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A place for the partner? Expectations and experiences of support during childbirth
A place for the partner? Expectations and experiences of support during childbirth Mary J. Somers-Smith Aim: to explore the expectations primigravidae have concerning the support that they hoped to have and would need from their partner during childbirth, and whether these kinds of support were actually provided by their partner. Additionally, to explore the thoughts and feelings of male partners concerning their supporting role, and, in retrospect, how well they felt they had managed. Participants: eight couples living in Hampshire, UK, who were interviewed six weeks before the birth and approximately 12 weeks following labour and delivery. Methods: semi-structured interviews were taped, transcribed and analysed. An ethnographic approach was used to identify concepts and themes. Findings: support provided by the male partner evoked very positive responses from the women.The fathers perceived that they were very helpful to their partner during childbirth.Though the women mostly found childbirth straightforward some fathers, nevertheless, found the experience stressful. Conclusions: the father's needs and role should be regularly assessed during childbirth.
INTRODUCTION
Mary J. Somers-Smith BA, MSc, RM, Bank Midwife, RoyalHampshireCountry Hospital, RauseyRd, Winchester, Hants, $D22 5DG, Lilt..
Manuscriptaccepted 30 June 1998
Approximately 95% of fathers in Britain now attend the birth of their baby (MacMillan 1994). Although a number of studies mention the benefits of male-partner attendance, such as women reporting less pain and requiring less medication, and expressing a more positive attitude toward birth and pregnancy, other studies have reported more equivocal findings (see Keinan 1997). Anecdotal evidence has also raised doubts over whether the male partner is always the most appropriate person to provide practical and psychological modes of support (Sherr 1995, Keirse et al. 1989). There has been little exploration, however, of the kinds of support that women, pregnant with their first baby, desire and anticipate during childbirth. This is matched by a lack of research into the types of support provided by male partners, or their thoughts and feelings, following the birth, concerning their support role (Coffman et al. 1994, Hodnett 1998). Social support itself is a problematic concept and, as a predictor variable, it has not performed Midwifery (1999)15,101-108 © 1999Harcourt BraceCc~Ltd
as well as researchers would like. Results are inconsistent and even conflicting. This is partly owing to conceptual and methodological shortcomings, and a consensus is lacking both on suitable instruments to measure social support and on the best definition for it (Schwarzer & Leppin 1991). Nonetheless, most researchers and clinicians, would agree with Cobb (t976), who defined social support as 'information leading the subject to believe that he is cared for and loved, esteemed, and a member of a network of mutual obligations' (p. 300). Substantial evidence points to the beneficial effects of social support and psychological wellbeing: in men, for instance, levels, types and perceptions of support correlate with eventual recovery from coronary heart disease (Helgeson 1993). Against this, however, research has also documented the negative effects of supportive encounters: minimising through challenging or maximising by catastrophising the seriousness of a disease or condition; being overprotective and draining a provider's own personal resources through supportive interactions (Hobfoll & Stephens 1990, Lehman & Hemphill 1990).
102 Midwifery Nonetheless, the burgeoning literature on support in the transition to parenthood identifies the decisive role the male partner has in alleviating stress. Research findings show that 'received support" and 'confirmation of support expectations' from the male partner correlate with a positive outcome in new mothers, and are over and above the practical effects of the support itself. Thus, a relationship with a male partner, in which support expectations are confirmed, more often leads to a positive maternal outcome (Brown & Harris 1978, Ruble et al. 1988, Levitt et al. 1993, Logsdon et al. 1994). In contrast, when expectations for support are not confirnaed, this may lead to feelings of loss of control and a high risk of depression (Brown & Harris, 1978, Brown et al. 1986). It is also thought that a woman's high expectations of support from her partner may be helpful during childbirth, and pregnancy itself frequently evokes his increased support (Ruble et al. 1988). During childbirth, however, a firsttime father may not know how best to help. Therefore, the primary aim of this study was to explore the expectations women, pregnant with their first baby, had concerning the support they would need and have from their partner during labour, and the satisfaction they subsequently gained from such support. Additionally, all expectations fathers had of their supporting role before childbirth and, following labour and delivery, their thoughts and feelings concerning their supporting role were explored.
METHOD The setting All participants in this study lived in Hampshire, UK. The women and their male partners were recruited from the antenatal clinics of two consultant maternity units. One of the two maternity units is located on the outskirts of a large city and has about 5500 births per annum. The other maternity unit is situated close to a small city centre and has approximately 2500 births per annum. The women were 'booked' for hospital confinement.
Design The study was prospective in design and a qualitative approach was used to obtain data from first-time mothers and fathers before and following childbirth. The aim was to gain an indepth perspective of both the women's expectations and experiences of support, as well as the male partner's thoughts and feelings concerning his role as supporter. Ethical approval to carry out the research was given by the Local Research
Ethics Committees at both hospitals. Verbal and written permission was sought and obtained from general practitioners, consultants in obstetrics and heads of two midwifery services, to interview women and their partners before and after their confinement. Letters were also sent to health visitors an community midwives informing them of the study. Confidentiality was assured in that, apart from the initial introduction through a hospital midwife, contact was directly with the researcher.
Sample Purposive sampling guided the selection of potential participants. This sampling method facilitates the selection of participants who are fairly typical of a population--in this case firsttime expectant parents. It also provides a greater range of potential data, range in this case being more important than typicality (Miles & Huberman 1994). Of 13 couples approached eight agreed to participate, giving a response rate of 61%. Ages ranged from 25 to 32 years for women and from 24 to 36 years for men. In the first questionnaire, items about occupation were included so that social class could be determined. It was hoped to have representatives from all social classes, but vetting procedures carried out at one antenatal clinic prevented couples coming from the lowest social class from attending an initial interview to have the study explained to them. Their presence might have enriched the data, as research indicates that women from the lowest social classes receive less interest and less emotional and practical support from their male partner (Quine et al. 1993).
