{"paper_id":"241ad577-8768-494e-84e9-b6a251155941","body_text":"1 \n \n“Go and bring your husband”: a COM-B guided \nqualitative study on the barriers to male involvement in \nantenatal care in Bamenda Health District, Cameroon. \n \nLily Haritu Foglabenchi1,2*, Tanya Marchant1¶, Heidi Stöckl1,3¶  \n1 Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel \nSt, London, WC1E 7HT, United Kingdom \n2 Maternal and Child Health Program, Cameroon Baptist Convention Health Services, \nFinance Junction, Bamenda, P .O Box 1, North West Region, Cameroon \n3 Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of \nMedicine, Ludwig-Maximilians-Universität München, Munich, Germany \n \n*Corresponding author:  Lily-Haritu.Foglabenchi@lshtm.ac.uk; lhfoglabenchi@gmail.com  \nContributing authors: Tanya.Marchant@lshtm.ac.uk;  \nheidi.stoeckl@ibe.med.uni-muenchen.de;  \n \n¶These authors contributed equally to this work. \n \n \n \n \n \n \n \n \n \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\n2 \n \nAbstract \nBackground \nIncreasing access to and utilization of skilled care during pregnancy and child birth can \nsignificantly reduce maternal and infant morbidity and mortality. Male involvement can \npositively influence utilization but resource limited settings like Cameroon encounter \nobstacles in engaging men in maternal and child health services. The aim of our study was to \nidentify contextually relevant barriers to male involvement in antenatal care attendance to \ninform the development of an intervention that is aimed at promoting male involvement in \nmaternal and child health in Cameroon. \n \nMethods \nThis study used a qualitative design with qualitative methods that draw on 68 semi-structured \ninterviews and three focus group discussions with pregnant women, male partners and health \nworkers. Both interviews and group discussions were audio-recorded, transcribed. Guided by \nthe Capability, Opportunity and Motivation (COM-B) model of behaviour and Theoretical \nDomains Framework (TDF), we analyzed data using directed content analysis, followed by \ninductive thematic analysis.  \nResults \nOur findings suggest that male involvement in antenatal attendance in Bamenda Health \nDistrict is under the influence of six multidimensional factors: limited awareness on the need \nfor male involvement, limited female agency to engage men on ANC, maternal extortion, \nrestrictive gender and socio-cultural norms regarding male ANC attendance, limited \nengagement of men by ANC staff and intrapersonal fears that fuel the avoidance of antenatal \nclinics. These overlapped across all three COM-B constructs, and 9 TDF . Overall, we noted \nthat the motivation of male partners to participate in antenatal attendance is strongly \ninfluenced by social opportunity factors categorised as restrictive gender, social and cultural \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n3 \n \nnorms on male ANC attendance and psychosocial capability underpinned by limited health \nsystem engagement and awareness of male role in antenatal care. \n \nConclusions \nThis study identified multi-dimensional barriers related to male partner capability, \nopportunity and motivation to participate in antenatal care services. There is a need for \ninterventions that employ gender-transformative approaches to adapt the socio-cultural \nenvironment and the messaging on antenatal care for optimal male involvement and \nsubsequently, better health outcomes for mothers and children in Cameroon. \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n4 \n \nIntroduction \nMaternal mortality has remained high despite global efforts to promote safe motherhood as \nlaid out in the Sustainable Development Goals (SDG3.1)(1). Worldwide, 287,000 women \ndied from pregnancy-related complications in 2020(2). Over 99% of these preventable deaths \noccur in low-income settings with sub-Saharan Africa (SSA) accounting for over 70% of the \nglobal burden of maternal deaths(3). Evidence suggests that access to and utilization of \nquality antenatal care and skilled attendance during pregnancy and childbirth can be an \neffective strategy to improve maternal and child health (MCH)(4–6). Male involvement in \nMCH has therefore been proposed as a crucial strategy in resource-limited settings because \nmale partners have economic and decision-making power and consequently significant \ninfluence over the health-seeking behaviours of their pregnant partners(7–9). There is \ncurrently no agreed definition and indicator for measuring male involvement in MCH. The \nterm varies depending on context—and this ranges from male antenatal care (ANC), \nimmunization or infant welfare attendance, male partner HIV testing during pregnancy, to \nspousal discussion and men’s domestic and financial support during pregnancy(10–12). In \nthis study, we define male involvement as a man attending ANC with his pregnant partner. \n \nThe global recognition of men as key players in MCH has its roots in the 1994 International \nConference on Population and Development (ICPD) in Cairo, Egypt(13).  The ICPD program \nof action laid emphasis on male shared responsibility and participation in sexual and \nreproductive health as a means of achieving gender equality, equity and women’s \nempowerment(13,14). Research points to the fact that the mechanism through which male \ninvolvement impacts maternal and child outcomes is linked to the influence men have over \nmaternal behaviours(7). Furthermore, data from an intervention study across African \ncountries suggests that the three indexes that consistently determine women’s use of antenatal \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n5 \n \nservices and skilled birth attendance (SBA) are: a husband’s involvement in maternal \ndecision-making, spousal discussions, and counselling on birth preparedness(15). This has \nrecently been supported by a number of studies that suggest that male involvement in \nmaternal health improves the utilization of prenatal and postnatal services, prevents \npregnancy complications and improves overall maternal and infant survival(16–18). Despite \nthese benefits, low levels of male involvement has been reported in SSA with figures as low \nas 14% in South Africa(19); 26% in Kenya(20); 27.1% in Nigeria(21);  and 6-65% in \nUganda(22). \n \nCameroon is currently ranked at the 16th position globally for maternal deaths with an \nestimated maternal mortality of 438 per 100,000 live births(2).  