Exploring Men’s Perception of Participating in the Natural Childbirth Process: A Qualitative Content Analysis

INTRODUCTION

Childbirth is one of the most exciting and at the same time most challenging events in a couple’s life. ¹ This period can be a unique and different experience not only for women but also for men. ² Men, as the most important companions and supporters of pregnant women, have a special role in the outcomes related to the health of mothers and babies. ^{3 , 4} Given the importance of men’s role in improving pregnancy and childbirth outcomes, male participation as a strategy is strongly recommended by the World Health Organization. ⁵ Men’s participation has a favorable role in strengthening marital relationships, increasing the quality of family relationships, successful mothers’ breastfeeding, as well as improving infant outcomes, such as proper weight gain. ⁶ Other consequences of men’s participation in the birth process include emotional support of the mother, better management of labor pain, preparation for safe delivery, and dynamic emotional relationships between the baby and the parent. ^{7 , 8}

Men’s participation in reproductive health programs can affect men’s health and development throughout their lives. ⁹ Therefore, the active participation of men in this regard will lead to changes in physical health, mental maturity, social health, and the overall development of men’s health. ⁹ Men have the potential to have a great impact as partners and beneficiaries in empowering themselves and their families. ¹⁰ The involvement of men in various reproductive periods, from pregnancy to childbirth, has begun to increase globally. ¹¹ However, it is still hampered by social and cultural barriers, lack of awareness, attitudes of both men and women, and attitudes of health service providers in certain societies, causing the absence or reduction of men’s participation in the birthing process. ¹² Some researchers believe that lack of support from the health system regarding men being present at childbirth, rejection on the part of the service providers, cultural issues, economic problems, and health barriers prevent men from actively being participants in pregnancy and childbirth. ¹³ Also, in another study, the cost of treatment centers, dissatisfaction with and avoidance of facilities, gender roles, and traditional treatment were cited as the main barriers to men’s participation. ¹⁴ Providing in-person prenatal education to men as an important component of prenatal care preparation leads to positive outcomes. ¹⁵ However,few studies on men’s involvement during pregnancy have been conducted in Iran throughout the past decades, ^{16 , 17} indicating that economic, social, cultural, personality-related, and organizational factors hold men back from participating in pregnancy and childbirth. ¹⁸

The few studies conducted in Iran cover many aspects of men’s involvement during pregnancy, whereas the present study focuses on men’s involvement during childbirth. Moreover, given that in qualitative studies, the researcher gains a deeper understanding of the participants’ perspectives, a deeper understanding of men’s perspectives seems essential to promote their participation in labor and delivery. Hence, considering the scarcity of studies on this subject and the lack of awareness of men’s preferences and needs concerning their participation in childbirth, this study explores men’s perceptions of participating in the natural childbirth process.

MATERIALS AND METHODS

This is a qualitative content analysis conducted as part of a mixed-methods study from June 2024 to November 2024. The COREQ reporting criteria were used in writing this report. ¹⁹ A targeted sampling method with extreme diversity was used for the recruitment of the subjects. The variation ensured maximum sampling diversity in terms of age, education, occupation, ethnicity, and place of residence.

Fifteen interviews were conducted with 15 men who had taken their pregnant wives to health centers for prenatal care in Ahvaz. Face-to-face interviews were conducted in a private room at selected health centers. Inclusion criteria were Iranian men whose wives had at least one history of vaginal delivery, those who were currently accompanying their pregnant wives to receive prenatal care, and men who could communicate to transfer information. Exclusion criteria included unwillingness to participate in the study. Eligible men who accompanied their pregnant women to health centers were identified by the researcher. Participants were selected from 4 health centers in different parts of Ahvaz city. Before starting the interview, the participants were assured that the interview would be completely confidential and anonymous. Written informed consent was obtained from participants to take part in the study, and verbal consent was obtained to record the interviews. For the convenience of the participants, the choice of the time and place of the interview was left to them. All interviews were conducted by the first author (L.B.) who was a PhD student in midwifery. The interview started with some general questions about age, education level, and occupation. Then, the main interview questions were asked: How do you understand men’s participation in the birth process? and How can you participate in your wife’s birth process? The interview process was guided by the responses of the participants. Also, probing questions such as “What do you mean by this sentence?” and “Please elaborate” were used. Attention was paid to the participant’s nonverbal cues (silence, smile, and sigh). Each interview lasted between 45 and 55 minutes. Data collection continued until data saturation, i.e., when no new data emerged from the participants’ conversations.

