Does involving male partners in antenatal care improve ...

© The Author(s) 2019. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided theoriginal work is properly cited. For commercial re-use, please contact [email protected]

doi:10.1093/inthealth/ihz073

ORIG

INAL

ARTI

CLE Does involving male partners in antenatal care improve healthcare

utilisation? Systematic review and meta-analysis of the publishedliterature from low- and middle-income countries

Dedih Suandia,c,*, Pauline Williamsb and Sohinee Bhattacharyaa

aCentre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Aberdeen AB25 2Z, UK;bCentre of Academic Primary Care, University of Aberdeen, Aberdeen AB25 2ZL, UK; cIndonesia Endowment Fund for Education (LPDP),

Indonesia Ministry of Finance, Jakarta 10330, Indonesia

*Corresponding author: Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Aberdeen AB25 2Z, UK.Tel: +62 21 31934379 exts. 2314, 2316; E-mail: [email protected], [email protected]

Received 2 May 2019; revised 11 July 2019; editorial decision 16 July 2019; accepted 17 July 2019

Background: Although in most low- and middle-income countries (LMICs) men are decision makers and controlthe household budget, their involvement in maternity care is limited. Reports from high-income countriesindicate 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. Wesearched MEDLINE, PubMed, CINAHL, Embase, NCBI, PsycInfo and other relevant databases using a comprehen-sive search strategy to retrieve relevant articles. A total of 17 articles were included. Meta-analysis of extracteddata was performed, using the generic inverse variance method where possible. All studies were conducted inSouth Asia and Africa.Results: We found that involving a male partner in antenatal care was associated with skilled birth attendanceutilization (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 moderncontraception utilization were also positively affected. However, it had no significant impact on the number ofantenatal visits.Conclusions: Male involvement in antenatal care had a positive impact on the uptake of maternal healthservices. Further research needs to investigate whether this translates into improved maternal and newbornhealth in developing countries.

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

IntroductionMaternal and newborn health are still major concerns world-wide. Around 99% of maternal deaths occur in low- and middle-income countries (LMICs).1 Complications during pregnancy andchildbirth that contribute to maternal and infant mortality arepreventable in many cases through appropriate care before andthroughout pregnancy and delivery. The three delays model hasbeen proposed for analysing the root cause of maternal mor-tality—delays in the decision to seek care, to reach care andto obtain care.2 Of these, the first delay in the decision to seekcare sits squarely in the community, specifically on the personresponsible for making household decisions.

In most developing countries, societies are patriarchal, withmen having the role of primary decision maker and controlling

the household budget. Thus the decision to seek care (the firstdelay) is usually made by the male partner or husband.3 Yet insome cultures, male members are not expected to be directlyinvolved in their wife’s pregnancy and delivery care. If they are,this is considered by their peers as a demonstration of weakness.4From a social perspective, the notion of joining one’s wife atthe antenatal clinic is unusual in many communities and thehusband’s presence is often considered superfluous.5 Vermeulenet al.6 reported that perceived traditional gender roles and a lackof knowledge and opportunities for involvement in obstetric carewere some of the barriers to male partner involvement in ruralTanzania and can probably be generalized to other LMICs.

Recently, sexual and reproductive healthcare has moved fromthe age-old tradition of being woman-centric to being couple-centric. Two systematic reviews addressing the impact of male

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partner involvement on outcomes of pregnancy were publishedin 2015.7,8 Including seven primary studies in their systematicreview, Aguiar and Jennings7 found a positive associationbetween male partner attendance at antenatal clinic visits andwomen’s knowledge of danger signs during pregnancy, but itdid not affect birth preparedness or utilization of antenatalcare (ANC). The review by Yargawa and Leonardi-Bee8 found asignificant reduction in post-partum depression and increasedutilization of delivery and postnatal unhyphenated throughoutcare with male partner involvement. However, their review foundthat male presence in the delivery room was not associatedwith increased spontaneous labour and delivery. Based onthese two systematic reviews, the World Health Organizationstrongly recommends male partner involvement in pregnancyand delivery to facilitate and support the care of women duringpregnancy and delivery, accessing skilled birth attendance (SBA)and the timely use of facility care for obstetric and newborncomplications. The idea of involving male partners in maternaland child health is designed as a means to support women’saccess to care, address gender inequality and promote men’spositive involvement as partners and fathers.9 To date, interven-tions using mass media campaigns, counselling and outreachprogrammes involving both men and women in the communityand workplace have met with modest success in improving birthoutcomes, promoting gender equality and positively involvingmen in women and children’s health. This review focuses on theimpact of involving male partners during ANC on the utilizationof healthcare facilities, including SBA, at the time of delivery andin the postnatal unhyphenated throughout period.

MethodsInclusion and exclusion criteriaFirst, a focused review question in the PECO (Participants, Expo-sure, Comparison, Outcome) format was formulated—‘What arethe effects of male partner involvement in ANC on utilizationof delivery and postnatal unhyphenated throughout care in lowand middle income countries?’ Inclusion criteria were primarystudies involving pregnant women and/or their partners in LMICs(according to the World Bank classification). A United Nation’sreport defined male involvement in maternal and child health(MCH) as a social and behavioural change process that is requiredfor men to play more responsible roles in MCH with the pur-pose of ensuring women’s and children’s well-being.10 In thisreview, male involvement in ANC is defined as the male part-ner’s/husband’s participation in ANC by escorting their girlfriend-s/wives and receiving any information regarding their pregnancyand health education during ANC. We hypothesized that malepartners’ involvement in ANC will improve men’s awareness andincrease their participation in all aspects of maternity and new-born care. Aborigo et al.5 argued that involving male partnersin ANC allows men to have access to critical information on thereproductive health of their partners and on birth preparednessand 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 forinclusion. 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 careor solely focusing on the uptake of human immunodeficiencyvirus (HIV) testing/counselling were excluded.

Search strategyMEDLINE, PubMed, Scopus, CINAHL, Embase, NCBI, PsycInfo andCochrane Collaboration—all mainstream electronic databases—were searched and used to retrieve the articles. No time orlanguage limits were used. Search terms used the followingkeywords and MeSH headings: ‘male involvement/male partic-ipation’, ‘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 alsoused. Boolean operators AND and OR were utilized as appropriateto connect the search terms.

