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Midwifery 94 (2021) 102921
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Review Article
First-time fathers’ experiences and needs during childbirth: A systematic
review
Maartje van Vulpen a,b,∗, Mariëlle Heideveld-Gerritsen a,b, Jeroen van Dillen a, Sabine Oude
Maatman c, Henrietta Ockhuijsen b,c, Agnes van den Hoogen b,c
a Radboud University Medical Center, Post Office Box 9101, 6500 HB Nijmegen, The Netherlands
b University Utrecht, Post Office Box 80125 3508 TC Utrecht, The Netherlands
c University Medical Center Utrecht, Post Office Box 85500, 3508 GA Utrecht, The Netherlands
a r t i c l e i n f o
Keywords:
first-time fathers
experiences
needs
childbirth
a b s t r a c t
Objective: Fathers have been increasingly involved in childbirth since 1990. Attendance at childbirth is considered
to benefit fathers’ health as well as that of their partner and children. However, childbirth is a life event that
parents may experience differently. First-time fathers’ experiences have been barely studied and may differ from
those of fathers who have already had a child. In order to adapt support and care during childbirth to the needs
of first-time fathers, a deeper insight must be gained into their experiences and needs during childbirth.
Design: A systematic review of qualitative studies was conducted using PubMed, Embase and CINAHL as well
as the snowball method. Quality appraisal was performed and evaluated using the Critical Appraisal Skills Programme. A thematic best evidence synthesis was performed.
Findings: Of 821 articles, eight qualitative studies and the qualitative data of one mixed methods study were
included. amongst other feelings, fathers experience a lack of knowledge and a need to be better prepared. Firsttime fathers want to be more involved and need guidance, information and honest answers to help them fulfil
a supportive role. Fathers disregard their own needs to focus on the needs of the mother. Meeting the baby for
the first time changes the focus from the mother to the child, and fathers need time and privacy for this special
moment.
Key conclusions and implications for practice: To adapt support and care during childbirth to the needs of first-time
fathers, professionals must be aware of their needs. Professionals must realise the significant influence of their
professional behaviour on first-time fathers’ experiences. Care for first-time fathers should be formalised. Followup research must be conducted on integrating the preparation of first-time fathers into prenatal care. Education
and training of professionals must be improved.
Introduction
Every minute, 258 births occur worldwide (“Indexmundi geboortecijfers,” 2018). The average annual number of births in the Netherlands has been approximately 177,000 over the last 10 years, most of
which are first children for the father (Perined, 2019). Childbirth is a
life event for both parents. In the past, care during childbirth was primarily focused on the expectant mother (Dye, 1980). Much research has
been published on mothers’ experiences of childbirth (Aune et al., 2015;
Beake RM, Chang BA, Cheyne RM, Spiby Mphil, Sandall RM, RM 2018;
de Jonge et al., 2014; Dixon et al., 2014; Elmir et al., 2010; Hall et al.,
∗ Corresponding author.
E-mail addresses: maartje.dekat-vanvulpen@radboudumc.nl (M. van Vulpen), marielle.heideveld-gerritsen@radboudumc.nl (M. Heideveld-Gerritsen),
jeroen.vandillen1@radboudumc.nl (J. van Dillen), s.m.oudemaatman@umcutrecht.nl (S. Oude Maatman), h.d.l.ockhuysen@umcutrecht.nl (H. Ockhuijsen),
ahoogen@umcutrecht.nl (A. van den Hoogen).
2018). Studies show the importance of attention to the individual needs
and coping experiences of the mothers as factors for empowering new
families. A holistic approach to care and support is essential for enabling
mothers to cope with childbirth and have a positive childbirth experience (Aune et al., 2015; Hildingsson, I, Johansson, M, Karlström, A,
I 2013; Hodnett, ED, Gates, S, Hofmeyr, G.J., Dakala, ED 2013).
Because parents experience childbirth differently, it is important also
to consider the fathers’ experiences (Belanger-Lévesque et al., 2017).
Fathers have been more involved in the births of their babies since
1990 (Draper, 1997; Johansson et al., 2012a; Plantin, 2007). Although
studying fathers’ involvement during pregnancy is difficult due to sehttps://doi.org/10.1016/j.midw.2020.102921
Received 21 February 2020; Received in revised form 25 November 2020; Accepted 30 December 2020
0266-6138/© 2021 Elsevier Ltd. All rights reserved.
M. van Vulpen, M. Heideveld-Gerritsen, J. van Dillen et al. Midwifery 94 (2021) 102921
lection effect of those not being present and since involvement might
be a proxy for other factors such as low income families or unstable relationships(Kaye et al., 2014; Redshaw and Henderson, 2013).
Being present at childbirth has been linked to a more emotionally
engaged, mature fatherhood and has been described to benefit fathers’ health and that of their partners and children (Johansson et al.,
2012a; Plantin, 2007). It also might strengthen the relationship between couples and facilitates bonding between fathers and their babies (Callister, 1995; Johansson et al., 2012a). Paternal involvement
in children’s lives is associated with various child outcomes, including
improved cognition and mental health (Allport BS, Johnson S, Aqil A,
Nelson T, Kc A, Carabas Y, BS 2018).
This important role for the father increased interest in the fathers’
experiences during childbirth. In 2015, Johansson et al. provided an
overview of fathers’ general experiences with childbirth in a metasynthesis and showed that birth experiences of fathers were complex
and multidimensional (Johansson et al., 2015). Childbirth was mostly
considered a life-changing event, and professionals’ positive, respectful
behaviour and language greatly affected men’s sense of involvement.
Being kept informed was important in enabling fathers to feel safe and
included. An implication for practice of the study by Johansson et al.
was that couples should explore how expectations may influence their
roles in labour (Johansson et al., 2015).
However, first-time fathers’ experiences are less frequently researched and may differ from those of fathers who have had a child
before. A ‘first-time father’ is defined as a biological father who lived
with the expectant mother during pregnancy and has not experienced
the live birth of his own child (Chandler and Field, 1997).
