A Qualitative Inquiry Into the Perspectives of Men on Maternal & Newborn Child Health in Timor-Leste
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A QUALITATIVE INQUIRY INTO THE PERSPECTIVES OF MEN ON MATERNAL & NEWBORN CHILD HEALTH IN TIMOR-LESTE SHANE HARRISON, FOR CATALPA INTERNATIONAL 1 Author Visuals Shane Harrison Catalpa International Gender Specialist & Principal Investigator, Photos, Layout, and Design Catalpa International Helder da Costa Maps Research Team Gabriela Leite-Soares Acknowledgments Health Manager & Primary Supervisor, Catalpa International It is imperative that the following persons are acknowledged for their contributions, without Maria dos Reis which such, this could never have taken Co-investigator, Catalpa International place: Aida Pinto, Manuel Guterra, Carlito Ana Mendes Mendes, Kristine Larsen, Heather Wallace, Co-investigator, Catalpa International Kayli Wild, Helen Henderson, Belinda Gito Santos Jennings, Marce Soares, Xian Warner, Co-investigator, Catalpa International Kathryn Robertson, Angelina de Araujo, Joni Alves Livio Conceição, Saturnina Belo, National Research Assistant, Catalpa International Institute of Health, and all our research participants who were kind enough to give their valuable time and attention often with External Reviewers children young and old in tow. The author United Nations Population Fund would like to thank the research team: Health Alliance International these intrepid individuals were a source of Marie Stopes International personal inspiration and are the foundation for social development in Timor-Leste. Cooperativo Café Timor National Institute of Health Government of Timor-Leste Contact Information Maternal & Newborn Child Health The author can be contacted at Government of Timor-Leste [email protected] St. John of God Healthcare Catalpa International can be contacted at Dr. Sara Niner, Monash University [email protected] Heather Wallace, La Trobe University 2 A QUALITATIVE INQUIRY INTO THE PERSPECTIVES OF MEN ON MATERNAL & NEWBORN CHILD HEALTH IN TIMOR-LESTE JULY 2017 SHANE HARRISON, FOR CATALPA INTERNATIONAL 3 FIGURES Figure 1 - Health Facilities in Manatuto Municipality 31 Figure 2 - Health Facilities in Suku Orlalan & Manelima 32 Figure 3 - Health Facilities in Suku Ma’abat 32 TABLES Table 1 - Health Justification of proposed research sites 33 Table 2 - No. of participants by sex, research type & location 36 Table 3 - Description of research tools 40 Table 4 - Summary statistics of participant data 48 4 CONTENTS Executive summary 1 Recommendations 5 Purpose 5 Introduction 7 Literature 11 Research Questions 24 Analytical Framework 25 Methodology 27 Results 47 Discussion 105 Conclusion 116 Notes 117 References 119 Footnotes 130 5 EXECUTIVE SUMMARY This paper provides the results of qualitative research into the perspectives of men on their role in supporting maternal and newborn child health (MNCH) in Timor- Leste, and closely follows a review of the literature on international and national evidence on men’s role and engagement in this area. These pieces of research were undertaken for Catalpa International in support of its Liga Inan maternal and child health program, with this inquiry focused on establishing how men perceive their role in MNCH, what actions they currently undertake to support childbearing, what motivates and inspires men to provide this support, and who the key role models are in the lives of Timorese men. Data was captured across three research sites in Manatuto municipality: Ma’abat, Manelima and Orlalan. Research sites were chosen to capture sufficient variation in levels of remoteness, employment characteristics, access to health facilities, ethno- linguistic composition and marriage practices. Purposeful sampling was used to collect responses from men and women who were pregnant or whose partners had been pregnant in the last two years and stakeholders working in MNCH using semi- structured in-depth interviews, focus-group discussions and key-informant interviews. In total, 13 female in-depth interviews, 16 male in-depth interviews, one female group discussion and 1 23 key-informant interviews were completed. This sample size means this research is exploratory in nature and not generalisable. Participant responses indicated that women and men perceive the role of the father primarily in terms of men’s responsibility for, and control over, family wellbeing. And whilst men did express emotional attachment to their partners and their children, their practical actions tended to be embedded within these masculine notions of provision and protection. Whilst fathers did note assisting with housework, childcare, and their partner’s nutrition and emotional wellbeing, in the main, men focused on increased workload and purchasing of clothing and food as their principal role. Men were rarely present