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Involving Men in Maternity Services
by Harald Breiding-Buss
Presented to the PHA Millenium Conference
Palmerston North, 24 July 2000
1.. The Present Situation for Men in
Maternity Services.
The delivery rooms of our hospitals have undergone a small, but quiet,
revolution. Both anecdotal and research evidence suggests that in
excess of 90% of fathers now attend the birth of their babies, and they
are encouraged even to attend a Caesarian Section. This is a remarkable
change from the situation just a few decades ago, where men were not
even allowed in the delivery room.
The most significant aspect of this change is perhaps that it was
achieved without men marching down the streets holding up banners
reading "Let me be with my Baby" or some such. The public discussion
about the issue at the time did not revolve around men's presence at
the birth being a fathers rights issue. The main argument put in favour
for it was - and is - that women want their partners there to support
them. And the main argument against was that this possible benefit is
outweighed by men simply being in the way.
Ante-natal and post-natal care, as well as the delivery itself of
course, are considered strictly women's health issues. When I ask men
about why they attend ante-natal classes the most common answer is
"because my wife asked me to". This is often interpreted as men not
really being interested in birth, babies or children. However, service
providers need to ask themselves whether they make the men feel
welcome. If they are attending a service, which is a service for their
partners, and if they are tolerated primarily because their partners
want them with them, then the very common observation that men do not
talk much in, for example, ante-natal classes makes perfect
psychological sense. In my personal experience when facilitating such
classes, how much men do talk is in direct relation to how much they
perceive the service to be a service for them as well as their partners.
Men are tolerated in ante-natal classes and encouraged to attend the
birth, but no such attempts in father involvement are made
post-natally. This is an ironic situation: as long as the baby is in
the womb a father can not really do much parenting at all. What happens
at the birth is also pretty much out of his hands - even though he may
very well be expected to make some crucial decisions. But only when the
baby is out does a man actually have the chance to be directly involved
- and at this time, suddenly, he is excluded from the information he
requires to do a good job as a parent.
The underlying reason for our rather clumsy attempts at father
involvement in maternity services is that little value is given to the
father-baby relationship in itself, and society at large may have
little confidence in a father's parenting abilities concerning young
infants. But we do acknowledge the relationship between father and
mother. The inevitable message that both new fathers and mothers at
present get out of maternity services is that dad's involvement has to
happen through mum, that his relationship to the baby is defined by how
supportive he is towards mum, and how much she allows him to be part of
it. The latter is often described as "gatekeeping" by mothers and is,
of course, most pronounced in parents that do not live together.
2. Mum, Dad and Baby - Three Good Reasons
For More Father Involvement
It could be argued that the father's restriction to a supporting role during pregnancy, birth and the early months is simply an acknowledgement of - partly biological - realities. However, modern service providers may not actually have a realistic picture of realities, in particular about the extent of men's and women's desire to work together in parenting.
2.1. Reason One: Parents And Society Want Shared Parenting
The 1999 Fathering in the New Millenium study by the Office of the
Children's Commissioner gauged the support for ideas of shared
parenting (Table 1) by asking a cross-section of 2000 New Zealanders
(Julian, 1999). The survey returned overwhelming majorities in favour
of equal parenting between men and women. 92% agreed with the statement
that "society should expect fathers to take an equal part in
parenting", 94% disagreed that "looking after children is not manly".
However, nearly half of respondents agreed that "women are better
looking after children" than men, and the margin was significantly
higher for men than for women holding this view.
In splitting up the responses into actual parenting problems, again
large majorities were returned for shared parenting. between 77 and 96%
of respondents believed both parents should be equally involved with
parenting issues such as discipline, behavioural problems, being
involved with sons or daughters.
However, men face a dilemma if society on the one hand expects
them to be equal parents, but on the other does not trust their
parenting abilities - or at least considers them secondary to mother's.
The difference between 92% of New Zealanders (including about as many
men) wanting shared parenting and 47% (including significantly less
men) believing men are as good at parenting as women reveales a
"confidence gap" that needs to be closed before shared parenting can
become a reality.
My own experience in facilitating both ante- and post-natal classes and
groups very much reflects such attitudes. In my ante-natal groups I
often do an exercise where I have the men and the women - in separate
groups - fill in lists of what they think is the role of the mother and
the role of the father. Neither the men's nor the women's groups
usually return with significant differences in the father's or the
mother's role. What often does show up in the men's group is the
expectation for a clear gender division in the respective roles for a
limited period of time - 6 months, a year. However this is outweighed
by the expectation that investing emotionally, timewise and
financially, they will be privy to similar emotional rewards that the
mother receives: a similar bond, similar acknowledgement.
In a society with clearly defined roles for men and women there would
be nothing wrong with limiting a father to the role of supporting the
mother. While I wouldn't suggest that in our today's society there no
longer are any clearly defined roles for men and women, both men and
women clearly have much greater expectations that they can make choices
that cross traditional gender lines.
