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Fathers’ Experiences and Perspectives of Breastfeeding: A Scoping Review

During the transition to parenthood, fathers may experience significant challenges, including finding a place for themselves as important participants in the context of infant breastfeeding by female partners. Although generally viewed as a healthy process and the preferred method of infant feeding, breastfeeding may result in some fathers feeling excluded, inadequate, and helpless. Breastfeeding is known to adversely affect various aspects of a father’s life, including parenting self-efficacy, quality of life (QOL), the relationship with the partner, and the perception that breastfeeding limits time available for father–infant bonding. The current scoping review explores the experiences, roles, and needs of fathers of breastfed infants by synthesizing and discussing the findings from relevant published research studies (n = 18). Recommendations, drawn from the scoping review findings, are offered to guide primary health providers and services.


Review
For most men, the transition to parenthood is an unquestionably life-changing experience. In fact, research suggests that this transition may impact a man's health considerably (Garfield, Isacco, & Bartlo, 2010). Fatherhood can have a protective effect on men's health by leading some men to make positive changes to health behaviors (Garfield et al., 2010). A growing body of evidence suggests some challenges faced by fathers during this transition can result in anxiety, distress, and an increased risk of depression (Kim & Swain, 2007;Kumar, Oliffe, & Kelly, 2018). Health challenges faced by new fathers are well recognized, wherein many men are compelled to reassess their priorities and time commitments, including work-life balance (de Montigny, Lacharité, & Devault, 2012). Other challenges fathers face during this transition are less obvious, such as in the context of maternal breastfeeding. Specifically, infant breastfeeding by female partners can negatively affect a father's quality of life (QOL; Chen et al., 2010), parenting self-efficacy, mood, and overall well-being (Jordan, 1986) . Because studies suggest that a number of men turn to health-care professionals for guidance and support during the first few months of fatherhood (Thomas, Bonér, & Hildingsson, 2011), further investigation into the experiences and needs of fathers of breastfed infants is necessary to guide primary health-care providers (HCPs) and services. This scoping review offers a synthesis and discussion of the empirical insights focusing on the health impacts of maternal infant breastfeeding on fathers.

Transition to Fatherhood: A Challenging Period for Many Men
In contemporary society, fathers' participation in childrearing is not only welcomed, it is often expected (Goodman, 2005), reflecting social discourses that emphasize involved fathering (Singley & Edwards, 2015). Research identifies that parenthood has diverse effects on the health of men, both positive and negative (Garfield et al., 2010). Garfield et al. (2010) reported that fatherhood has a protective effect on men's health due to improved nutrition and physical activity and decreased risky behaviors, motivated by the desire to be role models for their children and maintain their health to witness their children grow into adulthood (Garfield et al., 2010).
Although the transition to parenthood has positive health effects for some fathers, it is also understood as demanding and difficult for some new dads, negatively affecting their health (Singley & Edwards, 2015). Adjusting to parenthood can be a tumultuous time in the lives of some men, fraught with the increased stress of caring for a newborn, decreased sleep, and role strain and/or gender role conflict (Singley & Edwards, 2015). The diverse experiences of new fathers include the contrasting feelings of joy and excitement about becoming a new father along with anxieties about the postnatal period and infant care (Deave & Johnson, 2008) and concerns about relationship changes with their intimate partner (Chin, Daiches, & Hall, 2011;Deave & Johnson, 2008).

