Black Fathers’ Involvement in Maternal and Child Health Services During COVID-19: A Qualitative Study of Black Fathers’ Perspectives

Black Fathers’ Involvement in Maternal and Child Health Services During COVID-19: A Qualitative Study of Black Fathers’ Perspectives | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Black Fathers’ Involvement in Maternal and Child Health Services During COVID-19: A Qualitative Study of Black Fathers’ Perspectives Latrice Rollins, Tiara Giddings, Geoffrey Brown, Jennifer Elliott, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7835411/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Previous research has shown that maternal and child health services often overlook fathers, even though evidence indicates that father involvement can reduce maternal and infant mortality. We examined the experiences of new and expectant Black fathers and how COVID-19 affected their participation in health services. Two focus groups, involving a total of 15 fathers, were conducted. Participants were asked about the communication they received regarding COVID-19 policies related to their involvement in maternal and child health services, their thoughts and feelings about these policies, and how these policies have influenced their relationships with their partners and children. Each two-hour focus group was facilitated via Zoom, recorded, and transcribed. Several fathers reported that they were unaware of COVID-19 policies or were not permitted to participate in maternal and child health services, such as prenatal appointments and labor/delivery. Fathers also reported how systemic racism and stereotypes impacted their experiences with these services. These findings highlight the need for improved communication and more father-inclusive practices in maternal and child health, even during emergency responses. Effective father-inclusive practices adopt a family systems approach that involves both mothers and fathers in education and services, ensures that clinical environments are welcoming to fathers, provides literature tailored to fathers, and utilizes mobile technology to engage fathers. father involvement Black maternal mortality COVID-19 father-inclusive practices Highlights • Despite research demonstrating that father involvement reduces maternal mortality rates, fathers often face barriers to engaging in maternal and child health services. • The COVID-19 pandemic caused hospitals and providers to implement companion policies and procedures that further prevented fathers from engaging in these services. • This article draws attention to the obstacles that were created during the COVID-19 pandemic for father involvement and the need to eliminate these barriers, generally, and during emergency response. • This article serves as a call to action for maternal and child health services to embrace father-inclusive practices, specifically for Black fathers. Introduction Fathers play a vital role in maternal and child health (MCH), supporting children’s physical, emotional, and social development at all stages (Cabrera et al., 2018; Lee et al., 2021). However, Black fathers have historically been marginalized in research, practice, and policy, often depicted through deficit-based narratives that can obfuscate their resilience and contributions to children and families (Garfield et al., 2019; Rollins, 2020; Roberts, 2025). This invisibility not only sustains harmful stereotypes but also leads to gaps in services that do not meet fathers’ specific needs. The COVID-19 pandemic highlighted existing inequalities in health and social systems, with Black communities bearing the heavier burdens of illness, economic struggles, and death (Tai et al., 2021; Egede & Walker, 2020). For Black fathers, these disparities intersect with systemic obstacles like unstable jobs, excessive policing, and limited access to culturally sensitive mental health services, increasing stressors that hinder their ability to parent effectively (Gee & Ford, 2021; Heard-Garris et al., 2022). Despite these challenges, research shows that Black fathers’ involvement supports maternal health, improves birth outcomes, and boosts children’s cognitive and emotional growth (Cabrera et al., 2018; Osbourne et al., 2022). Black fathers also play a crucial role in intergenerational resilience by promoting family cohesion and protecting children from the harmful effects of racial discrimination (Anderson et al., 2022). However, few policies and interventions have focused on fathers, especially fathers of color, as key stakeholders in promoting health and equity. Advancing health equity in MCH requires explicitly centering Black fathers, not only in research but also in service delivery and policy innovation. Thus, we examined the implications of COVID-19 policies and procedures for Black fathers, highlighting structural determinants shaping father engagement, and proposing equity-centered pathways for integrating fathers into the design of future MCH systems. The Importance of Prenatal Father Involvement Although parenting research has traditionally concentrated on the maternal role, recent decades have seen a surge in studies examining the role of fathers in infant and child development (Schoppe-Sullivan & Fagan, 2020). This shift partially results from increased maternal employment compared to earlier generations, more egalitarian attitudes toward gender roles and household responsibilities, and a broader acknowledgment that fathers can provide sensitive and competent care from early infancy (Cabrera et al., 2018). Overall, research on fathering suggests that fathers’ positive involvement is linked to numerous beneficial outcomes across socio-emotional, cognitive, and physical health areas (Chang et al., 2020; Sarkadi et al., 2008; Walsh et al., 2021). Additionally, the advantages of engaged fathering are evident among both residential and non-residential fathers (Adamsons & Johnson, 2013). For many fathers, supporting their child and the child’s mother begins during the prenatal period. Involvement in prenatal care for expectant fathers can include various activities, such as attending doctors’ visits and ultrasound appointments, being present for birth, planning and making decisions about post-birth childcare and financial support, and providing emotional support to the mothers (Meier & Avillaneda, 2015). Overall, fathers who are more invested and involved before birth tend to be more engaged with their children post-birth (Aytuglu et al., 2025; Fagan, 2014; Witte et al., 2020; Zvara, 2013). Although most men participate in some way, Black fathers face several challenges that can impact their involvement during pregnancy and childbirth. Still, the experiences of young Black fathers during these times are not well understood. Additionally, a family systems theoretical framework guides this study’s expectation that paternal involvement is connected to maternal and child health outcomes. According to family systems theory (Cox & Paley, 2003), all individuals and relationships within a family are interconnected, and family transition points like the transition to parenthood provide opportunities for these relationships to reorganize in positive ways. Therefore, fathers’ engagement in prenatal care is likely to improve the quality of the couple and coparenting relationship with the child’s mother, which can lead to benefits for both child development and healthy relationship functioning after birth. Evidence indicates that most fathers’ contributions to child development during pregnancy mainly occur indirectly through support for the mother and enhanced couple relationship functioning (Cardenas et al., 2021). Additionally, recent ecological models of fathering suggest that father involvement partly depends on personal developmental histories and the specific environmental contexts in which fathers live (Cabrera et al., 2014; Palkovitz, 2018). The experiences of Black fathers may include both personal experiences of racial discrimination and marginalization from systems, such as healthcare and medical settings, that are often ill-equipped to meet fathers' needs. Consequently, the difficulties fathers encounter in supporting mothers and children during the prenatal period may be intensified within this population. The Role of Fathers in Black Maternal Health Well-documented racial disparities in the health of Black mothers and infants are rooted in social determinants shaped by systemic racism in the United States (Owens & Fett, 2019). Public policy and social structures based on racial discrimination and gender oppression have disproportionately impacted Black mothers and infants (Crear-Perry et al., 2020), leading to significant inequities in health outcomes such as maternal and infant morbidity and low infant birthweight (Bisson et al., 2022; Hailu et al., 2024; Kirby, 2017; Njoku et al., 2023). Notably, Georgia consistently ranks among the states with the highest maternal mortality rates, with Black mothers being disproportionately affected (Armstrong-Mensah et al., 2021). Therefore, policies and practices aimed at addressing the health needs of Black women in Georgia during prenatal and neonatal periods can have meaningful public health impacts. One protective factor that has received little attention is the role of the father in prenatal maternal health for Black women and their infants. An expanding body of research highlights fathers’ ability to support maternal health during pregnancy and childbirth across different racial and ethnic groups. Overall, fathers’ prenatal involvement can promote healthier maternal behaviors and improve family functioning (Fagan, 2014; Rollins et al., 2024). For example, one study found that partner influence was associated with lower maternal depressive symptoms and reduced alcohol use, which in turn was linked to better infant mental and psychomotor development (Kautz-Turnbull et al., 2021). Prenatal involvement has also been shown to weaken the connection between risky life history factors and both harmful parenting practices and couple conflict (Sayler et al., 2022). In a nationally representative sample of US parents, fathers’ involvement during pregnancy increased the likelihood of mothers seeking prenatal care in the first trimester and decreased cigarette smoking (Martin et al., 2007). Similarly, a cohort study in the UK found that mothers were less likely to smoke during pregnancy and more likely to start breastfeeding when they were closely connected to the child’s father (Kiernan & Pickett, 2006). Evidence from basic research and interventions indicates that fathers’ support for breastfeeding during prenatal and early postpartum periods is associated with higher rates of breastfeeding initiation and continuation (Hosking et al., 2025; Mitchell-Box & Braun, 2013). The advantages of fathers’ prenatal involvement may also benefit infant health outcomes, such as reducing risks of premature and low birthweight (Alio et al., 2010b). Although Black fathers are less likely than fathers from other racial or ethnic groups to be married or to regularly live with their children, most Black men are deeply committed to their parenting role during pregnancy and stay involved in their children’s lives in various ways after birth (Jones & Mosher, 2013). Black fathers who participate during pregnancy are also much more likely to stay engaged during infancy and early childhood (Aytuglu, 2025; Fagan, 2014; Cabrera, Fagan, & Farrie, 2008), suggesting that prenatal involvement can have long-term effects on the father-child relationship and future child well-being. Additionally, unmarried Black fathers present at their child’s birth are more likely to remain active in many aspects of parenting two years later (Bellamy, Thullen, & Hans, 2015). Importantly, the connection between prenatal and postnatal involvement also influences health-related parenting behaviors, with prenatal father involvement linked to fathers' participation in child health care and health decision-making (Zvara et al., 2013). Overall, these findings support the idea that encouraging paternal involvement during the prenatal period can help foster healthy early development and reduce health disparities among infants born to Black mothers. Fathers’ Exclusion and Inclusion from MCH Services Despite being historically overlooked, a variety of professional organizations have called for revising policies and practices in maternal and child health to promote fathers’ participation in pregnancy and childbirth. Recognizing and defining fathers’ optimal roles during pregnancy is also essential for developing interventions that maximize positive birth outcomes (Alio et al., 2013). Moreover, the integration of fathering initiatives into existing programs during pregnancy among African American communities has been identified as a particularly important priority area for promoting maternal health (Alio et al., 2011). This integration requires not just the commitment of fathers themselves, but intentional and systemic support from healthcare professionals. This includes support and provision of information from OBGYNs, pediatricians, nurses, midwives, and other hospital staff, as well as comprehensive reviews of administrative and logistical policies in healthcare settings (Poh et al., 2014a; Yogman et al., 2016). However, many fathers report a litany of barriers and