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UGANDA: Unfriendly Nurses and Culture Hinder Male Involvement in HIV Prevention

MBALE, Uganda, Aug 26 2010 (IPS) - Irene Wangolo was advised to undergo an HIV test during her antenatal visit and to return to the clinic with her husband so they could be counselled on preventing HIV transmission to their unborn baby. But her husband refused to accompany her saying it was not his business and Wangolo never returned to the clinic in Bungokho in eastern Uganda. So she missed all the services, including the prevention of mother-to-child transmission (PMTCT).

Salim Kato escorts his wife to all her antenatal visits. Credit: Wambi Michael/IPS

Salim Kato escorts his wife to all her antenatal visits. Credit: Wambi Michael/IPS

But Wangolo’s experience is similar to what many other pregnant women in Uganda face when it comes to accessing PMTCT services. Robina Kaitirimba from the NGO National Coordinator of Uganda National Health Users/Consumers Organisation told IPS that failure to reach sexual partners of HIV-positive women still remains the biggest barrier to PMTCT in Uganda. Male participation in PMTCT in Uganda stands at just five percent according to Kaitirimba.

Dr. Robert Byamugisha, lead author of the study “Determinants of male involvement in the prevention of mother-to-child transmission of HIV programme in Eastern Uganda”, said reasons for men not attending antenatal clinics with their spouses included cultural beliefs and economic reasons.

Accepted for publication in the Reproductive Health journal in June, the study also found that men felt the set up of antenatal clinics were not male user-friendly. Men had also been reluctant to attend because they found the midwives impolite. “Nurses and midwives should become friendlier to the mothers in antenatal clinics than they are at the moment,” one man had suggested.

Titus Namanda only ever accompanied his wife once to an antenatal clinic during her first pregnancy. He vowed never to go back because of the way midwives treated his wife and other pregnant women. “I love my wife and I always ride her to the clinic up to now. They made me wait for three hours and I witnessed them abusing my wife and other women. I decided not go back,” said Namanda, who lives in Bunghokho village in Mbale district, eastern Uganda.

The Study Findings:

The study was conducted in Mbale, eastern Uganda from July to August 2004, and had 387 male respondents.

Only four percent of men attended antenatal clinics with their partners, but the majority, 97 percent, provided financial support to their spouses to attend the clinics.

Men who had had eight or more years of education were twice as likely to become involved in the PMTCT programme than those less educated. Those who knew their HIV status were four times more likely to get involved in the PMTCT programme.

The study found that those men who had heard about the PMTCT programme were twice as likely to get involved. Those who feared to disclose their HIV status to their spouses were less likely to get involved.

"I believe it is not good to follow your wife to the antenatal clinic. Even though she exposed her privacy to you at home but when you reach the antenatal clinic it is different. So it is better she goes alone," one of the men interviewed during the study said, expressing his cultural belief.

One of the recommendations of the study was the need for the sensitisation of men about the benefits of antenatal care and PMTCT services. It also suggested the need to prioritise client-friendliness at the clinics in order to improve low male participation.

Men also said they should be invited by staff to attend antenatal clinics using the medical cards of their wives.

The men also suggested that provision of better remuneration to the health workers and building more health units by the government closer to the local people where antenatal care could be offered.

Byamugisha acknowledged that midwives were rough with pregnant mothers. “In some instances they did not allow men to enter with their pregnant wives to the clinics,” Byamugisha said.

Uganda was one of the pioneers of PMTCT programmes in Africa in 2000. Services are now available at most county-levels in over 80 districts. But statistics from the country’s health ministry indicate that while almost all women who attended clinics agreed to HIV testing and counselling, only two-thirds returned for their results. Of those who tested HIV-positive, only 17 percent returned to hospitals to deliver.

Uganda currently has over 110,000 children living with HIV/AIDS and continues to register about 25,000 new infections annually. Most children are infected at birth according to Dr. Zainab Akol, the health ministry’s head of HIV/AIDS programmes. “That is why we want the mothers to test with their partners. Sometimes they get infected later on during the pregnancy. During counselling and testing, we are able to inform both parents on responsible behaviour in order to save their unborn (child),” she said.

“In our cultures, when a woman is pregnant, men tend to go out (cheat) not knowing they risk not only themselves, but also the lives of their wives and the unborn child,” explained Akol.

But financial constraints were also a reason for men not being involved in PMTCT services. While the study found that 97 percent of men interviewed provided financial support so their spouses could attend antenatal clinics, many said they lacked either time or money to become involved in PMTCT programmes themselves.

Mutwalibu Wambete a husband and father of two told IPS that he would rather spend his time earning an income for his family then attending an antenatal clinic. “I hire this motorcycle from a rich man to carry passengers and earn money. The owner requires me to pay five dollars a day. So if I spend time at the clinic then we shall go hungry and the children will not go to school,” he explained.

Dr. Wilfred Ochan, head of Strategic Planning and Management at the Baylor College of Medicine Children’s Foundation agreed that men play a major role in reproductive health decisions in Uganda. He explained that men have the power to determine which clinic their wives will go to but added that many PMTCT services were focused mostly at women. “Traditionally, sexual and reproductive health services that include PMTCT have focused mostly on women, yet many observers have emphasised that the knowledge, attitudes, behaviours and health of men often play a critical role in determining the reproductive health of women.”

Ochan told IPS that the number of children being infected by their mother would have been lower if all pregnant women who tested positive returned to deliver in hospitals. Dr Phillipa Musoke, the chairperson of the Department of Paediatrics and Child Health, at Uganda’s Makerere University told IPS that cultural beliefs, social stigma and poor health services have been some of the factors why women preferred delivering at home despite this being a risk to the life of their unborn child.

But not all men have turned down the call to escort their wives to antenatal clinics. At Tororo Regional Hospital in eastern Uganda, Salim Kato sat besides his wife amidst 40 other pregnant women. Kato told IPS that he believed he had a responsibility to ensure that his wife gives birth to a healthy baby.

“The good thing with midwives here is that they handle my wife first whenever I come with her. So I save my wife from sitting for too long when I come along with her,” said Kato.

Kato and his wife initially tested negative for HIV but have returned for a confirmation test as recommended by the country’s PMTCT guidelines.

A senior nurse at the hospital who asked for anonymity because she was not authorised to speak to journalists told IPS that most of the men attend the clinic with their wives want to be attended to in privacy “So on top giving them priority when they come with their wives, we have improvised a room where we talk to the couple in privacy. And it seems to be working” she said.

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