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Fathers’ sensitive parenting enhanced by prenatal video-feedback: a randomized controlled trial using ultrasound imaging


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Background The aim of this study was to evaluate an interaction-based prenatal parenting intervention program aimed at promoting parental sensitivity and involvement in expectant fathers using ultrasound images: Prenatal Video-Feedback Intervention to Promote Positive Parenting (VIPP-PRE). Methods In this randomized controlled trial, 73 first-time, healthy expectant fathers were enrolled. Participants were randomly assigned to the VIPP-PRE intervention ( n = 39) or a dummy intervention ( n = 34). Parental sensitivity was coded from video-recorded 10-min interactions with an infant simulator at a prenatal pretest and with fathers’ own infant at a postnatal posttest. Prenatal and postnatal involvement was assessed via an application on participants’ smartphones. Results Fathers receiving VIPP-PRE demonstrated increased sensitivity across the perinatal period, relative to fathers receiving a dummy intervention. Fathers’ involvement with the infant increased significantly from the prenatal to postnatal period, regardless of the intervention. Conclusions Prenatal video-feedback using ultrasound imaging of the unborn child has the potential to promote the quality of parenting in an important, but understudied, population and period: men in the transition to fatherhood. Future research should examine the long-term effectiveness of VIPP-PRE and its effectiveness in increasing parenting quality in at-risk families. Impact This study identifies a brief and focused prenatal intervention using assisted interactions between the father and his baby by means of ultrasound imaging as a promising strategy to improve sensitive fathering in the early postnatal phase. Our study shows that pregnancy provides a window of opportunity for promoting prenatal involvement and bonding in expectant fathers, with potential long-term benefits for the future father–child relationship. Ultrasound measures are currently used to monitor fetal growth and development, but our results suggest that they may also create an opportunity for stimulating father–infant interaction to promote postnatal caregiving quality.
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Fatherssensitive parenting enhanced by prenatal video-
feedback: a randomized controlled trial using ultrasound
Renate S. M. Buisman
, Kim Alyouse-van Dijk
, Noor de Waal
, Ashwina R. Kesarlal
, Martine W. F. T. Verhees
Marinus H. van IJzendoorn
and Marian J. Bakermans-Kranenburg
© The Author(s) 2022
BACKGROUND: The aim of this study was to evaluate an interaction-based prenatal parenting intervention program aimed at
promoting parental sensitivity and involvement in expectant fathers using ultrasound images: Prenatal Video-Feedback
Intervention to Promote Positive Parenting (VIPP-PRE).
METHODS: In this randomized controlled trial, 73 rst-time, healthy expectant fathers were enrolled. Participants were randomly
assigned to the VIPP-PRE intervention (n=39) or a dummy intervention (n=34). Parental sensitivity was coded from video-
recorded 10-min interactions with an infant simulator at a prenatal pretest and with fathersown infant at a postnatal posttest.
Prenatal and postnatal involvement was assessed via an application on participantssmartphones.
RESULTS: Fathers receiving VIPP-PRE demonstrated increased sensitivity across the perinatal period, relative to fathers receiving a
dummy intervention. Fathersinvolvement with the infant increased signicantly from the prenatal to postnatal period, regardless
of the intervention.
CONCLUSIONS: Prenatal video-feedback using ultrasound imaging of the unborn child has the potential to promote the quality of
parenting in an important, but understudied, population and period: men in the transition to fatherhood. Future research should
examine the long-term effectiveness of VIPP-PRE and its effectiveness in increasing parenting quality in at-risk families.
Pediatric Research;
This study identies a brief and focused prenatal intervention using assisted interactions between the father and his baby by
means of ultrasound imaging as a promising strategy to improve sensitive fathering in the early postnatal phase.
Our study shows that pregnancy provides a window of opportunity for promoting prenatal involvement and bonding in
expectant fathers, with potential long-term benets for the future fatherchild relationship.
Ultrasound measures are currently used to monitor fetal growth and development, but our results suggest that they may also
create an opportunity for stimulating fatherinfant interaction to promote postnatal caregiving quality.
Fathers, like mothers, are pillars in their childrens social and
emotional development.
Although fathers in several western
countries have increased their participation in parenting over the
past decades, with a three- to six-fold increase over one
their roles range widely from primary-caregiver
fathers to absent fathers, and in most families, their parenting
role is still modest.
Also, research has repeatedly shown that
fathers are less sensitive to their infants and toddlers than
Thus, fathersinvolvement (representing the quantity
of caregiving) and their parental sensitivity in the interaction with
their children (representing the qualityof caregiving) may
benet from intervention efforts specically targeted at fathers.
With the aim of supporting paternal involvement and sensitive
caregiving from the earliest start of parenthood, we adapted the
Video-Feedback Intervention to Promote Positive Parenting
) for prenatal use (VIPP-PRE
) with fathers and tested its
efcacy in a preregistered randomized controlled trial (https://
Paternal sensitivity and engagement contribute substantially
and independently from maternal sensitivity to childrens
cognitive and socio-emotional development.
