Contextualising men’s role and participation in PMTCT programmes in Malawi and Zambia: A hegemonic masculinity perspective

ABSTRACT

This study sought to explore and contextualise the man’s role in antenatal services, and the barriers and strategies for engaging men in prevention of mother-to-child HIV transmission (PMTCT). We conducted 143 interviews with pregnant and breastfeeding women, male partners, health workers and policy makers in Malawi and Zambia. We employed thematic and critical discourse analysis using the hegemonic masculinity perspective. We found that men’s roles in PMTCT reflected hegemonic masculinities. As breadwinners, men supported their partners with material and financial resources. As decision makers, men were involved in decision making on the health of their partners. As social protectors, men supported their partners in accessing and adhering to antenatal care, HIV treatment and care. Barriers and challenges to male involvement in antenatal care were often the result of conflict between the clinic operating hours and men’s working hours, the perception of antenatal care services as female spaces, and men’s fear of HIV testing. Proposed strategies to increase male engagement in PMTCT included sensitising men about HIV and pregnancy; engaging leaders and employers, providing services outside working hours, and providing incentives. We conclude that men’s role and participation in PMTCT services are an extension and adaptation of hegemonic masculinities.

KEYWORDS:

• HIV
• prevention of mother-to-child transmission of HIV
• PMTCT
• men’s roles
• hegemonic masculinities
• sub-Saharan Africa

Introduction

Programs to prevent mother-to-child transmission of HIV (PMTCT) have contributed significantly to the reduction of HIV incidence and prevalence. Through these services, an increasing number of women are getting tested for HIV during pregnancy and are subsequently linked to lifelong HIV treatment and care (UNAIDS, 2019; Vrazo et al., 2018). In recent years, male involvement has been recognised as an important contributing factor to the success of PMTCT programmes, particularly, as efforts are made to eliminate paediatric AIDS (Besada et al., 2016; Blackstone et al., 2017). For example, the World Health Organization now recommends HIV couples counselling and testing as an essential component of PMTCT services. This includes strategies that encourage men to undergo HIV testing with their pregnant partners, with linkages for the rapid initiation of antiretroviral therapy. The Ministry of Health (MoH) in Zambia and Ministry of Health and Population (MoH&P) have adopted these recommendations and established national guidelines to engage male partners within the antenatal and postnatal care settings (MoH, 2020; MoH&P, 2018)

While considerable gains have been made to increase male partner engagement in antenatal services, challenges remain (Hershow et al., 2019). A better understanding of men’s societal role is needed to contextualise the nature of men’s roles in the health of women during pregnancy broadly and within PMTCT programmes specifically. Many studies have focused on the determinants of male involvement, including enablers and barriers (Brittain et al., 2015; Ditekemena et al., 2012; Manjate Cuco et al., 2016; Nyondo-Mipando et al., 2018). In contrast, few studies explored the influence of masculinities on general HIV testing and general health care (Chikovore et al., 2016; Zissette et al., 2016). To date, there has been limited exploration on men’s roles in PMTCT programmes from a hegemonic masculinities perspective using a critical discourse analysis approach.

Developed by Raewyn Connell, the theory of hegemonic masculinities postulates that inter-related masculinities exist in different forms. The dominant forms are called hegemonic masculinities and these identities form the basis for men’s expected social behaviours and roles in a given context (Connell & Messerschmidt, 2005). Hegemonic masculinities are determined by the prevailing cultural values of a particular society and are a cardinal component of patriarchy that promote traditional genders roles. Hegemonic masculinities are not fixed but contextual, and adapt to the changing domestic and public contexts and arenas while maintaining the basic patriarchal structure (Connell & Messerschmidt, 2005). Hegemonic masculinities operate in the context of other forms of masculinities which include complicit, marginalised, and subordinate masculinities (Connell & Messerschmidt, 2005). Complicit masculinities are performed by individuals who fail to meet the requirements of hegemonic masculinities but strongly believe in them and strive to perform them. Marginalised masculinities are performed by marginalised groups based on class, gender, and race and often challenge or do not conform to the hegemonic masculinities. Subordinate masculinities are performed by individuals who are politically or culturally excluded from mainstream – for example, men who have sex with men (Connell & Messerschmidt, 2005).