All interviews were recorded, transcribed word by word, and read line by line, and coding started from the first interview by the first author. Data analysis was done using the conventional content analysis method introduced by Granheim and Landman. ²⁰ Each interview was considered a unit of analysis. To get a general idea, the researcher immersed herself in the data by repeatedly reading the transcripts of the interviews. Then, extraction of semantic units of words, sentences, or paragraphs related to participants’ perception was done, and all similar codes were classified into primary categories. Similar primary subsets were grouped, and secondary categories emerged. Finally, the main classes were extracted. To ensure the accuracy of the data, the obtained results were provided to an external observer who was a professor of qualitative studies, and his comments were used in the final analysis.

To ensure the accuracy and reliability of the data, four main criteria, credibility, dependability, confirmability, and transferability, were used. ²¹ Credibility was achieved through extensive engagement with the data and validation of the coding and categorization by the research team. Furthermore, member checking was performed by allowing the participants to review and verify the accuracy of the interview transcripts. For dependability, sections of both the data and the analysis process underwent examination by three external experts, and a detailed audit trail was upheld. Confirmability was enhanced by obtaining feedback from three qualitative research specialists on all stages of the study, with particular attention to data collection, analysis, and category development. To ensure transferability, we provided a rich description of the phenomenon under investigation and implemented maximum variation sampling.

This study was approved by the Ethics Committee of Ahvaz Jundishapur University of Medical Sciences (Ethics Code: IR.AJUMS.REC.1403.149). The study objectives and methods, as well as the right to withdraw from participation at any time, were explained to the participants. All participants were assured that their personal identities would remain confidential. Written informed consent was obtained from all participants to participate in the study and to have the interviews recorded. This study conformed to the ethical standards of the Institutional Review Board and adhered to the principles outlined in the Declaration of Helsinki.

RESULTS

The participants included 15 men aged 26 to 56 years old. Table 1 reports their demographic characteristics. The data analysis obtained one theme, 4 main categories, and 14 subcategories. Four main categories emerged including: “Weaknesses of men’s awareness of participation in childbirth”, “Men’s fear of participation in childbirth”, “Men’s willingness to learn and participate in childbirth”, and “Strategies to improve men’s participation in childbirth “ and finally abstracted in the theme “Willingness to participate in an aura of weaknesses and fears”. Below are the results of the analysis of the interviews, along with the quotes (Table 2).

Willingness to Participate in an Aura of Fears and Weaknesses

The analysis of the participants’ conversations showed that, for various reasons, men live in an aura of weakness and fear regarding the category of participation in the childbirth process; on the other hand, the desire to learn and increase awareness seems to be high among them.

1. Weaknesses of Men’s Awareness of Participation in Childbirth

The analysis of the interviews showed that, in general, men have little information about their participation in the birth process. Men’s weak awareness of the importance of their role, weak knowledge of the birth process, and weak awareness of women’s preferences were the three subcategories of this category.

1.a. Weak Awareness of the Importance of One’s Role

Data analysis indicated that men who lacked adequate training or information regarding their roles in the childbirth process might hold an incomplete or inaccurate understanding of their responsibilities before, during, and after the delivery. Two participants said:

“Why does it matter whether I’m there during labor or not? No one has anything to do with us during labor. Whether I’m there or not doesn’t matter?”(P4).

