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Australian Fathers’ Study: What Influences
Paternal Engagement With Antenatal Care?
Timothy Jeffery
Ki-Yung Luo
Brandon Kueh
Rodney W. Petersen, MBA
Julie A. Quinlivan, PhD
ABSTRACT
This mixed-methods study explores factors associated with and levels of engagement of fathers in antenatal
care. One hundred expectant fathers were recruited from antenatal clinics and community settings in West
ern Australia. They completed validated questionnaires. Eighty-three percent of expectant fathers reported
a lack of engagement with antenatal care. Factors significantly associated with lack of engagement in mul
tivariate analysis were working more than 40 hours a week and lack of adequate consultation by antenatal
care staff. In qualitative analysis, 6 themes emerged in association with a lack of engagement. They were
role in decision making, time pressures, the observer effect, lack of knowledge, barriers to attendance, and
feeling unprepared or anxious. Care providers should involve fathers in consultations to improve paternal
engagement.
The Journal of Perinatal Education, 24(3), 181-187, http://dx.doi.org/10.1891/1058-1243.24.3T81
Keywords: expectant fathers, engagement, antenatal, Australia
The event of childbirth is a time of joy and chal
lenge for families (Teixeria, Figueriedo, Conde,
Pacheco, & Costa, 2009; Woods, Melville, Guo,
Fan, & Gavin, 2010) as well as a time of transi
tion. Many efforts have been taken in the health
care system to help mothers cope with childbirth
and the stress associated with postnatal life.
These efforts include the provision of a myriad of
health professionals focused on achieving maxi
mal health outcomes for the mother and child
(Beyondblue, 2011).
Less effort has been directed toward helping
fathers to adjust to the antenatal, birthing, and
postnatal period (Hildingsson, Thomas, Olofsson,
& Nystedt, 2009). However, fathers’ health outcomes
are particularly important, given their increasing
participation in pregnancy and childbirth over
the past few decades (Draper, 1997). The increase
in father attendance and participation coincides
with a gradual social shift in the role of fathers
(Draper, 1997). There has been a redefining of the
role of fatherhood from that of breadwinner and
Australian Fathers’ Study I Jeffery et al. 181
The presence of an engaged and supportive father figure in the
antenatal, birth, and postnatal setting has been demonstrated to
improve birth outcomes.
disciplinarian to one of active involvement in the
care of children of all ages (Chin, Hall, & Daiches,
2011; Redshaw & Henderson, 2013; Tallandini &
Genesoni, 2009). Significantly, this transition has
been applied to the antenatal and birth periods,
during which men are taking a more active role in
pregnancy processes (Chin et al, 2011; Tallandini &
Genesoni, 2009).
The presence of an engaged and supportive fa
ther figure in the antenatal, birth, and postnatal
setting has been demonstrated to improve birth out
comes. In particular, it has been shown that the pres
ence of a father figure throughout labor is associated
with lower epidural rates, pain, panic, and exhaus
tion and reduced rates of cesarean surgery (Kennel,
Klaus, McGrath, Robertson, & Hinkley, 1991). Fur
thermore, any significant psychological stress a fa
ther may experience as a result of the birth process
is likely to have disseminating effects on the entire
family. Specifically, fathers under stress are less likely
to provide adequate emotional support for their
partner during pregnancy and birth and may be less
involved in the development of their child (Kennel
et al., 1991; Tallandini & Genesoni, 2009).
Father engagement and participation through
out the antenatal period is a complex subject with
several different factors playing a role. Specifically,
demographic variables, attitudes of care providers
such as midwives and medical staff, occupational
factors, and strength of partner relationship have
been suggested to influence paternal engagement
(Hildingsson, Cederlof, & Widen, 2011; Johansson,
Rubertsson, Radestad, & Hildingsson, 2012). In
terms of modifiable factors to improve paternal out
comes, the standardized practices and expectations
of midwives and medical practitioners in the provi
sion of antenatal care is at the forefront (Backstrom
& Wahn, 2011; Johansson et al., 2012).
There is very limited Australian research on fa
thers and the birth process. Previous studies fre
quently focused heavily on psychological or birth
outcomes and did not explore antenatal engage
ment, the starting point of the journey into parent
hood (Fenwick, Bayes, & Johansson, 2012).
The purpose of this study is to assess levels of en
gagement in fathers in an Australian setting and to
determine whether the potentially modifiable factor
of consultation by antenatal care providers influ
enced paternal engagement.
