See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/265168526

Fathers’ prenatal relationship with ‘their’ baby and ‘her’ pregnancy –

implications for antenatal education

Article · January 2014

CITATIONS READS

4 826

3 authors:

Richard J Fletcher Jennifer StGeorge

The University of Newcastle, Australia The University of Newcastle, Australia
129 PUBLICATIONS 2,024 CITATIONS 57 PUBLICATIONS 609 CITATIONS

SEE PROFILE SEE PROFILE

Chris May
The University of Newcastle, Australia
31 PUBLICATIONS 433 CITATIONS

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Father-Child Play Research View project

Fatherhood and Family Violence View project

All content following this page was uploaded by Richard J Fletcher on 13 October 2014.

The user has requested enhancement of the downloaded file.

Title: A father’s prenatal relationship with ‘their’ baby and ‘her’ pregnancy –
implications for antenatal education

Authors:

Richard Fletcher, PhD, Senior Lecturer, Family Action Centre, Faculty of Health and
Medicine, The University of Newcastle Richard.fletcher@newcastle.edu.au

Chris May, RN, RM, PhD student, Antenatal Facilitator, Family Action Centre, Faculty of
Health and Medicine, The University of Newcastle Chris.May@Newcastle.edu.au

Jennifer St George, PhD, Senior Research Academic, Faculty of Health and Medicine, The
University of Newcastle; Jennifer.Stgeorge@newcastle.edu.au

See the article at: Fletcher, R., May, C., & St George, J. (2014) A fathers prenatal
relationship with ‘their’ baby and ‘her’ pregnancy – implications for antenatal
education. International Journal of Birth & Parent Education 1(3), 23-27 at
http://ijbpe.com/index.php/journals/past-issues
Title: A father’s prenatal relationship with ‘their’ baby and ‘her’ pregnancy –
implications for antenatal education

Summary

Men are involved today in pregnancy and childbirth in ways unimagined by their own fathers and in
some way at odds with current antenatal education. This paper discusses significant aspects of
men’s experiences of pregnancy that have the potential to impact upon their involvement in
fathering. These include the complex and indirect relationship that fathers have with their
developing baby in-utero, and the psychological and physiological changes in fathers triggered by
their partner’s pregnancy. The paper concludes by summarising the current state of knowledge
concerning both content and delivery when aiming to include fathers and meet their needs in
antenatal education.

Introduction
BOX 1 Men are involved today in pregnancy and childbirth in ways unimagined by
their own fathers. END BOX Ultrasound scans now allow fathers to ‘see’ the foetus;
men regularly attend antenatal classes and are present at the birth; and fathers may
now notice and name the powerful emotional dimensions of their experiences…

You will, on the day of the birth, pick up this absolutely compelling and
impelling mass of squirming, screaming humanity, your heart will melt and you
will wonder how you ever existed without that precious bundle you’re holding.
(Father in Fletcher and St George 2011, p. 1106)

In parallel with technological and psychological changes surrounding pregnancy,

there has been an expansion of research examining fathers’ views of labour and
birth as well as increased consideration of co-parenting and father-infant
relationships. We now have a body of evidence to draw on when considering how
services that are aiming to improve family health and wellbeing might approach
fathers. In this paper, our current understanding of how fathers relate to their unborn
babies and the fathers’ experience of pregnancy will be described to suggest how
fathers may be effectively included in antenatal programmes.
Fathers’ relationships with their yet-to-be-born infants
According to a recent national survey of 4616 women in England, more than 50% of
the fathers were present for pregnancy test. Most of the fathers also attended at
least one antenatal check, were present for ultrasound examinations and for the birth
(Redshaw and Henderson 2013). Similar figures were reported in a study of 600
Danish fathers (Madsen et al 2002, cited in Plantin and Olukoya 2011) and in a
longitudinal study of 205 Australian mothers and their partners (Svensson, Barclay
and Cooke 2006). In non-western settings, evidence of fathers’ antenatal
involvement is difficult to gauge. Salvadorian expectant fathers report similar rates to
those quoted above (Carter and Speizer 2005), however, among Kenyan fathers,
cultural prohibitions strongly discourage fathers’ involvement in birth-related activities
(Kwambai et al. 2013).

