The Paternal Experience of Fear of Childbirth: An Integrative Review

Background: It is estimated that approximately 13% of expectant fathers experience a pathological and debilitating fear of childbirth. Objective: The aim of this integrative review was to examine and synthesise the current body of research relating to paternal experience of fear of childbirth. Methods: A systematic literature search of five databases—CINAHL, Cochrane Library, MEDLINE, PsycArticles and PsycInfo—identified seventeen papers. Methodological quality of studies was assessed using the Crowe Critical Appraisal Tool. Results: Thematic data analysis identified three themes: the focus of fathers’ childbirth-related fears, the impact of fear of childbirth on health and wellbeing, and fear of childbirth as a private burden. Discussion: Fear of childbirth is a significant and distressing experience for expectant fathers who may benefit from an opportunity to express their childbirth-related fears in an environment where they feel validated and supported. Antenatal education is recommended to enhance fathers’ childbirth-related self-efficacy to reduce fear of childbirth. Conclusions: Fear of childbirth may negatively impact the lives of men and consequently their families. Further investigation into methods and models for identifying and supporting men at risk of or experiencing fear of childbirth is required to improve outcomes for this population of men.


Introduction
Fathers' attendance at childbirth has changed over the past 40 years, with approximately 96% of fathers in the developed world now being present during birth [1]. This change has coincided with an evolution in the perceived role of the father. Twenty-firstcentury fathers are viewed of as being providers and protectors who take a proactive hands-on role with their children in addition to giving practical and emotional support to their partner [2]. Prospective fathers are relied upon by their partners for support and assistance during pregnancy, childbirth and in the raising of their children [3]. The modern gender constructs of 'maleness' suggest that men should be strong and self-confident, which does not encourage fathers-to-be to express fears about their own capabilities [4]. Men may question the legitimacy of their psychological experiences during the perinatal period as they view themselves in a supportive role to their partner and consequently are reluctant to express and communicate their fears around birth and fatherhood [4]. Fatherhood, even when it is desired and planned for, can be a difficult time of transition for some men, negatively impacting their mental health, resulting in stress, anxiety and depression [5,6].
Fathers experience of childbirth has been particularly understudied despite evidence suggesting that the experience of birth contributes to a fathers' adjustment to fatherhood during the postpartum period [7]. When childbirth is experienced as a traumatic event by parents, this can negatively impact their postnatal mental health [8]. Childbirth can be perceived as a traumatic event by one or both parents when there is an actual or threatened risk of serious injury or death to mother or child [8]. This may result in some parents' experiencing intense fear, helplessness and a sense of loss of control [9]. Experiencing a difficult or stressful birth can heighten any pre-existing parental emotional vulnerabilities, which can subsequently contribute to negative postpartum outcomes, including difficulties with bonding [7].
A pathological fear of childbirth (FOC) is estimated to effect approximately 13% of fathers-to-be [11]. However, the focus of most research is on maternal FOC and tokophobia. Limited research has explored paternal FOC using validated screening tools and there is a lack of consistent definition of paternal FOC [12] across the literature, making the true incidence rate difficult to determine. These fathers-to-be with a pathological FOC experience severe anxiety, which impacts their daily functioning, causes distressing feelings of helplessness and affects their ability to prepare psychologically for fatherhood [13] as opposed to the common worry and uncertainty experienced by fathers-to-be in anticipation of childbirth. Fathers are categorised as having mild, moderate or severe/intense FOC using screening tools such as the Fear of Birth Scale (FOBS), which determines cut-off points between these categories [4,14]. The most frequently used tool for identifying FOC is the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ). This 33-item Swedish measure was developed by Wijma, Wijma, and Zar [15] and is considered a validated screening tool for evaluating FOC among women, with scores ranging from 0 to 165. The W-DEQ screening tool was intended for use in women but it is frequently used in the literature to screen for FOC among men [13,16]. A number of studies have revised the tool for use among men by omitting questions perceived to be irrelevant to males [13,17]. However, the reliability and validity of this screening tool among men requires further investigation.

