By Jennifer Abbass-Dick, Lynn Rempel, John Rempel, Tran Huu Bich, Duncan Fisher
Published by The Family Initiative, April 2018
1. Introduction: engaging fathers works
Programmes that engage fathers are more effective than ones that only involve mothers and professionals.
Outcomes from a mother-and-father group were better than from a mother-only group:
- Exclusive breastfeeding at six months was twice as likely, 51% compared to 26%
- Use of infant formula at 1 month was 4 times lower, 4% compared to 24%
- Use of infant formula at 6 months was 2 times lower, 20% instead of 44%
- Mothers’ own attitudes to and knowledge about breastfeeding improved more when fathers were involved too
- Mothers were happier: they said fathers were more supportive, cared for the baby more, did more housework and were more helpful when difficulties arose. (Su & Ouyang, 2016)
A mother-and-father approach in Vietnam, including information, support, home visits and community work doubled early initiation of breastfeeding from 40% to 81%, doubled exclusive breastfeeding at 4 months from 11% to 21% and quadrupled exclusive breastfeeding at 6 months from 4% to 16%. Fathers were more involved in supporting breastfeeding. (Bich et al, 2014; Bich et al, 2015; Bich & Cuong, 2017)
Research has long shown that family is the main influence on breastfeeding. A 2013 review of evidence concluded that families were more influential than professionals. (Mitchell-Box & Braun, 2013) A recent study in China found that family members are more influential than health professionals. (Yang et al, 2016) Many studies have shown that women often rate the influence of the father above all others, including professionals and other family members. (Abbass-Dick, 2013) Family influence is particularly salient where decision-making is more of a cooperative effort, such as in many developing countries.
The way that families influence breastfeeding is very diverse, depending on the make-up of the family, local culture and location (e.g. urban/rural). In some cultures, families are more supportive of breastfeeding than in others – for example, more so in Lebanon than in Ghana or Nigeria. (Balogun et al, 2015)
The influence of fathers is not necessarily intentional. In a UK study, most fathers say they don’t want to pressure the mother to do anything other than what she wants to do. (Earle & Hadley, 2018) But what fathers think and do influences the situation, for example:
- His presence after labour impacts on the likelihood and duration of breastfeeding
- A mother’s confidence in her partner correlates with her confidence in breastfeeding
- Feelings of fathers influence the decision of mothers to breastfeed in public
- When the father is pro-breastfeeding, the mother is more likely to breastfeed beyond 6 weeks. (Maycock et al, 2013)
- When fathers antenatally approve more strongly of longer breastfeeding duration, mothers tend to breastfeed longer than they initially plan. (Rempel & Rempel, 2004)
In this briefing we describe the principles of success that have been learned from interventions with published evaluations.
The key change we advocate here is that services engage with fathers where they can be a positive influence (that is, the majority of families). In some families, fathers are not an influence (they may work far from home or are at war, they may have walked away, they may not even be alive). In others, fathers can be a threat and a danger to mothers. Research that reports averages misses such variety, but for practitioners such variety is an everyday reality.
If the father is absent, practitioners are equally able to engage with other family members caring for the baby or just with the mother if she really is alone (and, therefore, high-need).
We expect that breastfeeding rates and duration will be lower if the default position of engaging only with mothers is adopted when fathers and other family members are present and ready to be included.
2. See fathers as assets
The key principle of engaging fathers is to see them as an asset for breastfeeding.
The successful breastfeeding programme, Alive and Thrive, sets out six positive strategies for engaging fathers, following work in Vietnam and Ethiopia. (Alive and Thrive, 2012a) These correspond with conclusions from work with fathers all over the world.
- Grab fathers with positive emotions, for example, using music and images.
- Ease the way by busting stereotypes – cultural norms are surprisingly vulnerable to some humour and surprising facts about the reality of human biology and behaviour.
- Find fathers where they already are. It is much easier to reach men this way than attempt to bring them into an unfamiliar space where they may not feel comfortable.