Received: 16 July 2021 Revised: 1 March 2022 Accepted: 6 March 2022
Clinical Child & Family Studies, Faculty of Behavioral and Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands.
Forensic Family and Youth Care Studies, Institute
of Education and Child studies, Leiden University, Leiden, The Netherlands.
Anna Freud National Centre for Children and Families, London, UK.
Department of Psychology,
Education and Child Studies, Erasmus University, Rotterdam, The Netherlands.
Research Department of Clinical, Education and Health Psychology, Faculty of Brain Sciences, UCL,
London, UK.
Leiden Institute for Brain and Cognition, Leiden University, Leiden, The Netherlands.
Center for Attachment Research, The New School for Social Research, New
York, USA. email:
fatherssensitivity has been found to predict brain development
both in the rst year
and in middle childhood.
Thus, enhancing
paternal sensitivity and involvement may benet a broad range of
child developmental outcomes.
Pregnancy provides a window of opportunity for promoting
prenatal involvement and bonding in expectant fathers, with
potential long-term benets for the future fatherchild relation-
and child developmental outcomes. Indeed, prenatal father
involvement predicts postnatal father involvement
infantfather attachment.
However, fathers are rarely involved
in prenatal parenting interventions, and we know of only two
parenting interventions that include fathers in the prenatal
Both are group interventions with educational sessions,
aiming to increase paternal involvement in their childrens lives,
but without opportunities for prenatal personal fatherbaby
contact. Among parenting interventions, those using personalized
video-feedback have been meta-analytically shown to be most
effective in promoting parenting sensitivity.
One of these
programs, with documented effects on parental sensitivity (VIPP-
SD, combined effect size based on twelve RCTs d=0.47
) has
shown its feasibility with fathers of toddlers.
The switch to
prenatal video-feedback, using ultrasound imaging of the child to
facilitate parent-infant interaction is, to our knowledge, unique.
Ultrasound imaging may help expectant fathers to develop an
emotional bond with the unborn baby.
This method of
recording real-life interactions, providing protocolized but perso-
nalized feedback to make the parent aware of the dyadic nature of
the interaction, and stimulating sensitive responses to the childs
behavior, has not yet been used to promote the fathers postnatal
caregiving behavior. We hypothesized that fathers in the
intervention arm, relative to fathers in the control arm, would
show (1) a stronger increase in sensitivity from pretest to posttest,
and (2) a stronger increase in involvement in caretaking activities
from the prenatal to the early postnatal phase.
A total of 73 rst-time expectant fathers participated in this study. The
average years of education following primary school was 8.80 (SD =1.44).
Enrollment Assessed for eligibility (n = 117)
Excluded (n = 44)
Not meeting inclusion criteria (n = 31)
Declined to participate (n = 0)
Scheduling difficulties (n = 8)
Fathers know too much about
intervention design (n = 1)
Undocumented reasons (n = 4)
Randomized (n = 73)
Allocated to VIPP-PRE intervention (n = 39)
Received allocated intervention (n = 38)
Did not receive allocated intervention
because of discontinuation due to
pregnancy complications (n = 1)
Lost to posttest due to paternal mental health
complications (n = 1) and non-response (n = 1)
Discontinued intervention (n = 0)
Analyzed for parental sensitivity (n = 39)
Excluded from analysis (n = 0)
Analyzed for involvement (n = 39)
Excluded from analysis (n = 0)
Allocated to dummy intervention (n = 34)
Received allocated intervention (n = 34)
Did not receive allocated intervention (n = 0)
Lost to posttest (n = 0)
Discontinued intervention (n = 0)
Analyzed for parental sensitivity (n = 34)
Excluded from analysis (n = 0)
Analyzed for involvement (n = 34)
Excluded from analysis (n = 0)
Fig. 1 Inclusion. CONSORT ow diagram of enrollment, intervention allocation, postnatal posttest, and data analysis.
R.S.M. Buisman et al.
Pediatric Research
Participantsage ranged from 26 to 41 years (M=32.62, SD =3.26). At the
time of inclusion, their partners were 1831 weeks pregnant. At that time,
we could conrm that their medical ultrasound showed no abnormalities
(routinely done around 20 weeks), additionally, it would allow us the time
needed to nalize pre-intervention and post-intervention measurements
as well as the intervention before the baby was born. At pretest, the
gestational age of their unborn infants, therefore, ranged from 20 to
32 weeks (M=24.95, SD =2.82). Partners of expectant fathers were low-
risk women with uncomplicated singleton pregnancies, conrmed by a
standard 20-week medical ultrasound. Participants received a travel
allowance and a nancial reward for their participation.
