Men’s experiences of the transition to fatherhood during the first postnatal year: A qualitative systematic review

Abstract

Introduction:

Fatherhood is a significant transition in a man’s life, introducing new challenges. Yet men’s experiences of this period remain poorly understood. Occupational therapists possess skills and knowledge to support individuals during transition. This study explored the experiences of men during the transition to fatherhood over the first postnatal year.

Method:

Underpinned by an occupational therapy theoretical perspective, a systematic review was conducted. Following searches of databases: AMED, CINAHL, Medline and PsycINFO, qualitative studies meeting selection criteria were retrieved and quality assessed. Data was extracted and synthesised using an established meta-ethnographic approach.

Findings:

Seven articles were included in the review. Four interconnected themes: (1) A New Occupational Identity, (2) Relationship Changes, (3) Challenges and Impact, (4) Unmet Occupational Needs, and four subthemes: Roles and Responsibilities, and Adjusting Priorities (theme 1); An Emotional Journey and Exhaustion (theme 3) were identified.

Discussion:

Fathers’ postnatal transitional experiences were reflective of a journey of adjustment and growth. Experiences indicated the requirement for greater support of fathers throughout the antenatal and postnatal transition. Occupational therapists have the skills to work with fathers to balance occupations, manage fatigue and adjust to new roles. Further research should focus on understanding experiences of men in under-represented groups.

Keywords

Father mental health transition postnatal psychology human activities

Introduction

Transitions are periods of alteration in everyday life from one stage to another (Orentlicher et al., 2015). Anticipated or unexpected, these periods of change are uniquely experienced and can impact an individual’s established routines, relationships, identity and roles. The transition to parenthood is amongst the most profound and life-altering periods an adult can experience. Alongside the excitement of a new addition comes a multitude of associated aspects requiring adaption, integration and alteration to daily functioning and occupations (Hamilton and De Jonge, 2010). Preparation and support for parents during the antenatal period is commonplace across Western cultures (Poh et al., 2014). However, the birth can bring change abruptly and unexpectedly. Emotional, social and physical changes can subsequently impact health and wellbeing (Shorey and Chan, 2020).

How individuals navigate and adjust during these dynamic times and the association between this, and a person’s health and well-being is a foundation of occupational therapy (Wilcock, 1998). Occupational therapists appreciate the significance of such transitional periods, working with individuals to minimise and overcome barriers encountered through life changes. Occupational therapy literature uniquely proposes that the outcome and experience of transition are directly impacted by occupation and the engagement with new or existing routines (Crider et al., 2015). The Occupational Perspective of Health (OPH), a theoretical framework (Wilcock, 2006), centralises the ‘doing, being, becoming and belonging’ of occupation. During the dynamic course of a lifetime, the intricate association between these concepts can influence an individual’s wellbeing (Hitch et al., 2014). The OPH provides a framework by which occupational therapists can gain a deeper understanding of occupational participation and analyse barriers and facilitators to engagement in meaningful occupations. The OPH framework also enables occupational therapists to consider challenges to occupational participation through concepts such as occupational deprivation and imbalance.

Parental transitions from the mother’s perspective have been explored extensively (Shorey and Chan, 2020) throughout the perinatal period, defined as pregnancy up to 12 months post birth (National Health Service England, 2020). This research commonly focuses on predictors and experiences of maternal postnatal depression (PND) (Mickelson and Biehle, 2017). Fatherhood introduces new occupations and identities that are developed through interaction with unfamiliar routines and roles. Whilst around 10% of fathers experience symptoms reflective of PND during the perinatal period (Singley and Edwards, 2015), research exploring the transition for males remains limited, and criteria for diagnosis of paternal PND do not yet exist. The prevalence of mental health difficulties amongst fathers over the transitional period may be considerably higher as men less commonly report or seek out support for psychological issues (Singley and Edwards, 2015).

Literature review

Across Western cultures, fathers are taking progressively more active roles during the perinatal period. Increased participation in antenatal (during pregnancy) preparation, childbirth and postnatal duties including childcare and domestic activities are encouraged by professionals (Chin et al., 2011; Mickelson and Biehle, 2017). National Institute for Health and Care Excellence (NICE) guidelines (National Institute for Health and Care Excellence, 2020) now specify the necessity, if appropriate, to assess the needs of partners and support them during the perinatal period. However, in this under-researched area (Baldwin et al., 2018), more attention is required to provide a deeper theoretical understanding of the needs and experiences of fathers.

