The way of Husband Involvement during Birth Preparedness and Complication Readiness Plan, Arba Minch town, Gamo zone, Southern Ethiopia: Qualitative Study

Globally, about 287,000 mothers die each year related to pregnancy and childbirth. Among those developing countries covers about 99%. Eighty-fi ve percent account by Southern Asia and Sub-Saharan Africa [1,2]. Concerning maternal and child mortality status, Ethiopia is one of six countries sharing 50% of the total world burden of maternal mortality [3]. In Ethiopia, the maternal mortality ratio is 412/100,000 live births [4]. This indicates that Ethiopia is one of the countries that share the toll burden of this grave [1,2,5].

5% of expected complications reach the medical facilities. This is because the three delays occurred on delay in decision to take care, delay to reach the health care center, and delay to receive adequate treatment [6]. Subsequently, these problems increase obstetric complications such as unfavorable pregnancy outcome, maternal morbidity and mortality, premature birth, low birth weight, neonatal death and infant abuse [5][6][7][8] Birth preparedness and complication readiness (BPCR) is one of the strategies to improve the use of skilled providers at birth and the key intervention to decrease maternal mortality [9]. It is the process of planning for normal birth and anticipating actions needed in case of emergency. It encourages women and households to make arrangements to give normal birth by reducing delays in reaching care once a problem arises [10,11]. Birth Plans and complication-readiness are crucial for timely Access to skilled maternal and neonatal services and promote active preparation and decision-making for delivery [1].
Evidence showed that pregnant women were not found to be well prepared for birth and its complication. For example, only 47.8% of women who have already given birth in Indore city in India [12]. 35% of pregnant women in Uganda [13].
27.5% of pregnant women in Northern Nigeria were prepared for birth and its complication [14]. Most of the fi ndings from different pocket studies conducted in different parts of Ethiopia documented that <20% of women practice BPCR [5,9,10].
In most parts of Ethiopia, women enjoy little independent decision making on most individual and family issues, including the option to choose whether to give birth in a health facility or seek the assistance of a trained provider. This condition makes husbands critical partners for the improvement of maternal health and reduction of maternal mortality by participating in birth preparation. Husband involvement will enable to support their spouses to utilize emergency obstetric services early and the couple would adequately prepare for birth and ready themselves for complications [1,15].
Study conducted among households targeting husbands with having at least one child of less than one year of age in Ethiopia at Mekele town showed that husbands' awareness of postnatal danger signs, husband's knowledge in birth preparedness, male involvement in ante natal care (ANC), educational status, economic status, and place of residence as infl uencing factors for husband participation in BPCR [15]. Therefore, the involvement of husband in BPCR during pregnancy, Labor, the postpartum period and its complication helps an expectant mother to make timely decisions to avoid delays that bring about complications that could result in morbidity or mortality and for achieving Sustainable Development Goals three [16]. However, previous studies conducted in different part of the country focused only among pregnant women's those of who attending ANC in health facilities, but it doesn't show the way how husbands can participant during pregnancy [5,9,10]. Additionally, exploration and analysis of Husband involvement among the husband can lead to a clearer and specifi c understanding of how the husband can involve and where intervention is likely to make a difference in a specifi c context. Therefore, this study aimed to explore how husbands involved during birth preparedness and complication readiness plan among husbands living in Arba Minch town, Gamo zone, Southern Ethiopia.

Study design and setting
A qualitative, phenomenological study was carried out at Arba Minch Town, in April 2017.

Data collection Procedures
To extract the required information, a focus group discussion guide was prepared in relevant local languages (Amharic). Six Focus Group Discussion (FGDs) were conducted among male, married and have at least one live-born child in the last 2 years, and able to speak Amharic language. The FGDs had on average of 6 participants in each group. A pretested discussion guide was used to conduct the FGDs. The principal data collector who has a good experience on qualitative data collection and master's degree-level female moderator and 2 male note takers with master degree backgrounds, all fl uent in the local language and culture. Tape-recorded focus group discussion was conducted at a private place and time that were mutually convenient for participants. Before beginning a focus group discussion, participants were reminded of the purpose of the study. Their names will not be recorded, but we gave a code that used to facilitate the discussions. The participants were encouraged to share their genuine ideas and discuss freely in the session. The participants' nonverbal expressions were noted in addition to recording their verbal responses.
After completing the discussion, the moderator summarized the discussion and key points with the participants to check for accuracy. On average, the focus group discussion lasted 60 min.

