Women and Birth
Volume 21, Issue 2 , Pages 65-70, June 2008

Bringing birth-related paternal depression to the fore

  • Marina Schumacher

      Affiliations

    • Faculty of Medicine, University of Caxias do Sul, Brazil
    • ,
  • Carlos Zubaran

      Affiliations

    • Faculty of Medicine, University of Caxias do Sul, Brazil
    • Department of Psychiatry, Blacktown Hospital, NSW 2148, Australia
    • Corresponding Author InformationCorresponding author at: Department of Psychiatry, Blacktown Hospital, NSW 2148, Australia. Tel.: +61 2 9881 8000; fax: +61 2 9881 8535.
    • ,
  • Gillian White

      Affiliations

    • School of Health Sciences, Massey University, New Zealand

Received 18 October 2007; received in revised form 17 March 2008; accepted 25 March 2008.

Article Outline

Summary 

Objectives

Maternal postpartum depression is a prevalent health disorder with important consequences to the family and child development. Research evidence demonstrates that fathers can also suffer from psychological distress in the postpartum period and that paternal depression has a detrimental effect on the child's behavioral and emotional development. This study aims to review the current literature available about birth-related paternal depression.

Method

A literature search from 1980 to 2007 was conducted through Medline electronic database, using the following Mesh terms: postpartum, postnatal, depression, fathers and paternal. Studies on maternal postpartum depression that examined issues related to paternal depression were also selected.

Results

Understanding about paternal depressive disorders during the postnatal period has advanced considerably in the last decade. Various studies demonstrate that birth-related paternal depression is a significant problem and closely associated with maternal depressive symptoms. Children of depressive fathers are also at risk for emotional and behavioral problems.

Conclusions

Men may suffer from psychological distress after childbirth and birth-related paternal depression is not a rare phenomenon. Since this disorder, also called ‘paternal postpartum depression’, presents potential deleterious effects for the child, an increased level of public health awareness and scientific interest is warranted. In addition, a more detailed assessment of fathers during the postnatal period is recommended, especially when their partners are also depressed, so that the condition will be promptly recognized and treated.

Keywords: Postpartum period, Puerperal disorders, Paternal behavior, Depression, Psychological adaptation

 

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Introduction 

Mood disturbances represent a common disorder during the postpartum period and can present with different degrees of severity.1 Postpartum depression refers to a non-psychotic depressive illness of moderate severity that affects about 13% of women in the first 3 months after birth.2 Much attention has been paid to women suffering from postpartum depression and the importance of emotional health during the transition to parenthood has been increasingly recognized.3 The consequences of postpartum depression affect the mother, the child and the family causing matrimonial conflict and damaging the child's social and cognitive development.1, 4, 5

The diagnosis of postpartum depression is infrequent despite its significant incidence and morbidity. It is often masked by normal postpartum behaviors such as the mother's reactions during the adjustment period to the new physiologic, social and behavioral conditions.6 The routine use of screening scales with the purpose of identifying characteristic or suggestive symptoms of depression is an effective way to overcome such difficulties.7 Some of them are specifically designed for detecting postpartum depression, like the Edinburgh Postnatal Depression Scale (EPDS)8 and the Postpartum Depression Screening Scale (PDSS).9

The World Health Organization (WHO) advocates that depression can be reliably diagnosed and treated in primary care settings.10 Primary health care was defined by the WHO as an “essential health care based on practical, scientifically sound and socially acceptable methods and technology, made universally available to individuals and families in the community”.11 This concept is based on the principles of accessible, comprehensive and continuous assistance and relates both to health care practice and health service delivery, which is promoted by primary care clinicians including physicians, nurses, midwives or other health workers properly trained for this purpose. Midwives have been considered as ideal primary health care providers due to their philosophy of care centered on the promotion of women's health.12

There is some evidence that men also experience depression after the birth of a child, and that paternal depression is linked to maternal depression.13, 14, 15 When a mother is depressed, there is a reasonable likelihood that the father may also present depressive symptoms.14 Although the emotional life of fathers in this period has been overlooked, leaving birth-related paternal depression a relatively unrecognized phenomenon, the number of scientific publications on paternal depression during the partner's postpartum period has been increasing considerably. A growing number of studies on postpartum depression in women have also taken note of the father's psychological well-being, but few studies focus on paternal depression exclusively.14, 15, 16, 17, 18, 19

