A proposal for a global approach to engaging fathers in maternal/newborn health and child development

UNICEF and WHO are searching for innovations in promoting strong early childhood development. In this article, we review the most recent evidence and conclude with a recommendation.

We propose three core principles to a global approach to engaging fathers in maternal/newborn health and child development:

  • Support mothers, fathers and other main carers of children to work as a parenting team. Address gender norms explicitly in this context.
  • Support the father-infant bond.
  • Get behind men in every corner of the globe who are shaping a new global masculinity – who aspire to be close to their infants, who believe in and practice gender equality and respect for women and who want to be equal partners in parenting with the mother of their children. Support them to convey their aspiration to other men.

Each of these principles is discussed individually below.

A note on terminology: In maternal and newborn health, the normal terminology is institutional: “women” are the clients, and around them are “partners”/”men”/”males”. But a new understanding of the power of relationships in child development is being globally promoted by WHO and UNICEF, for example through their Nurturing Care Framework; these relationships are important even before the birth. We, therefore, purposefully use relational words in our narrative – family, mothers, fathers, parents and carers.

Principle 1: support parents as a team, with specific attention to relationships and gender

Two new contributions to the debate about engaging fathers this month highlight the importance of addressing relationships.

The role of relationships in producing improved maternal and newborn health outcomes

A review of 13 studies, carried out by a team of researchers who work closely with the World Health Organisation, conclude that relationships are a key factor leading to improved health outcomes. (Tokhi et al, 2018) They propose a model showing the mediating role of relationships.

A positive couple relationship helps to improve support for the mother both within health services and at home, and this leads to improved care and better health outcomes.

fathers gender

The role of addressing gender issues specifically

Another report this month on a 15-session programme in Rwanda proves the effectiveness of engaging with mother-father relationships and specifically including gender considerations. (Doyle et al, 2018) In a controlled trial of 1200 families – half in a control group and half experiencing the programme – radical improvements were seen in gender equal behaviour:

Control group  Programme group

Reports of physical violence by mothers       57%                   33%

Reports of sexual violence by mothers          60%                   35%

Hours/day in house work reported                 1.4 hours          2.25 hours

Contraceptive use reported                              61%                   70%

Man has final say in financial decisions         79%                   56%

Average number of prenatal visits                  3.1                     3.2

Also both mothers and fathers reported less use of physical force with their children.

The programme explicitly addresses couple communication and decision-making, gender issues, caregiving, child development, and fathers’ roles in reproductive and maternal health. Eight of the sessions were for fathers only, and the others were for couples.

An earlier study from rural Ghana in 2014, quoted in Tokhi et al 2018, explores how gender shapes caring in families. (Dumbaugh et al, 2014) It comes to the same conclusion as the later studies above.

The authors note that if and when women and men wish to change gender roles around caring, they face barriers: cultural norms and institutional practices in maternal and newborn health.

The barriers to paternal engagement include:

  • Lack of information for fathers so they remain uninformed about what they can do.
  • A cultural definition of different roles women and men: motherhood is natural, whilst fatherhood is a duty and social responsibility; decisions about caring made by women only, except when money is needed and then decision-making transfers to men; the exclusive role of men to work and provide; lack of engagement of fathers in maternal and newborn healthcare settings. These definitions of roles are widely backed by both women and men, by older generations of women in families and by health services.
  • The risk of ridicule from both women and men for fathers seen to be close to their babies.

The researchers advocate that gender norms should explicitly be addressed in the context of couple relationships: “encourage men and women to view each other as equal partners in health and relationships”. The authors talk of “mutual empowerment for mothers and fathers”. “Empowerment” for fathers in this context needs to be understand as the freedom to be a loving, competent and confident carer of a child, building a life-affirming and life-long relationship with the child.

Traditional power relations should be explicitly addressed. The recent research from Rwanda reported above eloquently confirms the benefits of this. (Doyle et al, 2018)

Principle 2: support the father-baby bond

A recently published programme from Vietnam, which we reported on Family Included last year (Supporting fathers to bond with and love their babies improves early child development and breastfeeding), showed how engaging with the parenting team and specifically supporting the father-infant bond led to dramatic increases in breastfeeding, and better social, emotional and cognitive development in children in later years. In a recent review of breastfeeding research, we found other studies linking increased father-baby bonding and breastfeeding rates.

The driving force: fathers’ aspirations

A change in gender roles is sweeping across the world. There are fathers in every corner of the globe who desire to be closer to their children, who respect women and who want to share equal responsibility for the care of their children. This aspiration is found again and again in reports and studies, from developed and developing countries alike, from urban and rural areas. As new global communications allow the aspiration of men to care to be communicated everywhere, so it challenges cultures everywhere.

