male and female involvement in the birth and child-rearing process

CLINICAL ISSUES

Male and female involvement in the birth and child-rearing process

Gracia Maroto-Navarro, Guadalupe Pastor-Moreno, Ricardo Oca~na-Riola, Vivian Ben�ıtez-Hidalgo,

Mar�ıa del Mar Garc�ıa-Calvente, Mar�ıa del Pilar Guti�errez-Cuadra, Mar�ıa T Gij�on-S�anchez, Mar�ıa del

R�ıo-Lozano and Jorge Marcos-Marcos

Aims and objectives. To know the male involvement during pregnancy and childbirth, with special attention to their partici-

pation in public services of perinatal health and the impact that this participation has on their subsequent involvement in

child-rearing, to compare the male and female involvement in child-rearing and to identify the factors associated with a

greater male involvement.

Background. Most of the research on male involvement in birth and child-rearing comes from Anglo-Saxon and Scandina-

vian countries. These studies show a lower involvement of men in relation to women, even in countries with instruments to

promote gender shared responsibility. The Spanish Ministry of Health has developed strategies to improve the male involve-

ment in the public services of perinatal health to advance in gender equality. This is a suitable context to contribute to the

lack of information about fatherhood and the gender inequalities in the Spanish context.

Design. Transversal design.

Methods. A questionnaire was administered to 150 fathers and 157 mothers residing in Granada, with at least one biological

child aged 2 months to 3 years.

Results. A minority of the men attended the childbirth education whereas most of them attended pregnancy check-ups and

were present at birth. Women spent more time with their children and took charge of tasks of child-rearing to a larger

extent. The profile of an involved father is a man with a higher level of education, not married, his partner has a full-time

employment, born in Spain and attended to the childbirth education classes.

Conclusion. This study shows gender inequalities in the reproductive field beyond the biological conditions.

Relevance to clinical practice. The challenge of the health services is to promote social change and identify areas for

improvement to include the father figure in public services of perinatal health.

Key words: gender perspective, health promotion, inequalities in health, parenting, perinatal care, reproductive health

Accepted for publication: 24 October 2012

Introduction

At the Cairo Conference (United Nations 1995), for the

first time and from a bio-psycho-social approach, men were

designated as reinforcing agents of the reproductive health

of women, and the role they played in the achievement of

gender equality when they take part in the household

responsibilities and family care was recognised. It was also

Authors: Gracia Maroto-Navarro, ScD, Lecturer, Andalusian School

of Public Health, Granada and CIBER de Epidemiolog�ıa y Salud

P�ublica (CIBERSP), Madrid, Spain; Guadalupe Pastor-Moreno,

ScD, Research Specialist, Andalusian School of Public Health,

Granada; Ricardo Oca~na-Riola, PhD, Lecturer, Andalusian School of

Public Health, Granada; Vivian Ben�ıtez-Hidalgo, ScD, Research

Specialist, Andalusian School of Public Health, Granada; Mar�ıa del

Mar Garc�ıa-Calvente, PhD, MD, Lecturer, Andalusian School of

Public Health, Granada; Mar�ıa del Pilar Guti�errez-Cuadra, ScD,

System Information Director, Virgen de las Nieves Hospital,

Granada; Mar�ıa T Gij�on-S�anchez, PhD, Lecturer, University of

Malaga, M�alaga; Mar�ıa del R�ıo-Lozano, ScD, Research Specialist,

Andalusian School of Public Health, Granada; Jorge Marcos-Marcos,

ScD, Research Specialist, Institute for Women’s and Gender Stud-

ies, University of Granada, Granada, Spain

Correspondence: Gracia Maroto Navarro, Lecturer, Cuesta del

Observatorio s/n, 18080, Granada, Spain. Telephone: + 34 958

027400.

E-mail: [email protected]

© 2013 John Wiley & Sons Ltd

Journal of Clinical Nursing, 22, 3071–3083, doi: 10.1111/jocn.12153 3071

highlighted that male involvement in birth and child-

rearing gives them a right and an opportunity of personal

development, which they usually disregard due to gender

orders.

The Spanish State is integrated by 17 autonomous com-

munities. Andalusia is the Spanish Autonomous Community

with the greatest number of inhabitants (over 8 million)

and the second in surface. Historically, a crossroads of

three cultures – Christians, Muslims and Jewish –has

enjoyed remarkable growth and improvement in living con-

ditions. Since the accession of Spain to the European Union

in 1986, Andalusia has also successfully transformed itself

from a traditional region of emigration into a host region

for new immigrants. Despite the progress made, the region

lags behind the Spanish and the European Union averages

in key socio-economic indicators (Organisation for Eco-

nomic Co-operation and Development 2011a).

Public health services in Spain are one of the most direct

means of contact with the fathers and one of the few

resources available to empower them in the field of care

(Maroto-Navarro et al. 2009).

