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A narrative review of parental education in preparing expectant and new fathers for early parental skills
Midwifery 84 (2020) 102644
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/locate/midw
Review Article
A narrative review of parental education in preparing expectant and new fathers for early parental skills Rosalind Lau∗, Ana Hutchinson School of Nursing & Midwifery, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia
a r t i c l e
i n f o
Article history: Received 5 October 2019 Revised 8 January 2020 Accepted 19 January 2020
Keywords: Fathers Fatherhood Parenting skills Parental education engagement Preparedness
a b s t r a c t Objective: To explore expectant and new fathers’ views of antenatal education classes in preparing them for early parenting skills. Design: This review used a narrative review approach. Search strategy of electronic databases includes Medline, CINAHL, ProQuest, Scopus and PubMed. Studies from 20 0 0 to 2018 reporting parental education in preparing early parenting skills for fathers only or if the studies were on both parents, and the results reported on the fathers were available were included in the review. Findings: There were two quantitative and four qualitative studies. Studies were from Sweden (n = 4), United Kingdom (n = 1), and Australia (n = 1). There were three phenomenographical studies and three exploratory descriptive studies. The three key themes that emerged for expectant and new fathers were experiencing feelings of exclusion, lack of postnatal education, and need for support services. Conclusions: The evidence suggests that the current parental education classes do not meet the needs of expectant and new fathers in early parenting skills. In order to provide expectant and new fathers with early parental skills, it is necessary to adapt the current education classes to include the needs of these men. Alternatively, to have men only classes. It is important for midwives to actively include and engage expectant and new fathers in parental education. This review has identified the need for further research and to develop strategies to involve more men in parental education. © 2020 Published by Elsevier Ltd.
Introduction It is widely accepted that much has changed in father’s engagement in parenting over the past 50 years. Studies on expectant and new fathers have found that they wanted to be actively involved in the pregnancy of their partner, childbirth and child care (Redshaw and Henderson, 2013; Smyth et al., 2015). Most expectant and new fathers participate in antenatal activities, are present at the birth of their newborn child, and engage in child care more than in the past (Fagerskiold, 2008; Halle et al., 2008). Studies have showed that fathers are taking more responsibility for child care than previously (Almqvist and Duvander, 2014; Chesters et al., 2009). A report found Generation Y fathers (men born between 1980 and 1994) seemed to be spending more time with their children than Generation X fathers (men born between 1965 and 1979) (Families and Work Institute, 2002).
∗
Corresponding author. E-mail addresses: [email protected] (R. Lau), [email protected] (A. Hutchinson). https://doi.org/10.1016/j.midw.2020.102644 0266-6138/© 2020 Published by Elsevier Ltd.
Father greater involvement in child care is reflected in government policies. In 2003, United Kingdom (UK) passed a law allowing fathers to have two weeks of paternity leave after the birth of the baby (UK Government (Open Government Licence v3.0)). A decade later, in 2013, the Australian government introduced paternal pay leave scheme allowing the father to take two weeks after the birth of the baby (Australian Government, 2009). In Sweden, all families have 13 months of parental leave after the birth of the baby, paid at 80% of their regular salaries, which can be shared in a range of ways between the parents (Anderson et al., 2016). The World Health Organization on health promotion interventions for maternal and newborn health 2015 recommends that expectant fathers are actively involved during pregnancy, childbirth and the postnatal period (World Health Organization, 2015). For many individuals, becoming a father is a significant event and transition to fatherhood is a challenging time for them (Billingham, 2011; Premberg and Lundgren, 2006). A metasynthesis of six qualitative studies on father’s experiences of their transition to fatherhood found three key themes: emotional reactions including feeling of detachment, surprise and confusion at different phases of their transition; their role as a provider for
2
R. Lau and A. Hutchinson / Midwifery 84 (2020) 102644
the family; and changes in their sense of self and relationship with their partner (Chin et al., 2011). Studies of new fathers found they encountered challenges from several fronts including their sense of self, balancing work and family obligations, relationship changes, and playing a secondary role to the mother (Crespi and Ruspini, 2015; Miller, 2011). Historically, antenatal parental education classes (PECs) focused on the needs and experiences of women during pregnancy, labour and a baby is born (Ahldén et al., 2012; Premberg et al., 2008). The needs of the expectant or new fathers are rarely addressed. Although PECs are offered in many countries, there is no consensus on the content nor the structure and the effectiveness of PECs for parenthood remained unknown (Gagnon and Sandall, 2007). Most antenatal classes focus on educating the expectant parents on processes of labour and childbirth, and little or no information is given to parenting skills (Entsieh and Hallström, 2016). In the past decades, men’s transition to fatherhood has gained increasing interest, however most PECs have focused on preparing men for labour and childbirth (Deave et al., 2008; Fletcher et al., 2004). There is a lack of research on the preparation for early parenting skills. The aim of this narrative review is to explore expectant and new fathers’ views of antenatal education classes in preparing them for early parenting skills. Methods The search strategy includes the following electronic databases for studies published from 20 0 0 to 2018: Medline, CINAHL, ProQuest, Scopus and PubMed. The year 20 0 0 was selected in order to identify the most recent studies on parental education in preparing expectant and new fathers for early parenting skills. Articles published in English language from 20 0 0 to 2018 reporting parental education in preparing early parenting skills for fathers only or if the studies were on both parents, and the results reported on the fathers were available, they were included in the analysis. Search terms include father, antenatal parental classes, postnatal parental classes, postpartum, postnatal, postnatal care, postpartum care, fatherhood, parenting skills. Quality and assessment of the studies We found six papers relevant for the review, of which two were quantitative and four were qualitative studies. The two reviewers (RL and AH) independently assessed the quality of the papers. There were no discrepancies between the two reviewers on the quality appraisal of the six papers and all papers were evaluated as having a high risk of bias as the study designs used did not allow for control of potential confounders. Data extraction and synthesis All the studies focused on various aspects of antenatal education. The data were extracted independently by two reviewers (RL and AH) focusing on preparation for parenting skills. Qualitative content analysis was used to synthesize the outcomes of the quantitative studies. The key themes reported in each of the qualitative studies were reviewed independently by two reviewers (RL and AH), to identify recurrent themes and sub-themes across the included studies. Finally the key findings of the two stages of data extraction were integrated to identify key themes that emerged reflecting new fathers’ experiences and expectations of parental education classes in preparing them for parenting skills. Results Fourteen studies were found but only six were included in the narrative review because the other seven studies were not
on parental education classes or the focus was on pregnancy and childbirth and not on early parenting skills. The studies Deave and Johnson (2008) and Deave et al. (2008) used the same data, hence only one study was included in this review. There were two quantitative and four qualitative studies. Studies were from Sweden (n = 4), United Kingdom (n = 1), and Australia (n = 1). Studies are presented in Table 1. There were three phenomenographical studies and three exploratory descriptive studies. Through the process of synthesising the findings of the six studies, three key themes emerged reflecting new fathers’ experiences and expectations of parental education classes. The three themes that emerged were experiencing feelings of exclusion, lack of postnatal education, and need for support services.