Recruitment took place via midwife agencies and other pregnancy-
afliated organizations. Eligible families received an invitation to partici-
pate with information about the study. Interested fathers received a letter
and a phone call with more detailed information. Participants were
included if they were (a) rst-time expectant fathers, (b) sufciently uent
in Dutch, (c) lived with their partner who had an uncomplicated pregnancy
of a singleton and was between 18 and 31 weeks pregnant at the time of
inclusion. Because of other measures that were part of this study fathers
were excluded if they (a) had an endocrine or cardiovascular disease, (b)
currently abused drugs or alcohol, (c) used medication potentially
interfering with the endocrine system of neural activity, (d) had birth
defects in the families of either parent, or (e) had partners using alcohol,
tobacco, or illicit drugs during the pregnancy or with a BMI over 30 before
pregnancy. The study procedure was registered at the Central Committee
on Research Involving Human Subjects (CCMO, registry number
NL62696.058.17) and approved by the Ethics Committees of the Leiden
University Medical Centre and the Department of Education and Child
Studies before data collection. It was also registered at the ISRCTN (registry
number 11267699) after data collection. All participants gave informed
consent. Data collection took place from May 2018 to January 2020.
Study design
Figure 1depicts a ow diagram of enrollment, intervention allocation,
follow-up, and data analysis. The RCT included an experimental group
(n=39) and a control group (n=34), to which participants were randomly
assigned. Randomization was performed by one of the researchers before
the start of the study using a computer-generated randomization
sequence. Participants were enrolled by the second and third authors of
this manuscript. The pretest and posttest visits were separate from the
intervention sessions. At the end of the pretest visit, an envelope with the
group assignment was opened and the participants were informed of their
assignment. Attrition was absent in the control group and small in the
experimental group (n=2; we lost one participant after randomization
due to pregnancy complications, and one after the intervention sessions
due to mental health problems). Postnatal data on paternal sensitivity was
missing for one participant in the experimental group. Postnatal data on
paternal involvement was missing for seven participants in the experi-
mental group and for three participants in the control group. Recruitment
was stopped when we approached the end of the funding period. As
recruitment was slower than expected (we used an opt-in model as
requested by our ethics board, and the assessments, including neural
imaging, required substantial time and dedication from participants), this
resulted in a sample smaller than originally intended (N=73 vs. the
planned N=140), and in somewhat unequal numbers in experimental and
control groups. Using the software program G*Power, we computed what
effects we could detect as signicant with our sample. Power value was set
at 0.80, alpha at 0.05, and correlation between pre- and posttest measures
at 0.5, resulting in detectable effect sizes of Cohensf=0.166 which
corresponds to a Cohensdof 0.33. Pretest measures were administered at
the gestational age of 2032 weeks, followed by the intervention that
usually started 12 weeks later. The posttest was administered approxi-
mately 9 weeks postnatally.
Randomization was not blind for participants or interveners, but the two
arms of the study were presented to participants in similar ways, namely as
an intervention focusing on interaction with their infants (VIPP-PRE), and
an intervention discussing the pregnancy and the development of their
unborn infants (phone calls). Researchers coding pre- and posttest data
were blind to group membership.
VIPP-PRE. In VIPP-PRE, fathers are invited to interact with the fetus both
verbally and by touching and softly massaging the infant through the
mothers abdominal wall in three sessions. The fetus is made visible through
ultrasound. While recording, the intervener provides live feedback by using
speaking for the babytechniques, and the father is stimulated to readhis
babys signals and behave accordingly. For example, the intervener may
note: she is quite active; she may hear your voice and she is at an age that
she recognizes itor Look what happens now that you sung for him, he
relaxes and sucks his thumb. In addition, during the second and third
sessions, after the live ultrasounds, the intervener presents the recordings of
the previous session, pausing at relevant moments, and using a prepared
script to comment on these fragments, following the themes of attachment
and exploration (e.g., the difference between active, explorative behavior
and a calm, resting posture as infant signals asking for different parental
responses), speaking for the baby, and sensitivity chains.
The rst two
sessions focus on building a working relationship and emphasize positive
fatherinfant interactions. The third session also uses corrective messages
to actively improve parenting behavior (i.e., discussing insensitive behavior
and suggesting a more sensitive alternative).
During each ultrasound recording part of the session, the rst minutes
were shared with both parents, to accommodate motherswishes to see
their baby as well. However, the mothers were asked to stay aloof and read
a magazine as soon as the interactions between the father and his unborn
child started, and mothers were not present during the video-feedback part
of the session. Upon request of the ethics committee, all sessions took place
in a prenatal health clinic with an eye to incidental ndings. The
full intervention protocol is reported elsewhere.
In the intervention group,
one father missed two sessions; all other intervention fathers received three
sessions. Twenty percent of the intervention scripts were reviewed in
supervision sessions to ensure treatment delity.
Control condition. Fathers in the control group received phone calls from
a researcher during the same period and with the same frequency as
fathers receiving VIPP-PRE. Fathers were asked about the development of
the pregnancy, any pregnancy-related activities or appointments, their
preparations for birth and fatherhood, and communication about the
pregnancy or the baby in their social network. In both groups, information
on the current fetal developmental stage was provided during each
session. In the control group, one father missed one session; all other
control fathers received three sessions.
