Burnet Institute (Tokhi, Comrie-Thomson, Davis, Luchters); Monash University (Comrie-Thomson, Luchters); Ghent University (Comrie-Thomson, Luchters); World Health Organization (Portela); University of the Witwatersrand (Chersich)
This review was conducted to comprehensively assess the effectiveness of male involvement in improving maternal and newborn health (MNH) in low- and middle-income countries (LMICs), to inform World Health Organization (WHO) health promotion guidelines. To support interpretation of the complex evidence base, the review was designed to capture not only effects on health outcomes but also effects on key mechanisms by which male involvement is hypothesised to influence these health outcomes: care-seeking, home care practices, and couple relationships. Review findings therefore provide guidance on whether, and how, male involvement can affect MNH outcomes, to assist interpretation and application of the WHO health promotion guidelines that recommend male involvement.
The authors explain that, since the mid-1990s, there has been increased recognition of the importance of including men in MNH programmes. Evidence cited in the paper indicates several mechanisms by which male involvement in MNH can support improved health outcomes. Men can provide practical, financial, and emotional support to women and children to overcome demand-side barriers to accessing health services. Male involvement programmes can also contribute to normalising care-seeking within households and communities. Men can adopt, and encourage other household members to adopt, health-promoting behaviours at home, such as improved nutrition and hygiene practices. Interventions to increase male involvement in MNH have also been linked with increased couple communication and equitable decision-making, which contribute to improved health and care-seeking outcomes. However, existing systematic reviews of the effect of male involvement on maternal health, MNH, and related topics suffer from a complex evidence base and limited evidence of effectiveness for mortality and morbidity outcomes.
The present review was conducted in two stages, described in full elsewhere. In the final analysis, 13 studies were included in the review, all of which reported interventions intended to increase the involvement of men in MNH, either as a primary focus or as one component of a multi-component intervention to improve MNH. Eight studies were conducted in South Asia, three in Southern or Eastern Africa, and one each in Indonesia and Turkey. Three studies had experimental designs, and 10 were observational studies. All studies were primarily quantitative, with two studies reporting some qualitative findings.
Interventions ranged from five months to 12 years in duration and were delivered through diverse mechanisms including community outreach and education, home visits, facility-based counselling, workplace education programmes, and mass media social mobilisation campaigns. Rationales for involving men also varied between studies, with eight interventions seeking to leverage men's role as gatekeepers for women's health, three interventions aiming to improve men's access to health services, one parenting intervention designed to support new fathers, and five interventions that engaged men as one group under a broader strategy to increase community involvement in MNH.
The findings are presented in the following categories:
- Effect on care-seeking - In short, the review identified positive, sometimes substantial, effects on health care-seeking associated with engaging men in MNH. However, these effects were generally observed following interventions with multiple integrated components. For example, studies of complex community education or mobilisation interventions seeking to reach men alongside other community members reported increased facility births in Eritrea (odds radio (OR) 26.24, 95% confidence interval (CI) 11.42-60.27), India (home births 54.1% baseline, 38.4% post-intervention, p<0.001), Bangladesh (2.4% baseline, 20.5% post-intervention, p<0.01), northern Pakistan (4.8% baseline, 67.2% post-intervention, no significance reported), Indonesia (5.7% control, 11.4% intervention, p=0.00), and Tanzania (33.3% baseline, 49.8% post-intervention, no significance reported). With the exception of an increase in postpartum visits in one study, the five studies specifically designed to test the effect of male involvement found no change in maternity care service utilisation.
- Effect on home care practices - In short, male involvement - either alone or alongside other intervention components - can affect care provided in the home to women and newborns, but there is variation in this effect, with some harmful outcomes. For example, while several studies reported improved breastfeeding outcomes, one study found decreased exclusive breastfeeding, and another study reported more women ceasing breastfeeding due to advice from family members.
- Effect on mortality and morbidity - In short, there is some evidence of a positive effect on maternal morbidity, but most studies were not designed or powered to capture an effect on these outcomes.
- Effect on couple relationships - In short, these effects were variable and, importantly, detrimental effects were found on women's autonomy in two studies, even where other measures of couple relationships had improved.
The authors reflect: "Even in the absence of direct evidence of an effect on mortality and morbidity, review findings that male involvement interventions can affect care-seeking, home care practices, and couple relationships demonstrate that male involvement has a plausible effect on mortality and morbidity and is therefore a viable health promotion strategy to improve MNH. The variation in effects identified in the review, including a small number of detrimental effects, underscore that intervention design and implementation are critical to ensure that the positive potential of male involvement is realised....The report of a woman describing that she felt infantilised by her husband using his new knowledge to tell her what to eat...echoes findings from other studies that when men become involved in MNH their involvement may weaken women's autonomy in aspects of their lives where women have previously had a degree of authority."
In thinking about implications of the review for future research, the authors call for systematically collected and reported qualitative data, "particularly regarding women's autonomy, gender roles and norms, and power dynamics within couple relationships and households. Future research could draw on lessons from the large body of literature on working with men and boys for gender equality and sexual and reproductive health to inform study design, intervention design and implementation, and the selection of study measures."
They conclude: "Findings are of direct and immediate relevance to policy-makers, practitioners and clinicians who seek to interpret and apply the current WHO health promotion guidelines that recommend male involvement, and complement a recent series of papers focused on implementation considerations for the WHO guidelines."
PLoS ONE 13(1): e0191620. https://doi.org/10.1371/journal.pone.0191620. Image credit: Concern Worldwide via MenCare