Data collection All interviews were carried out by the researcher. They were conducted face-to-face, in the couples' own homes, and at a time that fitted their lifestyle. Before the start of the interview, verbal and written agreement to participate and for the interviews to be tape-recorded was confirmed. Each member of a couple was interviewed separately. The researcher believed that a fuller picture would be obtained of expectations and experiences if each participant was able to articulate them without interruption. There was a need, nonetheless, to be sensitive to the commitments of the participants, and on occasions, whilst one participants was being interviewed, the other would be in the same room, caring for the baby, for instance. Because of this, it was not unusual for the other partner to interrupt with comments and, in some instances, this stimulated a deeper discussion thereby providing richer data.
A place for the partner
The first interviews took place approximately six weeks before confinement and lasted from 0.5 to 0.75 hours. The second interviews were held between 10 and 16 weeks following childbirth and took from 0.5 to 1.13 hours. The questions were mainly open ended, to encourage the participants to talk naturally and expansively. The focus of the first interview for the women was their expectations of support from their partner during labour and delivery. At the second interview the women were questioned on the types of support their partner provided, and the extent to which their support expectations had been fulfilled. In the first interview expectant fathers were invited to explore their thoughts and feelings about supporting their partner during childbirth, and in the second they were invited to discuss their role as supporter.
Data analysis The analysis in this study was informed by a number of texts, particularly the work of Miles and Huberman (1994). The interviews were fully transcribed to typed format. The researcher listened to each tape several times to become familiar with the data and, simultaneously, each transcript was read. Words and phrases were highlighted in the text. Concepts in the highlighted data were coded. These codes were compared to other codes within the same interview, and with other interviews with different participants. Any similarities and differences were noted. Codes were grouped and categorised according to themes and these were then compared with concepts from the research literature. As the emphasis was on exploring expectations and experiences, the concepts of validity and reliability were considered inappropriate. Instead, a criterion of 'goodness' was adopted (Lincoln & Guba 1985). Codes and themes were checked by two psychologists.
FINDINGS AND DISCUSSION For clarity, analysis and discussion are kept together. To maintain confidentiality, instead of using names, each couple was assigned a letter from A to H.
Support expectations When the women participants were asked to describe their expectations of support from their partner they identified the practical support behaviour that they believed to be important and wanted their partner to perform for them during labour and delivery. The most common were sponging down, wiping the forehead and
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hand holding. What appeared more important for them, however, were the psychological and emotional expressions of caring, empathy and sympathy. One probable reason is that many women about to have their first baby feel frightened and vulnerable: If I was on my own I think ! would, probably, be very nervous and isolated but having 'J' there will help me and I will cope better (Mrs H, first interview) Nonetheless, their responses also suggested that a variety of factors impinged on how they viewed their future expectations for support. Three pregnant women were very confident about receiving good support from their partner during childbirth and, for one, this was based on a history of the partner having provided good support when it was needed: I think he'll be good, because urn, he doesn't panic.., in bad situations that we've had, he hasn't panicked outright . . . . (Mrs D, first interview) Research findings on support generally suggest that an existing perception of a partner having a high level of support knowledge covering a wide range of support behaviours, leads the other person confidently to expect that good support will be provided when it is needed (Johnson et al. 1993). Nevertheless, childbirth was an unknown event for all participants and it is posited that a prolonged and/or stressful childbirth can undermine the support provider's own personal resources (Hobfoll & Stephens 1990). This was possibly implicit in responses from the other pregnant women, as varying degrees of hesitancy concerning support, based on a number of different factors were revealed. Progress and normality of labour was one factor. I think he will, be very supportive... I think if it gets that it's going to be a difficult labour then no I don't think he will be, because he's not like . . . . (Mrs F, first interview) Thus, if labour was controllable and progressing well, they believed that their partner would manage the supporting role, and findings obtained from research, carried out in a laboratory setting, have suggested that the actual quality of support and information given is highest when the spouse has expertise and can influence the stressful situation. Against this, if the stress is not controllable, support provided by the partner might be inappropriate (Cutrona & Suhr 1992). This is more likely to occur when the progress of labour is slow and]or complications arise, and the partner does not know how best to help. One pregnant woman expressed concerns that her partner might be a great 'worrier' or become
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'overpowering' when instead she wanted calm. A concern for another was of her partner having to watch her in pain and be supportive at the same time: ... its when you see somebody that you know, you know and care a great deal for is in pain, and, stuff like that, its harder, when you're removed from t h e m . . , you can, sort of carry out reactions can't you, but when its somebody you know its very hard urn, bit difficult to. (Mrs E, first interview) The clinical findings reported by Raphael-Left (1991) as well as the research results of Berry (1988) both suggest that for first-time fathers childbirth is stressful and, for some men, the experience of witnessing a labour and delivery might prove psychologically damaging (Raphael-Left 1991). Thus, far from being a resource, support can become a burden for the recipient and, Odent (1984) writes, this can interfere with the normal progress of labour. The literature relating to chronic conditions also reveals that support is only beneficial if it matches the current needs of the recipient and promotes a positive outcome and a good adjustment (Lehman & Hemphill 1990, Helgeson 1993). When the men were questioned concerning how they felt about supporting their partner during childbirth, their responses suggested that they were particularly committed to the concept of paternal attendance. Indeed, most of them had made the decision early in the pregnancy to be present and support their partner: In our case we decided we both wanted, you're married, you're together, you should share things. (Mr C, first interview) The men gave a variety of reasons for attending the birth, but the main one was to be available. They believed that their presence was important, that it was unnatural not to be present and that they would have let their partner down if they were unable to attend the birth. Palkovitz (1987) similarly found a wide range of motives fathers acknowledged for attending the births of their children, but, in contrast to the findings of palkovitz (1987) and Barbour (1990), attitudes and pressures to attend may now be changing. Barbour (1990) reports that men, generally, had been subject to considerable pressure to be present during childbirth. Findings in this study, however, indicated that some expectant mothers had made alternative arrangements for a family member or close friend to be available in case the expectant father changed his mind. When they were questioned on the kinds of supportive behaviours they expected to perform, most were unsure about the kinds of support
