Effectiveness of men in maternity health (MiM) intervention on male involvement in maternal health care to improve maternal health outcomes in Naypyitaw, Myanmar

Study design and setting

A quantitative-qualitative sequential, explanatory mixed-methods study was conducted. The quantitative methods involved pre- and post-interventional surveys, while the qualitative methods included focus group discussions (FGDs) with MH service users and in-depth interviews (IDIs) with manager-level and field-level MH service providers.

This study was implemented in Naypyitaw territory, where ID was 35.8% in 2014.⁹ Naypyitaw encompasses two districts, each comprising four townships. Lewe Township from Dekkhina district was purposively selected for its high population density and middle socio-economic status as the intervention group. Takkone Township from Ottara district, with a comparable population density and socioeconomic status, served as the control group.

Quantitative research

Study population, sample size and participants selection

This study included men aged 18 years or older with primigravida female partners who were at least 16 weeks pregnant at the time of the intervention, residing in the study areas, and providing consent. In each intervention and control township, five health centres serving a high number of pregnant women were purposively selected. Midwives from these centres provided a list of eligible men whose female partners were pregnant. Using systematic random sampling, a total of 198 men (99 in each group) were selected to achieve the required sample size. Sample size calculations followed the two independent proportion formula, adapted from a study in Ethiopia, a low-income country comparable to Myanmar in terms of MMR and MHC provision.²³

Men in Maternity Health (MiM) Intervention

The six-month MiM education program focused on MH education for male partners of pregnant women in the intervention area. Topics included pregnancy and its complications, obstetric danger signs, the importance of MHC, including ANC, delivery care, and postnatal care, the benefits of BPCR, and safe delivery. Invitation letters were sent to male partners by public health supervisors at the health centres every first and third week to encourage participation in the MiM program’s activities. Two-hour-long education and discussion sessions occurred in five selected health centres every second and fourth week on Sundays, respectively, considering participants’ work schedules. Assigned midwives offered face-to-face health education using flip charts, distributed pamphlets, and organized group discussions, following the guidelines in the “Standardized Health Messages Handbook”.⁵ During discussions, male partners were encouraged to share their experiences, knowledge, and intentions regarding the adoption of new MHC-related behaviours, including topics covered in education sessions. Prior to implementation, providers were trained to deliver the MiM program’s education curriculum and guidelines. Attendance consistently remained high at 80% of participants every month, with home visits for absentees to provide health education.

Data collection

A quantitative survey, employing structured questionnaires, was conducted in a private room at the health centre both before and after the intervention and childbirth. The pre-intervention assessment took place from December 2018 to January 2019, and the post-intervention assessment from July to August 2019. The questionnaire was initially prepared in English, adapting Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO)’s monitoring BPCR tools,²⁴ which had been tested for validity in low-income settings similar to Myanmar. The questionnaire was then translated into Burmese and back-translated into English. Ten village health volunteers, all holding bachelor’s degrees, were trained as interviewers for data collection. The researcher validated reported ID by cross-referencing birth certificate records and obtaining information from assigned area midwives. Quantitative data collection lasted approximately 45 minutes. Pilot testing of questionnaires was conducted in a socio-economically and geographically similar township, strategically distant to avoid cross-contamination with study townships.

Quantitative data analysis

The Excel database developed by the researcher was used for quantitative data entry. Descriptive statistics, including frequency, percentage, mean, standard deviation, minimum, and maximum, were used for numerical variables. For categorical variables, frequency and percentage were employed. To evaluate group homogeneity, inferential statistics included paired t-tests for within-group analysis, independent t-tests for between-group comparisons, and chi-square tests for categorical data. For the practices of MI in BPCR, five key elements: preparing the health facility for birth, ensuring the presence of skilled birth attendants, arranging transportation for delivery or emergencies, identifying potential blood donors and saving money for delivery expenses, were considered. The scores ranged from 1 (‘Yes’) to 0 (‘No’) on a scale of 0 to 5. The Statistical Package for the Social Sciences (SPSS) version 28 (IBM Corp., Armonk, NY, USA) was used for analyzing the quantitative data.

Qualitative research

The FGDs and IDIs were conducted in the intervention township to gain a comprehensive understanding of the impact of the MiM program, exploring how acceptable and feasible the program is for preventing maternal emergencies and promoting IDs.

To ensure privacy and confidentiality, FGDs were organized in private rooms. Employing extreme case sampling, couples were chosen based on MI scores in BPCR practices related to maternal emergencies and their female partners’ ID status. Similarly, couples were selected where male partners had the lowest MI scores and their partners did not possess IDs. A total of eight FGDs were conducted separately; four sessions for male partners and four for their female partners, aiming to recruit 6-8 participants for each session.

