Father-Inclusive Perinatal ParentJoyce Y. Lee, MSW,a​ Heather Education A. Knauer, PhD,a​ Shawna J. Programs:Lee, PhD,​a Mark P. MacEachern, MLIS, b​ Craig F. Garfield, MDc,​d

CONTEXT: A Systematic’ Review abstract Fathers contribute to their children s health starting at the beginning of life. Few parent education programs include fathers. Among those that do, there is little effort to OBJECTIVE: report program effects on father outcomes. In this systematic review, we examined father-inclusive perinatal parent education DATA SOURCES: programs in the United States as they relate to a range of father outcomes. The databases searched were PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, Ovid Medline, Cochrane Central Register of Controlled Trials, and STUDY SELECTION: PsycINFO. ’ Studies were included if they included an evaluation of a parent education program and a report of father outcomes measured within 1 year of the child s birth and DATA EXTRACTION: were conducted within the United States. RESULTS: Of 1353 total articles, 21 met study criteria. The overall state of the father-inclusive perinatal parent education program literature was poor, with few interventions available to fathers. Available programs were ’ ’ associated with increased father involvement, coparenting relationship, partner relationship quality, father s mental health, and father s supportive behaviors. Program effects on father- infant interaction, parenting knowledge, and attitudes and parenting self-efficacy were LIMITATIONS: inconclusive. Three programs emerged as best evidence-based interventions. Risk of bias was high for many studies. Outcome variability, small sample size, and CONCLUSIONS: publication bias contributed to the weak evidence base. There is a need for more evidence-based interventions to support fathers. Clinicians play a key role in engaging fathers in early parent education programs and health care settings. PROSPERO registration number: CRD42017050099.

aSchool of Social Work, University of Michigan, Ann Arbor, Michigan; bTaubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan; cDepartment of Pediatrics, Feinberg School of Medicine, Northwestern University, Evanston, Illinois; and dDivision of Hospital Based Medicine, Lurie Children’s Hospital of Chicago, Chicago, Illinois Ms Lee conceptualized and designed the study, processed the data, developed the data abstraction and risk of bias instruments, conducted analyses, and drafted the initial manuscript; Dr Knauer processed the data, developed the data abstract and risk of bias instruments, conducted analyses, and drafted portions of the manuscript; Dr Lee conceptualized and designed the study and drafted portions of the manuscript; Mr MacEachern designed the data collection instruments, collected data, conducted analyses, and drafted a portion of the manuscript; Dr Garfield provided input on study conceptualization and design and drafted portions of the manuscript; and all authors reviewed and revised the manuscript and approved the final manuscript as submitted and agree to be accountable for all aspects of the work. DOI: https://​doi.​org/​10.​1542/​peds.​2018-​0437

To cite: Lee JY, Knauer HA, Lee SJ, et al. Father-Inclusive Perinatal Parent Education Programs: A Systematic Review. Pediatrics. 2018;142(1):e20180437

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 142, number 1, July 2018:e20180437 REVIEW ARTICLE Father involvement with children1 has increased in recent decades. Research has demonstrated the ’ positive contributions– fathers make to their children2 6 s health and well-being. ‍‍ For instance, father involvement has been linked to decreased risk of prematurity 2,3​ ’ and infant mortality. ‍ It has also been associated with the7 father s parenting confidence,​ positive8,9​ father-child interactions,10 ​ ‍ future father involvement,​ and healthier11 coparenting relationships. Father involvement benefits fathers themselves; men who are involved FIGURE 1 A CINAHL adaptation of the search template as an example of the search strategy. with their children report greater12,13​ physical and mental health. Despite the accumulating evidence 27 ’ for the benefits of father involvement, are high,​ a review that is focused pregnancy through the first year of few early parent education programs on US-based interventions is the child s life. have focused on including fathers. warranted. Hence, our aim in this We created a general search The vast majority of existing – systematic review was to examine template using keywords for father parent education programs target 14 18 ’ literature on US-based father- involvement in perinatal parenting mothers. ‍ This disparity in inclusive parent education programs programs that could be applied service likely hinders men s across the perinatal period. We to all 6 databases with minimal engagement in important pregnancy- used the Preferred Reporting Items tailoring (see Fig 1 for an example of and childbirth-related decision- ’ for Systematic Reviews and Meta-28,29​ a CINAHL adaptation) (Supplemental making processes. It is also important Analyses (PRISMA) approach ‍ Information). The computer-based to involve fathers in their children s and included a broad range of father search yielded 1353 unique results lives as early as possible because this × – outcomes and research designs to that were exported to an EndNote may serve to reduce the risk of child 30 19 21 ensure comprehensiveness. 6 library. This study was maltreatment. ‍‍ Among programs METHODS preregistered at PROSPERO: www.​ that do include fathers, relatively few crd.york.​ ​ac.​uk/​PROSPERO/​display_​ examine whether program effects Data Sources Inclusionrecord.php?​ and​ID= Exclusion​CRD42017050099. Criteria ​ are associated with father outcomes separate15 from that of mother or couple. This is because mother and A computer-based search was To capture the widest breadth, father data in analyses have been conducted in 6 electronic databases, 15 studies were included in this aggregated in studies. including PubMed, the Cumulative systematic review on the basis of the Index to Nursing and Allied Health Previous systematic reviews of following criteria: (1) the study was Literature (CINAHL), Embase, Ovid father-inclusive parent education conducted by using experimental Medline, Cochrane Central Register programs have been limited by (ie, RCT), quasi-experimental (ie, of Controlled Trials, and PsycINFO on having either a narrow scope (ie, no control group or no pretest), and July 28, 2017. including randomized controlled nonexperimental (eg, qualitative) trials [RCTs] only) or broad scope (ie, Publication date for included methods to evaluate perinatal parent looking at child outcomes spanning studies was not restricted. Because education programs; (2) the study “ ” from infancy– to adolescence, the United States context in which included or targeted fathers; (3) a including15, both22​ 25 international and US fathering occurs is diverse, father US sample was used in the study; studies). ‍ ‍ Given the unique was defined broadly to include (4) the methods of the study were characteristics of fathering in biological, residential, nonresidential, implemented in various settings (eg, the United States, where rates of26 adolescent fathers, father figures, hospital, online); (5) the researchers unmarried childbearing (40%) and father surrogates. Perinatal was of the study measured and reported and nonresidential fathering (16%) defined as a period spanning from on father outcomes (for details, see Downloaded from www.aappublications.org/news by guest on September 29, 2021 2 LEE et al next section); and (6) the researchers ’ of the study assessed outcomes within 1 year of the child s birth (but could have subsequent follow-up assessments). Studies were included regardless of program effectiveness but were excluded if the researchers only reported aggregated mother and father outcomes or if the studies were not peer-reviewed (eg, dissertations and theses). Detailed ’ inclusion and exclusion criteria can be found in the study s PROSPERO preregistration. By using these criteria, study titles, abstracts, and full-texts were reviewed. In Fig 2, a PRISMA flowchart of this selection Dataprocess Abstraction is provided.