they were expected to provide, although all had attended childbirth education: This sounds so crazy because a lot of people I suppose have got their own plans, and, everything else . . . . Till I know how 'S" is I don't know how I'm going to be (Mr B, first interview) Most of the men defined their role in terms of general support, to be there and comfort their partner, rather than providing specific kinds of support. This was indicated in some of their responses suggesting that they were aware of the importance of a familiar face. and that a woman in labour might prefer to voice her fears to someone she knew rather than a stranger. This was also implied by tile men in Barbour's (1990) study, who said that, despite their partner being surrounded by experts who care, tile experts are strangers, therefore, it was necessary for them (the partners)to be there and be available. Most of the men expressed confidence that they would do a good job providing support for their partner. Nonetheless, as some responses indicated, some men were subject to various fears. One fear, voiced by two men, was tile possibility of their partner dying: You know, the extreme of her dying through childbirth which you hear of, not as much hopefully nowadays as it used to be but urn, it is er, you know, a worry at tile back of the mind. Hopefully its something you know, that won't happen. Statistics can state, you know, whatever, but at the end of the day I don't want to be a statistic, I want her here, and I want my, our child. (Mr C, first interview) These fears may have little substance; but, as the quote above from one of the two men suggests, a number of expectant fathers are aware that it is only about two generations ago that childbirth and its complications were a major cause of death in the U K in women of childbearing age. Other fears the men admitted included the possibility of fainting, panicking and wondering whether they would have the ability to 'keep it together'. Two expectant fathers were concerned that they would fail to respond to the needs of their partner, and one stated that, despite attendance at childbirth education, he still wondered how he would manage: When I go in with 'L' I'll be completely shooting in the dark. (Mr H, first interview) It appears that the men mostly kept their fears to themselves, and this was a finding in two other studies (Shapiro 1987, Mercer et al. 1988). It may simply be a desire not to worry their partner. For some men, however, keeping fears to oneself will reflect early negative childhood or adolescent experiences when they sought help on emotional
A place for the partner
issues (Bryant 1985). It may also reflect the working situation, which one participant likened to 'being on test' (H first interview). Habitual wariness can foster lower trust of others in other areas of life, as the same participant admitted (Barbee et al. 1993). Alternatively, keeping fears to oneself may be a male characteristic, and this may be reinlbrced, in part, from cultural sanctions which permit the voicing of fears in women, but discourages this in men (Shapiro 1987, Mercer et al. 1988).
New fathers recalling their supporting role when the fathers were asked, at the second interview, how well they had managed their supporting role, their recollections mostly evoked good memories but, more importantly, almost all the men felt that they were needed: I think mmm she could're got by without me but, she would definitely preferred me to be there. (Mr A, second interview) Their role as supporter was possibly made easier by the fact that all the women in this study had a vaginal deliver and none, it seems, had a prolonged labour, a difficult normal or difficult instrumental delivery. The men's responses initially focussed on practical helpful behaviours such as encouraging relaxation, massaging, providing 'Entonox'; trying to make the woman comfortable, getting her drinks, walking with her, holding her hand, holding her leg, and cooling her down. It may simply show that men wanted to be of practical help to their partner, and it would seem that men find it easier to provide practical help, especially in a task situation where doing well is important (Winstead et al. 1992). Alternatively, men may more easily absorb the practical aspects of childbirth education, or they may feel that they are expected to perform what they have been taught (Keirse et al. 1989, Nichols 1993): There wasn't mopping the brow or anything [i.e. the mother did not want it]. I tried,.., she shooed me a w a y . . . I think the main care is support . . . . (Mr G, second interview) The women did not always want the practical support offered. As the quote above suggests, one partner needed to redefine his role and, instead, provide quiet support, thus enabling his partner to cope with her distress in a calmer frame of mind. Anecdotal evidence points to many women preferring calm, not stimulation (Chapman 1991) and this finding emerged from some other new fathers' non-specific, more general responses. It appears that what was more important for the labouring woman was the physical presence of her partner. Nichols
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(1993) similarly found that the mere presence of the male partner was frequently mentioned as a helpful supportive behaviour. However, in this study, it appeared also to signal to the woman that physical and psychological support was available, which could be called upon when necessary: ... and when she wanted somebody there to lean on that's just a question of standing there and being a convenient thing to lean on when, when she needs it. (Mr D, second interview) Although the fathers believed that they had coped well with providing support, it appeared that, for some of them, there were periods of anxiety. One father, in order to minimise his anxiety, relied on cues from the midwives: All I did was just take a back seat a n d . . , do what they wanted me to d o . . . a n y t h i n g I would have done it. (Mr E, second interview) Chapman (1992) likewise reported that some men looked to others such as their partner or professionals, to guide them in their helping role. Other men in this study were not so fortunate. Two fathers were simultaneously trying to keep their partner happy whilst hiding feelings of anxiety, guilt and, for one, perceived eventual uselessness because he was not sure what he had to do. Nochols (1993) similarly found that the labour experience for fathers evoked a significant number of negative feelings, such as anxiety. This suggests that some men require direction as to how best they can help, possibly, that is more in keeping with their natural helping role, rather than a role they are not accustomed to (Chapman 1992). The layout of the delivery room may also increase feelings of uselessness and was implicit in a response from one mother. She described how her partner was getting in the way because of the equipment, as was unable to rub her back. Equipment can obstruct true involvement and, although the obstruction is an incidental consequence of layout, it can emphasise a power imbalance between the partner and the staff (Sherr 1995).
