Aspects that Hinder Integration of Men in Reproductive Planning : an Integrative Review

This study aimed to identify aspects that hinder the integration of men into reproductive planning activities. An integrative literature review was carried out in January 2017 in the databases LILACS, BDENF and PubMed using the keywords "family planning" and "men", considering the period from 2005 to 2016. Nine articles were found. According to data, there were five publications in 2014, the Portuguese language was predominant, with five articles, and all researches have level of evidence IV. After reading the articles in full-length, five aspects that hinder the participation of men in reproductive planning were detected: social construction of gender, inadequacy of health services, socio-cultural issues, fear of side effects and lack of professional qualification and/or commitment. The study led to conclude that further research is needed to increase the scientific evidence and consolidate references to professionals and to extant public policies regarding the participation of men in reproductive planning. Aspects that Hinder Integration of Men in Reproductive Planning: an Integrative Review


Introduction
The 80's represented a period marked by the emergence of family planning in Brazil.This stemmed from social movements that struggled for the conquest of space and for the right of autonomy of women, low levels of fertility and birth control policies [1].In 1996, the Law n• 9263 was enacted to regulate reproductive planning in Brazil.This was intended to ensure the thorough provision of assistance to con-ception and contraception by the service network to women, men and/or couples [2,3].
Thus, it is necessary to reflect on the ethical conduct adopted in health services with regard to the freedom that couples have on wanting/deciding the number of children they will have.Family planning must include men in its activities and must take into account the position of women in society, aiming at their exercise of citizenship and autonomy [4].The literature shows that the term "family planning" has been replaced by "reproductive planning", since conception is something ample that can be practiced alone or in a shared manner by men and women [2].
The National Policy of Integral Attention to Men's Health (2009) in Brazil highlights the uniqueness of the male gender in different socio-cultural and political-economic contexts.It has the specific objective of encouraging the participation and inclusion of men in the planning of their sexual and reproductive lives.Planning should be mainly focused on the exchange of experiences and on the choice of contraceptive methods, thus sharing responsibilities with women.In this context, the inclusion of men in this scenario leads to decentralization of responsibilities and break of paradigms [5][6][7].
Based on these assumptions and considering the fact that men are subjects that form and direct opinions, as they are objects of public policies and of care and attention by health professionals [8], this study aimed to identify the aspects that hinder the integration of men into reproductive planning activities.

Methods
This study was based on discussions on reproductive planning that take place in the course entitled Fundamentals of Ethics and Bioethics in Health and Nursing.This course is offered by the Associate Graduate NursingProgram of the University of Pernambuco and Paraíba State University.As this is considered a very important issue, the present study intended to deepen it by carrying out an integrative review on it.
In order to achieve the proposed objective, the integrative review method was carried out by adopting the following steps: 1) identification of the hypothesis or guiding question; 2) sample selection: determination of inclusion and exclusion criteria of articles and selection of studies for sample composition; 3) categorization of studies to summarize and organize information; 4) evaluation of the studies critically; 5) discussion and interpretation of results and 6) presentation of review and knowledge synthesis [9].
The elaboration of this integrative review was based on the following guiding question: what are the aspects that make it difficult for men to participate in reproductive planning activities?
The search for data took place in January 2017 through online access to the databases: Latin American and Caribbean Health Sciences (LILACS), Nursing Database (BDENF) and Public Medline (Pub-Med).Combinations of descriptors were used for selecting articles.The Health Sciences Descriptors (DeCS) "Family planning" and "Men" were combined for the search in the LILACS and BDENF databases, and the Medical Subject Headings (MeSH) "Family planning" and "Men" were used in the PubMed database.The Boolean operator AND was used in the search.Figure 1 shows the flowchart of the article selection process.
It was mentioned earlier that the literature recommends the use of the term "reproductive planning" rather than "family planning".However, the recommended term was not used in the present search because it is not a descriptor and has no equivalent translation in MeSH (and thus, the descriptor and the MeSH "Family planning" were used).
The inclusion criteria that guided the selection of the sample were: scientific papers, available in full, electronically and written in English, Portuguese or Spanish, with publication period between 2005 and 2016.The exclusion criteria were: book chapters, dissertations, theses, reports, news, editorials, review articles and articles that are not consistent with the questioning of the study.
The data collection was performed by two researchers independently, as a way to guarantee rigor to the selection process of the articles.A validated instrument was used [10] and the information was extracted through exhaustive reading and re-reading of the publications, which were organized for data analysis.
The methodological characteristics of the studies were analyzed by using the classification of levels of evidence: I) meta-analysis of multiple controlled studies; II) individual study with experimental design; III) study with quasi-experimental design; IV) study with non-experimental design as descriptive correlational and qualitative research or case studies; V) case report or data obtained in a systematic manner, with verifiable quality or program evaluation data; VI) opinion of reputable authorities based on clinical competence or opinion of expert committees [11].

