Healthy mothers, healthy futures: exploring the influence of healthcare providers and male partners on pregnant women's dietary practices

¹University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda, ²University of Witwatersrand School of Public Health, Johannesburg, South Africa

^&Corresponding author
Aline Uwase, University of Rwanda, college of medicine and health sciences, Rwanda

Introduction    

Healthy maternal dietary practices during pregnancy are essential to meet increased nutritional demands for maternal and foetal health and to support future breastfeeding, with adherence to a balanced diet being a key recommendation [1]. Pregnant women's dietary choices are influenced by multiple factors, including their knowledge and beliefs, household and socioeconomic circumstances, cultural norms, and the support provided by healthcare providers, particularly nurses and midwives, as well as their male partners [2]. Midwives, as primary providers of prenatal care, are the main source of health information for pregnant women and play a central role in delivering dietary guidance, as highlighted by the International Confederation of Midwives [3]. Their involvement in delivering dietary guidance is explicitly outlined in the International Confederation of Midwives, a global organization that plays an important role in advancing the profession of midwifery and ensuring good maternal and newborn health worldwide [4]. Antenatal care services provide health professionals with the opportunity to engage in discussions and provide support about healthy dietary practices that are suggested for ensuring positive pregnancy experiences. A healthy diet includes increasing consumption of vegetables, fruits, and other key food groups, and abstaining from alcohol and tobacco [5]. However, healthcare providers often face challenges in delivering effective nutrition counselling due to limited knowledge of nutrition guidelines and insufficient resources, including shortages of educational materials, time, and trained personnel[6-8].

Male partners also influence maternal dietary practices through their involvement and provision of emotional, physical, and financial support. Such support has been associated with improved maternal and foetal outcomes, including increased health service utilization and greater dietary diversity [9-11]. However, male involvement may be constrained by limited knowledge, gender norms, sociocultural beliefs, and socioeconomic factors [12-15]. In Rwanda, especially in the Southern Province, maternal dietary practices during pregnancy are suboptimal, and poor nutritional status based on Mid-Upper Arm Circumference (MUAC) is estimated at 23% [16]. There is limited understanding of how healthcare providers and male partners support pregnant women's dietary practices and the challenges they encounter. This study therefore explored the support provided by healthcare providers and male partners to pregnant women in adopting healthy dietary practices. We specifically responded to the following research questions: 1) How do healthcare providers and male partners support pregnant women in adopting healthy dietary practices during pregnancy? 2) What experiences affect their ability to support pregnant women in adopting healthy dietary practices? 3) What recommendations do healthcare providers and male partners propose to strengthen support for healthy dietary practices among pregnant women?

Methods     

Study setting: this study was conducted in eight health centres located in the Southern Province of Rwanda; four were from a rural area, and the remaining four were from an urban area to capture diverse contextual perspectives on the support provided. The Rwanda Demographic Health Surveys of 2014/2015 and 2019/2020 show that the Southern Province accounts for the highest prevalence of underweight and anaemic pregnant women.

Study design and population: an exploratory descriptive qualitative research design was employed to explore the perspectives of male partners and healthcare providers regarding support for maternal dietary practices. Study participants included male partners of pregnant women and healthcare providers (nurses and midwives) delivering antenatal care services. Of the eight participating health centres, two urban and two rural health centres were purposively selected for the focus group discussions to ensure representation of diverse participant experiences. Data were collected through four focus group discussions (FGDs) with male partners (two rural, two urban). Each FGD consisted of 6–8 male partners, comprising 28 participants in total, and eight in-depth interviews (IDIs) with nurses or midwives, one from each health centre. Male partners were purposively selected based on residence in the study area and willingness to participate. Potential male partners were identified with assistance from healthcare providers at participating health centres and were approached by the research team after receiving permission from facility authorities. Nurses and midwives were eligible if they had worked in antenatal care services at the facility for at least six months.

