Midwifery 29 (2013) 351358

Contents lists available at SciVerse ScienceDirect

Midwifery
journal homepage: www.elsevier.com/midw

Let men into the pregnancyMens perceptions about being tested for
Chlamydia and HIV during pregnancy
Monica Christianson, RNM, PhD (Registered Nurse/ Midwife)a,n, Jens Boman, MD (Medical Doctor)b,
Birgitta Essen, MD, PhD (Medical Doctor, Gynecologist/Associate Professor)c
a

Department of Nursing, Ume

a University, SE-901 85 Ume
a, Sweden
Department of Public Health and Clinical Medicine, Dermatology and Venereology, Ume
a University, SE-901 85 Ume
a , Sweden
c
Department of Womens and Childrens Health, Uppsala University, Uppsala University Hospital, IMCH, SE-751 85 Uppsala, Drottninggatan 4, 4th oor, Sweden
b

a r t i c l e i n f o

abstract

Article history:
Received 1 July 2011
Received in revised form
12 January 2012
Accepted 5 February 2012

Objective: to investigate how to prevent transmission of HIV and Chlamydia trachomatis (CT) by
exploring whether screening of men during pregnancy may be an innovative way to reach men, to
increase detection, and to avoid the present gendered responsibility.
Design: an explorative research strategy with in-depth interviews and an analysis informed by
grounded theory principles was used.
Setting: the northern part of Sweden.
Participants: twenty men/becoming fathers in their twenties and early thirties were offered CT and HIV
testing and were interviewed about their perceptions about being tested during pregnancy.
Findings: Six categories emerged that concerned the mens risk perceptions, reasons for not testing
men, benets and negative consequences associated with being tested, incentive measures for reaching
men and the optional time for testing men during pregnancy. The majority of the men perceived their
own risk for having CT or HIV to be close to zero, trusted their stable partner, and did not see men as
transmitters. They did not understand how men could play a role in CT or HIV transmission or how
these infections could negatively affect the child. However, few informants could see any logical
reasons for excluding men from testing and the majority was positive towards screening men during
the pregnancy.
Key conclusions: mens sexual health and behaviour on social and biological grounds will affect the
health of women and their children during pregnancy and childbirth. As long as expectant fathers do
not count in this triad, there is a risk that CT and HIV infections in adults and infants will continue to
be an unsolved problem.
Implications for practice: knowledge from this research can contribute to inuencing the attitudes
among health-care providers positively, and inspiring policy changes.
& 2012 Elsevier Ltd. All rights reserved.

Keywords:
Screening
Pregnancy
Men
Gender

Introduction
Because pregnant women use antenatal clinics, they are
screened and tested for sexually transmitted infections (STIs)
more often than men, making screening during pregnancy both
a woman problem and a priority for womens sexual health
(Duncan and Hart, 1999; The National Board of Health and
Welfare, 2009). Since men visit health-care facilities less often
than women, they often go undiagnosed and untreated (Kalwij
et al., 2010). By ignoring men for testing, there is a risk that STIs
among men will go undetected and that they will spread. This is a

Corresponding author.
E-mail addresses: monica.christianson@nurs.umu.se (M. Christianson),
jens.boman@dermven.umu.se (J. Boman), birgitta.essen@kbh.uu.se (B. Essen).
URLS: http://www.umu/omvardnad.se (M. Christianson), http://www.umu.se
(J. Boman), http://www.kbh.uu.se (B. Essen).
0266-6138/$ - see front matter & 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.midw.2012.02.001

situation that has severe health consequences not only for men,
but also for women and their unborn child.
Health screening may be dened as a targeted action designed
to reduce mortality and morbidity in populations with elevated
risks (Heyman, 2010). Screening normally involves sorting out
subgroups within the population that are at high risk and offering
these high risk individuals access to diagnostic tests, such as
screening for congenital disorders. Screening is a public health
service that attempts to identify individuals who are more likely
to be helped than harmed by further tests or treatment to reduce
the risk of a disease or its complications (Low, 2007). In Europe,
there is an on-going debate whether national screening programs
should be introduced (Low and Egger, 2002; Polyzos et al., 2006).
The debates about screening address cost effectiveness and
preventive effectiveness with respect to long-term consequences
of infections. Although researchers have not reached a consensus
about the effectiveness of screening for CT and HIV, several claim

