WHO recommendation on male involvement interventions for maternal and neonatal health

Couple in a swimming pool during a birth preparedness class

WHO recommendation on male involvement interventions for maternal and neonatal health

 

Recommendation

Interventions to promote the involvement of men during pregnancy, childbirth and after birth are recommended to facilitate and support improved self-care of the woman, improved home care practices for the woman and newborn, and improved use of skilled care during pregnancy, childbirth and the postnatal period for women and newborns.

(Strong recommendation, very low quality of evidence)

 

Publication history

First published: May 2015

Updated: No update planned

Assessed as up-to-date: May 2015

 

Remarks

  • These interventions are recommended provided that they are implemented in a way that respects, promotes and facilitates women’s choices and their autonomy in decision-making and supports women in taking care of themselves and their newborns. In order to ensure this, rigorous monitoring and evaluation of implementation is recommended.
  • Additional research is required.

 

Background

In 2003 the World Health Organization (WHO) published “Working with individuals, families and communities to improve maternal and newborn health”, (1) the IFC framework that promotes integrating the health promotion approach set out in the Ottawa Charter (2) into national maternal and newborn health (MNH) strategies.

The IFC Framework was developed in response to analysis and global statements indicating that as well as strengthening services, MNH strategies need to improve the capacity of individuals, families and communities to provide appropriate care for pregnant women, mothers, and newborns in the home. It also addresses the reasons – over and above what happens in clinical services – why women do not reach good quality skilled care during pregnancy, childbirth and after birth. The Ottawa Charter’s health promotion components(2) were translated into MNH programme language and 12 promising interventions – identified through reviews of country experiences and the literature – were categorized into four priority areas. Community and intersectoral participation was recommended to guide implementation. Exact interventions to be adapted by country programmes were to be identified through local assessment; however, the framework highlighted the need for interventions to address all four priority areas at the same time. All six WHO Regions integrated this guidance into the regional maternal mortality reduction strategies.

There has been increased recognition of the need to include men in MCH programmes since the mid-1990s, given the important role men have as partners/ husbands, fathers and community members and as a way of promoting egalitarian decisions about reproductive and maternal health.(3) Chapter IV Section C of the ICPD Programme of Action calls for an understanding of the joint responsibilities of men and women so that they become equal partners in public and private lives and to encourage and enable men to take responsibility for their sexual and reproductive behaviour.

Different programmes have directed efforts to harness the support and active involvement of men for improved MNH outcomes. There are different models and rationales for seeking to involve men, including a view of men as gatekeepers and decision-makers for prompt access to MNH services both at the household and community levels; men as responsible partners of women and as an important sub-population within the community; the need to address men’s own health needs; and men’s preference to be involved as fathers/partners. Strategies often include mass media campaigns, community and workplace-based outreach and education for men only or for men and women together, home visits, facility-based counselling for couples, groups or men only.

This recommendation was published within the 2015 WHO guideline “WHO Recommendations on Health Promotion Interventions for Maternal and Newborn Health.”(4)

 

Methods

The recommendation was developed using standardized operating procedures in accordance with the process described in the “WHO handbook for guideline development”, guided by the GRADE approach.(5) Outcomes used for this recommendation were aligned with the prioritized outcomes from the WHO recommendations on health promotion interventions for maternal and newborn health (2015).(4)

A systematic review was conducted on interventions for male involvement in pregnancy, childbirth and the postnatal period.(6) In the review, randomized controlled trials relevant to the key question were screened by review authors, and data on relevant outcomes and comparisons were extracted. Evidence profiles (in the form of GRADE tables) were prepared for comparisons of interest, including the assessment and judgments for each outcome, and the estimated risks.

WHO convened a Guideline Development Group (GDG) meeting on recommendations on health promotion interventions for maternal and newborn health where this recommendation was developed. The GDG comprised of a group of independent experts, who used the evidence profiles to assess evidence on effects on the pre-specified outcomes. GDG members discussed the balance between desirable and undesirable effects, overall quality of supporting evidence, values and preferences of stakeholders, resource requirements, cost-effectiveness, acceptability, feasibility and equity, to formulate the recommendation. Remarks were added to clarify the recommendation, and aid implementation.

