Men’s and women’s knowledge of danger signs relevant to postnatal and neonatal care-seeking: A cross sectional study from Bungoma County, Kenya

Background Neonatal and maternal mortality rates remain high in Kenya. Knowledge of neonatal danger signs may reduce delay in deciding to seek care. Evidence is emerging on the influential role of male partners in improving maternal and newborn health. This study analysed the factors that determine men’s and women’s knowledge and practices in postnatal and neonatal care-seeking, in order to inform design of future interventions. Methods A quantitative, cross-sectional study was undertaken in Bungoma County, Kenya. Women who had recently given birth (n = 348) and men whose wives had recently given birth (n = 82) completed questionnaires on knowledge and care-seeking practices relating to the postnatal period. Univariate and multivariate logistic regression analyses were performed to investigate associations with key maternal and newborn health outcomes. Results 51.2% of women and 50.0% of men knew at least one neonatal danger sign, however women knew more individual danger signs than men. In the univariate model, women’s knowledge of a least one neonatal danger sign was associated with attending antenatal care ≥4 times (OR 4.46, 95%CI 2.73–7.29, p<0.001), facility birth (OR 3.26, 95%CI 1.89–5.72, p<0.001), and having a male partner accompany them to antenatal care (OR 3.34, 95%CI 1.35–8.27, p = 0.009). Higher monthly household income (≥10,000KSh, approximately US$100) was associated with facility delivery (AOR 11.99, 95%CI 1.59–90.40, p = 0.009). Conclusion Knowledge of neonatal danger signs was low, however there was an association between knowledge of danger signs and increased healthcare service use, including male partner involvement in antenatal care. Future interventions should consider the extra costs of facility delivery and the barriers to men participating in antenatal and postnatal care.


