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Midwifery 94 (2021) 102921Contents lists available at ScienceDirectMidwiferyjournal homepage: ArticleFirst-time fathers’ experiences and needs during childbirth: A systematicreviewMaartje van Vulpen a,b,∗, Mariëlle Heideveld-Gerritsen a,b, Jeroen van Dillen a, Sabine OudeMaatman c, Henrietta Ockhuijsen b,c, Agnes van den Hoogen b,ca Radboud University Medical Center, Post Office Box 9101, 6500 HB Nijmegen, The Netherlandsb University Utrecht, Post Office Box 80125 3508 TC Utrecht, The Netherlandsc University Medical Center Utrecht, Post Office Box 85500, 3508 GA Utrecht, The Netherlandsa r t i c l e i n f oKeywords:first-time fathersexperiencesneedschildbirtha b s t r a c tObjective: Fathers have been increasingly involved in childbirth since 1990. Attendance at childbirth is consideredto benefit fathers’ health as well as that of their partner and children. However, childbirth is a life event thatparents may experience differently. First-time fathers’ experiences have been barely studied and may differ fromthose of fathers who have already had a child. In order to adapt support and care during childbirth to the needsof first-time fathers, a deeper insight must be gained into their experiences and needs during childbirth.Design: A systematic review of qualitative studies was conducted using PubMed, Embase and CINAHL as wellas the snowball method. Quality appraisal was performed and evaluated using the Critical Appraisal Skills Programme. A thematic best evidence synthesis was performed.Findings: Of 821 articles, eight qualitative studies and the qualitative data of one mixed methods study wereincluded. amongst other feelings, fathers experience a lack of knowledge and a need to be better prepared. Firsttime fathers want to be more involved and need guidance, information and honest answers to help them fulfila supportive role. Fathers disregard their own needs to focus on the needs of the mother. Meeting the baby forthe first time changes the focus from the mother to the child, and fathers need time and privacy for this specialmoment.Key conclusions and implications for practice: To adapt support and care during childbirth to the needs of first-timefathers, professionals must be aware of their needs. Professionals must realise the significant influence of theirprofessional behaviour on first-time fathers’ experiences. Care for first-time fathers should be formalised. Followup research must be conducted on integrating the preparation of first-time fathers into prenatal care. Educationand training of professionals must be improved.IntroductionEvery minute, 258 births occur worldwide (“Indexmundi geboortecijfers,” 2018). The average annual number of births in the Netherlands has been approximately 177,000 over the last 10 years, most ofwhich are first children for the father (Perined, 2019). Childbirth is alife event for both parents. In the past, care during childbirth was primarily focused on the expectant mother (Dye, 1980). Much research hasbeen published on mothers’ experiences of childbirth (Aune et al., 2015;Beake RM, Chang BA, Cheyne RM, Spiby Mphil, Sandall RM, RM 2018;de Jonge et al., 2014; Dixon et al., 2014; Elmir et al., 2010; Hall et al.,∗ Corresponding author.E-mail addresses: [email protected] (M. van Vulpen), [email protected] (M. Heideveld-Gerritsen),[email protected] (J. van Dillen), [email protected] (S. Oude Maatman), [email protected] (H. Ockhuijsen),[email protected] (A. van den Hoogen).2018). Studies show the importance of attention to the individual needsand coping experiences of the mothers as factors for empowering newfamilies. A holistic approach to care and support is essential for enablingmothers to cope with childbirth and have a positive childbirth experience (Aune et al., 2015; Hildingsson, I, Johansson, M, Karlström, A,I 2013; Hodnett, ED, Gates, S, Hofmeyr, G.J., Dakala, ED 2013).Because parents experience childbirth differently, it is important alsoto consider the fathers’ experiences (Belanger-Lévesque et al., 2017).Fathers have been more involved in the births of their babies since1990 (Draper, 1997; Johansson et al., 2012a; Plantin, 2007). Althoughstudying fathers’ involvement during pregnancy is difficult due to se 21 February 2020; Received in revised form 25 November 2020; Accepted 30 December 20200266-6138/© 2021 Elsevier Ltd. All rights reserved.M. van Vulpen, M. Heideveld-Gerritsen, J. van Dillen et al. Midwifery 94 (2021) 102921lection effect of those not being present and since involvement mightbe a proxy for other factors such as low income families or unstable relationships(Kaye et al., 2014; Redshaw and Henderson, 2013).Being present at childbirth has been linked to a more emotionallyengaged, mature fatherhood and has been described to benefit fathers’ health and that of their partners and children (Johansson et al.,2012a; Plantin, 2007). It also might strengthen the relationship between couples and facilitates bonding between fathers and their babies (Callister, 1995; Johansson et al., 2012a). Paternal involvementin children’s lives is associated with various child outcomes, includingimproved cognition and mental health (Allport BS, Johnson S, Aqil A,Nelson T, Kc A, Carabas Y, BS 2018).This important role for the father increased interest in the fathers’experiences during childbirth. In 2015, Johansson et al. provided anoverview of fathers’ general experiences with childbirth in a metasynthesis and showed that birth experiences of fathers were complexand multidimensional (Johansson et al., 2015). Childbirth was mostlyconsidered a life-changing event, and professionals’ positive, respectfulbehaviour and language greatly affected men’s sense of involvement.Being kept informed was important in enabling fathers to feel safe andincluded. An implication for practice of the study by Johansson et al.was that couples should explore how expectations may influence theirroles in labour (Johansson et al., 2015).However, first-time fathers’ experiences are less frequently researched and may differ from those of fathers who have had a childbefore. A ‘first-time father’ is defined as a biological father who livedwith the expectant mother during pregnancy and has not experiencedthe live birth of his own child (Chandler and Field, 1997).First-time fathers appear to require more information about the birthprocess, including a tour of the delivery room, compared to those whohave had a child before (Eggermont et al., 2017). First-time fathers experience a multitude of feelings, including anxiety, due to the unknownevent they are about to experience (Labrague et al., 2013).In the Netherlands, no guidelines exist for managing and guidingfirst-time fathers. Books