Risk Factors for Paternal Perinatal Depression and Anxiety...paternal depression in the postnatal...

Risk Factors for Paternal Perinatal Depression and Anxiety: A SystematicReview and Meta-Analysis

Jasleen Chhabra, Brett McDermott, and Wendy LiJames Cook University

This article aims to identify the risk factors associated with paternal perinatal depression and anxiety.Studies published between January 1950 and December 2017 that report paternal depression and anxietyin the perinatal period were obtained from 5 different databases. In total, 84 studies were included in thesystematic review, and 31,310 participants from 45 studies were included in the final meta-analysis. Riskfactors obtained were classified based on the frequency of distribution of factors. Maternal depression isan important risk factor for fathers in the postnatal period (odds ratio [OR] � 3.34, 95% confidenceinterval [CI; 2.51, 4.46]). Marital distress was also linked to a twofold increase in the likelihood ofpaternal depression in the postnatal period (OR � 2.16, 95% CI [1.47, 3.19]). Parenting stress as a riskfactor was strongly and significantly associated with paternal anxiety in perinatal period (OR � 14.38,95% CI [7.39, 27.97]). The findings suggest that maternal depression, marital distress, and parental stressare important risk factors for fathers’ mental health in the perinatal period. The current meta-analysis alsoidentifies gender role stress, domestic violence, and mismatched expectancies from pregnancy andchildbirth as the risk factors that are unique to fathers only in the perinatal period. Future interventionprograms should screen and target fathers with no previous children, or a depressed partner, and aim toenhance relationship satisfaction.

Public Significance StatementLike women, men also show signs and symptoms of depression and anxiety in the perinatal period.Meta-analysis revealed that partner’s depression, marital distress, and parenting stress are significantrisk factors to fathers’ mental health in perinatal period. Counteracting these risk factors may reducethe risk of depression and anxiety in fathers in the perinatal period.

Keywords: depression, anxiety, fathers, pregnancy, childbirth

Depression is a common but serious mental health concern(World Health Organization [WHO], 2017). Depression is a typeof mood disorder characterized by anhedonia, loss of appetite,sleep disturbance, low energy, and typical cognitions such ashopelessness (American Psychiatric Association, 2018). Accord-ing to the WHO (2017), 322 million people suffered from depres-sion in 2015. Between 2005 and 2015, the total estimated preva-lence of depression had increased by 18.4%. In most cases,depression co-occurs with anxiety. Anxiety is defined as a feeling

of excessive fear and worry, with anticipation of future threat andis characterized by somatic symptoms such as palpitations, sweat-ing, and trembling (American Psychiatric Association, 2018). Theglobal prevalence of anxiety in 2015 was about 264 million or3.6% of the world population (WHO, 2017).

The symptoms of depression and anxiety can be elevated bystressful situations such as trauma and major life events (e.g.,pregnancy and childbirth). Several studies have established a re-lationship between pregnancy and childbirth and elevated depres-sive and anxiety symptoms (Gavin et al., 2005; Gaynes et al.,2005; Goodman, 2004). Depression or anxiety experienced duringpregnancy (first trimester until third trimester) is known as prena-tal depression or anxiety. Postnatal anxiety or depression occursafter childbirth and up to 1 year after the birth of the infant. Thus,depression or anxiety that occurs from the first trimester of preg-nancy up to 12 months after childbirth is collectively termedperinatal depression or anxiety (American Psychiatric Association,2018).

The impact of depression and anxiety on mental health duringthe perinatal period has been studied extensively among mothersbut has received much less attention in relation to fathers (Dudley,Roy, Kelk, & Bernard, 2001). Although fathers’ mental health hasonly received more focus over the past decade, studies have foundthat a significant portion of fathers also suffer from depression and

This article was published Online First February 27, 2020.X Jasleen Chhabra, Department of Psychology, College of Healthcare

Sciences, James Cook University; Brett McDermott, Department of Med-icine, College of Medicine and Dentistry, James Cook University; WendyLi, Department of Psychology, College of Healthcare Sciences, JamesCook University.

Some of the data and ideas in the manuscript were presented at Austra-lian Psychological Association 2018 and Asian Association of SocialPsychology conferences in 2019.

Correspondence concerning this article should be addressed to JasleenChhabra, Department of Psychology, College of Healthcare Sciences,James Cook University, 1 James Cook Drive, Townsville, Queensland4811, Australia. E-mail: [email protected]

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Psychology of Men & Masculinities © 2020 American Psychological Association2020, Vol. 21, No. 4, 593–611 ISSN: 1524-9220 http://dx.doi.org/10.1037/men0000259

593

https://orcid.org/0000-0002-2814-7114

mailto:[email protected]

http://dx.doi.org/10.1037/men0000259

anxiety in the perinatal period (Centre of Perinatal Excellence[COPE], 2017; Wee et al., 2013).

Giallo and colleagues (2012) reported a postnatal depressionprevalence of 10% in 3,219 Australian fathers. Gawlik et al. (2014)reported similar results in their study of new fathers in a commu-nity sample of 320 German fathers, among whom 9.8% experi-enced prenatal depression and 7.8% of fathers were depressedpostnatally. These results were replicated in a meta-analysis thatestimated the prevalence of paternal perinatal depression at 8.4%(Cameron, Sedov, & Tomfohr-Madsen, 2016). Research hasshown that the prevalence rates of non-Western perinatal de-pressed fathers are similar to those in Western countries. Mao,Zhu, and Su (2011) reported that 12.5% of Chinese fathers in theirsample reported perinatal depression. Similarly, Nishimura andOhashi (2010) reported 11.6% of Japanese fathers suffered fromperinatal depression. This rate closely aligns with the 10% prev-alence of depressed fathers in the perinatal period in samples fromthe United States and Australia (Giallo et al., 2012; Paulson &Bazemore, 2010).

Although the rates of perinatal depression are significant, it islikely that these rates underrepresent the true prevalence in fathers,given there may be a gendered context in men underreportingdepressive symptoms, leading to underdiagnoses (O’Brien et al.,2017). Although both men and women express depression as lowmood with reduced activity, depression in men may be “masked”with externalized behavior and disorders such as substance abuse,avoidance behavior, and anger (Addis, 2008; Cochran & Rabinow-itz, 2000). This masked phenomenon is termed as masked depres-sion or masculine depression (Addis, 2008). It has been hypothe-sized that due to gender norms some depressive men may displaythe aforementioned behaviors and disorders instead of overt, typ-ical depressive symptoms because these men may feel uncomfort-able or even fearful about displaying a depressive affect. More-over, many men have negative attitudes toward help-seeking, andtherefore are less likely to seek professional help as a result of thenegative attitudes (Addis, 2008; Good, Dell, & Mintz, 1989)influenced by masculine gender norms (Addis, 2008). Possiblemasculine gender norms include the traditional societally heldview of the man as the main provider or the breadwinner for thefamily, along with societal expectations of emotional inexpressive-ness, toughness, competitiveness, and of holding power overwomen (Addis & Cohane, 2005). These masculine gender normsdiscourage help-seeking when men experience depression and/oranxiety.

Similar to the frequencies for perinatal depression, studies havealso estimated the prevalence for anxiety in the perinatal period.Quinlivan and Condon (2005) and Tohotoa and colleagues (2012)estimated a prevalence of 12% of 50 fathers experiencing prenatalanxiety and 2.4% of 244 fathers experiencing postnatal anxiety,respectively, in Australia. Figueiredo and Conde (2011) reported aprevalence of 10% for prenatal anxiety among 260 Portuguesefathers. These results closely align with the estimated 3% preva-lence of paternal postnatal anxiety in 89 New Zealand fathers byCarter, Mulder, Bartram, and Darlow (2005). In their recent sys-tematic review, Leach, Poyser, Cooklin, and Giallo (2016) esti-mated the prevalence of paternal perinatal anxiety between 2 and18%. Similar to the studies in Western countries, Koh et al. (2015)estimated a prevalence of 3.4% for postnatal anxiety in 622 Chi-nese fathers and 2.6% for prenatal anxiety.

