This Clinical Opinion points to a potential conflict between the scarcity of evidence on paternal preconception risk factors for adverse pregnancy outcomes and the view that preconception care should be also directed at men. We argue that from an ethical perspective, responsible fatherhood starts already before conception, as long as the evidence increases on the benefits of paternal preconception lifestyle (modification). Our explorative study suggests that the strength of the evidence for paternal preconception lifestyle modification is important for men. We argue that 5 aspects together determine the moral responsibility of prospective fathers to modify their behavior: the strength of the evidence of the risk factor, the modifiability of the risk, the efforts necessary to eliminate or diminish the risk factor, the severity of harm, and the probability that harm will occur and that it will be prevented by modifying the risk factor. The case of paternal preconception smoking illustrates the analysis.
To further improve the health of future children, it is suggested that preconception care should also be directed at men. Improving the outcome of pregnancy through preconception care for men comprises 2 component actions. The first is to inform prospective fathers adequately, thereby improving their knowledge. The second is for these prospective fathers to modify their individual behavior based on the knowledge gained.
Tailored preconception counseling about unhealthy dietary and lifestyle behaviors appeared to be feasible and seems to decrease the prevalence of harmful behaviors in the short term for a target groups of subfertile couples in an outpatient tertiary clinic. However, evidence of the effects of paternal preconception lifestyle, and of the modification of that lifestyle, on the health of future children is scarce. Moreover, research on men’s willingness to engage in preconception care is lacking. This raises the question whether the suggestion to direct preconception care also at men is at odds with the scarcity of evidence.
In this Clinical Opinion, we will discuss whether the suggestion to direct preconception care at men and the scarcity of evidence are at conflict. We start with investigating whether there is a moral basis for expecting men to engage in preconception care. Next, we will discuss the findings of our explorative study. Then we will argue that risk factors for adverse pregnancy outcomes have 5 aspects that together determine how much effort can be expected of prospective parents to prevent harm inflicted on the future child: the strength of the evidence of the risk factor, the modifiability of the risk, the efforts necessary to eliminate or diminish the risk factor, the severity of harm, and the probability that harm will occur. We will finally indicate what preconception care for men could look like.
Early responsible fatherhood
Whereas most reproductive interventions are directed at women only (and possibly men in a supportive role), preconception care can involve men as well. Men and women contribute equally at conception by each providing 50% of the genetic material. Preconception care provides an opportunity for paternal involvement before pregnancy through offering men information and, if necessary, making interventions. (Strictly speaking, during preconception there is not yet a father and thus no paternal involvement. Throughout this Clinical Opinion, however, we also include the preconceptional period when using the terms, paternal or fatherhood.)
Prospective fathers can contribute to the future child’s health by, as recommended in this journal in 2008, “undergoing a comprehensive medical evaluation” and modifying “any high-risk behaviors or poorly controlled disease states before conception is attempted”.
There is much literature on fatherhood that reports on absent and uninvolved fathers. In a paper about ways to improve paternal involvement in pregnancy outcomes, Bond et al defined paternal involvement in pregnancy outcomes as “activities or practices by the male partner and a couple anticipating birth that ideally lead to an optimal pregnancy outcome.” In other words, paternal preconception involvement is the effort made by men to optimize the future child’s health.
The father as progenitor and the father as carer
Ives et al argued that men see fatherhood as a dyadic concept: the father as progenitor and the father as carer. In an interview study, the authors found that men considered the father as progenitor as a state of being and the father as carer as a state of doing. Only the father as carer was valued as moral fatherhood because it was assumed that men needed to make an effort to be a successful father and failing to do so led to being judged as a bad father. The father as progenitor, on the other hand, was not a good or a bad father; he only produced children.
According to this view, a man was a father as progenitor only before conception. However, if evidence increases and it becomes clear that the prospective father’s preconception health matters as well and that men must make an effort to optimize the health of future children, the moral distinction between these 2 types of fatherhood no longer holds. By generating evidence on the effects of improving men’s preconception health, the distinction between the father as progenitor and the father as carer disappears: both types of fatherhood have a moral dimension. Thus, from an ethical perspective, responsible fatherhood will already start before conception as long as evidence increases on the benefits of paternal preconception lifestyle (modification).
The father as progenitor and the father as carer
Ives et al argued that men see fatherhood as a dyadic concept: the father as progenitor and the father as carer. In an interview study, the authors found that men considered the father as progenitor as a state of being and the father as carer as a state of doing. Only the father as carer was valued as moral fatherhood because it was assumed that men needed to make an effort to be a successful father and failing to do so led to being judged as a bad father. The father as progenitor, on the other hand, was not a good or a bad father; he only produced children.
According to this view, a man was a father as progenitor only before conception. However, if evidence increases and it becomes clear that the prospective father’s preconception health matters as well and that men must make an effort to optimize the health of future children, the moral distinction between these 2 types of fatherhood no longer holds. By generating evidence on the effects of improving men’s preconception health, the distinction between the father as progenitor and the father as carer disappears: both types of fatherhood have a moral dimension. Thus, from an ethical perspective, responsible fatherhood will already start before conception as long as evidence increases on the benefits of paternal preconception lifestyle (modification).