mixed feelings toward their participation in the pregnancy and childbirth process. In general, reviews of fathers’ experiences suggest that most men have a strong desire to be informed and involved in pregnancy and childbirth but require support from partners and professionals to do so (Poh et al., 2014b). Despite these desires, fathers also face numerous impediments, including a lack of information regarding pregnancy, labor and delivery, and proper preparations for the transition to parenthood (Xue et al., 2018). As a result, many men have a sense of being marginalized in their parenting role, and can feel excluded, fearful, and unprepared for the challenges of pregnancy, childbirth, and parenting (Steen et al., 2012). Although many new fathers report feelings of fear and anxiety around the birth of a child (Moran et al., 2021), many also report a strong desire for knowledge, preparation, and guidance, as well as answers from healthcare providers that will help them fulfill a supportive role during pregnancy (van Vulpen et al., 2021). Among Black fathers, these mixed emotions, a desire for more information, and feelings of frustration might be further exacerbated. Young, Black fathers in particular report some supportive interactions with healthcare professionals during pregnancy and the newborn period, but also neutralizing and distancing interactions that may have negative consequences for their engagement and subsequent maternal health (Dallas, 2009). Some Black fathers experience mistrust of healthcare providers during the pregnancy and labor and delivery process, mainly stemming from a sense of not being integrated and receiving insufficient information (Edwards et al., 2020). Even when Black fathers do receive pregnancy information and resources from healthcare professionals, they still report limited opportunities for “trial and error” in terms of opportunities to provide maternal support prenatally and childcare postnatally (Allport-Altillo et al., 2020). Taken as a whole, it seems likely that many expectant Black fathers may experience some sense of dissatisfaction with their treatment in the healthcare system. The Impact of COVID-19 on Paternal Support for Black Maternal and Child Health For Black mothers expecting a child during the COVID-19 pandemic, the typical challenges of pregnancy and childbirth have intensified. Within the United States, Black individuals and communities have been hardest hit by the effects of the pandemic, thus widening pre-existing inequalities by race and ethnicity (Van Dorn et al., 2020; Yancy, 2020). Particularly stark disparities have emerged for Black women (Obinna, 2020), including increased complications in pregnancy and childbirth (Dashraath et al., 2020) and an emerging epidemic of mental health problems among expectant and new mothers (Molgora & Accordini, 2020). In the context of the COVID-19 pandemic, understanding how Black maternal health can be best supported by fathers, particularly during emergency response, is critical (Lemke et al., 2020). Paternal support is one factor that can help to mitigate maternal health problems associated with COVID-19 (Molgora & Accordini, 2020). Nonetheless, for men already experiencing ambivalence, mixed signals, and incomplete support for their involvement in pregnancy and childbirth, the effects of the pandemic amplified these challenges. Although practices vary widely across settings and providers, numerous policies were put in place prohibiting fathers’ participation in the labor and delivery process. Though well-intentioned, many of these policies were not evidence-based and may have played a role in further marginalizing fathers from both mothers and children, thus jeopardizing the health of both (Sacks et al., 2020). For instance, many future fathers were not allowed to attend ultrasound screenings, others were not allowed in the delivery room during birth, and hospital visits even in the maternity ward, were limited (Davis-Floyd et al., 2020; Gressier et al., 2020). Whereas some new and resourceful methods of connecting with fathers virtually in the perinatal period were developed throughout the pandemic (Pasadino et al., 2020), many safety precautions initiated during this period placed new barriers in the way of fathers’ support. Indeed, many fathers reported that organizational changes to prenatal healthcare delivery as a result of the pandemic limited their engagement and resulted in increased stress and isolation during pregnancy (Poulos et al., 2022). The Present Study The consequences of the COVID-19 pandemic exacerbated health disparities among Black mothers and infants. Despite the benefits to mothers during pregnancy and the early postnatal period, substantial impediments to fathers’ participation mounted during this period. Nonetheless, the experiences of Black fathers within the maternal and child health system during COVID-19 were not adequately considered. Thus, we share Black fathers’ experiences navigating the demands of a global pandemic while also attempting to support maternal prenatal health and childbirth within systems that already minimize their contributions to maternal and child health. Through qualitative interviews with two groups of Black fathers in Georgia, both structural barriers to paternal involvement and the emotional experiences of new and expectant Black fathers were explored. Specifically, we sought to answer the following questions: 1. What were Black expectant fathers’ experiences with healthcare systems during COVID-19? 2. What were Black expectant fathers’ perceptions of the COVID-19 companion policies? 3. How did COVID-19 companion policies affect Black expectant fathers’ involvement in prenatal services? 4. What did fathers recommend healthcare providers do to engage them in maternal and child health? Methods This study was conducted as part of a [Institution] T x TM Pilot Project, in partnership with the Georgia Department of Public Health (GA DPH) - Maternal and Child Health (MCH)’s Strong Fathers, Strong Families Georgia Coalition (The Coalition). Coined and patented at [Institution], T x TM is a scientific philosophy that intentionally promotes and supports interdisciplinary collaboration to advance health equity (Akintobi et al., 2019; Holliday et al., 2023 ). This pilot project focused on assessing the father-friendliness of maternal and child health partner agencies and the needs of new and expectant Black fathers. In 2019, Georgia Department of Public Health (GA DPH) established the Strong Fathers, Strong Families Georgia Coalition to develop and drive Georgia’s collective impact approach towards father engagement as a strategy to address infant and maternal mortality. The Coalition was an interdisciplinary team comprised of father- and family-serving agencies and organizations including state and local government : GA DPH, Georgia Department of Human Services, Cobb-Douglas County Health Department, Columbus (Muscogee County) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); academic partners : [Institution] Prevention Research Center and the University of Georgia Center for Family Research; and community-based, health services partners : Georgia Healthy Start Collaborative, Center for Black Women’s Wellness (CBWW), and TIME-ER Consulting (community-based fatherhood program). For this T x TM pilot project, a clinical services partner, the Centering Pregnancy (CP) program at Grady Public Hospital, was also included. Using a community-based participatory research and collective impact approach, the Coalition was involved in all phases of the pilot project. The Consolidated Criteria for Reporting Qualitative Research (COREQ) was followed to guide the reporting of the methods and findings. Participants and Recruitment Coalition members recruited focus group participants during weekly program activities or by distributing flyers to fathers who met the inclusion criteria. Participants were recruited using convenience sampling to identify individuals who serve the purpose and goals of this study. To be eligible for participation, individuals were required to be a new (child less than 18 months old) or expectant father, receive (or family receives) services from one of the coalition partners, self-identify as Black or African American, and be 18 years of age or older. After expressing interest in participating, fathers were assigned to one of two focus groups based on residence. A total of 15 fathers participated in the focus groups. Nine fathers participated in the metro-Atlanta-based focus group, and six fathers participated in the Columbus-based focus group in the summer of 2020. Table 1 shows that most of the fathers were new fathers, with infants 1 year old or less. The Institutional Review Board approved this study at [Institution]. Therefore, it was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. All participants provided informed consent before participation. Table 1 Focus Group Participant Characteristics Location Parental Status Number of Fathers Age of Child* Metro Atlanta New 4 3 days, 8 weeks, 2 months, 1 year Expectant 5 Columbus New 4 3 months, 6 months, 7 months, 8 months Expectant 2 *As of July 2020, when focus groups were conducted. This table includes the demographic characteristics of the fathers who participated in the focus groups in metro Atlanta and Columbus. These data were provided by the program staff. It includes the number of fathers who were new or expectant, and for new fathers, the age of their youngest child. [Insert Table 1 ] Focus Groups A semi-structured focus group guide was developed, reviewed, and modified by an interdisciplinary research team composed of the primary investigator, research assistants, research interns, and Coalition members. The focus group guide consisted of questions about new and expectant fathers’ experiences with maternal and child health services during the COVID-19 pandemic. Topics included communication with healthcare and service providers regarding COVID-19 and its impact on fathers’ engagement in services, the types and levels of support fathers received from providers, and any recommendations for improving services for new and expectant fathers (See Table 2 ). Table 2 Focus Group Guide If you were allowed to accompany your partner, were the procedures the same or different from your usual visits? (If different): Can you describe the differences? Were you subject to any health safety measures (e.g., temp taken, COVID-19 test given)? Was the space welcoming? Why or why not? Overall, what aspects of your experience were done well? What could have been done to improve your experience? Services/Support Today, which healthcare systems/providers are providing you (the father) with the most support? How have they helped you? What services were offered to you as a father or what services did you receive during this time? Were you satisfied with the services received? Why or why not? What type of support or services do you need during this time? Are you currently experiencing a worsening of mental health condition or chronic health problems? Do you need a referral for additional services? Recommendations What recommendations do you have for healthcare systems/staff to engage or help fathers during this time? [Insert Table 2 ] Focus groups were facilitated by the principal investigator (L.R.), who has experience in leading and evaluating community-based programs using qualitative methodological approaches, as well as two research interns trained in health and medicine. The focus groups were conducted in a private, virtual meeting session via Zoom. The facilitators followed the focus group guide with flexibility to allow for discretion in question wording, acknowledgement of new ideas and inquiries, and review of earlier topics. Coalition and staff members of the partner sites also attended each focus group to create a comfortable environment for participants. Each focus group was audio and video recorded, and facilitators took handwritten notes to capture changes in expression, tone, and group dynamics that enriched the interpretation of words said by participants. The focus groups lasted between 60 and 120 minutes. Fathers received a $ 50 gift card for their participation. Analysis Focus groups were transcribed verbatim and imported into NVivo 12.0 for data management and analysis. The principal investigator and a research assistant read each transcript independently and used an inductive thematic approach to generate codes from the focus groups (Guest et al., 2012). The two researchers then met to discuss the initial codes, resolve any differences in coding, and develop a consensus about emerging themes with references to the transcribed text. The researchers presented the preliminary themes that emerged from the first analysis to the entire research team, including Coalition members, and a final set of themes was identified, compiled, and agreed upon. Results The analysis of participant responses identified two overarching domains: (1) COVID-19–Related Disruptions and (2) Racism and the Experience of Being a Black Father. Together, these domains highlight both pandemic-specific barriers that restricted father involvement in maternal and child health services and the racialized experiences that shaped how Black fathers were treated within healthcare systems. Across both domains, fathers described a mix of structural