The Spanish National Health System – publicly funded,

universal and free – is configured as a coordinated set of de-

centralised health services in every autonomous community

(Ministry of Health & Social Polities 2010). Most of the

Spanish population and the population of Andalusia use pub-

lic health services during pregnancy and childbirth. The city

of Granada, one of the eight cities of Andalusia with 240,099

inhabitants (National Institute of Statistics 2011), has two

public and two private hospitals that attend births. Some

available data show that 90�3% of the births in the city of

Granada were attended in the only two public hospitals

(Virgen de las Nieves Hospital and San Cecilio Hospital; Health

Council of the Andalusian Regional Government 2006).

The Andalusian Health Service offers also a universal free

assistance during pregnancy and birth by family physicians

at primary health centres. The prenatal care includes the

early detection before the 12th week of gestation, at least

three ultrasounds and five check-ups, to assess obstetric risk

and to follow an analytical monitoring. This service offers

also free childbirth classes that are leaded by midwifery and

nurses (Andalusian Health Service webpage, http://www.

juntadeandalucia.es/temas/salud/servicios/embarazo.html;

accessed September 2012). The sessions are carried out

before 32 weeks of gestation, and these have a comprehen-

sive approach aimed at improving the biological, psychologi-

cal and social health. Each health centre plans the childbirth

classes autonomously, according to the characteristics of the

population attending. Usually, health centres organise

groups of at least 12 participants who attend 8 sessions of

approximately 2 hours in the morning and/or afternoon.

The professionals offer the childbirth sessions to women and

those wishing companions, with particular emphasis on the

importance of the father’s presence. Therefore, all the fathers

are ever invited to participate in the childbirth sessions. Also,

during birth, some laws include the right of the mother to

stay accompanied with ever person who she chooses, fathers

or close persons (Ordinance 101/1995). In practice, the

mother is exerting this right mainly in the case of uncompli-

cated deliveries, but not in all types of delivery.

Over the past years, the Spanish Ministry of Health

has developed two national strategies aimed at improving

the quality of the perinatal care in the public healthcare

system throughout the country. These are the Strategy for

Assistance at Normal Childbirth (Ministry of Health &

Consumer Affairs 2008) and the Strategy for Sexual and

Reproductive Health (Ministry of Health & Social Poli-

cies 2011). Both of them include the objective of promot-

ing a greater male involvement during the birth process.

From 2007, the Andalusian community is implementing

these recommendations in all healthcare services (including

those in the city of Granada) through the Program for

Humanisation of Perinatal Care in Andalusia (Health

Council of the Andalusian Regional Government 2012).

This programme, which is directed to the perinatal health

professionals who work in the public system of health, is

intended to disseminate the relevance of information, listen-

ing and shared decision-making among professionals of

perinatal care, as well as to promote good practices for an

active involvement of female users and their partners, em-

phasising the right of the mothers to have an accompanist

(usually the father) in all types of deliveries.

However, no quantitative data have been published to

analyse what response men are having to the participation

opportunities provided by health services, especially from

the implementation of the new strategies for improving peri-

natal care. In general, there is no information available at a

national or regional level, neither specifically from the city

of Granada, on the current participation of men in health

services, or the impact that this has on their subsequent

involvement in parenting. This work aims to contribute to

this lack of information in the Spanish context, studying the

population of fathers and mothers who have had a child in

one of the two public hospitals in the city of Granada.

Background

Most of the research on male involvement in the process of

birth and child-rearing comes from Anglo-Saxon and Scandi-

navian countries (World Health Organization 2007). In these


3072 Journal of Clinical Nursing, 22, 3071–3083

G Maroto-Navarro et al.

contexts, the benefits of the male involvement in the well-

being and in the health of the father, partner and child have

been identified. The factors that favour male involvement in

the process of child-rearing have also been studied. Among

these factors stand out a younger age, a higher level of educa-

tion, a remunerated employment of the partner or the enjoy-

ment of a paternity leave for birth (Sundstr€om & Duvander

2000, Costigan et al. 2003, O’Brien & Shemilt 2003, Allen

& Daly 2007, M�ansdotter & Lundin 2010). In the American

context, the National Institute of Child Health and Human

Development (NICHD Early Child Care Research Network

2000) manages two indicators to measure male involvement:

the presence of the father in the health services (which has

increased since the 1980s to the year 2000 from 27–85%)

and the performance of child-rearing tasks (which has

increased in the same period from 17–23%).

In Spain, there is not much available information on how

competences of men and women in child-rearing are chang-

ing. New paternity ideals arise, which praise the bond

between fathers and children, and their frequent and early

interaction (Bonino 2003). Some authors point out that the

evolution of social policies for gender equality and specifi-

cally paternity leaves for birth are enabling a more active

participation of men in the domestic sphere in several

European countries (Meil 2011).

In Spain, the paternity leave is of 2 weeks nontransferable,

at 100% paid, which has been used by more than 80% of

parents (Castro & Pazos 2011). However, the rights of both

parents have not yet been equalised in suitable conditions to

maximise the chances of responsibility, because the paternal

leave are still very different from maternity leave, which cur-

rently have 16 weeks paid at 100% of salary.

