Abstract

Becoming a father requires a process of personal development, inner reorientation, and adaptation to a new role. The literature on this process has been sparse, devaluing how challenging and problematic the transition to becoming a father can be. This qualitative, exploratory, descriptive, cross-sectional and retrospective study sought to understand the experiences of men in the transition to fatherhood during the prenatal period. It included a sample of 10 men experiencing, for the first time, a partner’s pregnancy. The data collection technique used was semi-structured interviews. The content analysis technique with semantic categorization and an inductive approach was used to analyze the data. As a result, 3 topics emerged: “experiencing the transition,” “development of the father identity” and “(de)constructing bridges for the transition”. This study deepens the understanding of this developmental transition and challenges the restructuring of prenatal care towards the inclusion of the father figure.

Key words:
Men; Fathers; Pregnancy; Nursing

Introduction

Historically, men have been considered as secondary, and sometimes unnecessary, in the transition process to fatherhood, and media representations disseminate and reinforce these cultural messages¹1 Schmitz RM. Constructing men as fathers: A content analysis of formulations of fatherhood in parenting magazines. J Men's Stud 2016; 24(1):3-23.. Nevertheless, the literature shows that men provide unique contributions in this transition²2 Jeynes WH. Meta-analysis on the roles of fathers in parenting: Are they unique? Marriage Fam Rev 2016; 52(7):665-688. and influence the growth / development and well-being of children³3 Cabrera NJ, Fitzgerald HE, Bradley RH, Roggman L. The ecology of father-child relationships: An expanded model. J Fam Theory Rev 2014; 6(4):336-354.. Currently, we see fatherhood characterized by a more affectionate masculinity, and fathers more involved in pregnancy and birth, and in the care and education of their children⁴4 McGill BS. Navigating new norms of involved fatherhood: Employment, fathering attitudes, and father involvement. J Fam Issues 2014; 35(8):1089-1106.. Such differences highlight a scenario of instability in the presence of fatherhood and the complexities of family life and require a broad reflection on what it means to be a father and mother in the 21^st century⁵5 Banchefsky S, Park B. The "new father": Dynamic stereotypes of fathers. Psychol Men Masc 2016; 17(1):103-107..

Becoming a father is a challenging journey for men, a transformative process of metamorphosis that starts during pregnancy⁶6 Kowlessar O, Fox JR, Wittkowski A. The pregnant male: a metasynthesis of first-time fathers' experiences of pregnancy. J Reprod Infant Psychol 2015; 33(2):106-127.. Pregnancy is a demanding period in terms of psychological reorganization of the self⁷7 Genesoni L, Tallandini MA. Men's psychological transition to fatherhood: an analysis of the literature, 1989-2008. Birth 2009; 36(4):305-318. and it is during this period that the desire to be a good father begins⁸8 Carlson J, Kendall A, Edleson JL. Becoming a good father: The developmental engine of first-time fatherhood. Father A J Theory, Res Pract about Men as Father 2015; 13(3):182-202.. The enthusiasm and joy experienced by the future birth of a child is commonly penetrated by the fear of becoming a father, by feeling unprepared and insecure when confronted with one’s partner’s expectations about their role as a father⁹9 Hildingsson I, Johansson M, Fenwick J, Haines H, Rubertsson C. Childbirth fear in expectant fathers: findings from a regional Swedish cohort study. Midwifery 2014; 30(2):242-247..

Not being prepared for this transition can have important implications for the relationship between the couple and the parent/child dyad, the baby’s development¹⁰10 Bawadi HA, Qandil AM, Al-Hamdan ZM, Mahallawi HH. The role of fathers during pregnancy: A qualitative exploration of Arabic fathers' beliefs. Midwifery 2016; 32:75-80. and the entire family¹¹11 May C, Fletcher R. Preparing fathers for the transition to parenthood: Recommendations for the content of antenatal education. Midwifery 2013; 29(5):474-478.. The literature highlights that men’s involvement since the early stages of pregnancy, in addition to promoting their own psychological well-being¹²12 Plantin L, Olukoya AA, Ny P. Positive health outcomes of fathers'involvment in pregnancy and childbirth paternal support: a scope study literature review. Fathering 2011; 9(1):87-102., extends to the entire family unit¹¹11 May C, Fletcher R. Preparing fathers for the transition to parenthood: Recommendations for the content of antenatal education. Midwifery 2013; 29(5):474-478..

