After interviewing with the participants, 1856 initial code was extracted, which33 final codes were obtained in the process of data analysis and comparison after classifying the codes and deleting similar codes. The main theme of the study was the "dual mechanisms of men’s involvement in perinatal care", which were classified into three main categories (including incentives, constraints, and authoritarian gender attitudes) and 12 sub-categories.
The main class of "incentives" consists of 5 sub-categories, including "individual factors", "family factors", "economic factors", "legislative factors" and "organizational factors" and main class of "constraints" consists of 4 sub-categories, including "individual factors", "organizational factors," "socioeconomic factors," and "legislative factors". Also, the class of “authoritarian gender attitudes” includes the sub-categories of “subjective norms”, “stereotypes”, and “hidden fears” (Table 3).
Besides some of the barriers that reduce men's involvement in prenatal, childbirth, and postpartum cares, a number of individual, family, economic, organizational, and legislative factors increase men’s involvement. This class consists of 5 sub-categories, including: individual incentives, family incentives, economic incentives, legislative incentives, and organizational incentives.
1-1- Individual factors
1-1-1- Enthusiasm for having children: The passion and interest of some men to become father was a factor that was considered by the participants in this study as a facilitator of men’s involvement.
"He is helping his wife for nine months. He is helping his wife for his desire to have a child" (Participant No. 19, self-employed, Diploma, 60 years old)
1-1-2: Optimal Awareness: Some participants believed that some men have good involvement because they are well aware of the importance of their involvement and issues related to prenatal and childbirth and postpartum cares.
"When her husband found out that his wife had to take iron, he forced her to come here to get iron, and when his wife gave birth, he brought his child here" (participant No. 16, midwife of the health center, bachelor, 33 years old).
1-1-3- Individual responsibility: According to some of the participants of this study, men's sense of responsibility and their commitment to their spouse and children cause them to involve more and more in cares of this period.
"Some people think they should be beside their wives always. When they marry, they commit, not that they think they are still single and they should be the same as they were single (participant No.14, faculty member, master, 33 years old).
4-1-1: Positive attitude: Some participants stated that men who have a positive attitude towards their spouse and believe that the duties and responsibilities are shared between husband and wife have a better involvement in family life.
"A man should know that he is a member of the family. Fifty percent of the family's responsibilities are for woman who accepts and does her own work, and the remaining 50 percent is for man and even some men believe that their share of life is more than 50%, so they should be equally involved in the family affairs (Participant No. 5, Woman, Faculty Member, PhD, 41 years old).
1-2-1: Accompanying families: based on the participants, men who are encouraged to involve by their primary family (father, mother, siblings) have better involvement and cooperation with their spouses in midwifery care.
"My mother-in-law also tells him be careful of your wife." (Participant No. 8, Pregnant Woman, bachelor, 35 years old).
1-2-2: Optimal interaction between couples: Some participants in this study believed that proper relationships between couples and the expression of desires by women increase the men’s involvement.
"I have told him don’t speak about things that you know annoy me when you see I'm sad or tired. When I am mentally occupied, it affects my appetite and causes a stress or tension in my mind that can leave an effect on the child. He usually listens my words and observes these points (participant No. 8, pregnant woman, bachelor, 35 years old).
1-3: Economic factors
1-3-1: Sustainable financing: Most participants believed that despite the high cost of living and the high cost of midwifery services, if a man does not have a reliable and sustainable financial source, he would not have an opportunity and motivation to help his wife. In contrast, having a good income and a reliable and stable financial source will be an incentive for his involvement.
"My brother helps his wife so much and it is due to his income. He has high income. He helps his wife and children in spending." (Participant No. 19, male, self-employed, diploma, 60 years old).
2-3-1: Free childbirth services: Some participants were satisfied with the free provision of some services during pregnancy and childbirth and after childbirth and thus increased men’s involvement, and hoped that such services to increase, especially for low-income families in the community.
"We have now contracted with several private clinics to hold free maternity classes for pregnant women and their spouses" (Participant No. 4, female, Head of Maternal Health Department, master, 44 years of old)
4-1: Legislative factors
1-4-1: Implementation of Health Transformation Plan: Some participants in this study believed that health transformation plan and reduction of midwifery service costs as an important turning point in increasing men’s involvement in midwifery cares.
"Fortunately, health transformation plan has reduced the costs significantly, including costs of maternity, hospitalization, and tests. We are currently performing some of our tests in comprehensive health centers for free” (Participant No. 4, female, Head of Maternal Health department, master, 44 years old).
2-4-1: Supportive role of officials and legislators: The cooperation and support of some managers of centers and political officials in increasing men’s involvement was one of the facilitating factors mentioned by some key informants.
"We have many phone calls with the women’s husbands. In general, our center accepts the cost of the phone call, and it is not something to say, because these are men, you shouldn't call" (Participant No. 9, clergyman, 35 years old)
"The postpartum leave dedicated for fathers, of course, if the government does not regret (laughs), will have a great impact" (Participant No. 16, midwife of health center, bachelor, 33 years old).
