ORIGINAL ARTICLE
‘Paddling upstream’: Fathers’ involvement during pregnancy as described by expectant fathers and mothers Margareta Widarsson, Gabriella Engstr€ om, Tanja Tyden, Pranee Lundberg and Lena Marmst al Hammar
Aims and objectives. To describe the perspectives of expectant mothers and fathers on fathers’ involvement during pregnancy. Background. Becoming a father is a major life event and paternal involvement during pregnancy has a positive influence on the family. However, research into both expectant mothers’ and fathers’ perspectives on fathers’ involvement during pregnancy is relatively scarce. Design. A descriptive qualitative study was used. Methods. Thirty expectant parents (20 women and 10 men) were interviewed either as part of one of four focus groups or in an individual interview. Qualitative content analysis was performed on the interview transcripts. Results. A theme of ‘Paddling upstream’ emerged as an expression of the latent content of the interviews concerning perspectives on fathers’ involvement. Five sub-themes described the manifest content: trying to participate, trying to be understanding, trying to learn, trying to be a calming influence and trying to find a balanced life. Expectant parents suggested several ways to improve fathers’ involvement and to meet parents’ need for shared involvement. Conclusion. Expectant mothers and fathers wanted the father to be more involved in the pregnancy. Although fathers attempted different strategies, they did not always perceive what was expected of them and encountered many barriers as they tried to navigate through this unique experience. The best support for the father was the mother. Expectant parents wanted their healthcare to include the father more thoroughly and to focus on the whole family. Relevance to clinical practice. Prenatal care professionals can overcome barriers that prevent paternal involvement. Although fathers are not able to engage in the pregnancy on the same level as the mother, we suggest that their specific needs also be recognised through an increased awareness of gender norms in healthcare.
Authors: Margareta Widarsson, MNursSci, RN, RM, Med LIC, Doctoral Student, Centre for Clinical Research, Uppsala University, V€astmanland County Hospital, V€aster as, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden; Gabriella Engstr€ om, RN, PhD, Associate Professor, Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida, USA; Tanja Tyden, RM, PhD, Professor, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden; Pranee Lundberg, RN, RM, PhD, Associate Professor,
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1059–1068, doi: 10.1111/jocn.12784
What does this paper contribute to the wider global clinical community?
• Expectant mothers and fathers
•
•
wanted the father to be more involved during the pregnancy, but encountered many barriers to such involvement. To facilitate fathers’ involvement, healthcare professionals should determine expectant fathers’ specific needs and help them overcome barriers. In promoting the progress of gender equality, we found it important – from both the paternal and maternal perspectives– for the father to be involved during the pregnancy. Shared involvement is important for their preparation for parenthood. The present study is a useful description for midwives and other healthcare professionals of how fathers can be involved during pregnancy.
Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden; Lena Marmst al Hammar, RN, PhD, Senior Lecturer, School of Health, Care and Social Welfare, M€ alardalen University, V€ aster as, Sweden Correspondence: Margareta Widarsson, Doctoral Student, Centre for Clinical Research, V€ astmanland County Hospital, S- 721 89 V€ aster as, Sweden. Telephone: +46 21 174102. E-mail: [email protected]
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Key words: antenatal care, content analysis, expectant fathers, expectant mothers, involvement, prenatal care Accepted for publication: 19 December 2014
Introduction Becoming a father is a major life event. For some, the transformative process may begin as soon as the pregnancy is confirmed; for others, it may occur when they hold their newborn child for the first time. This transition into fatherhood is complex and is described as a time of joy and hope as well as of confusion and frustration (Asenhed et al. 2013). Paternal involvement during pregnancy can positively influence health outcomes for the partner, the child and the father himself (Plantin et al. 2011), and most fathers demand to be involved in facilitating the well-being of their child and partner (Redshaw & Henderson 2013). This involvement is also insisted on by expectant mothers (Widarsson et al. 2012, Alio et al. 2013).
Background The father wants to support his partner’s positive perinatal experience (Fenwick et al. 2012, Alio et al. 2013), as well as to maintain a strong family (Lindberg & Engstr€ om 2013). However, fathers sometimes fall into a secondary role during pregnancy and may feel excluded from a largely maternal domain following childbirth. This can be problematic for both the father and the mother (Wells et al. 2013), and a lack of effective and engaging interactions with healthcare professionals can leave men feeling frustrated and distressed (Fenwick et al. 2012). There is a need to determine why fathers feel excluded during pregnancy, in spite of the pregnancy being about his child as well. The development of effective intervention strategies to address these deficiencies depends on such insight. Women commonly spend a greater portion of time caring for the children and family, which may reflect gendered norms and roles in both society and families (Connell 2009). On the other hand, there are inherent sex differences due to the woman carrying the foetus (Bird & Rieker 1999). Social and cultural norms, as well as policies and practices, have changed in recent decades. This has resulted in a shift in focus that promotes gender equality, from women’s empowerment to the roles and responsibilities of men (WHO 2006). However, healthcare-services have difficulty increasing fathers’ involvement in educational programmes, with the result that
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men can be less prepared for parenting than women (WHO 2007). Official Swedish gender equality policy regards women and men as having the same rights, obligations and opportunities in important life domains (Nationalencyklopedin 2014). This development of greater equality, including in the area of childcare, has been described as Sweden coming close to a ‘gender revolution’, in which the differences between fathers and mothers are gradually being reduced (Evertsson 2014). These changes are likely facilitated by the similar employment rates of 92% for fathers and 82% for mothers, (Statistiska centralbyr an 2013). Sweden also has one of the most extensive and egalitarian parental leave policies in the world (Ray et al. 2010), allowing 480 days of leave from work per child; these days are to be used up to the time the child is 12 years old, and may be shared between the parents (F€ ors€ akringskassan 2014). Despite this gender equality progress, mothers report more stress from paid work, conflicting demands and a greater overall workload than do fathers (Berntsson et al. 2006, Strandh & Nordenmark 2006). Mothers also report more control over household duties and total workload than fathers, who focus mainly on their paid work and seem fairly resistant to feelings of conflicting demands (Berntsson et al. 2006). The aim of maternal healthcare in Sweden is reproductive health for both men and women, implying that maternal healthcare provides assistance in parenting and support for both parents along with maternal childbirth preparations (Andersson-Ellstr€ om 2008). However, parents are dissatisfied with the antenatal support they receive (Edvardsson et al. 2011), in which men do not feel involved by midwives (Hildingsson & Sj€ oling 2011) and experience traditional gender roles as shortcomings in parental education (Edvardsson et al. 2011). Studies often focus on mothers’ and seldom on fathers’ experiences of pregnancy. The aim of this study, therefore, was to describe the perspectives of expectant mothers and fathers on the involvement of fathers during pregnancy.
Methods The study had a qualitative design, using a qualitative latent content analysis, described by Graneheim and
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1059–1068
Original article
Fathers’ involvement during pregnancy
Lundman (2004), to analyse interviews with expectant fathers and mothers.
Participants and setting Participants were expectant fathers and mothers recruited (1) through an open hospital lecture describing obstetric facilities, (2) by a midwife serving newly arrived immigrants, and (3) by midwives at maternity care units. Interested individuals were contacted by telephone. Thirty expectant parents (20 women, 10 men) agreed to participate and signed informed consent forms. Twenty were firsttime parents (12 women, eight men). Participants were 21– 56 years of age (mean 30 years), all were living with their partner and 90% had completed at least high school. Pregnancy duration ranged from 13–39 weeks (median 34 weeks).
