In human reproduction, gestation ispreceded by conception whereby the male

sperm cell fertilises the female egg, resultingin an offspring. While this practice has beenan acknowledged phenomenon for eons,men and expectant fathers have untilrecently been excluded from pregnancy andchildbirth. Retrospective studies have beenlargely reassuring that fathers play a vitalrole in child health and development;however, little is known regarding the role of the expectant father in pregnancyoutcomes.1

Pregnancy remains an immunological mystery.Why, then, if half of the embryo’s genes areinherited from the father, are men not directlyand equally involved in pregnancy andchildbirth? The exclusion of men fromreproductive health has limited our ability topredict how great an impact increasing the roleof men and expectant fathers can have onpregnancy outcomes and the health of families.

The little that we know about paternalinvolvement and pregnancy outcomessuggests that paternal involvement canhave a positive influence on maternalhealth behaviours during pregnancy.2

Much of what we know and understand

about fathers during pregnancy hasstemmed from research on the mother.1

Our attempt to advance paternalinvolvement presents a key opportunity toimpact the health and wellbeing of families,which comprise the most basic structuralunit of our society.3 Both American andEuropean investigators have documentedthat expectant fathers can be a strong sourceof support or stress during labour anddelivery,3,4 but more research is needed tounderstand exactly what role the expectantfather plays in pregnancy and childbirth.1

In 2009, the Joint Center for Political andEconomic Studies assembled the Commissionon Paternal Involvement in PregnancyOutcomes (CPIPO) with funding from the USDepartment of Health and Human Services.5

CPIPO is a transdisciplinary working group of ethnically diverse practitioners and public health professionals with training inepidemiology, family planning, medicalsociology, paediatrics, family medicine,urology, obstetrics, gynaecology, psychologyand anthropology.6 Members of CPIPO haveconducted research on men’s health, infantmortality, racial and ethnic disparities inpregnancy outcomes, and paternal

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Changing expectations: factorsinfluencing paternal involvement in pregnancy and childbirth

While studies have demonstrated that men are important tomaternal and child health, expectant fathers lack specificroles in pregnancy and childbirth. In this article, the authorexamines pathways to improve paternal involvement inchildbirth and family health.

JERMANE BOND

Jermane Bond, PhD, Director, Commission onPaternal Involvement in Pregnancy Outcomes;Research Scientist, Health Policy Institute, Joint Center for Political and Economic Studies,Washington, DC, USA

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involvement in pregnancy outcomes, andhave published books and numerousscholarly articles in peer-reviewed journals.

Many CPIPO members hold prestigiousacademic and clinical positions and areleaders in their respective fields. The purposeof CPIPO is to improve paternal involvementin pregnancy and family health by reframingdebates and informing research, policy andpractice to support greater involvement ofexpectant fathers in pregnancy and to shiftthe men’s health focus to a more positive,direct, active and constructive role in thereproductive health agenda.

WHAT IS PATERNAL INVOLVEMENTAND HOW IS IT MEASURED?Parenting is a multidimensional, evolvingcultural concept and much of the parentingliterature stems from research and theorydeveloped on mothers.7 Three dimensions ofpaternal involvement include: • engagement – the extent to which

fathers experience direct contact andshared interactions with their children inthe context of caretaking, play or leisure

• availability – a father’s presence oraccessibility to the child

• responsibility – the extent to which afather arranges for resources to beavailable to the child, includingorganising and planning children’s lives.8

However, a fourth dimension encompassingpregnancy and childbirth is lacking.1,8

The Commission has defined paternalinvolvement in pregnancy outcomes asactivities or practices by the male partnerand a couple anticipating birth that ideallylead to an optimal pregnancy outcome.1

Those activities may include the threedimensions described above, but are uniqueto the preconception and perinatal period.One evolving approach to increasing ourunderstanding of factors and predictors ofpaternal involvement is that of the life-courseperspective (Figure 1, Table 1), defined as ‘apattern of socially defined, age-graded eventsand roles that is subject to historical changes

in culture and social structure’;9 this is an idealorganising framework for paternal involvementin reproductive life and family formation.

CONTEMPORARY ASPECTS OF PATERNALINVOLVEMENT IN PREGNANCYMarital and relationship status definespaternal involvement during pregnancy.1

Fathers’ prenatal involvement may determinelater engagement2 and presence in the livesof mothers and families. Present fathersimpact development in the cognitive andlanguage skills of their children.8 Fathers havealways been indirectly involved duringpregnancy and experience pregnancy in theirown way. Biologically, men experiencesignificant pregnancy-related changes inprolactin, cortisol and testosterone.10

However, there is a gap in the theories thatbest explain paternal involvement in generaland in pregnancy outcomes.

