Skip to main content
NCBI home page
Maternal & Child Nutrition logoLink to Maternal & Child Nutrition
. 2021 Jul 9;17(Suppl 1):e13177. doi: 10.1111/mcn.13177

Father involvement, maternal depression and child nutritional outcomes in Soweto, South Africa

Roisin E Drysdale 1,✉, Wiedaad Slemming 2, Tawanda Makusha 1,3,4, Linda M Richter 1
PMCID: PMC8269140  PMID: 34241955

Abstract

Father involvement in South Africa is low, despite evidence that it can improve maternal and child health and wellbeing. Within a larger randomised controlled trial, we assessed whether father involvement during and after pregnancy increased birth weight and exclusive breastfeeding through improved maternal mental health. At 6‐week postnatal, mothers completed questionnaires on birth, feeding practices, social support, father involvement and postnatal depression. Father involvement during pregnancy was measured by their attendance at antenatal care and the study intervention, whereas postnatal involvement was measured by attendance at antenatal care and type of paternal support provided. Structural equation modelling was used to identify associations between father involvement, maternal depression, low birth weight and exclusive breastfeeding. Among the 212 mother–baby pairs, father involvement was very low with only 43%, 33% and 1% of partners attending early ultrasound, antenatal care and the birth of the child, respectively. Twenty‐nine percent of the mothers showed signs of depression during pregnancy, compared with 7% after birth. Eighteen percent of the infants were born low birth weight, and 57% of mothers reported exclusively breastfeeding at 6 weeks. Father involvement was directly associated with postnatal depression, but it did not directly or indirectly impact exclusive breastfeeding or low birth weight. We conclude that postnatal father involvement can improve postnatal maternal depression and that men would benefit from specific guidance on how they can support mothers during and after pregnancy.

Keywords: breastfeeding, depression, fathers, low birth weight, maternal mental health, maternal public health, pregnancy, South Africa

Key messages.

  • Father attendance at pregnancy ultrasound was low despite a personal invitation and the service being offered on a weekend.

  • Structural barriers within the public health system in South Africa continue to limit male attendance at the birth of their child.

  • Father involvement during and after pregnancy was associated with improved maternal mental health.

  • Interventions to improve male involvement should provide men with specific information and guidance on how best to support their partners during and after pregnancy.

  • Research is needed to assess the long‐term impacts of father involvement on maternal wellbeing and healthy child growth and development.

1. INTRODUCTION

The first 1,000 days of life, from conception to a child's second birthday, are a time of both tremendous potential and vulnerability (Richter et al., 2017). During this time, a child's brain grows more quickly than any other time, and health, nutrition, protection, and responsive care during pregnancy and infancy fundamentally affect a child's growth and development (Black et al., 2017; Prado & Dewey, 2014). Maternal undernutrition is a risk for preterm birth and low birth weight (Accrombessi et al., 2017; Blencowe et al., 2019), which both increase the risks of stunting and long‐term developmental challenges (Blencowe et al., 2013; Christian et al., 2013; Gluckman et al., 2006). Worldwide, approximately 15% of infants are born of low birth weight [World Health Organization (WHO), 2014a], and although there has been some improvement in the prevalence of low birth weight, the progress made is slower than required to meet either the Global Nutrition Targets (Blencowe et al., 2019; WHO, 2014b, 2018) or the Sustainable Development Goals (UNICEF, 2020). At the same time, child malnutrition remains a global challenge with 159 million children under five stunted and 49.5 million wasted (Global Nutrition Report, 2020). Research has indicated that exclusive breastfeeding for the first 6 months can reduce childhood undernutrition and simultaneously improve protection from infectious diseases and the associated adverse nutritional effects (Scherbaum & Srour, 2016). Despite this, in 2017, only 41% of infants aged between 0 and 5 months were exclusively breastfed globally; an increase of only 4% on the previous 5 years (Global Nutrition Report, 2020).

Nurturing care is key for optimal child development and growth both during and after pregnancy (Britto et al., 2016; Cusick & Georgieff, 2016; Schwarzenberg & Georgieff, 2018) with families and others playing a key role in reducing stress, providing information and practical or financial support. Evidence suggests that mothers with low levels of social support during early pregnancy are more likely to have babies with low birth weight (Elsenbruch et al., 2007), and mothers benefiting from emotional support from their partners, family or friends are less likely to suffer postpartum complications (Maharlouei, 2016). Family members can positively influence and support feeding practices, but also undermine feeding decisions made by the mother (Mphego et al., 2014; Raj & Plichta, 1998; Trafford et al., 2020). In traditional societies, women often face pressure from grandmothers, mothers or sisters to give solid food, water, formula or traditional medicine before an infant turns 6 months old (Mphego et al., 2014).

The role of men in the perinatal period is often neglected, but their involvement during pregnancy and early childhood can lead to improved health and developmental outcomes at birth and throughout a child's life (Feldman et al., 2013; Jackson, 2017; Lamb, 2010; McKee et al., 2018; Walsh et al., 2017). During pregnancy, fathers often provide financial, practical and emotional support to their pregnant partner (Plantin et al., 2011), and they can also promote positive maternal behaviours such as healthier eating, reduced smoking or drinking, and earlier attendance at and adherence to antenatal and postnatal health care (Alio et al., 2010; Makusha & Richter, 2018; Martin et al., 2007). In contrast, less father involvement during pregnancy has been found to be associated with low birth weight, small for gestational age (Alio et al., 2010) and preterm birth (Ghosh et al., 2010), all of which are associated with lifelong elevated risk for cardiovascular disease (Souza et al., 2019), hypertension and diabetes (Kibret et al., 2019; Knop et al., 2018). Lack of father involvement in infant and young feeding has been found to be associated with undernutrition in children (Kansiime et al., 2017), and studies have reported that if a women's partner approves of their breastfeeding, they are three times more likely to exclusively breastfeed than those whose partners don not approve (Perez‐Escamilla, 1994). In sum, engaged and informed men can encourage optimum feeding practices such as exclusive breastfeeding and appropriate complimentary feeding (Dinga et al., 2018; Maycock et al., 2013), both of which lead to improved child health, nutrition and development outcomes (Kramer & Kakuma, 2012; WHO, 2020).

In addition to improved birth and child development outcomes, father involvement can have a profound impact on the mental health of women. Mothers with partners who are highly involved during pregnancy have been found to report lower levels of antenatal depression (Cheng et al., 2016; Maselko et al., 2019), whereas lower partner involvement postnatally increases the risk of postnatal depression (Lin et al., 2017). Research suggests that antenatal depression can negatively impact foetal development and increase the risk of preterm or still birth as well as low birth weight (Brittain et al., 2015; Dadi, Miller, & Mwanri, 2020; Dadi, Miller, Woodman, et al., 2020), and postnatal depression has been associated with reduced exclusive breastfeeding (Silva et al., 2017). In this regard, increased father involvement can positively affect child birth and developmental outcomes indirectly through improved maternal mental health (Dadi, Miller, Woodman, et al., 2020; Maselko et al., 2019).

In South Africa, despite the evidence and calls from health professionals (McKee et al., 2018), there are a number of health system, individual, social and structural barriers that prevent men from being actively involved in antenatal care, the birth of their child or early childcare. These include poorly structured or under‐resourced health services, limited clinic hours, negative attitudes among health care workers, low marriage and cohabitation rates, low father–child residency, and high rates of migrant labour, unemployment and poverty (Hastings‐Tolsma et al., 2018; Makusha & Richter, 2018). At the same time, women face a range of social and economic issues that contribute to poor mental health, including high rates of gender‐based violence, crime, poverty and food insecurity (Perry et al., 2010; Van Heyningen et al., 2017).

