paternal fears of childbirth a literature

8/3/2019 Paternal Fears of Childbirth a Literature

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Paternal Fears of Childbirth: A LiteratureReviewSuzanne Hanson, MSN, CNMLauren P. Hunter, PhD, CNM, WHNP, FACNMJill R. Bormann, RN, PhDElisa J. Sobo, PhD

ABSTRACTTo date, most studies on paternal childbirth fears have been exploratory or descriptive, conductedoutside of the United States, and focused mainly on White, first-time fathers. Identified fears includeharm to the mother or newborn, partner pain, feelings of helplessness, lack of knowledge, and fear ofhigh-risk intervention. Fathers often report that childbirth classes are not helpful and, in some caseseven increase their fears. Some fathers view birth as traumatic, changing their perception of and relationship with their partner. Fathers also voice the need for more information and for reassurancethat they are doing the right things for their partner during childbirth. This article summarizes theresearch findings on paternal childbirth fears and recommends topics for future study.

The Journal of Perinatal Education, 18{4), 12-20 , doi: 10.1624/105812409X474672Keywords: childbirth, fathers, paternal, paternal fears

Prospective m others rely on their partn er for strengthand support during pregnancy, during childbirth,and after birth while raising their children. Westernsociety expects prospective fathers to attend andassist their partn er at the time of childb irth (Callister,1995; Shapiro, 1987), and many fathers-to-bedesire to be present during childbirth (Vehvilainen-Julkunen & Liukkonen, 1998). According to researchfindings, fathers believe their partner will do finewithchildbearing and rearing, but they have doubts abouttheir own capabilities in these areas (Chalmers &Meyer, 1996; Elster & Panzarine, 1983; Eriksson,Westman, &Ham berg, 2006; Szeverenyi, Poka, H etey,& Torok, 1998). Because fathers play a key role in

supporting their partner in childbirth and believetheir supportive role is an impo rtant part of the process of becom ing a father (Chalmers & Meyer, 1996Chandler & Field, 1997; Chap man , 1991; Dellman2004; John son, 2002 ; Lavender, 1997; Vehv ilainen-Julkunen & Liukkonen, 1998), their needs areequally impor tant as the m othe rs' needs. Howeverthe focus on paternal childbirth fears is relativelynew. In order to evaluate current progress andascertain future research needs, we conducted aliterature search on articles published from 1994to 2008, using CINAHL, Ovid, psycINFO, andPubMed electronic databases in addition to refer-ence lists from selected articles. Keysearch terms


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included "paternal," "fathers," "childbirth," and"childbirth fears." We reviewed pertinent articlesin English and included them in our review basedon each article's relevancy or currency and its abil-ity to add breadth and depth of knowledge to thesubject of paternal childbirth fears. Studies citedhere describe fathers' perceptions of childbirth aswell as their fears and coping mechanisms.KEY PATERNAL CHIL DBIRT H FEARSMost of the research related to paternal childbirthfears has focused on first-time fathers from White,middle-class backgrounds. Frequently expressedconcerns are fear for the safety of the mother andthe child, anxiety and fear from observing their part-ner inpain , feelings of helplessness, lack of knowledg eabout the process, risks of interventions such as op-erative delivery, limited finances, and inability to bea good father. Fathers identify health-care providersas their primary source of information (Chalmers &Meyer, 1996; Chandler & Field, 1997; Dellman,2004; Gage &Kirk, 2002; Greenhalgh, Slade, & Spiby,2000; May, 19 94). How ever, fathers express the needfor more su ppo rt from health-care providers and re-assurance that they are doing the right thing to sup -port their partner during childbirth. They alsoexpress a desire for more information about whatto expect during the hospital stay and m ore informa-tion abo ut th e feelings they will experience after bir thand during infant care (Beardshaw, 2001; Dellman,2004; Draper, 2002; Smith, 1999).

