The Critical Importance of Fathers

The Story of Fatherhood Research Through the History of one of its Pioneers

The Fatherhood Project is grateful to be collaborating with Milton Kotelchuck, one of the founders of fatherhood research. At a time when few realized it, he perceived fathers as an underappreciated population and understood the value for women and children of fatherhood research. Milt is the Principal Investigator of our recent study on Fathers in Prenatal Care.

Milton Kotelchuck
Senior Scientist of Maternal & Child Health, MGH for Children
Professor of Pediatrics, Harvard Medical School
Director of Research, The Fatherhood Project

 

Fatherhood Research: The Pioneer Days

The story of Milt Kotelchuck’s interest in fathers goes back to his doctoral thesis in 1972. He was studying attachment theory and was interested in the developing relationship between children and their mothers. At the time, attachment theory held that children’s relationship to their mothers was built-in, special, and exclusive. Deciding that was too narrow a view that diminished opportunities for children, he began thinking about where he could study the attachment of children to other people who clearly cared for them.

“It did not seem reasonable that in a world where mothers often die in childbirth that we’d have a species where children can’t adapt to other people,” said Milt.

“I spent many months trying to figure out who these other people could be. Then one day walking down the street I realized that all of these little kids had fathers! They were everywhere, there were lots of them, and this was an interesting topic. I went to the psychology abstracts, which was the bible of the field at the time (it was the internet of the era), and I looked up fathers and infants. There was such little information that I was able to read the entire literature on the topic in a couple of hours, and almost all of it was about father absence. I thought, well a more important element is to study their presence.”

For his PhD thesis, Milt studied the idea of this exclusive love between mothers and infants, by looking at fathers. There had been a famous study previously, nicknamed “The Strange Situation”, which monitored 12 month old children’s reactions as their mother and a stranger walk in and out of a room every couple of minutes. The children in this study were very responsive to their mother in contrast to a stranger. Milt proposed to study the same topic, but to include fathers this time.

He looked at 144 first born children in the Boston area, 12 children at each of 6, 9, 12, 15, 18, and 21 months of age, who remained in a playroom for 36 minutes of observation. He looked at how “the strange situation” played out for the children in all of these different age groups in their relationship to their fathers, their mothers and the strangers. As in the previous study, Milt saw that the attachment to the mother was so powerful that when the mother left the room and only the stranger was left there, the kids all cried. But when the mother walked out of the room and the father was left behind…nothing happened. The children glanced over at the father and continued playing. More importantly for this study, when the father left the room, and the stranger was still there, the children all cried. Their pattern of social development was almost identical in the moms and dads and was totally different than how they responded to the strangers. This meant that maybe attachment wasn’t such an exclusive, built-in, biological phenomena limited to mothers.

“People said that I wouldn’t be able to do this study, and this now goes to why I’m doing my current research. People thought you couldn’t study fathers, that they wouldn’t participate, that they’re not around. Well, they’re actually everywhere. Both parents were delighted to come in. The fathers were clearly involved and the kids clearly were attached to them. The central point was that I’d shown there was infant attachment to fathers.”

“People thought you couldn’t study fathers, that they wouldn’t participate, that they’re not around. Well, they’re actually everywhere.”

Milt went on to do a series of other fatherhood studies, in an era when many others were not looking at fathers. One community that found the work interesting was the custody world, because of the long held belief that attachment was exclusive to the mother.

“For awhile there I was being called to court as the only academic that was willing to testify that little kids actually also love their fathers. I was one of the pioneers of people doing studies on fathers. “

Good News for Women

The results of Milt’s studies had larger implications, too. His work was happening in the era of the women’s movement. His interest in opportunities for women was one of the reasons he began thinking of situations where children related to more than one person.

“My women friends asked me to think about the role of men and fathers in relationship to women and what their roles had to be if attachment was built-in. Attachment theory was being used to justify why women shouldn’t go to work. They needed to be home all the time to help this love grow, and I thought that was very constraining for women. And as it turns out it was also constraining for men.”

Maternal and Child Health

While he never completely stopped studying fathers, Milt’s career took a slightly different turn towards topics around public health, particularly in the Maternal & Child Health field around reproductive health and disparities. Because of his previous work, he often found himself asking where the men were in Maternal and Child Health. Where are the fathers?

“The Maternal and Child Health field is a field that comes out of the women’s movement and social justice for women and children who are historically less empowered in our society. They were not actually that friendly to fathers; it’s not that they were against fathers, they just put their emphasis on mothers and kids.”

The rise of the fatherhood movement

Around 2007, Milt was asked by Dr. Michael Lu (the current head of the Federal Maternal & Child Health Bureau) for his thoughts on whether men’s health in the preconception period makes any difference. Together, they wrote a paper on the impact of men’s preconception health for their future child’s health. Published as part of a set of papers having to do with preconception health in general, it turned out to be the only paper that’s ever been written on this subject.

“I wrote out a series of ideas based on all my experience in Public Health, thinking about fathers; these ideas that I had about fertility, family planning, support of the mother, quality of sperm, serving as a role model, a facilitator, and then ultimately his own health as being impacted by the pregnancy and his own development as a father and as a man. That this transition into parenthood wasn’t only happening to the mother, it was happening to the father. That these are really important events, even in the period just before they got pregnant, as they started thinking about it, and in keeping men involved.

In the 30-40 years since I had started my own research, the fatherhood field continued to develop and research showed more and more ways that men’s early involvement with their children was important. Yet, it’s played out politically in this country with the simultaneous rise of the absence of men in families. So there are now less men around and it turns out they are more important than people had believed.”

