Abstract
There is a knowledge gap about fathers’ experiences during the perinatal period globally. Limited literature addresses experiences of first-time fathers during the perinatal period in the sociocultural context of Pakistan. This is the first study to explore the experiences of first-time fathers during the perinatal period in Pakistan and seeks to clarify those experiences from the father’s perspectives. Critical realism (CR) philosophy was integrated with the socioecological model (SEM) framework to guide this qualitative descriptive study. Eight first-time fathers were recruited and interviewed individually at their homes by male research assistants. Four fathers were experiencing the prenatal phase and four were experiencing the postnatal phase up to 6 months after delivery. Interview data were analyzed using inductive content analysis technique. Results revealed the multifaceted relationship between agents and social structures in contributing to the perinatal experiences of first-time fathers in Pakistan. Religion played a strong role in shaping first-time Pakistani fathers’ experiences in both prenatal and postnatal phases of the perinatal period. Economic conditions in Pakistan contributed to fathers’ stress about providing for family expenses and their child’s future. Hospital and government policies were a major concern for postnatal fathers. All fathers developed a sense of responsibility after receiving news about becoming a father. Integration of CR and SEM facilitated new insights. This multilevel perspective may offer hope for improving the experiences of first-time fathers during their wives’ perinatal period. These new insights can also assist policymakers and researchers in developing strategies and interventions for successful transition to fatherhood in Pakistan.
Keywords
Most research into experiences during the perinatal period has focused on mother’s experiences. There is a knowledge gap about fathers’ experiences during the perinatal period globally. Limited literature addresses experiences of first-time fathers during the perinatal period in the sociocultural context of Pakistan.
This is the first study to explore the experiences of first-time fathers during the perinatal period in Pakistan and seeks to clarify those experiences from the father’s perspectives. Critical realism (CR) philosophy was integrated with the socioecological model (SEM) framework to guide this qualitative descriptive study. Eight first-time fathers were recruited, consented to, and participated in the study. Participants were grouped according to perinatal phases; four fathers were experiencing the prenatal phase and four were experiencing the postnatal phase up to six months after delivery. Participants were interviewed individually at their homes by male research assistants. Interview data were analyzed using inductive content analysis (ICA).
Results revealed the multifaceted relationship between agents and social structures in contributing to the perinatal experiences of first-time fathers in the context of Pakistan across all levels of the SEM framework. Religion played a strong role in shaping first-time Pakistani fathers’ experiences in both prenatal and postnatal phases of the perinatal period. Economic conditions in Pakistan contributed to fathers’ stress about providing for family expenses and their child’s future. Hospital and government policies were a major concern for postnatal fathers. All fathers developed a sense of responsibility after receiving news about becoming a father for the first time and became more considerate of their wives.
Integration of CR and SEM facilitated new insights into how nurses and other health care providers may support first-time fathers and their families across all socioecological levels and both perinatal phases. This multilevel perspective may offer hope for improving the experiences of first-time fathers during the perinatal period. These new insights can assist policymakers and researchers to develop strategies and interventions on all four socioecological levels that support first-time fathers’ successful transition to fatherhood in Pakistan.
Transitions in one’s life are inevitable as people move across the life course. Some life transitions are significant in nature, and becoming a parent is a key transition in couples’ lives (Clark et al., 2019). The perinatal period represents a substantial life transition that may lead to psychological distress in fathers, especially first-time fathers (Zindani et al., 2025). Predominantly, this transformation in men’s lives is influenced by various socioecological factors (Leahy-Warren et al., 2023; Molloy et al., 2022).
Traditionally, maternal mental health during the perinatal period has been the focus of researchers, policymakers, and health and social care practitioners (Azzam et al., 2022; Molloy et al., 2022). Emerging evidence from Australia, Canada, China, Sweden, Taiwan, the United Kingdom, and the United States, have documented that fathers, especially first-time fathers, experience psychological distress during their perinatal period (Zindani et al., 2025), suggesting that this phenomenon transcends cultural differences and geo-political boundaries. Fathers’ experiences, needs, and challenges during the perinatal period have gained research attention (Molloy et al., 2022; Onyeze-Joe & Godin, 2020); however there is a need to further explore the phenomena and how health and social care practices and policies can be integrated to mitigate its effects globally and in Pakistan.
Nurses and other health care professionals are trained to understand life course transitions from conception through birth to death (Deliktas et al., 2019). For the last four decades, researchers have been on a quest to better understand experiences of men becoming a father, mostly in the United States, Canada, Australia, and some European countries (Sansiriphun et al., 2010). Research in these contexts focused on men’s negative experiences during the perinatal period (Sansiriphun et al., 2010). Few studies have reported about expectant fathers compared with expectant mothers (Copland & Hunter, 2025; Hambidge et al., 2021; Leahy-Warren et al, 2023, n.d.; Shorey & Chan, 2020; Watkins et al., 2024), and little is known about fathers in Pakistan (Harrison et al., 2025; Husain et al., 2025; Maken et al., 2018; Maselko et al., 2019; Pirani & Karmaliani, 2015a, 2015b).
Snapshot of Pakistan
Pakistan, the second largest Muslim country in terms of population, gained independence from the United Kingdom in 1947 (Pakistan Bureau of Statistics, 2017; Shafiq et al., 2020). Pakistan has been a male-dominant country since its conception (Fatima, 2018), and patriarchy is integral in Pakistani society (Iqbal, 2017). The Brief on Census 2017 reported the total population of Pakistan was 207.68 million, of which 51% are males (i.e., n = 106.3 million) (Pakistan Bureau of Statistics, n.d.). The legal age for marriage in Pakistan is 18 years old and 41% of men were legally eligible for marriage (Pakistan Today, 2023). Being a male-dominant country, having a fertility rate of 3.76 births per woman in 2017, and despite 41% of the male population being at the legal age of marriage in 2017; no previous research has explored context specific experiences of first-time fathers in Pakistan and the underlying reasons for those experiences. We suspect causal mechanisms of fatherhood and culture differs between Pakistani men and men in other parts of the world and need to be explored and described. Likewise, there may be similarities that transcend cultures and need to be highlighted in relation to literature from other parts of the world.
