We employed a systematic review methodology to systematically search four electronic databases: Medline/PubMed, PsycINFO, CINAHL, and Web of Science. We incorporated peer-reviewed articles published from January 2000 to August 2024 for papers that met the inclusion criteria. We selected the study period to capture over two decades of evolving global focus on male involvement in maternal and reproductive health care. We used a combination of controlled vocabulary and Boolean-paired keywords relating to male participation, maternal reproductive health care, maternal mortality, and interventions. Additionally, we reviewed the bibliographies of selected studies for other relevant citations.

The search strategy was developed based on the PICO framework: Population (studies investigating maternal reproductive health interventions); Exposure (male involvement); Comparator (maternal reproductive health interventions without male involvement); Outcomes (maternal reproductive health outcomes e.g., miscarriage, spontaneous preterm birth, low birth weight, preterm premature rupture of membranes, pregnancy-induced hypertensive disorders and intrauterine growth restriction) (23). We included research studies that met the following criteria: 1) the paper discussed male involvement in maternal reproductive health outcomes in Africa; 2) the paper involved men with the goal of addressing maternal reproductive health outcomes or maternal mortality rates; 3) an intervention was evaluated; 4) paper was published in English. Exclusion criteria included: non-male involvement in maternal reproductive health, maternal mortality, or interventions in Africa; 2) conference abstracts, dissertations, editorials, and papers written in languages other than English. There was no limit to the publication date. We incorporated observational studies: cohort (retrospective and prospective), case-control, and cross-sectional studies.

Two reviewers independently reviewed the titles and abstracts of non-duplicative studies to assess their eligibility for a full-text review. Thus, study titles or abstracts that did not meet the PICO criteria were excluded. Subsequently, they reviewed the full-text studies to determine if they met the eligibility criteria. The reviewers discussed disagreements regarding the articles screened and referred them to a third reviewer for dispute resolution.

To assess the internal validity of the studies included in this review, we employed the Cochrane Collaboration's Risk of Bias assessment tool, which evaluates six key domains: selection bias, performance bias, detection bias, attrition bias, reporting bias, and other potential sources of bias (24, 25). Two reviewers (O.A. and U.N.) independently assessed each included study using the standardized criteria provided by the Cochrane Handbook. Each domain was rated as having a low, high, or unclear risk of bias. Discrepancies between reviewers were resolved through discussion to ensure consistency in judgment and to reach consensus. The risk of bias assessment was used solely to evaluate the methodological rigor and internal validity of the included studies; no study was excluded from the review based on its risk of bias score. A summary of the methodological assessment across the six studies is presented in Table 1.

Data were extracted from eligible studies into an electronic spreadsheet following the eligibility assessment of all full-text articles. The following data were extracted from selected studies meeting eligibility criteria: study characteristics (author, sample, study design, comparison/control components, intervention components, assessment, outcome variable, and outcomes). We used a narrative synthesis to describe the studies meeting the eligibility criteria. We define narrative synthesis here as an approach to synthesizing findings from multiple sources using words and texts from the sources to summarize and explain the sources (26). Prior research suggests that using narrative synthesis in cases of statistical meta-analysis or another specialist form of synthesis (such as meta-ethnography for qualitative studies) is not feasible, particularly due to substantial methodological and clinical heterogeneity between studies identified (26). Furthermore, we extracted the reach, effectiveness, adoption, implementation, and maintenance indicators using the RE-AIM framework as a guide.

For this study, Reach is defined as the extent to which the male involvement intervention engaged its target population, including participant characteristics and recruitment strategies. Effectiveness is the impact the intervention had on maternal reproductive health outcomes. Adoption is the extent to which participants, communities, or organizations (e.g., health centers) adopt the male involvement intervention. Implementation assesses the consistency and fidelity with which the intervention was delivered, while Maintenance evaluates whether outcomes were sustained over time at individual and organizational levels.