The significant prevalence of paternal perinatal depression andanxiety in both Western and non-Western countries suggests thatthe mental health of fathers is a significant public health concern.The affected population is most likely to incur the increased costof health care services associated with increased contact withgeneral practitioners, psychologists, and psychiatrists (Edoka, Pe-trou, & Ramchandani, 2011). Additionally, paternal perinatal anx-iety and depression can have a negative impact on an infant andchild’s behavior, mental health, and learning capabilities. Forexample, Ramchandani, Stein, Evans, and O’Connor (2005) re-ported in their study that a depressed father had a 109% higher riskfor having children with psychiatric disturbances. Moreover, de-pressed fathers are less likely to be engaging with their toddlerswhich may affect a child’s cognitive development (McLearn,Minkovitz, Strobino, Marks, & Hou, 2006). Furthermore, hiddenor masked depression, resulting in externalizing symptoms such asphysical illness, alcohol and drug abuse, and domestic violence,may delay treatments of depression. Research has reported thathidden depression appears to be a contributing factor of suicide inmen (Marcus, Yasamy, van Ommeren, Chisholm, & Saxena,2012).

Prevention has been identified as the key to reducing the healthcare costs in relation to paternal depression and anxiety, and thenegative impacts on children (COPE, 2017). To facilitate thedesign of prevention programs for paternal perinatal depressionand anxiety, identifying risk factors is imperative (Edoka et al.,2011).

A risk factor is defined as any characteristic or attribute theincreases the likelihood of developing a disease or injury (WHO,2017). A large body of literature has reviewed the risk factorsassociated with maternal depression and anxiety in the perinatalperiod. In their systematic review, Lancaster et al. (2010) reportedhistory of depression, lack of social support, lower income, lowereducation, smoking, single status, and poor relationship quality asrisk factors for maternal prenatal depression. In the postnatalperiod, a history of depression, unintended pregnancy, lower ed-ucation, single status, lower income, and lower education werefound to be risk factors associated with maternal postnatal depres-sion (Azad et al., 2019; Fiala, Švancara, Klánová, & Kašpárek,2017). However, similar to the research into prevalence of peri-natal mental health disorders, research into risk factors associatedwith paternal perinatal mental health has received less attentioncompared with mothers.

Several studies into risk factors associated with perinatal de-pression and anxiety in fathers have identified factors that aresimilar to risk factors identified in mothers during the perinatalperiod. Maternal depression has been found to be significantlycorrelated to paternal perinatal mental health, with published cor-relations ranging between 0.2 and 0.76 (Bielawska-Batorowicz &Kossakowska-Petrycka, 2006; Matthey, Barnett, Ungerer, & Wa-ters, 2000). Fathers are 2.5 times more likely to be depressed 6weeks postnatally if their partner is also suffering from postnataldepression (Matthey et al., 2000). Low socioeconomic status hasalso been reported to be associated with paternal perinatal mentalhealth disorders. Fathers with lower education status may havereduced chances of gaining well-paying employment (Gao, Chan,& Mao, 2009), and the arrival of a new baby may financially strainfathers who are not employed full-time (Bergström, 2013). Maritaldistress is another risk factor reported in the literature. Distress in

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594 CHHABRA, MCDERMOTT, AND LI

the marital relationship is likely to add to the stress related to thearrival of a new baby and may cause significant distress in fathersduring the perinatal period (Bergström, 2013; Nishimura, Fujita,Katsuta, Ishihara, & Ohashi, 2015). Fathers with a history ofprevious psychiatric illness are reported to be more likely to sufferdepression or anxiety during the perinatal period (Nishimura &Ohashi, 2010; Pinheiro et al., 2011; Ramchandani et al., 2008;Suto et al., 2016). Furthermore, the lack of social support is alsolikely to affect the mental health of fathers in the perinatal period.Boyce, Condon, Barton, and Corkindale (2007) suggested that intheir sample of Australian fathers, fathers were at a higher risk foremotional distress if they were dissatisfied with the social supportfrom their partner, family, and friends.

Apart from those risk factors, unplanned pregnancy (Gao et al.,2009; Nishimura & Ohashi, 2010), lack of parenting skills (Brad-ley, Slade, & Leviston, 2008; Zhang et al., 2016), and substanceabuse (Bronte-Tinkew, Moore, Matthews, & Carrano, 2007) arealso identified as risk factors for paternal perinatal depressionand anxiety. The relationship between age and new fathers’ de-pression and anxiety is inconclusive. Contradictory results havebeen found with some studies suggesting that younger age (�30years) is a risk factor for paternal perinatal mental health disorder(Bergström, 2013; Bielawska-Batorowicz & Kossakowska-Petrycka, 2006), whereas other studies suggest that older age ismore likely to be a risk factor for fathers in the perinatal period(Bronte-Tinkew et al., 2007; Ramchandani et al., 2008; Stramroodet al., 2013).

The aforementioned risk factors for paternal perinatal depres-sion and anxiety have been reported in individual studies. To theauthors’ knowledge, there is no published systematic review in thisfield that includes clearly defined inclusion and exclusion reviewcriteria and assessments of methodologic qualities of the reviewedstudies with explicit criteria of the methodological quality(Hoogendoorn, van Poppel, Bongers, Koes, & Bouter, 2000). Inthis article, a strict systematic approach has been used to identifyand summarize the risk factors for paternal perinatal depressionand anxiety in the literature, followed by a meta-analysis to esti-mate the effects of the risk factors on paternal perinatal depressionor anxiety. These methods are comparable with those in the liter-ature with regard to prevalence of paternal perinatal mental illness(Cameron et al., 2016). The current study aims to answer thefollowing research questions: (a) What are the risk factors associ-ated with paternal perinatal depression and anxiety? and (b) Whatare the unique risk factors for fathers’ perinatal depression andanxiety compared with those for mothers?

Method

A systematic review and meta-analysis on paternal perinataldepression and anxiety was conducted to identify risk factors inpeer-reviewed articles. Methodological considerations includedthe time of assessment of depression and anxiety and the measuresused to assess depression and anxiety. Risk factors were rankedbased on the frequency of the distribution of factors identifiedthrough review. Preferred Reporting Items for Systematic Reviewand Meta-Analysis (PRISMA; Figure 1) guidelines were followed(Hutton et al., 2015; Moher, Liberati, Tetzlaff, & Altman, 2009).

Search Strategy

Five electronic databases—CINAHL, Medline, PubMed, Psy-cINFO, and Scopus—were searched for articles from January 1950to December 2017 using Medical Subject Headings (MeSH) termsof fathers, dad, fatherhood, men, male, paternal, prenatal, antena-tal, pregnancy, postnatal, postpartum, childbirth, perinatal, depres-sion, anxiety, mental health disorder. Jasleen Chhabra performedsearches of all databases using these keywords and their severalcombinations (e.g., fathers or dad or fatherhood and postnatal anddepression and anxiety). The search was limited to articles pub-lished in English, in peer-reviewed journals, composed of MeSHterms within the title or abstract of the article, and contained maleparticipants over the age of 18 years.