The negative impact of these barriers is manifested in recent figures that suggest that 15% of births in South Africa are low birth weight and only 32% of babies under 6 months of age are exclusively breastfed [National Department of Health (NDoH), 2019]. In terms of maternal depression, estimates in South Africa vary depending on the measure used, time of measurement and characteristics of the sample (Pellowski et al., 2019), but range between 21% and 50% (Brittain et al., 2015; Peltzer et al., 2018; Van Heyningen et al., 2016). Lack of improvement on these indicators highlights that additional efforts to improve both maternal and child health outcomes are required in South Africa.

In order to improve father involvement during the antenatal and postnatal period, we invited the partners of pregnant women to attend a pregnancy ultrasound, part of an antenatal intervention to improve child growth and development. In the postnatal follow up of the intervention at 6 weeks, we assessed whether father involvement during and after pregnancy is associated with improved birth weight and exclusive breastfeeding in an urban setting in South Africa. We hypothesised that these relationships are mediated by maternal mental health.

2. METHODS

2.1. Study design

This paper reports on the 6‐week follow up from a randomised controlled trial assessing the impact of augmented ultrasound during pregnancy on healthy child growth and development compared with standard practice of care. Recruited participants were blindly allocated to the intervention or control arms. A routine ultrasound scan was offered to all participants in the study. The ultrasound examination in the control group followed standard practice of care, whereas the intervention group received additional messages to promote early childhood development, an educational baby book and a printed and electronic image of their ultrasound scan. Full details of the trial intervention and methods can be found in Richter et al. (2020).

2.2. Setting

The study is situated in Soweto, South Africa's largest township located near Johannesburg. All study procedures took place between March 2019 and August 2020 in a research unit at Chris Hani Baragwanath Hospital (CHBH), a tertiary hospital in Soweto.

2.3. Participants

Participants were recruited from the Foetal Medicine Unit (FMU) at CHBH and invited to participate if they had a singleton pregnancy <25 weeks gestation and were over the age of 18 years and lived within Soweto. Women who were found to have severe maternal comorbidities or major foetal abnormalities were excluded from the study but remained in clinical care at CHBH. Participants who attended the ultrasound were requested to attend follow‐up visits with their infant 6 weeks after birth. Mothers in both the intervention and control groups were encouraged to invite the father of the baby to attend all study appointments and were provided with invitation cards to give to their male partner on recruitment.

2.4. Data collection

During the ultrasound visit, women completed individual questionnaires on their sociodemographic characteristics and relationship status with the father of the baby. Antenatal depression was measured using the Edinburgh Postnatal Depression Scale (EPDS), a 10‐item self‐reported depression scale that has been validated for use during the antenatal period (Choi et al., 2012) and in South Africa (Lawrie et al., 1998). As per recommendations by Cox et al. (1987), mothers with a score of ≥10 were referred to a specialised nurse for further assessment and to receive counselling if required.

At the 6‐week follow‐up visit, the mothers were asked questions related to the birth of their baby, including the type of delivery and complications experienced by the mother or baby, as well as questions on their feeding practices, such as when the baby was put to the breast after birth. Mothers were asked if they had given their baby formula, water or porridge, and also asked to list all the foods and liquids they had given their baby up until the time of the interview. Those who did not report giving formula, water, porridge or other substances were recorded as having exclusively breastfed up to 6 weeks. To limit the overestimation of infants exclusively breastfed at 6 weeks, we chose not to follow the WHO infant and young child feeding guidelines that use a 24‐h recall method (WHO, 2008). Mothers were also asked about partner support and involvement during and after their pregnancy, specifically men's attendance at health checks or the birth, and the types of support partners were providing. Finally, mothers completed the EPDS for an assessment of postnatal depression and were referred for further assessment with a score of ≥10. Details of the infant, including their date of birth and birth weight, were taken from the Road to Health Book that is maintained for all children from birth in South Africa to keep track of their health, growth and development.

An index of socio‐economic status (SES) was calculated using a principal component analysis (PCA) based on data collected at baseline. Variables included in the index were crowding (number of rooms used for sleeping), household water and sanitation, internet access, and ownership of a washing machine, satellite television, DVD player, computer and car. The index was divided into tertiles. Antenatal father involvement was based on whether the partner attended the study ultrasound or additional antenatal health visits and was recorded as none, at least one or both. Postnatal father involvement was measured using a cumulative score comprising different forms of father involvement, such as responsibility or provisioning as per recommendations from Greene et al. (2001). This included whether the father had provided information, practical, emotional or financial support, was rated by the mother as providing her with the most help with the baby or her own health and how she rated this help, whether he made things harder for the mother by his behaviour or attitude and his attendance at antenatal health visits. We opted to use maternal reports of father involvement as perceived support is important, and we anticipated that father attendance at 6‐week follow‐up would be low. Low birth weight was classified as <2.5 kg. Binary variables were coded using 1 and 0 for yes and no responses, respectively.

2.5. Data analysis

Data were captured and analysed using Stata I/C 14. Categorical descriptive statistics are presented as frequencies and proportions. Continuous descriptive statistics are presented as minimum, maximum, mean and standard deviations.

Using structural equation modelling (SEM), two individual models were built to test our hypotheses; Model 1 assessed whether antenatal father involvement improved birth weight by improving antenatal maternal mental health, and Model 2 assessed whether father involvement during and after pregnancy increased exclusive breastfeeding through improved postnatal mental health. Antenatal variables were used in Model 1, whereas a combination of antenatal and postnatal variables was used in Model 2. Simple linear regression was undertaken to identify potential confounding variables for antenatal and postnatal maternal mental health. Variables with a p value < 0.10 were included in the SEM. For the main outcome variables (birth weight and exclusive breastfeeding), simple linear and univariate logistic regression, respectively, was conducted with all potential confounding maternal variables included in the SEM if the p value was <0.10. Intervention arm was controlled for both models. Figures 1 and 2 show the path diagrams used to guide each of the models. Due to the differing types of outcome data (continuous and binary), the results of the SEM are presented as total, direct and indirect β coefficients. We assess the fit of each model using the root square mean error of approximation (RMSEA), the comparative fit index (CFI) and the Tucker–Lewis index (TLI). A well‐fitting model has RMSEA < 0.05, and CFI and TLI > 0.95. All statistical tests were considered significant with a p value of <0.05, and 95% confidence intervals are presented.

FIGURE 1.

FIGURE 1

Open in a new tab

Pathway diagram for Model 1: antenatal father involvement, antenatal maternal mental health and birth weight. SES, socio‐economic status

FIGURE 2.

FIGURE 2

Open in a new tab

Pathway diagram for Model 2: father involvement, postnatal maternal mental health and exclusive breastfeeding. SES, socio‐economic status

2.6. Sample size

The required sample size for the trial was 100 participants per arm. In total, 249 pregnant women were enrolled in the trial, with 212 attending the 6‐week follow up. We conducted a reverse power analysis using G*power to determine whether the sample size of 212 was sufficient to conduct an SEM analysis. Based on an effect size of 0.17, alpha of 0.05 and two predictors, the power was 0.99 and the sample size sufficient for analysis.

2.7. Ethical considerations

The study was approved by the Human Research Ethics Committee (Medical) of the University of the Witwatersrand, South Africa (M181915). An amendment was approved by the University of the Witwatersrand in order to film some of the ultrasound appointments. Permission was obtained from CHBH to conduct the study and to oversee adherence to the study protocol. The trial is registered with the Pan African Clinical Trials Registry (PACTR201808107241133). Participants provided written consent and were given a unique study identifier to maintain confidentiality.

