A wide range of factors have been examined as potential explanations for the high rates of adverse birth outcomes (preterm birth [<37 completed weeks gestation] and low birthweight [<2,500 grams] infants) for women who identify as Black in the United States including socioeconomic status, health behaviors, and access to health care. Although the literature has identified a number of risk factors for adverse birth outcomes associated with the mother of the baby, little attention has been given to understanding the role of the father of the baby during pregnancy on these outcomes. The few studies that have explored paternal factors and birth outcomes have generally excluded understanding the dynamic, complex, and often correlated paternal-maternal relationship (Giurgescu & Misra, 2018; Misra et al., 2010). Several studies report higher risks for adverse birth outcomes among pregnant women with uninvolved partners, and unmarried women including those in non-cohabiting relationships (Brumberg & Shah, 2020). However, research has not examined paternal involvement and paternal-maternal relationship on birth outcomes among Black families with samples of father of the baby.
Most studies that focused on paternal involvement and paternal-maternal relationship during pregnancy among Black families included mothers only (Eboh et al., 2018; Giurgescu et al., 2018; Giurgescu & Templin, 2015). Research is limited on paternal involvement and their relationship with the mother of the baby during pregnancy among Black families (Giurgescu & Misra, 2018). For example, Caldwell et al. (2018) found that expectant Black fathers (N = 50) reported moderate levels of conflictual relationships with the expectant mother. Beyond the work of our team, studies collecting data directly from fathers about their relationship with the mother and exclusive to Black families are sparse. Two recent studies focus on the topic but are qualitative with small samples, one exclusive to Black families: Walsh et al. (2023) with focus groups of 5 expectant Black fathers and 3 Black fathers of an infant and Alio et al. (2013) with focus groups including 13 fathers where the majority (n not stated) were African American. A recent literature review that examined men's concerns and experiences during pregnancy reported fathers expressed concerns about their relationship with the mother of the baby during pregnancy and future changes to the relationship post-birth (Dabb et al., 2023). However, most fathers included in these studies were White and the review included only eight quantitative studies conducted in the United States (Dabb et al., 2023). More research is needed to examine paternal involvement and paternal-maternal relationship during pregnancy among Black families.
The Fathers Matter cohort study aims to better understand the role of the father of the baby on birth outcomes among Black families. Our study was guided by the Socioecological model that considers that health outcomes are influenced by personal and environmental factors (Bronfenbrenner, 1986). The Ecological model identifies systems with which an individual interacts. The microsystem refers to the people and groups that directly influence the person (e.g., father of the baby, family), whereas the mesosystem includes interactions between various aspects of the microsystem (e.g., relationships). In our Fathers Matter study, we considered that the father of the baby and the paternal-maternal relationship influence birth outcomes (e.g., preterm birth).
We began the Fathers Matter cohort study in 2018 to leverage our ongoing study of pregnant Black women by recruiting and collecting data from the man identified as the "father of the baby" (father of the baby) by the mothers (Hawkins et al., 2021; Vaughan et al., 2022). We give attention to the relationship of the father and mother with one another as critical to capturing the exposure to both social and psychosocial environments of expectant mothers and fathers. In contrast to nearly all studies of fathers and pregnancy (Giurgescu et al., 2018; Giurgescu & Misra, 2018; Giurgescu & Templin, 2015; Misra et al., 2010), our study collects paternal data from the father himself rather than relying solely on maternal perceptions with an emphasis on the relationship with the mother and exclusive to Black families. The purpose of this report is to describe the characteristics of participants enrolled in the Fathers Matter study prior to the COVID-19 pandemic (May 2018-March 2020) for a better understanding of the father of the baby who engage in pregnancy research involving primarily Black couples.
Methods
Design and Sample
Embedded within the Biosocial Impacts on Black Births (BIBB) Study, the Fathers Matter study used a prospective longitudinal design, identifying father-mother dyads during pregnancy and following these families until birth.
