Family inclusive care: evidence review 2015


One of our foundations is evidence and so we have started by assembling some. Making the evidence easily available on-line will be one of the future activities, so that anyone anywhere in the world can access it to make the case to local stakeholders.

Focus on family – whatever its form: the evidence

When considering the delivery of services to widely diverse populations, often residing in one area, it is better to engage with the family without making assumptions about the composition of that family. “Alloparents” are significant in families – grandparents, other blood relatives and community neighbours who directly provide care to children (Panter-Brick et al. 2014). Nevertheless, when engaging with the family, specific consideration needs to be given to the gendered and social nature of parenting – women and men arrive with significantly different expectations, assets, constraints and experiences (Ib.) Couple interventions worked better than father-only interventions in a substantial US study (Cowan et al. 2009).

A substantial study in Chile, covering 6,200 families and 25,000 individuals and looking at a wide range of common illnesses, found a correlation between poor health and poor family functioning. The strongest association was found with mental illness. The study concludes that families should be more of a target for clinical interventions (Garcia-Huidobro et al. 2012).

Engaging fathers: the evidence

Programmes engaging with fathers have shown marked successes. A randomized control trial in Nepal compared the impact of educating women and male partner together, educating the woman alone, and providing no education. Educating the woman and partner together improved birth preparation and access to postnatal services (Mullany et al. 2007). A UNFPA pilot project in Niger that engaged with men in the community increased the attendance of pregnant women at antenatal clinics from 15% to 74% (UNFPA 2011). An Indian study showed that working with expectant fathers led to them being more likely to assist with household work (up from 27% to 42%) and more likely to take their wives to clinics (Sinha 2008). A similar result has been found in rural Pakistan (Midhet & Becker 2010) and in Cambodia (Kakimoto et al 2007).

But this approach is rare. In a literature review of HIV prevention programmes during pregnancy, only 1.3% of 317,434 papers mentioned the family, and only 13 described engagement with the family (Sherr & Croome 2012). The US National HIV/AIDS Strategy has no family centred approaches (Joe 2015).

A literature review of 72 articles between 2000 and 2012 focusing on maternal health in low-income settings concluded “engaging men can yield benefits relating to the use of family planning and contraceptives in long-term couples, maternal workload during pregnancy, birth preparedness, postnatal care attendance, couple communication and emotional support for women during pregnancy” (Davis et al. 2013).

A UK study of 4,600 mothers showed a correlation between partner support on the one hand and, on the other, contact with health professionals before 12 weeks gestation, having a dating scan, the number of antenatal checks, attendance at antenatal classes, and breastfeeding. Paternity leave was also strongly associated with maternal well-being at three months postpartum (Redshaw & Henderson 2013).

There is research that suggests better outcomes from family engagement in specific pregnancy health interventions.


An Arabic study in Kuwait found that father support was a significant factor encouraging breastfeeding (Nassar et al. 2014). A Nigerian study found that family support – from partners and older female relations – is correlated with higher rates of breastfeeding (Olayemi 2007). An Iranian study compared two groups of breastfeeding mothers – one group with fathers attending training courses on breastfeeding and one control group. Maternal reports of active support from fathers were 94% in the group with trained fathers and 60% in the control group, with longer continuation of breastfeeding in the former group (Raeis et al. 2014). Conversely, a study in Vietnam showed that greater family support without educating the family resulted in less breastfeeding, owing to traditional beliefs (Nguyen et al. 2013). A study in Malawi considered the highly influential role that paternal grandmothers play in families and how their beliefs about breastfeeding can directly conflict with advice from health professionals (Bezner-Kerr et al. 2008). A Turkish study found a correlation between mothers getting breastfeeding support from services and family support. Earlier studies also show that family support plays a significant role in helping breastfeeding (de Sousa et al. 2013; Erkul et al. 2010; Tohotoa et al. 2009; Orr et al. 2004; Burgess 2007) and engagement with fathers on this subject has been found to be effective (Burgess 2007). Despite this positive impact, fathers continue to be frequently excluded (Sherriff et al. 2014).

Ante and postnatal depression

There is a correlation between a good family relationships and maternal mental health (Stapleton et al. 2012; Gjerdingen et al. 2009). A review of literature in East Asia found similar patterns of mental illness to western countries, with antenatal depression correlated with poor partner and family support (Schatz et al. 2012). Depression happens in fathers too, also related to the partner relationship. Depression in mothers influences fathers and vice versa; and depression in both influences children (Burgess 2007).

Smoking cessation

Reviews of smoking cessation programmes have shown that the woman’s family and social support network play a major role in smoking cessation; and, of course, smoking cessation is important for all those living in the same place as the baby (Fang et al. 2004; Burgess 2007).

Infant neurobiology

A study of low-income Mexican American families examined cortisol reactivity in infants born to mothers who had experienced stress during pregnancy. There was a correlation between higher cortisol reactivity in infants and lower partner support during the pregnancy (Luecken et al. 2013).


