Over 600 000 births were recorded in England and Wales in 2022 (Office for National Statistics, 2023), and similar rates were recorded in 2021 (Office for National Statistics, 2022), with 47% of these involving either instrumental or caesarean interventions. This creates the potential for complications during the childbirth continuum, including postpartum haemorrhage and perineal lacerations (NHS, 2022). These complications may be perceived by some women as traumatic, although this might not be representative of all women who experience obstetric complications (Greenfield et al, 2016; Attard et al, 2022). Greenfield (2021) suggested that birth trauma is characterised by lasting, physical and/or psychological damage experienced during the intrapartum period. This can result in individuals experiencing symptoms of post-traumatic stress disorder, which can last for years (Greenfield et al, 2016). Trauma may be a subjective notion and is individualised (Boals, 2018). Traumatic childbirth can be related to a variety of psychological effects, including depression, anxiety, post-traumatic stress symptoms (Seefeld et al, 2023) and, in extreme cases, postpartum psychosis (Reilly et al, 2023).
Approximately one in three women who give birth, will perceive their birth as traumatic (Slade et al, 2022). A traumatic birth experience can leave women feeling helpless and might impact their emotional wellbeing (Mullan, 2017). Beck (2015) reported that participants described experiences such as ‘my dignity being taken’, being ‘terrified to the core of my being’ and ‘feeling abandoned and alone’. As the topic of birth trauma has become more widely recognised in the literature, it is evident that it not only affects the birthing woman, but can also have a significant impact on those who witness the trauma, including fathers and others supporting the woman during the intrapartum period (Sweeney, 2018; Vallin et al, 2019; Hodgson et al, 2021). In the UK, the National Institute for Health, and Care Excellence (NICE, 2020) recommends considering the mental health of the partner and family, as well as providing support for the mother who experiences the trauma.
However, Baldwin et al (2019) argued that guidelines to support others who are present at a traumatic birth, such as fathers, are limited, and that their wellbeing is ignored. A report by the National Childbirth Trust stated that approximately one in three fathers experience postnatal depression, with a range of symptoms varying from low mood to post-traumatic stress disorder (Sweeney, 2018). It should be noted that this is not necessarily a direct result of witnessing birth trauma, but has been described as the impact that being a new parent can have on fathers (Shorey and Wong, 2022). However, Elmir and Schmied (2016) indicated that witnessing complications during birth with a direct threat to the life of either the mother or baby can cause post-traumatic symptoms in fathers and others supporting the woman during birth.
There is a paucity of evidence that focuses on the mental health of fathers, particularly those who have witnessed birth trauma (White, 2007; Elmir, 2013; Inglis et al, 2016; Etheridge and Slade, 2017; Daniels et al, 2020; Webb et al, 2021; Elmir and Schmied, 2022; Courtois and Wendland, 2023). The aim of this critical literature review was to examine the impact that traumatic birth has on fathers, in order to develop understanding of how fathers can be supported during this time. The review focused on perceived birth trauma from the father's perspective and the impact on their mental health.
Methods
This narrative literature review used a variety of key terms, including ‘birth trauma’, ‘mental health’, ‘fathers’ and aligning synonyms. Peer-reviewed primary research articles were screened for inclusion. The inclusion and exclusion criteria used are shown in Table 1. The inclusion criteria initially included articles dated between 2015–2023. However, as there were limited results, the date range was extended twice, first to 2010–2023 and then from 2005–2023. The full PRISMA diagram is shown in Figure 1.
| Inclusion | Exclusion |
|---|---|
| Published in English | Not published in English |
| Date range 2005–2023 | Published before 2005 |
| Qualitative methodologies | Quantitative methodologies |
| Specifically investigated only fathers' perceptions of birth trauma | Explored impact/perceptions of birth trauma of others (mothers or mothers and fathers) |
| UK & international studies in English | Not conducted or translated into English |
Quality appraisal
The Critical Appraisal Skills Programme (2018) provide tools backed by the Cochrane Qualitative and Implementation Methodologies Group that have become the accepted standard for assessing quality in qualitative evidence syntheses of health (Long et al, 2020). The set of checklists can be used to evaluate different types of research studies, including randomised controlled trials, qualitative studies and systematic reviews. They provide a framework for critically appraising the validity, relevance and applicability of research findings (Long et al, 2020). For this review, the tool was used to evaluate methodological rigour of the six articles identified following the PRISMA process. The articles were assessed for validity and reliability in terms of applicability to the research question.