First-time fathers appear to require more information about the birth
process, including a tour of the delivery room, compared to those who
have had a child before (Eggermont et al., 2017). First-time fathers experience a multitude of feelings, including anxiety, due to the unknown
event they are about to experience (Labrague et al., 2013).
In the Netherlands, no guidelines exist for managing and guiding
first-time fathers. Books and courses are available; however, no national
structural guideline exists. The guidance and care first-time fathers receive depend on the individual skills and attention of the professionals
and questions the fathers ask.
In order to adapt our support and care during childbirth to the needs
of first-time fathers, it is important to gain a deeper insight into their
experiences and needs. Unlike that of Johansson et al. (Johansson et al.,
2015), this systematic review provides an overview specifically of the
reported experiences and needs of first-time fathers during childbirth.
Methods
This systematic review includes qualitative data focusing on firsttime fathers’ experiences and needs during childbirth. The preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement were used (Moher et al., 2009).
Search strategy
Relevant articles were identified using the indexes of the PubMed,
CINAHL and Embase electronic databases. No restrictions were placed
on the date of publication. The search was performed until 15 February
2019 and a final search on 12 November 2020.
The search terms used were ‘first-time’, ‘fathers’, ‘experiences’,
‘needs’, ‘childbirth’ and synonyms of these terms. Parts of words extended by a star (∗) were used to cover as many different conjugations
as possible. The search terms contained subheadings (e.g. MeSH) and
free-text words.
Recently published articles, where search terms have not yet been
entered in databases, were also explored with the search terms in the
title or abstract. Full search strings are provided (Appendix 1). To complete the search, additional articles were obtained using the snowball
method with backward citation chasing and electronic citation tracking
using Scopus (Armstrong et al., 2005; Jalali and Wohlin, 2012).
Selection criteria
To answer the research question, articles that provided qualitative
data on the experiences or needs of first-time fathers during childbirth
were included. In English-language articles, labour and birth are sometimes divided into two different episodes. In this review, childbirth includes labour and delivery. Articles in Dutch, English and German were
included. Births by caesarean section were excluded because they are
different experiences (Chan and Paterson-Brown, 2002; Johansson et al.,
2013, 2012b; Rosich-Medina and Shetty, 2007).
All the articles were imported into Rayyan, a web application
(Ouzzani et al., 2016). Duplicates were removed. All articles were
screened for title and abstract. The full texts of the remaining articles
were obtained. If an article was not available in full text, its author was
contacted to obtain a full-text article.
The full-text articles were read and included if they met the inclusion
criteria and provided an answer to the research question (MV). Systematic reviews were excluded but informed the introduction and discussion
sections. Articles whose eligibility was uncertain were independently
screened by a second researcher (MHG). The selection of articles was
discussed until consensus was reached (MV, MHG, AH). The reasons for
exclusion were reported.
Data extraction
First, all the themes derived from the articles were listed for each
article, accompanied by quotes representing the themes. Only data relevant to the research question were extracted. An example is provided
(Appendix 2). Thus, the apparent relationships between the studies were
initially identified. Concepts within themes were subsequently extracted
and compared across studies. Main themes common to all studies were
identified.
Synthesis
Thematic analysis was used (Thomas and Harden, 2008). Repeated
reading of the text and constant comparison were used to identify similarities and differences in the data highlighting the themes. Categories
were developed, with at least two findings from different articles per
category. The main themes and categories were reviewed, and analytical themes were developed. The research group discussed the entire
process until agreement was reached (MV, MHG, AH).
To describe the best evidence synthesis, the methodological quality
of the studies and the evidence level of the findings were considered.
Proper et al. recognised three levels of evidence (Proper et al., 2011):
– Strong evidence – findings are consistent in two or more high-quality
studies;
– Moderate evidence – findings are consistent in one high-quality and
at least one low-quality study, and;
– Insufficient evidence – findings are only available in one study, or inconsistent findings are available in two or more studies (Proper et al.,
2011).
Methodological quality
The Critical Appraisal Skills Programme (CASP) for qualitative studies was adapted to appraise the evidence, and scores from 1–10 were
allocated (BS Critical Appraisal Skills Programme, 2018). This tool was
chosen because it contains only ten items and includes a user guide and
the facility to add notes. Assessment agreements were reached by the
research group (MV, MHG, AH). Consensus was reached on the interpretation of the CASP scores to classify the quality of the articles as
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M. van Vulpen, M. Heideveld-Gerritsen, J. van Dillen et al. Midwifery 94 (2021) 102921
good (8–10), moderate (5–7) or low (1–4). Two researchers performed
the appraisal (MV, MHG). Differences were discussed until consensus
was reached (MV, MHG, AH).
Results
The complete search strategies (Appendix 1) provided 821 articles
in total (Embase: 746, PubMed: 48 and CINAHL: 27). Additionally, five
articles were obtained using the snowball method. After removing duplicates, 791 articles were screened for title and abstract, and 768 articles were excluded. The remaining 23 articles were obtained in full
text. One article was not available in full text (Carbines, 2004). The
first author of this article was contacted through ResearchGate; however, no answer was received. Articles that did not meet the criteria
for inclusion were excluded. Excluded systematic reviews reported on
fathers’ experiences in general during birth and the transition to fatherhood (Hanson et al., 2009; Kunjappy-Clifton, 2007). Four quantitative
articles were excluded (Bowman et al., 2013; Eggermont et al., 2017;
Labrague et al., 2013; Schytt and Bergström, 2014), two articles were
excluded for not reporting specific birth experiences (Backstrom et al.,
2017; Darwin et al., 2017) and two for not being specific to first-time
fathers (Chapman, 1991; Nichols, 1995). Three articles were excluded
because they were available only in Chinese or Portuguese (Chou et al.,
1994; Santo and Bonilha, 2000; Tzeng et al., 1993).
Eight qualitative articles were included in this study (Bäckström and
Hertfelt Wahn, 2011; Chandler and Field, 1997; Ledenfors and Berterö,
2016; Longworth and Kingdon, 2011; Poh et al., 2014; Premberg et al.,
2011; Sansiriphun et al., 2015; Sapkota et al., 2012) as well as one mixed
methods study for which only qualitative data were taken into account
(Howarth et al., 2017). The full selection process is shown in the Prisma
2009 Flow Diagram (Fig. 1) (Moher et al., 2009). Table 1 provides an
overview of the articles. A final search was performed on 12 November
2020, and resulted in 329 studies deemed ineligible for inclusion.
