Childbirth is a vital time in the life of families and can affect future health and wellbeing. To achieve Sustainable Development Goal 3, ‘to ensure healthy lives and promote wellbeing for all at all ages’, it should be ensured that women and their children realise their maximum potential for living a healthy life (Fernandez, 2020). The selection of a birth companion during labour and childbirth is recommended for all women. This companion can be the woman's husband or sexual partner (World Health Organization (WHO), 2018). Providing emotional and social support during labour is a key aspect of high-quality maternal care (Bohren et al, 2019).
The experience of becoming a father for the first time is an important part of a man's life (Condon et al, 2004). Today, the definition of fatherhood has expanded, and their role is no longer limited to their children's life, but encompasses roles taken throughout the mother's pregnancy, labour and childbirth as well (Xue et al, 2018). Fathers play a major role in mothers' and infants' health (Plantin et al, 2011). Studies show that some fathers have good experiences of being present during their wife's labour and childbirth; nevertheless, some fathers realise that this process is much more difficult and emotional than they expected (Chandler and Field, 1997). First-time fathers are more vulnerable during the process of childbirth (Premberg et al, 2012). For these men, pregnancy and birth can be important and stressful events (Carlson et al, 2014).
In Iran, the presence of a companion during labour, such as a husband, is thought to help with a woman's adjustment to the process of labour (Fathi Najafi et al, 2017). However, the presence of fathers in the labour ward is not well accepted in all hospitals in Iran. Many Iranian labour wards are largely feminine and the structure of the labour units or religious reasons prevent men from being present in all labour units (Mortazavi and Mirzaii, 2012). In recent years, a change in hospital managers' attitude and awareness has led them to allocate separate rooms to women in labour, allowing husbands to be present during their wife's labour in a larger number of hospitals (Mortazavi and Mirzaii, 2012).
A major step towards facilitating the presence and cooperation of men during labour and childbirth in Iran was the expansion of efforts to improve men's attendance at antenatal childbirth preparation classes (Mortazavi and Mirzaii, 2012). Within public hospitals in which men can be present during labour, their presence is limited to the process of labour, and with the onset of the second stage of birth, husbands are no longer allowed in the birthing room. In private midwifery counselling centres, midwives offer classes to prepare both fathers and mothers for childbirth in a non-governmental context and thus pave the way for the presence of men during their wife's labour and childbirth in private hospitals (Ministry of Health and Medical Education, 2009). This experience is new in Iran and not yet widespread.
Studies in Iran have examined the role of men during pregnancy and labour, and instruments have been developed to investigate some features of men's experiences during pregnancy. Most studies have examined the presence of men during labour from the viewpoint of women (Mortazavi and Mirzaii, 2012; Fathi Najafi et al, 2017; Hajikhani et al, 2020a). Nonetheless, the presence of men during labour and childbirth is a new phenomenon in Iran that merits further examination in order to facilitate their presence and attend to their needs. However, there is no valid Persian questionnaire that can precisely examine the experiences of Iranian men, especially first-time fathers, with regard to their presence during labour and childbirth. In a study on the experiences of Swedish fathers about being present during their wife/sexual partner's labour and childbirth, Premberg et al (2012) developed the first time fathers questionnaire (FTFQ). The FTFQ has been translated into English, Spanish, and French (Premberg et al, 2012; Capponi et al, 2016; Molina-Velásquez et al, 2018), but it cannot be used in Iran. Therefore, this study was conducted to translate the FTFQ into Persian and culturally adapt it to the Iranian setting.
Methods
This methodological study was conducted to translate the FTFQ into Persian and culturally adapt it to the Iranian setting.
The first time fathers questionnaire
The FTFQ was developed by Premberg et al (2012) in Sweden. It is a 33-item questionnaire, 22 items of which assess the experiences of first-time fathers with regard to their presence during labour, childbirth, and postpartum in four dimensions: ‘information’, ‘worry’, ‘acceptance’, and ‘emotional support’, scored on a four-point Likert scale (1=disagree, 2=somewhat agree, 3=agree, 4=strongly agree). The minimum score is 22 and the maximum is 88. Lower scores indicate a more positive experience and higher scores indicate a more negative experience. The next 11 items focus on demographic details, type of childbirth and becoming prepared for labour and childbirth.