Abstract:
Background : Neonatal and maternal mortality rates remain high in Kenya. Knowledge of neonatal danger signs may reduce delay in deciding to seek care. Evidence is emerging on the influential role of male partners in improving maternal and newborn health. This study analysed the factors that determine men's and women's knowledge and practices in pregnancy and neonatal care, in order to inform design of future interventions.
Methods : A quantitative, cross-sectional study was undertaken in Bungoma County, Kenya. Women who had recently given birth (n=348) and men whose wives had recently given birth (n=82) participated in structured interviews on knowledge and practices relating to pregnancy and postnatal care. Univariate and multivariate logistic regression analyses were performed to investigate associations with key maternal and newborn health outcomes. Results : 51.2% of women and 50.0% of men knew at least one neonatal danger sign, however women knew more individual danger signs than men. In the univariate model, mother's knowledge of a least one neonatal danger sign was associated with attending antenatal care ≥4 times (OR 4.46,p<0.001), facility birth (OR 3.26, 95%CI 1.89-5.72, p<0.001), and male partner accompaniment to antenatal care (OR 3.34, 95%CI 1. 35-8.27, p=0.009). Men who completed secondary school or above had lower odds of accompanying their wives to antenatal care (AOR: 0.25, 95%CI: 0.07-0.95, p=0.042). Higher monthly household income (≥10,000KSh (Approx. 100 USD)) was associated with facility delivery (AOR 11.99,p=0.009). Conclusion : Knowledge of neonatal danger signs was low, however there was an association between knowledge of danger signs and increased healthcare service use, including male partner involvement in antenatal care. Future interventions should consider the extra costs of facility delivery and the barriers to men participating in antenatal care. Done 2. In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants for both the womens and mens samples. Please ensure you have provided sufficient details to replicate the analyses such as: a) the recruitment date range (month and year), b) a description of any inclusion/exclusion criteria that were applied to participant recruitment, c) a table of relevant demographic details, d) a statement as to whether your sample can be considered representative of a larger population, e) a description of how participants were recruited, and f) descriptions of where participants were recruited and where the research took place." Done. See the methods and results sections as well as the supplementary tables.
3. Please provide a sample size and power calculation in the Methods, or discuss the reasons for not performing one before study initiation." Women and men from the same geographic area were recruited independently, meaning that the responses to each questionnaire are not linked as mother-father dyads. In total, 82 men and 348 women participated in the study. Men whose female partners had recently delivered were recruited through convenience sampling, from those accompanying their female partners to healthcare clinics, and from men in market centres. Women who had recently delivered were recruited at antenatal and postnatal reproductive care units, and in maternal and child health clinics at two health facilities of Webuye level 5 hospital and Bungoma Referral hospital 4. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. Copies provided 5. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#locunacceptable-data-access-restrictions. In your revised cover letter, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. We have shared de-identified data at https://doi.org/10.6084/m9.figshare.13048718. Contact information for Mount Kenya University Ethics Review Committee is research@mku.ac.ke. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#locrecommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide. We have uploaded the 2 datasets at https://doi.org/10.6084/m9.figshare.13048718. 6. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files Done 7. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. Done Editor Comments: Thank you for your revisions. However, there are still many comments from reviewers Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation to address, but we are confident they will make the article stronger.
In addition to those from the reviewer: -There is inconsistency is the statement of the objective. The title states knowledge, but the paper suggests knowledge, attitudes and practices, and also at times says "determinants of ANC use and facility based childbirth. Please clarify.
The new title captures the attitudes as well.
-Further, the link between knowledge and male involvement isn't very clear. Indeed this forms part of our research question; what is the best way to address male involvement? What are the knowledge gaps for male involvement?
-The data presented are not very in-depth and it is not clear what this adds to previous literature on this topic, even from Kenya, since there are existing studies. Some of the more nuanced analysis may be in supplemental tables and the authors may want to consider including those info in the main paper.
We have included more tables to deepen the analyses. Our study is unique in that we address contextual issues in a high burden setting.
-There is some inconsistency in language about the questionnaire -in some places it is referred to as an interview. Corrected.
-I wouldn't say that fathers being influential in maternal and child health is new. Indeed, this is not new. However we aimed at understanding contextual issues around male involvement in knowledge and practice. In the study context, men have traditionally left child care to women. This perception has been so pervasive that men have been left out in the design of maternal and child health programs and policies. This study hoped to establish a scientific basis for either supporting or refuting these perceptions.
-"recently" delivered needs to be defined (was it deliveries within a year?); also, how were recently delivered women recruited from ANC?? Recently delivered means deliveries within a year. Yes, these were recruited from the ANC.
-the association between knowledge of danger signs and ANC is presented as if knowledge is a factor related to ANC, when it is likely that the association is the other way (those who attend ANC or deliver in a facility learn the danger signs) This is well understood. However, in our setting, the extended family is also an important source of knowledge on danger signs.
-low knowledge of danger signs is not only in low income countries, but also among those who are disadvantaged/uneducated in high income settings This is true, but also outside of the scope of this paper, which focuses on Kenya.
-if the authors refer to the "first delay" then the 3 delays model has to be explained We have taken out the word "first" so as to not complicate things with long explanations of a well-known concept. -there is redundant demographic info in the descriptions of the male and female samples Corrected.
-there should not be new findings presented in the discussion. The results around how long it took to seek care once identifying an illness should be in the results. This information is presented in both the results table S1 and the body of the text (currently line 289) -the limitations allude to confidence intervals but these are not presented. These are in the supplementary tables.
-why were the women's and men's cohorts not recruited the same way? Needs to be explained in the limitations. Done.
[Note: HTML markup is below. Please do not edit.] Reviewers' comments:

Reviewer's Responses to Questions
Comments to the Author Reviewer #1: Thank you for the opportunity to review this manuscript, which tackles the important problem of parents knowledge about neonatal danger signs using a cross sectional study from Bungoma County, Kenya.
Is the title reflective of the main message: Men's and women's knowledge and practices relating to pregnancy and postnatal care-isn't it really focused on neonatal danger signs? Well noted and corrected.
This is a strikingly well written manuscript which has been meticulously copy edited and is easy to read and follow. It makes clear points.
I have a few comments which I will hope to strengthen the manuscript further: 1. In the abstract, why are unadjusted models of mothers' knowledge presented instead of adjusted ones like for the men? 2. Similarly, in the body of the manuscript in the results section please focus only on the adjusted odds ratio's and remove the unadjusted ones. Flipping back-and-forth between adjusted and unadjusted ones is confusing to the reader. We reported on unadjusted odds ratios when the variable was considered to be on the causal pathway, and therefore not included in the multivariate model. This was explained in the methods and is noted in the relevant tables. If we take out the unadjusted ORs, we will lose a big chunk of the data/paper content.
3. Why do the conclusions in the abstract only refer to the mothers' knowledge?
We have states that "knowledge of neonatal danger signs was low", which was true for both mothers and men.
4. Please clarify in the introduction when ANC is used whether you mean all of antenatal care or antenatal and intrapartum and postpartum care e.g. particularly in lines 81 -89, but also elsewhere. We have clarified that this is during pregnancy.

