Men’s Role in Safe Motherhood and Family Well-being [Facilitator: If time permits, begin this session by reading the story of a death of a woman due to pregnancy complications titled, The Long Road to Maternal Death (see Module IV Activities List), or you may substitute a local story of a woman who has died unnecessarily during pregnancy or childbirth.] Each year, nearly 600,000 women die from largely preventable causes related to pregnancy. In this section, we will focus on how men can help to reduce maternal mortality and morbidity and have a positive effect on family well-being. World Health Organization IV - 1

Lack of Progress: Can Male Involvement Help? During first 10-year Safe Motherhood Initiative, no reduction in annual number of maternal deaths related to pregnancy Interventions rarely tried to counsel male partners of pregnant women A few studies have shown promise, but more research is needed Despite a decade of effort by the World Health Organization (WHO) and other agencies to lower maternal mortality, there has been no decline in the number of women dying annually of pregnancy-related causes; although improved reporting of maternal deaths may also have contributed to the lack of decline. Although research is needed to test the specific benefits that can accrue from greater male involvement through actual field-level interventions, there is already strong evidence that: men are concerned about the health of women and children; both women and men see potential benefits from an expanded role for men in reproductive health. IV - 2

Causes of Maternal Deaths Indirect causes (20%) Severe bleeding (25%) Other direct causes (8%) Infection (15%) Unsafe abortion (12%) Pregnancy-related complications cause one-fourth to one-half of all deaths among women of reproductive age in developing countries. More than one woman dies every minute from these causes – a total of 585,000 deaths each year worldwide. Most maternal deaths are due to sudden and unexpected complications, such as severe bleeding, infection, eclampsia and obstructed labor. Some unexpected complications can be anticipated if adequate ante-natal care is obtained. Unintended pregnancies are more likely to end in abortion. Complications of unsafe abortion cause 50,000 to 100,000 deaths each year. Preventing unintended pregnancies can reduce the number of maternal deaths, especially those due to abortions. Obstructed labor (8%) Eclampsia (12%) Source: Maternal Health around the World, WHO and World Bank, 1997. IV - 3

Consequences of Maternal Morbidity Effects of morbidity on women and families: Physical disability Psychological trauma Social isolation Infertility Increased caregiving responsibilities Reduced economic productivity [Facilitator: Before showing this slide, ask participants to name some of the consequences of maternal morbidity.] In addition to the nearly 600,000 annual deaths, one of every four women living in the developing world currently suffers from a short- or long-term illness or injury related to pregnancy or childbirth. Lifelong disabilities as a result of maternal complications include uterine prolapse, fistulae (holes in the birth canal that allow leakage from the rectum or bladder), incontinence, chronic pain, nerve damage and infertility. Maternal complications have severe consequences, not only for women’s health but also for the well-being of their children as well as their husbands, families and communities. Besides the physical disabilities, these complications can lead to: psychological trauma, social isolation, infertility, increased caregiving responsibilities placed on other family members or older siblings and reduced economic productivity and resources for families. IV - 4

Underlying Gender Inequity High rates of maternal morbidity and mortality, especially in regions where women have very low literacy and limited rights, reflect two important issues: Men lack understanding of the risks of pregnancy; Limited access to life-saving treatment reflects underlying societal gender inequity and the low value placed on women’s lives. Addressing these issues is key to any strategy designed to motivate men and the community at large to develop positive interventions to increase safe motherhood. The entire community must be mobilized to demand quality emergency services at the appropriate health facilities. Combining efforts to raise women’s status with practical strategies to reduce risks of pregnancy and improve access to lifesaving treatment can improve health outcomes for both women and newborns. U.S. Agency for International Development IV - 5

Safe Motherhood: Human Rights and Social Justice Women have limited: Exposure to information about danger signs during pregnancy/delivery Power in decision-making Access to education Financial resources and mobility The Safe Motherhood Interagency Group (which includes UNICEF, UNFPA, the World Bank, WHO, International Planned Parenthood Federation, the Population Council and Family Care International) has recognized maternal death as an issue of social justice. Factors affecting women’s access to emergency obstetric care include unequal access to employment, finances, education, basic health care and other resources, as well as women’s social role and value in the family and community. Making motherhood safer requires addressing these barriers: Limited exposure to information. Many societies do not see pregnancy as requiring special care, and people do not easily recognize danger signals. Men, in particular, are often unaware of the risks facing both mother and child. Limited power in decision-making. In many developing countries, men exercise the authority over whether and when a woman can seek outside care or be taken to a hospital. Limited access to education. Girls who are denied schooling tend to have poorer health, larger families and children with a higher risk of death. Limited financial resources. Without access to financial resources, women cannot make independent health decisions or seek services. Limited mobility. In some societies, women cannot leave their homes without the permission of the husband. Source: Safe Motherhood Interagency Group Fact Sheet, 1998. IV - 6

