A man walks towards a tree, eyes focused firmly on the ground before it. At its base is a pile of firewood. Arranged as a pyramid, the stack of wood is protected by a substantial barrier of thorns. The man crouches by this pile and begins to dig. Once he has dug a small, shallow hole he removes a package wrapped in white linen from his bag. He unwraps the parcel to reveal half a coconut shell. Within the shell is a large, fleshy pink object – a placenta. He places the shell and its contents in the hole and backfills it with soil. Finally, he sets aside the thorns, takes the firewood and builds a fire on top of the shallow grave. He lights it, stands back and watches as the individual sticks catch light and the flames grow. He will leave the fire to burn for a while, but will return regularly night and day to tend to it and ensure it never goes out. After five days he will return, remove the embers and dig the coconut shell and its contents back up. This he will rebury in a site he has selected on the corner of his street, close to his home. He is a new father and the placenta is that of his newborn son.
This man is a contemporary Thai Malay from the beautiful coastal region of Satun, in the south-west of the country. The Satun people believe that the placenta is the same-sex sibling of their baby and, as such, its destiny is intertwined with that of the living child. By burying it within their village, they can ensure that their child’s attachment to their community is maintained as, despite what the future may hold, they will not wish to stray permanently from their twin. But the exact location of its burial is dictated by the child’s sex and gives a telling insight into the strict sex roles that persist within this culture. Fathers will bury the placenta of their son on the nearest street corner to encourage their child to seek a future beyond the confines of the village, whereas that of their daughter will be buried as close to the family home as is practicable. A daughter’s future place is with her parents. Fathers attach considerable cosmological power to the ritual of the placenta burial. Beyond its importance in anchoring a child to its ethnicity and community, it has a role in protecting the child’s future well-being. Hence a man must not be distracted by his surroundings on his journey to the burial site, lest his wandering eyes lead to eye problems for his child. Likewise, the placenta must not be buried too near to water, to avoid future stomach troubles.
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Becoming a father is not a moment in time, it is a process; one that can start many years before a child is born, when the desire for a child might emerge, and continue for several years after birth. But pregnancy and birth are a special time in this process of change – a time of growing recognition of a new future and a new role. This period constitutes one of life’s key markers, the moment when attention shifts from the ‘I’ to the ‘we’ and life, in all its guises, is fundamentally and permanently changed.
In this chapter I want to explore dads’ experiences of birth. While in many cultures birth is a time of ritual, here in the West it is more usually a time dominated by hospitals, doctors, appointments and paperwork. This has consequences for the man’s experience, which, in some cases, can lead to issues coping with his new life and identity. I want to explore the causes and consequences of these issues and what the new dad can do to help his experience of birth be as positive and joyous as it can undoubtedly be.
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‘Couvade’ is a term derived from the French word couver, meaning to hatch or brood, and adopted by anthropologists to describe the phenomenon present in many societies of a series of ceremonies, rituals and psychological and physiological experiences that occur as a man becomes a father. Thought to have originated in Ancient Egypt, these occurrences and experiences are deemed to be important because they help the father, kept at a distance from the physical experience of pregnancy, to adapt to his new role, assert his significance to the family and gather essential support from his community. As a consequence, they have a vital role in helping the man deal with the practical and psychological impact of becoming a parent.
Couvade is split into two distinct categories of behaviour. The first set of behaviours fall under the heading of couvade rituals and are performed by the man to involve himself more fully in the process of pregnancy and birth, to provide protection to his child and the mother or to cement his new child’s place within their community. They are rituals that acknowledge both that becoming a father is a life-changing experience for a man and that the birth of a child is a community as well as individual matter. So, our Satun man will not only carry out the ritual of placental burial after birth but will fill the long pregnancy hours with practical jobs to support his wife once the baby is born, including constructing a wooden bed, the khrae, on which she will rest with her baby for forty-four consecutive days following birth. During this time, mum and baby will be warmed by a fire that the father will continuously tend to to ensure it doesn’t go out.
Why is the couvade a significant process for the men who take part? For women, the connection to their child is physical, visceral. For a man, his connection is social – made by the interactions he enjoys with his child and the social recognition of his role. By performing couvade rituals, he is publicly taking on the mantle of the father and, more vitally perhaps, asking his community for their help and support in successfully navigating the journey from man to father. Beyond this, many rituals are also tied up with the future protection and support of the child. Picture the Thai man burying his son’s placenta on the street corner. He is carrying out this ritual to ward off illness and also to encourage his child’s loyalty to his community but, in addition, his choice of burial location reflects his hopes that his son’s future will extend beyond the village. In these wishes are reflected two themes that I will return to again and again in this book. That is, regardless of the vagaries of time and the challenges of the environment, at the heart of every father’s role is the drive to ensure his child’s survival and to teach and guide his child so that he or she can operate separately as a successful, autonomous being when the time comes to enter the adult world.
