Becoming a first-time father is a major life event. Fathers' experiences of their first child's birth is also significant in their relationship with mother and infant (Premberg et al, 2012). Fathers' emotions may not be prioritised because of mothers' dominant role, as well as a lack of support and training during pregnancy, and fathers may not be fully prepared for their role (Sapountzi-Krepia et al, 2010). Some men describe fatherhood as undesirable and disappointing as a result (McKellar et al, 2008). First-time fathers experience a change in their identity and an altered relationship with their spouse (Barclay and Lupton, 1999). They must also manage evolving and complex emotions to establish a relationship with their child. This process begins with the onset of their partner's pregnancy and includes the experience of fatherhood during birth (Hildingsson et al, 2014). Although men express happiness and excitement about the birth of their first child, they also report concerns about parenthood because they feel unprepared or uncertain about their partner's expectations of them as fathers (Deave et al, 2008, Hildingsson et al, 2014).
The 1994 International Conference on Population and Development emphasised men's significant role in promoting sexual and reproductive health, and expanded efforts to promote men's responsibility in sexual and reproductive behaviours (World Health Organization, 2007). Additionally, men's participation is a major component of empowering women to promote sexual and reproductive health (Carter, 2002). To help mothers have a positive experience of labour and childbirth, it is recommended that all women choose an accompanying partner, who can be the woman's spouse or sex partner (World Health Organization, 2018). Offering emotional and social support during labour is a key aspect of high-quality maternal care that can enhance maternal and fetal outcomes and provide a positive childbirth experience for a mother (Bohren et al, 2019). Although some fathers feel positively about their experiences of childbirth (Nichols, 1993; Chan and Paterson-Brown, 2002), a significant number show negative reactions (Chan and Paterson-Brown, 2002). Men who attend their partner's labour and birth can feel satisfied, proud, empowered and strong, but may also face anxiety, stress, fear of the outcome and a sense of uselessness (Bradley et al, 2008; Sapountzi-Krepia et al, 2010).
Although men cannot attend the labour ward in many Iranian hospitals, Iranian women have been reported to prefer their husbands be present during labour. Many labour centres in Iran are largely feminine, where a lack of facilities and religious reasons prevent men from attending all labour wards (Mortazavi and Khadijeh, 2012). However, there are private midwifery counseling centers that hold birth preparedness classes for expecting parents and allow men to attend their partner's labour and birth in private wards (Ministry of Health and Medical Education, 2009). Men's presence during and after labour and birth is a novel experience in Iran, which is yet to become prevalent. With fathers' changing role and the increasing tendency for their presence at and participation in labour and birth, it is essential to identify their experiences. The aim of this is to empower maternal care specialists to meet fathers' and mothers' needs more effectively. Thus, this study aimed to examine first-time fathers' experiences attending their partner's labour and birth.
Methods
This was a descriptive cross-sectional study of 200 first-time fathers visiting midwifery counseling centers in Tehran, Iran. With an alpha of 0.05, z of 1.96, sigma of 7 and d of 1, the sample size was calculated at 189 based on the sample size formula (Molina-Velásquez et al, 2018). The final sample size was raised to 200 to account for possible withdrawal.
The inclusion criteria were being a first-time father aged over 21 years, who was literate, had no history of mental, visual or cognitive problems and no issues with addiction. Their fetus must be healthy and have a minimum gestational age of 37 weeks from a spontaneous natural conception and an uncomplicated pregnancy. The exclusion criteria were complications during labour, stillbirth, infant hospitalisation and unwillingness to participate in the study.
Data collection
Data were collected with a demographic information form and the first-time fathers questionnaire. The form gathered data on participants' and partners' age, education and occupation, as well as housing, insurance and income satisfaction. For occupation, the possible answers were worker, employee and professional, which carry specific definitions in Iran (Ministry of Cooperatives, Labor and Social Welfare, 2007). A ‘worker’ is someone whose requires manual or technical skills, whereas an ‘employee’ is someone whose job includes intellectual activity. A ‘professional’ job requires special expertise and training.