Despite progress in reversing \nthe trend for under-five mortality, the country’s maternal mortality ratio increased from 430 \nto 782 per 100,000 live births  between 1990 and 2011. In addition, the country witnessed a \ndecrease in 1st and 4th antenatal care visits and stagnation in access to skilled personnel during \npregnancy between 2004 and 2014. In response to this, the country’s government enacted the \n2013 multisectoral program known by its French acronym PNLMNI ( Order No. 095 / CAB / \nPM of 11 November 2013) to reduce maternal and child mortality(23). This was followed by \nthe 2016-2027 Health Sector Strategy that seeks to align the 2013 enactment with the \nSustainable Development Goals to target 80% of MCH issues both at the community and \nhealth facility levels by 2027(24). Although male involvement is not specifically enshrined in \nthe aforementioned health sector strategy, the National Gender Policy Document (2011-2020) \nin keeping with the country’s “Vision 2035”, highlights the need for men’s involvement in \nmaternal, reproductive health and HIV/AIDS prevention strategies(25). This has however not \nbeen translated to target male involvement in health service delivery models with only 4.7% \nof men participating in antenatal care with their pregnant partners(26).   \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n6 \n \n \nStudies in SSA with Cameroon inclusive have reported barriers to male antenatal attendance, \nincluding social or normative beliefs that antenatal care is a female affair, lack of time, \nnegative staff attitude and fear of HIV testing(17,27,28). While most of these barriers are \nreported from the perspectives of women, few studies have reported barriers from the \nperspectives of men and service providers. Additionally, the majority of the reported studies \ndo not provide the theoretical underpinning and contextual influences on male partner \nbehaviour during the antenatal period. We therefore used the Capability, Opportunity and \nMotivation (COM-B) Model of Behavioural analysis to contextualise male partner ANC \nbehaviour in order to inform the development of an intervention that is aimed at promoting \nmale involvement in maternal and child health in Cameroon. \n \nThe COM-B model posits that factors that influence a given behaviour (B) can be understood \nthrough an exploration of how Capability (C), Opportunity (O) and Motivation (M) interact \nto either enable or hinder the behaviour. This model is central to the  Behaviour Change \nWheel (BCW)— an encompassing behavioural framework that was developed through the \nsynthesis of 19 behaviour change frameworks in a behavioural theorist meeting that held in \nthe united States of America(29). It has mostly been used in combination with the Theoretical \nDomains Framework (TDF) which features 14 domains that further expand on COM-B \nconstructs and captures mediating factors on behaviour change(30,31). While COM-B has \nbeen applied to design interventions in a variety of contexts like medication adherence, \nsmoking cessation, non-communicable diseases and STI testing, limited evidence exists on its \nuse in developing countries or the design of RMCH interventions(32,33). Regarding male \ninvolvement behaviour specifically, there is limited consensus on theoretical approaches that \nare relevant in the investigation of the determinants of male involvement in Cameroon and \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n7 \n \nsub-Saharan Africa. To address this gap, this study explored barriers to male involvement in \nantenatal care attendance, in order to provide a theoretical understanding of male \ninvolvement behaviour and inform intervention development for pregnant couples in the \nNorth West Region of Cameroon. \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n8 \n \nMethods \nThis study was nested in a larger study that is being conducted to develop an intervention to \npromote male involvement in MCH/HIV during the prenatal period. It represents the \nformative phase of the study and data collection took place between January and December \n2021. We report this study’s methodology and results following guidance from the \nConsolidated Criteria for Reporting Qualitative Research (COREQ)(34).  \nStudy design  \nWe chose a qualitative study design underpinned by the naturalistic enquiry approach to \nexplore perspectives on the barriers to male ANC attendance(35).  This was suitable as it \nenabled us to use semi-structured interviews (SSIs) and Focus Group Descriptions (FGDs) to \ncapture participant accounts and provide comprehensive summaries of the factors that impede \nmale participation in antenatal care. \nStudy setting  \nOur study was conducted in Bamenda Health District in the North West Region of Cameroon. \nThe North-West region is a historically disadvantaged, politically unstable and high-density \nregion—currently ranked 3rd most populous in Cameroon with an estimated population of 2 \nmillion inhabitants(36). The region has one of the poorest reproductive, maternal and child \nhealth indices in the country. Antenatal care coverage of at least one visit was 58% in 2017; \nchildhood immunization coverage was 68% and under five mortality was 57 per 1000 live \nbirths(26,37) In 2018, the adult HIV prevalence in the region was estimated at 4.0%, which is \nhigher than the national average while maternal HIV prevalence was estimated at 5.0%(38). \nThe region is largely traditional and patriarchal with prohibitive gender norms and socio-\ncultural customs that impede male involvement in maternal and child health services(27). \nBamenda