Present as a partner and a parent: Mothers’ and fathers’ perspectives on father participation in prenatal care

Abstract

Supportive father involvement during pregnancy can positively impact maternal and child outcomes. Father participation in prenatal care is increasing, yet little research exists to understand how mothers and fathers experience father participation in prenatal care and their preferences for father participation. We interviewed expectant first-time mothers (N = 22) and fathers (N = 20) to learn about fathers’ participation in prenatal care, perceptions of providers’ treatment of fathers, and preferences for father participation. Interviews were coded using principles of grounded theory. Father participation ranged from attendance at visits considered “important” (e.g., ultrasounds) to attendance at every appointment. Experiences of father participation varied, with many describing it as both an important act of support for the mother and part of assuming the role of father. Most participants saw great value in father participation in prenatal care as an opportunity for fathers to learn how to support a healthy pregnancy, bond with their developing baby, and share joy and/or worries with mothers. Participants generally felt that fathers were made to feel welcome and wanted providers to be inclusive of fathers during appointments. Results of this study suggest that father participation presents an opportunity for prenatal care providers to foster fathers’ positive involvement in pregnancy, support for mothers, and preparation to parent.

1 ∣. INTRODUCTION

A growing body of research recognizes the impact of father involvement during pregnancy on maternal and child health outcomes (e.g., Alio et al., 2011; Ghosh et al., 2010; Lee et al., 2018; Misra et al., 2010) and the associations between prenatal and postnatal father involvement (Bronte-Tinkew et al., 2007; Cabrera et al., 2008), yet little research has focused specifically on father participation in prenatal care or explored the perspectives of both mothers and fathers on father participation. With prenatal care being one of the most common health interventions in the United States (Alexander & Kotelchuk, 2001) and father participation in prenatal care becoming increasingly normative (Walsh et al., 2017), it is timely and necessary to better understand the phenomenon of father participation in prenatal care and how father participation can be supported in ways that promote positive experiences of care for pregnant women. This study aimed to inform understanding of the concept of father’s participation in prenatal care from the perspectives of mothers and fathers in the United States and identify strategies for engaging fathers that are consistent with mothers’ needs and preferences for their care.

1.1 ∣. Prenatal father involvement

Father involvement during pregnancy is associated with a range of improved maternal and child health outcomes. When fathers are more involved, mothers are more likely to seek prenatal care and avoid unhealthy behaviors (e.g., alcohol and tobacco use) during pregnancy, and pre-term birth and low birth weight are less likely (Alio et al., 2010; Kiernan & Pickett, 2006; Lee et al., 2018; Martin et al., 2007; Teitler, 2001). In this literature, father involvement has been operationalized in diverse ways, including whether the father’s name is on the child’s birth certificate, provision of financial support to the mother during pregnancy, and indicators of the strength of the connection between mother and father (Zvara et al., 2013).

Prenatal father involvement is also associated with parenting outcomes. Father involvement during pregnancy is predictive of father engagement during the postpartum period and beyond (Bronte-Tinkew et al., 2007; Cabrera et al., 2008), and father engagement in turn is a salient predictor of child development (Lamb, 2010). In this literature, father involvement has been assessed via questions about specific actions fathers may have taken during pregnancy, such as buying things for the baby or discussing with the mother how the pregnancy was going (Zvara et al., 2013). Across multiple studies and varied approaches to measuring prenatal father involvement, there is a clear pattern to findings: Supportive father involvement benefits mothers and infants in multiple domains. Research also consistently demonstrates that supportive father involvement is hindered by social policies that do not encourage fathers’ involvement and numerous structural barriers (Alio et al., 2011; Yogman & Garfield, 2016).

1.2 ∣. Fathers and prenatal care

Research on father participation in prenatal care has been limited but suggests that paternal participation in prenatal care is increasing, and attendance at prenatal ultrasound examinations is rapidly becoming a norm in the United States. By both maternal and paternal reports, the great majority of men–upward of 80%–attend at least one prenatal ultrasound (Walsh et al., 2017; Walsh et al., 2019). While disparities exist such that fathers with lower education and income are less likely to attend an ultrasound, due at least in part to structural barriers (Alio, 2017; Dallas, 2009), even in these groups, the large majority of men report ultrasound attendance (Walsh et al., 2017; Walsh et al., 2019). Qualitative research, predominantly based on samples in European countries, has shown that ultrasound attendance is meaningful to men and contributes to feelings of connection to both partner and baby-to-be (Draper, 2002; Ekelin et al., 2004; Walsh et al., 2014).