Fear of Childbirth and the Request for Caesarean Section
FOC is a significant obstetric concern as it often leads couples to request birth by caesarean section (CS), which they perceive to be a safer and more controlled birthing option [18,19]. CS rates performed without medical indication are rising worldwide, with an increasing tendency to perform CS on a mother's request [20]. Maternal request for CS birth, commonly attributed to FOC, are estimated to account for approximately 7-22% of CS births in Finland, Sweden and the UK [21]. Similarly, Gao et al. [22], in a more recent study, estimated the rate of CS on maternal request as being 10-20% in Northern Europe, the USA, Sweden and Australia. However, it is unclear whether a fathers' experience of FOC influences his partners request for caesarean birth, which warrants further exploration. The World Health Organisation [23] recommends the use of non-clinical interventions such as health education as a means to reduce the rate of unnecessary CS births [24].

Rational for Undertaking This Review
Pregnancy is a natural and often longed for progression in a couple's life. It can, however, become a time of great worry and anxiety as preparations are made for the challenges that parenthood entails [25]. There is a wealth of research indicating that maternal stress is associated with adverse pregnancy outcomes [26,27]. Significantly fewer studies have examined the mental health challenges faced by fathers during this time [1,28]. A father's involvement in the life of his child has consistently been shown to influence child outcomes independent of maternal factors including improved intellectual outcomes and a reduction in child behavioural problems [29,30]. A fathers' experience of perinatal mental health conditions including anxiety and depression can impact on a fathers' mental and physical health, personal relationships and parenting ability [31,32]. Therefore, conditions such as paternal FOC are in need of greater exploration and understanding. The identification and treatment of paternal perinatal mental health problems (PMHPs) are significant as they have a protective benefit to the entire family in addition to improving child outcomes [2].
The majority of research to date has assessed fathers' anxiety during the perinatal period including a systematic review conducted by Philpott et al. [32]. This review found that factors contributing to fathers' anxiety were lower education levels, lower household income, poor co-parenting support, a partner's anxiety and depression and being present during a previous birth. However, there is a paucity of research examining fathers' experiences of FOC. This review aims to identify, explore, critically appraise and synthesise the evidence relating to men's experience of FOC in order to increase health professional's understanding of this condition in men. A synthesis of the findings of the relevant research can identify knowledge gaps, areas for further research, provide guidance on preventative measures and inform the development of appropriate treatment interventions and, in so doing, enhance family centred care within the maternity services.

Design
An integrative review method allows for the simultaneous inclusion of various diverse study methodologies [33] and supports the collation, analysis and integration of findings from existing primary research relating to a specific research question [34]. An integrative review was identified as the most appropriate review method to critically appraise the literature evidence relating to fathers' experience of FOC. This review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) [35].

Search Strategy
A search of the CINAHL, Cochrane Library, MEDLINE, PsycArticles and PsycInfo databases was conducted between 15 September 2019 and 15 January 2020 to identify primary studies related to the review question [36] using the following search terms: tokophobia OR tocophobia OR fear of childbirth OR childbirth fear AND fathers OR men OR dads OR paternal OR male. No restrictions were placed on publication date of studies as no previous systematic or integrative review had been identified on this topic, therefore warranting a full evaluation of available research. Details of inclusion/exclusion criteria are available in Table 1.

Search Results
A total of 297 citations were retrieved from selected databases and 201 papers remained after removal of duplicates. Screening of title and abstract excluded 160 articles which did not meet the inclusion criteria for the review, resulting in full-text review of 41 studies. A further 24 papers were excluded following full-text review as their content was not relevant to the review question ( Figure 1). A total of 17 papers met the inclusion criteria for this review, consisting of four qualitative studies, eleven quantitative studies and two mixed-methods studies.

Critical Appraisal
Eligible studies were critically appraised using Crowe's Critical Appraisal Tool (CCAT) [37]. CCAT scores among the studies varied between 19 and 32 out of a possible score of 40. The 17 papers were included in the review following quality appraisal, although a number of methodological limitations were identified as detailed in the data extraction table. Overall, the studies presented clear research aims, objectives and rationale for addressing their research question.

