Men’s Involvement in Maternal Healthcare in Accra, Ghana. From Household to Delivery Room Gloria Abena Ampim Master of Philosophy in Gender and Development Spring 2013 Faculty of Psychology Department of Health Promotion and Development Acknowledgements I am most grateful to God Almighty for His favour, protection and guidance throughout this entire Masters Programme. It is His grace that has brought me this far. I also express my gratitude to the faculty and administrative staff of GAD, Prof. Marit Tjomsland, Prof. Haldis Haukanes, Kristin Senneset, and especially my supervisor, Dr. Cecilie Ødegaard. Thank you very much Cecilie for your patience, suggestions and guidance. I am most grateful and will forever remember your enormous support. Victor Chimhutu and Padmaja Barua have also been very supportive and I appreciate it. In addition, I am grateful to CMI, especially the health cluster and Siri Lange for your comments and suggestions. I also thank my colleagues at GAD and CMI for their comments and suggestions. In addition, I appreciate the support of my colleagues and friends at the University of Ghana and the faculty members at the History Department, especially Dr. Kofi Baku for their support in diverse ways. My sincere appreciation also goes to the mothers and fathers who participated in this study. I also thank the entire staff of the Public health Unit of the Ghana Police Hospital, Accra, the Focus Region Health Project, Accra, Ghana, the John Hopkins Center for Communication Programs, Ghana and USAID department of maternal and child health, Ghana, especially Susan Wright. I also appreciate the support of the Association of Ghanaians in Bergen, the Fantoft Christian Fellowship and all Ghanaian friends in Bergen. My friends and family in Ghana have also been supportive in enormous ways, especially, my parents Olaf Kula and Dr. Laura Jane McGough, thank you very much for the support and encouragement. Finally, my dear Samuel Abaloo, your support, frequent calls, love, care, reading through my drafts are well noted and appreciated. God bless you all! i Table of content ACKNOWLEDGEMENTS .......................................................................................... i TABLE OF CONTENT ............................................................................................... ii LIST OF ABBREVIATIONS ...................................................................................... v ABSTRACT ................................................................................................................ vi CHAPTER 1: INTRODUCTION................................................................................. 1 1.0 Introduction ....................................................................................................... 1 1.1 Definition of key terms ...................................................................................... 2 1.2 Objectives and research questions ..................................................................... 3 1.3 Organization of the study .................................................................................. 4 CHAPTER 2: BACKGROUND TO THE STUDY ..................................................... 5 2.0 Introduction ....................................................................................................... 5 2.1 Global agenda for men in maternal healthcare .................................................. 5 2.2.0 National context............................................................................................... 6 2.2.1 Kinship ....................................................................................................... 8 2.2.2 Marriage, motherhood and fatherhood ....................................................... 9 2.2.4 Research area: Accra and the Ghana Police Hospital .............................. 10 CHAPTER 3: MASCULINITIES, POWER RELATIONS AND MEN’S PARTICIPATION IN REPRODUCTIVE HEALTH: A LITERATURE REVIEW . 11 3.0 Introduction ..................................................................................................... 11 3.1 Construction of masculinities and femininities in relation to fatherhood and motherhood ...................................................................................................... 11 3.2 Gender and power relations in reproduction ................................................... 14 3.3 Men in maternal healthcare ............................................................................. 18 3.4 Contribution of my study................................................................................. 20 CHAPTER 4: CONCEPTUAL FRAMEWORK ....................................................... 22 4.0 Introduction ..................................................................................................... 22 4.1 Gender identity and practice ............................................................................ 22 4.2.0 Hegemonic masculinity .................................................................................. 23 ii 4.2.1 Hegemonic, subordinate and complicit masculinities and emphasized femininity…….………………………………………………………...24 4.2.2 Individual, cultural and structural/institutional reproduction of hegemony …………………………………………………………………………..26 4.2.3 Africanist perspectives on masculinities .................................................. 28 4.3 Why Hegemonic masculinity .......................................................................... 31 CHAPTER 5: RESEARCH METHODOLOGY ....................................................... 33 5.0 Introduction ..................................................................................................... 33 5.1 Data collection unit.......................................................................................... 33 5.2 Selection of informants.................................................................................... 34 5.3.0 Data collection methods ................................................................................. 35 5.3.1 In-depth interviews ................................................................................... 35 5.3.2 Focus group discussion ............................................................................ 36 5.3.3 Observation and informal conversation ................................................... 38 5.3.4 Text .......................................................................................................... 39 5.4 Challenges and limitations of the study........................................................... 39 5.5 Ethics and reflexivity ....................................................................................... 