Table 3

Review findings and CERQual assessments

ThemeSubthemeSupporting quoteContributing papersCERQual grade
Resources and accessImportance of home visits: Fathers from studies largely conducted in HICs highlighted the importance of regular home visits by health providers, both for themselves and for their partner. Some fathers felt that these visits were particularly important following early discharge home and a few felt that more frequent and/or longer home visits (> once per week) would be beneficial. Fathers also felt that home visits should be flexible, unhurried, and responsive to parental needs rather than standardised, provider-led appointments.‘Then I thought it was good to have a home visit from the well children’s clinic. They came home and checked things. It felt very good. I could almost wish that there were more of those check-ups’. (Father), Persson, 2012, (Sweden)6 Studies: Al Taranweh, 2019 (Jordan); Fredriksson, 2003 (Sweden); Hunter, 2004 (UK); Kurth, 2016 (Switzerland); Persson, 2002 (Sweden); Persson, 2012 (Sweden)Moderate
Flexible contact opportunities: Fathers and co-mothers in studies from several HICs indicated that more flexible contact arrangements with healthcare providers had/would have a positive impact on their own engagement with PNC services. First-time fathers in particular felt that a 24-hour service or a dedicated hotline would be beneficial and emphasised the importance of being able to speak to a health provider at night.‘In the beginning it is good if one has somebody 24-hours a day, something like a telephone hotline, a central office.’ (Father), Kurth, 2016 (Switzerland).

‘My understanding is that you should try to have this kind of daily contact even if there isn’t anything special that’s happening. I don’t think we had any special questions, just the feeling of security if we did have a question’. (Father), Fredriksson, 2003, (Sweden).
5 Studies: Barimani, 2015 (Sweden); Fredriksson, 2003 (Sweden); Hunter, 2004 (UK); Kurth, 2016 (Switzerland); Persson, 2002 (Sweden)Moderate
Facility environment: Fathers and family members in several settings highlighted facility based organisational and environmental issues that impacted on their engagement with postnatal care. These included a lack of staff at the health facility which occasionally raised safety concerns as well as long waiting times at visits. A few family members also discussed the importance of the facility environment in terms of cleanliness and/or privacy while others highlighted the disruptive nature of hospital routines (ward rounds, visiting hours, alarms going off) as a factor in their desire to leave the ward early. In one setting the perceived poor quality of publicly funded health facilities prompted parents to seek expensive private care.‘It’s not a very nurturing look. If the environment was more welcoming then it soothes you. This is our house for these 3 days’. (Father), Gaboury, 2017, (Canada).

‘Women in the village inform each other about the waiting time to receive the service after birth and discourage themselves from receiving the service’ (Mother-in-law), Tesfaye, 2019, (Ethiopia)
7 Studies: de Montigny, 2004 (Canada); Fredriksson, 2003 (Sweden); Gaboury, 2017 (Canada); Memon, 2015 (Pakistan); Persson, 2012 (Sweden); Solberg, 2018 (Norway); Tesfaye, 2019 (Ethiopia).Low
Poor transport networks: Fathers and mothers-in-law from studies in isolated LMIC settings highlighted distance from a health facility and concerns with the road networks, topography and associated transport difficulties as potential barriers to PNC access for women and for themselves.‘Since Bajaj [tricycle vehicle] and ambulances can’t enter the village because of the difficult road for vehicles, it would be good if the roads connecting the village to the main road are constructed…’ (Mother-in-law), Tesfaye, 2019, (Ethiopia)5 Studies: Amare, 2018 (Ethiopia); Memon, 2015 (Pakistan); Newbrander, 2013 (Afghanistan); Tesfaye, 2019 (Ethiopia); Zamawe, 2015 (Malawi)Low
Adapting to fatherhoodImportance of fathers’ psychosocial needs: Fathers in a variety of different settings reported difficulties in coping with the postnatal period. Fathers experienced feelings of exhaustion, loneliness, insecurity, anxiety and inadequacy and sometimes felt ill-equipped to offer psychological and emotional support to their partners. In many cases they found it difficult to access support to meet their own psychosocial needs and some felt that provider-organised peer support groups would be beneficial.‘I have no idea what to do in the postpartum…never had such an experience before…I felt I need support too’. (Father), Al Tarawneh, 2019 (Jordan).