Simultaneously, IDIs were carried out with participants involved in the MiM program, including MH program managers (Township Medical Officers and Health Assistants) overseeing its implementation and MH providers (Lady Health Visitors, or Midwives). Participants included in IDIs were purposively chosen based on their roles in the MiM program, resulting in a total of 11 MH program stakeholders from the intervention township. Pilot testing of IDI and FGD guidelines was also conducted within the same township as the quantitative pilot testing. On average, IDIs and FGDs lasted around 60 and 90 minutes, respectively.

Qualitative data analysis

For the qualitative component, IDIs and FGDs were audio-recorded, transcribed verbatim, and analyzed thematically using the framework method. This analysis employed a combination of inductive and deductive techniques. Descriptive and analytical coding was applied to the transcripts to identify overarching themes and sub-themes, which are presented in the study findings. Qualitative data analysis were performed using NVivo version 12.

Ethics approval and consent to participate

This study protocol was approved by the Ethics Review Committee on Medical Research Involving Human Subjects, Department of Medical Research, Ministry of Health, Yangon, Myanmar (Approval No: ERC/DMR/2018/133) on 5^th October 2018. Before data collection, participants provided written informed consent, with confidentiality maintained throughout all stages of data collection, management, analysis, and reporting. This study was retrospectively registered with ClinicalTrials.gov on June 11, 2024 (NCT06451653), due to an initial oversight regarding the necessity of prior registration, which was corrected upon recognizing of its importance for transparency and adherence to guidelines.

The study was conducted in Naypyitaw, Myanmar, with most of the authors being Myanmar nationals. According to Myanmar’s regulations, research conducted within the country should receive ethical approval from an authorized local IRB. Consequently, we obtained approval from the Ethics Review Committee on Medical Research Involving Human Subjects, Department of Medical Research, Ministry of Health, Yangon, Myanmar. This committee, like the IRBs at the authors’ affiliated institutions, adheres to the Declaration of Helsinki. Choosing a local IRB ensured compliance with local ethical standards, streamlined the approval process, and ensured adherence to local regulations and guidelines. Additionally, while the first author is an academic researcher at Chulalongkorn University, the study’s location and context necessitated adherence Myanmar’s ethical procedures.

Socio-demographic characteristics of the study participants in intervention and control groups

Participants’ socio-demographic characteristics were equated for valid comparison of the intervention’s effects between the intervention and control groups. In the intervention group, male partners’ mean age was 29.64±5.68 years, while in the control group, it was 30.44±6.09 years. Both groups had similar educational levels, manual occupations, monogamous marriages, and living arrangements. While assessing economic status using the national quintile of wealth index, the majority of participants were in the highest (39.4%) and fourth (39.9%) levels. No significant differences were found between the groups (p>0.05), ensuring the validity of comparing the intervention effects at both time points (Table 1).

Effect of MiM intervention on maternal health knowledge and attitude among the intervention and control groups before and after intervention

The impact of MiM intervention on knowledge and attitudes was evaluated by mean scores comparison between intervention and control groups (Table 2). Before the intervention, there was no difference in MH knowledge between the groups (p=0.987). However, after the intervention, a notable difference emerged (p=0.001), with the intervention group scoring (39.2±10.9) compared to the control group (31.4±13.6). Similarly, attitude scores showed no statistically significant pre-interventional difference (p=0.664) but a significant post-intervention difference (p=0.044). The intervention group presented higher attitude scores (38.4±4.7) at post-intervention, while the control group’s scores remained consistent (36.5±4.0). Within-group analyses demonstrated significant improvements in knowledge and attitudes towards MH following the MiM in the intervention group (p<0.001). Additionally, the control group also experienced a significant increase in knowledge scores post-intervention compared to pre-intervention assessment (p<0.001).

The IDI interviews with health providers revealed that male partners initially lacked awareness regarding their role in supporting pregnancy and childbirth. However, through the influence of MiM program activities, male partners’ knowledge, attitudes, and support improved significantly, leading to increased utilization of MH services—particularly through active involvement during ANC visits.

Moreover, the FGD revealed a change in the attitude of male partners towards their roles in pregnancy and childbirth.

Effect of MiM intervention on birth preparedness and complication readiness (BPCR) practices among the intervention and control groups before and after intervention

The study assessed the effects of 6-month MiM intervention on MI in five key BPCR practices. Before the intervention, there were no significant differences between the two groups. However, after the intervention, a significant difference was observed between the intervention and control groups (p<0.05). The within group analysis revealed an increase in BPCR practices among participants receiving the MiM intervention (p<0.05). Male partners in the control group were more likely to secure skilled birth attendants during post-assessment, compared to pre-intervention assessment (p=0.019) (Table 3).

