Abstract

The article seeks to propose principles for male care geared to sexual health, reproduction and paternity, as well as present a blueprint for the involvement of men in prenatal care. The proposal of the authors was submitted to a consensus building process with invited experts. The main results presented include: (a) the principles of lines of male care geared to sexual health, reproduction and paternity; and (b) a blueprint for the involvement of men in prenatal care. The conclusion drawn is that the cultural preconceptions of how males should lead their lives, including their social relations and roles as fathers interfere in health care actions and touch on three main points: (a) the idea of man as a collaborator in the promotion of the health of his partner while pregnant and/or his offspring; (b) the idea of paternity being strongly linked to being the financial provider; (c) the hiatus generated between the traditional concept of paternity and the new family and gender patterns.

Men; Prenatal care; Paternity; Line of care

Initial Considerations

This article, which is objective and opinionated in nature, seeks to propose principles for male care geared to sexual health, reproduction and paternity, as well as present a blueprint for the involvement of men in prenatal care.

We understand principles to mean the basic structural foundations that provide guidelines for male care geared towards sexual health, reproduction and paternity. They are the starting points that enable new actions to be designed or for existing ones to be discussed in the light of the inter-relationships upon which they are based and according to their contexts. These are not norms procedures that should be followed.

We understand lines of care to mean an image that is created in the mind to express a blueprint for safe and guaranteed care for the users, so as to meet their health requirements¹1. Pessôa LR, Santos EHA, Torres KRBO, organizadores. Manual do Gerente: desafios da média gerência na saúde. Rio de Janeiro: Fiocruz; 2011. [acessado 2015 out 17]. Disponível em: http://www5.ensp.fiocruz.br/biblioteca/dados/txt_379517240.pdf
http://www5.ensp.fiocruz.br/biblioteca/d... . In one line of care, the managers of services can agree on norms, re-organizing the work process, so as to facilitate a user’s access to the Units and Services they require¹1. Pessôa LR, Santos EHA, Torres KRBO, organizadores. Manual do Gerente: desafios da média gerência na saúde. Rio de Janeiro: Fiocruz; 2011. [acessado 2015 out 17]. Disponível em: http://www5.ensp.fiocruz.br/biblioteca/dados/txt_379517240.pdf
http://www5.ensp.fiocruz.br/biblioteca/d... .

In this case, sexual and reproductive health is associated with the right and the desire of an individual to plan the formation or otherwise of his family or family entity, increasing, limiting or avoiding having any offspring²2. Gomes R. Os cuidados masculinos voltados para a saúde sexual, a reprodução e a paternidade a partir da perspectiva relacional de gênero: projeto de pesquisa. Rio de Janeiro: Fiocruz; 2013..

However, paternity is seen as the involvement of men and the possibility of these individuals experiencing pleasure in questions related to pregnancy, birth and more democratic and equitable relationships within the domestic sphere³3. Ribeiro CR, Gomes R, Moreira MCN. A paternidade e a parentalidade como questões de saúde frente aos rearranjos de gênero. Cien Saude Colet 2015; 20(11):3589-3598..

Our discussion is based on a gender related perspective, in the belief that:

The engagement of men in the provision of care has a positive effect on the gender socialization of boys and girls and makes children more open to question traditional gender roles⁴4. Instituto Promundo. Programa P. Manual para o exercício da paternidade e do cuidado. Rio de Janeiro: Instituto Promundo; 2014. [acessado 2015 out 12]. Disponível em: http://promundoglobal.org/wp-content/uploads/2014/12/Programa-P-Manual-para-o-exercicio-da-paternidade-e-do-cuidado.pdf
http://promundoglobal.org/wp-content/upl... .

In addition, we begin with two questions. The first refers to the participative role of men in sexual and reproductive health. When mentioning that some health professionals traditionally understood that men should be encouraged to participate as collaborators in the health of their partners, Arilha⁵5. Arilha M. Homens: entre a “zoeira” e a “responsabilidade”. In: Arilha M, Ridenti SGU, Medrado B, organizadores. Homens e masculinidades: outras palavras. São Paulo: ECOS, Ed. 34; 1998. p. 51-77. asked:

[...] is this really desirable? Should not men, of all age groups, also become subjected to rights in the field of sexual and reproductive rights?⁵5. Arilha M. Homens: entre a “zoeira” e a “responsabilidade”. In: Arilha M, Ridenti SGU, Medrado B, organizadores. Homens e masculinidades: outras palavras. São Paulo: ECOS, Ed. 34; 1998. p. 51-77..