In fact, there is no unanimity on the terminology used to describe this phenomenon. It has been stated that “paternal postpartum depression is neither a commonly used term nor a commonly recognized phenomenon”.13 Only a limited number of publications refer to ‘paternal postpartum depression’ while others refer to “postpartum psychiatric disorder, depressed mood, and distress”.13 Furthermore, pre-clinical and clinical evidence indicate that parental behavior is significantly influential on the development and well-being of offspring. These studies endorse the idea that disrupted parenting can produce a deleterious effect on neurobehavioral and neurobiological development of the offspring.20, 21 Additional evidence correlates women's postpartum emotional disturbances to their children's poorer outcomes.5, 22, 23 Mood disorders among fathers also have consequences for the infant because birth-related paternal depression may exacerbate the effects of mother's depression on the development of their babies.22, 23

In a longitudinal cohort study including 8431 men, it was observed that depression in fathers during the postnatal period was associated with a deleterious impact on emotional and behavioral development in children aged 3.5 years and with an increased risk of conduct problems in boys.19 Such association was evident in the form of behavioral symptoms (alterations of conduct and hyperactivity), rather than emotional symptoms (affliction and sadness). The risk for developing behavior problems at age 3–5 years remains significant even after treatment and control of depression in the mothers and other associated factors were accounted for.19

A mounting body of scientific evidence indicates that fathers can experience anxiety and somatization in the postpartum period.14, 24, 25, 26 This condition can evolve into a frank depression episode, which may be associated to alcohol and drug abuse.14, 16, 19 There is still insufficient public health awareness about birth-related paternal depression, which consequently hinders its prompt recognition and effective treatment. The objective of this work is to review the current knowledge about birth-related depression in fathers.

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Method 

A literature search was conducted through Medline electronic database, using the following Mesh terms: postpartum, postnatal, depression, fathers and paternal. The literature search was focused on publications from 1980 to 2007. Some studies about maternal postpartum depression were also reviewed, especially those including references about incidences of paternal depression. The selected articles for review contain a series of topics related to ‘paternal postpartum depression’, including assessment tools, predictors of paternal depression, the relationship with maternal depressive disorders and consequences for child development. A total of 30 articles specifically associated to birth-related paternal depression were selected. This review study also adds very recent research evidence not formerly included in any review publication on ‘paternal postpartum depression’.

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Birth-related paternal depression: clinical and epidemiological findings 

The impact of childbearing differs between men and women, and in comparison to motherhood, the father–infant relationship has not attracted much attention until recently.25 Yet, a growing number of studies are demonstrating that depressive symptoms also occur in fathers and that paternal depression in the postpartum period is not uncommon.13

Research projects on fatherhood or specifically on paternal depression are sparse.14, 15, 16, 17, 18, 19, 27 A pioneering study in this field is the Australian First Time Fathers, which was a prospective study on the specific issues faced by men during their transition to parenthood.16 This study demonstrated that, although there is no increased risk for men of developing depression after the birth of their first child, the majority of men experience significant distress when their partners are pregnant. The time of maximal distress among men going through the transition to first-time fatherhood happens when their partners are in early stages of the third trimester of pregnancy. Pregnancy rather than the postnatal period appears to be the most stressful period for men undergoing the transition to parenthood, which coincides with the male perception of a dramatic decline in sexual activity.16

It has been recognized that men can present depressive symptoms such as exhaustion, irritability, and despair in the period following childbirth, which can make them prone to poor disposition to parent their children. Similarly to what has been observed in mothers, these mood changes, when manifested during the first year after birth, can result in unfavorable effects on infant development.17

Goodman,13 in a review of 20 studies of postpartum depression that also included rates of paternal depression during the first year after birth, reported an incidence of depression in community-based sample of fathers that ranged from a low of 1.2% to a high of 25.5%. However, among men whose partners were also experiencing depressive symptoms, the incidence was 24–50%. In addition, Matthey et al.28, 29 demonstrated that the rate of diagnosed anxiety and other mood diseases like acute adjustment disorder and panic disorder in new fathers at 6 weeks postpartum is around 2–5%. These very divergent findings reflect different methods and cut-off points used.15

There are several risk factors for depressive symptoms among men preceding and following the birth of a child.17 Among expectant fathers, psychological distress, defined as a score of >4 on the general health questionnaire (GHQ),30 was associated with a range of psychological variables, including neuroticism and immaturity, as well as with unplanned pregnancy, poor marital relationship and deficient social networks. Higher rates of depression have been found for those men who are unemployed, who have less satisfactory relationship with their partners, and who have less emotional and social support from family and friends.17 Fathers who had insufficient information about pregnancy and childbirth were also at risk of being distressed, suggesting that more attention needs to be paid to providing information to men about their partner's pregnancy, childbirth and issues relating to caring for a newborn infant.27

