Introduction
Male participation is an important strategy in achieving the Millennium Development Goals, especially the third goal of ‘maternal health improvement’. In many communities, men are the decision makers and the financial source in families. Male participation in reproductive health responsibilities was particularly emphasized at the International Conference on Population and Development (ICPD) in 1994 (UNFPA, 1994). Male participation in safe motherhood programmes means facilitating access to PNC services, and involvement in safe birth plans and perinatal care (WHO, 2002). Men can participate by making appropriate decisions for birth limitation and spacing, helping women in contraceptive use and being a responsible father (Drennan & Robey, Reference Drennan and Robey1998).
Maternal health needs fathers' participation. Fathers are able to learn about participation through education (Lowdermilk & Perry, Reference Lowdermilk and Perry2004). This education may also help men to adapt to fatherhood, which is sometimes difficult for men, as they are often ignored by health services, families and friends (McKinney et al., Reference McKinney, Ashwill, Murray, James, Gorrie and Droske2008).
Several studies have demonstrated the positive effects of father's education on maternal health. Father's education prepares expectant fathers for helping in childbirth and improves the outcomes of pregnancy (Shefners-Roger & Sood, Reference Shefner-Rogers and Sood2004). It enhances men's knowledge, attitude and practice about maternal health care as well as improving couples' communication (Turan et al., Reference Turan, Nalbant, Bulut and Sahip2001; Turan & Say, Reference Turan and Say2003). Father's education is a contributor to the success of maternal care and improves families' health (Bhalerao et al., Reference Bhalerao, Galwankar, Kowli, Kumar and Chaturvedi1984; Carter & Speizer, Reference Carter and Speizer2005). Fathers' participation in breast-feeding classes increases the rate and continuation of breast-feeding (Wolfberg et al., Reference Wolfberg, Michels, Shields, O'Campo, Bronner and Bienstock2004). Father's education reduces mothers' stress, facilitates their adaptation to motherhood and improves the quality of couples' relationships (Diemer, 1997).
Expectant fathers need education during the perinatal period. However, a needs assessment is necessary before planning such education (Finnbogadottir et al., Reference Finnbogadottir, Crang Svalenius and Persson2003). There is no special formula for male participation in perinatal health programmes, but the most appropriate programmes are culturally acceptable. This study explores the perinatal educational needs of urban Iranian Muslim men. Pregnant women in Iran receive routine perinatal care (PNC) in the primary health care system, but there are no services for expectant fathers. This study aims to assess the perinatal educational needs of fathers in an urban Iranian community, including the appropriate content, place, time, educator and educational media. It is hoped that this will form the basis for future interventional programmes.
Methods
This paper forms the qualitative part of a sequential qualitative–quantitative study (triangulation research) to assess the perinatal educational needs of fathers for participation in PNC. Subjects for the study were selected objectively from four selected hospitals of Shahid Beheshti Medical Science University (SBMU). The women were clients of perinatal services including prenatal, postpartum and intensive maternal care units. The men were husbands who attended the hospitals to visit or help with the discharge of their wives. The focus group discussion (FGD) method was used to assess participants' perspectives. Eight groups, including four groups of men and four groups of women (in total 46 persons, including 24 women and 22 men), participated in the FGDs. The tool for data collection was a semi-structured questionnaire with seven guide questions. The questions were: 1. What is your opinion about the concept of male participation in PNC? 2. Do fathers believe that their participation in maternal care is necessary? 3. How do husbands help their wives during the perinatal period? 4. What are the barriers to male participation? 5. Do fathers need perinatal education? If yes what is your opinion about appropriate place, time, educator and media? 6. Do expectant fathers need any care during the perinatal period? 7. What are your suggestions to promote male participation?
The questionnaire (guide questions) was developed following a document review and counselling with ten experts of reproductive health. The questionnaire was piloted in two groups beforehand.
The aims and procedure of the study were explained to the participants, and they gave consent before the FGDs. Then, they were invited for discussion in a definite time and place in the hospitals. The FGDs were performed by a facilitator and a note-taker. All the procedures of discussions were recorded by MP3 player and notes were taken. The duration of the FGDs was 60–90 minutes.
