Fathers’ Experiences of Pregnancy and Childbirth with Particular Interest in Migrant Fathers: A Systematic Review and Narrative Synthesis

Objective The purpose of this review was to consider factors that inuence the experiences of pregnancy and childbirth by fathers with particular interest in migrant fathers. Method A systematic review and narrative synthesis were conducted as per the PRISMA guidelines. The spider tool was used to build a search strategy which was used to conduct literature search in eight identied electronic databases: ASSIA, CINAHL, EMBASE, MEDLINE, PsycINFO, PUBMED, Sage and Scopus. Grey literature was searched through the King’s Fund Library database, Ethos, The North Grey Literature Collection, Social Care Online and other charity websites such as the Refugee Council and Joseph Rowntree Foundation. The search was conducted across all the databases in the week commencing January 7, 2019 and restricted to studies published in the English language. Results The search across all the eight electronic databases identied 2564 records, 13 records through grey literature databases/websites and an additional 23 records identied through hand-searching/forward citation. The number of records after duplicates were removed was 2229. Record screening based on titles and abstracts identied 69 records for full text screening. Dual screening of these full text records identied 12 full records from 12 separate studies, eight of which were qualitative studies, three of which were quantitative studies and one mixed method study. This review has revealed three main themes: inuence of society and health professionals; adjustment to a new life of fatherhood; and involvement in maternity care. The literature of fathers’ experiences of pregnancy and childbirth is dominated by native fathers’ experiences at the detriment of migrant fathers more specically forced migrant fathers who are most vulnerable.


Introduction
Most research in the area of father's engagement with pregnancy and childbirth has mainly focused on white middle-class men (1). Non-white fathers and those from a low socioeconomic group have expressed lower satisfaction in maternity care (2) and for migrant fathers, this dissatisfaction could increase due to the their experience of being new in a country. Migrant fathers may have a challenging experience when interacting with maternity care, particularly because of potential language barriers, social isolation and discrimination, lack of knowledge of different midwifery practices and cultural differences (3)(4)(5)(6)(7). Given that in many countries, there is a rapid growth in the population of migrant families with children (8), it is imperative to consider the needs of migrant fathers in the context of maternity care.
It is estimated that one-seventh of the world's population now live in a different location other than where they were born (8). It is also estimated worldwide that large numbers of migrant women are of childbearing age, (9). for the purpose of this study, age 18-44 years. In the UK, lower maternal mortality rates (MMR) were recorded among indigenous whites (9 per 100000 maternities) compared to Indian migrants (20.5), Pakistani migrants (13.9), Bangladeshi migrants (11.1), Caribbean (18.5) and 26.9 among African migrants (10). There was similar trends in the USA (11,12), The Netherlands (13) and Australia (14,15). The majority of high income countries like the UK have experienced signi cant levels of both planned and forced migration in the last few decades, resulting in an increased ethno-cultural diversity (16) which have had respective impacts on health care delivery. This is because the expectations of the migrant may vary between different geographical and cultural locations (17). Poor maternal outcomes may have an effect on the migrant mother, the baby (18, 19) but also the migrant father.
There are different types of migrants. These includes asylum seekers, economic migrants and transients (20) who are temporary migrants with limited visas (21). Migrants have also been classi ed as undocumented, forced, free, controlled and 'illegal' (8). Several factors such as economic improvement, family reunion and seeking refugee status have served as motivation for migration. For the purpose of this paper, migrants will be classi ed as either economic migrants or forced migrants. Of all migrants, forced migrants (refugees and asylum seekers) have received the most attention in both academic and policy terms (22). This is because they may have particularly challenging migration trajectories as compared to other migrants. They may have suffered abuse and trauma during migration compared to other migrants, and they may be exposed to unfavourable conditions in their receiving countries. This includes Afghan migrants having to ee Afghanistan to other countries including the UK, USA, Australia and Canada due to the fear of the Taliban regime. Being a forced migrant increases the risk of marginalisation in maternity services (6, 23,24). There is therefore the need for greater understanding of the experiences of refugee, asylum-seeking and undocumented migrant families from their perspective to inform health, social services, practices and policies (25).
International research has demonstrated that many migrant women struggle accessing maternity care in the receiving country and experience poorer maternal health outcomes than the native women (5, 26-28). In addition, migrant fathers may experience stress being fathers in a country different to their home country. The way fatherhood is socially constructed may be different in the man's home country when compared to the host country and therefore, the man may experience different expectations in relation to his role during pregnancy and childbirth when compared to his home country (29,30). Stress exposure in varying forms has been cited as key in health inequalities (31,32). The ultimate outcome of this is an effect on the migrant mother and the baby (18, 19) and it could also affect the migrant father. Ethnic discrimination has been cited as one important source of stress (33,34) which may be experienced by migrant mothers. This can be linked with adverse birth outcomes including very low birth weight babies (35)(36)(37)(38), preterm birth, developmental delays and behavioural abnormalities in children (39)(40)(41). It is not clear how stress in uence the migrant father and research is needed to understand migrant fathers' experiences of maternity care in order to ensure their needs are met. In addition, there is the need to bring migrant fathers' experiences of pregnancy and childbirth more into focus (42) due to the potential mismatch between the expectations of the father during pregnancy and childbirth back home and in the host country.
Although there is a wealth of literature related to migrant mothers' maternity experiences (3,43), little evidence could be found on the migrant fathers' experiences. No systematically conducted review could be found that exclusively consider migrant fathers' experiences of pregnancy and childbirth. Therefore, this paper reports on a systematic review undertaken to explore father's experiences of pregnancy and childbirth generally, in order that data related to migrant fathers can be extracted and analysed to inform maternity care.

