There has been a significant cultural shift regarding the inclusion of male partners in childbirth in Western societies since the 1960s (Hildingsson et al, 2011). Male partners are no longer barred from maternity services, but instead there is a demand for their presence and involvement from both women and men themselves (Alio et al, 2013; Redshaw and Henderson, 2013). Within the UK, more than 80% of men attend their partner's antenatal appointments and ultrasounds, compared with 32% in 1986 (Andrews, 2012). This cultural shift is a worldwide phenomenon, and can be seen in Australia, the United States, Europe, the Middle East, Asia and across the developing world (Steen et al, 2012; Aguiar and Jennings, 2015; He et al, 2015).
There have been anecdotal reports, however, that negative attitudes and behaviour have been directed by health professionals towards male partners of pregnant women within the obstetric and midwifery environments. Research has identified that some male partners have expressed feelings of anger and frustration as the result of being ignored and of not being engaged or supported by midwives or doctors (Johansson et al, 2015). Disrespectful comments, a lack of information before and during adverse events or emergencies, and forced engagement in unwanted activities are some of the negative attitudes or behavioural issues that male partners have reported (Widarsson et al, 2015). Male partners have been described as ‘invisible bystanders’ (Poh et al, 2014: 550), who are pressured to attend births or to perform activities such as cutting the baby's umbilical cord, against their will. Male partners have also been reportedly subjected to unfriendly staff, who make them feel ‘in the way’, tell them ‘not to interfere’ (Johansson et al, 2015: 13), or tell them that their purpose at the birth is to be ‘taught a lesson’ (Steen et al, 2012: 427). These attitudes and behaviours cause male partners distress, anger, helplessness and disengagement from their partners (Poh et al, 2014), undermine the supportive role of male partners and the associated benefits, and defeat male partners' desire to be actively involved.
As male partners are increasingly involved in maternity settings, the negative attitudes and behaviours directed towards them require further investigation from a midwifery perspective. This study focuses on midwifery students' experiences of negative attitudes and behaviours directed at male partners in maternity environments.
Methodology
An online anonymous survey was used for this study, using open questions. Thematic analysis was used to explore the responses supplied by the participants, in order to identify common themes and discover if they had observed negative attitudes or behaviour being directed towards male partners in maternity environments.
Setting
This study was conducted in metropolitan Perth, Western Australia. All of the participating midwifery students were in the paid-employment model within the clinical midwifery areas in both public and private women's health services, including tertiary and general hospitals, birthing centres, and community midwifery programmes.
Participants
In Australia, midwifery students are either nurse/midwifery students (registered nurses who then train to be midwives) or direct-entry midwives. There are no direct-entry training courses at the university where this study was undertaken, so all students were registered nurses training to be midwives. Once qualified, all are classed as midwives, regardless of study path.
The participants in this study were postgraduate midwifery students from one University in Perth, Western Australia, who were all registered nurses and female. The midwifery students were employed by the hospital where they gained clinical experience. A total of 40 midwifery students were invited to participate in the study, and 21 (51.5%) students responded.
Data collection
Data was collected via an online survey using Qualtrics software, and consisted of some demographic questions, and open questions with free-text answer boxes to elicit descriptive answers. While participants were free to opt out at any time, the survey was also designed so that all the questions must be answered to complete the form, which thereby eliminated the potential for blank responses to certain questions. The potential participants were provided a link to the online survey through a closed-group social media site, where the only members were the students enrolled on the midwifery course. This social media site was a support and information resource set up by the participants while enrolled on the midwifery course. The survey link was open for 4 weeks allowing time for participants to complete it.
Data analysis
The collected data were analysed using thematic analysis. The responses were entered into an Excel spreadsheet and manual thematic analysis was used to code and categorise the responses to establish common themes. Additionally, the midwifery students' experiences regarding whether they had observed negative attitudes and behaviours towards male partners could be explored.