Experiencing feelings of exclusion New and expectant fathers who attended the antenatal or postnatal parental education classes often report feeling excluded during the sessions (Erlandsson and Häggström-Nordin, 2010; Hildingsson et al., 2013; Premberg and Lundgren, 2006). Fathers felt excluded because the classes were predominantly focused on the expectant woman’s needs. Fathers attended the classes primarily to accompany the woman and providing support (Erlandsson and Häggström-Nordin, 2010; Premberg and Lundgren, 2006). A study of Swedish fathers found PECs emphasised the role of the mother as a parent and did not emphasise father’s responsibility nor the importance of father’s involvement in the early stages of parenthood (Erlandsson and HäggströmNordin, 2010). This may perhaps explain why fathers did not see themselves as equal parent to the newborn and see themselves in a “secondary role” (Premberg and Lundgren, 2006).
Lack of postnatal education Expectant and new fathers were discontented with the information delivered at the PECs because no education was tailored to meet their needs (Premberg and Lundgren, 2006). In one Swedish study, 63% men felt the antenatal PECs prepared them for birth, however less fathers (43%) reported that the education prepared them for early parenthood (Hildingsson et al., 2013). This is supported by another Swedish study that there was a lack of postnatal education in parental classes (Erlandsson and Häggström-Nordin, 2010). This could explain why first-time fathers were lacking confident in caring for their newborns (Shorey et al., 2017). First-time fathers wanted information to prepare them for early postnatal care (Pålsson et al., 2017). They wanted information on their role as a new father and practical and general aspects of caring for their new baby (Pålsson et al., 2017; Premberg and Lundgren, 2006). For example, new fathers wanted basic information such as how to bathe the baby, how to interpret the baby’s cues, and how to support their partner during breastfeeding (Pålsson et al., 2017). One Swedish study suggested that sharing and discussing with other men was essential and would be beneficial (Premberg and Lundgren, 2006). One study from UK emphasised the importance for the expectant parents having the opportunity to meet other new parents, both before and after birth, to learn from their experiences about early parenthood (Deave et al., 2008). This is supported by the fathers who attended group antenatal sessions who felt that it was valuable to have had the opportunity to interact with and learn from their peers. Feeling and knowing that other expectant couples also experienced what they were going through was in itself a source of support and reassurance (Deave et al., 2008).
R. Lau and A. Hutchinson / Midwifery 84 (2020) 102644
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Table 1 Studies of parental education in preparing expectant and new fathers for early parental skills. Author and Country
Aim
Method
Pålsson et al. (2017); Southern Sweden
To describe first-time fathers experiences of their prenatal preparation in relation to challenges met in the early parenthood period.
Phenomenographical study Semi-structured interview First-time fathers were interviewed approximately one month after becoming fathers (n= = 15)
To explore first-time parents’ satisfaction with antenatal education and to explore its helpfulness in preparation for birth, early parenthood, and contact with other parents by comparing mothers’ and fathers’ experiences. To capture fathers’ conceptions of parental education topics, illuminated by their experiences as primary caregiver of their child immediately following birth
Survey First-time fathers (n= = 305)
Hildingssson et al. (2013); Northern region of Sweden
Erlandsson and Hȁggström-Nordin (2010); Sweden
Results
• Acquiring knowledge and forming realistic expectations
- caring for the baby in both health and illness - breastfeeding: more challenging than expected - still being a couple but not as before - being tired and bound - understanding emotional reactions • Developing strategies - adjusting priorities - acknowledging ones’ limitations - dealing with internal and external pressures - communicating with ones’ partner - forming a fatherhood identity • Being facilitated and supported - parental groups: the good and the bad - internet as an asset or a worrier - the need for guidance - information: the when and how
• 43% of the fathers reported that the antenatal education
was helpful for early parenthood • 24% reported having contact with other participants from
the antenatal education classes
Phenomenographical study Semi-structured interview between 8 days and 6 weeks postnatally (n= = 15)
• Exclusively prepares fathers for normal birth • Lack of information on complicated birth • Provide support to mother during labour and postnatally • Lack of information about maternal-infant separation
during complicated birth • Lack of information on postnatal care • Lack of emphasis on father as a parent
Deave et al. (2008); South-West England
To explore the needs of first-time parents in relation to the care, support and education during the antenatal period, particularly in relation to preparing for the transition to parenthood and their parenting skills
Cross-sectional study Semi-structured interviews Antenatally (last trimester) (n= = 20) Postnatally (3–4 months after the birth of the baby) (n= = 18)
• Few support systems • Lack of information specifically for new father • Excluded from antenatal appointments and classes. • Anxiety and feelings of exclusion around birth • Lack of practical and general information about baby-care • Lack of information to possible changes in relationships
with their partners Premberg and Lundgren (2006); South-West Sweden
To describe Swedish father’s experiences of childbirth education.