and courses are available; however, no nationalstructural guideline exists. The guidance and care first-time fathers receive depend on the individual skills and attention of the professionalsand questions the fathers ask.In order to adapt our support and care during childbirth to the needsof first-time fathers, it is important to gain a deeper insight into theirexperiences and needs. Unlike that of Johansson et al. (Johansson et al.,2015), this systematic review provides an overview specifically of thereported experiences and needs of first-time fathers during childbirth.MethodsThis systematic review includes qualitative data focusing on firsttime fathers’ experiences and needs during childbirth. The preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement were used (Moher et al., 2009).Search strategyRelevant articles were identified using the indexes of the PubMed,CINAHL and Embase electronic databases. No restrictions were placedon the date of publication. The search was performed until 15 February2019 and a final search on 12 November 2020.The search terms used were ‘first-time’, ‘fathers’, ‘experiences’,‘needs’, ‘childbirth’ and synonyms of these terms. Parts of words extended by a star (∗) were used to cover as many different conjugationsas possible. The search terms contained subheadings (e.g. MeSH) andfree-text words.Recently published articles, where search terms have not yet beenentered in databases, were also explored with the search terms in thetitle or abstract. Full search strings are provided (Appendix 1). To complete the search, additional articles were obtained using the snowballmethod with backward citation chasing and electronic citation trackingusing Scopus (Armstrong et al., 2005; Jalali and Wohlin, 2012).Selection criteriaTo answer the research question, articles that provided qualitativedata on the experiences or needs of first-time fathers during childbirthwere included. In English-language articles, labour and birth are sometimes divided into two different episodes. In this review, childbirth includes labour and delivery. Articles in Dutch, English and German wereincluded. Births by caesarean section were excluded because they aredifferent experiences (Chan and Paterson-Brown, 2002; Johansson et al.,2013, 2012b; Rosich-Medina and Shetty, 2007).All the articles were imported into Rayyan, a web application(Ouzzani et al., 2016). Duplicates were removed. All articles werescreened for title and abstract. The full texts of the remaining articleswere obtained. If an article was not available in full text, its author wascontacted to obtain a full-text article.The full-text articles were read and included if they met the inclusioncriteria and provided an answer to the research question (MV). Systematic reviews were excluded but informed the introduction and discussionsections. Articles whose eligibility was uncertain were independentlyscreened by a second researcher (MHG). The selection of articles wasdiscussed until consensus was reached (MV, MHG, AH). The reasons forexclusion were reported.Data extractionFirst, all the themes derived from the articles were listed for eacharticle, accompanied by quotes representing the themes. Only data relevant to the research question were extracted. An example is provided(Appendix 2). Thus, the apparent relationships between the studies wereinitially identified. Concepts within themes were subsequently extractedand compared across studies. Main themes common to all studies wereidentified.SynthesisThematic analysis was used (Thomas and Harden, 2008). Repeatedreading of the text and constant comparison were used to identify similarities and differences in the data highlighting the themes. Categorieswere developed, with at least two findings from different articles percategory. The main themes and categories were reviewed, and analytical themes were developed. The research group discussed the entireprocess until agreement was reached (MV, MHG, AH).To describe the best evidence synthesis, the methodological qualityof the studies and the evidence level of the findings were considered.Proper et al. recognised three levels of evidence (Proper et al., 2011):– Strong evidence – findings are consistent in two or more high-qualitystudies;– Moderate evidence – findings are consistent in one high-quality andat least one low-quality study, and;– Insufficient evidence – findings are only available in one study, or inconsistent findings are available in two or more studies (Proper et al.,2011).Methodological qualityThe Critical Appraisal Skills Programme (CASP) for qualitative studies was adapted to appraise the evidence, and scores from 1–10 wereallocated (BS Critical Appraisal Skills Programme, 2018). This tool waschosen because it contains only ten items and includes a user guide andthe facility to add notes. Assessment agreements were reached by theresearch group (MV, MHG, AH). Consensus was reached on the interpretation of the CASP scores to classify the quality of the articles as2M. van Vulpen, M. Heideveld-Gerritsen, J. van Dillen et al. Midwifery 94 (2021) 102921good (8–10), moderate (5–7) or low (1–4). Two researchers performedthe appraisal (MV, MHG). Differences were discussed until consensuswas reached (MV, MHG, AH).ResultsThe complete search strategies (Appendix 1) provided 821 articlesin total (Embase: 746, PubMed: 48 and CINAHL: 27). Additionally, fivearticles were obtained using the snowball method. After removing duplicates, 791 articles were screened for title and abstract, and 768 articles were excluded. The remaining 23 articles were obtained in fulltext. One article was not available in full text (Carbines, 2004). Thefirst author of this article was contacted through ResearchGate; however, no answer was received. Articles that did not meet the criteriafor inclusion were excluded. Excluded systematic reviews reported onfathers’ experiences in general during birth and the transition to fatherhood (Hanson et al., 2009; Kunjappy-Clifton, 2007). Four quantitativearticles were excluded (Bowman et al., 2013; Eggermont et al., 2017;Labrague et al., 2013; Schytt and Bergström, 2014), two articles wereexcluded for not reporting specific birth experiences (Backstrom et al.,2017; Darwin et al., 2017) and two for not being specific to first-timefathers (Chapman, 1991; Nichols, 1995). Three articles were excludedbecause they were available only in Chinese or Portuguese (Chou et al.,1994; Santo and Bonilha, 2000; Tzeng et al., 1993).Eight qualitative articles were included in this study (Bäckström andHertfelt Wahn, 2011; Chandler and Field, 1997; Ledenfors and Berterö,2016; Longworth and Kingdon, 2011; Poh et al., 2014; Premberg et al.,2011; Sansiriphun et al., 2015; Sapkota et al., 2012) as