Men’s involvement in women’s abortion-related care: a scoping review of evidence from low- and middle-income countries

Figures & data

Table 1. Outline of search terms for EMBASE, PsychINFO, MEDLINE (Ovid), CAB Direct, CINAHL.

Abortion/pregnancy search terms	Gender/men search terms	Pathways and trajectories search terms	Involvement search terms
Abortion* Termination* (Menstru* and regulat*) Antenatal	Man Men Male Masculin* Adolescen* Boy*	Pathw* Passage* Rout* Course* Traject* Direction*	Influen* Involv* Support* Participat*

Note: The * indicates truncated search terms.

((Abortion* or termination* or (menstru* and regulat*) or antenatal) and (man or men or male or masculin* or adolescen* or boy or boys) and (pathw* or passage* or rout* or course* or traject* or direction* or influen* or involv* or support* or participat*)).

Figure 1. Flow diagram of screening process.

Table

Lead Author / Year	Country / Region	Aims / objectives	Study sample	Study site	Method
Alex-Hart^63 2015	Nigeria Sub-Saharan Africa	To evaluate the sexual behaviours of secondary school students in Port Harcourt	1,047 students (537 women, 510 men)	Six public secondary schools	Quantitative
Summary of results	Abortion-specific experiences Of the 11% of men who reported a partner ever being pregnant, 26.8% of male respondents assisted their girlfriends in obtaining an abortion. Individual context 48.2% of men were reported to have denied paternity.
Appiah-Agyekum^70 2015	Ghana Sub-Saharan Africa	To explore the factors that influence abortion decisions	142 students (53 men, 89 women)	University of Ghana students	Qualitative
Summary of results	Individual context Key determinants of decision making among students were education, religious beliefs, health reasons, financial/economic factors, and family. Less influential were partner's views, societal pressure/stigma, work /career, and peer influence.
Aziato^65 2016	Ghana Sub-Saharan Africa	Gain an understanding of reactions to unplanned adolescent pregnancies in Ghana	15 focus groups with 92 adolescents aged 10-19 who had a recent termination	Public health facilities in Accra, Kumasi, Tamale	Qualitative
Summary of results	Abortion-specific experiences In response to pregnancy, girls reported that the character in the vignette would feel sad, alarmed, uncomfortable, not happy and that she might want to terminate the pregnancy. They mentioned that pregnancy and school were not seen as compatible. Respondents suggested that parents might facilitate an abortion. This was focused on disclosure to mothers, but also discussions included fear/concern over the reaction of both parents (e.g. calling the boy to deal with it). Some suggest parents would provide contraceptives to avoid it happening again. Respondents who had partners who obtained medication worried about the safety. Individual context With regards to partner reaction, adolescents suggested it would be shock, surprise, confusion, denial of pregnancy. If the partner was a student or unemployed, they might suggest termination. Male respondents reported that they could deny the pregnancy.
Bain^71 2019	Ghana Sub-Saharan Africa	To understand the adolescent decision-making process and outcome towards pregnancy and abortion	Adolescents aged 13-19 who had at least one pregnancy (n=15), one abortion (n=15) and 23 stakeholders	Jamestown, Accra, Ghana	Qualitative
	Individual context Partners, friends, and family members were the main groups involved in adolescent abortion decision-making. Fathers influenced in a "top-down" manner, having greater decision-making power including threatening to disown the adolescent unless the pregnancy was terminated.
Challa^43 2018	Ghana Sub-Saharan Africa	To explore the social ecological context of adolescent SRH in Ghana	63 women aged 15-24	School and clinic-based sites in Accra and Kumasi	Qualitative
Summary of results	Abortion-specific experiences Many women reported keeping pregnancy or abortion a secret from parents to avoid being disowned, abused verbally or physically), or ejected from the home by family.