Phenomenological approach. Interviewed 2–4 months after birth (n= = 10)
• Experience of childbirth education classes is as a person
in a secondary role • Desire for information specifically addressed to fathers • Lack of opportunity to talk and share experiences with
other men in the same situation and in small groups Fletcher et al. (2004); New South Wales, Australia
To assess how well antenatal classes currently being offered in the Hunter region of New South Wales (NSW), Australia, are meeting men’s needs and, secondly, to assess new fathers’ familiarity with and use of support services.
Survey (completed some months postnatally) n= = 212 (95% were first-time fathers)
• Well-prepared for the birth • Well-prepared for the supportive role • Less well prepared for their relationship changes • Less well prepared for their lifestyle changes • Lack of awareness of family-related support services
Availability and awareness of support services
Discussion
The men identified their own partner, their colleagues and health professionals as the key people from whom they could seek support (Deave et al., 2008). There was a low level of awareness of family support services, with one Australian study finding that new fathers compared to new mothers were less familiar with these services and what they could offer (Fletcher et al., 2004).
This review explored the extent to which current antenatal parental education prepares expectant and new fathers for early parental skills. Transition to fatherhood is an important event for men as their societal role changes and they learn how to become a father. Several studies found that new fathers experienced a life change which included: being a father, providing financially for
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their family, caring for their newborn, alternating between work and home life, and developing a different relationship with their partner as well as the child (Chin et al., 2011; Fägerskiöld, 2008). Several studies have showed that paternal involvement in child care is associated with positive outcomes for the family (Redshaw and Heikkila, 2010; Shorey et al., 2016; Tikotzky et al., 2015). Positive family outcomes include improved maternal wellbeing and sleep (Redshaw and Henderson, 2013; Tikotzky et al., 2015), lower paternal stress and anxiety and biopsychosocial development benefits for the infants (Shorey et al., 2016). Studies suggest that PECs may not be as effective as they could be in preparing fathers for early parenting skills. Several studies suggest that fathers are not receiving the education or the support they needed in order to be involved in the postnatal care of their infant (Carlon et al., 2014; May and Fletcher, 2013). A Swedish study on expectant parents’ expectations about antenatal PECs found that most men expect PECs would help them feel more secure as a parent and in caring of their newborn (Ahlden et al., 2012). However, the evidence does not support this. A study in UK found first-time fathers felt alienated during the postnatal period (Ives, 2014). A metasynthesis found that there is a need to actively include expectant fathers in pre-and post-parental education classes, providing early and realistic information about parenting skills, and proving support during early postnatal period from health care professionals (Entsieh and Hallström, 2016). Health professionals should support both women and their partners in the transition to parenthood. However, several studies found that midwives tend to focus on the women and that men felt excluded (Deave et al., 2008; Huusko et al., 2018). A Swedish study found that expectant fathers expect to be involved in PECs (Anderson et al., 2016). Fathers wanted basic practical information in caring for their newborn (Pålsson et al., 2017). This may perhaps explain their lack of confidence in their early parental role. Most men recognised that the focus of antenatal education is on the needs of the woman, and this may be a barrier to men feeling able to participate more actively in the classes. Hence, they see themselves in a secondary role, merely to accompany and support their partner (Carlon et al., 2014; Deave and Johnson, 2008; Deave et al., 2008). A Department of Health in United Kingdom commissioned a review on parental education found provision of education to be variable, and brought a group of experts together to consider Preparation for Pregnancy, Birth and Beyond (PPBB) (Billingham, 2011). Drawing on the evidence, the PPBB group developed a list of six themes for the content of antenatal education program. The topics under the theme “Caring for my/our baby,” include: health of baby, keeping baby safe, bathing, minor illness and seeking help, cues of the baby, and feeding plan (Billingham, 2011). Other content for the PECs includes role and relationship changes, increased risk of mental distress and depression, and providing support to the mother (May and Fletcher, 2013). Traditionally antenatal parental education has been provided in mixed-gender groups, with strong focus on the needs of the expectant woman. To increase father involvement in postnatal care there is a need is to provide information more tailored to their needs and one option is to have men-only classes to address men’s needs. Two pilot studies, one in rural Australia and the other in Michigan, United States demonstrated that fathers-only antenatal groups could better help new and expected fathers to understand their fathering roles. These pilot studies found that men-only classes were a feasible option, either as stand-alone classes or incorporated into a group model (Deibel et al., 2018; Nash, 2018). The limitation of both these studies is the small sample size, and there is a lack of evidence regarding the feasibility and acceptability of providing men-only classes for expectant fathers on a larger scale. Hence, studies with larger sample size