The questionnaire was developed by Premberg et al (2012) in Sweden and translated into Persian and validated by Dodel et al (2021). The 19-item questionnaire examines fathers' experience in four domains: preparedness, acceptance and support during labour, support during and after birth and worry. The scores range from 19 to 76. Lower scores indicate a more desirable experience while higher scores indicate a less desirable experience.
The data were collected from April to December 2021 in three midwifery counseling centers. First, a list of fathers who had attended their partner's labour and birth in the past 1–12 months was assembled. Eligible individuals were contacted over the phone and briefed about the study. Those who were willing to participate received an informed consent form via email or mail, and signed and returned it. They received the demographic information form and the Persian version of the questionnaire electronically. All questionnaires were self-reports filled out electronically.
Data analysis
The data were analysed in the statistical package for social science, version 21, using descriptive statistics. The average percentage score for each domain was calculated by dividing the mean score by the maximum possible score and multiplying by 100. Spearman's correlation coefficient, the independent t-test, the Mann-Whitney U test and the Kruskal-Wallis test were used to examine the relationship between demographic and gestational variables and different domains of first-time fathers' experiences. Multivariate linear regression analysis was performed to test the model and identify variables affecting the domains of first-time fathers' experiences. The significance level was set at P<0.05.
Ethical considerations
This study was approved by the ethics committee of the Shahid Beheshti University of Medical Sciences (IR. SBMU.PHARMACY.REC.1398.053). All participants provided written informed consent. They were assured that they could withdraw from the study at any point, and all their data would remain anonymous.
Results
Of 293 eligible fathers, 200 (63.3%) filled out the questionnaires. Their sociodemographic characteristics are shown in Table 1. The mean age was 32.51±4.34 years. Of this population, 70.0% had a university degree, and 49.5% were self-employed. The majority (93.7%) lived in cities and 81.4% had average economic status. All participants were married and lived with their wife, and 89.1% had a planned pregnancy. Most reported that their infant's sex was what they wanted (93.7%). Characteristics of prenatal care and childbirth preparation are presented in Table 2.
Table 1. Characteristics of first-time fathers (n=200)
| Variable | Frequency, n (%) | |
|---|---|---|
| Father's age | Mean ± standard deviation | 32.51±4.34 |
| Father's education | Primary and secondary school | 60 (30.0) |
| University degree | 140 (70.0) | |
| Father's occupation | Worker | 8(4.0) |
| Self-employed | 99(49.5) | |
| Employee | 65(32.5) | |
| Professional | 28(14.0) | |
| Partner's age | Mean ± standard deviation | 28.27±3.95 |
| Partner's education | Primary and secondary school | 39 (19.5) |
| University degree | 161 (80.5) | |
| Partner's occupation | Housewife | 143(71.5) |
| Self-employed | 17 (8.5) | |
| Employee | 20 (10.0) | |
| Professional | 20 (10.0) | |
| Housing | Rental | 111 (50.5) |
| Private | 89 (44.5) | |
| Insurance | Yes | 169 (84.5) |
| No | 31 (15.5) | |
| Supplementary insurance | Yes | 96 (48.0) |
| No | 104 (52.0) | |
| Hospital insurance coverage | Yes | 95 (47.5) |
| No | 105(52.5) | |
| Income satisfaction | Less than enough | 42 (21.0) |
| Enough | 150 (75.0) | |
| More than enough | 8 (4.0) |
Table 2. Prenatal care and childbirth preparation (n=200)
| Variable | Frequency, n (%) | |
|---|---|---|
| How did you prepare for the birth of your child? | Self study | 23 (11.5) |
| Internet/chatting | 38 (19.0) | |
| Getting information from friends and family | 2 (1.0) | |
| Attending preparation classes during pregnancy | 113 (56.5) | |
| Reading books | 9 (4.5) | |
| Other (eg psychological consultation) | 4 (2.0) | |
| Did not do anything | 11 (5.5) | |
| Did you attend childbirth preparation classes? | Yes | 149 (74.5) |
| No | 51 (25.1) | |
| Did you attend prenatal care visits? | Yes | 173 (86.5) |
| No | 27 (13.5) | |
| Who was your health provider? | Midwife | 127 (63.5) |
| Obstetrician | 73 (36.5) | |
| Did you check the birth ward before labour began? | Yes | 73 (36.5) |
| No | 127 (63.5) | |
| How prepared did you feel for the birth of your child? | Very good | 60 (30.0) |
| Good | 112 (56.0) | |
| Low | 22 (11.0) | |
| Not at all | 6 (3.0) | |
| Was your experience of childbrith what you expected? | Yes | 136 (68.0) |
| No | 64 (32.0) |
The mean score for fathers' overall experiences with labour and birth was 44.51±9.89 out of a possible highest score of 76. The mean percentage of overall scores of fathers' experiences was 43.68, indicating a relatively favourable overall experience. The most favourable experience was reported in the domain of acceptance and support during labour, and the most unfavorable was in the domain of worry (Table 3).
