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A few years ago, I helped a mother deliver her third baby at a government clinic in Dar es Salaam, Tanzania. Her admission card noted that she was HIV positive – something she had discovered during her first pregnancy eight years ago. Her husband was unaware of her status and, even though clinic staff encouraged her to bring him to her checkups, she had never had the courage to do so. She had been frightened by stories of other HIV-positive women being chased from their homes due to the fears and misinformation that surround HIV infection. So here she was, trying her best to prevent transmission of HIV to her child, while keeping her status secret from her husband, relatives and friends.
The burden of her secret weighed heavily on her. She recalled how hard it was to take her daily anti-retroviral drugs (ARVs) to stay well. She understood the importance of good adherence, yet confessed to occasionally missing her dose – not because she forgot, but because her husband was present and she could not take them publicly.
The evidence shows that with the right ARV treatments, we can reduce the risk of transmission from mothers to children to below five percent. And yet, Tanzania’s current HIV transmission rate is 25.7 percent. This is not because of poor services or treatment. Tanzania has made significant progress by integrating preventative HIV transmission treatments within the reproductive, maternal, newborn and child health services. Currently, 93 percent of such clinics have integrated services.
The missing piece of this intervention is fathers. What my patient went through – shame imposed by societal norms – is one of many barriers that hinder complete delivery of comprehensive services needed to speed up the reduction of HIV transmission.
Over the years in many sub-Saharan African countries, antenatal care and preventative transmission treatments have been perceived as a woman’s business – meaning the number of men going with their wives to the clinics has been very low. Research suggests men see the antenatal clinics as a place for women. Men feel that the clinics are not male friendly and if they do go, they feel they waste a lot of their time due to long clinic waiting times.
Men are also more reluctant to test for HIV, which in Tanzania leads to a low rate of HIV couple counselling and testing. On the other hand, women have continued to fear the negative reactions from their male partners if they are known to be HIV-positive. The resultant behaviours, such as physical abuse, stigmatisation and even divorce, further hinder HIV-positive pregnant women from disclosing their status and actively involving their spouses in their care.
What can be done to encourage more men’s involvement in antenatal care? As a start, infrastructural changes like clinic expansion to accommodate more space would allow for couples to be involved. This can be as simple as creating seating to allow women and their husbands to sit together while they wait for their appointment.
Furthermore, health education information provided at clinics should feature men as an integral part of a woman’s antenatal and postnatal care and men should be encouraged to enroll in midwifery colleges to encourage husbands’ active involvement in their wives’ care. Having male healthcare workers in reproductive and maternal health service outlets and using the example of couples who have been tested together to encourage other men to actively support their spouses in antenatal care would address the issue.
Overall, there is a need for African countries to make adjustments in their health systems to accommodate men and update their country's policies to cater to specific needs that will reduce the barriers to men’s participation in treatment programmes.
Tackling societal and health system barriers is a critical step, but without men directly involved, the well-being of their mothers, wives, sisters and daughters will continue to be compromised. We need fathers to help reduce mother-to-child transmission.
Mary Mwanyika-Sando (MD, MPH) is maternal and child health coordinator at Management and Development for Health (MDH) in Dar es Salaam, Tanzania and a 2013 New Voices Fellow with the Aspen Institute