5.
Another key limitation is that we do not know the response rate The response rate was 88%.
6. In the limitations or strengths could you please mention the degree to which your sample is reflective of the general population in terms of education, age, etc. Done.
7. For your tables, rather than putting the 1.00 in each of the cells indicating the reference, would you consider decluttering the table by putting (Reference) in the first column only? eg Less than 25 years (Reference) Done.
8. Similarly, since you were 95% confidence intervals indicate significance you could delete the P values and just bold the odds ratio's and 95% confidence intervals instead which would decrease clutter within the table and make it easier for your readers to see the main points We wish to maintain as is, as these complement each other and is the practice generally.
9. Throughout the tables, figures, and manuscript rather than using "father" please replace with "men" as you do in figure 1 for example. Why? We know from genetics research that 10% of male partners are not actually the father of the child Done.
10. Please comment on missing data for each question.
We had very few missing data which were treated automatically under regression analyses in stata.  Table S1 Knowledge of at least one postpartum danger sign -which one? ''At least one danger sign" refers to respondents listing one or more of the danger signs in their response and does not limit them to a particular one. The authors need to explain why for women data was not reported on the following: 1.Knowledge of at least one postpartum danger sign 2.Accompanied by partner to ANC 3.Accompanied by partner to delivery These weren't questions in the women's questionnaire. We do say in the methods that the questionnaires were similar. We have added in slightly more explanation to hopefully make this clearer.

DISCUSSION
Kenya has a "Mother Child Health Handbook" which is given for each pregnancy and is in taken home by the mother. This handbook has nearly all the information these authors were looking for in the current study, but it is not mentioned at all in the discussion of this paper The Mother Child Handbook captures most of the information we sought, however, in our study we aimed at studying the knowledge, attitudes and practices in our setting in Bungoma County where maternal and newborn indicators are among the worst in Kenya. In revision, we have highlighted the need to enhance utility of the Mother Child Handbook as a source of information on danger signs for families. Women who had recently given birth (n=348) and men whose wives had recently given birth 25 (n=82) completed questionnaires on knowledge and practices relating to pregnancy and 26 postnatal care. Univariate and multivariate logistic regression analyses were performed to 27 investigate associations with key maternal and newborn health outcomes. 28 29 Results: 51.2% of women and 50.0% of men knew at least one neonatal danger sign, however 30 women knew more individual danger signs than men. In the univariate model, mother's 31 knowledge of a least one neonatal danger sign was associated with attending antenatal care 32 ≥4 times (OR 4.46, Goal targets of a NMR of 12 per 1,000 live births or lower, and an MMR of less than 70 per 51 100,000 live births [3], are to be met. Moreover, whilst worldwide under-5 child mortality has 52 been declining, NMR has been reducing at a much slower rate, highlighting the need for 53 urgent attention [4]. 54 55 Low knowledge of obstetric and neonatal danger signs is widely reported throughout low-56 and middle-income countries [5][6][7][8]. JHPIEGO's birth preparedness and complication readiness 57 framework proposes that increasing knowledge and awareness of these danger signs will 58 improve problem identification, and thus will reduce the delay in deciding to seek care [9,10]. 59 Furthermore, caregivers' ability to recognise danger signs has been linked with use of 60 antenatal care (ANC) and skilled birth attendance [7,11,12]. 61

62
The importance of skilled birth attendance at every childbirth is widely recognised [11,13], 63 and has been described as the most significant single factor in averting maternal deaths [14]. health [3]. The WHO has listed male involvement as a key health promotion intervention for 89 maternal and newborn health [25,26]. It is recommended that men are engaged in health 90 services and optimal home practices during pregnancy, childbirth and also after birth, 91 6 however the level of evidence for interventions is low; resulting in calls for further research 92 into the impacts of male involvement strategies on health outcomes [25,27]. 93

94
Strict definitions of what male involvement entails are not yet broadly agreed [27][28][29], 95 however one elementary indicator is whether men participate in antenatal care visits [28]. 96 The WHO recommendations stipulate that male involvement interventions ought to be 97 culturally specific and thus may differ depending on the context [25,26]. An important factor, 98 however, is ensuring that male involvement interventions continue to promote, or at least 99 not detract from, female autonomy and decision-making [25,26,30]. Pregnancy and childbirth 100 are especially complex because these topics are often considered to be women's business 101 [30], but men are often household decision makers in relation to care-seeking [27,28]. 102 103