“I don’t think that my presence during childbirth matters because I can’t help.” (P1)

1.b. Weak Knowledge of the Birth Process

Men’s poor knowledge of the stages of labor and information related to how the birth process occurs makes them feel unfit to join and cooperate in the process. A participant stated:

“When I don’t know how childbirth takes place, how should I participate? I don’t have information about childbirth at all.” (P9)

1.c. Weak Awareness of Women’s Preferences

It seems that men’s lack of familiarity and awareness of women’s preferences in various areas, such as choosing a place to give birth or other interests and needs of women during childbirth, is an obstacle to men’s participation in the childbirth process. A man told:

“I do not know. Perhaps my wife does not want me to be with her during labor. Maybe he just does not care if I was present at that time.” (P5)

2. Men’s Fear of Participating in Childbirth

Men stated that various reasons, including fear of seeing women’s suffering, fear of feeling powerless, fear of socio-cultural stigma, and fear of communication challenges with providers, prevent them from participating in childbirth.

2.a. Fear of Seeing the Suffering of the Wife

The data analysis showed that witnessing the suffering of wives during childbirth might prevent men from searching for information about this issue. They believe that the pain experienced by women and the sounds of their cries and screams cause men to fear childbirth, leading them to avoid involvement. A participant implied:

“I don’t like to see my wife suffer. I’m very afraid to hear her scream. I’m sure it’s a painful scene.” (P8)

2.b. Fear of Feeling Powerless

Most men believed that they were afraid of the birth process. They considered the most important reason for their fear to be their inability to participate. The inability to help and participate in the birth process can have various reasons.

“They say childbirth hurts a lot. I’m afraid I can’t help her. My presence during childbirth will be disappointing.” (anxious face) (P10)

2.c. Fear of Socio-cultural Stigma

According to them, cultural and social norms have prevented men from being present at childbirth. Cultural factors seem to constitute one of the strongest barriers to men’s support during childbirth. However, cultural stereotyping has a considerable influence on men’s views. Participants implied:

“I don’t know... maybe I will be able to support my wife during childbirth, but I would be really afraid that my friends and acquaintances to mock me for the rest of my life.” (P7)

“It’s simply not right for a man to be present while his wife is giving birth; I could never do this. I’m afraid if someone finds out, someone might tell the others.” (P5)

2.d. Fear of Communication Challenges with Providers

According to men, communication problems with service providers are another reason that hinders their participation during childbirth. Improper attitudes from healthcare providers and their refusal to accept the presence of men in the women’s maternity environment are other barriers. Two men said:

“Men are treated very badly in hospitals, especially in women’s departments. Doctors and nurses do not allow a man to enter the ward.” (P3)

“When my wife was delivering, I went to the door to ask how she was doing. I was told that I shouldn’t come into the maternity ward since men weren’t allowed into the ladies’ ward.” (P4)

3. Men’s Willingness to Learn and Participate in Childbirth

The results showed that men had a desire to learn their role to support their wives in the birth process for various reasons. Despite the hurdles men must jump over in childbirth, they seem motivated enough to want to be involved in the birth of their children.

3.a. Men’s Motivation

Motivated men search for information and learning opportunities on childbirth. Men want to participate mainly to strengthen the emotional bond with their wives, to make their partner happy, and to support their wife during one of the most difficult and exciting events in their lives. A man said:

“Giving birth is an important event. I would like to learn how a man can help during childbirth so that I can help my wife during childbirth.” (P6)

3.b. Men’s Curiosity

Data analysis showed that curiosity could increase men’s willingness to learn how to participate in the birth process. Men are curious and seek to learn about the childbirth process and the unique, unforeseen events that can occur during each delivery. A participant told:

“Giving birth is a strange event. I want to know what can happen and how the baby is born.” (P2)

3.c. Support of Couple’s Emotional Connection

Men’s emotional connection with their wives makes them interested in learning how to support their wives. Emotional connections between husband and wife can be an important factor in men’s willingness to learn how to participate in the childbirth process. A participant said:

“My wife and I are very close. She is going to be the mother of my child. I will do whatever I can for her. If they arrange a class for men, I will attend so that I can help her.” (P1)

3.d. Men’s Personal Growth and Development

Most men believed that helping women during childbirth could lead to their growth and development. Therefore, they want to learn their role in the birth process.

“The woman indeed gives birth, but the man is also the father of the child. If I can help my wife during childbirth, I will feel stronger.” (P11)

4. Strategies to Improve Men’s Participation in Childbirth

Men had suggestions to improve their participation in the birth process after their desire to participate in the birth process.