The mothers for the BIBB study were recruited from two community prenatal clinics in the Detroit, Michigan Metropolitan Area and from one university hospital prenatal clinic in the Columbus, Ohio Metropolitan Area between May 2018 and March 13, 2020. Mothers were recruited for the BIBB Study if they: 1) self-identified as Black or African American; 2) were 18-45 years old; 3) had a singleton pregnancy; 4) had any parity; 5) were English speaking; and 6) were 8-29 weeks gestation. Mothers who enrolled in BIBB were invited to have the father of their baby (as they identify him) participate in the Fathers Matter study. We did not restrict enrollment to the biological father nor did we collect data on whether the father of the baby was the biological father. Fathers were included if they: 1) were >=18 years old; and 2) were English speaking. Mothers and fathers were excluded if they: 1) had an intellectual disability or serious cognitive deficit; or 2) were incarcerated or institutionalized. No fathers were thus excluded due to these criteria.
Procedures
The Fathers Matter study was approved by the Institutional Review Board at the participating universities. Research staff of both sexes reached out to all fathers whose contact information was provided by mothers enrolled in the BIBB study. We required a face-to-face meeting to complete the informed consent process. Except in a few cases, fathers were interviewed in the prenatal clinic at the same time as the mother. Fathers completed the questionnaire (15-30 minutes) on an electronic tablet provided by the study team. However, fathers could use a phone or other devices to complete the questionnaire later through an online secured link. The fathers completed the questionnaire during the prenatal period at <=35 maternal weeks gestation.
Measures
The questionnaire included questions on sociodemographic characteristics (e.g., paternal age, employment) and several social and psychological constructs as noted below. Some of these measures were single-item questions developed by the investigators of the Fathers Matter study.
Current contact with the mother of the baby was measured by a question developed by the study investigators: How often do you have contact with the mother of the baby? (6 categories, 1 = nearly every day to 6 = never). The relationship with the mother of the baby was assessed by multiple measures. The relationship of the father of the baby with the mother of the baby before and during the pregnancy was assessed by the following questions developed by the study investigators: How would you describe your relationship with the mother of the baby before she became pregnant? (5 categories, 1 = very close to 5 = very cold); How would you describe your current relationship with the mother of the baby? (same categories as before pregnancy). The Social Networks in Adult Relations Questionnaire (Antonucci, 1986; Jackson et al., 2016) was also used to measure the father's relationship with the mother. This instrument assesses subjective support and conflict with the mother of the baby. The support subscale has nine items (e.g., mother of the baby is always there when I need her) on a 5-point scale (1 = strongly disagree to 5 = strongly agree). The scale has a total possible score ranging from 9 to 45 with higher scores indicating more support. The conflict subscale has five items (e.g., mother of the baby is often critical [disapproving] of me) on a 5-point scale. The total possible score ranges from 5 to 25 with higher scores reflecting more conflict with the mother of the baby. The conflict subscale had a Cronbach's alpha of 0.69 in a sample of 50 Black fathers enrolled during pregnancy (Caldwell et al., 2018). The support subscale had a Cronbach's alpha of 0.88 in the same sample. Both subscales (support, conflict) had high Cronbach's alpha for our current study: support 0.95 (95% confidence interval [CI]: 0.94, 0.96); conflict, 0.81 (CI: 0.75, 0.86). Father of the baby's satisfaction of the current relationship with the mother of the baby was measured by the father choosing a value on a 7-point single item with two anchors (1 = completely dissatisfied to 7 = completely satisfied).
Involvement of the father of the baby during the pregnancy was measured by a question developed by the investigators of the Fathers Matter study: How often are you involved with the mother of this baby during her pregnancy? (1 = none of the time to 5 = all of the time). Satisfaction with his involvement during pregnancy was also assessed by the question, How satisfied are you with your involvement with the pregnancy? (1 = completely dissatisfied to 7 = completely satisfied).
Satisfaction of the father with the financial support he provided to baby during pregnancy was measured by: How satisfied are you with the amount of financial help you've given the baby during the pregnancy? (1 = completely dissatisfied to 7 = completely satisfied). The provision of support, advice, and help was measured by the question: During your relationship, would you say that you have provided more support, advice, and help to the mother of the baby than she has provided to you? (father of the baby provided a lot more or mother of the baby provided a lot more). The frequency of attending prenatal office visits was assessed by the question, How often do you go to prenatal office visits with the mother of the baby? (1 = all of the time to 4 = none of the time).
Data Analysis
We report descriptive statistics for father of the baby enrolled in the Fathers Matter study prior to the COVID-19 pandemic.