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M. Christianson et al. / Midwifery 29 (2013) 351358

that screening is benecial for many reasons. In Europe, there is a

growing consensus that increased HIV testing will have public
health benets (Renzi et al., 2004). Reducing the time between
HIV-infection and diagnosis is valuable for public health as the
earlier the infection is discovered, antiviral therapy and information about condom use will decrease the rate of transmission,
reduce morbidity and mortality, and reduce the cost for acute
treatment as well as reduce the loss of productivity among
infected people (Dodds and Weatherburn, 2007). In a systematic
review, it is suggested that the cost effectiveness of screening for
CT among young asymptomatic women may be benecial (Honey
et al., 2002). The presumed and severe consequences among
women, such as ectopic pregnancy and infertility, can be an
expensive health-care cost and result in loss of productivity.
Yet screening practices vary widely across the countries in the
European Union (Holland et al., 2006). Although policies are in
place in most EU countries and the role of antenatal HIV testing is
addressed in professional guidelines, there is a lack of integrated
policies in Europe (Deblonde et al., 2007). According to Postma
et al. (2000) universal screening for CT and HIV both early and
late in pregnancy can be cost effective for women and their
children. Testing for HIV and CT is benecial for many reasons: it
can prevent the spread of STIs and severe health consequences;
CT is easily treated; and it can protect the newborn child from
catching neonatal conjunctivitis in 30% of newborns and neonatal
pneumonia in 15% of newborns (Mangione-Smith et al., 1999).
The vertical (i.e. from mother to the child) transmission of HIV
can be reduced using pharmacotherapy, caesarean section, and
breast milk substitution (i.e. from mother to child) from 30% to 2%
(Postma et al., 2000).
The argument for screening women for CT has been that the
female reproductive tract appears to be more seriously affected
by the infection compared with men (Pacey and Lely, 2004).
Newer research, however, indicates that opportunistic screening
does not control transmission and that there is a need to screen
more men (Herrmann, 2006). As recently as Puro and Ippolito
(1998) suggested that discovering the highest possible number of
HIV infections during pregnancy would require offering the
couple the test rather than just offering the test to the woman.
In Sweden, and globally, midwives (usually women) provide
antenatal care for uncomplicated pregnancies. The expectant
father is welcome to take part in the pregnancy, mostly to support
the pregnant woman (Finnbogadottr et al., 2003). In maternity
care, many men nd themselves situated in an undened space
of uncertainty, where they are not-patient and not-visitor
(Steen et al., 2011). As the man often is viewed as a social and
psychological back-up for his pregnant partner, the biological
health risks of transmitting STIs to the woman and the unborn
child is neglected. Traditionally, testing for STIs in pregnancy has
been a womens issue despite the fact that it may be short sighted
and counterproductive to not offer screening for men. There is a
gap of knowledge concerning why men are more difcult to reach
for testing, and few if any empirically based explanations are
available concerning how men perceive testing in the context of
pregnancy.

Aim
This study investigates how to prevent transmission of HIV
and CT from a gender perspective by exploring whether screening
of men during pregnancy may be an innovative way to reach men,
to increase detection, and to avoid the present gendered responsibility. This paper focuses on expectant fathers perceptions
about being tested for HIV and CT during the same period their
pregnant partners are being tested.