and interpersonal challenges, as well as opportunities for improvement. Domain 1: COVID-19–Related Disruptions Fathers’ accounts revealed that the COVID-19 pandemic not only disrupted access to prenatal and delivery care but also intensified existing gaps in inclusion, communication, and emotional support. Most of the participants who attended appointments or deliveries reported feeling overlooked by obstetricians or nurses. Fathers discussed the emotional impact of being excluded which resulted in “unmet expectations” about the birth experience. Additionally, participants shared that the arrival of an infant during the COVID-19 pandemic felt isolating and not celebratory. Policies prohibiting visits from people who would typically serve as supporters for the new parents made this time more difficult. While it is understood that certain precautions are necessary, some of the negative emotions and experiences that fathers shared could have been prevented with better communication by service providers. Participants recommended better communication through father-specific materials, father-inclusive practices, customer service, and standardized COVID-19 “companion” policies across facilities. Father-Specific Communication While challenges with communication between providers and fathers is not new, the COVID-19 precautions that excluded fathers from appointments further widened the communication gap regarding the health of the mother and child and the care they received. One father explained, “You don't even know what's going on for real. All you see is a stomach growing every day,” while another said, “I wasn’t told anything until I tried to go into the room.” For some, the transition to telehealth added to this disconnect, as one described, “There was a lot of chaos… just trying to figure out what was going on with this video call session.” These gaps left fathers feeling excluded from decisions about their partners’ care and the health of their unborn children. One participant summed it up by noting, “They expect the mom to come back and tell us everything.” A few fathers, however, shared more positive experiences when allowed to attend appointments, as one noted, “I actually tend to ask most of the questions during her appointment… I just have a little bit more thought process when it comes to what’s going on with the development of the baby.” Father-Inclusive Practices Even when fathers were physically present during appointments or delivery, many reported feeling invisible to healthcare staff. One participant explained, “They didn’t ask me one question… I could’ve just laid over here and not done anything,” while another emphasized, “Fathers should be treated just as important as the mother.” Others felt that their exclusion was not simply a side effect of the pandemic but reflected deeper systemic patterns: “It’s like they want that separation. It’s pretty much exactly how the system already is.” Efforts to bridge restrictions through technology were inconsistent, and one father recalled, “The doctor rushed my girl so quickly through the heartbeat she didn’t have time to FaceTime me… it definitely made me feel a way for a couple of days.” One father shared, “there was a time where we wanted to take a video of the ultrasound and they didn't allow us to take a video.” In response to the feeling of exclusion, fathers suggest the need for providers to show more kindness, compassion, and empathy in all aspects of care. Additionally, fathers recommended that doctor’s offices should be more “male-friendly” and “have a section for men so that we feel like we are welcomed in a doctor’s office and not everything is directed toward women.” Standardized COVID-19 “Companion” Policies Most of the fathers shared that they did not receive any written or advance information about COVID-19 companion policies. Fathers described only receiving verbal communication about the companion policy as they attempted to enter a facility. Further, several fathers reported conflicting guidance between hospitals and providers: “The doctors just kept telling us different things… we need somebody with the right information.” These inconsistencies intensified fathers’ feelings of exclusion and uncertainty about whether they would be involved in critical moments of care for their child and child’s mother. Fathers who reported receiving advanced notice about the companion policies described exclusionary language within the communication. One father shared that his partner “received a couple emails about policy changes and what to expect upon her arrival for her appointments. But it was more towards her. Nothing was directed towards the father.” To address significant differences in the development, communication, and enforcement of these policies, a father suggested, “There should have been more standardization across healthcare. ” System Coldness & Lack of Compassion In addition to policy restrictions, fathers emphasized how interpersonal interactions with healthcare staff influenced their experiences. Several fathers described being treated as though they were not valued participants in a significant life event. One father noted being “handled… like an assembly line… not really with love,” while others described “no warmth, no compassion” and staff arriving “with this gray attitude.” These descriptions were not simply about impolite behavior; they reflected a broader perception that the healthcare system was operating with an efficiency-over-empathy approach that left fathers feeling emotionally sidelined. For many, this lack of compassion reinforced feelings of exclusion, as they sensed that their emotional needs and, by extension, their role in the pregnancy were not recognized or prioritized. Relationship Impact Fathers discussed the impact of the COVID-19 policies on their relationship with the unborn child and their partners. Most of the fathers shared that they had good communication with their partner. They admitted that the inability to accompany their pregnant partners can make them feel “unattached” to the fetus. However, some fathers described themselves as “pregnant through their spouse” and despite not being allowed in appointments, they had a positive perspective on the impact their involvement would have once the child was born. One father stated, “it’s more so about what do you do when your child is out, like, are you an active father when your child is out, or do you allow the fact that you wasn’t able to physically be at the meeting or at the birth…to come between the relationship you have now that as men, you’re able to physically touch this child and see this child.” Fathers described their role during pregnancy as supportive and empathetic. The fathers shared how COVID-19 companion policies served as barriers to them fulfilling these roles, which created conflict with their partners. One father said, “She’s still upset about that because she wants the support. She understands why I’m not there, but it doesn't make it any easier… I think that her emotional distress behind it is valid because I’ve been there for the other ones. And, you know, as my wife, I am her support system.” Another father expressed concern with having to choose whether he would be the allowed support person or a doula, “I'm just going to be there holding her hand versus the doula, with her experience and knows the medical terminology. She knows how to handle the doctor if they want to induce. She knows how to be an advocate for my wife…So, that’s something that we don’t know how it’s going to go down pretty much.” Domain 2: Racism and the Experience of Being a Black Father Beyond pandemic-specific disruptions, participants described how systemic racism, cultural stereotypes, and historical marginalization shaped their involvement in maternal and child health care. Many fathers spoke of being excluded from decision-making, treated with suspicion, or overlooked entirely. Fathers also described other challenges they experienced during this significant time, such as economic distress. These experiences were not perceived as isolated incidents but as part of a broader pattern in which Black fathers are undervalued in healthcare settings and society at large. Paternal Marginalization and Legal Disempowerment Fathers linked much of their exclusion from maternal care to entrenched systems that marginalize Black fatherhood. Some described interactions with child welfare agencies as adversarial, with one father stating, “DFCS (Department of Family and Children Services) ain’t here to help… they just secure their job.” Others felt that healthcare staff operated under assumptions that fathers would be disengaged, noting, “They expect the father to not be involved.” Even when fathers were physically present, they often felt stripped of decision-making power and treated as peripheral to the process, reinforcing the perception that the system was not designed to view them as equal partners in parenting. This lack of recognition extended beyond healthcare and into other institutions, creating a layered sense of legal and social disempowerment that undermined fathers’ ability to advocate for their partners and children. Systemic Racism and Historical Context Participants consistently tied their treatment in healthcare settings to a broader historical pattern of racism and exclusion. As one father put it, “We’ve been counted out,” capturing the sense that their role was dismissed before they even entered the room. Another reflected on the stigma attached to Black fatherhood, stating “…there’s some type of stigma when it comes to the Black men, especially the Black dads… I know how we feel when the blue lights pull up behind us. Everybody on this line feels the same way. But I think that there’s that kind of stigma, sometimes even when we’re going into our healthcare situations… we’re getting that being dads while Black”. These accounts illustrated how fathers viewed their healthcare experiences through the lens of broader systemic racism, connecting the unease and vigilance they felt in medical spaces to the same societal forces that shape their interactions with law enforcement and other institutions. Economic Insecurity & COVID-19 Financial Stress Fathers spoke candidly about the financial pressures brought on or intensified by the pandemic. Several described feeling as though they were being asked to survive with inadequate support, with one stating, “They expect us to survive with nothing,” and another describing the $ 1,200 federal stimulus as “a slap in the face.” Participants emphasized that the pandemic made “everything harder,” from meeting household needs to supporting their partners during pregnancy. Some suggested that “they could do better helping families during this time,” reflecting a broader sense of frustration with the limited systemic support available to working families. It is important to note that while mental health and trauma did not emerge as standalone themes, several fathers shared related experiences. One father described receiving his first depression diagnosis during the pandemic, which prompted him to seek counseling and treatment while preparing for the arrival of his child. Another father reflected on the intergenerational impact of unaddressed trauma in Black communities, noting that such issues often remain undiagnosed and untreated. These accounts underscore the importance of culturally responsive mental health support for fathers, even when it is not the central focus of their interactions with maternal health services. Across both domains, fathers’ narratives revealed how the COVID-19 pandemic both exposed and intensified existing gaps in communication, inclusion, and support within maternal and child health services. While some of these challenges stemmed from necessary public health precautions, others reflected longstanding systemic issues rooted in racial bias and institutional practices that marginalize Black fathers. Discussion In this study, fathers shared that father-inclusive practices and communication during the COVID-19 pandemic are a key factor in improving father engagement. Father-inclusive practice is a family systems approach that involves both the father and mother in education and services, ensures that the clinical environment is welcoming and friendly to fathers, provides literature with father-specific content, and uses mobile technology to include fathers (Tiedje & Darling-Fisher, 2003; Rollins, 2020 ). Recommendations to improve communication also included standardized COVID-19 companion policies. Additionally, the fathers shared ways in which these policies impacted their relationship with their unborn children and pregnant partners. Widarsson et al. (2015) reported similar findings in their sample of expectant fathers who felt excluded during prenatal visits due to the lack of information and communication directed to them. While they felt a personal involvement in their partners’ pregnancy, fathers experienced otherwise at prenatal visits and classes, where the content was largely focused on expectant mothers and there was a lack of attention towards fathers (Deave et al., 2008; Deave & Johnson, 2008). In this study, not all barriers and provider interactions were negative, and some positive exchanges took place between fathers and providers. The need for social distancing was well understood, but a humane