are warranted. A review of parental education program found no evidence to suggest that a single program or delivery format was effective for all parents (Gilmer et al., 2016). However, there is evidence to suggest that for fathers, a male facilitator was more effective than a female one (Gilmer et al., 2016). Conclusions The evidence suggests that the current parental education classes do not meet the needs of expectant and new fathers in early parenting skills. In order to provide expectant and new fathers with early parental skills, it is necessary to adapt the current education classes to include the needs of these men or alternatively, to have men-only classes. It is important for midwives to actively include and engage expectant and new fathers in parental education to make them feel included and acknowledged. Parental education should emphasise equally on both antenatal and postnatal issues. If parental education can facilitate men to feel more secure in caring for their newborn, it can be expected to benefit not only the man but his partner and their child. This review has identified the need for further research and the development of strategies to involve more men in parental education. Declaration of Competing Interest None declared. Ethical Approval Not applicable. Funding sources Not applicable. References Ahlden, I., Ahlehagen, S., Dahlgren, L., Josefsson, A., 2012. Parents’ expectations about participating in antenatal parenthood education classess. J. Perinat. Educ. 21 (1), 11–17. Almqvist, A.-L., Duvander, A.-Z., 2014. Changes in gender equality? Swedish fathers’ parental leave, division of childcare and housework. J. Fam. Stud. 20 (1), 19–27. Anderson, E., Norman, A., Kanlinder, C., Plantin, L., 2016. What do expectant fathers expect of antenatal care in Sweden? A cross-sectional survey. Sex. Reprod. Healthc. 9, 27–34. Australian Government, 2009. Australia’s Paid Parental Leave Scheme: Supporting Working Australian Families. Commonwealth of Australia, Barton. Billingham, K., 2011. Preparing for parenthood: the role of antenatal education. Community Pract. 84 (5), 36–38. Carlon, J., Edleson, J., Kimball, E., 2014. First-time fathers’ experiences of and desires for formal support: a multiple lens perspective. Fathering 12 (3), 242–261. Chesters, J., Baxter, J., Western, M., 2009. Paid and unpaid work in Australian households: trends in the gender divison of labour, 1986–2005. Aust. J. Lab. Econ. 12, 89–107. Chin, R., Hall, P., Daiches, A., 2011. Fathers’ experiences of their transition to fatherhood: a metasynthesis. J. Reprod. Infant Psychol. 29 (1), 4–18. Crespi, I., Ruspini, E., 2015. Transition to fatherhood: new perspectives in the global context of changing men’s identities. Int. Rev. Soc. 25 (3), 353–358. Deave, T., Johnson, D., 2008. The transition to parenthood: what does it mean for fathers? JAN 63 (6), 626–633. Deave, T., Johnson, D., Ingram, J., 2008. Transition to parenthood: the needs of parents in pregnancy and early parenthood. BMC Pregnancy Childbirth 8 (30), 1–11. Deibel, M., Zielinski, R., Rising, S., Low, L., 2018. Where are the dads? J. Perinat. Neonat. Nurs. 32 (4), 324–332. Entsieh, A., Hallström, I., 2016. First-time parents’ prenatal needs for early parenthood preparation: a systematic review and meta-synthesis of qualitative literature. Midwifery 39, 1–11. Erlandsson, K., Häggström-Nordin, E., 2010. Prenatal parental education from the perspective of fathers with experience as primary caregiver immediately following birth: a phenomenographic study. J. Perinat. Educ. 19, 19–28. Fagerskiold, A., 2008. A change in life as experienced by first-time fathers. Scand. J. Caring Sci. 22 (1), 64–71. Fägerskiöld, A., 2008. A view from inside the family-becoming a father a change in life experienced by first- time fathers. Scand. J. Caring Sci. 22, 64–71.
R. Lau and A. Hutchinson / Midwifery 84 (2020) 102644 Families and Work Institute, 2002. National Study of the Changing Workforce: Generations and Gender in the Workplace, Workforce Trends. The American Business Collaboration, New York. Fletcher, R., Silberberg, S., Gallloway, D., 2004. New fathers’ postbirth views of antenatal classes: satisfaction, benefits, and knowledge of family services. J. Perinat. Educ. 13 (3), 18–26. Gagnon, A., Sandall, J., 2007. Individual or group antenatal education for childbirth or parenthood, or both. Cochrane Database Syst. Rev. Art. No.: CD002869 https: //doi.org/10.10 02/14651858.CD0 02869.pub2. Gilmer, C., et al., 2016. Parent education interventions designed to support the transition to parenthood: a realist review. Int. J. Nurs. Stud. 59, 118–133. Halle, C., et al., 2008. Supporting fathers in the transition to parenthood. Contemp. Nurs 31, 57–70. Hildingsson, I., Dalén, K., Sarenfelt, L., Ransjö-Arvidson, A.-B., 2013. First-time parents’ perception of antenatal education in Sweden. Int. J. Child Birth 3 (1), 28–38. Huusko, L., Sjöberg, S., Ekström, A., Hertflet Wahn, E., Thorstensson, S., 2018. Firsttime fathers’ experience of support from midwives in maternity clinics: an interview study. Nursing Research & Practice 1–7. Article ID 9618036: https: //doi.org/10.1155/2018/9618036. Ives, J., 2014. Men, maternity and moral residue: negotiating the moral demands of the transition to first time fatherhood. Sociol. Health Illn. 37 (7), 1003–1019. May, C., Fletcher, R., 2013. Preparing fathers for the transition to parenthood: recommendations for the content of antenatal education. Midwifery 29, 474–478. Miller, T., 2011. Making Sense of Fatherhood: Gender, Caring and Work. Cambridge University Press, New York. Nash, M., 2018. Addressing the needs of first-time fathers in Tasmania: a qualitative study of father-only antenatal groups. Aust. J. Rural Health 26, 106–111.
