Postnatal maternal health is an important, but neglected component of the continuum of care, especially in low- and middle-income countries (LMICs). Although there have been substantial investments globally to expand access to skilled birth attendance and intrapartum care, preventable complications and inadequate quality of post-partum follow-up expose women to risk in the weeks following childbirth 1. The postpartum

period, usually considered to be the 6 weeks following childbirth, is a time of tremendous vulnerability and opportunity for maternal health internationally. Women's attendance at postnatal care visits immediately after delivery assumes a strategic approach to promote healthy lifestyle practices, including timely identification of hazardous signs, exclusive breastfeeding, and early initiation and continuation of maternal services 2. In Pakistan and other South Asian settings, cultural practices such as the 40-day confinement period (‘chilla’) give rest and emotional support, but at the same time may confine women’s ability to seek formal healthcare when needed 3.

Positive home-based practices and timely care seeking for postpartum problems are important to preserve the health of the mother, support her recovery, and promote the well-being of the newborn. Thus, male partner involvement (MPI), in terms of practical, emotional, and financial support, decision-making, and accompaniment to services, may play a significant role in postpartum health 4. Literature showed that only a third of women used maternal health services appropriately, and male partners’ education, women’s autonomy, residence in urban areas, and access to media significantly added to usage 5. Globally, there is increasing awareness of the importance and potential of involving men as partners in promoting maternal and newborn health throughout the antenatal, intrapartum, and postpartum continuum. Partners play an essential role in male-dominated societies and are central decision makers in their wives' mobility, utilization of household resources, timing of health facility visits, and acceptance of medical advice 6. On the other hand, low male involvement might lead to a delay in seeking care, with consequent grave effects. Relatively fewer studies have examined the postpartum period, during which women are particularly at risk of physical complications and psychological distress, and where supportive male involvement may be most influential 7. The low support from spouses may prompt women to turn to informal advice networks, postpone help seeking, or internalize distress factors that could lead to a higher likelihood of PPD and reduced health benefits 3. Despite the demonstrated improvements in maternal and newborn outcomes, husband involvement in postnatal care is still quite limited 8,9. The importance of male involvement in maternal health is increasingly being recognized; however, there is a critical knowledge gap in Pakistan 10. Despite the known value of engagement of the male partner, few studies in Pakistan have specifically investigated the context of postpartum involvement of the male partner. This study aims to assess the role of male partner involvement in improving postpartum maternal health behaviours in a district of Rawalpindi, Pakistan.

Study design and setting: A cross-sectional study design was employed to assess the determinants of male partner involvement and its association with postpartum maternal health behaviours, from January 2026 to April 2026. The research was performed in Rawalpindi District, Punjab province of Pakistan, after the ethical approval from the Institutional Review Board (IRB) of Health Services Academy, Islamabad, Pakistan. The primary data was collected directly from the postnatal women living in selected UCs of Rawalpindi, Pakistan. Study population & Sampling Technique: The study population consists of postpartum women aged 18-45 years who have delivered a live birth within the last 42 days and are living with their husband in the Rawalpindi district. Participants were drawn from both urban and semi-urban communities. A non-probability purposive sampling technique was used to select postpartum women for this study. Lady Health Workers (LHWs) in selected Union Councils of Rawalpindi assist in identifying eligible women who have recently delivered a live birth. From the list, participants were purposively recruited based on inclusion criteria. Sample size calculation & Sample recruitment: The sample size was calculated using the OpenEpi formula for a proportion. The estimated sample size was 384, and after adding 10% non-response, the final sample consisted of 422 postpartum women. A community-based approach utilizing the available Lady Health Worker (LHW) network and primary healthcare facilities in the selected Union Councils of Rawalpindi. Following authorization from local health authorities, LHWs prepared a register of women who gave birth to a liveborn within the last 42 days in their catchment areas. Female interviewers subsequently visit the households to screen women for eligibility and explain the study objectives and the invitation to participate. Postpartum women aged 18-45 years, residing in the Rawalpindi district, who have delivered a live birth within the last 42 days and are currently living with their husband, were included in the study. While women with stillbirth or neonatal death (due to psychological sensitivity), whose husbands are not currently living in the same household, and women with severe illness preventing participation were excluded from the study. Eligible women were recruited after obtaining written informed consent. Data collection techniques & tool: The data were collected using structured face-to-face interviews, after obtaining written informed permission from the concerned local health authorities of Rawalpindi, Pakistan. LHWs performing in the targeted Union Councils were involved in tracking eligible postpartum women who gave birth within 42 days. All female data collectors were trained to visit the households, explain the study, and get an informed written consent from each respondent before collecting data. Data was collected using a structured and validated questionnaire, adapted from the Male Partner Involvement (MPI) Scale 11, Demographic and Health Survey (DHS) male involvement indicators and World Health Organization (WHO) Postnatal care guidelines. The standardized questionnaire was subsequently introduced during a private setting and comfortable environment, lasting 20-25 minutes. Reliability and internal consistency of the Male Partner Involvement items using Cronbach’s alpha, with a value of ≥ 0.70 considered acceptable. Data analysis: Data collected through a structured questionnaire were reviewed daily for completeness and then entered into SPSS version 27. Descriptive statistics (frequencies, percentages, means, and standard deviations) summarise socio-demographics, male involvement scores, and postpartum behaviours. For bivariate analysis, the chi-square test was used to assess relationships between independent and dependent variables. Multiple logistic regression was used to examine the adjusted association between male partner involvement and postpartum maternal health behaviours. Ethical considerations: Ethical approval was obtained from the Institutional Review Board (IRB) of Health Services Academy (HSA), Islamabad, Pakistan (Ref No: 001020/HSA/MSPH-2024). Participation in the study was voluntary, and all potential respondents were provided with an explanation of the purpose of the study as well as a rundown of its methods, risks, and benefits. All participants provided written informed consent, and women were told that refusal to participate would not interfere with their health care or relationship with HCWs/LHWs. The confidentiality of the information was maintained at all stages of the study according to institutional guidelines and the Declaration of Helsinki.

