Exploring Men’s Perceptions, Experiences and Beliefs on Their Role in Maternal Healthcare in Rural Southern Malawi: A Qualitative study

Exploring Men’s Perceptions, Experiences and Beliefs on Their Role in Maternal Healthcare in Rural Southern Malawi: A Qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring Men’s Perceptions, Experiences and Beliefs on Their Role in Maternal Healthcare in Rural Southern Malawi: A Qualitative study Gabriella Millard, Alice Pennington, Christel Mcmullan, Ruthie Markus, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6889974/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Nov, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 6 You are reading this latest preprint version Abstract Background In Malawi, women experience poor maternal health outcomes. Although this is strongly linked to gender inequalities, men should not be excluded from the solution. Male partners can play a supportive role at home, or actively attend healthcare services. Their engagement has been shown to improve health outcomes for women, partly through increased consistent antenatal care service utilisation. Initiatives have been implemented in Malawi, although they have had little success. The aim of this study was to investigate the beliefs, perceptions and experiences of the lay male community members of Chilaweni, rural Blantyre district in Southern Malawi, on the role of men during pregnancy. Methods A qualitative study design was selected using flexible semi-structured interviews to explore participant views in depth. Interviews were conducted at two sites in Chilaweni. Participant responses were translated from Chichewa to English. Data was transcribed clean verbatim and analysed using Braun and Clarkes’ six step approach to reflexive thematic analysis. Results Twenty interviews were conducted. Four main themes addressing the aim of the study were identified: roles, barriers, facilitators and topic reception. Roles in maternal healthcare included attending clinics or providing transport. Although often men felt their role was to work instead. It was discussed that for some men work was a barrier, along with the social embarrassment driven by cultural beliefs surrounding men who are involved in women’s healthcare. Encouragingly, participants did recognise the benefits of active participation in maternal health which are presented under the theme ‘facilitators’, reporting factors such as the opportunity to be tested for sexually transmitted infections to motivate them, as well as several personal reasons including an act of love. The theme ‘topic reception’ considers participants’ awareness and approach to the topic, which was positive, serving as promise for change in the future. Conclusion Overall, this study highlights key roles men feel they play during pregnancy, as well as barriers and facilitators to their engagement. Participants were receptive to the concept of male partner involvement, wanting to actively take part. In addition, the study recommends several strategies based on the findings to increase men’s engagement in pregnancy in Malawi. Malawi Maternal healthcare antenatal care men rural facilitators barriers roles delivery Figures Figure 1 Figure 2 Background Maternal deaths are those associated with obstetric complications. 1 In Europe, the average maternal mortality ratio (MMR) is 5 maternal deaths per 100 000 live births. In Malawi, a low-income country (LIC) in Southern Africa, the MMR is 225 per 100 000. 2 Although in the context of Sub-Saharan Africa this statistic is below the regional average of 448 per 100 000, the United Nation’s (UN) sustainable development goals state no country should have a MMR greater than 70 maternal deaths per 100 000 live births. 2, 3 Many women in Malawi struggle to access healthcare services, despite being freely available, due to transport costs in comparison to low income, long distances and low autonomy to initiate service use. 4 Even after reaching healthcare services a low standard of care, such as poor infection control, presents challenges. 5 Malawian women do not have equal rights to men according to the UN gender inequality index, which considers reproductive health, labour market and empowerment. 6 Gender emancipation is crucial to improving women’s health outcomes. 7 However, male involvement in pregnancy and childbirth can reduce mortality and morbidity of neonates and mothers. 8 Research in LICs shows male partner involvement in maternal healthcare improves health outcomes for women and neonates. 8 Men also have an important supportive role at home during pregnancy. 9 As recommended by UNICEF, this can relieve stress, beneficial to the mother’s physical and mental wellbeing. 9 The ‘three delays’ model categorizes events leading to a maternal death. 10 Type one, two and three delays describe delays in deciding to seek maternal healthcare, reaching services and receiving care respectively. 10 Men are often the principal decision makers within the family so are important in reducing type one delays, which contribute to 40% of maternal deaths in Malawi. 10, 11 Men also have greater financial resources to facilitate transport to services, mitigating type two delays. 10, 11 Furthermore, a study reported fathers who were present at delivery were able to advocate for faster medical assessment of their partners, mitigating type three delays. 12 Frequency of antenatal care (ANC) visits correlates inversely with maternal and neonatal mortality through disease detection, treatment and health education. 13 The World Health Organisation (WHO) recommends a minimum of eight ANC visits. 14 However, in Malawi, only 51% of pregnant women utilize ANC four or more times. 15 Male partner involvement in ANC increases consistent uptake of ANC. ANC also educates men on obstetric emergency warning signs, informing decisions on when to seek care, therefore reducing type one delays. 8 Furthermore, it has been associated with quick initiation of breast feeding. 16 This is particularly beneficial in low resource settings as bottle feeding risks diarrhoeal disease, a significant cause of infant mortality. 17 ANC enables sexually transmitted infection (STI) testing for couples, including human immuno-deficiency virus (HIV). 18 Women who test for HIV with their partner are more likely to disclose their status, thus comply with medication, preventing mother to child transmission of HIV. 18 This is a WHO recognised global HIV prevention strategy, important in Malawi as the prevalence is high at 8.1%. 18, 19 The Malawi National Sexual and Reproductive Policy recommends increased male partner involvement in maternal healthcare. 20 Several districts have implemented by-laws which fine or refuse women service if they come alone. 21 The Blantyre district in Southern Malawi, the setting of this study, has implemented clinic-based initiatives in urban areas. 22 For example, nurses ask women to bring their husbands to ANC, attending to women who do so first. 22 Despite this, maternal health is still widely viewed as a woman’s domain in Malawi. 22 In 2016, the Blantyre district health office reported only 15% of male partners attended ANC. 23 This demonstrates the need for research informing effective initiatives promoting male partner involvement in maternal health. Existing literature A PubMed literature search identified seven relevant studies in Malawi. The search strategy and PRISMA diagram can be viewed in appendices two and three respectively. A study in Blantyre found that men who watched the delivery of their child experienced feelings of distress, fear or discomfort during the vaginal exam and when seeing their partner in pain. 12 Conversely, some men felt it was a bonding experience with their partner and child. 12 Six studies examined the barriers and facilitators to male partner involvement in maternal healthcare in Malawi. 24, 25, 26, 27, 28, 29 Although it was found some men feared HIV testing, others found it encouraging. 24, 25, 26, 27 Other facilitators identified were health education, a faster service than when women come alone and the opportunity to demonstrate their love for their partner. 24, 25, 26, 27, 29 Despite this, the social stigma surrounding men who are involved in maternal healthcare may lead them to assume roles such as providing transport, sourcing food or going to work instead. 24, 25, 26, 27, 28, 29 An inability to take time off work was also reported to be a barrier. 24, 26, 28 Regardless of the level of their involvement, it was found men believed they should lead decision making during pregnancy. 26, 27, 29 Despite a varied sample demographic in the two studies set in Blantyre, recruitment from a private hospital in Blantyre city and urban clinics limits the transferability of results to other contexts in Malawi. 12, 24, 30 83% of the population live rurally and there is a deep socio-economic divide between rural and urban populations, therefore challenges to male partner involvement may differ. 31, 32 Additionally, the male participants were recruited through maternity services or through their partners at ANC, perhaps biasing the data towards a positive view of the topic. 12, 24 Although one 2011 study was set in rural Southern Malawi, the predominant sample ethnicity was Ngoni, unlike Blantyre’s mostly Chewa population, therefore views may be different in the present study due to differing local cultures. 25, 33 Furthermore, the study’s failure to detail analytic methods, lack of demonstration of reflexivity and small number of quotes limits the credibility of the analysis. 25 Despite use of rigorous methodology, such as triangulation of data analysis with a Malawian national to increase accuracy of data interpretations, the remaining four studies are set in rural and urban central Malawi, so are of less relevance to the present study. 26, 27, 28, 29 Rationale Alex’s Medical and Educational Clinic in Africa Trust (AMECA) built a rural maternity and primary health centre in the Blantyre district. 34 AMECA suggested that the global research area of male involvement in maternal health could inform future initiatives to improve maternal health outcomes. The literature search revealed a gap for lay men from rural Southern Malawi, recruited from a community setting. For this study, ‘lay’ excludes health workers or men with leadership roles. As the target of initiatives, it is important their views are represented in the literature. Furthermore, women from rural areas experience worse maternal health outcomes, highlighting the need for research in this setting. 32 Aim The aim of this study was to explore the perceptions, experiences and beliefs of the lay male community members of Chilaweni on the role men have during their partner’s pregnancy and delivery, as well as barriers and facilitators to this. Methods Study design An inductive qualitative study design using semi-structured in-depth interviews was selected. A flexible interview structure enabled probing of participant responses, allowing deeper exploration of participants’ thoughts, facilitating development of unexpected themes. This is important to the study’s exploratory nature. Setting Recruitment and data collection occurred between 11th February and 8th March 2022 in Chilaweni, an area of 11 rural villages, in a rural part of the Blantyre District, in Southern Malawi. The AMECA health centre in Chilaweni serves 38,000 mainly Christian Chewa people living in 23 villages. 33 At the time of data collection, 75% of the local population live in poverty, higher than the national and regional average. 35 Access to healthcare is limited as AMECA is the only healthcare service and the nearest hospital is 16 kilometres away, a significant distance given the limited transport infrastructure. The local language is Chichewa, so a translator was required. AMECA supplied the population information stated without reference. Sample recruitment Two recruitment sites, AMECA and Makwelani village, were selected to increase sample diversity, enhancing data transferability to alternative settings. 30 First, convenience sampling was conducted at AMECA. 36 Patients in the primary health clinic waiting area were offered an explanation of the study. Inclusion criteria was any male over 18. Exclusion criteria were non-English or Chichewa speaking, individuals unable to give informed consent and those who work in healthcare or leadership positions. Interested individuals who met the criterion were given a participant information leaflet (PIL) and completed a demographic questionnaire (appendix three), facilitating purposive sampling in Makwelani to obtain a variety of perspectives, further increasing data transferability. 37, 30 Despite the researcher offering 24 hours to decide whether to give consent, all interviews happened on the same day. The main reason for non-participation was patients’ concern for losing their place in the AMECA clinic queue. No participants were recruited from the maternity clinic to avoid sampling men based on their involvement in maternal healthcare, which may have biased the results towards a positive topic perspective. Chief Makwelani advertised the study to men in Makwelani, with consideration of the inclusion and exclusion criteria. Based on the demographic questionnaire data, the chief was asked to advertise the study to older men. Those interested met the researcher in Makwelani at a time and date coordinated by the chief, where they were given the PIL. The authors had no prior relationship to any participants recruited in this study. Twenty participants were recruited. Data collection Interviews followed a flexible topic guide (appendix four) investigating the study objectives using open questions to provide an in-depth holistic understanding of participant beliefs, experiences and perceptions. A pilot interview with a male clinic staff member highlighted weaknesses in the topic guide which were modified. 