Why does engaging with families in maternal and infant care make such a positive difference?

Family Included

If human parenting has evolved to include both close and more distant relatives of the child, as this article argues, then it comes as no surprise that recent research has found that health and children’s services that connect with the resource that families represent for children achieve better outcomes than those that connect solely with the mother.

Anna Machin, Social and Evolutionary Neuroscience Research Group, Department of Experimental Psychology, University of Oxford

Duncan Fisher, Co-Founder of Family Included, FamilyIncluded.com

Reproduced with kind permission of the International Journal of Birth & Parenting Education.

Over the past few years, the question has been, ‘Does engaging with the woman’s family make a difference to the health and well-being of mother and baby?’ We think the evidence has already answered this question in the affirmative, and so we are asking a new question, ‘Why does it work?’ As far as we know, no-one has yet addressed this question.

Evidence for family inclusive practice

Family Included is now monitoring, collecting and communicating new resarch on family inclusive practice in maternal and infant health.

There is a constant stream of new research on this topic. Material published in August 2015 alone includes several valuable fresh insights.

  • A randomised controlled trial in Uganda found that a family and community approach was better at improving child cognitive skills and maternal mental health than a mother-focused approach (Singla et al., 2015). This was a carefully designed community intervention in which 12 group sessions, to which men were specifically invited, and both well people and unwell people, addressed the issue of how family relationships work.
  • A review of breastfeeding support internationally showed that approaches including fathers work substantially better than ones that do not (Maycock et al., 2015). A new study from northern Viet Nam showed that engaging with fathers – in relation to education materials, counselling services, home visits and a breastfeeding promotion social event – doubled the rate of breastfeeding initiation (40% to 81%) (Bich et al., 2015). This followed an earlier study by the same team showing that this approach increased the rate of exclusive breastfeeding at 6 months fourfold (3.9% to 16.0%), and the rate at 4 months by 82% (11.3% to 20.6%) (Bich et al., 2014).
  • Two studies from Ghana have concluded that family engagement is very important in relation to choice of place of birth, an issue of high significance given the improvements that using health facilities makes to health outcomes for mother and baby (Cofie et al., 2015; Ganle et al., 2015)
  • One breastfeeding study from Congo found that providing information to mothers about breastfeeding that they could share with the family, without actually engaging with the family, led to a decreased rate of breastfeeding (Yotebeing et al., 2015).

Why does family inclusive practice work?

This is an important question. Without a compelling theoretical underpinning, the practice of family inclusive care will never compete with the current norm – engagement solely with the mother as a single primary carer – a deeply embedded practice worldwide that is built on a set of undeclared assumptions that are highly open to challenge.

For the answer to the question, we must turn to anthropology and an analysis of the fundamental nature of human parenting.

Humans exist within a highly complex social world that is fundamental to survival. On average, the human social network comprises 150 individuals, both kin and non-kin, making it three times the size of that of our closest non-human primate relatives. The relationships within this network are characterised not only by their longevity, running in many cases to tens of years, but also by their embededness: those with whom we have a relationship within our network often have relationships with each other, particularly kin (Zhou et al., 2005). All of this complexity makes considerable demands on the individual in terms of time and cognitive cost: to operate successfully within the network, and avoid being exploited, one needs to keep track of the nature of one’s relationship with everyone else in the network.

It is generally the case that evolution does not bestow such a cost on a species without it in turn conferring a considerable survival advantage on the individual. So what could this advantage be?

In any human culture, humans need other humans to survive. They need them to pass on the knowledge of the technologies and social niceties that enable them to acquire the food and shelter that are essential for life and they need them to help them raise their children to adulthood.

Humans have evolved to give birth very early, leading to a long period of high dependence of children. This happened in response to the increase in the size of the human brain and the narrowing of the birth canal required for walking on two legs (bipediality). Gestation shortened so that birth was less dangerous for mother and child.

In order to reduce the period of the mother’s non-availability for mating, the length of breastfeeding reduced also. But this meant that a human mother would be pregnant and having babies at the same time as having other dependent children. In the environment of our ancestors, the need for help from the human family became vital to human survival.

Evolution of human fatherhood

In the first instance, because ‘trading favours’ with those of the same sex is cognitively less demanding than doing so with the opposite sex, help came in the form of female relatives – sisters, aunts and older female offspring. Even grandmothers may have had a look in if their life span allowed a post-menopausal stage. But 500,000 years ago, with the advent of the common ancestor to us and the Neanderthals, the ancestral brain took another huge leap in size and the assistance from female kin was no longer sufficient to raise an even more dependent child. At this point, human fatherhood evolved (Key, 1998).