3. RESULTS

Out of the 249 mothers who attended the ultrasound appointment at baseline, 12 of their babies died within their first 6 weeks of life, and 25 were lost‐to‐follow‐up. Presented results are based on the 212 mother–baby pairs who attended the 6‐week follow‐up visit.

3.1. Participant characteristics

The sociodemographic characteristics of the participants at baseline are shown in Table 1. The mean age of mothers' was 32 years (SD = 0.45), ranging from 18 to 47 years. The mean age of fathers' was 36 years (SD = 0.50), ranging from 20 to 56 years. A third of mothers (64%) had completed high school with the mean years at school being 11, the maximum 17 and the minimum 0. Forty‐five percent of the mothers were employed during pregnancy. Approximately, 90% of participants were either married or in a committed relationship with the father of their baby, although only 28% reported living with their partner. For 18% of mothers, this was their first pregnancy. Almost a third (30%) had had one previous pregnancy, with 29% and 12% having had two or three, respectively. For the mothers who had been pregnant before, 53% reported that they had breastfed their baby, either exclusively or mixed feeding. A small number of the mothers reported smoking (3%) and drinking alcohol (5%) throughout their pregnancy.

TABLE 1.

Descriptive statistics

n %
Maternal sociodemographic characteristics
Socio‐economic status
Highest 73 31.43
Middle 70 33.02
Lowest 69 32.55
Mother completed secondary school
Yes 135 63.7
No 77 36.3
Mother employed during pregnancy
Yes 96 45.3
No 116 54.7
Relationship status with father of baby
Not in a committed relationship 21 9.9
Married or committed relationship (living together) 60 28.3
Married or committed relationship (not living together) 130 61.3
Refuse to answer 1 0.5
Mother has other children
Yes 174 82.1
No 38 17.9
Mother breastfeed previous child
Yes 92 52.9
No 82 47.1
Mother reported smoking during pregnancy
Yes 7 3.30
No 205 96.70
Mother reported drinking alcohol during pregnancy
Yes 11 5.19
No 201 94.81
Birth information and feeding practices
Delivery type
Normal vaginal delivery 100 47.17
Caesarean section 112 52.83
Mother experienced complications at birth
Yes 34 16.04
No 178 83.96
Baby experienced complications at birth
Yes 30 14.15
No 182 85.85
Mother put baby to breast within 1 h after birth
Yes 120 56.60
No 92 43.40
Exclusive breastfeeding at 6 weeks
Yes 121 57.08
No 91 42.94
Low birth weight (<2.5 kg)
Yes 38 18.36
No 169 81.64
Open in a new tab

3.2. Child feeding and birth information

Mode of delivery was almost evenly distributed between normal vaginal delivery and caesarean section at 47% and 53%, respectively. Sixteen percent of mothers and 14% of babies reported experiencing complications at birth, respectively. Complications for the mother included excessive bleeding (9%), hypertension (27%) and infection (35%). Complications for the baby included preterm birth (27%), respiratory difficulties (17%) and jaundice (20%). Eighteen percent of babies were born low birth weight and the mean, minimum and maximum birth weight was 2.96 (SD = 0.57), 0.93 and 4.38 kg, respectively. Just over half (57%) of mothers reported that they put their baby to the breast within an hour after birth and by 6 weeks, 57% of the mothers were exclusively breastfeeding.

3.3. Father involvement

As seen in Table 2, fewer than half (43%) of male partners attended the study in United States with lower attendance (33%) of at least one routine antenatal care visit. Only 19% of the partners attended both the study ultrasound and at least one routine antenatal visit, whereas 37% attended one or the other, and 44% attended neither. Only 1% of partners were present at the birth of their child. Reasons given for fathers not attending their child's birth included hospital staff restricting their access (60%), the father working or living at a distance (28%), and the father being at work (8%). When asked if they felt that their partner made things harder for them because of the way they acted, 71% stated never, but 18% and 11% stated sometimes or always, respectively. Just over half of the mothers (52%) reported that their partners gave the most help with their own health, whereas 33% stated that they gave the most help with the baby. The majority of the participants rated their partners help as good or very good (83%), but 7% reported it as fair and 10% as poor. The most common type of support provided by the fathers was financial, although this was still low at 30% and the least common type of support provided was information (19%). The maximum father involvement score was 14, with 4% of male participants achieving the highest score. The mean father involvement score was 8 (SD = 3.49), and 7% of men had the lowest score of one. The majority had a father involvement score between five and nine (54%), whereas 19% and 27% had scores below five and above 10, respectively.

TABLE 2.

Father involvement

n %
Partner attended antenatal care
Yes 69 32.55
No 143 67.45
Partner attended study ultrasound
Yes 90 42.45
No 122 57.55
Partner attended birth
Yes 3 1.42
No 209 98.58
Reason partner not present during childbirth
He was not interested 3 1.44
He was at work 17 8.13
He works or lives away 57 27.27
The hospital would not let him 125 59.81
Other 7 3.35
Partner made things harder
Always 24 11.32
Sometimes 37 17.45
Never 151 71.23
Partner gave the most help with the baby
Yes 70 33.02
No 142 66.98
Partner gave most help with the mother
Yes 111 52.36
No 101 47.64
Partner provided information
Yes 41 19.34
No 171 80.66
Partner provided financial help
Yes 63 29.72
No 149 70.28
Partner provided practical help
Yes 61 28.77
No 151 71.23
Partner provided emotional support
Yes 56 26.42
No 156 73.58
Mother rating of partner help
Poor 22 10.38
Fair 14 6.60
Good 24 11.32
Very good 152 71.70
Open in a new tab

3.4. Maternal depression

Twenty‐nine percent of mothers scored more than 10 on the EPDS during pregnancy compared with 7% after birth. The mean antenatal depression score was seven (SD = 4.96), wereas the mean postnatal depression score was five (SD = 5.18). The maximum score on both occasions was 27.

3.5. Structural equation modelling

Table 3 shows the summarised results of the SEM for both models. Model 1 indicated that antenatal father involvement did not directly [β direct = −0.0088, p = 0.865, 95% confidence interval (CI) = −0.11 to 0.09] or indirectly impact birth weight (β indirect = −0.0018, p = 0.712, 95%CI = −0.01 to 0.01), nor did it directly affect antenatal maternal depression (β direct = −0.1762, p = 0.700, 95%CI = −1.07 to 0.72). The model also indicated that antenatal maternal depression did not directly impact birth weight (β direct = −0.0102, p = 0.186, 95%CI = −0.03 to 0.01). The results of the RMSEA and CFI suggested a well‐fitted model (RMSEA = 0.000, CFI = 1.00), but the TLI suggested a poorly fitted model (TLI = 0.411).

TABLE 3.

