Early Arrivals – Supporting Fathers of Premature Babies

Did you know that nearly 10% of babies are born early (less than 37 weeks)? Dads of these babies can have some extra challenges, especially if baby is in a neonatal intensive care unit. SMS4dads has developed some specific messages for these dads. For example, how to touch or arrange to hold a really small premature baby.

Early Arrivals – Supporting Fathers of Premature Babies -

Research has identified fathers of premature babies in NICU as at risk of poor health outcomes due to marginalisation and impaired transition to the fatherhood role.

The following report by Rebecca Liackman discusses the development of a message set in the SMS4dads program to support fathers of premature infants admitted to a neonatal intensive care unit.




To develop a set of key messages suitable for dads with premature babies (28-34 weeks) in a neonatal intensive care unit (NICU) enrolled in the SMS4dads program.


Research has identified fathers of premature babies in NICU as at risk of poor health outcomes due to marginalisation and impaired transition to the fatherhood role. This situation can also negatively impact his relationships and the development of the infant. SMS4dads is an evidence-based program that delivers a pre-determined sequence of antenatal and postnatal messages to the father’s mobile phone. It has the potential to reduce the burden on the family unit by anthropomorphising as a well-informed, non-judgmental and trustworthy support person for the father with a premature baby in NICU.


15 draft messages were appraised by a group of researchers, clinicians and consumers in the form of an online survey using an iterative, consultative process.


Eight messages were verified as useful and acceptable, two messages were considered not useful and five messages had variable but generally positive evaluation.


This study has identified a set of eight validated messages tailored for dads with premature babies in NICU that can complement the standard corpus of messages currently utilised by the SMS4dads program.

Early Arrivals – Supporting Fathers of Premature Babies -


The transformation to fatherhood can be a demanding life-phase, less extensively studied than motherhood, but emerging as a significant research area (Goldstein et al., 2020; Fletcher, 2011).

It is postulated that the physical, emotional and social wellbeing of men can be compromised during this time by deeply constructed traditional male gender roles of stoicism, emotional repression and stymied health-seeking behaviours. Evidence suggests that around 10% of men suffer from perinatal depressive disorders which can also negatively impact the infant’s development and partner relationships (Fletcher et al., 2011; Fletcher et al., 2018). SMS4dads is a text-based intervention that aims to support men through this time period, from 16 weeks pregnancy to 48 weeks post-birth, by delivering clear, informative and relevant messages to the participants mobile phone (Fletcher et al., 2016; Redfern et al., 2014).

The aim is to emphasise the salience of fathering within three domains of self-care, infant bonding and positive partnering using primary and secondary prevention strategies.

The program has been evaluated as an acceptable conduit to provide dads-to-be and new dads with timely, unobtrusive and beneficial advice and information using a feasible and scalable process (Fletcher et al., 2017a; Fletcher et al., 2017b). However, the corpus of 184 evidence-based messages is mapped chronologically, dependent on uneventful progress through pregnancy, birth and normal development of the baby at home. Unfortunately, for some families the prescribed context is different, and the frame of reference is thus discordant. An equitable public health approach is required to meet the needs of these fathers.

The unexpected premature arrival of a baby, defined as less than 37 weeks of gestation, occurs in 8.7% of births in Australia (AIHW 2020).

This scenario can further inhibit a safe transition to fatherhood due to increased levels of stress, disempowerment in the hospital environment and mitigation of infant care opportunity. Qualitative research has further unpacked these factors and a rapid systematic review by Fletcher et al. (n.d.) deduced that proximity, vulnerability, communication and isolation are themes that need to be addressed with respect to fathers.

Moreover, maternally biased health services and a general lack of father-inclusive practices are posited as underpinning the marginalisation that they experience (Fletcher et al., 2006).

SMS4dads has the capability and capacity to fill this service void by delivering a targeted set of messages to the group of new dads (Fletcher et al. 2018). The messages would facilitate the reframing of the roles appropriated to these men, so they feel more confident in the neonatal intensive care unit and have access to a suite of coping skills (Fletcher et al., 2019).

