In 1996, a document titled ‘Care in normal birth’ was published by the World Health Organization (WHO) with the purpose of spreading a culture of normal birth with the least interventions possible while still being safe (WHO, 1996). Many of the recommendations in the document are about women's wellbeing in labour. It is specifically recommended that all women should be accompanied by the people they trust and feel comfortable with, such as their partner, best friend, mother or sister (WHO, 1996).
In Italy, almost 85% of women choose to have their partner to stay with them during labour (Regione Emilia-Romagna, 2011; Regione Emilia-Romagna, 2012). Fathers' presence during birth is increasing all over the world (Steen et al, 2012), even in those countries where, traditionally, males were excluded from maternity services (Shibli-Kometiani and Brown, 2012). Liukkonen and Vehviläinen-Julkunen (1997) noted that for those fathers who assist their partners' delivery, their presence at birth is an important part of fatherhood, and international and national agencies now encourage new fathers' involvement not only at birth, but throughout the whole pregnancy process and postpartum period (National Childbirth Trust, 2009; Department for Children, Schools and Families, 2010). In 2011, the Royal College of Midwives also emphasised the importance of the fathers' presence in the maternity process by publishing a document aimed both at fathers and at society as a whole, underlining how important a father's involvement is for the child's overall wellbeing and development (RCM, 2011).
While the benefits of the partner's presence for a woman's wellbeing during labour are widely demonstrated (Hodnett et al, 2013), interest about how fathers themselves experience the phenomena of labour is growing. A number of studies have been conducted in different countries that report on both the positive and negative feelings fathers experience while being in the labour room. Overwhelmingly, the experience is a positive one for fathers and that there is pleasure in being present at the time of birth, that this presence facilitates bonding with the infant, and that men express high levels of love and gratitude to their partners for enduring labour (Vehviläinen-Julkunen and Liukkonen, 1998; Chan and Paterson-Brown, 2002; Sapountzi-Krepia, et al, 2010). The most common negative feeling reported is related to the difficulty many men experience in seeing their partner in pain (Capogna et al, 2007; Liukkonen and Vehviläinen-Julkunen, 1997; Vehviläinen-Julkunen and Liukkonen, 1998). Fathers' needs for more information on labour and on their role during childbirth; their desire to have a more active role and be involved in the experience; and their longing to see their needs recognised have been reported (Sapountzi-Krepia, et al, 2010). It has been shown that fathers tend to feel useless, powerless and not entirely accepted by health care workers (Vehviläinen-Julkunen and Liukkonen 1998; Hallgren et al, 1999; Chapman, 2000; de Carvalho, 2003, Singh and Newburn, 2003; Tomeleri et al, 2007). Overall, the quality and nature of the interactions between a father and the attending health professionals will have an impact on his overall perceptions of the birth experience. When fathers perceive health care providers as competent and when they involve the father in the labour, the birth experience is rated as a positive one (Johansson et al, 2012). In their metasynthesis of 23 qualitative studies of fathers' experiences of maternity care in high resource contexts, Steen et al (2002: 362) summarise that within the health care setting many fathers are treated as ‘not-patient and not-visitor’, which may lead to feelings of exclusion, fear, frustration or uncertainty. Shibli-Kometiani and Brown (2012) concluded that fathers want to share the moment of birth with their partners but they are afraid of what will happen. A well-prepared father has a positive effect on his partner, which promotes a positive birth experience for the mother and reduces the fear (especially of seeing his partner in pain) for the father (Department for Children, Schools and Families, 2010).
The aim of this study is to understand how Italian first-time fathers experience their partners' labour pain and the meaning they give to this experience. The research was conducted in a busy tertiary level Italian teaching hospital in Bologna.
Methods
Study design and sampling
This study was informed by the design principles of descriptive phenomenology with the overall objective of obtaining an in-depth description of the meaning that fathers give to the labour pain experience (Creswell, 1998; Holloway and Wheeler, 2002). Using purposive sampling, a homogenous sample of fathers were recruited to participate in this study. Inclusion criteria consisted of:
The birth itself had to meet the following characteristics:
Fathers were recruited from September 2009 until November 2010. Enrolment continued until data saturation occurred (Morse, 1994; Creswell, 1998).