Existing research suggests that fathers wish to be more involved in prenatal care (Boyce et al., 2007; Draper, 2002; Finnbogadottir et al., 2003), yet participation sometimes leads to feelings of role confusion, exclusion, and alienation (Salzmann-Erikson & Eriksson, 2013; Steen et al., 2012). Expectant fathers perceive their role in the prenatal healthcare system as “partner and parent” yet may experience treatment as “not-patient and not-visitor” (Steen et al., 2012). Healthcare providers that work with patients during the perinatal period, such as obstetricians and pediatricians, are not typically well-trained to engage and partner with fathers as well as mothers to promote positive maternal, child, and family health outcomes (Yogman & Garfield, 2016). One qualitative study found that interactions between adolescent fathers and perinatal health-care providers ranged from supportive to neutralizing (i.e., failed to acknowledge the father as a father) to distancing (i.e., diminished the father) (Dallas, 2009). Providers’ discomfort in interacting with men and addressing fathers’ unique concerns may present barriers to full inclusion and engagement (Alio, 2017; Yogman & Garfield, 2016). Further barriers include lack of time off from work and office hours that conflict with employment (Yogman & Garfield, 2016). Shifts in policy and practice may be needed to recognize the role of fathers, prioritize their access and inclusion across demographic groups, and strengthen the engagement of fathers in maternal and child health (Alio, 2017; Alio et al., 2011; Levtov et al., 2015).

1.3 ∣. The current study

The current study used qualitative methodology to explore expectant mothers’ and fathers’ experiences with and perspectives on father participation in prenatal care. We were particularly interested in understanding how fathers had participated in prenatal care, how mothers and fathers experienced father participation, how the role of fathers in prenatal care was understood, and how mothers and fathers would prefer fathers to participate. The translational goal of this research is to support both mothers and fathers in their transition to parenthood through the sensitive and responsive inclusion of fathers in prenatal care. Mothers’ and fathers’ experiences and perceptions regarding father participation in prenatal care have received little attention despite the increasing participation of fathers. Expanding the knowledge base in this area is critical for informing service and policy development.

2 ∣. Methods

2.1 ∣. Study participants

Twenty-two women pregnant with their first child and male partners of 20 of the 22 pregnant women participated in the study. All were approximately midway through pregnancy at the time of data collection. Eligibility criteria included (1) pregnant woman experiencing a low-risk pregnancy and planning to complete a routine ultrasound examination at approximately 20 weeks’ gestation or partner planning to accompany mother for 20-week ultrasound, (2) expecting the birth of their first child, (3) over 18 years of age, and (4) English-speaking. Mothers were predominantly in their 20s (55%), white (77%), married (59%) or cohabitating (32%), and employed full-time (73%). Father demographics were similar, with fathers on average older (55% in their 30s) and more likely to be employed full-time (90%). While six mothers and seven fathers acknowledged that they had not wanted to become pregnant yet or were unsure of how they felt at the time they learned of the pregnancy, all participants had chosen to continue the pregnancy and anticipated becoming parents. Table 1 provides additional information about sample characteristics.

TABLE 1.

Demographic characteristics of the sample

	Mother (N = 22)	Father (N = 20)
Age in years
≤ 24	5	2
25–29	8	7
30–34	9	10
≥ 35	–	1
Race/ethnicity
White	17	14
Black	4	4
Asian	2	1
Latino	2	3
Relationship status
Married	13	13
Living with partner	7	7
On again, off again	1	–
Never talk	1	–
Pregnancy Intention*
Wanted to be pregnant now	16	13
Wanted to be pregnant later	3	3
Unsure how I feel about being pregnant	3	4
Education
Some high school	1	–
High school	2	3
Some college	5	8
Completed college	9	5
Graduate or professional degree	5	4
Employment
Full-time	16	18
Part-time Unemployed	2	–
	4	2
Household income per year
<$25,000	3	1
$25,000–$49,999	8	8
$50,000–$74,999	4	4
$75,000 – $99,999	3	3
>$100,000	4	4

Note:

^*Pregnancy intention item asked participants to respond with reference to how they felt at the time they found out they were pregnant. All participants, including those who had wanted to be pregnant later or were unsure of how they felt at the time they learned they were pregnant, had chosen to continue the pregnancy.

2.2 ∣. Procedures

The current study is embedded in a larger mixed-methods study to examine expectant mothers’ and fathers’ expectations for their future child and the relationship they will share with their child, explore how prenatal care engages and motivates expectant parents to prepare for their transition to parenthood, and investigate expectant parents’ perceived needs for education and support during pregnancy. The goal of the overarching study is to inform and enhance services to foster positive transitions to parenthood. Pregnant women (and their partners) were recruited from among the patient population of four obstetrics and gynecology clinics associated with a university health system. The health system provides comprehensive pregnancy care, and all patients are scheduled for a routine prenatal ultrasound with a registered diagnostic medical sonographer at approximately 20 weeks’ gestation. The four clinics provided study information to pregnant patients prior to the 20-week ultrasound, and interested patients contacted the research team directly or signed a “consent to contact” form allowing the research team to follow up with the patient regarding the study. During an initial call, a team member described the project, offered to answer any questions, verified eligibility, and asked if the patient was interested to participate. Included in the project description was the information that the study was open to both pregnant women and their partners if their partner accompanied them to the 20-week ultrasound examination. The research team member asked each prospective participant if she was currently partnered, if she expected her partner to attend the 20-week ultrasound examination, and if she would be comfortable participating in the study together with her partner. If the patient indicated that her partner would be at the ultrasound and she was comfortable participating in the study together, the research team member asked the patient for her partner’s contact information and then contacted him regarding the study. (Note: All of the pregnant women in this sample who were currently in a relationship had male partners). If the partner consented to participate, the couple was enrolled in the study. If the patient indicated that she was not in a relationship or her partner would not be attending the 20-week ultrasound, she was enrolled in the study individually. All women who contacted the research team or completed the “consent to contact” form so that the research team could contact them, and all of their partners, chose to enroll in the study. The team member asked all study participants to notify the research team when the 20-week ultrasound examination was scheduled.