well as one mixedmethods study for which only qualitative data were taken into account(Howarth et al., 2017). The full selection process is shown in the Prisma2009 Flow Diagram (Fig. 1) (Moher et al., 2009). Table 1 provides anoverview of the articles. A final search was performed on 12 November2020, and resulted in 329 studies deemed ineligible for inclusion.Study characteristicsThe nine included studies described a total of 271 first-time fathers from seven countries (Canada (Chandler and Field, 1997), England (Longworth and Kingdon, 2011), New Zealand (Howarth et al.,2017), Nepal (Sapkota et al., 2012), Singapore (Poh et al., 2014), Sweden (Bäckström and Hertfelt Wahn, 2011; Ledenfors and Berterö, 2016;Premberg et al., 2011) and Thailand (Sansiriphun et al., 2015)).One mixed methods study was included due to an abundance ofqualitative data (Howarth et al., 2017). In this study, a post-birth questionnaire was used, in which fathers were asked to write down theirthoughts. Only qualitative data were extracted from this study.The eight qualitative studies all used interviews. Semi-structured indepth interviews (Ledenfors and Berterö, 2016; Longworth and Kingdon, 2011; Poh et al., 2014; Sansiriphun et al., 2015; Sapkota et al.,2012) were used in six studies. Of which one study initially used unstructured interviews and switched to semi-structured interviews afterthemes emerged (Chandler and Field, 1997). Other interview methodsused were re-enactment (Premberg et al., 2011) and open-ended questions (Bäckström and Hertfelt Wahn, 2011).Two studies provided information on issues other than childbirth;therefore, only data relevant to the research question were included(Poh et al., 2014; Sansiriphun et al., 2015). Seven of the eight qualitative studies reported that interviews were recorded (Bäckström andHertfelt Wahn, 2011; Chandler and Field, 1997; Howarth et al., 2017;Ledenfors and Berterö, 2016; Longworth and Kingdon, 2011; Poh et al.,2014; Sansiriphun et al., 2015; Sapkota et al., 2012). Premberg et al.did not report recording but used verbatim transcripts of the interviews(Premberg et al., 2011). In two articles, the interview duration was notreported (Chandler and Field, 1997; Longworth and Kingdon, 2011).The reported duration ranged from 10–90 min. Thematic analysis wasused in five studies (Chandler and Field, 1997; Ledenfors and Berterö,2016; Longworth and Kingdon, 2011; Poh et al., 2014; Sapkota et al.,2012). The remaining studies used interpretative phenomenologicalanalysis (Howarth et al., 2017; Premberg et al., 2011), analysis basedon grounded theory (Sansiriphun et al., 2015) and qualitative contentanalysis (Bäckström and Hertfelt Wahn, 2011). In one study, the analysis process included checks by an expert and members (Chandler andField, 1997). In all other studies, the analysis was performed by multipleanalysts.Methodological qualityThe quality of all the included articles was assessed as good. TheCASP scores ranged from 8–10 with a mean of 9.3. The total scores arepresented (Table 1), and an overview of the evaluation of the differentcomponents is added (Table 2).Results of individual studiesThe results of the individual studies are reported based on their mostimportant findings. Table 3 provides an overview of the main and subthemes, together with the core conclusions.Howarth et al. showed that fathers experienced the birth of theirchild as a life-changing event for themselves as well as the mothers(Howarth et al., 2017). They found that fathers needed to be includedas participants in this process along with the birthing mothers.Ledenfors and Bertero described the fathers’ experiences of childbirth as a transformative experience (Ledenfors and Berterö, 2016). Difficulties with supporting their wives and being involved are described,as well various emotions caused by childbirth, and recommendations onhow midwives can help first-time fathers.Sansiriphun et al. described the process from childbirth to postpartum as ‘the journey into fatherhood’, dividing it into three phases:‘labour’, ‘delivery’ and ‘family beginning’ (Sansiriphun et al., 2015).Family beginning largely transcended the experiences and needs of fathers during birth. This article emphasises the influence of local beliefsand traditions on fathers’ experiences.Poh et al. indicated that the experiences and needs of fathers in Singapore during pregnancy and childbirth were similar to those reportedin studies in western countries (Poh et al., 2014).Sapkota et al. reported that the attendance of first-time fathers atbirths was not culturally approved of in Nepal (Sapkota et al., 2012). Iffathers attended the birth, they were overwhelmed with emotions. Theauthors suggest that better preparation may reduce negative emotionalexperiences and improve satisfaction with childbirth experiences.Longworth and Kingdon described childbirth as the beginning of fatherhood for fathers (Longworth and Kingdon, 2011). Through lack ofknowledge and perceived control, fathers struggle to find a role in childbirth. First-time fathers must prepare themselves. Midwives can helpprovide fathers with effective information and should be mindful of fathers’ experiences and the importance of new families being together.Premberg et al. reported that first-time fathers struggled to experience the mothers’ pain and fear of the unknown (Premberg et al., 2011).These first-time fathers needed to be seen and supported as parents-tobe, emphasising the shared experience of childbirth for couples. Caregivers must acknowledge fathers as valued participants, based on theirexclusive knowledge of the needs of the mother, and support their significant position.The main theme outlined by Bäckström and Hertfelt Wahn(Bäckström and Hertfelt Wahn, 2011) was ‘being involved or being leftout’. The importance of fathers’ interaction with the midwife and withtheir partner was highlighted. Additionally, fathers mentioned the importance of being able to choose to be involved or step back.Finally, Chandler and Field reported that first-time fathers experienced many emotions and needed information, support, encouragementand to be involved (Chandler and Field, 1997). They believed that par-3M. van Vulpen, M. Heideveld-Gerritsen, J. van Dillen et al. Midwifery 94 (2021) 102921Fig. 1. Prisma Flow Diagram of study selection.ents needed to be treated as a couple and as individuals with uniqueneeds.Synthesis of resultsIn the nine studies, 32 main themes and 34 subthemes were reported.Five analytical themes were derived from the synthesis process: ‘Theunknown’, ‘Many different feelings’, ‘Interaction with professionals’, ‘Part ofthe labouring couple’ and ‘Meeting the baby/ Bonding’. Table 4 provides anoverview of the categories that