Both managers and field-level health providers recognized that a higher proportion of couples in the intervention group made childbirth plans according to BPCR guidelines, leading to safer deliveries and fewer maternal emergencies. During FGDs with male partners, it was evident that they actively participated in ensuring safe childbirth; however, their level of engagement varied depending on factors such as occupation, family size, and risk perceptions.

Effect of MiM intervention on institutional delivery (ID)

The study assessed the impact of MiM on ID rates, revealing that intervention group had a higher prevalence (64.6%) compared to the control group (39.4%), and this difference was statistically significant (p<0.001) (Table 4).

A manager-level health provider reported that a considerable proportion of women in the intervention group from rural areas favored home deliveries despite increased MH service utilization.

While most women had experiences with their male partners in BPCR activities, some encountered challenges such as cultural influences that favored home delivery and financial constraints.

Acceptability of the MiM program

The acceptability and feasibility of the MiM program were assessed exclusively through qualitative interviews. Health providers highlighted the positive response from participants towards the MiM as male partners expressed an understanding of MH and recognized their role in ensuring safe delivery.

FGDs with male partners revealed that they gained more confidence in supporting their female partners during pregnancy and became more willing to engage in discussions. Women preferred the program due to its positive impact on their partners’ knowledge and behavior, particularly including healthy pregnancy outcomes through nutrition.

The program enabled male partners to engage with MHC providers, addressing concerns and providing tailored materials for specific MH needs.

Both men and their partners recognized the impact of the program on their roles and improved MH outcomes by promoting the identification of issues and preventing complications.

Feasibility of the introduced MiM

Technical feasibility

Manager-level health providers emphasized the feasibility of MiM in terms of its technical aspects, specifically mentioning its design and ease of comprehension for male partners who have limited literacy skills.

Men and their partners found the health education materials, particularly the visuals, easily comprehensible, effectively conveying essential information on MH and emergency preparedness.

Time feasibility

Regarding the schedule of MiM, health providers emphasized the need for flexibility to accommodate the time constraints of male partners. Additionally, most men expressed their preference for weekend sessions and convenient locations, while some suggested shorter and more focused session durations to enhance engagement.

IDIs with health providers recommended a suitable program duration of six months for the male partners to acquire new skills. In FGDs, some men found that a six-month program duration was adequate for learning while others suggested it should be shorter due to their early knowledge acquisition.

Operational feasibility

Manager-level health providers addressed the challenges by engaging with the community and closely monitoring the process of the program. Field-level providers acknowledged that the implementation of MiM program has shown feasibility and positive outcomes. However, both emphasized the need for additional trained personnel with skills in engaging male partners to ensure the successful implementation of MiM.

Economic feasibility

Both manager- and field-level providers highlighted that one of the advantages of MiM is its feasibility, as it is offered free of charge, which encourages active participation. During FGDs with male partners, it was observed that they expressed favorable views regarding affordability but mentioned concerns about transportation costs and potential loss of daily income for those engaged in manual labor. Similarly, women acknowledged its affordability; however, one participant expressed concerns about her husband’s work absence during MiM sessions.

Strength and limitation of the study

This study employs a quantitative-qualitative sequential explanatory mixed-methods approach with methodological rigor, integrating pre- and post-intervention surveys with IDIs and FGDs. It represent the first intervention study with male partners to improve knowledge, attitudes, and BPCR practices for safe motherhood and ID in Nay Pyi Taw. The MiM intervention’s tailored focus on male partners addresses community-specific needs, resulting in increased ID rates through health education and discussion. Additionally, the use of systematic random sampling ensures the reduction of selection bias, while comprehensive training for data collectors is designed to minimize bias. These strengths enhance the credibility and validity of the findings, providing valuable insights into the MiM’s effectiveness in improving MH outcomes.

Despite its strengths, this study was conducted in two purposively chosen townships in Nay Pyi Taw Union Territory, thus limiting generalizability within Myanmar or beyond. The six-month intervention may have limited the assessment of long-term MiM impact, and this would justify a longer follow-up to understand changes over time. External co-interventions, such as mass media and information from nearby health providers, could influence the outcomes of the study. About 20% of the participants missed monthly MiM activities at health centres, which hampered collective learning through group discussions and overall intervention effectiveness, despite efforts to provide MiM face-to-face education at home. Future MI-focused interventions in MHC should, therefore, address such limitations for stronger impact and applicability in similar settings.