Eligibility criteria
Published and unpublished primary studies using qualitative, quantitative or mixed methods were eligible to be included in the review if they: a) were conducted in a LMIC; b) reported data on factors influencing male partners’ attendance at labour and birth from the perspectives of male partners, childbearing women or healthcare professionals; c) were published in English; and d) were published from 2002 onwards. For the purposes of the review, we defined male partners’ attendance at childbirth as follows: 1) male partners accompanying the woman to the health facility but not being physically present during childbirth; or 2) male partners accompanying the woman and being present at any stage of childbirth or throughout labour and birth.
Reviews were excluded but were used to identify relevant primary studies. In this review, the term LMICs encompassed low income, lower middle income, and upper middle income countries as defined by the World Bank’s country classification in 2017 by income levels (9).
Search strategy
The searches for Phases 1 and 2 were conducted separately using the same search terms in the following electronic databases: CINAHL, MEDLINE, ASSIA, PsychoInfo ProQuest, Web of Science, SCOPUS, and Google Scholar. The search for Phase 1 was conducted in May 2016 and updated in November 2016 and December 2018. The search for Phase 2 was conducted September – November 2016 and updated in December 2018. The search strategy was saved on CINAHL, MEDLINE, and Google Scholar. Alerts for each database were created to update search outputs until December 2018. Whenever papers were released, they were screened to identify eligible studies that were added to the review.
Study selection
Search results were exported to Endnote reference management software version 7 (10). At each phase, after the de-duplication process, records were evaluated by title and abstract to identify potentially relevant papers. One reviewer (TCU) screened all the search output and a 10% sample was double-checked by second reviewers (AM or HW) to ensure the screening process was rigorous (11). Where there was not enough information, or the paper was potentially eligible, the full text article was assessed against the inclusion criteria. Articles about which there was uncertainty were discussed by the review team and consensus reached.
Data extraction and quality appraisal
Relevant data including the objective of the study, setting, participants, sample size, recruitment and characteristics, and method of data collection and analysis were extracted by one reviewer. Quality appraisal of qualitative studies used the Critical Appraisal Skills Programme (CASP) checklist (12). For the quality assessment of both quantitative and mixed methods cross-sectional studies, AXIS, an appraisal tool for surveys, was used (13). The quality of experimental and quasi-experimental studies was appraised using SURE checklist (14) . Studies were critically assessed by TCU.
Findings
Search outcomes
The search for Phase 1 yielded 3,070 unique titles which were screened to identify 33 eligible papers as presented in Figure 1.
Study characteristics
This systematic review included 68 studies: 33 qualitative, 30 quantitative, and five mixed methods studies provided quantitative data (see table 1 and 2 on the attached document for details). Studies included in this review were published between January 2002 and December 2018. Studies were conducted in 27 LMICs, including seven low income countries (n=19 studies), 12 lower middle income countries (n=31 studies), and eight upper middle income countries (n=18 studies) The studies focused on a range of topics including barriers to male partners’ involvement in maternal health, male partners’ attendance and their experiences of childbirth, women’s perceptions of male partners’ presence, health providers’ attitudes to male partners’ attendance, women’s childbirth experiences, and the effects of male partners’ presence at childbirth. Included studies involved 18,045 participants; including 5,517 men, 10,471 women, 1,188 health providers, 851 female birth companions, 11 traditional birth attendants, six religious leaders, and seven village leaders.
Summary of the quality of studies
In Phase 1, all qualitative studies stated their aims clearly. All articles explicitly described the inclusion criteria. Methods used to generate data were extrapolated in every study. Two studies (19, 20) did not discuss consent, or other ethical requirements of the research conduct. Analytical approaches and evidence to support the findings were provided in all except in one study (21). Eleven papers did not discuss the credibility of their findings (19-29).
In Phase 2, 18 out of 32 surveys did not justify the sample size (30-46). Five studies (34, 40-43, 47) lacked details of the inclusion criteria. Ten studies reported measures undertaken to minimise non-response (36, 39, 47-54). All except one study (45) reported how outcome variables reflected their aims. However, in seven studies the outcome variables were measured using non-validated instruments (30, 32, 33, 42, 47, 49, 50). Eight studies did not discuss ethics and consent (33, 40-42, 44, 50, 51, 55). Unlike some surveys, experimental studies provided sufficient information about the recruitment process.