The lead researcher met participants at the clinic prior to the ultrasound examination, provided study information in writing, and gathered written consent. Next, participants completed a brief demographic questionnaire including questions about age, education level, employment status, annual household income, relationship status, and pregnancy intendedness. The researcher accompanied participants to the ultrasound examination, observed and documented the appointment using a structured protocol, and then interviewed mothers and fathers individually after the appointment ended, following a semi-structured interview guide. Findings from the ultrasound observations are reported elsewhere (Walsh, 2020). Mothers and fathers were not able to observe their partner’s interview.

Data collected through individual parent interviews are the focus of the current study. Interviews covered a list of topics defined in an interview guide, including experiences attending the ultrasound examination and prenatal care more broadly, perceptions of the care they and their partner received, preferences regarding father participation, and suggestions for improvement. For example, all mothers were asked, “How do you feel about the care you received today?” and mothers who were accompanied by their partner were asked, “What did it mean to you for your partner to be with you today?” and “Is there anything you would change about your partner’s involvement in your ultrasound visit?” Questions fathers were asked include, “How do you feel about the treatment you and your partner received today?” and “Was there anything about the visit that you found particularly ‘father-friendly’? Anything that made you feel unwelcome or unimportant?”

Interviews typically lasted 20–30 min, and were audio-recorded and transcribed verbatim for subsequent analysis. Mothers and fathers were individually compensated with $50 for their participation in the study. Data were collected between November 2015 and August 2016. Approval of all materials and procedures was obtained from the Education and Social/Behavioral Sciences Institutional Review Board at the University of Wisconsin-Madison.

2.3 ∣. Data analysis

A thematic analysis, drawing on principles of grounded theory (Strauss & Corbin, 1998) including iterative analysis and constant comparison, was conducted to identify themes from mothers’ and fathers’ accounts of their experiences in prenatal care and perspectives on father participation in prenatal care. The five authors of this paper, including one professor of social work and four social work doctoral students, all participated in data analysis and inter-pretation. All identify as women, four identify as white and one as Black, and three are mothers.

Transcripts were content-coded, and in the first round of open coding, data were organized into smaller segments, and descriptors were attached to the segments (Leech & Onwuegbuzie, 2008). In an iterative process, two members of the research team independently read each transcript multiple times to distinguish and refine the definition of recurrent themes and establish codes (Thomas, 2006). Disagreements were resolved through discussion in regular research team meetings. After achieving consensus, the team developed a codebook and all transcripts were then reexamined and coded accordingly. NVivo data-analysis software was used to support the analysis. Within-case and cross-case analyses were conducted, and results were verified by returning repeatedly to the data to search for disconfirming evidence.

3 ∣. Results

Three themes emerged as central in mothers’ and fathers’ discussion of their experiences and perspectives on father participation in prenatal care. These themes are related to beliefs regarding the role of fathers in prenatal care and motivations to participate, mothers’ experiences of their own partner’s participation in their prenatal care and fathers’ own experiences in prenatal care, and preferences for father participation in prenatal care. These themes, reflective of patterns across interviews, are expanded in the following section, accompanied by representative quotations to illustrate the data.

3.1 ∣. Beliefs regarding the role of fathers in prenatal care and motivations to participate

3.1.1 ∣. Mothers’ beliefs regarding the role of fathers in prenatal care

Mothers identified multiple potential roles for fathers in prenatal care, including sharing in the process, providing support to mothers, being actively involved in the pregnancy and engaged in healthcare for the child-to-be, and being involved without being physically present when faced with constraints. In one instance, a mother for whom English is a second language identified translator as an additional role for her partner. While mothers recognized and valued these various ways of participating, providing support to the mother was most consistently identified as a critical aspect of the father’s role in prenatal care. In particular, mothers described the presence, engagement, and support of fathers in prenatal care as vital in case they were to learn that “something was wrong” with the pregnancy. In the words of one mother:

Especially initially when I was feeling like worried about everything and having him there was so important for me to have that sort of emotional support and everything, so…if something didn’t look right… or something was going on with it, absolutely 100% having him there has been important to me.

Participating in prenatal care, and particularly attending ultrasound appointments, also meant that the fathers were able to share in the “big moments.” Mothers saw this both as away for their partners to provide them support and also as away for their partners to be engaged. As one participant stated:

It feels better for me to have him [there]… to have him sitting next to me, holding my hand, kind of sharing that big moment with me is really important to me.

Mothers also felt that the presence and participation of fathers in prenatal care were part of taking on the role of a parent. They referenced the dual function of prenatal care appointments as healthcare for mother and baby and identified the role of fathers in prenatal care as spanning supportive partner and engaged parent. While most mothers positioned father participation in prenatal care as optional and desirable, one mother firmly expressed that participation is a father’s role as a parent of the child. She believed father participation should be an expectation:

[The father] shouldn’t get praised for doing what is, what I think should be just like minimally expected of him as the father of this baby… That’s [i.e., prenatal care is] where he needs to be.

