Does involving male partners in antenatal care improve healthcare utilisation? Systematic review and meta-analysis of the published literature from low- and middle-income countries

Abstract

Background

Although in most low- and middle-income countries (LMICs) men are decision makers and control the household budget, their involvement in maternity care is limited. Reports from high-income countries indicate a beneficial effect of involving men in antenatal and delivery care on birth outcomes.

Methods

We conducted a systematic review to assess whether similar effects are observed in LMICs. We searched MEDLINE, PubMed, CINAHL, Embase, NCBI, PsycInfo and other relevant databases using a comprehensive search strategy to retrieve relevant articles. A total of 17 articles were included. Meta-analysis of extracted data was performed, using the generic inverse variance method where possible. All studies were conducted in South Asia and Africa.

Results

We found that involving a male partner in antenatal care was associated with skilled birth attendance utilization (pooled OR 3.19 [95% CI 1.55 to 6.55]), having institutional delivery (OR 2.76 [95% CI 1.70 to 4.50]) and post-partum visit uptake (OR 2.13 [95% CI 1.45 to 3.13]). Mother’s knowledge of danger signs and modern contraception utilization were also positively affected. However, it had no significant impact on the number of antenatal visits.

Conclusions

Male involvement in antenatal care had a positive impact on the uptake of maternal health services. Further research needs to investigate whether this translates into improved maternal and newborn health in developing countries.

Keywords: antenatal care, developing countries, male partner involvement, maternal health, newborn health, women’s health

Introduction

Maternal and newborn health are still major concerns worldwide. Around 99% of maternal deaths occur in low- and middle-income countries (LMICs).¹ Complications during pregnancy and childbirth that contribute to maternal and infant mortality are preventable in many cases through appropriate care before and throughout pregnancy and delivery. The three delays model has been proposed for analysing the root cause of maternal mortality—delays in the decision to seek care, to reach care and to obtain care.² Of these, the first delay in the decision to seek care sits squarely in the community, specifically on the person responsible for making household decisions.

In most developing countries, societies are patriarchal, with men having the role of primary decision maker and controlling the household budget. Thus the decision to seek care (the first delay) is usually made by the male partner or husband.³ Yet in some cultures, male members are not expected to be directly involved in their wife’s pregnancy and delivery care. If they are, this is considered by their peers as a demonstration of weakness.⁴ From a social perspective, the notion of joining one’s wife at the antenatal clinic is unusual in many communities and the husband’s presence is often considered superfluous.⁵ Vermeulen et al.⁶ reported that perceived traditional gender roles and a lack of knowledge and opportunities for involvement in obstetric care were some of the barriers to male partner involvement in rural Tanzania and can probably be generalized to other LMICs.

Recently, sexual and reproductive healthcare has moved from the age-old tradition of being woman-centric to being couple-centric. Two systematic reviews addressing the impact of male partner involvement on outcomes of pregnancy were published in 2015.^7,8 Including seven primary studies in their systematic review, Aguiar and Jennings⁷ found a positive association between male partner attendance at antenatal clinic visits and women’s knowledge of danger signs during pregnancy, but it did not affect birth preparedness or utilization of antenatal care (ANC). The review by Yargawa and Leonardi-Bee⁸ found a significant reduction in post-partum depression and increased utilization of delivery and postnatal unhyphenated throughout care with male partner involvement. However, their review found that male presence in the delivery room was not associated with increased spontaneous labour and delivery. Based on these two systematic reviews, the World Health Organization strongly recommends male partner involvement in pregnancy and delivery to facilitate and support the care of women during pregnancy and delivery, accessing skilled birth attendance (SBA) and the timely use of facility care for obstetric and newborn complications. The idea of involving male partners in maternal and child health is designed as a means to support women’s access to care, address gender inequality and promote men’s positive involvement as partners and fathers.⁹ To date, interventions using mass media campaigns, counselling and outreach programmes involving both men and women in the community and workplace have met with modest success in improving birth outcomes, promoting gender equality and positively involving men in women and children’s health. This review focuses on the impact of involving male partners during ANC on the utilization of healthcare facilities, including SBA, at the time of delivery and in the postnatal unhyphenated throughout period.

