An integrative review of fathers’ experiences during pregnancy and childbirth H.L. Poh1,2 BSc (Nursing)(Honours), RN, S.S.L. Koh3,4,5 PhD, RN & H.-G. He6 PhD, MD, RN 1 BSc (Nursing) (Honours) Graduate, 3 Adjunct Associate Professor, 6 Assistant Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, 2 Staff Nurse, Division of Nursing, National University Hospital, 4 Deputy Director (Patient Safety), Standards and Quality Improvement Division, Healthcare Performance Group, 5 Deputy Director, Hospital Services Division, Health Services Group, Ministry of Health, Singapore
POH H.L., KOH S.S.L. & HE H.-G. (2014) An integrative review of fathers’ experiences during pregnancy and childbirth. International Nursing Review 61, 543–554 Background: While fathers are increasingly expected to participate during their partners’ pregnancies and childbirth and many studies have reported their experiences during these periods, no review studies have examined fathers’ experiences and needs during pregnancy and childbirth together. Aim: To provide an overview of evidence on fathers’ experiences and needs during their partners’ pregnancies and childbirth to identify any gaps in the existing literature and practice. Methods: An integrative literature review was performed to analyse and synthesize fathers’ experiences and/or needs during pregnancy and/or childbirth based on articles published in CINAHL, PubMed, Scopus, PsycINFO and Web of Science databases between the years 2002 and 2012. Only articles found in the National University of Singapore’s online library collection were retrieved. Results: Altogether, 25 studies (six quantitative and 19 qualitative studies) that reported fathers’ experiences during pregnancy (n = 8), childbirth (n = 13) or during both periods (n = 4) were reviewed. Fathers experienced mixed feelings both during pregnancy and childbirth. They required support from their partners and healthcare professionals and wanted to be informed, involved and respected. However, more studies are needed to explore this phenomenon in different cultural contexts or care models. Conclusion: This review provides evidence for healthcare professionals to pay more attention to fathers when delivering perinatal care. Sociocultural-sensitive interventions should be developed to facilitate a smoother transition to fatherhood. Implications for nursing and health policy: Father-specific information should be given to prepare fathers for pregnancy and childbirth. Healthcare professionals and policymakers should take fathers’ feelings and concerns into consideration and provide family-centred care to the couple during the antenatal and intrapartum periods. Keywords: Childbirth, Fathers, Midwifery, Needs, Perceptions, Pregnancy, Review
Correspondence address: Hong-Gu He, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore 117597; Tel: 6516-7448; Fax: 6776-7135; E-mail: [email protected].
Funding statement: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Conflict of interest statement: There is no conflict of interest.
© 2014 International Council of Nurses
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Literature Review
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H. L. Poh et al.
Introduction Since the 1960s, there has been an increasing global trend in the number of fathers (defined in this literature review as including both experienced fathers and fathers-to-be) involved in their partners’ pregnancies and childbirth (Premberg et al. 2011). Currently, more than 90% of fathers in the USA participated in prenatal activities, for example, seeing an ultrasound of their child and discussing the pregnancy with their partners, while a similar percentage of fathers in the United Kingdom attended childbirth (Murphy 2009; National Responsible Fatherhood Clearinghouse 2010). While there has been considerable focus on women and the effects of fathers’ involvement, research about fathers’ experiences of their partners’ pregnancies and childbirth has relatively been lagging (Dellmann 2004; Rosich-Medina & Shetty 2007). This often resulted in the problem that fathers reported feeling inadequate and unprepared. Furthermore, they felt excluded and unsupported by the healthcare system (Fenwick et al. 2012; Widarsson et al. 2012). Therefore, to support fathers in their transition to fatherhood, knowledge about their experiences and needs during pregnancy and childbirth – appraised within their own sociocultural contexts – is important (Deave & Johnson 2008). This knowledge could enable healthcare professionals to adopt practices that are supportive and culturally sensitive (Kao & Long 2004). Ultimately, this could promote smoother transitions to fatherhood, aid in forming positive paternal experiences and relationship bonding and benefit the whole family (Finnbogadóttir et al. 2003; Kao & Long 2004).
Aim of this review The aim of this literature review was to provide an overview of studies about fathers’ experiences and needs during their partners’ pregnancies and childbirth so as to identify any gaps in the existing literature and practice.
nomenon of interest, it is best to summarize their findings using an integrative literature review design. Search methods
A literature search was performed in CINAHL, PubMed, Scopus, PsycINFO and Web of Science. Keywords such as ‘expectant fathers’, ‘fathers’, ‘husbands’, ‘men’, ‘spouses’, ‘experiences’, ‘life change events’, ‘meaning’, ‘perceptions’, ‘needs’, ‘support’, ‘antenatal’, ‘perinatal’, ‘pregnancy’, ‘prenatal’, ‘birth’, ‘childbirth’, ‘delivery’, ‘labour’ and ‘parturition’ were used singly or in various combinations when searching. Journal articles were included if they: (1) were published in English between 2002 and 2012, (2) can be found in the National University of Singapore (NUS)’s online library collection, and (3) focused on fathers’ experiences and/or needs either during pregnancy and/or childbirth. Articles with the following features were excluded: focused on fathers younger than 21 years old, investigated preterm infants or infants diagnosed with congenital abnormalities, recruited fathers whose partners had complications either during pregnancy or childbirth, were about tool validation or theoretical discussions, covered post-natal experiences, focused largely on women’s or healthcare professionals’ experiences, and/or measured variables not directly related to fathers’ experiences (such as sleep quality or smoking habits) or contained interventions. Search outcomes
Altogether, six quantitative and 19 qualitative studies were included. Eight of them reported fathers’ experiences and needs during pregnancy, 13 covered father’s experiences and needs during childbirth and the remaining four reported fathers’ experiences and needs during pregnancy and childbirth. The search strategies and outcomes are presented in Fig. 1 while the summary of the reviewed articles are shown in Table 1.