Inclusion and Exclusion Criteria

Inclusion and exclusion criteria were applied multiple timesthroughout the entire process. Exclusion criteria included studiesnot being in English, studies which did not have keywords in eithertheir title or abstract, studies which did not include male partici-pants, participants below the age of 18 years, and studies with afocus on unhealthy infants. When full-texts were being reviewed,articles were excluded if studies were not in the perinatal period;and reviews, editorials, systematic reviews, meta-analyses, com-ments, replies, animal studies, and qualitative studies were alsoexcluded. Studies were also excluded if they used data from shareddatabases to avoid duplication of data. Studies that reported vali-dation of various depression scales were also excluded. Lastly,inclusion–exclusion criteria were applied when the studies werebeing catalogued according to the risk factors. The exclusioncriteria included studies that did not report any risk factors asso-ciated with paternal perinatal depression and anxiety. Studies thatdid not report an estimated prevalence of perinatal depressionand/or anxiety in their sample were also excluded. Studies wereexcluded if they reported prevalence of depression and/or anxietyin their sample in mean and standard deviation but not enoughinformation was provided to determine the estimated prevalence.Longitudinal studies had multiple time points when data werecollected. To compare with cross-sectional studies, the largestsample size reported in longitudinal studies was included in thereview. If the longitudinal studies had a consistent sample sizethroughout the study, then the first reported sample size wasincluded.

Study Selection

All three authors independently assessed the eligibility of theretrieved studies. Disagreement about the inclusion of a study wasresolved through discussion among the three authors. The titlesand abstracts of the articles were coded as either “yes,” “no,” or“maybe” to determine eligibility. The studies marked as “no” wereremoved and studies marked as “yes” or “maybe” were included tobe reviewed thoroughly for inclusion. If the articles did not meetthe inclusion and exclusion criteria, then they were removed fromthe review.

Quality Assessment

Eligible studies were assessed for methodological quality usingthe Mixed Methods Appraisal Tool (MMAT), which facilitates

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595PATERNAL PERINATAL DEPRESSION AND ANXIETY

appraisal of studies using common methods and methodologieswith few generic quality criteria (Pace et al., 2012). The check-list has five specific sets of criteria and has been shown to be avalid and reliable tool for methodological quality assessment(Pace et al., 2012). A study was scored out of 100 and higherscores represent higher overall methodological quality. JasleenChhabra and Brett McDermott independently scored the stud-ies. Wendy Li resolved any discrepancies noted. The MixedMethods Appraisal Tool checklist is provided at the end of thearticle (see Appendix Table A1).

Data Extraction

Jasleen Chhabra independently coded the author and year of thestudy, country of the study, sample size, time points of assessmentof depression and anxiety, methods used to assess depression andanxiety, prevalence rate of depression and anxiety in fathers, andthe associated risk factors. Brett McDermott and Wendy Li inde-pendently reviewed the table for accuracy and completeness. If astudy used multiple methods to measure the symptoms of depres-

sion and anxiety at the same time, the symptoms reported byclinical interviews was given priority over self-report measuressuch as Edinburgh Postnatal Depression Scale (Cox, Holden, &Sagovsky, 1987).

Statistical Analysis

ProMeta, version, 3.0.0. (Internovi, 2015) was used to performall major statistical analysis given the program’s ability to inputdata in various formats and create summary forest plots, z valueand p value. Outcomes were reported as odds ratios (OR). OR wasselected as the reported measure of strength between variables,given ORs were the most commonly reported statistic in theincluded studies and are easily interpretable, as well as ProMetahaving the functionality to convert other outcomes to ORs. If theincluded article reported insufficient data to calculate an OR, thenthe relevant authors were contacted to provide the data. Separatemeta-analyses were conducted for each risk factor for depressionand anxiety respectively and data pertaining to prenatal and post-natal timeframes. A random effects model was used for all anal-

Figure 1. PRISMA flow of result of systematic review and meta-analysis. PRISMA � Preferred ReportingItems for Systematic Review and Meta-Analysis.

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yses, as considerable heterogeneity (inconsistency due to variationin study results rather than inconsistency compatible with chance)was expected. Heterogeneity was assessed using I2 statistics (Hig-gins & Thompson, 2002).

Results

Characteristics of Studies

Database (i.e., CINAHL, Medline, PsycINFO, PubMed, andSCOPUS) and hand-searching resulted in a total of 995 potentiallyeligible studies between 1950 and 2017. An initial screening of thetitle and abstract resulted in 173 articles, of which 89 were ex-cluded after full-text assessment of studies. The agreement rate ofthe inclusion of a study between authors was measured by Cohen’skappa (�; Marston, 2010). Initial agreement between authors wasmoderate (� � 0.62). Further screening of the remaining 84articles resulted in the exclusion of 39 articles, leaving a final 45articles, which are included in the meta-analysis (see Figure 1).

Of the 45 studies included in this meta-analysis, the majoritywere conducted in the United States of America (n � 8), followedby Australia (n � 6) and United Kingdom (n � 5). The remainingstudies were conducted in Finland, Norway, Sweden, Japan,China, Turkey, Iran, and Italy. Sample size of the individualstudies varied considerably (n � 12–10,975). The total number ofparticipants was 31,310 fathers across the 45 studies. In all, 38studies used self-report measures such as Edinburgh PostnatalDepression Scale (Cox et al., 1987), and seven studies employeddiagnostic interviews. A total of 30 studies were cross-sectional,and 15 studies were longitudinal. Participants were mainly re-cruited from maternity hospitals/clinics, and prenatal classes werealso used to recruit participants. Summaries of each study and theirmain findings are presented in Tables 1 and 2.

Associations Between Paternal Perinatal Depressionand Risk Factors

The socioeconomic factor of low income was positively asso-ciated with paternal postnatal depression. In four studies thatinvestigated this relationship, fathers categorized as having a lowincome were approximately two times more likely to experiencepostnatal depression (OR � 2.03, 95% CI [1.83, 2.25]; Bergström,2013; Carlberg, Edhborg, & Lindberg, 2018; Nath et al., 2016;Zhang et al., 2016), with zero heterogeneity (I2 � 0%).

Maternal depression and paternal depression in the postnatalperiod were found to be positively associated. This association wasexamined in 22 studies (Anding, Röhrle, Grieshop, Schücking, &Christiansen, 2016; Areias, Kumar, Barros, & Figueiredo, 1996;Ballard, Davis, Cullen, Mohan, & Dean, 1994; Bergström, 2013;Bielawska-Batorowicz & Kossakowska-Petrycka, 2006; Carro,Grant, Gotlib, & Compas, 1993; Cattaneo et al., 2015; Escriba-Agüir & Artazcoz, 2011; Field et al., 2006; Gao et al., 2009;Goodman, 2004; Mao et al., 2011; Matthey, Barnett, Howie, &Kavanagh, 2003; Matthey et al., 2000; Nath et al., 2016; Ngai &Ngu, 2015; Nishimura et al., 2015; Pinheiro et al., 2006; Ram-chandani et al., 2008; Soliday, McCluskey-Fawcett, & O’Brien,1999; Thorpe, Dragonas, & Golding, 1992; Zhang et al., 2016).Maternal depression increased the likelihood of paternal postnataldepression more than threefold (OR � 3.51, 95% CI [2.63, 4.68],

Figure 2) with substantial heterogeneity of results (I2 � 82.74%).Maternal depression was also found to be positively associatedwith fathers’ depression in the prenatal period. This associationwas examined in two studies (Ballard et al., 1994; Matthey et al.,2000; OR � 1.86, 95% CI [1.24, 2.77]), with zero heterogeneity.