Data collection process : data collection took place in October 2022. The first author, a female PhD candidate in maternal and child health and a university academic with clinical and qualitative research experience, conducted the IDIs and FGDs, assisted by a trained female research assistant experienced in qualitative research. Unstructured interview and FGD guides with open-ended questions were developed, translated into Kinyarwanda, and back-translated into English to ensure accuracy and uniformity [17]. Before data collection, the interview guide was pre-tested in a health centre with similar characteristics to the study sites but not included in the study. Feedback from the pre-test was used to refine the wording and clarity of some questions to enhance participants' understanding.

All FGDs and IDIs were conducted in Kinyarwanda, audio-recorded, and complemented with field notes. No prior relationship existed between the researchers and the participants. Before each interview, the researchers introduced themselves, explained the study objectives, and informed participants that the study formed part of the first author's doctoral research. No non-participants were present during the FGDs or IDIs. FGDs lasted approximately one hour, while IDIs lasted 45–60 minutes. Discussions with male partners focused on dietary knowledge during pregnancy, forms of support provided, and barriers to support. Interviews with healthcare providers explored their roles in nutrition counselling, the integration of dietary support into antenatal care, barriers to providing dietary support, and the management of maternal malnutrition. Saturation was assessed during data collection meetings between the research team members. Data collection was considered complete when additional interviews and FGDs no longer generated new concepts or themes relevant to the research questions. Each participant took part in a single IDI or FGD; no repeat interviews were conducted. No eligible participant declined participation or withdrew from the study.

Reflexivity: the research team considered their professional backgrounds and potential influence on data collection and interpretation. The first author's experience in maternal health research and clinical practice informed the development of the interview guides but may also have influenced interactions with participants. Reflexive discussions among the research team were conducted throughout data collection and analysis to maintain awareness of assumptions and ensure that interpretations reflected participants' accounts.

Data analysis: audio recordings were transcribed verbatim in Kinyarwanda and translated into English. Transcripts were reviewed for accuracy and completeness. Data management and coding were conducted using NVivo version 12. Data were analysed using thematic analysis following a six-step process described by Braun and Clarke: familiarisation, coding, theme development, review, definition, and reporting [18]. Both inductive and deductive approaches were used to identify and refine themes. The inductive approach involved generating themes directly from participants' narratives, while the deductive approach used the study objectives and research questions to guide data interpretation. An initial codebook was developed collaboratively by the research team. Independent coding of selected transcripts was conducted by two researchers to ensure consistency, and discrepancies were resolved through discussion. Themes and subthemes were refined iteratively and reported with illustrative verbatim quotations. Transcripts and findings were not returned to participants for comment.

Ethical consideration: the institutional review board of the University of Rwanda, where the study was conducted (287/CMHS IRB/2021), and the Human Research Ethics Committee (medical) of the University of Witwatersrand, where the corresponding author was enrolled in her PhD program (M211046) provided the ethical approvals. Before data collection, participants were informed about the study's purpose, potential benefits, and risks. They were assured of voluntary participation and confidentiality of their responses. Written informed consent, including permission for audio recording, was obtained before participation.

Results     

Demographic characteristics of participants: all healthcare providers participating in the study were female, specifically four nurses and four midwives. Their professional experience ranged from five to twelve years, and their ages spanned 36 to 50 years. The male partners of the pregnant women (n=28) were drawn from both urban (n=14) and rural (n=14) locales. Most male partners had attained a primary school education. Their ages ranged from 24 to 42 years (Table 1).

Themes and sub-themes: the thematic analysis generated three themes: (1) forms of support for dietary practices, (2) barriers to supporting healthy dietary practice, and (3) strategies for improvement of dietary practices (Table 2). Each theme had associated sub-themes, and we include verbatim quotes to provide evidence to support the themes in the presentation of the findings.

Forms of support for dietary practices of pregnant women: this theme reflects perspectives from both healthcare providers and male partners regarding their roles in supporting pregnant women's dietary practices.