Nursing has contributed to the understanding of the transition concept from the perspective of people’s life and health, defining it as “a passage or movement from one state, condition or place into another”¹³13 Chick N, Meleis AI. Transitions: A Nursing Concern. In: Meleis AI, editor. Transitions theory middle-range and situation-specific theories in nursing research and practice. New York: Springer publishing company; 2010. p. 24-37., implying that people will reach a period of greater stability¹⁴14 Meleis AI, Sawyer LM, Im E-O, Messias DKH, Schumacher KL. Experiencing transitions: an emerging middle-range theory. In: Meleis AI, editor. Transitions theory middle-range and situation-specific theories in nursing research and practice. New York: Springer publishing company; 2010. p. 52-64.. The study of transitions is particularly relevant, because the vulnerability of people undergoing transition can have an impact on their health and well-being. During the developmental transition of fatherhood, in particular, in addition to the risks that arise from the transition process (as in any other), there is also the possibility that the quality of the parent/child interaction and relationship will be compromised from the start.

This investigation appears in the context of deepening this phenomenon, seeking to answer the research question How is the process of parental transition experienced by men during the prenatal period?. We aim to understand the experiences of the transition to fatherhood, during the prenatal period, of first-time fathers.

Methods

This is an exploratory, descriptive, cross-sectional and retrospective study, included in a qualitative research paradigm. The qualitative research allows the understanding of behaviors from the perspective of the people being assessed and collection of data that is rich in descriptive details in relation to people, places and conversations, allowing the acceptance of the wealth of human experience¹⁵15 Bogdan RC, Biklen SK. Investigação qualitativa em educação: uma introdução à teoria e aos métodos. Porto: Porto Editora; 2013., assuming here a structuring function¹⁶16 Turato ER. Métodos qualitativos e quantitativos na área da saúde: definições, diferenças e seus objetos de pesquisa. Rev Saude Publica 2005; 39(3):507-514..

The study was developed with fathers who were taking the Childbirth Preparation Course at a care unit in the northern region of Portugal. The choice of this health unit was based on a convenience criterion, due to the geographical proximity to the place where we develop our daily professional practice.

The participants met the following inclusion criteria: men experiencing their partner’s pregnancy for the first time, in the last trimester of pregnancy, who lived with their partners and gestation without maternal-fetal pathology, and who agreed to participate in the study.

Ten men participated in the study, aged between 27 and 40 years old, of which 8 were married and 2 had a common-law marriage, with different professions (2 businessmen, 1 physical education teacher, 1 nurse, 1 physician, 1 electrician, 2 real estate agents, 1 salesman and 1 factory worker) and level of schooling ranging between the second year of high school and a university degree. The pregnant partners had gestational ages ranging between 33 and 38 weeks at the time of data collection. The sample representativeness was determined by data saturation¹⁷17 Fortin M. O processo de investigação: da concepção à prática. 3a ed. Loures: Lusociência; 2009..

Data collection was carried out using the semi-structured interview technique. It permits considerable shift within its structure, with the interviewees being free to speak about the subject and express their opinions¹⁸18 Bell J. Como realizar um projecto de investigação. Um guia para a pesquisa em Ciências Sociais e da Educação. Lisboa: Gradiva; 2002. and giving the interviewer the possibility of re-conducting the interview each time the interviewee deviates from the recommended objectives¹⁹19 Campenhoudt LV, Quivy R. Manual de investigação em ciências sociais. Lisboa: Gradiva Publicações; 2018..

The open question used to start the interview was: “How has your experience been since the moment you learned you were going to be a father?” Each participant was interviewed only once. The interviews took place from February to April 2017, at the site where the Childbirth Preparation Course took place, which was selected by the participants. The conversations were recorded using a voice recorder (MP3 device). After each interview, the main researcher took down field notes and transcribed the recordings.

The interviews were analyzed using the content analysis technique according to Bardin²⁰20 Bardin L. Análise de conteúdo. 4a ed. Lisboa: Edições 70; 2018., with semantic categorization and an inductive approach. The NVivo Qualitative Solutions Research (QSR) software, version 11.0, was used for data analysis.

All participants validated the interviews and the accuracy of the interpretations. Two external investigators reviewed the interpretations and conclusions to ensure credibility.

All ethical principles were met, namely the free and informed consent, voluntary participation and the participants’ right to withdraw from the study. Ethical approval was obtained from the Comissão Nacional de Proteção de Dados (National Data Protection Committee) and the Comissão de Ética da Administração Regional de Saúde do Norte (Ethics Committee of the Northern Regional Health Administration). To safeguard the participants’ anonymity, as well as the confidentiality of the data obtained from them, the interviews were coded (I1 to I10) and destroyed after the conclusion of this investigation.

