Recruitment and retention rates
In total, 86 fathers were interested in participating, the majority (n=78) referred by Research Midwives at the study sites. Eight fathers contacted the researcher directly. Seven men did not meet inclusion criteria and were excluded and 79 were invited to complete the baseline questionnaire, 52 (66%) of whom did so.
Of the 52 men, 50 also completed the postnatal questionnaire, a follow up and retention rate of 96%. Five of the 50 questionnaires however were invalid (three participants had moved out of the area, one lost their baby due to a miscarriage, and one questionnaire was incomplete). Data presented are based on the 45 men who completed baseline and postnatal questionnaires (Figure 3).
*Adrienne Burgess (Joint CEO and Head of Research) at the Fatherhood Institute and Dr Crispin Day (developer of the Promotional Guide System) from the Centre for Child and Parent Support
Participant Characteristics
The majority of participants (n= 32) were aged between 30 – 39 years (71%), seven (16%) aged between 25-29 years and six (13%) 40 – 44 years. Nineteen men (42%) were White British; eleven (24%) White other; seven (16%) Indian; three (7%) Asian; three (7%) Mixed ethnic group; one (2%) Black African; and one (2%) identified as ‘other ethnic group’. For 29% (n=13) of these men, English was not their first language, but they completed the questionnaires and interviews in English. Most (91%, n=41) were either in full-time employment or self-employed, with 9% (n=4) reporting to be in part-time employment. Annual income ranged from just over £5000 to over £61000. Of these, only one man reported to earn under £15,000 per year. Education levels ranged from GCSE (high school certificate) to doctorate, with 53% being educated up to degree (or equivalent) level. All 45 men were in a couple relationship with their baby’s mother and of these 30 (67%) were married. Only one father did not co-habit with his partner and baby at the time of the study. Full participant details are presented in Table: 1.
Feasibility of collecting outcome measures and impact
Questionnaire measure completion was high. Mean and standard deviation were calculated for all outcomes. Median and inter-quartile ranges were also calculated for EPDS, GAD7, CSI and MSPSS (Table: 2).
Mental Wellbeing using SWEMWBS:
The cut off scores used were based on those used in an evaluation to establish national norms for mental wellbeing based on the 2010–2013 Health Survey data for England.35 A cut-off point of 28 and above was considered as high mental wellbeing indicating positive mental health, 20-27 as average, and below 20 as low mental wellbeing.35 The mean (SD) metric scores for first-time fathers’ mental health and wellbeing at both time points [Antenatal = 25.1 (3.2), postnatal =24.8 (4.1)] suggested participants had ‘average’ mental wellbeing, similar to the English populations norms for men using SWEMWBS, the mean (SD) being 23.7 (3.92).35 The minimum metric score in the antenatal period was 18.6, with only one man reporting low mental wellbeing (score <20). In the postnatal period the minimum metric score was 16.9, with seven men reporting low mental wellbeing (scores = 19.98, 19.98, 16.88, 18.59, 19.25, 19.25, 19.98). The maximum metric score antenatally was 32.6, with nine men reporting high mental wellbeing (score ≥28); in the postnatal period the maximum metric score was 38.1, with seven men reporting a score ≥28.
Depression using EPDS:
The mean (SD) score was 4.7 (3.3) in the antenatal period, and 5.5 (4.5) postnatally. The highest score in the antenatal period was 13 and in the postnatal period 19, the median for both time points being 5.
The cut-off point used to indicate possible depression was an EPDS score of ≥ 10, with 12 or more suggesting major depression.36,37,38 Of the 45 men, 18% (n=8) reported a score of ≥10 on at least one point in time during the perinatal period, with 13% (n=6) reporting a score of 12 or more. Seven of these men had higher scores postnatally, suggesting depressive symptoms potentially increased. Two men had an EPDS score of 13 antenatally, with one increasing further in the postnatal period to 15, and the other reducing below the cut-off point (EPDS score= 7).
Anxiety using GAD7:
The cut-off point used was a score of 10, with scores of 10-15 suggesting moderate anxiety and over 15 severe anxiety.26 The mean (SD) GAD-7 score was 2.5 (2.4) antenatally, increasing to 3.1 (3.2) postnatally. Overall, there was a negative shift in the postnatal period with the median score increasing from 2 to 3. The maximum score (9) in the antenatal period remained below the cut-off point but increased to 14 in the postnatal period. Two men (4%) reported a score of over 10 (individual scores of 14 and 12), suggesting moderate anxiety. Both also scored high on the EPDS (19 and 14 respectively) and low on the SWEMWBS (16.9 and 18.6 respectively) in the postnatal period.
