Theme 1a. Being present

Low quality evidence from 2 studies reported on this theme. The evidence shows that male partners appreciated being involved at antenatal screening appointments as it made them feel present and responsible in the pregnancy. However, despite being present at appointments, male partners were aware that this experience did not necessarily guarantee them a role throughout the whole pregnancy and this was a perceived barrier. This awareness was reinforced if they experienced ambivalence from healthcare professionals, which most male partners reported. Sometimes, this experience caused male partners to supress their feelings and emotions, and keep their opinions to themselves, leading them to feeling like an observer.

Theme 1b. Choice and decision making

Low quality evidence from four studies reported on this theme. Male partners wanted to be involved in decision making, wanted to voice their opinions, and be given a choice about decisions that needed to be made during the pregnancy. This was not determined by whether the pregnancy was complicated or not. However, male partners were aware that their role was undefined, which restricted their ability to make choices in the screening process. Male partners also recognised that ultimately the woman would make the final decision, since it was her body and the tests would be happening to her.

However, feelings of being ignored by healthcare practitioners strengthened feelings of being excluded and powerlessness in decision-making. When male partners did feel comfortable sharing their opinions, they were concerned that they may be portrayed as ‘controlling’ and may be negatively noted by the healthcare professional. In some cases, male partners struggled to form an emotional connection with their unborn child, which negatively influenced involvement and decision making. This was a perceived as a barrier.

In most scenarios, male partners reported receiving little or no encouragement from healthcare professionals. However, in one case, a father reported a positive experience with a healthcare professional, highlighting the importance of positive relationships to empower partners to be involved in decision making, and as a facilitator for being involved in antenatal care. From a woman’s perspective, they mostly found their male partners’ decisiveness supportive.

Theme 1c. Taking the lead

High quality evidence from 1 study reported on this theme. The research shows that the way male partners viewed control of the situation in the pregnancy depended on whether the pregnancy was uncomplicated or complicated.

Male partners with uncomplicated pregnancies wanted the experts to take the lead, where in 1 study, male partners reported trusting the midwives so were content to remain bystanders. Otherwise, in an uncomplicated pregnancy, male partners rarely asked questions because they felt that healthcare professionals failed to address or include them in discussions.

This behaviour caused male partners to feel excluded and was a perceived barrier. In complicated pregnancies, male partners wanted more information and also wanted to actively participate in decision-making. However, male partners still felt excluded by healthcare professionals, which was a universal observation, regardless of the whether the pregnancy was uncomplicated or complicated.

Theme 1d. Range of emotions

Low quality evidence from 4 studies reported on this theme. The research shows that male partners experience many different emotions during pregnancy that arise from different situations and stimuli. In complicated pregnancies, male partners felt pressure to set aside any grief and anxiety to support their partners, since they felt they needed to support their partner and remove focus from their own feelings. In these situations, male partners can become the main channel of communication with healthcare professionals, acting as a shield for their partner, which could be perceived as a facilitator to partner involvement in antenatal care.

One study highlighted the difference between engaged and disengaged fathers. In situations where the male partner is disengaged from the pregnancy, they report feeling more anxious and unprepared for the arrival of their child than engaged male partners. Although attending antenatal care classes are considered helpful preparation for pregnancy and parenthood, the evidence showed that they can also make male partners feel uncomfortable and out of place. In male-only antenatal classes, some male partners felt anxiety about how they were expected to behave. In some situations, male partners felt annoyed with healthcare professionals perpetuating gender stereotypes and assuming all male partners were going to be ‘drinking beer and watching football’, which was a perceived barrier. In the context of antenatal genetic screening, male partners felt ambivalence, doubt, and uncertainty in relation to their perceived worth and their role in helping maintain or improve the health of their partners and babies.

Theme 1e. Responsibility

High quality evidence from 2 studies reported on this theme. The research shows that a sense of responsibility improved or facilitated involvement in antenatal care. The majority of male partners took responsibility by gathering information, being involved in decision making, and actively engaging with midwives. This made male partners feel more engaged and involved with the unborn baby and their health.

Additionally, when male partners attended screening appointments, it positively affected the way women perceived responsibility since the testing was no longer solely directed at them. From a different perspective, one study found that in situations where screening showed unfavourable results, male partners felt their role as a parent was pushed aside, therefore diminishing responsibility. This due to both the attitudes of the healthcare professionals but also men and women’s own perception of what male partners should be doing.

Theme 2a. Learning over time

High quality evidence from 2 studies reported on this theme. The research showed that time affected male partner involvement in antenatal care but could be interpreted differently, either as a facilitator or a barrier, depending on the context. Male partners reported that learning how to be more involved in antenatal screening was a skill that had to be learnt over time, especially learning how to communicate appropriately and effectively with healthcare professionals. Some participants discussed becoming a father was occurring at the ‘right time’ for them in their lives, which was considered an important factor in feeling involved during pregnancy.

Theme 2b. Involvement affected by time

Very low quality evidence from 1 study reported on this theme. This research showed that attending antenatal care classes was the first step towards improving male partners’ engagement in antenatal care. Male partners reported being unable to leave work to attend antenatal appointments/classes and consequently experienced dissatisfaction. As such, time and other work-related issues were considered barriers to attendance and therefore engagement.

