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Midwifery
journal homepage: www.elsevier.com/midw
Let men into the pregnancyMens perceptions about being tested for
Chlamydia and HIV during pregnancy
Monica Christianson, RNM, PhD (Registered Nurse/ Midwife)a,n, Jens Boman, MD (Medical Doctor)b,
Birgitta Essen, MD, PhD (Medical Doctor, Gynecologist/Associate Professor)c
a
a r t i c l e i n f o
abstract
Article history:
Received 1 July 2011
Received in revised form
12 January 2012
Accepted 5 February 2012
Objective: to investigate how to prevent transmission of HIV and Chlamydia trachomatis (CT) by
exploring whether screening of men during pregnancy may be an innovative way to reach men, to
increase detection, and to avoid the present gendered responsibility.
Design: an explorative research strategy with in-depth interviews and an analysis informed by
grounded theory principles was used.
Setting: the northern part of Sweden.
Participants: twenty men/becoming fathers in their twenties and early thirties were offered CT and HIV
testing and were interviewed about their perceptions about being tested during pregnancy.
Findings: Six categories emerged that concerned the mens risk perceptions, reasons for not testing
men, benets and negative consequences associated with being tested, incentive measures for reaching
men and the optional time for testing men during pregnancy. The majority of the men perceived their
own risk for having CT or HIV to be close to zero, trusted their stable partner, and did not see men as
transmitters. They did not understand how men could play a role in CT or HIV transmission or how
these infections could negatively affect the child. However, few informants could see any logical
reasons for excluding men from testing and the majority was positive towards screening men during
the pregnancy.
Key conclusions: mens sexual health and behaviour on social and biological grounds will affect the
health of women and their children during pregnancy and childbirth. As long as expectant fathers do
not count in this triad, there is a risk that CT and HIV infections in adults and infants will continue to
be an unsolved problem.
Implications for practice: knowledge from this research can contribute to inuencing the attitudes
among health-care providers positively, and inspiring policy changes.
& 2012 Elsevier Ltd. All rights reserved.
Keywords:
Screening
Pregnancy
Men
Gender
Introduction
Because pregnant women use antenatal clinics, they are
screened and tested for sexually transmitted infections (STIs)
more often than men, making screening during pregnancy both
a woman problem and a priority for womens sexual health
(Duncan and Hart, 1999; The National Board of Health and
Welfare, 2009). Since men visit health-care facilities less often
than women, they often go undiagnosed and untreated (Kalwij
et al., 2010). By ignoring men for testing, there is a risk that STIs
among men will go undetected and that they will spread. This is a
Corresponding author.
E-mail addresses: monica.christianson@nurs.umu.se (M. Christianson),
jens.boman@dermven.umu.se (J. Boman), birgitta.essen@kbh.uu.se (B. Essen).
URLS: http://www.umu/omvardnad.se (M. Christianson), http://www.umu.se
(J. Boman), http://www.kbh.uu.se (B. Essen).
0266-6138/$ - see front matter & 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.midw.2012.02.001
situation that has severe health consequences not only for men,
but also for women and their unborn child.
Health screening may be dened as a targeted action designed
to reduce mortality and morbidity in populations with elevated
risks (Heyman, 2010). Screening normally involves sorting out
subgroups within the population that are at high risk and offering
these high risk individuals access to diagnostic tests, such as
screening for congenital disorders. Screening is a public health
service that attempts to identify individuals who are more likely
to be helped than harmed by further tests or treatment to reduce
the risk of a disease or its complications (Low, 2007). In Europe,
there is an on-going debate whether national screening programs
should be introduced (Low and Egger, 2002; Polyzos et al., 2006).
