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      Involving men to improve maternal and newborn health: A systematic review of the effectiveness of interventions

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          Abstract

          Background

          Emerging evidence and program experience indicate that engaging men in maternal and newborn health can have considerable health benefits for women and children in low- and middle-income countries. Previous reviews have identified male involvement as a promising intervention, but with a complex evidence base and limited direct evidence of effectiveness for mortality and morbidity outcomes.

          Objective

          To determine the effect of interventions to engage men during pregnancy, childbirth and infancy on mortality and morbidity, as well as effects on mechanisms by which male involvement is hypothesised to influence mortality and morbidity outcomes: home care practices, care-seeking, and couple relationships.

          Methods

          Using a comprehensive, highly sensitive mapping of maternal health intervention studies conducted in low- and middle-income countries between 2000 and 2012, we identified interventions that have engaged men to improve maternal and newborn health. Primary outcomes were care-seeking for essential services, mortality and morbidity, and home care practices. Secondary outcomes relating to couple relationships were extracted from included studies.

          Results

          Thirteen studies from nine countries were included. Interventions to engage men were associated with improved antenatal care attendance, skilled birth attendance, facility birth, postpartum care, birth and complications preparedness and maternal nutrition. The impact of interventions on mortality, morbidity and breastfeeding was less clear. Included interventions improved male partner support for women and increased couple communication and joint decision-making, with ambiguous effects on women’s autonomy.

          Conclusion

          Interventions to engage men in maternal and newborn health can increase care-seeking, improve home care practices, and support more equitable couple communication and decision-making for maternal and newborn health. These findings support engaging men as a health promotion strategy, although evidence gaps remain around effects on mortality and morbidity. Findings also indicate that interventions to increase male involvement should be carefully designed and implemented to mitigate potential harmful effects on couple relationship dynamics.

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          Most cited references32

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          The impact of including husbands in antenatal health education services on maternal health practices in urban Nepal: results from a randomized controlled trial.

          Observational studies suggest that including men in reproductive health interventions can enhance positive health outcomes. A randomized controlled trial was designed to test the impact of involving male partners in antenatal health education on maternal health care utilization and birth preparedness in urban Nepal. In total, 442 women seeking antenatal services during second trimester of pregnancy were randomized into three groups: women who received education with their husbands, women who received education alone and women who received no education. The education intervention consisted of two 35-min health education sessions. Women were followed until after delivery. Women who received education with husbands were more likely to attend a post-partum visit than women who received education alone [RR = 1.25, 95% CI = (1.01, 1.54)] or no education [RR = 1.29, 95% CI = (1.04, 1.60)]. Women who received education with their husbands were also nearly twice as likely as control group women to report making >3 birth preparations [RR = 1.99, 95% CI = (1.10, 3.59)]. Study groups were similar with respect to attending the recommended number of antenatal care checkups, delivering in a health institution or having a skilled provider at birth. These data provide evidence that educating pregnant women and their male partners yields a greater net impact on maternal health behaviors compared with educating women alone.
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            Evaluating non-randomised intervention studies.

            To consider methods and related evidence for evaluating bias in non-randomised intervention studies. Systematic reviews and methodological papers were identified from a search of electronic databases; handsearches of key medical journals and contact with experts working in the field. New empirical studies were conducted using data from two large randomised clinical trials. Three systematic reviews and new empirical investigations were conducted. The reviews considered, in regard to non-randomised studies, (1) the existing evidence of bias, (2) the content of quality assessment tools, (3) the ways that study quality has been assessed and addressed. (4) The empirical investigations were conducted generating non-randomised studies from two large, multicentre randomised controlled trials (RCTs) and selectively resampling trial participants according to allocated treatment, centre and period. In the systematic reviews, eight studies compared results of randomised and non-randomised studies across multiple interventions using meta-epidemiological techniques. A total of 194 tools were identified that could be or had been used to assess non-randomised studies. Sixty tools covered at least five of six pre-specified internal validity domains. Fourteen tools covered three of four core items of particular importance for non-randomised studies. Six tools were thought suitable for use in systematic reviews. Of 511 systematic reviews that included non-randomised studies, only 169 (33%) assessed study quality. Sixty-nine reviews investigated the impact of quality on study results in a quantitative manner. The new empirical studies estimated the bias associated with non-random allocation and found that the bias could lead to consistent over- or underestimations of treatment effects, also the bias increased variation in results for both historical and concurrent controls, owing to haphazard differences in case-mix between groups. The biases were large enough to lead studies falsely to conclude significant findings of benefit or harm. Four strategies for case-mix adjustment were evaluated: none adequately adjusted for bias in historically and concurrently controlled studies. Logistic regression on average increased bias. Propensity score methods performed better, but were not satisfactory in most situations. Detailed investigation revealed that adequate adjustment can only be achieved in the unrealistic situation when selection depends on a single factor. Results of non-randomised studies sometimes, but not always, differ from results of randomised studies of the same intervention. Non-randomised studies may still give seriously misleading results when treated and control groups appear similar in key prognostic factors. Standard methods of case-mix adjustment do not guarantee removal of bias. Residual confounding may be high even when good prognostic data are available, and in some situations adjusted results may appear more biased than unadjusted results. Although many quality assessment tools exist and have been used for appraising non-randomised studies, most omit key quality domains. Healthcare policies based upon non-randomised studies or systematic reviews of non-randomised studies may need re-evaluation if the uncertainty in the true evidence base was not fully appreciated when policies were made. The inability of case-mix adjustment methods to compensate for selection bias and our inability to identify non-randomised studies that are free of selection bias indicate that non-randomised studies should only be undertaken when RCTs are infeasible or unethical. Recommendations for further research include: applying the resampling methodology in other clinical areas to ascertain whether the biases described are typical; developing or refining existing quality assessment tools for non-randomised studies; investigating how quality assessments of non-randomised studies can be incorporated into reviews and the implications of individual quality features for interpretation of a review's results; examination of the reasons for the apparent failure of case-mix adjustment methods; and further evaluation of the role of the propensity score.
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              Evaluating men's involvement as a strategy in sexual and reproductive health promotion.

