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. Author manuscript; available in PMC: 2024 Oct 15.
Published in final edited form as: J Affect Disord. 2023 Jul 17;339:593–600. doi: 10.1016/j.jad.2023.07.064

Fathers’Subjective Childbirth Stress Predicts Depressive Symptoms at Six Months Postpartum

Elizabeth C Aviv 1, Emma G Lindquist 1, Yael H Waizman 1, Aridenne A Dews 1, Genesis Flores 1, Darby E Saxbe 1
PMCID: PMC10923195  NIHMSID: NIHMS1919456  PMID: 37459973

Abstract

Background:

Childbirth is a seminal experience in parents’ lives. However, little research has investigated the link between fathers’ birth experiences and their postpartum mental health. We hypothesized that a more subjectively stressful birth will predict greater self-reported depressive symptoms in fathers at six months postpartum. We also investigated the association between mode of delivery and paternal subjective stress.

Methods:

Seventy-seven heterosexual fathers expecting their first child and cohabiting with their pregnant partners participated in the study. Depressive symptoms were assessed in pregnancy and again at six months postpartum. Subjective birth stress was measured within the first few days of the birth, and birth charts were collected to examine mode of delivery.

Results:

Fathers’ ratings of subjective birth stress significantly predicted postpartum depressive symptoms at six months postpartum. Subjective birth stress ratings varied significantly for fathers whose partners delivered via emergency cesarean section compared to those whose partners gave birth via both medicated and the unmedicated vaginal delivery.

Limitations:

The study was limited by its small community (non-clinical) sample, which was restricted to heterosexual, cohabitating couples. Additionally, births were mostly uncomplicated and only 14 mothers underwent emergency cesarean section.

Conclusion:

These findings highlight that the days immediately following childbirth are a window of opportunity for early intervention in new fathers at risk for postpartum depression.

Keywords: Postpartum Depression, Birth Stress, Fathers, Transition to Parenthood

Graphical abstract

graphic file with name nihms-1919456-f0003.jpg

Introduction

Childbirth, an event that parents often describe as one of the most challenging and meaningful experiences of their lifetime, can range from easy and joyful, to painful, medically complex, and even life-threatening (Saxbe et al., 2018). A large body of research has shown that for mothers, the childbirth experience impacts the adjustment to parenthood and can predict postpartum mental health outcomes (Bell & Andersson, 2016). In the last half-century, it has become normative for men in industrialized countries to attend their partners’ childbirth (Leavitt et al., 2017), a major shift from most of human history when fathers were rarely present at birth. However, despite preliminary evidence that childbirth may affect fathers’ well-being (Gürber et al., 2017a), few studies have linked fathers’ birth experiences to their subsequent mental health. The current study employs longitudinal data from before, during, and after birth to investigate the impact of fathers’ subjective birth stress on their subsequent postpartum depressive symptoms.

Paternal postpartum depressive symptoms

Postpartum depressive symptoms (PDS) range from commonly experienced short-term “baby blues” to clinically significant depression. Although postpartum depression and its related symptoms have been widely studied in women, postpartum depression in men has received less research attention (Scarff, 2019). Postpartum depression may manifest differently for fathers than it does for mothers (O’Brien et al., 2017). Some research (Eddy et al., 2019; Huang et al., 2023) has suggested that postpartum depression in men is characterized by different clusters or constellations of symptoms than it is for women (e.g., more self-blame but less crying), but this research is preliminary and points to the need to better understand the casues and consequences of depressive symptoms in men. Meta-analyses indicate that the incidence of clinically significant paternal postpartum depression ranges from around 3% up to nearly 29% across the perinatal period (Ansari et al., 2021), peaking in the 3- to 6-month postpartum period with a pooled prevalence of about 13% (Cameron et al., 2016). Early research also suggests that fathers’ PDS negatively impacts father-infant bonding (Wells & Jeon, 2023), predicts worse development and behavior outcomes in offspring, and is associated with negative parenting and health outcomes for fathers (Sweeney & MacBeth, 2016). Furthermore, mothers’ and fathers’ postpartum depressive symptoms reciprocally influence and exacerbate one another (Paulson et al., 2016). Given paternal PDS’s prevalence and wide-ranging impacts, understanding its risk factors is of vital importance to the whole family. Importantly, depressive symptoms that reflect men’s heightened distress after birth can still affect quality of life and parenting outcomes, even if they do not cross the threshold into clinically significant depression.

Risk factors for paternal PDS

Fathers’ risk for postpartum PDS can be shaped by maternal factors such as maternal depression (Barooj-Kiakalaee et al., 2022; Paulson et al., 2016), relationship factors such as marital satisfaction (Morris et al., 2022) and co-parenting (Wells et al., 2023), and paternal factors such as prenatal depression (Barooj-Kiakalaee et al., 2022) and perceived stress (Wang et al., 2021). In particular, childbirth-related perceived stress may be an important risk factor in the development of paternal PDS. Though previous research on the relationship between birth stress and PDS has emphasized delivery method and other birth complications such as preterm birth and abnormal heart rates as risk factors (Gastaldon et al., 2022) for PDS in mothers, fathers’ subjective perception of those experiences may have greater impact on subsequent postpartum adjustment than medical features of the birth. For instance, some parents may experience a medically uncomplicated birth as not stressful at all, whereas other parents may find this uncomplicated experience to be extremely stressful. Similarly, some parents may experience an emergency cesarean section as fairly easy, while others may perceive it as highly aversive. Given the diverging interpretations of the birth experience, an investigation into subjective childbirth stress may provide further insight into the development of subsequent PDS (Bell & Andersson, 2016; Gürber et al., 2017a).