The debates about screening address cost effectiveness and
preventive effectiveness with respect to long-term consequences
of infections. Although researchers have not reached a consensus
about the effectiveness of screening for CT and HIV, several claim
352
Aim
This study investigates how to prevent transmission of HIV
and CT from a gender perspective by exploring whether screening
of men during pregnancy may be an innovative way to reach men,
to increase detection, and to avoid the present gendered responsibility. This paper focuses on expectant fathers perceptions
about being tested for HIV and CT during the same period their
pregnant partners are being tested.
Method
This study used interview techniques to evaluate STI testing
during pregnancy (vreveit, 1998). The interviewees reported
their views on testing men during pregnancy, and their personal
motifs behind testing or not were explored. Furthermore, we also
wanted to know if the men found testing to be a successful
procedure or a failure. An explorative research strategy with
in-depth interviews and an analysis informed by grounded theory
principles was used (Strauss and Corbin, 1990). This method is
suitable when little is known about an area or when new knowledge is needed, such as in this case. Pregnant womens partners
were offered CT and HIV testing at the beginning of the pregnancy,
except for one man that was interviewed and tested during the
third trimester. Those who agreed to be tested were interviewed
about their experiences; those who did not agree to be tested were
also interviewed about their motifs for not being tested. Men did
not request tests without being included in the study.
Setting and participants
The data collection started in August 2009 and ended in April
2010. The inclusion criterion was that the informants should
speak Swedish or uent English, and ongoing pregnancy of the
partner. The setting was a university town with around 115,000
inhabitants in Sweden. During the pregnant couples rst visit to
the antenatal clinic, midwives recruited 35 expectant fathers
between 18 and 35 years old. They received written and verbal
information about the study. The rst author contacted the
recruited men via telephone. During this conversation, she
answered questions about the project and set a time and place
for the interview. In total, 20 men agreed. In addition, 15 men
who refused to participate provided several reasonse.g., they
did not have the time, they did not want to be interviewed, or
they were not interested in research.
The interviews
The rst author performed the interviews and the sampling for
CT and HIV. She was considered to be an experienced interviewer
and familiar with grounded theory (Christianson, 2006). The
interviewer and interviewees differed concerning age and gender,
and this may be a methodological problem (Hutchinson et al.,
2002) but the friendly atmosphere and the skilled interviewer
compensated these eventual effects. The issue of rigour was met
by rethinking rigour in the way that Davies and Dodd (2002)
suggested. The cluster of terms such as responsibility, attentiveness, empathy, openness, sensitivity, engagement and awareness
were part of the interviewers agenda for creating trust. All
interviews were carried out in a respectful manner, where the
men were encouraged to articulate their opinions, feelings and
thoughts in a way that did not create distance between interviewees and the interviewer. The interview session took
4590 mins. Twelve men were voluntarily tested, and these
interviews and tests for HIV and CT were carried out at a youth
clinic. Eight men refrained from testing and these interviews took
place at the university where the rst author worked. Before the
interview started, the interviewees gave their written consent.
Emphasis was put on informing the interviewees that the intention with the interviews was not to test their knowledge or
ignorance about STIs, but to explore their perceptions, i.e. to make
them feel comfortable during the interviews. A brief questionnaire about socio-demographic characteristics was collected
(Table 1).
The interview included open questions: What do you know
about CT and HIV? What are the consequences of the infections?
353
Table 1
Demographic background factors, in-depth interview study with men in a Swedish city.
