The results of the review yielded a total of 15 articles. The review process adopted a four-pronged approach which included:
1. Title review:
- 2190 hits were retrieved by using the Boolean phrases above. 149 duplicates were removed and 2041 titles were reviewed against the inclusion criteria.
2. Abstract review:
- 2007 articles were excluded and 34 article abstracts were reviewed of which 15 did not meet the stipulated inclusion criteria.
3. Full-text review:
- 19 articles were scrutinised in the full-text review phase and 7 were excluded.
4. Reference mining:
- Finally, reference mining of all 12 articles was conducted and 2 additional articles met the inclusion criteria.
- A second round of reference mining took place on the 2 additional articles included and a third study was deemed appropriate for inclusion. This final study was also subjected to a review of the references but no additional articles were included.
The table below provides an overview of the number of hits retrieved from each database.
Table 2
Database search results
Date of search
|
Keyword search
|
No. of publications retrieved
|
Database
|
11 February 2022
|
“Father” OR “Dad” OR “Paternal” AND “High risk pregnancy” OR “Complicated pregnancy” OR “Medical high-risk pregnancy” OR “Birth complications” OR “Pregnancy complications”
|
896
|
Academic Search Complete
|
11 February 2022
|
“Father” OR “Dad” OR “Paternal” AND “High risk pregnancy” OR “Complicated pregnancy” OR “Medical high-risk pregnancy” OR “Birth complications” OR “Pregnancy complications”
|
689
|
SocINDEX with Full Text
|
11 February 2022
|
“Father” OR “Dad” OR “Paternal” AND “High risk pregnancy” OR “Complicated pregnancy” OR “Medical high-risk pregnancy” OR “Birth complications” OR “Pregnancy complications”
|
383
|
CINAHL Plus with Full Text
|
11 February 2022
|
“Father” OR “Dad” OR “Paternal” AND “High risk pregnancy” OR “Complicated pregnancy” OR “Medical high-risk pregnancy” OR “Birth complications” OR “Pregnancy complications”
|
222
|
APA PsycArticles
|
Characteristics of the included studies
Of the 15 included studies, 11 were from High-Income countries and 4 were from Low-Middle Income countries. In particular, 4 were reported from the United States, 3 from Sweden, 2 from Uganda and the United Kingdom and 1 from Germany, Taiwan, Malawi and Thailand. The research designs for the 15 studies included a secondary data analysis of individual interviews (2); cross-sectional survey (1), a retrospective chart review (1) and individual interviews (11) of which one study also included a focus group discussion. Table 3 provides more details concerning the data extraction.
Table 3
Data extraction
|
|
Authors
|
Year
|
Country
|
Research Aim
|
Research Design
|
Data Collection Methods
|
Sample Characteristics
|
Related Themes
|
1
|
Koppel & Kaiser (24)
|
2001
|
Germany
|
To examine the situation of fathers with a newborn child on an intensive care unit
|
Qualitative approach
|
In-depth individual interviews
|
18 Fathers in NICU in September 1998
|
The father versus the healthcare professional and the hospital environment.
The impact of high-risk pregnancies on fathers.
Redefining the role of ‘father’ after experiencing high-risk pregnancy.
Focus on fathers: Recommendations for support during high-risk pregnancies.
|
2
|
Moore et al. (18)
|
2019
|
United Kingdom
|
To explore the discursive construction and social actions achieved by accounts given by men following a birth in which the mother developed life-threatening complications
|
Qualitative approach
|
Individual interviews, Secondary data analysis
|
4 Fathers
|
The father versus the healthcare professional and the hospital environment.
The impact of high-risk pregnancies on fathers.
|
3
|
McCain & Deatrick (26)
|
1994
|
Ohio, America
|
To describe the experience of high-risk pregnancy from the perspectives of mothers and fathers
|
Qualitative approach
|
Individual interviews, Secondary data analysis
|
21 Parents
(12 mothers and 9 fathers)
|
The impact of high-risk pregnancies on fathers.
