Original article

Keywords
Fathers Support Pregnancy Antenatal care

Fathers experiences of support during pregnancy and the rst year following childbirthndings from a Swedish regional survey
Ingegerd Hildingsson and Mats Sjo ling
Abstract Background: Support during pregnancy is mainly directed towards pregnant women, although parenthood is viewed as a joint project by society and by parents themselves. Research has shown that fathers often feel excluded by health care professionals. The aim of the present study was to describe personal and professional sources of support used by prospective and new fathers and to study factors associated with fathers having no support from anyone in mid-pregnancy. Methods: This was a prospective longitudinal study of 655 new fathers living in a northern part of Sweden who completed four questionnaires. Results: The majority of fathers reported having good personal support at most time points, but 18% reported that they did not have support from anyone, when asked in mid-pregnancy. A logistic regression analysis showed that the following factors were associated with not receiving support from anyone: having previous children (odds ratio (OR) = 3.4; 95% condence interval (CI) = 1.77.0, P <0.001), expectations from the midwife to attend antenatal visits (OR = 1.9; 95% CI = 1.13.4, P <0.05), not attending parent education classes (OR = 2.3; 95% CI = 1.14.8, P <0.05), not feeling involved by the prenatal midwife (OR = 1.9; 95% CI = 1.13.3, P <0.05), and not being offered the opportunity to attend fathers groups (OR = 3.5; 95% CI = 1.112.3, P <0.05). Conclusion: Although personal support seemed satisfying for the majority of fathers, those with no support from close family/friends also lacked support from midwives as well in terms of the organization of care. 2011 WPMH GmbH. Published by Elsevier Ireland Ltd.

Ingegerd Hildingsson, RN, RM, PhD Department of Health Sciences, Mid Sweden University, Holmgatan 10, SE-85170 Sundsvall, Sweden; and Department of Womens and Childrens Health, Karolinska Institutet, Stockholm, Sweden Mats Sjo ling, RN, PhD Department of Health Sciences, Mid Sweden University, Sundsvall, Sweden E-mail: Ingegerd.hildingsson@ miun.se

Introduction
Parenthood is, in most cases, a joint project and current fathers in high resource countries such as Sweden are, in general, involved during pregnancy and childbirth. The fathers role in the past focused mostly on breadwinning, but now fathers are expected to be actively involved in caring for their children [1,2]. For many men becoming a father can be overwhelming [2]. Fathers have many concerns about the shift into parenthood and a lack of

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support and involvement during pregnancy has been reported [3]. Research has shown that fathers often feel excluded by health care professionals during pregnancy [4] and after the baby is born [5], which implies a certain feeling that information and care activities are mainly directed towards prospective and new mothers. In an interview study, fathers supporting role and their own support needs during birth were described as Being involved or being left-out, where it was claried that fathers want to be seen as individuals but also