‘It’s challenging and difficult to broach topics related to this [fathers mental health] … what you feel.’ (Father), Solberg, 2018 (Norway).
11 Studies: Al Tarawneh, 2019 (Jordan); de Montigny, 2004 (Canada); Fredriksson, 2003 (Sweden); Hunter, 2004 (UK); Johansson, 2013 (Sweden); Kurth, 2016 (Switzerland); Mbekenga, 2011 (Tanzania); Ross, 2012 (UK); Simbar, 2010 (Iran); Solberg, 2018 (Norway); Vikstrom, 2016 (Sweden)High
Concerns about the financial impact of a new baby: Fathers and family members from a variety of different settings expressed concerns about the financial burden associated with having a new baby. For some fathers the arrival of a baby placed even more pressure on limited family finances and restricted contact with PNC services because of the costs associated with attendance (transport and medicine). For other fathers the financial responsibility of providing for an extra family member prompted them to work harder or take on more work which had a detrimental effect on their own ability to engage with PNC services.‘The husband is expected to provide for the family since there is expenditure every day. So, a husband must continue to produce to cater for household expenditure.’ (Mother-in-law), Rueben Mahiti, 2017 (Tanzania).

‘Money is definitely a thing that made me feel insecure, that we haven’t enough money. It’s just that feeling of taking care of the family in some way’. (Father), Persson, 2012 (Sweden).
8 Studies: de Oliveira, 2009 (Brazil); Gupta, 2015 (Ghana); Mbkenga, 2011 (Tanzania); Memon, 2015 (Pakistan); Newbrander, 2013 (Afghanistan); Rueben-Mahiti, 2017 (Tanzania); Persson, 2012 (Sweden); Zamawe, 2017 (Malawi)High
Willingness to embrace new responsibilities: Fathers, from studies predominantly conducted in high and middle-income settings, often expressed a willingness to become involved in supporting their partner and new baby during the postnatal period. Sometimes this was expressed as a sense of responsibility or duty and a recognition that they may need to advocate for their partner/wife during contact with postnatal services, even if this meant breaking with social norms. For some fathers the limited amount of paternity leave and/or the demands of work-related commitments curtailed their involvement in post-natal activities (including care-seeking) and caused frustration.‘So, she (partner) needs more of my attention. Just five days is too short a time to provide help to her. I think that (…) ten days (…) would be ideal.’ (‘Então ela precisa de mais atenção da gente. Só cinco dias é pouco tempo pra dar assistência a ela. Acho que (…) dez dias (…) seria ideal.’—(Father) de Oliveira, 2009 (Brazil).9 Studies: Al Tarawneh, 2019 (Jordan); de Oliveira 2009 (Brazil); Fredriksson, 2003 (Sweden); Johansson, 2013 (Sweden); Kurth, 2016 (Switzerland); Persson, 2002 (Sweden); Shorey, 2018 (Singapore); Simbar, 2010 (Iran); Vikstrom, 2016 (Sweden)Moderate
Socio-cultural influencesInfluence of decision maker: In a number of studies from LMICs, the decision to engage with formal postnatal services was often taken by a family member (husband, mother-in-law, or grandmother) or occasionally a community elder. In circumstances where formal postnatal care was appreciated and valued by the decision maker, engagement was authorised or encouraged, but in several instances, women were prohibited or discouraged from visiting facility based postnatal services by influential family members.‘If the baby is sick and the father is not around, you must send him [the baby] to hospital. So we take such decisions when it comes to baby’s health.’ (Grandmother), Gupta, 2015 (Tanzania).8 Studies: Gupta, 2015 (Tanzania); Mbkenga, 2011 (Tanzania); Newbrander, 2013 (Afghanistan); Raven, 2007 (China); Rueben-Mahiti, 2017 (Tanzania); Simbar, 2010 (Iran); Tesfaye, 2019 (Ethiopia); Zamawe, 2015 (Malawi)High
Influence of socio-cultural norms and practices: In studies conducted in a variety of different LMICs fathers and family members highlighted a range of established norms and practices that impacted on women’s engagement with formal PNC services. PNC practices about 'doing the month' or limiting interactions outside of the household during the postnatal period meant that women were unable to visit a health facility or receive attention from health workers for a prescribed amount of time. Local postnatal practices, the preference to see a Traditional birth attendant (TBA), and potentially harmful superstitious beliefs about the cause of postnatal problems, also limited women’s interactions with formal health providers. In other settings fathers, highlighted a tension between adhering to established postnatal practices and a desire to engage with formal approaches to post-natal care.‘We are not certain if the foreign way can be done here. It is not that we don't believe in it, we just don't want to try that way. So if we can follow the traditional way, we just follow it.’ (Husband), Raven, 2007 (China).10 Studies: Al Taranweh, 2019 (Jordan); Grant 2017 (South Africa); Mbkenga, 2011 (Tanzania); Newbrander, 2013 (Afghanistan); Probandari, 2017 (Indonesia) Raven, 2007 (China); Rueben-Mahiti, 2017 (Tanzania); Sharkey, 2017 (Sierra Leone); Simbar, 2010 (Iran); Tesfaye, 2019 (Ethiopia).High