Men’s attendance at key processes surrounding pregnancy, at least in western

industrialised countries, is an indication of fathers’ interest in being involved with their
baby’s development. To understand a father’s relationship to the foetus, however,
requires exploring his interior world; his mental picture of the developing baby and
his idea of being a father to this particular infant. We would also wish to track his
feeling states over the life of the pregnancy.

In the survey by Redshaw and Henderson (2013) for example, mothers reported that
over 80% of the men were ‘pleased or ‘overjoyed’ when the pregnancy was
confirmed. Another indication of the strength of a father’s connection to his unborn
infant is his reaction to a calamitous outcome such as stillbirth or neonatal death.
From a systematic review of quantitative and qualitative studies on the psychological
effects of stillbirth and neonatal death, Badenhorst and colleagues (2006) found that
“many fathers experience grief after a perinatal loss, suffering shock, anger,
emptiness, helplessness and loneliness” (p.254). While fathers’ grief reactions are
found in most cases to be less than mothers’, there seems little doubt that men are
deeply affected by such deaths and that this is due to the connection to their infant -
a connection gained without having the direct experience of pregnancy.
What are the ways that men connect to the foetus without the direct physical ‘reality’
of the pregnancy? Interview studies have asked men to describe their experience of
getting to know the growing foetus. Their ideas about their infant in the womb may
be vague and unformed prior to the ‘visual proof’ provided by the ultrasound images
of the infant. As a father interviewed by Draper (2002) explained,
Up until then it was just a sort of vague blobby thing that was going to happen
seven months away. It was going to happen at the end of the summer. And
ever since then it has felt real, it has felt as though there’s a human being
(Draper 2002 p.780)

Another avenue for investigating men’s relation to the foetus is to examine their
responses to statements such as “I imagine myself taking care of the baby”, and “I
try to picture what the baby will look like”. Men’s and women’s answers to such
questions (using gender-appropriate wording) were obtained from expectant couples
in Sweden. Analysis suggested that concern for the foetus was equally strong for
both mothers and fathers, although men’s thoughts about the developing infant were
focused on the baby’s life post-birth, whereas women’s responses to similar
questions indicated a focus on the foetus’ current health (Seimyr et al. 2009, p. 274).

The strength of a father’s ‘love’ for his unborn child can be measured by the Paternal
Antenatal Attachment Scale (PAAS) (Condon 1993), which assesses the expectant
father’s sense of closeness or distance from the foetus and his feelings of
tenderness or irritation. The scale also attempts to capture the father’s mental picture
of the growing foetus with questions on how often the father thinks about, dreams
about or talks to the foetus. In one study, fathers’ attachment showed considerable
consistency, suggesting a stable ‘bond’ between the father and foetus. As would be
expected though, attachment scores were lower for depressed expectant fathers
than non-depressed fathers (Condon et al. 2013). This finding also implies that those
fathers who will struggle to form an attachment with their infant may be readily
identified before the birth.

The PAAS scale was also used to map Australian fathers’ attachment to the foetus
onto a measure of their fathering identity during the antenatal period. As well as
completing the PAAS, fathers were asked how alike they were to vignettes of
fathering types: Caregiver, Emotional Supporter, Helper, Playmate, and
Breadwinner; and these answers were compared to the men’s attachment scores.
The father’s attachment to the foetus, as measured by his PAAS scores, increased
significantly over the pregnancy period, and this increase corresponded with a shift
from caregiver and emotional supporter to a caregiver more attuned to play (Habib
and Lancaster 2010). In this study the fathering elements of Helper and Breadwinner
did not explain fathers’ attachment scores at any point.