Data collection Data were collected through four focus group interviews (FGIs) (Krueger & Casey 2000) and 12 individual interviews (Kvale et al. 2009), conducted by the first author (Table 1). Swedish-speaking parents were given the opportunity to choose between an FGI and an individual interview; only individual interviews were available for non-Swedish-speaking participants. Two individual interviews were conducted in English and two through an interpreter. An observer assisted the FGI moderator with field notes during the FGI and a summary afterwards. FGIs lasted 71–109 minutes, included both first-time and experienced parents, and were conducted at the Centre for Clinical Research. The 12 individual interviews were carried out at the participant’s home or a community centre, based on the participant’s preference. The individual interviews lasted 31–65 minutes. The opening question in each focus group Table 1 Characteristics of participants in the four focus group interviews and the 12 individual interviews
Number of participants Women Men Swedish speakers Non-Swedish speakers First-time parents Not first-time parents
Focus group interviews
Individual interviews
12 6 18 0
8 4 8 4
13 5
7 5
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1059–1068
or individual interview was ‘Please tell us about your experiences becoming a father/mother’. This question was followed up with probing questions to steer the interviews towards the aim of our study (Polit & Beck 2008). After the interviews the first author, the observer, or the participants made a short summary, and the participants had the opportunity to verify the content (Krueger & Casey 2000).
Data analysis All interviews were analysed using qualitative content analysis according to Graneheim and Lundman (2004). Each audiotaped interview was transcribed verbatim and read several times to develop an overview. The analysis process began by highlighting sentences of importance. These sentences were first divided into meaning units. Second, the meaning units were condensed and labelled with short codes. Third, the codes were compared to identify similarities and differences. Fourth, categories were developed based on the codes, which included the manifest content, or what the text communicated. Fifth, a comparison and interpretation of the categories was undertaken, from which the five sub-themes were developed. The sub-themes are the underlying meanings of the categories, that is, expressions of the latent content on an interpretative level. Finally, the sub-themes formed one theme: (Table 2).
Ethics The Research Ethics Committee at Uppsala approved the study (Dnr: 247-2008).
Results From the analysis, a theme of ‘Paddling upstream’ emerged as a description of paternal involvement during pregnancy. This theme was built up from five sub-themes (Fig. 1). To maintain confidentiality, pseudonyms are used in the results section.
Theme: ‘Paddling upstream’ This theme is a metaphor for the expectant parents’ perspectives on the involvement of fathers during pregnancy. The parents wanted the father to be involved, but he was described as struggling to achieve that involvement. He faced many barriers, which are described in this section. The metaphor of ‘Paddling upstream’ – trying to make headway against the flow of a river – mirrors this struggle. He moves forward, but has to expend a lot of energy to
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M Widarsson et al. Table 2 Content analysis of transcribed data from all interviews with 30 expectant fathers and mothers. Examples of meaning units, condensed meaning units, codes, categories, sub-themes and theme Meaning unit
Condensed meaning unit
Code
Categories
Sub-themes
Theme
Reducing anxiety, calming things down. Because in most cases things work out well. On such forums, they don’t say that things go well for 1000 and then that they go badly for one, they talk about the times things go badly, or about complications. I’m more of a reducer of anxiety I try to take as much responsibility as I can concerning both her career and her working life, and her social life, and as a parent, and I try to help her and make things easier for her as much as possible. . . it’s always a matter of a compromise
Reducing anxiety, calming down. Most things work out well. On the forums, they don’t say things go well for 1000 and badly for one, they talk about things go badly, or about complications. I’m a reducer of anxiety
Ease anxiety
Anxiety reducer
Trying to be a calming influence
Paddling upstream
I take as much responsibility as I can concerning her career, working life and social life. I help her and make things easier for her as much as possible. It’s always a compromise
Take practical responsibility
Responsibility taker
Trying to find a balanced life
Paddling upstream
Trying to be understanding Trying to participate Trying to be a calming influence Trying to learn Trying to find a balanced life Figure 1 Theme and sub-themes revealed by the qualitative content analysis of interviews with 30 expectant fathers and mothers in Sweden.
battle against the current. The father, then, faced numerous obstacles to being involved. He often felt that the pregnancy was not quite real, as he could not feel the baby’s movements or see his own body changing as the mother was able to do. However, fathers tried to be present in more practical ways, such as managing practical matters. They had to try to work out what the mother wanted, as she did not clearly express her needs. On visits to the midwife, the father felt overlooked and superfluous, making other support groups such as friends and social media
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necessary as a source of the knowledge needed to facilitate involvement. Difficulty being away from work or arranging babysitting for siblings commonly hindered participation in healthcare visits. Fathers also worried about the mother’s pregnancy, planned for the coming child, and were excited to reach the end of the pregnancy journey.
Trying to participate The fathers wanted to participate in the pregnancy and tried to do so in different ways. Even though the mother was carrying the foetus, both parents described the pregnancy as an unreal experience, in the sense that, although they knew there was a baby, they could not see it. This meant that being fully involved was even more difficult for the father. One woman described how she wished the father would be a greater part of what was happening: He thinks it’s a real drag, not getting to experience the pregnancy. He thinks it’s so unfair, so he just lies there and as soon as there’s any kicking, there he is, feeling and listening. (Marie)
One way for the father to participate was to accompany his partner on visits to the midwife. Parents described this as a form of support for the mother and said that the father’s support was unique because he knew her best, but also that the father wanted support as well. As one father described his situation: © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1059–1068
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Fathers’ involvement during pregnancy
I really want to be there [on visits to the midwife], because I want
was . . . ‘But you shouldn’t be doing anything, go and lie down and
to participate as much as I can – there’s already that distance
take it easy, try to unwind’ [said her husband]. (Miriam)
between [my wife] and me as the child’s parents, in that she’s the one who’s carrying the baby. (Samuel)
Yet when the father accompanied his partner on these visits, he did not feel welcome, since the information and communication was directed at the mother. One mother commented: The midwife hardly said hello to him, and then there was just a
Despite the woman becoming more irritated due to the pregnancy, she nevertheless experienced greater understanding from the father. The father, though, did not always find this easy to manage. Nonetheless, the mothers described the fathers as more attentive, thoughtful and understanding, even though the mothers themselves expressed that they did not always deserve this. One mother explained:
conversation between me and the midwife. So he wondered after-
My husband supports me most of all. He’s so understanding and
wards, why was I there at all, the midwife treated me like air . . . it
really incredible. For many friends, from what I’ve heard, the men
was as if she didn’t have a single question for him, she never once
haven’t really understood why you are perhaps a bit more irritable
spoke to him. (Noomi)
and that things are more difficult. (Brigit)
Another way for the father to participate was during the ultrasound examination. Even if the father was a bystander at this exam, the parents described the ultrasound as a turning point when the pregnancy became more real for them both. Parents described an invisible shared bond that joined them and strengthened their relationship. After this experience, the father began to experience the pregnancy in a different way and took more responsibility in preparations for the delivery, including practical measures such as purchasing items for the child, which he had not done before. One mother said:
Fathers tried to be understanding of the mothers’ irritation or strange behaviour because it was described as something that was normal for pregnancy. The men realised that they could not psychologically experience being pregnant, so they simply tried to understand.