The research protocol was approved by the Ethical Committee of the teaching hospital Sant Orsola-Malpighi, Bologna, Italy.
Data collection and analysis
In-depth semi-structured interviews were conducted. Interviews generally took place within the first 10 days after birth, in a place chosen by the father.
They were recorded using digital audio recorders and transcribed verbatim by the researchers. Participants were fully informed of the nature and purpose of the study; written consent for participation was obtained.
At the beginning of each interview, open-ended questions were posed to each participant. Examples of the interview questions asked, were:
Based on ongoing analysis, the interview guide was then modified, both through adding questions as a strategy for member checking (for example ‘Some fathers experienced the need to go out for a while during labour—was it the same for you?’), and through deleting questions that were not producing relevant data.
For this descriptive phenomenology, Colaizzi's (1978) framework for analysis was used. The first step was to thoroughly read each transcript several times in order to be immersed in the fathers' accounts of their experiences during labour. Then significant statements about their experiences, and what those experiences meant to them, were developed. Each of these statements were then organised into themed clusters
Two researchers read the interviews independently, determined codes and categories personally and then met to share the results. Discrepancies in code assignment were discussed and reconciled. During this phase, new questions for the interviews were defined. Data collection and data analysis were performed simultaneously.
Strategies for increasing trustworthiness were used, such as member-checking, peer-examination, and code and recode procedures (Krefting, 1991).
Researchers also tried to clear their mind of their opinions on the issue by writing down their own thoughts on the topic before data analysis was performed. A third researcher was involved when categories similar to the researchers' previous thoughts were found.
Constant comparison between the team results and the fathers' views was assured. Once the data analysis was completed, fathers' opinions on the results were requested by sending each father an email summarising the results. Fathers who replied to the email answered that they agreed with the description.
Results
Description of the sample
Six fathers were involved in the study. Their age ranged from 30 to 43 years old. Their level of education ranged from middle school to university.
All of the fathers were experiencing their first experience of assisting a birth; one father chose to stay with his partner during labour, but not during birth.
One interview involved a father whose partner had epidural analgesia in labour that was not planned by the couple but was used for medical reasons. Because this information did not emerge until the interview, it was decided to complete the interview. The data analysis showed that this father's experience did not differ from that of the others; therefore, these data were included in the results.
The study was conducted in a third level, university hospital with more than 3500 births per year. Labour and birth are conducted by midwives. Gynaecologists are called for both when something differs from the normal birth process and at delivery time. Women are free to decide if they want someone to be with them during labour.
Themes
Five themes emerged from data analysis. The first theme gives a definition of labour pain. The second theme casts light on the fathers' perception of their role during their partner's labour, while the third and the forth enlighten fathers' fear, doubts and expectations. The last underlines the fathers' needs while present at their partners' labour.
1. ‘Labour pain is something you have to go through’
Fathers involved in the study defined labour pain as something that women have to face, in some way. They give different interpretations of labour pain, some learned during prenatal courses, some obtained by referring to religion:
‘It's written in the Bible’ (Participant B).
Talking about labour pain:
‘It's something you have to go through, there's nothing else you can say.’ (Participant B)
Fathers' description of labour pain varies when referring to the first or second stage of labour. Pain during the second stage of labour is observed by fathers as much more painful than pain in the first stage of labour. In addition, second stage pain is regarded as an active pain, where you can do something in response to the pain itself, for example, push the baby. It is also considered to be a sign that labour pain is almost finished. The baby also becomes a concrete presence for parents at this stage.
