Authors: Raymond A. Levy and Milton Kotelchuck

1 Introduction

Fatherhood as a positive and critically important topic has not been taken seriously in academia, health communities, obstetrical clinical practice, social policy or business until recent decades, despite the publications of Kotelchuck et al.,^[18] Kotelchuck ^[14], Lamb ^[22], Lamb and Lamb ^[24] and others starting in the 1970s. President Barack Obama initiated a federal program, My Brother’s Keeper^[28], which helped to generate credibility for the importance of fatherhood. Now, in the public-health, federal funding, and research worlds, more attention is being paid to fathers as a central component of family life, including their frontline parenting functions, in addition to their economic contribution to children and families. However, it still remains true that little attention has been paid to fathers in prenatal care, the emphasis of this chapter.

1. Raymond A. LevyThe Fatherhood Project, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
2. M. KotelchuckThe Fatherhood Project, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USAGeneral Academic Pediatrics Department, Center for Child and Adolescent Health Policy and Research, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA, USAVincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USADepartment of Pediatrics, Harvard Medical School, Boston, MA, USA

This chapter presents and discusses the results of two combined waves of Father Surveys conducted by The Fatherhood Project^[19][20] during prenatal care visits at the Vincent Obstetrics Department at the Massachusetts General Hospital, Boston, Massachusetts. This study’s survey of 959 fathers accom panying their wives and partners for prenatal care at a large urban tertiary hospital system, we believe, is the largest sample to date of direct men’s voices on their prenatal experiences, condition and preparedness. The results are followed by a targeted discussion of practice implications to increase men’s involvement during prenatal care and to make pregnancy and birth a healthier, more family-oriented event.

We began by exploring men’s voices and perspectives in prenatal care, as early in the family life course as practically possible, and we hoped that their voices might lead to enhanced clinical care. First, we present a more detailed history of the treatment of men in prenatal care within academic and service provision circles to further justify the importance of this study.

1.1 History of Men and Prenatal Care

There is a substantial and growing literature documenting that increased father involvement during the perinatal period is important for healthier births^[15], healthier infants and children^[39], healthier families and partners, as well as healthier men themselves.^[9][17] The broader Maternal and Child Health (MCH) life course and preconception health professional communities in the U.S. encourage early and continuous paternal involvement in the parenting process,^[17] as do national federal family and social policies and community-based fatherhood initiatives.^[1]

The course of prenatal care services is an important time in the pregnancy and birthing period, and conceptually a possibly important period for paternal involvement and development.^[16] Yet pregnancy and birth are not usually conceptualized as a father-inclusive family event. Obstetric and prenatal care services are seen primarily as women’s or mother’s domains as reflected in the names of our fields of study and care (Maternal and Child Health, Maternal Fetal Medicine; Obstetrics as women’s primary health care.)

Despite these negative factors, there is a changing reproductive health services reality on the ground; men are increasingly presenting for prenatal care and ultra sound visits, and now nearly 90% join their partners in the labor and delivery room^[31][32] and are increasingly eligible for, and using, post-partum paternal leave (In the U.S., seven states and Washington DC now have paid family leave). Fathers are increasingly welcomed into pediatric practice as well^[39].

These may in part reflect the evolving transitions from men’s and women’s traditional prescribed gender-based parental roles to more shared and equitable parental roles, with men assuming more engagement with infant care responsibilities.^[15] Yet existing programmatic and policy promotion efforts to encourage this transformation in the U.S. seem weak and underdeveloped—and especially not focused on the pre-birth roots of fatherhood.

Moreover, there is very limited prenatal attention to men’s own health or devel opment as a father, his generativity.^[17][9][16] Paternal engagement and commitment don’t just begin at birth; fatherhood, like motherhood, may be a developmental stage of life and health.^[16] Yet current understanding of the impact of pregnancy experi ences on men’s health and family health as well as the impact of contemporary institutional practices on men’s own health development are critical under-studied topics.

Men’s voices and perspectives in the prenatal period are too rarely assessed and are generally missing from the Maternal and Child Health literature,^[9][10] limiting knowledge about their potential needs, perceptions, contributions, and involvement. Fathers are often discouraged from involvement with MCH-related services and sometimes assumed to be uninterested.^[37][6] This data could provide an important basis for enhanced national and local father-friendly clinical practices. The earlier men are involved with their infants, the more likely they are to remain involved^[32] and the more likely their involvement will yield improved family outcomes.^[35]

1.2 Aims

This research study has six goals:

1. To learn about men’s paternal involvement, needs, and concerns during the time of prenatal care appointments
2. To learn the status of men’s health and mental health in the prenatal period
3. To assess how fathers were treated by the Massachusetts General Hospital Obstetrics staff during their partners’ prenatal care visit for quality improvement purposes
4. To learn what additional fatherhood information and skills they might like to acquire and through what formats and modalities
5. To learn how men feel about the fatherhood study and potential fatherhood prenatal care initiative
6. And finally, to discuss the implications of the results and offer practical recom mendations for improved prenatal care and obstetric practice, to ensure earlier and enhanced paternal involvement

2 Methodology

2.1 Sample

The target sample for each of the two 2-week, cross-sectional cohort study waves were all men attending prenatal services, including ultrasound, with their partners at the Obstetric Services of Massachusetts General Hospital (MGH), a large urban tertiary hospital system in Boston, Massachusetts with multiple community health centers (CHC) and offsite satellite clinics. The MGH Obstetric Services operates as a single hospital-wide practice, with centralized ultrasound, Maternal-Fetal Medicine specialty and delivery services, and approximately 3200+ births per year. Subjects were recruited at the central MGH prenatal clinic and at two of its major CHCs, in Chelsea and Revere, which serve communities with disproportionately large immi grant populations. The study took place during the first 2 weeks of August 2015 and the first 3 of September 2016. MGH Obstetrics sees approximately 100 prenatal care and ultrasound appointments daily.

2.2 Recruitment Methodology

When fathers arrived in the prenatal care waiting room accompanying their partners to prenatal medical visits, they were approached by one of the study’s research assistants or primary investigators and told about the voluntary, anonymous father hood study. They were then asked if they were willing to participate, and if so, take the fatherhood survey immediately, with no rewards offered for participation. If they agreed, they were given a mini-iPad tablet computer on which to complete the survey. If they preferred not to participate or could not be engaged in the recruitment efforts, they were not asked a second time.

2.3 Survey Instrument and Survey Collection Methodology

The fatherhood survey was developed by the researchers associated with The Fatherhood Project at MGH^[25] The survey instrument was a 15–20 min self-administered survey. It was composed of a series of closed-ended questions with an opportunity for open-ended comments at the end. It was available in multiple languages—English, Spanish, and Arabic in 2015; and also Portuguese and Serbian in 2016. The survey was formally reviewed and approved by the MGH Internal Review Board.

The survey, completed in the prenatal waiting room, was composed of two sections: prior to the prenatal clinical visit, the survey questions addressed broad fatherhood issues including paternal preparation and engagement, needs and concerns, and their physical and mental health status. After the prenatal visit, the survey questions assessed the men’s immediate prenatal care treatment experiences, their needs and desires for additional fatherhood information, their preferences for how that information should be delivered, and their assessment of the MGH father hood study and potential initiative.

A paper copy of the survey was offered to those unable to complete it electron ically in the waiting area, 14 in total. All iPad survey data was transferred electron ically to an online data system for analysis at the time of completion.

The survey instruments and recruitment procedures were very similar across the two waves of data collection. There were however some minor differences from the first to the second wave: Subjects information was now also collected at two MGH-affiliated community health centers—Chelsea and Revere Health Centers— in addition to the main MGH Obstetrics hospital campus. There were some minor edits in the survey instrument to improve clarity and response options, and some additional questions added on father’s roles, emotions, and attitudes. And the survey was also available in additional languages as described above.

2.4 Analysis

For this chapter, the results of the two waves of data collection are combined for analysis. Prior data analyses (not presented) had demonstrated a remarkable degree of similarity of responses across the two administrations of the survey, and we therefore combined them to obtain a larger single sample size. We further only examine those questions here that the two surveys had in common, the overwhelm ing majority of the survey items.

This study utilizes standard descriptive statistics to examine the overall findings. The results for each of the study aims will be presented in turn, immediately followed by a commentary on their meaning.

2.5 Methodologic Limitations

While we believe this study provides a successful methodologic framework for assessing father’s voices and experiences during the prenatal care period, we also recognize that this study has some limitations, especially around its study sample, that may restrict its full generalizability.

Specifically, first, the study sample is not fully representative of all men during the prenatal period; it is a convenience sample from a single urban tertiary hospital in Boston, MA—a state and region with a slightly higher SES population, less racial diversity, and more immigrants than the U.S. as a whole. Second, and probably most significant, this survey represents only those fathers who chose to accompany their partners to MGH Obstetric prenatal services during the study periods. While we estimated that we had surveyed a broad and substantial proportion (43–46%) of all potential male partners (data not included), we obviously cannot ascertain the opinions of the non-attendees. Third, the prenatal policies and practices of the MGH Obstetric Services that the fathers experienced and assessed may not be representative of all prenatal practices in the U.S.

And finally, fathers are a very heterogeneous population; responses were explored across a wide variety of sub-populations, but given the complexity of the analyses and findings, this specialized line of research was not more actively pursued for this chapter.

In sum, despite the limitations noted above, this study succeeded in obtaining the perspectives and voices of a very large and broad cross-sectional sample of fathers during the prenatal period. The study provides for important initial baseline esti mates of paternal topics heretofore under-studied.

3 Results and Results Discussion

Sample: The final sample of fathers who provided data during the two waves of data collection was N ¼ 959. All men accompanying a woman into the prenatal care waiting room (N ¼ 1412) were approached. One thousand one hundred seven fathers were eligible for the study; 959 provided data on the first part of the survey and 899 provided complete survey data, including 14 fathers who mailed in the second half of their survey. Overall, the study achieved a very high acceptance rate: 86.6% of eligible fathers (959/1107) participated in the survey, with only 148 fathers (13.4%) not providing answers to the survey, including 69 (6.2%) who formally declined.

Men who were not eligible included those whose partners were receiving non-prenatal care OB/GYN services, such as pre- or post-partum fertility or genetics counseling or post-partum follow-up care; those who had filled out the survey at a previous visit during the study period; and those who were not the father.

Given that this was an anonymous, voluntary survey, we were unable to system atically record the specific reasons for non-participation or the men’s or their partner’s demographic characteristics. Informally, we noted reasons varied from being too busy on a cell phone call, language issues, not wanting to be distracted from the primary maternal focus of the visit, late arrivals, child caretaking, or simply no explanation given.

Additionally, we have no knowledge about the fathers who did not come with their partners for prenatal care; nor were we able to ascertain the characteristics of women who came without a male partner or had no male partners.

3.1 Study Population Characteristics

3.1.1 Results

The majority of study fathers (76.3%) were over 30 years of age, with fathers 31–35 (39.7%) and 36–40 years old (24.5%) the larger age groups. Our cohort was slightly older than the overall Massachusetts fatherhood births population; with 68.3% above 30 years old, 34.4% 31–35 years old and 21.5% 36–40 years old. Relatively few fathers were either younger or older. (calculated from Massachusetts Department of Public Health 2018^[27])

The majority (61.9%) of the study participants were White, with 11.7% Asian fathers, 14.6% Hispanic fathers, and 6.6% Black fathers; relatively similar to the overall Massachusetts birth population (59.5%; 9.3% 18.4%; 9.9% respectively; calculated from Massachusetts Department of Public Health 2018^[27]).

The study fathers were well-educated: 41.3% had a post-BA degree and only 15.9% had high school or less education. The vast majority were married (84.5%), worked full-time (88.6%) and had private insurance (82.1%). Fewer MGH fathers (13.9%) utilized Medicaid than the overall state birth population (33.7%; calculated from Massachusetts Department of Public Health 2018^[27]) (Table 1).

The majority of study participants were disproportionately first-time fathers (61.2%), much higher than Massachusetts fathers in general (45.0%). While there was good representation across the trimesters of pregnancy when fathers were surveyed, the sample skewed slightly toward older gestational ages.

Overall, the surveyed fathers attending prenatal care visits at MGH Obstetrics are a diverse population that skewed towards older, higher socioeconomic status (SES) and first-time father populations, though racially and ethnically similar to all Mas sachusetts births.

3.2 Fatherhood Preparation and Engagementin Reproductive Health Services

3.2.1 Results

First, the survey reveals that the prenatal period is a time of active engagement and joy for men as they are becoming fathers and creating families, a potentially transformative period in men’s development. Over 98% of fathers say they are excited about becoming a father, 93.2% very excited, and almost 92% have spent time thinking about their emerging fatherhood, 57.2% a lot. Over 92% of expectant fathers have spoken with their partner or wife about becoming a father (60.7% a lot, and only 8% little or no time). And over 90% of the fathers plan to be in the delivery room and take time off after the birth of their child. Second, the fathers express a balance of general confidence and a recognition of needing more knowledge and practical fatherhood caretaking skills. While 94% say they are confident in their

fathering abilities (37.6% agree and 39.7% somewhat agree), it is also true that the fathers are asking for either a lot or some help with practical parenting skills (77.3%). Third, fathers demonstrate high levels of involvement in their partner’s prenatal care and future delivery health services. In our sample, fathers always or almost always (79.2%) accompany their partners or wives to prenatal visits and another 13% sometimes attend. And 19% of fathers took unpaid time off work to attend this study prenatal visit (Table 2).

3.2.2 Results Discussion

Our study findings on father’s involvement in maternal reproductive health ser vices—ultrasound visits, PNC, and delivery attendance expectations—is consistent to what others have also reported about fathers’ increasing presence for ultrasound and delivery.^[31][32]

The strong and consistent involvement of fathers with their wives and partners in prenatal care reflects their interest in active fatherhood, from thinking about and discussing impending fatherhood with partners to attending prenatal visits, taking unpaid time off work and being in the delivery room. Fathers’ interest establishes the foundation for an increase of paternal services and attention in prenatal care, which we elaborate on further in the Recommendations section.

3.3 Father’s Health, Health Care and Mental Health 3.3.1 Health and Health Care

Results

The vast majority of fathers profess an awareness of the importance (81.4% feel it is very important) of their health for the health of the newborn infant (15.2% feel it is somewhat important). However, despite this awareness, only 65.2% of fathers had a routine physician exam in the past year. Second, fathers coming to prenatal care visits were substantially overweight (49%) or obese (23%). These figures appear to be consistent with men’s elevated BMIs in the U.S. Third, excessive substance use was relatively uncommon in this sample of fathers, though possibly under-reported.

Smoking was much less common (9.1%) than drinking (62.5%) with 16.8% of men reporting 4 or more alcohol drinks per week and 10.6% men reporting 7 or more drinks per week. Fourth, 65.4% of pregnancies in this sample occurred at “the right time,” a potential indicator of good family planning. Still 14.0% of pregnancies occurred sooner than expected and 8.5% were not expected at all (Table 3).

Results Discussion

Overall, the survey findings suggest that fathers have substantial health and health service utilization needs during the prenatal period, reinforcing sporadic similar reports of men’s poor health and service needs pre-conceptually.^[8][4]

The study results should reinforce the emerging interest in encouraging men to attend to their own preconception and prenatal health care,^[17][9][3] in order to enhance his own life course health, as well as to his infant and partner’s well-being.^[15] That almost 35% of men have not had a routine physical exam in the past year is a missed opportunity to have a pre-birth check-up and learn about and address any existing, significant health issues.

3.3.2 Mental Health

Results

Although virtually all fathers in our study experience joy in the pregnancy period (98.6%), our findings show a significant presence of depressive symptoms as well. The survey’s PHQ-2 two question screener (Kroenke et al. 2003) yielded findings worthy of concern. Over 21% (21.4%) of fathers said they find little interest or pleasure in doing things while 15.5% described themselves as down, sad, or hopeless. In total, 26% of fathers endorsed one or more of these two symptoms, while 8% described themselves as having severe depressive symptoms as measured by at least one of the symptoms occurring more than half the time. At any given time in the US, 7.2% of adults are diagnosed with depression (SAMHSA 2019), which might suggest that our sample of fathers in the prenatal period have higher rates than average. The study also found that over 35% of men don’t have, or are uncertain about having, people and places to go to for fatherhood encouragement, potentially suggesting a feeling of isolation at a critical period of emotional vulnerability.

In addition, 56% of fathers endorsed the statement that the pregnancy period was a source of stress. Analyses using only our 2016 study participants (Levy et al. 2017), where we had explored the sources of the paternal stress more deeply, showed the concerns were focused on financial pressure (44%), the ability to care for the baby (29%), decreased time for oneself (20%), and the changing relationship with the mother (15%) (Data not presented in the tables). Additionally, a group of men (15%) were worried that they would repeat the mistakes of their father, mistakes that they likely experienced in their own development, perhaps abuse, neglect or absence at their most extreme.

Results Discussion

Our data reveals that the prenatal period is marked by substantial mental health needs for the majority of fathers. Entering and negotiating the unknown world of preg nancy and prenatal services can contribute to men feeling insecure and uncertain about expectations.

Joy: The overwhelming majority of men are trying hard to meet the challenges and are experiencing the joys of fatherhood. We observe men embracing their newfound fatherhood role as an opportunity for growth, for the realization of long held dreams and the healing of past disappointments and even traumas. Others see fatherhood as an opportunity for increased capacity to love and for the expansion of identity, a discovery of a previously unexpressed part of the self.

Stress: The current survey findings of elevated levels of prenatal paternal stress are consistent with other research, which similarly has noted greater stress among new fathers (Philpott et al. 2017; Gemayel et al. 2018). One’s circle of concern needs to expand to include the welfare of the new baby; and one needs to derive gratifi cation from the sacrifices for and pleasures of another. These psychological chal lenges are welcome for many, daunting for some, and insurmountable for others.

Additionally, the fathers are facing practical financial and childcare demands that can be challenging. There are financial pressures, changes in the demands of work life balance, and less time availability to enjoy the marital or partner relationship (Kotelchuck 2021b).

Isolation: In this study sample, over 35% of men don’t have or are uncertain about having people and places to go for fatherhood encouragement. Other paternal mental health researchers have also noted that fathers often feel isolated during the prenatal period, and that paternal isolation is a risk factor for pre- and postpartum depression and anxiety (Gameyal et al. 2018). With major changes to fathers’ lives, additional social supports can be helpful.

Depression: This study’s finding that 26% of fathers endorsed one of two depressive symptoms adds to the growing literature about men and depression during the perinatal period (Paulson and Bazemore 2010). Using our 2016 data (Levy et al. 2017), we found that elevated paternal stress, both overall and by specific source, was significantly associated with the father’s depressive symptoms. This finding suggests that fathers can be overwhelmed by the stresses of impending fatherhood, and they often struggle to master the internal and practical demands. The finding that 26% of the fathers endorsed one or both of the depression items on the PHQ-2 in our study does not confirm a diagnosis of clinical depression, although it certainly does indicate that further evaluation is warranted.

Currently, there appears to be little professional awareness about this level of stress and depression in fathers during the prenatal period. Of critical importance, some men who won’t allow themselves to ask for help externalize their problems and become angry, blaming friends, loved ones or society (Rowan 2016) and use sub stances to self-medicate, although curiously our sample seems relatively free of this phenomenon. Psychological evaluation of fathers in the prenatal period, when men clearly have mental health stresses while feeling vulnerable, could potentially prevent multiple problems in the family.

The voices of the fathers in this study, when asked, are expressing their mental health needs loudly. As we will describe in the Recommendations section, integrat ing mental health evaluation and referral for fathers into the Obstetric service may increase the likelihood that fathers will want to seek needed mental health services.

3.4 Perceptions of the Father-Friendliness of MGH Obstetric Services

3.4.1 Results

One of the goals of the Father Survey was to determine the current experience of fathers in the MGH Obstetric Services as they accompanied their partners and wives to prenatal visits, analogous to a continuous quality improvement effort, and one of the justifications for the department’s support of this study. We were interested in learning directly from fathers about what areas of the service and the interpersonal experience needed to be addressed to help it become more father and family friendly. Our Father Survey is perhaps the first time men visiting prenatal care have been asked how they were treated (Table 4).

Overall, fathers perceived their welcome and inclusion at MGH Obstetrics pre natal care services very positively, though there were some notable indications suggesting needed improvements. While there was some slight variation across the various specific staff roles, between 57.1% and 61.3% of men reported being made to feel both very included and very important during the prenatal care visit, with an additional 18.6–27.9% somewhat included and important. Between 15 and 20% of men explicitly noted their neutrality or dissatisfaction with an individual obstetric provider or service.

Second, strikingly, large numbers of fathers were not asked (21.4%) or weren’t sure (20.1%) they were directly asked, a single question by an MGH Obstetrics staff member during their partner’s clinical encounter, representing clear missed oppor tunities for greater father engagement.

Third, at the time of our father survey, MGH Obstetrics Services did not offer any written or media resources specifically directed at fathers in the waiting area. Despite that fact, 39.1% of fathers incorrectly reported that they were offered such resources. Of those who said that MGH did offer resources, 56% felt that they were very helpful and 42% somewhat helpful. These findings perhaps reflect some positive patient satisfaction bias. Fathers also may have equated information for mothers with resources for themselves.

3.4.2 Results Discussion

The study results suggest that overall, fathers perceived that they were very well treated at MGH Obstetric prenatal services; they felt included and an important part of their partner’s prenatal care visit—despite the widely remarked on observation in the literature that men often feel excluded from reproductive health services (Steen et al. 2012). No single staff role stood out for engaging men.