The electronic database searches retrieved 480 records (187 from PubMed, 47 from CINAHL, nine from PsycInfo, and 237 from Web of Science). After eliminating the duplicates in EndNote (n = 32), 448 studies remained for title and abstract screening. During this initial screening phase, 424 studies were excluded as they did not meet the inclusion criteria based on their titles and abstracts. They mainly were general HIV studies examining HIV status testing, general knowledge and attitudes, and treatment adherence. Twenty-four records were selected at the abstract level to undergo full-text review to assess their eligibility for inclusion in the review. During this phase, 18 studies were excluded as they did not meet the predefined eligibility criteria upon full-text evaluation. Ultimately, six studies/interventions were deemed eligible and included in the systematic review on male involvement in maternal reproductive health outcomes. During the full-text review, qualitative studies that solely focused on individual experiences, perceptions, or attitudes of males/partners/spouses related to maternal reproductive health were removed, and cross-sectional studies were excluded if they could not capture the dynamic and longitudinal aspects of male involvement. Figure 1 provides a flowchart of the study selection process.

The final sample consisted of six studies published between 2015 and 2024, all of which evaluated interventions designed to improve male involvement in maternal and reproductive health outcomes. The sample size for these studies ranged from 462 (27) to 1,144 (28). Two of the studies were located in South Africa (29, 30), one in Malawi (27), one in Burkina Faso (28), one in Rwanda (31), and one in Tanzania (32). Table 2 provides details on the description of the studies included in the review.

These studies demonstrate a diverse array of interventions, reflecting a comprehensive effort to address the complex dynamics of how male engagement was incorporated within maternal health interventions. Only one of the studies explicitly included a theoretically informed intervention to improve male involvement in maternal reproductive health outcomes (31). Doyle and colleagues employed sociological theories of gender and masculinity that highlight how gender inequalities are reproduced–or transformed–through “everyday interactions in [the] home (31). The intervention used a structured 15-session curriculum adapted from Program P, an open-source manual for engaging men in maternal and child health, created by Promundo, CulturaSalud, and REDMAS, which includes a curriculum for fathers/couples, community resources for designing health provider training, and community campaigns. Daniele and colleagues utilized different charts for counseling sessions adapted from existing counseling tools produced by the World Health Organization and the Ministry of Health of Senegal (28). Nyondo et al. (27) utilized invitation cards guided by the results of their study's formative phase, which used the PRECEDE-PROCEDE model, a planning model that reinforces a participatory approach, to identify strategies of male involvement (27).

Five of the six studies used randomized controlled trials (RCTs) to evaluate the impact of male partner involvement on maternal and child health outcomes (27–31). Three used individual-level RCTs (27, 28, 31) while two applied cluster RCTs (29, 30). The remaining study employed a controlled quasi-experimental intervention trial at the facility level without random assignment (32).

In Daniele et al (28), the intervention encompassed three distinct components to enhance male partner involvement in the maternal care period. The first component involved interactive group discussion sessions exclusive to male partners (28). These discussions were facilitated by health workers and revolved around narratives of fictional couples facing challenges due to a lack of communication and health information. These sessions, conducted in French and local languages, stimulated dialogue and understanding among three to 13 participants. The second component comprised individual couple counseling sessions during pregnancy, which took place in private consultation rooms with one or two health workers. These sessions covered various topics related to pregnancy, childbirth, and postpartum care. Discussions included the significance of antenatal and postnatal care, birth preparedness, danger signs for mothers and newborns, exclusive breastfeeding, family planning, and contraception. Interactive tools, including a flip chart with illustrations and relevant texts, facilitated effective communication between health workers and couples. The third component was postnatal couple counseling sessions occurring approximately 6 h after childbirth if the delivery occurred at a primary healthcare center. These sessions offered an opportunity for couples to further discuss relevant information pertaining to the postpartum period. Importantly, discussions also centered on contraception, enabling couples to make informed decisions regarding family planning. The same flip chart from the initial counseling session was utilized for continuity.