Social Determinants of Fatherhood in Pakistan
Social drivers including patriarchal and gender norms, family structure, social expectations around masculinity, and religious beliefs, considerably influence fatherhood in Pakistan (Fatima, 2018; Jeong et al., 2018; Sarfaraz et al., 2021; Shah, 2023). Fathers have decisive authority because they are the primary bread-earner and head of the family. Societal expectations of masculinity and gender roles demand fathers to continuously present themselves as strong, both mentally and emotionally, whether inside or outside of their families, which prevents them from verbalizing and seeking medical help for any distress they may experience. Joint family system where parents, grandparents, uncles, aunts, and siblings live together is prevalent in Pakistan (Jeong et al., 2018). This joint family structure influences the fatherhood role by reinforcing dominant societal and gender norms.
Pakistan is a predominantly Muslim country where 96% of the population follows the religion of Islam, and faith is an integral part of daily life and influences perceptions of well-being (Irfan, 2016; Pakistan Bureau of Statistics, 2017). The nucleus of Islamic belief is the Oneness of God (Allah), who is believed to be creator, omnipotent, and orchestrator of all happenings in the lives of the believers. Within this religious belief system, every illness is regarded as a trial or a means of spiritual purification from Allah, rather than a condition requiring medical intervention. Under this religious framework, Muslims usually turn to saints and faith-healers, whom they believe possess supranatural powers to address any misery and health problems (Elshamy et al., 2023; Fatma, 2024).
Structural Determinants of Fatherhood in Pakistan
Structural determinants including politics, governance, employment conditions, health care systems, and information access, silently script fatherhood experiences in Pakistan. Despite overrepresentation of men in positions of authority in Pakistan including elected members in National Assembly (80%) and Senate (82%) in 2018, fathers’ mental health is a not a health care policy priority in the National Action Framework for Non-Communicable Diseases and Mental Health 2021–2030 (Government of Pakistan, 2021; Pakistan Bureau of Statistics, 2019). Mostly, men are responsible for providing material and financial means to support their immediate and extended family members (i.e., four or five generations living together) (Pakistani—Family, 2016). Women fulfilling this role are considered threats to men’s authority and social status (Amir & Durrani, 2019). Even women participating in income-generating activities for their families experience a high hourly mean gender wage gap (34%) and most working women (90%) belong to the bottom (1%) of wage-earners (International Labour Organization, 2018). This situation puts undue financial pressure on men.
Due to cheap technological advancements and interconnectivity, information is readily accessible. Internet-based technology has introduced Pakistani people to the values, beliefs, and practices from other parts of the world. This information exchange is shifting societal norms and expectations. Now, fathers are also expected to participate in household chores and child raising (Landsberg, 2020). These expectations are in direct conflict with their traditional value-belief system and men may perceive their manhood is threatened.
Research Purpose
The goals of this qualitative descriptive study underpinned by the philosophy of critical realism (CR) were to explore men’s perspectives of their experiences of becoming first-time fathers in Pakistan and examine the role and relationship of structure and agency in generating those causal mechanism(s) that may underlie these experiences that have not been explored in Pakistan.
Research Questions
The research questions for this study are: What are the men’s perspectives of their experiences of becoming a first-time father in Pakistan? What is/are the causal mechanism(s) behind the experience(s) of men becoming a first-time father in Pakistan? What is the role of structure and agency in generating those mechanisms?
Method
Philosophical Underpinnings and Analytical Framework
This study is guided by CR philosophy which provides a foundation for analyzing the interaction between structure and agency that generates causal mechanism(s). Various socioecological factors affect the way people experience life course transitions (Torche & Rauf, 2021). Socioecological model (SEM) framework and CR philosophy were integrated to facilitate analysis and interpretation in this study (Koopmans & Schiller, 2022; Principles of Community Engagement, 2015). This integration assisted the researchers in gaining deeper, contextual, and socioecological factorial understanding of the casual mechanism(s) responsible for generating fathers’ experiences during perinatal period in Pakistan. The integration process is described by Kamwani and colleagues (Kamwani, 2024).
The main purpose of CR philosophy is to propose a complete understanding about the understudied phenomena including the causations or causal mechanism(s) that produce observable events and experiences (Brunson et al., n.d.; Koopmans & Schiller, 2022; Schiller, 2016). Generative mechanism, not deterministic causality, is the hallmark of CR philosophy and approach (Tikly, 2015). Contrary to the nature of deterministic causality that asserts cause and effect relationships and statistical correlation and generalizability of the outcome(s), this generative mechanism is context-specific and works in open systems (Bhaskar, 2008; Tikly, 2015). This means that even identical conditions may not produce similar outcome(s).
CR emphasizes investigating the uncharted reality underlying experiences and events (Koopmans & Schiller, 2022). Reality is stratified in empirical, actual, and real layers (Koopmans & Schiller, 2022). Reality is not fixed and changes according to context (Wynn & Williams, 2012). Hence, CR rejects the notion of an epistemic fallacy of equating reality with what is empirically observable (Bhaskar, 2008). CR-based qualitative studies can become the foundational research for tool development studies by generating items through the process of coding and retroduction (Fletcher, 2017), where causality may later be determined with a larger number of participants. This study contributes to the evidence based upon which future studies can generate items and test those items with larger numbers of participants.
