Journal of Community & Public Health Nursing
Open Access

Pregnancy and the transition to parenthood for the first or subsequent time represent a period of profound change and development within a family. While often joyous, this period can be stressful, as it necessitates adjustment across all domains of everyday life [1,2]. Therefore, it is important to identify the needs of parents throughout this period of diverse change, so that supports can be developed to enable them to reasonably anticipate, plan for, and adapt to, the challenges of new parenthood together. It is established that fathers have an important impact on maternal wellbeing and the social and emotional development of children [3-5]. However, with healthcare provision more often focused on improving the health outcomes of mother and infant, the experiences and needs of fathers can be somewhat overlooked during this critical time of family development [6]. Studies on the transition to fatherhood have reported a lack of preparedness among men for the changes wrought by this period [7-9], resulting in an even more challenging period of adjustment to parenthood. A recent systematic review [10] concluded that the literature on this topic remains fragmented, and that continued research into the factors affecting paternal involvement in pregnancy and the post-partum period is needed, while another systematic review has highlighted the need for father-focused interventions to support paternal mental health in the perinatal period [9]. As such, gaps remain in our understanding of the experiences of men as they transition to fatherhood and in our understanding of the actions needed to improve the experiences of men during this time.

No study has explored the perspectives of men who have recently had a term infant on the transition to fatherhood within the Irish context. Research on transitioning to parenthood from a paternal perspective remains relatively sparse when compared to the research that exists on this topic from a maternal perspective [9,11]. As such, this study sought to investigate the perspectives of fathers on their experience of pregnancy and the post-partum period, with the aim of identifying the topics on which information and guidance are most needed by men to enable them to approach fatherhood in an informed and prepared manner.

Ethical approval was obtained from the Coombe Women and Infants University Hospital. Data collection was completed in 2015, and to ensure compliance with the 2018 Health Research Regulations and General Data Protection Regulation, the dataset was fully anonymised in December 2018.

A retrospective, cross-sectional, and descriptive design was employed to issue and analyse a short questionnaire on fatherhood. The male partners of women who had given birth in the Coombe Women and Infants University Hospital four to seven months prior to the study were targeted. A list of women of Irish nationality who delivered a healthy live infant was obtained. Given the relatively limited sample size of this study, women of Irish nationality were targeted to limit culturally-mediated confounding. From this, men were targeted if they met all inclusion criteria, specifically:listed as next-of-kin, designated as a spouse or partner, living at the same postal address as the infant’s mother, and, having a healthy term (37-42 weeks gestation) infant.

Datacollection

Questions were devised by the two authors based on the available literature and the gaps in the literature. Closed-ended questions obtained data on useful sources of information on pregnancy (past experience; partner; doctor; midwife; books; Internet; other fathers; family; friends; others), perceived inclusion in their partner’s pregnancy (5-point Likert scale ranging from completely included to completely excluded), and attendance at antenatal classes (yes/no, with a further question to determine awareness of the legal entitlement to take time off work to attend two antenatal classes). Open-ended questions obtained data on information fathers would have liked on pregnancy; aspects of pregnancy that proved stressful; aspects of parenting on which more information should be available; times when they wanted more support after the arrival of their infant; and, on the impact of an infant on their relationship with their partner. Socio-demographic data were also obtained, to include parity, age, nationality, marital status, educational attainment and employment status.

The questionnaire was piloted with 20 male partners of women participating in a longitudinal study [12] in the hospital. The male participants in the pilot were recruited using convenience sampling, and were asked if they would be interested in completing the questionnaire while their partner was participating in an element of the longitudinal study in the hospital. The purpose of the pilot was to: assess the user-friendliness of the questionnaire, identify any phrasing that may have confused participants, and get an estimate of the time needed to complete the questionnaire. From the comments provided, minor adjustments were made to the layout of the questionnaire, but no changes were made to the wording of questions. Eligible fathers (n1405) were posted the final questionnaire. All questionnaires were accompanied by a letter outlining the value of the questionnaire and the time needed to complete it (approximately ten minutes). Fathers could not be identified from the questionnaire or return envelope, and were assured that their responses were anonymous. Strategies to increase response rates in this study included: personally addressed envelopes; personalised hand-signed letters; coloured ink; the inclusion of a stamped addressed envelope and pen; a university logo; providing assurance of anonymity; and the inclusion of an acceptable number of questions [13]. Incentives were not provided to participate, and men were given three months to return the questionnaire.

