Enhancing Fathers' Educational Experiences During the Early Postnatal Period

Abstract

Since the 1970s, men have been encouraged to actively participate in the childbirth process, resulting in a shared experience for couples. Nevertheless, after the baby is born, many fathers find themselves displaced, unsure of how to embrace the transition to parenthood. The shift in cultural practice and evolving needs of families calls for the recognition of fathers as well as mothers in the provision of midwifery services. Innovative strategies must be considered to enhance postnatal education that is father-inclusive and responsive to the needs of families in the 21st century. This article introduces one strategy created from an action research study conducted to develop, implement, and evaluate strategies to improve postnatal education for parents.

BACKGROUND

Over the past decade, the hospital stay after the birth of a baby has been shortened significantly (Cooke & Barclay, 1999). This change in practice continues to present challenges in providing care to families during this time. In particular, the provision of postnatal education and support has been considerably affected by shorter hospital stays (Brown, Bruinsma, Darcy, Small, & Lumley, 2004). Many parents find themselves at home without adequate knowledge and support to confidently embrace the transition to parenthood (Early, 2001; Matthey & Barnett, 1999). Most research has focused on the needs of women, with limited studies addressing the needs of fathers in the postnatal period. Nevertheless, since the 1970s, men have been encouraged to actively participate in the childbirth process, with the result that childbirth and the transition to parenthood are a shared experience for couples (Early, 2001). In Australia, over 90% of fathers attend the birth of their baby (Dellman, 2004; McKellar, Pincombe, & Henderson 2006). Fathers have also been invited to participate in antenatal classes, preparing them for the experience of birth. After the baby is born, however, many fathers find themselves displaced, unsure of how to embrace the transition to parenthood.

There is an expectation that the 21st-century father will be involved in the day-to-day care of his children. Women continue to carry the primary burden for domestic activities, but an attitude shift has occurred where fathers are more willing to be involved in parenting and domestic tasks. An emphasis on fatherhood being a positive experience for men has developed (Draper, 2003; Elliot, 1996). Men's role in contemporary western family life is an important issue needing attention (Elliot, 1996). Social-policy reforms supporting families are necessary and include maternity leave, parental leave, family-friendly employment practices, and out-of-hours services provision to assist parents in managing the transition to parenthood in the midst of changing sociocultural expectations (Barclay & Lupton, 1999; Draper, 2003).

An Australian study conducted by Barclay and Lupton (1999) identified that the birth of a baby challenged men's domestic abilities and demanded the learning of new skills. Most men in the study were unable to invest the time needed to acquire these skills. The study also identified that many new fathers had an expectation of being more involved with their infant than their own fathers were with them. Conceptually, this involved the idea of interacting with an older child, for instance playing a sport together. It was not associated with the thought of a new baby, who is perceived as being nonresponsive and demanding. This unmet expectation created a sense of confusion for many men, who chose to place their active role in parenting on hold until the baby was older (Barclay & Lupton, 1999). Many fathers found the early experience of fathering disappointing and frustrating (Barclay & Lupton, 1999; Mander, 2004). A lack of role models and appropriate education for fathers wanting to participate in the care of a small baby may have contributed to this outcome (Barclay & Lupton, 1999). Fathers identified that developing realistic expectations regarding being a “modern” father and the ability to learn new skills in caring for their baby was an important factor in positive parenting (Barclay & Lupton, 1999; Draper, 2003; Mander, 2004). In light of the shift in cultural practice and community need, it is appropriate to recognize fathers as well as mothers in research addressing the postnatal period and transition to parenthood (Early, 2001).

Fathers identified that developing realistic expectations regarding being a “modern” father and the ability to learn new skills in caring for their baby was an important factor in positive parenting.

This article outlines the study entitled “PREPARE: Parents' Reflections on Education Postpartum: An Action Research Enquiry” and presents findings specifically relating to the needs of fathers in the early postnatal period.

METHODOLOGY

The study adopted an action research methodology following the action research cycle of planning, action, observation, and reflection (Kemmis & McTaggart, 1982). Action research was chosen as an appropriate methodology because its fundamental aim is to improve practice and involve the people who will be affected by that modified practice (Kemmis & McTaggart, 1982). Fundamental to action research is the idea of democratic collaboration between the researcher and stakeholders (Greenwood, 1994). Prior to commencing the study, an ethics proposal was submitted to the Children, Youth, and Women's Health Services and to the University of South Australia Human Research Ethics committees, and ethics approval was obtained. In addition, communication with the hospital's postnatal unit head and midwifery staff gained support for the study.