The SEM framework consists of four levels: individual, relationship, community, and societal (Principles of Community Engagement, 2015). Factors in each level interact within and between factors in other levels having profound effects on individuals and the population (Principles of Community Engagement, 2015). Simultaneously, factors in these levels can become the sustainable source of targeted action for health promotion of individuals and their families (Principles of Community Engagement, 2015).
Setting and Sample
The population from which this study’s sample was drawn are first-time fathers in Pakistan. The setting where the sample was obtained is a hospital in Karachi, a large urban area. The convenience sample was recruited from among first-time fathers availing of perinatal services for their wives at the hospital. Approximately, 70 to 75 patients per day seek care from all specialties of medicine and surgery at the hospital. Permission to engage with staff and potential research participants to collect data was obtained from the hospital’s Chief Executive Officer.
Research guided by CR philosophy ought to be in-depth, small scale, and intensive study. Having a limited number of study participants facilitates thoroughly and systematically identifying and analyzing the causal mechanism(s) responsible for the understudied phenomenon, experience(s), event(s), and outcome(s) (Stutchbury, 2022). A single well-examined case can be sufficient to reveal a generative mechanism in a critical realist study (Danermark et al., 2002). Therefore, this qualitative study was conducted on a small scale, working closely with a limited number of participants; eight Pakistani men becoming a father for the first-time.
Formation of Community Advisory Board
A Community Advisory Board (CAB) of five fathers was formed to guide the research process and inform recruitment efforts. All CAB members were first-time fathers with children under 2 years of age. The CAB was consulted to devise and revise the recruitment process and procedures. CAB members supported the principal investigator (PI) in English to Urdu translation of data collection instruments, interview guides, informed consent forms, and participant recruitment text.
PI initiated data collection in the light of the CAB recommendation that gender would not influence the participation rate. However, participants did not agree to share information with a woman interviewer, suggesting there may be differences of opinions between CAB members and the participants.
Participant Subgroup Assignment Scheme
Individual, in-depth interviews were conducted with eight first-time fathers at their homes at a date and time convenient to them. The temporal dimension of peri-natality extends from pre-conception through pregnancy, childbirth, and infancy. To capture fathers’ experiences across these phases, participants were recruited into two groups: (1) first-time fathers during their prenatal period or (2) first-time fathers during their postnatal period, up to 6 months postdelivery. Each group consisted of four first-time fathers. To insure cultural and gender sensitivity, two male research associates (RAs) were hired and trained by PI to collect data. Each RA collected data from four participants. The PI listened, re-listened, and transcribed all the interview recordings to be familiar with the data. The interview data were transcribed and translated from Urdu to English. All transcriptions and translations by PI were verified by members of the study’s CAB.
Hiring and Training of Research Associates
Two male nursing interns were hired as RAs from a written announcement posted at the hospital. PI trained both RAs in all aspects of data collection, management, obtaining informed consent, and human subject considerations using an investigator developed training protocol. The RAs conducted a mock interview with a specialist nurse working in the obstetric department, as part of their training. PI monitored the mock interview of RAs as part of quality control and to enhance awareness of RA understanding of the study protocol and their capacity to complete interviews with first-time fathers.
Eligibility Criteria
Inclusion criteria for the participants were: first-time biological fathers, in perinatal period, opposite sex couple, can comprehend English or Urdu language, and agree to give consent and participate in the interview. Potential participants were excluded from the study if participants were experiencing an acute, moderate level of psychological distress; had a preterm baby; or had adverse pregnancy outcomes because the interview given under these conditions could worsen their psychological distress and distress under these conditions was not the focus of this study and is beyond its scope.
Screening of Participants
Potential participants were screened for psychological distress by a research team member using Kessler’s K6 Scale that has been translated to and validated in Urdu. The K6 scale is reported to be the most efficient scale for screening individuals with serious mental distress, and the internal consistency and reliability of the K6 Scale is reported to be α = .89. The sensitivity and specificity of the K6 Scale for screening people having a moderate level of mental distress was reported to be 0.76 and 0.75, respectively. Potential participants who scored > 4 on the K6 scale were to be excluded from the study because they were considered to have moderate psychological distress. If a potential participant excluded for having moderate psychological distress, they would receive a list of mental health resources available in Pakistan and offered a referral to the hospital’s house physician for further evaluation. No participants screened were ineligible based on the K6 scale score.
Potential participants were screened for the potential of having a preterm birth or other adverse pregnancy outcomes using questions from the Demographic Data Form and Health Information Form. These forms included self-reported medical history items specifically designed to capture such outcomes. No participants were excluded from the study based on these factors. If any had been excluded, they would have been provided with a list of medical and mental health resources and offered a referral to the hospital’s house physician for evaluation.
Data Collection
Nursing staff working in the Obstetrics and Gynecology clinic and inpatient unit at a hospital identified potential study participants and referred them to study staff to be screened for eligibility to participate in the study. RAs obtained participant’s written informed consent.
The Demographic Data Form, Health Information Form, and Interview Guide were developed by PI in consultation with the research team, then shared with CAB members for review and approval. Modifications suggested by the CAB were incorporated and final versions of the instruments and interview questions were translated to Urdu in consultation with CAB members before being implemented with participants. PI and the RAs are all fluent in both English and Urdu. RAs conducted audio-recorded interviews in Urdu and PI translated them to English for analysis.