General Health using EQ-5L-5D:
There were no changes in ‘self-care’ functions at baseline or postnatally (Table: 3). For usual activity there were six shifts in the negative direction. Forty-three (96%) men reported no problems with carrying on with their usual activity in the antenatal period and two (4%) reported slight problems. Postnatally 37 (82%) reported no problems, seven (16%) reported slight problems and one (2%) moderate problems with doing their usual activities.
For anxiety and depression, there were eight shifts in the negative direction. Antenatally, 37 (82%) men reported they were not anxious or depressed, five (11%) were slightly anxious or depressed, and three (7%) moderately anxious or depressed. Postnatally, 31 (69%) reported no anxiety or depression, 13 (29%) slight anxiety or depression, and one (2%) moderate anxiety or depression. Three men who reported anxiety and depression on this scale also scored high on the EPDS or on both the EPDS and GAD-7.
The EQ-5D scale also includes the EQ VAS, a visual analogue scale (ranging from 0-100) to record the respondent’s self-rated health. The mean (SD) EQ VAS was 85 (9.7) in antenatal period and 80.7 (11.8) in the postnatal period; and the median (IQR) as 75.5 (85-95) in the antenatal period and 71 (80- 90) in the postnatal period, suggesting a slight decline over the two time points.
Couple Satisfaction using CSI:
CSI scores can range from 0 to 81, with higher scores indicating higher levels of relationship satisfaction. CSI-16 scores falling below 51.5 suggest notable relationship dissatisfaction. The CSI mean (SD) was reported as 71.5 (8.5) antenatally and 67 (15.3) postnatally. There was one outlier, whose postnatal score was only 4, a marked decline from their antenatal CSI score of 50. This participant also scored high on the EPDS and GAD-7 scales, reported anxiety and depression on the EQ5, reported low mental wellbeing on the SWEMWBS and his EQ VAS scores reduced from 85 to 70 in the postnatal period.
Perceived Social Support using MSPSS:
This scale is divided into factor groups relating to source of the social support, namely family, friends and significant other. The overall score ranges from 12 to 84, higher scores indicating higher levels of perceived social support. Mean scores of 1 to 2.9 suggest low support; 3 to 5 moderate support; and 5.1 to 7 high levels of perceived social support.
The overall MSPSS score antenatally was 71.2, which decreased to 70.1 postnatally. The mean (SD) overall score was 5.9 (0.7) antenatally and 5.8 (0.9) postnatally, suggesting high levels of social support in both time points. This finding was consistent across the separate subscales, with the mean (SD) score for ‘Significant Other’ being 6.4 (0.6) antenatally and 6.3 (0.9) postnatally; for ‘Family’ being 5.8 (1.0) and 5.6 (1.2); and for ‘Friends’ being 5.6 (1.0) and 5.6 (0.9) respectively. Although the lowest overall mean score for MSPSS was 3.9 antenatally and 3.6 postnatally suggesting moderate levels of support, the minimum mean scores for two of the subgroups showed lower levels of support postnatally compared to the antenatal period (the minimum mean score for ‘significant other’ dropped from 4.5 to 2.5; and for ‘family from 2.8 to 2.3). The lowest mean score for ‘friends’ however increased from 2.5 in the antenatal period to 3.3 in the postnatal (Table: 2).
While antenatal and postnatal outcome measures were collected from 45 participants, none reported receiving the intervention at both time points (full intervention). Seven (16%) participants reported receiving the intervention at only one point in time (Antenatal Promotional Guide n=3, Postnatal Promotional Guide n=4). Of these seven, one father was also interviewed (discussed later) where it transpired that he had not actually received the intervention. Due to the very small number of fathers receiving the intervention (less than 14%), further analysis of differences between the two groups (intervention vs usual care) was not carried out.
Feedback from fathers – experience, engagement, mental health and research process
Twenty-nine (out of 45) men had indicated that they were happy to be contacted for the interview (64%). Ten men were interviewed, some of whom had no involvement with the Promotional Guide contacts and some who had. The demographic details of the men interviewed are shown in Table 1.