37 Face-to-face interviews were conducted in the community-based care centre in Makwelani and in a private room at the AMECA centre. Interviews were 20–50 minutes long and audio recorded. Participant responses were translated to English immediately, allowing the researcher to respond with exploratory probing questions. Steps were taken to minimise the risk of COVID-19 transmission, including masks and social distancing. Only the participant, researcher and local translator were present, encouraging a balanced interview dynamic so the participant felt comfortable discussing their views, further facilitated through privacy. Participants were given the opportunity to change or add anything to their answers. Refreshments were offered for comfort. No participants withdrew after giving consent. No repeat interviews were conducted. Data analysis Concurrent data collection and analysis enabled an iterative approach, by which the topic guide was adapted in response to emerging theories, enabling deeper investigation. Braun & Clarkes’ six step approach to reflexive thematic analysis was followed as an accessible method for the student researcher to produce a clearly structured presentation of results. 38 Although data saturation was theoretically achieved as no new themes were emerging towards the end of data collection, this was not the end point as the concept of saturation is rejected by Braun and Clarke’s approach to reflexive thematic analysis. 38 Instead, data collection finished when the researcher believed there was adequate data to reflect the complexities of the topic, answering the study aim. Interviews were transcribed clean verbatim by the primary researcher, allowing data familiarisation, the first of the six steps. 38 The primary researcher used complete coding to generate the preliminary codes and themes with an inductive approach, meaning they were derived directly from data interpretations due to the exploratory study design. These were reviewed by the co-researcher and the experienced research supervisor. Disagreements on the meaning of data were discussed. This is analytic triangulation, increasing credibility. 39 Additionally, the AMECA Trust Chief Executive Officer (CEO) reviewed data interpretations, enhancing accuracy due to their deep cultural understanding after working in Chilaweni for 15 years. The final codes and themes, supported by quotes, can be viewed in appendix five. Deviant case analysis was done by actively identifying concepts which contradicted existing findings, testing developing theories, enhancing the credibility of the analysis. 40 Deviant findings have been presented in the results to demonstrate complexities. Reflexivity A reflexive approach involves the author reflecting on how their background will have influenced the findings. 41 First, the presence of an international female student in interviews will have likely introduced social desirability bias. 40 Social desirability bias occurs when a participant’s response reflects what they think is the correct answer or what the researcher wants to hear, instead of what they truly think. 41 The primary researcher considered themselves a feminist, which may have influenced the interpretation of data concerning gender inequalities. The primary researcher used a constant reflexive approach, consciously avoiding biased interpretation of data through focusing on the practical implications of participants’ statements. The primary researcher’s personal influence on data interpretation will have also been mitigated through triangulation. However, the co-researcher was also a female medical student with a similar background, reducing the benefit of this. The primary researcher’s limited local knowledge, as well as the language and cultural barrier will have limited the accuracy of the data interpretation. To limit this, any field notes made during interviews by the researcher regarding the overall tone of the interview and participant demeanour were discussed with the translator to avoid incorrect assumptions. Finally, the primary author was a novice, although this was mitigated through guidance from the experienced research supervisor. Ethical consideration Ethical approval was granted by the College of Medicine Malawi Research and Ethics Committee (approval number: P.11/ 21/ 3458) and The University of Birmingham (reference number: IREC2020/Student1878440). Permission was obtained from the Blantyre district health management team, Chief Makwelani and AMECA centre’s chief clinical officer. All participants gave informed consent. It was made clear they may withdraw consent at any time, without reason. No incentives were offered to avoid coercion. It was made clear patients’ treatment at the clinic would not be affected by non-participation. Data handling followed the general data protection regulatory guidelines. Results Twenty interviews were conducted, nine in Makwelani and 11 at the AMECA centre. The average age of participants was 38.8 years (range 21 – 61). Figure one shows the distribution of participant demographic characteristics. Four themes were drawn from the data, which were divided into sub-themes, displayed in figure two. Roles All participants believed men had a role to play in their partner’s pregnancy. Healthcare-related roles: All participants believed men should ideally attend the ANC clinic with their partner. Five said they only attended the first ANC visit, two reporting this to be because it was the nurses’ requirement. Frequent involvement in ANC was reported by five. In addition, 11 participants felt their role was to facilitate maternal healthcare service use by paying for or providing transport. ‘Each time she had an antenatal visit I would take her on my motor bike because I did not want her to walk long distances.’ (P6) One participant reported the lack of emergency services meant it was important the man was there to ‘go to the hospital to bring back an ambulance should something go wrong’. (P13) Furthermore, three felt concern for the safety of their partners travelling alone. ‘We used to travel at night and maybe you meet robbers on the way they rob you of your money… you can run but someone who is in labour can’t’. (P15) This quote also highlights the difficulties in reaching care in this setting. Seven participants reported their role was to provide delivery equipment and clothing to wear to the clinic, difficulties in doing so may delay service use. Eighteen participants believed men should make decisions concerning their partner’s maternal healthcare, including when, where and how to seek care. All justifications involved the traditional role of women and the expectation of impaired cognition during pregnancy. ‘The man is the head of the family therefore he is there to make decisions and the woman is there to follow whatever the man decides.’ (P9) ‘The decision should come from the man because at the time a woman is pregnant her brain doesn’t work very well.’(P8) Roles at home: All participants believed men had a role at home during pregnancy. A key role at home was to provide. This was driven by the expectation that women are demanding when pregnant, requiring lots of ‘special things ’ ( P1), particularly regarding food. The role to provide food was also viewed to be important for health. ‘When a woman is pregnant she needs healthy food so that the expected baby should be born healthy, so I tried as much as possible to go running up and down to look for the food’. (P8) The expectation of fragility during pregnancy meant six participants felt they should take on laborious roles traditionally assigned to women, such as housework and collecting firewood. Finally, all spoke of the need to treat their partners well during pregnancy by providing love, psychological support and avoiding disappointment. ‘When you show your love, your whole love to the woman, the baby is also happy’. (P1) ‘Culturally it’s like I don’t have to beat my wife- she needs to have a better life during pregnancy’. (P7) Four participants believed infidelity should be avoided during pregnancy. One explained this was to prevent ‘combining blood’ (P16), likely referring to HIV transmission. ‘A bad omen to the child maybe the child can die simply because he moved around with other women.’(P8) Barriers Practical barriers The Monday- Friday ANC clinic schedule meant men’s role to work served as a barrier for six participants. For those informally employed, income was directly linked to time spent at work so time off to go to ANC was financially challenging. Long distances to clinics meant even more time off was required. Food and economic insecurities, as well as unaccommodating bosses reinforced this barrier. ‘ I was busy searching for food going for piece jobs so that she should at least find something to eat’. (P14) Two participants believed alcoholism stopped men supporting their pregnant partners. It was explained that alcohol was problematic in rural communities as men ‘don’t have anything tangible to do so they just go drinking’. (P5) Lastly, three participants stated that many do not know the benefits of their involvement in maternal healthcare. Constructed barriers This sub-theme describes barriers constructed by culture and social beliefs. Despite one participant saying the Chewa culture did not hinder male involvement in maternal health, two participants raised the belief that it is culturally unacceptable for men to watch childbirth, even a ‘bad omen’(P19) for the child . ‘It was a belief that the men are not supposed to see the baby’s umbilical cord’. (P19) Seven participants demonstrated the cultural taboo surrounding childbirth, with one referring to it as ‘a very big secret’. (P19) The stigma surrounding male involvement in women’s health means men feel embarrassed to accompany their partners, fearing other men would consider it ‘ shameful’ (P4), an ‘abomination’ (P6) or even ‘brain damaged’. (P16) When these beliefs are upheld by family members or healthcare workers, men may be actively excluded from their partners healthcare. ‘I was told by the nurses that only women should go in the ward I wasn’t allowed to go in as a man’. (P14) Two participants said men felt embarrassed to be the only man in the female dominated environment, generated by this culture. ‘They feel why should I go and be the only man among the ladies so they just feel shy’. (P7) Moreover, pregnancy was spoken of as a female domain to be handled by elderly female relatives. One participant said that male superiority prevented male involvement in something traditionally for women. Negative expectations of the behaviour of pregnant women also presented barriers. ‘One of the things that hinder the men from getting involved in their wives’ pregnancy is that most women are rude when they are pregnant they become so unruly such that they don’t listen to their husbands’. (P14) Men also expected pregnancy to be a life-or-death situation involving trauma and blood loss. This, combined with a lack of knowledge, means men are scared to be involved. ‘You are scared you are nervous… if she falls sick on the way or maybe she has those labour pains you think what do I do as a man I’ve never done it before’. (P15) Although one participant said traditional medicine was a thing of the past, another pointed towards a lack of trust in modern healthcare as barrier. ‘One of the rumours that I heard… if they have too much blood they say “we will take some of your blood”… the placenta and the like so sometimes they will take such things’. (P18) Finally, unstable domestic relations, embarrassment of the way their partner dressed and a ‘lack of love’ (P17) discouraged men. Two participants thought that some men think if they became too involved in their partner’s pregnancy they would need to stop sleeping with other women as it is dangerous for the child, therefore stopping them from engaging. Unfaithfulness presented an additional barrier as it drove a fear of HIV testing. ‘I think its because he is he likes to move with so many women so maybe he is afraid to come to hospital because he knows he will have some tests’. (P18) Facilitators External facilitators Seven participants’ positive experiences with ANC staff encouraged their attendance. They were offered a better and faster experience than if the woman came alone and understood this to be because health workers want men to be involved. ‘What happens is when you accompany your wife to the clinic she receives the care in good time’. (P1) Ten participants valued the advice given at ANC, all placing emphasis on hearing the advice together as a couple. For some, it gave a sense of unity. Others were motivated by a lack of trust in their partners. ‘It’s very important to escort my partner to the clinic because whatever you teach her here at the clinic I will hear it myself rather than her relaying the information to me as sometimes I may doubt her that it’s not true’. (P5) Despite presenting a barrier for some, STI testing encouraged six participants, based on an understanding of the health benefits and a trust in the nurses. ‘You are both positive, you can be counselled together on how best you can live positively and maybe they can even give you medication to safeguard the baby’. (P15) Personal motivations Twelve participants felt accompanying their partner to maternal healthcare services was a basic act of love and ‘humanity’ (P6), thought to be marriage strengthening and good for the baby. ‘That time it was only my love like ok let me escort my wife to the clinic’. (P6) Two participants felt work was not an excuse as the health of the woman should be prioritised. The importance of witnessing the challenges your partner goes through during delivery was discussed, with one referring to it as part of marriage to ‘walk the same step’ . (P7) Another said it motivates men to use family planning services. ‘It’s important that you go so you know the problems that your wife will encounter during birth it might encourage you to start family planning so that you do not give birth frequently because that may endanger her life’. (P8) Pride also motivated two participants. One wanted to be the first to know their child was born, the other taking pride in treating his wife well. Two participants’ religion inspired involvement. ‘In this bible it says man and women they are one body so they should be passionate about their wives if they are expecting and not leave them alone’. (P6) Possible strategies This final sub-theme describes participant ideas to increase male partner engagement. Eighteen participants believed education to sensitise men was the best way to increase male participation in maternal health. Six participants suggested education should be delivered by local men. The importance of peer influence in changing the approach of other men was highlighted by one participant who said: ‘I have eight friends and out of the eight friends seven listened to my advice and did what is supposed to be done’. (P18) To overcome men’s work schedule, weekend clinics were supported by two participants. ‘If the antenatal clinics and the like were done during weekends it would be very possible for example in my case to accompany my wife.’