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Including expectant fathers in antenatal education programmes in Istanbul, Turkey
Including Expectant Fathers in Antenatal Education Programmes in Istanbul, Turkey Janet Molzan Turan, Hater Nalbant, Aygen Bulut, Yusuf Sahip In this article we present the results of three studies investigating methods for including men in antenatal education in Istanbul, Turkey. Participants were first-time expectant parents living in low and middle-income areas. After a formative study on the roles of various family members in health during the period surrounding a first birth, an antenatal-clinic-based education programme for women and for couples was carried out as a randomised, controlled study. Based on the results, separate community-based antenatal education programmes for expectant mothers and expectant fathers were tested. There was demand among many pregnant women and some of their husbands for including expectant fathers in an tena tal education. In the short term, these programmes seemed to have positive effects on women and men’s reproductive health knowledge, attitudes and behaviours. In the clinic-based programme the positive effects of including men were mainly in the area of post-partum family planning, while in the community-based programme positive effects among men were also seen in the areas of infant health, infant feeding and spousal communication and support. Free antenatal education should be made available to all expectant mothers and when possible, men should be included, either together with their wives or in a culture such as that of Turkey, in separate groups.
Keywords: maternal programmes,
and child health, antenatal
OUNG women having their first child have special needs for physical and emotional support.’ Antenatal education and support programmes have become routine in the developed world, and in recent years they are being introduced in developing countries as we11.2-4 Including men in such programmes is one way of teaching them concrete ways of supporting their wives and children during pregnancy, birth and the post-partum period.5 Despite the recent attention given to male involvement in reproductive health, there have been relatively few intervention studies testing strategies that address men or couples,6 except in the area of family planning, where involving husbands can increase contraceptive use.7 On
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male involvement,
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the other hand, there may be risks in bringing men into domains where women have traditionally been in charge, including increased male dominance in decision-making.6 Antenatal education programmes in developed countries often include the expectant father as well as the mother, often with positive effects.5,gJo This is quite rare in developing countries and only a few examples can be found in the literature. In India a group in which expectant fathers were educated made significantly more antenatal visits and had significantly less perinatal mortality than a control group. ” A pilot study in’ Nicaragua found that a community-based programme with discussion groups and incentives for expectant and new fathers increased men’s
Reproductive Health Matters, Vol. 9, No. 18, November 2001
knowledge of reproductive health, breastfeeding and child development.12 In Egypt, knowledge and practice of contraception among couples who received antenatal information on family planning increased compared with a control group.r3 A study of post-partum health needs in Istanbul among new mothers up to 6 months after a birthI found that at l-2 months only 26 per cent had had post-par&m check-ups, 11 per cent were exclusively breastfeeding, and at 5-6 months only 34 per cent were using a modem contraceptive. The women also reported that they did not get the information and counselling they needed on pregnancy, childbirth and postpartum health during antenatal visits, and that they wanted their husbands to be involved in antenatal information and counselling. In response to these findings, a research team at the Woman and Child Health Research and Training Unit (WCH Unit), Istanbul University Medical School, has been investigating methods for delivering free antenatal education to both women and men since 1994, focusing primarily on promoting behaviours that are known to improve post-partum maternal and infant health. In order to be able to design appropriate programmes, the team studied the roles of family members in health in the period surrounding a first birth, especially fathers. A clinic-based antenatal education programme and community-based programmes for expectant mothers and fathers were then developed and evaluated. In this article, we present the results of these studies regarding expectant fathers. Results regarding antenatal education programmes developed for women are described elsewhere.‘5s16
Context All three studies described in this article were conducted in Istanbul, whose population is near 10 million and growing rapidly, largely due to migration from other parts of the country. Low and lower-middle income women mainly use Ministry of Health and Social Security Administration clinics or small, inexpensive private health facilities for antenatal care. Special antenatal education programmes and childbirth preparation
classes are offered only in the private sector and are available only to the upper and middle classes. In Turkey, sex segregation and a gendered division of labour persist in urban as well as rural contexts.17 Olson describes the Turkish family structure as ‘duofocal’, i.e. with separate spheres of influence for women and men.‘* Most domestic tasks are considered to be women’s work. Although mothers have the primary responsibility for childcare, fathers and other male relatives show great fondness for and spend time with children. Kandiyoti argues that women’s reliance on support networks of female relatives and domestic servants for help with domestic tasks has sheltered the traditional Turkish male role from redefinition. lg Even if women live in ‘nuclear’ households, they receive considerable support from relatives, who often live nearby.20 Men have traditionally been the major decision-makers in Turkish families.2’ On the other hand, ethnographic work among working-class, first and second generation migrants to Istanbul indicates that even though men have considerable power protected by tradition and law, in some contexts women find ways to negotiate with their husbands to get the things they want.22
Conceptual
framework
The conceptual framework for our work with expectant fathers is similar to that proposed by Diemer for evaluating the effects of educating expectant fathers on spousal relations.5 Fathers’ participation in antenatal education programmes is expected to result in changes in their knowledge, attitudes and skills related to perinatal health, i.e. family health during the pregnancy, birth and newborn periods. These, in turn, should result in behaviour changes that can positively affect the reproductive health status and psychological well-being of the family. These include use of antenatal care, post-pa&m and post-natal services, breastfeeding and prevention of unwanted pregnancy. We recognise the effects of the couple’s social and demographic characteristics (such as age, education, income level, place of residence, contact with relatives, etc) at all stages in the process. 115
Turan, Nalbant, Bulut, Sahip
Formative research on the family context of perinatal health A formative study using qualitative research methods was designed to obtain a better understanding of the roles of family members in health decision-making and behaviour before, during and after a first birth. The majority of the participants in this study were low and lower-middle income women and men using the services of the Istanbul Medical School Hospital. This is a large, government, university teaching hospital. Relatively low fees are charged for services. Government employees and people referred through the social security system are charged reduced fees. Initially, four focus group discussions were conducted with new parents (one with mothers, two with fathers and one with couples), recruited from the hospital well-baby clinic and two low-income neighbourhoods in the hospital catchment area. A total of 13 fathers and 9 mothers participated in these groups. Next, indepth interviews were completed with 10 mothers and 10 fathers who had recently given birth at the same hosmtal. Informants were chosen from the records’ of the maternity ward, selecting people from different groups in terms of age, occupation, delivery type and place of origin. Lastly, five focus group discussions were conducted with men and women who were expecting their first child (one group with fathers, three with mothers, and one with couples). Participants in this final set of groups (a total of 19 women and 7 men) were recruited from the hospital antenatal clinic on the days that they came in for antenatal visits.
