BACKGROUND

Pregnancy is a period when women are vulnerable and this vulnerability create some challenges to both parents during this period. This period of pregnancy is characterised by several discomfort and disorders, hence the support of husbands is neccessary¹. Husband’s role in women’s health especially maternal health is receiving an increasing attention globally and has been connected to pregnancy outcomes². It is interesting to note that husband support has been linked to increasing pregnant women‘s antenatal clinic attendance². This support by husband reduces maternal stress and negative health outcome during pregnancy which improves feto–maternal outcome³. Husband presence may serve as pain relief during labour and emotional stability. This provides physical, emotional, psychological, spiritual and financial support ⁴.

Maternal mortality is due to death resulting from pregnancy-related conditions which is currently a global concern⁵. According to World Health Organisation (WHO) report, 86% of maternal death were from Sub-Saharan Africa and Southern Asia, while that of Sub-Saharan Africa alone accounted for two –thirds of maternal deaths⁶. It was also noted that in Sub-Saharan Africa, the possibility of women’s death due to pregnancy and childbirth complication is 1 in 39, while in industrialised countries, it is 1 in 4,700. Malawi is not an exemption in contributing to this maternal death as the rate per 100,000 live birth is at 574⁷. This showed how important it is for pregnant women to have adequate support during pregnancy to reduce maternal mortality. Some social norms in the society  where husbands have power over their wives cause  negative impact on  the pregnant  women. Such power relationship could lead to intimate partner violence ^8,9.

 A study conducted in Ilorin on Spousal participation during pregnancy and delivery in Ilorin, revealed that men accompanied their partners to antenatal clinic, ultrasound scan and other investigations ^9.  Another study conducted on Spousal support during  pregnancy in  South- western Nigeria revealed  that spiritual support, such as  praying  and fasting  was top of the kinds of support pregnant women received and others including helping in the house chores, financial provision, taking care of children, accompanying to labour and sexual support¹⁰ .  Similar studies conducted in Pakistan and Northern Nigeria on Pregnant women perceptions regarding  their  in-laws’ support during pregnancy  and husband support during pregnancy, delivery and postpartum period revealed that there was lack of comprehensive support mechanism by their husbands during pregnancy  and that they provide essential items such as transportation to health  facility and nutritious food^11,12.

  Another study conducted in Gambia on social and cultural factors affecting maternal health. Showed that the division of domestic labour between men and women in a house setting was that women often involved in field work and household chores, with little financial support during pregnancy and were not even relieved by their husband or others from the polygamous family ^8.

A study conducted on The Prevalence of Domestic Violence among Pregnant Women in Nigeria revealed that the occurrence of domestic violence ranged from 2.3% and 44.6%. Physical, psychological, sexual and verbal were the most frequently types of domestic abuses reported and the most perpetrators being the husbands while the pregnant women with age range from 20 to 30 years were the victims ¹³.  In addition, a cross-sectional study conducted at Syangia district of Nepal on Prevalence of Gender Based Violence among Pregnant Women Attending Antenatal Care Clinic revealed that the prevalence rate of gender based violence was 91.1% (184).  Eighty seven (87%) faced economic violence followed by psychological abuse (53.8%), then sexual violence (41.8%) and Physical violence (4.3%). Most perpetrators were the husbands and other perpetrators were mothers-in-law ^14.

Similar study conducted in Ethiopia revealed that the most prevalent form of IPV was emotional abuse followed by physical and sexual violence ¹⁵. Similarly, a study in Namibia revealed that emotional abuse is the commonest experience by women attending antenatal clinic in Namibia ^{16 .} The empirical review above revealed some of the element of spousal support and domestic abuse affecting the health of pregnant women. Despite the fact that empirical studies abound providing information on the determinants of pregnant women health, much is still desired spousal support and domestic abuse on the core determinant of maternal health during pregnancy, hence this study is aimed at exploring spousal support and domestic abuse as determinants of maternal health of pregnant women attending antenatal clinic at Thyolo District Hospital, Malawi.