2011 WPMH GmbH. Published by Elsevier Ireland Ltd.

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Original article
as one part of the labouring couple and they want to interact with the midwife and with their partner [6]. In Sweden, political efforts have been made to get fathers more involved in parenting and to promote equality between the sexes. Of the 480 days of paid parental leave, 2 months are exclusively for the father. Fathers also have 10 days of paid leave on the birth of the baby to help care for the newborn and other children. Most fathers take advantage of these 10 days [7]. Fathers took approximately 22% of the total parental leave days used by couples in 2009 [8]. Government policies on health services have also focused on both parents in Sweden. The purpose of parental support in antenatal and child health clinics is to provide knowledge and information, to strengthen parents in their parenting role, and to provide contact with other parents [9]. Generally this is made through parenthood education classes directed towards rst-time parents. Antenatal Health Care (MVC) and Child Health Care (BVC) provide services to promote child health and development and strengthen parents ability to care for their newborn baby [10]. These organizations are responsible for co-ordinating parent education classes, focusing on parents own issues and interests, both during pregnancy and in the rst year after childbirth. A national survey reported that 84% of rst-time mothers attended prenatal education together with their partner [11]. In order to support those becoming fathers there are local attempts to create fathers groups as a supplement to parent education, these groups being an all male option for prospective and new fathers to meet with a male group leader [12]. The association between social support and health has been a focus of research for a long time [13,14]. Support from partner and social network is associated with womens well-being during pregnancy [15]. While new mothers often have social support from their own parents, friends, siblings and workmates, new fathers are more likely not to have the same supporting network [2,5]. Deave et al. [5] reported that contemporary fathers did not themselves have fathers who had been involved in their newborn and early upbringing period and, therefore, these new fathers lacked the possibility of accessing support from their own fathers. In addition, fathers are viewed by the health care professionals as being the main source of support for the woman. Little attention has been paid to the father himself and his own support needs. In a society that promotes gender equality it is important that both parents are treated equally in terms of receiving support. Research has shown that fathers are sometimes marginalized by health care providers. Lack of personal and professional support during the transition to fatherhood could have implications for the health of the family. The aim of the present study is to describe the personal and professional sources of support used by prospective and new fathers and to study the factors associated with fathers having no personal support from anyone in the mid-pregnancy period.

Methods
This descriptive study is one part of a longitudinal survey in a northern region of Sweden where expectant fathers were followed from mid pregnancy until 1 year after childbirth.

Subjects
Fathers who understood Swedish and where the ultrasound examination of the baby showed no malformations were eligible for this study. The study was approved by the Regional Research and Ethics Committee at ). University, Sweden (Dnr 05-134 O Umea

Procedure
Recruitment took place at three hospitals during the year 2007. Prior to the planned routine ultrasound (usually performed in the 1719th week of gestation), parents who had a booked appointment were sent letters of invitation to the study. The letter explained the purpose of the study, and that participation was voluntary and could be withdrawn at anytime without question. Potentially eligible fathers who attended the routine ultrasound examination were asked by the ultrasound midwives to take part in the study. After informed consent, participating subjects received four consecutive questionnaires to ll out over a 1 year period.

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Data collection
The rst questionnaire was handed out immediately after the ultrasound examination. The second questionnaire was sent to the participants in the 3234th week of pregnancy, the third was sent 2 months after the baby was born. The fourth questionnaire was distributed 1 year after childbirth, but only to those who had completed the rst three questionnaires. This decision was based on nancial restrictions within the project. Two reminders were sent to non-responders on all occasions. For the purpose of this paper we chose to include only those fathers who had completed all four questionnaires. Details of the recruitment process are reported elsewhere [16]. In the analysis these responses were dichotomized into Good support (To a very large extent + To a large extent) and Less good support (To a very little extent + Not at all). For the questions covering support from others (own siblings, friends, work colleagues, or no support from anyone) the respondents were told to select any appropriate person from whom they had received support (several choices were available).

Analysis
To assess changes over time, Friedmans test was used [18]. Odds ratios (OR) with a 95% condence interval (CI) were calculated between fathers who did not receive personal support from anyone and those who did receive support, and for the different categories of the explanatory variables. To nd out which variables contributed most to not having personal support from anyone when asked in mid-pregnancy, logistic regression analysis was performed [19].

The questionnaires
The questionnaires on which the majority of questions in this survey were based, were originally developed for a national Swedish survey of pregnant and new mothers (19992000) who were recruited in early pregnancy and followed up 2 months and 1 year after childbirth [17]. The questions from the original questionnaires were revised and re-formulated to t fathers needs. These revised questionnaires were pilot tested on 12 prospective fathers and only minor wording changes were made in response to their comments. Socio-demographic background, feelings about the impending birth and a rst assessment of antenatal care were collected from the rst questionnaire. In the third questionnaire, collected 2 months after the birth, data about the overall view of antenatal care were collected. The total number of visits to the midwife, the total number of midwives seen for antenatal care, participation in parental education classes and fathers groups, involvement in the care and satisfaction were also collected from that postpartum questionnaire. The questionnaires were mainly focused on personal support from people close to the prospective father (partner, own parents and siblings, friends and work colleagues). These questions about support were asked in all four questionnaires. There was a special interest in fathers reporting no support from anyone in mid-pregnancy. The questions about support from partner and own parents used 5-point Likert scales for the answers, which ranged from To a very large extent to Not at all,