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Pålsson, P., Persson, E., Ekelin, M., Hallström, I., Kvist, L., 2017. First-time fathers experiences of their prenatal preparation in relation to challenges met in the early parenthood period: implications for early parenthood preparation. Midwifery 50, 86–92. Premberg, A., Hellstrom, A., Berg, M., 2008. Experiences of the first year as father. Scand. J. Caring Sci. 22, 56–63. Premberg, A., Lundgren, I., 2006. Fathers experiences of childbirth education. J. Perinat. Educ. 15 (2), 21–28. Redshaw, M., Heikkila, K., 2010. Delivered With Care: a National Survey of Women’s Experiences of Maternity Care. The National Perinatal Epidemiology Unit, Oxford, UK. Redshaw, M., Henderson, J., 2013. Fathers’ engagement in pregnancy and childbirth: evidence from a national survey. BMC Pregnancy Childbirth 13 (70), 1–15. Shorey, S., et al., 2017. First-time fathers’ postnatal experiences and suppots needs: a descriptive qualitative study. JAN 73, 2987–2996. Shorey, S., He, H.G., Morelius, E., 2016. Skin-to-skin contact by fathers and the impact on infant and paternal outcomes: an integrative review. Midwifery 40, 207–217. Smyth, S., Spence, D., Murray, K., 2015. Does antenatal education prepare fathers for their role as birth partners and for parenthood? Br. J. Midwifery 23 (5), 336–342. Tikotzky, L., et al., 2015. Vll. infant sleep development from 3 to 6 months postpartum: links with maternal sleep and paternal involvement. MSRCD 107–124. UK Government (Open Government Licence v3.0), Paternity Leave and Pay. UK Government. https://www.gov.uk/paternity-pay.
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/locate/midw
Review Article
A narrative review of parental education in preparing expectant and new fathers for early parental skills Rosalind Lau∗, Ana Hutchinson School of Nursing & Midwifery, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia
a r t i c l e
i n f o
Article history: Received 5 October 2019 Revised 8 January 2020 Accepted 19 January 2020
Keywords: Fathers Fatherhood Parenting skills Parental education engagement Preparedness
a b s t r a c t Objective: To explore expectant and new fathers’ views of antenatal education classes in preparing them for early parenting skills. Design: This review used a narrative review approach. Search strategy of electronic databases includes Medline, CINAHL, ProQuest, Scopus and PubMed. Studies from 20 0 0 to 2018 reporting parental education in preparing early parenting skills for fathers only or if the studies were on both parents, and the results reported on the fathers were available were included in the review. Findings: There were two quantitative and four qualitative studies. Studies were from Sweden (n = 4), United Kingdom (n = 1), and Australia (n = 1). There were three phenomenographical studies and three exploratory descriptive studies. The three key themes that emerged for expectant and new fathers were experiencing feelings of exclusion, lack of postnatal education, and need for support services. Conclusions: The evidence suggests that the current parental education classes do not meet the needs of expectant and new fathers in early parenting skills. In order to provide expectant and new fathers with early parental skills, it is necessary to adapt the current education classes to include the needs of these men. Alternatively, to have men only classes. It is important for midwives to actively include and engage expectant and new fathers in parental education. This review has identified the need for further research and to develop strategies to involve more men in parental education. © 2020 Published by Elsevier Ltd.
Introduction It is widely accepted that much has changed in father’s engagement in parenting over the past 50 years. Studies on expectant and new fathers have found that they wanted to be actively involved in the pregnancy of their partner, childbirth and child care (Redshaw and Henderson, 2013; Smyth et al., 2015). Most expectant and new fathers participate in antenatal activities, are present at the birth of their newborn child, and engage in child care more than in the past (Fagerskiold, 2008; Halle et al., 2008). Studies have showed that fathers are taking more responsibility for child care than previously (Almqvist and Duvander, 2014; Chesters et al., 2009). A report found Generation Y fathers (men born between 1980 and 1994) seemed to be spending more time with their children than Generation X fathers (men born between 1965 and 1979) (Families and Work Institute, 2002).
∗
Corresponding author. E-mail addresses: [email protected] (R. Lau), [email protected] (A. Hutchinson). https://doi.org/10.1016/j.midw.2020.102644 0266-6138/© 2020 Published by Elsevier Ltd.