1-5-1- Factors related to health service providers: Some participants believed that adequate skills of midwifery providers were influential factors in increasing men’s involvement.
"In the classroom, as they hear these teachings from an expert, they are accepting them more. The same things may be said by his wife, but he may think that his wife says these things to make me aware of him." (Participant No. 13, midwife of the maternity ward and instructor of preparation classes for childbirth, bachelor, 41 years old).
2-5-1: Physical structure appropriate to health service recipients: The appropriate space of some centers, good facilities of the centers and the separation of the rooms were among the factors that were mentioned as facilitators of men’s involvement by key informants of this study.
"our other bases are very good, for example, Safashahr center, all are good rooms. For example, In Meysam center, all rooms are partitioned" (participant No. 16, midwife of health base, bachelor, 33 years old).
According to participants, in addition to authoritarian gender attitudes, a number of individual, economic, organizational, and legislative factors can also reduce men’s involvement in prenatal, childbirth, and postpartum care. This class consists of 4 sub- categories, including individual constraints, organizational constraints, socio-economic constraints, and legislative constraints.
1-2: Individual factors
2-1-1-Emotional-social immaturity: Some participants stated that problems in emotional and social personality of some men could be a barrier to their involvement in midwifery care.
"Many men are also jealous. I really had a client and I saw that he told the woman not to breastfeed the baby, because I want my wife to be mine and I don't want to breastfeed the baby and every time they came together, the baby was in the father’s arm” (participant No. 16, midwife of the health center, bachelor, 33 years old).
2-1-2: Lack of knowledge: According to the majority of participants in this study, men's non- involvement was due to lack of knowledge about issues related to pregnancy and childbirth and changes and needs of women in this period and lack of familiarity with way of participating and so on.
"They don't know that a woman has these needs, and in this way, for example, they can meet their wife's needs." (Participant No. 5, female, faculty member, PhD, 41 years old).
2-1-3: High-risk behaviors: The presence of high-risk behaviors such as addiction, leaving life, remarriage, inappropriate behavior of women, etc. are among the factors that were mentioned as reducing factors in men’s involvement by some participants.
"When I see some people worried, I talk to them for a while and ask them and I realize that either their husbands are addicted or they have a second wife" (Participant No. 13, midwife and instructor of childbirth preparation classes, bachelor, 41 years old).
2-1-4: Conflict in couples: According to some participants, marital conflicts and misunderstandings between couples can negatively affect men’s involvement.
"I think their cultures must be adapted with each other. I always say it might take three to five years so that couples culture to be adapted with each other. If a woman has a sensitive spirit, when her husband's family says something might be important for her, while it does not important for man. They need to be adapted with each other "(Participant No. 13, midwife and instructor of childbirth preparation classes, bachelor, 41years old).
2-2: Organizational factors
2-2-1: Human resources: The low number of midwifery service providers in each work shift, despite the large volume of works, was one of the barriers to men’s involvement, which was mentioned by some key informants of this study.
"It's not easy for men to enter and exit the ward where so many sick women have been hospitalized. We do not have that much strength, and we have high-volume work (Participant No. 15, midwife of maternity wife, bachelor, 42 years old).
2-2-2- Allocated Budget: Some of the key informants participating in this study were complaint of the budget allocated to centers and considered it a barrier to men's financial involvement in midwifery care.
"Of course, we have a budget constraint in this regard and we have a cost ceiling to introduce low-income people" (Participant No. 4, female, head of the Maternal Health Department, Master, 44 years old).
3-2-2: Inappropriate physical structure: Small space, lack of separating rooms and low number of seats in health service centers are among the organizational factors that were mentioned as barriers of men’s involvement by some key informants of this study.
"You see how small the waiting space for our clients is here. When men come here, they see that women have sated here, they see there is no more than 4 seats and women have seated and their child on their arm. Our space is very small. If space is enough, men will welcome well (Participant No. 16, health base midwife, bachelor, 33 years old).
3-2: Socio-economic factors
1-3-2: Lack of economic security: According to the participants, lack of job security in men and the possibility of dismissal from work, if they take leave to accompany their spouse, as well as high cost of services during this period are among the factors making men prefer their job over accompanying their spouse.
"All contracts are short-term and they can be easily dismissed and when they see the conditions, they refuse taking leave and cannot help his wife " (Participant No. 19, male, self-employed, diploma, 60 years old) .
2-3-2: Lifestyle changes compared to past: Some participants believed that changing the lifestyle of families compared to the past, high costs and concerns of today's lives have caused men to have less opportunities and motivation to help their spouse.
"In old days, only men managed it well. They did not have today's concerns (Participant No. 19, male, self-employed, diploma, 60 years old).
2-3-3: Changing roles: Some participants considered change in the roles and responsibilities of men and women in today's community and increasing men's expectations of women, even to fulfill men's responsibilities, as a barrier to men’s involvement.
