Historically, pregnancy and birth have been a predominantly female affair (Robertson, 2007; Caltabiano and Castiglioni, 2008), with limited reports of men being involved in the pregnancy or being present at the birth (Kitzinger, 2010). King (2012) suggests that 1 in 10 men attended the birth of their baby in the 1950s, but these statistics have changed dramatically over the past 60 years (Andrews, 2012). A change in societal attitudes has seen fathers become more involved in pregnancy and birth (Sapkota et al, 2012); almost all fathers in industrialised countries are now present at the birth of their child(ren) (Dex and Joshi, 2005; Pestvenidze and Bohrer, 2007).
Evidence suggests that most women want their partner to be involved in the pregnancy, to be present at the birth of their child and to share parenting (Turan et al, 2001; Davies, 2011). This trend is increasingly reflected in policy, and there is heightened awareness of the importance of health professionals actively including and engaging partners in antenatal education (Department of Health, 2007; Department for Children, Schools and Families, 2010; Royal College of Midwives, 2011).
Antenatal education is not a new concept and is seen as an integral part of maternity care (Nolan, 1997; Koehn, 2002; Jaddoe, 2009; Jordaan, 2009). However, figures suggest two thirds of first-time mothers, and less than a quarter of those who have given birth previously, attend antenatal classes (National Perinatal Epidemiology Unit (NPEU), 2007). Figures for partner attendance are based on women's responses, which suggest that two thirds of women who attended antenatal education classes were accompanied by their partner or husband (NPEU, 2007). On further investigation of the figures, disparities between demographic groups were found; for example, compared with the White ethnic group, Black and minority ethnic groups were (NPEU, 2007):
There is a substantial body of evidence to show the positive long-term benefits for the health and wellbeing of the mother, baby and family unit when fathers are actively engaged in maternity care (World Health Organization, 2007; Forster et al, 2008; Steen et al, 2012). This is reflected in an increasing focus on the role of fathers in supporting maternal and fetal wellbeing during pregnancy (Blackburn et al, 2005; Bottorff et al, 2006; Richardson and Carroll, 2008).
Despite the increased awareness of the need for a more holistic and family-centred approach to maternity care (Erlandsson et al, 2007; Hedges et al, 2012), there has been a relatively small focus on identifying and meeting the specific needs of fathers, and woman-centred care has continued to be the predominant approach (Greenhalgh et al, 2000; Beadshaw, 2001; Lee and Schmied, 2001; Leap, 2009). The aim of this review, therefore, is to explore men's views and attitudes regarding the effectiveness of antenatal education classes.
Methods
A systematic search of literature was carried out in September 2014 to identify studies exploring men's experiences of antenatal education and how effectively it prepared them for their role as birth partners and for parenthood. The databases MEDLINE, Maternity and Infant Care, Cochrane Central Library of Controlled Trials, Embase and CINAHL Plus were accessed. The search period was January 2004—September 2014. A combination of text terms and medical subject heading (MeSH) terms were used to maximise the volume of literature retrieved:
The search results were limited to studies of humans and those published in English.
Duplicates were removed, and titles and abstracts were screened. A manual search of reference lists produced a further 10 papers. Subsequently, 28 full papers were screened, and a total of 13 papers are included in this review (Figure 1).
The lead author (SS) independently extracted findings by interrogating each study using questions developed from the aim of the review:
Two authors (DS and KM) reviewed the findings and consensus was reached by all through discussion. A thematic synthesis was then undertaken; it was agreed that this was the most appropriate synthesis method for this review, owing to its potential to draw conclusions based on common elements and its accessibility for the reader (Lucas et al, 2007).
Results
Following data extraction and a narrative synthesis of the evidence, several key themes were identified, including: outnumbered, excluded, anxious and uncertain, and preparedness.
Outnumbered
A common theme of several studies was men feeling outnumbered by women and uncomfortable in raising their concerns when the primary focus was on the woman's needs (Premberg and Lundgren, 2006; Martin, 2008; Li et al, 2009; Erlandsson and Haggstrom-Nordin, 2010). Men who attended a fathers-only antenatal group (although a small sample) showed that they were more likely to be more satisfied with antenatal education than those who did not have this opportunity (Jungmarker et al, 2010).
A randomised prospective trial, including an additional 1-hour male-only session carried out by a male health professional as part of antenatal education, found 77% of men in the intervention group had a very positive experience at the birth of their baby, compared with 42% of the control group (Wockel et al, 2007). All women from the intervention group reported they felt their partners were well prepared and supportive during labour. Of men in the intervention group, 65% felt they were good supporters compared with 40% in the control group. The results of this trial suggest that male-only sessions may be helpful in preparing men for the birth of their baby and to effectively support their partners during birth.
