484387

research-article2013
JHLXXX10.1177/0890334413484387Journal of Human LactationMaycock et al

Original Research
Journal of Human Lactation

Education and Support for Fathers

29(4) 484­–490
© The Author(s) 2013
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DOI: 10.1177/0890334413484387

A Randomized Controlled Trial jhl.sagepub.com

Bruce Maycock, PhD1, Colin W. Binns, MBBS, PhD1, Satvinder Dhaliwal, PhD1,
Jenny Tohotoa, MPH, PhD1, Yvonne Hauck, PhD2, Sharyn Burns, PhD1,
and Peter Howat, PhD1,3

Abstract
Background: Studies have identified numerous factors affecting breastfeeding initiation and duration, including maternal
education, mode of delivery, birth weight, socioeconomic status, and support of the infant’s father.
Objective: The objective was to investigate the effects of an antenatal education session and postnatal support targeted to
fathers.
Methods: The Fathers Infant Feeding Initiative (FIFI Study) is a randomized controlled trial to increase the initiation and
duration of breastfeeding that was conducted in 8 public maternity hospitals in Perth, Western Australia. A total of 699
couples were randomized within hospitals to either intervention or control groups. The intervention consisted of a 2-hour
antenatal education session and postnatal support provided to fathers.
Results: The any breastfeeding rate for the intervention group was significantly greater at 6 weeks: 81.6% in the intervention
group compared to 75.2% in the control group, odds ratio 1.46 (95% CI, 1.01-2.13). After adjustment for age and hospital,
the odds ratio for any breastfeeding in the intervention group was 1.58 (1.06-2.35) and for socioeconomic status (SES), 1.56
(1.06-2.30). The infants of older fathers were more likely to be breastfed at 6 weeks compared to infants of younger fathers
(P < .01), and infants of fathers with high SES more likely than infants of fathers with low SES (P = .013).
Conclusion: Even a small increase in breastfeeding rates brings public health benefits. In this study, a minimal intervention
was found to significantly increase any breastfeeding at 6 weeks: 81.6% in the intervention group compared to 75.2% in the
control group.

Keywords
breastfeeding, breastfeeding duration, education, fathers, randomized controlled trial

Well Established introduction of appropriate complementary foods up to 2

Numerous cohort studies have shown that fathers have an
important role in supporting breastfeeding. There is a need for a
major randomized controlled trial of intervening with fathers to
improve breastfeeding rates as previous interventions have been
limited in size.
years or beyond.1 Although this policy is endorsed by many
national pediatric organizations, and despite the documented
benefits, the rates of breastfeeding are below optimum in
many countries.2 In the United States, it is estimated that at
6 months the “exclusive” breastfeeding rate is 16.3% and

Date submitted: October 27, 2012; Date accepted: March 6, 2013.

Newly Expressed 1
School of Public Health and Curtin Health Innovation Research Institute,
This randomized controlled trial has shown that a minimal pack- Curtin University, Perth, Australia
2
age of interventions with fathers has increased the prevalence of School of Nursing and Midwifery and Curtin Health Innovation Research
any breastfeeding to 6 weeks, the time when the breastfeeding Institute, Curtin University, Perth, Australia
3
School of Public Health, Centre for Behavioural Control of Cancer and
intervention stopped. Curtin Health Innovation Research Institute, Curtin University, Perth,
Australia
Background Corresponding Author:
Professor Colin W. Binns, School of Public Health, Curtin University,
The WHO recommends exclusive breastfeeding to 6 months GPO Box U1987, Perth 6845, Western Australia
of age, and continued breastfeeding together with the Email: c.binns@curtin.edu.au

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Maycock et al 485

Figure 1.  The Fathers Infant Feeding Initiative (FIFI Study)