The planning phase explored the experiences of mothers and fathers by conducting anonymous self-report questionnaires, which parents were asked to complete within 4 to 8 weeks after the birth of their baby. Questionnaires were purpose-designed for mothers and fathers, respectively, and provided an opportunity for parents to reflect on their own experiences, with emphasis given to the provision of education and support during the early postnatal period.

The completed questionnaires provided demographic and clinical data through a range of closed, scaled, and open-ended questions. The fathers' questionnaire asked similar questions to the mothers' questionnaire, but wording was changed to address fathers specifically. For example, questions regarding information needs on self-care were replaced with questions regarding information needs on partner-care. By invitation, we recruited study participants who were admitted to the postnatal ward of the Children, Youth, and Women's Health Service (CYWHS), a large city hospital in Adelaide, South Australia. The CYWHS assists a wide range of families from a variety of suburbs throughout Adelaide. The study used a convenience sample of parents who fulfilled the selection criteria. Each parent received an information letter and was asked to complete a written consent form giving us permission to record their address. We forwarded an additional letter and a questionnaire to their postal address.

In the planning phase, 150 parents were approached over a period of 2 months. Among these parents, 124 consented to take part in the study and were mailed a questionnaire within 2 weeks after the birth of their baby. Eighty-five parents returned completed questionnaires within 6 weeks after the birth of their baby. Numeric data from the questionnaire were analyzed as simple descriptive statistics using the software package SPSS 14, and thematic analysis was employed to process the written data. The issues of rigor in this study have been addressed through a number of means, including triangulating data collection methods and checking validity by reviewing the findings with parents (Lincoln & Guba, 1985; Sandelowski, 1986).

The findings from the questionnaires, combined with a review of current literature, informed an action research group, which consisted of midwives who predominantly worked on the postnatal ward (ward midwives), the fatherhood support worker, and an infant and perinatal mental health nurse. A number of strategies to enhance the provision of postnatal education were proposed. One strategy in particular was the development of four educational postcards targeted specifically for fathers. The postcards were designed with significant input from the fatherhood support worker, from focus-group discussions with fathers, and from the Centre for Health Promotions at the CYWHS. The final design was a series of four postcards with black-and-white photographs of babies and fathers. The information on the back of the postcards was succinct and presented in dot-point format for easy and quick reading (see Figure 1 and Figure 2).

“My Dad…” postcard example

“My Dad…” postcard text example

In all, three educational strategies were implemented on the postnatal ward and evaluated through an anonymous self-report questionnaire for both mothers and fathers, respectively. The questionnaires were similar in design to the initial questionnaires but with strategy-specific questions. Inclusion criteria for parents and implementation of the questionnaires remained the same. One hundred twenty-two parents completed the second questionnaire.

FINDINGS

The findings presented in this article principally focus on data collected from the questionnaires for fathers in the planning and observation phases and evaluation of the educational postcards.

Planning Phase

Questionnaire

The participants who completed the first questionnaire consisted of 52 (61.2%) mothers and 33 (38.8%) fathers. Of the 33 fathers who responded, 19 (57.6%) were first-time fathers and 14 (42.4%) were fathers-again. The participants came from diverse demographic areas and socioeconomic groups (see Table 1). Sixteen (84.2%) first-time fathers attended antenatal classes (ANC), while none of the fathers-again attended. Approximately 50% of the parents attending ANC attended the 6-hour Saturday program. All but one father (97.0%) were present at the birth of their baby. The father who was not present arrived at the birth a few minutes too late.

TABLE 1.

Participant Demographics

Age	N = 85	%
<20 years	2	4.5
20–25 years	12	15.9
26–30 years	21	22.7
31–35 years	41	45.4
>35 years	9	11.3
Patient status
Public	67	78.8
Private	18	21.2
Suburb
*Western suburbs	5	5.9
Southern suburbs	12	14.1
Eastern suburbs	8	9.4
*Northern suburbs	32	37.6
Inner city	5	5.9
Hills/Rural	22	25.9
Missing	1	1.2
Country of Birth
Australia	67	78.8
Canada	1	1.2
England	6	7.1
France	1	1.2
Iraq	2	2.4
New Zealand	1	1.2
Philippines	1	1.2
South Africa	3	3.5
Sri Lanka	1	1.2
Tonga	1	1.2
Vietnam	1	1.2

^*Low-income area

Fathers were asked to indicate whether they received any personal education from a midwife while their partner was admitted to the hospital. Sixteen (48.2%) fathers did not receive direct education. This number included 7 (36.8%) first-time fathers (see Table 2). Fathers who had received direct education were asked to rate the information they received. Of these, all the fathers-again rated the information they received as good or very good. Seven (58.4%) first-time fathers rated the information as good or very good, and 4 (33.3%) first-time fathers rated it as poor or very poor (see Table 3).