In a man’s life, the birth of a child is a major occurrence. Intense emotions surrounding the arrival of a child are often reported by men with emotions fluctuating from love and happiness to uncertainty and immense responsibility are frequently cited (Deave and Johnson, 2008). Whilst for many men the transition to fatherhood is relatively seamless, some can face challenges. Difficulties can be encountered throughout transition as societal expectations place pressure upon fathers as they attempt to meet new requirements and adapt to sudden life changes (Crider et al., 2015) whilst adjusting to the demands of a new child, routines and experiences (Chin et al., 2011). Returning to work can present barriers for fathers, preventing them from a more active parenting role. Work has been associated with fathers feeling disconnected (Darwin et al., 2017). It has been suggested that the struggle to balance occupational demands may be detrimental to a father’s self-esteem and identity (Blair, 2000). Raanaas et al. (2019) suggest that the course of transition can introduce uncomfortable and unwelcome changes to occupational identity as societal and cultural expectations generate conflict between an individual’s former and developing self. Raanaas et al. (2019) propose that identity is strengthened through experience and chances to achieve a sense of normality.

Transition and concepts from occupational science are inextricably linked. Occupational science centralises occupation and its significance to human life, wellbeing, health and development (Wilcock, 1998), emphasising that adaptation to change is promoted through ‘doing’. Opportunities to engage with, and master new occupations during transitions supports growth, development and wellbeing. Throughout a transitional period, an individual may experience changes to their division of time and organisation of occupations resulting in occupational imbalance (Wagman et al., 2015; Wilcock, 1998). Furthermore, as new or old occupations develop, the significance and meaning attached to previous occupations may naturally or forcibly be lost (Larson, 2000). As humans express and experience meaning in their lives through the occupations they engage in, changes to how an individual can express themselves may alter their identity, purpose, health and wellbeing (Jonsson et al., 2000; Kielhofner and Burke, 1980).

A previous systematic review (Chin et al., 2011) explored the transition to fatherhood throughout the perinatal period. The study investigated experiences of men across the antenatal period to 2 years postnatal through a synthesis of eight published studies. However, this study included papers only up to 2008, and limited reporting of population characteristics reduced transferability of findings. A more recent integrative review from Poh et al. (2014) explored the needs and experiences of men throughout pregnancy and childbirth and found that fathers experience fluctuating emotions and desire more support. These findings were limited to the antenatal and childbirth phases of transition, rather than the potentially more significant postnatal period (Baldwin et al., 2018; Genesoni and Tallandini, 2009).

A literature review including 32 studies (Genesoni and Tallandini, 2009) reviewed challenges encountered by fathers over the perinatal period, concluding the postnatal period as presenting the most demanding phase of transition as men struggle balancing new roles and responsibilities. Baldwin et al. (2018) echoed Genesoni and Tallandini’s (2009) findings in a systematic review exploring wellbeing and mental health needs and experiences of fathers throughout the perinatal period. Fathers included in this review described a dissociation throughout pregnancy due to not physically experiencing the sensations of carrying a child, with the intense phenomenon of fatherhood not appreciated until the physical reality of the child arrives. Therefore, the postnatal period following birth may represent the most significant period of change throughout the parenthood transition for men and may benefit from greater attention and prominence in future research.

This study aimed to systematically review and synthesise qualitative evidence, using an occupational therapy perspective, to answer the question: What are the experiences of men during their transition to fatherhood over the first postnatal year?

Methods

A systematic review of qualitative evidence, based on the principles suggested by Boland et al. (2017) was undertaken. Researchers engaged in peer supervision throughout an interpretive, inductive process.

Search strategy

The search strategy was determined after the authors conducted an initial scoping search, contacted an expert – a member of the Royal College of Occupational Therapist’s (RCOT) Perinatal Mental Health Forum, and received support from RCOT library service.

Search terms were developed around the PICo (Population, phenomena of Interest, Context) classification method (Stern et al., 2014). This approach ensured the search and selection criteria reflected the key components of the research question as is described below.

Relevant evidence was retrieved using the following terms: Population: ‘father*’ or ‘paternal’ and Phenomena of Interest: ‘transition’ or ‘barrier’ or ‘experience*’ and ‘qualitative’; and Context: ‘perinatal’ or ‘prenatal’ or ‘antenatal’ or ‘postnatal’ or ‘natal’ or ‘pregnan*’. The full search is documented in Supplemental Appendix A.

Information sources

The final search was completed through the interface EBSCOhost across four bibliographic databases (AMED, CINAHL, Medline and PsycINFO). To review the evidence that has been produced in the last decade, databases were searched from 1 January 2013 to 30 November 2023.

Eligibility criteria

Papers were included if they qualitatively reported the transition that men (18 years or older) experienced during the postnatal period (from birth through to 12 months after birth), were primary research, based in a Western culture and written in English language. Only studies based in Western countries were included to recognise the similarities in health, political and social care systems (Baldwin et al., 2018).