Chalmers and Meyer (1996) conducted a de-scriptive study using a pilot-tested postbirth ques-tionnaire designed to determine what fathers thinkabout pregnancy, birth, and parenthood. No mea-sures of validity or reliability were provided for thequestionnaire. White, first-time fathers (N = 46)were recruited through convenience sampling fromtwo different h ospital facilities in South Africa. Mo stfathers in the study were excited abou t the pregnancy,thou gh they had significant fears ofa newborn abnor-mality, their partner's p ain, and their partner or babydying. Other frequently reported paternal fears werefear of labor, operative interventions including episi-otomy, not being a good father, and loss of maritalcloseness.

Chandler and Field (1997) conducted in-depthinterviews with 14 first-time, high-income. White,Canadian fathers both prior to birth and 4 weeksafter the birth. The authors reported that the fa-thers' fears were prolonged labor, the inability oftheir partner to cope, and operative delivery. The

men described feelings of anguish over the paintheir partner endured and of anger and helplessnesswhen they were excluded from decision-making ordenied the ability to provide su ppo rt. Fear and neg-ative emotions escalated with the length of laborand did not abate until birth was imminent. Fathersin the study also described the need to hide or c on-trol their emotions and fears from their partner.Vehvilainen-Julkunen and Liukkonen's (1998)descriptive study examined the experience of fatherswho attended the birth of their child. The re-searchers examined what fathers felt during thebirth and how fathers viewed the meaning of child-birth. The study included a nonrandom sample of137 both first-time and repeat fathers at the U niver-sity Hospital of Kuopio in Finland, all of whomhad been present for the birth of their child. Thefathers were asked Likert-type questions with fivepreset choices followed by open-ended questionsabout their childbirth experience. Cronbach's alphawas performed on questions related to the fathers'feelings and was calculated as 0.74. Health-care pro-viders evaluated the instru men t for con tent validity,and the instrument was pilot-tested before beingused. Study results showed that of four main cate-gories, the category "feeUngs of discomfort" relatedto fear, anxiety, and helplessness. The fathers' great-est concerns were related to how their partnerwould cope during labor and birth. The most com-mon concern expressed by the fathers was an in-creased feeling of helplessness during labor andbirth, followed closely by a concern for the well-being of the baby and by fear that their partnermight die. Answers to open-ended questions re-vealed that the fathers were most fearful of theirpartner's experience of pain. Other fears expressedin the open-ended questions were feeling helplessand the fear of blood and operative interventions.The researchers found that fathers under 32 yearsold and first-time fathers were more uncomfortableduring birth than older and more experiencedfathers. The reliable and valid question naire in com -bination with open-ended questions, an adequatesample, and a high response rate (81%) lends cre-dence to the study results.

Szeverenyi et al.'s (1998) quantitative study ex-plored reasons for childbirth-related fears in cou-ples. The researchers recruited 216 couples froman antenatal class in Hungary. During the first an-tenatal class, fathers were given a 52-item question-naire developed by Ringler (19 85). Responses aboutchildbirth fears were rated on a 5-point scale rang-

Cronbacb's alpha isa reliability index thatestimates homogeneity ortbe internal consistency oa measure. The closera score is to 1.0, tbe moaccurate tbe measure (sePolit & Beck, 20041.


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ing from "absolutely no t" to "very mu ch." R eliabilityand validity for the questionnaire were confirmedprior to the study. Results of the study revealeda similar ranking of paternal childbirth-related fearsto studies in other countries (Chalmers & Meyer,1996; Vehvilainen-Julkunen & Liukkonen, 1998).The fathers' number one fear was that the motherwould endure severe pain and suffering. The sec-ond greatest fear was the possibility of a cesareanor vacu um delivery, followed by having a baby withbirth injuries and by fears of other complications,feelings of helplessness, inability to help, and still-birth.

