Mariam Tokhi

Bio: Mariam Tokhi is an academic researcher from Burnet Institute. The author has contributed to research in topics: Health promotion & Infant mortality. The author has an hindex of 2, co-authored 2 publications receiving 185 citations.

Involving men to improve maternal and newborn health: A systematic review of the effectiveness of interventions

Abstract: Background Emerging evidence and program experience indicate that engaging men in maternal and newborn health can have considerable health benefits for women and children in low- and middle-income countries. Previous reviews have identified male involvement as a promising intervention, but with a complex evidence base and limited direct evidence of effectiveness for mortality and morbidity outcomes. Objective To determine the effect of interventions to engage men during pregnancy, childbirth and infancy on mortality and morbidity, as well as effects on mechanisms by which male involvement is hypothesised to influence mortality and morbidity outcomes: home care practices, care-seeking, and couple relationships. Methods Using a comprehensive, highly sensitive mapping of maternal health intervention studies conducted in low- and middle-income countries between 2000 and 2012, we identified interventions that have engaged men to improve maternal and newborn health. Primary outcomes were care-seeking for essential services, mortality and morbidity, and home care practices. Secondary outcomes relating to couple relationships were extracted from included studies. Results Thirteen studies from nine countries were included. Interventions to engage men were associated with improved antenatal care attendance, skilled birth attendance, facility birth, postpartum care, birth and complications preparedness and maternal nutrition. The impact of interventions on mortality, morbidity and breastfeeding was less clear. Included interventions improved male partner support for women and increased couple communication and joint decision-making, with ambiguous effects on women’s autonomy. Conclusion Interventions to engage men in maternal and newborn health can increase care-seeking, improve home care practices, and support more equitable couple communication and decision-making for maternal and newborn health. These findings support engaging men as a health promotion strategy, although evidence gaps remain around effects on mortality and morbidity. Findings also indicate that interventions to increase male involvement should be carefully designed and implemented to mitigate potential harmful effects on couple relationship dynamics.

Challenging gender inequity through male involvement in maternal and newborn health: critical assessment of an emerging evidence base

Abstract: Men's involvement in the health of women and children is considered an important avenue for addressing gender influences on maternal and newborn health. The impact of male involvement around the time of childbirth on maternal and newborn health outcomes was examined as one part of a systematic review of maternal health intervention studies published between 2000 and 2012. Of 33,888 articles screened, 13 eligible studies relating to male involvement were identified. The interventions documented in these studies comprise an emerging evidence base for male involvement in maternal and newborn health. We conducted a secondary qualitative analysis of the 13 studies, reviewing content that had been systematically extracted. A critical assessment of this extracted content finds important gaps in the evidence base, which are likely to limit how ‘male involvement’ is understood and implemented in maternal and newborn health policy, programmes and research. Collectively, the studies point to the need for an evidence base that includes studies that clearly articulate and document the gender-transformative potential of involving men. This broader evidence base could support the use of male involvement as a strategy to improve both health and gender equity outcomes.

Involving men to improve maternal and newborn health: A systematic review of the effectiveness of interventions

Abstract: Background Emerging evidence and program experience indicate that engaging men in maternal and newborn health can have considerable health benefits for women and children in low- and middle-income countries. Previous reviews have identified male involvement as a promising intervention, but with a complex evidence base and limited direct evidence of effectiveness for mortality and morbidity outcomes. Objective To determine the effect of interventions to engage men during pregnancy, childbirth and infancy on mortality and morbidity, as well as effects on mechanisms by which male involvement is hypothesised to influence mortality and morbidity outcomes: home care practices, care-seeking, and couple relationships. Methods Using a comprehensive, highly sensitive mapping of maternal health intervention studies conducted in low- and middle-income countries between 2000 and 2012, we identified interventions that have engaged men to improve maternal and newborn health. Primary outcomes were care-seeking for essential services, mortality and morbidity, and home care practices. Secondary outcomes relating to couple relationships were extracted from included studies. Results Thirteen studies from nine countries were included. Interventions to engage men were associated with improved antenatal care attendance, skilled birth attendance, facility birth, postpartum care, birth and complications preparedness and maternal nutrition. The impact of interventions on mortality, morbidity and breastfeeding was less clear. Included interventions improved male partner support for women and increased couple communication and joint decision-making, with ambiguous effects on women’s autonomy. Conclusion Interventions to engage men in maternal and newborn health can increase care-seeking, improve home care practices, and support more equitable couple communication and decision-making for maternal and newborn health. These findings support engaging men as a health promotion strategy, although evidence gaps remain around effects on mortality and morbidity. Findings also indicate that interventions to increase male involvement should be carefully designed and implemented to mitigate potential harmful effects on couple relationship dynamics.

Gender-transformative Bandebereho couples' intervention to promote male engagement in reproductive and maternal health and violence prevention in Rwanda: Findings from a randomized controlled trial.