Data analysis
Thematic analysis was used for this review, which is a qualitative research approach to data analysis that involves the identification, analysis and reporting of themes that emerge in a dataset (Braun and Clarke, 2006), with a flexible approach that is compatible with multiple epistemological approaches (Williamson and Whittaker, 2020). A theme matrix was used to support the process of the identification and development of themes (Aveyard et al, 2023).
Results
The locations and participant demographic profiles of the six studies included varied. Two were conducted in Australia (Inglis et al, 2016; Elmir and Schmied, 2022), two in the UK (Etheridge and Slade, 2017; Daniels et al, 2020), one in New Zealand (White, 2007) and one in Uganda (Mbalinda et al, 2015). The number of included participants ranged from 11 (Etheridge and Slade, 2017) to 69 (Inglis et al, 2016). Full details of the included articles are shown in Table 2.
| Reference | Design | Methods | Sample and setting | Results |
|---|---|---|---|---|
| Inglis et al (2016) | Mixed methods | Semi structured interviews, thematic analysis | Australia n=69 participants recruited through online social media forums (not all from Australia) n=7 interviewed | Men are meant to be the breadwinner and provide for the family. Terrifying seeing the complication and partner/baby in distress. |
| Elmir and Schmied (2022) | Phenomenological | Semi-structured interviews, 4 face to face, 11 by phone, 2 by email; thematic analysis | n=16 participants from Australia, n=1 from New Zealand | Fathers were mostly unprepared and feared birth complications or adverse experiences. Fearful for the lives of baby and partner. Wanted to be involved but found that they were ‘pushed aside’ and ‘excluded’, specifically when things went wrong. Did not feel supported or able to talk about their feelings to either their partner and/or midwife, feeling they needed to be the ‘caregiver’, which impacted their own mental health and, in some cases, their relationship with baby and partner |
| Daniels et al (2020) | Qualitative questionnaire | Online questionnaire, thematic analysis | n=61 participants recruited in UK | Majority of fathers felt excluded, perceived trauma had a profound impact on mental wellbeing. Relationships were affected long into the postnatal period, including physical and emotional intimacy with partner and some found it difficult to bond with baby. Fathers were perceived as less important than mothers but recognised the need in an emergency for the focus to be on mothers to potentially save lives. Most found prenatal support was beneficial, except for antenatal classes which were mostly tailored to ‘normal’ births and did not account for complications. Support afterwards was poor. There was a perceived need to keep emotions bottled up and not express themselves |
| Etheridge and Slade (2017) | Phenomenological | Phone interviews after online study advertisement | n=11 fathers in the UK recruited via Birth Trauma Association website, newletter from the Fatherhood Institute and two internet forums | Fathers felt they had to keep feelings bottled up, not discuss them with partner. Some had delayed impact from birth. Not being listened to during birth and not feeling welcomed. Focus was on the women; some fathers understood this, as they wanted their partner to be helped and saved, but would have liked someone to communicate with them when their partner and/or baby was taken away. Two fathers sought professional help, but had a history of depression and reached significant level of distress before seeking help. Strain on relationships, some positive, some negative. Having someone to talk to after the birth helped them to process what happened, have a ‘debrief’ |
| White (2007) | Phenomenological | Participants narrated experiences face to face, via tape or through written letter or email, content analysis | n=21 fathers recruited in New Zealand through the Trauma and Birth support group website, newspapers, radio, television and word of mouth | Felt like they were pushed aside, deemed to be a spectator and some felt they were seen as a nuisance by staff, who did not take their views into account. When they rang for help, took time for staff to come. Became fearful and scared for lives of baby and/or partner. Two fathers witnessed death of their wives; their quotes were not included in the article but responses were taken into account for the themes that emerged. Affected their relationship sexually; they either had to wait for a long time or found it brought back distressing memories of the birth. Some marriages broke down as a result |
| Mbalinda et al (2015) | Phenomenological | In-depth narrative interviews 4–12 months after traumatic experience. Interviewed twice, second 3–6 months after first | n=25 participants in Uganda recruited from three districts, not stated how recruitment was carried out | Felt they were not well supported, were ignored and cast aside. Felt their opinions did not matter and wanted to be included in decisions made about the care of their wife. Felt they lacked information about birth and possible complications. They wanted to be informed about decisions being made and be made aware of what was happening. When some were given practical information, it helped to make sense of events. Concerns and fears regarding partner and baby when they separated. Separated and excluded for a long time, with no information from professionals |
Three themes emerged: toxic masculinity: the role of fathers in the birth environment, unpreparedness: expectation vs reality and relationships with partner and others.