Emotional support: while many men focused on their role in providing material resources, some men also stressed that their primary role was to provide a conducive household environment without any conflict. One male partner asserted that pregnant women must be emotionally supported and mentioned the impact this support could have: "…when there is no peace at home, even if you can provide everything it won't help. Because the first thing is peace and comfort, once you provide peace she gets time to feel safe, you take care of her, and she behaves like you have provided everything….the positive impact is that she will take a balanced diet, get full security, which then positively affects the baby" (male partner, 38 years, FGD2, rural).

Educational support: health care providers viewed dietary support during pregnancy as consisting of disseminating nutritional information and guidance regarding appropriate food choices during gestation, how to prepare a balanced diet, strategies to access inexpensive foods, and the importance of micronutrient supplementation like Iron and Folic Acid (IFA). The midwife in this study described the information they provide during ANC visits: "Firstly, we explain the pregnant women about a balanced diet and the proper way they should eat, and sometimes we show them how to prepare the meals because you may tell them the constituents of a balanced diet, but they may prepare them wrongly when they arrive at home. We give them some examples of foods that they may include in their meal that are not expensive to make a balanced diet. For instance, as the cultivating land is being reduced, we advise them to have a kitchen garden and some livestock like chickens so they have access to vegetables and eggs" (midwife, 40 years, IDI2, rural).

Healthcare providers address maternal malnutrition in different ways. Some refer patients to a nutritionist for specialized dietary management, while others conduct home visits to identify the underlying causes of malnutrition and develop appropriate interventions, as explained by this nurse: "The first thing we do is a home visit. We evaluate what kind of support is needed. Do they need mental support? Do they have poor information? Why are they losing weight? Is it a family conflict with the husband? Then, we encourage the male partners to influence their wife's nutrition by informing them of the importance of good dietary practices. In case of poor knowledge, we restart education in case" (nurse, 39 years, IDI1, urban).

Material support: the provision of food by male partners was seen as their significant contribution to supporting the dietary practices of their pregnant wives or partners. Some men felt immense responsibility to make available the necessary food or money for household food security and for the health of mother and baby. One man described how he saw his role in relation to providing resources for this: "You see, the first thing at home, when she needs for example, these fruits, you have to provide money for her to obtain them. If she also needs eggs, that money can help her buy them. But as a male partner, I have to provide the foods to a pregnant woman so that she will give birth to a baby with appropriate weight" (male partner, 29, FGD3, urban). To assist malnourished pregnant women coming from low-income families, the health care providers refer the pregnant women to a nutritional service within the health centre to get food supplements that consist of mixed flour to make fortified porridge or advocate for other food types from the local leaders. A nurse explained: "When we find that malnutrition is caused by the lack of food, we sometimes work with sector officers to see if they may have some food to help us. We also have some vocational foreigners who sometimes bring food here, and we can also give some to the pregnant women. Another thing we do is to refer the women to the nutritional service to get the mixed-flour (Shishakibondo) to make the porridge" (nurse, 37 years, IDI6, rural).

Barriers to supporting healthy dietary practices of pregnant women: male partners and healthcare providers experienced challenges which limited their ability to support the dietary practices of pregnant women.

Limited knowledge about good dietary practices: healthcare providers talked about how they might miss information about dietary practices or how it can be superficial, especially when they are required to educate pregnant women. They are required to play multiple roles while their education focuses mainly on providing ANC in general. Some expressed concern about their skills in communicating about dietary practices, often feeling unprepared to offer comprehensive dietary counselling: "We provide information as nurses/midwives but not nutritionists. You may listen to a nutritionist presenting and hear the difference. That means we miss some skills" (nurse, 50 years, IDI5, urban).

These limitations in knowledge negatively affect the daily practices of nurses and midwives aiming at supporting or taking care of pregnant women in terms of healthy dietary practices. A nurse explained how limited training in nutrition often hinders comprehensive dietary support: "….otherwise there are some who don't educate the clients because they have no information about it; some don't want to take anthropometric measures because they don't know how to interpret and intervene" (midwife, 37 years, IDI6, rural). Though nutrition education was delivered during ANC, male partners reported not being able to retain all the information, ignoring some or occasionally supplementing this with community beliefs, which are sometimes not correct. One male partner explained: "We are taught at the health centre, but not everybody remembers the lessons after leaving here. A nurse may continue teaching you, but eventually, you do not retain everything. You may only remember four or five messages, which means that the knowledge we have is not enough. That is why we usually rely on common knowledge because we remember much less of what nurses teach us, or there is some information that we do not consider" (male partner, 35, FGD4, rural).

