The attendance of fathers at the births of their babies was one of the most radical social changes in developed countries in the 20th century. What triggered this worldwide phenomenon? There was certainly no organised lobby in favour, no-one arguing the case to expectant mothers and fathers, no-one researching the pros and cons. It just happened, everywhere in the developed world, all at the same time.
The change steadily occurred with the move of birth from the home to hospital.
But, as we now see in the challenges of encouraging pregnant women to come into health facilities in developing countries, leaving their home to give birth in an alien environment is a daunting prospect. Women want to be in a familiar environment with trusted people about. So, when birth moved out of the home into hospital, women took what they could from home with them. In societies where families predominantly live in small family units, the most available person was the father.
The presence of fathers at the birth, therefore, was driven by pregnant women.
So I do not ask “should fathers be at the birth of their babies?” Perhaps it is just that, as a father, I feel no entitlement to make such a choice! But I do prefer the question, “should pregnant women have the right to have family and friends of their choice with them?”
Family members at the birth: neither patient nor visitor
Having family members at a birth is a challenge for health services. Traditionally people in health facilities are divided into three groups: patients, visitors and professionals. But fathers and other partners women may want with them at the birth are none of these. They don’t fit into the system and the system struggles.
Making maternity care family inclusive – welcoming those the woman brings with her, supporting the family to work together to support the mother and the baby, informing family members so they can be more effective – has been a long and slow process, driven by the demands of women and pioneered by doctors and midwives who have a vision for what a good birth is from the woman’s point of view. In some birth facilities worldwide, the family inclusive arrangements have become very good. Being family inclusive is more and more widely recognised as a standard mark of quality in maternity care, not an optional addition.
But this good practice is still limited. In most of the world, maternal health services are not family inclusive – and that is because they are not women centred either. Rather, they are health professional centred.
Earlier this year we reported on research from Nepal, which found that health professionals claimed that mothers did not want fathers with them at the birth, but then found the mothers did want that. So the exclusion of families was linked to not listening to pregnant women. The remarkable research on family inclusive maternity care that we reported on recently from Ghana sees woman-centred and family inclusive care as the same thing.
This struggle within health services is typical of the entire history of birth in medical facilities. Many professionals react against the presence of families and the presence of men and then pin the blame elsewhere – mothers don’t want it, fathers don’t want it, “local culture” does not want it. But time and again, all of these things have turned out to be much less certain upon examination; local cultures are remarkably open to change, particularly because in every community there are women and their families who will gladly pioneer a different way of doing things. The core problem is that health services don’t want it. When they change and start facilitating it, other barriers are not so significant.
If this analysis is correct, then family inclusiveness at the birth is fundamentally a human rights issue. Every woman giving birth should have the right to the person/people they want around them, wherever the birth takes place. It is not something that has to be justified on the basis of evidence – we could never say to women that they must, against their will, give birth away from their loved-ones because there is no evidence that it improves immediate health outcomes!
The benefits of having family present at the birth
The evidence of immediate improvements in health outcomes of having family at the birth is inconclusive. However, if enabling women to bring family to a birth in a medical facility increases the chances of them using the facility, then it indirectly improves health outcomes substantially.
It would be valuable to undertake research on this, finding out what women really want. This, of course, is shaped for these women by what they think is available and permissible. That means listening to women and giving them real choices.
But there is another benefit of engaging fathers around the birth, raised in the State of the World’s Fathers report: the link between a father’s engagement during the pregnancy and after the birth and his subsequent investment in the child’s future. In other words, it is not just about the immediate health outcomes. It is about longer-term child welfare.
Debrah Lewis, a leading midwife from Trinidad and a former Vice-President of the Internatoonal College of Midwives, argues passionately that if we expect fathers to take a bigger part in raising their children, they should be there at the beginning.
And there is a third important argument. A fundamental driver of gender inequality across the world is the uneven distribution of low-valued care between women and men. Economists are starting to observe that if men are introduced to caring roles early on after the birth of their babies, it shifts important imbalances between women and men around caring, domestic and earning activities.
Fathers at the birth: the question of competence
If the choice is openly available for a father or other family member to be at a birth, then it matters a great deal that this person is well prepared to be there.
The great reformer of maternal health in UK in the 1940s, Grantly Dick-Read, could see the influence that family members have, and from this drew the conclusion that it was essential to engage with them. (He was writing at a time and in a context where the only other family member was the husband in almost all cases.) In his international best-seller, Childbirth without Fear, he wrote:
“The importance of the husband’s attitude towards, and understanding of childbirth, cannot be exaggerated. His words and actions, and even the atmosphere in the house that he may create in silence, have a profound effect upon his wife. Her health and happiness during pregnancy, and certainly her approach to labour, will be influenced for better or for worse by harmony or discord that she feels in her husband’s mind.”
It is a testament to the challenge that this statement poses to maternal health services that it remains as strong a contribution to the debate 70 years after it was written!
Grantly Dick-Read’s answer to the question, “should fathers be at the birth?” was: it depends entirely on the husband. He argued that, if a woman wants the father to be at the birth, then he must be prepared:
“The totally unprepared man has no place at the birth of his child….If he is not occupied himself to be interested and to have an understanding of childbirth at least equivalent to his wife, he should remain absent until such time as the obstetrician requests him to greet his wife and their newborn child.”
In contrast, he states that fathers who are knowledgeable and know how to offer practical help “cannot be superseded in the value of their service by the most patient nurse or obstetrician”.
The key is knowledge. This means that an essential component of a family inclusive maternal health service is the offer of preparation to be a birth partner to any individual that the woman would choose to have with her. Without this, the option for a woman to have family present is not a genuine choice, just another risk and uncertainty that she has to calculate.
Header photo: Jake Slagle. Creative Commons.