This review was conducted in accordance with recommendations outlined in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement (44). It was undertaken adopting a narrative synthesis framework (45). The review protocol was registered with the International prospective register of systematic reviews PROSPERO with reference CRD42019127792.
Search Strategy
This was designed in conjunction with an experienced health studies librarian. In January 2019, eight identified electronic databases: ASSIA, CINAHL, EMBASE, MEDLINE, PsycINFO, PUBMED, Sage and Scopus were searched to identify eligible studies based on our search criteria. Grey literature was searched through the King’s Fund Library database, Ethos, The North Grey Literature Collection, Social Care Online and other charity websites such as the Refugee Council and Joseph Rowntree Foundation. The SPIDER tool (46) was used to identify search terms (see Table 1). These respective Medical Subject Headings (MeSH) terms were used including the Boolean terms “OR”/ “AND,” and truncation.
Table 1
Search terms using the SPIDER Tool
SPIDER
|
SPIDER Tool
|
Search Terms
|
Sample
|
S
|
“fathers” OR “men” OR “paternal” or “migrant fathers" OR “migrant men" OR “economic migrant fathers" OR "forced migrant fathers" OR "international migrant fathers" OR " undocumented migrant fathers" OR "documented migrant fathers" OR "educational migrant fathers" OR "transients" OR "refugee fathers" OR "asylum seeker fathers" OR "first generation migrants" OR "second generation migrants" OR "regular migrant fathers " OR (im) migrants OR "minority"
|
Phenomenon of Interest
|
P of I
|
"pregnancy experience" OR "pregnancy outcomes" OR "maternal experiences" “paternal experiences” OR "maternal health outcomes" OR “perinatal period” OR “antenatal period” OR “postnatal period” OR “postpartum period”
|
Design
|
D
|
"questionnaire*" OR "survey*" OR "interview*" OR "focus group*" OR "case study*" OR "observ*"
|
Evaluation
|
E
|
"view*" OR "experienc*" OR "opinion*" OR "attitude*" OR "perce*" OR "belie*" OR "feel*" OR "know*" OR "understand*"
|
Research Type
|
R
|
"qualitative" OR "quantitative" OR "mixed methods"
|
Included studies were all research designs, published from 2009 to 2021, in the English language. Studies were based on primary research focusing on fathers, exploring their experiences in pregnancy and up to six weeks following birth in high income countries, as defined by the World Bank (47).
Study Selection
The electronic search identified 2564 records, 13 records through grey literature databases/websites and an additional 23 records identified through hand-searching. After duplicates were removed, 2229 remained. Screening based on titles and abstracts identified 69 records. Screening of these full text records identified 12 papers from 12 separate studies, eight of which were qualitative studies, three quantitative and one mixed method studies (see figure 1).
Quality appraisal and Data extraction
All study details including study aims, participant details, study settings, methods of data collection, findings, results and analyses were initially extracted using standardised data extraction forms for qualitative (48), quantitative (49) and a self-devised mixed-method data extraction form. These were selected due to ease of use to thoroughly extract the data needed to address the review question.
The relevant data from each study was extracted including study aims, participant details, study settings, methods of data collection, findings, results and analyses. Standardised data extraction forms for qualitative (48) and quantitative (49) research were used. A self-devised mixed-method data extraction form was used for mixed methods study. This was created by adopting the contents of both the qualitative (48) and the quantitative (49) data extraction forms. Data extraction was checked by the co-authors and discrepancies resolved as a group. We adopted the QATSDD tool, a 16-item quality assessment tool (50) to appraise the quality all study designs. Criterion for each respective study was scored between 0- 3 and the items not relevant to a particular study were excluded.
The percentage of maximum quality score for each study was calculated by dividing the respective total quality score by the maximum score each study could have scored and multiplied by 100 (See Table 2). The methodological quality of the studies included in this review mostly ranged from high to medium, except for one study that scored low (51). However, no study was excluded based on quality.