Articles retrieved from electronic databases were screenedfor relevance based on their titles and abstracts as an initialstep. Full texts were retrieved for the remaining articles andscreened based on inclusion and exclusion criteria. Includedreferences were imported into the reference managementsoftware RefWorks (ProQuest, Ann Arbor, MI, USA) and duplicatesremoved. Data from all included articles were extracted using asimple data extraction form. The extracted information consistedof author, year of publication, study setting, study aim, studydesign, study population, type of exposure or intervention, thenumber of participants, study outcomes and results of thestudy. The Downs and Black checklist for assessing study qualitywas used, as the primary studies included in the review variedby study design. The search strategy was developed and runindependently by two reviewers (DS and PW) with the help ofa medical librarian and were initially screened for relevance.Two reviewers (DS and PW or SB) independently assessedquality and extracted data from the included studies. Anydisagreements were settled through discussion or by arbitrationof the third reviewer. Meta-analysis of extracted data was donewhere appropriate using RevMan version 5.3 software (Cochrane,London, UK), and pooled ORs with 95% CIs were calculatedfor the outcomes of institutional delivery, SBA and postnatalunhyphenated throughout visit. ORs for male partner attendanceat antenatal clinics were extracted from the primary studieswhere available and these were pooled using the generic inversevariance method. We assessed between-study heterogene-ity using the I2 statistic and used a random effects modelwhere heterogeneity was high, as evidenced by I2>50%. Thesearch was rerun in May 2019 using the same search strategyand exclusion methods, and four new relevant papers werefound.

ResultsSearch flowAfter removing duplicates, 876 citations were identified fromthe electronic bibliographic database search and 103 articlesremained after the initial screening of titles and abstracts. Afterthe second round of screening, full texts of 22 potentially rele-vant articles were retrieved. In the final round, five articles were

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Figure 1. Article search flow.

excluded. Two investigated the relationship between maternalmortality, birth preparedness/complication readiness and maleinvolvement, but it was not clear whether male involvementincluded ANC attendance or not. Two articles investigated thelevel of male involvement and risk factors that contribute to maleinvolvement. Another paper solely presented the influencing fac-tors of male involvement in ANC. In the end, 17 articles wereincluded. Details of the search flow are shown in Figure 1.

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 conductedin Nepal,11–13 two in India,14,15 one in Indonesia,16 one inMyanmar17 and one in Bangladesh,18 in the Southeast Asiaregion. In the Africa region, one study was conducted each inKenya,19 Malawi,20 Zambia,21 South Africa,22 Burkina Faso23 andUganda,24 while three studies were conducted in Ethiopia.25–27

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

In all the included studies, the population was women ofreproductive age, although some were recruited from antenatalclinics while others participated in surveys after pregnancyand delivery. All the studies compared couple attendanceat ANC with attendance by the pregnant woman alone. Theoutcomes 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 outcomesreported included birth preparedness, knowledge about maternaland reproductive health, newborn immunization, exclusivebreastfeeding and contraceptive use post-partum. Kalemboet al.,20 in their study including HIV-positive women, also reportedon the uptake of prevention of mother-to-child transmission(PMTCT) and HIV status of the newborn.

The Downs and Black checklist for assessing study qualitywas used, as the primary studies included in the review variedby study design. The majority of papers scored ≥13 out of 26.

The ones that scored <13 were Chattopadhyay14 (10), Forbeset 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 was14/26; the highest scoring study was Daniele et al.23 (23) and thelowest scoring studies were by Timsa et al.24 and Mohammedet al.26 (8). The external validity criteria scored proportionatelylower (22%) compared with other criteria in the checklist and asa percentage of the total possible points collected (49%).

Maternal healthcare utilizationMale partner involvement in pregnancy care appeared to havethe greatest effect on healthcare utilization.

Number of ANC visits

In terms of the number of ANC visits, Mullany et al.11 showed thatthere was no significant impact of male involvement. However,in Myanmar, women who were accompanied by their partnerto an ANC visit were more likely to have more than four ANCvisits during pregnancy (adjusted OR [aOR] 5.82 [95% CI 3.34to 10.15]).17 In Ethiopia, the absence of male partners in ANCwas not significantly associated with ANC commencement in thefirst trimester (aOR 1.05 [95% CI 0.79 to 1.39]) or having four ormore ANC visits (aOR 1.06 [95% CI 0.82 to 1.38]).25 Similarly, theabsence of male partners during ANC was not significantly linkedto less likelihood of receiving all components of ANC (aOR 0.65[95% CI 0.39 to 1.10]).25 A study in Bangladesh demonstratedthat women accompanied by their husband were 4.5 times morelikely 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 includedstudies conducted in separate countries in Southeast Asia andAfrica was statistically significant. However, the differences

D. Suandi et al.

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Tabl

e1.

Char

acte

ristic

sof

incl

uded

stud

ies

Refe

renc

eCo

untr

ySt

udy

desi

gnPo

pula

tion

Inte

rven

tion/

expo

sure

Out

com

eEf

fect

mea

sure

Chat

topa

dhya

y14In

dia

Cros

s-se

ctio

nal

•Wom

en15

–49

yof

age

(n=1

2438

5)•M

en(n

=74

369)

inIn

dia

and

thre

ese

lect

edst

ates

Hus

band

’spr

egna

ncy

know

ledg

ean

dw

ife’s

part

icip

atio

nin

hous

ehol

dde

cisi

onm

akin

g

Util

izat

ion

ofAN

Can

din

stitu

tiona

ldel

iver

y;w

omen

’sde

cisi

onm

akin

gin

heal

thca

re

Wiv

esw

ithhu

sban

dspr

esen

tdur

ing

ANC

had

inst

itutio

nald

eliv

ery

1.35

times

mor

eth

anth

ose

with

out

(OR

1.35

,p<

0.00

1)Da

niel

eet

al.23

Burk

ina

Faso

RCTs

Preg

nant

wom

en15

–45

yof

age,

coha

bitin

gw

itha

man

,ge

stat

iona

lage

20–3

6w

kan

dex

pect

edto

beab

leto

give

birt

hin

apr

imar

yhe

alth

cent

re,

•int

erve

ntio

n(n

=583

)and

thei

rpar

tner

s•c

ontr

ol(n

=561

)