The transcripts of discussions were analysed using the content analysis method. Content analysis is a process for identifying, coding and categorizing patterns in data. The analysis of the material started with the first FGD. Data collection ran parallel throughout the study. The analysis began by going back to the purpose of the investigation and guide questions. Each interview was re-read several times to gain a feeling of completeness. Meaning units consistent with the study's objectives were highlighted. The sections were coded and grouped into main and sub-categories that reflected the main message of the interviews. The themes were discussed between the first and second author until consensus was reached. Theoretical saturation was reached after eight FGDs. The approval of the university ethical committee was obtained for the study.
Results
There were seven main points of focus based on the objectives and guide questions of the study:
Focus 1: concept and ways of participation
Most participants in the FGDS mentioned the emotional support of women as the main concept of male participation in the perinatal period. Most women talked about helping with household responsibilities, and many men mentioned providing the requirements of life as the most common way of participating. However, they thought that the ultimate result of any form of participation was emotional support of women. One woman said, ‘They can do many things to help, but ultimately they improve the emotional health of women.’
A man said, ‘Participation can be in any form; for instance, men can help women with household work,’ and another man said, ‘Depression increases during pregnancy and women have concerns and expectations that we should understand.’ The majority of men also mentioned providing family's income as a concept of participation. One man thought, ‘The best kindness is that I can buy something for her during pregnancy.’
Most women and half of men believed that husbands' presence in the delivery room could be a form of male participation in PNC. One man said, ‘It would be very good if we were expected to be present there.’ Some participants mentioned mother and infant care as a sort of participation. Another said, ‘Men can care for both mother and infant after birth.’
Focus 2: the importance of male participation in PNC
The majority of participants in FGDs believed that male participation in PNC is important. However, they mentioned some cultural and social factors as barriers. One woman said, ‘My husband will do anything for his baby; he likes to provide anything that the baby needs and he has many wishes for the child.’
Most men believed that their participation was important but they claimed that the majority of men do not participate. One man said, ‘Men did not participate so much in the past, but they participate nowadays because family members are far from each other now, and only couples can help each other.’ Another man said, ‘It relates to men's culture. The culture needs time to be changed.’
Focus 3: the practice of men
The majority of women said that their spouses help when they are at home. One woman stated, ‘Men with easy jobs are less tired – they can help, but sometimes they are workers and so they are too tired to help.’
Most men stated that they attempt to help at home and with baby care. One man said, ‘I have seven brothers – only one helps. It is an old belief that men do not like to help’. Some men stated that they do not know how to help. A man said, ‘When the baby does not let her to sleep, I get up and sit, but there is not anything that I could do.’
Some participants claimed that husbands of employed women help more than others. One man stated, ‘Some women are house workers; some are teachers, like my own wife. If I feel that she is tired, for example she can't cook, I'll do it.’
A few women mentioned some kinds of men's malpractice. One woman said, ‘My friend should not have sex after her childbirth at least for 40 days; her husband pushed her for sex.’ Another woman stated, ‘My husband does not help me, and smokes and abuses drugs at home.’
Focus 4: barriers to men's participation
Family and friends were mentioned as barriers as well as motivators for male participation. Most women and men thought that male participation was an acceptable issue nowadays. However, there are still some social and cultural barriers in some social classes. One woman said, ‘My husband thinks that delivery starts suddenly and everything will be finished overnight.’ Another woman stated, ‘I think it relates to the husband's family. If his father helps, he will help; if not, he will never help.’ Another woman said, ‘My husband's friends tell him that you have just a problem that you are servile to your wife.’ One woman said, ‘They do not like to help. They think this is women's work.’
However, a minority of participants thought that family and friends were motivators. One woman explained, ‘My friend is living with her mother-in-law; the mother-in-law tells her son that it is not your wife's job to do all the work at home; it is your job too.’
The majority of women and men mentioned long working hours and economic problems as the main barriers to male participation in PNC. One man said, ‘There are problems such as our long work hours’. A woman said, ‘The barrier may be the tiredness of men after their day's work.’
Health services were also mentioned as a barrier by a few women and men. One woman said, ‘The presence of men in some PNC services is prohibited. You should permit them to attend and listen to the doctors' comments,’ and a man said, ‘Perinatal services are provided in a female environment and we cannot attend.’