Results

“Experiencing the transition”, “Development of the father identity” and “(De)constructing bridges for the transition” are the topics that emerged from this investigation, clarifying the developmental transition of becoming a father. They highlight the prenatal period as a key moment in the transition to fatherhood, characterized by the enormous psychological and emotional demands and emerging as the mechanism of the development of the father identity. The categories that integrate each of these topics are shown in Chart 1.

Experiencing the transition

Experiencing the transition is a topic that describes the organization and adaptation path that men go through during the pregnancy, from the initial period of acceptance of reality to their effective involvement in the pregnancy and the development of feelings of attachment and belonging towards the fetus, in a trajectory characterized by several experienced changes and emotional responses.

The ultrasound scans and the perception of fetal movements stand out as the key events in this experience, promoting the acceptance of reality, which allow men to position themselves in an emotional space closer to the pregnancy and the fetus: When we see them on the ultrasound, there they are, there is one more reinforcement of reality and that they are really growing [...] and if until then there was any doubt, with the ultrasound it is “they really exist. I(4); We started to feel the baby’s own movements, the kicks, the fact that we put our hand on the mother’s belly and start feeling it, I think this bond gets stronger and stronger I(2).

Men express their involvement in the pregnancy by showing commitment and responsibility and being present: I have participated 100% in the pregnancy, without a doubt, I have been to all consultations. I have been trying to go to all of them [...] because it is my child, I want to participate in everything, I want to see everything, I don’t know if it will be like this with a second child, but at this moment it is like this, I want to go and participate in everything. I have participated in all these experiences, some are for blood collection, others for the vaccines. I(9). They try to care for the pregnant woman’s health and well-being and see this care extended to the child in utero: What I try to do is make sure that both of them want for nothing, I take care of the mother, so that the daughter is also well I(6) .

Several changes are felt during this transition, which can be seen as preparatory strategies to assume the role of father. They include behavioral changes, which are reflected in smoking cessation decisions, driving more carefully, a more defensive attitude in extreme sports or other types of self-care, aiming to ensure they will be present in their child’s life: When I talk about changing behaviors, either on the road, or regarding health or in my personal life, a child is coming who will need me for many years, me and the mother, we have to be there as long as life allows us I(8); emotional changes, seeing themselves as more sensitive, calmer and happier, I became more thoughtful and calmer because I am a very stressed person and I start grumbling for anything and everything… I became more thoughtful, calmer too. I(3); physical changes, reflected as symptoms usually associated with pregnancy, such as weight gain, nausea, vomiting, fatigue and heartburn, Before the pregnancy, I was one of those men who got up early to walk my dog ​​and even at night… now I look like a pregnant woman, very tired I(3); and changes that permeate social life, translating into the readjustments they undertake to provide more comfort to the pregnant woman or have more time to be with her: I was a soccer coach for 4 years, now I left because my wife is pregnant, it is something I had to give up to be with her more often, otherwise I would be away for many days, I would always arrive later I(5). The expected changes after the child’s birth are also the object of reflection for future fathers, as they believe that she [the partner] will be more focused on the child than on me, but it is normal for that to happen I(6).

The reported emotional responses are intense and diverse, making pregnancy a complex and demanding period from a psycho-emotional point of view. They oscillate between positive emotional reactions, such as joy and happiness, Learning that she was pregnant was a joyful thing, it was a huge emotion. I(7), and negative emotional responses, such as fear, anxiety, insecurity and concern, The concern that affects me is really the baby’s health, I just want her to be well. I(10). The “roller coaster of emotions” metaphor is very significant of how strong, ambivalent and intense are the emotions experienced by men during the pregnancy: It’s a roller coaster of emotions, we have emotions that makes us very happy because we are with the baby, and we know that she is pregnant and at the same time we are always afraid that something will happen. I(9). Of the vast array of emotional responses that are in the negative domain, the ones that are most prevalent in the men’s experience is the fear of failing as a father and the anxiety related to the responsibility towards a dependent being and the desire to have the child in their arms and verify that the child is healthy.