Eriksson et al. (2005,2006) developed a question-naire to examine experiential factors associatedwith childbirth-related fears in Swedish men (n =329) and women (n = 410). The tool ranked fathers'level of fear and types of fear. Answers were rankedon a 6-point scale, with responses ranging from "nofear at all" to "very high fear." Thirteen percent ofthe fathers expressed an intense level of childbirth-related fear, and 59% reported a mild to moderatelevel of fear. Fathers with the highest levels of fearwere asked to describe what worried them or whatthey feared in relation to childbirth. Their answerswere analyzed using content analysis. The mostcommonly expressed fear was for the health andsafety ofthe baby (79 %). This fear included the pos-sibility of a deformed, disabled, or handicappedbaby, or death. Concern for the health and safetyof their partner (injury and death) ranked second(49%), and fear ofthe labor and birth process (longlabor, partner's pain, interventions) ranked third(37%). The fathers also doubted their own child-rearing capabilities but rarely feared for their part-ner's ability to raise their child.

Eriksson et al. (2005,2006) reported that, in theirstudies, fathers with intense childbirth-related feartended to be older, and that questions with the high-est loading factors of fathers' childbirth-related fearconcurred with the paternal childbirth fear data de-scribed in previous ethn ograph ic analysis (Chand ler& Field, 1997). These questions were, "Pregnancycan feel like being in captivity waiting for torture"(Eriksson et al., 2005, p. 65); "I did not want toworry my partner so I said nothing about the fearI felt" (p. 66); "Fear related to childbirth is neverspoken about" (p. 66); and "Childbirth is a riskysituation" (p. 66). Fathers' reluctance to expressfears because of the need to protect their partnerhas also been described in males who have experi-enced a postperinatal loss (O'Leary & Thorwick,

2006). According to Courtenay (2000), men oftenview admission of fear as a sign of weakness, anda reluctance to acknowledge fear may be an accultu-rated Westernized male gender response. Data forCourtenay's retrospective study was gathered 11/2 years after birth, and the reliability of a father'srecall of the birth experience after that length oftime is not known.An interesting study from Poland examined theconcept of family labor and birth (father present)with both participating (384) and nonparticipating(121) fathers (Wielgos et al., 2006). No reliabilityor validity data were provided about the anon ym ous20-question survey that was given to the fatherswithin 3 days of birth. Participating fathers weremost concerned about their partners' suffering.Non participating fathers' reasons for not attendingchildbirth included an aversion to witnessing suf-fering, fear of fainting, lack of emo tional readiness,fear of feeling useless, and fear of a decline in thequality of sex life. To date, W ielgos et al.'s investiga-tion is the only study that has sought to understandwhy fathers, if given the choice, do not attend child-birth.

Many of Eriksson et al.'s (2006) findings weresupported by White (2007), who used phen omen ol-ogy to explore the phenomenon of post-traumaticstress disorder following the witnessing of what thefathers felt to be a traumatic birth. White's studytook place in New Zealand. Sampling was purposiveand obtained through the Trauma and Birth Stresssupport group's Web site (Trauma and Birth Stress,2006) and other sources such as television, newspa-per, radio, and word of mouth. A total of 21 fathers(18 Wh ite, 2 Pacific Islanders, 1 Maori) participatedin the study, and their narratives were collected ei-ther verbally or in writing, depending on each par-ticipant's preference. The participants' exact ageswere not reported, but they ranged from early20s to 60 years old. Four main paternal childbirththemes emerged from their narratives. In the firsttheme, "Not a spectator's sport," fathers describedhow they felt pressured by society to be present, butas a spectator rather than a participant. They didnot feel emotionally prepared for the experience.The second theme, "It's about being included," de-scribed the men's experiences of being excludedfrom the relationship with their partner, as wellas the men's feelings of alienation, belittlement,and depersonalization. The fathers wished to be sup-portive and helpful but were disempowered fromdoing so. They felt excluded during decision-making.


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as if their opinion did not matter. Waidenstrom,Hildingsson, and Ryding (2006), however, reportedthat fathers whose partner gave birth in a birthingcenter felt more freedom to express emotions andwere more encouraged by staff to be involved.

The third them e in W hite's (2007) study, "Sexualscarring," described paternal reports of psychosex-ual scarring. The fathers described how they wouldhave a difficult time seeing their p artn er as a sexualbeing after witnessing the b irth. W hite's results weresimilar to findings reported by Wielgos et al. (2006)and by Eriksson et al. (2006).