PATERNAL INVOLVEMENT INPREGNANCY OUTCOMESAlthough men are important in maternal and child health,11 they have not played a

significant role in reproductive healthcareand only recently have men’s health issuesbeen integrated into the US Healthy PeopleObjectives.1 Evidence suggests that men canidentify with their partners’ pregnancies10

and they can ‘feel pregnant’.10 The knowledgebase is sparse and that limits our ability toengage men – particularly men of colour – inthe health of their families. Paternal supportplays a significant role in pregnancy outcomeand close relationships with the motherresult in positive pregnancy outcomes.2

Prenatal paternal involvement enhancesfathering and marital adjustment and isindependently associated with prenatal care,drug and alcohol use, smoking, and reducesthe risk of low birth weight.2–5

Although men are important to maternaland child health,1,11 they are frequently onthe margins of reproductive health. Studiesof fathers tend to be methodologically andtheoretically weak and findings fromprospective longitudinal studies are oftenbased on ‘add-on’ father data collectionefforts after a major project was designed

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Prenatal

Interconception

Preconception

TrajectoriesTransitions

Turning pointsCultural and contextual influences

Timing in livesLinked lives

Adaptive strategies

Paternal involvement in pregnancy

Pregnancy outcomes

Figure 1. Conceptual framework for paternal involvement in pregnancy outcomes

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and launched.1 Developing standardisedmeasures of paternal involvement inpregnancy outcomes, and identifying bestclinical practices in reproductive healthcarefor men using the life-course perspective isone possible solution.

Employing the life-course perspective to improve paternal involvement inpregnancy outcomes can also be apromising context for reproductive healthto increase our understanding of healthrisk, protective factors, and environmentalmediators experienced throughout the lifecourse. Lu and Halfon12 synthesised theearly programming and cumulativepathways models using the life-courseperspective and suggested that research onracial and ethnic disparities in pregnancyoutcomes must examine differentialexposures to risk and protective factors in

pregnancy and throughout the life course.CPIPO has developed 40 best and promisingrecommendations to improve paternalinvolvement in pregnancy outcomes.1 Thesekey recommendations attempt to addressresearch, policy and clinical practice toimprove paternal involvement in pregnancyand family health.

Advancing research on paternalinvolvementThere is a need to develop evidence-basedstrategies to improve paternal involvementin reproductive health, particularly incommunities where paternal involvementhas been low and pregnancy outcomeshave been poor. Pathways to paternalinvolvement are poorly understood, as aremechanisms linking paternal involvementto pregnancy outcomes. More interventionresearch is needed to identify effective

strategies for enhancing paternalinvolvement in pregnancy outcomes. Most importantly, setting the researchagenda is the first step in advancing therecommendations below. Urologists andGPs are ideally situated to address thetarget male population by developingspecific research questions that naturallyresult from relevant clinical experiencesand by formulating research hypothesesfor exploratory and experimental studies.

Addressing policy barriers to paternalinvolvementManaging a professional career and familylife can pose an enormous challenge for anexpectant father. While reform of current UStax, welfare and child-support policies isneeded to encourage family formation andfather involvement, Europe’s genderegalitarian policies offer more liberal andvaried family-friendly options. Urologists andGPs can play a greater role by promotingfamily-friendly values and evidence-basedpractices while encouraging insuranceproviders to cover preconception health andcare for men and future fathers.

Promoting best and promising practicein paternal involvementPreconception presents a key opportunityto engage men regarding their health andreproductive life plans. Preconceptionhealth has been promoted for women butnot men.1 Best and promising practicesneed to be identified to help men preparefor pregnancy and fatherhood. Duringroutine health maintenance visits,urologists and GPs should be prepared toguide men on the path to fatherhood byassessing health risk, promoting healthybehaviours and recommending appropriateclinical and psychological counselling.