Explorative interview study
What views do men have on this perspective of early fatherhood? (We recognize that the empirical part of this study is unusually short. This interview study, however, has been conducted for explorative purposes only. Further research is needed to verify these preliminary results. In this Clinical Opinion, the ethical analysis plays a central role instead.)
For explorative purposes, we interviewed 9 men about their attitudes towards paternal preconception lifestyle modification: 8 without children who had a latent or active child wish and 1 young father (key questions in Table 1 ). (According to Dutch law, no review by the institutional review board is needed for this type of study. All respondents were adequately informed on the study before participating, and all agreed to participate.) All respondents perceived birth or the prenatal period as the start of paternal responsibilities. However, when potential benefits of preconception lifestyle modification for their future children’s health were pointed out to them, almost all (n = 8) acknowledged that paternal responsibilities could already start before pregnancy.
| What do you consider to be good fatherhood and what responsibilities come along with it? |
| When does parental responsibility begin? |
| What do you do to prepare for fatherhood? |
| To what extent do you believe that your lifestyle affects your future child’s health? |
| Are you willing to adjust your lifestyle if that is recommended? |
| Some lifestyle adjustments are expected but not proven to positively affect the birth outcome. Does the lack of proof change your intention to adjust your lifestyle? |
| Who would you prefer to provide you with paternal preconception lifestyle information? |
Another finding of this small inventory was that the majority of respondents demanded strong evidence of the effects of lifestyle and lifestyle modification to consider lifestyle modification before pregnancy. They were in principle not unwilling to modify their lifestyle, but they needed to be convinced of the benefits with evidence-based facts (eg, “I need to be convinced that there is a causal relation and then I will modify my lifestyle. I am a real critic; I can’t apply vague assumptions”).
The importance of evidence reappeared when asked which provider they preferred for preconception care. The men’s answers varied (general practitioner, midwife, gynecologist, special counselor), but they gave the same reason: they wanted to receive information or care from the real specialist. That specialist must be able to convince them with evidence, preferably using exact percentages, and should have answers to all their questions. For example, they said, “I get many contradictory pieces of advice, so it would be useful to attain clarity from an expert.”
This exploration suggests that prospective fathers recognize the ethical importance of evidence regarding paternal preconception lifestyle (modification). Motivation for lifestyle changes before conception seems to be based on evidence. When evidence is lacking or weak, this is apparently a barrier.
The prevention of harm
In the following section, we will further discuss the role of evidence and other aspects that play a role in what one may reasonably expect of prospective fathers. A general moral principle is the principle of nonmaleficence, which prescribes the prevention of harm. Applied to the role-specific responsibility of a prospective father, this moral principle prescribes the prevention of harm to his future child as well as harm to his partner, the prospective mother. Because there are many kinds of potential harm, we will first illustrate our argumentation with a case before addressing the question of how much effort we may expect from prospective fathers.
Case: paternal preconception smoking
For many paternal preconception lifestyle risk factors for adverse pregnancy outcomes such as alcohol use and various occupational exposures, findings are not consistent yet. We here focus on 1 of the few risk factors for which there is evidence: regular paternal preconception cigarette smoking. In the literature, emphasis lies on the direct harm of smoking. However, from an ethical perspective, it is important to distinguish between direct and indirect harm, both with respect to the future child and with respect to the partner.
Direct harm
Cigarette smoking is known to cause deoxyribonucleic acid (DNA) damage in sperm. Sperm containing DNA lesions can still fertilize an ovum, which may lead to pathology in the offspring. There is an association that seems to be evidence based between paternal preconception smoking and childhood acute lymphoblastic leukemia (ALL). Liu et al found that the association between preconception smoking and the chance that a child develops ALL is increased by 25%, and Milne et al found this increase to be 44% for the paternal smoking of 20 or more cigarettes per day around the time of conception. The potential harm to the child caused by a prospective father’s preconception smoking behavior, we call direct harm. Smoking fewer cigarettes seems to carry less risk. Adverse effects of preconception smoking are likely to be reversed by removing the exposure.
It should be noted that the studies discussed focus on the relative risk of the behavior, which is the increased chance of the future child developing childhood ALL. The relative risk is considerable (25-44%). However, considering the absolute risk, we must acknowledge that it is very small. Between 1973 and 1998, the incidence rate in the United States of ALL for children and adolescents younger than 20 years old was almost 27 per million (0.0027%). The adjusted incidence rate based on a presumed increase of 25% is about 34 per million (0.0034%).
The smoking behavior of the prospective father may have a direct adverse effect on the prospective mother as well, by exposing her to second-hand smoke. Reducing the number of smoked cigarettes indoors is likely to reduce harm, and smoking outside could bypass this direct harm altogether.
Indirect harm
Although maternal preconception smoking has not been associated with childhood ALL, there is wide consensus that maternal smoking during pregnancy has adverse health effects on both the pregnant woman and the future child, such as prematurity, and mortality. To prevent these kinds of harm, women should be encouraged to stop smoking before pregnancy. The prospective mother’s smoking behavior is associated with that of the prospective father. When a prospective father smokes, chances are smaller that a prospective mother wants and succeeds to stop smoking. So paternal preconception cigarette smoking also has indirect adverse effects on the woman’s health and therefore on the child’s health. Paternal smoking cessation thus reduces the chance that indirect harm is inflicted upon the partner and future child. It should be noted that this indirect harm is only relevant in the case that the mother smokes.
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