Development of the father identity

The topic of the development of the father identity captures the essence of the personal development journey that men undertake during the pregnancy and which will allow them to prepare themselves to assume new roles and new responsibilities. During this process, men make an assessment of themselves, their experiences as a child, and their responsibilities and priorities, opening up the possibility for changes in values ​​and objectives, including the values ​​of professional life. They place themselves in a psychological and social space that allows them to view life in a different way and start to redefine their personal values ​​and priorities in the context of being a father, I think we start looking at life in a different way, perhaps giving priority to other things that we didn’t give before the pregnancy, especially at work; sometimes we focus too much on work and then, when we know we are going to be a father, I think we start thinking about what we have to change in our life I(2) . The focus becomes the family and the baby that is about to be part of your life.

As for the meaning of a father’s role, there is a sense strongly characterized by the role of providing support to the pregnant woman and her child in utero, reflecting a changing social construct: I think men should stop thinking they are the ones whose only role is to earn money and being the providers at home; I think men have to try to comprehend that they are a key element in the pregnancy experience and, therefore, they must be very close to this entire process, including the mother’s support and in the affection towards the mother and baby. I(2). The representation of a father figure very present in the child’s daily life stands out, being a father is to be a full-time father I(8), in educating, loving and showing affection.

The pregnancy triggers psychological maturity and a sense of responsibility, I feel that, but it is a good responsibility because I have always wanted to be a father I(1), and prompts men to reflect on their experiences as a child, having as premise the cognitive construction of the parental model they want for the future. The construction one’s identity as a father is permeated by the individual history of each man and his family patterns, whether to deny them, confront them or confirm them: I think a lot about it, I think about education, I think about what my education was and in what it could have been different, and let’s say that I can try to avoid some mistakes, something that could have been better in mine and now try to do better for him I(4). The desire for a unique parenting experience, however, remains ever present.

For some men, feeling like a father emerges with the confirmation of pregnancy, the first test, when we took the first test, I felt I was a father, I felt there was something there, it is a being in there I (8), but, for others, only childbirth, which has not yet happened, but is close, will allow the identity implementation, I might only feel completely like a father on the day my daughter is born I(10).

(De)construction of bridges for the transition

The (de)construction of bridges for the transition is a topic that seeks to explain the conditions that favor or, in contrast, inhibit the experience of a positive transition experience by the men, along the path to fatherhood.

Most of the men in the study reported receiving support during the pregnancy and emphasize, in the first place, the spouse as a source of support: Yes, I have received a lot of support from my wife and I have been giving support too. This is mutual I(1). The family also gains prominence in the men’s discourse I have a family circle that, thank God, is a very strong one [...] It is more of an emotional support, that support that I often receive as a jest even to de-stress, we have even joked about that and these jokes have been very healthy because, it does not seem like it, but we internalize them. I(9), as well as friends who care about their well-being during this transition: Friends are also part of this group of people who care, I have friends who even send messages every week [...] they are very important, on this journey we are taking I(5).

In order to prepare for fatherhood, future fathers invest in the search for knowledge. They look for information on the internet, I really felt the need to look for information on the internet about sexuality during pregnancy. Whether we can, whether we should or not, the precautions we must take. Yes, I felt the need to search for information, I did have doubts. I(4); in books, I’ve been reading since I learned I was going to be a father, there are things I have heard here that I knew [...] maybe because I am reading some books I don’t feel the need for information, because I already have it on the other side, perhaps that. I(6), and also seek information from friends who are already fathers, allowing them to anticipate changes that will occur and make the experience of pregnancy a more peaceful one: I have some friends who are already fathers and others are from the health area, and with them I try to get as much information as possible [...] this helps us, so that the pregnancy path is seen in a more peaceful way, if we don’t look for information, if we don’t worry about anything and if something happens, we see ourselves between a rock and a hard place, and it’s scary. I(9).

Most men report having some previous experience with babies, not only in terms of interaction, but also in providing direct care, and this practical knowledge makes them feel more capable of playing the role of a father: I always had my nephews who came to my parents’ house [...] and I did everything with them, from changing diapers, feeding them, giving them bottles and going out for a stroll with them [...] Of course, then I have another experience, I have had some training in that sense, a training that many people do not have. I(3). Very limited experience or the lack of experience with childcare were also described by some participants, causing anxiety in the transition to fatherhood: “I really do not have this experience of taking care of babies, of being responsible for them. The experience I have is to stay with them for a very short time, but not being responsible for them and so, it causes more anxiety because of that. I(4).