Ethical considerations
This study was conducted as part of a Masters by coursework degree, and ethical permission was granted by the University Ethics Committee (ethics number 17751). All potential participants were emailed an invitation letter that invited them to take part in the research project and included a link to the online survey. The invitation letter outlined the purpose and the implications of the study. There were no identifiable costs to potential participants, other than up to 15 minutes of time for completion of the survey. Participants were informed that they had the right to decline participation by disregarding the link to the online survey. Informed consent was implied by all participants who completed the online survey reflecting the participants' willingness for involvement in the study.
Findings
Of the 21 respondents, 19 (90%) said that they had observed negative attitudes or behaviour directed towards male partners by doctors, midwives and female partners, and that it had occurred during all stages of maternity care. The participants' responses were grouped into three overarching themes and labelled as: ‘observed negative behaviours’ and ‘behaviour reasoning’. Under each of these main themes, several sub-themes were listed to direct the narrative of the findings.
Observed negative behaviours
Under the first over-arching theme of ‘observed negative behaviours’, three sub-themes emerged that were labelled as ‘aggression’, ‘exclusion’, and ‘condescension’.
Aggression
Aggressive behaviour towards male partners was observed on several occasions, but only from women who were in what was described by the participants as active labour. These observed experiences ranged from nonverbal cues such as intentionally ‘grimacing’ at the male partner, or to verbally ‘snap’ and ‘yell’ with ‘nasty’ and ‘derogatory comments’. There were also examples of physical aggression that manifested as ‘slapping’, ‘hair pulling’ and ‘pushing’. One respondent recounted:
‘I have seen women pinch skin and pull the hair of their partners. I saw one woman bite her partner on the arm during labour.’
Exclusion
The participants described that the negative behaviour observed from doctors and midwives consisted mainly of exclusion from interactions. Doctors and midwives were observed to actively exclude men from interactions by introducing themselves to women only, turning their backs on the men, addressing only the women, not explaining common procedures to men, and then asking them to leave during procedures. One participant commented:
‘I strongly agree that they don't involve [male partners] in decisions, I find that midwives mostly ignore the male and only talk to the woman.’
Interestingly, one of the participants did not see the male partners being ignored as a negative behaviour:
‘I don't think doctors ignoring male partners is a negative thing. It isn't about them—is it?’
When male partners did express concerns or questions, midwives were reported to be dismissive:
‘I have seen a midwife dismiss a male partner's fear of blood, and she said that they will [be] stepped over if they faint because their focus is on the woman. It came across as a bit rude.’
Another participant commented:
‘Male partners are not always included at all phases of the process. They are sometimes treated like a support person instead of a father-to-be. Often there is an assumption that men aren't informed and therefore can't be part of the discussion and therefore excluded.’
Condescension
Doctors and midwives were also observed being condescending to male partners. Participants stated that they had observed male partners being ‘talked down to’, receiving negative comments ‘for yawning or relaxing on the couch’, and being treated as ‘annoyances’.
Behaviour reasoning
Under the second over-arching theme, ‘behaviour reasoning’, four subthemes emerged: ‘excusable by pain’, ‘preoccupied’, ‘misplaced support’ and ‘respectful inclusion’. The participants suggested reasons behind negative attitudes and behaviours, with some saying that negative attitudes and behaviours were justified, and that male partners warranted it either by their own actions or by the pain experienced by their partners.
Excusable by pain
When the negative behaviours were observed originating from labouring women during the intrapartum period, the participants claimed they were excusable, due to pain or the stress of labour that the woman was experiencing. Many comments from participants echoed this example:
‘The woman was in labour with pretty intense contractions and was yelling at him to help her. Rightly so I feel, as the woman was trying to cope with the pain.’
Preoccupied
Participants reported that male partners were often preoccupied with smartphones, ‘sport on the TV in the labour ward’ and iPads during antenatal or intrapartum events. The participants also described male partners as being preoccupied with asking questions that were not related to the immediacy of the maternity situation:
‘A husband once asked me where he could park his car without getting a parking ticket as I was helping his wife through a really tough contraction. I couldn't believe it.’