METHODS

Research Design

The researcher adopted a qualitative descriptive cross sectional design. This design was adopted because the aimed at identifying the subjective nature of the problem, and the different experiences participants have with their spouses during pregnancy and as it affects their health. ⁹

Study Setting

The study was carried out at Thyolo District Hospital, situated in the southern region of Malawi in Thyolo District. This setting was chosen because the hospital functions as a secondary referral center and apart from other departments like Admission & Emergency (A& E), Obstetric and Gynecological (O & G) and many more.  Also the researcher had observed some pregnant women attending antenatal care in Thyolo District Hospital voicing out their concerns about their spousal behaviors towards them.  Furthermore, Women were attending antenatal care at Thyolo District Hospital which is a referral center from all health centers around Thyolo District, hence the choice of this setting.       

Study Population

The study population consisted of pregnant women who were registered for antenatal clinic. A total 1,061 pregnant women were registered for the past four months from January to April 2021 with an average of 265 pregnant women per month. The choice of pregnant women were considered because the researcher had observed some pregnant women attending antenatal care in Thyolo District Hospital voicing out their concerns about their spousal behaviors towards them.

Table 1. TDH ANC Register

                   Source: TDH ANC Register 2020/2021

Sampling

Principle of saturation was adopted in determining sample size of the participants ^17.  Data saturation is the point in a research process where enough data has been collected to draw necessary conclusions, and any further data collection will not produce value-added insights. Saturation is the most common guiding principle for assessing the adequacy of purposive samples in qualitative research  ¹⁸

Participants were interviewed and data was found saturated on 10^th participant. The sample size was ten (10).

Sampling Technique            

Purposive sampling method was used to select the participants for the study.

 Inclusion Criteria

• Registered for antenatal clinic within the last four months (Jan to April, 2021)
• Aged 18-45years
• Pregnant, and must be living with their spouses

Instrument for data collection

A semi structured in-depth interview guide developed by the researchers was used for  data collection. This guide consist of two section; section A; consist of social demographic data while section B consist of probing questions to elicit participant’s responses on spousal support and domestic

abuse in relation to health of pregnant women

Some of the probing questions include

(i)         What does your husband do for a living? 

(ii)        How do men /husband perceive pregnant women in your society?

(iii)       Can you explain how hard/tough household activities you perform during pregnancy?

(iv)       What activities do your husband/ partner involve himself in your health care (i.e . accompanying you  to the hospital for health services during antenatal and labour)?

(v)        Can you tell us about your experience about domestic violence during pregnancy?

 Validity of instrument

Validity of the instrument was ensured using face and content validity by experts in the field of obstetrics and clinical psychology. Their comments were put into consideration when developing the final instrument 

Trustworthiness of Instrument for Data Collection

Trustworthiness of the study instrument was done using the four criteria as described by Lincoln and Guba ¹⁸ which include credibility, dependability, transferability and conformability. Credibility which refers to the confidence that can be placed in the truth of the research findings was ensured through prolonged engagement with data on the research site by spending time with the participants before commencing the interview and persistent observation of negative cues from the participants. Dependability which is the ability of the findings of this study to be consistent when repeated in the same cohort was ensured through audit trialing which involve keeping a track record of the data collection and kept safe for future use. Transferability which is the extent to which the findings of the study can be transferred to other setting group was ensured by giving a thick description, which involves providing adequate details on the site, participants and methods or procedures used to collect data during the study. Confirmability which refers to the objectivity or neutrality of the data obtained was ensured by thorough data checked and rechecked throughout data collection and analysis to ensure results would likely be repeatable by others. This can be documented by a clear coding schema that identifies the codes and patterns identified in analyses.  The above explanation showed trustworthiness of the semi-structured in-depth interview guide that was used ¹⁸

Ethical Consideration

Ethical approval with protocol number Tm/1/11/20 was obtained from the Ethical Committee of National Health Sciences in Malawi, after the committee  screened the proposal submitted to them and  approved of it. In addition, permission was also obtained from the District Health Officer, the District Nursing Officer, nurse in charge of the Maternal and Child Health (MCH) Unit of Thyolo District Hospital and participants. 

 Data Collection

Participants data were collected during their routine antenatal care. They were allowed to complete the normal activities for the clinic before the interviews. A room which was free from eavesdrops and distraction was prepared in an office within the health facility. The client was made comfortable and privacy and confidentiality of the information was assured. Permission was sought for the use of audio recorder and it was granted by all the participants. In order to familiarize with the participants, a general question such as a wellbeing of the family was asked. Information on bio data was collected. The local language preferred by all participants was used.

