Abbreviations

WHO RCM CINAHL

World Health Organisation Royal College of Midwives Cumulative Index to Nursing and Allied Health Literature

MIDIRS BPS HWG

Midwives Information and Resource Service Birth Participation Scale Healthy Women in Georgia

INTRODUCTION: Traditionally, a womans preparation for birth would have involved the female members of her society; she would be supported through pregnancy, birth and the postpartum period by her mother, sisters and other women of the community. However, in the 60s, the natural childbirth movement started to demand that fathers be allowed attend the birth of their babies (Dellman 2004). In the Western world today, there is an expectation that men should not only be present for the birth of their baby but also be able to support their partner (Ip 2000; Vehvilainen-Julkunen and Liukkonen 1998). There is increasing pressure on the father to attend the birth, with many feeling ill-equipped and unprepared to meet this role (Chandler and Field 1997; Hollins-Martin 2008; Johnson 2002a; Li et al 2009; Wockel et al 2007). Many report feeling anxious and stressed and unable to meet expectations (Bergstrom et al 2009; Johnson 2002b). The topic of the fathers role in childbirth is one which has recently attracted interest, with many studies being carried out in the last 3-4 years (Backstrom and Hertfelt Wahn 2009; Bergstrom et al 2009; Friedewald 2008; Hollins Martin 2008; Pestvenidze and Bohrer 2007; Svensson et al 2008; Wockel et al 2007). However whilst there is now current literature available surrounding this topic, there is little information in relation to the UK (Greenhalgh et al 2000; Hollins Martin 2008; Johnson 2002a) and none in relation to Ireland. While in the last 30/40 years the expectations of men are rising, little is being done to address how best to ensure that they are prepared for this role. This literature review will first examine the area of the support person in childbirth, focusing on the fathers role. Fathers fears, anxieties and stresses and how they impact on the birth experience will then be investigated in depth. Thirdly, the review will explore fathers preparation for labour, looking at the effects that antenatal education may have on their expectations. These themes reflect the pertinent issues surrounding fathers in relation to their role in childbirth as reflected in the literature (Bergstrom et al 2007; Fletcher et al 2007; Gungor and Beji 2007; Johnson 2002; Kainz et al 2010; Premberg and Lundgren 2006; Svensson et al 2008; Wockel et al 2007).

The first area to be explored in the literature review will be the role of the support person in labour (Campbell et al 2006; Hodnett et al 2002; Sauls 2002; Somers-Smith 1999). The potential benefits/drawbacks of having support in labour will be investigated, focusing in particular on the role of the father (Backstrom and Hertfelt Wahn 2009; Gungor and Beji
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2007; Ip 2000; Kainz et al 2010; Pestvenidze and Bohrer 2007; Wielgos et al 2006). It is essential to ascertain the value of labour support in order to comprehend why understanding fathers anticipations and thus adapting subsequent antenatal preparation is critical to their fulfilment of this role.

THE SUPPORT PERSON IN LABOUR:

Support in labour can come from many sources, including midwives, partners, family and friends. While some couples employ a doula, an independent trained birth partner, more often than not it is fathers who undertake this role. To gain an insight into the effects of support in labour, prior to examining the role of the father, two generalised studies will be reviewed in depth.

The first randomised controlled trials on continuous support in labour were conducted in Guatemala (Sosa et al 1980; Klaus et al 1986) and concluded that women with a birth companion had shorter labours and fewer perinatal complications (Sauls 2002). However because of the lack of generalizability to Western women where attitudes and practices would be quite different, subsequent research was completed by Kennell et al (1991) to see if these results could be replicated in a more modern setting. This seminal American study consisted of a randomised controlled trial, which according to Parahoo (2006) is the gold standard of research design when looking at the effects of interventions, and included an excellent sample size of 412 women. Both these particulars strengthen the findings of this study. The women were randomly assigned to a supported group (n=212), or an observed group (n=200). A control group (n=204) was later added to address the potential supportive effects of the observers on women in the observed group, thus adding further validity to the study. Women in the supported group had reductions in caesarean births, epidural analgesia, oxytocin and length of labour. However, a positive effect on outcomes was also noted in the observed group, thus leading to the hypothesis that the very presence of the doula or observer could have had an impact on the care given by the hospital staff, a possible limitation of the study. Whilst identifying a need for further research, the study demonstrated that the effects of continuous support on labour outcomes are impressive and should not be discounted when assessing the care of a labouring woman.