The following information was abstracted from each study: author, publication year, study aim, study design, name of the program, population, father outcomes, and results. Abstracted father outcomes included: (1) father-infant ’ interaction; (2) father involvement; ’ (3) father s parenting knowledge; FIGURE 2 ’ (4) father s attitude and parenting A PRISMA flowchart of the study selection process. self-efficacy; and (5) father s ’ coparenting relationship with the mother. Father s mental health 31,32​ “ ” and effects across programs. ‍ We attrition, and reporting. We assigned was abstracted as a secondary “ ” “ ” “ ” thematic category, along with other used father outcomes as classification an RoB rating for each category ’ father-related outcomes, including schemes for synthesizing data. We as low,​ high,​ or unclear. A ’ partner relationship quality, father s also organized the narrative by value of 1 was assigned to low-risk supportive behaviors, and father s study design and risk of bias (RoB) responses and a value of 0 to high- assessment to weigh the evidence risk and unclear responses. Each evaluationData Synthesis of the intervention. according to methodological32 study received a total value between strengthsAssessment and of weaknesses RoB . 0 and 4. Studies receiving a score of 2 or less were deemed to be high- We used a narrative approach, which risk. The adapted RoBANSs, along ’ is a preferred method when empirical with details of each bias category, is approaches and variables are highly To assess RoB in each study, we used included in the study s PROSPERO varied across studies, for example, in an adapted version of the risk of bias preregistration. terms of population, interventions, assessment tool for33 nonrandomized RESULTS outcomes, and measurement of studies (RoBANSs) rather34 than the outcomes. This approach relies Cochrane Risk of Bias Tool because Description of Studies on the use of words and texts to of the small number of RCTs and summarize31 and explain study greater flexibility of the RoBANSs findings. We examined aspects in assessing studies with various Twenty-one of 1353 articles met of study designs and intervention research designs. We assessed RoB study criteria. Of these, 16 studies characteristics as reasons for for the following bias categories: were quantitative (7 RCTs, 1 quasi- potential differences in directions participant selection, detection, RCT, 7 quasi-experimental, and 1 Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 142, number 1, July 2018 3 TABLE 1 Research Designs of Included Studies (N = 21) Research Design Distribution of Studies nonexperimental) and 5 studies were Frequency, n (%) Reference No. qualitative (4 mixed methods and 1 phenomenological) (Table 1). In Quantitative studies 16 (76.2) ,​ ,​ ,​ ,​ ,​ ,​ the 21 studies, 19 different father- RCT 7 (33.3) ‍34 ‍35 ‍38 ‍46 47 ‍51 ‍52 Quasi-randomized 1 (4.8) 49‍ inclusive perinatal interventions Quasi-experimental 7 (33.3) were evaluated, of which 11 were Pretest-posttest control group 3 (14.3) ‍36,‍37​ ,‍54​ ,​ ,​ ,​ focused on general– education of No pretest or no control group 4 (19.0) ‍39 ‍40 ‍48 ‍53 childbirth and infant care and Nonexperimental 1 (4.8) ‍41 35 46 Qualitative studies 5 (23.8) development,​ ‍‍ 4 –were focused Mixed methods 4 (19.0) ‍42–‍45 on partner relationship and/or 47 51 – Phenomenological 1 (4.8) 50‍ coparenting skills,​ ‍‍ and– 4 were clinical- or case management52 55 based interventions (Table 2). ‍‍ In 8 programs, middle-class, majority – samples, lack of blinding, and income an RCT of a clinical intervention in white parents were primarily 38,40​ 44,47,​ 48,​ 51​ outcome data. The following section which fathers observed a neonatal targeted. ‍‍ ‍ ‍ In 4 of the 52 – provides a narrative synthesis assessment revealed improvement programs, unmarried couples were 35 37,49​ of study outcomes, with more in the quality of father-infant included. ‍ ‍ Four programs were consideration given to studies with interactions at 2 months postpartum. designed for adolescent parents, lowNarrative RoB than Synthesis those with by Father high RoB. Although all of the above revealed all of whom were ethnic and racial 39,50,​ 54,​ 55​ Outcomes significant positive program effects minorities. ‍ ‍ In 8 programs, – – – on some aspect of father-infant first-time parents were primarily Father-Infant Relationship 35 37,42,​ 52​ 35 37,43,​ 47​ 49,51,​ 52​ interaction,​ ‍ ‍ ‍ all but the first targeted. ‍‍ ‍ ‍‍ ‍ ‍ For further 47 RCT were at high RoB. details see Table 3. Father Involvement In 6 quantitative studies (4 RCTs, Study sample sizes were small, and 1 quasi-experimental, and 1 they ranged between 14 and 173 nonexperimental),– researchers Researchers for 4 quantitative participants. Most studies included examined 35father-child37,42,​ 47,​ 52​ interaction studies (2 RCTs, 1 quasi-RCT, and 1 examination of a father-inclusive outcomes. ‍ ‍ ‍ ‍ The results of quasi-experimental) examined48,50,​ 52,​ 54​ father perinatal parent education program an RCT of47 a coparenting relationship involvement outcomes. ‍ ‍ ‍ The at a single time point. Only 1 study program revealed that intervention results of48 an RCT of a coparentingd contained an examination48 of long- group fathers demonstratedd = program revealed significantly term outcomes. In the majority of fewer dysfunctional parent-child more positive parenting ( = d0.45; the studies, researchers implemented interactions (effect size 0.70) eg, support for child exploration) ’ programs in hospital settings, with compared with control group fathers and less negative parenting ( = outcomes based on parents self- at 6 months postpartum. The results 0.60; eg, irritability) by the father reports.– Some researchers delivered of an RCT35, of36​ a general education when the child was 1 year old. The the intervention35 40,48,​ 55​ at the group43, 49,​ 52​ program ‍ revealed significantly results of a quasi-randomized study50 level,​ ‍‍ ‍ ‍ couple10,42,​ level,45,​ 46​ ​ ‍ ‍ improved sensitivity during father- of another coparenting program or individual level. ‍ ‍ Studies infant feeding interactions before revealed no effects at posttest ’ also differed in whether researchers hospital discharge but not at the (during pregnancy) but did reveal a used a manualized curriculum, who 1-month follow-up. The results of significant improvement in father s delivered the sessions (eg, nurse a quasi-experimental study of a engagement in caregiving activities 37 ’ versus social worker), when the second general education program (eg, feeding the infant, changing ’ p sessions were delivered (eg, before revealed significantly more diapers) by both father s and p 2 birth versus after birth), and mode of socioemotional growth fostering by mother s reports2 (effect sizes η​​ ​ ​ = intervention delivery (eg, in-person fathers and mutual socioemotional 0.07 and ​​η​ ​ ​​= 0.08, respectively) at versus mobile application) (for father-child interactions with 3 months postpartum. Both of these details see Table 2). Of the 21 studies, children ages 6 to 24 months. The studies were rated to have low RoB. only 4 were categorized as low RoB results of a nonexperimental study The results of a quasi-experimental