Inte

rven

tion

inw

hich

the

part

nerw

asin

vite

d:•i

nter

activ

egr

oup

disc

ussi

on•c

oupl

e’s

coun

selli

ngdu

ring

preg

nanc

y•p

ostn

atal

unhy

phen

ated

thro

ugho

utco

uple

’sco

unse

lling

sess

ions

Prim

ary

outc

ome:

•att

enda

nce

atpo

stna

tal

unhy

phen

ated

thro

ugho

utca

reco

nsul

tatio

ns•e

xclu

sive

brea

stfe

edin

g•m

oder

nco

ntra

cept

ion

usag

e

Inte

rven

tion

grou

pw

asas

soci

ated

with

high

erra

tes

ofpo

stna

tal

unhy

phen

ated

thro

ugho

utca

reat

tend

ance

(RR

1.23

[95%

CI1.

11to

1.37

]),e

xclu

sive

brea

stfe

edin

g3

mo

post

-par

tum

(RR

1.35

[95%

CI1.

15to

1.59

])an

def

fect

ive

mod

ern

cont

race

ptio

nus

e8

mo

post

-par

tum

(RR

1.12

[95%

CI1.

01to

1.24

])

(Con

tinue

d)


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Tabl

e1.

Cont

inue

d

Refe

renc

eCo

untr

ySt

udy

desi

gnPo

pula

tion

Inte

rven

tion/

expo

sure

Out

com

eEf

fect

mea

sure

Forb

eset

al.25

Ethi

opia

Seco

ndar

yda

taan

alys

isW

omen

and

men

15–4

9y

ofag

ew

itha

child

0–2

yof

age:

•wom

enat

tend

edat

leas

t1AN

C(n

=143

8)•m

enre

port

edab

outA

NC

atte

ndan

ce(n

=120

4)

Mal

epa

rtne

ratt

enda

nce

atAN

C•C

omm

ence

dAN

Cin

the

first

trim

este

r•a

tten

ded

atle

ast4

ANC

appo

intm

ents

•rec

eive

da

urin

ete

st•r

ecei

ved

abl

ood

test

•wer

eco

unse

lled

abou

tpr

egna

ncy

com

plic

atio

ns•m

etth

ese

focu

sed

ANC

guid

elin

es

•The

rew

asno

sign

ifica

ntas

soci

atio

nbe

twee

nm

ale

atte

ndan

ceat

ANC

and

com

men

cing

ANC

inth

efir

sttr

imes

ter.

No

mal

eat

tend

ance

was

nots

igni

fican

tlym

ore

likel

yto

com

-m

ence

ANC

inth

efir

sttr

imes

tert

han

with

mal

eat

tend

ance

(aO

R1.

05[9

5%CI

0.79

to1.

39])

•The

rew

asno

sign

ifica

ntas

soci

atio

nbe

twee

nm

ale

atte

ndan

ceat

ANC

and

rece

ivin

gth

ere

com

men

ded

num

bero

fvis

its.N

om

ale

atte

ndan

cew

asno

tsig

nific

antly

mor

elik

ely

toha

vefo

uror

mor

eAN

Cvi

sits

than

with

mal

eat

tend

ance

(aO

R1.

06[9

5%CI

0.82

to1.

38])

•The

rew

asno

sign

ifica

ntas

soci

atio

nbe

twee

nm

ale

atte

ndan

ceat

ANC

and

rece

ivin

gal

lrec

omm

ende

dco

m-

pone

nts

ofAN

C.N

om

ale

atte

ndan

cew

asno

tsig

nific

antly

less

likel

yto

rece

ive

allc

ompo

nent

sof

ANC

than

with

mal

eat

tend

ance

(aO

R0.

65[9

5%CI

0.39

to1.

10])

•Wom

enat

tend

ing

ANC

with

outa

mal

epa

rtne

rwer

esi

gnifi

cant

lyle

sslik

ely

tore

port

that

they

had

been

coun

selle

dab

outp

ossi

ble

com

plic

a-tio

nsdu

ring

preg

nanc

y(a

OR

0.64

[95%

CI0.

48to

0.86

])•W

omen

atte

ndin

gAN

Cw

ithou

tam

ale

part

nerw

ere

sign

ifica

ntly

less

likel

yto

have

aur

ine

test

than

thos

ew

itha

mal

epa

rtne

r(aO

R0.

73[9

5%CI

0.55

to0.

97])

•Wom

enat

tend

ing

ANC

with

outa

mal

epa

rtne

rwer

esi

gnifi

cant

lyle

sslik

ely

toha

vea

bloo

dte

stth

anth

ose

with

am

ale

part

ner(

aOR

0.70

[95%

CI0.

53to

0.93

])

(Con

tinue

d)

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Tabl

e1.

Cont

inue

d

Refe

renc

eCo

untr

ySt

udy

desi

gnPo

pula

tion

Inte

rven

tion/

expo

sure

Out

com

eEf

fect

mea

sure

Kale

mbo

etal

.20M

alaw

iCo

hort

HIV

-pos

itive

wom

enw

itha

mal

epa

rtne

r(n=

65)a

ndw

ithou

tam

ale

part

ner

(n=4

11)

•AN

Ccl

inic

atte

ndan

ce,

•rec

eivi

ngco

unse

lling

for

HIV

•dis

clos

ing

HIV

resu

lt

•Upt

ake

ofPM

TCT

•con

dom

use

•pla

ceof

deliv

ery

•inf

antH

IVst

atus

(infe

cted

,uni

nfec

ted,

dead

)

Mal

epa

rtne

rinv

olve

men

twas

sign

ifica

ntly

asso

ciat

edw

ithco

ndom

use

(aO

R5.