Study characteristics
The nine included studies described a total of 271 first-time fathers from seven countries (Canada (Chandler and Field, 1997), England (Longworth and Kingdon, 2011), New Zealand (Howarth et al.,
2017), Nepal (Sapkota et al., 2012), Singapore (Poh et al., 2014), Sweden (Bäckström and Hertfelt Wahn, 2011; Ledenfors and Berterö, 2016;
Premberg et al., 2011) and Thailand (Sansiriphun et al., 2015)).
One mixed methods study was included due to an abundance of
qualitative data (Howarth et al., 2017). In this study, a post-birth questionnaire was used, in which fathers were asked to write down their
thoughts. Only qualitative data were extracted from this study.
The eight qualitative studies all used interviews. Semi-structured indepth interviews (Ledenfors and Berterö, 2016; Longworth and Kingdon, 2011; Poh et al., 2014; Sansiriphun et al., 2015; Sapkota et al.,
2012) were used in six studies. Of which one study initially used unstructured interviews and switched to semi-structured interviews after
themes emerged (Chandler and Field, 1997). Other interview methods
used were re-enactment (Premberg et al., 2011) and open-ended questions (Bäckström and Hertfelt Wahn, 2011).
Two studies provided information on issues other than childbirth;
therefore, only data relevant to the research question were included
(Poh et al., 2014; Sansiriphun et al., 2015). Seven of the eight qualitative studies reported that interviews were recorded (Bäckström and
Hertfelt Wahn, 2011; Chandler and Field, 1997; Howarth et al., 2017;
Ledenfors and Berterö, 2016; Longworth and Kingdon, 2011; Poh et al.,
2014; Sansiriphun et al., 2015; Sapkota et al., 2012). Premberg et al.
did not report recording but used verbatim transcripts of the interviews
(Premberg et al., 2011). In two articles, the interview duration was not
reported (Chandler and Field, 1997; Longworth and Kingdon, 2011).
The reported duration ranged from 10–90 min. Thematic analysis was
used in five studies (Chandler and Field, 1997; Ledenfors and Berterö,
2016; Longworth and Kingdon, 2011; Poh et al., 2014; Sapkota et al.,
2012). The remaining studies used interpretative phenomenological
analysis (Howarth et al., 2017; Premberg et al., 2011), analysis based
on grounded theory (Sansiriphun et al., 2015) and qualitative content
analysis (Bäckström and Hertfelt Wahn, 2011). In one study, the analysis process included checks by an expert and members (Chandler and
Field, 1997). In all other studies, the analysis was performed by multiple
analysts.
Methodological quality
The quality of all the included articles was assessed as good. The
CASP scores ranged from 8–10 with a mean of 9.3. The total scores are
presented (Table 1), and an overview of the evaluation of the different
components is added (Table 2).
Results of individual studies
The results of the individual studies are reported based on their most
important findings. Table 3 provides an overview of the main and subthemes, together with the core conclusions.
Howarth et al. showed that fathers experienced the birth of their
child as a life-changing event for themselves as well as the mothers
(Howarth et al., 2017). They found that fathers needed to be included
as participants in this process along with the birthing mothers.
Ledenfors and Bertero described the fathers’ experiences of childbirth as a transformative experience (Ledenfors and Berterö, 2016). Difficulties with supporting their wives and being involved are described,
as well various emotions caused by childbirth, and recommendations on
how midwives can help first-time fathers.
Sansiriphun et al. described the process from childbirth to postpartum as ‘the journey into fatherhood’, dividing it into three phases:
‘labour’, ‘delivery’ and ‘family beginning’ (Sansiriphun et al., 2015).
Family beginning largely transcended the experiences and needs of fathers during birth. This article emphasises the influence of local beliefs
and traditions on fathers’ experiences.
Poh et al. indicated that the experiences and needs of fathers in Singapore during pregnancy and childbirth were similar to those reported
in studies in western countries (Poh et al., 2014).
Sapkota et al. reported that the attendance of first-time fathers at
births was not culturally approved of in Nepal (Sapkota et al., 2012). If
fathers attended the birth, they were overwhelmed with emotions. The
authors suggest that better preparation may reduce negative emotional
experiences and improve satisfaction with childbirth experiences.
Longworth and Kingdon described childbirth as the beginning of fatherhood for fathers (Longworth and Kingdon, 2011). Through lack of
knowledge and perceived control, fathers struggle to find a role in childbirth. First-time fathers must prepare themselves. Midwives can help
provide fathers with effective information and should be mindful of fathers’ experiences and the importance of new families being together.
Premberg et al. reported that first-time fathers struggled to experience the mothers’ pain and fear of the unknown (Premberg et al., 2011).
These first-time fathers needed to be seen and supported as parents-tobe, emphasising the shared experience of childbirth for couples. Caregivers must acknowledge fathers as valued participants, based on their
exclusive knowledge of the needs of the mother, and support their significant position.
The main theme outlined by Bäckström and Hertfelt Wahn
(Bäckström and Hertfelt Wahn, 2011) was ‘being involved or being left
out’. The importance of fathers’ interaction with the midwife and with
their partner was highlighted. Additionally, fathers mentioned the importance of being able to choose to be involved or step back.
Finally, Chandler and Field reported that first-time fathers experienced many emotions and needed information, support, encouragement
and to be involved (Chandler and Field, 1997). They believed that par-
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M. van Vulpen, M. Heideveld-Gerritsen, J. van Dillen et al. Midwifery 94 (2021) 102921
Fig. 1. Prisma Flow Diagram of study selection.
ents needed to be treated as a couple and as individuals with unique
needs.
Synthesis of results
In the nine studies, 32 main themes and 34 subthemes were reported.