Findings Both women and men agreed that the main duty of a man is to earn the income that will provide the family with a good standard of living. Even though it was assumed that the father would spend much less time with children than the mother, his role in raising the child was also seen as important. The father was expected to be involved in the child’s education and serve as a moral guide. Being a good role model was seen as especially important if the child was a boy. Housework and childcare were not seen as responsibilities of fathers. They should help the mother with these tasks if needed and if there 116
is time. Several of the new fathers claimed that they did not have any time or energy to deal with the baby or household matters after working long hours. New mothers generally accepted that men should be excused from much involvement in ‘women’s work’. There was -also a general feeling among both women and men that men are less competent than women in caring for children and housework. In joint living situations there may be less need for men to get involved in household tasks, since there are several women around to do the work, and there is pressure from older relatives to stick to the traditional division of labour. Husband’s help was seen as more necessary during pregnancy and right after birth, when the mother was not as strong physically. One of the duties of the new father during the first few months is to play with the baby, so that the mother can do the housework. ‘. . .Now that we have a child, I take care of the baby when I come home from work so that my wife can easily do her housework.. . there is a little bit more sharing than before. ’ (New father) Most of the women had help with household tasks from their mothers, mothers-in-law, sisters or other women in their immediate environment. They mainly expressed expectations for communication, understanding and emotional support from the fathers of their children, rather than physical assistance with the tasks of motherhood. ‘It’s important for the father to be helpful at home. Not in terms of the work, but in terms of psychological support. At home friendship is important, sharing and taking an interest is important, talking is important. ’ (Pregnant woman) Ideas about fatherhood seem to be undergoing a change in Istanbul. Families are now getting messages from the media and elsewhere that fathers should somehow be more involved in raising children and daily household responsibilities. Many young fathers said that the ideal father should have a warm and close relationship with his child and be closely involved m the child’s upbringing. Several male participants described their own fathers as physically and emotionally distant, and thought this was at least partly because there were so many
Reproductive Health Matters, Vol. 9, No. 18, November
children. Several men repeated the saying ‘Hayat Mtisterektir’ (life is shared by spouses). However, it was unclear exactly what this new father role entails. Even when they wanted to, the men did not know exactly how they could be more helpful to their wives. ‘For example at home we help out with some jobs, but beyond that we don’t have any information aboutfeeding or about how we can be helpful to our wives. Nobody taught me, I didn’t get any information.’ (Expectant father) In this population of first-time parents in Istanbul, it appears that mothers are the main ones responsible for most of the daily behaviours that influence infant health in the post-par-turn period. The father’s role in these areas is usually seen as supplementary. Daily decisions regarding infant feeding and care are usually made by the mother, with important input from other women and doctors. Fathers may be informed and consulted at times, but they are often not around when such decisions are made. ‘I’m planning to breastfeed until he is 10 months old. They say it’s not good for the baby after that. I’m doing the same as my neighbour did. Of course my mother and my mother-in-law say some things.. . As for infant care, my husband says to me, “You know what’s best.” He doesn’t ask. ’ (New mother) Post-partum health behaviours in which fathers are more actively involved include visits to health care facilities and pregnancy prevention after the birth. Many fathers accompany their wives and children on visits to health care facilities and are involved in decision-making regarding when, where and how to seek health care. Many couples use male contraceptive methods, such as withdrawal or condoms, as their first post-par-turn family planning method. In addition, decisions regarding adoption of a family planning method were most often described as couple decisions. ‘Up until now we never protected ourselves. Before the birth we used our own will-power. After the birth we chose the IUD because it is more reliable. We heard that pills are habitforming and cause infertility and that some condoms have holes in them. My wife and I decided together. ’ (New father)
2001
There was clearly a strong demand from the new parents who participated in the focus groups and interviews for information and counselling about pregnancy, childbirth and the post-par-turn period. They felt that they had been unprepared for the events that occurred and that having more information before the birth would somehow have made it easier. Expecting parents also agreed that it would be best to start getting information during pregnancy. ‘No one gave us any information for after the birth. If only they had given us 3-4 pages of information. We have had a lot of problems. We have to take the child to the doctor every day. That’s really bad. ’ (New father) ‘It would be better if we could get all the information during pregnancy. If some time passes after the birth, it may be dificult to fix any mistakes that you have made. You may have lost opportunities.’ (Expectant mother) Young women saw bringing husbands into information and counselling sessions at a health facility as a way to get them to provide more emotional support and understanding. They wanted their husbands to see what other men were doing and hoped that would encourage them to be more supportive. ‘It would be better if the family is together. What can he know about pregnancy? You should be beside him too so that you can do the talking and he can contribute. It’s better like that. ’ (Expectant mother) implications for programmes The data from this research were used to shape the form and content of the antenatal support programme tested in the second study, described below. In spite of the needs expressed in relation to new fathers’ involvement, the participants in this study generally agreed that it would not be easy to get men to participate in antenatal programmes, since it was asking them to do something outside their regular domain of responsibility. Further, we learned that we should include health during pregnancy and childbirth as well as post-partum health. We also learned that most participants preferred group sessions, rather than individual
Turan, Nalbant, Bulut, Sahip
or couple sessions. As young couples preferred to get information from experts, it was decided that at least one health professional should be on the team leading educational sessions.
Clinic-based couples
antenatal
programme
for
An antenatal education programme was designed to meet couples’ expressed needs for information about health topics and women’s desire for communication and understanding from their partners, In addition to providing factual information, emphasis was placed on describing the important role that fathers can play in supporting women during pregnancy, delivery and post-partum. A total of 333 pregnant women expecting their first child agreed to participate in the study. These women were relatively young (mean age 24 years) and had been married for relatively short periods of time (mean 11 months). Fifty-six percent had been raised in an urban area. Fifty-eight percent had worked outside the home at some point in their lives. Husbands tended to be slightly older (mean age 28 years) and have a little more schooling (mean 9.6 years) than their wives (mean 8.6 years). Programme activities took place at the Istanbul Medical School Hospital Antenatal Clinic, located in the WCH Unit. Women were accepted at this clinic after the fourth month of pregnancy. There were no scheduled appointments; women were seen on a first-come, lirstserved basis each day. The team of doctors providing antenatal care rotated every three months and a woman was likely to see a different doctor on each antenatal visit. This study had a randomised, controlled design. After completing the informed consent procedure and a baseline interview, participants were randomised into three groups: the couples group (n=l lo), the women-only group (n= 11 l), or the control group (n= 112). A lack of significant differences in demographic and socio-economic characteristics between the groups indicated that the randomisation was successful, In the couples group, both partners were invited to participate together in an antenatal education programme. In the womenonly group, only women were invited to par118
ticipate. Control group members were not invited to participate in the programme, but could take advantage of the regular services offered by the WCH Unit (routine antenatal care, family planning services, well baby check-ups, well woman check-ups). At four months after their babies were born, 279 of the women (84 per cent) and 253 of the men (76 per cent) who participated in the study were interviewed in their homes to assess postpartum health beliefs, attitudes and behaviours. Questions focused on infant feeding, protection from unwanted pregnancy and preventive health care utilisation for mother and baby. Relatively few differences between the characteristics of those followed up and those not followed up were identified, indicating that the final sample for evaluating the programme was not biased. The programme The main components of the programme were group educational sessions, a booklet and a telephone counselling service. Couples and women were invited to attend four go-minute group sessions during the pregnancy. Topics of the sessions were: pregnancy, childbirth, infant feeding and care and postpartum women’s health and family planning (see box). Modules for the group sessions were developed by an education specialist and a nurse hired for the project, along with other members of the research team, and conducted by the educational specialist and the nurse. Although the sessions were normally held on weekday mornings, sessions were periodically arranged on Sunday afternoons for those who could not take time off work during the week. Participants attending all four sessions were presented with a certificate and a small gift. The formative research had helped the team to identify a series of common problems and commonly asked questions. Experts in appropriate fields (obstetrics and gynaecology, paediatrics, family planning and women’s health) wrote answers to 63 questions, which were edited and revised by a psychologist on the research team into a 29-page booklet, which was mailed to all participants in the couples and women-only groups, addressed respectively to the couple or the woman only. Project staff also established a telephone
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Topics covered in antenatal
group sessions
Pregnancy 1. Signs of pregnancy 2. Women’s reproductive 3. Process of fertilisation
anatomy
4. Baby’s development in the womb 5. Importance and content of antenatal care 6. Taking care of the mother and baby during
pregnancy
7. Common symptoms and complaints during pregnancy (nausea, constipation, etc) 8 Situations in which you need to go to the doctor or hospital
immediately
Birth 1. Planning for the birth (place, list of items to take to the hospital) 2. Signs that the birth is starting 3. Stages of labour and delivery 4. 5. 6. 7.
Breathing and pushing techniques Episiotomy Risks to the mother and/or baby Caesarean and vacuum births
8. Care of the baby and mother birth 9. Relaxation
in the hospital
after the
exercises
Infantcareand feeding 1, Baby’s needs (nutrition, love, etc) 2. Breastfeeding 3. Prevention of common
sleep, hygiene,
infant
communication,
illnesses
4. How to handle some common infant illnesses (fever, jaundice, diarrhoea, etc) 5. Infant development during the first six months 6. Basics of infant care (bathing, diapers, clothing, sleep, etc) 7. Things to be careful
of in the home
(potential
accidents)
Post-partum women’shealthand family planning 1. Post-partum traditions 2. Care of the mother after the birth 3. Changes in a woman’s to fertility 4. Reproductive anatomy 5. Methods for preventing 6. Common
rumours
about
body after a birth and the return and processes unwanted pregnancy family
planning
methods
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18, November
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~ counselling service, with a dedicated telephone I number, to function during clinic working hours (M-F, 08:30-16:30). The number was mailed and/or given directly to members of both intervention groups but not to members of the control group. Project educators answered the calls, and clinic doctors were available when a more expert opinion was deemed necessary. For each phone call, information was recorded about the caller, the questions asked and the advice/information given.
