Improving Prenatal Health

Abstract

The U.S. infant mortality rate is among the highest in the developed world, with recent vital statistics reports estimating 6.14 infant deaths per 1,000 live births. Traditional health education and promotion to improve maternal, infant, and child health in the United States has focused only on women, leaving men out of important health messages that may affect pregnancy outcomes as well as family well-being. Recently, public health scholars have suggested that men be included in prenatal health education in an effort to improve birth outcomes and reduce infant mortality. Incorporating men in prenatal health promotion and education has been found to improve overall birth preparedness, reduce the risk of maternal–infant HIV transmission, and reduce perinatal mortality in less-developed nations. Although these results are positive, research on paternal impact in pregnancy outcomes in the United States to date is lacking. This article proposes a U.S.-specific research agenda to understand the current role of men in pregnancy health, as well as actual involvement, barriers, and the influence men can have in prenatal health. A discussion of culture, individual motivations, health care providers, and social marketing is also considered.

The infant mortality rate in the United States ranks among the highest of all developed nations. The most recent vital statistics report estimates 6 infant deaths per 1,000 live births in the United States, compared with less than 4 infant deaths per 1,000 live births in other developed nations such as Germany, France, and Japan (Central Intelligence Agency, 2012; Murphy, Xu, & Kochanek, 2012). The leading causes of infant mortality in the United States are congenital anomalies (birth defects), preterm birth (<37 weeks), and low/very low birth weight (Murphy et al., 2012). The problem of high infant mortality is even more pronounced among different racial and ethnic minorities, who are disproportionately affected by disparities in pregnancy outcomes. Improving pregnancy outcomes is one of the current goals of the U.S. government’s Healthy People 2020 initiative (U.S. Department of Health and Human Services, 2012).

Traditionally, research aimed at improving maternal and child health (MCH) outcomes has focused almost entirely on interventions that target women (Bond, 2010; Dudgeon & Inhorn, 2004; Gerein, Mayhew, & Lubben, 2003). The mother–baby entity has historically been viewed outside of a defined male role, with males often being portrayed as unconcerned or disinterested in pregnancy-related health (Dudgeon & Inhorn, 2004). Although considerable attention has been given to men’s involvement in childhood development, few—if any—studies in the United States have focused on men’s involvement in prenatal health and pregnancy outcomes (Bond, 2010). From this limited research, we know that men can be a significant source of “stress or support” to pregnant women (Gerein et al., 2003). However, beyond this general finding, the role of expectant fathers in pregnancy and in potential to improve birth outcomes is still unclear.

In contributing to this area of research, scholars in the public health and health promotion fields have recognized the potential of including men in prenatal education. Recently, Bond (2010) called for an expansion of research on MCH to include men, suggesting that moving beyond traditional prenatal health promotion that only involves women may reduce overall infant mortality, particularly in populations with considerable health disparities. This article builds on calls from Bond (2010) and the Commission on Paternal Involvement in Pregnancy Outcomes’ (CPIPO, 2010) for more research in this area. In doing so, we first highlight international research on the male role in prenatal health promotion and then propose a specific agenda for U.S. research in this field.

Successful Involvement of Men in Prenatal Health Outside the United States

When including men in both prenatal and postpartum health promotion efforts in less developed nations, public health researchers have had positive results (Molzan Turan, Nalbant, Bulut, & Sahip, 2001; Mullany, Becker, & Hindin, 2007; Shefner-Rogers & Sood, 2004). For example, including men in maternal and infant health education programs has been reported to be advantageous in seeking medical care during a pregnancy, in taking antiretroviral medication to reduce maternal–fetus HIV transmission, and in postpartum best practices such as birth preparedness and breastfeeding (Mullany et al., 2007; Rosane Odeh & Giugliani, 2008). Additionally, findings suggest that men who were more educated about a woman’s pregnancy were more likely to be able to identify obstetric emergencies and take their partners to get medical care (Molzan Turan et al., 2001; Shefner-Rogers & Sood, 2004). The effects of involving men in pregnancy-related decisions have been shown to open up communication between partners, making the man feel included (Molzan Turan et al., 2001).