Breastfeeding as a Health Hazard for Fathers
These challenging and, oftentimes, overwhelming adjustments in men's lives have been identified as risk factors for paternal postpartum depression (PPD; Kim & Swain, 2007), and depression is more prevalent among new dads than among the general male population (Paulson & Bazemore, 2010). Some ecological risk factors for PPD include changes in the conjugal relationship, feelings of exclusion from the mother-infant dyad, and difficulties bonding with the infant (Kim & Swain, 2007). Risk factors for PPD are also connected to breastfeeding: Some fathers associate maternal breastfeeding with feelings of exclusion from the mother-infant relationship and with negatively affecting father-infant bonding (deMontigny, Larivière-Bastien, Gervais, St-Arneault, Dubeau, & Devault, 2018). In the past, breastfeeding has been identified as a negative paternal risk factor for father-infant bonding and the marital relationship (Goodman, 2004). Psychosocial factors such as parenting distress, perceived parenting efficacy, and quality of the spousal relationship also contribute to PPD in fathers of breastfed infants (deMontigny, Girard, Lacharité, Dubeau, & Devault, 2013). Such evidence provides the basis to further investigate the effects maternal breastfeeding may have on men's health during the transition into fatherhood.

Rationale for Current Scoping Review
Men are becoming fathers in a world where breastfeeding is strongly encouraged, promoted, and recommended as the gold standard source of nutrition for infants (World Health Organization [WHO], 2017). Consequently, there is a growing body of research studying fathers in the breastfeeding context that focuses on the influence a father has on a mother's decision to initiate and continue breastfeeding and on interventions to assist fathers to fulfil their role as support providers to their breastfeeding partners (deMontigny, Gervais, Larivière-Bastien, & St-Arneault, 2018).
Knowledge gaps exist in the literature regarding the lived experiences of fathers and how breastfeeding affects their health (deMontigny, Gervais, Larivière-Bastien, & St-Arneault, 2018). Given that studies with the objective to improve the health of fathers are limited (deMontigny, Gervais, Larivière-Bastien, & St-Arneault, 2018), the aim of the current scoping review was to explore the experiences, roles, and needs of fathers of breastfed infants by reviewing the findings from relevant published research studies. Recommendations, drawn from the scoping review findings, are offered to guide primary health providers and services.

Methods
As forms of knowledge synthesis, scoping reviews address exploratory research questions with the goal of informing programs, policy, and clinical practice and directing research priorities for the future (Colquhoun et al., 2014). Scoping reviews are appropriately undertaken when a summary of the literature that pertains to a specific research question is required in order to address gaps in existing knowledge (Arksey & O'Malley, 2005). Scoping reviews provide a mechanism for disseminating this knowledge to practitioners, policy makers, and consumers who may lack resources or time to undertake this work independently (Arksey & O'Malley, 2005). The process used for this current scoping review was guided by the five-stage methodological framework as outlined by Arksey and O'Malley (2005), which included (a) identifying the research question, (b) identifying relevant studies, (c) selecting relevant studies, (d) charting the data, and (e) summarizing and reporting the results.
The current scoping review was undertaken to answer the following research questions: What are the experiences, roles, and needs of fathers of breasted infants? How can HCPs use this knowledge to assist, support, and engage fathers? To explore possible answers to these questions, literature was retrieved from several databases, including CINAHL, MEDLINE, and Google Scholar using the following keyword search terms: father(s), dad (s), men, male, paternal, breastfeeding, breast-feeding, feeding, infantfeeding, lactation, suckling, attitude(s), perception(s), belief(s), feeling(s), role(s), challenge(s), barrier(s), and need(s) in various configurations.

Selecting Relevant Studies
In total, the searches yielded 5,608 articles. Abstracts and titles of each article were reviewed for relevancy based on the following inclusion criteria: empirical studies published in English between 2008 and 2018 with fathers of breastfed infants as the main focus of the study. Articles that focused on breastfeeding preterm/hospitalized infants, maternal experiences with breastfeeding, bottlefeeding, or other types of infant feeding without making explicit mention of fathering in the context of breastfeeding were excluded. Duplicates were also excluded. Eighteen articles met the inclusion criteria for the review.