Data Extraction, Reduction and Analysis
Data from each of the 17 eligible studies were organised into a data extraction table  (Table 2). The extraction fields chosen in this review were: author(s), year, title, country, study design/setting, sampling strategy/size, data collection methods, analytical approach, findings, strengths and limitations and quality appraisal. Data relevant to the review question was extracted from each selected study and analysed according to the thematic analysis (T.A.) approach described by Braun and Clarke [38,39].
Excerpts from the data findings section of each of the selected studies was transferred verbatim into a thematic synthesis table (Table S1). Coded data developed through iterative and interactive readings of primary study findings was compared, contrasted and categorised into three descriptive themes agreed by authors (E.M., M.N.). A thematic map was created (see Figure 2) to outline themes and subthemes that emanated from the synthesis of data across eligible studies.
Two studies [13,17] present secondary analysis of data collected from a randomised control trial [49] designed to investigate two models of antenatal education. Three papers reported on different results from the same longitudinal cohort study [14,43,45] and two papers reported on different findings from the same cross-sectional survey [4,11]. This culminated in inclusion of a total of 17 papers, representing 13 primary studies. Various scales were used across the studies including the W-DEQ [13,16,17], the FOBS [43,45], the Cambridge Worry Scale [13,17], and the Impact of Event Scale [9], and several researchers developed self-rated questionnaires [4,11,40,[45][46][47][48]. Many of the studies tested the reliability of their chosen instruments for use in fathers using split-half reliability; Cronbach's alpha and construct validity [16]; Cronbach's alpha [43]; factor analysis [11]; pilot testing [17,47]; pilot testing and Pearson correlation coefficient [13]; analysis of variance [44]; and face-to-face validation [48]. Authors of three studies did not detail validity measures [14,40,45].

Focus of Fear
The first theme that emerged from a synthesis of findings across studies was the focus of fear, which offers an insight into what men with FOC are fearful of in relation to childbirth [1,4,9,11,[40][41][42]44,46,47] and is explored under the following subthemes: the health and life of the baby, the health and life of their partner, and reactions and behaviour.

The Health and Life of the Baby
The most commonly expressed paternal fear was for the health and life of the baby [1,4,9,11,40,44,46,47]. Findings from Eriksson et al.'s [11] study found that 98% of men with intense childbirth fear and 92% with mild-moderate fear believed that every expectant parent is afraid that their baby would not be born healthy. Specific fears that the baby would be born with an abnormality, disease or "handicapped" were reported by participants in two studies [4,47]. In Chalmers and Meyer's study [47], 50% of the responding fathers reported checking the baby for an abnormality at birth. Fear of malformation in the baby was found to be more anxiety provoking among parents with higher education levels [46]. The baby experiencing a birth injury was a very strong fear among 13% of fathers surveyed by Szeverényi et al. [44]. In many of the studies, a significant and predominant fear was the fear that their baby would be stillborn or might die [1,4,9,42,44,47]. Men's fear levels did not reduce with increasing parity, in contrast to fear levels in parous women which were very often reduced [46].    State-Trait Anxiety Inventory (STAI) and self-assessment questionnaire.
Statistics ANOVA and t-tests.
Fathers did not report reduced scores for FOC with second or subsequent children as was found for women. Fear of foetal malformation was found to be more anxiety provoking in parents with higher levels of education. Fear for the unborn child's health was the most prominent fear. Anxiety rose in both men and women as gestational age increased.

