Factors influencing whether or not male partners from low and middle income countries attend childbirth: a mixed methods systematic review

Currently, there is a global drive to promote respectful maternity care including a woman’s right to have a companion of her choice during labour and birth. This may include but is not limited to doula, female relatives or friends, and male partners. Evidence suggests that male partners’ attendance at childbirth, when it is a woman’s choice, may be associated with a positive emotional experience for the woman. However, these potential benefits were reported from studies conducted in high income settings only. There is limited information about male partners’ attendance at labour and birth in low and middle income countries (LMICs). Although male partners’ attendance at childbirth is being implemented in a few health facilities in LMICs, there is a paucity of evidence on the acceptability and feasibility of this practice and the moderators of implementation in the context of LMICs.

views of women; the perspectives of partners and health personnel were not covered.
The World Health Organization (WHO) acknowledges that male partners can contribute to a woman's positive experience of pregnancy, childbirth, and the postnatal period (6)While in high income settings male partners' attendance may be embedded in cultural norms, in LMICs, the practice is uncommon due to a number of factors. Cultural norms in more traditional societies may discourage male partners from attending childbirth (7). Moreover, lack of privacy within maternity wards prevents facilities from permitting male partners' attendance(8). However, hospitals' encouragement and facilitation of male partners' attendance at childbirth remains an understudied area in the context of LMICs. For example, it is unclear whether or not male partners' attendance at labour and/or birth would be an acceptable and feasible practice to implement in LMICs health facilities if a woman prefers this. It is also not known which individual, clinical, contextual, and cultural factors are likely to influence male partners' attendance at childbirth in LMICs. Further exploration is needed of the factors influencing whether male partners are able to attend childbirth in LMICs when they are the woman's preferred birth companion. We conducted a systematic review to investigate the factors that influence male partners' attendance at childbirth in LMICs.

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 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.

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.

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.

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 ( (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

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 (

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).

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). Although the current review included studies from different continents, and from low, lower middle, and upper middle income countries, there were strikingly similar themes in terms of individual, community and organisational acceptability of male partners' attendance at labour and/or birth. This suggests that the relevant country's income level was not a major factor. However, in terms of encouragement of male partners' attendance, Brazil appeared to be the only country that had a national policy addressing birth companionship (98). A few studies attempted to examine the association between demographic characteristics and male partners' attendance at childbirth among female and male participants but the evidence was weak. The findings from this review indicate that while some women from LMICs wish male partners to stay with them during labour and/or birth, individual, organisational, attitudinal, clinical, structural, and contextual constraints limit women's ability to make that choice. This finding is important because it complements other review work that examined only the barriers affecting male partners' experiences of childbirth in low income countries (99,100).

Discussion
This review found that some women did not choose male partners' attendance due to privacy related issues and cultural norms. Interestingly, the studies that found that men were embarrassed to attend childbirth were all from low income countries. However, there was limited information about predictive factors other than culture and gender norms. The effect of education, age, and income levels could be further investigated.
Some studies recruited participants solely either from rural or from urban areas. There might be differences in how people in these two settings view male partners' attendance, though the current review could not draw conclusions on this aspect. Some studies were limited due to small unrepresentative samples from diverse populations. In addition, studies were carried out in countries with very different cultures. In some cases, only one study was found from a particular country.
Therefore, caution should be taken when applying these findings to the wider context of LMICs.

Strength And Limitations
As far as we are aware, this is the first review that identified facilitators, motivators, and barriers to male partners' attendance at childbirth in LMICs. Our systematic review synthesised both published peer-reviewed articles and unpublished resources such dissertations and theses. However, the review has some limitations. First, data extraction and quality appraisal was conducted by one reviewer.
Secondly, there may be important studies that were not included because of the language limiter set.      Figure 1 PRISMA Summary of the screening process for Phase 1 Figure 2 PRISMA Summary of the screening outcomes for Phase 2