Toxic masculinity: the role of fathers in the birth environment
The included studies acknowledged the existence of toxic masculinity, with most discussing the gendered stereotypes of fathers, despite not specifically mentioning toxic masculinity (Park and Banchefsky, 2018). Toxic masculinity related to suppression of the father's emotions, with some fathers acknowledging that they needed to seek support but did not do so (Mbalinda et al, 2015; Inglis et al, 2016; Etheridge and Slade, 2017; Daniels et al, 2020).
In five of the studies (White, 2007; Inglis et al, 2016; Etheridge and Slade, 2017; Daniels et al, 2020), fathers' emotional suppression was exacerbated by feelings of inadequacies as a result of being excluded or isolated from the birthing experience, leading some to feel they were a ‘nuisance’ (White, 2007). Furthermore, fathers felt an obligation to fulfil the stereotypical role of being ‘strong’ and the ‘rock of the family’, which negatively impacted their psychological distress (Mbalinda et al, 2015; Inglis et al, 2016).
There was a perceived lack of support and information being given at the time the traumatic birth occurred.
‘I just feel like I got left behind … never told me what was going on and I was just waiting in this room like is my wife about to die?’
Inglis et al (2016) reported that a lack of information created a traumatic experience for some fathers, which was directly influenced by communication and a lack of support from healthcare staff. One participant in the Philippines stated that for cultural reasons, fathers were not allowed in the birthing room and were not provided with information about the birth, which had occurred 45 minutes previously despite labour having started 36 hours before (Inglis et al, 2016). Although they did not witnessing birth trauma, this participant's experience was impacted by a lack of support and information from healthcare providers, resulting in a perceived traumatic experience that adversely affected their mental health.
The lack of communication from healthcare professionals intensified fathers feeling heard or able to express their emotions. This lack of communication may encourage or reinforce stereotypical gendered roles (Inglis et al, 2016). Healthcare professionals may not acknowledge that some fathers might require support to help them manage their expectations of the birth experience.
Unpreparedness: expectation vs reality
All six studies discussed fathers' expectations, which were often different to what was experienced. Fathers in five of the studies directly stated that they felt unprepared for birth. In two of the studies, fathers attributed this unpreparedness to antenatal education (White, 2007; Daniels et al, 2020). They felt that antenatal education failed to acknowledge potential complications, with some fathers highlighting that antenatal classes conveyed an idealistic view of childbirth without providing any information about potential complications (Daniels et al, 2020). Participants in Daniels et al (2020) suggested that they would have appreciated information in antenatal classes that would have enabled them to support their partner. Etheridge and Slade (2017) similarly found that fathers valued antenatal education that focused on instrumental birth, which provided reassurance when this was later experienced.
