Authors
- SmithBattle, Lee PhD, RN
- Phengnum, Wisitsri MSN, RN, NNP
- Shagavah, Anne Winnie MSN, RN, FNP-BC
- Okawa, Satoko PhD, RN
Abstract
Background: Although teen fathers are a vulnerable group of parents, they have received far less attention than teen mothers.
Purpose: We conducted a systematic search of qualitative studies that examined their prenatal and postpartum experience to better understand teen fathers' concerns, strengths, and vulnerabilities.
Methods: We searched nine electronic databases through September 2017; 29 studies represented in 30 articles met study criteria. All authors independently extracted data from each article. Coding decisions were reviewed weekly and differences were settled by consensus.
Results: From pooling the results of 29 primary studies, we describe how a tenuous ground contributes to teen paternity and imperils young fathers' involvement with their children. In the best of circumstances, the ground begins to stabilize for teens who become involved parents despite significant challenges and hardships.
Clinical Implications: Our results contribute to the visibility of teen fathers and the social disparities that imperil fathering. We provide clinical guidance for strengthening the ground for teen fathers and their families, recognizing that clinicians often encounter challenges such as interpersonal factors and sociocultural conditions that systematically erode fathers' ties to their children, partners, professional caregivers, and institutions.
Article Content
Background
Despite a steady decline in the birth rate for teens of both sexes, the United States has the highest rate among developed countries (Martin, Hamilton, & Osterman, 2018; Sedgh, Finer, Bankole, Eilers, & Singh, 2015). Until recently, teen mothers have received far more attention than teen fathers; the relative invisibility of fathers contributes to the stereotype that teens are irresponsible or absent fathers (Kiselica & Kiselica, 2014).
Because fathers' age and race are often underreported on birth certificates for unmarried or teenaged women, accurate numbers of teen paternity are difficult to come by. A recent report estimated that the U.S. fertility rate for males aged 15 to 19 in 2015 was 12.3 per 1,000, which represented an 8% decline from 2014 (Martin et al., 2018). Another study reported that 48% of teen fathers were White, 29% Black, 19% Hispanic, and 4% other (Scott, Steward-Streng, Manlove, & Moore, 2012); the majority (66%) had their first child at age 18 or 19. Few teen fathers (8%) married and the majority (56%) were not living with the child's mother at birth. Marriages increased to 26% by age 24, and close to 50% were living with at least one of their biological children. Almost 50% of teen fathers had additional children by age 24, and 9% had additional children with more than one woman which is referred to as multipartner fertility (Scott et al.).
Teen fathers are a vulnerable group of parents because they are disproportionately disadvantaged and of color (Mollborn & Lovegrove, 2011). Although teen fathers are less likely to be married and more likely to be cohabiting or nonresident than older fathers, attitudes and levels of paternal involvement do not differ by age (Mollborn & Lovegrove), and over the first 8 years, a majority of teen mothers' children (59%) had consistent father contact (Howard, Lefever, Borkowski, & Whitman, 2006). Teen fathers who were younger; Puerto Rican; raised without fathers; no longer intimately involved with mothers of their children; or more disadvantaged were less likely to be involved (Wilkinson, Magora, Garcia, & Khurana, 2009).
Although teen parents rarely marry, paternal involvement remains important for children regardless of paternal age. Research is limited but partner support contributed to positive birth outcomes for teen mothers (Shah, Gee, & Theall, 2014), promoted maternal identity (Mallette, Futris, Brown, & Oshri, 2015), and protected children from the impact of maternal depression (Lewin et al., 2015; Smith, Grau, Duran, & Castellanos, 2013). Teen fathers' children fared worse on behavioral and cognitive measures at age 2 than children of older fathers but differences were attributed to young fathers' greater disadvantage (Mollborn & Lovegrove, 2011). Children with more father contact had better socioemotional and academic outcomes at 8 and 10 years, even when teen fathers did not reside with the child (Howard et al., 2006). Given the significance of fathers for children, the purpose of this meta-synthesis was to describe teens' path to paternity and their experience of fathering.