Data analysis
A thematic content analysis using Open Code software version 3.6.2 was conducted, during which the principal investigator in the study team independently read and coded the English language transcript line by line. We discussed the codes and resolved any differences in coding. A fi nal consensus agreement was reached on the coding. The analysis was held until theme saturation was achieved.

Participants
A total of 38 participants were participated in this study. Those participants were married and have at least one liveborn child in the last 2 years, and able to speak Amharic language which includes religious leaders, community leaders, and model householders.

Key themes and Sub-themes identifi ed in this study
In this study, three main themes and twelve sub-categories emerged with some properties. The main themes are Theme 1: importance of birth preparedness and complication readiness, Theme 2: ways of husbands' involvement in birth preparedness and complication readiness, and Theme 3: barriers of husband involvement in birth preparedness and complication readiness. Each category is presented and discussed in detail with appropriate descriptions and quotes cited in the text to support the categories using elements of the paradigm model which is an analytical tool.

Values concerning the importance of birth preparedness and complication readiness
A 52 years old man responded: "More importantly, every care that I gave for her needs to be considered as it is for oneself because primarily we are one soul. Previously my brother said that in doing this the most benefi ciary was he. Within the community, all should aware of these issues so that the government could get the opportunity to plan a program for women and children.
A 40 years old man who is a community agricultural extension worker said that; "…. male involvement in every care of wife is very important because pregnancy by itself is a very diffi cult situation so that the women should not worry alone, if she worries by herself she might suicide herself. If we tried, she will be healthy. If she is healthy, we are healthy and happy. As a result, a happy child will join us that will bring love."

Beliefs concerning the involvement of husband in birth preparedness and complication readiness
One of the 30 years old participant said that "No No… there is no culture that prevent us to involve. It is not culture but the behavior of individual", the other52years participant also said that "it is not culture, but it is behavior and perception" yes it is perception; By the way, at this time there is a person who does not accept the involvement in maternal care."

Theme Two: Ways of Husbands' Involvement in Birth Preparedness and Complication Readiness Identifying place of delivery
A 28 years old man said that; "….I always thinks about why pregnant women go to the health center for delivery since there are eight traditional birth attendants in our village. If labor started we call upon them and receive counsel and service from them."

Arrangement for skilled birth assistance
A 30 years old man whose mother was a traditional birth attendant mentioned that: "…. One upon a time one mother gave birth by the help of a traditional birth attendant but she did not tie appropriately the cord and the baby died due to bleeding. After that, the mother was very sad and understood everything."

Arranging for cultural food, clean clothes & other materials for Baby and Mother
A 30 years old man whose mother was a traditional birth attendant said that; "…. I always prepared everything for the new stranger (newborn).
If you are ready for everything, the mother and child health would not be aff ected." Another 40 years old man who is a community agricultural extension worker also said that; "…everybody must think and prepared for their newborn before the occurrence of labor and delivery."

Personally accompanying
A 52 years old man said: "…while my wife came to this hospital to give childbirth, the health professional working in this hospital gave her a medication, which was a medication for hypertension. I said that please do not use this medication because it is for the treatment of hypertension. I said again and again but they refused. As a result, the labor prolonged for the third day and lastly, she gave birth by cesarean section. After birth the newborn became yellowish. Even the medical chart of the mother disappeared from the hospital record room. As a result of these disappointments, my wife did not receive the PNC follow up and never interested to visit this hospital again."

Awareness of an emergency & its immediate action
The majority of study participant had different perception on severity of delivery this act as a barrier for husband involvement. They think that should involve if the mother had severe symptoms and ready to seek immediate care. Some participants, however, expressed that the cause of maternal death is not only related to pregnancy problems but also health care interventions:

Participant-suggested interventions
These results represent the participant's wishes and concerns about their wife's care. Participants suggested many interventions to improve care for women; some were educational and directed towards the community. The suggested intervention was strengthening and promotion of husband involvement and commitment to preserving women's and child wellbeing.