Method
This study used interview techniques to evaluate STI testing
during pregnancy (vreveit, 1998). The interviewees reported
their views on testing men during pregnancy, and their personal
motifs behind testing or not were explored. Furthermore, we also
wanted to know if the men found testing to be a successful
procedure or a failure. An explorative research strategy with
in-depth interviews and an analysis informed by grounded theory
principles was used (Strauss and Corbin, 1990). This method is
suitable when little is known about an area or when new knowledge is needed, such as in this case. Pregnant womens partners
were offered CT and HIV testing at the beginning of the pregnancy,
except for one man that was interviewed and tested during the
third trimester. Those who agreed to be tested were interviewed
about their experiences; those who did not agree to be tested were
also interviewed about their motifs for not being tested. Men did
not request tests without being included in the study.
Setting and participants
The data collection started in August 2009 and ended in April
2010. The inclusion criterion was that the informants should
speak Swedish or uent English, and ongoing pregnancy of the
partner. The setting was a university town with around 115,000
inhabitants in Sweden. During the pregnant couples rst visit to
the antenatal clinic, midwives recruited 35 expectant fathers
between 18 and 35 years old. They received written and verbal
information about the study. The rst author contacted the
recruited men via telephone. During this conversation, she
answered questions about the project and set a time and place
for the interview. In total, 20 men agreed. In addition, 15 men
who refused to participate provided several reasonse.g., they
did not have the time, they did not want to be interviewed, or
they were not interested in research.
The interviews
The rst author performed the interviews and the sampling for
CT and HIV. She was considered to be an experienced interviewer
and familiar with grounded theory (Christianson, 2006). The
interviewer and interviewees differed concerning age and gender,
and this may be a methodological problem (Hutchinson et al.,
2002) but the friendly atmosphere and the skilled interviewer
compensated these eventual effects. The issue of rigour was met
by rethinking rigour in the way that Davies and Dodd (2002)
suggested. The cluster of terms such as responsibility, attentiveness, empathy, openness, sensitivity, engagement and awareness
were part of the interviewers agenda for creating trust. All
interviews were carried out in a respectful manner, where the
men were encouraged to articulate their opinions, feelings and
thoughts in a way that did not create distance between interviewees and the interviewer. The interview session took
4590 mins. Twelve men were voluntarily tested, and these
interviews and tests for HIV and CT were carried out at a youth
clinic. Eight men refrained from testing and these interviews took
place at the university where the rst author worked. Before the
interview started, the interviewees gave their written consent.
Emphasis was put on informing the interviewees that the intention with the interviews was not to test their knowledge or
ignorance about STIs, but to explore their perceptions, i.e. to make
them feel comfortable during the interviews. A brief questionnaire about socio-demographic characteristics was collected
(Table 1).
The interview included open questions: What do you know
about CT and HIV? What are the consequences of the infections?

M. Christianson et al. / Midwifery 29 (2013) 351358

353

Table 1
Demographic background factors, in-depth interview study with men in a Swedish city.
Age (years) (mean age 27.5)

Ethnic background

Expects rst/second child

Home district

Occupation

Civil status

21
23
24
24
25
25
26
27
27
27
28
28
28
28
28
28
29
29
30
34

Swedish
Swedish
Swedish
Swedish
Swedish
Swedish
Swedish
Swedish
Swedish/parents from Finland
Norwegian
Swedish
Swedish
Swedish
Swedish
Swedish
Swedish
Swedish
Swedish
Swedish/parents from Finland
Swedish

First child
First child
First child
First child
First child
First child
First child
First child
First child
Second
First child
First child
First child
Second
First child
Second
First child
Second
First child
First child

Village
Town
Town
Town
Town
Village
Conurbation
Town
Town
Town
Village
Town
Village
Town
Town
Conurbation
Town
Conurbation
Town
Village

Unemployed
Welder
Storeman
Planning mill
Student
Carpenter
Unemployed
Dispenser
Chef
Bartender
Truck driver
Inspector
Engineer
Porter
Student
Floor dresser
Auditor
Purchaser
Machine operator
Police

Cohabiting
Cohabiting
Cohabiting
Cohabiting
Cohabiting
Cohabiting
Cohabiting
Married
Cohabiting
Cohabiting
Cohabiting
Married
Cohabiting
Married
Cohabiting
Cohabiting
Cohabiting
Cohabiting
Cohabiting
Cohabiting

What is your susceptibility for these infections? What reasons are

there for not offering tests to men during their partners pregnancy? What are the benets and the negative effects of the
intervention? What are the incentives for actions that would be
helpful to reach men? The interviews were tape-recorded and
transcribed verbatim.
After receiving their test results, a short follow-up telephone
interview was conducted. In this interview, the informants were
asked to explore their reactions to the test results and they were
given the opportunity to comment further about the study. These
reections were included in the analysis. All men were HIVnegative. One man had a CT infection, and he and his pregnant
partner were treated with antibiotics at their primary health-care
centre. A second follow-up telephone interview was conducted
with him due to the distress he experienced when he was
informed that he had CT. All men approved to be contacted if
the research team had more questions.

Ethical considerations
The participants were assured condentiality and were carefully informed both verbally and in writing about the aim of the
study and the voluntary nature of the study. Testing was not done
without informed consent. The Regional Ethical Review Board in
Sweden approved the study in May 2009 (Dnr 09-048 M).
Umea,

Findings
The men/expectant fathers perceptions were categorised
in six categories and 15 subcategories concerning mens risk
perceptionsreasons for not testing men, benets associated
with testing, drawbacks associated with being tested and how
to normalise testing for men.