New mothers' recollections of support From the mothers' responses it quickly became apparent that they were very grateful for the support their partner gave. Practical support behaviours particularly appreciated included: holding her hand, helping her with relaxation, running her a bath, being someone to lean one, making her tea, massaging her back, and reminding her how to use the Entonox. The tops of my legs they really did h u r t . . . j u s t being there rubbing my legs was the main
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issue of the thing really. (Mrs C, second interview) It was evident that, for most mothers, practical support from the partner was an important component of the supporting process overall. One mother, for instance, appeared grateful for all forms of support even when, objectively, some were possibly counterproductive. I wasn't particularly amused at being offered fish and chips . . . . That's just trying to help. (Mrs B, second interview) Further probing revealed that what seemed to override any possible mismatch in the practical support the partner provided was the relief on the mother's part of having someone taking control. Two explanations are possible. First, as Chapman (1992) found, some women have a high desire for their partner to be in charge of the labour process, or they view their partner as being a critical factor in their own ability to maintain overall control during labour. Second, the literature on support suggests that positive feelings about the partner generally enable the woman to focus on the quality overall of supportive interactions (e.g. warmth, empathy) and to overlook ineffective ones (Cutrona & Suhr 1992). This is enhanced in an intimate relationship, which frequently includes an understanding of how best to communicate support needs without causing upset (Barbee et al. 1993, Johnson et al. 1993): ... I think if you've got someone who is quite close to you they know t h a t . . , if I said 'no no no you are not doing it right' he felt he wasn't going to be h u r t . . . i f it was a complete s t r a n g e r . . . I can't tell them that they aren't doing it right. (Mrs D, second interview) Although appreciating the practical support provided by their partner, many women possibly put more value on forms of psychological support, including 'being there', 'you can do it', accepting abuse, making eye-to-eye contact, •giving encouragement and 'being available': When the midwife was saying push, he was saying push and giving me lots of encouragement,.., if he hadn't been there I probably wouldn't have pushed that little bit more and they would have had to use forceps or whatever . . . . (Mrs E, second interview) w h a t . . , gave you the encouragement to go on? (Interviewer) Him just being there. (Mrs F, second interview) The mothers appreciated and appeared to benefit from the supportive presence of their partner. The partner 'being there' meant that immediate
physical and psychological support was available, which could be called upon when necessary. As Stolte (1987) found, and as the quote above possibly suggests, the partner does not necessarily have to give practical help: mere presence is supportive. Indirect backing for this hypothesis is provided by Cutrona & Suhr (1992), who found that high levels of emotional support were associated with recipient satisfaction regardless of event controllability. Thus, the supportive presence of the partner can act as a morale booster by alleviating the mother's distress. This is turn may enable her to tackle her labour in a calmer frame of mind, and increase her confidence and motivation to continue. In contrast, as the response of one new mother suggests, when the partner was not present, fear could set in. She recalled wanting someone there to express her pain to 'or just to hold', and finding 'there was no-one there' (G, second interview). Although the use of touch during labour has not been evaluated (Hodnett 1998) the mother's response suggests that the availability of her partner's hand was comforting, and she missed it when he was not with her. A review of responses overall suggests that the presence of the partner at this critical time had an emotional impact on the well-being of all the new mothers; they felt valued, cared for, and appreciated for what they were going through. Although these feelings have been documented by many researchers as salient in the months before and after the first baby is born (Brown & Harris 1978, Simons et al. 1993, Longsdon et al. 1994), responses from the women in this study indicated that they are equally important and necessary during childbirth and, for nearly all of them, it led to a satisfying birth experience.
Limitations of the study The focus of this study was on exploring the women's expectations and experiences of support provided by their partner during childbirth, and the thoughts and feelings of the male partner concerning their supporting role. A number of limitations are inherent in this study, such as one geographical location, little ethnic diversity, and a small sample size. Additionally, a refusal rate of 39% by the women's partners raises questions about how those who refused to participate in the study may have differed. A commitment to participate in research that involves two interviews may have influenced some of the men in their decision not to participate. Lack of time was cited by one expectant father, and lack of interest was the main reason given by two other men. In two further instances this was also given as a reason by women, who acted as 'gatekeepers'. Stress may have been a factor for the one couple who
A place for the partner
were not successfully contacted, by telephone, for the second interview (couple H). Finally, the phenomenon of support could have been more completely explored by taking account of other key players, for instance, community and hospital carers.
CONCLUSIONS
The women in this study wanted their partner to be with them and give support during childbirth. The men similarly wanted to be present and provide support during this stressful time. The literature on male partner support during labour, throws up conflicting opinions (Sherr 1995, Keinan 1997). It was stated earlier that the male partner might not necessarily be the appropriate person to act as supporter during labour. However, research also indicates that the presence of the father-to-be is helpful and valuable to most women in labour. The results of this study corroborate this view: the mothers were very satisfied with the support provided by their partner. Although all the fathers were pleased with the support they had provided, some found childbirth a stressful experience. They were uncertain a b o u t their support role, the well-being of their partner during labour and any complications that might occur, either to the m o t h e r or the baby. A l t h o u g h anxiety is more likely to occur when labour is prolonged and painful, even when childbirth is apparently straightforward some men will find the experience stressful. There is a slight risk of a vicious circle: the w o m a n makes support demands the partner c a n n o t meet; he becomes visibly stressed, and this in turn adds to the w o m a n ' s stress and consequent demands. Findings from this study have given an insight into the expectations women have of the support they believe they will need from their partner during labour and delivery, and into the patterns and types of support offered by their partner. The findings have also given an insight as to how men view their supporting role during childbirth. Nevertheless, this was only an initial exploration, and further research is needed to deepen our understanding of the psychological factors which enhance or dampen supportive endeavours. Results suggest, however, that the father's needs should be assessed regularly during childbirth, as some fathers may need support. On this basis, the labouring couple should not be left alone for a long period and relief for the partner should be at hand. Midwives need to use their time economically, but a wise midwife will, during labour, through informal conversation and observation, form a rough judgement of those
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non-critical or ancillary tasks that may be allotted to the partner. Additional study is needed to explore any conditions that may affect the provision of support. For instance, when the data were coded, it became apparent that, apart from anxieties at the time, some fathers-to-be have fears before and following child-birth. Other ethnic groups should be included and there is a need for more representation from social classes IV and V. Finally, this research should be extended to women who are having a second or subsequent baby and their partners, as their needs are likely to be different. The psychological literature on social support can increase our understanding of the interactions involved when a woman is supported by her partner during labour and delivery. Little of this literature, or of other psychological theories, has been integrated into labour-ward practice and, although there has been an attempt to bridge the gap in this study, it is only a very small beginning (Slade 1993, Sherr 1995). It is hoped, however, that research grounded in the experience of a wider range of couples can move on from these initial findings, and that a psychological framework for the support given by expectant fathers during labour can be more fully constructed. ACKNOWLEDGEMENTS
The study reported in this article is based on a research dissertation that formed part of the requirements for a Master's Degree in the Social Sciences in Health Psychology. I wish to thank Sandra Horn, my supervisor, Department of Psychology, University of Southampton, for her comments and advice on an earlier draft of this manuscript. REFERENCES
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INTRODUCTION
Mary J. Somers-Smith BA, MSc, RM, Bank Midwife, RoyalHampshireCountry Hospital, RauseyRd, Winchester, Hants, $D22 5DG, Lilt..