Papers were excluded if they focussed on experiences of a specific medical condition or complications, experiences during COVID-19 pandemic or surrogacy, adoption and transgender pregnancies. This reflects that some populations of fathers may experience this transition differently due to their individual circumstances, for example, additional, specific needs related to complications during the postnatal period, health conditions of parent(s) or child or adolescent parenthood (Reeves, 2006).

Selection process

Results were exported into and managed using Endnote. This reference management software was selected based on availability and cost. One researcher reviewed titles and abstracts for inclusion by applying selection criteria. The full text of all sources not excluded was scrutinised by the same researcher, and a decision about inclusion was made. Any uncertainty about inclusion was discussed within a peer supervision group, and a decision was made. Reference lists of included articles were also examined for additional relevant studies.

Data collection process

Data were extracted to a specifically developed and piloted data extraction form by one researcher. The data extraction was confirmed by a second researcher. Extracted data included sample characteristics, methodology and data collection methods, setting and findings. Both researchers were occupational therapists; therefore, the data extraction was underpinned by the philosophical beliefs of the profession.

Study quality assessment

Following data extraction, eligible studies were critically appraised using the McMaster Qualitative Review Form (Letts et al., 2007). Two researchers (CW and KJ) independently undertook a quality assessment for each study. Papers were rated as poor, moderate or high quality by each researcher; ratings were compared and, where there was a difference, discussed and agreed. The McMaster tool requires a detailed narrative of the paper. This narrative was used to agree a rating for each paper. The quality rating did not determine inclusion in the review; however, it was considered in the analysis, with the lower rated papers being given less weighting to the inductive synthesis.

Synthesis methods

The studies within this review were synthesised based on a meta-ethnographical approach (Noblit and Hare,1988). This method is consistent with an interpretive, inductive approach as it generates critical examinations of various versions of an event (Boland et al., 2017). Using the approach guided by Noblit and Hare (1988) reciprocal translation was undertaken. Concepts in each included paper, relevant to the research question, were compared against each other in chronological order and aggregated until the synthesis was complete. Similarly, a refutational translation was undertaken to identify concepts that did not translate onto other studies. Following comparison, results were classified, generating new themes and sub-themes to develop the ‘line of argument’ (Noblit and Hare, 1988). The emerging themes were discussed during group supervision providing external peer review and promoting a reflexive approach throughout the synthesis. The researcher used field notes and a decision trail during this process.

Findings

Included studies

Final searches were completed on 30 November 2023 returning a total of 693 potentially relevant records. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) diagram (Moher et al., 2009) in Figure 1 displays the search strategy. No additional articles were retrieved through the reference list search. Overall, a total of seven studies remained for inclusion in the review. The characteristics and quality rating for the included papers can be viewed in Table 1.

Figure 1.

PRISMA flow diagram of selection process.

Table 1.

Results table displaying characteristics and quality rating of studies.