In many African contexts – including in Zambia and Malawi, where our study was conducted – the hegemonic forms of masculinities at the domestic level dictate that adult men are expected to marry, have children, and provide social support and protection (Hendricks et al., 2010; Heslop & Banda, 2013; Mweemba et al., 2018). Men are also expected to work to be able to perform the breadwinning role and thereby legitimise their status as heads of the household and ultimate decision makers (Mweemba et al., 2018; Silberschmidt, 2005). At the individual level, men are expected to be healthy and strong, both physically and emotionally. They may also engage in violence to demonstrate their masculinity (Blackstone et al., 2017; Chikovore et al., 2016; Skovdal et al., 2011). Men are generally guided by these hegemonic forms of masculinities in their behaviour and performance of social roles, though some men may engage in other forms of masculinities depending on their social circumstances and contexts.

As part of broader efforts to study HIV prevention during pregnancy and breastfeeding (Chi et al., 2018), we used the hegemonic masculinity perspective as an innovative framework to analyse our data, organise findings and position the discussion about male involvement in PMTCT programmes.

Methods

Study site and participants

This study was embedded in formative qualitative research performed in Lilongwe, Malawi and Lusaka, Zambia, aimed at improving HIV prevention services during pregnancy and breastfeeding (Hershow et al., 2019; Zimba et al., 2019). The two countries share geographical boundaries, similar cultures, and common Bantu ethnic groups and tribes such as the Chewa and Tumbuka. The HIV epidemic – and the public health response – has also been similar, including longstanding services for PMTCT in the public sector.

Participants in our study included pregnant and breastfeeding women, their invited male partners (though only a subsample of the latter agreed to participate), and health workers. These groups were recruited from Bwaila District Hospital (Malawi) and Kamwala Health Centre and Women and Newborns Hospital at the University Teaching Hospitals (Zambia). Policy makers from both countries were identified from Ministries of Health, implementing partners, and donor agencies; they were purposively recruited based on their knowledge of HIV/AIDS policies and their experience in PMTCT implementation.

Research approach and data collection

A qualitative case study was employed as the research approach. The data were collected through single in-depth interviews from June 2017 to May 2018. The interviews were conducted in local languages (Bemba, Nyanja, Chichewa) with female participants and their partners, and in English with health care workers and policy makers. Interviews for women, male partners, and health workers were conducted individually in health centres and homes depending on the preference of the participant while the policy maker interviews were conducted in their offices. Experienced bilingual male and female interviewers aged between 25 and 45, conducted the interviews, with efforts to gender and age where possible. Most interviews lasted between 30 and 45 min. Since the interviews were conducted as part of a larger study, topics covered in the interviewer’s guide covered a range of topics, including existing HIV services, programmatic gaps, and potential solutions (Table 1).

Table 1. Interview topics by participants.

Interview topics	HIV+ women	HIV− women	Partners of HIV+ women	Partners of HIV− women	HCW	Policy makers
Relationship with partner	X	X	X	X
HIV disclosure experiences	X		X
HIV treatment experiences	X		X
Male partner testing history	X	X	X	X
Male partner testing: Challenges and Strategies	X	X	X	X	X	X
Partner support for ART adherence, retention and care: challenges and strategies	X		X		X	X

Data management and analysis

Interviews were audio-recorded, transcribed, and – for those captured in local language – translated for analysis. We employed an internal quality control mechanism where each transcript was peer-reviewed for accuracy and completeness. Approximately 10% of these transcripts were randomly selected to check for accuracy and completeness by study investigators. The data on men’s roles and participation in PMTCT programme and challenges and strategies for optimising men’s participation in PMTCT programme was analysed initially using thematic approach. We developed a codebook with deductive codes and themes based on the interview guide and interview transcripts. Multiple team members (local and US-based) independently reviewed the data and compared and agreed on the sub-themes, which were developed into a codebook. The data were coded using QSR NVivo 12 (QSR International Pty Ltd, Chadstone, Victoria, Australia). The team regularly discussed the coding process to make sure there was consistency in the coding. Since the initial deductive codes were broad, we (OM, TFM, KC) further coded inductively on the roles male partners played in testing and treatment in the context of PMTCT programmes as well as the challenges and proposed strategies to play a supportive role in PMTCT programmes. The findings from the focused coding were further analysed using Fairclough’s method of Critical Discourse Analysis (CDA) with a hegemonic masculinities perspective (Fairclough, 2013). CDA explores the linkage between participant’s narratives and social processes and structures (Fairclough, 2013; Han, 2015). We specifically analysed the underlying meanings of the men’s roles in PMTCT and how they reflect the hegemonic and other forms of masculinities. We paid attention to how latent and manifest narratives reflect the power dynamics of hegemonic masculinities and how men and women navigated these in the context of PMTCT services (Fairclough, 2013; Han, 2015).

