Male partner involvement in birth preparedness, complication readiness and obstetric emergencies in Sub-Saharan Africa: a scoping review

Background Maternal mortality remains a pressing concern across Sub-Sahara Africa. The ‘Three Delays Model’ suggests that maternal deaths are a consequence of delays in: seeking care, reaching medical care and receiving care. Birth Preparedness and Complication Readiness (BPCR) refers to a plan organised during pregnancy in preparation for a normal birth and in case of complications. Male partners in many Sub-Saharan African communities could play a pivotal role in a woman’s ability to prepare for birth and respond to obstetric complications. This review aimed identify: the extent and quality of research performed on the topic of male partner involvement in BPCR in Sub-Saharan Africa; the degree to which populations and geographic areas are represented; how male partner involvement has been conceptualized; how male partners response to obstetric complications has been conceptualised; how the variation in male partners involvement has been measured and if any interventions have been performed. Methods In this scoping review, articles were identified through a systematic search of databases MEDLINE, EMBASE and Maternity and Infant Care and a manual scan of relevant papers, journals and websites. All authors contributed to the screening process and a quality assessment using the Kmet checklist. The PRISMA checking list for Scoping Reviews was used to guide the search, data charting and reporting of the review The protocol was registered with PROSPERO (ID: CRD42019126263). Results Thirty-five articles met inclusion criteria, reporting: 13 qualitative, 13 cross-sectional, 5 mixed method and 4 intervention studies. Data were contributed by approximately 14,550 participants (numbers were not always reported for focus groups) including: women who were pregnant or who had experienced pregnancy or childbirth within the previous 3 years, their male partners and key informants such as health workers and community leaders. Conclusions The diversity of study designs, aims and source countries in this body of literature reflects an emerging stage of research; as a result, the review yielded strong evidence in some areas and gaps in others. Male partner’s involvement in BPCR and responding to obstetric emergencies can be conceptualised as being centrally involved in responding to complications and having some role in preparing for birth through their position in the chain of decisions and provision of logistic support. However, their knowledge of pregnancy complications and level of preparation for birth is low, suggesting they are making decisions without being fully informed. There is limited evidence on interventions to improve their knowledge. Future research efforts should be focused on producing standardised, culturally appropriate, higher level evidence. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03606-x.


Background
Globally, approximately 830 women die each day due to pregnancy complications, 66% of these deaths occur in Sub-Saharan Africa [1]. Most of these deaths could be prevented by timely access to medical support during pregnancy, labour and the postnatal period. According to the 'three delays' model, maternal deaths are frequently related to a delay in: 1) seeking care, 2) reaching medical care and 3) receiving adequately skilled care once at a facility [2,3].
Advanced preparation for childbirth by women who are pregnant and their families, is one method of reducing life threatening delays in receiving care during birth [4,5]. Birth preparedness and complication readiness (BPCR) refers to a plan, organised during pregnancy in preparation for a normal delivery and in case of complications [4,5]. BPCR includes: identifying a skilled birth attendant, identifying the nearest facility, saving money for the birth costs, organising transport in advance, identifying a birth companion, identifying a potential blood donor and knowing the signs of complications [6]. In 2015, the World Health Organisation (WHO) endorsed the use of BPCR interventions stating that, 'BPCR interventions are recommended to increase the use of skilled care at birth and to increase the timely use of facility care for obstetric and newborn complications' [7].
Data from the Demographic Health Survey (DHS) indicates that male partners in many parts of Sub-Saharan Africa are key decision makers in many families, including decisions about maternal health [8]. It is plausible that male partners could play a pivotal role in a woman's ability to prepare for birth and respond to obstetric complications. Male involvement in reproductive health was first agreed to be an international priority at the International Conference on Population and Development (UNFPA 1994) in Cairo. Since then countries throughout Sub-Saharan Africa have, to varying degrees, recognised the importance of including male partners in reproductive healthcare [9].
Most research and evidence syntheses about BPCR has been conducted from among women [4,5,10]. Although there is some evidence about the level of involvement and the role of men in BPCR and responding to obstetric complications, it is yet to be synthesised in systematically conducted reviews.
The literature contains significant diversity in the way male partner involvement has been conceptualised, the types of questions that have been asked, the research methods employed and the results. The lack of uniformity amongst the evidence prevents a systematic review being performed at this stage, and suggests that a scoping review is appropriate to determine the extent of research and to map, summarise and identify gaps in the evidence.