This paper describes a positivist approach to establish a useful, supportive and validated bank of messages that could be sensitively delivered to dads whose babies are born prematurely and are admitted to a neonatal intensive care unit (May & Fletcher, 2017).

Early Arrivals – Supporting Fathers of Premature Babies -


Reviewers awarded a score to each message from 1 – lowest importance/usefulness to 5 – highest importance. Tallies of responses enabled a total score for each message which informed the key points. Variation of opinion is reflected in the third column of the tables where the % of participants who ranked the message as one of the two most or least useful in the group is displayed.

Early Arrivals – Supporting Fathers of Premature Babies -
Early Arrivals – Supporting Fathers of Premature Babies -
Early Arrivals – Supporting Fathers of Premature Babies -


Threats to internal validity were selection bias and the novel measuring instrument.

The sample size was small but represented a diverse range of expertise and experience.

Early Arrivals – Supporting Fathers of Premature Babies -


A set of eight validated text messages for fathers with premature babies in NICU was identified by a multi-disciplinary reference group using an iterative, consultative process previously utilised by SMS4dads.

It is recommended that the messages complement the standard corpus of messages in SMS4dads to achieve gender equality and improve health outcomes in this context driven by a public health approach.

Early Arrivals – Supporting Fathers of Premature Babies -


Early Arrivals – Supporting Fathers of Premature Babies -


Australian Institute of Health and Welfare. (2020). Australia’s mothers and babies 2018—in brief. Canberra: AIHW.

Fletcher, R., Matthey, S., & Marley, C. (2006). Addressing depression and anxiety among new fathers. Medical Journal of Australia, 185(8), 461–463. https://doi.org/10.5694/j.1326-5377.2006.tb00650.x

Fletcher, R. (2011). Field testing of father‐inclusive guidelines for web‐based information and support aimed at families with perinatal depression. Health Promotion Journal of Australia, 22(3), 231–233. https://doi.org/10.1071/HE11231

Fletcher, R., Feeman, E., Garfield, C., & Vimpani, G. (2011). The effects of early paternal depression on children’s development. Medical Journal of Australia, 195(11-12), 685–689. https://doi.org/10.5694/mja11.10192

Fletcher, R., May, C., Wroe, J., Hall, P., Cooke, D., Rawlinson, C., Redfern, J. & Kelly, B. (2016). Development of a set of mobile phone text messages designed for new fathers. Journal of Reproductive and Infant Psychology, 34:5, 525-534, DOI: 10.1080/02646838.2016.1214250

Fletcher, R., May, C., Kay Lambkin, F., Gemmill, A., Cann, W., Nicholson, J., Rawlinson, C., Milgrom, J., Highet, N., Foureur, M., Bennett, E., & Skinner, G. (2017a). SMS4dads: Providing information and support to new fathers through mobile phones – a pilot study. Advances in Mental Health, 15(2), 121–131. https://doi.org/10.1080/18387357.2016.1245586

Fletcher, R., Kay-Lambkin, F., May, C., Oldmeadow, C., Attia, J., & Leigh, L. (2017b). Supporting men through their transition to fatherhood with messages delivered to their smartphones: a feasibility study of SMS4dads. BMC Public Health, 17(1), 1–10. https://doi.org/10.1186/s12889-017-4978-0

Fletcher, R., May, C., Attia, J., Garfield, C., Skinner, G., & Fletcher, R. (2018). Text-Based Program Addressing the Mental Health of Soon-to-be and New Fathers (SMS4dads): Protocol for a Randomized Controlled Trial. JMIR Research Protocols, 7(2), e37–e37. https://doi.org/10.2196/resprot.8368

Fletcher, R., Knight, T., Macdonald, J., & StGeorge, J. (2019). Process evaluation of text-based support for fathers during the transition to fatherhood (SMS4dads): mechanisms of impact. BMC Psychology, 7(1), 63. https://doi.org/10.1186/s40359-019-0338-4

Fletcher, R., Symonds, I., Warland, J., Stark, M., Dowse, E., Tait, J., Margrie, F., Mattner, H., Feeley, N. (n.d.) Message content for a text-based, mobile phone intervention for fathers of infants in intensive care or deceased: A rapid systematic review. [Manuscript submitted for publication]. Faculty of Health and Medicine, The University of Newcastle.