Review Question:
What are father's experiences of pregnancy and childbirth? Sub-question: What are migrant fathers' experiences of pregnancy and childbirth?

Methods
This review was conducted in accordance with recommendations outlined in the PRISMA (Preferred Reporting Items for Systematic Reviews and Metaanalyses) statement (44). It was undertaken adopting a narrative synthesis framework (45). The review protocol was registered with the International prospective register of systematic reviews PROSPERO with reference CRD42019127792.

Search Strategy
This was designed in conjunction with an experienced health studies librarian. In January 2019, eight identi ed electronic databases: ASSIA, CINAHL, EMBASE, MEDLINE, PsycINFO, PUBMED, Sage and Scopus were searched to identify eligible studies based on our search criteria. Grey literature was searched through the King's Fund Library database, Ethos, The North Grey Literature Collection, Social Care Online and other charity websites such as the Refugee Council and Joseph Rowntree Foundation. The SPIDER tool (46) was used to identify search terms (see Table 1). These respective Medical Subject Headings (MeSH) terms were used including the Boolean terms "OR"/ "AND," and truncation. Table 1 Search terms using the SPIDER Tool

SPIDER SPIDER Tool
Search Terms Sample S "fathers" OR "men" OR "paternal" or "migrant fathers" OR "migrant men" OR "economic migrant fathers" OR "forced migrant fathers" OR "international migrant fathers" OR " undocumented migrant fathers" OR "documented migrant fathers" OR "educational migrant fathers" OR "transients" OR "refugee fathers" OR "asylum seeker fathers" OR " rst generation migrants" OR "second generation migrants" OR "regular migrant fathers " OR (im) migrants OR "minority" Phenomenon of Interest P of I "pregnancy experience" OR "pregnancy outcomes" OR "maternal experiences" "paternal experiences" OR "maternal health outcomes" OR "perinatal period" OR "antenatal period" OR "postnatal period" OR "postpartum period" Design D "questionnaire*" OR "survey*" OR "interview*" OR "focus group*" OR "case study*" OR "observ*" Evaluation E "view*" OR "experienc*" OR "opinion*" OR "attitude*" OR "perce*" OR "belie*" OR "feel*" OR "know*" OR "understand*" Research Type R "qualitative" OR "quantitative" OR "mixed methods" Included studies were all research designs, published from 2009 to 2021, in the English language. Studies were based on primary research focusing on fathers, exploring their experiences in pregnancy and up to six weeks following birth in high income countries, as de ned by the World Bank (47).

