Knowledge From the Afrikan World, For the World

PMC Articles

Factors influencing fathers’ involvement in the care of hospitalized preterm newborns in Balaka, Malawi

PMCID: PMC10463498

PMID: 37644490

Abstract

Background Malawi has one of the highest incidences of premature birth, with twice the mortality compared to full-term. Excluding fathers from preterm newborn care has negative consequences, including father feeling powerless, missed bonding opportunities with the newborn, additional strain on the mother, and negative family dynamics such as breakdown in communication, reduced trust, and strained relationships. In Malawi, there is no deliberate policy to have fathers involved in preterm care despite having high incidence of preterm birth and neonatal mortality. There is also limited literature on the factors that influence fathers’ involvement in the care. The aim of the study was to explore factors influencing fathers’ involvement in the care of hospitalized preterm newborns. Methods A descriptive qualitative study design was used, guided by Theory of planned behaviour and the model proposed by Lamb on male involvement. Sixteen in-depth interviews were conducted with fathers of preterm infants purposively and conveniently sampled in June 2021. Interviews were digitally recorded and transcribed verbatim. Data were organized and analyzed using Nvivo software and thematic analysis approach was used because the approach allows deeper understanding of the data, identification of patterns and themes, and provides rich insights into participants’ experiences and perspectives. Results The barriers and facilitators that influence a father’s involvement in the care of preterm newborn babies include: perceived difficulty with care activities and benefits of involvement, gender roles and socio-cultural beliefs, work and other family responsibilities, social support, baby’s physical appearance/nature and health status, feedback from the baby, multiple births, and hospital’s physical environment and provision of basic needs. Conclusion The study found that fathers value their involvement in caring for hospitalized preterm newborns but face barriers. Evidence-based interventions like education programs, training sessions, and support groups can help fathers overcome barriers and promote better outcomes for infants and families.

Full Text

The first 28 days of life (newborn period) are the most critical for a child’s survival. In 2020, 2.4 million newborns died, which accounts for 47% of all under-five deaths [1]. A majority (43%) of these deaths occurred in Sub-Saharan Africa where neonatal mortality is 27 deaths per 1000 live births [1]. Preterm birth is one of the dominant risks in neonatal mortality [2], and it accounted for 35% of neonatal deaths worldwide in 2019 [3]. Malawi has one of the highest preterm births and neonatal mortality. Preterm birth is estimated to range from 7.9 to 29.7% [4], and neonatal mortality rate is estimated at 27 deaths per 1,000 live births [5]. Neonatal mortality rate is higher in Malawi when compared against neighboring countries, with Zambia reporting 24 deaths, and Tanzania had 20 deaths in 2021 [6]. The Malawi government developed guidelines and protocols for preterm newborn care in order to reduce neonatal mortality rates. However, Malawi still lacks a deliberate policy on male involvement in the care of preterm newborns, despite the Ministry of Health recognizing the importance of involving fathers.
Fathers’ involvement in the care of preterm newborns is critical to influencing the newborns’ behavioural and psychological outcomes, [7] as well as overall health [8, 9]. These positive outcomes are because fathers (or male partners) play a vital role in making decisions about the health of the children in the home [8]. Fathers who are involved in care activities become good parents [9], finding fatherhood more fulfilling and considering themselves naturally important to their children [10]. Fathers that are involved in care are more likely to have a positive feeling about their interactions with the children [11, 12], better understand, and appreciate their children and develop a rich bond with them. Therefore, fathers’ engagement in care practices needs to be initiated from the first days of the child’s life, even in situations when the mother is recovering and able to provide care [13].
Male involvement in the care of preterm newborns can have several benefits, that could help reduce the high mortality. When fathers share caregiving responsibilities, it can lessen the burden on mothers and prevent the mothers from feeling overwhelmed [14, 15]. Moreover, fathers who participate in the care of their preterm newborns are more likely to be well-informed about their baby’s health, adhere to medical advice, and actively contribute to decision-making about their child’s care. These factors can ultimately lead to better health outcomes for the baby. Lamb et al. argue that male involvement has three components, which include availability (accessibility), engagement, and responsibility [10]. Accessibility is where a father is physically present but only plays a passive or supervisory role to ensure the child is safe. Engagement represents the more intensive, one-on-one interaction with the child, while responsibility is the ability of the father to know what is needed so that they can plan and arrange for the provision of certain aspects of child care [10].