Charting the Data and Summarizing/ Reporting the Results
First, each article was read in full, annotated, analyzed, and compared with the other papers in order to identify key themes derived from the empirical findings. To help organize and compare the reviewed studies, a synthesis matrix was created (please see Table 1). This matrix included features of each study: the geographical location, publication year, author's purpose, study designs or methodology, sample size, pertinent features of the study populations, and empirical findings. By classifying the primary findings in each study, three key themes with subthemes were identified from this analysis (Thorne, 2016). Theme 1 pertained to fathers' views on the pros and cons of breastfeeding and contained the following subthemes: breastfeeding and father-infant bonding; partner relationships and breastfeeding; and breastfeeding in public. Theme 2 described fathers' involvement in the breastfeeding process and contained two subthemes: initiating breastfeeding and roles in breastfeeding. Theme 3 focused on support interventions for fathers during breastfeeding-what do fathers need?

Findings
The 18 international studies that comprised this review consisted of the following methodologies: One (6%) study employed quantitative methodology, 15 (83%) studies relied on qualitative approaches, and 2 (11%) used mixed-method designs. Seven studies (39%) were conducted with fathers in the United Kingdom, five studies (28%) were conducted in North America, and six (33%) were carried out in other countries, including Australia, Pakistan, Jordan, and Taiwan.
Fathers in several studies reported concerns about the perceived insufficiency of breast milk (Brown & Davies, 2014) and the inconvenience when compared with infant formula (Henderson et al., 2011;Mitchell-Box & Braun, 2012), and viewed it as challenging for their breastfeeding partners (Abu-Abbas et al., 2016;Brown & Davies, 2014). In a cross-sectional postal survey in Ireland, most participants (N = 417; 77.7%) responded with at least one disadvantage of breastfeeding (Bennett et al., 2016). Common drawbacks included physical pain for the mother (Banks et al., 2013), difficulties with latching (Mitchell-Box & Braun, 2012), and the inability to determine precisely how much feed the baby was receiving, leading to concerns about infant weight gain (Sherriff et al., 2009;Sherriff & Hall, 2011). In one study fathers reported breastfeeding as a burdensome task (Hansen et al., 2018), while others spoke about difficulties managing the rivalries of non-breastfeeding children for maternal attention (Bennett et al., 2016).
Regarding breastfeeding knowledge, one study reported that some fathers were reasonably well informed (Datta et al., 2012). Participants in other studies were unable to clearly articulate the specific benefits of breastfeeding (Henderson et al., 2011;Sherriff et al., 2009;Sherriff & Hall, 2011). Fathers in two studies had minimal knowledge of the challenges to establish successful breastfeeding (Bennett et al., 2016;Sherriff et al., 2009) and were surprised that breastfeeding "did not just happen" with ease (Bennett et al., 2016, p. 172).
Breastfeeding and father-infant bonding. Early bonding with their infant was often a primary goal for new fathers (deMontigny, Larivière-Bastien, Gervais, St-Arneault, Dubeau, & Devault, 2018); however, some participants also described breastfeeding as a hindrance that delayed or affected the creation of this bond (Bennett et al., 2016;deMontigny, Larivière-Bastien, Gervais, St-Arneault, Dubeau, & Devault, 2018). This perceived lack or delay of bonding time led some fathers to experience feelings of being "left out" (Ayton & Hansen, 2016;Brown & Davies, 2014;Mitchell-Box & Braun, 2012;Tohotoa et al., 2009) and jealousy or envy over the mother-infant  Rempel & Rempel, 2011). Breastfeeding also appeared to adversely affect some fathers' self-efficacy. Fathers reported the inability to feed their child independently led to feelings of inadequacy (Chen et al., 2010;Tohotoa et al., 2009), incompetency (Brown & Davies, 2014), and low self-efficacy as fathers (Banks et al., 2013;deMontigny, Larivière-Bastien, Gervais, St-Arneault, Dubeau, & Devault, 2018). A particularly noteworthy study by Chen et al. (2010), investigating the relationship between infant-feeding practices and fathers' health-related QOL, determined that after adjusting for confounding factors, fathers of breastfed infants reported lower QOL scores than fathers of bottle-fed infants. Chen et al. (2010) attributed the lower scores of fathers of infants that were breastfed with the fact that breastfeeding limited the opportunity for those fathers to develop a closer bond with their baby and contributed to the time spent away from their partner during breastfeeding.
In some reports, fathers detailed ways to navigate the father-infant bonding challenges they perceived to result from breastfeeding by involving themselves with infant care. These activities included changing diapers, burping after feeding, bathing, massaging, cuddling, putting the infant to bed, and singing or playing with the baby (deMontigny, Gervais Partner relationships and breastfeeding. Fears that breastfeeding might lead to an emotional rift and decreased intimacy with partners were reported by some men in qualitative and quantitative work (Bennett et al., 2016;Henderson et al., 2011;Rempel & Rempel, 2011). Fathers also reported how negative emotions surrounding breastfeeding, such as helplessness, inadequacy, and incompetency, led to an increased number of conflicts between mothers and fathers (Brown & Davies, 2014). In Pakistan, some fathers felt that breastfeeding brought them closer to their partners (Mithani et al., 2015) and others suggested that breastfeeding was beneficial to their relationship as it allowed them to work through challenges together (Rempel & Rempel, 2011). Fathers in family units who bedshared with their infants expressed appreciation for the limited sleep interruptions due to breastfeeding, but also reported barriers to intimacy this arrangement presented (Rempel & Rempel, 2011). In two studies, men also discussed the challenges in compartmentalizing the act of feeding from sexualizing their partners' breasts (Banks et al., 2013;Henderson et al., 2011). Similarly, fathers in a U.K. study viewed breastfeeding as a process that negatively impacted a woman's body shape, leading to "saggy" breasts (Henderson et al., 2011, p. 67). Other fathers described breastfeeding as having a positive impact, reporting their partners were better and more quickly able to regain their prepregnancy body shape (Bennett et al., 2016); others indicated that they found the larger size of their partners' breasts attractive (Bennett et al., 2016;Rempel & Rempel, 2011). Fathers in a U.S. study felt that concerns based on body image should not affect the decision to breastfeed and that stopping breastfeeding should not occur "just because women don't want their boobs to sag" (Mitchell-Box & Braun, 2012, p. 44).