Another issue is related to the thoughts expressed by Gomes⁶6. Gomes R. As questões de gênero e o exercício da paternidade. In: Silveira P, organizador. Exercício da paternidade. Porto Alegre: Ed. Artes Médicas; 1998. p. 175-181. about the exercise of paternity that end with the following questions:

How is paternity exercised in situations where a woman is the head of the household? How does one define a paternal figure in the case of a homosexual couple who decide to adopt a child? What is it to be a father when there is no mother figure?

These questions, that date back more than fifteen years, are still valid today, in spite of some progress in the area. One of these was the creation of a national male health policy in Brazil⁷7. Brasil. Ministério da Saúde (MS). Política Nacional de Atenção Integral à Saúde do Homem: Princípios e Diretrizes. Brasília: MS; 2009., where these questions are debated. In addition, several studies have been addressing the issue of the involvement of men in prenatal care and paternity⁸8. Ávila MB, Ferreira V, organizadores. Trabalho remunerado e trabalho doméstico no cotidiano das mulheres. Recife: SOS Corpo; 2014.

9. Kato-Wallace J, Barker G, Eads M, Levtov R. Global pathways to men’s caregiving: Mixed methods findings from the International Men and Gender Equality Survey and the Men Who Care study. Global Public Health 2014; 9(6):706-722.^-1010. Nakano AMS, Silva LA, Beleza ACS, Stefanello J, Gomes FA. O suporte durante o processo de parturição: a visão do acompanhante. Acta paul enferm 2007; 20(2):131-137..

In these studies, the following questions are highlighted: (a) women continue to be held responsible for family planning and child care⁸8. Ávila MB, Ferreira V, organizadores. Trabalho remunerado e trabalho doméstico no cotidiano das mulheres. Recife: SOS Corpo; 2014.; (b) there is still a certain amount of apprehension between genders as regards their relevant participation in health care issues⁹9. Kato-Wallace J, Barker G, Eads M, Levtov R. Global pathways to men’s caregiving: Mixed methods findings from the International Men and Gender Equality Survey and the Men Who Care study. Global Public Health 2014; 9(6):706-722.; (c) involving men in child care involves issues such as: paternity and/or parental leave; working hours and transformations in gender relationships¹⁰10. Nakano AMS, Silva LA, Beleza ACS, Stefanello J, Gomes FA. O suporte durante o processo de parturição: a visão do acompanhante. Acta paul enferm 2007; 20(2):131-137.; (d) recognizing the importance of paternal participation as an instrument to improve maternal and child health, though difficulties exist in recognizing this participation as a man’s right¹⁰10. Nakano AMS, Silva LA, Beleza ACS, Stefanello J, Gomes FA. O suporte durante o processo de parturição: a visão do acompanhante. Acta paul enferm 2007; 20(2):131-137.; (e) men feel intimidated by the attitude of a health professional who does not involve them in the process of childbirth as being an important player within this scenario¹¹11. Medrado B, Lyra J, Oliveira AR, Azevedo M, Nanes G, Felipe DA. Políticas públicas como dispositivo de produção de paternidades. In: Moreira LVC, Petrini G, Barbosa FB, organizadores. O pai na sociedade contemporânea. Bauru: EDUSC; 2010. p. 53-79.; and (f) some men do not participate in the medical consultations of their partners due to the embarrassment this causes the pregnant women or their partners themselves; these appointments coincide with their working hours and with restrictions imposed on fathers by prenatal care services¹²12. Pesamosca LG, Fonseca AD, Gomes VLO. Percepção de gestantes acerca da importância do envolvimento paterno nas consultas pré-natal: um olhar de gênero. Rev Mineira de Enfermagem 2008; 12(2):182-188..

With regards to the queries raised by Arilha⁵5. Arilha M. Homens: entre a “zoeira” e a “responsabilidade”. In: Arilha M, Ridenti SGU, Medrado B, organizadores. Homens e masculinidades: outras palavras. São Paulo: ECOS, Ed. 34; 1998. p. 51-77. and Gomes⁶6. Gomes R. As questões de gênero e o exercício da paternidade. In: Silveira P, organizador. Exercício da paternidade. Porto Alegre: Ed. Artes Médicas; 1998. p. 175-181., we do not intend to directly respond to these by putting forward specific recommendations, but to present proposals that – either directly or indirectly – relate to these issues instead.