Practices such as those of the Satun people were once widespread. But with the onset of the medicalization of childbirth, even in remote areas, the opportunity to carry out such ceremonies, particularly around birth, has diminished. For Thai men, who are traditionally excluded from birth, the moment of new fatherhood today is more likely to be marked with hospital bureaucracy and endless form-filling than the careful removal and burial of the placenta. Such ceremonies only remain for those who choose home birth or who have the confidence and time to wade through the metres of red tape that are required before a placenta can be removed from the hospital setting. But what remains in societies after these rituals have died out is an astonishing physiological phenomenon that is perhaps the body’s reaction to the profound emotional and practical experience of becoming a father.
Having a kid is life-changing! It is obvious to say, but it really is . . . I don’t know where my time went before or what I used to do, what I spent my time doing, because I don’t seem to get any time now! I mean, I have to make it, which involves getting up at stupid o’clock and doing things then.
Dylan, dad to Freddie (six months)
If you are a father, then Dylan’s story will be familiar to you. Having a child causes an inevitable disruption to your daily routine. The demands of work and home need to be juggled, so you grab food whenever there is the opportunity and a full night’s sleep is but a fond and distant memory. For many of you, these changes in lifestyle will have had a physical consequence – you put on weight. Gone are the days of frequent gym visits or Sunday morning five-a-side, to be replaced with a diet heavy in carbohydrates, fat and sugar, to fuel the long days and broken nights. But for some of you, the impact of impending fatherhood on your physical health may be more severe and striking. You might suffer stomach cramps and diarrhoea and feel listless and lacking in appetite. If this is you, then you are exhibiting the second category of couvade behaviour: couvade syndrome.
Couvade syndrome is a difficult phenomenon to grasp. Its diverse set of symptoms, which focus largely on the digestive system but can stretch to muscle cramping, loss of libido and toothache, are hard to pin down. As such, diagnosis is difficult, and men’s complaints are often dismissed. One consequence of this is that we have little idea of its frequency in modern populations; global estimates from a number of studies range from 11 per cent to 50 per cent. What we do know is that it is largely a phenomenon of industrialized cultures. It is most likely to occur with first pregnancies and be at its most severe in the first and third trimester, symptoms more often than not disappear once the baby is born, and there are certain categories of father and personality types who are more likely to experience it. Teenage first-time fathers, men whose fathers were absent when they were growing up and the fathers of unplanned pregnancies are at increased risk, as are men who are closely bonded to their partner and exhibit strong empathizing skills. In addition, unluckily for them, men who are also keen to be closely involved in their partner’s pregnancy increase their chance of experiencing this – in all probability, psychosomatic – syndrome.
All these men have one thing in common. They all probably experience heightened anxiety about becoming a father. For the teenage boy or son of a single mother, simple youth and inexperience or the lack of an adequate fathering role model can mean they find impending fatherhood more anxiety-inducing than most. For the father of the unplanned child, the gentle transition into fatherhood afforded by a planned pregnancy is denied him and he must quickly come to terms with this unforeseen, and possibly unwelcome, change in his circumstances. Men who are closer to their partner and more in tune with her experience may take on some of her concerns, worry and distress, resulting in this physical manifestation of a psychological state. Indeed, psychologist Anne Storey and her colleagues from Memorial University of Newfoundland, Canada, have found physiological evidence for this phenomenon. In their study of thirty-four Canadian first-time parents, fathers-to-be who experienced two or more couvade symptoms not only exhibited lower testosterone and higher prolactin levels (the hormone linked to milk production in mothers) than those who did not, making them more responsive partners and fathers, but their female partners also showed raised cortisol levels, indicating that they were experiencing significant levels of stress during pregnancy, a state of being that the men might well be mirroring.
The question remains as to why couvade syndrome exists and why it is a modern phenomenon, largely confined to developed countries. There have been numerous attempts at explanation, utilizing every argument from male envy at the female’s ability to bear a child to jealousy of the foetus’s close relationship with the mother. For me, the reason is more clear-cut and grounded in the father’s everyday experience. It is an unconscious manifestation of the father’s lack of recognition and support as he undergoes this key developmental stage. This lack of recognition and support will be particularly pertinent for those men who wish to be closely involved in their partner’s experience during pregnancy or those who might require additional support due to lack of life experience or an adequate role model. Couvade rituals, as described above for our Thai father, allow men to take a distinct role during pregnancy and birth, and to display not only their new role to the community but to advertise their need for support. They find security in having a firm, socially mandated role and being clear about what it involves. Their role is acknowledged as important by their community. Within the West, where all sectors – social, commercial, medical – focus exclusively on the mother, a lack of overt couvade ritual means that fathers can struggle to identify a role and garner recognition and support for their experience. This can lead to greater anxiety and, as a consequence, the symptoms of couvade syndrome. This lack of recognition is evident in Steve’s experience of antenatal care:
[The check-up] I did go to, my partner got on the seat and the midwife drew the curtain [in front of] me and my partner said, ‘He can watch,’ and she said, ‘Oh, right,’ and I thought, Well, I am the husband . . . in a month’s time I’m going to be seeing everything. And the midwife was a bit weird, as though I shouldn’t be there.