Redefining the role of ‘father’ after experiencing high-risk pregnancy.
|
4
|
Nansubuga & Ayiga (30)
|
2015
|
Rakai District, Central Uganda
|
The study examined the roles played by men after the onset of maternal near miss complications in Uganda.
|
Both qualitative and quantitative (retrospective, cross-sectional study)
|
Narratives and in-depth individual interviews
|
40 maternal near-misses and 10 partners.
|
Redefining the role of ‘father’ after experiencing high-risk pregnancy.
|
5
|
Hsieh et al. (21)
|
2006
|
Southern Taiwan
|
To evaluate the experiences of first-time expectant fathers with a tocolyzed spouse.
|
Qualitative approach: Descriptive phenomenological design
|
In-depth individual interviews
|
6 first-time fathers
|
The father versus the healthcare professional and the hospital environment.
The impact of high-risk pregnancies on fathers.
Focus on fathers: Recommendations for support during high-risk pregnancies.
|
6
|
Aarnio et al. (20)
|
2018
|
Mangochi district, Malawi
|
To provide information about husbands’ role in decision-making and healthcare seeking in cases of pregnancy complications
|
A qualitative interview study
|
In-depth individual interviews
|
24 individuals, with 12 of them being the fathers and the other 12 the mothers.
|
The father versus the healthcare professional and the hospital environment.
Redefining the role of ‘father’ after experiencing high-risk pregnancy.
Focus on fathers: Recommendations for support during high-risk pregnancies.
|
7
|
Cole et al. (29)
|
2016
|
Philadelphia, Pennsylvania
|
To describe the incidence of psychological distress (symptoms of post-traumatic stress and de pression as endorsed on objective measures) among expectant parents, shortly after they received the diagnostic confirmation of a fetal anomaly at a high-risk fetal centre.
|
A 2-year retrospective medical chart review.
|
CFDT mental health screening tool and the Revised Impact of Events Scale (IES-R)
|
1820 participants were screened, with 788 being expectant fathers and 1032 expectant mothers.
|
The impact of high-risk pregnancies on fathers.
|
8
|
Linberg & Engström (19)
|
2013
|
Sweden
|
The objective of the study was to describe new fathers’ experiences of care in relation to complicated childbirth.
|
A qualitative thematic content analysis
|
In-depth individual interviews
|
8 fathers.
|
The father versus the healthcare professional and the hospital environment.
The impact of high-risk pregnancies on fathers.
Focus on fathers: Recommendations for support during high-risk pregnancies.
|
9
|
Maloni & Ponder (27)
|
1997
|
United States
|
To describe the problems and stress of men whose pregnant partners are on bed rest and the assistance they received.
|
Cross-sectional survey design (descriptive retrospective approach)
|
The Paternal Bed Rest Questionnaire (PBRQ) of open-ended questions.
|
59 Caucasian men of partners with prescribed antepartum bed rest.
|
The impact of high-risk pregnancies on fathers.
Redefining the role of ‘father’ after experiencing high-risk pregnancy.
Focus on fathers: Recommendations for support during high-risk pregnancies.
|
10
|
Patel et al. (22)
|
2018
|
Sweden
|
To explore the experiences of healthcare in fathers whose partner was suffering from peripartum cardiomyopathy.
|
Qualitative research design
|
In-depth individual interviews
|
14 fathers of which 8 are first-time fathers with partners presenting symptoms of peripartum cardiomyopathy (PPCM).
|
The father versus the healthcare professional and the hospital environment.
The impact of high-risk pregnancies on fathers.
Redefining the role of ‘father’ after experiencing high-risk pregnancy.
Focus on fathers: Recommendations for support during high-risk pregnancies.
|
11
|
Patel et al. (28)
|
2019
|
Sweden
|
To learn more about fathers’ reactions over their partner’s diagnosis of peripartum cardiomyopathy.
|
Qualitative research design
|
In-depth individual interviews
|
14 fathers of partners with (PPCM).
|
The impact of high-risk pregnancies on fathers.
Redefining the role of ‘father’ after experiencing high-risk pregnancy.
Focus on fathers: Recommendations for support during high-risk pregnancies.
|
12
|
Tanasirijiranont et al. (6)
|
2019
|
Northern Thailand
|
The research question was: “What is going on in the process of becoming a first-time father among Thais whose wives have a high-risk pregnancy?”
|
Grounded Theory design
|
In-depth individual interviews
|
23 Thai men informants.
|
The impact of high-risk pregnancies on fathers.
