Missed opportunities for prenatal family-centered care during the COVID-19 pandemic: a qualitative study

ABSTRACT

Background:

The purpose of this study was to describe the impact of COVID-19 on fatherhood experiences during pregnancy.

Methods:

A semi-structured interview guide was developed to collect qualitative data from fathers about their experiences in pregnancy and prenatal care, how they communicated with providers, strategies for information seeking, and social support they received during the pregnancy. One-time, virtual interviews were conducted via Zoom with fathers that were either expecting a baby or fathers who had a baby after March 2020 and were 18 years or older. Thematic analysis was used to identify themes that highlighted the fatherhood experience.

Results:

In total, 34 interviews with new or expectant fathers were completed. Two central themes that highlight the experiences of fathers: missed opportunities to shift toward family-centered care and inequity in the parent dyad during pregnancy. Additional supporting themes included: limited patient-provider relationship, lack of telemedicine use, inadequate uncertainty management for parents, unidirectional information sharing between parents, and limited opportunities for achieving role attainment during pregnancy.

Conclusion:

The COVID-19 pandemic created a decision point for prenatal care. Instead of focusing on family-centered practices, prenatal care exclusively centered on the mother and fetus, resulting in problematic experiences for fathers including limited access to information about the pregnancy and health of the mother and fetus, heightened stress related to COVID-19 safety requirements, and few opportunities to attain their role as a father. Prenatal care should actively seek robust strategies to improve family-centered care practices that will withstand the next public health emergency.

KEYWORDS:

• Father
• prenatal care
• family-centered care
• pregnancy

Background

The COVID-19 pandemic disrupted much in March 2020 [1]. Families were asked to physically isolate from anyone outside of their household, healthcare organizations instituted strict disease mitigation strategies, schools and businesses closed, and mental anxiety and worry over disease transmission spiked. While these restrictions have eased, research is needed to understand how these dramatic changes to the prenatal care environment impacted the lives and health of individuals and families. This study aims to understand how the COVID-19 pandemic affected expectant fathers’ experiences during prenatal care.

To mitigate the transmission of COVID-19, virtual or phone-based healthcare rose exponentially across a variety of health care sectors [2]. This rapid shift to telemedicine also created new norms for patient-provider communication that had been less accessible until recently. When patients did need to attend in-office appointments, there were practices implemented to decrease the spread of the COVID-19 virus, including restricting visitors, requiring facial coverings, temperature checks or screenings, and minimizing overlapping or non-essential appointments [3,4].

Changes in clinical practices and procedures were intended to decrease the risk of disease transmission, yet they restricted support persons attending appointments with patients. In the case of prenatal care, this decreased or removed the possibility of fathers attending prenatal appointments [5], thus undermining a primary tenet of family-centered care in obstetrics. Strong evidence suggests that when fathers attend prenatal care appointments with the mother, there are health benefits for the mother, infant, and family [6–8]. Prenatal care appointments also provide fathers a unique opportunity to ask questions to the provider, learn about the expectations of fatherhood, and share meaningful experiences with the mother [9–12]. Recent research also suggests that patients and families perceived that they had less agency over their birthing experiences during COVID because of changes in healthcare restrictions during the pandemic [13] as well as missed out on perinatal social rituals that are often seen as small, yet essential paths for father involvement in pregnancy [14].

COVID-19 created a once-in-a-generation opportunity for providers to change how they engage and communicate with families during prenatal care. The study explored fathers’ perspective of prenatal care practices during COVID-19. Given the limited research focused on father involvement in prenatal care [5,9] and the novelty of prenatal care during a pandemic, qualitative data collection with new and expecting fathers was used to understand the context and diversity of experiences.