Synthesis of the findings
After the analysis of the articles, themes from Phase 1 and Phase 2 were grouped into three broad categories: motivators, facilitators, and barriers that may determine male partners’ attendance at childbirth in LMICs (Table 3). Whilst the motivators to male partners’ attendance are the perspectives of only male partners, the facilitators and barriers were from the perspectives of male partners, pregnant women, health professionals, and community leaders.
Table 3: Themes that emerged from synthesised studies
Broad category
|
Themes
|
Obtained from Phase One
|
Obtained from Phase Two
|
Motivators
|
To be there for their partners
|
ü
|
ü
|
Facilitators
|
Women’s wish for male partners’ presence
|
ü
|
ü
|
Support from healthcare professionals
|
ü
|
|
Couples’ current relationship and closeness
|
ü
|
ü
|
Educational attainment
|
|
ü
|
Positive attitudes towards male partners’ attendance
|
ü
|
ü
|
Men accompanying their partners to antenatal care visits
|
|
ü
|
Barriers
|
Restrictions imposed by health facilities
|
ü
|
ü
|
Professionals’ negative perceptions
|
|
ü
|
Sociocultural barriers
|
ü
|
ü
|
Lack of information and preparation on childbirth
|
ü
|
|
Men’s negative experiences
|
ü
|
|
Women’s opposition
|
ü
|
ü
|
Lack of privacy
|
ü
|
|
Work-related constraints
|
ü
|
ü
|
Family structure influence
|
ü
|
ü
|
- Motivators to male partners’ attendance
Motivators of male partners’ attendance at childbirth were garnered from both male partners who attended childbirth and those who had not yet attended labour and/or birth. Male partners’ presence was viewed as an important practice to uphold.
Some male partners expressed their intention to ‘be there for their partners’ as reported in 19 studies, including 13 qualitative studies and six quantitative studies (22, 24, 27, 39, 46, 52, 56-68). Reasons for attendance varied depending on the country’s societal and contextual understanding of male partners’ role during childbirth. In a study from Brazil, fathers said they attended childbirth because they thought it was their right to participate (56). In contrast, men from studies conducted in Uganda, Rwanda, and Tanzania held the view that male partners would not necessarily be physically present at childbirth, but should stay within the premises to receive updates on the woman’s labour progress (57, 69, 70). Some men whose partners birthed in private hospitals stated that they attended birth to provide emotional support to their partners (28, 58, 71). Other reasons that motivated male partners to attend included the fulfilment of their responsibility (24, 57, 59-61, 72), safety of the mother and baby during their stay at the health facility (22), and curiosity to witness what happens during childbirth (23, 68, 73). Some male partners said they would participate in childbirth to play a role in decision-making about the care given to their partners (22, 61, 68, 74).
Cross-sectional surveys provided estimates of some of the reasons that led to male partners’ attendance (36, 39, 46, 52, 65, 67). In a study conducted in Nigeria involving 149 male partners, 81.2% reported that they attended childbirth because they felt it was needed, and 53.7% desired to support their partners (46). A study from the Philippines reported that 80.4% of 50 first time fathers attended childbirth because of anxiety about the birth outcome (39). Two studies reported that 22.8% (n=34) of men from a study in China (46) and 6.5% (n=34) of men in a study from Nigeria (52) attended childbirth to welcome their baby. A study from Turkey reported that 73.9% (n=90) of male partners wished to attend childbirth to provide practical support to their partners like assisting them to do breathing exercises during labour (67).
- Facilitators of male partners’ attendance
This broad theme covers individual and health system facilitators to male partners’ attendance.
Women’s wish for male partners’ presence
Five qualitative studies from Brazil, Nigeria, Rwanda, South Africa, and Uganda (20, 26, 29, 70, 75) reported that some women wished to have their husbands as birth companions. A study conducted in Nigeria, reported that women who were left unattended by midwives wished their spouses were present with them (26). Some women reported that they wanted emotional support from their husbands/partners (75). Other women whose husbands were present at childbirth reported that they felt protected and empowered to concentrate on the birthing task (70). Some women wanted their male partners to stay with them throughout childbirth to witness the endurance of labour (20).