Breastfeeding in public.
Having their partner breastfeed in public caused considerable discomfort for some men. Fathers in the United Kingdom and United States described public breastfeeding as "embarrassing" (Brown & Davies, 2014;Mitchell-Box & Braun, 2012), and others felt that mothers were "crossing the line between immodesty and decency when breastfeeding in public" (Mitchell-Box & Braun, 2012, p. 45). Concerns associated with breastfeeding in public included people seeing their partner's breasts (Bennett et al., 2016;Henderson et al., 2011), offending others, and having their partner receive unpleasant comments from onlookers (Bennet et al., 2016). Cultural implications influenced fathers' views of breastfeeding in public. For example, Abu-Abbas et al. (2016) attributed Jordanian fathers' consistent negative attitudes toward public breastfeeding to that country's conservative cultural norms. In contrast, fathers who grew up in jurisdictions where exposure to breastfeeding was commonplace and normed felt comfortable with women breastfeeding in public (Mitchell-Box & Braun, 2012). Socioeconomic factors also appeared to affect comfort levels with public breastfeeding. Men living in less affluent and disadvantaged areas were more likely to report discomfort with public breastfeeding (Hansen et al., 2018). Men classified as low income in Australia described public breastfeeding as embarrassing and a cause of significant anxiety (Henderson et al., 2011). Conversely, many fathers in Ireland reported complete comfort with their partner breastfeeding in public (Bennett et al., 2016). These men stated they were not embarrassed by public breastfeeding, although they conceded to being conscious of their partners' modesty (Sherriff et al., 2009) and certain stigmas attached to public breastfeeding (Hounsome & Dowling, 2018). One father among 28 in an Australian focus group investigation declared the need for fathers to support public breastfeeding without shame and to expand their conception of breasts from purely sexual to functional (Tohotoa et al., 2009).