In 2006, a further randomised controlled trial of 600 nulliparous women by Campbell et al concurred with Kennells (1991) findings. It found that the continuous presence of a doula significantly reduced labour length, resulted in greater cervical dilatation at the time of an epidural and recorded higher Apgar scores for the baby post delivery. A convenience sample was used, which is appropriate for this type of study. Convenience sampling, or accidental sampling, involves the selection of the most readily available persons to participate in a study (Polit and Beck 2006). This sampling type provides little opportunity to control for biases but is often used in health studies, as the strict criteria of the sampling frames are not available for many populations (Burns and Grove 2007). It was noted by the researcher that another possible limitation of the study was that only one doula was used, whose personality and style could have influenced the outcome of the study. However, the strengths of the large sample size and wide time interval of the longitudinal study (1998- 2002) go some way to offsetting these limitations.

In a comprehensive updated Cochrane Review of 16 trials from 11 countries, involving over 13,000 women in a wide range of settings and circumstances, Hodnett et al (2009) correlated these findings. It was found that women who had continuous support were more likely to have a shorter labour and a spontaneous vaginal birth, more likely to be satisfied and less likely to need analgesia. However, whilst these studies concluded that labour support appeared to be more effective when it was provided by women who were not part of the hospital staff, they did not look at the support of the father. Consequently this area will now be explored. FATHERS SUPPORT IN LABOUR:

Not many women have access to a doula and unfortunately, due to the demands of the job it is often impossible for the midwife to give continuous support. Thus the father can be the only person continuously supporting the labouring woman (Hodnett et al 2009). It has been shown (Bowers 2002; Kennell et al 1991; Maher 2004) that the type of person giving support during labour is important. In many countries hospital staff permit multiple birth partners, allowing for both the husband and a female support person to be present. In Irelands delivery suites, there is generally only one support person allowed, usually the father, hence warranting research into the topic of the fathers role in the labour ward.

Ip (2000) conducted a quantitative study in Hong Kong which examined the relationship between the partners support and maternal outcomes. A convenience sample of primigravidae women was used (n=45). Due to a shortage of staff, the women in the study did not have continuous support by the midwife and consequently the father had an important role. The women rated their partners practical support significantly lower than their psychological support and it was this psychological support that had a positive effect on the length of labour and reduced the need for analgesia. It was also found that the fathers support during childbirth is only useful when he has the ability to help his partner meet her personal needs during labour. Healthcare professionals must help to prepare fathers to provide practical as well as psychological support to be of maximum benefit (Ip 2000; Somers-Smith 1999). It must be noted that generalizability of this study should be limited to Chinese women and may not be as applicable to Western women or Western practices. Also, the study used a retrospective design which may affect the reliability of the findings. Respondents memories may be selective in the questionnaires and as the data collected from the medical records was not initially collected for research purposes, it is not subject to the same rigours and therefore not as reliable (Parahoo 2006). A mixed method study by Gungor and Beji (2007) also examined the effects of the fathers presence on the childbirth experience. They found that a partners presence could give the woman strength and could help counteract the loneliness, pain, and uncertainty that can be part of labour. Women whose partners adopted an active role had more positive effects than those whose partners were present as witnesses to the birth. This research endorses previous studies (Campbell et al 2006; Chan and Paterson-Brown 2002; Ip 2000; Kennell et al 1991) and points to the need for the midwife to have a greater awareness of her responsibility to help the father fulfil his role. However, limitations to this study must be taken into account. The couples sampled were from a high socio-economic group and thus cannot be applied to the general diverse population. In addition the study was conducted in Turkey and while the conclusions are valid, they may not be as relevant in Ireland where the attitudes of the population may be quite different.