Summary results of the structural equation modelling (SEM)

Effect standardized coefficient (SE) Model fit statistics
Total Indirect Direct RMSEA CFI TLI
Model 1 0.000 1.000 1.411
Antenatal father involvement → Maternal antenatal depression score −0.1762 −0.1762
Maternal antenatal depression score → Birth weight −0.0102 −0.0102
Antenatal father involvement → Birth weight −0.0070 −0.0018 −0.0088
Model 2 0.000 1.000 1.429
Postnatal father involvement → Maternal postnatal depression score −0.1578 * −0.1578 *
Maternal postnatal depression score → Exclusive breastfeeding 0.0144 0.0144
Postnatal father involvement → Exclusive breastfeeding 0.0007 −0.0023 0.0030
Open in a new tab

Note: Each model controlled for intervention arm. Model 1—associations between father involvement and depression controlled for SES, number of years mother completed education, and relationship with the father of the baby. Associations between father involvement and birth weight controlled for mother employment, SES and type of delivery. Model 2—associations between father involvement and depression controlled for SES, mother having completed secondary school and maternal smoking and alcohol behaviours. Associations between father involvement and exclusive breastfeeding controlled for mother employment and SES.

Abbreviations: CFI, comparative fit index; RMSEA, root square mean error of approximation; SES, socio‐economic status; TLI, Tucker–Lewis index.

*

p < 0.05.

**

p < 0.01.

The fit indexes for Model 2 fit the criteria for a well‐fitting model (RMSEA = 0.000, CFI = 1.000, TLI = 1.429). The results indicated that postnatal father involvement can directly impact maternal postnatal depression (β direct = −0.1578, p = 0.019, 95%CI = −0.29 to −0.03) but that it does not indirectly (β indirect = −0.0023, p = 0.208, 95%CI = −0.01 to 0.001) or directly (β direct = 0.0030, p = 0.756, 95%CI = −0.02 to 0.02) influence exclusive breastfeeding. The results also indicated that postnatal depression did not directly influence whether a mother exclusively breastfed her infant (β direct = 0.0144, p = 0.136, 95%CI = −0.01 to 0.03).

4. DISCUSSION

We hypothesised that father involvement could positively impact birth weight and exclusive breastfeeding at 6 weeks and that the relationship may be mediated by maternal mental health.

Although our study did not find that father involvement positively impacted birth weight or exclusive breastfeeding, we found that higher levels of father involvement after pregnancy were associated with better postnatal maternal mental health, similar to that found by Lin et al. (2017). Children require a nurturing and responsive environment to ensure optimal growth and development but poor mental health and depression in mothers can reduce their ability to recognise and respond appropriately to a child's needs, and affect how they express warmth, affection and pleasure (WHO et al., 2018). In addition, depression in mothers has been linked to stunting (Rahman et al., 2004) and long‐term adverse impacts on child development, including behavioural and mental health problems (Mezulis et al., 2004; Netsi et al., 2018). Therefore, it is vital to continuously involve fathers and encourage them to support their partners from conception and throughout childhood to reduce the negative impact poor mental health can have on both the mother and child.

That said, the results of the study highlight that male involvement during and after pregnancy and birth in South Africa is low and that a number of barriers to paternal support remain. Although the majority of the mothers did not rate their partners help poorly, they did indicate that it was not their partner who helped the most with the baby, and very few provided emotional, financial or practical support. We did not explore the reasons as to support was low, but research indicates this could include men working at a distance, unemployment, non‐fulfilment of cultural practices such as inhlawulo (acknowledgement of paternity) or lobola (bride price), poverty, housing shortages or incarceration (Makusha & Richter, 2018; Posel & Rudwick, 2014). The public health system can also act as a barrier with antenatal and postnatal services usually offered only during weekdays and working hours, which is a constraint for working men, particularly those in the informal industry. In addition, few public health facilities in South Africa accommodate a birthing companion, either male or female, due to staff attitudes or a lack of space, privacy concerns or resources (Brown et al., 2007; Lambert et al., 2018; Spencer et al., 2018). In this study, 60% of the women indicated that hospital staff denied their partner access to the birth, similar to experiences reported by Hastings‐Tolsma et al. (2018) and Malatji and Madiba (2020), also in South Africa. Although we offered the ultrasound appointment on a weekend to accommodate working men, very few utilised this option suggesting there could be additional social or cultural reasons for non‐attendance or low involvement, all of which should be explored further if male involvement is to be improved.

For the men that did attend the study ultrasound, after witnessing the scan, they reported positive feelings towards their partner and forthcoming child, as well as a desire to provide them with more support (Drysdale et al., 2020). As these results indicate, interventions that have targeted men directly and aimed to improve their involvement during the antenatal period have been shown to improve antenatal care attendance, maternal nutrition, birth preparedness and postpartum care. They can also improve communication and encourage joint decision‐making among couples (Tokhi et al., 2018). However, we also know that these interventions targeted at individual partners need to be supported by structural programmes, which include the uptake of paternity leave provisions for working fathers and creating a conducive health care system that accommodates both women and men during the perinatal period. By not targeting men, we may be missing an opportunity to improve child health, nutrition and development, as well as maternal health outcomes. Health services should incorporate messages and guidance specifically directed at men on how they can support women and children during and after pregnancy. These could include information on the importance of attending antenatal care, supporting their partners' adherence to antenatal supplements and the discouragement of substance use, and purchasing infant formula which men sometimes do to demonstrate their capacity to support their child, and preferably to support exclusive breastfeeding.

At 18%, the prevalence of low birth weight in this study was slightly higher than the 15% national average (NDoH, 2019). This may be attributable to the recruitment procedures of our study. Enrolled mothers were screened for foetal abnormalities and serious maternal health conditions. However, they were attending CHBH for antenatal care because they were deemed to be at risk during pregnancy due to comorbidities such as hypertension, diabetes or HIV. Research highlights that individual factors, such as maternal nutritional status, dietary practices and maternal behaviours such as smoking contribute to poor foetal growth and low birth weight (Bailey & Byrom, 2007; He et al., 2018; Kataoka et al., 2018; Rao & Raje, 2017; Sharma & Mishra, 2014). Based on this and our findings, we suggest that father involvement alone, especially in the context of low marriage and cohabitation rates and high unemployment and poverty, is not sufficient to improve birth weight. Nonetheless, as indicated by previous research, men can encourage and support women to practice healthy behaviours during pregnancy (Alio et al., 2010; Makusha & Richter, 2018; Martin et al., 2007), and specific guidance or advice on how to do so, as previously suggested, could help to reduce adverse birth outcomes.

In terms of feeding practices, 57% of the mothers were exclusively breastfeeding at 6 weeks, which is higher than the national average (NDoH et al., 2019). However, we anticipate that the rate of exclusive breastfeeding would fall by the time the infants are 6 months old. Early mother–infant separation remains one of the biggest barriers to exclusive breastfeeding in South Africa, mainly due to mothers returning to economic or educational activities (Horwood et al., 2020; Remmert et al., 2020) and a lack of supportive economic policies. For example, in South Africa, women working in the formal sector are entitled to a minimum of 4 months paid maternity leave claimed through the Department of Labour, which includes time prebirth and postbirth (Basic Conditions of Employment Act 75 of 1997). This is despite the NDoH recommendation to exclusively breastfeed up to 6 months and to continue breastfeeding up to 2 years (NDoH, 2013). Women working in the informal sector have no option but to return to work earlier. Although not apparent in our study, men can support and encourage breastfeeding if educated and informed (Dinga et al., 2018; Maycock et al., 2013) but without removing the aforementioned economic barriers in South Africa, exclusive breastfeeding will continue to be low in infants up to 6 months. The health and developmental benefits of early initiation and continued breastfeeding are conclusive (Hansen, 2016; Horta & Victoria, 2013a, 2013b; Kramer & Kakuma, 2012; Victoria et al., 2016; WHO, 2020); therefore, policies need to be reassessed and updated to ensure women receive the time, space and support to optimally feed their infants.