Methods

Inclusion and exclusion criteria

First, a focused review question in the PECO (Participants, Exposure, Comparison, Outcome) format was formulated—‘What are the effects of male partner involvement in ANC on utilization of delivery and postnatal unhyphenated throughout care in low and middle income countries?’ Inclusion criteria were primary studies involving pregnant women and/or their partners in LMICs (according to the World Bank classification). A United Nation’s report defined male involvement in maternal and child health (MCH) as a social and behavioural change process that is required for men to play more responsible roles in MCH with the purpose of ensuring women’s and children’s well-being.¹⁰ In this review, male involvement in ANC is defined as the male partner’s/husband’s participation in ANC by escorting their girlfriends/wives and receiving any information regarding their pregnancy and health education during ANC. We hypothesized that male partners’ involvement in ANC will improve men’s awareness and increase their participation in all aspects of maternity and newborn care. Aborigo et al.⁵ argued that involving male partners in ANC allows men to have access to critical information on the reproductive health of their partners and on birth preparedness and could also increase adherence to guidance given at the clinic.

All quantitative study designs, including cross-sectional, case–control, cohort and randomised control trials, were eligible for inclusion. Those studies that were done in high-income countries, not reporting the effect of male involvement in ANC on the uptake of delivery and postnatal unhyphenated throughout care or solely focusing on the uptake of human immunodeficiency virus (HIV) testing/counselling were excluded.

Search strategy

MEDLINE, PubMed, Scopus, CINAHL, Embase, NCBI, PsycInfo and Cochrane Collaboration—all mainstream electronic databases—were searched and used to retrieve the articles. No time or language limits were used. Search terms used the following keywords and MeSH headings: ‘male involvement/male participation’, ‘husband involvement’, ‘antenatal care’, ‘perinatal care’, ‘maternal health service’, ‘labour’, ‘delivery room’, ‘childbirth’, ‘new-born health’, ‘infant health’ and ‘developing countries’. Grouped terms such as ‘male involvement and ANC’ were also used. Boolean operators AND and OR were utilized as appropriate to connect the search terms.

Articles retrieved from electronic databases were screened for relevance based on their titles and abstracts as an initial step. Full texts were retrieved for the remaining articles and screened based on inclusion and exclusion criteria. Included references were imported into the reference management software RefWorks (ProQuest, Ann Arbor, MI, USA) and duplicates removed. Data from all included articles were extracted using a simple data extraction form. The extracted information consisted of author, year of publication, study setting, study aim, study design, study population, type of exposure or intervention, the number of participants, study outcomes and results of the study. The Downs and Black checklist for assessing study quality was used, as the primary studies included in the review varied by study design. The search strategy was developed and run independently by two reviewers (DS and PW) with the help of a medical librarian and were initially screened for relevance. Two reviewers (DS and PW or SB) independently assessed quality and extracted data from the included studies. Any disagreements were settled through discussion or by arbitration of the third reviewer. Meta-analysis of extracted data was done where appropriate using RevMan version 5.3 software (Cochrane, London, UK), and pooled ORs with 95% CIs were calculated for the outcomes of institutional delivery, SBA and postnatal unhyphenated throughout visit. ORs for male partner attendance at antenatal clinics were extracted from the primary studies where available and these were pooled using the generic inverse variance method. We assessed between-study heterogeneity using the I² statistic and used a random effects model where heterogeneity was high, as evidenced by I²>50%. The search was rerun in May 2019 using the same search strategy and exclusion methods, and four new relevant papers were found.

Results

Search flow

After removing duplicates, 876 citations were identified from the electronic bibliographic database search and 103 articles remained after the initial screening of titles and abstracts. After the second round of screening, full texts of 22 potentially relevant articles were retrieved. In the final round, five articles were excluded. Two investigated the relationship between maternal mortality, birth preparedness/complication readiness and male involvement, but it was not clear whether male involvement included ANC attendance or not. Two articles investigated the level of male involvement and risk factors that contribute to male involvement. Another paper solely presented the influencing factors of male involvement in ANC. In the end, 17 articles were included. Details of the search flow are shown in Figure 1.

Figure 1 Article search flow. (Figure not reproduced here; see the original article.)

Table 1 presents the characteristics of the included studies. All included studies were conducted in Southeast Asia (n=8) or sub-Saharan Africa (n=9). Three studies were conducted in Nepal,^11–13 two in India,^14,15 one in Indonesia,¹⁶ one in Myanmar¹⁷ and one in Bangladesh,¹⁸ in the Southeast Asia region. In the Africa region, one study was conducted each in Kenya,¹⁹ Malawi,²⁰ Zambia,²¹ South Africa,²² Burkina Faso²³ and Uganda,²⁴ while three studies were conducted in Ethiopia.^25–27

In terms of study design, there were five randomized controlled trials (RCTs),^11,12,15,23 of which one was a cluster RCT,²² one was a non-randomized controlled trial¹³ and the others were all cohort studies or cross-sectional surveys.