4.a. Holding Related Training Courses

Men believed that there was a need for training courses for men to learn how to participate in the birth process and that the healthcare system should consider this training to increase men’s awareness and preparation. Two participants said:

“I think health centers or hospitals should hold classes for men and teach us what we can do that will be useful.” (P15)

“If they hold a class for men about childbirth, I will participate. Everything that is needed can be taught in different ways. Face-to-face or online classes are both good.” (P12)

4.b. Health System Support

Men stated that health system support was needed to improve participation. If the healthcare system does not support men’s presence and participation in the childbirth process, other efforts will be futile. Two men implied:

“In my opinion, the hospitals should first cooperate and accept the presence of men in the maternity hospital.” (P10)

“Health centers and hospitals should make sure that men can be with their wives during childbirth. For example, the delivery room should be private so that no one will be disturbed.” (P2)

4.c. Striving for Cultural Changes

According to men, the most important principle for improving men’s participation in the birthing process is cultural changes. Although changing cultural stereotypes takes time, accepting men’s presence in the childbirth process as partners requires addressing cultural issues. Two participants stated:

“Until we grow culturally, this problem exists. In my opinion, educational programs such as films on television should be used to change people’s culture.” (P9)

“The main issue is culture. Our culture does not accept the presence of men during childbirth. We have to correct the culture first.” (P13)

DISCUSSION

The present study aimed to explore men’s perceptions of participating in the natural childbirth process. From the analysis of the interviews, an overall theme of “Willingness to participate in an aura of weakness and fear” and four main categories, “Weaknesses of men’s awareness of participation in childbirth”, “Men’s fear of participation in childbirth”, “Men’s willingness to learn and participate in childbirth” and “Strategies to improve men’s participation in childbirth”, were extracted.

Weaknesses of men’s awareness of participation in childbirth were one of the key findings of the present study. Many men do not seem to be sufficiently cognizant of their position in the whole process of birthing, and thus in this process. A possible cause of ignorance may include many factors, like an absence of proper education about childbirth and related processes. Also, cultures and social attitudes can cause men not to pay attention to this issue, leading to a sense of weakness in them. In most traditional societies, childbirth is thought to be the sole responsibility of women. Therefore, men may feel left out of this process and may not seek awareness of their role in the birthing process. ²² A study identified a lack of awareness of men’s roles as a major barrier to men’s participation in pregnancy and childbirth. ²³ However, due to cultural beliefs that discourage male involvement in childbirth, there are challenges in helping men recognize their significant role during childbirth and the postnatal period. It is essential to address these issues by promoting awareness among men. ^{24 , 25} Many men do not know about the biology of pregnancy, the processes of labor, and the physical and emotional changes in the course of delivery. ²⁶ While in the world, education about danger signs, preparation for childbirth, and preparation for childbirth complications among men have been considered essential. ^{27 , 28} Men’s poor awareness of their partner’s preferences during labor can have a significant impact on the birth experience for them. Therefore, men should know their wives’ preferences so that they can meet their wives’ needs during childbirth. ²⁶

Men’s fear of participating in childbirth can have different dimensions, such as fear of seeing their wives suffer, fear of feeling powerless, fear of socio-cultural stigma, and fear of communication challenges with providers. Seeing a partner in pain or discomfort can be distressing for men, so men’s fear of their emotional reactions, such as anxiety, can be an obstacle to active participation in the birthing process. ²⁹ Men may also fear feeling powerless or helpless during the birth process, especially if they are unsure of how to provide effective support or how to deal with unexpected challenges in the birth process. ³⁰ Negative beliefs and cultural-social stereotypes can also affect men’s fear of participating in the birth process. ³¹ Cultural taboos may prevent men from seeking information about childbirth and prevent them from wanting to learn about childbirth, and engage in supportive behaviors during the process. ^{32 , 33} Another reason that has led to men’s fear of participating in childbirth is the fear of communication challenges from providers, such as bad behavior or their non-cooperation for the presence of men in childbirth environments. The lack of support from health care providers and the medical system makes men not seek to learn information about the birth process because they feel they have no special role in childbirth. ³⁴ In general, the fear of childbirth is an important and uncomfortable experience for men. Therefore, men need appropriate opportunities to talk about their fears of childbirth. ²⁹