METHODS
Type of Study and Ethics Approval
This mixed-methods study forms part of the
Australian Fathers’ Study, a larger longitudinal study
of fathers’ attitudes toward antenatal, birth, and
postnatal care. The Australian Fathers’ Study has
institutional ethics committee approval, and indi
vidual informed consent was obtained from each
participant.
Study Population
The data reported in this report come from public
care participants recruited within the North Met
ropolitan Health Service of Western Australia who
were male partners of women in their third trimester
of pregnancy. The paternal population in this region
is representative of the wider Australian popula
tion of public care expectant fathers. The mean age
of fathers is 31.2 years compared to a background
rate of 31.1 years. The percentage of families with
a religious belief is 74% compared to a background
rate of 74.4%. The percentage of first births is 43%
compared to a background rate of 41% (Australian
Bureau of Statistics, 2012). The study excluded men
who were not fluent in English or where the preg
nancy had a known fetal anomaly.
Fathers were recruited by research staff and
completed questionnaires addressing demographic,
attitudinal, and psychological symptomatology.
Quantitative and qualitative data were collected.
Hypothesis
The primary hypothesis was that, consistent with
the single overseas study, only 50% of fathers would
report feeling engaged with antenatal care. The sec
ondary hypothesis was that greater satisfaction with
the consultation experience in antenatal care would
increase engagement.
Variables to Be Measured and Examined
The antenatal questionnaire was based on those used
in previous studies (Fenwick et al., 2012; Johansson
et al., 2012). There were qualitative and quantitative
components to the questionnaire. Given that fathers’
level of engagement was the primary outcome, the
182 The Journal of Perinatal Education I Summer 2015, Volume 24, Number 3
following broad areas were examined and used as
the framework for analysis:
• Background demographics
• Relationship with partner
• Role in decision making
Sampling Recruitment and Size
The sample size for this study was calculated us
ing Minitab Version 16 (University of Melbourne).
The sample size calculation assumed that levels of
engagement in fathers could be equally divided be
tween those participants who selected the options of
“engaged” or “somewhat engaged” from a choice of
four options in accordance with a previous report
(Johansson et ah, 2012). The remaining two options
were “neutral” and “not engaged.” For internal vali
dation, participants were also asked to score their
level of engagement in a Likert scale from 0 to 10,
where 0 represented no engagement and 10 complete
engagement. The correlation coefficient between a
score greater than 5 and the options of “engaged”
and “somewhat engaged” was high (r = 0.89).
The sample size calculation assumed that with
adequate consultation, engagement would increase
by 30% from a baseline level of 50%. To measure this
with a power of more than .80 and alpha error of .05,
a sample size of 90 fathers was required.
Statistical Analysis
Data were entered onto a data sheet using Minitab
Version 16 (University of Melbourne). A descrip
tive analysis was used for the quantitative data. To
analyze for differences in responses between fathers
engaged in antenatal care and those who are not, the
significance (p) of the differences was determined by
a chi-square test (x2) for independence. Fisher exact
test was used where cell size was less than 5. A p value
of .05 was set for rejection of the null hypothesis.
A method described by Mantel and Haenzel (as
cited in Rothman, 2012) was used to determine the
relative risk of the variables asked in the questionnaire
on lack of engagement. A logistic regression analysis in
the Minitab package (Minitab Version 16, University
of Melbourne) identified those factors most strongly
associated with negative impacts on antenatal engage
ment. Variables significant in univariate analysis at a
level ofp < 0.1 were included in the model.
For the qualitative data in the “Comments” sec
tion of the questionnaire, an inductive content anal
ysis was performed in accordance with methodology
described by Elo and Kyngas (2008). The written
comments were independently read by the principal
researchers, and an abstraction process was used to
summarize and conceptualize the overall meaning
and implications of the comments. Open coding
was perform ed to maximize the num ber of headings
to describe all aspects of the content.
Both quantitative and qualitative aspects of the
data were integrated for data interpretation.
