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Supporting fathers is essential in the child health field

In this issue of Acta Paediatrica, Michael B. Wells demonstrates a stark lack of gender equality in the essential areas of maternity and child health services (1). Wells based his findings on 62 papers published between 2000 and 2015 and restricted his review to Sweden, which together with the other Nordic countries, is considered to have the lowest global gender inequities (2). Wells found that fathers wanted to be involved in their child’s development from the very beginning, during pregnancy. Yet, fathers perceived disrespectful attitudes from midwives when they interacted with maternal health services. For example, they felt that the prenatal clinic was just a world for women and they were excluded and ignored. One-third to one-half of fathers were also dissatisfied with child health services, citing problems with the information they received on early parenthood and the practical instructions they received for parenting their infant. They felt that they were not able to participate in decisionmaking and were not able to influence the type of care they received. At the child health centres, they felt like they were treated like an ancillary parent and described themselves as invisible. They perceived that the services seemed to be designed for mothers, without involving fathers. A previous systematic review demonstrated that father’s engagement promoted social, behavioural and psychological outcomes in their children (3). Most parents in Sweden also stated that parenting should be equally divided between the parents (4). Thus, institutions that are designed to promote child health, via services for parents, would be expected to be directed at both mothers and fathers, but that is obviously not the case. To correct this problem, it is important to understand its causes. Caring for children is culturally determined. In traditional agricultural societies, and during the industrial period, the father’s work was often more mobile than the mother’s work, families were large and household work was taxing due to the lack of labour-saving equipment. Therefore, the responsibility for caring for the children unusually fell to the mother and took place in the family home. However, in modern service-based economies, these factors are no longer relevant and in high-income countries women participate in the workforce to almost the same extent as men. The difference between genders in the Nordic countries was smaller in 2014 than in most other countries, with 78% of women aged 15–64 participating in the workforce, compared to 82% of men (5). This situation is also reflected in the time parents devote to their children. In 2007, women aged 18 and over in the Nordic countries spent an average of 28 hours per week caring for and educating their children, while men spent 21 hours. In one of the studies that Wells reviewed, Massoudi et al. found that 50% of the nurses in child health services had an ambivalent attitude towards the fathers’ caring capacity compared to the capacity of the mothers (6). Given that attitude, it is rational for nurses to give less support to fathers. It is possible that the nurses’ attitudes partly reflect the gender roles during their own upbringing, and, if so, changes in attitudes would be expected to be slow. A slow pace of change is in fact common in the child public health field. The development of cash maternity benefits for fathers in Sweden illustrates the rate of change. In 1974, fathers became eligible for a cash benefit when they were at home caring for their newborn child (7). In 2014, the number of days that fathers received reimbursement for caring for their children had gradually increase to 25%, while the remaining 75% was given to mothers. At this rate, they would receive equal shares by 2044, 70 years after the 1974 reforms. However, attitudes have changed more rapidly and in 2012, 61% of adults in Sweden stated that reimbursement for parental leave should be split evenly between mothers and fathers (5). The pace of change is also illustrated by the development of another child health issue in Sweden and that has been attitudes to the corporal punishment of children. In 1965, 53% of parents thought that this was a good idea (8), but 46 years later in 2011 this percentage had fallen to 8%. From a child public health perspective, it is desirable to accelerate the timescale for introducing routines that might be expected to improve child health, but that is challenging. In the medical field, which is more coherent than cultural practices for caring for children, the pace is also rather slow when no commercial interests are involved. This is illustrated by the development of the practice of using antenatal corticosteroid treatment when preterm delivery is expected (9). The results from the first human trial were published in 1972 and in 1979; a systemic review was published followed by a strong recommendation in the Lancet. Yet, in 1999, 20 years after the Lancet recommendation, 42% of the eligible women in the USA had not received this treatment.