There are several reasons, however, to be cautious in over-interpreting the very positive overall paternal responses. First, the MGH Obstetrical Services may already be especially father-friendly, and its providers may be at their father-friendliest when we are conducting our fatherhood survey. Second, most surveys of clinical care provider satisfaction generally reveal very positive responses. Third, maybe the fathers had very low expectations of involvement in their partners’ prenatal care services, which historically are not usually directed at them, beyond being welcomed and treated courteously. And fourth, men may be very reluctant to say anything too critical that might reflect negatively on their partner’s important upcoming delivery care.

Yet, there were also clearly some indications of missed opportunities for service improvement and greater paternal and family engagement. First, despite the fathers professed satisfaction with the prenatal care visit, when asked objectively about their own informational and skill development needs, substantial numbers indicated a desire to receive information about a wide range of fatherhood and reproductive pregnancy topics not currently being provided them at these visits. (See next section, 3.5.) Secondly, at MGH, when the study began, fathers were not represented and mirrored in the waiting area. There were no pictures of men as fathers on the waiting room walls, nor targeted brochures for them, nor any special explicit fatherhood focused prenatal care activities or programs. Third, a small but sizable number of the fathers explicitly noted their neutrality or dissatisfaction with individual obstetric providers or services. And finally, some of the fathers added written survey com ments indicating that they wanted more involvement and were aware of not being included. Others were simply pleased to be recognized and treated as though they mattered through the attention of the Father Survey. (See Sect. 3.6.)

These perceptions of the Obstetric Services friendliness and opportunities for practice improvements are potentially readily remediable. In the subsequent Rec ommendations section, we propose several ways that an Obstetric Service can potentially provide father-specific resources during their partner’s prenatal care visit.

3.5 Paternal Information Needs and Potential Formats for Delivery

3.5.1 Results

The fathers report a balance of confidence and of recognition of needing more skills. Although only 35.5% of fathers initially said they wanted more information about being a father, (25.4% unsure, 39% no), it is clear that as more specific content areas were presented in the Father Survey, more fathers (33.2–59.7%) acknowledged the need for information topics and skills that they could potentially learn (Table 5).

Specifically, fathers were most interested in how to support their wives and partners prenatally (59.7%), and in learning about the stages of pregnancy (54.6%). They expressed strong interest in learning about their role in infancy (54.3%) and about their baby’s emotions and needs (52.5%), both suggesting that fathers plan to be on the frontline of caretaking. Fathers also wanted to know more about their contribution to healthy pregnancy and childbirth (53.2%). Plus, 46.5% stated they wanted to learn more about practical parenting skills. Fathers were relatively less interested in specialized father topics of finances and paternal health impacts. There was a relatively similar distribution of responses between first-time and experienced fathers (data not included).

The fathers most preferred methods for receiving desired paternal information is through written materials: publications (46.6%) or social media (43.3% on the web; 30.7% via texts), though similar numbers (41.4%) also desired this information from health professionals at the prenatal care visit. Fathers desire more reproductive health and fatherhood information and skills at prenatal visits (41.4%) from across a wide range of fatherhood-related topics. Study participants were currently much less interested in direct experiential sharing modalities. These results are similar to other studies of father’s information method preferences (DeCosta et al. 2017).

3.5.2 Results Discussion

Fathers’ voices clearly inform us that they desire more parenting skills and knowl edge, suggesting that they want to participate more actively and knowledgably in the pregnancy and beyond. We believe that most fathers are unaware of the multiple areas of potential and complex learning needed to effectively interact with and care for their infants, as they have not been historically socialized to care for infants and children. Seeing the list of possibilities mentioned in the Father Survey excited fathers’ interest for specific topics.

We believe that the fathers’ requests for more specific fatherhood information and skills prenatally is a further indication that their attitudes toward reproductive health, their parental roles and responsibilities, and child development are in the process of significant cultural transformation; i.e., that we are witnessing a new era of increased paternal commitment to caretaking roles and potentially a stronger emotional engagement with their families and infants.

Currently, there is very limited information directed at fathers here at MGH Obstetric Services, nor likely elsewhere at other Obstetric Services. Like mothers, fathers are clearly desirous of similar prenatal information, and usually are less familiar with it. That 35% of fathers had no known person or places to go to for fatherhood motivational encouragement and information further emphasizes the potential importance of prenatal care visits as a realistic site to learn more about fatherhood.

3.6 Father’s Assessment of the MGH Fatherhood Prenatal Care Initiative

3.6.1 Results

Free Form Father Quotes from the Father Survey

• “I strongly think that obstetrics should increase fathers’ involvement during pregnancy. Thank you for doing this. It’s about time obstetrics involve fathers. Thank you again.”

• “Love the way you guys are thinking. Incredibly impressed with MGH and proactive initiatives like this.”
• “I’m excited you are even asking these questions!”
• “It’s a wonderful experience.”
• “Very good initiative. I’m proud to be a father.”
• “Would be nice to see if system also considers and recognizes fatherhood equally important!”
• “Try to include them (fathers) as much as possible and explain how important they can be to both the mother and baby throughout the pregnancy and childbirth.

In addition to these comments, one father said proudly to his wife that his conver sation with one of the study’s primary investigators was “just for daddies.” And another returned with twins, one on each arm, 4 days after their birth, asking if he could finish the second half of the Father Survey.

Fathers overall were very supportive of this initial MGH fatherhood prenatal care study, with over 86% agreeing to participate in this baseline fatherhood survey. The fathers who responded to our survey were very enthusiastic about the involvement of men in prenatal and obstetric care: 79.5% thought the initiative was very important, 15.4% somewhat important (combined 94.9%), while only 5.1% thought it was of neutral or lower importance (Table 6).

3.6.2 Results Discussion

The very high rate of survey completion and the general positive and cooperative affective tenor of the fathers both indicate that the fathers were pleased to have interest and attention during their prenatal visits. Indeed, just hearing fathers’ voices and perspectives in prenatal care is already an initial form of positive inclusion.

Overall, these findings suggest that fathers no longer think of themselves as merely chauffeurs to their partner’s prenatal visits, but as active participants in the support to their wives and partners during the birth process and childcare. Their voices are actively requesting support toward these goals. This evolution of men’s paternal interests far surpasses what Obstetric Services currently are aware of and have planned for. Programmatic changes in Obstetric Services to enhance father inclusion could help improve reproductive outcomes and men’s own health and early family involvement.

4 Discussion

The fathers’ very positive response to this study’s survey should help further refute any notions that fathers are relatively unaffected or disengaged by the pregnancy; that pregnancy is not a family event; that they are not present at reproductive health services; that they have limited interest in prenatal care services; or that they will not participate in reproductive health services research. The men in our study were highly engaged, curious, and eager for prenatal involvement and information and skill acquisition.

Specifically, this study documents:

1. that men have come of age as frontline, engaged fathers who expect themselves to be actively involved with their partners during the prenatal and birth process. Engaged fathering is the new norm and reflects an expansion of men’s identity.
2. that the prenatal period is also marked by substantial paternal physical and mental health needs. This period reveals elevated paternal obesity, insufficient family planning, and lack of primary care health services. Fathers are also burdened with substantial paternal stress, elevated depressive symptoms, and personal isolation.
3. that fathers perceive they were made welcome and included by professional staff during their partners prenatal care visits, though many men (~40%) were not asked a single question at the prenatal care visit and no targeted fatherhood resources, information, or services were offered them.
4. that fathers desire more fatherhood information and skills training at the prenatal care visit—across a wide range of fatherhood-related topics—which they would prefer to receive from publications, social media, online education or health professional counseling rather than through experiential fatherhood sharing modalities.
5. that fathers demonstrate an active and engaged “voice” during prenatal care, and are strongly supportive of initiatives, like at MGH, to enhance their involvement in reproductive health services.
6. and finally, that men are willing to participate directly in research and surveys about fatherhood, and that the important and unique information they provide (fathers’ voices) can serve to help develop interventions that foster earlier and more enhanced paternal involvement and engagement in reproductive and child health care, family-centric pregnancy and childbirth, and men’s own health and health care.

The Father Survey findings detailed above potentially reflect major changes in male identity in which fatherhood responsibilities are becoming more important and have expanded to become a broader and deeper part of fathers’ psychological life. Fathers now more often include their nurturing capacity and the development of a bond and emotionally engaged relationship with their children as part of their parenting role. Fathers’ self-esteem, anxiety, pleasure, and sense of responsibility are extended to various fatherhood pursuits. Perhaps this is to be expected as families often have two adults working and sharing parenting duties, placing fathers in frontline caretaking roles.

5 Father-Friendly Obstetric Prenatal Care Practice Recommendations

From its conception, The Fatherhood Project sought to build a collaboration with staff at MGH Obstetrics, to address men’s involvement with fatherhood in the prenatal period and to assess the widely held view that Obstetric Services were not father and family friendly. The Fatherhood Surveys were intended to collect data to provide father-specific guidance to these efforts. As this chapter shows, we believe that we have successfully researched and heard father’s voices at MGH about a set of themes that might lead to enhanced reproductive health services, improved fathers’ health, and increased father involvement with their partners, and ultimately their infants, during prenatal and delivery care.

Based on the fatherhood survey results, an MGH Obstetric Practice Task Force on Fatherhood was created that meets monthly to discuss the implementation of the lessons learned and put them into practice. Based on the joint discussions between The Fatherhood Project and the Task Force, we developed a set of potential practice interventions to enhance obstetric prenatal care and make it more father-friendly and more family-centric, without diminishing the traditional maternal and infant focus of obstetrics. None of the proposed interventions replaces or interferes with existing care or emphasis.

These proposed interventions fall into five broad practice categories that can be conceptualized as sequential steps of increasingly greater father involvement:

1. Staff Training about Father Inclusion
2. Father-Friendly Clinic Environment
3. Explicit Affirmation of Father Inclusion
4. Development of Educational Materials for Fathers
5. Specialized Father-focused Reproductive Health Care Initiatives

5.1 Staff Training About Father Inclusion

5.1.1 Rationale

Currently, many obstetric staff may not think of father inclusion as a practice goal and may not be comfortable interacting with men (Davison et al. 2017). Over 40% of fathers in our study said no questions were directed at them during their partner’s prenatal visit. Staff training can offer new approaches to including men in the obstetric practice.

5.1.2 Recommendations

1. At the practice level, we believe that consistent nursing and clinical staff training that emphasizes the importance of relating to fathers is important for enhanced fatherhood involvement. Training of Obstetric staff by fatherhood experts has the potential to influence providers to talk with fathers regularly and directly during visits and to overcome implicit and explicit biases about fathers as fully compe tent caretakers.
2. Formal presentations and father engagement trainings need to emphasize the research-based, improved emotional, social, behavioral, and academic outcomes for children with greater father engagement.
3. Training on relating to fathers can help some female staff feel less anxious and more competent when addressing fathers. Since the Father Survey was implemented, The Fatherhood Project conducts an annual fatherhood staff train ing for all nursing and nursing-associated staff in the Obstetrics Department.
4. Reaching beyond the practice site is recommended as well. Critical staff training can start earlier at provider educational institutions. Obstetrics can be taught with an inclusive attitude toward fathers in medical, nursing, and midwife programs. Knowledge about the improvement in reproductive health when fathers are engaged in the prenatal period should be emphasized.

5.2 Father Friendly Office Environment

5.2.1 Rationale

Many men don’t feel comfortable in clinical settings for women’s reproductive health services or prenatal care (Steen et al. 2012).

5.2.2 Recommendations

1. The waiting area can display photographs on the wall that reflect all configura tions within families, including fathers with babies, which will communicate inclusion and importance.
2. An educational video that includes fathers and discusses the critical areas of prenatal and infant care can be running in the waiting room.
3. There can be educational materials specifically directed at fathers—pamphlets and magazines—that focus on topics related to fathers’ role in the prenatal and early postnatal period.
4. A chair for a second adult or father can be routinely provided in all exam rooms.

Rationale: Men are hesitant to enter into what is widely perceived as a woman’s traditional world (Johansson et al. 2015; Jomeen 2017).

5.3.1 Recommendations

1. To make the concept of family-centric obstetric care real, obstetric practices must make it explicitly clear to both the mothers and fathers (or other partners) that they are both wanted and expected to participate in all prenatal services. Inclusion of fathers needs to begin with the first contact with the obstetric clinical service, the welcoming script that nurses use in their initial phone medical evaluation of new pregnant mothers. At the MGH Obstetric Service, fathers or partners are now actively welcomed and expected to attend services, especially the first visit, thereby establishing the norm for his inclusion throughout the pregnancy. Explic itly saying “you and your husband or partner” rather than solely “you” signals to the mother that the orientation of the service is inclusive of the father, partner, and family, contributing to more positive reproductive outcomes. We recognize that this may seem problematic for evaluation of domestic abuse, but this critical information can be ascertained in many ways without excluding fathers from routine prenatal visits.
2. Fathers’ information is not generally collected in the obstetric records, except perhaps for his name and insurance status. We propose recording fathers’ infor mation on all enrollment forms and especially in the EPIC-based Electronic Medical Record. This modification would help define the family as a unit of interest and enable providers to cross reference fathers when they are recording information about mothers.
3. It would be helpful to document fathers’ and others’ attendance at prenatal visits. Family-centric pregnancy care necessarily would require family-centric medical records, which currently don’t exist—and father’s health records are not ever linked to their child’s records. Frequently, knowing about the father can be helpful to a provider’s service to the mother. We recognize, of course, that waivers of confidentiality would need to be obtained to share this information.
4. Prenatal care clinics could conduct annual anonymous (Continuous Quality Improvement) cross-sectional surveys of the father’s perceptions of their experi ences at OB prenatal care services—similar to the second half of the current MGH Fatherhood Surveys—and publicize the results. This would help demonstrate to fathers that the prenatal care practice valued fathers and their opinions.
5. To enhance father involvement, when fathers are present in the exam room, nurses, midwives, and doctors should talk directly to them, in addition to the usual conversation between mothers and providers. As we have noted, nearly 40% of fathers didn’t recall being asked any questions during their MGH prenatal accompanying visit.
6. Providers can include father-directed information during appointments, i.e., how to support their partners in the prenatal period (highly desired by the men in our study). If fathers are not present at a visit, mothers can be encouraged to have the father come to the next appointment.
7. The importance of co-parenting can be highlighted when both parents are present.

5.4 Development of Educational Materials for Fathers

5.4.1 Rationale

There is very limited educational material directed at fathers, in the obstetric office and online (Albuja et al. 2019).

5.4.2 Recommendations

1. The fathers’ voices in this study documented the extensive desire for more paternally oriented pregnancy, childbirth, parenting, and partnering information and skills. The MGH Obstetric Nursing Practice Task Force on Fatherhood has encouraged The Fatherhood Project to create brochures for their practice relating to fathers’ interest in their partner’s pregnancy and delivery as well as infant caretaking and development. Over 50% of men in this survey desired more information and skills.
2. We recommend that practices also develop father-specific electronic educational materials. For example, practices may want to offer expectant fathers weekly text messages that they can choose to receive. These text messages can contain the kinds of information fathers requested in our study.
3. Additionally, obstetric practices that currently have a dedicated webpage for mothers can develop a similar webpage for fathers. The webpage can allow for interactive question and answer responses and address the fathers’ areas of interest. Referrals for coaching, psychotherapy, and medical evaluation can be available through the website. Most fathers indicated on our survey that they prefer to receive information through electronic means. We recognize that a website and text messages can also serve the fathers who are unable to attend prenatal care visits or whose interest would increase with viewing educational materials they are unaware of.
4. Experienced expectant fathers or men who recently became fathers could also be engaged in being peer mentors, working individually, or as a leader of a class or support groups. Announcements of these possibilities can be made available to fathers at the time of visits, or by text and webpage.

5.5.2 Recommendations

1. One idea that we strongly encourage and have proposed is the creation of a specific prenatal visit, perhaps named “The Family Visit,” during which the father (or other partner) will be offered an opportunity to speak confidentially with a dedicated professional about his prenatal fatherhood concerns, hopes, and related health and social issues. We conceptualize this meeting possibly in conjunction with the fourth maternal prenatal visit, the lengthy Glucose Tolerance Test (GTT) visit. Fathers would be invited and informed in advance. During this appointment, fathers would have the opportunity to be evaluated for health and mental health related concerns. This can include drug and alcohol use, obesity, financial concerns, anxiety, depression, anger dysregulation, and other, perhaps more severe, mental health issues. Referrals can be made following evaluation.
2. Alternatively, some of these father-targeted health concerns could be addressed with an enhanced primary care visit scheduled during the early pregnancy period. However, most primary care visits do not inquire about potential paternity concerns, plus a man-only visit, however good, is less likely to foster a sense of family-oriented pregnancy. A father visit held through the Obstetric Service as described above during the prenatal period that is about the pregnancy and his needs would be more ideal.

In this section, we presented a sequence of five practical and limited cost interven tions to make obstetric prenatal services more father-friendly and more family centric in order to ensure earlier and enhanced fatherhood engagement and experi ences. These suggestions are all responsive to the fathers’ voices that emerged from our Father Survey.

6 Concluding Comments

From the beginning, our Fatherhood Survey was intended as a public health initia tive aimed at gathering fathers’ voices to guide us in the important work of suggesting interventions and alterations in health service delivery at obstetric practices.

This study attempted to hear the direct perspectives and voices of fathers about their experiences and needs during the prenatal period. The results, we believe, have proven to be very informative—for improving fatherhood experiences, men’s health, and the creation of more father-friendly health services. Fathers’ direct voices are critical—for creating new scientific knowledge about their perinatal conditions, for shaping the new emerging more family-friendly clinical programs (such as the prior obstetric practices recommendations), and for developing the political will to help transform current Maternal and Child Health (MCH) services (Richmond and Kotelchuck 1983). We hope it will be one of many such systematic paternal listening efforts across a wide range of MCH programs and policies.

This study further documents the health, and especially the added mental health, needs of men during the prenatal reproductive period. The isolation, stress, anger dysregulation, and depression expressed by the men can be addressed through father-friendly prenatal initiatives for the improvement of reproductive health out comes. As we have suggested, fathers’ voices inspired practice interventions designed to respond to fathers’ needs in the obstetric service without interference with pre-existing care for pregnant women.

We believe that our study results can lead to a recognition that there is a fatherhood revolution hiding in plain sight that needs to be welcomed and supported in obstetric practices around the country. Fathers and fathers’ health are important to their families’ lives and, in this historical moment, fathers have become eager to engage in the reproductive prenatal care period, presumably leading to their greater engagement with their children and families as frontline caretakers and breadwinners.

Hopefully, Obstetric Services beyond MGH will find the study’s new data on men’s reproductive health needs valuable and will implement some of the proposed paternal health service changes, perhaps altered to fit the particular needs of indi vidual practices.

We hope that this descriptive study of fathers’ prenatal “voices” inspires many more similar perinatal research studies to explore men’s impact on infants’, mothers’, families’, and men’s own health. We hope that others will be motivated to develop and create more father-friendly MCH health services. Ultimately, the critical issue is to hear fathers’ voices—and to engage and uplift the millions of interested fathers while improving reproductive health.

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The post Fatherhood and Reproductive Health in the Antenatal Period: From Men’s Voices to Clinical Practice appeared first on The Fatherhood Project.

Milton Kotelchuck

1. The Importance of Enhancing Father’s Health and Engagement During the Perinatal Reproductive Health Period to Improve Maternal and Infant Health and Development and His Own Life Course Health

This, the first of two related chapters, provides a broad overview, and new conceptualization, of the various ways in which father’s health impacts reproductive and infant health and development. It is paired with a subsequent chapter that examines the ways in which fatherhood influences the health and development of men (Kotelchuck 2021). These chapters endeavor to bring to light the heretofore underappreciated topic of father’s importance and necessary active involvement in reproductive health and health care to enhance infant, maternal, family, and men’s own health and development outcomes. Fathers’ increased participation in reproductive health care activities, their actions on the ground, are perhaps outstripping the public health research and conceptual theories about their role and importance.

Traditionally, the principal focus of the Maternal and Child Health (MCH) field (and closely aligned Obstetric, Pediatrics and Nursing fields) has been on the mother’s health and behavior and its impact on reproductive and infant/child health and development outcomes. Reproductive health and early parenting has been perceived as primarily, if not exclusively, the mothers’ responsibility and her cultural domain, and to a significant extent fathers and men have been excluded. This chapter does not argue to diminish the importance of women’s health and reproductive responsibility, but rather seeks to expand upon and complement her role with an enhanced paternal and family perspective on reproductive and infant health and development and to encourage greater equity in parental responsibility and engagement in reproductive and infant care. Increased paternal involvement in the perinatal period is not a zero-sum game. This chapter focuses on fathers, by far the largest group of women’s partners, but it does not presume that traditional two parent families are the only form of families that can raise healthy children; perhaps some of the lessons learned here will apply to all additional parental partners.

First, there is a large, well-established, and growing literature demonstrating the positive impacts of fathers’ involvement on multiple facets of child development and family relationships (e.g., Yogman et al. 2016; Lamb 1975, 2010), which co- authors in this volume further discuss (Yogman and Eppel 2021). Fathers’ participation, roles, and potential contributions during the perinatal time period (e.g., preconception, pregnancy, delivery, and very early infant life and family formation) are by comparison a very under-studied topic. This chapter will explore how fathers’ multifaceted perinatal involvement and health improves reproductive and infant health outcomes; and more explicitly expand our understanding of men’s life course development and responsibility, as fathers, into an earlier temporal period before delivery.