Age (years) (mean age 27.5)
Ethnic background
Home district
Occupation
Civil status
21
23
24
24
25
25
26
27
27
27
28
28
28
28
28
28
29
29
30
34
Swedish
Swedish
Swedish
Swedish
Swedish
Swedish
Swedish
Swedish
Swedish/parents from Finland
Norwegian
Swedish
Swedish
Swedish
Swedish
Swedish
Swedish
Swedish
Swedish
Swedish/parents from Finland
Swedish
First child
First child
First child
First child
First child
First child
First child
First child
First child
Second
First child
First child
First child
Second
First child
Second
First child
Second
First child
First child
Village
Town
Town
Town
Town
Village
Conurbation
Town
Town
Town
Village
Town
Village
Town
Town
Conurbation
Town
Conurbation
Town
Village
Unemployed
Welder
Storeman
Planning mill
Student
Carpenter
Unemployed
Dispenser
Chef
Bartender
Truck driver
Inspector
Engineer
Porter
Student
Floor dresser
Auditor
Purchaser
Machine operator
Police
Cohabiting
Cohabiting
Cohabiting
Cohabiting
Cohabiting
Cohabiting
Cohabiting
Married
Cohabiting
Cohabiting
Cohabiting
Married
Cohabiting
Married
Cohabiting
Cohabiting
Cohabiting
Cohabiting
Cohabiting
Cohabiting
Ethical considerations
The participants were assured condentiality and were carefully informed both verbally and in writing about the aim of the
study and the voluntary nature of the study. Testing was not done
without informed consent. The Regional Ethical Review Board in
Sweden approved the study in May 2009 (Dnr 09-048 M).
Umea,
Findings
The men/expectant fathers perceptions were categorised
in six categories and 15 subcategories concerning mens risk
perceptionsreasons for not testing men, benets associated
with testing, drawbacks associated with being tested and how
to normalise testing for men.
Analysis
354
Few men could formulate how and in what ways the health of
the child could be affected if men were tested during pregnancy.
This thought had never hit them. One mans rst thought,
however, was that it was good if diseases could be discovered
that otherwise can be transferred. Another man had difculties to
grasp how he could inuence his childs well-being:
The problem is that when the sperm has reached the woman,
at that point it feels too late to do anythingy The role of the
men feels rather unimportant mechanicallyy I can give
psychological support and things like that but I cannot do
anything more with my body now!
Another man thought that preventive measures should be
done before the pregnancy has happened:
Its a bit late to do something for a child that is already
contaminated with HIV when its already in the womb.
Few men believed that medically, testing would not affect
anything. Several men noted that a pregnant womans lifestyle,
not his, would affect the unborn childs health:
I cannot see any direct link between my eventual smoking and
how that would affect the child.
Insecurity was raised concerning whether contagions could
affect the child during pregnancy. The possibility to treat the child
was perceived as ambiguous:
In this pregnancy a test wont help this child, but certainly in a
new pregnancy, that child will be cured.
355
356
Early testing
The majority stated that these tests should be done early in the
pregnancy: for them it felt natural to have it done early. Other
suggestions were made with respect to the timing and location of
the testing:
During the sign-in is a good opportunity to have them both
tested. To be informed that it is very important to test men
also. I dont think that there are many who will say no.
The men suggested that men could be tested during their rst
visit at the maternity care, and that it was reasonable to test one
time and as soon as possible:
For the sake of the child, take the test the rst time couples
meet the midwife.
Another man thought:
Its too late at the end of the pregnancyy. It gets worse the
longer one has it [STIs].
The optimum time for testing was discussed. The men thought
that although the issue was rather sensitive it was a good idea to
test men a bit later in the pregnancy:
I dont know if it is common or sometimes it happens for sure
that meny There is not so much sex during those nine months
perhaps and there is an increased risk of indelity during this
period. Maybe one has to be a bit tactical and test after
half way.
Some of the men thought that it was pointless to test late in
pregnancy. A couple of men also claimed that it did not hurt
anyone to be tested more than once:
It is better and perhaps even more strategic to test more
frequently.
The risk for men who would feel supervised or harmed was
discussed. One man disliked the idea of testing men more than
once: he thought that the aim was wrong and there will be an
indelity control. Another man argued that the indelity control
is directed towards the women although from his opinion this
issue seldom was raised. One man claimed that men should be
tested both early and late in pregnancy even if men could feel
embarrassed and in extreme cases also supervised. One man
claimed that during pregnancy and childbirth, indelity sometimes occurs, so he recommended tests, both early and late in the
pregnancy. Some men concluded that people do not give birth
that many times during a lifetime so testing could be reproduced:
Testing could be repeated during a second, third, or during a
fourth pregnancy.
