A plethora of literature has examined the factors behind low breastfeeding rates and has indicated that a mother's decision to breastfeed is associated with social, cultural, personal and environmental factors, as well as mothers' and fathers' attitudes toward breastfeeding (Earle, 2002; Kong and Lee, 2004). Although findings from studies conducted with mothers indicate that they make their initial infant-feeding decision before conception (Giugliani et al, 1994b), mothers have identified the infant's father to be a major influence on their decision to breastfeed (Giugliani et al, 1994) as well as a major source of support during the breastfeeding period (Scott and Binns, 1999; Garfield and Isacco, 2006). Changes in the role of fathers have allowed them to make a greater contribution to a child's social and educational development (Sarkadi et al, 2008): compared to earlier generations, modern fathers are more involved in infant upbringing and responsibilities (Cassidy, 1999; Lamb, 2010). Gage and Kirk (2002) argue that this level of involvement has a long-term impact on enhancing the health of mothers, infants, and children. Research evidence shows that mothers who received support from their partners were also more likely to initiate and sustain breastfeeding for longer periods, compared with mothers who did not receive support from their partners (Hunter and Cattelona, 2014). Although the impact of fathers on breastfeeding behaviours has been highlighted in the literature (Bar-Yam and Darby, 1997), since then, research with fathers and breastfeeding has been somewhat limited (Sherriff and Hall, 2011). The focus of this paper is to review and present findings of existing literature on fathers and breastfeeding, using a narrative style and a systematic approach.
Method
The review process evolved over time due to the complex nature of the subject. Although the search term started as meshed and general, a wider view on the subject was required to incorporate research from different professions outside of nursing and midwifery. The search was later confined to evidence-based practice and empirical work only, as all other sources and grey literature were eliminated during appraisal process.
Rationale for using meta-narrative review
Research into fathers and breastfeeding has examined attitudes, knowledge, involvement, and/or evaluation of father-friendly breastfeeding support. However, a father's involvement in breastfeeding is a multi-dimensional phenomenon and the complexity of issues necessitates consideration and evaluation of a wide range of concepts and evidence. In order to provide a comprehensive review of the variety of research designs around this topic, a meta-narrative approach to literature review was undertaken to structure and synthesis the findings in this paper. In accordance with RAMESES (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) standard, the six principles of meta-narrative review (pragmatism, pluralism, historicity, contestation, reflexivity and peer review) were adhered to throughout the process of completing this review (Greenhalgh et al, 2005; Wong et al, 2013). This narrative review adhered to the list of items to be reported in a meta-narrative review RAMESES guidelines (Wong et al, 2013).
Scoping the literature
The search process started by defining and refining the search terms, which included: father(s), dad(s), partner(s), infant(s), baby, newborn, breastfeeding, feeding, breast milk, breastfeeding, suckling, and infant feeding. These were later expanded following the initial search to include: decision(s), attitudes(s), perception(s), knowledge, initiation, continuation, commitment, self-efficacy, support, intervention, and involvement. Inclusion and exclusion criteria were developed to limit sources and to provide focus for this review. There were no constraints placed as to the research paradigm or discipline from which the studies were derived.
Search process
The search process involved a number of terms, using combinations of AND/OR as appropriate (Figure 1). An electronic search of the literature was undertaken, using CINAHL, MeSH data on PubMed, Psychinfo, Scopus, Cochrane Database of Systematic Reviews, British Nursing Index and Google Scholar. Tracking for citations was undertaken to identify other potential information sources. Results were limited to papers which met the following inclusion criteria:
- Published in English
- Addressed adult participants, fathers/parents of full-term infant and non-compromised children
- Fathers as main participants/focus
- Published in peer-reviewed journals from 1992 to 2015.
Figure 1. Review flow chart
The time period selected for the review reflected the increased attention to breastfeeding internationally as a result of the introduction of the Baby Friendly Hopsital Initiative started by the World Health Organization (WHO) and UNICEF (2009).
Selection and appraisal of documents
The initial database search yielded a total of 3257 articles, and EndNote software was used to identify and eliminate duplications. Abstracts of the retrieved articles were manually screened against the inclusion criteria and relevance to the review (Figure 1). The total number of abstracts was filtered down to 148. Sources were initially grouped according to research design and appraised for quality using modified versions of appropriate standardised tools to determine the quality, strength of evidence and relevance.
Qualitative studies were appraised using the Critical Appraisal Skills Programme (CASP) for Qualitative Research Checklist (CASP, 2014a). Screening assessed the presence of defined aims or objectives and their relevance to the study; the appropriateness of methodology research design and recruitment strategies; data collection methods and settings; ethics; funding statement; rigor; risk of bias; and contribution of the study to current knowledge. Nineteen qualitative studies were deemed to meet the aims and objectives of the review. Quantitative studies were appraised with a modified version of the Health Care Practice Research and Development Unit (HCPRDU) evaluation tool for quantitative studies (Long et al, 2002) and included assessment of six sub-sections: study overview, settings, sample, ethics, group comparability and outcome measurement, and policy and practice implications. In total, 29 quantitative papers were deemed appropriate for inclusion in the review.