Table 2
Quality score and percentage of maximum quality score of each included study
|
|
INCLUDED EMPIRICAL STUDIES
(SCORE- 1-3)
|
QUALITY CRITERIA
|
(Alio 2013)
|
(Bäckström 2011)
|
(Chin 2011)
|
(Fenwick 2012)
|
(Hildingsson 2011)
|
(Howarth 2016)
|
(Johansson 2012)
|
(Kuljanić 2016)
|
(Poh 2014)
|
(Porrett 2013)
|
(Premberg 2011)
|
(Riggs 2016)
|
Explicit theoretical framework
|
3
|
2
|
1
|
3
|
1
|
1
|
1
|
2
|
2
|
2
|
3
|
3
|
Aims and objectives stated in body
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
Clear setting description
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
Sample size considered in terms of analysis
|
3
|
3
|
2
|
1
|
3
|
3
|
3
|
3
|
2
|
3
|
3
|
2
|
Representative sample of target group of a reasonable size
|
1
|
2
|
2
|
2
|
3
|
3
|
3
|
3
|
2
|
3
|
2
|
2
|
Data collection procedure description
|
3
|
3
|
2
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
Data collection tool rationale
|
3
|
3
|
2
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
Detailed recruitment data
|
3
|
3
|
2
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
Statistical assessment of reliability and validity of measurement tool(s)
|
-
|
-
|
-
|
-
|
3
|
-
|
3
|
3
|
-
|
3
|
-
|
-
|
Fit between stated research question and data collection method (Quantitative)
|
-
|
-
|
-
|
-
|
3
|
-
|
3
|
3
|
-
|
3
|
-
|
-
|
Fit between stated research question and format/content of data collection tool (Qualitative)
|
3
|
3
|
3
|
3
|
-
|
3
|
3
|
-
|
3
|
-
|
3
|
3
|
Fit between research question and method of analysis
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
3
|
|
3
|
3
|
3
|
Good justification for analytical method
|
3
|
3
|
2
|
3
|
3
|
3
|
3
|
2
|
3
|
|
3
|
3
|
3
|
Assessment of reliability of analytical process (Qualitative only)
|
3
|
2
|
3
|
3
|
-
|
3
|
1
|
-
|
3
|
|
-
|
3
|
2
|
Evidence of user involvement in design
|
3
|
3
|
2
|
3
|
3
|
1
|
2
|
2
|
3
|
|
2
|
2
|
2
|
Strengths and limitations discussed critically
|
3
|
1
|
0
|
1
|
3
|
3
|
3
|
1
|
3
|
|
3
|
2
|
3
|
Total quality score for each study
|
40
|
37
|
30
|
37
|
40
|
38
|
43
|
37
|
36
|
|
40
|
39
|
38
|
Percentage of maximum quality score (%)
|
95.2
|
88.1
|
71.4
|
88.1
|
95.2
|
90.5
|
89.6
|
88.1
|
85.7
|
|
95.2
|
92.9
|
90.5
|
Adapted from Sirriyeh, Lawton (50). |
Key To Scores:
0= not at all
1= very slightly
2= moderately
3= completely
The stages of this synthesis were conducted iteratively using the appropriate elements of Popay, Roberts (45) toolbox. These are to develop a theory, to develop a preliminary synthesis, explore relationships between/within studies and assess the robustness of the synthesis process
The characteristics of the included studies are as shown in Table 3.
Table 3
Showing characteristics of included studies
STUDY,
COUNTRY
|
STUDY TITLE
|
STUDY AIM
|
NO. OF FATHERS (NO. OF MIGRANT FATHERS)
|
STUDY DESIGN
|
RESULTS
|
(52),
USA
|
A community perspective on the role of fathers during pregnancy: A qualitative study
|
The primary objective of the focus groups was to obtain mothers’ and fathers’ thoughts on the role of the father during their partner’s pregnancy to inform next steps of the National Healthy Start Association’s fatherhood initiative.
|
13(0)
|
Community-based participatory approach, focus groups, content and thematic analysis
|
In this study, an involved father during pregnancy is defined by participants as being accessible (present or available); engaged (cares about the pregnancy and wants to learn more about the process); responsible (caregiver, provider, protector); and maintaining relationship with the woman carrying the child, regardless of their own partnership status.