Results Methods
Fathers’ experiences during their partners’ pregnancies
Design
Positive and negative feelings
An integrative literature review is a review method that gives a more comprehensive understanding of a particular phenomenon or healthcare problem because it summarizes both empirical and theoretical research (Whittemore & Knafl 2005). It is also the only method that allows for the inclusion of articles with diverse methodologies (Whittemore & Knafl 2005). Given that fathers’ experiences and needs during pregnancy and childbirth are best explored using qualitative approaches and that there are also a few quantitative studies investigating this phe-
Pregnancy confirmation is the very first step of the transition to fatherhood. In her study to explore fathers’ experiences of pregnancy confirmation, Draper (2002) found that they felt disbelief and distanced initially as they could not experience the physical changes their partners were undergoing and could neither ‘feel’ nor see the unborn foetus. Similarly, Finnbogadóttir et al. (2003) determined, with expectant first-time fathers’ experiences of pregnancy, that fathers felt a sense of unreality when they learnt of the pregnancy. Both Draper’s (2002) and
© 2014 International Council of Nurses
A review of fathers’ experiences
Potential articles identified from search strategy (n=82 227)
545
Articles excluded after limiting to: • • • • • •
Articles evaluated based on their titles and abstracts (n=6751)
Full articles retrieved for detailed examination (n=44)
years 2002 to 2012 English language journal/review articles peer-reviewed, academic journals ‘nursing’ subject inclusion and exclusion criteria (n=75 476)
Articles excluded after accounting for duplicates in search results and evaluation of titles and abstracts (n=6707)
Articles excluded after review of full article (n=19) Articles included in this literature review (n=25)
Quantitative studies (n=6)
Qualitative studies (n=19)
•
• • • • •
cross-sectional (n=6)
qualitative descriptive (n=8) ethnographic (n=1) grounded theory (n=2) phenomenology (n=7) naturalistic inquiry (n=1)
Fig. 1 Flow diagram depicting search strategies and outcomes.
Finnbogadóttir et al.’s (2003) findings contrasted with Rosich-Medina & Shetty’s (2007) cross-sectional study of 142 first-time fathers, which reported that fathers felt connected throughout the pregnancy. Fathers wanted to connect to their unborn child and, hence, they engaged in ‘body-mediated moments’, a term coined by Draper (2002), where they connected with their foetus by feeling for their movements through their partners’ bodies. In investigating expectant parents’ experiences during a routine ultrasound examination, Ekelin et al. (2004) found that the first ultrasound scan was of great importance as it was a confirmation of a new life. It was also the first-time fathers could ‘see’ their foetus (Finnbogadóttir et al. 2003). These experiences helped fathers gain a sense of reality about the pregnancies (Draper 2002; Finnbogadóttir et al. 2003). Similarly, in exploring Australian fathers’ pregnancy experiences and childbirth expectations, Fenwick et al. (2012) also described that being present at the ultrasound screening and being able to feel their
© 2014 International Council of Nurses
foetus’ movements were significant in connecting both novice and experienced fathers to their foetuses. The findings of these qualitative studies were confirmed by Rosich-Medina & Shetty (2007) who found that fathers felt most connected to the pregnancy when feeling their foetus’ movements and during the ultrasound scans. During pregnancy, despite being excited about the birth of their child and wanting their partners’ sufferings to end, fathers also had strong apprehension regarding the new challenges they were about to face (Fenwick et al. 2012; Kao & Long 2004). Additionally, in their research about the support needs of expectant parents, Widarsson et al. (2012) found that fathers felt helpless when they could only see their wives suffer. Two studies interviewing first-time fathers had similar results where anxiety, inadequacy and a sense of powerlessness were common as they faced new situations and problems or were unsure about their future role as a father (Finnbogadóttir et al. 2003; Kao & Long 2004). However, these four qualitative studies either did not state their participants’ ethnicities and/or employment status or they recruited participants who were of the same ethnicities and were employed. On the other hand, participants in Deave & Johnson’s (2008) study also echoed feeling unprepared in becoming a father. Unlike the other studies, Deave & Johnson (2008) had participants who were unemployed or receiving state incapacity benefits and were of different ethnicities. As pregnancy progressed, fathers tended to interact more with their foetus and bond by talking to them and feeling their movements (Kao & Long 2004). Sansiriphun et al. (2010) also reported the same findings in their study on Thai first-time fathers. Fathers tended to fantasize about their child, plan for their future and after-birth care (Kao & Long 2004; Sansiriphun et al. 2010). However, due to cultural beliefs, only fathers in Sansiriphun et al.’s (2010) study planned post-partum confinement care for their wives. With the impending birth, however, these first-time fathers worried about how to help during childbirth (Deave & Johnson 2008; Kao & Long 2004). In contrast, Forsyth et al. (2011) found that during pregnancy, fathers were most concerned about their partners’ pain instead. This could be because they recruited experienced fathers who may have experienced childbirth and, hence, had seen their partners in pain before. Perhaps, this is why their main concern was about their partners’ pain, in contrast to first-time fathers’ whose main concern was how to help their partners during childbirth, as reported in the other three studies. However, as the relationship between first-time/experienced fathers and main worry was not investigated in Forsyth et al.’s (2011) study, it was inconclusive about whether first-time and experienced fathers have different concerns.
