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Integrative Review of Fathers’ Perspectives on Breastfeeding Support
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Integrative Review of Fathers’ Perspectives on Breastfeeding Support Patcharin Ngoenthong, Nantaporn Sansiriphun, Warunee Fongkaew, and Nonglax Chaloumsuk
Correspondence Nantaporn Sansiriphun, RN, PhD, Faculty of Nursing, Chiang Mai University, 110/ 406 Inthawaroros Road, Suthep District, Chiang Mai, Thailand, 50200. [email protected] Keywords breastfeeding father’s perspective infant feeding integrative review
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ABSTRACT Objective: To critically review and summarize the results of published articles on fathers’ perspectives regarding breastfeeding support for their partners. Data Sources: We searched the following databases for articles published between January 2010 and May 2019: CINAHL, MEDLINE, PubMed, Scopus, Web of Science, ThaiJo, and ThaiLis. We included articles published in English and Thai. Study Selection: After duplicates were removed, our initial search yielded 3,927 articles. We excluded articles in accordance with pre-established criteria. We performed a quality appraisal of the selected full-text articles and ultimately included 27 in this review. Data Extraction: We analyzed studies that met inclusion criteria and extracted and organized data related to fathers’ perspectives on breastfeeding support into a structured table. Data Synthesis: The data were synthesized into three themes: Attitude Toward Breastfeeding, Knowledge of Breastfeeding, and Fathers’ Perceptions of the Breastfeeding Support They Provided. Conclusion: Our results showed that fathers’ perspectives on breastfeeding support were shaped by their knowledge of breastfeeding and participation in the breastfeeding process. To promote breastfeeding, further research is required to design and implement appropriate interventions to help fathers effectively support their breastfeeding partners.
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Patcharin Ngoenthong, RN, MNS, is a lecturer in the Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand. Nantaporn Sansiriphun, RN, PhD, is an associate professor in the Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand. Warunee Fongkaew RN, PhD is a professor in the Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand. Nonglax Chaloumsuk, RN, MNS., PhD, is a lecturer in the Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand.
The authors report no conflict of interest or relevant financial relationships.
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reastfeeding and human milk are the normative standards for infant feeding and nutrition. Breast milk is widely acknowledged as the optimal source of nutrition for infants. It delivers the ideal nutrients for human brain growth, including microminerals, and is an outstanding source of immunologic protection. The American Academy of Pediatrics (2012) strongly recommended exclusive breastfeeding for 6 months and in combination with other appropriate foods for 1 year or longer. Similarly, the World Health Organization (2016) and the United Nations Children’s Fund (2018) recommended that infants should be exclusively breastfed for the first 6 months of life and then continue to be breastfed in combination with appropriate food for an additional 2 years. Fathers play critical roles in the initiation and continuation of breastfeeding through the support they provide, which has received attention from an increasing number of researchers in recent years
(Bich, Hoa, & Ma˚lqvist, 2014; Odom, Li, Scanlon, Perrine, & Strawn, 2014; Palsson, Persson, Ekelin, Hallstrom, & Kvist, 2017; Rantisari, Thaha, & Thamrin, 2017; Rempel, Rempel, & Moore, 2017; Sherriff, Panton, & Hall, 2014; Tadesse, Zelenko, Mulugeta, & Gallegos, 2018; Yourkavitch, Alvey, Prosnitz, & Thomas, 2017). Fathers are increasingly expected to share parenting duties with their partners and to assume active roles as infant caregivers (Williams, Hewison, Wildman, & Roskell, 2013). They have been recognized as important sources of support for women during pregnancy and the postpartum period (Widarrson, Engstrom, Tyden, Lundberg, & Hammar, 2015). In the postpartum period, fathers can engage in parenting practices and establish routines to support infant feeding, including breastfeeding (Kowlessar, Fox, & Wittkowski, 2014). Evidence indicates that the positive attitude of the father influences his partner to initiate and
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Fathers’ Perspectives on Breastfeeding Support
Despite perceived obstacles, fathers are eager to be involved in the breastfeeding of their infants.
maintain breastfeeding (Hansen, Tesch, & Ayton, 2018; Odom et al., 2014; Tadesse et al., 2018). Fathers who viewed breastfeeding positively understood its benefits and often encouraged their partners to continue breastfeeding for as long as possible (Matos, Oliveira, Coelho, Dodt, & Moura, 2015; Sansiriphun, Kantaruksa, Klunklin, Baosuang, & Liamtrirat, 2015). On the other hand, women discontinued breastfeeding early when their infants’ fathers had negative attitudes and did not accept breastfeeding (Gewa & Chepkemboi, 2016). Prior research in this area provides lessons applicable to specific contexts, including Thailand, which has adopted the Baby Friendly Hospital Initiative as a national breastfeeding strategy. The Baby Friendly Hospital Initiative includes the provision of hospital or health facility– based capacity to support breastfeeding. The policy was instituted in 1997 and significantly limits aggressive and inappropriate marketing of breastmilk substitutes (Thepha, Marais, Bell, & Muangpin, 2017). In recent years, another strategy in Thailand has been to help fathers actively support breastfeeding through various projects, including parents’ school, which provides antenatal and postnatal education classes for parents; the Family Love Bonding project to promote breastfeeding in the community through home visits after birth; and childbirth preparation classes in which fathers are encouraged to support their partners (Thailand Department of Health, 2011). However, Sansiriphun and colleagues (2015) reported that fathers felt left out of these interventions because the information given was not directed to them. In a number of countries, fathers have been emphasized as one target in breastfeeding promotion because of their important roles in the breastfeeding practices of their partners (Ng, Shorey, & He, 2019; Sansiriphun et al., 2015; Tadesse et al., 2018). In one study (de Montigny et al., 2016), fathers indicated that breastfeeding was sometimes an obstacle to their relationships with their infants; they saw bottle feeding as a turning point or the beginning of greater involvement and thus symbolic of fatherhood.
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However, de Montigny et al. (2016) did not address fathers’ perspectives on breastfeeding support in their study. Findings of other studies on fathers and breastfeeding highlighted the critical importance of a father’s knowledge about and attitude toward breastfeeding (Abhinaya, Arunprasath, & Padmasani, 2016; Matos et al., 2015; Robert, Coppieters, Swennen, & Dramaix, 2015) or focused on educational breastfeeding ¨ zlu¨ses & C programs for parents (O ¸ elebioglu, 2014; Tadesse et al., 2018; Yourkavitch et al., 2017). Therefore, the aim of our integrative review was to critically review and summarize the results of published articles on fathers’ perspectives regarding breastfeeding support for their partners.
Methods Design An integrative review combines the evidence from studies with a diversity of research methodologies toward the goal of more comprehensive perspectives on a specific phenomenon or problem. The results of the integrative review capture the depth and breadth of the topic, which enhances a holistic understanding and provides information for further research or policy initiatives (Oermann & Hays, 2016). We used the integrative review method described by Whittemore and Knafl (2005) to synthesize data on fathers’ perceptions of breastfeeding and support for their partners from various primary sources.
Data Sources and Search Methods We searched electronic databases, including CINAHL, PubMed, MEDLINE, Scopus, Web of Science, ThaiJo, and ThaiLis, using the following keywords and Medical Subject Headings (MeSH) under the main search areas of fathers’ perspectives, breastfeeding support, and designs: father*, father’s role, role, father’s view, perspective of father, perspective*, perceive*, perceptions (and/or) breastfeeding, breastfeeding*, breastfeeding context, support*, involve*, partner*, support his partner, experiences*, infant feeding, breastfeeding perspective* (and/or) intervention, qualitative, quantitative, descriptive, RCT, and quasi*. Studies published from January 2010 to May 2019 were included in the search. The inclusion criteria for articles were as follows: (a) publication between January 2010 and May 2019 in Thai or English; (b) primary research based on quantitative or qualitative designs, including randomized controlled trials
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Identification Screening
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Additional record identified from reference list (n = 15)
Articles retrieved from an initial search of the databases (n = 3,912)
Total potential records identified from the search strategy (n = 3,927)
Articles excluded after limiting to those published in English and Thai (n = 2,786) • CINAHL (n = 768) • PubMed (n = 565) • MEDLINE (n = 286 ) • Scopus (n = 667) • Web of Science (n = 488) • ThaiJo & ThaiLis (n = 12) Articles retrieved after duplicates removed (n = 213) Articles remaining for title and abstract screening (n = 2,573)
Eligibility
Full-text articles retrieved to assess for eligibility (n = 298)
Exclusion screening (n = 2,275) • Title removed (n = 1,843) • Abstract removed (n = 432 )
Full-text articles excluded (n = 271) • Intervention did not target fathers (n = 168) • Articles are not related to fathers and breastfeeding support (n = 79) • Focused on co-parenting but did not mention about fathers (n = 16) • Re-publication and rewritten by using the same data (n = 8)
Articles included in the review (n = 27)
Included
print & web 4C=FPO
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Quantitative study (n = 13)
Qualitative study (n = 14)
Figure 1. PRISMA flowchart on literature search process, strategies, and outcomes.
and quasiexperimental, descriptive, or qualitative studies; and (c) findings related to fathers’ perspectives regarding breastfeeding support for their partners or interventions focused on breastfeeding that predominantly targeted fathers. Publications that are generally not peer reviewed were excluded, such as reports or newsletters; those from academic institutions, corporations, blogs, conference proceedings, and census reports; and books and theses. Published literature reviews also were excluded.