Unexpected situations during labour created frustration for some fathers as they felt unprepared. Inglis et al (2016) found that participants had a perfect image of what childbirth should be and were unaware that potential problems could occur. Fathers typically expected an ‘uneventful birth’ (Elmir and Schmied, 2022) and therefore complications had a significant impact on the participants that continued after the birth. For some fathers, the fear of their partner and/or baby dying was a causal factor in not having more children (Etheridge and Slade, 2017). White (2007) explained that this fear extended to a lack of desire to be intimate with their partner, for fear that they might become pregnant again, which further added to their trauma, leading to some couples parting.
Relationships with partner and others
Fathers perceived that trauma had affected their relationships with others involved in the birth. This overarching theme included four subthemes: the partner, the baby, friends and healthcare professionals.
The partner
Fathers in all six studies discussed the negative impact that birth trauma had on their relationships with their partner, with some stating this was exacerbated by the mental health difficulties experienced in the postnatal period (White, 2007). Three of the studies explored fathers' sexual intimacy with their partner (White, 2007; Inglis et al, 2016; Daniels et al, 2020). Fathers discussed how their sexual encounters were restricted in the postnatal period because of the injuries their partner had sustained (White, 2007). Some expressed fear of sexual activity, causing increased psychological distress. This led some men to relive the event and consider interventions such as a vasectomy (Inglis et al, 2016).
Other fathers completely withdrew from their relationship in order to process what they had witnessed. Some found it difficult to express their feelings to their partner, which two of the studies noted led to conflict in their relationship and subsequently, some relationships to break down (Etheridge and Slade, 2017; Elmir and Schmied, 2022). Conversely, four studies highlighted that witnessing a traumatic birth and how their partner managed the experience aided their ability to process it and they felt a stronger bond with their partner as a result (Inglis et al, 2016; Etheridge and Slade, 2017; Daniels et al, 2020; Elmir and Schmied, 2022).
The baby
Four studies noted how traumatic birth had a negative effective on fathers' relationships with their baby. Some felt that the baby was a reminder of the trauma they had witnessed and the potential threat to the life of their partner (Inglis et al, 2016). They used a variety of coping strategies, such as not interacting with the baby, which had an impact on their ability to effectively bond with their baby (Etheridge and Slade, 2017; Elmir and Schmied, 2022). This created guilt that further impacted their relationship with their baby, and generated feelings of hopelessness and inadequacy in being able to care for their child (Daniels et al, 2020).
Friends
Four studies discussed how trauma impacted their relationship with their friends (Mbalinda et al, 2015; Inglis et al, 2016; Daniels et al, 2020; Elmir and Schnied, 2022). Birth trauma could negatively impact relationships with friends, as fathers had difficulty seeking support from friends either for cultural reasons (Elmir and Schmied, 2022) or a perceived lack of understanding of their experience (Daniels et al, 2020). However, two studies noted positive interactions, where fathers found it helpful to seek support from friends, which contributed to how they coped with the outcome of their experience (Mbalinda et al, 2015; Inglis et al, 2016).
Healthcare professionals
All six studies discussed the relationship with the healthcare professional and how this was influenced by whether fathers were able to communicate effectively with them. Fathers in two studies felt reassured when provided with information regarding the welfare of their partner and/or baby following an emergencym which reduced psychological distress (Mbalinda et al, 2015; Inglis et al, 2020). Participants discussed the importance of being provided with explanations as to why or how the complication had occurred and how it was being managed. Healthcare professional shift changes led some fathers to feel unable to establish a rapport with a new staff member (Mbalinda et al, 2015). This contributed to feeling excluded, which impacted their mental health following the birth and whether they sought support (Elmir and Schmied, 2017; Daniels et al, 2020). However, when continuity of care was provided, fathers felt reassured and able to process the experience more effectively (Elmir and Schmied, 2017).
Discussion
Fathers are frequently present during the childbirth continuum (Vallin et al, 2019), but there a paucity of research into fathers' experiences, with most evidence examining the couple's experience rather than focusing on the father (McNab et al, 2022). This review explored fathers' perceived birth trauma and the potential impact on their mental health. While some fathers had experienced historical trauma, which might have been impacted by recall bias (Krayem et al, 2021), the studies nevertheless provided valuable insights, which could be used when providing care during the intrapartum period.