TABLE 2.

Number of Fathers Who Personally Received Teaching While Partner Was in the Hospital

	First-Time Father		Father-Again
	n	%	n	%
No	7	36.8	9	64.3
Yes	12	63.2	5	35.7
Total	19	100.0	14	100.0

TABLE 3.

Rating of Fathers' Education

	First-Time Father		Father-Again
	n	%	n	%
Very poor	1	8.3	0	0.0
Poor	3	25.0	0	0.0
Adequate	1	8.3	0	0.0
Good	2	16.7	3	60.0
Very good	5	41.7	2	40.0
Total	12	100.0	5	100.0

The questionnaire used open-ended questions to identify parents' primary concerns since the birth of their baby and to specify with whom they had been able to address their concerns. Subthemes were identified that categorized the concerns of mothers and fathers. For fathers, the most commonly described concerns centered on their partner and their own role. Sixteen (48.5%) fathers identified their partner's wellbeing as a concern. Eleven (33%) fathers were concerned about having a healthy and settled baby, and 5 (21.2%) were concerned about their role as a father. In specifying their primary source of support for discussion of their concerns, fathers identified their partner first, followed by midwives, family, and friends (see Table 4).

TABLE 4.

People With Whom Fathers Discussed Their Concerns

	First-Time Father		Father-Again
	n = 19	%	n = 14	%
Partner	14	77.8	9	64.3
Midwife	13	72.2	6	42.8
Family/Friends	12	66.7	5	35.7
Children, Youth, and Women's Health Service staff	7	38.9	3	15.8
General practitioner	1	5.6	0	0.0

In specifying their primary source of support for discussion of their concerns, fathers identified their partner first, followed by midwives, family, and friends.

The most frequently noted requests from fathers were the provision of father-specific information and to stay overnight with their partner if they desired. Stated requests from fathers were as follows:

• 19 (57.6%) – Father-specific information.

• 12 (36.4%) – Stay overnight with partner (representing 10, or 71.4%, first-time fathers).

• 4 (12.1%) – Present for teaching with midwife.

• 3 (9.1%) – Individualized teaching plan.

• 1 (3.0%) – Enforced visiting hours.

Focus group

A focus-group discussion was conducted with fathers to validate the findings from the questionnaire and contribute further to the development of actions. Nine fathers attended the group, of whom 4 were fathers already and 5 were expecting their first child. The fatherhood support worker was also present and contributed to the discussion. The discussion continued for a half-hour, and the fathers were very eager to offer their thoughts and ideas. A number of themes emerged, supporting the findings from the questionnaire and the action research group regarding the need to include fathers and provide father-specific information.

Need to include fathers

A number of fathers identified that they did not feel they really belonged in the maternity-service environment. One father stated strongly that he had felt uncomfortable from the time he first attended antenatal appointments. He stated, “As soon as I walked in, people look at me strangely.” Another father agreed, stating, “I didn't feel comfortable.” One expectant father commented on the name of the hospital, stating that “even the name of the hospital says you don't fit.” Discussion continued with laughter about the name of the hospital, which included women and children but not men. Fathers agreed that this contributed to the alienation of men as consumers of maternity services. The fathers continued the discussion with the notion that maternity care should be more family-centered. One father even commented that the “male midwife is a myth.” He suggested that the presence of male midwives might help fathers feel more included. Further comments were made about the problem of sharing rooms with other families and the difficulties this caused. There was brief discussion about the modern family and fathers wanting to be more involved.

Need for father-specific information

Fathers identified a lack of father-specific information. Their comments were: “There is no information for dads”; “Can't find any”; and “Add-on only!” It was suggested that information should be available for fathers, with appropriate pictures and information. Most fathers agreed that they would read something if it was aimed specifically at them. They also commented that they did not want too much information. One father stated that he wanted to know about issues related to his partner's needs, including tiredness and feeding.

Action Phase

The educational postcards were developed in response to these findings. The aim of the postcards was to provide father-specific education and to include fathers in the provision of education and support during the postnatal period. The postcards addressed four topics: “newborn abilities and needs,” “being involved in baby's care,” “supporting each other,” and “services and support for fathers.” The postcards were distributed as part of the admission pack parents received when they arrived on the postnatal ward.