Parents enrolled for antenatal classes and were randomized to

treatment or control

863 women signed 712 men signed

consent forms consent forms

Antenatal classes
delivered to treatment
and control groups
separately

Follow up at 6 weeks and 6 months

postpartum

Only couples, where both mother and

father of the infant consented to be in
the study, were included in the analysis

n=699

the “any” breastfeeding rate is 47.2%.3 Although initiation
rates of breastfeeding in Australia are now high (92%), only
about 50% of infants are even partially breastfed to 6
months.4 The situation in China is similar, with breastfeed-
ing rates for duration in urban and rural areas falling below
the Ministry of Health’s targets.5
There have been numerous studies and reviews of the fac-
tors affecting breastfeeding initiation and duration, including
maternal education, mode of delivery, birth weight, socio-
economic status (SES), and support of the infant’s father.6-9
However, only a limited number of risk factors can actually
be modified in the short to medium term and can therefore be
incorporated into health promotion programs. An important
potentially modifiable factor in initiation is the “support of
the infant’s father for breastfeeding.”10 There is a general
consensus that in many cultures the father of the baby is one
of the most influential persons to the mother concerning
breastfeeding.11 The contribution of fathers’ support to
breastfeeding has been quantified in epidemiological studies
in both Caucasian and Asian societies.5,12-14 In a survey of
2145 men from Texas, support by the fathers for breastfeed-
ing was found to be related to ethnicity, country of origin,
education level, and SES.15 This study found that men’s atti-
tudes to breastfeeding were formed early in life and were
related to ethnicity and SES.
Although the evidence from observational epidemiologi-
cal studies for the importance of fathers in breastfeeding is
strong, the number of intervention studies is limited. In a
small randomized controlled trial (n = 59), Wolfberg and col-
leagues were able to show that a health education activity for
American fathers increased breastfeeding initiation rates
from 41% to 74%.16 Similarly, a controlled trial of fathers’
education about breastfeeding in Italy (n = 280) increased
breastfeeding rates at 6 and 12 months.17 The rates of initia-
tion of breastfeeding in Australia are higher than in Italy and
the United States, but the duration of exclusive and any
breastfeeding needs improvement.4 In Australia, the positive
effect of mothers receiving health promotion material and
education antenatally and/or postnatally on breastfeeding
outcomes has been shown in a cohort study, but no similar
data are available for fathers.18 Because of the small number
of intervention studies targeting fathers, a randomized con-
trolled trial was planned. The aim of the study was to inves-
tigate the effects of an antenatal education package and
postnatal support targeted to fathers on the initiation and
duration of breastfeeding.
Methods
The Fathers Infant Feeding Initiative (FIFI Study) is a ran-
domized controlled trial to increase the initiation and duration
of breastfeeding that was conducted in 8 public maternity hos-
pitals in Perth, Western Australia (see Figure 1). The design of
the intervention involved an exploratory study undertaken to
identify parents’ perceptions of what constitutes “best prac-
tice” support for breastfeeding. This study focused on the best
ways for fathers to support breastfeeding. Prior to the interven-
tion study, focus groups were held with groups of mothers and
fathers, and interviews and an online survey were also devel-
oped for fathers.19,20 A logo was created and a motto used to