A handful of longitudinal studies have begun highlighting negative childbirth experiences as potentially powerful predictors of PDS in fathers. Gürber et al. (2017b) followed couples from pregnancy to four weeks postpartum and found that negative birth experiences, measured one week after childbirth, predicted PDS for both parents over and above the effect of depressive symptoms during pregnancy. Hughes et al. (2020) followed couples from pregnancy to four months postpartum and found that negative emotional birth memories, assessed four months after the baby’s birth, mediated the relationship between delivery method and PDS for mothers, but not fathers, and that negative memories predicted PDS in both parents.

Delivery method and birth stress.

Emerging evidence suggests that, as with mothers (Adams et al., 2012; Carter et al., 2022), the mode of delivery may influence fathers’ subjective birth experience. Capogna et al. (2007) followed fathers from their partners’ pregnancy through the first day postpartum and found that fathers whose partners received epidural analgesia experienced less stress and anxiety than those whose partners did not receive the same medical intervention. A large cohort study in Sweden (Johansson et al., 2015) found that fathers whose partners delivered either via spontaneous vaginal delivery or elective cesarean section had equivalently high levels of positive birth experiences, rated at two months postpartum. Fathers whose partners gave birth via an instrumental vaginal delivery (i.e., with the aid of forceps, a vacuum device, or another extraction instrument) had less positive assessments of the birth experience, while fathers whose partners delivered by emergency cesarean section had the least positive ratings of the birth experience. Taken together, these studies suggest that fathers’ birth experience—that is, whether the birth was positive or stressful—is at least partially shaped by the mode by which their partner delivers the infant.

Current Study

The current study extends the growing literature on maternal birth stress and PDS along two crucial dimensions. First, we measured subjective birth stress immediately after childbirth, rather than relying on retrospective reports. Second, we followed up with fathers at six months postpartum, a timeframe that dovetails with the highest prevalence of PDS in new parents (Cameron et al., 2016). Rather than binarize our outcomes as depressive symptoms that reach a clinically specified cut-off (i.e., “postpartum depression”), we used a continuous variable representing postpartum depressive symptoms (i.e., “PDS”) in order to have a more sensitive measure of men’s psychological distress, even at subthreshold levels. We hypothesized that 1) mothers’ delivery method will impact fathers’ reported birth stress such that emergency cesarean section will predict higher birth stress and 2) a more subjectively stressful birth will predict higher levels of fathers’ self-reported depressive symptoms at six months postpartum, controlling for mother’s delivery method and other birth complications, as well as fathers’ prenatal depressive symptoms.

Methods

Participants

Heterosexual fathers in Los Angeles who were expecting their first child and cohabiting with their partners were recruited during their partner’s second trimester of pregnancy from the greater Los Angeles area through fliers posted in obstetricians’ offices, at community health clinics, and on social media. The study included two in-lab visits: a prenatal visit in mid-to-late pregnancy, and a postpartum visit at about six months postpartum. There was also a perinatal visit scheduled within the first 1–2 days following the birth that took place at the hospital or birth center where the baby’s delivery occurred. Demographics for all fathers and their partners are shown in Table 1. There were no significant differences between mothers and fathers, or between fathers based on their partners’ delivery method, on any demographic measure.

Table 1.