Ethics approvals

This study was approved by the University of Zambia Biomedical Research Ethics Committee (Lusaka, Zambia), the Malawi National Health Sciences Research Committee (Lilongwe, Malawi) and the University of North Carolina at Chapel Hill Institutional Review Board (Chapel Hill, NC, USA). All participants provided written informed consent prior to initiating study activities.

Findings

Sociodemographic characteristics of the participants

Overall, 143 participants were interviewed from Malawi and Zambia: 80 pregnant/postpartum women (40 Malawi, 40 Zambia), 28 of their male partners (15 Malawi, 13 Zambia), 19 healthcare workers (10 Malawi, 9 Zambia), and 16 policymakers (10 Malawi, 6 Zambia). This is shown in Table 2.

Table 2. Sociodemographic characteristics of pregnant/postpartum women and male partners in Malawi and Zambia (N = 108)^a.

	HIV+ Women (N = 41)	Male partners of HIV+ Women^b (N = 14)	HIV– Women (N = 39)	Male partners of HIV– Women (N = 14)
	N (%) or Mean
Age in years (mean)	29	37	26	31
Highest education level completed
None  Primary school  Secondary school  Tertiary education	16 (39) 17 (41) 6 (15) 2 (5)	4 (31) 5 (38) 2 (15) 2 (15)	9 (23) 13 (33) 8 (21) 9 (23)	0 (0) 6 (43) 2 (14) 6 (43)
Marital status
Married  Single  Separated/divorced	40 (98) 0 (0) 1 (2)	13 (100) 0 (0) 0 (0)	36 (92) 3 (8) 0 (0)	14 (100) 0 (0) 0 (0)
Employment status
Employed (full- or part-time)  Homemaker  Student  Unemployed	20 (49) 16 (39) 0 (0) 5 (12)	12 (92) 0 (0) 0 (0) 1 (8)	15 (38) 18 (46) 2 (5) 4 (10)	13 (93) 0 (0) 0 (0) 1 (7)

^a Percentages may not sum to 100 due to rounding.

^b Missing data (except for male partner’s HIV testing history): Male partners of HIV+ Women: N = 1.

Forty-one of the pregnant/postpartum women were HIV positive while 39 were HIV negative. Fourteen of the male partners were spouses of HIV positive women; the other 14 were spouses to HIV negative women. Of these 28 participating couples, 13 were both HIV-negative, nine were both HIV-positive, and two were HIV sero-discordant with HIV-positive women. The mean age for HIV positive women was 29 compared to HIV negative women whose mean age was 26. The mean age for partners to HIV positive women was 34 compared to 31 for partners to HIV negative women. The majority of the women and male partners never enrolled in school or attended school up to primary level. Almost all the pregnant/postpartum women reported to be married. The majority of the pregnant/postpartum women reported to be engaged in some form of employment (Table 3).

Table 3. Number and percentage of study participants by participant type and country^a.

	Pregnant or postpartum women N (%)		Male partners N (%)		Healthcare workers N (%)	Policymakers N (%)	Total N (%)
	HIV–	HIV+	Female partner HIV–	Female partner HIV+
Malawi	20 (51)	20 (49)	7 (50)	8 (57)	10 (53)	10 (63)	75 (52)
Zambia	19 (49)	21 (51)	7 (50)	6 (43)	9 (47)	6 (38)	68 (48)
Total	39 (100)	41 (100)	14 (100)	14 (100)	19 (100)	16 (100)	143 (100)

^a Percentages may not sum to 100 due to rounding.

Men’s role in PMTCT and hegemonic masculinities

Men’s perceived roles reflected elements of hegemonic masculinities. Behaviours that men were expected to adhere to included breadwinner, head of household, decision-maker, and social protection and support.