Findings Eighty-three per cent of women in the intervention groups who completed a home interview (n=187) reported that they and/or their husbands had participated in the antenatal programme, either attending at least one educational session, reading some or all of the booklet and/or calling the telephone counselling service. Participation of expectant fathers together with their wives in the educational sessions was lower than expected. Only 22 men from the couples group (26.2 per cent) said that they had attended one or more sessions. Seven men attended only one session, five men attended two sessions, four attended three sessions and six attended all four sessions. Furthermore, women’s attendance at one or more sessions was higher in the women-only group (53.8 per cent) than the couples’ group (40.4 per cent) (p=.O93). The men who did attend the group sessions tended to be more educated, older and more likely to have some form of health insurance than men who did not participate (all p’s from x2 < .05). Their wives were also more likely to be more educated, be working outside the home and have wider social support networks than the wives of men who did not attend (all p’s from x2 < .05). The question-and-answer booklet reached a greater number of women and men than the group sessions, with 63 per cent of men and 74 per cent of women reporting that they had received the booklet. Of those who reported receiving the booklet, 84 per cent of men (n=105) and 94 per cent of women (n=140) reported having read some or all of it. The men in the couples’ group were significantly more likely to report having read the booklet than the husbands of women in the women-only 119
Turan, Nalbant, Bulut
Sahip
group (61.9 per cent versus 42.9 per cent, (x2=5.37, p=.020)). Men who said they had read the booklet were not different in their background characteristics from men who said they had not read the booklet. Thirty-two per cent of participants (59) from both intervention groups reported that they had used the telephone counselling service at least once. No difference was found between telephone counselling service use by members of the couples’ group and the women-only group. Only one new father (from the couples group) called the service. The most common questions asked over the phone were to do with infant care and health (50 per cent), infant feeding (2 1 per cent), women’s health after the birth and family planning (14 per cent), accessing health services (7 per cent), childbirth (5 per cent), and pregnancy (4 per cent). Men’s knowledge and behaviour Men’s knowledge regarding breastfeeding, preventive health care and family planning were measured in the follow-up interviews. The only subject on which there were some differences in men’s knowledge was family planning. Men in the couples’ group tended to have more correct knowledge about post-partum family planning, particularly the use of hormonal contraceptives, compared to men in the other two research groups. Fathers were asked their most important sources of information on infant feeding, infant health, maternal health and family planning after the birth. Family members dominated as sources of infant feeding information (mentioned by 99.6 per cent of fathers), though they were not as frequently mentioned as sources of other types of information. The subject on which the highest percentage of fathers said they had no source of information was maternal health (13.8 per cent). Friends were important sources of family planning information for fathers (58.6 per cent), as were media channels (68.5 per cent). Although all study participants were users of the services of the antenatal clinic in the WCH Unit, fathers in the couples’ group were more likely to cite the WCH Unit as a source of health information than were husbands of women in the women-only group or the control group. Though increased dominance by men in 120
decision-making where women have traditionally made the decisions was a risk we were concerned about, when,new mothers and fathers were asked who made household decisions on infant feeding, infant health, post-partum women’s health, and family planning, no differences were found in decision-making among members of the three study groups. Post-partum health behaviours Of the four post-par-turn health behaviours examined, only the use of contraceptives offered through the medical system (IUD, pills, steriliTation and condoms) was significantly higher in the intervention groups (62 per cent in the couple group and 57 per cent in the womenonly group) as compared to the control group (47 per cent). Exclusive breastfeeding, infant check-up and woman’s post-partum check-up were only slightly more common in the intervention groups as compared to the control group. Logistic regression analysis was used to control for background characteristics and potential confounding variables when examining the relationship between study group and FP method use. This analysis revealed that use of modern methods in the couples’ group was significantly higher than modern method use in both the control group and the women-only group. Participants in the couples group were 1.49 times as likely as control group members to use a modern FP method. The odds ratio for the women-only group versus the control group did not differ significantly from 1.0 (OR=.97, p=.865). The woman’s source of post-partum health care and her past experience with family planning methods retained significance in the final model. Implications for future programmes Given that 99 per cent of the women participating in the baseline survey said that they wanted to use a family planning method to postpone their next pregnancy, increased use of modern family planning methods at four months after a birth appears to be a positive impact of the programme. The relatively low participation of men in the group sessions offered in this programme indicated that different strategies would have to be used to reach most expectant fathers. In
Reproductive Health Matters, Vol. 9, No. 78, November 2001
particular, it appeared that men of lower socioeconomic status would need special encouragement and recruitment efforts to participate in such programmes. We also learned that in a programme for couples, men’s participation should not be made mandatory as it may be a barrier to participation for some wives. Given the greater use of the project booklet as compared to the other programme components, we also felt that written educational materials should be used for antenatal education. These would need to address the concerns of expectant fathers as well as expectant mothers.
Community-based expectant fathers
programme
for
Taking into account the lessons learned in the clinic-based programme, which continues as an on-going programme attended mostly by women, the research team developed a followup project to test similar programmes for expectant mothers and expectant fathers in a community-based setting. This focused on the effects of antenatal education not only on postpartum health behaviours but also on health knowledge, attitudes and behaviours during pregnancy and childbirth. The programmes were offered free at a community centre run by a non-governmental organisation in a lower middle-class neighbourhood in the Fatih District of Istanbul. Members of the local community were active in the planning and operation of the programmes, which is described elsewhere.23 Participants were first-time, expectant parents who had heard about the programme from leaflets distributed in the community and/or from members of the community team. From November 1998 to July 2000, the programme for expectant mothers was offered 13 times with 142 women participating, while the programme for expectant fathers was offered seven times with 43 expectant fathers participating. The vast majority of expectant fathers who participated were the husbands of expectant mothers in the programme at the site. Thirty-seven of the men (86 per cent) who began the programme completed the six sessions and received a certificate. Group sizes ranged from 3 to 13 men. The mean age of participants was 32. All had at
least a high school education and the majority had some university education. The men tended to be working in professions such as teaching, engineering and accounting. Although the majority of their wives were not currently working outside the home, they also tended to have high school or university education. Around half the men were born in Istanbul. They were by no means in the highest socioeconomic group in Istanbul, but were well above the average in that district. The programme for expectant fathers was evaluated using pre- and post-tests and feedback from expectant fathers and their wives. Questionnaires with 20 mostly open-ended questions were filled out by participants on their own on the first and last days of the programme. Questions covered knowledge and attitudes regarding health during pregnancy, birth and post-partum, communication and the father’s role. Expectant fathers were also asked to write down their thoughts and feelings about the course on the post-test form.
The programme As a first step, an educational programme for expectant mothers was initiated at the community centre in December 1997. Six months later, a programme for expectant fathers was developed in partnership with the Father Support Programme of the Mother-Child Education Foundation (MOCEF), which has been helping Turkish fathers of children aged 3-9 to develop parenting skills since 1996. Based on the experience of MOCEF, it was decided to offer a separate programme for expectant fathers only, taught exclusively by male educators, in addition to the existing programme for women. It was felt that both women and men would be more comfortable and be able to ask more personal questions in same-sex groups. The clinic-based programme was expanded to include topics such as communication techniques and adjustment to motherhoodlfatherhood. Special topics for expectant fathers included the psychological state of the expectant father, ways to support good nutrition during pregnancy, support of women during labour and delivery, support for breastfeeding and adjustment to fatherhood. The six-session programme for expectant fathers was held once a week on weekends or evenings. Each session 121
Bulut, Sahip
Turan, Nalbant,
Figure 1. Changes in expectant fathers’ knowledge and attitudes, proportion of men answering correctly pre- and post-test (n=33) Effective contraceptive
method
Support giving Many fathers emphasised that the programme helped them to improve their communication skills and to have a closer and more sharing relationship with their wives. Women whose husbands participated in the programme also reported that their husbands had become more communicative and supportive.
Need for infant ,-he&-up
within
7 days
Importance
of father’s
suppofl
breastfeeding
for
“Baby friendly” birth hospital Bleeding as warning sign during pregnancy Need for protein in
pregnancy
diet
0
Pre-test
H
20%
40%
Post-test
@$I
60%
80%
lasted approximately three hours. The groups were led by two trained male physicians. Group leaders presented information and used participatory techniques such as large and small group discussions, demonstrations, role play, games and question-and-answer sessions. Booklets and brochures were also provided on topics such as pregnancy nutrition, preparing for childbirth, post-par-turn women’s health, infant care, breastfeeding and contraceptive methods. Videos on preparing for parenthood, infant care and breastfeeding were also shown and discussed. Findings Selected findings from the pre- and post-tests are presented in Figure 1. All differences between pre- and post-test scores were statistically significant according to McNemar’s Test (for paired categorical responses).24 Although the sample size is small, there were significant gains in men’s knowledge and a shift in attitudes. Participants improved their knowledge on topics related to pregnancy. birth. infant health, infant feeding and post-partum contraception. It should be kept in mind that many of these men’s wives had participated in the community-based programme for expec122
tant mothers and had probably shared the information they gained with their husbands. Thus, pre-test knowledge levels are likely to have been higher than among men whose wives had not attended such a programme.
‘During this six-week course I got more information than I expected to get. I participated because 1 wanted to learn more about my wife’s physical and psychological condition, our child’s development and how I can support them. After participating in the course 1 understand my wife’s situation better and we communicate better. I shared the things I learned with people in my environment.’ ‘I came to this course because I wanted to learn what I need to do as a father. I wanted to learn this in a scientiJc manner. But as the course continued I realised that the real goal was to kelp us understand our wives and become aware of their feelings and mental state. I see that if we ty to understand our wives and share their “mother’s world” we can successfully carry out our responsibilities as fathers. ’ ‘Due to this programme I have closer relationskips with people in my environment, I got closer to my wife, and I learned a lot about how to understand my wife and baby. This is a programme that all men should de$niiely attend.’