Methods
A meta-synthesis begins with a comprehensive search to identify relevant studies. The findings of primary studies are treated as "data" and analyzed to create a more holistic interpretation of a phenomenon (Sandelowski & Barroso, 2007). For this review, teen fathering was defined as any male below the age of 20 who is a father or expectant father. Eligible studies included: (1) primary research with expectant or teenage fathers; (2) qualitative, quantitative, and mixed-methods studies; (3) published in English; and (4) conducted in countries with advanced economies, as defined by the International Monetary Fund (April, 2016). We limited the search to these countries to enhance the generalizability of findings to the United States. Research that included samples with teen and older fathers were included only if results were specified for teen fathers.
A systematic literature search of nine electronic databases was conducted through September 2017 with the assistance of a medical librarian (Figure 1). Search terms included: "teen father*" or "adolescent* father*" OR ("adolescent pregnancy" AND father*). The search yielded 2,960 articles; 1,776 citations remained after duplicates were removed. Review of titles and abstracts yielded 347 articles. The team then reviewed full-text qualitative (n = 74) or mixed-methods (n = 11) studies; 29 studies represented in 30 articles met study criteria. In our initial reading of articles, we identified six codes that represented major findings across studies. They include Challenges, Barriers, and Constraints for Fathering; Supports for Fathering; Fathering Responsibilities; Meanings of Fathering; Stigma; and Path to Pregnancy and Paternity. All authors independently extracted data from each article and placed data in a matrix table. Coding decisions were reviewed in weekly meetings and differences were settled by consensus.
Results
The final sample included 29 studies represented in 30 articles on teen fathering (Table 1). A majority of the studies originated in the United States (n = 17, 58.6%): the remaining studies were conducted in the United Kingdom (6), Canada (2), Australia (1), New Zealand (2), and Sweden (1). Study participants were recruited from community centers (n = 11), the justice system (n = 6), high schools (n = 5), health clinics (n = 3), youth centers (n = 2), and by radio (1). Two studies did not identify recruitment sites, and one author accessed data from the internet blogs of teen fathers. Qualitative approaches included phenomenology (3), grounded theory (3), narrative (4), and content analysis (2); seven studies used other approaches. To assure completeness, we included all eligible studies without regard to their quality, as low-quality articles may have some clinical utility.
The total number of teen father participants in pooled studies was 470; 296 were from the United States and 174 from other developed countries. The number of teen fathers per study ranged from 5 to 38. Four studies recruited expectant fathers only; 5 included expectant and fathering teens; 5 followed youth from pregnancy to postpartum; and 15 studies (51.7%) sampled teen fathers exclusively. Socioeconomic status of the fathers was rarely reported but most appeared to be low-income and urban. The first study was published in 1983; research increased substantially after 2005.
Seven non-U.S. studies did not report participants' race. Studies from the United States included teen fathers who were Black/African American (133), followed by Latino/Mexican (67), White (60), Mixed or Biracial (18), and Native American. The samples for 16 of the 29 studies (55.2%) included teen fathers and other participants, including teen mothers (s = 7); grandparents of the child (s = 2); teens who were neither expectant nor teen fathers (s = 2); older fathers (s = 6); and professionals or service providers (s = 2). (Numbers do not add to 16 because some studies included several types of informants.)
Findings
The path to paternity and the enactment of fathering for the mostly disadvantaged participants occurred on tenuous ground. The ground appeared to stabilize for teens who embraced fathering. This metaphor gives attention to the vulnerabilities of teen fathers vis-a-vis their children, the mothers of their children, clinicians, and services, and also highlights how the possibilities for fathering are grounded in the interpersonal and social realities in which a father finds himself. Teen fathers cannot create a more hospitable ground on their own when grim childhoods and traumatic experiences are rooted in toxic environments that shape the ways of being a man or a woman, and a mother or father. Although pregnancy and parenting may introduce new meanings and priorities, these new possibilities depend on interpersonal support and material resources. For example, even if magically transplanted to a middle-class neighborhood, a low-income teen lacks the experiences, skills, and economic resources that structure fathering for middle-class parents.