informed the analytical themes and liststhe categories identified in each article. The synthesis of the results isreported according to the analytical themes and categories.The synthesis described is also the best evidence synthesis. Themethodological quality of all individual studies was assessed as good,and all findings are supported by at least two articles. Consequently,this best evidence synthesis comprises only strong evidence as definedby Proper et al. (Proper et al., 2011).You are in unknown territory. When you’re there, you know youreally don’t know anything about this. I don’t know what’s going tohappen. I was worried there would be no room for us; you know, theworst case scenario. We were prepared to have to go to a differenthospital; you always expect the worst. I don’t think it matters howmuch you rely on your partner; it’s good to have an expert nearby,especially a woman. (IP5)(Premberg et al. p.850)The unknownThe unknown is divided into three categories: ‘totally new’, ‘knowledge’ and ‘preparation’.4M. van Vulpen, M. Heideveld-Gerritsen, J. van Dillen et al. Midwifery 94 (2021) 102921Table 1Characteristics of included articles.Article Methodogy Sample Analysis QualityCASPHowarth et al., 2017,New Zealand,Questionnaire Post-birthquestionnaire, fathers were askedto write down their thoughts.n = 155 Recruited by advertising. Phenomenological thematicanalysis informed byinterpretativephenomenological analysis(IPA) Two analysts9,5Ledenfors and Bertero,2016, Sweden,Interviews – Interview guide –Digitally voice recorded –Duration: 10–60 min. median23 min.n = 8 Recruited at maternitywards, six different child welfarecentres and three open daysnurseries in a county in Southeast SwedenThematic analysis Twoanalysts10Sansiriphun et al.,2015, ThailandIn-depth interviews – Interviewedtwice (n = 17) – Interviewed threetimes (n = 26), – Interviewed fourtimes (n = 4) – Recorded –Duration: 70–90 min.n = 41 Recruited from twohospitals in Chiang Mai.Theoretical sampling.Analysis based on groundedtheory. Four analysts and anexpert.9,5Poh et al., 2014,SingaporeSemi-structured interviews. –Interview guide – Audiotaped –Duration 22–54 min mean 33 minn = 16 Recruited from a tertiaryhospitalThematic analysis. Threeanalysts9,5Sapkota et al., 2012,NepalIn-depth interviews, – Semistructured interview guidelines. –Audio taped – Duration average41.08 +/-7.9 min.n = 12 (six had supported theirwives during both labour anddelivery, the rest only duringlabour by taking turns withanother female member of thefamily/relative.)Thematic Analysis Threeanalysts8,5Longworth andKingdon, 2011,EnglandSemi-structured interviews – Attwo timepoints (antenatal andpostnatal) – Similarity ofquestions – Tape recorded –Duration not reportedn = 11 Recruited at antenataleducation with purposivesamplingThematic analysis Twoanalysts9,5Premberg et al., 2011,SwedenRe-enactment interviews –Recording not reported –Duration: 40–90 minn = 10 recruited at SahlgrenskaUniversity Hospital, Gothenburgwith strategical selectionPhenomenological lifeworldapproach Two analysts8,0Bäckström andHertfelt Wahn, 2011,SwedenOpen-ended interviews. – Sameopening question and samefollow-up questions – Recorded –Duration: 20 to 50 min.n = 10 Recruited at one hospitalin a south-western county ofSwedenQualitative content analysisFour analysts9,5Chandler and Field1997, CanadaInterviews – At two timepoints(antenatal and postnatal) –Initially unstructured face-to-faceinterviews – After themesemerged, semi-structuredinterviews. – Tape recorded –Duration not reportedn = 6 and 6 secondary informants(for validation, check new themesand possible negative cases).Thematic analysis resulting ina model showing relationshipsExpert for analysis Membercheck9,5Totally newseen movies … what is happening … it was not like that at all! (7)It went so quickly … quickly and smoothly and well for us … noproblems, no complications, nothing … everything just went on inone sweep … nothing that spoiled it … it was really nice … muchquicker and easier than I thought it would be … expectations weredifferent actually … I thought it would be much worse … in all ways… so it was a relief. (8)(Ledenfors and Bertero p.28)The term ‘totally new’ refers to becoming a father as a completely new life-changing experience in an unfamiliar environment,with new people (Ledenfors and Berterö, 2016; Premberg et al., 2011;Sansiriphun et al., 2015) creating anxiety in the first-time father, whois unsure how he will react and cope (Premberg et al., 2011). Expectations do not reflect the reality (Chandler and Field, 1997; Ledenfors andBerterö, 2016).KnowledgeHusbands should be mentally prepared. For instance, the birthingprocess could be discussed before pregnancy check-ups, and weshould be informed about how to help our wives. (21-year-old carpenter)(Sapkota et al. p.48)Knowledge refers to knowing what to expect, what to do or what isnormal. Not knowing what to do made first-time fathers feel helpless andlike an outsider (Bäckström and Hertfelt Wahn, 2011; Howarth et al.,2017; Ledenfors and Berterö, 2016). To understand labour and delivery and their roles in these processes, fathers must prepare themselvesand gain information (Sansiriphun et al., 2015; Sapkota et al., 2012).Knowledge gained from preparation made fathers feel supported andcalm and improved satisfaction (Bäckström and Hertfelt Wahn, 2011;Howarth et al., 2017).PreparationYou thought that you were prepared, but you were not … not beforeyou had … had the child in your arms … then you realized that youwere not as prepared as you thought. (1)(Ledenfors and Bertero. p.28)Preparation refers to how fathers can prepare themselves for childbirth. First-time fathers can actively prepare themselves by gatheringinformation, discussing childbirth, mentally preparing themselves and5M. van Vulpen, M. Heideveld-Gerritsen, J. van Dillen et al. Midwifery 94 (2021) 102921Table 2Appraisal of the articles.Howarth et al.,2017Ledenfors andBertero 2016Samiriphunet al. 2015Poh et al., 2014 Sapkota et al.,2012Longworth andKingdon 2011Premberg et al.,2011Bäckström andHertfelt Wahn2011Chandler andField 1997Section A: Are the results valid?1. Was there a clear statement of the aims ofthe research?2. Is a qualitative methodology appropriate?3. Was the research design appropriate toaddress the aims of the research??4. Was the recruitment strategy appropriateto the aims of the research?? ?5. Was the data collected in a way thataddressed the research issue?6. Has the relationship between researcherand participants been adequately considered?? ? ? ? ?Section B: What are the results?7. Have ethical issues been taken intoconsideration?? ? ?8. Was the data analysis sufficiently rigorous?9. Is there a clear statement of findings?Section