Dataanalysis

Data were entered into SPSS for Windows, version 24.0 (IBM, New York, United States). Normally distributed data on age and parity were summarised numerically using the mean and standard deviation (SD). Data from closed-ended questions were presented in frequencies and percentages. The associations between categorical variables were assessed using cross-tabulations and the Chi-squared statistics test was used to assess statistical significance. Yates’ Continuity Correction was used for 2X2 contingency tables to improve the Chi-square approximation. Given the number of open-ended questions, multivariate analyses were not conducted.

To analyse the answers to open-ended questions, the first author reviewed the answers given for each open-ended question, and a list of common categories (where answers centred on a similar category of pregnancy or parenting) was devised from the answers provided until data saturation was reached and no new categories were generated. The categories developed from answers to open-ended questions were reviewed by the second author to ensure consistency of interpretation. Agreement between authors on the categories developed was 100%. Each category was assigned a numerical code that was entered into SPSS. All resulting codes were quantitatively counted and presented as frequencies and percentages. Quotes from fathers that best illustrated a particular category accompanied the final frequencies and percentages given [14,15].

Of the 1,405 questionnaires posted, seven were returned undelivered, resulting in 1,398 eligible questionnaires. Of these, 583 fathers returned a completed questionnaire, giving a response rate of 42%. Of the questionnaires returned, 97.7% (n562) of the questionnaires were fully completed. The mean age of fathers was 35.9 (SD ± 4.7) years (Table 1). Most fathers were Irish (97.1%,n566), married (85.6%, n499), and had at least one other child (61.6%, n359). Over two-thirds had a college education (69.3%, n404) and almost all were in full-time employment (91.1%, n530).

Table 1: Socio-demographic characteristics of 583 men in Ireland who have become fathers for the first or subsequent time

Experience of Pregnancy

When asked about the degree to which they felt included in the pregnancy (e.g. by health professionals in discussions during scans and appointments and by their partner in preparation for the infant’s arrival), most fathers felt completely (51.2%, n298) or mostly (30.5%, n178) included in their partner’s pregnancy. One in six (15.9%, n93) felt mostly excluded and 2.4% (n14) felt completely excluded from the pregnancy.

When asked about the sources of information that best informed their expectations of pregnancy, two-thirds (64.5%, n376) identified their partner as one of the most useful sources of information on what to expect with the pregnancy, with first-time fathers significantly (p<0.001) less likely to report this when compared to men who had fathered at least one other child (35.9% (n135) versus 64.1% (n241), respectively). More than two in five (45.3%, n264) of the total cohort stated that their previous experience was also useful, and of these, 98.5% (n260) were men who had fathered at least one other child. Almost a quarter of the total group (23.0%, n134) cited the Internet as helpful in letting them know what to expect, with 65.7% of first-time fathers citing this compared to 34.3% of men who had fathered at least one other child. Doctors (10.5%, n61) and midwives (7.5%, n44) were less frequently cited. Positively, the majority of fathers had sufficient information on what to expect in pregnancy, with no significant difference (p=0.204) between first-time fathers and men who had fathered at least one other child (87.5% versus 90.9%, respectively).

Three-quarters (73.9%, n431) of fathers had attended antenatal classes, either during the most recent pregnancy (43.1%, n251) or during a previous pregnancy (30.8%, n180). Of those who had never attended antenatal classes (26.1%, n152), over a third (36.8%, n56) felt that the classes were not relevant for them, a quarter (25.7%, n39) did not attend because their partner chose not to attend, and 23.0% (n35) cited work commitments as the reason for non-attendance. Less than a third (31.6%, n184) of all fathers were aware that they are legally entitled (in Ireland) to take time from work to attend two antenatal classes, and fathers were significantly (p=0.01) more likely to attend these classes if they were aware of this entitlement. A smaller proportion of first-time fathers (40.2%, n74) were aware of this entitlement when compared to men who had fathered at least one other child (59.8%, n110), but this difference was not statistically different (p=0.454).