Search Outcome and Study Selection The search and study selection processes are depicted in the Preferred Reporting Item for Systematic Reviews and Meta-Analysis (PRISMA) flowchart (Moher, Liberati, Tetzlaff, & Altman, 2009; see Figure 1). The preliminary search yielded 3,927 research articles. After the removal of duplicates and the application of exclusion criteria, the titles and abstracts of 2,573 articles were reviewed, and 2,275 articles were excluded. After the final assessment of eligible full-text articles, 27 articles were included in our review.
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Fathers’ Perspectives on Breastfeeding Support
Fathers need more input, information, and acknowledgment from nurses and midwives to provide required breastfeeding support.
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Although it is not essential to calculate quality scores for integrative review methods, we used QualSyst, a standardized assessment tool for the evaluation of research studies across diverse fields, to assess the quality of methods for each study and thus enhance the rigor of our review. We adopted a QualSyst score of greater than 0.55 as the cutoff for the inclusion of research studies across diverse fields (Kmet, Lee, & Cook, 2004). The results of the quality appraisal for the 13 quantitative and 14 qualitative studies are included in Supplemental Tables S1 and S2, respectively.
Data Extraction and Synthesis We analyzed 27 articles to extract and tabulate the following data: authors/year/country, study design, objective of the study, sample size, data collection methods, main finding, QualSyst score, and our comments regarding methods. The data extracted and analysis are presented in Supplemental Table S3 and Table 1. After all articles were reviewed, the first author (P.N.) conducted thematic analysis as described by Braun and Clarke (2006). To start, the first author read and reread each study, making notes on early impressions. Next, each segment of data was coded to capture the findings that related to the purpose of the study, and categories were developed. The third step was to define themes using a matrix table and mapping. Then, the second author (N.S.) reviewed all themes and checked supporting data to ensure the themes were sound. Next, the third (W.F.) and fourth (N.C.) authors discussed and agreed on the list of themes. The findings from each article were categorized accordingly.
Results Summary of Study Characteristics
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A total of 4,336 individuals (3,615 fathers and 721 mothers) participated in the 27 studies. The largest sample size was 699 participants (Maycock et al., 2013), and the smallest sample size was 6 participants (Hounsome & Dowling, 2018). Five studies were conducted in the United Kingdom (Brown & Davies, 2014; Datta, Graham, & Welling, 2012; Hounsome & Dowling, 2018; Merritt, Vogel, Ladbury, & Johnson, 2019; Sherriff & Hall, 2011); three studies were
conducted in Australia (Hansen et al., 2018; Kuliukas et al., 2019; Maycock et al., 2013); three studies were conducted in Canada (Abbass-Dick, Stern, Nelson, Watson, & Dennis, 2015; de Montigny, Gervais, Larivie`re-Bastien, & St-Arneault, 2018; Rempel & Rempel, 2011); three studies were conducted in the United States (Jolly et al., 2013; Lovera, Sanderson, Bogle, & Acosta, 2010; Mitchell-Box & Braun, 2012); two studies were conducted in Malaysia (Mohamad, Draman, Muhamad, & Yusoff, 2015; Muda, Rozi, ¨ zlu¨ses & & Aakhtar, 2017) and Turkey (O C ¸ elebioglu, 2014; Taspinar, C ¸ oban, Ku¨c¸u¨k, & Sirin, 2013); and one study each was conduct- Q3 ed in Brazil (Azevedo et al., 2016), Iran (Raesi, Shariat, Nayeri, Raji, & Dalili, 2014), China (Su & Ouyang, 2016), Ireland (Bennett, McCartney, & Kearney, 2016), Jordan (Abu-Abbas, Kassab, & Shelash, 2016), Pakistan (Mithani, Premani, Kurji, & Rashid, 2015), South Africa (Mgolozeli, Shilubane, Khoza, & Nesamvuni, 2018), Sweden (Palmqvist, Za¨ther, & Larsson, 2015), and Vietnam (Bich, Long, & Hoa, 2019). Of the 27 articles selected for final analysis, 11 were qualitative descriptive studies (Azevedo et al., 2016; Brown & Davies, 2014; Datta et al., 2012; de Q4 Montigny et al., 2018; Hansen et al., 2018; Mgolozeli et al., 2018; Muda et al., 2017; Palmqvist et al., 2015; Rempel & Rempel, 2011; Mithani et al., 2015; Sherriff & Hall, 2011). Two studies were grounded theory studies (Merritt et al., 2019; Mitchell-Box & Braun, 2012), and one was a phenomenological study (Hounsome & Dowling, 2018). Of the 13 quantitative studies, three were randomized controlled trials (Abbass-Dick et al., 2015; Maycock et al., 2013; Raesi et al., 2014), three were quasiexperimental (Bich et al., 2019; ¨ zlu¨ses & C O ¸ elebioglu, 2014; Su & Ouyang, 2016), five were cross-sectional (Abu-Abbas et al., 2016; Bennett et al., 2016; Jolly et al., 2013; Mohamad et al., 2015; Tainar et al., 2016), one was a mixed Q5 method study (Kuliukas et al., 2019), and one was a cohort study (Lovera et al., 2010). Extracted data for each study are presented in Supplemental Table S3. Studies were grouped according to three themes with accompanying subthemes: Attitude Toward Breastfeeding, Knowledge of Breastfeeding, and Fathers’ Perceptions of the Breastfeeding Support They Provided.