Health District is the largest of the 19 districts in the North West Region. The \ndistrict is located in an urban and peri-urban locality composed of 17 health areas and 35 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n9 \n \nhealth facilities—18 public, 12 lay private and 5 confessional serving an estimated population \nof 800,000 urban and rural residents(36). The main public facility is Bamenda Regional \nHospital – a level 2 referral hospital. The district covers a total surface area of 560km2 and is \ncentrally located within the city of Bamenda —which serves both as the administrative \nheadquarters of Mezam Division and capital city of the North West Region of Cameroon. The \ncity is cosmopolitan with inhabitants originating across the national territory and \nneighbouring Nigeria. It is made up of three towns: Mankon, Nkwen and Bamendankwe \nrepresented by Bamenda  I, II, and III  Sub-divisions respectively(36). \n \nStudy participants for this study were drawn from Nkwen Baptist Health Centre within \nCameroon Baptist Convention Health Services (CBCHS) —a private faith-based NGO in \nCameroon. The facility has a modern infrastructure with a 114 bed capacity and 250 staff \nattending to over 18000 patients monthly(39). It was purposively chosen because it is \ncentrally located within Nkwen town in Bamenda II Sub-division, and has high volume \nantenatal clinics (over 358 clients per month) with well-established Option B+ services.  It \nalso attracts a mix of clients with varying socio-cultural backgrounds that was important for \nthis study \n \nParticipant recruitment and sampling approach \nPregnant or recently postpartum women, male partners and ANC/HIV health workers who \nwere 18 years and above were eligible for inclusion in this study. We employed purposive \nmaximum variation sampling in order to achieve maximal variation regarding age, parity and \ncouple ANC attendance. The variation in our selection was underpinned by the need to \ncapture a wide range of perspectives, perceptions and experiences in order to identify and \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n10 \n \nreport common patterns that emerge from heterogeneity(40). We therefore observed group \nantenatal and post-natal consultations to subjectively identify information-rich participants \nwhom we subsequently approached and invited for interviews or group discussions(41).  \n \nWe followed recommendations for sample size estimation based on the study question, \nestablished evidence on sample size estimates for similar studies and informational \nredundancy as per the +3 criterion(42,43) . A total of 103 eligible women and their male \npartners were therefore approached of whom 90 consented; four women declined and nine \nmen who were contacted through telephone were unreachable. Of the 80 pregnant women \nand male partners who accepted our invitation, 44 were women (n= 38 SSIs; n=6, FGDs) and \n36 were men ( n= 30 SSIs; n=6, FGDs). We purposefully recruited 10 Staff members (two \nmale and eight female) for an FGD based on their clinical roles within ANC/HIV units and \ntheir level of education.  \n \nTo ascertain that saturation was being achieved, we adopted a hybrid approach—data set and \nindividual interviews by discussing the depth and breadth of participant views and \nperspectives during debriefing sessions, reviewed fieldnotes for recurrent and divergent \nthemes, and noted where infrequent or no new views were expressed(44). Additionally, we \nprobed participant views during interviews until no new information about a particular topic \nwas forthcoming. \nData collection  \nThe data collection process began with site visits for institutional approval, ANC observation, \nparticipant recruitment between January and June 2021. This was closely followed by \ninterviews and FGDs interspaced with debriefing sessions between July and December 2021. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n11 \n \nThe corresponding author (LHF)— conducted the majority of SSIs (53) and co-facilitated all \nFGDs. LHF was assisted by a female Bachelor’s degree nurse midwife and a female master’s \nlevel sociologist who served as co-interviewers, observers and note-takers during group \ndiscussions. The study’s languages were Pidgin (Cameroonian Creole) and English \ndepending on participant preference. We took field notes during interviews and FDGs to \ncapture non-verbal cues and unanticipated events. Although these notes served as an \nadditional source of data, they were not used as primary data sources during analysis. They \nprovided context to participant responses, aid debriefing and enrich analytic memos. \n \nSSIs and group FGDs were conducted using topic guides. The development of these guides \nwas theoretically underpinned by empirical evidence, the National MCH handbook and the \nCOM-B model mapped unto the TDF.  Participants were broadly asked: What are the \nbarriers that prevent men from attending ANC? Why do you perceive them as barriers? How \ndo you feel about these barriers? We used these guides iteratively with additional prompts \nbeginning with participants’ responses to enrich and add depth to concepts that emerged \nduring interviews and group discussions \n \nWith the exception of the staff FGD guide, topic guides and demographic forms were piloted \nwith two postpartum women and one pregnant woman. These were further refined following \nfeedback from participants and the research team. With the exception of two SSIs, all SSIs \nand FGDs were conducted face-to-face in a private room at the health facility. With \npermission from participants, interviews and FDGs were audio-recorded, translated and \ntranscribed verbatim. Interviews sessions lasted between 22 – 65 minutes while FGDs lasted \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n12 \n \nbetween 1-2hrs. Participants were provided snacks and transport reimbursements which \nranged between 350frs CFA (40pence) and £1 (750frs CFA). \nData management and analysis \nBoth FGDs and SSIs