© 2014 International Council of Nurses during their partners’ pregnancies
pregnancy, during pregnancy and
To explore ‘the feelings and experiences of fathers about their wife/partner’s delivery’
Sapountzi-Krepia et al. (2010)
Bäckström & Hertfelt Wahn (2011)
birth
To explore first-time fathers’ descriptions of requested and received support during a normal
To evaluate first-time fathers’ experiences during pregnancy and to compare labour experiences between three different modes of delivery
Rosich-Medina & Shetty (2007)
Qualitative studies
To explore fathers’ birth experiences and factors contributing to a less positive birth experience (Part of another study)
and to explore factors related to midwifery care resulting in positive experiences
To identify the proportion of fathers who had a positive birth experience
Qualitative descriptive design Open-ended interviews in the first post-partum week
Quantitative; descriptive, cross-sectional study Kuopio Instruments for Fathers (KIF) was given 1 week to 1 year post-partum
Quantitative; cross-sectional design Questionnaires distributed and completed by fathers after childbirth
Quantitative; cross-sectional design Questionnaires distributed and completed 2 months post-partum
months post-partum
Quantitative; cross-sectional design Questionnaires were completed 2
Questionnaires measuring various outcomes about men’s experiences
sources of support
Quantitative; cross-sectional design
Not explicitly stated
Questionnaires measuring fathers’ experiences during labour and delivery and mothers’ perceptions of their partners’ emotions
Quantitative; cross-sectional design
Design and data collection methods
To find out men’s emotions and worries when learning about the
labour and delivery and to compare their emotions among different types of delivery
To investigate fathers’ experiences of
Aim of study
Johansson et al. (2012)
Hildingsson et al. (2011)
Forsyth et al. (2011)
(2002)
Chan & Paterson-Brown
Quantitative studies
Author (year)
Table 1 Details of included studies (n = 25)
Ten first-time fathers whose partners had a normal vaginal birth
Snowballing technique to recruit 417 fathers
In Thessaloniki city and six other cities located in the vicinity of Thessaloniki, Greece
One labour ward in a hospital in a south-western country of Sweden
Convenience sampling of 142 (95.2%) first-time fathers
Convenience sample of 827 fathers
assisted) vaginal deliveries
595 fathers who had attended normal (excluding
couples
Convenience sampling of 48
and 88 of fathers and mothers
Convenience sampling of 86
Participants
Aberdeen Maternity Hospital, Scotland
Three hospitals in the northern part of Sweden
council, Sweden
Three hospitals in a middle-north country
General public, Australia
in London, United Kingdom
Post-natal wards in a hospital
Settings
Main theme: ‘being involved or being left out’. Other themes: • an allowing atmosphere • balancing involvement • being seen • feeling left out
• Both positive and negative feelings towards the childbirth experience, their partners and infants • Pain generally was the most unpleasant and difficult thing • Generally positive towards the staff and the environment
Fathers’ involvement during pregnancy: most attended antenatal visits and classes and all ultrasound scans • Paternal experiences of pregnancy: pregnancy was real and fathers felt connected to it throughout especially during ultrasound scans and when feeling foetal movements but least connected during antenatal classes; they did not feel alienated during pregnancy • Paternal experiences of labour: most felt that labour had not matched their expectations but felt included by their partners during labour
• The fathers’ birth experiences: related most to the mode of delivery • Competence of the healthcare professionals: professionalism, partner’s medical care, support, information received, professionals’ approach and involvement in care, the organization
Factors that would provide a more positive experience for fathers: • midwives’ support • midwives’ presence • provision of information
The vast majority of fathers had a positive or very positive birth experience.
doctors and in antenatal classes
Men’s sources of support: partner (main), less so by
Men’s pregnancy-related worries: partners’ pain, baby’s health, financial concerns
Men’s feelings and emotions: generally positive
it rewarding and enjoyable. However, caesarean sections were found to be more traumatic and caused more anxiety compared with normal vaginal delivery. Both parents felt that their relationship as a couple improved after childbirth.