Finally, in White's (2007) study, when the fathers"toughed it out" they referred to holding back thefears they experienced during the birth. Somefathers feared the loss of their wife and their unbornchild. They reported coping the best they could w ith-out revealing their fears to their partner . Wh ite cap-tured the richness of the fathers' experiences in theirown w ords. Add itional qualitative research w ith spe-cific ethnic groups could further validate White'sfindings.

Svensson, Barclay, and Cooke (2006) interviewed205 expectant couples in Australia during preg-nancy and after birth to assess their concerns, inter-ests, and learning needs. Methods included repeatedin-depth interviews, focus groups, participant ob-servation of antenatal sessions, and surveys. Datacollection took place at less than 12 weeks, at 12-28weeks, at 28-4 0 weeks of pregnancy, an d at 8 weeksafter birth, using a different sample each time. In-terviews were conducted with both pa rtners present.The fathers in this study expressed concerns aboutlabor, care of the infant, and the birth's effect onthe relationship with their partner.

lohnson's (2002) prospective thematic analysisof interviews with 53 fathers who attended theirpartner's normal birth confirmed paternal confu-sion and fear, lack of preparedness for birth, andunpleasant memories regarding the pain of theirpartner's labor and the inability to assist with thepain. Role ambiguity was a consistent themegleaned from the interviews. Nevertheless, fathersreported that they wanted to be present at futurebirths. Being involved (e.g., wiping a brow, holdingtheir partner's hand, or cutting the umbilical cord)made the fathers feel useful.PATERNAL COPING M ECHANISMSCreenhalgh et al. (2000) examined fathers' copingstyles, experiences of labor, and the pos tpartu m ex-periences. The researchers used a quasi-experimen -

tal design consisting of two naturally occurringgroups recruited from two hospitals in England{N = 78) to determine if a father's attendance atantenatal classes impacted his childbirth experience,his emotional well-being, or his attachment to thebaby. Fathers were contacted between 48 hoursand 6 days after the baby's birth. The Experienceof Childbirth q uestionnaire (Salmon & Drew,1992; Salmon, Drew, & Miller, 1990), the MillerBehavioral Style Scale (Miller, 1987), and theEdinburgh Postnatal Depression Scale (Cox,Holden, & Sagovsky, 1987) were given to partici-pants while they were still on the postnatal unitand again 6 weeks later.

Creenhalgh et al. (2000) discovered that fathersuse blunting (avoidance of the anxiety-producingsituation), monitoring (a form of seeking informa-tion and responding with action), or a com binationof both as coping techniques. In their study, fatherswho used blun ting as a coping techniqu e had signif-icantly lower fulfillment and delight dimensionscores on the Ed inburgh Postnatal Depression Scale.Rep orts of low fulfillment and high distress du ringlabor were associated with subsequent increasedsymptoms of depression in fathers. Higher ratesof depression were also noted in unm arried fathers.Fathers who used monitoring as a coping methodand attended antenatal classes had similar satisfac-tion and distress scores on the childbirth experiencescale com pared to fathers with similar coping m ech-anisms who did not attend antenatal classes.RITUAL TRANSITION THEORY AN DPATERNAL ROLE ATTAINMENTIn addition to cataloging fathers' fears and copingstrategies, several researchers applied what is knownas "transition theory" to paternal role attainmentduring the vulnerable time of childbirth. The originsof the transition theory can be traced to Van Cen nep(1909, 1960), a Cerman anthropologist and ethnog-rapher whose seminal work first described transitionin terms of the rites of passage. According to VanGennep, the stages of the rites of passage includea separation or a removal from the norm, a periodof time when one is transitioning (liminal phase)between stages, and the final incorporation intoa new stage in life. Van Cennep used the transitiontheory to describe maternal rituals of pregnancy andchildbirth.