An open-ended question was used to prompt fathers to suggest one topic on which information would be most useful for expectant fathers (Table 2). Practical advice on supporting their partner’s emotional wellbeing (27.4%, n158) and on how to help during labour and the period between birth and discharge from hospital (27.4%, n158), were equally identified as important and useful. Mirroring this, when asked about the most stressful aspects of pregnancy for them, as partners (Table 3), over a quarter (28.0%, n163) highlighted their partner’s emotional wellbeing and their uncertainty over how to respond effectively to a partner in a heightened or depressed emotional state. A first-time father expressed a degree of bafflement and helplessness in the face of his partner’s emotional health, stating that he “just couldn’t understand” why his partner was so frequently tearful, while a secondtime father appeared more frankly accepting of his belief that women “just go a little crazy sometimes” due to hormonal changes. Fathers also reported difficulty reassuring their partner over the inevitable changes to their pregnant body and managing the impact this may have had on intimacy with their partner. A third (34.3%, n200) of fathers also found the persistent general worry about the health of their partner and unborn infant particularly stressful, and one in five (21.3%, n124) stated that labour was one of the most stressful aspects of pregnancy for them as partners.

Table 2: Topics on which 583 fathers wanted more information in advance of the birth of their Infant.

Table 3: Stressful aspects of pregnancy according to the perspectives of 583 new fathers.

Experience of the early post-partum period

When reflecting upon the early post-partum period, over half (55.4%, n323) of fathers reported having parenting experiences that differed significantly to their expectations. The remaining 44.6% (n260) reported that the post-partum period was exactly as they expected. First-time fathers were significantly (p=0.004) more likely to report that their experience of fatherhood was markedly different to their expectations, when compared with men who already had at least one other child (62.9% versus 50.6%, respectively). The unexpected difficult experiences of the early post-partum period (Table 4) included: physical challenge of sleep deprivation; feeling overwhelmed; navigating a new family structure, and managing changes in their relationship with their partner.

Table 4: Notable experiences of the post-partum period among 583 fathers.

The most common (72.4%, n422) challenge was sleep deprivation and consequent exhaustion, where, even those who expected it, underestimated its inevitable adverse impact on their wellbeing (Table 4). A first-time father noted that even though he had been told to expect disrupted sleep, “actually experiencing it is totally different” to expecting interrupted sleep in theory, while a second-time father noted that the tiredness “still hits you with a bang” even though it was expected.

A majority (57.5%, n335) of fathers described feeling over whelmed at times (Table 4). First-time fathers in particular described a sense of loss over their “old life” as they adapted to the new routines of early fatherhood. They reported feeling lonely during this unpredictable transition, which was felt by some to be an all-consuming “continuous cycle” in which night and day became indistinguishable. In particular, fathers reported feeling out of their depth when their infant was unsettled and not responsive to their efforts to comfort them; this feeling did not appear to differ between first-time fathers and fathers with at least one other child.

The challenges of adjusting to a new family structure were also highlighted by over a third (33.6%, n196) of fathers (Table 4). Men described being unprepared for the sheer intensity of the focus on the infant, sometimes to the perceived exclusion of them, as fathers. A first-time father described being on the outside of the “little bubble” of his wife and daughter, while a second-time father reported feeling more “hemmed in” by the arrival of a second child and consequent additional demands on schedules. Fathers with at least one other child more frequently stressed the time pressure they experienced as they cared for other young children in addition to the new infant.

The adverse impact of sleep deprivation, changeable and depressed moods, and decreased sexual intimacy on the relationship between partners was reported (Table 4), as fathers realised the need to not only develop a new relationship with their infant, but also to readjust their existing relationship with their partner. Fathers acknowledged that they were often unable to understand their partner’s emotional state and the challenges she was experiencing in the post-partum period.

