In the present study, fathers enrolled were reasonably well informed about breastfeeding Almost all fathers were aware of the beneficial effects of breastfeeding on infants’ and mothers’ health, skin-to-skin contact, rooming-in practice and responsive feeding, although only half of them were aware of the recommendations on the use of pacifiers. Moreover, fathers showed an overall positive attitude toward breastfeeding, although pointing out that breastfeeding might cause difficulties in their everyday life, and generally felt personally involved in their babies’ feeding, regardless of type of feeding.
Exclusive breastfeeding rate at discharge (76.5%) resulted higher than the national (57.2%) and regional average (67.3%) [22, 23], and in line with the WHO/UNICEF Global Strategy for Infant and Young Child Feeding recommended rate of 75% [24]. The high exclusive breastfeeding rate at discharge strikes even more when compared with the high cesarean section rate of our study population (44%), a known barrier to breastfeeding initiation [25]. Our cesarean section rate is consistent with data reported by the Italian National Statistics Institute, although at the upper limit of the national average [26].
The correlation between a higher questionnaire total score (hence a greater paternal knowledge and positive attitude) and exclusive breastfeeding rates at discharge may indicate a potential positive influence of fathers on newborn’s feeding choices at discharge.
It has been described how fathers play an important role in the initiation and duration of breastfeeding. According to Bar-Yam and Darby [27], fathers may influence four different aspects: the breastfeeding decision, assistance at first feeding, duration of breastfeeding, and risk factors for artificial feeding. Mitchell-Box and Braun [28] reported in a systematic review how an increased paternal breastfeeding knowledge can positively affect breastfeeding outcomes (initiation, exclusivity and continuation) and two randomized controlled trials showed how educating fathers for the role of “breastfeeding coach” has positive effects on breastfeeding in terms of increased initiation rate, reduced worry about low milk supply, and reduced premature breastfeeding cessation [13, 29]. Interestingly, some Authors have reported how fathers themselves want to know more about breastfeeding [13, 30]. The majority of fathers enrolled stated they had received sufficient information either prior to their baby’s birth or during hospital stay or at discharge. The high percentage of answers in line with the BFHI principles demonstrates a generally solid knowledge of the subject.
A recent study by Chen et al. reported lower Quality of Life scores in fathers of breast-fed infants than in fathers of bottle-fed infants, mainly due to the perceived more limited bonding opportunities with the baby [31]. Paternal post-partum depression is a worrying reality, connected with feelings of inadequacy and reduced self-efficacy often prompted by a sense of uselessness when compared to the mother’s nursing role [32]. A greater paternal involvement in breastfeeding may provide fathers with more occasions to bond with their newborn, thus proving beneficial for their mental health as well [32]. The fact that fathers in our study felt generally involved in their babies’ feeding, regardless of type of feeding, should therefore be regarded as a positive, well-boding, result.
A high percentage of fathers interviewed declared to be in favor of breastfeeding in public, a possible sign of the changing times. Breastfeeding in public is still a controversial issue [33]: several studies have reported how it is often perceived by men as uncomfortable, embarrassing and even distasteful [18, 21, 34, 35], showing a correlation with socio-economic status [18, 35] and cultural background [30, 36]. A significant push toward the rethinking of breastfeeding in public has been given by the implementation of the Baby-Friendly Community Initiative (BFCI) [9]. In particular, the 6th step of the BFCI [9] aims at the creation of breastfeeding-friendly environments, where nursing mothers can feel welcome. As Boyer pointed out in a recent paper, acceptance of breastfeeding in public is first of all a cultural issue, that the Government could help address by implementing programmes that challenge current social norms [37].
Finally, a correlation was found between total score obtained from the questionnaire and exclusive breastfeeding at discharge. The higher the score (hence paternal knowledge and positive attitude) the higher the probability of exclusive breastfeeding at discharge. The statistical power of our questionnaire in predicting exclusive breastfeeding at discharge was understandably limited, since it seems unrealistic to expect of any one test to reliably predict such a complex outcome, bound for its very nature to be influenced by numerous factors. However, our results are in line with current international Literature [38] in highlighting how fathers more invested in breastfeeding and more informed about it may influence their newborns’ feeding choices.
Therefore, there appears to be an ever-growing need for father-focused interventions to teach fathers how to better help and support their partners, thus expanding the classic mother-baby dyad to include them as well, as part of the breastfeeding team [30, 39].
We acknowledge that the present study has some limitations. Firstly, data were collected from a single Italian center, thus our results and subsequent considerations may not apply to different settings. Secondly, breastfeeding rates were evaluated only at discharge. A long-term follow-up and a correlation with paternal breastfeeding education and attitude would probably add more interesting information. However, our study addressed a relatively large number of fathers, whose answers were blinded to mothers, thus not influenced by partners’ opinions.