Objectives
This review aimed identify: the extent and quality of research performed on the topic of male partner involvement in BPCR in Sub-Saharan Africa; the degree to which populations and geographic areas are represented; how male partner involvement has been conceptualized; how male partners response to obstetric complications has been conceptualised; how the variation in male partners involvement has been measured and if any interventions have been performed.

Methods
This review adhered to Cochrane Consumers and Communication review group guidelines, JBI Manual for Evidence Synthesis Chapter 11: Scoping Reviews and the PRISMA checking list for Scoping Reviews to guide the search, data charting and reporting of the review [11][12][13]. The review was registered with PROSPERO (ID: CRD42019126263).

Definitions
BPCR was defined as planning and/or organising during pregnancy in preparation for a normal delivery or in case of complications. The BPCR actions included saving money for birth; identifying transport; identifying the birth location; knowing the signs of pregnancy complications; identifying a skilled birth attendant, identifying someone to donate blood. Complications were defined as: Immediate, life threatening pregnancy or labour complications.
Male partner involvement was defined as a male partner's attitudes, behaviours or experiences in relation to BPCR or obstetric emergencies.

Information sources and search strategy
Databases (EMBASE, Ovid MEDLINE and Maternity and Infant Health) were searched for records in English. The review topic was divided into the following concepts 1) Male involvement, 2) Birth preparedness and complication readiness, 3) Obstetric emergencies and 4) Sub-Saharan Africa. Appropriate MeSH terms and truncated key words were adopted for each concept. Boolean operators AND /OR were used to link concepts and associated terms in the following way: (male involvement) AND (birth preparedness complication readiness OR obstetric emergencies) AND (Sub-Saharan Africa) (see supplementary table 1 for detailed search strategy). The authors also undertook a manual search of the reference lists in relevant publications, journals and websites for additional studies.

Eligibility criteria
The following eligibility criteria were adopted: peerreviewed research; humans; English language; Sub-Saharan Africa; primary research; male participants or other participants reporting on male partner involvement (men's attitudes, behaviours or experiences) and BPCR (at least one indicator) OR Pregnancy/ birth complications in aims, primary outcome (quantitative studies) or main theme (qualitative studies). All studies which met criteria after 2005 and until the final search date November 2019 were included.

Study selection
Study screening was performed in Covidence [14] with participation from all four reviewers. Studies were double screened at 1) title and abstract stage and 2) full text review stage. Differences of opinion at any stage were resolved by discussion between the author group.

Scope of the review
The search strategy specifically sought studies reporting on male partner involvement in birth preparedness and complication readiness or obstetric emergencies. The findings were analysed to identify male partner attitudes, behaviours and experiences in relation to BPCR and response to obstetric complications as defined by the review aims. Results regarding only attendance at antenatal care, the presence of skilled birth attendance and general involvement of men during pregnancy, childbirth and in maternal and child healthcare were not included. Male involvement in post-partum complications was reported if the results were available in the included articles, however the search strategy did not specifically search post-partum complications.

Data charting process and data items
At least two authors extracted data independently for each paper. Data charting fields included; authors (date); country; study design; aim; inclusion criteria; sample characteristics; number of participants; recruitment strategy; data source; analysis and key findings related to review.

Critical appraisal of sources of evidence
In order to evaluate the quality of research available on this topic, in accordance with the reviews aims a critical appraisal of the literature was performed using the Kmet checklist [15]. Separate checklists were used to evaluate research deemed primarily qualitative and primarily quantitative. Individual criteria were scored 0-2 and a final score was produced (sum of scores as a proportion of potential maximum score). All papers were assessed by two authors and differences of opinion resolved via discussion until a consensus was achieved.

Results
The selection process for all sources of evidence included is provided in a flow chart (Fig. 1).
The study characteristics and results as they relate to the review aims, are provided for quantitative, qualitative and mixed-method studies in Table 1 and intervention studies in Table 2.

Extent and quality of research
The identification of papers is illustrated in Fig. 1. The extent and quality of research has been summarised below using the sub-headings: Study designs, populations and geographic locations and quality of research.

Populations and geographic locations of included research
Overall data were reported from approximately 14,550 participants including pregnant women or those who had experienced pregnancy or childbirth within the previous 3 years, their male partners and key informants such as health workers and community leaders.