6[9

5%CI

2.3

to13

.5])

,ho

spita

ldel

iver

y(a

OR

25.9

[95%

CI10

.6to

63.6

])an

dco

mpl

etio

nof

follo

w-u

pin

the

prog

ram

me

(aO

R16

.8[9

5%CI

8.5

to33

.4])

Kash

itala

etal

.21Za

mbi

aRe

tros

pect

ive

coho

rtPr

egna

ntw

omen

who

acce

ssed

ANC

serv

ice

Mar

ch20

12–D

ecem

ber2

012

(n=2

007)

.Gro

ups:

ANC

visi

tco

uple

s(n

=220

),AN

Cvi

sit

with

outp

artn

er(n

=178

7)

Mal

ein

volv

emen

tin

ANC

Hav

ing

inst

itutio

nal

deliv

ery/

SBA,

post

nata

lun

hyph

enat

edth

roug

hout

care

visi

tatt

enda

nce

Mal

epa

rtne

rinv

olve

men

twas

sign

ifi-

cant

lyas

soci

ated

with

deliv

ery

ata

heal

thca

refa

cilit

y(O

R1.

53[9

5%CI

1.15

to2.

04])

;pos

t-pa

rtum

visi

tatt

en-

danc

e(O

R1.

58[9

5%CI

1.2

to2.

1])

Kune

neet

al.22

Sout

hAf

rica

Clus

terR

CTW

omen

who

atte

nded

the

ANC

clin

ics

inth

ein

ter-

vent

ions

clin

ic:i

nter

vent

ion

grou

p(n

=995

),co

ntro

lgro

up(n

=108

1).

Atte

nded

with

am

ale

part

ner:

inte

rven

tion

grou

p(n

=608

),co

ntro

lgro

up(n

=558

)

•Im

prov

ing

the

exis

ting

ANC

serv

ices

•int

rodu

cing

stre

ngth

ened

coun

selli

ngfo

rpre

gnan

tw

omen

and

thei

rpar

tner

s

•Will

ingn

ess

ofm

ento

acco

mpa

nyth

eirp

artn

ers

durin

gan

tena

tala

ndpo

st-p

artu

mca

re•t

heef

fect

ofth

eac

com

-pa

nim

ento

nfa

mily

plan

ning

know

ledg

ean

dus

e,on

sexu

ally

tran

smitt

edin

fect

ion

(STI

)kn

owle

dge

and

prev

entio

n,co

uple

com

mun

icat

ion

and

mal

ein

volv

emen

t,re

cogn

ition

ofpr

egna

ncy

dang

ersi

gns

and

mot

hera

ndba

by’s

heal

thca

reat

6m

opo

st-p

artu

m

No

sign

ifica

ntdi

ffere

nce

foun

dbe

-tw

een

inte

rven

tion

and

cont

rolg

roup

onth

eus

eof

cont

race

ptio

nat

6m

opo

st-p

artu

m,t

hele

velo

fas-

sist

ance

give

nby

mal

epa

rtne

rs,

know

ledg

eof

dang

ersi

gns,

imm

uni-

zatio

nan

dba

byfe

edin

gpr

actic

ean

din

-ris

kbe

havi

ourf

orST

Isor

inco

ndom

use

with

eith

erre

gula

rorn

on-r

egul

arpa

rtne

rs

Man

geni

etal

.19Ke

nya

Seco

ndar

yda

taan

alys

isCo

uple

sth

atre

port

eda

birt

hin

the

3ye

ars

befo

reth

esu

rvey

(200

8/20

09)(

n=87

3)

Mal

ein

volv

emen

tin

mat

erna

lhea

lthU

tiliz

atio

nof

SBA

Wom

enw

hose

husb

ands

atte

nded

atle

asto

neAN

Cvi

sitw

ere

mor

elik

ely

toha

veSB

Ath

anth

ose

who

sehu

sban

dsdi

dno

tatt

end

anAN

Cvi

sit(

aOR

2.17

[95%

CI1.

14to

4.11

])

(Con

tinue

d)


489

Dow



Tabl

e1.

Cont

inue

d

Refe

renc

eCo

untr

ySt

udy

desi

gnPo

pula

tion

Inte

rven

tion/

expo

sure

Out

com

eEf

fect

mea

sure

Moh

amm

edet

al.26

Ethi

opia

Com

mun

ity-

base

dcr

oss-

sect

iona

lst

udy

210

coup

les

who

rece

ntly

had

aba

by<

6m

ool

dan

dliv

edin

Addi

sAb

aba

atle

asta

year

Mal

ein

volv

emen

tin

mat

erna

lhea

lthse

rvic

es:

•ini

tiate

ddi

scus

sion

with

part

nera

bout

ANC/

PMTC

T•r

eque

sted

part

nerb

ete

sted

forH

IV•t

ook

time

tofin

dou

tw

hato

ccur

red

durin

gth

epa

rtne

r’sAN

Cvi

sits

•rem

inde

dpa

rtne

rabo

utAN

Cfo

llow

-up

•cov

ered

cost

sof

part

ner’s

ANC

visi

t•a

ccom

pani

edpa

rtne

rto

ANC

clin

icat

leas

tonc

e•p

hysi

cally

ente

red

the

ANC

room

with

part

ner,

coun

selle

dan

dte

sted

for

HIV

with

part

ner,

over

all

mal

epa

rtne

rinv

olve

men

tsc

ale

scor

e

Prim

ary

outc

ome:

mat

erna

lhea

lthca

rese

rvic

esut

iliza

tion:

•am

inim

umof

one

ANC

atte

ndan

cedu

ring

the

last

preg

nanc

y•t

hefir

stAN

Cap

poin

tmen

tin

the

first

12w

kof

preg

nanc

y•f

ouro

rmor

eAN

Cvi

sits

thro

ugho

utpr

egna

ncy

•tes

ted

forH

IVdu

ring

preg

nanc

y•S

BA•d

eliv

ered

ata

heal

thca

refa

cilit

y

•Too

ktim

eto

find

outw

hato

ccur

red

durin

gpa

rtne

r’sAN

Cvi

sits

asso

ciat

ed-s

igni

fican

tlyw

ithon

eor

mor

eAN

Cvi

sit(

aOR

5.17

[95%

CI1.