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486 Journal of Human Lactation 29(4)
reflect the philosophy of the project, “Smarter, stronger:
breastfeed longer,” and these were used on all education mate-
rials and correspondence with the participants. Fathers and
their partners were randomized, with a random number gen-
erator with no blinding, to either a control or intervention
group in each hospital prior to their first attendance at their
antenatal classes. Antenatal classes are offered at all of the par-
ticipating hospitals and are attended by almost all mothers. In
general, they continue weekly for 4 weeks beginning at the
33rd week. Both the intervention and control groups received
the usual care available at the participating hospitals, includ-
ing an antenatal education program and routine hospital and
postnatal care. In addition, the intervention group also received
an antenatal education session (2-hour duration) led by a male
facilitator, followed by a social support package for 6 weeks
postnatal. The additional support for the intervention group
included printed materials and promotional materials at
weekly intervals. At birth, a congratulatory card was sent to
fathers, and at 4 weeks a beer can holder bearing the study
logo. The antenatal education session provided information on
the benefits of breastfeeding to infants and mothers and dis-
cussed difficulties, such as engorgement and mastitis, that
might be encountered and the support and encouragement that
could be offered. Infant developmental milestones and postna-
tal depression were specifically included. Resources to assist
in reducing fathers’ anxiety and increasing their problem-
solving abilities were also discussed. The intervention has
been described in detail elsewhere.20
The sample was recruited over a 13-month period from
May 2008 to June 2009 at 8 public maternity hospitals
located in metropolitan Perth, Western Australia. Mothers
who had enrolled for antenatal education and were older than
18 years of age were invited to participate along with the
father of their infant. A total of 1575 (863 women, 712 men)
participants were originally recruited between May 2007 and
July 2008, and after withdrawals the final sample included
699 couples. There were no specific inclusion or exclusion
criteria other than the participants had to be older than 18
years to give their informed consent. For fathers to be eligi-
ble to participate, they had to be contactable by telephone or
email at home or in the community, reside within Western
Australia, and intend to participate in the rearing of their
child. The study was powered to detect a difference of at
least 10% in any breastfeeding proportions between the
intervention group and control group. A sample size of 294
participants was required to detect this difference at 80%
power and 5% level of significance. Assuming a loss to fol-
low-up of 20%, the study planned to recruit a minimum of
368 participants into each group.
To avoid contamination between intervention and control
groups, a minimal washout period of 4 weeks was imple-
mented. As the classes began at 33 weeks, the chance of
overlap between a control and intervention class was there-
fore remote and did not occur at any of the hospitals. Five
male educators conducted a total of 45 education sessions for
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the intervention group in the 8 participating maternity hospi-
tals. An average of 6 participants attended each session with
a range of 2 to 14 attendees. Of the 385 men in the interven-
tion group who affirmed their intent to participate in the pro-
gram, 342 (89%) attended the antenatal sessions and 295
(86%) responded to the 6-week questionnaire. Work com-
mitments, including working away from the city at the time
of the session, was the main reason cited for fathers not
attending the class.
Participants in the study were invited to complete ques-
tionnaires during the antenatal period and postnatally at 6
weeks and 6 months.19 Mothers in both the control and inter-
vention nominated groups were all given baseline question-
naires (self-completion), whether they had a partner or not at
the antenatal classes, to avoid discrimination or alienation.
Fathers were given their baseline questions at the specific
session organized for them. The follow-up self-completion
questionnaires were administered by printed questionnaires
or by telephone (by the research officer) according to their
individual preferences. The questionnaires included the Iowa
Infant Feeding Attitude Scale, a valid and reliable measure
that evaluates this knowledge and attitudes in cross-cultural
settings.20 The outcome variables were any breastfeeding,
full breastfeeding, and full formula feeding, and these were
assessed at 6 weeks. The project was approved by the Curtin
University Human Ethics Review Committee and the ethics
committees of the individual hospitals. Written consent to
participate in the study was obtained from all participants
prior to commencement of the study. Participants were
advised of the confidentiality of the data collected and the
right to withdraw at any time without prejudice. The study
was registered as a clinical trial with the Australian New
Zealand Clinical Trials Registry (ACTRN12609000667213).
Analysis of the data was undertaken on an “intention to treat”
basis on the randomization of the fathers to intervention or
control groups. The analysis was undertaken using SPSS
version 18.21 Quantitative data were analyzed as frequencies
or medians (with interquartile ranges) as appropriate. The
two groups, intervention and control, were compared using
logistic regression, both before and after adjustment for the
covariates age, hospital, or socioeconomic status. All covari-
ates were specified a priori. Socioeconomic status was cate-
gorized into 3 groups using maternal postcode.22 The effect
of the intervention compared to the control is represented as
odds ratios and associated 95% confidence intervals (CIs)
for any breastfeeding, full breastfeeding, and full formula
feeding.23
Results
The age distribution and education level of the mothers and
fathers who participated in the study in the intervention or
control groups are presented in Table 1. The majority of the
mothers were born in Australia—69.0% in the intervention
group and 66.9% in the control group—and for fathers, the
Maycock et al 487

Table 1.  Demographics of Participants in the Randomized Controlled Trial

Male Female
Variable Intervention Control P Value Intervention Control P Value
Age, median, y (interquartile range) 29 (16-51) 29 (17-54) .994 27 (14-44 ) 27 (16-42) .836
Education, n (%)
 Tertiary 70 (19.3) 70 (22.4) .769 101 (26.9) 101 (32.2) .133
 Trade/diploma 141 (38.8) 117 (37.5) 125 (33.2) 84 (26.8)  
  Year 12 74 (20.4) 58 (18.6) 95 (25.3) 74 (23.6)  
  Year 10 55 (15.2) 43 (13.8) 40 (10.6) 46 (14.6)  
  < Year 10 23 (6.3) 24 (7.7) 15 (4.0) 9 (2.9)  
Born in Australia, n (%)
 Yes 238 (66.5) 203 (68.1) .772 252 (69.0) 202 (66.9) .773
 No 120 (33.5) 95 (31.9) 113 (30.9) 100 (33.0)  
Employment, n (%)
 Employed 342 (93.1) 278 (88.5) .034 250 (66.0) 190 (60.3) .124
 Unemployed 25 (6.8) 36 (11.5) 129 (34.0) 125 (39.7)  
Marital status, n (%)
 Married 213 (58.8) 169 (55.3) .523  
 Defacto 115 (31.8) 110 (35.9)  
 Single 34 (9.4) 27 (8.8)  
Family income, n (%)
  < $15,000 7 (2.0) 4 (1.4) .796  
 $15,000-$45,000 50 (14.4) 43 (14.9)  
 $45,000-$75,000 97 (28.0) 87 (30.0)  
 $75,000-$105,000 110 (31.7) 80 (27.5)  
 $105,000-$120,000 90 (25.9) 80 (27.6)  