40 5.6 Data handling and analysis .............................................................................. 41 CHAPTER 6: HOUSEHOLD RELATIONS AND ITS IMPACT ON MEN’S ROLE AND CONTRIBUTION TOWARDS MATERNAL HEALTHCARE ..................... 43 6.0 Introduction ..................................................................................................... 43 6.1 Household arrangements in Accra ................................................................... 44 6.2 Work and household division of labour .......................................................... 47 6.3 Extended family relations ................................................................................ 50 6.4.0 Fathering and mothering ................................................................................. 53 6.4.1 Provision for the household ..................................................................... 53 6.4.2 Decision-making in the household ........................................................... 55 6.4.3 Protection of the family ............................................................................ 58 6.5 Changing gender and household relations and their implication for maternal healthcare in Accra…………………………………………………….……59 6.6 Chapter summary............................................................................................. 61 iii CHAPTER 7: PATERNAL INVOLVEMENT IN ANTENATAL, DELIVERY AND POSTNATAL SERVICES ......................................................................................... 62 7.0 Introduction ..................................................................................................... 62 7.1.0 Antenatal and postnatal clinic ......................................................................... 63 7.1.1 The significance of men’s presence ........................................................... 63 7.1.2 Men at the clinic ....................................................................................... 68 7.1.3 Men’s reluctance/inability to attend antenatal and postnatal clinics ........ 70 7.2.0 Men’s experiences of labour and childbirth .................................................. 73 7.2.1 Expectations of male partners during labour and delivery ....................... 73 7.2.2 Men’s accounts and expectations of labour and delivery ........................ 76 7.3 Engaging dominant gender ideals at antenatal, delivery and postnatal clinics 79 7.4 Chapter summary............................................................................................. 81 CHAPTER 8: HEALTH PROGRAMMES AND POLICIES INVOLVING MEN IN MATERNAL HEALTHCARE .................................................................................. 82 8.0 Introduction ..................................................................................................... 82 8.1.0 Pregnancy school ............................................................................................ 82 8.1.1 Men at pregnancy classes ......................................................................... 85 8.1.2 Significance of the pregnancy school ...................................................... 88 8.2 Hospital policy: come with your partner and you will be served first ............ 91 8.3 Structural alteration and reproduction of hegemonic masculinity .................. 93 8.4 Chapter summary............................................................................................. 95 CHAPTER 9: CONCLUDING COMMENTS ........................................................... 96 REFERENCE LIST .................................................................................................. 100 APPENDIX 1 ........................................................................................................... 115 APPENDIX 2 ........................................................................................................... 117 iv List of Abbreviations FGD Focus Group Discussion GDP Gross Domestic Product GHS Ghana Health Service GSS Ghana Statistical Service ICPD International Conference on Population and Development JHS Junior High School MDG Millennium Development Goals MOH Ministry of Health, Ghana NDPC National Development Planning Commission, Ghana NGO Non-Governmental Organizations NHIS National Health Insurance Scheme SHS Senior High School UN United Nations UNICEF United Nations International Children’s Fund UNFPA United Nations Fund for Population Activities WHO World Health Organization USAID United States Agency for International Development v Abstract Mid-way through working towards the Millennium Development Goal (MDG) five, which is concerned with improving maternal health, the international health community now realises that the goal is impossible to achieve without involving men as “partners, fathers, husbands, brothers, policy makers and community and religious leaders” (UNFPA, 2007, para.3). Subsequently, there has been a call to educate men on the dynamics of women’s health, especially during pregnancy, childbirth and the postpartum period so that they will give the necessary support. In Ghana, some district health directorates provide incentives to men who accompany their partners to the antenatal clinic by rewarding them financially (Kofoya-Tetteh, 27th Jan. 2012 p.20). Some NGOs and health facilities also organize pregnancy schools for couples to prepare them for the challenges of pregnancy, childbirth and parenting. Despite the growing interest in involving men, few studies have been conducted to explore what and how men support their partners during pregnancy and childbirth, and the factors which shape their support in specific contexts. This thesis is based on a qualitative study conducted with mothers, fathers and healthcare providers in Accra, Ghana to explore the factors that shape men’s participation in maternal healthcare. The thesis draws on Connell’s (1987; 1995) concepts of masculinities and femininities to explore how gender ideals, household and kin relations and healthcare practices shape men’s contribution to maternal healthcare. The study highlights the alteration of dominant gender roles during pregnancy, the reasons which account for this change and social perceptions of the change. It also illustrates the significance of men’s participation in antenatal, delivery and postnatal services and explores why most men are unable to participate. Moreover, the study demonstrates how two healthcare programmes; pregnancy school and the arrangement of serving women who attend clinics with their partners’ first, could shape men’s participation in maternal