Maternal perinatal mental health problems have been extensively studied and addressed to be a significant health problem. Postpartum depression, in particular, has been thoroughly studied and recognized to be a significant mental health problem with a prevalence of 10–20% among women [
Studies on the relationship between maternal antenatal and postpartum depression showed that maternal depression during pregnancy was the strongest predictor of maternal postpartum depression [
Thus, the present study aims at examining the prevalence of paternal depression in early, late pregnancy, and six weeks postpartum, investigating the relationship between paternal antenatal and postpartum depression and identifying risk factors among expectant fathers in a longitudinal manner.
A consecutive sample of 622 expectant fathers was recruited from the antenatal clinics in two major regional hospitals in Hong Kong. The inclusion criteria included (1) expectant fathers, (2) fathers of Chinese ethnicity, and (3) fathers being able to read and write Chinese. The exclusion criteria included (1) couples considering termination of pregnancy (2) fathers with primary residence outside of Hong Kong. The expectant fathers were administered a set of questionnaires at first presentation (12 weeks gestation of pregnancy) in the antenatal clinic at a regional hospital in Hong Kong. The questionnaires were completed the expectant fathers during the waiting time in the antenatal clinic. They were re-assessed when the pregnancy progressed to 36 weeks and again at 6 weeks after childbirth. In all, the participants were assessed on 3 time-points. The study was approved by the Institutional Review Board of the university and the hospital. All eligible expectant fathers attending the antenatal clinic at first antenatal presentation were invited to participate in the study. Subjects were informed about the objective, background, and procedure of the research. Upon providing informed written consent, subjects completed a set of self-administered questionnaire.
The Edinburgh Postnatal Depression Scale (EPDS) [
Demographic risk factors including age, educational level, marital status and family income were assessed at first presentation (12 gestational weeks). Psychosocial risk factors including unplanned pregnancy, social support, self-esteem, marital satisfaction and work-family conflict were assessed at all three time point.
Expectant fathers were asked to indicate whether the pregnancy was planned or unplanned.
Social support was measured with the multidimensional scale of perceived social support which consisted of 12 items measuring perceived social support from family, friends, and significant others [
The 10-item Rosenberg self-esteem Scale (RSE) [
The work-family conflict Scale [
The validated 3-item Kansas Marital Satisfaction Scale [
The statistical package for the social sciences (SPSS) was used for all analyses. The overall level of significance was taken as 5% and all estimates were accompanied by 95% confidence intervals. Descriptive statistics was presented by means and SDs for continuous variables and percentages for categorical variables. To examine the effect of hypothesized risk factors. ANCOVA and hierarchical hierarchical multiple regression were conducted with potential confounding factors controlled for.
A total of 622 expectant fathers were recruited in the present study at 12 weeks of their partners’ pregnancy. The response rate was 72.56%. At 36 weeks gestation weeks, 337 (54.2%) completed the questionnaires for both time-points, yielding an attrition rate of 45.8%. At six weeks postpartum, 150 (24.1%) participants dropped out from the study. A total of 187 (30.1%) participants completed all three time points of the survey.
An attrition analysis was conducted between the group of participants who completed both antenatal time points (
Bonferroni correction was used to address the problem of multiple comparisons. The significance level of .05 was adopted in the current study. Using Bonferroni correction, each category of variables (demographic, psychosocial risk factors and main outcome variables) was tested at a significance level of
After Bonferroni correction, results showed that there was no significance difference in risk factors and main outcomes between those who completed both antenatal time points and those who dropped out at 36 weeks gestation (Table
Sample characteristics and attrition analysis of expectant fathers with comparison between fathers who completed both antenatal time points and fathers who dropped out in late pregnancy.