Breadwinner role

Male breadwinners played a positive role by providing financial and material support for women’s health during pregnancy. Men were reported to offer financial support women and material supplies to women during pregnancy and breastfeeding. Men provided transport or money for transport for women to get to the clinic for antenatal and postnatal care or other health visits. In preparation for delivery, men also provided (or were expected to provide) money for buying supplies for the baby such as clothes and delivery materials such as basins. Further, men provided recommended food supplies for women and for the child for complementary feeding.

I have to make sure that I buy food that she wants like orange squash; the reason is that she and the baby we are expecting should be healthy … So I try to make sure that the food that she requires is readily available so that she should not stay hungry … sometimes I leave money so that she is able to buy rice … (Male partner, Malawi)

Despite this expected breadwinner role, some men and women in Zambia reported that some men exhibited complicit masculinities as they struggled to play this role due to economic hardships and limited economic opportunities.

Head of house and decision-making role

As head of house and ultimate decision maker, men were reported to be actively involved in health-related decision-making during pregnancy. Both men and women in this study reported that men were the primary advisors and key decision-makers on health-related decisions during pregnancy and breastfeeding. Almost all women reported that they had to consult and seek approval from their partners on decisions that related to their health. Though issues they consulted their partners on varied, some women consulted their partners on what medication to take when they are unwell, what foods to eat, going for medical check-ups, family planning, and general well-being.

… When she is unwell she might be tempted to get some drugs in order to ease the pressure of that pain … but she would always consult to say, ‘Should I take this medication, is it going to be good for my health and also the child.’ Sometimes it pertains to some food stuffs … (Male partner, Zambia).

However, there are a few women who exhibited some marginalised forms of masculinities by defying men’s leadership and decision-making role. These women reported that they never consulted or sought approval from their partners. Such women were aware of the potential consequences but opted not to engage their partners for fear of retribution and abandonment from their partners in case their HIV test was positive.

Social protection and support roles

Related to men’s decision-making role during pregnancy, men were also reported to provide social protection and support roles in two ways: supporting and participating in HIV testing during antenatal clinic visits and supporting spouses on HIV treatment and care.

Participants from both countries reported that men played a role by making sure or encouraging women to go to the clinic or take the children to the clinic when they were not well. Both male and female participants confirmed and reported, respectively that male partners ensured that women visit the clinic and, in some cases, accompanied them for antenatal and postnatal care and were generally supportive during the whole duration of the pregnancy.

Last Sunday. I was not feeling well … my pregnancy has grown too big, now at 32 weeks; he was really supportive; he made sure we had to go to the clinic, even when I hesitated, he still insisted we go to the clinic which we did (Pregnant woman, Zambia).

My support to her as a pregnant woman, because you tell them to come to the antenatal clinic on their scheduled visit dates I make sure I support her to come to the clinic as scheduled (Male partner – Malawi)

Some men and women also reported that some men not only supported their partners attendance at antenatal clinics but also engaged even more by participating in HIV couples testing during these visits. The policy of encouraging men to test with their spouses during antenatal visits seemed to have helped women to communicate with their partners about HIV testing during pregnancy and for the men to agree to participate.

When I became pregnant, I told him ‘I am not supposed to go to the clinic alone, we should be together.’ … My partner had never been tested. So, I waited for him until he was tested and found HIV positive and initiated on ARVs and started taking them (HIV positive woman, Malawi)

I don’t know if it is a rule or policy that when you come for antenatal of course both of you have to be tested. So I couldn’t miss the chance to let my partner test alone, I grabbed the opportunity and be there and both get tested, we get the results together then that would be better not only for us but also for the child that is developing (Male partner, Zambia)

Some men played a prominent role in HIV treatment by supporting their partners’ adherence to treatment and care. Some women reported that their partners made sure that they checked the dates for appointments and reminded them, even when they planned not to go, that they are supposed to go to the ART clinic for a health check-up and refills when their medication ran out. Some men made sure they escorted their partners to collect drugs or collected drugs from the clinic for their partners.

He’s been very supportive especially when I was pregnant, I’d say like ‘today I’m supposed to go and get medicine, I’m not going, I will go tomorrow morning’ and he will wake me up early in the morning and say, ‘let’s go’ and will even escort me … (Pregnant woman, Zambia).

