Shattered Schemata and Fragmented Identities

Abstract

While pregnant women’s views about antenatal screening have been widely researched, those of expectant fathers remain underexplored. Interviews were thus conducted with 12 men and 6 women, either during pregnancy or soon after birth. Findings suggested that the men started to construct a schema of their child and a paternal identity even before she/he was born. One of the paternal responsibilities men encountered was to participate in screening. However, men’s ideas, beliefs, and feelings about being a father and about the future child were challenged by the receipt of screening results. Their child-schema became splintered into a wanted, imagined child and the at-risk fetus. Moreover, their paternal identity became fragmented into genetic and social components. Screening thereby caused some disruption in men’s experience of impending fatherhood and of pregnancy, eliciting ambivalence and confusion. Further research is now required to explore the issues raised in the study.

Keywords

antenatal screening prenatal diagnosis men and reproduction

Introduction

The National Health Service (NHS) offers pregnant women in Great Britain antenatal screening and testing as part of their routine maternity care. Screening commences with blood tests between 8 and 10 weeks’ gestation for hemoglobinopathies, such as thalassemia and sickle-cell. To screen for chromosomal anomalies like Down syndrome, an ultrasound scan is offered alongside further blood tests between 11 and 14 weeks (Alldred, Deeks, Neilson, & Alfirevic, 2010). Another ultrasound scan is offered between 18 and 21 weeks to look for structural anomalies and neural tube defects. Blood and ultrasound tests have a false-positive rate of 3% to 5%, meaning 3 to 5 fetuses out of 100 will be screened as high-risk when they are unaffected, and a false-negative rate of 30% to 35%, which means for every 100 affected fetuses, a diagnosis will go undetected in 30 to 35 (NHS Choices, 2010). If the screening test indicates there is a high risk of the fetus being affected by a genetic or chromosomal anomaly, invasive prenatal diagnosis—chorionic villus sampling or amniocentesis—is usually offered to determine whether the developing fetus is indeed affected. Diagnostic tests have a 1% to 2% risk of miscarriage (NHS Choices, 2012). The potential for false results and miscarriage are limitations of screening and testing that expectant parents might consider when deciding whether to undergo the procedures.

As Reed (2012) suggests, handling screening information can have an iatrogenic effect of increasing anxiety or uncertainty for pregnant women rather than providing reassurance. Other research suggests that women have to process large amounts of intimidating, confusing, and frightening information and make decisions within short timeframes about what tests they want to take-up (Green, Hewison, Bekker, Bryant, & Cuckle, 2004; Reid, Sinclair, Barr, Dobbs, & Crealy, 2009). Women often know little about the conditions for which they are screened and generally want more information about what life with an affected child would be like (Carroll, Owen-Smith, Shaw, & Montgomery, 2012; Pilnick & Zayts, 2012). In her study about amniocenteses, Rapp (2000) found that in particular women worried about the financial and emotional strain that having a child with additional needs might place on the existing family, especially if they already had young children.

Because of the issues women face in screening, some of the feminist literature suggests that reproductive technologies diminish choice, autonomy, and sense of control for women because they face sociocultural pressures to take up screening and accept further testing for high-risk results (Katz-Rothman, 1994). Choice is also limited because if a diagnosis is made, women have just two potentially difficult options, which are to terminate the pregnancy or raise a child with a disability (Ettore, 2002; Katz-Rothman, 1994; Rapp, 2000; Ward, 2005).

Since making decisions about screening can cause considerable stress and anxiety for women, and also since tests and procedures are performed on their bodies, men’s experiences of making decisions about screening, and how screening affects them psychologically, have been marginalized in the literature (Locock & Alexander, 2006). However, various studies suggest that women take men’s views into account when deciding whether to take up screening, particularly since decision making can be burdensome, and the decisions made can have a long-term impact on the couple and not just the woman (e.g., Aune & Möller, 2012; Dheensa, Metcalfe, & Williams, 2013; Van den Berg et al., 2008). Indeed, men’s involvement in screening can be beneficial because if there are two people to receive and process screening information, decision making can be more informed and shared between the couple.

There are also potential long-term benefits of men being involved in screening, as it provides them with a chance to get involved with the pregnancy more generally. Involvement in pregnancy has been shown in some research to predict involvement in the child’s life up to 3 years postpartum, such as increased paternal participation in playing and reading (Bronte-Tinkew, Ryan, Carrano, & Moore, 2007; Cabrera, Fagan, & Farrie, 2008). In turn, fathers’ involvement in children’s lives can have positive developmental, educational, and mental and physical health outcomes (e.g., Flouri, 2008).

Men’s experiences of screening are of particular relevance in the United Kingdom, as there is a current drive among policy makers to encourage fathers’ involvement in pregnancy and in their child’s early life (Department for Children, Schools and Families/Department of Health, 2009; Department of Health, 2009a, 2009b). Accordingly, the U.K. Royal College of Midwives (2011) published guidance for involving fathers in antenatal and postnatal care. With regard to screening, the guidelines state that midwives should acknowledge women’s desire to have men involved, but they offer little suggestion about whether men and women should make decisions about screening together, and how such joint decision making could be facilitated. These shortcomings are possibly due to the lack of research with men regarding screening.

