Paternal perinatal mental health: evidence review

4. Factors affecting paternal perinatal mental health

The perinatal period is complex and life changing as people prepare for the birth of their child and experience the subsequent adjustment to parenthood. It can be a stressful time, with changes to lifestyles and routines sometimes significantly impacting on the mental wellbeing of both parents (Pinto, 2015). The following section reports on some of the factors that can affect paternal mental health during the perinatal period. These include, how men experience childbirth, lifestyle changes, hormonal changes and experiences of gendered social expectations and norms.

4.1. Fathers’ experiences of childbirth

There has been a recent increase in research exploring how giving birth can affect the mental health of mothers. Recent studies, for example, have found that unplanned caesareans are associated with psychological distress and a higher risk of women developing postnatal depression (Dekel et al., 2019; Tonei & Valentina, 2018). The potentially stress-causing nature of childbirth has also been found to have negative mental health implications for fathers during the perinatal period.

Multiple studies have noted that fear of childbirth can impact on the mental health of fathers (Shibli-Kometiani & Brown, 2012; Etheridge & Slade, 2017; Schytt & Bergström. 2014; Hildingsson et al., 2014). Findings from the UK Born and Bred in Yorkshire (BaBY) study – a long-term study of the health and wellbeing of babies born in Yorkshire and their parents from pregnancy onwards - showed that anxieties about childbirth were a source of stress for men during pregnancy (Darwin et al., 2017). This was particularly the case for fathers who had experienced a previous difficult birth.

Research has also shown that fathers can develop symptoms of PTSD from witnessing their partner having a traumatic birth and other perinatal traumas (Daniels et al., 2020). Other aspects of childbirth that can affect fathers mental health include sudden changes to the birth plan, emergency caesarean, post-birth complications and feelings of inadequate care received from staff. A feeling of a lack of control around the unfolding of the birth may also increase the likelihood of it being perceived as traumatic by fathers (Daniels et al., 2020).

4.2. Lifestyle changes

The changes to lifestyles and routines that follow becoming a parent can significantly impact on the mental wellbeing of parents (Saxbe et al., 2018). Becoming a father commonly necessitates lifestyle changes due to increasing responsibilities while caring for the new baby, financial concerns, changes in marital/partner lifestyle, reduced or disrupted sleep, reduced social life and experiencing uncertainty in a new role as a father. Becoming a father can also alter how men perceive their place in the family (Pedersen et al., 2021) and lead to shifts in family dynamics (Kowlessar et al., 2015).

The lifestyle changes that accompany becoming a parent can also be a source of stress for fathers (Darwin et al., 2021). Fathers have reported difficulties balancing the competing demands of family, work and their own needs, and struggling with impaired relationships and breakdowns in communication with their partners (Edhborg et al., 2016).

A driver of these stresses may be that men are unprepared for the changes to their lives that follow becoming a father. For example, research has found that men’s expectations of parenthood can be unrealistic and that the changes they experience to their lives were accompanied by feelings of frustration, disappointment, distress, and disruption to other aspects of their lifestyle (Goodman, 2005). It may also be the case that the mental health impacts of becoming a father are more confined to first time-parents. Ferketich and Mercer (1995), for example, studied fetal attachment in experienced and inexperienced fathers as a predictor of paternal-infant attachment over the first 8 months after birth. They found that fathers with older children reported fewer symptoms of depression and anxiety than first-time fathers. They suggest this was due to existing fathers being able to adjust more easily on account of knowing what to expect once their child was born.

Parents commonly have to adjust their sleep patterns in the weeks after their child is born and some may experience problems with their sleep such as poor sleep quality, interrupted sleep or no sleep at all, which may result in potential mood disorders such as depression and anxiety. A qualitative study by Darwin et al. (2017) based on fathers’ views and experiences of their own mental health during pregnancy and the first postnatal year described how men attributed changes to sleep as one of the demands of early parenting that resulted in greater stress. A quantitative study from Australia by MacDonald et al. (2021) reported on 204 fathers from four independent cohorts. They noted how self-reported sleep problems in the first three years postpartum were consistently associated with concurrent symptoms of depression, anxiety and stress. Using both qualitative and quantitative data, a study by Chhabra, Li and McDermott (2022) on the potential risk factors associated with paternal perinatal mental distress in a sample of Australian men, identified sleep disturbances as a risk factor for PPD and PPA.

For men who are vulnerable to depression, anxiety or stress, the disruption to sleep patterns when an infant is in the home may contribute to the onset or maintenance of symptoms of mental ill health (Da Costa et al., 2019). A 2019 scoping review of paternal sleep up to 12 months postpartum and fathers’ wellbeing identified evidence of associations between fathers’ sleep problems and poorer mental health, disrupted relationships with partners, and reduced safety compliance at work (Wynter et al., 2020). Similarly, toddler sleep disruption is associated with lower marital satisfaction and higher parenting stress among fathers (Bernier et al., 2013).