The facts are also different by sex. According to the OECD

(Organisation for Economic Co-operation & Development

2011a,b), women spend twice as much time caring for others

as a primary job. In Spain, women, regardless of their work,

spend two hours more than men on the household and

family, while men devote one and a half hours more than

women to remunerated work (National Institute of Statistics

2010).

There are gender differences, not only in the division of

productive and reproductive work, but also equality policies

and formal institutions respond to a traditional cultural

pattern where the social role assigned to women has been

predominantly of ‘caregiver’, as in the case Spain (Garc�ıa-

Calvente et al. 2010a,b). Maybe these important differences

between paternal and maternal leaves can partially explain

the important gap between the intention of sharing eco-

nomic and parenting responsibilities, and the data on the

use of time by men and women (Tobio 2012). However, in

the Swedish context with a generous parental leave much

better than the one of the Spanish, some authors indicate

that men share fairly equally only if their partner has

returned to work full-time (Thomas & Hildingsson 2009).

Therefore, the gender roles are important factors to explain

these inequalities even under favourable conditions.

More research is needed to know whether a paternal

model open to new gender roles in the reproductive field is

emerging in the Spanish context. This requires consider-

ation of those instruments available to promote the gender

shared responsibility, such as the parental leaves. Also, the

strategies from the national health system to improve the

male involvement in perinatal care services during the birth

process present a new and suitable context to explore the

situation of the male involvement in the birth process. Now

is time to contribute to the general lack of information in

the Spanish context about the male involvement in relation

to the women involvement in this reproductive field. For

these reasons, this work arises with the following objec-

tives: (1) to know the male involvement during pregnancy

and childbirth, with special attention to their participation

in public services of perinatal health and the impact that

this participation has on their subsequent involvement in

child-rearing; (2) to compare the male and female involve-

ment in child-rearing and (3) to identify the factors associ-

ated with a greater male involvement.

Methods

Design

A transversal design was used to carry out the study in

Granada, city located in the autonomous community of

Andalusia, southern Spain.

Sample

Population

The population of interest was all parents who during the

study had at least one biological child aged 2 months to

3 years, with the following criteria of inclusion:

• The child was born alive between 1 December 2006 and

30 September 2010 in any of the two public hospitals of

Granada (Virgen de las Nieves or San Cecilio Hospital).

• The child is the oldest, in case of two or more children

of the same mother in this period.

• The hospital has contact data of the parents, including

telephone number.

• The parents cohabitate with the child in the city of

Granada.


Journal of Clinical Nursing, 22, 3071–3083 3073

Clinical issues Male and female involvement

Sample size calculation

To carry out the study, a minimum of 300 subjects (150

fathers and 150 mothers) were needed. This simple size

ensures detection of gender differences with a significance

level of a = 0�05, a power of 1-b = 0�80 and an effect size

of d = 0�324 or higher (Cohen 1977, Machin & Campbell

1987).

Respondent selection

Mothers and fathers had to be localised through the hospital

birth registries. Taken into account the criteria of inclusion,

a population of 6677 births was considered in a common

database with 3953 registries from Virgen de las Nieves

Hospital and 2724 registries from San Cecilio Hospital.

Each birth was randomly selected from the global data-

base. Once the registry was selected, the person who will

be interviewed (the mother or the father of the child) was

alternatively assigned. That is, the first respondent was a

mother; the respondent for the second registry was a father

and so on. The fathers and mothers included in the study

never were couples.

The first contact with the respondent was carried out by

telephone. During a short conversation, the interviewer

verified the criteria of inclusion. Following, a personal

appointment was requested to conduct the survey.

When the respondent did not comply some of the criteria

of inclusion or he/she did not want to participate in the

study, a new birth was randomly selected from the global

database.

Final sample

Finally, 307 subjects (150 fathers and 157 mothers) were

surveyed. Seven mothers more than the stipulated size for

this group were included. This number far exceeded the

minimum sample size for the study, according to the statis-

tical power.

A total of 586 telephone calls were needed to obtain 307

respondents. Of the 586 contacts, 116 were excluded

because they did not meet some criteria of inclusion. Of the

470 remaining contacts, 126 rejected participating due to

lack of time or lack of interest in the subject of the study,

37 were not in home at the time of the appointment and

307 were surveyed. This supposes an average of 1�9 calls

by each performed interview.

Ethical considerations

Each participant was provided with information regarding

the purposes of the research, and they were asked for con-

sent to participate, first verbally through the telephone and

later in writing, at the home appointment. The participant

was informed about the confidentiality of the data, safe-

guarding the integrity and privacy in accordance with

Organic Law 15/99 on Personal Data Protection. The study

protocol was reviewed and approved by the Internal

Research Commission of the institution responsible for the

project and both hospitals. These commissions did not con-

sider necessary to submit the project to a specific process of

ethical review, because in Spain ethical review is only

mandatory for studies of clinical nature.

Data collection

Between December 2010 and July 2011, the data were

collected through a structured questionnaire designed in a

previous phase of this study. Every questionnaire was

administered by personal interview, prior appointment in

the most appropriate place and at the most opportune time

for the interviewer. The structured questionnaire was

administered by an average of 36 minutes. The places

where the information was collected were as follows: 75%

home, 12% respondent workplace and 13% elsewhere.