A metasynthesis of the existing research about men and antenatal screening was conducted by Dheensa et al. (2013), where it was found that men wanted to be involved in screening to ensure the fetus was developing normally. It was also found that men involved themselves in screening by seeking technical and statistical information and using this information to guide women’s decisions. Through being involved, men experienced anxiety, which they felt they had to hide in order to support their partners. Also, many men felt marginalized in the antenatal unit, and as studies with women have suggested (e.g., Reid et al., 2009; Tsianakas, Atkin, Calnan, Dormandy, & Marteau, 2012), they did not feel they had made informed decisions, leading them to feel frustrated and confused. Two studies that were particularly important and relevant to the metasynthesis were by Reed (2009, 2011) and Locock and Alexander (2006), both of which focused on men in the U.K. setting. Although contributing valuable and rich data to this field, fewer men were interviewed than women in both studies, and moreover, couples were often interviewed together, which may have caused men to feel limited in what they could reveal before their partners and vice versa. The metasynthesis findings left some questions unanswered, such as how men dealt with any disagreements in their partnership regarding screening, how they managed internal emotional conflict, and whether screening was indeed a good way for men to be involved in the pregnancy. To improve on these limitations, and to answer the questions posed by the metasynthesis, the current research was conducted with a specific focus on men’s experiences of screening.¹

Design

This was an exploratory study using semistructured interviews, conducted between September 2010 and June 2011. Interviews were offered face-to-face, by telephone, email, or instant messenger. We gave participants the option because previous studies suggest that recruiting and engaging men in qualitative psychosocial research, particularly in face-to-face interviews, is difficult (Butera, 2006; Williams, 2007). The reason is that open discussion of emotions, behaviors, and attitudes can conflict with the suppression of emotion and vulnerability that comprises the enactment of typical Western masculine practice (Connell, 2000). Previous research has shown that disembodied interviews can be beneficial, because they maximize the chances of recruiting men and make it more likely that men will willingly and openly discuss the topics being investigated (Fontes & O’Mahony, 2008; Hunt & McHale, 2007; Kazmer & Xie, 2008; Opdenakker, 2006; Williams, Dheensa, & Metcalfe, 2011).

Sampling

There were 723,913 live births in England and Wales in 2011, meaning the population of expectant parents from which the current sample was drawn was huge. Of these births, 25.5% were to women born outside of the U.K, with most being born in Poland. The same data are unavailable for men, but most non-U.K. born men were born in Pakistan. Of the U.K. (27.3%) and non-U.K. (32.4%) born mothers, the most common age group was 30 to 34, just below the age when women are deemed to be “at risk.” More non-U.K.-born women were married (75%) than U.K. born women (45%) at the time of birth (Office for National Statistics, 2012).

In accordance with grounded theory, criterion sampling was initially used to recruit participants. Inclusion criteria were for participants to be a minimum of 16 years old and to have been offered at least one screening test by the time of interview. As with previous research (e.g., Reed, 2011), we recruited first-time fathers and men who already had children. To maximize the sampling pool, men whose partners were up to 12 months postpartum were also included. Broad inclusion criteria were used because the exploratory nature of the study meant no presumptions were made that any one demographic of men would have more valuable views than another.

To get an understanding of women’s feelings about having men involved, it was necessary to interview them too. Interviewing women also meant a more authentic and useful picture was gained of how men’s involvement in screening worked in day-to-day life, allowing more practical implications to be identified. Women’s views were additionally useful so comparisons could be made with men’s views, leading to a richer and more nuanced analysis. Sampling was ceased once theoretical saturation of the main topics was achieved.

Recruitment

Recruitment began in June 2010 and finished August 2011. Initially, we presented the research protocol at a 2010 antenatal screening coordinators conference in one metropolitan borough of England. Five antenatal screening coordinators stated their interest in facilitating recruitment, and so were given 50 study packs for women and 50 for men. Midwives handed study packs to men and women they saw for antenatal appointments and were asked to give packs to women to pass on to men, which was one way to access men who did not attend appointments. The packs contained an information sheet and reply form for willing individuals to send back. On this form, individuals were asked to state which interview method they wanted. We then contacted the individual to arrange an interview.

Midwives stated they had handed all of the packs out, meaning 500 were handed out in total. We also handed out roughly 10 packs to men and 10 to women across two inner-city children’s centers—places where expectant parents and parents of young children can receive services such as antenatal screening and child care provision. However, very few expectant fathers attended these centers. We additionally recruited participants from online mailing lists and parenting forums, where individuals could contact the researchers to state their interest. It is unclear how many people this invitation will have reached. In total, 10 participants were recruited through forums and mailing lists, 2 from children’s centers, and 4 through the NHS.

The Interviews

Before the interview began, participants completed a consent form and were given the chance to ask questions. We emailed consent forms to participants taking part in disembodied interviews and asked for them to be emailed back initialed and signed.

Instant messenger and telephone interviews worked much the same as face-to-face interviews, in that participants were given time to think about and answer each question, and follow-up questions were formulated based on what they had said.

Participants interviewed by email were given one opening question and then two or three questions at a time in response. These interviews therefore lasted around 5 days. Participants’ emails were usually responded to within a day to maintain contact. One interview schedule was used for all interviews, but the semistructured style meant that different questions were posed to each participant. Both email interviews were deemed to be complete—neither participant withdrew partway through the interview and both answered all of the questions posed in detail.

Data Analysis

We analyzed data using grounded theory (Corbin & Strauss, 2008), where the aim is to build theory that can later be tested. It was deemed appropriate because as Glaser (2002) argues, by using grounded theory, the analyst can identify concepts that affect people every day. Therefore, it was a suitable way to identify the everyday issues that affected men during pregnancy. Interview transcripts were initially coded for concepts and processes. In the next stage of coding, similar concepts were collated to create categories and arguments. If any gaps or weaknesses in emergent concepts were identified, the raw data were revisited to see if these gaps could be filled in. If they could not, then questions were added to the interview schedule to explore and develop the concepts further. The final stage of coding involved the integration and refinement of the categories.

We used analyst triangulation to help ensure findings were trustworthy. That is, the authors reviewed the findings together and discussed differing interpretations of the data. We also maintained a reflexive dialogue, whereby we identified potential researcher biases and their possible impact on analyses. For the same reason, SD kept a reflexive diary (Lincoln & Guba, 1985).