Just like the mothers, the birth of a preterm baby in a family is equally stressful for the fathers. Fathers need targeted nursing interventions that are different from those applied to mothers [16]. Factors influencing their involvement in care need to be explored because fathering a preterm newborn is multifaceted and predisposed by personal differences, and traditional, and contextual factors that would help develop interventions that respond to fathers’ needs. In Malawi, there is no policy on male involvement in the care of preterm newborns despite the numerous benefits that come with fathers’ involvement. Furthermore, there is no literature on male involvement in preterm infant care despite Malawi having a high incidence of preterm births and high neonatal mortality. As such, exploring the factors that influence fathers’ involvement in the care of their hospitalized preterm newborns would be key for the health care providers to professionally involve fathers in the daily care activities and build a strong foundation for continued involvement even after discharge from the hospital.
There are both barriers and facilitators to fathers’ involvement in the care of preterm newborns. Barriers can result in few men reported to be actively involved. Some of the barriers are social-cultural beliefs that influence gender norms [17, 18], the baby’s physical nature [7, 13, 19–21], the hospital environment [13, 19, 22], work and other family responsibilities [19–21, 23], and exclusion by health care staff [24]. On the other hand, factors that facilitate fathers’ involvement in care are good communication from health care providers [7, 22], social support [19, 24, 25], encouragement from male champions in the community [18, 26] and their spouses [19, 24, 27], feedback from the infant itself when held by the father [24, 28], and multiple births [19].
The study utilized the constructs of the Theory of Planned Behaviour to assess fathers’ involvement based on the components of male involvement as proposed by Lamb et al. [10] (availability, engagement, and responsibility). The Theory of Planned behaviour explains what encourages a person to exhibit a specific kind of behaviour [29], in light of the several social factors outside one’s control that may encourage or impede that particular behaviour. The theory proposes that behaviour is not only born out of an intention but also out of one’s aptitude to exhibit that behaviour [30]. According to the theory, attitudes, subjective norms, and perceived behavioural control are factors that influence the intention to perform a behaviour [31]. This means an individual is likely to have an intention to perform certain behaviours such as caring for their preterm newborns if they have a positive attitude, believe that social pressure allows the performance of that behaviour and that they believe they have what it takes to perform those behaviours correctly [29, 32]. If one has these three, they are likely to have a stronger intention and more likely to perform the behaviour. However, several external factors may encourage or discourage an individual performance of that particular behaviour, despite the intention being there [32]. The aim of the study was to explore factors influencing fathers’ involvement in the care of hospitalized preterm newborns.
A descriptive qualitative research design was used in this study. In this qualitative research, the researcher seeks to understand the participants’ lived experiences in a manner that would help conceptualize the experiences and increase the researcher’s knowledge and understanding of human experiences [33].
The study was conducted in Balaka district, Malawi. Balaka is a rural district in the southern region bordering Mangochi, Neno, Machinga, and Ntcheu districts. It has a population of 438, 379 [34]. As of 2017, the district had an estimated 91,176 women of childbearing age with approximately 18,592 annual expected pregnancies and deliveries [35]. The study was conducted at Balaka District Hospital in June 2021 where all preterm newborns in the district are referred. The district was selected due to its high infant mortality rate estimated at 51 per 1,000 live births, which is above the national average of 42 per 1,000 live births as stated in the 2017 Demographic and Health Survey [36].
The sample consisted of sixteen fathers who had preterm neonates hospitalized at Balaka district hospital. The number resonates with methodological literature on saturation of qualitative data [37, 38], which argues that saturation could be reached with between 9 and 24 interviews, especially in research like this where the sample is relatively homogeneous and the research is aims-focused [38]. Data were collected until saturation was reached.
Data were collected in June 2021 using in-depth interviews (IDIs) conducted by an experienced and trained research assistant, who has a Public Health background. The research assistant training covered objectives of the study, data collection procedures, qualitative data collection, ethics, and communication skills. The training was conducted to ensure that research assistant understands the importance of ethical considerations and is able to conduct research in a responsible and ethical manner. Interviews were conducted in a private room at the hospital and the privacy allowed participants to get engaged in a comfortable conversation making it easy for them to share experiences as compared to them having to fill out a survey questionnaire [39]. The interviews were conducted in the language of participants’ choice (Chichewa or English) using a semi-structured guide and were audio-recorded. Each took a maximum of 40 min.
To ensure the trustworthiness of the study, the researcher put into serious consideration the validity, dependability, and conformability of the results. To ensure validity, the researcher employed procedures that ensured the credibility and transferability of the data. To ensure credibility, the researcher ensured the data collection tools were checked and vetted by an expert in health-related qualitative research. The tools were also pilot-tested to see if they were gathering the data they were supposed to. During the interviews, rapport was built from the beginning to ensure participants were fully engaged and probes were used to ensure the respondent adequately addresses the questions. Adequate time was allocated to analysis to ensure interpretations are in line with the data from the participants. Transferability was accomplished by ensuring participants had varied demographic characteristics so that there was wide representation and provides a detailed description of context, data collection, and analysis approaches used to allow replication in a different place and different populations [40].