Why Involve Men? Men are key decision-makers regarding pregnancy and childbirth Men have generally not been involved in trying to make pregnancy and childbirth safer Nearly all efforts to make motherhood safer have focused on identifying high-risk pregnancies, improving emergency obstetric-care facilities and training midwives, traditional birth attendants and women themselves to recognize danger signs. Although men are key decision-makers, few attempts have been made to involve men in the effort to reduce maternal mortality. If men better understood that pregnancy is not merely a natural event, but one that carries potential health risks for women, they would be in a better position to help ensure that their partners receive pre-natal care, adequate rest and good nutrition. Policies of health care establishments and attitudes of service providers also serve as barriers to greater involvement of men even when they accompany women to health facilities. IV - 7

Safe Motherhood: Male Involvement Safeguarding women’s health during pregnancy – ante-natal care and nutrition Arranging for skilled care during delivery What can men do? Men need to understand that pregnancy carries potential health risks for all women, and that it is particularly important that they help ensure that their partner gets proper ante-natal care, good nutrition and plenty of rest. This may entail providing transportation or money for clinic visits, learning the danger signs of pregnancy and assisting with household or other tasks. Men can also help by arranging for a trained attendant and necessary supplies to be available for the delivery and by paying for these services. In addition, men can and should be knowledgeable and involved in the full range of reproductive health concerns beginning with responsible sexual behavior through positive contributions to the care and well-being of children. L. Rigsby Source: Drennan, Popul Rep 1998;J(46). IV - 8

Men Often Control Decisions Respond to complications Seek medical help Pay for transport Allocate family and community resources US Agency for International Development Men are often the ones who decide when a woman’s condition is serious enough to seek medical attention, yet few men have been educated in understanding the risks of pregnancy and in assessing when a symptom requires urgent attention. Programs such as SEWA-Rural in India have been able to increase pregnant women’s use of health facilities by working directly with men and extended family members to help them prepare for an impending birth as soon as a pregnancy is acknowledged. Men’s involvement can help reduce maternal and child mortality and morbidity by: increasing women’s participation in ante-natal care; reducing delays in getting treatment by being trained to recognize and respond to complications of pregnancy and delivery; arranging for delivery in a health facility or to be attended by a qualified practitioner; paying and arranging in advance for transport; allocating necessary family and community resources. Men need to be involved in community-wide decisions to ensure that resources and systems for medical assistance and transport are in place and available to women who need them. Source: Drennan, Popul Rep 1998;J(46). IV - 9

Male Involvement in the Reproductive Process Participating in birthing process Helping after baby is born Traditional cultures vary in the degree to which men are present during birth. While in many instances their role is limited or nonexistent, in others – such as in parts of Peru and Bolivia – men actually assume the role of birth attendant. Yet even in these instances, their participation is not supported (and, in fact, it is often discouraged) by the health care establishment. A study in Kenya of actual and desired participation of men in reproductive health services found that women, men and service providers see important benefits to greater male involvement in and around the birth process, although this may or may not include their actual presence during childbirth (Population Council, 2000). Mexfam United Nations IV - 10

How Do Men Learn To Be Fathers? Groups working on masculinity issues in Mexico, the United States and other countries have discovered that a major factor influencing how men perceive their role as fathers is their experience of being a son. Many men express a strong desire for a better relationship with their children than they had with their fathers, but they do not know how to go about it. Looking at their relationship with their own fathers has proven to be a good starting point for reflecting on what kind of fathers they want to be themselves. Attitudes of extended family members – especially mothers-in-law – as well as the larger community, have also been shown to play a critical role in inhibiting or supporting new modes of fathering. [Facilitator: If time permits, before moving onto the next slide, ask participants to think about how men learn to be fathers and how children view their fathers. Ask participants to do the activity titled, “Different Ways of Being a Father” (see Modules IV Activities List).] B. Genier/World Health Organization IV - 11

Father: Provider Just as there are multiple ways of being a MAN, there are different ways of being a FATHER. In a strategy to learn from children’s views, two non-governmental organizations in Mexico, Salud y Genero and Coriac, promoted a drawing contest on how children viewed their fathers. In more than 500 drawings, children depicted their fathers in many different ways. This slide shows the most dominant theme from the drawings, when children drew their father as a worker, a provider or an important public person. The next several slides show some other themes from the drawings. Salud y Genero/Coriac IV - 12

