Conceptually, this study aims to expand the understanding of how structural determinants interact with local cultural values in family health behaviours. The findings are expected to enhance maternal health policies and programmes that focus on husband–wife partnerships, drawing on the Maluku local wisdom of ‘Bakele’ (togetherness), which highlights solidarity, collective responsibility and shared well-being during pregnancy.

This study adopted a sequential explanatory mixed-methods design consisting of two consecutive and complementary phases. The first phase involved a quantitative approach to identify factors associated with husbands’ involvement in ANC. Findings from the quantitative phase informed the second, qualitative phase, which aimed to provide deeper explanations of the observed associations by exploring the social and cultural contexts influencing husbands’ involvement in their wives’ ANC. This design enabled the integration of measurable associations with contextual interpretations. Mixed-methods integration was achieved through joint displays, where qualitative findings were used to explain and expand upon significant quantitative results.

The population comprised husbands of pregnant women in the catchment areas of six community health centres across West Seram, South Buru and Southwest Maluku regencies (representing urban, remote, island and indigenous settings with varying ANC quality). The quantitative sample size of 300 was calculated using a single population proportion formula (assuming 30% expected involvement based on regional studies, 95% confidence interval (CI), 5% margin of error, design effect 1.5 for clustering), yielding adequate power. Convenience cluster sampling was applied based on the health centre catchment areas. Inclusion criteria included husbands living with pregnant wives and with prior pregnancy experience. Those who did not meet these criteria and unwilling to participate were excluded.

The qualitative phase included 114 informants (purposively selected for diversity and information richness): health officials (n = 10), health centre leaders (n = 8), village or sub-district heads (n = 12), traditional leaders (n = 15), religious leaders (n = 12), midwives (n = 10), traditional birth attendants (n = 8), health cadres (n = 10), pregnant women (n = 10), husbands (n = 15) and senior family figures/parents-in-law (n = 14). The sample size was determined by thematic saturation; such a large sample ensured comprehensive coverage of stakeholder perspectives in a culturally diverse setting.

This study received ethical approval from the appropriate institutional ethics review board (Fakultas Kesehatan Masyarakat, Universitas Airlangga, dengan nomor sertifikat 229/EA/KEPK/2025). All participants provided written informed consent after receiving a clear explanation of the study’s objectives, procedures, potential risks and benefits. Participation was voluntary, and participants were informed of their right to refuse or withdraw from the study at any stage without any consequences. Confidentiality and anonymity were strictly maintained by removing personal identifiers and securely storing all data, which were accessible only to the research team. The study was conducted in accordance with internationally recognised ethical principles for research involving human participants.

A total of 300 husbands participated in the study, of whom only 27% were actively involved in standardised ANC, defined as accompanying their wives to ANC visits and providing emotional and practical support. As shown in Table 1, bivariate analysis demonstrated that husbands’ involvement in standardised ANC was significantly associated with several socio-demographic, access-related and socio-cultural factors. Older husbands (≥ 20 years) were more likely to be involved than younger husbands (p = 0.028), and higher educational attainment was significantly associated with active involvement (p = 0.016). Occupational status was also relevant, with entrepreneurs showing higher participation compared to husbands employed in the private sector (p = 0.010).

Access-related variables exhibited the strongest associations with husbands’ involvement. Husbands who reported access to ANC counselling services, ease of reaching health facilities and sufficient ANC facilities and counselling quality were significantly more likely to be actively involved (all p < 0.001). These findings highlight the central role of service availability and their perceived quality in facilitating husbands’ participation in their wives’ ANC.

Socio-cultural and family-related factors were also significantly associated with involvement. Husbands who provided active support during pregnancy, endorsed cultural values and local wisdom regarding husbands’ roles and participated in joint family decision-making involving parental figures demonstrated substantially higher involvement in standardised ANC (all p < 0.01). Notably, husbands’ knowledge of ANC and their perceived family leadership role showed the strongest bivariate association with involvement (χ² = 22.673, p < 0.001).

In contrast, perceived social stigma was not significantly associated with husbands’ involvement in standardised ANC (p = 0.203), suggesting that normative social pressures alone may be less influential than structural access and family decision-making dynamics in this setting.

Multivariable logistic regression analysis demonstrated adequate model fit (Hosmer–Lemeshow goodness-of-fit test, p = 0.412) and moderate explanatory power (Nagelkerke R² = 0.48). As presented in Table 2, three factors remained independently associated with husbands’ active involvement in standardised ANC after adjustment for potential confounders.