"Unfortunately, both before and after childbirth, the only expectation is from the spouse, while the duty and role of the man is forgotten" (Participant No. 9, clergyman, 35 years old).
2-4- legislative factors
2-4-1: Defect in the existing rules: Some participants believed that the rules to protect men and increase their involvement are defected and need to be reformed.
"All contracts have become 3-month contracts and they are dismissed easilly" (Participant No. 19, male, self-employed, diploma, 60 years old).
2-4-2- Lack of supportive laws: Some participants stated that there were no rules to support men’s involvement, and even the rules that had previously been passed in this regard were removed after a while.
"The two-week postpartum leave rule considered for men was very good and helpful in that regard, but unfortunately it was removed." (Participant No. 4, female, Head of Maternal Health Department, Master, 44 years old)
"Unfortunately, we have no plans to train men." (Participant No. 14, female, faculty member, master, 33 years old).
2-4-3- Lack of integrated implementation of related rules: Some participants complained of lack of coordinated and integrated implementation of some rules between different public and private centers.
"In private hospitals, the presence of men is not a problem, but in public hospitals, conditions are different" (Participant No. 9, clergyman, master., 35 years old). At least during pregnancy, employer should give a leave for a husband whose wife is pregnant, when his wife has an ultrasound or a physician’s appointment so that he can accompany his wife. If he says, I want to go after my wife, they should agree with him, whether it is private or public. Private clinics do not support at all." (Participant No. 12. Pregnant woman, bachelor, 42 years old).
3: gender authoritarian attitude
Considering male gender as a superior gender is one of the factors that are effective in men’s involvement by most key informants. This class consists of 3 sub- categories, including subjective norms, stereotypes, and hidden fears.
1-3: Subjective norms:
The subjective norm refers to the social pressure perceived by the individual to do or not to do the desired behavior. Individuals do often according to their perception of others (friends, family, co-workers, etc.) (23). Models that men adopt them as norm are extremely influential in their participatory behaviors. These norms can be family, friends, acquaintances, or the media, whether real or virtual media.
3-1-1-Other important people: some participants referred to high effect of man’s primary family (mother, father, siblings), friends and relatives on men’s participatory behavior.
"I know someone who has a PhD level of education but when I said these things in class, his mother said, 'What do you expect men to do? Don't say that to men. It is clear that the family is reminding the man not to help his wife. " (Participant No. 13, midwife of the maternity ward and instructor of preparation classes for childbirth, bachelor, 41 years old).
3-1-2: Media: Some participants referred to the role of TV series and movies in creating authoritative attitudes in men and reducing their involvement.
"When a family series is played, the whole family sits at the TV and watches it, but what do we see? We see the man go to work and then he comes home with a newspaper on his hand and he seats on sofa and watches the TV and drinks a tea, and then, at the end of the night, after eating the dinner, he goes to bed. " (Participant No. 13, female, midwife of the maternity ward and instructor of preparation classes for childbirth, bachelor, 41 years old).
People stereotypes and beliefs about men have a great effect on men’s involvement.
3-2-1- Social conformity: Some participants believed that some men, as a result of following the values and behaviors of the majority of society, agreed with them and considered it shameful to involve and accompany their spouse.
"In private conversations with each other, working at home and taking care of their child is a shame and disgrace" (Participant No. 5, female, faculty member, PhD, 41 years old).
3-2-2- Habits: According to the participants, some of the habits of men reduce their involvement in prenatal, childbirth and postpartum care.
"I think, one of the needs of a person is receiving psychological attention as well as emotional support, understanding it and expressing it. Sometimes, we are thinking that man is understanding but men do not tend to express many things verbally (Participant No. 15, midwife, midwife of maternity ward, 42 years old).
3-2-3: Socialization: Some participants believed that accepting the values and norms of society can affect men’s involvement.
"The norm of society is that the man earns money and it is a social anti-norm for the man to help his wife at home. And these norms of society have a great impact on men's performance and their involvement and, in fact, their behavior." (Participant No. 5, female, faculty member, PhD, 41 years old).
3-3-1: Fear of judgment: According to some participants, some men refuse to involve because of the possibility of negative judgments about them.
"Someone may like to work, to collaborate, but he says to himself, 'I'm a man, it is non-accepted to do that work (Participant No. 11, midwife of the maternity ward, bachelor, 40 years old).
3-3-2- Fear of rejection: According to some participants, some men think that actively participating in midwifery care causes them to be rejected by those around them.
"For example, a man may think 'If I want to say to my wife let me listen to baby’s heart, or if I want to talk about the classes on childbirth, I will be rejected by others (Participant No. 11, midwife of maternity ward, 41 years old).
3-3-3: Fear of power inversion: Some participants believed that some men think that if they involve, their spouse may become a superior power at home over time, so they have to do the their wife’s duties and responsibilities.
"I saw that some men were saying that if we involve, our wife might be spoiled and she does not do her works and we have to their works and duties (Participant No. 13, midwife of the maternity ward and instructor of preparation classes for childbirth, bachelor, 41 years old).