(P9) However, overall participants favoured a village-based approach, so the information would reach all men, even those who do not listen to their partners. The idea of educational men’s village meetings was also raised by four. Two believed education should be through health personnel, with one participant suggesting: ‘ they should leave their offices go out into the village and sensitise the men .’(P20) Chiefs were identified by three participants to educate men as people trust their advice. A village clinic was suggested by one participant, to overcome barriers including distance and embarrassment. ‘Maybe inviting the health personnel to come and do their services in the village so men are not shy to be at the clinic… some are also worried about the distance so if they are in the village then everybody is walkable.’(P6) Topic Reception There was mixed opinion regarding the normality of involvement in their partners’ maternal healthcare. Two even said it would be ‘abuse’ (P14) (P16) to not engage in their partners’ health. ‘My role was to accompany her each time she went for antenatal services.’ (P2) ‘I have never heard of one friend of mine that has done that [attended ANC]’. (P19) This was different with regards to attending childbirth. Although two participants did report attending delivery, all others who discussed the topic thought it was unusual. Participants recognised the topic importance, predominantly for reasons discussed under the ‘facilitators’ theme. Whilst some viewed the need for male partner involvement for health education and caring purposes, three believed male involvement compensates for female shortcomings. ‘Women lose their lives during birth because the men are left aside so the decision and everything else is left in the hands of women because you know women are always late in decision making… if men get so much involved and they will be very quick to decide on a certain issue so that a woman is helped accordingly’. (P6) Regardless of whether they were able to, all wanted to be involved in their partners maternal healthcare. ‘When you are at a village like this sometimes you decide among the family who is to go [to delivery] so sometimes you stay behind but I would have loved to go’. Furthermore, four participants volunteered to promote male partner involvement, reflecting their enthusiasm for the topic. ‘ I will go back to the village and tell my fellow men about the goodness of getting involved’. (P4) Encouragingly, many participants frequently referred to a culture change towards male partner involvement. ‘Previously men were not allowed to be with the women at the clinic or escort them to the clinic but this time around things have changed’. (P16) Discussion The study aimed to explore the beliefs, experiences and perceptions of the lay male community members of Chilaweni on their role in pregnancy, including examining facilitators and barriers men might face. Participants recognised the importance of their active role in maternal healthcare, encouraged by factors such as love and an opportunity for health education. However, socio-cultural and economic barriers to this were identified. Consequently, men may find their role is in the home or at work. Overall, the findings are in line with existing literature. The concept that as the head of the family men should lead decision making was an important finding in this study and existing literature. 26, 27 Past studies were set in rural and urban central Malawi, and Zambia, demonstrating high dependability of this finding, a key component of trustworthiness. 30 This study found the assumption of impaired thinking during pregnancy, rendering women incapable of decision making, which was not identified by previous similar studies reviewed by the author. Based on these findings, we recommend initiatives in Malawi to promote joint decision-making during pregnancy through gender equality education. This is supported by evidence showing that increased women’s decision-making power improves healthcare access in Sub-Saharan Africa. 7 A key theme was men’s role at home during pregnancy, including the role to provide food, also found by existing studies. 24, 26, 27, 28 The narrative of ‘finding food’ or ‘looking for food’ reflects on the challenges of food insecurities, which may magnify the importance of the role. Participants in this study and existing studies also recognized the importance of food provision to avoid malnutrition. 24, 26, 27, 28 39.3% of pregnant Malawian women are anaemic, often due to malnutrition, which increases the risk of maternal mortality. 42, 43 This highlights the health importance of the role to provide food. Furthermore, a finding presented in this study, but not in the existing literature identified by the author, was the role of men to stop sleeping with other women during their partner’s pregnancy, which was implied to otherwise be acceptable. This is beneficial to the health of the mother and foetus by reducing the risk of STI transmission. Local initiatives should include promotion of these roles at home due to the beneficial health effects. Traditional gender roles drive barriers identified in this study, including the role of men to work, limiting time available to attend ANC appointments. The conflict between work and ANC schedules is also widely reported in existing literature. 24, 26, 28 Based on this finding, which is prevalent in both southern and central Malawi, this study recommends the introduction of mobile ANC clinics in villages as men may require less time off work to attend due to reduced travel times. If successfully integrated into the village, ANC may be viewed as less of a female only environment, which currently prevents men from attending. The cultural barriers to male partner involvement are thoroughly examined by existing literature. 24, 25, 26, 27, 28, 29 However, this study presents additional complexities, including the belief that men should not see the umbilical cord or the placenta. This belief may be exclusive to this setting, however the taboo surrounding childbirth in Malawi may have prevented participants of existing studies from commenting on it. Education to de-stigmatise childbirth is recommended to improve this. A lack of trust underpinned several motivators to attend ANC, such as needing to hear the advice yourself as women will not remember or relay it accurately. This builds on existing findings that men need to be involved to remind women of appointments and when to take medications. 26 This reflects on the prevalent concept throughout the results of a low expectation of pregnant women. We recommend education to reduce the stigma surrounding pregnant women, including expectations of impaired cognition and rude behaviour. The lack of trust in pregnant women is also why we support the existing recommendation to not rely on the strategy of nurses asking women to advise their partners to attend ANC, as men may not listen. 22 A recurrent finding was the need for education sensitizing men to the concept of male partner involvement in maternal health. There was a strong consensus that this should be delivered by men because of the strong peer influence affecting men’s decision on whether to participate in maternal healthcare, highlighted by the fear of what other men think. This is supported by an existing study which concluded the strategy of men discussing the importance of male partner involvement with other men was an effective approach. 44 We therefore recommend peer education schemes. Men could be encouraged or coordinated to discuss the topic with their friends by health surveillance assistants, an existing system of health workers operating within the community, or by male village chiefs. This is recommended for AMECA due to their strong links with local chiefs. Education should be inclusive of women and health workers as it was found they also represented a barrier to male partner involvement. Education should address specific barriers identified by this study, as well as emphasize factors found to motivate male partner involvement, including explanations of the benefits. Overall, the topic was received well. While all the existing research also reported men understood some aspects of the importance of their involvement, the participants in this study appeared to show more enthusiasm. 24, 25, 26, 27, 28, 29 Furthermore, male participants from other studies in Southern Malawi were selected through exposure to initiatives, engagement in maternal healthcare or recruited through their pregnant partners. This study found men who have not been selected on these grounds, showing they are aware of the issue and possibly amenable to change. This is a significant change from a 2011 study which presented a theme of male involvement being a foreign concept. 25 This is reflected on by the concept of changing times found by this study. Recommendations for future research The motivation to utilise family planning services after witnessing the challenges of childbirth was found by this study and existing literature in Blantyre. 12 This is a possible benefit of male partner presence at delivery because of the positive economic and health impacts of family planning, as well as enabling women to exercise their right to control their fertility. This combined with the evidence of health and psychological benefits of male partner presence at delivery in high-income settings, is why we recommend future research investigating the benefits of male partner presence at birth in LICs, as there is currently none. 45 We support the recommendation from existing studies that gender equality education must be part of initiatives. 46 Much of the importance men assigned to their involvement was based on the view that women are incapable. This will be exacerbated by promoting their involvement, without gender emancipation education. For future research, this study recommends research in Northern Malawi, where there is no existing literature. Finally, we recommend qualitative and quantitative research evaluating the impacts of any initiatives. Limitations & strengths Several limitations were identified. Some participants thanked the researcher for teaching them, which implies that social desirability bias may have influenced their responses. 40 Despite casual clothing at the clinic, the primary researcher likely represented a healthcare worker. Participants acknowledged in interviews that healthcare workers want men to be involved, so they may have answered questions accordingly. This was mitigated to some extent through interviewing in the village, where the researcher was less likely to have appeared as a healthcare worker. Social desirability bias was further limited through indirect questioning, which uncovered many negative or taboo concepts. For future research, focus groups should be done to reduce the overall presence of the researcher. Some of the essence of participants’ responses will have been lost in translation, reducing the depth of meaning in the data. Member validation, whereby data interpretations are reviewed by participants, was not possible due to logistical difficulties in re-meeting participants, limiting the accuracy of the data interpretation. 47 This was mitigated through analytic triangulation with the AMECA CEO. 39 The main strength of this study was that men were not recruited for their prior engagement in maternal healthcare, unlike existing literature in the region, reducing positive bias towards male partner involvement. As only 15% of men engage, it is more representative to interview a lay sample. The multi-site study design and diverse sample, representative of the socio-economic structure of Malawi, increases the transferability of the study findings and recommendations can be transferred to other settings in Malawi. 