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Suami SIAGA: male engagement in maternal health in Indonesia

A. Kurniati, C. M. Chen, F. Efendi, L. J. Elizabeth Ku, and S. M. Berliana, “Suami SIAGA: male engagement in maternal health in Indonesia,” Heal. Policy Plan, 2017.

Abstract
Suami SIAGA, which translates literally as the ‘alert husband’, is a national campaign that was created in early 2000 to promote male participation in maternal and child health program in Indonesia. The purpose of this study was to identify the proportion of men who took part in Suami SIAGA and the factors associated with their participation using the 2012 Indonesia Demographic and Health Survey (IDHS). This study also examined the relationship between Suami SIAGA and the following results related to the national campaign: the presence of husbands at antenatal care (ANC) units and the place of delivery at health facilities. Data on the characteristics of husbands and wives, as well as other related factors, the perceived elements of Suami SIAGA, and the national campaign outcomes were obtained from a total of 1256 eligible male subjects, drawn from the matched couples’ data set. The data was analyzed using bivariate and multiple logistic regression to test the associations. This study found that 86% of the respondents were categorized as SIAGA husbands. After controlling all the variables, age and education of wife factors were significantly associated with Suami SIAGA, especially in the group of women aged 41–49 years old (OR¼2.4, 95% CI: 1.1–5.5) and women with a secondary level of education (OR¼1.8, 95% CI: 1.2–2.7) and higher (OR¼2.8, 95% CI: 1.4–5.6). SIAGA husbands were more likely to attend their wives’ ANC (OR¼2.3; 95% CI: 1.4–3.7). This study provides evidence for the benefit of husband involvement in maternal health, especially to improve ANC attendance. Empowering women themselves should also be addressed in leveraging the impact of Suami SIAGA.

Discussion:

The findings of this study show that most of the men in the study population (86%) acquired at least one of the Suami SIAGA attributes, as they had carried out discussions with someone in relation to birth preparedness. Husband’s knowledge about Suami SIAGA significantly associates with planning the delivery in a health facility (Anggraini, 2012). Husbands are more open to discuss maternal health issues and proud to get involved with their wives in preparing for the birth of their children. A qualitative study in Malawi about strategies to promote husbands’ participation in maternal health program, as voiced by the local health personnel, reported husbands’ positive behaviour changes in health care, an increasing number of deliveries at hospital, and a decreasing number of maternal deaths (Kululanga et al., 2011). A study reflecting Indonesian Muslims’ perspective revealed that, although husbands’ involvement is still generally limited, they actually can accept responsibility in maternal health affairs and are aware of the importance of accompanying wives for the prenatal check-up (Ilyas et al., 2006). Wives whose husbands join their ANC are more likely to use skilled birth attendants (Mangeni et al., 2012, Chattopadhyay, 2012). In the current study, the wife’s factors (age and education) show a significant association with the possibility of their husbands becoming Suami SIAGA. The probability of women having a SIAGA husband is greater as they get older. This confirms the results of a review study by Ditekemena et al. (2012), which found that women with older age were associated with greater men involvement in maternal and child health services. According to Chakraborty et al. (2003), women’s age may represent their cumulative knowledge on health issues and thus may influence their decisions about what actions to take during pregnancy. Since older women presumably have better knowledge about maternal health issues, they also may become more cautious about the risks related to pregnancy, and so be able to convince their husbands to be more attentive. On the other hand, older husbands would show more empathy to their wife for the burden during pregnancy and want to support (Ilyas et al., 2006).Consistent with the finding from a study in Nepal (Thapa and Niehof, 2013), this present study show a strong association between education level of women and participation of husbands in maternal care. Among various socioeconomic factors, women’s education was consistently found to have a significant association with the maternal health care utilization in many previous studies (Ahmed et al., 2010; Rai et al., 2012; Moyer and Mustafa, 2013; Achia and Mageto, 2015). This is similar to our results that the increased level of women’s education increases the probability of Suami SIAGA as well as the use of institutional delivery. Formal education plays a vital role in empowering women and enhancing their autonomy, as educated women understand their rights and are more confident in making decisions and choices for their own health (Achia and Mageto, 2015). Our results show that SIAGA husbands have significant associations with husband’s attendance at ANC and the institutional delivery, although the latter become insignificant after adjusting variables in the regression model. In the same vein, Yargawa and  reported a significant association between male participation and the increased use of maternal health care, especially with regard to the delivery by skilled attendants and postpartum services. . Yet, higher potential maternal benefits may be achieved from involving men during pregnancy and postpartum than delivery (Yargawa and Leonardi-Bee, 2015). Continuous efforts are needed to increase men’s awareness about maternal health issues. In this study, place of residence is associated with delivery in health facilities. Those who live in urban areas have a greater chance of giving birth in health facilities compared to rural residents. This may be linked to inequity in the accessibility and infrastructure availability over the country. Balitbangkes-MoH and UNFPA (2012) indicated that rural areas have more difficult access to health facilities than urban areas, which contributed to the higher maternal deaths occurring at home among rural dwellers. In addition, two consecutive IDHS reports in 2012 and 2007 have shown a higher percentage of urban women giving birth in health facilities, 80% and 70%, respectively (Statistics Indonesia (Badan Pusat Statistik et al., 2013, Statistics Indonesia – Badan Pusat Statistik – BPS and Macro International, 2008). Providing easier access to birth facilities for rural inhabitants should become a priority agenda in SDGs. The results of the present study show that the wealth index variables associates with the husband’s involvement in ANC and wife’s delivery in a health facility. Increasing husband’s wealth enhance the chance of husbands getting more involved in ANC contact and choosing health facilities for the delivery. Similarly, a strong association between husband’s wealth and the use of ANC was reported by a study in India (Chattopadhyay, 2012). A study conducted by Wai et al. (2015) in Myanmar noted that husbands were the primary financial supporters of ANC despite insignificant association. Literature has shown the evidence supporting the relationship between income level and birth at a health facility: women from a high economic status family are more likely to give birth in health facilities (Chattopadhyay, 2012; Moyer and Mustafa, 2013; Yesuf et al., 2014). With current government policies encouraging male involvement and acknowledging the socio-economic factors, it is important to target the poorest and most vulnerable families under a conditional program. New ideas and approaches within national policy guidelines should be considered in fostering the involvement of male partners among poor families. Undecided about the child wish indicates a negative association with husband involvement in ANC and birth at health facilities in this study. In comparison to husbands who desire to have or not to have another child, those with the undecided option are less likely to get involved in ANC and utilise institutional delivery. Linking this finding by strengthening the family planning intervention in men’s roles within a family may have a positive impact on women’s health. This study reveals that parity has a negative association with husband’s presence at ANC and birth at health facilities. Higher parity decreases the odds of ANC accompaniment and delivery at a health facility, which is similar to the finding of other studies (Chattopadhyay, 2012; Tey and Lai, 2013; Wai et al., 2015). Women’s previous experience with uncomplicated pregnancy and their heavy responsibility to look after other children might affect the perception and the willingness to use maternity services (Joshi et al., 2014). This finding supports the evidence of the beneficial effect of male involvement in maternal and healthcare utilisation. Involving male is a potential gender-transformative that can contribute to the improvement of maternal health outcomes (ComrieThomson et al., 2015). Therefore, this study highlights a call to engage husbands under the continuum of care dimension. Due to the strong relation between women’s factors and Suami SIAGA, it is important to focus maternal health education efforts on both men and women as couples. In our study, husbands who had discussions on birth preparedness with someone, probably the closest family including wives, were more likely to make joint visits to the ANC. This finding is consistent with previous research which reported that husbands and wives who had discussions on health tended to be more open to the idea of receiving antenatal and delivery care (Furuta and Salway, 2006; Mullany et al., 2007). Improving how couples communicate in relation to maternal health issues may improve health care seeking behaviour related to pregnancy, childbirth and the postpartum period (Mullany et al., 2007). Therefore, the Suami SIAGA campaign should be repackaged and widely disseminated, aiming at couples. Further, improving methods for identifying and targeting the uneducated and youngest women to receive MNH services at village level may be beneficial in leveraging

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