Results
In total 655 fathers were included in this study. This number corresponds to 46% of the fathers who, in early pregnancy, agreed to participate in the study and to 85% of those who received the fourth questionnaire. The loss of participants was due to the termination of the pregnancy, stillbirth, moving away from the area, and not receiving questionnaire three. Those who did not receive the third questionnaire were the fathers who did not respond to surveys one or two. The fourth questionnaire was only sent to those fathers who had completed the rst three.

Sample description
Of the 655 fathers included in the study, 47% were expecting their rst baby, while 53% had previous children (Table 1). The majority were aged 2535 years, of Swedish origin, living with their partner and had a high-school education. Every third father used some form of tobacco (smoking or snuff).

Support over time

Table 2 shows the percentages of fathers sources of personal support and how these

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Table 1 Sociodemographic background (n = 655)
n (%) Age groups (n = 648) <25 years 2535 years >35 years Country of birth (n = 651) Sweden Other countries Martial status (n = 655) Living with partner Not living with partner Level of education (n = 650) Comprehensive school grade 19 High school 13 years College/University Residential area (municipals) (n = 647) Large municipal area and its surroundings Middle-sized municipal area and its surroundings Rural municipal area Tobacco habits (n = 652) Users Non-users First time fathers Fathers with previous children 25 (3.8) 447 (69.0) 176 (27.2) 630 (96.8) 21 (3.2) 644 (98.3) 11 (1.7) 37 (5.7) 341 (52.5) 272 (41.8) 270 (41.7) 236 (36.5) 141 (21.8) 204 448 310 345 (31.3) (68.7) (47.3) ()52.7)

changed over time. Friedmans test revealed a statistically signicant change over time for all reported sources. The greatest amount of support from the partner and own parents was found 2 months after the birth. Support from own siblings and friends was highest 1 year after childbirth. The fathers reported the greatest amount of support from work colleagues in late pregnancy. Approximately one fth of these fathers reported having no personal sup-

port from anyone, although this percentage decreased over time.

Fathers not receiving any personal support

In mid-pregnancy 123 (18.9%) of the fathers reported that they did not get any personal support. Only two background factors were associated with fathers reporting having no

Table 2 Sources of support and changes over time for expectant and new fathers
Mid pregnancy % Received sufcient support Partner Own mother Own father Friends Own siblings Work mates No support from anyone from: 95.9 65.7 56.5 61.7 44.5 29.6 18.9 Late pregnancy % 90.4 52.2 42.3 55.6 40.2 31.3 20.5 Two months after childbirth % 97.2 73.7 61.3 59.3 46.1 27.9 12.7 One year after childbirth % 94.6 68.2 59.8 62.7 47.0 23.0 13.9 Friedmans test Chi2 P-value 3 df P P P P P P P <0.001 <0.001 <0.001 <0.006 = 0.005 = 0.001 <0.001

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Table 3 Sociodemographic background factors in relation to support
No support from anyone (n = 123) n (%) Age groups <25 years 2535 years >35 years Country of birth Sweden Other than Sweden Martial status Living with partner Not living with partner Level of education Comprehensive school grade 19 High school 13 years College/university Residential area (municipals) Large municipal area and its surroundings Middle-sized municipal area and its surroundings Rural municipal area Tobacco habits Users Non-users Previous children No previous children Have previous children
**P <0.01, ***P <0.001.