Fathers were generally keen to attend childbirth and found
Findings
546 H. L. Poh et al.
© 2014 International Council of Nurses
To discuss men’s experiences of pregnancy confirmation (Part of another study)
To conceptualize women’s and their partners’ experiences during a routine ultrasound examination in the second trimester of pregnancy
To explore the implications, from a father’s perspective of experiencing intense fear pertaining to childbirth (Part of another study)
To describe fathers’ experiences at the birth of their child
Ekelin et al. (2004)
Eriksson et al. (2007)
Erlandsson & Lindgren (2009)
healthcare professionals’ subjective and experiential constructions of masculinity about pregnancy and childbirth
Not explicitly stated To explore first-time fathers’ and
parenting skills
support and education provided by the healthcare professionals during the antenatal period, particularly with regard to preparing men for the transition to fatherhood and
To explore the needs of first-time fathers pertaining to the care,
Draper (2002)
Dolan & Coe (2011)
Deave & Johnson (2008)
Qualitative descriptive design Open interviews between 8 days and 6 weeks post-partum
Qualitative descriptive design Open, permissive interviews 2 to 3 years after the birth
Grounded theory Open interviews 2 to 4 weeks after the first ultrasound examination
Longitudinal, ethnographic design Semi-structured interviews conducted twice during pregnancy and once post-partum
twice, 4 to 8 weeks pre- and post-partum
Qualitative descriptive design Semi-structured interviews conducted
last trimester of pregnancy and 3 to 4 months post-partum
Qualitative descriptive design Semi-structured interviews done in the
Two district maternity clinics, Sweden
Umeå University Hospital, Sweden
University Hospital, Sweden
Antenatal classes in north of United Kingdom
A large maternity unit in United Kingdom
south-west England, United Kingdom
Two healthcare provider organizations in
16 fathers who were present at the birth of their child were included
20 fathers who had experience of intense childbirth-related fear
Convenience sampling of 22 couples
18 novice and experienced fathers were recruited via snowballing method
were recruited
Five first-time fathers and five health professionals
Purposive sampling of 20 first-time fathers
Main theme: ‘from belonging to belonging through a blessed moment of love for a child’. Other themes: • changing perspective of life • being in a relationship • living through a life change
Men’s experiences: – dimensions of fear: • content • manifestation – ways of dealing with the fear: increasing sense of control – reasons for not showing the fear: gender constructions and thoughtfulness for one’s partner – motives for attending childbirth: responsibility (towards partner), involvement (for self), obligation (societal)
Main theme: confirmation of a new life. Other themes: • visualizing • overwhelming to see life • becoming a family • reassuring
Themes: • body-mediated moments • confirmation • forms of knowledge of pregnancy: pregnancy test kit, medical examinations, through their partners’ bodies
• men felt that more attention could have been directed to them during antenatal classes • childbirth threatens men’s ability to control themselves physically and emotionally • men just followed instructions and generally felt that they were excluded from making decisions
• maintaining health to meet the demands of partner, new child and family • men intended to be present during childbirth and were willing to be attentive towards their partners and ‘take the abuse’
Men’s experiences and expectations: • positive relationship between being male and fertility
• lack of practical information about baby care • challenges of the changes in relationships with partners
• sources and quality of information received • experiences of antenatal healthcare provision and the lack of involvement in it • anxiety around the time of birth • lack of preparation for the post-natal period
Themes: • support, both received and available
A review of fathers’ experiences 547
Aim of study
To explore and describe men’s experiences related to pregnancy and their childbirth expectations
To describe expectant, first-time fathers’ experiences of pregnancy
To explore expectant first-time fathers’ experiences during their wives’ third trimester of pregnancy
To explore fathers’ role, expectations and meanings pertaining to their presence at birth
To further describe Swedish fathers’ experiences of childbirth education
To describe first-time fathers’ experiences of childbirth
Author (year)
Fenwick et al. (2012)
Finnbogadóttir et al. (2003)
Kao & Long (2004)
Longworth & Kingdon (2011)
Premberg & Lundgren (2006)
Premberg et al. (2011)
Table 1 Continued
© 2014 International Council of Nurses Two labour wards in Sahlgrenska University Hospital, Gothenburg, Sweden
method 4 to 6 weeks post-partum
13 hospitals in south-west Sweden
Hospital-based parent craft sessions (antenatal classes), United Kingdom
Taiwan
Antenatal clinic, southern Sweden
An Australian hospital
Settings
Phenomenological lifeworld approach Interviews guided by a re-enactment
Phenomenological design Unstructured interviews carried out 2 to 4 months post-partum
interviews ranged from 24 h to 8 days post-partum
Heideggerian hermeneutical phenomenology Pre- and post-natal semi-structured interviews done. Post-natal
Descriptive phenomenology Open interviews conducted when the participants’ wives were 34–36 weeks pregnant
Qualitative descriptive design Semi-structured interviews conducted in the 38–39th week of gestation
Qualitative descriptive design Emailing of diary entries and/or unstructured interviews at the second and third trimesters and about 8 weeks post-partum
Design and data collection methods
level) of ten first-time fathers
Purposive sampling (age, ethnicity and educational
Ten first-time fathers who had attended childbirth education classes
11 first-time fathers who attended the classes with their partners
Purposive sampling of 14 expectant first-time fathers
Seven first-time expectant fathers
Convenience sampling of 12 fathers whose partner was expecting a singleton pregnancy
Participants
social changes physical change responsibility development
to be informed to listen to and share other parents’ narratives to be there for the woman to imagine what the future holds to be parent number two
• • • •
a process into the unknown a mutually shared experience to guard and support the woman in an exposed position with hidden strong emotions
Main theme: ‘an interwoven process pendulating between euphoria and agony’. Other themes:
• • • • •
Main theme: childbirth education takes a secondary role while simultaneously creating preparedness for birth and fatherhood. Other themes:
• fatherhood beginning at birth and reconnection
Men’s experiences: • fathers’ disconnection with pregnancy and labour • fathers on the periphery of events during labour • control (also a cross-cutting theme)
• the wonder of foetal movement • expanded vision
Men’s experiences: • jubilation • adjustment • preparation for fatherhood • engagement • gender concerns
• • • •
Main theme: time of transition. Other themes, feelings of: • unreality • insufficiency and inadequacy • exclusion • reality
• excited but . . .! • antenatal visits: feeling sidelined • men’s childbirth expectations
Themes: • pregnancy news: heralds profound change • adjusting to pregnancy and working to see things differently • birth looming • the bags are packed – ‘We’re organised’