Discussion Our research indicates that antenatal education programmes for expectant fathers as well as expectant mothers can have positive effects on their reproductive health knowledge, attitudes and behaviours. Because of the low attendance of men at the group sessions of the clinic-based programme, it is difficult to assess the effects, which seemed to be limited to post-partum contraception. However, this
Reproductive
low level of participation by fathers is a reality in this setting and other programmes in Turkey using a similar strategy will most likely face the same problems. There were a number of institutional and social barriers specific to men’s participation, e.g. the ‘female’ atmosphere of the antenatal clinic, past exclusion from antenatal visits and difficulties in getting time off work. Perhaps more importantly, men do not generally see pregnancy, birth and infant care as being in their sphere of responsibility. Women wanted them to attend but most did not have the negotiating power to get them to do so. In the community-based programme, positive effects were also seen in the areas of infant health and feeding, spousal communication and support. Sustained behaviour change and effects on maternal and child health status could not be measured, but no negative effects of including men, such as increased male domination in decision-making, were detected. However, men invited to participate in the clinic-based programme were randomised into the couples group by the research team, whereas men in the community-based programme were selfselected. It should also be kept in mind that decision-making processes and the perspectives of the various participants are probably too complex to capture in a structured questionnaire. Although further research is necessary, it seems likely that the more intensive, continuous and ‘support group’ nature of the community-based programme for expectant fathers, compared to the clinic-based programme, may be a more successful method for involving men. In our programmes, men’s attendance was better when sessions were held on evenings or weekends. In addition, men were more comfortable attending the programme in a neutral place than in an antenatal clinic. Special efforts, such as telephone calls and encouragement from wives, were often needed to get men to attend the first session, but when the first session met or surpassed the men’s expectations, they were likely to continue. Thus, the quality of the first session is very important. Specific topics were designed by and for expectant fathers, instead of including men in a programme meant for women. Sessions specifically addressed men’s experiences, feelings
Health Matters, Vol. 9, No. 18, November 2001
and need for guidance, as well as women’s. Programmes for both men and women included social and psychological concerns, along with basic information on reproductive health during the pregnancy, birth and newborn periods. The question of whether to have a couples ’ programme or separate programmes for women and men should be investigated in each programme setting. Focus groups or other qualita! tive research methods could be used to explore I who would be attending and their level of , comfort with members of the opposite sex on programme topics. Men and women might be together for some topics and separate for others. However, in patriarchal cultures such as Turkey, the disadvantages of programmes for ~ couples together should be kept in mind. ) Women are the most important target group for ~ antenatal education and a programme aimed at ~ couples may discourage the participation of women whose husbands will not or cannot attend. A programme in which some women’s husbands attend and others don’t may create feelings of inferiority and resentment in women who attend alone. We recommend that free antenatal education should be made available to all expectant mothers and when possible, men should be included, either together with their wives or in separate groups. The antenatal education programmes developed during the course of our research continue to be offered at the community centre and the hospital clinic. In order to aid the development of other such programmes in Turkey, the research team has developed a comprehensive guide to antenatal education, including detailed educational modules for both the women’s and the men’s programmes.25 This guide has been distributed to the Ministry of Health, the Istanbul Health Directorate, the Social Security Administration, maternity hospitals, nursing schools, medical schools, health centres and non-governmental organisations working in reproductive health. ~ To reinforce the use of the guide, training of ~ trainers courses for antenatal education are ~ also being organised and a study is planned to ~ look at the longer-term effects of educating expectant fathers.
123
Turan, Nalbant, Bulut, Sahip
Acknowledgements Thejrst two studies presented in this paper were conducted as a part of theBrst author’s doctoral dissertation. The studies were supported financially by AVSC, MEAwards Program, Population Council Ebert Program, Mellon Foundation, International Women of Istanbul Association and European Commission. We would like to thank all members of the research teams based at the Istanbul Medical School, Woman and Child Health Training and Research Unit for their contributions; Dr WH Mosley, Johns Hopkins University School of Hygiene and Public Health for help evaluating the clinicbased programme; Dr Joel Gittelsohn, Johns Hopkins University and Dr Niikhet Sir-man, B$azi@ University, for serving as advisers for the formative research; Dr Ali Kemal Cetin and other staff of the Father Support Proqramme, Mother ChildEducation Foundation, Istanbul for
their important contributions to the development and implementation of the education programme for expectant fathers; Biilent Turan and Dr Nuriye Ortayli for helpful comments on this paper; and all the expectant and new parents who participated in the studies. Some of the information presented here will also appear in Turan JM, Nalbant H, Bulut A et al. Promoting post-partum health in Istanbul: does including fathers make a difference? From Principles to Practice: Case Studies of Post-Cairo Change. New York, Population Council (in press). Correspondence Dr Janet Molzan Turan, Istanbul Ttp Fakiiltesi, Kadzn ve Cocuk Saglujt Egitim ve Arapttrma Birimi, Cerrahi Monoblok kargzst, Capa 34390, Istanbul, Turkey. Fax: 90-2 12-63 I- 17 10. E-mail: [email protected]
References I. Hayes BA, Muller R, Bradley BS, 2001. Perinatal depression: a randomized controlled trial of an antentatal education intervention for primiparas. Birth. 2.
28(1):28-35.
Thassri J et al, 2000. The development and evaluation of a health education programme for pregnant women in a regional hospital in southern Thailand. Journal of Advanced 32(6):1450-58.
Nursing.
Rana L, 2000. Organising antenatal education for safe motherhood. Nursing Journal of India. 91(3):50-52. 4. Langer A et al, 1993. The Latin American trial of psychosocial support during pregnancy: a social intervention evaluated through and experimental design. Social Science and 3.
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36(4):495-507.
5. Diemer G, 1997. Expectant fathers: influence of perinatal education on stress, coping, and spousal relations. Research in Nursing
and Health.
20:281-93.
6. Becker S, 1996. Couples and reproductive health: a review of couple studies. Studies in Family
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Planning. 27(6):291-306. 7. New perspectives on men’s participation. Population Reports. 26(2), Series J, Number 46, October 1998. 8. Helzner JF, 1996. Men’s involvement in family planning. Reproductive 7:146-54.
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9. Swedin G, 1996. Modern Swedish fatherhood: the challenges and the opportunities. Reproductive Health
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10. Westney OE, Cole OJ, Munford TL, 1988. The effects of prenatal education intervention on unwed prospective adolescent fathers. Journal of Adolescent Health Care. 9:214-18. 11. Bhalerao VR, Galwankar M, Kowli SS et al, 1984. Contribution of the education of the prospective fathers to the success of maternal health care programme. Journal of Postgraduate Medicine. 30( 1): IO- 12. 12. Loftin C, Engle P, 1999. Father Involvement Project: Soy Padre de Campeones. Report to the Population Council, Second Phase: January-August, 1999.
13. Soliman MH, 2000. Impact of antenatal counselling on couples’ knowledge and practice of contraception in Mansoura, Egypt. Eastern Mediterranean HealthJournal. 5(5):1002-13. 14. Bulut A, Turan JM, 1995. Postpartum family planning and health needs of women of low income in Istanbul. Studies in Family Planning. 26(2):88100. 15. Turan JM, 1997.The Design and Evaluation of an Intervention to Promote Postpartum Health in Istanbul: Does Including Fathers Make a Difference? Unpublished doctoral dissertation, Johns Hopkins University School of Hygiene and Public Health. 16. Turan JM, Say L. Community based antenatal education in Istanbul: effects on health behaviors (in preparation) 17. Vergin N, 1985. Social change and the family in Turkey. Current Anthropology. 26(5):571-74. 18. Olson EA. 1982. Duofocal family structure and an alternative model husband-wife relationship. In: Se.r Roles, Family, Turkey.
and Community
in
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Indiana
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University Turkish Studies. 19. Kandiyoti D, 1982. Urban change and women’s roles in Turkey: an overview and evaluation. In: Sex Roles, Family, and Community in Turkey. Bloomington: Indiana University Turkish Studies. 20. Sirman N, 2001. Cocugun Yasammda Babamn Rolii ve &emi [The Role and Importance of Fathers in Children’s Lives]. Symposium Report. Istanbul: Anne Cocuk Egitim Vakft.
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2 1. Kuyas N, 1982. Female labor power relations in the urban Turkish Family. In: Se.r Roles, Family, and Community in Turkey. Bloomington: Indiana University Turkish Studies. 22. Angm Z, Shorter F, 1998. Negotiating reproduction and gender during the fertility decline in Turkey. Social Science and Medicine. 47(5): 555-64. 23. Turan JM, Say L, GtingSr AK et al. Community participation for perinatal health in Istanbul.
(submitted for publication) 24. Bland M, 1987. An Introduction to Medical Statistics. Oxford Medical Publications, Oxford. 25. Turan JM et al, 2000. D@m ijncesi EJitim: Program Haztrlayanlar ve EJiticiler iqin Rehber (Antenatal Education: Guidebook for Trainers). Istanbul Tip Fakiiltesi, Kadm ve Cocuk Sa#@ Egitim ve Aragttrma Birimi, Istanbul.