Excluded
Fathers who attend antenatal classes often report ‘feeling on the periphery’, and this was a theme of several of the studies reviewed (Li et al, 2009; Erlandsson and Haggstrom-Nordin, 2010; Longworth and Kingdon, 2011). Fathers felt excluded for two main reasons: firstly, that the focus of the classes was primarily on the expectant woman's needs, and secondly, because of a physical disconnection with the pregnancy and uncertainty regarding their role.
There was a general consensus by men that antenatal classes are, and should be, focused primarily on the needs and the physical and emotional wellbeing of the mother and mother/baby unit (Jungmarker et al, 2010); however, Li et al (2009) suggest that this focus on women's needs is one of the main reasons why men do not rate antenatal education as useful or relevant to them, and why they can feel excluded.
One study reported, ‘mothers first, and that may be right, but not always’ (Erlandsson and Haggstrom-Nordin, 2010: 22), which highlights the need for classes to be more inclusive of men as their needs may not always be the same as those of women. This assertion was reinforced by Bergström et al (2011), who identified that while women were interested in all intrapartum issues, men stated labour, birth and infant care as the topics they were most interested in.
A study carried out by Bergström et al (2009) divided a sample into two groups: standard and natural. Each group had four 2-hour education sessions during pregnancy and one follow-up session after delivery. They spent different amounts of time focusing on different aspects of maternity care; the natural group spent 5.8 hours on labour and birth issues and the remainder on postnatal (primarily breastfeeding), while the standard group spent 3.9 hours on labour and birth preparation and the remainder on the newborn and postnatal period. Bergström et al (2009) found no statistical difference in mode of delivery or satisfaction of childbirth experience, for both men and women.
Men's self-perception that they are parent ‘number two’, with women being the main focus, appears to be reinforced by the woman-centred approach in antenatal classes (Premberg and Lundgren, 2006). For some men, this may also reflect cultural norms and traditional gender roles. Several studies called for antenatal education to more actively engage with fathers and address their needs. Martin (2008), using a Birth Participation Scale, recommended that men should have tailor-made and individualised preparation, and that feeling included and in control were equally important issues for men as for women.
Many expectant fathers expressed a physical disconnection from the pregnancy, which alienated some of them from the process, and some struggled to understand their role. They reported feeling confused and uninvolved, and one participant stated, ‘obviously it's got nothing to do with me, it's her body’ (Longworth and Kingdon, 2011: 590).
Anxious and uncertain
Most fathers wanted to attend the birth with their partner but were anxious about what the experience would involve and how they would cope. Wockel et al (2007) found 80% of expectant fathers were fearful about birth; Li et al (2009) found that those who attended an antenatal education class had reduced anxiety, increased self-confidence and a more positive birth experience.
Participants in one study (Longworth and Kingdon, 2011) reported that antenatal education classes had not helped them in understanding what their role would be during labour and at birth; they concluded that if this is how those who have attended antenatal classes feel, then those who have not must feel even less prepared. Men commented on feeling inadequate during childbirth, especially when complications arose (Martin, 2008). When complications did arise, men reported feeling unprepared, and they believed antenatal education should provide information on possible complications (Erlandsson and Haggstrom-Nordin, 2010).
Preparedness
Conclusions drawn from a range of studies highlight that preparation for birth is important for men and women, and there is strong evidence to suggest that men would value more targeted preparation, especially for labour and birth (Premberg and Lundgren, 2006; Martin, 2008; Bergström et al, 2011; Alio et al, 2013). While a large-scale survey found that men overwhelmingly felt that antenatal education classes helped them feel more confident about labour and birth (Fletcher et al, 2004), they still did not feel adequately prepared for the birth (Martin, 2008).
The correlation between fathers' satisfaction with the birth experience and how well prepared they felt was evident in several of the studies (Fletcher et al, 2004; Wockel et al, 2007; Longworth and Kingdon, 2011). A survey carried out after antenatal education classes showed 62% of men wanted more preparation (Wockel et al, 2007). They were asked the same question in the postpartum period, and this figure rose to 79%.
There were conflicting findings on where and how men prefer to receive information. Literature, internet and partners were named as primary information sources (Wockel et al, 2007; Li et al, 2009), while men in one study commented that information gained from these sources was as valuable as information obtained from antenatal education classes (Premberg and Lundgren, 2006). However, fathers included in Jungmarker et al's study (2010) rated antenatal education classes as more important and expressed a desire for more information to be provided through this medium. In addition, a clear correlation appeared between men's satisfaction with antenatal classes and the qualities of the class leader, with calm and reassuring qualities rating more highly than knowledge (Bergström et al, 2011).
Discussion
This literature review confirms the more active role men now play during pregnancy and birth; however, it has also suggested that antenatal education classes may not be as effective as they could be in preparing fathers for their role as birth partners or for parenthood. The lack of consistency in and evaluation of the effectiveness of antenatal education classes means there is no established benchmark to compare findings against—any conclusions can only be tentative at this stage and further research is required.