Second, the limited research on the father’s contribution to perinatal health can be found across very scattered sets of MCH literature—with often seemingly random observations and assessments of possible paternal causal mechanisms and associations. Hopefully, this chapter will help to coalesce these many diverse threads of research into a more systematic organized framework—in order to better facilitate further discussion, analysis, and ultimately action around enhancing fathers’ contributions to reproductive/perinatal health.

Third, many of the conceptual themes about fathers’ health in this chapter build upon similar themes from an earlier preconception health and fatherhood article (Kotelchuck and Lu 2017), but here move beyond its more limited preconception health time frame, explore additional new evolving paternal reproductive health themes, and separate the impacts on infants from impacts on fathers. This chapter adopts a very broad holistic approach to men’s health, blending mental, physical, genetic, social health dimensions and some health service utilization themes into a
single comprehensive fatherhood framework.

Fourth, this chapter, and the following one, model and build upon the current women’s pre-conception health perspective in the MCH field, which simultaneously addresses the impact of the mother’s pregnancy on both the infant’s and the mother’s own lifetime health (Moos 2003)—an intergenerational approach that respects the integrity and health of both mothers and infants simultaneously, without valuing one’s life above the other (Wise 2008). These paired chapters adopt this same dual orientation.

Fifth, this chapter does not emerge in an ahistorical vacuum, but is linked to numerous ongoing political and professional movements. In particular, this chapter is partially embedded in (and contributes to) the larger evolving social and gender equity debates over roles and opportunities for women and men in society, especially the role of fathers, given that many aspects of parenthood are socially determined. This is also a period of substantial economic and cultural transitions, as fatherhood transforms from an older patriarchal model of fathers as distant, controlling
economic providers with stay-at-home nurturing mothers to a newer model based on greater parental equity in childcare responsibilities and combined joint family incomes. This chapter also builds upon the U.S. National Academy of Science, Engineering and Medicine’s (NASEM) multigenerational lifecourse-inspired movement to foster effective parenting and parenting health, recognizing that the “early caregiving environment is crucial for the long-term development of the child” and that “effective parenting presupposes the caregivers own well-being” (NASEM 2016, 2019a), but now expands upon these parenting themes to more actively include fathers.

Sixth, it is hoped that in articulating the multiple domains of fathers’ impact on perinatal health, this chapter will guide more effective and targeted ameliorative interventions and policies that will encourage and enhance father involvement in perinatal health period (i.e., moving from theory to action), as well as provide a better framework to guide further research on this emerging topic. Moreover, beyond fathers’ potential contributions to improve reproductive and infant health, the perinatal period may also add opportunities for improved men’s health and better targeted primary care and mental health services. This chapter specifically provides the scientific evidence base for the contribution of fathers’ health and greater involvement in the perinatal period to healthier infants, families, and men themselves.

2. The Impact of Father’s Health on Reproductive and Infant Health

There are multiple pathways by which the father’s health and health behaviors can directly and indirectly impact on the reproductive and early life health and wellbeing of his children. This manuscript will note and briefly explore the current knowledge base within eight distinct domains of potential paternal impact.

1. Paternal planned and wanted pregnancies (family planning)
2. Paternal biologic and genetic contributions
3. Paternal epigenetic contributions
4. Paternal reproductive health practices that could enhance their partner’s health behaviors and self-care practices
5. Paternal reproductive biologic and social health that could enhance their partner’s reproductive health biology
6. Paternal support for maternal delivery and post-partum care
7. Paternal mental health influences
8. Paternal contributions to the family’s social determinants of health
   Three of these eight pathways reflect pre-conception to conception influences (1–3); three reflect father-mother perinatal interactions (4–6); and two reflect systemic influences (7–8).

2.1 Paternal Planned and Wanted Pregnancies (Family Planning)

First, father’s preconception health and health behaviors have a direct impact on maternal and infant health through family planning, one of the most traditional reproductive health and health service topic. Men are critical participants in family planning, with an inherently shared partnered responsibility (Grady et al. 1996); although traditionally, most family planning efforts have been directed at women, assuming it is their principle responsibility. Currently, in the U.S., men report between 35 and 40% of the births are unintended, 27% mis-timed, and 9% unwanted. Rates vary substantially, with more unintended pregnancies among young, unmarried, low-income, and minority women, especially those with non- residential partners (Lindberg and Kost 2014; Mosher et al. 2012).

Planned and wanted pregnancies are associated with healthier birth outcomes, especially decreased low birthweight (LBW) and pre-term births (PTB) (Kost and Lindberg 2015; Shah et al. 2011; Tsui et al. 2010). More generally, family planning is associated with improved birth spacing, smaller family size, fewer abortions, especially unsafe abortions, and fewer sexually transmitted infections (STI) (Tsui et al. 2010). Active paternal family planning efforts thereby also further mitigate against adverse maternal health behaviors associated with unwanted pregnancies including less folic acid consumption, increased smoking, elevated maternal stress, less prenatal care and less subsequent breastfeeding) (Cheng et al. 2009; Kost and Lindberg 2015). Unplanned pregnancies are associated with a wide array of negative health, economic, social, and psychological outcomes for the mother, child, and family—both in the U.S. and throughout the world (Brown and Eisenberg 1995).

Planned and wanted pregnancies are associated with greater paternal engagement during pregnancy, childbirth, and postpartum periods (Bronte-Tinkew et al. 2007; Redshaw and Henderson 2013). By contrast, unplanned pregnancies are associated with lessened willingness of fathers to form and sustain family relationships, to live with the mother and child, to remain involved and support them, or to more positively self-appraise their own fathering quality and identity (Linberg et al. 2016).

Family planning is a reproductive health service that directly offers men the opportunity to improve their own health status: to obtain and use effective contraceptive methods, to prevent and treat STIs, and to address their subfertility issues. Increasingly national and state public health efforts are targeting men toencourage their family planning responsibilities and assure access to needed family planning services. Yet only 12% of men of reproductive age in the United States reported receiving family planning services, birth control, or STD screening services in the prior year (Chabot et al. 2011). “Still, the sexual and reproductive health needs of men in their own right—as individuals and not simply as women’s partners—have been largely ignored” (Wulf 2002). The first recommendation in the seminal U.S. report on Preconception Health and Health Care calls for partners separately and together to prepare a reproductive life course plan (Johnson et al. 2006). The Centers for Disease Control and Prevention (CDC) has implemented separate men’s and women’s preconception and family planning websites to improve the chances of healthy planned, conceptions (CDC 2019a). And the U.S. Office of Population Affairs, Title X Family Planning administrators, have now for the first time explicitly mandated clinical guidelines for quality men’s family planning and related preconception health services (Gavin et al. 2014).

Europe, in general, has more effective and equitable family planning educational and contraceptive policies than U.S., which perhaps contributes to their less frequent unintended pregnancies (Sedgh et al. 2014) and healthier reproductive outcomes (MacDormand and Mathews 2010). Men’s sexual and reproductive health programs are also important to international development agencies, which focus extensively on men’s involvement—and, too often, non-involvement or lack of responsibility— in family planning. These programs cover a broad range of topics including:
avoidance of unwanted pregnancy; HIV/STI prevention; promotion of women’s reproductive health; gender norms and couple communication; intimate partner violence prevention; and promotion of fatherhood (see, e.g., Sternberg and Hubley 2004), although the effectiveness of such interventions for men has been questioned (Hardie et al. 2017).

Paternal family planning (and preconception health care) services ensure that all pregnancy risks and responsibilities are not held solely by women. They provide a locus to enhance future reproductive outcomes through the practical encouragement of planned and wanted pregnancies and the enhancement of men’s own health. Family planning promotion and services, a major area of current public health interventions, address a key pathway by which fathers can enhance reproductive and infant outcomes. Given how many pregnancies are unplanned, there remains much room for family planning enhancements, utilization, and targeting. Disappointingly, the relatively extensive maleoriented family planning services are not built upon during the subsequent fatherhood journey into the antenatal period and beyond.

2.2 Paternal Biologic and Genetic Contributions

Second, father’s reproductive health, through his genetic contributions, has a direct biologic impact on his infant’s health and development. Father’s genes reflect half of the child’s genetic inheritance. This pathway—father’s genetic contributions, his sperm—is the most traditionally conceptualized domain for father’s direct biologic responsibility and contribution to his child’s subsequent health and well-being (and his/her appearance, personality, and intelligence among other themes). And this is often viewed as his only direct biological means of reproductive influence. Moreover, historically in patri-centric cultures, a father’s genetic contributions have provided the legal basis to assert his progenitor control over his offspring and to assure the inheritance of societal property, his social determinants of health (SDOH) status and characteristics.

Three inter-related issues are important to successful procreation of healthy non- genetically compromised children: sperm quantity (getting pregnant), sperm quality (assuring a healthy fetus), and men’s preconception health, the precursor to both. Each of these reflects long-standing traditional areas of public health research and practice.

Threats to sperm quantity. First, there are increasing reports of threats to the quantity of men’s sperm, and therefore to his biologic capacity to impregnate women (e.g., Carlsen et al. 1992). A meta-analysis by Levine et al. (2017) suggests a 52.4% decline in men’s sperm concentration and 59.3% decline in sperm count in Western countries in the last 40 years. And these declines are coinciding with increasing incidence of related cryptorchidism, hypospadias, and male testicular cancer (Carlsen et al. 1992; Levine et al. 2017).

Numerous reports document the extensive range of threats to the quantity (and quality) of men’s sperm (e.g., Frey et al. 2008; Levine et al. 2017). Major threats include occupational and environmental influences (e.g., radiation, lead, endocrine disrupting chemicals); lifestyle factors (e.g., smoking, alcohol, high BMI); genetic disorders and chronic diseases (e.g., cystic fibrosis or diabetes); medicines (e.g., anabolic steroids, cancer chemotherapies); and demographic factors (e.g., paternal age).

Male infertility and subfertility represent a substantial direct biologic reproductive health problem. Impaired fecundity affects 13% of U.S. women (CDC 2019b). The decline in male sperm quantity likely contributes to the high rates of the total infertility due to male infertility factors alone (~30 40%) or joint male/female infertility factors (~10–20%) (Kumar and Singh 2015; Argwal et al. 2015). Infertility also can be a reproductive mental health stress for men, women, and families; male infertility is associated with increased family stress, low self- esteem, embarrassment, and depression (Noncent et al. 2017).

Threats to sperm quality. Second, similar to the quantity of men’s sperm, the quality of men’s genetic contributions can also strongly influence reproductive and infant health and development. Sperm quality can be damaged through a variety of mechanisms (e.g., immature sperm cells, DNA fragmentation, single or double strand DNA breaks, abnormalities of semen, testicular damage, sperm motility, etc.) (de Kretser 1997). Almost all of the prior risks for reduced sperm quantity have also been associated with sperm quality (Frey et al. 2008; Levine et al. 2017), and new risks continue to be established. On a more positive note, some damaged sperm can be replaced, as sperm regenerates every 42–76 days (de Jonge and Barratt 2006), and many of the clinical, environmental, and health behavior risk factors can be prevented or minimized.

There is a trend towards increasing number of births to older fathers in developed countries. Notably, advanced paternal age has been associated with poorer birth outcomes (stillbirths, preterm births); increased congenital anomalies (especially Down syndrome and PDA heart defects); and childhood acute lymphoblastic leukemia, autism, and schizophrenia (Andersen and Urhoj 2017), all of which are linked to increased de novo paternal genetic mutations that increase with age (Kong et al. 2012). Additionally, there is a well-established MCH epidemiologic literature demonstrating stable cross-generational father and infant/child characteristics, including height and weight, birth weight, and prematurity history (e.g., Misra et al. 2010; Shah and the Knowledge Synthesis Group on Determinants of Preterm/Low Birthweight Births 2010), although the causal mechanism for these associations may not operate only through direct genetic pathways.

Men’s preconception health. Third, efforts to enhance men’s successful fertility, via the quantity and quality his sperm, have infused the growing men’s preconception health efforts (Kotelchuck and Lu 2017; Garfield 2018). Men’s targeted preconception health sites exist, but they mostly encourage personal responsibility and behaviorally focused preventative approaches. Societal and employment policies, such as environmental toxic exposures regulations or community-wide lifestyle improvements or public awareness campaigns, could also be very influential. Primary care clinical approaches targeted at men’s preconception health are just now being developed (Frey et al. 2008; O’Brien et al. 2018), however too few men receive any formal preconception care services, despite evident need (Frey et al. 2012; Choiriyyah et al. 2015). Men’s preconception interventions could not only enhance his sperm quantity and quality but could also promote his health more generally over his lifetime.

Men’s (sub-) fertility and the potential for impaired genetic quantity and quality of his sperm is the most traditionally conceptualized pathway for men’s direct biologic impact on reproductive and infant health and development— plus it is a pathway that influences men’s own health and development. While an extensive basic, epidemiologic, and clinical research literature exists addressing men’s fertility, including a nascent focus on men’s preconception health interventions, this pathway still remains understudied and underappreciated. Given how few births are planned, too many fathers are not optimally prepared for their healthiest conceptions.

2.3 Paternal Epigenetic Contributions

Scientifically father’s sperm (his genetic germ line) has been, heretofore, viewed as the only direct biologic means to influence the infant’s health, yet emerging today is another newly discovered and important direct biologic mechanism, epigenetics, by which men’s sperm continues to differentially influence fetal maturation and child development long after the procreation of that infant. Epigenetics can be viewed as
an on/off switch for genes based on a man’s lived experiences (technically through gene methylation, histone modification, and mitochondrial RNA expression). It  represents an exciting new pathway by which father’s own current well-being and health experiences, a kind of Lamarckian genetics, influences his gene’s expression and amends its original genetic contributions to the health and development of his child—and possibly alters his genetic expression over subsequent generations. More broadly, this pathway derives from our increasing scientific understanding of how environmental influences can alter (epigenetically) parental gene expression and ultimately changes the phenotype and behavior/health trajectories of their offspring. It also reflects new thinking about how our species can more rapidly adapt to changing environments, beyond the long periods needed for the genetic adaptation of the fittest.

While the epigenetic field initially focused on the mothers contributions, given that fathers contribute half of the infant’s genetic material, paternal epigenetic contributions to perinatal and child well-being has recently emerged as a rapidly developing, though still small, basic science and clinical research area (Hehar and Mychasiuk 2015; Day et al. 2016; Soubry 2018). Soubry (2018) coined the term “POHaD,” Paternal Origins of Health and Disease, to describe this newly emerging conceptual area. To date, most paternal epigenetic research utilizes animal models, though there is some limited literature demonstrating epigenetic transformations and impacts in humans.

Diet. Epigenetic changes in their offspring have been associated with father’s diet. A growing epidemiologic literature shows that fathers’ weight and BMI status independently influences the birth weight, obesity, and diabetes of their offspring (e.g., Dodd et al. 2017). For example, during Swedish famines, low and high food availability in pre-pubescent adolescents males led to changes in their children’s and grandchildren’s obesity, diabetes, and cardiovascular health, especially among sons, independent of their mother’s health and food exposure; these were epigenetic changes too fast for spontaneous genetic alterations (Brygren et al. 2001; Kaati et al. 2002). A wide range of paternal dietary changes in experimental studies in animal models have led to marked epigenetic metabolism and tissue modifications in their offspring (Soubry 2015). Soubry et al. (2016) have shown epigenetic marker differences between obese and lean men in the cord blood DNA methylation among their offspring. Men’s pre-conception physical health characteristics, such as men’s diabetes, have been associated with sub-optimal birth outcomes (Moss and Harris 2015).

Alcohol and smoking. Paternal drinking/alcohol consumption is associated with epigenetic changes in their offspring. Heavy paternal alcohol intake has long been known to impact reproductive and child’s health and developmental outcomes (Finegersh et al. 2015). Seventy-five percent of children with Fetal Alcohol Syndrome Disorders (FASD) have alcoholic fathers—even in the absence of maternal alcohol consumption (Day et al. 2016). Paternal alcohol exposure in rodent studies alters their sperm’s DNA and offspring’s epigenetic characteristics, and is associated with a variety of alcohol susceptible features in their offspring, including low birth weight and hyper-responsiveness to stress, also commonly seen in children with FASD (Day et al. 2016). Similarly, paternal pre-pubertal tobacco smoking has been linked epidemiologically to their children’s obesity and asthma (Northstone et al. 2014; Svanes et al. 2017); and in animal studies, pre-conception smoke exposures have been associated with epigenetic changes in transcription factors and miRNA Day et al. 2016).

Other environmental and behavioral factors. Soubry (2018) documents a series of other environmental exposures in fathers that are associated with epigenetic changes in their sperm or offspring, including organophosphate flame-retardants, Vitamin D supplementation, and exercise. In rodent studies, paternal stress prior to conception has been shown to alter methylation patterns and gene expression associated with their offspring’s brain (Rodgers et al. 2013), HPA axis blunting (Dietz et al. 2011), and increased depressive and anxiety-like behaviors (Mychasiuk et al. 2013). Men’s pre-conception elevated lead blood levels are associated with sub-optimal birth outcomes (Esquinas et al. 2014).

A note of caution however, most epigenetic research studies are based in rodent models; human studies are relatively rare and often not sufficiently rigorous. Furthermore, some of the purported paternal effects may be due to maternal or fetal compensatory behavioral changes adjusting to the father’s altered characteristics (Curley et al. 2011). The intergenerational permanence of the environmentally induced epigenetic effects in the paternal germ line also remains under-explored, especially in humans. Epigenetic changes, however, do suggest plausible biologic mechanisms by which some of the previously noted paternal sperm quality risk factors and epidemiologic environmental exposures (including older age) are associated with poorer reproductive and infant health outcomes.

The emergence of paternal epigenetic pathways provides exciting new biological insights into how father’s preconception and ongoing current health status, health behaviors, and environmental exposures can directly impact fetal, infant, and child’s health and development over their lifetime and intergenerationally. Epigenetics, a kind of Lamarckian genetics that compliments Mendalian genetics, provides a richer understanding of how father’s social and health experiences, his lived experiences, enters into his body and then influences the quality of his sperm and its genetic and, now, epigenetic contributions to his offspring’s health and development. These “lived” gene experiences are still a new area of research, and their practical clinical implications are not yet developed. No longer should only women or only pregnant women be encouraged to be healthy to assure their future infant’s health, but now fathers should be too; their own current health status and behaviors may have a direct epigenetic influence on their infant’s health.

2.4 Paternal Reproductive Health Practices That Could Enhance

Their Partner’s Health Behaviors and Self-Care Practices Paternal reproductive practices have an indirect impact on the infant’s health through
their encouragement of enhanced or diminished reproductive health behaviors and self-care practices of their partners. Father’s own health care, behaviors, and attitudes offer opportunities to support, model and promote positive women’s reproductive health and health care seeking behaviors.

Enhancing maternal health behaviors. Fathers can serve as a role model to foster or discourage maternal preventative health-related behaviors—which can directly influence reproductive outcomes—both before conception and during pregnancy. For a woman to eat nutritiously, quit smoking, exercise, and not use drugs, etc., can be more difficult if her enabling partner continues his reproductively negative health behaviors. There is an extensive literature on the co-occurrence of maternal and paternal negative health behaviors across a wide range of reproductive health promoting behaviors, including alcohol usage (e.g., Leonard and Eiden 1999), smoking (e.g., Gage et al. 2007) and dietary habits (e.g., Saxbe et al. 2018). A
woman, for example, is 6.2 times as likely to be obese if her partner is obese compared to normal weight (Edvardsson et al. 2013). Fathers who are more actively engaged and socially supportive during the pregnancy are associated with reduced maternal cigarette consumption (Martin et al. 2007; Elsenbruch et al. 2007; Cheng et al. 2016; Bloch et al. 2010) and drug usage (Bloch et al. 2010). Fathers are an important antenatal and postnatal influence on mother’s breastfeeding decisions and success (Bar-Yam and Darby 1997; Wolfberg et al. 2004; Rempel and Rempel 2011), and greater paternal involvement is associated with more breastfeeding (Redshaw and Henderson 2013). Improving father’s antenatal reproductive health behaviors also directly benefits the father’s lifetime health.

Enhancing maternal reproductive health service utilization. Fathers can play an important role in encouraging or discouraging women’s utilization of prenatal care (PNC) and other reproductive and pediatric health services. Fathers who were more actively engaged during their partner’s pregnancy were more likely to encourage earlier and more frequent prenatal care (Martin et al. 2007; Teitler 2001; Redshaw and Henderson 2013) and more postnatal care (Redshaw and Henderson 2013). PNC utilization was less adequate among couples with disagreement about the pregnancy wantedness (Hohmann-Marriott 2009) and earlier among fathers desiring the pregnancy in a Hispanic sample (Sangi-Haghpeykar et al. 2005). Recognizing that fathers can also be a controlling gatekeeper in decisions around maternal usage of reproductive health services—a role that varies within different cultural groups— fathers could be more actively targeted to encourage their partner’s PNC usage, similar to the messages now routinely directed at them to support their partner’s breastfeeding.

Providing maternal emotional and logistical support to influence maternal health behaviors. Fathers can be a major source of emotional, logistical, and financial support or stress for their partners during pregnancy and early parenthood (May and Fletcher 2013; Alio et al. 2013); and in general, increased maternal stress is strongly associated with poorer pregnancy outcomes (Wadhwa et al. 2011; Lu and Halfon 2003). More paternal emotional support and involvement during pregnancy is widely associated with less maternal anxiety, stress, and depression (Elsenbruch et al. 2007; Cheng et al. 2016; Bloch et al. 2010), and with less post-partum maternal psychological stress (Redshaw and Henderson 2013). Elevated maternal stress can lead to the adoption of reproductively unhealthy coping behaviors (Lobel et al. 2008; Hobel et al. 2008; Bloch et al. 2010), a possible causal pathway for poorer pregnancy outcomes. Conceptually, this topic encourages fathers to provide the traditionally ascribed positive “support” for their partners during pregnancy.