approach to visiting policies in hospitals and provider offices should not be incompatible with an effective pandemic response. Healthcare providers need to acquire greater emotional literacy in how they deal with fathers. Not doing so “risks throwing away recent gains in higher quality, safer, more appropriate, effective, and efficient care” (Coulter & Richards, 2020). Healthcare providers can develop strategies to incorporate fathers in maternal health care needs. Fathers who accompanied their wives for prenatal visits were able to listen to their fetus’s heartbeat and view ultrasound scans, which fostered their motivations to be engaged and continue participating in prenatal activities (Zvara et al., 2013 ). They can employ strategies using alternate forms of communication during prenatal and post-delivery visits when fathers cannot be physically available (e.g., allowing mothers to talk and give visit information over the phone or utilize other mobile technology and telehealth strategies). During the pandemic, many maternal health guidelines were rapidly produced. Disagreements between guidelines regarding birth companions can create uncertainties for those receiving health services and their companions. Some guidelines indicated that women should be allowed and encouraged to have a companion present, provided the companion is asymptomatic. However, other guidelines advised that no birth partners should be allowed (Pavlidis et al., 2020). The fathers in this study shared how anxiety-producing and confusing the lack of standardized processes can be at such a critical time. The impact of COVID-19 created emotional distress that had repercussions among the couple and the newly formed family, since emotional support between parents is vital (Lista & Bresesti, 2020). Compared to their partners, fathers usually take longer to connect to a pregnancy as they do not undergo physical and hormonal changes in their bodies (Adamsons, 2013 ). Additionally, the time during pregnancy is also a crucial time for expectant fathers to establish their involvement in child health matters and, in the process, participate in their parental role from an earlier stage (Kaye et al., 2014; Zvara et al., 2013 ). Given that mothers want the fathers’ assistance during pregnancy and in raising their children, policies and programs should facilitate, build upon, and maintain the commitment that fathers articulate specifically at the “magic moment” of their children’s births. A variety of professional organizations have called for revising policies and practices in maternal and child health to promote fathers’ participation in pregnancy and childbirth. Recognizing and defining fathers’ optimal roles during pregnancy is also essential for developing interventions that maximize positive birth outcomes (Alio et al., 2013 ). Moreover, the integration of fathering initiatives into existing programs during pregnancy among Black communities has been identified as an essential priority area for promoting maternal health (Alio et al., 2011 ). Black fathers face numerous barriers to maternal and child services, including the perception that their parenting role is insignificant (Russell et al., 2024 ; Walsh et al., 2022 ). Racism can perpetuate the attitude that Black fathers are failing in their parenting duties. Bäckström and Wahn (2011) concluded that while fathers desired to be involved during childbirth, they often felt neglected and unprepared for their supportive role and preferred to be instructed on what to do. In health care settings, fathers often feel ignored on postpartum units and at well-baby visits, and practitioners frequently miss the opportunity to engage fathers in care (Copeland & Sams Abiodun, 2020). The integration of fathers into maternal and child health services not only requires commitment from fathers themselves but also intentional and systemic support from healthcare professionals. OBGYNs, pediatricians, nurses, midwives, and other hospital staff should provide systemic support and information to fathers, and there should be routine comprehensive reviews of administrative and logistical policies in healthcare settings (e.g., Poh et al., 2014a ; Yogman et al., 2016 ). Additionally, policy barriers to paternal involvement need to be addressed to facilitate, not hinder, the role of fathers in pregnancy and childbirth. Father-friendly clinics and hospitals and father-inclusive practices are essential to engage fathers, enhance pregnancy and childbirth experiences, and reduce maternal health disparities (Bond, 2012). Black fathers can successfully fulfill their desired role in pregnancy, childbirth, and beyond with the support of healthcare providers who recognize that their presence matters. Limitations There are some limitations to this research. The fluid nature of the pandemic caused changes in the implementation of companion policies over time, which in turn affected how well those policies were understood and followed. This exploratory study utilized homogeneous convenience sampling, constraining the sampling frame to sociodemographic characteristics of the target population. Although convenience samples limit the generalizability of study results to a large population, a homogenous convenience sample is representative of the target population, allows for preliminary investigation into the experiences of a population that is often underrepresented, and addresses the sociodemographic disparities that exist in rates of maternal mortality and morbidity (Jager et al., 2017). Conclusion This study explored the structural barriers to paternal involvement and the emotional experiences of new and expectant Black fathers in the context of the COVID-19 pandemic. Fathers emphasized the importance of father-inclusive practices and clear, standardized, father-specific communication in improving father engagement during this critical time in the mother’s and child’s health. Declarations Author Contribution All authors have contributed to the conceptualization of the manuscript and writing of the manuscript. L.R., T.G., J.R., D.C., and J.E. analyzed the focus group transcripts and refined the domains and themes. G.B. and J.R. completed the background and literature review. C. A., T.M., and T.G. contributed to data collection and writing methods sections. All authors have reviewed the manuscript and consent to the submission and publication of the manuscript. Acknowledgement We would like to thank the fathers who shared their experiences with us, Roosevelt Muhammad and Chris White at TIME-ER, Center for Black Women’s Wellness, Clayton County Health, and Centering Pregnancy at Grady Hospital for recruiting the fathers, and the Strong Fathers, Strong Families Georgia Coalition for their contributions to the project. We would also like to thank Ethan Lennox for his review of this manuscript. References Adamsons, K., & Johnson, S. K. (2013). An updated and expanded meta-analysis of nonresident fathering and child well-being. Journal of Family Psychology, 27 (4), 589–599. https://doi.org/10.1037/a0032110 Alio, A. P., Bond, M. J., Padilla, Y. C., Heidelbaugh, J. J., Lu, M., Parker, W. J., ... & Salihu, H. M. (2011). Addressing policy barriers to paternal involvement during pregnancy. Maternal and Child Health Journal, 15 (4), 425–430. https://doi.org/10.1007/s10995-011-0781-1 Alio, A. P., Kornosky, J. L., Mbah, A. K., Marty, P. J., & Salihu, H. 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J., Schoppe‐Sullivan, S. J., & Dush, C. K. (2013). Fathers' involvement in child health care: Associations with prenatal involvement, parents' beliefs, and maternal gatekeeping. Family Relations, 62 (4), 649–661. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7835411","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":588508348,"identity":"a4f79848-af29-4d8a-b4fd-b0b2e67c8112","order_by":0,"name":"Latrice Rollins","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAsElEQVRIiWNgGAWjYBACPgYGxgMPDBgY+CF8ZsJa2ID4QAJQi2QDaVqAhMEBorVIHz5wIKHgjr3xteNPNzBUWCc2ENTCl5YAdNizxG23c8xuMJxJJ0ILD48BUMvhBLPbOWw3GNsOE6/F3nh2+rMbjP9I0MK4QTrB7AZjA1Fa2EB+OZw4A+SXhGPpxgS18PMwH3zw4c9he36Qwz7UWMsS1IIKEkhTPgpGwSgYBaMAFwAA3pVAS50v5QcAAAAASUVORK5CYII=","orcid":"","institution":"Morehouse School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Latrice","middleName":"","lastName":"Rollins","suffix":""},{"id":588508350,"identity":"eac80a41-c601-4e4c-9120-6ea8be8f9c92","order_by":1,"name":"Tiara Giddings","email":"","orcid":"","institution":"Morehouse School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Tiara","middleName":"","lastName":"Giddings","suffix":""},{"id":588508354,"identity":"15fe05eb-b8c4-42b8-86b7-f9054dfe3e35","order_by":2,"name":"Geoffrey Brown","email":"","orcid":"","institution":"University of Wisconsin–Madison","correspondingAuthor":false,"prefix":"","firstName":"Geoffrey","middleName":"","lastName":"Brown","suffix":""},{"id":588508358,"identity":"7a9b024c-26e5-43bc-8d34-3150fc675157","order_by":3,"name":"Jennifer Elliott","email":"","orcid":"","institution":"University at Buffalo, State University of New York","correspondingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"","lastName":"Elliott","suffix":""},{"id":588508359,"identity":"65d4f2d9-afa6-4ebe-82b4-7e46b0807102","order_by":4,"name":"J. Dontae Roberts","email":"","orcid":"","institution":"University of North Carolina at Greensboro","correspondingAuthor":false,"prefix":"","firstName":"J.","middleName":"Dontae","lastName":"Roberts","suffix":""},{"id":588508361,"identity":"28764140-652e-4638-9cbd-2fc835ccaaa2","order_by":5,"name":"Diamond Cunningham","email":"","orcid":"","institution":"Tulane University","correspondingAuthor":false,"prefix":"","firstName":"Diamond","middleName":"","lastName":"Cunningham","suffix":""},{"id":588508362,"identity":"db6290cd-09f9-4308-b509-4a84247f6600","order_by":6,"name":"Wykinia Jones","email":"","orcid":"","institution":"Equity for Health, Inc.","correspondingAuthor":false,"prefix":"","firstName":"Wykinia","middleName":"","lastName":"Jones","suffix":""},{"id":588508365,"identity":"36ceb2ec-bc89-4867-9b2d-88eee7e91c3c","order_by":7,"name":"Trenton Madison","email":"","orcid":"","institution":"Morehouse School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Trenton","middleName":"","lastName":"Madison","suffix":""},{"id":588508366,"identity":"daf91e42-d91a-4559-8f55-20fd08f3863e","order_by":8,"name":"Cottrell Armistad","email":"","orcid":"","institution":"Morehouse School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Cottrell","middleName":"","lastName":"Armistad","suffix":""},{"id":588508368,"identity":"82a7c7f6-8e05-42e4-b696-c3647dbe3c68","order_by":9,"name":"Shlonda Smith","email":"","orcid":"","institution":"Georgia Department of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Shlonda","middleName":"","lastName":"Smith","suffix":""},{"id":588508369,"identity":"9be91989-7ad8-4652-9f8d-65cc39592978","order_by":10,"name":"Twanna Nelson","email":"","orcid":"","institution":"Georgia State University","correspondingAuthor":false,"prefix":"","firstName":"Twanna","middleName":"","lastName":"Nelson","suffix":""}],"badges":[],"createdAt":"2025-10-11 13:08:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7835411/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7835411/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102746595,"identity":"729e9261-dd88-47d0-a047-2f4049b18056","added_by":"auto","created_at":"2026-02-16 08:58:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":868085,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7835411/v1/431faa58-e3bb-4d3e-afb8-579d550d8b2b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Black Fathers’ Involvement in Maternal and Child Health Services During COVID-19: A Qualitative Study of Black Fathers’ Perspectives","fulltext":[{"header":"Highlights","content":"\u003cp\u003e\u0026bull; Despite research demonstrating that father involvement reduces maternal mortality rates, fathers often face barriers to engaging in maternal and child health services.\u003c/p\u003e\u003cp\u003e\u0026bull; The COVID-19 pandemic caused hospitals and providers to implement companion policies and procedures that further prevented fathers from engaging in these services.\u003c/p\u003e\u003cp\u003e\u0026bull; This article draws attention to the obstacles that were created during the COVID-19 pandemic for father involvement and the need to eliminate these barriers, generally, and during emergency response.\u003c/p\u003e\u003cp\u003e\u0026bull; This article serves as a call to action for maternal and child health services to embrace father-inclusive practices, specifically for Black fathers.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eFathers play a vital role in maternal and child health (MCH), supporting children’s physical, emotional, and social development at all stages (Cabrera et al., 2018; Lee et al., 2021). However, Black fathers have historically been marginalized in research, practice, and policy, often depicted through deficit-based narratives that can obfuscate their resilience and contributions to children and families (Garfield et al., 2019; Rollins, 2020; Roberts, 2025). This invisibility not only sustains harmful stereotypes but also leads to gaps in services that do not meet fathers’ specific needs.