Theme 3a. Directed support for partners

High quality evidence from 2 studies reported on this theme. To encourage involvement in antenatal care men-only antenatal groups have been considered. The research shows that male partners have conflicting opinions regarding the benefit of gender specific sessions, where some viewed them as a facilitator and others viewed them as a barrier. However, for most, these sessions were a way of sharing information and an opportunity to meet other expectant parents.

Some male partners thought that men-only classes would provide them a safe environment in which they could talk about their thoughts and feelings without fear of offending, or the risk of appearing incompetent in front of their partner and other women.

When the group size was small this helped encourage open discussion and when there were enough sessions, partners also got to know one another. In 1 study, male partners appreciated the class being facilitated by another male, since insights about fatherhood and emotions from a male perspective could be discussed.

Although some male partners considered these groups a good idea, others expressed the view that fatherhood is very personal and felt it could be uncomfortable to share such intimate feelings in front of other men.

Furthermore, the atmosphere of the classes could sometimes be competitive between parents, making open conversation difficult. In one study, male partners were offered classes in a pub.

Although some felt comfortable in this setting, others – in particular, those who believed in gender equality in parenting – expressed the view that this setting allowed class facilitators to invoke outdated stereotypes of men, which annoyed them.

Theme 4a. Impact of staff behaviour

Moderate quality evidence from 7 studies reported on this theme. The research shows that the way healthcare professionals interact with the mother and their partner can positively or negatively affect partner involvement in antenatal care.

In one study, male partners were not offered a chair in the screening appointment and were literally made ‘bystanders’, which they associated with loss of parent status, loss of control, and losing the ability to support his wife. Male partners felt that healthcare professionals pushed them out of screening experiences, making it only about the woman. At times, male partners felt that midwives’ views reflected a traditionally gendered approach to antenatal care.

From a woman’s perspective, professional support was viewed as a positive way to facilitate partner involvement. Women considered it was vital that support was available at a time when the partner could participate, highlighting the importance of attendance to improve partner involvement. Male partners wanted greater involvement during pregnancy, to be treated as a couple by healthcare professionals, and to be given opportunities that would allow them to support the woman.

Furthermore, male partners wished to establish rapport and trust with healthcare professionals, in order to discuss information and make decisions more fully. Research showed that male partners valued continuity of care, since it allowed the formation of stronger relationships and promoted involvement. One study reported that respectful and healthy relationships with healthcare professionals led to positive and improved involvement. In some cases, male partners described that feelings of exclusion could be a result of their own choice, as well as by other people. They felt as though they were supposed to support and help women during the birth, but not be involved in the birth or the first months of the child’s life. Male partners described how their only role was to offer practical support causing them to exclude themselves, leading to feelings of resentment. In this scenario, male partners wanted healthcare professional to actively involve them more so that they could feel as equally involved as the woman.

Theme 4b. Availability of information

Moderate quality evidence from 6 studies reported on this theme. There was a lot of variation in how partners and women perceived the importance of information, and how they accessed it.

Women found that ultrasound scans provided information for male partners and thought this was a good way of facilitating and increasing male partners’ involvement in antenatal care. Male partners regarded receiving appropriate information as an important part of their experience during the antenatal period, whilst a lack of knowledge led to feeling disengaged. For men, finding information allowed them to interact with the healthcare professional with a sense of control over the situation and empowerment.

First-time male partners, who lacked previous experience, were unsure about what type of support they needed so they had no specific questions. In this case, male partners felt that healthcare professionals should be proactive in signposting them to the best available resources. In one study, fathers found healthcare professionals warm and welcoming, but found that receiving information and support from them was not spontaneous. Male partners had to show an interest themselves and ask questions to get involved during clinical visits, which was a perceived barrier.

Male partners often turned to the internet for information but found that information was scarce for expectant male partners. Although information was available quickly online, there was also concern on the reliability of the content. The evidence showed that male partners had individual preferences for how the information should be presented and therefore different methods of communication should be used.

One study showed that male partners preferred written information to be succinct and simple, with footnotes for further information resources. One study showed that male partners preferred to have another person, an ‘expert’ for example, provide them with information rather than having to seek it out themselves.

Theme 5a. Partner rights

Low quality evidence from 2 studies reported on this theme. Research for this theme demonstrated that partner rights required further consideration as pressures from employers prevent male partners from attending antenatal care appointments. Employers are obligated to accept medical certificates for women attending antenatal care, but most male partners have difficulty accessing medical certificates for leave to attend an antenatal clinic appointment.

However, when male partners were able to access antenatal care and had a positive experience with healthcare professionals, engagement levels significantly improved.

Research shows that both men and women perceive work as a barrier to male partners’ involvement in antenatal care appointments.