Participants who |
Participant |
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Significance level at Bonferroni correction: 0.05/5 = 0.01 | |||||
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Demographic risk factors | |||||
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Mean | SD | Mean | SD | ||
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Age | (18) | ||||
33.86 | 5.04 | 34.47 | 5.34 |
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% |
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% | ||
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Marital status | (3) | ||||
Married/cohabitating | 281 | 45.18 | 331 | 53.22 |
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Divorce/single | 3 | 0.48 | 4 | 0.64 | |
Parity | (15) | ||||
Primigravida | 191 | 30.71 | 220 | 35.37 |
|
Multigravida | 85 | 13.67 | 111 | 17.85 | |
Education level | (2) | ||||
Secondary or below | 128 | 20.58 | 132 | 21.22 |
|
Tertiary or above | 156 | 25.08 | 204 | 32.80 | |
Family income | (20) | ||||
<20000 | 46 | 7.40 | 57 | 9.16 |
|
20000–30000 | 73 | 11.74 | 77 | 12.38 | |
>30000 | 158 | 25.40 | 191 | 30.71 | |
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Significance level at Bonferroni correction: 0.05/5 = 0.01 | |||||
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Psychosocial risk factors | |||||
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% |
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% | ||
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Planned/unplanned pregnancy | (7) | ||||
Planned pregnancy | 219 | 35.21 | 276 | 44.37 |
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Unplanned pregnancy | 61 | 9.81 | 59 | 9.49 | |
Marital dissatisfaction | (12) | ||||
Marital distress | 42 | 6.75 | 45 | 7.23 |
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Marital satisfied | 235 | 37.78 | 288 | 46.30 | |
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Mean | SD | Mean | SD | ||
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Self-esteem | (24) | ||||
20.71 | 4.60 | 21.43 | 4.50 |
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Social-support | (14) | ||||
61.77 | 14.77 | 63.48 | 13.65 |
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Work-family conflict | (39) | ||||
30.63 | 11.90 | 30.36 | 11.70 |
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Significance level at Bonferroni correction: 0.05/7 = 0.007 | |||||
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Baseline main outcome variables | |||||
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Mental health problems | Mean | SD | Mean | SD | |
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Depression | (41) | ||||
5.32 | 3.59 | 5.12 | 3.59 |
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The same analysis was conducted between the group of participants who completed all time points (
Again, results showed that there is no significant difference in risk factors and main outcomes between those who completed all three time points and those who dropped out at six weeks postpartum (Table
Sample characteristics and attrition analysis of expectant fathers with comparison between fathers who completed all time points and fathers who dropped out at six weeks postpartum.
Participants that |
Participant that |
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Significance level at Bonferroni correction: 0.05/5 = 0.01 | |||||
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Demographic risk factors | |||||
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Mean | SD | Mean | SD | ||
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Age | (13) | ||||
33.95 | 4.94 | 34.88 | 5.61 |
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% |
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% | ||
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Marital status | (2) | ||||
Married/cohabitating | 146 | 43.32 | 185 | 53.22 |
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Divorce/single | 3 | 0.89 | 1 | 0.30 | |
Parity | (6) | ||||
Primigravida | 101 | 29.97 | 119 | 35.31 |
|
Multigravida | 47 | 13.95 | 64 | 18.99 | |
Education level | (1) | ||||
Secondary or below | 59 | 17.51 | 73 | 21.66 |
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Tertiary or above | 90 | 26.71 | 114 | 33.83 | |
Family income | (12) | ||||
<20000 | 21 | 6.23 | 36 | 10.68 |
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20000–30000 | 30 | 8.90 | 47 | 13.95 | |
>30000 | 93 | 27.60 | 98 | 29.08 | |
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Significance level with Bonferroni correction: 0.05/9 = 0.0056 | |||||
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Psychosocial risk factors | |||||
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% |
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% | ||
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Planned/unplanned pregnancy | (2) | ||||
Planned pregnancy | 115 | 34.12 | 161 | 47.77 |
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Unplanned pregnancy | 34 | 10.10 | 25 | 7.42 | |