Chatchawet^58 2010	Thailand East Asia and the Pacific	To gain a greater understanding of the type and amount of support men can offer women obtaining abortions	23 people (12 women and 11 men) who had experienced complications of unwanted pregnancy termination	Three hospital in-patient departments	Qualitative
Summary of results	Abortion-specific experiences Men demonstrated accepting some responsibility for the pregnancy termination. Support was demonstrated by searching for information about pregnancy termination; accompanying women to appointments; staying with them during termination. Most men said desire to assist was about ensuring their partners had an efficient and safe termination. Support could also take the form of providing financial assistance needed. Men in the sample reported that they showed support by not leaving their partner during the abortion. This included: being physically close to their partners; waiting nearby, e.g. in front of the room, during the termination of the pregnancies; and, telephoning their partners. Male partners providing support was seen as lessening any emotionally negative experience of abortion by women.
Che^61 2017	China East Asia and the Pacific	To explore perceptions and decision making around contraceptive use, experiences of abortion services, and post-abortion contraceptive decision-making	40 in-depth interviews with women who had experienced abortions and select partners Seven focus groups with men and women	Facilities in urban and rural settings	Qualitative
Summary of results	Abortion-specific experiences Men reported being able to accompany their partners and were invited to join in post-abortion family planning discussions. Men considered being involved in these discussions important.
Coast^72 2016	Zambia Sub-Saharan Africa	Analysing care-seeking pathways of women who had either a safe abortion or sought care following an unsafe abortion	112 women who sought care for abortions or post-abortion care	A hospital in Lusaka, Zambia	Qualitative
Summary of results	Abortion-specific experiences In accounts of decision-making, women reflected on weighing up the risks, such as the risk of physical harm versus desperation to remove the pregnancy. Financial costs played a role in the timing and complexity of trajectories of abortion; women without independent means faced dilemmas. Individual context Different sources of advice were sought based on different age groups - e.g. adolescents went to peer groups from fear of parental disapproval. Among married women who feared their partner’s reaction, it was harder to seek informed advice.
Dahlbäck^69 2010	Zambia Sub-Saharan Africa	To explore young women's experiences of pregnancy loss	87 young women who had induced abortions (n=34) and spontaneous abortions (n=53)	A hospital in Lusaka, Zambia	Mixed methods
Summary of results	Abortion-specific experiences and Individual context Partner factors played a "decisive role" in the final decision-making process to have an abortion. Five partners abandoned their girlfriends and 11 denied paternity. They refused financial and emotional responsibility.
Freeman^42 2017	Zambia Sub-Saharan Africa	To examine men's involvement in women's abortion seeking	71 women who obtained abortions and 41 who obtained post-abortion care	A hospital in Lusaka, Zambia	Qualitative
Summary of results	Abortion-specific experiences Some women deliberately excluded men due to fear of men's interference with abortion decisions or fear of their reaction to the pregnancy. Men's active involvement - most influential when acting as shared decision makers, sounding boards, facilitators to obtaining care by paying, arranging, or accompanying a woman. Husbands and boyfriends were most frequently featured in respondents' narratives of men's participation in abortion decision making. Respondents who decided with their partner to abort the pregnancy typically reported that their partner continued to be involved when they obtained services. These men provided emotional support, facilitated abortion by seeking and providing information about where services could be obtained, and accompanied respondents to access care. Most frequently, men supplied the money for transportation and treatment. Individual context Men rejected paternity or the relationship - this was a common reason that women gave for men being absent. Where men were absent, women were more likely to be attending for post-abortion care, while where men knew of their partner’s abortion, the majority of abortions were safe. Younger women were more likely to report partner violence or rejection than older women, although age did not appear to have an impact on involvement.
Hirz^41 2017	Philippines East Asia and the Pacific	To understand men's belief and perception of their roles surrounding unintended pregnancy and induced abortion	15 men for interviews and 43 for focus group discussions	An urban area in the Philippines	Qualitative
Summary of results	Abortion-specific experiences Men stated they would feel morally and financially responsible in the event a pregnancy occurred. Men were more nuanced in the responses in in-depth interviews. They recognised that women are fearful of disclosure, that there are physical and social consequences facing women and that a man's decisions would heavily influence abortion outcomes. (Inter)national and sub-national contexts Occurrence of unintended pregnancies was attributed to God's will. Participants in FDGs endorsed belief that induced abortions were a sin. Men expressed frustration at a perceived lack of control over situations regarding pregnancy and induced abortion, and fear that they did not want to commit or be complicit in a sin.