4.1. Study limitations

The study uses panel data collected at two time points to conduct a path analysis using SEM. Although this cannot determine causality, it is a useful approach to test our hypothesis and correlation between the variables of interest. As with many longitudinal studies, attrition occurred, and there was a loss to follow‐up rate of 14%: 4% due to death of the infant, and 10% due to mother withdrawal, relocation or inability to contact her. Due to limited information available, we are unable to determine whether father involvement or maternal mental health was in any way associated with infant death or loss to follow up. One strength of the study was the ability to take into account changes in mental health over time with repeated use of the EPDS; however, we did not take into account possible changes in sociodemographic characteristics, such as income or relationship status. In addition, antenatal father involvement was measured unidimensionally, which may explain the lack of associations between involvement and antenatal depression, particularly because more women showed signs of antenatal depression compared with postnatal depression. The data were collected from the female participants and is therefore missing valuable information on the fathers, including their employment or education status. In the 6‐month follow up, this information was collected from the men who attended the visit, but in future, it should be collected from baseline. Finally, the study assessed the impact of father involvement at birth and 6 weeks when the baby is very young, which may be too early to gauge any impact of father involvement. However, follow‐up is continuing to 6 months, and we plan to further assess whether father involvement influences child nutritional status and cognitive development at 6 months.

5. CONCLUSIONS

Our study found no association between father involvement, low birth weight or exclusive breastfeeding at 6 weeks; however, increased father involvement was associated with improved maternal postnatal mental health. Progress towards improving low birth weight and exclusive breastfeeding in South Africa remains slow and additional information, support and policy changes are required to effect large‐scale change. Men should be encouraged to attend antenatal health visits with their partner and should be provided with specific messages and guidance on how best to provide support during and after pregnancy. Given the South African context where more than two thirds of children reside in a household without their biological father, both public health and individual approaches will be needed. The overall message should be to encourage every father to be present, supportive and involved during and after pregnancy regardless of their relationship or residency status. Future research should conduct in‐depth analyses on barriers to father involvement and how these may impact maternal mental health.

CONFLICTS OF INTEREST

The authors declare that they have no conflicts of interest.

CONTRIBUTIONS

RED conceptualised the paper, conducted the analysis and wrote the first draft. WS, TM and LMR read and commented on the paper. LMR is the principal investigator of the Healthy Pregnancy Healthy Baby study. All authors read and approved the final version of the manuscript before submission.

TRIAL REGISTRATION

The trial was registered through the Pan African Clinical Trials Registry in August 2018 (PACTR201808107241133).

ACKNOWLEDGMENTS

The project is funded by Saving Brains, a partner of Grand Challenges Canada, the Aga Khan Foundation Canada, the Bernard van Leer Foundation, the Bill and Melinda Gates Foundation, the ELMA Foundation, Grand Challenges Ethiopia, the Maria Cecilia Souto Vidigal Foundation, the Palix Foundation, the UBS Optimus Foundation and World Vision Canada (SB‐POC‐1810‐19664).

Drysdale RE, Slemming W, Makusha T, Richter LM. Father involvement, maternal depression and child nutritional outcomes in Soweto, South Africa. Matern Child Nutr. 2021;17:e13177. 10.1111/mcn.13177

Funding information UBS Optimus Foundation and World Vision Canada, Grant/Award Number: SB‐POC‐1810‐19664; ELMA Foundation; Bill and Melinda Gates Foundation; Bernard van Leer Foundation; Aga Khan Foundation Canada; Grand Challenges Canada