Translation
First, permission of the original developers was sought for the translation and psychometric assessment of the FTFQ. The English version of the FTFQ was translated into Persian by two Persian-speaking translators who were proficient in English (forward translation) (de Groot et al, 1994). Only one of the translators was familiar with the objective of the study and the questionnaire. Each translator provided a translation of the items and a list of possible alternative translations. In the next step, the translators and the research team compared the translations, resolved inconsistencies and obtained a single Persian version. In the second stage (backward translation) (de Groot et al, 1994), two bilingual translators whose first language was English and had sufficient knowledge of Persian helped translate the Persian version back into English. These translators did not have access to the English version of the questionnaire. After back translation into English, the items that did not match the original items were discussed by the research team and corrections were applied. The final translation was forwarded to the original developers and their comments were applied to the final version.
Content validity
The items were examined by eight reproductive health experts and four midwives to determine the questionnaires' content validity. Expert consensus about the relevance of the content of the items was examined via content validity ratio. The experts investigated the items in terms of the necessity of their presence in the questionnaire on a three-point Likert scale (1= the item is not essential; 2=the item is useful but not essential, and 3=the item is essential). Subsequently, the content validity ratio was calculated using the content validity ratio formula. A score of 3 in each item demonstrated its validity. Based on the Lawshe (1975) table, a content validity ratio of ≥0.56 was deemed acceptable for each item.
To see whether the instrument had been developed in the best manner to measure the phenomenon of interest, the content validity index was calculated. Experts were asked to evaluate each item on a four-point Likert scale in terms of their content relevance (1=not relevant; 2=the item is somewhat relevant but needs revision; 3=relevant but needs revisions; 4=the item is highly relevant), clarity (1=not clear; 2=needs major revisions; 3=clear but needs minor revision; 4=highly clear) and simplicity (1=the item is not simple; 2=the item needs revision; 3=simple but needs minor revision; 4=very simple). The mean content validity index for each item was calculated by dividing the number of experts who had scored the item 3 and 4 by the total number of experts. A mean index of ≥0.78 was deemed acceptable for every item. A scale content validity index average of 0.9 was considered acceptable (Polit and Beck, 2006).
Face validity
Face validity was examined qualitatively and quantitatively. For qualitative face validity, 10 first-time fathers were asked to examine each item in terms of difficulty, appropriateness and ambiguity. To determine the importance of each item, the items were given to the 10 fathers to rate on a five-point Likert scale (1=very important, 2=important, 3=somewhat important, 4=relatively important, 5=not important). If the impact score of each item (based on the formula: frequency (%) × importance = impact score) was ≥1.5, it would be deemed appropriate for further analysis (Lacasse et al, 2002).
Data collection
First-time fathers were selected from private midwifery counselling centres in Tehran (Iran) from August 2019 to February 2020. Eight centres were initially selected, three centres did not have enough clients and two centres did not agree to participate in the research. The remaining three centres had more clients, were known among the people of Tehran because of their activities in social media and had clients from all over Tehran, and were selected to participate in the research. After contacting potential participants, explaining the objectives of the study to them and receiving their consent for participation, a link to the electronic questionnaire was sent via social media and questionnaires were completed online. The sample size was 10 times the number of preliminary items, 220 people (DeVellis, 2016). The inclusion criteria were being Iranian, having Persian literacy, being more than 20 years old, being a first-time father, the continuous presence of the father during labour, birth and postpartum, a minimum gestational age of full 37 weeks, a low-risk pregnancy without complications, healthy infants, and a natural birth. The exclusion criteria were an unwillingness to complete the questionnaire, a caesarean section or assisted birth and infant hospitalisation after birth.