Manuscriptaccepted 30 June 1998
Approximately 95% of fathers in Britain now attend the birth of their baby (MacMillan 1994). Although a number of studies mention the benefits of male-partner attendance, such as women reporting less pain and requiring less medication, and expressing a more positive attitude toward birth and pregnancy, other studies have reported more equivocal findings (see Keinan 1997). Anecdotal evidence has also raised doubts over whether the male partner is always the most appropriate person to provide practical and psychological modes of support (Sherr 1995, Keirse et al. 1989). There has been little exploration, however, of the kinds of support that women, pregnant with their first baby, desire and anticipate during childbirth. This is matched by a lack of research into the types of support provided by male partners, or their thoughts and feelings, following the birth, concerning their support role (Coffman et al. 1994, Hodnett 1998). Social support itself is a problematic concept and, as a predictor variable, it has not performed Midwifery (1999)15,101-108 © 1999Harcourt BraceCc~Ltd
as well as researchers would like. Results are inconsistent and even conflicting. This is partly owing to conceptual and methodological shortcomings, and a consensus is lacking both on suitable instruments to measure social support and on the best definition for it (Schwarzer & Leppin 1991). Nonetheless, most researchers and clinicians, would agree with Cobb (t976), who defined social support as 'information leading the subject to believe that he is cared for and loved, esteemed, and a member of a network of mutual obligations' (p. 300). Substantial evidence points to the beneficial effects of social support and psychological wellbeing: in men, for instance, levels, types and perceptions of support correlate with eventual recovery from coronary heart disease (Helgeson 1993). Against this, however, research has also documented the negative effects of supportive encounters: minimising through challenging or maximising by catastrophising the seriousness of a disease or condition; being overprotective and draining a provider's own personal resources through supportive interactions (Hobfoll & Stephens 1990, Lehman & Hemphill 1990).
102 Midwifery Nonetheless, the burgeoning literature on support in the transition to parenthood identifies the decisive role the male partner has in alleviating stress. Research findings show that 'received support" and 'confirmation of support expectations' from the male partner correlate with a positive outcome in new mothers, and are over and above the practical effects of the support itself. Thus, a relationship with a male partner, in which support expectations are confirmed, more often leads to a positive maternal outcome (Brown & Harris 1978, Ruble et al. 1988, Levitt et al. 1993, Logsdon et al. 1994). In contrast, when expectations for support are not confirnaed, this may lead to feelings of loss of control and a high risk of depression (Brown & Harris, 1978, Brown et al. 1986). It is also thought that a woman's high expectations of support from her partner may be helpful during childbirth, and pregnancy itself frequently evokes his increased support (Ruble et al. 1988). During childbirth, however, a firsttime father may not know how best to help. Therefore, the primary aim of this study was to explore the expectations women, pregnant with their first baby, had concerning the support they would need and have from their partner during labour, and the satisfaction they subsequently gained from such support. Additionally, all expectations fathers had of their supporting role before childbirth and, following labour and delivery, their thoughts and feelings concerning their supporting role were explored.
METHOD The setting All participants in this study lived in Hampshire, UK. The women and their male partners were recruited from the antenatal clinics of two consultant maternity units. One of the two maternity units is located on the outskirts of a large city and has about 5500 births per annum. The other maternity unit is situated close to a small city centre and has approximately 2500 births per annum. The women were 'booked' for hospital confinement.
Design The study was prospective in design and a qualitative approach was used to obtain data from first-time mothers and fathers before and following childbirth. The aim was to gain an indepth perspective of both the women's expectations and experiences of support, as well as the male partner's thoughts and feelings concerning his role as supporter. Ethical approval to carry out the research was given by the Local Research
Ethics Committees at both hospitals. Verbal and written permission was sought and obtained from general practitioners, consultants in obstetrics and heads of two midwifery services, to interview women and their partners before and after their confinement. Letters were also sent to health visitors an community midwives informing them of the study. Confidentiality was assured in that, apart from the initial introduction through a hospital midwife, contact was directly with the researcher.
Sample Purposive sampling guided the selection of potential participants. This sampling method facilitates the selection of participants who are fairly typical of a population--in this case firsttime expectant parents. It also provides a greater range of potential data, range in this case being more important than typicality (Miles & Huberman 1994). Of 13 couples approached eight agreed to participate, giving a response rate of 61%. Ages ranged from 25 to 32 years for women and from 24 to 36 years for men. In the first questionnaire, items about occupation were included so that social class could be determined. It was hoped to have representatives from all social classes, but vetting procedures carried out at one antenatal clinic prevented couples coming from the lowest social class from attending an initial interview to have the study explained to them. Their presence might have enriched the data, as research indicates that women from the lowest social classes receive less interest and less emotional and practical support from their male partner (Quine et al. 1993).
Data collection All interviews were carried out by the researcher. They were conducted face-to-face, in the couples' own homes, and at a time that fitted their lifestyle. Before the start of the interview, verbal and written agreement to participate and for the interviews to be tape-recorded was confirmed. Each member of a couple was interviewed separately. The researcher believed that a fuller picture would be obtained of expectations and experiences if each participant was able to articulate them without interruption. There was a need, nonetheless, to be sensitive to the commitments of the participants, and on occasions, whilst one participants was being interviewed, the other would be in the same room, caring for the baby, for instance. Because of this, it was not unusual for the other partner to interrupt with comments and, in some instances, this stimulated a deeper discussion thereby providing richer data.
