Men’s Perceptions, Practices about Prenatal Care Findings from A Low Resource Hilly Forestry Region of India

Prenatal care plays crucial role in the pregnancy outcome, maternal, foetal and neonatal health. While it is the women who must know and take appropriate action it is important that men share their responsibilities. They must be aware of essentialities of quality prenatal care. This becomes more important in communities where men take decisions for family for almost all issues, even women’s health including prenatal care. It is essential to understand the perceptions, and practices of men, in order to have safe maternity. There may be lack of awareness or lack of involvement or other reasons. In a study there was high level of awareness of men about maternal health, but their involvement during care was poor and only about half Men’s Perceptions, Practices about Prenatal Care Findings from A Low Resource Hilly Forestry Region of India

of them had positive attitude towards maternal health care [1]. In Melghat region of India, around 60% women deliver at home. There is high maternal mortality [2]. Compared to other parts of Maharashtra (one of the few states of India with better health indicators), women who live in Melghat are at more than twice the risk of dying during pregnancy, birth, or abortion. There are various reasons including communication problems, lack of transport, awareness, resources which lead to lack of quality prenatal care. For safe pregnancy it is essential that there is availability and use of prenatal care and compliance to advice. Compliance depends on support of family, especially husband. So it is essential to know their perceptions and their practices.

objectives
The objectives of the study were to know prenatal care related practices and perceptions of men from communities living with extreme poverty.

Materials and Methods
Study was done in sixty five villages, (20% of the villages of Melghat region of Amravati district of Maharashtra province of India), accessible from the base health facility within resources, willingness of the villagers to participate in the study. Approval of the institute's ethics committee was taken. Inclusion criterion was married men of 20-39 years whose wife had given birth within last 5 years. Men were from every 10 th house of all the villages. Wife may or may not have been pregnant at the time of interview. However if there was no such man in 10 th house, next family was approached. There were 50-250 or so houses in each village. Minimum 10% families were included from a particular village and the numbers from each village depended on population of a particular village and availability of men as per inclusion criteria. Informed consent of the respondent was taken prior to participation in the research. Study was done by doing interviews by the research assistant hired for the job, through a predesigned and pretested questionnaire developed in adherence to international norms for research involving human respondents, usually sitting in the house of the family. These men were willing to provide the desired information. Questions were both open and closed-ended. Information was recorded on the questionnaire by the interviewer assigned the job. No study subject was given the questionnaire to fill. Information collected was about involvement of men in prenatal care of their wives last pregnancy and their perceptions. Focus group discussions were also conducted with groups of men in the villages to get over all opinions of men. FGDs were conducted by the social worker (who did interviews) and the medical, with the area and who was briefed about the objectives of the study. The same tool which was used for individual interviews was used as a base for FGDs also. However in FGDs the age of study subjects and birth interval were relaxed. All men willing to join the FGDs were invited, keeping the numbers to around 10-15 at a time.
Analysis of information collected from the interviews and FGD was done. Majority of men were of 25-29 years (512 of 1000) 26.50% (265 of 1000) 30-34 years, 7.1% (71 of 1000) of 35-39 years, and 15.2% (152 of 1000) were of 20-24 years. Overall 34.10% (341 of 1000) had primary school education, 34.5% (345 of 1000) secondary school; 17.0% (170 of 1000) upto higher secondary; 14.1% (141 of 1000) were illiterate and only 3 were graduates. Almost all study subjects belonged to lower economic class, modified from Kuppuswami [3], only one was of upper class, one of upper middle class and 2 middle class. Majority (98.62%) of men were wage earners, either on annual or daily basis, earning 2 to 4 dollars per day.

Results
Almost all men (996/1000) belonged to the lower EC and 597/996 had not joined their wives during prenatal check-up during last pregnancy. All the 1000 men reported that their wives had antenatal check-up by the nurse midwives, silver lining! However the quality of care, including content needed to be looked into. Number of men who accompanied their wives increased with the educational level of men. However, only few had education beyond schooling. 40.6% (399 of 996) men of lower EC accompanied their wives for prenatal care. Of other four, one from upper class accompanied his wife for antenatal care, of the 2 from middle class, one accompanied and one from upper middle class had also accompanied his wife (Table 1).
Overall 41.66% had knowledge whether their wives had problem or no problem during pregnancy but they did not know about the problem. Of all the men interviewed, 41.99% (215 of 512) men of 25-29 years, 44.15% (117 of 265) men of 30-34 and 43.66% (31 of 71) men of 35-39 years knew that their wives had some problem or no problem during pregnancy and only 36.18% (55 of 152) men of 20-24 years had knowledge about problems during pregnancy. It was further revealed that 68.09% (96 of 141) illiterate men, 40.76% (139 of 341) men with primary school education, 44.46% (229 of 515) men with secondary and higher school education and all graduate men said that their wives had problems during pregnancy. In many FGDs it was revealed that none of the husbands who were present in FDGs had accompanied their wives for prenatal care. Some said they did not even know for some months that their wives were pregnant. They did not know whether their wives had prenatal care or not and whether wives had problem or no problem.
When men were asked about quality of prenatal care, 26.97% (41 of 152) men of 20-24 years, 24.02% (123 of 512) men of 25-29 years, 29.81% (79 of 265) men of 30-34 years said that antenatal care was very good and they were satisfied with the services provided by nurse midwives at sub-centre or at anganwadi. men with higher secondary education and one of three graduate men. Thirty one of 141 (21.99%) illiterate men, 29.33% (100 of 341) men with primary school education, 25.80% (89 of 345) men with secondary education, 13.53% (23 of 170) men with higher secondary education and none of the graduate men said there was no problem with male HP examining women. Objection to male HP decreased with increasing education, 46.10% (65 of 141) illiterate men, 33.43% (114 of 341) men with primary school education, 29.28% (101 of 345) men with secondary education, 27.65% (47 of 170) men with higher secondary education. However, two of three graduates also said that it should be nurse midwives or lady doctor. Overall 42.87% (427 of 996) men's choice was lady doctor, 32.83% (327 of 996) men preferred NM and only 24.30% (242 of 996) men said that male or female did not matter (Table 4).