(ie, scoring 3 or higher) and 17 high of a third42 general educational study of a case management54 program RoB (ie, scoring 2 or less) as shown in program revealed a significant link for adolescent fathers revealed ’ ‍Table 4. Most of the high-risk studies between full program participation that fathers in the intervention were given that categorization and mothers reports of father-infant group had greater attendance of because of the use of convenience relationship. Finally, the results of prenatal health visits, fatherhood Downloaded from www.aappublications.org/news by guest on September 29, 2021 4 LEE et al TABLE 2 Types of Father-Inclusive Perinatal Parent Education Programs (N = 19) Author, y Program Name Program Description and Details General education programs of childbirth, infant care, and development Bryan,37​ 2000 Growing as a Couple and The intervention delivered 3 classes (total 2 h) of parent-child interaction content in the areas of Family parental roles, infant communication abilities, and patterns of development across the first 3 mo of the infant’s life. Use of manualized curriculum was unclear. Intervention was delivered before birth. Mode of delivery included media and potentially in-person lessons. Diemer,​38 1997 N/A The intervention delivered father-focused perinatal discussion classes that included content regarding pregnancy, childbirth, parenting, social network support, and coping skills. The intervention was an 8-wk program and used both a standard curriculum by childbirth educators and a curriculum developed by the researchers. Veteran childbirth teachers taught the classes in person during pregnancy. Fawcett and N/A The intervention was an antenatal educational program. Mode of delivery involved a pamphlet with Burritt,​43 1985 cesarean birth information and a follow-up home visit or telephone call to review the pamphlet content. The intervention did not use a manualized curriculum. It was unclear who delivered the intervention. It seems as if intervention occurred during pregnancy. Fawcett and N/A The intervention involved the same pamphlet as above, as well as focused discussions about caesarian Henklin,​44 1987 birth instead of home visit or telephone call. Mode of delivery included a pamphlet and in-person sessions. There was no manualized curriculum. Discussions were delivered by a childbirth educator during pregnancy. Hart and Foster,​40 N/A The intervention delivered childbirth education classes that included sessions on labor, pain 1997 management, unexpected events, relaxation, vaginal or cesarean birth, and rehearsing labor day. Use of manualized curriculum was unclear. It was also unclear who delivered the intervention. It seems to have occurred during pregnancy. Mode of delivery seems to have included both video and in-person sessions. Mackert et al,​45 2015 My Pregnancy Today The intervention was an e-health application that included a slideshow that detailed fetal development wk-by-wk. A total of 5–7 min was allotted for navigating and browsing the application content on a tablet computer. The e-health application was developed by BabyCenter, LLC. It was unclear when the intervention was delivered. Mode of delivery included mobile device. Mackert et al,​46 2017 N/A The intervention was an e-health application that included a slideshow that detailed fetal development wk-by-wk. A total of 5–7 min was allotted for navigating and browsing the application content on a tablet computer. The e-health application was developed by the researchers. It was unclear when the intervention was delivered. Mode of delivery included mobile device. Pfannenstiel and Information and The intervention involved 2 1.5-h in-person sessions regarding fetal capacity and functioning, Honig,​35,‍36​ 1991, Insights About Infants pregnancy, father self-image, attitude toward infant, infant capacity and functioning, responsive 1995 Intervention parent-infant interactions, and skills and activities in caring for an infant. A booklet summarized content, and a life-size doll was used to model nurturing and caregiving behaviors. The intervention was delivered between 2 mo of pregnancy and birth by an “intervenor.” Smith and Smith,​41 Parent Education Project The intervention involved 9 in-person prenatal and postpartum group classes to educate parents about 1978 pregnancy, child birth, infant care, parenting, and child development. The intervention employed a teaching guide to facilitate discussion. The intervention was delivered by an “instructor” and lay volunteers. Four classes were delivered before birth and 5 classes were delivered after birth. Van de Carr and Prenatal University The intervention involved an instructional manual distributed to expectant parents, a video shown in the Lehrer,​42 1986 physician’s office, and a question and answer period with the physician. The intervention materials included information to enhance fetal development, early communication, brain growth, and health practices during pregnancy. Two physicians seemed to have delivered the intervention during pregnancy. Mode of delivery included videos, audios, and in-person sessions. Westney et al,​39 1988 N/A The intervention delivered 4 2-h in-person prenatal classes that addressed sexuality, pregnancy and prenatal care, labor and delivery, and infant and child care. The classes employed lectures, audiovisual aids, and discussions. Use of manualized curriculum was unclear. The intervention was delivered during pregnancy by a registered nurse. Mode of delivery included video, audio, and in- person sessions. Relationship or coparenting programs Fagan,​50 2008 Minnesota Early Learning The intervention involved 5 1.5-h in-person sessions of a coparenting curriculum to educate young Design for Young Dads fathers about responsibilities for parenthood, communication with the mother, benefits to infants when parents support each other, and development of coparenting solidarity. A manualized curriculum was used. The intervention was delivered prenatally by experienced social workers and peers (ie, male African American parents).

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 142, number 1, July 2018 5 TABLE 2 Continued Author, y Program Name Program Description and Details Feinberg and Kan,47​ Family Foundations The intervention involved 8 psychoeducational group classes. The intervention was focused on emotion 2008; Feinberg management, conflict management, problem solving, communication, and mutual support strategies. et al,​48 2009 A manualized curriculum was used. Four sessions were delivered prenatally and 4 postnatally. The intervention was delivered by a male-female team. Mode of delivery included didactic presentations, exercises, videos, and group discussion. Gambrel and Mindful Transition to The intervention delivered a 4-wk group-based program that used mindfulness practices (eg, body Piercy,​51 2015 Parenthood Program scan, mindfulness of breath, open awareness) and activities (eg, communication and perspective- taking exercise) to develop interpersonal attunement. Each session was 2 h long and held once a wk. Use of a manualized curriculum was unclear. The intervention was delivered by Gambrel51 who has experience working as a therapist for 15 y. It was unclear exactly when the intervention was delivered, although it seems as if it occurred during pregnancy. Mode of delivery included in-person sessions. Salman-Engin Figuring It Out for the The intervention involved 6 sessions of a dyadic coparenting curriculum, and intervention content et al,​49 2017 Child included consciousness raising, skill building, and enactment of skills. A booster session was delivered 1 mo postpartum. A manualized curriculum was used. The intervention was delivered prenatally by 3 African American male mentors who were affiliated with county fatherhood programs and 4 African American female mentors who were experienced home visitors or health educators. All mentors had experience working with young African American men or women but had little to no formal couple counseling experiences. Mode of delivery involved in-person sessions. Clinical or case management programs Barth et al,​54 1988 Teenage Pregnancy and The intervention involved in-person sessions with counselors to manage clients across programs Parenting Project and systems. The intervention provided one-to-one counseling, brokering services, and a weekly fatherhood group. A manualized curriculum was not used. It was unclear when the intervention was delivered, although seemingly it was delivered postpartum. The intervention was delivered by counselors. Beal,​52 1989 Neonatal Behavioral The intervention involved a single in-person demonstration of the Neonatal Behavioral Assessment Assessment Scale Scale. Immediate and continuing feedback, as well as a terminal summary statement, was provided to parents during the demonstration. A manualized curriculum was not used. The intervention was delivered 2–3 d postpartum, usually before hospital discharge, by Beal.52 Field et al,53​ 2008 N/A The intervention involved fathers learning how to conduct a pregnancy massage, a DVD on the massage, and fathers delivering 20-min massages to the mother twice a wk for 16 wk. Each session included the father massaging the mother’s head, neck, back, arms, hands, and feet. A manualized curriculum was not used. The intervention was delivered between the second trimester and 32 wk of pregnancy by trained massage therapists. Mode of delivery involved DVD and in-person sessions. Smith et al,​55 2016 Centering Pregnancy The intervention was a group-based prenatal care program and case management. The prenatal class examined nutrition, exercise, relaxation, childbirth preparation, infant care and feeding, postpartum care, communication, relationships, and parenting. Case management involved assessment of participant needs and identification of resources. The intervention used handouts, worksheets, and skill-building exercises to enhance group sessions. Use of a manualized curriculum was unclear. The intervention seems to have been delivered during pregnancy. The intervention was delivered by male social workers. Mode of delivery involved in-person sessions. DVD, digital video disc; e-health, electronic health; N/A, not applicable.