Have support (n = 529) n (%) 21 (84.0) 376 (84.1) 129 (73.3) 510 (81.3) 16 (76.2) 518 (80.8) 11 (100.0) 32 (86.5) 278 (81.5) 216 (80.0) 211 (78.7) 199 (84.3) 112 (80.0) 163 (79.9) 366 (81.7) 283 (91.9) 246 (71.5)

OR for not having support (95%CI) 1.0 (0.4-2.5) 1.0 Ref. 1.7 (1.3-2.9)** 1.0 Ref. 1.3 (0.62.8) 1.0 Ref. not calculated 0.7 (0.31.7) 1.0 Ref. 1.1 (0.81.5) 1.0 Ref. 0.7 (0.51.1) 0.9 (0.61.4) 1.1 (0.81.5) 1.0 Ref. 1.0 Ref. 3.5 (2.3-5.3)***

4 (16.0) 71 (15.9) 47 (26.7) 117 (18.7) 5 (23.8) 123 (19.2) 0 5 (13.5) 63 (18.5) 54 (20.0) 57 (21.3) 37 (15.7) 28 (20.0) 41 (20.1) 82 (18.3) 25 (8.1) 98 (28.5)

support from anyone, namely age > 35 years and having previous children (Table 3). Fathers with no personal support more often reported mixed or negative feelings towards the pregnancy, although no association was found between lack of support and whether the pregnancy was planned or not (Table 4), fear of childbirth, feelings about the forthcoming birth, or feelings about the forthcoming baby. In addition, in mid-pregnancy, when parents have usually met the antenatal midwife twice, fathers who did not get any support were less likely to agree with the statement that the antenatal visits help me to ask questions about pregnancy, compared to fathers who had support. In the follow-up questionnaire 2 months after childbirth (Table 5), fathers who had reported that they did not have any personal support from anyone in mid-pregnancy were less likely to attend the whole antenatal pro-

gram (>5 visits), as well as parental education classes during the present pregnancy. Fathers who lacked support were more likely to report that parental education had not been helpful for parenthood preparation. There was no difference in the assessments of benets gained from parental education classes in relation to the birth or in the contacts with other participants from the parental education class. Fathers without support were not offered, or did not attend, fathers groups to the same extent as fathers who had support. They felt less involved by the antenatal midwife and were more dissatised with the emotional aspects of antenatal care, compared to fathers who received support. When all of the variables were entered into a logistic regression analysis, the following factors were associated with not receiving support from anyone: having previous children (OR = 3.4; 95% CI = 1.77.0, P <0.001),

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Table 4 Attitudes of prospective fathers in relation to support
No support from anyone (n = 123) n (%) Planned pregnancy Yes No Experience of expecting a child Very positive or positive Mixed or negative feeling Childbirth-related fear None or little Much or very much Feelings about the approaching birth Very positive or positive Mixed or negative feeling Feelings about a new-born baby Very positive or positive Mixed or negative feeling 114 (20.2) 2 (20.0) 115 (18.4) 8 (84.4) 115 (18.6) 7 (21.9) 93 (18.0) 30 (23.3) 105 (18.4) 18 (23.4) Have support (n = 529) n (%) 450 (79.8) 8 (80.0) 511 (81.6) 10 (55.6) 502 (81.4) 25 (78.1) 424 (82.0) 99 (76.7) 467 (81.6) 59 (76.6) OR for not having support (95%CI) 1.0 Ref. 1.0 (0.3-3.4) 1.0 Ref. 2.4 (1.4-4.2)*** 1.0 Ref. 1.2 (0.6-2.3) 1.0 Ref. 1.3 (0.9-1.99) 1.0 Ref. 1.3 (0.8-2.0)

Agreement with the following statements: My partner expects that I am present during antenatal visits Strongly agree 67 (17.6) Do not strongly agree 55 (20.8) The antenatal midwife expects that I am present during the visits Strongly agree 29 (20.9) Do not strongly agree 92 (18.3) The antenatal visits make me feel involved with the baby Strongly agree 102 (17.7) Do not strongly agree 20 (27.0) The antenatal visits help me to ask questions about the pregnancy Strongly agree 99 (17.2) Do not strongly agree 23 (31.1)
*P<0.05, **P <0.01, ***P <0.001.