Results
Sample Characteristics
A sample of 456 women were enrolled in the BIBB study between May 2018 and March 13, 2020, while the father recruitment was active in person at the clinical sites. Over the same period, we consented 116 fathers linked to women enrolled in the BIBB study. Among the 340 women for whom a father was not enrolled the study, we received contact information from the mother for 140 of those fathers (41.8%, 140/340). These 140 fathers who were not enrolled but for whom we had contact information included: 23 fathers who did not respond to any of our multiple contact efforts; 102 who were not contacted due to our insufficient staff time during eligibility period; 16 passively declined to participate (expressed interest but never enrolled or explicitly declined participation); and 1 declined to participate in the study. The response rate among those for whom we had contact information and attempted to contact was 75% [116/(116+38)] with active refusals, among those reached, rarely occurring (0.65%, 1/154).
Three of 116 consented fathers did not answer any items in the questionnaire. We excluded one additional father from analysis because the mother was later determined to be outside the gestational age window for the study. Another father began the questionnaire but skipped all except the demographic questions. Our analyses are based on the 111 remaining fathers because these reasons for nonresponse are not directly related to birth outcomes. Fathers were recruited at a mean gestational age of 138.2 +/- 47.2 days (median 132 days; range 60-243 days). Table 1 includes the numbers and distributions of sociodemographic characteristics of the fathers who enrolled and provided questionnaire data. Although not an eligibility criterion, most of the fathers reported Black race. Fathers had a median age of 25.0 years (range 18.0-51.0 years) with a mean age of 27.2 years (standard deviation 7.18 years). Race/ethnicity of the father of the baby was not initially collected so the missing percent is high. Most of the cohort had a high school diploma/graduate equivalency diploma or higher (87.4%) and more than half the sample reported an annual household income of $10,000 or less (51.4%). Fathers' responses about their financial status show that the participants were struggling financially with 29.4% of the sample reporting that they are either very poor, not enough to get by, or barely enough to get by.
Table 2 describes the fathers' reports of their relationship with the mother of the baby and includes proportions for categorical variables and means and standard deviations for continuous measures. Slightly more than half of the fathers (59.4%) were in married or cohabiting relationships with the mother. All but 3 of the 111 fathers (2.7%) reported being in contact with the mother nearly every day. Most of the fathers reported that their relationship with the mother was close or very close both before (n = 92, 82.9%) and during (n = 85, 76.6%) the pregnancy. There was more variability in the father's ratings about satisfaction with his relationship with the mother, satisfaction with his involvement in the pregnancy, and satisfaction with the amount of financial support he provided during the pregnancy. Nearly all fathers (107/111, 96.4%) reported that they provided equal or more support, advice, and help to the mother of the baby (mother of the baby) than she provided to him with about half (59/111, 53.2%) reporting that it was equal between them and the mother of the baby. More than half of fathers reported attending prenatal visits all the time, with the remainder of fathers distributed approximately equally between attending visits some or most of the time. (We did not ask fathers about how many visits were attended.) The mean score for conflict in the paternal-maternal relationship was approximately half the magnitude (13.1 +/- 4.91) of the maximum possible score of 25. The mean score for support in the paternal-maternal relationship (39.8 +/- 6.88) was close to the maximum possible score of 45.
Clinical Implications
We reported on characteristics of fathers who participated in the Fathers Matter study. Most of the fathers reported that their relationship with the mother of the baby was close or very close. Findings were not homogeneous with few exceptions. Rather our measures show variability in the fathers' experiences and their relationships with the mothers. The high Cronbach's alphas suggest that our relationship conflict and support scales have high internal consistency (reliability), a prerequisite to analysis of these constructs as predictors of birth outcomes in future studies.
Our study focusing on fathers builds on ours and others' studies although differing in several important ways. Innovative aspects include direct collection of data from fathers and a multidimensional assessment of the mother-father relationship. Our early results demonstrate that the relationships are heterogeneous. Investigators should not assume that the relationships of unmarried or non-cohabiting parents are homogeneous or poor relationships. This is especially important in studies of Black families where rates of marriage or cohabitation may be low (Misra et al., 2010). In 2021, 40% of U.S. births were to unmarried women; however, the birth rates to unmarried Black women were more than twice than the birth rates for unmarried White women (70.1% and 27.5%, respectively; Osterman et al., 2023). The U.S. birth certificate data do not report on couples living together so partnership and relationships are under appreciated. In future analyses, we will examine how the father-mother relationship is associated with birth outcomes.