In a multi-site randomized controlled trial conducted in Rwanda by Doyle and colleagues (31), the Bandebereho couples’ intervention was assessed for its impact on male engagement in reproductive and maternal health. Over 21 months, 1199 men from local communities participated, undergoing structured questionnaires and follow-up surveys at 9 and 21 months. The intervention implemented by Rwanda Men's Resource Center (RWAMREC) aimed to transform masculinity norms through 15 sessions for men and their partners, focusing on topics like gender dynamics, fatherhood, communication, caregiving, and male engagement in health. The study's rigorous design, data collection method, and extensive follow-up contributed to a comprehensive understanding of the intervention's potential to reshape gender dynamics and promote positive models of fatherhood for improved maternal and child health outcomes. Jones et al. (29) sought to evaluate the impact of male involvement on enhancing the prevention of mother-to-child transmission outcomes (29). The research employed a two-phase, two-condition experimental or control cluster randomized controlled trial period. Only women were engaged during phase one, whereas phase two included female and male partners. Baseline assessments occurred between 6 and 30 weeks of pregnancy, followed by participation in antenatal group intervention sessions led by lay healthcare workers. Postpartum, two individual sessions were conducted. Antenatal reassessments were conducted at 32 weeks of pregnancy, and post-natal evaluation took place at six weeks, six months, and 12 months.

The randomized controlled trial by Nyondo and colleagues (27) conducted in Blantyre, Malawi, aimed to assess the feasibility and effectiveness of using invitation cards to enhance male partner involvement (MI) and prevention of mother-to-child transmission (PMTCT) of HIV services among pregnant women attending antenatal care period the study included two groups: Group A utilized invitation cards for MI in PMTCT. At the same time, Group B employed word-of-mouth invites. Pregnant women up to 30 weeks of gestation were enrolled from South Lunzu and Mpemba health centers, with the primary outcome being the proportion of women attending PMTCT services with their partners. The invitation card, developed based on formative research and literature, was seen as a more plausible strategy for MI by study participants.

Peltzer et al. (30), conducted a longitudinal clinic cluster randomized control trial investigating the impact of male involvement on PMTCT uptake and depressive symptoms among perinatal rural women living with HIV in South Africa. The intervention implementation employed a 2-phase, two-condition design. In this intervention, pregnant women living with HIV with male partners were enrolled in phase one, while women only were enrolled in phase two, including both partners. The Protect Your Family (PYF) intervention was led by lay health care workers and comprised tender Pacific antenatal group sessions, individual or couple sessions, and postpartum sessions. Audio Computer-Assisted Self-Interview Software (ACASI) assessments were conducted, and a control group received time-matched video presentations. Spanning recruitment from April 10th, 2014, to January 30th, 2017, the study aimed to understand the influence of male involvement on PMTCT and maternal wellbeing, contributing to insights into the potential benefits of engaging male partners in PMTCT services within the rural South African context.

In a multi-site implementation study on partner involvement in Mbeya Region, Tanzania, a controlled intervention trial was conducted at Ruanda Health Centre to assess the effectiveness of invitation letters for male partner engagement (32). The study involved pregnant women attending their first antenatal care (ANC) visit between April and May 2013, with criteria including confirmed pregnancy and accessible partners. Participants were assigned to intervention or control groups using a quasi-randomized approach. Interviews conducted in Swahili covered socio-demographics, and HIV status knowledge was self-reported. The intervention group received a written invitation letter for partners, while the control group was instructed to verbally invite their partners to the next ANC session. A joint ANC session was offered if partners attended, and couple voluntary counseling and testing sessions were provided (CVCT). Follow-up interventions explored partner attendance and reasons for non-attendance. The study aimed to assess the impact of invitation letters on male partner involvement in ANC sessions and CVCT uptake, contributing insights into strategies for enhancing male engagement in maternal health services.