transcripts were anonymized with numbers and combined to represent \none data set and managed using NVIVO(45). The first five transcripts were checked against \naudio for accuracy following the agreed SOP that was developed for this study. The overall \napproach to analysis was directed content analysis followed by inductive thematic \nanalysis(46,47). Summarily, analysis broadly involved a 7-stage approach with combined \nguidelines adapted from both Hsieh and Braun as outlined in the supplemental file 1 &2 \n(46,47). The relevance of themes for inclusion was informed by three criteria: (1) frequency \nof occurrence, (2) presence of conflicting beliefs (3) perceived strength of the belief to \ninfluence the target behaviour(48,49). This was finalized with a tabular representation of \nthemes matched to, belief statements, COM-B constructs and relevant theoretical domains. \nThis matrix (See supplementary file 3) was reviewed by TN and HS for further insight, \nrefinement, interpretation and exploration of dissonant areas. \nEthical consideration \nEthical approval for this study was granted by the London School of Hygiene and Tropical \nMedicine ethics committee (Ref: 18003) and the Cameroon Baptist Convention Health \nServices Internal Review Board (IRB2019-33 ). Written informed consent was sought from \nall participants. Participants were assured of confidentiality, anonymity and the non-impact of \ntheir participation on the care they were receiving. \n \n \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n13 \n \nResults \nTable 1 presents the socio-demographic characteristics of study participants. Over half (56%) \nwere female; 73% were married, 25% were cohabitating while 3% were single. Our \nrespondents had varied occupations, with 36% in professional employment (excluding staff \nmembers), 55% reporting self-employment such as bike or taxi driver, farmer, trader and hair \ndressing.  Majority were literate with (37%) having college or university level education. \nVery few (19%) reported that they had attended ANC with their partners. Among staff \nmembers, two were male while eight were female among which we had midwives (06), \nnutritionist(01), an HIV physician (01), an HIV site nurse(01), an Option B+ team lead(01) a \nPMTCT regional Focal point nurse(01). \nTable 1. Socio-demographic characteristics of study participants. \nVariable SSIs (n=68) Male & Female FGDs \n(n=12 participants) \nStaff FGD (n=10 \nparticipants) \nFemale Male Female Male Female Male \nN % N % N % N % N % N % \n38 56 30 44.1 6 100 6 100 8 80 2 20 \nMarital status             \nMarried 29 76 20 67 4 66.7 5 83 -- -- -- -- \nCohabiting 7 18 10 33 2 33.3 1 17 -- -- -- -- \nSingle 2 5 -- -- -- -- -- -- -- -- -- -- \nLevel of \nEducation \n            \nPrimary or less 10 26 7 23 1 16.7 2 33 0  0  \nSecondary to high \nschool \n13 34 11 37 2 33.3 3 50 3  0  \nCompleted \nuniversity \n15 40 12 40 3 50 1 17 5  2  \nEmployment \nstatus* \n            \nEmployed \nprofessional \n15 40 7 23 3 50 4 67 -- -- -- -- \nSelf-employed 16 42 23 77 3 50 2 33 -- -- -- -- \nNot working 7 18 --- --- -- -- -- -- -- -- -- -- \nANC Visit with \npartner** \n            \nNo 30 83 23 77 3 50 4 67 -- -- -- -- \nYes 3 8 7 23 3 50 2 33 -- -- -- -- \nMean age 31 30 37 \n*Not working includes students, housewives and not employed; Self-employed includes bike rider, farmers, \ntraders, hairdresser etc ; ** Five missing data on ANC attendance with partner; -- not applicable or data not \ncollected. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n14 \n \n \nSix themes emerged from our analysis: (1) limited awareness/knowledge on the need for \nmale involvement, (2) limited female agency to engage men on ANC, (3) maternal extortion, \n(4) restrictive gender and socio-cultural norms regarding male ANC attendance, (5) limited \nengagement of men by ANC staff and (6) intrapersonal fears that fuel the avoidance of ANC \nclinics.  \n \nWe conceptually organised these by mapping them to belief statements and theoretical \nconstructs within the capability, opportunity and motivation domains in COM-B model in \nFigure1:  Conceptual analysis of barriers to male involvement in ANC underpinned by \nthe COM-B model of behaviour change\n (29,31)\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n15 \n \nLimited awareness on the need for men in antenatal attendance  \nThe majority of participants reported that the low involvement of men in ANC is as a result \nof the limited awareness and knowledge about their role in MCH and specifically ANC \nattendance which is generally perceived as a woman’s duty. \n \n“I think the very first thing is that men fail to know that they have a part to play during \nantenatal attendance because they think it is the woman’ s duty to come, learn and practice \nwhat she has been told”— Male FGD participant, in their 20s.  \n \n“He is not really informed about the importance of couple ANC visit as a parent or partner \nshould” —Female SSI participant, in their 30s. \n \nA  subset of study participants who echoed this perspective blamed this lack of awareness on \nthe health system that has not made provision for men by requiring and duly informing them \nfor ANC attendance with their pregnant partners. \nI blame the ignorance on the part of the health authorities. They have not made a provision \nfor us. If a pregnant woman does not go for antenatal care, even an uneducated grandmother \nwill ask her why because they know it is mandated. However, when a man does not go, \nnobody will ask him questions because it is not mandated anywhere. I believe that these \nhealth institutions should be the ones to make it mandatory and permit men to have their own \nclinic day or come along with their wives.