Focus 5: educational needs for participation
The importance of education and an appropriate educator, as well as appropriate content, time, place and duration of education, were also asked.
All women and the majority of men emphasized the importance of education. A woman said, ‘Men want to help, but they don't know how to help. It is hard for them to.’ The content was suggested to be about ‘the importance of participation’, ‘emotional support of wife’ and ‘signs and symptoms of risks in prenatal and neonatal care’. One man said, ‘My wife was pregnant. She was exhausted. I thought she was pretending because she wanted to rest.’ A woman said, ‘Some husbands ask their wives for sex. But some women feel sick about sex in pregnancy. Their husbands should understand that pregnant women do not feel as usual.’
The minority of men thought that some things should only be taught to women. One man said, ‘Personal health must be taught to women. But the signs of risks during pregnancy should be taught to both men and women.’
The majority of men stated that they cannot attend classes because of their long working hours. A man said, ‘Most men have no time for participation in the classes.’ However, one man thought, ‘If a man wants to know, he will devote some time for it.’ Another man stated, ‘I bought many books and read them with my wife. She also explains to me everything that she learns.’
Some participants believed that the education should be started at high school. But, some thought that this could be too soon. Some participants suggested it should be started at pre-marital classes. Others said that it would be appropriate to start the education at the perinatal time. One woman said, ‘It is late for our husbands – the education should be planned for school,’ but another said, ‘Counselling should be before marriage. School age is too soon and they cannot understand such things.’
The majority of men stated that the classes should start at high school. One man said, ‘Sooner is better. Anytime it starts, it is not late’. Another man stated, ‘The appropriate time for initiation is the time that couples get the positive pregnancy test.’
Participants suggested education in groups of men or individual or couple counselling. Many participants preferred self-learning materials. One woman suggested, ‘If you educate us, we will transmit information to our husbands. You can give us the booklets; we will read them and explain for our husbands.’
The evenings and weekends were the preferred times for the classes for the majority of participants, and the duration of education should be appropriate for the fathers' needs. Participants suggested that 1–15 hours of education would be appropriate.
The majority of participants preferred self-learning materials. One man said, ‘There are books such as 9 months pregnancy. My wife read a few books that I am reading too.’ Some participants suggested television or radio, saying that everybody needs some sort of media.
The majority of participants preferred health centres, and some preferred hospitals, as where the education should take place. The majority said that accessibility was important. One man said, ‘The place is not important; it should just be close to us.’
Focus 6: necessary care for expectant fathers
The majority of women and half of men thought that care is necessary for expectant fathers. A woman stated, ‘They need emotional help too; they get lonely after the baby's birth; some of them think that baby will fill their place in their wife's heart.’ Half of men believed that men do not need care. One man said, ‘A man prepares himself for the responsibilities when he gets married.’
Focus 7: strategies to promote participation
The majority of participants thought that cultural interventions were necessary, especially through the mass media. A few women also thought that parents also need the education. Their suggestions were ‘promotion through mass media’, ‘making TV series’ and ‘giving the educational books or CDs to clients’. One man also suggested, ‘It would be good if we had booklets or CDs for the first time.’
Discussion
To the authors' knowledge, this was the first study of the educational needs of fathers for participation in perinatal care. There are a few studies about male participation in perinatal care in Iran (Ozgoli et al., Reference Ozgoli, Rahmanian and Nahidi2002; Movahed, Reference Movahed and Tourajianfar2007; Tavoussi & Heidarnia, 2008), while male participation in reproductive health has been emphasized highly for achievement of the Millennium Development Goals (UNFPA, 2009; WHO, 2009). Men's behaviour in families is affected by societies' norms. These norms are from the hidden dimensions of society. Here, focus group discussions have been used for the first time to assess these dimensions in Iran.
The findings show that most participants thought that male participation (in any form) is a sort of maternal emotional support. Women in pregnancy undergo physiologic and emotional changes. The emotional changes are mostly related to maternal adaptation to motherhood roles and responsibilities. Fathers also experience similar emotional changes as they adapt to their new fatherhood responsibilities. Therefore, the perinatal period is a period of time when couples should prepare themselves for their parenting roles. It is also an opportunity for health care providers to help couples with the adaptation. Besides, research demonstrates a high prevalence of depression among pregnant women, and has suggested men's education to help wives face emotional problems. Emotional problems have also been demonstrated in expectant fathers, and care has also been suggested for men (Ghafari et al., Reference Ghafari, Pourghazneyn and Mazloom1995).