Methods

Semi-structured interviews were developed based on Theory of Planned Behavior [15] and interpersonal communication practices [16]. Theory of Planned Behavior provided a basis for questions focused on perceived norms and expectations related to prenatal care and pregnancy. For example, to understand the experiences and expectations of prenatal care from the father’s perspective, the following question was asked to begin the interview, ‘How do you think the ongoing coronavirus/COVID-19 pandemic has affected your pregnancy experience and how are these different from your expectations?’ Additional questions highlighted interpersonal communication between fathers and their pregnant partner, family members, or prenatal care providers. Example questions included, ‘How were you included during prenatal care appointments?’ ‘How did you receive information about the health of your partner and baby?’ The completed interview guide included sections on the impact of COVID-19 on the pregnancy experience, prenatal care experiences and expectations, communication strategies and information seeking, and social and emotional changes during pregnancy. Each section had primary questions with additional probing questions to facilitate rich discussion between the participant and interviewer. The interview guide was reviewed and refined by the research team prior to beginning recruitment. The complete interview guide is available upon request from the corresponding author.

Participants

Eligible participants identified as a father, were at least 18 years old, and were an expectant parent or had a baby after March 2020. Participants were recruited through direct email, social media, and snowball sampling techniques. Participants received a $50 electronic gift card. A total of 54 fathers were contacted for participation in the study. Data saturation was achieved after 34 interviews, and therefore, additional recruitment was stopped.

The total study sample includes 34 interviews. Most participants had already had their baby (n = 22). The sample was closely split between first-time fathers (n = 18) and fathers with other children (n = 16). Most fathers resided in Texas (n = 22), with the remaining spread across 11 other states. Most fathers were employed full-time (82%). Among working fathers, over half (53%) were working from home, with fewer fathers working outside the home (27%) or working from home some days (20%).

Data collection

Interviews took between 30–45 min to complete and were voice recorded. All interviews were conducted virtually using Zoom with a single researcher present. Each interview was conducted by one of three trained research staff with graduate degrees in public health. All interviewers were active researchers with training in qualitative methods. Two research staff were female and one was male. Field notes were not taken during the interview, but reactions were discussed at regular meetings with the collective research team. No repeat interviews were completed.

The voice recording of the interview was transcribed using Rev [17]. All transcription files were analyzed with NVIVO 12 [18]. Study protocols were approved by The University of Texas at Tyler, Health Science Center Institutional Review Board (IRB# 21-002).

Data analysis

This study used a reflexive thematic analysis approach to data analysis [19]. This approach was chosen to allow for themes to be identified that cut across interviews and provide context to the experience of fathers through thoughtful, reflexive engagement with the data. The first author had a deep understanding of the data, as they supported the development of the interview guide, performed all interviews, and developed initial coding structures. The broader research team was comprised of researchers with experience in family-centered care, interpersonal communication, fatherhood, and qualitative data analysis. All authors met regularly to review transcripts and discuss individual reflections, as well as collaboratively describe key sentiments identified in interview transcripts. Through the iterative process of data analysis and revision, the research team identified themes that described the data. Supporting themes were identified to further elucidate the shared meaning of each theme. A single coder identified example quotations for this manuscript.

Results

Interviews focused on wide variety of experiences and beliefs that new fathers had during the height of the COVID-19 pandemic among 34 fathers. Two central themes were identified as describing the overall prenatal care experience of fathers during the COVID-19 pandemic: 1.) missed opportunities to shift toward family-centered care, and 2.) inequity in the parent dyad during prenatal care and pregnancy.

Missed opportunities within prenatal care to shift toward family-centered care was the first central theme identified across father experiences. Practices that intentionally engage the family unit during health care appointments were rarely described by fathers. For example, there was limited patient-provider relationship, lack of telemedicine use, and inadequate uncertainty management for fathers.

Patient-provider relationship. The first example of missed opportunity centered on the lack of relationship development between health care providers and fathers. Fathers described experiences of prenatal care that focused only on the mother and fetus, with no or very little attempt to include the father in any meaningful way. Fathers were not asked by the provider to participate via phone during appointments nor were they direct information on what was covered during appointments. Nevertheless, fathers often reported trying to engage with prenatal care appointments by driving their partner and waiting for her to return from her appointment, writing down questions for the partner to ask the provider, and, if allowed, having his partner call him from in the exam room – yet few fathers reported physical interaction or communication with the doctor providing prenatal care. One father who wanted to participate, but was unable to because of COVID safety protocols said, ‘As soon as we'd get that call [that the room was ready], then she would go in by herself and I would just kind of sit and wait and have to hear whatever the results were from that day, if things are going well, if things were kind of not going well.’