\u003c/p\u003e\n\u003cp\u003eThe COVID-19 pandemic highlighted existing inequalities in health and social systems, with Black communities bearing the heavier burdens of illness, economic struggles, and death (Tai et al., 2021; Egede \u0026amp; Walker, 2020). For Black fathers, these disparities intersect with systemic obstacles like unstable jobs, excessive policing, and limited access to culturally sensitive mental health services, increasing stressors that hinder their ability to parent effectively (Gee \u0026amp; Ford, 2021; Heard-Garris et al., 2022). Despite these challenges, research shows that Black fathers’ involvement supports maternal health, improves birth outcomes, and boosts children’s cognitive and emotional growth (Cabrera et al., 2018; Osbourne et al., 2022). Black fathers also play a crucial role in intergenerational resilience by promoting family cohesion and protecting children from the harmful effects of racial discrimination (Anderson et al., 2022). However, few policies and interventions have focused on fathers, especially fathers of color, as key stakeholders in promoting health and equity.\u003c/p\u003e\n\u003cp\u003eAdvancing health equity in MCH requires explicitly centering Black fathers, not only in research but also in service delivery and policy innovation. Thus, we examined the implications of COVID-19 policies and procedures for Black fathers, highlighting structural determinants shaping father engagement, and proposing equity-centered pathways for integrating fathers into the design of future MCH systems.\u003c/p\u003e\n\u003cp\u003eThe Importance of Prenatal Father Involvement\u003c/p\u003e\n\u003cp\u003eAlthough parenting research has traditionally concentrated on the maternal role, recent decades have seen a surge in studies examining the role of fathers in infant and child development (Schoppe-Sullivan \u0026amp; Fagan, 2020). This shift partially results from increased maternal employment compared to earlier generations, more egalitarian attitudes toward gender roles and household responsibilities, and a broader acknowledgment that fathers can provide sensitive and competent care from early infancy (Cabrera et al., 2018). Overall, research on fathering suggests that fathers’ positive involvement is linked to numerous beneficial outcomes across socio-emotional, cognitive, and physical health areas (Chang et al., 2020; Sarkadi et al., 2008; Walsh et al., 2021). Additionally, the advantages of engaged fathering are evident among both residential and non-residential fathers (Adamsons \u0026amp; Johnson, 2013). \u003c/p\u003e\n\u003cp\u003eFor many fathers, supporting their child and the child’s mother begins during the prenatal period. Involvement in prenatal care for expectant fathers can include various activities, such as attending doctors’ visits and ultrasound appointments, being present for birth, planning and making decisions about post-birth childcare and financial support, and providing emotional support to the mothers (Meier \u0026amp; Avillaneda, 2015). Overall, fathers who are more invested and involved before birth tend to be more engaged with their children post-birth (Aytuglu et al., 2025; Fagan, 2014; Witte et al., 2020; Zvara, 2013). Although most men participate in some way, Black fathers face several challenges that can impact their involvement during pregnancy and childbirth. Still, the experiences of young Black fathers during these times are not well understood. \u003c/p\u003e\n\u003cp\u003eAdditionally, a family systems theoretical framework guides this study’s expectation that paternal involvement is connected to maternal and child health outcomes. According to family systems theory (Cox \u0026amp; Paley, 2003), all individuals and relationships within a family are interconnected, and family transition points like the transition to parenthood provide opportunities for these relationships to reorganize in positive ways. Therefore, fathers’ engagement in prenatal care is likely to improve the quality of the couple and coparenting relationship with the child’s mother, which can lead to benefits for both child development and healthy relationship functioning after birth. Evidence indicates that most fathers’ contributions to child development during pregnancy mainly occur indirectly through support for the mother and enhanced couple relationship functioning (Cardenas et al., 2021). Additionally, recent ecological models of fathering suggest that father involvement partly depends on personal developmental histories and the specific environmental contexts in which fathers live (Cabrera et al., 2014; Palkovitz, 2018). The experiences of Black fathers may include both personal experiences of racial discrimination and marginalization from systems, such as healthcare and medical settings, that are often ill-equipped to meet fathers' needs. Consequently, the difficulties fathers encounter in supporting mothers and children during the prenatal period may be intensified within this population.\u003c/p\u003e\n\u003cp\u003eThe Role of Fathers in Black Maternal Health\u003c/p\u003e\n\u003cp\u003eWell-documented racial disparities in the health of Black mothers and infants are rooted in social determinants shaped by systemic racism in the United States (Owens \u0026amp; Fett, 2019). Public policy and social structures based on racial discrimination and gender oppression have disproportionately impacted Black mothers and infants (Crear-Perry et al., 2020), leading to significant inequities in health outcomes such as maternal and infant morbidity and low infant birthweight (Bisson et al., 2022; Hailu et al., 2024; Kirby, 2017; Njoku et al., 2023). Notably, Georgia consistently ranks among the states with the highest maternal mortality rates, with Black mothers being disproportionately affected (Armstrong-Mensah et al., 2021). Therefore, policies and practices aimed at addressing the health needs of Black women in Georgia during prenatal and neonatal periods can have meaningful public health impacts. One protective factor that has received little attention is the role of the father in prenatal maternal health for Black women and their infants. \u003c/p\u003e\n\u003cp\u003eAn expanding body of research highlights fathers’ ability to support maternal health during pregnancy and childbirth across different racial and ethnic groups. Overall, fathers’ prenatal involvement can promote healthier maternal behaviors and improve family functioning (Fagan, 2014; Rollins et al., 2024). For example, one study found that partner influence was associated with lower maternal depressive symptoms and reduced alcohol use, which in turn was linked to better infant mental and psychomotor development (Kautz-Turnbull et al., 2021). Prenatal involvement has also been shown to weaken the connection between risky life history factors and both harmful parenting practices and couple conflict (Sayler et al., 2022). In a nationally representative sample of US parents, fathers’ involvement during pregnancy increased the likelihood of mothers seeking prenatal care in the first trimester and decreased cigarette smoking (Martin et al., 2007). Similarly, a cohort study in the UK found that mothers were less likely to smoke during pregnancy and more likely to start breastfeeding when they were closely connected to the child’s father (Kiernan \u0026amp; Pickett, 2006). Evidence from basic research and interventions indicates that fathers’ support for breastfeeding during prenatal and early postpartum periods is associated with higher rates of breastfeeding initiation and continuation (Hosking et al., 2025; Mitchell-Box \u0026amp; Braun, 2013). The advantages of fathers’ prenatal involvement may also benefit infant health outcomes, such as reducing risks of premature and low birthweight (Alio et al., 2010b). \u003c/p\u003e\n\u003cp\u003eAlthough Black fathers are less likely than fathers from other racial or ethnic groups to be married or to regularly live with their children, most Black men are deeply committed to their parenting role during pregnancy and stay involved in their children’s lives in various ways after birth (Jones \u0026amp; Mosher, 2013). Black fathers who participate during pregnancy are also much more likely to stay engaged during infancy and early childhood (Aytuglu, 2025; Fagan, 2014; Cabrera, Fagan, \u0026amp; Farrie, 2008), suggesting that prenatal involvement can have long-term effects on the father-child relationship and future child well-being. Additionally, unmarried Black fathers present at their child’s birth are more likely to remain active in many aspects of parenting two years later (Bellamy, Thullen, \u0026amp; Hans, 2015). Importantly, the connection between prenatal and postnatal involvement also influences health-related parenting behaviors, with prenatal father involvement linked to fathers' participation in child health care and health decision-making (Zvara et al., 2013). Overall, these findings support the idea that encouraging paternal involvement during the prenatal period can help foster healthy early development and reduce health disparities among infants born to Black mothers. \u003c/p\u003e\n\u003cp\u003eFathers’ Exclusion and Inclusion from MCH Services\u003c/p\u003e\n\u003cp\u003eDespite being historically overlooked, a variety of professional organizations have called for revising policies and practices in maternal and child health to promote fathers’ participation in pregnancy and childbirth. Recognizing and defining fathers’ optimal roles during pregnancy is also essential for developing interventions that maximize positive birth outcomes (Alio et al., 2013). Moreover, the integration of fathering initiatives into existing programs during pregnancy among African American communities has been identified as a particularly important priority area for promoting maternal health (Alio et al., 2011). This integration requires not just the commitment of fathers themselves, but intentional and systemic support from healthcare professionals. This includes support and provision of information from OBGYNs, pediatricians, nurses, midwives, and other hospital staff, as well as comprehensive reviews of administrative and logistical policies in healthcare settings (Poh et al., 2014a; Yogman et al., 2016).\u003c/p\u003e\n\u003cp\u003eHowever, many fathers report a litany of barriers and mixed feelings toward their participation in the pregnancy and childbirth process. In general, reviews of fathers’ experiences suggest that most men have a strong desire to be informed and involved in pregnancy and childbirth but require support from partners and professionals to do so (Poh et al., 2014b). Despite these desires, fathers also face numerous impediments, including a lack of information regarding pregnancy, labor and delivery, and proper preparations for the transition to parenthood (Xue et al., 2018). As a result, many men have a sense of being marginalized in their parenting role, and can feel excluded, fearful, and unprepared for the challenges of pregnancy, childbirth, and parenting (Steen et al., 2012). Although many new fathers report feelings of fear and anxiety around the birth of a child (Moran et al., 2021), many also report a strong desire for knowledge, preparation, and guidance, as well as answers from healthcare providers that will help them fulfill a supportive role during pregnancy (van Vulpen et al., 2021).\u003c/p\u003e\n\u003cp\u003eAmong Black fathers, these mixed emotions, a desire for more information, and feelings of frustration might be further exacerbated. Young, Black fathers in particular report some supportive interactions with healthcare professionals during pregnancy and the newborn period, but also neutralizing and distancing interactions that may have negative consequences for their engagement and subsequent maternal health (Dallas, 2009). Some Black fathers experience mistrust of healthcare providers during the pregnancy and labor and delivery process, mainly stemming from a sense of not being integrated and receiving insufficient information (Edwards et al., 2020). Even when Black fathers do receive pregnancy information and resources from healthcare professionals, they still report limited opportunities for “trial and error” in terms of opportunities to provide maternal support prenatally and childcare postnatally (Allport-Altillo et al., 2020). Taken as a whole, it seems likely that many expectant Black fathers may experience some sense of dissatisfaction with their treatment in the healthcare system.\u003c/p\u003e\n\u003cp\u003eThe Impact of COVID-19 on Paternal Support for Black Maternal and Child Health\u003c/p\u003e\n\u003cp\u003eFor Black mothers expecting a child during the COVID-19 pandemic, the typical challenges of pregnancy and childbirth have intensified. Within the United States, Black individuals and communities have been hardest hit by the effects of the pandemic, thus widening pre-existing inequalities by race and ethnicity (Van Dorn et al., 2020; Yancy, 2020). Particularly stark disparities have emerged for Black women (Obinna, 2020), including increased complications in pregnancy and childbirth (Dashraath et al., 2020) and an emerging epidemic of mental health problems among expectant and new mothers (Molgora \u0026amp; Accordini, 2020). In the context of the COVID-19 pandemic, understanding how Black maternal health can be best supported by fathers, particularly during emergency response, is critical (Lemke et al., 2020).