Study Selection
The electronic search identi ed 2564 records, 13 records through grey literature databases/websites and an additional 23 records identi ed through handsearching. After duplicates were removed, 2229 remained. Screening based on titles and abstracts identi ed 69 records. Screening of these full text records identi ed 12 papers from 12 separate studies, eight of which were qualitative studies, three quantitative and one mixed method studies (see gure 1).

Quality appraisal and Data extraction
All study details including study aims, participant details, study settings, methods of data collection, ndings, results and analyses were initially extracted using standardised data extraction forms for qualitative (48), quantitative (49) and a self-devised mixed-method data extraction form. These were selected due to ease of use to thoroughly extract the data needed to address the review question.
The relevant data from each study was extracted including study aims, participant details, study settings, methods of data collection, ndings, results and analyses. Standardised data extraction forms for qualitative (48) and quantitative (49) research were used. A self-devised mixed-method data extraction form was used for mixed methods study. This was created by adopting the contents of both the qualitative (48) and the quantitative (49) data extraction forms.
Data extraction was checked by the co-authors and discrepancies resolved as a group. We adopted the QATSDD tool, a 16-item quality assessment tool (50) to appraise the quality all study designs. Criterion for each respective study was scored between 0-3 and the items not relevant to a particular study were excluded.
The percentage of maximum quality score for each study was calculated by dividing the respective total quality score by the maximum score each study could have scored and multiplied by 100 (See Table 2). The methodological quality of the studies included in this review mostly ranged from high to medium, except for one study that scored low (51). However, no study was excluded based on quality.  Explicit  theoretical  framework   3  2  1  3  1  1  1  2  2  2  3 Aims and objectives stated in body   3  3  3  3  3  3  3  3  3  3  3   Clear setting  description   3  3  3  3  3  3  3  3  3  3  3 Sample size considered in terms of analysis Representative sample of target group of a reasonable size Data collection procedure description 3  3  2  3  3  3  3  3  3  3  3   Data collection  tool rationale   3  3  2  3  3  3  3  3  3  3  3   Detailed  recruitment  data   3  3  2  3  3  3  3  3  3  3  3 Statistical assessment of reliability and validity of measurement tool(s) Fit between stated research question and data collection method (Quantitative) Fit between stated research question and format/content of data collection tool (Qualitative)   3  3  3  3  -3  3  -3  -3   Fit between  research  question and  method of  analysis   3  3  3  3  3  3  3  3  3  3   Good  justi cation for  analytical  method   3  3  2  3  3  3  3  2  3  3 Assessment of reliability of analytical process (Qualitative only) design   3  3  2  3  3  1  2  2  3  2 Adapted from Sirriyeh, Lawton (50).

INCLUDED EMPIRICAL STUDIES
(SCORE-1-3) limitations  discussed  critically   3  1  0  1  3  3  3  1  3  3   Total quality  score for each  study   40  37  30  37  40  38  43  37  36  40 Percentage The stages of this synthesis were conducted iteratively using the appropriate elements of Popay, Roberts (45) toolbox. These are to develop a theory, to develop a preliminary synthesis, explore relationships between/within studies and assess the robustness of the synthesis process

