Should we strive to involve men in a meaningful way during pregnancy?

Rethinking men’s involvement in antenatal care

Heather Draper and Jonathan Ives

Background

• Men’s involvement in antenatal care part of broader social and political narrative on the ‘modern’ father.– Ideal of physical and emotional presence;

economic and social responsibility ; strong bond with child not mediated by mother.

• ?tension between men’s aspirations as fathers and their practices.– Implicit hegemonic masculinity: fathers as

breadwinners

• Modern fatherhood includes the antenatal period:– antenatal consultations with GPs and midwives,

antenatal classes, scans and hospital appointments

• The norm for fathers to attend birth (NHS: 96%)

Child Health Strategy 2009

“One of the most important ways of improving young children’s outcomes and users’ experiences is through the better engagement of fathers. There is strong evidence that early involvement of fathers has significant benefits for children’s social, emotional and intellectual development and wellbeing. But despite the immensely important role that fathers play, it is too often overlooked, particularly during pregnancy and the early years. Our ambition is to ensure that fathers, as well as mothers, are fully engaged in the range of services supporting healthy child development. This is particularly important in the early years, and we will focus on improvement in fathers’ involvement in maternity services [and] antenatal support” (3.32)

• How can ‘involvement’ be justified?• What does ‘involvement’ mean?

Leading to...

• Problems with ‘medicalised’ involvement• Tensions between different kinds of

involvement• Suggestions for future

3 arguments, 3 kinds of involvement

1) The man qua autonomous agent2) The man qua advocate for the mother3) The man qua responsible father

1) Involvement as decision maker in own right2) Involvement to protect mother’s interests3) Involvement to protect child’s interests

THE MAN QUA AUTONOMOUS AGENT

P1The existence of the resulting child generates parental responsibilities.

P2Parental responsibilities are weighty and last a lifetime.

P3Decisions made during pregnancy, about pregnancy and childbirth, have the potential to affect the characteristics of the child that will be born which will, in turn, affect the nature of the parental responsibilities (P1) that are weighty and long lasting (P2)

P4It is unjust that one person can make a decision that gives, or changes the nature of the, lifelong responsibilities for another.

C. Therefore, all parties who will gain life-long parental responsibilities have an interest in making decisions that generate or alter these responsibilities.

• Substantial counter-argument would be required to exclude a man from equal decision-making

• Substantial justification obvious– The mother as a competent adult has the legal

right to make, and moral interest in making, decisions about her own body and behaviour.

– Her interest bodily integrity outweighs his interest in shaping his future responsibilities

• Nonetheless, putative father have a legitimate interest (short of veto) so PPPs that exclude them should be challenged and changed

But• Involvement also needs to be squared with

norms of medical interactions– i.e. a private and confidential consultation

between patient and care.

• Need consent of patient (mother) to insert 3rd party

• Easy when mother and father are together, harder when separated/acrimonious.

• Men who are not in a relationship with the mother least likely to be involved in antenatal care or be present at the birth.

• Given the mother’s right to confidentiality and privacy, however, these men might be the hardest group to include in antenatal health services.

• Suggests engagement in antenatal services might not be the best means of achieving more active fathering in this group of men.

THE MAN QUA ADVOCATE FOR THE MOTHER

• Pregnant woman can easily become isolated in a service where they are outnumbered by the professionals.

• Another argument for a man’s involvement in those parts of pregnancy and labour that are shared with the health services is quite simply that the mother may want or need him there.

• More significantly, the mother may want her partner to act as her advocate.

An advocate:• Provides support and ensures voice heard• Represents the wishes/interests of a person

unable to represent them for herself– E.g. during latter stages of labour

• Is an extension of the represented person• Legitimised by respect for autonomy

• A man may have a responsibility to engage with antenatal health services – based on what it means to be in a marriage or equivalent relationship.

• On this argument, policies, practices and procedures for pregnancy and labour should involve men as the mother’s advocate at her request.