The dependability of the research process was ascertained by the clear description of procedures and processes involved during the research. These included objective recruitment of study participants and a proper description of data analysis methods employed to allow others who may wish to audit and replicate them to do so [41]. Conformability was achieved by ensuring results are objective and neutral, independent of the researcher’s views [40]. Conformability enabled the findings to be consistent with those from similar related studies. Personal beliefs and opinions did not affect the research findings.
Data were managed using NVivo version 12. Data collection and analysis were done concurrently. Audio-recorded interviews were transcribed verbatim in Microsoft Word immediately after completion of the interviews. Rigorous review and quality control were performed by the authors to ensure accuracy and consistency between the transcripts and audio recordings. The analysis was conducted by the authors using qualitative thematic analysis approach [42]. The authors familiarized themselves with the data by reading and re-reading the transcripts while taking notes of initial codes as they read the transcripts. The coding scheme combining a priori codes and data-driven codes was developed based on key concepts from the Theory of Planned Behaviour and Lamb’s model of fathers’ involvement, and repeated reading of the transcripts. This approach allowed for the incorporation of existing theoretical constructs while also allowing new themes to emerge. Codes were then grouped into categories which combined similar codes and these later were organized under overarching themes based on recurring patterns, concepts, or ideas in the data and data reduction techniques were applied to identify the most illustrative examples within each themes while preserving the core meanings and experiences expressed by the participants. The authors then examined the relationships between themes, identify connections, and explore the implications of the findings to develop a coherent and comprehensive description. They also paid attention to avoid overwrapping themes and those with very minimal data to stand alone as a theme. These were combined with other themes to better illustrate the findings. The data analysis process involved iterative revisits to previous steps to achieve a better representation of the findings and encompassed multiple discussions of the results between the authors.
The study had 16 participants from different demographics as per Table 1 below. Participants belonging to Lomwe and Ngoni tribes were the majority with 44% and 38% respectively. In terms of age, 38% were those aged 25–29 and 31% were those 35 years and above. The mean and median age were 29.8 years and 29 years respectively with the standard deviation 5.57 years. The majority of the participants were first-time fathers (44%) and three quarters were Christians. Slightly more than half of the participants (56%) were educated to the secondary school level and majority (63%) were not employed.
There were five main categories of factors that influence fathers’ involvement in the care of preterm newborns. These are personal factors, interpersonal factors, infant factors, environmental factors, and economic factors as in Table 2 below.
The findings from the current study suggest that several factors act as barriers as well as facilitators to fathers’ involvement in the care of hospitalized preterm newborns. Guided by the Theory of Planned Behaviour and Lamb’s model of fathers’ involvement, it is evident that fathers’ personal motivational factors, interpersonal factors, infant factors, environmental factors, and economic factors affect fathers’ involvement in care. The findings suggest that fathers did not find tasks such as skin-to-skin care difficult and believed their involvement was an opportunity to express love to the newborn and develop a bond with the child. These findings are consistent with other studies that reported that fathers considered child care provision as responsibility for both the father and the mother, and that fathers’ involvement enhances the bonding between the father and the baby [43]. This suggests that more involvement in caregiving would be a motivating factor for fathers to frequently visit the baby at the hospital and create more chances for them to get involved in care as it would help them feel more responsible for their newborns.
Interpersonal factors such as unfriendly gender roles and cultural beliefs made fathers consider some roles as feminine hence not taking part in care. Earlier studies [44–46] found that childcare is culturally considered a feminine role. This necessitates a shift of mentality to help fathers realise that they can also take part in caregiving activities. Work and other responsibilities have been reported in the current study as impeding fathers’ involvement in the care of hospitalized preterm newborns. This is consistent with findings from other studies [19, 47–50], which reported that multiple responsibilities prevented the fathers from being engaged in caregiving activities. It is worth noting that at the time of the study, the Malawi labour laws were not allowing for paternal leave for those formally employed, and also the majority of the participants were not in formal employment which meant they still needed to work to earn something for the families.