4.3. Hormonal changes

While female hormones have long been known to change during pregnancy, there is now growing evidence of how changes to men’s hormones may impact their behaviour and mental health during the perinatal period (Edelstein et al., 2015; Grebe et al., 2019). Testosterone, for example, has been shown to decline during the transition to parenthood (Saxbe et al, 2017). Research suggests that changes in paternal testosterone levels may be indicative of fathers' investment in pair-bonding and caregiving and, therefore, may be associated with maternal and familial well-being. For example, in comparison to those who offer little or no care for their children, fathers who actively take greater care of their children's needs were shown to have lower testosterone levels (Edelstein et al., 2015; Grebe et al., 2019).

Changes in paternal testosterone levels, both increasing and decreasing, have also been linked with both maternal and paternal depressive symptoms, fathering stress, and intimate partner aggression following the birth of a child. A study by Saxbe et al. (2017) looked at testosterone samples from fathers when infants were approximately nine months old and reported postpartum depressive symptoms from both parents at two, nine and 15 months postpartum. The findings described how higher paternal testosterone predicted adverse family outcomes, specifically fathering stress and intimate partner aggression at 15 months postpartum, as well as depression risks among partners.

4.4. Emotional changes

While impending fatherhood may be viewed as a positive experience before birth (Hambidge et al., 2021), the arrival of a baby can cause fathers to feel unhappy, inadequate and overwhelmed, as becoming a father may not result in the improvements and personal growth they had hoped for or anticipated (Hambidge et al., 2021; Pedersen et al., 2021). Expectations among fathers that they should be strong enough to manage challenges when becoming a parent can lead to feelings of inadequacy (Pedersen et al., 2021).

Emotional changes during the perinatal period can have physical and behavioural manifestations and may include difficulty concentrating at work and experiencing headaches (Darwin et al., 2017). Men often do not associate these symptoms with mental health difficulties experienced during the perinatal period, instead attributing them to general fatigue (Darwin et al., 2017).

4.5. Gender social constructs

Research has shown that some fathers may find it difficult to engage with their infant children, especially their sons, due to prevalent stereotypes that attribute activities, such as playing and cooing, to mothers, and to avoid being considered “feminine” or “weak” (Singley & Edwards, 2017). Men can also experience difficulties if they feel a disconnect between a more traditional male gender role and contemporary expectations of fathering behaviour, which in some cases may lead to the development of mental health concerns including anxiety and depression (Singley & Edwards, 2015).

Many men consider their roles during the perinatal period as being primarily about providing financial and emotional support to their partners (Benoit & Magnus, 2017; Singley & Edwards, 2017). When combined with long-standing observations about how masculinity norms, stereotypes, and ideologies that are related to reduced help-seeking behaviour among men – often associated with feelings relating to the importance of self-reliance, physical toughness, and emotional control (Addis & Mahalik, 2003) - this can mean that men are at greater risk of masking symptoms of poor mental health through anger, irritation, substance use and withdrawal (Rabinowitz & Cochron, 2008).

A qualitative study by Ghaleiha et al. (2022), explored how fathers navigated their transition to fatherhood and whether and how they sought help and advice. It showed how fathers viewed their role as being defined by the financial, emotional, and psychological support they offered to their partners and children. This perspective resonates with the findings from other studies showing how fathers viewed themselves as "protectors," "providers," and "role models" for their families (Benoit & Magnus, 2017; Darwin et al., 2017). The pressure of these roles can make balancing work and family life during the perinatal period challenging for men. For example, research has shown that some fathers spend more time at work to help manage feelings of added pressure to provide for their family financially (Chhabra et al., 2022; Cooklin et al., 2015; Ghaleiha et al., 2022; Singley & Edwards, 2017).

4.6. Relationships with partners

How parents adjust to parenthood is heavily influenced by the nature of their relationship with one another (Singley & Edwards, 2017). Positive coparenting relationships – which are characterised by shared decision-making, sensitivity and respect for each other's viewpoints - have been found to correlate with a reduced incidence of depression symptoms (Giallo et al., 2013; Herman & Newland, 2022). Likewise, research suggests that satisfaction in the spousal relationship contributes to less anxiety during the transition to parenthood for both men and women (Don et al., 2014). Contrastingly, relationship dissatisfaction has been identified as a risk factor for PPD (Gawlik et al., 2014; Singley & Edwards, 2017).