Understanding the father-baby bond: biology

The key to understanding this aspiration on the part of men is that a close father-baby bond is natural – biological. A body of research into the biology of fatherhood is doing much to help our understanding of this aspect of human nature.

Because of the pivotal imporance of this point and the degree to which this evidence gets squeezed out by the dominant narrative, we produce here a detailed explanation of the existing science.

When fathers are more engaged in caring for their babies, they experience stronger hormonal and neurobiological changes. These changes are, in turn, associated with short and longer-term benefits for the infant.

  • Oxytocin is associated with human sociality, including empathy, social collaboration, care of infants and romantic love. It increases in fathers as in mothers through physical contact such as skin-to-skin, and decreases less quickly than in mothers post skin-to-skin. (Cong et al, 2015) When fathers are administered oxytocin (via a nasal spray), they become more attuned to their baby and the baby’s own oxytocin levels also become higher and the baby’s social orientation and behaviour increase. (Abraham et al, 2016)
  • Testosterone decreases in men when a baby is born. If the father is more involved in caring, the testosterone decreases more. (Gettler et al, 2015) Fathers with lower testosterone are more affectionate and sensitive towards their babies. (Weisman et al. 2014) Testosterone also drops more if the father is more committed to the relationship with the mother after the birth of the baby. In these couples, there are stronger correlations in testosterone levels between the mother and father. (Saxbe et al, 2017)
  • Cortisol is commonly associated with stress, but not necessarily negatively. Fathers with higher cortisol levels are more alert and responsive to a baby crying. (Fleming et al, 2002) This increase in cortisol might help new parents pay attention to their baby’s signals. In contrast, higher cortisol levels in both mothers and fathers are associated with a poorer relationship between them. (Saxbe et al, 2015) Skin-to-skin care is associated with a drop in cortisol in fathers, as in mothers, with the effect being longer lasting in fathers post skin-to-skin. (Cong et al, 2015)
  • Prolactin is associated with breastfeeding, but it increases in new fathers too. Experienced fathers exhibit increases in prolactin when they hear a baby crying. (Fleming et al, 2002) Prolactin levels are highest when babies are most needy and vulnerable. (Gettler, 2014)

Neuroscience has identified two areas of the brain associated with caregiving and both can be activated in fathers like mothers, the more so the father cares for his baby. (Abraham et al, 2014)

  • The “emotional empathy” brain network. This network enables an automatic understanding of the baby’s mental state, allowing the parent to “feel” and experience in herself/himself the physical pain or emotional distress of the baby.
  • The “socio-cognitive” brain network. This is a later developing circuit, including cortical and frontal brain areas. It is associated with mentalizing, cognitive empathy, and social understanding. In relation to caring for an infant, it enables a parent to infer infant’s mental state from behaviour, to predict infant needs and plan future caregiving activities.

Actively caring fathers show greater activation in the “emotional empathy” brain network. When fathers engage in regular active day-to-day care of children – particularly in the extreme case when fathers raise their babies with no maternal involvement – they become as attuned and as sensitive to the baby’s cues as mothers do. (Abraham et al, 2014)

Longitudinal research has since found that emotional empathy brain activity in a father in year one is associated with better emotion regulation in the child four years later. Similarly, higher activity in the socio-cognitive brain network is associated with a child’s higher social skills four years later. (Abraham et al, 2017)

Global inhibition of the father-baby relationship

A common feature both of patriarchal cultures and medical models of maternal and newborn care, which originate in developed countries, is the lack of support for the father-infant bond. The dominant model, ubiquitously represented in the health and child development literature, positions the father in an ancillary position to a mother-baby dyad, and frames fatherhood in terms of helping and moral duty, rather than relationship with and love for the infant.

This oversight has long been challenged, most recently in relation to UNICEF/WHO’s Nurturing Care Framework, and is profoundly significant. It disconnects the global effort to engage fathers in health and child development from the actual driving force of this change.

Back fathers to drive the change

Interventions illustrate what happens when the established culture is challenged and both women and men are enabled to live differently. The Rwanda study above is part of a decades-long tradition of extremely successful interventions.

Interventions are expensive, and health and social welfare services will never have the capacity, nor in most cases the inclination, to lead cultural change. This is the story of services in developed countries since the 1950s: however much they advance to engage families and family relationships – and there a multitude of such advances, with spectacularly good family inclusive services – the majority of services remain behind the constantly advancing expectations of mothers, fathers and families.

The energy for change comes from fathers and mothers themselves. Aspirational fatherhood videos and images on-line are now normal, viewed by hundreds of millions of people. They represent a new global masculinity that is ultimately stronger than patriarchy.

This video of aspirational fatherhood has had 14.5 million views on YouTube.


The 2014 Dumbaugh at al paper, quoted above, was prescient in its recommendations to build on the energy that fathers are bringing to this.