‘It was a pain … not a passive one, it was active. It's a pain that gives life … and it's a pain you face … in a different way, in a different way compared with other pains you have had and I believe it's really challenging for a woman even if it's very tough.’ (Participant B)
In this second stage of labour, fathers also spoke of becoming more engaged and active in the process by actively encouraging their partner. Across the interviews, some participants drew parallels between the second stage of labour and a sporting event, where they could ‘cheer’ their partner on to the end. As one father expressed:
‘I decided to stay at the head of the bed, I didn't want to see anything, but I wanted to help my wife keep the right position for pushing. I also helped her by saying, “push, push, you are doing great. You are almost done”.’ (Participant A)
‘I saw that she was pushing and everything was going well. I saw it was liberating for her, that the moment in which the pain would have ended was becoming closer—it was positive.’ (Participant C)
2. A silent presence that gives courage
Interviewed fathers reported that during their partners' labour, they felt as if they could do nothing and were powerless and useless. They reported to have felt a sense of ambivalence: they wanted to do something to alleviate their partner's pain but they knew that their partner had to go through the pain:
‘Yes, yes … on the one side I felt really useless, because I could do absolutely nothing, apart from saying ‘well’ … going back and forth calling for someone those three or four times I stood up from my seat, because I just sat down the way you do with a sick person, and so … it means an unsuitable way of being because… I felt I was absolutely useless in that moment, except for being there.’ (Participant C)
Fathers who were interviewed affirmed that being there was the most important thing they could do. They recognised the importance of the emotional support. They claimed that by being at the birth, they gave courage to their partner.
Every father also developed a specific way to give support to his partner, tailored on the character of both of them and on the stage of labour. Most of them described themselves as sitting next to their partner, providing support through little things such as: bringing their partner some water, massaging her, holding her hand or making her laugh between contractions.
‘Well, there is very little you can do. I held her hand, I did everything I could … but really … I tried to wisecrack, not to make it dramatic, we laughed at it as long as she was lucid. In the final phase, she fell asleep between contractions and we were silent, but it means that … apart from offering your hand … I think that everything you do is important, but you do so little, so little. So I have to say … I thought it was going to be worse.’ (Participant B)
The interviews showed that while being next to their partners in the labour room, fathers discovered how important words are in conveying courage. They reported that they were careful not to say commonplace words. Fathers were also enlightened about how important silence was during labour pain.
‘I didn't want to say “Don't worry, it will finish”, because at the end I had no pain. Unfortunately, she is the person who is in pain, so in my opinion they were useless sentences. I think the most important thing was to be there.’ (Participant E)
Some fathers had to struggle with their fear and emotional suffering. They had to show that they were sure, even if they were not.
‘You pretend it's nothing; you don't have to show that you are suffering, too, if she is in pain. And you try to make her feel courageous, you try to inspire courage.’ (Participant F)
3. ‘I hope I can stay until the end of the birth’
Fathers reported that at the end of pregnancy, they were scared that they would not be strong enough to stay in the labour room until the end of their partners' birth. Again, the men reported ambivalent feelings: they wanted to share this moment with their partner, but they were scared of what they would see. It emerged from the interviews that fathers were scared not to be up to the situation.
The strong odours and seeing blood were the things that scared them most. That father who chose not to stay for the delivery said that it was because they considered it as something really private and did not want to see their partner's body changing so much.
For some of the fathers, it is a matter of male pride to decide to go into the labour room. For most fathers, it is also really exciting to see their own baby being born.
‘[Days before delivery] She told me “if you can't manage, just tell me—I will ask someone else”. But I started feeling a sort of male pride and told to myself “how could I leave you with no support, do you want me not to take part … to such a moment … don't you want me to be proud, don't you … how could I”.’ (Participant B)
‘When we went to visit the labour room [during the antenatal course], we went close to the bed and I was just opposite the bed and … but if I am here … will I manage or not? For someone like me, who is scared by blood's odour … but I believe … at the end it's all because of the adrenalin, the pick of adrenalin you have in that moment.’ (Participant E)
4. ‘I didn't know that would happen’
Despite attending at least one meeting of a prenatal course each, all fathers interviewed said they were not really well-prepared for what happens during labour. They reported that they could not imagine the changes in their partner's behaviour that took place, or the strategies she chose for coping with pain. As a consequence, they sometimes waited for something that did not happen, while at other times, they were not prepared for things that did happen, especially changes in their partners' behaviour. Fathers were equally unprepared for their own role.