\u003c/p\u003e\n\u003cp\u003ePaternal support is one factor that can help to mitigate maternal health problems associated with COVID-19 (Molgora \u0026amp; Accordini, 2020). Nonetheless, for men already experiencing ambivalence, mixed signals, and incomplete support for their involvement in pregnancy and childbirth, the effects of the pandemic amplified these challenges. Although practices vary widely across settings and providers, numerous policies were put in place prohibiting fathers’ participation in the labor and delivery process. Though well-intentioned, many of these policies were not evidence-based and may have played a role in further marginalizing fathers from both mothers and children, thus jeopardizing the health of both (Sacks et al., 2020). For instance, many future fathers were not allowed to attend ultrasound screenings, others were not allowed in the delivery room during birth, and hospital visits even in the maternity ward, were limited (Davis-Floyd et al., 2020; Gressier et al., 2020). Whereas some new and resourceful methods of connecting with fathers virtually in the perinatal period were developed throughout the pandemic (Pasadino et al., 2020), many safety precautions initiated during this period placed new barriers in the way of fathers’ support. Indeed, many fathers reported that organizational changes to prenatal healthcare delivery as a result of the pandemic limited their engagement and resulted in increased stress and isolation during pregnancy (Poulos et al., 2022). \u003c/p\u003e\n\u003cp\u003eThe Present Study\u003c/p\u003e\n\u003cp\u003eThe consequences of the COVID-19 pandemic exacerbated health disparities among Black mothers and infants. Despite the benefits to mothers during pregnancy and the early postnatal period, substantial impediments to fathers’ participation mounted during this period. Nonetheless, the experiences of Black fathers within the maternal and child health system during COVID-19 were not adequately considered. Thus, we share Black fathers’ experiences navigating the demands of a global pandemic while also attempting to support maternal prenatal health and childbirth within systems that already minimize their contributions to maternal and child health. Through qualitative interviews with two groups of Black fathers in Georgia, both structural barriers to paternal involvement and the emotional experiences of new and expectant Black fathers were explored. Specifically, we sought to answer the following questions:\u003c/p\u003e\n\u003cp\u003e1. What were Black expectant fathers’ experiences with healthcare systems during COVID-19? \u003c/p\u003e\n\u003cp\u003e2. What were Black expectant fathers’ perceptions of the COVID-19 companion policies? \u003c/p\u003e\n\u003cp\u003e3. How did COVID-19 companion policies affect Black expectant fathers’ involvement in prenatal services?\u003c/p\u003e\n\u003cp\u003e4. What did fathers recommend healthcare providers do to engage them in maternal and child health?\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study was conducted as part of a [Institution] T\u003csup\u003ex TM\u003c/sup\u003e Pilot Project, in partnership with the Georgia Department of Public Health (GA DPH) - Maternal and Child Health (MCH)\u0026rsquo;s Strong Fathers, Strong Families Georgia Coalition (The Coalition). Coined and patented at [Institution], T\u003csup\u003ex TM\u003c/sup\u003e is a scientific philosophy that intentionally promotes and supports interdisciplinary collaboration to advance health equity (Akintobi et al., 2019; Holliday et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). This pilot project focused on assessing the father-friendliness of maternal and child health partner agencies and the needs of new and expectant Black fathers.\u003c/p\u003e \u003cp\u003eIn 2019, Georgia Department of Public Health (GA DPH) established the Strong Fathers, Strong Families Georgia Coalition to develop and drive Georgia\u0026rsquo;s collective impact approach towards father engagement as a strategy to address infant and maternal mortality. The Coalition was an interdisciplinary team comprised of father- and family-serving agencies and organizations including \u003cem\u003estate and local government\u003c/em\u003e: GA DPH, Georgia Department of Human Services, Cobb-Douglas County Health Department, Columbus (Muscogee County) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); \u003cem\u003eacademic partners\u003c/em\u003e: [Institution] Prevention Research Center and the University of Georgia Center for Family Research; and \u003cem\u003ecommunity-based, health services partners\u003c/em\u003e: Georgia Healthy Start Collaborative, Center for Black Women\u0026rsquo;s Wellness (CBWW), and TIME-ER Consulting (community-based fatherhood program). For this T\u003csup\u003ex TM\u003c/sup\u003e pilot project, a clinical services partner, the Centering Pregnancy (CP) program at Grady Public Hospital, was also included. Using a community-based participatory research and collective impact approach, the Coalition was involved in all phases of the pilot project. The Consolidated Criteria for Reporting Qualitative Research (COREQ) was followed to guide the reporting of the methods and findings.\u003c/p\u003e\n\u003ch3\u003eParticipants and Recruitment\u003c/h3\u003e\n\u003cp\u003eCoalition members recruited focus group participants during weekly program activities or by distributing flyers to fathers who met the inclusion criteria. Participants were recruited using convenience sampling to identify individuals who serve the purpose and goals of this study. To be eligible for participation, individuals were required to be a new (child less than 18 months old) or expectant father, receive (or family receives) services from one of the coalition partners, self-identify as Black or African American, and be 18 years of age or older.\u003c/p\u003e \u003cp\u003eAfter expressing interest in participating, fathers were assigned to one of two focus groups based on residence. A total of 15 fathers participated in the focus groups. Nine fathers participated in the metro-Atlanta-based focus group, and six fathers participated in the Columbus-based focus group in the summer of 2020. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows that most of the fathers were new fathers, with infants 1 year old or less. The Institutional Review Board approved this study at [Institution]. Therefore, it was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. All participants provided informed consent before participation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFocus Group Participant Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParental Status\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of Fathers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAge of Child*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMetro Atlanta\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNew\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 days, 8 weeks, 2 months, 1 year\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExpectant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eColumbus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNew\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 months, 6 months, 7 months, 8 months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExpectant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*As of July 2020, when focus groups were conducted.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eThis table includes the demographic characteristics of the fathers who participated in the focus groups in metro Atlanta and Columbus. These data were provided by the program staff. It includes the number of fathers who were new or expectant, and for new fathers, the age of their youngest child.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e[Insert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eFocus Groups\u003c/h2\u003e \u003cp\u003eA semi-structured focus group guide was developed, reviewed, and modified by an interdisciplinary research team composed of the primary investigator, research assistants, research interns, and Coalition members. The focus group guide consisted of questions about new and expectant fathers\u0026rsquo; experiences with maternal and child health services during the COVID-19 pandemic. Topics included communication with healthcare and service providers regarding COVID-19 and its impact on fathers\u0026rsquo; engagement in services, the types and levels of support fathers received from providers, and any recommendations for improving services for new and expectant fathers (See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFocus Group Guide\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIf you were allowed to accompany your partner, were the procedures the same or different from your usual visits?\u003c/p\u003e \u003cp\u003e(If different): Can you describe the differences?\u003c/p\u003e \u003cp\u003eWere you subject to any health safety measures (e.g., temp taken, COVID-19 test given)? Was the space welcoming? Why or why not?\u003c/p\u003e \u003cp\u003eOverall, what aspects of your experience were done well?\u003c/p\u003e \u003cp\u003eWhat could have been done to improve your experience?\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eServices/Support\u003c/em\u003e\u003c/p\u003e \u003cp\u003eToday, which healthcare systems/providers are providing you (the father) with the most support?\u003c/p\u003e \u003cp\u003eHow have they helped you?\u003c/p\u003e \u003cp\u003eWhat services were offered to you as a father or what services did you receive during this time?\u003c/p\u003e \u003cp\u003eWere you satisfied with the services received? Why or why not? What type of support or services do you need during this time?\u003c/p\u003e \u003cp\u003eAre you currently experiencing a worsening of mental health condition or chronic health problems?\u003c/p\u003e \u003cp\u003eDo you need a referral for additional services?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eRecommendations\u003c/em\u003e\u003c/p\u003e \u003cp\u003eWhat recommendations do you have for healthcare systems/staff to engage or help fathers during this time?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e[Insert Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eFocus groups were facilitated by the principal investigator (L.R.), who has experience in leading and evaluating community-based programs using qualitative methodological approaches, as well as two research interns trained in health and medicine. The focus groups were conducted in a private, virtual meeting session via Zoom. The facilitators followed the focus group guide with flexibility to allow for discretion in question wording, acknowledgement of new ideas and inquiries, and review of earlier topics. Coalition and staff members of the partner sites also attended each focus group to create a comfortable environment for participants. Each focus group was audio and video recorded, and facilitators took handwritten notes to capture changes in expression, tone, and group dynamics that enriched the interpretation of words said by participants. The focus groups lasted between 60 and 120 minutes. Fathers received a \u003cspan\u003e$\u003c/span\u003e50 gift card for their participation.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAnalysis\u003c/h3\u003e\n\u003cp\u003eFocus groups were transcribed verbatim and imported into NVivo 12.0 for data management and analysis. The principal investigator and a research assistant read each transcript independently and used an inductive thematic approach to generate codes from the focus groups (Guest et al., 2012). The two researchers then met to discuss the initial codes, resolve any differences in coding, and develop a consensus about emerging themes with references to the transcribed text. The researchers presented the preliminary themes that emerged from the first analysis to the entire research team, including Coalition members, and a final set of themes was identified, compiled, and agreed upon.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe analysis of participant responses identified two overarching domains: (1) COVID-19\u0026ndash;Related Disruptions and (2) Racism and the Experience of Being a Black Father. Together, these domains highlight both pandemic-specific barriers that restricted father involvement in maternal and child health services and the racialized experiences that shaped how Black fathers were treated within healthcare systems. Across both domains, fathers described a mix of structural and interpersonal challenges, as well as opportunities for improvement.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eDomain 1: COVID-19–Related Disruptions\u003c/h3\u003e\n\u003cp\u003eFathers\u0026rsquo; accounts revealed that the COVID-19 pandemic not only disrupted access to prenatal and delivery care but also intensified existing gaps in inclusion, communication, and emotional support. Most of the participants who attended appointments or deliveries reported feeling overlooked by obstetricians or nurses. Fathers discussed the emotional impact of being excluded which resulted in \u0026ldquo;unmet expectations\u0026rdquo; about the birth experience. Additionally, participants shared that the arrival of an infant during the COVID-19 pandemic felt isolating and not celebratory. Policies prohibiting visits from people who would typically serve as supporters for the new parents made this time more difficult. While it is understood that certain precautions are necessary, some of the negative emotions and experiences that fathers shared could have been prevented with better communication by service providers. Participants recommended better communication through father-specific materials, father-inclusive practices, customer service, and standardized COVID-19 \u0026ldquo;companion\u0026rdquo; policies across facilities.