  • Fathers want to be more involved in the care of their children, some enthusiastically. In all communities, some men are doing this already. “Many men embrace the importance of newborn care and some already go against deeply entrenched cultural norms to carry out healthy practices such as exclusive breastfeeding, institutional delivery and joint decision-making with their partners.”
  • Build on this – put these men at the heart of the strategy and be careful with gender narratives that render these crucially important men invisible. “Men’s already-existing positive behaviours and attitudes should be built upon as entry points for supporting and increasing involvement along the entire continuum of maternal and child care.”
  • Engage mothers too. “Wives and senior women with influence over newborn care should also be engaged in exercises in gender transformation so they better understand the benefits of male involvement and can support men in expanding their role as fathers.”
  • Communicate to fathers through fathers. “Alternative masculinities that include increased involvement can be encouraged through peer networks.”

Our recommendation

WHO and UNICEF are looking for innovative strategies to promote positive early childhood development and have recognised that men have a role in this. We have provided evidence here for a global strategy based on three principles:

  • Focus on the key point of aspiration: the father-child relationship.
  • Support programmes that advance peer-to-peer communication and inspiration, building on the lead that men in communities all over the world are already taking.
  • Promote team parenting tools that specifically address gender norms.

 

Abraham E, Hendler T, Shapira-Lichter I, Kanat-Maymone Y, Zagoory-Sharona O & Feldman R (2014), Father’s brain is sensitive to childcare experiences, PNAS 111

Abraham E, Hendler T, Zagoory-Sharon O & Feldman R (2016), Network integrity of the parental brain in infancy supports the development of children’s social competencies, Social Cognitive and Affective Neuroscience

Abraham E, Hendler T, Zagoory-Sharon O & Feldman R (2016), Network integrity of the parental brain in infancy supports the development of children’s social competencies, Social, Cognitive, and Affective Neuroscience 11

Bich TH, Hoa DTP & Målqvist M (2014), Fathers as supporters for improved exclusive breastfeeding in Viet Nam, Journal of Maternal Child Health 18

Bich TH, Hoa DTP, Ha NT, Vui LT, Nghia DT & Målqvist M (2015), Fathers’ involvement and its effect on early breastfeeding practices in Viet Nam, Maternal & Child Nutrition 12

Cong X, Ludington-Hoe SM, Hussain N, Cusson RM, Walsh S, Vazquez V, Briere C & Vittner D (2015), Parental oxytocin responses during skin-to-skin contact in pre-term infants, Early Human Development 91.7

Doyle K, Levtov RG, Barker G, Bastian GG, Bingenheimer JB, Kazimbaya S, Nzabonimpa A, Pulerwitz J. Sayinzoga F, Sharma V & Shattuck D (2018), Gender-transformative Bandebereho couples’ intervention to promote male engagement in reproductive and maternal health and violence prevention in Rwanda: Findings from a randomized controlled trial, PLoS ONE

Dumbaugh M, Tawiah-Agyemang C, Manu A, ten Asbroek GHA, Kirkwood B & Hill Z (2014), Perceptions of, attitudes towards and barriers to male involvement in newborn care in rural Ghana, West Africa: a qualitative analysis, BMC Pregnancy and Childbirth 14

Fleming AS, Corter C, Stallings J & Steiner M (2002) Testosterone and prolactin are associated with emotional responses to infant cries in new fathers, Hormonal Behavior 42

Gettler LT (2014), Applying Socioendocrinology to Evolutionary Models: Fatherhood and Physiology, Evolutionary Anthropology 23.4

Gettler LT, McDade TW, Agustin SS, Feranil AB, Kuzawa CW (2015), Longitudinal perspectives on fathers’ residence status, time allocation, and testosterone in the Philippines, Adaptive Human Behavior and Physiology

Saxbe DE, Adam EK, Schetter CD, Guardino CM, Simon C, McKinney CO, Shalowitz MU, Kennedy E (2015), Cortisol covariation within parents of young children: Moderation by relationship aggression, Psychoneuroendocrinology 62

Saxbe DE, Edelstein RS, Lyden HM, Wardecker BM, Chopik WJ & Moors AC (2017), Fathers’ decline in testosterone and synchrony with partner testosterone during pregnancy predicts greater postpartum relationship investment, Hormones and Behavior

Tokhi M, Comrie-Thomson L, Davis J, Portela A, Chersich M & Luchters S (2018), Involving men to improve maternal and newborn health: a systematic review of the effectiveness of interventions, PLoS ONE 13.1

Weisman O, Zagoory-Sharon O & Feldman R (2014), Oxytocin administration, salivary testosterone, and father–infant social behaviour, Progress in Neuro-Psychopharmacology & Biological Psychiatry 49

Photos: Soki Briggs, Adam Cohn, Simply CVR, Andrés Nieto Porras. Creative Commons.