Many years have passed, like 10 years but I could come collect the drugs for her. If all families would do what we do, then it would be okay rather than saying you focus on your life, and I focus on mine (Male partner, Malawi).

One key role played male partners was that of reminding women to take medication at the right time. This is regardless of whether or not these men were on ART themselves. Some men were reported to be strict by ensuring that the medicine was taken at the right time. Some were even monitoring adherence to medication by counting the number of tablets taken against those supplied.

On my part I’m strict, when that time comes, I make sure that we both take the medicines. In the cases when I’m not around, I have to count the tablets I left in the bottle and the days I’m away (Male partner, Zambia)

Further, some women who found it hard to come to terms with their HIV status also narrated how their partners remained supportive and encouraged them not only to take the medication but also to accept their status.

Barriers and challenges in engaging men in PMTCT programmes

This study identified barriers and challenges in getting men to participate in PMTCT programmes. Men were shunning the PMTCT services because of their working hours, the perception that PMTCT services were female spaces, and fear of HIV testing. Some HIV positive women didn’t want their partners to accompany them to the clinic because they feared that their HIV status would be known. All these barriers and challenges are in one way or another related to the performance of hegemonic masculinity roles and behaviours such as men’s working and breadwinner roles, and the perception that men are usually strong and healthy.

Men’s working role and health facility working hours

Since men are expected to work or engage in income-generating activities, one fundamental challenge raised by the study participants was that healthcare services do not fit men’s working schedules. The health services are generally offered during working hours which is the same time men in formal employment are working and those in informal employment engage in income-generating activities such as street trading. Furthermore, most men in medium and low-density areas in Lusaka are engaged in casual work and paid on a daily rate, which makes it difficult for them to take time off work to access healthcare services. The study also revealed that some men who take time off from work or other economic activities expressed concern that the time spent at health facilities was too long – sometimes an entire day, making them lose income which was usually their only source of livelihood.

The other challenge is where to find them. Men mainly are working. Most of the programs that we’ve had have been targeting people in the community. So, when you go into a community you set up your tent for testing, men are in the work place (Policy maker, Zambia)

Men’s health and configuration of PMTCT services

The perception that men are strong and health have made some men to shun health facilities, because health services are considered to be for the sick, weak and generally female and children spaces. This was especially true for antenatal and postnatal services as well as under five clinics which have been historically associated with pregnant women and children. This perception has kept some men away from antenatal health care services because they suppose the main activities to be centred on women and children’s health rather than men’s health.

There are social cultural factors where men believe that they cannot escort a woman to the facility … Men don’t want to be seen in that clinic where there are a lot of women. When seen one is perceived as being weak. ‘How do you go to a facility where there are just women, then you are a weak man’ [even]when the health education is given, it is more centred to women (Policy maker, Zambia)

Men’s health and men’s fear of HIV testing

The perception that men are strong and healthy have also compounded men’s fear for HIV testing. In this study, some men have been reported to avoid accompanying their wives to antenatal services because they feared being tested for HIV. Both health workers and women felt that men were reluctant to get tested for HIV because they did not have enough information about HIV testing including the benefits of HIV couples testing. Most men feared being stigmatised as weak and sickly if they tested HIV positive.

I have tried to tell him to go to the clinic for HIV testing and he responds saying that he will go to the clinic when he falls sick. I have told him a couple of times saying, ‘Let us go to the clinic,’ even when I come to refill my medicine, I tell him to come along to the clinic, but he does not listen to me (HIV+ woman, Malawi)

Men’s breadwinner role and women’s fear of disclosure of HIV status

One challenge to engaging men was reluctance by women who were not sure how HIV testing during an antenatal visit might affect their marriage. Because female participants often depended on men for their livelihood, some feared they would be divorced if found to be HIV-positive and hence, preferred to come alone. For fear of divorce and consequently loss of material support, some of the women who tested alone and turned out to be HIV-positive did not disclose their HIV status to their partner and were taking drugs secretly.

Women come on their own because they have no option, when a test comes out positive, a problem comes; she goes home, she tells the husband her results, there is a fight even divorce, she is chased. As a result, they keep quiet, even if she’s positive she’ll just keep quiet about it … She’s afraid to tell the husband, she’ll be taking medication secretly. She would keep the medication at the neighbours’ house or her friends’ place (Male partner, Zambia).