30 However, transferability is limited due to the small study size. Conclusion In conclusion, male partner involvement during pregnancy is important to improve maternal health. This study identified key roles, facilitators and barriers to male partner participation in maternal healthcare. The results supported the existing literature, furthering the understanding of this topic in Malawi. The findings should be considered when designing initiatives to increase male partner participation in maternal health locally and other parts of Malawi where the data may be applicable. We recommend initiatives should be educational and village based, incorporating gender equality teachings. Abbreviations MMR- maternal mortality ratio LIC- low-income country UN- united nations ANC- antenatal care WHO- World Health Organisation STI- sexually transmitted infection HIV- human immunodeficiency virus AMECA- Alex’s Medical and Educational Clinic in Africa PIL- participant information leaflet CEO- chief executive officer Declarations Ethics approval and consent to participate Ethical approval: granted by the College of Medicine Malawi Research and Ethics Committee (approval number: P.11/ 21/ 3458) and The University of Birmingham Internal Research and Ethics Committee (reference number: IREC2020/Student1878440). Permission to collect data was gained from the Blantyre District Health Management Team. All participants gave informed consent to participate. Consent for publication Not applicable, participants non-identifiable. Availability of data sets and materials Full datasets can be supplied upon request to the author. Competing interests None. Funding Provided by the University of Birmingham College of Medical and Dental Sciences. Author contributions The primary researcher developed the protocol submitted ethical approval applications to Malawi and Birmingham, developed the topic guide, interviewed participants and analysed data. This was with significant guidance from supervisors CM, GW, MG. The analysis was triangulated with supervisor CM, RM and the student co-researcher AP. Acknowledgements The author would like to thank Chief Makwelani for coordination of interviews, Grace Mkandawire for translating interviews and the participants for their contribution to the study. The author would also like to thank Ruthie Markus, AMECA Chief Executive Officer, for facilitating the study and providing cultural insight as part of analytical triangulation. Author and affiliation Dr Gabriella Millard - The University of Birmingham Medical School, Edgbaston, Birmingham, B15 2TT, United Kingdom. Dr Alice Pennington - The University of Birmingham Medical School, Edgbaston, Birmingham, B15 2TT, United Kingdom. Dr Christel McMullan - The University of Birmingham Department of Applied Health Sciences, Edgbaston, Birmingham, B15 2TT, United Kingdom. Dr Miriam van Goor - Kamuzu University of Health Sciences, Private Bag 360, Chichiri BT3, Malawi. Ruthie Markus - The AMECA trust, 48 Woodlands Road, Epsom, Surrey, KT18 7HP. Dr Gilles de Wildt - The University of Birmingham Medical School, Edgbaston, Birmingham, B15 2TT, United Kingdom. References The World Health Organisation. Maternal deaths. No date. https://www.who.int/data/gho/indicator-metadata-registry/imr-details/4622. Accessed 25 Apr 2022. The World Bank Group Data. Maternal Mortality Ratio (modelled estimate per 100,000 live births) – Sub-Saharan Africa. Maternal mortality ratio (modeled estimate, per 100,000 live births) - Sub-Saharan Africa | Data. Accessed 21 May 2025. UN Women. 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Male Involvement in Maternity Health Care in Malawi. Af J Reprod Health. 2012; 16(1): 145–157. Mweemba O, Zimba C, Chi B, Chibwe K, Dunda W, Freeborn K et al. Contextualising men’s role and participation in PMTCT programmes in Malawi and Zambia: A hegemonic masculinity perspective. Glob Public. 2021. https://doi.org/10.1080/17441692.2021.1964559. Accessed 22 Apr 2022. Manda-Taylor L, Mwale D, Phiri T, Walsh A, Matthews A, Brugha R et al. Changing times? Gender roles and relationships in maternal, new born and child health in Malawi. BMC Pregnancy Childbirth. 2017. https://doi.org/10.1186/s12884-017-1523-1. Accessed 29 Sept 2021. Aarnio P, Chipeta E, Kulmala T. Men’s perceptions of delivery care in rural Malawi: exploring community level barriers to improving maternal health. Healthcare Women Int. 2013. https://doi.org/10.1080/07399332.2012.755982. Accessed 29 Sept 2021. Aarnio P, Kulmala T, Olsson P. Husband’s role in handling pregnancy complications in Mangochi district, Malawi: a call for increased focus on community level male involvement. Sex Reprod Health. 2018. https://doi.org/10.1016/j.srhc.2018.02.005. Accessed 29 Sept 2021. Elo S, Kääriäinen M, Kanste O, Pölkki T, Utriainen K, Kyngäs H. Qualitative Content Analysis: A Focus on Trustworthiness. SAGE Open. 2014. https://doi.org/10.1177%2F2158244014522633. Accessed 26 Apr 2022. Trading Economics. Malawi- rural population. 2021. https://tradingeconomics.com/malawi/rural-population-percent-of-total-population-wb-data.html. Accessed 03 Dec 2021. Yaya S, Bishwajit G, Shah V. Wealth, education and urban-rural inequality and maternal healthcare service usage in Malawi. BMJ Glob Health. 2016. https://gh.bmj.com/content/1/2/e000085.info. Accessed 09 May 2022. National Statistics Office. 2018 Malawi population and housing census report. 2018 http://www.nsomalawi.mw/images/stories/data_on_line/demography/census_2018/2018%20Malawi%20Population% 20and%20Housing%20Census%20Main%20Report.pdf. Accessed 30 Sept 2021. AMECA. About Us. No date. https://ameca.org.uk/about-us/. Accessed 2025 May 21. Malawi National Statistics Office. Malawi multidimensional poverty index. 2017. https://ophi.org.uk/wp-content/uploads/Malawi_MPI_report_2021.pdf. Accessed 25 Apr 2022. Luborsky M, Rubinstein R. Sampling in qualitative research. Res Aging. 1995. https://dx.doi.org/10.1177%2F0164027595171005. Accessed 22 Oct 2021. Majid M, Othman M, Mohamad M, Lim S, Yusof A. Piloting interviews in qualitative research: operationalization and lessons learnt. Int J Acad. 2017; 7(4): 1073–1080. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006. https://www.tandfonline.com/doi/abs/10.1191/1478088706qp063oa. Accessed 10 Oct 2021. Carter N, Bryant-Lukosius D, DiCenso A, Blythe J, Neville AJ. The use of triangulation in qualitative research. Oncol Nurs Forum. 2014. https://doi.org/10.1188/14.onf.545-547. Accessed 12 Oct 2021. Fisher R. Social desirability bias and the validity of indirect questioning. J Consum Res. 1993. https://doi.org/10.1086/209351. Accessed 10 Oct 2021. Braun V, Clarke V, Carmichael M. Successful qualitative research: a practical guide for beginners. SAGE; 2013. The World Bank. Prevalence of anaemia among pregnant women (%)- Malawi. 2019. https://data.worldbank.org/indicator/SH.PRG.ANEM?locations=MW. Accessed 10 May 2022. Young F. Maternal mortality and risk of anaemia: a call for action. Lancet Glob Health. 2018. https://doi.org/10.1016/S2214-109X(18)30185-2. Accessed 10 May 2022. Birt L, Scott S, Cavers D, Campbell C, Walter F. Member Checking: A Tool to Enhance Trustworthiness or Merely a Nod to Validation? Qual Health Res. 2016. https://doi.org/10.1177/1049732316654870. Accessed 10 Oct 2021. Aliesio L, Vellone E, Amato E, Alvaro R. The positive effects of fathers’ attendance to labour and delivery: a quasi-experimental study. Int Nurs Perspect. 2009. https://www.researchgate.net/profile/Ercole-Vellone/publication/236679605_The_positive_effects_of_father%27s_attendance_to_labour_and_delivery_ A_quasi_experimental_study/links/00463526ea2d2d7fce000000/The-positive-effects-of-fathers-attendance-to-labour-and-delivery-A-quasi-experimental-study.pdf. Accessed 23 Apr 2022. Mkandawire E, Hendriks S. A qualitative analysis of men’s involvement in maternal and child health as a policy intervention in rural central Malawi. BMC Pregnancy Childbirth. 2018. https://doi.org/10.1186/s12884-018-1669-5. Accessed 29 Sept 2021. Birt L, Scott S, Cavers D, Campbell C, Walter F. Member Checking: A Tool to Enhance Trustworthiness or Merely a Nod to Validation? Qual Health Res. 2016. https://doi.org/10.1177/1049732316654870. Accessed 10 Oct 2021. Additional Declarations No competing interests reported. Supplementary Files Appendix.docx Cite Share Download PDF Status: Published Journal Publication published 18 Nov, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Reviewers agreed at journal 29 Jun, 2025 Reviewers invited by journal 24 Jun, 2025 Editor invited by journal 20 Jun, 2025 Editor assigned by journal 17 Jun, 2025 Submission checks completed at journal 17 Jun, 2025 First submitted to journal 13 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6889974","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":475539643,"identity":"717d1d1d-3bc3-49aa-b8ad-a70a3923619f","order_by":0,"name":"Gabriella 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1","display":"","copyAsset":false,"role":"figure","size":76715,"visible":true,"origin":"","legend":"\u003cp\u003eFigure one: participant demographic characteristics\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6889974/v1/a3ddfcc2f5ac159325bc2a3e.jpg"},{"id":85644206,"identity":"c1319157-9336-44c9-a1b1-f17ed879e0b8","added_by":"auto","created_at":"2025-06-30 08:10:00","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":41605,"visible":true,"origin":"","legend":"\u003cp\u003eFigure two: themes and corresponding sub-themes.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6889974/v1/d2a3334f88b880878f2035cb.jpg"},{"id":96650933,"identity":"fcdf3509-8bbd-4ebf-a448-0f6e867f5c48","added_by":"auto","created_at":"2025-11-24 16:12:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":787029,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6889974/v1/23d0e3da-5bf3-4633-a802-36b1a180e94f.pdf"},{"id":85644210,"identity":"d4ebcc13-c949-419e-aec9-a621382a595a","added_by":"auto","created_at":"2025-06-30 08:10:00","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1666596,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-6889974/v1/1c1f9bddd255598cfc049c67.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eExploring Men’s Perceptions, Experiences and Beliefs on Their Role in Maternal Healthcare in Rural Southern Malawi: A Qualitative study\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eMaternal deaths are those associated with obstetric complications.\u003csup\u003e1\u003c/sup\u003e In Europe, the average maternal mortality ratio (MMR) is 5 maternal deaths per 100 000 live births. In Malawi, a low-income country (LIC) in Southern Africa, the MMR is 225 per 100 000.\u003csup\u003e2\u003c/sup\u003e Although in the context of Sub-Saharan Africa this statistic is below the regional average of 448 per 100 000, the United Nation\u0026rsquo;s (UN) sustainable development goals state no country should have a MMR greater than 70 maternal deaths per 100 000 live births.\u003csup\u003e2, 3\u003c/sup\u003e Many women in Malawi struggle to access healthcare services, despite being freely available, due to transport costs in comparison to low income, long distances and low autonomy to initiate service use.\u003csup\u003e4\u003c/sup\u003e Even after reaching healthcare services a low standard of care, such as poor infection control, presents challenges.\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMalawian women do not have equal rights to men according to the UN gender inequality index, which considers reproductive health, labour market and empowerment.\u003csup\u003e6\u003c/sup\u003e Gender emancipation is crucial to improving women\u0026rsquo;s health outcomes.\u003csup\u003e7\u003c/sup\u003e However, male involvement in pregnancy and childbirth can reduce mortality and morbidity of neonates and mothers.\u003csup\u003e8\u003c/sup\u003e Research in LICs shows male partner involvement in maternal healthcare improves health outcomes for women and neonates.\u003csup\u003e8\u003c/sup\u003e Men also have an important supportive role at home during pregnancy.\u003csup\u003e9\u003c/sup\u003e As recommended by UNICEF, this can relieve stress, beneficial to the mother\u0026rsquo;s physical and mental wellbeing.\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe \u0026lsquo;three delays\u0026rsquo; model categorizes events leading to a maternal death.\u003csup\u003e10\u003c/sup\u003e Type one, two and three delays describe delays in deciding to seek maternal healthcare, reaching services and receiving care respectively.\u003csup\u003e10\u003c/sup\u003e Men are often the principal decision makers within the family so are important in reducing type one delays, which contribute to 40% of maternal deaths in Malawi.\u003csup\u003e10, 11\u003c/sup\u003e Men also have greater financial resources to facilitate transport to services, mitigating type two delays.\u003csup\u003e10, 11\u003c/sup\u003e Furthermore, a study reported fathers who were present at delivery were able to advocate for faster medical assessment of their partners, mitigating type three delays.\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFrequency of antenatal care (ANC) visits correlates inversely with maternal and neonatal mortality through disease detection, treatment and health education.\u003csup\u003e13\u003c/sup\u003e The World Health Organisation (WHO) recommends a minimum of eight ANC visits.\u003csup\u003e14\u003c/sup\u003e However, in Malawi, only 51% of pregnant women utilize ANC four or more times.\u003csup\u003e15\u003c/sup\u003e Male partner involvement in ANC increases consistent uptake of ANC. ANC also educates men on obstetric emergency warning signs, informing decisions on when to seek care, therefore reducing type one delays.\u003csup\u003e8\u003c/sup\u003e Furthermore, it has been associated with quick initiation of breast feeding.