Strengths and
The characteristics of the included studies are as shown in Table 3. To explore rst-time fathers' experiences of becoming a father, focusing on their expectations and experiences, and their views on how they are coping with this transition.
One overarching superordinate theme derived from the analytic process was 'searching for a place', which re ected the process in which fathers searched for their role and position in relation to their partner and child (54) The aim was to identify the proportion of fathers having a positive experience of a normal birth and to explore factors related to midwifery care that were associated with a positive experience. Core themes included safety of mother and baby, understanding support role, mother in control, managing pain/care and communication after birth.
Fathers commented on what impacted on their childbirth experiences and outlined their needs for a positive experience. The aims of the current study were to document men's self-reported perceptions of their partners' antenatal, labor, and birthing experiences and to explore the relationships between these perceptions and men's feelings of bene cial presence to the birthing mother 163(0) Voluntary anonymous questionnaire and regression analysis.
There was a signi cant relationship between perceived bene t of the partners' presence and positive perception of both antenatal experience and birth involvement.
There also was a positive relationship between realized birth expectations and both antenatal experience and birth involvement. The four themes constituting the essence were: 'a process into the unknown', 'a mutually shared experience', 'to guard and support the woman' and 'in an exposed position with hidden strong emotions'. Aimed to explore the experiences of Afghan women and men of refugee background having a baby in Melbourne, Australia.
Afghan men reported playing a major role in supporting their wives during pregnancy and postnatal care, accompanying their wives to appointments, and providing language and transport support.
The data from the included studies were organised into smaller groups in order to manage the synthesis process effectively by looking for patterns within and across these groups. We started with the groups and clusters by taking the themes from the text and then developed each main theme from the commonalities from the texts. The themes were then grouped as shown in Table 4.  This included information from the midwife: "I felt good when the midwife showed me, because then I was able to be involved' (53).
Being involved in antenatal education was considered bene cial for the native fathers' experiences: "Practice makes perfect. Hands-on la, better. Cos if the class itself is… we looked through the slides most of the time, I would say 99%. Then the rest is the baby doll, the dummy… (laughs)" (59).
Quantitative data supported this with antenatal class attendance of the majority of the expectant native fathers (103, 86.6%), making them well informed about the pregnancy, childbirth process and possible complications (60).
Information from healthcare professionals was highlighted as a need of expectant fathers. The study involving only migrant fathers (62) highlighted how the health professionals supporting the migrant father also had an impact on the mother: "The nurses were very kind and nice and they worked very hard to serve us, I think if there was anything in the world that could be done they would do it for us.. . their support gave me good feeling and I could provide moral support to my wife" (62).

ADJUSTING TO A NEW LIFE OF FATHERHOOD
Seven studies (51,52,54,56,59,61, 62) discussed how fathers' experiences of pregnancy and childbirth were in uenced by their ability to adjust to fatherhood. This included a total of 213 native fathers, 195 rst-time fathers and 16 migrant fathers. Some native fathers discussed how they felt like they were in an uncharted territory when faced with pregnancy and childbirth issues. This included not knowing what to expect from pregnancy and childbirth (54).
This not knowing had a negative impact on one native father's experience: "You are in unknown territory ... When you're there you know you really don't know anything about this. I don't know what's going to happen … I was worried there would be no room for us; you know the worst case scenario" (61).
Another study (51) revealed that new father's membership of social groups changed when confronted with pregnancy and childbirth. One native father stated that: "people who are already fathers come over and have a chat with you and it is sort of a bit of a club you suddenly nd yourself in" (51).
For migrant fathers, the concept of an unknown territory was exacerbated as it involved becoming a father but also this transition was taking place in a new country. Some migrant men experienced a cultural clash between the expectations of the father back home and in the new country. One migrant father had previous experience of childbirth in Afghanistan: "Actually here all the time I was with my wife but in Afghanistan, my family, my father, mother and other relatives would take care of my wife and child, but here I play a hundred roles during pregnancy and appointments" (62).
Another migrant father shared his experience in Australia: "Here in Australia, men and women have equal rights, and men are obligated to go to the hospital for every appointment, but not in Afghanistan. This is a big difference, yes" (62).
Pregnancy led to a profound change in some expectant fathers' role in the household across the studies. This included some native fathers feeling an increased sense of responsibility looking after their partners (52). This increased responsibility included providing practical support: "Making sure she eats healthy, go to her doctor's appointments. If she has to take off because of a high-risk pregnancy, he'll maintain the bills, or other kids, if there are other kids, just whatever is needed" (52).
Increased responsibility also included emotional support: "The role of a man during pregnancy is to be present, to support, to understand, to be patient, and to have sympathy for the woman carrying his child" (52).
And getting prepared for the birth: We're a lot more organised I think this time.. . I just made sure that I knew that we'd go to that door and just refreshed it…. had the car serviced... petrol's always full, and the bag is packed and ready to go.. . (54).
For some fathers, this increased responsibility led to the need to adapt their current life to meet the needs of the mother: We used to meet on and off during the weekends. So, I stopped going there and then even for parties, I used to attend a lot. She can't stay there for long time.
She'll get pain… So, even if we're going, we just go and then say hi and spend there 10 min and come back One study reported a native rst-time father showing sel essness with birth looming by stating that: "My plan was to ensure mum and baby were kept as safe and comfortable as possible during the process" (56).