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

  • What interventions used to increase male involvement have been effective in increasing care-seeking behaviour during pregnancy, for childbirth and after birth for women and newborns and in improving key maternal and newborn health outcomes?

 

Evidence summary

Evidence on interventions for male involvement in pregnancy, childbirth and the postnatal period was extracted from a systematic review conducted by Tokhi et al. (forthcoming)(6) of 13 studies, including one RCT, three cluster RCTs, one cohort analytic study, four pre-post designs, three repeat cross-sectional and one programme evaluation using data from the health information system. Three of these studies report qualitative findings. The 13 studies were conducted in Bangladesh, Eritrea, India, Indonesia, Nepal, Pakistan, South Africa, Tanzania and Turkey.

Male involvement strategies are employed as a means to support women to access care, address the influence of gender inequality on MNH and promote men’s positive involvement as partners and fathers.

Four studies did not measure the critical outcome of birth with a skilled birth attendant or facility birth; three studies were primarily aimed to increase use of skilled care for obstetric complications.(7-9)

The modes of interventions in the 13 studies included mass media campaigns, community-based outreach and education for men only or for men and women together, home visits, facility-based counselling for couples or for groups or for men only and workplace-based educationfor men. There was not sufficient evidence to determine which of these strategies or which combination of strategies were most effective.

 

For the outcome of birth with a skilled birth attendant or facility birth, the quality of the evidence ranged from very low to low.

•          In one RCT (Mullany, Becker and Hindin, 2007) the impact of the intervention on SBA and facility birth is unclear. Low-quality evidence.(10)

 

•          Six observational studies (Mushi, Mpembeni and Jahn, 2010; Purdin, Khan and Saucier, 2009; Sinha, 2008; Sood et al., 2004 Indonesia; Sood et al., 2004 Nepal; Turan, Tesfagiorghis and Polan, 2011) reported some benefit for male involvement either for the presence of an SBA/facility birth or both. In one before and after study (Mushi, Mpembeni and Jahn, 2010) there was a statistically significant increase in presence of an SBA for the intervention group and most of these births were at facilities. Two studies using a pre and post intervention design reported a statistically significant increase in facility birth for the intervention group (Sinha 2008, Turan Tesfagiorghis and Polan, 2011); no SBA data were reported. The programme evaluation study using a health information system (Purdin, Khan and Saucier, 2009) observed an increase in births in an EmOC facility among refugee women. In a repeat cross-sectional study (Sood et al., 2004 Indonesia) women (and husbands) reported a statistically significant increase of use of SBA and facility birth for the exposed group. In the final study (Sood et al., 2004 Nepal), women not exposed to the intervention were more likely than the exposed group to report giving birth at a hospital and reported being assisted by a doctor. This contrasts with data from husbands; a higher percentage of those exposed than not exposed to the intervention reported their wives had given birth in hospital and gave birth assisted by a doctor. Very low-quality evidence.(11-16)

 

•          For those studies whose focus was increasing access to skilled care for complications:

o          The cluster RCT (Midhet and Becker, 2010) showed a statistically significant increase in facility birth at the district hospital and a non-significant increase in birth with an SBA or trained TBA for the intervention groups. Moderate-quality evidence.(9)

 

o          In one quasi-experimental study (Hossain and Ross, 2006) facility birth increased statistically in the intervention group. Low-quality evidence.(8)

 

For the outcome of care with a skilled birth attendant or in a facility in case of complications/illness in women and newborns, the quality of the evidence ranged from low to moderate.

•          One non-equivalent control group study (Varkey et al., 2004) reports an increase in visiting the dispensary in the intervention group, but not for attending hospital during presence of danger signs. Low-quality evidence.(17)

 

•          For those studies whose focus was increasing access to skilled care for complications:

  • One cluster RCT (Midhet and Becker, 2010) showed a statistically significant increase in women accessing hospital for treatment of problems during pregnancy but unclear impact during delivery, immediately after delivery or during the postpartum period. Moderate-quality evidence.