Women with more direct paternal emotional support during pregnancy (as well as practical or financial support) are associated with better birth outcomes, in low- income Black urban communities (Bloch et al. 2010), in Latin communities with moderate-high stress levels (Ghosh et al. 2010), and among smokers (Elsenbruch et al. 2007), although such findings are not always strong or consistent across all populations (Cheng et al. 2016). Paternal emotional support, as an isolated variable, may not be sufficient to counteract the stronger, longitudinal maternal reproductive
health stresses prevalent in low-income communities. Birth certificate analyses of women in father-absent or single-parent households, who would theoretically have less paternal emotional support (as well as less financial support), have poorer birth outcomes (Gaudino et al. 1999; Alio et al. 2011a; b; Hibbs et al. 2018).

Most fathers want to, and can be encouraged to, help ensure healthier offspring by promoting their partner’s positive reproductive health behaviors and self-care practices and by diminishing her need to adopt negative stressrelated coping behaviors. This indirect paternal reproductive health pathway encourages the traditional supportive roles for fathers during pregnancy. The importance of these efforts however is often under-appreciated; too many fathers unfortunately do not sufficiently model or promote positive health behaviors, nor provide enough
emotional, logistical, or financial support. This pathway also encourages fathers to simultaneously improve their own health and health behaviors during the perinatal period, and possibly to enhance the epigenetic health of their future children.

2.5 Paternal Reproductive Biologic and Social Health That Could Enhance Their Partner’s Reproductive Health Biology

Father’s health status and health behaviors can have a direct positive, neutral, or negative impact on the physical and biological health of the pregnant woman and her developing fetus. Or, stated alternatively, the absence of father’s negative health status and negative health behaviors can enhance (and/or not harm) the woman’s and fetus’s reproductive health status during the pregnancy. Conceptually, there are multiple channels through which the father’s influence can be manifested. The negative modalities are the more popularly known.

Intimate partner violence (IPV). Sexual violence and reproductive control, disproportionately targeting women of childbearing age, especially younger and poorer women, is a direct threat to the reproductive health of the mother and fetus. Though the vast majority of fathers do not engage in IPV, 3–9% of women report being abused during pregnancy (Chu et al. 2010; Chen et al. 2017), with slightly lower rates reported in Europe and Asia and higher rates in the Americas and Africa (Devries et al. 2010). IPV is associated with a wide range of maternal reproductive health problems (including unintended and rapid repeat pregnancies, increased STIs); maladaptive coping behaviors; serious mental health problems (including pre- and post-partum depression); and poor infant outcomes (including prematurity and infant mortality) (Alhusen et al. 2015). IPV and injuries are the leading cause of maternal mortality, with IPV associated with ~50% of pregnancy related suicides and homicides (Palladino et al. 2011). But importantly, by implication, this means that lack of IPV by fathers is associated with neutral or better birth outcomes for mothers, infants, and families. A wide variety of men’s IPV prevention interventions have been implemented, most heavily focused on addressing the masculinity and gender-related social norms implicated in violence. These have proven only marginally effective, and more community-based ecological approaches are now being advocated (Jewkes et al. 2015). The concerns of women’s health care providers about the possibility of IPV, and their ability to inquire about IPV confidentially, have often led to the discouragement of, and even hostility towards, fathers participating in maternal reproductive health services during pregnancy (Davison et al. 2019).

Sexually transmitted infections. Fathers with sexually transmitted infections (STIs), can potentially expose their pregnant partners and through them their fetuses to these infectious diseases. The prevalence of STIs in men is substantial and varies by infection; one in two sexually active men will contract a STI by age 25 (ASHA 2019). Untreated STIs are associated with a wide range of poor birth outcomes (including miscarriages, PTBs, infant mortality, and infant eye, lung, or liver damage); maternal morbidities (including pelvic inflammatory disease and tubule infections, that increase the likelihood of infertility); as well as paternal morbidities (including systemic infections, infertility, penile cancer, sores/flare ups and death) (CDC 2019c). Since most STIs can be prevented or well managed through safe sex and antibiotics, fathers must play a key role in their prevention, treatment, and mitigation—a responsibility towards both the current and future pregnancies. Yet, only 12% of adolescents and young adult men are formally screened for STIs annually (Cuffe et al. 2016). STI treatment of women without simultaneous treatment of their infected male partners is doomed to failure.

Paternal infectious diseases. Beyond STIs, the father’s exposures to other infectious diseases can serve as a direct vector for their introduction to their partners (e.g., rubella, chicken pox, tuberculosis, Zika, and coronavirus). Recently, CDC/AAP has begun advising fathers to obtain the Tdap vaccines during the pregnancy to ensure a healthy environment during the infant’s early life vulnerability to pertussis; and similarly to obtain annual influenza vaccinations (CDC 2011).

Paternal second-hand smoke and other environmental exposures. In metareview articles, household second-hand smoke (SHS) exposure among non-smoking pregnant women is associated with a small but significant decrease in infant birth weight (Salmasi et al. 2010; Leonardi-Bee et al. 2011). SHS exposure during pregnancy has been also associated with an increased risk of infertility, stillbirth, and pre-term delivery (Meeker and Benedict 2013). The only SHS intervention specifically directed at fathers showed positive impact on paternal quitting rates (Stanton et al. 2004). Beyond SHS, fathers may potentially expose women to a variety of other teratogenic and mutagenic occupational and environmental toxins
(Knishkowy and Baker 1986). Infants born to the partners of U.S. and Australian soldiers in Vietnam who handled Agent Orange/dioxin had increased birth defects (Ngo et al. 2006). Paternal pre-conception and perinatal health care screenings potentially allows for the mitigation of maternal and fetal exposure to environmental toxins (Frey et al. 2008).

Direct paternal influence on maternal and child nutritional status. Beyond the already noted indirect pathways by which fathers can encourage positive or negative maternal nutritional health practices, fathers can play an important direct role in influencing maternal weight gain, obesity, and nutritional status during pregnancy and beyond. Fathers are not necessarily passive bystanders in the nutritional well-being of their households. They can potentially directly influence food and meal preparation, household food and beverage purchases, formal dining practices, and
the availability of needed family income to obtain adequate nutrition. More men cook and spend more time cooking now than over the past 40 years (Smith et al. 2013). There is increasing theoretical recognition that fathers could directly contribute to infant obesity prevention and metabolic health, perhaps starting even prior to birth (Davison et al. 2019), yet few nutrition interventions directly target fathers (Morgan et al. 2017; Davison et al. 2017). Father’s own weight is an independent predictor of childhood obesity (Freeman et al. 2012; Dodd et al. 2017).

Stress and its direct impact on maternal reproductive health biology. Paternally induced stress can be harmful to mothers and their developing fetuses through multiple direct and indirect modalities, and may even have lifelong impacts. Previously in this chapter, maternal response to elevated stress through maladaptive health behaviors was viewed as an indirect causal pathway. Here, additionally, elevated maternal stress is viewed as having a direct causal effect on women’s reproductive biology, impacting her developing maternal-placental-fetal endocrine, immune, vascular, and genetic systems, as well as through the effects of stress on nutrition utilization and stress on infectious disease susceptibility (Wadhwa et al. 2011; DiPietro 2012). Both humans and animal maternal stress models (often paternally induced) have repeatedly documented changes in cortisol and corticotropinreleasing hormone (CRH) levels, hypothalamic-pituitary-adrenal (HPA) axis functioning, vascular changes, hypertension, etc. (Wadhwa et al. 2011; NASEM 2019a), reflecting biologic changes widely hypothesized as the physiologic basis for pre-term births, Black-White infant reproductive disparities, and sub-optimal African-American women’s health over their life-course (e.g., the “weathering hypothesis” Geronimus 1992, 1996). Moreover, the direct biologic impact of increased maternal stress may have long-term epigenetic consequences on the infant’s brain and behavioral response to stress. Furthermore, if the biological responses to stress interact with increased negative maternal pregnancy behaviors, they may perhaps further foster epigenetic dietary and metabolic disease, alcohol susceptibility, etc. in their offspring (Wadhwa et al. 2011).

Father’s health and social health behaviors (both positive and negative) during the perinatal period can have a direct biologic impact on maternal and fetal/infant health and development. Beyond the widely noted concerns over IPV and STIs, father’s health operates through multiple other modalities to impact the mother’s reproductive health biology. Father’s health (after procreation) is not usually thought of as a direct mechanism or pathway to influence reproductive outcomes, but it should be. This is an important new and expanding conceptual pathway for paternal reproductive health impact. Moreover, addressing father’s reproduction- linked health issues will directly enhance his own lifetime health, as well as enhance the reproductive health biology of women and their fetuses in the current and future pregnancies.

2.6 Paternal Support for Maternal Delivery and Post-partum Care

Fathers can impact reproductive and infant health through their active and direct provision of clinical support to their partners during the perinatal period, especially around delivery and post-partum care. This is a new emerging conceptual pathway— fathers as direct quasi-health care providers for their partners. For example, in most marriages or stable relationships, partners provide palliative and supportive functional nursing care when their partner is sick. During the perinatal period, fathers can and often do provide some very specific maternal reproductive health services.

Obstetric emergency support: Fathers can potentially prevent maternal and infant mortality and morbidity by recognizing and acting on obstetric emergencies, especially for very premature deliveries, as delays in getting antenatal clinical interventions can have serious maternal or fetal consequences. Thaddeus and Maine (1994) emphasized that fathers should be able to recognize an obstetric emergency, be able to take decisions to seek care (or encourage their partner to seek care), and be able to transport their partners to high quality health services. The European WHO agency sees these as some of father’s principle antenatal responsibilities (WHO 2007). Most fathers provide ambulance-like transportation to the delivery hospitals for their partner’s premature and normal gestation pregnancies.

Delivery support: Fathers can play an important supportive role for mothers. increasingly present in hospital delivery rooms, providing familial emotional reassurance and practical support to their partner during her birthing experience. Recent figures suggest that up to 90% of fathers in Britain are present at delivery (Redshaw and Heikkilä 2010), with nearly universal participation in most western countries today (Redshaw and Henderson 2013). Historically, the women’s reproductive health movement led the fight for their partner’s presence in the birthing room (Leavitt 2010). Many women view their partner’s presence as a secondary advocate or advisor on emergent obstetric decisions, independent of the clinician-centric hospital culture. Conceptually, these paternal delivery support roles are analogous to some of the roles of a doula (e.g., Dads as Doulas.) Many fathers themselves also now want to be present at delivery for their own emotional and psychological growth and infant bonding.

There is very limited systematic research on the impact of father’s presence in the delivery room to date. These are mostly small case series, some reporting more positive impact for the mothers and the fathers (Kainz et al. 2010), and others reflecting more mixed experiences (Bohren et al. 2019), especially for first time fathers who may be unfamiliar or uncomfortable with obstetrical practices during delivery (Johansson et al. 2015; Jomeen 2017). Moreover, many clinicians are resistant to their presence in the delivery room and do not always treat them favorably, i.e., “not patient, not visitor,” and hindering fathers’ desires to be more supportive (Steen et al. 2012). However, accommodating the increasing father delivery participation trends, many birthing centers now provide supportive fatherfriendly post-partum sleeping accommodations for both parents.

Post-partum recovery care and support. Following the birth, many fathers provide instrumental help, social support, and nursing-like health care for the mother during her post-partum recovery, especially for post-operative Cesarean sections care, as well as begin to provide newborn and family care. In situations where the mother’s or infant’s health is seriously compromised, fathers often must take on more emergency or even full-time care of their newborns and be a resource to help manage the mother’s emotional and practical needs (Erlandson and Lindgren 2011). And, if
an infant is premature, many Neonatal Intensive Care Units (NICUs) now encourage paternal skin-to-skin kangaroo care to reduce neonatal morbidity and facilitate neuro-behavioral development (Ludington-Hoe et al. 1992).

Paternal leave. Beyond the father’s own potential desire for infant bonding, paternal post-partum leave allows the time and space to provide more supportive nursing care for his partner. Paternal leave’s impact may operate through the mother’s well-being; increased paternal workplace paid-leave flexibility is associated with reduced maternal post-partum physical health complications and improved mental health (Persson and Rossin-Slater 2019). While a large literature documents the health and developmental benefits of paid leave for mothers (Gault et al. 2014), less research exists on the paternal leave benefits. Longer paternal leave is associated with greater subsequent infant and childcare involvement (Boll et al. 2014; Huerta et al. 2013; Nepomnyaschy and Waldfogel 2007).

Maternal post-partum depression observer. Finally and importantly, fathers are the frontline mental health observers of maternal post-partum depression (Garfield and Isacco 2009). They would be the first to notice emerging mental health problems and could act on that knowledge, perhaps even before a clinician’s awareness. This responsibility is similar to the initial antenatal paternal responsibility for monitoring obstetric emergencies, only now in the post-partum period.

This emerging domain reflects a new reproductive health pathway for fathers as active and direct quasi-clinical care support for their partner. This role exists throughout the perinatal period, if not before and after, but is especially important around the delivery and the early post-partum period. This pathway potentially offers fathers the opportunity for more concrete action-oriented roles and contributions. Fathers, like doulas, can be a positive influence on maternal delivery and post-partum health experiences. The increased presence of fathers in the delivery room, and their provision of post-partum care, helps serve as a bridge between the father’s antenatal reproductive health experiences and his subsequent
post-natal family, parenting, and child health and development activities.

2.7 Paternal Mental Health Influences

Father’s mental health status (including stress, depression, and anxiety) has a strong and well-established impact on multiple domains of child health and development (e.g., Yogman et al. 2016; Yogman and Eppel 2021, in this volume); however, there is very limited literature on the consequences of father’s antenatal mental health on reproductive health or birth outcomes. By contrast though, there is a much larger
literature on the impact of pregnancy on father’s mental health (Kotelchuck 2021, in this volume). However, given the early origin implications of MCH life course theory, it is likely that father’s antenatal mental health status may play an important role in reproductive and infant outcomes.

Paternal mental health functioning is a substantial health issue during the perinatal period. Perinatal period is associated with elevated rates of paternal depression (10.4%) (Paulson and Bazemore 2010); anxiety (4–16%) (Leach et al. 2016; Philpott et al. 2019); and stress (Philpott et al. 2017). Whether paternal antenatal mental health problems impact reproductive outcomes, or vice versa, may be a chicken-egg problem, but father’s mental health status amplified by his pregnancy experiences needs to be addressed starting in the antenatal period.

The epidemiologic literature on paternal mental health status and birth outcomes is a very limited. In a Swedish population, Lui et al. (2016) documented that new onset paternal depression, though not chronic depression, was associated with elevated very preterm births. In animal models, paternal stress exposure in the preconception or antenatal periods has been repeatedly associated epigenetically with behavioral stress markers in their offspring (Dietz et al. 2011; Pang et al. 2017); and LBW has been documented among the offspring of paternally alcohol-exposed rodents (Day et al. 2016). Plus, as noted previously, the epigenetic consequences of paternal alcoholism, often a behavioral manifestation of mental health issues, is associated with FASD in their offspring (Finegersh et al. 2015)

The father’s mental health status may be the underlying systemic source for several of the paternal perinatal reproductive health pathways discussed in this essay, especially those associated with increased maternal stress. Fathers who provide their partners with limited emotional and relational support may themselves have underlying mental health problems or limited relational skills. Men compared to women with depressive symptomatology often display higher levels of externalized irritability and anger, which may be particularly stressful for pregnant
women (Madsen and Burgess 2010). Fathers with elevated mental health or stress symptoms may be a less reliable source of steady employment, financial security, or consistent practical help, important areas of maternal antenatal stress. Fathers often behaviorally self-medicate (e.g., increased alcohol and substance use) to avoid addressing their own mental health problems, which not only may add to the mother’s stress, but further serves as a poor behavioral health role models for her. In the extreme, paternal mental health issues could manifest themselves in IPV or
family abandonment. Ultimately, it is likely that all of the paternal reproductive health pathways discussed in this chapter reflect, in part, some paternal mental health components. However, to date, an appreciation of the secondary contribution of father’s antenatal mental health to the other paternal reproductive health pathways is limited, a derivative topic at best.

Father’s positive mental health status may help compensate for mental health problems of their partners. Engaged, non-depressed fathers have been shown to be developmentally protective for the infants and children with depressed mothers (e.g., Hossain et al. 1994; Mezilius et al. 2004), though this same theme hasn’t yet been explored in the antenatal period. Father’s positive mental health status may also play an important role in fostering a growing sense of paternal generativity and involvement starting in the antenatal period (Kotelchuck 2021, in this volume).

Finally and critically, paternal mental health issues can potentially be acknowledged, assessed, and treated even during the antenatal period. The men’s preconception health literature exhorts them to improve their mental and behavioral health (CDC 2019a), but after conception little further attention is directed at this topic. Moreover, despite a nascent advocacy literature calling for attention to fathers often stressed and depressed mental health status during the perinatal period (e.g., Philpott et al. 2017; Gemayel et al. 2018), there are virtually no intervention programs directed at them during this period (Romanov et al. 2016).

Fathers experience substantial mental health challenges during the antenatal period. These may be underlying systemic contributors to many of the paternal reproductive health and health behaviors pathways, especially those associated with increased maternal stress, which ultimately may lead to poorer reproductive and infant health and development outcomes. This domain has not yet been sufficiently addressed by the larger reproductive health community, though it has been emphasized importantly within the child development and pediatric fields. Given the longitudinal assumptions underlying the MCH life course theory, paternal perinatal mental health is likely to be an important and emergent reproductive health topic in the future, similar to the recent increased focus on maternal antenatal depression. Unfortunately, too limited awareness of fathers’ needs and too few mental health interventions are currently directed towards them in the perinatal period.

2.8 Paternal Contributions to the Family’s Social Determinants of Health

Finally, father’s contributions to their family’s social determinants of health, the family’s social well-being, can be viewed conceptually as a “new” systemic pathway by which father’s health and well-being impacts on reproductive, infant, family and their own health. Fathers are a key, and perhaps the dominant vector, for influencing the SDOH of their families. SDOH, in turn, are critically important factors for reproductive and infant health (Kotelchuck 2018; NASEM 2019a). The MCH public health field believes that differential family SDOH over the life course are the principle source of optimal or suboptimal lifetime health, and of social and racial health disparities manifested from birth outcomes onward (Lu and Halfon 2003; Pies and Kotelchuck 2014). Between 50 and 80% of health status is believed to be determined by SDOH, not medical care (Whitehead and Dalgren 1991).

The widely known positive stepwise gradient of better child health and development with higher family income or social class (e.g., NASEM 2016, 2019b) has been similarly demonstrated for reproductive outcomes (O’Campo and Urquia 2011). That more positive reproductive outcomes are associated with increasing father/ family income is a fact known and documented repeatedly since the 1920s (Woodbury 1925). More recently, for example, adverse birth outcomes throughout Canada were associated with decreasing father education, even controlling for maternal characteristics (Shapiro et al. 2017). Father-absent families, with their much lower incomes, have poorer reproductive and infant health outcomes than father-present families (Gaudino et al. 1999; Alio et al. 2011a, b; Hibbs et al. 2018). Residential geographic location, especially for poorer and minority families, is also strongly associated with poorer reproductive outcomes (O’Campo et al. 2008). European countries, which provide more extensive social welfare benefits to optimize their citizen’s reproductive health and diminish social class disparities, have better infant and child health outcomes than the U.S., especially for prematurity and LBW (WHO 2017). And cross-generationally in Chicago, fathers from lower
versus higher lifelong social classes, measured by neighborhood income from their own birth to their current paternity, had more infants with early and overall PTBs (Collins et al. 2019).

Father’s social class, race, education, employment, and residence are not paternal “reproductive health choices”; they primarily reflect his birth and historical life circumstances, including exposure to systemic racism. Multiple mechanisms have been posited about how the negative structural aspects of paternal or family SDOH, especially those associated with poverty, get translated into poorer reproductive outcomes—limited access to healthier foods, poorer quality housing, more toxic environmental exposures, inadequate education, and poorer quality medical care, to name but a few (e.g., Braveman and Gottlieb 2014; NASEM 2019a, b). But beyond these more obvious direct structural aspects of SDOH, there are also multiple other paternal-specific SDOH experiences that could influence reproductive outcomes.

First, the father’s historic and current SDOH experiences influences his mental and physical health, which in turn further impacts reproductive and infant health outcomes. Fathers’ own current health status diminishes as their income decreases or poverty level rises (Williams 2003), and their health is further compounded with their life course exposures to childhood poverty and adverse childhood experiences (ACEs) (Treadwell and Ro 2008). Poor and working-class fathers’ health is impacted by their economic marginality, adverse working conditions, and greater work-life psychological stress and inflexibilities. Moreover, poorer men have less access to health insurance for themselves or their families (Cormon et al. 2009). Poor paternal health is thus both a consequence and cause of their poverty.

Second, as previously noted, father’s SDOH or social well-being can directly and indirectly influence the mother’s health, health behaviors and stress levels, which may impact reproductive and infant health outcomes. Poorer paternal SDOH may increase maternal stress over his reliability as a source of financial security and steady employment, his availability to provide consistent needed instrumental and emotional support, or his adoption of maladaptive coping behaviors to avoid addressing his own enhanced SDOH stresses.

Third, father’s current social class or SDOH may limit his ability to participate in reproductive and infant health services. Poorer fathers’ work schedules, in general, have less work flexibility (Gerstel and Clawson 2018), less time off to accompany their partners to antenatal, delivery, or pediatric care, and less paid newborn family leave—findings confirmed in our MGH fatherhood prenatal care study (Levy and Kotelchuck 2021, in this volume). These social class limitations can potentially diminish father’s involvement with the pregnancy and infancy, reinforce traditional
parental gender roles, and allow less attachment bonding time.