Steve, dad to Anna (six months)
Over the years I have spoken to many new fathers, and what is clear is that, alongside excitement, pride and fear, many men, like Steve, find the experience of pregnancy and birth marginalizes them. With the medicalization of pregnancy and childbirth, many of the processes that could have afforded an opportunity for public ritual are removed from the community to the hospital. As such, men are denied the opportunity to gain public acknowledgement of their role. Despite dad being a presence in the birthing room for nearly forty years, stories of exclusion are common. Dads who are asked to wait outside while mums are examined, questions regarding wishes for the birth or aftercare directed solely at mum, fathers left to let their worst imaginings run riot when their partner is whisked off for an emergency procedure. This exclusive focus on the mother can be to the detriment of the father’s well-being – many men report being made to feel like an imposter or a spare and unwelcome part. Unfortunately, this sense of exclusion is a constant subject of discussion during my conversations with fathers:
What is surprising is that these experiences are from the very recent past, when it is accepted best practice, both nationally and internationally, for a father to be fully involved with pregnancy and childbirth as an equal member of the parenting team. Numerous reports from bodies as esteemed as the World Health Organization and the United Nations have repeatedly stated that fathers should be fully included in all decisions and processes surrounding pregnancy and birth for the good of the mother, the baby and the man. Indeed, a number of recent studies have reported that the health outcomes for mum and baby, and the continuing health of the new family, are improved by fathers being involved in all aspects of antenatal care and birth. But such reports don’t appear to have influenced real-world practice. This sense of being a bystander is not just voiced by the men I have interviewed in the UK; it is a problem that is evident across Western culture. In her analysis of pregnancy and birth experiences from nine countries, including the UK, Sweden, the USA, Japan, South Africa and New Zealand, Mary Steen, a professor of midwifery at the University of Chester, summed up the overall experience of fathers as being that of someone occupying the no man’s land between being a patient and being a visitor. They are not undergoing a physiological process that requires medical intervention, hence they are not a patient, but they are also not in the category of hospital visitor; they are more than this. They are undergoing a life-changing experience alongside their partner, which, within medical circles, defies definition. And as it defies definition, no one quite knows what to do with them, either emotionally or physically. Steen recounts an incidence where one father was asked to stand in the corner and ‘not interfere’ during birth, and concludes that while men are now regularly in the birthing room, they still feel excluded from the process, even though physically present. Again, the dads in my study echo this experience:
Since getting home with our baby, the midwives would come, the health visitors would come, and even though I’m here, they don’t really acknowledge me, that I’m here. I don’t think there is any real support there for fathers, and if something had gone wrong at any stage, I don’t think there was anyone there to support the father. When the health visitors were here, no one said to me, ‘How are you?’ It was almost as if I were intruding, coming into the room when Kate was talking to the health visitor. It was like, ‘Huh, you’re here as well? Okay.’ It was like they didn’t know how to deal with it. But why should I not be here? He’s my son as well.
David, dad to Harry (six months)
Why does it matter how fathers are treated by healthcare professionals? Why should we be concerned that they are having to deal unsupported with significant psychological, if not physiological, change during the period encompassing pregnancy and birth? It matters for two main reasons. Firstly, fathers who are involved in pregnancy and birth are much more likely to be involved fathers after birth. Numerous studies among all socio-economic classes and ethnicities of father have shown that by involving a father from the early stages of pregnancy you are instilling in him a habitual routine that will naturally continue after birth. This is of importance to him because fathers who have an identifiable role are much more likely to transition to parenthood smoothly, which in turn will have a positive and significant impact on his partner and child. One of the key, and arguably easiest, ways health and social care practitioners can make sure fathers feel involved and encourage them to take on a role is to acknowledge them as a significant player. It is a simple and cost-neutral act to ensure they are included in all discussions regarding their baby, to enquire after their health and well-being, listen to their queries and concerns and support them in their chosen role during pregnancy and at the birth. To empower them to embark on the process of becoming a dad. Those of us who research and campaign for fathers just need to find an effective way to get this message across.