Demographic characteristics

Mothers Fathers
Demographic Overall (n = 77) Overall (n = 77) Vaginal Delivery/Elective C-Section (n = 63) Emergency C-Section (n = 14)
Age, mean (SD), years 31.645 (4.282) Range: 21 – 39 33.675 (5.716) Range: 22 – 57
Race/Ethnicity, No. (%)
  White 36 (47.4%) 40 (52.0%) 35 (55.6%) 5 (35.7%)
  Black 5 (6.6%) 6 (7.8%) 4 (6.4%) 2 (14.3%)
  Hispanic/Latinx 15 (19.7%) 12 (15.6%) 10 (15.9%) 2 (14.3%)
  American Indian/Alaska Native 1 (1.3%) 0 (0%) 0 (0%) 0 (0%)
  Asian and Pacific Islander 14 (18.4%) 13 (16.9%) 9 (14.3%) 4 (28.6%)
  Other 5 (6.6%) 6 (7.8%) 5 (7.9%) 1 (7.1%)
Education
  High School or Equivalent 1 (1.3%) 1 (1.3%) 1 (1.6%) 0 (0%)
  Some College 6 (7.9%) 7 (9.1%) 3 (4.8%) 4 (28.6%)
  Associate Degree 2 (2.6%) 2 (2.6%) 2 (3.2%) 0 (0%)
  Bachelor’s Degree 28 (36.8%) 40 (52.0%) 33 (52.4%) 7 (50.0%)
  Master’s Degree 32 (42.1%) 16 (20.8%) 13 (20.6%) 3 (21.4%)
  Professional/Doctoral Degree 7 (9.2%) 11 (14.3%) 11 (17.4%) 0 (0%)
Couples
Overall (n = 77) Vaginal Delivery/Elective C-Section (n = 63) Emergency C-Section (n = 14)
Relationship Status, No. (%)
  Married or Domestic Partnership 63 (81.8%) 54 (85.7%) 9 (64.3%)
  Cohabitating 14 (18%) 9 (14.3%) 5 (35.7%)
Perinatal Visit Timing, No. (%)
  Day Of Birth 29 (37.7%) 24 (38.1%) 5 (36%)
  Day After Birth 41 (53.2%) 35 (55.6%) 6 (42.9%)
  2–7 Days After Birth 4 (5.2%) 3 (4.8%) 1 (7.14%)
  More Than 1 Week After Birth 3 (3.9%) 1 (1.6%) 2 (14.3%)
Delivery Method, No. (%)
  Unmedicated Vaginal 15 (19.5%) 15 (23.8%) 0 (0%)
  Medicated Vaginal 46 (59.7%) 46 (73.0%) 0 (0%)
  Emergency C-Section 14 (18.2%) 0 (0%) 14 (100%)
  Elective C-Section 2 (2.6%) 2 (3.2%) 0 (0%)
Other Birth Complications, No. (%)
  Uncomplicated Birth 53 (68.8%) 45 (71.4%) 8 (57.1%)
  Complicated Birth 24 (31.2%) 18 (28.6%) 6 (42.9%)
Preterm Birth, No. (%)
  Full Term 67 (87.0%) 54 (80.6%) 13 (92.9%)
  Preterm 9 (11.7%) 9 (14.3%) 0 (0%)
  Missing 1 (1.3%) 0 (0%) 1 (7.1%)
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A total of 100 fathers participated in this study and provided at least some data, and 72 fathers provided complete data at all longitudinal timepoints. Prenatal variables were available for all fathers. Subjective birth experience data was available for 93 fathers, with seven couples declining to participate in the childbirth visit. Of those 93 fathers, delivery method information was available for 77 families, with missing data largely due to challenges obtaining medical records from hospitals. Postpartum depressive symptoms data was available for 72 out of the 77 fathers, with data missing due to attrition at the six-month laboratory visit in five fathers. Delivery method, BEQ, and postpartum BDI data were missing completely at random relative to fathers’ prenatal depressive symptoms (t98 = −0.49, p = .629; t98 = 0.56, p = .576; t98 = 0.87, p = .384). Across all study measures, fathers who provided data did not differ from those with missing data by age, race/ethnicity, education, or PDS. Missingness was not associated with any other independent variable or covariate tested in the current analyses.

Procedure

Couples visited the laboratory for a four-hour prenatal visit in mid-to-late pregnancy (mean 28.2 weeks, SD 4.2 weeks). They completed computer-based questionnaires using the Qualtrics platform, including the Beck Depression Inventory. During the prenatal visit, participants also provided information on their age, race, education, and other demographic information. Approximately one day after the birth (median = 1 day; mean = 4.5 days), lab personnel visited the hospital or birth center where the baby was delivered and directed each member of the couple to independently complete a paper copy of the Birth Experiences Questionnaire, a measure of birth stress. The researchers obtained birth charts from the hospital and birth center following the birth. The researchers then abstracted delivery method and birth complication information from the birth charts. Ten couples completed the childbirth visit remotely, and the remaining 83 completed the childbirth visit in person. Most (80%) of the childbirth visits occurred either on the day of the birth or one day after; nine of the childbirth visits occurred within two weeks of the birth, and another nine occurred more than two weeks after the birth. Couples returned to the laboratory when their infant was approximately six months old (mean 28.7 weeks, SD 3.1 weeks) to complete a postpartum visit that followed a similar structure to the prenatal visit. Couples completed another battery of questionnaires at this visit, which again included the Beck Depression Inventory to measure the presence of depressive symptoms during the postpartum period. Additional information on study procedure can be found in other published studies that used the same multi-wave data set, including (Cardenas et al., 2021, under review; Corner et al., 2023; Khaled et al., 2020, 2021; Saxbe et al., 2023). There were no significant differences in prenatal or postpartum visit timing between the sample of participants included in the current study’s analyses (n = 77) and those who did not provide delivery method data. There was a significant difference in the timing of the hospital or birth center visit (t94 = 4.787, p < .001), such that fathers with missing delivery method data (n = 23) had a mean visit timing of 16 days, in contrast to the overall sample’s (n = 100) mean of 4.5 days and the subsample’s (n = 77) mean of 1.5 days. For the majority of the sample of 23 participants who did not provide delivery method data, lab personnel were unable to schedule the hospital visit while participants were still in the hospital, and instead visited participants virtually or in their homes several weeks after the birth. As a result, obtaining hospital birth charts was more difficult than for those participants visited in the hospital.

Measures

Depressive Symptoms.