Limitations to our study include how the information about the father of the baby was obtained. Pregnant women enrolled in the BIBB study provided contact information for the father of the baby. Thus, our results are not generalizable to fathers of the baby who do not have contact with the mothers of the baby. Although our experience with studying these fathers is promising thus far, we recognize that families in which fathers can be enrolled might potentially differ from families in which fathers cannot be reached. We plan to later compare findings for mothers with no father in the study to those with a father in the study to understand the representativeness of our sample in the study of couple's agreement. Data were collected at clinical sites in metropolitan areas in the Midwestern United States. Results cannot be generalizable to the father of the babies from other geographical areas (e.g., rural areas).
As the COVID-19 pandemic restrictions subside, prenatal clinics are allowing more visitors during prenatal care visits. Maternity nurses should assess the pregnant woman's desire for the father of the baby to participate at prenatal care visits. If the woman desires his participation, nurses should encourage the father of the baby to participate at those visits. Approximately 80% of fathers in our study reported attending prenatal visits all the time or most of the time. A recent study with 430 men (8% Black) attending prenatal care services with their partners reported on fathers' perception of father-friendliness of prenatal/obstetric services (Kotelchuck et al., 2022). Eighty-two percent of fathers reported that nurses made them feel that they are very included/important or somewhat included/important as part of the visit (Kotelchuck et al., 2022). However, 38% of the participants reported that nurses did not ask them questions during the visit (Kotelchuck et al., 2022). Fathers reported that they would like more information about their skills to understand and support their partner, their contribution to healthy pregnancy and childbirth, and knowing what to do or expect about the pregnancy (Kotelchuck et al., 2022). In a qualitative study with 22 (n = 4 Black) pregnant women and 20 (n = 4 Black) expectant fathers, fathers valued the shared experience of attending prenatal care and generally felt that providers were receptive to their questions (Walsh et al., 2021). Fathers noted that prenatal care is first and foremost about the mother and the baby (Walsh et al., 2021). However, they described concern about relying on asking questions to obtain information, reported limits of their knowledge as first-time fathers, and questioned whether they would know the right questions to ask the providers (Walsh et al., 2021). They acknowledged that engagement in prenatal care is a distinct experience that cannot be fully replaced through conversation with the mother about what occurred at appointments (Walsh et al., 2021). Thus, maternity nurses should not only recommend fathers' participation at prenatal care visits but involve fathers during the visit. Nurses should ask fathers what information they would like to receive related to their partner's pregnancy and birth. Family-focused counseling services should be made available for fathers and mothers who experience conflict in their relationship. Understanding the contributions of fathers during the prenatal period and successful birth outcomes (e.g., infants born at full term) could expand service, intervention, and policy efforts beyond the typical focus on mothers. Experiences of Black fathers are a contribution to the literature that should spur other investigators to consider the role of fathers in understanding the high rates of adverse birth outcomes in the Black community and what may underlie successful outcomes.
Funding
National Institutes of Nursing Research, National Institute of Nursing Research Grant # R01NR017626 (PIs: Dawn Misra, Carmen Giurgescu, Cleo Caldwell).
NR017626 and National Institute of Minority Health and Health Disparities Grant # R01MD011575 (PI: Carmen Giurgescu).
CLINICAL IMPLICATIONS
* Maternity nurses should assess the pregnant woman's desire for the father of the baby to participate at prenatal care visits and invite the father of the baby to attend if the mother is in agreement.
* Family-focused counseling services should be made available for fathers and mothers who experience conflict in their relationship.
* Fathers desire information about how to understand and support their partner, how to contribute to a healthy pregnancy and birth, and what to do or expect about the pregnancy. Nurses can offer this type of information to fathers at prenatal visits.
* Services and interventions should go beyond the typical focus on mothers and include fathers as supporters of successful birth outcomes.
INSTRUCTIONS Fathers Matter: Black Fathers' Relationships with their Partners during Pregnancy and Postpartum
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References