The Determinants of Husbands’ Support in Maternal Care Access in

Public Health Centers

A Cross-sectional Study on Planned Behavior Theory

Setho Hadisuyatmana, Ni Ketut Alit Armini and Nusrotud Diana

Faculty of Nursing Universitas Airlangga, Kampus C Mulyorejo, Surabaya, Indonesia

Keywords: Husbands’ Support, Intention, Behavior, Maternal Care, Healthcare Access

Abstract: A husband’s support is fundamental for mothers to access maternal care and check-ups. However, the

fluctuating numbers of mothers gaining access requires further investigation. A cross-sectional approach

was used to explore the variables highlighted in the Theory of Planned Behavior (attitude, subjective norm,

perceived behavior control, intention, and participative behavior). One hundred and four husbands

participated in this study. Data were collected using questionnaires and observation checklists and then

tested using the Spearman rho with the α < 0.005. The results indicated that positive attitude and perceived

behavior control significantly correlates with the intention to support wives (the value of p = 0.000, r =

0.440 and p = 0.001, r = 0.309 respectively). Nevertheless, there is no correlation between the subjective

norm and intention (p = 0.904 [p > α]). Further analysis shows that intention mildly correlates with

participative behavior (p = 0.041 and r = 0.200). This study reveals that the lack of health education and the

clashing of participants’ working hours and health services’ opening-hours hinders access to maternal health

support. It is suggested that husbands’ involvement in health education, and the health services’ opening

hours, should be elaborated as ways to improve mothers’ access and health outcomes.

1 BACKGROUND

The maternal care program is one of the Ministry of

Health’s priorities and acts as one of the key

indicators in the Indonesia’s national long-term

development plan for 2005–2025 (Darmin, 2016).

The program was designed for mothers to ensure

they access regular check-ups during pregnancy and

to promote safe delivery and regular post-partum

check-ups for 40 days post-delivery. This program is

publicly provided through public health centers

(known as Puskesmas) and other primary healthcare

service facilities across the country. However, the

monthly report shows that the number of mothers

accessing the Puskesmas was far from satisfactory.

As in Surabaya, this situation was indicated by the

low number of pregnant and post-labor mothers

accessing the service in Puskesmas-es (Dinas

Kesehatan Kota, Surabaya, 2015). Prior research

suggests that many husbands did not sufficiently

support these mothers in attending maternal visits

(Musyriqoh, 2016). Kaye et al. (2014) highlight that

a husband holds a significant role in mother’s

maternal health outcomes. Positive attitude and

knowledgeable support from the husband are

significant for improving attendance, which, in turn,

promotes better health outcomes (Sari, 2013).

Nevertheless, there is a paucity of reports suggesting

factors that determine husbands’ support with access

to maternal care.

The local health office, Dinas Kesehatan Kota

Surabaya (2015) reported that the monthly

percentage of mothers accessing maternal care

varied across regions of Surabaya, ranging from

71.05% to 78.17%. It was suspected that this

fluctuation was due to inconsistent support from

husbands. This presumption is possible, since a

husband holds a central role in decision making,

particularly in the Javanese community, including

access to maternal health-care (Ishak, 2005).

Furthermore, a husband’s role is significant in

providing comfort and safety for his wife during her

pregnancy and the first post-labor month of

(Anggraini, 2012; D.A. Sestu Retno et al., 2016).

This included accessing health care for maternal

control, complying to professional advice, and

receiving care deliveries. This supportive behavior is

Hadisuyatmana, S., Armini, N. and Diana, N.

The Determinants of Husbands’ Support in Maternal Care Access in Public Health Centers.

DOI: 10.5220/0008320300510055

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 51-55

ISBN: 978-989-758-336-0

influenced by various factors and conditions, both

internal and external (Shahjahan, 2006). A husband’s

knowledge and level of education, as well as

psychological maturity, determine his readiness to

become a father (Hafidz, 2007). As external factors,

the cultural norms and views in Indonesia that put

women into a generally lower position, conflicts

with the expectations of husbands becoming more

supportive to their wives when pregnant and in labor

(Hargi, 2013). Moreover, the traditional norms also

limit women’s access to a higher level of education,

roles in decision making within a household, and in

accessing maternal healthcare (Davis, 2016; Putri,

2015).

Research around husbands as contributors to

maternal health outcomes is expected to be one of

the alternative solutions in developing strategies to

promote access for mothers to healthcare (Kadam &

Payghan, 2013). This research aims to explore

factors that correlate with husbands’ participation in

supporting their wives to access maternal health.

Ajzen’s (2005, 2006) Theory of Planned Behavior is

believed to be reliable as a lens with which to unveil

the studied variables.

2 METHODS

This study adopts a cross sectional approach to

unveil the correlations between independent

variables (men’s attitude, subjective norm, and

perceived control behavior) and dependent variables

of the intention to support their female partners

accessing maternal healthcare. Also, in investigating

the correlation between the support and participative

behavior. The p value of smaller than the α = 0.05 to

reaches the significant level of 95%.