The father’s growing interest in being able to play with his baby fits with notions of
fathers’ future orientation found in other studies of paternal antenatal attachment
(Seimyr et al. 2009) and also with popular notions of a father’s role (Fletcher 2011).
However,BOX 2 the links between his self-perception as caregiver and emotional
supporter of his partner, and his level of attachment to the foetus, highlights the
indirect route that a father must pursue to form a connection to his unborn child END
BOX.

In summary, we have evidence that, at least in western industrialised societies,

where social norms strongly favour father-involvement with children, fathers are
motivated to form a relationship with their unborn child. The expectant father’s
curiosity about the foetus, his mental engagement and preoccupation with the
wellbeing, activities and personality of the foetus are markers of the strength of this
relationship.

Fathers’ experience of pregnancy

Related to a father’s commitment to the unborn child is his own personal experience
of the pregnancy. These experiences include his role as support to the mother, his
changing relationships to others and to self, and physical hormonal changes that
influence his attitudes and behaviour.

Fathers can influence the course of pregnancy through the effect that their
behaviours have on the health and wellbeing of their partner. Women whose
partners remain involved and reside with them during their pregnancy are more likely
to attend antenatal care, take better care of their health and deliver healthier babies
(Martin et al., 2007; Padilla and Reichman 2001; Perriera and Cortes 2006). Paternal
behaviours in relation to the consumption of tobacco and alcohol also are important.
Partners can assist women’s efforts to cease smoking (Muller 1987), and a recent
study found that both mothers and fathers reduce their alcohol consumption during
pregnancy (Mellingen, Torsheim and Thuen 2013). These changes are important
because pregnant women are more likely to report prenatal tobacco, alcohol and
other substance use when their partner’s consumption continues during the
pregnancy (Mellingen, Torsheim and Thuen 2013; Prierra and Cortes 2006). Links
between paternal and maternal behaviour during the pregnancy in relation to such
substances provide powerful examples of the responsibility that fathers share in the
health of a pregnancy. BOX 3 The changes that fathers make to their behaviours
during pregnancy signal both an understanding of this responsibility and an early
commitment to the wellbeing of their developing family.END BOX

However, the father can also expect to have a personal experience of the pregnancy
which is characterised by turmoil. Indeed, the pregnancy period can be more
stressful than either the labour-birth or postnatal periods (Genesoni and Tallandini
2009). Some fathers describe confusion during the pregnancy due to changing
relationships (Barclay et al. 1996). Changes in relationships can be triggered by
interactions with an array of health professionals, changes in mothers’ behaviours
and sexuality (Bogren 1991), and the involvement of extended family, most usually
from the maternal lineage (Pollet, Nettle and Nelissen 2006). These changes occur
while the father’s relationship with his partner is transforming from one primarily
founded on companionship, to a relationship in which he has an unfamiliar and
poorly defined supporting role (Cowan and Cowan 2000). Many fathers feel that
there are not enough resources to support their education, spaces to support their
involvement, or recognition of their experiences and feelings about pregnancy,
labour, birth, and fathering (St George and Fletcher 2011). It is no wonder then that
fathers’ growing connection to the pregnancy may be accompanied by emotional
responses such as fear, anxiety and curiosity (Hildingsson et al. 2013).

In fact, a father’s maladjustment to the pregnancy can lead to a range of

dysfunctional behaviours including the misuse of alcohol, which in turn increases the
risk of intimate partner violence (Helmith et al. 2013). In a study by Gartland (2011),
for example, a significant minority of mothers reported fear of an intimate partner,
and experienced physical and/or emotional abuse in the perinatal period. However, a
father’s developing relationship with the pregnancy may also be a powerful incentive
to give up violence in relationships (Maxwell et al. 2012).