Father greater involvement in child care is reflected in government policies. In 2003, United Kingdom (UK) passed a law allowing fathers to have two weeks of paternity leave after the birth of the baby (UK Government (Open Government Licence v3.0)). A decade later, in 2013, the Australian government introduced paternal pay leave scheme allowing the father to take two weeks after the birth of the baby (Australian Government, 2009). In Sweden, all families have 13 months of parental leave after the birth of the baby, paid at 80% of their regular salaries, which can be shared in a range of ways between the parents (Anderson et al., 2016). The World Health Organization on health promotion interventions for maternal and newborn health 2015 recommends that expectant fathers are actively involved during pregnancy, childbirth and the postnatal period (World Health Organization, 2015). For many individuals, becoming a father is a significant event and transition to fatherhood is a challenging time for them (Billingham, 2011; Premberg and Lundgren, 2006). A metasynthesis of six qualitative studies on father’s experiences of their transition to fatherhood found three key themes: emotional reactions including feeling of detachment, surprise and confusion at different phases of their transition; their role as a provider for
2
R. Lau and A. Hutchinson / Midwifery 84 (2020) 102644
the family; and changes in their sense of self and relationship with their partner (Chin et al., 2011). Studies of new fathers found they encountered challenges from several fronts including their sense of self, balancing work and family obligations, relationship changes, and playing a secondary role to the mother (Crespi and Ruspini, 2015; Miller, 2011). Historically, antenatal parental education classes (PECs) focused on the needs and experiences of women during pregnancy, labour and a baby is born (Ahldén et al., 2012; Premberg et al., 2008). The needs of the expectant or new fathers are rarely addressed. Although PECs are offered in many countries, there is no consensus on the content nor the structure and the effectiveness of PECs for parenthood remained unknown (Gagnon and Sandall, 2007). Most antenatal classes focus on educating the expectant parents on processes of labour and childbirth, and little or no information is given to parenting skills (Entsieh and Hallström, 2016). In the past decades, men’s transition to fatherhood has gained increasing interest, however most PECs have focused on preparing men for labour and childbirth (Deave et al., 2008; Fletcher et al., 2004). There is a lack of research on the preparation for early parenting skills. The aim of this narrative review is to explore expectant and new fathers’ views of antenatal education classes in preparing them for early parenting skills. Methods The search strategy includes the following electronic databases for studies published from 20 0 0 to 2018: Medline, CINAHL, ProQuest, Scopus and PubMed. The year 20 0 0 was selected in order to identify the most recent studies on parental education in preparing expectant and new fathers for early parenting skills. Articles published in English language from 20 0 0 to 2018 reporting parental education in preparing early parenting skills for fathers only or if the studies were on both parents, and the results reported on the fathers were available, they were included in the analysis. Search terms include father, antenatal parental classes, postnatal parental classes, postpartum, postnatal, postnatal care, postpartum care, fatherhood, parenting skills. Quality and assessment of the studies We found six papers relevant for the review, of which two were quantitative and four were qualitative studies. The two reviewers (RL and AH) independently assessed the quality of the papers. There were no discrepancies between the two reviewers on the quality appraisal of the six papers and all papers were evaluated as having a high risk of bias as the study designs used did not allow for control of potential confounders. Data extraction and synthesis All the studies focused on various aspects of antenatal education. The data were extracted independently by two reviewers (RL and AH) focusing on preparation for parenting skills. Qualitative content analysis was used to synthesize the outcomes of the quantitative studies. The key themes reported in each of the qualitative studies were reviewed independently by two reviewers (RL and AH), to identify recurrent themes and sub-themes across the included studies. Finally the key findings of the two stages of data extraction were integrated to identify key themes that emerged reflecting new fathers’ experiences and expectations of parental education classes in preparing them for parenting skills. Results Fourteen studies were found but only six were included in the narrative review because the other seven studies were not
on parental education classes or the focus was on pregnancy and childbirth and not on early parenting skills. The studies Deave and Johnson (2008) and Deave et al. (2008) used the same data, hence only one study was included in this review. There were two quantitative and four qualitative studies. Studies were from Sweden (n = 4), United Kingdom (n = 1), and Australia (n = 1). Studies are presented in Table 1. There were three phenomenographical studies and three exploratory descriptive studies. Through the process of synthesising the findings of the six studies, three key themes emerged reflecting new fathers’ experiences and expectations of parental education classes. The three themes that emerged were experiencing feelings of exclusion, lack of postnatal education, and need for support services.
Experiencing feelings of exclusion New and expectant fathers who attended the antenatal or postnatal parental education classes often report feeling excluded during the sessions (Erlandsson and Häggström-Nordin, 2010; Hildingsson et al., 2013; Premberg and Lundgren, 2006). Fathers felt excluded because the classes were predominantly focused on the expectant woman’s needs. Fathers attended the classes primarily to accompany the woman and providing support (Erlandsson and Häggström-Nordin, 2010; Premberg and Lundgren, 2006). A study of Swedish fathers found PECs emphasised the role of the mother as a parent and did not emphasise father’s responsibility nor the importance of father’s involvement in the early stages of parenthood (Erlandsson and HäggströmNordin, 2010). This may perhaps explain why fathers did not see themselves as equal parent to the newborn and see themselves in a “secondary role” (Premberg and Lundgren, 2006).
Lack of postnatal education Expectant and new fathers were discontented with the information delivered at the PECs because no education was tailored to meet their needs (Premberg and Lundgren, 2006). In one Swedish study, 63% men felt the antenatal PECs prepared them for birth, however less fathers (43%) reported that the education prepared them for early parenthood (Hildingsson et al., 2013). This is supported by another Swedish study that there was a lack of postnatal education in parental classes (Erlandsson and Häggström-Nordin, 2010). This could explain why first-time fathers were lacking confident in caring for their newborns (Shorey et al., 2017). First-time fathers wanted information to prepare them for early postnatal care (Pålsson et al., 2017). They wanted information on their role as a new father and practical and general aspects of caring for their new baby (Pålsson et al., 2017; Premberg and Lundgren, 2006). For example, new fathers wanted basic information such as how to bathe the baby, how to interpret the baby’s cues, and how to support their partner during breastfeeding (Pålsson et al., 2017). One Swedish study suggested that sharing and discussing with other men was essential and would be beneficial (Premberg and Lundgren, 2006). One study from UK emphasised the importance for the expectant parents having the opportunity to meet other new parents, both before and after birth, to learn from their experiences about early parenthood (Deave et al., 2008). This is supported by the fathers who attended group antenatal sessions who felt that it was valuable to have had the opportunity to interact with and learn from their peers. Feeling and knowing that other expectant couples also experienced what they were going through was in itself a source of support and reassurance (Deave et al., 2008).