Izugbara^49 2014	Kenya Sub-Saharan Africa	Explore the drivers of women's choices when pregnant	80 women aged 16-49	Nairobi, Kenya	Qualitative
Summary of results	Abortion-specific experiences Fear of partner responses led to women keeping their pregnancies a secret. One respondent reported her partner being violent when she disclosed her pregnancy. Men exerted "considerable" influence over the pregnancy trajectory, both to seek an abortion or continue a pregnancy. Some men paid the women to terminate the pregnancy. Individual context Women with unacceptable pregnancies reported abandonment and rejection by male partners and parents. The type of man was important for women as to whether the pregnancy was acceptable (e.g., age, wealth).
Kalyanwala^57 2010	India South Asia	To examine the abortion-related experiences of unmarried women aged 15-24 who obtained abortions	549 women aged 15-24	16 clinics in Janani	Quantitative
Summary of results	Abortion-specific experiences 92% of respondents whose partners knew of the pregnancy reported receiving support: 86% reported emotional support, 51% financial support. Other pregnant individuals reported their father's providing financial support. Women who did not receive support from their partner had higher odds of second trimester abortion than those with full partner support. Those who had first trimester abortions compared to second were more likely to receive partner support (95% vs 82%) and have a partner accompany them (78% vs 48%).
Kalyanwala^56 2012	India South Asia	To interrogate the experiences of unmarried young abortion-seekers	549 women aged 15-24, 26 for interview	16 clinics in Janani	Mixed methods
Summary of results	Abortion-specific experiences Lack of partner support was reported by only a few women and most had disclosed their pregnancy / abortion. Partners are more likely than any other to provide support. This support can be: deciding on abortion together, emotional support, accompanying to facility, arranging covering costs More women reported not disclosing to their family out of fear of reaction.
Kumi-Kyereme^50 2014	Ghana Sub-Saharan Africa	To examine the key influences in abortion decision-making in Ghana	401 women with records in abortion logbooks	Three abortion service providers	Mixed methods
Summary of results	Abortion-specific experiences Overall, 32.67% (n = 131) of the respondents did not seek approval from anyone before receiving an abortion; 54.36% (n = 218) required their partner’s approval; 8.23% (n = 33) consulted with their mother for the decision; and the remaining 4.74% (n = 19) made the abortion decision with role-players categorized as “Others”, which includes friends, siblings, aunts/uncles, employers and mothers-in-law. Men operationalised their role as ‘breadwinners’ during decision-making around pregnancies and abortions. Individual context Knowledge of the law, occupational status, number of children living and level of formal education increased odds of seeking consent of male partners over "others".
Leone^47 2016	Zambia Sub-Saharan Africa	To compare the costs of post-abortion care following unsafe abortion with the costs of safe abortion care	112 women who sought care for abortions or post-abortion care	A hospital in Lusaka, Zambia	Qualitative
Summary of results	Abortion-specific experiences 705 of women reported receiving some help, including from husbands or partners, with 50.4% of that help being financial (e.g., money for transport).
Macleod^75 2013	South Africa Sub-Saharan Africa	To study men's constructions of abortions in South Africa	37 articles on abortion and 20 men	University and East London, South Africa	Mixed methods
Summary of results	(Inter)national and sub-national contexts Men reported shock at the notion that a woman would terminate a pregnancy without their consent. The 'New Man' discourse of being supportive and attentive was used in discourses by some focus-group discussants to explain how to persuade a woman out of an abortion.
Marlow^64 2019	Ghana Sub-Saharan Africa	To understand what men, know about abortion, why they support their partners, and develop an intervention to improve safe abortion access	11 focus groups of men aged 15-54 (8-12 men in each focus group)	Upper East and Upper West provinces, Ghana	Qualitative
Summary of results	Abortion-specific experiences Men reported learning about abortion services from the hospital, friends, and the radio. Some reported arriving to the hospital having previously tried methods. Men reported seeking the services of herbalists and drugs from pharmacists to keep abortions secret from the community. Out of the 11 focus groups, 7 reported supporting women to abort to finishing schooling, 6 if the women had a young child, 5 for mothers’ life, 4 for incest, 3 to care for current family, 2 if pregnancy unplanned and 1 to avoid shame. Whilst men understood that abortions were more safely provided in hospitals, they reported seeking other providers. (Inter)national and sub-national contexts In seven focus groups, men utilised the language of “sin” and that an abortion was “killing” to draw on community norms against abortions.
