Part 2: exploring views from fathers and perinatal practitioners on the inclusion of fathers by perinatal services

This is the second of a two-part series of a paper exploring the inclusion of fathers by professionals in the perinatal years. In the first paper, previous research was reviewed which suggested that fathers' inclusion in their baby's early years is important for the baby's development and mother's wellbeing. It also suggested that some fathers themselves struggle with adjustment to fatherhood. However, the literature also suggests that fathers feel excluded by some professional practices in the perinatal years. This research therefore explores what fathers, midwives and health visitors think are the important factors to consider in aiming for inclusive practices perinatally and through Delphi methodology attempts to draw consensus between these groups.

Results

Participant information

A total of 51 participants contributed to the study (27 fathers, 24 healthcare professionals [HCPs]). R2 responses from participants who did not complete R3 were used as their final responses (Pipon-Young et al, 2010), giving a final sample size of 46 (24 fathers, 22 HCPs). Only one father took part in all three rounds with three fathers dropping out after the first round. The rate of HCPs (40.9%) and fathers (70.8%) continuing from R2 to R3 represents typical completion rates expected in Delphi studies (Gordon, 1994).

Delphi round 1

Thematic analysis of each focus group transcript identified significant themes relating to the research aims. Related themes from both groups were collapsed together to form six final themes. These were practical, psychosocial and relational aspects of becoming a father; the importance of fathers; father's position; social, and cultural contexts of men as fathers; perceived strengths and weaknesses of perinatal services; and ideas for improvement. The 82 statements for the R2 survey were organised within these six final themes for both groups, with 14 additional statements presented separately for HCPs.

Delphi rounds 2 and 3

In line with the research questions, Table 3 displays the statements for which there was strong consensus between HCPs and fathers divided by the above themes. As the difference did not vary more than one Likert scale point for any participant between R2 and R3, it was deemed justifiable to include data from R2-completers with data from R3-completers in the final percentage averages displayed in the results tables. Results from each table will be discussed in the text, with illustrative quotes from R1 and R2.

Theme 1: practical, psychosocial and relational aspects of becoming a father

A total of 18 statements were relevant to theme 1. Both groups strongly agreed that fathers observed changes in themselves, the mother, and their relationship, and that communication, negotiation, and compromise between the parents is important during this time. This is reflected in the following quote from a father:

‘These are roles that we're sort of playing … trying to work out what our new sort of position is in our relationship now that there's a third person … there's definitely been a change.’

(Focus group father)

Fathers strongly agreed that during pregnancy, men anticipate and build expectations about what fatherhood might bring-an aspect which received weak consensus among HCPs. Fathers also strongly agreed that it feels like two caregivers are necessary to meet the demands of parenthood, and that parents experience difficulties in their sexual relationship during this time, which received no consensus from HCPs.

HCPs reached moderate-to-strong consensus regarding statements suggesting that if experiencing difficulties, fathers may not feel able to turn to professionals, parents may want to appear like they are coping, and may worry about what process they might be entered into if they disclosed difficulties. Fathers reached weak-to-no consensus on these statements. Although, it is worth noting that over half of fathers disagreed with feeling able to approach professionals for support.

A third of statements reached no within- or between-group consensus, such as statements around mother-father relationship difficulties. However, a lack of consensus does not mean the results are unimportant. For instance, at least a third of fathers reported experiencing difficult emotions (eg anxiety, low mood), increased partner conflict, and feeling alone or divided from the mother over the perinatal period.

Theme 2: the importance of fathers

Fathers and HCPs demonstrated strong consensus on all nine statements relating to theme 2, with 100% agreement that fathers are important for mothers' and babies' psychological wellbeing. Both groups strongly agreed that fathers are equally able as mothers to be good primary caregivers for their children, although fathers did not agree as strongly as HCPs. No participants indicated disagreement with any statements under this theme. As strong consensus was reached on all statements at R2, this theme was not included in R3. Within this theme, one focus group father highlighted how he is in a position to recognise difficulties that the mother may be experiencing, and inform a HCP:

‘I feel that sometimes there is some input I could give to the health visitor about what I've seen that maybe mum hasn't noticed herself, or is trying to hide … which could be helpful.’