A previous history of depression and the presence of depression in their wives or partners during pregnancy or soon after birth is also associated with a higher incidence of depression.31 A correlation between family structure and occurrence of depressive symptoms has also been reported. Men in stepfamilies and partners of single mothers are at higher risk for developing depressive symptoms than men from traditional families.17 There is evidence that depression in fathers begins after the onset of depression in women,29 although paternal depression does not consist of a transient phenomenon.32, 33 Ballard et al.32 reported that approximately 5.4% of fathers depressed at 6 weeks postpartum remained with symptoms at 6 months postpartum. This finding has been replicated by Zelkowitz et al.,33 who also observed a high rate of fathers still presenting depressive symptoms within same period.

Men may manifest depressive disorders in ways that differ from women, and symptoms cannot be recognized by current diagnostic systems.34 Depression in new fathers is usually problematical to recognize as symptoms can be interpreted as natural anxieties about changing social and financial conditions.35 Men may even fear ridicule if drawing attention to their own needs “after all women go through in childbirth” and delay seeking treatment. In fact, data from a study of 148 couples indicate that postpartum anxiety and depression in new fathers may be symptoms of a same diagnostic entity rather than distinct comorbid disorders.24 Studies have also shown that anger attacks, affective rigidity, self-criticism, alcohol and drug abuse occur more often in men suffering from depression, and some authors refer to these symptoms as the male depressive syndrome.36 In addition, during the transition to fatherhood, men can present somatic symptoms like indigestion, increased or decreased appetite, weight gain, diarrhea or constipation, headache, toothache, nausea and insomnia, a condition know as Couvade syndrome.37 Couvade syndrome is still a poorly understood phenomenon that usually occurs during the third gestational month, with a secondary rise in the late third trimester, and its psychiatric symptoms include depression, anxiety, irritability and hypochondria, which generally resolve with childbirth.37, 38

Due to the differences between men and women on the expression of depressive symptoms, the dimension of men's psychological distress may not be detected by the current self-report instruments or diagnostic interviews used for women. However, the EPDS, which is the most known and used screening tool in women, was validated in an Australian male population by Matthey et al.18 According to this study, the EPDS is a reliable and valid instrument to assess fathers in the postpartum period, and it should be used not only to detect depressive disorders but also anxiety. Nevertheless, the cut-off score of ≥13 that is widely used to indicate a probable depressive disorder in women39 is not adequate for men, to whom a lower cut-off point is recommended.18 Analysis of the EPDS for fathers revealed that a cut-off of 5/6 displayed optimal performance, while for mothers the optimum cut-off screening value was 7/8.18 Condon et al.16 emphasized the importance of developing another method to detect depressive disorders in men in order to identify symptoms that traditional instruments are not capable to assess, such as anger attacks, affective rigidity, self-criticism, alcohol and drug abuse. Madsen et al.15 identified depressive fathers using both the EPDS and another scale specifically developed for men called The Gotland Male Depression Scale. The latter instrument was designed to improve the recognition of major depression episodes through a typical male depressive symptomatology.36 In this study, it was observed that both instruments can estimate the prevalence of depression in fathers at 6 weeks postpartum. However, not only male-specific symptoms have to be considered when traditional tools are used but also more reliable methods still need to be developed.15

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Association between paternal and maternal depression in the postnatal period 

Several investigations have identified maternal depressive symptoms as the most important predictor for paternal depression in the postnatal period.17, 29, 31, 32, 33, 40, 41 Most of these studies demonstrated that depression in one partner is significantly correlated with depression in the other, and fathers are more likely to be depressed if their partner is experiencing postpartum depression.17, 31, 32, 33, 41 A study conducted by Pinheiro et al. demonstrated an association between paternal depression and moderate to severe maternal depressive symptoms between the 6th and 12th weeks postpartum.42

The prevalence of postpartum depression in both parents has also been investigated.26, 41 Raskin et al. found that in 4.7% of couples both parents present depressive symptoms at 8 weeks postpartum, whereas Soliday et al. found a rate of 19.6% of depressed couples at approximately 1 month postpartum.26, 41 Matthey et al.29 did not find any association between maternal and paternal depression during pregnancy, but this association increased throughout the first year postpartum, reaching the highest rates of distress in both parents 1 year after birth.