Father’s Knowledge, Attitudes, and Mental Health groups, birthing classes, and at birth of methodological limitations, such Father's Parenting Knowledge compared with control group fathers. as ambiguity in when pretest and posttest were administered (eg, Additionally, mothers in a qualitative51 study of a relationship program whether during pregnancy or how Researchers for 3 quantitative reported greater commitment Father'smany months Attitudes at postpartum). and Parenting studies (1 RCT, 1 quasi-experimental, from their male partners as well as ’ Self-Efficacy and 1 nonexperimental) examined willingness from male partners to fathers parenting knowledge 35,39,​ 41​ ’ discuss preparations for childbirth outcomes. ‍ ‍ All 3 programs and future involvement. However, had significant effects on fathers Researchers for 3 quantitative these studies were rated at high RoB. knowledge of infant care and/or studies (1 RCT, 1 quasi-RCT, ’ In contrast, the results of an RCT of 52 development or pregnancy and35,39,​ 41​ and 1 nonexperimental) and 1 a clinical intervention with a high prenatal parent knowledge. ‍ qualitative study– examined father s

RoB revealed no effects on father However, these studies were attitudes and40,50​ parenting52 self-efficacy involvement in caregiving. deemed to be at high RoB because outcomes. ‍ ‍ ‍ The results of Downloaded from www.aappublications.org/news by guest on September 29, 2021 6 LEE et al tum < .01). No difference in father-infant interaction quality ( P < .01). No difference in father-infant amount between groups between groups differences between groups interactions compared with control at 6 mo postpartum ( P < .05) sensitivity) and lower levels of negative parenting (eg, irritability) compared with control at 1 y ( P < .05) parenting-based closeness with their partner compared with control at 6 mo postpartum ( P < .05). Lower coparental competition and triangulation compared with control at 1 y ( P < .05). No significant difference between groups for coparenting undermining at 6 mo or 1 y groups for depressive symptoms and anxiety at 6 mo compared with control at 1 y ( P < .05) anxiety compared with control ( P < .01) of relationship with their partner compared with control ( P < .01) discharge of infant) and 1 mo postpartum discharge than control interactions on the day of hospital discharge ( P < .01). Fade out of program effect by 1 mo postpartum ( P = .06) and development than control ( P < .001) Outcomes assessed at 2 mo postpartum interaction interaction: higher father-infant Father-infant Father involvement in caregiving: no significant differences Father ’ s attitude and parenting self-efficacy: no significant Results Related to Father Outcomes Father-infant interaction: less parent-child dysfunctional Father-infant Father involvement: higher levels of positive parenting (eg, Coparenting relationship: higher coparenting support and Father ’ s mental health: no significant differences between Other (ie, partner relationship): more partner warmth Outcomes assessed at 6 mo and 1 y postpar Outcomes assessed at 32-wk gestation Father ’ s mental health: decreased levels of depression and Other (ie, partner relationship quality): improved perceptions Outcomes assessed at intrapartum (birth through hospital interaction: more sensitive during feeding Father-infant Father ’ s parenting knowledge: more knowledge of infant care 000; 90%

of education; working class; majority white mean age 29.76 y; 14.5 y of education; median family income $65 white income, ethnic and racial minorities their partner in second trimester of pregnancy; mean age 27.9 y; 46% of women with high school degree or less; predominantly low to middle income; 59% of the women Hispanic, 32% African American, 9% white white y; mean 11 y of education; 70% white; 54%; unmarried Target population: working class, white Target N = 44 fathers All first-time fathers; mean age 28 y; 14 y Study Population Target population: middle class, white Target N = 169 couples All primiparous and cohabiting couples; Target population: low- to middle- Target N = 47 women Prenatally depressed women and Target population: low-income, majority Target N = 67 fathers All first-time fathers; age range 19 – 32 on father-infant interaction and on father-infant other outcomes positive effects on the short-term outcomes, including coparenting, parental depression and anxiety, and distress in the parent-infant relationship at posttest massage therapy delivered by fathers twice a wk for 16 could reduce fathers ’ mental health issues and improve perceptions of relationship with mother a prenatal information support program on father ’ s knowledge of child care and development, sensitivity, and empathy with infants among first-time, low- income fathers-to-be in both low- and high-risk pregnancy situations To investigate the effects of NBAS Study Aim To assess whether the FF had To examine whether pregnancy To determine the effectiveness of ’ s Parenting and Health Outcomes ( N = 21) RCT Study Design RCT RCT RCT ; ​ 36 ‍ 35, 56 g n Feinberg Feinberg 47 ​ ; pregnancy 53 l ; FF  Study Characteristics and Results for Father

48 l ; NBAS; Brazelto 52 l massage therapy delivered to mothers by fathers et a Information and Insights About Infants (III) Author, Program Author, Feinberg and Kan, Feinberg Bea Field et a Pfannenstiel and Honi TABLE 3

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 142, number 1, July 2018 7 = 0.05. ​ ​​ 2 p ​ tum η ​​ = 0.19) ​ ​​ 2 p ​ ​​ η = 0.07) ​ ​​ 2 p ​ ​​ η ’ reports ’ s support of the mother ( P < P < .001) at follow-up ( = 0.07 for fathers ​ ​​ 2 p ​ ​​ η = 0.10, respectively. Significant increases ​ ​​ 2 p ​ ’ s supportive behaviors): significant increases η ​​ = 0.09 and ​ ​​ 2 p ​ in parenting alliance ( η differences in parenting competence at follow-up alliance ( P < .001) and communication .01) compared with controls immediately after program. Effect sizes, ​​ compared with controls in father ’ s support of the mother ( P < .05) compared with control immediately after program. Effect size, Significant increases in father .05) compared with controls at follow-up ( higher in socioemotional growth fostering ( P < .05) compared with control group fathers. Intervention group fathers also scored higher on the contingency scores for mutual socioemotional interaction between father and child compared with control group fathers ( P < .05) significantly increased mean total parenting knowledge scores ( P < .05), as well on pregnancy and prenatal ( P < .05) and infant development care .01) subscales, compared with control correlations ( P < .05) between father ’ s parenting knowledge and supportive behaviors for both intervention and control group fathers pregnancy) with a follow-up at 3 mo postpartum in prenatal involvement immediately after program. There was significantly higher father involvement with infant caregiving compared with control at 3 mo postpartum ( P < .05). Effect size, Father ’ s attitude and parenting self-efficacy: no significant Coparenting relationship: significant increases in parenting Other (ie, father Results Related to Father Outcomes Father-infant interaction: intervention group fathers scored Father-infant Outcomes assessed at on average 10.5 mo postpar Outcomes assessed immediately after the program Father ’ s parenting knowledge: intervention fathers Other (ie, father ’ s supportive behaviors): significant Outcomes assessed immediately after program (during Father involvement: no significant differences between groups 999;