A place for the partner
The first interviews took place approximately six weeks before confinement and lasted from 0.5 to 0.75 hours. The second interviews were held between 10 and 16 weeks following childbirth and took from 0.5 to 1.13 hours. The questions were mainly open ended, to encourage the participants to talk naturally and expansively. The focus of the first interview for the women was their expectations of support from their partner during labour and delivery. At the second interview the women were questioned on the types of support their partner provided, and the extent to which their support expectations had been fulfilled. In the first interview expectant fathers were invited to explore their thoughts and feelings about supporting their partner during childbirth, and in the second they were invited to discuss their role as supporter.
Data analysis The analysis in this study was informed by a number of texts, particularly the work of Miles and Huberman (1994). The interviews were fully transcribed to typed format. The researcher listened to each tape several times to become familiar with the data and, simultaneously, each transcript was read. Words and phrases were highlighted in the text. Concepts in the highlighted data were coded. These codes were compared to other codes within the same interview, and with other interviews with different participants. Any similarities and differences were noted. Codes were grouped and categorised according to themes and these were then compared with concepts from the research literature. As the emphasis was on exploring expectations and experiences, the concepts of validity and reliability were considered inappropriate. Instead, a criterion of 'goodness' was adopted (Lincoln & Guba 1985). Codes and themes were checked by two psychologists.
FINDINGS AND DISCUSSION For clarity, analysis and discussion are kept together. To maintain confidentiality, instead of using names, each couple was assigned a letter from A to H.
Support expectations When the women participants were asked to describe their expectations of support from their partner they identified the practical support behaviour that they believed to be important and wanted their partner to perform for them during labour and delivery. The most common were sponging down, wiping the forehead and
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hand holding. What appeared more important for them, however, were the psychological and emotional expressions of caring, empathy and sympathy. One probable reason is that many women about to have their first baby feel frightened and vulnerable: If I was on my own I think ! would, probably, be very nervous and isolated but having 'J' there will help me and I will cope better (Mrs H, first interview) Nonetheless, their responses also suggested that a variety of factors impinged on how they viewed their future expectations for support. Three pregnant women were very confident about receiving good support from their partner during childbirth and, for one, this was based on a history of the partner having provided good support when it was needed: I think he'll be good, because urn, he doesn't panic.., in bad situations that we've had, he hasn't panicked outright . . . . (Mrs D, first interview) Research findings on support generally suggest that an existing perception of a partner having a high level of support knowledge covering a wide range of support behaviours, leads the other person confidently to expect that good support will be provided when it is needed (Johnson et al. 1993). Nevertheless, childbirth was an unknown event for all participants and it is posited that a prolonged and/or stressful childbirth can undermine the support provider's own personal resources (Hobfoll & Stephens 1990). This was possibly implicit in responses from the other pregnant women, as varying degrees of hesitancy concerning support, based on a number of different factors were revealed. Progress and normality of labour was one factor. I think he will, be very supportive... I think if it gets that it's going to be a difficult labour then no I don't think he will be, because he's not like . . . . (Mrs F, first interview) Thus, if labour was controllable and progressing well, they believed that their partner would manage the supporting role, and findings obtained from research, carried out in a laboratory setting, have suggested that the actual quality of support and information given is highest when the spouse has expertise and can influence the stressful situation. Against this, if the stress is not controllable, support provided by the partner might be inappropriate (Cutrona & Suhr 1992). This is more likely to occur when the progress of labour is slow and]or complications arise, and the partner does not know how best to help. One pregnant woman expressed concerns that her partner might be a great 'worrier' or become
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'overpowering' when instead she wanted calm. A concern for another was of her partner having to watch her in pain and be supportive at the same time: ... its when you see somebody that you know, you know and care a great deal for is in pain, and, stuff like that, its harder, when you're removed from t h e m . . , you can, sort of carry out reactions can't you, but when its somebody you know its very hard urn, bit difficult to. (Mrs E, first interview) The clinical findings reported by Raphael-Left (1991) as well as the research results of Berry (1988) both suggest that for first-time fathers childbirth is stressful and, for some men, the experience of witnessing a labour and delivery might prove psychologically damaging (Raphael-Left 1991). Thus, far from being a resource, support can become a burden for the recipient and, Odent (1984) writes, this can interfere with the normal progress of labour. The literature relating to chronic conditions also reveals that support is only beneficial if it matches the current needs of the recipient and promotes a positive outcome and a good adjustment (Lehman & Hemphill 1990, Helgeson 1993). When the men were questioned concerning how they felt about supporting their partner during childbirth, their responses suggested that they were particularly committed to the concept of paternal attendance. Indeed, most of them had made the decision early in the pregnancy to be present and support their partner: In our case we decided we both wanted, you're married, you're together, you should share things. (Mr C, first interview) The men gave a variety of reasons for attending the birth, but the main one was to be available. They believed that their presence was important, that it was unnatural not to be present and that they would have let their partner down if they were unable to attend the birth. Palkovitz (1987) similarly found a wide range of motives fathers acknowledged for attending the births of their children, but, in contrast to the findings of palkovitz (1987) and Barbour (1990), attitudes and pressures to attend may now be changing. Barbour (1990) reports that men, generally, had been subject to considerable pressure to be present during childbirth. Findings in this study, however, indicated that some expectant mothers had made alternative arrangements for a family member or close friend to be available in case the expectant father changed his mind. When they were questioned on the kinds of supportive behaviours they expected to perform, most were unsure about the kinds of support