The RAs collected qualitative data from eligible participants individually, via in-depth, semi-structured, in-person interviews conducted at the participants’ homes. Each interview lasted about 45 to 50 min and was audio recorded. The interview guide (Appendix A) consisted of questions (Appendix B and C) regarding first-time fathers’ experiences during their pregnancy, delivery, and postdelivery period; the reasons behind those experiences; the way by which fathers manifested their experiences; the reasons behind the ways fathers manifested their experiences; and the ways by which their stress or anxiety could have been reduced during those experiences. During interviews, RAs asked participants probes to clarify responses to interview guide questions. RAs informed participants about the possibility that the research team may reach out to them for clarification and as part of the study findings verification process, and a means to communicate with them in the future was established when written consent was obtained. Data collection continued until the adequacy of the data was achieved.
Initially, PI listened to recorded interviews of both RAs. Once PI was satisfied with the interview process, then the RAs proceeded with the next interview. If further clarification was required after PI listened to the recorded interview, the RA who completed the interview approached the participant for clarification. During the data collection process, Field Notes (non-verbal clues of participants) and Reflective Diaries (experiences and feelings of RAs) written in English by both RAs were included in the study datasets. Field Notes and writing Reflective Diaries assisted in documenting study findings, data validation, and in reflecting on the interview process.
Data Analysis
Consistent with this study’s CR philosophical under pinning and SEM analytical framework, we used inductive content analysis (ICA) for data analysis. The SEM framework was introduced after listening and re-listening to the interviews as the data started to gather around the SEM categories. The components of SEM were used as codes with CR categories to analyze the data, from which the theme emerged. For example, hospital’s policies and policymakers were assigned the code of “society” from the SEM framework and were respectively categorized as social structures and agency under the CR philosophy, and CR causal mechanism(s) was the theme embedded in the culture and context of Pakistan.
Data analysis occurred in five phases that merged the analytical steps of ICA with CR stages, which are summarized in Table 1. Data from the two groups of first-time fathers, prenatal period and postnatal period up to 6 months after the child’s birth, were analyzed separately. Merging the steps of ICA with CR approach improves the rigor, practicality, and utility of the study findings (Leung & Chung, 2019). Data collection and data analysis occurred concurrently, starting with the first interview. Data will be conserved for 5 years starting from the end of the data collection activity.
Data Analysis Scheme.
Phase I: Data Immersion; Initial Reflections
Data analysis began with PI immersing herself in the data. This process included listening to, transcribing, and translating the interviews to become fully conversant with the data. PI read the field notes and reflective diaries of the RAs for validation of specific details that were not evident from listening to and transcribing interviews. This phase aligns with ICA step I and CR stage I.
Phase II: Creating Narratives and Initial Coding
In this step, PI created a narrative summary of each interview. The interview narratives are an analytical tool for subsequent analysis phases. After narrating each interview, sections of the text that contribute to answering the research questions were identified and labeled (Vears & Gillam, 2022). This phase integrates ICA step II with CR stage II to facilitate deeper reflection on interview narratives and first round-coding of the data. Field notes and RAs’ reflective diaries informed data analysis during this phase and helped in validating the categories and subcategories generated during the data analysis process starting with this phase.
Phase III: Explicating Structure and Context; Revise Coding
In Phase III, the sections of text that were coded in Phase II were revisited to identify the structures, context, and agency presented in the data. During this phase, subcategories identified in Phase II as part of first-round coding were further analyzed to explicate the structure and context in which those subcategories occurred and new subcategories specific to structure and context for first-time fathers’ experiences with the transition to fatherhood emerged. This phase integrated ICA step III, second round coding, and CR stage III, explication of structure and context.
Phase IV: Refine Subcategories From Phases II and III
During this phase of analysis, two researchers reviewed the narratives and preliminary categories and subcategories independently and then discussed them to come to consensus on the definitions and meanings of the categories and subcategories, making revisions as needed until both researchers were satisfied that the categories and subcategories represented their understanding of the experiences of first-time fathers. The narratives, categories, and subcategories were presented to the other research team members for further validation before presentation to CAB members and first-time fathers in Phase V. Categories and subcategories were compared again with the other researchers so it can be collapsed into similar subcategories and dissimilar subcategories are kept separated. To assure reliability and validity of generated codes, categories, and subcategories, consistency and agreement was sought among all the data coders. Two different coders coded the data twice and then compared their codes, categories, and subcategories for agreement. All researchers discussed codes, categories, and subcategories to achieve consensus on their definitions and meanings. This phase aligns with ICA step IV and CR does not have an analogous stage.
Phase V: Synthesize, Interpret, Corroborate, and Disseminate
The final analytical phase of our research process included four main activities, synthesis, interpretation, corroboration, and dissemination of findings. Data interpretation, ICA Step V (Vears & Gillam, 2022), and CR stage IV, Retroduction (Wynn & Williams, 2012), were crucial aspects for synthesizing the data collected on first-time fathers experiences of transitioning to fatherhood. These processes, when combined, facilitated exploration of this understudied phenomenon and men’s experiences with the events and outcomes of their perinatal experiences. This allowed us to hypothesize and interpret the first-time fathers’ experiences in terms of the causal mechanism(s) that could have generated them. During synthesis and retroduction in this analytical phase, we observed that data clustered around the four levels of the study’s organizing SEM framework (Principles of Community Engagement, 2015).
The final activities of this analytical phase are derived from the last two CR stages, in which we corroborated first-time fathers’ experiences and disseminated those findings. We used triangulation to establish validity of the analysis by looking at the coded text reflecting a similar meaning in relation to the ICA categories that were formed. PI translated the summary of key findings into Urdu and the RAs validated them with the study participants. This validation with participants marks the transition to dissemination activities for the study. The study’s findings are represented here in narrative, tabular, and graphical forms.