(Focus group father)

Theme 3: fathers' position

Of 16 statements relating to the positioning of fathers, both fathers and HCPs strongly agreed that fathers who are present tend to be involved fathers, and moderately agreed that fathers can feel like a spectator on the sidelines, not always able to help or be involved when they want to. This reflected the discussion between fathers at the focus group, who described feeling like ‘an alien in the room’, ‘excluded’, and like ‘a secondary figure’. One father reflected on an experience he had on the ward following the birth when a HCP came to speak to his wife:

‘A lady came around and pulled the curtain around the bed with me standing on the other side of the curtain … there wasn't even an acknowledgement that I was in the room.’

(Focus group father)

Fathers strongly agreed that they are considerate of the mother's experiences, and of health services and professionals' point of view, and are accepting of how they are treated by services. HCPs moderately agreed with fathers' consideration of mothers but reached no consensus regarding fathers' consideration and acceptance of HCPs and services. This may be due to HCPs working with a variety of men, making it difficult to generalise. Indeed, one HCP reflected: ‘It is difficult to generalise about fathers as everyone is very different’.

Fathers strongly agreed that aside from physical/medical care, women should still get more support and attention than men, and the mother of the baby has more power than the father during the perinatal period, whereas HCPs reached no consensus on either statement. Half of fathers agreed with being aware that health professionals assessed whether they can be trusted with the mother and baby, whereas interestingly, only 4.5% of HCPs agreed that fathers are aware of this.

Theme 4: social and cultural context of men as fathers, and HCPs working with fathers

A total of three of the five statements under theme 4 received strong consensus among fathers, and moderate consensus among HCPs (creating strong consensus overall): that parenting support for men needs to catch up with society's expectations of men as involved parents, that today's fathers were raised more by their mothers than their fathers, and that sharing parental leave more would have benefits for the family. As a midwife reflected:

‘They come from a generation … that their parents weren't like that, so they're kind of these “new men” … they're getting more involved in early family life.’

(Focus group HCP)

Fathers and HCPs moderately agreed that men tend to have less preparation for parenthood than women. The weakest consensus among both groups pertained to whether equality between the sexes is getting better.

Theme 5: perceived strengths and weaknesses of perinatal services

Of the 18 statements relevant to theme 5, 12 had weak overall consensus between groups, and four lacked consensus. Only one statement reached strong consensus overall, with both groups agreeing that services are mainly geared towards mothers rather than both parents. One statement reached moderate consensus overall, that support for fathers provided by HCPs varies a lot between different members of staff. This is reflected in the following contrasting comments from fathers:

‘Psychological needs are probably very similar … my experience was the mums were reached out to on that properly and quite well … I was certainly never asked.’

(Focus group father)

‘The midwife was very, very engaging in terms of ready and waiting to answer any questions … showing as much concern for my emotional wellbeing as for [my wife's].’

(Focus group father)

The remaining statements reached weak or no overall consensus-many with different consensus levels between groups. For instance, fathers reached strong consensus in agreeing that the process was unclear as to how they could seek help from services about their own or the mother's coping, whereas HCPs reached no consensus for this statement. HCPs reached weak consensus on three statements that received moderate consensus from fathers, suggesting that fathers are not drawn in by services, and that attention toward the father-baby relationship and fathers' psychological coping is lacking. HCPs reached no consensus for three further statements for which fathers reached moderate consensus in agreeing that there is not enough attention to the father-mother relationship, the family unit, or to the fathers' role and how they can be involved. HCPs reached moderate consensus in their agreement that HCPs genuinely respect and value fathers, whereas fathers reached no consensus about this.

Neither group reached consensus on whether HCPs do a good job with father-inclusion and engagement.

Theme 6: ideas of what services should continue, enhance, or improve to benefit fathers' experiences

Table 4 illustrates the levels of consensus amongst fathers and HCPs for ideas for service improvement. A total of 11 out of 16 statements relating to ideas of what services should continue or improve received strong overall consensus between groups, with groups agreeing that there should be more focus on the father-mother relationship, the psychological, emotional and relational impact of parenthood, for services to be family centred, for HCPs to receive more training on working with fathers, and for improved father-inclusion (via body language, invitations to appointments, skin-to-skin with baby after birth, facilitating overnight stays on the ward, and father-specific preparation, information and guidance). As two focus group fathers suggested: ‘more of the psychology behind what might be going on and what … could happen’, and ‘more about the… relationship impact’.