And finally, paternal SDOH can be conceptualized as a systemic influence that affects all the reproductive and infant pathways discussed in this chapter. For example, paternal poverty may limit access to contraceptive services and supplies; increase exposure to dangerous occupational or environmental toxins that impact sperm quality and quantity; or increase mental health stress and substance use that perhaps also are sources of paternal epigenetic transformations.

However, despite the discouraging epidemiologic associations between paternal poverty and poorer reproductive and infant outcomes, this paternal SDOH pathway does not simply represent a fixed permanent risk factor. It is amenable to broad integrated multifaceted policy and practice interventions to enhance paternal and family social well-being (Kotelchuck 2021). Kotelchuck and Lu (2017) outlined three broad domains of social interventions that are needed: paternal clinical policy and practice transformations; enhanced paternal social welfare and employment policies; and paternal agency and generativity programs.

Unfortunately, to over-generalize, in the MCH health care communities father’s social status and well-being, beyond his presence or absence in the family and his insurance status, is not usually singled out as a special reproductive social determinant of health factor that needs to be formally addressed as a potential causal issue for poor maternal and infant health outcomes, but it should be.

Father’s contributions to their family’s SDOH can be viewed as a “new” foundational pathway by which father’s health and well-being impact on reproductive, infant, family and their own health. Fathers are the key vectors for the social well-being/SDOH of their families, and SDOH are likely the most powerful direct influence on reproductive and infant health and development and their associated racial and social class disparities. Paternal SDOH operates systemically through multiple direct and indirect pathways, many of which are amenable to public programs and policies. However, given the general lack of interest in fathers in the MCH reproductive health communities, not surprisingly, this topic is rarely considered. One cannot ameliorate the SDOH root causes of poor reproductive health without directly addressing father’s contributions to his family’s SDOH.

3. Significance of the New Father’s Reproductive Health Conceptualization and Findings and Their Implications for Health Service Programs

This chapter articulates eight broad pathways through which father’s health, health behaviors and attitudes, and social well-being, directly and indirectly influences reproductive health and infant health. Men’s contributions to reproductive outcomes are more than the quantity and quality of his sperm. This emerging conceptual framework covers the entire developmental span from preconception through pregnancy until birth and slightly beyond—a time period not usually thought of as reflecting paternal health influences on reproductive health outcomes (beyond his genetics at contraception), and perhaps beyond what most readers or MCH health professionals might currently think. Hopefully, this chapter will serve as a foundational scientific knowledge base for this evolving area of paternal reproductive health conceptualization and be used to support new and enhanced programs, policies, and research that encourage more active, healthier and earlier involvement of fathers during the perinatal period.

First, this chapter presents a broad systematic exploration of the father’s multifaceted (biological, behavioral, and social) perinatal contributions to
reproductive and infant health outcomes and a new eight-pathway conceptual framework to organize them. Heretofore, there has been only a very diverse and scattered MCH perinatal health fatherhood literature—focusing on a few specialized fatherhood themes (e.g., family planning or inter-generational birth outcome epidemiology) or targeted disease or intervention topics with a strong fatherhood emphasis (e.g., FASD/alcoholism or IPV initiatives). The proposed new conceptual framework builds upon an earlier and more limited one deriving from a men’s preconception health paper (Kotelchuck and Lu 2017)—three of the proposed pathways reflect pre-conception to conception influences; three reflect father-mother
perinatal interactions; and two reflect systemic influences. Among the pathways are several important new themes (including epigenetics, fathers as SDOH vectors); expansions of several traditional themes (especially father’s direct ongoing health impact on mother’s biologic health status); as well as several emerging themes (like father’s quasi-clinical support of maternal delivery and post-partum care). Hopefully, others will build upon this initial conceptualization, as further new scientific understandings of paternal antenatal health impact emerge and evolve.

Second, this chapter has endeavored to push back the MCH field’s appreciation of the developmental time frame for the father’s impact on child development and early family life into the reproductive antenatal health period, if not earlier. This expanded time frame better aligns with the emerging scientific knowledge bases deriving from the MCH life course, Developmental Origins of Health and Disease (DoHAD), and First Thousand Days perspectives (Halfon et al. 2014; Wadwha et al. 2009; BlakeLamb et al. 2018). These perspectives emphasize that conception, or even earlier epigenetically, not the birth, is the true developmental starting point for the impact of both parent’s health and well-being on their infant/child’s life course risks and protective factors. This expanded temporal framework places fatherhood better into an intergenerational context—both as the source of his infant’s health and well-being and as a bi-directional event for his own life’s health and development. In addition, it reinforces the perspective that the earlier the father’s involvement the better for the infant, family, and his own health. Historically, father’s temporal
contributions to child development have steadily moved to earlier and earlier ontogenetic time frames.

Third, this chapter’s broad holistic view of father’s health allows us to appreciate his impact on multiple reproductive and infant health domains simultaneously rather than focus only on single disease topics. This orientation is consistent with life course theory that early generic or upstream exposures impact multiple downstream disease-specific topics. Moreover, this chapter should expand our understanding that critical reproductive and infant health topics, such as nutritional health and dietary intake, substance use, stress, etc., can be, and are, impacted by several of the distinctive fatherhood conceptual pathways, perhaps at the same time. Indeed, for any critical reproductive health topic, one could examine each of the causative paternal health pathways and conceptualize their unique added contributions, thereby, increasing the number and timing of potential paternal interventions. Moreover, the eight specific pathways are written to try to isolate and better articulate them conceptually, but many of them overlap and are synergistic.

Fourth, as noted earlier, this chapter’s themes are linked to numerous ongoing political and professional movements. First and most importantly, this chapter contributes to the evolving larger social and gender equity debates about the roles and opportunities for women and men in society. It contradicts the prevailing view that mothers alone are responsible for positive reproductive and infant outcomes. The infant’s biology, beyond genetics, is a more shared responsibility than heretofore generally thought. Second, and not surprisingly, this chapter is being written during a period of major economic, social, and childcare transformations, with more than 70% of women with young children in the U.S. and other industrial countries now employed, and more single- and dual-income family fathers are now providing primary caretaking for their children during at least part of the day (Yogman et al. 2016).  Third, this chapter expands upon the NASEM-inspired efforts to foster effective parenting and parenting health (NASEM 2016, 2019a); it  explicitly highlights some potential additional and under-appreciated pathways to achieve those parenting goals during the antenatal period, beyond simply calling for parent’s generic well-being and positive mental health status. Fourth, by recognizing the importance of father’s SDOH contributions to reproductive outcomes, this chapter suggests that interventions focused only on maternal SDOH-related themes without also acknowledging or directly addressing the father’s SDOH contributions are likely to fail. Moreover, social class differences in the parent’s own health, including the fathers’ health and mental health, are themselves a major source of developmental inequalities in reproductive and infant health. And finally, this chapter also emphasizes new reproductive health involvement dimensions to the emerging men’s health movement.

Fifth, and importantly, this chapter also opens up a new empirical developmental science policy rationale for the father’s increased, earlier, and healthier perinatal involvement. It documents the growing enhanced scientific knowledge base to support the emerging paternal perinatal health movements. Independent of one’s ideological or policy rationale for supporting greater paternal antenatal involvement, the reality of his greater involvement (via his health and health behaviors) is objectively associated with better reproductive and infant outcomes.

Finally, the themes of this chapter (the impact of father’s health on reproductive and infant health) and the next (the impact of fatherhood on men’s health) are intractably bound. Fathers impact their child’s health, and the child impacts the father’s health, development, and generativity. Both perspectives are needed and critical; they coexist at the same time. The MCH field, which historically hasn’t heavily emphasized the importance of fatherhood, must address this topic from the perspectives of both the child and family and the father himself—similar to the dual women’s preconception health perspectives. One is not more important than another (Wise 2008).

3.1 Implications for Health Services Programs and Policies

This chapter’s detailed recitation of the father’s reproductive and infant health impacts hopefully should encourage more, and more well targeted, men’s health care interventions across the lifespan for his family’s and his own health. Antenatal reproductive health services for fathers are not currently a major focus of men’s clinical health care. While a full discussion of antenatal reproductive health services or programs for fathers is beyond the scope of this chapter, I will simply note four broad health services transformations that would appear to be warranted: (1) Reorient current reproductive and pediatric health services to be more father or family inclusive; (2) Provide some father or family targeted health services during existing mother-focused reproductive and pediatric health services; (3) Encourage more reproductive health-focused primary health care for men; and (4) Increase mental health care for fathers in the perinatal period. Additional potential father- supportive prenatal care obstetric practices are discussed in the Levy and Kotelchuck (2021) chapter in this volume. New and emerging opportunities to foster more specific father-inclusive public health services or policies were also highlighted within each of the eight paternal pathways, where possible. Ultimately however, paternal health is only marginally impacted by the health or medical care sector; it is also deeply influenced by social welfare and employment policies
(SDOH) directed at men, as well as father’s own agency and generativity (see Kotelchuck and Lu 2017; Kotelchuck 2021). [Additional details about potential fatherhood enhancing programs and policies are discussed in other sectors of this book, and especially in the concluding chapter.]

4 Conclusion

Enhancing father’s health and health behaviors before, during, after pregnancy, and in early parenthood is critical to improve reproductive and infant health and development, and ultimately the health of their families, communities, and the men themselves. This chapter articulates eight direct and indirect pathways by which father’s antenatal health and health behavior, broadly construed, impacts reproductive and infant health. It brings together and expands upon the existing scattered fatherhood scientific knowledge base and pushes back the developmental time frame for father’s reproductive health importance into the antenatal pre-birth period, if not earlier. Awareness of father’s increased importance, involvement, and health during pregnancy and early family life should encourage a rebalancing of the culturally traditional maternal and paternal parental role expectations and practices.

Clearly, the core public health action message of this chapter is that there should be earlier, healthier, and more paternal involvement during the perinatal period, in order to improve reproductive and infant health and development and the father’s own health and development—“to empower fathers to be active, informed, and emotionally engaged with their children and families” (Levy et al. 2012) from the onset of the pregnancy, if not before. Healthy men and healthy fathers help insure healthy children, healthy families, healthy workforces, and healthy communities.

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The post The Impact of Father’s Health on Reproductive and Infant Health and Development appeared first on The Fatherhood Project.

Milton Kotelchuck, PhD, MPH
Harvard Medical School/MGH Fatherhood Project

This chapter, the second of a pair of related chapters, provides a broad overview, and new conceptualization, about the various ways in which fatherhood influences the health and development of men. [The first chapter explored the impact of father’s health on reproductive and infant health and development (Kotelchuck, 2019)]. Together these two deeply inter-related chapters endeavor to illuminate the here-to-fore under appreciated topic of men’s/father’s importance and necessary active involvement in the reproductive/perinatal health and health care period, including for his own health anddevelopment.

As noted in the previous Chapter, the traditional focus of my own MCH field (and closely aligned Obstetric, Pediatrics and Nursing fields) has been on the mother’s health and behavior and its impact on reproductive and infant health and development outcomes. Reproductive health and early parenting has been perceived as primarily, if not exclusively, the mother’s responsibility and her cultural domain; and to a significant extent, fathers and men have been excluded. Not surprisingly, as a result, the impact of fatherhood on men’s health and mental health, especially in the perinatal period, has not been the subject of much inquiry.

First, this chapter, for men/fathers, models and builds upon the current women’s preconception health perspectives in the MCH field, which simultaneously addresses the impact of the mother’s pregnancy/perinatal health on both infant’s health outcomes and on mother’s own life time health – an intergenerational approach that respects the integrity and health of both mothers and infants simultaneously, without valuing one’s life above the other (Wise 2005). These paired chapters adopt this same dual orientation; they explore both the father’s health contributions to infant health (in the previous chapter) and the impact of fatherhood on men’s own health – a virtually new topic in the MCH literature – in this chapter.

Second, this chapter attempts to create a new conceptual framework that can organize and document the multiple pathways by which perinatal fatherhood impacts on men’s own health and development. By comparison to the previous chapter, there is an even more limited and scattered set of research (and popular culture references) on this second theme; it is a very under-explored topic. 

Third, this chapter, like the prior chapter, will also explore the perinatal roots of the impact of fatherhood on men’s health and development, or if not even earlier. Fatherhood research here-to-fore has primarily been supported by the large, well established developmental psychology literature demonstrating the positive impacts of fathers’ involvement on multiple facets of child development and family relationships (e.g. Yogman and Garfield, 2017; Lamb 1975, 2000; Yogman and Eppel, 2019). This chapter aims to more explicitly expand the understanding of men’s life course development, impact and responsibilities, as fathers, into earlier temporal periods before delivery.

Fourth, several of this chapter’s conceptual themes about the health impacts of fatherhood build upon similar themes from an earlier preconception health and fatherhood paper, especially paternal generativity and men’s primary health care needs (Kotelchuck and Lu, 2018). This chapter however moves beyond that essay’s more limited reproductive health time frame, explores additional new evolving paternal reproductive health themes, and separates the reproductive health impacts on infants from those on fathers. This chapter adopts a very broad holistic approach to men’s health – blending mental, physical, genetic, and social health dimensions -into a single comprehensive fatherhood framework.

Fifth, as noted in the initial associated chapter, this chapter’s focus on fatherhood and men’s health themes does not emerge in an ahistorical vacuum, but is linked to, and hopefully contributes to, numerous ongoing political and professional movements. In particular, this chapter is partially embedded in the larger evolving social and gender equity debates over roles and opportunities for women and men in society, especially given that many aspects of parenthood are socially determine and that fatherhood is transitioning from a traditional distant patriarchy model to a newer one based on greater parental equity and paternal engagement. The major economic, social, and child care work place transformations associated with the increasingly large numbers of women who have now entered into the paid labor market is undoubtedly hastening this conversation. This chapter also builds upon the IOM/NASEM-inspired multigenerational life-course movement to foster effective parenting and parenting health, but now expanded to explicitly include fathers (NASEM, 2019).  And finally, this Chapter derives in part from the emerging men’s health movement, and emphasizes new reproductive/fatherhood health dimensions to that movement. 

Sixth, as before, it is hoped that in articulating the multiple domains of fatherhood’s impact on men’s health and development, it will spur and guide more effective targeted father-oriented reproductive health interventions and policies, encouraging father’s earlier involvement in the perinatal health period, strengthening what they bring to and take from their fatherhood experiences, and improving their subsequent health and development throughout their life course. That is, to move this chapter’s conceptual research synthesis on this emerging fatherhood topic from theory to programmatic and policy action; to provide better guidance for further research, and to enhance the political will and advocacy for greater paternal perinatal involvement. 

This chapter specifically provides the scientific evidence base for the impact of fatherhood on men’s health and development – that in turn should lead to healthier infants, families and communities.

 THE IMPACT OF FATHERHOOD ON MEN’S HEALTH AND DEVELOPMENT

There are multiple pathways through which fatherhood and its associated experiences could impact men’s health and development during the perinatal and early parenting periods and over his life course.  This Chapter will note and briefly explore six distinct pathways. These pathways, in turn, directly and indirectly influence reproductive and infant health and development, two sets of deeply inter-related topics.  Specifically,

• Men’s physical health status during the perinatal period
• Impact of Fatherhood on Men’s physical health: Changes in men’s physical health during the perinatal period 
• Impact of Fatherhood on Men’s Mental Health/Stress: Changes in men’s mental health/stress during the perinatal period
• Impact of Fatherhood on Men’s Social well-being: Changes in men’s social well-being/ SDOH 
• Men’s Improved Capacity for Parenthood and Fatherhood: Psychological maturation of paternal generativity 
• Men’s Life Course Development as Fathers. Life Course transformations in fatherhood 
• Men’s physical health status during pregnancy and early parenthood. 

Perhaps not surprisingly, in the United States, given men’s generally sub-optimal health status and health care utilization, men’s physical health status during perinatal period reveals substantial health problems and potential opportunities for their improvement. 

Ascertaining men’s health status on a population-basis during their prime reproductive years has been methodologically challenging, and possibly here-to-fore of limited reproductive health interest. Although some broad longitudinal epidemiologic data exists for men of childbearing ages, they are their not usually stratified by parenting status; the NHANES survey, for example, appears to have no publications describing father’s health. Yet health status may differ for men between pre- and post-fatherhood years. In general though, fathers initially should be healthier than non-fathers, as men with a wide variety of health issues are less likely to achieve successful fertility (CDC 2019; Frey et al 2008).

Choiriyyah et al (2015) examined the 2006-2010 US National Survey of Family Growth, which suggested that 60% of men aged 15-44 were in need of preconception healthcare; 56% were overweight or obese; 58% binge drank in the last year; and 21% had high STI risk.  Pre-pregnancy overweight and obesity is a more pervasive problem for men than for women (53% vs. 29%) (Edvarson et al 2013), which takes on added importance since men’s obesity is an independent predictor of childhood obesity (Freeman et al 2012). One might assume that fathers in the perinatal period would continue to still have a similar set of broad health risks. Smoking rates are highest among men during childbearing years; ~30% of men aged 20-24 and ~25 % of men aged 25-34 smoked in Canada (Canadian Tobacco Use Monitoring survey 2006). 

MGH Obstetric Prenatal Fatherhood studies (See Chapter by Levy and Kotelchuck, 2019) reinforce some of the above pre-conception physical [and later mental] health findings: ~75% of men were overweight (25% obese), reflecting their self-reported high sedentary, low physical activity and extensive media usage levels; plus ~14% of men noted signs of infertility or delayed fertility. 

Men are well known for their lesser use of health services than women, even adjusting for women’s reproductive health services usage (Bertakis et al 2000; Smith et al 2006).  Perhaps due to their own social construction of masculinity, men differentially ignore screening and preventive health care and delay help seeking for symptoms (Smith et al 2006; Mahalik et al 2003). Yet the opportunity for care exists, as most men (~70%) in the US would appear to receive primary health care annually (Choiriyyah et al 2015; Levy and Kotelchuck 2019). However, too many receive no preconception health care at those visits; Choiriyyah et al (2015) reported very limited receipt of STD/HIV testing (<20 %) or counseling (<11 %) services. 

These limited, one-time, self-reported assessments of men’s/father’s health during the preconception and antenatal periods suggest that there is much room for improvement in men’s own health status and health care utilization. Similar to women, the perinatal period could be an opportune time to address men’s health overall.  There remains great need for more creative secondary epidemiological studies of men’s overall health status during his prime reproductive years, and specifically stratified by fatherhood status.

• Changes in Men’s Physical Health during Pregnancy/ perinatal Health period 

Pregnancy and early parenthood are associated with multiple changes in men’s physical health status.

Changes in paternal weight–Fatherhood, on a population basis, is associated with increased weight and BMI compared to comparable aged men who are not fathers.  Using the American Changing Lives panel data, Umberson et al (2011), showed that fathers have more accelerated weight gain throughout their life course and weigh ~14 pounds more than non-parental males. Garfield et al (2016), using the National Longitudinal Study of Adolescent to Adult Health (ADD Health) data base, documented that the transition to fatherhood was association with an additional weight gain of 3.5-4.5 pounds more for residential fathers than for non-residential fathers or non-fathers.  These paternal weight gains set the stage for their greater obesity morbidity throughout their lives (Umberson et al 2011; Saxbe et al 2018).

Moreover, popular literature has noted and commented extensively on the “Dad Bod” or “preg-MAN-cy weight”; i.e., weight gain among antenatal and new fathers. One widely cited informal British study estimates an 11 pound weight gain (Mary 2014), and speculates that fathers partake in their partner’s binge eating and finish up the left over foods, eat out more in restaurants and increase eating to respond to their own stress. Saxbe et al (2018) more formally assessed 7 possible behavioral, hormonal, psychological and partner mechanisms for the increased weight gain in fathers; the likely sources included decreased sleep, less exercise, less testosterone, more stress and partner effects (shared diets).

Specifically, the transition to fatherhood is associated with significant sleep disturbance and disruption (e.g. partnered men with young children sleep about 13 fewer minutes per night or approximately 80 fewer hours per year than single, childless men (Burgard & Ailshire, 2013)) and reduced time available for leisure and exercise (e.g. 5 hours/week decrease in physical activity with the first child and an additional 3.5 hours/week with a subsequent child (Hull et al., 2010)). Parenting-associated physical activity declines were more pronounced for men than for women. Fatherhood was not associated with changes in men’s diet (Saxbe et al 2018). 

In many cultures, fathers experience “Couvade Syndrome” or “Sympathetic Pregnancy”, physical and psychological symptoms and behaviors that mimic the expectant mother’s during her pregnancy and post-partum period (Kazmierczak et al 2013). Physical symptoms can include insomnia, nausea, headaches, toothaches and abdominal pain, as well as increased stress and weight gain. Couvade is not a recognized (DSM5) mental illness or (ICD10) disease. Thus, the extent of couvade syndrome prevalence has been difficult to ascertain, and estimates (11-65%) vary widely depending on the symptoms and populations being assessed (Masoni et al 1994).  Symptoms seem most common in the first and third trimesters, and most go away after the baby is born (Brennan et al 2007). The sources of couvade in men remain elusive, with extensive psychological and psychosomatic theorizing (e.g., empathetic responses to pregnancy; compensatory or even competitive symptoms; or shared hormonal changes (Kazmierczak et al 2013)). Traditionally called ‘primitive couvade”, it was associated with anthropologic studies of male pregnancy rituals, in which men refrained or partook in special pregnancy/birthing rituals thought to impact the spirit of the developing child. Couvade symptoms are associated with increased paternal health service utilization, though they are often un-recognized or associated with the partner’s pregnancy status (Lipkin and Lamb, 1982).