during antenatal consultations, endeavoured to be present at birth but failed to attend postnatal consultations. After birth, the gender demarcation of household roles often returned once women were physically able. This study identified 2 three components to men’s motivations to support their partners, the first being necessity due to pregnancy complications or the physical impairment of their partner, the second being comprehension that support would favour improved outcomes for their partner and the third being care for their partner’s wellbeing. Men’s attitude and knowledge of childbearing, economic responsibilities, family and community attitudes, and health system structures were all found to be barriers to greater paternal involvement. Role models and influencers in the lives of men in the context of maternal health were close family, elder peers, community leaders and health professionals. There were many identified actions that men could take to support pregnancy, and in seeking to improve upon current practices, informants favoured community education efforts and communication media leveraging men’s concern for their own health and sense of responsibility as head of the family. The results contained with this paper closely reflect established literature on men’s limited contributions during pregnancy from contexts such as Ghana, Myanmar and Nigeria, and align with research on men’s and women’s health behaviours, family planning and gender-based violence in Timor-Leste. Of 3 significance for future MNCH programming is that men are already conducting some limited support activities, wish to be present during birth and often care deeply about their partner and children. This, and the fact women often want their partners to be involved, are strengths on which an approach to male engagement can be built, and tangible shifts in maternal and newborn child health outcomes can be generated. But engaging men must be approached with caution. Interventions should be highly localised, channelled through trusted individuals, work within the context of couple and family relationships and address the gendered environment in which men exist through ecological approaches to behaviour change. Whilst this study was limited in its geographical coverage and in the research questions it could address, it represents a crucial step in a more nuanced understanding of the role of men in maternal health in Timor-Leste, and in gender-relations more broadly. 4 RECOMMENDATIONS This paper recommends the following courses of action, with the specificities of each to be negotiated within the contexts of each community & reflexive in their implementation. This list is purposefully concise, & should be read in conjunction with the gaps in knowledge identified in the literature review. PURPOSE This paper provides the results of a qualitative study into the perceptions of men on their role in supporting maternal and newborn child health (MNCH) in Timor- Leste. Conducted over a three-month period between July and September 2016, it captured the views of both women and men using a mixture of focus group discussions, in-depth interviews and key-informant interviews across three sites in Manatuto municipality. The results will form the base of behaviour change interventions to be conducted by Catalpa International in support of the mHealth Liga Inan program. 5 Improve knowledge and understanding Address practical barriers to healthcare 1 of reproductive health amongst women 7 seeking. This may include improved and men, boys and girls in Timor-Leste. road systems, reliable ambulances, couple consultation days, men-only health clinics, and men-friendly open- ing hours or waiting rooms. Conduct outreach work with men (par- Use multi-sector approaches to ad- 2 ticularly first-time fathers) to encourage 8 dress negative behaviours during their active participation in antenatal pregnancy and post-partum, including care and postnatal care consultations, smoking, excessive alcohol use, con- and get them to ask questions to, and trolling behaviours and violence. the advice of health professionals. Identify simple actions in each com- Improve the sensitivity of the health munity where men may be more open system to male engagement in ma- 3 to change, and then leverage these in 9 ternal health. This may include training programming. For example, preparing of health providers, tighter implemen- food for children, making birth plans, tation of existing policies, improved asking questions to health profession- health infrastructure, and staff atti- als and being present at birth. tudes towards all clients. Reframe fatherhood in Timor-Leste Integrate positive messaging on men’s 4 in terms of care and concern, using a 10 involvement in family health into exist- strengths-based approach to increase ing public health campaigns, such