Socioeconomic constraints to good dietary practices: food availability was another challenge, with participants noting that even when they had money, some foods were unavailable locally. In addition, food unavailability sometimes involves extra transport costs, leading to the unaffordability of such food in case of insufficient finance. A man said: " You may have money, and your wife may need to eat fish, but you cannot find it in your region because fish are not traded there. She may also need oranges, but they may not be available in the local market, and you have to travel to another region, such as Kigali, which requires additional transport costs. You may end up being unable to buy these foods because you only have enough money to cover the price of the food itself, without the additional transport expenses" (male partner, 45 years, FGD2, rural).

Male partners described poverty as a structural barrier that limited their ability to fulfil their perceived provider role, particularly when nutritious foods were unavailable or unaffordable. Healthcare providers confirmed that household financial constraints, especially in urban settings, negatively affect pregnant women"s ability to maintain adequate diets. A nurse explained the reactions of low-income families when they are educated about adequate dietary practices: "The main challenge we face is poverty because there are some poor families who cannot afford what is needed. This is an urban area, and there may be people who migrated from rural areas who live with casual work paying one thousand FRW (1USD) or one thousand five hundred. They laugh at you when you tell them to find a balanced diet because they can buy sweet potatoes only to satisfy their children. Simply, the challenge is poverty" (nurse, 43 years, IDI3, urban)

Gender, cultural norms and beliefs: in Rwandan culture, food preparation is traditionally considered women's work, and men are not typically raised or educated in this area. Consequently, male partners in this study reported experiencing a lack of skills in food preparation as a limitation to effective support. A male partner expressed how such norms challenge the support of pregnant women's dietary practices: "The problem is not just poverty; we have food resources but are unable to prepare a balanced diet. Sometimes you find yourself trying sweet potatoes and mix with…., where you are not able to prepare an important diet. You have the food, but you do not know how to prepare that balanced diet" (male partner, 47 years, FG,D4, rural). Participants reported that rigid gender norms discourage men from engaging in dietary support for pregnant women, as such involvement is perceived to undermine masculinity. These beliefs limit male participation in caregiving even when pregnant women clearly need support. "…there are many women who get pregnant but 'can't get support; this is very often, and I have a lot of testimonies. Some men think that when you go into the kitchen to cook for the woman, she is absolutely dominant, and once the woman rules you, you are an undervalued and incapable man" (male partner, 36 years, FGD4, rural).

Healthcare system challenges: healthcare providers emphasized the importance of standardized guidelines and teaching resources for effective dietary counselling during pregnancy. However, shortages of educational materials limited their ability to deliver consistent and comprehensive nutrition education to pregnant women in antenatal care settings. A midwife described the role of education materials in delivering dietary counselling and their strategies to deal with this: "…another is that teaching resources are not mostly available, and once you cannot access them, you then tell what you remember just because you have nothing else to remind you or to refer to. I think they are called image cards. We have some for pregnancy danger signs, but we don't have for nutrition. These image cards are very clear, having illustrating pictures containing key messages, which makes it easier for you when you are preparing the education session since you have information source" (midwife, 41 years, IDI4, rural). Shortages of healthcare providers increase workload within already overburdened services, limiting adequate dietary guidance. This constrains personalized counselling and reduces the frequency and depth of nutrition education delivered to pregnant women during antenatal care. A midwife explained how she manages such a situation: "… As the number of clients to receive increases, and I also have another service to deliver after ANC, I give a short summary and sometimes superficial information to ensure that they get back home early and I get the time for the clients in another service" (midwife, 39 years, IDI7, urban).