Interview times were 53% in the afternoon from 16:00–

20:30 and 47% in the morning (8:00–16:00). The informa-

tion of each questionnaire was collected in paper format,

where the closed responses of the participants were marked.

Subsequently, all the information was recorded in a

database designed ex profess.

Methods

In a previous phase, the questionnaire used in this study

was designed ex profess during 2008 by some of the

authors of the present research team. Specifically, a struc-

tured questionnaire was developed from a bibliographical

review, a consultation to experts and a qualitative explora-

tion of 50 fathers and mothers. Later, it was piloted with

an intentional sample of 50 men and 50 mothers who had

the same profile as the reference population of this study.

That is, the pilot took place with fathers and mothers of

the region of Andalusia who lived with at least one child

up to 3 years old, and different socio-demographic charac-

teristics (age, level of education, country of origin, employ-

ment status, socio-economic status).

This questionnaire was piloted in three languages (Spanish,

French and English). However, only the Spanish version was

used, because every participant who was born in other coun-

tries out of Spain, could understand the Spanish language

to answer to the Spanish questionnaire. The psychometric




validation showed a reliability of 0�71 according to Cron-

bach’s alpha quotient.

This questionnaire consists of closed-ended questions

distributed in different parts of the contents: involvement

indicators and socio-demographic characteristics.

The involvement indicators and their response options

are as given follows: (1) the active search of any kind of

information related to the process of birth and child-rearing

(such as changes experienced in the body of the woman,

breastfeeding, rights during the process of birth, newborn

care, changes in the relationship, concerns and feelings of

the parents, or any other content of interest) (yes/no); (2)

the participation in the healthcare services during preg-

nancy and birth (such as attendance to pregnancy check-

ups with their partners, attendance to childbirth education

classes, and presence during labour) (yes/no); (3) the time

devoted to the baby after birth (number of hours per day);

and (4) the degree of responsibility taken with respect to

child-rearing tasks. This last indicator, the degree of

responsibility with respect to child-rearing tasks, is mea-

sured on a scale of 0–44 points built from a sum of 22

items which assess whether different upbringing tasks are

undertaken individually (grade 2 of involvement), shared

(grade 1) or delegated (grade 0). In accordance with the

adopted definition of childcare (Garc�ıa-Calvente et al.

1999), this battery of items includes tasks related to per-

sonal care (hygiene and clothing), instrumentation (house-

work, transportation, shopping and running other errands

out of the house), home-caring (company, watching,

response to demands, entertainment) and health (accompa-

niment, doctor’s appointments).

The degree of responsibility with respect to child-rearing

tasks was used as the main dependent variable. Independent

variables are the involvement indicators during pregnancy

and birth previously mentioned, as well as some socio-

demographic factors also included in the questionnaire: age

of the parent and the child, level of education, employment

status, civil status and country of origin, paternity leave for

birth, self-funded assistance with childcare and housework,

and social class constructed from the occupational classifi-

cation of the Spanish Society of Epidemiology (�Alvarez-

Dardet et al. 1995).

Data analysis

After the recording of the information obtained in purpose-

built databases, and the treatment of logical inconsistencies,

each variable was statistically described. The chi-square or

Fisher tests were used to analyse the differences according

to gender in the involvement qualitative indicators. The

Student’s t-test was used to analyse the differences by sex

in the quantitative indicators.

The gender gap of the involvement indicators was also

calculated, which indicates the magnitude of the distance

between sexes, subtracting the corresponding proportions

of men and women, where zero involves a parity situation,

a positive figure shows an unbalance in favour of males

and the negative in favour of women (Garc�ıa-Calvente

et al. 2010a,b).

The study of the factors related to male involvement was

performed by a multivariate linear regression model, also

carrying out a further diagnosis of the model to ensure the

goodness of fit and the fulfilment of the implementation

conditions (Fox 2008). A generalised standard error infla-

tion factor was used to ensure the absence of colinearity

between independent variables (Fox & Monette 1992);

homoscedasticity was ensured using both residuals versus

fitted plot and the Breusch-Pagan test (Breusch & Pagan

1979); linearity of the quantitative independent variables

was checked through partial regression plots, and normality

of the errors was guaranteed by normal QQ plot with 95%

confidence bands (Fox 2008). A 5% significance level was

used to establish statistical significance. R language was

used for statistical data analysis (Iaka & Gentleman 1996).

Results

Socio-demographic characteristics

The average age of participants is 35�2 years old and that of

the child is 18 months old. Most of subjects were born in

Spain, have university studies, are married, work full time

and enjoyed parental leave. In addition, most participants

belong to a social class manual, and they do not pay for pri-

vate services to care dependent persons at home or housework

services. These characteristics do not differ by sex, except a

significantly higher percentage of women than men in manual

social class and part-time employment or unemployed

(Table 1).