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

REFERENCES

  1. Accrombessi, M. , Zeitlin, J. , Massougbodji, A. , Cot, M. , & Briand, V. (2017). What do we know about risk factors for fetal growth restriction in Africa at the time of Sustainable Development Goals? A scoping review. Paediatric and Perinatal Epidemiology, 32, 184–196. 10.1111/ppe.12433 [DOI] [PubMed] [Google Scholar]
  2. Alio, A. P. , Salihu, H. M. , Kornosky, J. L. , Richman, A. M. , & Marty, P. J. (2010). Feto‐infant health and survival: Does paternal involvement matter? Maternal & Child Health Journal, 14, 931–937. 10.1007/s10995-009-0531-9 [DOI] [PubMed] [Google Scholar]
  3. Bailey, B. A. , & Byrom, A. R. (2007). Factors predicting low birth weight in a low‐risk sample: The role of modifiable pregnancy health behaviours. Maternal and Child Health Journal, 11, 173–179. 10.1007/s10995-006-0150-7 [DOI] [PubMed] [Google Scholar]
  4. Basic Conditions of Employment Act . (1997). Act 75. South Africa.
  5. Black, M. M. , Walker, S. P. , Fernald, L. C. H. , Anderson, C. T. , DiGirolamo, A. M. , Lu, C. , McCoy, S. , McCoy, D. C. , Fink, G. , Shawar, Y. R. , Shiffman, J. , Devercelli, A. E. , Wodon, Q. T. , Vargas‐Barón, E. , Grantham‐McGregor, S. , & for the Lancet Early Childhood Development Series Steering Committee . (2017). Early childhood development coming of age: Science through the life course. Lancet, 389, 77–90. 10.1016/S0140-6736(16)31389-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Blencowe, H. , Krasevec, J. , de Onis, M. , Black, R. E. , An, X. , Stevens, G. A. , Borghi, E. , Hayashi, C. , Estevez, D. , Cegolon, L. , Shiekh, S. , Hardy, V. P. , Lawn, J. E. , & Cousens, S. (2019). National, regional, and worldwide estimates of low birthweight in 2015, with trends from 2000: A systematic analysis. The Lancet, 7, E849–E860. 10.1016/S2214-109X(18)30565-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Blencowe, H. , Lee, A. C. C. , Cousens, S. , Bahalim, A. , Narwal, R. , Zhong, N. , Chou, D. , Say, L. , Modi, N. , Katz, J. , Vos, T. , Marlow, N. , Cousens, S. , & Lawn, J. E. (2013). Preterm birth‐associated neurodevelopmental impairment estimates at regional and global levels for 2010. Pediatric Research, 74, 17–34. 10.1038/pr.2013.204 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Brittain, K. , Myer, L. , Koen, N. , Koopowitz, S. , Donald, K. A. , Barnett, W. , Zar, H. J. , & Stein, D. J. (2015). Risk factors for antenatal depression and associations with infant birth outcomes: Results from a South African birth cohort study. Paediatric and Perinatal Epidemiology, 29, 505–514. 10.1111/ppe.12216 [DOI] [PubMed] [Google Scholar]
  9. Britto, P. R. , Lye, S. J. , Proulx, K. , Yousafzai, A. K. , Matthews, S. G. , Vaivada, T. , Perez‐Escamilla, R. , Rao, N. , Ip, P. , Fernald, L. C. H. , MacMillan, H. , Hanson, M. , Wachs, T. D. , Yao, H. , Yoshikawa, H. , Cerezo, A. , Leckman, J. F. , Bhutta, Z. A. , & Early Childhood Development Interventions Review Group, for the Lancet Early Childhood Development Series Steering Committee . (2016). Nurturing care: Promoting early childhood development. The Lancet, 389, 91–102. 10.1016/s0140-6736(16)31390-3 [DOI] [PubMed] [Google Scholar]
  10. Brown, H. , Hofmeyr, G. J. , Nikodem, V. C. , Smith, H. , & Garner, P. (2007). Promoting childbirth companions in South Africa: A randomised pilot study. BMC Medicine, 5, 7. 10.1186/1741-7015-5-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Cheng, E. R. , Rifas‐Shiman, S. L. , Perkins, M. E. , Rich‐Edwards, J. W. , Gillman, M. W. , Wright, R. , & Taveras, E. M. (2016). The influence of antenatal partner support on pregnancy outcomes. Journal of Women's Health, 27, 672–679. 10.1089/jwh.2015.5462 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Choi, S. K. , Kim, J. J. , Park, Y. G. , Ko, H. S. , Park, I. Y. , & Shin, J. C. (2012). The simplified Edinburgh Postnatal Depression Scale (EPDS) for antenatal depression: Is it a valid measure for pre‐screening? International Journal of Medical Sciences, 9, 40–46. 10.7150/ijms.9.40 [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Christian, P. , Lee, S. E. , Angel, M. D. , Adair, L. S. , Arifeen, S. E. , Ashorn, P. , Barros, F. C. , Fall, C. H. D. , Fawzi, W. W. , Hao, W. , Hu, G. , Humphrey, J. H. , Huybregts, L. , Joglekar, C. V. , Kariuki, S. K. , Kolsteren, P. , Krishnaveni, G. V. , Liu, E. , Martorell, R. , … Black, R. E. (2013). Rick of childhood undernutiriton related to small‐for‐gestational age and preterm birth in low‐ and middle‐income countries. International Journal of Epidemiology, 42, 1340–1355. 10.1093/ije/dyt109 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Cox, J. L. , Holden, J. M. , & Sagovsky, R. (1987). Detection of postnatal depression. Development of the 10‐item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782–786. 10.1192/bjp.150.6.782 [DOI] [PubMed] [Google Scholar]
  15. Cusick, S. E. , & Georgieff, M. K. (2016). The role of nutirition in brain development: The golden opportunity of the “first 1000 days”. The Journal of Pediatrics, 175, 16–21. 10.1016/j.jpeds.2016.05.013 [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Dadi, A. F. , Miller, E. R. , & Mwanri, L. (2020). Antenatal depression and its associations with adverse birth outcomes in low and middle‐income countries: A systematic review and meta‐analysis. PLoS One, 15, e0227323. 10.1371/journal.pone.0227323 [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Dadi, A. F. , Miller, E. R. , Woodman, R. J. , Azale, T. , & Mwanri, L. (2020). Effect of antenatal depression on adverse birth outcomes in Gondar town, Ethiopia: A community‐based cohort study. PLoS One, 15, e0234728. 10.1371/journal.pone.0234728 [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Dinga, L. A. , Kiage, B. M. , & Kyallo, F. M. (2018). Effect of father involvement in infant feeding on nutritional status and morbidity in Kisumu, Kenya. Journal of Nutrition and Health Sciences, 5, 1. 10.15744/2393-9060.5.105 [DOI] [Google Scholar]
  19. Drysdale, R. E. , Slemming, W. , Makusha, T. , & Richter, L. M. (2020). Fathers' experiences of early pregnancy ultrasounds in Soweto, South Africa: The Healthy Pregnancy Healthy Baby Randomised Trial. Manuscript submitted for publication.
  20. Elsenbruch, S. , Benson, S. , Rücke, M. , Rose, M. , Dudenhausen, J. , Pincus‐Knackstedt, M. K. , Klapp, B. F. , & Arck, P. C. (2007). Social support during pregnancy: Effects on maternal depressive symptoms, smoking and pregnancy outcome. Human Reproduction, 22, 869–877. 10.1093/humrep/del432 [DOI] [PubMed] [Google Scholar]
  21. Feldman, R. , Bamberger, E. , & Kanat‐Maymon, Y. (2013). Parent‐specific reciprocity from infancy to adolescence shapes children's social competence and dialogical skills. Attachment & Human Development, 15, 407–423. 10.1080/14616734.2013.782650 [DOI] [PubMed] [Google Scholar]
  22. Ghosh, J. , K, C. , Wilhelm, M. H. , Dunkel‐Schetter, C. , Lombardi, C. A. , & Ritz, B. R. (2010). Paternal support and preterm birth, and the moderation of effects of chronic stress: A study in Los Angeles County mothers. Archives of Women's Mental Health, 13, 327–338. 10.1007/s00737-009-0135-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Global Nutrition Report . (2020). 2020 Global Nutrition Reprot: Action on equity to end malnutrition. Bristol, UK: Development Initiatives. [Google Scholar]
  24. Gluckman, P. D. , Hason, M. A. , & Beedle, A. S. (2006). Early life events and their consequences for later disease: A life history and evolutionary perspective. American Journal of Human Biology, 19, 1–19. 10.1002/ajhb.20590 [DOI] [PubMed] [Google Scholar]
  25. Greene, A. D. , Halle, T. G. , Le Menestrel, S. M. , & Moore, K. A. (2001). Measuring father involvement in young children's lives: Recommendations for a fatherhood module for the ECLS‐B. Working Paper No. 2001‐02. Washington, DC, United States: U.S. Department of Education, National Centre for Education Statistics.
  26. Hansen, K. (2016). Breastfeeding: A smart investment in people and in economies. The Lancet, 387, 416. 10.1016/s0140-6736(16)00012-x [DOI] [PubMed] [Google Scholar]
