Understanding Gender Roles and Inequalities Influencing Maternal Health Care Behaviors in Rural Jimma, Ethiopia

Abstract

Introduction: Gender is defined as what society believes about people's appropriate roles, duties, rights, and responsibilities, as well as their attitudes, values, relative power, accepted behaviors, and opportunities based on sex. Gender norms and roles have a significant impact on the use of maternal healthcare services and affect women's access to antenatal care, skilled birth attendance, and postnatal support. Research findings indicate how patriarchal systems, decision making processes, and socio-cultural expectations can either hinder or promote access to maternal healthcare. Various groups highly recommend gender-equity maternal and child health service utilization at different times: the World Health Organization (WHO), the International Conference on Population and Development (ICPD), the Beijing Declaration, and the Addis Ababa Declaration. Despite all the efforts, maternal health service use and maternal and child health are far from the target explicitly set in low and middle-income countries like Ethiopia. Various initiatives that encourage and promote various actors like community members, religious leaders, and partners are believed to significantly improve maternal health service utilization and help to achieve the Sustainable Development Goal (SDG), reducing maternal mortality to 70/100,000. Ethiopia has shown improved maternal service utilization and reduced maternal and newborn mortality rates. However, the maternal health service utilization, maternal morbidity, and mortality are very high in developing countries, including Ethiopia, compared with developed countries. Objective: The objective of the current study is to understand qualitatively about gender based roles beliefs, perceptions, knowledge, attitude, decision making, and support regarding MCH services utilization. The gender dimension basically compared between men and women. The study also determined couples ODS (Obstetrics Danger Signs) knowledge and attitude towards maternal healthcare, as well as, couples concordance and discordance decision-making on financial and maternal and child healthcare. Method and materials: The study was conducted in three districts of rural Jimma Zone, Oromia, Ethiopia. Overarching mixed-method community-based comparative cross-sectional quantitative and qualitative studies were used. 24 Primary health care units (PHCUs) were randomly selected from Gomma, Seka, and Kersa districts; eight from each district. A total of 3840 women who gave live and dead birth, and a history of abortion one year before data collection, with their partners included in the study. This study used the baseline qualitative and xi quantitative data for further analysis. A total of 3235 couple participants were identified based on the household ID for quantitative analysis. For the qualitative study, data were purposively collected from Health extension workers, women's health development army, men's health development army, primary health care unit directors, and midwifery nurses till saturation of information was reached. Descriptive, chi-square, and logistic regression analyses were applied to quantitative studies. Odds ratio, p-value less than 0.05, and 95% confidence interval were used to declare the level of significant association. Result: Under the first qualitative analysis to understand gender perception during pregnancy, gender-based roles and norms, psychosocial variation, social support, and gender relations emerged in the analysis. The informants described that men's and women's independent and shared roles were improving maternal health care service use during pregnancy. Once the women became pregnant, men undertook various demanding duties to enhance maternity service consumption. Gender relations and shared decision-making were essential to facilitate maternal healthcare utilization during pregnancy and beyond. In the second qualitative study, independent and shared gender-based roles, norms, and decision-making were identified to determine the utilization of maternal healthcare services during the delivery and postnatal period. Men can persuade pregnant women to use delivery services and postnatal care. The place of delivery was determined by the levels of gender power relations at the household level, but women were usually the final decision-makers. Furthermore, the women’s belief that giving birth in a health facility makes women look clean and neat, as opposed to home delivery, increases their intention to use maternal health care services. In the quantitative analysis, on average, men and women participants identified at least two obstetric danger signs. Most women could mention more antenatal, childbirth, and postnatal obstetrics danger signs than their male partners. Both women and their male partners who listened to the radio at least once per week had a statistically significant positive attitude towards obstetric care. Nonetheless, both had almost similar magnitudes of attitude towards obstetric care irrespective of belonging to different occupational, educational, and other social strata. Men's knowledge of obstetrics danger signs during pregnancy (95% CI= (1.07-1.62), AOR=1.32, P<.008) and postnatal care (95% CI= (1.16-1.89), AOR=1.48, P<.002) had a statistically significant association with the women utilization of antenatal care (ANC) service, though not delivery care (DC) or postnatal (PNC), respectively. In the fourth quantitative study, household xii couple joint decision-making was positively associated with higher ANC and PNC utilization. Conversely, decisions made solely by the husband, especially regarding finances, negatively impacted women's access to healthcare services, with a 63% reduction in ANC utilization when men exclusively controlled financial decisions. Women's involvement in financial decision making increased the odds of women utilizing ANC services by 1.32 times. Conclusion: The study revealed that obstetric maternal health care should not be limited to women alone. Men's and women's prior maternal health experiences, in addition to their knowledge and beliefs, have made a significant impact on the utilization of maternal healthcare services during pregnancy. Men's and women's improved roles, knowledge level, belief, decision-making, and social support contribute to pregnant women receiving delivery and postnatal services at the health facility. Pregnant women were the final decision makers for utilizing a health facility to give birth. There were gender based knowledge gap and negative beliefs that limits health facility delivery and postnatal services utilization. There were inequalities in obstetric danger signs knowledge between females and their male partners. Male partners' knowledge of obstetric danger signs is not only significant during pregnancy and delivery but also has a lasting impact on postnatal service utilization, which underlines the importance of their involvement in maternal healthcare service utilization. Joint couple household decision-making was the common form of decision-making, positively associated with using maternal healthcare services. Recommendation: Growing community-level social support can improve maternal health care service utilization. Men's concern about institutional delivery should be increased when they are viewed as the primary audience during maternal health education. Researchers should focus on the mechanisms by which men participate at the time of pregnancy, childbirth, and postnatal services to address men's involvement in maternal health care services fully. Policymakers and academics should consider men's essential contribution in the continuum of maternal healthcare. However, to increase their intention to use maternal health care services, it is necessary to identify the interests of women in how and when men should be involved. A gender-responsive maternal healthcare policy that recognizes the role of couples' decision-making power in the household in maternal health care and women's empowerment in financial decision-making in households should be promoted. Gender transformative studies should be promoted to educate, targeting both men and women, which could play a pivotal role in shifting gender norms and xiii promoting more equitable decision-making within households, which is crucial for maternal health care service utilization.