Such positive findings are not limited to structured educational programs alone. An evaluation of a mass media campaign on safe motherhood, targeted at Indonesian men, identified that exposure to the messages led to overall better birth preparedness and better awareness of pregnancy emergencies that could harm the mother and fetus (Shefner-Rogers & Sood, 2004). Additionally, studies focusing on the effects of mass communication on conversations about reproductive health in communities in Bolivia and Peru have yielded positive results. Consistent with the findings that media campaigns can be a catalyst to communication and health behavior change, the studies reported that women relied on a network of interpersonal relationships between peers, family, and their male partners. However, discussions on issues of reproduction and prenatal health often came about due to mass media such as health pamphlets, radio commercials, soap operas, and newspapers (Alcalay, Ghee, & Scrimshaw, 1993; Valente, 1996; Valente & Saba, 1998).

Though male impact on birth outcomes has been reported to be considerable in underdeveloped and developing nations, research on paternal impact in pregnancy outcomes in the United States is lacking. It is difficult if not impossible to translate the findings of studies done in poorer, developing societies without advanced healthcare systems, to the United States. These factors, along with the many cultural variations in fatherhood within the United States itself, leave gaps in theoretical and methodological frameworks of research on paternal involvement (CPIPO, 2010). Assessing the current level of male involvement in pregnancies in the United States is essential. From there, researchers can focus on building health interventions that include expectant fathers to promote better pregnancy outcomes and reduce pregnancy-related disparities that exist in certain communities.

A Proposed U.S. Research Agenda

In an effort to lower the infant mortality rate in the United States, the Joint Center for Political and Economic Studies established the CPIPO in 2009. In 2010, the panel issued 40 recommendations to improve best practices in three critical areas—policy, research, and clinical practice related to men and MCH to achieve better pregnancy outcomes. The research aim called for improved measurements of male impact on pregnancy, understanding cultural differences in paternal involvement and perspectives of pregnancy, and recruiting men in populations that are disproportionately affected by poor pregnancy outcomes (CPIPO, 2010). Historically, there has been a disparity in pregnancy outcomes among Hispanic and non-Hispanic blacks when compared to the pregnancy outcomes for non-Hispanic whites. Though the gap between white and black birth outcomes has been reduced, poor birth outcomes among Hispanics in the United States have persisted despite public health campaigns to address important prenatal health issues such as folic acid consumption and seeking appropriate medical care (Thomas, Hauser, Rodriguez, & Quinn, 2010; Williams, Rasmussen, Flores, Kirby, & Edmonds, 2005).

Given the CPIPO recommendations and the existing body of research that suggests men can have a positive impact on birth outcomes, it is prudent to shift research focus to paternal involvement in pregnancy in the United States rather than simply “adding it on” to established studies and programs intended for women (Dudgeon & Inhorn, 2004). Building off Bond (2010) and the CPIPO’s recommendations, research surrounding men and prenatal health in communities with existing poor birth outcomes must become a priority. Populations already impacted by these disparities could benefit the most from the findings of this research, such as Hispanics. Developing interventions that resonate with these populations will put the findings to work more immediately in an effort to mend the current disparities in birth outcomes. The effort to reduce the overall infant mortality rate in the United States is still the core focus of this argument, but targeting the communities with considerably poor pregnancy outcomes may be an expeditious way of achieving this goal.

Due to the relative lack of information about paternal involvement in prenatal health in the United States, the first step in uncovering the perceived/actual role of men in pregnancy health will involve a mix of methods and approaches. Initial research should start at a more general level, including men of various races, ethnicities, and demographics. From there, researchers can drill down into different communities of men to explore cultural variations on the role of men in prenatal health. The research on cultural differences in the pregnancy-related health decisions of females is a robust field that has brought about unique ways of advancing prenatal care that resonates with intended audiences (Alcalay et al., 1993; O’Rourke & Roddy, 2007; Thomas et al., 2010). Expanding this research to include the perceived male role, which has been chronically understudied, may provide even more avenues to promote better birth outcomes. If research finds that the role (or lack thereof) of men in prenatal health negatively affects certain communities, subsequent measures can be taken to reverse this trend.