|
(53),
SWEDEN
|
Support during labour: first-time fathers' descriptions of requested and received support during the birth of their child
|
The aim of this study was to explore how first-time fathers describe requested and received support during a normal birth, it was decided that individual interviews was the most suitable method to understand their descriptions
|
10(0)
|
Open-ended interviews, latent content analysis
|
The support described is presented as one main theme, ‘being involved or being left out’, which included four underlying categories: ‘an allowing atmosphere’, ‘balancing involvement’, ‘being seen’ and ‘feeling left out’.
|
(51),
UK
|
A qualitative exploration of first-time fathers' experiences of becoming a father
|
To explore first-time fathers’ experiences of becoming a father, focusing on their expectations and experiences, and their views on how they are coping with this transition.
|
9(0)
|
Semi-structured interviews and interpretive phenomenological analysis.
|
One overarching superordinate theme derived from the analytic process was ‘searching for a place’, which reflected the process in which fathers searched for their role and position in relation to their partner and child
|
(54),
AUSTRALIA
|
A qualitative investigation into the pregnancy experiences and childbirth expectations of Australian fathers-to-be
|
To explore and describe men’s experiences of pregnancy and childbirth expectations.
|
12(0)
|
Qualitative descriptive design and thematic analysis.
|
Five themes emerged:
Pregnancy news heralds profound change: adjusting to pregnancy and working to see things differently; birth looming; feeling side-lined in antenatal visits; men’s childbirth expectations.
|
(55),
SWEDEN
|
Fathers’ birth experience in relation to midwifery care
|
The aim was to identify the proportion of fathers having a positive experience of a normal birth and to explore factors related to midwifery care that were associated with a positive experience.
|
595(0)
|
Longitudinal survey, questionnaires, descriptive statistics and odd ratios.
|
The majority of fathers (82%) reported a positive birth experience. The strongest factors associated with a positive birth experience were midwife support (OR 4.0; 95 CI 2.0—8.1), the midwife’s ongoing presence in the delivery room (OR 2.0; 1.1—3.9), and information about the progress of labour (OR 3.1; 1.6—5.8).
|
(56),
NEW ZEALAND
|
First-time fathers’ perception of their childbirth experiences
|
This research seeks to provide more evidence about the importance of the role of first-time fathers and provide some reflection on their experiences.
|
155(0)
|
Survey questionnaire, phenomenological thematic analysis.
|
Core themes included safety of mother and baby, understanding support role, mother in control, managing pain/care and communication after birth. Fathers commented on what impacted on their childbirth experiences and outlined their needs for a positive experience.
|
(57),
SWEDEN
|
Childbirth–an emotionally demanding experience for fathers
|
The objective was to explore Swedish fathers’ birth experiences, and factors associated with a less-positive birth experience.
|
827(0)
|
Prospective longitudinal cohort survey, descriptive statistical analysis, content analysis.
|
In total, 604 (74%) of the fathers had a positive or very positive birth experience. Identified a less-positive birth experience associated with emergency caesarean section (RR 7.5; 4.1–13.6). Instrumental vaginal birth (RR 4.2; 2.3 8.0), and dissatisfaction with the partner’s medical care (RR 4.6; 2.7–7.8) were recorded.
|
(58),
CROATIA
|
Prospective Fathers: Psychosocial Adaptation and Involvement in the Last Trimester of Pregnancy
|
The current study focused on expectant fathers’ perception of involvement in pregnancy during the last trimester of pregnancy that was often reported to be the most stressful time for men in their transition to parenthood.
|
143(0)
|
Questionnaire, one-way ANOVA, Correlational analysis and hierarchical regression analysis.
|
The prospective fathers showed high involvement in their partner’s pregnancies, elevated levels of perceived stress and high relationship quality. There were no differences in these variables regarding complications in pregnancy and pregnancy duration.
|
(59),
SINGAPORE
|
First-time fathers' experiences and needs during pregnancy and childbirth: A descriptive qualitative study
|
To explore first-time fathers' experiences and needs during their wives' pregnancy and childbirth in Singapore.