Study author (year)	Sample and recruitment method	Methods and methodology	Aim	Setting	Data collection setting	Findings	Quality
Kowlessar et al. (2015)	N = 10 first time fathers Children aged 7–12 months	Interpretive phenomenological analysis Semi-structured interviews	To examine father’s experiences during the first year of parenthood, including experiences of support to improve awareness of transition to fatherhood	United Kingdom: NHS trust, no geographical location disclosed	Participants homes N = 10	Two themes: Experiences during pregnancy Feelings of separation Six subthemes: Fatherhood – the early days Helplessness Trial and error parenting She leads, I follow Working together Gaining confidence and regaining control	Moderate
Darwin et al. (2017)	N = 19 first time and subsequent fathers Children up to 12 months	Interpretive Qualitative Semi-structured interviews	To explore insights and experiences of fathers reporting symptoms of psychological distress relating to perinatal mental health	United Kingdom: maternity settings over four sites in North Yorkshire and East Lincolnshire	Participants homes N = 12 University setting N= 3 Telephone interviews N = 4	Four themes: Legitimacy of paternal stress and entitlement to support Protecting the partnership Navigating fatherhood Diversity of men’s support networks	Good
Pålsson et al. (2017)	N = 15 first time fathers Children up to 1 month	Qualitative Interviews	To describe first time fathers’ experiences of preparation in relating to challenges encountered in the early fatherhood period	Southern Sweden: three healthcare units	Participants homes N = 14 University setting N = 1	Three themes: Acquiring knowledge and forming realistic expectations Developing strategies Being facilitated and supported	Moderate
Baldwin et al. (2019)	N = 21 first time fathers Children up to 12 months	Qualitative Approach In-depth face-to-face interviews	To develop understanding of needs related to mental health and wellbeing and understand the transition to fatherhood in first time fathers	United Kingdom: Two London NHS trusts	Participants homes N = 18 Health care centre N = 1 Hotel lounge N = 1 University setting N = 1	Nine themes: Preparation for fatherhood Rollercoaster of feelings New identity, challenges and impacts Changed relationship: ‘We’re in a different place’ Coping and support Health professionals and services: Experience, provision and support Barriers to accessing support Men’s perceived needs: What fathers want	Good
Martins (2019)	N = 10: Five mothers Five fathers (Four first-time parent couples, one subsequent parent couple) Children up to 6 months	Qualitative Semi-structured interviews at few days, first, fourth and sixth months of child’s life	To understand experiences of parents’ health and wellbeing throughout the first 6-month transitional period to parenthood	Northern Portugal: health care centre	Participants homes N = 10 Parents interviewed on four occasions, separately followed by an interview together	One theme: Living on the edge of one’s capacity Four subthemes: Feeling exhaustion Perceiving exhaustion in the mother Overflowing emotions Feeling less exhaustion	Moderate
Gemayel et al. (2022)	N = 12 first time and subsequent perinatal fathers Children up to 12 months old	Qualitative Semi-structured interviews	To understand antenatal and postnatal challenges and explore reactions to these challenges	Sydney, Australia: services providing antenatal and postnatal classes	Not stated N = 12 perinatal fathers	Five themes: Conflictual father-mother relationships, Lack of support, Inability to adjust to lifestyle changes, Birth event barriers and Conflictual father-child relationship Sixteen subthemes: Inability to adjust to the responsibilities towards the partner, Lack of intimacy with the partner, Disappointment in sexual relationship changes with the partner, Mother’s poor emotional well-being Negative perceptions about the partner, Lack of perinatal support services, Lack of social and family supports Social and lifestyle changes Unplanned pregnancy, Birth event complications, Birth event concerns Lack of parental knowledge, Father’s engagement problems with the child, Inability to adjust to the responsibilities towards the child, Negative perceptions about the child	Moderate–poor
De Waal et al. (2023)	N = 30 fathers Children up to 6 months	Qualitative Semi-Structured interviews	To understand the experiences and views of fathers’ paternal bonding during pregnancy and first postnatal year	Netherlands	Online environment	Two themes: Feelings of bonding Facilitators Four subthemes: Positive emotions, Uncertainties and worries, Meeting the child, Interaction	Moderate–poor

NHS: National Health Service.

Quality

Included studies received a rating of good, moderate or moderate-poor quality following application of the McMaster tool. Based on the narrative assessment from the McMaster tool, good-quality papers (Baldwin et al., 2019; Darwin et al., 2017) displayed transparency, credibility and member checking to validate researchers’ interpretations of the data contributing to good overall rigour. The moderate quality papers (Kowlessar et al., 2015; Martins, 2019; Pålsson et al., 2017) included less evidence of rigorous design. The moderate-poor rated article (De Waal et al., 2023; Gemayel et al., 2022) lacked detail relating to methodology, with limited report of rigour. Theoretical perspectives of researchers were only articulated in two papers: Kowlessar et al. (2015) and Gemayel et al. (2022). Four studies reported sampling to data redundancy (Baldwin et al., 2019; Darwin et al., 2017; De Waal et al., 2023; Martins, 2019).

Themes

Four interrelated themes and four subthemes were identifiable across the studies.

Theme 1: A new occupational identity

The synthesised findings of this theme summarise the first 12 months, where men encounter the phenomenon of an emerging identity of oneself as a father. This was articulated across studies as men associate themselves with new roles and adjust lifestyles to support this role. This theme consists of two subthemes: Roles and Responsibilities and Adjustment of Priorities.

Roles and responsibilities

Intertwined with transitional phases are new roles and responsibilities which are described by fathers across studies. Fathers begin to associate themselves with roles such as protector, breadwinner and carer within the first year (Baldwin et al., 2019; Darwin et al., 2017; Gemayel et al., 2022; Martins, 2019; Pålsson et al., 2017). Although, importantly the synthesis also identified fathers diversifying and adopting non-traditional roles such as cleaning and cooking to support the mother and prioritising the needs of her and the child (Baldwin et al., 2019; Darwin et al., 2017; Gemayel et al., 2022; Pålsson et al., 2017). When trying to be a ‘good father’ and balance new roles, feelings of stress and pressure were often described amongst fathers; this is explored in a later subtheme (An Emotional Journey). As experience increased, confidence within the father role appeared to improve. As new realities are integrated into life, ability managing and balancing new roles increased, and fathers began to recognise improvements in wellbeing (Kowlessar et al., 2015; Martins, 2019).