These and other recent studies (Backstrom and Hertfelt Wahn 2009; Kainz et al 2010; Wielgos et al 2006) examine issues surrounding men and the childbirth process. There has also been discussion in the journals (Bainbridge 2008; Daniel 2005; Dellman 2004; Longworth 2006; Symon 2001) and some controversy in the popular press (Burgess 2009;
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Jamieson 2009; Odent 2008; Sykes 2010). Leading obstetrician Michel Odent has stated that the fathers presence hinders the woman, makes her anxious and can cause emotional fallout leading to postnatal depression in the father. He advocates continuous support with a doula or other supportive woman (Odent 1999; Odent 2008). However he does acknowledge that a lack of knowledge and preparation can have a detrimental effect on the effectiveness of the father as birth partner.

It can be concluded that the research points to clear benefits of having good support in childbirth; that this is synonymous with a shorter labour, a likelihood of spontaneous vaginal birth and less reliance on analgesia (Campbell et al 2006; Gungor and Beji 2007; Hodnett et al 2009; Sauls 2002). Fathers are usually the person expected to take on this role, yet the literature states that they cannot offer the level of support necessary if they are fearful and anxious and do not have adequate preparation (Chandler 1997; Daniel 2005; Greenhalgh et al 2000; Li et al 2009; NCT 2009; Wockel et al 2007). Therefore this literature review will examine fathers fears and anxieties surrounding the childbirth experience and critique the relevant studies highlighting this area. FATHERS FEARS, ANXIETIES AND STRESSES:

Reports have shown that both men and women have similar fears in relation to childbirth. Using a convenience sample of first-time fathers (n=48) and second-time fathers (n=36), Hollins Martin (2008) conducted a quantitative study with the aim of creating a tool to measure fathers attitudes and needs in relation to birth. Whilst convenience sampling does not ensure the representativeness of the participants of the general population (Nieswiadomy 2008), by sampling both new and experienced fathers a broader range of experiences and attitudes was ensured, giving more depth and thus strengthening the results. Hollins Martin created the BPS, a questionnaire specifically for expectant fathers, to be utilised in the study. Whilst the results are consistent with other research in this area (Backstrom and Hertfelt Wahn 2009; Ip 2000; Johnson 2002b; Premberg and Lundgren 2006), the need for validity and reliability tests on the BPS to justify the use of this scale was also highlighted. It was found that even when labour is straightforward, fathers often experience stress and expressed feelings of helplessness and frustration at witnessing their partners pain in labour (Backstrom and Hertfelt Wahn 2009; Hollins Martin 2008; Premberg and Lundgren 2006).

These were feelings the fathers felt that they had had to hold back, needing to be strong for their partner (Backstrom and Hertfelt Wahn 2009).

This study correlates with previous findings by Johnson (2002b) whose longitudinal study investigated stress experienced by men in the perinatal period. Both these studies are relevant to practice in Ireland, as they have been conducted in the UK, where attitudes and practices would be similar. 53 men agreed to take part and were evaluated by way of questionnaires at three points during the childbirth process. One of the main advantages of questionnaires is the absence of the interviewer effect (Parahoo 2006). Some men may find it difficult to be open and frank when discussing their feelings thus the anonymity of the questionnaires can promote a more honest response. However, conversely, there is no opportunity for

expansion, elaboration or clarification of these answers (Parahoo 2006). Various questionnaires were used including the IES, which has been validated as a versatile tool which is particularly suited to a longitudinal study of this nature (Johnson 2002b). Demographic information was collected in the first trimester and then experiential data was collected at 2 points, 48 hrs and 6 weeks after the birth. The study found that the perinatal period is associated with high levels of stress, peaking at the birth. Men identified feelings of fear and anxiety and were concerned for the safety of both the mother and baby. A common factor noted was that men who perceived pressure to attend the birth reported higher levels of stress than those who did not. It is important not to make assumptions about a fathers eagerness or fitness to participate at the birth. Midwives need to identify whether fathers genuinely want to be present. If he is in the labour ward under duress, alongside raising his own stress levels, his presence can indeed have a negative effect on the labouring woman (Hollins Martin 2008). Recently the debate on fathers presence in the delivery room has intensified. In Johnsons research (2002b), 61% (n=25) of the men interviewed said that they had felt pressure to be present at the birth, not only from their partner, but also from the midwife. Yet, more than half of the men (n=23) reported they had been made to feel as if they were in the way . There was a disparity between the mens expectations of the birth and the reality of the labour room. Midwives are increasingly delegating specific tasks to the father yet rapidly dismiss these same men if complications develop, or during procedures such as vaginal examination (Ip 2000; Johnson 2002b; Premberg and Lundgren 2006). It appears that men are wanted on the labour ward, but only when it suits the professionals.
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A blameless approach needs to be adopted by health professionals when a father decides to relinquish the role of support person. The midwife should try to offer understanding and alternatives such as recruiting a friend, sister, mother, or doula (Hodnett et al 2009). Sometimes exploring the reasons why the partner chooses not to be present and trying to address these can make all the difference.