314 (82.4) 209 (79.2) 110 (79.1) 410 (81.7) 473 (82.3) 54 (73.0) 476 (82.8) 51 (68.9)

1.0 Ref. 1.2 (0.9-1.6) 1.0 Ref. 0.9 (0.6-1.3) 1.0 Ref. 1.5 (1.0-2.3)* 1.0 Ref. 1.8 (1.2-2.6)**

expectations from the midwife to attend prenatal visits (OR = 1.9; 95% CI = 1.13.4, P <0.05), not attending antenatal education classes (OR = 2.3; 95% CI = 1.14.8, P <0.05), not feeling involved by the antenatal midwife (OR = 1.9; 95% CI = 1.13.3, P <0.05), and not being offered the opportunity to attend fathers groups (OR = 3.5; 95% CI = 1.112.3, P <0.05).

Discussion
One of the main ndings of this study was that fathers received support to a great degree both

during and after the birth, with rst time fathers being the focus for both personal and professional support. Not having personal support was also associated with lack of professional support. Having a baby seems to increase the amount of support and the highest levels were shown shortly after birth. One year after birth, support from friends was greater, which could be interpreted as the family in general are now attending activities that involve other people, which might not be the case 2 months after birth. Support from work colleagues was lower 1 year after birth, a period when many fathers begin their parental leave. Being a rst-time

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Table 5 Antenatal care in relation to support
No support from anyone (n = 123) n (%) Attendance at antenatal visits No visits 12 visits 35 visits >5 visits Dont remember/not reported Number of midwives met during antenatal visits One midwife Two midwives Three or more midwives Dont remember/not reported Attended parental education classes Yes No Attended during a previous pregnancy 16 50 36 11 10 (25.0) (23.0) (19.8) (18.3) Have support (n = 529) n (%) 48 (75.0) 167 (77.0) 146 (80.2) 121 (91.7) 47 292 (81.3) 116 (80.0) 63 (87.5) OR for not having support (95%CI) 1.1 1.0 0.9 0.4 (0.71.8) Ref. (0.61.2) (0.20.7)***

67 (18.7) 29 (20.0) 9 (12.5)

1.0 Ref. 1.1 (0.71.6) 0.7 (0.31.3)

25 (9.2) 45 (27.4) 49 (25.0)

248 (90.8) 119 (72.6) 147 (75.0) 248 (90.8) 119 (72.6) 147 (75.0) 117 (93.6) 107 (86.3) 47 (90.4) 59 (86.8) 212 (91.0) 76 (96.2) 255 (76.3) 134 (85.9) 213 (88.4) 262 (78.2) 40 225 (87.2) 238 (80.4) 50 237 (85.9) 255 (77.5) 418 (82.3) 87 (75.0)

1.0 Ref. 3.0 (1.94.7)*** 2.7 (1.74.3)*** 1.0 Ref. 2.0 (0.94.1) 0.6 (0.22.7) 1.0 Ref. 2.1 (1.04.8)** 1.5 (0.54.4) 1.0 Ref. 0.7 (0.31.4) 1.0 Ref. 6.2 (2.019.2)*** 3.7 (1.112.0)* 1.0 Ref. 1.9 (1.32.8)**

Parental education helped in preparing for childbirth Yes 25 (9.2) No 45 (27.4) Dont know 49 (25.0) Parental education helped in preparing for early parenthood Yes 8 (6.4) No 17 (13.7) Dont know 5 (9.6) Still meets with any of the class participants Yes No Participated in fathers groups Yes Were not offered Was not able to attend/did not want to attend The antenatal midwife makes me involved Totally agree/agree Only partly agree/do not agree Not applicable The antenatal midwife cares about me Totally agree/agree Only partly agree/do not agree Not applicable 9 (13.2) 21 (9.0) 3 (3.8) 79 (23.7) 22 (14.1) 28 (11.6) 73 (21.8) 17 33 (12.8) 58 (19.6) 27

1.0 Ref. 1.5 (1.02.3)*

Satisfaction with the emotional aspects of antenatal care Satised/very satised 39 (14.5) Mixed/dissatised/very dissatised 74 (22.5) Overall assessment of antenatal care Satised/very satised Mixed/dissatised/very dissatised
*P<0.05, **P <0.01, ***P <0.001.