Attitude Toward Breastfeeding Positive Attitudes Toward Breastfeeding. A positive attitude toward breastfeeding was
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Table 1: Summary of Data Analysis Theme
Subtheme
Attitude Toward Breastfeeding
Positive Attitudes
Authors Azevedo et al., 2016; Bennett et al., 2016; Brown & Davies,
Toward Breastfeeding
2014; Datta et al., 2012; de Montigny et al., 2018; Hansen et al., 2018; Hounsome & Dowling, 2018; Merritt et al., 2019; Mgolozeli et al., 2018; Mitchell-Box & Braun, 2012; Mithani et al., 2015; Muda et al., 2017; Palmqvist et al., 2015; Rempel & Rempel, 2011; Sherriff & Hall, 2011
Negative Attitudes
Bennett et al., 2016; Brown & Davies, 2014; Hansen et al.,
Toward Breastfeeding
2018; de Montigny et al., 2018; Hounsome & Dowling, 2018; Merritt et al., 2019; Mgolozeli et al., 2018; Mitchell-Box & Braun, 2012; Muda et al., 2017; Palmqvist et al., 2015; Rempel & Rempel, 2011; Sherriff & Hall, 2011
Knowledge of Breastfeeding
Basic Aspect of Breastfeeding Knowledge
Azevedo et al., 2016; Bennett et al., 2016; Brown & Davies, 2014; Datta et al., 2012; Hounsome & Dowling, 2018; Merritt et al., 2019; Mgolozeli et al., 2018; Mitchell-Box & Braun, 2012; Mithani et al., 2015; Muda et al., 2017; Palmqvist et al., 2015; Rempel & Rempel, 2011; Sherriff & Hall, 2011
Information Needs of Fathers
Azevedo et al., 2016; Bennett et al., 2016; Brown & Davies, 2014; de Montigny et al., 2018; Hansen et al., 2018; Hounsome & Dowling, 2018; Merritt et al., 2019; MitchellBox & Braun, 2012; Sherriff & Hall, 2011
Provision of Breastfeeding Education
Abass-Dick et al., 2015; Bich, Long, & Hoa, 2019; Kuliukas et al., 2019; Lovera et al., 2010; Maycock et al., 2013; ¨ zlu¨ses & C O ¸ elebioglu, 2014; Raesi et al., 2014; Su & Ouyang, 2016
Fathers’ Perceptions of the
Breastfeeding is the Right of Women
Datta et al., 2012; de Montigny et al., 2018; Hansen et al.,
Breastfeeding Support They
2018; Hounsome & Dowling, 2018; Muda et al., 2017;
Provided
Rempel & Rempel, 2011 Taking Part in Breastfeeding Support
Azevedo et al., 2016; Bennett et al., 2016; Datta et al., 2012; de Montigny et al., 2018; Hansen et al., 2018; Mgolozeli et al., 2018; Mitchell-Box & Braun, 2012; Muda et al., 2017; Palmqvist et al., 2015; Rempel & Rempel, 2011
Perceptions of Contextual Factors Related to Breastfeeding
characterized by the belief that breastfeeding is a necessary activity for infants. The participating fathers perceived the advantages of breastfeeding and disadvantages of formula feeding. They wanted their infants to be breastfed and worked to ensure this was the case (Azevedo et al., 2016; Bennett et al., 2016; Brown & Davies, 2014; Datta et al., 2012; de Montigny et al., 2018; Hansen et al., 2018; Hounsome & Dowling, 2018; Merritt et al., 2019; Mgolozeli et al., 2018; Mitchell-Box & Braun, 2012; Mithani et al., 2015; Muda et al., 2017; Palmqvist et al., 2015; Rempel & Rempel, 2011; Sherriff & Hall, 2011). Most fathers felt that breastfeeding
Hounsome & Dowling, 2018; Mgolozeli et al., 2018; Mithani et al., 2015
is a natural process, and they had no knowledge of potential breastfeeding-related problems (Datta et al., 2012; Hansen et al., 2018; Merritt et al., 2019). In addition, Mithani et al. (2015) identified the interesting perspective of fathers in Pakistan that breastfeeding can decrease domestic violence because men value breastfeeding mothers, and they perceive breastfeeding women to be very weak physically. Negative Attitudes Toward Breastfeeding. Fathers reported negative attitudes about breastfeeding when they felt unable to assist, helpless, anxious, or guilty about being unable to
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help their partners overcome breastfeeding problems. Some fathers reported less intimacy with their partners because they felt excluded and dismissed by their partners and health care professionals. This resulted in feelings of powerlessness and uselessness in the breastfeeding process (Bennett et al., 2016; Brown & Davies, 2014; Hansen et al., 2018; Hounsome & Dowling, 2018; Merritt et al., 2019; Mgolozeli et al., 2018; Mitchell-Box & Braun, 2012; de Montigny et al., 2018; Muda et al., 2017; Palmqvist et al., 2015; Rempel & Rempel, 2011; Sherriff & Hall, 2011). Bennett and colleagues (2016) reported that fathers thought breastfeeding resulted in fewer opportunities for them to bond with their infants. They felt frustrated that they could not directly feed their infants, and bottle feeding was only an intermittent practice. Some fathers felt unprepared to support their partners’ breastfeeding and were shocked when the mothers encountered breastfeeding problems (Hansen et al., 2018; Merritt et al., 2019). In addition, some fathers reported that breastfeeding education only targeted mothers, and that fathers were invisible in antenatal classes (Merritt et al., 2019; Sherriff & Hall, 2011). Fathers also felt that professional advice about breastfeeding for mothers was too pushy and did not take into consideration that the mothers tried and experienced difficulty (Merritt et al., 2019). Fathers often felt discomfort and shame when their partners breastfed in front of family members or in public because of the sexualization of breasts in the media (Bennett et al., 2016; Brown & Davies, 2014; Mitchell-Box & Braun, 2012).
Knowledge of Breastfeeding Basic Aspects of Breastfeeding Knowledge. Fathers obtained knowledge about breastfeeding from their partners, supportive health care professionals, and the Internet (Bennett et al., 2016; Brown & Davies, 2014). Although most fathers focused on the benefits of breastfeeding for their infants, theys had only superficial knowledge about the other benefits of breastfeeding, including the positive effect on the mother–infant relationship, financial savings related to the decreased need for infant formula, immune-boosting properties, and positive effect on infant growth and development (Azevedo et al., 2016; Bennett et al., 2016; Brown & Davies, 2014; Datta et al., 2012; Hounsome & Dowling, 2018; Merritt et al., 2019; Mgolozeli et al., 2018; Mitchell-Box & Braun, 2012; Mithani et al., 2015;
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Muda et al., 2017; Palmqvist et al., 2015; Rempel & Rempel, 2011; Sherriff & Hall, 2011). Information Needs of Fathers. Most fathers needed specific information to enhance their knowledge and empower them to help their partners (Azevedo et al., 2016; Bennett et al., 2016; Brown & Davies, 2014; de Montigny et al., 2018; Hansen et al., 2018; Hounsome & Dowling, 2018; Merritt et al., 2019; Mitchell-Box & Braun, 2012; Sherriff & Hall, 2011). For example, they wanted to know how to resolve breastfeeding problems, including latching, blocked ducts, and mastitis. Fathers also needed information on the benefits of breastfeeding, the adequacy of breastfeeding for the infant, clarifications about the three stages of milk production (colostrum, transitional milk, and mature milk), positions for breastfeeding, risks of formula feeding, and ways in which they can support their partners while breastfeeding (Azevedo et al., 2016; Bennett et al., 2016; Brown & Davies, 2014; Mithani et al., 2015). Provision of Breastfeeding Education. In eight studies, researchers tested breastfeeding interventions for fathers. Three of these studies were conducted as part of an education program during the antenatal period (Kuliukas et al., 2019; Raesi et al., 2014; Su & Ouyang, 2016), four were conducted from the antenatal through the postnatal periods (Abbass-Dick et al., 2015; Bich et al., 2019; Lovera et al., 2010; Maycock et al., 2013), and one began on the day that a woman was admitted to the hospital for childbirth and continued until she and the newborn were discharged from hospital ¨ zlu¨ses & C (O ¸ elebioglu, 2014). The interventions mostly lasted between 60 to 120 minutes and included the use of slide presentations, breast models, infant manikins, or booklets about breastfeeding. The interventions provided basic knowledge about breastfeeding physiology and techniques (Maycock et al., 2013; Su & Ouyang, 2016). In the Bich et al. (2019) study, fathers in the intervention group were given breastfeeding education materials, counseling services at community health centers, and household visits. Lovera et al. (2010) trained fathers of children being breastfed as peer dad counselors to provide counseling in prenatal and postnatal classes. The interventions in these studies produced significant improvements in breastfeeding initiation (Bich et al., 2019), duration (Lovera et al., 2010; Maycock et al., 2013, Su & Ouyang, 2016), and exclusivity (Bich et al., 2019;
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Su & Ouyang, 2016). All the strategies mentioned were found to be effective and successful.
Fathers’ Perceptions of the Breastfeeding Support They Provided Breastfeeding Is the Right of Women. Our findings revealed that fathers wanted their partners to maintain breastfeeding and that they were generally involved in breastfeeding practices and decisions related to infant feeding. Although the fathers tried to help their partners overcome breastfeeding problems, they were aware of the effect of breastfeeding difficulties on mothers and felt that the decision to cease breastfeeding should be made by the women (Datta et al., 2012; de Montigny et al., 2018; Hansen et al., 2018; Hounsome & Dowling, 2018; Muda et al., 2017; Rempel & Rempel, 2011). Datta et al. (2012) found that the fathers perceived breastfeeding as involving the mother’s body, time, and energy, which made them concerned about the mother’s health and emotions. For this reason, they felt that women have the right to make the decisions to stop or continue breastfeeding and did not hesitate to support their partners’ decisions. Taking Part in Breastfeeding Support. Fathers perceived breastfeeding support to be one of their roles. In 10 studies, researchers reported that some fathers took over household chores because they could not participate directly in the breastfeeding process and wanted to assist their partners (Azevedo et al., 2016; Bennett et al., 2016; Datta et al., 2012; de Montigny et al., 2018; Hansen et al., 2018; Mgolozeli et al., 2018; Mitchell-Box & Braun, 2012; Muda et al., 2017; Palmqvist et al., 2015; Rempel & Rempel, 2011). They also took care of their infants and generally supported their partners, particularly through positive conversations about breastfeeding and providing mothers with supplementary diets to improve milk supply. Perceptions of Contextual Factors Related to Breastfeeding. In three studies, researchers addressed contextual and cultural factors related to fathers’ perspectives on the support of breastfeeding (Hounsome & Dowling, 2018; Mgolozeli et al., 2018; Mithani et al., 2015). According to Hounsome and Dowling (2018), men’s awareness of breastfeeding starts at an early age and is mediated by the visibility of breastfeeding in their communities. Mgolozeli and colleagues (2018) reported that, in patriarchal societies, men
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Future studies should be focused on breastfeeding information specifically targeted at fathers and the development of appropriate programs for them.