– $29 000

income, white age 28 y; 44% of participants had some college education and 39% had completed college or beyond; median annual income $20 majority white; primiparous American for intervention group fathers; mean age 17 y for control group fathers; African American and racial minorities grade; 47.3% African American, 38.8% Hispanic; 85.5% primiparous Study Population Target population: low- to middle- Target N = 77 couples All married or unmarried couples; mean Target population: adolescent, African Target N = 28 couples All unmarried couples; mean age 16.9 y Target population: adolescent, ethnic Target N = 154 fathers Age range 14 – 25 y; 55% completed <12th GCF, a prenatal couple group GCF, intervention, on parent-infant interaction postbirth prenatal education program for unwed adolescent fathers on their knowledge of prenatal delivery, and infant care, labor, development and care; (2) the relation between knowledge and supportive behaviors toward mother coparenting intervention on fathers ’ support of the mother, parental alliance, coparenting communication, father prenatal involvement, father engagement with the infant, and parenting self-efficacy Study Aim To determine the effects of To examine the effects of a prebirth pretest-posttest control group) follow an intent-to-treat model, the authors created a no-intervention control group from the postrandomization attrition group Study Design Quasi-experimental (ie, RCT, nonrandom sampleRCT, To examine (1) the effects of a Quasi-RCT; rather than Quasi-RCT; for Young 57 n ; prenatal 39 l Continued

; Minnesota Early ; GCF 50 37 n n Learning Desig education program Dads (Minnesota Early Learning Design, 1997) Author, Program Author, Brya Westney et a Faga TABLE 3

Downloaded from www.aappublications.org/news by guest on September 29, 2021 8 LEE et al ’ s mental health: higher levels of seeking social support as a coping mechanism compared with control ( P < .05). No significant group differences in other coping strategies support compared with control ( P < .05). There were no significant group differences in other spousal supportive behaviors (eg, infant and/or pregnancy support) conflict tactic compared with control ( P < .05). No significant group differences in the use of verbal aggression as a conflict tactic and at birth birth ( P < .01), participate in prenatal health visit ( P < .05), attend fatherhood groups ( P < .001), birthing classes ( P < .001) compared with non-TAPP fathers father ’ s levels of anticipated control during labor and delivery after participating in the childbirth classes ( P < .01) scores did not significantly decline between groups groups Results Related to Father Outcomes Outcomes assessed during third trimester Father Other (ie, father ’ s supportive behaviors): more housework Other (ie, partner relationship quality): more reasoning as a Outcomes assessed at various time points during pregnancy Father involvement: TAPP fathers were more likely to attend Outcomes assessed immediately after the program Father ’ s attitude and parenting self-efficacy: increase in Outcomes assessed at 3 mo postpartum Father ’ s mental health: fathers self-reported depression Outcomes assessed at 1 mo postpartum Other (ie, father ’ s supportive behaviors): no differences Other (ie, partner relationship quality): no differences between 250;

y; average family income $35 majority white and married; 71% first pregnancy and racial minorities and 34% graduated from high school; 50% African American, 30% Hispanic, 10% white majority white high school degree and 42% had college degree; majority white; 82% of mothers primiparous American for fathers (range: 14 – 40); all families had income 200% below poverty level; African American; unmarried and racial minorities of mothers in school; 42.2% did not have enough money to live on; majority African American and Hispanic Study Population Target population: middle-income, white Target N = 83 couples Mean age 28 y; average education 14.3 Target population: adolescent, ethnic Target N = 121 fathers Mean age 19; 33% enrolled in school Target population: middle-income, Target N = 73 couples Mean age 31 y (range: 15 – 54); all had Target population: low-income, African Target N = 14 couples All primiparous couples; mean age 24 y Target population: adolescent, ethnic Target N = 173 adolescents Mean age 18.7 (range: 15 – 29); majority focused discussion perinatal classes with traditional childbirth classes on expectant fathers ’ stress or psychological symptom status, coping strategies, social support, and spousal relations at posttest effects on infants ’ birth weights attitudes toward childbirth before and after childbirth education classes derived material benefits from participation in the prenatal FIOC coparenting intervention prenatal intervention on partner relationship and perceived male partner support Study Aim To compare the effects of father- To describe TAPP and analyze its To examine couples ’ prenatal To examine whether parents To examine the effects of pretest-posttest control group) pretest; posttest only with nonequivalent groups) control group; 1 group pretest-posttest) control group; 1 group pretest-posttest) pretest-posttest control group) Study Design Quasi-experimental (ie, Quasi-experimental, (ie, no Quasi-experimental (ie, no Quasi-experimental (ie,

; FIOC Quasi-experimental (ie, no ​ 58 49 l ; child birth 40 r ; Rising, ; TAPP 55 54 l l Continued ; father-focused ; father-focused

38 r discussion perinatal classes education classes that included sessions on signs stages of labor, of labor, pain management, etc group-based prenatal care program and case management Author, Program Author, Dieme Smith et a Hart and Foste Salman-Engin et a Barth et a TABLE 3

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 142, number 1, July 2018 9 knowledge of when a child begins to see or hear, but there knowledge of when a child begins to see or hear, was improvement in father knowledge of child development ( P < .05) application was used reported enjoying the graphics and stated that they were easy to understand. They also liked the overall “ feel ” of application. Men expressed mixed opinions about whether they would use an application such as this one in the future during pregnancy generally stated that the application was easy to use and that it contained useful information; in general, participants felt there was ‘‘ just the right amount of information ’’ presented, and they did not need to click on the videos for more information fathers indicated that the pamphlet was informative. All fathers stated that the follow-up home visit or phone call was beneficial in that it provided opportunity for clarification of pamphlet content and provision additional information about pregnancy in general and cesarean birth differences in men ’ s reactions to the pamphlet were found between the fathers from cesarean delivery group and those from the vaginal delivery group. Most men indicated that the pamphlet provided information they needed to prepare for the possibility of a cesarean birth. All but 1 man in each delivery group stated that the pamphlet and class discussion provided desired information reported more enhanced father-child relationship compared reported more enhanced father-child with the nonparticipants group ( P < .05) Results Related to Father Outcomes Outcomes assessed at last session Father ’ s parenting knowledge: no improvement in father Outcome assessed during and immediately after the e-health Other (ie, father ’ s evaluation of the intervention): most men Outcome assessed during and immediately after using the tool, Other (ie, father ’ s evaluation of the intervention): men Outcome assessed shortly after birth Other (ie, father ’ s evaluation of the intervention): 13 of 15 Outcome assessed at 1 – 3 wk postpartum Other (ie, father ’ s evaluation of the intervention): no significant Outcomes assessed on 6 mo to 3-y-old children interaction: full- and partial-participantFather-infant groups married of mothers completed greater than high school; 73% were primiparous; married level of postsecondary education; 52% white, 26% Hispanic, 9% Asian, 4% African 9% multiracial or other, American minorities least high school diploma or GED; 38% Hispanic, 28% African American; white; 6% multiracial; majority had at least 1 child or a partner who was pregnant mean age 31.3 y for fathers; upper- middle to upper class upper class mean age 31.5 y for men; majority to upper class upper-middle information) Study Population Target population: middle- income, Target N = 41 couples Mean age 29.1 y; 70% of fathers and 47% population: majority white Target N = 23 adult men Mean age 26 y; all men had at least some population: ethnic and racial Target N = 32 adult men Mean age 33.2 y; 75% reported having at Target population: upper-middle income population: upper-middle Target N = 15 couples Primiparous who had a cesarean birth; Target population: upper-middle to population: upper-middle Target N = 42 couples Pregnant women and their male partner; Target population: middle-income Target N = 150 parents Multiparous (no other demographic physical and psychological aspects of pregnancy, childbirth, infant care, parenting, and child development, and to establish and strengthen parents ’ systems of support e-health application to educate men about pregnancy-related health e-health application to educate men about pregnancy-related health information regardless of the men ’ s level of health literacy education program of cesarean birth information delivered and cesarean- delivered parents to an antenatal educational program of cesarean birth information and to determine the feasibility of incorporating the educational program into Lamaze childbirth preparation classes Prenatal University program on relationships as father-infant perceived by the mother Study Aim To educate parents about the To investigate the value of an To investigate the value of an To develop and test an antenatal To compare responses of vaginally To examine the effects of control group; 1 group pretest-posttest) posttest only) Study Design Quasi-experimental (ie, no Mixed methods Mixed methods Mixed methods Mixed methods Nonexperimental (3 groups, ; 42 r ; ; 44 43 n t ; parent 41 h ; pregnancy- ; My Pregnancy 46 45 l l Continued