Redefining the role of ‘father’ after experiencing high-risk pregnancy.
Focus on fathers: Recommendations for support during high-risk pregnancies.
|
13
|
May (23)
|
1994
|
United States; Southern State
|
To describe the impact on expectant fathers of their partners' activity-restricted pregnancies
|
Qualitative
|
Phase 1: semi-structured interview
Phase 2: semi-structured focus group discussion
|
Phase 1: 15 Fathers 2 weeks after partners restriction and
Phase 2: 15 fathers 1-2 years after partners activity-restricted pregnancies
|
The father versus the healthcare professional and the hospital environment.
The impact of high-risk pregnancies on fathers.
Redefining the role of ‘father’ after experiencing high-risk pregnancy.
|
14
|
Kaye et al. (17)
|
2014
|
Uganda
|
To gain a deeper understanding of their experiences of male involvement in their partners' healthcare during pregnancy and childbirth
|
Qualitative
|
In-depth individual interviews
|
16 Fathers whose wives were admitted to hospital for severe obstetric complications
|
The father versus the healthcare professional and the hospital environment.
The impact of high-risk pregnancies on fathers.
Focus on fathers: Recommendations for support during high-risk pregnancies.
|
15
|
Hinton et al. (25)
|
2014
|
UK
|
To explore the impact of near-miss obstetric emergency, focusing particularly on partners
|
Qualitative
|
In-depth individual interviews
|
35 women, 10 male partners and 1 lesbian partner
|
The father versus the healthcare professional and the hospital environment.
The impact of high-risk pregnancies on fathers.
Focus on fathers: Recommendations for support during high-risk pregnancies.
|
Narrative synthesis
The results of the included articles are synthesized into the following 4 themes: (1) The father versus the healthcare professional and the hospital environment; (2) The impact of high-risk pregnancies on fathers; (3) Redefining the role of ‘father’ after experiencing high-risk pregnancy and (4) Focus on fathers: Recommendations for support during high-risk pregnancies.
1. The Father versus the Healthcare Professional and the Hospital Environment
The first major theme that emerged from the data is concerned with father’s engagement with healthcare staff and navigating an environment in which they may not always feel welcome.
In terms of father’s engagement with healthcare staff, fathers reported a lack of communication, feelings of neglect and near-total exclusion from healthcare professionals concerning issues of their spouses. The lack of communication experienced by fathers often lead to their inability to adequately prepare for worse-case-scenarios, which increased feelings of alienation and insecurity and precipitated feelings of anxiety and powerlessness (17-19). As such, fathers indicated that they did not have a lot of knowledge regarding the prognosis of the high-risk pregnancy and its associated complications. This information was often given to mothers by healthcare professions which impedes the father’s ability to assist the mother when complications arise (20). This exclusion can lead to role ambiguity and not knowing what was going to happen to their partners or their child (19). These negative experiences are therefore related to fathers’ being at the periphery and a lack of acknowledgement by healthcare professionals as well as being related to inadequate healthcare received by their partners (21,22). This lack of support was also extended beyond the birth through to follow-up assessments and outpatient care in which fathers experienced neglect from nursing staff (23).
Fathers characterised the hospital environment as unwelcoming. This was exacerbated by a lack of privacy and an absence of facilities and space for men to occupy within the hospital environment, which is not uncommon within low-income settings (17). Fathers expressed that they wanted to be involved and respected (22). In one study, fathers were excluded from being present during the birth of their child without receiving adequate information as to why they were excluded (24). Contrastingly, in the study by Hinton et al. (25) participants from a high-income country indicated that they were surprised and shocked to experience life-saving interventions for high-risk pregnancies particularly when they considered childbirth as a safe and routine procedure.
A high-risk pregnancy can be considered a traumatic experience for both partners. The lack of acknowledgement from healthcare professionals in recognising the trauma faced by men impedes the help-seeking behaviours of men specifically within the context of hegemonic masculinity (18).
2. The impact of high-risk pregnancies on fathers
The second major theme centred on the impact and effects of the high-risk pregnancy on fathers specifically.
