This study reviewed projects that employed strategies to engage men in EBF promotion and support in several geographic settings and calculated EBF prevalence changes in project areas. No clear pattern emerged, in terms of increased EBF prevalence where certain strategies were employed or in the choice of strategies in different geographic areas. In addition, not every project area had an increase in EBF prevalence.
We do not know how effective the reported male engagement strategies were in engaging men because this type of analysis was not conducted as part of the project evaluations. Several independent project evaluators commented on male engagement, or lack of male engagement, in their final evaluation reports, with most indicating approval of male engagement to promote or support EBF. Only one comment considered having male volunteers speak with mothers about breastfeeding techniques as potentially inappropriate (American Red Cross, Cambodia). The final evaluator for Care’s project in Sierra Leone noted that the concerted effort during project planning to include household decision-makers (men and older women) in the project approaches contributed to the adoption of positive health behaviors among women, which was revealed by women in project focus group discussions.
With increased emphasis on male involvement in the reproductive health care and decisions in global health, it is important to understand where engaging men as a social and behavior change approach, broadly speaking, may support EBF practice and if it could hinder it. This study provided a mainly descriptive review of strategies, and we conclude that, unlike peer support, professional support in the antenatal and postpartum periods, and other evidence-based strategies [8], engaging men in EBF promotion and support has had mixed results and appears to be highly dependent on context. Thus, it cannot be assumed to be appropriate or effective everywhere. There is evidence of its success in some contexts, both high- (e.g., [15]) and low-income (e.g., [21]), but local gender factors related to decision-making, power, autonomy, and what is considered “women’s space” should be understood before “engaging men” is adopted as a general approach. In addition, most projects that reported a male engagement strategy also reported engaging women (mothers and grandmothers) alongside men (Table 2), making it difficult to disentangle the approaches. We do not know if strategies to engage men alone would have had a different impact on EBF prevalence in these areas.
One cannot consider male engagement in women’s health issues without considering the gender norms that govern relationships in households and communities. Less than one-quarter of these projects reported using formative research to inform their strategies (Table 2). Formative research would enable the opportunity to investigate gender norms in order to create an appropriate intervention that is gender-sensitive and could, in some circumstances, be gender transformative [25]. This type of formative research could also inform a project-wide gender and social and behavior change strategy. Whereas decisions about health care often involve money for travel and services, and money is often under the jurisdiction of male authority, decisions about infant care are often left to mothers themselves. Some societies have deeply embedded cultural beliefs about the gendered division of family responsibilities, with men focusing on financial matters and women focusing on household matters, even when those women work in the formal sector or outside of the home, as documented by Nkwake [26] in Uganda. Taking care of the family, deference to men, and inequality with men at home and in public are gender norms that form a “model of domestic virtue,” which has persisted over the past century [27]. Likewise, in Benin, there is evidence of persistent gender disparities regarding access to and control of resources, and men often make decisions related to health care [28]. Where women’s movements are restricted or require male permission, as documented in Liberia, Sierra Leone, Nepal, Bangladesh, and Afghanistan [29,30,31,32,33], they may not be able to access or provide peer breastfeeding support, which has been shown to reduce suboptimal breastfeeding practices [8].
The impact of gender norms on women’s infant feeding practices is not well understood. Meanwhile, there is some evidence that high rates of child stunting (low height for age) can co-exist with relatively high values for positive indicators of child health, such as immunization coverage [34]. Stunting reflects both mothers’ and children’s health status; where women have little autonomy, are deprived of their rights to education and health, and are forced into early marriage, their health is negatively affected [35,36,37], and thus, the health of their children is negatively affected.
There is evidence of male, specifically fathers’ , influence on infant feeding practices [10, 38]. We found some evidence of this in project reports; at least one evaluator cited male decision-making authority in household matters. A study about engaging men to reduce malnutrition in Mozambique found that men were primary influencers for exclusive breastfeeding [39]. The influence of other household actors was not examined in this study but has been shown to influence infant feeding, particularly mothers-in-law (infants’ grandmothers) [40, 41]. The influence of other household actors could confound the association between fathers and EBF. The role and influence of different household actors should be considered when planning EBF promotion and support activities as they may present barriers, or even enabling factors, to achieving the goals of the activities.
Conceptual theory about male engagement in EBF promotion and support is not well developed, and we do not know if the reported male engagement strategies effectively engaged men. We did not attempt an advanced quantitative assessment of the association of male engagement strategies with EBF prevalence changes but merely report those associations as part of our descriptive approach to documenting efforts to engage men in EBF promotion and support in LMIC. National or local campaigns to increase EBF may have contributed to prevalence changes in project areas, although we did not find evidence of such efforts in the project final evaluation reports. Nonetheless, we were careful not to ascribe EBF prevalence increase to these projects’ efforts. All project final evaluation reports were program evaluations and not impact evaluations; therefore, the true extent of the impact of the strategies to engage men is unknown beyond the conclusions drawn in the reports. We did not specifically examine or describe how male engagement strategies could have a detrimental effect on EBF practice nor where male involvement in infant feeding decisions reinforces gender inequality, but these questions merit further research.
If considering implementation on a national scale, it would be important to evaluate the effectiveness of male engagement strategies and conduct multiple tests in different areas to determine if strategies are scalable. More comparative studies and impact evaluations are needed within countries to determine which strategies are most effective at promoting and supporting EBF with different populations. Contextual information about societal dynamics can indicate where and with whom interventions are most efficiently targeted [40]. Specifically, more studies about the effect of male engagement on breastfeeding practices are needed, including formative research about male involvement in decisions regarding infant feeding and women’s desire for male involvement in breastfeeding promotion and support.