education project related e-health application on a tablet computer developed by authors no date), Today (BabyCenter, a pregnancy-related e-health application on a tablet computer educational pamphlet on cesarean delivery and follow-up via home visit or telephone call to reinforce pamphlet content educational pamphlet on cesarean delivery and follow-up via home visit or telephone call to reinforce pamphlet content Prenatal University (Van de 1979) program during Carr, pregnancy Author, Program Author, Smith and Smit Van de Carr and Lehre Fawcett and Henkli Mackert et a Mackert et a Fawcett and Burrit TABLE 3

Downloaded from www.aappublications.org/news by guest on September 29, 2021 10 LEE et al a quasi-RCT of a coparenting 50 ’

ting program revealed no program effects on fathers sense of parenting competence at 3 months postpartum. This was the only study considered to

have low RoB. Similarly, the results52 of an RCT of a clinical program ’ revealed no program effects on fathers attitudes toward caregiving at 2 months postpartum. In contrast,

the results40,51​ of 2 nonexperimental studies ‍ revealed positive effects in the prepartum period. Specifically, stronger commitment from their male partners as well as more willingness from male partners to discuss preparations for childbirth and future involvement preparedness for parenthood; they felt more confident about becoming parents regulation of negative emotions and feelings joy, level as a result of relaxation, peace, enjoyment, and energy the intervention they felt the intervention helped them to be more present with their partner and led to deeper connections in their relationships. They felt more love and appreciation for from partners. Fathers also experienced an increased ability to relate partner ’ s point of view and resolve conflict more effectively Father ’ s attitude and parenting self-efficacy: fathers reported Father ’ s mental health: fathers reported increases in Other (ie, partner relationship quality): fathers reported that Outcome assessed 1 wk after last session Father involvement: mothers in the program repor Results Related to Father Outcomes the results of 1 nonexperimental

study of a40 general education 000; program revealed a significant ’

– $39 increase from pretest to posttest in 000 fathers level of anticipated control during labor and delivery. The results of another study, which was

a qualitative51 study of a relationship program,​ revealed that fathers reported feelings of confidence and

majority white parents age 24 – 41 y old; median range of income was $30 73% were white preparedness for fatherhood before Target population: middle-income, Target N = 13 couples Couples expecting their first child; Study Population theFather's birth Mental of the Healthinfant.

Researchers for 4 quantitative (2 RCTs and 2 quasi-experimental) ’ and 1 qualitative studies

examined 38,fathers47,​ 49,​ 53​ mental health outcomes. ‍ ‍ ‍ The results of a low RoB quasi-experimental study

parenting program on internal and interpersonal attunement 38 To assess the effects of Study Aim of a general education program ’ revealed significant increases in fathers social support seeking related to pregnancy-related stressors measured during the third trimester. It was reported in a qualitative study of a relationship

program intervention51 that occurred study during pregnancy that fathers Phenomenological qualitative Study Design felt improved emotion regulation and greater relaxation, peace, and enjoyment after the intervention. In 59 ; Mindful m 51

y a high RoB RCT of a massage-based 53’ program,​ significant decreases in fathers depression and anxiety Continued

levels at 36 weeks of pregnancy were reported. In contrast, the results of 2 Transition to Parenthood Transition Program adapted from the Mindfulness-Based Stress Reduction progra 47,49​ Author, Program Author, Gambrel and Pierc studies of coparenting programs ‍ TABLE 3 Teenage Pregnancy and Parenting Growing as a Couple and Family; GED, General Education Development; NBAS, Neonatal Behavioral Assessment Scale; TAPP, Family Foundations; FIOC, Figuring It Out for the Child; GCF, e-health, electronic health; FF, Project. ’ did not reveal significant effects on fathers mental health in the Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 142, number 1, July 2018 11 TABLE 4 RoB Assessment for Included Studies Author, y Participant Selection Blinding of Outcome Incomplete Outcome Selective Reporting Cumulative Risk Value Data Barth et al,​54 1988 Low Low Unclear High 2 Beal,​52 1989 Unclear Low Unclear Low 2 Bryan,​37 2000 Low High Low High 2 Diemer,​38 1997 Low Unclear Low Low 3 Fagan,​50 2008 Low Low Low Low 4 Fawcett and Burritt,43​ 1985 Unclear Unclear Unclear Unclear 0 Fawcett and Henklin,​44 1987 Unclear Low High Low 2 Feinberg and Kan,​47 2008 Low High Low Low 3 Feinberg et al,​48 2009 Low Low Unclear Low 3 Field et al,​53 2008 Low High Unclear Low 2 Gambrel and Piercy,​51 2015 Unclear Unclear Low Low 2 Hart and Foster,​40 1997 Low Unclear Unclear Low 2 Mackert et al,​45 2015 Unclear Unclear Low Low 2 Mackert et al,​46 2017 Unclear Unclear Low Low 2 Pfannenstiel and Honig,36​ 1991 Low Low High High 2 Pfannenstiel, and Honig,​35 1995 Low High Unclear High 1 Salman-Engin et al,​49 2017 Unclear Unclear Unclear Low 1 Smith and Smith,​41 1978 High Unclear Unclear High 0 Smith et al,​55 2016 High Unclear High Low 1 Van de Carr and Lehrer,​42 1986 Low Unclear High Low 2 Westney et al,​39 1988 Unclear Unclear Unclear Unclear 0

Low risk = 1; high risk = 0; unclear risk = 0. Each study could receive up to a cumulative risk value of 4. Studies scoring a cumulative risk value of ≤2 are considered to possess high RoB.