Data extraction
Data extraction tables for identified studies were developed, and illustrated author name(s), year of publication, country (or settings), type of study, method, sample type/numbers, and key findings/conclusions for each study. The selection of the extracted information informed the next step of data analysis and synthesis. The tables give a summary picture of the quality of evidence, and validity of evidence around fathers' involvement in breastfeeding. Studies were categorised according to the focus of enquiry, regardless of their methodology types. These were: attitudes, knowledge, perceptions, involvement, support, support from fathers, support for fathers, and interventions to support breastfeeding. This grouping was revisited before synthesising the literature.
Analysis and synthesis
The review encompasses a variety of research traditions, designs and methodologies. A greater prevalence of research with fathers was evident over the past decade. The complex nature of human behaviours, including breastfeeding, produced a shift in the type of research from a quantitative nature to a qualitative approach to understanding fathers and breastfeeding. The findings of this review were synthesised using a concrete level synthesis approach (Green et al, 2006) to encompass the variety of research traditions. Throughout the synthesis process, sources were grouped based on the major areas being investigated. Secondary screening helped to categorise the included studies into themes using a grounded theory like approach (Strauss and Corbin, 1990).
Results
In total 48 studies were selected for inclusion as per the document flow diagram (Figure 1).
Document characteristics
Only empirical and peer-reviewed research papers were included in the review. The included studies were drawn from different research traditions including quantitative, qualitative, reviews, randomised controlled trials and evaluation research; although all studies that were included investigated fathers and breastfeeding. Studies with similar content and events were then grouped together and organised under themes, which enabled an analytic induction process. These themes were: fathers' attitudes to breastfeeding; fathers' needs and involvement; nature of fathers' support; and interventions for fathers. In instances where contradictory findings were reported, the research team discussed and determined suitability for inclusion.
Theme one: fathers' attitudes towards breastfeeding
The decision to breastfeed is associated with personal, environmental, social, economic and cultural factors (Wambach and Riordan, 2010). Fathers' attitudes and behaviours impact mothers' breastfeeding decisions (Earle, 2000). Attitude is a determinant of breastfeeding decision and practice: couples who have a positive attitude toward breastfeeding are more likely to result in mothers breastfeeding their infant (Arora et al, 2000). Attitude is, however, a complex phenomenon that encompasses cognitive knowledge and thoughts, affective feelings and behavioural action components (Olson and Maio, 2003). Therefore, the literature included in this section discussed fathers' attitudes in terms of knowledge, feelings, and actions. The 13 studies included addressed fathers' attitudes, knowledge and feelings in relation to breastfeeding (Table 1).
Table 1. Studies included in theme one: fathers' attitudes to breastfeeding
| Study | Methods | Sample | Analysis Methods | Findings |
|---|---|---|---|---|
| Freed et al (1992) USA | Descriptive questionnaire | Expectant fathers (n=268) | Quantitative analysis | Partners' decision to breastfeed predicted positive attitudes among men |
| Pollock et al (2002) USA | Descriptive questionnaire | Men (n=100) | Quantitative analysis | Men's positive attitudes were associated with their ethnicity, cultural background and being breastfed themselves |
| Rempel and Rempel (2004) Canada | Longitudinal questionnaire | Women (n=317)Men (n=213) | Quantitative analysis | Men's perspectives and beliefs on breastfeeding predicted their partners' breastfeeding intentions |
| Scott et al (2004) UK | Descriptive questionnaire | Couples (n=108) | Quantitative analysis | Attitudes toward breastfeeding were shared by couples; however, only the mothers' attitudes were significantly linked to breastfeeding decisions |
| Laanterä et al (2010) Finland | Descriptive questionnaire | Mothers (n=123)Fathers (n=49) | Quantitative analysis | Participants' attitudes were influenced by parity, age, being fed as infant, and breastfeeding knowledge. Education level was not significant in influencing attitudes |
| Kenosi et al (2011) Ireland | Descriptive questionnaire | Fathers (n=67) | Quantitative analysis | Fathers felt excluded from the decision to breastfeed and reported insufficient support for them during antenatal period |
| Chezem (2012) USA | Descriptive questionnaire | Couples (n=71) | Quantitative analysis | Older age and higher education levels were associated with positive attitudes compared with younger or less educated couples |
| Karande and Perkar (2012) India | Descriptive questionnaire | Couples (n=238) | Quantitative analysis | Fathers' attitudes supported breastfeeding; however, this did not influence actual duration of exclusive breastfeeding |
| Mitchell-Box and Braun (2012) Hawaii | Qualitative interviews | Fathers (n=14) | Grounded theory | Fathers' exclusion from breastfeeding decisions resulted in fathers feeling excluded from infant care |
| Henderson et al (2011) UK | Qualitative interviews | Men (n=28) | Content analysis | Low income men were concerned about breastfeeding in terms of sexuality, embarrassment of feeding in public, and social norms within their communities |
| Mitchell-Box and Braun (2013) Hawaii | Descriptive questionnaire | Couples (n=112) | Quantitative analysis | Attitudes toward breastfeeding were shared by couples. Positive attitudes were predictive of breastfeeding behaviours |
| Vaaler et al (2011) USA | Descriptive questionnaire | Men (n=2145) | Quantitative analysis | Attitudes were influenced by men's race and ethnicity; positive attitudes among men were linked to feeding choices. |
| Van Wagenen et al (2015) USA | Descriptive questionnaire | Men (n=502) | Quantitative analysis | Fathers' breastfeeding attitudes are influenced by ethnicity, education level, and exposure to breastfeeding. |
To understand the role of fathers in first-time mothers' breastfeeding decisions and behaviours, Rempel and Rempel (2004) conducted a longitudinal study involving a total of 530 people (317 women and 213 men) in Canada and reported that fathers' positive attitudes were more likely to strengthen their partners' breastfeeding intentions. Men's beliefs also predicted changes in women's breastfeeding intentions after birth, and influenced how long the mothers intended to breastfeed (Rempel and Rempel, 2004). Couples in the USA (n=112) and India (n=238) were found to share similar attitudes, with those registering higher attitude scores being more likely to breastfeed (Mitchell-Box et al, 2013; Karande and Perkar, 2012). In Scotland, Shaker et al (2004) surveyed breastfeeding attitudes among 108 couples during the antenatal period and reported that positive breastfeeding attitudes were associated with initiation of breastfeeding among participants. In the same study, fathers of breastfed infants were found to have significantly higher positive breastfeeding attitudes and knowledge, compared to fathers of formula-fed infants (Scott et al, 2004).