Adjustment of priorities

A recognised shift in priorities for fathers was described in all but two papers (Baldwin et al., 2019; Darwin et al., 2017; Gemayel et al., 2022; Martins, 2019; Pålsson et al., 2017) and was associated with a change to everyday life and routines. An innate desire to care for and support mother and child in a protector role was a recurring concept throughout the articles (Baldwin et al., 2019; Darwin et al., 2017; Kowlessar et al., 2015; Pålsson et al., 2017) and this often resulted in the displacement of existing life and activities (Baldwin et al., 2019; Gemayel et al., 2022; Pålsson et al., 2017). Fathers articulated difficulty finding balance between new roles and previous activities including caring for the child, supporting the mother, resting and returning to work (Baldwin et al., 2019; Darwin et al., 2017; Gemayel et al., 2022; Martins, 2019; Pålsson et al., 2017). They also reported less free time to engage in previous activities (Baldwin et al., 2019; Pålsson et al., 2017), and appeared to disregard previous behaviours as the needs of mother and child were prioritised and the image of being a ‘good father’ was sought.

Theme 2: Relationship changes

This theme describes the variable nature of relationships across the postnatal year. Fathers report unity and strength within partnerships as strategies and routines are collaboratively developed. However, strain is placed upon relationships as time together and intimacy is reduced leading to feelings of distance and frustration between partners.

Following the arrival of a child, fathers consistently reported experiencing a change to relationship dynamics with their partner (Baldwin et al., 2019; Darwin et al., 2017; Gemayel et al., 2022, Kowlessar et al., 2015; Martins, 2019; Pålsson et al., 2017). Many men appeared to appreciate the evolution of the relationship as it progressed to a new stage following the child’s birth (Baldwin et al., 2019; Kowlessar et al., 2015; Pålsson et al., 2017). Markedly, most fathers appear to describe a growing unity to approach and address the challenges presented in early parenthood (Baldwin et al., 2019; Darwin et al., 2017; Kowlessar et al., 2015; Martins, 2019; Pålsson et al., 2017). Working together with a partner was highly valued and supported the development of routines and strategies which helped a father adapt to the new priorities and responsibilities described in the theme ‘A New Occupational Identity’.

Conversely, however, whilst noting the positive relationship changes, most fathers appeared to place more emphasis upon the challenges parenthood introduced to a relationship (Baldwin et al., 2019; Darwin et al., 2017; Kowlessar et al., 2015; Martins, 2019; Pålsson et al., 2017). Fathers describe a shift in their position in the mother’s affection, now secondary to the intuitive maternal bond and demands of the child (Darwin et al., 2017; Kowlessar et al., 2015). A growing distance between fathers and mothers was recognised with reference to feelings such as isolation and separation (Gemayel et al., 2022; Kowlessar et al., 2015) which may have been compounded by a reduction in time together (Baldwin et al., 2019; Darwin et al., 2017) as new priorities such as those identified in the theme ‘A New Occupational Identity’ take precedence. It could be suggested that the lack of time together may be associated with what some fathers describe as a loss of intimacy and romantic connection (Baldwin et al., 2019; Gemayel et al., 2022; Pålsson et al., 2017), resulting in mutual irritation, frustration and disagreements within the partnership, further compounded by tiredness. This is examined in more detail in the theme ‘Barriers and Impacts’.

Theme 3: Barriers and impacts

This theme defines the difficulties men experience throughout the first postnatal year and the effects such as heightened physical and psychological experiences that require adjustments associated with other concepts. This theme was identified in the study by Baldwin et al. (2019) and was adopted within this current research due to the convergence of data to this theme from across the included studies.

An emotional journey

All participants referred to emotional aspects of fatherhood, with negative feelings more prominently articulated (Baldwin et al., 2019; Darwin et al., 2017; Kowlessar et al., 2015; Martins, 2019; Pålsson et al., 2017). Six studies describe feeling guilt (Darwin et al., 2017; Martins, 2019) associated with helplessness and ineffectiveness in supporting the mother and assisting with the child (Baldwin et al., 2019; Darwin et al., 2017; De Waal et al., 2023; Kowlessar et al., 2015; Martins, 2019). This suggests the first postnatal year to be a particularly poignant period for fathers. Emotive narratives were commonly cited alongside the descriptions of being unprepared for this period (Darwin et al., 2017; Kowlessar et al., 2015; Pålsson et al., 2017). Such findings highlight the importance of adequate preparation for fathers in limiting psychological distress in the postnatal period. Whilst clearly an emotionally charged period for fathers, remarkably, only in the studies exploring experiences of psychological health and wellbeing (Baldwin et al., 2019; Darwin et al., 2017) were the terms ‘mental health’ directly stated when referencing feelings and emotions instead, terms such as ‘stress’, ‘anxiety’ or ‘guilt’ were more commonly articulated. The lack of instant happiness or connection with the child was noted by some fathers (Baldwin et al., 2019; Pålsson et al., 2017), which may be a continuation of the separation felt during the pregnancy (Baldwin et al., 2019). Notably, intrapersonal factors including stress and anxiety were commonly reported with reference to external pressures such as relationships and fatherhood responsibilities (Darwin et al., 2017; Martins, 2019; Pålsson et al., 2017).