This review did not use a single definition of birth trauma because of the subjective nature of trauma (Boals, 2018). A similar approach was taken in one of the included studies (Inglis et al, 2016). The results highlighted contributing factors to the perceived traumatic experience of complications during childbirth. Fathers faced challenges with their role during birth, particularly during emergency situations (Inglis et al, 2016; Etheridge and Slade, 2017; Daniels et al, 2020; Elmir and Schmied, 2022), which caused significant stress.
Toxic masculinity is a multifaceted phenomenon defined by traditional gender roles (Parent et al, 2019). The core characterisation of the term relates to male views on homophobia, misogyny and violence (Harrington, 2021); however, it also holds that men should reject emotional displays, often leading to the inability to seek help when required (De Boise, 2019).
While experiencing considerable distress and anxiety, fathers frequently felt unable to discuss their feelings with their partners (Parent et al, 2019). Stigma relating to men expressing their emotions is a common concept (Chatmon, 2020) and, in the case of birth, generated feelings that healthcare professionals were excluding them from the experience (Ramirez and Badger, 2014). Consequently, fathers felt reluctant to seek support for poor mental health (Mahalik and Di Bianca, 2021). This is an important finding as while women are more likely to access secondary mental health services, men are at an increased risk of suicidal ideation and suicide, while being less likely to seek professional support (Richardson, et al, 2021).
In the UK, there is a focus on improving outcomes related to poor maternal perinatal mental health (Baldwin and Bick, 2018). The NHS (2019) long term plan highlights that perinatal services should allow partners to access assessment with signposting for support if required. However, when referred to another service, such as community mental health, there are still challenges in terms of accessing therapies or treatment as a result of staffing shortages (Baker et al, 2019). Vipham, (2023) suggested that during the postnatal period, only a small percentage of healthcare professionals assess the mental health of fathers during each contact, with most staff only completing this assessment during the first postnatal appointment. Wells (2016) argued that this does not create a holistic approach to care for the mother or child, as the father's needs are ignored. This may be the result of a reported lack of confidence in assessing mental health for healthcare professionals (Vipham, 2023). Increased training for midwives and health visitors could enable effective evaluation of paternal mental health, facilitating improvements.
Assessing paternal mental health might help to mitigate the effect of birth trauma on a couple's relationship, reducing the risk of depression and anxiety in the perinatal period (Figueiredo et al, 2018). The correlations between maternal and paternal mental health challenges support the present review's findings on the impact of perceived support on fathers' distress and mental health, which is also consistent with findings on maternal mental health (Reid and Taylor, 2015). Delicate et al's (2018) meta-synthesis investigated the impact of post-traumatic stress related to childbirth and found that traumatic birth experiences strengthened some couple's relationships, although the authors were unaware of causal mechanisms. The authors recommended early detection by healthcare professionals, as this led to positive outcomes for the couple's relationship (Delicate et al, 2018). NICE (2020) guidelines include recommendations regarding mental healthcare of partners during the intrapartum period, encouraging them to seek assistance from friends and family. This supports the present review's findings that fathers found support from friends to be beneficial. However, NICE (2020) does not currently include guidelines that healthcare professionals should signpost mental health services where required for fathers.
Fathers highlighted the need for information and communication to feel prepared and mitigate any potentially traumatic impacts of witnessing birth trauma. While the NHS (2019) long term plan recommends assessment of mental health for partners, it would be beneficial to address this issue during antenatal care. Antenatal education is associated with positive outcomes following birth (Mousumi, 2015; Krysa et al, 2016; Cross et al, 2023). For example, Cross et al (2023) found that women who received broad information about birth complications had improved decision making, coping strategies and emotional responses to the birth, regardless of whether they subsequently experienced birth trauma. In the UK, the content of antenatal education varies significantly (Cross et al, 2023) and is usually determined individually by local NHS trusts (Care Quality Commission, 2020). When centralised guidance for antenatal education is not provided, this can have a negative impact on both maternal and paternal mental health.