The fatherhood movement arose out of efforts to involve men in families. Men’s absence was associated with poverty and dysfunctional families. There were government efforts to increase men’s involvement. President Obama asked the National Institute of Child Health and Development to develop a conference on the subject. NICHD had never done work on fathers before. With the help of the Maternal and Child Health Bureau and the Agency for Youth and Family, they organized a research conference. Milt’s colleague, Dr. Lu, encouraged them to include the preconception health of men and go through the first year of life. Dr. Lu reached out to Milt and asked him to be the keynote and closing speaker of the conference.

“There was a lot of work showing the importance of men in terms of healthy birth outcomes, in terms of language development. It was a very exciting conference, and it re-motivated me.”

Having said that, there’s an amazing amount of resistance to this topic still. It’s hard to get funding, there’s not a lot of initiatives. I know by working in the Public Health Sector, the ways in which public programs encourage or too often discourage fathers’ participation. I once gave a talk called something like “Men/Fathers: Not Welcome Here” about subtle ways our programs discourage men from being involved.”

I once gave a talk called something like “Men/Fathers: Not Welcome Here” about subtle ways our programs discourage men from being involved.”

Joining The Fatherhood Project

It was around this time that Milt met The Fatherhood Project’s Executive Director, Dr. Raymond Levy.

“I called him up and he was interested in one of the problems fathers have, which is that some of them don’t really have the social/relational skills to parent. I was worried that our Maternal & Child Health programs were pushing them away, and he’s thinking about all of the things that they could learn that would actually help them. These were not unrelated topics; these were closely related topics.

This led to the current research (TFP’s Fathers in Prenatal Care study), which grew out of the interest in trying to figure out how we can involve men as early as possible. There’s no doubt that when it comes to engaging fathers, the earlier the better. People don’t realize it, but the dads are already there. They always have been there. They haven’t always been welcome, but they are there. So what can we do, especially in a society that’s got a high number of fathers who leave families?”

Milt and Ray began thinking about how they could look at fathers as early as possible to make the parental bond happen early so it was stronger later. Obstetrics and prenatal care, a field that Milt had expertise in, was an obvious answer. There are virtually no studies in the U.S. looking at men during the prenatal period: what their health needs are, their hopes and their fears for fatherhood.

There are virtually no studies in the U.S. looking at men during the prenatal period: what their health needs are, their hopes and their fears for fatherhood.

The two, along with TFP Director of Programs, John Badalament, approached the nurses from MGH’s Vincent Obstetrics, Hiyam Nadel and her team.

“They were enthusiastic. They too understood that the men showed up. They just had no idea what to do with them. They didn’t have any organized activities as we learned right from the first time we went. They had no pictures of men on the wall, they had no brochures for men. This was like a whole new area of work. But they knew that men were actually involved and did care and did come, and they were interested to think about this and what they could do.”

The Fatherhood Project and Hiyam’s team of nurses began developing a survey that would be conducted over a two week period at Vincent Obstetrics. Targeting fathers attending prenatal appointments, the study looked at a range of ideas about men’s feelings about upcoming fatherhood, their own health, things that they wanted to know and ways they could be helpful or not helpful to their partners. The survey also inquired about the men’s perceptions of Vincent Obstetrics. How were they treated by each person there? Did the staff make eye contact with them? Did they ask them questions?

“It worked better than any of us could possibly have anticipated. We had 401 fathers who participated and answered our survey completely. 401 is a huge number of fathers. It makes this one of the largest father studies in the country. Over 85% of the men who showed up during that 2 week period participated. The study was done in English, Spanish, and Arabic and has a good cross representation of social classes. Not only did we get a high number, we had great enthusiasm. The fathers really enjoyed this. You know, they’re coming to this waiting room, and no one ever really talks to them, and all of a sudden, here’s this team that’s got a sign that says “Fatherhood Survey”. It wasn’t men vs women, it was finally someone recognizes there’s another partner involved in this pregnancy who has concerns, feelings, and needs that could be addressed.”

It wasn’t men vs women, it was finally someone recognizes there’s another partner involved in this pregnancy who has concerns, feelings, and needs that could be addressed.

The Results

Of the men who came there was a high level of joy about being fathers, along with high levels of stress. There were also a substantial amount of health problems: high rates of depression, unplanned pregnancy, obesity and a surprisingly high number of men had nobody who could give them support for being a father. (See more about the survey and its findings here)

The team also looked at subgroups within the survey population, examining data of men that had high levels of education and private health insurance, those who were on Medicaid, those who were of Latino decent, as well as first time fathers versus experienced fathers.

“The nurses loved the findings and then they met to talk about what they could do with this data. They were thinking about the idea of developing a bunch of brochures on various topics for men, to be sure they had pictures up depicting fathers, to make sure they had a place to write men’s names down in their records. One of the thoughts they are thinking of doing is having a depression screening for the men as well as the women.”

Intended as a pilot study, The Fatherhood Project ultimately plans to improve the questionnaire and replicate the study in other settings, such as MGH’s community health centers. Ray and Milt have begun giving talks at conferences to use the results to stimulate more thinking about these issues at health centers and hospitals around the country. The idea is to translate this study into more research and more action.

 

Final Thoughts

“I think of fatherhood research as sort of the arc of my life, I started on this topic, have come back to it, and will continue working on it. I’m very enthused and I do think the world is changing, that there’s a receptivity to this topic that hasn’t been there before.”

“I think of fatherhood research as sort of the arc of my life, I started on this topic, have come back to it, and will continue working on it. I’m very enthused and I do think the world is changing, that there’s a receptivity to this topic that hasn’t been there before.”