Fathers' experiences, views and perspectives of childbirth attendance: A qualitative evidence synthesis protocol

Background The involvement of husbands and male partners in childbirth no longer ceases at conception and pregnancy, rather fathers wish to be more involved in supporting their partners during childbirth. This aligns with the World Health Organization's (WHO) call for promoting male participation in childbirth, emphasising the benefits of support and the positive impact attending childbirth has for husbands/partners, and their maternal partner. This knowledge has led to global initiatives promoting "humanised" birth and a family-approach. To gain in-depth insight and understanding of childbirth attendance from the perspectives of fathers, a qualitative evidence synthesis is proposed. Methods To explore fathers' experiences, views, and perspectives of childbirth attendance. All studies that used qualitative methodologies to explore the phenomenon of interest will be included. MEDLINE, CINAHL, PsycINFO, MIDIRS, Web of Science, and Google Scholar will be systematically searched from their dates of inception to present, supplemented by a search for grey literature and a search of the reference list of included studies. Peer Review of Electronic Search Strategies (PRESS) will be used to ensure the comprehensiveness of the search strategy. Methodological quality assessment of included studies, using The Critical Appraisal Skills Programme assessment tool, and will be extracted from the included studies by two reviewers independently using a standard data extraction form. Thomas and Harden’s three-stage approach will be used to thematically synthesise the data: coding of data, developing descriptive themes, and generation of analytical themes. The Grading of Recommendations Assessment, Development, and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual confidence in the synthesised findings Comprehensive insight and understanding of fathers’ perspectives of childbirth attendance will be ascertained PROSPERO Registration No CRD42023470902

independently using a standard data extraction form.Thomas and Harden's three-stage approach will be used to thematically synthesise the data: coding of data, developing descriptive themes, and generation of analytical themes.The Grading of Recommendations Assessment, Development, and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual confidence in the synthesised findings Comprehensive insight and understanding of fathers' perspectives of childbirth attendance will be ascertained

Introduction
Historically, childbirth was considered a domain exclusive to women.Societal expectations and legal restrictions were some of the main reasons that largely excluded men from the childbirth process until the mid-20th century (Leathers & Esterberg, 2004).Up until the 1970s it was not the norm for fathers to attend childbirth.When fathers were gradually facilitated to attend birth, there was initial resistance from both the public and healthcare institutions that prevented men's attendance in the birthing room (Davis-Floyd, 2009;Leap & Murphy, 1994).Chapman (1991) speculated that concerns over increased infection rates and potential legal implications such as malpractice or negligence contributed to the reluctance to allow men in the labour room.Additionally, it was argued that fathers might struggle to cope with the physiological aspects of childbirth, potentially leading them to panic, resulting in increased workload for healthcare professionals (Chapman, 1991;Draper, 1997).
In 1985, the World Health Organisation (WHO), reported that only 13 countries facilitated fathers to be present during birth.In the same year, WHO advocated for unrestricted access to a chosen person or family member to support and ensure the well-being of the mother (WHO, 1985).Subsequently, in 2015, the WHO established guidelines to encourage men's involvement in the birthing process (WHO, 2015).Furthermore, evolving societal and professional attitudes towards fatherhood and family-centered care have prompted research efforts and increased awareness among healthcare professionals (Lamb et al., 2004).This shift recognises birth as a shared experience extending beyond the traditional mother-baby dyad, fostering a more inclusive and supportive birthing environment.A growing body of research highlights the benefits of support during labour and birth such as increased emotional attachment, reduced post-birth trauma, and improved outcomes for both mother and baby (Hodnett et al., 2014;Moore & Anderson, 2017).Fathers who were present at birth reported feeling more confident and prepared for their role as fathers and experienced a stronger emotional bond with their newborn (Johnson et al., 2012).Furthermore, women reported experiencing reduced anxiety and pain, and felt more satisfied with the birth when their husbands were involved or supported them during birth (Grøtela et al., 2018).Alternatively, studies suggest that women who did not receive or lacked support from their partner's during childbirth had increased maternal stress and a higher risk of postpartum depression (Beck, 2009;Schmied et al., 2018).
Although no country-wide national policies that restrict men from attending childbirth appear to exist, some cultures or religious sects may have traditions that discourage men from being present during childbirth or beliefs may influence childbirth practices, limiting the fathers' involvement (Mohammad-Ali et al., 2022).Similar trends are observed in some Middle Eastern regions such as Bahrain and Saudi Arabia (Mathews & Macintyre, 2018).As part of a wider body of research, that aims to explore fathers' views and perspectives of childbirth attendance in the Kingdom of Bahrain, we undertook this qualitative evidence synthesis (QES) to first gain insight and understanding of fathers' perspectives in the global context.Although two other qualitative reviews of fathers' experiences of childbirth were identified, these reviews focused on factors that influenced fathers' experiences (McNab et al., 2022;Mprah et al., 2023).The current QES, contrastingly, will focus explicitly on the notion of childbirth attendance, thus bringing together the perspectives of fathers who have and may never have attended childbirth.The findings of this QES, while informing aspects of the wider study (e.g., semistructured interview guide), will also have broader international practice and policy implications as it will identify potential areas for improvement in clinical practice and provide valuable insight to inform and support institutional guidelines.