who supported breastfeeding were not regarded as real men. Mithani and colleagues (2015) concluded that four factors are related to fathers’ support of breastfeeding. The first is a social context in which the role of the male parent is only that of a breadwinner, meaning that fathers are unable to do anything directly to help breastfeeding because they might be viewed as henpecked husbands. Thus, the cultural perception of masculinity and emphasis on the provision of financial support affect their support of breastfeeding. Second, paternity leave allows fathers to encourage and support their partners. Third, family members and health care providers can encourage and offer crucial support to fathers, without which early cessation of breastfeeding can result. Fourth, religious and traditional beliefs affect breastfeeding in ways that vary by context. For instance, in Islam, the father takes a role as a major driving force for breastfeeding by encouraging his wife to initiate and maintain breastfeeding because the Prophet Mohammed recommended that breast milk is a godly diet for infants and that mothers should breastfeed a child as long as possible.
Discussion The aim of our integrative review was to summarize existing knowledge related to fathers’ perspectives regarding breastfeeding support for their partners. Results from recent studies suggested the important role fathers play in encouraging breastfeeding, and our results suggest consensus about the centrality of this support. This implies that nurses and midwives should create strategies to encourage fathers to participate in the breastfeeding of their infants. Most fathers perceived the benefits of breastfeeding as better infant health, better relationship between mother and infant, and reduced cost of infant feeding. Benefits to the infant were the priority. According to Muda et al. (2017), fathers with knowledge about breastfeeding had positive attitudes and wished to encourage their partners’ breastfeeding. They perceived breastfeeding to be the right thing to do but did not qualify reasons. In addition, the studies included in our
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review revealed changes in fathers’ perceptions on breastfeeding in public; in particular, they overcame feeling embarrassed to the extent that they viewed breastfeeding in public as respectable and were comfortable with it. When fathers had negative attitudes about breastfeeding, these attitudes originated from obstacles to participation, and fathers felt unable to assist or were excluded. Fathers can create various obstacles to breastfeeding (Rempel et al., 2017). Positive perceptions helped fathers support their partners to breastfeed, influenced feeding decisions, and encouraged continuation of breastfeeding. When fathers had negative attitudes, these attitudes influenced mothers’ attitudes about breastfeeding, and mothers intended to breastfeed for shorter periods of time (Rempel et al., 2017; Su & Ouyang, 2016).
include supporting the mother’s decision to continue breastfeeding, providing physical and emotional support for breastfeeding, and being an active member of the team to facilitate breastfeeding, such as setting aside time to support the partner in what she is doing. Nurses and midwives cannot provide day-to-day support, making fathers the primary source of support, and strong support from fathers may be associated with psychological benefits for women that vary according to the sociocultural setting and traditional beliefs of their communities (Mithani et al., 2015; Oliveira et al., 2017). According to Zakar, Zakar, Zaheer, and Fischer (2018), cultural beliefs, such as the belief that colostrum is dirty and too heavy for infants’ consumption, influence parental perceptions and knowledge of breastfeeding practice.
Limitations Breastfeeding knowledge influenced the positive perspectives of the fathers who worked to ensure their infants were breastfed. However, our findings suggest that most fathers have limited breastfeeding knowledge. The basic aspect of breastfeeding knowledge emphasized the benefits for infants. The reasons fathers had limited breastfeeding knowledge might be that fathers were unable to attend any education classes and that information about breastfeeding was passed on to them only via their partners, which in turn indicates that nurses and midwives might not interact enough directly with fathers. Fathers wanted to know how to support their partners to initiate or continue breastfeeding and practical strategies about what to do to address breastfeeding problems. Interventions for fathers, such as antenatal education, counseling, peer support, and educational materials written specifically for fathers, are meant to improve breastfeeding initiation and continuation rates. Therefore, any intervention should account specifically for the information needs of fathers (Bich et al., 2019; Lovera et al., 2010; Maycock et al., 2013; Su & Ouyang, 2016). The perception of support provided refers to how a father perceives himself as interested in and eager to support his breastfeeding partner. Fathers’ support has been identified as one of the strongest predictors of exclusive breastfeeding (Chanapai, Sinsuksai, Thananowan, & Phahuwatanakorn., 2014; Linares, Rayens, Dozier, Wiggins, & Dignan, 2015; Oliveira et al., 2017). Critical activities of the father
8
There are some limitations to our review that should be acknowledged. First, we considered only articles published in Thai or English and may have omitted valuable research written in other languages. Second, fathers’ perceptions regarding breastfeeding in some studies linked perceptions to cultural norms. However, only three studies in our review provided sufficient evidence to support this conclusion. Third, the interventions and breastfeeding perspectives in the studies included involved and supportive fathers. Therefore, sampling bias may exist. In addition, interventions for fathers in our review took different forms across studies, such as educational topics, materials, or methods. Conclusions cannot be drawn about the efficiency and effectiveness of interventions on fathers’ practices or support of breastfeeding. Fourth, there are few studies related to fathers’ perspectives on breastfeeding support for their partners. To confirm data saturation, further studies are needed.
Implications for Practice and Research Findings from our review showed that fathers’ perspectives on breastfeeding are shaped by their breastfeeding knowledge. Fathers’ positive perspectives influenced them to encourage and support their breastfeeding partners. Our findings point to ways in which nurses and midwives can improve breastfeeding outcomes through enhanced participation of fathers during the pregnancy, labor and birth, and postpartum periods in breastfeeding interventions. Health care providers must understand and address the needs
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of fathers, including the provision of support and information to help them fulfill their critical roles. Although the reviewed studies clarified the multidimensionality of fathers’ perspectives on breastfeeding, a key finding is fathers’ perceived lack of breastfeeding knowledge. To encourage fathers’ participation in breastfeeding, there is a need for accessible prenatal and postnatal breastfeeding education sessions for fathers. Breastfeeding education should include basic information, such as the benefits of breastfeeding and disadvantages of formula, as well as advanced knowledge on the realities of breastfeeding. Postnatal education should focus on fathers’ breastfeeding problems, breastfeeding techniques, and how to support their partners, particularly during the early days and weeks after the infant’s birth. In our review, fathers revealed their concerns about the opportunities available to them to develop relationships with their infants when their partners are breastfeeding. This concern should be considered by health care providers, and fathers should be included in any appropriate process related to childbearing, including during labor and birth. Fathers have indicated their willingness to provide support for their partners, including emotional support. In addition, fathers should participate in skin-to-skin contact to develop a relationship with their infants and promote continued breastfeeding. The findings of our review did not sufficiently cover the perspectives of fathers who did not support breastfeeding because of the sampling bias in the included studies. Fathers are often considered harder to reach for research than mothers, although they have also likely been less targeted. Hence, future studies should target this population and use simple random sampling to avoid sampling bias.
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paternity leave and effective community collaboration. Community-based strategies are important in policy design and the delivery of breastfeeding promotion programs for fathers. The approaches to community-based breastfeeding promotion and support depend on the context of each setting and culture. There is a need for further studies to examine the effects of breastfeeding programs for fathers because there is currently insufficient evidence to determine the effectiveness of these programs. For an improved understanding of the influence of these interventions on fathers, mixed methods research designs may be helpful.
Conclusion The findings of our integrated review indicated that the fathers who participated in the 27 studies were largely enthusiastic to support their partners’ breastfeeding, and their positive perspectives originated from breastfeeding knowledge and participation in the breastfeeding process. If the level of breastfeeding knowledge is inadequate, fathers may be unwilling to support their partner’s breastfeeding. Nurses and midwives should engage and support fathers to ensure that they are encouraged to support their partners’ breastfeeding. Appropriate intervention programs for fathers should be evaluated in future research. Q7
Supplementary Material Note: To access the supplementary material that accompanies this article, visit the online version of the Journal of Obstetric, Gynecologic, & Neonatal Nursing at http://jognn.org and at https://doi.org/10.1016/j.jogn.2019.09.005.