The Participants

Table 1 contains information about participants. All names were changed. Two participants resided in Scotland and the others in England. Three participants lived with their partners and the remainder were married. In the case of three of the participants, their partners were also interviewed. Two couples were interviewed separately, and one had a joint interview at their request. SD conducted the remaining 16 interviews with individual participants. Participants were not representative of the population of England, as all but one were White British and of a medium or high socioeconomic status. Contrastingly, in England, 11.8% of people are non-White and 24.4% of a lower socioeconomic status (Office for National Statistics, 2011, 2012).

Table 1.

Participants’ Demographic Details.

Pseudonym	Age	Interview method	Other children	Education	Gestation (weeks)	All tests offered and accepted?	Additional information
Andy	34	Instant messenger	3-Year-old son	Degree	<1 postnatal	✓	Wife had blighted ovum and dilation and cutterage in previous pregnancy
Bryan	30	Phone		Degree	22	Interviewed after 12-week screening tests. Refused Down syndrome scan.
Melissa	29	Phone		Degree	22	As above
Chris	36	Phone	2-Year-old son	PhD	9	Interviewed before offer of 12 week screening tests.
Daniel	29	Phone	1-Year old son	Degree	12	Interviewed just after 12-week screening test. All tests offered and accepted.	Refused Down syndrome scan in previous pregnancy
Eric	32	Phone		PhD	22	✓
Olivia	28	Phone		PhD	16	✓
Natalie	29	Phone			28	✓
Frank	40	Phone		Degree	34	✓	Wife had ovarian cyst in current pregnancy
Geoff	28	Phone		Unknown	18	✓
Harry	39	Phone	3-Year-old son	Degree	21	✓	High-risk screen for Down syndrome
							Prenatal diagnosis (amniocentesis) showed unaffected fetus
Iain	42	Email	2-Year-old son	Unknown	34 postnatal	✓	First child still-born
Luke	42	Phone		Unknown	39	✓	Two previous miscarriages
Joshua	39	Phone		Degree	20	Interviewed just before 20-week screening tests. All other tests offered and accepted.	Partner used IVF and egg donation, and was pregnant with twins
Samantha	39	Email		Doctorate	20	As above	As above
Karl	35	Face-to-face		Degree	34 postnatal	✓	Chromosomal translocation. Wife had four miscarriages. Conceived naturally. Prenatal diagnosis (chorionic villus sampling) showed unaffected fetus
Polly	37	Face-to-face		Diploma	34 postnatal	✓	As above
Rachna	34	Telephone		Degree	31	✓	Carrier of Haemo-globin E, but husband was tested and was not a carrier.

Results

Details about the participants—12 of whom were men and 5 of whom were women—are presented in Table 1. The results presented here are a subset of a larger project about this topic. One category is presented out of five that we constructed in the wider analysis. The views of a few participants therefore feature more heavily than others. The encompassing subcategories are (a) being a good parent, (b) deconstructing the child-schema, (c) deconstructing paternal identity, and (d) ambivalence and uncertainty. Overall, the findings suggest that men considered themselves as parents to the child even before he or she was born. They also formed a conceptualization of their future child, which is referred to in the current findings as a child-schema—a schema being a framework that helps to organize knowledge (Piaget, 1928; Sandelowski, Black, Mercer, Bergum, & Stainton, 1994).

Being a Good Parent

Attending screening appointments, being involved in seeking information, and making decisions about screening helped these men to integrate a paternal identity into their self-concept. It did this in three ways. First, being at screening appointments gave them a chance to enact responsibilities associated with this paternal identity, that is, checking fetal health. Second, seeing the fetal image made the pregnancy seem more real. Third, getting confirmation that the fetus was developing normally engendered some reassurance that the pregnancy was proceeding normally. The responsibility the men felt to the fetus was articulated by Chris, who discussed his screening experiences in his wife’s previous pregnancy:

It was our decision to have a child, [ . . . ] I would therefore expect to go in to [screening appointments to] find out everything that goes along with that so I could be as good a parent as possible during that phase and every other phase. (Chris)

By being involved in screening, men were following the perceived normative rules for fatherhood, which were to check and confirm fetal health and well-being.

The child-schema was the object of men’s feelings of responsibility. A key aspect of the schema was that there would be a resemblance between the child and the father. These imagined resemblances were important because as Mason argues, resemblances are “highly charged with kinship” (Mason, 2008, p. 30).

I wonder what it’ll look [like], you know, hope it gets this from my wife, I hope it gets this from me. . . . I mean I hope to God it’s not the worst bits of both of us, otherwise it’ll be a nightmare! (Geoff)

I say it in a sort of abstract way that you know joking about, oh it’s going to have, the baby will have hair like this, erm, it, neither of us are very tall so we joke about the baby being short and stuff like that. (Frank)

Imagining resemblances appeared to be an implicit way for men to stake their genetic claim to the fetus and was suggestive of men’s assumptions that they would be genetic fathers to the child (Lewis & Kattman, 2004; Venville, Gribble, & Donovan, 2005). Men also discussed their intentions to be social fathers to the child, by explaining the activities they would enjoy with them and ways they would interact with him or her:

Most of the outdoor stuff that I do I imagine I’ll carry on doing it [ . . . ] I’ll be able to get them on my back and do stuff and go walking. (Joshua)

These visualizations appeared to be a way for men to prepare for impending fatherhood. As is discussed in the remainder of this Results section, screening results sometimes challenged men’s preparations and assumptions about the child and their status as a father.