There are many reasons cited as influencing the decision of the father not to attend the birth. These include fears such as: seeing their partner suffer (Dellman 2004; Johnson 2002b; Somers-Smith 1999; Vehvilainen-Julkunen and Liukkonen 1998), not being able to help if complications occur (Wockel et al 2007), what could happen at the birth (Dellman 2004) and letting their partner down (Backstrom and Hertfelt Wahn 2009; Johnson 2002b). They are also often worried about the babys life and health, including the risk of having a disabled child (Backstrom and Hertfelt Wahn 2009; Hollins Martin 2008; Wockel et al 2007). The decision to attend the birth is a personal one and should be made individually by each couple in terms of their knowledge of one another without undue pressure by others (Draper 1997).

Some men appear better able to manage these fears and feelings of helplessness and are able to support their partner more positively (Hallgreen et al 1999). Fathers who find labour stressful are less able or willing to participate actively, and tend to assume an observational role, which is of less benefit to the woman (Ip 2000). Chapman (2000) (cited in Dellman 2004), states that mens levels of anxiety, frustration and sense of helplessness would be greatly reduced if they knew in advance that it is normal for women to feel more pain during some parts of labour. Antenatal preparation is therefore of crucial importance to help fathers overcome these fears and offer truly beneficial support to help their partners during the birth (Ip 2000; Lee and Schmied 2001; McElligot 2001; Pestvenidze and Bohrer 2007; Premberg and Lundgren 2006). It is thus pertinent to assess and review the literature addressing antenatal preparation for childbirth from the viewpoint of the father.

ANTENATAL EDUCATION AND MEN:

Men have needs in relation to preparing for the birth of their child and these are often separate and additional to those of the expectant mother (Fletcher et al 2004). According to the literature the majority of men want training to help them prepare for their role as birth partner (Fletcher et al 2004; Greenhalgh et al 2000; McElligott 2001; Premberg and
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Lundgren 2006; Svensson et al 2008); however, current figures show that very few fathers actually attend conventional antenatal classes (Hollins Martin 2008). The reasons for this are varied. Classes are often held during the day when the father is at work and therefore will mainly be full of women. The fathers reported feeling like observers and that they are looked at as having a secondary role in the classes (Fletcher et al 2004; Premberg and Lundgren 2006); they often attended merely to accompany their partner. The content of these classes is usually very woman-focused, with fathers saying that there is a lack of consideration for them and that the information is too basic and presented in an inefficient way (Fletcher et al 2004, McElligott 2001; Premberg and Lundgren 2006). They were disappointed that there was no education addressed specifically to the fathers (Premberg and Lundgren 2006).

As previously referenced, many fathers have fears and anxieties which affect their ability to act as a capable labour support person. Expectations can place great strain on the father, particularly when he has negative feelings about undertaking the task. Fathers are expected to perform a supportive role yet many are unclear about what to anticipate (Hollins Martin 2008). Antenatal education needs to address this issue, by trying to ascertain fathers personal concerns and tailor subsequent birth preparation to meet their individual needs.