Five analytical themes were derived from the synthesis process: ‘The
unknown’, ‘Many different feelings’, ‘Interaction with professionals’, ‘Part of
the labouring couple’ and ‘Meeting the baby/ Bonding’. Table 4 provides an
overview of the categories that informed the analytical themes and lists
the categories identified in each article. The synthesis of the results is
reported according to the analytical themes and categories.
The synthesis described is also the best evidence synthesis. The
methodological quality of all individual studies was assessed as good,
and all findings are supported by at least two articles. Consequently,
this best evidence synthesis comprises only strong evidence as defined
by Proper et al. (Proper et al., 2011).
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. We were prepared to have to go to a different
hospital; you always expect the worst. I don’t think it matters how
much you rely on your partner; it’s good to have an expert nearby,
especially a woman. (IP5)
(Premberg et al. p.850)
The unknown
The unknown is divided into three categories: ‘totally new’, ‘knowledge’ and ‘preparation’.
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M. van Vulpen, M. Heideveld-Gerritsen, J. van Dillen et al. Midwifery 94 (2021) 102921
Table 1
Characteristics of included articles.
Article Methodogy Sample Analysis Quality
CASP
Howarth et al., 2017,
New Zealand,
Questionnaire Post-birth
questionnaire, fathers were asked
to write down their thoughts.
n = 155 Recruited by advertising. Phenomenological thematic
analysis informed by
interpretative
phenomenological analysis
(IPA) Two analysts
9,5
Ledenfors and Bertero,
2016, Sweden,
Interviews – Interview guide –
Digitally voice recorded –
Duration: 10–60 min. median
23 min.
n = 8 Recruited at maternity
wards, six different child welfare
centres and three open days
nurseries in a county in South
east Sweden
Thematic analysis Two
analysts
10
Sansiriphun et al.,
2015, Thailand
In-depth interviews – Interviewed
twice (n = 17) – Interviewed three
times (n = 26), – Interviewed four
times (n = 4) – Recorded –
Duration: 70–90 min.
n = 41 Recruited from two
hospitals in Chiang Mai.
Theoretical sampling.
Analysis based on grounded
theory. Four analysts and an
expert.
9,5
Poh et al., 2014,
Singapore
Semi-structured interviews. –
Interview guide – Audiotaped –
Duration 22–54 min mean 33 min
n = 16 Recruited from a tertiary
hospital
Thematic analysis. Three
analysts
9,5
Sapkota et al., 2012,
Nepal
In-depth interviews, – Semistructured interview guidelines. –
Audio taped – Duration average
41.08 +/-7.9 min.
n = 12 (six had supported their
wives during both labour and
delivery, the rest only during
labour by taking turns with
another female member of the
family/relative.)
Thematic Analysis Three
analysts
8,5
Longworth and
Kingdon, 2011,
England
Semi-structured interviews – At
two timepoints (antenatal and
postnatal) – Similarity of
questions – Tape recorded –
Duration not reported
n = 11 Recruited at antenatal
education with purposive
sampling
Thematic analysis Two
analysts
9,5
Premberg et al., 2011,
Sweden
Re-enactment interviews –
Recording not reported –
Duration: 40–90 min
n = 10 recruited at Sahlgrenska
University Hospital, Gothenburg
with strategical selection
Phenomenological lifeworld
approach Two analysts
8,0
Bäckström and
Hertfelt Wahn, 2011,
Sweden
Open-ended interviews. – Same
opening question and same
follow-up questions – Recorded –
Duration: 20 to 50 min.
n = 10 Recruited at one hospital
in a south-western county of
Sweden
Qualitative content analysis
Four analysts
9,5
Chandler and Field
1997, Canada
Interviews – At two timepoints
(antenatal and postnatal) –
Initially unstructured face-to-face
interviews – After themes
emerged, semi-structured
interviews. – Tape recorded –
Duration not reported
n = 6 and 6 secondary informants
(for validation, check new themes
and possible negative cases).
Thematic analysis resulting in
a model showing relationships
Expert for analysis Member
check
9,5
Totally new
seen movies … what is happening … it was not like that at all! (7)
It went so quickly … quickly and smoothly and well for us … no
problems, no complications, nothing … everything just went on in
one sweep … nothing that spoiled it … it was really nice … much
quicker and easier than I thought it would be … expectations were
different actually … I thought it would be much worse … in all ways
… so it was a relief. (8)
(Ledenfors and Bertero p.28)
The term ‘totally new’ refers to becoming a father as a completely new life-changing experience in an unfamiliar environment,
with new people (Ledenfors and Berterö, 2016; Premberg et al., 2011;
Sansiriphun et al., 2015) creating anxiety in the first-time father, who
is unsure how he will react and cope (Premberg et al., 2011). Expectations do not reflect the reality (Chandler and Field, 1997; Ledenfors and
Berterö, 2016).
Knowledge
Husbands should be mentally prepared. For instance, the birthing
process could be discussed before pregnancy check-ups, and we
should be informed about how to help our wives. (21-year-old carpenter)
(Sapkota et al. p.48)
Knowledge refers to knowing what to expect, what to do or what is
normal. Not knowing what to do made first-time fathers feel helpless and
like an outsider (Bäckström and Hertfelt Wahn, 2011; Howarth et al.,
2017; Ledenfors and Berterö, 2016). To understand labour and delivery and their roles in these processes, fathers must prepare themselves
and gain information (Sansiriphun et al., 2015; Sapkota et al., 2012).
Knowledge gained from preparation made fathers feel supported and
calm and improved satisfaction (Bäckström and Hertfelt Wahn, 2011;
Howarth et al., 2017).
Preparation
You thought that you were prepared, but you were not … not before
you had … had the child in your arms … then you realized that you
were not as prepared as you thought. (1)
(Ledenfors and Bertero. p.28)
Preparation refers to how fathers can prepare themselves for childbirth. First-time fathers can actively prepare themselves by gathering
information, discussing childbirth, mentally preparing themselves and
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M. van Vulpen, M. Heideveld-Gerritsen, J. van Dillen et al. Midwifery 94 (2021) 102921
Table 2
Appraisal of the articles.