R&urn6 ~ Resumen etudes ont analyse des methodes pour / Tres investigaciones analizaron 10s metodos associer les hommes a l’education prenatale. i para incluir a 10s hombres en la education Les participants, issus de quartiers a revenus prenatal en Estambul, Turquia. Los particifaibles et moyens d’Istanbu1, Turquie, attenpantes eran parejas que Vivian en areas de daient leur premier enfant. Apres une etude bajos y medianos ingresos, quienes esperaban initiale des roles en matiere de Sante des memsu primer bebe. Despues de un estudio bres de la famille pendant la p&ode entourant ~ formativo acerca de 10s roles de 10s distintos une premiere naissance, un programme d’eduintegrantes de la familia en relation a la salud cation a donne des soins prenatals en dispendurante el period0 previo y posterior a un saire aux femmes et aux couples, dans le cadre primer nacimiento, se implement6 un estudio d’une etude aleatoire et contrblee. En fonction aleatorio controlado en la forma de un prodes resultats, des programmes communautaires grama educative para mujeres y para parejas en d’education prenatale, separes pour les futurs una clinica prenatal. En base a 10s resultados, Peres et les futures meres, ont ete testes. Beause probaron programas educativos prenatales coup de femmes enceintes et quelques maris comunitarios para mujeres embarazadas y sus souhaitaient associer les futurs Peres a l’educaparejas. Hubo una demanda entre muchas de tion prenatale. A court terme, ces programmes las mujeres embarazadas y algunos de sus semblaient avoir des effets positifs sur les conesposos para incluir a 10s futuros padres en la naissances, les attitudes et les comportements education prenatal. A corto plazo, estos prodes hommes et des femmes en matiere de Sante gramas parecian tener efectos positivos en las genesique. Dans le programme mene au disattitudes, comportamientos y conocimientos de pensaire, l’inclusion des hommes avait des la salud reproductiva de las mujeres y 10s avantages touchant a la planification familiale hombres. En el programa de la clinica, 10s post-partum, alors que les effets positifs du efectos positivos de incluir a 10s hombres se programme communautaire concernaient la ~ notaban principalmente en el ambito de la Sante infantile, l’alimentation des nourrissons, I planificacion familiar postparto, mientras que la communication et le soutien entre Ppoux. ~ en el programa comunitario, se notaban Une education prenatale gratuite devrait @tre ademas 10s efectos positivos en 10s ambitos de proposee a toutes les futures meres et, lorsque la salud y la alimentacion infantil, el apoyo de c’est possible, les hommes devraient y etre 10s hombres a sus esposas y la comunicacion associb, soit avec leurs epouses soit, dans une I con ellas. Se recomienda ofrecer education culture comme celle de la Turquie, dans des prenatal gratuita a todas las mujeres embaragroupes &pares. zadas y cuando sea posible a 10s hombres, en ~ conjunto con sus esposas 0, en una cultura coma la de Turquia, en grupos separados.
Trois
Keywords: maternal programmes,
and child health, antenatal
OUNG women having their first child have special needs for physical and emotional support.’ Antenatal education and support programmes have become routine in the developed world, and in recent years they are being introduced in developing countries as we11.2-4 Including men in such programmes is one way of teaching them concrete ways of supporting their wives and children during pregnancy, birth and the post-partum period.5 Despite the recent attention given to male involvement in reproductive health, there have been relatively few intervention studies testing strategies that address men or couples,6 except in the area of family planning, where involving husbands can increase contraceptive use.7 On
Y
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education,
male involvement,
community-based
Turkey
the other hand, there may be risks in bringing men into domains where women have traditionally been in charge, including increased male dominance in decision-making.6 Antenatal education programmes in developed countries often include the expectant father as well as the mother, often with positive effects.5,gJo This is quite rare in developing countries and only a few examples can be found in the literature. In India a group in which expectant fathers were educated made significantly more antenatal visits and had significantly less perinatal mortality than a control group. ” A pilot study in’ Nicaragua found that a community-based programme with discussion groups and incentives for expectant and new fathers increased men’s
Reproductive Health Matters, Vol. 9, No. 18, November 2001
knowledge of reproductive health, breastfeeding and child development.12 In Egypt, knowledge and practice of contraception among couples who received antenatal information on family planning increased compared with a control group.r3 A study of post-partum health needs in Istanbul among new mothers up to 6 months after a birthI found that at l-2 months only 26 per cent had had post-par&m check-ups, 11 per cent were exclusively breastfeeding, and at 5-6 months only 34 per cent were using a modem contraceptive. The women also reported that they did not get the information and counselling they needed on pregnancy, childbirth and postpartum health during antenatal visits, and that they wanted their husbands to be involved in antenatal information and counselling. In response to these findings, a research team at the Woman and Child Health Research and Training Unit (WCH Unit), Istanbul University Medical School, has been investigating methods for delivering free antenatal education to both women and men since 1994, focusing primarily on promoting behaviours that are known to improve post-partum maternal and infant health. In order to be able to design appropriate programmes, the team studied the roles of family members in health in the period surrounding a first birth, especially fathers. A clinic-based antenatal education programme and community-based programmes for expectant mothers and fathers were then developed and evaluated. In this article, we present the results of these studies regarding expectant fathers. Results regarding antenatal education programmes developed for women are described elsewhere.‘5s16
Context All three studies described in this article were conducted in Istanbul, whose population is near 10 million and growing rapidly, largely due to migration from other parts of the country. Low and lower-middle income women mainly use Ministry of Health and Social Security Administration clinics or small, inexpensive private health facilities for antenatal care. Special antenatal education programmes and childbirth preparation
classes are offered only in the private sector and are available only to the upper and middle classes. In Turkey, sex segregation and a gendered division of labour persist in urban as well as rural contexts.17 Olson describes the Turkish family structure as ‘duofocal’, i.e. with separate spheres of influence for women and men.‘* Most domestic tasks are considered to be women’s work. Although mothers have the primary responsibility for childcare, fathers and other male relatives show great fondness for and spend time with children. Kandiyoti argues that women’s reliance on support networks of female relatives and domestic servants for help with domestic tasks has sheltered the traditional Turkish male role from redefinition. lg Even if women live in ‘nuclear’ households, they receive considerable support from relatives, who often live nearby.20 Men have traditionally been the major decision-makers in Turkish families.2’ On the other hand, ethnographic work among working-class, first and second generation migrants to Istanbul indicates that even though men have considerable power protected by tradition and law, in some contexts women find ways to negotiate with their husbands to get the things they want.22
Conceptual
framework
The conceptual framework for our work with expectant fathers is similar to that proposed by Diemer for evaluating the effects of educating expectant fathers on spousal relations.5 Fathers’ participation in antenatal education programmes is expected to result in changes in their knowledge, attitudes and skills related to perinatal health, i.e. family health during the pregnancy, birth and newborn periods. These, in turn, should result in behaviour changes that can positively affect the reproductive health status and psychological well-being of the family. These include use of antenatal care, post-pa&m and post-natal services, breastfeeding and prevention of unwanted pregnancy. We recognise the effects of the couple’s social and demographic characteristics (such as age, education, income level, place of residence, contact with relatives, etc) at all stages in the process. 115
Turan, Nalbant, Bulut, Sahip
Formative research on the family context of perinatal health A formative study using qualitative research methods was designed to obtain a better understanding of the roles of family members in health decision-making and behaviour before, during and after a first birth. The majority of the participants in this study were low and lower-middle income women and men using the services of the Istanbul Medical School Hospital. This is a large, government, university teaching hospital. Relatively low fees are charged for services. Government employees and people referred through the social security system are charged reduced fees. Initially, four focus group discussions were conducted with new parents (one with mothers, two with fathers and one with couples), recruited from the hospital well-baby clinic and two low-income neighbourhoods in the hospital catchment area. A total of 13 fathers and 9 mothers participated in these groups. Next, indepth interviews were completed with 10 mothers and 10 fathers who had recently given birth at the same hosmtal. Informants were chosen from the records’ of the maternity ward, selecting people from different groups in terms of age, occupation, delivery type and place of origin. Lastly, five focus group discussions were conducted with men and women who were expecting their first child (one group with fathers, three with mothers, and one with couples). Participants in this final set of groups (a total of 19 women and 7 men) were recruited from the hospital antenatal clinic on the days that they came in for antenatal visits.