  27. Hastings‐Tolsma, M. , Nolte, A. G. W. , & Temane, A. (2018). Birth stories from South Africa: Voices unheard. Women and Birth, 31, e42–e550. 10.1016/j.wombi.2017.06.015 [DOI] [PubMed] [Google Scholar]
  28. He, Z. , Bishwajit, G. , Yaya, S. , Cheng, Z. , Zou, D. , & Zhou, Y. (2018). Prevalence of low birth weight and its association with maternal body weight status in selected countries in Africa: A cross‐sectional study. BMJ Open, 8, e020410. 10.1136/bmjopen-2017-020410 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Horta, B. L. , & Victoria, C. G. (2013a). Long‐term effects of breastfeeding: A systematic review. Geneva: World Health Organization. [Google Scholar]
  30. Horta, B. L. , & Victoria, C. G. (2013b). Short‐term effects of breastfeeding: A systematic review on the benefits of breastfeeding on diarrhoea and pneumonia mortality. Geneva: World Health Organization. [Google Scholar]
  31. Horwood, C. , Haskins, L. , Engebretsen, I. , Connolly, C. , Coutsoudis, A. , & Spies, L. (2020). Are we doing enough? Improved breastfeeding practices at 14 weeks but challenges of non‐initiation and early cessation of breastfeeding remain: Findings of two consecutive cross‐sectional surveys in KwaZulu‐Natal, South Africa. BMC Public Health, 20, 440. 10.1186/s12889-020-08567-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Jackson, D. B. (2017). The interplay between early father involvement and neonatal medical risk in the prediction of infant neurodevelopment. Prevention Science, 18, 106–115. 10.1007/s11121-016-0734-4 [DOI] [PubMed] [Google Scholar]
  33. Kansiime, N. , Atwine, D. , Nuwamanya, S. , & Bagenda, F. (2017). Effect of male involvement on the nutritional status of children less than 5 years: A cross sectional study in a rural Southwestern District of Uganda. Journal of Nutrition & Metabolism, 2017, 3427087. 10.1155/2017/3427087 [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Kataoka, M. C. , Carvalheira, A. P. P. , Ferrari, A. P. , Malta, M. B. , Carvalhaes, A. B. L. , & Parada, C. M. G. L. (2018). Smoking during pregnancy and harm reduction in birth weight: A cross‐sectional study. BMC Pregnancy and Childbirth, 18, 67. 10.1186/s12884-018-1694-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Kibret, K. T. , Chojenta, C. , Gresham, E. , Tegegne, T. K. , & Loxton, D. (2019). Maternal dietary patterns and risk of adverse pregnancy (hypertensive disorders of pregnancy and gestational diabetes mellitus) and birth (preterm birth and low birth weight) outcomes: A systematic review and meta‐analysis. Public Health Nutrition, 22, 506–520. 10.1017/s1368980018002616 [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Knop, M. R. , Geng, T. T. , Gorny, A. W. , Ding, R. , Li, C. , Ley, S. H. , & Huang, T. (2018). Birth weight and risk of type 2 diabetes mellitus, cardiovascular disease and hypertension in adults: A meta‐analysis of 7 646 267 participants from 135 studies. Journal of the American Heart Association, 7, e00870. 10.1161/jaha.118.008870 [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Kramer, M. S. , & Kakuma, R. (2012). Optimal duration of exclusive breastfeeding. Cochrane Database of Systematic Reviews, 2021, 8. 10.1002/14651858.cd003517.pub2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Lamb, M. E. (2010). The role of the father in child development. Hoboken: John Wiley & Sons. [Google Scholar]
  39. Lambert, J. , Etsane, E. , Bergh, A. M. , Pattinson, R. , & van den Broek, N. (2018). ‘I thought they were going to handle me like a queen but they didn't’: A qualiatiative study exploring the quality of care provided to women at the time of birth. Midwifery, 62, 256–263. 10.1016/j.midw.2018.04.007 [DOI] [PubMed] [Google Scholar]
  40. Lawrie, T. A. , Hofmeyr, G. J. , De Jager, M. , & Berk, M. (1998). Validation of the Edinburgh Postnatal Depression Scale on a cohort of South African women. South African Medical Journal, 88, 1340–1344. [PubMed] [Google Scholar]
  41. Lin, W. , Chang, S. , Chen, Y. , Lee, H. , & Chen, Y. (2017). Postnatal paternal involvement and maternal emotional disturbances: The effect of maternal employment status. Journal of Affective Disorders, 219, 9–16. 10.1016/j.jad.2017.05.010 [DOI] [PubMed] [Google Scholar]
  42. Maharlouei, N. (2016). The importance of social support during pregnancy. Women's Health Bulletin, 3, e34991. 10.17795/whb-34991 [DOI] [Google Scholar]
  43. Makusha, T. , & Richter, L. M. (2018). Father involvement in the first 1,000 days. In van den Berg W. & Makusha T. (Eds.), State of South Africa's fathers (Vol. 2018) (pp. 49–62). Cape Town: Sonke Gender Justice and Human Sciences Research Council. [Google Scholar]
  44. Malatji, R. , & Madiba, S. (2020). Disrespect and abuse experienced by women during childbirth in midwife‐led obstetric units in Tshwane District, South Africa: A qualitative study. International Journal of Environmental Research and Public Health, 17, 3667. 10.3390/ijerph17103667 [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Martin, L. T. , McNamara, M. J. , Milot, A. S. , Halle, T. , & Hair, E. C. (2007). The effects of father involvement during pregnancy on receipt of prenatal care and maternal smoking. Maternal & Child Health Journal, 11, 595–602. 10.1007/s10995-007-0209-0 [DOI] [PubMed] [Google Scholar]
  46. Maselko, J. , Hagaman, A. K. , Bates, L. M. , Bhalotra, S. , Biroli, P. , Gallis, J. A. , O'Donnell, K. , Sikander, S. , Turner, E. L. , & Rahman, A. (2019). Father involvement in the first year of life: Associations with maternal mental health and child development outcomes in rural Pakistan. Social Science & Medicine, 237, 112421. 10.1016/j.socscimed.2019.112421 [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Maycock, B. , Binns, C. W. , & Dhaliwal, S. (2013). Education and support for fathers improves breastfeeding rates: A randomized controlled trial. Journal of Human Lactation, 29, 484–490. 10.1177/0890334413484387 [DOI] [PubMed] [Google Scholar]
  48. McKee, C. L. , Stapleton, P. B. , & Pidgeon, A. M. (2018). History of pre and perinatal (PPN) parenting education: A literature review. Journal of Prenatal & Perinatal Psychology & Health, 32, 191–219. [Google Scholar]
  49. Mezulis, A. H. , Hyde, J. S. , & Clark, R. (2004). Father involvement moderates the effect of maternal depression during a child's infancy on child behaviour problems in kindergarten. Journal of Family Psychology, 18, 575–588. 10.1037/0893-3200.18.4.575 [DOI] [PubMed] [Google Scholar]
  50. Mphego, Z. , Madiba, S. , & Ntuli, B. (2014). The influence of the family on adherence to exclusive breastfeeding: Experiences of women living in extended family households in poorly resourced communities of Mpumalanga Province, South Africa. African Journal for Physical, Health Education, Recreation and Dance, S1, 279–290. [Google Scholar]
  51. National Department of Health . (2013). South Africa infant and young feeding policy, 2013. Pretoria: National Department of Health. [Google Scholar]
  52. National Department of Health, Statistics South Africa, South Africa Medical Research Council, & ICF . (2019). South Africa Demographic and Health Survey 2016. Pretoria: National Department of Health. [Google Scholar]
  53. Netsi, E. , Pearson, R. M. , Murray, L. , Cooper, P. , Craske, M. G. , & Stein, A. (2018). Association of persistent and severe postnatal depression with child outcomes. JAMA Psychiatry, 75, 247–253. 10.1001/jamapsychiatry.2017.4363 [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Pellowski, J. A. , Bengtson, A. M. , Barnett, W. , DiClemente, K. , Koen, N. , Zar, J. , & Stein, D. J. (2019). Perinatal depression among mothers in a South African birth cohort study: Trajectories from pregnancy to 18 months postpartum. Journal of Affective Disorders, 259, 279–287. 10.1016/j.jad.2019.08.052 [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Peltzer, K. , Rodriguez, V. J. , Lee, T. K. , & Jones, D. (2018). Prevalence of prenatal and postpartum depression and associated factors among HIV‐infected women in public primary care in rural South Africa: A longitudinal study. AIDS Care, 30, 1372–1379. 10.1080/09540121.2018.1455960 [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Perez‐Escamilla, R. (1994). Breastfeeding in Africa and the Latin America and Caribbean region: The potential role of urbanization. Journal of Tropical Pediatrics, 40, 137–143. 10.1093/tropej/40.3.137 [DOI] [PubMed] [Google Scholar]