Pollock et al (2002) surveyed a convenience sample (n=100) of low-income, inner-city men's knowledge and attitudes toward breastfeeding. They concluded that the majority (81%) of men had positive attitudes towards breastfeeding; 90% believed breastfeeding promoted mother/infant attachment; 96% would support their partner to breastfeed; and 97% said that they have respect for mothers who breastfeed. However, the majority of men (98%) believed that breastfeeding would interfere with their sexual lives, while others believed that breastfeeding in public was embarrassing and that formula had nutritional benefits comparable to breast milk; or were concerned about mothers' diet and health (Pollock et al, 2002). The researchers reported that positive attitudes were associated with participant ethnicity and cultural background and were higher among men who were breastfed as an infant. Students had the lowest attitude scores compared to all employment categories, including those who were unemployed (Pollock et al, 2002). Concerns about the impact of breastfeeding on sexuality and sensitivity toward breastfeeding in public were also expressed among low-income men in the UK (n=28) (Henderson et al, 2011).
Positive attitudes toward breastfeeding are linked to higher levels of knowledge about breastfeeding (Shaker et al, 2004). Similar links between attitude and knowledge were found by Freed et al (1992) among men in the USA (n=268). Men with a positive attitude towards breastfeeding believed that it was better for the infant, and helpful in mother/infant bonding, and that it protected the infant from diseases. They also demonstrated higher levels of respect towards breastfeeding women (Freed et al, 1992). On the other hand, men favouring formula-feeding believed that breastfeeding was bad for breasts, made breasts ugly and interfered with their sexual lives (Freed et al, 1992). The majority of both groups of men were not supportive of breastfeeding in public. However, in Finland, couples (n=172) had positive attitudes towards breastfeeding (95%) and the majority found it acceptable to breastfeed in public as long as the infant was less than one-year-old (Laanterä et al, 2010). The participants' attitudes were reported to be influenced by parity, age, being breastfed as infant, and breastfeeding knowledge, while education level did not influence participants' attitudes (Laanterä et al, 2010). In a study from the US, fathers of breastfed infants perceived breastfeeding to be of greater health benefit, but fathers who were not included in the breastfeeding decision considered formula feeding to be more convenient and reported that breastfeeding made them feel excluded from their infants' care and bonding (Mitchell-Box and Braun, 2012). Such feelings of exclusion from preparation and the decision process were also reported from quantitative studies in Ireland (n=67) and Turkey (n=203) (Kenosi et al, 2011; Taşpınar et al, 2013).
Fathers' attitudes toward breastfeeding were found to be affected by social factors such as ethnicity, country of origin, education levels, and socioeconomic status (Vaaler et al, 2011). Couples in the USA (n=71) with a positive attitude towards breastfeeding were found to be older in age and to have higher education levels when compared with parents negatively disposed to breastfeeding (Chezem, 2012). Similarly, in the USA, men's (n=502) positive attitudes were associated with being white/non-Hispanic; higher education levels; and earlier exposure to breastfeeding through witnessing breastfeeding by a family member or friend (Van Wagenen et al, 2015). A qualitative inquiry reported that fathers in the USA (n=10) were positive about breastfeeding, despite lacking knowledge on how to provide support (Banks et al, 2013). In summary, this section of the review demonstrated several factors that could affect fathers' attitudes towards breastfeeding, which included influencers that were personal, sociocultural, economic and environmental factors (Sharma and Petosa, 1997).
Theme two: fathers' needs and involvement
Although breastfeeding is a relatively brief period in fatherhood, it can be associated with insecurities and concerns toward breastfeeding (Pontes et al, 2009). Inability to provide support after birth increased a father's worries in their fathering role (Thomas et al, 2011) and problems such as jealousy, isolation, and resentment have been cited in literature (Pontes et al, 2008; Magaraggia, 2013). In total, 13 included studies related specifically to father's needs and/or involvement in breastfeeding (Table 2). Mothers and fathers in Australia reported fathers' emotional, practical and physical involvement to be crucial to a successful breastfeeding experience (Tohotoa et al, 2009). Fathers' preparation and inclusion in support programmes can help address their needs in relation to fathering and their breastfeeding support role (Schmied et al, 2002; Wöckel et al, 2007), whereas exclusion of fathers from breastfeeding preparation may potentially lower breastfeeding rates (Mullany et al, 2006).