Proposed strategies for engaging men in PMTCT programmes

Most of the proposed strategies were aimed at overcoming the barriers and challenges identified by the participants. These strategies also reflect and intended to fit men’s agenda and behaviours. These include targeted sensitisation of men, targeted sensitisation of community and opinion leaders; offering male friendly services and providing transport money for men willing to come to the clinic.

Targeted sensitisation of men

Participants emphasised the need to scale up information, education and communication programmes targeting men. The participants argued that men should be informed about the importance of accompanying their partners to antenatal clinics, and the benefits of HIV testing for their health, the health of the spouse, and the health of their children.

Men should be made aware of the benefits of HIV testing. Women do test and many are obligated to test during antenatal. But for the men, a way must be found to sensitise them because this thing concerns their health as well (HIV positive pregnant woman, Malawi).

This sensitisation should also be innovative and strategic, aimed to reach more men who are typically not reached using ‘traditional’ outreach programmes which are largely limited to clinics. They suggested the need to expand outreach services to traditionally male spaces such as bars, football arenas, and workplaces.

I would suggest that we sensitise mostly in places where men are found, like working places, markets, bars. We go and sensitise the importance of the male partners to be escorting their wives for antenatal services through the radios and TV (Health Worker, Zambia)

Sensitisation of community and opinion leaders

Some participants suggested that sensitisation should go beyond the healthcare sector by including the community and key opinion leaders such as traditional leaders, religious leaders, political leaders and employers. Training men to talk to their peers about women’s health during pregnancy may also be useful.

When we engage the chiefs at that level, information will trickle down to their subjects … We can equally engage, encourage our district, when they have stakeholder’s meetings or community meetings. They have the neighbourhood health committees and it’s through those neighbourhood health committees that information trickles down to the community. We are also working with Safe Motherhood Action Groups … we call them SMAG. They are community-based volunteers and among the SMAGS we have a number of men being trained as SMAGs. So SMAGS are not just women, we have men spearheading those groups as well (Policymaker, Zambia)

Male friendly services

Some suggested a restructuring healthcare services, particularly maternal and child health services (including PMTCT programmes) to make them more friendly to men. Participants recommended that women who access antenatal services with their male partners should be given priority and express services to enable the men get back to their ‘work’ or business and reduce loss of income, which forms a basis for the breadwinner role. The operating hours for the PMTCT services should be flexible to include after work hours and weekends as well as outreach community services to enable more men and their spouses access the services as a couple.

They might have specific weekend days; what we call family testing days. We can bring the partners together because mainly the husband is busy with work during the week. Or they can actually go talk to them in their workplaces and later follow-up and test them in their household in the community if they are comfortable (Policy maker, Malawi).

Transport reimbursement

Participants suggested providing transport money or reimbursing men who find it difficult to reach the services because of distance. Further, some participants recommended that men could be motivated to come to the facility for PMTCT services with incentives such as T-shirts, caps, and training skills.

Those people who want to come and have their test from the hospital. I think they are just looking at their movements in terms of transportation because not everyone has some money and is comfortable … but of course you have to identify a group of people that can be given some transport money (Male partner, Zambia).

Discussion

This study highlights the positive roles that men can play in support of PMTCT programmes, many of which are aligned with those of hegemonic masculinities. These positive roles included men providing their spouses with material support including providing money for food and transport to seek health services. It also included men getting involved in decision making on the health of their spouses during pregnancy and breastfeeding. Further, men offered social support and participated in HIV testing with their spouses; those whose spouses tested HIV-positive provided support for HIV treatment. The identified barriers and challenges reflected a conflict with the performance of hegemonic masculinities associated with men’s working and breadwinner roles, and their perceptions about men’s health. These included the operating hours of PMTCT services, the perception that PMTCT programmes are female spaces and for the sick and weak, men’s fear that a positive status will make them be seen as weak, and women’s fear of disclosing their HIV positive status to their partners due to fear of loss of marriage and material support. The proposed strategies to optimise men’s engagement in PMTCT programmes were also fitting the men’s roles and activities which included targeted sensitisation of male audience, engaging community leaders and employers, providing services outside work hours, and provide men transport reimbursement.