Fathers' Roles in the Breastfeeding Process
Initiating breastfeeding. The findings in the current scoping review suggested that most fathers believed that the ultimate decision to breastfeed should reside with the breastfeeding partner (Bennett et al., 2016;Brown & Davies, 2014;Datta et al., 2012;deMontigny, Gervais, Larivière-Bastien, & St-Arneault, 2018;Hounsome & Dowling, 2018;Mitchell-Box & Braun, 2012;Rempel & Rempel, 2011). Notably, fathers often reported that deference to the mother was not due to indifference or to escape responsibility, but because breastfeeding primarily involved the female partner's time, body, and energy (Datta et al., 2012). Although they may have encouraged breastfeeding, most fathers felt this decision was their partner's independent choice (Banks et al., 2013;deMontigny, Gervais, Larivière-Bastien, & St-Arneault, 2018;Hounsome & Dowling, 2018). A small subgroup of Canadian fathers (deMontigny, Gervais, Larivière-Bastien, & St-Arneault, 2018) who highly valued breastfeeding enjoyed discussing the benefits with their partners even when their partners did not share the same level of enthusiasm for breastfeeding. These men found they had to "negotiate a space for themselves within the decisionmaking process" (p. 8). Although only a small proportion of fathers reported ambivalence as to how their baby should be fed (Brown & Davies, 2014), many felt excluded from the breastfeeding decision-making process (Banks et al., 2013). Regardless of which parent made the final decision to breastfeed, fathers generally wanted to present to friends and family as a unified team, making the best decisions for their family together (Rempel & Rempel, 2011).

Roles in breastfeeding.
Fathers perceived their main roles in breastfeeding to be supporters and facilitators of the process (Datta et al., 2012;deMontigny, Gervais, Larivière-Bastien, & St-Arneault, 2018;Rempel & Rempel, 2011;Sherriff et al., 2009). Supporting the process included providing practical support to their partner during breastfeeding, such as performing domestic activities, providing care to older children, ensuring the comfort of their partner, providing meals, recognizing infant signs or cues of hunger, burping, and changing the infant's diaper after feeding (Datta et al., 2012;deMontigny, Gervais, Larivière-Bastien, & St-Arneault, 2018;Mithani et al., 2015;Rempel & Rempel, 2011). Datta et al. (2012) andSt-Arneault (2018) reported that fathers also felt the need to provide emotional and practical support to the mother during breastfeeding through encouragement, affection, and anticipating her needs to reassure her that breastfeeding was a team effort (deMontigny, Gervais, Larivière-Bastien, & St-Arneault, 2018). In other accounts, fathers assumed the responsibility of ensuring the overall health of the marital relationship by organizing outings to ensure "the couple had an existence beyond parenthood" (deMontigny, Gervais, Larivière-Bastien, & St-Arneault, 2018, p. 10). Finally, fathers in Australia described the role of breastfeeding advocate as involving communicating to HCPs, family, and friends about the importance of breastfeeding to their family unit (Tohotoa et al., 2009).
The majority of fathers perceived the ability to feed their child as a positive experience and as a contributing factor to formation of the father-infant bond (deMontigny, Larivière-Bastien, Gervais, St-Arneault, Dubeau, & Devault, 2018), through either bottle-feeding expressed breast milk or infant formula during the breastfeeding period or feeding solids when the baby was ready (Hansen et al., 2018;Rempel & Rempel, 2011). Fathers reported feeling a sense of appreciation when experiencing their infant's satisfaction more directly during bottle-feeding and noted that the intimate connection that was felt primarily by the breastfeeding mother became attainable for them (deMontigny, Larivière-Bastien, Gervais, St-Arneault, Dubeau, & Devault, 2018). Clearly, the role of feeding was one of great significance for some fathers. In fact, a father in deMontigny, Larivière-Bastien, Gervais, St-Arneault, Dubeau, and Devault (2018) study stated that feeding his son "helped remind him that he was a father" (p. 493). Overall, fathers supported breastfeeding but some felt that bottle-feeding could grant them a greater role (Henderson et al., 2011;Mitchell-Box & Braun, 2012;Sherriff et al., 2009;Sherriff & Hall, 2011).
To promote fathers' involvement in breastfeeding, Bennett et al. (2016) suggested that HCPs emphasize the value of the father to the process and provide clear guidance on how he may be involved in meaningful ways, such as recognizing hunger cues and lactation problems, calming the infant before feeding, ensuring comfortable positioning of mom and baby during feeding, burping, and changing diapers after feeding. Teaching fathers how to recognize signs that the baby is receiving enough breast milk, such as adequate weight gain, wet diapers, and fullness cues can provide dads with important tools to be active members of the breastfeeding team and reduce concerns about babies receiving adequate feed (Bennett, et al., 2016).