Discussion
The majority of the men perceived their own risk for having CT
or HIV to be close to zero. Many of them were already tested,
trusted their stable partner, and did not see men as transmitters.
They did not understand how men could play a role in STI
transmission or how these infections could negatively affect the
child. Few of them could see any logical reasons for excluding
men from testing and were positive towards screening men
during the pregnancy.
Presently, these maternity clinics for antenatal care have a
specic gender framing that stands in contrast with other health
care, as the expectant father is not involved in the care as a
patient. Not surprisingly, the interviewed men and men in general
do not have natural entryways into antenatal care and a variety
of incentives are suggested to make it natural for men to be
tested. The men want concrete and adequate information about
testing, and treatment. Moreover, they want to know how the
infections affected their reproductive organs and how the unborn
child might be affected.
Midwives are perceived to be signicant motivators for testing
men, but they are part of a system where gender is not considered
when it comes to screening men during pregnancy. Hence, a
recent review on barriers towards HIV testing shows that healthcare providers such as midwives and general practitioners
attitudes may play a role in encouraging or discouraging testing
357
tested during the rst trimester, although some men recommended tests both early and late in the pregnancy. Although
these mens observations offer a solid point of departure, policy
programs directed towards men need to be revised by policy
makers in collaboration with researchers and health-care
providers.
In discussions about benets concerning who would gain and
who would lose from screening, there will be some individuals
who will be harmed physically or psychologically by screening
(Heyman, 2010). For instance, in some cases amniocentesis may
cause a spontaneous abortion or a mammography may cause
distress among some women in cases of false positive results.
These potentially harmful effects need further investigation.
Therefore, some people will pay a price as screening may perhaps
create false security, insecurity, or over-complacency (Bach
Nielsen et al., 2009). Two men emphasised that it was inappropriate to test men during pregnancy, as it could be seen as a type of
control. Nevertheless, the eventual harm that men who are
screened may experience and the safety of others, in this case
the preventative goals for the fetuses and the pregnant women,
are more important. STIs during pregnancy will have harsh
consequences for women and children when men are not controlled (Bonhomme, 2009). However, many men are unaccustomed with being controlled by the health-care system. In
addition, midwives could welcome men who are becoming
fathers and discuss strategies for better reproductive health
(Mbekenga, et al., 2011). Clearly, to let men into the pregnancy
is easier said than done. In maternity care men may feel that they
are partners and parents (Steen et al., 2011), but not patients and
this is one main item that needs to be changed. To educate men,
midwives, stakeholders in health care and partners about the
importance of changing mens role as outsiders towards a patient
and co-parent centred perspective is a challenge.
By ignoring mens sexual health, this women-dominated area
may be ignoring the mothers and unborn childs health. The
exclusion of fathers from screening for STIs during pregnancy
seems to arise more from cultural and gender attitudes rather
than medical risks. In the case of STI screening during pregnancy,
it is pregnant women, not heterosexual men, who are subjected to
discipline and control. According to Lupton, it is normally members of marginalised groups women, deprived, unemployed,
injecting drug users, gays, lesbians, and non-whites who are
constructed as grotesque bodies (i.e. open, polluted, and irrational) and therefore at risk (Lupton 1999) while heterosexual
men are not viewed as risk actors. We would like to conclude that
our results show that one out of 12 tested men was CT positive.
This is an important nding.
Limitations
The interviewees were of white Swedish ethnic background
and all but one was born in Sweden. They were heterosexual men
in their twenties and early thirties, they were employed or
students (one was unemployed), and they had stable relations
with their partners. All these characteristics limit the generalisation of the ndings as we can only speak about these specic
men. Those who did not speak Swedish or uent English were
excluded, and the chance to provide alternative interpretations
and explanations were not possible. However, many men worldwide are heterosexual, have a wife or a girlfriend and are
expecting a child. Findings from this study may very well
harmony with the perceptions that other men in other context/countries have, despite different political system, demography and/or ethnicity/race.