Baseline marital dissatisfaction | (4) | ||||
Marital distress | 17 | 5.04 | 28 | 8.31 |
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Marital satisfied | 130 | 38.58 | 158 | 46.88 | |
Marital dissatisfaction in late pregnancy | (13) | ||||
Marital distress | 18 | 5.34 | 29 | 8.61 |
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Marital satisfied | 126 | 37.39 | 151 | 44.81 | |
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Mean | SD | Mean | SD | ||
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Baseline self-esteem | (14) | ||||
21.49 | 4.68 | 21.39 | 4.36 |
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Self-esteem in late pregnancy | (8) | ||||
21.67 | 4.53 | 21.44 | 4.36 |
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Baseline social support | (8) | ||||
64.82 | 13.08 | 62.42 | 14.03 |
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Social support in late pregnancy | (5) | ||||
63.76 | 13.45 | 61.36 | 14.78 |
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Baseline work-family conflict | (21) | ||||
30.52 | 12.02 | 30.24 | 11.47 |
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Work-family conflict in late pregnancy | (25) | ||||
31.22 | 12.04 | 30.88 | 12.96 |
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Significance level with Bonferroni correction: 0.05/13 = 0.0038 | |||||
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Main outcome variables | |||||
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Mental health problems | Mean | SD | Mean | SD | |
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Baseline depression | (22) | ||||
5.00 | 3.59 | 5.22 | 3.60 |
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Depression in late pregnancy | (19) | ||||
5.31 | 4.07 | 5.17 | 3.32 |
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All of the expectant fathers were recruited from 12 to 28 gestation weeks of pregnancy at their spouse’s first presentation at the antenatal clinic. The average gestational week was 15.7 weeks. The majority of the first assessment (82.8%) was conducted at or before 18 weeks of gestation. The remaining minority was first assessed after 18 weeks because of late presentation at the antenatal clinic. However, Chi-square and independent
Concerning the fathers’ marital condition, most of the expectant fathers (612, 98.9%) were either married or cohabitating with their partners, and a small proportion of them (1.1%) as reported was being single or divorced.
A total of 411 (67.7%) of the expectant fathers were first-time father, and 196 (32.3%) were experienced father. Most of them (99.3%) reported no history of psychiatric illness, while 0.7% of them had a history of psychiatric illness, among them, majority suffered from depression.
Most (58.1%) of the expectant fathers were considered highly educated, having received tertiary or above education. Less than half (41%) of the expectant fathers finished secondary school education only and only .90% of them finished primary school education. Due to the small number of low educated sample, the analyses were done by combining fathers reaching primary school and secondary school education level into one group, making the percentage to 41.9%.
With regard to total family income, 58% of the families received a total monthly income of HKD 30000 or above, while 24.9% of them had a total monthly family income ranging from HKD 20000 to 30000. A small proportion of the families (17.1%) reported a relatively low family income of HKD 20000 or below per month. The summary of the sample characteristics can be viewed in Table
Sample characteristics of expectant fathers in the present study.
Characteristic |
|
% |
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Age | (18) | |
≤25 | 19 | 3.1 |
26–34 | 310 | 51.3 |
≥35 | 275 | 45.5 |
Mean age = 34.19, |
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Marital status | (3) | |
Married/cohabitating | 612 | 98.9 |
Single/divorced | 7 | 1.1 |
History of psychiatric illness | (9) | |
Yes | 4 | .7 |
No | 609 | 99.3 |
Parity | (15) | |
Primigravida | 411 | 67.7 |
Multigravida | 196 | 32.3 |
Education Level | (2) | |
Secondary | 260 | 41.9 |
Tertiary or above | 360 | 58.1 |
Family income | (20) | |
<20000 | 103 | 17.1 |
20000–30000 | 150 | 24.9 |
>30000 | 349 | 58.0 |
The Edinburgh postnatal depression scale (EPDS) [
The mean and standard deviations of the EPDS scores across early, late pregnancy and six weeks postpartum were 5.22 (SD = 3.59); 5.23 (SD = 3.67); and 5.15 (SD = 4.17) respectively. Using ≥13 as the standardized cut-off for probable case of depression, the prevalence increased as the pregnancy progress and reached a peak at 6 weeks postpartum, with 1 3.3% of the participants scoring above cut-off in early pregnancy, 4.1% in late pregnancy and 5.2% at six weeks postpartum, respectively. Figure
Prevalence rate of paternal depression from early pregnancy to six weeks postpartum using EPDS Scale (Recommended cut-off of ≥13).