Enhancing paternal involvement inpregnancy and childbirthTraditionally, men have not had a definedrole in pregnancy and childbirth.1 Today,expectant fathers are encouraged andinvited to attend prenatal visits and wantto be present at the time of birth. The

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Trajectories Stable patterns of health behaviour Alcohol, tobacco use, or health across time chronic disease

Transitions Changes in social roles or Marriage, divorce, birth of a responsibilities first child, career change

Turning points Transitions that are major changes Educational decision that in ongoing social role trajectories impacts career path

Cultural and Events that shape and constrain the A recession, race, gender or contextual process of change or adaptation neighbourhood factors that influences affect childhood

Timing in lives The interaction between age/stage Age at the time of a major of the life course and timing of an event; age at birth of first event or transition child

Linked lives Dependencies of the development Influence of spouse on theof one person on the presence, other’s health behavioursinfluence, or development of another

Adaptive Conscious decisions that people Changes in health strategies make to improve their health or behaviour; individual coping

wellbeing or social norms that frame strategies, such as taking the way in which decisions are made action, denial, or avoidanceto adapt to external changes

Concept Definition Examples

Table 1. Key concepts and definitions of the life-course perspective

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pregnancy period is a magnificent occasionto engage, educate and empowerexpectant fathers. Just as mothers areopen and available to receive healthinformation, most expectant fathers alsowant to be involved, want to ask questionsand try to understand the role they have in ensuring a healthy and safe delivery.Urologists and GPs can help by designingeducational material for expectant fathers,working with obstetricians and byfacilitating antenatal education coursesspecific to expectant fathers. This is vital toprevent health problems and complicationsduring pregnancy. Antenatal education forexpectant fathers should also includeplanning for pregnancy and the perinataland postpartum periods.

CONCLUSIONWhile studies have demonstrated that menare important to maternal and childhealth,1 expectant fathers lack specificroles in pregnancy and childbirth. We now know that expectant fathers have the ability to contribute positively ornegatively to pregnancy and childbirth.More funding should be made available to increase our understanding of the role of expectant fathers. Future studies of paternal involvement should focus on developing specific measures and indicators of involvement whileaddressing the healthcare needs of the expectant father.

Subsequently, policy barriers to paternalinvolvement need to be addressed toencourage family formation, preconceptionhealth and reproductive life planning. Finally,in order to change expectations regardingthe role of expectant fathers in pregnancyand childbirth, father-friendly clinics andhospitals are necessary to welcome, educateand encourage equal father participation andengagement to enhance the pregnancy andchildbirth experience.

Declaration of interests: none declared.

REFERENCES1. Commission on Paternal Involvement in

Pregnancy Outcomes. Commission outlook:best and promising practices for improvingresearch, policy and practice on paternalinvolvement in pregnancy outcomes.Washington, DC: Joint Center for Political andEconomic Studies, May 2010. www.jointcenter.org/hpi/sites/all/files/CPIPO%20Report%20051910%20Final.pdf

2. Teitler J. Father involvement, child health andmaternal health behaviour. Children andYouth Services Review 2001;23:403–25.

3. Plantin L, Olukoya AA, Ny P. Positive healthoutcomes of fathers’ involvement inpregnancy and childbirth paternal support: a scope study literature review. Fathering2011;9:87–102.

4. Mullings L, Wali A, McLean D, et al. Qualitativemethodologies and community participationin examining reproductive experiences: the

Harlem Birth Right Project. Matern ChildHealth J 2001:5:85–93.

5. Alio AP, Bond MJ, Padilla YC, et al. Addressingpolicy barriers to paternal involvement during pregnancy. Matern Child Health J2011;15:425–30.

6. Bond MJ, Heidelbaugh JJ, Robertson A, et al.Improving research, policy and practice topromote paternal involvement in pregnancyoutcomes: the roles of obstetricians–gynecologists. Curr Opin Obstet Gynecol2010;22:525–9.

7. Hoffman S, Hatch MC. Stress, social supportand pregnancy outcome: a reassessmentbased on recent research. Pediatr PerinatEpidemiol 1996;10:380–405.

8. Lamb ME, Pleck JH, Charnov E, et al. Abiosocial perspective on paternal behaviourand involvement. In: Lancaster JB, Altman J,Rossi AS, et al, eds. Parenting across thelifespan: biosocial dimensions. New York:Aldine de Gruyter, 1987;111–42.

9. Elder GH. Children of the Great Depression:social change in life experience, 25thanniversary edn. Boulder, CO: Westview, 1999.

10. Storey AE, Walsh CJ, Quinton RL, Wynne-Edwards DE. Hormonal correlates of paternalresponsiveness in new and expectant fathers.Evol Hum Behav 2000;21:79–95.

11. Lu MC, Jones L, Bond MJ, et al. Where is the F inMCH: father involvement in African Americanfamilies? Ethn Dis 2010;10(S2):49–61.

12. Lu MC, Halfon N. Racial and ethnic disparitiesin birth outcomes: a life-course perspective.Matern Child Health J 2003;7:13–30.

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