In all the included studies, the population was women of reproductive age, although some were recruited from antenatal clinics while others participated in surveys after pregnancy and delivery. All the studies compared couple attendance at ANC with attendance by the pregnant woman alone. The outcomes reported included institutional delivery,^{11,14,17,20,21,26} SBA,^{11,16,17,19,27} and post-partum visit.^11,17,21,23 Other outcomes reported included birth preparedness, knowledge about maternal and reproductive health, newborn immunization, exclusive breastfeeding and contraceptive use post-partum. Kalembo et al.,²⁰ in their study including HIV-positive women, also reported on the uptake of prevention of mother-to-child transmission (PMTCT) and HIV status of the newborn.

The Downs and Black checklist for assessing study quality was used, as the primary studies included in the review varied by study design. The majority of papers scored ≥13 out of 26. The ones that scored <13 were Chattopadhyay¹⁴ (10), Forbes et al.²⁵ (10), Mohammed et al.²⁶ (8), Timsa et al.²⁴ (8), Wai et al.¹⁷ (10) and Wicaksono¹⁶ (12). The average score of the studies was 14/26; the highest scoring study was Daniele et al.²³ (23) and the lowest scoring studies were by Timsa et al.²⁴ and Mohammed et al.²⁶ (8). The external validity criteria scored proportionately lower (22%) compared with other criteria in the checklist and as a percentage of the total possible points collected (49%).

Maternal healthcare utilization

Male partner involvement in pregnancy care appeared to have the greatest effect on healthcare utilization.

Number of ANC visits

In terms of the number of ANC visits, Mullany et al.¹¹ showed that there was no significant impact of male involvement. However, in Myanmar, women who were accompanied by their partner to an ANC visit were more likely to have more than four ANC visits during pregnancy (adjusted OR [aOR] 5.82 [95% CI 3.34 to 10.15]).¹⁷ In Ethiopia, the absence of male partners in ANC was not significantly associated with ANC commencement in the first trimester (aOR 1.05 [95% CI 0.79 to 1.39]) or having four or more ANC visits (aOR 1.06 [95% CI 0.82 to 1.38]).²⁵ Similarly, the absence of male partners during ANC was not significantly linked to less likelihood of receiving all components of ANC (aOR 0.65 [95% CI 0.39 to 1.10]).²⁵ A study in Bangladesh demonstrated that women accompanied by their husband were 4.5 times more likely to have ANC from a medically trained provider (OR 4.7 [95% CI 2.5–9.0]; aOR 4.5 [95% CI 2.3 to 8.7]).¹⁸

Institutional delivery

The pooled OR (2.76 [95% CI 1.70 to 4.50]) from five included studies conducted in separate countries in Southeast Asia and Africa was statistically significant. However, the differences between the effect of the individual study and the pooled effect across studies were considerable (I²=90%). Therefore the random effects model was applied. Figure 2 shows the effect of male partner involvement in ANC with the chance of having an institutional delivery.

Figure 2 Meta-analysis of having institutional delivery. (Figure not reproduced here; see the original article.)

SBA

Similar to institutional delivery, the pooled aOR for SBA was statistically significant (3.19 [95% CI 1.55 to 6.55]) using a random effects model, as I² was 94% (Figure 3). Five studies showed a positive association between male ANC attendance and utilization of SBA. Kashitala et al.²¹ conducted a cohort study in Zambia and found that women with male accompaniment had higher odds than unaccompanied women (OR 1.53, p<0.005) of arranging for skilled attendance at delivery. This evidence was supported by other studies in Kenya that revealed women with a partner were more likely to have SBA (aOR 2.17 95% CI 1.14 to 4.11]).¹⁹ In India (aOR 1.35 [95% CI 1.14 to 4.11]),¹⁴ Ethiopia (aOR 6.27 [95% CI 4.2 to 9.3])²⁷ and Indonesia (aOR 2.17 [95% CI 1.77 to 2.70]),¹⁶ similar patterns were observed. Kalembo et al.²⁰ found that accompanied women had increased odds of having a hospital delivery than those who were unaccompanied (aOR 25.9, p<0.001). In contrast, Mullany et al.¹¹ and Wai et al.¹⁷ found no significant differences between women with and without a partner.