  57. Perry, E. C. , Potgieter, C. , & Bob, U. (2010). Environmental conflicts and women's vulnerability in Africa. African Journal on Conflict Resolution, 10, 121–136. 10.4314/ajcr.v10i2.63315 [DOI] [Google Scholar]
  58. Plantin, L. , Olukoya, A. A. , & Ny, P. (2011). Positive health outcomes of fathers' involvement in pregnancy and childbirth paternal support: A scope study literature review. Fathering, 9, 87–102. 10.3149/fth.0901.87 [DOI] [Google Scholar]
  59. Posel, D. , & Rudwick, S. (2014). Ukukipita (Cohabiting): Socio‐cultural constraints in urban Zulu society. Journal of Asian and African Studies, 49, 282–297. 10.1177/0021909613485705 [DOI] [Google Scholar]
  60. Prado, E. L. , & Dewey, K. G. (2014). Nutrition and brain development in early life. Nutrition Reviews, 72, 267–284. 10.1111/nure.12102 [DOI] [PubMed] [Google Scholar]
  61. Rahman, A. , Iqbal, Z. , Bunn, J. , Lovel, H. , & Harrington, R. (2004). Impact of maternal depression on infant nutritional status. Archives of general Psychology, 61, 946–952. 10.1001/archpsyc.61.9.946 [DOI] [PubMed] [Google Scholar]
  62. Raj, V. K. , & Plichta, S. B. (1998). The role of social support in breastfeeding promotion: A literature review. Journal of Human Lactation, 14, 41–45. 10.1177/089033449801400114 [DOI] [PubMed] [Google Scholar]
  63. Rao, S. , & Raje, S. (2017). Nutritional risk factors of low birth weight among poor rural mothers from Maharashtra, India. Journal of Nutritional Health & Food Science, 5, 1–7. 10.15226/jnhfs.2017.001104 [DOI] [Google Scholar]
  64. Remmert, J. E. , Mosery, N. , Goodman, G. , Bangsberg, D. R. , Safren, S. A. , Smit, J. A. , & Psarps, C. (2020). Breastfeeding practices among women living with HIV in KwaZulu‐Natal, South Africa: An observational study. Maternal & Child Health Journal, 24, 127–134. 10.1007/s10995-019-02848-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  65. Richter, L. M. , Dealmans, B. , Lombardi, J. , Heymann, J. , Boo, F. L. , Behrman, J. R. , Lu, C. , Lucas, J. E. , Perez‐Escamilla, R. , Dua, T. , Bhutta, Z. A. , Stenberg, K. , Gertler, P. , Darmstadt, G. L. , & the Lancet Early Childhood Development Series Steering Committee . (2017). Investing in the foundation of sustainable development: Pathways to scale up for early childhood development. The Lancet, 389, 103–118. 10.1016/S0140-6736(16)31698-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  66. Richter, L. M. , Slemming, W. , Norris, S. A. , Stein, A. , Poston, L. , & Pasupathy, D. (2020). Health Pregnancy Healthy Baby: Testing the added benefits of pregnancy ultrasound scan for child development in a randomised control trial. Trials, 21, 25. 10.1186/s13063-019-3924-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  67. Scherbaum, V. , & Srour, M. L. (2016). The role of breastfeeding in the prevention of childhood malnutrition. In Biesalski H. K. & Black R. E. (Eds.), Hidden hunger. Malnutrition in the first 1,000 days of life: Causes consequences and solutions. Krager: World Review of Nutrition & Dietetics. [DOI] [PubMed] [Google Scholar]
  68. Schwarzenberg, S. J. , & Georgieff, M. K. (2018). Advocacy for improving nutrition in the first 1000 days to support childhood development and adult health. Pediatrics, 141, e20173716. 10.1542/peds.2017-3716 [DOI] [PubMed] [Google Scholar]
  69. Sharma, M. , & Mishra, S. (2014). Effects of maternal health and nutrition on birth weight of infant. International Journal of Science and Research, 3, 855–858. [Google Scholar]
  70. Silva, C. S. , Lima, M. C. , Sequeira‐de‐Andrade, L. A. S. , Oliveira, J. S. , Monteiro, J. S. , Lima, N. M. S. , Santos, R. M. A. B. , & Lira, P. I. C. (2017). Association between postpartum depression and the practice of exclusive breastfeeding in the first three months of life. Jornal de Pediatria, 93, 356–364. 10.1016/j.jpedp.2017.01.003 [DOI] [PubMed] [Google Scholar]
  71. Souza, L. V. , De Meneck, F. , Oliveira, V. , Higa, E. M. , Akamine, E. H. , & do Carmo Franco, M. (2019). Detrimental impact of low birth weight on circulating number and functional capacity of endothelial progenitor cells in health children: Role of angiogenic factors. The Journal of Pediatrics, 206, 72–77. 10.1016/j.jpeds.2018.10.040 [DOI] [PubMed] [Google Scholar]
  72. Spencer, N. S. , du Preez, A. , & Minnie, C. S. (2018). Challenges in implementing continuous support during childbirth in selected public hospitals in the North West Province of South Africa. Health SA Gesondheid, 23, 1–8. 10.4102/hsag.v23i0.1068 [DOI] [PMC free article] [PubMed] [Google Scholar]
  73. Tokhi, M. , Comrie‐Thompson, L. , Davis, J. , Portela, A. , Chersich, M. , & Luchters, S. (2018). Involving men to improve maternal and newborn health: A systematic review of the effectiveness of interventions. PLoS One, 13, e0191620. 10.1371/journal.pone.0191620 [DOI] [PMC free article] [PubMed] [Google Scholar]
  74. Trafford, Z. , Jewett, S. , Swartz, A. , LeFevre, A. E. , Winch, P. J. , Colvin, C. J. , Barron, P. , & Bamford, L. (2020). Reported infant feeding practices and contextual influences on breastfeeding: Qualitative interviews with women registered to MomConnect in three South African provinces. International Breastfeeding Journal, 15, 81. 10.1186/s13006-020-00315-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  75. UNICEF . (2020). Reducing stunting. Retrieved from https://www.unicef.org/esa/reduce‐stunting
  76. Van Heyningen, T. , Honikman, S. , Myer, L. , Onah, M. N. , Field, S. , & Tomlinson, M. (2017). Prevalence and predictors of anxiety disorders amongst low‐income women in urban South Africa: A cross‐sectional study. Archives of Women's Mental Health, 20, 765–775. 10.1007/s00737-017-0768-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  77. Van Heyningen, T. , Myer, L. , Onah, M. , Tomlinson, M. , Field, S. , & Honikman, S. (2016). Antenatal depression and adversity in urban South Africa. Journal of Affective Disorders, 203, 121–129. 10.1016/j.jad.2016.05.052 [DOI] [PMC free article] [PubMed] [Google Scholar]
  78. Victoria, C. G. , Bahl, R. , Barros, A. J. D. , França, G. V. A. , Horton, S. , Krasevec, J. , Murch, S. , Sankar, M. J. , Walker, N. , & for the Lancet Breastfeeding Series Group . (2016). Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet, 387, 475–490. 10.1016/S0140-6736(15)01024-7 [DOI] [PubMed] [Google Scholar]
  79. Walsh, T. B. , Tolman, R. M. , Singh, V. , Davis, M. M. , & Davis, R. N. (2017). Expectant fathers' prescence at prenatal ultrasounds: An opportunity for engagement. Social Work Research, 31, 181–185. 10.1093/swr/svx014 [DOI] [Google Scholar]
  80. World Health Organization . (2008). Indicators for assessing infant and young child feeding practices: Conclusions of a consensus meeting held 6–8 November 2007 in Washington, DC, USA. Geneva: World Health Organization. [Google Scholar]
  81. World Health Organization . (2014a). Global nutrition targets 2025: Low birth weight policy brief (WHO/NMH/NHD/14.5). Geneva: World Health Organization. [Google Scholar]
  82. World Health Organization . (2014b). Comprehensive implementation plan on maternal, infant and young child nutrition. Geneva: World Health Organization. [DOI] [PMC free article] [PubMed] [Google Scholar]
  83. World Health Organization . (2018). Reducing stunting in children: Equity considerations for achieving the Global Nutrition Targets 2025. Geneva: World Health Organization. [Google Scholar]
  84. World Health Organization . (2020). Infant and young child feeding: Key facts. Retrieved from https://www.who.int/news‐room/fact‐sheets/detail/infant‐and‐young‐child‐feeding

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Articles from Maternal & Child Nutrition are provided here courtesy of Wiley

RESOURCES