The causal relationship between postpartum depression in women and men is unclear, but it is known that when a mother is severely depressed, the risk of partners developing depression is high, with almost 50% of them presenting depressive symptoms.43 Some studies reported that male partners of depressed women felt less supported and experienced fear, confusion, frustration, helplessness, anger, disrupted family and uncertainty about future.44

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Implications for clinical practice and primary health care 

Core competencies for basic midwifery practice contribute to the scope of midwifery practice in both professional and policy arenas.45 However, the concept of “scope of practice” is dynamic as its breadth and depth evolve with new technology, advanced education, and research findings.46 Scope of practice has been used to describe the practice of midwives, to identify clients for whom midwives can provide care, and to assist in the development of additional practice guidelines.

There are inflexible boundaries as mandated by the law of the country and adjustable clinical parameters that vary according to midwifery experience, the practice setting, clinical context, collaborative relationships and community needs. In best practice scenarios where midwives provide continuity of care throughout the antenatal, intrapartum, and postpartum periods, a trustworthy and friendly relationship with the couple is developed as a result of a positive professional alliance. Yet, in all models of health care, midwives can be trained to detect early warning signs of a paternal distress. After all, midwives are usually the professionals in the best position for early recognition of birth-related parental depression due to their most intimate contact with the family at this meaningful time. Evidently the performance of diagnostic evaluations of a father's mental state is not a plausible part of the midwifery scope of practice. Despite of this limitation and in view of current evidence regarding depression in new fathers and its impact, if left untreated, upon the family unit, marital relations and child's development, it is incumbent upon the midwife to be alert to the needs of the new father. Rather than being engaged exclusively to care for the mother and baby, the midwife has an ethical responsibility to the family as every significant other influences maternal well-being. Focusing on the family as a unit extends the clinical parameters of midwives and brings with it an obligation to inform the family if there is any sort of professional concern.

As long ago as 1984 formal screening for prepartum mood disorders was proposed for expectant parents in recognition of its strong prediction of depression following birth.47 It has been advocated that obstetric health care workers should pay greater attention to new fathers.48 In response to this demand the United States Department of Health and Human Services and the National Institute of Mental Health have initiated interventions to help men handle the transition to fatherhood.49 Although economic and cultural factors may hinder the participation of new fathers in every health service visit of their partners, supplementary initiatives such as father-specific sessions to prepare for childbirth are being developed.14 Evaluation studies found that fathers included in parenthood preparation sessions presented an increased awareness of the maternal experience and as a result the emotional adjustment of the mother was significantly ameliorated. Such antenatal care programs could be expanded to become part of the routine care across all health services.50, 51 In the early postpartum period, priority should be given to the identification of families in which both parents are depressed and the screening of men whose partners are depressed after childbirth. Fathers whose screening indicate depression should be consequently referred to mental health care providers.13

The educational innovations in contemporary midwifery portray its solid foundations and provide direction for the future. Continued innovation and creativity will be required to prepare midwives for the 21st century.52 The implementation of a primary health focus to midwifery practice represents a strategic approach to new societal challenges.53 In order to contribute meaningfully to the betterment of society midwives and allied health professionals should participate actively in the generation of efficient alternatives to face the global health challenges of a rapidly changing world.54

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Conclusions 

While becoming a parent is generally a rewarding life experience, this major life transition can be a trigger for depression and/or anxiety. The transition to parenthood cause important changes and a great psychological impact in both mothers and fathers. Birth-related paternal depression is a very new research agenda and there are no consensual paradigms on this issue. However, paternal depression is a clinically meaningful phenomenon that causes important emotional and behavioral problems to the child as well. Fathers should be evaluated for mood disorders, especially when their partners are depressed. In addition, a more profound evaluation of postnatal adjustment for the couple is recommended. Finally, more research is needed in this area, so that additional epidemiological, clinical and cultural data are gathered, which will ultimately favor the advancement of knowledge in this rather forsaken scientific domain.

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Acknowledgments 

We kindly thank Dr. Katia Foresti-Zubaran, Mrs. Andrea Pavan and Mr. Marcelo Roxo for their valuable assistance during distinct phases of this study. This study was partially supported by grant #000605-25.00/03-8 from the Secretaria de Ciência e Tecnologia do Estado do Rio Grande do Sul, Brazil.

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PII: S1871-5192(08)00026-7

doi:10.1016/j.wombi.2008.03.008

Women and Birth
Volume 21, Issue 2 , Pages 65-70, June 2008

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