Table 3. Mean score and domains on questionnaire (n=200)
| Domains | Mean ± standard deviation | Average percentage | Score range |
|---|---|---|---|
| Preparedness | 4.57±1.73 | 41.8 | 2–8 |
| Acceptance and support during labour | 8.52±3.55 | 23.3 | 5–20 |
| Support during and after birth | 12.88±4.45 | 53.1 | 5–20 |
| Worry | 18.54±5.83 | 54.7 | 7–28 |
| Total score | 44.51±9.89 | 43.7 | 19–76 |
Correlations between domains of experience and demographic, socioeconomic and gestational variables were also examined (Table 4). Preparedness was associated with checking the ward before labour (P=0.005) and having a planned pregnancy (P=0.016). Acceptance and support during labour was associated with both the father's (P=0.048) and their partner's (P=0.030) education, the father's occupation (P=0.020), hospital insurance coverage (P=0.021) and compatibility of expectations and experiences of birth (P=0.001). Support during and after birth was associated with wife's age (P=0.021), both the father's (P=0.015) and partner's (P=0.001) education and income satisfaction (P=0.045). Worry was associated with father's education (P=0.008), place of residence (P=0.031), level of preparedness (P=0.002) and compatibility of experiences and expectations of birth (P=0.0001). For the overall experience, method of preparation for birth (P=0.003), level of preparedness (P=0.006) and compatibility of expectations and experiences (P=0.0001) were associated with the total score for first-time fathers' experiences.
Table 4. Correlation of first-time fathers' experience domains with characteristics (n=200)
| Domain | Variable | Mean ± standard deviation/correlation coefficient | P value | |
|---|---|---|---|---|
| Preparedness | Checking birth ward before labour | Yes | 4.51 ± 1.83 | 0.005* |
| No | 4.52 ± 1.69 | |||
| Planned pregnancy | Yes | 4.41 ± 1.70 | 0.016† | |
| No | 5.33 ± 1.83 | |||
| Acceptance and support during labour | Education (correlation coefficient) | Father | 0.134 | 0.048‡ |
| Partner | 0.146 | 0.030‡ | ||
| Father's occupation | Worker | 7.50 ± 1.64 | 0.020§ | |
| Self-employed | 7.71 ± 2.66 | |||
| Employee | 8.71 ± 3.81 | |||
| Professional | 10.10 ± 3.95 | |||
| Hospital insurance coverage | Yes | 7.96 ± 3.24 | 0.021 | |
| No | 9.05 ± 3.69 | |||
| Compatibility of birth experience with father's expectations | Yes | 8.06 ± 3.08 | 0.001* | |
| No | 9.50 ± 4.27 | |||
| Support during and after birth | Partner's age (correlation coefficient) | 0.156 | 0.021‡ | |
| Education (correlation coefficient | Father | 0.164 | 0.015‡ | |
| Partner | 0.223 | 0.001‡ | ||
| Income satisfaction | Less than enough | 13.05 ± 4.38 | 0.045§ | |
| Enough | 12.97 ± 4.46 | |||
| More than enough | 12.63 ± 5.76 | |||
| Worry | Father's education (correlation coefficient) | -0.180 | 0.008 | |
| Place of residence | City | 18.39 ± 5.77 | 0.031† | |
| Village | 23.50 ± 5.89 | |||
| Preparedness for birth | Very good | 16.36 ± 6.02 | 0.002§ | |
| Good | 18.78 ± 5.50 | |||
| Low | 21.00 ± 5.01 | |||
| Not at all | 21.14 ± 8.28 | |||
| Compatibility of birth experience with father's expectations | Yes | 17.17 ± 5.60 | 0.0001* | |
| No | 21.50 ± 5.21 | |||
| Overall experience | Preparation for birth | Self-study | 46.92 ± 12.25 | 0.003§ |
| Internet/chatting | 40.12 ± 9.26 | |||
| Friends and family | 41.68 ± 11.08 | |||
| Classes | 45.39 ± 9.84 | |||
| Books | 44.36 ± 8.75 | |||
| Other | 48.70 ± 7.69 | |||
| Did not prepare | 46.94 ± 8.77 | |||
| Level of preparedness | Very good | 41.66 ± 9.88 | 0.006§ | |
| Good | 44.40 ± 8.73 | |||
| Low | 49.10 ± 10.74 | |||
| Not at all | 51.28 ± 16.02 | |||
| Compatibility of birth experience with expectations | Yes | 42.64 ± 8.75 | 0.0001* | |
| No | 47.98 ± 10.94 |
Mann-Whitney test,
‡Spearman's correlation,
§Kruskal-Wallis test