19to

22.4

8])

-sig

nific

antly

with

first

ANC

visi

tw

ithin

the

first

trim

este

r(aO

R1.

93[9

5%CI

1.04

to3.

60])

-not

sign

ifica

ntly

with

less

likel

yto

have

four

orm

ore

ANC

visi

ts(a

OR

0.82

[95%

CI0.

41to

1.62

])-n

otsi

gnifi

cant

lyw

ithte

sted

forH

IV(a

OR

2.15

[95%

CI0.

91to

5.07

])-s

igni

fican

tlyw

ithSB

A(a

OR

2.93

[95%

CI1.

24to

6.9]

)-n

otsi

gnifi

cant

lyw

ithha

ving

inst

itu-

tiona

ldel

iver

y(a

OR

1.95

[95%

CI0.

93to

4.08

])-n

otsi

gnifi

cant

lyw

ithle

sslik

ely

tout

ilize

alls

ervi

ces

(aO

R0.

77[9

5%CI

0.37

to1.

59])

•Acc

ompa

nied

part

nert

oAN

Ccl

inic

atle

asto

nce

asso

ciat

ed-s

igni

fican

tlyw

ithon

eor

mor

eAN

Cvi

sit(

aOR

5.49

[95%

CI1.

07to

28.2

0])

-not

sign

ifica

ntly

with

first

ANC

visi

tw

ithin

the

first

trim

este

r(aO

R1.

78[9

5%CI

0.98

to3.

22])

-not

sign

ifica

ntly

with

less

likel

yto

have

four

orm

ore

ANC

visi

ts(a

OR

1.63

[95%

CI0.

83to

3.18

])-s

igni

fican

tlyw

ithte

sted

forH

IV(a

OR

2.95

[95%

CI1.

25to

7.00

])-n

otsi

gnifi

cant

lyw

ithSB

A(a

OR

1.85

[95%

CI0.

80to

4.26

])-n

otsi

gnifi

cant

lyw

ithha

ving

inst

itu-

tiona

ldel

iver

y(a

OR

1.15

[95%

CI0.

57to

2.34

])-n

otsi

gnifi

cant

lyw

ithut

ilize

dal

lser

-vi

ces

(aO

R1.

68[9

5%CI

0.80

to3.

52])

(Con

tinue

d)

D. Suandi et al.

490

Dow



Tabl

e1.

Cont

inue

d

Refe

renc

eCo

untr

ySt

udy

desi

gnPo

pula

tion

Inte

rven

tion/

expo

sure

Out

com

eEf

fect

mea

sure

•Phy

sica

llyen

tere

dth

eAN

Cro

omw

ithpa

rtne

rass

ocia

ted

-not

sign

ifica

ntly

with

havi

ngon

eor

mor

eAN

Cvi

sit(

aOR

0.94

[95%

CI0.

10to

8.98

])-n

otsi

gnifi

cant

lyw

ithfir

stAN

Cvi

sit

with

inth

efir

sttr

imes

ter(

aOR

1.01

[95%

CI0.

49to

2.44

])-n

otsi

gnifi

cant

lyw

ithfo

uror

mor

eAN

Cvi

sits

(aO

R1.

29[9

5%CI

0.49

to3.

36])

-not

sign

ifica

ntly

with

test

edfo

rHIV

(aO

R1.

81[9

5%CI

0.35

to9.

23])

-not

sign

ifica

ntly

with

SBA

(aO

R1.

20[9

5%CI

0.81

to1.

77])

-not

sign

ifica

ntly

with

havi

ngin

stitu

-tio

nald

eliv

ery

(aO

R7.

58[9

5%CI

0.92

to62

.20]

)-n

otsi

gnifi

cant

lyw

ithut

ilize

dal

lse

rvic

es(a

OR

1.02

[95%

CI0.

36to

2.86

])•O

vera

llm

ale

part

neri

nvol

vem

ent

scal

esc

ore

-ass

ocia

ted

sign

ifica

ntly

with

havi

ngon

eor

mor

eAN

Cvi

sit(

aOR

1.61

[95%

CI1.

05to

2.45

])-s

igni

fican

tlyw

ithfir

stAN

Cvi

sit

with

inth

efir

sttr

imes

ter(

aOR

1.19

[95%

CI1.

03to

1.39

])-n

otsi

gnifi

cant

lyw

ithle

sslik

ely

toha

vefo

uror

mor

eAN

Cvi

sits

(aO

R0.

98[9

5%CI

0.83

to1.

15])

-sig

nific

antly

with

test

edfo

rHIV

(aO

R1.

52[9

5%CI

1.18

to1.

96])

-sig

nific

antly

with

SBA

(aO

R1.

44[9

5%CI

1.13

to1.

84])

-sig

nific

antly

with

havi

ngin

stitu

tion-

alde

liver

y(a

OR

1.22

[95%

CI1.

01to

1.48

])-n

otsi

gnifi

cant

lyw

ithle

sslik

ely

tout

ilize

alls

ervi

ces

(aO

R0.

97[9

5%CI

0.82

to1.

15])

(Con

tinue

d)


491

Dow



Tabl

e1.

Cont

inue

d

Refe

renc

eCo

untr

ySt

udy

desi

gnPo

pula

tion

Inte

rven

tion/

expo

sure

Out

com

eEf

fect

mea

sure

Mul

lany

etal

.11N

epal

RCT

Preg

nant

wom

enw

ithge

stat

iona

lage

16–2

8w

kat

tend

ing

thei

rfirs

tAN

Cvi

sit

who

sehu

sban

dsw

ere

pres

ent

atth

eho

spita

lcom

poun

d(n

=442

).Th

eysh

ould

be≥1

8y

and

live

<90

min

from

the

hosp

ital.

Grou

pA:

coup

les

(n=1

45),

grou

pB:

wom

enal

one

(n=1

48),

grou

pC:

cont

rol(

n=14

9)

Mal

ein

volv

emen

tin

ante

nata

lhea

lthed

ucat

ion

•Birt

hpr

epar

edne

ss(p

urch

ased

safe

deliv

ery,

save

mon

eyfo

rdel

iver

yet

c.)