Draper (2002) used the theoretical framework ofthe rites of passage stages to better understand fa-thers' transition to fatherhood from their personal


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perspective. According to findings in Draper's eth-nograp hic study of first-time an d experienced expec-tant fathers {N = 18), fathers accomplish the stagesof transition in relation to their partner's transitionto mothe rhood . For the men in Draper's study, tran-sition to fatherhood began with the news ofthe preg-nancy and progressed as the pregnancy progressed.The fathers began to see themselves differently, as didfamily and friends. Because they saw themselves ina different light, they began thinking about longtermimplications and changing their behavior. With thisre-evaluation of their role within the family, the fa-thers moved into transition, entering a state of limbobetween life stages. Because the fathers did not di-rectly experience the pregnancy, frustrations arose.Being between stages was potentially harmful andthreatening for some fathers because they were nei-ther in one state nor another. They no longer felta part oftheir old world and had not yet transitionedto their new fatherhood role. Some of the fatherswere helped through this stage of transition by at-tending the u ltrasound and childb irth classes, whichalso enhanced their new social identity. However,feelings of vulnerability, powerlessness, and exclu-sion were particularly heightened during labor.The fathers expressed feelings of dislocation at thetime of birth, and they did not know whether theyshould stay with their partner or remain with thebaby.

Ritual transition theory supports the informa-tion gleaned from studies that demonstrate howchildbirth can be a traumatic time for expectantfathers, during which they feel vulnerable, fearfulfor their partner and infant, and are in a transitionalperiod that leaves them powerless, conflicted, andin limbo as a spectator without a traditional malerole (Callister, 1995; Gage & Kirk, 2002; Kunjappy-Clifton, 2007; Shapiro, 1987). Lavender (t997)added that role conflict in combination with a mar-ginalized position of status during childbirth leavesfew ways for men to validate the transition to father-hood . Draper (2002) reported that, among the par-ticipants in her study, the final transition tofatherhood was seen at the time of the infant'shomecoming from the hospital, when the new fa-therhood role became a reality.PATERNAL PRESENCE AND ROLEDURING CHILDBIRTHPaternal fear of childbirth can impact fathers' abilityto be emotionally and physically supportive ofth eirpartner and affect their ability to assume a father-

hoo d role during a vulnerable time of transition. Although men report being invited, pressured to bpresent, and in some cases forced into the childbirtarena, they are led to understand that they are stioutsiders (Draper, 2002; Shapiro, 1987; VehvilainenJulkunen & Liukkonen, 1998). However, fathers often express a desire to be part of the laboring coup lenot just a support person (Chandler & Field, 1997Lavender, 1997). Chandler and Field's (1997) ethnographic study of 14 fathers found that attendinthe birth validates the pregnancy and the newbornIt helps fathers come to terms with their new roland transition into fatherhood. When questionewhy they want to be at the birth of their child, fathers report that it is an importa nt step in the process of becoming a father (Chalmers & Meyer1996; Vehvilainen-Julkunen & Liukkonen, 1998Fathers also express the desire to be mo re e mo tionally connected with their child than their fatherhad been, and they believe that their physical presence at the birth will be the first step tow ard accomplishing that goal (Gage & Kirk, 2002). Howeverfathers also express a need for additional information on caring for the infant, m ore encouragemenof their efforts during labor and birth, and, fofathers who choose not to attend the birth, morfrequent labor upda tes (Chalm ers & Meyer, t996Elster & Panzarine, 1983; Vehvilainen-Julkunen &Liukkonen, 1998).

Dellman (2004), the most recent author to publish a literature review of fathers' experience ochildbirth, examined studies published from1980-2002. He reported that findings reveal fatherthink childbirth is both distressing and wonderfuFathers feel they are not living up to their role andyet, they are confused about what their role isThey simply do not feel like they know what tdo. Dellman's findings were supported by Whit(2007), who stated that the father's role durinchildbirth has never been truly defined.