Men’s biologic adaption to fatherhood: hormonal and brain structure transformation– While it has long been noted that women’s hormones change or adapt as a function of motherhood (Fleming et al 1997; Edelstein et al 2013), there is also now growing evidence of men’s biologic adaptation to fatherhood (Edelstein et al 2013; Gettler et al 2011; Grebe et al 2019). Testosterone, which is important to male sexuality, mating and aggression, declines as men prepare to assume enhanced parental roles. Testosterone levels are lower among fathers than non-fathers (Grebbe et al 2019), decline over the course of pregnancy (Edelstein et al 2013), and further decrease among fathers who more actively provide infant care compared to men who provide little or no care (Grebe et al 2019), especially for the youngest infants (Gettler et al 2011).  The synchronous decline in paternal and partner’s testosterone levels during pregnancy is associated with greater post-partum relationship investment (Saxbe et al 2017). The internal regulation of testosterone levels presents a biologic conflict between men’s mating and men’s caretaking characteristics in the ~6% of animal species where men participate in parenting activities; paternal caretaking increases the Darwinian survival of their children. Other paternal hormones: estradiol (Edelstein et al 2013); oxytocin (Gordon et l 2010); and prolactin (Hashemian et al 2016) also increase in men over the course of pregnancy and early post-partum period; and all are associated with increased child care, nurturing behaviors and engagement in both men and women. 

The term “Dad Brain” has also gained prominence in the popular literature, perhaps inadvertently reflecting the new beginning exploration and documentation of the plasticity of men’s brain structure associated with parenting. There is growing evidence that fathers and mothers neurally process infant stimuli in similar manner (e.g. global parent caregiving neural network) (Abraham et al 2014). Paternal brain plasticity is associated with greater paternal caretaking involvement, especially in the social–cognitive pathway network (e.g. amygdala-superior temporal sulcus brain connectivity), which in part allows men to better infer infant mental states from their behavior (Abraham et al 2014). Fathers, like most mothers, can recognize and pick out their own infant’s crying, but only if they spend extensive time daily with them (Gutafsson et al 2013). Moreover, within the first four months postpartum, there are changes in the volume of gray matter in the regions of the paternal brain involved in motivation and decision-making (Kim et al 2013), further suggesting plasticity in father’s brain after becoming a parent.  Additionally, there is an extensive and growing animal literature showing paternal brain structure changes with active fatherhood, especially among prairie volves (Rollin and Hascaro 2017)

Paternal longevity– And finally and positively, fathers live longer than men without children, even controlling for marital status (Modig et al 2017; Grundy and Kravdal 2008; Keizer et al 2011), similar to that reported for mothers. The longevity impact of parenthood is stronger for men than women (e.g. 2.0 versus 1.5 years greater life expectancy gap at 60 years of age (Modig et al 2017)), and for 2 or 3 children versus none (Grundy and Kravdal 2008; Keizer et al 2011). When older, fatherhood could be a source of deep emotional satisfaction, as well as companionship and non-isolation. This longevity finding may perhaps also reflect a confounding of healthier men have children being played out over their life courses.

Father’s physical health is much more profoundly affected by early fatherhood than perhaps most of the existing popular and professional literature here-to-fore would likely have assumed. During the perinatal period and likely beyond, father’s minds and bodies, like the mother’s, adapt biologically to their new parenting roles – perhaps preparing them for the physical and mental stresses, joys and requirements of parenthood. The impact of fatherhood on men’s physical health reinforces the need to insure physically healthy fathers and to attend to their changing physical health needs during the perinatal period and beyond, encouraging both greater health promotion and utilization of paternal reproductive and primary health services. Basic research on this topic is just beginning, as interest in father’s health in the perinatal period is increasing.

• Impact of Fatherhood on Men’s Mental Health/Stress.

Pregnancy and the onset of parenthood is a time of substantial mental health transition for men – as it is for women/mothers (Singley and Edwards 2015). There is greater awareness and recognition of fatherhood’s impact on men’s mental health than on his physical health, perhaps due to the growing awareness of maternal perinatal depression on women’s health and the increasing calls to similarly address paternal mental health by the family sociology, clinical psychology and nurse-midwifery communities [REF]]. Men’s mental health responses to fatherhood are very salient during pregnancy and early parenthood – both as sources of stress and of growth and love. 

Pregnancy/parenthood, especially for first time fathers, is an unknown and unfamiliar event, out of men’s normal control (e.g. Baldwin et al 2018); a source of multiple potential perinatal stresses include changing relationship with the mother, added financial obligations, and concerns over ability to be a competent parent (Coleman & Karraker, 1998; Singley and Edwards 2015).  Moreover, given limitations in sex/parenting education in schools and in gender role experiences developmentally, most men have limited or no understanding about pregnancy biology, perinatal health services or practical parenting skills; and they often feel helpless and lack knowledge about what to expect or do as they enter into fatherhood. And postnatally, fathers/men must confront additional new concerns about the physical well-being of the mother and baby, breastfeeding and bonding, restrictions and frustrations of new fatherhood roles, and more work-family balance conflicts; plus sleep deprivation and childcare logistics. Moreover, men often lack of social/peer support (beyond their partner) to help them adjust to their new fatherhood roles. 

Men, especially first time fathers, are further challenged to creating a new internal fatherhood identity for themselves (Baldwin et al 2018); and there may be deeper conflicting fatherhood gender role identity expectations at play (Singley and Edwards, 2015). Many men today had been raised in an era of more traditional male gender roles and now are being confronted with expectations for greater engagement with their infants and more equity in caretaking, and perhaps even perceiving these roles as feminine or weak: a fatherhood generation gap. Overall, a potent brew of men’s mental health challenges in the perinatal period.

Paternal Stress, Anxiety and Depression: 

Given the formidable parental role transformations associated with fatherhood, not surprisingly, there are numerous reports of substantial elevated paternal stress associated with pregnancy and early parenthood. A review article by Philpott et al 2017 found 18 studies on paternal stress in the antenatal period, with XX% rates of elevated paternal stress reported. They report that paternal stress increases continuously throughout antenatal period, peaks at birth and then declines afterwards.  The principle factors identified that contribute to paternal stress included negative feelings about the pregnancy, role restrictions related to becoming a father, fear of childbirth, and feelings of incompetence related to infant care. Higher stress levels negatively impact father’s health and mental health, contributing to increased anxiety, depression, psychological distress and fatigue (Philpott et al 2017).

The MGH Obstetric Prenatal Fatherhood studies (Levy and Kotelchuck 2019) reinforce these observations antenatally; ~56% men endorsed the observation that pregnancy is associated with high levels of paternal stress; with concerns focused on financial issues (44%), ability to care for the baby (29%), less time for self (20%), changing relationship with mother (15%), and not repeating their father’s mistakes (14%). Further, 35% of men reported not having any place or person to go to for fatherhood support, which likely further added to their stress symptoms. 

Paternal Anxiety: Substantial clinical anxiety disorders are found among men during the perinatal period. A recent systematic review by Leach et al  (2016) reported the prevalence rates of anxiety disorders in men ranged between 4.1%–16.0% during the prenatal period and 2.4%–18.0% during the postnatal period. [As compared to a 13.0% rate in general population of men (McLean et al 2011)].  Anxiety disorders increase steadily throughout antenatal period and then decline after birth (Philpott et al 2019). Factors contributing to anxiety disorders included lower income levels, less co-parent support, fewer social supports, work-family conflict, partner’s anxiety and depression, and paternal anxiety history during a previous birth. Higher anxiety levels contribute to paternal stress, depression, fatigue and lower self-efficacy (Philpott et al 2019). The few clinical trials to reduce paternal anxiety, to date, have all been successful (Philpott et al 2019).

Paternal depression: There are numerous reports of elevated levels of depression associated with fatherhood. A meta-analysis of the prevalence of men’s depression in the perinatal period (Paulson and Bazemore 2010) showed higher rates of paternal depression (10.4%) than in similar aged men in the general population (4.8% over 12 month period) (Kessler et al 2003). Garfield et al 2014, using the ADD Health data, documented that new father’s were 1.68 times more likely to be depressed compared to comparable aged men without children, and that resident father’s depression symptoms increased from before pregnancy through the pregnancy and beyond.  

Paulson and Brazemore (2010) analysis documented substantial rates of paternal depression throughout the pregnancy; 11% in first and second trimester and 12% in third trimester; and then varied rates throughout the first year post-partum: 8% at 1-3 months, peaking at 26% at 3-6 months, and then 9% from 6-12 months. When stratified by country, paternal depression rates are higher in the US (14.1%) than in the rest of the developed world (perhaps associated with our lack of childcare support and paid parental leave in the US (Glass et al 2016)). Paternal depression is strongly correlated (r= ~.30) with maternal depression (Ramchanandi et al 2008; Paulson and Bazemore, 2010), though prevalence rates are consistently higher for mothers. In the MGH Obstetric Prenatal Fatherhood studies, 26% of the antenatal fatherhood sample endorsed at least one of the two PHQ-2 depression screener symptoms, with 8% reporting more severe/frequent symptoms (Levy and Kotelchuck 2019). A wide variety of risk factors have been linked to paternal depression: prior mental health/depression experiences, changing paternal hormones, lack of social supports, maternal depression, and poor relationship satisfaction (Singley and Edwards 2015; Gemayal et 2018). 

Paternal post-partum depression: Increasingly, there has been a heightened awareness that post-partum depression (PPD) is not restricted to only women, that men also experience PPD (Kim and Swain 2007; Ramchanandi et al 2008; Singley and Edwards 2015). Paternal PPD is increasingly recognized as a chronic condition, with the10% prevalence rate from the Paulson and Brazemore (2010) meta-analysis widely quoted.  Ramchanandani et al 2008, using the Avon Longitudinal study (ALSPAC) found the highest predictors of paternal PPD to be high prenatal anxiety, high prenatal depression, and a history of severe depression; findings consistent with a more recent meta-analysis (Gemayel et al 2018).  

Other paternal mental health disorders: Beyond depression, there is only a very thin literature on other men’s perinatal mood and anxiety disorders. Singley & Edwards (2015) posited rates of 0-4.7% for post-partum PTSD; 4.4-9.7% for post-partum anxiety disorders; 3.4% 3^rd trimester and 1.8% post-partum OCD rates; and they noted that among depressed fathers, 42% also experienced co-morbid manic episodes. It is hard to assess if these prevalence rates are primarily attributable to the new pregnancy, as comparable non-pregnancy data generally doesn’t exist.  

Behavioral and externalizing mental health impacts of fatherhood. The mental health consequences of fatherhood aren’t only manifested internally, but also through externalizing behaviors. Men often express their depression, stress or anxiety through “self-medicating” drinking, over-eating, interpersonal anger, or physical/residential absence. IPV, for example, is known to be markedly elevated after conception and again after delivery (Nannini et al 2011). Singley & Edwards (2015) note that many new fathers retreat to over-working at their employment (the traditional model of fathers as providers) to withdraw more from the family/infant involvement and associated stresses. Theoretically, many negative paternal perinatal health behaviors can be interpreted as mental health linked. In general, however, there is little or no systematic, population-based, longitudinal research on the changes in men’s mental health and health-related behaviors attributable to the pregnancy and post-partum period.

Positive mental health impacts of fatherhood. While fatherhood is a time of much emotional stress, it is also a time of deep joy, happiness, and satisfaction for most men. While most qualitative studies of men’s mental health during the perinatal period acknowledge positive emotional responses, few have explored them in detail. Baldwin et al’s (2018) systematic review concluded “Fathers who were involved with their child and bonded with them over time found the experience to be rewarding. Those who recognized the need for change, adjusted better to the new role, especially when they worked together with their partners.” Satisfaction resulted from achieving mastery, confidence and pleasure over the reality of dealing with a newborn, becoming a competent father, and doing it in a constructive way with one’s partner. [[The family planning literature also explores men’s happiness with the pregnancy conception as its core outcome measure]] Moreover, some men, like many women, improve their mental health-influenced health behaviors as they move into their new parental roles.  In the Fragile Families and Child Well Being Study, for example, among low-income urban fathers, fatherhood was associated with, more healthy behaviors and decreased substance use ⁽Garfield et al 2010).  In the subsequent section (1.5), the (positive) impact of fatherhood on men’s psychological development and generativity is further explored.

Perinatal/infant specific sources of paternal depression. The post-partum mental health impact of fatherhood has bi-directional roots; it can be and is influenced by the infant’s health and behavior characteristics, not just his own psychological responses to the pregnancy and new paternal and family roles.

Fatherhood and pregnancy loss: While there is a robust literature on the impact of fetal loss on mothers’ mental health, the equivalent literature for fathers is very limited; a summary review by Due et al (2017) identified only 29 articles on paternal responses to fetal loss versus 3868 articles on maternal responses. They concluded that fathers primarily feel the need to be supporters of their partners, and that they receive less recognition for their own responses to the loss, feeling overlooked and marginalized. Like the mothers, fathers experience a loss of parental identity and of parental hopes and dreams for their deceased infant, though less enduring levels of negative emotions. I am unaware of any informational brochures about fetal loss specifically directed towards fathers. 

Fatherhood and prematurity. Fathers of premature or LBW infants are more likely than mothers to experience post-partum depressive symptoms; this takes on added significance since paternal depression is also an independent predictor of subsequent child development (Cheng et al 2017). Interventions to address parental mental health needs (including depression) of infants in NICUs are increasing, but only some are directed at both parents (Garfield et al 2014). 

In sum, the perinatal period is a time of significant mental health transition for fathers, especially first time fathers, as they address the multiple new challenges of fatherhood. Fatherhood is associated with both substantially elevated levels of stress, anxiety and depression, as well as joy, pride and emotional maturation. Interest in men’s perinatal mental health derives heavily from the increasing appreciation of maternal depression and its impact on reproductive and child outcomes. Paternal mental health has been the main initial focus of interest in the exploration of the impact of fatherhood on men’s health.  Moreover, men’s perinatal mental health represents an important cultural crossover theme, necessarily dealing with such broad issues as contemporary masculinity, family gender roles, as well as the realities of parenthood. Only recently has there begun to be any even slight professional recognition of men’s own mental health needs in the perinatal period, and virtually no mental health services are directed at them. Fathers’ mental health, however, in turn, has a major impact on maternal reproductive and parenting heath and on infant health and development.  

The impact of fatherhood on men’s social well-being. The social impacts of fatherhood

Fatherhood doesn’t only influence men’s physical and mental health, but also his social well-being; that is, his social capacities and characteristics, as an employee, as a family and community member, and as an economic provider. Different professional communities have focused on different aspects of fatherhood’s impact on men’s social well-being.

Fathers as better and more stressed employees. 

There is a growing recognition within the business communities, especially their human resources professionals, that more family (and father) friendly workplaces are associated with higher productivity and profits than traditional work places [possibly through more motivated, loyal and skilled employees, with less staff turn over and burn out (Ladge 2019). [As women increasingly enter the paid labor force, family child caretaking /employment conflicts have gained greater salience, and in a more gender equity awareness era, their impact on fathers as employees is being examined more.] 

First, in general, parenthood, including fatherhood, is associated with positive contributions to their work/employment capacities. Father’s psychological development and maturity make them better employees; the skills of parenthood carry over into the work place – better self-managerial skills, enhanced time management, focus, patience, responsibility, and leadership (Ladge 2019). Fathers at work are perceived as more kind, compassionate and mature (Humbred et al 2015), and builders of social connections and bonds (Ladge 2019).  Among men with the similar skill levels and CV’s, fathers are more likely to be offered a position (Correl et al 2007). In some employment situations fatherhood is associated with a “fatherhood premium” (i.e., increased wages to be able to support their families) (Correl et al 2007).  

Second, fatherhood has the potential to add to men’s work-family stress. Fathers often experience added conflicts about the competing demands of work and family life [which may not have existed pre-fatherhood] (Baldwin 2018). In general, men increase work hours post-delivery, perhaps to meet in part the growing family economic needs (Budig 2014). Work challenges may heighten the conflicting internal/cultural views over nature of fatherhood; men sense of masculinity is closely linked to employment and occupational career (Neuman and Mennser, 2017). Younger men trying to achieve the new dual caring father/successful breadwinner fatherhood ideal feel more pressured by the conflicting roles (Harrington 201X). [NYT article] Involved fathers who work in family friendly environments have greater job satisfaction, less work-family conflict, and less likely to think about quitting their job, though they also may have weaker career identity (Ladge 2016). 

Third, paternal paid leave is an opportunity for men’s psychological and practical growth as fathers (i.e., paternal generativity).  Fathers who take 2 or more weeks of leave are more involved in direct childcare at 9 months (Nepomnyaschy and Waldfogel 2007). While the value of paternal leaves for their partner’s health and wealth has been studied (Rossin-Slater 2019; Bartel et al 2015), its benefits for the father are less well researched. Short or no paternal newborn leaves, in general, are associated with difficulties establishing sense of paternal identity, paternal confidence and competence in caregiving, and more work-family stress (Harrington et al 2014). 

Subsequent chapters in this book (e.g. Chapters X, Y, and Z) examine the challenges that working new fathers experience in trying to achieve a healthier work life balance, and the employment and social welfare practices and policies that could help reduce the social developmental burdens. 

Fathers as better family and community members assuming societal parental roles and responsibilities

Fatherhood, for most men, increases their sense family responsibility and commitment, and draws them into family life ever more tightly. Men, encouraged by cultural and religious norms, their own sense of paternal generativity, and governmental policy, generally adopted the social welfare expectations of fatherhood [no matter what their perspectives are on the nature of fatherhood] This topic is often presented from a negative father-absent family, deadbeat dads, perspective; but will be consider here from a more positive fatherhood social well-being prospective. [

The first social responsibility of men as fathers is the acknowledgement of his paternity. Historically, acknowledgement of paternity was related to infant legitimacy and inheritance, and was closely tied to the marital status of the father and mother. [Despite increases in births to unmarried parents (~40 % of US births, with substantially higher rates in younger, Black and Latinx populations (Birth 2018)), the vast majority of men embrace and acknowledge their paternity, and the rate appears to be increasing]. [In the US, for each birth to an unmarried mother, there is a legally mandated effort to establish an “Acknowledgement of Paternity” (AOP).] Almond and Rossin-Slater (2013) documented that over nearly 15 years in Michigan, rates of acknowledgement of paternity among unmarried mothers rose substantially, from 26% to 62%, and among all births lack of paternal acknowledgement declined from 25% to 15%, despite stabilized rates of unmarried birth (~35%). Birth outcomes (and maternal social characteristics) among unmarried but acknowledged paternity births were intermediate between births to married women and to women unmarried without paternity acknowledgement (Almond and Rossin-Slater 2013.) 

A second social welfare responsibility or social impact of fatherhood is the decision to reside with and support their families (financially and emotionally) during the perinatal period and beyond. The vast majority of men do accept this social responsibility, (though obviously a partnered decision); but over time the extent of their financially, emotionally and child engaged involvement does decline. In Great Britain in 2013, 15% of families are unmarried at birth, rising to 23% by one year of age. In the US, paternal involvement decreases as children age (REF/Census 2017); among fragile families with unmarried couples at birth, 50% are still living together at the child’s first birthday, and 63% are separated by the child’s fifth birthday (McLanahan, 20XX). Married marital status, per se, conveys social and developmental benefits for the father and his children (McLanahan 20XX), though it is increasingly a marker of higher social classes (Census 2017).  Men’s continued presence in the family can be viewed, in part, as a bi-directional impact of fatherhood on men’s social well-being –a behavioral response to stresses and joys of parenthood and his relationship with the child’s mother. 

  Even among non-residential fathers, fatherhood can serve as a source of engagement (social well being) for themselves and their children.  In the Fragile Families Study, the majority of non-resident fathers at one year of age saw their children, provided informal and in-kind support (McLanahan et al 2019), and fatherhood gave meaning to their lives (Garfield et al 2010). Both governmental and community-based fatherhood programs are trying to encourage more positive non-residential father emotional and financial involvement with their children (e.g., Yogman and Eppel, 2019). 

The impact of fatherhood on men’s social well-being, especially for poor and minority men, is heavily influenced by federal and state government social welfare policies that both encourage and discourage paternal involvement with their families –perhaps reflecting the ambivalence towards low income fathers who do not conform to the traditional roles of fatherhood, as well as their partners (mothers). Many US social benefits are structure to penalize or limit benefits (in housing, food, welfare) for single men and non-residential non-married fathers. Aggressive federal and state child support enforcement agency efforts, while perhaps enhancing mother’s income, often decrease father’s family involvement, especially for very poor men with limited education, skills, and employment opportunities, and past incarceration (Tollestrup 2018), by further burdening them with high child support interest rates, asset seizures and possible incarceration (Boggess et al 2014).  Older welfare and Medicaid eligibility regulations restricted support to mothers without residential male partners, which are still widely and incorrectly believed to be true today. The federal Healthy Marriage and Responsible Fatherhood Initiative is theoretically a more positive motivational and skill-based approach to engage fathers with their families {and perhaps also diminish government expenditures on poor families}, though its initial evaluations are quite mixed (Knox et al 2011);  [its limited programs may be insufficient to overcome the structural realities for poor men in the US]. Other countries provide more positive supports for the social welfare consequences of fatherhood – such as family allowances.  

Fatherhood increases/decreases men’s own social or economic welfare 

The impact of fatherhood on men’s own social and economic welfare, his lived SDOH, has only just begun to emerge as a topic in the MCH [reproductive health] community with its growing attention to SDOH and the father’s importance in its determination (Kotelchuck 2019). This topic, however, has historically drawn the attention of economists and social welfare policy analysts focused on gender pay equity and women’s employment/wages over her life course (e.g. Hodges and Budig 2014).