EPDS is a self-report symptoms instrument instead of a diagnostic tool to define paternal depression; hence the subsequent analyses used continuous scores of EPDS instead of cut-off scores.
Using Pearson correlation, paternal depression in early pregnancy was significantly correlated with depression in late pregnancy [
Correlation of paternal depression from early pregnancy to six weeks postpartum.
Depression in |
Depression in late |
Depression at six weeks | ||
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Depression in early pregnancy |
|
.53** | .55** | |
Depression in late pregnancy |
|
.53** | .57** | |
Depression at six weeks postpartum |
|
.55** | .57** |
To examine the independent and combined predictive power of antenatal paternal depression at both time points for postpartum paternal depression, a multiple linear regression was also performed with EPDS scores at both antenatal time points entered into the same model. It was found that both paternal depression in early pregnancy (
A series of statistical analyses were performed to examine which risk factors significantly predicted EPDS scores. Specifically, for dichotomous predictor variables, ANCOVA was used, with appropriate covariates entered into the model, where relevant, post hoc analyses were conducted as well. For continuous predictor variables, multiple regression analyses were conducted. Dependent variables were EPDS scores in early and late pregnancy and at 6 weeks postpartum.
Various statistical analyses were carried out to examine the relationships between demographic risk factors and expectant fathers’ depression, including one-way ANOVA, Pearson’s correlation and independent samples
Multiple regression was conducted to test the effect of psychosocial variables on EPDS scores across different time points. In order to control for the effect of demographic variables, the significant demographic risk factor (i.e., family income in early pregnancy) was included in Block 1 as covariate. All the psychosocial risk factors were then included in Block 2 in one regression model.
In early pregnancy the following predictor variables were tested: Block 1: family income, Block 2: unplanned pregnancy, marital dissatisfaction, self-esteem, social support, and work-family conflict, with fathers’ EPDS score as the outcome variable. The model produced an adjusted
Unplanned pregnancy, marital dissatisfaction, self-esteem, social support and work-family conflict, were entered into one regression model in order to examine the effect of psychosocial risk factors in late pregnancy. The model produced an adjusted
At six weeks postpartum, the regression model produced a good fit (adjusted
The results of multivariate analyses are summarized in Tables
Hierarchical multiple regression analysis of significant psychosocial risk factors for EPDS scores in early pregnancy.
Model | Early pregnancy | ||||
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Edinburgh postnatal depression scale (EPDS) | |||||
Adjusted |
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| |
1 | .011 | 5.47 | .020* | ||
Family income | −.06 | −1.47 | .14 | ||
2 | .20 | 22.42 | .000** | ||
Unplanned pregnancy | .016 | .40 | .69 | ||
Marital Satisfaction | −.14 | −3.36 | .001** | ||
Self-esteem | −.24 | −5.37 | .000** | ||
Social-support | −.039 | −.92 | .36 | ||
Work-family conflict | .22 | 5.24 | .000** |
Hierarchical multiple regression analysis of significant psychosocial risk factors for EPDS scores in late pregnancy.