Despite the paternal role confusion reporteby Dellman (2004), according to findings fromChandler and Field's (1997) qualitative analysiand from Kunjappy-Clifton's (2007) ph eno me nological study, fathers assume one of three roles duringlabor: coach, teammate, or witness. The role of coacrequires active participation in the labor process. Thteammate needs to be present to respond to the needand requests of his partner. The witness prefers ttake a more passive role as an observer. KunjappyClifton's (2007) analysis of interviews with six fatherat 26 weeks postpartum confirmed the finding th


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men continue to support their partner in one of thethree roles described above.

Nolan (1996) documented a case study on onebirth to compare the perceptions of the mother tothe perceptions of the father. The father was excitedat the onset of labor and was convinced his wife wasin labor long before his wife believed so. As laborprogressed, he expressed frustration at not beingmore helpful to his partner. He and his wife werevery sensitive to the midwife's com men ts indicatingher disappointment because of slow labor progress.The father gradually felt that his supportive effortsin the coach role were unrewarded, and he began tofeel more distanced from his wife and the midwife.He felt confiicted between being a strong support per-son and expressing concern and confiision about thelength of labor. He eventually replaced his sup por t ofhis wife with attention to the monitor. Frustrationeventually turned into anger due to the perceivedor institutionally defined "slow" progress of labor.The father eventually expressed gratitude towardthe midwife, who explained things more clearly tohim.STRATEGIES TO DECREASE PATERNAL FEARSDURING CHILDBIRTHA paucity of research addresses strategies to decreasepaternal fears. Yet, many agree that men feel theylack information about the realties of childbirthand what to expect (Bartels, 1999; Beardshaw,2001; Dellman, 2004; Smith, 1999). Fathers oftenstate that childbirth classes give them neither theskills and information they need to feel preparedat the birth of their child nor the tools they needto support their partner and cope with their ownfears (B artels, 1999; Chalmers & M eyer, 1996; Dell-man, 2004; Draper, 2002; May, 1994; Nolan, 1996;W hite, 2007). They report feeling childbirth educa-tion classes help m others but d o not su ppo rt fathers'needs (Olin & Faxelid, 2003; W hite, 2007). They of-ten seek information from television, videos, andfamily and friends (Kunjappy-Clifton, 2007). Fa-thers desire more direction than traditional child-birth classes provide (Dellman, 2004; Draper,2002; May, 1994; Nolan, 1996).

According to research findings, fathers learn byobservation rather than by trial and error, and anoverabundance of information is overwhelming(Svensson et al., 2006). Fathers desire more direc-tion from health professionals to guide them in theirrole during the birth (Premberg & Lundgren, 2006).The hospital may be an uncom fortable or in timidat-

ing place for many, and fathers may be afraid tospeak, make decisions with their partner, or offeradvice. Perhaps related to this viewpoint is thata majority of fathers' concerns when asked aboutbirth relate to fatherhood, parenthood, and sexualactivity, but not the birthing process itself (Callister,1995; Dellman, 2004).

Friedewald, Fletcher, and Fairbairn (2005) devel-oped a discussion forum including only expectantfathers to explore areas of importance for men.The forum focused, from a paternal standpoint, ontopics related to pregnancy and childbirth, aware-ness of the importance of the paternal role duringchildbirth and the postpartum period, and discus-sion of issues of particular concern to men (malecircumcision, breastfeeding, postpartum depres-sion). The fathers participating in the forum werealso attending routine antenatal classes with theirpartner. The 112 forums were conducted duringa 2-2 1/2-hour session, separate from the mothers,and held during one of the antenatal classes. Threemale educators conducted the sessions over the lifeof the program. The forums included 749 fathersand took place in New S outh W ales, Australia, overa period of 6 years. Groups ranged in size from 2-12 ,with an average grou p size of seven. M ost of the p ar-ticipants were first-time fathers.