TABLE 5 Recommendations for Father-Inclusive Perinatal Parent Education Programs 1. Father-inclusive perinatal parent education programs should employ a family systems approach by involving both the father and mother60 2. When possible, programs should employ men or male-female teams as facilitators47,‍48​ 3. Consider employing facilitators that mirror the characteristics (eg, ethnicity or race, age, culture, language) of the fathers being served61,‍62​ 4. Train facilitators to welcome, engage, and directly speak with fathers6,‍15,​ ‍63​ 5. Include father-only group sessions to provide a safe space for men to express their feelings, combat social isolation, and receive peer support38,‍60​ 6. Use a strengths-based perspective by focusing and building on the positive characteristics fathers bring to parenting60,‍63,​ ‍64​ 7. Implement programs that are tailored to fathers’ parenting needs (for example, programs that are sensitive to the needs of nonresidential fathers)62,‍64​ 8. Consider whether aspects of the clinical environment are welcoming and friendly to fathers (eg, pictures of men with infants, magazines for fathers and mothers in the waiting room)65 9. Include in the curriculum content related to improving the coparenting relationship between the father and mother15,‍60​ 10. Allow room for fathers and mothers to discuss topics that are most relevant to their parenting circumstances and needs60 11. Develop special events that celebrate fathers and fatherhood64 12. Provide literature, such as brochures, to fathers that contain educational content related to infant care and development, stress management, and community-based resources64 13. Educate mothers about the importance of father involvement on child development and well-being6 14. Consider providing child care, financial incentives, meals, and/or transportation60,‍65​ 15. Deliver programs during times (eg, evenings or weekends) when it is convenient for fathers to participate62,‍64​ 16. Offer parent education along with other services, such as employment assistance, General Education Development test preparation, and support to address mental health and substance abuse problems65,‍66​ 17. When welcomed, use mobile technology, such as text messages, as reminders for program sessions, check-ins, and follow-ups (especially after a father misses a session)60

Father-Mother Relationship ’ d Father s Coparenting Relationship With postpartum period. More specifically, ’ increased fathers d coparenting Mother the results of a quasi-experimental49 support ( = 0.54) and closeness study of a coparenting program with the mother ( = 0.44) at 6 ’ (high RoB) revealed no program months postpartum. Interventiond effects on fathers depressive scores Researchers for 3 quantitative group fathers also reportedd reduced at 3 months postpartum. Similarly, studies (2 RCTs and 1 quasi-RCT) coparenting competition ( = 0.36) ’ the results of an RCT of another evaluated 2 coparenting programs and triangulation ( = 0.28) when 47 ’ 47,48​ coparenting program (low RoB) that assessed father s coparenting47,48,​ 50​ the child was 1 year old. ‍ The revealed no effects on fathers relationship with the mother. ‍ ‍ results of a quasi-RCT of another 50 ’ depressive symptoms and anxiety at The results of 2 RCTs 47,of48​ the same coparenting program revealed 6 months postpartum. coparenting program revealed moderate effects on fathers reports Downloaded from www.aappublications.org/news by guest on September 29, 2021 12 LEE et al p ’ p 2 p ’ p 2 of parenting alliance (η​​ ​ ​ ​​ = 0.09) and on both fathers (​​η​ ​ ​​ = 0.05) and of father-focused prenatal childbirth 2 ’ 2 coparenting communication (​​η ​ ​ = mothers (​​η​ ​ ​​ = 0.07) reports of education programs in protecting

0.10) at posttest during50 pregnancy. fathers supportive behaviors against paternal postpartum The same program had a greater toward the mother at posttest during depression and improving partner p effect on parenting alliance2 at 3 pregnancy. Similarly, the results of a relationship quality. Partnermonths Relationship postpartum Quality (​​η ​ ​ = 0.19). quasi-experimental study of a general 38 ’ Given the weak evidence base, we education program revealed a were unable to draw firm conclusions significant positive effect on fathers about the effectiveness of early support with housework in the third Researchers for 4 quantitative studies father-inclusive parent education trimester. Both of these studies had (2 RCTs and 2 quasi-experimental) programs. Nevertheless, there was ’ low RoB. In contrast, a high RoB and 1 qualitative study examined some limited (ie, primarily based quasi-experimental study of a case couples partner38,48,​ 51,​ 53,​relationship55​ quality on 3 low RoB studies) evidence to management program for expectant outcomes. ‍ ‍ ‍ The results of48 ’ 55 suggest that early father-inclusive adolescent parents found no effects an RCT of a coparenting program parent education programs may on fathers support for the mother at revealed positive intervention improve outcomes related to 1 month postpartum. effects on men's warmth toward father involvement, coparenting their female partner when the DISCUSSION relationship, partner relationship child was 1 year old. The results quality, father's mental health, and of a quasi-experimental study38 of father's supportive behaviors. On the a general education program other hand, there was generally a To the best of our knowledge, revealed positive effects on men's lack of evidence for program effects we are the first to examine, in use of reasoning measured during on father-infant interaction, father's a systematic review, US-based the third trimester. Both studies parenting knowledge, and father's father-inclusive perinatal parent were considered to have low RoB. attitudes and parenting self-efficacy. education programs, and whether Researchers for a qualitative51 study such programs are associated with Results from the RoB assessment of a relationship program reported important father outcomes. Overall, suggested that 2 coparenting that fathers felt the intervention we demonstrated in our review of programs (Minnesota Early 50 helped them establish deeper the literature that there are few Learning Design for Young47,48​ Dads connections in their relationships, father-inclusive programs during and Family Foundations ‍ ) feel more love and appreciation ’ the perinatal period. We found as well as a general perinatal toward their partner, relate to only 19 different father-inclusive education38 program developed by their partner s point of view, and perinatal interventions evaluated in Diemer may serve as the best set resolve conflict more effectively the literature despite considering of father-inclusive evidence-based during pregnancy. Researchers for a broad range of outcomes and interventions given their rigorous a high RoB RCT of a massage-based 53 ’ taking a comprehensive approach study designs, low levels of bias, clinical program also reported ’ to our review, with no limitations promising outcomes, and methods significant increases in both fathers on publication date and research of implementing the intervention and mothers perceptions of partner methodology. In addition to the small that appeal to fathers. For example, relationship quality at 36 weeks of number of interventions, we found the Minnesota Early Learning50 Design pregnancy. In contrast, a high RoB the general state of this research for Young Dads program not only quasi-experimental study of a case base to be weak, with only 4 out of used a manualized coparenting management program55 for expectant the 21 studies rated as having low curriculum but also aimed to provide adolescent parents found no effects RoB. These results are consistent positive role models to adolescent on partner relationship quality at 1 with previous systematic reviews fathers by employing previous Fathermonth spostpartum. Supportive Behaviors ’ on father-inclusive15,22,​ 24,​ 25,​ 60​ parent education male participants as47, facilitators.48​ programs. ‍ ‍ ‍ For example, Family Foundations ‍ also used a in their review of the literature on manualized coparenting curriculum Researchers for 3 quantitative father involvement programs for low- as well as a male-female facilitator ’ 60 studies (1 quasi-RCT and 2 quasi- income families, Pruett et al noted team to implement interactive38 skills- experimental) examined fathers38, 50,​ 55​ few privately and federally funded based group sessions. Diemer supportive behavior outcomes. ‍ ‍ programs have yielded24 promising developed a general perinatal The results of a quasi-randomized50 outcomes. Suto et al found similar education program that allowed for study of a coparenting program results in that their review revealed a a men-only and women-only group revealed moderate program effects lack of evidence for the effectiveness for the first session so that fathers Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 142, number 1, July 2018 13 can share their feelings, combat their strengthening program that has visits, welcoming fathers directly, sense of isolation, and experience been successful in promoting77,78​ and soliciting their opinions when peer support. In subsequent mixed- father involvement,​ ‍ is currently appropriate. Research suggests that sex groups, veteran childbirth being tested with high-risk couples many fathers do attend early health educators were trained to ask involved in the child welfare care visits, and positive interactions 60 ’ questions and share comments system. In hospital settings, with health care providers are directly with fathers to encourage Conscious Fathering, an early father79 important in fathers evaluations Emergingparticipation. Intervention Practices involvement program by Dorsey,​ of their experiences with the health has been providing expectant men care system and their willingness90 with infant care skills and education to participate in future visits. on responsive fathering. Clinicians can highlight fathers as As noted, there are few father- Clinical Implications ’ important contributors to their inclusive perinatal parent education children s health and well-being by programs. However, innovative ’ – educating men on the roles they play perinatal programs are emerging Despite the emergence of several 67 71 in their children s early years. to help fill this void. ‍ One noteworthy programs, research intervention approach that shows to develop and test early father- Clinicians can also play a key role “ ” promise is the use of home visitation inclusive interventions has generally in promoting positive coparenting program add-ons that target not kept pace with demographic and partner relationship quality by fathers. Home visitation models, such trends showing increased father openly discussing with fathers and as the Nurse Family Partnership, involvement and the important roles mothers the changes they are likely that target low-income mothers fathers play in promoting optimal to experience during pregnancy and are recognized as having lasting child development. This issue after the birth of the infant. Research positive effects on the 69health and likely persists80,81​ because of multiple suggests that men typically rely on well-being of children72 . The Dads factors,​ ‍ including clinicians women for parenting knowledge Matter program has trained being unwilling or inadequately and thus could benefit from having 15,63​ ’ 91 female home visitors to work with trained to engage fathers,​ ‍ positive male role models. In this fathers during their home visits, thus programs not being tailored to men s regard, male health care staff may 14,61,​ 65​ ’ expanding the program to include parenting needs,​ ‍ ‍ and maternal be effective in directly engaging working with mothers and fathers. gatekeeping preventing men s active fathers, educating them about infant

