Women’s Participation in Research to Improve Maternal, Newborn and Child Health Outcomes Through Evidence Base Data in West Africa

Background: Women participation in decision-making fora is key to ensure that their concerns are take into consideration, especially in maternal, newborn and child health issues. The objective of this study was to analyse the participation of stakeholders in the various meetings organized as part of the project "Moving for Maternal, Newborn and Child Evidence into Policy in West Africa". Methods: A gender analysis was conducted using data drawn from the attendance lists at the various meetings organized during the project implementation. Results: This analysis showed that women were under-represented in the various meetings organized by the project, but that their prole was not different from that of men. There was a higher proportion of women among the decision-makers during the engagement, dialogue workshops and at the international workshops without signicant difference. Nevertheless, in the training workshops, there was a low proportion of women among the decision-makers with statistical signicant difference. Conclusion: The women participating in the regional platform meeting have the same prole as men in terms of decision-making power. An inequitable participation of women in the health research meetings in West Africa noted in this analysis need to be addressed in the future by the application of some innovative approaches including women as part of the organizers or by the introduction of quotas.


Background
Community participation in health activities is de ned by the World Health Organization (WHO) [1] as "a process by which people are empowered to be actively and effectively involved in de ning issues that affect them, in decision-making about factors that affect their lives, in formulating and implementing policies, in planning, developing and delivering services and in taking action to achieve change". The importance of this participation is further demonstrated in that it allows the community's need, concerns and local knowledge to be taken into consideration and it improves adherence to research and community capacity building [2,3].
The choice of stakeholder representatives to participate in programmes is usually in uenced by several factors including decision-making power, level of knowledge in the subject area, position in the society, role and social relations in the society [4]. Thus, the use of designation as criteria can lead to several inequalities, including gender inequality, which could result in the under-representation of one sex.
Moreover, many studies have noted that gender parity in leadership is not a reality in many areas such as business, justice, science, education, technology, politics and health [5]. In the latter sector, although women are the most numerous in terms of the number of employees, it is noted that they are usually under-represented at the top level of institutional leadership, at policy and governance level and in decision-making structures, both in the public and private service levels [6]. This lack of women in leadership is more the result of a labyrinth, a series of obstacles that are both visible and invisible, than a sudden limit that prevents women from reaching the top [6].
In relation to research, this under-representation of women has been reported widely [7], particularly in maternal and child health research activities where this might limit the quality of studies because the perspectives of the most concerned individuals are not taken into account. This is why it is increasingly recommended to generate information on issues this gender disparities when reporting participation in research activities, which is beyond sex representation [8]. Unfortunately, in Africa, particularly in West Africa, very little data exist on gender parity in the participation of stakeholders in research project meetings. In West Africa within the framework of the Canadian Initiative called "Innovating for Mother and Child in Africa (IMCHA)" (9) the West African Health Organization, a regional health institution of the Economic Community of West African States, acts as the Health Policy and Research Organization. In this function it facilitate the connection between researchers and decision-makers, facilitate the environment for knowledge transfer and build the capacity of both researchers and decision-makers to strengthen the use of research ndings through the project "Moving for maternal newborn and child evidence into policy in West Africa" (10) implemented during the period from 2015 to 2021. WAHO organised multiple meeting in regional and country level. We sought to review during these meetings the participation of men and women in terms of their proportion, level of responsibility in their country and roles during these meeting. Speci cally, we aimed to (i) determine the proportion of women during these meeting (ii) compare the level of responsibility of participants women and men in their respective country and (iii) the role of women compare to men during these meeting and formulate recommendations.
These results can help in advocacy to improve women's representation at meetings discussing maternal and child health issues. Thus, during implementation, several meetings were organized at country and regional levels with various stakeholders to inform, raise awareness, engage, validate the results and identify the interventions to be implemented, build capacity and promote dialogue between decision-makers and researchers. These meetings gathered several types of stakeholders such as health decision-makers from different levels of the health system, health professional associations, journalists, civil society organizations, nongovernmental organizations, religious and traditional leaders, technical and nancial partners and researchers. In inviting participants for the meetings, the pro les of the desired persons without gender distinction were de ned by the representative of the bene ciary organizations. The meetings held at country and regional level for periods ranging from one day to one week.