Positive associations were found between paternal postnataldepression and marital distress and lack of social support. Maritaldistress was associated with a twofold increase in the likelihood ofpaternal depression, and this association was examined by 15studies (OR � 2.16, 95% CI [1.47, 3.19], Figure 3), with substan-tial heterogeneity (I2 � 97.78%; Anding et al., 2016; Bergström,2013; Bielawska-Batorowicz & Kossakowska-Petrycka, 2006;Buist, Morse, & Durkin, 2003; Condon, Boyce, & Corkindale,2004; deMontigny, Girard, Lacharité, Dubeau, & Devault, 2013;Dudley et al., 2001; Escriba-Agüir & Artazcoz, 2011; Gawlik etal., 2014; Greenhalgh, Slade, & Spiby, 2000; Leathers & Kelley,2000; Nath et al., 2016; Nishimura et al., 2015; Roubinov, Lu-ecken, Crnic, & Gonzales, 2014; Top, Cetisli, Guclu, & Zengin,2016). Lack of social support increased the likelihood of paternalpostnatal depression more than fourfold (OR � 4.76, 95% CI[1.04, 21.73]), with substantial heterogeneity (I2 � 91.33%; Gao etal., 2009; Mao et al., 2011; Wang & Chen, 2006). Compared withmarital distress, lack of social support had a larger effect size.Marital distress and lack of social support were also positivelyassociated with fathers’ depression in the prenatal period: maritaldistress (OR � 3.32, 95% CI [2.19, 5.02]), with low heterogeneity(I2 � 46.30%; Ahlqvist-Björkroth et al., 2016; Koh, Chui, Tang, &Lee, 2014; Leathers & Kelley, 2000; Morse, Buist, & Durkin,2000; Top et al., 2016), and lack of social support (OR � 3.71,95% CI [2.19, 6.28], with zero heterogeneity (Koh et al., 2014;Wee et al., 2013).

Paternal postnatal depression and prenatal depression, history ofpsychiatric illness, and alcohol abuse were positively associated.Prenatal depression was associated with a fivefold increase in thelikelihood of paternal depression (OR � 5.20, 95% CI [3.13,8.65]), with substantial heterogeneity (I2 � 75.07%; Escriba-Agüir& Artazcoz, 2011; Gawlik et al., 2014; Hall & Long, 2007; Koh etal., 2014; Matthey et al., 2000; Ngai & Ngu, 2015; Ramchandaniet al., 2008; Soliday et al., 1999; Suto et al., 2016). History ofpsychiatric illness was associated with a more than threefoldincrease in the likelihood of paternal depression (OR � 3.30, 95%CI [1.95, 5.57]), with substantial heterogeneity (I2 � 87.36%;Areias et al., 1996; Bronte-Tinkew et al., 2007; Cattaneo et al.,2015; Nishimura et al., 2015; Nishimura & Ohashi, 2010; Ram-chandani et al., 2008; Suto et al., 2016). Alcohol abuse wasassociated with a more than twofold increase in the likelihood ofpaternal depression (OR � 2.40, 95% CI [1.86, 3.29]), with zeroheterogeneity (Bronte-Tinkew et al., 2007; Condon et al., 2004;Pinheiro et al., 2006).

Moreover, paternal postnatal depression and unplanned preg-nancy, parenting stress, and preference for a male baby werepositively associated with each other in the current meta-analysis.Unplanned pregnancy was associated with a more than threefoldincrease in the likelihood of paternal depression (OR � 3.34, 95%CI [2.13, 5.23]), with low heterogeneity (I2 � 30%; Fisher, Tran,Nguyen, & Tran, 2012; Gao et al., 2009; Nishimura & Ohashi,2010; Top et al., 2016). Parenting stress was associated with athreefold increase in the likelihood of paternal depression (OR �3.04, 95% CI [1.07, 8.64]), with substantial heterogeneity (I2 �

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Tab

le1

Maj

orC

hara

cter

isti

csof

Stud

ies,

Pre

vale

nce,

and

Ris

kF

acto

rsfo

rP

ater

nal

Dep

ress

ion

inth

eP

erin

atal

Per

iod

IDA

utho

ran

dye

arC

ount

ryT

ime

ofas

sess

men

tM

easu

reSa

mpl

esi

zeC

ases

(%)

Ris

kfa

ctor

s

1.A

hlqv

ist-

Bjö

rkro

thet

al.,

2016

Finl

and

20w

eeks

gest

atio

nE

PDS

�10

153

15(9

.8)

Mar

ital

dist

ress

2.A

ndin

get

al.,

2016

Ger

man

y2

wee

kspo

stpa

rtum

EPD

S�

1027

615

(5.4

)M

arita

ldi

stre

ss,

mat

erna

lde

pres

sion

,an

dpa

rent

alst

ress

3.A

reia

set

al.,

1996

Port

ugal

24w

eeks

gest

atio

nSA

DS

422

(4.8

)3

mon

ths

post

nata

l12

2(1

6.7)

12m

onth

spo

stna

tal

4210

(53.

7)M

ater

nal

depr

essi

onan

dhi

stor

yof

depr

essi

onin

men

4.B

alla

rdet

al.,

1994

Uni

ted

Kin

gdom

6w

eeks

post

nata

lE

PDS

�13

178

16(9

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2012

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92.88%; Anding et al., 2016; deMontigny et al., 2013; Soliday etal., 1999; Vismara et al., 2016; Zhang et al., 2016). Preference fora male baby was associated with a one and a half times increase inthe likelihood of paternal depression (OR � 1.5, 95% CI [1.04,2.38]), with zero heterogeneity (Gao et al., 2009; Mao et al., 2011).Positive association between unplanned pregnancy and paternalprenatal depression was also found in one study (Top et al., 2016).The risk factor increased the likelihood of paternal prenatal de-

pression by a more than twofold (OR � 2.68, 95% CI[1.10–6.55]).

Furthermore, work family conflict (WFC) and perceived stresswere associated with paternal depression in the postnatal period. WFCwas associated with a more than fourfold increase in the likelihood ofpaternal depression (OR � 4.85, 95% CI [1.51, 15.59]; Koh et al.,2014). Perceived stress (OR � 7.51, 95% CI [1.14, 49.52]), withsubstantial heterogeneity (I2 � 95.92%; Gao et al., 2009; Kamalifard,

Table 2Major Characteristics of Studies, Prevalence, and Risk Factors for Paternal Anxiety in the Perinatal Period

ID Author and year Country Time of assessment MeasureSample

size Case (%) Risk factors

1. Fisher et al., 2012 Vietnam Third trimester to 6weeks postnatal

SCID 231 10 (4.3) Domestic violence and unplanned pregnancy

2. Koh et al., 2015 China Early pregnancy HADS � 7 622 72 (11.6) Maternal depression, marital distress, socialsupport, and work–family conflict

36 weeks gestation 337 45 (13.4) Maternal depression and marital distress6 weeks postnatal 187 27 (14.2)

3. Matthey et al., 2003 Australia 6 week postnatal DIS 356 26 (14.1) Maternal depression4. Vismara et al., 2016 Italy 3 months postnatal STAI-S � 40 181 46 (25.4) Parenting stress

STAI-T � 40 47 (26)6 months postnatal STAI-S � 40 42 (23.2) Parenting stress

STAI-T � 40 26 (19.9)

Note. SCID � Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders; HADS � Hospital Anxiety and Depression Scale;DIS � Diagnostic Interview Schedule; STAI-S � State-Trait Anxiety Inventory–State Anxiety Scale; STAI-T � State-Trait Anxiety Inventory–TraitAnxiety Scale.

Figure 2. Forest plot of the meta-analysis of risk factor maternal depression for paternal postnatal depression.ES � effect size.

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Hasanpoor, Babapour Kheiroddin, Panahi, & Bayati Payan, 2014;Mao et al., 2011) was a larger effect. WFC was also positivelyassociated with fathers’ depression in the prenatal period, with anOR � 3.53, 95% CI [2.01, 6.23], with low heterogeneity (I2 �27.89%). This association was examined in three studies (Hall &Long, 2007; Koh et al., 2014; Top et al., 2016).

Associations Between Paternal Perinatal Anxiety andthe Relevant Factors

Maternal depression and paternal postnatal anxiety were foundto be positively associated in three studies (Koh et al., 2015;Matthey et al., 2003; Vismara et al., 2016). Maternal depressionincreased the likelihood of paternal postnatal anxiety more thanthreefold (OR � 3.86, 95% CI [2.54, 5.89], Figure 4) with zeroheterogeneity. Positive association between paternal prenatal anx-iety and maternal depression was also examined in one study (Kohet al., 2015). The factor had an OR � 1.61, 95% CI [1.18, 2.19].