Thirteen studies provided quantitative data on reasons why women wanted fathers to be present (30, 37, 40, 45, 47, 49, 51, 54, 67, 76-79). In one study from Nigeria that involved 506 women, 345 desired male partners’ presence at labour and birth and reasons included appreciation of the woman’s value (57.7%), witnessing childbirth ordeal (32.2%), interceding on their behalf for improved care (24%), receiving encouragement from their partner (21%), and 7.9% perceived that fathers would develop an early bond with the baby if they attended childbirth (49). In two studies, 86.6% (n=102) of 142 women from Nigeria and 86% (n=99) from Turkey whose male partners were present at labour reported that their partners’ presence was important for them because they benefitted from their emotional, psychological, physical, and financial support (67, 79).
Support from healthcare professionals
Studies conducted in Brazil and Gambia indicated that health professionals assisted fathers with information during childbirth such as measures to relieve labour pain and helping partners to support women into alternative positions (28, 29). In some instances, receiving information from healthcare practitioners during antenatal classes enabled male partners to attend childbirth (22, 24, 56, 59, 60). Men who received information, guidance, and encouragement from health professionals in private health facilities attended childbirth and felt engaged in the birth process (24, 60, 80).
Couples’ current relationship and closeness
Six qualitative studies suggested that among couples who reported having a good relationship, male partners were more likely to attend childbirth (27, 29, 57, 59, 70, 74). Two quantitative studies complemented these findings (48, 81). For example, a survey from El Salvador reported that men who were married or in a stable relationship with their partners at the time of birth were more likely to attend than those in less stable relationships (81).
Educational attainment
Six quantitative studies (31, 40, 41, 44, 49, 51) found that a higher level of education was associated with male partners’ attendance. Four studies conducted in Nigeria, found that the higher the level of the woman’s schooling, the more likely male partners were to attend the birth (40, 41, 49, 51). In a study in India, among men who reported that they attended childbirth, 48.3% (n=472) were educated at secondary school level and 57.1% ( n=389) had tertiary level education (44).
Positive attitudes towards male partners’ attendance
One qualitative study reported that some health providers thought male partners’ presence in the labour and/or delivery wards, would inspire them to use family planning (82). In addition, some midwives expressed that if male partners were allowed to attend childbirth, it would protect health providers from accusations of negligence (82).
In three quantitative studies, there was an association between positive attitude of women and male partners’ attendance. A survey from Ethiopia reported that 70.5% of women (n=277) viewed men’s involvement in childbirth as essential (48). An Iranian study reported that 88.4% (n=130) of women and 82.1% (n=119) of men had positive attitudes towards fathers’ presence during labour (55). A study from Egypt reported that 64% (n=124) of women had positive attitudes to their male partners’ stay in the delivery room (35).
Men accompanying their partners to antenatal care visits
This theme was from three quantitative studies (48-50). A study from Ethiopia reported that women who attended antenatal care sessions with their husbands were 3.8 times more likely to be accompanied at delivery than those who did not attend with their spouses (48). A study from El Salvador reported that men who attended prenatal care with their partners were likely to attend birth (50).
- Barriers to male partners’ attendance
This theme encompasses individual, sociocultural, contextual, and health system related barriers that may limit male partners’ attendance.
Restrictions imposed by health facilities
Most public health facilities did not permit men’s presence at labour and/or birth and others put some restrictions on male partners’ attendance (19, 22, 26, 28, 29, 57, 60, 62, 72-75, 78, 83-88). For example, a study conducted in a public health facility in South Africa reported that male partners had to request permission to attend the first stage of labour in writing (60). In Syria, male partners’ presence was prohibited in the second stage of labour (72, 83). Lack of written protocols and some providers’ negative attitudes also limited male partners’ attendance (19, 26, 28, 29, 75, 83, 87, 88). Eight quantitative studies assessed the extent of this issue from the reports of men who wished to attend childbirth or of women who wanted their male partners to be present (35, 45, 49, 50, 52, 78, 89-91). Available estimates indicate that between 32.5% and 95% of male partners were restricted from accessing maternity wards.