It was great when he suggested things. Let’s go and buy a buggy, and now it’s time to buy a cot, and we’re not going to be stingy when it comes to the mattress. That’s when I begin to see that he thinks this is very important. (Tabita)
Trying to learn Fathers wanted to prepare themselves by learning about pregnancy, delivery and parenthood. They tried to show their involvement by taking part in midwife visits, parenting classes, father classes, and psychoprophylaxis courses. The courses for fathers were particularly appreciated as they provided an opportunity to converse with other fathers. One mother said: Perhaps it should be a bit more obligatory to have a fathers’ group as well, where they’re on their own in some way and able to talk
Trying to be understanding Fathers described how the pregnancy made their partner more important to them and how they cared for her more than before the pregnancy. Fathers reported trying to be understanding by giving the woman psychological support and taking care of household matters, which was a great relief to the mother. Despite these efforts, fathers were not always successful because the mother did not always express her needs, but expected him to notice those needs. When the father was successful in his attempt to be understanding and noticed his partner’s needs, she felt looked after and happy. To the mother, this meant hope for the future, that he would take responsibility for the family. One mother described the father’s attempt to be understanding: I ran to catch a bus, I felt it was a very stressful thing for me. When I got home, I felt I was tired and I told him how incredibly stressed I
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1059–1068
about their thoughts and . . . worries. I’m sure it’s not easy for them either to have a grumbling woman at home [laughter] . . . in that way they could perhaps come closer and be involved in a different way in the pregnancy. (Rebecca)
As a way to learn about pregnancy and childbirth, the fathers spoke of their need to meet other expectant fathers and mothers. Most appreciated parental groups that encouraged active participation and in which the father could gather information. An especially valuable parenting group was the psychoprophylaxis course at which fathers were able to gather practical knowledge in preparation for the delivery. This provided an opportunity for the parents to communicate about the upcoming delivery and to learn about breathing and relaxation. Parents experienced this as a very good way to get the father to be a part of the pregnancy and the preparations for the approaching delivery. One father noted:
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M Widarsson et al. If we hadn’t taken the psychoprophylaxis course, we actually wouldn’t have known anything. I think that’s rather a pity. I have a pretty good idea of things, after the previous times, both the prophylaxis course and the parent group, I think I’ll be well equipped. (David)
When questions arose about pregnancy, childbirth and parenthood, the father commonly asked the mother for information first and after that would consult friends who had children. In addition, the fathers tried to learn and prepare themselves by seeking knowledge on the Internet and from books, newspapers and personal contacts. However, fathers considered it important not to gather too much information, because they did not feel they had the competence to identify which information was most relevant. One father commented: This inner anxiety about am I doing enough for my child, am I adequately prepared, am I searching for too little information, or too much information, is it good information, what do I think of all this? To sift through it all and arrive at something that suits me, or us. (John)
Trying to be a calming influence Fathers showed their involvement by trying to calm the mothers’ inevitable anxieties. They described reassuring their partner when something disturbed her, discussing issues with her, and giving comforting hugs when needed. Fathers wanted to facilitate for the mother, be a balancing factor when she was anxious about what might happen during the pregnancy and delivery. This role became clear when it came to information on the Internet, and various forums for chatting in which the mothers took part. The father took part when the mother brought up something from a forum, although he may have felt that she should avoid these venues and should realise that she had limited control over pregnancy and delivery situations. Fathers felt that chat forums focused on complications and horror stories. One father described his role: Reducing anxiety, calming things down. Because in most cases things work out well. On such forums, they don’t say that things go well for 1000 and then that they go badly for one, they talk about the times things go badly, or about complications. I’m more of a reducer of anxiety. (Levi)
Fathers tried to be a calming influence by reassuring and encouraging mothers when they described their fears about the delivery. They felt she should prepare herself better by reading and preparing mentally for what was going to hap-
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pen. While the father tried to calm the mother, she described that she did not feel confident that he himself would cope with the delivery. One mother reflected: And I don’t know, he’s like, ‘Yes, but I’m so calm’, and ‘This is going to go well, I’ll cope with this and the delivery. It’s going to go really well.’ And I just picture him, you know, passing out there. (Marie)
When fathers tried to soothe their partner by reflecting on what would take place at the delivery and thereafter, mothers found this to be quite reassuring. Mothers described how the father took part by listening when she described what made her fearful, and by being present to relieve her anxiety. Fathers, who themselves were worrying, tried not to show this to the mother, even when she was aware of his anxiety. As one mother said: It’s wonderful, especially when you have a wonderful husband who helps you and gives you hope and a sense of security, who helps you to feel safe. I have to carry the child within me, but the father is around me and if he doesn’t give me enough peace, attention and involvement the baby will feel it. (Lisa)
Trying to find a balanced life The fathers were described as taking part in trying to balance their and their partner’s lives, including work, careers and leisure activities, and for some, children as well. Finding sufficient time for everything was described as difficult. Some situations were discussed with other parents, with a goal of gaining support for the situation. Even though fathers wanted to be involved in the pregnancy, and both parents explained that they wanted him to take part in the midwife visits, the father also had to prioritise other matters. With the mother’s agreement, the father sometimes prioritised work and, in the case of experienced parents, other children. Fathers described their involvement as doing what the mother said he should do; from his perspective, she was considered to bear the main responsibility for the home and family. One father described how he took more responsibility during the pregnancy than previously: I try to take as much responsibility as I can concerning both her career, her working life, her social life, and as a parent, I try to help her and make things easier for her as much as possible . . . it’s always a matter of a compromise. (Samuel)
The mothers’ description of her partner’s involvement in juggling everyday life was that they shared the workload. The father’s involvement and his additional responsibilities also meant that the parents had less time together, time © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1059–1068
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which they missed. When they did have opportunities to spend time together, it was impacted by her fatigue and stress at not being able to manage life as she had before. The parents described pressures that were sometimes troublesome. Even though they realised that life would be more difficult to manage after the birth, it was a joint decision to have a child. The parents described how they had waited and longed for the arrival of their child, even at the cost of their closeness and their time together. As one mother described: And yet we both feel that’s a price to pay, we were prepared for that before we decided to have children . . . That’s the way things are, something of the purpose of life. But this real closeness, being together, hugging one another, kissing each other, having sex or . . . there’s much less, that has changed. (Elisabeth)
Discussion Our theme of ‘Paddling upstream’ provides a greater understanding of parents’ experiences of the involvement of fathers during pregnancy. The main finding from our analysis of interviews with both expectant fathers and mothers was that the father was expected to be involved early in the pregnancy. Both parents described how the father tried to live up to these expectations and that he was the best support for the mother. However, he did not always know what to do and was dependent on the mother. As the mother was the one carrying the child, it is natural that he could not be as involved as she was. The parents described the father’s involvement as a struggle, as he encountered barriers on the pregnancy journey. One barrier was described as a lack of support from the prenatal care system from which the parents expected to receive support during the pregnancy. These professionals seemed to address the needs of the expectant mother and the child, rather than the whole family. It is evident that maternal services have difficulty reaching men. The WHO (2007) suggests that health professionals should facilitate changes that make men more active, equal and participating, leading to greater well-being for the whole family. Society is often described as a patriarchal system, in which men have the power and women are discredited. Looking at the prenatal care system as a microcosm of society, we find that it too excludes one sex, only it is an inverted system. A gendered pattern shows that even if fathers are invited to attend parental education and prenatal care visits, and they want to be involved during the pregnancy, fathers are not as included as mothers (Fenwick et al. 2012). We found that fathers did not always feel wel© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1059–1068