Mothers defined an active role for fathers in prenatal care to include asking questions and engaging in discussions with the medical staff, learning about fetal health and development.

Mothers identified and emphasized multiple barriers to father participation in prenatal care (e.g., scheduling, ability to take time off of work, military duties, incarceration) and recognized a loss for fathers when they were unable to attend. They described this loss as exacerbating an inevitable gap between mothers’ and fathers’ experiences during pregnancy; as one mother said, “He misses out on a lot already because he doesn’t, he’s not carrying it, you know.” Of note, mothers identified aspects of involvement that were still possible and important even when fathers could not be physically present. Among the roles they identified for fathers in these circumstances were keeping track of appointments and milestones, helping mothers to remember and bring their questions to their healthcare provider, asking about appointments and particularly results of any testing, sharing in anticipatory and resultant happiness and worries.

3.1.2 ∣. Fathers’ motivations to participate and beliefs about their role in prenatal care

Fathers described their participation in prenatal care as rooted both in self-motivation and the desire of their partner that they participate. As one father said, “She wanted me at these [appointments] and I wanted to be at these [appointments].” Some fathers described conversations with their partners about which appointments they should attend, and others described a default assumption that they would participate as often as possible. In the words of one father:

The baby’s from both parents not from only the mother… It’s the responsibility of me [to go to the appointments] because I would like to know about my baby.

Multiple fathers explicitly described their experience in prenatal care as secondary to that of the mother and prioritized understanding and accommodating their partner’s wishes for their participation.

I think just communicating about how you want to go about it… You know, if you want to be at everything, if you don’t want to be at a couple of them. If she’s okay with you not being there, or doesn’t, maybe even want you to be there so she’s comfortable… You know, she is going through more than I am going through…

Like mothers, fathers identified a role for themselves in prenatal care as both partner and parent. The majority of fathers named both roles as fundamental to their motivation to participate and often described these roles as intermingled.

I want to hear what the doctor has to say about everything, how things could be going, and to be there for support for [my wife]. I mean I want to support [her] and then you know it’s my child and I just want to know what could be going on and hear what the doctor says.

Multiple fathers described their participation in prenatal care as an intentional demonstration to themselves and their partner that they are and will be a team in pregnancy and parenting. One father explained:

I’m trying, I think, trying to make a conscious effort to be there for all the prenatal stuff and things like that; it’s kind of me getting in the mode of fatherhood, that this is going to be something that, this is something that’s important and that I’m trying to do and that I’ve got to find ways to make fit with everything else.

Another father echoed this intention while also acknowledging that employment can present a barrier to participation.

I feel like moms, they’ll understand when you got to work, you got to do things like that. But if your schedule allows it you should [participate in prenatal care], just because it does show a level of sincerity, a level of care, a level of, that you want to be a part of it, and a level of I’m there for you.

Similar to mothers, fathers identified and emphasized multiple barriers that hindered their access to participation in prenatal care and/or that they recognize as limiting more widespread participation of fathers in prenatal care.

For some fathers, participation in prenatal care was “just something I kind of knew I wanted to do.” Others recounted advice they had received from other fathers–family members, friends, or co-workers–to participate in prenatal care. This advice typically spoke to the meaning of participation to mothers as well as fathers themselves and encompassed the dual role of fathers in prenatal care as partner and parent.

Some fathers identified specific aspects of participation in prenatal care as particularly compelling and motivating their participation. Most often mentioned was the opportunity to have a direct experience rather than hear an update later from their partner.

[It means a lot] just to be there for myself to see it, and I can experience that and not have to see it or hear about it secondhand.

Also, frequently mentioned was the opportunity to ask questions of prenatal care providers.

Usually like you know, if we ever have questions that come up between appointments we’ll talk about it, you know, like oh we gotta remember to ask this. And I’m like okay, you try and remember it and I’ll try to remember it, you know between the two of us we should always remember. And usually we always do. If I forget she’ll bring it up, and if she forgets I’ll bring it up.

Fathers wanted to be present to support their partners with remembering and asking questions of providers, to ask questions of their own, and, as illustrated in the preceding quote, to operate as a team with the mother in generating and bringing questions to prenatal care and learning about the baby.

3.2 ∣. Experiences of father participation in prenatal care

3.2.1 ∣. Mothers’ experiences of father participation in prenatal care

Nearly all mothers reported that the baby’s father had participated in prenatal care to some degree, ranging from attendance at visits considered “important” to attendance at every appointment. Ultrasound examinations and the very first prenatal care appointment were frequently identified as the “important” (or “milestone”) appointments, and these were the appointments that fathers were most likely to attend. While some mothers described conversations with fathers about whether and which prenatal appointments to attend, others described an implicit, mutual understanding that it was important for fathers to participate. One mother explained:

When I made the first appointment I made it at a time that he would be able to come if he wanted to, and so I just told him like ‘hey, my doctor’s appointment is at this time on this date’, and he’s like ‘cool, I’ll be there. I’ll meet you there’ … And had he not said that, I probably would have been like, why doesn’t he want to come? You know, I probably would have thought that, but we didn’t even have to discuss it.