In linear regression, a more highly educated partner (P=0.028), lack of insurance coverage for hospital charges (P=0.025), provision of prenatal care by obstetricians (P=0.030), feeling less prepared for childbirth (P=0.006) and a lack of compatibility between expectations and experiences (P=0.002) were associated with a higher total experience score, indicating a less desirable experience (Table 5).
Table 5. Linear regression results (n=200)
| Domain | Variable | Beta | P value |
|---|---|---|---|
| Overall experience | Partner's education | 1.77 | 0.028 |
| Lack of insurance coverage for hospital charges | 2.85 | 0.025 | |
| Obstetrician/gynaecologist provided pregnancy care | 2.85 | 0.030 | |
| Preparedness for birth | 2.51 | 0.006 | |
| Compatibility of experience and expectations | 4.35 | 0.002 |
Discussion
This descriptive cross-sectional study investigated first-time fathers' experiences of attending labour and birth. Fathers' overall experience was relatively favourable. The most favourable experience was reported in the domain of acceptance and support during labour, and the most unfavorable was in the domain of worry. Factors that increased the experience score, indicating a less desirable experience, were having a more highly educated partner, a lack of insurance coverage for hospital charges, provision of prenatal care by an obstetrician, feeling less prepared and incompatibility of expectations and experiences.
Preparedness
A planned pregnancy and checking the ward before the onset of labour were associated with fathers' experiences in the domain of preparedness. Naturally, checking the ward where they would experience the birth of their first child might affect a father's sense of preparedness. Similarly, Wilkes et al (2012) reported that men's experiences of fatherhood changed if a pregnancy was not planned, if the father was a teenager or if there were concerns about financial and occupational resources (Wilkes et al, 2012).
Acceptance and support during labour
In acceptance and support during labour, parents' increased education, the father working as a professional, hospital charges not being covered by insurance and incompatibility of experiences and expectations were associated with a less favourable experience. However, Hildingsson et al (2011; 2014) found no association between level of education and fathers' experiences of childbirth and Kululanga et al (2012) examined fathers' experiences in Malawi and found that fathers' preparedness led to a favourable experience. In Kululanga et al's study, all childbirth-related hospital services were covered by insurance or charity organisations for all social strata. In the present study, a lack of insurance coverage for hospital charges was correlated with acceptance and support during labour. Differences in cultural settings and service provision systems should not be discounted when considering the results.
Parents with higher education and professional jobs are likely to have higher expectations of the healthcare system because of their socioeconomic status, and failure to meet these expectations may affect fathers' experiences of childbirth. Maharlouei et al (2017) reported that a higher socioeconomic status is associated with lower satisfaction with public health services in Iran.
Additionally, a lack of insurance coverage for hospital charges can cause financial concerns for fathers who are, in this cultural context, usually in charge of the family's finances (Eskandari et al, 2015). Adding to the likelihood of having a less favourable experience is the fact that first-time fathers may have preconceived ideas about childbirth that may not necessarily reflect reality, as they lack the experience of a previous birth. These factors may shape fathers' experiences in acceptance and support during labour, which is the first step in experiencing childbirth.