Furthermore, the ability to take time off work is strongly determined by socioeconomic factors and workplace norms, which can discourage male partners from taking time off work or requesting flexible working hours. This suggests a policy change is required to make it easier for partners to obtain the appropriate paperwork to allow them to take time off work so that they can be involved in antenatal appointments

Involving the partner in antenatal care

Evidence from the themes ‘being present’ and ‘responsibility’ showed that although male partners want to be involved, they understand that it is for the woman to make the final decision since it is her body. Evidence from the theme ‘impact of staff behaviour’ showed that partners’ experience of interacting with healthcare professionals varies widely. Evidence from the theme ‘taking the lead’ suggested that male partners felt healthcare professionals failed to address or include them in discussions, which they perceived as a barrier. The committee discussed why this might be and suggested that this may be due to the fact that the role of the midwife in relation to involving the partner is often not defined and that there may be different preferences on the appropriate level of involvement.

Some evidence from the theme ‘range of emotions’ suggested that some male partners felt uncomfortable and out of place in antenatal appointments. Evidence from the theme ‘directed support for partners’ suggested that some male partners perceived male-only classes as a facilitator to involvement, whilst some male partners felt anxiety about how they were expected to behave. From their knowledge and experience, the committee were aware that often male-only groups work better when the male partners are already connected in some other way, for example, through their workplace. Four studies from the theme ‘choice and decision making’ showed that male partners want to be involved in shared decision-making with their partner throughout pregnancy. Findings from the same theme found that women find their partner’s involvement in decision making supportive. Therefore, the committee agreed, using their knowledge and experience, that teamwork between woman and partner during pregnancy, labour and parenthood was important and therefore agreed that healthcare professionals should have discussions during antenatal appointments how the woman and her partner could support each other throughout pregnancy and in preparation for parenthood.

The committee discussed that it is important to be aware of the different situations that women are in and the different support structures they have when they are expecting a baby. The people supporting the woman might be the father of the baby, a partner, a friend, or a member of the family and it is important that the woman’s wishes define who is involved in supporting her during the antenatal period. The committee agreed that antenatal care services could be improved by engaging actively with those whom women have chosen for support. Therefore, the committee recommended explaining to the woman that she is welcome to bring anyone she feels supported by to the antenatal care appointments and classes.

Arranging antenatal classes at convenient times for partners to attend

Evidence from the themes ‘learning over time’, ‘involvement affected by time’, and ‘partner rights’ highlighted that attendance at antenatal appointments and classes is the first step to supporting partner involvement. The evidence showed that male partners can find it difficult to take time off work due to pressures from employers or colleagues, or secure flexible working hours to attend classes or appointments. The committee agreed that appointments and classes are often offered during regular working hours on weekdays, which may prevent partners from attending. Arranging all appointments to be outside the regular working hours would be a huge reconfiguration of services and without robust cost-effectiveness evaluation is not warranted. However, the committee agreed that antenatal services should consider being flexible in the timing of antenatal classes to facilitate attendance of the partner. In addition, the committee were aware of the increase in use of virtual platforms in antenatal appointments which could facilitate partner involvement. For example, the woman might attend in person but the partner might join virtually if not in person. However, the committee recognised that evidence on virtual/remote antenatal care was not reviewed for this guideline, and when evidence on this will emerge in the future, it will be important to consider the benefits, harms and experiences related to them when planning services. Furthermore, the committee also agreed that it is important to carefully assess any potential inequalities issues that could be associated with virtual appointments. For example blanket policies on virtual appointments or remote attendance may disadvantage some people, for example people with sensory impairments or language barriers, some minority groups, or in relation to individuals’ access to devices or internet connection.

Providing a welcoming environment for antenatal appointments

Evidence from the theme ‘availability of information’ showed that women and their partners valued timely and accessible information and considered it a good way to support partner involvement. Three studies from the same theme showed that partners feel there is not enough information specifically aimed at them. In 1 study from the same theme, male partners reported there is little or no information available online for them. The committee were aware of online resources about the role of partners and how a woman and her partner can support each other. The committee agreed that health services should provide information to partners how they can be involved in supporting the woman during and after pregnancy. Furthermore, the committee agreed that resources of general pregnancy information should be provided to women as well as their partners.

In 1 study, from the theme ‘choice and decision making’ a male partner felt hesitant to share his opinions for fear of being perceived as ‘controlling’, a fear that was exacerbated by external stimuli in the antenatal setting. For example, a male partner felt that posters about domestic abuse influenced the consultation style, where he felt it was assumed that he conformed to a stereotype. The committee agreed that domestic abuse is a prevalent public health issue and that the woman’s safety is paramount. The committee agreed that it is important to have those messages in antenatal clinics in order to raise awareness about domestic abuse and possibly lower the threshold for women or male partners to discuss it in antenatal appointments. However, the committee agreed that it is also important to have positive messages and imagery about caring partners in these spaces in order to avoid stereotypes and facilitate involvement of partners who are men.

Evidence from the theme ‘impact of staff behaviour’ highlighted the effects of the physical environment of antenatal services on partners. In 1 study from the same theme, a woman reported her husband being unable to see the ultrasound scan as there was nowhere from him to sit to see the monitor. Therefore, the committee agreed it is important to adapt the physical environment to suit the woman and her partner’s needs, for example by providing enough chairs in consultation rooms so women and partners can sit together.