2.2. Reason Two: Women's Health
There are women's or child health issues that ask for more father
involvement, such as post-natal depression or breastfeeding, in both of
which the father's involvement or non-involvement has been shown to
make a huge difference to the outcome for baby and mother. Recent years
have seen a significant decline in breastfeeding rates and a
corresponding increase in women returning to work earlier after the
baby is born. Ante-natal education has somewhat adjusted to including
information about pumping and storing breastmilk, but there is still a
lack of consideration on who administers the pumped breastmilk to the
baby. The father is normally one, if not the main, person doing this -
or he is, at least, very important in attempting it in the first place.
Educating him directly about breastmilk storage and breastmilk feeding
not only relieves the mother of the need to take all the initiative and
teach him about it, but also acknowledges his importance in the
process.
A detailed description about the Father&Child Trust's involvement
in the Christchurch Plunket Society's post-natal adjustment programme
is beyond the scope of this paper (see Morgan et al., 1997, for the
concept). Research has strongly indicated the benefits of partner
involvement in the healing process for women's post-natal depression,
and there is also concern for the mental health of the partners of
these women (Campbell et al., 1992; Webster et al., 1994). The
involvement of the partners in the Christchurch programme has led to
the spontaneous formation of a support network of the partners in two
out of three cases. If a father is not fully involved in the maternity
care of his partner it will make it harder for him to deal with such
situations that can put a great strain on the relationship between the
partners and the family as a whole. It also means that he is not as
beneficial to the process as he could be. In not involving fathers in
maternity services, we are letting women down.
2.3. Reason Three: Parenting of Young Children
The economic circumstances of today's families have changed quite
dramatically since the early 80s (Callister, 1998). Still, fathers are
the primary income earners for the vast majority of two-parent
families, but it is worth to take a closer look at the circumstances of
this setup. While 20 years ago, "Primary Income Earner" usually
described a man that is at work from Monday to Friday, 9 to 5, we are
fast moving to this work arrangement becoming a minority model. In the
United States it already is.
Even though mothers are rarely the main income earners, about half of
mothers with pre-schoolers do contribute a signficant income - and
while they are working the primary childcarer is dad. Dad may be
working regular night- and/or weekened shifts, while mum holds down a
part-time job for a few days a week. Such a family would appear in the
statistics as a 'traditional' family, and yet the father may not only
be the primary income earner but also spend more time with the children
than mum. Such cases are not hypothetical, but the reality for many New
Zealand families (see Breiding-Buss, 1998).
Anecdotal evidence is available to anyone who looks around on an
average weekday morning in an average neighbourhood. Men pushing prams
or carrying young children have become a common sight not only on
weekends. They can be seen in park and swimming pools. Economic reforms
have meant that men have to work more hours for the same wage, but they
have also meant that they spend more time with their children - alone.
Given that midwives and Plunket nurses are people who are very
important for many women in developing their post-natal support
networks and support systems, systems that help them to be adequate
parents while getting support for their own needs as well for years to
come, not involving men in this robs them of the opportunity to form
such networks and support systems for themselves. As a result young
children spend more and more time alone with a parent that is entirely
unsupported, has very limited access to parenting information, and may
as a result feel isolated and perhaps have low self-confidence. In not
involving men in maternity services we are letting children down.
3. What Needs to Change?
Any provider of a service needs to think about: who is their
client? For maternity services, mum, dad and baby, should be the
recipients of the service. The fathers' role at the birth should not
primarily be considered as that of a support person for the mother,
even though this will inevitably be a big part of how he sees himself.
Her partner's presence tends to make a mother more comfortable and more
in control with the birth process. But first and foremost the father
needs to be seen as a client, who is undergoing a great practical and
emotional change in his life. He takes part in an event that a majority
of US men rate as the biggest event in their lives.
If maternity service providers see the father as a recipient of the
service, how will he be prepared? His partner may have vowed not to use
any painkillers to interfere with the birth experience, but may change
her mind very vehemently once the birth is in progress. Or his
partner's eyes may be on him when after three hours of pushing the
decision has to be made whether or not forceps should be used. It is a
common experience that mothers put their partners in the position of
decision-maker if they don't feel confident enough in a particular
situation to make that decision themselves. And, indeed, in most cases
no other person in the delivery room will know that woman as well as
her partner. No other person - not the midwife, not any doctor, nor any
nurses - has the potential to assist the mother in the decision-making
as well as he, because of the bond they share and the many discussions
they will have had about their expectations for this day.