Moore^51 2011	Uganda Sub-Saharan Africa	To examine men's and women's perspectives on men's involvement in abortion decision-making and seeking post-abortion care	61 women aged 18-60 and 21 men aged 20-50	Kampala and Mbarara, Uganda	Qualitative
Summary of results	Abortion-specific experience There were conditions under which some men expressed support, e.g., being involved in the decision making, helping women make doctors' appointments, providing financial support / facilitating transport. Due to secrecy, men talked about not knowing if their partners had abortion complications. Men stated that if a man finds out that the woman terminated a pregnancy without his knowledge, he cannot support her no matter what health problems she experienced. (Inter)national and sub-national contexts Men's responses largely reflect the prevailing socio-cultural norms and values. When questioned generally, male respondents’ status that men are not supportive of women having abortions. Reasons including not agreeing with the practice, belief that the child is a member of society, that the women could die, fear of being arrested, the woman is hiding an affair. Less frequent were costs of abortion and PAC.
Mwilike^68 2018	Tanzania Sub-Saharan Africa	To determine the feasibility of an education programme	15 pregnant adolescents aged 15-19	A health facility in rural Tanzania	Mixed methods
Summary of results	Individual context Rejecting and denying paternity had a significant role on women's decisions about whether to abort, particularly for unmarried, pregnant adolescents.
Nonnenmacher^46 2014	Brazil Latin America and the Caribbean	To explore the perception of women in relation to the reactions and behaviour of their partner in abortions	285 women who had miscarriages and 31 women who had abortions	Hospitals in two Brazilian cities	Quantitative
Summary of results	Abortion specific experiences Women reported that their male partners were more supportive of spontaneous than induced abortions and they would try to hide the latter from these partners.
Obiyan^76 2014	Nigeria Sub-Saharan Africa	To explore parental involvement in adolescents' sexual and reproductive health education	460 female adolescents for questionnaires, 31 female adolescents and 33 parents for focus group discussions	Yoruba communities in Osun State	Mixed methods
Summary of results	(Inter)national and sub-national contexts Male participants believed that single women were more likely to consider abortion than non-single. Men had mixed feelings about whether unintended pregnancies were their responsibility or not. Fathers argued that mothers were closer to their daughters when it came to discussing abortion intentions and that there were gaps in communication between fathers and adolescents.
Olsson^73 2010	Sri Lanka South Asia	To understand experiences of unmarried pregnancy termination seekers to influence future programme development	19 women who had abortions	A health centre, Colombo	Qualitative
Summary of results	Individual context Women had various factors that they considered in the decision to seek pregnancy termination: family pressure; partner's qualities and attitude towards pregnancy; economic aspects; own feelings, values and future fertility. Pregnancies and termination occurred in relatively long-lasting relationships - preceding planned marriage - as out of wedlock pregnancy was reported as unacceptable.
Omidey^52 2011	Nigeria Sub-Saharan Africa	To explore whether abortion options were chosen and how they were perceived	17 (10 women, 7 men) interviews, 4 focus group discussions (2 with men, 2 with women)	Local universities and surrounding areas	Qualitative
Summary of results	Abortion-specific experiences Women reported being given money by partners and told to seek an abortion, if unmarried. Partners' reactions were significant, as were parent's reactions for women who were single. Fear of repercussions led some women to decide to abort. Male partners played a significant role in determining pregnancy outcomes, including providing financial, material, and emotional support. Individual context Women reported that their concerns over their partner denying their pregnancy led them to seek abortions, including to avoid a known pregnancy not being associated to a “responsible” man.