•util

izat

ion

ofSB

A•n

umbe

rofA

NC

visi

ts•p

ost-

part

umvi

sit

atte

ndan

ce

Wom

enin

the

coup

les

grou

pw

ere

mor

elik

ely

tobe

high

lypr

epar

edfo

rbi

rth

cont

rolt

han

thos

ein

the

cont

rol

grou

p(R

R5.

19[9

5%CI

1.86

to14

.53]

).W

omen

inth

eco

uple

sgr

oup

wer

e1.

29tim

esm

ore

likel

yto

atte

nda

post

-par

tum

visi

ttha

nw

omen

inth

eco

ntro

lgro

up(R

R1.

29[9

5%CI

1.04

to1.

60])

.How

ever

,the

impa

ctof

the

inte

rven

tion

was

nots

tatis

tical

lysi

g-ni

fican

tfor

utili

zatio

nof

SBA,

num

ber

ofAN

Cvi

sits

and

atte

ndin

gSB

AM

ulla

nyet

al.12

Nep

alRC

TW

omen

pres

entin

gat

hosp

ital

from

Augu

st20

03to

Janu

ary

2004

.Gr

oup

A:co

uple

s(n

=145

),gr

oup

B:w

omen

alon

e(n

=148

),gr

oup

C:co

ntro

l(n=

149)

•Ant

enat

alhe

alth

educ

atio

nM

ater

nala

ndre

prod

uctiv

ehe

alth

know

ledg

ele

vel

Wom

ened

ucat

edw

ithhu

sban

dha

dm

ore

know

ledg

eof

preg

nanc

yco

mpl

icat

ions

atth

etim

eof

follo

w-u

pco

mpa

red

with

the

wom

en-a

lone

grou

p(R

R1.

15[9

5%CI

1.0

to1.

32])

,w

ere

slig

htly

mor

elik

ely

toha

vehi

ghkn

owle

dge

scor

esat

follo

w-u

pco

m-

pare

dw

ithw

omen

educ

ated

alon

e(R

R1.

18[9

5%CI

1.01

to1.

38])

,wer

em

ore

likel

yto

have

impr

ovem

enti

nkn

owle

dge

from

base

line

tofo

llow

-up

than

thos

ew

how

ere

inth

eco

ntro

lgr

oup

(RR

1.25

[95%

1.04

to1.

51])

(Con

tinue

d)

D. Suandi et al.

492

Dow



Tabl

e1.

Cont

inue

d

Refe

renc

eCo

untr

ySt

udy

desi

gnPo

pula

tion

Inte

rven

tion/

expo

sure

Out

com

eEf

fect

mea

sure

Rahm

anet

al.18

Bang

lade

shCr

oss-

sect

iona

lM

arrie

dw

omen

19–4

9y

ofag

ew

itha

birt

hhi

stor

yin

the

12-m

ope

riod

prec

edin

gth

esu

rvey

,rec

ruite

dfro

man

othe

rla

rger

stud

y,as

this

stud

yw

asem

bedd

ed

Mal

eac

com

pany

ing

in•A

NC

•dur

ing

child

birt

h•p

ostn

atal

unhy

phen

ated

thro

ugho

ut•c

are

and

care

seek

ing

for

com

plic

atio

nsdu

ring

preg

nanc

y

•Lev

elof

know

ledg

eof

wom

enan

dth

eir

husb

ands

rega

rdin

gM

NH

issu

es•e

ngag

emen

tofw

omen

and

thei

rhus

band

•lev

elof

invo

lvem

ento

fhu

sban

dsin

term

sof

acco

mpa

nyin

gth

eirw

ives

•ass

ocia

tion

betw

een

husb

and’

skn

owle

dge

and

acco

mpa

nyin

gth

eirw

ives

whi

lere

ceiv

ing

mat

erna

lan

dne

onat

alhe

alth

(MN

H)

serv

ices

•ass

ocia

tion

betw

een

thei

rin

volv

emen

tand

wom

en’s

utili

zatio

nof

skill

edM

NH

serv

ices

•Wom

enw

hore

ceiv

edAN

Cw

ithth

eir

husb

and

wer

em

ore

likel

yto

getA

NC

from

am

edic

ally

trai

ned

prov

ider

(OR

4.7

[95%

CI2.

5to

9.0]

,aO

R4.

5[9

5%CI

2.3

to8.

7])

•Wom

enw

how

ere

acco

mpa

nied

byth

eirh

usba

nddu

ring

child

birt

hha

dan

OR

2tim

eshi

gher

inha

ving

deliv

-er

yat

ahe

alth

faci

lity

than

thos

ew

ithou

tthe

irhu

sban

d(O

R2.

0[9

5%CI

1.1

to3.

9],a

OR

1.5

[95%

CI0.

8to

3.1]

)

Sapk

ota

etal

.13N

epal

Non

-ra

ndom

ized

cont

rolle

dtr

ial

Wom

en(p

rimig

ravi

da)

adm

itted

toth

eho

spita

l.M

ixed

supp

ortg

roup

(n=1

1),

coup

les

grou

p(n

=97)

,with

fem

ale

frie

ndgr

oup

(n=9

6),

cont

rolg

roup

(not

acco

mpa

nied

;n=1

05)

Acco

mpa

nim

entd

urin

gch

ildbi

rth

Feel

ing

inco

ntro

ldur

ing

labo

ur,

Labo

urAg

entr

ySc

ale

(LAS

)

The

husb

and’

spr

esen

cedu

ring

child

-bi

rth

was

mor

epo

sitiv

ely

rela

ted

toth

ew

omen

’sfe

elin

gof

bein

gco

ntro

l(β

=0.5

7,p<

0.00

1).A

lso,

thos

ew

hoga

vebi

rth

with

thei

rhus

band

’ssu

ppor

tre

port

edhi

gher

mea

nLA

Ssc

ores

(47.