Methodological Framework

This study consists of an opinion-based work on the experience of the authors, and is one that further goes on to seek the validation of experts on the subject, thereby broadening the forum of opinions in order to attain a consensus. For this, we adapted the consensus conference technique proposed by Souza et al.¹³13. Souza LEPF, Silva LMV, Hartz ZM. Conferência de consenso sobre a imagem-objetivo da descentralização da atenção à saúde no Brasil. In: Hartz ZMA, Silva LMV, organizadores. Avaliação em: dos modelos teóricos à prática de programas e sistemas de saúde. Salvador, Rio de Janeiro: EDUFBA, Fiocruz; 2005. p. 65-102.. As regards the methodological process, this adaptation was divided into six stages.

The authors prepared two models, based on the references mentioned here and on their accumulated experience related to this subject, one of which is called “Image-objective for lines of male care geared to sexual health, reproduction and paternity,” and another called “A blueprint for the involvement of men in prenatal care.”

Experts were then selected by searching through scientific database search engines, such as Scientific Electronic Library Online (SciELO), the Lattes Platform and The Virtual Health Library (VHL), using the following key words: male health, prenatal care and paternity. During this search, it was possible to identify eighteen experts, of whom eleven, four men and seven women, who completed all the validation stages. In professional terms, three were doctors, four were nurses and four were psychologists. All of them had experience in the area or were involved in working with issues that articulate the theme of male health, prenatal care and paternity.

During the third stage, by using an online research tool, the two models we submitted to the eleven experts for due validation. The first model presented fourteen principles divided into three dimensions: the political/management dimension; the health care dimension and the education in health dimension. The second model presented steps and actions related to the proposal for a blueprint for the involvement of men in prenatal care. In both models, each expert could award points to the proposed principles and actions on a scale from zero to ten, where zero represented an issue of no importance or one that should be excluded, and ten represented one of maximum importance. In addition, in the final section of each dimension it was possible to include observations or suggest principles with key words or stages with relevant actions, if the experts judged this to be necessary.

In the fourth stage, the authors analyzed the scores for the first version of the models, consolidating data and checking the consensus of opinion for each of the principles/stages, based on Souza et al.¹³13. Souza LEPF, Silva LMV, Hartz ZM. Conferência de consenso sobre a imagem-objetivo da descentralização da atenção à saúde no Brasil. In: Hartz ZMA, Silva LMV, organizadores. Avaliação em: dos modelos teóricos à prática de programas e sistemas de saúde. Salvador, Rio de Janeiro: EDUFBA, Fiocruz; 2005. p. 65-102., by means of an analysis of average and standard deviations; averages lower than seven and/or standard deviations higher than two were considered as dissensus. Based on this analysis the two models were reformulated, taking into consideration the suggested changes and inclusions made by the experts. None of the experts suggested excluding a principle or an action.

The fifth stage involved re-submitting the two models to the experts. At this stage, any suggestions for the inclusion or exclusion of principles or actions were no longer taken into account, only scores.

Lastly, a final validation analysis was conducted, taking into account the same parameters¹³13. Souza LEPF, Silva LMV, Hartz ZM. Conferência de consenso sobre a imagem-objetivo da descentralização da atenção à saúde no Brasil. In: Hartz ZMA, Silva LMV, organizadores. Avaliação em: dos modelos teóricos à prática de programas e sistemas de saúde. Salvador, Rio de Janeiro: EDUFBA, Fiocruz; 2005. p. 65-102. used in the first analysis.

Findings

There was a consensus as regards most of the principles and stages proposed and only one principle was removed from the original proposal. These findings can be seen in the two charts shown below.

In Chart 1, the lines of male health care geared towards sexual health, reproduction and paternity involve three principles: macro principles that provide guidelines to plan actions and their management (management-policy); relations between professionals and users in dealing with issues highlighted by this paper (health care), and educational actions geared towards professionals and users (education in healthcare).

Chart 2 sets out a proposal for a blueprint for the involvement of men in prenatal care. The stages are not necessary linear or exclusive. At certain moments, these can co-exist and even overlap.

We believe that integrating principles (Chart 1) and the blueprint (Chart 2) represent what we understand to be lines of care.

Discussion

The principles and blueprint include cross-sectional issues that serve to help develop the discussion. This debate reexamines philosophical perspectives, which serve as guidelines for reflection and criticism, leading to the acquisition of knowledge. And we highlight here, the fact that this philosophy does not only indicate a benefit in itself, but represents the first systemized form of questioning the world and the search for explanations that can lead to different responses and actions. Thus, we have adopted the proposal based on three cross-sectional themes that generate change, geared towards diversity and plurality: 1) the polarities in masculine representations that serve as a benchmark and give prominence to relations with feminine and childhood dimensions, which need to be reexamined and reevaluated in the light of the battle for hegemony; 2) equity in recognizing the social markers of differentials; 3) social participation as a tool to promote rights of access and care.