The second reason for recognizing dads during pregnancy and birth is that, alongside the quality of his relationship with his partner, how well a father navigates the journey to fatherhood is significantly impacted by how he is treated by healthcare staff. The transition to fatherhood can last a significant period of time, up to two years after birth, compared to around nine months in mothers, meaning that, arguably, fathers may require support for longer than mothers. And it can include some key points of change that have the potential to cause significant distress. Many of these can occur in the first few weeks after the birth, when the resources available to dads – professional and personal – are probably at their lowest. These significant events are the birth itself, the immediate post-birth period and the return to work. For many men, the birth is a time with huge emotional and practical consequences. There is the need to cope with your own psychological and emotional experience and to identify a practical role within the birthing room. Again, in some cultures a series of couvade rituals define this period and provide a clear route for dad to follow that can ease his anxiety. In both historical and contemporary non-industrialized societies, such as the aboriginal people of Australia and the Basques of Spain, men are reported to imitate the behaviours of their pregnant partner – withdrawing from work, displaying swollen stomachs and, when the day of birth itself arrives, remaining in their bed and imitating the sounds and actions of labour. Significantly, many of these men will be excluded from the birth itself, unlike fathers in the West, but will ensure their involvement and cement their bond with their wife and child by this public display. Without such prescribed public rituals to fall back on, it is this need to identify a role during birth that often causes dads in the West the most difficulty. And being among the first generation to enter the birthing room, there are few traditions to follow or role models to emulate.
There was never a doubt I was going to be there no matter what, completely. My mum said she wanted to come down to the hospital and be there, but we said, ‘No, stay away, this is our moment for us, we want it to be just us.’ So, I was always going to be there, I was never going to be anywhere else. I wasn’t going to pass out either! Although after she was born, I did sit down for one moment . . .
Neil, dad to Libby (six months)
Within the UK, the most recent government statistics suggest that 96 per cent of fathers will be present at the point of their child’s birth. Having fathers at the birth is an overwhelmingly positive thing for them and their family; it increases the likelihood of a father being involved with his child long-term, acknowledges that having a baby is a shared experience within the couple and allows for the commencement of bonding between dad and baby at the earliest opportunity. For the dads I interviewed, being able to see their baby’s first breath, to hear their first cry is a life-changing and unforgettable moment. And for many men, being there allows them to achieve some significant ‘firsts’ – first hold or first nappy change – enabling them to feel they have had a unique experience with their child. For one of my dads, Frank, the consequence of a rather traumatic birth that left his wife requiring some medical attention meant that through all the stress and difficulty, a silver lining emerged. He was not only the first to hold his baby but got to spend an exclusive hour with him, one on one.
There was quite a situation [after the birth], but during that time I just had him, and that was actually very special because for an hour I had a first special bonding, chatting to him . . .
Frank, dad to Tom (six months)
Frank’s experience is reflective of that of most men, even those who experience the most objectively straightforward birth. It is a time of hugely contrasting emotions, a real roller coaster. The excitement of realizing labour has commenced is quickly replaced by the anxiety engendered by an unknowable, and uncontrollable, future. The desire to stay strong for your partner is contrasted by the distress of seeing a loved one in pain. The pride you feel as your partner goes through this most physical of experiences is balanced by your frustration when she will not heed advice that will make her more comfortable. And at the end, the overwhelming relief and joy of birth can be replaced by concerns regarding the health of your baby and partner, and the sudden awareness that your attention has now to be split in two.
Because everyone kind of pictures it that it would be a case of baby is delivered, baby is given to mum, mum’s on the hospital bed holding the baby, then I can come over and it is the three of us together. But Liz was on the bed quite immobile, Poppy’s on the other side of the room being looked at by the doctors and there definitely was a moment where I thought, Who do I go to? I definitely felt, I don’t want to bother anybody, but I am worried about both of them.
Nigel, dad to Poppy (six months)
For fathers sitting at the centre of the whirlwind of feelings that accompany birth, not having the support of the professionals who surround you and your partner can make you feel like the most insignificant person in the room. In the terminology of Mary Steen, what fathers actually need is to be helped to identify an authentic role and then fully supported in acting out that chosen role by those around them. What this role might be is entirely open to the father and his partner. Together you may decide you will be her advocate, giving voice to her needs and desires when she might be otherwise unable to speak. Or you may take on a practical role, timing contractions, providing physical support, even using your body as a scaffold, as she labours:
I was actively involved in the birth, which I really enjoyed; I like actually having a part and holding legs up and things, that was really good . . . cutting the cord. But there were other bits I had to look away from . . . bits I didn’t feel comfortable with and [I] had to turn away, but afterwards, when you get to the end, it is completely worth it.
Theo, dad to Lila (six months)
Or you and your partner may decide that you, the father, will not attend. All of these are personal choices that need to be made within the couple before birth and then supported, without judgement, by those within the birthing room and beyond.