Findings Both women and men agreed that the main duty of a man is to earn the income that will provide the family with a good standard of living. Even though it was assumed that the father would spend much less time with children than the mother, his role in raising the child was also seen as important. The father was expected to be involved in the child’s education and serve as a moral guide. Being a good role model was seen as especially important if the child was a boy. Housework and childcare were not seen as responsibilities of fathers. They should help the mother with these tasks if needed and if there 116
is time. Several of the new fathers claimed that they did not have any time or energy to deal with the baby or household matters after working long hours. New mothers generally accepted that men should be excused from much involvement in ‘women’s work’. There was -also a general feeling among both women and men that men are less competent than women in caring for children and housework. In joint living situations there may be less need for men to get involved in household tasks, since there are several women around to do the work, and there is pressure from older relatives to stick to the traditional division of labour. Husband’s help was seen as more necessary during pregnancy and right after birth, when the mother was not as strong physically. One of the duties of the new father during the first few months is to play with the baby, so that the mother can do the housework. ‘. . .Now that we have a child, I take care of the baby when I come home from work so that my wife can easily do her housework.. . there is a little bit more sharing than before. ’ (New father) Most of the women had help with household tasks from their mothers, mothers-in-law, sisters or other women in their immediate environment. They mainly expressed expectations for communication, understanding and emotional support from the fathers of their children, rather than physical assistance with the tasks of motherhood. ‘It’s important for the father to be helpful at home. Not in terms of the work, but in terms of psychological support. At home friendship is important, sharing and taking an interest is important, talking is important. ’ (Pregnant woman) Ideas about fatherhood seem to be undergoing a change in Istanbul. Families are now getting messages from the media and elsewhere that fathers should somehow be more involved in raising children and daily household responsibilities. Many young fathers said that the ideal father should have a warm and close relationship with his child and be closely involved m the child’s upbringing. Several male participants described their own fathers as physically and emotionally distant, and thought this was at least partly because there were so many
Reproductive Health Matters, Vol. 9, No. 18, November
children. Several men repeated the saying ‘Hayat Mtisterektir’ (life is shared by spouses). However, it was unclear exactly what this new father role entails. Even when they wanted to, the men did not know exactly how they could be more helpful to their wives. ‘For example at home we help out with some jobs, but beyond that we don’t have any information aboutfeeding or about how we can be helpful to our wives. Nobody taught me, I didn’t get any information.’ (Expectant father) In this population of first-time parents in Istanbul, it appears that mothers are the main ones responsible for most of the daily behaviours that influence infant health in the post-par-turn period. The father’s role in these areas is usually seen as supplementary. Daily decisions regarding infant feeding and care are usually made by the mother, with important input from other women and doctors. Fathers may be informed and consulted at times, but they are often not around when such decisions are made. ‘I’m planning to breastfeed until he is 10 months old. They say it’s not good for the baby after that. I’m doing the same as my neighbour did. Of course my mother and my mother-in-law say some things.. . As for infant care, my husband says to me, “You know what’s best.” He doesn’t ask. ’ (New mother) Post-partum health behaviours in which fathers are more actively involved include visits to health care facilities and pregnancy prevention after the birth. Many fathers accompany their wives and children on visits to health care facilities and are involved in decision-making regarding when, where and how to seek health care. Many couples use male contraceptive methods, such as withdrawal or condoms, as their first post-par-turn family planning method. In addition, decisions regarding adoption of a family planning method were most often described as couple decisions. ‘Up until now we never protected ourselves. Before the birth we used our own will-power. After the birth we chose the IUD because it is more reliable. We heard that pills are habitforming and cause infertility and that some condoms have holes in them. My wife and I decided together. ’ (New father)
2001
There was clearly a strong demand from the new parents who participated in the focus groups and interviews for information and counselling about pregnancy, childbirth and the post-par-turn period. They felt that they had been unprepared for the events that occurred and that having more information before the birth would somehow have made it easier. Expecting parents also agreed that it would be best to start getting information during pregnancy. ‘No one gave us any information for after the birth. If only they had given us 3-4 pages of information. We have had a lot of problems. We have to take the child to the doctor every day. That’s really bad. ’ (New father) ‘It would be better if we could get all the information during pregnancy. If some time passes after the birth, it may be dificult to fix any mistakes that you have made. You may have lost opportunities.’ (Expectant mother) Young women saw bringing husbands into information and counselling sessions at a health facility as a way to get them to provide more emotional support and understanding. They wanted their husbands to see what other men were doing and hoped that would encourage them to be more supportive. ‘It would be better if the family is together. What can he know about pregnancy? You should be beside him too so that you can do the talking and he can contribute. It’s better like that. ’ (Expectant mother) implications for programmes The data from this research were used to shape the form and content of the antenatal support programme tested in the second study, described below. In spite of the needs expressed in relation to new fathers’ involvement, the participants in this study generally agreed that it would not be easy to get men to participate in antenatal programmes, since it was asking them to do something outside their regular domain of responsibility. Further, we learned that we should include health during pregnancy and childbirth as well as post-partum health. We also learned that most participants preferred group sessions, rather than individual
Turan, Nalbant, Bulut, Sahip
or couple sessions. As young couples preferred to get information from experts, it was decided that at least one health professional should be on the team leading educational sessions.
Clinic-based couples
antenatal
programme
for
An antenatal education programme was designed to meet couples’ expressed needs for information about health topics and women’s desire for communication and understanding from their partners, In addition to providing factual information, emphasis was placed on describing the important role that fathers can play in supporting women during pregnancy, delivery and post-partum. A total of 333 pregnant women expecting their first child agreed to participate in the study. These women were relatively young (mean age 24 years) and had been married for relatively short periods of time (mean 11 months). Fifty-six percent had been raised in an urban area. Fifty-eight percent had worked outside the home at some point in their lives. Husbands tended to be slightly older (mean age 28 years) and have a little more schooling (mean 9.6 years) than their wives (mean 8.6 years). Programme activities took place at the Istanbul Medical School Hospital Antenatal Clinic, located in the WCH Unit. Women were accepted at this clinic after the fourth month of pregnancy. There were no scheduled appointments; women were seen on a first-come, lirstserved basis each day. The team of doctors providing antenatal care rotated every three months and a woman was likely to see a different doctor on each antenatal visit. This study had a randomised, controlled design. After completing the informed consent procedure and a baseline interview, participants were randomised into three groups: the couples group (n=l lo), the women-only group (n= 11 l), or the control group (n= 112). A lack of significant differences in demographic and socio-economic characteristics between the groups indicated that the randomisation was successful, In the couples group, both partners were invited to participate together in an antenatal education programme. In the womenonly group, only women were invited to par118
ticipate. Control group members were not invited to participate in the programme, but could take advantage of the regular services offered by the WCH Unit (routine antenatal care, family planning services, well baby check-ups, well woman check-ups). At four months after their babies were born, 279 of the women (84 per cent) and 253 of the men (76 per cent) who participated in the study were interviewed in their homes to assess postpartum health beliefs, attitudes and behaviours. Questions focused on infant feeding, protection from unwanted pregnancy and preventive health care utilisation for mother and baby. Relatively few differences between the characteristics of those followed up and those not followed up were identified, indicating that the final sample for evaluating the programme was not biased. The programme The main components of the programme were group educational sessions, a booklet and a telephone counselling service. Couples and women were invited to attend four go-minute group sessions during the pregnancy. Topics of the sessions were: pregnancy, childbirth, infant feeding and care and postpartum women’s health and family planning (see box). Modules for the group sessions were developed by an education specialist and a nurse hired for the project, along with other members of the research team, and conducted by the educational specialist and the nurse. Although the sessions were normally held on weekday mornings, sessions were periodically arranged on Sunday afternoons for those who could not take time off work during the week. Participants attending all four sessions were presented with a certificate and a small gift. The formative research had helped the team to identify a series of common problems and commonly asked questions. Experts in appropriate fields (obstetrics and gynaecology, paediatrics, family planning and women’s health) wrote answers to 63 questions, which were edited and revised by a psychologist on the research team into a 29-page booklet, which was mailed to all participants in the couples and women-only groups, addressed respectively to the couple or the woman only. Project staff also established a telephone
Reproductive
/--
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Topics covered in antenatal
group sessions
Pregnancy 1. Signs of pregnancy 2. Women’s reproductive 3. Process of fertilisation
anatomy
4. Baby’s development in the womb 5. Importance and content of antenatal care 6. Taking care of the mother and baby during
pregnancy
7. Common symptoms and complaints during pregnancy (nausea, constipation, etc) 8 Situations in which you need to go to the doctor or hospital
immediately
Birth 1. Planning for the birth (place, list of items to take to the hospital) 2. Signs that the birth is starting 3. Stages of labour and delivery 4. 5. 6. 7.
Breathing and pushing techniques Episiotomy Risks to the mother and/or baby Caesarean and vacuum births
8. Care of the baby and mother birth 9. Relaxation
in the hospital
after the
exercises
Infantcareand feeding 1, Baby’s needs (nutrition, love, etc) 2. Breastfeeding 3. Prevention of common
sleep, hygiene,
infant
communication,
illnesses
4. How to handle some common infant illnesses (fever, jaundice, diarrhoea, etc) 5. Infant development during the first six months 6. Basics of infant care (bathing, diapers, clothing, sleep, etc) 7. Things to be careful
of in the home
(potential
accidents)
Post-partum women’shealthand family planning 1. Post-partum traditions 2. Care of the mother after the birth 3. Changes in a woman’s to fertility 4. Reproductive anatomy 5. Methods for preventing 6. Common
rumours
about
body after a birth and the return and processes unwanted pregnancy family
planning
methods
Health
Matters,
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18, November
2001
~ counselling service, with a dedicated telephone I number, to function during clinic working hours (M-F, 08:30-16:30). The number was mailed and/or given directly to members of both intervention groups but not to members of the control group. Project educators answered the calls, and clinic doctors were available when a more expert opinion was deemed necessary. For each phone call, information was recorded about the caller, the questions asked and the advice/information given.