Some mothers reported that fathers participated as often and fully as they and the fathers wished, while others described constraints (e.g., appointments during work hours) that limited father participation. Recognizing the existence of constraints, some mothers expressed active appreciation for their partner’s choice and effort to participate.

I appreciate him [coming] because I know he’s working a lot and I know the baby’s important for him, but he’s showing me that importance because he comes every time.

Several mothers mentioned that advice from other fathers influenced or reinforced their partner’s choices about when and how to participate.

I think he’s the last one of his colleagues to have a kid and so they’re all like, you have to be at all the visits and you have to do this and [that]… And I think he would either way, but he says that’s definitely the…everyone’s always asking him like ‘are you going? You should be going, you should be at the appointments.’

Mothers generally felt that fathers were made to feel welcome and valued their inclusion; however, they noted room for improvement in this area, and a few offered recommendations for some very basic adaptations to make the environment more welcoming toward fathers.

Sometimes I wish like at the beginning of the visit, like that they would care more about like his name. Like I know it’s like a small thing, but like, I’m like this is my husband [NAME]; and they’re like oh, okay. Occasionally people be like, hi [NAME], nice to meet you, but more times it’s like, okay that’s fine he can be in the room. But it’s like no, no, he’s the dad… I don’t think of the appointments as being like as appointments for me, even though they are under my name; they are like appointments for both of us.

Other suggestions included considering both parents in scheduling, shaking hands with both parents at the start of the appointment, and addressing and inviting questions from both parents during appointments.

Mothers experienced father participation as both an important act of partner support and an act of assuming the role of father. They valued father participation for both reasons. They characterized father participation in prenatal care as a shared opportunity to learn how to support a healthy pregnancy, learn about and bond with their developing baby, and share the joy and/or worries evoked by experiences in prenatal care. As one mother stated:

We’re doing this together, like we made the baby together, we’re gonna raise it together, and I want him to have the same joy of like being able to see the baby move when I get to see it.

3.2.2 ∣. Fathers’ experiences in prenatal care

Similar to mothers, fathers made a distinction between what one father referred to as “the monumental appointments” and “the regular checkups,” and prioritized attending the former. Sometimes the father intuited this distinction, and other times he related that the mother had told him which appointments were important for him to attend.

She has told me numerous times, she’s like, I really want you to be at this one; I don’t care if you’re at this one; I’m going to go to this one alone.

A few fathers had attended all visits, whereas most had attended every appointment including an ultrasound, and some had additionally attended the first prenatal appointment. Even among those who attended all appointments, the 20-week ultrasound was experienced as distinct.

I’m kind of in a supporting role mainly to some of these appointments, but like this one is obviously, I think, for both of us…”

Multiple fathers described the effort it took to attend appointments, with one father, a truck driver, recounting showing up to an appointment directly after a long-haul drive.

Mainly I mean it’s my job, I’m going to be tired, it’s a stressful job, but I have family to take care of and I need to make sure that my wife and my kid, you know, know that I’m there to support and stuff so if I’m tired, I’m tired, so be it.

Fathers frequently described a mismatch between what they felt and what they showed at prenatal care.

I mean I know I don’t always show my emotions on the outside so I mean just sitting there pretty calmly, one, because I’m exhausted because of my job, but I’m excited, I mean it’s an unbelievable thing.

Though they varied in the degree to which they demonstrated their emotions, fathers consistently described the powerful impact of hearing their baby’s heartbeat at a routine prenatal appointment or seeing the baby on the screen at an ultrasound examination. Similarly, fathers’ accounts revealed variation in how frequently they asked questions and how much they directly engaged with providers.

I mean, I didn’t really have any questions. I just sort of sat there, just kind of taking it in… I don’t know what to expect with it being our first child [so I don’t necessarily know what to ask].

Fathers who described themselves as “quiet” during appointments were equally likely to attend consistently and discuss the importance of their participation as both partner and parent. With multiple fathers representing their experience as centered on listening, absorbing, and learning, limited engagement with providers should not be interpreted as an indicator of detachment or disinterest.

Like mothers, fathers valued the shared experience of attending prenatal care together. They described the connection they felt being alongside their partner, receiving information together, and “getting to know our baby” together. Some fathers also described ways that they and their partner complement each other and can strengthen each other’s experience of prenatal care.

I mean [my partner] and I hear things differently just because we are different type of people, so then we come back home and talk about what we heard.

As described by this father, he and his partner help one another to balance fear and reason and maintain a healthy perspective through the ups and downs of pregnancy.

On the whole, fathers felt welcome and included in prenatal care. Several fathers mentioned that prenatal care was the first setting in which they were recognized as a father, and the experience meant a lot to them.

They definitely made me feel included because they called me “dad” and I was like, what? Wow, yeah, I guess that’s me.

