Paternal postpartum depression: emotional and social availability for women in the early postnatal period

02 January 2025
Volume 33 · Issue 1

Abstract

Midwives are in an optimum position to address the mental health of new fathers and paternal perinatal mental health is a recognised concern. However, the mechanisms that exist to recognise, escalate and intervene appropriately are limited in scope and effectiveness. Screening tools may have the potential to identify fathers at risk of postpartum depression, but they are limited in sensitivity and specificity, meaning that when there may be deterioration in a partner's mental health, diagnosis may not follow. This has implications for the health and wellbeing of the family, especially if male partners are relied upon as the mainstay of emotional and social support for women in the early postnatal period. To actualise strategies to address these issues, changes in policy, education and practice are required. Recommendations for research, education and patient engagement are made to assure early intervention and to ensure that emotional and social support in the family is optimised.

Postpartum depression is a mental health condition that affects both men and women following childbirth (Gedzyk-Nieman, 2021). Paternal postpartum depression is less recognised; in comparison to maternal postpartum depression, research remains limited and screening is not routine (Swami et al, 2020). It has been reported that around 8% of fathers experience paternal postpartum depression, but factors such as associated stigma may reduce the accuracy of prevalence estimates (Rao et al, 2020). Furthermore, a recent evidence review by the Scottish Government (2024) highlighted the varience in reported prevalence, with quoted rates ranging from 4–25% in first-time fathers, emphasising the lack of accuracy in determining the extent of the issue.

The incidence of paternal postpartum depression increases incrementally with maternal postpartum depression, with rates as high as 50% reported in this context (Wang et al, 2021). Although imprecise, these rates suggest that there may be opportunities to recognise the risk of paternal postpartum depression early, when midwifery care is being provided. This article discusses the extent to which paternal postpartum depression is considered by midwives in the childbearing journey and suggests that changes are required to enhance recognition and early intervention.

Paternal postpartum depression: why is this important for midwives to consider?

While 1 in 1000 births are registered to same sex couples, in the UK, 91% of fathers are present throughout the continuum of maternity care (Davies, 2018), and it is mostly men that provide practical and emotional support to their female partner in the early postnatal period; this is support that women want and need (Burgess and Goldman, 2018). Partners are often the first to recognise changes in a new mother's mental health and play an important role in the prevention and treatment of mental health disorders (Pilkington et al, 2016). This support is vital. Between 6 weeks and 1 year postpartum, 40% of maternal deaths have been attributed to mental ill health, with suicide being the leading cause (Knight et al, 2023). Additionally, there has been an exponential increase in perinatal mental illness after the COVID-19 pandemic, with a subsequent increase in demand for services (Kasaven et al, 2023). Many men may find they are not prepared for a role as a carer; first-time fathers in particular report a lack of caring experience and many feel emotionally unequipped to provide the level of care required in the early postnatal period (Daniele, 2021). As a result, men may find themselves emotionally overwhelmed in the early postnatal period, compounded by lack of preparedness and the impact of the birth experience.

The risk of paternal postpartum depression may go unnoticed, as the focus of early postnatal care is usually on the mother and baby (National Institute of Health and Care Excellence (NICE), 2021). This results in healthcare professionals, such as midwives or health visitors, being less vigilant or less likely to inquire about fathers, and with no routine screening for paternal postpartum depression in the UK, many fathers may slip through the gaps. Many men's reluctance to access mental health services or disclose how they feel to healthcare professionals, family or friends further reduces the likelihood of diagnosing paternal postpartum depression (Sedlier et al, 2020). This is compounded by the social stigma of mental ill health in men, traditional gender roles and the expectation for fathers to be the providers and protectors of the family, despite their own fears and anxieties (Darwin et al, 2017). Moreover, support available to women from a male partner is sometimes assumed (Mongan et al, 2023). With this additional reliance on men as carers, there is a need to consider whether maternity care is an opportunity to recognise, escalate and mobilise care to meet the mental health needs of men in the postnatal period.

The role of the midwife in paternal postpartum depression

NICE (2014) guidance focuses on the assessment, diagnosis and management of postpartum depression in women only. This means that there is no care requirement by midwives, the lead professional in the early postnatal period, to assess the quality of support available from the male partner. However, even if this was a requirement, there are challenges with both the presentation of paternal postpartum depression and the validity and specificity of assessment tools. NICE (2022) recommends that diagnosis of postpartum depression should be made using criteria from the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013). While this can be used for men and women, onset and how paternal postpartum depression presents are likely to differ.

The manual defines peripartum depression as a major depressive disorder that occurs within 4 weeks after birth or during pregnancy; however, research suggests that the onset of paternal postpartum depression is more likely to occur between 3 and 6 months after birth (Cameron et al, 2016). Women with maternal postpartum depression are commonly tearful and anxious, while men are more likely to display anger or hostility and participate in avoidance behaviour, such as working additional hours and spending time away from the family unit (Berg and Ahmed, 2016). Substance and alcohol misuse is also more likely in men and, when compared to those without paternal postpartum depression symptoms, the risk of suicide is increased (Quevedo et al, 2011; Bruno et al, 2020). Long-term effects on children have also been documented, such as behavioural and emotional issues and an increased risk of psychiatric morbidity in early adulthood (Gutierrez-Galve et al, 2019).