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Integrative Review of Fathers’ Perspectives on Breastfeeding Support Patcharin Ngoenthong, Nantaporn Sansiriphun, Warunee Fongkaew, and Nonglax Chaloumsuk
Correspondence Nantaporn Sansiriphun, RN, PhD, Faculty of Nursing, Chiang Mai University, 110/ 406 Inthawaroros Road, Suthep District, Chiang Mai, Thailand, 50200. [email protected] Keywords breastfeeding father’s perspective infant feeding integrative review
Q8
ABSTRACT Objective: To critically review and summarize the results of published articles on fathers’ perspectives regarding breastfeeding support for their partners. Data Sources: We searched the following databases for articles published between January 2010 and May 2019: CINAHL, MEDLINE, PubMed, Scopus, Web of Science, ThaiJo, and ThaiLis. We included articles published in English and Thai. Study Selection: After duplicates were removed, our initial search yielded 3,927 articles. We excluded articles in accordance with pre-established criteria. We performed a quality appraisal of the selected full-text articles and ultimately included 27 in this review. Data Extraction: We analyzed studies that met inclusion criteria and extracted and organized data related to fathers’ perspectives on breastfeeding support into a structured table. Data Synthesis: The data were synthesized into three themes: Attitude Toward Breastfeeding, Knowledge of Breastfeeding, and Fathers’ Perceptions of the Breastfeeding Support They Provided. Conclusion: Our results showed that fathers’ perspectives on breastfeeding support were shaped by their knowledge of breastfeeding and participation in the breastfeeding process. To promote breastfeeding, further research is required to design and implement appropriate interventions to help fathers effectively support their breastfeeding partners.
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Patcharin Ngoenthong, RN, MNS, is a lecturer in the Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand. Nantaporn Sansiriphun, RN, PhD, is an associate professor in the Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand. Warunee Fongkaew RN, PhD is a professor in the Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand. Nonglax Chaloumsuk, RN, MNS., PhD, is a lecturer in the Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand.
The authors report no conflict of interest or relevant financial relationships.
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reastfeeding and human milk are the normative standards for infant feeding and nutrition. Breast milk is widely acknowledged as the optimal source of nutrition for infants. It delivers the ideal nutrients for human brain growth, including microminerals, and is an outstanding source of immunologic protection. The American Academy of Pediatrics (2012) strongly recommended exclusive breastfeeding for 6 months and in combination with other appropriate foods for 1 year or longer. Similarly, the World Health Organization (2016) and the United Nations Children’s Fund (2018) recommended that infants should be exclusively breastfed for the first 6 months of life and then continue to be breastfed in combination with appropriate food for an additional 2 years. Fathers play critical roles in the initiation and continuation of breastfeeding through the support they provide, which has received attention from an increasing number of researchers in recent years
(Bich, Hoa, & Ma˚lqvist, 2014; Odom, Li, Scanlon, Perrine, & Strawn, 2014; Palsson, Persson, Ekelin, Hallstrom, & Kvist, 2017; Rantisari, Thaha, & Thamrin, 2017; Rempel, Rempel, & Moore, 2017; Sherriff, Panton, & Hall, 2014; Tadesse, Zelenko, Mulugeta, & Gallegos, 2018; Yourkavitch, Alvey, Prosnitz, & Thomas, 2017). Fathers are increasingly expected to share parenting duties with their partners and to assume active roles as infant caregivers (Williams, Hewison, Wildman, & Roskell, 2013). They have been recognized as important sources of support for women during pregnancy and the postpartum period (Widarrson, Engstrom, Tyden, Lundberg, & Hammar, 2015). In the postpartum period, fathers can engage in parenting practices and establish routines to support infant feeding, including breastfeeding (Kowlessar, Fox, & Wittkowski, 2014). Evidence indicates that the positive attitude of the father influences his partner to initiate and
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Fathers’ Perspectives on Breastfeeding Support
Despite perceived obstacles, fathers are eager to be involved in the breastfeeding of their infants.
maintain breastfeeding (Hansen, Tesch, & Ayton, 2018; Odom et al., 2014; Tadesse et al., 2018). Fathers who viewed breastfeeding positively understood its benefits and often encouraged their partners to continue breastfeeding for as long as possible (Matos, Oliveira, Coelho, Dodt, & Moura, 2015; Sansiriphun, Kantaruksa, Klunklin, Baosuang, & Liamtrirat, 2015). On the other hand, women discontinued breastfeeding early when their infants’ fathers had negative attitudes and did not accept breastfeeding (Gewa & Chepkemboi, 2016). Prior research in this area provides lessons applicable to specific contexts, including Thailand, which has adopted the Baby Friendly Hospital Initiative as a national breastfeeding strategy. The Baby Friendly Hospital Initiative includes the provision of hospital or health facility– based capacity to support breastfeeding. The policy was instituted in 1997 and significantly limits aggressive and inappropriate marketing of breastmilk substitutes (Thepha, Marais, Bell, & Muangpin, 2017). In recent years, another strategy in Thailand has been to help fathers actively support breastfeeding through various projects, including parents’ school, which provides antenatal and postnatal education classes for parents; the Family Love Bonding project to promote breastfeeding in the community through home visits after birth; and childbirth preparation classes in which fathers are encouraged to support their partners (Thailand Department of Health, 2011). However, Sansiriphun and colleagues (2015) reported that fathers felt left out of these interventions because the information given was not directed to them. In a number of countries, fathers have been emphasized as one target in breastfeeding promotion because of their important roles in the breastfeeding practices of their partners (Ng, Shorey, & He, 2019; Sansiriphun et al., 2015; Tadesse et al., 2018). In one study (de Montigny et al., 2016), fathers indicated that breastfeeding was sometimes an obstacle to their relationships with their infants; they saw bottle feeding as a turning point or the beginning of greater involvement and thus symbolic of fatherhood.
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However, de Montigny et al. (2016) did not address fathers’ perspectives on breastfeeding support in their study. Findings of other studies on fathers and breastfeeding highlighted the critical importance of a father’s knowledge about and attitude toward breastfeeding (Abhinaya, Arunprasath, & Padmasani, 2016; Matos et al., 2015; Robert, Coppieters, Swennen, & Dramaix, 2015) or focused on educational breastfeeding ¨ zlu¨ses & C programs for parents (O ¸ elebioglu, 2014; Tadesse et al., 2018; Yourkavitch et al., 2017). Therefore, the aim of our integrative review was to critically review and summarize the results of published articles on fathers’ perspectives regarding breastfeeding support for their partners.
Methods Design An integrative review combines the evidence from studies with a diversity of research methodologies toward the goal of more comprehensive perspectives on a specific phenomenon or problem. The results of the integrative review capture the depth and breadth of the topic, which enhances a holistic understanding and provides information for further research or policy initiatives (Oermann & Hays, 2016). We used the integrative review method described by Whittemore and Knafl (2005) to synthesize data on fathers’ perceptions of breastfeeding and support for their partners from various primary sources.
Data Sources and Search Methods We searched electronic databases, including CINAHL, PubMed, MEDLINE, Scopus, Web of Science, ThaiJo, and ThaiLis, using the following keywords and Medical Subject Headings (MeSH) under the main search areas of fathers’ perspectives, breastfeeding support, and designs: father*, father’s role, role, father’s view, perspective of father, perspective*, perceive*, perceptions (and/or) breastfeeding, breastfeeding*, breastfeeding context, support*, involve*, partner*, support his partner, experiences*, infant feeding, breastfeeding perspective* (and/or) intervention, qualitative, quantitative, descriptive, RCT, and quasi*. Studies published from January 2010 to May 2019 were included in the search. The inclusion criteria for articles were as follows: (a) publication between January 2010 and May 2019 in Thai or English; (b) primary research based on quantitative or qualitative designs, including randomized controlled trials
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Identification Screening
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Additional record identified from reference list (n = 15)
Articles retrieved from an initial search of the databases (n = 3,912)
Total potential records identified from the search strategy (n = 3,927)
Articles excluded after limiting to those published in English and Thai (n = 2,786) • CINAHL (n = 768) • PubMed (n = 565) • MEDLINE (n = 286 ) • Scopus (n = 667) • Web of Science (n = 488) • ThaiJo & ThaiLis (n = 12) Articles retrieved after duplicates removed (n = 213) Articles remaining for title and abstract screening (n = 2,573)
Eligibility
Full-text articles retrieved to assess for eligibility (n = 298)
Exclusion screening (n = 2,275) • Title removed (n = 1,843) • Abstract removed (n = 432 )
Full-text articles excluded (n = 271) • Intervention did not target fathers (n = 168) • Articles are not related to fathers and breastfeeding support (n = 79) • Focused on co-parenting but did not mention about fathers (n = 16) • Re-publication and rewritten by using the same data (n = 8)
Articles included in the review (n = 27)
Included
print & web 4C=FPO
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Quantitative study (n = 13)
Qualitative study (n = 14)
Figure 1. PRISMA flowchart on literature search process, strategies, and outcomes.
and quasiexperimental, descriptive, or qualitative studies; and (c) findings related to fathers’ perspectives regarding breastfeeding support for their partners or interventions focused on breastfeeding that predominantly targeted fathers. Publications that are generally not peer reviewed were excluded, such as reports or newsletters; those from academic institutions, corporations, blogs, conference proceedings, and census reports; and books and theses. Published literature reviews also were excluded.