Telemedicine use. Fathers in our sample indicated that there was limited use of modern telehealth technologies to provide prenatal care to families. Telehealth appointments were only occasionally reported as a viable appointment type. When telehealth was used, there was little attempt at including the father in the appointment, even if he was also in the house at the time. As one father told us, ‘Telehealth was offered. […] I think [my partner] had those appointments about every other week,’ yet when asked if they were able to directly engage with the provider, this father said, ‘I think there might have been one telehealth appointment that I sat in on […] But beyond that, no.’ Alternatively, one father described the benefits of telehealth as supporting them through describing the care process and answering questions.

I felt like that's how it was when I would just get hearsay from my wife versus going through tele-medicine, actually being there with the doctor, the doctor explaining to me everything that was going along with the pregnancy and how they were testing for this and how they were expecting test results to come back. And it gave me a sense of calm knowing that I could still talk to an actual doctor and not have to get a relayed message from my wife that would sometimes be lacking detail or she would just forget some certain things. It was a godsend.

A unique experience that one father reported about virtual appointments was also the strongest example of a family-centered care practice identified. During the pregnancy, the midwife directly engaged the father in each virtual appointment by asking for and answering his questions, and teaching him to take a fundal height measurement and use a fetal doppler radar. These activities laid the foundation for strong communication and trust building between the family and provider.

We ended up getting a small, like a Doppler I think it is, to basically listen to the baby's heart rate at home. And so our midwife would just ask me like, all right, like listen to the baby's heart rate, tell me like what the heart rate is, measure the fundal height. So I guess it made, it helped us feel like a little bit more like we had a bit more involvement with the health care, because it's like, we're the ones measuring the heart rate. We're the ones measuring, basically we're doing a lot of the tests that the midwife or a nurse would do at a standard practice.

Uncertainty management. Most fathers said they felt unsupported in making choices in the unknown environment of childbirth during COVID-19. This lack of uncertainty management support left families feeling unable to prepared to navigate the changing COVID-19 safety practices of hospitals and delivery centers. One father reported calling the hospital every week to see what the current policy was and if they would be allowed in the hospital or what was going to be required to enter the hospital. Another father described the stress of not knowing what COVID-19 protocols were at the hospital. He said, ‘There was just a lot of anxiety, I think, heading up to the delivery because you're going into a hospital situation. You don't know what the precautions are going to be like at the hospital. You don't know how bad the COVID situation was going to be. Like when we were having the baby, is it going to be like in the middle of a spike here […]? Or was it going to be in a lull point? So there was a lot of anxiety related to that.’ While prenatal care providers also could not predict changes in COVID-19 protocol, families did not receive guidance or support from providers to mitigate this uncertain and stressful experience.

Limited equity in the parenting dyad during prenatal care and pregnancy was identified as a second central theme of the fatherhood experience during pregnancy and in prenatal care. This theme centers on examples of unidirectional information sharing and limited opportunities for achieving role attainment during pregnancy.

Unidirectional information sharing. Fathers consistently reported the mother as the primary source of information from the prenatal care provider. For example, one father said, ‘on the monthly appointments … it sort of just reduced to a follow-up text from my wife telling me how it went and that's all I got out of it. And if there was anything important, or a note, we talked about over the phone, but usually it was … just a text recapping what they discussed.’ Another father said, ‘[S]he would come home, she would just be like, “Everything's fine,” instead of [me]being there and being part of it. It was different. It was just a lot different. But I felt like we tried our best to include me, but also it was nearly impossible.’ When fathers had questions for the prenatal care providers, fathers said that mothers would report back to them what the answers to their questions were based on information in the prenatal care visits. A common sentiment among fathers was information seeking was primarily for the mother and that the mother would provide an update on what they should know about. Additionally, if fathers had a question for the prenatal care provider, communication was through the mother – not directly. As one father said, ‘[W]e got to a point where we shared a notes folder in our phone and we just wrote down questions we had for the doctor because it was like, “Okay. We got to make sure to ask these.”’