Fathers’ involvement during pregnancy
come and that they sometimes felt ignored and excluded from antenatal care, a finding consistent with other studies (Leite 2007, Deave et al. 2008), even though maternal healthcare should provide support for both parents in preparing for childbirth and parenting (Andersson-Ellstr€ om 2008). The antenatal care and parental education system is often described as a ‘matriarchy’, with predominantly female midwives working in a traditionally female-dominated area. Our findings reflect both gendered norms in society and gendered roles in families, a point also made by Connell (2009); on the other hand, there is an obvious sex difference in pregnancy, since the foetus develops within the woman. The man’s expected participation is to support his partner during the pregnancy, and his focus in a supporting role is to create optimal conditions for the woman and their child or children. Consistent with our findings, others have reported that parents are dissatisfied with their prenatal support (e.g. Edvardsson et al. 2011). Although Sweden is a leading country for parents, and close to a ‘gender revolution’ (Evertsson 2014) with one of the most extensive and egalitarian parental leave policies (Ray et al. 2010), parents in our study, as in others (Edvardsson et al. 2011, Plantin et al. 2011), described the father as an outsider. The father’s invisibility is noteworthy in the light of evidence that active involvement by the father leads to beneficial health effects for him, his partner and their child (WHO 2007, Plantin et al. 2011). Consistent with sex differences, this can be a result of gender roles in the family (Connell 2009), where expectations of ‘new’ equal gender roles are in opposition to embedded sex differences in relation to pregnancy. Another barrier was different parent expectations. Mothers expected fathers to understand their needs implicitly, without their having to communicate them, which has also been described during postpartum (Negron et al. 2013). Furthermore, fathers expected the mother to have the main responsibility for the home and family, consistent with Connell’s (2009) finding that women possess more power in the family. For example, in our study, in preparing for their child, the man did what the woman told him to do and trusted her because he felt that she had primary responsibility. Furthermore, when the woman did not communicate her needs to her partner, he did not always discover them. This inadequate communication could be one of the contributing factors to why mothers experience more stress related to paid work, and have more control over household duties and a higher total workload than fathers (Berntsson et al. 2006, Strandh & Nordenmark 2006),
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which could impair the health of mothers and families. The father’s health is also enhanced, as he develops a stronger attachment to the baby (WHO 2007). Fenwick et al. (2012) reported that fathers experienced the pregnancy as unreal and struggled to be fully involved. However, the parents in our study described different approaches to securing greater paternal involvement. First, early involvement during pregnancy was important. Redshaw and Henderson (2013) suggest a first contact with health professionals before the 12th week of pregnancy. Second, the ultrasound examination made the pregnancy more real, as other studies (Fenwick et al. 2012, Asenhed et al. 2013) have found. Third, the expectant father should be given opportunities to gather information related to his questions, needs and desires, to develop competence and confidence. Our proposal is confirmed by Alio et al. (2013), who suggest that fathering courses be offered to increase paternal parenting confidence. Fathers’ involvement during pregnancy has been positively associated with co-parenting when the child is born (Fagan 2014). Therefore, co-parenting issues are important to discuss during pregnancy to prepare couples for parenthood (Feinberg 2002). Our study demonstrates, as have others (Edvardsson et al. 2011, Alio et al. 2013), that women and men perceived pregnancy as a shared responsibility and that the man’s role is important, as illustrated by our metaphor of ‘Paddling upstream’. Both the fathers and the mothers in our study expected the fathers to play an active part from early on in the pregnancy. Further, the mothers in our study described their partners’ support as unique, since he best understood her, as another study (May & Fletcher 2013) has shown. This may reflect the shift in focus that the WHO (2006) describes as happening when men take more responsibility for the family, although fathers in our study still identified the mothers as having primary responsibility. Both parents’ participation in parental education classes facilitates the man’s engagement and transition to parenthood (Ahlden et al. 2012), which can make the pregnancy more real for both fathers and mothers. In sum, prenatal visits and education classes must be more inclusive and welcoming towards fathers. The challenge is to develop programmes to support fathers’ involvement and to create forums in which midwives learn about gender issues. Male educators may be an important factor towards greater equality. To help fathers and make the pregnancy more real for them, new and convenient techniques such as Internet-based parent education (WHO 2007) may hold potential. Finally, making prenatal care
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appointments and parental education classes available during evenings and weekends may facilitate fathers’ participation.
Methodological considerations One strength of this study was its inclusion of expectant fathers as well as mothers, even though there were more mothers (n = 20) than fathers (n = 10). Although our goal was to include a wide perspective, one weakness may have been our inclusion of both first-time and experienced parents, as well as both Swedish and non-Swedish speakers. These groups’ experiences may differ in ways that were overlooked here. The use of an interpreter was valuable and allowed interviews of a broader range of parents, but individuals who participated through interpreters may have been limited in what they were able to share. We are aware that there are different configurations of families, but to achieve our aim in this study we included only mothers and fathers from a traditional family constellation. Further studies should be carried out of family forms other than the traditional mother–father form, such as single parents or same-sex families. Data collection consisted of both FGIs and individual interviews, with a view to broadening the study (O’Hagan et al. 2013). It was a strength to be able to offer both options. Some individuals felt more comfortable in an individual interview than in an FGI, so these methods complemented each other (Kaplowitz & Hoehn 2001). However, as FGIs aim to generate discussion and negotiation on a topic, while individual interviews aim for in-depth probing, it might be problematic to view the data collected by the two methods as homogeneous. Nevertheless, the results from the two types of interviews revealed similar content and did not contradict each other. With individual interviews conducted by a midwife (first author), there is always a risk that they will develop into educational or therapeutic conversations. However, the interviewer always sought to guide the discussion to maintain the purpose of the interview. The trustworthiness of the results was improved in several ways. The interviews were based on the same interview guide, and the transcribed interviews were discussed by the research team. The first and last authors compared the steps in the analysis, and the emerging categories and sub-themes were discussed by all authors. Appropriate quotations from the interviews, translated from Swedish into English by a professional native translator, were used. Finally, the participants, the data collection procedure and the analysis steps were carefully described. © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1059–1068
Original article
Fathers’ involvement during pregnancy
Conclusion
Acknowledgements
The expectant mothers and fathers wanted the father to be more involved during the pregnancy and he tried to be so in different ways. He did not always perceive what was expected of him by the mother or the community and encountered many barriers around which he tried to navigate. The best support for the father was the mother. Both parents wanted their care providers to be more inclusive of the father and to consider the man an asset in their efforts to serve the whole family.
Relevance to clinical practice This study will be useful for midwives and other healthcare professionals seeking to integrate the father throughout pregnancy and childbirth, with benefits for the future child and family. In their support, professionals can overcome barriers that prevent the expectant father’s involvement and make the pregnancy a more real experience. Even though fathers are not able to engage fully due to biological limitations, we suggest that the expectant father’s specific needs should be included through an increased awareness of gender norms.
We thank all the participating expectant mothers and fathers.
Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; and (3) final approval of the version to be published.
Conflicts of interest The authors have no conflict of interest to declare.
Funding The study was supported by grants from the County Council of V€ astmanland, Sweden.