Some of the most profound findings concerning a father’s experience of pregnancy

come from hormonal studies. Hormonal changes during pregnancy indicate that
fathers also experience physiological responses to pregnancy. Fathers living with
their pregnant partners during the pregnancy have been found to experience lower
levels of testosterone and cortisol, and higher levels of estradiol than matched
controls whose partners were not pregnant (Berg and Wynne-Edwards 2001). The
estradiol hormones appear to enhance fathers’ sensitivity and responsiveness to
their infant’s cry, while fathers with lower levels of testosterone are found to have
higher sympathy for their crying infant and more likely to attend to the infant than
fathers with higher levels of testosterone (Fleming et al. 2002). This biochemical
adaptation may account for the interest that fathers develop in learning about
relationships, baby care and parenting during this time (Deave and Johnson 2008).
These physiologic changes indicate that men may be biologically primed by their
partner’s pregnancy for roles as both a parent and a support to their partner in the
transition to parenthood.

Including fathers in antenatal programs

The primary avenue for support and education in expectant couples’ transition to
parenthood are antenatal classes offered by hospitals and professionals. Although
there has been increasing attention to mothers’ post-birth care of the newborn,
including screening for later depression and anxiety, antenatal class content tends to
centre on the mother’s preparation for the birth. The expectation for fathers to attend
antenatal education increases the need for these programs to identify father relevant
program content and father-inclusive modes of delivery.

While there is evidence from qualitative studies that fathers find current antenatal
programs deficient, particularly as preparation for relationships changes (Fletcher,
Silberberg and Galloway 2004; Goodman 2005; Deave and Johnson, 2008), how to
address these challenges in ways that suit expectant fathers has received little
attention. A small survey of Scottish fathers found that father’s role, care of the baby
after delivery and ‘what could go wrong’ were the most popular topics; least popular
were bottle feeding technique and the discomforts of pregnancy (McElligott 2001).
Similar results were found when 105 Australian fathers selected topics for an online
antenatal education program. Information on father-infant interaction was the most
commonly selected followed by work-family balance and postnatal depression. As in
the Scottish sample, breastfeeding knowledge was accorded a low priority (Fletcher
et al 2008).

Based on evidence linking father’s preparation to family wellbeing, May and Fletcher
(2013) proposed six domains as appropriate content for antenatal programs that
include fathers: fathers’ role and relationship changes, father as a support person,
parenting alliance, paternal depression, infant crying, and infant communication.
While the evidence base for the domains is not uniformly strong, the domains
provide a rationale for content targeting fathers. They represent BOX 4 the main
issues in men’s transition through pregnancy to fatherhood: constructing a new
identity, supporting his partner and preparing to father a newborn END BOX.
Importantly, the domains encompass personal and relational aspects for both
mothers and fathers.

Identifying material specifically for fathers raises the issue of whether to have all-
male groups or male educators when delivering antenatal education to fathers. In a
review of qualitative studies of new fatherhood, Goodman (2005) suggested that in
fathers-only classes, “men can develop competence and confidence away from their
partner whom they may perceive as more capable” (198). Yet fathers attending
antenatal classes have mixed responses regarding male educators and all-male
groups. Fathers surveyed in London stated a preference for attending mixed
sessions and were happy to have the usual, female educator (Shia and Alabi 2013).
However, some, but not all respondents from black, Asian and Chinese backgrounds
did prefer all-male options. Post-hoc evaluations of all-male sessions suggest that
new fathers appreciate the chance to hear from other men in similar situations and
fathers may talk more freely in such environments (Friedewald M, Fletcher R and
Fairbairn 2005). However, these evaluations lack comparison with equivalent
sessions led by female educators.
Another major issue affecting the success of father-targeted antenatal education is
how to recruit the men to attend clinics and related services. While father’s
participation at the birth and at ultrasound examinations is now accepted practice in
western nations, father’s involvement in the more time-consuming antenatal classes
is much less common (Redshaw and Henderson 2013). However, new
communication technologies offer a cost effective channel for reaching fathers since
the vast majority of adults have access to a mobile phone and text message costs
are low. Online interactive and text-based interventions also have the benefit of
reaching rural areas and being available at any time, and there is increasing
evidence of the effectiveness of these avenues of support (Head et al. 2013;
Nystrom and Ohrling 2008).