Deconstruction of the Child-Schema

Although men went into screening with some anxiety, none were expecting to receive a high-risk result. Thus, if an anomaly were detected, participants’ child-schemata suddenly became disrupted and distorted. For example, prior to screening, Harry “felt like [he]’d won the lottery again [and was] absolutely delighted” about the pregnancy. These feelings were challenged when the fetus was screened as high-risk for Down syndrome, particularly because of the potential negative impact on their existing son’s quality of life if a sibling with additional needs were born:

With the lifestyle and everything we’ve got, [ . . . ] just with the set up we’ve got, a Down’s child [sic] was not something that would fit into our lifestyle [ . . . ] The responsibility for having to look after a sibling is immense. The decision you make is, you might be able to cope with it and deal with, you’re also, when you’re gone, putting that then onto [son] and there’s gonna be an effect on how he has his life, what decisions he makes in his life and you’re making a commitment for him . . . that wouldn’t be fair. (Harry)

For men who faced these complications, the child-schema became splintered into a wanted imagined child and the potentially unwanted fetus. The potential for screening to shatter the child-schema has been touched on by Seglow and Canham (1999) as well as Raphael-Leff (1993), who suggested that “prenatal knowledge through sonography or amniocentesis [ . . . ] might puncture the bubble of imagining” (p.40), but these authors did not explore the nature and consequence of this puncturing. Karl highlighted some of the consequences he experienced, such as feeling confused and taking a practical stance toward decision-making, focusing on short-term goals:

We volunteered for [chorionic villus sampling] ’cus we were still quite concerned [ . . . ] even when we were pregnant, when we got passed the 12-week scan, and everything was incredible, we were still terrified, again ’cus then we still didn’t really understand the full extent of what the translocation could mean [ . . . ] it probably made our lives much more short-term. We’d never planned for the future, but it probably meant, that we weren’t talking about the future at all very much then. (Karl)

Here, Karl’s ambivalence (feeling “incredible” and “terrified”) was engendered by the multiple ways of conceptualizing the child—the wanted, imagined child, and the fetus with potential anomalies. He not only felt excited about having the imagined child but also understood that this child may not actually exist. These findings extend what Katz-Rothman (1994) illustrated in her work with women about amniocenteses: screening and testing caused pregnancies to feel tentative, meaning any attachment or bond with the fetus/future child was put on hold.

Men’s distinction between the wanted, imagined child and the fetus was a possible source of conflict between couples, because for women, the child-schema was accompanied with a physical and persistent gestational link. Since men did not have such a link, their child-schema and feelings toward the fetus appeared somewhat more vulnerable to change as a result of receiving medical information. Indeed, Olivia talked about how any screening decisions she made would be based on how she felt about the fetus, whereas her husband may have been more likely to make less emotionally imbued decisions based on statistics about risk. She too had planned to make decisions based on information about risk, but once pregnant, felt she could not ignore her emotions:

I know that [my husband] was particularly sort of nervous about having a baby that had a disability and I am too, but I don’t know how I would have felt. We had these discussions before we got pregnant and at the time I was sort of in agreement with him, but once you’re pregnant things feel a bit different [ . . . ] you’ve already seen a picture of your baby on the scan. (Olivia)

The subtle contrasts between men and women’s child-schemata were also shown by Daniel when talking about his first child. His developing child-schema was threatened by the 20-week scan, not because it revealed a genetic anomaly but because it was a male fetus. This revelation was a “shock” because he and his wife had “convinced themselves it was a girl.” Daniel’s wife was worried about the impact this would have on his feelings toward the future child:

I think she was worried that I wouldn’t be as keen on that baby or I wouldn’t be able to love it like I would have done if it had been a girl. And I was a little apprehensive at first, not quite sure how I felt. (Daniel)

For men who experienced anomalies, this shattering of the child-schema was also accompanied by a fragmentation of paternal identity.

Deconstructing Paternal Identity

As Bury (1982) has argued, illness can cause disruption of taken-for-granted assumptions. Although the illness in question here was a risk rather than a certainty, and about the person’s child rather than themselves, the potential for fetal anomalies caused disruption to Harry and Karl’s taken-for-granted assumptions that they would be genetic and social fathers to their child. These men, both of whom faced anomalies in the pregnancy, were forced to see paternity not as a coherent concept, but one with social and genetic components (Ives, Draper, Pattison, & Williams, 2008; Sheldon, 2005). This idea was portrayed by Harry when he discussed the option of adopting away a child if he or she were born with Down syndrome:

Part of the options we were told about after the amnio, if we had got a Down’s [sic], was go through the pregnancy and have the child adopted and we both kind of went, “Can’t do that.” If we bring a child into the world, and it’s our child, it lives with us ’cus it’s part of our family, it’s us, it’s physically part of us. (Harry)

Harry made a distinction between the fetus and the child who would be born. The pregnancy, that is, the fetus, would be terminated if a Down syndrome diagnosis were made. In contrast, the birth of a child, regardless of whether it had Down syndrome, would bring with it the responsibility to then raise and nurture that child, because it was “physically part” of the couple.

Harry’s view that termination, but not adopting away, was an acceptable option leads to the question of why termination was permissible, but adoption not, even though the fetus would also be “physically part” of the couple. The bottom line for Harry was that he had a responsibility to prioritize his son. If a termination of the current pregnancy would prevent his son’s quality of life from being diminished, then it would quite unsurprisingly be seen as the favorable option. However, the point still remains that if the child had been born with Down syndrome, then that child would not have been adopted away and Harry’s son’s quality of life might have been diminished as a result. This finding may therefore suggest that during the pregnancy, Harry’s genetic link to the fetus was abstract, and that the genetic link would be made real once the child was born, which in turn would strengthen the social and emotional responsibilities toward the child. Indeed, Marsiglio and Hutchinson (2004) suggest that men have a desire to pass on their genetic material to a child, and since they do not have a physical experience of pregnancy, they are somewhat reliant on an enduring social relationship to feel they have fulfilled their role as a procreator. For Harry, these social responsibilities may have outweighed the difficult implications the child could have for their family dynamic.