 

For the outcome of use of antenatal care (one or four visits), the quality of the evidence ranged from very low to low.

•          One RCT (Mullany, Becker and Hindin, 2007) reported no difference between the study groups in use of more than three ANC visits. Low-quality evidence.(10)

 

•          Six observational studies (Mushi, Mpembeni and Jahn, 2010; Purdin, Khan and Saucier, 2009; Sinha, 2008; Sood et al., 2004 Indonesia; Sood et al., 2004 Nepal; Turan, Tesfagiorghis and Polan, 2011) reported data on antenatal visits. One study using a pre and post intervention design (Sinha, 2008) and one programme evaluation using a health information system (Purdin, Khan and Saucier, 2009) showed more women made three or more ANC visits between baseline and follow-up. Another pre and post study (Mushi, Mpembeni and Jahn, 2010) showed a non-significant increase in four or more ANC visits. A one group before-and-after evaluation (Sood et al., 2004 Nepal) found no significant differences between exposed (post-intervention) and unexposed (pre-intervention) groups in four or more ANC visits. Two pre and post intervention studies with control groups (Sood et al., 2004 Indonesia; Turan, Tesfagiorghis and Polan, 2011) showed women and husbands exposed to the intervention were significantly more likely to report four or more ANC visits than those unexposed, but no baseline data are provided (Sood et al., 2004 Indonesia) and a statistically significant increase in more than one and more than four visits (Turan, Tesfagiorghis and Polan, 2011). Very low-quality evidence. (11-16)

 

•          For those studies whose focus was increasing access to skilled care for complications:

o          One cluster RCT (Midhet and Becker, 2010) showed significantly more pregnant women in the intervention arms in comparison to the control arm received adequate prenatal care (visits to qualified health care provider solely for the purpose of routine medical check-ups during first or second trimester of pregnancy) but the differences between intervention arms were not significant. Moderate-quality evidence.(9)

 

For the outcome of breastfeeding, the quality of the evidence was assessed as very low to low.

•          One cluster RCT (Kunene et al., 2004) shows that the percentage of women commencing mixed feeding at six months was higher in the intervention group than the control group. The results were not statistically significant. Low-quality evidence.

 

•          In one non-equivalent control group study design in which three dispensaries provided the intervention while three others functioned as control sites (Varkey et al., 2004), significantly more women in the control group continued exclusively breastfeeding for six months in comparison to the intervention group. Very low-quality evidence.(17)

 

•          In one cohort analytic study (Sahip and Turin, 2007), men in the intervention group reported a significant increase in their wives breastfeeding at three months. Very low-quality evidence.(18)

 

•          One repeat cross-sectional study (Fullerton, Killian, and Gass, 2005) found a significant increase in women who breastfed within one hour of birth following the male involvement intervention. Very low-quality evidence.(7)

 

For the outcome of postpartum care visits for women, the quality of the evidence ranged from low to very low.

•          One randomized controlled trial (Mullany, Becker and Hindin, 2007) showed women assigned to the couples group were significantly more likely to attend the postpartum visit than those assigned to the control group or women-alone group. Low-quality evidence.(10)

 

•          Two observational studies report on postpartum check-ups for mothers. In one cohort analytic study (Sahip and Turan, 2007), there was no significant difference between men in the control and intervention groups reporting whether their wife had a postpartum check-up. A programme evaluation (Purdin, Khan and Saucier, 2009) showed an increase in postpartum care within 72 hours of birth post intervention. Very low-quality evidence.(12, 18)

Additional outcomes not identified as critical and important were reported by some of the studiesincluding birth preparedness and complications readiness, male partners accompanying women to antenatal care, increased support for women and interaction between couples. In addition, information was available from those studies that reported on maternal nutrition, maternal death, stillbirths, perinatal mortality and neonatal mortality.(6) These were discussed in the meeting and considered by the GDG in its decision on the strength of the recommendation.