Analysis

Risk perceptions are based on safety

The transcription of the open coding included examining,

comparing, conceptualising, and categorising the data (Strauss
and Corbin, 1990). In this case, a line-by-line coding was performed; the interviews were read carefully and sentences or parts
that were perceived to be important were underlined. Concrete
words were written in the margins of the text. Thereafter, the text
was broken down into parts where each part was given a name
that described the phenomena, occurrences, or emotions. In the
next step, the open codes were sorted into categories. The axial
coding was the next phase. This coding reorganised and put
together the data in new ways. The concepts that seemed to
pertain to the same phenomenon were categorised. This process
involves several steps, but in a more focused way. During this
analysis, a thorough content of the study material was gained. It is
important to sort the data that is relevant when trying to answer
the research question (Malterud, 2001), so the subcategories that
did not t were left out. This procedure meant a back and forth
movement between subcategories and data, looking for similarities and differences, an act that Strauss refers to as a constant
interplay between proposing and checking (Strauss and Corbin,
1990). The authors then evaluated the categorisation to nd
consent. Finally, a more abstract phase of analysis began and
the emerging subcategories and categories were identied.

Own risk is low

All men estimated their risk of having an STI as relatively
small, very low, or absent. Some of them claimed that their risk
for catching an STI was in principle zero. The men thought that
their sexual activities reected their morality: one man summarised his low risk by stating:
I dont run around in pubs and exchange girls every night.
Another man said:
I have never had any casual relations, and my previous
partners were both tested so I have never felt that it was on
the agenday. I mean if one had been single and had been
going out a loty having had one-night standsy but I havent
done thaty
One man thought that he had been good at protecting himself
with condoms and another man used the word careful. The men
concluded that they did not worry about catching HIV, and one
man made a parable to tombola:
Its a bigger chance that I will win one million on Lotto than
catching HIV.

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M. Christianson et al. / Midwifery 29 (2013) 351358

Minimal risk for HIV transmission was seen if health-care

providers withheld precautions during operations and a small risk
was estimated among people who were working with HIVpositive patients and were getting the virus in the eye, or if
people were injecting drugs. HIV was seen as atypical in Sweden,
more common among vulnerable groups in the society and these
views made them feel safe.
Trust in the relationship
All men were living with their pregnant partner. According to
the interviewees, their intimate relationships were built on
condence and safety. The mens beliefs that they were not at
risk, or had minimal risk were linked to trust, feeling secure in the
relation, were living in a monogamous relationships, were having
a stable partner or had been living together for a long time. Trust
in the relation was often built on emotions:
We feel secure with each other, and we are together most of
the time yand yes I am mind-blowing in love with my
girlfriend and I know that she loves me as much as I love her.
For a couple of the men, their pregnant partner was their
rst and only sexual contact. Risks were linked with being single
and having unprotected sex. The pregnancy was described as
shaping strong ties between man and woman and having extramarital partners was seen as out of the realm of possibility.
Indelity was perceived as having major problems in the
relationship.
Men are not transmitters
They perceived that STIs were more common among other
peopleimplicitly, women who have had unprotected sex with
many people. An eventual increased risk for STIs depended on the
partners/womans risk for being infected and thereby infecting
him:
If she [my partner] would be walking around the block there
would be an increased risk for STIs, but I really have a hard
time believing she would do that.
Few men thought that they could infect their partner:
In fact, I have never thought the other way around, that men
infect their wives.
One man referred to the high rate of divorces in Sweden and
speculated about a potential future separation where new relationships would increase his risk for being infected by a new
woman:
We might separate in ve years and I might meet a new
woman who can infect me.

In addition, mens health depended on the control of the

women: men relied on that the woman was controlled and if
she was healthy, he would also be healthy:
If you havent been unfaithful and the girlfriend is tested then
its green.
Five men argued that they did not understand why men
should be tested during the pregnancy as it was the wife who
was carrying the baby:
You dont have to test the man if one is a man because its the
wife who is carrying the child, and then his test will be
overlooked. I can imagine that it has to do with this. She is
the one who gives birth, not the man and she is the one to be
testedyand yeahy
A couple of men referred to the Law of Communicable Diseases
Act that implied that if infections are detected in women, men
will also be tested.
Normal men dont need to be controlled
Testing men was experienced as logical in specic situations.
The men thought that in case of an unplanned pregnancy it would
be better to test, while being with the same girl for many years
there is no reason to be tested. The men talked about we and
them, where men who were close friends were perceived to be
normal and did not need a check-up. One man referred to unusual
situations seen in movies:
Such as in the documentary lms where ve to six men could
be the father of the child.
Two men were dubious towards testing men during pregnancy. One man perceived it inappropriate and referred to
rational perceptions concerning secure and monogamous relations: i.e. the trustworthy kinship between husband and the
pregnant wife ensured low or no risk for STIs. Another man
thought that testing should have been done before the pregnancy
or done earlier in life, not now.
Men are sidestepped
Many men believed that because health care should focus on
the pregnant woman, they were sidestepped. One man during his
rst visit at the maternity care felt it was strange that men were
not tested. Several men concluded that they could not see any
logical reasons for excluding men from testing:
If I can infect my partner, I can also infect my child. In my eyes
it would be obvious to test both men and women. But the
mother is in the centre and the father; he is left outsidey
Thats the way it is.
Several men thought that it was remarkable that men were
not tested and they thought that testing should be offered.