Involvement differences according to sex

Regarding men, 74�7% searched for information on birth

and child-rearing (in comparison with 84�7% of the

women), 42�7% attended childbirth education classes (in

comparison with 61�8% of the women), 90�7% attended

pregnancy check-ups with their partners and 67�3% were

present during labour and delivery. They were mainly pres-

ent during eutocic labours, in comparison with a 25�4%presence in dystocic labours. The majority of mothers said




to spend more than 10 hours a day with their children,

whereas men spend between 4–6 hours. Both the time spent

with the child (Fig. 1) and the degree of responsibility with

respect to child-rearing tasks (Table 2 and Fig. 2) were

greater in women than in men.

Factors related to the degree of responsibility with

child-rearing tasks

The degree of responsibility taken with respect to child-

rearing tasks was 5�4 points higher in men with secondary

studies or university degree than in men with primary

education. The degree of responsibility of married men

decreased 4�1 points in comparison with unmarried men.

Men born in Spain increased 5�4 points with regard to

those born outside Spain. When men had a partner with a

full-time employment, their degree of responsibility yielded

five points more than men whose partners had a part-time

employment. Moreover, the degree of responsibility of men

who attended childbirth education classes increased 2�8points (Table 3).

The diagnosis of all multivariate models for both sexes

yielded a good adjustment. The generalised standard error

inflation factor was lower than 1�5 in all cases, showing the

absence of collinearity. Both residuals versus fitted plots and

the Breusch-Pagan test, at a 5% level of significance, did not

give evidence against the homoscedasticity hypothesis. Partial

regression plots confirmed linearity of the quantitative inde-

pendent variables, and normal QQ plot with 95% confidence

bands showed aligned points over the central line, guaranty-

ing normality of the errors.

Discussion

The diversity of ways to access paternity has progressively

increased over the last decades. Therefore, the study of bio-

logical paternity of the present work represents only a frag-

ment of the Spanish social reality. On the other hand,

approaching involvement is a complex matter as for its defi-

nition is extensive and multidetermined (Plantin et al.

2011). The exhaustive delimitation of factors potentially

related can be unapproachable; therefore, only several of

special interest for the objectives of this study were selected,

leaving others for further research. Moreover, the results of

the current study must be interpreted in the light of the

constraints of a cross-sectional design regarding the estab-

lishment of associations and not of causal relations.

Taking into account its limitations, this work yields some

quantitative data practically inexistent in the city of

Granada and even throughout Spain. It provides figures of

male involvement in the perinatal healthcare context never

managed before. It verifies relevant differences regarding

gender, both during pregnancy and during child-rearing. It

has also enabled the identification of cultural factors associ-

ated with greater male involvement, as well as this

study reveals the impact that the male involvement in some

health services or programmes, such as those of childbirth

4%

20%

32%

22%

6,70%

15,30%

03,80%

10,80%

17,80%21%

46,50%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

< 2 hours 2-4 hours 4-6 hours 6-8 hours 8-10 hours > 10 hours

Daily time spent with child

Perc

enta

ge

MenWomen

Figure 1 Daily time spent with child.

Table 1 Socio-demographic characteristics

Hombres Mujeres Total

n (%) n (%) n (%)

Level of education

No education 2 (1�4) 0 2 (0�7)Primary education 24 (16�0) 31 (19�7) 55 (17�9)Secondary education 41 (27�3) 38 (24�2) 79 (25�7)University degree 83 (55�3) 88 (56�1) 171 (55�7)

Employment status*

Full-time employment 117 (78) 43 (27�7) 160 (52)

Part-time employment 9 (6) 40 (25�2) 49 (16)

Unemployment 24 (16) 74 (47�1) 98 (32)

Occupational social class**

Manual (blue collar) 68 (45�9) 88 (59�9) 156 (52�9)No manual (white collar) 80 (54�1) 59 (40�1) 139 (47�1)

Marital status

Married 116 (77�3) 108 (69) 224 (73)

Other status 34 (22�7) 49 (31) 83 (27)

Country of origin

Spain 132 (88) 129 (82�2) 261 (85)

Other country 18 (12) 28 (17�8) 46 (15)

Paternity leave

Yes 111 (73�8) 152 (96�8) 263 (85�7)No 39 (26�2) 5 (3�2) 44 (14�3)

Pay services for dependents at home

Yes 15 (10) 11 (7) 26 (8�5)No 135 (90) 146 (93) 281 (91�5)

Pay housework services at home

Yes Yes Yes 82 (26�7)No No No 225 (73�3)

*p < 0�05; **p < 0�001.




education, has on their subsequent involvement in child-

rearing.

In the first place, in regard to male involvement in the

public services perinatal health, the information that this

study offers varies depending on the indicator approached.

The fact that the most of the fathers have participated in

health check-ups during pregnancy can be interpreted in

different ways simultaneously. This may understood as a

male involvement in the cognitive and affective level, differ-

ent to the instrumental level which can in other indicators

reflects, such as the degree of responsibility with child-rear-

ing tasks. This result also reveals a desire for control and

protection more consistent with the model of the patriar-

chal father. And it is also important to consider this high

involvement in pregnancy check-ups like prove of that the

general population has a great adherence to this

programme of health monitoring, firmly established for

some time ago.