- Provide crystal clear guidance about what fathers can do – and these things must be things fathers are able and willing to do based on discussions with them.
- Give fathers practice so they can gain confidence.
- Show fathers a benefit to their involvement that they care about. The key to this is understanding that fathers care about their babies – how does their role in supporting breastfeeding help their baby?
3. Information for fathers works
Simply informing fathers can improve breastfeeding rates.
A randomised controlled trial with 699 families in Australia, involving a 2-hour education session antenatally followed by weekly information postnatally, resulted in a breastfeeding rate at 6 weeks of 81.6% compared to 75.2% in a control group. (Maycock et al, 2013)
An Italian trial with 280 couples found that education for fathers increased exclusive breastfeeding at 6 months from 15% to 25%. The rate of any breastfeeding at 12 months increased from 11% to 19%. (Pisacane et al, 2005)
A Japanese study found that when fathers are more active but not informed, breastfeeding rates are less. (Ito et al, 2013)
In Australia, a team is currently testing digital information for fathers about breastfeeding – the “MilkMan” app. Working with 1,426 fathers, they are comparing the relative impacts of an antenatal session alone, the app alone, the two together and, as a control group, just the normal breastfeeding promotion service at the hospital. (Maycock et al, 2015) Early results show that 86% of fathers being offered the MilkMan app use it and particularly like the time-sensitive push notifications and the discussion forums. Most consultation of the on-line library of materials follows conversations in the forum.
In US, a programme of three information sessions designed for fathers, mainly low-income, showed improvement in their knowledge of breastfeeding. Care was taken to organise the sessions around the needs of fathers – in a community setting, not in a health setting; evening sessions after working hours; male facilitator and not a health professional; pocket-sized information; and additional community support services offered to the fathers attending. (Furman et al, 2016)
Many studies find that fathers and family members commonly do not get information about pregnancy, childbirth and babycare from maternal and newborn health services, even when they accompany the mother to health facilities. This applies to breastfeeding support. (Goodman, 2005; Ingram & Johnson, 2004; Earle & Hadley, 2018) A recent study showed that Pakistani fathers are supportive of breastfeeding but none reported being given any information; most felt left out. (Mithani et al, 2015)
As suggested by Alive and Thrive above, fathers want facts and very clear instructions. As one father put it bluntly, what is needed is “a no bullshit idea of what to expect and how to help, even if that means doing nothing but being there with her and the baby”. (Earle & Hadley, 2018)
In an Irish study, 78% of fathers admitted to being unprepared at some point during breastfeeding. Of these, half were surprised at the difficulty their partner experienced at the beginning. (Bennett et al, 2016)
Fathers included in a breastfeeding support programme in Canada valued the face to face interaction with the lactation specialist above the other purely educational components of the intervention. This may be that fathers want to be treated as a coparent and not a supporter and addressed in a manner that acknowledges their responsibility in assisting with breastfeeding success. (Abbass-Dick & Dennis, 2017)
4. Fathers being informed and respecting the mother’s autonomy is a winning combination
Several studies have shown that sometimes breastfeeding is actually less when other family members are more involved in caring for the baby. This happens:
- if the couple relationship is poor (Sullivan et al, 2005)
- if the father or grandmother is highly involved in parenting but not present a lot to provide emotional support (a UK study). (Emmott & Mace, 2015)
Lynn and John Rempel (2011) identified four things that fathers need to do, beyond just knowing about breastfeeding: provide practical support; appreciate the mother; be fully present when breastfeeding is happening; and be responsive to what is needed (including knowing when help is not needed).
The last of these is about fathers respecting the mother’s autonomy and her ability to learn her own way to breastfeed. The research asked Canadian mothers (144) and fathers (106) what types of support they received and found that only “responsive” support was related to longer breastfeeding – this kind of support included “paying attention to how much and how your partners wants you to participate in breastfeeding”. (Rempel, Rempel & Moore, 2016).