Quality of research overall
The study designs included in the review reflect an emerging field of research. The majority of study designs were either qualitative or cross-sectional observation surveys (many purely descriptive). There were no randomised controlled trials, but there were three quasiexperimental intervention studies [46][47][48] and one evaluation study [49]. These study designs limit the level of evidence available on the topic.
Sixteen primarily qualitative research studies were assessed using the Kmet qualitative checklist (see column QA in Tables 1 and 2). The quality of the studies was reasonable with a median score of .75 (range of .60 to .85). The criteria most commonly not met were the use of verification procedures to establish credibility and reflexivity of account (no study adequately documented the latter).
Fifteen primarily cross-sectional studies were assessed using the Kmet quantitative checklist (see column QA in Tables 1 and 2). The quality for the sources of evidence was reasonable with 3 studies receiving full scores [1] and only four dropping below .6. They produced a median score of .76 (range of .45 to 1). The criteria most commonly not met included: not controlling for confounding variables, not providing a measure of variance and flaws relating to the outcome measure.
Of three intervention studies included in this review, the median score for the Kmet quantitative checklist, was .45 (range: .67-1.0). Only one completed appropriately complex analysis of the data. A fourth evaluation study was assessed using the qualitative checklist to fit the reported data; this received a score of .60.

Conceptualisation of male partner involvement in BPCR
Nine studies discussed the role or conceptualisation of male partner involvement in BPCR using qualitative research methods [9, 19-21, 27, 36, 39, 41, 45]. Qualitative studies did not report a structured definition of BPCR;   See Table 3 1. †

Ghana
Atuahene, Arde-Acquah, Atuahene, Adjuik&-Ganle (2017) [32] To describe the level of male involvement in inner city safe motherhood projects Married men aged 18+ whose wife/ partner was pregnant and in 3rd trimester or had children 5 or younger Average age 37 Multistage sampling procedure to select: houses, households then respondents. Simple random sampling.
-Descriptive statistics See Table 3 .  Table 3 .45 †  Table 3 .59 † .54 † Uganda instead they relied on participants' accounts of preparing for birth.
Male partners were described as playing an important role in pregnancy and birth decisions including preparing for birth and potential complications [27,45]. These processes were complex, involved many people and varied between communities.
It was reported that although women have a central position in pregnancy and birth, they frequently lack decision-making power and resources [45]. Several studies described scenarios where pregnant women lacked agency and were not participants in decision-making processes around their health and body [16,19,22,23]. This pertained in particular to decision about when to attend a health facility for a normal birth or to seek help in the case of obstetric complications.
Specific BPCR responsibilities reported for male partners were often related to material support [16,20,22,40,41,45]. The most common role for men was to provide financial support for buying birth items (for example, a birth kit) or providing nutritious food [40]. Another common role described was to identify and organise transport to a facility [18,19,21].
A common conceptualisation was that male partners viewed pregnancy and childbirth as a "natural" process and this then influenced their ideas of how to prepare for birth [22]. This was explained through the use of finances for birth, which would not be used for birth in a facility unless complications occurred, and would instead be used for clothes and food. In general male partners strived to do their best [26], for example providing adequate care to one's wife was considered a symbol of social status in Malawi [41]. However, men's involvement was often hampered by barriers. Lack of awareness and poverty were common challenges experienced by male partners in fulfilling their perceived responsibilities [16,40].

Measurement of BPCR in male partners
Fourteen studies reported the level of BPCR or recognition of obstetric danger signs among male partners [30-32, 36-38, 41-43, 49]. All except one study [49] used quantitative methods. Nine studies employed a standardised tool developed by John Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO) to measure BPCR (this consisted of using the BPCR tool to identify if male partners had performed the following items: saving money for birth; identifying transport; identifying the birth location; knowing the signs of pregnancy complications; identifying a skilled birth attendant, identifying someone to donate blood) or measured the recognition of pregnancy danger signs (please see Table 4 for a full list) [28-31, 34, 35, 37, 42, 43]. Each study adapted the questionnaire to local conditions. Three studies used a study specific questionnaire to measure BPCR [38,41,43]. Two studies reported aspects of BPCR through a questionnaire designed for other purposes [32,36].
As displayed in Table 3, proportions of male partners who had completed each BPCR indicator varied between studies. Commonly performed actions included: saving money, 20-99%; purchasing a birth kit, 38-54%; organising transport, 10-69%; and identifying where to go in an emergency, 2-78%. The least commonly performed actions included: identifying a skilled birth attendant, 1-41% and identifying a blood donor, 0-18%.
As displayed in Table 4, there was variability in the way studies reported men's recognition of various pregnancy, childbirth and postpartum danger signs. Pregnancy danger signs were more commonly reported  indicators (compared to childbirth or postpartum). Several studies reported that very small proportions of male partners indicated recognition of danger signs (< 15% recognition for most indicators) [30,35,37,42]. The remaining studies reported reasonably low rates (< 60% for most indicators) [28,31,34,43].