One participant stated that she had witnessed instances of male partners being reluctant to engage with the birth process, citing examples of partners who were:
‘Prompting women to ask midwives questions that the man had, rather than asking themselves.’
This type of behaviour by male partners appeared to trigger a negative reaction from the participants describing the incidents.
Misplaced support
The participants reported that sometimes male partners warranted negative behaviour from midwives by engaging in two types of misplaced support for their female partners. The first type of misplaced support reported by participants suggested male partners sometimes provided ‘overbearing support’, or were ‘attention grabbing’, and sometimes were seen as trying to make decisions on behalf of the woman. One participant commented:
‘I've seen male partners try to influence a woman against what the midwife is recommending. I've seen a partner telling the midwife to get his partner an epidural, despite the woman saying she didn't want one. He wanted her to have one because he couldn't cope. He didn't seem to be bothered about what she wanted.’
The second type of misplaced support was when male partners appeared ‘not interested’, and adopted a ‘disinterested bystander position’ that then provoked negative behaviour from midwives and doctors. Participants stated that:
‘Male partners in my experience often seem bored and don't really want to be there. They make excuses to leave the room and don't seem to know what to say.’
‘I've seen men sleep through most of their partner's labour, or bring in a take-away and eat in front of her, knowing she can't eat. How is that supportive?’
Participants described labour and birth in terms of ‘teamwork’ and said that male partners should ‘bear some responsibility’ in providing support. One participant acknowledged that male partners needed to be involved in support by stating:
‘I think the midwife wants to help the woman and do everything she can for her, but sometimes they have to back off and let the husband have a role in birth.’
Respectful inclusion
The survey encouraged participants to express their perspective regarding the role of the male partner in pregnancy and childbirth. All 21 participants (100%) stated that male partners should be supported and included in maternity-care decisions. The supportive behaviour of men was described by participants as positive, yet generalised as ‘taking an interest’ in the antenatal or intrapartum period, or that male partners should ‘focus on their partner’. This support was also described as ‘valuable’, ‘beneficial’ and ‘rewarding’ to the childbirth experience, both for women and their male partners.
Participants were clear in suggesting that male partners should be actively included and supported in decisions regarding maternity care, and that they should be ‘treated with equal importance and respect,’ saying that:
‘Male partners should be involved and included in all aspects of maternity care. It is his baby too.’
‘Health professionals should find out what the couple want [for labour and birth], and not just the woman.’
The participants were suggesting that male partners should be included in all aspects of care and that they should be involved in discussions and decision-making, thereby validating feelings and opinions.
‘Participants were clear in suggesting that male partners should be actively included and supported in decisions regarding maternity care, and that they should be ‘treated with equal importance and respect’’
Discussion
This study has identified that midwifery students have observed negative attitudes and/or behaviour being directed towards male partners by health professionals in maternity environments. Midwifery students also reported that female partners were perpetrators of negative attitudes and/or behaviour to their male partners. These findings are consistent with the available contemporary literature, despite some of the body of knowledge being quite dated. It has been reported that both overt and covert exclusion of male partners during care episodes occur, and that the imbalance of power is reflected in negative attitudes and assumptions towards male partners, with condescending behaviours of doctors and midwives reminiscent of those occurring 20 years ago (Bedford and Johnson, 1988; Schytt and Bergström, 2014). The midwifery students in this study reported additional observations of male partners being subjected to both verbal and physical aggression and violence from their female partners, which has not yet undergone examination in the existing literature.
Negative behaviour from labouring women
Previous studies have outlined that excluding and unsupportive behaviours towards male partners are associated with fear, post-traumatic stress, and paternal postpartum mental health problems (Elmir and Schmied, 2016; Inglis et al, 2016). However, the midwifery students in this study framed the behaviours discussed as negative, and indicated that perhaps some of these behaviours were not considered as serious when committed by labouring women against male partners, and at times they were readily excusable due to the woman's labour pains. It is possible that the midwifery students considered the woman's inability to control her behaviour during the natural process of labour, a stronger phenomenon.