— Male FGD participant, in their 30s. \n \nLimited female agency to initiate male involvement \nBased on anecdotal evidence, health providers verbally require pregnant women to bring their \npartners for ANC attendance. Most of our female participants reported that they do not have \nthe agency to bear the initial responsibility of convincing and involving their male partners \nfor participation in ANC activities. Both men and women in our study therefore expressed the \npreference for the health system to bear the initial invitation for male involvement—not \nwomen who think their partners will not believe them and not a self-initiative from men \nthemselves who don’t wish to intrude because of long-held perceptions that antenatal clinics \nare spaces reserved for women.  \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n16 \n \n \n“Sometimes I when I tell him that they said men should come for ANC, he thinks I am joking \nand only  want him to be moving around with me. When he sees an invitation from the \nhospital he would know that it is a serious issue. Otherwise, it will sound like I am the one \nforcing him to come.”— Female SSI participant, in their 20s.  \n \nMaternal extortion \nMost respondents opined that men generally bear the financial responsibility for prenatal care \nin Cameroon and some pregnant women prevented their partners from participating in ANC \nattendance because they preferred to conceal the true cost of accessing ANC services. They \ndid so in the hope of receiving more money than is actually needed. As such, respondents \ntherefore classified these group of women as part of the barriers to male ANC attendance as \nthey fear the presence of male partners could expose their extortionary schemes. \n \n“W omen are also barriers. They don’t want their partners to come as participant number 5 \nmentioned because they don’ t want the men to know the amount they are spending for ANC. \nThey use pregnancy as a forum to exhort a lot of money from their partners.” \n— Staff  FGD participant, in their 40s. \nSome women don’t also give the opportunity for their husbands to come with them for \nfinancial reasons. They don’t want them to know what is happening here and how much is \nbeing spent. — Female SSI participant, in their 30s. \n \nRestrictive gender, social & cultural norms on male ANC attendance \nApart from the fact that men feel out of place in antenatal clinics, restrictive gender, social \nand cultural norms on masculinity inhibited the effective participation of men in antenatal \ncare. Gender normative assumptions that men are superior to women and should opt-out of \nantenatal care in order to maintain their bread-winning role and dominance were some of the \nfactors participants stated for the low participation of men in ANC. Sub-themes that emerged \nunder this are substantiated below with illustrative quotes. \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n17 \n \nMale partner sense of superiority about attending ANC \nDuring interviews and group discussions, it was noted that the Cameroonian society is largely \npatriarchal. Study participants reported that men hold positions of dominance and are \nconsidered superior to women to the extent that attending ANC together with other women is \na tacit admission that they are in equal standing with women. Respondents therefore \nintimated that this perception on the superiority of men prevented most men from attending \nANC together with their partners. They also noted that some men who eventually made it to \nANC clinics decided to sit at the periphery to observe from a non-identifiable distance. \n \n“I think there is a cultural [gender] attachment to this. You know, we African men we have a \ncertain way of relating with women—it  is a kind of boss-subordinate relationship. I am the \nhead of the family. I have to dictate and the woman follows…Men don’t see themselves and \nwomen as being equals. So they don’t feel comfortable sitting and being given health \neducation together with women. A man may feel like, ‘if I go to clinic with my wife, it may \nappear like my wife and I are equal’ ” — Male SSI participant, in their 30s. \n \nLack of male social identity in antenatal clinics \nParticipants reported that men perceive ANC as a woman’s affair because it is largely \nattended by women who run their own feminine activities which men don’t socially identify \nwith. In the absence of peers or forefathers who modelled the behaviour, the few men who \nattended ANC felt shy, out-numbered and out of place in a large pool of women who were \nclapping, singing and dancing to issues that pertain to their pregnancies. \n \nThe first day I went, I was in a pool of women and all eyes were on me. I was like…OK “what \nam I doing here?” I am not pregnant! —Male SSI participant, in their 30s.  \n“I am always scared of going for ANC. Imagine being the only man among hundreds of \nwomen and the stares you will receive. It makes me feel a type…there are songs that women \nwill be singing, clapping and even dancing to… and they may be expecting you to be clapping \nand singing as well [laughs]. When you are not clapping because you don’ t identify, it \nbecomes a call for concern. When you sing along for solidarity, it is still a call for concern \nbecause it may appear as though you are pregnant as well, of which you are not!” \n —Male SSI participant, in their 30s. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n18 \n \nEngendered perception of the time value of ANC attendance \nThe notion that time is not created equally for men and women in Cameroon emerged as an \nimportant factor in this study. Participants reported that the majority of Cameroonian men \nwere primary bread-winners—and being able to provide was a source of masculine identity \nand pride. This came with the expectation for men to appear busy in income-generating \nactivities. Respondents did not therefore rate ANC attendance as an income-generating \nactivity. They rather perceived it as an opportunity cost—a liability to their bread-winning. \nRespondents also acknowledged that while ANC attendance was an obligatory activity for \nwomen it was often perceived as an optional affair for men who did not wish to spend long \nhours in ANC clinics.  \n“The point is that coming to the clinic for me is a must. Time or no time I must be at the clinic \non the appointed date until delivery. That is not the same for my husband. As a man, he must \ngo out and struggle to work so that he can get something (money) to give me for ANC \nattendance.” —Female SSI participant, in their 30s. \n \n“Y ou have the issue of time…time factor which is also something so important because the \nman is always busy from morning till night… and remember that it is the man who  in most \ncases (I can say about 80% or 70% of cases), the man is the one who provides everything in \nthe house. So, he makes sure that he catches up with those activities in order to be able to \nprovide. Because when he sits somewhere and loses a day, it is really something big that he \nhas lost” —Male SSI participant, in their 30s. \n \n“Woman Wrapper” stigma—male fear of losing control and female fear of \nappearing in control \nMost Cameroonian men from the North West Region have been conditioned to exercise \ndominance over women. Since ANC has traditionally been an activity reserved for women, \nthe introduction of men into this space was perceived by study participants as an attempt to \nusurp their power and relegate men to the background. The mental picture that the majority of \nparticipants presented about male ANC attendance was a woman at the forefront and the man \nbehind her as a follower. Men who therefore made attempts to attend ANC clinics were \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n19 \n \nmocked by community members and ridiculed as weaklings who have given up their \nmasculine power or are under metaphysical forces from women.  \n \nAccording to several participants, some Cameroonian phrases or idioms have been coined to \nlabel men who are in favour of accompanying their partners for ANC. ‘Woman wrapper’  \nwhich literally translates to being too attached and subdued under a woman’s loin cloth was \none of such derogatory terms. According to participants, this describes a man who takes \norders from his wife or always follows her around. \n \n“To add to what my brother has said, let me speak from my community. It appears like, \nattending ANC with a woman is a way of giving up your authority as a man. When your \nfellow men see you, they look at you like you are a woman [group laughter]. Yes, you are a \nwoman and not the man because if you were a man, you will not be following  your wife to go \ndo women’ s things” —Male FGD participant, in their 30s. \n \nThe need for men to maintain dominance is so normative in the Cameroonian context to the \nextent that even women who attended ANC with their partners reflectively defended their \npartner’s choice in order to distance themselves from any perceived notion that they are \ncontrolling their husbands. \n“ Y ou know, African men have a mentality that if they follow their wives for antenatal care, \npeople might see them and think that he lacks something to do or he is a “woman wrapper” \n[weakling, sissy or subdued man]…The day we came for ANC,  he was the only man who \ncame for ANC and even though some women will think that I am controlling my husband, that \nwas his personal decision” — Female SSI participant, in their 20s. \n \nLimited engagement of men by ANC staff \nHealth system factors were also thought to limit male participation in antenatal care. Staff \nand participants who had previously attended ANC opined that the engagement of men by \nANC staff was ridden with tokenism which some men find derogatory. Others felt their \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n20 \n \npresence in ANC made no difference because the focus was mostly on their pregnant \npartners. Sub-themes that emerged from this are explained below: \n \nToken-based engagement (ANC claps for men who attend) \nParticipants reported that men who were spotted in ANC clinics were given a special ‘ANC \nclap’ as a form of recognition. While this was generally good-intentioned on the side of \nservice providers, some men received this with mixed feelings . ‘ANC claps’ for men who \nattended clinics was perceived as an insult to their identity. They felt it reduced them to \npreschool children who have to be clapped for, for fulfilling the bare minimum of ANC \nattendance with their wives—something they do not have to be coerced with claps to do. \n \n“Some men have said: “I came to the clinic and at the end they said ‘let’ s clap for papa, papa \ncame for clinic today’  and they felt like they were in primary school. So they will not come \nagain, because they don’ t like being treated as kids” —Staff FGD participant in their 30s. \n \nLack of male engagement and female-focused health education \nSome participants reported that health facilities have not made provision for their presence in \nANC clinics. This is evident in the fact that male attendance has not been required and for \nthose who made the effort to attend, providers rarely engaged them. Rather, the entire focus \nwas on their pregnant partners. Some participants substantiated this with the fact that the need \nfor couple attendance is something they only heard about through this study. \n \n“Y ou are the first to bring up this procedure on couple ANC attendance and testing for HIV . \nThat is what we should have done before but the attention of the hospital has mostly been on \nher .” —Male SSI participant, in their 40s. \n \nIntrapersonal Emotions (Fear) \nStudy participants across FGDs and SSIs echoed the fact that male ANC attendance evokes a \nrange of emotions that serve as barriers to their attendance, including fear. Sub-themes below \nfurther expand on these: \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n21 \n \nFear of being judged or discovered for extra-marital affairs \nParticipants mentioned that a pregnant woman in the Cameroonian context is more of an \nabandoned sexual project and most men use this period to visit their “deuxième bereau”—\nlocal lexicon denoting experimentation with extra-marital relationships. They [men] therefore \navoided ANC clinics because attending might expose their deeds. A minority of participants \nequally noted that some aspects of health education during ANC have a judgmental tone that \nmight prick the consciences of men involved in such practices.  \n \n“Once a woman becomes pregnant, some men get into the practice of what we call ‘side \nchicks’… they avoid ANC all-together because they don't want to be judged about their sinful \nlives and extra-marital affairs. They don't want health talks at the clinic to echo in their mind \nand their consciences” —Female SSI participant, in their 30s. \n \nFear of HIV testing \nMale involvement in the Cameroonian context is largely driven by the HIV epidemic and \nneed for PMTCT to the extent that participants associated male ANC attendance with HIV \ntesting. As such, participants reported that men feared attending ANC because they will be \nrequired to test for HIV if they came with their pregnant partners. \n \n“The ANC testing requirement is also a barrier . Perhaps they are aware that if they come, \nthey will be checked and tested and for those who are unaware/unsure of their status, they \ndon’t want to come” — Male SSI participant, in their 30s.  \n“If a woman is coming for ANC and she tells her husband that they are going to do HIV \ntesting for both of them, at that point you will hear the man say ‘my coming is not necessary’. \nThe name HIV alone cancels the whole issue” —Female SSI participant, in their 20s. \n \nAvoidance of responsibility \nIn a setting like Cameroon where paternity is rarely established through civil and legal \nmeans, male ANC attendance is seen as an explicit form of taking both paternal and financial \nresponsibility and some men want to shy away from this. Additionally, the wide practice of \nextra-marital affairs during pregnancy probably resulted in pregnancies that most men did not \nwant to be publicly associated with through ANC attendance. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n22 \n \n“I think there is also a financial barrier . Some men don’ t want to attend ANC because \nattending will mean they are taking responsibility as authors of the pregnancy and this also \nmeans they are required to show up as fathers and engage in financial responsibilities”  \n—Male SSI participant, in their 30s. \n \n“Some men are ashamed especially when they have impregnated many girls in the \nneighbourhood and they don’ t want to be tagged as a particular woman’ s husband when there \nare other women he has impregnated and he is denying being responsibility for their \npregnancies.” —Female SSI participant, in their 20s. \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n23 \n \nDiscussion \nThis research paper sought to identify and characterize barriers to male partner involvement \nin antenatal care in the North West Region of Cameroon. Our study findings illustrate the \ncomplexity of factors that influence men’s perceptions and behaviour towards ANC \nattendance. We conceptualised these using the COM-B model of behaviour and TDF with the \nmain barriers reported as: limited awareness on the male role in ANC, inadequate health \nsystem engagement, fear of judgement and HIV testing, and restrictive gender and social \nnorms on male ANC attendance.  \n \nThe COM-B component of Opportunity was highly salient in this study, with social \nopportunity strongly representing the viewpoints of participants through four thematized \nbarriers: male superiority, lack of male social identity in ANC clinics, engendered perception \nof time and fear of the ‘woman wrapper’ stigma. Significant among these is the widespread \nbelief that antenatal attendance is a female affair and men who engage in antenatal-seeking \nbehaviours are seen as jobless, “weak” and under the control of their wives. As a result, the \nparticipation of men in ANC activities is socially outlawed as it competes with their bread-\nwinning roles and shapes perception on the identity, masculine credibility and engagement of \nmen who venture into antenatal clinics. These perceptions on male ANC attendance has been \nechoed across previous studies in sub-Saharan Africa(8,28,50,51) . Our study further \nhighlights the engendered dimension on male social identity and the ‘woman wrapper’ stigma \nassociated with men who accompany their partners for ANC. This underscores the need to \nreconstruct ANC services through a theoretical and gender-transformative approach that \nstrategically considers prevailing socio-cultural and gender norms in male involvement \nprogramming in Cameroon. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n24 \n \nPhysical opportunity took the form of the organizational culture where the health system does \nnot adequately initiate male involvement and fails to engage male partners when they make \nthe effort to attend ANC alongside their pregnant partners. For the few men who had \nexperienced ANC attendance the ‘ANC clap’, which seeks to recognise their presence, was \nperceived as a reinforcement of their exclusion. Our female participants equally reported that \nthey do not have the agency to bear the responsibility of involving their partners for antenatal \ncare. This stems from the current health system practice which requires pregnant women to \nhand invitation letters to their partners or verbally inform them on the need for couple ANC \nattendance –a common practice as reported by similar studies in Sub-Saharan Africa(52).  \nThis finding highlights that the lack of male involvement awareness limits men’s perceptions \nof psychological capability and informed decision-making on the need to attend ANC with \ntheir partners. \n \nFurther analysis on the health system reliance on women as relay agents to men revealed that \ninformation on male involvement from women is perceived by men as incomplete or \nexaggerated. As such, participants in our study proposed that the health system needs to go \nbeyond the traditional ‘go and bring your husband’  agenda by extending a direct appeal to \nmen through health and gender sensitive messaging. While this recommendation is consistent \nwith recent study implications in Malawi and Zambia(53), it is in stark contrast to a study in \nTanzania in where participants proposed that women should bear the emotional and \nintellectual burden of involving their partners in maternal and child health(54).  \nPsychological capability was equally a key domain, which underpins male involvement in \nANC through limited awareness and knowledge on the need for male partner participation in \nantenatal activities.  Consistent with our study, evidence from studies in South Africa and \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n25 \n \nGhana demonstrated that the lack of awareness on the need for male involvement influenced \nmale behaviour and non-participation in ANC activities(55,56). Despite the documentation of \nhigh levels of knowledge regarding ANC activities by Nkuoh and colleagues in \nCameroon(27), our study demonstrates that this does not necessarily translate to interest in \nmale involvement. This disconnect between knowledge and interest could likely be as a result \nof the perception that ‘clinic’ as referenced by participants is a female-focused interventions. \nTo counter this, we therefore argue for the health system to tailor communication on antenatal \neducation to messaging that engages men directly, reflects need and the inclusivity of men in \nthe antenatal care package.  \n \nFurther to inadequate health system engagement and motivation, participants in our study \nassociated the involvement of men in antenatal care with HIV testing. This might be due to \nthe fact that the initiation of male involvement programs in Cameroon and other African \nsettings historically focused on their role in PMTCT(27,28,57). Additionally, the fear men \nexpressed for HIV testing and its possible outcome in antenatal settings could be attributed to \nthe prevailing gender norm that men are strong and should therefore not be sick or seen in \nspaces generally reserved for weak and vulnerable members of the society like women and \nchildren. It is against this backdrop that male ANC attendance is highly stigmatised. Thus, the \nneed to go beyond applauding mere ANC attendance or HIV testing to the involvement of \nmen in clinical assessments like foetal heart monitoring, health education and convenient \nANC scheduling. These could potentially reframe the stigmatization of male ANC attendance \nand impact motivation to participate in ANC activities.  \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n26 \n \nThis is the first study in Cameroon to identify and conceptualise factors that influence male \nengagement in ANC. A unique feature in our study is the use of the COM-B model and TDF \nas an additional step following thematic analysis to characterise male involvement behaviour \naround ANC. The endorsement of barriers across COM-B components demonstrates the \ncomplexity of male involvement behaviour in the North West Region of Cameroon. With \nCOM-B centrally located within the behaviour change wheel, the identified factors in our \nstudy can be linked to appropriate intervention functions and behaviour change techniques \nthat could address barriers to male involvement in ANC \n \nOur study should however be interpreted in light of methodological and practical constraints \nthat limit the generalizability of our findings. First, specific gender and socio-cultural norms \nthat characterise the North West Region may limit the extent to which our results are \ngeneralizable to other regions in Cameroon. Notwithstanding, there was no indication that our \nfindings on the barriers to male involvement in ANC differ significantly from the prevailing \nliterature in Cameroon and Africa at large. \n \nConclusion \nOur study drew upon the diverse perspective of pregnant women, male partners and health \nworkers to explore the barriers to male ANC attendance in the North West Region of \nCameroon. We found that the low motivation of male partners to participate in antenatal care \nis at the intersection of social and physical opportunities (socio-cultural and gender norms) \nand psychological capability (limited knowledge and agency). Based on this finding, we \nrecommend that the development of interventions for male involvement in a patriarchal \nsetting like the North West Region of Cameroon should target the low levels of awareness \nand direct engagement of male partners with messaging that override restrictive gender \nnorms.  \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n27 \n \n \nAcknowledgments \nThe authors would like to thank the Cameroon Baptist Convention Health Services for \ngranting us permission to work within their facility. We acknowledge Ms Nancy Nyakieh \n(NN), for assisting with interviews and preliminary analysis,  Mrs Tiyang Monica (TM) for \nassisting with data collection—Focus Group  observation and note-taking  and Mrs Tibah \nTchouba Carine-Flore for her transcription and translation services. Finally, we wish to \nextend our gratitude to all participants who participated in this study.  \n \nSupporting Information \nS1 Text. Code Book  \nS2 Text. Data Analysis stages \nS3 Text. Coding Matrix \nS4_Fig.PDF Conceptual Analysis of Barriers \n \n \n \n \n \n \n \n \n \n \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 15, 2024. ; https://doi.org/10.1101/2024.02.13.24301733doi: medRxiv preprint \n\n28 \n \nReferences \n1. UNDESA. Transforming our world: the 2030 Agenda for Sustainable Development | \nDepartment of Economic and Social Affairs [Internet]. 2015 [cited 2023 Sep 6]. \nAvailable from: https://sdgs.un.org/2030agenda \n2. WHO. Trends in maternal mortality 2000 to 2020 estimates by WHO, UNICEF, \nUNFPA, World Bank Group and UNDESA/Population Division. Geneva; 2020.  \n3. WHO. Maternal mortality, Key Facts. [Internet]. 2023 [cited 2023 Aug 14]. Available \nfrom: https://www.who.int/news-room/fact-sheets/detail/maternal-mortality \n4. Campbell OM, Graham WJ. Strategies for reducing maternal mortality: getting on with \nwhat works. 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