A Shaky Ground Permeates Childhood
A shaky ground is apparent in expectant teen fathers' accounts of sex and pregnancy. In the context of hard childhoods, bleak futures, and transient relationships, prospective fathers typically deferred to partners to prevent pregnancy (Dallas & Chen, 1999; Jaime, Robbins, & De Los Santos, 2015; Tyrer, Chase, Warwick, & Aggleton, 2005; Weber, 2012), and condom use was sporadic (Tyrer et al.; Weber). Upon learning of pregnancy, prospective fathers reported excitement, anger, or ambivalence (Anderson, 1990; Deslauriers, 2011; Leite, 2007; Shade, Kools, Pinderhughes, & Weiss, 2012; Tyrer et al.; Wilkes, Mannix, & Jackson, 2012). Those who rejected fatherhood doubted the unborn baby was theirs or blamed the partner for "trapping" them (Leite; Paschal, Lewis-Moss, & Hsiao, 2011). Teens who accepted paternity were often in lengthier relationships, and deferred to their partners to continue or terminate the pregnancy (Buston, 2010; Deslauriers; Wilkes et al.). The impending birth motivated them to reduce risky behavior, improve their education, or make lifestyle changes. Fathers described the importance of making sacrifices to become better fathers than their fathers had been to them. Given few opportunities to continue their education or find work, fathering introduced purpose and meaning that had been largely absent in their lives (Meek, 2011; Paschal et al.). Without skills or resources to support a child, they often felt ill-prepared for fathering and expressed concerns about the challenges that lay ahead (Jaime et al.; Weber; Wilkes et al.).
The Ground Shifts to Strengthen or Imperil Fathering
As the birth approached, an anticipated relationship with the child shifted the ground beneath them (Jaime et al., 2015; Johansson & Hammaren, 2014; Reeves, 2006). Fatherhood provided a new identity (Frewin, Tuffin, & Rouch, 2007) anchored by the responsibilities of nurturing the child and providing financially for the child (Dallas, Wilson, & Salgado, 2000). Being a nurturing presence meant spending time with the child, avoiding their parents' example (e.g., alcohol abuse, child abuse), shielding the child from bad influences, and improving their own lives (Anderson, 1990; Lemay, Cashman, Elfenbein, & Felice, 2010; Meek, 2011; Tuffin, Rouch, & Frewin, 2010). Being an involved father was very salient for young men whose fathers had been abusive or absent in their lives. Taking up paternal responsibilities offered a way to distinguish themselves from their fathers (Allen & Doherty, 1996; Jaime et al.; Negura & Deslauriers, 2010; Reeves; Shade, Kools, Pinderhughes, & Weiss, 2013). Providing material goods that they lacked as a child was another marker of fathering and was consistent with partners' expectations (Meek; Shade et al., 2012). They provided diapers, food, and clothing by doing odd jobs, working part time, or from illegal activities (Allen & Doherty; Jaime et al.; Paschal et al., 2011; Tuffin et al.). Those with full-time jobs found that physically demanding, low-skill work interfered with caring for the child (Tuffin et al.). Teen fathers from earlier generations, who typically married their pregnant girlfriends, became the family breadwinner while mothers became full-time homemakers (Elster & Panzarine, 1983; Formby, Hirst, & Owen, 2010).
As challenges far outweighed support, fathers' aspirations to be involved fathers and economic providers were often thwarted. Few identified paternal role models, supportive partners, or close family ties (Barker, 1998; Reeves, 2006; Shade et al., 2013; Shannon, 2007). As they rarely resided with the child, they depended on the mother's (and her mother's) good graces to see the child. Mistrust often pervaded these relationships and was exacerbated by fathers' limited financial contributions. When relationships dissolved, mothers had the power to exclude them from seeing the child. It was the rare father who knew how to establish paternity (Dallas et al., 2000) or obtain joint custody (Jaime et al., 2015). Fathers were also rarely acknowledged as the father by professionals (Dallas, 2009; Formby et al., 2010; Smith, 2010). They were further marginalized by pejorative media stories and biases that favored mothers at their expense (Allen & Doherty, 1996; Tyrer et al., 2005). When teen fathers were excluded from parenting, subsequent pregnancies with another partner were fairly common within 2 years of a first birth (Dallas, 2013). Having another child with a new partner revived young men's hopes to be an involved father while eroding emotional and financial commitments to the prior child.
Teen fathers recruited from the justice system also described fathering as a potential catalyst for improving their lives and avoiding future criminal activity (Anderson, 1990; Shannon, 2007). Their childhoods were particularly grim; they grew up in neighborhoods where drugs, unemployment, and crime were widespread (Meek, 2011). Teen fathers reported chaotic families and exposure to substance abuse, chronic poverty, and life-threatening situations. Antisocial behavior of some youth included contempt for girls and women (Shade et al., 2012). Some preferred a son who would need fathers' guidance for surviving the streets, and daughters needed their protection from predators (Shade et al., 2013).