Male involvement was measured differently across the studies. In the study conducted by Daniele et al. (28), male engagements were based on the attendance and participation of male partners in the three educational sessions provided as part of the intervention. “Good relationship adjustment” 8 months postpartum was also measured using the Dyadic Adjustment Scale (33) and the Locke-Wallace Marital Adjustment Test (34), which determined a woman's satisfaction with her partner and the degree of communication, shared decision-making, and agreement between the couple on issues related to reproductive health. Doyle et al. (31) measured men's involvement by participating in and assessing the impact of the Bandebereho couples’ intervention. Jones et al. (29) and Peltzer et al. (30) adapted a Male Involvement Index (35), assessing male participation during pregnancy. Nyondo and colleagues (27) assessed male involvement by measuring the proportion of pregnant women accompanied by their partners at weeks 2 and 6 of the study after receiving an invitation card. Theuring et al. (32) measured partner involvement by partner return rate and CVCT rate.

The findings of all interventions were relatively similar across all studies. Daniele et al. (30) reported that the intervention led to a follow-up rate exceeding 96%, with 74% of couples attending at least two study sessions. Moreover, attendance at postnatal care consultations was notably higher in the intervention group than in the control group (CI: 6.0–17.5) and involving men as supportive partners correlated with improved adherence to recommended postpartum practices. Doyle et al. (31) reported substantial improvements attributed to the Bandebereho intervention, which showed greater male accompaniment at antenatal care (IRR 1.50, p < 0.001), and heightened participation of men in childcare and household tasks. In Jones et al. (29) study, Mail involvement was associated with self-reported maternal or infant antiretroviral therapy (ART) adherence, highlighting its relevance during pregnancy in the antenatal clinic setting.

Additionally, findings supported using male involvement and depression treatment as supplementary strategies to enhance maternal and infant medication uptake as part of the PMTCT protocol. Nyondo et al. (27) revealed that the invitation card group exhibited a 50% higher likelihood of being accompanied by male partners to antenatal care clinics compared to the standard of care (SoC) group (RR: 1.49; 95% CI: 1.06–2.09; p = 0.02). Peltzer et al. (30) found that interventions combining multi-session PMTCT and male partner participation reduced depressive symptoms among perinatal HIV-positive women. Theuring et al.'s (32) study involving invitation letters resulted in 30.9% of male partners returning for antenatal care, indicating the efficacy of these simple measures in increasing male partner attendance.

The individual interventions encompassed 9–14 (with a median of 14) out of the 27 RE-AIM indicators. None of the examined interventions encompassed all 27 indicators across the five dimensions of the RE-AIM framework. The proportions of reporting varied across dimensions, with the highest average reporting rates observed for reach (83.4%), followed by efficacy/effectiveness (70%), adoption (40.5%), implementation (38.9%), and the lowest reporting rates were for maintenance (13.3%). Table 3 summarizes the overall percentage of studies reporting on each dimension of the RE-AIM framework, while Table 4 presents specific implementation outcomes from each of the selected studies as conceptualized within the RE-AIM framework.

The methodological quality of the six selected studies was assessed using a standardized evaluation tool covering key aspects of study design, implementation, and analysis. All six studies were described as randomized or controlled trials, with five explicitly using randomized designs (27–31), and one applying a quasi-randomized approach (32). Randomization procedures were adequately described in five studies, and allocation concealment was implemented in four (27–29, 31). None of the studies blinded participants or providers to group assessments due to the nature of the interventions, and only one study (28) indicated probable blinding of outcome assessors, though not with certainty. The lack of blinding across most studies introduces potential performance and detection bias. These limitations reduce confidence in subjective outcomes which we therefore interpret results for self-reported outcomes more cautiously.

Most studies demonstrated strong adherence to intervention protocols, utilized valid and reliable outcome measures, and implemented intention-to-treat analysis. Sample size calculations with at least 80% power were reported in five of the six studies (27–31), while all studies identified outcomes prior to analysis. Four studies (27, 28, 31, 32) reported overall and differential dropout rates within acceptable limits, while Jones (29) and Pelzer (30) experienced higher attrition, particularly in Phase 1. Despite some limitations, the overall methodological rigor of the included studies was moderate to high, with most studies addressing core elements of trial validity and reliability. A summary of findings can be found in Table 4.