\u003c/p\u003e\n\u003ch3\u003eFather-Specific Communication\u003c/h3\u003e\n\u003cp\u003eWhile challenges with communication between providers and fathers is not new, the COVID-19 precautions that excluded fathers from appointments further widened the communication gap regarding the health of the mother and child and the care they received. One father explained, \u0026ldquo;You don't even know what's going on for real. All you see is a stomach growing every day,\u0026rdquo; while another said, \u0026ldquo;I wasn\u0026rsquo;t told anything until I tried to go into the room.\u0026rdquo; For some, the transition to telehealth added to this disconnect, as one described, \u0026ldquo;There was a lot of chaos\u0026hellip; just trying to figure out what was going on with this video call session.\u0026rdquo; These gaps left fathers feeling excluded from decisions about their partners\u0026rsquo; care and the health of their unborn children. One participant summed it up by noting, \u0026ldquo;They expect the mom to come back and tell us everything.\u0026rdquo; A few fathers, however, shared more positive experiences when allowed to attend appointments, as one noted, \u0026ldquo;I actually tend to ask most of the questions during her appointment\u0026hellip; I just have a little bit more thought process when it comes to what\u0026rsquo;s going on with the development of the baby.\u0026rdquo;\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eFather-Inclusive Practices\u003c/h2\u003e \u003cp\u003eEven when fathers were physically present during appointments or delivery, many reported feeling invisible to healthcare staff. One participant explained, \u0026ldquo;They didn\u0026rsquo;t ask me one question\u0026hellip; I could\u0026rsquo;ve just laid over here and not done anything,\u0026rdquo; while another emphasized, \u0026ldquo;Fathers should be treated just as important as the mother.\u0026rdquo; Others felt that their exclusion was not simply a side effect of the pandemic but reflected deeper systemic patterns: \u0026ldquo;It\u0026rsquo;s like they want that separation. It\u0026rsquo;s pretty much exactly how the system already is.\u0026rdquo; Efforts to bridge restrictions through technology were inconsistent, and one father recalled, \u0026ldquo;The doctor rushed my girl so quickly through the heartbeat she didn\u0026rsquo;t have time to FaceTime me\u0026hellip; it definitely made me feel a way for a couple of days.\u0026rdquo; One father shared, \u0026ldquo;there was a time where we wanted to take a video of the ultrasound and they didn't allow us to take a video.\u0026rdquo;\u003c/p\u003e \u003cp\u003eIn response to the feeling of exclusion, fathers suggest the need for providers to show more kindness, compassion, and empathy in all aspects of care. Additionally, fathers recommended that doctor\u0026rsquo;s offices should be more \u0026ldquo;male-friendly\u0026rdquo; and \u0026ldquo;have a section for men so that we feel like we are welcomed in a doctor\u0026rsquo;s office and not everything is directed toward women.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStandardized COVID-19 “Companion” Policies\u003c/h3\u003e\n\u003cp\u003e Most of the fathers shared that they did not receive any written or advance information about COVID-19 companion policies. Fathers described only receiving verbal communication about the companion policy as they attempted to enter a facility. Further, several fathers reported conflicting guidance between hospitals and providers: \u0026ldquo;The doctors just kept telling us different things\u0026hellip; we need somebody with the right information.\u0026rdquo; These inconsistencies intensified fathers\u0026rsquo; feelings of exclusion and uncertainty about whether they would be involved in critical moments of care for their child and child\u0026rsquo;s mother. Fathers who reported receiving advanced notice about the companion policies described exclusionary language within the communication. One father shared that his partner \u0026ldquo;received a couple emails about policy changes and what to expect upon her arrival for her appointments. But it was more towards her. Nothing was directed towards the father.\u0026rdquo; To address significant differences in the development, communication, and enforcement of these policies, a father suggested, \u0026ldquo;There should have been more standardization across healthcare. \u0026rdquo;\u003c/p\u003e\n\u003ch3\u003eSystem Coldness \u0026 Lack of Compassion\u003c/h3\u003e\n\u003cp\u003eIn addition to policy restrictions, fathers emphasized how interpersonal interactions with healthcare staff influenced their experiences. Several fathers described being treated as though they were not valued participants in a significant life event. One father noted being \u0026ldquo;handled\u0026hellip; like an assembly line\u0026hellip; not really with love,\u0026rdquo; while others described \u0026ldquo;no warmth, no compassion\u0026rdquo; and staff arriving \u0026ldquo;with this gray attitude.\u0026rdquo; These descriptions were not simply about impolite behavior; they reflected a broader perception that the healthcare system was operating with an efficiency-over-empathy approach that left fathers feeling emotionally sidelined. For many, this lack of compassion reinforced feelings of exclusion, as they sensed that their emotional needs and, by extension, their role in the pregnancy were not recognized or prioritized.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eRelationship Impact\u003c/h2\u003e \u003cp\u003eFathers discussed the impact of the COVID-19 policies on their relationship with the unborn child and their partners. Most of the fathers shared that they had good communication with their partner. They admitted that the inability to accompany their pregnant partners can make them feel \u0026ldquo;unattached\u0026rdquo; to the fetus. However, some fathers described themselves as \u0026ldquo;pregnant through their spouse\u0026rdquo; and despite not being allowed in appointments, they had a positive perspective on the impact their involvement would have once the child was born. One father stated, \u0026ldquo;it\u0026rsquo;s more so about what do you do when your child is out, like, are you an active father when your child is out, or do you allow the fact that you wasn\u0026rsquo;t able to physically be at the meeting or at the birth\u0026hellip;to come between the relationship you have now that as men, you\u0026rsquo;re able to physically touch this child and see this child.\u0026rdquo;\u003c/p\u003e \u003cp\u003eFathers described their role during pregnancy as supportive and empathetic. The fathers shared how COVID-19 companion policies served as barriers to them fulfilling these roles, which created conflict with their partners. One father said, \u0026ldquo;She\u0026rsquo;s still upset about that because she wants the support. She understands why I\u0026rsquo;m not there, but it doesn't make it any easier\u0026hellip; I think that her emotional distress behind it is valid because I\u0026rsquo;ve been there for the other ones. And, you know, as my wife, I am her support system.\u0026rdquo; Another father expressed concern with having to choose whether he would be the allowed support person or a doula, \u0026ldquo;I'm just going to be there holding her hand versus the doula, with her experience and knows the medical terminology. She knows how to handle the doctor if they want to induce. She knows how to be an advocate for my wife\u0026hellip;So, that\u0026rsquo;s something that we don\u0026rsquo;t know how it\u0026rsquo;s going to go down pretty much.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDomain 2: Racism and the Experience of Being a Black Father\u003c/h2\u003e \u003cp\u003eBeyond pandemic-specific disruptions, participants described how systemic racism, cultural stereotypes, and historical marginalization shaped their involvement in maternal and child health care. Many fathers spoke of being excluded from decision-making, treated with suspicion, or overlooked entirely. Fathers also described other challenges they experienced during this significant time, such as economic distress. These experiences were not perceived as isolated incidents but as part of a broader pattern in which Black fathers are undervalued in healthcare settings and society at large.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePaternal Marginalization and Legal Disempowerment\u003c/h2\u003e \u003cp\u003eFathers linked much of their exclusion from maternal care to entrenched systems that marginalize Black fatherhood. Some described interactions with child welfare agencies as adversarial, with one father stating, \u0026ldquo;DFCS (Department of Family and Children Services) ain\u0026rsquo;t here to help\u0026hellip; they just secure their job.\u0026rdquo; Others felt that healthcare staff operated under assumptions that fathers would be disengaged, noting, \u0026ldquo;They expect the father to not be involved.\u0026rdquo; Even when fathers were physically present, they often felt stripped of decision-making power and treated as peripheral to the process, reinforcing the perception that the system was not designed to view them as equal partners in parenting. This lack of recognition extended beyond healthcare and into other institutions, creating a layered sense of legal and social disempowerment that undermined fathers\u0026rsquo; ability to advocate for their partners and children.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSystemic Racism and Historical Context\u003c/h2\u003e \u003cp\u003eParticipants consistently tied their treatment in healthcare settings to a broader historical pattern of racism and exclusion. As one father put it, \u0026ldquo;We\u0026rsquo;ve been counted out,\u0026rdquo; capturing the sense that their role was dismissed before they even entered the room. Another reflected on the stigma attached to Black fatherhood, stating \u0026ldquo;\u0026hellip;there\u0026rsquo;s some type of stigma when it comes to the Black men, especially the Black dads\u0026hellip; I know how we feel when the blue lights pull up behind us. Everybody on this line feels the same way. But I think that there\u0026rsquo;s that kind of stigma, sometimes even when we\u0026rsquo;re going into our healthcare situations\u0026hellip; we\u0026rsquo;re getting that being dads while Black\u0026rdquo;. These accounts illustrated how fathers viewed their healthcare experiences through the lens of broader systemic racism, connecting the unease and vigilance they felt in medical spaces to the same societal forces that shape their interactions with law enforcement and other institutions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eEconomic Insecurity \u0026amp; COVID-19 Financial Stress\u003c/h2\u003e \u003cp\u003eFathers spoke candidly about the financial pressures brought on or intensified by the pandemic. Several described feeling as though they were being asked to survive with inadequate support, with one stating, \u0026ldquo;They expect us to survive with nothing,\u0026rdquo; and another describing the \u003cspan\u003e$\u003c/span\u003e1,200 federal stimulus as \u0026ldquo;a slap in the face.\u0026rdquo; Participants emphasized that the pandemic made \u0026ldquo;everything harder,\u0026rdquo; from meeting household needs to supporting their partners during pregnancy. Some suggested that \u0026ldquo;they could do better helping families during this time,\u0026rdquo; reflecting a broader sense of frustration with the limited systemic support available to working families.\u003c/p\u003e \u003cp\u003eIt is important to note that while mental health and trauma did not emerge as standalone themes, several fathers shared related experiences. One father described receiving his first depression diagnosis during the pandemic, which prompted him to seek counseling and treatment while preparing for the arrival of his child. Another father reflected on the intergenerational impact of unaddressed trauma in Black communities, noting that such issues often remain undiagnosed and untreated. These accounts underscore the importance of culturally responsive mental health support for fathers, even when it is not the central focus of their interactions with maternal health services.\u003c/p\u003e \u003cp\u003eAcross both domains, fathers\u0026rsquo; narratives revealed how the COVID-19 pandemic both exposed and intensified existing gaps in communication, inclusion, and support within maternal and child health services. While some of these challenges stemmed from necessary public health precautions, others reflected longstanding systemic issues rooted in racial bias and institutional practices that marginalize Black fathers.