C: Will the results help locally?10. How valuable is the research? ? ?Total out of ten items (max 10 points) 9,5 10 9,5 9,5 8,5 9,5 8,0 9,5 9,5Yes (1 point) ? Can’t tell (0,5 points) ⌧ No (0 points).Critical Appraisal Skills Programme (BS 2018). CASP Qualitative Checklist. [online] Available at: Accessed: 26–02–2019.buying all the necessary items (Bäckström and Hertfelt Wahn, 2011;Poh et al., 2014; Sansiriphun et al., 2015; Sapkota et al., 2012). Somefirst-time fathers acknowledged their lack of knowledge but avoided acquiring further information (Longworth and Kingdon, 2011; Poh et al.,2014).The most wonderful thing I have been through my whole life butalso the most dreadful to see her suffer the way she did. (IP6)(Premberg et al. p.850)Many different feelingsThe birth of a first child involves many different emotions, both negative and positive.Negative feelingsI could not watch my wife so restless and crying. It was very difficult to control myself. It was so frustrating not being able to doanything while she was undergoing labour pains. It was like a sortof punishment, I would say. (23-year-old private business employee)(Sapkota et al., p.48)Feelings of insecurity, fear, powerlessness and inadequacy are frequently reported (Bäckström and Hertfelt Wahn, 2011; Howarth et al.,2017; Ledenfors and Berterö, 2016; Poh et al., 2014; Premberg et al.,2011; Sapkota et al., 2012). Clear information is needed to reduce fearand vulnerability (Howarth et al., 2017; Ledenfors and Berterö, 2016;Poh et al., 2014; Premberg et al., 2011; Sansiriphun et al., 2015). Fear,helplessness and frustration were more intense during labour than during delivery (Chandler and Field, 1997; Sapkota et al., 2012). Seeingthe mothers in pain was a major burden and frustrated first-time fathers(Premberg et al., 2011; Sansiriphun et al., 2015).Positive feelingsIt was like everything! It was just relief, joy, everything! Kev (postnatalinterview, normal vaginal birth, 48 h after birth)You know, it’s been the best experience of my life! Steve (postnatalinterview, normal vaginal birth, eight days after birth)(Longworth and Kingdon p.591)First-time fathers were excited about the new situation and experienced many different feelings: satisfaction, pride, relief and gratitude that their wives and babies were healthy and safe (Bäckström andHertfelt Wahn, 2011; Chandler and Field, 1997; Howarth et al., 2017;Ledenfors and Berterö, 2016; Poh et al., 2014; Sansiriphun et al.,2015). They experienced an unexpected outburst of feelings when thebaby was born, including happiness, tears of joy and fascination withthe wonder of life (Chandler and Field, 1997; Howarth et al., 2017;Ledenfors and Berterö, 2016; Longworth and Kingdon, 2011; Poh et al.,2014; Premberg et al., 2011; Sansiriphun et al., 2015).First-time fathers may hide strong feelings behind a calm and securefaçade to avoid worrying the mother during labour. However, whenthe baby is born, fathers can release their true feelings (Chandler andField, 1997; Premberg et al., 2011; Sapkota et al., 2012).I got a lot of support, especially when I broke down, standing therecrying like a three-year-old boy in the corner. So they took care ofme right away, all of them, the physician, the midwife; I got a lot ofsupport but it was a little bit hard too; it affects your masculinity.It was really nice but I felt mixed feelings, nice to be comforted andthat they cared so much and really checked up on me, but I am usedto being a man, not being so sensitive. (IP5)(Premberg et al. p.850)6M. van Vulpen, M. Heideveld-Gerritsen, J. van Dillen et al. Midwifery 94 (2021) 102921Table 3Results of individual studies; Themes, subthemes and core conclusions.Article Main themes and sub themes Key conclusionsHowarth et al., 2017. Core themes: – Safety of mother and baby – Understandingsupport role – Mother in control and managing pain – Careand communication after birthFathers commented on what impacted on their childbirthexperiences and in so doing outlined their needs for apositive experience. Fathers experienced a high level ofsatisfaction along with a need to be involved and included.Ledenfors and Bertero2016.Main theme: transformative experience. 4 subthemes: –Preparing for childbirth – Feeling vulnerable in a newsituation – Being confirmed as part of a unit – Meeting theirchild for the first time.The findings indicate that the needs of prospective fathersshould be given more re cognition during childbirth. Thefindings also show that the midwife is an important personfor prospective fathers, both before and during the birth.Sansiriphun et al.,2015.The process from childbirth to postpartum is described as:“the journey into fatherhood”. The process had three phases:Labour – Seeking information confirming labour pain;preparing for the hospital – Focusing on their wife;supporting and encouraging; waiting with patience Delivery– Focusing on delivery process; supporting and encouraging– Focusing on baby; checking the baby Family beginning –Observing and learning the baby’s behaviours; seekinginformation – Devoting themselves to the child – Supportingtheir wife – Following traditional confinement – Eliminatingthe conflicts and difficulties of being a father – BalancingtasksWithin the process, there were various situations, challenges,and pressures, which caused many changes of mood andfeelings for the first-time fathers. Throughout this process,they applied various strategies to manage their concerns andneeds, in order to develop into masterly fathers.Poh et al., 2014. 4 themes emerged from 16 subthemes: Emotional changesexperienced; (1) Happy, excited and amazed, (2) Fascinationwith the wonder of life, (3) Shocked, (4) Anxious, worriedand fearful, (5) Relaxed and relieved Adaptive and supportivebehaviours adopted;(6) Following cultural practices, (7)Modifying daily routine, (8) Understanding, caring andsupporting wife more, (9) Exercising self-control Socialsupport received; (10) Tangible and intangible support fromfamily and friends, (11) Support from work and environment,(12) Support from healthcare professionals Suggestions forimprovement to the current maternity care; (13) Review ofantenatal classes, (14) Provide more information, (15) Providemore professional support, (16) Administrative/ logisticalissuesAll fathers modified their behaviours for the sake ofprotecting their wives and unborn children. Support fromtheir family, friends, workplaces and the health careprofessionals were invaluable and greatly appreciated.Sapkota et al., 2012. 