\u003csup\u003e16\u003c/sup\u003e This is particularly beneficial in low resource settings as bottle feeding risks diarrhoeal disease, a significant cause of infant mortality.\u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eANC enables sexually transmitted infection (STI) testing for couples, including human immuno-deficiency virus (HIV).\u003csup\u003e18\u003c/sup\u003e Women who test for HIV with their partner are more likely to disclose their status, thus comply with medication, preventing mother to child transmission of HIV.\u003csup\u003e18\u003c/sup\u003e This is a WHO recognised global HIV prevention strategy, important in Malawi as the prevalence is high at 8.1%.\u003csup\u003e18, 19\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe Malawi National Sexual and Reproductive Policy recommends increased male partner involvement in maternal healthcare.\u003csup\u003e20\u003c/sup\u003e Several districts have implemented by-laws which fine or refuse women service if they come alone.\u003csup\u003e21\u003c/sup\u003e The Blantyre district in Southern Malawi, the setting of this study, has implemented clinic-based initiatives in urban areas.\u003csup\u003e22\u003c/sup\u003e For example, nurses ask women to bring their husbands to ANC, attending to women who do so first.\u003csup\u003e22\u003c/sup\u003e Despite this, maternal health is still widely viewed as a woman\u0026rsquo;s domain in Malawi.\u003csup\u003e22\u003c/sup\u003e In 2016, the Blantyre district health office reported only 15% of male partners attended ANC.\u003csup\u003e23\u003c/sup\u003e This demonstrates the need for research informing effective initiatives promoting male partner involvement in maternal health.\u003c/p\u003e \u003cp\u003eExisting literature\u003c/p\u003e \u003cp\u003eA PubMed literature search identified seven relevant studies in Malawi. The search strategy and PRISMA diagram can be viewed in appendices two and three respectively. A study in Blantyre found that men who watched the delivery of their child experienced feelings of distress, fear or discomfort during the vaginal exam and when seeing their partner in pain.\u003csup\u003e12\u003c/sup\u003e Conversely, some men felt it was a bonding experience with their partner and child.\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSix studies examined the barriers and facilitators to male partner involvement in maternal healthcare in Malawi.\u003csup\u003e24, 25, 26, 27, 28, 29\u003c/sup\u003e Although it was found some men feared HIV testing, others found it encouraging.\u003csup\u003e24, 25, 26, 27\u003c/sup\u003e Other facilitators identified were health education, a faster service than when women come alone and the opportunity to demonstrate their love for their partner.\u003csup\u003e24, 25, 26, 27, 29\u003c/sup\u003e Despite this, the social stigma surrounding men who are involved in maternal healthcare may lead them to assume roles such as providing transport, sourcing food or going to work instead.\u003csup\u003e24, 25, 26, 27, 28, 29\u003c/sup\u003e An inability to take time off work was also reported to be a barrier.\u003csup\u003e24, 26, 28\u003c/sup\u003e Regardless of the level of their involvement, it was found men believed they should lead decision making during pregnancy.\u003csup\u003e26, 27, 29\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDespite a varied sample demographic in the two studies set in Blantyre, recruitment from a private hospital in Blantyre city and urban clinics limits the transferability of results to other contexts in Malawi.\u003csup\u003e12, 24, 30\u003c/sup\u003e 83% of the population live rurally and there is a deep socio-economic divide between rural and urban populations, therefore challenges to male partner involvement may differ. \u003csup\u003e31, 32\u003c/sup\u003e Additionally, the male participants were recruited through maternity services or through their partners at ANC, perhaps biasing the data towards a positive view of the topic.\u003csup\u003e12, 24\u003c/sup\u003e Although one 2011 study was set in rural Southern Malawi, the predominant sample ethnicity was Ngoni, unlike Blantyre\u0026rsquo;s mostly Chewa population, therefore views may be different in the present study due to differing local cultures.\u003csup\u003e25, 33\u003c/sup\u003e Furthermore, the study\u0026rsquo;s failure to detail analytic methods, lack of demonstration of reflexivity and small number of quotes limits the credibility of the analysis.\u003csup\u003e25\u003c/sup\u003e Despite use of rigorous methodology, such as triangulation of data analysis with a Malawian national to increase accuracy of data interpretations, the remaining four studies are set in rural and urban central Malawi, so are of less relevance to the present study.\u003csup\u003e26, 27, 28, 29\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eRationale\u003c/h3\u003e\n\u003cp\u003eAlex\u0026rsquo;s Medical and Educational Clinic in Africa Trust (AMECA) built a rural maternity and primary health centre in the Blantyre district.\u003csup\u003e34\u003c/sup\u003e AMECA suggested that the global research area of male involvement in maternal health could inform future initiatives to improve maternal health outcomes. The literature search revealed a gap for lay men from rural Southern Malawi, recruited from a community setting. For this study, \u0026lsquo;lay\u0026rsquo; excludes health workers or men with leadership roles. As the target of initiatives, it is important their views are represented in the literature. Furthermore, women from rural areas experience worse maternal health outcomes, highlighting the need for research in this setting.\u003csup\u003e32\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eThe aim of this study was to explore the perceptions, experiences and beliefs of the lay male community members of Chilaweni on the role men have during their partner\u0026rsquo;s pregnancy and delivery, as well as barriers and facilitators to this.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design\u003c/p\u003e \u003cp\u003eAn inductive qualitative study design using semi-structured in-depth interviews was selected. A flexible interview structure enabled probing of participant responses, allowing deeper exploration of participants\u0026rsquo; thoughts, facilitating development of unexpected themes. This is important to the study\u0026rsquo;s exploratory nature.\u003c/p\u003e \u003cp\u003eSetting\u003c/p\u003e \u003cp\u003eRecruitment and data collection occurred between 11th February and 8th March 2022 in Chilaweni, an area of 11 rural villages, in a rural part of the Blantyre District, in Southern Malawi. The AMECA health centre in Chilaweni serves 38,000 mainly Christian Chewa people living in 23 villages.\u003csup\u003e33\u003c/sup\u003e At the time of data collection, 75% of the local population live in poverty, higher than the national and regional average.\u003csup\u003e35\u003c/sup\u003eAccess to healthcare is limited as AMECA is the only healthcare service and the nearest hospital is 16 kilometres away, a significant distance given the limited transport infrastructure. The local language is Chichewa, so a translator was required. AMECA supplied the population information stated without reference.\u003c/p\u003e \u003cp\u003eSample recruitment\u003c/p\u003e \u003cp\u003eTwo recruitment sites, AMECA and Makwelani village, were selected to increase sample diversity, enhancing data transferability to alternative settings.\u003csup\u003e30\u003c/sup\u003e First, convenience sampling was conducted at AMECA.\u003csup\u003e36\u003c/sup\u003e Patients in the primary health clinic waiting area were offered an explanation of the study. Inclusion criteria was any male over 18. Exclusion criteria were non-English or Chichewa speaking, individuals unable to give informed consent and those who work in healthcare or leadership positions. Interested individuals who met the criterion were given a participant information leaflet (PIL) and completed a demographic questionnaire (appendix three), facilitating purposive sampling in Makwelani to obtain a variety of perspectives, further increasing data transferability.\u003csup\u003e37, 30\u003c/sup\u003e Despite the researcher offering 24 hours to decide whether to give consent, all interviews happened on the same day. The main reason for non-participation was patients\u0026rsquo; concern for losing their place in the AMECA clinic queue. No participants were recruited from the maternity clinic to avoid sampling men based on their involvement in maternal healthcare, which may have biased the results towards a positive topic perspective.\u003c/p\u003e \u003cp\u003eChief Makwelani advertised the study to men in Makwelani, with consideration of the inclusion and exclusion criteria. Based on the demographic questionnaire data, the chief was asked to advertise the study to older men. Those interested met the researcher in Makwelani at a time and date coordinated by the chief, where they were given the PIL. The authors had no prior relationship to any participants recruited in this study. Twenty participants were recruited.\u003c/p\u003e \u003cp\u003eData collection\u003c/p\u003e \u003cp\u003eInterviews followed a flexible topic guide (appendix four) investigating the study objectives using open questions to provide an in-depth holistic understanding of participant beliefs, experiences and perceptions. A pilot interview with a male clinic staff member highlighted weaknesses in the topic guide which were modified.\u003csup\u003e37\u003c/sup\u003e Face-to-face interviews were conducted in the community-based care centre in Makwelani and in a private room at the AMECA centre. Interviews were 20\u0026ndash;50 minutes long and audio recorded. Participant responses were translated to English immediately, allowing the researcher to respond with exploratory probing questions.\u003c/p\u003e \u003cp\u003eSteps were taken to minimise the risk of COVID-19 transmission, including masks and social distancing. Only the participant, researcher and local translator were present, encouraging a balanced interview dynamic so the participant felt comfortable discussing their views, further facilitated through privacy. Participants were given the opportunity to change or add anything to their answers. Refreshments were offered for comfort. No participants withdrew after giving consent. No repeat interviews were conducted.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eConcurrent data collection and analysis enabled an iterative approach, by which the topic guide was adapted in response to emerging theories, enabling deeper investigation. Braun \u0026amp; Clarkes\u0026rsquo; six step approach to reflexive thematic analysis was followed as an accessible method for the student researcher to produce a clearly structured presentation of results.\u003csup\u003e38\u003c/sup\u003e Although data saturation was theoretically achieved as no new themes were emerging towards the end of data collection, this was not the end point as the concept of saturation is rejected by Braun and Clarke\u0026rsquo;s approach to reflexive thematic analysis.\u003csup\u003e38\u003c/sup\u003e Instead, data collection finished when the researcher believed there was adequate data to reflect the complexities of the topic, answering the study aim.\u003c/p\u003e \u003cp\u003eInterviews were transcribed clean verbatim by the primary researcher, allowing data familiarisation, the first of the six steps.\u003csup\u003e38\u003c/sup\u003e The primary researcher used complete coding to generate the preliminary codes and themes with an inductive approach, meaning they were derived directly from data interpretations due to the exploratory study design. These were reviewed by the co-researcher and the experienced research supervisor. Disagreements on the meaning of data were discussed. This is analytic triangulation, increasing credibility.\u003csup\u003e39\u003c/sup\u003e Additionally, the AMECA Trust Chief Executive Officer (CEO) reviewed data interpretations, enhancing accuracy due to their deep cultural understanding after working in Chilaweni for 15 years. The final codes and themes, supported by quotes, can be viewed in appendix five.\u003c/p\u003e \u003cp\u003eDeviant case analysis was done by actively identifying concepts which contradicted existing findings, testing developing theories, enhancing the credibility of the analysis.\u003csup\u003e40\u003c/sup\u003e Deviant findings have been presented in the results to demonstrate complexities.\u003c/p\u003e \u003cp\u003eReflexivity\u003c/p\u003e \u003cp\u003eA reflexive approach involves the author reflecting on how their background will have influenced the findings.\u003csup\u003e41\u003c/sup\u003e First, the presence of an international female student in interviews will have likely introduced social desirability bias.\u003csup\u003e40\u003c/sup\u003e Social desirability bias occurs when a participant\u0026rsquo;s response reflects what they think is the correct answer or what the researcher wants to hear, instead of what they truly think.\u003csup\u003e41\u003c/sup\u003e The primary researcher considered themselves a feminist, which may have influenced the interpretation of data concerning gender inequalities. The primary researcher used a constant reflexive approach, consciously avoiding biased interpretation of data through focusing on the practical implications of participants\u0026rsquo; statements. The primary researcher\u0026rsquo;s personal influence on data interpretation will have also been mitigated through triangulation. However, the co-researcher was also a female medical student with a similar background, reducing the benefit of this. The primary researcher\u0026rsquo;s limited local knowledge, as well as the language and cultural barrier will have limited the accuracy of the data interpretation. To limit this, any field notes made during interviews by the researcher regarding the overall tone of the interview and participant demeanour were discussed with the translator to avoid incorrect assumptions. Finally, the primary author was a novice, although this was mitigated through guidance from the experienced research supervisor.