Data were analysed using Framework analysis. Six major categories were identified:
- Experience of health visitor contact
- Experience of Promotional Guides
- Experience of perinatal health services
- Experience of fatherhood
- Fathers’ mental health and wellbeing
- Experience of the research process
1. Experience of health visitor contact
Invitation to attend
Feedback from questionnaires
Men were asked if they were invited to attend a planned appointment with the health visitor when their partner was 28-32 weeks pregnant (the appointment at which Antenatal Promotional Guide is used), 11 (24%) of whom stated ‘yes’. Thirteen (29%) men had attended this appointment, which included all 11 who were invited and two who were not. Similarly, men were also asked whether they were invited to attend a planned appointment with the health visitor when their baby was around 6 – 8 weeks old. Over half reported being invited (n= 25, 56%), 17 of whom attended and eight did not (five due to work commitments, three did not specify). In addition, five men who were not invited also attended, making it 22 (49%) in total.
Feedback from interviews
None of the 10 fathers were explicitly invited to attend any appointments with the health visitor. As one father stated “… it was never an explicit appointment for me” (F11). Some were present during home visits in the postnatal period, as one father explained “they didn’t specifically ask me to be at home when they came, so they didn’t have to ask me specifically, I was present, so they didn’t have to invite me or anything, I was just there in the same room with P [wife] and the baby” (F19).
Visits from the Health Visitor
No participant recalled receiving a visit from the health visitor in the antenatal period, as one father said “I don’t think we had any health visitors prior to her giving birth” (F38), while another said “nobody came to the house when she [wife] was pregnant” (F35).
One father talked about seeing different health visitors in the postnatal period meaning there was no opportunity to build a relationship with any single practitioner: “there were different ones that came and so there wasn’t really a relationship as such” (F13).
Involvement during health visitor contacts
Men’s experiences with the health visiting service varied. Some felt very involved during the consultations (postnatal) and described feeling “very much part of the conversation”, One father said “I was being listened to, they were asking me specific questions as well. Not just about me but about how I was perceiving my wife’s state of mind or physical exhaustion to be” (F19). Another felt the health visitor was “trying to involve both parents, asking different types of questions, observing the behaviour, how we [they] talked to each other…. I think it was like a 50/50, based on [the parents’ needs]” (F28).
Some described feeling “not really that involved, …. when the health visitor came it was sort of talking to L [partner] but I was sort of sat on the sofa as well, and she didn’t really sort of engage with me really”. This father accepted not being spoken to because he justified that his partner “was the one who was pregnant and I [he] sort of felt as if I [he] was sort of the support person” (F13).
Some fathers described health visitors as task oriented where “they came round, weighed, measured, checked over, asked if we had any questions and then kind of said goodbye” (F32). “It was never them saying to me, “Do you have anything to say, would you like to know anything?”” (F35).
2. Experience of Promotional Guides
Feedback from questionnaires
Three fathers reported the Promotional Guide being used antenatally and four postnatally. One man recalled only one topic card was discussed, ‘Our labour & our baby's birth’, while another stated that ten of the eleven topic cards were discussed. One father who originally indicated in the questionnaire that all eleven topic cards were discussed during the antenatal visit (F32) could not recall seeing any topic card or the Promotional Guides when asked during his interview.
Four men reported the Promotional Guide topic cards being discussed in a postnatal visit, including ‘Our emotional wellbeing’, ‘Becoming a mum, a dad & parents’, ‘Our baby’s development’; ‘Caring for our baby’, ‘Our baby’s cues’.
Feedback from interviews
When asked about the use of the Promotional Guides, fathers’ responses included “that doesn’t ring a bell” (F19); “no, I can’t remember that being the case” (F13); “I don’t recall that happening” (F10); “no, absolutely not, no. So, the first time I heard of that was through your study which was quite recent actually” (F38); “no, there was nothing of that sort” (F45). This was despite giving fathers an explanation of what the Promotional Guides were and what the topic cards may have contained.
3. Experience of perinatal health services
Feedback from questionnaires
The fathers described positive and negative experiences. One father was “very impressed from start to finish, the care at the hospital during labour was incredible, follow-up midwife appointments were good, the health visitor provided lots of info…” (F2).
Despite this, many did not feel included or involved by health professionals. One father described the postnatal ward as feeling “a little hostile to fathers at times” (F6). Others stated how the services were mainly geared towards the mother (F15, F25, F28, F36, F45), with one father describing his experience as “being a passenger rather than participant” during the perinatal period (F24).