Husbands who provided active support during pregnancy – such as accompanying their wives to ANC visits, offering encouragement and actively seeking pregnancy-related information – were substantially more likely to be involved in standardised ANC compared with those who did not provide such support (AOR = 25.2; 95% CI: 1.2–536.9; p = 0.039). Supportive family dynamics characterised by joint decision-making involving parental figures were also significantly associated with higher involvement (AOR = 2.7; 95% CI: 1.3–5.3; p = 0.005). In addition, husbands with good knowledge of ANC and a clear understanding of their role as family head demonstrated significantly greater participation in standardised ANC (AOR = 10.7; 95% CI: 1.4–82.7; p = 0.024).

In contrast, socio-demographic characteristics (age, education and occupation) and structural access-related factors – including access to ANC counselling services, ease of reaching health facilities and perceived adequacy of ANC facilities and counselling quality – did not remain statistically significant in the adjusted model. These findings suggest that, in this setting, husbands’ involvement in standardised ANC is primarily driven by socio-cultural and knowledge-related factors rather than structural access alone.

Qualitative thematic analysis (see Table 3) resulted in five major themes that explain the socio-cultural context of husbands’ involvement in their wives’ ANC: (1) husbands’ participation is still passive, (2) social structures and family power dynamics influence decision-making, (3) religious values provide moral legitimacy for the husband’s role, (4) community leaders are effective agents of change in fostering awareness and male role modelling and (5) husbands need educational media based on local languages and trimester-based guides to strengthen sustained involvement.

The research findings reveal that husbands’ involvement in pregnancy care is shaped by an interplay of social, cultural and knowledge-related factors (Boniphace et al. 2021). Quantitatively, husbands’ active support role strongly predicts involvement in ANC accompaniment (AOR = 25.2; 95% CI: 1.2–536.9; p = 0.039), with emotional and informational support defined as encouragement, shared decision making and information-seeking increasing participation up to 25-fold. Supportive family dynamics, including joint decision-making with parental figures, were significantly associated with higher levels of husbands’ involvement in standardised ANC (AOR = 2.7; 95% CI: 1.3–5.3; p = 0.005). This finding is consistent with previous studies highlighting the reinforcing roles of wives and parental figures in promoting ANC practices (Wood et al. 2024). In addition, husbands’ knowledge about ANC and his awareness as the head of the family are significantly associated with the likelihood of them accompanying their wives for ANC visits (AOR = 10.7; 95% CI: 1.4–82.7; p = 0.024), indicating that understanding the benefits of ANC strengthens decision-making ability in emergency situations.

Conversely, structural factors such as age, education, type of work, access to services and quality of facilities did not show a significant association after adjustment. These results emphasise that husbands’ involvement is more influenced by socio-cultural mechanisms and masculinity values that shape perceptions of reproductive responsibility.

Qualitative data complement these results by showing limited and discontinuous husband participation, constrained by gender norms that view pregnancy as a woman’s domain. Better-informed husbands were more likely to accompany wives to health facilities, while social barriers (e.g. embarrassment, long waiting times) hindered emotional support. Parental/in-law dominance often restricted husbands’ autonomy in reproductive decisions although supportive parental roles could motivate involvement. Community and religious leaders play key roles in conferring social legitimacy for active participation.

Religious and spiritual values provide a solid moral foundation, placing the husband as the family’s imam who cares for his wife both physically and emotionally. The involvement of religious leaders in prenatal education has been proven to increase male participation. In the context of Maluku culture, these values are manifested in the view that the husband is responsible for maintaining the harmony and safety of the pregnancy environment to keep it healthy and protected, as a form of respect for the family’s dignity. Access to information and contextual educational media is also an important factor (Mapunda et al. 2022). Respondents stated that media created using non-medical language and tailored to the stages of pregnancy are considered more effective in encouraging real behavioural changes (Oziwele & Ogerugba 2024). In addition, the involvement of community leaders also increases trust and acceptance of the health messages conveyed (Lansing et al. 2023; Petiwala et al. 2021).

Leveraging the values of ‘Bakele’ or togetherness as the basis for intervention allows for the design of ANC programmes that position husbands and extended family figures as active partners through family counselling sessions, official invitations for husbands and talks by traditional and religious leaders. This approach not only increases social legitimacy for men’s presence in health facilities but also speeds up emergency decision-making, which contributes to reducing delays in maternal and perinatal care.