RESULTS
Participants (N — 100) were recruited via their pregnant
partner. Table 1 summarizes the demographic char
acteristics of the cohort. The mean age was 30.1 years,
and most were born in Australia (79%) and living with
TA BLE 1
Demographics of Cohort
Fa th ers A us tra lia n
(N =
1 00) D ata
A ge in ye ars
M ea n
[SD]
30 .1 (3.2)
C ou ntry o f bir th
A u s tra l ia 79
Els e w he re 21
R ela tio nsh ip statu s
Liv ing w ith pa rtn er 87
N ot liv ing w ith pa rtn er 13
Education
Le ss th an 12 y ears 24
12 y ears 30
F urth er e du ca tion 46
E m pl oy m e nt
Noa 18
Yes— lo cally 68
Yes— FIFO 14
H ou rs e mp lo ye d
N ot ap pli ca bl e 18
1 - 15 12
1 5 -4 0 33
4 0 + 37
S m ok e r
Yes 29
No 71
F irs t-ti m e fa th er
Yes 54
No 46
P regnancy pla nnin g
N a tu ra l— p la nn e d 68
IVF— p lan n ed 6
Unplanned 26
Note.
FIFO = fly- in, fly-o ut: IVF = in vit ro fe rtiliz atio n.
“ Inclu des n ew sta rt, yout h allo w an ce , p ar en ting pay me nt, care r,
an d pension recip ients who m ay wo rk , s tud y o r re tra in fo r u p to
8 -1 5 hou rs a w eek, and re tain th e ir govern me nt ben efit.
Australian Fathers’ S tud y
I Jeffery et al. 183
their partner (87%). Approximately half the cohort
Fly-in fly-out is a method of
^ad undertaken farther education beyond Year 12, and
employing people in remote '
areas by flying them tempo-
82% were employed. There was a high fly-in, fly-out
rarity to the work site instead
workforce prevalence of 14%. One-third of the cohort
of relocating the employee
and their family permanently
worked in excess of 40 hours each week. Smokers rep-
This is common in large min-
resented 29% of the cohort. Half were first-time fathers,
ing states in Australia.
, , . . .
and the pregnancy was planned m most cases (74%).
Table 2 summarizes the impact of demographic
and pregnancy variables on engagement. Overall,
only 17% of the cohort reported being engaged
with antenatal care. In univariate analysis, fac
tors significantly impacting engagement were age
(engaged = 29.6 years, not engaged = 31.8 years;
p = .03), further education (engaged = 82%, not
engaged = 38%;p = .001), employment (engaged =
53%, not engaged = 88%; p < .001), smoking sta
tus (engaged = 47%, not engaged = 25%; p = .04),
and adequate consultation (engaged = 94%, not en
gaged = 63%; p
= .008).
To refine the negative impact of employment on
engagement, the employment variables of “fly-in,
fly-out” employment status and working more than
40 hours a week were explored as univariate asso
ciations of lack of engagement. In univariate analy
sis, fly-in, fly-out working status was not associated
with engagement, but employment for more than
40 hours a week was significantly associated with
lower levels of engagement (p = .02).
In the multivariate analysis, modeling included
the variables significant at p < 0.1 in univariate anal
ysis. These variables were age, country of birth, edu
cation, employment, working more than 40 hours a
week, smoking, and adequate consultation. Working
more than 40 hours a week (p = .04) and adequate
consultation (p = .02) retained their significant as
sociation with engagement.
In qualitative analysis, 59 respondents wrote com
ments relating to their engagement with the antenatal
care process. Among fathers who indicated that they
were engaged, two themes emerged: a valued role in
decision making and staff behavior. In contrast, among
fathers who indicated that they were not engaged, six
themes emerged: no role in decision making, time pres
sures, the observer effect, lack of knowledge, barriers to
attendance, and feeling unprepared and/or anxious.
The two themes from fathers who reported feel
ing engaged are as follows:
TABLE 2
Im p ac t o f De m og rap h ic F ac to rs on En ga ge m en t
Engaged
/V = 17
n(%)
N o t
Engaged
N=
83
n
(%)
p Value
0R(
95% Cl)
Age (years) 29 .6 (3.3) 31 .8 (3.0) .03
Coun try o f birth
Australia 11 (65) 68 (82) .07
Elsew here 6(3 5 ) 15(18) 0.4 [0 .1.1 .3 ]
Relationship sta tus
Living w ith 15(8 9) 72 (87) .61
pa rtner
No t liv ing w ith 2(1 1) 11 (13) 1.1 [0.2, 11.7]
pa rtner
Education
12 years or less 3(1 8) 51 (62) .001
Furth er ed ucation 14(8 2) 32 (38) 0.13 [0.02 , 0 .5]
Employment
Yes 9(5 3) 73 (88) < .001
Noa 8 (4 7) 1 0(12 ) 64.9 [7.2, 580]
Fly-in, fly-out w orker
Yes 1 (6) 13(16) .45
No 16( 94) 70 (84) 0.34 [0.04, 2.8]
W orker for m ore th an
40 hr a w eek
Yes 2(12) 35 (42) .025
No 1 5 (88) 48(58) 0.1 8(0.0 4,0 .8 5 ]
Smoker
Yes 8(47) 21 (25) .04
No 9 (53) 62 (75) 2.6 [0.0 , 7 .7]
First -tim e f ath er
Yes 9(53) 45(54) .46
No 8 (47) 38 (46) 0.9 [0 .3-2.7 ]
Preg nan cy pla nning
Planned 15(88) 5 9(7 1 ) .12
Unplanned 2(1 2) 24 (29) 3.1 [0.6, 29 .3]
Adequate consultation
Yes 16( 94) 52 (63) .008
No 1 (6) 31(37) 9.5(1.3,412 ]
Note. OR =
odds ratio.