The support in the postnatal period was “less thorough” with “no immediate continuous support with postnatal issues comparable to the prenatal service” (F3). The lack of adequate communication between health professional was also highlighted (F1). In addition, fathers not being acknowledged by health professionals featured strongly in the feedback (F2, F26, F29, F34, F35, F36, F45).
Feedback from interviews
Some fathers had positive experiences of health professionals in the postnatal period, for example “we were massively, massively impressed by the care and support we received from the NHS and especially the ….hospital staff, they were exceptionally helpful for my wife” (F19). Fathers talked about feeling grateful for the services they received, in particular appreciating the home visits by the midwives following their baby’s birth (F1). One father also acknowledged that “you guys [health professionals] do as much as you can” (F38).
In contrast, others reported a lack of support, particularly in the postnatal period. One father of a seven-month-old felt that support following the birth was non-existent both for himself and his partner “I’d say in terms of…initial dad support, … there hasn’t been anything but since then there hasn’t been anything at all for me..…..so it’s that lack of support just continues...” (F13).
Fathers who attended antenatal classes had to use their own initiative, as this father stated “I think there is not much ongoing for fathers, I would feel, unless you really want to get involved. And you seek the information, you seek advice” (F28). Inpatient postnatal care was described by one father as being “… a bit different, things felt like they were a bit disorganised, unorganised” (F45). This father also felt responsible and unsupported when his partner and baby were separated for over an hour after birth.
4. Experience of fatherhood
Feedback from questionnaires
Many fathers described feeling tired and sleep deprived, which increased their stress levels and anxiety in the postnatal period (F2, F15, F18, F24, F34, F36, F42). One father was “occasionally snappy, angry and impatient…” (F26). Another stated that due to being sleep deprived, his mood could “fluctuate quickly” (F29).
Financial responsibility was also a concern, “more concerned about long term finances since becoming a father” (F20); “it's too stressful, I'm always tired, have to work hard for money, its expensive” (F37).
They wanted to spend more time with their child (F45), and the two week’s paternity leave was not long enough (F19, F32).
Some men were concerned about their own weight gain in the postnatal period; “I feel a bit fat (F45); “I have spent almost zero time doing any exercise, I've gained weight” (F1); and “would like to be in better shape and go back to doing some exercise” (F17).
Feedback from interviews
Fathers found it difficult to go back to work and be separated from their baby. According to one father “for that first six months it’s almost harder for the father because, you know, I have to go to work and so I see him for, you know, 30 minutes in the morning and then I get back and I see him for an hour in the evening, and you’ve got a son and where you’ve got to relate that to living to the weekends. And so I’d say in a way it’s the type of support that is required is slightly different for that because it’s almost sort of dealing with separation from your son and it’s something which is quite difficult” (F13).
Breastfeeding difficulties and a lack of support to overcome these were challenging. One father’s wife felt ‘judged’ because she was not able to breastfeed “There was something … an inadequacy with her rather than the other problems. So in the end we just went to a private lactation consultant to help us out because we tried multiple support groups, and everyone had such a different opinion. It was not scientific, it was more an anecdotal kind of set up” (F11).
Increased anxiety was also mentioned in the postnatal period because “if you are a father to a new born child and you have some kind of financial problems, the level of anxiety would definitely go up because you now have to worry about your children as well on top whatever your existing set up was” (F11).
5. Fathers’ mental health and wellbeing
Enquiry by health visitors
Feedback from questionnaires
Only one of the 45 men was asked about his experiences or needs relating to becoming a father antenatally. Comments included “it [the antenatal contact] was all about my partner and the baby” (F36) and the father “wasn’t asked anything beyond how I was doing” (F19). Postnatally, only two fathers were asked about their own experiences or needs. Comments included “the visit is focussed on the mother and the baby, the father does not appear to be on top of the list in terms of priority” (F11).
Feedback from interviews
Most fathers were not asked about their own mental health and wellbeing by the health visitor during the perinatal period, as the focus was on the women: “about my partner’s wellbeing? Very much so. Not so much my own” (F10). Another said, “they never asked anything to the birthing partner or the father, so they never ask are you feeling exhausted, are you feeling [over] … and are you okay?” (F11).