The participants were asked open-ended questions using the probing questions in the in-depth interview guide. Clues such as really, nodding of the head, eye contact were used to elicit more information required from the participants. Participants were allowed to ask questions after each interview and adequate information was given.  Field notes were taken during the interview and all participants were appreciated after each interview and the interview were also recorded.  Data was found saturated on tenth participant.

Method of Data Analysis

The audio recorded data were transcribed, translating in English and transformed into raw data.  The qualitative data were  analysed using the thematic approach as outlined by Creswell ¹⁹. The raw data were  thoroughly inspected by reading repeatedly in order to identify the words that were appearing more frequently in the data set which were similar in nature and common. A list of all topics and similar topics were clustered together and were arranged in major and unique topics. The list was compared with the original data. Abbreviations of topics as codes were made and codes were written next to the appropriate segment of the text. Themes and sub-themes were developed. The thematic analysis was finally done by the Data Analyst using Atlas ti version 9.1. ATLAS ti is a software used for qualitative research and specifically is used for the analysis of unstructured text, audio, video, and image data, including (but not limited to) interviews, focus groups, surveys, social media ^19..

RESULTS

Table 2: Socio-Demographic Data

The ages of the women interviewed ranged from 19 to 38 and is within reproductive age group meeting the inclusion criteria. The number of pregnancies ranged from 1 to 5. All women reported to belong to Christianity religion. Most of them were married and length in marriage ranged from 1 to 20 years.

Themes Development

Coding of themes are created by the transcribed participant narratives²⁰. In this analysis, codes were developed and shifted to themes. These themes were described and supported by participant quotations and this made a clear presentation of data. There were two main themes that were developed from the participant’s responses to Spousal support which are;” Husband Support” and “Domestic abuse”

Theme 1: Husband Support

Subtheme 1: husband support on transportation to the hospital

Participants who were interviewed reported that their husbands assisted them by hiring vehicles, accompanying them and giving cash directly. However, a few respondents reported to have no support from the husband. These responses were captured below

“Whenever am sick, or if labour starts, my husband takes me to the hospital by a hired motor bike”. (R1).

“When I fall sick my husband accompanies me to the hospital”. “It is a long distance. Hiring a motor bike costs k700 (350naira). If we do not have money, then we just walk”. “Perhaps we borrow a bicycle with which he takes me to the hospital” (R2)

“… Hmm… This is my first time to stay with him. This is just my first pregnancy with him. I do not really know how he is going to take me through because he is just new to me. But essentially, any sort of sickness on me is left in his hands” (R3)

“My husband hires a car to take me to the hospital” (R4)

“Whenever am sick, my husband hires a car to take me to the hospital”. (R5).

“I was told I should go to the hospital when the pregnancy is three months old but I was reluctant to do that because there is no one I can leave home for, my husband is not there because there is no longer marriage and does not support me with anything” (R6)

Sub-theme 2: Assistance in Household Chores

Most respondents reported that there was assistance in household chores by their husbands and support from other members such as a mother and children. However, a few of the interviewers reported no assistance. These responses were captured below

“… hmm…(smiles) I don’t have to lie. Currently there is nothing hard that I do at home because he does farming and almost everything for me. Perhaps the hard activity that I may say I am doing is my work at the Tea Plantation. Otherwise I am just okay”. (R3)

“… Hmmm no, never, (shakes her head) my husband could only do those activities which are done by men, my child is the one who assists me in households chores because I am pregnant”. (R6)

“when I do the following work making ridges (farming) as well as feeding tame animals, it causes pain on my back and waist, this is so because my husband is always at his work he is a min-bus driver, sometimes he does cooking” (R5)

“My husband assists me in fetching water”. (R8)

“He assists me in washing clothes”. (R7)

Subtheme 3: escorting to antenatal Care visit

Most participants reported that their husband follow them to the hospital during antenatal care visit, however, a few of the interviewers reported no assistance. These responses were capture in the below

“My husband escorts me to hospital for antenatal checkup and the health workers recommended us so much and told everyone who had not brought their husbands with them to go at the back of line”. R2

“……sometimes, yes he escorts me to antenatal clinic if he has money for transport, sometimes no if there is not enough transport money for both of us”.R7

“The time I was to come and start my medical checkups, I called my husband and this time he was in Lilongwe. He managed to send me money for transport enough for to and from the hospital “.R3

“He accompanies me to the hospital for checkups”R1

Sub-theme 4: Husband Support in General

The participants explains that their husband assisted by proving cash directly, buying wrappers, buying nutritious food however, few, reported no assistance at all. The excerpt for their responses are show below

“When he has money, he provides my needs and if he does not have money he does nothing”.