Parental sensitivity. Parental sensitivity was assessed based on video-
recorded observations both prenatally and postnatally. Prenatally, the
infant simulator (RealCare Baby II-Plus; Realityworks, Eau Claire, WI) was
used; a life-like doll resembling a young infant in appearance, size, and
weight. Use of the infant stimulator has previously been shown to provide
a reliable and valid way of assessing parental sensitivity
and is also
suitable for populations without children of their own. In a room with a PC
with internet access as a competing activity and to increase the ecological
validity of the situation (because in the home environment passive
distractors are almost always present), participants were instructed to take
care of the doll as if it were their own child, including careful handling such
as offering neck support. They were told that the doll could cry just like a
real infant. They could use various objects to soothe the child (i.e.,
a blanket, toys, bottle, diaper, and the second set of clothes), and could use
the PC if they wanted to check their e-mail or do something else online.
The simulator was programmed to be quiet for approximately 3 min, then
cry for approximately 5 min, followed by being quiet for approximately
2 min. A similar protocol has been previously used.
The cry sounds
consisted of pre-set recordings of a real infant and increased in intensity
during the 5-min cry episode. Unbeknownst to the participants, they were
not able to effectively soothe the infant. During the postnatal posttest
assessment, fatherinfant interactions were observed at home during a 10-
min play session. Participants were instructed to engage in their usual
routines of play, the rst 5 min without play material and the last 5 min
with play material. All videotaped fatherdoll and fatherinfant interac-
tions were coded by independent coders using the Ainsworth Sensitivity
with scores ranging from 1 (insensitive) to 9 (sensitive). Five coders
were trained to code the fatherdoll interactions, and reliability with expert
coders was adequate 0.690.79 (ICC, single measures, absolute agree-
Five different coders were trained to code the infantfather
interactions (ICC =0.680.76).
R.S.M. Buisman et al.
Pediatric Research
Involvement. Paternal involvement was prospectively assessed via an
application on participantssmartphones in the week after the pre- and
post-tests. During this week, participants received six notications per day
to complete questions on their smartphones (at random times between 9
and 10 am, 11 and 12 am, 1 and 2 pm, 3 and 4 pm, 7 and 8 pm, and 9 and
10 pm). First, participants were asked whether they had thought about,
spoken about, or communicated with their infant to measure cognitive/
affective involvement.
Second, accessibility (i.e., being present and
available) was assessed by asking participants whether they were in the
proximity of their partner (prenatal) or infant (postnatal) andin case of
postnatal assessmentsif the infant was awake. When in the proximity,
engagement (i.e., interacting with the infant) was measured by asking
participants whether they had interacted (e.g., changed the infants diaper,
felt the unborn infant kicking) or communicated with their (unborn) infant.
All responses were coded 0 =no, 1 =yes. In accordance with previous
studies using a smartphone application for behavioral assessments,
scores on cognitive/affective involvement and on accessibility were
averaged for each participant over the 1-week period by dividing the
sum of scores by the total number of responses. In addition, for each
participant, a score for engagement relative to access to the infant or
mother was calculated by dividing the sum of engagement across the one-
week period by the sum of accessibility or (for postnatal assessments) the
sum of times when the infant was awake across the 1-week period.
Cognitive/affective involvement and engagement were correlated on
pretest (r=0.36, p=0.003) and posttest (r=0.33, p=0.011). Since
accessibility did not correlate with engagement at pre- and posttest
(r< 0.05) and was correlated with cognitive/affective involvement only at
posttest (r=0.63, p< 0.001), cognitive/affective involvement and engage-
ment were averaged into one component indicating involvement. Scores
ranged from 0 to 1 with higher scores indicating more paternal
Covariates. Participants reported on the following demographic and
health-related variables: age, average years of education following primary
education, current depressive symptomatology, age of mother, infant
gestational age at pretest, infant age at the posttest, infant sex, infant
health, and pregnancy and birth complications.
Data analysis
Preliminary analyses. Data inspection revealed that the continuous
variables were normally distributed with no outlying values. Three percent
(range: 011%) of the data was missing. Littles MCAR test
showed that
values were missing completely at random (χ
(24) =34.60, p=0.075). To
follow an intent-to-treat approach, missing values were imputed by means
of multiple imputation using the package mice
in R.
Betas were
computed as estimates of effect sizes for continuous outcome variables.
Main analyses. In line with the preregistration, two-level linear mixed
effect models accounting for repeated measures of sensitivity and
involvement over time (level 1) in individuals (level 2) were incrementally
compared using the likelihood ratio test for imputed datasets with the
The nal model included the xed effects of time
(coded as 0 =pretest, 1 =posttest), the main effect for condition (coded
as 0 =Control, 1 =VIPP-PRE), and the interaction between time and
condition. The signicance of model and parameter estimates was
determined at α=0.05. In sensitivity analyses, models were tested in the
non-imputed dataset and involvement analyses were repeated in
participants with >33% valid responses on the posttest of the smartphone
application. In addition, analyses on parental sensitivity were repeated
including pretest scores on sensitivity as a covariate.