Like Harry, participation in screening led Karl to consider the different ways of being a father. Due to his chromosomal translocation, he and his wife Polly had experienced four miscarriages, each when the pregnancy was around 12-weeks’ gestation. Despite the difficulties they faced with conceiving naturally, and the distress recurrent miscarriages caused to them as a couple, using a sperm donor or adopting a child were not acceptable options. For Karl, being a genetic father was a necessary precursor to being a social father. While for Harry the thought of being a genetic but not a social father was synonymous with shirking fatherly responsibilities, for Karl, the idea of being a social but not a genetic father was seen as a threat to masculinity:

Let’s not even touch that [using a sperm donor] yet. . . . It’s quite a sensitive point actually I think, it goes back to a macho aspect, from a male’s point of view, it’s kind of like (gasp) let’s not even talk about that, ahh that’s too much . . . and adoption was probably in the same vein actually. (Karl)

As the previous subcategory indicated, for many men, the genetic component of fatherhood had a relatively superficial basis: men talked about how their child might resemble them. As illustrated in this subcategory, when the genetic component was threatened, men were forced to consider its importance and meaning. These men shared an all-or-nothing view, in that they would not want to be fathers at all, or they would be both genetic and social fathers. Hence, while screening caused these men to deconstruct the ways of being a father, they did not redefine their idea of what fatherhood should entail. These findings therefore contrast Bury’s (1982) suggestion that following the disruption caused by illness, individuals can experience a rethinking of their self-concept and the establishment of an altered identity. Men in the current study were unwilling to reestablish this altered paternal identity, preferring instead to seek out options to fulfill fatherhood in the way they desired.

Ambivalence and Uncertainty

Although prenatal diagnostic tests had the potential to provide reassurance that the fetus was healthy, the threat posed by medical complications did some lasting damage to Karl’s paternal identity and child-schema. The possible inaccuracy of screening and the contrast between his lay ideas and the medical information provided caused him to feel confused and ambivalent:

You trust medicine as far as they know as well, and there was always this horrible chance that she might come out without any legs, or worse, you know, I guess an organ issue for her. (Karl)

For Karl and Polly, the uncertainty and confusion about what impact a chromosomal translocation could have was most intrusive when the problem was first identified, particularly since neither participant had considered that the reasons for their four miscarriages could be chromosomal in origin. Rather, they thought it was due to a fertility problem in Polly’s body. In fact, the couple continued to refer to their experiences as being due to a fertility problem, even when Karl’s diagnosis was confirmed:

I immediately assumed that there was absolutely nothing wrong with me at all, and it really was down to stress, or I didn’t think anything else it could have been. As Polly described, I guess [you] wrongly think of fertility—outside of things like sperm count—as being a woman’s realm. So discovering that was a huge shock to me and to my family actually as well, my mum, and you know and my parents, who again none of us really understood the process. (Karl)

A potential reason why the couple referred to the translocation as a “fertility issue” can be extrapolated from research by Walter, Emery, Braithwaite, and Marteau (2004) and Santos and Bizzo (2005). These authors make suggestions for how lay people understand genetic anomalies and suggest that when fewer family members are affected by an anomaly, affected individuals have a less clear understanding of the problem. Santos and Bizzo argue that this inexperience and unfamiliarity permits individuals to develop their own potentially inaccurate explanations for the causes of the problem. Such individuals tend to develop a syncretic understanding of the issue. That is, they combine information gained from scientific sources (in this case, their genetic counselor) with their own lay perceptions, influenced by nonmedical sources and past experiences. Parsons and Atkinson (1992) found that women often translated information about genetic risk into “recipes for reproductive action” (p. 454). A quotation from Polly, “My husband and I, together, we just have this problem and it’s something that we’ve got to get to the bottom of,” is an example of such a recipe, and of how Polly felt responsible for seeking out ways to successfully bear children.

Discussion

In this study, we aimed to investigate men’s experiences of antenatal screening and testing. Presented here is a small subset of a lager study, where 18 participants were interviewed about men’s experiences and involvement. The findings suggested that the participants’ conceptualizations of themselves as fathers and of their children encouraged their involvement in screening, and also that these conceptualizations could be distorted and disturbed if screening indicated there was a high-risk result. The study has raised some important points that require further research, particularly about men’s identities as fathers and the way they think about the fetus.

Although men wanted to be involved in screening, there were risks to their involvement, because the medical information received could disrupt their feelings of adaptation to prospective fatherhood. One such way was the fragmentation of the child-schema caused by high-risk results. The multiple ways that men had of thinking about the fetus reflects the wider ambiguity about the status of the fetus, as discussed by Williams et al. (2001). These authors point out that there is in research, practice, and law confusion as to whether the fetus is a “patient”—evidenced by the clinical specialty of fetal medicine, a “nobody”—evidenced by the fact that a miscarriage does not require a death certificate, or a “commodity,” evidenced by the use of fetal cells in research. As Williams et al. wrote, prenatal screening might be changing the relationship between the pregnant woman, the fetus, and the social world, because screening and testing lead to a focus on creating a “perfect baby.” A slightly contrasting finding in Sandelowski et al.’s (1994) study was that ultrasound screening changed the way women conceptualized their fetus because seeing the image caused them to think of it as a separate being rather than their “baby—a being whom they did not know”. Therefore, previous research has not only shown how women can use screening as a way to acquaint themselves to and imagine a wanted child but also that screening can impose on women a feeling of unfamiliarity and distance from the fetus. The current findings suggest that men too might experience these confusions, although further research is needed before any firm conclusions can be drawn.

The implication of these issues, as Williams et al. (2001) have suggested, is that health care professionals need to be aware of how they themselves conceptualize the fetus and how this might influence how women feel about their options and the decisions they make. For example, some midwives may choose not to call the fetus a “baby” if the woman is deciding whether to have a termination. The current findings suggest that men might also have conceptualizations, and that these can differ from women’s. This finding suggests that health care professionals could benefit from training to raise their awareness of how both parents think about the fetus and how one party’s conceptualizations may affect the other’s, particularly when making decisions about whether to take up invasive diagnostic tests that pose a risk to the fetus.