In a follow-up study in Vietnam, the Rempels augmented Bich and colleagues’ intervention with guidance about how to provide responsive breastfeeding support. Responsiveness was taught to new Vietnamese fathers by using the analogy of a high-level two-person sports team (e.g. beach volleyball, doubles badminton). With only two players, each partner must have a generalized, flexible skillset, regardless of specific strengths or weaknesses. They need to coordinate their activities by constantly observing, communicating, and adjusting and they need to trust each other – staying out of the way when the partner has matters under control and being ready to step in and assist if necessary. In this study, fathers provided more breastfeeding support (particularly more responsive support), had stronger marital relationship quality, and their wives were more likely to breastfeed exclusively than a control group. (Rempel, Rempel et al, 2014).
5. The closer the father is to his baby, the more likely is breastfeeding – it is not a competition
If the father is more attached to his baby, the baby is more likely to be breastfed.
In a study in Taiwan, two groups of 72 fathers were compared. One group received hands-on support with skin-to-skin care from a member of the health team, whilst the fathers in the other group did not. Exclusive breastfeeding in the three months after the birth was higher when fathers experienced skin-to-skin care. No specific promotion of breastfeeding was involved in this study – the only difference was the skin-to-skin support. (Wang, 2018)
Fathers in Vietnam who were counselled on how both to support breastfeeding and to interact directly with their infants right from birth reported significantly greater attachment to their infants throughout the first year than fathers in a comparison group. (Rempel et al, 2017)
When a father is physically close to his baby, particularly skin-to-skin, it triggers hormonal changes that promote attachment. The closer a father is to his baby, the more substantial the biological changes within him become and the quicker these responses are. Similar to mothers, oxytocin and prolactin levels increase and testosterone decreases. Hormonal changes play a role in generating neurobiological changes in the father, affecting his care for children for the rest of his life. (For a review of current evidence on the biology of fatherhood, see Family Initiative’s project, www.fatherhood.globa/category/biology-of-fatherhood.)
These new findings from biology and neuroscience offer an explanation for why fathers who attach early to babies are more attentive to their care later on. This may explain greater breastfeeding rates, arising from a father’s great attunement to the baby’s needs.
“In terms of my love and attachment to him, I don’t think it makes any difference . . . that he’s more often with his mother. . . . It’s more . . . unconditional and internal, and . . . I think that, as soon as he was born . . . there was a deep attachment. . . . Even if I’m less involved in his care, in the sense that . . . I’m not the one breastfeeding him,… that doesn’t make any difference in how attached I feel to him, and I’m sure it works both ways.” (de Montigny et al, 2016)
These new insights are important, because promotion of breastfeeding is often linked to the promotion of an exclusive mother-baby bond, which can lead to other carers being seen as a threat to or in competition with this essential bond. Modern biology and neurobiology can allay these fears. These insights are part of a wider new understanding of parenting as a collective activity, with babies connected into a community of care.
Because breastfeeding has been promoted so heavily as a route to exclusive mother-baby bonding, breastfeeding can give rise to a worry on the part of some fathers that they cannot bond. However, a Canadian study found that only a minority of fathers feel they are missing out when the mother breastfeeds. (de Montigny et al, 2016)
This worry, if it is present, is a misconception: babies have multiple needs that can be met by multiple caregivers, and they can all lead to the biological changes that result in attachment – changing diapers, carrying, cuddling, playing, bathing, comforting. Feeding is one of many activities during the day and does not take up a big part of the day.
6. A family approach to breastfeeding: “teamwork”
The research above points to three important things in promoting breastfeeding, in addition to directly supporting the mother:
- Inform fathers about how best to support breastfeeding
- Support the mother-father relationship
- Support the father-baby relationship
The teamwork approach lies behind the spectacular results from Vietnam quoted at the start of this paper. (Bich et al, 2014; Bich et al, 2015; Bich & Cuong, 2017)
Abbass-Dick and Dennis (2017) have defined five domains of a “Breastfeeding Coparenting Framework”.
1. Set breastfeeding goals together
If a family group agrees to the goals, then success in achieving them is more likely.