Fathers felt that providers were generally receptive when they asked questions and particularly appreciated when providers were thorough with explanations. They felt their partners had more knowledge coming into appointments, and it helped them to “keep up” when providers were clear and detailed in explaining what they were doing, assessing, and learning about the health of mother and baby.

3.3 ∣. Preferences for father participation in prenatal care

3.3.1 ∣. Mothers’ preferences for their partner’s participation in prenatal care

The vast majority of mothers in this sample wanted their partners to be included in their prenatal care. They saw father participation as important and beneficial to fathers themselves, mothers, the couple relationship, and the nascent family. Particularly early in pregnancy, mothers perceived participation in prenatal care as a way to make the baby “more real” for the father and facilitate adjustment to their new life stage as parents-to-be.

In general, mothers expressed a strong preference for their partners to be present at what they perceived to be significant appointments, such as the first appointment and the 20-week ultrasound, and attached less weight to father participation at more routine appointments. One mother described her reasoning this way:

My regular doctor’s appointment… [is] pretty much, ‘How you feeling? Good, let’s listen to the heartbeat. Okay, see you next month.’ So I don’t want him to take off work for that.

Many mothers echoed this sentiment, naming the need to take time off from work as the primary reason they did not want or expect their partner to attend all prenatal appointments and articulating a belief that routine appointments did not warrant that. In contrast, a small number of women had a strong preference for their partner to be present for all appointments.

[That way] they’re still in the loop and they know everything that’s going on, because I know that like each appointment, I mean some appointments are longer than others, but they give you a lot of information… [and it would be helpful if fathers could be there] so they know all the information as well.

These mothers explicitly recognized that at every visit, there is a possibility of learning something significant about the course of the pregnancy and felt that the father should be present in case of this eventuality. At the same time, they recognized that many fathers face notable barriers to consistent participation in prenatal care, in particular inflexible jobs and the availability of prenatal care appointments only during standard working hours.

An important caveat to the general wish for father participation is the understanding of one mother in the sample that her abusive former partner’s presence would be harmful. Her perspective is an important reminder that father participation is not safe for all mothers. She talked about bringing her close friend, who she described as a “mother figure,” with her to the 20-week ultrasound. Much like the other participants, she described attending appointments together as a sign of support and as a bonding experience that was powerful for both of them. Her experience highlights the importance of a support system during pregnancy generally and specifically in the context of prenatal care and underscores that it is not always a partner who is best suited to provide support. It is essential that the mother has the ability to choose who is included in her prenatal care.

3.3.2 ∣. Fathers’ preferences for participation in prenatal care

Given the design of the study, all participating fathers had elected to attend at least one prenatal appointment (the 20-week ultrasound). At the time of the interview, immediately after the 20-week ultrasound, fathers were unanimous in stating that they would recommend other fathers attend the 20-week ultrasound, and most suggested that fathers should attend other appointments to the extent they are able. Several fathers expressed a strong preference to participate in all aspects of prenatal care, recognizing this level of engagement as their responsibility as a parent.

I mean, this is something we are both doing, you know and it’s, I mean, it’s um, like by nature she’s the one carrying the baby inside.…inside herself, right. But for everything else it’s like, I mean it’s my business not just it’s hers, you know.

Notably, the few fathers who had attended all visits were employed in roles that allowed flexibility to shift their work hours and could attend appointments without losing shifts or income. Some fathers distinguished between preferable and feasible participation in prenatal care, acknowledging that they would like to attend more often than they had been able to do due to barriers that they faced.

It’s kind of harder because like, I do only, I work like four tens, so it’s kind of hard for me to get to some of the appointments… I mean if she can have them on a Friday, then I try to make it. Of course I want to be there so I’ve made it to most of them, but some of them I couldn’t, but I’m kind of sad if I can’t make it because I actually, I want to be there; I’m excited about everything very much so.

Still other fathers perceived that attending select appointments, such as the first appointment and appointments including an ultrasound examination, was both desirable and feasible, allowing them to be present on the occasions when their participation would be most meaningful. They described this arrangement as suiting both mothers and themselves, noting that their partner did not necessarily want or need them to accompany her to every appointment.

While fathers generally felt that providers were receptive to their questions, they expressed a wish that providers would be forthcoming with important information so that they did not need to ask the right questions in order to learn what they need to know to be effective partners and parents. Multiple fathers acknowledged that while they have lots of questions as first-time parents, “I don’t know what I don’t know,” and hoped that prenatal care could be designed to proactively address the fundamentals that all men should learn in order to support their partner through pregnancy and prepare for fatherhood.

As they discussed their preferences for how they could be engaged in prenatal care, fathers were clear that prenatal care is first and foremost about mother and baby.

I mean I’m kind of secondary with everything… I mean I…I kind of want the focus to be on her. And the baby.

Men saw value to mothers and babies, as well as fathers themselves, in attending to the needs of fathers for education and support; but they specified that this should be secondary, with the health, comfort, and support needs of women at the center of prenatal care.