INVOLVEMENT IN THE MATERNITY EXPERIENCE
Eight studies found that how involved a father felt in the maternity experience in uenced how they experienced pregnancy and childbirth (51-54, 56, 58, 61, 62). A total of 364 native fathers and 322 rst-time fathers were in uenced by this and this included 16 migrant fathers (61, 62).
A quantitative study reported that most expectant fathers were actively involved in their partner's pregnancy (58). However, the level of involvement was also in uenced by how close the father felt to the mother: "When my wife was pregnant, I was at all the appointments… so, I was there. I think it depends ... how you feel about that girl.. . [If]…you just got some random chick pregnant you're not going to feel like going to an appointment with her, you're not going to feel like, encouraging her" (Alio 2013: 5).
Interestingly, one study found that fathers who initially did not want to be involved in the mother's maternity experience changed their mind as the pregnancy progressed: "I didn't want to be very involved beforehand, but when it all started, it was just me in there with the midwife, so I ended up getting a lot more involved than I had wanted to, but it was great" (56).
This positive experience included during labour: "When she was pushing at the end, I held one hand behind her neck to give her strength … and the other round her leg, so I held her together! I really felt part of it all and she said that afterwards… in that sense it felt really good. I didn't feel left out at all!" (61).
Migrant fathers who perhaps may not be involved in maternity back home were also positive about the high level of involvement they had in maternity: "The fact that I was there with my wife during labour [was good], because I had never seen someone giving birth so I could understand her pain and also my wife was happy that I was there standing by her" Riggs, Yelland (62).
Another migrant father went on to state that: "I had a big role in this. I kept her company and was always there with her to help her and support her" (62).
Native fathers were not always actively involved in their partners maternity experience and studies reported that some native fathers felt left out (53).
In one study, a native father discussed negatively his lack of involvement in the pregnancy and childbirth process and stated that: "I wanted to help, but I felt left out, I could not do anything…. I wanted to help somehow but could not…." (53).
Another native father sought to nd an excuse for the exclusion: "Well obviously you're not the priority and that's fair enough but sometimes you feel like you're just sort of like barely even in the room" (54).
Feeling left out was also an issue for some native fathers during labour: "I felt like an absolute spare part. In all of that that went on there was nothing I could do, nothing physically… which is really weird because you want to get involved" (51).
Although migrant fathers were actively involved in their adopted country some faced challenges with the language (62). They could not effectively communicate their concerns and they had to rely on people to translate. A migrant father stated that: "I would call someone else to get help if I didn't understand and try to nd some way solve my problems" (62).