It can be no surprise to hear that even for fathers who experience a relatively stress-free transition to fatherhood, becoming a new dad requires huge amounts of practical, emotional and intellectual resources. There is so much to learn in a short period of time, and it is often very clear that the baby has not read the manual you have. Watching your baby develop is one of the great joys of parenthood – the first time they smile, sit unaided, babble or walk – but for parents, this also means that the rate of change can be fast and you need to run to catch up. Your baby’s first steps are wonderful, but then having to move all the ornaments away from baby’s reach and tackle the complexities of stair gates is not so much fun. However, I would say that the overwhelming opinion of the fathers I have worked with over the years is that, with time, it becomes easier to keep up – you become better at the job of fatherhood, your baby starts to repay your dedication with the most wonderful opportunities to interact, and you get more sleep! Henry’s experience is pretty typical:
Our lifestyle has changed completely, in ways for the better, but it is a massive struggle; it’s like taking on another job almost, because it has been very tiring, a lot of hard work, a lot of sleepless nights . . . The further you go back, the worse it was . . . learning everything, being a dad for the first time, everything is brand new . . . I think when it started off, she was such a responsibility, she was such a . . . ‘burden’ is not the word . . . she was such hard work that I think it is difficult to build a bond straight away . . . I think your resentment of ‘you are making me get up at this time, making me do this again’ is quite overpowering, but as they get older you play with them more, see their personality . . . your bond grows.
Henry, dad to Ruby (six months)
It is truly the case that, like for Henry, becoming a father will test you to your very limits and cause you to dig deep on a quest for mental and physical resources that you didn’t even know you had. But for some fathers, the period before and after the birth can be tougher than for most, as Colin explains:
You do get a bit depressed. You do get a bit down, because your life isn’t what it used to be and you kind of doubt yourself and you doubt whether you made the right decision to be a dad. You doubt whether you’re going to be good at it because you think, This is my child, I shouldn’t be feeling this tired. I shouldn’t be feeling this resentful. Anxiety and doubt creep in as well, because you want to make sure you made the right choice and that you are the right kind of father.
Colin, dad to Freya (six months)
Postnatal depression in mothers is a phenomenon with which we are all familiar, and mothers are assessed regularly both during pregnancy and for up to a year after birth to ensure that cases are caught and treated early. It can be the most debilitating condition and have a profound effect on the woman, her baby and family. But it is only very recently, in the past five years, that the possibility that fathers can also suffer from this condition has been entertained. Indeed, it is only with the move towards encouraging involved fathering and with the acknowledgement that many fathers wish to co-parent their children that the idea that becoming a father may be as profound an experience as becoming a mother has been part of the discussion. But we now know that fathers bond with their babies just as deeply and profoundly as mothers, that fathers have a unique and separate role to play in their child’s development and that fathers undergo a shift in their hormone profile akin to that which occurs in mothers. All of this suggests the possibility that dad as well as mum may be vulnerable to mental ill health as a result of this key life transition. Mark’s experience is not unusual:
I had had the first week of elation – ‘Look what I have done’ – which was obviously great, and then I started to get, I guess, the baby blues. I thought, Hold it, she doesn’t seem to respond to me. I felt like – it sounds weird – but I felt like I didn’t get a good vibe from my baby. I didn’t think I was doing anything right.
Mark, dad to Emily (four) and George (three)
While the research on paternal mental health is still at an early stage, sufficient studies have now been carried out to give us some idea of the nature of this condition in men. In their summary of sixty-three global studies of postnatal depression (PND), published in 2015, Karen-Leigh Edward and her colleagues from the Australian Catholic University found that the rate of PND in fathers rested at around 10 per cent, compared to 14 per cent in mothers, and that this was significantly higher than the rate of depression in a comparable population of non-fathers of between 7 and 8 per cent. This would suggest that, rather than being a symptom of age or lifestyle, these men were suffering with poor mental health as a result of becoming fathers. But what is of more significance is the fact that the nature of PND in men differs significantly from that in women. In men, the key risk factors are whether the mother has PND – this is known as co-morbidity – and the quality of the relationship between mum and dad. Further, feeling a sense of exclusion from the mother–infant relationship, finding a significant gap between the expectation and reality of new fatherhood, balancing home and work life and financial concerns also increased the risk for fathers of suffering from this debilitating condition. Dads who have PND tend to experience more anxiety, aggression, distress and doubts about their parenting than mothers, and this can cause them to withdraw from the family and turn to forms of self-medication – generally alcohol or drugs – to ease their symptoms. In their study of parental loneliness, Niina Junttila and colleagues from Turku University in Finland found a strong relationship between the levels of emotional and social loneliness in fathers and the incidence of depression – men with PND were more likely to report a lack of social contact and support and an absence of a close bond within their relationship. Finally, the trajectory of paternal PND differs from that of mothers. While for mothers the key risk period for PND is during the first year after birth, for fathers the arrival of their child’s first birthday is the critical moment when their period of risk commences, midway through their transition journey. Perhaps the accumulation of stressors over the first year of fatherhood becomes too much for some.