Reasons for not offering tests for men during pregnancy

Men dont see their role in transmission
The woman is controlled
Few men had reected on testing men, because in maternity
care they thought that it was the woman one was interested in.
Most men were expecting their rst child and this was perceived
as a novel phase in life were the focus was on the pregnant
woman:

Few men could formulate how and in what ways the health of
the child could be affected if men were tested during pregnancy.
This thought had never hit them. One mans rst thought,
however, was that it was good if diseases could be discovered
that otherwise can be transferred. Another man had difculties to
grasp how he could inuence his childs well-being:

One hasnt been thinking about men as disease carriers

towards the child.

I do not know if it plays a role in the childs health if one is

tested when the pregnancy already is a fact, but probably not.

M. Christianson et al. / Midwifery 29 (2013) 351358

The problem is that when the sperm has reached the woman,
at that point it feels too late to do anythingy The role of the
men feels rather unimportant mechanicallyy I can give
psychological support and things like that but I cannot do
anything more with my body now!
Another man thought that preventive measures should be
done before the pregnancy has happened:
Its a bit late to do something for a child that is already
contaminated with HIV when its already in the womb.
Few men believed that medically, testing would not affect
anything. Several men noted that a pregnant womans lifestyle,
not his, would affect the unborn childs health:
I cannot see any direct link between my eventual smoking and
how that would affect the child.
Insecurity was raised concerning whether contagions could
affect the child during pregnancy. The possibility to treat the child
was perceived as ambiguous:
In this pregnancy a test wont help this child, but certainly in a
new pregnancy, that child will be cured.

Benets if men are tested

An extra safety precaution
The majority thought that there were many good reasons to
test men. They claimed that there were only pros to be tested, a
better overview of the situation was gained, and it was the right
thing to do. Commitment by men was perceived to decrease the
eventual stigma connected with STIs and new testing routines
would make men feel more involved in the pregnancy and be
healthier. Testing would be seen as an extra safety precaution.
The ability to protect the health of the child was seen as crucial:
To one-hundred per cent one wants to do everything to stay
healthy and to improve the health of the child.
Some men implied that there would be psychological benets
for women:
If the woman is worried, she will be less worried for her
husband when he is tested.
To detect, treat, and prevent the spreading of STIs was seen as an
advantage. Thoughts about nancial benets and efcacy occurred:
Its more expensive to treat three persons instead of
treating one.
The societal benets and life savings if both partners were
tested was mentioned:
For the whole society, it would be better if people were tested
and contagions were discovered.
Improving mens health
The importance of being informed about ones own health and
to raise consciousness that these infections may infect men too
was mentioned. Furthermore, to make men more actively concerned about their own health would make it natural and less
shameful for men to be tested:
I would like to be tested to get some peace in my mind because
if I have Chlamydia or HIV, I would like to know.
To prove that you dont have HIV that otherwise can be spread.

355

Testing was perceived to increase diagnosis among people

who were unaware of their infections. This was expressed in the
following way: discovery of wrongness and nding people that
are sick. Furthermore, testing would make men aware of their
risks as the sexual life did not stop because couples were
expecting a child:
If I have it [an STI] I must treat myself, otherwise she will be
infected by me.