2. Share responsibility
Mothers should not be considered to be solely responsible for the care of a baby, including feeding. Family members, particularly fathers, are more likely to step up to take responsibility when they understand how important their own part is in securing the health and welfare of their child.
3. Support each other
There are numerous ways that family members can support breastfeeding, particularly when the mother is encountering problems, such as when the baby is learning to latch on and the mother is exhausted. Support can be emotional, showing appreciation for the breastfeeding and what it does for the baby. It can involve simply sitting together and enjoying the time. It can be practical, ensuring the environment is quiet and comfortable for breastfeeding. Family members can help share tasks around the house.
The recommendation is “support each other” because there is much mothers can also do to support the involvement of others in caring for the baby.
4. Fathers and others get involved in caring for the baby
A baby needs a lot more than just feeding and, above all, they need to bond with other coparents.
5. Communicate well and solve problems together
This is particularly important when there are struggles and/or when the mother is very tired – when the early cessation of breastfeeding is most likely to happen.
This approach, when applied in Canada – education for fathers and weekly information till 6 weeks after the birth – increased breastfeeding duration beyond 12 weeks from 88% to 96%. (Abbass-Dick et al, 2014)
The Rempel’s analogy of a high-level, two-person sports team shares the key features of coparenting concepts. It also elaborates the value of effective support that aligns with what the recipient wants and needs without undermining the recipient’s sense of efficacy and personal control. The teamwork analogy makes it easier for fathers to envision how they can enact the key elements of effective breastfeeding support.
7. Engaging fathers is not yet mainstream
Engaging families in breastfeeding is a highly effective tool for increasing breastfeeding, yet the vast majority of breastfeeding literature and practice does not address this. Even UNICEF’s 10 Steps make no reference to the strong influence of families and the need to engage with them. (The Canadian version of the 10 Steps has added a reference to family to Step 3: provide information antentally to mothers and their families.)
A 2012 literature review, mostly from low-income countries, by Alive and Thrive, concluded, “Experience in the field suggests that failure to include fathers in infant and young child feeding may limit efficacy and effectiveness” of breastfeeding programmes and initiatives (Alive and Thrive, 2012b)
8. Proposals for next steps to promote evidence-based practice
We propose three actions to facilitate the implementation of the principles set out in this briefing.
- A global event that brings together pioneers of family teamwork in breastfeeding with the lead organisations promoting breastfeeding, such as WHO, UNICEF, WABA and La Leche. The focus of this would be on mainstreaming father and family engagement in global breastfeeding promotion.
- The launch of father engagement tools to promote breastfeeding. This could be a resource website for professionals and tools for parents that could be adapted and used globally by breastfeeding programmes.
- A project to review UNICEF’s 10 Steps in the light of the evidence.
This briefing was compiled by Jennifer Abbass-Dick (Canada), Tran Huu Bich (Vietnam), Duncan Fisher (UK, Family Initiative), John Rempel (Canada) and Lynn Rempel (Canada).
Jennifer Abbass-Dick is an Assistant Professor in Nursing at the University of Ontario Institute of Technology, Canada. Her research involves designing and evaluating coparenting breastfeeding interventions.
Tran Huu Bich is an Associate Professor in Epidemiology at Hanoi School of Public Health in Vietnam. His research is focused on understanding and promoting the role of fathers in child nutrition and development.
Lynn Rempel is an Associate Professor in Nursing at Brock University, Canada. She and John Rempel have studied the role of fathers as members of the breastfeeding and parenting team in Canada, Botswana and Vietnam.
John Rempel is a Psychology Professor at St. Jerome’s University at the University of Waterloo, Canada. His research is focused on understanding a variety of interpersonal processes in couple and parent-child relationships.
Duncan Fisher OBE leads research, policy and innovation at the Family Initiative. He has worked for 20 years in UK promoting improved engagement of fathers and families in maternal and newborn healthcare. He is compiling new evidence from around the world on FamilyIncluded.com.
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