Although reports of negative emotions were more frequently cited within the included studies, positive responses were also described within studies that collected data throughout the first year. The rewards of fatherhood were evident (Darwin et al., 2017; De Waal et al., 2023; Pålsson et al., 2017); fathers described the experience of bonding with the child and forming a relationship as well as watching and contributing to their growth and development. Such experiences increased as the child became less dependent and were related to feelings of increased well-being and efficacy in the fathering role (Baldwin et al., 2019; Kowlessar et al., 2015; Martins, 2019).

Exhaustion

The sensation of exhaustion was frequently cited amongst fathers (Baldwin et al., 2019; Darwin et al., 2017; Gemayel et al., 2022; Martins, 2019; Pålsson et al., 2017). The impacts of exhaustion presented in various ways including increased irritability and lack of patience with the family and difficulty concentrating at work (Baldwin et al., 2019; Darwin et al., 2017; Pålsson et al., 2017). Lack of rest was associated with the copious demands of parenting (Pålsson et al., 2017) as fathers also struggled to find occupational balance between the two (Martins, 2019). Compelled to meet demands, lack of sleep impacted wellbeing as fathers cited missing meals and emotional drain (Baldwin et al., 2019; Darwin et al., 2017; Martins, 2019). Importantly, tiredness was also attributed to heightened emotions and strained relationships with others, including the child (Baldwin et al., 2019; Gemayel et al., 2022; Martins, 2019; Pålsson et al., 2017). Some men noted the consuming nature of fatigue as effects were generalised across every aspect of life (Martins, 2019; Pålsson et al., 2017). This could signify impacts to daily functioning as energy reserves were drained and motivation dipped. Whilst impacting on every aspect of life, the cyclical pattern of exhaustion was usually eased with time as routines were established resulting in improvements to sleep pattern and wellbeing (Kowlessar et al., 2015; Martins, 2019). This suggests a natural adaption to changes as experience and exposure to new conditions increases.

Theme 4: Unmet occupational needs

A lack of support throughout the antenatal period translated to feeling ill prepared during the postnatal period. The realities of parenthood further highlighted gaps in the education of expectant fathers.

Most articles reported fathers feeling unprepared during the transition (Baldwin et al., 2019; Darwin et al., 2017; Gemayel et al., 2022; Kowlessar et al., 2015; Martins, 2019; Pålsson et al., 2017), despite many of the fathers attending antenatal classes. This was associated with feelings of helplessness and ineffectiveness as described in the theme ‘Barriers and Impacts’. Retrospectively, fathers expressed the need to be forewarned and forearmed. Receiving realistic preparation and education of how to support the mother (Pålsson et al., 2017), practical aspects of child rearing (Baldwin et al., 2019; Darwin et al., 2017; Gemayel et al., 2022; Pålsson et al., 2017) and emotional and physical demands of postnatal parenthood (Baldwin et al., 2019; Gemayel et al., 2022; Pålsson et al., 2017) were proposed as ways to support the fatherhood transition. However, men noted a shortage of tailored support for fathers as mother-centric services and resources were felt to fail in delivering relevant or accessible information for fathers (Baldwin et al., 2019; Darwin et al., 2017; Gemayel et al., 2022).

Discussion and implications

The current qualitative systematic review aimed to explore the experiences of men during the transition to fatherhood within the first postnatal year. The results provide an exploration of the experience of fathers, with meta-ethnographic synthesis highlighting changes to identity and relationships. With increased experience and confidence, fatherhood appeared to gradually integrate into daily life; however, there were unanticipated challenges and needs that required adaptation.

The four components identified by Wilcock (2007), doing, being, becoming and belonging, are evident in the experiences reported by fathers in this current study. As fathers take on this new role [doing], they increase their knowledge, skills and abilities as evidenced in the theme ‘A New Occupational Identity’. Findings indicated that fathers learn ‘on the job’ over the first postnatal year, with the realities and opportunities to develop the practical skills not available to men until the arrival of the child.