\u003c/p\u003e \u003cp\u003eEthical consideration\u003c/p\u003e \u003cp\u003e Ethical approval was granted by the College of Medicine Malawi Research and Ethics Committee (approval number: P.11/ 21/ 3458) and The University of Birmingham (reference number: IREC2020/Student1878440). Permission was obtained from the Blantyre district health management team, Chief Makwelani and AMECA centre\u0026rsquo;s chief clinical officer.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e All participants gave informed consent. It was made clear they may withdraw consent at any time, without reason. No incentives were offered to avoid coercion. It was made clear patients\u0026rsquo; treatment at the clinic would not be affected by non-participation. Data handling followed the general data protection regulatory guidelines.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTwenty interviews were conducted, nine in Makwelani and 11 at the AMECA centre. The average age of participants was 38.8 years (range 21 \u0026ndash; 61). Figure one shows the distribution of participant demographic characteristics.\u003c/p\u003e\n\u003cp\u003eFour themes were drawn from the data, which were divided into sub-themes, displayed in figure two.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRoles\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll participants believed men had a role to play in their partner\u0026rsquo;s pregnancy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealthcare-related roles:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants believed men should ideally attend the ANC clinic with their partner. Five said they only attended the first ANC visit, two reporting this to be because it was the nurses\u0026rsquo; requirement. Frequent involvement in ANC was reported by five. In addition, 11 participants felt their role was to facilitate maternal healthcare service use by paying for or providing transport.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;Each time she had an antenatal visit I would take her on my motor bike because I did not want her to walk long distances.\u0026rsquo; (P6)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOne participant reported the lack of emergency services meant it was important the man was there to\u003cem\u003e\u0026nbsp;\u0026lsquo;go to the hospital to bring back an ambulance should something go wrong\u0026rsquo;. (P13)\u0026nbsp;\u003c/em\u003eFurthermore, three felt concern for the safety of their partners travelling alone.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;We used to travel at night and maybe you meet robbers on the way they rob you of your money\u0026hellip; you can run but someone who is in labour can\u0026rsquo;t\u0026rsquo;. (P15)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis quote also highlights the difficulties in reaching care in this setting.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSeven participants reported their role was to provide delivery equipment and clothing to wear to the clinic, difficulties in doing so may delay service use.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEighteen participants believed men should make decisions concerning their partner\u0026rsquo;s maternal healthcare, including when, where and how to seek care. All justifications involved the traditional role of women and the expectation of impaired cognition during pregnancy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;The man is the head of the family therefore he is there to make decisions and the woman is there to follow whatever the man decides.\u0026rsquo; (P9)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;The decision should come from the man because at the time a woman is pregnant her brain doesn\u0026rsquo;t work very well.\u0026rsquo;(P8)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRoles at home:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants believed men had a role at home during pregnancy. A key role at home was to provide. This was driven by the expectation that women are demanding when pregnant, requiring lots of \u003cem\u003e\u0026lsquo;special things\u003c/em\u003e\u0026rsquo; (\u003cem\u003eP1),\u0026nbsp;\u003c/em\u003eparticularly regarding food. The role to provide food was also viewed to be important for health.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;When a woman is pregnant she needs healthy food so that the expected baby should be born healthy, so I tried as much as possible to go running up and down to look for the food\u0026rsquo;. (P8)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe expectation of fragility during pregnancy meant six participants felt they should take on laborious roles traditionally assigned to women, such as housework and collecting firewood. Finally, all spoke of the need to treat their partners well during pregnancy by providing love, psychological support and avoiding disappointment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;When you show your love, your whole love to the woman, the baby is also happy\u0026rsquo;. (P1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;Culturally it\u0026rsquo;s like I don\u0026rsquo;t have to beat my wife- she needs to have a better life during pregnancy\u0026rsquo;. (P7)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFour participants believed infidelity should be avoided during pregnancy. One explained this was to prevent \u003cem\u003e\u0026lsquo;combining blood\u0026rsquo; (P16),\u0026nbsp;\u003c/em\u003elikely referring to HIV transmission.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;A bad omen to the child maybe the child can die simply because he moved around with other women.\u0026rsquo;(P8)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBarriers\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePractical barriers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Monday- Friday ANC clinic schedule meant men\u0026rsquo;s role to work served as a barrier for six participants. For those informally employed, income was directly linked to time spent at work so time off to go to ANC was financially challenging. Long distances to clinics meant even more time off was required. Food and economic insecurities, as well as unaccommodating bosses reinforced this barrier. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;\u003cem\u003eI was busy searching for food going for piece jobs so that she should at least find something to eat\u0026rsquo;.\u0026nbsp;(P14)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTwo participants believed alcoholism stopped men supporting their pregnant partners. It was explained that alcohol was problematic in rural communities as men \u003cem\u003e\u0026lsquo;don\u0026rsquo;t have anything tangible to do so they just go drinking\u0026rsquo;. (P5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eLastly, three participants stated that many do not know the benefits of their involvement in maternal healthcare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConstructed barriers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis sub-theme describes barriers constructed by culture and social beliefs. Despite one participant saying the Chewa culture did not hinder male involvement in maternal health, two participants raised the belief that it is culturally unacceptable for men to watch childbirth, even a\u003cem\u003e\u0026nbsp;\u0026lsquo;bad omen\u0026rsquo;(P19)\u0026nbsp;\u003c/em\u003efor the child\u003cem\u003e.\u0026nbsp;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;It was a belief that the men are not supposed to see the baby\u0026rsquo;s umbilical cord\u0026rsquo;.\u0026nbsp;\u003c/em\u003e(P19)\u003c/p\u003e\n\u003cp\u003eSeven participants demonstrated the cultural taboo surrounding childbirth, with one referring to it as\u003cem\u003e\u0026nbsp;\u0026lsquo;a very big secret\u0026rsquo;. (P19)\u003c/em\u003e The stigma surrounding male involvement in women\u0026rsquo;s health means men feel embarrassed to accompany their partners, fearing other men would consider it \u0026lsquo;\u003cem\u003eshameful\u0026rsquo; (P4),\u0026nbsp;\u003c/em\u003ean \u003cem\u003e\u0026lsquo;abomination\u0026rsquo; (P6)\u0026nbsp;\u003c/em\u003eor even \u003cem\u003e\u0026lsquo;brain damaged\u0026rsquo;. (P16)\u0026nbsp;\u003c/em\u003eWhen these beliefs are upheld by family members or healthcare workers, men may be actively excluded from their partners healthcare.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;I was told by the nurses that only women should go in the ward I wasn\u0026rsquo;t allowed to go in as a man\u0026rsquo;. (P14)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTwo participants said men felt embarrassed to be the only man in the female dominated environment, generated by this culture.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;They feel why should I go and be the only man among the ladies so they just feel shy\u0026rsquo;. (P7)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMoreover, pregnancy was spoken of as a female domain to be handled by elderly female relatives. One participant said that male superiority prevented male involvement in something traditionally for women.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNegative expectations of the behaviour of pregnant women also presented barriers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;One of the things that hinder the men from getting involved in their wives\u0026rsquo; pregnancy is that most women are rude when they are pregnant they become so unruly such that they don\u0026rsquo;t listen to their husbands\u0026rsquo;. (P14)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMen also expected pregnancy to be a life-or-death situation involving trauma and blood loss. This, combined with a lack of knowledge, means men are scared to be involved.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;You are scared you are nervous\u0026hellip; if she falls sick on the way or maybe she has those labour pains you think what do I do as a man I\u0026rsquo;ve never done it before\u0026rsquo;. (P15)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAlthough one participant said traditional medicine was a thing of the past, another pointed towards a lack of trust in modern healthcare as barrier.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;One of the rumours that I heard\u0026hellip; if they have too much blood they say \u0026ldquo;we will take some of your blood\u0026rdquo;\u0026hellip; the placenta and the like so sometimes they will take such things\u0026rsquo;. (P18)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFinally, unstable domestic relations, embarrassment of the way their partner dressed and a \u003cem\u003e\u0026lsquo;lack of love\u0026rsquo;\u003c/em\u003e \u003cem\u003e(P17)\u003c/em\u003e discouraged men. Two participants thought that some men think if they became too involved in their partner\u0026rsquo;s pregnancy they would need to stop sleeping with other women as it is dangerous for the child, therefore stopping them from engaging. Unfaithfulness presented an additional barrier as it drove a fear of HIV testing.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;I think its because he is he likes to move with so many women so maybe he is afraid to come to hospital because he knows he will have some tests\u0026rsquo;. (P18)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFacilitators\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExternal facilitators\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeven participants\u0026rsquo; positive experiences with ANC staff encouraged their attendance. They were offered a better and faster experience than if the woman came alone and understood this to be because health workers want men to be involved.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;What happens is when you accompany your wife to the clinic she receives the care in good time\u0026rsquo;. (P1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTen participants valued the advice given at ANC, all placing emphasis on hearing the advice together as a couple. For some, it gave a sense of unity. Others were motivated by a lack of trust in their partners.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;It\u0026rsquo;s very important to escort my partner to the clinic because whatever you teach her here at the clinic I will hear it myself rather than her relaying the information to me as sometimes I may doubt her that it\u0026rsquo;s not true\u0026rsquo;. (P5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDespite presenting a barrier for some, STI testing encouraged six participants, based on an understanding of the health benefits and a trust in the nurses.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;You are both positive, you can be counselled together on how best you can live positively and maybe they can even give you medication to safeguard the baby\u0026rsquo;. (P15)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePersonal motivations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwelve participants felt accompanying their partner to maternal healthcare services was a basic act of love and \u003cem\u003e\u0026lsquo;humanity\u0026rsquo; (P6),\u003c/em\u003e thought to be marriage strengthening and good for the baby.