Depressive symptoms were measured during the prenatal and postpartum laboratory visits using the Beck Depression Inventory (BDI-II; Beck et al., 1996), a widely used 21-item self-report questionnaire that assesses mental and somatic complaints related to depression, including loss of pleasure and changes to sleep and appetite. Respondents rate items on a 4-point scale (0 = not at all, 3 = severely), and responses are summed such that higher scores indicate a greater number of depressive symptoms. Extensive research has demonstrated high internal consistency (e.g., α = .89; Whisman et al., 2000) and validity (e.g., Storch et al., 2004).

Subjective Birth Stress.

Subjective birth experience was assessed one to two days after childbirth using the Birth Experiences Questionnaire (BEQ; Saxbe et al., 2018), a 10-item self-report questionnaire that was developed to capture the psychological constructs relevant to the birthing experience, including birth-related perceived stress, pain, fear, and violation of expectations. Respondents rate items on a 7-point scale (0 = not at all, 7 = extremely), and responses are summed so that higher scores indicate a more negative birth experience. The BEQ has not been designed as an instrument for identifying clinically significant distress, and it has not been normed on a clinical population. The BEQ was originally validated with a subset of the current data (Saxbe et al., 2018), and reliability within the larger sample used in the current paper was found to be acceptable (α = .701).

Medical Records.

Delivery method was abstracted from medical birth records, and fathers were categorized as witnessing one of four delivery types: unmedicated vaginal birth, medicated vaginal birth, emergency cesarean section, and scheduled cesarean section.

Given that this was a healthy community sample, there was a relatively low rate of preterm birth (< 38 weeks) and other birth complications, including prolonged labor, heart rate decelerations, and breech presentation. Therefore, we summarized preterm birth and birth complications as a binary of presence vs. absence in order to covary for the medical complexity and unpredictability of the birth. As shown in Table 1, 24% of couples had births that we categorized as medically complex.

Model Considerations

To test Hypothesis 1, we conducted a one-way analysis of variance (ANOVA) to investigate the effect of delivery method on fathers’ subjective birth stress. We then performed a post-hoc analysis using Tukey’s honest significance test (HST) for multiple comparisons to establish the difference in means between each level of delivery method and their significance, thereby determining which kinds of delivery methods were more or less subjectively stressful (Hypothesis 1). We then tested the association between birth stress and PDS (Hypothesis 2) via a multiple regression analysis predicting fathers’ depressive symptoms at six months postpartum. Covariates included prenatal depressive symptoms, delivery method, and the birth complication binary variable. We tested the model with and without race (operationalized as a binary of white vs. non-white) and education (operationalized as an ordinal variable with six levels from high school to professional/doctoral degree) demographics as covariates, and the results did not substantively vary, so we report the most parsimonious model. To account for the positive skew of the data, the analyses used a square-root transformation (Bartlett, 1936) of the BDI, which corrected our sample’s moderate skewness better than a logarithmic transformation. Seventy-seven fathers were included in the analyses for Hypothesis 1, and 72 fathers were included in the analyses for Hypothesis 2.

Results

Mean scores for study measures by delivery method can be found in Table 2. Table 3 shows zero-order correlations between key study variables.

Table 2.

Descriptive statistics

Measure Overall (n = 77) Vaginal Delivery/Elective C-Section (n = 63) Emergency C-Section (n = 14)
Mean (SD) Range Mean (SD) Range Mean (SD) Range
BEQ 3.476 (.878) 2.1 – 5.7 3.328 (.810) 2.1 – 5.4 4.223 (0.870) 2.8 – 5.7
BDI 7.986 (5.445) 0 – 23 7.707 (5.157) 0 – 21 9.143 (6.597) 0 – 23
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Abbreviations: BDI, Beck Depression Inventory; BEQ, Birth Experiences Questionnaire.

Table 3.

Zero-Order Correlations for Relevant Measures

1 PP BDI 2 PN BDI 3 BEQ 4 Delivery Method 5 Preterm Birth 6 Birth Complications 7 Age 8 Race 9 Education
2 .716*** -
3 .324** .284** -
4 .105 .225* .360** -
5 .252 .114 .095 −.166 -
6 −.021 .026 .183 .119 .101 -
7 −.183 −.133 .003 −.121 .012 .012 -
8 −.005 −.033 −.215* −.153 .021 .105 .324** -
9 −.363*** −.249* −.305** −.218 .022 −.041 .141 .251* -
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Abbreviations: PP, postpartum; PN, prenatal; BDI, Beck Depression Inventory; BEQ, Birth Experiences Questionnaire.

•

p < 0.06

*

p < 0.05

**

p < 0.01

***

p < 0.001

Hypothesis 1 was supported (F3, 68 = 4.54, p = .006). Mean subjective birth stress levels for each delivery method can be found in Figure 1A, and results from the post-hoc Tukey’s HST for multiple comparisons can be found in in Figure 1B. The HST revealed that the mean value of subjective birth stress varied significantly between the emergency cesarean section group (mean 4.22, SD = .87) compared to both the medicated (mean 3.44, SD 0.88, t53 = 2.80, p = .021) and the unmedicated (mean 3.16, SD 0.65, t27 = 3.71, p = .006) vaginal delivery groups. Fathers’ birth stress did not significantly differ for medicated vs. unmedicated vaginal deliveries. Fathers whose partners had scheduled cesarean sections reported lower levels of birth stress (mean 2.93, SD 0.25) than fathers whose partners had emergency cesareans at the trend level (t13 = −2.04, p = .062). The mean level of subjective birth stress for fathers whose partners underwent scheduled cesarean sections did not significantly differ from the two vaginal delivery conditions, and the two vaginal delivery conditions did not significantly differ from one another in terms of subjective birth stress.