Howarth et al.,
2017
Ledenfors and
Bertero 2016
Samiriphun
et al. 2015
Poh et al., 2014 Sapkota et al.,
2012
Longworth and
Kingdon 2011
Premberg et al.,
2011
Bäckström and
Hertfelt Wahn
2011
Chandler and
Field 1997
Section A: Are the results valid?
1. Was there a clear statement of the aims of
the research?2. Is a qualitative methodology appropriate?
3. Was the research design appropriate to
address the aims of the research?
?
4. Was the recruitment strategy appropriate
to the aims of the research?
? ?
5. Was the data collected in a way that
addressed the research issue?6. Has the relationship between researcher
and participants been adequately considered?
? ? ? ? ?
Section B: What are the results?
7. Have ethical issues been taken into
consideration?
? ? ?
8. Was the data analysis sufficiently rigorous?
9. Is there a clear statement of findings?
Section C: Will the results help locally?
10. How valuable is the research? ? ?
Total out of ten items (max 10 points) 9,5 10 9,5 9,5 8,5 9,5 8,0 9,5 9,5
Yes (1 point) ? Can’t tell (0,5 points) ⌧ No (0 points).
Critical Appraisal Skills Programme (BS 2018). CASP Qualitative Checklist. [online] Available at: https://casp-uk.net/casp-tools-checklists/ Accessed: 26–02–2019.
buying all the necessary items (Bäckström and Hertfelt Wahn, 2011;
Poh et al., 2014; Sansiriphun et al., 2015; Sapkota et al., 2012). Some
first-time fathers acknowledged their lack of knowledge but avoided acquiring further information (Longworth and Kingdon, 2011; Poh et al.,
2014).
The most wonderful thing I have been through my whole life but
also the most dreadful to see her suffer the way she did. (IP6)
(Premberg et al. p.850)
Many different feelings
The birth of a first child involves many different emotions, both negative and positive.
Negative feelings
I could not watch my wife so restless and crying. It was very difficult to control myself. It was so frustrating not being able to do
anything while she was undergoing labour pains. It was like a sort
of punishment, I would say. (23-year-old private business employee)
(Sapkota et al., p.48)
Feelings of insecurity, fear, powerlessness and inadequacy are frequently reported (Bäckström and Hertfelt Wahn, 2011; Howarth et al.,
2017; Ledenfors and Berterö, 2016; Poh et al., 2014; Premberg et al.,
2011; Sapkota et al., 2012). Clear information is needed to reduce fear
and vulnerability (Howarth et al., 2017; Ledenfors and Berterö, 2016;
Poh et al., 2014; Premberg et al., 2011; Sansiriphun et al., 2015). Fear,
helplessness and frustration were more intense during labour than during delivery (Chandler and Field, 1997; Sapkota et al., 2012). Seeing
the mothers in pain was a major burden and frustrated first-time fathers
(Premberg et al., 2011; Sansiriphun et al., 2015).
Positive feelings
It was like everything! It was just relief, joy, everything! Kev (postnatal
interview, normal vaginal birth, 48 h after birth)
You know, it’s been the best experience of my life! Steve (postnatal
interview, normal vaginal birth, eight days after birth)
(Longworth and Kingdon p.591)
First-time fathers were excited about the new situation and experienced many different feelings: satisfaction, pride, relief and gratitude that their wives and babies were healthy and safe (Bäckström and
Hertfelt Wahn, 2011; Chandler and Field, 1997; Howarth et al., 2017;
Ledenfors and Berterö, 2016; Poh et al., 2014; Sansiriphun et al.,
2015). They experienced an unexpected outburst of feelings when the
baby was born, including happiness, tears of joy and fascination with
the wonder of life (Chandler and Field, 1997; Howarth et al., 2017;
Ledenfors and Berterö, 2016; Longworth and Kingdon, 2011; Poh et al.,
2014; Premberg et al., 2011; Sansiriphun et al., 2015).
First-time fathers may hide strong feelings behind a calm and secure
façade to avoid worrying the mother during labour. However, when
the baby is born, fathers can release their true feelings (Chandler and
Field, 1997; Premberg et al., 2011; Sapkota et al., 2012).
I got a lot of support, especially when I broke down, standing there
crying like a three-year-old boy in the corner. So they took care of
me right away, all of them, the physician, the midwife; I got a lot of
support but it was a little bit hard too; it affects your masculinity.
It was really nice but I felt mixed feelings, nice to be comforted and
that they cared so much and really checked up on me, but I am used
to being a man, not being so sensitive. (IP5)
(Premberg et al. p.850)
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M. van Vulpen, M. Heideveld-Gerritsen, J. van Dillen et al. Midwifery 94 (2021) 102921
Table 3
Results of individual studies; Themes, subthemes and core conclusions.
Article Main themes and sub themes Key conclusions
Howarth et al., 2017. Core themes: – Safety of mother and baby – Understanding
support role – Mother in control and managing pain – Care
and communication after birth
Fathers commented on what impacted on their childbirth
experiences and in so doing outlined their needs for a
positive experience. Fathers experienced a high level of
satisfaction along with a need to be involved and included.
Ledenfors and Bertero
2016.
Main theme: transformative experience. 4 subthemes: –
Preparing for childbirth – Feeling vulnerable in a new
situation – Being confirmed as part of a unit – Meeting their
child for the first time.
The findings indicate that the needs of prospective fathers
should be given more re cognition during childbirth. The
findings also show that the midwife is an important person
for prospective fathers, both before and during the birth.
Sansiriphun et al.,
2015.
The process from childbirth to postpartum is described as:
“the journey into fatherhood”. The process had three phases:
Labour – Seeking information confirming labour pain;
preparing for the hospital – Focusing on their wife;
supporting and encouraging; waiting with patience Delivery
– Focusing on delivery process; supporting and encouraging
– Focusing on baby; checking the baby Family beginning –
Observing and learning the baby’s behaviours; seeking
information – Devoting themselves to the child – Supporting
their wife – Following traditional confinement – Eliminating
the conflicts and difficulties of being a father – Balancing
tasks
Within the process, there were various situations, challenges,
and pressures, which caused many changes of mood and
feelings for the first-time fathers. Throughout this process,
they applied various strategies to manage their concerns and
needs, in order to develop into masterly fathers.