This study invited men who were husbands to

mothers who access one public health center in

central Surabaya for maternal health checks, ranging

from antenatal care to those who had infants

younger than 45 days old. The invitation was limited

to men younger than 45 years old who were able to

read and write. This is because the maternal health

manual provided by the government of Indonesia is

only provided in book format.

The data were collected through a self-assigned

set of questionnaire as the main instrument for this

study. The instrument in this study was developed

with reference to Francis et al. (2004) and was

adapted and modified from previous studies by

Anggraini (2012), Sari (2013), Fitria (2010),

Ocbrianto (2012), and Rafidah (2012), all of which

were tested for validity and reliability. The content

of the Maternal Health Manual (2016) was translated

into an observational checklist to triangulate men’s

participative behavior.

A total of 119 sets of questionnaires were

distributed and consent was offered to husbands who

were accompanied their wives for maternal health

checks at the public health center. As many as 104

(87.4% response rate) men voluntarily participated

and returned the finished questionnaire. The data

were then sorted and cleansed for further analysis.

Studied variables were analyzed using the Spearman

rho test. This study was ethically evaluated and

granted by the Health-Research Ethic Committee of

The Universitas Airlangga under the certification

No. 397-KEPK.

3 RESULTS

One hundred and four participants (104) were

predominantly aged between 31 and 40 years

(49.1%). More than half of them had graduated from

senior high school as their highest level of education

(55.8%). Most of the participants were Moslem by

religion (98.1%) and had a monthly income lower

than Surabaya’s standard minimum wage (52.9%)

(see Table 1).

Table 1: Demographic characteristics of men participating

in the current study, exploring their support for mothers’

access for maternal health service dated June–July 2017

Partici

ants’ characteristics n

(

)

e ran

e in

ears

–

30 44

(

42.3%

)

–

40 51 (49.0%)

>41 9 (8.7%)

hest education level

Primar

school 8

(

7.7%

)

Year 9 16

(

15.4%

)

Year 12 58 (55.8%)

Higher education 22 (21.2%)

Religion

Moslem 102

(

98.1%

)

Christian 2

(

1.9%

)

Monthl

income

<City standar

55 (52.9%)

Average 27 (26.0%)

>City Standar

22 (21.2%)

∑

104

The univariate analysis identified that 52.9%

participants provided sufficient support for their

wives regarding accessing maternal care and 39.4%

intended improving their wives’ access to Puskesmas

for proper maternal care (The Spearman test showed

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

the value of p = 0.000 (α<0.050) with a correlation

coefficient of (r) = 0.440. This implies that

husbands’ positive attitude significantly correlates

with their intention to improve access to proper

maternal care for their wives (see Table 2).

Men’s subjective norm reflects their level of trust

in healthcare facilities and motives in ensuring their

wives access maternal healthcare (Ajzen, 2005,

2006). More than half of the participants (57.69%)

did not trust health centers and had low motivation

when supporting their wives. However, 53.85% of

the participants preserved their intention to

encourage their wives to attend health centers for

check-ups. Regarding this phenomenon, the

Spearman rho test indicated a value of p = 0.904 (α

= 0.050), which means there is no correlation

between the two variables (see Table 2).

Table 2: Univariate and bivariate test results on the studied

phenomenon to explain attitude, subjective norm, and

perceived behavior control with the intentions of men as

participants

Measured Var. Intention

Attitude

High Low Total

n (%) n (%) ∑(%)

Supportive

41 (39.4) 14

(13.5)

(52.9)

Negative

15 (14.4) 34

(

32.7

)

(

47.1

)

Total

56 (51.8) 48

(46.2)

104

(100)

= 0.000, r =0.440

Sub

ective Nor

Positive

24 (23.08) 20

(

19.23

)

(

42.3

)

Negative

32 (30.77) 28

(26.92)

(57.7)

Total

56 (53.85) 48

(

46.15

)

104

(

100

)

= 0.904, r = 0.012

Perceived Behavior Control

Positive 36 (34.62)

(

15.38

)

(

)

Negative 20 (19.23)

(

30.77

)

(

)

Total 56 (53.85)

(46.15)

104

(100)

= 0.001, r = 0.309

Table 3: The Spearman test on the correlation between

men’s intention and supportive behavior to their wives’

access to maternal healthcare

Intention Im

lemented su

ort

Sufficient Insufficient Total

n (%) n (%) n (%)

High 39 (37.5) 17 (16.34) 56

(

53.84

)

Low 24 (23.08) 24 (23.08) 48

(

46.16

)

Total 63

(

60.58

)

(

39.42

)

104

(

100

)

= 0.041, r = 0.200

The perceived behavior control illustrates the

perceptions of participants regarding the ease of

supporting their partners access to maternal

healthcare (Ajzen, 2005; 2006). Half of the

participants (50%) perceived that it was easy to

provide the expected support. However, about a fifth

of them claimed to be supportive to their wives. The

statistic test (Spearman rho) result indicated that the

two tested variables were significantly interrelated

(p = 0.001 lower than α of 0.050). Nevertheless, the

coefficient was weak (r = 0.309).