• But:– his presence is justified only insofar as he acts as an

effective advocate. – must reflect her views/interests rather than his own. – Expressing his own anxieties and fears or seeking

information for his own ends/needs would be unwarranted.

• Healthcare professionals tread a difficult line between:– Welcoming into the consultation anyone who the

mother chooses to bring with her as an advocate And, for same reasons– Ensuring that this person is behaving as an advocate

ought to.

• Partner-advocate’s behaviour as an advocate scrutinised to protect the mother’s interests

• This scrutiny may be perceived as hostility, a lack of trust, or active exclusion.

THE MAN QUA RESPONSIBLE FATHER

• Encouraging antenatal involvement of men serves the child’s interest– It encourage patterns of active and involved fathering

that will continue once the child is born– Men are more likely to bond effectively with child if they

possess a strong concept of themselves as a father during pregnancy

– High level of caring activity after birth improves fathers’ parenting

• Mothers ought to protect the interests of their children

• Mothers have all things being equal obligation to involve men

• And fathers should also protect the interests of their children

• They have an equal all things being equal obligation to be involved.

Two difficulties:1. Two parents – they may not agree about what

best serves a foetus’ interests– Not unique to pregnancy.– Mother’s bodily integrity (therefore veto) again,

pregnancy is an important reality – BUT father’s parental concerns carry equal weight

2. Unclear what it means to be the father to (or parent of) a foetus...

• Arguments about parenting a foetus tend to focus on looking after the needs of the future child (to avoid ‘status of the foetus’ debates).

• Accordingly, the interests that the parents are reputed to have responsibility for are those of the child the embryo or foetus will become.

But surely could be more than this?

• Parents can love a foetus and have a sense of responsibility for a foetus, even though there is less that can be done for a foetus than is required for a child once born.

• Expectant fathers cannot express that love/concern/responsibility through direct care.

• Active (antenatal) fathering is most likely to be centred on preparing oneself for future actions, though feelings associated with active fathering (love, concern etc) may nonetheless focus on the present relationship, with an emphasis on the supporting role a man can play as a helper and advocate for his partner.

• New fathers may also prepare through antenatal education.

• But, not obvious that the best or only way of gaining the requisite skills for active parenting is through state/DH sponsored classes.

• In fact, there may be good reasons for thinking that such educational activities are best conducted outside of a medical environment.

This brings us to our concerns about current policy.

THE ARGUMENTS IN THE CONTEXT OF POLICY: SOME CONCERNS

From the general to the particular

• A distinction needs to be drawn between what might in general serve the interests of future children and which can be offered, or even actively promoted, to all ‘expectant’ fathers in the service of this good end

And • That which serves the interests of individual

future children and helps to promote active fathering for individual putative fathers (i.e. the same good end in individual cases).

• It is possible to accord value to a general policy and the good ends it seeks to achieve, whilst at the same time recognising that a failure to act according to that policy is not always an indication of a failure to recognise those good ends.

• Pregnancy and childbirth is experienced in quite diverse ways and under a range of circumstances and it is almost inevitable that a ‘one size fits all’ approach will not work for every individual.

• Failure to engage with antenatal health and maternity services is not necessarily indicative of failure of paternal responsibility.

• It is important to recognize and value the variety of ways in which men can prepare for fatherhood and be fathers. – E.g. preparing the home for the impending arrival,

reading pregnancy and parenting books, choosing baby accessories, giving up smoking, giving support to one’s partner.

• The view that parents should be equally involved with their children in all of the same ways overlooks the value of a division of labour according to skills, temperament and circumstances.

Medicalising fatherhood?• Arguments around the medicalisation of

pregnancy and childbirth are well rehearsed.• Balance to be struck between maternal/child

health and acknowledging that pregnancy and giving birth are normal events.

• Drawing men into this process medicalises their experience

• But no health trade off for men to being medicalised.

• Ambiguity around what their ‘medicalised’ involvement can or should entail.