Maternity services also play a significant role in determining to what
extent parents feel free to exercise their choices regarding their
parenting arrangements. Society often takes the view that men take a
secondary parenting role - and women the primary - because it is "in
our genes". If this was so, however, providers of services to parents
would have to put special emphasis on fathers parenting skills to meet
society's objective of equal shared parenting. The opposite is true:
Maternity service providers - like virtually all parent service
providers - employ a "mother-as-primary-caregiver" philosophy. This
manifests itself in the targeting of all services to the mother only -
information, practical support, education etc. Evaluation forms are
usually not handed out to fathers, underlining the fact that service
providers do not consider fathers their clients. However, a person that
receives support and education is more likely to develop into a
confident caregiver with a sense of being needed, is more likely to
establish a "primary" bond with a baby than a person who does not. The
"secondary" caregiver instead perceives his involvement with baby as a
long list of chores without reward, responsibilities without the power
to participate in decision-making, a sense of being used rather than
needed. It is not surprising that many young fathers start to feel more
comfortable at work than at home, because it is only at work that their
efforts reap some rewards. As I have argued in more detail in an
earlier paper (Breiding-Buss, 1999a), encouraging a primary-secondary
caregiver model means encouraging stereotypical roles for men and women
that initially they did not want. It means taking a choice away from
them, and it means setting the scene for a relationship breakup if
their expectations are disappointed.
Instead service providers should adopt a team model as their underlying
philosophy. They should assume that decisions on all aspects of
parenting are made by both parents together, that the caregiving is
shared and that both will have a significant degree of involvement. I
have outlined structural problems of parent service providers and
possible solutions in an earlier paper (Breiding-Buss, 1999).
Maternity Service Providers need to put more emphasis on the
relationship changes that childbirth brings about. Childbirth,
especially but not only the first child, represents a huge change for
the woman, for the man, for their relationship with each other and also
for the relationships with practically everybody else. Grassroots
community support is not very strong in New Zealand contemporary
society, and cannot be relied on to effectively coach parents through
those changes.
Also, many parents now live physically too removed from their own
extended families for them to be much help. State services, such as
maternity health services, have to take some of the responsibility of
supporting, helping, teaching, guiding new parents, but without taking
any choices away from them.
4. How Can Fathers Be Involved?
An essential ingredient in any programme that aims to involve
fathers is bringing in men as co-facilitators in such programmes.
In both, the ante-natal classes and the post-natal depression groups I
facilitate or co-facilitate there is one evening focussing on
relationship and partner issues. Usually I divide the group in men and
women, but often they are not told before the class. The focus of these
groups is, initially, on the question of how best to support their
partners. However, the common experience is that the men very quickly
start talking about their own issues without having been prompted. In
two out of three post-natal depression partners groups I facilitated
the men spontaneously formed a support network and kept meeting by
themselves. Such experiences confirm the idea that the observed
quietness and seeming emotinal distance of fathers in ante-natal and
other groups are a result of the facilitation being unsuitable to men,
rather than the men being uninterested or unmotivated. A detailed
description of succesful facilitation techniques for men's groups is
beyond the scope of this paper, however some very useful work has been
done for instance by Lynch (1994), and facilitation of men's groups in
ante-natal classes has been described in more detail in a specific
resource on the subject by the Father&Child Trust (Breiding-Buss,
1999b).
Russell et al. (1999) have pointed out the effectiveness of informal
(i.e. non-face-to-face) provision of information to fathers, such as
through the internet or the media. Such avenues are also explored by
the New Zealand Father&Child Society.
I believe with the approaches described above we are only beginning to
explore the potential for partner involvement in maternity services.
Why should ante-natal classes not be male/female co-facilitated
throughout, or be held as weekend events with more emphasis on
networking between the parents, bot the mums and the dads? Why not
involve the men from the first week in a post-natal depression
programme, instead of just one evening at the fourth as it is now, and
give them the information, the skills, the support they need to keep
their families together? I believe more innovative and sometimes
experimental approaches are needed to achieve the equality in parenting
that New Zealanders so strongly want and to give our children to
competent and confident parents.
Breiding-Buss H (1998). "Non-Stereotypical Fathers". In:
Perspectives on Fathering, Massey University Centre for Public Policy
Evaluation.
Breiding-Buss H (1999a). "Developing support services to fathers." In:
Perspectives on Fathering II, Massey University Centre for Public
Policy Evaluation.
Breiding-Buss H (1999b). "Dads in Ante-Natal Classes: A Guide For
Service Providers." Resource by Father&Child Trust Christchurch. (http://www.fatherandchild.net.nz/projects/newdadsproject.html)
Callister, P (1998) "'Work-rich' and 'work-poor' individuals and
families: Changes in the distribution of paid work from 1986 to 1996",
Social Policy Journal of New Zealand, 10, 101-121.
Campbell S B, Cohn J F, Flanagan C, Popper S & Meyers T (1992).
"Course and correlates of postpartum depression during the transition
to parenthood." Development and Psychopathology 4, 29-47.
Julian R (1999). "Fathering in the New Millenium." Office of the
Children's Commissioner.
Morgan M, Matthey S, Barnett B & Richardson C (1997). "A group
programme for postnatally distressed women and their partners". Journal
of Advanced Nursing 26, 913-920.
Russell G, Barclay L, Edgecombe G, Donovan J, Habib G, Callaghan H,
Pawson Q (1999): "Fitting Fathers Into Families" Report to the
Commonwealth Dept of Family and Community Services (Aust).
Webster M L, Thompson J M D, Mitchell E A & Werry I. S. (1994).
"Postnatal depression in a community cohort". Australian and New
Zealand Journal of Psychiatry 28, 42-49.