Results
Based on the search conducted in the databases and on the application of the inclusion and exclusion criteria, nine studies were summarized in Table 1.
Studies were published from 2009 to 2015, and there were five (5) publications (55.6%) in 2014.Four articles were written in English and five in Portuguese.The nine articles were published in  What hinders the participation and the low involvement of men in family planning are issues related to the desire of having more children, the refusal of men's participation by the partner and/or wife, religious prohibition, fear of side effects related to contraceptive methods, lack of knowledge about contraceptives and/or the thought that family planning is something for women only.
Barriers to male involvement in contraceptive uptake and reproductive health services: a qualitative study of men and women's perceptions in two rural districts in Uganda.

Reproductive Health (2014)
PubMed -To analyze the perception that men and women have of obstacles related to the encouragement and use of modern contraceptives by men.
Five main reasons were found to justify the difficulty of integrating men into family planning: 1) fear that contraceptive methods may cause side effects that interfere with sexual activity; 2) few options of male contraceptive methods and fear of vasectomy; 3) the perception that reproductive is something for women only, due to gender norms imposed by society; 4) preference for large families, which is linked with the desire of having many children and, therefore, avoiding contraceptive methods; and 5) the concern on the part of men that the use of contraceptives by women may lead to extramarital sex.
Male participation in family planning and its underlying factors

UFSM Journal of Nursing (2014)
BDENF -To identify the forms of male participation in the family planning process, as well as the factors involved in their participation, to know the men's knowledge about the method used by the couple and to describe how the negotiation process happens in the choice of method.
Men participate in family planning in rare occasions.
According to the authors' description, there was no discussion as to which method to use.They also claimed lack of time due to work activities and that health services were not organized to meet this demand.Overall, it has been shown that responsibility for contraception is on women.

I Mustafa G, Azmat SK, Hameed W
Family planning knowledge, attitudes, and practices among married men and women in rural areas of Pakistan: findings from a qualitative need assessment study.

Int J Reprod Med (2015)
PubMed To explore the knowledge, attitudes and practices on family planning and factors that influence the need and use of modern contraceptives.
Most men still seemed resistant to accept the use of family planning as a way to set more time between births.Also, they did not seem very much in favor of family planning for financial and religious reasons.
Source: Research Data.ID*: identification nine different journals.All studies are descriptive with quantitative approach (01) and qualitative (08).Thus, all are classified as having level of evidence IV.
After reading and re-reading the studies, it was identified the aspects that make it difficult for men to participate in reproductive planning activities, as described in Table 2.