 

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:

http://apps.who.int/iris/bitstream/10665/172427/2/9789241508742_tables_eng.pdf?ua=1

 

Implementation considerations

  • Male involvement strategies for MNH should primarily be targeted to support women’s careseeking and decision-making for their own health and the health of their children. Their implementation should not reduce women’s autonomy (in careseeking and decision-making in relation to their own health and the health of their children). It is necessary to avoid reinforcing gendered stereotypes of men as the decision-makers.
  • Additionally, male involvement strategies should be linked to other efforts to implement gender transformative programming (e.g., programmes that promote egalitarian gender norms and women’s empowerment) and should promote the positive role that men can play as partners and fathers.
  • Reflecting on the balance of benefits versus harms, the balance depends on the strategy to be employed and the context. In contexts where intimate partner violence is high, male involvement through facilitybased male involvement strategies need to be implemented with caution with due attention to not compromising women’s safety and confidentiality.
  • Harms/risks can be mitigated through implementation approaches that train health providers and programme staff in gender-sensitive programming that promotes egalitarian decisionmaking between couples and respects women’s rights and autonomy along with close monitoring and evaluation for adverse impacts on women’s rights and autonomy.
  • It is important to recognise the diversity in women’s values and preferences. Programmes should be designed having undertaken qualitative research and dialogue with women.
  • When considering interventions such as couples counselling or facility-based interventions where the male partner is invited to accompany the woman for antenatal care, it is extremely important to obtain woman’s autonomous consent and in discuss in detail the aspects in which she wants him to be involved. Tailored and nuanced care is essential. There will be some women who want their male partners involved and they should be supported. There will be other women who do not want their male partners involved and this should be respected. If the woman does not wish to involve her male partner or is not able to engage with him, his involvement should not be conditional for providing services. Perhaps the most important implementation consideration noted was the need to ensure women’s permission, consent and perspective on male involvement before inviting men to be involved.
  • The diversity of pregnant women’s partnership and family arrangements, including women without partners, needs to be considered in promoting male involvement interventions.
  • Male involvement in clinical care around the time of pregnancy, childbirth and after birth should be contingent on the approval or request of women. Women should be consulted, in private, as to which aspects of care they would like to be confidential. Thisis particularly relevant to potentially sensitive clinical services, such as postpartum family planning.
  • Health facilities should be male-friendly and health systems should be oriented towards dealing with men as well as women around the time of pregnancy, childbirth and after birth. However, access to quality care for women and newborns must not be contingent on men’s attendance or involvement.
  • Many health services are not set up for men to accompany their partners. Physical infrastructure and the capacity of health providers to work with men and couples through gender-sensitive approaches need to be addressed.

 

 

Research implications

The GDG identified that further research on the following high-priority questions is needed:

  • Studies that are designed and powered to measure the effect of including men together with women in discussions and decision-making about MNH. Studies that measure the separate effects of including men and other key household decision-makers are also required.
  • Studies of male involvement interventions that systematically record qualitative as well as quantitative information about the values and preferences of women and men relating to changes in men’s behaviours. In particular, qualitative information that relates to women’s bodily autonomy and autonomy in decision-making, genderstereotypes and power dynamics within relationships or households should be recorded. Existing studies that report on men’s or couple’s behaviours without reporting on women’s and men’s values and preferences relating to these behaviours risk obscuring differences between harmful and positive gender outcomes.
  • Context-specific investigations of how interventions to promote male involvement influence intrahousehold dynamics, including relationships between mothers-in-law and daughters-in-law, and between grandparents and newborns/infants.
  • The cost implications of making and sustaining health system changes that support the involvement of men around the time of pregnancy, childbirth and after birth, such as developing male-friendly health facilities and training health workers to respond to men and couples as well as women. Research addressing this gap should also consider the quality of health services.
  • Assessments of the influence of male involvement interventions implemented at the level of local government on priority setting and resource allocation at the community level.
  • Research on male involvement in MNH that integrates lessons extrapolated from the larger body of literature that exists on working with men and boys on gender equality and for other sexual and reproductive health topics.