Findings Eighty-three per cent of women in the intervention groups who completed a home interview (n=187) reported that they and/or their husbands had participated in the antenatal programme, either attending at least one educational session, reading some or all of the booklet and/or calling the telephone counselling service. Participation of expectant fathers together with their wives in the educational sessions was lower than expected. Only 22 men from the couples group (26.2 per cent) said that they had attended one or more sessions. Seven men attended only one session, five men attended two sessions, four attended three sessions and six attended all four sessions. Furthermore, women’s attendance at one or more sessions was higher in the women-only group (53.8 per cent) than the couples’ group (40.4 per cent) (p=.O93). The men who did attend the group sessions tended to be more educated, older and more likely to have some form of health insurance than men who did not participate (all p’s from x2 < .05). Their wives were also more likely to be more educated, be working outside the home and have wider social support networks than the wives of men who did not attend (all p’s from x2 < .05). The question-and-answer booklet reached a greater number of women and men than the group sessions, with 63 per cent of men and 74 per cent of women reporting that they had received the booklet. Of those who reported receiving the booklet, 84 per cent of men (n=105) and 94 per cent of women (n=140) reported having read some or all of it. The men in the couples’ group were significantly more likely to report having read the booklet than the husbands of women in the women-only 119
Turan, Nalbant, Bulut
Sahip
group (61.9 per cent versus 42.9 per cent, (x2=5.37, p=.020)). Men who said they had read the booklet were not different in their background characteristics from men who said they had not read the booklet. Thirty-two per cent of participants (59) from both intervention groups reported that they had used the telephone counselling service at least once. No difference was found between telephone counselling service use by members of the couples’ group and the women-only group. Only one new father (from the couples group) called the service. The most common questions asked over the phone were to do with infant care and health (50 per cent), infant feeding (2 1 per cent), women’s health after the birth and family planning (14 per cent), accessing health services (7 per cent), childbirth (5 per cent), and pregnancy (4 per cent). Men’s knowledge and behaviour Men’s knowledge regarding breastfeeding, preventive health care and family planning were measured in the follow-up interviews. The only subject on which there were some differences in men’s knowledge was family planning. Men in the couples’ group tended to have more correct knowledge about post-partum family planning, particularly the use of hormonal contraceptives, compared to men in the other two research groups. Fathers were asked their most important sources of information on infant feeding, infant health, maternal health and family planning after the birth. Family members dominated as sources of infant feeding information (mentioned by 99.6 per cent of fathers), though they were not as frequently mentioned as sources of other types of information. The subject on which the highest percentage of fathers said they had no source of information was maternal health (13.8 per cent). Friends were important sources of family planning information for fathers (58.6 per cent), as were media channels (68.5 per cent). Although all study participants were users of the services of the antenatal clinic in the WCH Unit, fathers in the couples’ group were more likely to cite the WCH Unit as a source of health information than were husbands of women in the women-only group or the control group. Though increased dominance by men in 120
decision-making where women have traditionally made the decisions was a risk we were concerned about, when,new mothers and fathers were asked who made household decisions on infant feeding, infant health, post-partum women’s health, and family planning, no differences were found in decision-making among members of the three study groups. Post-partum health behaviours Of the four post-par-turn health behaviours examined, only the use of contraceptives offered through the medical system (IUD, pills, steriliTation and condoms) was significantly higher in the intervention groups (62 per cent in the couple group and 57 per cent in the womenonly group) as compared to the control group (47 per cent). Exclusive breastfeeding, infant check-up and woman’s post-partum check-up were only slightly more common in the intervention groups as compared to the control group. Logistic regression analysis was used to control for background characteristics and potential confounding variables when examining the relationship between study group and FP method use. This analysis revealed that use of modern methods in the couples’ group was significantly higher than modern method use in both the control group and the women-only group. Participants in the couples group were 1.49 times as likely as control group members to use a modern FP method. The odds ratio for the women-only group versus the control group did not differ significantly from 1.0 (OR=.97, p=.865). The woman’s source of post-partum health care and her past experience with family planning methods retained significance in the final model. Implications for future programmes Given that 99 per cent of the women participating in the baseline survey said that they wanted to use a family planning method to postpone their next pregnancy, increased use of modern family planning methods at four months after a birth appears to be a positive impact of the programme. The relatively low participation of men in the group sessions offered in this programme indicated that different strategies would have to be used to reach most expectant fathers. In
Reproductive Health Matters, Vol. 9, No. 78, November 2001
particular, it appeared that men of lower socioeconomic status would need special encouragement and recruitment efforts to participate in such programmes. We also learned that in a programme for couples, men’s participation should not be made mandatory as it may be a barrier to participation for some wives. Given the greater use of the project booklet as compared to the other programme components, we also felt that written educational materials should be used for antenatal education. These would need to address the concerns of expectant fathers as well as expectant mothers.
Community-based expectant fathers
programme
for
Taking into account the lessons learned in the clinic-based programme, which continues as an on-going programme attended mostly by women, the research team developed a followup project to test similar programmes for expectant mothers and expectant fathers in a community-based setting. This focused on the effects of antenatal education not only on postpartum health behaviours but also on health knowledge, attitudes and behaviours during pregnancy and childbirth. The programmes were offered free at a community centre run by a non-governmental organisation in a lower middle-class neighbourhood in the Fatih District of Istanbul. Members of the local community were active in the planning and operation of the programmes, which is described elsewhere.23 Participants were first-time, expectant parents who had heard about the programme from leaflets distributed in the community and/or from members of the community team. From November 1998 to July 2000, the programme for expectant mothers was offered 13 times with 142 women participating, while the programme for expectant fathers was offered seven times with 43 expectant fathers participating. The vast majority of expectant fathers who participated were the husbands of expectant mothers in the programme at the site. Thirty-seven of the men (86 per cent) who began the programme completed the six sessions and received a certificate. Group sizes ranged from 3 to 13 men. The mean age of participants was 32. All had at
least a high school education and the majority had some university education. The men tended to be working in professions such as teaching, engineering and accounting. Although the majority of their wives were not currently working outside the home, they also tended to have high school or university education. Around half the men were born in Istanbul. They were by no means in the highest socioeconomic group in Istanbul, but were well above the average in that district. The programme for expectant fathers was evaluated using pre- and post-tests and feedback from expectant fathers and their wives. Questionnaires with 20 mostly open-ended questions were filled out by participants on their own on the first and last days of the programme. Questions covered knowledge and attitudes regarding health during pregnancy, birth and post-partum, communication and the father’s role. Expectant fathers were also asked to write down their thoughts and feelings about the course on the post-test form.
The programme As a first step, an educational programme for expectant mothers was initiated at the community centre in December 1997. Six months later, a programme for expectant fathers was developed in partnership with the Father Support Programme of the Mother-Child Education Foundation (MOCEF), which has been helping Turkish fathers of children aged 3-9 to develop parenting skills since 1996. Based on the experience of MOCEF, it was decided to offer a separate programme for expectant fathers only, taught exclusively by male educators, in addition to the existing programme for women. It was felt that both women and men would be more comfortable and be able to ask more personal questions in same-sex groups. The clinic-based programme was expanded to include topics such as communication techniques and adjustment to motherhoodlfatherhood. Special topics for expectant fathers included the psychological state of the expectant father, ways to support good nutrition during pregnancy, support of women during labour and delivery, support for breastfeeding and adjustment to fatherhood. The six-session programme for expectant fathers was held once a week on weekends or evenings. Each session 121
Bulut, Sahip
Turan, Nalbant,
Figure 1. Changes in expectant fathers’ knowledge and attitudes, proportion of men answering correctly pre- and post-test (n=33) Effective contraceptive
method
Support giving Many fathers emphasised that the programme helped them to improve their communication skills and to have a closer and more sharing relationship with their wives. Women whose husbands participated in the programme also reported that their husbands had become more communicative and supportive.
Need for infant ,-he&-up
within
7 days
Importance
of father’s
suppofl
breastfeeding
for
“Baby friendly” birth hospital Bleeding as warning sign during pregnancy Need for protein in
pregnancy
diet
0
Pre-test
H
20%
40%
Post-test
@$I
60%
80%
lasted approximately three hours. The groups were led by two trained male physicians. Group leaders presented information and used participatory techniques such as large and small group discussions, demonstrations, role play, games and question-and-answer sessions. Booklets and brochures were also provided on topics such as pregnancy nutrition, preparing for childbirth, post-par-turn women’s health, infant care, breastfeeding and contraceptive methods. Videos on preparing for parenthood, infant care and breastfeeding were also shown and discussed. Findings Selected findings from the pre- and post-tests are presented in Figure 1. All differences between pre- and post-test scores were statistically significant according to McNemar’s Test (for paired categorical responses).24 Although the sample size is small, there were significant gains in men’s knowledge and a shift in attitudes. Participants improved their knowledge on topics related to pregnancy. birth. infant health, infant feeding and post-partum contraception. It should be kept in mind that many of these men’s wives had participated in the community-based programme for expec122
tant mothers and had probably shared the information they gained with their husbands. Thus, pre-test knowledge levels are likely to have been higher than among men whose wives had not attended such a programme.