Fathers felt the communication and support from the health providers helped them get better engaged in care. These findings are similar to other studies which acknowledged that inclusive interaction about childcare with the providers helped the fathers feel recognized and get more involved in the care of their preterm newborns [13, 43, 51]. These findings, however, differ from other studies [7, 52] where fathers felt sidelined by the health providers in the provision of care to the newborns which mean providers’ attributes and approach to work may affect fathers’ involvement in care. Additionally, the findings show that getting help from different individuals, sharing experiences, or talking to fellow fathers who are having or have ever had preterm babies helped them cope with the situation and encouraged them to get more involved in care activities. The findings are consistent with those from other studies conducted in Malawi where parents received social support from family and community members [44, 53]. The experiences shared with fellow fathers of preterm newborns helped fathers deal with feelings of being isolated [54], and helped them realise that they are not alone [55]. These findings imply that talking to fellow fathers of preterm newborns or being able to interact with those that have ever gone through a similar situation helps the fathers get to learn from each other on how best to handle the situation; hence the need to provide safe spaces where they could be having such interaction. A case could also be made from this on how important male champions could be in reproductive health.
Infant factors such as physical appearance, health status, and feedback from the baby influence fathers’ involvement in care. The findings from the current study suggest that physical appearance and fragile-looking skin impeded fathers’ involvement since they feared they could harm the baby. These findings are similar to another study conducted in Malawi, which reported that caregivers including fathers, were afraid of holding the preterm newborns because they looked small and fragile, and the caregivers feared harming them [44], which is consistent with findings from studies conducted in other countries [51, 56]. This fear made fathers unwilling to touch and hold the babies [7, 19, 20, 57]. On the other hand, fathers felt encouraged to get more involved when they heard and saw that the babies’ health status was improving. This was further enhanced by the feedback they were getting from the baby whenever they hold or talk to the baby. These findings are similar to other studies where fathers reported feeling encouraged by babies’ developmental improvements [58], and the feedback helped them deal with their fears and get more involved in care [19, 20, 59]. On the other hand, the absence of improvement in health status and a lack of feedback from the newborn may lead to withdrawal from care by the father [19]. Providers supporting fathers in the hospitals, therefore, have a duty to help fathers understand the different non-verbal cues the baby makes so that lack of them may not act as a deterrent from involvement in care.
The presence of multiple births had a positive influence on the fathers’ involvement in the care of preterm newborns because fathers felt the mother on her own was lacking since there were two babies to be attended to and the fathers had to come in to help with caregiving activities. These findings are consistent with a Swedish study which found that twin birth meant there was a need for more people to help with the caregiving activities and enabled the fathers to get more involved [19]. For instance, when the mother was done breastfeeding one, the father took the responsibility of burping that one while the mother breastfed the other twin.
The physical environment at the hospitals where the babies were admitted was reported as another factor impeding the fathers from being involved in care activities. Fathers in the current study needed more private space and not an open ward where everyone could see them. Other studies have also reported that lack of privacy in open-spaced hospital wards prevented the fathers from getting involved in care [60]. However, these findings do not support previous research, which found that the open-spaced beds allowed the fathers an opportunity to see their colleagues hold the babies and get involved in care activities which helped them realise that it was possible to get involved in care [19]. As such, there is a need for the healthcare staff attending to the preterm newborns to frequently engage fathers and get their preferences, and if resources are available, provide more privacy to those that may need it so that they get more engaged in care.
Economic factors influence fathers’ involvement in care. As per the model of male involvement proposed by Lamb et al. [10], responsibility entails the father being able to provide for what the newborn may need. The current study suggests that fathers that had formal employment considered their financial stability as a facilitator to involvement in care while those financially unstable would be spending more time running errands and doing piece works to earn some money to provide for the baby thereby limiting the time they could take part in care activities. These findings are consistent with other studies, which reported that the ability to provide for basic needs meant the father had time to be involved in care [23, 61] and further reduced parents’ psychological distress which usually affects their involvement in care activities [61]. In Malawi, it was reported that due to financial challenges, fathers were unable to provide for what is needed for the baby [26, 44].