Support during and after birth
Fathers' experiences of support during and after birth were less favourable in those with older or more educated partners, and those with less satisfaction with their income. Madhavan et al (2014) reported that a mother's age can affect fathers' financial support for children, indicating that partners' age may influence parenting and the birth experience. Parents with higher education and a more advanced occupation are likely to have a higher economic status and more time to spend on spouses and children (Cabrera and Bradley, 2012), potentially accounting for less support being associated with lower income satisfaction.
Another significant variable in support during and after birth was reduced satisfaction with income. According to Palm (2014), a decline in a family's income affects fathers' emotional adaptation and prevents them from engaging in enjoyable interactions with their children (Palm, 2014). Declined satisfaction of fathers' experiences with a reduction in income is expected, but why it affects support during and after birth merits further research.
Worry
Fathers' experience in the domain of worry was significantly correlated with their education, place of residence, level of preparedness and the compatibility of the experience with their expectations. Molina-Velásquez et al (2018) reported a significant inverse correlation between worry and healthcare system support, suggesting that the greater the support available from the healthcare system, the less parents worry. In combination with the present study's results, this suggests that support from the healthcare system aimed to reduce parents' worry should take into account father-specific factors such as their preparedness and their expectations of labour and birth.
Regarding expectations and experiences, Dellmann (2004) reported that the majority of fathers described childbirth as an amazing but upsetting experience. Most of their expectations were not met and they were confused about their role (Dellmann, 2004). Additionally, Premberg et al (2011) found that the experience of seeing their partners' pain during birth was difficult for men, and they were afraid of the unknown during birth. Premberg et al (2011) reported that an assumption of male superiority affected their expectations of their role during labour and birth. These assumptions and expectations were challenged during labour and birth, when the woman and health providers were the focus of attention. This shift in mentality can be difficult for men who are going to become fathers (Premberg et al, 2011).
Similarly to the present study, Anderson et al (2005) reported that place of residence was correlated with postpartum depression in fathers, along with other factors that included unemployment, the inability to afford expenses, limited access to reliable transport, lack of a proper house and inefficiency of social support. Such issues may also affect their experience of worry in childbirth. Pollock et al (2005) found that fathers were most concerned about their partners' and children's health, followed by financial issues, educational issues and limited relationships with their partners (Pollock et al, 2005). A comparison of the present study's results with the literature shows that inadequate preparedness, fear of the unknown, fear of pain and worrying about financial issues can impact first-time fathers' experiences in the domain of worry. Sapountzi-Krepia et al (2010) explored the fathers' experiences in northern Greece via the Kuopio instrumentation for fathers. Of the participating fathers, 82.1% reported a positive experience of childbirth. They felt proud of becoming a father, and felt love and expressed gratitude towards their spouses. Similarly, Hildingsson et al (2011) reported that 82% of fathers reported a positive experience of attending childbirth. However, Sapountzi-Krepia et al (2010) also found that half of the participants felt anxious and nervous. Although anxiety and nervousness were measured with a single item, their results confirm the present study's findings in the dimension of worry. The difference between the high rate of positive experiences of childbirth in their study and the lower rate reported in the present study can likely be attributed to the different instruments, samples and sociocultural and health-related structures of the two studies.
Chandler and Field (1997) conducted ethnography on first-time fathers' experiences of attending childbirth. They found that fathers had expected to be treated like a partner in labour, but found the focus was on mothers and a supportive role was assigned to the first-time fathers. Fathers felt sufficiently self-confident to support their wives at the outset of labour, but later realised that labour was more difficult than they had expected. They were concerned about the outcome; at first, they were worried about their wives, but as birth continued, their fear shifted to the infant (Chandler and Field, 1997). There are numerous reasons why men may be worried or scared during labour and birth. Although Chandler and Field's (1997) study was qualitative, its results confirm the present study's results in the domain of worry and show that to give fathers a favourable experience of attending labour and birth, fathers' worries need to be addressed.