Marital distress and social support were found to be positivelyassociated with paternal perinatal anxiety. One study (Koh et al.,2015) examined the association between marital distress and pa-ternal anxiety in the perinatal period. In the postnatal and prenatalperiod, marital distress increased the likelihood of paternal anxietymore than fourfold, with an OR � 4.69, 95% CI [1.73, 12.72], andOR � 4.17, 95% CI [2.45, 7.10], respectively. Social support andpaternal prenatal anxiety were also found to be positively associ-ated and the association was examined in one study (Koh et al.,2015). The factor had an OR � 1.80, 95% CI [1.34, 2.42].

Parenting stress and WFC were also positively associated withpaternal prenatal anxiety in the current meta-analysis. Parentingstress increased the likelihood of paternal anxiety in the perinatalperiod by more than 14-fold (OR � 14.38, 95% CI [7.39, 27.97],Vismara et al., 2016). WFC increased the likelihood of paternalprenatal anxiety by more than threefold (OR � 3.55, 95% CI [2.59,4.87]; Koh et al., 2015).

Associations Between Paternal Perinatal Anxiety andDepression and Unique Factors

Gender role related stress was found to be a unique factor for,and was positively associated with, paternal depression in the

perinatal period. According to Eisler and Skidmore (1987), genderrole stress has five factors: Physical Inadequacy (stress in malesrelated to fears of not being competitive physically), EmotionalExpression (stress in males related to difficulties expressing feel-ings of affection, fear, or pain), Intellectual Inferiority (stress inmales related to their coping abilities), Subordination to Women(stress in males due to perceived competitive threat from women),and Performance Failure (stress in males related to potential failureto perform up to masculine standards in the areas of work andsexual adequacy; Eisler & Skidmore, 1987). In the current meta-analysis, aspects of gender roles were only reported by Buist et al.(2003), finding positive associations between paternal postnataldepression and perceived physical inadequacy (OR � 3.55, 95%CI [2.59, 4.87]), emotional expression (OR � 10.33, 95% CI [2.96,36.04]), and intellectual inferiority (OR � 5.29, 95% CI [1.54,18.22]). The gender role related stress was also positively associ-ated with paternal depression in the prenatal period. This positiveassociation was examined in two studies (Buist et al., 2003; Morseet al., 2000). Reported associations included emotional expression(OR � 3.04, 95% CI [1.21, 7.64], with substantial heterogeneity[I2 � 64.33%]), subordination to women (OR � 2.03, 95% CI[1.02, 4.02], with low heterogeneity [I2 � 37%]), intellectualinferiority (OR � 3.33, 95% CI [1.31, 8.49], with substantialheterogeneity [I2 � 65.31%]), and performance failure (OR �4.59, 95% CI [1.60, 13.20], with substantial heterogeneity [I2 �72.54%]). An overall meta-analysis of all of the factors of genderrole stress estimated that postnatally the risk of paternal depressionincreased more than fourfold (OR � 4.66, 95% CI [2.14, 10.15],Figure 5). Meanwhile, the risk of prenatal paternal depressionincreased more than threefold (OR � 3.12, 95% CI [2.07, 4.69],Figure 6) with medium heterogeneity (I2 � 54.80%).

Mismatched expectations from pregnancy and childbirth wasalso found to be positively associated with paternal postnataldepression (Greenhalgh et al., 2000). This factor increased thelikelihood of paternal postnatal depression threefold (OR � 3.71,95% CI [1.55, 8.89]).

Domestic abuse experienced by fathers and paternal perinataldepression and anxiety were also positively associated in thecurrent meta-analysis. This factor increased the likelihood of pa-ternal perinatal depression and anxiety ninefold (OR � 9.64, 95%CI [3.50, 26.30]). This association was examined by one study(Fisher et al., 2012). Summaries of the findings from meta-analysisof risk factors are presented in Table 3.

Figure 4. Forest plot of the meta-analysis of risk factor maternal depres-sion for paternal postnatal anxiety. ES � effect size.

Figure 3. Forest plot of the meta-analysis of risk factor marital distressfor paternal postnatal depression. ES � effect size.

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Discussion

This article reports a systematic review of 45 studies with acombined sample size of 31,310 fathers. Twelve risk factors forpaternal perinatal depression were identified: low income, mater-nal depression, marital conflict, social support, prenatal depres-sion, history of psychiatric illness, alcohol abuse, unplanned preg-nancy, parenting stress, preference for a male baby, WFC, andperceived stress. Five risk factors were reported for perinatalanxiety in fathers: maternal depression, marital conflict, socialsupport, WFC, and parental stress. Three risk factors (gender rolerelated stress, mismatched expectations from pregnancy and child-birth, and domestic violence) and their associations with paternalperinatal depression and anxiety were found to be unique to fathersonly. Each risk factor and its associations were examined individ-ually, and separate meta-analyses were conducted for each riskfactor for depression and anxiety, respectively.

Using OR to determine effect size, a large effect size (OR �5)was observed for perceived stress and prenatal depression, con-curring higher risk of depression in the postnatal period amongfathers. A medium effect size (OR �2) was seen for the riskfactors low income, maternal depression, marital distress, socialsupport, history of psychiatric illness, alcohol abuse, parentingstress, and WFC in the postnatal period. In the prenatal period,marital distress, social support, unplanned pregnancy, and WFChad a medium effect size. A small effect size (OR �2) wasobserved for the preference for a male baby in the postnatal periodand maternal depression in the prenatal period.

Perceived stress is the feelings or thoughts of how much stressan individual is under at a given point in time or over a period of

time (Cohen, Kamarck, & Mermelstein, 1983). Having a baby ismost likely to add new responsibilities and stress on new fathers,such as financial stress and stress related to parenting. Along withthe addition of new responsibilities, fathers may also experiencechanges in their lifestyle and habits, which may further add to theirexperience of stress. The continuous sense of stress within allsectors of a father’s life may cause them to feel melancholic andlead to depression in the prenatal period (Mao et al., 2011).Concurrently, if the father is feeling depressed in the prenatalperiod, the stressors related to childbirth and a new baby mayaggravate the symptoms of depression in the postnatal period(Matthey et al., 2000). The result of the current meta-analysissupports the findings by Cohen et al. (1983) and Matthey et al.(2000), where a strong association between paternal postnataldepression and the risk factors of perceived stress and prenataldepression was seen.

Although perceived stress and prenatal depression had the larg-est effect size on paternal postnatal depression, studies examiningthe association between maternal depression (n � 22) and paternalpostnatal depression, and marital distress/conflict (n � 15) andpaternal postnatal depression were the statistical relationships mostfrequently reported. Maternal mental health during the perinatalperiod is an important risk factor for the mother and the mentalhealth, physical health, and behavior of the infant (Beydoun &Saftlas, 2008). Simultaneously, an interactive relationship betweenthe mental health of the fathers and mothers has also been notedpreviously (Matthey et al., 2000; Pinheiro et al., 2006). Having adepressed partner increases the risk of fathers to be depressedthemselves in the perinatal period at a rate of 2.5 times or higher

Figure 5. Forest plot of the meta-analysis of risk factor gender role stress for paternal postnatal depression.ES � effect size.

Figure 6. Forest plot of the meta-analysis of risk factor gender role stress for paternal prenatal depression.ES � effect size.

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Tab

le3

Sum

mar

yof

Met

a-A

naly

sis

ofR

isk

Fac

tors

for

Pat

erna

lA

nxie

tyan

dD

epre

ssio

nin

Bot

hP

rena

tal

and

Pos

tnat

alP

erio

d

IDR

isk

fact

or

Pren

atal

anxi

ety

Post

nata

lan

xiet

yPr

enat

alde

pres

sion

Post

nata

lde

pres

sion

OR

95%

CI

Cita

tions

OR

95%

CI

I2(%

)C

itatio

nsO

R95

%C

II2

(%)

Cita

tions

OR

95%

CI

I2(%

)C

itatio

ns

1.So

cioe

cono

mic

fact

ors

——

——

——

——

——

——

——

—L

owIn

com

e—

——

——

——

——

——

2.03

[1.8

3,2.