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Statistiska centralbyr an (Statistics Sweden) (2013) Allt fler mammor jobbar heltid (More and more mothers are working full-time). Available at: http://www.scb. se/sv_/Hitta-statistik/Artiklar/Allt-flermammor-jobbar-heltid/ (accessed 5 March 2014). Strandh M & Nordenmark M (2006) The interference of paid work with household demands in different social policy contexts: perceived work–household conflict in Sweden, the UK, the Netherlands, Hungary, and the Czech Republic. British Journal of Sociology 57, 597–617. Wells MB, Varga G, Kerstis B & Sarkadi A (2013) Swedish child health nurses’ views of early father involvement: a qualitative study. Acta Paediatrica 102, 755–761. WHO (2006) The role of men in promoting gender equality. Available at: http://www.who.int/gender/topics/role_ of_men/en/ (accessed 26 March 2014). WHO (2007) Fatherhood and health outcomes in Europe. Available at: http:// www.euro.who.int/__data/assets/pdf_ file/0017/69011/E91129.pdf (accessed 10 November 2012). Widarsson M, Kerstis B, Sundquist K, Engstr€ om G & Sarkadi A (2012) Support needs of expectant mothers and fathers: a qualitative study. Journal of Perinatal Education 21, 36–44.
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This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
‘Paddling upstream’: Fathers’ involvement during pregnancy as described by expectant fathers and mothers Margareta Widarsson, Gabriella Engstr€ om, Tanja Tyden, Pranee Lundberg and Lena Marmst al Hammar
Aims and objectives. To describe the perspectives of expectant mothers and fathers on fathers’ involvement during pregnancy. Background. Becoming a father is a major life event and paternal involvement during pregnancy has a positive influence on the family. However, research into both expectant mothers’ and fathers’ perspectives on fathers’ involvement during pregnancy is relatively scarce. Design. A descriptive qualitative study was used. Methods. Thirty expectant parents (20 women and 10 men) were interviewed either as part of one of four focus groups or in an individual interview. Qualitative content analysis was performed on the interview transcripts. Results. A theme of ‘Paddling upstream’ emerged as an expression of the latent content of the interviews concerning perspectives on fathers’ involvement. Five sub-themes described the manifest content: trying to participate, trying to be understanding, trying to learn, trying to be a calming influence and trying to find a balanced life. Expectant parents suggested several ways to improve fathers’ involvement and to meet parents’ need for shared involvement. Conclusion. Expectant mothers and fathers wanted the father to be more involved in the pregnancy. Although fathers attempted different strategies, they did not always perceive what was expected of them and encountered many barriers as they tried to navigate through this unique experience. The best support for the father was the mother. Expectant parents wanted their healthcare to include the father more thoroughly and to focus on the whole family. Relevance to clinical practice. Prenatal care professionals can overcome barriers that prevent paternal involvement. Although fathers are not able to engage in the pregnancy on the same level as the mother, we suggest that their specific needs also be recognised through an increased awareness of gender norms in healthcare.
Authors: Margareta Widarsson, MNursSci, RN, RM, Med LIC, Doctoral Student, Centre for Clinical Research, Uppsala University, V€astmanland County Hospital, V€aster as, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden; Gabriella Engstr€ om, RN, PhD, Associate Professor, Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida, USA; Tanja Tyden, RM, PhD, Professor, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden; Pranee Lundberg, RN, RM, PhD, Associate Professor,
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1059–1068, doi: 10.1111/jocn.12784
What does this paper contribute to the wider global clinical community?
• Expectant mothers and fathers
•
•
wanted the father to be more involved during the pregnancy, but encountered many barriers to such involvement. To facilitate fathers’ involvement, healthcare professionals should determine expectant fathers’ specific needs and help them overcome barriers. In promoting the progress of gender equality, we found it important – from both the paternal and maternal perspectives– for the father to be involved during the pregnancy. Shared involvement is important for their preparation for parenthood. The present study is a useful description for midwives and other healthcare professionals of how fathers can be involved during pregnancy.
Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden; Lena Marmst al Hammar, RN, PhD, Senior Lecturer, School of Health, Care and Social Welfare, M€ alardalen University, V€ aster as, Sweden Correspondence: Margareta Widarsson, Doctoral Student, Centre for Clinical Research, V€ astmanland County Hospital, S- 721 89 V€ aster as, Sweden. Telephone: +46 21 174102. E-mail: [email protected]
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Key words: antenatal care, content analysis, expectant fathers, expectant mothers, involvement, prenatal care Accepted for publication: 19 December 2014
Introduction Becoming a father is a major life event. For some, the transformative process may begin as soon as the pregnancy is confirmed; for others, it may occur when they hold their newborn child for the first time. This transition into fatherhood is complex and is described as a time of joy and hope as well as of confusion and frustration (Asenhed et al. 2013). Paternal involvement during pregnancy can positively influence health outcomes for the partner, the child and the father himself (Plantin et al. 2011), and most fathers demand to be involved in facilitating the well-being of their child and partner (Redshaw & Henderson 2013). This involvement is also insisted on by expectant mothers (Widarsson et al. 2012, Alio et al. 2013).
Background The father wants to support his partner’s positive perinatal experience (Fenwick et al. 2012, Alio et al. 2013), as well as to maintain a strong family (Lindberg & Engstr€ om 2013). However, fathers sometimes fall into a secondary role during pregnancy and may feel excluded from a largely maternal domain following childbirth. This can be problematic for both the father and the mother (Wells et al. 2013), and a lack of effective and engaging interactions with healthcare professionals can leave men feeling frustrated and distressed (Fenwick et al. 2012). There is a need to determine why fathers feel excluded during pregnancy, in spite of the pregnancy being about his child as well. The development of effective intervention strategies to address these deficiencies depends on such insight. Women commonly spend a greater portion of time caring for the children and family, which may reflect gendered norms and roles in both society and families (Connell 2009). On the other hand, there are inherent sex differences due to the woman carrying the foetus (Bird & Rieker 1999). Social and cultural norms, as well as policies and practices, have changed in recent decades. This has resulted in a shift in focus that promotes gender equality, from women’s empowerment to the roles and responsibilities of men (WHO 2006). However, healthcare-services have difficulty increasing fathers’ involvement in educational programmes, with the result that
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men can be less prepared for parenting than women (WHO 2007). Official Swedish gender equality policy regards women and men as having the same rights, obligations and opportunities in important life domains (Nationalencyklopedin 2014). This development of greater equality, including in the area of childcare, has been described as Sweden coming close to a ‘gender revolution’, in which the differences between fathers and mothers are gradually being reduced (Evertsson 2014). These changes are likely facilitated by the similar employment rates of 92% for fathers and 82% for mothers, (Statistiska centralbyr an 2013). Sweden also has one of the most extensive and egalitarian parental leave policies in the world (Ray et al. 2010), allowing 480 days of leave from work per child; these days are to be used up to the time the child is 12 years old, and may be shared between the parents (F€ ors€ akringskassan 2014). Despite this gender equality progress, mothers report more stress from paid work, conflicting demands and a greater overall workload than do fathers (Berntsson et al. 2006, Strandh & Nordenmark 2006). Mothers also report more control over household duties and total workload than fathers, who focus mainly on their paid work and seem fairly resistant to feelings of conflicting demands (Berntsson et al. 2006). The aim of maternal healthcare in Sweden is reproductive health for both men and women, implying that maternal healthcare provides assistance in parenting and support for both parents along with maternal childbirth preparations (Andersson-Ellstr€ om 2008). However, parents are dissatisfied with the antenatal support they receive (Edvardsson et al. 2011), in which men do not feel involved by midwives (Hildingsson & Sj€ oling 2011) and experience traditional gender roles as shortcomings in parental education (Edvardsson et al. 2011). Studies often focus on mothers’ and seldom on fathers’ experiences of pregnancy. The aim of this study, therefore, was to describe the perspectives of expectant mothers and fathers on the involvement of fathers during pregnancy.
Methods The study had a qualitative design, using a qualitative latent content analysis, described by Graneheim and
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Fathers’ involvement during pregnancy
Lundman (2004), to analyse interviews with expectant fathers and mothers.