Today, while the mother’s role within the family is relatively stable across cultures, the myriad of roles adopted by men around the world highlight the flexible nature of the father’s role. Fathering is said to be facultative – able to respond quickly via changes in behaviour, psychology and physiology to need. This has conferred a vital advantage to human flourishing in different environments.

Ethnographic research shows that men can alter their role within their own lifetime, even within the same week. Their key aim is to ensure the survival of their offspring and they will adopt any role, even at cost to themselves, to ensure this occurs.

This might explain research that has noted how fathers can express high anxiety at not being informed and equipped to help with the health and safety of mother and baby (Lewis et al., 2015).

We know that the attachment between father and child is as important as that between mother and child, even buffering the impact of dysfunction in the latter (Machin, 2015; Ramchandani et al., 2013; Grossman et al., 2008; Amato & Rivera, 1999). Babies have evolved the capacity to attach to several carers because of the survival advantage this brings them.

Fathers’ brains have evolved to support the role that they play in their child’s socialisation and education. Recent research has shown that fathers who care for babies experience permanent brain changes (Abraham et al, 2014). When a father is less involved in caring for a child (e.g. a mother is the main carer), brain activation is seen only in the neocortex. But when the father is highly involved (particularly if no mother is present at all as a result of her death, or in the case of gay parenting) the more ancient part of the brain, the limbic area, associated with emotions and caring, is also activated, as it is in mothers. And in these fathers, there is a new neural connection between the neo-cortex and the limbic area.

Once changed, the father responds very differently to a baby. A screaming baby will lead to a fall in testosterone in a father who has experienced the changes brought about by earlier nurturing, leading to greater sensitivity to the baby’s needs; meanwhile, a man who has not been so conditioned will experience the opposite, an increase in testosterone, with a greater risk of an inappropriate aggressive response (van Anders et al., 2012). Fathers who care actively for babies and who are close to pregnant women experience changes in hormones linked to trust, sensitivity and love (oxytocin, cortisol, prolactin) (Fatherhood Institute, 2014; Atzil et al., 2012). These changes occur more quickly and are more pronounced the more the father is experienced in care (Gray & Anderson, 2010).

Families’ investment in children

So what does this evolutionary story tell us about today? It tells us that the human child has evolved to be raised by a family not just by a mother, nor just by biological parents. All of a child’s kin, due to shared genetic descent, have a stake in the success of a child. This is the basis of the concept of kin selection encompassed in ‘Hamilton’s Rule’: that is, it is advantageous to the relative to help the child, as long as the cost of their help is outweighed by the benefit to the child. This advantage increases as the degree of relatedness increases. So there is an advantage to be gained by grandparents, aunts, uncles, siblings and cousins by investing in a child. Indeed, in some cultures, the standing of these individuals within the child’s life is such that they are awarded the role of honorary parent. Hence the word for father among the Aka of the Congo, ‘tao’, includes not only the biological father but all of his brothers as well (Hewlett & Macfarlan, 2010). And the economic pressures of life in South Africa mean that the grandfather, or ‘ntata omdala’ (older father), and the uncles and older male siblings, or ‘malome’ (male mother), adopt the role of the father in place of the absent, wage earning biological father (Townsend, 2013).

Families have evolved to be wonderfully flexible and while evolutionary theory may reduce family involvement to a cold picture of genetic advantage, in actuality what we see is a strong and fundamental need to assist in the birth and care of a child. And children’s behaviour and psychology are adapted to reflect our evolutionary history of multiple caretakers; their ability to attach to more than one individual is testament to this.


Abraham, E., Hendler, T., Shapira-Lichter, I., Kanat-Maymon, Y., Zagoory-Sharon, O., et al. (2014) Father’s brain is sensitive to childcare experiences. Proceedings of the National Academy of Sciences, 111:9792-9797.

Atzil, S., Hendler, T., Zagoory-Sharon, O., Winetraub, Y., Feldman, R. (2012) Synchrony and specificity in the Maternal and Paternal Brain: Relations to Oxytocin and Vasopressin. Journal of the American Academy of Child and Adolescent Psychiatry, 51, 798-811.

Bich, T., Hoa, D., Ha, N., Le Vui, Nghia, D., et al. (2015) Fathers’s involvement and its effect on early breastfeeding practices in Viet Nam. Maternal & Child Nutrition, DOI: 10.1111/mcn.12207.

Bich, T., Hoa, D., Målqvist, M. (2014) Fathers as Supporters for Improved Exclusive Breastfeeding in Viet Nam. Journal of Maternal Child Health, 10(18),1444-1453.