For fathers, acknowledging and coping with poor mental health during pregnancy and in the period following birth can be a challenge, due to prevailing attitudes in society towards masculinity and mental illness and a lack of targeted services for fathers. In her 2017 study, Zoe Darwin from the School of Healthcare at the University of Leeds interviewed nineteen fathers who had reported symptoms of poor mental health during the perinatal period – that is during pregnancy, birth and the first year after birth. She found that fathers had difficulty acknowledging their feelings – referring to their poor mental health as stress, rather than depression or anxiety – felt that they did not have a right to feel down and believed that they were not entitled to look for support from health or social care professionals. They experienced considerable guilt, as they felt they were letting their partner and baby down, and especially guilty if they were driven to access limited professional resources that they felt should, by rights, be given to their partner. Those who did want to seek help were unsure of how to because of the weak relationships they had developed with healthcare staff – their contact being limited to, at most, accompanying their partner during the all-too-brief antenatal appointments. They felt underprepared to be fathers and struggled as their previous tactics for handling workplace stress – distraction or avoidance – failed to lessen their feelings in this context. This made them feel less than ‘real men’, as their role of protector was replaced by the need to be protected. However, in the absence of formal support, men did identify some tactics that helped them to get over the most severe periods. Some found reminding themselves that the speed of change with a new baby, a cause of stress in its own right, was also, ironically, a positive, as most difficult phases did not last for long. Others found that carving out specific daddy and baby time helped – the opportunity to bond one-on-one allowed dad to achieve competency in his new role, and the smiles and giggles of their baby had powerful mood-lifting effects. Others found that playing sport or relying on the advice and support of their established social networks – friends, family and work colleagues – was a huge help in giving them a break from the relentless nature of some aspects of parenting and normalized their experiences. Colin was one of the dads in my study who was diagnosed with postnatal depression:
I mean, I was signed off recently for stress, which was a new thing for me, [I’d] never been signed off before. I was off for two weeks. It was probably my fault as well, because I got a new job as she was born, so a new job, a new baby, it was fantastic. A lot of responsibility added on at work, a lot at home, so it all mingled into one. So, a lot of anxiety and depression, but it all stemmed from stress because I took on too much. And it was definitely the result of what was happening at home, because it affected work – lack of sleep, and I had so much less energy. I was taking on more work and my memory was going through the roof, I couldn’t remember what I was supposed to do at work, I couldn’t remember where I was supposed to be. So, that wasn’t good. Just a complete nightmare for a time.
Colin, dad to Freya (six months)
As an academic community, we are only just coming to terms with the extent of poor mental health within the population of fathers within the UK. Government and society are even further behind. As a specialist in this area, I am asked to join radio and TV discussions about the ‘existence’ of paternal PND on a reasonably regular basis and, while a hot topic with journalists, the normal response I see is less one of empathy and more one of ‘all these men need to pull themselves together and stop moaning – they haven’t given birth’. A depressingly narrow-minded response and one that, you would hope, would not be directed towards a woman in a comparable situation. Because paternal PND is real and it carries a cost. There is the obvious cost to the father, but if that does not motivate someone to listen and act, then there are the costs to the child’s development, to the happiness and cohesiveness of the family and to our society, in terms of treating and policing the increased antisocial behaviour and addiction that can arise further down the line in the children of depressed parents. So, realizing that we are unlikely to get fathers the tailored support they need without appealing to the economics of the situation, several researchers have tried to put a price on poor paternal mental health.
The immediate and long-term cost of poor maternal mental health in the UK is around £6.6 billion each and every year; 60 per cent of which is related to the costs to the child of the negative impact on their development (for example, additional behavioural and educational support services or police and court costs associated with anti-social behaviour). It is likely, with the independent influence that a father has on his children’s development and the particular responsibility he has for their social behaviour and long-term mental health, that the cost of poor paternal mental health is within the same ballpark. Within Australia, the cost to the system of paternal PND was $18 million in 2012 alone. In the first study of its type within the UK, a team from the universities of York, Warwick and Oxford, which included my colleague, psychiatrist Paul Ramchandani, calculated that for each and every man who presented with symptoms of PND it cost the NHS, at the most conservative estimate, an additional £158 as compared to a man without PND. This may sound like an insignificant sum compared to £6.6 billion, but if we remember that the rate within our population of paternal PND is around 10 per cent of fathers and that this sum does not include the use of any specific father-targeted programmes of intervention, only drugs and GP costs alone, and excludes the cost to the child’s development and our society in terms of policing or social care, it is a considerable amount of money.