Late pregnancy | |||||
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Edinburgh postnatal depression scale (EPDS) |
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Adjusted |
|
|
|
| |
.27 | 20.21 | .000** | |||
Unplanned pregnancy | .096 | 1.82 | .069 | ||
Marital satisfaction | −.092 | −1.69 | .092 | ||
Self-esteem | −.28 | −4.69 | .000** | ||
Social-support | −.13 | −2.21 | .028* | ||
Work-family conflict | .21 | 3.75 | .000** |
Hierarchical multiple regression analysis of significant psychosocial risk factors for EPDS scores at six weeks postpartum.
Model | Six weeks postpartum | ||||
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Edinburgh postnatal depression scale (EPDS) |
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Adjusted |
|
|
|
| |
.39 | 23.00 | .000** | |||
Unplanned pregnancy | −.019 | −.32 | .75 | ||
Marital satisfaction | −.048 | −.78 | .44 | ||
Self-esteem | −.45 | −6.61 | .000** | ||
Social-support | −.12 | −1.84 | .068 | ||
Work-family conflict | .18 | 2.68 | .008* |
The large scale survey by National Institute of Mental Health (NIMH) in 2005 documented the 12 months prevalence of major depressive disorder among United States’ male adults to be 5.2% using DSM-IV [
Studies on the relationships of maternal antenatal and postpartum depression showed that maternal depression during pregnancy was the strongest predictor of maternal postpartum depression [
Preliminary studies showed that the risk factors associated with paternal perinatal psychological distress and mental health problems included poor marital relationship, poor social network and insufficient information about pregnancy and childbirth, having an unsupportive relationship, past history of psychiatric disorder, young age, being unemployed and poor social function [
The current findings not only confirmed the salience of psychosocial factors identified in previous studies as strong predictors of paternal depression across the perinatal period but also contribute to new knowledge by identifying additional risk factors. Poor self-esteem, poor social support, marital dissatisfaction, high level of work-family conflict were found to significantly predict higher level of EPDS scores in fathers in different time points during the perinatal period. Cronenwett and Kunst-Wilson [
Acknowledgment of the limitations of the present study is essential to make appropriate interpretation and generalization of the results. It also guides the directions for future research. First, due to time constraint and scope of the present study, we could only study depressive symptoms of the fathers until six weeks postpartum. Six weeks postpartum might be a period which was still quite hectic for new parents as they just entered the new life of parenthood and were still pretty green with taking care of the babies. This might increase the risk of overestimating the prevalence rate of paternal depression. Also, the effect of the maternal depression on expectant fathers was well addressed to be a significant predictor of paternal depression in previous studies [
With time, the severity of paternal depression might be reduced as fathers develop more adaptive coping. Thus, the current design might not be able to capture full picture of paternal postpartum depression. Another potential problem is that the fathers who had nonpregnant partners were not included in the present study as the comparison group. Although the prevalence rate of depression in the healthy control group of men from National Institute of Mental Health was included in discussion, it could not give a clear picture on comparisons as the DSM-IV was used to define the cases of depression in the NIMH study. Matched controls should be included in future studies in order to provide a reliable comparison group for the purpose of investigating prevalence rate as well as identifying risk factors. In addition, the present study used self-report symptoms instruments instead of diagnostic tools to define paternal mental health problems. As stated in the literature, males tended to hide the emotions they experienced in comparison to females which justified the under estimation of the rate of males’ mental health problems [
In conclusion, expectant fathers in Hong Kong scored higher in EPDS in the postpartum period compared to the antenatal period and paternal depression during the perinatal period should not be overlooked. As maternal perinatal depression is being documented as a significant health problem, it should be acknowledged that fathers, being one of the parents, also experience a phase of transition and substantial stress during and after their partners’ pregnancy. Thus, prevention, early identification and intervention of paternal perinatal depression are needed.
The present study has also investigated the relationship between paternal antenatal and postpartum depression as well as identified significant demographic and psychosocial risk factors for paternal perinatal depression. Such knowledge contributes to the effective design of screening, prevention, and intervention strategies and also helps in the identification of high risk groups.
The authors declare that there is no conflict of interests regarding the publication of this paper.