The fact that it is a first pregnancy does not favor men to feel prepared to be fathers, because nobody is prepared to be a father, at least at the first time I think nobody is, nobody knows what it is like, we only know what they tell us I(6). To envision the child as a life goal, that is, the fruit of the desire and pregnancy planning, provides the construction of bridges for the transition and encourages motivation to overcome it. The meaning attached to the transition is undoubtedly a positive one; the adjective that best characterizes the transition to fatherhood is “good”: a piece of myself will be born and I really believe that having a daughter will be very good, despite the difficulties I believe I will also have. I(1), which favors the implementation of positive expectations about the process of becoming a father.

The men’s experience during prenatal care consultations is described by the participants as being one of the exclusion of the father figure. They emphasize a professional speech aimed at women, with the man being left out: I think it is also part of it, a little bit, for the doctors to give a little speech also focused on the fathers, and they don’t do that. There are really some fathers who have no idea what it is like to have a child or what it might be [...] Of course, there must always be something for the father, I think, but that does not always happen. I(3).

The distancing they feel from the health professionals and the care they provide make men characterized themselves as the secondary “character” of the story: I feel that I am there playing my role as a father, and they look at me as someone who is beside the mother only, I have no other type of participation [...] in practice, we are really the secondary character of the story I(7). Therefore, they have some suggestions for improvement, so they can feel effectively involved in the prenatal care. One of the most important concerns the time of the appointments, recognizing they do not favor the male presence, even if there is a desire to participate: Again, it is the time, either it is in the morning or during the morning, or during the afternoon […] I liked it, of course I liked it, but I can’t, and then she will pass on the information to me and I like to hear it I(8).

Discussion

This study highlights the prenatal period as the driving force that leads to the development of the paternal identity. During the pregnancy, future fathers undertake a reflective exercise regarding the fatherhood model they wish for the future. The childhood experience encourages them to follow their fathers’ educational model when they perceive that the education they received was positive, but above all, men want to be different and better for their child than their own fathers were for them. The literature confirms that the construction of the father identity is influenced by childhood experiences and the presence or absence of father figures in the child’s life²¹21 East L, Jackson D, Power T, Woods A, Hutchinson M. "Holes in my memories": a qualitative study of men affected by father absence. Issues Ment Health Nurs 2014; 35(8):604-612.. The perception of an inadequate or unsatisfactory experience with their own fathers lead men to adopt a closer relationship with their own children²²22 Habib C. The transition to fatherhood: A literature review exploring paternal involvement with identity theory. J Fam Stud 2012; 18(2-3):103-120.. This reflection on childhood constitutes a normal reaction to imminent fatherhood and allows solidifying the mental self-image of the type of father the man intends to become⁶6 Kowlessar O, Fox JR, Wittkowski A. The pregnant male: a metasynthesis of first-time fathers' experiences of pregnancy. J Reprod Infant Psychol 2015; 33(2):106-127.. It favors the psychological adjustment to the father role and will influence the future parental style²³23 Chin R, Hall P, Daiches A. Fathers' experiences of their transition to fatherhood: a metasynthesis. J Reprod Infant Psychol 2011; 29(1):4-18.

24 Herland MD, Hauge M-I, Helgeland IM. Balancing fatherhood: Experiences of fatherhood among men with a difficult past. Qual Soc Work 2015; 14(2):242-258.^-2525 East L, Hutchinson M, Power T, Jackson D. "Being a father": constructions of fatherhood by men with absent fathers. J Fam Stud [serial on the Internet] 2018 Apr [cited 2020 Apr 14]: [about 11 p.]. Available from: https://www.tandfonline.com/doi/pdf/ 10.1080/13229400.2018.1459308?needAccess=true
https://www.tandfonline.com/doi/pdf/ 10.... . The construction of one’s identity as a father involves a complex subjective, conscious and unconscious work, of dealing with the legacies received from their own father and deciding whether to transmit them to their children²⁵25 East L, Hutchinson M, Power T, Jackson D. "Being a father": constructions of fatherhood by men with absent fathers. J Fam Stud [serial on the Internet] 2018 Apr [cited 2020 Apr 14]: [about 11 p.]. Available from: https://www.tandfonline.com/doi/pdf/ 10.1080/13229400.2018.1459308?needAccess=true
https://www.tandfonline.com/doi/pdf/ 10.... ^,2626 Castoldi L, Gonçalves TR, Lopes RCS. Envolvimento paterno da gestação ao primeiro ano de vida do bebê. Psicol em Estud 2014; 19(2):247-259..