Figure 3 Meta-analysis of utilization of SBA. (Figure not reproduced here; see the original article.)

Post-partum visits

Involving male partners in ANC was associated with increasing post-partum care attendance. The pooled OR for postnatal unhyphenated throughout visits was found to be 2.13 (95% CI 1.45 to 3.13) using a random effects model, as heterogeneity was 81% (Figure 4). In Zambia, women who came with their spouse for ANC visits were 58% more likely to use post-partum care.²¹ Women who received antenatal health education along with their partners were more likely to attend a post-partum visit than those who received education alone (RR 1.25 [95% CI 1.01 to 1.54]) in Nepal,¹¹ whereas a study in Myanmar found no significant impact of male partner involvement on receiving post-partum care.¹⁷

Figure 4 Meta-analysis of post-partum visit. (Figure not reproduced here; see the original article.)

Effective modern contraception usage

Daniele et al.²³ investigated the effect of male involvement during an antenatal education session on the utilization of effective modern contraception 8 mo post-partum. Inviting male partners into antenatal education sessions positively affected the use of effective modern contraception in women, with the effect size 1.12 greater than for women in the control group (RR 1.12 [95% CI 1.01 to 1.24]).

Reproductive health knowledge and birth preparedness

Knowledge of miscarriage and danger signs

Four studies reported conflicting results regarding the effect of male involvement on knowledge of miscarriage and danger signs. In Nepal, Mullany et al.¹² found that women who had antenatal education with their partner were likely to know more about pregnancy complications (aRR 1.15 [95% CI 1.00 to 1.32]) and were significantly more likely to show improvement in knowledge from baseline to follow-up (RR 1.25 [95% CI 1.04 to 1.51]) compared with those who attended alone. Similar results were found in India. Inviting a male partner into ANC counselling significantly increased the knowledge of pregnancy danger signs in 24% of women 13% of control women (z=2.99, p<0.05).¹⁵ In Ethiopia, women who attended ANC without a male partner were less likely to report that they had been counselled about possible pregnancy complications (aOR 0.64 [95% CI 0.48 to 0.86]).²⁵ In contrast, in South Africa, Kunene et al.²² found no difference between couples who received and did not receive ANC counselling in knowledge of miscarriage or obstetric danger signs (p>0.05).

Birth preparedness

One study investigated the association between male involvement and birth preparedness (purchased safe delivery, save money for delivery, having blood donor, etc.).¹¹ Women who were educated with a spouse were 1.3 times more likely to make more than three birth preparations as compared with those who received education alone, although the effect was not statistically significant (aRR 1.30 [95% CI 0.78 to 2.15]).¹¹

Newborn health outcome

Articles that were directly related to newborn outcomes were mostly conducted in HIV-positive pregnant women.

Breastfeeding initiation

In India, an intervention involving the male partner in ANC significantly increased breastfeeding initiation within the first hour after birth in 63.1% of women in the intervention arm vs 47.3% of women in the control arm (z=3.28, p<0.05).¹⁵ A recent study from Daniele et al.²³ in Burkina Faso showed similar findings. Women in the intervention arm were 1.35 times more likely to breastfeed exclusively compared with those who only received routine care (RR 1.35 [95% CI 1.15 to 1.59]).²³ In contrast, in South Africa there was no significant difference found in terms of breastfeeding initiation between those who came with or without a man (p=0.1).²²

Discussion

Not all studies included in this review showed that male involvement had a significant impact on maternal and child health. However, most studies reported that men’s participation in ANC is more likely to have a positive impact on improving healthcare utilization in terms of SBA, institutional delivery and post-partum care. The number of ANC visits and birth preparedness were not significantly influenced by male involvement. HIV survival and breastfeeding initiation are newborn outcomes that were affected positively by male partner involvement. While male involvement in ANC had no impact on infant mortality and vertical transmission of HIV infection, male presence during labour had a positive impact on relieving the stress of the mother during childbirth and resulted in a higher proportion of spontaneous labours.

This review found that knowledge improvement was greater among those who had a male partner accompanying them than those who did not. This finding was similar to evidence in Tanzania, where male involvement improved knowledge of danger signs and birth preparedness.²⁸ The relationship between couples and the shared decision-making process may be responsible for the impact of male partner involvement seen in knowledge improvement.²⁹ For this reason, women who were educated with their male partners were more likely to share information together and have a discussion with their partner regarding pregnancy and delivery. Furthermore, male accompaniment in health education may aid retention of knowledge and increase a couple’s communication.⁷ All these reasons help explain how men’s involvement is more likely to improve women’s knowledge.