There was a consistent reaction experienced by fathers, as reported in most studies, those were, fathers feeling extremely stressed and near total exhaustion of mental resources (24,21,26). Stress was largely related to maintaining employment, ensuring that household tasks were still completed and ensuring that the mother felt supported (23). Supporting the mother and infant served as the primary focus for fathers, often at the expense of their own need for support so as to not detract from the needs of their partners (22). Fathers attempted to ensure that mothers felt supported by hiding or controlling their emotions and fears from their partners (27). To outwardly demonstrate being strong and secure was essential to fathers as a sign that they were able to cope and an admission of fear was viewed as a sign of weakness (28). The experience of a high-risk pregnancy was perceived as a period of extreme pressure, concern, worry and confusion (6). Fathers expressed feeling torn between wanting to be there for their partners and wanting to be there for their babies (19).
As a result, fathers are at an increased risk for the onset of mental health problems which is further exacerbated by the reorganisation of the self (serving as both the breadwinner and ‘single’ parent) often without support (28). Cole et al. (29) determined that 14% of fathers within their study were at risk of developing Major Depressive Disorder (MDD). They also determined that 8.1% of fathers had elevated symptoms of both traumatic stress and depression. These findings are contrasted with the findings of May (23) where 30% of fathers in that study reported clinical levels of depression.
Some of the effects experienced by fathers were as a result of their experiences with healthcare professionals and in the hospital setting. Although support and communication are valued, it is often lacking and the long-term mental health consequences are noted (25). The hardest experience for fathers was to witness their partners in pain and to not be able to intervene.
Childbirth, in particular high-risk pregnancies, can be traumatic for fathers leaving them in a state of vulnerability and fearful for their partner and child. The father is cast aside into a position of powerlessness, conflicted and in limbo as a spectator (22). The impact of this predisposes men to psychological and mental scarring which is attributed to being alienated, ignored or mistreated by healthcare providers (17). These experiences further contributed to men’s feelings of fear and anxiety which culminated into profound long-term consequences for both men and their partners (25).
The impact for fathers is also experienced at home, when mothers are placed on bedrest or activity restriction for the remainder of the pregnancy which results in household disruption. In the study by May (23), the effects of maternal activity restriction resulted in accidental cases of child poisoning, maternal postpartum depression (which in turn, impacts the father), child abuse and significant marital strain.
Beyond this, guilt was also experienced by fathers as they thought they had a better experience in comparison to their partners (19). In an effort to cope, fathers employed a strategy of cognitive refraining in changing their focus from themselves to that of the mother of the foetus and calculating cost-benefit ratios (27). Furthermore, men indicated that they felt inspired by their unborn child to be brave and a desire to exchange their lives for the lives of their baby (6). By being involved, fathers felt more connected and this strengthened the relationship between fathers and their partners (19).
Ultimately, men need to negotiate the dilemma of maintaining traditional constructions of masculinity within the context of disempowerment, lack of agency and confrontation with their own vulnerability (18). These narratives call on men to reconstruct their identities and how they imagine their future. Within this, family relationships serve as the primary source for healing and shared-meaning making (18). Although this period is incredibly difficult for both parents, fathers indicated that it was worthwhile particularly if the mother and child came through healthily (23,27).
3. Redefining the role of ‘father’ after experiencing high-risk pregnancy
The next theme to arise from the data, is focused on fathers reconstructing their ideas of what it means to be a father in relation to the experience of a high-risk pregnancy.
As determined in the previous theme, fathers’ reactions to a high-risk pregnancy was characterised as being fearful for their wives and once fathers knew that their wives were safe, their fear turned to their child (24). Furthermore, fathers sought to provide support for their wives at the expense of their own needs (26). Moreover, in the study conducted by Aarnio et al. (20) they found that fathers regretted not being part of the pregnancy experience when they were side-lined, and not receiving updates regarding the status of their wives or child(ren).
Interestingly, hegemonic masculinity seems to be a predominant theme amongst fathers in the included studies, albeit to varying degrees. Childbirth can be traumatic for fathers who want to remain strong in the face of their vulnerability and fear for the partner and infant. This façade hinders fathers from seeking professional support (28). This was also supported by Aarnio et al. (20) in which fathers are required to take care of their wives and if they are unable to do so, their social capital is directly influenced. In a short space of time, a father is required to re-evaluate his role as he tries to support, care and stand-up for his family (22).