Conceptualisation of male partner involvement in responding to obstetric complications
Eleven studies reported information about male partners role in responding to complications [16-20, 22-26, 41].
In all descriptions of families responding to complications, male partners were central to the decision making process [16-20, 22-26, 41]. Two studies reported that male partners were involved in maternal healthcare only when pregnancy complications occurred [16,17]. Frequently the decisions male partners made in relation to preparing for birth were not unilateral, but involved consultation with women, other family members such as male partners' mothers or traditional birth attendants [16,19,27,41].
The conceptualisation of complications in childbirth by study participants was a mixture of medical and spiritual conditions. Responses were guided by these ideas, some conditions requiring medical treatment and others needing guidance from a traditional birth attendant (TBA). For example in one study male partners would seek advice from a spiritual healer instead of a health facility if their partner experienced convulsions while pregnant [22].
In general, male partners were found to be involved throughout the process of responding to complications. In the healthcare setting there were reports that male partners were not always welcomed. Some men described being excluded by health professionals or not having a clear role [18,24,26]. In the home setting partners were responsible for sourcing and administering several types of medications [25]. Emotionally male partners were impacted by the experience of pregnancy complications with experiences characterised by intense fear, worry and loss [24]. It was noted that although male partners often played a key role in decisions around maternal health, they lacked knowledge on maternal and child health [20,22,40]. Both women and men reported a desire for men to be more knowledgeable about BPCR [22].

Interventions to improve BPCR or knowledge of danger signs among male partners
The findings from four trials of interventions to improve levels of male partner knowledge of BPCR or awareness of danger signs are summarised in Table 2 Evaluation methods were mixed in the complexity of analyses and type of data collected -which prohibits reliable comparison. The most methodologically robust evaluation did report a significant improvement in male partners' awareness of danger signs [48]; the remaining three did not report any improvement.

Discussion
To our knowledge, this is the first scoping review conducted of sub-Saharan studies on the involvement of male partners in BPCR and response to obstetric emergencies. The synthesis of the literature on this topic has implications for research, policy and practice across the region.

Extent and quality of research into male partner involvement in BPCR
The diversity of study designs, aims and source countries in this body of literature reflects an emerging stage of research; as a result, the review yielded strong evidence in some areas and gaps in others. The evidence from quantitative studies may be regarded as limited because most of the study designs sit low on the hierarchy of evidence [50] and the samples/studies do not represent all of the Sub-Saharan Africa. The studies are limited to certain regions within the countries studied and lack population level results. There is a distinct lack of higher-level research, for example robust research trialling interventions to increase male involvement in BPCR. Although the average quality of included studies was reasonable, it is not possible to generalise based on the large proportion of qualitative research.

Conceptualisation of male involvement in BPCR and responding to obstetric emergencies
Defining the role of or conceptualising male partner's involvement in preparing for birth and responding to complications was achieved using qualitative research methods. This is appropriate given the lack of adequate evidence in this area. However qualitative research often has small, selective samples and cannot be used to generalise to the broader populations. Moreover, the geographic coverage of the research was inconsistent across Sub-Sahara Africa, leaving many countries and cultural groups unrepresented and some countries with multiple studies. Consequently, the concepts and roles of male partners' involvement in BPCR can only be used as a guide to inform future research and cannot be considered definitive. The conceptualisation of male partner involvement yielded key themes across studies. In many contexts male partners had some role in preparing for birth and consistently across studies they were instrumental in responding to obstetric complications. They were directly involved through their position in the chain of decisions and indirectly involved through providing financial and logistical support. The understanding of their role is significant to the development of interventions to support BPCR in families and communities. Knowledge of the male partner's role should be further developed with more widespread research, to inform interventions to increase BPCR in families.
Male partners were interested in taking appropriate action [26]. However, their involvement did not always align smoothly with other systems and processes. Participants reported difficulties in dealing with the healthcare system, with some male partners reporting being excluded from healthcare decisions [39]. On the other hand, healthcare staff described delays in providing care because male partners were not available to give permission. Poverty was also described as a common barrier to male partners fulfilling what they saw as their responsibilities [45].