Overall experience
The regression analysis revealed that wives' education, lack of insurance coverage for hospital charges, provision of pregnancy care by an obstetrician-gynaecologist, inadequate preparedness for childbirth and incompatibility between experiences and fathers' expectations increased the overall score of experience, indicating a less favourable experience. Molina-Velásquez et al (2018) reported that parents who were adequately prepared for childbirth had a more favorable experience than those who were not. Fathers who are not sufficiently prepared are likely to have a more negative experience of childbirth (Bergström et al, 2013).
Although most fathers in the present study had taken childbirth preparation classes, those who received information from other people or the internet reported a more positive experience. The available educational sources offer information on pregnancy, childbirth and the postpartum period to fathers, but may fail to provide adequate information about the emotional aspects of fatherhood to help men play a better role. Education programmes should include fathers' needs and help them manage their emotions, participate in pregnancy and come to terms with the reality of fatherhood (Graham, 2007).
Men in the present study reported a different experience depending on the type of caregiver during labour and birth (obstetrician-gynaecologist or midwife). Similarly, Hildingsson et al (2012; 2014) reported that the presence of a midwife in the labour ward was the most important factor in a positive experience of birth. In the present study, a midwife was present in the labour ward for all births, which may explain the favourable experiences reported in the domain of acceptance and support during labour and the relatively favorable experience in preparedness and support during and after birth. Hildingsson et al (2011) investigated the experience of childbirth with one item on a 5-point Likert scale, showing a range of experiences from highly positive to highly negative. The present study used the Persian version of the first-time fathers' questionnaire which contains 19 items in four domains. The questionnaire enabled the assessment of different aspects of fathers' experiences more precisely and specifically examined the experience of first-time fathers. However, Hildingsson et al (2011) studied participants that included first-time fathers and fathers who had experienced fatherhood before. The experience of a previous birth can affect subsequent experiences for mothers (Størksen et al, 2012), and the same may be true for fathers.
Fathers need a sense of security and wish to participate in their partners' gynecological care (Hildingsson et al, 2013). Midwives can facilitate access to this information and allow men to play a major role in childbirth (Johansson et al, 2010). Midwives can also shape positive childbirth experiences for fathers in support, presence and information about the progress of labour (Hildingsson et al, 2011). Their support is invaluable, and fathers have been shown to trust midwives and their ability to help women in childbirth (Hallgreen et al, 1999; Hildingsson et al, 2013). Fathers need midwives' help to learn how to support their partners during labour and midwives also assist fathers in dealing with the overwhelming emotions that can be caused by childbirth (Dellmann, 2004).
Men attending labour and birth is relatively new in Iran. This was the first study of its kind to examine fathers' experiences with a tool compatible with Iran's cultural setting. As this study focused on fathers' experience of attending labour and birth, and this could be fully realised only in the private sector as a result of restrictions on male presence in public hospitals, the sample was selected from private centres only, which may affect the generalisability of the results. However, the results indicate that all socioeconomic strata participated in the present study.
Conclusions
This study identified first-time fathers' experiences attending their partners' labour and birth in selected centers in Tehran using the Persian version of the first-time fathers questionnaire. Four domains, preparedness, acceptance and support during labour, worry and support during and after childbirth, were examined. The findings revealed that the overall experiences of first-time fathers were relatively favourable. Fathers reported a relatively favourable experience in preparedness and support during and after childbirth and a favourable experience in the domain of acceptance and support during labour. However, unfavourable experiences were reported in the domain of worry. Counseling programmes based on fathers' needs should be developed to improve their experiences, allay their concerns and account for factors that shape their experiences.
Key points
- This study examined first-time fathers' experience of attending labour and birth.
- Fathers' overall experiences were relatively favorable. The participants reported an unfavourable experience in the domain of ‘worry’.
- Counselling programmes should be developed to improve their experiences.
- The results can help midwifery services to promote their quality of care during childbirth and improve the experience for both parents.
CPD reflective questions
- How might first-time fathers experience labour and birth?
- How can first-time fathers be supported during labour and birth, to ensure optimum care for both parents and the newborn?
- In your practice, are fathers' experiences and expectations considered during labour and birth?