The roles that fathers undertake during this time include not only the assumed duties and responsibilities of each parent but to also execute these roles well which may include: being a father; a good husband/partner; a strong family leader; a son; active member of society and a worker. Coupled with this he is also planning for any uncertainties concerning the care for the mother, baby, the financial and work implications thereof (6,23). The stress associated with caring for their partners, maintaining the family’s financial status and their own mental health was pervasive and all encompassing. This increased burnout, depression and placed significant strain on the marital relationship between the father and the mother (27).
According to Tanasirijiranont et al. (6) a core theme within their study was fathers’ concern for the well-being and health of their unborn child. This translated into striving for increased care (nutrition, medicine, dietary control) in the hope that the high-risk pregnancy condition would not become worse.
In other instances, fathers assume the role of heads of the household and therefore, they are typically the one’s left to make decisions that impact on the economic resources of the family. These include which hospital to attend and how to manage any pregnancy complications that may arise (20). In preventing maternal deaths and reducing the risk of pregnancy, the study by Nansubuga and Ayiga (30) highlight the role played by men. Firstly, this included the long-term or permanent use of contraceptives. Secondly, the study highlighted the roles of fathers in averting maternal death by managing obstetric complications within the household (e.g. administering essential haemorrhage medication (oral or injectable), massaging the uterus when the placenta was not expelled). Finally, the study highlighted the supportive roles undertaken by men including decision-making during emergencies, financial support and access to obstetric care, transport, social and emotional support etc. Fathers in this study believed that they were financially obligated to ensure that their wives had access to emergency medical services even if it meant borrowing or selling assets to achieve this. In terms of support, fathers sought to accompany their wives to healthcare facilities, providing emotional support and caring for sick mothers. This study highlights the importance of the role of the father in being engaged in birth preparedness and complication readiness (30).
4. Focus on fathers: Recommendations for support during high-risk pregnancies
The final theme that emerged from the synthesis details the support needed and recommendations made by fathers in navigating the context of a high-risk pregnancy.
Central to the essence of fathers’ experiences of high-risk pregnancy was their interactions between the hospital environment and healthcare practitioners. Expectant fathers adopt the role of central caregiver, increased concern over a shortage of income and time which increases the pressure he faces (21). Fathers stressed the importance of improved communication and support from nurses and physicians (24,19), which culminates in fathers feeling a sense of control and facilitates a greater sense of coping (28). Feeling prepared and receiving clear, honest communication were essential elements to an overall positive experience which enables fathers to provide better support to their partners (22).
This was demonstrated further in the study by Lindberg and Engström (19) where fathers appreciated status updates on their partners and babies and being invited to the c-section (whether inside or outside the operating room) as it validated fathers’ presence and desire to support his family. In the study by Patel et al. (22) only one (n=14) father reported an instance where the family was invited to receive a status update on the wife and child which highlights the lack of family centredness. Family care tends to exclude the father which may impede further involvement and contravenes the major role he plays in supporting his partner (27). Nursing staff should provide proper assistance and support for fathers, never excluding him from the nursing service (21).
In the study by Tanasirijiranont et al. (6), fathers relied on their faith to guide them through their experience. This was related specifically to the Buddhist concept of karma and therefore, in a way to improve the status of their wife and baby, fathers engaged or did not engage in various activities or tasks as a means to try and increase good karma and protect his wife and expectant child.
The study by Hinton et al. (25) highlighted that the interview was often fathers’ first opportunity to talk about their experiences, with some interviews taking place years after the experience. This demonstrates the pervasive long-lasting trauma experienced by fathers and a sense of isolation owing to the ‘rarity’ of their experience. Fathers indicated that they would like stronger male networks that can help them with their wives’ pregnancy complications and overall improved maternal health knowledge for husbands (20). Interventions to improve male involvement should focus on educational support, a conducive environment, motivational information and positive healthcare provides attitudes towards fathers (17).
It is therefore noteworthy that despite the existence of supportive policies (in some contexts) for male involvement, men’s experiences highlight the dissonance between social expectations and men’s experiences as well as the dissonance between policy for male involvement and practice within the health system (17).