proportion was 66% and 65%, respectively. There was a high
level of employment among the participants, with 95% of the
fathers in the intervention group and 92% of the control
group employed. Perth is the center of a state with a large
mining industry, and there is a large number of “fly in, fly
out” employees who spend a large part of their month work-
ing in remote locations: 17% of the intervention group and
16% of the control group fathers. For the demographic vari-
ables that were included in the study, there were no differ-
ences between the intervention and the control groups. The
proportion of births by cesarean section was similar in both
groups: 31.8% of the control group and 28.3% of the inter-
vention group. The Iowa Infant Feeding Attitude Scale was
measured at baseline and at 6 months. Within the fathers’ and
mothers’ groups, no significant differences were found
between the intervention and control groups. The raw scores,
presented as median (IQR), for fathers at baseline were 57.5
(56.4, 58.5) for the controls and 56.8 (55.9, 57.7) for the
intervention group, and at 6 months were 57.1 (55.8, 58.4)
and 57.5 (56.4, 58.5), respectively. The raw scores, presented
as median (IQR), for mothers at baseline were 59.3 (58.3,
60.4) for the controls and 59.3 (58.5, 60.2) for the interven-
tion group, and at 6 months were 54.6 (53.5, 55.8) and 55.9
(55.0, 56.9), respectively.
The antenatal intervention and the additional resource
materials distributed postnatally were designed to enhance
fathers’ knowledge and develop skills to help reduce anxiety
and increase problem-solving abilities relating to childbirth
and infant feeding. The intervention targeted at the fathers
also affected the mothers’ knowledge and attitudes. In the
mothers of the intervention group, the proportion with favor-
able or highly favorable attitudes toward breastfeeding was
43% compared to 35% in the control group, after the fathers
had attended the education session.
The infant feeding outcomes were then compared between
the intervention and control groups. The rate of prelacteal
feeds was 25% in both groups. The comparison of breast-
feeding variables in the control and treatment groups is
shown in Table 2 (unadjusted analyses), Table 3 (adjusted for
the covariates age and hospital), and Table 4 (adjusted for the
covariates age and SES).
The any breastfeeding rates for the intervention group
were significantly greater at 6 weeks: 81.6% in the inter-
vention group compared to 75.2% in the control group.
The intervention group was 1.46 times (95% CI, 1.01-
2.13) more likely than the control group to be breastfeed-
ing (any breastfeeding) in the unadjusted analyses, and the
effect remained significant after adjusting for age, employ-
ment rate of fathers, SES, and hospital. The infants of older
fathers were more likely to have any breastfeeding at 6
weeks compared to younger fathers (P < .01), and infants
of fathers with high SES more likely than infants of fathers

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488 Journal of Human Lactation 29(4)

Table 2.  Comparison of Breastfeeding and Formula Feeding at 6 Weeks between Intervention and Control Groups (Unadjusted
Analyses)

Any Breastfeeding Full Breastfeeding Full Formula Feeding

Groups
  Intervention, n (%) 288 (81.6) 164 (46.5) 65 (18.4)
  Control, n (%) 224 (75.2) 133 (44.6) 74 (24.8)
Intervention vs control, 1.46 (1.01-2.13) (P = .047) 1.08 (0.79-1.47) (P = .641) 0.68 (0.47-0.99) (P = .047)
odds ratio (95% CI)
Abbreviation: CI, confidence interval.

Table 3.  Comparison of Breastfeeding and Formula Feeding at 6 Weeks, after Adjusting for Paternal Age and Hospitala (Odds Ratios
and 95% Confidence Intervals)

Any Breastfeeding Full Breastfeeding Full Formula Feeding

Intervention vs control 1.58 (1.06-2.35) (P = .024) 1.10 (0.79-1.53) (P = .581) 0.63 (0.43-0.94) (P = .024)
Paternal age
  21-30 vs ≤ 20 y 2.40 (1.07-5.38) (P = .034) 1.73 (0.73-4.11) (P = .216) 0.42 (0.19-0.94) (P = .034)
  ≥ 31 vs ≤ 20 y 3.30 (1.43-7.64) (P = .005) 2.38 (0.99-5.72) (P = .053) 0.30 (0.13-0.70) (P = .005)
Age distribution is as follows: intervention group, < 20 years n = 17, 21-30 years n = 213, > 30 years n = 142; control group, < 20 n = 17, 21-30 years
n = 184, > 30 years n = 127.
a
Differences between hospitals were not statistically significant.