Strategies to improve maternal dietary practices

Enhancing the health system: healthcare providers requested additional training in maternal nutrition, particularly for identifying and managing malnutrition. They emphasized the need for standardised guidelines to ensure consistent care across health centres and recommended continuous training of community health workers to strengthen collaborative support for pregnant women"s dietary practices. "If there can be training to ensure that every health care provider is aware of adequate dietary practices during pregnancy, the clinical manifestation of malnutrition of a pregnant woman, what to do in the presence of these signs, like the way we know that a person with a low Hb level is managed in a given way, like transfusion or others. We need to know what we can do for pregnant women having moderate, severe, or mild malnutrition. This will ensure that I, as a nurse or midwife I am aware of this information and I can measure nutritional parameters, provide interpretation of the result and know how to intervene on the result..." (midwife, 41 years, IDI4, rural).

To facilitate effective dietary education sessions, healthcare providers suggested availing the teaching resources they can use when delivering nutrition education because people remember better what they have seen than what they have heard. A midwife explained that: "I think that the more important priority is to have training material. It is hard to forget training materials like videos or pictures; they can implement the taught practices easily as they have been seen in videos and short films indicating how to prepare a balanced diet. This will benefit pregnant women and babies" (midwife, 42 years, IDI3, urban). The nurses and midwives suggested the involvement of nutritionists in ANC services to deliver nutrition counselling to pregnant women because they possess advanced nutritional knowledge and skills which nurses or midwives do not have.

Enhancing male partners' involvement: healthcare providers reported that men rarely attend health centres for nutrition education due to traditional beliefs. Formal home visits were proposed to educate entire families and improve male involvement in maternal dietary practices because the actual visits are informal and depend on individual health centre initiatives rather than a structured programme. A nurse suggested: "As many men can't come to the health centre, they can understand if we move toward their home to avoid shame. So we gather them and teach them as a whole family with children if they are elderly because some mother gets pregnant while having elderly children who can prepare food for their parent. We can observe direct improvement of dietary practices of pregnant women receiving daughters' and male partners' support" (nurse in IDI5, urban). Male partners suggested men"s groups to allow them to share nutritional information and experiences of what happens in their households.

Addressing socioeconomic barriers: participants emphasized that improving household economic conditions is essential for better maternal dietary practices. Suggested strategies included providing small livestock, promoting savings groups, supporting income-generating activities, and expanding government food supplementation to households excluded due to misclassification, to reduce food insecurity among pregnant women. One participant explained, "Supporting families with income-generating activities or small livestock can help them access nutritious foods because poverty remains a major barrier to providing a balanced diet during pregnancy" (male partner, 37, FGD4, rural). Expanding food assistance to those who are vulnerable would help improve maternal nutrition. Another participant highlighted the importance of targeted assistance, stating, "Some families need additional support because they are not able to provide a diverse diet during pregnancy" (nurse, 34 years, in IDI8, urban).

Discussion     

This study explored the support provided by healthcare providers and male partners to pregnant women in adopting healthy dietary practices during pregnancy. Three main themes emerged from the findings: forms of support for dietary practices, barriers influencing effective support, and strategies to improve dietary practices. These findings illustrate how healthcare providers and male partners perceive their roles, challenges, and opportunities in supporting maternal nutrition during pregnancy.

Household and community level: traditional gender norms strongly influenced male partner involvement, with food preparation and dietary care largely perceived as women's responsibilities. Participants described gender norms that positioned food preparation and dietary care primarily as women's responsibilities, reflecting broader gender expectations reported in Rwanda and other similar settings [19]. Emotional support plays a critical role in dietary adherence. Male partners highlighted that a stress-free household environment fosters better dietary habits, corroborating findings from Abrahams, who reported that emotional well-being enhances dietary adherence in pregnant women [20]. Though male partners stated the willingness to offer emotional support and acknowledged the significance of household peace, cultural belief of masculinity mainly the stigma of appearing submissive or dominated hindered direct involvement, such as cooking or food preparation. This suggests the need for gender-transformative interventions aimed at reshaping norms around male engagement in maternal dietary practices beyond financial provision. Low retention of dietary information among male partners and reliance on community beliefs highlight the influence of sociocultural knowledge systems. Similar challenges have been reported in other settings, emphasizing the need to bridge clinical nutrition guidance with community beliefs through culturally sensitive counselling. Healthcare providers also reported navigating food taboos, such as restrictions on milk or meat consumption (8), often adapting advice to respect beliefs while promoting nutritional adequacy. Formal integration of such adaptive strategies into maternal nutrition education could enhance acceptability and effectiveness.