Fatherhood role attainment. Fathers have little access to opportunities that support attaining their role as a father through the existing prenatal care system. In addition to not being allowed the attend prenatal appointments, most fathers also did not complete or have intentions of completing prenatal or infant care classes due to difficulty finding classes that met their needs, were affordable, or were considered high quality. One father said, ‘So we went from our whole plan being in-person classes at the hospital to getting online, reading books.’ When asked about pregnancy or parenting classes, one father said, ‘We were scheduled for one, I think maybe two weeks before she was expecting, but they canceled it […] because of the COVID […] so we didn't get to attend one of those.’ While some fathers reported attending or watching pregnancy or parenting videos online, others were unable to find quality virtual education. For example, one father said:

There was no classes virtually available. We had planned and scheduled to participate in that in March, April, and May. All of that had been canceled. We looked around and we just found maybe previously recorded videos available on YouTube or […] on Facebook[…]. But again, those were primarily more a free intro, and then you got to pay a fee to get more details, and we were just like, ‘This is not helping us.’

Fathers were also given little directed attention on tasks they could do to support the pregnancy or skills they needed to develop for successful parenting. One father described the information that he wished he had:

The biggest thing that I could have out there is just for first time fathers, just to understand how to be a father, really. I mean, it sounds like a stupid thing, it sounds kind of dumb, but it's like, it's really tough being a dad and getting thrown into it and going, ‘Okay.’ Because the whole pregnancy, it was pretty much her, right? You could help here or there, you could do the things that she couldn't do anymore, but whenever you become a father it's like wham, it's there. ‘Here's a baby. Here, take him, he's crying here. Here, here's a bottle, feed him.’ That kind of stuff. And really, the biggest thing that I wish I would have had more knowledge on is how to adapt to parenthood.

Discussion

Despite some research that suggests COVID-19 provided a unique time for pregnant families to bond and reconnect [20], findings of this study suggested some significant missed opportunities to pivot toward or strengthen family-centered prenatal care during the COVID-19 pandemic. Instead of capitalizing on the new circumstances and changes in norms brought about by the pandemic, prenatal care exclusively centered on mother and fetus with little attention given to the father. As previously documented, this exclusion of fathers left them feeling isolated from the pregnancy and with limited opportunities to gain the experience needed to feel prepared for fatherhood when the baby arrived [5,21]. This is particularly concerning as even before COVID-19, fathers often reported mixed feelings related to becoming a father, difficulty adjusting to their new role as a parent, and stresses on their mental health [22,23]. Further, the inequities that father exclusion created in the family dyad also limited information seeking behaviors among fathers. Similar to recent research [24], this study highlights that prenatal care missed the opportunity to implement creative strategies for fatherhood inclusion and likely contributed to deepening inequities in the family dyad and exacerbated existing stresses of adjusting to parenthood. Yet, many of the practices being implemented were seen as risk-mitigation strategies related to the spread of COVID-19. Therefore, the question for the field is, what can be learned from these missed opportunities to put practices into place that could support family-centered care?

First, fathers felt isolated from the pregnancy because of the lack of connection they had with the prenatal care providers and learning opportunities that they missed out on in prenatal care appointments. This limited access to education from prenatal care providers and education classes is concerning as research suggests fathers, particularly first time fathers, need access to education about pregnancy, childbirth, and how to best support their partner during labor and delivery [25]. Further, research has suggested that even before COVID-19 related protocols, fathers wanted more, high quality information from the healthcare provider about how to support their partner and how to navigate their emotions [26]. To shift engagement toward family-centered care, support family-centered communication, and leverage technologies, prenatal care providers should consider using alternative strategies such as telehealth to support father inclusion. This shift may be in the form of traditional telehealth appointments with the provider or father inclusion through video conference if they are unable to physically attend an appointment or through directed communication and inclusion of the father at prenatal appointments, education sessions, and hospital tours.