Table 4.  Comparison of Breastfeeding and Formula Feeding at 6 Weeks, after Adjusting for Paternal Age and Socioeconomic Status
(SES) (Odds Ratios and 95% Confidence Intervals)

Any Breastfeeding Full Breastfeeding Full Formula Feeding

Intervention vs control 1.56 (1.06-2.30) (P = .026) 1.09 (0.79-1.51) (P = .587) 0.64 (0.44-0.95) (P = .026)
Paternal age
  21-30 vs ≤ 20 y 2.54 (1.14-5.67) (P = .022) 1.79 (0.76-4.23) (P = .182) 0.39 (0.18-0.88) (P = .022)
  ≥ 31 vs ≤ 20 y 3.54 (1.54-8.13) (P = .003) 2.46 (1.03-5.86) (P = .042) 0.28 (0.12-0.65) (P = .003)
SES
  Medium vs low 1.26 (0.80-2.00) (P = .322) 1.16 (0.79-1.70) (P = .455) 0.79 (0.50-1.26) (P = .322)
  High vs low 2.04 (1.16-3.58) (P = .013) 2.61 (1.71-3.98) (P < .001) 0.49 (0.28-0.86) (P = .013)
Age distribution is as follows: intervention group, < 20 years n = 17, 21-30 years n = 213, > 30 years n = 142; control group, < 20 n = 17, 21-30 years
n = 184, > 30 years n = 127. SES is as follows: intervention group, low SES n = 201, medium SES n = 111, high SES n = 60; control group, low SES
n = 184, medium SES n = 75, high SES n = 69.

with low SES (P = .013). Full breastfeeding at 6 weeks was Discussion

not significantly different between the intervention and
control groups.
The converse of the increase in the breastfeeding rate, the
rate of full formula feeding at 6 weeks, was significantly
higher in the control group compared to the intervention,
before and after adjustment (P < .05) (see Tables 2-4). Infants
of older fathers were less likely compared to those of younger
fathers, and infants of fathers with high SES less likely than
infants of fathers with low SES, to have full formula feeding
at 6 weeks (P < .05). No significant differences were found
in breastfeeding rates between the 2 groups at the 6-month
follow-up.
These results suggest that the intervention with the fathers
to promote breastfeeding increased the any breastfeeding
rate at 6 weeks and reduced the number of infants being fully
fed on infant formula.
The intervention was found to make a significant improve-
ment to infant feeding patterns at 6 weeks. The intervention
stopped at 6 weeks, and this may have contributed to the lack
of any significant difference at 6 months. The health and eco-
nomic benefits of breastfeeding have been shown to be sub-
stantial in studies in the United States and Australia.24,25
Even a small increase in breastfeeding rates brings substan-
tial benefits, and the 6% increase shown in this study is of
public health significance.
The advantage of this study was the larger sample size
compared to the previous studies by Wolfberg et al and
Pisacane et al.16,17 The disadvantage is that breastfeeding rates
in Australia are already higher than in the United States and
Italy, making it more difficult to measure change. Also, in this
study the objective was to provide a minimal intervention with

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Maycock et al 489
only 1 education session together with follow-up information
to the fathers until 6 weeks postpartum. Since control and
intervention groups were recruited at the same hospital, there
is the possibility of contamination between the intervention
and the control groups if mothers and fathers from these
groups spoke to each other, although this risk was minimized
by the washout period. Every effort was made to ensure con-
sistency of the intervention delivery across the 8 different hos-
pitals in the study. One limitation of this study was that data on
parity and previous breastfeeding experience were not avail-
able. A further limitation is that cessation of any intervention
after 6 weeks and a repeat of the study with interventions that
lasted until 6 months are needed to further examine the full
potential of intervening with fathers. In the meantime, there is
sufficient evidence to incorporate education sessions for
fathers into the regular antenatal program.
Conclusion
The results of previous observational studies have shown an
association between support of breastfeeding by fathers and
breastfeeding outcomes. The results of this study confirm
that fathers’ support promotes breastfeeding rates. The inter-
vention was more effective in older fathers and fathers from
higher socioeconomic groups. What is unknown is the rela-
tive effect of the hospital-based antenatal education com-
pared to the post-hospital social support intervention. The
study suggests the need for further studies examining the
effect of interventions, including the intensity, length, and
type. In the meantime, there is now sufficient evidence from
3 randomized controlled trials to justify the involvement of
fathers in antenatal education about optimal infant feeding.
Acknowledgments
The support of the Health Promotion Foundation of Western
Australia (Healthway) is gratefully acknowledged. The authors
would like to thank the parents and the hospitals for their support,
without which the project would not have been possible.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The authors disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
Funding for the development implementation and development of
the Fathers Infant Feeding Initiative was provided by the Health
promotion Foundation of Western Australia Project Number
16175.
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