Lack of awareness about the benefits of PNC: In studies conducted in several LMIC settings fathers and family members’ sometimes held a view that engagement with formal postnatal care was unlikely to be beneficial and/or that interaction with formal PNC services should only occur in the event of an emergency. In some of these settings there was also a tendency to prioritise antenatal care over postnatal care or prioritise the needs of the baby over the concerns of the woman which limited women’s access in these contexts.‘…After giving birth it is not important for the woman to go a health facility or no need for check-up unless she faces health problems, because she is healthy, and the newborn is also fine…’ (Husband), Tesfaye, 2019 (Ethiopia).5 Studies: Memon, 2015 (Pakistan); Probandari, 2017 (Indonesia); Rueben-Mahiti, 2017 (Tanzania); Tesfaye, 2019 (Ethiopia); Zamawe, 2015 (Malawi)Moderate
Perceptions of masculinity: In some studies from LMIC settings societal beliefs relating to masculinity affected men's willingness to become involved in post-natal care. In these contexts men believed that post-natal care was women's business and their involvement would be viewed as servile, controlling or shameful by the local community. The perception of postnatal care as women’s business was also evident in some husbands’ reluctance for their wife to be seen by a male care provider.‘I want to share with my wife the care of our new baby, but in reality it is difficult. Imagine if [people] see me helping my wife with bathing the baby! They would tell me that such acts are shameful and that I should avoid them.’ (Father), Al Tarawneh, 2019 (Jordan).6 Studies: Al Tarawneh 2019 (Jordan); Grant, 2017 (South Africa); Mbkenga, 2011 (Tanzania); Rueben-Mahiti, 2017 (Tanzania); Simbar, 2010 (Iran); Tesfaye, 2019 (Ethiopia);Low
Experiences of careNeed for information: In a wide variety of settings and contexts, fathers (particularly first-time fathers) highlighted their need for information and advice about postnatal care. Usually, this related to practical skills around infant care needs (recognising crying cues, feeding, bathing, signs of distress) and many fathers highlighted the importance of having this information delivered to both parents at the same time. Some fathers felt unprepared prior to leaving a hospital after delivery and thought that information about the postnatal period should be given during the antenatal phase. Other fathers felt that there should be more information tailored to fathers’ needs and/or there should be more use of technology to convey information (e.g. phone apps, dedicated web pages).‘I would have liked more advice on how to care for a newborn baby. To be told what to do at every stage of development. We are not informed…’. (Father), Mbkenga, 2011 (Tanzania).

‘If something is wrong, they should tell us without our having to push for the information’ (Father), de Montigny, 2004 (Canada).
18 Studies: Al Tarawneh, 2019 (Jordan); Barimani, 2015 (Sweden); Danbjorg, 2014 (Denmark); de Montigny, 2004 (Canada); de Oliveira, 2009 (Brazil); Fredriksson, 2003 (Sweden); Gaboury, 2017 (Canada); Henshaw, 2018 (USA); Johansson, 2013 (Sweden); Kurth, 2016 (Switzerland); Mbkenga, 2011 (Tanzania); Persson, 2012 (Sweden); Ross, 2012 (UK); Sharkey, 2017 (Sierra Leone); Shorey, 2018 (Singapore); Solberg, 2018 (Norway); Vikstrom, 2016 (Sweden); Zamawe, 2015 (Malawi)High
Being included/excluded: Some fathers felt included in conversations with health providers and, in one context, were given priority in a queueing system if they visited a health facility with their partner. However, a larger majority felt ignored or excluded in their interactions with providers. Sometimes this was experienced non-verbally, i.e. attention was directed at the mother only, whilst in other settings fathers were made to feel unwelcome and even prohibited from attending PNC appointments with their partner.‘I wasn’t excluded by nurses, they didn’t ask me to leave the room, but it was a nonverbal exclusion, by the way their body was…they never asked me how I felt as a dad.’ (Partner) de Montigny, 2004 (Canada).

