In the present study, 21 interviews were performed. A total of 5 pregnant or recently- delivered, 7 men and 9 key informants with an age range of 24 to 60 years and a mean age of 38.3 years (Tables 1 and 2) participated. After interviewing with the participants, 1856 initial code was extracted, which 33 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 (Table 3). There were 5, 4, and 3 subcategories in incentives, constraints, and gender attitudes respectively.
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
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. Some of them 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. Individual responsibility and Positive attitude were other Individual factors that were stated by the participants.
"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)
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. Some participants in this study believed that proper relationships between couples and the expression of desires by women increase the men’s involvement.
"My mother-in-law also tells him be careful of your wife." (Participant No. 8, Pregnant Woman, bachelor, 35 years old).
1-3: Economic factors
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. 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.
"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).
4-1: Legislative factors
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. 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.
"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).
Some participants believed that adequate skills of midwifery providers were influential factors in increasing men’s involvement. 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
Some participants stated that problems in emotional and social personality of some men could be a barrier to their involvement in midwifery care. 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. 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.
"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).
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
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. 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).
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.
3-2: Socio-economic factors
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. 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).
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
Some participants believed that the rules to protect men and increase their involvement are defected and need to be reformed. 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. Also, some participants complained of lack of coordinated and integrated implementation of some rules between different public and private centers
"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)
"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).
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.) (18). 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. some participants referred to high effect of man’s primary family (mother, father, siblings), friends and relatives on men’s participatory behavior and TV series and movies in creating authoritative attitudes in men and reducing their involvement.
"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).
People stereotypes and beliefs about men have a great effect on men’s involvement. 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. Also, some of the habits of men reduce their involvement in prenatal, childbirth and postpartum care.
"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).
According to some participants, some men refuse to involve because of the possibility of negative judgments about them, fear of rejection by those around them and fear of power inversion (they have to do their wife’s duties and responsibilities).
"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).