Participants and setting Participants were expectant fathers and mothers recruited (1) through an open hospital lecture describing obstetric facilities, (2) by a midwife serving newly arrived immigrants, and (3) by midwives at maternity care units. Interested individuals were contacted by telephone. Thirty expectant parents (20 women, 10 men) agreed to participate and signed informed consent forms. Twenty were firsttime parents (12 women, eight men). Participants were 21– 56 years of age (mean 30 years), all were living with their partner and 90% had completed at least high school. Pregnancy duration ranged from 13–39 weeks (median 34 weeks).
Data collection Data were collected through four focus group interviews (FGIs) (Krueger & Casey 2000) and 12 individual interviews (Kvale et al. 2009), conducted by the first author (Table 1). Swedish-speaking parents were given the opportunity to choose between an FGI and an individual interview; only individual interviews were available for non-Swedish-speaking participants. Two individual interviews were conducted in English and two through an interpreter. An observer assisted the FGI moderator with field notes during the FGI and a summary afterwards. FGIs lasted 71–109 minutes, included both first-time and experienced parents, and were conducted at the Centre for Clinical Research. The 12 individual interviews were carried out at the participant’s home or a community centre, based on the participant’s preference. The individual interviews lasted 31–65 minutes. The opening question in each focus group Table 1 Characteristics of participants in the four focus group interviews and the 12 individual interviews
Number of participants Women Men Swedish speakers Non-Swedish speakers First-time parents Not first-time parents
Focus group interviews
Individual interviews
12 6 18 0
8 4 8 4
13 5
7 5
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or individual interview was ‘Please tell us about your experiences becoming a father/mother’. This question was followed up with probing questions to steer the interviews towards the aim of our study (Polit & Beck 2008). After the interviews the first author, the observer, or the participants made a short summary, and the participants had the opportunity to verify the content (Krueger & Casey 2000).
Data analysis All interviews were analysed using qualitative content analysis according to Graneheim and Lundman (2004). Each audiotaped interview was transcribed verbatim and read several times to develop an overview. The analysis process began by highlighting sentences of importance. These sentences were first divided into meaning units. Second, the meaning units were condensed and labelled with short codes. Third, the codes were compared to identify similarities and differences. Fourth, categories were developed based on the codes, which included the manifest content, or what the text communicated. Fifth, a comparison and interpretation of the categories was undertaken, from which the five sub-themes were developed. The sub-themes are the underlying meanings of the categories, that is, expressions of the latent content on an interpretative level. Finally, the sub-themes formed one theme: (Table 2).
Ethics The Research Ethics Committee at Uppsala approved the study (Dnr: 247-2008).
Results From the analysis, a theme of ‘Paddling upstream’ emerged as a description of paternal involvement during pregnancy. This theme was built up from five sub-themes (Fig. 1). To maintain confidentiality, pseudonyms are used in the results section.
Theme: ‘Paddling upstream’ This theme is a metaphor for the expectant parents’ perspectives on the involvement of fathers during pregnancy. The parents wanted the father to be involved, but he was described as struggling to achieve that involvement. He faced many barriers, which are described in this section. The metaphor of ‘Paddling upstream’ – trying to make headway against the flow of a river – mirrors this struggle. He moves forward, but has to expend a lot of energy to
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M Widarsson et al. Table 2 Content analysis of transcribed data from all interviews with 30 expectant fathers and mothers. Examples of meaning units, condensed meaning units, codes, categories, sub-themes and theme Meaning unit
Condensed meaning unit
Code
Categories
Sub-themes
Theme
Reducing anxiety, calming things down. Because in most cases things work out well. On such forums, they don’t say that things go well for 1000 and then that they go badly for one, they talk about the times things go badly, or about complications. I’m more of a reducer of anxiety I try to take as much responsibility as I can concerning both her career and her working life, and her social life, and as a parent, and I try to help her and make things easier for her as much as possible. . . it’s always a matter of a compromise
Reducing anxiety, calming down. Most things work out well. On the forums, they don’t say things go well for 1000 and badly for one, they talk about things go badly, or about complications. I’m a reducer of anxiety
Ease anxiety
Anxiety reducer
Trying to be a calming influence
Paddling upstream
I take as much responsibility as I can concerning her career, working life and social life. I help her and make things easier for her as much as possible. It’s always a compromise
Take practical responsibility
Responsibility taker
Trying to find a balanced life
Paddling upstream
Trying to be understanding Trying to participate Trying to be a calming influence Trying to learn Trying to find a balanced life Figure 1 Theme and sub-themes revealed by the qualitative content analysis of interviews with 30 expectant fathers and mothers in Sweden.
battle against the current. The father, then, faced numerous obstacles to being involved. He often felt that the pregnancy was not quite real, as he could not feel the baby’s movements or see his own body changing as the mother was able to do. However, fathers tried to be present in more practical ways, such as managing practical matters. They had to try to work out what the mother wanted, as she did not clearly express her needs. On visits to the midwife, the father felt overlooked and superfluous, making other support groups such as friends and social media
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necessary as a source of the knowledge needed to facilitate involvement. Difficulty being away from work or arranging babysitting for siblings commonly hindered participation in healthcare visits. Fathers also worried about the mother’s pregnancy, planned for the coming child, and were excited to reach the end of the pregnancy journey.
Trying to participate The fathers wanted to participate in the pregnancy and tried to do so in different ways. Even though the mother was carrying the foetus, both parents described the pregnancy as an unreal experience, in the sense that, although they knew there was a baby, they could not see it. This meant that being fully involved was even more difficult for the father. One woman described how she wished the father would be a greater part of what was happening: He thinks it’s a real drag, not getting to experience the pregnancy. He thinks it’s so unfair, so he just lies there and as soon as there’s any kicking, there he is, feeling and listening. (Marie)
One way for the father to participate was to accompany his partner on visits to the midwife. Parents described this as a form of support for the mother and said that the father’s support was unique because he knew her best, but also that the father wanted support as well. As one father described his situation: © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1059–1068
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Fathers’ involvement during pregnancy
I really want to be there [on visits to the midwife], because I want
was . . . ‘But you shouldn’t be doing anything, go and lie down and
to participate as much as I can – there’s already that distance
take it easy, try to unwind’ [said her husband]. (Miriam)
between [my wife] and me as the child’s parents, in that she’s the one who’s carrying the baby. (Samuel)
Yet when the father accompanied his partner on these visits, he did not feel welcome, since the information and communication was directed at the mother. One mother commented: The midwife hardly said hello to him, and then there was just a
Despite the woman becoming more irritated due to the pregnancy, she nevertheless experienced greater understanding from the father. The father, though, did not always find this easy to manage. Nonetheless, the mothers described the fathers as more attentive, thoughtful and understanding, even though the mothers themselves expressed that they did not always deserve this. One mother explained:
conversation between me and the midwife. So he wondered after-
My husband supports me most of all. He’s so understanding and
wards, why was I there at all, the midwife treated me like air . . . it
really incredible. For many friends, from what I’ve heard, the men
was as if she didn’t have a single question for him, she never once
haven’t really understood why you are perhaps a bit more irritable
spoke to him. (Noomi)
and that things are more difficult. (Brigit)
Another way for the father to participate was during the ultrasound examination. Even if the father was a bystander at this exam, the parents described the ultrasound as a turning point when the pregnancy became more real for them both. Parents described an invisible shared bond that joined them and strengthened their relationship. After this experience, the father began to experience the pregnancy in a different way and took more responsibility in preparations for the delivery, including practical measures such as purchasing items for the child, which he had not done before. One mother said:
Fathers tried to be understanding of the mothers’ irritation or strange behaviour because it was described as something that was normal for pregnancy. The men realised that they could not psychologically experience being pregnant, so they simply tried to understand.
