Discussion
According to fathers and other family members, the factors that influence uptake of PNC are wide ranging and multifaceted. Our four key findings highlighting resources and access, adaptation to fatherhood, sociocultural beliefs and experiences of care, reflect a variety of practical, personal, societal and health system considerations that impact on PNC engagement by fathers and family members.
Our finding relating to resources and access highlights a persistent issue in maternity care engagement12 28 and, in this instance, a key consideration for fathers and family members in low-income settings where inadequate or expensive transport options limited PNC engagement. While previous reviews exploring barriers to maternity care access highlight poor infrastructure and transportation costs, the focus invariably falls onto antenatal and intrapartum care with little attention paid to PNC engagement.31 Similarly, demand-side initiatives including cash initiatives/subsidies and community engagement tend to prioritise antenatal and intrapartum care at the expense of PNC.32 While the rationale for these approaches is quite rightly framed around the desire to reduce maternal and neonatal mortality and morbidity, the emphasis on these aspects of maternity care may undermine the relevance and significance of PNC for fathers, family members and women.
Our finding around the influence of sociocultural practices contains insights that support the notion of PNC as an underused and/or overlooked aspect of maternity care, particularly in LMICs. It is, therefore, important that resources and interventions aimed at increasing women’s uptake of ANC or facility-based childbirth by targeting influential family members also focus on PNC utilisation. While interventions like the Birth Preparedness and Complication Readiness programme33 may lead to more facility-based births and subsequent facility-based PNC34 35 new interventions focusing specifically on increasing PNC utilisation are needed, especially in settings and communities where influential family members act as gatekeepers. Interventions may be particularly useful in settings where family members advocate an adherence to potentially harmful postnatal care practices or do not recognise the benefits of formal postnatal services. However, efforts to increase PNC utilisation through community-based education programmes aimed at fathers or couples in LMICs have had limited success.21 36 Some authors argue that ‘gender-transformative’ approaches, that is, using interventions that ‘actively examine and promote the transformation of harmful gender norms and seek to reduce inequalities between men and women to achieve desired outcomes’37 are more likely to be effective.38 39 Our finding related to ‘perceptions of masculinity’ suggests that, in some settings, younger generations of fathers may be open to these insights. Studies incorporating gender transformative approaches have been largely limited to reproductive healthcare, domestic violence and HIV transmission contexts39 although the gender transformative approach forms a key component of ‘The Fathers Club Manual’ a MenCare sponsored multicountry initiative aimed at engaging men in maternal, newborn and child health.40
From a supply-side perspective, our findings highlight the importance of home visits, particularly in HIC settings, as an opportunity for fathers and family members to become more involved in PNC and to have their own queries and concerns addressed. These findings resonate with evidence from other studies, which suggest that fathers feel more comfortable discussing their concerns with health professionals in their own homes and are better able to develop a father–infant bond under these circumstances.41 42 The recently published WHO recommendations on maternal and newborn care for a positive postnatal experience support this view and recommend home visits during the postnatal period across all care settings.3
Our key finding relating to ‘adaptation to fatherhood’ contains some unique insights into PNC utilisation from the perspective of fathers. In a variety of different settings, fathers expressed a willingness to become involved in PNC activities but often cited a lack of support in this regard. At a societal level, there are ongoing legal, ethical and cultural discussions about the nature, duration and benefits of paternity leave, but it is apparent that restrictive policies inevitably curtail PNC engagement by fathers. Social policies offering fathers extended periods of parental leave during the postnatal phase have proved successful in some Scandinavian contexts.43 44 However, in other settings, where extended/shared leave schemes are available, evidence suggests that prevailing attitudes towards gender roles, financial concerns and workplace culture can limit fathers’ engagement with PNC services (and mother and infant support) even when legal allowances are in place.45 46
With regards to our finding relating to experiences of care, we highlight a variety of paternal responsibilities and associated concerns (psychological, emotional and financial) that often go unacknowledged by healthcare providers. Fathers may feel obliged to adopt a supportive role, supressing or sacrificing their own emotional and psychological needs in favour of women’s and baby’s’ well-being. In this regard, our findings support a small but growing body of evidence highlighting an unmet requirement for more psychosocial support for fathers during the postnatal period.47 48 This may include targeted mental health support for fathers or partners who may be struggling with specific postnatal conditions like depression, post-traumatic stress disorder or anxiety49 or referral to fathers’ support groups or networks for fathers who may need additional social support or peer-to-peer connection.50