At the end of Friedewald et al.'s (2005) forum,fathers were given a questionnaire offiveLikert-typequestions regarding the helpfulness of the session,the effectiveness of the facilitator, the format of dis-cussion, and the amount of time allotted to themen-only discussion group. Answers ranged from"strongly agree" to "strongly disagree." The ques-tionnaire also included two open-ended questions.Results of the questionnaire showed that 99% of thefathers found the sessions helpful in their role asa father. Elements fathers verbalized as particularlyhelpful included having a relaxing atmosph ere w ithan opportunity for everyone to share his fears andconcerns. The focus was on the fathers' concernsand their new roles, not the mo thers ' roles. They feltmore at ease expressing their fears in an all-malegroup than they would have in front of their part-ners. The fathers found sharing their common fearsgave them reassurance.

Premberg and Lundgren (2006) explored themeaning of the childbirth education experiencesamong 10 first-time Swedish fathers. Similar toChandler and Field's (1997) findings, the fathersin Premberg and Lundgren's study perceived child-birth classes as being designed for women, and they


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felt their participation was a secondary event. Thefathers' thoug hts were also consistent with findingsreported by Friedewald et al. (2005): Fathers valueand prefer small all-male groups for sharing infor-mation and experiences about childbirth. In gen-eral, most study results indicate that childbirtheducation is much more helpful and supportiveto mothers than to fathers (Kunjappy-Chfton,2007; W hite, 2007); men's desire for practical infor-mation and instruction regarding participation inthe birth is not met in antenatal classes (Beardshaw,2001; Chandler & Field, 1997); and, as in childbirth,fathers feel relegated to a secondary role during pre-natal classes (Kunjappy-Clifton, 2007).

Using a variety of study participants in health-care research, investigators have examined man tramrepetition, which, according to Bormann and Oman(2007), is a complementary, spiritually-based, por-table practice of silently repeating a meaningfulword or phrase to manage psychological distress.Findings indicated significant improvements inlowering levels of perceived stress, anxiety, and an-ger (Bo rmann , 2005; Bormann, Becker, et al., 2006;Bormann, Cifford, et al., 2006; Bormann, Oman,et al., 2006; Bormann et al., 2005). A small studyon the feasibility of mantram repetition indicatesthe potential for using this intervention to helpnew fathers and mothers manage their childbirthfears and anxiety (Hunter et al., 2009).

Other possible, though not evidence-based,strategies to decrease paternal fears during child-birth include postpartum debriefings for paternaldiscussions of childbirth feelings and experiences(Kun jappy-Clifton, 2007; Olin & Faxelid, 2003;Smith, 1999) and including the father's desired rolein birth plans (Kunjappy-Clifton, 2007).SUMMARYA majority of the reviewed studies on paternalchildbirth-related fears were qualitative or descrip-tive. Most study participants were White, and themajority included first-time fathers. However, thenumber one rated fear for fathers remains consis-tent from country to countrythe fear of losingtheir partner's well-being and the fear of a partnerpossibly dying during childbirth (Chalmers &Meyer, 1996; Elster & Panzarine, 1983; Erikssonet al., 2006; Creenhalgh et al., 2000; Vehvilainen-Julkunen & Liukkonen, 1998; White, 2007). Anequally large proportion of fathers rate fear forthe loss of well-being and fear for the health of theirunborn child as their greatest fears (Chalmers &