The first assesses cultural representations¹⁴14. Laplantine F. Antropologia dos sistemas de representações da doença: sobre algumas pesquisas desenvolvidas na França contemporânea à luz de uma experiência brasileira. In: Jodelet D, organizadora. Representações Sociais. Rio de Janeiro: Eduerj; 2001. p. 241-259.about males, which associate men with concepts of danger, strength, haste and provision. These representations reinforce a model of masculinity that distorts or eliminates other forms of masculine existence that can impose limits on actions involving male healthcare and reduce the possibility of support being given to men/partners/fathers in the healthcare process of a woman and her child, and/or associates males with ideas of contagion, violence and oppression of this diad. These are concepts that tend to distance men from health services. Based on Gramsci¹⁵15. Gramsci A. Os intelectuais e a organização da cultura. Rio de Janeiro: Civilização Brasileira; 1978., we understand that certain cultural notions become hegemonic, prevailing in space and in time. Even though these are not unique, they become established based on a position established in the field, serving to organize social forces and, in the case indicated above, organize roles related to gender. We venture to suggest that, within this tradition, the level of ideas, notions, values, shared social expectations – which constitute the raw material of cultural notions¹⁴14. Laplantine F. Antropologia dos sistemas de representações da doença: sobre algumas pesquisas desenvolvidas na França contemporânea à luz de uma experiência brasileira. In: Jodelet D, organizadora. Representações Sociais. Rio de Janeiro: Eduerj; 2001. p. 241-259. – play a fundamental role in bringing about social change. In this sense, we should ask what would happen if we had a movement where men pursue certain male initiatives – as, for example, men who when they marry take the surname of their wives¹⁶16. Quando o homem assume o sobrenome da mulher. [acessado 2015 out 18]. Disponível em: http://oglobo.globo.com/sociedade/quando-homem-assume-sobrenome-da-mulher-17805074
http://oglobo.globo.com/sociedade/quando... , and not the contrary; or even men who run the home and take care of their children, while their wives go out to work – would be highlighted and associated with movements for broader rights?

The second evokes social difference markers, equal access and the need for equal healthcare – gender, race/color, social class, age, education, sexual orientation – with emphasis on sexual orientation and gender roles. Issues that address the debate related to new family and gender arrangements based on the satisfaction of looking after oneself or another person, related to emotional and sexual involvement, and in the construction of parenthood. In this respect, several ideas have already been discussed in a previous study³3. Ribeiro CR, Gomes R, Moreira MCN. A paternidade e a parentalidade como questões de saúde frente aos rearranjos de gênero. Cien Saude Colet 2015; 20(11):3589-3598., but give rise to further discussions. One of these, which involves our principles and blueprint, is the desire to discuss frontiers between sex and gender, men and women, masculine and feminine, and father and mother³3. Ribeiro CR, Gomes R, Moreira MCN. A paternidade e a parentalidade como questões de saúde frente aos rearranjos de gênero. Cien Saude Colet 2015; 20(11):3589-3598., taking into account different family arrangements³3. Ribeiro CR, Gomes R, Moreira MCN. A paternidade e a parentalidade como questões de saúde frente aos rearranjos de gênero. Cien Saude Colet 2015; 20(11):3589-3598.. In this sense, there will be moments when something more than paternity, and parenting will have to be addressed, as a set of functions geared towards developing autonomy and a sense of security for children, which guarantees generativeness¹⁷17. Barroso RG, Machado C. Definições, dimensões e determinantes da parentalidade. Psichologia 2010; 52(1): 211-229.. We need to think about homosexual-parenting, in the case of families formed by people of the same sex. Or even, parenting by transsexual and/or transvestite people³3. Ribeiro CR, Gomes R, Moreira MCN. A paternidade e a parentalidade como questões de saúde frente aos rearranjos de gênero. Cien Saude Colet 2015; 20(11):3589-3598.^,1818. Zambrano E. Parentalidades “impensáveis”: pais/mães homossexuais, travestis e transexuais. Horiz. antropol. 2006; 12(26):123-147.. And, within this diversity, it will be important to ensure that the care and upbringing of a child is seen from the point of view of establishing bonds, and as a relationship of healthcare asset exchange³3. Ribeiro CR, Gomes R, Moreira MCN. A paternidade e a parentalidade como questões de saúde frente aos rearranjos de gênero. Cien Saude Colet 2015; 20(11):3589-3598..