Discussion
The search in the databases corroborates the findings of a prior study that showed the lack of research addressing reproductive planning with a focus on men's health, despite the existence of studies addressing the theme sexuality [12].Regarding the level of scientific evidence, it is necessary to carry out studies with more accurate methodologies.
It is also worth mentioning the importance of conducting studies that make a link between practice and legal and ethical support of the participation/insertion of men in this scenario by academics and professionals with experience in assistance, as well as studies that evaluate the offer of reproductive planning services, using as a parameter what is recommended by law.
In scientific productions on men's health, studies that focus on diseases predominate over other aspects related to health.This shows the need for greater production of knowledge in the area supported by the critical use of data presented by epidemiological information systems and that incorporates the relational perspective of gender [13].
One of the aspects listed by the National Policy for Comprehensive Care to Men's Health that strengthens what had already been proposed by the reproductive planning program is the need to make men aware of their duty and their right to participate in reproductive planning, participating in the whole process, from the decision whether or not to have children, how and when to have them, until the follow-up of pregnancy, childbirth, puerperium and education of the child.Therefore, information and contraceptive methods should be made available to the public and in the event of pregnancy, parenting should be experienced in a responsible manner [5].
According to the International Conference on Population and Development, the ethical inquiry on the responsibility of men in the promotion and involvement regarding responsible parenthood, sexual and reproductive behavior is a proposal for world governments, especially for countries where such occurrences are greater, as is the case of Brazil [4].
The inclusion of men in reproductive planning occurs in a specific and limited way, since women take this responsibility [14].Therefore, motivating the insertion of men has been a challenge for the health services due to some aspects, such as gender relations, health services that are still unavailable for the male category and the recognition by health professionals that men need attention and quality and resolute care [15].
Therefore, the process of identity construction takes place in the social context, marked by relations of power, symbolism and cultural attributes.In order to understand the issue of gender identity, it is necessary to understand the existing inequalities between men and women that are permeated by power relations and to understand the varied meanings that these inequalities assume in the historical and social context [16].
It should be emphasized that the responsibility of men and women to regulate fertility is presented in an unequal manner, which is clearly perceived from Table 2. Categorization of aspects that make it difficult for men to participate in reproductive planning.