Table 2. Studies included in theme two: fathers' needs and involvements
| Study | Methods | Sample | Analysis Methods | Findings |
|---|---|---|---|---|
| Deave and Johnson (2008) England | Qualitative interviews | First time fathers (n=20) | Content analysis | First-time fathers needed preparation for parenthood and father-based support during the antenatal period |
| Pontes et al (2009) Brazil | Group discussion | Men (n=9)Women (n=11) | Content analysis | Breastfeeding considered to be a brief period of fatherhood, however, participants expressed insecurity and concern towards breastfeeding |
| Sherriff et al (2009) England | Qualitative interviews | Fathers (n=8) | Content analysis | Content and timing of breastfeeding classes were a source of concern for some fathers. Fathers were ready to provide support while their partners were breastfeeding |
| Tohotoa et al (2009) Australia | Qualitative interviews | Mothers (n=48)Fathers (n=28) | Thematic analysis | A successful breastfeeding experience can be enhanced by the fathers' emotional, practical and physical support |
| Chie et al (2010) Taiwan | Descriptive questionnaire | Fathers (n=1699) | Quantitative analysis | Not receiving breastfeeding support and fathering breast-fed infants was associated with lower quality of life |
| Flacking et al (2010) Sweden | Prospective cohort | Fathers (n=51 671) | Quantitative analysis | Increasing fathers' involvement in infant care (e.g. paid paternal leave) and being from higher socioeconomic class were associated with increasing breastfeeding duration during the first 6 months |
| Engebretsen et al (2010) Uganda | Qualitative interviews | Women (n=43)Men (n=38) | Content analysis | Ugandan fathers supported breastfeeding, although exclusive breastfeeding was seen as unrealistic and was stigmatised, as men believed that they must provide food for their infant |
| Sherriff and Hall (2011) UK | Qualitative interviews | Fathers (n=8) | Content analysis | Health visitors were identified as important in providing support to fathers. Greater support should be directed toward fathers' needs regarding breastfeeding |
| Banu and Khanom, (2012) Bangladesh | Questionnaire interviews | Couples (n=202) | Quantitative analysis | Higher levels of education was associated with better perceptions of breastfeeding |
| Datta et al (2012) UK | Qualitative interviews | Fathers (n=14)Mothers (n=4) | Content analysis | Although participants were in an area with high breastfeeding rates, parents reported that they still needed breastfeeding-related support and information |
| Taşpınar et al (2012) Turkey | Questionnaire | Fathers (n=203) | Quantitative analysis | Not all fathers discussed feeding choices with their partners. Fathers required breastfeeding support and information targeting their needs |
| Banks et al (2013) USA | Group discussion | Fathers (n=10) | Thematic analysis | Fathers did not know how to support their partners during breastfeeding. Low-income fathers had positive views toward breastfeeding |
UK fathers were interested in breastfeeding and participated in preparation courses in areas where breastfeeding rates were high (Deave and Johnson, 2008; Sherriff and Hall, 2011; Datta et al, 2012). Fathers held mixed opinions on the appropriateness of the content and timing of antenatal classes when it came to their needs (Sherriff et al, 2009). Some fathers reported the experience of breastfeeding to be smooth, whereas other fathers reported it to fraught with problems (Sherriff et al, 2009). Chie et al (2010) assessed the quality of life of fathers of breastfed infants (n=1699) and reported that they scored lower on quality of life when compared to fathers of bottle-fed infants. In addition, fathers believed that breastfeeding was not beneficial for them as individuals (Chie et al, 2010). In Uganda, breastfeeding was considered the norm, despite poverty and increased risk of acquiring HIV, and fathers reported involvement in the decision to breastfeed (Engebretsen et al, 2010). However, reliance on breastfeeding exclusively was considered to limit father involvement in infant care in terms of nutritional provision (Engebretsen et al, 2010).
A prospective, population-based cohort study of fathers in Sweden (n=51 671) found that fathers' levels of education and employment status was significant in increasing fathers' knowledge, perceptions, and involvement in the breastfeeding process (Flacking et al, 2010). Lower socioeconomic status was associated with less knowledge and negative perceptions (Flacking et al, 2010). There is a need to target fathers for support in a systematic way in order to develop support programmes for men from different cultural and socioeconomic backgrounds (Sherriff, 2007). Focusing on fathers as a major part of the breastfeeding family and engaging them in the preparation and support process would certainly impact positively upon their parenting self-efficacy and support their transition to fatherhood (de Montigny et al, 2012).
Theme three: nature of fathers' support
The notion of fathers' support is still relatively vague and ill-defined from a conceptual view point (Sherriff et al, 2009). Six studies were included under this theme referencing fathers support (Table 3). In order to develop and implement successful strategies that engage fathers in breastfeeding support, a distinct understanding of what comprises the nature of fathers' support is essential (Sherriff and Hall, 2011). In England, Sherriff et al (2014a) conducted an analysis of the literature and held subsequent group discussion/interviews with breastfeeding parents (n=16). They then proposed a conceptual model of what constitutes fathers' support in relation to health services. The model outlined five essential characteristics of fathers who support breastfeeding as follows: being knowledgeable about breastfeeding, having positive attitudes towards breastfeeding, involvement in feeding decision-making, providing practical support, and providing emotional support (Sherriff et al, 2014a).