The third issue evokes evidence of the right to access and health decisions: health care participation which involves men, women and children in different scenarios and health promotion spaces, where physical and conceptual changes are required, as well as environmental requalification. As far as possible, and while protecting aspects that requires discretion and privacy, the whole idea of going beyond the consulting room and a relationship seems very promising, to converse in waiting rooms or chat circles, a process that encourages reflection, appraisals and participation. This idea functions as a dialogic strategy of acceptance of another person in their diversity, where the solitude felt by those who are waiting for healthcare can be reconfigured through conversation, through inter-action, transforming a conflict of ideas into working material.

These conversations can also make full use of playful activities, of games, to promote discussions about gender roles, diversity, daily difficulties related to healthcare choices, how to manage domestic and public life, the education of one’s children and the exercise of parenthood. Thus, health services can be viewed as spaces that promote life, health and personal bonds. The theme of participation also involves the potential itself to invite healthcare professionals to place themselves in a counter-hegemonic movement, repositioning themselves as users and adopting an attitude related less to teaching, and more to a process of exchange and learning.

The need to highlight other possible ways of interpreting male care – care for yourself and what this offers to others – becomes an urgent priority when we recognize that health care actions exemplify a tradition whose models are faced with a multiplicity of contemporary transformations, and by male morbid-mortality rates, when compared to those of females¹⁹19. Gomes R. Sexualidade masculina, gênero e saúde. Rio de Janeiro: Editora Fiocruz; 2008^,2020. Couto MT, Gomes R. Homens, saúde e políticas públicas: a equidade de gênero em questão. Cien Saude Colet. 2012; 17(10):2569-2578.. Thus, even after nearly two decades, the observations made by Arilha⁵5. Arilha M. Homens: entre a “zoeira” e a “responsabilidade”. In: Arilha M, Ridenti SGU, Medrado B, organizadores. Homens e masculinidades: outras palavras. São Paulo: ECOS, Ed. 34; 1998. p. 51-77. and Gomes⁶6. Gomes R. As questões de gênero e o exercício da paternidade. In: Silveira P, organizador. Exercício da paternidade. Porto Alegre: Ed. Artes Médicas; 1998. p. 175-181. remain surprisingly relevant even today.

Final considerations

The opinions discussed in this work confront several limitations. One of these relates to the fact that, since this involves a very recent and contemporary debate, we have not based this work solely on our own experiences, but have instead submitted our opinion to a broader forum. However, the search to find experts in this subject was something of a challenge, since it is not easy to find specialists in a field that is still not given much visibility.

The second limitation refers to what this article offers or attempts to offer by way of a contribution to the field of health care. It may well express the tensions that exist between the traditional family model and other family arrangements. Thus, when proposing arrangements that deal with lines of care for healthcare actions that are geared, for example, to “same-sex couples,” we may at the very least be putting forward ideas that will appear rather unusual to both users and health professionals alike.

The interfaces between cultural constructions about the role that men play in life, in their social relationships as a father, and that which involves healthcare actions touch on three points: (a) the idea of man as a collaborator in the promotion of the health of his partner while pregnant and/or his offspring; (b) the idea of paternity being strongly linked to being the financial provider; (c) the hiatus generated between the traditional concept of paternity and the new family and gender arrangements. We highlight the fact that these points are included in an intense political arena of national and international debates about male involvement in healthcare, in the exercise of paternity and in promoting gender equality. Thus, we cannot detach our analysis from the wider global context in which these issues are continually being debated.

These ideas/understandings encounter strong opposition from traditional groups and reflect attitudes that ignore the changes that are currently taking place with regards the way these groups and individuals battle to affirm and receive recognition for their rights. These efforts occur on several fronts, for example, within the scope of the Federal Legislative Power, where a proposed bill presented as “Family Bylaws,” ignores the diversity of family arrangements, or the satisfaction that cements emotional relationships and the changes that have occurred in gender roles, and thereby proposes only one family model, which goes against what we observe in reality.

Acknowledgements

For their participation in the consensus technique, we would like to thank the following professionals: Bárbara Tarouco da Silva, Caroline Oliveira de Castro, Eduardo Schwarz Chakora, Fabio de Mello, José Medeiros do Nascimento Filho, Márcia Reis Longhi, Marcus Renato L. N. de Carvalho, Maria Cristina Montenegro Pereira, Maria Luiza Mello de Carvalho, Viviane Manso Castello Branco and Waglânia de Mendonça Faustino e Freitas.

References

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