Health system level: although antenatal care (ANC) was recognized as a key platform for delivering nutrition education, nurses and midwives reported limited training in maternal nutrition and a lack of teaching resources, including visual aids and standardized guidelines. These constraints reflect broader workforce and capacity challenges within the Rwandan health system [21] and are consistent with findings from Ethiopia, where access to effective nutrition information during pregnancy remains limited [22]. Participants perceived that limited nutrition counselling reduced opportunities to strengthen maternal dietary practices and address nutritional challenges during pregnancy [23]. Evidence from Senegal indicates that only a small proportion of ANC providers receive formal training in maternal nutrition while studies elsewhere have shown insufficient nutrition education within medical curricula [24,25]. Addressing these gaps through in-service training, standardized guidelines, and the integration of nutritionists into ANC services may contribute to improving the quality of dietary counselling. In addition, the absence of structured home-visit programmes limits opportunities to engage male partners and family members, particularly given low male attendance at health facilities.

National policy and strategies: socioeconomic precarity, food insecurity, and food unavailability emerged as major barriers to adequate maternal dietary practices, reflecting national patterns of poverty and inequality in Rwanda [26]. These challenges were particularly pronounced in urban settings with high living costs and among household's dependent on informal labour. Similar associations between food insecurity and poor pregnancy outcomes have been documented in other low-income contexts [27]. In rural areas, limited food availability and transport costs further constrained access to diverse diets, reinforcing geographic inequities in food security [26]. Comparable findings from India highlight how food unavailability undermines maternal dietary adequacy [28]. These results emphasize that improving dietary practices during pregnancy requires not only health system interventions but also strengthened social protection measures, livelihood support, and expanded food supplementation programmes.

Strengths and limitations of the study: the strength of this study relies on its inclusion of different perspectives from urban and rural settings, offering a deep understanding of how location and socioeconomic status affect dietary practices of pregnant women. In addition, the use of verbatim quotes enhances the contextual significance of our findings. However, the findings should be interpreted considering some limitations. The sample was not intended to be representative of the broader population, and participants who voluntarily participated in FGDs and IDIs may have differed from those who were not included. To mitigate this limitation, participants were purposively selected from different settings to capture a range of experiences and perspectives. Social desirability and recall biases may also have influenced participants' responses; these were minimized by assuring confidentiality, creating a supportive environment during data collection, and using open-ended questions to encourage participants to share their experiences freely.

Conclusion     

Support for maternal dietary practices in Rwanda is multidimensional, involving emotional, educational, and material contributions from male partners and healthcare providers. However, this support is constrained by limited nutrition knowledge, gender and cultural norms, health system limitations, and economic and food insecurity. Addressing these interconnected barriers requires integrated, context-sensitive interventions that engage pregnant women, male partners, healthcare providers, and community structures.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Aline Uwase, Etienne Nsereko, Nirvana Pillay, and Jonathan Levin conceptualised the protocol; Aline Uwase, Henriette Usanzineza, and Etienne Nsereko were involved in data collection; Aline Uwase, Henriette Usanzineza, and Sara Jewett participated in data analysis; Aline Uwase drafted the manuscript; all authors revised, commented and approved the final version of the manuscript.

Acknowledgments     

We thank the Consortium for Advanced Research Training in Africa for funding this study, the research assistants and study participants for their effort and time.

Tables     

Table 1: demographic characteristics of study participants, including male partners (n=28) and healthcare providers working in antenatal care (n=8) in Rwanda, October 2022

Table 2: themes and sub-themes identified from FGDs with male partners (n=28) and IDIs with healthcare providers working in antenatal care (n=8) in Rwanda, October 2022

References