Poh et al., 2014. 4 themes emerged from 16 subthemes: Emotional changes
experienced; (1) Happy, excited and amazed, (2) Fascination
with the wonder of life, (3) Shocked, (4) Anxious, worried
and fearful, (5) Relaxed and relieved Adaptive and supportive
behaviours adopted;(6) Following cultural practices, (7)
Modifying daily routine, (8) Understanding, caring and
supporting wife more, (9) Exercising self-control Social
support received; (10) Tangible and intangible support from
family and friends, (11) Support from work and environment,
(12) Support from healthcare professionals Suggestions for
improvement to the current maternity care; (13) Review of
antenatal classes, (14) Provide more information, (15) Provide
more professional support, (16) Administrative/ logistical
issues
All fathers modified their behaviours for the sake of
protecting their wives and unborn children. Support from
their family, friends, workplaces and the health care
professionals were invaluable and greatly appreciated.
Sapkota et al., 2012. 6 themes: – Being positive towards attendance – Hesitation –
Poor emotional reactions – Being able to support – The need
to be mentally prepared – Enlightenment.
The husbands’ experiences revealed that Nepalese husbands
tend to experience over- whelming feelings in the labour or
delivery room if they can attend the birth without prior
preparation.
Longworth and
Kingdon, 2011.
4 main themes: – Fathers’ disconnection with pregnancy and
labour – Fathers on the periphery of events during labour –
Control – Fatherhood beginning at birth and reconnection
Control was evident both as a distinct and a cross-cutting
theme.
Birth is the moment that fathers ascribe as the beginning of
fatherhood. However, through their lack of knowledge and
perceived control, they struggle to find a role there.
Implications
Premberg et al., 2011. 4 constituents: – A process into the unknown – A mutually
shared experience – To guard and support the woman – In
an exposed position with hidden strong emotions.
Childbirth was experienced as a mutually shared process for
the couple. The fathers’ high involvement in childbirth, in
cooperation with the midwife, and being engaged in support
and care for his partner in her suffering is fulfilling for both
partners, although the experience of the woman’s pain, fear
of the unknown and the gendered preconceptions of
masculine hegemony can be difficult to bear for the
father-to-be.
Bäckström and Hertfelt
Wahn, 2011.
Main theme: being involved or being left out. 4 categories: –
An allowing atmosphere – Balancing involvement – Being
seen – Feeling left out.
Fathers perceived that they were given good support when
they could ask questions during labour, when they had the
opportunity to interact with the midwife and their partner,
and when they could choose when to be involved or to step
back. Fathers want to be individuals who are part of the
labouring couple. If fathers are left out, they tend to feel
helpless; this can result in a feeling of panic and can put
their supportive role of their partner at risk.
Chandler and
Field, 1997.
9 themes – It’s happening – It’s beginning – More work than
anticipated – Increased fear – Hidden fears and emotions –
Lack of inclusion – Increased excitement – Relief – We made
it – Time to get acquainted.
Although the fathers expected to be treated as part of a
labouring couple, they found that they were relegated to a
supporting role. Initially the fathers were confident of their
ability to support their wives, but they found that labour was
more work than they had anticipated. They became fearful of
the outcome, but hid these fears from their partners.Later,
they found that their focus moved from their wives to their
babies at the time of birth. The men all completed the
experience with an enhanced respect for their wives. Fathers
should be included in labour management plans and need
support for their role as coach, particularly when their wives
experience pain. They also need to be encouraged to eat and
take a break from their wives’ labour when appropriate.
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Table 4
Reported categories and analytical themes in articles.
Analytical themes and including categories
The unknown Many different feelings Interaction with professionals Part of the labouring couple Meeting the baby/ Bonding
Articles
Totally
new Knowledge Preparation
Negative
feelings
Positive
feelings Support Professionalism Information
Feeling
included
and
involved
Giving
support
Leave
attention to
the mother
Shifting
attendance
from mother
to child
Need space
and time
Howarth et al., 2017
Ledenfors and Bertero
2016Sansiriphun et al.,
2015Poh et al., 2014
Sapkota et al., 2012
Longworth and
Kingdon 2011Premberg et al., 2011
Bäckström and Hertfelt
Wahn 2011Chandler and Field
1997Interaction with professionals
Interaction with professionals comprises the following categories:
‘(provided) support’, ‘professionalism’ and ‘information’.
Support
We had a good relationship … the midwife encouraged this good relationship and she gave me some tips about how to do things … act
with X, calm her, where I should hold her and how I should push …
pull her knees; I stood by the side and kept the head and pulled the
knees; she showed me and that was very good. She instilled confidence and you felt that you did something helpful and, at the same
time, it helped me to be in the position … helping … you could in
some way help. (5)
(Ledenfors and Bertero p.29)
First-time fathers need guidance in their supportive role
(Bäckström and Hertfelt Wahn, 2011; Chandler and Field, 1997;
Howarth et al., 2017; Ledenfors and Berterö, 2016; Premberg et al.,
2011). Adapting the level of involvement to the wishes of the fathers is
important to enable them to experience good support (Bäckström and
Hertfelt Wahn, 2011; Ledenfors and Berterö, 2016). The midwife being
present in the room and cooperating with the father gave fathers a safe
feeling (Bäckström and Hertfelt Wahn, 2011; Premberg et al., 2011).
Professionalism
I feel extremely grateful and have a lot of respect for all the people
that helped us, especially all the midwives; they were fantastic. I
don’t have a lot of experience from healthcare, but I have never been
better taken care of in any healthcare situation. (IP2)
(Premberg et al. p.851)
Health professionals appeared to have an impact on the feelings of
the fathers (Bäckström and Hertfelt Wahn, 2011; Longworth and Kingdon, 2011; Premberg et al., 2011). First-time fathers experienced comfort and trust due to involved, experienced professionals who provided
empathic care, worked together and communicated well (Howarth et al.,
2017; Poh et al., 2014; Premberg et al., 2011; Sapkota et al., 2012).