Discussion
In many parts of the world men tend to be the decision makers in families, often about the allocation of money, transport, women's workload and access to health services too. Studies have revealed that engaging future fathers during the antenatal period, improved birth preparedness, contributed to better couple communication, increased assistance when complications occurred, facilitated more equitable relationships and improved attendance even at postnatal care [4]. There is a significant need to scale up men's participation in prenatal care, provide them with the information to help them make right decisions, support their partners' decisions and share responsibility the care of the baby. In addition to measures taken to encourage and motivate men to participate in prenatal care, special attention has to be paid to the obstacles they face and complex approaches to overcome them. More rigorous evaluation of male involvement However antenatal care was sometimes only weight and injection tetanus toxoid, sometimes with blood pressure. Rest of the men irrespective of the educational status reported that the services, provided were quite satisfactory. Overall, with a scale of five, 256 of 996 (25.70%) of lower EC said that antenatal care was very good, while 314 of 996 (31.53%) said that it was good, 396 of 996 (39.76%) said that it was satisfactory and only three persons were not satisfied with the care. One from upper lower class said antenatal care was good, of 2 from middle class, one said it was fair and other had no idea and one from upper middle class said it was good (

Global Journal of Research and Review ISSN 2393-8854
initiatives is needed in order to strive for better maternal and newborn health outcomes and well-being [5]. In many prenatal clinics in India, there is no place for men to sit. Actually men are asked to go out because of the lack of awareness, in health professionals, their attitude, in addition to problems of space, with crowds of women, problem of privacy of other women and so on.  In the present study 39.59% (135 of 341) men with primary school education, 42.71% (220 of 515) men with secondary and higher school education and two of three graduate men accompanied their wives for antenatal check-up, only 31.91% (45/141) illiterate men accompanied wives for antenatal care. NFHS-3 also revealed that men's presence with wife during antenatal checkup increased with educational level of the men [6].
In the present study all men said that their wives had antenatal care (100%). It is essential to build on the concept to provide quality care. All the men said that antenatal check-up was done by the nurse midwives. It means women did visit anganwadi or subcentre, the usual place of antenatal care. Usually only weight was taken and tetanus toxoid was given, sometimes blood pressure was recorded. Though for quality basic prenatal care also, a lot more is needed, which is not even done at primary health centre.
Only 23.61% of husbands were aware whether their wives had problems or no problem during pregnancy, rest did not know anything [7]. Those who knew also did not know any details. It was revealed that 42.73% (332 of 777) men of 25-34 years had knowledge whether their wives had problems or no during pregnancy, only 36.18% (55 of 152) men in younger age 20-24 years had knowledge about problems or no problems. Rest did not know. This might be due to their lack of knowledge of maternity related issues. May be with lack of awareness normal things were taken as problem by illiterate men.
A total of 25.6% (256 of 1000) men said that they were satisfied with care given during pregnancy and reported the services provided were very good. Rest of the men said that they were quite satisfied with the care provided. In a study a woman was at risk of domestic violence if her spouse found that she took another man as her spouse for ANC [9]. Researchers reported that while attending antenatal clinic with a male partner was indeed honorable, it unfairly had pressure on the women to convince their partners to tag along for ANC services in a culture where this has long been a woman's niche. Some, and indeed many, of these vulnerable women were denied the right to access cares because they had failed to convince their partners to attend. This is not the scenario in India, where neither there is pressure to get men, nor is it someone else, as it is mostly husbands who do not accompany and are not welcome at prenatal clinics too. An additional barrier to integration may be societal discrimination. Maternal deaths are the culmination of layers of structural, discrimination, and exclusion that women face in society [10]. In a study related to prevention of mother to child transmission of HIV it was found that using men in the media and community to reach out to fellow men with prevention messages tailored to suit specific audiences helped [11] and similar things need to be done for maternal care so that their perceptions about maternal care being women's domain, also change. Vermeulen et al. [12] reported that although several barriers impede male involvement during antenatal care, men's internal motivation and attitudes towards their role during pregnancy was generally positive. Increasing community awareness and knowledge about the importance of male involvement and increasing accessibility of antenatal clinics can reduce some of the barriers. Yargawa and Bee [13] also reported that male involvement is associated with improved maternal health outcomes in developing countries.
Over the last several years, research on male involvement in reproductive and maternal health has shown incredible impacts on the health outcomes of women and newborns. Male involvement strategies to encourage men to accompany their spouses during prenatal care are essential.

Conclusion
There are many challenges in increasing male involvement/ participation in prenatal care. Awareness programs should be carried out by governmental, nongovernmental organizations, civil society to stress the necessity of involvement of men in promoting prenatal care and also being agent of change for promotion of maternal neonatal health.