Along similar lines, our finding around inclusion/exclusion resonates with other studies in this area51 52 and suggests that more effort is required to actively engage with men during the postpartum period. This may be challenging in certain contexts particularly where heavy workloads and overcrowding impact on provider capacity to involve men or where lack of training on men’s needs and concerns or negative stereotypes of fathers inhibit provider engagement.41 Health professionals should be aware that although there appears to be a certain amount of ambivalence about how fathers perceive their role in terms of acting as support for mother and baby and being seen as a parent and individual with their own expectations and needs, acknowledgement of the latter is likely to lead to greater levels of satisfaction and an increased desire to engage with PNC services. Approaches using new technologies like mobile phone apps and online training may satisfy education and access needs in certain contexts, especially in remote communities where access to services may be challenging. Initial findings from several studies exploring digital health interventions and online forums with parents (or fathers only) during the postnatal period indicate that these platforms offer flexible contact opportunities and may be useful in facilitating PNC engagement by women and their families.53–56
These key findings closely resemble the themes identified by women in the primary review22 where access and availability; physical and human resources; external influences; social norms and experience of care were important influences on PNC uptake. Similarly, specific findings from this review relating to the need for information, reassurance and continuity as well as a desire to be cared for by respectful, empathic and compassionate staff are reflected in previous qualitative syntheses exploring women’s expectations and experiences of antenatal,12 27 intrapartum28 and postnatal care.57
Strengths and limitations
While our review is framed around fathers and other family members, 29 of our 30 studies incorporated the views of fathers with more limited information coming from other family members, so our findings are heavily weighted towards fathers’ perceptions. Many of our included studies explored the views of fathers and other family members together, but only one study58 explicitly examined the views of other family members (grandmothers) and the scope of this study was across the maternity continuum rather than during the postnatal period specifically. This may limit our findings as the unique views of other family members may provide additional insights in contexts where influential family elders determine access to maternity care. Similarly, although our review identified two studies where same sex coparents (mothers) were included in the data collection phase, the views of the non-birthing partner were subsumed into the author-generated themes representing the wider body of participants (largely fathers), with little or no consideration of their differing circumstances or views. Additional research with these populations is likely to further enhance understanding of their own engagement with PNC and their influence on access by women.
In addition, some of our findings highlight issues and concerns that appear to be relevant to fathers, partners and other family members in certain contexts, for example, our subthemes relating to ‘flexible contact opportunities’, ‘the importance of home visits’, ‘need for reassurance’ and ‘continuity of care’ feature in HICs only, while ‘poor transport networks’, ‘influence of decision maker’, ‘perceptions of masculinity’, ‘lack of awareness about the benefits of PNC’ and ‘the influence of socio-cultural norms and practices’, relate primarily to LMICs. While we acknowledge that there may be context-specific issues, we are bound by the content of the included articles and recognise that different questions may have been posed to participants in different contexts, depending on the nature of the research inquiry and the pre-existing beliefs of the research team members.
One of the strengths of our review is the incorporation of a wide range of studies from different contexts around the world, including a mix of studies from high, middle and low-income settings. The data from the studies are relatively current, with all of the included articles being published within the last 20 years and over half published since 2015. We identified a very limited number of studies from Oceania and South America and information from fathers and family members in these regions is likely to add to the richness of the data and potentially contribute further insights beyond the findings from this review.
Our review offers some original insights into the perceptions of fathers and other family members regarding access to PNC services. They highlight a number of factors that could enhance engagement. Central to these findings is the need for a more inclusive service, which places the woman and baby at the heart of care but recognises and supports the significant role played by the wider family, particularly the father, during the postnatal period. Across a wide range of settings and contexts, PNC engagement is likely to be enhanced by a high-quality service offering inclusive, flexible contact opportunities with kind, respectful healthcare providers who appreciate and support infant well-being as well as the practical, informational and psychosocial needs of the entire family.