Ethical Considerations
The PI is Good Clinical Practice (GCP) certified and trained all team members in Pakistan in the study procedures, human subject protection, and maintaining confidentiality and privacy of the data. For conducting this study, ethics approval was obtained holding the certificate number: H-02-23-8846. PI obtained permission to access the study population from the hospital’s Chief Executive Officer. To protect confidentiality, the RAs assigned each participant a unique identification number that included their group classification. The digital data was password protected electronically, stored in PI’s hard drive, and kept in PI’s locked cabinet. At the end of the data conservation period, PI will destroy all data and consent forms from the study.
Results
Researchers used demographic information collected for descriptive purposes. Demographic data included ethnicity, socioeconomic status, education level, age, ethnicity, occupation, type and area of residence, income level, religious identity, and type of family. Medical data collected included experiences with physical or mental illness, wife’s month of pregnancy, delivery date, age of newborn, sex of newborn, and medications being taken. Demographic and medical data are summarized in Table 2.
Sociodemographic and Medical Data.
Findings from this study are reported for each participant group, that is, prenatal period and postnatal period up to 6 months after delivery. Total eight fathers were recruited, four in each group. The age range of fathers in the prenatal group was 26 to 35 years old and in the postnatal group was 31 to 38 years old. Most fathers were well educated and had acquired a graduate degree. Most fathers in both groups reported earned income of 1 to 2 lakhs PKR (low income) per month (USD 352.39–USD 704.78. As of May 20, 2025; 1 USD = 283.78 PKR). One father in the prenatal group earned below 50,000 PKR (below low income) per month (USD < 176.20$). Another father in the postnatal group earned 300,000 PKR (moderate income) per month (USD 1057.17$). Half of the prenatal fathers were employed, and half were running their own businesses. Most postnatal fathers were employed and only one father was running his own business. Half of the fathers in both groups were living in a nuclear family (becoming prevalent, particularly in urban areas), and half of them were living in a joint family system (traditional family system). Most prenatal fathers were living in an underdeveloped area and only one father was living in a well-developed area. All the fathers in the postnatal group were living in well-developed areas. None of the fathers reported any medical history and none of them took any medications. None of the participants scored > 4 on the K6 scale. Most prenatal fathers had only experienced the first trimester of pregnancy and only one father experienced the second trimester of pregnancy. Among fathers in the postnatal group, most deliveries were conducted via cesarean section and only one delivery was conducted using forceps. Three fathers reported their child was male and one reported a female child. Sociodemographic and medical data for both groups are summarized in Table 2.
The Story of Pakistani Men Becoming Fathers for the First Time
PI for this study is a Pakistani citizen, a woman, a wife, a mother, and a nurse who explored the perspectives of men’s experiences of becoming a father for the first time in Pakistan. The approach used in this study facilitated bringing to life the perspectives of these men on a topic that may not have otherwise discussed. Below is the story of their collective journey of becoming fathers for the first time, during prenatal and postnatal periods.
Story of Prenatal Fathers
All four fathers in the prenatal group expressed joy upon learning of the pregnancy, often linking fatherhood to religious blessings, family continuity, and emotional fulfillment. For example, PR-01 was on cloud nine for getting married to his love-interest and being able to have a baby. He believed that his wife’s love and affection for him would increase when the baby was born. He believed that the more children he produces, the more blessings he will have from Allah. He learnt these beliefs from his religious-minded friends and religious gatherings. PR-02 cheered because his parents would be able to have their grandchild. For him, marriage and procreation are important aspects of life. He stated his belief that “this is how the world works, and Allah has kept this system in place.” PR-03 was excited about having a new addition to his family and believed that a child gives purpose to a man’s life. PR-04 was happy and reported that he considers children a blessing from Allah. He expressed sadness about loneliness experienced by childless couples because, “men get older and still are lonely without children.”
All men observed significant changes in their wives’ attitude and temperament during pregnancy. Their wives had frequent mood swings and became irritated and angry over minor matters, and men exercised patience during those times. Because men had observed in their families and among friends, and had learnt from doctors, social media, TV, dramas, movies, and society that reacting angrily to a pregnant woman could negatively affect the baby’s health. Participants believed that women are less intelligent and can hurt themselves if men disputed with them as PR-02 pointed out, “women are a little unwise. God forbid if she tries to harm herself after I hit her, that would be something I fear.”
Men used different methods to manage their reaction and stress from their wives. Sometimes, men left their rooms when their wives were angry or went to their other family members or friends to distract themselves. Some of the men visited mosques to get Allah’s help for controlling their anger because men learnt that anger comes from the devil. So, men prayed in the mosque to take Allah’s refuge from the devil. Participants believed that only Allah could solve their problems, so men referred to HIM during times of trials and tribulations.
All men were worried about their rising financial expenses during the pregnancy. These expenses included doctor’s consultations charges, laboratory tests, and provision of healthy food for their wives, along with paying for their housing and daily household expenses. During that time, either men themselves tried to curtail their daily utility expenses, or their family members, friends, or in-laws extended financial support to them. Their belief about Allah’s help for sustaining the new life consoled them during troubled times. None of them shared concerns with their pregnant wives as men did not want their wives to be stressed during pregnancy. Because participants had learnt from family, friends, or media sources that taking on stress during pregnancy can negatively affect the health of both the mother and child.
All men preferred to take guidance either from their family members or another wise, knowledgeable, trustworthy man. For medical related issues, men preferred to consult with doctors or nurses. None of them preferred to share their wives’ matters with their friends or colleagues because men had observed their friends making a mockery if such matters were shared with them. Second, men had learnt that their religion does not allow them to discuss their wives’ matters with their friends. So, all men followed their religious teachings and acted accordingly.