Search Outcome and Study Selection The search and study selection processes are depicted in the Preferred Reporting Item for Systematic Reviews and Meta-Analysis (PRISMA) flowchart (Moher, Liberati, Tetzlaff, & Altman, 2009; see Figure 1). The preliminary search yielded 3,927 research articles. After the removal of duplicates and the application of exclusion criteria, the titles and abstracts of 2,573 articles were reviewed, and 2,275 articles were excluded. After the final assessment of eligible full-text articles, 27 articles were included in our review.
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Fathers’ Perspectives on Breastfeeding Support
Fathers need more input, information, and acknowledgment from nurses and midwives to provide required breastfeeding support.
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Although it is not essential to calculate quality scores for integrative review methods, we used QualSyst, a standardized assessment tool for the evaluation of research studies across diverse fields, to assess the quality of methods for each study and thus enhance the rigor of our review. We adopted a QualSyst score of greater than 0.55 as the cutoff for the inclusion of research studies across diverse fields (Kmet, Lee, & Cook, 2004). The results of the quality appraisal for the 13 quantitative and 14 qualitative studies are included in Supplemental Tables S1 and S2, respectively.
Data Extraction and Synthesis We analyzed 27 articles to extract and tabulate the following data: authors/year/country, study design, objective of the study, sample size, data collection methods, main finding, QualSyst score, and our comments regarding methods. The data extracted and analysis are presented in Supplemental Table S3 and Table 1. After all articles were reviewed, the first author (P.N.) conducted thematic analysis as described by Braun and Clarke (2006). To start, the first author read and reread each study, making notes on early impressions. Next, each segment of data was coded to capture the findings that related to the purpose of the study, and categories were developed. The third step was to define themes using a matrix table and mapping. Then, the second author (N.S.) reviewed all themes and checked supporting data to ensure the themes were sound. Next, the third (W.F.) and fourth (N.C.) authors discussed and agreed on the list of themes. The findings from each article were categorized accordingly.
Results Summary of Study Characteristics
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A total of 4,336 individuals (3,615 fathers and 721 mothers) participated in the 27 studies. The largest sample size was 699 participants (Maycock et al., 2013), and the smallest sample size was 6 participants (Hounsome & Dowling, 2018). Five studies were conducted in the United Kingdom (Brown & Davies, 2014; Datta, Graham, & Welling, 2012; Hounsome & Dowling, 2018; Merritt, Vogel, Ladbury, & Johnson, 2019; Sherriff & Hall, 2011); three studies were
conducted in Australia (Hansen et al., 2018; Kuliukas et al., 2019; Maycock et al., 2013); three studies were conducted in Canada (Abbass-Dick, Stern, Nelson, Watson, & Dennis, 2015; de Montigny, Gervais, Larivie`re-Bastien, & St-Arneault, 2018; Rempel & Rempel, 2011); three studies were conducted in the United States (Jolly et al., 2013; Lovera, Sanderson, Bogle, & Acosta, 2010; Mitchell-Box & Braun, 2012); two studies were conducted in Malaysia (Mohamad, Draman, Muhamad, & Yusoff, 2015; Muda, Rozi, ¨ zlu¨ses & & Aakhtar, 2017) and Turkey (O C ¸ elebioglu, 2014; Taspinar, C ¸ oban, Ku¨c¸u¨k, & Sirin, 2013); and one study each was conduct- Q3 ed in Brazil (Azevedo et al., 2016), Iran (Raesi, Shariat, Nayeri, Raji, & Dalili, 2014), China (Su & Ouyang, 2016), Ireland (Bennett, McCartney, & Kearney, 2016), Jordan (Abu-Abbas, Kassab, & Shelash, 2016), Pakistan (Mithani, Premani, Kurji, & Rashid, 2015), South Africa (Mgolozeli, Shilubane, Khoza, & Nesamvuni, 2018), Sweden (Palmqvist, Za¨ther, & Larsson, 2015), and Vietnam (Bich, Long, & Hoa, 2019). Of the 27 articles selected for final analysis, 11 were qualitative descriptive studies (Azevedo et al., 2016; Brown & Davies, 2014; Datta et al., 2012; de Q4 Montigny et al., 2018; Hansen et al., 2018; Mgolozeli et al., 2018; Muda et al., 2017; Palmqvist et al., 2015; Rempel & Rempel, 2011; Mithani et al., 2015; Sherriff & Hall, 2011). Two studies were grounded theory studies (Merritt et al., 2019; Mitchell-Box & Braun, 2012), and one was a phenomenological study (Hounsome & Dowling, 2018). Of the 13 quantitative studies, three were randomized controlled trials (Abbass-Dick et al., 2015; Maycock et al., 2013; Raesi et al., 2014), three were quasiexperimental (Bich et al., 2019; ¨ zlu¨ses & C O ¸ elebioglu, 2014; Su & Ouyang, 2016), five were cross-sectional (Abu-Abbas et al., 2016; Bennett et al., 2016; Jolly et al., 2013; Mohamad et al., 2015; Tainar et al., 2016), one was a mixed Q5 method study (Kuliukas et al., 2019), and one was a cohort study (Lovera et al., 2010). Extracted data for each study are presented in Supplemental Table S3. Studies were grouped according to three themes with accompanying subthemes: Attitude Toward Breastfeeding, Knowledge of Breastfeeding, and Fathers’ Perceptions of the Breastfeeding Support They Provided.