Researchers must enter into this exploration with the understanding that, ultimately, individual differences among men will drive their knowledge and motivation to get involved in their partner’s pregnancy health. Much like pregnant women are all not the same, despite all carrying babies, it can be assumed that prospective fathers will all not be the same either. The advancement of mobile and web health promotion is allowing for appropriate message tailoring to specific individuals, which research indicates is often an effective way of influencing health behavior change (Kreuter, Lukwago, Bucholtz, Clark, & Sanders-Thompson, 2003; Kreuter, Strecher, & Glassman, 1999; Rimer & Kreuter, 2006). Tailoring has been reported to improve prenatal health behaviors in women (Ershoff, Solomon, & Dolan-Mullen, 2000). In addition to tailoring, social marketing campaigns targeted to women have shown positive results when “rolled out” to those who belong to different subgroups, such as low-income Hispanic women (Alcalay et al., 1993).

Finally, we note that health care providers are often considered trusted sources of information, even if they are more limited in the time and frequency they see patients (Yarnall, Pollak, Ostbye, Krause, & Michener, 2003). Effective public health interventions for prenatal health will require sound research to build upon, and it is necessary to understand how these health care providers such as physicians, nurses, and educators currently view the role and involvement of men in prenatal health. Do health care providers even think about men when caring for a pregnant woman? Would holding different office or prenatal class hours allow for men to be more involved in their partner’s pregnancy health? How can health care providers reach men without compromising the attention given to women? A discussion of these topics with the appropriate health care providers is essential.

Discussion

There is a considerable need to address the United States’ high infant mortality rate and to improve the health of mothers, infants, and child (U.S. Department of Health and Human Services, 2012). Reducing the high infant mortality rate must include the successful collaboration of health care providers, educators, public health promoters, policy makers, community mentors, and social marketers. A broad research agenda to enhance the understanding of paternal involvement to improve birth outcomes must develop a clearer picture of the role of men in pregnancy, with the understanding that not all men are motivated by the same issues both across and within various cultures in the United States. It is recommended that the insight of health care providers regarding male involvement in pregnancy be explored as well.

As it stands, men are currently absent from almost all prenatal health education programs in the United States, and advancing research on men and pregnancy is conspicuously absent from the Healthy People 2020 objectives for MCH. Even social marketing tactics used for public health (such as mobile apps for tracking pregnancy) tend to be designed exclusively for women, leaving half of the population out of potentially vital information. Implications for health providers, such as nurses and physicians, are also important. Health care providers areoften limited in terms of time spent with patients; therefore, an effective campaign should incorporate a provider focus and a social marketing focus to augment the interactions between providers and patients. Messages from clinics, nonprofits, churches, schools, and so on could complement provider information and play a key role in getting men involved in their partner’s pregnancy.

The outcome of expanded research on paternal involvement in prenatal health should inform best practices for these different groups, much like research on women and pregnancy has already done. It is important to note that, like women, all men are not likely to be motivated by the same messages, as there are inherent differences between and within cultures and on the individual level. Research on effective prenatal campaigns targeted toward women indicates that messages are often too broadly defined and become irrelevant (Flores, Prue, & Daniel, 2007; Thomas et al., 2010)—the same would reasonably hold true for prenatal campaigns targeted toward men. Further research is needed to develop effective campaigns geared toward expectant fathers, with the understanding that some men may be motivated by their partner’s health and/or the health of their child, among others (Pollak et al., 2010).

Bond (2010) made a strong case for advancing research in the area of men and prenatal health to (a) enhance paternal involvement in pregnancy and (b) reduce the infant mortality rate and disparities in pregnancy outcomes that exist in the United States. Immediate attention to this field could improve health promotion campaigns, policy recommendations, public health, and overall healthcare costs. Reaching these important public health goals will require researchers and practitioners to understand the role that men can have in improving pregnancy outcomes, and this article expands on previous calls for research in this area and outlines a specific roadmap for advancing research in this critical area.