Fathers reached strong consensus in agreeing that it should be a formal service requirement for HCPs to directly check in with fathers on their experiences and coping, while HCPs reached moderate consensus. HCPs reached moderate consensus in agreeing that there should be more single-sex sessions for men and women, while fathers reached no consensus.

The most divergence was seen for the statement suggesting services provide fathers with a 10-minute ‘dad-alone’ session. A father at R1 suggested having: ‘a 10-minute dad-alone session … where you would be able to say more directly what you were really experiencing.’ This received agreement with all focus group fathers and strong agreement among fathers online. However, HCPs reached no consensus, with one HCP from R2 commenting: ‘it would be at the expense of time … with pregnant women, which is unacceptable’.

Yet fathers at R1 highlighted wider benefits of the ‘dad-alone’ time: ‘to take your value judgement on … how is mum doing’, and another reflected: ‘you kind of wonder now why that doesn't happen … for your benefit, and for the benefit of … your little proto-family.’ These fathers’ points correspond with the statement that reached strong agreement across both groups that suggested services should be more family centred.

Additional statements for HCPs related to service context, provision, and constraints

Table 5 shows the 14 statements specific to HCPs. There was strong consensus for nine statements highlighting the stressful workload, stretched resources, time pressures, lack of training to work with fathers, and the absence of a service requirement for professionals to meet with fathers.

‘It would be great to offer more but … time and workload … too heavy.’

(Online HCP)

‘I feel I'm not trained … in my training like nearly 18 years ago, fathers weren't part of, they were present, but they weren't as involved…’

(Focus group HCP)

HCPs did not reach agreement on three statements, including statements relating to HCPs’ reactions to fathers, and whether HCPs sometimes do not ask parents about their experiences due to lack of time.

Discussion

This Delphi study gained understanding of fathers' experiences during the perinatal period and of professionals' experiences and understanding of fathers, as well as both groups' ideas for improving paternal perinatal support. The findings are discussed in relation to important areas of between-group consensus and divergence, and are linked with previous empirical and theoretical literature and changes to services. Strengths, limitations, and implications for future research and clinical practice are considered.

Sociopolitical

HCPs' responses reflect wider societal constraints on their capacity to involve fathers, such as staff shortages and lack of resources to provide continuity of care. In response to these issues, the UK government recently announced plans to create over 3 000 midwifery training places and improve continuity of care, which the Royal College of Midwives welcomed but expressed that this may only remedy part of the problem (BBC News, 2018).

The change in culture towards more involved fatherhood (Ranson, 2001) is reflected in both groups' agreement that shared parental leave can benefit the whole family. Historical events, such as law and policy changes (eg shared parental leave, closing the gender pay gap) are hypothesised to facilitate changes to social norms (Bronfenbrenner, 1989). However, despite introducing shared parental leave over 40 years before the UK, Scandinavian research suggests that women still have more responsibility for the home and children than men (Haavind and Magnusson, 2005).

Changes to how shared leave is applied for and more information about shared leave in work places is urgently needed if father involvement in the first year is to be increased. In addition, the lack of enhanced paternity pay compared to enhanced maternity pay is a significant financial barrier for families and should be addressed if employers wish to see an improvement in the gender pay gap (Birkett and Forbes, 2019). It is possible that a system of longer ‘use it or lose it’ paid parental leave, such as that currently available in Canada, is what is needed to increase the uptake of parental leave in the UK (when this was trialled in Quebec, 85% of fathers took up the option).

Community

Both groups agreed that society's expectations for involved fatherhood is not mirrored by paternal perinatal support in the community. This may be particularly difficult for fathers as participants agreed that men may have fewer life experiences than women to prepare them for parenthood, and possibly come from generations in which their own fathers were less involved. This has been associated with men having less of a parenting role model, and feeling less skilled for parenthood than women (Condon et al, 2004), which may hinder adjustment to parenthood and bonding with the baby (Fletcher, 2011).