Findings
548 H. L. Poh et al.
To explore husbands’ experiences with
Sapkota et al. (2012)
© 2014 International Council of Nurses
To describe the experience of black fathers regarding support for their wives/partners during labour
To explore first-time fathers’ role during childbirth and to ascertain their perceptions and experiences
To describe fathers’ experience related to witnessing a traumatic birth
To describe expectant parents’ perceived needs of support during pregnancy
Sengane (2009)
Shibli-Kometiani & Brown (2012)
White (2007)
Widarsson et al. (2012)
regard to supporting their wives during childbirth
To explore the processes of becoming a father
Sansiriphun et al. (2010)
Naturalistic inquiry Focus groups and interviews. Period of data collection not stated
Descriptive phenomenology Email, snail mail or open interviews were conducted. The number of years since the traumatic birth ranged from
POH H.L., KOH S.S.L. & HE H.-G. (2014) An integrative review of fathers’ experiences during pregnancy and childbirth. International Nursing Review 61, 543–554 Background: While fathers are increasingly expected to participate during their partners’ pregnancies and childbirth and many studies have reported their experiences during these periods, no review studies have examined fathers’ experiences and needs during pregnancy and childbirth together. Aim: To provide an overview of evidence on fathers’ experiences and needs during their partners’ pregnancies and childbirth to identify any gaps in the existing literature and practice. Methods: An integrative literature review was performed to analyse and synthesize fathers’ experiences and/or needs during pregnancy and/or childbirth based on articles published in CINAHL, PubMed, Scopus, PsycINFO and Web of Science databases between the years 2002 and 2012. Only articles found in the National University of Singapore’s online library collection were retrieved. Results: Altogether, 25 studies (six quantitative and 19 qualitative studies) that reported fathers’ experiences during pregnancy (n = 8), childbirth (n = 13) or during both periods (n = 4) were reviewed. Fathers experienced mixed feelings both during pregnancy and childbirth. They required support from their partners and healthcare professionals and wanted to be informed, involved and respected. However, more studies are needed to explore this phenomenon in different cultural contexts or care models. Conclusion: This review provides evidence for healthcare professionals to pay more attention to fathers when delivering perinatal care. Sociocultural-sensitive interventions should be developed to facilitate a smoother transition to fatherhood. Implications for nursing and health policy: Father-specific information should be given to prepare fathers for pregnancy and childbirth. Healthcare professionals and policymakers should take fathers’ feelings and concerns into consideration and provide family-centred care to the couple during the antenatal and intrapartum periods. Keywords: Childbirth, Fathers, Midwifery, Needs, Perceptions, Pregnancy, Review
Correspondence address: Hong-Gu He, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore 117597; Tel: 6516-7448; Fax: 6776-7135; E-mail: [email protected].
Funding statement: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Conflict of interest statement: There is no conflict of interest.
© 2014 International Council of Nurses
543
bs_bs_banner
Literature Review
544
H. L. Poh et al.
Introduction Since the 1960s, there has been an increasing global trend in the number of fathers (defined in this literature review as including both experienced fathers and fathers-to-be) involved in their partners’ pregnancies and childbirth (Premberg et al. 2011). Currently, more than 90% of fathers in the USA participated in prenatal activities, for example, seeing an ultrasound of their child and discussing the pregnancy with their partners, while a similar percentage of fathers in the United Kingdom attended childbirth (Murphy 2009; National Responsible Fatherhood Clearinghouse 2010). While there has been considerable focus on women and the effects of fathers’ involvement, research about fathers’ experiences of their partners’ pregnancies and childbirth has relatively been lagging (Dellmann 2004; Rosich-Medina & Shetty 2007). This often resulted in the problem that fathers reported feeling inadequate and unprepared. Furthermore, they felt excluded and unsupported by the healthcare system (Fenwick et al. 2012; Widarsson et al. 2012). Therefore, to support fathers in their transition to fatherhood, knowledge about their experiences and needs during pregnancy and childbirth – appraised within their own sociocultural contexts – is important (Deave & Johnson 2008). This knowledge could enable healthcare professionals to adopt practices that are supportive and culturally sensitive (Kao & Long 2004). Ultimately, this could promote smoother transitions to fatherhood, aid in forming positive paternal experiences and relationship bonding and benefit the whole family (Finnbogadóttir et al. 2003; Kao & Long 2004).
Aim of this review The aim of this literature review was to provide an overview of studies about fathers’ experiences and needs during their partners’ pregnancies and childbirth so as to identify any gaps in the existing literature and practice.
nomenon of interest, it is best to summarize their findings using an integrative literature review design. Search methods
A literature search was performed in CINAHL, PubMed, Scopus, PsycINFO and Web of Science. Keywords such as ‘expectant fathers’, ‘fathers’, ‘husbands’, ‘men’, ‘spouses’, ‘experiences’, ‘life change events’, ‘meaning’, ‘perceptions’, ‘needs’, ‘support’, ‘antenatal’, ‘perinatal’, ‘pregnancy’, ‘prenatal’, ‘birth’, ‘childbirth’, ‘delivery’, ‘labour’ and ‘parturition’ were used singly or in various combinations when searching. Journal articles were included if they: (1) were published in English between 2002 and 2012, (2) can be found in the National University of Singapore (NUS)’s online library collection, and (3) focused on fathers’ experiences and/or needs either during pregnancy and/or childbirth. Articles with the following features were excluded: focused on fathers younger than 21 years old, investigated preterm infants or infants diagnosed with congenital abnormalities, recruited fathers whose partners had complications either during pregnancy or childbirth, were about tool validation or theoretical discussions, covered post-natal experiences, focused largely on women’s or healthcare professionals’ experiences, and/or measured variables not directly related to fathers’ experiences (such as sleep quality or smoking habits) or contained interventions. Search outcomes
Altogether, six quantitative and 19 qualitative studies were included. Eight of them reported fathers’ experiences and needs during pregnancy, 13 covered father’s experiences and needs during childbirth and the remaining four reported fathers’ experiences and needs during pregnancy and childbirth. The search strategies and outcomes are presented in Fig. 1 while the summary of the reviewed articles are shown in Table 1.