25]

0(B

ergs

tröm

,20

13;

Car

lber

get

al.,

2018

;N

ath

etal

.,20

16;

Zha

nget

al.,

2016

)2.

Mat

erna

lde

pres

sion

1.61

[1.1

8,2.

19]

(Koh

etal

.,20

15)

3.86

[2.5

4,5.

89]

0(K

ohet

al.,

2015

;M

atth

eyet

al.,

2003

;V

ism

ara

etal

.,20

16)

1.86

[1.2

4,2.

77]

0(B

alla

rdet

al.,

1994

;M

atth

eyet

al.,

2000

)

3.34

[2.5

1,4.

46]

82.7

4(A

ndin

get

al.,

2016

;A

reia

set

al.,

1996

;B

alla

rdet

al.,

1994

;B

ergs

tröm

,20

13;

Bie

law

ska-

Bat

orow

icz

&K

ossa

kow

ska-

Petr

ycka

,20

06;

Car

roet

al.,

1993

;C

atta

neo

etal

.,20

15;

Esc

riba

-Agü

ir&

Art

azco

z,20

11;

Fiel

det

al.,

2006

;G

aoet

al.,

2009

;G

oodm

an,

2004

;M

aoet

al.,

2011

;M

atth

eyet

al.,

2000

;M

atth

eyet

al.,

2003

;N

ath

etal

.,20

16;

Nga

i&

Ngu

,20

15;

Nis

him

ura

etal

.,20

15;

Pinh

eiro

etal

.,20

06;

Ram

chan

dani

etal

.,20

08;

Solid

ayet

al.,

1999

;T

horp

eet

al.,

1992

;Z

hang

etal

.,20

16)

3.M

arita

ldi

stre

ss4.

17[2

.45,

7.10

](K

ohet

al.,

2015

)4.

69[1

.73,

12.7

2](K

ohet

al.,

2015

)3.

32[2

.19,

5.02

]46

.30

(Ahl

qvis

t-B

jörk

roth

etal

.,20

16;

Koh

etal

.,20

14;

Lea

ther

s&

Kel

ley,

2000

;M

orse

etal

.,20

00;

Top

etal

.,20

16)

2.16

[1.4

7,3.

19]

97.7

8(A

ndin

get

al.,

2016

;B

ergs

tröm

,20

13;

Bie

law

ska-

Bat

orow

icz

&K

ossa

kow

ska-

Petr

ycka

,20

06;

Bui

stet

al.,

2003

;C

ondo

net

al.,

2004

;de

Mon

tigny

etal

.,20

13;

Dud

ley

etal

.,20

01;

Esc

riba

-Agü

ir&

Art

azco

z,20

11;

Gaw

liket

al.,

2014

;G

reen

halg

het

al.,

2000

;L

eath

ers

&K

elle

y,20

00;

Nat

het

al.,

2016

;N

ishi

mur

aet

al.,

2015

;R

oubi

nov

etal

.,20

14;

Top

etal

.,20

16)

4.So

cial

supp

ort

1.80

[1.3

4,2.

42]

(Koh

etal

.,20

15)

——

——

3.71

[2.1

9,6.

28]

0(K

ohet

al.,

2014

;W

eeet

al.,

2013

)4.

76[1

.04,

21.7

3]91

.33

(Gao

etal

.,20

09;

Mao

etal

.,20

11;

Wan

get

al.,

2006

)5.

Pren

atal

depr

essi

on—

——

——

——

——

——

5.20

[3.1

3,8.

65]

75.0

7(E

scri

ba-A

güir

&A

rtaz

coz,

2011

;G

awlik

etal

.,20

14;

Hal

l&

Lon

g,20

07;

Koh

etal

.,20

14;

Mat

they

etal

.,20

00;

Nga

i&

Ngu

,20

15;

Ram

chan

dani

etal

.,20

08;

Solid

ayet

al.,

1999

;Su

toet

al.,

2016

)6.

His

tory

ofps

ychi

atri

cill

ness

——

——

——

——

——

—3.

30[1

.95,

5.57

]87

.36

(Are

ias

etal

.,19

96;

Bro

nte-

Tin

kew

etal

.,20

07;

Cat

tane

oet

al.,

2015

;N

ishi

mur

a&

Oha

shi,

2010

;N

ishi

mur

aet

al.,

2015

;R

amch

anda

niet

al.,

2008

;Su

toet

al.,

2016

)7.

Alc

ohol

abus

e—

——

——

——

——

——

2.40

[1.8

6,3.

29]

0(B

ront

e-T

inke

wet

al.,

2007

;C

ondo

net

al.,

2004

;Pi

nhei

roet

al.,

2006

)8.

Unp

lann

edpr

egna

ncy

4.22

[1.6

,11.

3](F

ishe

ret

al.,

2012

)—

——

—2.

68[1

.10,

6.55

]—

(Top

etal

.,20

16)

3.34

[2.1

3,5.

23]

0(F

ishe

ret

al.,

2012

;G

aoet

al.,

2009

;N

ishi

mur

a&

Oha

shi,

2010

;T

opet

al.,

2016

)

Thi

sdo

cum

ent

isco

pyri

ghte

dby

the

Am

eric

anPs

ycho

logi

cal

Ass

ocia

tion

oron

eof

itsal

lied

publ

ishe

rs.

Thi

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ticle

isin

tend

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for

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oadl

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Tab

le3

(con

tinu

ed)

IDR

isk

fact

or

Pren

atal

anxi

ety

Post

nata

lan

xiet

yPr

enat

alde

pres

sion

Post

nata

lde

pres

sion

OR

95%

CI

Cita

tions

OR

95%

CI

I2(%

)C

itatio

nsO

R95

%C

II2

(%)

Cita

tions

OR

95%

CI

I2(%

)C

itatio

ns

9.Pa

rent

ing

stre

ss14

.38

[7.3

9,27

.97]

(Vis

mar

aet

al.,

2016

)—

——

——

——

—3.

04[1

.07,

8.64

]92

.88

(deM

ontig

nyet

al.,

2013

;So

liday

etal

.,19

99;

Vis

mar

aet

al.,

2016

;Z

hang

etal

.,20

16)

10.

Pref

eren

cefo

ra

mal

eba

by—

——

——

——

——

——

1.5

[1.0

4,2.

38]

0(G

aoet

al.,

2009

;M

aoet

al.,

2011

)11

.W

ork–

fam

ilyco

nflic

t3.

55[2

.59,

4.87

](K

ohet

al.,

2015

)—

——

—3.

53[2

.01,

6.23

]27

.89

(Hal

l&

Lon

g,20

07;

Koh

etal

.,20

14;

Top

etal

.,20

16)

4.85

[1.5

1,15

.59]

—(K

ohet

al.,

2014

)

12.

Perc

eive

dst

ress

——

——

——

——

——

7.51

[1.1

4,49

.52]

95.9

2(G

aoet

al.,

2009

;K

amal

ifar

det

al.,

2014

;M

aoet

al.,

2011

)13

.G

ende

rro

lest

ress

——

——

——

——

——

——

Phys

ical

inad

equa

cy—

——

——

——

——

—3.

55[2

.59,

4.87

]—

(Bui

stet

al.,

2003

)E

mot

iona

lex

pres

sion

——

——

——

3.04

[1.2

1,7.

64]

64.3

3(B

uist

etal

.,20

03;

Mor

seet

al.,

2000

)

10.3

3[2

.96,

36.0

4]—

(Bui

stet

al.,

2003

)

Subo

rdin

atio

nto

wom

en—

——

——

—2.

03[1

.02,

4.02

]37

(Bui

stet

al.,

2003

;M

orse

etal

.,20

00)

——

—

Inte

llect

ual

infe

rior

ity—

——

——

—3.