Addressing gender inequality is one of the recognized strategies to improve maternal and child health³⁰ and is supported by Sustainable Development Goal 5. This not only focuses on women’s empowerment, but also the support of men, since gender is a social construct that affects both men and women.²⁹ ANC is the first step for raising awareness of both the mother and father about maternal and infant health. Men, as the chief decision makers in patriarchal societies, have the potential to prevent the first delay in the three-delays model proposed by Dudgeon and Inhorn.^31,32

Men are dominant in the patriarchal household and responsible for the planning and provision of healthcare for household members. Antenatal classes could be a way to change men’s knowledge and views towards maternal and infant health. In this context, it would be helpful to define the role of the male partner in pregnancy care. It is obviously more than just accompanying the pregnant woman for antenatal visits, and implies joint decision making with regard to pregnancy and birth planning for the benefit of the mother and the newborn.

This review also found that the presence of male partners in the delivery room had a positive impact on women’s feeling of being in control during childbirth,¹³ and their accompaniment during childbirth was positively linked to having an institutional delivery.¹⁸ Several studies have shown that male involvement during labour shortens the labour and reduces the epidural rate.³³ Studies have demonstrated that the presence of social support is a significant factor in women’s adjustment to the stress of childbearing.³⁴ In addition, Nepalese women felt the presence of their husband gave them greater self-confidence and relief of stress, and facilitated communication.³⁵ The husband’s love and emotional support were expected by women during pregnancy and delivery.³⁶ In contrast, a study in Hong Kong found that husbands’ involvement during labour was associated with a higher dosage of analgesia.³⁴

Men’s engagement in different reproductive programmes resulted in positive outcomes, such as increased condom use, more couples following the PMTCT HIV transmission programme and the use of SBA.³⁷

A comprehensive and inclusive literature search based on a focused review question and inclusion and exclusion criteria agreed to a priori are major strengths of this review. On the other hand, restricting the publications to the English language in the interest of time and resource constraints may have resulted in some relevant articles being missed. Most of the included literature came from sub-Saharan Africa and South Asia and thus the findings may not be generalizable to other LMIC settings. Since involving the male partner in pregnancy and delivery care is an intervention, it should, in an ideal world, be evaluated by randomized controlled trials. However, many of the studies included in this review were observational studies, which are prone to bias and confounding. Few of these controlled for confounding factors and reported adjusted effect estimates. We also cannot rule out potential publication bias, as studies with negative findings are less likely to be published. The outcomes assessed in the primary studies included in the review were most often process outcomes, such as an increase in knowledge or birth preparedness. While some of these process outcomes, such as SBA, have been shown to be effective in reducing maternal and perinatal mortality, others have no such evidence base. It is difficult to firmly conclude whether male partner involvement in pregnancy and childbirth improves birth outcomes for both the mother and the baby, as it is entirely plausible that the women who are accompanied by their male partners are already equal partners in the decision-making process and it is this empowerment that bestows the beneficial effects, not the involvement of the partner per se.

Conclusions

In developing countries, male accompaniment in ANC has a beneficial impact on improving the mother’s knowledge of danger signs, utilization of an SBA and relieving stress and anxiety during labour, as well as increasing uptake of post-partum care and initiation of breastfeeding. However, further research needs to unpack the psychosocial elements that underpin the impact of male partner involvement in maternity care.

Contributor Information

Dedih Suandi, Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Aberdeen AB25 2Z, UK; Indonesia Endowment Fund for Education (LPDP), Indonesia Ministry of Finance, Jakarta 10330, Indonesia.

Pauline Williams, Centre of Academic Primary Care, University of Aberdeen, Aberdeen AB25 2ZL, UK.

Sohinee Bhattacharya, Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Aberdeen AB25 2Z, UK.

Authors’ contributions

All authors contributed to the development of the paper, including developing the search strategy, screening, data extraction, quality assessment, meta-analysis and writing the paper.

Funding

This work was supported by the Indonesia Endowment Fund for Education (LPDP), Ministry of Finance, Republic of Indonesia (grant no. 20160612046995).

Competing interests

None declared.

Ethical approval

Not required.

References

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