Regarding high attendance to pregnancy check-ups, a

low male participation in childbirth education classes is

observed in this study. In general terms, European data

regarding male involvement in childbirth education classes

not only surpass the figures referred to men in this study,

but also those referred to women. In the nineties, 80% of

the Danish men and 90% of the Swedish already

participated in prenatal preparation courses (World Health

Organization 2007), whereas in this work the current figure

is less than 50% for the participating men and a slightly

more for women. Similarly, more than a decade ago the

British exceeded by more than 30% the data observed in

this study (Draper 1997).

To understand the low rate of participation in the health

education field of the fathers in the city of Granada, it is

necessary to consider those cultural and gender factors

involved, as well as it is important to explore the character-

istics offered by the healthcare services. In general, the

0

1

2

3

4

5

6

7

8

9

10

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44

Degree of responsibility

Perc

enta

ge

Women Men

Figure 2 Degree of responsibility taken with

respect to the child-rearing tasks.

Table 2 Involvement in the birth and child-rearing process

Pregnancy and delivery

Men Women

Gender gap†n (%) n (%)

Looks for information on birth and child-rearing* 112 (74�7) 133 (84�7) 10

Attends pregnancy check-ups* 136 (90�7) 157 (100) 9�3Attends childbirth education classes* 64 (42�7) 97 (61�8) 19�1Are present during birth (men) 101 (67�3) – –

Are present depending on the type of delivery*

Noninstrumental deliveries 87 (92�6)Instrumental deliveries 11 (47�8)Caesarean 3 (9�4)

After birth Men Women

Mean (SD) Mean (SD)

Degree of responsibility with the child-rearing tasks (0–44 points) 12�04 (7�119) 34�03 (6�714) 21�99

*p < 0�05.†Difference (subtraction) between the percentage of men and women.




childbirth education classes are being questioned due to its

low impact on certain birth results such as the decreased

anxiety during delivery, the shortest period of dilatation,

reduced use of anaesthesia drugs, satisfaction with child-

birth or breastfeeding duration (Artieta-Pinedo et al. 2010).

The positive impact that this education can have on the

Table 3 Factors related to the degree of responsibility of fathers with respect to child-rearing tasks

Factors

Unstandardised

coefficients

Wald p-value

95% confidence interval for B

B SE Lower bound Upper bound

Socio-demographic profile (men)

Age (20–49 years old) �0�0013 0�136 �0�093 0�926 �0�282 0�257Level of education

Secondary education or university degree 5�414 2�202 2�458 0�016 1�046 9�782Primary education � Reference

Employment status

Full-time employment �0�972 2�242 �0�433 0�666 �5�419 3�475Part-time employment �1�122 3�120 �0�360 0�720 �7�310 5�066Unemployment � Reference

Employment status (partner – mother) 5�032 1�631 3�086 0�003 1�798 8�267Full-time employment

Part-time employment 2�723 1�649 1�652 0�102 �0�547 5�992Unemployment � Reference

Occupational social class

Manual (blue collar) 1�102 1�381 0�798 0�427 �1�636 3�840No manual (white collar) � Reference

Marital status

Married �4�117 1�483 �2�777 0�007 �7�057 �1�176Other status � Reference

Country of origin

Spain 5�456 2�489 2�192 0�031 0�520 10�391Other country � Reference

Age of the child (2–47 months) 0�092 0�052 1�767 0�080 �0�011 0�196Pregnancy and delivery (men)

Attend pregnancy check-ups

Yes �3�163 2�248 �1�407 0�162 �7�621 1�296No � Reference

Attend childbirth education classes

Yes 2�874 1�232 2�332 0�022 0�430 5�318No � Reference

Look for information on birth and child-rearing

Yes 1�026 1�665 0�616 0�539 �2�276 4�327No � Reference

Are present during birth

Yes �1�662 1�273 �1�306 0�194 �4�187 0�862No � Reference

After birth (men)

Paternity leave

Yes 0�634 1�398 0�453 0�651 �2�138 3�405No � Reference

Pay care services for dependents at home

Yes 3�227 1�904 1�695 0�093 �0�549 7�003No � Reference

Pay housework services at home

Yes �1�328 1�517 �0�875 0�383 �4�336 1�680No � Reference

Constant 8�028 5�939 1�352 0�179 �3�751 19�806

R2 = 0�38.




adaptation to the fatherhood of the men is still lower, espe-

cially when they feel not very included (Finnbogadottir

et al. 2003). Thanks to a qualitative study carried out also

in the city of Granada, it was learned that men of high

socio-educative level feel invisible to the healthcare services

during the pregnancy and labour process (Maroto-Navarro

et al. 2009). This low participation of men in childbirth

education classes invites to reflect on the sessions offered

and to make continuous revisions of them, both regarding

methodology as to the contents (Early 2001, Bremberg

2006). This study shows that the childbirth education is

not listed as a widespread practice among fathers. How-

ever, it seems a key tool to promote of male involvement

during the child-rearing, because this study has also

checked the association between the attending to the

childbirth education and the greater responsibility with

child-rearing tasks, according to the scale used.