Table 3. Studies included in theme three: nature of fathers' support
| Study | Methods | Sample | Analysis Methods | Findings |
|---|---|---|---|---|
| Gamble and Morse (1993) Canada | Qualitative interviews | Fathers (n=14) | Grounded theory | Fathers involved in breastfeeding were categorised as: being involved; being assister; being supervisor; or being detached |
| Schmidt and Sigman-Grant (2000) USA | Group discussion | Couples (n=34) | Content analysis | Both parents viewed fathers as having a substantial role in the breastfeeding experience. Support included helping with the decision, emotional support; and actively engaging by providing physical support |
| Rempel and Rempel (2011) Canada | Qualitative interviews | Couples (n=21) (reporting from fathers' interviews only) | Thematic analysis | Experiential learning was evident among fathers. Fathers supported their partners to breastfeed by valuing breastfeeding mothers and sharing house chores and childcare |
| Brown and Davies (2014) UK | Cross-sectional questionnaire | Fathers (n=117) | Content analysis | Fathers encouraged breastfeeding but felt left out of the experience and helpless in support provision |
| Avery and Magnus (2011) USA | Focus group Mothers (n=81) | Fathers (n=40) | Content analysis | Fathers and mothers agreed on the fathers' role in providing care for the infant, but did not agree on fathers' role in providing support for mothers |
| Sherriff et al (2014a) England | Concept analysis | Parents, (n=16) | Thematic analysis | The study identified attributes of fathers who supported breastfeeding: knowledge about breastfeeding; positive attitude; involvement in breastfeeding decision making; practical support and emotional support. |
Sullivan et al (2004) found that fathers' support with domestic and/or childcare tasks was useful in encouraging breastfeeding continuation among an ethnically diverse group of urban middle-class women (n=115) in the USA. Mothers' confidence in breastfeeding was also found to be higher when fathers were actively supportive (Mannion et al, 2013). Although fathers were interested in breastfeeding and wanted to be involved, they were not sufficiently prepared to provide support (de Montigny and Lacharité, 2004) and most felt left out or excluded from their infants' care (Mitchell-Box and Braun, 2012). Although fathers in the UK (n=117) provided support and encouraged their partner to breastfeed, they report similar experiences (Brown and Davies, 2014). While these studies give an insight to how fathers might support mothers, there remains a limited understanding of the exact nature of father support (Sherriff et al, 2014b). Given the importance of fathers' support in breastfeeding initiation (Scott et al, 2001) and continuation (Gage and Kirk, 2002), more studies are needed to explore the nature of this support.
Some researchers have sought out information about fathers' support and involvement in breastfeeding from mothers (Britton et al, 2007). Nickerson et al (2012) conducted qualitative interviews with 19 US mothers and classified eight ways fathers could support breastfeeding experience: involvement in the decision to breastfeed; participation in breastfeeding preparation; participation in breastfeeding consultation; support with infant care; sharing the house work; emotional support; support when difficulties and challenges happen in early breastfeeding period; and involvement in father-focused breastfeeding support (Nickerson et al, 2012).
Earlier work by Gamble and Morse (1993) provided a typology of fathers' involvement in breastfeeding decisions and infant caretaking based on interviews with married men whose infant was breastfed. These are categorised as: Involver (involved in the decision and the provision of infant care), Assister (mother decides to breastfeed and the father is supportive), Supervisor (involved only with the decision), and Detached (unconcerned about the decision nor involved in infant care) (Gamble and Morse, 1993). This typology provides a linear and somewhat simplistic categorisation, and may underestimate father involvement, commitment and expectations from breastfeeding. Moreover, Gamble and Morse (1993) suggested that fathers needed realistic education on how to connect with their breastfeeding infants, in order to establish a bond with their newborn. Fathers elsewhere supported their partner by being involved in the decision, providing emotional and physical support (Schmidt and Sigman-Grant, 2000); expressing empathy for mothers (Avery and Magnus, 2011) and using their knowledge to encourage, value, assist and share chores and childcare (Rempel and Rempel, 2011).
Theme four: interventions designed to support fathers
A total of 16 studies were located that sought to demonstrate the effect of increasing father's knowledge and support on influencing breastfeeding rates and duration (Table 4). Eight were clinical trials; five programme evaluations; and three quasi-experiments. The studies underlined the impact of fathers' inclusion in breastfeeding support on improving breastfeeding experiences and outcomes. The following studies are grouped according to the type and timing of intervention in order to prevent repetition where similar interventions took place.
