Background
Becoming a father for the first time is a central episode in life [
1‐
3]. Since fathers entered the delivery room some decades ago, their role has mainly been to give emotional support to the birth giving woman [
4,
5]. Nonetheless, attending childbirth also has benefits for the father. For example, it has been shown to facilitate the transition to fatherhood [
6,
7], solidify the father’s relationship with his birth giving partner [
8‐
10], and promote early attachment between father and infant and their bonding [
1,
11].
On the other hand, fathers sometimes find childbirth more emotional and demanding than expected [
12] and their need of personal support is well recognized [
13,
14]. In interviews with first-time fathers, we found that fathers oftentimes feel compelled to hide their feelings of insecurity, nervousness, irritation and frustration behind a confident, calm façade when supporting their partner during childbirth [
15‐
17]. Some fathers also feel that they are unimportant during childbirth and feel ignored by midwives and other staff members. Fathers also frequently consider that the information they receive from midwives is conciliatory or erroneous, which has also been found in earlier research on fathers-to-be [
18].
Little attention has focused on how such experiences impact on the fathers’ supportive role during labour and childbirth or subsequently on their role as fathers after childbirth. However, two recent studies indicate that fathers’ negative experiences during childbirth may be associated with depressive symptomatology after childbirth [
19,
20]. There is therefore a need to further investigate fathers’ childbirth experiences both to address the fathers own needs of support during childbirth and to identify fathers whose needs of support have not been met.
Questionnaires for assessing fathers’ experiences of the pregnancy period and childbirth have been developed [
21‐
26]; however, there is only one validated instrument for assessing fathers’ experiences during labour and birth [
6]. Given that first-time fathers are presumably particularly vulnerable during childbirth, an instrument designed specifically for assessing their experiences seems called for. The aim of this study was thus to develop and validate an instrument to assess first-time fathers' experiences of childbirth (FTFQ).
Discussion
This study reports on the development and validation of an instrument designed to assess first-time fathers' experiences of childbirth. Currently, the only available validated instrument [
6] assesses fathers' experiences in a broad perspective, including perceived competence of healthcare providers and the environment in the delivery ward. Moreover, it focuses on fathers in general rather than explicitly on first-time fathers.
Domains and items comprising the instrument were principally derived directly from interviews with first-time fathers, supplemented by literature searches and a focus group interview with experienced midwives. The focus group interview added one item, but it was subsequently excluded in the factor analysis. The literature search was made mainly in medical and nursing databases; however, extending the search to other databases, such as the Sociological Abstracts, might conceivably have added more domains. A draft version of the questionnaire was evaluated by an expert panel and pilot tested in a group of first-time fathers. A revised version was completed by 200 first-time fathers (81% response rate).
Principal components analysis of the questionnaire yielded four domains, reflecting the complexity and multidimensionality of first-time fathers' experiences of childbirth:
Worry, Information, Emotional support and Acceptance (Table
2). Of the five initial domains identified in our interviews, one could not be corroborated in these analyses, namely
'support to the woman'. This was due primarily to the fact that many of the items in this domain had extremely high ceiling effects or items hypothesized to belong to this domain were absorbed by the
Emotional support domain
.
Most of the variance in the instrument was explained by the domain
Worry, which confirms the importance attributed to this domain in earlier and more recent research [
38,
39]. Interestingly, this domain, comprising items about worries and anxiety about the mother and child, corresponds well with the strongest dimension, Discomfort, in [
6]. The importance of the second domain,
Information, has also been confirmed in research [
40,
41]. Support has often been emphasized in research on the childbirth experiences of fathers in general [
13,
42,
43]; however, our
Emotional support domain also taps aspects related to guidance and comfort, which has not been accentuated in previous questionnaires. It is noteworthy that the fourth domain,
Acceptance, accounted for a significant proportion of the variance. Despite the fact that fathers in Sweden have been present during childbirth for decades, the fact that
Acceptance represented an independent domain suggests that they are still not always well received [
18,
22,
44].
Some items regarding fathers' participation in childbirth and support to their partners had extreme ceiling effects (>90% endorsed the most positive response choice) and were omitted since they were judged to weaken the discriminant validity of the instrument. Possible explanations for the highly positive ratings on these items may be either that father's see their participation and support during childbirth as self-evident or that they wish to present themselves in a positive light and thus respond in a socially desirable manner. Moreover, some of the items about fathers' participation were derived from studies conducted nearly 15 years ago and in a different cultural setting [
12,
42]. Hence, the items may not be relevant or appropriate for Swedish fathers or for current childbirth practices.
The domains Emotional support and Acceptance did not meet conventional reliability standards for group comparisons (Cronbach alpha > 0.70). Excluding one or two items in these domains would have yielded acceptable alphas; however, we retained these items because they were considered to be clinically relevant. Multitrait-scaling analysis confirmed that these domains otherwise adequately met scaling assumptions for aggregating item ratings to scale scores and known-groups analyses supported their external validity.
Known groups analyses showed that the instrument could discriminate between subgroups of fathers known to differ on key clinical or socio demographic variables, specifically caesarean vs vaginal birth, older vs younger fathers, Swedish-born vs immigrant fathers, and high vs low education level. Supporting its discriminant validity, significant differences in the expected direction were found in comparisons between these groups, with the exception education level. However, educational level may be a poor indicator of socioeconomic status, which has previously been found to be associated with fathers' experiences of childbirth [
3,
45,
46].
Due to the fact that there is no paternity registry in Sweden, the questionnaire was mailed to the mothers of the newborn with the instruction to give it to the infant's father. This approach may have biased our sample in favour of fathers who currently live with or are on good terms with the mothers. This potential bias may be important since fathers with poor marital relationships have been shown to report higher levels of psychological distress and depressive symptomatology [
40,
41]. Hence, there may be a need to further validate the questionnaire in a more heterogeneous sample, with respect to marital status.
A strength of the study was that the domains and most items were based on interviews with first-time fathers [
15‐
17], supplemented by a literature search and focus group discussions with experienced midwives. The fact that the items were evaluated iteratively for face validity with regard to comprehensiveness, relevance and comprehension in a panel of experts in paternity research and in a pilot study of first time fathers also supports the validity of the questionnaire. Another strength of the study was the relatively large (n = 296) sample size and the high response rate (81%).
Conclusions
Our results suggest that this instrument adequately assesses important aspects of first-time fathers' experiences of childbirth. It may serve as a useful and sensitive tool for assessing first-time fathers' experiences and needs at labour wards and may be used to help identify fathers in need of extra support and counselling following negative birth experiences. However, more work is needed to improve the reliability of the instrument, particularly regarding the item content of the domains Emotional support and Acceptance, before it can be used with confidence for screening purposes.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
ÅP participated in the design of the study, data collection and analyses, writing the first draft of the manuscript and thereafter in revising and developing the manuscript in collaboration with the co-authors. MB participated in the design of the study and the development of the manuscript and supervision; CT participated in the design of the study, data analyses, supervision and manuscript preparation; and ALH participated in the design of the study and development of manuscript.