Organisational

HCPs indicated feeling stretched and stressed with their workloads, and said that they lack father-specific training or formal service requirements to meet with fathers. Both groups agreed that services are mother-centred. Organisational structures, such as these, have been found to limit HCPs' likelihood of involving fathers (Whitelock, 2016), and fathers' sense of involvement and likelihood to help-seek from services (Rominov et al, 2017). An example of mother-centred organisational structures is the way that data is collected about expectant fathers. The standard NHS form asks the mother about the father's mental health, medical issues and smoking and alcohol use, and there are no formal structures for asking fathers for this information directly (Burgess and Goldmann, 2018).

Healthcare professionals have expressed that they lack the father-specific training needed to meet with fathers

Changes of commissioning of health visitor services from the NHS to local authorities may explain why the fathers in the study had different experiences of support from these services. The Institute of Health Visiting (iHV) in their annual survey found a large difference between different local authorities in levels of investment and there was a drift to employing non-specialist nursing staff for some roles. A further concern was that performance was largely measured by the key performance indicators of the five mandated health reviews, rather than in quality of support. A lack of continuity for families with the same health visitor across time is a particular concern for health visitors and for parents.

Without this continuity, it is unlikely that fathers would be seen by a health visitor or build up enough of a relationship to disclose their concerns to professionals. (iHV, 2019b). Consensus among HCPs that fathers can feel excluded from their baby by perinatal services and that parents may not disclose coping difficulties, corresponds with previous findings (Darwin et al, 2017). However, this was challenged by fathers who reached weak-to-no consensus for these statements. Nevertheless, over half of fathers in this study indicated feeling unable to disclose difficulties to professionals.

Fathers concurred that services do not attend enough to the father-mother relationship, family unit, or father's role and involvement-associated in the literature with feelings of exclusion and reduced likelihood to help-seek (Rominov et al, 2017). If they did feel able to voice difficulties, most fathers agreed the help-seeking process for their own or the mother's coping was unclear. HCPs did not agree which is concerning, considering the negative associations of parental psychological distress with partner and child wellbeing (Kane and Garber, 2004; Ramchandani et al, 2011).

Interpersonal

Both groups agreed that fathers who are present tend to be involved. There was a remarkable level of consensus across groups regarding the importance of fathers, including their potential benefits to the psychological wellbeing of mother and baby-which is strongly supported in the literature (Sarkadi et al, 2008; Whisman et al, 2011). However, participants also agreed that fathers can feel like spectators on the sidelines. This juxtaposition between the acknowledgement of fathers' importance and their reports of feeling sidelined reflects the ambivalence that can occur across systems during times of change (Hunter et al, 2017).

Both groups recognised that fathers can notice changes in the mother and their couple-relationship. For some parents, relationship changes can increase conflict associated with less cohesive co-parenting interactions (McHale, 1995), parental psychological distress (Paulson and Bazemore, 2010) and poorer child outcomes (McHale, 2007). Attachment research has moved beyond the ‘infant and the other’ dyadic model (Winnicott, 2002), and increasingly acknowledges the importance of family cohesiveness to children's security (McHale, 2007). This is supported by participants' agreement that services should be family centred, rather than mother- or baby centred. The idea of women-focused, family centred care first appeared in the National Service Framework for Children, Young People and Maternity Services (DfES and DH, 2004) but remains aspirational rather than the experience of most fathers. (Fatherhood Institute, 2017).

There was high consensus between participant groups that fathers are equally able as mothers to be good primary caregivers

Interestingly, a parallel response pattern emerged in the father-HCP relationship, whereby fathers indicated consideration and understanding of health services' and professionals' perspectives but HCPs did not agree; while HCPs indicated that they genuinely respect and value fathers but fathers did not agree. Additionally, half of fathers indicated awareness of HCPs assessing their trustworthiness, while HCPs did not think fathers are aware of this.

It is possible that the father-HCP relationship may be influenced by the high proportion of female staff in perinatal services (Nursing and Midwifery Council, 2016), as reflected in this study's all-female HCP group.