How men and women think about the fetus is an especially timely and relevant area for further research because abortion and the way a fetus is conceptualized continues to spark debate among U.K. government ministers. For example, a parliamentary debate took place in 2008 in which ministers narrowly voted against reducing the legal limit of abortion to 22 or 20 weeks’ gestation (BBC News, 2008). Moreover, although no policy changes are currently planned, the U.K. prime minister, women’s minister, and health secretary have expressed a preference in the media for the abortion limit to be reduced to 20 or 12 weeks’ gestation because of the ambiguity about when “life” begins and about whether a fetus is seen as a child (BBC News, 2012). Presently in Great Britain, abortion is legal up to 24 weeks’ gestation as long as two doctors agree that having a child would be detrimental to the woman’s mental or physical health, or the health of any children she already has. Abortion is permitted after this time if there is evidence for severe fetal abnormality or grave risk of physical or mental injury to the woman (Abortion Act (Great Britain), 1967). In Northern Ireland, abortion is illegal and only considered lawful if the pregnant woman’s life is at danger, or if a serious and long-term risk is posed to her physical or mental health (Offences Against the Person Act, 1861; Criminal Justice Act (Northern Ireland), 1945).

For men in the current study, the shattering of the child schema was accompanied by a fragmentation of fatherhood into genetic and social component. The idea of fragmented fatherhood has been posited by writers such as Sheldon (2005), who suggest that the increasing divorce rates and numbers of nonresidential fathers, as well as adoption and reproductive technologies (such as the use of sperm donation), have caused a “widespread sub-division of fatherhood” (p. 528), whereby a man may be a genetic father, but not a social one, and vice versa. In a study in which the meaning of fatherhood was explored with a range of different men, some of whom were not yet fathers, Ives et al. (2008) found that genetic fatherhood was not “normatively loaded” (p. 78), in that there were no duties or obligations that were specific to being a child’s genetic father that were not duties and obligations of being a social/emotional father as well. In other words, the genetic aspect of fatherhood did not bring anything specific to the father–child relationship. However, in Ives et al.’s (2008) study, nonresident biological fathers, some of whom had no social relationship with their child, tended to place more emphasis on their genetic role. These men saw genetic paternity as the normative and “correct” definition of fatherhood, suggesting that it made them the real father. Like these nonresident fathers, men in the current study who faced a threat to being a father emphasized that their genetic relationship would be important. The men were reluctant to redefine fatherhood as something without a genetic component.

What was prominent in the current findings was that the men also emphasized that a social relationship was a natural consequence of a genetic relationship. The men strove to be fathers in a way that was acceptable for them via means such as engaging in diagnostic tests so that they could be sure they would be able to fulfill both the genetic and social elements. The finding that men wanted to be genetic and social fathers suggests that there is a caveat to Taylor’s (2005) suggestion, that reproductive technologies are challenging and changing definitions of parenthood. Findings also challenge Mason’s notion that advances in reproductive technologies are leading to changes in the way people understand kinship.

As Venville et al. (2005) found, “The strong focus on relationships as opposed to the structural and functional aspects of the gene mean that [ . . . ] understandings of kinship and inheritance [are emphasized and] and understandings of genetics [are deemphasized]” (p. 629). Indeed, genes and chromosomes were seen by the participants as traits that brought together family members and underpinned social relationships. This perception of genes appeared to be why men like Harry and Karl were unwilling to become fathers in a nongenetic way, and also why Karl and Polly did not identify faulty chromosomes as being the reason for their miscarriages. Karl and Polly’s syncretic understanding highlights a potential difficulty from health care professionals’ points of view of ensuring that the information has been understood correctly. The growing body of research about lay perceptions of genetics throws into question whether individuals are able to provide informed consent for genetic screening and diagnostic tests if they rely on this limited understanding.

There are various other possible implications of the current findings. As suggested by the U.K.’s Royal College of Midwives (2011), one-to-one contact between men and midwives could allow men’s emotional and informational needs to be addressed, as well as women’s. While these guidelines are one step toward encouraging a father-inclusive approach, more research and training is required to highlight to midwives what issues men face in screening. Following training, midwives and healthcare professionals would be better able to engage with men and attend to the possible consequences of screening information on men’s perceptions of themselves as fathers and of their future children. However, conclusions cannot be drawn from this small study alone, meaning further research is required, particularly to build on the limitations of the project.

Limitations

Although it is not the aim of qualitative research to create generalizable findings, the sample was not representative of the total population meaning findings may have been different if an alternative group of men were interviewed. Moreover, since men were drawn from across England and Scotland, there may have been some variations in the tests they were offered, for example, the number of hormones that were targeted in serum screening, and how they were offered them.

The sample may have been limited by selection bias: men who participated were likely to have been engaged with the pregnancy and involved in screening, which may have limited the range of findings gathered. Men who were not involved in screening may have shared completely different opinions and feelings about the topic. This limitation is linked to the sampling strategy: men who attended antenatal units and children’s centers or paid attention to online forums about parenting were likely to have been involved parents already. The men in the study were also well-educated and middle-class.

Regarding interview timings, four participants’ babies had already been born, meaning there could have been retrospective bias in their interviews. Some men talked hypothetically about what they would do, for example, if an anomaly were detected. As genetic counselors in Rapp’s (2000) study said, a hypothetical plan might be abandoned when a diagnosis is made, or if an affected child is born. Since there were few men and women who had experienced high-risk pregnancies, there was a reliance on a few participants’ views for the analysis, which is another limitation.