Table 1. Socio-Demographic Characteristics of the Study Population (n = 422)

The mean age for respondents was 28.08 ± 6.40 years, and the largest number of participants, 283 (67.1%), were in the 18 to 30 years group. Among the educational levels, the largest 150 (35.5%) participants had completed secondary education. Regarding the educational levels of partners, it was observed that most husbands of the respondents were educated up to secondary level, with 181 (42.9%). The occupational representation of the respondents indicates that more than half were not in paid employment and are housewives, with 215 (50.9%). The occupational characteristics of the husbands revealed that most of them were involved in income-generating activities. The majority of the husbands, 352 (83.4%), were in employment, which comprised the largest group. Family type categorization of the respondents reveals that joint family systems prevail. A vast majority, that is, 323 (76.5%) participants, fall under joint family systems. The data shows that caesarean section was the dominant mode of giving birth. A total of 282 (66.8%) respondents had a caesarean section, while 140 (33.2%) had a normal vaginal delivery. The distribution of place of delivery for the respondents reveals that most of them delivered their children in health facilities. Almost half of them, 194 (46.0%), gave birth in public health facilities, while 178 (42.2%) gave birth in private health facilities (Table 1).

Figure 1. Male Partner Involvement (MPI) Levels among the study population

The distribution of MPI values among the respondents shows that the greatest number of respondents reported moderate values for MPI. A total of 267 (63.3%) reported moderate MPI levels. The same number of respondents reported low values for MPI, composed of 78 (18.5%), and high values for MPI, composed of 77 (18.2%), respectively.

Table 2. Postpartum Health Behaviours among Study Population (n = 422)

The result of postpartum health behaviors in Table 2 shows a mixed response in the application of the advised postpartum health behaviors by the respondents. Less than half of the respondents, 193 (45.7%), had postpartum checkups within 48 hours of childbirth, while 229 (54.3%) did not have the checkup. Likewise, 204 respondents (48.3%) had at least one postpartum checkup in six weeks; however, slightly over half of the respondents, 218 (51.7%), had not had any postpartum checkups in six weeks. Exclusive breastfeeding for the initial six weeks was observed by 202 respondents (47.9%), while 220 (52.1%) did not observe the practice. Over half of the respondents, 229 (54.3%), had received postpartum nutrition counseling; however, 193 (45.7%) did not receive the counseling. On the issue of family planning, 213 respondents (50.5%) were using modern methods of family planning; however, 209 (49.5%) were not utilizing the method.

Table 3. Association Between Socio-Demographic Factors and MPI among study Population (n = 422)

The relation between socio-demographic and obstetric variables of the respondents and MPI distribution is given in Table 3. Although age was not a statistically significant factor in MPI distribution (p = 0.314), a higher percentage of women in the age group 41-45 years (29.6%) were classified in the higher MPI group. Educational status of the respondents was also not significantly associated with MPI (p = 0.678). Likewise, husbands' education was a statistically insignificant factor in MPI distribution (p = 0.814). Occupation of the respondents was found to be non-significantly associated with MPI (p = 0.665). The occupation of the husband was also non-significantly associated with MPI (p = 0.597). Family type was the only variable that showed a statistically significant relationship with the distribution of MPI (p = 0.041). The percentage of women belonging to nuclear families who are of high MPI is 24.2%, which is less compared to those who are of joint families (16.4%). Mode of delivery (p = 0.405) and type of delivery (p = 0.940) are not significantly related to MPI distribution. In this case, moderate MPI has the largest percentage.