Communication was identified as important. Issues with communication led to tensions between fathers and healthcare professionals, where fathers felt that healthcare staff were excluding them from the experience (Inglis et al, 2016). This led to issues with fathers' interpersonal relationships and their mental health, compounding the issues of gendered stereotypes and not seeking support (Krayem et al, 2021).
Communication is a key aspect in healthcare (Howick et al, 2018). According to Höglander et al (2023), effective communication is a complex phenomenon that facilities rapport with patients and provides person-centred care encompassing both verbal (Ratna, 2019) and non-verbal (Sibiya, 2018) communication. Effective communication is associated with improved experiences for patients and improved health outcomes. Howick et al (2018) noted that without effective communication, the healthcare provided to families during the childbirth continuum may be impaired. Communication is imperative as it enables the needs of the individual to be identified (Höglander et al, 2023), which may explain why in the present review, it was found that fathers felt alienated and isolated when healthcare professionals prioritised the needs of the mother and baby. It is important that care should be approached holistically and include the needs of families, in this instance the father, involved with patient care. Elmir and Schmied (2022) found that fathers needed to talk to someone after the birth, as this would have helped them to process the experience. Debriefs following traumatic experiences have been shown to provide positive insights while permitting individuals the time to process the events effectively (Toews et al, 2021).
Limitations
There were limitations to this literature review, including the sample size and methodology. The review used studies predominantly from developed countries, with only one included study from a developing country. The demographics of the participants were mainly from White ethnic backgrounds, which might limit the generalisability of the review. Furthermore, there is an argument that the qualitative research designs used in the studies may be a limitation. While qualitative data provide rich informative insights into the experiences of individuals (Kelly, 2023), low sample sizes associated with this methodology may limit the generalisability of the review. Nevertheless, the literature included provide important insights into the experiences of fathers and birth trauma.
Another limitation of the review was the search strategy, as the author failed to recognise all possible search terms. Terms such as ‘vicarious trauma’ and ‘secondary traumatic stress’ were overlooked in the initial strategy. Both terms explain how individuals display mirroring trauma responses while not being directly involved in trauma themselves (Isobel and Thomas, 2022). Not including these terms may have hindered the inclusion of additional articles appropriate for review.
Implications for practice
The literature reviewed demonstrate that fathers experience birth trauma, implying the need to develop inpatient maternity services that address poor paternal mental health following birth trauma. This might include assessment and treatment of fathers in inpatient maternity services or directing mothers and fathers to further support.
The experience of birth trauma and the mental health impact on fathers requires further research. This should include the generation of a specific timeframe of when birth trauma occurrs, to determine the immediate impact and needs of the father following birth trauma. This would inform practice and support the needs of fathers and mothers alike.
The provision of antenatal education should be developed and include discussions of potential adverse outcomes during the labour and birth. Maternity service provision could also include an increased number of specialist mental health nurses to provide support for those experiencing mental health difficulties following childbirth. Additional training could be provided to midwives and other maternity care professionals, which would aid in the assessment, treatment and signposting to relevant services for those who do not have mental health expertise. This would support the recovery of those experiencing birth trauma, including fathers.
The review highlighted communication challenges, particularly when care was transferred between maternity and mental health services. This is significantly impacted by the number of different systems used across the NHS, which could result in important information not being shared. Improving communication between healthcare providers would maximise effective person-centred care for the individual involved and sequentially improve outcomes (NHS England, 2018).
Conclusions
This literature review aimed to examine the mental health impact on fathers who witnessed birth trauma. While fathers wanted to be involved and share the experience with their partner, they often felt that they were excluded, which led to frustration and feelings of inadequacy. When complications arose, fathers felt isolated, fearful and hopeless, which continued for a significant period following the birth. Some fathers experienced post-traumatic stress symptoms but were often reluctant to seek support from their partner, friends, family or healthcare professionals.
The review highlights the need to develop services that address paternal mental health following birth trauma and ensure that fathers are not overlooked when considering the effects of a traumatic birth. Antenatal education should prepare women and their partners for the possibility of adverse outcomes during birth.