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;That time it was only my love like ok let me escort my wife to the clinic\u0026rsquo;. (P6)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTwo participants felt work was not an excuse as the health of the woman should be prioritised. The importance of witnessing the challenges your partner goes through during delivery was discussed, with one referring to it as part of marriage to \u003cem\u003e\u0026lsquo;walk the same step\u0026rsquo;\u003c/em\u003e. \u003cem\u003e(P7)\u003c/em\u003e Another said it motivates men to use family planning services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;It\u0026rsquo;s important that you go so you know the problems that your wife will encounter during birth it might encourage you to start family planning so that you do not give birth frequently because that may endanger her life\u0026rsquo;. (P8)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePride also motivated two participants. One wanted to be the first to know their child was born, the other taking pride in treating his wife well. Two participants\u0026rsquo; religion inspired involvement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;In this bible it says man and women they are one body so they should be passionate about their wives if they are expecting and not leave them alone\u0026rsquo;. (P6)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePossible strategies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis final sub-theme describes participant ideas to increase male partner engagement. Eighteen participants believed education to sensitise men was the best way to increase male participation in maternal health. Six participants suggested education should be delivered by local men. The importance of peer influence in changing the approach of other men was highlighted by one participant who said:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;I have eight friends and out of the eight friends seven listened to my advice and did what is supposed to be done\u0026rsquo;. (P18)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTo overcome men\u0026rsquo;s work schedule, weekend clinics were supported by two participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;If the antenatal clinics and the like were done during weekends it would be very possible for example in my case to accompany my wife.\u0026rsquo;(P9)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, overall participants favoured a village-based approach, so the information would reach all men, even those who do not listen to their partners. The idea of educational men\u0026rsquo;s village meetings was also raised by four. Two believed education should be through health personnel, with one participant suggesting: \u0026lsquo;\u003cem\u003ethey should leave their offices go out into the village and sensitise the men\u003c/em\u003e.\u0026rsquo;(P20) Chiefs were identified by three participants to educate men as people trust their advice. A village clinic was suggested by one participant, to overcome barriers including distance and embarrassment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;Maybe inviting the health personnel to come and do their services in the village so men are not shy to be at the clinic\u0026hellip; some are also worried about the distance so if they are in the village then everybody is walkable.\u0026rsquo;(P6)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTopic Reception\u003c/p\u003e\n\u003cp\u003eThere was mixed opinion regarding the normality of involvement in their partners\u0026rsquo; maternal healthcare. Two even said it would be \u003cem\u003e\u0026lsquo;abuse\u0026rsquo; (P14) (P16)\u0026nbsp;\u003c/em\u003eto not engage in their partners\u0026rsquo; health.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;My role was to accompany her each time she went for antenatal services.\u0026rsquo; (P2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026lsquo;I have never heard of one friend of mine that has done that [attended ANC]\u0026rsquo;. (P19)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis was different with regards to attending childbirth. Although two participants did report attending delivery, all others who discussed the topic thought it was unusual.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants recognised the topic importance, predominantly for reasons discussed under the \u0026lsquo;facilitators\u0026rsquo; theme. Whilst some viewed the need for male partner involvement for health education and caring purposes, three believed male involvement compensates for female shortcomings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;Women lose their lives during birth because the men are left aside so the decision and everything else is left in the hands of women because you know women are always late in decision making\u0026hellip; if men get so much involved and they will be very quick to decide on a certain issue so that a woman is helped accordingly\u0026rsquo;. (P6)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRegardless of whether they were able to, all wanted to be involved in their partners maternal healthcare.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;When you are at a village like this sometimes you decide among the family who is to go [to delivery] so sometimes you stay behind but I would have loved to go\u0026rsquo;.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFurthermore, four participants volunteered to promote male partner involvement, reflecting their enthusiasm for the topic.\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;\u003cem\u003eI will go back to the village and tell my fellow men about the goodness of getting involved\u0026rsquo;. (P4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEncouragingly, many participants frequently referred to a culture change towards male partner involvement.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;Previously men were not allowed to be with the women at the clinic or escort them to the clinic but this time around things have changed\u0026rsquo;. (P16)\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study aimed to explore the beliefs, experiences and perceptions of the lay male community members of Chilaweni on their role in pregnancy, including examining facilitators and barriers men might face. Participants recognised the importance of their active role in maternal healthcare, encouraged by factors such as love and an opportunity for health education. However, socio-cultural and economic barriers to this were identified. Consequently, men may find their role is in the home or at work. Overall, the findings are in line with existing literature.\u003c/p\u003e \u003cp\u003eThe concept that as the head of the family men should lead decision making was an important finding in this study and existing literature.\u003csup\u003e26, 27\u003c/sup\u003e Past studies were set in rural and urban central Malawi, and Zambia, demonstrating high dependability of this finding, a key component of trustworthiness.\u003csup\u003e30\u003c/sup\u003e This study found the assumption of impaired thinking during pregnancy, rendering women incapable of decision making, which was not identified by previous similar studies reviewed by the author. Based on these findings, we recommend initiatives in Malawi to promote joint decision-making during pregnancy through gender equality education. This is supported by evidence showing that increased women\u0026rsquo;s decision-making power improves healthcare access in Sub-Saharan Africa.\u003csup\u003e7\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA key theme was men\u0026rsquo;s role at home during pregnancy, including the role to provide food, also found by existing studies. \u003csup\u003e24, 26, 27, 28\u003c/sup\u003e The narrative of \u003cem\u003e\u0026lsquo;finding food\u0026rsquo;\u003c/em\u003e or \u003cem\u003e\u0026lsquo;looking for food\u0026rsquo;\u003c/em\u003e reflects on the challenges of food insecurities, which may magnify the importance of the role. Participants in this study and existing studies also recognized the importance of food provision to avoid malnutrition.\u003csup\u003e24, 26, 27, 28\u003c/sup\u003e 39.3% of pregnant Malawian women are anaemic, often due to malnutrition, which increases the risk of maternal mortality.\u003csup\u003e42, 43\u003c/sup\u003e This highlights the health importance of the role to provide food. Furthermore, a finding presented in this study, but not in the existing literature identified by the author, was the role of men to stop sleeping with other women during their partner\u0026rsquo;s pregnancy, which was implied to otherwise be acceptable. This is beneficial to the health of the mother and foetus by reducing the risk of STI transmission. Local initiatives should include promotion of these roles at home due to the beneficial health effects.\u003c/p\u003e \u003cp\u003eTraditional gender roles drive barriers identified in this study, including the role of men to work, limiting time available to attend ANC appointments. The conflict between work and ANC schedules is also widely reported in existing literature.\u003csup\u003e24, 26, 28\u003c/sup\u003e Based on this finding, which is prevalent in both southern and central Malawi, this study recommends the introduction of mobile ANC clinics in villages as men may require less time off work to attend due to reduced travel times. If successfully integrated into the village, ANC may be viewed as less of a female only environment, which currently prevents men from attending.\u003c/p\u003e \u003cp\u003eThe cultural barriers to male partner involvement are thoroughly examined by existing literature.\u003csup\u003e24, 25, 26, 27, 28, 29\u003c/sup\u003e However, this study presents additional complexities, including the belief that men should not see the umbilical cord or the placenta. This belief may be exclusive to this setting, however the taboo surrounding childbirth in Malawi may have prevented participants of existing studies from commenting on it. Education to de-stigmatise childbirth is recommended to improve this.\u003c/p\u003e \u003cp\u003eA lack of trust underpinned several motivators to attend ANC, such as needing to hear the advice yourself as women will not remember or relay it accurately. This builds on existing findings that men need to be involved to remind women of appointments and when to take medications.\u003csup\u003e26\u003c/sup\u003e This reflects on the prevalent concept throughout the results of a low expectation of pregnant women. We recommend education to reduce the stigma surrounding pregnant women, including expectations of impaired cognition and rude behaviour. The lack of trust in pregnant women is also why we support the existing recommendation to not rely on the strategy of nurses asking women to advise their partners to attend ANC, as men may not listen.\u003csup\u003e22\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA recurrent finding was the need for education sensitizing men to the concept of male partner involvement in maternal health. There was a strong consensus that this should be delivered by men because of the strong peer influence affecting men\u0026rsquo;s decision on whether to participate in maternal healthcare, highlighted by the fear of what other men think. This is supported by an existing study which concluded the strategy of men discussing the importance of male partner involvement with other men was an effective approach.\u003csup\u003e44\u003c/sup\u003e We therefore recommend peer education schemes. Men could be encouraged or coordinated to discuss the topic with their friends by health surveillance assistants, an existing system of health workers operating within the community, or by male village chiefs. This is recommended for AMECA due to their strong links with local chiefs. Education should be inclusive of women and health workers as it was found they also represented a barrier to male partner involvement. Education should address specific barriers identified by this study, as well as emphasize factors found to motivate male partner involvement, including explanations of the benefits.\u003c/p\u003e \u003cp\u003eOverall, the topic was received well. While all the existing research also reported men understood some aspects of the importance of their involvement, the participants in this study appeared to show more enthusiasm.\u003csup\u003e24, 25, 26, 27, 28, 29\u003c/sup\u003e Furthermore, male participants from other studies in Southern Malawi were selected through exposure to initiatives, engagement in maternal healthcare or recruited through their pregnant partners. This study found men who have not been selected on these grounds, showing they are aware of the issue and possibly amenable to change. This is a significant change from a 2011 study which presented a theme of male involvement being a foreign concept.\u003csup\u003e25\u003c/sup\u003e This is reflected on by the concept of changing times found by this study.\u003c/p\u003e \u003cp\u003eRecommendations for future research\u003c/p\u003e \u003cp\u003eThe motivation to utilise family planning services after witnessing the challenges of childbirth was found by this study and existing literature in Blantyre.