Results Methods
Fathers’ experiences during their partners’ pregnancies
Design
Positive and negative feelings
An integrative literature review is a review method that gives a more comprehensive understanding of a particular phenomenon or healthcare problem because it summarizes both empirical and theoretical research (Whittemore & Knafl 2005). It is also the only method that allows for the inclusion of articles with diverse methodologies (Whittemore & Knafl 2005). Given that fathers’ experiences and needs during pregnancy and childbirth are best explored using qualitative approaches and that there are also a few quantitative studies investigating this phe-
Pregnancy confirmation is the very first step of the transition to fatherhood. In her study to explore fathers’ experiences of pregnancy confirmation, Draper (2002) found that they felt disbelief and distanced initially as they could not experience the physical changes their partners were undergoing and could neither ‘feel’ nor see the unborn foetus. Similarly, Finnbogadóttir et al. (2003) determined, with expectant first-time fathers’ experiences of pregnancy, that fathers felt a sense of unreality when they learnt of the pregnancy. Both Draper’s (2002) and
© 2014 International Council of Nurses
A review of fathers’ experiences
Potential articles identified from search strategy (n=82 227)
545
Articles excluded after limiting to: • • • • • •
Articles evaluated based on their titles and abstracts (n=6751)
Full articles retrieved for detailed examination (n=44)
years 2002 to 2012 English language journal/review articles peer-reviewed, academic journals ‘nursing’ subject inclusion and exclusion criteria (n=75 476)
Articles excluded after accounting for duplicates in search results and evaluation of titles and abstracts (n=6707)
Articles excluded after review of full article (n=19) Articles included in this literature review (n=25)
Quantitative studies (n=6)
Qualitative studies (n=19)
•
• • • • •
cross-sectional (n=6)
qualitative descriptive (n=8) ethnographic (n=1) grounded theory (n=2) phenomenology (n=7) naturalistic inquiry (n=1)
Fig. 1 Flow diagram depicting search strategies and outcomes.
Finnbogadóttir et al.’s (2003) findings contrasted with Rosich-Medina & Shetty’s (2007) cross-sectional study of 142 first-time fathers, which reported that fathers felt connected throughout the pregnancy. Fathers wanted to connect to their unborn child and, hence, they engaged in ‘body-mediated moments’, a term coined by Draper (2002), where they connected with their foetus by feeling for their movements through their partners’ bodies. In investigating expectant parents’ experiences during a routine ultrasound examination, Ekelin et al. (2004) found that the first ultrasound scan was of great importance as it was a confirmation of a new life. It was also the first-time fathers could ‘see’ their foetus (Finnbogadóttir et al. 2003). These experiences helped fathers gain a sense of reality about the pregnancies (Draper 2002; Finnbogadóttir et al. 2003). Similarly, in exploring Australian fathers’ pregnancy experiences and childbirth expectations, Fenwick et al. (2012) also described that being present at the ultrasound screening and being able to feel their
© 2014 International Council of Nurses
foetus’ movements were significant in connecting both novice and experienced fathers to their foetuses. The findings of these qualitative studies were confirmed by Rosich-Medina & Shetty (2007) who found that fathers felt most connected to the pregnancy when feeling their foetus’ movements and during the ultrasound scans. During pregnancy, despite being excited about the birth of their child and wanting their partners’ sufferings to end, fathers also had strong apprehension regarding the new challenges they were about to face (Fenwick et al. 2012; Kao & Long 2004). Additionally, in their research about the support needs of expectant parents, Widarsson et al. (2012) found that fathers felt helpless when they could only see their wives suffer. Two studies interviewing first-time fathers had similar results where anxiety, inadequacy and a sense of powerlessness were common as they faced new situations and problems or were unsure about their future role as a father (Finnbogadóttir et al. 2003; Kao & Long 2004). However, these four qualitative studies either did not state their participants’ ethnicities and/or employment status or they recruited participants who were of the same ethnicities and were employed. On the other hand, participants in Deave & Johnson’s (2008) study also echoed feeling unprepared in becoming a father. Unlike the other studies, Deave & Johnson (2008) had participants who were unemployed or receiving state incapacity benefits and were of different ethnicities. As pregnancy progressed, fathers tended to interact more with their foetus and bond by talking to them and feeling their movements (Kao & Long 2004). Sansiriphun et al. (2010) also reported the same findings in their study on Thai first-time fathers. Fathers tended to fantasize about their child, plan for their future and after-birth care (Kao & Long 2004; Sansiriphun et al. 2010). However, due to cultural beliefs, only fathers in Sansiriphun et al.’s (2010) study planned post-partum confinement care for their wives. With the impending birth, however, these first-time fathers worried about how to help during childbirth (Deave & Johnson 2008; Kao & Long 2004). In contrast, Forsyth et al. (2011) found that during pregnancy, fathers were most concerned about their partners’ pain instead. This could be because they recruited experienced fathers who may have experienced childbirth and, hence, had seen their partners in pain before. Perhaps, this is why their main concern was about their partners’ pain, in contrast to first-time fathers’ whose main concern was how to help their partners during childbirth, as reported in the other three studies. However, as the relationship between first-time/experienced fathers and main worry was not investigated in Forsyth et al.’s (2011) study, it was inconclusive about whether first-time and experienced fathers have different concerns.