The physical and logistical challenges experienced by parents when caring for a new infant, such as sleep deprivation and balancing the care of an infant with caring for other small children, may have compounded these communication challenges during the post-partum period, with one father- of-two noting that “sleep deprivation will make your partner want to kill you and vice versa”. The importance of having some time apart for relaxation and “me time” was frequently highlighted as a means of reducing tension, whereas suggestions to spend time together to discuss relationship challenges occurred less frequently. First-time fathers, in particular, voiced the importance of alerting pregnant couples to these potential relationship challenges in the post-partum period.

Alongside the emotional challenges experienced, one in three (32.1%, n187) fathers reflected on the need for skills-based support (Table 4), to include being taught skills on how to hold, feed, change, bathe, and dress a baby. The importance of having easily accessible professional support, “web-based resources,” and “how-to courses” was also emphasised. However, alongside all the challenges of this time, men also consistently highlighted the joy they felt at becoming fathers (Table 4), further highlighting the complexity of transitioning to fatherhood, whether for the first of subsequent time. It is a tough, lifechanging experience, but I wouldn’t be without the kids. Fatherhood is the most amazing experience and the most rewarding job a man can have [5031, father of three].

Pregnancy and the transition to parenthood provoke profound changes within a family, representing an extended period of significant adjustment and readjustment [7]. This study highlights the challenges faced by men as they endeavor to simultaneously adjust to fatherhood and support their partners during pregnancy and the post-partum period. Participants noted the challenge of not having a clear role during labour and of navigating the physical and emotional difficulties inherent in the post-partum period; difficulties which are challenging for mothers and fathers, but for which fathers tend to receive less support when it comes to their management.

Fathers wanted more information on how to manage certain elements of pregnancy, to include their role during labour and the short period between birth and discharge from hospital. This is in line with the literature [11], where fathers often struggle with their perceived passive role in labour and are discomfited by feelings of helplessness during this event. Although three-quarters of men in this study had attended antenatal classes at some point, only two in five attended classes on the most recent pregnancy, perhaps indicating that these classes are not engaging men to the extent that they could. Male-only antenatal classes have been positively perceived by men [16], as they can acquire evidence- based information on what to expect, prepare, and do to support their partner during labour. These classes can also provide men with multiple opportunities to express concerns without embarrassment [16] and may help foster a peer support network for fathers after their infant’s arrival. As highlighted by a recent systematic review [1], research in this area is limited, but the role of male-only parenthood education classes in improving feelings of readiness for the birth of an infant is worthy of further investigation.

Fathers also highlighted the competing demands of managing logistics, finances, professional commitments, and their own mental wellbeing, with supporting the health of their partner and infant throughout pregnancy and during the early months after the birth of their infants. A UK- based qualitative study [17] reported that the men in their study felt that the focus ‘should’ be on the mother and baby, and they found it difficult to prioritise their mental wellbeing and readiness for fatherhood, even if these were compromised partly due to their efforts to support their partner. A likely consequence of family healthcare that is skewed towards mothers and infants is that this hierarchy compounds the belief among men that the transition to fatherhood is less deserving of support and attention when compared to the transition to motherhood. This skewed focus may lead to missed opportunities for men to mentally prepare for the transition to fatherhood and to acquire appropriate parenting skills in a timely fashion [18-20].

In line with other literature [17,21], fathers in this study expressed a wish for practical, skills-based guidance on the transition to fatherhood. Research has demonstrated that although women identify their partners as a key source of support, they report that their partners sometimes do not know how to adequately support them through common challenges such as breastfeeding [22] or decision-making on infant care [23,24]. As such, making easily accessible and targeted support and solution-focused learning opportunities available to men may reduce some of the challenges experienced in the transition to fatherhood and may help optimize the wellbeing of their partner in their transition to motherhood [17]. Related to, but distinct from, the challenges experienced during the transition to parenthood, were the challenges experienced in the relationship between partners. One in five fathers felt poorly prepared for the changes in their relationship with their partner, with many highlighting the need to alert couples to the likelihood of relationship strain in the post-partum period, echoing the findings of other research [25-29]. In contrast to some literature [27], the fathers in this study more often suggested having time apart as a means of coping with relationship tensions, as opposed to having uninterrupted time together as a couple. It is important that parents face the transition to parenthood as a united team, and teaching men and women positive coping strategies to resolve relationship stress related to raising an infant is essential to facilitate the development of a cohesive family unit [28,30]. A mindfulness-based brief intervention for pregnant couples in the UK demonstrated significant improvements in the mental health of both parents [31], which may facilitate constructive conversation on managing challenges together in the post-partum period, although it has been acknowledged that further investigation in this area is needed [9].