Figure 1.

Figure 1.

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Sample size flow chart

Hypothesis 2 (Table 4) was also supported, such that a father’s rating of his subjective birth stress reported shortly after his partner’s childbirth significantly predicted PDS six months later. The zero-order correlation (Table 3) was r =.32 (p = .002). Given that the findings from Hypothesis 1 suggested the statistical equivalence of three of the four delivery types, and because of the small sample size (n = 2) of the elective cesarean section group, we created a binary delivery method variable in which emergency cesarean sections were coded as “1” and all other methods—which included both vaginal delivery methods and scheduled cesarean sections—were grouped and coded as “0.” Subjective birth stress continued to predict PDS in a regression model that included this delivery method binary covariate along with prenatal depressive symptoms and the medical complexity of the birth. As there were only two scheduled cesarean sections in our sample, we tested the model with and without fathers whose partners underwent scheduled cesareans. The two models were not substantively different. Delivery method and birth complications did not significantly predict fathers’ PDS.

Table 4.

Predictors of PDS at six months postpartum (Hypothesis 2)

Variable β SE 95% CI
Intercept .615 .635 −.653 1.883
BEQ .269 * .126 .016 .522
Delivery Method −.362 .284 −.928 .205
Prenatal Depression .136 *** .020 .095 .176
Other Complications −.118 .179 −.476 .240
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Abbreviations: PDS, Postpartum depressive symptoms; BEQ, Birth Experiences Questionnaire.

*

p < 0.05

**

p < 0.01

***

p < 0.001

Discussion

Within a sample of first-time parents, we found associations between fathers’ birth stress and subsequent postpartum depressive symptoms, as well as associations between fathers’ birth stress and partners’ mode of delivery. Specifically, we found that first-time fathers whose partners underwent emergency cesarean section reported higher subjective birth stress in the days immediately following birth than did fathers whose partners delivered vaginally or via scheduled cesarean section. Fathers whose partners delivered vaginally reported equivalent subjective birth stress regardless of whether their partners’ births were medicated or unmedicated. Similarly, fathers whose partners gave birth via scheduled cesarean section reported equivalent levels of birth stress to those fathers whose partners delivered vaginally. Furthermore, fathers who reported higher subjective birth stress within a few days of their partners’ birth subsequently reported greater depressive symptoms at six months postpartum. This effect held after controlling for fathers’ prenatal depressive symptoms, suggesting that pre-existing depressive symptoms did not explain the association between birth stress and fathers’ later depressive symptoms. It also held after controlling for obstetric factors such as delivery method, birth complications, and preterm birth. Despite our finding that men whose partners underwent emergency cesarean section reported higher subjective birth stress than men whose partners delivered vaginally, the association between subjective birth stress and postpartum depressive symptoms held even after we controlled for mode of delivery. In other words, although the mode of delivery appears to have a meaningful influence on fathers’ subjective experience, it does not predict fathers’ later mental health outcomes on its own. These findings extend the research literature on the birth experiences of fathers and provide insight into the potential for negative long-term effects resulting from men’s subjectively stressful experiences of their partners’ birth. The study’s findings indicate the importance of assessing fathers’ experiences in the days immediately following childbirth to maximize early prevention and intervention efforts.

Our finding that emergency cesarean section is associated with poorer subjective experiences of the birth is largely consistent with previous literature. In comparing positive ratings of birth experiences in fathers, Johansson and colleagues (2015) found that Swedish fathers whose partnered delivered by emergency cesarean had the least positive ratings of their birth. Though we did not find a significant difference between birth experiences in the other three delivery method groups, the descriptive means for each of the three follow the same pattern as that in Johansson’s study: scheduled cesarean sections and unmedicated/spontaneous vaginal delivery were the least aversive delivery methods, while medicated/instrumental vaginal delivery was less aversive than emergency cesarean delivery but more aversive than unmedicated/spontaneous vaginal delivery and scheduled cesarean section for fathers. However, the current study is in partial contrast to the previous finding that fathers whose partners receive epidural analgesia during vaginal delivery report lower state anxiety and higher satisfaction than fathers whose partners delivered vaginally without anesthesia (Capogna et al., 2007). The authors of the earlier study suggested that fathers’ negative subjective experiences of unmedicated births may be due to anxiety related to witnessing their partner in pain and feelings of helplessness. Given that interpretation, the reasons for which a mother has a medicated or unmedicated vaginal delivery, as well as the agency a mother has in selecting her mode of delivery, may be the cause of the discrepancy between our results and Capogna et al.’s. A mother who has a birth plan that includes a “natural” or unmedicated birth would likely interpret and experience childbirth pain more positively than a mother who wished for anesthesia but did not receive it, and in turn fathers will experience a greater sense of agency and a lower aversive reaction to their partner’s pain. Because of the relatively high number of home births in our sample, as well as anecdotal evidence that mothers in the Los Angeles area are more likely to elect unmedicated births than elsewhere in the country, it is possible that the relatively low paternal birth stress may be related to the presence of “natural” birth plans, rather than the lack of medical intervention in itself.

