This section begins with a brief description of the maternity clinic, how ANC activities are organised and where men are located when at the clinic. It will then continue to discuss the varying forms of male involvement found in the study, including men’s own agendas at the clinic. It ends with a presentation of health workers’ engagement of men at the clinic.
The maternity clinic and male partners
The maternity clinic was managed by a nurse-midwife and offers three fairly distinct services: antenatal care; labour and delivery care and postnatal care. The antenatal care (ANC) division had one gynaecologist and about four nurse-midwives per work shift. The clinic operates between 8am and 5pm from Monday to Friday. Mothers began to arrive as early as 6am to form a queue, sometimes coming in the company of other mothers or partners. By 8am when sessions started, the seats in the waiting area where ANC takes place were usually fully occupied by expectant mothers. The sessions commenced with a nurse-midwife leading the group of expectant mothers in the waiting area in a Christian worship session lasting about ten minutes. She then led the group in a short exercise session before giving an educational talk on topics such as nutrition, birth preparedness, signs of labour, among others. More mothers arrived as the educational session proceeded.
During the session, mothers talked among themselves and with health workers, asked questions and shared jokes. When the educational session ended, individual mothers were called upon, and their folders were sorted according to their assigned nurse-midwives. At this point women waited for a one-on-one consultation with their individual midwives in a separate room. This is a key service provided during ANC. Although the waiting area was largely congested during the educational session, the space began to open-up as the educational sessions closed and women continuously moved in and out of the clinic. It was common to find expectant mothers moving around in pairs or more to the canteen, washroom and laboratory. Women who attended the clinic with their partners walked around with them.
Men who accompanied their partners to the clinic were encountered mostly at three different locations. Some sat among the expectant mothers in the waiting area during the educational sessions. From observation we found only two to three men sat among over 100 women. Others stayed in an open space outside the maternity clinic, while others again were seen under trees on the broader compound of the hospital. Although men may not be present in the waiting area, they were still sometimes called by their partners to join them for the one-on-one consultation. Statistics from the hospital show that between 2016 and 2019, male attendance at the maternity clinic has had a ratio of approximately ten mothers to one father. These numbers include men who came for antenatal, labour and delivery care and postnatal care. Labour and delivery care have the most substantial attendance by men according to health workers. Thus, very few men attended ANC sessions with their partners. From the few men who came for ANC, we found different ways and levels of involvement.
Varying involvement of men in antenatal care
The first question that we asked men after greeting them at the maternity clinic was, “What brought you here today”. Most men responded by saying, “I came to escort someone”. This was clear also in the ways that men and women occupied space at the hospital; while women usually gathered in the waiting area, most men were found waiting under trees and at isolated spaces behind the clinic. Expectant fathers who remained outside during the general session said that they were uncomfortable inside the maternity clinic. One man, Ibrahim, for example, said that he was surprised to see so few men when he attended the clinic with his wife for the first time, and this made him feel uncomfortable. Another expectant father specifically mentioned that he was uncomfortable sitting among the women.
I would not like to be among the ladies. That place is only meant for the women. So if I come with someone, I would not like to sit in the midst of the ladies (Elorm, 30, Artist).
Other expectant fathers decided to make themselves invisible at the clinic, also saying it was because they felt shy. When we interviewed one man, Derrick, for the first time, his wife was eight months pregnant. According to him, he had attended the ANC since they received a positive pregnancy test, but sometimes the nurse-midwives did not even see him because he was mostly hanging around under trees surrounding the facility. He did not participate in either the educational or the consultation session because he did not see other men doing so. He nonetheless concluded by saying that if he is invited, he will join the educational session. He explained:
I feel shy. Well, I do not go into the room with her unless I am invited. The only time I went inside was when I was called to donate blood. I have not been there since then. If it is allowed, I would go (Derrick, 32, Driver).
Some men revealed that they were only shy during the first visit, and later became more comfortable sitting among the expectant mothers in the waiting area.
When you come for the first time, you would be shy because you would meet a lot of women, and the reaction from their faces would be like: “Ah, is your wife the only pregnant woman?” Well, fortunately, I do not take notice of such things because I know my purpose there. So I just sit quietly and mind my business (Joseph, 32, Sales Manager).
Although the seats in the waiting area were mostly fully occupied by expectant mothers, none of the men interviewed mentioned lack of seating space as the reason why they waited outside. Rather, as we have shown above, they related their staying away from the waiting area to experiencing shyness and discomfort. Some expectant fathers were unhappy with the limited level of involvement at the clinic and felt that activities should be tailored to include them, especially in the individual consultation.