In terms of offering disembodied interviews, Opdenakker (2006) suggests the interviewer cannot be sure whether the interviewee is alone. Distractions were audible in three telephone interviews, where participants’ spouses interrupted the interview to ask them a question, albeit only momentarily. Moreover, since few participants opted for instant messenger or email interviews, it was difficult to make comparisons between the kinds of data each type of interview elicited. Limitations aside, disembodied interviews were useful because individuals were given some freedom and choice, meaning people who would normally be unable to participate could take part.

Conclusion

In conclusion, our study provided some insight into a small group of men’s antenatal screening experiences and how these experiences might have influenced, or been influenced by, their perceptions of their changing family. For these men, routine participation in screening and the period following the receipt of results either encouraged their paternal identity and child-schema, or caused confusion and disruption in their experience of pregnancy and impending fatherhood. This disruption not only affected men’s feelings towards their fetus but also their feelings about the future baby’s impact on their relationship with their existing children. Further research is now required to explore the issues raised in this small study.

Footnotes

Acknowledgements

Thank you to all the participants from this study and the screening coordinators and midwives who helped with recruitment. Thank you also to the organizers of the Men and Reproduction section of the ISA conference 2012 and the anonymous reviewers for their comments on an earlier draft of this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received financial support from University of Birmingham for the research, authorship, and/or publication of this article.

Notes

References

The Abortion Act (Great Britain) 1967. Retrieved from http://www.legislation.gov.uk/ukpga/1967/87/contents

Alldred

S. K.

Deeks

J. J.

Neilson

J. P.

Alfirevic

(2010). Antenatal screening for Down’s syndrome: Generic protocol. Cochrane Database of Systematic Reviews: Protocols, (4). doi:10.1002/14651858.CD007384.pub2

Aune

Möller

(2012). “I want a choice, but I don’t want to decide”: A qualitative study of pregnant women’s experiences regarding early ultrasound risk assessment for chromosomal anomalies. Midwifery, 28, 14-23.

BBC News. (2008, October 6). Abortion law: David Cameron has “no plans” for new rules. Retrieved from http://www.bbc.co.uk/news/health-19857977

BBC News. (2012, May 20). MPs back 24-week abortion limit. Retrieved from http://news.bbc.co.uk/1/hi/uk_politics/7409696.stm

Bronte-Tinkew

Ryan

Carrano

Moore

K. A.

(2007). Resident fathers’ pregnancy intentions, prenatal behaviors and links to involvement with infants. Journal of Marriage and Family, 69, 977-990.

Bury

(1982). Chronic illness as biographical disruption. Sociology of Health and Illness, 4, 167-182.

Butera

K. J.

(2006). Manhunt: The challenge of enticing men to participate in a study on friendship. Qualitative Inquiry, 12, 1262-1282.

Cabrera

N. J.

Fagan

Farrie

(2008). Explaining the long reach of fathers’ prenatal involvement on later paternal engagement. Journal of Marriage and Family, 70, 1094-1107.

10.

Carroll

F. E.

Owen-Smith

Shaw

Montgomery

A. A.

(2012). A qualitative investigation of the decision-making process of couples considering prenatal screening for Down syndrome. Prenatal Diagnosis, 32(1), 57-63.

11.

Connell

R. W.

(2000). The men and the boys. Berkeley: University of California Press.

12.

Corbin

Strauss

(2008). Basics of qualitative research (3rd ed.). London, England: Sage.

13.

Criminal Justice Act (Northern Ireland) 1945. Retrieved from http://www.legislation.gov.uk/apni/1945/15/contents

14.

Department for Children, Schools and Families/Department of Health. (2009). Getting maternity services right for pregnant teenagers and young fathers (Rev. ed.). London, England: Author. Retrieved from https://www.education.gov.uk/publications/standard/publicationDetail/Page1/DCSF-00673-2009

15.

Department of Health. (2009a). Healthy lives, brighter futures: The strategy for children and young people’s health. London, England: Author. Retrieved from http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_094397.pdf

16.

Department of Health. (2009b). The healthy child programme. London, England: Author. Retrieved from http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_108866.pdf

17.

Dheensa

Metcalfe

Williams

(2013). Men’s experiences of antenatal screening: A metasynthesis of the qualitative research. International Journal of Nursing Studies, 50, 121-133.

18.

Ettore

(2002). Reproductive genetics, gender and the body. London, England: Routledge.

19.

Flouri

(2008). Fathering and adolescents’ adjustment: The role of father’s involvement, residence and biology status. Child: Care, Health & Development, 34, 152-161.

20.

Fontes

T. O.

O’ Mahony

(2008). In-depth interviewing by Instant Messaging. Social Research Update, 53. Retrieved from http://sru.soc.surrey.ac.uk/SRU53.pdf

21.

Glaser

B. G.

(2002). Constructivist grounded theory? Retrieved from www.qualitative-research.net/index.php/fqs/article/view/825

22.

Green

J. M.

Hewison

Bekker

H. L.

Bryant

L. D.

Cuckle

H. S.

(2004). Psychosocial aspects of genetic screening of pregnant women and newborns: A systematic review. Health Technology Assessment, 8(33), 117-128.

23.

Hunt

McHale

(2007). A practical guide to the email interview. Qualitative Health Research, 17, 1415-1421.

24.

Ives

Draper

Pattison

Williams

(2008). Becoming a father/refusing fatherhood: An empirical bioethics approach to paternal responsibilities and rights. Clinical Ethics, 3(2), 75-84.

25.

Katz-Rothman

(1994). The tentative pregnancy: Amniocentesis and the sexual politics of motherhood. New York, NY: Pandora.

26.

Kazmer

M. M.

Xie

(2008). Qualitative interviewing in Internet studies: Playing with the media, playing with the method. Information, Communication, and Society, 11, 115-136.

27.

Lewis

Kattman

(2004). Traits, genes, particles and information: Revisiting students’ understandings of genetics. International Journal of Science Education, 26, 195-206.

28.

Lincoln

Y. S.

Guba

E. G.

(1985). Naturalistic inquiry. Newbury Park, CA: Sage.