Negative consequences for men if they are tested during

pregnancy
To be supervised
Pregnancy was seen as a good entryway where it would be
feasible to reach men, although the men thought that a minority
of other men would perceive testing as unnecessary. These
other men would perceive testing as an indignity against both
women and men, or people may resent it. Some men could also
feel singled out, pressured, inicted, or a bit pounding:
If testing would be mandatory for men, then I think that some
minor negative things could happen, such as that some men
would be feeling supervised. For me, I have problems with
authorities and in extreme cases perhaps some would feel
singled out.
Some also may see being required to do something as a bad
idea since being imposed is never good. Some men may also
perceive required testing as an integrity offence, a bit of a control,
a registration, or specically as an indelity control, which was
perceived as negative for men who try to conceal their side steps
to avoid ending an otherwise stable relationship. One man was
rationalised it this way:
You do it [testing] long before you are planning a pregnancy, as
testing during a pregnancy could cause troubles in the relationship. This is especially true for men who are unfaithful and
lie about it.
The men perceived that people in the risk zone did not want
the relationship to be broken so therefore some men would avoid
being tested.

Normalise testing for men

Hands-on information about testing
The men wanted information about the tests, such as where to
go to be tested, and conrmation that the tests were free and
painless, and conrmation about the efcacy of the tests. Furthermore, men wanted information about how these infections
affected mens reproductive organs, how the unborn child could
be affected, and how the infections were treated. In addition,
several men wanted more information about the consequences of
not being tested. Perceived taboos linked to the stigma of being
tested were mentioned; one man suggested testing should be
done anonymously.
Make it natural
Health-care providers could recommend tests for men. Men
need to break some social barriers in order to be tested in the
maternity ward, whereas it was seen as natural for women to be
tested during pregnancy. Some men identied and addressed

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M. Christianson et al. / Midwifery 29 (2013) 351358

these barriers so as to make it simple to be included in maternity

care: one man claimed:
Let men into the pregnancy.
Another idea was to create all-round clinics for both men
and women.

Equality aspects concerning testing were also mentioned:

Once is enough for the woman and once is enough for the man.
Furthermore, the men wanted to be tested at the same time as
the mother was tested.
Tactical testing

Natural promoters for men

Several men stated that the midwife had a natural position
and was often mentioned as the best promoter because men trust
the midwife and during the pregnancy the couples have faith in
the midwife and listen to her:
Midwives are the ones you meet with through health care and
in connection with the pregnancy. It becomes natural to relate
to the midwife, thats what I think.
The men suggested that those pamphlets concerning living
habits that were sent home could also include information
about tests for men, as this would be effective to be invited to
be tested.
Signicant persons in the surrounding were also seen as
promoters:
If my parents or partner would ask me to be tested, I would
do it.
Specically, testing through occupational health care, during
military service, or through athletic associations were recommended. Inuencing and shaping of traditions such as massive
testing of 18-year-old men or focus on older men were seen as
important strategies. One man suggested testing all men when
they turn 30 years old.

One-off testing during pregnancy

All men reected on how often men should be tested. Two
men claimed that their medical understanding was insufcient
and one of these men thought that this question was better posed
to a doctor. One man suggested that it was best to focus solely on
the pregnant women:
She could be tested a couple of weeks before giving birth.

Early testing
The majority stated that these tests should be done early in the
pregnancy: for them it felt natural to have it done early. Other
suggestions were made with respect to the timing and location of
the testing:
During the sign-in is a good opportunity to have them both
tested. To be informed that it is very important to test men
also. I dont think that there are many who will say no.
The men suggested that men could be tested during their rst
visit at the maternity care, and that it was reasonable to test one
time and as soon as possible:
For the sake of the child, take the test the rst time couples
meet the midwife.
Another man thought:
Its too late at the end of the pregnancyy. It gets worse the
longer one has it [STIs].

The optimum time for testing was discussed. The men thought
that although the issue was rather sensitive it was a good idea to
test men a bit later in the pregnancy:
I dont know if it is common or sometimes it happens for sure
that meny There is not so much sex during those nine months
perhaps and there is an increased risk of indelity during this
period. Maybe one has to be a bit tactical and test after
half way.
Some of the men thought that it was pointless to test late in
pregnancy. A couple of men also claimed that it did not hurt
anyone to be tested more than once:
It is better and perhaps even more strategic to test more
frequently.
The risk for men who would feel supervised or harmed was
discussed. One man disliked the idea of testing men more than
once: he thought that the aim was wrong and there will be an
indelity control. Another man argued that the indelity control
is directed towards the women although from his opinion this
issue seldom was raised. One man claimed that men should be
tested both early and late in pregnancy even if men could feel
embarrassed and in extreme cases also supervised. One man
claimed that during pregnancy and childbirth, indelity sometimes occurs, so he recommended tests, both early and late in the
pregnancy. Some men concluded that people do not give birth
that many times during a lifetime so testing could be reproduced:
Testing could be repeated during a second, third, or during a
fourth pregnancy.