These findings are generally consistent with findings reported by other studies (Blackstone et al., 2017; Brittain et al., 2015; Mabachi et al., 2020; Manjate Cuco et al., 2016; Nyondo-Mipando et al., 2018). However, a critical discourse analysis employed in this study suggests that men’s roles and participations in PMTCT is a navigation of the hegemonic masculinity ideologies, norms, and roles. Using the hegemonic masculinities perspective, the findings in this study and others suggest that pregnancy is a pivotal moment in a man’s life because it begins his journey to fulfil expected masculine roles as a father, head of the household, breadwinner, and ultimate decision maker (Hendricks et al., 2010; Silberschmidt, 2005). Men providing material support to their spouses during pregnancy – including encouragement or participation in HIV testing, treatment, and care – is a performance of hegemonic masculinity roles. This suggests that hegemonic masculinities could be harnessed to encourage men to play a positive role in the promotion of maternal-child health services, which has been traditionally considered to be for women (Slegh et al., 2013). Men engaging in complicit masculinities (struggling to perform hegemonic masculinities) can be supported with resources such as employment and business skills to enable them perform these supportive roles to maternal and child health. This is especially important since men who engage in complicit masculinities have a tendency of engage in toxic forms such as gender-based violence, multiple sexual partners, and unprotected sex (Jewkes et al., 2015; Jewkes & Morrell, 2010).

It is also fair to acknowledge that men’s supportive role is not always a reflection of performance of hegemonic masculinities, but rather reflects men’s deliberate behaviour to engage in historically marginalised masculinities due changing perceptions and behaviours on gender issues (Closson et al., 2020). For example, the issue on emotional support, care and love which did not come out explicitly in this study is becoming an emerging issue in recent scholarly work. This work, mostly on transformative and changing gender norms, has reported cases of men offering genuine care, love, and emotional support to their partners (Closson et al., 2020; Gibbs et al., 2020; Madhavan et al., 2018).

The changing perceptions and behaviours of men – and inclusion of marginalised and subordinate masculinities to the mainstream hegemonic masculinities – creates a hierarchy of masculinities, making it difficult for men to balance these contradictory, conflicting, and often dynamic social and gender roles (Gibbs et al., 2020; Madhavan et al., 2018; Russell, 2019). This struggle to balance the changing gender and social roles with traditional roles may explain why some hegemonic masculinity norms can paradoxically hinder male participation in PMTCT services (Chikovore et al., 2016; Mabachi et al., 2020; Manjate Cuco et al., 2016; Sileo et al., 2018; Zissette et al., 2016). For example, one of the barriers and challenges to male participation in PMTCT services was that the services were not in conformity with men’s working hours. This ‘challenge’ is directly conflicting with some of the valued and interconnected hegemonic masculinities that men found difficult to negotiate. As indicated above, for men to be considered breadwinners, they need to work or in some way generate income to support their families (Blackstone et al., 2017; Silberschmidt, 2005). So when the PMTCT operational hours are in conflict with the time they generate their income to support their families, it creates conflict within these perceived roles and can make it difficult for some to participate (Sileo et al., 2018; Zissette et al., 2016). This dynamic can be extended to other barriers identified in this study. For example, women’s reluctance to disclose their HIV-positive status because they feared abandonment or divorce, as also shown by other studies (Anglewicz et al., 2017; Chikovore et al., 2016), is underlined by women’s dependence for survival on their male partners as breadwinners.

The perception that PMTCT services are part of a woman’s healthcare (Anglewicz et al., 2017; Chikovore et al., 2016; Manjate Cuco et al., 2016; Sileo et al., 2018; Zissette et al., 2016) and the fear expressed by some men about HIV testing (Nyondo-Mipando et al., 2018; Sileo et al., 2018) underline the notion in hegemonic masculinity that men are strong, aggressive and not expected to be weak or sick (Blackstone et al., 2017; Chikovore et al., 2016; Skovdal et al., 2011). With such reasoning, the hospital – and the antenatal and under-five clinics in particular – are associated with weak members of society (Skovdal et al., 2011). This perception has been escalated by the configuration of healthcare systems which have historically treated antenatal care as a female service, where men (including male midwives), were not allowed (Blackstone et al., 2017; Skovdal et al., 2011). Even the name ‘PMTCT’ emphasises the role of the ‘mother’ in the original paradigm of vertical transmission of HIV, despite the role male partners play as the source of HIV infection to the baby through the mother. With such a historical configuration of PMTCT services, in a context that upholds and celebrates a strong and aggressive man (Skovdal et al., 2011), a man who attends antenatal services and seeks an HIV test could be seen as weak and controlled by his spouse (Anglewicz et al., 2017; Zissette et al., 2016).