6 themes: – Being positive towards attendance – Hesitation –Poor emotional reactions – Being able to support – The needto be mentally prepared – Enlightenment.The husbands’ experiences revealed that Nepalese husbandstend to experience over- whelming feelings in the labour ordelivery room if they can attend the birth without priorpreparation.Longworth andKingdon, 2011.4 main themes: – Fathers’ disconnection with pregnancy andlabour – Fathers on the periphery of events during labour –Control – Fatherhood beginning at birth and reconnectionControl was evident both as a distinct and a cross-cuttingtheme.Birth is the moment that fathers ascribe as the beginning offatherhood. However, through their lack of knowledge andperceived control, they struggle to find a role there.ImplicationsPremberg et al., 2011. 4 constituents: – A process into the unknown – A mutuallyshared experience – To guard and support the woman – Inan exposed position with hidden strong emotions.Childbirth was experienced as a mutually shared process forthe couple. The fathers’ high involvement in childbirth, incooperation with the midwife, and being engaged in supportand care for his partner in her suffering is fulfilling for bothpartners, although the experience of the woman’s pain, fearof the unknown and the gendered preconceptions ofmasculine hegemony can be difficult to bear for thefather-to-be.Bäckström and HertfeltWahn, 2011.Main theme: being involved or being left out. 4 categories: –An allowing atmosphere – Balancing involvement – Beingseen – Feeling left out.Fathers perceived that they were given good support whenthey could ask questions during labour, when they had theopportunity to interact with the midwife and their partner,and when they could choose when to be involved or to stepback. Fathers want to be individuals who are part of thelabouring couple. If fathers are left out, they tend to feelhelpless; this can result in a feeling of panic and can puttheir supportive role of their partner at risk.Chandler andField, 1997.9 themes – It’s happening – It’s beginning – More work thananticipated – Increased fear – Hidden fears and emotions –Lack of inclusion – Increased excitement – Relief – We madeit – Time to get acquainted.Although the fathers expected to be treated as part of alabouring couple, they found that they were relegated to asupporting role. Initially the fathers were confident of theirability to support their wives, but they found that labour wasmore work than they had anticipated. They became fearful ofthe outcome, but hid these fears from their partners.Later,they found that their focus moved from their wives to theirbabies at the time of birth. The men all completed theexperience with an enhanced respect for their wives. Fathersshould be included in labour management plans and needsupport for their role as coach, particularly when their wivesexperience pain. They also need to be encouraged to eat andtake a break from their wives’ labour when appropriate.7M. van Vulpen, M. Heideveld-Gerritsen, J. van Dillen et al. Midwifery 94 (2021) 102921Table 4Reported categories and analytical themes in articles.Analytical themes and including categoriesThe unknown Many different feelings Interaction with professionals Part of the labouring couple Meeting the baby/ BondingArticlesTotallynew Knowledge PreparationNegativefeelingsPositivefeelings Support Professionalism InformationFeelingincludedandinvolvedGivingsupportLeaveattention tothe motherShiftingattendancefrom motherto childNeed spaceand timeHowarth et al., 2017Ledenfors and Bertero2016Sansiriphun et al.,2015Poh et al., 2014Sapkota et al., 2012Longworth andKingdon 2011Premberg et al., 2011Bäckström and HertfeltWahn 2011Chandler and Field1997Interaction with professionalsInteraction with professionals comprises the following categories:‘(provided) support’, ‘professionalism’ and ‘information’.SupportWe had a good relationship … the midwife encouraged this good relationship and she gave me some tips about how to do things … actwith X, calm her, where I should hold her and how I should push …pull her knees; I stood by the side and kept the head and pulled theknees; she showed me and that was very good. She instilled confidence and you felt that you did something helpful and, at the sametime, it helped me to be in the position … helping … you could insome way help. (5)(Ledenfors and Bertero p.29)First-time fathers need guidance in their supportive role(Bäckström and Hertfelt Wahn, 2011; Chandler and Field, 1997;Howarth et al., 2017; Ledenfors and Berterö, 2016; Premberg et al.,2011). Adapting the level of involvement to the wishes of the fathers isimportant to enable them to experience good support (Bäckström andHertfelt Wahn, 2011; Ledenfors and Berterö, 2016). The midwife beingpresent in the room and cooperating with the father gave fathers a safefeeling (Bäckström and Hertfelt Wahn, 2011; Premberg et al., 2011).ProfessionalismI feel extremely grateful and have a lot of respect for all the peoplethat helped us, especially all the midwives; they were fantastic. Idon’t have a lot of experience from healthcare, but I have never beenbetter taken care of in any healthcare situation. (IP2)(Premberg et al. p.851)Health professionals appeared to have an impact on the feelings ofthe fathers (Bäckström and Hertfelt Wahn, 2011; Longworth and Kingdon, 2011; Premberg et al., 2011). First-time fathers experienced comfort and trust due to involved, experienced professionals who providedempathic care, worked together and communicated well (Howarth et al.,2017; Poh et al., 2014; Premberg et al., 2011; Sapkota et al., 2012).InformationWe were both well informed during each step and I felt our midwifeand others provided information fast and clearly, which kept us bothwith the feeling that things were well under control. (099)(Howarth et al. p.8)First-time fathers need information about physiology, possible complications, how to cope and progress during labour (Bäckström and Hertfelt Wahn, 2011; Howarth et al., 2017; Poh et al., 2014; Premberg et al.,2011). First-time fathers must be able to ask questions (Bäckström andHertfelt Wahn, 2011; Ledenfors and Berterö, 2016). Fathers needunderstandable and honest answers; otherwise, answers are deemedunreliable, and fathers may feel irritated and not taken seriously(Bäckström and Hertfelt Wahn, 2011; Premberg et al., 2011).When she was pushing at the end, I held one hand behind her neck togive her strength and the other round her leg, so I held her together!I really felt part of it all and she said that afterwards in that sense itfelt really good. I didn’t feel left out at all! But I have to say that, eventhough I took part in the process, the focus must of course always beon the woman. (IP2)(Premberg et al. p.850)8M. van Vulpen, M. Heideveld-Gerritsen, J. van Dillen et al. Midwifery 94 (2021) 102921Part of the labouring coupleFeeling included and involved in the experience of childbirth is important for first-time fathers. First-time fathers support their labouringpartners in the best way they can but allow the mother to be the centreof attention.Feeling included and involvedThey took over from me instead of helping me to help Laura. I beganto feel like an appendage rather than being really involved.