104
The 'Collaborative Newborn Support Project' has been implemented in Bungoma County,105 Kenya in order to reduce maternal and neonatal mortality from October 2015 to April 2019. 106 It is an intervention of quasi-experimental design, involving newborn special care units, 107 telehealth, call centre establishment, neonatology training, and community awareness 108 programs [31]. The cross-sectional study reported here forms part of the 'Collaborative 109 Newborn Support Project' and aimed to inform interventions through an assessment of men's 110 and women's knowledge and practices relating to pregnancy and postnatal care. in the form of subsistence farming and cash crops, is the main form of economic activity, 120 followed by manufacturing and retail services [31]. Data from the 2019 census shows that 121 11.3% of the population live in urban areas, and 21.6% use mains electricity as their main 122 source of lighting [33]. 123 124 Study population 125 Women and men from the same geographic area were recruited independently, meaning that 126 the responses to each questionnaire are not linked as mother-father dyads. In total, 82 men 127 and 348 women participated in the study. Men whose female partners had recently delivered 128 were recruited through convenience sampling, from those accompanying their female 129 partners to healthcare clinics, and from men in market centres. Mothers who had recently 130 The data were cleaned and analysed using Stata 13 [34] to find summary statistics and to 149 undertake univariate and multivariate logistic regression analyses. Complete case analysis 150 was used in regression analyses. Some variables were grouped to dichotomous responses, 151 based on analysis team consensus, to ensure no group was too small for regression analysis. 152 The common approach of interpreting a p-value of less than 0.05 as indicating statistical 153 significance was taken. women's and men's age and education levels, monthly household income, time to healthcare 166 facility, gravidity, age at first pregnancy and shared decision making for health service seeking 167 between mother and male partner. Potential confounding factors included in the men's 168 multivariate model were women's and men's age and education level, and monthly 169 household income. Outcomes considered to be on the causal pathway between exposure and 170 outcome were included in univariate models, but not in multivariate models. years of age (67%). Over a third were first time mothers (38.2%) and around half had 181 completed secondary school or higher (54.8%). Women reported their husbands as slightly 182 higher educated, with 68.7% having completed secondary school or higher (at least 12 years 183 of formal school). 63.3% lived in households with a monthly income at or above 10,000 KSh 184 (approximately USD100). More than half (59.1%) lived more than 5 kilometres away from the 185 nearest health facility. Over a third of women reported sharing pregnancy and childbirth 186 decision making with their husband (38.8%), with the rest either making the decision 187 themselves, their husband making the decision without them, or the decision was made by 188 another family member, such as a mother in law (Table 1). 189 Men's sample 195 Since the women's and men's cohorts were not recruited in the same way, they represent 196 comparable, but not matched, populations. Sampled male respondents, along with their 197 wives, tended to be slightly older, more educated and in higher income households than 198 those in the women's sample. Most men were 30 years of age or older (71.9%), with most of 199 their wives at least 25 years of age (69.5%). Three quarters of the men had completed 200 secondary school or higher (75.6%), while 65.8% of their wives had completed secondary 201 school or higher. Most households had a monthly income of over 10,000 KSh (80.5%) ( and were attended by a nurse or midwife (73.8%) (S1 Table). 220 221 Identification of neonatal danger signs 222 Figure 1 illustrates that overall the sample of women could identify a larger number of danger 223 signs than the men, although a similar proportion of women and men were not able to 224 identify any neonatal danger signs (48.8% of women, compared to 50.0% of men). Each 225 individual danger sign was identified by a greater percentage of women than men. Some 226 danger signs were identified approximately twice as frequently by women than by men, such 227 as poor breastfeeding or not able to breastfeed, fast breathing, fever, and difficult to wake, 228 lethargic or unconscious.   Table). 262 263 Characteristics associated with men's practices 264 In the men's sample, both male partner's and mother's education was associated with men 265 accompanying their wife to antenatal care during her most recent pregnancy. However, these 266 associations were in opposing directions. Men who completed secondary school or higher 267 had an odds ratio of 0.25 (95% CI: 0.07-0.95, p=0.042), meaning they had a 75% decrease in 268 odds of accompanying their wife to antenatal care, compared with counterparts who had 269 completed primary school only. Conversely, men whose wife had completed secondary 270 school or higher had increased odds of accompanying their wife to antenatal care (AOR: 3.45, 271 95% CI: 1.09-11.28, p=0.036). In univariate analysis, men who knew at least one neonatal 272 danger sign showed increased odds of accompanying their wife to antenatal care during her 273 most recent pregnancy (AOR: 3.34, 95% CI: 1.35-8.27, p=0.009) (S5 Table). 274 Men in households with a monthly income at or above KShs 10,000 had increased odds of 275 their wives delivering in a healthcare facility (AOR: 11.99, 95% CI: 1.59-90.40, p=0.016), 276 compared with those who were in households with monthly incomes below 10,000 KSh, after 277 adjusting for confounding factors (S6 Table). 278