It is therefore unsurprising that strategies aimed at enhancing and optimising men’s participation in PMTCT programmes reflect the ways that hegemonic masculinity ideology and norms are deeply held, conformed to, and reinforced (Connell & Messerschmidt, 2005). These strategies are common across many studies in sub-Saharan Africa (Mabachi et al., 2020; Manjate Cuco et al., 2016) and include educating men and custodians of social norms on the benefits of HIV testing and treatment, restructuring the PMTCT services to make them male friendly, and providing incentives may have some utilitarian value. However, they may do little to transform the patriarchal norms, which give breath to the hegemonic masculinities that underlie men participating in PMTCT programmes.

The policies and programmes on HIV prevention and treatment, including PMTCT programmes need a more transformative approach aimed at dismantling and de-centering the patriarchal norms and the influence of hegemonic masculinities in the configuration of the healthcare system (Gibbs et al., 2020). There is a need to reconstruct PMTCT services and broad healthcare systems through progressive gender and health transformative programmes that are showing positive results elsewhere where men are playing positive roles in maternal-child health programmes, without exacerbating the gender gap between men and women and maintaining women’s autonomy (Gibbs et al., 2020; Russell, 2019). For example, transformative gender and health programmes implemented in South Africa and Rwanda showed that men developed some positive attitudes towards women’s rights, and participated more in domestic work including child care (Slegh et al., 2013).

Our study contributes to the body of knowledge in a number of ways. First, the use of the hegemonic masculinity perspective puts into context the role of men in women’s health during pregnancy (Aliyu et al., 2019). Second, the use of data from two different African countries for this analysis adds depth and value to the analysis. Third, the fact that we are still seeing some of the same challenges on engaging men in antenatal care over time despite the fact that the landscape of HIV treatment and care has changed dramatically is important to document. However, we also note several limitations. For example, our study was not configured to present differences between Zambia and Malawi. In our themes of interest, what emerged was reflective of nuances rather than actual differences in the hegemonic masculinity perspective. Our use of a single and focused theoretical perspective may leave out other contextual issues that underlie the role and participation of men in PMTCT programmes in our study settings. We also acknowledge that the information we have presented here lacks firsthand perspectives from the majority of men not willing to participate in PMTCT services. This is not unique to this study but a general challenge in the medical literature (Russell, 2019; Sileo et al., 2018). There is a need to invest in research on innovative methods and technologies that would help reach men to play research and practical roles in PMTCT programmes (Gibbs et al., 2020; Mweemba et al., 2021). Further, the emerging issues of men’s emotional support and care in maternal child health programmes, in the context of marginalised and subordinate masculinities, requires further research (Comrie-Thomson et al., 2020; Gibbs et al., 2020; Madhavan et al., 2018). Finally, we recognise that participants’ real lives and experiences are much more complex than depicted in this study because of the dynamic socio-demographic contexts and interpersonal relationships. As such, our findings should interpreted reflexively.

Conclusion

In this critical discourse analysis, we demonstrated that men play both positive and negative roles in PMTCT programmes and these can be explained in part by hegemonic masculinities. These include head of household, ultimate decision maker, breadwinner, worker and the expectation for men to be strong and healthy. Without an understanding of how men shift and adapt their power and hegemonic masculinities, newly introduced interventions to increase male partner involvement in PMTCT may produce unintended – and possibly contradictory – results.

Acknowledgements

We thank the study participants for participating in this research. We also extend our appreciation for the support from the Ministries of Health in Malawi and Zambia, University of North Carolina Malawi and Zambian Projects, and the University of Zambia.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was funded with support from the National Institute of Allergy and Infectious Diseases [grant number: R01 AI131060, K24 AI120796, P30 AI050410], the National Institute of Mental Health [grant number: R00 MH104154], and the Fogarty International Center [ grant number: D43 TW009340].