Many of the issues that impacted on first-time fathers in this study also impacted on men who had fathered at least one other child, though with some differences in how issues were perceived and managed. For example, both categories of men seemed to struggle with sleep deprivation and with instances of feeling overwhelmed in the first few months of their infants’ life. However, when it came to navigating a new family structure, first-time fathers tended to have a greater psychosocial struggle in terms of establishing their place and role within this new structure. Conversely, men who had fathered at least one other child tended to highlight more logistical and physical demands in supporting the needs of all within their further expanded family unit. This difference is expected, given that it takes time for men to develop their paternal identity and overcome feelings of incompetence often associated with the early stages of parenthood [11,32]. When focusing on the changes in the relationship between partners, first-time fathers appeared to be more unpleasantly surprised at the change in intimacy and instances of communication breakdown with their partner. Men who had fathered at least one other child did not express such surprise, and instead seemed to accept these challenges as inevitable and focused on solutions, such as allowing each other to have ‘me time’. Although there are nuances to these issues for both categories of men, similar actions can be taken by all fathers to address each issue. Therefore, while the social, psychological, and emotional underpinnings of these issues may differ, given the male preference for solution-focused guidance (as opposed to emotion-focused guidance) [17], the actions needed to resolve the issues are generally similar, regardless of whether or not a man is a first-time father.

A combination of closed-ended and open-ended questions were used in the study questionnaire. Given the lack of any existing validated instruments to capture the experiences of men during the transition to fatherhood, and given that few studies have been conducted in Ireland on the views of fathers on the early post-partum period, a questionnaire comprised entirely of closed-ended questions would have been inappropriate. The open-ended questions allowed for some initial exploration of topics that have not been explored to date [33]. Although several best practice measures were taken to enhance the return of surveys, the response rate of 42% was lower than anticipated. Despite this, the group of fathers to which the results best apply is known from the socio-demographic data collected, and the study remains one of the largest to date on the transition to fatherhood. This questionnaire represents fathers who were more educated compared to the national population. Furthermore, respondents were self-selected, possibly resulting in participation bias. There may also have been some information bias, due to participants providing what they believed to be socially desirable responses. However, the anonymous nature of the questionnaire should encourage a more frank expression of views held on pregnancy and the early post-partum period [34], thereby reducing information bias. Future research should investigate the views of younger fathers and fathers from more disadvantaged backgrounds, and should identify other ways of encouraging men in Ireland to take part in research related to fatherhood.

This study highlights the challenges faced by men as they endeavour to simultaneously adjust to fatherhood and support their partners during pregnancy and the post-partum period. It emphasizes the ongoing need to create appropriate opportunities for men to prepare for all aspects of the transition to fatherhood. Practical solutionfocused guidance for men may help to promote the development and wellbeing of men during this challenging period, and by association, the wellbeing of mothers and infants.

AEB was responsible for study design, data collection, data analysis, drafting the manuscript, and making critical amendments to the manuscript. JMK was the study supervisor and contributedtodata analysis and manuscriptrevision.

This research received ethical approval from the Coombe Women and Infants University Hospital Research Ethics Committee.

The authors have no conflict of interest todeclare.

AEB’s doctoral research was supported by a Dublin Institute of Technology Fiosraigh Scholarship, which was equally funded by Dublin Institute of Technology and Danone Nutricia. Danone Nutricia had no role in the: study design; collection, analysis, and interpretation of data; writing of the manuscript; and decision to submit the manuscript for publication.

The data presented in this manuscript is from a fully anonymised datasetto ensure compliance with the 2018 Health Research Regulations and General Data Protection Regulation.