The Health and Life of the Partner
Along with the fear that their baby may die, fathers also expressed significant fears for the health of their partners [4,40,41,45,47]. Fathers were found more likely to fear for the welfare of the woman than the women themselves [4]. Greer et al. [41] found that many fathers (42%) feared that their baby was too large to be born vaginally and their partner would be unable to cope with the pain. Similar results were found by Chalmers and Meyer [47], where 43.5% of fathers feared their partner experiencing pain. Other fears reported across the studies included injury to their partner [4], partner's postnatal mental health being negatively affected by a traumatic birth [41], prolonged birth [4], episiotomy [47], fear of interventions [4] and caesarean birth [44]. Fears relating to the health and life of the woman and the health and life of the baby were reported significantly more often by men with intense FOC than by men with a mild or moderate fear [4].
One study found that men were more positive than women about the use of medical interventions during labour, such as the use of epidural [41]. All of these men wanted their partner to have as much pain relief as possible during childbirth in the hope that it would make the birth easier and safer. Similar findings were reported by Hildingsson [14] who found that men desired a birth that was the safest, least painful and stressful option for the woman and one that optimised recovery. A perception that childbirth is intrinsically dangerous was increased when there was history of a previous negative birth experience [41].

Reactions and Behaviour
A number of studies found that fathers experience fears relating to their own capabilities and reactions, as well as concerns regarding the competence and behaviour of health professionals [4,40]. Men were fearful of doing something wrong during labour [44], and doubts about their own reactions were common [40]. Other reported fears were not being able to give help and support to their partner during childbirth and not being able to endure the situation [4]. A lack of knowledge about childbirth served to increase fathers' anxiety [1]. Fathers expressed fear that they may not be present at the birth [47], and the possibility of fainting or panicking [42]. Fathers with FOC were found to feel more unprepared for childbirth and experience childbirth as a more frightening experience than fathers who did not report fear [13].

Impact on Health and Wellbeing
The second theme reports on the impact FOC has on fathers' health and wellbeing under three subthemes: mental health, physical health, and coping mechanisms and avoidance.

Mental Health
The impact of experiencing FOC on fathers' mental health was reported across twelve studies [1,9,11,13,17,[40][41][42][43]45,47,48]. Some fathers described fear of childbirth in terms of a mental preoccupation in which they thought about their fear to a great extent [40]. Other participants had not been as consumed by fear but reported that the fears brought with it a sense of increased vigilance. Fathers with FOC were found to be twice as likely to report they were thinking about the birth of their baby compared to those without FOC [45].
In one study, men reported preoccupation, rumination and flashbacks in the weeks, months and years following the birth [9]. This study also found that the pain and suffering of the woman in labour had a direct effect on the man, with his distress mirroring hers [9]. Shibli-Kometiani and Brown [1] reported that as labour progressed, men's anxiety, fear and distress increased and with it they became passive and less supportive. Despite their fear constituting emotional distress, a number of more positive aspects emanating from their fear were reported by fathers in one study [40]. One man reported that his fear had helped to make the pregnancy and impending birth seem more real and another man described his fear as giving him greater insight into what is really important in life.

Physical Health
Physical health symptoms experienced by men with FOC were reported across five studies [9,40,42,43,47]. Experiencing FOC impacted fathers' physical health in various ways including changes in perception and a sense of heightened physical awareness [9], sleep disturbance, weight gain, nausea [47], and uneasy body sensations, restlessness, stomach ache and erectile problems [40].

Coping Mechanisms and Avoidance
Coping mechanisms utilised by some of the fathers were identified across studies [9,16,40,43]. Fathers attempted to increase their sense of control in a number of ways including preparing for the birth, relieving the woman of her daily chores and restricting the woman from pursuing any activities they deemed harmful [40]. Others engaged in more frequent religious practice [16], and kept busy with extra work and physical training [40]. Some fathers avoided external stimuli such as television programs on childbirth which triggered memories of birth [9]. Other men with FOC avoided attending antenatal care visits as they did not want to talk about everything that could happen [40]. However, these results are not supported by Hildingsson et al. [43], who found that fathers with previous children and FOC attended antenatal visits to the midwife more often than fathers without fear.

A Private Burden
This third identified theme is examined under the subthemes of gender constructs, non-disclosure and giving and receiving support. It captures a sense of what the experience is like for men with varying levels of FOC.