280
Overall, knowledge of neonatal danger signs was low, a finding mirrored in similar studies in 281 other low-and middle-income settings, as well as elsewhere in Kenya [6,7,35,36]. Women 282 were better able than men to identify danger signs, especially when asked to name specific 283 danger signs, even though the men's sample tended to be older, more educated, and from 284 higher income households. In general, knowledge of danger signs was associated with wealth 285 and education, as others have also found [7,[35][36][37]. If men are to be actively involved in 286 decision making and healthcare seeking in maternal and newborn health, improving their 287 knowledge of key issues such as danger signs is a necessary starting point. Our regression 288 models show strong associations between women's and men's knowledge of neonatal danger 289 signs and positive healthcare seeking behaviours in pregnancy and postnatal care. Whilst the 290 cross-sectional study design of this research cannot show causation, these associations 291 suggest a correlation between danger signs knowledge and healthcare seeking practices 292 during pregnancy and childbirth. 293

294
The results show that knowledge is not adequate in explaining delays in health care seeking 295 among mothers of newborns: 30% of mothers waited over 6 hours after recognising that their 296 newborn was ill before seeking care. Other factors observed to influence health care-seeking 297 16 in our results echo the findings of others in suggesting that education and wealth are key 298 determining factors in use of antenatal care [18], and skilled delivery [12,21,35]. In both the 299 men's and women's samples, higher income was associated with both higher knowledge and 300 healthier practices, such as a woman's most recent childbirth occurring in a facility, even after 301 adjusting for confounding factors. Given that Kenya now has free maternity health services 302 [22,23], there may be other cost barriers, aside from cost of care itself, at play in the decision 303 to seek care. Future programs may need to consider, for example, the cost of transport, 304 accommodation, and the opportunity cost of missing employment. Our age and parity 305 findings also suggest that health promotion interventions and health communication 306 initiatives should target first time and/or young mothers; this may also present an 307 opportunity for peer-based community learning, such as through group antenatal care [38], 308 whereby more experienced and older mothers are able to assist in the teaching of danger 309 signs. 310

311
This study has highlighted the low proportion of men accompanying their wives to antenatal 312 care, as seen elsewhere [39]. The conflicting findings whereby more educated women had 313 healthier practices, but more educated male partners (in the men's sample) seemed less likely 314 to accompany their wives to antenatal care warrants consideration. It may be that better 315 educated men are more likely to be in formal employment, and programs aiming to increase 316 male involvement may need to consider clinic scheduling that better enables men (and 317 women) to balance parental responsibilities with paid work requirements, for example by 318 offering ANC sessions on weekends, outside office hours, or close to the workplace. Shifting 319 gender norms and attitudes among men, women, health providers and employers can also 320 be expected to contribute to men's increasing participation in antenatal care, for example by 321 reducing stigma, normalising men's leave from work or flexible working, and providing 322 inclusive antenatal health services that address both parents' reproductive health needs. 323 participants. This meant that confidence intervals were wide and there was often weak 336 evidence of associations since the small sample size reduced the power of the study to detect 337 smaller differences. Additionally, this may reduce the representativeness of this group to the 338 general male population. Women and men were also administered different questionnaires 339 and were sampled in different ways, limiting the potential for direct comparison between the 340 two groups. We estimated that we were going to get less biased cohort of men in market 341 places than the few motivated ones who accompany their partners in the ante natal clinics. 342 18 Additionally, due to cultural barriers, men who accompany their partners to ANC are really 343 outliers. Relying exclusively on this catchment may have denied the study representativeness 344 of the general population.The regression analysis undertaken used similar outcomes and 345 exposures in order to smooth the differences between the two cohorts. 346