|
16(0)
|
Descriptive qualitative design, semi-structured interviews and thematic analysis.
|
First-time fathers experienced a range of emotions from being happy and excited to feeling shocked and worried and to feeling calm. Adaptive and supportive behaviours were adopted to deal with the pregnancy changes and better support their wives.
|
(60),
AUSTRALIA
|
An Exploration of the Perceptions of Male Partners Involved in the Birthing Experience at a Regional Australian Hospital
|
The aims of the current study were to document men’s self-reported perceptions of their partners’ antenatal, labor, and birthing experiences and to explore the relationships between these perceptions and men’s feelings of beneficial presence to the birthing mother
|
163(0)
|
Voluntary anonymous questionnaire and regression analysis.
|
There was a significant relationship between perceived benefit of the partners’ presence and positive perception of both antenatal experience and birth involvement. There also was a positive relationship between realized birth expectations and both antenatal experience and birth involvement.
|
(61),
SWEDEN
|
First-time fathers’ experiences of childbirth—A phenomenological study
|
To describe fathers’ experiences during childbirth
|
10(2)
|
Phenomenological lifeworld approach, interviews guided by re-enactment method.
|
The four themes constituting the essence were: ‘a process into the unknown’, ‘a mutually shared experience’, ‘to guard and support the woman’ and ‘in an exposed position with hidden strong emotions’.
|
(62),
AUSTRALIA
|
Fatherhood in a New Country: A Qualitative Study Exploring the Experiences of Afghan Men and Implications for Health Services
|
Aimed to explore the experiences of Afghan women and men of refugee background having a baby in Melbourne, Australia.
|
14(14)
|
Community-based participatory approach, interviews/focus groups and thematic analysis.
|
Afghan men reported playing a major role in supporting their wives during pregnancy and postnatal care, accompanying their wives to appointments, and providing language and transport support.
|
The data from the included studies were organised into smaller groups in order to manage the synthesis process effectively by looking for patterns within and across these groups. We started with the groups and clusters by taking the themes from the text and then developed each main theme from the commonalities from the texts. The themes were then grouped as shown in Table 4.
Table 4
Groupings and clusters of studies with respective themes
THEME AND SUB-THEMES
|
GROUPINGS AND CLUSTERS
|
Influence of society and health professionals
|
|
Outside support
|
Social support received (59), how helpful educators were in antenatal classes (60), competence of healthcare professionals (57), midwifery support and positive birth experience (55), An allowing atmosphere (53)
|
Need for information
|
To have the right to ask (53), current maternity care improvement (59), addressing father’s needs and concerns (14 migrant fathers) (62), how well informed male partners felt about pregnancy (60)
|
Adjusting to a new life of fatherhood
|
|
Change in fathers’ roles
|
Accessibility, responsibility (52), pregnancy heralds profound change, birth looming but, adjustment to pregnancy (54), adaptive and supportive behaviour (59), emotional changes experienced (59), to guard and support the woman (2 migrant fathers) (61), supporting women during pregnancy, labour and birth (14 migrant fathers) (62), (safety of mother and baby (a. Safety as a priority, b. Healthy mother and baby) (56)
|
An uncharted territory
|
Process into the unknown (2 migrant fathers) (61), searching for a place (51), not having a clue (54), fatherhood in a new country (14 migrant fathers) (62), in an exposed position with hidden strong emotions (2 migrant fathers) (61)
|
Involvement in the maternity
|
|
Active/passive involvement in maternity
|
Engagement (52), being seen (53), understanding support role (56), clearly actively engaged in pregnancy (58), mutually shared experience (2 migrant fathers) (61), care and communication after birth (56), couple relationship maintained regardless (52), support to pregnant wives/partners (14 migrant fathers) (62)
|
Feeling side-lined and marginalised
|
Feeling left-out (53), feeling side-lined (51, 54)
|
FINDINGS
This review incorporated data from 827 fathers from the mixed method study, 901 fathers across the quantitative studies and 249 fathers across the qualitative studies. Of these, 606 were first time fathers but only 16 were migrant fathers (61, 62). Ages ranged from 18-52 years for all fathers and 25-43 for migrant fathers. The majority of these studies were conducted in Sweden (n=4) (53, 55, 57, 61), followed by Australia (n=3) (54, 60, 62) and one each in the United States of America (52), United Kingdom (51), New Zealand (56), Croatia (58) and Singapore (59). Of all these countries, migrant fathers were only studied in Sweden (n=2) (61) and Australia (n=14) (62).