healthcare as well as alter and reproduce hegemonic masculine ideals. : Keywords men, maternal healthcare, antenatal, postnatal, pregnancy school, masculinities, femininities, equality. vi CHAPTER 1: INTRODUCTION 1.0 Introduction Until recently, pregnancy and childbirth have generally been viewed as the domain of women, with men relegated to the periphery (Plantin, Olukoya & Ny, 2011). In Ghana, evidence shows that women stayed with their mothers and matrikin during pregnancy, childbirth and the postpartum period, therefore, the matrikin provided antenatal, delivery and postnatal care (Badasu 2004; Jansen, 2006). Men’s role was limited to providing money for medical bills and other material needs and naming the baby (Badasu, 2004; Jansen, 2006). Some of these practices still occur in smaller communities (Jansen, 2006). However, in urban areas, immigration and urbanization has fragmented kin ties, and the nuclear family structure has become more common (Badasu, 2004; 2012; Kwansa, 2012). Consequently, kin support for maternal healthcare and other domestic services is becoming uncommon (Kwansa, 2012). In this regard, paternal support in maternal healthcare is becoming more relevant in other ways than simply the provision of financial and material resources. Mid-way through working towards the Millennium Development Goal (MDG) five, which is concerned with improving maternal health, the international health community now realises that the goal is impossible to achieve without involving men as “partners, fathers, husbands, brothers, policy makers and community and religious leaders” (UNFPA, 2007, para.3). The UNFPA has also indicated that in promoting gender equality, especially in sexual and reproductive health, it is inappropriate to exclude men because men usually have strong reproductive decision-making power in relation to the number of children and the use and choice of contraceptives (UNFPA, 2011, para.1; Ministry of Health, Ghana (MOH), 2009 p.16). Subsequently, there has been a call to involve men in reproductive and maternal healthcare. This call is to educate men on the dynamics of women’s health, especially during pregnancy, childbirth and the postpartum period so that they will give the necessary support. In Ghana, some district health directorates motivate men who accompany their partners to the antenatal clinic by rewarding them financially (Kofoya-Tetteh, 27th Jan. 1 2012 p.20). Some NGOs and health facilities also organize pregnancy schools for couples to prepare them for the challenges of pregnancy, childbirth and parenting. Despite the growing interest in involving men, few studies have been conducted to explore what and how men support their partners during pregnancy and childbirth, and the factors which shape their support. Some studies conducted in Ghana have focused on gender relations in reproductive decisions and paternal support in childcare, saying very little about paternal support during pregnancy, childbirth and the postpartum period (Adomako-Ampofo, 2001; DeRose, Dodoo & Patil, 2002; Takyi &Dodoo, 2005; Kwansa, 2012). Other studies conducted in some parts of Africa are usually based on quantitative or mixed research methods and not theoretically grounded (Odimegwu et al., 2005; Falnes et al., 2011). In this thesis, I explore some factors that shape men’s participation in maternal healthcare in Accra using in-depth interviews, focus group discussions, participant and non-participant observation. The findings of the study are discussed with Connell’s (1987; 1995) conceptual framework of masculinities and femininities. 1.1 Definition of key terms Maternal health: According to WHO, maternal health refers to “the health of women during pregnancy, childbirth and the postpartum period” (the period just after delivery)1. Men in maternal health broadly refer to men as “partners, fathers, husbands, brothers, policy makers, and community and religious leaders” (UNFPA, 2007, para.3). But this study focuses on men as partners, husbands and fathers. Thus, men’s involvement in maternal healthcare refers to the social role, support and contribution of men as partners, husbands and fathers towards women during pregnancy, childbirth and the postpartum period. Gender equality has been defined by Oxfam as giving “women and men the same entitlements to all aspects of human development including economic, social, cultural, civil and political rights; the same level of respect; the same opportunity to make choices; and the same level of power to shape the outcomes of these choices 1 http://www.who.int/topics/maternal_health/en/ 2 (2003, p.1). What equality means and issues such as equality of what and equality of who has remained debatable (Sen, 1980; Annfelt, 2009). In relation to parenting rights and responsibilities, for instance, Annfelt has illustrated how equality has changed overtime from being “equality-fairness-women” to “equality-fairness-men” in Norway (2009, p.130). Whereas women were seen as underprivileged in the 1970s, men are now seen as the underprivileged in rights and responsibilities towards their children (Annfelt, 2009). With regards to reproductive rights and responsibilities, the International Conference on Population and Development (ICPD) 1994 has emphasized equality as a harmonious partnership between men and women (UN, 1995, p.27). Harmonious partnership, the ICPD 1994 has explained as the sharing of household, childcare and sexual rights and responsibilities between couples. The ICPD 1994 has indicated that harmonious partnership would promote equality between men and women in both private and public spheres (UN, 1995, p.27). Since this study focuses on men in maternal healthcare, the notions of equality and partnership are adopted from the ICPD 1994, to refer to the sharing of roles among couples in the household and responsibilities related to pregnancy and childbirth. Thus, equality and partnership will be used interchangeably. 1.2 Objectives and research questions The study has two basic objectives. The first is to explore men’s support for their partners during pregnancy, childbirth and the postpartum period, and also to discuss some of the factors that shape their participation. Secondly, the study explores the extent to which men’s participation in maternal healthcare can be seen to shape dominant gender ideas and ideals about reproductive roles. Three major questions are used to guide these objectives: - In what ways do gender ideals shape men’s decisions and contribution in relation to maternal healthcare? - In what ways do household arrangements, women’s employment and kin relations shape men’s contribution to maternal healthcare? 3