4 ∣. Discussion

Prenatal care is a vital setting for promoting positive pregnancy outcomes, and increased participation of fathers in prenatal care affords an opportunity to engage men in promoting maternal and child health. Despite increasing participation of fathers in prenatal care and emerging efforts to promote “father-friendly” prenatal care settings (Albuja et al., 2019), little research has focused specifically on father engagement in prenatal care or explored the perspectives of both mothers and fathers on father participation. This study generated an in-depth understanding of mothers’ and fathers’ experiences of father participation in prenatal care and insight into ways of supporting father engagement in prenatal care that promote positive experiences of care for women.

4.1 ∣. Incorporating mothers’ and fathers’ perspectives

Twenty-two pregnant women and 20 of their male partners participated in this study. There was a strong correspondence between mothers’ and fathers’ perspectives on father participation with some notable distinctions. Both mothers and fathers recognized multiple dimensions of the father’s role in prenatal care, emphasizing that fathers participate as both partner and parent. Providing support to the mother and learning about fetal health and development were both identified as key functions of participation, with sharing the experience and fortifying the alliance between mother and father an additional, related priority. Most mothers and fathers endorsed father participation in the first prenatal visit and ultrasound appointments, and some believed that fathers should participate in all aspects of prenatal care, with mothers and fathers both identifying work hours and scheduling as a prominent barrier to father participation.

In comparison to mothers, fathers were more tentative about their role in prenatal care. Mothers were largely firm in their conviction that fathers should be fully welcomed into prenatal care and given a co-equal voice as a co-parent. While expressing both a desire and a sense of parental responsibility to participate in prenatal care, fathers frequently specified their deference to mothers in prenatal care, recognizing the mother’s comfort and needs as primary. Consistent with fathers’ perception of their role as secondary, fathers offered few recommendations for how prenatal care could be made more welcoming toward fathers. Both mothers and fathers were generally positive about the care they had experienced, but mothers offered numerous, specific, suggestions for including fathers more comprehensively in prenatal care. These findings in a sample of expectant mothers and fathers in the United States are consistent with findings of research conducted with expectant parents in Sweden, where mothers report that their partners’ involvement is very important (Hildingsson et al., 2001), and disregard for the partner’s needs is a primary reason for maternal dissatisfaction with prenatal care (Hildingsson & Radestad, 2005); yet fathers perceived care provided to the mother as the most important aspect of prenatal care and were comfortable with “playing second fiddle” (Jungmarker et al., 2010).

More so than mothers, fathers emphasized the importance of clear and thorough explanations from providers throughout appointments and clear and thorough communication of information about how to support a healthy pregnancy. Both mothers and fathers felt that providers were receptive to questions from both parents, but fathers described concern about relying on questions to gather necessary information; they acknowledged the limits of their knowledge as first-time fathers and questioned whether they would know the right questions to ask. Fathers acknowledged feeling less well-informed about the pregnancy than their partners and cited multiple reasons for this–the mother’s bodily experience of pregnancy, mother’s greater knowledge about pregnancy and infants, and constraints that prevented the father from attending all prenatal appointments to learn alongside his partner. Both mothers and fathers identified ways for fathers to be involved when they could not attend prenatal appointments, and both placed great value on the father’s presence when possible. Fathers acknowledged that direct engagement in prenatal care is a distinct experience that cannot be fully replaced through conversation with the mother about what occurred at appointments.

4.2 ∣. Strengths and limitations

Nationally and globally, researchers and clinicians have begun to consider the role of fathers in promoting maternal and child health, and father participation in prenatal healthcare is increasingly encouraged (Albuja et al., 2019; Firouzan et al., 2018; Lewis et al., 2015; Singh et al., 2014; WHO, 2007). In this context, it is critical to develop a clear understanding of the impact of father participation on women’s prenatal care experiences, how mothers and fathers define their needs and expectations with regard to prenatal care and father participation, and how prenatal care is meeting their needs or could be improved to better meet their needs. Yet there is scant research on the perspectives of US mothers on father participation in prenatal care, and relatively few studies explore fathers’ experiences of prenatal care. This study makes an important contribution to the literature by illuminating the perspectives of a small sample of US mothers and fathers on father participation in prenatal care. It is not possible, based on the qualitative design of this study, to generalize to the larger population of expectant mothers and fathers in the United States. However, the current study provides an important foundation for continued investigation of mothers’ and fathers’ experiences with and perspectives on father presence and participation in prenatal care. Results of the study suggest that further exploration of this topic is warranted as both mothers and fathers hold expectations for father involvement and perceive value in father participation.

By design, our sample included only first-time parents and only fathers who had attended at least one prenatal visit (the 20-week ultrasound). Future research is needed to examine the perspectives of experienced parents on father participation in prenatal care and the perspectives of fathers who are unable to choose not to attend any component of prenatal care. Experienced parents may face different barriers to participation than first-time fathers (e.g., care for older siblings), and fathers with no engagement in prenatal care may hold different expectations and attitudes toward father participation. Participants were recruited from multiple clinics associated with a single healthcare system, and mothers and fathers participating in prenatal care in other healthcare systems may have divergent experiences; indeed, relative to prior research in other prenatal care settings, participants in the current study reported high levels of overall satisfaction with care (Salzmann-Erikson & Eriksson, 2013; Steen et al., 2012).