Gender Constructs
All of the men in the Eriksson et al. [40] study felt that talking about childbirth-related fears was difficult and was not in the nature of men. Participating fathers referred to societal expectations and their responsibility to be strong and look after the woman's needs. Fathers expressed the opinion that it did not seem appropriate to talk about their own fears, while others spoke about not wanting to look weak. Similarly, fathers in the Etheridge and Slade [9] study referred to trying to keep strong for their partner which was motivated by the thought that seeing him upset was not going to do her any good.

Non-Disclosure
Men's experience of childbirth fear often became a hidden and personal burden. A number of studies identified that most of the fathers had not expressed or spoken about their fears to either their partner, friends or relatives [40,42]. Fathers did not want to worry their partner and were afraid that talking about their fears might generate fear in the woman [11]. Other reasons given for not expressing their fear were not wanting to disappoint their partner or give her the impression that she could not expect his support, feeling the issue was of no interest to anybody and that talking would make their fears worse, suggesting a sense of isolation some men feel. On reflection, some men felt that talking about their fear may have been beneficial and even desirable [40].
Etheridge and Slade [9] found that during childbirth, most men tried to hide their feelings but became so overwhelmed that they broke down. The men who did manage to contain their emotions during the birth reported becoming extremely distressed and breaking down in tears when on their own, describing feelings of utter helplessness. Fathers were afraid that others may not understand or would dismiss their distress, which affected how they shared their experiences of birth [9]. Fathers in this study felt that they did not have the right to be affected because "nothing actually happened to me". Eriksson et al. [11] found that 65% of men with intense fear reported that nobody ever asked them how they felt about childbirth, suggesting that lack of assessment and validation of men's childbirth-related fears may be contributing to their lack of disclosure.

Giving Support
Men were found to experience giving support during childbirth as being harder than they had expected and expressed concerns in relation to their ability to meet the needs of their partner [1,41,42]. Feelings of uncertainty and perceiving themselves as unable to do anything practical increased fathers' feelings of helplessness [9,42]. Notably, a minority of participants in one study expressed more confidence in their ability to provide support to their partner following a CS birth rather than support during active labour [41]. Overall, men felt most comfortable with a practical and well-defined supportive role [1,42].

Receiving Support
Fathers' feelings about receiving support was reported in five studies [1,9,41,43,47]. Most of the men expressed a need for support [1]. The partner was identified as the most important source of emotional support for fathers [47]. Other sources of support were midwives [41,43]. In contrast, one study found that putting their trust in health professionals gave fathers a feeling of unease as this was in contrast to their usual experience of feeling in control [9].

Discussion
The aim of this review was to identify, explore, critically appraise and synthesise the evidence relating to men's experience of FOC. A synthesis of findings across the selected studies identified the nature of paternal childbirth fears, the impact of FOC on paternal perinatal wellbeing, the silence surrounding this fear and the coping strategies that fathers engaged with to respond to their fears.

Paternal PMH and Childbirth Fears
Increased awareness of fathers' perinatal mental health needs in relation to FOC, including risk factor and symptom identification, and the development and provision of support structures may reduce the negative impacts of FOC on postnatal mental health difficulties and improve outcomes for men, women and their families [50][51][52]. Early identification of fathers with FOC would support the planning of timely interventions to reduce the distress and potential negative impacts for fathers with severe FOC [52]. However, findings of this review offer only a limited examination of the factors associated with men's risk of developing FOC outside of broad demographic explanations such as increased risks in first-time fathers [13,45], inconsistent findings re fathers' age [11,17,46], the father's country of birth [45], frequency of religious practice [16], and educational factors [46].
Effective screening methods are central to identifying fathers with PMH needs. However, despite FOC being a serious perinatal mental health condition there is a lack of clear recommendations regarding assessment tools and appropriate timing of screening [53]. There is a need for reliable and valid screening tools to identify FOC in fathers. However, screening in pregnancy is insufficient to improve clinical outcomes in fathers without appropriate follow up for diagnoses and treatment. The establishment of multidisciplinary care pathways for the treatment of fathers' perinatal mental health conditions including FOC would facilitate staff confidence and encourage enquiry about fathers' mental health needs [54].

