Demographic distribution of study participantsOne hundred and twenty-nine participants were involved in the FGDs with different categories and age groups. The majority of participants (38) were aged between 20-29 years, and most of them (36) were married men (See Table 1 below).Table 1 Distribution of the FGDs participants by age, sex, and marital statusFull size tableCharacteristics of the IDIs participants by age and sexA total of 30 IDI was conducted with key informants, including 21 males and nine females. The majority (11) of study participants were aged between 30-39 years, as shown in Table 2 belowTable 2 Distribution of the IDIs participants by age and sexFull size tableGender social norms in relation to utilization of reproductive health servicesFGDs participants were asked to share their experiences on the existing gender norms in their communities which may hinder women from utilizing reproductive health services. The majority mentioned social norms as the main drivers of gender inequalities among women, men, boys, and girls in the community. Most of them negatively perceive family planning services and cannot allow their spouses to use them. As a result, some women secretly opt for family planning (F.P.) methods without their spouse’s knowledge. If uncovered, that could result in divorce or physical and psychological violence, limiting women from effectively utilizing maternal health services. For example, a participant provided a scenario as follows;
“A woman who decided to use an implant family panning method secretly was forced to remove the plaster before arriving home for fear of being noticed by her husband. (IDI- District official, Meatu DC)

Participants shared their experiences, emphasizing that every community has its traditions and directives. One of the community health workers said that sometimes they take severely malnourished children to the health facility, but they will be warned by the father to bring them home (mother and child) because he doesn’t want her to be admitted. She further said that anemia is prevalent among pregnant women in Simiyu, which could be due to forbidding women to take some foods, including some fruits like pawpaw, which are crucial during pregnancy. This was narrated as follows;

“Sometimes community health workers bring severely malnourished children to the health facility, but she/he will be warned by the father to bring them home (mother and child), no admission please.” (A CHW – Meatu DC)

For example, a traditional practice of paying dowry when the girls get married was also among the social norms of enslaved people, causing women and girls to be treated as enslaved people and commodities in the family, becoming inferior to men and limiting their access to reproductive services. This was elaborated as follows;
“Our community believes in the tradition of having many kids, as we pay high bride prices, so they cannot give birth to a few children. For example, payment of 20 cows for bride price and the woman want to have only two children, it is not accepted, so we can’t allow them to use family planning” (Married man – Busega DC)

It was also observed that traditional social norms and practices would continue to exist in the community because after getting married, men stay in their father’s households for up to 45 or 50 years. As a result, children will observe their father’s brutal behavior and continue living under the same behavior when they grow up. Hence the limited access to RMNCAH services may persist in the study area if not intervened.
“The traditional behaviors of men leading their family as they wish have been inherited from their forefathers. Anything said by a man should be obeyed; the woman cannot tell his man anything, and if a man listens to his wife, the members of the community will think that the man is the married one” (CHW – Busega DC)
Decision-making power in relation to access to reproductive health servicesMen across all ethnic groups in the region dominate decision-making processes. This includes deciding on whether the RMNCAH services should be sought or not. Participants further reported that decision-making being solely at men’s hands has been fatal. For example, it was noted that one woman died following an ectopic complication because her husband did not consent to the operation as he was away on safari.It was also reported that women and girls and men and boys are valued differently across all ethnic groups that were interviewed. Men are considered to be superior in all tribes in Simiyu. Boys are preferred over girls, and this practice perpetuates gender inequality in almost all tribes interviewed. Women and girls are considered weak and inferior beings who cannot be trusted with anything.This was elaborated as follows;
“We men, when you bring (marry) a woman, you have bought her, which means, if I bought her, she must bring me a profit. A woman is a housewife, a man is a decision-maker, and her job is to give birth to children for me to have a big family. You know a man will get hurt if a woman gets an education. If a woman gets money, she is cruel to her husband (Married man –Bariadi DC)
Roles and responsibility in relation to access to reproductive health servicesIn Sukuma society the roles of men and women in the society are mainly patriarchal, where women are under the control of men hence leading to gender inequality. The findings from FGD revealed that in the Sukuma community, women and girls are responsible for all domestic duties ranging from cooking, collecting water and wood, taking care of patients, serving men, and sometimes farm activities, including animal grazing. They perform these activities with the assistance of children perpetuating men wanting many children to help perform family activities. This practice could limit women from utilizing maternal health services due to many responsibilities and limited time. This was reported as follows;