So, what can be done? At this point in time, in the absence of specific, father-focused interventions, we have to fall back on established systems of antenatal and postnatal education and try to find some space in there for dad. In their recent meta-analysis of the impact that established interventions have on the mental health of dads, Australian psychologists Holly Rominov, Pamela Pilkington, Rebecca Giallo and Thomas Whelan were able to assess which methods were the most effective for preventing paternal PND. They found that one of the most effective techniques was to train dads to deliver massages to their partners and, once born, their babies. Massage is often one of the techniques that dads are taught during antenatal classes to help them feel involved in their partner’s pregnancy and, following birth, to find them an exclusive role during the first few weeks of their baby’s life, when they can often feel excluded. But Holly and her team found that an added bonus was that, in repeated studies, it helped reduce depression and anxiety in fathers. With the insight we have from neuroscience, it is clear that dad, baby and partner gain a neurochemical reward from these interactions, making it a win-win all round. Touch is one of the most effective ways of releasing the feel-good chemicals oxytocin, dopamine and beta-endorphin, and this flood of positive chemicals in dad’s brain counteracts the release of the stress hormone cortisol and improves his mental health. From a psychological standpoint, by learning a skill he also gains confidence in his competency as a dad, which raises his self-esteem.
The other intervention that Holly and her team identified as having a positive impact on paternal mental health was the traditional antenatal class – but with a twist. It is not unusual for dads to attend antenatal classes with their partners to learn about pregnancy, birth and baby caretaking, but in most cases they are there in a supporting role. However, there is a growing recognition that fathers benefit hugely from male-only antenatal classes. In an era of global austerity, these classes are thin on the ground, but where they do exist, even in the form of one men-only class out of the usual run of six or eight couples’ classes, they have a profound impact on a man’s mental health. Being able to take part in one of these classes allows men to relinquish their role as ‘emotional rock’ and speak freely about their fears and anxieties, focus on the skills that will help them as a dad and ask all the questions that they fear may make them look stupid in front of an audience of mums-to-be. The classes are particularly beneficial where the teacher has seen fit to invite a few experienced fathers, as it is increasingly becoming apparent that men feel most comfortable asking questions of and gathering information from their peers. And this can mean that sometimes they find support in the most unlikely of places.
The Lions Barber Collective is an international organization first established in the UK. It brings together a group of leading barbers, all of whom have an interest in tackling the worryingly high rate of male suicide and raising awareness of men’s mental health. For years, those of us who wish to support men who struggle with their mental health have found it difficult to make contact and find suitable and effective interventions that encourage men to talk about their experiences. The Lions Barber Collective, all members of which are trained as mental health support workers, is effective because it exploits the often close and long-term relationship that men build with their barber and the confidentiality of barber chair chat to encourage men to open up about their lives. An added bonus is that men do not often include their barber in their social circle, so they do not feel the need to edit their stories to protect others. This scheme has garnered huge amounts of attention, and deservedly so, because it works. It acknowledges that men find it difficult to actively seek out help, that they need something they can access easily in their daily lives and that they will often speak more readily to a friend or acquaintance – barber, fellow sports team member – than a professional. While not explicitly focused on perinatal mental health in men, it is a model that we can follow to attempt to provide the much-needed support that fathers require.
Our understanding of paternal mental health is growing. As I finished writing this chapter, a new study by the University of Southern California confirmed a long-held hunch that, as with maternal PND, hormones have a part to play in paternal PND. As a dad, while the drop in testosterone that accompanies fatherhood is good for redirecting your focus onto your family, it increases your risk of suffering from PND; it has long been known that high levels of testosterone are a protective factor against depression. In this case, men in the study with the lowest levels of testosterone were the most likely to report depressive symptoms. Not good news if you are one of these men, but the greater the knowledge we have of this condition the more likely it is that we can work to prevent and cure it. The challenge for those of us within the field is to take this knowledge and make it generally known. To continue to voice the reasons, probably in the language of economics rather than empathy, for providing men with targeted support and intervention. At present, much of the research focuses on prevention rather than cure and, in the absence of professional help, there is certainly much a man can do during the lead-up to the birth, and afterwards, to help his mental health. This can include making use of all the tools modern technology has to offer in seeking your own support network:
I am part of a Facebook group, which is fantastic because you get everything from a dad reporting in . . . (‘It’s Jeff here, reporting from the dog house, I’ve done x or y’) to difficult subjects like a dad trying to keep in touch with his kids following divorce. There are always dads in similar positions to you that you can relate to. It’s really useful.