When developing the paternal identity, we witnessed the reformulation of men’s values ​​and priorities, which is also found in other studies⁶6 Kowlessar O, Fox JR, Wittkowski A. The pregnant male: a metasynthesis of first-time fathers' experiences of pregnancy. J Reprod Infant Psychol 2015; 33(2):106-127.^,2727 Sansiriphun N, Kantaruksa K, Klunklin A, Baosuang C, Jordan P. Thai men becoming a first-time father. Nurs Health Sci 2010; 12(4):403-409.. They question their own definition of fatherhood and open up the possibility to a new conception and way of experiencing fatherhood, with greater emotional intensity. The affections were transversal to the interviewees’ reports, and it is expected that, during the exercise of fatherhood, they can occupy a more comfortable place in the home setting, previously occupied only by the woman / mother. Regarding the increase in the responsibility and psychological maturity in response to imminent fatherhood, the literature highlights that the perception of the meaning of fatherhood can play a crucial role in the performance of paternal responsibilities²⁸28 Tehrani SG, Bazzazian S, Nayeri ND. Pregnancy experiences of first-time fathers in Iran: a qualitative interview study. Iran Red Crescent Med J [serial on the Internet] 2015 Feb [cited 2020 Apr 14]; 17(2): [about 5 p.]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4376989/pdf/ircmj-17-02-12271.pdf
https://www.ncbi.nlm.nih.gov/pmc/article... and that maturity is motivated by the child’s dependence related to the satisfaction of their needs²⁹29 Santos SC, Kreutz CM. O envolvimento do pai na gestação do primeiro filho. Pensando Fam 2014; 18(2):62-76..

The ultrasound and fetal movements were highlighted by men as powerful experiences in confirming and accepting the pregnancy. In particular, the ultrasound allows a powerful perception of the baby’s reality and encourages the rapid expansion of thoughts and feelings about becoming a father³⁰30 Walsh TB, Tolman RM, Davis RN, Palladino CL, Romero VC, Singh V. Moving up the "magic moment": Fathers' experience of prenatal ultrasound. Fathering 2014; 12(1):18-37.. This represents a significant transitional change, in which men move from an emotionally distant space and start feeling more involved with the pregnancy³¹31 Kowlessar O. A qualitative exploration of men's transition to fatherhood and experiences of early parenting [tese]. Manchester: University of Manchester; 2012., with these moments being considered, by the author, as key events in the transition to fatherhood.

The desire for involvement with the pregnancy, demonstrated in the present study, is in line with the findings of Kaye et al.,³²32 Kaye DK, Kakaire O, Nakimuli A, Osinde MO, Mbalinda SN, Kakande N. Male involvement during pregnancy and childbirth: men's perceptions, practices and experiences during the care for women who developed childbirth complications in Mulago Hospital, Uganda. BMC Pregnancy Childbirth [serial on the Internet] 2014 Jan [cited 2020 Apr 14]; 14(1): [about 8 p.]. Available from: https://link.springer.com/content/pdf/10.1186/1471-2393-14-54.pdf
https://link.springer.com/content/pdf/10... where men listed the characteristics of an ideal father in the context of the pregnancy and childbirth. They describe him as accessible (present, available) and responsible (concerned with the woman, caregiver and protector), a father who expects and wants to get involved, worries about the pregnancy and the future child, and wants to be supported by the health system to fulfill his role.