Table 4. Association Between MPI Level and Postpartum Maternal Health Behaviors among the study Population (n = 422)

The relationship of postpartum health behaviors and the distribution of MPI is shown in Table 4. Attendance within 48 hours of giving birth did not have a significant relationship with the distribution of MPI (p = 0.239) since equal percentages of low, medium, and high MPI were recorded among those who were seen and those who were not. Attendance of at least one visit did not have a significant relationship with the MPI (p = 0.270) since the medium MPI still comprised the larger proportion among both those who were seen and those who were not. Also, exclusive breastfeeding practices were not found to have any significant association with MPI distribution (p = 0.968), since almost equal proportions of low, moderate, and high MPI were found in women who practiced breastfeeding compared to those who didn't. Again, receipt of nutritional counseling in the post-partum period wasn't found to have any significant association with MPI levels (p = 0.996). Also, modern family planning practices weren't found to be significantly associated with MPI distribution (p = 0.637). Overall, the results show that post-partum health behavior, such as post-partum care, lactation, diet counseling, and family planning, was not significantly affected by multidimensional poverty status, as moderate MPI predominantly existed in all categories of health behavior.

Table 5. Multivariable Logistic Regression Predicting High MPI

The result of the multinomial logistic regression in Table 5 indicated that there was no significant influence between postpartum health behaviors and MPI levels, where the higher MPI group was treated as a standard. It was shown that there were no significant predictors among the postpartum health behaviors variables toward the MPI level. For attendance of postnatal care (PNC) within 48 hours, women who did not attend PNC had lower odds of being in the low MPI category compared to women who did attend. The odds were not statistically significant (OR = 0.76, 95% CI: 0.41–1.44; p = 0.402). Likewise, there were no statistically significant results for the moderate MPI category (OR = 1.15, 95% CI: 0.69–1.91; p = 0.600). PNC attendance within six weeks was also not significantly related to MPI level. The odds ratio of women who did not attend PNC to be in the lower MPI group was (OR=1.06, 95% CI=0.56-2.02), p=0.850. The odds ratio of women who did not attend PNC in relation to attendance in the moderate group of MPI was also not significant (OR=0.75, 95% CI=0.45-1.25), p=0.274. No significant relationship was observed between

exclusive breastfeeding and MPI level. The odds of falling in the low, OR = 0.98, 95% CI: 0.52–1.85, p = 0.949, or moderate MPI category, OR = 0.93, 95% CI: 0.56–1.56, p = 0.793, were the same for women who did not practice exclusive breastfeeding as for women who did. Postpartum nutrition counselling was not a significant predictor of MPI level. Women who did not receive counselling had nearly identical odds of being in the low, OR = 1.00, 95% CI: 0.53–1.89; p = 0.999, or moderate MPI category, OR = 1.02, 95% CI: 0.61–1.70; p = 0.951. Finally, the current use of modern family planning methods was not significantly associated with MPI. Non-users had slightly lower odds of falling in the low MPI category compared to users (OR = 0.76, 95% CI: 0.40–1.44; p = 0.402) and similar odds of falling in the moderate MPI category (OR = 0.93, 95% CI: 0.56–1.55; p = 0.782).