Cofie, L.E., Barrington, C., Singh, K., Sodzi-Tetty, S., Akaligaung, A. (2015) Birth location preferences of mothers and fathers in rural Ghana: Implications for pregnancy, labor and birth outcomes. BMC Pregnancy and Childbirth, 15(165). (Reported at familyincluded.com/ghana-family-community).

Fatherhood Institute (2014) Fathers, care-taking and hormones. Available at: www.fatherhoodinstitute.org/2014/fi-research-summary-fathers-care-taking-and-hormones. <accessed 21st August 2015>

Ganle, J.K., Obent, B., Segbefia, A.Y., Mwinyuri, V., Yeboah, J.Y., et al. (2015) How intra-familial decision-making affects women’s access to, and use of maternal healthcare services in Ghana: a qualitative study. BMC Pregnancy and Childbirth, 15(173). DOI: 10.1186/s12884-015-0604-2. (Reported at familyincluded.com/ghana-family-community).

Gray, P.B., Anderson, K.G. (2010) Fatherhood: Evolution and Human Paternal Behavior. Cambridge, Mass., Harvard University Press.

Grossmann, K., Grossmann, K.E., Kindler, H., Zimmermann, P. (2008) A wider view of attachment and exploration: The influence of mothers and fathers on the development of psychological security from infancy to young adulthood. In Cassidy, J., Shaver, P.R. (Eds.), Handbook of attachment: Theory, research and clinical applications. New York, NY: Guilford Press, 857-879.

Hewlett, B. S., Macfarlan, S. J. (2010) Fathers’ roles in hunter-gatherer and other small-scale cultures. In Lamb, M.E. (Ed.) The Role of the Father in Child Development New Jersey: Wiley and Sons Inc., 413-434.

Hill, K., Hurtado, M. (1996) Ache Life History: The ecology and demography of a foraging people. New York, Aldine de Gruyter.

Key, C. A. (1998) Cooperation, paternal care and the evolution of hominin social groups. Unpublished PhD Dissertation, UCL, London.

Lewis, S., Lee, A., Simkhada, P. (2015) The role of husbands in maternal health and safe childbirth in rural Nepal: a qualitative study, BMC Pregnancy & Childbirth, 15(162),1-10.

Machin, A. J. (2015) Mind the Gap: The expectation and reality of involved fatherhood. Fathering, 13, 36-59.

Maycock, B.R., Scott, J.A., Hauck, Y.L., Burns, S.K., Robinson, S. (2015) A study to prolong breastfeeding duration: Design and rationale of the Parent Infant Feeding Initiative (PIFI) randomised controlled trial. BMC Pregnancy and Childbirth, 15(159). DOI: 10.1186/s12884-015-0601-5 (Reported at familyincluded.com/unicef-fathers-breastfeeding)

Ramchandani, P.G., Domoney, J., Sethna, V., Psychogiou, L., Vlachos, et al. (2013) Do early father-infant interactions predict the onset of externalising behaviours in young children? Findings from a longitudinal cohort study. The Journal of Child Psychology and Psychiatry, 54, 56-64. DOI: 10.1111/j.1469-7610.2012.02583.x

Singla, D.R., Kumbakumba, E., Aboud, F.E. (2015) Effects of a parenting intervention to address both maternal psychological wellbeing and child development and growth in rural Uganda: A community-based, cluster-randomised trial. Lancet Global Health, 3(8), e458–e469. (Reported at familyincluded.com/family-inclusive-project-uganda-depression)

Townsend, N. W. (2013) The complications of fathering in Southern Africa: Separation, uncertainty and multiple responsibilities. In Shwalb, D.W., Shwalb B.J., Lamb, M.E. (Eds.) Fathers in Cultural Context. New York, Routledge, 173-200.

van Anders, S.M., Tolman, R.M., Volling, B.L. (2012) Baby cries and nurturance affect testosterone in men. Hormones and Behavior, 61(1), 31–36.

World Health Organisation (2015) Recommendations on health promotion interventions for maternal and newborn health, 2015. Geneva, WHO.

Yotebeing, M., Labbok, M., Soeters, H.M., Chalachala, J.L., Lapika, B., et al. (2015) Ten Steps to Successful Breastfeeding programme to promote early initiation and exclusive breastfeeding in DR Congo, A cluster-randomised controlled trial. The Lancet, 3(9), e546–e555. (Reported at familyincluded.com/unicef-fathers-breastfeeding).

Zhou, W. X., Sornette, D., Hill, R. A., Dunbar, R. I. M. (2005) Discrete hierarchical organisation of social group sizes. Proceedings of the Royal Society B 272,439-444.