This study also corroborates pregnancy as a complex and demanding period from a psycho-emotional point of view³³33 Poh HL, Koh SSL, He H. An integrative review of fathers' experiences during pregnancy and childbirth. Int Nurs Rev 2014; 61(4):543-554.. The emotional reactions reported by the men were intense and ambivalent, findings that are consistent with other investigations, which show male experiences of pregnancy characterized by mixed feelings of admiration, disbelief, anxiety, fear and insecurity, in addition to feelings of happiness, emotion, joy and pride²⁸28 Tehrani SG, Bazzazian S, Nayeri ND. Pregnancy experiences of first-time fathers in Iran: a qualitative interview study. Iran Red Crescent Med J [serial on the Internet] 2015 Feb [cited 2020 Apr 14]; 17(2): [about 5 p.]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4376989/pdf/ircmj-17-02-12271.pdf
https://www.ncbi.nlm.nih.gov/pmc/article... ^,3434 Baldwin S, Malone M, Sandall J, Bick D. Mental health and wellbeing during the transition to fatherhood: a systematic review of first time fathers' experiences. JBI database Syst Rev Implement reports 2018; 16(11):2118-2191.^,3535 Philpott LF, Fitzgerald S, Leahy-Warren P, Savage E. Stress in fathers in the perinatal period: A systematic review. Midwifery 2017; 55:113-127.. The anxiety grows as the birth approaches. Elevated levels of anxiety and depressive symptoms during the pregnancy are the most significant predictors of depression in men in the postnatal period³⁶36 Ramchandani PG, O'Connor TG, Evans J, Heron J, Murray L, Stein A. The effects of pre-and postnatal depression in fathers: a natural experiment comparing the effects of exposure to depression on offspring. J Child Psychol Psychiatry 2008; 49(10):1069-1078., emphasizing the need for greater support for men in the pre- and postnatal periods. However, it should be noted that men are taught by society to not ask for help and how difficult it can be to do so during a period when they believe they need to support and provide for their partner. The literature is unanimous in pointing out that men suffer psychological difficulties in the perinatal period, but internally, they question the legitimacy of their experiences, often being reluctant to express their need for support or seek help when facing their concerns. They fear this fact may impair the meeting of their partners’ needs by health professionals³⁷37 Darwin Z, Galdas P, Hinchliff S, Littlewood E, McMillan D, McGowan L, on behalf of the Born and Bred in Yorkshire (BaBY) team. Fathers' views and experiences of their own mental health during pregnancy and the first postnatal year: a qualitative interview study of men participating in the UK Born and Bred in Yorkshire (BaBY) cohort. BMC Pregnancy Childbirth [serial on the Internet] 2017 Jan [cited 2020 Apr 14]; 17(1): [about 15 p.]. Available from: https://bmcpregnancychildbirth.biomedcentral.com/track/pdf/10.1186/s12884-017-1229-4
https://bmcpregnancychildbirth.biomedcen... .

The literature reinforces that the behavioral, emotional, physical and social changes experienced by men in response to their partner’s pregnancy signal the understanding of their responsibility and an early commitment to the well-being of their families³⁸38 Fletcher R, May C, St George J. Fathers prenatal relationship with their baby and her pregnancy - implications for antenatal education. Int J Birth Parent Educ 2014; 1(3):23-27.

39 Poh HL, Koh SSL, Seow HCL, He H-G. First-time fathers' experiences and needs during pregnancy and childbirth: A descriptive qualitative study. Midwifery 2014; 30(6):779-787.

40 Villamor NJE, Guzman AB, Matienzo ET. The Ebb and flow of Filipino first-time fatherhood transition space: a grounded theory study. Am J Mens Health 2016; 10(6):NP51-NP62.^-4141 Widarsson M, Kerstis B, Sundquist K, Engström G, Sarkadi A. Support needs of expectant mothers and fathers: a qualitative study. J Perinat Educ 2012; 21(1):36-44.. The family support network, the partner and friends, as providers of emotional, informative and tangible support⁴¹41 Widarsson M, Kerstis B, Sundquist K, Engström G, Sarkadi A. Support needs of expectant mothers and fathers: a qualitative study. J Perinat Educ 2012; 21(1):36-44.^,4242 Forsyth C, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. Men's emotional responses to their partner's pregnancy and their views on support and information received. Aust New Zeal J Obstet Gynaecol 2011; 51(1):53-56., therefore become crucial in facilitating this transitional process⁴³43 Barimani M, Vikström A, Rosander M, Forslund Frykedal K, Berlin A. Facilitating and inhibiting factors in transition to parenthood - ways in which health professionals can support parents. Scand J Caring Sci 2017; 31(3):537-546..

During the gestation process, men take a proactive attitude and try to get involved, but they find obstacles and not bridges to help their transition. The attitude that permeates prenatal services is, from the perspective of future fathers, a not very inclusive practice regarding the father figure. They feel excluded by health professionals, who focus their care on the woman and the fetus, not recognizing them as equal partners in the transition, as shown in other studies⁴⁴44 Åsenhed L, Kilstam J, Alehagen S, Baggens C. Becoming a father is an emotional roller coaster - an analysis of first-time fathers' blogs. J Clin Nurs 2014; 23(9-10):1309-1317.

45 Fenwick J, Bayes S, Johansson M. A qualitative investigation into the pregnancy experiences and childbirth expectations of Australian fathers-to-be. Sex Reprod Healthc 2012; 3(1):3-9.

46 Widarsson M, Engström G, Tydén T, Lundberg P, Hammar LM. 'Paddling upstream': Fathers' involvement during pregnancy as described by expectant fathers and mothers. J Clin Nurs 2015; 24(7-8):1059-1068.^-4747 Johnsen H, Stenback P, Halldén B-M, Crang Svalenius E, Persson EK. Nordic fathers' willingness to participate during pregnancy. J Reprod Infant Psychol 2017; 35(3):223-235..