All participating fathers planned to nurture their child in a good environment. To them, a good environment includes teaching their child to be respectful with their elders. They believed that the outside environment affects a child’s behavior more than the home environment. They witnessed people spoiling children outside the home environment. They were thoughtful about their child’s good image in front of their family members and friends. Suggesting, men valued the moral upbringing of their child. Regarding the destiny of his child, PR-02 believed that the child’s future profession is pre-destined by Allah and is against HIS will if the father decides for his child.
Story of Postnatal Fathers
In contrast, fathers in the postnatal group conveyed experiences that were shaped by their experiences during labor and delivery and in the postnatal period. Three of these fathers worried and were fearful during labor and delivery phases of their wife’s pregnancy. For example, the wife of PP-01 experienced artificial pains when labor was induced and continued throughout the whole night. PP-01 and PP-02 felt that it was challenging to see their wives in pain, and men were stressed out. PP-01 was frightened when he recalled stories about pregnant relatives or in movies when women were in distress during labor and delivery. PP-01 expressed his feelings for that time saying, “There was a lot of stress at that time. I did not cry yet I felt stressed, and my hands and legs were shivering. It is like experiencing death from close.”
PP-03 had mixed feelings of excitement to receive his baby and panic about the baby’s arrival, simultaneously. A state of emergency occurred during the birthing process. His son could not breathe 15 min prior to the delivery. So, it was a mixed emotional experience for him. PP-04 remained calm during labor and delivery. The doctor had recommended his wife have a cesarean section prior to the delivery because his child’s position was not feasible for a natural delivery. So, his emotions were stable during the delivery.
Despite being apprehensive and anxious at the delivery time, fathers depicted themselves as being tough and strong, and concealed their apprehension and worries about supporting their wives as PP-02 said: I was tense. My wife was induced. So, she was in a lot of pain. When I used to go to her, I had to be strong to be able to support her morally. If I had shown some weakness, she would have felt low too.
During difficult times of labor and delivery, parents and siblings of the fathers were with them in the hospital. The hospitals’ policies of not allowing husbands in the labor and delivery room, lack of timely communication to them about the situation of their wives and baby, asking them to sign on the Consent Form, and requiring them to take full responsibility of the outcome made fathers more anxious and apprehensive at that time. PP-01 stated, “We knew that the mother [pregnant lady] is inside [Labor Room], and the child will be delivered but we did not know what the situation was.” Similarly, PP-02 revealed, “After inducing my wife, the doctor called me several hours later and gave me a Consent Form where my signatures were required. The Form mentioned that during this operation, if God forbid something adverse happens, neither the doctor nor the hospital will be accountable. For me, this was quite challenging as I had to sign on behalf of my wife.” Likewise, PP-03 shared, I came to know a bit late about the complication. Her designated doctor requested that I stay outside . . . I learned the situation after it had passed . . . Generally, a doctor is on the rounds and an allocated nurse. But I saw several doctors entering the room, which worried me. Even though I did not witness the entire situation, I observed something troubling. (PP-03)
All fathers took the help of prayers and performed good deeds (charity) during the difficult times as men had learnt from their families since their childhood. One father said, the family’s background matters in this aspect . . . Whenever we start a task, we usually begin it with “Bismillah Hi Rahman Ar Raheem” (In the name of Allah, the most Gracious, the most Merciful) or whichever religion we practice. I did the same, which was a part of my upbringing and that supported me as well . . . I kept such (stress) emotions inside me. At times when we feel stuck, we pray to Allah, and we start doing good deeds. I did the same things and prayed so that I could be helped by nature and kept myself strong because I could only support her when I was strong. (PP-02)
All fathers expressed immense happiness in receiving their baby as the addition of a new member had extended and united their family. All of them had distributed sweets to hospital staff and their relatives. After the delivery of a child, working fathers reported challenges managing competing responsibilities between work and family. For example, If the child is sick, [the] husband will take the wife and child to the hospital . . . When the child wakes up frequently at night, husband and wife manage together. As husbands, we must go to work in the morning, which has no leniency when it comes to the workload. People at work will only be supportive to some extent. Employers will eventually ask us to be productive as we are being paid by them. (PP-02)
In a joint family system, men had to take care of their parents. To manage their dual home and office responsibilities effectively, men made some compromises such as cutting down on their hobbies and socializing with friends.
All men experienced a sense of responsibility after the delivery of their child. After delivery, PP-02 and PP-03 felt the instinct to take responsibility for their child as PP-02 explained, “This is a cycle that goes on. Just like [my father] played a role for his child, I now must do the same . . . This is a natural trait that comes from Allah that we tend to help our children.” PP-04’s love for his child was natural but he acknowledged that he had expectations from his child as he declared, We expect our children to help us. Today we are entertaining and supporting them [child], so tomorrow child will do the same because the government does not support us in our country. So, we rely on our children . . . This baby is my child and my property, and I am investing in it [child]. You must be responsible for it [child] so in the future he can take responsibility [for us] when he grows up. (PP-04)
All fathers had to adjust their sleeping routine at night, to take care of their child who used to remain awake late at night. All of them were supportive to their wives and learnt new skills for helping their wives, including changing the baby’s diapers, burping the baby after feeding, putting the baby to sleep, bathing the baby, holding the baby’s head properly, soothing the crying baby, and other childcare activities. Families of all the couples were supportive of them. The parents of the men guided them about prevailing norms in society such as keeping the pregnant woman indoors during a lunar eclipse; consuming Semolina for gaining strength after delivering a baby; child naming rituals and processes; and taking decisions about cesarean section. Fathers did not require emotional support from anyone beyond performing daily chores as PP-04 asserted, “I do not need any emotional support because I am quite intelligent emotionally. In today’s time, it is enough if family and friends are helping me with chores.”