Sections

"[{\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"CR1\", \"CR1\", \"CR2\", \"CR3\", \"CR4\", \"CR5\", \"CR6\"], \"section\": \"Background\", \"text\": \"The first 28 days of life (newborn period) are the most critical for a child\\u2019s survival. In 2020, 2.4\\u00a0million newborns died, which accounts for 47% of all under-five deaths [1]. A majority (43%) of these deaths occurred in Sub-Saharan Africa where neonatal mortality is 27 deaths per 1000 live births [1]. Preterm birth is one of the dominant risks in neonatal mortality [2], and it accounted for 35% of neonatal deaths worldwide in 2019 [3]. Malawi has one of the highest preterm births and neonatal mortality. Preterm birth is estimated to range from 7.9 to 29.7% [4], and neonatal mortality rate is estimated at 27 deaths per 1,000 live births [5]. Neonatal mortality rate is higher in Malawi when compared against neighboring countries, with Zambia reporting 24 deaths, and Tanzania had 20 deaths in 2021 [6]. The Malawi government developed guidelines and protocols for preterm newborn care in order to reduce neonatal mortality rates. However, Malawi still lacks a deliberate policy on male involvement in the care of preterm newborns, despite the Ministry of Health recognizing the importance of involving fathers.\"}, {\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"CR7\", \"CR8\", \"CR9\", \"CR8\", \"CR9\", \"CR10\", \"CR11\", \"CR12\", \"CR13\"], \"section\": \"Background\", \"text\": \"Fathers\\u2019 involvement in the care of preterm newborns is critical to influencing the newborns\\u2019 behavioural and psychological outcomes, [7] as well as overall health [8, 9]. These positive outcomes are because fathers (or male partners) play a vital role in making decisions about the health of the children in the home [8]. Fathers who are involved in care activities become good parents [9], finding fatherhood more fulfilling and considering themselves naturally important to their children [10]. Fathers that are involved in care are more likely to have a positive feeling about their interactions with the children [11, 12], better understand, and appreciate their children and develop a rich bond with them. Therefore, fathers\\u2019 engagement in care practices needs to be initiated from the first days of the child\\u2019s life, even in situations when the mother is recovering and able to provide care [13].\"}, {\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"CR14\", \"CR15\", \"CR10\", \"CR10\"], \"section\": \"Background\", \"text\": \"Male involvement in the care of preterm newborns can have several benefits, that could help reduce the high mortality. When fathers share caregiving responsibilities, it can lessen the burden on mothers and prevent the mothers from feeling overwhelmed [14, 15]. Moreover, fathers who participate in the care of their preterm newborns are more likely to be well-informed about their baby\\u2019s health, adhere to medical advice, and actively contribute to decision-making about their child\\u2019s care. These factors can ultimately lead to better health outcomes for the baby. Lamb et al. argue that male involvement has three components, which include availability (accessibility), engagement, and responsibility [10]. Accessibility is where a father is physically present but only plays a passive or supervisory role to ensure the child is safe. Engagement represents the more intensive, one-on-one interaction with the child, while responsibility is the ability of the father to know what is needed so that they can plan and arrange for the provision of certain aspects of child care [10].\"}, {\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"CR16\"], \"section\": \"Background\", \"text\": \"Just like the mothers, the birth of a preterm baby in a family is equally stressful for the fathers. Fathers need targeted nursing interventions that are different from those applied to mothers [16]. Factors influencing their involvement in care need to be explored because fathering a preterm newborn is multifaceted and predisposed by personal differences, and traditional, and contextual factors that would help develop interventions that respond to fathers\\u2019 needs. In Malawi, there is no policy on male involvement in the care of preterm newborns despite the numerous benefits that come with fathers\\u2019 involvement. Furthermore, there is no literature on male involvement in preterm infant care despite Malawi having a high incidence of preterm births and high neonatal mortality. As such, exploring the factors that influence fathers\\u2019 involvement in the care of their hospitalized preterm newborns would be key for the health care providers to professionally involve fathers in the daily care activities and build a strong foundation for continued involvement even after discharge from the hospital.\"}, {\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"CR17\", \"CR18\", \"CR7\", \"CR13\", \"CR19\", \"CR21\", \"CR13\", \"CR19\", \"CR22\", \"CR19\", \"CR21\", \"CR23\", \"CR24\", \"CR7\", \"CR22\", \"CR19\", \"CR24\", \"CR25\", \"CR18\", \"CR26\", \"CR19\", \"CR24\", \"CR27\", \"CR24\", \"CR28\", \"CR19\"], \"section\": \"Background\", \"text\": \"There are both barriers and facilitators to fathers\\u2019 involvement in the care of preterm newborns. Barriers can result in few men reported to be actively involved. Some of the barriers are social-cultural beliefs that influence gender norms [17, 18], the baby\\u2019s physical nature [7, 13, 19\\u201321], the hospital environment [13, 19, 22], work and other family responsibilities [19\\u201321, 23], and exclusion by health care staff [24]. On the other hand, factors that facilitate fathers\\u2019 involvement in care are good communication from health care providers [7, 22], social support [19, 24, 25], encouragement from male champions in the community [18, 26] and their spouses [19, 24, 27], feedback from the infant itself when held by the father [24, 28], and multiple births [19].