Another opportunity for male involvement in the health-

care services is their participation in the birth. A majority

of the fathers are now present during birth, and this

presence is increasing among several European countries,

including Eastern countries, where the men have been

incorporating later to this type of involvement (Plantin

et al. 2011). Results of the present study enable some clari-

fication regarding this situation in the general European

context. Data from the city of Granada show that it is not

a generalised practice when all types of deliveries are con-

sidered on an aggregate basis. However, this figure rises

considerably to almost the total number of fathers who are

present at birth if only ‘eutocic’ deliveries are considered.

This is a clear reflection of how clinical protocols for

labour and delivery work in hospitals. That is to say, in the

case of ‘dystocic’ deliveries fathers are advised to wait out-

side the delivery room. Currently and progressively, this

reality may be changing as for the National Strategy for

Assistance at Normal Childbirth (Ministry of Health &

Consumer Affairs 2008) and the Strategy for Sexual and

Reproductive Health (Ministry of Health & Social Policies

2011) are placing value and making visible the right of

fathers to participate in the birth process and in the

first moments of their child’s life, regardless of the type of

birth.

The male involvement has a worst position in relation to

the female involvement in the birth process and child-rear-

ing. During pregnancy, women show a greater interest in

searching for information on birth and child-rearing. To

look for information during pregnancy is an indicator which

reflects not only the behavioural dimension, but also the

emotional dimension, cognitive and ethics, advocated by

some authors (Palkovitz 1997, Daly 2001, Hawkins et al.

2002). Considering all these dimensions, women show more

involvement than men. These results can be indicating that,

for males who participated in the study, the information

search involves qualities assigned traditionally to women,

related to the organisation and the anticipation of the care.

Later, women spend more time with their child on a

daily basis. Relatively speaking, a different type of measure-

ment used in the Spanish context also highlights that

mothers spend a higher proportion of time on childcare.

They devote 2 hours and 22 minutes, whereas men devote

1 hour and 46 minutes (National Institute of Statistics

2010). Although the daily time spent with child is an indi-

cator that deserves clarifications (such as what is done in

that time), it clearly shows gender inequalities as the other

indicator of involvement in parenting used in this work.

This one is completely unprecedented in Spain and equally

points out that women undertake more responsibility for

childcare tasks, regardless of their social class or the fact

that the family unit pays for childcare at home.

The data in this study reflect gender inequalities. Men

show lower interest in searching for information on birth

and child-rearing, they are less involved in childbirth educa-

tion and above all, they spend a lower amount of time in

childcare and undertake less responsibility for childcare

tasks. All these facts are mediated by biological arguments,

traditionally ascribed to women (Covas 2009). The lower

male involvement, despite the additional factors to be con-

sidered, may be interpreted from the male detachment with

regard to the reproductive field marked by the traditional

gender system (Dolan & Coe 2011).

Regarding the characteristics that define the most

involved men, it must be considered that a decade ago a

new responsible paternity was associated with a profile of a

cultured male who was critical with hegemonic masculinity

and social conventions (Steinberg et al. 2000). A previous

work in Granada indicates that shared responsibility

is modelled by economic and educational resources

(Maroto-Navarro et al. 2007). This study shows a greater

involvement in men with a higher level of education and in

those not married. A greater male involvement is confirmed

when their partners are more committed to their jobs, as

several studies unanimously prove (Sundstr€om & Duvander

2000, Costigan et al. 2003, Rodriguez 2009). Nevertheless,

the female entrance in the public space in Spain has not

corresponded equally to a entrance of the men in the house-

hold (Organisation for Economic Co-operation & Develop-

ment 2011a,b, Garc�ıa-Calvente et al. 2012), given the

greater assumption of the double work shift by women,

with the health costs that it entails (Bartley et al. 1999,

Milkie et al. 2002, Artazcoz et al. 2004). And as the gender




system still pushes women into the domestic and reproduc-

tive field, it also exerts a limiting influence on male involve-

ment (Henwood & Procter 2003, Renk et al. 2003,

M�ansdotter & Lundin 2010).

In this regard, the policies implemented to promote con-

ciliation and shared responsibility in childcare have a spe-

cial significance. In the case of Spain, the implementation

of the Gender Equality Act (Law 3/2007) resulted in a con-

siderable step forward in this field, which later in 2009

gave rise to an extension of the duration of the paternity

leave for birth, adoption or taking in a foster child of 15

continuous days for the father. In this work, paternity

leaves had no impact on male involvement in child-rearing.

In any case, it is necessary to deeply explore the determi-

nants of social and cultural origin which surround paternity

leaves, mostly enjoyed by middle and high classes (World

Health Organization 2007). The results of this study point

out the fathers born in Spain showed a greater involvement

in child-rearing tasks than those born outside this country.