Postnatal fathers experienced their wife’s agitation and anger after giving birth. Fathers were considerate and understood that this is normal for a postnatal mother, so fathers remained composed and peaceful. PP-01 accepted that both husband and wife experience postnatal depression that may contribute to fights between them. He believed that a man should be mentally strong and give importance to his wife’s depression rather than his own because he considers a man the “captain of the ship” (PP-01).
When speculating about their child’s future, fathers emphasized discipling their children and teaching them manners. Fathers believe that children’s education is necessary and teaching them proper behavior is of equal importance so that their children can have their own identity with impressive personality. Fathers highlighted the importance of planning for the future, Planning is extremely important. If you look at Pakistan’s economic condition, it has certainly become very challenging. [Children’s] upbringing, medical, and education have gotten expensive. Not only should you plan financially but manage your time as to how much input you can give. Both these things matter . . . If you think you can plan accordingly then [have children], otherwise wait for the right time. (PP-02)
Reflections of RAs
All the fathers behaved respectfully with the RAs which made both the RAs think that it would be easy to conduct interviews from them. However, initially, fathers were reluctant to open up to RAs. As the time passed, fathers became comfortable in being more expressive to RAs. This helped RAs to identify the experiences, origins of emotions, and sources of behaviors of men becoming first-time fathers in Pakistan.
Discussion
This study aimed to investigate the experiences of men becoming first-time fathers in Pakistan, and to explore about the function and association of structure and agency (the terms “agency” and “structure” originated from the philosophy of CR) in producing the causal mechanism(s) behind these experiences. The men who participated in the study were separated into two groups: (1) prenatal period and (2) postnatal period up to 6 months after delivery. The correlation between structure and agency is further described using the SEM framework.
Most previous studies about psychological distress among first-time fathers have used quantitative research approaches (Da Costa et al., 2017, 2019; Leathers & Kelley, 2000; Matthey et al., 2000; Zhang et al., 2016), except a few that applied qualitative (Baldwin et al., 2019) or mixed-method approaches (Chhabra et al., 2022). No previous study has used CR philosophy and SEM to understand the multilayered perinatal experiences of first-time fathers. This study is innovative because we integrated CR philosophy and SEM to generate the hypothesis about causal mechanism(s) affecting experiences and events of men becoming first-time fathers in the context of Pakistan.
Prenatal Period
During the prenatal period, the complex interplay occurring among the agencies (parents, wisemen, doctors, nurses, friends, religious people) was evident in the study’s results. For example, the interconnectivity and relationship of participants with their parents’ expectations; knowledge received from parents, wisemen, doctors, nurses, friends, and religious people; desire for receiving more love from wife and blessings from Allah; and individual’s value for living a meaningful life became the reasons behind first-time fathers going through their prenatal experiences in Pakistan. Similarly, the multifaceted interactions taking place between agency and structure, for instance; societal norms for extending generations, religion (gatherings and teachings), social loneliness, and various systems (world system, societal system, and Allah’s system); were the cause that brought prenatal experiences to the first-time fathers in Pakistan.
The prenatal experiences of first-time Pakistani fathers, analyzed thoroughly, reveals that reasons underlying their experiences originated from one or more SEM framework level. For example, an individual’s value of having purpose is at the individual SEM level. The desire for increased affection from their wife is at the SEM relationship level. Religious teachings received is at the SEM community level. Finally, social norms and systems occur at the SEM societal level. Hence, as a part of the CR process, it is hypothesized that the influence of all four levels of the SEM framework (i.e., Individual, Relationship, Community, and Societal) were the basis of the experiences of first-time fathers in Pakistan during their prenatal period. The causal mechanism for generating this hypothesis is situated in the context of Pakistan and Pakistani society.
Postnatal Period
During labor, delivery, and postdelivery phases (termed here collectively as “postnatal period”) the interplay among the agencies (fathers, wives, babies) reported in the results section above included: love and affection of fathers for their wives and babies, fathers’ senses of responsibility; expectation of fathers from their baby when child grew up; female’s reproductive physiology of going through labor pain, and respiratory physiology of the newborn baby; making compromises and adjustments; and learning new skills; became the reasons for fathers for experiencing postnatal period for the first time in the context of Pakistan. Similarly, the interplay of a medical agent (i.e., doctor) with the agent’s characteristic of having proper and timely communication with members of a couple assisting them to remain calm during the birthing process. Likewise, interactions between agency/agent and structure made fathers both anxious and peaceful during the postnatal period, for example: relatives, movies, religion and religious teachings; societal expectation of men showing strength during challenging times; societal norm of positioning men as a head of their families; religion (prayers and good deeds); family (support and guidance); family system; office work; provision of information (timely, accurate, and late); medical condition for labor induction; hospital’s rule of getting Consent Forms signed by the husband of the pregnant woman; hospital policy of not allowing husbands in the labor and delivery room; medical rule for deciding about cesarean section prior in case of abnormal fetal position in the womb; lack of effective government policy to support parents in old age; and economic conditions of the country.
Careful analysis of the reasons for first-time fathers to be worried, frightened, or calm during the postnatal period in the context of Pakistan originated from one or more SEM framework level. For instance, fathers’ expectation from their child, an individual’s biological and physiological characteristics and communication style is at the SEM individual level. Having love and affection for family and receiving guidance from them is at the SEM relationship level. Office workload and responsibilities, and religion, religious settings, and religious teachings are at the SEM community level. Finally, social norms, government policies, economic conditions, hospital policies, and medical rules are at the SEM societal level. As a part of the CR process, it is hypothesized that the impact of all four levels (i.e., Individual, Relationship, Community, and Societal) of the SEM framework contributed to making first-time fathers distressed or stress-free during their postnatal period. The causal mechanism for this hypothesis is based in the context of Pakistan and Pakistani society.