Measurement of male partner's involvement in BPCR
Measurement of male partner's level of BPCR had some degree of consistency because many studies used the tool developed by JHPIEGO [6]. However, there were still discrepancies between studies in scoring or summarising the results from the tool (e.g. defining good/ poor BPCR). Although there has been an effort to validate and adapt the standardised tool to different cultural contexts, it is not clear if it has been adapted for use with male partners.
Studies that did not use the tool developed by JHPIEGO contained diverse definitions of BPCR, making it hard to compare. The studies using research specific tools to measure involvement also tended to report higher levels of involvement.
There was little consistency in summarising recognition of danger signs: most studies had unique indicators, which prevented a comparison between studies. This variance was greater between studies not using a standardised measure. For example it was reported that 58% of participants could correctly identify more than nine danger signs when presented and asked if they were 'true' or 'false' [33] with a study specific questionnaire. Researchers using a standardised measure asked men to spontaneously mention danger signs and found that 42% (37), 49% (30) and 53% (31) of men could not identify more than one.
The literature overall presented a general theme that although male partners frequently make decisions about maternal healthcare, in general, they lack knowledge regarding maternal health concerns. This was described in the findings from both qualitative and quantitative papers included in this scoping review. Male partners'  [37] Ethiopia (n = 824) [30] Ethiopia (n = 592) [31] Nigeria (n = 389) [42] Ethiopia (n = 406) [28] Nigeria (n = 386) [43] Nigeria (n = 1627) [34] Nigeria (n = 259) [ NR recognition of pregnancy and birth danger signs was poor across all studies and their level of BPCR was generally low. Saving money and purchasing birth items were the most commonly performed actions, and some BPCR actions were almost completely neglected. For instance, very few men identified a potential blood donor or a skilled birth attendant. This increases the risk of adverse pregnancy and birth outcomes. These results suggest that male partner's preparation for birth and complications can often be improved, and this has the potential to improve outcomes for women and children.

Interventional studies
Studies of male involvement interventions were the least common type of research with large variation in the quality of methods. Only one interventional study was considered robust and received the maximum QA score of 1 [48]. Home Based Life Saving Skills provided joint training of pregnant women and family with the aim to educate about BPCR, danger signs, promote health seeking behaviour and provide skills to handle emergencies. This study reported significant improvement in male partners' recognition of pregnancy danger signs, suggesting that properly designed interventions may be useful in improving male partner knowledge.

Implications for future research
The gaps revealed in this scoping review provide future research opportunities. In many sub-Saharan African countries, there is inadequate evidence on the role of male partners in preparing for birth and responding to pregnancy complications. From the 46 countries listed as Sub-Sahara Africa by the United Nations, only 10 were identified as having any evidence regarding male involvement in BPCR. Future research could focus on reporting levels of BPCR among male partners in Sub-Saharan countries with long delays in receiving care not represented in this review. From the countries already represented (for example Ethiopia), future research could focus on examining associations between male partner's level of BPCR and maternal health outcomes. It is assumed because of male partners' role in decision making that increased knowledge of danger signs and BPCR will translate into improved maternal health outcomes [4], but this hypothesis remains to be tested in different contexts.
Research should also focus on evaluating interventions to improve male partner level of BPCR and knowledge of obstetric complications. This is extremely limited at present and it is not clear what interventions are useful in improving male partner BPCR and knowledge of danger signs.

Implications for policy, programs and practice
The findings suggest that in specific countries in sub-Saharan Africa, male partners are involved in BPCR and responding to pregnancy complications, yet their level of preparation and knowledge of pregnancy complications is poor. Policies, programs and practice could focus on improving male partners' level of knowledge about complications and the importance of preparing for birth. As with all interventions encouraging male involvement in maternal health, this would need to be performed in a way that did not compromise women's autonomy or safety and may involve additional training for healthcare workers.

Conclusions
In conclusion, the diversity of study designs, aims and source countries in this body of literature reflects an emerging stage of research; as a result, the review yielded strong evidence in some areas and gaps in others. Male partners' involvement in BPCR and responding to obstetric emergencies can be conceptualised as being centrally involved in responding to complications and having some role in preparing for birth through their position in the chain of decisions and provision of logistic support. However, their knowledge of pregnancy complications and level of preparation for birth is low, suggesting they are making decisions without being fully informed. There is limited evidence on interventions to improve men's knowledge on BPCR and signs of complications, however improvements were recorded following an intervention in Tanzania [48]. Future research efforts should be focused on producing standardised, culturally appropriate, higher level evidence and randomised controlled trials of interventions. As pregnancy complications are a leading cause of maternal mortality in Sub-Saharan Africa, appropriate preparation for birth and complications by women, male partners, families and the community have the potential to lower these risks.