they were expected to provide, although all had attended childbirth education: This sounds so crazy because a lot of people I suppose have got their own plans, and, everything else . . . . Till I know how 'S" is I don't know how I'm going to be (Mr B, first interview) Most of the men defined their role in terms of general support, to be there and comfort their partner, rather than providing specific kinds of support. This was indicated in some of their responses suggesting that they were aware of the importance of a familiar face. and that a woman in labour might prefer to voice her fears to someone she knew rather than a stranger. This was also implied by tile men in Barbour's (1990) study, who said that, despite their partner being surrounded by experts who care, tile experts are strangers, therefore, it was necessary for them (the partners)to be there and be available. Most of the men expressed confidence that they would do a good job providing support for their partner. Nonetheless, as some responses indicated, some men were subject to various fears. One fear, voiced by two men, was tile possibility of their partner dying: You know, the extreme of her dying through childbirth which you hear of, not as much hopefully nowadays as it used to be but urn, it is er, you know, a worry at tile back of the mind. Hopefully its something you know, that won't happen. Statistics can state, you know, whatever, but at the end of the day I don't want to be a statistic, I want her here, and I want my, our child. (Mr C, first interview) These fears may have little substance; but, as the quote above from one of the two men suggests, a number of expectant fathers are aware that it is only about two generations ago that childbirth and its complications were a major cause of death in the U K in women of childbearing age. Other fears the men admitted included the possibility of fainting, panicking and wondering whether they would have the ability to 'keep it together'. Two expectant fathers were concerned that they would fail to respond to the needs of their partner, and one stated that, despite attendance at childbirth education, he still wondered how he would manage: When I go in with 'L' I'll be completely shooting in the dark. (Mr H, first interview) It appears that the men mostly kept their fears to themselves, and this was a finding in two other studies (Shapiro 1987, Mercer et al. 1988). It may simply be a desire not to worry their partner. For some men, however, keeping fears to oneself will reflect early negative childhood or adolescent experiences when they sought help on emotional
A place for the partner
issues (Bryant 1985). It may also reflect the working situation, which one participant likened to 'being on test' (H first interview). Habitual wariness can foster lower trust of others in other areas of life, as the same participant admitted (Barbee et al. 1993). Alternatively, keeping fears to oneself may be a male characteristic, and this may be reinlbrced, in part, from cultural sanctions which permit the voicing of fears in women, but discourages this in men (Shapiro 1987, Mercer et al. 1988).
New fathers recalling their supporting role when the fathers were asked, at the second interview, how well they had managed their supporting role, their recollections mostly evoked good memories but, more importantly, almost all the men felt that they were needed: I think mmm she could're got by without me but, she would definitely preferred me to be there. (Mr A, second interview) Their role as supporter was possibly made easier by the fact that all the women in this study had a vaginal deliver and none, it seems, had a prolonged labour, a difficult normal or difficult instrumental delivery. The men's responses initially focussed on practical helpful behaviours such as encouraging relaxation, massaging, providing 'Entonox'; trying to make the woman comfortable, getting her drinks, walking with her, holding her hand, holding her leg, and cooling her down. It may simply show that men wanted to be of practical help to their partner, and it would seem that men find it easier to provide practical help, especially in a task situation where doing well is important (Winstead et al. 1992). Alternatively, men may more easily absorb the practical aspects of childbirth education, or they may feel that they are expected to perform what they have been taught (Keirse et al. 1989, Nichols 1993): There wasn't mopping the brow or anything [i.e. the mother did not want it]. I tried,.., she shooed me a w a y . . . I think the main care is support . . . . (Mr G, second interview) The women did not always want the practical support offered. As the quote above suggests, one partner needed to redefine his role and, instead, provide quiet support, thus enabling his partner to cope with her distress in a calmer frame of mind. Anecdotal evidence points to many women preferring calm, not stimulation (Chapman 1991) and this finding emerged from some other new fathers' non-specific, more general responses. It appears that what was more important for the labouring woman was the physical presence of her partner. Nichols
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(1993) similarly found that the mere presence of the male partner was frequently mentioned as a helpful supportive behaviour. However, in this study, it appeared also to signal to the woman that physical and psychological support was available, which could be called upon when necessary: ... and when she wanted somebody there to lean on that's just a question of standing there and being a convenient thing to lean on when, when she needs it. (Mr D, second interview) Although the fathers believed that they had coped well with providing support, it appeared that, for some of them, there were periods of anxiety. One father, in order to minimise his anxiety, relied on cues from the midwives: All I did was just take a back seat a n d . . , do what they wanted me to d o . . . a n y t h i n g I would have done it. (Mr E, second interview) Chapman (1992) likewise reported that some men looked to others such as their partner or professionals, to guide them in their helping role. Other men in this study were not so fortunate. Two fathers were simultaneously trying to keep their partner happy whilst hiding feelings of anxiety, guilt and, for one, perceived eventual uselessness because he was not sure what he had to do. Nochols (1993) similarly found that the labour experience for fathers evoked a significant number of negative feelings, such as anxiety. This suggests that some men require direction as to how best they can help, possibly, that is more in keeping with their natural helping role, rather than a role they are not accustomed to (Chapman 1992). The layout of the delivery room may also increase feelings of uselessness and was implicit in a response from one mother. She described how her partner was getting in the way because of the equipment, as was unable to rub her back. Equipment can obstruct true involvement and, although the obstruction is an incidental consequence of layout, it can emphasise a power imbalance between the partner and the staff (Sherr 1995).