“A woman is a housewife; her job is to give birth to many children to have a big family” (Community leader – Busega DC)

It was also reported that some men misuse the family resources from farm activities due to alcoholic behavior. This may cause women to have limited financial resources, which could help in accessing maternal health care even when they have contributed to the financial gains of the family. One Sukuma female respondent reported as follows;

“You know for Sukuma, women do almost everything; even if you want to access services, it becomes difficult because we don’t have time. For example, we have to wait and cook for the young boys who went for cattle grazing”. (Married Women – Busega district in Nyashimo village)

On a positive note, some participants reported improvements regarding gender roles and responsibilities in the community owing to years of awareness created by the government and other health stakeholders. Participants said that, unlike in the past when women were seen as laborers working on the farmsteads, kitchen, and other household chores, men nowadays assist them by doing household activities like fetching water and wood, carrying luggage, and bringing food home. They also explained women’s role in economic activities, as now they can engage in entrepreneurship and other economic activities. This helps them earn and increase their confidence in the household, including using reproductive and child health services. This was narrated as follows;
“This issue was alarming but has subsided after seminars and mothers joining entrepreneurial groups. Entrepreneurial groups have greatly contributed to mothers engaging in small businesses and stopping relying on men. When a man goes out for a drink, a woman goes to her business and feeds the family. A man lacks the strength to attack a woman because he knows a woman can live independent lives.” (FGD with Community leader –Bariadi DC)

Access to resources in relation to reproductive health servicesIn Sukuma societies, a traditional conception of access to resources and economic power is determined by the patriarchal system in which men hold primary power and predominate in social and economic roles at the family level, thus creating economic inequality between men and women. Consequently, lack of access to and control over resources affects women’s health-seeking behavior.Economic empowerment is a pre-condition for realizing the full spectrum of human rights. Across all ethnic groups in the Simiyu region, women and girls do not have equal access to or control over resources such as land, livestock, money, houses, education, etc. Men, however, have access to and control over family resources and decide how and when the resources will be used. These practices impact women’s access to quality RMNCAH services. Women do not have the confidence or financial autonomy to exert control over their lives, including the sexual and reproductive health aspects of life. For example, one of the DRHCOs shared a scenario below
“A woman in her 8th pregnancy took her husband to the health facility for counseling. She felt too tired to continue bearing children and asked for family planning. Her husband responded, “My mother had 13 of us; my target is 14 children” (CHW-Busega DC)
During FGDs, participants said that boys are given preference, access to family resources, are educated, and are provided with the best meals. Regarding inheritance, boys are given valuable resources like land, houses, and even cars. On the other hand, girls are given a share of household items like cooking pans, plates, clothes, etc. In some families where girls were given a share of livestock, they got less than boys. For example, one of the adolescent girls gave her a scenario that;
“In our family, we are five girls and one boy owning ten cows, when parents distributed these cows to us – a boy was given five cows while girls were given one cow each.” (A girl, in FGD –Busega DC)
However, other participants reported that economic power or ownership of resources gives a person power over decision-making. It was also reported that when a woman is the owner of the properties, she may be disrespectful to her husband, or her respect for the husband becomes very low. . This notion was perceived as gender inequity that affects men and the other way around was not viewed as such as demonstrated by this quote from a community leader.
“If I can say from my side, I could say if the husband has economic power, it is unusual to observe gender inequalities in the family. However, in a case where the wife owns most or all of the family properties and the husband does not own, a woman will not respect her husband as ahead of the family “Community leader – Bariadi DC)