347
The primary strength of this research is that it was conceived and led by local Kenyan 348 researchers and thus addressed local priorities. Additionally, this research has combined data 349 from both women and men in one study, which is not widely seen in the existing literature, 350 thus enabling a level of comparison between these two interconnected groups.   Methods: A quantitative, cross-sectional study was undertaken in Bungoma County,Kenya. 42 Women who had recently given birth (n=348) and men whose wives had recently given birth 43 (n=82) participated in structured interviewscompleted questionnaires on knowledge and 44 practices relating to pregnancy and postnatal care. Univariate and multivariate logistic 45 regression analyses were performed to investigate associations with key maternal and 46 newborn health outcomes. 47 Results: 51.2% of women and 50.0% of men knew at least one neonatal danger sign, however 49 women knew more individual danger signs than men. In the univariate model, mother's 50 knowledge of a least one neonatal danger sign was associated with attending antenatal care 51 ≥4 times (OR 4.46, Low knowledge of obstetric and neonatal danger signs is widely reported throughout low-75 and middle-income countries [5][6][7][8]. 5-8 JHPIEGO's birth preparedness and complication 76 readiness framework proposes that increasing knowledge and awareness of these danger 77 signs will improve problem identification, and thus will reduce the first delay of in deciding to 78 seek care [9,10]. 9,10 Furthermore, caregivers' ability to recognise danger signs has been linked 79 with use of antenatal care (ANC) and skilled birth attendance [7,11,12]. 7,11,12 80 81 The importance of skilled birth attendance at every childbirth is widely recognised [11,13], 82 11,13 and has been described as the most significant single factor in averting maternal deaths 83 [14]. 14  to understand the additional determinants of ANC use and childbirth occurring in a facility, 101 especially those relating to mothers' women's and fathers' men's perspectives. 102

104
Since the 1994 International Conference on Population and Development, there has been 105 increasing recognition of the shared rights and responsibilities of women and men in sexual 106 and reproductive health, including the critical role of male partners and fathers in maternal 107 and child health [3]. 3 The WHO has listed male involvement as a key health promotion 108 intervention for maternal and newborn health [25,26]. 25,26 It is recommended that men are 109 engaged in health services and optimal home practices during pregnancy, childbirth and also 110 7 after birth, however the level of evidence for interventions is low; resulting in calls for further 111 research into the impacts of male involvement strategies on health outcomes [25,27]. 25