Bezner-Kerr R, Dakishoni L, Shumba L, Msachi R, Chirwa M (2008) “We grandmothers know plenty”: breastfeeding, complementary feeding and the multifaceted role of grandmothers in Malawi. Social Science & Medicine 66(5):1095-105

Burgess A (2007) Costs and Benefits of Active Fatherhood. Fatherhood Institute

Cowan PA, Cowan CP, Pruett MK, Pruett K, Wong JJ (2009) Promoting Fathers’ Engagement With Children: Preventive Interventions for Low-Income Families. Journal of Marriage and Family 71.3

Davis J, Luchters S & Holmes W (2013) Men and maternal and newborn health: benefits, harm, challenges and potential strategies for engaging men, Compass: Women’s and Children’s Health Knowledge Hub, Melbourne, Australia.

de Sousa AM, Fracolli LA, Zoboli EL (2013) Family practices related to breast-feeding maintenance: literature review and meta-synthesis [review, in Portuguese]. Pan American Journal of Public Health 34(2):127-34

Erkul PE, Yalcin SS, Kilic S (2010) Evaluation of breastfeeding in a Baby-Friendly City, Corum, Turkey. Central European Journal of Public Health 18(1):31-7

Fang, Wei Li, et al. (2004) Smoking cessation in pregnancy: a review of postpartum relapse prevention strategies. The Journal of the American Board of Family Practice 17.4: 264-275

Gabr S & Al-Qattan S (2014), ممارسات الرضاعة الطبيعية من الثدي في الكويت: محددات النجاخ وأسباب الفشل, EMHJ 20(7), 409-415

Garcia-Huidobro D, Puschel K & Soto G (2012) Family functioning style and health: opportunities for health prevention in primary care. British Journal of General Practice 62:596;e198-203

Gjerdingen D, Fontaine P, Crow S, McGovern P, Center B, Miner M (2009) Predictors of mothers’ postpartum body dissatisfaction. Women & Health 49(6):491-504

Joe JR (2015) Evaluating the National HIV/AIDS Strategy: Making Room for Families. The Family Journal March 2015

Kakimoto K, Kanal K, Mukoyama Y, Chheng T, Vuoch Chou T, Leng & Sedtha C (2007) Influence of the involvement of partners in the mother class with voluntary confidential counselling and testing acceptance for prevention of mother to child transmission of HIV programme (PMTCT programme) in Cambodia. AIDS care, 19.3

Luecken LJ, Lin B, Coburn SS, MacKinnon DP, Gonzales NA, Crnic KA (2013) Prenatal stress, partner support, and infant cortisol reactivity in low-income Mexican American families. Psychoneuroendocrinology 38(12):3092-101

Midhet F, Becker S (2010) Impact of community-based interventions on maternal and neonatal health indicators: Results from a community randomized trial in rural Balochistan, Pakistan. Reproductive Health 7: 30

Mullany BC, Becker S & Hindin MJ (2007) The impact of including husbands in antenatal health education services on maternal health practices in urban Nepal: results from a randomized controlled trial. Health Education Research 22: 166-176

Nassar MF, Abdel-Kader AM, Al-Refaee FA, Mohammad YA, AlDhafiri S, Sherriff N, Hall V & Hall V (2014) Rhetoric or reality? Father support in promoting breastfeeding. International Journal of Birth and Parent Education 1(4), 19-22

Nguyen PH, Keithly SC, Nguyen NT, Nguyen TT, Tran LM, Hajeebhoy N (2013) Prelacteal feeding practices in Vietnam: challenges and associated factors. BMC Public Health 13:932

Olayemi O, Aimakhu CO, Bello FA, Motayo VO, Ogunleye AA, Odunukan OW, Ojengbede OA (2007) The influence of social support on the duration of breast-feeding among antenatal patients in Ibadan. Journal of Obstetrics & Gynaecology 27(8):802-5.

Orr ST (2004) Social support and pregnancy outcome: a review of the literature. Clinical Obstetrics and Gynecology 47.4: 842-855

Panter-Brick C, Burgess A, Eggerman M, McAllister F, Pruett K, Leckman J (2014) Engaging Fathers: Recommendations for a Game Change in Parenting Interventions based on a systematic review of the global evidence base. Journal of Child Psychology and Psychiatry, published online 1 July, DOI: 10.1111/jcpp.12280

Raeisi K, Shariat M, Nayeri F, Raji F, Dalili H (2014) A single center study of the effects of trained fathers’ participation in constant breastfeeding. Acta Medica Iranica 52(9):694-6

Redshaw M & Henderson J (2013) Fathers’ engagement in pregnancy and childbirth: evidence from a national survey. BMC Pregnancy & Childbirth 13:70

Schatz DB, Hsaio MC & Liu CY (2012) Antenatal depression in East Asia: a review of the literature. Psychiatry Investigation 9(2)

Sherr L & Croome N (2012) Involving fathers in prevention of mother to child transmission initiatives – what the evidence suggests. J Int AIDS Soc, 15.2

Sinha D (2008) Empowering communities to make pregnancy safer: an intervention in rural Andhra Pradesh. New Delhi: Population Council

Stapleton LRT, Schetter CD, Westling E, Rini C, Glynn LM, Hobel CJ & Sandman CA (2012) Perceived partner support in pregnancy predicts lower maternal and infant distress. Journal of Family Psychology, 26(3), 453

Tohotoa J, Maycock B, Hauck YL, Howat P, Burns S & Binns CW (2009) Dads make a difference: an exploratory study of paternal support for breastfeeding in Perth, Western Australia. International Breastfeeding Journal 4(1), 1

UNFPA (2011) L’École des Maris au Niger, des chiffres et des homes


Photo: Ian Schmidt. Creative Commons.