Figure 1presents the number of participants at each time point.
Characteristics of participants are summarized in Table 1. The
intervention and control groups did not differ on potential
covariates or pretest measures. Correlations between study
variables are presented in Supplementary Table S1.
The unconditional means model (Model 1) revealed that the
proportion of explained variance (ICC) was 0.06 at the individual
level. Adding the main effects of time and condition to the
unconditional means model did not improve model t (see
Table 2). Adding the xed effect of the interaction between time
and condition signicantly improved model t, and the interaction
effect was signicant (β=0.28, SE =0.54, p=0.043). A plot of this
interaction effect (Fig. 2) revealed a decline in sensitivity in the
control group (slope β=0.16), and an increase in sensitivity in
the intervention group (slope β=0.16).
The unconditional means model (Model 1) revealed that the
proportion of explained variance (ICC) was 0.00 at the individual
level. Adding the xed effects of time and condition signicantly
improved model t (see Table 3). Time (β=0.77, SE =0.03,
p< 0.001), but not condition (β=0.07, SE =0.03, p=0.230), was
signicantly positively associated with involvement, meaning that
fathersinvolvement increased over time regardless of their group
status. Adding the interaction effect of time and condition did not
improve model t and the interaction was not signicant
(β=0.05, SE =0.05, p=0.572).
Sensitivity analyses
Analyses in the non-imputed dataset yielded similar outcomes as
analyses on the multiply imputed datasets (see Supplementary
Tables S2 and S3): the interaction of time × condition was
signicant for sensitivity (p=0.033) and for involvement, only the
main effect of time was signicant (p< 0.001). Results of the mixed
models on involvement in the sample with >33% valid answers on
Table 1. Participant characteristics.
Measure VIPP-PRE Control t/χ
Mean (SD)
n=39 n=34
Age father 32.57 (2.87) 32.66 (3.71) 0.12
Education father 8.56 (1.48) 9.06 (1.37) 1.47
Race father (%
93 97 0.79
Age mother 30.05 (3.33) 30.95 (3.64) 1.11
Gestational age infant
at pretest (weeks)
24.91 (2.78) 25.00 (2.89) 0.13
Age infant at posttest
11.07 (4.77) 9.72 (2.41) 1.50
Infant sex (% boys) 38 38 0.00
Health-related variables
complications (% yes)
35 56 2.91
Birth complications
(% yes)
41 47 0.24
Infant health 0.11 (0.70) 0.08 (0.79) 1.02
symptoms father
5.03 (3.41) 5.12 (3.13) 0.12
Outcome variables at pretest
Sensitivity 5.34 (1.78) 6.11 (1.80) 1.83
Involvement 0.42 (0.17) 0.40 (0.15) 0.42
Outcome variables at posttest
Sensitivity 5.94 (1.56) 5.56 (1.57) 1.03
Involvement 0.81 (0.12) 0.76 (0.18) 1.42
Descriptives are calculated on the non-imputed data.
Unless indicated otherwise.
tests and t-test were performed to test whether there were pretest
group differences between fathers in the VIPP-PRE and control conditions.
No signicant group differences were found.
R.S.M. Buisman et al.
Pediatric Research
the posttest (n=45) conrmed results in the total group, i.e.,
involvement increased from the prenatal to the postnatal phase
(ps < 0.001). Finally, analysis of parental sensitivity including
pretest scores on sensitivity as a covariate yielded similar
outcomes: the interaction between condition and time remained
signicant (β=0.28, p=0.02).
This preregistered RCT ( of the rst trial
of VIPP-PRE demonstrated promising efcacy in improving
sensitive fathering in the early postnatal phase. As hypothesized,
fathers receiving the prenatal VIPP-PRE intervention showed a
signicant enhancement of their sensitive parenting across the
perinatal period, relative to fathers receiving a dummy interven-
tion with phone calls. Fathersinvolvement with their infants
increased signicantly from the prenatal to postnatal period,
regardless of the intervention.
The positive effect of assisted interactions with the unborn child
on fatherssensitive parenting aligns with considering the
perinatal period as an important window of opportunity for
intervening, with potential long-term positive effects for future
fatherchild interactions.
The transition to parenthood is often
experienced as stressful for both mothers and fathers.
compared to mothers, fathers may be neurobiologically and
behaviorally less prepared for the birth of their child
their transition even more challenging. This may negatively affect
their wellbeing and capacity to provide appropriate care for their
Yet, so far, only two other prenatal interventions that
focus on parentchild interactions have included fathers.
line with our results, both interventions demonstrated a positive
effect on fatherchild interaction quality. However, these inter-
ventions were either broad, impeding knowledge of effective
or included many sessions.