92±6

.95)

than

thos

ew

ithfe

mal

efr

iend

’ssu

ppor

tand

the

wom

anin

the

cont

rolg

roup

Tekl

esila

sie

and

Dere

ssa27

Ethi

opia

Pros

pect

ive

coho

rt70

9an

tena

talw

omen

inth

ebe

ginn

ing

with

gest

atio

nal

age

betw

een

24an

d36

wk,

livin

gw

ithth

eirh

usba

ndat

leas

taye

ar.A

tthe

end

offo

llow

-up,

664

wom

enw

ere

incl

uded

fora

naly

sis.

Inte

rven

tion

grou

p(n

=385

),co

ntro

lgro

up(n

=279

)

Hus

band

’sin

volv

emen

tin

ANC

SBA

utili

zatio

nW

omen

acco

mpa

nied

byth

eir

husb

ands

toAN

Cw

ere

6.27

times

mor

elik

ely

tous

eSB

Asdu

ring

birt

h(O

R6.

33[9

5%CI

4.5

to8.

9],a

OR

6.27

[95%

CI4.

2to

9.3]

)

(Con

tinue

d)


493

Dow



Tabl

e1.

Cont

inue

d

Refe

renc

eCo

untr

ySt

udy

desi

gnPo

pula

tion

Inte

rven

tion/

expo

sure

Out

com

eEf

fect

mea

sure

Tim

saet

al.24

Uga

nda

Cros

s-se

ctio

nal

Allw

omen

who

had

deliv

ered

ach

ildin

the

past

12m

oan

dw

ere

livin

gin

one

ofth

ese

lect

edvi

llage

s:Ig

anga

(n=3

94),

Luuk

a(n

=797

)or

Buye

nda

(n=8

19)

Stra

tegi

esfo

rhel

ping

fam

ilies

prep

are

forb

irth:

pres

ence

inde

liver

yro

om

Dete

rmin

ants

ofbi

rth

prep

ared

ness

Bein

gpr

epar

edfo

rbirt

hw

asas

soci

ated

with

havi

ngfo

urAN

Cvi

sits

(aO

R1.

92[9

5%CI

1.1

to1.

83])

,att

enda

nce

atAN

Cdu

ring

the

first

(aO

R1.

94[9

5%CI

1.09

to3.

44])

orse

cond

trim

este

r(a

OR

1.87

[95%

CI1.

09to

3.22

]),

coun

selli

ngon

dang

ersi

gns

(aO

R2.

07[9

5%CI

1.57

to2.

74])

,acc

ompa

nied

byhu

sban

dto

plac

eof

deliv

ery

(aO

R1.

47[9

5%CI

1.15

to1.

89])

,hi

gher

econ

omic

stat

us(a

OR

2.04

[95%

CI1.

38to

3.01

])an

dha

ving

are

gula

rinc

ome

(aO

R1.

83[9

5%CI

1.2

to2.

79])

Wai

etal

.17M

yanm

arCr

oss-

sect

iona

lH

usba

nds

≥18

yof

age

who

had

atle

asto

nech

ildw

ithin

2ye

ars

atth

etim

eof

the

inte

rvie

w

Mal

ein

volv

emen

tin

ANC

atte

ndan

ce,fi

nanc

ial

supp

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D. Suandi et al.

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Figure 2. Meta-analysis of having institutional delivery.

Figure 3. Meta-analysis of utilization of SBA.

between the effect of the individual study and the pooledeffect across studies were considerable (I2=90%). Therefore therandom effects model was applied. Figure 2 shows the effect ofmale partner involvement in ANC with the chance of having aninstitutional delivery.

SBA

Similar to institutional delivery, the pooled aOR for SBA was sta-tistically significant (3.19 [95% CI 1.55 to 6.55]) using a randomeffects model, as I2 was 94% (Figure 3). Five studies showeda positive association between male ANC attendance and uti-lization of SBA. Kashitala et al.21 conducted a cohort study inZambia and found that women with male accompaniment hadhigher odds than unaccompanied women (OR 1.53, p<0.005) ofarranging for skilled attendance at delivery. This evidence wassupported by other studies in Kenya that revealed women witha partner were more likely to have SBA (aOR 2.17 95% CI 1.14to 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% CI1.77 to 2.70]),16 similar patterns were observed. Kalembo et al.20

found that accompanied women had increased odds of havinga hospital delivery than those who were unaccompanied (aOR25.9, p<0.001). In contrast, Mullany et al.11 and Wai et al.17 foundno significant differences between women with and without apartner.

Post-partum visits

Involving male partners in ANC was associated with increas-ing post-partum care attendance. The pooled OR for postnatal

unhyphenated throughout visits was found to be 2.13 (95% CI1.45 to 3.13) using a random effects model, as heterogeneitywas 81% (Figure 4). In Zambia, women who came with theirspouse for ANC visits were 58% more likely to use post-partumcare.21 Women who received antenatal health education alongwith their partners were more likely to attend a post-partumvisit than those who received education alone (RR 1.25 [95% CI1.01 to 1.54]) in Nepal,11 whereas a study in Myanmar found nosignificant impact of male partner involvement on receiving post-partum care.17

Effective modern contraception usage

Daniele et al.23 investigated the effect of male involvement dur-ing an antenatal education session on the utilization of effectivemodern contraception 8 mo post-partum. Inviting male partnersinto antenatal education sessions positively affected the use ofeffective modern contraception in women, with the effect size1.12 greater than for women in the control group (RR 1.12 [95%CI 1.01 to 1.24]).

Reproductive health knowledge and birth preparednessKnowledge of miscarriage and danger signs

Four studies reported conflicting results regarding the effect ofmale involvement on knowledge of miscarriage and dangersigns. In Nepal, Mullany et al.12 found that women who hadantenatal education with their partner were likely to knowmore about pregnancy complications (aRR 1.15 [95% CI 1.00to 1.32]) and were significantly more likely to show improvement


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Figure 4. Meta-analysis of post-partum visit.

in knowledge from baseline to follow-up (RR 1.25 [95% CI 1.04 to1.51]) compared with those who attended alone. Similar resultswere found in India. Inviting a male partner into ANC counsellingsignificantly increased the knowledge of pregnancy danger signsin 24% of women 13% of control women (z=2.99, p<0.05).15

In Ethiopia, women who attended ANC without a male partnerwere less likely to report that they had been counselled aboutpossible pregnancy complications (aOR 0.64 [95% CI 0.48 to0.86]).25 In contrast, in South Africa, Kunene et al.22 found nodifference between couples who received and did not receiveANC counselling in knowledge of miscarriage or obstetric dangersigns (p>0.05).