              Nearly 10 years has passed since the 1994 International Conference on Population and Development recognized men as legitimate targets for sexual and reproductive health promotion. This recognition was born of the experience of many health promoting agencies in the 1980s and 1990s who realized that without working with men, change would be very difficult or impossible. It was proposed that men should be involved because their active participation was crucial to the success of programs and to the empowerment of women. However, the idea that men should play an active role in health promotion has not been without its critics, who have posed serious questions about the efficacy of involving men and the effects their involvement would have on women and children. In an effort to examine the lessons learned from men's involvement, this paper reviews published evaluations of interventions that have targeted heterosexual men. Twenty-four studies that met the criteria for inclusion (reported on interventions in areas of sexual and reproductive health that targeted heterosexual men and contained evaluation data) were found. From their review of these studies, the authors suggest that there is some evidence that the use of media approaches may be a successful strategy and that there may be some problems with the application of some cognitive behavior change approaches. However, the fact that few interventions have targeted heterosexual men and have been the subject for detailed evaluation suggests that there is a need for more interventions and better evaluations, which would examine not only the process of men's involvement, but also their impact on the lives of both the men themselves and their families. The reality is that although perhaps no longer regarded as part of the problem, men have yet to be seen as part of the solution.
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                Author and article information

                Contributors
                Role: InvestigationRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: InvestigationRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Writing – review & editing
                Role: MethodologyRole: Writing – review & editing
                Role: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                25 January 2018
                2018
                : 13
                : 1
                : e0191620
                Affiliations
                [1 ] Burnet Institute, Melbourne, Victoria, Australia
                [2 ] Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
                [3 ] Department of Uro-gynaecology, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
                [4 ] Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
                [5 ] Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
                [6 ] Department of Obstetrics and Gynaecology, International Centre for Reproductive Health (ICRH), Ghent University, Ghent, Belgium
                TNO, NETHERLANDS
                Author notes

                Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: Anayda Portela is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this article and they do not necessarily represent the decisions, policy or views of the World Health Organization. This does not alter our adherence to PLOS ONE policies on sharing data and materials. The authors have no other competing financial or non-financial interests to disclose.

                ‡ These authors are joint first authors on this work.

                Author information
                http://orcid.org/0000-0002-6412-1309
                Article
                PONE-D-17-35975
                10.1371/journal.pone.0191620
                5784936
                29370258
                062083e3-2474-4ab5-9312-81ef5f0cdaea
                © 2018 Tokhi et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 6 October 2017
                : 8 January 2018
                Page count
                Figures: 2, Tables: 1, Pages: 16
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/501100004963, Seventh Framework Programme;
                Award ID: 282507
                Funded by: funder-id http://dx.doi.org/10.13039/100004423, World Health Organization;
                The initial MASCOT/MH-SAR review and mapping was funded by the European Union’s Seventh Framework Programme (FP7/2007-2013; https://ec.europa.eu/research/fp7/index_en.cfm; grant agreement number 282507) and NWO/Wotro (Netherlands Organisation for Scientific Research, WOTRO Science for Global Development, https://www.nwo.nl/en/about-nwo/organisation/nwo-domains/wotro). MC was supported by this funding. The World Health Organization Department of Maternal, Newborn, Child and Adolescent Health ( http://www.who.int/maternal_child_adolescent/en/) provided support during the MASCOT/MR-SAR mapping for reviewers to identify articles addressing this question, and supported the second stage of the review. AP, MC, SL, LCT and MT were supported by this funding. The authors acknowledge the contribution to this work of the Victorian Operational Infrastructure Support Program received by the Burnet Institute. SL, LCT, MT and JD were supported by this funding. No individuals employed or contracted by the funders (other than the named authors) played any role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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