Professionals’ negative perceptions
Three quantitative studies reported health providers’ perceptions that may limit male partners’ attendance (77, 91, 92). A study from Malawi reported that 5% of 60 midwives thought that permitting male partners’ attendance would increase litigation(77). Another survey from Nigeria indicated that 60.4% (n=136) of health providers perceived that male partners might disturb the caring team, 23.6% (n=53) feared that male partners would sue the hospital for negligence, and 3.6% (n=8) thought that male partners would collapse upon seeing blood (91).
Sociocultural barriers
Sociocultural barriers to male partners’ participation in the birth process was mentioned in 16 qualitative studies and one quantitative study (20, 22, 23, 25-28, 59, 60, 72, 74, 83, 87, 93, 94). Studies from Gambia, Syria, Botswana, Malawi, Kenya, South Africa, Nigeria, and Rwanda reported that men and women in rural and semi-urban areas did not favour male partners’ presence at labour and/or birth. This may have been influenced by cultural norms that regarded pregnancy and childbirth as a woman’s realm and patriarchal attitudes that childbirth is an intimate event which a man should not witness (20, 22, 26, 62, 70, 74, 83, 91, 93, 94). In one survey conducted in a rural Rwandan hospital, 51% of women (n=178) said that men’s presence at childbirth was not culturally appropriate (37).
Lack of information and preparation on childbirth
Fourteen qualitative studies contributed to this theme (19, 20, 22, 23, 56, 57, 59-61, 74, 85-87, 93). Male partners who attended childbirth reported that insufficient preparation restricted their participation during childbirth (19, 22, 23, 57, 61, 74, 85, 86, 93). Male partners who had not yet attended labour and/birth voiced their concern over the kind of support they could provide to their partners (19, 22, 57, 74, 85, 86, 93).
Men’s negative experiences
In hospitals that allowed male partners to attend, some men reported that they were scared to attend because of the embarrassment of being seen in labour wards (19, 22, 23, 57, 67, 69, 74, 83). Another embarrassing event for some men was vaginal examinations, which some participants labelled as an invasion to the couple’s privacy (58). Some men from Tanzania stated that they could not attend labour for fear that their partners might make offensive statements that might embarrass them (69). Another negative experience was male partners’ fear of seeing their partners in pain during labour and seeing blood during birth (21-23, 29, 56, 58-60, 67, 93).
Women’s opposition
Some women were against male partners’ presence at childbirth because they presumed that a man does not know about labour (19, 22, 57, 70, 72-74, 83, 85, 93, 95).
Nine quantitative studies reported that women’s opposition may be a limiting factor to male partners’ attendance (30, 32, 35, 37, 41, 49, 51, 67, 69). Reasons underlying women’s opposition varied. For example, a study from Nigeria reported that 39.3% of 140 women perceived that male partners’ presence was not needed, 27.9% thought that male partners’ presence would disturb attending health professionals, and 18.6% perceived that their partners could not cope with delivery (49). In a study conducted in Turkey, 45.4% (n=25) of women who did not wish male partners’ presence reported that there was no need for them to stay with them during childbirth (67).
Lack of privacy
Studies conducted in Nepal, Malawi, Syria, and Nigeria reported that lack of privacy in the labour wards may limit male partners’ attendance (23, 74, 83, 96). Men who have ever accompanied their partners to deliver reported that the way labour wards are designed and the high number of parturient women pose privacy issues to male partners’ presence (23, 83, 96).
Work-related constraints
Five qualitative studies reported that unavailability due to work was a limiting factor to male partners’ attendance. Some women reported that they were supported by their mothers or mothers-in-law at the time of birth because their husbands migrated to cities for jobs (27). Some male partners reported that they did not attend childbirth because the labour occurred when they were at work (29, 87, 95). Similarly, quantitative studies from Nigeria and India echoed this finding (66, 97).
Family structure influence
Three quantitative studies from India, Nigeria, and El Salvador reported that family structure may limit male partners from attending childbirth (33, 44, 45). For instance, in India, one study reported that 85% of men reported that they did not attend because at the onset of labour, their partners were staying with their parents (44). In El Salvador, women from extended families were less likely to report on male partners’ attendance than women from nuclear families (33). In a qualitative study from Gambia, some men who had more than one wife reported that they did not attend childbirth for fear of instilling jealousy among their co-wives (94).