1.0 Ref. 1.6 (1.12.3)** 1.0 Ref. 1.4 (1.02.0)

90 (17.7) 29 (25.0)

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father increased the probability of having support, as the number of children was signicantly associated with support from other people irrespective of when the questions were asked. Having the rst baby usually entailed receiving more attention and support than did having the second or third child [20]. Fathers who reported not having support were more often older and had previous children and, therefore, were not offered the chance to attend parental education classes or fathers groups, two of the major sources of professional support, both of which are mainly directed towards rst-time parents. In a national Swedish survey of prospective and new mothers, those with previous children felt that parental education classes should be offered to all parents, regardless of the number of children [21]. It can be assumed that the same needs are part of fathers preferences. The reason that women suggested that parental education classes should be offered to all parents was mainly that it was seen as a means of getting to know other parents in the same situation, which was also the goal when parental education classes were introduced in Sweden in the 1970s. Antenatal education consisted of 810 sessions in the beginning [22], but today the average number of sessions is four [23]. It has, however, been recently argued that parental support should not be limited to pregnancy and the rst year after the baby is born, but should be be offered to all parents of children aged 018 years and be based on those parentsneeds [24]. In recent years, a number of alternative programmes for parental education have been developed, mainly run by private companies and mostly with very good results. However, such private alternatives mainly attract parents who really would like to invest time and money and are already more engaged in the subject than parents in general (Hildingsson, unpublished results). Another problem that arises when relying on private alternatives is the skewed access, where such alternatives are more likely to be found in large cities, while a third problem is that of the nancial circumstances of the parents, which could exclude certain groups. Another nding was that fathers who reported not having support from anyone felt that the midwife expected them to attend the antenatal visits, but sometimes they did not feel involved when they did. We do not know the fathers opinions about actually participating during the antenatal visits, especially fathers with previous children who might have attended during a previous pregnancy, but since parenthood is, in most cases, a joint project, the fathers presence would be taken for granted in a modern society. Despite the fact that fathers have been regular attendees at antenatal care appointments for decades, it seems as though there is a boundary for midwives in terms of having a family-orientated way of providing care. Not much seems to have happened since an interview study from 1999 where fathers were treated as strange visitors in the womens world when attending antenatal care appointments [25]. Fathers have also been made invisible in midwives narratives of being supportive towards prospective parents during pregnancy [26], but, despite this, fathers have also reported feeling great satisfaction with antenatal care and being happy to play second ddle to their partners [4]. The exclusion of fathers has been carried forward into studies on postnatal care, where they are described as being still behind the glass wall [21] and being discontented with postnatal care, as expressed in comments such as we feel like one, they see us as two [27]. This raises a challenge for a change in midwives perspectives into family-orientated care, where the couple is the focus together with the realization that antenatal care is not only concerned with biomedical issues. From the womens perspective it could be argued that they need a platform of their own during pregnancy, but from the fathers and the babies perspectives it is very important that fathers are invited and involved and taken care of, since it is known that the period around childbirth is also a vulnerable period for fathers [2830] and that a fathers mental health has an impact on his childs development [3,5,31]. Fathers should be encouraged to establish an independent relationship with their child. It has been suggested that fathers may obtain less support and encouragement than mothers, even when opportunities are available to both parents. One study has argued that since there is an awareness of the contribution of fathers to their families, then focusing on the father himself, and his wishes, from his point of view is important [32].

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Conclusions
Fathers who lack personal support also lack professional support. Changes within the health care system towards a more familyorientated care package also require changes in the attitudes of health care providers.

Acknowledgements
This research was supported by funding from the Swedish Research Council awarded to Ingegerd Hildingsson. The funding source has no role in the actual study besides funding.

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