Information
We were both well informed during each step and I felt our midwife
and others provided information fast and clearly, which kept us both
with the feeling that things were well under control. (099)
(Howarth et al. p.8)
First-time fathers need information about physiology, possible complications, how to cope and progress during labour (Bäckström and Hertfelt Wahn, 2011; Howarth et al., 2017; Poh et al., 2014; Premberg et al.,
2011). First-time fathers must be able to ask questions (Bäckström and
Hertfelt Wahn, 2011; Ledenfors and Berterö, 2016). Fathers need
understandable and honest answers; otherwise, answers are deemed
unreliable, and fathers may feel irritated and not taken seriously
(Bäckström and Hertfelt Wahn, 2011; Premberg et al., 2011).
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! But I have to say that, even
though I took part in the process, the focus must of course always be
on the woman. (IP2)
(Premberg et al. p.850)
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M. van Vulpen, M. Heideveld-Gerritsen, J. van Dillen et al. Midwifery 94 (2021) 102921
Part of the labouring couple
Feeling included and involved in the experience of childbirth is important for first-time fathers. First-time fathers support their labouring
partners in the best way they can but allow the mother to be the centre
of attention.
Feeling included and involved
They took over from me instead of helping me to help Laura. I began
to feel like an appendage rather than being really involved.
(Chandler and Field p.21)
Childbirth is a shared experience in which both parents are important (Ledenfors and Berterö, 2016; Premberg et al., 2011). Fathers
want to be included and involved and try to be part of the process in different ways. However, fathers often feel excluded from the
labour (Bäckström and Hertfelt Wahn, 2011; Chandler and Field, 1997;
Howarth et al., 2017; Ledenfors and Berterö, 2016). Fathers feel involved when included in conversations and asked for their opinions and
when their personal needs are responded to and decisions are taken together (Bäckström and Hertfelt Wahn, 2011; Chandler and Field, 1997;
Howarth et al., 2017; Premberg et al., 2011).
Communication with the mother, midwife and other healthcare professionals guided fathers to a more supportive and active role and improved the experienced level of control and involvement of fathers during childbirth (Bäckström and Hertfelt Wahn, 2011; Longworth and
Kingdon, 2011). Fathers reported that intense communication between
the mother and midwife decreased their feelings of involvement and
increased their feelings of disconnection from their partner’s labour
(Ledenfors and Berterö, 2016; Longworth and Kingdon, 2011).
Giving support
It was a lot of patting on the back, holding and massaging. Trying to get
her to drink a lot, water and juice … a lot of talking and encouragement.
(During pushing:) I’m sitting behind her on a stool and holding her under
her arms, she’s sitting on her haunches. I can press her together by bending
myself, if I bend forward then she ends up like this with her chin on her
chest in the right position and then when the contractions subside, she
relaxes and stretches out backwards and then I can hold her … it was
hard physical work but it felt good to be able to do it. I’m used to physical
work. (IP10)
(Premberg et al. p.851)
Fathers want something meaningful to do during childbirth: to
support and encourage their partners (Ledenfors and Berterö, 2016;
Poh et al., 2014; Premberg et al., 2011; Sansiriphun et al., 2015;
Sapkota et al., 2012). Fathers need advice and guidance to provide better support (Howarth et al., 2017; Premberg et al., 2011; Sapkota et al.,
2012). The support given by first-time fathers helped to soothe and reassure their wives during childbirth (Premberg et al., 2011; Sapkota et al.,
2012).
Leave attention to the mother
All the focus is on her … try to make it as good I can … be a great
support … and just being two centimetres away, standing there …
feeling the hand or you could feel the … voice … well … it … it is
a feeling of confidence and that is big for me … I try to stand there
stable by her side … and calm … which she is not able to be in that
moment. That is my task – trying to be that … that part in … as a
partner. Since this is … this is our, this is our experience, it is our …
that is coming … out of this. (4)
(Ledenfors and Bertero p. 29)
During childbirth, the fathers focus on the needs of the mothers,
and disregard their own needs (Bäckström and Hertfelt Wahn, 2011;
Ledenfors and Berterö, 2016; Premberg et al., 2011; Sansiriphun et al.,
2015). Fathers want to be there, to protect the mothers and plead
the case of the mother if conflicts emerge (Howarth et al., 2017;
Premberg et al., 2011). Fathers hid their fears and did not discuss any
irregularities or worrying signs to avoid upsetting the mothers in labour
(Chandler and Field, 1997; Poh et al., 2014; Premberg et al., 2011;
Sapkota et al., 2012).
Meeting the baby/ bonding
Difficult journey but overall helped me appreciate and love my wife
more for it. … The chance to deliver my son helped with bonding
process. (034)
(Howarth et al. p.9)
The theme ‘meeting the baby/bonding’ comprises the following categories: ‘shifting attendance from wife to child’ and ‘need time and space’.
Shifting attendance from mother to child
When I heard her voice ‘Waa’ I was very happy. I was so glad that
I almost cried . . . I turned to the baby only . . . I took a look at his
body. At first, I counted his fingers and toes. (c1, c3, c6, c12, c28,
c37)
(Sansiriphun et al. p.463)
The moment the child is born is defined as amazing, indescribable,
emotional, special and simply the best experience in life (Howarth et al.,
2017; Ledenfors and Berterö, 2016; Longworth and Kingdon, 2011;
Poh et al., 2014; Sansiriphun et al., 2015). Fathers report that from the
moment the baby is born, the relief that childbirth is over will turn
to worry whether all is well with the child (Chandler and Field, 1997;
Ledenfors and Berterö, 2016; Sansiriphun et al., 2015).
Need time and space
[It] was heartbreaking when they said I couldn’t stay the night. I had
been with her that whole time and suddenly I had to go. (027)
(Howarth et al. p.9)
The time together with the baby immediately after the birth was
important. Fathers needed space and privacy to get to know their
newborn babies and their newborn family (Chandler and Field, 1997;
Howarth et al., 2017; Longworth and Kingdon, 2011).
Discussion
In this review, findings from various articles providing qualitative
data were integrated to answer the research question, ‘What are the reported experiences and needs of first-time fathers during childbirth?’