Nearly all participants in this study believed that male participation was important in PNC. As a matter of fact, male participation results in less experiences of anxiety, pain and tiredness by women perinatally (WHO, 2007). Male participation decreases the risk of low birth weight, due to fathers' control of maternal nutrition, and decreases maternal mortality because of their information about how to access timely obstetric emergency care (WHO, 2007). This study and another report (Modares-Nejad et al., Reference Modares-Nejad and Ameri2004) have demonstrated a demand for husbands' birth attendance services. Fathers' attendance at birth could decrease the duration of labour and the use of epidural anaesthesia (WHO, 2007).
The majority of respondents thought that education is necessary to prepare men to play their roles as fathers. Most believed that the education should be started at school. In the health system of Washington, US, education and counselling services about responsible fathering are available for 24- to 25-year-old men (Sonenstein, Reference Sonenstein2000). The perinatal period is also an opportunity to prepare parents for parenthood responsibilities. Parenthood classes are held in many countries, including Scandinavian countries. More than 95% of fathers participate in these classes (WHO, 2007).
The ignorance of fathers of the care system was also mentioned as a barrier. Experts recommend perinatal classes with appropriate content and teaching methods for more effective learning (McKinney et al., Reference McKinney, Ashwill, Murray, James, Gorrie and Droske2008). Clients' needs should be considered in selecting the most appropriate content, educator, media, place and time (Simbar, Reference Simbar2005). The most popular suggested content was the emotional support of pregnant women, and the complications of pregnancy and neonatal care.
Couples' and individual's face-to-face counselling or education in groups of men were suggested. These are recommended by experts as well (Lowdermilk & Perry, Reference Lowdermilk and Perry2004; McKinney et al., Reference McKinney, Ashwill, Murray, James, Gorrie and Droske2008).
The long working hours of men was mentioned as a barrier to men participating in the classes. Self-learning materials were suggested by the majority of participants, which could be an alternative to overcome their concerns about time limitation. So, the main points can be taught in the classes and further details can be taught by self-learning materials. Besides, accessibility of the classes and appropriateness of the time of classes should be considered in education planning. The preferred educators were physicians or midwives. However, educators' gender and specialty should undoubtedly be appropriate to the content.
Pre-marital classes were suggested to be an opportunity for initiation of the education. In fact, education about male participation in reproductive health should be started from adolescence, but education about their participation in PNC can be started from pre-marital or in pre-pregnancy classes.
The findings show that men with employed wives have more participation than others. It is demonstrated that women's employment leads to male participation in family affairs and improves the quality of family life as well as couples' satisfaction with it (Eghdami & Hoseinchri, Reference Eghdami and Hoseinchri2008).
Male participation is encouraged in Islam as the prophet Mohammad said, ‘One hour help to wife is equal to complete reading of Quran,’ (Women and Family Center of Presidential, Office 2008).
The majority of subjects in the study thought that male participation is going to be the norm in Iranian society. This trend was attributed to the gradual transformation of the expanded family form to a nuclear family form.
Programmes to promote male participation in reproductive health including PNC should consider a place for them in the health care system and provide male-friendly services (WHO, 2002). The success of interventional programmes is dependent on friendly, available, accessible and affordable services as well as skilled health personnel. The programmes should be integrated into PHC services and need advocacy policies for their promotion (Info Project, 2008). They should be advocated by the mass media, NGOs and public education (Barker et al., Reference Barker, Ricardo and Nascimento2007). They should clarify the role of parents in the family. Parents should understand that they share the responsibilities of raising and caring for children (UNFPA, 2007).
Conclusion
Male participation in perinatal care is essential for improving maternal health. It can be promoted by education. Individuals' or couples' face-to-face education using self-learning materials are necessary. Male participation needs to be advocated through the mass media. Education about responsible fathering should be initiated from adolescence and education about male participation in PNC should be considered in pre-marital, pre-pregnancy and especially in perinatal classes.