These results align with Ethiopian and Zambian studies highlighting emotional support and family communication as key to men’s maternal service participation (Wood et al. 2024). Global evidence shows that religious values and community legitimacy can shift masculinity norms towards inclusivity. Integrating local cultural values strengthens intervention relevance and acceptance (Joseph & Maluka 2021; Paunno et al. 2024; Rahayu et al. 2023; Sahani et al. 2024; Shaluhiyah, Suryoputro & Indraswari 2023). The findings extend prior literature by detailing socio-cultural drivers in Maluku/eastern Indonesia (regional surveys) and resonate with studies on ANC quality in India, Pakistan and Africa, where cultural barriers limit involvement while family-centred approaches offer solutions (Atif et al. 2023; Gessesse et al. 2024; Girotra et al. 2023; Harrison et al. 2024; Nihal & Shekhar 2024).

These findings align with studies in Ethiopia and similar African contexts, where emotional support, family communication and knowledge significantly enhance men’s participation in maternal services (Gessesse et al. 2024; Wood et al. 2024). Emotional support serves as a key catalyst for maternal health decision-making, while open family dialogue reinforces service utilisation – patterns consistent with the strong effects of family dynamics and husbands’ knowledge observed here.

Global evidence indicates that religious values and legitimacy from community leaders can shift traditional masculinity norms towards greater participation in reproductive health (Joseph & Maluka 2021; Shaluhiyah et al. 2023). In patriarchal settings, religious endorsement provides moral justification for men’s involvement, mirroring the qualitative emphasis on spiritual legitimacy and leader roles in Maluku.

Integrating local cultural values such as ‘Bakele’ (togetherness) and ‘Moi Kintal’ harmony into antenatal services improves relevance, trust and acceptance, as culturally adapted interventions align health messages with community norms (Mapunda et al. 2022; Shiferaw & Minale 2025). This approach addresses gaps in prior quantitative-dominant research by detailing socio-cultural mechanisms in Maluku/eastern Indonesia, where involvement of husbands in their wives’ pregnancy care remains lower than national averages. It also resonates with evidence from India, Pakistan and broader African settings, where cultural barriers limit male engagement, but family-centred, norm-sensitive strategies improve outcomes (Atif et al. 2023; Gessesse et al. 2024; Harrison et al. 2024; Nihal & Shekhar 2024). The WHO guidelines encourage partner-inclusive psychosocial support to reduce perinatal burdens (World Health Organization 2023).

These findings offer practical guidance for community-based interventions (Shaluhiyah et al. 2023). Firstly, antenatal counselling should incorporate relevant cultural and spiritual values to strengthen the meaning and acceptance of health messages. A model grounded in local wisdom can reinforce husbands’ responsibility for family honour and well-being during pregnancy. Secondly, engaging traditional leaders, religious figures and parents in educational activities enhances social legitimacy and promotes active participation of husbands in their wives’ ANC (Joseph & Maluka 2021; Paunno et al. 2024; Rahayu et al. 2023; Sahani et al. 2024). Thirdly, developing trimester-specific educational media improves communication effectiveness and supports husbands’ evolving roles across pregnancy stages.

Family-centred interventions that involve the entire social unit beyond pregnant women and midwives can effectively reduce decision-making delays (three delays model) and improve maternal and neonatal outcomes. Embedding these results into primary care policies will foster a culturally responsive health system in settings like Maluku.

The sequential explanatory mixed-methods design enabled the integration of quantitative and qualitative findings, providing a richer understanding of the socio-cultural context of husbands’ involvement in ANC. However, causal inferences cannot be drawn due to the cross-sectional nature of the quantitative phase and the use of a convenience cluster sampling strategy, which was applied to capture regional diversity and local socio-cultural variation in Maluku. The complementary use of quantitative and qualitative approaches enhanced the overall robustness of the findings. Although confidence intervals were wide for some estimates, this likely reflects contextual heterogeneity and the socio-cultural complexity of the study setting, as well as variability across geographically remote and culturally diverse communities.

Family-based ANC involving married couples (bakele) should be made an integral part of maternity classes to strengthen communication and joint decision-making. The development of educational media using a progressive multi-channel community communication approach from Hulur to Hilir, tailored to the stages of pregnancy, childbirth and the neonatal period, will help husbands understand their role at each phase of the child’s development.

In the future, longitudinal and quasi-experimental studies are needed to assess the long-term impact of bakele ANC interventions on maternal and neonatal outcomes, while also opening opportunities to replicate ANC programmes in Indonesia.