Data analysis
Descriptive tests were used to examine demographic characteristics. Construct validity was examined through an exploratory factor analysis using the principal component analysis with Varimax rotation in the statistical package for social sciences version 16. To confirm the results of the exploratory factor analysis, a confirmatory factor analysis was performed in the International Business Machines Statistical Package for the Social Sciences Analysis of a Moment Structures (version 24.0). The maximum likelihood estimation was used to evaluate the model. The Chi-square/degrees of freedom ratio (X2/DF), root mean square error of approximation and comparative fit index were used to determine the fit of the model. X2/DF<2, root mean square error of approximation<0.05, and comparative fit index<0.9 indicated the fit of the model (Browne and Cudeck, 1993). The intraclass correlation coefficient was used to determine stability (Koo and Li, 2016). The reliability of the extracted factors and that of the entire questionnaire was investigated by Cronbach's alpha and the level of significance was set at P<0.05.
Ethical considerations
This study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences (IR.SBMU.PHARMACY.REC.1398.358). The objectives were explained to all participants. An electronic consent form was sent to participants. To maintain confidentiality, all questionnaires were anonymous and coded.
Results
Of the 284 eligible fathers, 220 (77.46%) participants whose children had been born 10 days–12 months before the study began fully completed and returned the questionnaire. All fathers were married and lived with their spouses. Table 1 presents the demographic characteristics of the fathers participating in this study. The mean age of the fathers was 28.18 years ± 3.98. Most fathers had a university degree (79.1%) and were self-employed (49.1%).
Table 1. Sociodemographic characteristics of first time fathers
| Variable | Frequency, n=220 (%) |
|---|---|
| Age (mean±standard deviation) | 28.18±3.89 |
| Education | |
| Primary and secondary school | 46 (20.9) |
| University degree | 174 (79.1) |
| Occupation | |
| Worker | 9 (4.1) |
| Self employed | 108 (49.1) |
| Employee | 72 (39.7) |
| Professional job | 31 (14.1) |
| Preparation for childbirth | |
| Self study | 26 (11.8) |
| Through internet/chatting | 49 (22.3) |
| Getting information from friends and family | 2 (0.9) |
| Attending pregnancy preparation classes during spouse's pregnancy | 115 (52.3) |
| Other types of training eg psychological consulting | 13 (5.9) |
| Did not do anything | 15 (6.8) |
Face and content validity
When determining content validity, item 8, ‘I felt good when I called the labour ward’, was removed from the list of items as it had a content validity ratio of 0.50. The experts did not consider item 24, ‘when I was upset, they embraced me and that calmed me down’, to be appropriate for Iranian culture and suggested that it be modified to ‘when I was upset, they consoled me and that calmed me down’. The rest of the items received an acceptable score and, of the 22 original items, 21 items remained after content validity assessment. In examining the qualitative face validity, all 10 fathers reported all items to be appropriate, as they all obtained an impact score >1.5.
Exploratory factor analysis
An exploratory factor analysis was performed to examine the construct validity of the instrument. The Kaiser-Meyer-Olkin value was 0.81 in this study, and the Bartlett's test of sphericity was significant with X2=1.458E3 (P=0.001), indicating a sufficient sample size.
In the next step, the number of factors was determined to facilitate summarisation of the items. To this end, a scree plot and Kaiser-Guttman analysis were used. The scree plot showed five factors. The Kaiser-Guttman analysis also showed that five factors covered 57.25% of the variance.
Taking into account the five factors, a principal component analysis was performed with Varimax rotation. The matrix rotation revealed that of the 21 items, item 7, ‘we were admitted to the labour ward of the hospital we had chosen before for my wife's childbirth’, and 14, ‘there were situations during labour/birth when I wished I hadn't been there’, had a factor loading of <0.3 (the minimum value required for a load to become significant). Therefore, item 7, which had the lowest factor loading (0.23), was removed from the analysis, and item 14 was removed.
After eliminating items 7 and 14, four factors were obtained with a Kaiser-Meyer-Olkin of 0.81 and a statistically significant X2=1.391E3 for Bartlett's test of sphericity (P=0.001). Kaiser-Guttman analysis showed that four factors covered 56.23% of the variance, and this finding was confirmed by the scree plot (Figure 1). Principal component analysis was performed with Varimax rotation. The matrix rotation indicated that all the 19 items had a factor loading of >0.3 and were distributed among four factors based on their factor loading. The first factor was ‘worry’ (seven items), the second was ‘acceptance and support during labour’ (five items), the third was ‘support during and after birth’ (five items), and the fourth was ‘preparedness’ (two items) (Table 2).