Support Interventions for Fathers During Breastfeeding-What do Fathers Need?
Fathers of breastfed infants reported requiring diverse resources. Many of the men in these studies sought guidance from HCPs, breastfeeding literature, antenatal support groups, father-father mentorship groups, the Internet, and other modes of technology. With reference to support provided by HCPs, some fathers felt inundated with information (Ayton & Hansen, 2016) that was often conflicting (Banks et al., 2013), whereas others were disappointed with the lack of programming and supports specifically tailored for them (Banks et al., 2013;Bennett et al., 2016;Tohotoa et al., 2009). Few fathers reported receiving information directly from HCPs and most indicated that information had been passed to them through their partner in the form of pamphlets or perhaps did not reach them at all (Brown & Davies, 2014). Conversely, some men who were provided antenatal guidance by HCPs felt the information provided was helpful (Hounsome & Dowling, 2018;Mitchell-Box & Braun, 2012). Regarding formal antenatal programs, some fathers indicated these were useful, especially for firsttime fathers, as long as they were specifically tailored to their needs (Mitchell-Box & Braun, 2012;Tohotoa et al., 2009). A number of fathers highlighted that access to these services was often limited especially when organized groups occurred during working hours (Sherriff et al., 2009;Sherriff & Hall, 2011). In several studies, fathers who did attend programs felt these services were generally targeted toward mothers (Ayton & Hansen, 2016;Mithani et al., 2015;Tohotoa et al., 2009) and reported feeling alienated and dismissed by HCPs, as though their role was tokenistic and/or delinked from breastfeeding (Brown & Davies, 2014). In one study fathers reported feeling patronized when communicating with HCPs, for example, by the demeaning suggestion that they needed to be convinced that breastfeeding was worthwhile by thinking about the personal benefits (Brown & Davies, 2014,), such as their partner gaining breast size or not having to participate in night feedings (Brown & Davies, 2014). Fathers also suggested that some HCPs were too authoritative and pressured women to breastfeed (Datta et al., 2012;Hansen et al., 2018), and they were dismayed by the guilt placed on mothers who did not breastfeed (Brown & Davies, 2014). Fathers suggested that an overload of information placed additional pressure on new parents who often already struggled with a lack of practical support once the baby arrived (Brown & Davies, 2014).
Fathers noted the need for consistent, specific, and practical advice with regard to breastfeeding informational materials (Bennett et al., 2016;Brown & Davies, 2014), such as troubleshooting information when difficulties arose, including latching problems, mastitis, blocked ducts, and diet recommendations for the mother (Bennet et al., 2016;Mitchell-Box & Braun, 2012). Other types of useful information identified by fathers included knowing how and when to wean the infant, strategies for supporting their partner when breastfeeding was unsuccessful, and help managing feelings of exclusion or jealousy over the mother-infant bond created through breastfeeding (Bennett et al., 2016). The Internet was also reported as an important resource wherein several fathers learned more about breastfeeding and other types of feeding methods online (Bennett et al., 2016;Mitchell-Box & Braun, 2012). Alongside practical guidance and procedural information, fathers wanted insight about the realities of breastfeeding and what they could really expect from the experience (Brown & Davies, 2014). Fathers in the United Kingdom felt the educational literature was mostly aimed toward mothers, including materials intended for "parents" (Sherriff & Hall, 2011). These fathers suggested the literature be more tailored by including positive imagery of fathers with their infants and by providing information on the emotional aspects that both parents may experience during the process (Brown & Davies, 2014;Sherriff & Hall, 2011).
Social connectedness through father-to-father mentorship was viewed as an important resource that helped provide reassurance to men in breastfeeding families (Ayton & Hansen, 2016;Brown & Davies, 2014). Fathers participating in a mixed-methods study in the United Kingdom (Brown & Davies, 2014) placed value on mentorship and learning about breastfeeding from more experienced fathers, particularly how to support their partners in the breastfeeding process (Brown & Davies, 2014). Similarly, a study involving young Australian fathers under the age of 24 years reported that connecting with other fathers gave them confidence and helped them cope with the demands of young parenthood (Ayton & Hansen, 2016).