“Men are encouraged to participate fully in the pregnancy and birth of their children, but are

simultaneously given to understand, in a multitude of ways, that they are outsiders. Most of all, it is made clear that while their presence is

requested, their feelings are not, if those feelings might upset their wives. Anxiety, anger,

sadness and fear are all unwelcome” (Shapiro, 1987)

• Many men have overwhelmingly positive experiences of pregnancy and birth, others report feelings of:– hopelessness, discouragement, exclusion, fear and

helplessness, unfulfilled expectations

• Inconstancies in the roles the father is asked to play: nurturing, emotionally engaged father AND masculine stoic in order to be a supportive partner and advocate.

• Do men’s complaints suggest inability to take into account the needs of others (me, me, me)?

• Or is ‘sense of failure’ inevitable in absence of clearly defined role for men and a better understanding what of engagement is seeking to achieve and what ‘involvement’ means at different times and in different places.

• If a man is attending as an advocate, then his own views are not pertinent.

• If he is attending to protect his own future interests and those of his child, his views may justifiably be listened to but not ultimately decisive.

• Equally, whilst it may be the right thing to do for a man to adopt a silent, stoic attitude, it would be wrong to dismiss the problems that may be experienced by men trying to be the best they can.

• So, whilst policies, practices and procedures should not be excluding men, careless application of a policy designed to engage men early as fathers runs the risk of disengagement. – He becomes a passive and unnecessary ‘bystander’

• It is potentially disastrous for the promotion of active fathering if a man’s first ‘official’ experiences as a father leave him with the impression that he is surplus to requirements.

• It is easy for healthcare professionals to overlook the power differentials at play in consultations

• Men attending antenatal consultations may be doubly disadvantaged by being perceived as a guest rather than a participant.

• And for mothers, a policy of encouraging men to engage with maternity services through the medium of healthcare professionals may generate a coercive pressure to invite a man to attend her (private and confidential, medical) consultations.

• Or feeling ‘abnormal’ if there is no man to bring or no desire to have one present

• The significance of, and value attached, to technology and medicine alters perceptions of what really matters during pregnancy and why.

• This distorts the significance given to the limitations for men’s involvement in this medicalised setting– i.e. the perception that these routine medicalised

interactions hold special significance. • Non-medicalised preparations for fatherhood lend

themselves to greater activity and more equal decision-making.

• A better preparation for fatherhood than the medicalised experiences?

• Good reasons for using healthcare services to structure men’s transition into fatherhood:– Authority of the healthcare professionals; value

accorded to technology and medicine; pragmatic attraction of achieving added benefits through services that are already in place and widely accessed.

• But medicalisation not cost-free: – Can erode personal skills and resilience; devalue

experiences and activities that take place outside the medical environment

– Can pacify, de-skill and encourage acceptance of the role of others as experts rather than preparing men for the kinds of everyday and/or emergency decisions that may need to be made as a new father or partner of long-standing

3 WAYS FORWARD?

1. Continue to engage men through existing services– Encourage prior negotiation between mother

and putative father about what involvement entails and limitations of men’s different roles

– Full and frank initial discussion highlights man’s legitimate interests AND manages expectations, based on the norms of equal involvement.

1. s2. Provide separate services to address men’s

needs as future parents in their own right– Additional and separate services would enable

men, where necessary, to be able to delineate their different roles and give them the opportunity to express concerns and anxieties that they might be reluctant to express in front of their partners in their role as advocate.

– Some evidence to suggest that antenatal services designed specifically for men are more effective at preparing men for fatherhood.

• Not new suggestions• Both retain the element of medicalistion.• Medicalisation of the transition to fatherhood may

prevent the kind of active engagement that is needed.

• Little attention paid to whether or not there is genuine scope for more father-inclusive practices that supports a model of active involved fathering in antenatal and maternity services that are increasingly medicalised

1. S2. J

3. Engage men in a non medicalised setting and encourage them to prepare for fatherhood outside of and alongside the pregnancy– Has potential to engage putative fathers who

are not in a relationship with the mother– Reinforces the value of active fathering in non-

medicalised contexts where more equal involvement is possible and where a pattern for future active fathering might better be established.