“he accompanies me to hospital for checkup” R1

“He gives me money when I explained to him what I want”. “he buys wrappers”. R7

“He does assist me by giving me money to buy wrappers and nutritious food ”.R8

“My husband supports me in many ways, he gives me money for transport to antenatal clinic he buys food for me to eat and many more”, R9

“He goes and buys wrappers”…………“when I need a specific food, he buys like squash, rice etc. R5

Theme 2: Domestic abuse

Sub-theme 1: Physical abuse

The participants interview agree that they have not experience any form of physical violence from their husband or spouse, except but one of the participant who said she had experience such but in rare occasion. Nevertheless they all spoke well of their husbands as being supportive and have not physically verbally assaulted them. These is supported by the fooling quotes below

“One day he wanted to beat me because I was confronting him for taking his clothes away, it’s  his child who rescued me, but I was asking him who would take me to the hospital if labor starts in his hospital”.R 6

 “I have never experienced any type of violence from my husband, he very kind” R8

“mmm no any type of violence so far” R9

“My husband does not abuse me in any form” R10

Sub-theme 2: Psychological issue

The participants express themselves with regards to some psychological issues they are experiencing though not caused by their husbands/spouse but is related to their husband/spouse financial incapability at times. They said they always have psychological issue like depression whenever their husband don’t have money to care for their need. These is supported by the fooling quotes below

“mm… No not really, but sometimes I get worried if my husband does not have money to support me”.R7

 “… I have experienced some sort of depression when there is no money for any assistance “. R3

…… am always depressed when my husband don’t have money R8

  Sub-theme 3: Sexual deprivation

All participants that were interviewed reported their husband/spouses don’t deprive them of sex however, they abstinence from sexual activities because of ceremonial initiations, being separated from the husband and due to advanced pregnancy that pregnant women were not allowed to do any sexual activity and that it was not a deliberate act to starve them of sex by their husband. The excerpt for their responses are shown below

“ Mm,  no we discuss and agree about sex…..they stop us to sleep  with a man when the pregnancy  is eight or nine months old, they say you can  just hold him tight so that he can be eased”. R1

“No, he does not abuse me sexually (smiles with shyness). We sleep separately when my pregnancy is advanced”. R2

“… we as women in the village, we always have initiation ceremonies where we teach each other on what to do about sex when a woman is pregnant, we are told to refrain from sex when we get into the ninth month of pregnancy, some take it and others don’t”.R5

“Since I fell pregnant, I have never experienced any sexual abuse even though we don’t normally have sex, my husband understand”. R9

“We only had sex at the beginning of the pregnancy, my husband know that when the pregnancy is growing we cannot have sex, so he does not force”. R10

DISCUSSION

The study explored the spousal support and  domestic abuse  as determinants of  maternal health  among  pregnant women attending antenatal clinic in  Thyolo District Hospital, Malawi.

The findings from the study revealed that the words “go” and “accompanies pregnant wife to hospital” appeared more frequently on the data set. It implies that husband support which are in the area of assistance/provision of means of transportation to the hospital for antenatal care such as paying for the transportation arranging for the transportation. This means that in the society, most husbands escorted and accompanied their pregnant women to hospital during pregnancy, in times of sickness and at labour commencement.  This places the women in the right psychological mind frame to deliver their babies. When  pregnant women expect  their husband’s support and received  it , it makes them happy  and this in turn  enhances their  wellbeing  which has a capacity of improving  the overall mental health of mother and baby.

Finding on assistance in Household chores revealed that their husband assisted them in house hold chores such as washing of clothes, cooking, washing plates, fetching water and helping out in the farm during pregnancy period. However, assisting their wives in household chores and others services requires that men are ready to enter into the female domain. This may even be frown at by their relatives and friends. This also showed that their husbands were committed to the family which creates a sense of belonging and bonding seeing their husbands involved in household chores despite men’s dominance. This finding is at variance with the study conducted in Gambia ^8, which revealed that in most cases, women did not enjoy privileges in their households when they were pregnant.