Paternal identity offered an alternative to a criminal career (Meek, 2011). Those who succeeded in connecting to their children upon release from the justice system credited their paternal responsibilities for desisting from criminal behavior and avoiding crime-involved peers (Wilkinson et al., 2009). In rare cases, mothers supported the father's connection to the child upon release. More commonly, fathers' hopes to connect with the child were dashed when the child's mother rebuffed him or her whereabouts were unknown. Fathers' hopes were also foiled by their inability to support the child (Shannon, 2007). Some incarcerated fathers were fatalistic about connecting with their children (Wilkinson et al.) and expressed regrets for past behavior (Parra-Cardona, Sharp, & Wampler, 2008) and disconnection (Shannon).
Discussion
This study synthesizes the findings from 29 studies that generally complemented each other; variations in study aims, sample characteristics, and time periods added social and historical context to our interpretation. For example, the study by Elster and Panzarine (1983) underscored how the social landscape for teen sex, pregnancy, and parenting has changed. Expectant teen fathers were White, middle-class, and had dated partners for at least 14 months; more than half (58%) reported that pregnancy was expected; and 75% married prior to the birth. Marriages to legitimize a premarital pregnancy are now rare, and births are less prevalent among middle-class teens who avoid pregnancy to protect their future. Their success is based on having access to birth control methods, abortion, college, and careers. In contrast, low-income teens are more likely than middle-class peers to engage in unprotected sex, reject abortion, and choose motherhood in the event of pregnancy (Mollborn, 2017).
Despite the best of intentions, a shaky ground permeates and imperils paternal involvement for teens who are marginalized by poverty and traumatized by adverse childhood experiences (ACEs). The landmark ACE study suggests that teen and adult males with more ACE are at greater risk of impregnating a teen (Anda et al., 2002). Although childhood exposure to toxic environments was notable across primary studies (Barker, 1998), difficult childhoods were especially prevalent among teens recruited from the justice system (Shade et al., 2012).
Contemporary teens are unlikely to marry or reside with the child's mother before the birth. Male youth who are contemptuous of girls, and women tend to reject paternity (Shade et al., 2012). When accepted, fathering offers an identity when other paths to adulthood are restricted. A shaky ground persists; fathering is difficult to enact when involvement is contingent on mothers' gatekeeping and fathers' ability to provide financial support, especially when their relationships are plagued by mistrust and couples lack skills for de-escalating conflicts that are exacerbated by the stress of poverty (Barker, 1998; Sherman, 2016). Mistrust also saturates fathers' relationships with services that are fragmented or biased against fathers and coparents (Dudley, 2007; Mollborn & Jacobs, 2015). For men of color, paternal responsibilities are also constrained by systemic injustices that infuse educational (Siegel-Hawley, Diem, & Frankenberg, 2018), housing (Rothstein, 2017), and criminal justice systems (Wildeman & Wang, 2017).
Paternal involvement becomes even more complex when either parent has subsequent children with new partners (Tach & Edin, 2011). Fathers' imprisonment is a strong predictor of multipartner fertility and has increased dramatically with the mass incarceration of men of color (Wildeman & Wang, 2017). Mass incarceration is largely due to changes in policing, not to increased criminality (Wildeman & Wang), and is harmful to family formation (Cancian, Chung, & Meyer, 2016) and child well-being (Turney & Lanuza, 2017).
Strengths and Limitations of this Review
This study brings visibility to a stigmatized group of parents. Despite an extensive search, we may have missed some studies. In the studies reviewed, disadvantaged, urban youth of color were overrepresented, whereas the voices of rural and middle-class teens were largely missing. The near exclusion of the latter groups oversimplifies a complex issue. Including diverse participants in future studies is a high priority for understanding how interpersonal relationships and structural inequalities contribute to teen paternity, and how the aspirations of diverse teen fathers are achieved or thwarted.