Table 4. Studies included in theme four: Interventions for fathers
| Study | Methods | Sample | Aim/objective | Findings |
|---|---|---|---|---|
| Sciacca et al (1995) USA | Randomised controlled trial (RCT) | Couples (n=55)Control (n=26)Intervention (n=29) | To determine the effects of health education on breastfeeding among low-income women | Using an incentives-based intervention among parents of a lower socioeconomic status can significantly impact positive changes in attitudes and breastfeeding behaviours |
| Susin et al (1999) Brazil | Controlled trial (CT) | Couples (n=601)Control (n=208)Intervention 1 (n=197)Intervention 2 (n=196) | To assess the parents' knowledge of breastfeeding after receiving postpartum advice | Breastfeeding intervention was effective in increasing breastfeeding rates in both intervention groups. However, exclusive breastfeeding was higher in the group with both parents at 3 months postpartum, compared to the mothers-only group |
| Stremler and Lovera (2004) USA | Pilot programme evaluation | Site 1: 4 trained by father-to-father supportSite 2: 5 trained by father-to-father support | To pilot a father-to-father peer support programme | The information fathers received was important and helpful in guiding them to support their partner. Breastfeeding rates increased in clinics where the programme took place |
| Wolfberg et al (2004) USA | CT | Couples (n=59)Control (n=32)Intervention (n=27) | To assess the effectiveness of simple education programme for fathers on breastfeeding choices | Educating fathers significantly influenced breastfeeding initiation rate: 74% in the intervention group compared to 41% in control group (P=0.02) |
| Pisacane et al (2005) Italy | RCT | Couples (n=560)Control (n=140)Intervention (n=140) | To investigate the effect of providing fathers with support regarding their role on the success of breastfeeding | Mothers in the intervention group reported receiving more support from their partners compared with control group (91% versus 34%) and a higher breastfeeding prevalence at 6 months |
| Sahip and Turan (2007) Turkey | Programme evaluation | Fathers (n=160) | To test the feasibility and effect of using the workplace as a venue to educate expectant fathers on breastfeeding | The workplace was found to be a feasible venue for father-based breastfeeding programmes where fathers do not attend antenatal classes |
| Fletcher et al (2008) Tasmania | RCT | Fathers (n=105) | Assess fathers' readiness to receive online breastfeeding support | Internet-based father support was reported to be satisfactory when compared with antenatal classes. However, the majority of the respondents were from higher socioeconomic classes and education levels |
| Salonen et al (2008) Finland | Quasi-experiment | Families (n=1300)Control (n=612)Intervention (n=776) | Describe the development and comparability of online support for parents to hospital based support | Internet-based parent support was comparable to hospital based support, and both groups scored similarly high self-efficacy scores. Intervention group mothers were significantly more likely to breastfeed exclusively |
| Susin and Giugliani (2008) Brazil | CT | Couples (n=586)Control (n=201)Intervention 1 (n=192)Intervention 2 (n=193) | To assess the impact of paternal inclusion in a breastfeeding education programme | The inclusion of fathers in a breastfeeding support intervention significantly increased the rate of exclusive breastfeeding among participants but did not the rate of breastfeeding in general |
| Lovera et al (2010) USA | Programme evaluation | Couples (n=200:Control (n=99)Intervention (n=101) | To evaluate breastfeeding among Hispanic couples enrolled in a pilot peer support programme | There was no significant difference in the duration of breastfeeding among groups; the inclusion of Hispanic fathers in breastfeeding support did not affect the duration of breastfeeding |
| Salonen et al (2011) Finland | Quasi-experiment | Families (n=1300) | To evaluate the effectiveness of an internet-based intervention to support mothers' and fathers' parenting satisfaction and parenting self-efficacy | No significant effects of the intervention were detected. Both groups presented increased levels of self-efficacy during the postpartum period |
| Tohotoa et al (2011) Australia | Programme evaluation | Fathers (n=342) | To describe the development and process evaluation of a perinatal education and support program for fathers to support their partners to breastfeed | The father-based programme was a successful intervention to promote awareness of fathers' roles, increase knowledge on breastfeeding and reinforce how fathers can play a part |
| Maycock et al (2013) Australia | RCT | Couples (n=699):Control (n=314)Intervention (n=385) | To investigate the effects of an antenatal education session and postnatal support targeted to fathers | Perinatal breastfeeding support for fathers increased breastfeeding rates at 6 weeks among intervention group (81.6%) compared to control group (75.2%) |
| Bich et al (2014) Vietnam | Quasi-experiment | Couples (n=492):Control (n=241)Intervention (n=251) | To determine the extent of exclusive breastfeeding practices among those whose partners received breastfeeding education support and counselling | Interventions targeting fathers were able to significantly increase the rate of exclusive breastfeeding |
| Özlüses and Çelebioglu (2014) Northern Cyprus | Programme evaluation | Couples (n=117):Control (n=99)Intervention 1 (n=39)Intervention 2 (n=39) | To determine the effect of breastfeeding education provided to fathers on breastfeeding rates and paternal-infant attachment | The provision of breastfeeding education to fathers significantly increased breastfeeding rates among participants and strengthened father-infant attachments |
| Raeisi et al (2014) Iran | Programme evaluation | Couples (n=100):Control (n=50)Intervention (n=50) | To evaluate the influence of fathers' participation on successful breastfeeding experience | Fathers were more likely to participate and support their partners when they were exposed to a training programme aimed at fathers |
| Abbass-Dick et al (2015) Canada | RCT | Couples (n=214):Control (n=107)Intervention (n=107) | To evaluate the effectiveness of a co-parenting intervention on exclusive breastfeeding among primiparous mothers and fathers | Co-parenting breastfeeding support showed significant improvement in breastfeeding duration, fathers' attitudes and self-efficacy, as well as mothers' perceptions of fathers' role in breastfeeding involvement and support |
Antenatal interventions
Perinatal education and support was reported to be successful in positively impacting on breastfeeding among Australian fathers (n=342) and helping them to understand their role in the breastfeeding experience (Tohotoa et al, 2011). Iranian fathers (n=100) were more likely to provide support to their partners when they were exposed to training programmes aimed at their own needs (Raeisi et al, 2014). Likewise, a clinical trial in the USA, to test the effect of a 2-hour education class for expectant fathers (n=59) on breastfeeding outcomes, reported that mothers whose partner attended were significantly (P=0.02) more likely to initiate breastfeeding (74%) compared to women in the control group (41%) (Wolfberg et al, 2004). A pilot father-to-father peer support study in the US reported that expectant fathers recognised that information from other fathers was important and helpful in guiding them to support their breastfeeding partners (Stremler and Lovera, 2004).