Overcoming Barriers and Screening
This review identifies a number of barriers faced by those delivering antenatal care to identify men experiencing FOC. Non-disclosure is one barrier evident across studies [9,11,40,42]. Fathers can be reluctant to express their FOC support needs or seek help for fear that in doing so would detract from their partner's needs [2,55]. Fathers want professional support from midwives but not at the expense of the mothers' needs [56]. It is widely acknowledged that men's general reluctance to talk about their FOC may lead to an underestimation of the problem [13,40,57]. Men find it difficult to seek help for mental health problems in general, are more likely to express negative attitudes toward therapy, and are more likely to discontinue treatment than women [58]. Professionals need to be proactive and flexible in support provision, which would limit the impact of personal barriers and encourage fathers' active engagement [50]. Offering fathers with FOC their own appointment with the midwife would give the man an opportunity to talk about his fears without the risk of causing fear to his partner [40].
Men's difficulty in speaking about their FOC may be related to socially constructed norms and expectations [40]. A systematic review by Ruffell et al. [50] found feeling overwhelmed, worrying they were a burden to others, and believing that others would see them as 'weak', were significant challenges for men in seeking support. A key challenge for health professionals is to be mindful of the unconscious gendered stereotypes that may exist as a result of socialisation concerning gender and parental roles [55]. Seeking therapy conflicts with masculine norms of self-reliance and can inhibit fathers seeking help and successfully engaging in treatment [58]. Recent evidence highlights the need to develop suitable gender-oriented PMH interventions for men which are sensitive to a father's role [31]. A comprehensive knowledge of paternal PMH needs in health care professionals can help to break down barriers and ensure appropriate referral [59].

Self-Efficacy and Antenatal Education
The results of this review suggest that fathers with FOC often have a poor sense of self-efficacy in relation to childbirth. Increasing childbirth-related self-efficacy through interventions such as antenatal education may improve parents' sense of control and confidence [60][61][62]. Despite the intention to involve fathers during the antenatal period, fathers are often described as having a secondary role during antenatal care and education [63]. Men have described feeling marginalised, invisible, side-lined and ignored during their experience of antenatal care with their partner in what they described as a female-dominated arena [64,65].
This review identifies that some men with FOC are found to avoid antenatal education in an attempt to not increase their fears [40], while, in contrast, other fathers with FOC were found to engage in more frequent antenatal visits compared to fathers without FOC [43]. Calls have been made for antenatal classes specifically for men and that address issues of concern for men as fathers may feel more at ease expressing their fears among an all-male group [2,[66][67][68]. Further research is required to evaluate the effect of co-designed antenatal education specifically for men with FOC [62].
The findings of this review suggest that men underestimate their supportive capabilities and the comfort they are providing their partners. Therefore, health professionals have an important role in engaging fathers in antenatal conversations about their birth expectations, feelings, fears and role in childbirth to alleviate anxiety, increase self-confidence and promote relaxation [12,69]. Effective communication between the mother, father and midwife can make a difference to the level of control and connection that fathers feel at birth, which in turn influences their development of positive or negative birth perceptions [70].
Childbirth can be a time of psychological distress for men with FOC as they attempt to maintain support for their partner whilst managing their own anxiety [9]. Providing fathers with clear communication on the health of their baby and partner, can help alleviate the expectant father's anxiety. A review by Hanson et al. [3] identified that fathers seek reassurance that they are doing the right thing for their partner during childbirth. Positive involvement of men in the perinatal period has the potential to decrease men's anxiety, increase their trust in health professionals and offers them the opportunity to engage in psycho education [12]. Each of these elements helps to strengthen their role as they transition into fatherhood, and ultimately helps to shape the health and wellbeing of the new family. Findings from Greer et al. [41] suggest that some men feel more confident in their ability to support their partner after a CS birth, supporting the argument that men desire a more defined and practical role. In a review of fathers' experiences of childbirth, Dellmann [71] found that providing practical and emotional support to their partner during childbirth alleviated men's feelings of helplessness, making them feel useful and appreciated.
The specific focus of fathers' childbirth-related fears was the most dominant and frequently reported finding across selected studies. Fathers fear most for the health and safety of both their partner and infant during childbirth and this finding is reported consistently across the broader literature [12,21]. Results from three of the review studies suggest that men with FOC perceive childbirth to be risk laden and are more likely to favour the use of medical intervention during labour than men without FOC [11,14,41]. Men are particularly fearful of the risks of childbirth when there is a history of a previous negative birth experience [41]. This is supported by evidence from a large Swedish study of 1105 expectant fathers which found that fathers with a previous negative birth experience were less likely to agree with the statement 'Giving birth is a natural process' and more likely to express a strong preference for birth by CS [72]. This finding needs to be taken into consideration when supporting women requesting a caesarean birth as their request may be influenced by the father's FOC and view that CS is a safer birth option. An intervention that includes the couple may be appropriate in some cases.