‘I believed it would be a bit easier … I couldn't imagine you had to think how to behave—what can I say? You don't have to show if you lose confidence, I didn't think about that before. I thought it had to be an easy way to support … but you discover you have to provide quite a strong support … that you have to insist … I was scared about needles … driven … you don't know what to expect…her way of acting… so calm but determined in telling me what she was expecting from me… it was a surprise.’ (Participant A)
During the labour process, some fathers also expressed high levels of anxiety and worry. These feelings often manifested when they were left alone for short periods of time with their labouring partner. They found it particularly distressing when their partner experienced an increase in pain or if something unanticipated began to occur and a health professional was not present. Fathers would feel anxious and helpless if the event was not something they anticipated and where their partner was expressing a need for help, as one father explained:
‘I didn't know what was happening. I thought everything was fine. But [my wife] continues calling for the midwife and asking me to call the midwife.’ (Participant D).
5. Fathers' need to ‘recharge their batteries’
Fathers shared that while they were supporting their partners, they also had their own needs to be attended to. It was identified that they would have appreciated if the midwife gave them permission to leave the labour room for a short period of time. Other strategies they found useful were to concentrate on their partners' desires and think positively about what was happening. These strategies helped them face their fear, enhance their sense of usefulness and gave them new, positive energy:
‘Well, about this thing … I am … I try to think positive, to be positive, in everything I do, I try to stay up. I don't think I am a very strong person, I get excited when the situation is exciting, even during movies, but let's say that I like it and that helps me to go on … so I tried not to panic, to keep calm, everything I do and when it's requested I try to keep calm, because if you are calm you convey your calmness and peace to people around you.’ (Participant E)
Discussion
It has already been noted that fathers are becoming more involved in childbirth and even in countries where males are traditionally excluded from maternity services, men are attending the births of their children (Steen et al, 2012). The RCM hopes fathers will become more involved during the whole pregnancy and labour process (RCM, 2011). Midwifery care should focus on the family as a whole, not on the mother–baby dyad only. Therefore understanding how fathers live the experience of their partners' labour pain is important.
Italian fathers involved in the study defined labour pain as ‘something you have to go through’ and some of them referred to religion for an explanation. Research by Shibli-Kometiani and Brown (2012), involving Arabian and Israeli fathers, came to similar conclusions.
Italian fathers involved in this research felt that they had a defined role during their partners' labour, which they describe as ‘a silent presence that gives courage’. Steen et al (2012) confirm the high importance that fathers place on being present during labour and the centrality of their role as a support to their partner and Kainz et al's (2010) description of fathers giving courage and helping their partners' wellbeing mirrors this research.
In this study, fathers reported ambivalence to fear. They were unsure about what would happen in labour and birth but also hoped to stay until the baby was born. The fathers' fear of being unable to stay throughout the birth was linked to physical aspects such as blood or ‘strange odours’ rather than emotional fear, which has been reported in other studies (Hanson et al, 2009). Fathers stated that they did not know what to expect during their partners' labour even though they had attended antenatal classes. This sense of uncertainty emerged in other studies too (Somers-Smith MJ, 1999; Shibli-Kometiani and Brown, 2012; Steen et al, 2012).
Other studies also underline how important it is to focus on the father's needs. Singh and Newburn (2003) stated that fathers wanted to feel part of a holistic caring atmosphere. The father's believed that midwives should ask them if they want to go out for a while, as well as help them focusing on their partner's needs and thinking positively.
Conclusions emerged from this research that can be useful for caregivers not only during labour, but also for antenatal classes. Results from Steen et al's (2012) metasynthesis also concluded that men would value anticipatory guidance during prenatal education on what their role is during labour.
Traditionally phenomenological inquiries involve small samples so that a particular phenomenon can be described in-depth. While the results of this study are not generalisable, the findings may be transferable to other context where midwives are engaged in providing care to a family that includes a first-time Italian father. It is desirable that other studies will be conducted in Italy, with the aim of reaching a deeper knowledge of the fathers' needs, experience and feelings during the whole process of their partners' pregnancy and childbirth.
Conclusions
This study describes first-time Italian fathers' experiences about labour pain. The results describe fathers' feelings, split between their desire to be there for their partner and their fear not to be up to the situation. They also highlight that fathers struggle between a sense of helplessness and a clearly-felt role of supporter (provided mainly through their presence). Interviewed fathers also suggested strategies to help their wellbeing during their role of support. The results can be useful for caregivers and fathers-to-be, both during labour and during antenatal classes, as they offer a deeper knowledge of fathers' experience during labour and give practical advice to help fathers facing this experience.