Attitude Toward Breastfeeding Positive Attitudes Toward Breastfeeding. A positive attitude toward breastfeeding was
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Table 1: Summary of Data Analysis Theme
Subtheme
Attitude Toward Breastfeeding
Positive Attitudes
Authors Azevedo et al., 2016; Bennett et al., 2016; Brown & Davies,
Toward Breastfeeding
2014; Datta et al., 2012; de Montigny et al., 2018; Hansen et al., 2018; Hounsome & Dowling, 2018; Merritt et al., 2019; Mgolozeli et al., 2018; Mitchell-Box & Braun, 2012; Mithani et al., 2015; Muda et al., 2017; Palmqvist et al., 2015; Rempel & Rempel, 2011; Sherriff & Hall, 2011
Negative Attitudes
Bennett et al., 2016; Brown & Davies, 2014; Hansen et al.,
Toward Breastfeeding
2018; de Montigny et al., 2018; Hounsome & Dowling, 2018; Merritt et al., 2019; Mgolozeli et al., 2018; Mitchell-Box & Braun, 2012; Muda et al., 2017; Palmqvist et al., 2015; Rempel & Rempel, 2011; Sherriff & Hall, 2011
Knowledge of Breastfeeding
Basic Aspect of Breastfeeding Knowledge
Azevedo et al., 2016; Bennett et al., 2016; Brown & Davies, 2014; Datta et al., 2012; Hounsome & Dowling, 2018; Merritt et al., 2019; Mgolozeli et al., 2018; Mitchell-Box & Braun, 2012; Mithani et al., 2015; Muda et al., 2017; Palmqvist et al., 2015; Rempel & Rempel, 2011; Sherriff & Hall, 2011
Information Needs of Fathers
Azevedo et al., 2016; Bennett et al., 2016; Brown & Davies, 2014; de Montigny et al., 2018; Hansen et al., 2018; Hounsome & Dowling, 2018; Merritt et al., 2019; MitchellBox & Braun, 2012; Sherriff & Hall, 2011
Provision of Breastfeeding Education
Abass-Dick et al., 2015; Bich, Long, & Hoa, 2019; Kuliukas et al., 2019; Lovera et al., 2010; Maycock et al., 2013; ¨ zlu¨ses & C O ¸ elebioglu, 2014; Raesi et al., 2014; Su & Ouyang, 2016
Fathers’ Perceptions of the
Breastfeeding is the Right of Women
Datta et al., 2012; de Montigny et al., 2018; Hansen et al.,
Breastfeeding Support They
2018; Hounsome & Dowling, 2018; Muda et al., 2017;
Provided
Rempel & Rempel, 2011 Taking Part in Breastfeeding Support
Azevedo et al., 2016; Bennett et al., 2016; Datta et al., 2012; de Montigny et al., 2018; Hansen et al., 2018; Mgolozeli et al., 2018; Mitchell-Box & Braun, 2012; Muda et al., 2017; Palmqvist et al., 2015; Rempel & Rempel, 2011
Perceptions of Contextual Factors Related to Breastfeeding
characterized by the belief that breastfeeding is a necessary activity for infants. The participating fathers perceived the advantages of breastfeeding and disadvantages of formula feeding. They wanted their infants to be breastfed and worked to ensure this was the case (Azevedo et al., 2016; Bennett et al., 2016; Brown & Davies, 2014; Datta et al., 2012; de Montigny et al., 2018; Hansen et al., 2018; Hounsome & Dowling, 2018; Merritt et al., 2019; Mgolozeli et al., 2018; Mitchell-Box & Braun, 2012; Mithani et al., 2015; Muda et al., 2017; Palmqvist et al., 2015; Rempel & Rempel, 2011; Sherriff & Hall, 2011). Most fathers felt that breastfeeding
Hounsome & Dowling, 2018; Mgolozeli et al., 2018; Mithani et al., 2015
is a natural process, and they had no knowledge of potential breastfeeding-related problems (Datta et al., 2012; Hansen et al., 2018; Merritt et al., 2019). In addition, Mithani et al. (2015) identified the interesting perspective of fathers in Pakistan that breastfeeding can decrease domestic violence because men value breastfeeding mothers, and they perceive breastfeeding women to be very weak physically. Negative Attitudes Toward Breastfeeding. Fathers reported negative attitudes about breastfeeding when they felt unable to assist, helpless, anxious, or guilty about being unable to
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Fathers’ Perspectives on Breastfeeding Support
help their partners overcome breastfeeding problems. Some fathers reported less intimacy with their partners because they felt excluded and dismissed by their partners and health care professionals. This resulted in feelings of powerlessness and uselessness in the breastfeeding process (Bennett et al., 2016; Brown & Davies, 2014; Hansen et al., 2018; Hounsome & Dowling, 2018; Merritt et al., 2019; Mgolozeli et al., 2018; Mitchell-Box & Braun, 2012; de Montigny et al., 2018; Muda et al., 2017; Palmqvist et al., 2015; Rempel & Rempel, 2011; Sherriff & Hall, 2011). Bennett and colleagues (2016) reported that fathers thought breastfeeding resulted in fewer opportunities for them to bond with their infants. They felt frustrated that they could not directly feed their infants, and bottle feeding was only an intermittent practice. Some fathers felt unprepared to support their partners’ breastfeeding and were shocked when the mothers encountered breastfeeding problems (Hansen et al., 2018; Merritt et al., 2019). In addition, some fathers reported that breastfeeding education only targeted mothers, and that fathers were invisible in antenatal classes (Merritt et al., 2019; Sherriff & Hall, 2011). Fathers also felt that professional advice about breastfeeding for mothers was too pushy and did not take into consideration that the mothers tried and experienced difficulty (Merritt et al., 2019). Fathers often felt discomfort and shame when their partners breastfed in front of family members or in public because of the sexualization of breasts in the media (Bennett et al., 2016; Brown & Davies, 2014; Mitchell-Box & Braun, 2012).
Knowledge of Breastfeeding Basic Aspects of Breastfeeding Knowledge. Fathers obtained knowledge about breastfeeding from their partners, supportive health care professionals, and the Internet (Bennett et al., 2016; Brown & Davies, 2014). Although most fathers focused on the benefits of breastfeeding for their infants, theys had only superficial knowledge about the other benefits of breastfeeding, including the positive effect on the mother–infant relationship, financial savings related to the decreased need for infant formula, immune-boosting properties, and positive effect on infant growth and development (Azevedo et al., 2016; Bennett et al., 2016; Brown & Davies, 2014; Datta et al., 2012; Hounsome & Dowling, 2018; Merritt et al., 2019; Mgolozeli et al., 2018; Mitchell-Box & Braun, 2012; Mithani et al., 2015;
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Muda et al., 2017; Palmqvist et al., 2015; Rempel & Rempel, 2011; Sherriff & Hall, 2011). Information Needs of Fathers. Most fathers needed specific information to enhance their knowledge and empower them to help their partners (Azevedo et al., 2016; Bennett et al., 2016; Brown & Davies, 2014; de Montigny et al., 2018; Hansen et al., 2018; Hounsome & Dowling, 2018; Merritt et al., 2019; Mitchell-Box & Braun, 2012; Sherriff & Hall, 2011). For example, they wanted to know how to resolve breastfeeding problems, including latching, blocked ducts, and mastitis. Fathers also needed information on the benefits of breastfeeding, the adequacy of breastfeeding for the infant, clarifications about the three stages of milk production (colostrum, transitional milk, and mature milk), positions for breastfeeding, risks of formula feeding, and ways in which they can support their partners while breastfeeding (Azevedo et al., 2016; Bennett et al., 2016; Brown & Davies, 2014; Mithani et al., 2015). Provision of Breastfeeding Education. In eight studies, researchers tested breastfeeding interventions for fathers. Three of these studies were conducted as part of an education program during the antenatal period (Kuliukas et al., 2019; Raesi et al., 2014; Su & Ouyang, 2016), four were conducted from the antenatal through the postnatal periods (Abbass-Dick et al., 2015; Bich et al., 2019; Lovera et al., 2010; Maycock et al., 2013), and one began on the day that a woman was admitted to the hospital for childbirth and continued until she and the newborn were discharged from hospital ¨ zlu¨ses & C (O ¸ elebioglu, 2014). The interventions mostly lasted between 60 to 120 minutes and included the use of slide presentations, breast models, infant manikins, or booklets about breastfeeding. The interventions provided basic knowledge about breastfeeding physiology and techniques (Maycock et al., 2013; Su & Ouyang, 2016). In the Bich et al. (2019) study, fathers in the intervention group were given breastfeeding education materials, counseling services at community health centers, and household visits. Lovera et al. (2010) trained fathers of children being breastfed as peer dad counselors to provide counseling in prenatal and postnatal classes. The interventions in these studies produced significant improvements in breastfeeding initiation (Bich et al., 2019), duration (Lovera et al., 2010; Maycock et al., 2013, Su & Ouyang, 2016), and exclusivity (Bich et al., 2019;
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Su & Ouyang, 2016). All the strategies mentioned were found to be effective and successful.
Fathers’ Perceptions of the Breastfeeding Support They Provided Breastfeeding Is the Right of Women. Our findings revealed that fathers wanted their partners to maintain breastfeeding and that they were generally involved in breastfeeding practices and decisions related to infant feeding. Although the fathers tried to help their partners overcome breastfeeding problems, they were aware of the effect of breastfeeding difficulties on mothers and felt that the decision to cease breastfeeding should be made by the women (Datta et al., 2012; de Montigny et al., 2018; Hansen et al., 2018; Hounsome & Dowling, 2018; Muda et al., 2017; Rempel & Rempel, 2011). Datta et al. (2012) found that the fathers perceived breastfeeding as involving the mother’s body, time, and energy, which made them concerned about the mother’s health and emotions. For this reason, they felt that women have the right to make the decisions to stop or continue breastfeeding and did not hesitate to support their partners’ decisions. Taking Part in Breastfeeding Support. Fathers perceived breastfeeding support to be one of their roles. In 10 studies, researchers reported that some fathers took over household chores because they could not participate directly in the breastfeeding process and wanted to assist their partners (Azevedo et al., 2016; Bennett et al., 2016; Datta et al., 2012; de Montigny et al., 2018; Hansen et al., 2018; Mgolozeli et al., 2018; Mitchell-Box & Braun, 2012; Muda et al., 2017; Palmqvist et al., 2015; Rempel & Rempel, 2011). They also took care of their infants and generally supported their partners, particularly through positive conversations about breastfeeding and providing mothers with supplementary diets to improve milk supply. Perceptions of Contextual Factors Related to Breastfeeding. In three studies, researchers addressed contextual and cultural factors related to fathers’ perspectives on the support of breastfeeding (Hounsome & Dowling, 2018; Mgolozeli et al., 2018; Mithani et al., 2015). According to Hounsome and Dowling (2018), men’s awareness of breastfeeding starts at an early age and is mediated by the visibility of breastfeeding in their communities. Mgolozeli and colleagues (2018) reported that, in patriarchal societies, men
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Future studies should be focused on breastfeeding information specifically targeted at fathers and the development of appropriate programs for them.