At six months postpartum, men who reported higher birth stress in the first days after childbirth reported higher depressive symptoms. This extends previous research on fathers’ subjective experience of birth, which found that negative birth experiences and negative birth memories predicted depressive symptoms for fathers at four weeks (Gürber et al., 2017b) and four months (Hughes et al., 2020) postpartum. This effect is over and above that of prenatal depressive symptoms. Our model also indicated that delivery method and other birth complications did not, in themselves, predict fathers’ PDS, a finding that consistent with both Gürber et al. (2017b) and Hughes et al., (2020).

As a particularly vulnerable inflexion point at the transition to parenthood, childbirth presents a unique opportunity to screen for PDS risk in both parents, but particularly fathers. Both parents are more often present at childbirth than in subsequent postpartum primary care visits, so providers increase the likelihood of including fathers in the screening process begins at birth. Since we found that subjective stress seemed to be a better predictor of risk for PDS in fathers than delivery method or birth complications, fathers who subjectively witness a vaginal delivery or uncomplicated birth as stressful may be passed over in preventive PDS screenings or referrals. Asking fathers about their experience of the birth, or even administering a brief subjective stress measure to fathers in the hospital following delivery, would allow providers to quickly identify this vulnerable group of fathers and help connect them to support and treatment options. This research also suggests that prenatal childbirth education programs may help to prevent fathers’ PDS by preparing them for what might happen during the birth process and empowering fathers to play an active role in supporting their partners through labor and delivery (see review in Suto et al., 2017). Including fathers in birth preparation classes and engaging with them during prenatal check-up visits might mitigate some potential mental health risks that emerge when their partner’s birth feels unpredictable or alarming.

This study is a novel step in understanding the impact of fathers’ childbirth stress on subsequent depressive symptoms, but is limited by its small sample, which was restricted to heterosexual, cohabitating couples. Furthermore, while racially and ethnically diverse, the sample was well-educated, mostly married, and reported high relationship satisfaction and low levels of clinically significant depression, limiting the generalizability of our findings. Future research should seek to include more diverse families to understand the impact of birth stress on a wider range of the population. The study also estimated paternal postpartum depressive symptoms using the Beck Depression Inventory, which was not specifically designed to measure paternal postpartum depression. However, a recent scoping review (Berg et al., 2022) found that the Beck Depression Inventory was the third most common measure of paternal perinatal depression across 59 studies, following the Edinburgh Postnatal Depression Scale and the Center for Epidemiologic Studies Depression Scale, the latter of which was also not designed specifically for perinatal depression. Finally, births were mostly uncomplicated and the delivery method group size was uneven, with only 14 mothers undergoing emergency cesarean section, and the remaining 63 undergoing either vaginal or elective cesarean. Future research should include more couples who experience medically challenging births to better capture the impact of delivery method and birth complications on paternal postpartum depressive symptoms.

Despite some limitations, this project has important public health implications to promote fathers’ healthy adjustment to parenthood. This was a prospective, longitudinal study and, to our knowledge, the first to include both birth data from medical charts and self-report data collected only hours after childbirth. Much of the childbirth literature either excludes the psychological implications of birth or focuses exclusively on the mother’s experience of that stress, and our study’s focus on fathers’ subjective birth experiences provides insight into the lesser explored transition to fatherhood, while also providing novel insight into screening and early intervention for fathers at risk for negative postpartum outcomes.

Figure 2.

Figure 2.

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Mean values and mean differences of birth stress for each delivery method

Highlights:

  • Higher paternal birth stress within 2 days of birth predicts greater postpartum depression

  • Emergency c-sections were associated with higher subjective birth stress in first-time fathers

  • The days after birth are an opportunity for early intervention for paternal postpartum depression

Role of funding sources

This work was supported by a National Science Foundation CAREER Award (#1552452) to Dr. Saxbe, an NIH R01 (NIH-NICHD R01 HD104801) to Dr. Saxbe. The funding sources has no involvement in the collection, analysis, and interpretation of data, in the writing of the report, or in the decision to submit the article for publication.

Abbreviations:

PDS

Postpartum depressive symptoms

HST

honest significance test

Footnotes

Declaration of interest: None.