In contrast, the VIPP-
PRE is a brief and focused intervention program promoting
sensitive interaction between the father and his baby by using
each specic dyad as its own model. Elsewhere we have
developed a model of what we think are the active ingredients
of the VIPP,
which we further tested in a meta-analysis of the
rst 25 randomized controlled trials on the effects of the VIPP.
For VIPP-PRE in particular, the opportunity to see their infant and
see the infant responding to what happens seems to have an
impact on the fathers. One father noted: Seeing the baby and her
reaction to my voice was specialand another father said: I like
having a moment to admire my son. To see that he responds to
my presence and to follow his development better. These are
precious moments to me. Moreover, the intervenerscomments
helped them to realize that the infant has a mind of their own and
a behavioral status that makes them ready or not ready for
interaction. Thus, over the sessions, interveners noted that fathers
more carefully observed their baby on the ultrasound images
before starting the interaction or verbalized their babys
Our ndings suggest that VIPP-PRE is a promising
candidate for boosting the development of adequate parental
care behaviors in the postnatal period when infants are highly
receptive to the effects of caregiving quality.
Whether such
intervention effects remain observable over time is a question that
has been meta-analytically answered in the afrmative for other
versions of the VIPP program,
but is an outstanding question for
Our results indicate that involvement increased from the
prenatal to the postnatal period, regardless of the intervention,
in line with previous ndings that fathers feel more responsible for
their infants after birth.
The physical presence of the infant and a
growing bond may explain fathersincrease in activities with their
child. In our low-risk sample, these factors may be sufcient to
elicit parental involvement. Moreover, the VIPP-PRE intervention
focused less on enhancing paternal involvement than on paternal
sensitivity to their infants signals and responding to these signals
in prompt and adequate ways. The control condition may also
have promoted involvement with the baby.
Our results should be cautiously interpreted as promising, given
the limited power (see of the modest sample
size and the relatively homogeneous group of well-educated,
Fig. 2 Paternal sensitivity before the birth (pretest) of their infant
and after the birth of their infant (posttest). Data of complete
cases are plotted. VIPP-PRE: Video-Feedback Intervention to
Promote Positive Parenting Prenatal. Control: Dummy program
consisting of telephone calls. The shadows surrounding the lines
represent 95% condent interval levels.
Table 2. Parameter estimates of the linear mixed model on sensitivity.
Model 1 Model 2 Model 3
Fixed effects Coef (se) Coef (se) Coef (se)
Intercept 5.71 (0.15)** 5.82 (0.25)** 6.11 (0.29)**
Time 0.03 (0.28) 0.55 (0.39)
Condition 0.23 (0.29) 0.77 (0.39)*
Time × Condition 1.09 (0.54)*
Variance components (ICs)
Individual level 0.16 0.15 0.22
Residual 2.71 2.71 2.56
Change in model t(F) 0.33 3.96*
Unstandardized regression coefcients are displayed. Time: 0 =pretest, 1 =posttest; Condition: 0 =Control, 1 =VIPP-PRE.
*p< 0.05; **p< 0.01.
R.S.M. Buisman et al.
Pediatric Research
motivated participants. It is tempting to suggest that results may
be stronger rather than weaker in fathers who show initially low
engagement with their partners pregnancy, but this hypothesis
needs empirical evidence. Moreover, the effects of the interven-
tion might be mediated through mothers or the relationship
quality, which we did not examine in the current paper. The VIPP-
PRE program may have helped to improve the partner and co-
parenting relationship by providing the shared experience of extra
ultrasounds, whereas in the control group only fathers and not
mothers were involved in the phone calls. This may have led to
differences between the two groups. However, the video-
feedback was done without the mothers being present.
Furthermore, pretest and posttest measures of sensitivity differed
in that an infant doll was used at the pretest. Previous work has
however shown adequate associations (r=0.53) between parent-
ing behavior with the doll and ones own child.
correlations are equal to, or stronger than, stability of sensitivity
in longitudinal studies starting after birth, strongly suggesting that
we measured the same construct at different points in time. Lastly,
the study design did not include a condition with ultrasounds
without video-feedback, so the effects of VIPP-PRE cannot be
distinguished from the effects of providing extra ultrasounds per se.
Nevertheless, the effect size of VIPP-PRE (d=0.49) is in line with the
meta-analytic effect size on parental sensitivity of other VIPP trials
(d=0.47, 95% CI 0.34, 0.59, PI 0.24, 0.72).
While the meta-analytic
VIPP effects remained of similar strength over time,
research should examine whether this holds for VIPP-PRE as well.
In virtually all western countries, ultrasounds are part of the
standard care during pregnancy. Ultrasound measures are
currently used to monitor fetal growth and development but
may also create an opportunity for stimulating fatherinfant
interaction with feedback to promote postnatal caregiving quality.