 

 

Related links

WHO recommendations on health promotion interventions for maternal and newborn health (2015)full document and evidence tables

 

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health

Newborn Health

 

Supporting systematic reviews:

Tokhi M, Comrie-Thomson L, Davis J, Portela A, Chersich M, Luchters S. Involving men to improve maternal and newborn health: A systematic review of the effectiveness of interventions. PloS one. 2018;13(1):e0191620.

 

References

  1. Working with individuals, families, and communities to improve maternal and newborn health. Geneva: World Health Organization; 2010. [26 November 2014] http://wwwwhoint/maternal_child_adolescent/documents/who_fch_rhr_0311/en/.
  2. The Ottawa Charter for Health Promotion [website]. Geneva: World Health Organization; 1986. [30 March 2014] http://wwwwhoint/healthpromotion/conferences/previous/ottawa/en/.
  3. Davis J, Luchters S, Holmes W. Men and maternal and newborn health: benefits, harms, challenges and potential strategies for engaging men. Melbourne, Australia: Compass: Women's and Children's Health Knowledge Hub. 2012.
  4. WHO recommendations on health promotion interventions for maternal and newborn health 2015: World Health Organization; 2015.
  5. WHO Handbook for Guideline Development - 2nd edition. Geneva: World Health Organization; 2014. World Health Organization. 2014.
  6. Tokhi M, Comrie-Thomson L, Davis J, Portela A, Chersich M, Luchters S. Involving men to improve maternal and newborn health: A systematic review of the effectiveness of interventions. PloS one. 2018;13(1):e0191620.
  7. Fullerton JT, Killian R, Gass PM. Outcomes of a Community-and Home-Based Intervention for Safe Motherhood and Newborn Care. Health Care for Women International. 2005;26(7):561-76.
  8. Hossain J, Ross SR. The effect of addressing demand for as well as supply of emergency obstetric care in Dinajpur, Bangladesh. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2006;92(3):320-8.
  9. Midhet F, Becker S. Impact of community-based interventions on maternal and neonatal health indicators: Results from a community randomized trial in rural Balochistan, Pakistan. Reproductive Health. 2010;7:30.
  10. Mullany LC, Lee TJ, Yone L, Lee CI, Teela KC, Paw P, et al. Impact of community-based maternal health workers on coverage of essential maternal health interventions among internally displaced communities in eastern Burma: the MOM project. PLoS medicine. 2010;7(8):e1000317.
  11. Mushi D, Mpembeni R, Jahn A. Effectiveness of community based Safe Motherhood promoters in improving the utilization of obstetric care. The case of Mtwara Rural District in Tanzania. BMC pregnancy and childbirth. 2010;10:14.
  12. Purdin S, Khan T, Saucier R. Reducing maternal mortality among Afghan refugees in Pakistan. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2009;105(1):82-5.
  13. Sinha D. Empowering communities to make pregnancy safer: an intervention in rural Andhra Pradesh: Population Council; 2008.
  14. Sood S, Chandra U, Mishra P, Neupane S. Measuring the effects of behavior change interventions in Nepal with population-based survey results. 2004.
  15. Sood S, Chandra U, Palmer A, Molyneux I. Measuring the effects of the SIAGA behavior change campaign in Indonesia with population-based survey results. 2004.
  16. Turan JM, Tesfagiorghis M, Polan ML. Evaluation of a community intervention for promotion of safe motherhood in Eritrea. Journal of midwifery & women's health. 2011;56(1):8-17.
  17. Varkey LC, Mishra A, Das A, Ottolenghi E, Huntington D, Adamchak S, et al. Involving men in maternity care in India. New Delhi: Population Council. 2004:62.
  18. Sahip Y, Turan JM. Education for expectant fathers in workplaces in Turkey. Journal of biosocial science. 2007;39(6):843-60.

 

Citation: WHO recommendation on interventions to promote the involvement of men during pregnancy, childbirth and after birth (2015). WHO Reproductive Health Library; Geneva: World Health Organization.