Recommendations for Future Research
This review has highlighted a number of areas for further research. Paternal FOC as a construct is poorly defined and future research needs to distinguish between normal levels of fear surrounding childbirth and severe levels of FOC/tokophobia or posttraumatic stress disorders that may be experienced by men. The development of valid, reliable, acceptable and culturally appropriate FOC screening tools specific for men that distinguish between diagnosis are important in order to identify men requiring additional support and to develop and evaluate appropriate psychological interventions. Further investigation is also recommended to identify predicting factors for father's development of FOC, knowledge of which would support those providing antenatal care to target timely assessment, and access to treatment and resources to those most in need of support.
The distinction between primary and secondary FOC in the literature is poor as limited research has explored men's experiences of developing FOC following a previous traumatic birth, miscarriage, stillbirth or neonatal death. Further research is required to establish whether these men with FOC have additional needs to that of men experiencing FOC in other circumstances and findings may be used to inform the development of appropriate care pathways. Currently, in many countries, men are not routinely asked about their fears surrounding childbirth and further co-designed research will need to establish with men the most appropriate and acceptable screening method. Identification of men with FOC will have little success without the availability of evidence-based treatment interventions.

Limitations
Data extraction from the primary studies of this review was complex due to the wide range of variables studied across the multiple reports and was further impacted upon by challenges of discerning pathological FOC from what might be considered normal fears in relation to childbirth. The findings of this review should be interpreted in light of the methodological limitations within the included studies. These include small sample sizes [1,9,16,42] sample bias, and high attrition rates [43,48]. Eight of the studies included only native-speaking participants, therefore excluding participants of other nationalities [4,11,13,14,17,40,46,48]. Including participants from a variety of cultures and nationalities may achieve greater sample diversity and recognises that giving birth in a foreign country may be a risk factor for developing FOC [73]. Research was predominately represented from Western societies which have medically advanced health care and lower obstetric risks than in other parts of the world. Paternal childbirth fears are likely to be experienced differently in countries that have more medical risk associated with childbirth limiting this reviews generalisability [74]. Language bias is present in this review as studies were restricted to those written in the English language only.

Conclusions
This review utilised a systematic and rigorous approach in identifying and examining the current available literature reporting on fathers' experiences of FOC. Non-disclosure of childbirth-related fears is a significant issue among expectant fathers for fear that others would not understand or be dismissive of their fears. Men require opportunities to express their childbirth-related fears and anxieties and to have their fears validated by health professionals. Promoting fathers' childbirth-related self-efficacy through antenatal care and education is recommended to improve fathers' confidence and feelings of preparedness for childbirth. Further research is warranted to explore risk factors for FOC, secondary FOC, outcomes of FOC, screening methods and evidence-based interventions and care pathways for treatment and referral for paternal FOC. This review recommends that a family centred perinatal mental health model is required which focuses on maximising the wellbeing of each parent to facilitate family wellbeing.