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References

  1. Adams S, Eberhard-Gran M, Sandvik Å, & Eskild A. (2012). Mode of delivery and postpartum emotional distress: A cohort study of 55 814 women: Mode of delivery and maternal postpartum emotional distress. BJOG: An International Journal of Obstetrics & Gynaecology, 119(3), 298–305. 10.1111/j.1471-0528.2011.03188.x [DOI] [PubMed] [Google Scholar]
  2. Ansari NS, Shah J, Dennis C, & Shah PS (2021). Risk factors for postpartum depressive symptoms among fathers: A systematic review and meta- analysis. Acta Obstetricia et Gynecologica Scandinavica, 100(7), 1186–1199. 10.1111/aogs.14109 [DOI] [PubMed] [Google Scholar]
  3. Barooj-Kiakalaee O, Hosseini S-H, Mohammadpour-Tahmtan R-A, Hosseini-Tabaghdehi M, Jahanfar S, Esmaeili-Douki Z, & Shahhosseini Z. (2022). Paternal postpartum depression’s relationship to maternal pre and postpartum depression, and father-mother dyads marital satisfaction: A structural equation model analysis of a longitudinal study. Journal of Affective Disorders, 297, 375–380. 10.1016/j.jad.2021.10.110 [DOI] [PubMed] [Google Scholar]
  4. Bartlett MS (1936). The Square Root Transformation in Analysis of Variance. Supplement to the Journal of the Royal Statistical Society, 3(1), 68. 10.2307/2983678 [DOI] [Google Scholar]
  5. Beck AT, Steer RA, & Brown G. (1996). Beck Depression Inventory–II [Data set]. In APA PsycTests. 10.1037/t00742-000 [DOI] [Google Scholar]
  6. Bell AF, & Andersson E. (2016). The birth experience and women’s postnatal depression: A systematic review. Midwifery, 39, 112–123. 10.1016/j.midw.2016.04.014 [DOI] [PubMed] [Google Scholar]
  7. Cameron EE, Sedov ID, & Tomfohr-Madsen LM (2016). Prevalence of paternal depression in pregnancy and the postpartum: An updated meta-analysis. Journal of Affective Disorders, 206, 189–203. 10.1016/j.jad.2016.07.044 [DOI] [PubMed] [Google Scholar]
  8. Capogna G, Camorcia M, & Stirparo S. (2007). Expectant fathers’ experience during labor with or without epidural analgesia. International Journal of Obstetric Anesthesia, 16(2), 110–115. 10.1016/j.ijoa.2006.08.009 [DOI] [PubMed] [Google Scholar]
  9. Cardenas SI, Stoycos SA, Sellery P, Marshall N, Khoddam H, Kaplan J, Goldenberg D, & Saxbe DE (2021). Theory of mind processing in expectant fathers: Associations with prenatal oxytocin and parental attunement. Developmental Psychobiology, 63(5), 1549–1567. 10.1002/dev.22115 [DOI] [PubMed] [Google Scholar]
  10. Cardenas SI, Tse W, León G, Kim A, Tureson K, Lai M, & Saxbe DE Prenatal testosterone synchrony in first-time parents predicts fathers’ postpartum relationship quality. Manuscript submitted for publication. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Carter J, Bick D, Gallacher D, & Chang Y. (2022). Mode of birth and development of maternal postnatal POST- TRAUMATIC stress disorder: A mixed- methods systematic review and META-ANALYSIS. Birth, 49(4), 616–627. 10.1111/birt.12649 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Corner GW, Rasmussen HF, Khaled M, Morris AR, Khoddam H, Barbee N, Herzig S, Brasby Y, Seibert E, Sellery PE, Margolin G, & Saxbe D. (2023). The birth of a story: Childbirth experiences, meaning-making, and postpartum adjustment. Journal of Family Psychology. 10.1037/fam0001062 [DOI] [PubMed] [Google Scholar]
  13. Eddy B, Poll V, Whiting J, & Clevesy M. (2019). Forgotten Fathers: Postpartum Depression in Men. Journal of Family Issues, 40(8), 1001–1017. 10.1177/0192513X19833111 [DOI] [Google Scholar]
  14. Gastaldon C, Solmi M, Correll CU, Barbui C, & Schoretsanitis G. (2022). Risk factors of postpartum depression and depressive symptoms: Umbrella review of current evidence from systematic reviews and meta-analyses of observational studies. The British Journal of Psychiatry, 1–12. 10.1192/bjp.2021.222 [DOI] [PubMed] [Google Scholar]
  15. Gürber S, Baumeler L, Grob A, Surbek D, & Stadlmayr W. (2017a). Antenatal depressive symptoms and subjective birth experience in association with postpartum depressive symptoms and acute stress reaction in mothers and fathers: A longitudinal path analysis. European Journal of Obstetrics & Gynecology and Reproductive Biology, 215, 68–74. 10.1016/j.ejogrb.2017.05.021 [DOI] [PubMed] [Google Scholar]
  16. Gürber S, Baumeler L, Grob A, Surbek D, & Stadlmayr W. (2017b). Antenatal depressive symptoms and subjective birth experience in association with postpartum depressive symptoms and acute stress reaction in mothers and fathers: A longitudinal path analysis. European Journal of Obstetrics & Gynecology and Reproductive Biology, 215, 68–74. 10.1016/j.ejogrb.2017.05.021 [DOI] [PubMed] [Google Scholar]
  17. Huang J, Zheng J, & Ling-ling G. (2023). Individual and dyadic network analyses of depressive symptoms in Chinese postpartum couples: A cross-sectional study. Midwifery, 116, 103529. 10.1016/j.midw.2022.103529 [DOI] [PubMed] [Google Scholar]