Discussions
In general, this qualitative study explored the view, perception, and experiences of husband's on birth preparedness and complication readiness among residents of Arba Minch Town. According to the participants in this study, husbands have a great role in birth preparedness and complication readiness. In this discussion, we identify three main themes emerging from this qualitative study that emphasized on Theme 1: importance of birth preparedness and complication readiness, Theme 2: ways of husbands' involvement in birth preparedness and complication readiness, and Theme 3: barriers of husband involvement in birth preparedness and complication readiness.
The fi nding of this study reveals that husbands had a positive perception of birth preparedness and complication readiness. The attributes of individuals have a detrimental effect on the involvement of the husband in the care of the pregnant mother. The husbands' believed that not involved in the care for the pregnant mother is mainly due to the lack of awareness, perception, and behavior of the individual. They believed that it is important for the health of the mother and the baby. This fi nding supported by a study conducted in Wolaita Sodo town and Gurage zone, Southern Ethiopia [9,17]. This may be due to the fact that most of the husbands in Ethiopia more likely give attention for the problem they faced during delivery as well as post-partum period. Secondly, this may be due to lack of husband participation during ante natal care follow up especially among prirmgrvida mothers. Thirdly this may be associated with lack of wives are counseled by health professionals during ANC to bring their husbands [11]. This fi nding supported by a study conducted in a qualitative study among community members in rural Tanzania [18].
The fi nding of this found that majority of study participant involve during birth preparation and complication readiness by identifying place of delivery and identifying skilled birth attendant. This fi nding support the fi nding of the study conducted in Goba woreda, Oromia region, Sodo town, Wolaita zone and Robe Woreda, Arsi Zone [9,15,19].This may give direction for intervention for better involvement of husbands and we should create awareness focusing importance of identifying place of birth and skill birth attendant One of the important fi ndings in this study ways the majority of husbands involved in BPCR by different methods like arranging for cultural food and clean clothes. This fi nding is supported by study from Goba woreda, Oromia region [19]. This fi nding is also supported by study from Abeshige district, Guraghe zone which found that the majority of the husband involve by identifying a health facility for delivery, identifying means of transportation, by preparing different food items for the mother and different cloth for the mother and neonate [17]. Another fi nding which support this fi nding was communitybased study conducted in rural Uganda, Mbarara district which fi nding that the majority of the husbands involve by identifi ed a skilled provider, saving money, identifi ed means of transport, and arranging materials for the neonate [3]. However, this fi nding don't supported by a study conducted in Wolaita Sodo town, Southern Ethiopia [9]. Regarding barriers as study participants stated, barriers for husbands' involvement during birth preparedness and complication readiness practice was related to negative beliefs like women were more likely to give birth by chance and negative attitude to institutional delivery. This fi nding supported by a study conducted in a qualitative study among community members in rural Tanzania [18].Another study also supported by a qualitative study conducted in rural Rwanda [20]. Another study conducted in Axum town, Tigray region supported our fi nding [21]. This may be given direction for intervention for better improvement of husbands.
Furthermore, the fi nding of this study shows that most of the study participants stated, they were involved during birth preparedness and complication readiness practice by savings money by using common account numbers. This fi nding supports the world health organization (WHO) strategy to save funds for birth-related and emergency expenses [22]. Also, this fi nding supported by the fi nding of a study done in Goba woreda, Oromia region [19]. This inducted that saving the money by using common account numbers may be the best strategy to solve the problem related to income which may require facilitating referral in case of complications.
This fi nding also may help the women to make decisions by themselves.

Conclusion
This study proves the importance of the husband's involvement. Regarding the husbands 'roles during birth preparedness and complication readiness, majority of the participants mentioned that their wives delivered by skilled birth attendant where their role was identifying signs of labor or date of birth and told their wife to go to the health facility for the childbirth and get skilled birth attendant. Besides, they mentioned that they arranged for cultural food, clean clothes & other materials for the Mother and Baby and accompanied their wife in the labor room. The majority of the participants agreed that any warning signs of potential adverse outcomes mandate an immediate course of action and decisions should be best considered and made before delivery. These include identifying emergencies& its immediate action, saving money for emergencies and identifying decision-makers for emergencies. So it is helpful if husbands are given information in a nonjudgmental, nonthreatening environment so that they may make appropriate, well-considered, and informed decisions about birth preparedness and complication readiness.

Limitations
The limitation this study maybe this study was qualitative study conducted only with husbands in Arba Minch town further triangulation was not done with women and due to shortage of money and time only six FGD was conducted there may not be representative

Data availability
The data used to support the fi ndings of this study are available from the corresponding author upon request.

Disclosure
The College has no role in the design of the study, collection, analysis, and interpretation of the data and in writing the manuscript.