Discussion
This review examined the evidence from a total of 1977 fathers who were studied across 12 different countries from 12 separate studies. However, migrant fathers' experiences of pregnancy and childbirth were under-represented in the literature, with only 16 migrant fathers across two studies living in Australia (62) and Sweden (61). This suggests there is a lack of research bout migrant fathers' experiences of pregnancy and childbirth.
Including all native and migrant fathers, three themes emerged which explored factors that had either a positive or negative in uence on father's experiences: society and health professionals, the adjustment to a new life involving fatherhood and involvement in maternity care. Support from family was considered positive for native fathers re ecting previous studies but no data were available for migrant fathers, perhaps because they did not have family in their host country. Information and support from health professionals led to a positive experience for native fathers re ecting previous research (63-67). Positive support from health professionals also had a good in uence on the experience of some of the migrant fathers (61).
Adjusting to becoming a father was a common theme across the studies with men reporting not knowing what to expect from pregnancy and childbirth re ecting ndings from a UK based survey (68). This theme included data from all the migrant men (n=16) who reported that di culties adjusting to fatherhood were exacerbated by being in a new country. Some men reported cultural clashes between the expected role of a father back home compared to their expected role in their new country.
Being involved in maternity care was considered both positive and negative for native fathers, supporting previous research (69), Interestingly, this was considered positive for migrant fathers despite the cultural differences between the role of the father back home, where in some areas of the world, due to cultural differences, it is common to have minimal involvement in childbirth (70).
Although there was a relatively small number of migrant fathers included in this review, there were similarities reported in the experiences of migrant fathers within the themes. For example, the need for support from health professionals and the di cult transition to fatherhood. However, it is important to consider how being a migrant in a new country may distort these experiences due to language and cultural barriers men may face in their new country (71). In addition, it is important to understand the heterogeneity of migrants and how factors may in uence the experiences of men who originate from different areas of the world where cultural expectations on the father's role in pregnancy and childbirth will vary (72,73). Men who have previously experienced childbirth back home may have a different experience of becoming a father in the new country. How long the migrant father has lived in the new country may also affect the experience due to the process of acculturation (74,75). With acculturation, his exposure to a new culture, in this case around maternity care, results in changes in his original culture patterns (76). In addition, the reason for migration may lead to different experiences for example economic migrants, generally move to a new country voluntarily compared to men who may have been forced to migrate including asylum seekers and refugees (77). The underrepresentation of migrant men in the literature meant that the heterogeneity of the migrant father could not be fully explored. More research is needed to address this in order that we can understand the needs of different groups of migrant men around pregnancy and childbirth in their new country.
The ndings from this review have implications for clinical practice. Midwives and other health professionals should be alert to the needs of any father when providing maternity care. Providing psychological support and information and including the father in care episodes could have a positive impact on his experience. The dearth of data for migrant fathers suggest the same principles can be followed, however midwives need to be sensitive to any barrier migrant men may face within the maternity context including cultural, language or lack of understanding of maternity care (78). Ultimately, more research is needed to explore migrant fathers' experiences and to identify their needs in pregnancy and childbirth in order that interventions can be developed to support them.

Strengths and limitations of review
Although this review refers to the pregnancy and childbirth experiences of fathers, most of the expectant fathers included in this review were native fathers only 16 in total being migrant fathers. Nonetheless, this review has exposed the scarcity of research on the involvement of migrant fathers in pregnancy and childbirth care episodes and also the lack of consideration to the type of migrant and how this may in uence the father's experience of pregnancy and childbirth.

Conclusion
This review has revealed three main themes that in uence fathers' experiences of pregnancy and childbirth. These are: in uence of society and health professionals; adjustment to a new life of fatherhood; and involvement in maternity. However, the literature is dominated by native fathers' experiences at the exclusion of migrant fathers. Migrant fathers are a heterogenous group with some men choosing to move to a new country and others being forced-including asylum seekers and refugees. Due to their life experiences, forced migrant fathers are in a more vulnerable position as compared to economic and educational migrants. Even though this review has exposed a dearth of research on migrant fathers, this is exacerbated for forced migrant fathers. It is important that future research investigates the heterogeneity of migrant fathers and how this in uences their experiences of pregnancy and childbirth in their new country. From this, migrant fathers' needs can be assessed, and appropriate interventions developed.

Declarations
Ethical approval and consent to participate Not applicable Consent for Publication Not applicable.

Availability of data and materials
The datasets generated or analysed during the current study are not publicly available due to this review being part of a PhD research. They are available from corresponding author upon reasonable request.

Competing Interests
No competing interests.