\"}, {\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"CR10\", \"CR29\", \"CR30\", \"CR31\", \"CR29\", \"CR32\", \"CR32\"], \"section\": \"Background\", \"text\": \"The study utilized the constructs of the Theory of Planned Behaviour to assess fathers\\u2019 involvement based on the components of male involvement as proposed by Lamb et al. [10] (availability, engagement, and responsibility). The Theory of Planned behaviour explains what encourages a person to exhibit a specific kind of behaviour [29], in light of the several social factors outside one\\u2019s control that may encourage or impede that particular behaviour. The theory proposes that behaviour is not only born out of an intention but also out of one\\u2019s aptitude to exhibit that behaviour [30]. According to the theory, attitudes, subjective norms, and perceived behavioural control are factors that influence the intention to perform a behaviour [31]. This means an individual is likely to have an intention to perform certain behaviours such as caring for their preterm newborns if they have a positive attitude, believe that social pressure allows the performance of that behaviour and that they believe they have what it takes to perform those behaviours correctly [29, 32]. If one has these three, they are likely to have a stronger intention and more likely to perform the behaviour. However, several external factors may encourage or discourage an individual performance of that particular behaviour, despite the intention being there [32]. The aim of the study was to explore factors influencing fathers\\u2019 involvement in the care of hospitalized preterm newborns.\"}, {\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"CR33\"], \"section\": \"Study design\", \"text\": \"A descriptive qualitative research design was used in this study. In this qualitative research, the researcher seeks to understand the participants\\u2019 lived experiences in a manner that would help conceptualize the experiences and increase the researcher\\u2019s knowledge and understanding of human experiences [33].\"}, {\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"CR34\", \"CR35\", \"CR36\"], \"section\": \"Study setting\", \"text\": \"The study was conducted in Balaka district, Malawi. Balaka is a rural district in the southern region bordering Mangochi, Neno, Machinga, and Ntcheu districts. It has a population of 438, 379 [34]. As of 2017, the district had an estimated 91,176 women of childbearing age with approximately 18,592 annual expected pregnancies and deliveries [35]. The study was conducted at Balaka District Hospital in June 2021 where all preterm newborns in the district are referred. The district was selected due to its high infant mortality rate estimated at 51 per 1,000 live births, which is above the national average of 42 per 1,000 live births as stated in the 2017 Demographic and Health Survey [36].\"}, {\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"CR37\", \"CR38\", \"CR38\"], \"section\": \"Sample size\", \"text\": \"The sample consisted of sixteen fathers who had preterm neonates hospitalized at Balaka district hospital. The number resonates with methodological literature on saturation of qualitative data [37, 38], which argues that saturation could be reached with between 9 and 24 interviews, especially in research like this where the sample is relatively homogeneous and the research is aims-focused [38]. Data were collected until saturation was reached.\"}, {\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"CR39\"], \"section\": \"Data collection\", \"text\": \"Data were collected in June 2021 using in-depth interviews (IDIs) conducted by an experienced and trained research assistant, who has a Public Health background. The research assistant training covered objectives of the study, data collection procedures, qualitative data collection, ethics, and communication skills. The training was conducted to ensure that research assistant understands the importance of ethical considerations and is able to conduct research in a responsible and ethical manner. Interviews were conducted in a private room at the hospital and the privacy allowed participants to get engaged in a comfortable conversation making it easy for them to share experiences as compared to them having to fill out a survey questionnaire [39]. The interviews were conducted in the language of participants\\u2019 choice (Chichewa or English) using a semi-structured guide and were audio-recorded. Each took a maximum of 40\\u00a0min.\"}, {\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"CR40\"], \"section\": \"Trustworthiness of the study\", \"text\": \"To ensure the trustworthiness of the study, the researcher put into serious consideration the validity, dependability, and conformability of the results. To ensure validity, the researcher employed procedures that ensured the credibility and transferability of the data. To ensure credibility, the researcher ensured the data collection tools were checked and vetted by an expert in health-related qualitative research. The tools were also pilot-tested to see if they were gathering the data they were supposed to. During the interviews, rapport was built from the beginning to ensure participants were fully engaged and probes were used to ensure the respondent adequately addresses the questions. Adequate time was allocated to analysis to ensure interpretations are in line with the data from the participants. Transferability was accomplished by ensuring participants had varied demographic characteristics so that there was wide representation and provides a detailed description of context, data collection, and analysis approaches used to allow replication in a different place and different populations [40].\"}, {\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"CR41\", \"CR40\"], \"section\": \"Trustworthiness of the study\", \"text\": \"The dependability of the research process was ascertained by the clear description of procedures and processes involved during the research. These included objective recruitment of study participants and a proper description of data analysis methods employed to allow others who may wish to audit and replicate them to do so [41]. Conformability was achieved by ensuring results are objective and neutral, independent of the researcher\\u2019s views [40]. Conformability enabled the findings to be consistent with those from similar related studies. Personal beliefs and opinions did not affect the research findings.