Fathers may be unintentionally marginalised by perinatal health services and by the maternal focus of social practices surrounding new babies.
There is increasing recognition that a father’s depression and anxiety in the perinatal period can have serious consequences for his family.
Health services could better support new fathers by providing them with information on parenting from a father’s perspective, or by running father-specific sessions as part of routine antenatal care programs.
The birth of his first child marks one of the most profound changes a man may undergo, transforming his standing in the community, his most intimate relationships and his identity. Yet he may come to the moment of his infant’s birth naïvely, unprepared for the speed of the changes taking place, and unaware of the range and depth of the demands he will face (Box). In the interests of the new baby, it is important for the father to be ready to provide care and sustenance and to support the mother in her new role, but it is also important for him to have the mental and emotional resources needed to form a secure and nourishing relationship with his child.
Supporting men who need assistance in preparing for fatherhood may arguably be seen as a public health responsibility. However, even a cursory scan of existing perinatal health services reveals that few of them are designed to meet a father’s specific needs.1,2
In a bygone era, a father’s lack of engagement and his relegation to the role of “anonymous helper” by health services may have been appropriate, from both the perspective of social mores and our understanding of child development. Today, a central community expectation of fathers is that they will nurture and care for their offspring. Belatedly, the scientific study of fathers is also shifting towards exploring their impact on the development of infants and young children, and health services are being called into question about the mother-centred bias in their clinics and programs.
In the past few years, the importance of a woman’s emotional health during the transition to parenthood has been increasingly recognised, to the extent that routine psychosocial screening has been proposed, or implemented, in several sites in Australia.3-6 A debate has now begun on the need to provide a similar service for men,2,7 given what we know about the mental health of men during this transition, as outlined below.
When a new mother is distressed, there is a reasonable likelihood that the father may also be distressed;8,9 in 50% of couples where the mother is depressed, so is the father.10 In addition, the rate of diagnosed anxiety or depressive disorders in new fathers at 6 weeks postpartum is around 2%–5%,11,12 and a recent Australian study found that a new father’s experience of the antenatal period is more stressful than the postnatal period.13 Mood disorders among fathers have consequences for their offspring. A father’s postnatal depression may exacerbate the effects of the mother’s depression on their child’s development, and children with two depressed parents are at an elevated risk of social, psychological and cognitive deficits.14,15 Well fathers, on the other hand, have been shown to have a buffering effect against the detrimental consequences of a mother’s depression on the infant’s wellbeing.16,17
A father’s depression alone can also negatively affect infant development. After controlling for maternal depression and later paternal depression, having a father who was depressed at 8 weeks postpartum was found to double the risk of behavioural and emotional problems in children at 3.5 years of age.18 These findings, which mirror the well documented impact of maternal postnatal depression on infants and children, strongly suggest that when assessing the health of a new family, the man’s emotional health should be considered alongside that of the woman’s. This has triggered the debate regarding potential benefits to the community if health services consider the emotional health of both mother and father during the transition to parenthood.2,7
Economic and cultural factors may make it impossible for new fathers to accompany their partners to every health service visit. However, more could be done to provide for a father’s need for support when he does attend with his partner, and specific information on their role as fathers could be directed to men during the perinatal period.
Many couples attend classes to prepare for childbirth. In recent times, some services have piloted the inclusion of father-specific sessions in these programs, usually facilitated by male health workers. In one region where father-only sessions have been established as part of standard antenatal care, an evaluation study found that fathers valued the opportunity to discuss their parenting role with other fathers and strongly endorsed the value of the session.19 In addition, a randomised controlled trial has been conducted that included expectant fathers in a parenthood preparation session focusing on postnatal emotional adjustment for the couple.20 This study found that the emotional adjustment of mothers was significantly enhanced due to her partner’s increased awareness of what she was experiencing. Such programs could be expanded to become part of routine care across all health services, providing a more active focus on the partnership between mothers and fathers, as well as supporting the father’s role.
Men in the age group 20–35 years rarely seek medical advice unless they have acute symptoms, and are reluctant to seek advice regarding emotional health issues.21,22 Regular contact with mothers during the perinatal period through antenatal clinics, general practitioners and early childhood clinics provides an opportunity to supply information for their partners on parenting from a father’s perspective. This will assist new fathers to distinguish between mood disorders and the normal stress occasioned by a new baby, and to make them aware of existing support services. Clinicians could provide information and advice for expectant or new fathers, either directly to an attending father or to the mother, along with a self-assessment tool such as the Edinburgh Postnatal Depression Scale (EPDS).23 This scale, which has been validated for use by English-speaking fathers postnatally,24 is already widely used in antenatal and postnatal assessment of mothers and is freely available as a “self-test”,25 although it is important to note that different cut-off scores to those validated for women need to be used when screening for a mood or anxiety disorder in men.24 Advice about the common stresses experienced by new fathers and the use of the EPDS as an aid to seeking appropriate help (from his GP, for example) could be included, as well as a letter or brochure outlining the importance of a father’s wellbeing to himself and his family.
Pamphlets describing a father’s role in infant wellbeing and providing brief guides and checklists have been produced by various health and education bodies, and many of these are available at low cost. Support for fathers via the perinatal clinic could also be provided by remote services, using a dedicated telephone help line, such as one being piloted in the United Kingdom for new fathers during the perinatal period.1
Services in Australia are matching (and sometimes leading) those in other countries with respect to assessing and providing support for psychosocial health in expectant and new mothers. Given the impact of both parents’ emotional health on each other and their children, it is timely to now consider ways that similar services can be provided for expectant and new fathers. We have put forward some suggestions regarding such male-oriented services, and would hope that an evaluation is performed of whatever services are offered so that a sound evidence base can be built up, to assist clinical services in the future.
The new father’s role — usual arrangements*
When Michelle and Anthony attend Michelle’s general practitioner after a positive pregnancy test, Anthony expresses his support but asks few questions. When asked about the couple’s intentions for pregnancy care, Anthony’s quick glance towards Michelle flags his uncertainty. For the following visits, Michelle attends the clinic alone. Anthony does participate in the ultrasound consultation and he joins in when prompted during the antenatal classes, but he accepts that the emphasis throughout is appropriately on the mother and ensuring a successful birth. During the birth, he wonders if he is in the way and is grateful in the end that the mother and baby are healthy. After the birth, when the home visiting nurse arrives, Anthony goes to make coffee and misses most of the discussion. His return to work precludes him attending the doctor’s checkups for mother and baby.
Anthony’s minimal involvement with health professionals is mirrored at home and in social settings. Michelle reads the books, brochures and magazines and tells Anthony about popular names, baby development, and the dangers of SIDS (sudden infant death syndrome). Anthony is affectionately ribbed by workmates about sleep deprivation and nappy changing, and although one of his mates has also just become a father, Anthony has little chance to learn about the business of fathering. Social time with the new baby is dominated by eager mothers or girlfriends and there are few opportunities for Anthony to try out “holding the new baby” without drawing unwanted attention to himself.
* This scenario captures important elements of the situation of new fathers and is based on the combined experience of the authors, including 20 years in family general practice, interviews, research, and facilitating educational and therapy groups for fathers.
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