Antenatal education is traditionally provided in mixed-gender groups, led by women, and strongly focused on the needs of the expectant woman. The research suggests some men are anxious about the birth of their baby and see it as an uncertain, emotional and stressful experience (Mander, 2004; White, 2007). Societal expectations, cultural norms and traditional gender stereotypes may inhibit those who do attend from showing uncertainty or concerns in this setting or in front of their partner (Seymour-Smith et al, 2002; Coles, 2009). Most of the men who participated in the studies acknowledged and respected the strong focus on the needs of the woman, but this acceptance may also act as a barrier to men feeling able to ask questions or participate more actively in the class.
The findings from this review and a review of antenatal education by the Department of Health (2009) confirm that men feel unprepared for the unpredictability of the birth process and are unsure of their role (Draper, 2003; Dellman, 2004; Locock and Alexander, 2006). Evidence suggests men feel more in control when they understand how they can practically support their partner (Newburn et al, 2011; Newburn and Taylor, 2011); this perhaps explains why men are specifically interested in the subjects of labour, birth and infant care when they can play an active role.
The consensus that attendance at antenatal education can support men in developing their understanding of their role, not just as a birth partner, but also as a parent, highlights the importance of focusing on men's needs. There is a growing belief that effective engagement and involvement of men throughout pregnancy could positively affect men's feelings of involvement and satisfaction with the birth experience, and confidence and adequacy as a new parent in handling the newborn child (Chin et al, 2011; Newburn, 2012). This belief is reinforced in a recent policy briefing paper (Shaw and Lohan, 2012) that suggests there is no single area more important in generating fuller engagement of fathers in the lives of their children than maternity services.
The challenge is to ensure that fathers receive the information they need in a way that is accessible, appropriate and timely (Coulter, 2006; Squire et al, 2006; Azari, 2007; Vahabi, 2007; Nolan, 2009). While men whose partners experienced complications at birth felt they needed more preparation at the antenatal stage, there was recognition that every potential complication cannot be covered (Erlandsson et al, 2007). There is some evidence to suggest a male-only class or session might be an effective way of addressing men's needs (Friedewald et al, 2005), but the costs and practicalities would need to be considered alongside the added value and benefits (Department of Health, 2009).
Implications for midwifery practice
Midwives should be aware of the needs and concerns of fathers and involve them as actively as possible throughout the antenatal, labour, birth and postpartum stages. They can do this through proactive communication, providing information, coaching and encouraging questions from men, especially if complications arise (Darling, 2011). This is supported by Bäckström et al (2011), who found that fathers perceived that they were given good support when they were allowed to ask questions and they had the opportunity to interact with the midwife.
For those leading antenatal education classes, an assessment of men's needs in terms of topics and preferred learning styles would be beneficial to ensure classes are relevant (Hildingsson et al, 2013). Guidance and training for midwives delivering antenatal education, based on evidence of best practice, is needed to promote consistency and good practice.
Implications for midwifery research
There is little evaluation of the effectiveness of antenatal education in general, which is viewed as a deficit by some critics (Ferguson et al, 2013). A wide-scale evaluation of current antenatal education is needed to inform the evidence-base for the development of best-practice guidelines to be implemented nationwide.
There is limited research from men's perspective of the effectiveness of antenatal education in helping them to prepare for labour, birth and parenthood, and several studies have called for more research in this area (Carter, 2002; Dolan and Coe, 2011; Redshaw and Henderson, 2013). The concept of family-centred maternity care and respecting and supporting fathers' roles in this process needs to be further explored and developed (Barlow et al, 2008).
Opinions vary as to how expectant fathers' needs should or can best be addressed, particularly with limited resources (Friedewald, 2007). Research that specifically focuses on men's perspectives of their needs for antenatal education, and preferences in terms of delivery methods, is needed. This research needs to consider and explore demographics, to include ethnic groups, social class and age, to ensure the needs of all men are addressed. More comparative studies into methods of delivering antenatal education, including men-only sessions, are also needed. The use of technology as an educational tool also warrants further exploration.
Conclusions
Fathers play an important role in their children's lives. Helping them to develop an understanding of their role during pregnancy may help foster a stronger attachment and commitment to parenthood (Ives, 2013). Antenatal education classes can provide the opportunity to help men understand how they can support their partner during pregnancy, labour and birth and to prepare for parenthood.
This review has identified the need for further research and the development of strategies to improve the engagement of men in antenatal education. The challenge for the maternity service is how it can adapt and develop current maternity care practice, including antenatal education, to be truly family-centred and inclusive of both expectant mothers and fathers (Newburn and Dodds, 2010).