New mothers' recollections of support From the mothers' responses it quickly became apparent that they were very grateful for the support their partner gave. Practical support behaviours particularly appreciated included: holding her hand, helping her with relaxation, running her a bath, being someone to lean one, making her tea, massaging her back, and reminding her how to use the Entonox. The tops of my legs they really did h u r t . . . j u s t being there rubbing my legs was the main
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issue of the thing really. (Mrs C, second interview) It was evident that, for most mothers, practical support from the partner was an important component of the supporting process overall. One mother, for instance, appeared grateful for all forms of support even when, objectively, some were possibly counterproductive. I wasn't particularly amused at being offered fish and chips . . . . That's just trying to help. (Mrs B, second interview) Further probing revealed that what seemed to override any possible mismatch in the practical support the partner provided was the relief on the mother's part of having someone taking control. Two explanations are possible. First, as Chapman (1992) found, some women have a high desire for their partner to be in charge of the labour process, or they view their partner as being a critical factor in their own ability to maintain overall control during labour. Second, the literature on support suggests that positive feelings about the partner generally enable the woman to focus on the quality overall of supportive interactions (e.g. warmth, empathy) and to overlook ineffective ones (Cutrona & Suhr 1992). This is enhanced in an intimate relationship, which frequently includes an understanding of how best to communicate support needs without causing upset (Barbee et al. 1993, Johnson et al. 1993): ... I think if you've got someone who is quite close to you they know t h a t . . , if I said 'no no no you are not doing it right' he felt he wasn't going to be h u r t . . . i f it was a complete s t r a n g e r . . . I can't tell them that they aren't doing it right. (Mrs D, second interview) Although appreciating the practical support provided by their partner, many women possibly put more value on forms of psychological support, including 'being there', 'you can do it', accepting abuse, making eye-to-eye contact, •giving encouragement and 'being available': When the midwife was saying push, he was saying push and giving me lots of encouragement,.., if he hadn't been there I probably wouldn't have pushed that little bit more and they would have had to use forceps or whatever . . . . (Mrs E, second interview) w h a t . . , gave you the encouragement to go on? (Interviewer) Him just being there. (Mrs F, second interview) The mothers appreciated and appeared to benefit from the supportive presence of their partner. The partner 'being there' meant that immediate
physical and psychological support was available, which could be called upon when necessary. As Stolte (1987) found, and as the quote above possibly suggests, the partner does not necessarily have to give practical help: mere presence is supportive. Indirect backing for this hypothesis is provided by Cutrona & Suhr (1992), who found that high levels of emotional support were associated with recipient satisfaction regardless of event controllability. Thus, the supportive presence of the partner can act as a morale booster by alleviating the mother's distress. This is turn may enable her to tackle her labour in a calmer frame of mind, and increase her confidence and motivation to continue. In contrast, as the response of one new mother suggests, when the partner was not present, fear could set in. She recalled wanting someone there to express her pain to 'or just to hold', and finding 'there was no-one there' (G, second interview). Although the use of touch during labour has not been evaluated (Hodnett 1998) the mother's response suggests that the availability of her partner's hand was comforting, and she missed it when he was not with her. A review of responses overall suggests that the presence of the partner at this critical time had an emotional impact on the well-being of all the new mothers; they felt valued, cared for, and appreciated for what they were going through. Although these feelings have been documented by many researchers as salient in the months before and after the first baby is born (Brown & Harris 1978, Simons et al. 1993, Longsdon et al. 1994), responses from the women in this study indicated that they are equally important and necessary during childbirth and, for nearly all of them, it led to a satisfying birth experience.
Limitations of the study The focus of this study was on exploring the women's expectations and experiences of support provided by their partner during childbirth, and the thoughts and feelings of the male partner concerning their supporting role. A number of limitations are inherent in this study, such as one geographical location, little ethnic diversity, and a small sample size. Additionally, a refusal rate of 39% by the women's partners raises questions about how those who refused to participate in the study may have differed. A commitment to participate in research that involves two interviews may have influenced some of the men in their decision not to participate. Lack of time was cited by one expectant father, and lack of interest was the main reason given by two other men. In two further instances this was also given as a reason by women, who acted as 'gatekeepers'. Stress may have been a factor for the one couple who
A place for the partner
were not successfully contacted, by telephone, for the second interview (couple H). Finally, the phenomenon of support could have been more completely explored by taking account of other key players, for instance, community and hospital carers.
CONCLUSIONS
The women in this study wanted their partner to be with them and give support during childbirth. The men similarly wanted to be present and provide support during this stressful time. The literature on male partner support during labour, throws up conflicting opinions (Sherr 1995, Keinan 1997). It was stated earlier that the male partner might not necessarily be the appropriate person to act as supporter during labour. However, research also indicates that the presence of the father-to-be is helpful and valuable to most women in labour. The results of this study corroborate this view: the mothers were very satisfied with the support provided by their partner. Although all the fathers were pleased with the support they had provided, some found childbirth a stressful experience. They were uncertain a b o u t their support role, the well-being of their partner during labour and any complications that might occur, either to the m o t h e r or the baby. A l t h o u g h anxiety is more likely to occur when labour is prolonged and painful, even when childbirth is apparently straightforward some men will find the experience stressful. There is a slight risk of a vicious circle: the w o m a n makes support demands the partner c a n n o t meet; he becomes visibly stressed, and this in turn adds to the w o m a n ' s stress and consequent demands. Findings from this study have given an insight into the expectations women have of the support they believe they will need from their partner during labour and delivery, and into the patterns and types of support offered by their partner. The findings have also given an insight as to how men view their supporting role during childbirth. Nevertheless, this was only an initial exploration, and further research is needed to deepen our understanding of the psychological factors which enhance or dampen supportive endeavours. Results suggest, however, that the father's needs should be assessed regularly during childbirth, as some fathers may need support. On this basis, the labouring couple should not be left alone for a long period and relief for the partner should be at hand. Midwives need to use their time economically, but a wise midwife will, during labour, through informal conversation and observation, form a rough judgement of those
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non-critical or ancillary tasks that may be allotted to the partner. Additional study is needed to explore any conditions that may affect the provision of support. For instance, when the data were coded, it became apparent that, apart from anxieties at the time, some fathers-to-be have fears before and following child-birth. Other ethnic groups should be included and there is a need for more representation from social classes IV and V. Finally, this research should be extended to women who are having a second or subsequent baby and their partners, as their needs are likely to be different. The psychological literature on social support can increase our understanding of the interactions involved when a woman is supported by her partner during labour and delivery. Little of this literature, or of other psychological theories, has been integrated into labour-ward practice and, although there has been an attempt to bridge the gap in this study, it is only a very small beginning (Slade 1993, Sherr 1995). It is hoped, however, that research grounded in the experience of a wider range of couples can move on from these initial findings, and that a psychological framework for the support given by expectant fathers during labour can be more fully constructed. ACKNOWLEDGEMENTS
The study reported in this article is based on a research dissertation that formed part of the requirements for a Master's Degree in the Social Sciences in Health Psychology. I wish to thank Sandra Horn, my supervisor, Department of Psychology, University of Southampton, for her comments and advice on an earlier draft of this manuscript. REFERENCES
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