Raised awareness among midwives and new mothers regarding the differences in how postpartum depression may present is required to increase early identification and intervention. Early intervention strategies include holistic family-focused interventions based on thresholds of need, where professional and social support is mobilised for families at risk rather than depending on screening or diagnosis before mobilising support. Examples of this include the Family Nurse Partnership (Gov.uk, 2024) and the LEAP project (Lambeth Early Action Partnership, 2024).

There is an opportunity for midwives to recognise existing risk factors for paternal postpartum depression, such as maternal postpartum depression or traumatic birth, and request a review at the 6-week postnatal check with a GP or health visitor during the transfer of care. However, this does not provide any safety net for those without known risk factors. Blanket screening may help in avoiding this situation, but the timing, professional responsibility and appropriateness of screening tools will also require consideration.

Diagnosing: challenges and solutions

For women, NICE (2014) recommend the use of the Edinburgh postnatal depression scale or the patient health questionnaire if professionals have concerns about women with the symptoms of postpartum depression. The Edinburgh postnatal depression scale is a screening tool designed to detect symptoms of depression in women specific to the postnatal period (Cox et al, 1987). The patient health questionnaire is not a screening tool but monitors the severity of depression and has been validated for use in primary care (Kroenke et al, 2001). It is not specific to the postnatal period and research on its effectiveness with regards to paternal postpartum depression is limited.

One comparison study with Chinese men reported that the Edinburgh postnatal depression scale was significantly more accurate than both the patient health questionnaire and Beck depression inventory (Lai et al, 2010). Some researchers have validated use of the Edinburgh postnatal depression scale for men, but a systematic review and meta-analysis of studies (Shafian et al, 2022) included only one UK study by Edmondson et al (2010). Furthermore, an agreed cut-off score to indicate if onward referral is required remains debatable (Shafian et al, 2022). This is an important factor in the screening process as, where accuracy is reduced, the potential for false positive and false negative assessments increases, resulting in either missed or unnecessary referrals (World Health Organization, 2020). This reduction in sensitivity and specificity also has cost implications for service providers, as expenditure is likely to be greater in the absence of an effective screening and treatment programme (Wilkinson et al, 2017). Looking at other screening tools for use with fathers in the postnatal period may be advantageous.

Research is much needed and timely, as an accurate screening tool for use in the early postnatal period will enable accurate data on prevalence alongside identifying a need for care provision, with all the benefits that this entails for the individual and family unit (Pollard, 2016). One way to expedite research findings in this area would be to ensure that fatherhood status is routinely included in the demographic profile in research on depression in men.

While establishing the point of care where such a screening tool could be introduced presents a challenge, opportunities exist, such as at the 6-week postnatal check. Facilitating this would require significant changes in policy and improvements in practice to ensure that midwives and the primary care team possess the necessary skills and that the needs and expectations of parents, service users and providers are met (Gilworth et al, 2020). Antenatal care and parent education may be an ideal opportunity for midwives to increase awareness among expectant parents of the signs, symptoms and risk factors for paternal postpartum depression. One example of this could be displaying posters in areas where fathers are most likely to spend time, such as anomaly scan waiting areas. However, even with access to this information, fathers may still be reluctant to engage with services. Given reports of short-term effects on infants (Gutierrez-Galve et al, 2019), screening at intervals throughout the first year following birth may provide the best opportunity to recognise and identify paternal postpartum depression.

Such provision would require additional training to enable screening by midwives, which will have an impact on workload and incur additional costs to services. However, the cost versus benefits of screening for paternal postpartum depression compared to not screening is likely to be significant (Asper et al, 2018), providing an economic and public health argument for the inclusion of paternal postpartum depression screening in routine healthcare for new families.

Conclusions

Further UK-based research to identify accurate prevalence rates is required to establish the extent of paternal postpartum depression. In addition, validation of appropriate screening methods is needed alongside a complete package of service provision, including antenatal education for parents, in particular fathers, about the prevalence, risks, signs and symptoms of paternal postpartum depression. This may enable improved recognition of paternal postpartum depression and encourage more men to seek help. Finally, embedding paternal postpartum depression screening into routine maternity care may optimise early diagnosis, treatment and early intervention, improving outcomes not just for men, but for the whole family unit in both the short and long term.

Key points

  • The health of the maternal-paternal-infant triad is fundamental to the health of the family.
  • The early postnatal period is a time of flux and readjustment, which midwives are well placed to address.
  • Midwifery mobilisation of paternal support should include assessment of paternal emotional availability.
  • Early intervention in the early postnatal period requires interprofessional working to ensure that the needs of the family are met.
  • Tools available to enable screening for paternal postpartum depression are limited in their effectiveness; therefore, providing holistic family-focused care may be compromised.
  • CPD reflective questions

  • How would you assess the availability of consistent maternal support in the early postnatal period?
  • What early interventions can midwives initiate to aid transition to parenthood for woman and their partners?
  • How can interprofessional interactions be maximised in the postnatal period to enable family support?
  • What opportunities are available for midwives to influence the professional dialogue around effective screening, diagnosis and intervention for maternal and paternal postpartum depression?