Birth preparedness

One study investigated the association between male involve-ment and birth preparedness (purchased safe delivery, savemoney for delivery, having blood donor, etc.).11 Women whowere educated with a spouse were 1.3 times more likely tomake more than three birth preparations as compared withthose who received education alone, although the effect wasnot statistically significant (aRR 1.30 [95% CI 0.78 to 2.15]).11

Newborn health outcomeArticles that were directly related to newborn outcomes weremostly conducted in HIV-positive pregnant women.

Breastfeeding initiation

In India, an intervention involving the male partner in ANC sig-nificantly increased breastfeeding initiation within the first hourafter 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 studyfrom Daniele et al.23 in Burkina Faso showed similar findings.Women in the intervention arm were 1.35 times more likely tobreastfeed exclusively compared with those who only receivedroutine care (RR 1.35 [95% CI 1.15 to 1.59]).23 In contrast, inSouth Africa there was no significant difference found in terms ofbreastfeeding initiation between those who came with or withouta man (p=0.1).22

DiscussionNot all studies included in this review showed that male involve-ment had a significant impact on maternal and child health.

However, most studies reported that men’s participation in ANCis more likely to have a positive impact on improving healthcareutilization in terms of SBA, institutional delivery and post-partumcare. The number of ANC visits and birth preparedness werenot significantly influenced by male involvement. HIV survivaland breastfeeding initiation are newborn outcomes that wereaffected positively by male partner involvement. While maleinvolvement in ANC had no impact on infant mortality and ver-tical transmission of HIV infection, male presence during labourhad a positive impact on relieving the stress of the mother duringchildbirth and resulted in a higher proportion of spontaneouslabours.

This review found that knowledge improvement was greateramong those who had a male partner accompanying them thanthose who did not. This finding was similar to evidence in Tan-zania, where male involvement improved knowledge of dangersigns and birth preparedness.28 The relationship between couplesand the shared decision-making process may be responsiblefor the impact of male partner involvement seen in knowledgeimprovement.29 For this reason, women who were educatedwith their male partners were more likely to share informa-tion together and have a discussion with their partner regardingpregnancy and delivery. Furthermore, male accompaniment inhealth education may aid retention of knowledge and increasea couple’s communication.7 All these reasons help explain howmen’s involvement is more likely to improve women’s knowledge.

Addressing gender inequality is one of the recognized strate-gies to improve maternal and child health30 and is supportedby Sustainable Development Goal 5. This not only focuses onwomen’s empowerment, but also the support of men, sincegender is a social construct that affects both men and women.29

ANC is the first step for raising awareness of both the motherand father about maternal and infant health. Men, as the chiefdecision makers in patriarchal societies, have the potential toprevent the first delay in the three-delays model proposed byDudgeon and Inhorn.31,32

Men are dominant in the patriarchal household and responsi-ble for the planning and provision of healthcare for householdmembers. Antenatal classes could be a way to change men’sknowledge and views towards maternal and infant health. In thiscontext, it would be helpful to define the role of the male partnerin pregnancy care. It is obviously more than just accompanyingthe pregnant woman for antenatal visits, and implies joint deci-sion making with regard to pregnancy and birth planning for thebenefit of the mother and the newborn.

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This review also found that the presence of male partnersin the delivery room had a positive impact on women’s feel-ing of being in control during childbirth,13 and their accom-paniment during childbirth was positively linked to having aninstitutional delivery.18 Several studies have shown that maleinvolvement during labour shortens the labour and reduces theepidural rate.33 Studies have demonstrated that the presence ofsocial support is a significant factor in women’s adjustment tothe stress of childbearing.34 In addition, Nepalese women felt thepresence of their husband gave them greater self-confidence andrelief of stress, and facilitated communication.35 The husband’slove and emotional support were expected by women duringpregnancy and delivery.36 In contrast, a study in Hong Kongfound that husbands’ involvement during labour was associatedwith a higher dosage of analgesia.34

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

A comprehensive and inclusive literature search based ona focused review question and inclusion and exclusion criteriaagreed to a priori are major strengths of this review. On theother hand, restricting the publications to the English language inthe interest of time and resource constraints may have resultedin some relevant articles being missed. Most of the includedliterature came from sub-Saharan Africa and South Asia and thusthe findings may not be generalizable to other LMIC settings.Since involving the male partner in pregnancy and delivery care isan intervention, it should, in an ideal world, be evaluated by ran-domized controlled trials. However, many of the studies includedin this review were observational studies, which are prone to biasand confounding. Few of these controlled for confounding factorsand reported adjusted effect estimates. We also cannot rule outpotential publication bias, as studies with negative findings areless likely to be published. The outcomes assessed in the primarystudies included in the review were most often process out-comes, such as an increase in knowledge or birth preparedness.While some of these process outcomes, such as SBA, have beenshown to be effective in reducing maternal and perinatal mortal-ity, others have no such evidence base. It is difficult to firmly con-clude whether male partner involvement in pregnancy and child-birth improves birth outcomes for both the mother and the baby,as it is entirely plausible that the women who are accompaniedby their male partners are already equal partners in the decision-making process and it is this empowerment that bestows thebeneficial effects, not the involvement of the partner per se.

ConclusionsIn developing countries, male accompaniment in ANC has a ben-eficial impact on improving the mother’s knowledge of dangersigns, utilization of an SBA and relieving stress and anxiety duringlabour, as well as increasing uptake of post-partum care andinitiation of breastfeeding. However, further research needs tounpack the psychosocial elements that underpin the impact ofmale partner involvement in maternity care.

Authors’ contributions: All authors contributed to the developmentof the paper, including developing the search strategy, screening,

data extraction, quality assessment, meta-analysis and writing thepaper.

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

Competing interests: None declared.

Ethical approval: Not required.

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