Observation Phase

The primary purpose of the observation phase was to provide an evaluation of the actions implemented on the postnatal ward. As outlined earlier in this article, a questionnaire was employed to collect feedback from parents with regard to each action developed and implemented. Data were also collected by phone interviews with parents to check the validity of the findings. Development of the second questionnaire followed criteria provided by the Centre for Health Promotion (2003) to evaluate health information resources for consumers. Specifically, the postcards were evaluated for their appeal, readability, content, and perceived usefulness from the perspective of fathers. The second questionnaire for fathers also provided an opportunity for them to reflect on their experience in the early postnatal period with regards to education and support.

Forty-five fathers responded to the second questionnaire, of whom 22 (48.9%) were first-time fathers and 23 (51.1%) were fathers-again. Demographics were similar to participants in the first questionnaire, with notably more fathers-again responding. All fathers had attended the birth of their baby.

Thirty-four (75.6%) fathers indicated that they had read the postcards. Twenty (58.8%) of these were first-time fathers, representing 95% of first-time fathers who responded to the questionnaire. Fourteen (41.2%) were fathers-again. Fathers were asked to indicate how well they read the postcards. Nineteen (55.9%) stated that they had read most or all of the information on the postcards, 13 (38.2%) that they had read half the information, and 2 (5.9%) that they had read only some of the information (see Table 5). Of the 34 fathers who read the postcards, 33 (97.1%) stated that the postcards answered relevant questions and were helpful.

TABLE 5.

Degree of Postcards Read

	First-Time Father		Father-Again
	n	%	n	%
All	9	45.0	5	35.7
Most	4	20.0	1	7.1
Half	7	35.0	6	42.9
Some	0	0.0	2	14.3
None	0	0.0	0	0.0
Total	20	100.0	14	100.0

Fathers were asked to identify which postcard topics were the most helpful. Twenty-four (70.6%) fathers identified “being involved in baby's care” as being helpful, 21 (61.8%) identified “newborn abilities and needs,” 18 (52.9%) identified “supporting each other,” and 6 (17.6%) identified “services and support for fathers.” It is interesting that only 2 (5.9%) fathers had accessed any of the Web sites listed on the postcards, and 1 (2.2%) father had contacted the Fatherhood Support Program. Eight (23.5%) fathers, however, indicated that they would like to attend the Fatherhood Support Program in the future.

Several questions from the first questionnaire were repeated in the second questionnaire. Although the small sample size limits comparisons, the contrast in findings is noteworthy. Fathers were asked to indicate if they received any personal education from a midwife while their partner was admitted to the hospital. Twenty-nine (64.4%) fathers received direct education from a midwife. This finding is in contrast with data from the first questionnaire, in which 17 (51.5%) fathers received direct education from a midwife (see Table 6). Note that this difference represents an improvement of 13% in the number of fathers who had direct involvement in postnatal education.

TABLE 6.

Fathers Who Personally Received Education While Partner Was in Hospital

Received Education	First Questionnaire Fathers		Second Questionnaire Fathers
	n	%	n	%
No	16	48.5	16	35.6
Yes	17	51.5	29	64.4
Total	33	100.0	45	100.0

Fathers were asked to identify how well they had been able to discuss their concerns/questions since the birth of their baby. Twenty-nine (64.5%) fathers expressed that they had been able to discuss their concerns/questions well or very well. This finding contrasted with data from the first questionnaire, in which 18 (54.5%) fathers identified that they had been able to discuss their concerns well or very well. This difference represented a 10% increase in fathers being able to discuss their concerns while their partner was in the hospital. Based on the appraisal of fathers, the postcards should be considered as quality health information for parents. The postcards contributed beneficially to the knowledge of fathers in this study, providing relevant education during the early postnatal period.

DISCUSSION

Despite the reduction of length in hospital stay after birth, when parents are admitted to the hospital and during the early postnatal period, a window of opportunity continues to exist in which mothers and fathers are receptive to the delivery of education and support. It is imperative to maximize the effectiveness of this time for preparing both mothers and fathers for parenthood. The findings in this study suggest that although fathers indicate their partner is the primary source of information after the birth of their baby, midwives, more than any other health-care professional, may be a significant source of information and education for fathers in the postnatal period. In light of this finding, it is reasonable to assert that the postnatal hospital stay and midwifery program, as key sources of education, must be more fully developed and utilized in order to maximize fathers' preparation for their role.