124
The 'Collaborative Newborn Support Project' has been implemented in Bungoma County,125 Kenya in order to reduce maternal and neonatal mortality from October 2015 to April 2019. 126 It is an intervention of quasi-experimental design, involving newborn special care units, 127 telehealth, call centre establishment, neonatology training, and community awareness 128 programs [31]. 31 The cross-sectional study reported here forms part of the 'Collaborative 129 Newborn Support Project' and aimed to inform interventions through an assessment of men's 130 and women's knowledge and practices relating to pregnancy and postnatal care. 131 independently, meaning that the responses to each questionnaire are not linked as mother-147 father dyads. In total, 82 men and 348 women participated in the study. Fathers Men whose 148 female partners had recently delivered were recruited through convenience sampling, from 149 those accompanying their female partners to healthcare clinics, and from men in market 150 centres. Mothers who had recently delivered were recruited at antenatal and postnatal 151 reproductive care units, and in maternal and child health clinics at two health facilities: 152 The data were cleaned and analysed using Stata 13 [34] 34 to find summary statistics and to 169 undertake univariate and multivariate logistic regression analyses. Complete case analysis 170 was used in regression analyses. Some variables were grouped to dichotomous responses, 171 based on analysis team consensus, to ensure no group was too small for regression analysis. 172 The common approach of interpreting a p-value of less than 0.05 as indicating statistical 173 significance was taken. 174 confounding. Potential confounding factors included in the women's multivariate model were 185 mother's women's and father's men's age and education levels, monthly household income, 186 time to healthcare facility, gravidity, age at first pregnancy and shared decision making for 187 health service seeking between mother and male partner. Potential confounding factors 188 included in the men's multivariate model were mother's women's and father's men's age and 189 education level, and monthly household income. Outcomes considered to be on the causal 190 pathway between exposure and outcome were included in univariate models, but not in 191 multivariate models. years of age (67%). O38.2%ver a third were first time mothers (38.2%) and around half had 202 completed secondary school or higher (54.8%). Women reported their husbands as slightly 203 higher educated, with 68.7% having completed secondary school or higher (at least 12 years 204 of formal school). 63.3% lived in households with a monthly income at or above 10,000 KSh 205 (approximately USD100). More than half (59.1%) lived more than 5 kilometres away from the 206 nearest health facility. 38.8% ofOver a third of women reported sharing pregnancy and 207 childbirth decision making with their husband (38.8%), with the rest either making the 208 decision themselves, their husband making the decision without them, or the decision was 209 made by another family member, such as a mother in law (Table 1). 210 Since the women's and men's cohorts were not recruited in the same way, they represent 217 comparable, but not matched, populations. Sampled male respondents, along with their 218 wives, tended to be slightly older, more educated and in higher income households than 219 those in the women's sample. 71.9% ofMost men were 30 years of age or older (71.9%), with 220 most of their wives at least 25 years of age (69.5%). Three quarters of the men had completed 221 secondary school or higher (75.6%), while 65.8% of their wives had completed secondary 222 school or higher. Most households had a monthly income of over 10,000 KSh (80.5%) (Table  223   1 (79.0%) and were attended by a nurse or midwife (73.8%) (S1 Table S1 Figure 1 illustrates that overall the sample of women could identify a larger number of danger 245 signs than the men, although a similar proportion of women and men were not able to 246 identify any neonatal danger signs (48.8% of women, compared to 50.0% of men). Each 247 individual danger sign was identified by a greater percentage of women than men. Some 248 danger signs were identified approximately twice as frequently by women than by men, such 249 as poor breastfeeding or not able to breastfeed, fast breathing, fever, and difficult to wake, 250 lethargic or unconscious. 251  Characteristics associated with men's practices 286 In the men's sample, both father's male partner's and mother's education was associated 287 with men accompanying their wife to antenatal care during her most recent pregnancy. 288 However, these associations were in opposing directions. Men who completed secondary 289 school or higher had an odds ratio of 0.25 (95% CI: 0.07-0.95, p=0.042), meaning they had a 290 75% decrease in odds of accompanying their wife to antenatal care, compared with 291 counterparts who had completed primary school only. Conversely, men whose wife had 292 completed secondary school or higher had increased odds of accompanying their wife to 293 antenatal care (AOR: 3.45, 95% CI: 1.09-11.28, p=0.036). In univariate analysis, men who knew 294 at least one neonatal danger sign showed increased odds of accompanying their wife to 295 Overall, knowledge of neonatal danger signs was low, a finding mirrored in similar studies in 305 other low-and middle-income settings, as well as elsewhere in Kenya [6,7,35,36]. 6,7,35,36 306 Women were better able than men to identify danger signs, especially when asked to name 307 specific danger signs, even though the men's sample tended to be older, more educated, and 308 from higher income households. In general, knowledge of danger signs was associated with 309 wealth and education, as others have also found [7, 35-37]. 7,35-37 If men are to be actively 310 involved in decision making and healthcare seeking in maternal and newborn health, 311 improving their knowledge of key issues such as danger signs is a necessary starting point. 312 Our regression models show strong associations between women's and men's knowledge of 313 neonatal danger signs and positive healthcare seeking behaviours in pregnancy and postnatal 314 care. Whilst the cross-sectional study design of this research cannot show causation, these 315 associations suggest a correlation between danger signs knowledge and healthcare seeking 316 practices during pregnancy and childbirth. 317