Men’s willingness to learn and participate in childbirth was one of the key findings of the present study. According to the findings of this study, it appears that curiosity, support from partners, and men’s efforts to promote their own personal growth can increase men’s motivation to participate in the birth process. In fact, men are motivated to learn how to be a part of the birth process by wanting to support their partners and prepare themselves to face the challenges of childbirth. Men are more motivated than before to seek out information, resources, and opportunities to learn about childbirth. ³⁵ Curiosity can increase their willingness to learn how to participate in the birth process and adapt to the demands of supporting their partner during labor and delivery. ³⁶ Men’s desire to participate in the birthing process can be to provide emotional support to their partner. Being present, paying attention, and responding to the needs of the partner can strengthen the bond between couples and provide psychological support and a positive birth experience. ³⁷ Additionally, men’s desire to learn about childbirth participation may stem from a desire for personal growth and development. Learning how to participate in the birth process can be an opportunity to strengthen their skills, deepen their relationship with their partner, and grow personally. ^{37 , 38} Studies show that today’s men are willing to learn and participate in the pregnancy and childbirth process. ^{39 , 40}

Strategies to improve men’s participation in childbirth were among other categories found in the present study. It seems necessary to hold training courses related to men’s needs, health system support for men’s participation, and efforts for cultural changes to improve participation. The results of a systematic review showed that educating men during pregnancy is the most important factor for their participation during this period, and improvement of family health. ¹⁵ Educating men through related books or attending childbirth preparation classes will help. These trainings help men learn about the stages of childbirth, relaxation methods, and how to support their wives, and they can understand the importance of their role in this challenging process. ³⁸ Also, the health system can help improve men’s participation by creating a supportive environment, encouraging midwives and doctors to welcome men’s participation in childbirth, and asking men’s opinions on various decisions. Men’s experiences of the childbirth process are strongly dependent on the support of treatment systems and service providers. ³⁹ On the other hand, cultural changes can play an important role in increasing male participation in childbirth. Holding workshops, seminars and training sessions regarding the importance of men’s role in childbirth and family health; sharing the positive experiences of men who participated in childbirth; and creating a suitable space for open conversations about childbirth will be effective in changing the culture. ⁴¹

Given the limited number of studies on male participation in the vaginal birth process in Iran, it seems that this study provides a deep understanding of men’s preferences and needs in light of the cultural context in this regard. As a limitation of this study, participants were limited to men who accompanied their wives to receive care at health facilities. Because this was a selected population, it seems that their views may not be representative of all men who were unable to accompany their wives for whatever reason. However, we tried to examine men’s perceptions through in-depth interviews and provide new knowledge about men’s needs and preferences according to the culture present in the region.

CONCLUSION

This study provides a detailed understanding of men’s perspectives regarding their participation and cooperation in the birth process. This study shows that despite men’s desire to participate in the birth process, weaknesses of men’s awareness, inability, and fear prevent them from doing this important work. Enhancing awareness and education for men about their significance and roles during pregnancy and childbirth appears essential. Establishing social networks and cultural programs to encourage men to take on an active role in the family and the pregnancy process can lead to substantial improvements at the community level.

Acknowledgment

This article was extracted from the thesis of Leila Bozorgian, a PhD student in midwifery. We thank all the men who participated in this study and the cooperation of Ahvaz Jundishapur University of Medical Sciences for financial support.

Authors’ Contribution

LB and SM were responsible for the conceptualization and design of this study. The data collection was conducted by LB. The data analysis and interpretation were done by LB, SM, MJ, and MI. LB drafted the initial manuscript. All authors critically reviewed and revised the manuscript and approved the final version for publication. All authors take responsibility for the data integrity and the data analysis. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

Funding Source

The Vice Chancellor for Research of Ahvaz University of Medical Sciences supported this study (grant code 330102625).

Conflict of Interest

None declared.

Declaration on the Use of AI

In this study, the authors used ChatGPT (version 4o) to edit the translation of a limited number of sentences.

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