Those asked about their own wellbeing were asked questions such as “how I [he] was managing work and the baby and everything else” (F19), or “along the lines of, “How are you coping? Everything going okay? Are you getting much sleep?” so probably more in a soft way” (F32) rather than being asked direct questions about mental health.
Health professionals were perceived as speaking to fathers in a more ‘light-hearted’ way. According to one father “it was mainly just kind of, you know, the odd jokes, you know, joke around as if it was my job to change the nappies, or, you know, look after … I have to look after my wife and the baby and sort of thing. So, I don’t have any sort of recollection of staff or health professional’s kind of taking my health into consideration” (F45).
Barriers to accessing support
Feedback from interviews
Fathers talked about barriers to accessing support for their own mental health and wellbeing and not being informed about antenatal or postnatal appointments with health professionals which were normally arranged directly with their partner. As this father described “before the baby was born, I wasn't really notified from my point of view, I think it was just my wife” (F28).
Another barrier was the “lack of visibility or lack of communication and, you know, when you go to the appointments at the hospital, there’s, you know, all of the literature and all of the stuff which is on the walls and is about more for the mother” (F13).
Several men spoke about clinicians’ views on childbirth as a barrier to involving them; “the main barrier in offering any kind of support to the fathers is the mindset that birth is all about the mother and the child, and everything else is a secondary consideration” (F11).
Need for better pre and post birth support
Feedback from questionnaires
Fathers identified several things that would support their wellbeing during their transition to fatherhood, including information about fathers’ groups, childcare and support services, “feeding and general how-to-dos for caring for the baby” (F19), tailored information for fathers, “online videos and bitesize information” (F40), and preparation for changes in new fatherhood. One father stated, “Probably more that the health visitor shows interest in fatherhood and supports them too along with the mother” (F35), while another wanted “acknowledgment [from health professionals] that my life will also change” (F45).
They wanted better facilities for fathers on postnatal wards so that they could better support their partners. As one father explained that there “was just a bed over there and a very uncomfortable chair for me to be around with her and the baby, and given that I had not slept for more than 40, 45 hours, like it was quite physically exhausting to the extent that I literally slept on the floor” (F11).
Feedback from interviews
Fathers wanted “the ability to meet other people who are in the same situation” (F13), through antenatal classes or groups, with adequate antenatal preparation considered important by most.
Similar to questionnaire responses, fathers wanted to be asked about their own wellbeing - “some simple stuff. How are you feeling? You know, how are you doing? Do you have any concerns? But even maybe to build like a small little relationship every time with the father” (F35). Some suggested a routine antenatal appointment for discussing the practical issues relating to new fatherhood, as well as to “have a professional to talk to, to kind of just say how are you doing and, you know, any support, and, you know, just similar to what my wife had, mental health questions and all that sort of stuff” (F45).
Offering the father a separate appointment to the mother was seen as being appropriate “because if it is a man or a woman, if they are going through some sort of abusive phase, facing abuse rather, it would be easier for them to speak up separately” (F19).
Fathers felt that they were not offered sufficient information about breastfeeding difficulties and in infant feeding classes “it was almost presenting a utopian view of how feeding would come about, you know, you take the baby and you plonk him on it, and it just works like magic” (F19).
6. Experience of the research process
The fathers’ main motivation for taking part included: interest in the topic (F11, F45), being able to share their own views and experiences (F28), father’s mental health being an under-researched area (F10), contribute to research on fathers (F1, F11, F13, F19, F38, F45), and to benefit other fathers (F38).
This father summed up the views of most who participated: “From my perspective, I feel like the fathers are sort of the forgotten entity when it comes to the pregnancy and the post pregnancy sort of thing. I wanted to be a part of contributing in any way that I could to make sure that this also an area of research or study that is taken up. Because more and more I see fathers being very, very involved in the child rearing, right from the very beginning and being supportive to their partners in their pregnancy…… I would say the gender roles are more fluid now, it’s not like the man is completely hands off, so I want to make sure that I can participate and contribute in any way that I can because I see that this is an evolution of the role for me” (F19).
Fathers referred to several beneficial impacts of participating in the study, such as improving services for other fathers and involving fathers by asking their views. Completing the questionnaires allowed men to reflect on their own feelings about becoming a father, “those questionnaires do make you think a lot actually about where you are as a person, and where you’re going as a dad, and how you’re feeling about things coming” (F38). Participating in this study also enabled fathers to access additional resources which they may not have had accessed otherwise.