The narrative synthesis identified three themes; Influence of society and health professionals, adjusting to a new life of fatherhood and Involvement in the maternity care which are described below:
1. INFLUENCE OF SOCIETY AND HEALTH PROFESSIONALS
Six studies found that elements of society and health professionals influenced expectant fathers (53, 55, 57, 59, 60, 62). This included a total of 1611 native fathers with 268 being first-time fathers and 14 migrant fathers.
Poh, Koh (59) reported a narrative from a native and first-time father which discussed the positive influence of the wider family on the father’s maternity experience:
Generally, it's very useful and supportive if your parents or parents-in-law uuhh… are able to contribute as in, provide advice, share their previous experience and help you to prepare along the way. It's a big encouragement and emotional support ah, from the family
Quantitative data highlighted that health care professionals’ competence and supportive nature towards the expectant native father led to a positive birth experience (57). Eighty two percent of fathers (488 fathers) in Hildingsson, Cederlöf (55), reported a positive birth experience for fathers with the strongest associated factor being midwife support (OR 4.0; 95 CI 2.0—8.1), the midwife’s ongoing presence in the delivery room (OR 2.0; 1.1—3.9), and information about the progress of labour (OR 3.1; 1.6—5.8). None of the quantitative studies included migrant fathers.
Two studies discussed how the quality of the information the native (no migrant) fathers had received about childbirth positively influenced his experience. This included information from the midwife:
“I felt good when the midwife showed me, because then I was able to be involved’ (53).
Being involved in antenatal education was considered beneficial for the native fathers’ experiences:
“Practice makes perfect. Hands-on la, better. Cos if the class itself is… we looked through the slides most of the time, I would say 99%. Then the rest is the baby doll, the dummy… (laughs)” (59).
Quantitative data supported this with antenatal class attendance of the majority of the expectant native fathers (103, 86.6%), making them well informed about the pregnancy, childbirth process and possible complications (60).
Information from healthcare professionals was highlighted as a need of expectant fathers. The study involving only migrant fathers (62) highlighted how the health professionals supporting the migrant father also had an impact on the mother:
“The nurses were very kind and nice and they worked very hard to serve us, I think if there was anything in the world that could be done they would do it for us.. . their support gave me good feeling and I could provide moral support to my wife” (62).
2. ADJUSTING TO A NEW LIFE OF FATHERHOOD
Seven studies (51, 52, 54, 56, 59, 61, 62) discussed how fathers’ experiences of pregnancy and childbirth were influenced by their ability to adjust to fatherhood. This included a total of 213 native fathers, 195 first-time fathers and 16 migrant fathers.
Some native fathers discussed how they felt like they were in an uncharted territory when faced with pregnancy and childbirth issues. This included not knowing what to expect from pregnancy and childbirth (54).
“I’ve probably just blundered along following her (his partner’s) lead” (54).
This not knowing had a negative impact on one native father’s experience:
“You are in unknown territory ... When you’re there you know you really don’t know anything about this. I don’t know what’s going to happen … I was worried there would be no room for us; you know the worst case scenario” (61).
Another study (51) revealed that new father’s membership of social groups changed when confronted with pregnancy and childbirth. One native father stated that:
“people who are already fathers come over and have a chat with you and it is sort of a bit of a club you suddenly find yourself in” (51).
For migrant fathers, the concept of an unknown territory was exacerbated as it involved becoming a father but also this transition was taking place in a new country. Some migrant men experienced a cultural clash between the expectations of the father back home and in the new country. One migrant father had previous experience of childbirth in Afghanistan:
“Actually here all the time I was with my wife but in Afghanistan, my family, my father, mother and other relatives would take care of my wife and child, but here I play a hundred roles during pregnancy and appointments” (62).