Figure 1. Scree plot for the first time fatherhood questionnaire adapted to Persian
Table 2. Distribution of items in factors
| Factor | Item | Score |
|---|---|---|
| Worry | I was worried something would go wrong (17) | 0.838 |
| I was afraid of the unknown event (19) | 0.769 | |
| I worried about not being able to support my spouse (18) | 0.764 | |
| There were some issues that scared me during labour (23) | 0.725 | |
| I was worried about my spouse (15) | 0.700 | |
| I was worried about my child (16) | 0.664 | |
| I was worried about my reaction (20) | 0.637 | |
| Acceptance and support during labour | I was given sufficient information (11) | 0.750 |
| I was welcomed upon entry to the maternity ward (9) | 0.701 | |
| I received enough attention from the staff (10) | 0.699 | |
| I was not given enough information (13) | 0.686 | |
| I was informed on how to support my spouse (12) | 0.677 | |
| Support during and after birth | They showed me how to hold my baby (25) | 0.801 |
| They encouraged me to hold my baby (26) | 0.709 | |
| When I was upset, they consoled me and that calmed me down (24) | 0.644 | |
| I felt that midwives and other members of staff would want to know how I felt (21) | 0.547 | |
| Staff and other caregiver offered to look after my spouse while I could have some rest (22) | 0.539 | |
| Preparedness | I felt I was prepared (6) | 0.851 |
| I felt I was well informed (5) | 0.850 |
Confirmatory factor analysis
Confirmatory factor analysis was performed to analyse the fit of the four-factor FTFQ model. The goodness-of-fit indices of the model were root mean square error of approximation=0.05, X2/DF=1.6, and comparative fit index=0.9. Modifications were made to check the improvement of the model fit. To this end, the items of factor 1 with weaker factor loadings were removed. The goodness-of-fit indices of the model were root mean square error of approximation=0.06, X2/DF=1.8, and comparative fit index=0.9. As the goodness-of-fit indices of the model were slightly confounded, this factor was not removed, and the model was confirmed with four factors and 19 items (Figure 2). The overall score of the questionnaire ranged from 19–76.
Figure 2. The Persian model of the first time fatherhood questionnaire
Reliability
The overall Cronbach's alpha of the FTFQ was 0.78, and the overall intraclass correlation coefficient was 0.74 (Table 3). For the ‘worry’ factor, the corrected item-total correlation was between r=0.52 (item 16) and r=0.73 (item 17). For the ‘acceptance and support during labour’ factor, the corrected item-total correlation was between r=0.48 (item 9) and r=0.71 (item 11). For the ‘support during and after birth’ factor, the corrected item-total correlation was between r=0.39 (item 22) and r=0.57 (item 26). For the ‘preparedness’ factor, the corrected item-total correlation was r=0.49.
Table 3. Mean score number of items, Cronbach's alpha and intra-class correlation for first time fatherhood questionnaire
| Subscale | Number of items | Cronbach's alpha | Intra-class correlation | Mean score |
|---|---|---|---|---|
| Worry | 7 | 0.85 | 0.76 | 18.53±5.81 |
| Acceptance and support during labour | 5 | 0.73 | 0.80 | 8.50±3.51 |
| Support during and after birth | 5 | 0.80 | 0.72 | 12.97±4.46 |
| Preparedness | 2 | 0.72 | 0.70 | 4.50±1.73 |
| Overall | 19 | 0.78 | 0.74 | 43.97±9.07 |
Discussion
This study translated the FTFQ into Persian and culturally adapted it to serve as a valid questionnaire for examining the experiences of first-time fathers accompanying their wives during labour and birth in Iran. A translation was performed from English to Persian and then questionnaire validation was carried out. In this process, items 7, 8 and 14 did not meet the standards of the context of maternity services in Iran and were removed. Item 24 was modified because it was not appropriate for Iranian culture. The rest of the items were classified into four dimensions, which differs from the classification of the original questionnaire. The overall score of the questionnaire ranged from 19 to 76.