© 2014 International Council of Nurses during their partners’ pregnancies
pregnancy, during pregnancy and
To explore ‘the feelings and experiences of fathers about their wife/partner’s delivery’
Sapountzi-Krepia et al. (2010)
Bäckström & Hertfelt Wahn (2011)
birth
To explore first-time fathers’ descriptions of requested and received support during a normal
To evaluate first-time fathers’ experiences during pregnancy and to compare labour experiences between three different modes of delivery
Rosich-Medina & Shetty (2007)
Qualitative studies
To explore fathers’ birth experiences and factors contributing to a less positive birth experience (Part of another study)
and to explore factors related to midwifery care resulting in positive experiences
To identify the proportion of fathers who had a positive birth experience
Qualitative descriptive design Open-ended interviews in the first post-partum week
Quantitative; descriptive, cross-sectional study Kuopio Instruments for Fathers (KIF) was given 1 week to 1 year post-partum
Quantitative; cross-sectional design Questionnaires distributed and completed by fathers after childbirth
Quantitative; cross-sectional design Questionnaires distributed and completed 2 months post-partum
months post-partum
Quantitative; cross-sectional design Questionnaires were completed 2
Questionnaires measuring various outcomes about men’s experiences
sources of support
Quantitative; cross-sectional design
Not explicitly stated
Questionnaires measuring fathers’ experiences during labour and delivery and mothers’ perceptions of their partners’ emotions
Quantitative; cross-sectional design
Design and data collection methods
To find out men’s emotions and worries when learning about the
labour and delivery and to compare their emotions among different types of delivery
To investigate fathers’ experiences of
Aim of study
Johansson et al. (2012)
Hildingsson et al. (2011)
Forsyth et al. (2011)
(2002)
Chan & Paterson-Brown
Quantitative studies
Author (year)
Table 1 Details of included studies (n = 25)
Ten first-time fathers whose partners had a normal vaginal birth
Snowballing technique to recruit 417 fathers
In Thessaloniki city and six other cities located in the vicinity of Thessaloniki, Greece
One labour ward in a hospital in a south-western country of Sweden
Convenience sampling of 142 (95.2%) first-time fathers
Convenience sample of 827 fathers
assisted) vaginal deliveries
595 fathers who had attended normal (excluding
couples
Convenience sampling of 48
and 88 of fathers and mothers
Convenience sampling of 86
Participants
Aberdeen Maternity Hospital, Scotland
Three hospitals in the northern part of Sweden
council, Sweden
Three hospitals in a middle-north country
General public, Australia
in London, United Kingdom
Post-natal wards in a hospital
Settings
Main theme: ‘being involved or being left out’. Other themes: • an allowing atmosphere • balancing involvement • being seen • feeling left out
• Both positive and negative feelings towards the childbirth experience, their partners and infants • Pain generally was the most unpleasant and difficult thing • Generally positive towards the staff and the environment
Fathers’ involvement during pregnancy: most attended antenatal visits and classes and all ultrasound scans • Paternal experiences of pregnancy: pregnancy was real and fathers felt connected to it throughout especially during ultrasound scans and when feeling foetal movements but least connected during antenatal classes; they did not feel alienated during pregnancy • Paternal experiences of labour: most felt that labour had not matched their expectations but felt included by their partners during labour
• The fathers’ birth experiences: related most to the mode of delivery • Competence of the healthcare professionals: professionalism, partner’s medical care, support, information received, professionals’ approach and involvement in care, the organization
Factors that would provide a more positive experience for fathers: • midwives’ support • midwives’ presence • provision of information
The vast majority of fathers had a positive or very positive birth experience.
doctors and in antenatal classes
Men’s sources of support: partner (main), less so by
Men’s pregnancy-related worries: partners’ pain, baby’s health, financial concerns
Men’s feelings and emotions: generally positive
it rewarding and enjoyable. However, caesarean sections were found to be more traumatic and caused more anxiety compared with normal vaginal delivery. Both parents felt that their relationship as a couple improved after childbirth.
Fathers were generally keen to attend childbirth and found
Findings
546 H. L. Poh et al.
© 2014 International Council of Nurses
To discuss men’s experiences of pregnancy confirmation (Part of another study)
To conceptualize women’s and their partners’ experiences during a routine ultrasound examination in the second trimester of pregnancy
To explore the implications, from a father’s perspective of experiencing intense fear pertaining to childbirth (Part of another study)
To describe fathers’ experiences at the birth of their child
Ekelin et al. (2004)
Eriksson et al. (2007)
Erlandsson & Lindgren (2009)
healthcare professionals’ subjective and experiential constructions of masculinity about pregnancy and childbirth
Not explicitly stated To explore first-time fathers’ and
parenting skills
support and education provided by the healthcare professionals during the antenatal period, particularly with regard to preparing men for the transition to fatherhood and
To explore the needs of first-time fathers pertaining to the care,
Draper (2002)
Dolan & Coe (2011)
Deave & Johnson (2008)
Qualitative descriptive design Open interviews between 8 days and 6 weeks post-partum
Qualitative descriptive design Open, permissive interviews 2 to 3 years after the birth
Grounded theory Open interviews 2 to 4 weeks after the first ultrasound examination
Longitudinal, ethnographic design Semi-structured interviews conducted twice during pregnancy and once post-partum
twice, 4 to 8 weeks pre- and post-partum
Qualitative descriptive design Semi-structured interviews conducted
last trimester of pregnancy and 3 to 4 months post-partum
Qualitative descriptive design Semi-structured interviews done in the
Two district maternity clinics, Sweden
Umeå University Hospital, Sweden
University Hospital, Sweden
Antenatal classes in north of United Kingdom
A large maternity unit in United Kingdom
south-west England, United Kingdom