Discussion
The majority of the men perceived their own risk for having CT
or HIV to be close to zero. Many of them were already tested,
trusted their stable partner, and did not see men as transmitters.
They did not understand how men could play a role in STI
transmission or how these infections could negatively affect the
child. Few of them could see any logical reasons for excluding
men from testing and were positive towards screening men
during the pregnancy.
Presently, these maternity clinics for antenatal care have a
specic gender framing that stands in contrast with other health
care, as the expectant father is not involved in the care as a
patient. Not surprisingly, the interviewed men and men in general
do not have natural entryways into antenatal care and a variety
of incentives are suggested to make it natural for men to be
tested. The men want concrete and adequate information about
testing, and treatment. Moreover, they want to know how the
infections affected their reproductive organs and how the unborn
child might be affected.
Midwives are perceived to be signicant motivators for testing
men, but they are part of a system where gender is not considered
when it comes to screening men during pregnancy. Hence, a
recent review on barriers towards HIV testing shows that healthcare providers such as midwives and general practitioners
attitudes may play a role in encouraging or discouraging testing

M. Christianson et al. / Midwifery 29 (2013) 351358

(Deblonde et al., 2010). If medical personnel are unwilling to

address HIV testing or focus on HIV ineffectively, then the prevention will be unproductive. For example, in a Swedish context, it
may be common to see heterosexual youth as a risk-free population. This way of thinking may act as a barrier for HIV-testing and
increase missed opportunities for early diagnose of HIV within
primary care (Christianson et al., 2010).
There are few studies that examine mens view about testing
men in the context of pregnancy. Antenatal screening in EU countries mostly address the needs of pregnant women and how to
prevent infections in unborn children and infants (Deblonde et al.,
2007). In antenatal care for the prevention of mother-to-child
transmission of HIV, services must be available and utilised early
enough to identify HIV-positive mothers so they can get antiretroviral treatment (McIntyre, 2007). Traditionally, testing for
STIs during pregnancy has been a womans issue despite the fact
that it may be short sighted and counterproductive to not offer
screening for men. For example, screening only women for STIs
implies blame and can stigmatise women (Duncan et al., 2001).
In a recent review, Sherr (2010) discussed the cost benets for
women and children if men are involved, such as stigma reduction for women, the reduction of vertical transmission, and higher
rates of testing for women. In addition, the positive health
outcomes for men should not be underestimated. The discussion
concerning cost effectiveness for screening is ambiguous, depends
partly on the prevalence of STIs in the screened population and
the access to care (Rietmeijer et al., 2008), but research clearly
indicate that earlier diagnose of HIV are cost saving because if
people are aware of their infection, fewer are transmitting the
virus to other people (Vimalanand et al., 2011). Moreover, to
reach couples in antenatal care will promote HIV testing
among men and reduce the risk for HIV transmission (Katz
et al., 2009).
In our study, 18 out of 20 men are positive towards testing
men for CT and HIV during pregnancy as new testing routines
would make men feel more involved in the pregnancy, would
protect the health of the unborn child, and would make men
healthier. Although little is known about complications in men,
research shows that CT can cause adverse health outcomes such
as epididymitis, epididymo-orchitis, reactive arthritis, and proctitis (Kalwij et al., 2010). It appears incomprehensible and weird,
as some interviewed men said, that men are not routinely tested
considering that testing would help stop transmission of STIs and
protect unborn children from negative health complications such
as preterm delivery, low birth weight, conjunctivitis, and pneumonia (Kalwij et al., 2010).
Research indicates that there is a need to screen more men
(Herrmann, 2006), and the WHO recommends that counselling
and testing should be available to pregnant women and the
expectant fathers (McIntyre, 2007). To reach men is a challenging
task and a major public health issue. Men seldom visit health-care
facilities because of nancial barriers or men may fear a positive
test would bring them down (Kalmuss and Austrian, 2010). In
addition, constructions of masculinity may deter real men from
seeking health care. It has been claimed that men may reject
healthy thinking and behaviours to achieve manhood (Courtenay,
2000). They may repress their own health-care needs or may not
seek a doctor without cause. A focus group study reveals that
young men generally resisted testing due to shame and fear, fear
of painful examinations, deformity of their genitals, or worries
about STIs (Christianson et al., 2007). Men may argue that if they
do not have symptoms, they do not need testing no symptoms,
no test (Kalmuss and Austrian, 2010) which may be a barrier
for men.
The vast majority would appreciate a health policy directed
towards men. According to these participants, men should be