Another clinical trial in Italy evaluated fathers' roles in breastfeeding promotion among a sample of couples (n=560) planning to breastfeed (Pisacane et al, 2005). Exclusive breastfeeding prevalence was 10% higher at 6 months postpartum in the intervention group (Pisacane et al, 2005). Compared to the control group (n=48 of 140, 34%), mothers in the intervention group reported receiving significantly more support from their partners during breastfeeding (n=128 of 140, 91%). Encouragement, empowerment and support with problem solving contributed to successful breastfeeding experience (Pisacane et al, 2005). A study in Turkey tested the use of the workplace as a venue for father-based education by recruiting a sample of expectant fathers (n=160) and providing them with workplace antenatal classes (Sahipand Molzan Turan, 2007). The researchers concluded that thisapproach was feasible, recommending that workplace physicians might deliver classes for fathers. They further suggested that workplace-based classes could be a more acceptable means by which men in these cultures could receive antenatal education (Sahip and Turan, 2007).
‘The researchers concluded that workplace physicians might deliver classes for fathers, which could be a more acceptable means by which men in certain cultures could receive antenatal education’
Postnatal interventions
Clinical trials targeting fathers for breastfeeding education and support during the postnatal period were found to be effective in increasing exclusive breastfeeding rates and duration compared with studies targeting mothers alone (Susin et al, 1999). Internet-based education is a promising medium to convey messages to new fathers (Riordan, 2000; May and Fletcher, 2013), however, it was important to direct the information towards fathers' needs (Fletcher et al, 2008). In Tasmania, fathers (n=105) considered the antenatal clinic as irrelevant for them but reported that tailored web-based information was a more feasible means for receiving support (Fletcher et al, 2008). In Finland, Salonen et al (2008) developed and evaluated the usefulness of internet-based interactive support for parents among a sample of 1300 families. The findings indicated that both the control group (who received support in hospital settings) and intervention group (who received the online intervention) reported similar levels of satisfaction in regard to their parenting self-efficacy and attitudes towards breastfeeding (Salonen et al, 2008). The study produced similar results when repeated for further validation of the findings with a similar sample in Finland (Salonen et al, 2011). The consistency between hospitals and internet-based support in Finland as demonstrated here would require more investigation, as this country does have particularly high rates of breastfeeding compared to neighbouring countries (National Institute for Health and Welfare, 2014).
Both antenatal and postnatal intervention
In a randomised controlled trial, Sciacca et al (1995) administered an incentive-based breastfeeding educational programme in order to positively enhance breastfeeding knowledge, attitudes and support of low-income parents in the USA. Parents in the intervention group (n=29) experienced positive changes in their breastfeeding knowledge and attitudes. The study also reported that fathers in the intervention group were more likely to support breastfeeding, compared with fathers in the control group (Sciacca et al, 1995). Similar conclusions were derived from a randomised controlled trial with expectant couples (n=699) in Australia (Maycock et al, 2013). Additionally, in a quasi-experimental study with couples (n=492) in Vietnam, Bich et al (2014) reported that, among couples who received the breastfeeding intervention, fathers demonstrated more active involvement in supporting their partners to breastfeed.
Co-parenting support
Abbass-Dick et al (2015) argued that there was a need to implement co-parenting breastfeeding support in order to maximise breastfeeding intervention effects. Although their comparison of co-parenting intervention among couples (n=214) in Canada did not detect any significant difference in breastfeeding rates between groups at 6 weeks, the intervention group were more likely to be breastfeeding at 12 weeks (96.2%) compared to the control group (87.6%). The co-parenting intervention was associated with increased self-efficacy and higher attitudes scores among fathers at 6 weeks postpartum. A clinical trial in Brazil with parents (n=586) showed that, in the mothers-only group, 60.3% were likely to be breastfeeding at 6 months, compared to the other two groups (50% mother-father, and 46.4% control) (Susin and Giugliani, 2008). However, exclusive breastfeeding rates were higher among mother-father groups at 4 months (16.5%), compared with mothers-only and control groups (11.1% and 5.7% respectively). Breastfeeding rates were lower across all groups where fathers had less than eight years of education (Susin and Giugliani, 2008).
In the Turkish republic of Northern Cyprus, Özlüses and Çelebioglu (2014) compared the effect of providing breastfeeding education for both parents with providing breastfeeding education for mothers only (n=117). They concluded that the inclusion of fathers in breastfeeding education significantly increased the rates of breastfeeding practice among participants, and also positively influenced father-infant attachment. Elsewhere, in a study conducted among a Hispanic population in the USA, Lovera et al (2010) did not detect any significant difference in breastfeeding rates between an intervention group in which only mothers received support and an intervention group in which mothers and fathers received peer support, highlighting the need for such studies to consider of social context and the value of cultural norms before designing breastfeeding support content.