Discussion
The findings of the current scoping review demonstrate that the experiences, perspectives, and needs of fathers in the context of partners' breastfeeding have important implications for HCPs and services. For some fathers, finding a space for themselves as important members of breastfeeding teams can be challenging. Men may feel inadequate due to a lack of breastfeeding knowledge or a belief that their concerns and needs are secondary to those of their partner. HCPs must address these concerns, especially considering many men are reluctant to ask for help or explicitly ask for information (Tohotoa et al., 2009). To respond effectively, it is essential that HCPs recognize and affirm the important roles fathers play in the breastfeeding process.
DeMontigny, Larivière-Bastien, Gervais, St-Arneault, Dubeau, and Devault, (2018) suggest that parental selfefficacy may be enhanced if HCPs engage in dialogue with fathers and attempt to normalize the range of their feelings and experiences during the breastfeeding process. For instance, fathers can be encouraged to form rituals, such as bathing, or schedule designated specific one-on-one time after feeding or before bedtime to foster the development of stronger and earlier father-infant bonds.
This review reveals a need for pragmatic education in which HCPs support parents by reinforcing an approach that recognizes although breastfeeding is a natural and normal process, it can also be challenging. Preparing families with realistic expectations of how breastfeeding may impact them as individuals, as a couple, and as a family unit can help them manage these challenges and foster success with breastfeeding (Jordan & Wall, 1990). HCPs must ensure that support provided to fathers is communicated in a manner that is clear, consistent, culturally sensitive, inclusive, nonjudgmental, and nonpatronizing. Factors such as age, ethnicity, and socioeconomic status should also be considered to provide tailored breastfeeding education that addresses the specific needs of different family backgrounds.
Overwhelmingly, the studies included in the current scoping review revealed the need for targeted strategies to reach men regarding their potential roles in breastfeeding. Father-focused interventions can assist fathers in learning about breastfeeding; however, their roles in the process must be practical, specific, and detailed, with the ultimate goal of expanding the breastfeeding dyad of mom and babe to a triad including dad. Father-centered interventions should include information about the basic aspects of breastfeeding, such as health benefits to the mother and infant and the differences with infant formula and should clarify any misunderstandings or myths about breastfeeding. Advanced breastfeeding information should also be provided, such as how to troubleshoot common breastfeeding problems, assess milk supply, facilitate breastfeeding (e.g., the importance of skinto-skin contact), and techniques and positions for successful latching. Guidance on how to support their partners, whether practically, such as helping with household tasks and managing other children, or emotionally, such as providing a comforting touch and words of encouragement is also critical. DeMontigny, Gervais, Larivière-Bastien, and St-Arneault (2018) posit that HCPs first assess the type of support the mother requires to help the father respond to her needs effectively, while simultaneously recognizing and communicating his own. HCPs can also provide advice on how to maintain intimacy within relationships during a time when some men feel the loss of sexual or physical connection with their partners. Providing suggestions, such as planning a weekly date night or simply making the time to connect with each other one-on-one every evening may help to maintain closeness between couples.