Most participants in this study were supportive

(53.84%) and 37.5% of them actively participated

when their wives needed to access maternal

healthcare (see Table 3). However, the Spearman test

revealed a value of p = 0.041 (lower than α = 0.05)

and r = 0.200. This result implies a weak correlation

between the tested variables.

4 DISCUSSION

The statistical results of this study show significant

correlations among tested variables. The first result

indicated that husbands’ attitude has a significant

correlation with their intention and participative

action regarding supporting their wives in properly

accessing maternal health services. Most participants

aged 31–40 years fully supported their wives for

antenatal visits and continued supporting them until

completing the post-partum care program. This

participative activity is reflected through

participants’ presence in accompanying their wives

accessing maternal care. This finding shares a

similar result with an earlier study, suggesting that

men’s age and maturity were significant

determinants to their readiness to become fathers

(Hafidz, 2007). Presumably, their age-range reflects

men’s peak physical state, which enables them to

actively participate when their wives need to access

maternal healthcare.

Furthermore, an earlier study addressed the need

for women to receive continual support during

pregnancy (Anggraini, 2012). The respondents of

the study stated that a husband’s presence would

make them feel more comfortable, secure, and

encouraged. Further support, such as actively

encouraging wives to access maternal healthcare,

would improve the health outcomes (Rumaseuw et

The Determinants of Husbands’ Support in Maternal Care Access in Public Health Centers

al., 2018; Suryondari, 2010). This is mainly due to

the central role of the husband in decision making

within the household, including permitting his

pregnant wife to have periodic pregnancy check-ups,

promote safe labor, and post-natal control (Kadam &

Payghan, 2013).

A deeper analysis revealed the participants’

preferences in supporting their wives. Although the

participants were supportive, they would prefer not

to support their wives. These participants were

reluctant and many preferred to put their wives off,

if possible. This negativism was highly influenced

by their lack of understanding regarding the reasons

for supporting their wives in accessing maternal care

and health services. The respondents of this research

anecdotally voiced the absence of health education

as reasons for the low support they give to their

spouses. They added that health professionals had

never informed them of the importance of periodic

check-ups, safe deliveries, and post-partum care, as

well as the role of a husband in supporting his wife.

Rumaseuw et al. (2018) and Singh (2014) support

this result and suggest that education for husbands

should be included as a strategy to promote their

active participation in maternal health and access to

care. This finding supports previous research results

by Bishwajit (2017), Suryondari (2010), and

Wardani (2012), highlighting the significance of

maternal health education for husbands as a strategy

in improving mothers’ access to healthcare centers.

The results also reveal the correlation between

the variables of perceived control behavior and

husbands’ intention to participate in supporting their

wives in their maternal health. This was indicated by

most participants’ perceptions toward the results of

their wives’ visits for maternal care, despite low

health literacy, monthly income, and social support.

Secondly, the parallel of the

respondents’ work

hours and Puskesmas’ service-hours often became a

significant barrier in supporting access to maternal

healthcare (Nesane, Maputle, & Shilubane, 2017).

Because participants’ working hours are usually at

the same time as the maternal health service hours, it

becomes

evident that this hindrance was inevitable.

Thus, this finding suggests

that the Puskesmas need

to reconsider their open-for-service hours to enable

husbands to take their wives for maternal healthcare

check-ups, and subsequently actively participate in

promoting health outcomes.

Ajzen (2005) identifies intentions as an indicator

of how strongly a person is convinced, and how

likely individuals are to implement intentions into

action. The results of this study indicate that

husbands’ intentions are weakly correlated with their

participative support in taking their wives to access

Puskesmas. The lack of males’ involvement in

maternal healthcare education and time barriers are

reasons for this weak correlation. Not only does this

limit the support they can give to their wives, but

also prevents active participation in promoting

mother and child’s health outcomes. Therefore, it is

suggested that the results of this study should be

considered to improve mothers’ access to healthcare

and better health outcomes.

5 CONCLUSIONS

In summary, this research reveals two significant

contributors to husbands’ low participation in

supporting their wives access to maternal healthcare

in Puskesmas settings. The absence of maternal

support is reasoned by the lack of health education

of males as the primary decision maker in the

household. Secondly, the clash of husbands’ working

hours and opening hours of Puskesmas centers were

inevitable. Furthermore, this research highlights at

least three strategies to improve husbands’

participative actions and access to maternal care in

Puskesmas. Firstly, maternal health education for

husbands is significant in developing fundamental

understanding and awareness towards the central

male role as the decision maker in a household.

Secondly, this result suggests that Puskesmas need

to extend their opening hours to allow working

husbands to accompany their wives for maternal

check-ups.

ACKNOWLEDGMENTS

We would like to thank family members and men

participating in the current study, exploring their support

for mothers’ access for maternal health service

in this

research. We also appreciated all nurses and staff of

Puskesmas Surabaya Indonesia for all facilitation

during this research.

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The Determinants of Husbands’ Support in Maternal Care Access in Public Health Centers