33[1

.31,

8.49

]65

.31

(Bui

stet

al.,

2003

;M

orse

etal

.,20

00)

5.29

[1.5

4,18

.22]

—(B

uist

etal

.,20

03)

Perf

orm

ance

failu

re—

——

——

—4.

59[1

.60,

13.2

0]72

.54

(Bui

stet

al.,

2003

;M

orse

etal

.,20

00)

——

——

14.

Mis

mat

ched

expe

ctat

ions

from

preg

nanc

yan

dch

ildbi

rth

——

——

——

——

——

—3.

71[1

.55,

8.89

]—

(Gre

enha

lgh

etal

.,20

00)

15.

Dom

estic

viol

ence

9.64

[3.5

,26.

3](F

ishe

ret

al.,

2012

)—

Not

e.O

R�

odds

ratio

;C

I�

conf

iden

cein

terv

al.

The

estim

ated

effe

ctsi

zeis

repo

rted

inO

R.

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ocia

tion

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ticle

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lely

for

the

pers

onal

use

ofth

ein

divi

dual

user

and

isno

tto

bedi

ssem

inat

edbr

oadl

y.


(Matthey et al., 2000; Pinheiro et al., 2006). Fathers with depressedpartners are also likely to experience conflict or distress in theirmarital relationship. With their partner being depressed, it is pos-sible that fathers are unable to communicate the difficulties andexperiences they are facing to their partner. Many factors are likelyto be interconnected. For example, depressed mothers might not beable to take care of their infant, which may further put new fathersunder pressure and thus cause them stress. Maternal depressionalone and/or diminished care for the infant may also negativelycontribute toward a worsening marital relationship betweenmother and father. This in turn may cause distress for fathers,which may lead to depression.

As previously mentioned, fathers may also suffer from financialstress after having a baby. This stress is more likely to occur infathers belonging to a lower socioeconomic group who earn abelow average salary. An unplanned pregnancy may be stressful tothe father because they did not have sufficient time to prepare fortaking care of an infant. Lack of planning may occur across severalemotional or financial domains, which may be independent orexacerbate each other, leading to depression in the perinatal pe-riod. Financial stress may also interact with perceived gender role.Fathers are often viewed as being the main provider of the family(Buist et al., 2003). Inability to fulfil this role may cause distressin fathers through a perception of their personal inadequacy ortheir perception that they are not meeting the expectations of othermales. Similarly, to the stress related to finances, fathers may alsoexperience parenting stress. If the father has no previous experi-ence of parenting, he may become uncertain, stressed, and over-whelmed and may seek assistance and support from his partner.Men tend to have a poorer social support system compared withwomen because men tend to rely primarily on their partner forsocial support (Cronenwett & Kunst-Wilson, 1981). However, ifthe father is unable to receive this support from his partner becausehis partner is depressed, this may cause him distress and maycause depression in the father. Again, these risk factors are likelyto be highly interactive: Dissatisfaction from the paternal role maybe related to increase parenting stress, both making paternal de-pression more likely. Another domain commonly affected is work.Demanding and strained situations and responsibilities at homeand fathers’ own mental health may also affect their work andinteraction with their colleagues. Again, gender role stress mayplay a contributing factor to WFC. Masculine gender norms sug-gest that men are expected to be competitive and excel in theirwork (Good et al., 1989). However, inability to achieve their bestat work due to poor perinatal mental health may cause work–family conflict and further contribute toward the deterioratingmental state of the father (Koh et al., 2014).

Fathers may also experience depression in the perinatal period ifthey have a history of a psychiatric disorder. Life events such aspregnancy and childbirth may exacerbate the symptoms of previ-ous psychiatric illness and affect the mental health of fathersduring the perinatal period. Alcohol abuse and paternal postnataldepression were also found to be positively correlated in thismeta-analysis. Research suggests that alcohol abuse and depres-sion commonly coexist in men (Zilberman, Tavares, Blume, &el-Guebaly, 2003) and that individuals with alcoholism are at a twotimes higher risk for depression (National Institute of MentalHealth, 2003). The alcohol–depression interaction is complex.Possibilities include self-medication of depressive symptoms with

alcohol or alcohol directly causing low mood. Alcohol abuse mayhave been used to mask the symptoms of depression (Cochran &Rabinowitz, 2000). In these scenarios, alcohol abuse may beconsidered as an underlying symptom of depression. Finally, fa-thers’ mental health may also be affected by their cultural expec-tations. For example, in many Asian cultures there is a preferencefor a male baby as he is expected to carry the family name and carefor his aged parents (Koh et al., 2014). If the fathers do not havea male baby, they may suffer from depression in these cultures.This was also noted in the results of the current meta-analysis asthe factor of preference for a male baby had a small effect size onpaternal perinatal depression. However, as mentioned previously,there is a lack of studies on paternal perinatal depression innon-Western countries and thus, this risk factor should be exploredfurther.

When considering paternal anxiety, a large effect size was observedfor parenting stress in the prenatal period for paternal anxiety. Amedium effect size was observed for maternal depression, maritalconflict, and social support in the postnatal period, and WFC ex-pressed a medium sized effect in the prenatal period for paternalanxiety. A small effect size was seen for maternal depression andsocial support in the prenatal period for paternal anxiety.

Similar to depression, fathers are more likely to develop anxietyduring the perinatal period if they are a new father and have not takencare of a baby previously. They are more likely to be uncertain,distressed, and unsure of how to take care of the baby and may seekassistance from their partner. If the father is not able to receive thisguidance, it may cause them distress and possible anxiety in theperinatal period. Fathers are less likely to receive this guidance andsupport from their partner if their partner is suffering from depressionthemselves during the perinatal period (Koh et al., 2015). Moreover,this may also affect the social support system of the father. Asmentioned earlier, men tend to rely heavily on their partner for socialsupport (Cronenwett & Kunst-Wilson, 1981) and if this support ismissing, it may lead to anxiety in the father. As with the previousdiscussion about paternal depression, these risk factors are likely to beinterrelated. Lack of social support and a partner’s depression maycontribute to marital conflict and thus further deteriorate the father’smental health. Financial stress may require longer hours at work, adeterioration of work–family balance, and put fathers at higher risk ofanxiety in the perinatal period. Also, similar to paternal depression,gender role conflict may contribute toward the aforementioned riskfactors and cause further distress leading to perinatal anxiety infathers. It should be noted that the associations between perinatalanxiety and the factors mentioned were examined in only three studiesand thus should be interpreted with caution, and require further study.

This analysis reported some risk factors that were unique to fathersand were associated with fathers’ depression and anxiety in theperinatal period. Unique risk factors such as low emotional expressionin men had a large effect size and increased the likelihood of paternalpostnatal depression. A medium effect size was seen for a father’sperception of physical inadequacy. In the prenatal period, low emo-tional expression, feelings of subordination to women, intellectualinferiority, and performance failure factors had a medium effect size.These factors clearly relate to the concept of masculine gender norms.Low emotional expression is often considered as behavior of a “typ-ical male.” Consequently, men may fear a negative response fromtheir peers if they share their symptoms or experience of depression(Joiner, Alfano, & Metalsky, 1992). Physical toughness and the em-

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phasis of power over women are consistent with masculine norms andmay precipitate concerns of being unable to perform to masculinestandards in the arenas of work and sexual adequacy. These masculinenorms can offer an explanation of why perceptions of physical inad-equacy, subordination to women, intellectual inferiority, and perfor-mance failure are unique risk factors for fathers’ perinatal depressionand anxiety (Buist et al., 2003). The findings add value to the existingliterature where positive correlations have been demonstrated be-tween masculine gender role conflict and elevated scores on self-report depression measures (Magovcevic & Addis, 2005; Shepard,2002).