Premberg and Lundgren (2006) conducted a descriptive phenomenological study based on Husserls (1936/1970) philosophy, which emphasises descriptions of human experience (Polit and Beck 2006). It found that men felt that other sources, such as Web sites, books, friends, and family were just as good for accessing information about pregnancy and birth. Antenatal classes were not viewed as anything unique. Phenomenological studies have the ability to understand the persons lived experience (Mander 2003). Through experience the person undergoes a change in feelings, attitudes and even beliefs. Because of the nature of phenomenological research, the sample sizes tend to be small, as sometimes two or more indepth (time-consuming) conversations or interviews are needed (Polit and Beck 2006). The sample group in this trial of first-time fathers was small (n=10), and while this is appropriate for a phenomenological approach, it is hard to generalise from such a study. The participants, who had all attended childbirth education classes, felt that all-male discussion groups would be beneficial. Premberg and Lundgren (2006) in conclusion, suggest that an experienced father leading a men-only session at some point during childbirth education may be useful and pointed out that this has been tested in Scotland and Australia with good results.

Furthermore, a prospective randomised study by Wockel et al (2007) seems to confirm Premberg and Lundgrens (2006) findings. They gave fathers-to-be an additional hour of special training within antenatal classes with a male obstetrician, who was also a father. This study, although having a large sample size of 223 couples, has some limitations in that the men were preselected and had all shown an interest in antenatal education. They would naturally be more enthusiastic and knowledgeable than a more general sample and therefore a bias in the results cannot be ruled out. Women whose partners received the training felt that they were better supported throughout both the pregnancy and birth. The men themselves also benefited, feeling more prepared and more able to support their partners. Both partners reported that they generally had a more positive birth experience. The fathers felt better able to express their fears and ask questions without their partners presence. What is remarkable is that there was improvement in the birth experience after an additional preparation time of only one hour (Wockel et al 2007). Wockel et al conclude that men would feel more confident and provide better support if separate educational sessions were offered.

There are various suggestions as to what would help to improve antenatal education for men. The research has indicated that men want to be prepared both psychologically and physically (Gungor and Beji 2007; Ip 2000; Johnson 2002a; Wockel et al 2007) to provide practical support that can meet their partners needs in labour (McElligott 2001). It has been reported that partners want information on coping strategies for women (Johnson 2002a), pain relief (Fletcher et al 2004) and what to expect in labour (Backstrom and Hertfelt Wahn 2009; Wockel et al 2007). A UK study by Greenhalgh et al (2000) examined fathers information-seeking styles in relation to antenatal education, with surprising results. They found that antenatal education cannot be assumed to enhance all fathers subsequent childbirth experiences. Early in the postnatal period three questionnaires were given to first-time fathers (n=78). At 6 weeks postpartum they were given two further questionnaires. Whilst these scales are reported as having good reliability and validity, they are all designed for use with women and thus may be a limitation to this study. Another limitation identified was whether the experience itself of attending the birth may have affected the fathers ability to assess their emotional well -being from before the birth. Perhaps information gathered during the antenatal period would have enabled the researchers to ascertain exactly how the birth process had changed the attitudes and beliefs of the fathers. The study identified that some men are blunters (information
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avoiders) and giving these men too much information can be associated with less positive experiences, indeed can even increase their anxieties. It also identified that less fulfilling experiences of childbirth directly related to higher depressive symptomatology at 6 weeks. This compares to Johnsons findings (2002b). Interestingly, the monitors (information seekers) also perceived no added benefit of the classes, perhaps because they would have looked for the information elsewhere if they had not attended the classes. It is clear therefore that antenatal classes need to be tailored to the needs of each group of parents rather than a one-size-fits-all approach (Greenhalgh et al 2000; Lavender 1997; Svensson et al 2008).

So what exactly is it that expectant fathers want from antenatal education? In Australia (2008) Svensson et al proposed to answer exactly that question and to plan antenatal education based on their findings. They conducted a comprehensive mixed method study including in-depth interviews, focus groups, surveys and participant observation with a sample size of 251 women and their partners. In nursing research, due to the complexities of the topics, the use of quantitative and qualitative approaches in combination can provide a better understanding of the research problems than either approach alone (MacInnes 2009). The participants of this study identified that a variety of antenatal programmes would be beneficial, supporting the hypothesis by Greenhalgh et al (2000). They also expressed the need for antenatal education to encompass the whole childbirth experience, not merely the last few weeks and for mens needs to be specifically addressed. The results challenge the current approach to childbirth education, not only in Australia, but here in Ireland also. It would appear that antenatal education needs to actively encourage men, offer role-play, involve them in practical support tasks, give knowledge about possible complications and discuss their expectations and fears (Gungor and Beji 2007; Johnson 2002b; Li et al 2009; Wockel et al 2007).