It is also essential to take into consideration that a great

amount of the foreign population residing in Granada lives

under disadvantaged socio-economic conditions. This wid-

ens the debate on the relationships established between

cultural factors, gender mandates and socio-economic struc-

tural dimensions (Gonz�alez & Zarco 2008). Moreover, it is

of interest to analyse how in our context pregnancy pro-

cesses, birth and child-rearing influence on the reformula-

tion of male identities.

Conclusion and relevance to clinical practice

The findings of this study are important to show some

information about male and female involvement in repro-

ductive field, which, in general, is absent in the Spanish

context. The quantifying of the differences by sex reflects

gender inequalities, which were already confirmed in other

contexts. Also, it is relevant concluding that perinatal

health professionals have an important challenge to encour-

age to the men to involve in their fatherhood as early as

possible and, in this way, to promote social changes that

are needed to advance in shared responsibilities. Health

professionals are relevant pieces to identify and provide

feedback concerning the strengths (Feeley & Gottlieb 2000)

and the opportunities that family have to progress in gender

equality.

This study has let to know how current participation of

men in health services is during the pregnancy and child-

birth. The health professionals continue inviting the father

in uncomplicated deliveries, but not in all the difficult

births, in spite of the formal recommendations currently.

This is an important area for improvement, which the

policymakers must follow emphasising.

Other important finding has been the impact that the

male involvement in health services during the birth process

(such as the childbirth education classes) has on their subse-

quent involvement in child-rearing. Such as it was described

in several qualitative studies (Early 2001, Maroto-Navarro

et al. 2009), the perinatal health services are important

social agents to promote involvement from the beginning of

the reproductive process. In this sense, the low male partici-

pation of parents in childbirth education classes should be

improved.

Currently, The Program for Humanisation of Perinatal

Care in Andalusia (Health Council of the Andalusian Regio-

nal Government 2012) develops training courses to sensiti-

sation of health professionals concerning the need to improve

the quality and warmth of perinatal care and to promote

some good practices to involve fathers, for example, through

changing strategies to attract fathers to the childbirth educa-

tion classes or changing some of the contents of these classes

for others which are more directed to the situation that the

fathers are living. All these changes require a previous defini-

tion of the father like other protagonist during pregnancy

and also during birth, regardless of the type of delivery.

It is difficult to transform the perinatal health routines

because these routines were being effective to ensure clinical

safety and good obstetric outcomes. However, it seems now

necessary to change to an approach that considers birth as

a social process and not just biological, and including also

the father figure and the personal satisfaction of families as

significant objectives.

Insofar that health professionals can clearly recognise

gender inequalities in reproductive health, it is probably

they will change some attitudes as a first step in developing

better strategies for attracting parents during pregnancy in

primary health care, and they will be able to ensure further

the involvement of parents in all types of hospital births, as

an important right of the families. If the improvement were

possible in public health services, it would mean that the

most of the population will be involved in an important

cultural change.

Also, this study describes, by the first time, the socio-

demographic profile of Spanish men involved in child-

rearing, checking some coincidences with studies from other

contexts.

In Spain, new policy measures to facilitate the emancipa-

tion of men in the home and care are necessary, because

the reduced parental leave does not seem a useful tool to

increase their involvement. And beyond a better, longer and

nontransferable paternity leave (not ever useful as other




countries show), a significant gender sensitisation of the

population is necessary to bring all men to the home and

care, which should involve every formal institution (educa-

tional institutions, social institutions and, of course, health

institutions). Nowadays, the men who reach at child-rear-

ing are they who have no choice (when mothers work out-

side home, whether or not they have more support at home

to care) or those with a more educated social profile (more

educated) and less conservative, that is those unmarried

men and those with Spanish origin, because most are born

in other countries or come from cultures where gender

inequalities are even more entrenched.

There is still a long way to go in terms of shared respon-

sibility in child-rearing. It is important that the sensitisation

towards gender equality comes to any social profile.

It is expected that as new paternity models are encour-

aged, for instance the strategies implemented by the

National Health System, attitudes and behaviours will

change, and finally they will pervade the social tissue

(Bonino 2003). It is important to follow reinforcing these

tools although the social changes are slower than desired.

This study answered several questions as well as it also

poses further queries. Future research would have to

approach other maternities and paternities established not

by biological but by social bonds. Likewise, it is relevant to

tackle male involvement from longitudinal designs in order

to observe temporal changes.

Acknowledgement

This study was made possible thanks to funding from the

Ministry of Health and Consumer Affairs (2008) and the

Health Council of the Andalusian Regional Government

(2010–2011), Spain. The authors are particularly grateful

for the participation of expert professionals and all the

mothers and fathers who made this study possible.

Contributions

Study design: GMN, ROR, VBH, MMGC, MPGC, MTGS;

data collection and analysis: GMN, GPM, ROC, MPGC

and manuscript preparation: GMN, GPM, ROR, VBH,

MMGC, MPGC, MTGS, MRL, JMM.

Funding

The Ministry of Health and Consumer Affairs (2008)

funded a first phase of this study to design a questionnaire.

The Health Council of the Andalusian Regional Govern-

ment (2010–2011) funded a second phase to collecting

information and conclusions.

Conflict of interest

The authors declare that they have no conflict of interests.

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