‘During this six-week course I got more information than I expected to get. I participated because 1 wanted to learn more about my wife’s physical and psychological condition, our child’s development and how I can support them. After participating in the course 1 understand my wife’s situation better and we communicate better. I shared the things I learned with people in my environment.’ ‘I came to this course because I wanted to learn what I need to do as a father. I wanted to learn this in a scientiJc manner. But as the course continued I realised that the real goal was to kelp us understand our wives and become aware of their feelings and mental state. I see that if we ty to understand our wives and share their “mother’s world” we can successfully carry out our responsibilities as fathers. ’ ‘Due to this programme I have closer relationskips with people in my environment, I got closer to my wife, and I learned a lot about how to understand my wife and baby. This is a programme that all men should de$niiely attend.’
Discussion Our research indicates that antenatal education programmes for expectant fathers as well as expectant mothers can have positive effects on their reproductive health knowledge, attitudes and behaviours. Because of the low attendance of men at the group sessions of the clinic-based programme, it is difficult to assess the effects, which seemed to be limited to post-partum contraception. However, this
Reproductive
low level of participation by fathers is a reality in this setting and other programmes in Turkey using a similar strategy will most likely face the same problems. There were a number of institutional and social barriers specific to men’s participation, e.g. the ‘female’ atmosphere of the antenatal clinic, past exclusion from antenatal visits and difficulties in getting time off work. Perhaps more importantly, men do not generally see pregnancy, birth and infant care as being in their sphere of responsibility. Women wanted them to attend but most did not have the negotiating power to get them to do so. In the community-based programme, positive effects were also seen in the areas of infant health and feeding, spousal communication and support. Sustained behaviour change and effects on maternal and child health status could not be measured, but no negative effects of including men, such as increased male domination in decision-making, were detected. However, men invited to participate in the clinic-based programme were randomised into the couples group by the research team, whereas men in the community-based programme were selfselected. It should also be kept in mind that decision-making processes and the perspectives of the various participants are probably too complex to capture in a structured questionnaire. Although further research is necessary, it seems likely that the more intensive, continuous and ‘support group’ nature of the community-based programme for expectant fathers, compared to the clinic-based programme, may be a more successful method for involving men. In our programmes, men’s attendance was better when sessions were held on evenings or weekends. In addition, men were more comfortable attending the programme in a neutral place than in an antenatal clinic. Special efforts, such as telephone calls and encouragement from wives, were often needed to get men to attend the first session, but when the first session met or surpassed the men’s expectations, they were likely to continue. Thus, the quality of the first session is very important. Specific topics were designed by and for expectant fathers, instead of including men in a programme meant for women. Sessions specifically addressed men’s experiences, feelings
Health Matters, Vol. 9, No. 18, November 2001
and need for guidance, as well as women’s. Programmes for both men and women included social and psychological concerns, along with basic information on reproductive health during the pregnancy, birth and newborn periods. The question of whether to have a couples ’ programme or separate programmes for women and men should be investigated in each programme setting. Focus groups or other qualita! tive research methods could be used to explore I who would be attending and their level of , comfort with members of the opposite sex on programme topics. Men and women might be together for some topics and separate for others. However, in patriarchal cultures such as Turkey, the disadvantages of programmes for ~ couples together should be kept in mind. ) Women are the most important target group for ~ antenatal education and a programme aimed at ~ couples may discourage the participation of women whose husbands will not or cannot attend. A programme in which some women’s husbands attend and others don’t may create feelings of inferiority and resentment in women who attend alone. We recommend that free antenatal education should be made available to all expectant mothers and when possible, men should be included, either together with their wives or in separate groups. The antenatal education programmes developed during the course of our research continue to be offered at the community centre and the hospital clinic. In order to aid the development of other such programmes in Turkey, the research team has developed a comprehensive guide to antenatal education, including detailed educational modules for both the women’s and the men’s programmes.25 This guide has been distributed to the Ministry of Health, the Istanbul Health Directorate, the Social Security Administration, maternity hospitals, nursing schools, medical schools, health centres and non-governmental organisations working in reproductive health. ~ To reinforce the use of the guide, training of ~ trainers courses for antenatal education are ~ also being organised and a study is planned to ~ look at the longer-term effects of educating expectant fathers.
123
Turan, Nalbant, Bulut, Sahip
Acknowledgements Thejrst two studies presented in this paper were conducted as a part of theBrst author’s doctoral dissertation. The studies were supported financially by AVSC, MEAwards Program, Population Council Ebert Program, Mellon Foundation, International Women of Istanbul Association and European Commission. We would like to thank all members of the research teams based at the Istanbul Medical School, Woman and Child Health Training and Research Unit for their contributions; Dr WH Mosley, Johns Hopkins University School of Hygiene and Public Health for help evaluating the clinicbased programme; Dr Joel Gittelsohn, Johns Hopkins University and Dr Niikhet Sir-man, B$azi@ University, for serving as advisers for the formative research; Dr Ali Kemal Cetin and other staff of the Father Support Proqramme, Mother ChildEducation Foundation, Istanbul for
their important contributions to the development and implementation of the education programme for expectant fathers; Biilent Turan and Dr Nuriye Ortayli for helpful comments on this paper; and all the expectant and new parents who participated in the studies. Some of the information presented here will also appear in Turan JM, Nalbant H, Bulut A et al. Promoting post-partum health in Istanbul: does including fathers make a difference? From Principles to Practice: Case Studies of Post-Cairo Change. New York, Population Council (in press). Correspondence Dr Janet Molzan Turan, Istanbul Ttp Fakiiltesi, Kadzn ve Cocuk Saglujt Egitim ve Arapttrma Birimi, Cerrahi Monoblok kargzst, Capa 34390, Istanbul, Turkey. Fax: 90-2 12-63 I- 17 10. E-mail: [email protected]
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2 1. Kuyas N, 1982. Female labor power relations in the urban Turkish Family. In: Se.r Roles, Family, and Community in Turkey. Bloomington: Indiana University Turkish Studies. 22. Angm Z, Shorter F, 1998. Negotiating reproduction and gender during the fertility decline in Turkey. Social Science and Medicine. 47(5): 555-64. 23. Turan JM, Say L, GtingSr AK et al. Community participation for perinatal health in Istanbul.
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R&urn6 ~ Resumen etudes ont analyse des methodes pour / Tres investigaciones analizaron 10s metodos associer les hommes a l’education prenatale. i para incluir a 10s hombres en la education Les participants, issus de quartiers a revenus prenatal en Estambul, Turquia. Los particifaibles et moyens d’Istanbu1, Turquie, attenpantes eran parejas que Vivian en areas de daient leur premier enfant. Apres une etude bajos y medianos ingresos, quienes esperaban initiale des roles en matiere de Sante des memsu primer bebe. Despues de un estudio bres de la famille pendant la p&ode entourant ~ formativo acerca de 10s roles de 10s distintos une premiere naissance, un programme d’eduintegrantes de la familia en relation a la salud cation a donne des soins prenatals en dispendurante el period0 previo y posterior a un saire aux femmes et aux couples, dans le cadre primer nacimiento, se implement6 un estudio d’une etude aleatoire et contrblee. En fonction aleatorio controlado en la forma de un prodes resultats, des programmes communautaires grama educative para mujeres y para parejas en d’education prenatale, separes pour les futurs una clinica prenatal. En base a 10s resultados, Peres et les futures meres, ont ete testes. Beause probaron programas educativos prenatales coup de femmes enceintes et quelques maris comunitarios para mujeres embarazadas y sus souhaitaient associer les futurs Peres a l’educaparejas. Hubo una demanda entre muchas de tion prenatale. A court terme, ces programmes las mujeres embarazadas y algunos de sus semblaient avoir des effets positifs sur les conesposos para incluir a 10s futuros padres en la naissances, les attitudes et les comportements education prenatal. A corto plazo, estos prodes hommes et des femmes en matiere de Sante gramas parecian tener efectos positivos en las genesique. Dans le programme mene au disattitudes, comportamientos y conocimientos de pensaire, l’inclusion des hommes avait des la salud reproductiva de las mujeres y 10s avantages touchant a la planification familiale hombres. En el programa de la clinica, 10s post-partum, alors que les effets positifs du efectos positivos de incluir a 10s hombres se programme communautaire concernaient la ~ notaban principalmente en el ambito de la Sante infantile, l’alimentation des nourrissons, I planificacion familiar postparto, mientras que la communication et le soutien entre Ppoux. ~ en el programa comunitario, se notaban Une education prenatale gratuite devrait @tre ademas 10s efectos positivos en 10s ambitos de proposee a toutes les futures meres et, lorsque la salud y la alimentacion infantil, el apoyo de c’est possible, les hommes devraient y etre 10s hombres a sus esposas y la comunicacion associb, soit avec leurs epouses soit, dans une I con ellas. Se recomienda ofrecer education culture comme celle de la Turquie, dans des prenatal gratuita a todas las mujeres embaragroupes &pares. zadas y cuando sea posible a 10s hombres, en ~ conjunto con sus esposas 0, en una cultura coma la de Turquia, en grupos separados.
Trois