Conclusion
Fathers have both psychological and physiological responses to pregnancy as they
develop complex relationships with their unborn child and negotiate a new
relationship with their parenting partner. These responses indicate a need to support
fathers through their transition to parenthood. Fathers’ antenatal preparation can
have a positive influence on maternal, paternal and child outcomes. Antenatal
programs should therefore avoid framing the father’s role simply in terms of a helper
at the birth. Programs aiming to enhance fathers’ bond to their unborn child, build
their support of the mother and lay the groundwork for effective coparenting of the
new baby are likely to be more appealing to expectant fathers and more effective in
promoting family wellbeing. Program content will need to take into account the man’s
changing relationships with his partner and society, his own physiological and
psychological responses to pregnancy and his emerging awareness of the unborn
child. While delivery of antenatal education may be enhanced by use of interactive e-
technologies or male educators, we have limited information on how these
approaches might work. Effective engagement of fathers in antenatal education is
unlikely to require a completely new workforce using a novel skill set. Current
educators, using their current clinical competencies, aided by information on fathers’
needs and a flexible service delivery model, should be able to develop father-
inclusive practices to benefit both parents and newborns.
Badenhorst W., Riches S. Turton P. and Hughes P., 2006. The psychological effects
of stillbirth and neonatal death on fathers: Systematic review. Journal of
Psychosomatic Obstetrics & Gynecology, 27, pp.245-256.

Berg S. L., and Wynne-Edwards K. E., 2001. Changes in testosterone, cortisol and
estradiol in men becoming fathers. Mayo Clinic Proceedings, 76(6), pp.582-592.

Bogren L. Y., 1991. Changes in sexuality in women and men during pregnancy,
Archives of Sexual Behaviour, 20(1), pp.35-45.

Barclay L., Donovan, J. and Genovese A., 1996. Men’s experiences during their
partner’s first pregnancy: a grounded theory analysis. Australian Journal of
Advanced Nursing, 13(3), pp.12-24.

Carter M. W., And Speizer, I., 2005. Salvadoran fathers' attendance at prenatal care,
delivery, and postpartum care. Revista Panamericana de Salud Pública, 18, pp.149-
156.

Condon J. T., 1993. The assessment of antenatal emotional attachment:

development of a questionnaire instrument. British Journal of Medical Psychology,
66, pp.167-183.

Condon J., Corkindale C. Boyce P. And Gamble E., 2013. A longitudinal study of
father-to-infant attachment: antecedents and correlates. Journal of Reproductive and
Infant Psychology, 31, pp.15-30.

Deave T., and Johnson, D., 2008. The transition to parenthood: what does in mean
for fathers? Journal of Advanced Nursing, 63(6), pp.626-633.

Fletcher R., Vimpani G. Russell G. and Keatinge D., 2008. The evaluation of tailored
email and web-based information for new fathers. Child Care Health & Development
4 (4), pp.439–446

Fletcher R., Silberberg S. and Galloway D., 2004. New fathers’ post-birth views of
antenatal classes: satisfaction, benefits, and knowledge of family services, The
Journal of Peri-natal Education, 13(3), pp. 18–26.

Fleming A. S., Corter C. Stallings. J. and Meir S., 2002. Testosterone and prolactin
are associated with emotional responses to infant cries in new fathers. Hormones
and Behavior, 42(4) pp.399-413.

Friedewald M., Fletcher R. and Fairbairn H., 2005. All-male discussion forums for
expectant fathers: Evaluation of a model. The Journal of Perinatal Education, 14 (2),
pp.8–18.

Gartland D., Hemphill S. A. Hegarty K. and Brown S. J. 2011. Intimate partner

violence during pregnancy and the first year postpartum in an Australian pregnancy
cohort study. Maternal and child health journal, 15, pp.570-578
Genesoni L. and Tallandini M. A., 2009. Men's psychological transition to fatherhood:
An analysis of the literature, 1989–2008. Birth, 36, pp.305-318.

Habib C. and Lancaster S., 2010. Changes in identity and paternal–foetal

attachment across a first pregnancy. Journal of Reproductive and Infant
Psychology, 28, pp.128-142.