\"}, {\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"CR42\"], \"section\": \"Data analysis\", \"text\": \"Data were managed using NVivo version 12. Data collection and analysis were done concurrently. Audio-recorded interviews were transcribed verbatim in Microsoft Word immediately after completion of the interviews. Rigorous review and quality control were performed by the authors to ensure accuracy and consistency between the transcripts and audio recordings. The analysis was conducted by the authors using qualitative thematic analysis approach [42]. The authors familiarized themselves with the data by reading and re-reading the transcripts while taking notes of initial codes as they read the transcripts. The coding scheme combining a priori codes and data-driven codes was developed based on key concepts from the Theory of Planned Behaviour and Lamb\\u2019s model of fathers\\u2019 involvement, and repeated reading of the transcripts. This approach allowed for the incorporation of existing theoretical constructs while also allowing new themes to emerge. Codes were then grouped into categories which combined similar codes and these later were organized under overarching themes based on recurring patterns, concepts, or ideas in the data and data reduction techniques were applied to identify the most illustrative examples within each themes while preserving the core meanings and experiences expressed by the participants. The authors then examined the relationships between themes, identify connections, and explore the implications of the findings to develop a coherent and comprehensive description. They also paid attention to avoid overwrapping themes and those with very minimal data to stand alone as a theme. These were combined with other themes to better illustrate the findings. The data analysis process involved iterative revisits to previous steps to achieve a better representation of the findings and encompassed multiple discussions of the results between the authors.\"}, {\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"Tab1\"], \"section\": \"Participant demographics\", \"text\": \"The study had 16 participants from different demographics as per Table\\u00a01 below. Participants belonging to Lomwe and Ngoni tribes were the majority with 44% and 38% respectively. In terms of age, 38% were those aged 25\\u201329 and 31% were those 35 years and above. The mean and median age were 29.8 years and 29 years respectively with the standard deviation 5.57 years. The majority of the participants were first-time fathers (44%) and three quarters were Christians. Slightly more than half of the participants (56%) were educated to the secondary school level and majority (63%) were not employed.\"}, {\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"Tab2\"], \"section\": \"Factors influencing fathers\\u2019 involvement\", \"text\": \"There were five main categories of factors that influence fathers\\u2019 involvement in the care of preterm newborns. These are personal factors, interpersonal factors, infant factors, environmental factors, and economic factors as in Table\\u00a02 below.\"}, {\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"CR43\"], \"section\": \"Discussion\", \"text\": \"The findings from the current study suggest that several factors act as barriers as well as facilitators to fathers\\u2019 involvement in the care of hospitalized preterm newborns. Guided by the Theory of Planned Behaviour and Lamb\\u2019s model of fathers\\u2019 involvement, it is evident that fathers\\u2019 personal motivational factors, interpersonal factors, infant factors, environmental factors, and economic factors affect fathers\\u2019 involvement in care. The findings suggest that fathers did not find tasks such as skin-to-skin care difficult and believed their involvement was an opportunity to express love to the newborn and develop a bond with the child. These findings are consistent with other studies that reported that fathers considered child care provision as responsibility for both the father and the mother, and that fathers\\u2019 involvement enhances the bonding between the father and the baby [43]. This suggests that more involvement in caregiving would be a motivating factor for fathers to frequently visit the baby at the hospital and create more chances for them to get involved in care as it would help them feel more responsible for their newborns.\"}, {\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"CR44\", \"CR46\", \"CR19\", \"CR47\", \"CR50\"], \"section\": \"Discussion\", \"text\": \"Interpersonal factors such as unfriendly gender roles and cultural beliefs made fathers consider some roles as feminine hence not taking part in care. Earlier studies [44\\u201346] found that childcare is culturally considered a feminine role. This necessitates a shift of mentality to help fathers realise that they can also take part in caregiving activities. Work and other responsibilities have been reported in the current study as impeding fathers\\u2019 involvement in the care of hospitalized preterm newborns. This is consistent with findings from other studies [19, 47\\u201350], which reported that multiple responsibilities prevented the fathers from being engaged in caregiving activities. It is worth noting that at the time of the study, the Malawi labour laws were not allowing for paternal leave for those formally employed, and also the majority of the participants were not in formal employment which meant they still needed to work to earn something for the families.