Intrapersonal

Both groups acknowledged that fathers can experience a complex mixture of emotions and notice personal changes in themselves. Fathers reached strong consensus about anticipating and building expectations of fatherhood during pregnancy, and that two caregivers are necessary for the baby. HCPs did not reach consensus on these statements, perhaps due to encountering single mothers coping alone. It may also reflect the mother-focused nature of services, in which fathers' experiences and involvement can be overlooked or underestimated (Hogg, 2014).

Despite identified shortfalls in service provision, fathers indicated acceptance and understanding toward services and felt that mothers still deserved more attention from services beyond physical and medical reasons. This may suggest ambivalence in fathers regarding their entitlement to support, which emerged as a theme in a recent study with UK fathers (Darwin et al, 2017). HCPs did not reach consensus on these statements, perhaps due to the variety of parents they see.

Fathers' and healthcare professionals' ideas for paternal perinatal support improvements

Areas of consensus

Fathers and HCPs reached moderate-to-strong consensus with several service-improvement ideas, mostly around increasing support for psychological and relational changes that can occur for parents, and improving overall involvement of fathers through communication and practice. These suggestions will be considered further in ‘clinical implications’ below.

Areas of divergence

Most divergence occurred for the suggestion that services provide fathers with a 10-minute ‘dad-alone’ session, which received strong consensus among fathers but not HCPs. This may be due to HCPs' stretched workloads. Although less common, it is important to acknowledge that men can experience male-to-male or female-to-male domestic abuse (Stanko, 2001). Additionally, previous research has found fathers would not disclose psychological difficulties to perinatal services due to perceived lack of opportunities to do so (Colquhoun and Elkins, 2015).

Limitations and further research

Despite efforts to obtain a heterogenous sample using various recruitment methods across diverse areas of London, fathers were predominantly employed, living with the mother and children, white, and university educated, with high household incomes. This demographic profile represents positions of privilege and power argued to be encouraged by hegemonic masculinity (Connell, 1987). Unrepresented groups may be at higher risk of difficulties. For instance, parents with low socioeconomic status have been observed to find the parenthood transition more stressful (Goyal et al, 2010), and single fathers have a fourfold risk of mental health problems (Cooper et al, 2007) compared to the general population. Sexuality was not measured in this study but higher psychological distress is observed in gay and bisexual fathers (Colquhoun and Elkins, 2015). Self-selecting participants were also possibly motivated by certain views on fatherhood and services. Together, these factors limit the generalisability of the results. Future research is needed to explore whether these findings are relevant to those with different ethnic, cultural and socioeconomic backgrounds, and diverse family types, including same-sex couples, single parents, blended families and adoptive families.

Limited qualitative comments by online survey participants provided insufficient information to interpret why groups did not reach consensus. For example, did HCPs' lack of consensus reflect ambivalence regarding fathers' entitlement to 10 minutes alone, or their limited capacity with stressful workloads? Qualitative studies exploring the reasons for low consensus would be useful.

Consensus achieved via the Delphi methodology does not indicate ‘correct’ opinions or answers (Hasson et al, 2000). Rather, this study identified areas important to the participants. Empirical research exploring the need, efficacy and feasibility of the service improvement ideas endorsed in this study among diverse populations is needed. For example, quantitative research could provide father-specific training to HCPs, and measure the impact on fathers' experiences and the father-baby attachment, paying attention to vulnerable populations. Research could trial the 10-minute ‘dad-alone’ session and measure 1) topics that arise compared to fathers not receiving the session; 2) whether patterns emerge among fathers from different backgrounds; 3) how fathers experience it; and 4) how HCPs experience providing it within their capacity. Until further research corroborates ideas suggested in this study, clinical implications drawn from these results must be considered tentatively.

Clinical implications

Although these findings are only applicable to those who participated, the service improvement suggestions correspond with issues commonly reported in empirical research with fathers from different classes and ethnicities (May and Fletcher, 2013).

Previous literature recommends that services should be more family focused due to fathers' importance to mother and baby, and in recognition of the relationship changes that occur within the father-mother-infant triad during the perinatal period (Sarkadi et al, 2008; Genesoni and Tallandini, 2009; Whisman et al, 2011; Ramchandani and Iles, 2014). The recent government committee report ‘First 1000 days of life’ explicitly recommends support to be given to fathers and for a whole family approach to be a guiding principle for universal support.