Preliminary evidence from an RCT of involvement82, in83​ programs during care and child development, and the Dads Matter program suggested pregnancy. ‍ These factors may providing anticipatory guidance. ’ that the program was associated help explain some of the reasons When appropriate and welcomed, ’ with increases in fathers reports for men feeling marginalized from fathers can be encouraged to provide ’ 84,85​ of attitudes regarding the values of health care settings ‍ and men s supportive behaviors to mothers and ’ their contributions to children s well- perceptions that there is little role for assume’ more active child care roles. ’ – being, mothers reports of support their involvement86 88 during pregnancy Fathers mental health is another area from fathers, and both parents70, 71​ and infancy. ‍ ‍ of concern for clinicians. Research reports of father engagement. ‍ Clinicians play a key role in reveals that elevated paternal Another promising approach is promoting early father involvement postpartum depression is associated– facilitating positive father-child because they are likely to be among with negative fathering behaviors92 94 and subsequent child outcomes. ‍‍ interactions.73 The Baby Elmo the first to come in contact with Yet, paternal depression is rarely Program is a brief intervention mothers and fathers expecting an6,89​ originally designed for incarcerated infant or recently had an infant. ‍ As acknowledged in health care settings. teenage fathers. It uses a theoretically such, it is important for clinicians to Clinicians can95 adopt both a family- 96 driven intervention approach and consider fathers when developing or centered care and family systems ’ interactive sessions to help fathers implementing programs for parents approach, screening both mothers understand their infant s emotional as well as to employ practices that and fathers for depression at pediatric settings to improve the health of needs and thus support positive73,74​ would support fathers to be engaged father-child interactions. ‍ The with the mother and infant across men, their children, and their6,92​ families Limitationsacross the perinatal of the Evidence period. ‍Quality program is now being tested as an the perinatal period (6Table 5). RCT with community-based samples Yogman and Garfield have provided 75,76​ ’ of low-income fathers. clinical recommendations, including Supporting Father Involvement, acknowledging fathers presence The majority of studies in this a group-based relationship when they attend health care systematic review were deemed Downloaded from www.aappublications.org/news by guest on September 29, 2021 14 LEE et al CONCLUSIONS to possess high RoB, suggesting are promising, more rigorous that the general quality of evidence evaluation research is necessary supporting father-inclusive parent In this systematic review, we to examine program effects on education programs is weak. This examined the current state of father outcomes. Clinicians can systematic review may also97 be limited the literature on father-inclusive help promote optimal outcomes by the file drawer problem. Because perinatal parent education programs. for children and families by we included only published studies, it There were several notable findings. involving men in early parent is possible that unpublished research First, the overall evidence base education programs and health of father-inclusive interventions was revealed that there were few care visits across the perinatal missed. Furthermore, publication programs in which fatherhood period. bias may result in some studies is targeted across the perinatal ACKNOWLEDGMENTS reporting significant results only, thus period. This underscores the need biasing the systematic review toward for evidence-based interventions significant findings. We note that in which fathers are supported Thank you to Muzi Lin for her this review is exclusively focused on during this important period of child contribution in compiling articles US-based programs to complement development. Second, available included in this article. Thank you to Drs. Brenda L. Volling and Andrew existing research15, 23​conducted programs were associated with internationally. ‍ Most studies in increased father involvement, Grogan-Kaylor for their helpful this systematic review implemented coparenting relationship, partner comments on an earlier version of interventions within a clinical setting, relationship quality, father's mental this article. preventing the generalization of health, and father's supportive ABBREVIATIONS findings to other contexts.43,​44,47,​ 48,​ With50​ behaviors. Third, evidence for several exceptions,​ ‍ ‍ ‍ most program effects on father-infant studies examined program effects at interaction, father's parenting CINAHL: Cumulative Index to a single time point without follow- knowledge, and father's attitudes Nursing and Allied ups. As such, the existing evidence and parenting self-efficacy was Health Literature does not allow for understanding inconclusive. Finally, the Minnesota PRISMA: Preferred Reporting long-term program effects. Variability Early Learning Design for Young 50 47,48​ Items for Systematic in the operationalization and Dads and Family Foundations ‍ ’ Reviews and measurement of study outcomes, coparenting programs and 38 Meta-Analyses small sample sizes, and other Diemer s perinatal education RCT: randomized controlled trial intervention characteristics also program emerged as the best RoB: risk of bias contribute to the weak evidence base. evidence-based interventions. RoBANS: risk of bias assessment The authors of previous systematic Collectively, these results suggest tool for nonrandomized reviews have noted similar that although some early father- 15,​22,24​ study methodological limitations. ‍ inclusive parent education programs Accepted for publication Apr 11, 2018 Address correspondence to Joyce Y. Lee, MSW, School of Social Work, University of Michigan, 1080 South University Ave., Ann Arbor, MI 48109. E-mail: joyceyl@ umich.edu PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2018 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2018/06/13/peds.2 018-0437 References This article cites 75 articles, 4 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2018/06/13/peds.2 018-0437#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Fetus/Newborn Infant http://www.aappublications.org/cgi/collection/fetus:newborn_infant_ sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 29, 2021 Father-Inclusive Perinatal Parent Education Programs: A Systematic Review Joyce Y. Lee, Heather A. Knauer, Shawna J. Lee, Mark P. MacEachern and Craig F. Garfield Pediatrics originally published online June 14, 2018;

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