Wendy Holmes, Brad Otto, Marcia Soumokil, Sri Nopiyani Made and Sang Gede Purnama
A proud father with his daughter in Bali
The expression 'expectant father' is a bit old fashioned - we don't often hear it now, certainly not in public health circles. The pregnant woman tends to be the focus of our attention when we think of improving maternal and newborn health. Indonesia has a very high rate of maternal deaths compared to other countries in the region. In 2005 there were estimated to be 307 deaths per 100,000 live births (compared to 39 pregnancy-related deaths per 100,000 live births in Malaysia). If we want to improve the chances that mothers and babies will be healthy and happy we need to involve expectant fathers more in health care services during and after pregnancy.
Not just women's business
We think of family planning, pregnancy and breastfeeding as women's business - but these domains are often governed by men. Men are usually the decision makers, although they rarely receive the information they need to make good choices. For example, they need to know the warning signs of danger during pregnancy and after childbirth so that they can arrange to take their wife for medical help if there is a problem. They need to know how to help their partner to be healthy during pregnancy and how to support her to breastfeed the baby during the first six months. Also, men's behaviour can affect the health of their wife and child. If a man has sex with someone else when his wife is pregnant he may get a sexually transmitted infection, including HIV. Then when he has sex with his wife he can easily transmit the infection to her. Gonorrhoea can damage the baby's eyes, syphilis can make the baby small and ill at birth or it may die in the womb. HIV can pass to the baby - and the risk is very high if the woman is newly infected. An expectant father needs to know the risks to their wife and baby so that they have sex only with their wife, or use a condom if they have sex with someone else.
For these reasons we want to encourage men to attend antenatal and postnatal visits with their pregnant wives. But these are culturally sensitive topics and work commitments can make it difficult for men to attend the local health centre or hospital. Burnet Institute in Indonesia has collaborated with Udayana University in Denpasar in a study to learn about the pregnancy-related knowledge, attitudes, beliefs and practices of expectant fathers, pregnant women, young men and women, and older women, working closely with the Bali Provincial Health Department. Our team developed a question guide and conducted 28 focus group discussions with Hindus and Muslims in both rural and urban areas. We also interviewed health care providers and health officials. The group discussions and interviews were analysed to ascertain the full range of beliefs and practices followed by participants, in order to better understand what people think and do. The findings from the study will be helpful in modifying health care services to make them more male-friendly. There was a widespread desire amongst both men and women for men to receive information and play a greater role in sexual, reproductive, maternal and newborn health.
Many marriages occur as a result of pregnancy, and both men and women may use pregnancy as a way to get their partner to marry them
We found that first pregnancies are rarely planned and that first pregnancy and marriage often happen close together. Pregnancy before marriage is not socially acceptable but does occur, especially because babies are seen as the purpose of marriage and men often want to be sure that their partner is fertile beforehand. Many marriages occur as a result of pregnancy, and both men and women may use pregnancy as a way to get their partner to marry them. This suggests that health messages should be aimed at those planning marriage rather than planning pregnancy.
A chance to act
Most men felt happy, proud and responsible when their wife was pregnant. So pregnancy is a good time to reach men with messages about avoiding risky sexual behaviour. This will help to protect fathers as well as pregnant and breastfeeding mothers and their babies from becoming infected with HIV and other sexually transmitted infections. It was common for both Hindu and Muslim men to bring their wife to the antenatal clinic, but rare for them to be invited into the consultation. Women pointed out that waiting times can be long at the antenatal clinic and suggested that to encourage men to attend, clinics should provide sports magazines, playstations or TVs. Older women felt that midwives and the men's mothers and mothers-in-law could have an influence on men's involvement in antenatal care.
We learned that there are no cultural beliefs in Bali against having sex during pregnancy, although some feared harming the baby. Some men did admit to having sex outside the marriage during their wife's pregnancy and several suggested that they felt ashamed because of this. It will be important for health workers to have training in communication and counselling skills so that they feel confident to talk about sensitive matters with both men and women. This could have additional benefits in other aspects of their work, which may become more satisfying and interesting. The men also told us that they currently receive no information about pregnancy, except from TV advertisements, or if they read their wife's clinic record. The expectant fathers thought that an effective way to receive information would be in small groups at meetings of the banjar, or hamlet community association, through the trusted kelian dinas (head of the banjar). Some of the men said they would be less embarrassed to discuss these sensitive issues with him than with a health care provider. These findings have been discussed with provincial and national level health officials and policy makers, and information materials have been developed., including a guide for midwives and information for men about sex during pregnancy.
Healthier, happier families
The findings of our study suggest that changes should be made to health services in order to make them more welcoming to men. Such a change takes time, but where men have been invited to attend antenatal care, for example in projects in India and South Africa, they have shown that they are willing to do so. In Indonesia, the Planned Parenthood Association has been working to improve knowledge and change attitudes of expectant fathers in West Java through community radio programs, home visits by male volunteers, and by providing information at religious and village gatherings.
Greater involvement of men in antenatal care across Indonesia should result in many benefits. We could expect less risk of sexually transmitted infections and HIV and less delay in reaching emergency obstetric care when there are delivery complications. Pregnant women may be better nourished, lowering the risk of anaemia or low infant birth weight. Fathers might support their wives to breastfeed exclusively, protecting their babies from infectious diseases. More couples might choose to use contraception resulting in fewer abortions. Finally, more communication between couples and greater support from expectant fathers is likely to lead to better mental and emotional health, resulting in happier families and healthier children.
Wendy Holmes, Brad Otto and Marcia Soumokil are from the Burnet Institute and Sri Nopiyani Made and Sang Gede Purnama are researchers from Udayana University. Wendy Holmes (email@example.com) is the corresponding author. The plan for this study was approved by ethics committees in both Melbourne and Bali.
This article is part of our Health in Indonesia mini-series.