Men who are recognized in their new position as future fathers and experience emotional support during the pregnancy have better physical and psychological health¹²12 Plantin L, Olukoya AA, Ny P. Positive health outcomes of fathers'involvment in pregnancy and childbirth paternal support: a scope study literature review. Fathering 2011; 9(1):87-102.. The active involvement of men in the pregnancy is associated with long-term benefits, both in terms of health and social benefits for the mother, the baby and the family³³33 Poh HL, Koh SSL, He H. An integrative review of fathers' experiences during pregnancy and childbirth. Int Nurs Rev 2014; 61(4):543-554.^,4848 Steen M, Downe S, Bamford N, Edozien L. Not-patient and not-visitor: a metasynthesis fathers' encounters with pregnancy, birth and maternity care. Midwifery 2012; 28(4):422-431.^,4949 Alio AP, Lewis CA, Scarborough K, Harris K, Fiscella K. A community perspective on the role of fathers during pregnancy: a qualitative study. BMC Pregnancy Childbirth [serial on the Internet] 2013 March [cited 2020 Apr 14]; 13(60): [about 11 p.]. Available from: https://link.springer.com/content/pdf/10.1186/1471-2393-13-60.pdf
https://link.springer.com/content/pdf/10... , and is strongly associated with the direct involvement of men in postpartum childcare⁵⁰50 Zvara BJ, Schoppe-Sullivan SJ, Dush CK. Fathers' involvement in child health care: associations with prenatal involvement, parents' beliefs, and maternal gatekeeping. Fam Relat 2013; 62(4):649-661.. Responding to the men’s needs during the pregnancy can act as an early intervention for the family system and a reduction in the financial costs for long-term health services⁶6 Kowlessar O, Fox JR, Wittkowski A. The pregnant male: a metasynthesis of first-time fathers' experiences of pregnancy. J Reprod Infant Psychol 2015; 33(2):106-127..

Although there is clear evidence of gains, at several levels, from the early involvement of men in prenatal care, their transferability into the clinical practice of health professionals is not confirmed, perpetuating the men’s invisibility in prenatal care. What is required of modern man - greater sensitivity and the exercise of a more responsible and participatory fatherhood -is not reflected in the clinical practices, which continue to create lines of weaknesses in the exercise of fatherhood. The stereotyped lens with which fatherhood is viewed translates into a practice based on gender, with male discrimination⁵¹51 Silva C, Martins C, Pinto, C. Tornar-se pai: uma exploração qualitativa da experiência dos homens portugueses. In: Atas do 8º Congresso Ibero-Americano em investigação qualitativa: investigação qualitativa na saúde; 2019; Lisboa. p. 675-684..

In the light of the transitions theory¹⁴14 Meleis AI, Sawyer LM, Im E-O, Messias DKH, Schumacher KL. Experiencing transitions: an emerging middle-range theory. In: Meleis AI, editor. Transitions theory middle-range and situation-specific theories in nursing research and practice. New York: Springer publishing company; 2010. p. 52-64., clinical practices that exclude the father figure can be seen as factors that inhibit the transition to fatherhood, which may affect one’s perception of security for assuming his father functions. On the other hand, inclusive practices have the potential to increase future fathers’ confidence, decrease their fear and increase their resilience in the face of uncertainty and adversity, thus promoting a more positive transition. Healthy families, and the paternal roles played within them, do not happen by chance, but depend on relational skills, psychological maturation, adequate models and stimulating environments, which can and should develop throughout the pregnancy.

Health professionals can be the connections that promote a transition to a more positive fatherhood. As many of the emotional responses experienced by the men are delicate and embarrassing, the professionals must have the sensitivity and a set of communicational and interpersonal skills and abilities to be able to effectively support men in this transition. In the scope of health care, men must be included as the focus of attention.

As limitations of this study, it is important to say that its qualitative nature does not allow the generalization of results, referring us to a contextual reality. The fact that the sample consists only of fathers whose partners attended the Childbirth Preparation Course does not allow us to know whether fathers whose partners who did not attend it had the same experiences, so, as a suggestion, it would be relevant to expand the study to include this population of fathers. Comparative studies with first-time fathers and fathers with a previous experience could also be developed, and the investigation could be extended to other stages of the process of transition to fatherhood, in a longitudinal logic. Another line of future studies could explore, from the perspective of health professionals, the reasons for the exclusion of the father figure from the prenatal period.

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