Study recruitment began with mothers, and fathers were invited to participate only with the mother’s permission. This protocol ensured safety and respect for mothers’ physical and emotional wellbeing. However, it means that the perspectives of mothers and fathers who share a strong connection are over-represented in the sample, and future research is needed to explore the perspectives of fathers and mothers with weaker ties or deliberate estrangement. In the current study, all partners were male, and all were the biological father of the baby; future research should address whether and how experiences and preferences for participation vary when the mother’s partner is not male or not the biological father. Participants were primarily white, married or cohabitating, and employed full-time. Employment and demographic characteristics have been associated with father involvement (Pleck & Masciadrelli, 2004), and future research with larger and more demographically diverse samples can explore whether and which characteristics are associated with father participation in prenatal care specifically and with fathers’ experiences of participation in prenatal care. Participants in the current study identified fathers’ work hours as a significant factor in father participation. It is particularly important that future research explore the experiences and perspectives of fathers who face structural barriers that may prevent them from being further engaged in the prenatal period, such as jobs that are inflexible. Such research can inform recommendations for action to address barriers and foster father engagement.

This study relied on cross-sectional interview data collected immediately after the 20-week ultrasound appointment. Participants were asked to reflect on their overall experience in prenatal care, but their experience at the 20-week ultrasound was likely most salient at that moment. Longitudinal research can examine experiences across the span of prenatal care, whether and how experiences at different timepoints and with different providers may vary, and explore whether perspectives and preferences regarding father inclusion evolve over the course of pregnancy.

4.3 ∣. Clinical implications

While caution is appropriate in identifying implications of research conducted with a small sample in a highly specific context, the results of this study suggest the importance to both mothers and fathers of attending to the needs of all parents in prenatal care. Partner support benefits mothers and infants, and prenatal care affords an opportunity to build capacity among fathers to support their pregnant partner and promote optimal maternal and child health outcomes. Fathers participate in prenatal care as both partner and parent, and providers can recognize and offer resources relevant to both roles.

This study indicated near-consensus that fathers should have a role in prenatal care and further revealed variation in mothers’ and fathers’ assessments of when and how fathers should participate. Accordingly, providers should assess and respond to individual preferences and constraints. As a starting point, providers can elicit, respect, and prioritize mothers’ wishes for father participation (or non-participation). When mothers express the desire for their partner to be included in their prenatal care, providers can make efforts to facilitate partner participation by considering partner availability in scheduling appointments, making partners feel welcome and included, addressing explanations to and inviting questions from both parents. To the extent possible, extended clinic hours should be considered as a means of removing a prominent barrier to father participation.

While centering mothers’ medical care, providers can include fathers as well as mothers in efforts to address informational and socio-emotional needs in the transition to parenthood. Infant development is supported by the caregiving relationships and community context surrounding the child and family (Rosenblum et al., 2019), and prenatal promotion of mothers’ and fathers’ wellbeing and preparation to parent stands to benefit baby, parents, and family. Providers should presume high interest from fathers as well as mothers in learning about pregnancy and preparing for parenthood and recognize that few questions or subdued affect on the part of the father may reflect uncertainty, fatigue, or a reserved nature rather than disengagement. Further, providers can strengthen father engagement by proactively addressing with fathers information that will facilitate fathers’ preparation to support their partner through pregnancy and jointly prepare for parenthood.

4.4 ∣. Conclusion and directions for future research

Results of this study underscore the importance of a thoughtful approach to engaging fathers in prenatal care. Father participation in prenatal care holds the potential to benefit mothers, children, and fathers themselves, but father participation in prenatal care is not universally appropriate, and when appropriate, should vary in form, consistent with the needs and preferences of both mother and father. By assessing and aiming to meet the needs of fathers as well as mothers, prenatal care providers can increase the support available to mothers and increase the preparation of fathers to parent and to co-parent. Future research can continue to deepen understanding of the varied roles and expectations of fathers as participants in prenatal care and advance the development of policies and interventions to increase father engagement in prenatal care, support father involvement in pregnancy, and improve outcomes for mothers, children, and fathers themselves.

Key Findings and their Implications for Practice/Policy.

1. Mothers and fathers both want prenatal care to be father-inclusive. Providers should make efforts to welcome and engage fathers alongside mothers in prenatal care.

2. Mothers and fathers vary in their assessment of when and how fathers should participate in prenatal care. Providers should learn about and respond to individual preferences and constraints.

3. Mothers and fathers described father participation in prenatal care as both an important act of support for the mother and part of assuming the role of father, allowing opportunity for fathers to learn how to support a healthy pregnancy, bond with their developing baby, and share joy and worries with mothers. Providers should recognize the dual role of fathers in prenatal care and respectfully engage with fathers as both a support person to their pregnant partner and a parent in their own right.

Statement of relevance to the field of infant and early childhood mental health.

This research suggests that IECMH professionals should recognize the dual role of expectant fathers and respectfully engage with expectant fathers as both a support person to their pregnant partner and a parent in their own right. Further, this research suggests that mothers and fathers want fathers to have opportunity to engage with professionals and learn how to support a healthy pregnancy, bond with their developing baby, and share joy and worries with mothers.