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Table 1 Studies of parental education in preparing expectant and new fathers for early parental skills. Author and Country
Aim
Method
Pålsson et al. (2017); Southern Sweden
To describe first-time fathers experiences of their prenatal preparation in relation to challenges met in the early parenthood period.
Phenomenographical study Semi-structured interview First-time fathers were interviewed approximately one month after becoming fathers (n= = 15)
To explore first-time parents’ satisfaction with antenatal education and to explore its helpfulness in preparation for birth, early parenthood, and contact with other parents by comparing mothers’ and fathers’ experiences. To capture fathers’ conceptions of parental education topics, illuminated by their experiences as primary caregiver of their child immediately following birth
Survey First-time fathers (n= = 305)
Hildingssson et al. (2013); Northern region of Sweden
Erlandsson and Hȁggström-Nordin (2010); Sweden
Results
• Acquiring knowledge and forming realistic expectations
- caring for the baby in both health and illness - breastfeeding: more challenging than expected - still being a couple but not as before - being tired and bound - understanding emotional reactions • Developing strategies - adjusting priorities - acknowledging ones’ limitations - dealing with internal and external pressures - communicating with ones’ partner - forming a fatherhood identity • Being facilitated and supported - parental groups: the good and the bad - internet as an asset or a worrier - the need for guidance - information: the when and how
• 43% of the fathers reported that the antenatal education
was helpful for early parenthood • 24% reported having contact with other participants from
the antenatal education classes
Phenomenographical study Semi-structured interview between 8 days and 6 weeks postnatally (n= = 15)
• Exclusively prepares fathers for normal birth • Lack of information on complicated birth • Provide support to mother during labour and postnatally • Lack of information about maternal-infant separation
during complicated birth • Lack of information on postnatal care • Lack of emphasis on father as a parent
Deave et al. (2008); South-West England
To explore the needs of first-time parents in relation to the care, support and education during the antenatal period, particularly in relation to preparing for the transition to parenthood and their parenting skills
Cross-sectional study Semi-structured interviews Antenatally (last trimester) (n= = 20) Postnatally (3–4 months after the birth of the baby) (n= = 18)
• Few support systems • Lack of information specifically for new father • Excluded from antenatal appointments and classes. • Anxiety and feelings of exclusion around birth • Lack of practical and general information about baby-care • Lack of information to possible changes in relationships
with their partners Premberg and Lundgren (2006); South-West Sweden
To describe Swedish father’s experiences of childbirth education.
Phenomenological approach. Interviewed 2–4 months after birth (n= = 10)
• Experience of childbirth education classes is as a person
in a secondary role • Desire for information specifically addressed to fathers • Lack of opportunity to talk and share experiences with
other men in the same situation and in small groups Fletcher et al. (2004); New South Wales, Australia
To assess how well antenatal classes currently being offered in the Hunter region of New South Wales (NSW), Australia, are meeting men’s needs and, secondly, to assess new fathers’ familiarity with and use of support services.
Survey (completed some months postnatally) n= = 212 (95% were first-time fathers)
• Well-prepared for the birth • Well-prepared for the supportive role • Less well prepared for their relationship changes • Less well prepared for their lifestyle changes • Lack of awareness of family-related support services
Availability and awareness of support services
Discussion
The men identified their own partner, their colleagues and health professionals as the key people from whom they could seek support (Deave et al., 2008). There was a low level of awareness of family support services, with one Australian study finding that new fathers compared to new mothers were less familiar with these services and what they could offer (Fletcher et al., 2004).
This review explored the extent to which current antenatal parental education prepares expectant and new fathers for early parental skills. Transition to fatherhood is an important event for men as their societal role changes and they learn how to become a father. Several studies found that new fathers experienced a life change which included: being a father, providing financially for
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their family, caring for their newborn, alternating between work and home life, and developing a different relationship with their partner as well as the child (Chin et al., 2011; Fägerskiöld, 2008). Several studies have showed that paternal involvement in child care is associated with positive outcomes for the family (Redshaw and Heikkila, 2010; Shorey et al., 2016; Tikotzky et al., 2015). Positive family outcomes include improved maternal wellbeing and sleep (Redshaw and Henderson, 2013; Tikotzky et al., 2015), lower paternal stress and anxiety and biopsychosocial development benefits for the infants (Shorey et al., 2016). Studies suggest that PECs may not be as effective as they could be in preparing fathers for early parenting skills. Several studies suggest that fathers are not receiving the education or the support they needed in order to be involved in the postnatal care of their infant (Carlon et al., 2014; May and Fletcher, 2013). A Swedish study on expectant parents’ expectations about antenatal PECs found that most men expect PECs would help them feel more secure as a parent and in caring of their newborn (Ahlden et al., 2012). However, the evidence does not support this. A study in UK found first-time fathers felt alienated during the postnatal period (Ives, 2014). A metasynthesis found that there is a need to actively include expectant fathers in pre-and post-parental education classes, providing early and realistic information about parenting skills, and proving support during early postnatal period from health care professionals (Entsieh and Hallström, 2016). Health