Head K. J., Noar S. M. Iannarino N. T. and Grant Harrington N., 2013. Efficacy of
text messaging-based interventions for health promotion: A meta-analysis. Social
Science & Medicine, 97, pp.41-48.

Helmith J. C., Gordon K. C. Stuart G. L. and Moore T. M., 2013. Risk factors for
intimate partner violence during pregnancy and postpartum. Archives of Women’s
Mental Health, 16, pp.19-27.

Hildingsson I., Johansson M. Fenwick J. Haines H. and Rubertsson C., 2013.

Childbirth fear in expectant fathers: Findings from a regional Swedish cohort study.
Midwifery.

Kwambai T. K., et al., 2013. Perspectives of men on antenatal and delivery care
service utilisation in rural western Kenya: a qualitative study. BMC pregnancy and
childbirth, 13, p.134.

McElligott M., 2001. Antenatal information wanted by first-time fathers. British

Journal of Midwifery, 9, pp.556-558.

Martin T.L., McNamara M. J. Milot A. S. Halle T. and Hair, E. C., 2007. The effects of
father involvement during pregnancy on receipt of prenatal care and maternal
smoking. Maternal Child Health Journal, 11, pp.595-602.

May C. and Fletcher R., 2013. Preparing fathers for the transition to parenthood:
Recommendations for the content of antenatal education. Midwifery, 29, pp.474-
478.

Maxwell N., Scourfield J. Holland S. Featherstone B. and Lee J., 2012. The benefits
and challenges of training child protection social workers in father engagement. Child
Abuse Review, 21, pp.299-310.

Mellingen S., Torsheim T. and Thuen F., 2013. Changes in alcohol use and
relationship satisfaction in Norwegian couples during pregnancy. Substance Abuse
Treatment, Prevention, and Policy, 8(5). Retrieved 13th February 2014 from:
http://www.substanceabusepolicy.com/content/8/1/5

Muller J., 1987. Smoking in pregnancy: a needs assessment. Queen Elizabeth

Hospital, Brisbane. Report to the Anti-Smoking Committee of the Queeensland
Cancer Fund.

Nyström K. and Öhrling K., 2008. Electronic encounters: fathers' experiences of

parental support. Journal of telemedicine and telecare, 14, pp.71-74.
 Padilla Y. C., and Reichman N. E., 2001. Low birthweight: Do unwed fathers help?.
Children and Youth Services Review, 23(4/5) pp.427-452.

Perriera K. M., and Cortes K. E., 2006. Alcohol and tobacco use in pregnancy.
American Journal of Public Health, 96(9), pp.1629-1636

Plantin, L., Olukoya, A. A. & Ny, P. 2011. Positive health outcomes of fathers'
involvment in pregnancy and childbirth paternal support: A scope study literature
review. Fathering: A Journal of Theory, Research, and Practice About Men As
Fathers, 9, pp.87-102.

Pollet T.V., Nettle D. and Nelissen M., 2006. Contact frequencies between
grandparents and grandchildren in a modern society: Estimates of the impact of
paternity uncertainty. Journal of Cultural and Evolutionary Psychology, 4, pp.203-
213.

Redshaw M., and Henderson J., 2013. Fathers’ engagement in pregnancy and
childbirth: evidence from a national survey. BMC pregnancy and childbirth, 13, p.70.

St. George J. M., and Fletcher R. J., 2011. Fathers online: learning about fatherhood
through the internet. The Journal of perinatal education, 20, p.154.

Seimyr L., Sjögren, B. Welles-Nyström B. And Nissen E., 2009. Antenatal maternal
depressive mood and parental–fetal attachment at the end of pregnancy. Archives of
women's mental health, 12, pp.269-279.

Shia N., and Alabi O., 2013. An evaluation of male partners’ perceptions of antenatal
classes in a national health service hospital: Implications for service provision in
london. The Journal of perinatal education, 22, p.30.

View publication stats