318
The results show that knowledge is not adequate in explaining delays in health care seeking 319 among mothers of newborns: 30% of mothers waited over 6 hours after recognising that their 320 newborn was ill before seeking care. Other factors observed to influence health care-seeking 321 in our results echo the findings of others in suggesting that education and wealth are key 322 determining factors in use of antenatal care [18], 18 and skilled delivery [12,21,35]. 12,21,35 In 323 both the men's and women's samples, higher income was associated with both higher 324 knowledge and healthier practices, such as a woman's most recent childbirth occurring in a 325 facility, even after adjusting for confounding factors. Given that Kenya now has free maternity 326 health services [22,23], 22,23 there may be other cost barriers, aside from cost of care itself, at 327 play in the decision to seek care. Future programs may need to consider, for example, the 328 cost of transport, accommodation, and the opportunity cost of missing employment. Our age 329 and parity findings also suggest that health promotion interventions and health 330 communication initiatives should target first time and/or young mothers; this may also 331 present an opportunity for peer-based community learning, such as through group antenatal 332 care [38], 38 whereby more experienced and older mothers are able to assist in the teaching 333 of danger signs. 334 335 This study has highlighted the low proportion of men accompanying their wives to antenatal 336 care, as seen elsewhere [39]. 39 The conflicting findings whereby more educated women had 337 healthier practices, but more educated fathers male partners (in the men's sample) seemed 338 less likely to accompany their wives to antenatal care warrants consideration. It may be that 339 better educated men are more likely to be in formal employment, and programs aiming to 340 increase male involvement may need to consider clinic scheduling that better enables fathers 341 men (and motherswomen) to balance parental responsibilities with paid work requirements, 342 for example by offering ANC sessions on weekends, outside office hours, or close to the 343 workplace. Shifting gender norms and attitudes among men, women, health providers and 344 employers can also be expected to contribute to men's increasing participation in antenatal 345 participants. This meant that confidence intervals were wide and there was often weak 360 evidence of associations since the small sample size reduced the power of the study to detect 361 smaller differences. Additionally, this may reduce the representativeness of this group to the 362 general male population. Women and men were also administered different questionnaires 363 and were sampled in different ways, limiting the potential for direct comparison between the 364 two groups. We estimated that we were going to get less biased cohort of men in market 365 places than the few motivated ones who accompany their partners in the ante natal clinics. 366 Additionally, due to cultural barriers, men who accompany their partners to ANC are really 367 outliers. Relying exclusively on this catchment may have denied the study representativeness 368 of the general population.The regression analysis undertaken used similar outcomes and 369 exposures in order to smooth the differences between the two cohorts. The primary strength of this research is that it was conceived and led by local Kenyan 372 researchers and thus addressed local priorities. Additionally, this research has combined data 373 from both women and men in one study, which is not widely seen in the existing literature, 374 thus enabling a level of comparison between these two interconnected groups. 375 Overall, knowledge of neonatal danger signs in Bungoma County, Kenya is low among both 377 women and men. Whilst it is suggested that improving knowledge of the neonatal danger 378 signs can reduce the delay in deciding to seek care [9,10], 9,10 there still exists a certain 379 disconnect between knowledge translating into practice for some mothers in Bungoma 380 County who did not immediately seek care once realising their newborn was ill. 381

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The key determining factors in men's and women's knowledge and practices relating to 383 pregnancy and postnatal care were education level, income, gravidity and age at first 384 pregnancy. Future interventions, including those in the 'Collaborative Newborn Support 385 Project', must thus consider the extra costs of childbirth occurring in a facility. Furthermore, 386 interventions should address the barriers to men participating in antenatal care, including 387 work commitments and pervasive social and gender norms around pregnancy and child-388 rearing. Target  We are very grateful to the reviewers for their comments. We have comprehensively addressed these and strongly believe that they have enriched the revised manuscript. Kindly see our responses in blue after each comment.
Thank you and best regards, Jesse Gitaka on behalf or authors.

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Done
Editor Comments: Thank you for your revisions. However, there are still many comments from reviewers to address, but we are confident they will make the article stronger.
In addition to those from the reviewer: -There is inconsistency is the statement of the objective. The title states knowledge, but the paper suggests knowledge, attitudes and practices, and also at times says "determinants of ANC use and facility based childbirth. Please clarify.
The new title captures the attitudes as well.
-Further, the link between knowledge and male involvement isn't very clear.
Indeed this forms part of our research question; what is the best way to address male involvement? What are the knowledge gaps for male involvement?
-The data presented are not very in-depth and it is not clear what this adds to previous literature on this topic, even from Kenya, since there are existing studies. Some of the more nuanced analysis may be in supplemental tables and the authors may want to consider including those info in the main paper.
We have included more tables to deepen the analyses. Our study is unique in that we address contextual issues in a high burden setting.
-There is some inconsistency in language about the questionnaire -in some places it is referred to as an interview. Corrected.
-I wouldn't say that fathers being influential in maternal and child health is new.
Indeed, this is not new. However we aimed at understanding contextual issues around male involvement in knowledge and practice. In the study context, men have traditionally left child care to women. This perception has been so pervasive that men have been left out in the design of maternal and child health programs and policies. This study hoped to establish a scientific basis for either supporting or refuting these perceptions.
-"recently" delivered needs to be defined (was it deliveries within a year?); also, how were recently delivered women recruited from ANC??
Recently delivered means deliveries within a year. Yes, these were recruited from the ANC.
-the association between knowledge of danger signs and ANC is presented as if knowledge is a factor related to ANC, when it is likely that the association is the other way (those who attend ANC or deliver in a facility learn the danger signs) This is well understood. However, in our setting, the extended family is also an important source of knowledge on danger signs.
-low knowledge of danger signs is not only in low income countries, but also among those who are disadvantaged/uneducated in high income settings