In Georgia, a recent study published in 2007, seems to confirm the benefits both of men in the labour room and of antenatal education focused on their needs. A longitudinal multimethod study was undertaken to evaluate the effects of the HWG programme on fathers involvement in childbirth. Whilst maternity practices in Georgia seem far removed from Irish practices, this study by Pestvenidze and Bohrer has interesting results and has implications for maternity practice in other countries also. Traditionally Georgia was a country where fathers would not have been present in the delivery room. Through the efforts of the HWG programme beginning in 2006, the maternity practices were transformed in a matter of
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months. The approach was two-fold, involving men in the antenatal classes and encouraging and supporting them in the labour room. Quantitative data was collected by health care providers in three maternity hospitals using specially designed data sheets over a four month period. Validity was ensured by monthly supervisory visits and cross-checking medical records. It is not clear whether the data collectors had any training in relation to collecting the data and this in itself is a possible limitation of the study. However the four month time frame and the fact that the data was collected in three different hospitals allow for more diversity in the sample and thus strengthen the results. Interviews with postpartum women were also conducted. Data on 659 deliveries was collected and analysed. The large sample size makes the findings more relevant and strengthens the validity of this study. The results show tangible progress in the partners participation but also improved delivery outcomes leading to better maternal and child health. Johnson (2002b) showed that when mens role or function in labour is not clear, they will have higher levels of stress and be of less use to the labouring woman. It is therefore clear that fathers require support themselves in order to give support to their partner during labour (Backstrom and Hertfelt Wahn 2009). Effective antenatal education has been shown to improve the level of support a partner can give (Pestvenidze and Bohrer, 2007; Svensson et al 2008; Wockel et al 2007), while understanding expectant fathers anticipations and addressing their fears and anxieties leads to more realistic expectations of the birth experience. Improving antenatal education for fathers will lead to more satisfaction and a more positive birth experience for both partners (Wockel et al 2007).

IMPLICATIONS FOR PRACTICE: Healthcare professionals need to see the fathers presence as a help rather than a hindrance; welcoming, including, supporting and encouraging them in the labour room. The WHO recommends family-centred maternity care and emphasises fathers participation (Martis 2007). The RCM (2008) endorses this view and urges midwives to support and encourage the fathers in their role. Fathers emotional needs should be recognised, supported, and integrated into intrapartum care (Dellman 2004). Antenatal education in a traditional womens model may not be the best way to prepare fathers (Premberg and Lundgren 2006). More research is needed to better understand and identify how antenatal education classes can be tailored to fathers and how to facilitate greater participation by them (Ip 2000).
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Research is also needed to explore the nature of fathers participation during labour and their need of support during childbirth (Dellman 2004; Hollins Martin 2008; Ip 2000; Premberg and Lundgren 2006). Midwives ought to look at their own practice in relation to fathers and to readdress the cultural belief that birth is women's business, not only in antenatal classes, but also in society as a whole.

CONCLUSION:

The research clearly shows that good support in labour has a positive effect on the childbirth experience (Campbell et al 2006; Hodnett et al 2002; Kainz and Eliasson 2010; Kennell et al 1991), with improved outcomes for both the mother and baby (Hodnett et al 2009; Sauls 2002). Fathers are now expected to take on this role; however, an ill-prepared birth partner will not have the same positive results (Daniel 2005; Greenhalgh 2000; Ip 2000; NCT 2009; Wockel et al 2007).

Antenatal education aimed specifically at men would be very beneficial to the labour experience of couples (Gungor and Beji 2007; Kainz et al 2010; McElligott 2001; Svensson et al 2008). Men need to be given the opportunity to address their fears and anxieties (Backstrom and Hertfelt Wahn 2009; Johnson 2002b) and to learn how to best support their labouring partner. Healthcare professionals need to work with couples to enhance the fathers role in the labour ward (Backstrom and Hertfelt Wahn 2009; Lavender 1997; Wockel 2007). Supporting fathers should be seen as an investment in the care of women and infants.

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