Aim
To provide a protocol for a QES that will synthesise the available qualitative evidence on fathers' experiences, views, and perspectives of childbirth attendance.
To ensure transparency and methodological rigor, the proposed QES has been registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023470902, h t t p s : / / w w w. c r d .y o r k .a c .u k / p r o s p e r o / d i s p l a y _ r e c o r d .php?RecordID=470902).The protocol report adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines (Supplementary file 1: https://osf.io/9wscm/).

Inclusion criteria
The inclusion criteria were defined using the SPIDER acronym (Cooke et al., 2012).Studies will be considered for inclusion if they report on: Sample: Cis-gender male fathers above 18 years of age.
The QES will include all fathers regardless of their previous experience of attending childbirth.The sample population is limited to Cis-gender males to enable the application of the findings into the context of the wider study within Bahrain.Bahrain, being a culturally Islamic country, by law only recognises parenthood within a heterosexual marriage.

Phenomenon of Interest:
All studies reporting on fathers' experiences, views or perspectives of father attendance during labour and birth will be included.
Design: All published and unpublished studies using qualitative methodologies such as focus groups, interviews or narrative research, irrespective of date conducted, or country of origin will be included.
Evaluation of outcomes: Themes derived from the qualitative or narrative data that are representative of fathers' views, perspectives, and experiences of childbirth attendance.
Research type: Primary qualitative studies (e.g., grounded theory, phenomenology, qualitative descriptive studies) that use recognised methods of qualitative data collection (e.g., interviews) and qualitative data synthesis methods.Survey designs with free-text response options will also be considered for inclusion if the available qualitative data provides sufficient depth and has been analysed formally using a structured approach (e.g.thematic analysis, content analysis, etc.).In case of mixed method studies, the qualitative component of the study where the participants' experiences are reported separately, will be included.Opinion pieces and commentaries from fathers on childbirth will be considered for inclusion if there is qualitative data of sufficient depth to contribute to data synthesis.

Search strategy
Guided by SPIDER, search strings were developed for retrieving relevant literature.Within string search terms are combined using the OR Boolean operand, and each complete string combined then using the AND operand (Table 1).
A systematic search of the databases MEDLINE, CINAHL, PsycINFO, MIDIRS, Web of Science, and Google Scholar will be conducted from the database date of inception to the date the search is implemented.The search strings will be adapted for controlled vocabulary across the databases (Supplementary file 2: https://osf.io/9wscm/).Grey literature sources will include Open Grey, ProQuest Dissertations & Theses Abstract & Index, and Trinity's Access to Research Archive (TARA).The reference lists of included studies will be screened to identify potentially relevant additional studies that may not have been captured by the search of all other sources.To enhance methodological rigor, the search strategy was independently assessed by a topic expert not involved in the review using the Peer Review of Electronic Search Strategies (PRESS) checklist (Supplementary file 3: https://osf.io/9wscm/).
While the initial search will be conducted with no restrictions on language, only studies published in English will be included in the QES.The purpose of including non-English publications in the search is to identify the extent of potentially relevant studies that are not in English and whether this may lead to language bias and thus a potential limitation of the QES.

Study selection
All the citations retrieved from the search will be uploaded to Covidence which is a proprietary software, an open access similar to this software could be used-Rayyan, a web-based software specifically designed to streamline the screening process for reviews.Duplicates will be identified and removed automatically by Covidence.Using AMSTAR 2 guidance stands for "A Measurement Tool to Assess Systematic Reviews" version 2. It's a widely used tool designed to critically evaluate the methodological quality of systematic reviews especially in healthcare (Shea et al., 2007), two reviewers will initially pilot screen 10% of retrieved records on title and abstract independently to ensure a consistent application of the inclusion criteria.If agreement on include or exclude is more than 80% one reviewer will proceed to further complete the screening by title and abstract.Full-text articles of relevant studies will be independently screened by two reviewers.Any disagreement or conflicts will be resolved through discussion and consensus, involving a third reviewer if necessary.The PRISMA flowchart will be used to report the screening and inclusion process (Moher et al., 2009).