Abstract: Rigorous evidence of the effectiveness of male engagement interventions, particularly on how these interventions impact relationship power dynamics and women's decision-making, remains limited. This study assessed the impact of the Bandebereho gender-transformative couples' intervention on impact on multiple behavioral and health-related outcomes influenced by gender norms and power relations.We conducted a multi-site randomized controlled trial in four Rwandan districts with expectant/current fathers and their partners, who were randomized to the intervention (n = 575 couples) or control group (n = 624 couples). Primary outcomes include women's experience of physical and sexual IPV, women's attendance and men's accompaniment at ANC, modern contraceptive use, and partner support during pregnancy. At 21-months post-baseline, 1123 men and 1162 partners were included in intention to treat analysis. Generalized estimating equations with robust standard errors were used to fit the models.The Bandebereho intervention led to substantial improvements in multiple reported outcomes.Compared to the control group, women in the intervention group reported: less past-year physical (OR 0.37, p<0.001) and sexual IPV (OR 0.34, p<0.001); and greater attendance (IRR 1.09, p<0.001) and male accompaniment at antenatal care (IRR 1.50, p<0.001); and women and men in the intervention group reported: less child physical punishment (women: OR 0.56, p = 0.001; men: OR 0.66, p = 0.005); greater modern contraceptive use (women: OR 1.53, p = 0.004; men: OR 1.65, p = 0.001); higher levels of men's participation in childcare and household tasks (women: beta 0.39, p<0.001; men: beta 0.33, p<0.001); and less dominance of men in decision-making.Our study strengthens the existing evidence on male engagement approaches; together with earlier studies our findings suggest that culturally adapted gender-transformative interventions with men and couples can be effective at changing deeply entrenched gender inequalities and a range of health-related behavioral outcomes.

Gendered health systems: evidence from low- and middle-income countries.

Abstract: Gender is often neglected in health systems, yet health systems are not gender neutral. Within health systems research, gender analysis seeks to understand how gender power relations create inequities in access to resources, the distribution of labour and roles, social norms and values, and decision-making. This paper synthesises findings from nine studies focusing on four health systems domains, namely human resources, service delivery, governance and financing. It provides examples of how a gendered and/or intersectional gender approach can be applied by researchers in a range of low- and middle-income settings (Cambodia, Zimbabwe, Uganda, India, China, Nigeria and Tanzania) to issues across the health system and demonstrates that these types of analysis can uncover new and novel ways of viewing seemingly intractable problems. The research used a combination of mixed, quantitative, qualitative and participatory methods, demonstrating the applicability of diverse research methods for gender and intersectional analysis. Within each study, the researchers adapted and applied a variety of gender and intersectional tools to assist with data collection and analysis, including different gender frameworks. Some researchers used participatory tools, such as photovoice and life histories, to prompt deeper and more personal reflections on gender norms from respondents, whereas others used conventional qualitative methods (in-depth interviews, focus group discussion). Findings from across the studies were reviewed and key themes were extracted and summarised. Five core themes that cut across the different projects were identified and are reported in this paper as follows: the intersection of gender with other social stratifiers; the importance of male involvement; the influence of gendered social norms on health system structures and processes; reliance on (often female) unpaid carers within the health system; and the role of gender within policy and practice. These themes indicate the relevance of and need for gender analysis within health systems research. The implications of the diverse examples of gender and health systems research highlighted indicate that policy-makers, health practitioners and others interested in enhancing health system research and delivery have solid grounds to advance their enquiry and that one-size-fits-all heath interventions that ignore gender and intersectionality dimensions require caution. It is essential that we build upon these insights in our efforts and commitment to move towards greater equity both locally and globally.

Gender dynamics affecting maternal health and health care access and use in Uganda

Abstract: Despite its reduction over the last decade, the maternal mortality rate in Uganda remains high, due to in part a lack of access to maternal health care. In an effort to increase access to care, a quasi-experimental trial using vouchers was implemented in Eastern Uganda between 2009 and 2011. Findings from the trial reported a dramatic increase in pregnant women's access to institutional delivery. Sustainability of such interventions, however, is an important challenge. While such interventions are able to successfully address immediate access barriers, such as lack of financial resources and transportation, they are reliant on external resources to sustain them and are not designed to address the underlying causes contributing to women's lack of access, including those related to gender. In an effort to examine ways to sustain the intervention beyond external financial resources, project implementers conducted a follow-up qualitative study to explore the root causes of women's lack of maternal health care access and utilization. Based on emergent findings, a gender analysis of the data was conducted to identify key gender dynamics affecting maternal health and maternal health care. This paper reports the key gender dynamics identified during the analysis, by detailing how gender power relations affect maternal health care access and utilization in relation to: access to resources; division of labour, including women's workload during and after pregnancy and lack of male involvement at health facilities; social norms, including perceptions of women's attitudes and behaviour during pregnancy, men's attitudes towards fatherhood, attitudes towards domestic violence, and health worker attitudes and behaviour; and decision-making. It concludes by discussing the need for integrating gender into maternal health care interventions if they are to address the root causes of barriers to maternal health access and utilization and improve access to and use of maternal health care in the long term.