JINJA, Uganda (WOMENSENEWS)--One recent morning, in the maternity ward of Mpumudde Health Center No. 4, a dozen women waited on a harried midwife in a long white uniform. Three were pregnant, a handful needed contraceptives and one exhausted mother who had delivered minutes earlier sipped a Coke in one of the iron-framed twin dormitory beds.

There was also one man. Moses Funga, a shopkeeper who sells "general goods" out of a wooden shack in a nearby village, had for the first time accompanied his six months' pregnant wife, Claire Nakitende, for a routine prenatal check. What finally inspired him to take the two-kilometer boda boda ride to the clinic, he said, was a simple note he received recently.

His wife presented the short typed form letter, signed by the local district health director, after a visit to the clinic; it contained some basic information and a polite request to come to a clinic in person to discuss matters such as HIV testing, what to expect during the delivery and how to care for a pregnant woman.

Waiting nervously for an HIV test on a bench at the Mpumudde clinic, Funga said he'd been meaning to come to the clinic with his wife, but he was always too busy.

"But once you see a letter like this, you get the courage to come," he said. "It will help me to know what is required of her."

The "love letter" to fathers, as health workers here dub it, is part of a yearlong effort to involve men in reproductive care. Health workers say that for childbirth to become safer for mothers and babies, women must have support from families, communities and especially their partners.

Small Success Story

While similar outreach efforts aimed at men have run aground, health workers call the letter a modest but significant success.

They say it's boosted the number of men who accompany their wives or girlfriends to clinics to 7 percent from 2 percent.

"Now we have men going home to the village saying that they listened to the heartbeat of their unborn baby!" said David Kitimbo, local district health director.

Written in both English and Luganda, the local tongue, the love letter addresses the partner of every pregnant woman who sets foot in a public health facility in the district of Jinja, an area about an hour east of the Ugandan capital.

Kitimbo says the secret of the love-letter success is its direct and personal appeal. "If a man really cares for his wife and his unborn child and he receives this letter, then he should come," he said. "It's a sign of love for his family."

The critical hurdle seems to be getting men to show up for that first visit. After that, they tend to come back.

Global Aims Off-Target

Global efforts to meet international targets of greatly reducing maternal and child mortality by 2015--part of the United Nations' so-called millennium development goals--have so far been very slow.

Some 536,000 women in the world die each year as a result of largely preventable pregnancy and childbirth-related complications, the vast majority of them in the developing world. In Uganda, the maternal mortality ratio (the number of women who die during pregnancy, childbirth and the six weeks following pregnancy) is 435 deaths per 100,000 live births annually, among the world's highest. They die from hemorrhage, infection, unsafe abortions and other causes that are easily avoidable if women get proper medical care.

Ambitious and well-funded projects often fail, health workers here say, because they don't sufficiently address the social aspects of the problem: Building clinics is not enough.

"Without the knowledge and support of the husband, it is very difficult for women to seek proper and consistent care, regardless of their situation," said Sarah Byakika, Jinja's deputy district director of health services, who helped spearhead the love letter campaign.

When a man arrives at the clinic for a first prenatal visit, he is not treated passively. He is weighed; his temperature and blood pressure taken alongside his partner's. Men should feel as though they're getting value for taking the trouble to show up, Byakika said. It is also to drive home the point to the father that he is directly involved in the childbearing process.

Men Missing From AIDS Testing

Byakika and her colleagues were pioneers in Uganda's ambitious effort to reduce the rate of mother-to-child transmission of the AIDS virus, which began in 2000. They realized back then that one of their biggest challenges was reaching men. While more than 95 percent of women who came to clinics agreed to voluntary testing and counseling for HIV, almost none of the men showed up.

"They just don't come," said Byakika.

Byakika said the love letter, in addition to getting some men to come to the clinics, also gives women much-needed bargaining power; it provides them with a way to confront their husbands about sensitive issues of health care.

Without male support, Byakika said it was virtually impossible to get HIV-positive women to follow through on interventions to protect their babies and themselves. The stigma surrounding AIDS remains powerful in Africa. Infected women who covertly tried to seek treatment at health centers faced suspicious questioning from their husbands and the threat of punishments or beatings, health workers found. Under those conditions practicing safe sex was virtually impossible.

Before hitting on the love letter approach, Jinja district health workers employed a variety of strategies to coax men to come to clinics with their pregnant wives. They composed a catchy radio jingle since radio is the main means of mass communication in Uganda. They tried appearing on radio and television talk shows to educate the public on the importance of male involvement in the childbearing process. These campaigns ran for over a year but registered almost no impact, said Byakika.

Rachel Scheier is a freelance writer based in Kampala, Uganda.

Women's eNews welcomes your comments. E-mail us at editors@womensenews.org.

For more information:

U.N. Millennium Project, Child and Maternal Health:
http://www.unmillenniumproject.org/reports/tf_health.htm

"Political Neglect Kills Mothers by the Millions":
http://womensenews.org/article.cfm/dyn/aid/3352/context/archive

"Maternal Health Donations Overflow Bush Blockade":
http://womensenews.org/article.cfm/dyn/aid/3378/context/archive

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