The involvement of the male partner was evaluated in this study to establish the association between the involvement and post-partum behaviors among 422 women. The mean level of MPI was predominantly medium in this study, at 63.3%, even as a percentage was low at 18.5% and 18.2% in the low and high groups, respectively. The distribution can indicate a partial handling of MPI on the part of the fathers as opposed to extensive involvement in other dimensions and contexts. This finding can be linked to modern studies focusing on men’s involvement in maternal and reproductive healthcare as having very broad dimensions and therefore warranting careful definition and operation in studies and initiatives 12,13. A critical implication arising from our findings, in which MPI is not significantly associated with behaviours, is the measurement. MPI measurement may only capture a very specific slice, such as ‘accompanies her’ or ‘provides money,’ whereas actual decision-making or caregiving may be more extensive than that. It is possible that while MPI is measured in a very specific way, there may be no association between MPI and other specific breastfeeding activities, such as PNC attendance or exclusive breastfeeding. Recent research has emphasized that when an indicator is inconsistent or specific, there are challenges in establishing relevance in association with various outcomes. As such, your ‘moderate’ category for MPI could encompass very different levels of participation, making any association less measurable in statistical contexts 12. Our study found PNC within 48 hours is 45.7%, and at least one postnatal visit within 6 weeks is 48.3%, which is less than the ideal continuity of care. The WHO guidelines have identified two structured postnatal contacts: one early and one subsequent check. The fact that the early PNC remains less than half of the targeted population shows early discharge missed opportunities, a weak follow-up mechanism, perceived unmet needs, or access barriers in the form of transport, permission, cost, and time constraints. More importantly, these gaps can exist when the partner's involvement is rated as moderate, particularly because men are not informed about the schedule of post-natal visits or are not counseled. Thus, the low coverage in your sample is consistent with the wider global concern for immediate attention and health system strengthening needed to improve utilization of postnatal care 14,15. Current literature highlights the fact that postnatal care is the most neglected period when it comes to mother and child care services. The above scenario is important when it comes to your analysis, given the point that facility delivery failures are not necessarily linked to post-delivery follow-ups. If MPI is set at a slightly low level, poor utilization of PNC services may still occur, given the fact that such institutions may have an early discharge plan that does not involve return appointments and effective counseling that communicates post-delivery services. Thus, your analysis on the less than 50% utilization of early post-delivery services may lie more within the realm of service failures and less within the context of partner levels of involvement 15. From bivariate analysis, there is no significant link between MPI distribution and PNC in 48 hours (p = 0.239) or postnatal visits (p = 0.270). With current evidence in mind, a possible interpretation is that while male involvement is important when men are educated with clear roles in postnatal care, their poor involvement may mean poor action. In your category of "moderate MPI," if your male partners are involved but lack direct roles in health education, their participation may not necessarily prompt all of them to come on time. Current research relating to male roles in PNC suggests modest levels of male involvement in certain settings, implying a lack of automatic action in male involvement 4. Although our MPI variables were not linked to exclusive breastfeeding, there exists high-quality evidence suggesting that male partner education/support interventions have improved outcomes for breastfeeding. Our data also suggest that just being ‘naturally’ involved in different levels (low, moderate, or high) does not have an impact on changing breastfeeding practices, and significant participation does have an impact. Thus, not just participation, but how, in relation to supporting breastfeeding, giving mom a rest, debunking myths, and accompanying her in early initiation/continence, needs to be promoted 16. The result from our multinomial regression showed that postpartum behaviors (PNC, BF, Counseling, FP use) do not serve as significant predictors of the level of MPI (as all p-values > 0.05). It can be concluded that the MPI was viewed as a general quality related to the relationship or structure, and was not defined by the postpartum behaviors themselves. Indeed, recent literature indicated that male involvement can be affected by factors like men’s knowledge levels, attitudes, residence status, as well as previous involvement experience like accompanying the woman to ANC, but not postpartum behaviors alone 17. Strengths and Limitations of the Study There are a number of key strengths for this research study. The research targets an essential yet largely unexplored domain of maternal healthcare by taking into consideration involvement by a male partner during the postpartum healthcare period. The research employed a fairly large sample size to ensure greater accuracy of results. Many postpartum healthcare behaviors are explored to ensure a comprehensive view is gained on maternal healthcare behaviors. Moreover, the research employed bivariate and multivariable analysis, offering a comprehensive method to interpret correlations between MPI and significant variables. There are a number of limitations that need to be taken into account when interpreting the results of this study. Firstly, because it is a cross-sectional study, it is not possible to determine cause-and-effect relationships between male partner involvement and postpartum health behaviors. Secondly, because it relies on responses provided by participants, it may be subject to recall bias or social desirability bias, especially concerning health issues such as lactation and attendance at PNC for mothers. Thirdly, it is possible that MPI may not be a comprehensive measure of the extent of participation. Finally, it does not explore the quality of healthcare delivery or provider attitude with regard to the impact that may have in relation to the use of postpartum health services that are uninfluenced by male partner participation.

The study evaluated the extent of male partner involvement (MPI) in postpartum maternal health and explored its relationship with socio-demographic variables, obstetric variables, and postpartum health practices among women. The result shows that male partner involvement in postpartum maternal healthcare was found to be largely moderate, with fewer women having lesser and greater involvement. Notwithstanding the high institutional delivery, there was suboptimal use of key postpartum healthcare services such as postnatal visit 48 hours, postnatal visit six weeks, exclusive breastfeeding, nutrition counseling, and modern family planning.

Notably, there was no significant relationship found between male partner involvement and postpartum health behavior, implying that the mere presence of male involvement may be ineffectual in shaping maternal health behaviors. Family type was found to be the only variable having a significant effect on Male Partner Involvement, where there was significantly more involvement on the part of the mother in joint families. The results emphasize that in order to optimize postpartum health outcomes, it is crucial that focus be placed on optimizing the quality and structure of involvement in maternal health care for men as well.

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