Findings revealed that “husband support” as reported in this study was the male partner escorting their wives to the hospital for antenatal care visit. The supportive role by their husband in the study could be due to motivation from societal norms that husbands must take part in pregnancy, especially in Thyolo District of Malawi where the penalty for failure to support pregnant wife is one live goat to the society. This is in line with the studies conducted in Nigeria ^9,10 which showed that male partners accompanied their wives who were pregnant to antenatal clinic and ultra sound scanning and this showed that men are increasingly becoming active in participating in antenatal, intrapartum  and postpartum care.

Furthermore, findings on general support revealed that almost all pregnant women reported that their husbands supported them financially by providing them with cash directly to buy their own things. In addition, the husbands were able to buy wrappers, and giving them money to buy themselves any materials of their own choice.  This is in tandem with the studies conducted in Nigeria ^10,12 which revealed husband support in the area of financial support, accompanying to labour and house chores. The financial support is a masculine way for men to take part in pregnancy such as economic power backed cultural norms and practices inherent in Africa.  The general support rendered to these pregnant women has proven that irrespective of the power bestowed on men by cultural norms of the African society, they made it their responsibility to support their pregnant wives. This is at variance with the study conducted in Pakistan which revealed lack of comprehensive support mechanism by their husbands during pregnancy ^11. Nevertheless, very few participants reported less support in terms of finance, nutrition and material due to lack of money.  The active involvement of husbands in supporting their pregnant partners indicates a conducive environment for pregnancy. This support can have numerous positive effects, including improved maternal health outcomes, reduced stress levels for both partners, and enhanced bonding between spouses and with the unborn child.

Domestic based abuse is as another factor influencing the health of pregnant women as revealed by other empirical studies.  However, it is pertinent to note that majority of the women in the present study never experienced domestic violence in terms of physical or psychological. Even though they express lack of sexual activities which they said is normal as a result of their advancing pregnancy.  And it is the norm in their village “we as women in the village, we always have initiation ceremonies where we teach each other on what to do about sex when a woman is pregnant, we are told to refrain from sex when we get into the ninth month of pregnancy” This could be attributed to the ceremonial initiations of the men. This is at variance with the studies conducted in Ethiopia and Nigeria which reported physical, psychology and sexual abuse ^9,10.  Nevertheless, some participants experienced some psychological issue. It was noted that the psychological issue was as a result of lack of money which caused anxiety and depression among them.  The absence of reported domestic abuse suggests that the relationships between pregnant women and their spouses are characterized by trust, mutual respect, and support. This points to healthy dynamics within these partnerships, which can contribute to overall well-being and satisfaction for both partners. While the absence of reported domestic abuse is encouraging, it’s essential for healthcare providers and policymakers to remain vigilant. This presents an opportunity to implement preventive measures and support systems that can help identify and address any potential instances of domestic abuse early on, ensuring the continued well-being of pregnant women and their families.

Limitations of the Study

The study is limited due to the fact that only one health Centre was used with limited sample size based on data saturation. Post-natal mothers should have also been used to explore their experiences on this subject matter since they might have had similar experience during their pregnancy.  

Conclusion

In conclusion, the results demonstrated that spouses actively supported their pregnant partners by providing transportation for antenatal care visits, helping with household tasks, and accompanying them to medical appointments. However, notably absent were reports of domestic abuse, including physical violence, psychological issues, and sex deprivation. Overall, the study suggests that while pregnant women received significant support from their husbands, instances of domestic abuse were not reported, indicating a positive environment of care and support within these relationships during pregnancy. The study underscores the need for further research to explore the intricacies of spousal support and domestic dynamics during pregnancy, including factors influencing the absence of reported domestic abuse. This can contribute to a deeper understanding of the complexities involved and inform targeted interventions aimed at fostering supportive and safe environments for pregnant women and their families.

 Competing interests – The authors declared that they have no competing interests.

Funding – Not Applicable

Authors’ Contributions

JOB conceived the idea of the study and wrote the first draft of the paper. JOB and CAE participated in data collection, data analysis. JOB and CAE was also involved in interpretation of data, as well as critical revision of the drafts of the paper. JOB and CAE read, corrected and approved the final manuscripts.

Acknowledgements

The authors extend sincere thanks to all the local actors involved in the study, especially to the District Health Officer, the District Nursing Officer, nurse in charge of the Maternal and Child Health (MCH) Unit of Thyolo District Hospital, Malawi and all participants.