\"}, {\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"CR13\", \"CR43\", \"CR51\", \"CR7\", \"CR52\", \"CR44\", \"CR53\", \"CR54\", \"CR55\"], \"section\": \"Discussion\", \"text\": \"Fathers felt the communication and support from the health providers helped them get better engaged in care. These findings are similar to other studies which acknowledged that inclusive interaction about childcare with the providers helped the fathers feel recognized and get more involved in the care of their preterm newborns [13, 43, 51]. These findings, however, differ from other studies [7, 52] where fathers felt sidelined by the health providers in the provision of care to the newborns which mean providers\\u2019 attributes and approach to work may affect fathers\\u2019 involvement in care. Additionally, the findings show that getting help from different individuals, sharing experiences, or talking to fellow fathers who are having or have ever had preterm babies helped them cope with the situation and encouraged them to get more involved in care activities. The findings are consistent with those from other studies conducted in Malawi where parents received social support from family and community members [44, 53]. The experiences shared with fellow fathers of preterm newborns helped fathers deal with feelings of being isolated [54], and helped them realise that they are not alone [55]. These findings imply that talking to fellow fathers of preterm newborns or being able to interact with those that have ever gone through a similar situation helps the fathers get to learn from each other on how best to handle the situation; hence the need to provide safe spaces where they could be having such interaction. A case could also be made from this on how important male champions could be in reproductive health.\"}, {\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"CR44\", \"CR51\", \"CR56\", \"CR7\", \"CR19\", \"CR20\", \"CR57\", \"CR58\", \"CR19\", \"CR20\", \"CR59\", \"CR19\"], \"section\": \"Discussion\", \"text\": \"Infant factors such as physical appearance, health status, and feedback from the baby influence fathers\\u2019 involvement in care. The findings from the current study suggest that physical appearance and fragile-looking skin impeded fathers\\u2019 involvement since they feared they could harm the baby. These findings are similar to another study conducted in Malawi, which reported that caregivers including fathers, were afraid of holding the preterm newborns because they looked small and fragile, and the caregivers feared harming them [44], which is consistent with findings from studies conducted in other countries [51, 56]. This fear made fathers unwilling to touch and hold the babies [7, 19, 20, 57]. On the other hand, fathers felt encouraged to get more involved when they heard and saw that the babies\\u2019 health status was improving. This was further enhanced by the feedback they were getting from the baby whenever they hold or talk to the baby. These findings are similar to other studies where fathers reported feeling encouraged by babies\\u2019 developmental improvements [58], and the feedback helped them deal with their fears and get more involved in care [19, 20, 59]. On the other hand, the absence of improvement in health status and a lack of feedback from the newborn may lead to withdrawal from care by the father [19]. Providers supporting fathers in the hospitals, therefore, have a duty to help fathers understand the different non-verbal cues the baby makes so that lack of them may not act as a deterrent from involvement in care.\"}, {\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"CR19\"], \"section\": \"Discussion\", \"text\": \"The presence of multiple births had a positive influence on the fathers\\u2019 involvement in the care of preterm newborns because fathers felt the mother on her own was lacking since there were two babies to be attended to and the fathers had to come in to help with caregiving activities. These findings are consistent with a Swedish study which found that twin birth meant there was a need for more people to help with the caregiving activities and enabled the fathers to get more involved [19]. For instance, when the mother was done breastfeeding one, the father took the responsibility of burping that one while the mother breastfed the other twin.\"}, {\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"CR60\", \"CR19\"], \"section\": \"Discussion\", \"text\": \"The physical environment at the hospitals where the babies were admitted was reported as another factor impeding the fathers from being involved in care activities. Fathers in the current study needed more private space and not an open ward where everyone could see them. Other studies have also reported that lack of privacy in open-spaced hospital wards prevented the fathers from getting involved in care [60]. However, these findings do not support previous research, which found that the open-spaced beds allowed the fathers an opportunity to see their colleagues hold the babies and get involved in care activities which helped them realise that it was possible to get involved in care [19]. As such, there is a need for the healthcare staff attending to the preterm newborns to frequently engage fathers and get their preferences, and if resources are available, provide more privacy to those that may need it so that they get more engaged in care.\"}, {\"pmc\": \"PMC10463498\", \"pmid\": \"37644490\", \"reference_ids\": [\"CR10\", \"CR23\", \"CR61\", \"CR61\", \"CR26\", \"CR44\"], \"section\": \"Discussion\", \"text\": \"Economic factors influence fathers\\u2019 involvement in care. As per the model of male involvement proposed by Lamb et al. [10], responsibility entails the father being able to provide for what the newborn may need. The current study suggests that fathers that had formal employment considered their financial stability as a facilitator to involvement in care while those financially unstable would be spending more time running errands and doing piece works to earn some money to provide for the baby thereby limiting the time they could take part in care activities. These findings are consistent with other studies, which reported that the ability to provide for basic needs meant the father had time to be involved in care [23, 61] and further reduced parents\\u2019 psychological distress which usually affects their involvement in care activities [61]. In Malawi, it was reported that due to financial challenges, fathers were unable to provide for what is needed for the baby [26, 44].\"}]"

Metadata

"{\"issue-copyright-statement\": \"\\u00a9 BioMed Central Ltd., part of Springer Nature 2023\"}"