who supported breastfeeding were not regarded as real men. Mithani and colleagues (2015) concluded that four factors are related to fathers’ support of breastfeeding. The first is a social context in which the role of the male parent is only that of a breadwinner, meaning that fathers are unable to do anything directly to help breastfeeding because they might be viewed as henpecked husbands. Thus, the cultural perception of masculinity and emphasis on the provision of financial support affect their support of breastfeeding. Second, paternity leave allows fathers to encourage and support their partners. Third, family members and health care providers can encourage and offer crucial support to fathers, without which early cessation of breastfeeding can result. Fourth, religious and traditional beliefs affect breastfeeding in ways that vary by context. For instance, in Islam, the father takes a role as a major driving force for breastfeeding by encouraging his wife to initiate and maintain breastfeeding because the Prophet Mohammed recommended that breast milk is a godly diet for infants and that mothers should breastfeed a child as long as possible.
Discussion The aim of our integrative review was to summarize existing knowledge related to fathers’ perspectives regarding breastfeeding support for their partners. Results from recent studies suggested the important role fathers play in encouraging breastfeeding, and our results suggest consensus about the centrality of this support. This implies that nurses and midwives should create strategies to encourage fathers to participate in the breastfeeding of their infants. Most fathers perceived the benefits of breastfeeding as better infant health, better relationship between mother and infant, and reduced cost of infant feeding. Benefits to the infant were the priority. According to Muda et al. (2017), fathers with knowledge about breastfeeding had positive attitudes and wished to encourage their partners’ breastfeeding. They perceived breastfeeding to be the right thing to do but did not qualify reasons. In addition, the studies included in our
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Fathers’ Perspectives on Breastfeeding Support
review revealed changes in fathers’ perceptions on breastfeeding in public; in particular, they overcame feeling embarrassed to the extent that they viewed breastfeeding in public as respectable and were comfortable with it. When fathers had negative attitudes about breastfeeding, these attitudes originated from obstacles to participation, and fathers felt unable to assist or were excluded. Fathers can create various obstacles to breastfeeding (Rempel et al., 2017). Positive perceptions helped fathers support their partners to breastfeed, influenced feeding decisions, and encouraged continuation of breastfeeding. When fathers had negative attitudes, these attitudes influenced mothers’ attitudes about breastfeeding, and mothers intended to breastfeed for shorter periods of time (Rempel et al., 2017; Su & Ouyang, 2016).
include supporting the mother’s decision to continue breastfeeding, providing physical and emotional support for breastfeeding, and being an active member of the team to facilitate breastfeeding, such as setting aside time to support the partner in what she is doing. Nurses and midwives cannot provide day-to-day support, making fathers the primary source of support, and strong support from fathers may be associated with psychological benefits for women that vary according to the sociocultural setting and traditional beliefs of their communities (Mithani et al., 2015; Oliveira et al., 2017). According to Zakar, Zakar, Zaheer, and Fischer (2018), cultural beliefs, such as the belief that colostrum is dirty and too heavy for infants’ consumption, influence parental perceptions and knowledge of breastfeeding practice.
Limitations Breastfeeding knowledge influenced the positive perspectives of the fathers who worked to ensure their infants were breastfed. However, our findings suggest that most fathers have limited breastfeeding knowledge. The basic aspect of breastfeeding knowledge emphasized the benefits for infants. The reasons fathers had limited breastfeeding knowledge might be that fathers were unable to attend any education classes and that information about breastfeeding was passed on to them only via their partners, which in turn indicates that nurses and midwives might not interact enough directly with fathers. Fathers wanted to know how to support their partners to initiate or continue breastfeeding and practical strategies about what to do to address breastfeeding problems. Interventions for fathers, such as antenatal education, counseling, peer support, and educational materials written specifically for fathers, are meant to improve breastfeeding initiation and continuation rates. Therefore, any intervention should account specifically for the information needs of fathers (Bich et al., 2019; Lovera et al., 2010; Maycock et al., 2013; Su & Ouyang, 2016). The perception of support provided refers to how a father perceives himself as interested in and eager to support his breastfeeding partner. Fathers’ support has been identified as one of the strongest predictors of exclusive breastfeeding (Chanapai, Sinsuksai, Thananowan, & Phahuwatanakorn., 2014; Linares, Rayens, Dozier, Wiggins, & Dignan, 2015; Oliveira et al., 2017). Critical activities of the father
8
There are some limitations to our review that should be acknowledged. First, we considered only articles published in Thai or English and may have omitted valuable research written in other languages. Second, fathers’ perceptions regarding breastfeeding in some studies linked perceptions to cultural norms. However, only three studies in our review provided sufficient evidence to support this conclusion. Third, the interventions and breastfeeding perspectives in the studies included involved and supportive fathers. Therefore, sampling bias may exist. In addition, interventions for fathers in our review took different forms across studies, such as educational topics, materials, or methods. Conclusions cannot be drawn about the efficiency and effectiveness of interventions on fathers’ practices or support of breastfeeding. Fourth, there are few studies related to fathers’ perspectives on breastfeeding support for their partners. To confirm data saturation, further studies are needed.
Implications for Practice and Research Findings from our review showed that fathers’ perspectives on breastfeeding are shaped by their breastfeeding knowledge. Fathers’ positive perspectives influenced them to encourage and support their breastfeeding partners. Our findings point to ways in which nurses and midwives can improve breastfeeding outcomes through enhanced participation of fathers during the pregnancy, labor and birth, and postpartum periods in breastfeeding interventions. Health care providers must understand and address the needs
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of fathers, including the provision of support and information to help them fulfill their critical roles. Although the reviewed studies clarified the multidimensionality of fathers’ perspectives on breastfeeding, a key finding is fathers’ perceived lack of breastfeeding knowledge. To encourage fathers’ participation in breastfeeding, there is a need for accessible prenatal and postnatal breastfeeding education sessions for fathers. Breastfeeding education should include basic information, such as the benefits of breastfeeding and disadvantages of formula, as well as advanced knowledge on the realities of breastfeeding. Postnatal education should focus on fathers’ breastfeeding problems, breastfeeding techniques, and how to support their partners, particularly during the early days and weeks after the infant’s birth. In our review, fathers revealed their concerns about the opportunities available to them to develop relationships with their infants when their partners are breastfeeding. This concern should be considered by health care providers, and fathers should be included in any appropriate process related to childbearing, including during labor and birth. Fathers have indicated their willingness to provide support for their partners, including emotional support. In addition, fathers should participate in skin-to-skin contact to develop a relationship with their infants and promote continued breastfeeding. The findings of our review did not sufficiently cover the perspectives of fathers who did not support breastfeeding because of the sampling bias in the included studies. Fathers are often considered harder to reach for research than mothers, although they have also likely been less targeted. Hence, future studies should target this population and use simple random sampling to avoid sampling bias.
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paternity leave and effective community collaboration. Community-based strategies are important in policy design and the delivery of breastfeeding promotion programs for fathers. The approaches to community-based breastfeeding promotion and support depend on the context of each setting and culture. There is a need for further studies to examine the effects of breastfeeding programs for fathers because there is currently insufficient evidence to determine the effectiveness of these programs. For an improved understanding of the influence of these interventions on fathers, mixed methods research designs may be helpful.
Conclusion The findings of our integrated review indicated that the fathers who participated in the 27 studies were largely enthusiastic to support their partners’ breastfeeding, and their positive perspectives originated from breastfeeding knowledge and participation in the breastfeeding process. If the level of breastfeeding knowledge is inadequate, fathers may be unwilling to support their partner’s breastfeeding. Nurses and midwives should engage and support fathers to ensure that they are encouraged to support their partners’ breastfeeding. Appropriate intervention programs for fathers should be evaluated in future research. Q7
Supplementary Material Note: To access the supplementary material that accompanies this article, visit the online version of the Journal of Obstetric, Gynecologic, & Neonatal Nursing at http://jognn.org and at https://doi.org/10.1016/j.jogn.2019.09.005.
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