Father: Entertainer, Emotionally Close Some children saw the father as a provider of entertainment on afternoons, weekends or vacations. Others saw the father as very close and emotionally involved in their lives. Salud y Genero/Coriac Salud y Genero/Coriac IV - 13

Father: Discipline, Authority, Violence “Don’t beat me, daddy.” For some children, the main characteristics of their fathers had to do with discipline, authority and even violence. Children also complained about their fathers being addicted to alcohol and cigarettes. Salud y Genero/Coriac IV - 14

Father: Absent or Dead “Heaven for fathers” Many children perceived their fathers as absent due to various reasons, including: abandonment of the family; migration for employment; divorce; early death, sometimes related to the risk factors mentioned earlier. Salud y Genero/Coriac IV - 15

Father: Household Worker Not one of the 500 children drew a father who was involved in a domestic task, although a few drew fathers helping children with homework. While some fathers do share some of these chores, that role was not significant or dominant in the children’s eyes. B. Thomas/WHO/UNICEF IV - 16

Traditional Masculinity Limits the Role of Fathers Mostly, father is considered only a provider and authority figure Lack of alternative models – “This is what my father taught me” Limited cultural acceptability of men’s emotional expression and involvement Little opportunity to learn to care for others Many men find fatherhood difficult, and they lack positive role models. When men have not learned appropriate avenues for emotional expression, violence and child abuse may result. Research in Brazil has shown the importance of how boys are socialized in terms of how they interpret masculine roles as adults (Barker, 1998). For many, the side effects of traditional socialization result in: fathers viewed primarily as a provider and authority figure; lack of alternative role models; limited cultural acceptability for men’s emotional expression and involvement as a father, e.g., phrases such as “boys don’t cry” remain powerful; little opportunity to learn to care for others – mothers typically involve daughters but not sons in the care of younger siblings. For these reasons, there is growing recognition of the importance of identifying instances where young men exemplify non-traditional attitudes and behavior in order to gain an understanding of where and how to intervene positively in the socialization process. IV - 17

Research Needed on Benefits of Fathering Involving men in fathering may lead to: Better communication, stronger bonding between couples and among family Better role modeling for children Increased commitment to contraceptive use and practice of prevention behaviors Increased support during pregnancy Reduced violence in the home It is important that we move ahead to test and evaluate field interventions aimed at promoting greater and more positive involvement of men as fathers. Potential positive results that are expected but still need to be verified include: better communication and stronger bonding between the couple and among other family members; better role modeling for children; increased commitment to contraceptive use (male and female) and practice of disease-prevention behavior; increased support for women during pregnancy; reduced violence in the home. More involvement is important, but it is the quality of the involvement that can enrich the lives of individuals – father, mother and child. IV - 18

Initial Lessons Learned Egypt Post-abortion Care Study Women whose husbands were counseled had better outcomes India Pre-natal Care Study Involving men in pre-natal care increased their involvement in their wives’ and children’s health care Jamaica Teenage Father Study Reaching out to “baby fathers” helped young men stay involved with their child There has been a significant increase in the number of programs that are attempting to increase men’s involvement in reproductive health care. For example: In Egypt, women whose husbands were counseled about their wife’s need for rest and recovery post-abortion had better physical and emotional outcomes than those whose husbands did not get counseling. In India, direct involvement of health providers with men during pregnancy has resulted in increased support for women’s health and nutrition during pregnancy, greater participation of women in ante-natal care, more deliveries in health facilities and more men bringing their children to health centers for immunization. In Jamaica, a program addressing unmarried teenage fathers (known as “baby fathers”) is helping them to be better parents and to stay emotionally involved with their children. IV - 19

Promising Research Efforts Midwives in Mexico are training men as community health workers to teach other men about reproductive health (MacArthur Foundation) Projects in 7 countries are focusing on improving communication and joint decision-making between men and women about reproductive health (PAHO) Oaxaca, Mexico, has one of the highest rates of maternal mortality in the country. In this project, midwives are training men as community health workers. Through these male health workers, other men in the community learn how they can participate more effectively in pre-natal care and during and after delivery. They also address gender inequality and its relationship to reproductive health, including gender-based violence. The Pan American Health Organization (PAHO) is sponsoring demonstration projects in seven Latin American countries (Belize, Costa Rica, El Salvador, Honduras, Guatemala, Nicaragua and Panama). The projects hope to show that involving men in communication and joint decision-making about reproductive health issues can improve health outcomes for women, including maternal health. The USAID-supported ReproSalud Project in Peru has, at the request of participating women, made the training and involvement of men a central element in its efforts to improve the quality of reproductive health care in rural parts of the country. [Facilitator: Ask participants if they would like to discuss other examples of promising research efforts involving men with safe motherhood and family well-being.] IV - 20