Goldstein, Z., Rosen, B., Howlett, A., Anderson, M., & Herman, D. (2020). Interventions for paternal perinatal depression: A systematic review. Journal of Affective Disorders, 265, 505–510. https://doi.org/10.1016/j.jad.2019.12.029

Govindaswamy, P., Laing, S., Waters, D., Walker, K., Spence, K., & Badawi, N. (2019). Needs and stressors of parents of term and near-term infants in the NICU: A systematic review with best practice guidelines. Early Human Development. 139, 104839. https://doi.org/10.1016/j.earlhumdev.2019.104839

Hedwig J. A. van Bakel & Ruby A. S. Hall (2020) The Father-infant relationship beyond caregiving sensitivity, Attachment & Human Development, 22:1, 27-31, DOI: 10.1080/14616734.2019.1589058

Kan, M., & Feinberg, M. (2014). Can a family-focused, transition-to-parenthood program prevent parent and partner aggression among couples with young children? Violence and Victims., 29(6), 967–980. https://doi.org/10.1891/0886-6708.vv-d-12-00162

Maastrup, R., Weis, J., Engsig, A. B., Johannsen, K. L., & Zoffmann, V. (2018). ‘Now she has become my daughter’: parents’ early experiences of skin-to-skin contact with extremely preterm infants. Scandinavian journal of caring sciences32(2), 545–553. https://doi.org/10.1111/scs.12478

May, C., & Fletcher, R. (2019). The development and application of a protocol for the writing, assessing, and validating of a corpus of relationship-focused text messages for new and expecting fathers. Health Informatics Journal, 25(2), 240–246. https://doi.org/10.1177/1460458217704249

ntropy data. (2020). https://www.ntropydata.com/

Provenzi, L., & Santoro, E. (2015). The lived experience of fathers of preterm infants in the Neonatal Intensive Care Unit: a systematic review of qualitative studies. Journal of Clinical Nursing, 24(13-14), 1784–1794. https://doi.org/10.1111/jocn.12828

Redfern, J., Thiagalingam, A., Jan, S., Whittaker, R., Hackett, M., Mooney, J., De Keizer, L., Hillis, G., Chow, C. (2014). Development of a set of mobile phone text messages designed for prevention of recurrent cardiovascular events. European Journal of Preventive Cardiology, 21(4), 492–499. https://doi.org/10.1177/2047487312449416

Roque, A., Lasiuk, G. C., Radünz, V., & Hegadoren, K. (2017). Scoping review of the mental health of parents of infants in the NICU. Journal of obstetric, gynecologic, and neonatal nursing: JOGNN46(4), 576–587. https://doi.org/10.1016/j.jogn.2017.02.005

Rowe, H. J., & Fisher, J. R. W. (2015). Prevention of postnatal mental health problems in women: Knowledge exchange in primary care in Victoria, Australia. Health Promotion Journal of Australia, 26(1), 64-69. doi: http://dx.doi.org.ezproxy.lib.uts.edu.au/10.1071/HE14062

Serlachius, A., Hames, J., Juth, V., Garton, D., Rowley, S., & Petrie, K. (2018). Parental experiences of family-centred care from admission to discharge in the neonatal intensive care unit. Journal of Paediatrics and Child Health., 54(11), 1227–1233. https://doi.org/10.1111/jpc.14063

Sisson, H., Jones, C., Williams, R., & Lachanudis, L. (2015). Metaethnographic synthesis of fathers’ experiences of the Neonatal Intensive Care Unit environment during hospitalization of their premature infants. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 44(4), 471–480. https://doi.org/10.1111/1552-6909.12662

Treherne, S. C., Feeley, N., Charbonneau, L., & Axelin, A. (2017). Parents’ perspectives of closeness and separation with their preterm infants in the NICU. Journal of obstetric, gynaecologic, and neonatal nursing: JOGNN46(5), 737–747. https://doi.org/10.1016/j.jogn.2017.07.005

Richard Fletcher

Associate Professor, PhD

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