Of course, the current ndings should be replicated in larger
pragmatic randomized trials. A special focus may be on fathers
who are difcult to reach and who might receive home visits with
ultrasound imaging using the portable equipment that we used in
the current study. The feasibility and acceptability of VIPP-PRE
together with its efcacy as shown in the current preregistered
RCT, suggest that prenatal video-feedback using ultrasound
imaging of the child holds the potential to enhance the quality
of parenting in an important but understudied group of parents,
namely fathers, in a period that is critical in their lives and may
have a lasting impact: the transition to fatherhood.
The datasets generated during and/or analyzed during the current study are not
publicly available to prevent compromising individual privacy but are available from
the corresponding author on reasonable request.
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Table 3. Parameter estimates of the linear mixed model on involvement.
Model 1 Model 2 Model 3
Fixed effects Coef (se) Coef (se) Coef (se)
Intercept 0.60 (0.02)** 0.40 (0.02)** 0.41(0.03)**
Time 0.37 (0.03)** 0.35 (0.04)**
Condition 0.03 (0.03) 0.02 (0.04)
Time × Condition 0.03 (0.05)
Variance components (ICs)
Individual level 0.00 0.00 0.00
Residual 0.06 0.02 0.02
Change in model t(F) 59.75** 0.34
Unstandardized regression coefcients are displayed. Time: 0 =pretest, 1 =posttest; Condition: 0 =Control, 1 =VIPP-PRE.
**p< 0.01.
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The authors thank Prof. Femmie Juffer for her contributions to the VIPP-PRE protocol,
and Verloskundig Centrum De Poort in Leiden, the Netherlands, for offering their
services for the prenatal ultrasounds. Also, we thank Lieuwke Zwerver, MSc, for
contributing to the study as a VIPP-PRE intervener alongside K.A.-v.D. and N.d.W.
Conceptualization: M.J.B.-K. and M.H.v.I.J.; methodology: R.S.M.B., M.H.v.I.J., and M.J.B.-
K.; formal analysis: R.S.M.B. and M.J.B.-K.; data collection: K.A.-v.D., N.d.W., A.R.K.; data
curation: R.S.M.B., K.A.-v.D., N.d.W., and M.W.F.T.V.; writingoriginal draft: R.S.M.B. and
M.J.B.-K.; writingreview and editing: R.S.M.B., M.J.B.-K., K.A.-v.D., N.d.W., M.W.F.T.V.,
M.H.v.I.J., and A.R.K.; visualization: R.S.M.B. and K.A.-v.D.; supervision: M.J.B.-K.; project
administration: K.A.-v.D. and M.J.B.-K.; resources: K.A.-v.D.; funding acquisition: M.J.B.-
K. and M.H.v.I.J. All authors approved the nal manuscript as submitted, and agree to
be accountable for all aspects of the work.
The study was supported by the European Research Council (M.J.B.-K.; ERC AdG
669249) and by the Netherlands Organization for Scientic Research (M.H.v.I.J.;
SPINOZA prize).
The authors declare no competing interests.
Supplementary information The online version contains supplementary material
available at
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Full-text available
Although parenting interventions including expectant fathers are scarce, they yield promising results. The Prenatal Video‐feedback Intervention to promote Positive Parenting (VIPP‐PRE) is a recently developed intervention, that is both manualized and personalized, aiming to enhance paternal sensitivity and involvement before the birth of the baby. Illustrating the intervention process, the current study presents two case studies of expectant fathers receiving VIPP‐PRE (clinical trial registration NL62696.058.17). The VIPP‐PRE program is described along with the individual dyads’ prenatal video fragments and feedback specific for each father‐fetus dyad. In addition, changes in paternal sensitivity and involvement levels are presented, as well as fathers’ and intervener's evaluation of the intervention. VIPP‐PRE promises to be a feasible short‐term and potentially effective parenting intervention for expectant fathers. Currently, a randomized controlled trial (RCT) is under review that systematically investigates the efficacy of the VIPP‐PRE. Here we aim to provide further information on the intervention process, as well as fathers’ and intervener's evaluations of this process, and the benefits of using ultrasound imaging in a parenting intervention.
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Improving parenting, child attachment, and externalizing behaviors: Meta-analysis of the first 25 randomized controlled trials on the effects of Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD). VIPP-SD combines support of parental sensitive responsiveness with coaching parents in sensitive limit setting. Here, we present meta-analyses of 25 RCTs conducted with more than 2,000 parents and caregivers. Parents or children had various risks. We examined its effectiveness in promoting parental cognitions and behavior regarding sensitive parenting and limit setting, in promoting secure child–parent attachment, and reducing externalizing child behavior. Web of Science, MEDLINE, PubMed, and recent reviews were searched for relevant trials (until May 10, 2021). Multilevel meta-analysis with META, METAFOR, and DMETAR in R took account of the 3-level structure of the datasets (studies, participants, measures). The meta-analyses showed substantial combined effect sizes for parenting behavior ( r = .18) and attitudes ( r = .16), and for child attachment security ( r = .23), but not for child externalizing behavior ( r = .07). In the subset of studies examining effects on both parenting and attachment, the association between effect sizes for parenting and for attachment amounted to r = .48. We consider the way in which VIPP-SD uses video-feedback an active intervention component. Whether VIPP-SD indeed stimulates secure attachment through enhanced positive parenting remains an outstanding question for further experimental study and individual participant data meta-analysis.