Maternity services are predominantly women-centered. This approach has facilitated a partnership between midwives and mothers and has achieved significant benefits for women throughout childbirth (Barnes, 1999; Freeman, 2006). Nevertheless, it appears that men also want to be vitally involved in the childbirth experience, both during birth and beyond the labor room (Draper, 2003; Early, 2001). It has been suggested that fathers have been excluded in maternity health-care aims and policies because of a primary focus on the mother and baby (Burgess & Russel, 2004). Notably, Tiedje and Darling-Fisher (2003) reported comments similar to the remarks made by fathers in the current study, concerning the use of gender-specific titles in health-care institutions. For example, the continued use of language such as “Maternal and Child Health Departments” reinforces the sense of exclusion and alienation for men (Tiedje & Darling-Fisher, 2003, p. 352).

Questions have been raised regarding the best method to include fathers. Becoming aware of the lack of inclusion is important; however, health-care providers must move beyond awareness to proactively develop strategies that welcome fathers as genuine consumers of maternity care (Burgess & Russel, 2004; Tiedje & Darling-Fisher, 2003). Specifically, it may be appropriate to give attention to the language of midwifery. The development of inclusive language policies has been a positive step in moving toward more equitable communities (Tiedje & Darling-Fisher, 2003). By embracing the nomenclature “family-centered care” in preference to “women-centered care,” a positive and more inclusive culture might be articulated for midwifery practice. This is certainly appropriate, at least in the context of postnatal care, where both men and women must traverse the transition to parenthood (Tiedje & Darling-Fisher, 2003). In addition, there is a need to facilitate purposeful interactions with men during the provision of maternity care and to provide information that is appropriate and specific to the needs of fathers. In the present study, the educational needs of fathers differed significantly from the needs of mothers. Men indicated that being provided with father-specific information and being able to stay overnight with their partner would be beneficial in their transition to parenthood.

The findings from the second questionnaire suggest that after implementation of the educational postcards, more fathers were included in the provision of postnatal education. It seems reasonable to propose that specifically targeting fathers in educational strategies may positively influence the number of fathers who are personally included in education during the postnatal period. Interestingly, in follow-up phone interviews with parents to check the validity of the findings, fathers who indicated on the questionnaire that they had not read the postcards stated that this was because they had not received them. It became apparent throughout the process of this study that a number of difficulties surrounded implementing new strategies in practice. For example, the postcards were distributed to fathers as part of the postnatal ward admission pack. Admission packs were standard in the ward admission process but were not always handed directly to parents. Parents were left to discover the packs themselves and to discern what information was most valuable during the early and often overwhelming postnatal period. In a focus group with ward midwives to review the strategies, it was suggested that handing the postcards directly to fathers would be a more effective practice and would also foster a father-inclusive environment. Placing the father-specific resources into men's hands and drawing their attention to them may have improved uptake of the educational opportunity.

Specifically targeting fathers in educational strategies may positively influence the number of fathers who are personally included in education during the postnatal period.

CONCLUSION

This study's findings raise implications for practices, particularly concerning childbirth education. It seems that a family-centered approach would be an appropriate evolution and enhancement of women-centered care, enabling men to access knowledge in a way that best accommodates them and their family. Various studies advocate for employing male-specific educational strategies throughout the childbirth period in order to move fathers from their position as a secondary focus in postnatal education to being a primary focus (Friedewald & Newing, 2006; Premberg & Lundgren, 2006). Arguably, normalizing the inclusion of fathers in maternity care is imperative in assisting men in their transitional experience (Friedewald & Newing, 2006; Premberg & Lundgren, 2006). The actions employed in the current study appear to have enabled midwives to incorporate more fathers, more effectively, into the scope of midwifery practice. The findings suggest that the postcards developed in this study are an effective means to provide fathers with specific information and to encourage recognition of fathers in the early postnatal period, facilitating more effective inclusion of fathers in postnatal education. We recommend that further research be undertaken to address the educational needs of fathers and develop more innovative strategies to engage fathers in education, preparing men more fully for the transition to parenthood in the 21st century.

LIMITATIONS

We acknowledge that there are limitations to the current study. In particular, due to the small sample size, it is difficult to draw conclusions and generalize from the findings. Furthermore, due to limitations in resources, the study only included participants who were literate in English. Nevertheless, the study's findings provide insights from parents that may contribute to further discussion and research and may be useful in developing strategies to provide enhanced education and support for parents.