Areas that are identified as needing targeted support are with paternal mental health, parental conflict, domestic abuse and drug and alcohol use as problems in this area will have a high impact on infant development. (Health and Social Care Committee, 2019). In line with these recommendations, the iHV (2019a) has identified areas in which health visitors can make a difference in high impact areas and have included fathers' needs in perinatal mental health as well as identifying the need for supporting healthy couple relationships. However, the same organisation has also produced a report showing how a steady decline in health visitor numbers, increase workloads (including a large increase in child protection work) has resulted in a decline in workforce morale, and feedback from staff described a reduced quality of service even for minimum standards such as the number of visits carried out (iHV, 2019b).

It will be interesting to see if the COVID-19 pandemic changes the culture for father involvement with the Office for National Statistics (2020) suggesting a 58% increase in father's caring for their children. At the same time, due to COVID-19 restrictions, there is a suggestion that some fathers' access onto maternity wards and to visits with HCPs has decreased (Fatherhood Institute, 2020).

This study suggested that fathers were not always clear about how to go for support for themselves or if they were worried about mothers. Perinatal services could draw upon evidence-based information and resources on the Fatherhood Institute website. Parents could be signposted to the Dads Matter UK website which provides information and resources for fathers to access mental health support for themselves or their partner. Both groups agreed that services should be formally required to check on fathers' coping. The results from this study suggests a need for time and resources to be allocated by services to allow time for fathers to engage with HPC's and also for there to be clearly communicated referral pathways for further help for fathers.

HCPs work hard to support the survival and wellbeing of mothers and babies, and although the current findings indicate examples of positive father-inclusion, HCPs' capacity to offer more is constrained by limited resources. Increased allocation of resources to improve father inclusion is justified by evidence that paternal postnatal psychological distress increases community healthcare costs via fathers' increased contact with GPs and psychologists (Edoka et al, 2011). Early intervention can benefit the wellbeing of all family members by potentially preventing their involvement with psychological services in the future.

In terms of training, some HCPs indicated there was a gap in their training on how to involve fathers and how to encourage them to take a variety of roles in their baby's care. This study did not explore the training for midwives and health visitors of father inclusive practice but it may be that changes need to happen at this level or that further training needs to be included as continual professional development. It might also be interesting for fathers to be included in training as ‘service users’. Given that perinatal services are largely made up of women (Harris, 2018), it may be that HCPs often draw on their experience of being a mother but there will be fewer professionals who have personal experience of fatherhood.

It is also possible that by engaging fathers more with perinatal services and encouraging their parenting, a change in culture may happen where boys and men become more attracted to working as midwives and health visitors themselves, which might be one way of addressing the gender imbalance in the profession. As one male health visitor said in a recent article, ‘we could be raising a generation of male children who have good role models and who are happy and comfortable being affectionate and caring. This might in turn lead to society being more “accepting of men in caring roles'” (Harris 2017).

Conclusion

The idea of fatherhood is expressed through numerous sociocultural and interpersonal processes, embedded within a larger ecological context. There was overwhelming consensus across participants in this study regarding the importance of fathers in caring for the family. However, this time of sociocultural change creates an ambivalence, whereby traditional values of fatherhood co-occur with newer cultural values. This may partly explain why fathers continue to report feeling like a secondary figure at a time when their importance is clearly recognised. The consensus that was reached in this study of the importance of fathers is being recognised in some major reports but is not currently backed up by adequate funding for HCPs, nor are the structures in place that would encourage fathers to participate more in childcare or to allow services to directly address the needs of fathers.

This Delphi study encouraged collaboration between fathers and HCPs, and supported them to build consensus around important areas for attention regarding father-inclusion in perinatal services. However, study limitations include poor representation of fathers from diverse backgrounds, potential selection bias, and limited understanding of why low consensus occurred. Further research is needed to deepen our understandings of fathers' and HCPs' experiences and perspectives, and to corroborate service improvement among more diverse groups of fathers.

Continued efforts to close the gap between mothers and fathers in research and clinical practice could have substantial benefits across all systems. This could include a generational shift, whereby role models provided by more positively involved fathers today could support future male generations with their own transitions to fatherhood.