Referred article Aspects
A the number of contraceptive methods for women and men [16].This confirms that the reproductive process is centered on the female figure, since the conception happens in her body [6,17].
The greater participation of women in reproductive planning may be associated with the patriarchal culture and human biology [18].Contraception is expected to be a phenomenon resulting from the joint efforts of both parties and not from women, exclusively [19].However, it is important to note that male autonomy in the couple's decisions about reproductive planning also refers to a culture in which women, since the creation of policies aimed at controlling fertility, have been responsible for reproduction [20].
The male being is also associated with social characteristics of masculinity, such as invulnerability, strength and virility.These characteristics are incompatible with the demonstration of signs of weakness, fear and anxiety that is represented by the demand for health services, a fact that would put masculinity in doubt and bring men closer to representations of femininity [12,21].
The way that health services are organized also contributes to the non-integration of men, since men's work activity is a barrier to the search for primary health care services [6,12,21], as the hours of operation of health services do not meet male demands, because they coincide with their workload [12] and little availability of time [6].In addition, the labor market generally does not formally guarantee the adoption of such a practice and the man at a given time may be harmed and feel that his role of provider is threatened [21].
An example of a form of organization of the health service can be observed in the Basic Health Units (BHU), which have been offered services aimed at, almost exclusively, women, children and the elderly.There are many assumptions and/or justifications regarding the low male presence in these services, since it is associated with a masculine identity characteristic related to their socialization process [22].
Practical obstacles referred by men, such as lack of time, do not justify the limited role they play in controlling fertility, since women also play a variety of domestic, family, and professional activities [19].
Another relevant factor is the need for expansion in services on men's health, taking into account that most services do not systematically provide services to this target audience [20].It is also necessary to involve men and women in a participatory way through the use of creative actions, educational and motivational programs in reproductive and sexual health, creating more field of action for nursing practices and actions [12].
It is up to the managing bodies to redistribute or hire personnel to implement a reproductive planning program, since the lack of personnel is a paradox with the demand, as well as with the actions and health programs implemented.However, there is a need for collective action for decision-making, social responsibility and the policy of integration of man through the use of an active, dialogical, participatory and ethical method [4].
The health team needs to work in an integrated way, valuing healthy interpersonal relationships in the environment to operationalize work and, consequently, qualify the health care [23].There has been highlight to the lack of training or qualification of health professionals in the field of health education, reproductive and sexual rights, and masculinity [17].
The idea of feminized health services needs to be changed to include the health needs of the male audience.This fact does not mean changes in the percentage of workers of both genders in these services, nor even in the creation of specific services for the male population, since the paradigmatic change and the practical posture of all professionals is more important than having men providing care [22].These professionals need to be more sensitive to the interactions between gender conceptions and men's demands [12,22].
It was observed that socio-cultural issues are crucial for the lack of participation of men in reproductive planning activities in countries such as Ethiopia, Uganda and Pakistan.In these countries, there is a preference for large families, as well as there are religious issues and concerns that women have extramarital relations [24][25][26].In these contexts, patrilineal traditions to preserve family lineages value the presence of children and encourage large families, as having many children indicates wealth and financial security.In addition, the number of children is also associated with conservative religious issues, as it is understood that reproductive planning affects the husband's desires of fertility [25].
The lack of participation and support to the spouse on the use of contraceptive methods is also associated with perceived side effects reported as causing reduced sexual pleasure, increased risk of infertility, diseases and, mainly, irregular and prolonged bleeding and vaginal dryness.These effects were reported as having harmful impact on marriages as they lead to decreased sexual interest on the women's side, limiting the number of opportunities for men to have sex with their partners [25].
It is important to consider that respect for autonomy and individual dignity is imperative in the ethics field and not simply a favor that can be granted or not.Therefore, the integration of men and the discourse that favors the equality of opportunities between the genders is considered to be ethical.Therefore, the commitment to the readiness to attend this clientele constitutes a professional duty [4].It is necessary to understand that the involvement of men in reproductive planning can not be limited only to the use of methods, but it must also consider the attitude of support and shared responsibility with their partners.[24] The participation of nurses in this scenario is important to stimulate educational health actions, aiming to promote the construction of horizontal knowledge, considering the expectations and desires of the both individuals involved: men and women [14].
A new intervention model for reproductive planning should initially result from analyzing the main shortcomings of currently used programs and ma-king the relevant adjustments [24].It is also the duty of the State to inform and guide, not imposing its practices, but respecting religious beliefs.Christian principles and doctrines are not discussed here, but one should consider how these principles direct the experience of reproduction without any birth control [20].

Conclusion
The results highlight that the relevant participation of men in reproductive planning represents a process of integration of the whole, and it is, therefore, a democratic right.In this scenario, the health professional, especially the nurse, needs to be empowered with care practices and scientific knowledge to create strategies that allow the integration of the man in this space.
On the other hand, experiences of studies on reproductive planning with a focus on male health need to be disclosed so that health professionals and managers know their needs and be able to understand and modify care.
In this meantime, more research on this subject is necessary to increase the scientific evidence, consolidate references for the work of professionals and the existing public policies.Partnerships need to be formed between health institutions, health organizations, universities and schools in order to stimulate discussion and reflection on the importance of integrating men into reproductive planning.Men must receive information about contraception and must be empowered to exercise their rights and duties, emphasizing the importance of self-care practices to reduce morbidity and mortality from preventable causes.

Figure 1 :
Figure 1: Flowchart of the selection process of the articles.Recife-PE, 2017.

F
, B, C, D, E, F, G, H Gender social construction A, B, D, E, HInadequacy of health services

Table 1 . Distribution of articles according to
identification letter, authors' name, study title, journal, year of publication, databases, objectives and study results.Recife-PE, 2017.attitude,sinceonlyone man participated.It is evident that the responsibility is centralized on the female figure and that, in addition, no specific strategies were used to modify this scenario.This article is available at: www.intarchmed.comandwww.medbrary.com4Itwas identified that the basis of the reproductive planning of couples is the agreement/consensus on the number of children they want to have, but the responsibility for contraception is on the woman.This indicates that the inclusion of men in reproductive health occurs in a specific and limited manner.