The only time you will see the nurses is when they come to mention the names of those whose cards they have. So when they are calling the names and you are also following, you know the nurses are rude at times, they ask where I am going and all sorts of questions. And even seeing some of the men around, even though most men do not come, at least they should come and ask what we came to do or who we came with and all that. They just move back to the rooms after mentioning the (women’s) names (Eric, 30, Sales executive).
Some of these men, like Eric, seemed not to be aware that men were actually allowed to participate in the consultations. Derrick also said he would participate if it was allowed. Ibrahim similarly said:
We came together, we even went down there but I am currently sitting here because she is going for a scan and she is the only one expected to be present there. After the scan, the next is lab and a whole lot before seeing the midwife. That is why I am waiting for her here (Ibrahim, 32, Trader).
When asked whether he will join his wife in the consultation with the nurse-midwife, he answered, “If I am permitted, why not?”
Interaction at the clinic was, for most men, limited to interacting with their partners. There was hardly any communication between the men themselves or between men and women. Most men played on their mobile phones and tablets in their idleness. They explained that it was better to focus on their purpose at the clinic rather than chatting with other men.
Although the men who kept a distance and did not involve themselves a lot were in a substantial majority among our study participants, there were also a few who were more assertive and who actively participated in the consultation with their partners as shown below.
As for the consulting room, I always make sure I am there with her because I want to see if everything is in place. So if there is any lab test, I would like to know its result and what to do about it. We went there together yesterday when time was due for the test they conducted. That was when she (nurse-midwife) told us what to buy for the child and other things needed for the pregnancy (Eddie, 28, Self-employed).
Eddie usually joined his partner for the educational session and would after that drop out and wait outside until it was time for her consultation with her assigned midwife when he would be called to join in. Charles was another man who said that he participated in the consultation with the midwife regularly. When observed at the clinic, Charles appeared to be in control and aware of his rights and privileges, leading his wife through the various proceedings, carrying her folder and handbag while she followed behind. Men like Derrick became more involved in activities towards the end of the pregnancy. He joined in the consultation when his wife’s due date was drawing closer and she developed complications, which required that she attended more regular check-ups.
Men’s agenda at the maternity clinic
Irrespective of the varying forms of involvement at the clinic, expectant fathers seemed to have their own agenda for attending ANC with their partners. Observations showed that most men at the clinic made payments on behalf of their partners, bought them food and carried their handbags and folders. One expectant father, Eric, for example was observed at the clinic sitting in an empty space, holding his partner’s handbag and folder. Although Eric was disappointed that health workers did not involve men in the ANC activities, he found a way to make himself useful. Our study participants also shared that they performed some roles in the form of seeking knowledge and providing emotional and physical support for their partners at the clinic.
I always want to come here to know more about pregnancy, so I do not take anything for granted. Sometimes, the woman may complain of a headache and you would not know what that means, but when you come here and they teach, you would know how to treat such things. It helps me to take good care of her. Sometimes she forgets the things they teach there as well so when I go there, I take notes like a student so that I do not forget the lessons (Joseph, 32, Sales Manager).
The quote above indicates two motivational elements of men attending ANC; to acquire knowledge in supporting a partner and to help remind their partner of information. Some expectant fathers also viewed antenatal visits as an extension of their role as the head and protector of their family.
This is her first time she has been pregnant and her family members are not here. So I am supposed to support and help her out during this time. I have some questions to ask the midwife. She alone will not be able to ask all those questions you know. How will she do all that because she is a young girl and does not know anything about it (Elorm, 32, Artist).
Men also claimed that spousal love and affection was a key motivation for their involvement in ANC with their partners. Charles, when asked why he continued to attend ANC with his partner, answered, “The woman, she is good”. Similarly, men emphasised that attending ANC was an expression of love for their partners and that going through the process of pregnancy with their partners will promote respect for women as indicated in the two quotes below.
I am happy that I came here with her because she knows that I support her. Just staying away from work for a day for her won’t affect anything. Just, she knowing that I support her in the pregnancy gives me joy as well (Martin, 38, Mechanic)
It is good for every man to go through that process so that they would have some respect for every woman they see. Some men do not respect women. All they are about is hey, after all, she is just my girlfriend. They do not see them as their fellow human being and treat them as such. I believe after they go through this experience, their respect and care for women would increase. So I think when you are always there with her throughout the process, there would be a change of mind-set on how to treat women. It has really changed my mind and mentality about women (Joseph, 32, Sales Manager).