It was great when he suggested things. Let’s go and buy a buggy, and now it’s time to buy a cot, and we’re not going to be stingy when it comes to the mattress. That’s when I begin to see that he thinks this is very important. (Tabita)
Trying to learn Fathers wanted to prepare themselves by learning about pregnancy, delivery and parenthood. They tried to show their involvement by taking part in midwife visits, parenting classes, father classes, and psychoprophylaxis courses. The courses for fathers were particularly appreciated as they provided an opportunity to converse with other fathers. One mother said: Perhaps it should be a bit more obligatory to have a fathers’ group as well, where they’re on their own in some way and able to talk
Trying to be understanding Fathers described how the pregnancy made their partner more important to them and how they cared for her more than before the pregnancy. Fathers reported trying to be understanding by giving the woman psychological support and taking care of household matters, which was a great relief to the mother. Despite these efforts, fathers were not always successful because the mother did not always express her needs, but expected him to notice those needs. When the father was successful in his attempt to be understanding and noticed his partner’s needs, she felt looked after and happy. To the mother, this meant hope for the future, that he would take responsibility for the family. One mother described the father’s attempt to be understanding: I ran to catch a bus, I felt it was a very stressful thing for me. When I got home, I felt I was tired and I told him how incredibly stressed I
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about their thoughts and . . . worries. I’m sure it’s not easy for them either to have a grumbling woman at home [laughter] . . . in that way they could perhaps come closer and be involved in a different way in the pregnancy. (Rebecca)
As a way to learn about pregnancy and childbirth, the fathers spoke of their need to meet other expectant fathers and mothers. Most appreciated parental groups that encouraged active participation and in which the father could gather information. An especially valuable parenting group was the psychoprophylaxis course at which fathers were able to gather practical knowledge in preparation for the delivery. This provided an opportunity for the parents to communicate about the upcoming delivery and to learn about breathing and relaxation. Parents experienced this as a very good way to get the father to be a part of the pregnancy and the preparations for the approaching delivery. One father noted:
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M Widarsson et al. If we hadn’t taken the psychoprophylaxis course, we actually wouldn’t have known anything. I think that’s rather a pity. I have a pretty good idea of things, after the previous times, both the prophylaxis course and the parent group, I think I’ll be well equipped. (David)
When questions arose about pregnancy, childbirth and parenthood, the father commonly asked the mother for information first and after that would consult friends who had children. In addition, the fathers tried to learn and prepare themselves by seeking knowledge on the Internet and from books, newspapers and personal contacts. However, fathers considered it important not to gather too much information, because they did not feel they had the competence to identify which information was most relevant. One father commented: This inner anxiety about am I doing enough for my child, am I adequately prepared, am I searching for too little information, or too much information, is it good information, what do I think of all this? To sift through it all and arrive at something that suits me, or us. (John)
Trying to be a calming influence Fathers showed their involvement by trying to calm the mothers’ inevitable anxieties. They described reassuring their partner when something disturbed her, discussing issues with her, and giving comforting hugs when needed. Fathers wanted to facilitate for the mother, be a balancing factor when she was anxious about what might happen during the pregnancy and delivery. This role became clear when it came to information on the Internet, and various forums for chatting in which the mothers took part. The father took part when the mother brought up something from a forum, although he may have felt that she should avoid these venues and should realise that she had limited control over pregnancy and delivery situations. Fathers felt that chat forums focused on complications and horror stories. One father described his role: Reducing anxiety, calming things down. Because in most cases things work out well. On such forums, they don’t say that things go well for 1000 and then that they go badly for one, they talk about the times things go badly, or about complications. I’m more of a reducer of anxiety. (Levi)
Fathers tried to be a calming influence by reassuring and encouraging mothers when they described their fears about the delivery. They felt she should prepare herself better by reading and preparing mentally for what was going to hap-
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pen. While the father tried to calm the mother, she described that she did not feel confident that he himself would cope with the delivery. One mother reflected: And I don’t know, he’s like, ‘Yes, but I’m so calm’, and ‘This is going to go well, I’ll cope with this and the delivery. It’s going to go really well.’ And I just picture him, you know, passing out there. (Marie)
When fathers tried to soothe their partner by reflecting on what would take place at the delivery and thereafter, mothers found this to be quite reassuring. Mothers described how the father took part by listening when she described what made her fearful, and by being present to relieve her anxiety. Fathers, who themselves were worrying, tried not to show this to the mother, even when she was aware of his anxiety. As one mother said: It’s wonderful, especially when you have a wonderful husband who helps you and gives you hope and a sense of security, who helps you to feel safe. I have to carry the child within me, but the father is around me and if he doesn’t give me enough peace, attention and involvement the baby will feel it. (Lisa)
Trying to find a balanced life The fathers were described as taking part in trying to balance their and their partner’s lives, including work, careers and leisure activities, and for some, children as well. Finding sufficient time for everything was described as difficult. Some situations were discussed with other parents, with a goal of gaining support for the situation. Even though fathers wanted to be involved in the pregnancy, and both parents explained that they wanted him to take part in the midwife visits, the father also had to prioritise other matters. With the mother’s agreement, the father sometimes prioritised work and, in the case of experienced parents, other children. Fathers described their involvement as doing what the mother said he should do; from his perspective, she was considered to bear the main responsibility for the home and family. One father described how he took more responsibility during the pregnancy than previously: I try to take as much responsibility as I can concerning both her career, her working life, her social life, and as a parent, I try to help her and make things easier for her as much as possible . . . it’s always a matter of a compromise. (Samuel)
The mothers’ description of her partner’s involvement in juggling everyday life was that they shared the workload. The father’s involvement and his additional responsibilities also meant that the parents had less time together, time © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1059–1068
Original article
which they missed. When they did have opportunities to spend time together, it was impacted by her fatigue and stress at not being able to manage life as she had before. The parents described pressures that were sometimes troublesome. Even though they realised that life would be more difficult to manage after the birth, it was a joint decision to have a child. The parents described how they had waited and longed for the arrival of their child, even at the cost of their closeness and their time together. As one mother described: And yet we both feel that’s a price to pay, we were prepared for that before we decided to have children . . . That’s the way things are, something of the purpose of life. But this real closeness, being together, hugging one another, kissing each other, having sex or . . . there’s much less, that has changed. (Elisabeth)
Discussion Our theme of ‘Paddling upstream’ provides a greater understanding of parents’ experiences of the involvement of fathers during pregnancy. The main finding from our analysis of interviews with both expectant fathers and mothers was that the father was expected to be involved early in the pregnancy. Both parents described how the father tried to live up to these expectations and that he was the best support for the mother. However, he did not always know what to do and was dependent on the mother. As the mother was the one carrying the child, it is natural that he could not be as involved as she was. The parents described the father’s involvement as a struggle, as he encountered barriers on the pregnancy journey. One barrier was described as a lack of support from the prenatal care system from which the parents expected to receive support during the pregnancy. These professionals seemed to address the needs of the expectant mother and the child, rather than the whole family. It is evident that maternal services have difficulty reaching men. The WHO (2007) suggests that health professionals should facilitate changes that make men more active, equal and participating, leading to greater well-being for the whole family. Society is often described as a patriarchal system, in which men have the power and women are discredited. Looking at the prenatal care system as a microcosm of society, we find that it too excludes one sex, only it is an inverted system. A gendered pattern shows that even if fathers are invited to attend parental education and prenatal care visits, and they want to be involved during the pregnancy, fathers are not as included as mothers (Fenwick et al. 2012). We found that fathers did not always feel wel© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1059–1068