In clu de s n ewstart, youth allowan ce, p arenting paym ent, carer,
and pension recip ients wh o may work, study or retra in fo r up to
8-15 hours a w eek, and retain th eir governm ent bene fit.
2. Staff behavior
The staff were fantastic and welcoming.
The six themes from fathers who reported they
were not engaged are as follows:
1. Valued role in decision making
The midwife went out of her way to make sure we
were a couple making decisions together.
1. No role in decision making
I wanted to have a say but they didn’t listen to my
opinion.
184 The Journal of Perinatal Education I Summer 2015, Volume 24, Number 3
2. Time pressures
This is the busiest time of year and making time to
get here has been difficult, even though its [sic] a pri
ority for me.
I haven’t had time to think about the baby let alone
the prenatal stuff.
3. The observer effect
Antenatal care is really for her. There’s no baby yet.
I feel I ’m looking on but its [sic] happening to her
and not me.
4. Lack of knowledge
I want to be more involved but don’t know enough
to ask.
Most o f the time I don’t understand what they talk
about.
5. Barriers to attendance
I haven’t been able to attend appointments as I
work. This is my first time at the hospital and the
baby is nearly here.
I miss a lot of things due to work.
6. Feeling unprepared and anxiety
Maybe I’m too anxious to be involved.
I can’t believe the baby’s due in a few weeks. Noth
ings [sic] ready. I ’m not.
DISCUSSION
This is the first Australian study to evaluate en
gagement by fathers in antenatal care. Engagement
rates were poor but were positively influenced by
adequate consultation with antenatal care staff and
negatively influenced by long working hours.
Research into the effects of pregnancy and birth
on men is quite recent, corresponding with increased
rates of birth attendance. Most studies have been ex
clusively directed at the experience of childbirth it
self and not on antenatal and postnatal health. More
data has evaluated the psychological transition to
fatherhood (Hildingsson et al., 2011; Tallandini &
Genesoni, 2009). The limited available studies con
cluded that the form of transition and the roles fathers
chose were guided by the social context in which they
lived, particularly in relation to expectations of the
medical profession, as well as personal characteristics
and the quality of partner relationship (Tallandini &
Genesoni, 2009; Hildingsson et al., 2011).
Consistent with these studies, we found that
positive engagement with care providers, either
medical or midwifery, improved engagement. In the
thematic analysis, fathers documented satisfaction
when their opinions were valued and dissatisfaction
when they were not. Thematic analysis also found
that fathers needed to identify a role for themselves
in the antenatal period, and this could be achieved
through caregiver consultation.
Our results are consistent with two Swedish stud
ies demonstrating that 74% of all fathers with a pos
itive birth experience reported that attending staff
addressed their specific concerns and valued their
role (Hildingsson et al., 2009; Woods et al„ 2010).
The overlying theme in studies from this area of re
search suggests that to improve father satisfaction,
men need to be linked more closely to medical and
midwifery professionals (Hildingsson et al., 2009). It
is therefore suggested that services should endeavor
to meet fathers individually, discuss expectations re
garding the father’s role, and assess their experience
during the birth process (Hildingsson et al., 2009;
Woods et al., 2010).
The main driver for poor engagement stemmed
from difficulties men experienced in attending an
tenatal care appointm ents. Employment for more
than 40 hours a week was associated with poorer
engagement. Thematic analysis revealed fathers ex
perienced dissatisfaction related to time pressures
and work-related barriers to attendance.