The fathers in the included studies gave insights into their lived experiences of ‘being’ a father. These were evident in the ‘Barriers and Impacts’ theme. Fathers reflected positively on the interactions with their child and contributing to development, but also reported feeling helpless, and ineffective at times. Notably, fathers across the study reported experiencing occupational barriers that resulted in them feeling ill-prepared for the fatherhood role. Internal factors such as reduced confidence and experience in the fathering roles presented difficulties when attempting to acquire these new skills.

The transition to ‘becoming’ was characterised by the emergence of ‘A New Occupational Identity’ and the development of confidence and competency in new roles and responsibilities. The articulation of stereotypical roles such as protector and breadwinner indicated the enduring nature of historic societal perceptions of fathers (Marshall et al., 2014). Importantly, the fulfilment of one role often compromised the ability to perform in other areas; for example, the return to work often restricted fathers’ ability to care for their partner and child (Darwin et al., 2017; Kowlessar et al., 2015). Participation in selected occupations is recognised as being inherent to an individual’s identity and conceptualised through occupational identity (Raanaas et al., 2019; Segal, 2005). Fathers reported shifts to their roles, responsibilities and priorities. These alterations supported the development of the identification of the men as fathers.

Challenges to ‘belonging’ were particularly evident in the ‘Barriers and Impacts’ and ‘Relationship Changes’ themes. As fathers aimed to meet societal norms and return to work, they managed sleep deprivation, working and family responsibilities whilst attempting to maintain new and existing leisure occupations. Fathers also reported exhaustion affecting interpersonal relationships and engagement in social activity as well as daily functioning. This contributed to the uncomfortable transition men report as they struggle to find balance and time to meet expectations across all their roles.

Collectively, the themes identified within this study were reflective of previous systematic reviews (Baldwin et al., 2018; Chin et al., 2011; Poh et al., 2014) and builds on previous work by considering findings from an occupational therapy perspective. It was notable that fathers must overcome unique challenges that impact their experience during the transition to parenthood. Shifts in occupational identity, psychological challenges and unmet needs were highlighted. It is appreciated that the theme of ‘Unmet Occupational Needs’ relates to the antenatal period. Whilst this study set out to explore the postnatal period, these unmet antenatal needs, identified in hindsight, are inseparable from the fathers’ postnatal experience. The identified lack of preparation may provide an explanation for the emotional dissociation experienced by men during the antenatal period described by Baldwin et al. (2018).

Sparsity of appropriate and targeted information and practical education during the antenatal period to realistically prepare men for fatherhood resulted in reports of feeling ill-prepared for new occupations, expectations and responsibilities. This resulted in reports of psychological distress and isolation and reduced confidence in fulfilling the fatherhood role. The prevalence of this concept across studies may indicate the significance of this experience to fathers. This is an important finding as it suggests, despite attempts to prepare education and services during the perinatal period, these are not sufficient. It would appear that a gap exists between current provision of healthcare services and the needs of fathers in the perinatal period. Better preparation may assist men in developing their fathering identity through greater understanding of realities, reducing the psychological distress reported. Findings align with occupational therapy theory; fathers feel unprepared and under-skilled, preventing them from fulfilling and engaging in meaningful occupations, which potentially impacts their psychological health.

Relevance and implications for occupational therapy

Whilst evidence is limited (Darwin et al., 2021), estimations indicate that perinatal depression occurs in 8–10% (Cameron et al., 2016; Paulson and Bazemore, 2010), and perinatal anxiety in 2–18% (Leach et al., 2016) of fathers. Our study identifies factors, unmet occupational needs, and challenges associated with the transition to fatherhood that pose threats to occupational balance. Occupational balance does not necessitate an equal amount of time to be spent on work, leisure and self-care; rather, it refers to a dynamic interaction of meaningful occupations that facilitate health and well-being (Westhorp, 2003). Our findings support the supposition that this dynamic interplay can be challenged during the transition to fatherhood, with a risk of occupational imbalance (preclusion from fair privileges for diverse participation) (Durocher et al., 2014) and occupational deprivation (preclusion from engagement in occupations of necessity and/or meaning due to factors that stand outside the immediate control of the individual) (Durocher et al., 2014). New roles and responsibilities including caring for a baby, supporting a partner and returning to work, led to a move away from, and reduced access to, previously valued activities. Alongside the impact of the emotion and exhaustion in a context where there was insufficient formal, tailored support for fathers, an occupational perspective elucidates potential routes to ill-health and reduced well-being for fathers during the perinatal period.

Occupational therapists increasingly work with mothers experiencing psychological and physical difficulties throughout the perinatal period in areas such as fatigue management, role change preparation and development of routines (Health Education England, 2019). However, similar experiences are described within the current research of healthy fathers. Occupational therapists have the knowledge and skills to support people experiencing transition of roles and responsibilities. There are opportunities to prevent and reduce occupational imbalance and deprivation through novel and innovative occupational therapy practice, with potential for service development to extend interventions to fathers and contribute to the assessment of fathers’ needs as recommended in current guidance (National Institute for Health and Care Excellence, 2020).

