Background: Effective and quality RMNCAH outcomes are linked to reduced risk to violence. This study explored negative stereotypes of hegemonic masculinity and the social structures linked to it. An exploration of 8 Sub-Saharan African countries found country-specific definitive social structures impacting the stereotypes, i.e., Enabling; Restrictive; and Hindering structures.
According to MoH Guidelines on Maternal Nutrition in Uganda (2010), this includes all processes ensuring safer, optimal birth outcomes, maternal wellbeing, nutrition and autonomy for women to have opportunities for self care. Maternal malnutrition, sets in place an intergenerational cycle of maternal nutrition. Which in turn affects pregnancy, lactation, undernourishment in utero, low birth weight babies, stunted growth and adolescent pregnancies.
Violence as related to maternal health and nutrition here is all those actions that tend to discriminate against women’s maternal health and nutrition needs. They subsume women and elevate male needs. AT household level these come in the form of: aggression or such actions that are used to deliberately deny a women or children access to resources that are life promoting, agency, set preservation and autonomy. According to WHO (2002), violence is “the intentional use of force or power, threatened or actual, against oneself, another person, or against a group or community that either results in, or has a higher likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.”
Whether men seek consent before sexual intercourse; whether men are conscious of the notion of age of consent; precarious toxic masculinity practices and notion of transgression such as: gender role transgression, perceiving safer sex initiated by women as threats, tendencies for aggression to portray/power posturing, blocking or denying women access to resources (toxic custodianship) and silencing women by shaming feminine voicing ( toxic censorship). According to Dr Olaro Charles, the Director Clinical and Community Services, “Women who give birth before age 20 are at greatest risk of fistula. Poor nutrition during a girl’s childhood can also cause stunted growth and increase her risk for fistula.”
One of the findings in a study by Kaye (2006) titled “Domestic violence as risk factor for unwanted pregnancy and induced abortion in Mulago Hospital, Kampala, Uganda,” was that pregnancy intentions have many causes: One is to pacify and aggressive male partner who may demand a child (virility) or for the woman to prove her fertility (fecundity). In other words, pregnancy intentions have social pressure causes too, on top of others.
- d’Oliveira et al (2002) in a study titled “Violence against women in health-care institutions: an emerging problem,” argue that Maternal morbidity and mortality in childbirth also stems from violence committed by health workers in childbearing or abortion services, which affects health-service access, compliance, quality, and effectiveness.
- The unavailability of formal recording and reporting tools that capture assault women face from their partners in domestic settings make it harder to generate accurate cross cultural estimates of wife assault because only a few countries have attempted a nationwide accounting. But the data that do exist give cause for concern according to Heise of cisas.org.
-Enlisting and emancipating women to report violence against them is one way violence will be checked. Whether or not women will participate fully is another matter. There is fear that if they voice, then they will exit their homes, which therefore means they prefer to take up silence and suffering. This has implications. According to (WHO 2013) report titled ‘Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence,’ “Violence against women has consequences to women’s physical, mental and reproductive health. What is new is the growing recognition that acts of violence against women, violates the rights of women and girls, limits their participation in society, and damages their health and well-being. It is a global public health problem that affects approximately one third of women globally.”
Methods: Meta-analysis of data from 2000-2019 of relationship between violence against women and children, is reflected in reports generated during: Trauma Informed Care (TIC); comprehensive RMNCAH strategies such as IMNI, A/PNC, KMC, perinatal death review, and/or integrated maternal and perinatal death surveillance and response (MPDSR) processes; catalyze the well woman agency; enforcement of legal gender equality; religious and traditional support for respect and dignity of women; uptake of gender-specific prevention services; Domestic Violence (DV) reports and HIV Prevention. 170 articles and reports were identified but 80 met inclusion criteria.
Results: Stereotypes of hegemonic masculinity exist in all 8 countries studied. Politics, religion and tradition influence risk reduction, e.g., enforcement of legal gender equality, political commitment and accountable judiciary ensure women can report abuses. Male dominance beliefs; traditions e.g. precarious toxic masculinity, indifference to expectant mother health by males, stigmatization of frequent clinic visits; and gender of breadwinner are linked to violence-related risks. Compared to all 8 countries, Rwanda, Ethiopia and Kenya have a hindering structure promoting significant risk reduction with institutions fostering increased rule of law, political commitment to RMNCAH outcomes, enforcement and risk-reduction consciousness. Uganda and Tanzania have a restrictive structure characterised with legal loopholes, irregular enforcement and ambivalent political commitment to address acts of violence against women and children. In Senegal, South Africa and Nigeria political, religious and traditional factors blatantly backing traditional negative stereotypes of hegemonic masculinity foster violence enabling structures entrenching repressive acts and hate crimes against women and children. In all countries however, Delivery room reception; level of Health Information Management skills; HIV criminalization; affinity and sensitivity to quality health by all people; stigma around attending clinics by males; negotiating for safer sex by women which is circumscribed as a threat to male dominance, subvert or support optimal RMNCAH goals.
These are precarious male identity and masculinity tendencies that are aggressive, abusive, silence the voice of women and children, use sexual, gender roles to posture and portray power. They are characterized as influencing sexual, gender, agency, autonomy roles. Through sexual roles, males expect and assume they are entitled to sexual intercourse at their will even if it meant without any form of protection. A precarious gender role situates the woman as the submissive kind who should not transgress that expectation. Gender transgression is construed as a threat to male identity and power. By precarious agency is meant that it is only males who are supposed to think on behalf of the family. If women demand things beyond what the male provides, this depicts him as a failed provider. A failed complex means that the man is inadequate and therefore feels threatened. Precarious autonomy, means that it is the males who are independent, get the prestige, respect, recognition and praise for all that is good and not the woman. The woman is dependent and so are all the children. This has implications on age of first sexual debut, how the woman’s input is sought when it does to planning the size of family, money and time set aside for maternal nutrition and self care. Power is derived from authority, economic, social, cultural and leadership positions.
According to the UNICEF’s Maternal And Health Disparities Uganda (2017), these negative and toxic male stereotypes contribute to higher numbers of adolescent pregnancies, higher Maternal Mortality Ratio and Neonatal mortality Rate (NMR).
According to MoH Guidelines on Maternal Nutrition in Uganda (2010), these included: preconception, pregnancy stage, lactation stage and recognising partner affinity to provide safe and optimal birth outcomes. The list included provisions such as: Folic acid; ensuring proper weight gain during pregnancy; Antenatal care; iron and folic acid supplementation; malaria and worm control to prevent anaemia; diet during pregnancy and lactation; Vitamin A Supplementation; Postnatal care and iron and folic acid supplementation; Iodine supplementation; Nutrition counselling and education; Breastfeeding and family planning; Education regarding local practices that negatively affect maternal nutrition; nutrition during emergencies.
Women emancipated and empowered to engage in safer sex negotiations, access to contraceptives, gain contraceptive-use expertise, provide peer education to other women who are contraceptive-use naive and ensure maternal health autonomy.
Conclusions: Safer and optimal birth outcomes are dependent on overarching social, political and economical dispensation. These manifest as: economic autonomy, religion and traditional backing which contribute effectively to overall risk-reduction as far as maternal nutrition and health are concerned. Contexts hindering violence prevail where state-led commitment thrives and these have far reaching benefits e.g., more people demand, access and benefit from RMNCAH outcomes. Effective and quality RMNCAH programming in the countries studied will be effective if it is designed to involve males and addresses hegemonic masculinity practices too. Mortality implementation audits need to be disaggregated to reflect causes of and contributing factors to deaths such as assault to women and lack of male involvement in practices promoting optimal birth outcomes.