Another migrant father shared his experience in Australia:
“Here in Australia, men and women have equal rights, and men are obligated to go to the hospital for every appointment, but not in Afghanistan. This is a big difference, yes” (62).
Pregnancy led to a profound change in some expectant fathers’ role in the household across the studies. This included some native fathers feeling an increased sense of responsibility looking after their partners (52). This increased responsibility included providing practical support:
“Making sure she eats healthy, go to her doctor’s appointments. If she has to take off because of a high-risk pregnancy, he’ll maintain the bills, or other kids, if there are other kids, just whatever is needed” (52).
Increased responsibility also included emotional support:
“The role of a man during pregnancy is to be present, to support, to understand, to be patient, and to have sympathy for the woman carrying his child” (52).
And getting prepared for the birth:
We’re a lot more organised I think this time.. . I just made sure that I knew that we’d go to that door and just refreshed it…. had the car serviced... petrol’s always full, and the bag is packed and ready to go.. . (54).
For some fathers, this increased responsibility led to the need to adapt their current life to meet the needs of the mother:
We used to meet on and off during the weekends. So, I stopped going there and then even for parties, I used to attend a lot. She can't stay there for long time. She'll get pain… So, even if we're going, we just go and then say hi and spend there 10 min and come back
One study reported a native first-time father showing selflessness with birth looming by stating that:
“My plan was to ensure mum and baby were kept as safe and comfortable as possible during the process” (56).
3. INVOLVEMENT IN THE MATERNITY EXPERIENCE
Eight studies found that how involved a father felt in the maternity experience influenced how they experienced pregnancy and childbirth (51–54, 56, 58, 61, 62). A total of 364 native fathers and 322 first-time fathers were influenced by this and this included 16 migrant fathers (61, 62).
A quantitative study reported that most expectant fathers were actively involved in their partner’s pregnancy (58). However, the level of involvement was also influenced by how close the father felt to the mother:
“When my wife was pregnant, I was at all the appointments… so, I was there. I think it depends ... how you feel about that girl.. . [If]…you just got some random chick pregnant you’re not going to feel like going to an appointment with her, you’re not going to feel like, encouraging her” (Alio 2013: 5).
Interestingly, one study found that fathers who initially did not want to be involved in the mother’s maternity experience changed their mind as the pregnancy progressed:
“I didn’t want to be very involved beforehand, but when it all started, it was just me in there with the midwife, so I ended up getting a lot more involved than I had wanted to, but it was great” (56).
This positive experience included during labour:
“When she was pushing at the end, I held one hand behind her neck to give her strength … and the other round her leg, so I held her together! I really felt part of it all and she said that afterwards… in that sense it felt really good. I didn’t feel left out at all!” (61).
Migrant fathers who perhaps may not be involved in maternity back home were also positive about the high level of involvement they had in maternity:
“The fact that I was there with my wife during labour [was good], because I had never seen someone giving birth so I could understand her pain and also my wife was happy that I was there standing by her” Riggs, Yelland (62).
Another migrant father went on to state that: “I had a big role in this. I kept her company and was always there with her to help her and support her” (62).
Native fathers were not always actively involved in their partners maternity experience and studies reported that some native fathers felt left out (53).
In one study, a native father discussed negatively his lack of involvement in the pregnancy and childbirth process and stated that:
“I wanted to help, but I felt left out, I could not do anything…. I wanted to help somehow but could not….” (53).
Another native father sought to find an excuse for the exclusion:
“Well obviously you’re not the priority and that’s fair enough but sometimes you feel like you’re just sort of like barely even in the room” (54).
Feeling left out was also an issue for some native fathers during labour:
“I felt like an absolute spare part. In all of that that went on there was nothing I could do, nothing physically… which is really weird because you want to get involved” (51).
Although migrant fathers were actively involved in their adopted country some faced challenges with the language (62). They could not effectively communicate their concerns and they had to rely on people to translate. A migrant father stated that:
“I would call someone else to get help if I didn’t understand and try to find some way solve my problems” (62).