Do male engagement and couples' communication influence maternal health care-seeking? Findings from a household survey in Mozambique.

BACKGROUND: This study explored effects of couples' communication and male participation in birth preparedness and complication readiness (BPCR) on delivery in a health facility ("institutional delivery"). A cross-sectional, baseline household survey was conducted in November 2016 prior to an integrated maternal and child health project in Nampula and Sofala Provinces in Mozambique. METHODS: The study used the Knowledge, Practices and Coverage survey tool, a condensed version of the Demographic and Health Survey and other tools. The sample included 1422 women. Multivariable logit regression models tested the association of institutional delivery with couples' communication and four elements of BPCR both with and without male partners: 1) saving money, 2) arranging transport, 3) choosing a birth companion, and 4) choosing a delivery site; controlling for partners' attendance in antenatal care and social and demographic determinants (education, wealth, urban/rural location, and province). RESULTS: The odds that women would deliver in a health facility were 46% greater (adjusted odds ratio (aOR) = 1.46, 95% confidence interval (CI) = 1.02-2.10, p = 0.04) amongst women who discussed family planning with their partners than those who did not. Approximately half of this effect was mediated through BPCR. When a woman arranged transport on her own, there was no significant increase in institutional delivery, but with partner involvement, there was a larger, significant association (aOR = 4.31, 2.64-7.02). Similarly, when a woman chose a delivery site on her own, there was no significant association with institutional delivery (aOR 1.52,0.81-2.83), but with her partner, there was a larger and significant association (aOR 1.98, 1.16-3.36). Neither saving money nor choosing a birth companion showed a significant association with institutional delivery-with or without partner involvement. The odds of delivering in a facility were 28% less amongst poor women whose partners did not participate in BPCR than wealthy women, but when partners helped choose a place of delivery and arrange transport, this gap was nearly eliminated. CONCLUSIONS: Our findings add to growing global evidence that men play an important role in improving maternal and newborn health, particularly through BPCR, and that couples' communication is a key approach for promoting high-impact health behaviors.

Expanding the agenda for addressing mistreatment in maternity care: a mapping review and gender analysis.

BACKGROUND: This paper responds to the global call to action for respectful maternity care (RMC) by examining whether and how gender inequalities and unequal power dynamics in the health system undermine quality of care or obstruct women's capacities to exercise their rights as both users and providers of maternity care. METHODS: We conducted a mapping review of peer-reviewed and gray literature to examine whether gender inequality is a determinant of mistreatment during childbirth. A search for peer-reviewed articles published between January 1995 and September 2017 in PubMed, Embase, SCOPUS, and Web of Science databases, supplemented by an appeal to experts in the field, yielded 127 unique articles. We reviewed these articles using a gender analysis framework that categorizes gender inequalities into four key domains: access to assets, beliefs and perceptions, practices and participation, and institutions, laws, and policies. A total of 37 articles referred to gender inequalities in the four domains and were included in the analysis. RESULTS: The mapping indicates that there have been important advances in documenting mistreatment at the health facility, but less attention has been paid to addressing the associated structural gender inequalities. The limited evidence available shows that pregnant and laboring women lack information and financial assets, voice, and agency to exercise their rights to RMC. Women who defy traditional feminine stereotypes of chastity and serenity often experience mistreatment by providers as a result. At the same time, mistreatment of women inside and outside of the health facility is normalized and accepted, including by women themselves. As for health care providers, gender discrimination is manifested through degrading working conditions, lack of respect for their abilities, violence and harassment,, lack of mobility in the community, lack of voice within their work setting, and limited training opportunities and professionalization. All of these inequalities erode their ability to deliver high quality care. CONCLUSION: While the evidence base is limited, the literature clearly shows that gender inequality-for both clients and providers-contributes to mistreatment and abuse in maternity care. Researchers, advocates, and practitioners need to further investigate and build upon lessons from the broader gender equality, violence prevention, and rights-based health movements to expand the agenda on mistreatment in childbirth and develop effective interventions.