Palomino^53 2011	Peru Latin America and the Caribbean	To explore participants' individual experiences with reproduction and reproductive decision-making	Interviews with 12 women aged 21-35, 7 men aged 18-37, 2 focus groups with men and 2 with women (33 participants overall)	Metropolitan Lima	Qualitative
Summary of results	Abortion-specific experiences Partners were not always the main sources of finances and resources, and an adolescent boy reported that his financial dependence reduced his role in pregnancy decision-making, which was also reported by adolescent women in the study. Individual context Pregnancy-related decisions were not made by the woman alone. Their partner was generally involved, as well as family members. Men and women differed on who had control, with evidence suggesting it ranged between equal decision-making to male controlled decisions. Some respondents reported being coerced to have an abortion by partners or family members, while multiple men argued that they made the decisions on pregnancy outcomes, including abortions. Other men had more equitable views, including that the pregnant woman should decide. For women, age had an impact on their decision-making, with respondents linking being younger or less informed with allowing partners to take control.
Petitet^62 2015	Cambodia East Asia and the Pacific	To examine the implementation and the effects of the distribution of Medabon on women's reproductive choices and practices	10 women, 6 men, 8 health care providers, 4 pill sellers	One site in Takmao and 7 in Phnom Penh	Qualitative
Summary of results	Abortion-specific experiences Men knew about different abortion services and learnt about them through newspapers and radios. Four men had accompanied their partners for medical abortion and expressed a desire to help their partners were possible. Three accompanied their partners for PAC.
Rehnström Loi^67 2018	Kenya Sub-Saharan Africa	To explore decision-making preceding induced abortion	9 women aged 19-32	Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH) or Kisumu East District Hospital (KDH) in Kisumu, Kenya	Qualitative
Summary of results	Abortion-specific experiences Disclosure of pregnancies to partners was often done to seek financial support. Almost all women expressed that they had a disagreement with their partner and that their fear of possible consequences (including anger, violence, or divorce) was a factor in the decision to seek care without telling a partner. Women reporting feeling forced or misled into abortions, with one respondent reporting that her partner involved an abortion provider to help him terminate the pregnancy without her consent. Individual context Women reported that their partners’ unwillingness to financially support a child was a key reason for seeking abortions. In addition, unstable relationships with partners were cited. The context of the relationship of the woman and the man responsible for the pregnancy also influenced disclosure - women who were single were more likely not to tell their partner of the pregnancy or abortion.
Rominski^44 2017	Ghana Sub-Saharan Africa	To understand the perspective of women who decide to terminate	18 women seeking care for complications from abortions and 11 for abortion-care (aged 13-35)	Three hospitals in Ghana	Qualitative
Summary of results	Abortion-specific experiences Women reported that they self-managed their abortion over fear of disclosure. Women learnt abortion methods through social networks. They expressed taking drugs provided by friends or boyfriends, despite not necessarily knowing what they were.
Schwandt^45 2013	Ghana Sub-Saharan Africa	To understand the decision-making process associated with induced abortion in Ghana	58 interviews (19 with men, 20 with women, 11 with family planning nurses, 8 obstetricians / gynaecologists) and 9 focus groups (4 with women, 2 with men, 1 with family planning nurses, 2 with obstetricians / gynaecologists)	two teaching hospitals, Ghana	Qualitative
Summary of results	Abortion-specific experiences Women discussed fears disclosing and some did not disclose prior to abortion over fear of reaction. Individual context Men were the first decision makers post pregnancy discovery. Their acceptance or rejection was critical - acceptance was of paternity. Men's ability to deny responsibility was a major fear of respondents. This has an indirect impact on the abortion trajectory of a woman
Shekhar^40 2010	Kyrgyzstan Europe and Central Asia	To estimate the abortion rates by different background characteristics	3848 women aged 15-49 (Demographic and Health Survey)	National	Quantitative
Summary of results	Individual context Women's attitude towards becoming pregnant and their husband's attitude towards abortion were significantly associated with the likelihood of an induced abortion.
Sowmini^55 2013	India South Asia	To identify the reasons that cause delay for adolescents and young women seeking safe abortion services	34 unmarried young women seeking abortion	Tertiary hospital abortion clinic, Trivandrum	Qualitative
	Abortion-specific experiences Most adolescents were accompanied by their mothers to obtain an abortion, with few involving their sexual partners and only two reported that their partner accompanied them or provided financial support.