Healthcare providers should also consider providing fathers with directed information materials that will support their involvement in the pregnancy. These materials may include activities that the father can do with the mother to engage with the fetus, as well as information and tasks specific to how they can support a healthy pregnancy. This was highlighted in recent research that suggests fathers want more information about how to support their partner and growing infant both physically and emotionally [27]. Further, fathers suggest that when they do not receive adequate, quality information it impacts their mental health [26]. While simple in nature, directed communications and education for fathers would provide fathers with opportunities to consider what fatherhood will look like for them and support their role as a father once the infant is born. The example of family-centered care identified during this study can serve as an example and starting place for providers to leverage modern technology to support fathers feeling connected to the pregnancy.

By providing intentional focus on the father during pregnancy, prenatal care will also regain some of the equity in the parenting dyad during pregnancy. This focus is important as fathers having adequate space to take responsibility for their baby during pregnancy will facilitate them to take responsibility more fully during parenting [12]. If fathers feel like they have no place or relevance during pregnancy, it is difficult for them to feel confident in decision making related to their baby [11]. While recent research suggests that father involvement in education is a way to improve parity in parenting roles [28], we believe that father inclusion throughout the prenatal care process in equally as important to support role attainment for fathers.

This study’s strengths include a large, diverse sample of fathers, yet limitations exist. Perspectives of mothers or prenatal care providers were not included. While these perspectives are important, currently there is a dearth of research that highlights the experiences of fathers during pregnancy and early parenting. This study was completed during the height of visitor restrictions within prenatal care, and therefore, may be providing some of the most severe fatherhood experiences related to COVID-19 safety policies. Lastly, this study focused on individuals who identify as fathers, which we acknowledge does not include all individuals who may identify as new co-parents, such as partners in same-sex relationships. Nevertheless, this study gives providers data to learn from and so they can move towards equitably engagement of families now and during the next pandemic.

Conclusion

Prenatal care missed an opportunity to strengthen family-centered care practices through directed communication and inclusion of all family members. Instead of leveraging technology or alternative appointment styles, fathers were excluded from prenatal care immediately following the arrival of the COVID-19 virus, which in turn, created inequities in access to information, support, and feelings of prepareness among fathers. To better support families moving forward, prenatal care providers should actively seek ways to implement robust family-centered care practices that will support families, even during a pandemic.

Ethics approval and consent to participate

The University of Texas at Tyler, Health Science Center Institutional Review Board (IRB#21-002) approved the study protocol and verbal consent process to participate in the study on September 22, 2020. A waiver of written informed consent was approved by the Institutional Review Board, as the board considered that written informed consent was not required due to the virtual nature of interviews. All participants provided informed consent verbally prior to participation in and recording the interview. All methods were carried out in accordance with relevant guidelines and regulations.

Author contributions

NP completed interviews, analyzed data, and drafted manuscript. DM, ED, and MM analyzed data and provided critical contributions to the manuscript revision. All authors read and approved of the final manuscript.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due the sensitive nature of the topic and identifying information in transcripts, but are available from the corresponding author on reasonable request.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This project was funded by the Texas Department of Family and Protective Services to Dr. Dorothy Mandell for the Texas Safe Babies project (IAC 24307170). The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Texas Department of Family and Protective Services.

Notes on contributors

Natalie S. Poulos

Natalie Poulos is an assistant professor in the department of nutritional sciences at the University of Texas at Austin. Her research primarily focuses on early family health through a range of perspectives including father involvement in perinatal care to food and nutrition security of families.

Erin E. Donovan

Erin Donovan is a professor at the University of Texas at Austin in the department of communication studies. His research and teaching focus on how people can successfully navigate difficult conversations with family, friends, and healthcare providers while coping with illness, stress, and uncertainty.

Michael Mackert

Michael Mackert is a professor at the University of Texas at Austin in the department of population health and Stan Richards School of Advertising and Public Relations. His research focuses primarily on the strategies that can be used in traditional and new digital media to provide effective health communication to low-health literate audiences.

Dorothy J. Mandell

Dorothy Mandell is an associate professor at the University of Texas Health Sciences Center Houston in the School of Public Health. Her research has spanned multiple topics in maternal and child health including understanding the long-term effects of a variety of perinatal and post-natal insults and intergenerational transfer of traits.