Meyer, 1996; Chandler & Field, 1997; Erikssonet al., 2006; Creenhalgh et al., 2000; Vehvilainen-Julkunen & Liukkonen, 1998). Am ong the most difficult experiences reported by fathers are observingthe mother experience pain, feeling concern for thebaby's well-being related to heart sounds, and a feel-ing of helplessness in regard to appropriate actionthat might be taken.Based on findings from the reviewed studies, fa-thers experience a variety of fears related to child-birth. Some fathers feel that, rather than beinga part of the childbirth experience, they are in theway. A small percentage of fathers express fearsrelated to concerns over the safety and potentiasexual health risk of episiotomy, to the risks of ma-ternal morbidity, and to mortality from cesareansurgery. Some are concerned that the sight of bloodmight make them feel sick (Chalmers & Meyer1996; May, 1994; Shapiro, 1987; Vehvilainen-Julkunen & Liukkonen, 1998). An equally small percentage of fathers fear their child might be mixed upwith someone else's child (Draper, 2002; Shapiro1987). A prolonged second-stage labor often in-creases fathers' stress, fatigue, fear, and hopeless-ness. The fear of a partner's inability to cope witha perceived lack of progress in labor may becomea focus, along with the fear of a lack of supp ort froma midwife or other professional as labor progresses(Bartels, 1999; Chandler & Field, 1997; Lavender1997). Following birth, reactions to parenthoodfears are often refiected in changes related to life-styles, sexual relations, and marital relationshipsas well as in financial concerns (Chalmers & Meyer1996; Cage & Kirk, 2002; Shapiro, 1987). Althoughfathers may feel fearful during pregnancy and laborthey hide their fears from their partner, and the fo-cus of their fears moves from their partner to theirbaby after the birth of the child (Chandler & Field1997; Lavender, 1997;May, 1994;O'Leary&Thorwick2006; Shapiro, 1987).

RECOMMENDATIONSRecently, researchers have placed increased em-phasis on learning more about paternal fears andpaternal roles during childbirth. Further studiesare needed to assess institutional policies that mar-ginalize the paternal role during childbirth, exam inecrosscultural paternal populations, investigate different childbirth environments, and evaluate fathersrole in providing maternal comfort and suppor(Bartels, 1999). Given the currently available dataregarding fathers' perceived secondary, diminished


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role in childbirth education classes, interventionalstudies may be prudent, especially in the develop-ment of educational strategies for fathers.In certain cultural contexts, fathers can be an im-portant and primary support person for the mothe rduring childbirth. Their supportive role takes placeat the same vulnerable time during their transitioninto the father role. Additionally, because of presentinstitutional educationa l strategies, fathers feel fear-ful regarding a myriad of real and im agined ha zards,as well as confused about their role during child-birth and unprepared for the actual childbirth event(Bartels, 1999; Friedewald et al., 2005; Premberg &Lundgren, 2006). Therefore, pro motin g the acknow l-edgment of paternal fears may require more innova-tive methodological approaches in future research.There appears to be a discrepancy between whatfathers are learning from childbirth education classes(with a focus on the mother and helping her cope),their health-care providers (who tell fathers they arean equal part of the process, but ultimately the pro-vider makes the final decision), and media sources(which portray birth as painful but short-lived). Try-ing and evaluating new childbirth education strate-gies may help clarify the information fathers needand mitigate their paternal fears. Strategies may in-clude antenatal classes that use the successful "pro-motora" model for men (in which a father mentorsa father-to-be), father-facilitators in childbirth edu-cation classes or separate men's groups and break-out sessions with male mentors, and contemporarycoping techniques for men.Fathers' childbirth-related fears have been stud-ied in many countries; however, study participantshave been limited mostly to White, first-time fa-thers. Teenaged fathers, poor fathers, wealthy fa-thers, and fathers from a variety of ethnicitiesand cultural backgrounds or who do not speak En-glish have rarely been included in research that ex-amines paternal fears (Dellman, 2004; Greenhalghet al., 2000). Furthermore, no recent studies on pa-ternal fears have been conducted in the UnitedStates. To m ake study results of paternal fears mo regeneralizable, additional research is needed, espe-cially U.S. studies tha t include fathers representingvarious ethnic and cultural groups, ages, income,and levels of fatherhood experience.REFERENCESBartels, R. (1999). Experience of childbirth from the fa-ther's perspective. British Journal of Midwifery,

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SUZANNE HANSON has been a certified nurse-midwife for 2years and a m aternal-child registered nurse for over 20 yearsSh e is currently employed at Maricopa Medical Center in PhoenArizona. LAUREN P. HUNTER is an associate professor of nuring at San Diego State University in San Diego, California. IILLBORMANN is a research nurse scientist at the VA San DiegoHealthcare System and an adjunct associate research professthe School of Nursing at San Diego State University. ELISA J. SOs a professor of anthropology at San Diego State University.


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