The majority of primary studies were cross-sectional and rarely included couples. Including couples in the same study, and following both parents from pregnancy on would more fully capture how couples negotiate decisions related to contraception, breastfeeding, child health, and paternal involvement; and how they manage stress and conflicts (Mollborn & Jacobs, 2015). Unpacking these issues would help to strengthen clinical care and improve coparenting interventions (Florsheim et al., 2012) so they are consistent with young couples' strengths and vulnerabilities.
Few studies explored teen fathers' perspectives on childhood trauma even though depression is more prevalent among younger than older fathers (Lee, Fagan, & Chen, 2012), and high ACEs are associated with teen paternity (Anda et al., 2002). With the exception of the study by Barker (1998), fathers' perspectives on intimate partner violence (IPV) received little attention. Although the majority of pregnant teens and their young partners (64%) do not report IPV, clinicians should be aware that 23% report male IPV victim only; 7% report mutual IPV; and 5% report female IPV victim only (Lewis et al., 2017, p. 26). These distinctions merit further study if clinicians are to intervene effectively.
Clinical Implications: Shoring up Shaky Foundations
Despite declining rates, teen pregnancies and births remain a public health issue. Reducing teen fertility further will be difficult to achieve as long as the United States rejects evidence-based policies (e.g., medically accurate sexual health education and low-cost, confidential contraception) (Charo, 2017; Packham, 2017; Santelli et al., 2017) that are common in countries with low teen birth rates (Sedgh et al., 2015). Preventing teen births also requires mitigating high rates of U.S. poverty that lead disadvantaged and disaffected youth to "drift" into parenting in search of meaning and fulfillment (Smith, Strohschein, & Crosnoe, 2018).
Some teen fathers will reject paternity, but those who yearn to be involved should be welcomed to perinatal and pediatric care. By respecting and validating their aspirations to be responsible, nurses strengthen the ground for fathering and support the couple in making decisions that foster a healthy pregnancy and child well-being, including decisions related to contraception and breastfeeding. Supporting coparenting, even after relationships dissolve, may also deter young fathers from having another child with a new partner to replace the first.
To mitigate harmful stereotypes and gender biases, clinicians would benefit from training on father-friendly services and knowledge of teen fathers' strengths and vulnerabilities (Dudley, 2007; Kiselica & Kiselica, 2014). Because health outcomes are many times determined by individual and social factors, addressing teen parents' social vulnerabilities may be furthered by a medical home model (Cox, Buman, Woods, Famakinwa, & Harris, 2012) or case management services (Kiselica & Kiselica) to improve parents' access to educational and vocational opportunities, mental health and substance abuse care, legal and housing assistance, and gang desistance programs. Comprehensive care is crucial because few programs target teen fathers, and those serving teen mothers rarely reach out to fathers (Kiselica & Kiselica). Group prenatal care should also be considered based on growing evidence of its effectiveness in improving teen mothers' outcomes (Trotman et al., 2015). Including fathers is indicated because those who attended at least one group session were reported by the teen mother to be more emotionally and financially supportive (Smith, Buzi, Kozinetz, Peskin, & Wiemann, 2016). Education on trauma-informed care is recommended (Substance Abuse and Mental Health Services Administration, 2014). Teen fathers may need referrals to primary care and subsidized health insurance.
Our meta-synthesis expands upon qualitative findings to show how a tenuous ground permeates and imperils paternal involvement for teens. An unstable ground sets the conditions for youth to "drift" into paternity, and makes fathering difficult, but not impossible. Clinicians contribute to a more stable ground when they include teen fathers in care and coordinate with multidisciplinary services to address their social vulnerabilities. These efforts are crucial for interrupting gendered stereotypes and the social inequities that erode teen fathers' ties to their children, partners, clinicians, and health and social institutions.
Clinical Implications
* Nurses strengthen the ground for fathering by welcoming fathers to clinical appointments and supporting young couples to make decisions that foster healthy pregnancies and child well-being.
* Nurses validate teen fathers' aspirations by noting the importance of fathers in children's lives.
* Clinicians would benefit from education on father-friendly services, motivational interviewing, and knowledge of teen fathers' strengths and vulnerabilities.
* Improving health outcomes for teen parents and their children requires multidisciplinary models of care that address their social vulnerabilities.
* Screening teen fathers for depression and childhood trauma should be considered after clinicians receive education on trauma-informed care.
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Fathering on Tenuous Ground
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