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Objective: the transition period in which men become fathers might provide an important window of opportunity for parenting interventions that may produce long-term positive effects on paternal care and, consequently, child development. Existing prenatal programs traditionally focus on maternal and infant health and seldom involve the father. Study design: This paper describes an interaction-based prenatal parenting intervention program for first-time fathers using ultrasound images, the Prenatal video Feedback Intervention to promote Positive Parenting (VIPP-PRE). We randomised a group of expectant fathers (N = 73) to either the VIPP-PRE or a control condition. Results: Expectant fathers thought the VIPP-PRE was more helpful and influenced their insights into their babies to a greater extent than the control condition. Expectant fathers receiving the VIPP-PRE reported that they particularly liked seeing and interacting with their unborn children as well as receiving feedback on these interactions. The intervention was well received and was considered feasible by both expectant fathers and sonographers and midwives. Discussion: We discuss the VIPP-PRE based on the experiences and perspectives of fathers, interveners, and sonographers and midwives.
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This longitudinal study examined whether prenatal family alliance and prenatal paternal testosterone levels predicted infant–mother and infant–father attachment security and whether this association was mediated by postnatal family alliance and postnatal paternal testosterone levels. In 105 couples expecting their first child, family alliance was assessed in the third trimester of pregnancy with the prenatal version of the Lausanne Trilogue Play (LTP). Family alliance was measured again 6 months postnatally, using the LTP. Fathers provided testosterone samples prenatally and at 6 months postnatally. Infant– parent attachment was assessed with the Attachment Q-Sort (AQS) at 24 months. Results indicated an increase in paternal testosterone levels from the pre- to the postnatal period. A more positive prenatal family alliance predicted higher infant–father attachment security at 24 months, but not infant–mother attachment security. The association between prenatal family alliance and attachment security was not mediated by postnatal family alliance or postnatal paternal testosterone levels. This study highlights the significance of prenatal family relations, and the need to consider in research and practice the divergent effects of prenatal family alliance patterns on the emerging infant–mother and infant–father attachment relationships. The underlying hormonal mechanisms during the transition to fatherhood are important targets for future research.
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As a result of societal changes, fathers participate more actively in child care than they used to. In this article, we propose a context‐dependent biobehavioral model of emergent fatherhood in which sociocultural, behavioral, hormonal, and neural factors develop and interact during the first 1,000 days of fatherhood. Sociocultural factors, including different expectations of fathers and varying opportunities for paternal caregiving through paid paternal leave, influence paternal involvement. Levels of hormones (e.g., testosterone, vasopressin, oxytocin, cortisol) predict fathers’ parenting behaviors, and involvement in caregiving in turn affects their hormones and brain responses to infant stimuli. The birth of the first child marks the transition to fatherhood and may be a critical period in men’s lives, with a smoother transition to fatherhood predicting more optimal involvement by fathers in subsequent years. A focus on prenatal and early postnatal fathering may pave the way for developing interventions that effectively support fathering during pregnancy and in the first years of their children’s lives.
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Aims To explore factors influencing paternal involvement at six months postpartum and to detail the trend of these factors over a period of six months. Background There is a dearth of studies on paternal involvement during infancy in the unique Asian context. Design A prospective four‐timepoint longitudinal design was adopted. Methods A total of 201 participants were recruited from a local hospital from May 2016 ‐ December 2017 using convenience sampling. Self‐administered questionnaires were used for data collection. Data were statistically analyzed. Results Parenting self‐efficacy at six‐month postpartum, paternal involvement and paternal postnatal depression on the day of wife's hospital discharge, wife in paid work and wife's antenatal class attendance significantly influenced paternal involvement at six months postpartum. A sub‐analysis of first‐time and experienced fathers revealed that parenting self‐efficacy at six‐month postpartum, paternal involvement on the day of wife's hospital discharge and wife in paid work were significant factors influencing paternal involvement for first‐time fathers. Significant factors influencing paternal involvement for experienced fathers were paternal involvement on the day of wife's hospital discharge and wife's antenatal class attendance. Conclusion Fathers (first‐time and experienced) who were involved during their infant's birth were also involved at six‐month postpartum. Healthcare professionals may encourage paternal involvement through teaching fathers infant care skills during the antenatal period, especially first‐time fathers as they may be lacking in such skills, which may hinder their parenting satisfaction. Paternal involvement throughout the perinatal period can be enforced by healthcare professionals to promote paternal involvement. This article is protected by copyright. All rights reserved.
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