358
Conclusion
Mens sexual health and behaviour on social and biological
grounds may affect the health of women and their children during
pregnancy and childbirth. As long as expectant fathers do not
count in this triad, there is a risk that STIs including HIV
infections in adults and infants will continue to be an unsolved
problem. There are social and cultural obstacles to testing men:
these barriers need to be overcome by carefully approaching and
informing men about the value of being tested. Time must show if
knowledge from this research and additional research can contribute to reduce incidence and prevalence of STIs, inuencing the
attitudes among health-care providers, inspiring policy changes.
To start, men should be offered testing during their partners rst
trimester of pregnancy. We believe that this strategy will improve
the health of men, their pregnant partners, and their unborn
children. It will take further research, both qualitative and
quantitative approaches, in settings outside Sweden, with a
variety of men included before a complete theory about men
and testing can emerge.
Author contribution
MC and BE created the conception of the design. MC collected
the data. MC, JB and BE analysed and interpreted the data, MC
wrote the manuscript draft, and together with JB and BE critically
revised it. All authors gave their nal approval of the version to be
published.
Acknowledgement
This study was supported by grants from the Swedish
Research Council, Challenging Gender Research Centres of Gender
Excellence and Centre for Gender Studies, Umea University,
Sweden.
References
Bach Nielsen, K.D., Dyhr, L., Lauritzen, T., Malterud, K., 2009. Couldnt you have
done just as well without the screening? A qualitative study of benets from
screening as perceived by people without a high risk score. Scandinavian
Journal of Primary Health Care 27, 111116.
Bonhomme, J.J.E., 2009. A family health question: what about dad? Journal of
Mens Health 6, 402.
Christianson, M., 2006. Whats Behind Sexual Risk Taking? Exploring the Experiences of Chlamydia-Positive, HIV-Positive and HIV-Tested Young Women and
Men in Sweden. Thesis. Umea University, Print & Media:Umea Sweden.
Christianson, M., Lalos, A., Johansson, E.E., 2007. Concepts of risk among young
Swedes tested negative for HIV in primary care. Scandinavian Journal of
Primary Health Care 25, 3843.
Christianson, M., Berglin, B., Johansson, E.E., 2010. It should be an ordinary
thinga qualitative study about young peoples experiences of taking the
HIV-test and receiving the test result. Scandinavian Journal of Caring Sciences
24, 678683.
Courtenay, W.H., 2000. Constructions of masculinity and their inuence on mens
well-being: a theory of gender and health. Social Science and Medicine 50,
13851401.
Davies, D., Dodd, J., 2002. Qualitative research and the question of rigor.
Qualitative Health Research 12, 279289.
Deblonde, J., Claeys, P., Temmerman, M., 2007. Antenatal HIV screening
in Europe: a review of policies. European Journal of Public Health 17,
414418.
Deblonde, J., De Koker, P., Hamers, F., Fontaine, J., Luchters, S., Temmerman, M.,
2010. Barriers to HIV testing in Europe: a systematic review. European Journal
of Public Health 20, 422432.
Dodds, C., Weatherburn, P., 2007. Reducing the length of time between HIV
infection and diagnosis. British Medical Journal 334, 13291330.
Duncan, B., Hart, G., 1999. A social science perspective on screening for Chlamydia
trachomatis. Sexually Transmitted Infections 75, 239241.
Duncan, B., Hart, G., Scoular, A., Bigrigg, A., 2001. Qualitative analysis of psychosocial impact of diagnosis of Chlamydia trachomatis: implications for screening. British Medical Journal 322, 195199.
Finnbogadottr, H., Crang Svalenius, E., Persson, E.K., 2003. Expectant rst-time
fathers experiences of pregnancy. Midwifery 19, 96105.