Analysis
A gender analysis, de ned as a process for understanding health systems research as to how gender power relations create inequalities in access to resources, work and role distribution, social norms and values, and decision-making (11), was conducted. It is recognized that this type of analysis allows one to look at the data by comparing men and women, and to analyze gender roles, powers, access to resources and gender relations, and how these all could explain gender conditions and differing experiences.
The data used was drawn from the attendance lists at the various meetings. The lists provided information on the identity of the participant, surname and rst name, profession/position held and the State of origin. Also, in order to enable the purchase of plane tickets or to prepare the perdiem expenses each participant sent a copy of their passport or national identity document. Finally, the reports of the meetings provided information on the persons who led the work in plenary, in working groups and the rapporteurs. The gender, the profession/position held and the structure of origin and the role during the meeting of the participant was determined from these different documents. Based on function or occupation, the participants were classi ed into ve different groups (decision makers, researchers, partners, consultants, WAHO team). A proportion comparison test was carried out to measure the difference in the pro le of women and men according to the type of meetings. For this purpose, the statistical signi cance for the study was set at 0.05. Microsoft Excel software was used for the data analysis.

Results
A total of 18 meetings or workshops were conducted between August 2015 and June 2019. There were two international workshop meetings, 6 stakeholder engagement meetings in countries, 4 meetings to promote dialogue between researchers and decision-makers and 6 training workshops. Table 1 gives the proportion of women by workshops and type of workshops and in all meetings. There was a general under-representation of women in all workshops with the proportion of women per workshop ranging from 13.9% at the rst knowledge translation training workshop in Burkina Faso to 46.4% at the project information meeting in 2015. The average proportion of women at these meetings was 35.4% and differed very little by the type of meeting between 34% at the dialogue meetings between researchers and decision-makers and 36.9% at the international meetings. Table 2 shows the comparison of the pro le of men and women in all workshops. There is a higher proportion of women among the decision-makers during the engagement, dialogue workshops and at the international workshops without signi cant difference. Nevertheless, in the training workshops, there was a low proportion of women among the decision-makers with statistical signi cant difference.
The chairperson of the meeting was a women in 8 of all the 18 meetings (5 of 6 stakeholder engagement meetings in countries, zero in the two international workshop meetings, 2 of the 4 meetings to promote dialogue between researchers and decision-makers, and one of the 6 training workshops). In 8 meetings (6 stakeholder engagement meetings in countries and 2 international workshop meetings) groups works were organised but the information were available on the chairperson in only 4 meetings. During these 4 meeting 8 groups work were organised and women chaired 3 groups work compared 5 chaired by men). All the trainers were men in the 6 training workshops organised.

Discussion
This analysis showed that women were under-represented in the various meetings organized by the project, but that their pro le was not different from that of men, with a few times more female decisionmakers than men. The women were less represented in the key role during the meeting.
Although underrepresented in number, our work noted that the pro le of women was similar to that of men. This result may also re ect the fact that women who came to meetings have the same technical skills and powers as men and should be able to contribute equally with the men. In a study based on the analysis of thousands of 360-degree reviews, women outscored men on 17 of the 19 capabilities that differentiated excellent leaders from average or poor ones [22] Our results showed the low representation of women in the keys leading roles during the meetings and during group work. One of the raison of this underrepresentation of women in the keys roles during these meeting can be the fact that many men and women think it's not 'natural' for women to speak up in public often poses a key barrier to women's access to decision-making [23].
The advocacy may need to continue to get the equitable representation of women in these meetings. It is well noted that management of power inequalities can help to improve the contribution of the marginalised groups during the meeting [24]. A study in the United States showed that the presence of women among the organizers of scienti c fora improved the presence of women as communicators [25].
Perhaps by including women in the organizing committee of these meetings, we can contribute to improving the number of women participation in the meetings. It is also suggested that quotas can be effective if well designed and properly implemented because they often address institutional barriers, whether within political parties or at a national level [26].

Conclusion
Page 6/10 In conclusion, an inequitable participation of women in the health research meetings in West Africa, identi ed in this gender analysis must be addressed in the future with the application of some innovative approaches including women as part of the organizers or by the introduction of quotas.

Declarations
Ethics approval and consent to participate This study sued secondary data from the workshop reports, publicly available at the institution library. Thus, authors did not seek for ethical approval. Therefore, data were anonymised before utilisation for the study.

Consent for publication
Not applicable

Availability of data and materials
The datasets supporting the conclusions of this article are available on demand from the corresponding author and in WAHO archives.

Competing interests
The authors declare that they have no competing interests.

Funding
The Innovating for Mothers and Child in Africa (IMCHA) initiative funded by Global Affaires Canada (GAC), Canadian Institutes of Health Research (CIHR) and International Development research centre (IDRC) supports this study (Reference: IDRC 107892_001).
Authors' contribution IS and EAKJ conceptualised design the study, drafted the initial manuscript, and reviewed and revised the manuscript. MA designed the data collection instruments, collected data, carried out the initial analyses, and reviewed and revised the manuscript. VL and AO critically reviewed the manuscript and made major revision. . All authors approved the nal manuscript as submitted.