29.

Locock

Alexander

(2006). Just a bystander? Men’s place in the process of fetal screening and diagnosis. Social Science & Medicine, 62, 1349-1359.

30.

Marsiglio

Hutchinson

(2004). Sex, men, and babies: Stories of awareness and responsibility. New York: New York University Press.

31.

Mason

(2008). Tangible affinities and the real life fascination of kinship. Sociology, 42(1), 29-45.

32.

NHS Choices. (2010, June). Amniocentesis. Retrieved from http://www.nhs.uk/conditions/Amniocentesis/Pages/Introduction.aspx

33.

NHS Choices. (2012). Chorionic villus sampling. Retrieved from http://www.nhs.uk/conditions/Chorionic-Villus-sampling/Pages/Introduction.aspx

34.

Offences Against the Person Act 1861. Retrieved from http://www.legislation.gov.uk/ukpga/Vict/24-25/100/contents

35.

Office for National Statistics. (2011). Ethnic breakdown of England and Wales mapped. Retrieved from http://www.guardian.co.uk/news/datablog/interactive/2011/may/19/ethnic-breakdown-england-wales

36.

Office for National Statistics. (2012). Births in England and Wales by parents’ country of birth. Retrieved from http://www.ons.gov.uk/ons/rel/vsob1/parents–country-of-birth–england-and-wales/2011/sb-parents–country-of-birth–2011.html

37.

Opdenakker

(2006, September). Advantages and disadvantages of four interview techniques in qualitative research. Forum: Qualitative Social Research, 7(4), Article 11. Retrieved from http://www.qualitative-research.net/index.php/fqs/article/view/175/391

38.

Parsons

Atkinson

(1992). Lay constructions of genetic risk. Sociology of Health & Illness, 14, 437-455.

39.

Piaget

(1928). Judgment and reasoning in the child. London, England: Routledge & Kegan Paul.

40.

Pilnick

Zayts

(2012). “Let’s have it tested first”: Choice and circumstances in decision-making following positive antenatal screening in Hong Kong. Sociology of Health & Illness, 34, 266-282.

41.

Raphael-Leff (1993) Pregnancy the full story. Karnac: New York

42.

Rapp

(2000). Testing women, testing the fetus: The social impact of amniocentesis in America. New York, NY: Routledge.

43.

Reed

(2009). “It’s them faulty genes again”: Women, men and the gendered nature of genetic responsibility in prenatal blood screening. Sociology of Health & Illness, 31, 343-359.

44.

Reed

(2011). Making men matter: Exploring gender roles in prenatal blood screening. Journal of Gender Studies, 20(1), 55-66.

45.

Reed

(2012). Gender and genetics: The sociology of the prenatal. London, England: Routledge.

46.

Reid

Sinclair

Barr

Dobbs

Crealy

(2009). A meta-synthesis of pregnant women’s decision-making processes with regard to antenatal screening for Down syndrome. Social Science & Medicine, 69, 1561-1573.

47.

Royal College of Midwives. (2011). Reaching out: Involving fathers after maternity. Retrieved from http://www.rcm.org.uk/college/policy-practice/government-policy/fathers-guide/

48.

Sandelowski

Black

P. B.

Mercer

R. T.

Bergum

Stainton

M. C.

(1994). The epistemology of expectant parenthood. Western Journal of Nursing Research, 16, 601-622.

49.

Santos

Bizzo

(2005). From “new genetics” to everyday knowledge: Ideas about how genetic diseases are transmitted in two large Brazilian families. Science Education, 89, 564-576.

50.

Seglow

Canham

(1999). Intra-uterine life and the experience of birth. In Hindle

Vaciago

(Eds.), Personality development a psychoanalytic perspec(pp. 13-32). New York, NY: Routledge

51.

Sheldon

(2005). Fragmenting fatherhood: The regulation of reproductive technologies. Modern Law Review, 68, 523-553.

52.

Taylor

(2005). Whose baby is it? The impact of new reproductive technologies on kinship. Human Fertility, 8, 189-195.

53.

Tsianakas

Atkin

Calnan

M. W.

Dormandy

Marteau

T. M.

(2012). Offering antenatal sickle cell and thalassaemia screening to pregnant women in primary care: A qualitative study of women’s experiences and expectations of participation. Health Expectations: An International Journal of Public Participation in Health Care and Health Policy, 15, 115-125.

54.

Van den Berg

Timmermans

D. R.

Knol

D. L.

van Eijk

J. T.

de Smit

D. J.

van Vugt

J. M.

van der Wal

(2008). Understanding pregnant women’s decision making concerning prenatal screening. Health Psychology, 27, 430-437.

55.

Venville

Gribble

S. J.

Donovan

(2005). An exploration of young children’s understandings of genetics concepts from ontological and epistemological perspectives. Science Education, 89, 614-633.

56.

Walter

F. M.

Emery

Braithwaite

Marteau

T. M.

(2004). Lay understanding of familial risk of common chronic diseases: A systematic review and synthesis of qualitative research. Annals of Family Medicine, 2, 583-594.

57.

Ward

(2005). Whose right to choose? The new genetics, prenatal testing and people with learning difficulties. In Bunton

Petersen

(Eds.), Genetic governance: Health, risk and ethics in the biotech era (pp. 121-135). London, England: Routledge.

58.

Williams

Alderson

Farsides

(2001). Conflicting perceptions of the fetus: Person, patient, “nobody”, commodity? New Genetics and Society, 20, 225-238.

59.

Williams

R. A.

(2007). Masculinities fathering and health: the experiences of African-Caribbean and white working class fathers. Social Science & Medicine, 64, 338-349.

60.

Williams

R. A.

Dheensa

Metcalfe

(2011). Men’s involvement in antenatal screening: A qualitative pilot study using email. Midwifery, 27, 861-866.