professionals should support both women and their partners in the transition to parenthood. However, several studies found that midwives tend to focus on the women and that men felt excluded (Deave et al., 2008; Huusko et al., 2018). A Swedish study found that expectant fathers expect to be involved in PECs (Anderson et al., 2016). Fathers wanted basic practical information in caring for their newborn (Pålsson et al., 2017). This may perhaps explain their lack of confidence in their early parental role. Most men recognised that the focus of antenatal education is on the needs of the woman, and this may be a barrier to men feeling able to participate more actively in the classes. Hence, they see themselves in a secondary role, merely to accompany and support their partner (Carlon et al., 2014; Deave and Johnson, 2008; Deave et al., 2008). A Department of Health in United Kingdom commissioned a review on parental education found provision of education to be variable, and brought a group of experts together to consider Preparation for Pregnancy, Birth and Beyond (PPBB) (Billingham, 2011). Drawing on the evidence, the PPBB group developed a list of six themes for the content of antenatal education program. The topics under the theme “Caring for my/our baby,” include: health of baby, keeping baby safe, bathing, minor illness and seeking help, cues of the baby, and feeding plan (Billingham, 2011). Other content for the PECs includes role and relationship changes, increased risk of mental distress and depression, and providing support to the mother (May and Fletcher, 2013). Traditionally antenatal parental education has been provided in mixed-gender groups, with strong focus on the needs of the expectant woman. To increase father involvement in postnatal care there is a need is to provide information more tailored to their needs and one option is to have men-only classes to address men’s needs. Two pilot studies, one in rural Australia and the other in Michigan, United States demonstrated that fathers-only antenatal groups could better help new and expected fathers to understand their fathering roles. These pilot studies found that men-only classes were a feasible option, either as stand-alone classes or incorporated into a group model (Deibel et al., 2018; Nash, 2018). The limitation of both these studies is the small sample size, and there is a lack of evidence regarding the feasibility and acceptability of providing men-only classes for expectant fathers on a larger scale. Hence, studies with larger sample size
are warranted. A review of parental education program found no evidence to suggest that a single program or delivery format was effective for all parents (Gilmer et al., 2016). However, there is evidence to suggest that for fathers, a male facilitator was more effective than a female one (Gilmer et al., 2016). Conclusions The evidence suggests that the current parental education classes do not meet the needs of expectant and new fathers in early parenting skills. In order to provide expectant and new fathers with early parental skills, it is necessary to adapt the current education classes to include the needs of these men or alternatively, to have men-only classes. It is important for midwives to actively include and engage expectant and new fathers in parental education to make them feel included and acknowledged. Parental education should emphasise equally on both antenatal and postnatal issues. If parental education can facilitate men to feel more secure in caring for their newborn, it can be expected to benefit not only the man but his partner and their child. This review has identified the need for further research and the development of strategies to involve more men in parental education. Declaration of Competing Interest None declared. Ethical Approval Not applicable. Funding sources Not applicable. References Ahlden, I., Ahlehagen, S., Dahlgren, L., Josefsson, A., 2012. Parents’ expectations about participating in antenatal parenthood education classess. J. Perinat. Educ. 21 (1), 11–17. Almqvist, A.-L., Duvander, A.-Z., 2014. Changes in gender equality? Swedish fathers’ parental leave, division of childcare and housework. J. Fam. Stud. 20 (1), 19–27. Anderson, E., Norman, A., Kanlinder, C., Plantin, L., 2016. What do expectant fathers expect of antenatal care in Sweden? A cross-sectional survey. Sex. Reprod. Healthc. 9, 27–34. Australian Government, 2009. Australia’s Paid Parental Leave Scheme: Supporting Working Australian Families. Commonwealth of Australia, Barton. Billingham, K., 2011. Preparing for parenthood: the role of antenatal education. Community Pract. 84 (5), 36–38. Carlon, J., Edleson, J., Kimball, E., 2014. First-time fathers’ experiences of and desires for formal support: a multiple lens perspective. Fathering 12 (3), 242–261. Chesters, J., Baxter, J., Western, M., 2009. Paid and unpaid work in Australian households: trends in the gender divison of labour, 1986–2005. Aust. J. Lab. Econ. 12, 89–107. Chin, R., Hall, P., Daiches, A., 2011. Fathers’ experiences of their transition to fatherhood: a metasynthesis. J. Reprod. Infant Psychol. 29 (1), 4–18. Crespi, I., Ruspini, E., 2015. Transition to fatherhood: new perspectives in the global context of changing men’s identities. Int. Rev. Soc. 25 (3), 353–358. Deave, T., Johnson, D., 2008. The transition to parenthood: what does it mean for fathers? JAN 63 (6), 626–633. Deave, T., Johnson, D., Ingram, J., 2008. Transition to parenthood: the needs of parents in pregnancy and early parenthood. BMC Pregnancy Childbirth 8 (30), 1–11. Deibel, M., Zielinski, R., Rising, S., Low, L., 2018. Where are the dads? J. Perinat. Neonat. Nurs. 32 (4), 324–332. Entsieh, A., Hallström, I., 2016. First-time parents’ prenatal needs for early parenthood preparation: a systematic review and meta-synthesis of qualitative literature. Midwifery 39, 1–11. Erlandsson, K., Häggström-Nordin, E., 2010. Prenatal parental education from the perspective of fathers with experience as primary caregiver immediately following birth: a phenomenographic study. J. Perinat. Educ. 19, 19–28. Fagerskiold, A., 2008. A change in life as experienced by first-time fathers. Scand. J. Caring Sci. 22 (1), 64–71. Fägerskiöld, A., 2008. A view from inside the family-becoming a father a change in life experienced by first- time fathers. Scand. J. Caring Sci. 22, 64–71.
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