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, fathers shared that father-inclusive practices and communication during the COVID-19 pandemic are a key factor in improving father engagement. Father-inclusive practice is a family systems approach that involves both the father and mother in education and services, ensures that the clinical environment is welcoming and friendly to fathers, provides literature with father-specific content, and uses mobile technology to include fathers (Tiedje \u0026amp; Darling-Fisher, 2003; Rollins, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Recommendations to improve communication also included standardized COVID-19 companion policies. Additionally, the fathers shared ways in which these policies impacted their relationship with their unborn children and pregnant partners.\u003c/p\u003e \u003cp\u003eWidarsson et al. (2015) reported similar findings in their sample of expectant fathers who felt excluded during prenatal visits due to the lack of information and communication directed to them. While they felt a personal involvement in their partners\u0026rsquo; pregnancy, fathers experienced otherwise at prenatal visits and classes, where the content was largely focused on expectant mothers and there was a lack of attention towards fathers (Deave et al., 2008; Deave \u0026amp; Johnson, 2008). In this study, not all barriers and provider interactions were negative, and some positive exchanges took place between fathers and providers.\u003c/p\u003e \u003cp\u003eThe need for social distancing was well understood, but a humane approach to visiting policies in hospitals and provider offices should not be incompatible with an effective pandemic response. Healthcare providers need to acquire greater emotional literacy in how they deal with fathers. Not doing so \u0026ldquo;risks throwing away recent gains in higher quality, safer, more appropriate, effective, and efficient care\u0026rdquo; (Coulter \u0026amp; Richards, 2020).\u003c/p\u003e \u003cp\u003eHealthcare providers can develop strategies to incorporate fathers in maternal health care needs. Fathers who accompanied their wives for prenatal visits were able to listen to their fetus\u0026rsquo;s heartbeat and view ultrasound scans, which fostered their motivations to be engaged and continue participating in prenatal activities (Zvara et al., \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). They can employ strategies using alternate forms of communication during prenatal and post-delivery visits when fathers cannot be physically available (e.g., allowing mothers to talk and give visit information over the phone or utilize other mobile technology and telehealth strategies).\u003c/p\u003e \u003cp\u003e During the pandemic, many maternal health guidelines were rapidly produced. Disagreements between guidelines regarding birth companions can create uncertainties for those receiving health services and their companions. Some guidelines indicated that women should be allowed and encouraged to have a companion present, provided the companion is asymptomatic. However, other guidelines advised that no birth partners should be allowed (Pavlidis et al., 2020). The fathers in this study shared how anxiety-producing and confusing the lack of standardized processes can be at such a critical time.\u003c/p\u003e \u003cp\u003eThe impact of COVID-19 created emotional distress that had repercussions among the couple and the newly formed family, since emotional support between parents is vital (Lista \u0026amp; Bresesti, 2020). Compared to their partners, fathers usually take longer to connect to a pregnancy as they do not undergo physical and hormonal changes in their bodies (Adamsons, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Additionally, the time during pregnancy is also a crucial time for expectant fathers to establish their involvement in child health matters and, in the process, participate in their parental role from an earlier stage (Kaye et al., 2014; Zvara et al., \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Given that mothers want the fathers\u0026rsquo; assistance during pregnancy and in raising their children, policies and programs should facilitate, build upon, and maintain the commitment that fathers articulate specifically at the \u0026ldquo;magic moment\u0026rdquo; of their children\u0026rsquo;s births.\u003c/p\u003e \u003cp\u003eA variety of professional organizations have called for revising policies and practices in maternal and child health to promote fathers\u0026rsquo; participation in pregnancy and childbirth. Recognizing and defining fathers\u0026rsquo; optimal roles during pregnancy is also essential for developing interventions that maximize positive birth outcomes (Alio et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Moreover, the integration of fathering initiatives into existing programs during pregnancy among Black communities has been identified as an essential priority area for promoting maternal health (Alio et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBlack fathers face numerous barriers to maternal and child services, including the perception that their parenting role is insignificant (Russell et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Walsh et al., \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Racism can perpetuate the attitude that Black fathers are failing in their parenting duties. B\u0026auml;ckstr\u0026ouml;m and Wahn (2011) concluded that while fathers desired to be involved during childbirth, they often felt neglected and unprepared for their supportive role and preferred to be instructed on what to do. In health care settings, fathers often feel ignored on postpartum units and at well-baby visits, and practitioners frequently miss the opportunity to engage fathers in care (Copeland \u0026amp; Sams Abiodun, 2020). The integration of fathers into maternal and child health services not only requires commitment from fathers themselves but also intentional and systemic support from healthcare professionals. OBGYNs, pediatricians, nurses, midwives, and other hospital staff should provide systemic support and information to fathers, and there should be routine comprehensive reviews of administrative and logistical policies in healthcare settings (e.g., Poh et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2014a\u003c/span\u003e; Yogman et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdditionally, policy barriers to paternal involvement need to be addressed to facilitate, not hinder, the role of fathers in pregnancy and childbirth. Father-friendly clinics and hospitals and father-inclusive practices are essential to engage fathers, enhance pregnancy and childbirth experiences, and reduce maternal health disparities (Bond, 2012). Black fathers can successfully fulfill their desired role in pregnancy, childbirth, and beyond with the support of healthcare providers who recognize that their presence matters.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThere are some limitations to this research. The fluid nature of the pandemic caused changes in the implementation of companion policies over time, which in turn affected how well those policies were understood and followed. This exploratory study utilized homogeneous convenience sampling, constraining the sampling frame to sociodemographic characteristics of the target population. Although convenience samples limit the generalizability of study results to a large population, a homogenous convenience sample is representative of the target population, allows for preliminary investigation into the experiences of a population that is often underrepresented, and addresses the sociodemographic disparities that exist in rates of maternal mortality and morbidity (Jager et al., 2017).\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study explored the structural barriers to paternal involvement and the emotional experiences of new and expectant Black fathers in the context of the COVID-19 pandemic. Fathers emphasized the importance of father-inclusive practices and clear, standardized, father-specific communication in improving father engagement during this critical time in the mother\u0026rsquo;s and child\u0026rsquo;s health.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors have contributed to the conceptualization of the manuscript and writing of the manuscript. L.R., T.G., J.R., D.C., and J.E. analyzed the focus group transcripts and refined the domains and themes. G.B. and J.R. completed the background and literature review. C. A., T.M., and T.G. contributed to data collection and writing methods sections. All authors have reviewed the manuscript and consent to the submission and publication of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to thank the fathers who shared their experiences with us, Roosevelt Muhammad and Chris White at TIME-ER, Center for Black Women\u0026rsquo;s Wellness, Clayton County Health, and Centering Pregnancy at Grady Hospital for recruiting the fathers, and the Strong Fathers, Strong Families Georgia Coalition for their contributions to the project. We would also like to thank Ethan Lennox for his review of this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAdamsons, K., \u0026amp; Johnson, S. K. (2013). An updated and expanded meta-analysis of nonresident fathering and child well-being. \u003cem\u003eJournal of Family Psychology, 27\u003c/em\u003e(4), 589\u0026ndash;599. https://doi.org/10.1037/a0032110\u003c/li\u003e\n\u003cli\u003eAlio, A. P., Bond, M. 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A community perspective on the role of fathers during pregnancy: A qualitative study. \u003cem\u003eBMC Pregnancy and Childbirth, 13\u003c/em\u003e(1), 60. https://doi.org/10.1186/1471-2393-13-60\u003c/li\u003e\n\u003cli\u003eAlio, A. P., Salihu, H. M., Kornosky, J. L., Richman, A. M., \u0026amp; Marty, P. J. (2010a). Feto-infant health and survival: Does paternal involvement matter? \u003cem\u003eMaternal and Child Health Journal, 14\u003c/em\u003e(6), 931\u0026ndash;937. https://doi.org/10.1007/s10995-009-0531-8\u003c/li\u003e\n\u003cli\u003eAllport-Altillo, B. S., Aqil, A. R., Nelson, T., Johnson, S. B., Labrique, A. B., Carabas, Y., \u0026amp; Marcell, A. V. (2020). 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Fathers\u0026rsquo; roles in the care and development of their children: The role of pediatricians. \u003cem\u003ePediatrics, 138\u003c/em\u003e(1), e20161128.\u003c/li\u003e\n\u003cli\u003eZvara, B. J., Schoppe‐Sullivan, S. J., \u0026amp; Dush, C. K. (2013). Fathers\u0026apos; involvement in child health care: Associations with prenatal involvement, parents\u0026apos; beliefs, and maternal gatekeeping. \u003cem\u003eFamily Relations, 62\u003c/em\u003e(4), 649\u0026ndash;661.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"father involvement, Black maternal mortality, COVID-19, father-inclusive practices","lastPublishedDoi":"10.21203/rs.3.rs-7835411/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7835411/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cdiv class=\"SectionHeadings\"\u003e\u003cdiv class=\"SectionHeading\"\u003e\u003cdiv class=\"Paragraphs\"\u003e\u003cp\u003ePrevious research has shown that maternal and child health services often overlook fathers, even though evidence indicates that father involvement can reduce maternal and infant mortality. We examined the experiences of new and expectant Black fathers and how COVID-19 affected their participation in health services. Two focus groups, involving a total of 15 fathers, were conducted. Participants were asked about the communication they received regarding COVID-19 policies related to their involvement in maternal and child health services, their thoughts and feelings about these policies, and how these policies have influenced their relationships with their partners and children. Each two-hour focus group was facilitated via Zoom, recorded, and transcribed. Several fathers reported that they were unaware of COVID-19 policies or were not permitted to participate in maternal and child health services, such as prenatal appointments and labor/delivery. Fathers also reported how systemic racism and stereotypes impacted their experiences with these services. These findings highlight the need for improved communication and more father-inclusive practices in maternal and child health, even during emergency responses. Effective father-inclusive practices adopt a family systems approach that involves both mothers and fathers in education and services, ensures that clinical environments are welcoming to fathers, provides literature tailored to fathers, and utilizes mobile technology to engage fathers.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e","manuscriptTitle":"Black Fathers’ Involvement in Maternal and Child Health Services During COVID-19: A Qualitative Study of Black Fathers’ Perspectives","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-12 09:34:41","doi":"10.21203/rs.3.rs-7835411/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5f288e3d-b1c8-4dac-9118-8b532d0fd85c","owner":[],"postedDate":"February 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T12:18:23+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-12 09:34:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7835411","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7835411","identity":"rs-7835411","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}