Fatherhood, in part, allows for the potential transformation in men’s own social and economic well-being. Fathers are eligible for societal benefits that favor families relative to single or married men without children; the latter are often restricted from (or last to receive) societal social welfare benefits, a positive discrimination in favor of fathers. There are specific father-targeted programs that non-fathers are not eligible for, such as paid paternity leave or family allowances. Tax benefits, in general, also favor families (and therefore fathers with children), such as child tax credits, child and dependent care tax credits and EITC (for employed families). Whether these benefits are merely compensation for the extra costs of child rearing or improve father’s lived SDOH can be debated, but they do increase father’s social and economic well being. 

Economists have documented a fatherhood pay bonus. In adjusted analyses, fathers earn 6% more salary than non-fathers (Hodges 2014). Moreover, the wage gaps between employed men and women increases substantially for parenthood; non-parent women earn 93% of non-parent men’s salary, whereas, mothers earn only 76% of father’s wages (Hodges 2014); plus further reinforcing social disparities, the wage gap is even greater for low-income fathers and mothers. This paternal pay bonus may be due in part to higher salaries for married men (who are perceived as better workers), an increase in men’s work hours to compensate for increased family financial needs, and a positive selection bias for father’s employment (Correll et al 2007). However, as noted previously, fatherhood can also limit or harm men’s social and financial status, especially for low income, non-residential fathers,

In sum, fatherhood impacts on men’s own social well-being – in employment, family commitment and social and economic resources. Fathers (relative to non-fathers) may socially benefit from their fatherhood status, though the evidence for the poorest fathers is less clear.  While health professionals have not explored this theme, as father’s health has not heretofore been an important focus, other business, social welfare/government policy, and economic professionals have focused on different aspects of this theme. The business community, in particular, has a critical role in shaping the family-related employment benefits and experiences of fatherhood. The impact of fatherhood on men’s social well-being may be culturally specific, and depend on the unique policies and practices within each country. The United States, in particular, has weak and often punitive social welfare policies that substantially impact on fathers, especially low income fathers. The reproductive health community must be cognizant of the changing social realities for new fathers and their families. 

Men’s Psychological Development/Growth of Paternal Generativity: Men’s Improved Capacity for Parenthood and Fatherhood

Fatherhood can be a major influence on men’s own adult psychological development and maturation, especially during his initial pregnancy experiences and early parenthood. This transformation represents one of most important health impacts of fatherhood. Virtually all men can biologically procreate children, but it takes more than just sperm to become a father. Having children is a powerful biologic urge that can profoundly affect men and women’s psychological maturation. Many fathers, similar to most mothers, go through substantial psychological transformations and growth during the perinatal period. Fatherhood can be viewed as an adult psychological developmental stage of life. 

In reviews of men’s psychological transition to fatherhood studies, Genesoni and Tallandini (2009) found pregnancy to be the most demanding period for the father’s psychological reorganization of self, and labor and birth to be the most emotional moments. Baldwin et al (2018) characterized some of the most salient features of the positive psychological transition into their new fatherhood identity: “Becoming a father gave men a new identity, which made them feel like they were fulfilling their role as men, with a recognition of changed priorities and responsibility and expanded vision; however they worried about being a good father and getting it right…. Fathers who were involved with their child and bonded with them over time found the experience to be rewarding. Those who recognized the need for change, adjusted better to the new role, especially when they worked together with their partners.” 

Beyond the predominantly qualitative literature, describing men’s psychological transition to fatherhood, this developmental concept is perhaps best noted in a series of movies and television shows that captures the profound paternal transformation of men as a result of parenthood (e.g., Kramer vs. Kramer; Mrs. Doubtfire; Three Men and a Baby; Marriage Story). This transition has been well documented in the popular media, in religious communities, and occasionally in the professional literature.

As fathers are increasingly attending their partner’s birth, there is a growing literature on its transformative effects on his psychological development (Johansson et al 2015).  His presence allows him to share the joy and miracle of birth, to be supportive of his partner, to be involved in the well-being of his new family, and possibly to demonstrate his assumption of greater paternal-maternal equity in childcare responsibilities. But his roles and responsibilities in the delivery room are often unclear, he may not know what is happening obstetrically or feel anxious and uncomfortable (Shibli-Kometiani and Maria 2012). The responsiveness of the delivery staff towards the accompanying fathers is quite mixed, and they are not always treated in a supportive way (e.g., “not patient, not visitor” (Steen et al 2012); [Pol and Koh 2014]). Yet for many men delivery is deeply emotional and psychological transformative moment (Genesoni and Talladini, 2009). And only now are efforts beginning to be undertaken to enhance father’s contributions and engagement during delivery to foster a more positive family-forming health event and to support his own psychological development as a father (Pol and Koh 2014; Johansson et al 2015). 

There are numerous different terms used to describe this developmental transformation in men from biological procreation to responsible fatherhood. For many, it is commonly and best discussed in terms of life fulfillment or even of religious or spiritual goals; e.g., “Fatherhood as the highest calling in life”.  I prefer to use the psychological term of “generativity”, to describe this transformation; it is a term coined by Dr. Erik Erikson (1973) and defined as  “establishing and guiding the next generation, with a capacity for love and sense of optimism about humanity”, (i.e. successfully nurturing the next generation). Hawkins and Dollohite (1997) and Hawkins et al (1997) have expanded on this concept and coined the term “generative fathering”, a perspective on fathering rooted in the ethical obligations for fathers to meet the needs of the next generation.  They conceptualize fathering as generative work rather than as a social role embedded in a changing socio-historical context from which both fathers and children benefit and grow. Singley and Edwards (2015) interpret the term generative fathering to describe the type of parenting used by fathers who respond readily and consistently to their child’s development needs over time, a key element of Erik Erikson’s adult development rooted in broadening the sense of self to include the next generation. The generative fathering perspective highlights a clear way that men can focus their instinct to protect and to provide their children in a strengths-based way – by being involved and responsive to their children’s needs even from their earliest (antenatal) age. Men themselves are the agents of their own psychological transformation.

This fatherhood psychological transition is not universal. Generative or responsible fathers don’t just happen but reflect a gradual transformative process; men can be helped along in this transformation.  [Beyond the previously noted federal Healthy Marriage and Responsible Fatherhood Initiative, which primary emphasizes men’s social roles in child development/engagement and family financial support and less his own psychological transformation and motivations,] Community-based, non-profit social service and welfare, advocacy and religious groups have taken the initiative to emphasize and develop men and fatherhood responsibility and generativity programs. These efforts have primarily emerged within the Black community’s parenting, men’s, and religious organizations (e.g. Concerned Black Men of America, Colorlines, etc.), backed up by national fatherhood resource and training organizations (e.g. The Fatherhood Project, the National Fatherhood Initiative, Mr. Dad, etc.). These non-governmental organizations, which are not restricted to the narrower federal political perspectives on family structure and marriage, try to emphasize the father’s own social and psychological health and development, and the need for his moral, spiritual, and psychological engagement with his children and family, as well as his financial support. These organizations explicitly counter the debilitating myths of Black men’s non-involvement with their children. 

The Healthy Start Initiative was the first and currently is the principal U.S. national MCH perinatal program to actively incorporate a positive mandate to address Fatherhood and Male Engagement (REF/HRSA HSI; Harris 2018). Its Dads Matter Initiative, with its Dads and Diamonds are Forever curriculum, and an annual Fatherhood Conference, emphasizes father’s “inclusion, involvement, investment and integration” across the life course, enhancing men’s sense of value to himself, his children, the mothers of his children and his community (i.e. generative fathering) (Harris 2018).  Several other MCH programs serving low income communities, such as MIECHV/home visiting, Head Start and WIC programs, also have begun to target and address father’s needs, though not as systematically as Healthy Start (Davidson et al 2018). 

Even for the most marginalized fathers, creating and nurturing life is perceived as one of the most meaningful statement about one’s presence on earth and contribution to life (Edin and Nelson 2013). In the Fragile Families and Child Well Being Study, fatherhood was associated with being present for their child’s future  (Garfield et al 2010).  From a parallel perspective, Roubinov et al (2015; 2017) describe “familism” in Latino (Chicano) communities as a father’s deep ethical and cultural commitment to nurturing their children and family, even if also deeply imbued with a “machismo” social roles perspective. And the Black women’s reproductive justice movements are now beginning to recognize the importance of economic and reproductive justice for their poor Black male partners as well {REF}.

The perinatal period for many men, as for women, is also a period of marked openness for behavioral, social and health changes (Mahalik et al 2003). Fatherhood imperatives can trump masculine stereotypes.  Mental health, relational, and fathering skills can be taught (MGH Obstetric Prenatal Fatherhood Project; Tollestrup 2018; Knox et al 2011). The transition from traditional fatherhood expectations to a more equitable childcare taking partnership may also free fathers from other gendered sex role stereotypes that harm their psychological capacities to experience and express emotions and health needs, and treat their partners more respectfully. Father’s developmental transitions during the perinatal period however are not generally recognized or appreciated by most reproductive and primary health care professionals (Pol and Kuh 2014), and they are not usually given the institutional support for their psychological development as generative fathers – a few fatherhood books and two week post-partum leave not withstanding.  Moreover, from a life-course perspective, the earlier the paternal involvement with the responsibilities and joys of parenthood, the stronger and longer lasting the subsequent child and family attachments (Redshaw and Henderson 2013) and the more positive his own adult psychological growth and development as a generative father. Much more research is needed to understand what facilitates the growth of men’s paternal generativity, and even how to measure it

Similar to women, men’s adult psychological developmental as a more generative parent is one of most important positive mental health impacts of pregnancy and early fatherhood, especially for the first time fathers. Paternal generativity doesn’t just happen. While the momentum for paternal generativity must ultimately come from and be empowered by each man himself, all MCH and father-involving programs must consciously engage with and support his developmental maturation.  Culturally and professionally, we must create the paternal expectations and opportunities, beyond the federal emphasis on his financial and marital responsibilities, to help men celebrate the joys and deep satisfactions of fatherhood. Most fathers make the successful adult psychological transition to generative parenting and are happy to have accomplished that transition. 

Men’s Life Course Development as Fathers. 

Generative responsible fathers don’t just happen, but reflect a gradual longitudinal developmental process that has its roots long prior to the pregnancy conception and continues long after the delivery; and it can be helped and hindered all along the way. Paternal generativity is both personal and intergenerational. The perinatal period, the focus of this essay, is one of its principle sensitive periods of accelerated growth. 

Drs. Kotelchuck and Lu (2018) in their publication on men and preconception health graphically highlight several key conceptual features about the growth of men’s paternal generativity over the life course. To quote from that article “First, as with women’s reproductive life course, it [this graph] encourages us to view men’s health and development longitudinally, recognizing that the impact of his health and generativity transcends the moment of pregnancy conception, and appreciate the intergenerational continuity and the bi-directionality of men’s health. Father’s reproductive health and generativity is not a fixed; each stage of life/health builds on both prior and current life/health experiences and evolves over the life course (Fine and Kotelchuck, 2010). This new MCH fatherhood life course graphic acknowledges that some men have more negative or positive life experiences (prior and currently); that the root causes of men’s reproductive health and paternal generativity reflects both the negative and positive social determinants influencing his health –including his adverse childhood and adolescent experiences, sexual health education and socialization, current and past poverty, employment, and environmental and occupational exposures, etc. The men’s/father’s MCH life course model thus reflects both a resiliency and a deficit perspective. One’s reproductive potential is not immutable. We can and must help build boy’s and men’s resiliency to achieve both the biology and paternal generativity of fatherhood, and thereby optimize both their own and their children’s health [and development]. The men’s reproductive health life course graphic also reminds us that there are multiple times and places to intervene to enhance (or diminish) men’s health and paternal generativity.”

And although this graph focuses on men’s individual generativity, efforts to encourage his shared responsibility for healthy parenthood and for equitable parental childcare and involvement must start earlier than conception with his shared responsibility for sexuality and family planning. Further, men’s development as generative fathers must also necessarily address his pre-fatherhood adolescent social and gender norms, perhaps beginning with parenting, sexuality and gender-role training programs in schools. The preconception time period for paternal generativity must be pushed backwards in developmental ontological time.

Additionally, men’s paternal generativity is not a simple linear age trend, but is embedded within our larger human biologic development. The roots of men’s intergenerational and epigenetic generativity starts before birth, and has at least two special sensitive periods of growth: puberty and the initial antenatal and early postnatal transition to fatherhood. The latter is perhaps the most sensitive transformational life course period for men’s psychosocial development and maturation as a father (Genesoni and Tallandini (2009)); it may perhaps also reflect a new paternal biological sensitive period due to his changing perinatal hormones and brain structure. The experiences and health consequences of fatherhood are then further filtered through and modified by the men’s pre-existing life course health that he bring into the pregnancy/perinatal period, similar to that of pregnant women. 

 The developmental roots of paternal generativity are not restricted only to the perinatal period but build off of men’s prior life course health and experiences. Paternal generativity can even be viewed as an intergenerational and epigenetic phenomenon, building off of prior generations and building towards future generations. The perinatal period is a critical sensitive period for paternal generativity transformation. The momentum for paternal generativity, for fatherhood, with all its benefits and stresses, must be empowered by each man himself; but it is embedded in the larger developmental world in which his reproductive potential grows and thrives or is stunted and unachieved. A fatherhood life course perspective allows us to see that there are multiple places and time points in which positive and negative experiences and interventions can help influence men’s paternal generativity.  Paternal generativity is not fixed, but malleable. Paternal generativity, the essence of fatherhood, is critical for the health and development of his infant, his family and himself; it is shaped over his life course. 

Discussion: The significance of this chapter 

Fatherhood profoundly impacts men’s health and development.  It impacts his physical, mental and social health, and his sense of paternal generativity, both immediately and over his life course. These, in turn, impact his infant’s, partner’s, and family’s health. Indeed, fatherhood can be viewed as a risk or resiliency factor for men’s subsequent health across his life course. The focus on men’s changing health as a consequence of fatherhood is an important new perspective for the MCH reproductive health field, which has historically focused on the mother and her health. 

This chapter on the impact of fatherhood on men’s health is one of a pair of inter-related chapters that parallel for fathers the dual approach of the current women’s preconception health framework, which simultaneously addresses the impact of the mother’s perinatal health both on the infant’s health outcomes and on the mother’s own subsequent lifetime health. Both topics are critical and intractably bound. Father’s health is similarly a bi-directional, intertwined and inter-generational topic.   

To date, there is only a very limited and scattered MCH perinatal fatherhood health literature, especially exploring the impacts of fatherhood on men’s health and development. [And despite a growing recognition that parent’s health is a key contributor for ensuring and optimizing infant and child health (NASEM, 2016, 2019); it’s bi-directional inverse, that infant and child health impact parent’s health, remains a relatively understudied subject, especially concerning fathers.] No broad, systematic effort, as far as I know, has explored this topic across the full range of its potential impacts. 

This chapter reflects an effort to create a new broad encompassing conceptual framework to understand and organize the multiple potential pathways by which fatherhood influences men’s health and development.  It moves beyond a generic overall assertion that fatherhood impacts men’s health to emphasize six distinct conceptual pathways -men’s pre-existing health, his perinatal changed physical, mental, and social health and development, his generativity, and his life-course experiences. The six specific pathways are written to try to isolate and better articulate them, but many of them likely overlap and are synergistic. Hopefully, these six pathways will provide a useful organizing framework to guide future research, practice and policy on father’s perinatal and life course health and development. A couple of themes merit further comment.

First, this essay, in particular, emphasized and explored the impact of fatherhood on men’s psychological maturation into more generative, healthy and engaged fathers, a much less well-articulated fatherhood topic, especially antenatally. The psychological development of men as fathers has not been a focus of professional MCH or prenatal health services – though a large popular ‘Advice for new Dads” literature exists, which may at times touch on this theme.  The psychological empowerment of fathers requires, in part, that our current health service systems (and the men themselves) overcome culturally derived, internalized sexist assumptions about men’s supposedly limited roles and needs during pregnancy and early childhood, and explicitly attend to their developmental needs. The concept of generativity, or generative fathering, adds an internal motivational and moral dimension to men’s ongoing psychological transformation in becoming fathers, a sense of paternal agency. 

Second, this essay also tries to illuminate the topic of the impact of fatherhood on men’s social health and well-being.  This pathway may be a difficult to appreciate for reproductive health clinicians, if they even focusing on the health of fathers, as it links more broadly to the larger SDOH roles of men in families; and that men’s SDOH/social well-being characteristics may partially transform with parenthood is yet another step removed from clinicians usual reproductive health concerns.  Yet social welfare policies for single-parent families, paternal work-family balance and father’s employment/incomes directly affect the health and mental health of mothers and children (and their fathers).  Moreover, these topics (and the achievement of gender equity across multiple domains of life) directly and necessarily link the clinical health professions to similar concerns and interventions in other business, social and government policy, and economics professions (all represented at this multi-professional Fatherhood conference). This essay represents an initial discussion about this important but still emerging paternal social well-being pathway.

Third, this chapter further builds upon the growing recognition that fathers are a key vector for the social well-being/SDOH of their families (Kotelchuck 2018). Beyond simply considering the father’s presence and economic contributions to the family as a direct fixed risk factor for reproductive and child health, his own social well-being/SDOH can further indirectly modulate the father’s own mental, physical, social and generative health, and therefore its impact on his family. In addition to the objective added financial burdens of parenthood, father’s historical life course SDOH experiences (childhood poverty, childhood ACES, etc.) may increase his initial physical and mental health vulnerabilities to the challenges of fatherhood; his current SDOH/social-well being realities (such as being poor) may further exacerbate his reactions to the new psychological stresses of parenthood; and his capacity to actively engage with his child (and perhaps challenge traditional gender roles expectations) may be undercut by inflexible employment work schedules and leave practices, especially among lower income fathers. And while paternal generativity is not principally determined by social class, but poverty does make it harder for some men. Fathers however do have some personal agency in determining their own and family’s social well-being, and often feel strongly about that responsibility; but ultimately, father’s social well-being is not simply a personal responsibility. His social class, race and employment are not fully paternal “reproductive health” choices, but primarily reflect the accident of his birth. The father’s historical and current SDOH/social well-being can diminish his positive health responses to fatherhood and limit his fullest and healthiest participation in the perinatal period and beyond.  

Fourth, the positive or negative impact of fatherhood on men’s physical, mental, social or generative health and development is not ordained, and often is both. This essay (reflecting the limited existing literature) predominantly noted negative paternal physical health and especially mental health/stress impacts of fatherhood. Where appropriate, those were balanced with more positive health experiences (e.g. mental health focus on joy, happiness and satisfaction; adult psychological maturation/generative fatherhood; enhanced employee characteristics; greater primary care motivations, etc.). The impact of fatherhood on men’s mental health, to date, is the most widely examined topic; and policies and programs to prevent or mitigate father absence are the most widespread targeted fatherhood interventions with federal/state governmental support. 

Fifth, this chapter documents that the impact of fatherhood on men’s health begins before delivery (i.e., the perinatal roots of men’s/father’s health); it strongly reinforces the initial chapter’s parallel efforts to push the time frame for the impact of men’s health on reproductive and infant health and development back into the antenatal period. This essay emphasizes not merely the perinatal impact of fatherhood on men’s health, but an even longer life course perspective on father’s health. The health of men and their paternal generative characteristics start early, long before conception; though like for women, the experiences during the perinatal and early parenthood period seem to be a biologically sensitive period of impact.  Moreover, the preconception health and social well-being that men bring into the pregnancy not only directly influences the mother’s and infant’s health, but also indirectly modulates the men’s fatherhood experiences and his health consequences. Fatherhood/paternal generativity must be conceptualized across the life course; fatherhood is not simply a sperm and post-partum parenting. A life course perspective additionally suggests that there are multiple places, timing and synergy for potential paternal interventions to enhance men’s/father’s health. 

Sixth, much of this essay’s discussion and the MCH research literature are written as if fathers are a relatively homogeneous group. This is clearly not true. Different subgroups of fathers may experience the health and developmental challenges of fatherhood differently, based on their own historical and current life course experiences, both personal and social – whether the groups of fathers are characterized by first time/experienced status, race/ethnicity, socio-economic status, disability status, planned/unplanned pregnancies, residential status, or any other unique fatherhood groupings (including teenage, incarcerated or military fathers).  The extensive documentation of the risk factors (often fatherhood sub-groups) associated with men’s mental health responses to fatherhood further demonstrates men’s heterogeneous experiences. In particular, some fatherhood advocates have emphasized the often negative and unintended consequences of public social welfare and clinical policies on low income and minority fathers, especially non-residential fathers; they have tried to counter the myths of Deadbeat Dads and encourage all fathers, irrespective of residency status, to actively engage in their children’s lives, for the children and themselves  (Yogman and Eppel, 2019; Garfield and Yogman 2017; Bond et al 2015). Future research, practice and policy papers examining the impact of fatherhood on men’s health should perhaps stratify their major findings by important fatherhood sub-groups.  

Seventh, this chapter [and the prior chapter] disputes the prevailing view that mothers and their health/well-being alone are principally responsible for positive reproductive and infant outcomes and that they are the only or primary ones affected by parenthood. If men assume, or are allowed, to participate in the joys and responsibilities of reproductive and infant care; they will become more generative fathers, and in turn could help free up women and men from overly prescribed gendered parental roles. This chapter, while a self-contained and innovative MCH theme, is also inspired by and hopefully contributes to the larger social gender equity movement; to the growing men’s health movement; and to the cultural efforts to rebalance the traditional maternal/paternal parental role expectations. 