This study offered primary evidence on the validity and reliability of the FTFQ. Previously, the FTFQ was translated into Spanish and French and validated for those cultures. Capponi et al (2016) translated the FTFQ into French and validated it. In their study, of the 22 items of the original questionnaire, 19 items remained and were distributed within three dimensions. Molina-Velásquez et al (2018) translated the FTFQ into Spanish and validated it for use in Latin America. As a result of this process, items 2, 3 and 9 were removed from their questionnaire as they did not yield adequate proof of validity, and the rest of the items were distributed into two dimensions, ‘fathers' worry’ and ‘support from the healthcare system’.
In the original FTFQ (Premberg et al, 2012) and the Spanish version (Molina-Velásquez et al, 2018), ‘worry’ had eight items. In the present study, however, this dimension had seven items, and item 14, ‘there were situations during childbirth when I wished I hadn't been there’, was removed because of low factor loading. This disparity could be because in some cultures, fathers think they should mask insecurity, anger, irritability or fatigue with self-confidence (Ellberg et al, 2010).
In all three versions, the items classified into ‘worry’ are similar. It seems that worrying is shared by all first-time fathers who accompany their wife during labour and birth. Premberg et al (2011) concluded in a qualitative study that the heart of the experience of first-time fathers about their presence during labour and birth can be described as an intertwined process of enjoy and suffering. Midwives' support to help the father be present and cooperate was deemed effective in realising this experience (Premberg et al, 2011). In another study in Iran, Rafat et al (2016) showed that 91.9% of the fathers had a positive attitude toward fathers' presence during labour and birth.
In a mixed-method study, Hajikhani et al (2020a) developed a questionnaire for examining the concerns of fathers during pregnancy. In this study, 24 final items were classified into three dimensions, ‘pregnancy and childbirth’, ‘mother and child health’, and ‘individual-family concerns’. The overall alpha of the questionnaire was 0.93 and its ICC was 0.99. These researchers concluded that fathers' concerns are directly correlated with those of their spouse. These findings show that concerns experienced by fathers need more attention.
Molina-Velásquez et al (2018) found a significant negative correlation between ‘fathers' worries’ and ‘support from the healthcare system’. In other words, support mitigates fathers' worries. Redshaw and Henderson (2013) examined fathers' cooperation in pregnancy and labour. They concluded that the maximum degree of cooperation was observed in white women's spouses who were becoming fathers for the first time. When fathers met the caregiver early in the pregnancy, the chances of continued cooperation also increased. The present study likewise reflects the important role of support in fathers' cooperation and experience.
Although more than a decade has passed since the implementation of physiologic birth programs in Iran, few studies have examined the presence and cooperation of fathers during labour and birth (Rafat et al, 2016). By translating the FTFQ into Persian and with its validation, it is now possible to examine the experiences of first-time fathers of their presence during labour and birth in Iran. This version can probably be used for other Persian language countries as well.
A limitation of this study was that the participating fathers were recruited solely from private midwifery counselling centres, and those visiting public centres were not included. The reason for this was that after holding childbirth preparation classes for couples, only midwifery counselling centres in the private sector allow fathers to be present during labour and birth (Ministry of Health and Medical Education, 2009). However, understanding the experiences of fathers with regard to their presence during labour and birth can help promote this practice and resolve any issues.
Conclusions
This questionnaire can be employed to evaluate the experiences of fathers with regard to their presence during labour and birth in midwifery services planning to promote their quality of care during childbirth. The authors recommend that this questionnaire is used in future research to assess fathers' experiences when attending labour and birth.
Key points
- This study translated and validated the first time fathers questionnaire into Persian.
- The Persion version of the questionnaire can be used to evaluate the experiences of fathers who are present during childbirth.
- The use of this questionnaire to assess fathers' experiences will help midwifery services when planning to improve their quality of care during childbirth.
CPD reflective questions
- Is the Persian first time fathers questionnaire valid for other Persian speaking countries?
- Is the Persian questionnaire sensitive to interventions to improve fathers' experiences of attending labour and birth?