Health workers engagement of men at ANC
In general, health workers seemed to be happy to see men at the clinic, although they had divergent opinions on how to include men in the activity. Apart from giving preferential treatment to women whose partners attended ANC, health workers had no clear agenda about facilitating male involvement in maternity services. Irrespective of what midwives viewed as the appropriate way to involve men in ANC, their primary concern was related to how male attendance demanded an increase in their already substantial workload. In this regard, they held that it would be more convenient for health workers if ANC focused mainly or only on women.
Jumping the queue
Health workers mentioned that there is a recommendation to motivate men who attend ANC by allowing their partners to move quicker up the line. This principle is justified by the idea that men have to go to work as providers for their families, and therefore their partners should be allowed to move more quickly up the queue so the men can go back to work. This incentive was stressed in all the interviews, discussions and informal conversations with the health workers and is summarised in the below excerpt:
When you come with your wife, we give you priority. We see you first. Because among the lot, about 200, 300, we have about five men. We treat you as a special guest for that day. That is what we have been doing. So even when I am walking around and I see a man sitting, I ask the wife, which room do you go to? Then I tell the midwife in that consulting room, do not forget there is a man there. See that person first (Naana, Nurse-midwife).
However, this incentive and practice was not something we came across in the interviews with the men or in the observation at the clinic. Only one of our study participants, Charles, said that he ‘helped his wife to jump the queue’. During the follow-up interview after birth, while Charles and his wife were expecting their second child, he was still attending ANC to help his wife to move more quickly up the line. Interviews and observation showed that very few men at the clinic knew of the incentive of giving queue privileges to women who were joined by their partners to ANC. One reason for this might be that health workers in practice seemed to keep silent about this privilege and incentive. Naana, one nurse-midwife, explained that expectant mothers waiting for ANC regularly engaged in quarrels about issues relating to the queue and about people they suspected to be cheating. Consequently, health workers gave this preferential treatment silently and only men and women who were already aware of the privilege were able to take advantage it.
Challenges of male involvement
Health workers shared different views on how men should be involved in the activities at the clinic as well as of the challenges involved. Community health nurses talked about inadequate physical space for men at the clinic, while nurse-midwives talked about whether the inclusion of men should really be a priority.
The antenatal care usually, they [the women] are very plenty. Sometimes they (men) enter there and they see plenty of women there and they will just go back. We do not even have space (physical) for the men. So we are not making it comfortable for the men to involve themselves (CHN, FGD, 2017).
CHN’s views on sitting/waiting space at ANC seemed to support men’s concern that sitting among women was uncomfortable. Naana, as shown above, argued that men who accompanied their partners should be treated as special and served quickly. Nevertheless, she believed that the presence of men should not be a priority unless the condition of a pregnant woman demanded her partner’s participation in ANC services. She gave the following example:
If your husband is not coming to postnatal with you or the antenatal we are not bothered. We are not bothered. We only need the woman. If everything is fine, yeah. Unless she comes and there is a problem. Then we will call the man (Naana, Nurse-midwife).
Rebecca, another midwife, said that men participating in the consultation would increase their workload. Therefore, she had suggested to the hospital that the morning sessions should be communicated through videos, which would include videos on what men can do to support their partners. Additionally, she emphasised that a separate all men’s group would be better than men participating in the consultation with the pregnant women. Nonetheless this should happen only if and when specific health workers could be assigned to male attendants.
Agnes, another midwife, held a slightly different position, and argued that men should participate in the consultations because it would make their work much easier.
As I said before it is something very good and makes the work simple for us. When you tell them what to do and what not to do, the men remind them at home to comply with the instructions. They are always there to check their wives for us (Agnes, Nurse-midwife).
Agnes’ claim here reiterates that health workers found the men’s own agenda for attending ANC, in the form of acquiring knowledge and reminding their partners at home, useful. Unlike Rebecca, Agnes claimed that men’s participating in consultations will neither prolong nor increase the workload. Separation of the women and men would, however, require additional caregivers and time, which the hospital may not be able to provide. She concluded by saying that it would be possible to organize a separate information session for expectant fathers only when they start coming to the clinic in larger numbers.
 Health workers spoke about this incentive in the form of a policy that is implemented in all government health facilities in Ghana. However, we found no documentation to show that the Ghana Health Services has a policy that permits giving preferential treatment of women who attend the ANC with their partners. Another study by Ganle et al. 2016. “If I go with him, I can't talk with other women,” also mentioned a health facility giving preferential treatment but not as part of a health sector policy.