Fathers’ involvement during pregnancy
come and that they sometimes felt ignored and excluded from antenatal care, a finding consistent with other studies (Leite 2007, Deave et al. 2008), even though maternal healthcare should provide support for both parents in preparing for childbirth and parenting (Andersson-Ellstr€ om 2008). The antenatal care and parental education system is often described as a ‘matriarchy’, with predominantly female midwives working in a traditionally female-dominated area. Our findings reflect both gendered norms in society and gendered roles in families, a point also made by Connell (2009); on the other hand, there is an obvious sex difference in pregnancy, since the foetus develops within the woman. The man’s expected participation is to support his partner during the pregnancy, and his focus in a supporting role is to create optimal conditions for the woman and their child or children. Consistent with our findings, others have reported that parents are dissatisfied with their prenatal support (e.g. Edvardsson et al. 2011). Although Sweden is a leading country for parents, and close to a ‘gender revolution’ (Evertsson 2014) with one of the most extensive and egalitarian parental leave policies (Ray et al. 2010), parents in our study, as in others (Edvardsson et al. 2011, Plantin et al. 2011), described the father as an outsider. The father’s invisibility is noteworthy in the light of evidence that active involvement by the father leads to beneficial health effects for him, his partner and their child (WHO 2007, Plantin et al. 2011). Consistent with sex differences, this can be a result of gender roles in the family (Connell 2009), where expectations of ‘new’ equal gender roles are in opposition to embedded sex differences in relation to pregnancy. Another barrier was different parent expectations. Mothers expected fathers to understand their needs implicitly, without their having to communicate them, which has also been described during postpartum (Negron et al. 2013). Furthermore, fathers expected the mother to have the main responsibility for the home and family, consistent with Connell’s (2009) finding that women possess more power in the family. For example, in our study, in preparing for their child, the man did what the woman told him to do and trusted her because he felt that she had primary responsibility. Furthermore, when the woman did not communicate her needs to her partner, he did not always discover them. This inadequate communication could be one of the contributing factors to why mothers experience more stress related to paid work, and have more control over household duties and a higher total workload than fathers (Berntsson et al. 2006, Strandh & Nordenmark 2006),
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which could impair the health of mothers and families. The father’s health is also enhanced, as he develops a stronger attachment to the baby (WHO 2007). Fenwick et al. (2012) reported that fathers experienced the pregnancy as unreal and struggled to be fully involved. However, the parents in our study described different approaches to securing greater paternal involvement. First, early involvement during pregnancy was important. Redshaw and Henderson (2013) suggest a first contact with health professionals before the 12th week of pregnancy. Second, the ultrasound examination made the pregnancy more real, as other studies (Fenwick et al. 2012, Asenhed et al. 2013) have found. Third, the expectant father should be given opportunities to gather information related to his questions, needs and desires, to develop competence and confidence. Our proposal is confirmed by Alio et al. (2013), who suggest that fathering courses be offered to increase paternal parenting confidence. Fathers’ involvement during pregnancy has been positively associated with co-parenting when the child is born (Fagan 2014). Therefore, co-parenting issues are important to discuss during pregnancy to prepare couples for parenthood (Feinberg 2002). Our study demonstrates, as have others (Edvardsson et al. 2011, Alio et al. 2013), that women and men perceived pregnancy as a shared responsibility and that the man’s role is important, as illustrated by our metaphor of ‘Paddling upstream’. Both the fathers and the mothers in our study expected the fathers to play an active part from early on in the pregnancy. Further, the mothers in our study described their partners’ support as unique, since he best understood her, as another study (May & Fletcher 2013) has shown. This may reflect the shift in focus that the WHO (2006) describes as happening when men take more responsibility for the family, although fathers in our study still identified the mothers as having primary responsibility. Both parents’ participation in parental education classes facilitates the man’s engagement and transition to parenthood (Ahlden et al. 2012), which can make the pregnancy more real for both fathers and mothers. In sum, prenatal visits and education classes must be more inclusive and welcoming towards fathers. The challenge is to develop programmes to support fathers’ involvement and to create forums in which midwives learn about gender issues. Male educators may be an important factor towards greater equality. To help fathers and make the pregnancy more real for them, new and convenient techniques such as Internet-based parent education (WHO 2007) may hold potential. Finally, making prenatal care
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appointments and parental education classes available during evenings and weekends may facilitate fathers’ participation.
Methodological considerations One strength of this study was its inclusion of expectant fathers as well as mothers, even though there were more mothers (n = 20) than fathers (n = 10). Although our goal was to include a wide perspective, one weakness may have been our inclusion of both first-time and experienced parents, as well as both Swedish and non-Swedish speakers. These groups’ experiences may differ in ways that were overlooked here. The use of an interpreter was valuable and allowed interviews of a broader range of parents, but individuals who participated through interpreters may have been limited in what they were able to share. We are aware that there are different configurations of families, but to achieve our aim in this study we included only mothers and fathers from a traditional family constellation. Further studies should be carried out of family forms other than the traditional mother–father form, such as single parents or same-sex families. Data collection consisted of both FGIs and individual interviews, with a view to broadening the study (O’Hagan et al. 2013). It was a strength to be able to offer both options. Some individuals felt more comfortable in an individual interview than in an FGI, so these methods complemented each other (Kaplowitz & Hoehn 2001). However, as FGIs aim to generate discussion and negotiation on a topic, while individual interviews aim for in-depth probing, it might be problematic to view the data collected by the two methods as homogeneous. Nevertheless, the results from the two types of interviews revealed similar content and did not contradict each other. With individual interviews conducted by a midwife (first author), there is always a risk that they will develop into educational or therapeutic conversations. However, the interviewer always sought to guide the discussion to maintain the purpose of the interview. The trustworthiness of the results was improved in several ways. The interviews were based on the same interview guide, and the transcribed interviews were discussed by the research team. The first and last authors compared the steps in the analysis, and the emerging categories and sub-themes were discussed by all authors. Appropriate quotations from the interviews, translated from Swedish into English by a professional native translator, were used. Finally, the participants, the data collection procedure and the analysis steps were carefully described. © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1059–1068
Original article
Fathers’ involvement during pregnancy
Conclusion
Acknowledgements
The expectant mothers and fathers wanted the father to be more involved during the pregnancy and he tried to be so in different ways. He did not always perceive what was expected of him by the mother or the community and encountered many barriers around which he tried to navigate. The best support for the father was the mother. Both parents wanted their care providers to be more inclusive of the father and to consider the man an asset in their efforts to serve the whole family.
Relevance to clinical practice This study will be useful for midwives and other healthcare professionals seeking to integrate the father throughout pregnancy and childbirth, with benefits for the future child and family. In their support, professionals can overcome barriers that prevent the expectant father’s involvement and make the pregnancy a more real experience. Even though fathers are not able to engage fully due to biological limitations, we suggest that the expectant father’s specific needs should be included through an increased awareness of gender norms.
We thank all the participating expectant mothers and fathers.
Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; and (3) final approval of the version to be published.
Conflicts of interest The authors have no conflict of interest to declare.
Funding The study was supported by grants from the County Council of V€ astmanland, Sweden.
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