomfort in sharing physical spaces and benches with women at the health facilities. Similar experiences men's discomfort are found in Uganda [8], and in South Africa, men were sometimes told by health care workers to go outside because the space is only for women [18].
Our study echoes other studies where locally held beliefs about gender result in embedded and rigid masculine norms [12,19,20]. In Sukuma tribe, men are the providers for the family; our study found that fear of social stigma among community members in Misungwi was attributed to the lack of appropriate clothing during delivery and being perceived as a poor provider. Issues of poverty impacting the uptake of ANC services have likewise been found in Geita in Northern Tanzania [10]. While having multiple sex partners in Tanzania is perceived as normal practice by men, for women it is perceived as prostitution [21] and can create con ict within the family if discovered. As such men keep their affairs secret and refrain from attending appointments with women with whom they are having affairs; similar to the study in Uganda, they fear being seen, found out, judged by HCWs and want to avoid con ict with their wife or family members [22].
The social stigma associated with HIV and HIV testing at health facilities, has been identi ed as a barrier for male attendance to maternal services [8,10,12]. Men in our study fear being tested, but also fear that their results will be disclosed without their consent. Lack of con dentiality and trust among HCW's has, likewise has been found in South Africa [13]. The social stigma of HIV and HIV testing combined with the lack of con dentiality experienced by community members has strong implication on the uptake of maternal and newborn child health services. It impairs digni ed respectful maternity care to the clients [8,10]. This may in turn form mistrust for HCWs competencies, as a result the community members may decide not to seek health care services to their facility and may lead to malpractices which has legal implication to HCWs at the health facility [14,15].
This study involved perspectives of a variety albeit relatively small sample of men and health workers from a narrow demographic group (rural communities; over 25 years old). Our sample may have missed men who may have characteristics and logistics that make it di cult for them to attend ANC and delivery services, such as those working full time, working away from the community, or men anxious about their personal situations and disclosure (i.e., polygamy, age difference, casual partner relationship). The strength of our study is that it has considered rural population where maternal service seeking for men is not favorable [23]. Qualitative data collection allowed us to explore men's perspectives on a topic which is culturally not considered to be their role and to explore the sensitive topic of their fears of social stigma.

Recommendations And Conclusion
This study is important for policymakers, government, and development partner maternal program implementers who strive to integrate men into visits to enhance family-centered care. In rural settings in Tanzania, increased male attendance at ANC and delivery will not increase solely because of policy or encouragement. Real change in male engagement in maternal issues will occur when there are clearer understandings of the local source of stigma that might inhibit men's attendance, and strategies that are respectful of cultural and gender norms. This study suggests incorporating locally relevant strategies to encourage men's attendance, such as local government meetings that incorporate an agenda to discourage unfavorable gender norms through community-based education and role modeling at various levels of local government and community. Community health care workers (CHWs) and "male champions" can help to educate men and model for men, the importance of attending ANC services with their partners, while also speci cally addressing and validating their fear of social stigma. The health facility management can consider health facility environment which supports men's needs during ANC and delivery, such as adherence to con dentiality, sensitivity and strategies that address language barriers and programs that provide supplies to those who cannot afford them.
Addressing uptake of maternal and newborn services in culturally bound communities requires understanding of the social stigma experienced by men, as stipulated in this study, to help in formulating interventions that are tailed to community needs in rural settings in Tanzania. While social stigma may vary from one community to another, men must be heard and understood within their local context, with community solutions developed to acknowledge and challenge sources of stigma. The respondent signed consent forms and con dentiality of their information was observed during the research study. To ensure con dentiality, respondents were given numbers and asked to mention it instead of names during the interview and all information collected were kept con dential in the research unit.

Consent for publication
The respondents gave permission to the researchers to publish the ndings in different academic forums such as conferences and public it in peer review journal but keeping in mind not exposing their names in the quotes as was signed in the consent forms.

Availability of data and Materials
For data and materials used in this study can be requested from the project principal investigator through this contact: Dr. Dismas Matovelo at magonza77@yahoo.co.uk.

Competing interests
All authors in this study do declare that we do not have any competing interest. LS and ZM: provided technical inputs to the study and involved in the design of the protocol. All authors read, agreed, and approved manuscript to be send in peer review journal for publication consideration.