Hopefully, this chapter and the prior chapter have demonstrated that a focus on father’s health should be a more formal and important perinatal health research, practice and policy topic. These chapters begin to open up a new positive empirical developmental science policy rationale to support greater and earlier paternal perinatal involvement: for enhanced reproductive and infant health and for men’s own health, based on an ever-stronger empirical and theoretical rationale. 

Clearly the core public health action message of this essay is that there should be greater paternal involvement in the perinatal period, in order to improve reproductive and infant health and development, and father’s own health and development. This essay should add to the momentum for more targeted and effective father-oriented perinatal health interventions and policies to enhance the impact of fatherhood on men’s health and development. Many of this Chapter’s themes call out for doable ameliorative actions and interventions. The fatherhood life course perspective suggests that there are many places and times to intervene to enhance father’s health throughout his life course. The six pathways presented in substantial detail in this Chapter[our current Scientific Knowledge Base] should provide a useful organizing framework.Without an over-arching framework to synthesize the growing fatherhood literature, it is ultimately difficult to develop effective targeted fatherhood interventions (Programmatic/Policy Social Strategies) or to create more effective and scientifically justified fatherhood advocacy efforts (Political Will) for their implementations (Richmond and Kotelchuck, 1984). To improve father’s health, I believe requires three inter-related and synergistic domains of interventions: paternal clinical health care; social welfare and employment policies; and men’s agency initiatives–but sadly, there is little professional recognition of men’s unique perinatal health needs – and even less health, social welfare or generativity/agency services directed at them.  [The three sets of inter-related intervention domains are discussed fully in the next section.]

Fatherhood is a life course developmental achievement. Fatherhood is not a singular point in the life course– but a profoundly human experience that occurs over time and across generations. The developmental trajectory of fatherhood starts long before conception and impacts him and his children and family throughout their lives, long after conception and inter-generationally.  

Men’s fatherhood health interventions/practices recommendations.

While this essay primarily focused on describing and organizing the current knowledge base about the impact of fatherhood on men’s health, many of its theme’s call out for ameliorative actions and interventions to address the added challenges of fatherhood on men’s health and hopefully ensure a more optimal healthy life course development of men (and enhanced paternal generativity) – which should also improve the health and development of his children and family. 

While the intent of this chapter was not to present a menu of the needed preventative or ameliorative interventions and policies to ensure greater healthy paternal involvement in the perinatal period [for himself and his children, family and community]; I do wish to briefly highlight three broad distinct sets of interventions needed to address the six [multi-sectorial] pathways identified in this Chapter: namely, paternal health care services reform; improved paternal social welfare and employment policy; and enhanced paternal sense of agency (or generativity) initiatives.  No single domain alone can influence fathers’ health and development; all sectors must be synergistically involved.

 MCH life course Paternal Reproductive Health Policy Triangle/Model

Optional, as visualized in the graph above, modeled on/derived from the MCH Life Course Reproductive Health Policy triangle discussed in (Kotelchuck and Lu 2017,) 

Health Service reforms;

Clinically addressing and enhancing men’s health before, during, after pregnancy and while parenting in early childhood is an obvious critical intervention pathway to respond to the [changing] health impacts of fatherhood, both prevention and treatment. Currently, however, reproductive health clinical services don’t generally address men’s perinatal health issues, nor do men’s primary health care health, address his new developmental health needs as a father. 

In the previous Chapter, four ways that existing clinical perinatal, primary care and mental health services could be enhanced were briefly discuss – both to improve men’s current perinatal physical and mental health status and to be aware of and begin to address the changes in men’s health and development due to his new fatherhood status and its associated experiences: 1) Reorient reproductive health services to be more father/family inclusive; 2) Expanded men’s (or family) health care during existing mother-focused reproductive and pediatric services; 3) Encourage more and more enhanced approaches to reproductive primary health care for men; and 4) Increased mental health care for men in the perinatal period.  These four health care interventions apply as importantly to address this Chapter’s health consequences of fatherhood as to the existing father’s health impacts on reproductive and infant health in the prior chapter. 

The longitudinal roots of men’s health and fatherhood generativity would suggest that preconception health care (both pediatric and adolescent health care) would be important loci for preventive clinical services and enhanced gender role guidance. The MCH life course perspective emphasizes the continuity and impact on men’s health across the perinatal time frame. 

Ultimately however, paternal health is only marginally impacted by the health/medical care sector; it is also more deeply influenced directly and indirectly by SDOH and employment policies directed at men – which are briefly discussed next and in other Chapters of this book.

Fatherhood Social Welfare and Employment (SDOH) Policy Recommendations:  

There are a wide range of social welfare and employment policies and practices that could positively modulate the impact of fatherhood on men’s health. This domain mostly reflects the traditional population-based [non-clinical/medical model] public health/social policy approaches to enhance the health and social welfare of men and their families. Specifically,

Social welfare/SDOH and employment policies could directly enhance the current financial status and social realities (SDOH) of poor and working class fathers; through 1) poverty reduction/income enhancement initiatives such as family/childhood allowances, higher minimum wages, enhanced jobs opportunities, and family tax benefits (EITC, child credits); 2) Enhanced family friendly employment practices/policies that reduce the inevitable work family balance stresses of parenthood, and enhance paternal availability for needed family engagement and bonding (paid family leave, flex time); 3) social welfare/public health policies that address the derivative consequences of poverty –environmental injustice, poorer housing, poorer access to nutritious foods, poor education quality and opportunities – and other broad community development initiatives; 4) social justice reforms, including criminal justice  and child support enforcement, that diminish the ability of low income fathers to be active, present and financially supportive of their families; and 5) health care/health insurance policies (especially in the US) that insure access to high quality clinical care and equitable distribution of needed health care resources (such as ACA/Obamacare; Medicaid). Unfortunately, given our highly partisan political divide in the US today, most national social welfare and economic policies will be contested.

A second set of social welfare/SDOH and employment policies could attempt to mitigate the historical life-course social realities (SDOH) of currently poor and working class children; and therefore change the [subsequent] pre-existing health and mental health characteristics that they will bring to their future fatherhood experiences and that will modulates their adaptive or maladaptive responses to fatherhood’s health challenges. Most of the prior adult –oriented social policy initiatives would apply equally well to the current generation of children. For example: 1) family income policy enhancements would additionally need to address the unjust/unequal socio-economic and racism-based eligibility criteria (for mothers and fathers) that too often fosters childhood poverty and ACES; or 5) health care policy issues would also have to particularly address improved access to child and adolescent pediatric health care (including mental and behavioral health care); or new 6) educational reform policies that would increase access to Pre-K education, quality schools and higher education, influencing future employment/career opportunities, as well as increase access to more scientific sexuality and gender education and contraceptive availability]. The impact of these proposed social welfare (and educational) policies will only have positive influences on children’s (and especially boys for this essay) early life health and well-being, who will grow into the next generation of fathers

Social welfare and employment policies are (directly and indirectly) important to fatherhood health, though they are not usually characterized as (paternal) perinatal public health programs – but should be.  (See later chapters for more detailed discussion of social and employment practices that influence more adaptive fatherhood experiences)

Paternal sense of health agency. 

Beyond health services and social/employment policy interventions, the father’s own volition, his agency, his sense of responsibility can play an important role in modulating how fatherhood impacts on men’s health and development. Interventions in this third domain empower men during the perinatal period to be able to assume greater direct responsibility for their child’s, family’s and own health, and to more effectively handle the new health challenges that arise from fatherhood.  That is, to help fathers consciously effectuate their own initiatives and activities to enhance reproductive and infant outcomes and to enhance their own fatherhood health. This domain also encourages fathers to address their own psychological limitations as fathers, such as internalized sexism or internalized male marginality, and to struggle against traditional male/female parental role identity expectations, both of which limit father’s engagement with their children. This domain’s core concept is most closely related to the development of a sense of paternal generativity.

Programmatically, this domain covers a wide range of interventions, an effort to move beyond the traditional medical model vs. public health approaches to addressing health outcomes. They roughly fall in four broad groupings.

1) Interventions to enhance father’s knowledge and skills to deal with his newborn/infant (an increased sense of parental efficacy) – such as perinatal knowledge and skills training; fatherhood information provision; childbirth education classes.

2) Interventions to enhance men’s capacity to address his own sense of fatherhood – such as family planning; male sexuality and sex-role parenting education; and relational skills training; fatherhood support groups

3) Interventions to provide fathers with the tools needed to handle and advance SDOH/social well-being of his family — such as job training; financial empowerment programs; executive functioning training 

And 4) Interventions to help father’s directly address and enhance his own paternal health and well-being – such as internalized health promotion/disease prevention capacities; yoga, stress-reduction activities, smoking cessation; resiliency coaching. 

And fathers needn’t be alone in addressing these systemic barriers and promoters of perinatal and fatherhood health [healthy fatherhood] Community-based fatherhood programs and support groups are a powerful means to enhance men’s sense of agency or develop paternal generativity (such as Healthy Start fatherhood programs, Black fatherhood empowerment groups, or self-help groups). The sum of individual agency is collective or community agency, the empowerment to demand political (policy and programmatic) actions to address the men’s/father’s needs (e.g. Teitler 2001). 

These agency enhancing efforts encompass having the internal psychological skills and external political/cultural supports and skills to be able to respond positively to the health and developmental opportunities and challenges of fatherhood, and to successfully mature into a healthy, competent and engaged father. At the heart of this domain is an enhanced sense of his paternal generativity, a transformation of his consciousness as a responsible, loving parent.

Summary/Conclusion: 

Fatherhood directly and substantially impacts men’s physical, mental and social health, and his sense of paternal generativity, which in turn impacts his infant’s, partner’s, and family’s health, both currently and intergenerationally. The systematic exploration of men’s changing health as a consequence of fatherhood is a new focus for the MCH field; though it does parallel a similar evolution in the women’s preconception health field, which focuses both on the mother’s health as a predictor of pregnancy outcomes and now as a consequence of the pregnancy. This Chapter pulls together a here-to-fore scattered fatherhood literature and articulates 6 broad pathways through which fatherhood could potentially positively or negatively impact men’s health and development – [men’s pre-existing health, his perinatal changed physical, mental, and social health, his generativity, and his life-course experiences]. This emerging conceptual framework encompasses the father’s entire life course, but focuses here especially on the perinatal time period, a time frame not usually thought of as impacting on men’s health. Father’s health is bi-directional and intergenerational, synergistically intertwined with reproductive and infant health. Hopefully, this essay provides a firmer scientific knowledge base and rationale to encourage and support new, targeted fatherhood perinatal health programs, policies and research [that encourage men’s early and continuing involvement in the perinatal period].  The goals of enhanced father’s health, like for women’s preconception health, should be to both improve reproductive and infant health outcomes, and also to improve men’s own health across the life course. Together, these should lead to a healthier, more engaged fatherhood for men and for their families and communities. 

These aspirations will require a major cultural shift – and this Conference is part of that shift – with necessary changes in health care systems, social policies and employment practices, and society’s/men’s own conceptions of their paternal roles (agency/generativity). This Fatherhood Conference begins to provide some of the emerging science-based evidence and to generate political will (and coordination of cross-sector policy) to ensure the success of enhanced fatherhood efforts. And we can do something about it –Healthy men/fathers help insures healthy children, healthy families, healthy workforce and healthy communities.

The post The Impact of Fatherhood on Men’s Health and Development appeared first on The Fatherhood Project.

Science tells us that serve and return interactions are essential to the development of brain architecture. When adults interact with children in a caring, responsive way, they help build and reinforce neural connections in a child’s brain that support the development of important cognitive, social, and language skills. If an adult’s responses are consistently unreliable, inappropriate, or simply absent, children may experience disruptions to their physical, mental, and emotional health.
http://developingchild.harvard.edu/resources/serve-return-interaction-shapes-brain-circuitry

The emphasis of our viewing, I informed them, was to pay close attention to the positive interaction, the back and forth, the serve and return, between the dad and his daughter. Specifically, I asked them to watch for what she served and how he returned it. The overall emphasis in this session was the importance of paying attention, focusing and being present for your children so you can see what they serve and respond accordingly. By pointing out the positive micro-interactions in the video, the aim was to strengthen all of the dads’ understanding of interactions with their children.

Watch the video and see how you do describing the ways this dad is attuned to what his daughter is “serving” him. Our thoughts are below.

SUMMARY POINTS:

The following is a combination of points made by the group of dads, the two group leaders, (Lindsay Dibona, LICSW and myself) and Dr. Ray Levy after viewing the video:

• The play occurs in the context of a loving and empathic relationship, which seems primary to this father at all times. Dad is gentle which matches his daughter’s style, approach, affect – she’s a gentle girl feeling her way. He matches–soft, facilitating, no quick actions, no raised voice– and allows her to find her way and express herself.

• Dad is on the floor, the site of her play, very physically present (non-verbal body language)

• She points, he responds by looking to where she’s pointing

• Dad recognized when she served uncertainty and the need for help, and he returned with approval, giving her confidence and a willingness to take her own risks and move forward

• Dad seems to understand she wants all the figures on the truck and doesn’t fuss with the two she has lying down–he allows her fantasy without adult interference.

• Dad follows her lead in playing with the figures & truck by asking her questions, engaging in dialogue (verbal serve and return)

• She tries some things and looks to him for approval and he returns nodding, smiling, affirming verbal responses

• Dad actually increases the complexity of the interaction by pushing the truck (serving) and she responds, or plays along, which encourages her to take initiative, think creatively, and return his serve. His move actually keeps things from getting boring, keeps the interaction going.

Research on parent/child emotional connection and the development of complex brain circuitry teaches us that a parent’s capacity to understand and match, a child’s serve–her affect and approach to play– builds the neural circuitry and leads to the development of important cognitive, social and language skills.

We hope you can use this video demonstration and brief discussion for the benefit of your child’s growth.

The post Dads and Kids Connect: The Serious Business of Play appeared first on The Fatherhood Project.

FOR IMMEDIATE RELEASE: May 16, 2017

Contact Name: Raymond Levy, PsyD                       
The Fatherhood Project at MGH
(781) 248-5505
rlevy2@mgh.harvard.edu

Teaming Up For Dads in Recovery

Three Massachusetts programs are collaborating to reconnect fathers recovering from addiction with their children.

Lowell, MA: The Fatherhood Project at MGH has teamed up with Billy Cabrera of The Resource & Reclamation Center and the Child Support Enforcement Division of the Massachusetts Department of Revenue (DOR)* to offer an innovative program to fathers in substance use recovery in the greater Lowell area. Cabrera, a former heroin addict who spent time in prison, now dedicates his time to helping men reclaim their lives from the clutches of addiction and incarceration. He has built a safe haven and sense of community for these men at his business, Billy’s Barber Shop, where The Resource & Reclamation Center operates. The Fatherhood Project (TFP) has partnered with him to offer their innovative Dads in Recovery program there, which provides fathers recovering from addiction a chance to reconnect with their children and parent effectively, leading to a powerful reason to remain sober. DOR is allocating a portion of the federal Access and Visitation grant to fund this initiative.

“Research shows that addiction driven behaviors damage family relationships, leaving fathers with a negative or limited relationship with their children, uncertainty about their role in the family and a powerful sense of guilt and shame,” says TFP Executive Director Raymond Levy. “Disengagement negatively impacts a father’s mental health and his children’s ability to reach positive behavioral, emotional and academic outcomes, fueling a multi-generational cycle of parental abandonment and substance abuse.”

Led by TFP Director of Programs John Badalament, Dads in Recovery is an evidence-based program that provides fathers recovering from addiction with psycho-educational counseling that supports their recovery, and helps them to:

• Establish or repair their relationship with their children
• Parent with increased skills, confidence and competence
• Understand aspects of child development

“I got to see my kids for the first time in six months.”

Louis, a participant of the program felt its impact immediately. “We did this activity, Your Fatherhood Legacy, and I had almost a physical reaction. I realized that I could leave a different legacy for my kids. We also used role-playing to practice talking to our co-parents. Using those lessons, I had a successful probate court appearance with my ex-wife to discuss my visitation rights and was able to focus on the best interest of our children. Because of that I got to see my kids for the first time in six months.”

Cabrera, a well-known and respected presence in Lowell, recruits fathers for the program from his relationships with local recovery homes, and does follow up work with group members.

The Fatherhood Project is a non-profit program at Massachusetts General Hospital. Their mission is to improve the health and well-being of children and families by empowering fathers to be knowledgeable, active, and emotionally engaged with their children.

*DOR is the single state agency in the Commonwealth responsible for the administration of the child support enforcement program. DOR provides services to individuals and families, whether or not they receive public assistance, to establish paternity and to establish, enforce, and modify child support orders. DOR also provides child support information and assistance to individuals through its partnerships, with veterans, re-entry and fatherhood programs, as well with correctional facilities.

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Join The Fatherhood Project on June 16th at 6:30pm at Bemis Hall in Lincoln for free food and drinks, live music, and a celebration of fathers’ impact on all our lives.

The evening will feature our guest speaker, Andre Dubus III, author of Townie, The Garden of Last Days, and House of Sand and Fog.

Register for A Celebration of Fatherhood

Reserve your seat now!

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This post first appeared on the U.S. News & World Report Parenting Blog.

The post Fathers: We Must Learn From Our Children appeared first on The Fatherhood Project.

06/08/17 Fathers as Caretakers
Whether by choice or necessity, many modern dads do more to nurture their kids than their fathers did.

04/12/17 Beyond Heroes or Villains: Looking Back at Your Father’s Legacy
Pen your thoughts about your father to help clarify what you want for your kids.

03/31/17 Practice Positive Discipline to Help Kids Learn From Their Mistakes
Defying parents is part of growing up, so take advantage of these teachable moments.

02/23/17 Creating Your ‘Dad’s Vision Statement’
Why – and how – you should put into writing what kind of father you want to be for your kids.

02/06/17 The Serious Business of Play
How having fun with your child can help with brain development.

01/23/17 Fathers: We Must Learn From Our Children
By paying careful attention to who our kids are, we can help them realize their dreams.

The post U.S. News and World Report Partnership appeared first on The Fatherhood Project.

Our mission is to improve the well-being of children by empowering fathers to be knowledgeable, active, and emotionally engaged with their children.

The Fatherhood Project is making a difference in families’ lives. Below, Rachid and his wife discuss how our Dads Matter program changed Rachid’s relationship with their two-year-old son.

Here, a man from our Dads in Recovery program shares the overwhelming impact the program had on him as a father.

In order to continue empowering families, we need your help! We’ve been given a challenge to raise $40,000 by January 1st. When we reach our goal of $40,000 it will be matched 100%!

TFP is active in schools, pediatric and obstetric settings, inner-city neighborhoods, and now in substance use treatment centers and with divorcing dads. We just completed the largest study of fathers in prenatal care in the U.S., and we continue to be asked to present around the country: Richmond, Washington DC, Tulsa, Denver, and Chicago this year alone.

Please donate today. The Fatherhood Project and the children and families we serve greatly appreciate your generosity.

The post Dads Make a Difference appeared first on The Fatherhood Project.

Despite research demonstrating the importance of fathers for children’s social, academic, and emotional development, teen dads remain an underserved population. Most programs dedicated to low-income families and teen pregnancy focus on mothers rather than fathers. Research shows that 25% of teen dads want to be an active part of their children’s lives (B.A. Laris, MPH, personal communication, October 2016), but there are many barriers that can make involved fatherhood difficult for these young men, including financial restraints, the relationship with the baby’s mother, and a lack of parenting skills. In an effort to reach this at-risk population — often referred to as ‘the forgotten partner in teen pregnancies’ — TFP’s Teen Dads Program provides expecting and parenting teen fathers with support, fathering skills and resources.

For most teenage boys, this sporty duffle bag would be filled with a uniform, dirty socks, some notebooks…anything but what you see: diapers, wipes, a copy of Good Night Moon and other board books. A version of this Dads Kit is given to each of the young men attending The Fatherhood Project’s Teen Dads Program, along with tools and exercises to help them understand that an essential aspect of parenting is taking responsibility and being knowledgeable about their children every day.

“The Fatherhood Project provided a great service to the young men at our school who are fathering. Our young dads were able to recognize how important they are in their children’s lives and to think about what kind of dad they want to be. TFP’s program is a great resource for our students.”

– Lauren Bard, CIS Site Coordinator at Boston English High School”

Many of these young dads feel alienated and experience a lot of judgment from their family and from their friends at school. Our co-facilitated group model provides them with a safe, educational and positive place to be with others going through similar experiences, as well as to learn important relationship skills.

The content of the group meetings is based on the stories young fathers share about their everyday lives — the challenges they face, the strengths and resources they draw upon — interspersed with:

• Fathering skill-building activities
• Usable knowledge about child development (including the latest in brain science)
• Co-parenting information
• Practical parenting tips
• Thematic ‘virtual visits’ from guests brought in via video

TFP has applied for a grant in collaboration with Fathers Uplift in order to run eight sessions of our Teen Dads Program. We look forward to partnering with Fathers Uplift Founding Director, Charles Daniels, to bring this necessary program to more young fathers in the Boston area.

“I have learned how to be a better father and to better communicate with my significant other. Hearing that other guys have the same issues as we do really helps.” 

-Corey, Teen Dads Program, Healthy Families at Catholic Charities of Merrimack Valley in Haverhill, MA 

TFP’s Teen Dads program uses a co-facilitated group model and provides these young men with a safe, educational, and positive place to learn to be a father while being with others going through similar experiences. Their children benefit from the fathers’ confidence and competence which promotes more emotional engagement. For more information contact us at connect@thefatherhoodproject.org.

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