Quality appraisal of included studies
The methodological quality of studies included will be appraised by using the Critical Appraisal Skills Programme (CASP) quality assessment tool specifically designed for qualitative research.This assessment tool consists of 10 questions based on three key aspects (i) clarity and validity of research papers (ii) the methodology used, and (iii) the relevance and presentation of the findings.Two reviewers will independently appraise the included studies to assess their overall quality.

Data extraction and synthesis
Data will be extracted from the included studies through a purposively designed data extraction form (Appendix 4.) developed for the QES based on the aim of the review.The form will be initially piloted by two reviewers independently on the first three included studies to ensure its suitability; if required amendments will be made to the format and documented in the QES.To ensure the robustness of the process, one reviewer will extract the data, and a second reviewer will independently verify the extracted data.Data extracted will include study aim, study design, source and type of publication (journal paper, unpublished thesis, conference proceeding, abstract, etc.), location and year of study, description of participants, sampling and study settings, method (s) of data collection and analysis, and findings related to the views, experiences and perspectives of fathers on childbirth attendance.
Findings from the included studies will be synthesised using Thomas and Harden's (2008) three-stage thematic synthesis approach.The extracted 'findings' data from included studies will be coded (line by line coding).These codes will then be grouped into descriptive themes, and, from these themes, analytical themes will be developed.
Assessing the confidence of the QES findings A systematic assessment of the confidence of the QES findings will be conducted using the Grading of Recommendations Assessment, Development, and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) framework.The framework focuses primarily on four components: (i) Methodological limitations, (ii) Coherence (iii) Adequacy of data, and (iv) Relevance of the findings (Booth et al., 2018).To ensure consistency and transparency, a pre-defined set of criteria aligned with the GRADE-CERQual framework will be established prior to commencing the review.Two reviewers will independently evaluate each study and assign confidence ratings.The confidence ratings are categorized into four levels: very low, low, moderate, and high confidence, based on the four primary components.Any discrepancies will be discussed and resolved by consensus.

Discussion
Undertaking this comprehensive QES will provide insight and in-depth understanding of fathers' perspectives on childbirth attendance and will inform clinical practice and guidelines for a family-centered approach in maternity care.The findings of the QES will be disseminated through peer-reviewed journals in the field of maternal health, presentations at relevant conference and through posts on social media platforms.
The abstract provides an overview of the protocol and justifies the needs for the study.A comprehensive introduction presenting the historically nature of men's presence at birth is presented.A gap in the literature is clearly articulate.I would suggest rewording qualitative evidence synthesis to just qualitative synthesis.The inclusion and exclusion criteria is appropriate, however a limit to the date of published papers that will be reviewed needs to be placed and justified to assist in containing the search Is the rationale for, and objectives of, the study clearly described?Yes

Is the study design appropriate for the research question? Yes
Are sufficient details of the methods provided to allow replication by others?Yes

Are the datasets clearly presented in a useable and accessible format? Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Women's health, midwifery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.The methods for searching, study selection, quality appraisal, synthesis and assessment of confidence in review findings are well described, enable replication and align with published guidance on conduct of QES.
I suggest the following minor changes: Abstract: Include 'grey literature sources' to be searched.
Search strategy: Consider translating and including non-English publications identified in the search strategy.
Study selection: Suggest consistency across the protocols (Prospero and HRB Open Research) and consider two reviewers independently undertake title and abstract screening.
Quality appraisal of included studies: Suggest authors specify how disagreements between reviewers will be resolved in relation to the quality appraisal of included studies.
Data extraction and synthesis: Please indicate whether findings from the included studies will be extracted from the findings/results section of the included studies or from both the findings/results section and discussion section.
Consider including an author reflexivity statement in the protocol.
Consider completing the most recent version of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram (Page et al., 2021).
Is the rationale for, and objectives of, the study clearly described?Yes

Is the study design appropriate for the research question? Yes
Are sufficient details of the methods provided to allow replication by others?
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Reviewer Report 13
July 2024 https://doi.org/10.21956/hrbopenres.15216.r40882© 2024 Noonan M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Maria Noonan Department of Nursing and Midwifery, University of Limerick, Limerick, County Limerick, Ireland Thank you for asking me to review this comprehensive, clearly rationalised and well-written QES protocol: Fathers' experiences, views and perspectives of childbirth attendance: A qualitative evidence synthesis protocol.I look forward to reading the final article.