Results Interpretation
Pakistan is an Islamic State where more than 96% of the population follows the religion of Islam (Demographics of Pakistan, 2024). Muslims receive teachings from different schools of thoughts and are brought up accordingly. These findings are situated within the specific sociocultural and religious context of Pakistan. While these may offer insights into the experiences of Pakistani Muslim fathers elsewhere, differences in societal structures, health care systems, and cultural norms may influence how similar mechanisms manifest in diasporic settings.
Attitudes of people related to procreation are not influenced by high taxes, inflation, and having no or limited support from the government for running their households in Pakistan. Yet, to be culturally adaptable and acceptable, the same population migrating to European or Western countries may not keep producing babies despite receiving education, health care, and childcare support from the government. This shows that cultural norms of a society play a vital role in the way people conduct their lives. In this regard, it is important to involve faith-based leaders in sensitizing people and bringing health care reforms about screening of fathers’ mental health during their perinatal period in Pakistan.
Some fathers in this study expressed that their faith in Allah provided them with comfort and reassurance during the perinatal period, and a few reported no additional formal support was necessary. Similar findings have been reported in other Muslim-majority settings where religious beliefs serve as an important coping resource during pregnancy and childbirth (Pakzad et al., 2018; Trisiani et al., 2024). Research from faith-oriented settings suggests that religious coping often coexists with, rather than replaces, the use of professional health care (Wells et al., 2022). Our data did not explore these faith–health care dynamics in depth, but future research is needed to understand how spiritual beliefs interact with fathers’ willingness to seek psychosocial and medical care. Recognizing the role of faith in coping may help health care providers engage fathers in culturally sensitive ways while offering evidence-based support.
Limitation and Strength
The limitations of this study includes the absence of purposive sampling. First-time fathers having diversified sociodemographic characteristics and across all trimesters of pregnancy could have been included to maximize variation in the study. The maximization of the variation could have led to exploration of different experiences of first-time fathers in Pakistan. A strength of this study is that it is the first study in the context of Pakistan in which the experiences of men becoming first-time fathers have been explored with the intent to identify and understand the causal mechanism(s) responsible for generating these experiences and events, using CR philosophy. The novelty of this study is the integration of CR philosophy with the SEM framework to propose the hypothesis of the identified causal mechanism(s), in the context of Pakistan.
Study Implications
Results of this study have implications for supporting first-time fathers in Pakistan during this life transition at all SEM framework levels, for example:
On an individual level, fathers need to be educated prior to the birthing process and about hospitals’ policies as the study findings showed fathers became distressed due to being unaware of hospital policies.
On the relationship level, couples and their immediate family members need to discuss the husband’s legal authority for deciding on their wife’s behalf in case any medical emergency occurs. The study findings revealed that due to lack of recognition of a husband’s legal position as a decisive authority on behalf of his wife, fathers participating in this study experienced pressure to abide by societal norms and policies. These findings reflect broader patterns in Pakistan’s health care context. Jafarey and Farooqui (2005) described how informed consent is often shaped by family hierarchies or physicians rather than by women themselves (Jafarey & Farooqui, 2005). Menon and colleagues (2020) highlighted ethical tensions that arise when cultural norms prioritize family involvement over individual autonomy (Menon et al., 2020). The Human Rights Commission of Pakistan’s report Securing Health as a Fundamental Right (2023) similarly calls for clearer legal frameworks to protect patient rights and clarify decision-making authority during medical emergencies. Framing our results within this literature underscores the importance of preparing couples and families to discuss and understand legal roles before emergencies occur.
On the community level, reproductive health education should be included in secular and religious school curriculums. Mental health challenges faced by fathers during the perinatal period should be included in the curriculums of health care professionals’ (HCPs) training programs. HCPs should be trained to identify fathers at risk of developing psychological distress during their perinatal period and they should be equipped with skills and knowledge necessary for managing perinatal psychological distress in fathers.
On the societal level, the public needs to be sensitized about perinatal mental health challenges faced by fathers through mass communication and social media platforms. Hospitals’ administrators and health care policymakers should be educated and encouraged to bring reforms to the existing health care service delivery system.
Conclusion
The integration of CR philosophy and SEM provides a solid foundation for assisting first-time fathers during their perinatal period especially in the context of Pakistan by understanding and exploring the causal mechanism(s) behind the experiences of fathers on each SEM framework level. It is recommended that future studies use mixed-method research approaches to investigate the understudied phenomena of first-time fathers’ experiences during the perinatal period with various lenses which will help researchers to advocate for policy reforms on national and international levels. Results of this study can help health and social care practitioners to bring reforms in the existing health-sciences and social-sciences curriculum for sensitizing and equipping future leaders about the men’s experiences and their underlying causes that influence their health and the health of their family as men become first-time fathers. The study may facilitate practitioners and health care administrators to integrate fathers’ mental health in the existing health care system including actions such as assigning nursing staff to evaluate fathers’ mental health during antenatal and postnatal visits of the mothers in clinics, community settings, and hospitals. In this way, it is anticipated that this baseline study will pave the way for health care reforms that support first-time fathers during the perinatal period in Pakistan. These efforts could improve the physical and mental health and well-being of first-time fathers, their families, communities, and Pakistani society.
Footnotes
Author Contributions
SZ conceptualized, visualized, and wrote the original draft. JCP supervised, conceptualized, edited, and reviewed the manuscript. JC and JH conceptualized, edited, and reviewed the manuscript.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.