\u003csup\u003e12\u003c/sup\u003e This is a possible benefit of male partner presence at delivery because of the positive economic and health impacts of family planning, as well as enabling women to exercise their right to control their fertility. This combined with the evidence of health and psychological benefits of male partner presence at delivery in high-income settings, is why we recommend future research investigating the benefits of male partner presence at birth in LICs, as there is currently none.\u003csup\u003e45\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWe support the recommendation from existing studies that gender equality education must be part of initiatives.\u003csup\u003e46\u003c/sup\u003e Much of the importance men assigned to their involvement was based on the view that women are incapable. This will be exacerbated by promoting their involvement, without gender emancipation education.\u003c/p\u003e \u003cp\u003eFor future research, this study recommends research in Northern Malawi, where there is no existing literature. Finally, we recommend qualitative and quantitative research evaluating the impacts of any initiatives.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLimitations \u0026amp; strengths\u003c/h2\u003e \u003cp\u003eSeveral limitations were identified. Some participants thanked the researcher for teaching them, which implies that social desirability bias may have influenced their responses.\u003csup\u003e40\u003c/sup\u003e Despite casual clothing at the clinic, the primary researcher likely represented a healthcare worker. Participants acknowledged in interviews that healthcare workers want men to be involved, so they may have answered questions accordingly. This was mitigated to some extent through interviewing in the village, where the researcher was less likely to have appeared as a healthcare worker. Social desirability bias was further limited through indirect questioning, which uncovered many negative or taboo concepts. For future research, focus groups should be done to reduce the overall presence of the researcher.\u003c/p\u003e \u003cp\u003e Some of the essence of participants\u0026rsquo; responses will have been lost in translation, reducing the depth of meaning in the data. Member validation, whereby data interpretations are reviewed by participants, was not possible due to logistical difficulties in re-meeting participants, limiting the accuracy of the data interpretation.\u003csup\u003e47\u003c/sup\u003e This was mitigated through analytic triangulation with the AMECA CEO.\u003csup\u003e39\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe main strength of this study was that men were not recruited for their prior engagement in maternal healthcare, unlike existing literature in the region, reducing positive bias towards male partner involvement. As only 15% of men engage, it is more representative to interview a lay sample. The multi-site study design and diverse sample, representative of the socio-economic structure of Malawi, increases the transferability of the study findings and recommendations can be transferred to other settings in Malawi.\u003csup\u003e30\u003c/sup\u003e However, transferability is limited due to the small study size.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, male partner involvement during pregnancy is important to improve maternal health. This study identified key roles, facilitators and barriers to male partner participation in maternal healthcare. The results supported the existing literature, furthering the understanding of this topic in Malawi. The findings should be considered when designing initiatives to increase male partner participation in maternal health locally and other parts of Malawi where the data may be applicable. We recommend initiatives should be educational and village based, incorporating gender equality teachings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cul\u003e\n \u003cli\u003eMMR- maternal mortality ratio\u003c/li\u003e\n \u003cli\u003eLIC- low-income country\u003c/li\u003e\n \u003cli\u003eUN- united nations\u003c/li\u003e\n \u003cli\u003eANC- antenatal care\u003c/li\u003e\n \u003cli\u003eWHO- World Health Organisation\u003c/li\u003e\n \u003cli\u003eSTI- sexually transmitted infection\u003c/li\u003e\n \u003cli\u003eHIV- human immunodeficiency virus\u003c/li\u003e\n \u003cli\u003eAMECA- Alex\u0026rsquo;s Medical and Educational Clinic in Africa\u003c/li\u003e\n \u003cli\u003ePIL- participant information leaflet\u003c/li\u003e\n \u003cli\u003eCEO- chief executive officer\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eEthical approval: granted by the College of Medicine Malawi Research and Ethics Committee (approval number: P.11/ 21/ 3458) and The University of Birmingham Internal Research and Ethics Committee (reference number: IREC2020/Student1878440).\u003c/p\u003e\n\u003cp\u003ePermission to collect data was gained from the Blantyre District Health Management Team.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll participants gave informed consent to participate.\u0026nbsp;\u003c/p\u003e\n\u003ch2 id=\"_Toc201050910\"\u003eConsent for publication\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eNot applicable, participants non-identifiable.\u0026nbsp;\u003c/p\u003e\n\u003ch2 id=\"_Toc201050911\"\u003eAvailability of data sets and materials\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eFull datasets can be supplied upon request to the author.\u003c/p\u003e\n\u003ch2 id=\"_Toc201050912\"\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eNone.\u0026nbsp;\u003c/p\u003e\n\u003ch2 id=\"_Toc201050913\"\u003eFunding\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eProvided by the University of Birmingham College of Medical and Dental Sciences.\u003c/p\u003e\n\u003ch2 id=\"_Toc201050914\"\u003eAuthor contributions\u003c/h2\u003e\n\u003cp\u003eThe primary researcher developed the protocol submitted ethical approval applications to Malawi and Birmingham, developed the topic guide, interviewed participants and analysed data. This was with significant guidance from supervisors CM, GW, MG. The analysis was triangulated with supervisor CM, RM and the student co-researcher AP.\u0026nbsp;\u003c/p\u003e\n\u003ch2 id=\"_Toc201050915\"\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe author would like to thank Chief Makwelani for coordination of interviews, Grace Mkandawire for translating interviews and the participants for their contribution to the study. The author would also like to thank Ruthie Markus, AMECA Chief Executive Officer, for facilitating the study and providing cultural insight as part of analytical triangulation.\u0026nbsp;\u003c/p\u003e\n\u003ch2 id=\"_Toc201050916\"\u003eAuthor and affiliation\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eDr Gabriella Millard - The University of Birmingham Medical School, Edgbaston, Birmingham, B15 2TT, United Kingdom.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDr Alice Pennington - The University of Birmingham Medical School, Edgbaston, Birmingham, B15 2TT, United Kingdom.\u003c/p\u003e\n\u003cp\u003eDr Christel McMullan - The University of Birmingham Department of Applied Health Sciences, Edgbaston, Birmingham, B15 2TT, United Kingdom.\u003c/p\u003e\n\u003cp\u003eDr Miriam van Goor - Kamuzu University of Health Sciences, Private Bag 360, Chichiri BT3, Malawi.\u003c/p\u003e\n\u003cp\u003eRuthie Markus - The AMECA trust, 48 Woodlands Road, Epsom, Surrey, KT18 7HP.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDr Gilles de Wildt - The University of Birmingham Medical School, Edgbaston, Birmingham, B15 2TT, United Kingdom.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eThe World Health Organisation. 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Successful qualitative research: a practical guide for beginners. SAGE; 2013.\u003c/li\u003e\n\u003cli\u003eThe World Bank. Prevalence of anaemia among pregnant women (%)- Malawi. 2019. https://data.worldbank.org/indicator/SH.PRG.ANEM?locations=MW. Accessed 10 May 2022.\u003c/li\u003e\n\u003cli\u003eYoung F. Maternal mortality and risk of anaemia: a call for action. Lancet Glob Health. 2018. https://doi.org/10.1016/S2214-109X(18)30185-2. Accessed 10 May 2022.\u003c/li\u003e\n\u003cli\u003eBirt L, Scott S, Cavers D, Campbell C, Walter F. Member Checking: A Tool to Enhance Trustworthiness or Merely a Nod to Validation? Qual Health Res. 2016. https://doi.org/10.1177/1049732316654870. Accessed 10 Oct 2021.\u003c/li\u003e\n\u003cli\u003eAliesio L, Vellone E, Amato E, Alvaro R. The positive effects of fathers\u0026rsquo; attendance to labour and delivery: a quasi-experimental study. Int Nurs Perspect. 2009. https://www.researchgate.net/profile/Ercole-Vellone/publication/236679605_The_positive_effects_of_father%27s_attendance_to_labour_and_delivery_ A_quasi_experimental_study/links/00463526ea2d2d7fce000000/The-positive-effects-of-fathers-attendance-to-labour-and-delivery-A-quasi-experimental-study.pdf. Accessed 23 Apr 2022.\u003c/li\u003e\n\u003cli\u003eMkandawire E, Hendriks S. A qualitative analysis of men\u0026rsquo;s involvement in maternal and child health as a policy intervention in rural central Malawi. BMC Pregnancy Childbirth. 2018. https://doi.org/10.1186/s12884-018-1669-5. Accessed 29 Sept 2021.\u003c/li\u003e\n\u003cli\u003eBirt L, Scott S, Cavers D, Campbell C, Walter F. Member Checking: A Tool to Enhance Trustworthiness or Merely a Nod to Validation? Qual Health Res. 2016. https://doi.org/10.1177/1049732316654870. Accessed 10 Oct 2021.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Malawi, Maternal healthcare, antenatal care, men, rural, facilitators, barriers, roles, delivery","lastPublishedDoi":"10.21203/rs.3.rs-6889974/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6889974/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn Malawi, women experience poor maternal health outcomes. Although this is strongly linked to gender inequalities, men should not be excluded from the solution. Male partners can play a supportive role at home, or actively attend healthcare services. Their engagement has been shown to improve health outcomes for women, partly through increased consistent antenatal care service utilisation. Initiatives have been implemented in Malawi, although they have had little success. The aim of this study was to investigate the beliefs, perceptions and experiences of the lay male community members of Chilaweni, rural Blantyre district in Southern Malawi, on the role of men during pregnancy.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA qualitative study design was selected using flexible semi-structured interviews to explore participant views in depth. Interviews were conducted at two sites in Chilaweni. Participant responses were translated from Chichewa to English. Data was transcribed clean verbatim and analysed using Braun and Clarkes\u0026rsquo; six step approach to reflexive thematic analysis.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTwenty interviews were conducted. Four main themes addressing the aim of the study were identified: roles, barriers, facilitators and topic reception. Roles in maternal healthcare included attending clinics or providing transport. Although often men felt their role was to work instead. It was discussed that for some men work was a barrier, along with the social embarrassment driven by cultural beliefs surrounding men who are involved in women\u0026rsquo;s healthcare. Encouragingly, participants did recognise the benefits of active participation in maternal health which are presented under the theme \u0026lsquo;facilitators\u0026rsquo;, reporting factors such as the opportunity to be tested for sexually transmitted infections to motivate them, as well as several personal reasons including an act of love. The theme \u0026lsquo;topic reception\u0026rsquo; considers participants\u0026rsquo; awareness and approach to the topic, which was positive, serving as promise for change in the future.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOverall, this study highlights key roles men feel they play during pregnancy, as well as barriers and facilitators to their engagement. Participants were receptive to the concept of male partner involvement, wanting to actively take part. In addition, the study recommends several strategies based on the findings to increase men\u0026rsquo;s engagement in pregnancy in Malawi.\u003c/p\u003e","manuscriptTitle":"Exploring Men’s Perceptions, Experiences and Beliefs on Their Role in Maternal Healthcare in Rural Southern Malawi: A Qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-30 08:09:56","doi":"10.21203/rs.3.rs-6889974/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"51520937941474954770928337852641509190","date":"2025-06-29T08:16:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-24T05:57:29+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-20T05:45:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-18T01:37:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-18T01:36:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-06-13T17:01:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d88a223a-2cf4-4802-8163-80eb3ae93840","owner":[],"postedDate":"June 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-24T16:09:32+00:00","versionOfRecord":{"articleIdentity":"rs-6889974","link":"https://doi.org/10.1186/s12884-025-08367-5","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2025-11-18 15:58:26","publishedOnDateReadable":"November 18th, 2025"},"versionCreatedAt":"2025-06-30 08:09:56","video":"","vorDoi":"10.1186/s12884-025-08367-5","vorDoiUrl":"https://doi.org/10.1186/s12884-025-08367-5","workflowStages":[]},"version":"v1","identity":"rs-6889974","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6889974","identity":"rs-6889974","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}