Domestic violence toward fathers was also identified as a factorunique to men and had a large effect size in paternal perinataldepression and anxiety. Domestic violence also known as intimatepartner violence may be described as a pattern of abusive behaviors ofone or both partners in an intimate relationship (Drijber, Reijnders, &Ceelen, 2013). As mentioned before, one of the many masculinegender norms is power and control over women. The Duluth model(Pence & Paymar, 1983) exemplifies this norm by stating domesticviolence is a matter of power and control, of which only men in asystem of patriarchy are capable (Hines & Douglas, 2009), whichrules out the possibility of men experiencing domestic violence com-mitted by their partners. Thus, men who experience domestic violencemay feel embarrassed, a fear of being ridiculed, and as a result are lesslikely to seek help (McNeely, Cook, & Torres, 2001). Even if theyovercome this internal barrier, an external barrier is the availability oflimited resources that specifically cater to men (Hines & Douglas,2009). Existing literature has reported that men who experience do-mestic violence also experience greater levels of depression, stress,and other psychological and psychosomatic symptoms (Coker et al.,2002). This finding was replicated in the current meta-analysis wheredomestic violence against fathers correlated positively with perinataldepression. This risk factor challenges the common understandingthat domestic violence is exclusively perpetrated by men againstwomen.

A father’s mismatched expectations from pregnancy and child-birth had a medium effect size and is a unique factor for paternaldepression the postnatal period. During pregnancy, women are theones who experience changes in their hormones and physicalbodies and are able to feel the movement of the baby (Donaldson-Myles, 2012). Fathers could be considered as the “outsiders” tothis process and are perhaps unable to comprehend the complexityof pregnancy and childbirth. Furthermore, their expectations as aparent during the pregnancy period might not match the realityafter their children are born. Also, current resources on pregnancy,childbirth, and parenting are mainly oriented toward mothers witha clear lack of information for fathers (Greenhalgh et al., 2000).However, during the labor and after childbirth, fathers are ex-pected to play a more active role in caring for and parenting of thenew born (Greenhalgh et al., 2000). The lack of resources andexperience in parenting may cause an inconsistency between theexpectations from pregnancy and childbirth for fathers in thepostnatal period. This also challenges the masculine gender norms,as fathers may have to ask for help from their partner, and theymay question their rational coping abilities, their decision-makingcapabilities, and their intellectual capability to handle a situationassociated with parenting (Morse et al., 2000).

It is important to note that available data for comparison andevaluation of the aforementioned unique factors is minimal and

requires further study. Similar to anxiety, the unique risk factorsincluded in this meta-analysis have been examined in one or twostudies only. This limits the interpretation and conclusions that canbe drawn about these risk factors but at the same time highlightsthe areas that warrant further investigation.

This systematic review and meta-analysis provides empiricalevidence about the risk factors associated with paternal perinatalmental health; however, there are limitations. First, studies usedvarying measuring methods and cutoff scores. This lack of stan-dardization of both risk factors and outcome variables associatedwith paternal perinatal mental health makes interpretation of re-sults across studies difficult. Second, the review is populated bycross-sectional studies. The limited number of longitudinal studiesincluded in this review restricts the ability to comment on causa-tion or the relative strength of risk factor over time that is fromprenatal to postnatal period. Third, the majority of the studies usedself-report measures to quantify the risk factors associated withpaternal perinatal mental health. This makes both over- and un-derexaggeration of the symptoms and risk factors a possibility.Last, it should also be noted that a number of studies wereexcluded from the review due to stringent inclusion/exclusioncriteria such as teen fathers, fathers with infants in Natal CareIntensive Unit, previous loss of an infant, and fathers with aninfant suffering from illness. Studies were also excluded if theinformation about the reported risk factors was insufficient or ifthe contacted authors failed to respond.

Despite the limitations, the systematic review and meta-analysisis strengthened by the clear use of gold standard PRISMA guide-lines, providing a clear and transparent view into how the datawere collected and analyzed, and allows replication of the data forfuture studies. The results of multiple statistically significant as-sociations between the risk factors and paternal depression andanxiety in the perinatal period suggest the need for further re-search. This study provides preliminary evidence of the impor-tance of screening fathers, especially if their partner is diagnosedwith depression and/or anxiety. This study also brings into focusthe potential risk of masculine gender role stress for contributing toperinatal mental health concerns for fathers. The interaction of thiswith some of the other risk factors identified also requires furtherstudy. Health care professionals should also be aware that fatherswho adhere to traditional gender norms may have negative atti-tudes toward help-seeking and are at risk of being underdiagnosedor misdiagnosed. Interventions based on these risk factors mayhelp reduce the prevalence of depression and anxiety in fathers inthe perinatal period.

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Appendix

Mixed Methods Appraisal Tool (Pace et al., 2012)

Received October 18, 2019Revision received December 16, 2019

Accepted January 22, 2020 �

Table A1MMAT Criteria and One-Page Template

Types of mixed-methods studycomponents orprimary studies Methodological quality criteria (see tutorial for definitions and examples)

Responses

Yes NoCan’ttell Comments

Screeningquestions (forall types)

Are there clear qualitative and quantitative research questions (or objectivesa), or a clear mixed-methods question (or objectivea)?

Do the collected data allow address the research question (objective)? E.g., consider whether thefollow-up period is long enough for the outcome to occur (for longitudinal studies or studycomponents).

Further appraisal may be not feasible or appropriate when the answer is “No” or “Can’t tell” to one or both screening questions.1. Qualitative 1.1. Are the sources of qualitative data (archives, documents, informants, observations) relevant to

address the research question (objective)?1.2. Is the process for analyzing qualitative data relevant to address the research question (objective)?1.3. Is appropriate consideration given to how findings relate to the context, e.g., the setting, in

which the data were collected?1.4. Is appropriate consideration given to how findings relate to researchers’ influence, e.g., through

their interactions with participants?2. Quantitative

randomizedcontrolled(trials)

2.1. Is there a clear description of the randomization (or an appropriate sequence generation)?2.2. Is there a clear description of the allocation concealment (or blinding when applicable)?2.3. Are there complete outcome data (80% or above)?2.4. Is there low withdrawal/drop-out (below 20%)?

3. Quantitativenonrandomized

3.1. Are participants (organizations) recruited in a way that minimizes selection bias?3.2. Are measurements appropriate (clear origin, or validity known, or standard instrument, and

absence of contamination between groups when appropriate) regarding the exposure/interventionand outcomes?

3.3. In the groups being compared (exposed vs. nonexposed; with intervention vs. without; cases vs.controls), are the participants comparable, or do researchers take into account (control for) thedifference between these groups?

3.4. Are there complete outcome data (80% or above), and, when applicable, an acceptable responserate (60% or above), or an acceptable follow-up rate for cohort studies (depending on the durationof follow-up)?

4. Quantitativedescriptive

4.1. Is the sampling strategy relevant to address the quantitative research question (quantitative aspectof the mixed-methods question)?

4.2. Is the sample representative of the population understudy?4.3. Are measurements appropriate (clear origin, or validity known, or standard instrument)?4.4. Is there an acceptable response rate (60% or above)?

5. Mixedmethods

5.1. Is the mixed-methods research design relevant to address the qualitative and quantitative researchquestions (or objectives), or the qualitative and quantitative aspects of the mixed-methods question(or objective)?

5.2. Is the integration of qualitative and quantitative data (or resultsa) relevant to address the researchquestion (objective)?

5.3. Is appropriate consideration given to the limitations associated with this integration, e.g., thedivergence of qualitative and quantitative data (or resultsa) in a triangulation design?

Criteria for the qualitative component (1.1 to 1.4), and appropriate criteria for the quantitative component (2.1 to 2.4, or 3.1 to 3.4,or 4.1 to 4.4), must be also applied.

Note. MMAT � Mixed Methods Appraisal Tool.a These two items are not considered as double-barreled items, as in mixed-methods research, (a) there may be research questions (quantitative research)or research objectives (qualitative research), and (b) data may be integrated, and/or qualitative findings and quantitative results can be integrated.

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