Five analytical themes were derived from the synthesis process: ‘The unknown’, ‘Many different feelings’, ‘Interaction with professionals’, ‘Part of
the labouring couple’ and ‘Meeting the baby/ Bonding’. First-time fathers
experience much insecurity, anxiety and lack of knowledge in this unknown situation and need preparation. Interacting with professionals is
important for first-time fathers to cope with both negative and positive
feelings, . Guidance in their supportive role, professionalism, information and honest answers are needed. First-time fathers want to feel involved; this can be achieved by involving them in communication and
decision-making. Fathers may experience difficulties in their supporting
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M. van Vulpen, M. Heideveld-Gerritsen, J. van Dillen et al. Midwifery 94 (2021) 102921
role, but first-time fathers focus on the needs of the mother and disregard their own needs. Meeting the baby shifts the attention from the
mother to the child, and fathers need time and privacy for this special
moment.
The results of this systematic literature review match those of the
meta-synthesis by Johansson et al., which provides an overview of fathers’ experiences in general but emphasises the greater need for information, guidance and support due to the inexperience of first-time
fathers (Johansson et al., 2015).
Other studies also report the difficulties experienced by fathers in
a new situation, for example, by identifying ‘finding a place’ as the
main theme (Chin R., Daiches, 2011). Most fathers reported being
anxious because of the unknown event (Labrague et al., 2013). Firsttime fathers more frequently reported an uncomfortable feeling during
delivery (Vehvilainen-Julkunen and Liukkonen, 1998). Recommendations were made to increase knowledge and skills in antenatal classes
(Labrague et al., 2013). In Sweden, for example, antenatal class content focused on childbirth preparation (67% of the entire course) and
parenting preparation (33%) (Pålsson et al., 2019). Childbirth preparation increased parents’ understanding of the childbirth process, birthing
milieu, the partners’ role, potential problems during delivery and pain
relief advantages and disadvantages. Experiencing positive and negative feelings has also been reported for first-time fathers but also for
fathers who have had a child before (Labrague et al., 2013; SapountziKrepia et al., 2013; Vehvilainen-Julkunen and Liukkonen, 1998). Firsttime fathers not only disregard their own needs; in the most extreme
cases, they even go along with the questions outside the guideline of
their wives (Hollander et al., 2020).
The significant impact of professional support and professionalism
on fathers’ experiences is also reported in other studies (Johansson et al.,
2015; Labrague et al., 2013; Sapountzi-Krepia et al., 2013). The association between professional behaviour perceived as negative and negative childbirth experiences has been highlighted, which also emphasises the important role of professionals (Wikander and Theorell, 1997).
The association of good childbirth experiences of fathers with confidence in the staff has also been reported (Vehvilainen-Julkunen and
Liukkonen, 1998). More attention should be devoted to supporting and
providing guidance for the father during delivery (Eggermont et al.,
2017; Vehvilainen-Julkunen and Liukkonen, 1998). Increased information needs by first-time fathers, because they have never experienced
childbirth before(Eggermont et al., 2017), should be addressed with
honest and clear information (Danerek and Dykes, 2008; Grobman et al.,
2010; Johansson et al., 2015).
The strengths of this review are the structured methodology used
and reproducibility achieved through its transparency and working in
a research group. Discussing differences until consensus was reached
increased the reliability of the study. Primary source quotes were used
to generate a rich description and emphasise the original data.
This review has limitations. First, experiences after a caesarean section should have been excluded. However, in one article, it was difficult
to separate the experiences of first-time fathers after a caesarean section from those after a normal birth. Some fathers’ experiences after a
caesarean section could have been included. However, the collection
of excellent information from the article outweighs potential consideration of experiencing a birth by caesarean section. Second, articles that
provided more information than experiences during birth yielded minimal information after relevant data were extracted. Sapkota focused on
cultural influences on fathers’ attendance at birth (Sapkota et al., 2012).
Therefore, these specific findings, which are not present in other articles,
are often not provided in this best evidence synthesis. Finally, the use
of the CASP appraisal checklist was more difficult than expected. Much
consultation and discussion within the research group were needed to
determine the quality of the articles.
The importance of this review for clinical practice relates to its recommendations for professional awareness and care to be adapted to the
specific needs of first-time fathers. Care for first-time fathers should be
formalised by devoting more attention to fathers within the antenatal
care system. For example, structural attention should be given to firsttime fathers’ expectations, preparation, role and needs when debating a
delivery plan and referring to existing or develop new paternity classes.
The important influence of professional behaviour on the experiences of
first-time fathers must be considered. Eggermont et al. reported various
needs of fathers during childbirth and stated that professionals should
adapt to these needs to provide a better childbirth experience for fathers
(Eggermont et al., 2017). It is important to realise that these reported
experiences of first-time fathers should not be overgeneralised. The expectant father must be seen as a unique person with unique experiences
and needs.
Follow-up research must be conducted on how preparation of firsttime fathers can be integrated into the prenatal care of couples. Despite
variations in childbirth culture, similarities in first-time father experiences and needs are outlined. Translating the implications into local
environments poses a challenge.
Professional education must consider the different needs of first-time
fathers and fathers who have had a child before. It is also important
to train professionals to improve their communication and supportive
skills. An evidence-based professional training program should be developed and evaluated using the Medical Research Council framework
(Craig et al., 2008; Henoch et al., 2013). It is recommended that the
enriched development phase of the MRC framework is used to develop
a training program that is well-adopted, effective and tailored to the
context (Bleijenberg et al., 2017).
In conclusion, strong evidence exists that first-time fathers experience much insecurity, anxiety and lack of knowledge in the unknown
situation and need preparation and guidance. First-time fathers want
to feel involved; this can be achieved by involving them in communication and decision making. Professionals must be aware of the specific needs of first-time fathers, and care must be adapted. Professionals
must also realise the significant influence of their professional behaviour
on first-time fathers’ experiences. Care for first-time fathers should be
formalised. Follow-up research must be conducted on integrating the
preparation of first-time fathers into prenatal care.
Conflict of interest
None declared
Ethical approval
Not applicable
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Clinical Trial Registry and Registration number PROSPERO 152,805.
Supplementary materials
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.midw.2020.102921.
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