This post is part of the Woman-Centered Universal Health Coverage Series, hosted by the Maternal Health Task Force and USAID|TRAction, which discusses the importance of utilizing a woman-centered agenda to operationalize universal health coverage. To contribute a post, contact Katie Millar.
Over the last several years, research on male involvement in reproductive and maternal health care has shown incredible impacts on the health outcomes of women and newborns. For example, educating male partners about HIV in general and how it is transmitted is essential to successful, long-term approaches to eliminating HIV/AIDS. Male involvement in antenatal care (ANC) can reduce the risk of mother-to-child transmission of HIV and infant mortality by more than 40 percent.
In response to this overwhelming research, Uganda officially launched a male involvement strategy in November 2014. The main objective of this strategy is to include men in all aspects of a family’s health: nutrition, water and sanitation, family planning, immunizations, and the fight against malaria and HIV/AIDS. However, this and other male involvement strategies have had unexpected consequences on women’s access to care:
I went to the facility when my pregnancy was 2 month but was denied access to services because I had not gone with my husband. I again went there when it was 6 months and the same happened. I decided to go back home and wait for the time of delivery because I had nothing to do. My husband is not always at home. I tried to explain to the health worker but she could not listen to me. When the time for delivery reached, I decided to deliver from home because I feared to go back to the facility. Two days after delivery, my child died. – Ugandan Mother
Male involvement strategies are intended to encourage men to accompany their spouses during ANC visits. Unfortunately the interpretation of these policies has been left to health providers and non-governmental organizations, who seek to demonstrate desirable outputs for targets such as couples testing for HIV. It almost seems as if the responsibility to “catch” the men who have long eluded the health system and HIV screening has been unfairly transferred to the pregnant spouse. Even prior to the launch of this strategy, some facilities all over Uganda made it mandatory for a woman to bring her spouse if she wanted access to ANC services.
Mmmhmmm!… (with a shrug) …If a woman comes without a spouse we send them to another facility where services might not be as good as here. – Midwife in Northern Uganda
While male involvement can lead to better outcomes, it should not prevent a woman from accessing care. Since when does attending ANC without a spouse qualify a pregnant woman for a referral? Moreover in a setting where every shilling is valuable and transport is hard to find, referrals create increased costs and barriers for women to access care. The above quotes from both a mother and a midwife depict the potentially deleterious consequences of not incorporating the notion of power and culturally accepted gender roles in policy making. They also expose the insidiousness risk posed by leaving gender sensitive policies wide open to interpretation.
Alternatively, some women have resorted to beating the system by “hiring” spouses for ANC visits in order to access care. This has several implications:
- Women are forced to bear the ridicule of having failed to convince their spouse to accompany them to ANC
- Women are forced to incur additional costs to “hire” a spouse to escort them for ANC
- HIV tests conducted at ANC are not valid since they are not a true reflection of a legitimate couple’s test
- A woman is at risk of domestic violence if her spouse finds out that she took another man as her spouse for an ANC visit
While attending ANC with a male partner is indeed honorable and augurs well for the family, it unfairly puts pressure on the woman to convince their partner 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 are denied the right to access care because they have failed to convince their partners to attend ANC! Is this morally acceptable? Should someone’s right to health be premised on the availability of another (over whom they wield no power)?
Ultimately, the lesson learned from the implementation of Uganda’s male involvement strategy is that women’s health suffers when policies do not take power and culturally ingrained gender roles into consideration, do not carefully sensitize implementers on the policy content and limits, and fail to monitor unintended effects of policy change. This is unacceptable!