357

tested during the rst trimester, although some men recommended tests both early and late in the pregnancy. Although
these mens observations offer a solid point of departure, policy
programs directed towards men need to be revised by policy
makers in collaboration with researchers and health-care
providers.
In discussions about benets concerning who would gain and
who would lose from screening, there will be some individuals
who will be harmed physically or psychologically by screening
(Heyman, 2010). For instance, in some cases amniocentesis may
cause a spontaneous abortion or a mammography may cause
distress among some women in cases of false positive results.
These potentially harmful effects need further investigation.
Therefore, some people will pay a price as screening may perhaps
create false security, insecurity, or over-complacency (Bach
Nielsen et al., 2009). Two men emphasised that it was inappropriate to test men during pregnancy, as it could be seen as a type of
control. Nevertheless, the eventual harm that men who are
screened may experience and the safety of others, in this case
the preventative goals for the fetuses and the pregnant women,
are more important. STIs during pregnancy will have harsh
consequences for women and children when men are not controlled (Bonhomme, 2009). However, many men are unaccustomed with being controlled by the health-care system. In
addition, midwives could welcome men who are becoming
fathers and discuss strategies for better reproductive health
(Mbekenga, et al., 2011). Clearly, to let men into the pregnancy
is easier said than done. In maternity care men may feel that they
are partners and parents (Steen et al., 2011), but not patients and
this is one main item that needs to be changed. To educate men,
midwives, stakeholders in health care and partners about the
importance of changing mens role as outsiders towards a patient
and co-parent centred perspective is a challenge.
By ignoring mens sexual health, this women-dominated area
may be ignoring the mothers and unborn childs health. The
exclusion of fathers from screening for STIs during pregnancy
seems to arise more from cultural and gender attitudes rather
than medical risks. In the case of STI screening during pregnancy,
it is pregnant women, not heterosexual men, who are subjected to
discipline and control. According to Lupton, it is normally members of marginalised groups women, deprived, unemployed,
injecting drug users, gays, lesbians, and non-whites who are
constructed as grotesque bodies (i.e. open, polluted, and irrational) and therefore at risk (Lupton 1999) while heterosexual
men are not viewed as risk actors. We would like to conclude that
our results show that one out of 12 tested men was CT positive.
This is an important nding.

Limitations
The interviewees were of white Swedish ethnic background
and all but one was born in Sweden. They were heterosexual men
in their twenties and early thirties, they were employed or
students (one was unemployed), and they had stable relations
with their partners. All these characteristics limit the generalisation of the ndings as we can only speak about these specic
men. Those who did not speak Swedish or uent English were
excluded, and the chance to provide alternative interpretations
and explanations were not possible. However, many men worldwide are heterosexual, have a wife or a girlfriend and are
expecting a child. Findings from this study may very well
harmony with the perceptions that other men in other context/countries have, despite different political system, demography and/or ethnicity/race.

358

M. Christianson et al. / Midwifery 29 (2013) 351358

Conclusion
Mens sexual health and behaviour on social and biological
grounds may affect the health of women and their children during
pregnancy and childbirth. As long as expectant fathers do not
count in this triad, there is a risk that STIs including HIV
infections in adults and infants will continue to be an unsolved
problem. There are social and cultural obstacles to testing men:
these barriers need to be overcome by carefully approaching and
informing men about the value of being tested. Time must show if
knowledge from this research and additional research can contribute to reduce incidence and prevalence of STIs, inuencing the
attitudes among health-care providers, inspiring policy changes.
To start, men should be offered testing during their partners rst
trimester of pregnancy. We believe that this strategy will improve
the health of men, their pregnant partners, and their unborn
children. It will take further research, both qualitative and
quantitative approaches, in settings outside Sweden, with a
variety of men included before a complete theory about men
and testing can emerge.

Conict of interest statements

The authors declare that there is no competing interest.

Author contribution
MC and BE created the conception of the design. MC collected
the data. MC, JB and BE analysed and interpreted the data, MC
wrote the manuscript draft, and together with JB and BE critically
revised it. All authors gave their nal approval of the version to be
published.

Acknowledgement
This study was supported by grants from the Swedish
Research Council, Challenging Gender Research Centres of Gender
Excellence and Centre for Gender Studies, Umea University,
Sweden.
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