Fathers who cannot attend antenatal clinics are
not going to have an opportunity to receive any
form of consultation from care providers, adequate
or not. Attendance is important as the first step for
engagement to occur. Although many workplaces
offer caregiver’s leave, this is often limited and men
may be reluctant to use it for the antenatal period,
preferring to keep it for the birth and immediate
postnatal period. There may also be other pressures
from employers. Employers are obligated to accept
medical certificates for women attending antena
tal care, but most fathers have difficulty accessing
medical certificates for leave to attend an antenatal
clinic appointm ent. However, when fathers were
able to access antenatal care and encountered posi
tive consultation with care providers, engagement
levels were significantly improved.
We predicted that fly-in, fly-out fathers might
report poorer antenatal engagement. However, this
was not dem onstrated in our analysis. The impact
of employment on poor engagement was exerted
Australian Fathers’ Study I Jeffery et al. 185
Greater insight into the psychological experiences of fathers can
help to identify vulnerable fathers, just as many services now screen
for anxiety and depression in mothers in the antenatal period.
principally through number of hours worked. It
may be that fly-in, fly-out fathers miss certain an
tenatal opportunities for engagement when they
are away with work. However, this may be offset by
greater flexibility when they are home, which in turn
enables them to attend sessions of care provision.
The father who works lengthy hours but does not
fly-in and fly-out lacks even this flexibility to attend
antenatal care appointments.
Anxiety was another theme emerging from fa
thers reporting a lack of engagement. This theme
has been previously reported. Two previous studies
have reported that poorly engaged fathers reported
feeling helpless, anxious, and depressed during the
antenatal period (Fenwick et ah, 2012; Johansson
et ah, 2012). Greater insight into the psychological
experiences of fathers can help to identify vulnerable
fathers, just as many services now screen for anxiety
and depression in mothers in the antenatal period.
Research has shown that a father’s experiences have
a genuine impact on the family’s emotional response
to the birthing process (Backstrom & Wahn, 2011;
Hildingsson et al., 2011). Strategies that improve
the psychological health of either parent are likely
to benefit the family into the future. The change in
social norms means there is untapped potential to
improve outcomes for fathers by providing more
medical and psychological support throughout the
pregnancy period (Hildingsson et ah, 2011).
A lack of knowledge was the final theme emerg
ing from fathers reporting a lack of engagement.
Although there is a plethora of online and hard copy
materials available for the expectant mother, less is
available for the expectant father. Given the lack of
research data on fathers, most data are highly sub
jective or anecdotal. Hospitals should consider de
veloping a pamphlet for expectant fathers to help
alleviate their gaps in knowledge.
This study is limited because it includes fa
thers from a single Australian metropolitan region.
Although there is a plethora of online and hard-copy materials
available for the expectant mother, less is available for the
expectant father.
However, the region selected was representative of
the wider Australian community in age, religion, and
country of birth, although fly-in, fly-out rates were
likely to be higher than those reported nationally.
In recent years, medical professionals and mid
wives have actively encouraged paternal birth at
tendance because of its associated improvement
in health outcomes and the positive psychologi
cal impact it has on the mother (Johansson et ah,
2012; Kennel et ah, 1991). However, this may not be
enough. The needs of fathers should be individually
assessed before labor. Furthermore, this evaluation
must consider the father’s unique role and individ
ual needs and not merely regard him as an extension
of the mother.
IMPLICATIONS FOR PRACTICE
Paternal engagement is improved by positive ante
natal experiences. Health-care providers should be
encouraged to involve expectant fathers in consulta
tions throughout the antenatal period. In particular,
concerns of expectant fathers should be addressed.
Improving paternal engagement throughout the an
tenatal period is likely to have effects on the family
by improving paternal bonding with the newborn
and support of the mother. Making antenatal care
available outside of routine office hours is impor
tant, not only for working mothers but also for
working fathers who may otherwise be excluded
from care episodes. Our research suggests many fa
thers feel unprepared and anxious about birth and
may benefit from greater antenatal engagement
in care.
ACKNOWLEDGMENTS
We acknowledge the support of the fathers who par
ticipated in the trial.
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TIMOTHY JEFFERY, KI-YUNG LUO, and BRANDON
KUEH are medical students who completed this research
as part of their undergraduate degree program. RODNEY
PETERSEN is the divisional director of Women’s and Babies’
Health at the Women’s and Children’s Hospital, Australia.
He is a former associate dean (Teaching and Learning).
JULIE QUINLIVAN is a former dean of health (Medicine
and Nursing), dean of medicine, and executive dean of med
icine. She has taught nursing, physiotherapy, and medical
students across Australia.
Australian Fathers’ Study I Jeffery et al. 187
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