Ben, dad to Rosie (eighteen months) and one on the way
If you are an expectant dad, the nine months of pregnancy are a wonderful opportunity to discuss with your partner your thoughts and concerns about your role during pregnancy, birth and beyond. You can take the time to discuss how you will work together as a parenting team and identify possible points of tension and how you can resolve them. You can use the time to pep up your massage skills and to build your own support network consisting of friends, family, professionals, colleagues and virtual groups. There is a growing number of online support communities just for dads, which many men, like Ben, find invaluable.
It had gone from this ridiculous thing of lasting for so long to all of a sudden you’ve got a baby, and everyone’s going out the room, and there’s all this blood everywhere and you’ve just seen the baby’s head come out. It’s ‘oh my god’ and there he is. And I just wanted to tell people; it was a really proud moment, I guess. Yes, it was just a really proud moment and I couldn’t wait . . . because there’s not much you can do then, apart from hold him. I wanted to tell everyone, ‘Look, I’m a proud dad.’
Zac, dad to Aidan (six months)
Some of the issues or points of tension that you encounter around birth will be personal to you, but from my own research I know that some have the potential to be universal. Many fathers can struggle finding a space to connect with their baby during those first intense months, particularly in the early stages when a baby may be with mum for long periods of breastfeeding. It is important that you explore how you will feel about this. Some fathers are content to be mum’s supporter at this stage, knowing that their time will come, but others find it helps to identify an exclusive activity that will be just for them and their baby; bath time, the midnight bottle or the pre-bedtime massage are often popular. While some hospitals now offer family rooms that enable dads to stay after birth, these are still thin on the ground and many dads do find themselves out on the streets once baby has been delivered – the hospital car park at 3 in the morning can be a very bleak and unwelcoming place. For some fathers, the sharp contrast between the drama of birth, the joy of becoming a family and the swift ejection onto the street once mum is settled on the ward can be very difficult to take. If this is a likelihood, then identify someone who you can ring to talk to or meet once you leave the hospital, whatever the hour. Someone who can help you celebrate, reflect, laugh and cry, and provide you with a much-needed meal and drink. And whatever birth plan you have, you will be interacting with healthcare staff. Discuss with your partner how you both want to approach these interactions so that both your needs and concerns are addressed and so that you are supported in your chosen role.
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One thing I wasn’t prepared for is I find her really, really funny. It’s got to be her reaction. Everything is amazing and new for her, and exciting. She seems to never get tired of stuff. Genuinely most times when we’re interacting, at some point she will do something that just cracks me up.
Nigel, dad to Poppy (six months)
For the majority of men becoming a dad, while tough at times, is a period that is overwhelmingly characterized by joy – the happiness engendered by seeing life anew through your baby’s eyes, the beaming grin and open arms that greet you when you get home from work, the shared experience of learning together. Ben is dad to 18-month-old Rosie and has one on the way. All parents-to-be could do well to remember his sage advice:
To all the men who are friends of ours who are starting to think about becoming a dad, I am overwhelmingly positive. It is absolutely amazing, it changes your world, it makes everything lighten up, you have a reason to bounce out of bed most times. If I realize Rosie is up, then fantastic. If you weigh the positives and the negatives, the positives win outright. Yes, there is dealing with nappies and being woken up, but they always have that cheeky smile. I absolutely love being a dad.
Holly Rominov’s work on baby massage and men-only antenatal classes has shown us that, even without great investment, there are small things that can be done to ease the symptoms of poor mental health; taking time out for yourself away from the family to do something you enjoy, using massage as a way to connect with your baby and partner and lighten your mood, building a support network of peers – in the real world or online – so you can share your feelings and be acknowledged and supported. And if your symptoms become overwhelming, then the therapies that are available to all those who suffer with poor mental health are also available to you. Taking the step to talk to a professional – midwife, health visitor or GP – is often the first step towards recovery.
Ultimately, prevention is better than cure and we all have a role to play in this. We may no longer have a tradition of couvade rituals in the West, but as fathers become more and more involved with their children, maybe we need to begin a new set of traditions aimed at recognizing and supporting men as they endeavour to successfully navigate this life-changing journey. At the very least, we can acknowledge that pregnancy and birth happen to dads too. If you are reading this as a way to better understand and support your partner or friend, take the time to ask how he is and listen with empathy to his response. Offer to babysit so he can take a well-earned break. Get a group of experienced and inexperienced dads together so that questions can be asked and issues discussed in a supportive atmosphere. Or go the whole hog and throw him a daddy-shower. When a baby is born or adopted, then it is generally the case that two people are commencing on the journey of parenthood and at least one of them is likely to be a dad. Let’s make sure we are all there to support and celebrate with him.