A labouring woman's control over her own behaviour has been previously been researched, with studies reporting that pain, and pain relief, were strong predictors affecting a woman's self-control (Green and Baston, 2003; Bergstrom et al, 2010). These studies suggested that midwives could either help restore the woman's self-control through informed and reassuring support, or prevent distressed states from occurring with a mutually understanding and supportive partner (Karlsdottir et al, 2014). Male partners are ideally placed to act as trusted supports for women and to provide continuity of care, and if male partners were seen as a possible solution, this could reduce the negative behaviour they receive during labour (Kuliukas et al, 2015). It is important to note that the excusing of a woman's uncontrolled behaviour towards her male partner, due to pain experienced during labour, has not yet been examined in the literature.
Misplaced support
One study reported findings of midwifery students being uncertain as to whether they believed male partners to be the best person to accompany the woman during birth (Fraser and Hughes, 2009). In this study, midwifery students reported that negative attitudes towards male partners occurred when male partners did either too much, and too little, in their attempts to provide support, detracting from the woman in labour. Male partners were also reported as being preoccupied with smartphones and portable devices, or asking questions that were not immediately relevant to the situation, leading to them being ignored or excluded by midwives and doctors. This finding is reinforced by a previous study that suggested that a disconnect of effective communication between health professionals and male partners occurred through exclusion during care, primarily in decision making (Steen et al, 2012). Some of the midwifery students in this study reported that male partners were sufficiently included; however, the literature suggests the onus appears to remain upon male partners to negotiate their own inclusion in the childbirth process (Dolan and Coe, 2011). In this study, ‘misplaced support’ was used to describe the midwifery students' perception of male partners as either withdrawing into insufficiency and preoccupation, or taking the initiative to find their voice as an active player, which was described by some participants as a hindrance. This hindrance may then frustrate women and health professionals, which is then expressed as condescension toward male partners, perpetuating a cycle of exclusion.
Preparing for the birth
Antenatal education has undergone extensive review and there is a steady focus to include and cater for male partners, who are offered information and preparation, as women are (Newburn, 2012; Porrett et al, 2013; Smyth et al, 2015). This study's findings are consistent with the cultural acceptance of male partners in the antenatal and intrapartum setting, in that midwifery students reported that male partners were asking questions and expected to be included during antenatal and intrapartum settings. All of the midwifery students who participated in this study reported that they expected male partners to be supported and included during both antenatal or intrapartum care events by all health professionals.
Limitations
This study focused on 21 midwifery students' observations and perceptions of negative attitudes and behaviours directed towards male partners during maternity care. The sample size was small, and the relationship dynamics between the women, male partners and health professionals were not recorded, which may have added richness to the data and could have determined the frequency, duration and analysis of negative attitudes and behaviours. The study did not differentiate between negative attitudes or behaviours occurring in antenatal and intrapartum settings. Further research is required in this area, and the inclusion of same-sex relationships in regards to negative attitudes and behaviours directed towards partners should be explored.
Implications for midwifery practice
It is important that male partners continue to be recognised as key stakeholders in their partners' childbirth journey. The inclusion of male partners within maternity care should be advocated for and cultivated by health professionals. Perhaps the targeting of specific needs of male partners would bring a greater benefit overall to women during pregnancy and birth. The knowledge base of health professionals relating to the value and significance of male partners requires investigating, with the possibility of education being provided in this area. This may help to alleviate future negative attitudes and behaviour towards male partners.
Conclusion
The negative attitudes or behaviour directed toward men by their female partners, midwives and doctors during antenatal and intrapartum care is a topic that has not previously received adequate attention within the literature. This study has presented information from the perspective of midwifery students, and reports that male partners are not always accommodated into maternity settings in a way that meets their needs, and are at times disempowering through negative attitudes and behaviours.