Breastfeeding literature for fathers should also include positive imagery of fathers as part of the breastfeeding team. Furthermore, any antenatal literature for fathers would benefit by including the term "father" instead of "parent," a term that has often been interpreted by men as being synonymous with "mother" (Sherriff & Hall, 2011). The need for accessible antenatal services for working fathers is also highlighted by this review, since work commitments was the primary reason men cited for not attending classes (Sherriff & Hall, 2011;Tohotoa et al., 2011). Some fathers may also benefit from attending antenatal education sessions that are held within informal or casual settings, such as pubs or sports clubs; engaging men through conventional health services is often challenging (Robertson, Witty, Zwolinsky, & Day, 2013). Mobile antenatal services where HCPs travel to workplaces of expecting or new fathers and provide education during break times may also be a viable option to increase accessibility of education for working fathers (Robertson et al., 2013).
Mentorship and social connectivity appeared to be important avenues of support for fathers and interventions focused on peer connectedness might assist men with concerns they may have about breastfeeding and the transition into fatherhood in general. Men-only sessions have been reported to promote camaraderie with father peers (Nash, 2018) and give fathers the opportunity to share opinions or experiences they would otherwise feel uncomfortable sharing with their partners. deMontigny, Gervais, Larivière-Bastien, and St-Arneault (2018) suggested that guidance from peers in father-only sessions may help men to have these difficult conversations with their partners. Furthermore, Gamble and Morse (1993) highlighted the use of mentors in antenatal sessions as a way of normalizing fathers' feelings and experiences while assuring them that the relationship with their infant will not be adversely affected in the long term by breastfeeding.
The idea of breastfeeding in public caused men in a number of studies to feel anxious, embarrassed, and concerned. According to Bennett et al. (2016), a conflict seems to exist between the natural and intimate process of breastfeeding from the perspective of progressive values and tradition-based conservative values. HCPs might thoughtfully consider fostering an environment where breastfeeding in public is promoted as an essential, normative, everyday activity that can complement family-based values (Bennett et al., 2016). HCPs can inform and influence parents to exercise their rights to breastfeed and provide suggestions on breastfeeding discretely to encourage being comfortable (Bennett et al., 2016). For example, a nursing cover can create a symbolic "private" space during public breastfeeding that may also desexualize the act of breastfeeding (Owens, Carter, Nordham, & Ford, 2018).
In terms of limitations, the approach to men's health in this scoping review focused on fathers' instrumental roles and the pragmatic means whereby men can adjust to and participate in breastfeeding their infant. Though previous research (i.e., Goodman, 2004) has identified PPD as a significant health challenge for new fathers, the findings drawn from the current scoping review did not provide evidence about potential linkages between men's mental health or PPD and fathers' breastfeeding roles and experiences. This knowledge gap should be addressed by future research as a means to thoughtfully consider targeted interventions. The international breadth of this review might also be regarded as a limitation due to the diverse societal values represented; however, this diversity can also be argued as a strength demonstrating how fathers' involvement in breastfeeding is a universal topic of concern and interest to men around the world regardless of local gender norms and values.

Conclusion
The current scoping review highlights the need for comprehensive breastfeeding antenatal support and education tailored for fathers of breastfed infants and a wider need to support involved fathering in infant nutrition as this may act as a catalyst for long-term involvement of fathers in their children's nutrition. A concerted effort on the part of HCPs who wish to engage fathers to be active members of their breastfeeding teams must first recognize the wide array of fathers' needs and experiences in order to make these efforts effective. Supporting fathers in their various roles within the breastfeeding context and recognizing them as fundamental members of the breastfeeding triad may also help overcome feelings of inadequacy and exclusion and facilitate health promotion for men, affording a range of important benefits for the entire family.