(Chandler and Field p.21)Childbirth is a shared experience in which both parents are important (Ledenfors and Berterö, 2016; Premberg et al., 2011). Fatherswant to be included and involved and try to be part of the process in different ways. However, fathers often feel excluded from thelabour (Bäckström and Hertfelt Wahn, 2011; Chandler and Field, 1997;Howarth et al., 2017; Ledenfors and Berterö, 2016). Fathers feel involved when included in conversations and asked for their opinions andwhen their personal needs are responded to and decisions are taken together (Bäckström and Hertfelt Wahn, 2011; Chandler and Field, 1997;Howarth et al., 2017; Premberg et al., 2011).Communication with the mother, midwife and other healthcare professionals guided fathers to a more supportive and active role and improved the experienced level of control and involvement of fathers during childbirth (Bäckström and Hertfelt Wahn, 2011; Longworth andKingdon, 2011). Fathers reported that intense communication betweenthe mother and midwife decreased their feelings of involvement andincreased their feelings of disconnection from their partner’s labour(Ledenfors and Berterö, 2016; Longworth and Kingdon, 2011).Giving supportIt was a lot of patting on the back, holding and massaging. Trying to gether to drink a lot, water and juice … a lot of talking and encouragement.(During pushing:) I’m sitting behind her on a stool and holding her underher arms, she’s sitting on her haunches. I can press her together by bendingmyself, if I bend forward then she ends up like this with her chin on herchest in the right position and then when the contractions subside, sherelaxes and stretches out backwards and then I can hold her … it washard physical work but it felt good to be able to do it. I’m used to physicalwork. (IP10)(Premberg et al. p.851)Fathers want something meaningful to do during childbirth: tosupport and encourage their partners (Ledenfors and Berterö, 2016;Poh et al., 2014; Premberg et al., 2011; Sansiriphun et al., 2015;Sapkota et al., 2012). Fathers need advice and guidance to provide better support (Howarth et al., 2017; Premberg et al., 2011; Sapkota et al.,2012). The support given by first-time fathers helped to soothe and reassure their wives during childbirth (Premberg et al., 2011; Sapkota et al.,2012).Leave attention to the motherAll the focus is on her … try to make it as good I can … be a greatsupport … and just being two centimetres away, standing there …feeling the hand or you could feel the … voice … well … it … it isa feeling of confidence and that is big for me … I try to stand therestable by her side … and calm … which she is not able to be in thatmoment. That is my task – trying to be that … that part in … as apartner. Since this is … this is our, this is our experience, it is our …that is coming … out of this. (4)(Ledenfors and Bertero p. 29)During childbirth, the fathers focus on the needs of the mothers,and disregard their own needs (Bäckström and Hertfelt Wahn, 2011;Ledenfors and Berterö, 2016; Premberg et al., 2011; Sansiriphun et al.,2015). Fathers want to be there, to protect the mothers and pleadthe case of the mother if conflicts emerge (Howarth et al., 2017;Premberg et al., 2011). Fathers hid their fears and did not discuss anyirregularities or worrying signs to avoid upsetting the mothers in labour(Chandler and Field, 1997; Poh et al., 2014; Premberg et al., 2011;Sapkota et al., 2012).Meeting the baby/ bondingDifficult journey but overall helped me appreciate and love my wifemore for it. … The chance to deliver my son helped with bondingprocess. (034)(Howarth et al. p.9)The theme ‘meeting the baby/bonding’ comprises the following categories: ‘shifting attendance from wife to child’ and ‘need time and space’.Shifting attendance from mother to childWhen I heard her voice ‘Waa’ I was very happy. I was so glad thatI almost cried . . . I turned to the baby only . . . I took a look at hisbody. At first, I counted his fingers and toes. (c1, c3, c6, c12, c28,c37)(Sansiriphun et al. p.463)The moment the child is born is defined as amazing, indescribable,emotional, special and simply the best experience in life (Howarth et al.,2017; Ledenfors and Berterö, 2016; Longworth and Kingdon, 2011;Poh et al., 2014; Sansiriphun et al., 2015). Fathers report that from themoment the baby is born, the relief that childbirth is over will turnto worry whether all is well with the child (Chandler and Field, 1997;Ledenfors and Berterö, 2016; Sansiriphun et al., 2015).Need time and space[It] was heartbreaking when they said I couldn’t stay the night. I hadbeen with her that whole time and suddenly I had to go. (027)(Howarth et al. p.9)The time together with the baby immediately after the birth wasimportant. Fathers needed space and privacy to get to know theirnewborn babies and their newborn family (Chandler and Field, 1997;Howarth et al., 2017; Longworth and Kingdon, 2011).DiscussionIn this review, findings from various articles providing qualitativedata were integrated to answer the research question, ‘What are the reported experiences and needs of first-time fathers during childbirth?’Five analytical themes were derived from the synthesis process: ‘The unknown’, ‘Many different feelings’, ‘Interaction with professionals’, ‘Part ofthe labouring couple’ and ‘Meeting the baby/ Bonding’. First-time fathersexperience much insecurity, anxiety and lack of knowledge in this unknown situation and need preparation. Interacting with professionals isimportant for first-time fathers to cope with both negative and positivefeelings, . Guidance in their supportive role, professionalism, information and honest answers are needed. First-time fathers want to feel involved; this can be achieved by involving them in communication anddecision-making. Fathers may experience difficulties in their supporting9M. van Vulpen, M. Heideveld-Gerritsen, J. van Dillen et al. Midwifery 94 (2021) 102921role, but first-time fathers focus on the needs of the mother and disregard their own needs. Meeting the baby shifts the attention from themother to the child, and fathers need time and privacy for this specialmoment.The results of this systematic literature review match those of themeta-synthesis by Johansson et al., which provides an overview of fathers’ experiences in general but emphasises the greater need for information, guidance and support due to the inexperience of first-timefathers (Johansson