Two healthcare provider organizations in
16 fathers who were present at the birth of their child were included
20 fathers who had experience of intense childbirth-related fear
Convenience sampling of 22 couples
18 novice and experienced fathers were recruited via snowballing method
were recruited
Five first-time fathers and five health professionals
Purposive sampling of 20 first-time fathers
Main theme: ‘from belonging to belonging through a blessed moment of love for a child’. Other themes: • changing perspective of life • being in a relationship • living through a life change
Men’s experiences: – dimensions of fear: • content • manifestation – ways of dealing with the fear: increasing sense of control – reasons for not showing the fear: gender constructions and thoughtfulness for one’s partner – motives for attending childbirth: responsibility (towards partner), involvement (for self), obligation (societal)
Main theme: confirmation of a new life. Other themes: • visualizing • overwhelming to see life • becoming a family • reassuring
Themes: • body-mediated moments • confirmation • forms of knowledge of pregnancy: pregnancy test kit, medical examinations, through their partners’ bodies
• men felt that more attention could have been directed to them during antenatal classes • childbirth threatens men’s ability to control themselves physically and emotionally • men just followed instructions and generally felt that they were excluded from making decisions
• maintaining health to meet the demands of partner, new child and family • men intended to be present during childbirth and were willing to be attentive towards their partners and ‘take the abuse’
Men’s experiences and expectations: • positive relationship between being male and fertility
• lack of practical information about baby care • challenges of the changes in relationships with partners
• sources and quality of information received • experiences of antenatal healthcare provision and the lack of involvement in it • anxiety around the time of birth • lack of preparation for the post-natal period
Themes: • support, both received and available
A review of fathers’ experiences 547
Aim of study
To explore and describe men’s experiences related to pregnancy and their childbirth expectations
To describe expectant, first-time fathers’ experiences of pregnancy
To explore expectant first-time fathers’ experiences during their wives’ third trimester of pregnancy
To explore fathers’ role, expectations and meanings pertaining to their presence at birth
To further describe Swedish fathers’ experiences of childbirth education
To describe first-time fathers’ experiences of childbirth
Author (year)
Fenwick et al. (2012)
Finnbogadóttir et al. (2003)
Kao & Long (2004)
Longworth & Kingdon (2011)
Premberg & Lundgren (2006)
Premberg et al. (2011)
Table 1 Continued
© 2014 International Council of Nurses Two labour wards in Sahlgrenska University Hospital, Gothenburg, Sweden
method 4 to 6 weeks post-partum
13 hospitals in south-west Sweden
Hospital-based parent craft sessions (antenatal classes), United Kingdom
Taiwan
Antenatal clinic, southern Sweden
An Australian hospital
Settings
Phenomenological lifeworld approach Interviews guided by a re-enactment
Phenomenological design Unstructured interviews carried out 2 to 4 months post-partum
interviews ranged from 24 h to 8 days post-partum
Heideggerian hermeneutical phenomenology Pre- and post-natal semi-structured interviews done. Post-natal
Descriptive phenomenology Open interviews conducted when the participants’ wives were 34–36 weeks pregnant
Qualitative descriptive design Semi-structured interviews conducted in the 38–39th week of gestation
Qualitative descriptive design Emailing of diary entries and/or unstructured interviews at the second and third trimesters and about 8 weeks post-partum
Design and data collection methods
level) of ten first-time fathers
Purposive sampling (age, ethnicity and educational
Ten first-time fathers who had attended childbirth education classes
11 first-time fathers who attended the classes with their partners
Purposive sampling of 14 expectant first-time fathers
Seven first-time expectant fathers
Convenience sampling of 12 fathers whose partner was expecting a singleton pregnancy
Participants
social changes physical change responsibility development
to be informed to listen to and share other parents’ narratives to be there for the woman to imagine what the future holds to be parent number two
• • • •
a process into the unknown a mutually shared experience to guard and support the woman in an exposed position with hidden strong emotions
Main theme: ‘an interwoven process pendulating between euphoria and agony’. Other themes:
• • • • •
Main theme: childbirth education takes a secondary role while simultaneously creating preparedness for birth and fatherhood. Other themes:
• fatherhood beginning at birth and reconnection
Men’s experiences: • fathers’ disconnection with pregnancy and labour • fathers on the periphery of events during labour • control (also a cross-cutting theme)
• the wonder of foetal movement • expanded vision
Men’s experiences: • jubilation • adjustment • preparation for fatherhood • engagement • gender concerns
• • • •
Main theme: time of transition. Other themes, feelings of: • unreality • insufficiency and inadequacy • exclusion • reality
• excited but . . .! • antenatal visits: feeling sidelined • men’s childbirth expectations
Themes: • pregnancy news: heralds profound change • adjusting to pregnancy and working to see things differently • birth looming • the bags are packed – ‘We’re organised’
Findings
548 H. L. Poh et al.
To explore husbands’ experiences with
Sapkota et al. (2012)
© 2014 International Council of Nurses
To describe the experience of black fathers regarding support for their wives/partners during labour
To explore first-time fathers’ role during childbirth and to ascertain their perceptions and experiences
To describe fathers’ experience related to witnessing a traumatic birth
To describe expectant parents’ perceived needs of support during pregnancy
Sengane (2009)
Shibli-Kometiani & Brown (2012)
White (2007)
Widarsson et al. (2012)
regard to supporting their wives during childbirth
To explore the processes of becoming a father
Sansiriphun et al. (2010)
Naturalistic inquiry Focus groups and interviews. Period of data collection not stated
Descriptive phenomenology Email, snail mail or open interviews were conducted. The number of years since the traumatic birth ranged from