Discussion and summary of findings
There is evidence that fathers play a crucial role in breastfeeding behaviour in both the developed (Giugliani et al, 1994), and developing world (Gangal et al, 2007). Although the Baby Friendly Hospital Initiative (WHO and UNICEF, 2009) was introduced to target global breastfeeding promotion, there is little attention drawn to the inclusion of families and fathers in this initiative. Research with fathers and breastfeeding has increased in the last decade, yet it is limited compared to research with mothers. Some conclusive findings suggest that fathers' positive attitudes toward breastfeeding can significantly increase breastfeeding rates (Scott et al, 2001; Persad and Mensinger, 2008). Other studies reported that fathers' positive attitudes did not influence the duration of exclusive breastfeeding (Karande and Perkar, 2012), which may be explained by small sample sizes and/or complexity of breastfeeding behaviours among different subjects. Nevertheless, fathers' attitudes were influenced by level of knowledge of breastfeeding, ethnicity, age, level of education, socioeconomic status and cultural beliefs (Freed et al, 1992; Scott et al, 2004; Shaker et al, 2004). Fathers were also more likely to have positive attitudes if they were breastfed as infants, experienced fathers, and exposed to a recent breastfeeding experience (Van Wagenen et al, 2015). Negative perceptions such as feeling left out or false information could lead to negative attitudes, which could then influence the mothers' decisions and hinder fathers' support to mothers (Kenosi et al, 2011; Mitchell-Box and Braun, 2012; Taşpınar et al, 2013).
Fathers' positive attitudes strengthened their partners' breastfeeding intentions/confidence (Swanson and Power, 2005) and may change their breastfeeding behaviours (Rempel and Rempel, 2004). Mothers needed fathers' support to prolong their commitment to breastfeeding (Mannion et al, 2013). However, fathers needed support to help them understand their role and how they can support their partners (Datta et al, 2012). Preparing and supporting fathers demonstrated increased levels of self-efficacy among fathers and impacted on breastfeeding rates and duration positively (de Montigny et al, 2012). Programmes tailored for both parents were shown to be more effective in increasing breastfeeding rates and duration (Abbass-Dick et al, 2015). Fathers' level of involvement in breastfeeding could be either full involvement in decision and care, assisting in care but not the decision, supervisory, or detached from both the decision and baby care (Gamble and Morse, 1993). Support providers needed to recognise these differing roles in the preparation of fathers.
The design of father-based interventions should consider the fathers' unique set of social circumstances. For example, the needs of first-time fathers differed from experienced fathers, who had already experienced infant feeding and upbringing (Laanterä et al, 2010). The number of randomised clinical trials was limited and therefore it was more difficult to assess the usefulness of integrated father-based interventions. The evidence indicated that father-friendly programmes influenced breastfeeding rates and duration for up to 6 months after birth. Father-based programmes, however, showed no improvement in breastfeeding rates and duration when the design of the programme did not take into account fathers' personal, cultural and environmental needs (Susin and Giugliani, 2008). Feasible venues to target fathers support were identified, including antenatal classes, father peer counselling, internet education, father-tailored information packs, postnatal ward teaching, postnatal classes, home visits and fathers' workplace classes.
Strengths and limitations
This review provided a summary of research on fathers and breastfeeding. Data were drawn from different research traditions that were not easily compared, but the adapted approach enabled for a synthesis of both qualitative and quantitative studies. One limitation was that the review was limited to literature in English. Besides summary evidence, this review provided confirmation of the importance of fathers' role in breastfeeding.
Conclusion and recommendations
While some of the studies did not support the notion that fathers impacted the initiation and duration of breastfeeding, taken collectively, the review findings demonstrate that focusing on fathers is an important part of breastfeeding preparation and that engaging them in the preparation and support process would certainly impact positively on breastfeeding rates. Fathers' attitudes and knowledge were factors that influenced mothers' decisions to breastfeed, their commitment, and the duration of breastfeeding. Attitudes toward breastfeeding were hugely influenced by a father's personal, social and cultural backgrounds, meaning that health-care providers must focus on addressing fathers' needs within a father-friendly framework. There was also a lack of evidence as to what constitutes the nature of fathers' support. More research is needed to scrutinise the exact nature of fathers' support; provide comprehensive understanding of fathers' needs and examine the effectiveness of breastfeeding programmes in order to design successful preparation initiatives that are suitable for both parents and underpinned by justifiable evidence.
Key Points
- Fathers are a major source of social support for breastfeeding mothers
- This review aimed to examine the literature surrounding father's attitudes towards breastfeeding
- The results showed that fathers played an important role in the breastfeeding period, and that engaging their suppport could positively imapct on breastfeeding rates
- Attitudes toward breastfeeding were hugely influenced by a father's personal, social and cultural backgrounds
- There was a lack of detail about what constituted a fathers' support amd father-friendly interventions to support breastfeeding
CPD reflective questions
- What experience have you had with fathers supporting mothers to breastfeed?
- in your Trust, what influences fathers' attitudes towards breastfeeding, and what could be done to improve breastfeeding rates?
- Are you familiar with successful interventions targeted at fathers? What made them successful?