et al., 2015).Other studies also report the difficulties experienced by fathers ina new situation, for example, by identifying ‘finding a place’ as themain theme (Chin R., Daiches, 2011). Most fathers reported beinganxious because of the unknown event (Labrague et al., 2013). Firsttime fathers more frequently reported an uncomfortable feeling duringdelivery (Vehvilainen-Julkunen and Liukkonen, 1998). Recommendations were made to increase knowledge and skills in antenatal classes(Labrague et al., 2013). In Sweden, for example, antenatal class content focused on childbirth preparation (67% of the entire course) andparenting preparation (33%) (Pålsson et al., 2019). Childbirth preparation increased parents’ understanding of the childbirth process, birthingmilieu, the partners’ role, potential problems during delivery and painrelief advantages and disadvantages. Experiencing positive and negative feelings has also been reported for first-time fathers but also forfathers who have had a child before (Labrague et al., 2013; SapountziKrepia et al., 2013; Vehvilainen-Julkunen and Liukkonen, 1998). Firsttime fathers not only disregard their own needs; in the most extremecases, they even go along with the questions outside the guideline oftheir wives (Hollander et al., 2020).The significant impact of professional support and professionalismon fathers’ experiences is also reported in other studies (Johansson et al.,2015; Labrague et al., 2013; Sapountzi-Krepia et al., 2013). The association between professional behaviour perceived as negative and negative childbirth experiences has been highlighted, which also emphasises the important role of professionals (Wikander and Theorell, 1997).The association of good childbirth experiences of fathers with confidence in the staff has also been reported (Vehvilainen-Julkunen andLiukkonen, 1998). More attention should be devoted to supporting andproviding guidance for the father during delivery (Eggermont et al.,2017; Vehvilainen-Julkunen and Liukkonen, 1998). Increased information needs by first-time fathers, because they have never experiencedchildbirth before(Eggermont et al., 2017), should be addressed withhonest and clear information (Danerek and Dykes, 2008; Grobman et al.,2010; Johansson et al., 2015).The strengths of this review are the structured methodology usedand reproducibility achieved through its transparency and working ina research group. Discussing differences until consensus was reachedincreased the reliability of the study. Primary source quotes were usedto generate a rich description and emphasise the original data.This review has limitations. First, experiences after a caesarean section should have been excluded. However, in one article, it was difficultto separate the experiences of first-time fathers after a caesarean section from those after a normal birth. Some fathers’ experiences after acaesarean section could have been included. However, the collectionof excellent information from the article outweighs potential consideration of experiencing a birth by caesarean section. Second, articles thatprovided more information than experiences during birth yielded minimal information after relevant data were extracted. Sapkota focused oncultural influences on fathers’ attendance at birth (Sapkota et al., 2012).Therefore, these specific findings, which are not present in other articles,are often not provided in this best evidence synthesis. Finally, the useof the CASP appraisal checklist was more difficult than expected. Muchconsultation and discussion within the research group were needed todetermine the quality of the articles.The importance of this review for clinical practice relates to its recommendations for professional awareness and care to be adapted to thespecific needs of first-time fathers. Care for first-time fathers should beformalised by devoting more attention to fathers within the antenatalcare system. For example, structural attention should be given to firsttime fathers’ expectations, preparation, role and needs when debating adelivery plan and referring to existing or develop new paternity classes.The important influence of professional behaviour on the experiences offirst-time fathers must be considered. Eggermont et al. reported variousneeds of fathers during childbirth and stated that professionals shouldadapt to these needs to provide a better childbirth experience for fathers(Eggermont et al., 2017). It is important to realise that these reportedexperiences of first-time fathers should not be overgeneralised. The expectant father must be seen as a unique person with unique experiencesand needs.Follow-up research must be conducted on how preparation of firsttime fathers can be integrated into the prenatal care of couples. Despitevariations in childbirth culture, similarities in first-time father experiences and needs are outlined. Translating the implications into localenvironments poses a challenge.Professional education must consider the different needs of first-timefathers and fathers who have had a child before. It is also importantto train professionals to improve their communication and supportiveskills. An evidence-based professional training program should be developed and evaluated using the Medical Research Council framework(Craig et al., 2008; Henoch et al., 2013). It is recommended that theenriched development phase of the MRC framework is used to developa training program that is well-adopted, effective and tailored to thecontext (Bleijenberg et al., 2017).In conclusion, strong evidence exists that first-time fathers experience much insecurity, anxiety and lack of knowledge in the unknownsituation and need preparation and guidance. First-time fathers wantto feel involved; this can be achieved by involving them in communication and decision making. Professionals must be aware of the specific needs of first-time fathers, and care must be adapted. Professionalsmust also realise the significant influence of their professional behaviouron first-time fathers’ experiences. Care for first-time fathers should beformalised. Follow-up research must be conducted on integrating thepreparation of first-time fathers into prenatal care.Conflict of interestNone declaredEthical approvalNot applicableFundingThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Clinical Trial Registry and Registration number PROSPERO 152,805.Supplementary materialsSupplementary material associated with this article can be found, inthe online version, at doi:10.1016/j.midw.2020.102921.ReferencesAllport, B.S., Johnson, S., Aqil, A., Nelson, T., Kc, A., Carabas, Y, M.A., 2018. Promoting Father involvement for Child and Family health. Acad. 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