‘Perinatal services are provided in a female environment and we cannot attend’. (Unlabelled), Simbar, 2010 (Iran).
11 Studies: de Montigny, 2004 (Canada); Gaboury, 2017 (Canada); Hunter, 2004 (UK); Johansson, 2013 (Sweden); Mbkenga, 2011 (Tanzania); Persson, 2002 (Sweden); Ross, 2012 (UK); Reuben-Mahiti, 2017 (Tanzania); Simbar, 2010 (Iran); Solberg, 2018 (Norway); Vikstrom 2016 (Sweden)Moderate
Need for reassurance: Fathers in studies from some HICs expressed a desire to have their contributions to postnatal care recognised by health providers. They wanted to be asked questions by midwives or health visitors and to have their concerns addressed with understanding and reassurance.‘It was important to me that all the involvement I had had during pregnancy, childbirth and now, after, be recognized by someone else than my spouse’. (Father), de Montigny, 2004 (Canada).

‘I mean the high point for me was just them saying … ‘yes, you're both doing fine’. (Partner), Hunter, 2004 (UK)
9 Studies: Barimani, 2015 (Sweden); Danbjorg, 2014 (Denmark); de Montigny, 2004 (Canada); Hunter, 2004 (UK); Kurth, 2016 (Switzerland); Persson, 2002 (Sweden); Persson, 2012 (Sweden); Shorey, 2018 (Singapore); Vikstrom, 2016 (Sweden)Moderate
Importance of provider attitude and behaviour: Fathers and family members in a variety of different settings described how the attitude of healthcare providers could influence their engagement with postnatal services. Staff displaying personal qualities of care and compassion and the ability to empower parents were viewed favourably whilst healthcare providers who were perceived to be disrespectful, judgemental, untrustworthy or professionally incompetent were viewed negatively and a potential deterrent to parental engagement with postnatal services.‘Staff attitude is also not good with patients and that is why people do not prefer to visit the RHC [Reproductive Health Centre].’ (Father), Memon, 2015 (Pakistan).

‘It doesn’t matter if they are highly skilled if they don’t have the personal qualities to build relationships.’ (Father), Solberg, 2018 (Sweden)
10 Studies: Amare 2018 (Ethiopia); Danbjorg, 2014 (Denmark); Gaboury, 2017 (Canada); Grant, 2017 (South Africa); Hunter, 2013 (UK); Memon, 2015 (Pakistan); Persson, 2002 (Sweden); Probandari, 2017 (Indonesia); Ross, 2012 (UK); Solberg, 2018 (Norway);Moderate
Continuity of care: Fathers in studies from several HICs indicated that it was important to build a relationship with a known midwife, ideally one that had been present at the birth of their baby. Some expressed frustration at having to repeatedly recite information to different health professionals during the post-natal phase.‘It would be good if one already knew in pregnancy who the midwife will be, who’s coming for postpartum visits.’ (Partner), Kurth, 2016 (Switzerland).5 Studies: Barimani, 2015 (Sweden); Hunter, 2004 (UK); Kurth, 2016 (Switzerland); Persson, 2002 (Sweden); Vikstrom, 2016 (Sweden)Low
Inconsistent advice: Fathers in studies from some HICs expressed frustration at the inconsistent and occasionally conflicting advice given to them about postnatal care practices by health providers. This was particularly apparent in discussions around the support they could give to their wife/partner experiencing difficulties with breastfeeding.‘It’s like, even though you’re somewhere where everyone’s supposed to be an expert on breastfeeding they all say different things about what to do when things get difficult’ (Father), Persson, 2012 (Sweden)6 Studies: Barimani, 2015 (Sweden); Henshaw, 2018 (USA); Hunter, 2004 (UK); Kurth, 2016 (Switzerland); Persson, 2012 (Sweden); Vikstrom, 2016 (Sweden)Low