Srivastava^66 2019	India South Asia		20 medical abortion users and 20 partners	Three districts, Uttar Pradesh, India	Qualitative
Summary of results	Abortion-specific experiences Men were frequently the ones bringing MA kits for their female partners. Male respondents indicated that the chemist was often a male friend of theirs. Lack of knowledge meant the chemist was often trusted to provide the right information and dosage, as well as potential side effects. Such information could be lost in transit when male partners obtained the abortion method on behalf of their partner, leading to a lack of knowledge of side effects amongst women.
Steven^74 2019	Democratic Republic of the Congo Sub-Saharan Africa	To explore leaders' perceptions of their role in addressing unintended pregnancies in the community	12 male community leaders	Six rural health zones, North and South Kivu	Qualitative
Summary of results	(Inter)national and sub-national contexts Community leaders were all male. Their attitudes towards abortion were very negative, including perceiving abortion as unchristian, immoral, or in violation of community norms. Women who had abortions were seen as criminals, and community leaders reported involving the police in instances of abortions or isolating / forcing a woman out of the community. In spite of this, community leaders indicated that women who had an abusive, alcoholic, or unemployed partner, or who faced financial difficulties, could seek an abortion. Community leaders considered themselves responsible for the provision of PAC.
Tatum^48 2012	Mexico Latin America and the Caribbean	To examine the factors influencing how young women make reproductive decisions	12 interviews and 4 focus groups with women aged 13 to 17	Mexico City	Qualitative
Summary of results	Abortion-specific experiences Partners could offer emotional support, though often support was in accordance with the partner's wishes and not necessarily the respondent’s. Of the six interview respondents who had an abortion, four reported that their partner was willing to assume responsibility of fatherhood, including involving the adolescent’s father for approval. Two respondents described being forced to have an abortion by their fathers without their consent. Individual context Absence of a viable co-parent influenced some women to abort. In all cases where partner was not involved, women decided to abort. For the two focus group discussion participants who did not have an abortion, their partners assumed responsibility and were working.
Tong^59 2014	Malaysia East Asia and the Pacific	To explore the experiences of women and their needs regarding abortion	31 women aged 21-43 who had obtained abortions	An urban family planning clinic in Penang	Qualitative
Summary of results	Abortion-specific experiences Some respondents indicated that an abortion decision should be between a woman and her partner. Others reported that they felt forced to abort as their partner claimed not to be ready for marriage or to financially support the child, thus making the pregnancy unacceptable. Partners could play a supportive role, including seeking information, paying for services and accompanying women.
Ushie^54 2019	Kenya Sub-Saharan Africa	To understand community perception of abortion is critical in informing the design and delivery of interventions to increase access to safe abortion	36 women and 12 men for interview, 9 health care workers. 9 focus groups with women and 9 with men	Kisumu and Nairobi counties	Qualitative
Summary of results	Abortion-specific experiences The study reported that the majority of girls relied on boyfriends, as well as friends, relatives, and mothers, to raise money for their care. This includes one (male) respondent referencing that this could result in unwanted disclosure of a pregnancy. (Inter)national and sub-national contexts In communities where men, and their families, conduct informal “background checks” on women, knowledge of abortions is considered undesirable and means a woman is perceived as a bad potential wife. Men report thinking that these women might continue to have abortions, which limits their ability to achieve social success through parenting. However, men and women also reported that abortions were increasingly normalised in their communities.
Zuo^60 2015	China East Asia and the Pacific	To examine why unmarried women delay obtaining an abortion and identify correlates of the delayed decision	1,271 unmarried women aged 15-24 who had sought abortions	Shangai, Chengdu, and Taiyun	Quantitative
Summary of results	Abortion-specific experiences 73-85% of male partners had positive reactions to pregnancy disclosures and provided comfort / solutions. 12-28% of women reported that partners were pleased about the pregnancy, either due to it cementing their relationship or to confirming fertility. 6-12% of partners responded with fear.