Occupational therapists working in perinatal services may be in a position to offer postnatal father-child groups to promote positive relationships, self-efficacy and any signposting for any recognised challenges. Working with a preventative approach as an emerging role, occupational therapists could also integrate into existing antenatal services, targeting fathers to provide preparatory classes including realistic education, practical skills, health promotion and peer support to promote social connections. To allow sessions to be accessible, these could be offered outside of working hours with follow-ups continuing throughout the first postnatal year to support sleep management, establishment of routine and adaptation to work, partner and fatherhood responsibilities.

Future research should explore the experiences of fathers, particularly those from minority and under-represented groups, to identify where support should and could be offered throughout the transition into fatherhood. In addition, future research exploring current paternal services could identify gaps in current services that could be opportunities for future emerging service development.

Limitations

This study is limited through the inclusion of only English language papers and studies undertaken in Western countries meaning that some culture-specific experiences may not have been represented. Furthermore, only biological fathers participated in the included studies. Stepfathers, adoptive fathers and fathers in non-heterosexual relationships were not included. This will limit the transferability of the findings of this research. Whilst this current study offers valuable new insights, there remains a gap in the current evidence base, with a need for future research.

As the searches and subsequent study selection were completed by one researcher, there was a risk of researcher bias that may have been reduced had a second researcher been involved through these stages. This was mitigated by the adoption of a reflexive approach, and regular peer review sessions which provided oversight of the process and opportunity for discussion and challenge of decisions. It is possible that searching additional databases such as Education Resources Information Centre may have identified additional studies.

Whilst meta-synthesis can be seen as being removed from primary data, every effort has been made to describe the data analysis process in detail to ensure transparency and retain essence of the original findings.

Conclusion

This systematic review aimed to explore the experiences of men during the transition to fatherhood over the first postnatal year. The synthesised findings defined men’s experiences characterised by the emergence of a new occupational identity, alterations to relationships and emotional, physical and preparatory challenges that are reflective of a journey of adjustment and growth. Unmet occupational needs were identified and indicate a potential avenue for the occupational therapy profession.

To date, this is the first paper to synthesise the transitional experiences of fathers over the first postnatal year from an occupational therapy perspective, highlighting potential occupational disruption in this population. The necessity for improved support and realistic preparation for fathers throughout the antenatal and postnatal period was identified. Recommendations to enhance current services have been made. These recognise the importance of occupational therapists’ skills and knowledge to support men throughout the transition to fatherhood. Future research should explore experiences of fathers from a wider range of populations including minority and under-represented groups. This will provide greater understanding of the experiences and needs of fathers to enable the development of inclusive services that support men throughout the transition to fatherhood.

Key findings

Men experience unmet needs and challenges to occupational participation during the transition to fatherhood across the postnatal period.

Experiences indicated the requirement for greater support of fathers throughout the antenatal and postnatal periods to promote a healthy transition.

Occupational therapists are well positioned to provide interventions and should seek opportunities to support fathers during this time.

What the study has added

This paper synthesises transitional experiences of fathers over the first postnatal year from an occupational therapy perspective, highlighting potential occupational disruption in this population and emerging roles for occupational therapists.

Supplemental Material

sj-docx-1-bjo-10.1177_03080226241258577 – Supplemental material for Men’s experiences of the transition to fatherhood during the first postnatal year: A qualitative systematic review

Supplemental material, sj-docx-1-bjo-10.1177_03080226241258577 for Men’s experiences of the transition to fatherhood during the first postnatal year: A qualitative systematic review by Catherine White and Kathryn Jarvis in British Journal of Occupational Therapy

Footnotes

Acknowledgements

We would like to thank Samantha Pywell for early research supervision and idea formulation, the Systematic Review Peer Supervision Group for idea refinement and guidance, Louise Bellingham for support throughout the research process and Poppy Lancelotte for proof-reading services.

Research ethics

Not applicable.

Consent

Not applicable.

Patient and public involvement data

During the development, progress and reporting of the submitted research, patient and public involvement in the research was not included at any stage of the research.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) declared no financial support for the research, authorship and/or publication of this article.

Contributorship

CW and KJ conceived the study. CW and KJ undertook searches, retrieved papers, assessed quality and extracted and synthesised data. CW wrote the manuscript. Both authors reviewed and edited the manuscript and approved the final version of the manuscript.

ORCID iD

Kathryn Jarvis

Supplemental material

Supplemental material for this article is available online.

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