  18. Hughes C, Foley S, Devine RT, Ribner A, Kyriakou L, Boddington L, & Holmes EA (2020). Worrying in the wings? Negative emotional birth memories in mothers and fathers show similar associations with perinatal mood disturbance and delivery mode. Archives of Women’s Mental Health, 23(3), 371–377. 10.1007/s00737-019-00973-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Johansson M, Fenwick J, & Premberg Å (2015). A meta-synthesis of fathers׳ experiences of their partner׳s labour and the birth of their baby. Midwifery, 31(1), 9–18. 10.1016/j.midw.2014.05.005 [DOI] [PubMed] [Google Scholar]
  20. Khaled M, Corner GW, Horton K, Khoddam H, Stoycos S, & Saxbe DE (2020). Prenatal relationship conflict behavior predicts childbirth experiences and birth outcomes. Journal of Family Psychology, 34(6), 759–765. 10.1037/fam0000650 [DOI] [PubMed] [Google Scholar]
  21. Khaled M, Corner GW, Morris A, Havaldar S, Luo E, & Saxbe DE (2021). Physiological linkage in pregnancy: Couples’ cortisol, negative conflict behavior, and postpartum depression. Biological Psychology, 161, 108075. 10.1016/j.biopsycho.2021.108075 [DOI] [PubMed] [Google Scholar]
  22. Leavitt CE, McDaniel BT, Maas MK, & Feinberg ME (2017). Parenting Stress and Sexual Satisfaction Among First-Time Parents: A Dyadic Approach. Sex Roles, 76(5–6), 346–355. 10.1007/s11199-016-0623-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Morris AR, Aviv EC, Khaled M, Corner GW, & Saxbe DE (2022). Prenatal romantic relationship satisfaction predicts parent–infant bonding for fathers, but not mothers. Couple and Family Psychology: Research and Practice. 10.1037/cfp0000225 [DOI] [Google Scholar]
  24. O’Brien AP, McNeil KA, Fletcher R, Conrad A, Wilson AJ, Jones D, & Chan SW (2017). New Fathers’ Perinatal Depression and Anxiety—Treatment Options: An Integrative Review. American Journal of Men’s Health, 11(4), 863–876. 10.1177/1557988316669047 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Paulson JF, Bazemore SD, Goodman JH, & Leiferman JA (2016). The course and interrelationship of maternal and paternal perinatal depression. Archives of Women’s Mental Health, 19(4), 655–663. 10.1007/s00737-016-0598-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Saxbe D, Horton KT, & Tsai AB (2018). The Birth Experiences Questionnaire: A brief measure assessing psychosocial dimensions of childbirth. Journal of Family Psychology, 32(2), 262–268. 10.1037/fam0000365 [DOI] [PubMed] [Google Scholar]
  27. Saxbe D, Martínez Garcia M, Cardenas SI, Waizman Y, & Carmona S. (2023). Changes in left hippocampal volume in first- time fathers: Associations with oxytocin, testosterone, and adaptation to parenthood. Journal of Neuroendocrinology, e13270. 10.1111/jne.13270 [DOI] [PubMed] [Google Scholar]
  28. Scarff JR (2019). Postpartum Depression in Men. Innovations in Clinical Neuroscience, 16(5). [PMC free article] [PubMed] [Google Scholar]
  29. Storch EA, Roberti JW, & Roth DA (2004). Factor structure, concurrent validity, and internal consistency of the beck depression inventory?second edition in a sample of college students. Depression and Anxiety, 19(3), 187–189. 10.1002/da.20002 [DOI] [PubMed] [Google Scholar]
  30. Suto M, Takehara K, Yamane Y, & Ota E. (2017). Effects of prenatal childbirth education for partners of pregnant women on paternal postnatal mental health and couple relationship: A systematic review. Journal of Affective Disorders, 210, 115–121. 10.1016/j.jad.2016.12.025 [DOI] [PubMed] [Google Scholar]
  31. Sweeney S, & MacBeth A. (2016). The effects of paternal depression on child and adolescent outcomes: A systematic review. Journal of Affective Disorders, 205, 44–59. 10.1016/j.jad.2016.05.073 [DOI] [PubMed] [Google Scholar]
  32. Wang D, Li Y-L, Qiu D, & Xiao S-Y (2021). Factors Influencing Paternal Postpartum Depression: A Systematic Review and Meta-Analysis. Journal of Affective Disorders, 293, 51–63. 10.1016/j.jad.2021.05.088 [DOI] [PubMed] [Google Scholar]
  33. Wells MB, & Jeon L. (2023). Paternal postpartum depression, coparenting, and father-infant bonding: Testing two mediated models using structural equation modeling. Journal of Affective Disorders, 325, 437–443. 10.1016/j.jad.2022.12.163 [DOI] [PubMed] [Google Scholar]
  34. Wells MB, Jeon L, & Aronson O. (2023). Bidirectional associations between paternal postpartum depression symptoms and coparenting: A cross-lagged panel model of fathers of infants and toddlers. Journal of Affective Disorders, 324, 440–448. 10.1016/j.jad.2022.12.128 [DOI] [PubMed] [Google Scholar]
  35. Whisman MA, Perez JE, & Ramel W. (2000). Factor structure of the Beck Depression Inventory—Second Edition (BDI-ii) in a student sample. Journal of Clinical Psychology, 56(4), 545–551. [DOI] [PubMed] [Google Scholar]

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