The transition to parenthood is characterised by a period of adjustment experienced by both mothers and fathers (Delicate et al, 2018). For mothers, postnatal relationships with their partners and infants are subject to significant change (Jeong et al, 2021). In particular, mothers' perceptions of partner support have an influence on their experiences during the transition to parenthood. The importance of partner support to new mothers has been described as ‘emotional or instrumental’ (Kirova and Snell, 2018: 207). This is significant, since relationship intimacy has possibly the strongest effect on mothers' quality of life in the postnatal period (Jeong et al, 2021).
Mothers also benefit from a supportive partner and partner support may protect mothers from postnatal fatigue (Henderson et al, 2019). Mothers also consider partner contributions in household chores as validation of their new role as mothers (Kirova and Snell, 2017). Furthermore, a mother's perception of her partner's contribution to household tasks has also been shown to be associated with a higher sense of intimacy in her relationship (McDonald et al, 2017). Thus, the father's prioritisation of his family positively influences maternal perceptions of partner support (Kirova and Snell, 2017).
However, at times, support from the father may be impeded. One such barrier to effective support is paternal postnatal depression (PND), which can have a negative impact on men's emotions (Pedersen et al, 2021), coping (Edhborg et al, 2016), relationships (Eddy et al, 2019), and role transition (Barral and de Guzman, 2021). This may help explain why paternal PND is so closely associated with PND in mothers (Goodman, 2008; Paulson and Bazemore, 2010). For healthcare practitioners, considering fathers' mental health is, therefore, also important in their support for mothers.
Based on our findings where fathers described the mother of their child(ren) as the first person to detect their PND (Davenport and Swami, 2023a), as well as partners being the main person influencing fathers' help-seeking for PND (Davenport and Swami, 2023b), it is clear that in the context of a father experiencing PND, the role of the mother/partner is vital. Yet, at the time of writing, little was known about maternal perceptions of paternal PND. Mothers are noted by their health visitors to seek advice for their partner's PND (Davenport and Swami, 2023c); but, considering that health visitors are much less likely to encounter fathers following the antenatal and new birth visit (Davenport and Swami, 2023c), understanding how mothers communicate their partner's mental health can offer new insight into understanding family health, particularly when fathers are not able to attend appointments due to working commitments.
Currently, men are not routinely recognised or diagnosed with PND. However, in research fathers do identify as suffering with the condition. In this context, we sought to examine the perspectives of partners of diagnosed fathers – however, this recruitment was unsuccessful. Accordingly, this study aimed to understand mothers' experiences of living with fathers who are presumed to suffer PND, and women's perspectives around paternal PND generally, to provide new knowledge in this under-researched area.
Method
Research design
Originally, we aimed to recruit and interview mothers using online dissemination of study adverts, including on Mumsnet and Twitter. However, this was unsuccessful in gaining responses from mothers. Therefore, to source mothers' experiences as closely as possible, we adapted our design to mirror Eddy et al's (2019) content analysis of online parenting sites as a way to examine paternal PND. While that study examined fathers' online postings, this study examines the posts written by mothers.
Content analysis (CA) is based on a constructivist epistemology (Drisko and Maschi, 2015), based on the understanding that meaning is interpreted from the (textual) data (Drisko and Maschi, 2015). Given the shift from interviews to online data, CA was selected based on its potential to analyse secondary data (Pope et al, 2007). The CA process sought to reduce data into common meanings. For the purposes of this study, we aligned this process to the aims, so searched the data to collect understandings of women's experiences of having a depressed partner/father, and women's perceptions of paternal PND more generally.
Data rules
To analyse the mothers' data, it was necessary to source and extract relevant information. To maintain a systematic approach, four ‘rules’ of coding were pre-designed (Mayring, 2014). Two rules examined the content from original posters, while two rules examined the responding posters data. The content was analysed with the following rules:
Data were extracted following repeated reading of the forum posts and coded into tables under headed categories (e.g., ‘advice’), and are narrated into two themes in the findings section.
Procedures
Data sources were popular UK parenting sites Netmums and Mumsnet. Search terms included ‘fathers' postnatal depression’; ‘partner's postnatal depression’, and ‘PND men’. The search date was 8 November 2022. Overall, 16 threads contributed to the final dataset, of which five came from Netmums and 11 from Mumsnet. The responses to the threads ranged from 1 to 60, with a mean of 16.
Ethics
While the data was in the public domain, due to the sensitivity of the topic ethical approval was granted from the relevant school ethics panel (approval code: EHPGR21_04). Permission was also granted by the site owners prior to data collection. To maintain confidentiality, users' names were removed and replaced with a participant number.
Participants
As the data were collected from a secondary source, it was not possible to corroborate the details of the participants. It was assumed that they were (mostly) mothers by their participation on parenting sites with ‘mums’ in the site name. The total number of participants was 127, comprising 16 mothers who were ‘original posters’ and 111 were respondents. Original posters described living with a depressed father, but it was not clear if these fathers were diagnosed with PND. However, UK fathers are not routinely diagnosed with PND, so the ability to recruit partners of fathers with a PND diagnosis is limited.
Reflexivity
Throughout the research process, the first author (as a mother and health visitor) engaged in written and spoken reflection around their preconceptions, thoughts and reactions to the data. In particular, the risk of interpreting mothers' written word through personal perceptions was minimised by reflecting on reactions to the data. This sought to ensure that the analysis and findings remained close to the textual core meanings made by mothers (Erlingsson and Brysiewicz, 2017).
Results
Following the data collection and analysis, two themes relevant to health visiting practice were produced.
Theme 1: Mothers consider their partner to have PND due to his sudden behaviour changes and/or a lack of bonding with the baby
It is important to reinforce that the mothers' reports of fathers' ‘postnatal depression’ were not verified by medical diagnoses. Mostly, the mothers posted on the forums because they suspected PND in their partner. However, this is because they had observed many changes in their partner, as well as a negative impact on their own wellbeing. These are presented here.
Mothers notice fathers' behavioural, emotional, and character changes
Opening posters described emotional changes, including withdrawal: ‘He'd shut himself off from me emotionally and withdraw’; ‘My DP [dear partner] seems to have become withdrawn’; and ‘He's a zombie almost … he won't open up or talk about his feelings’.
Anger was also described: ‘My husband has become increasingly irritable, moody, verbally aggressive and very short tempered’; ‘This is sheer anger at being awake. He's not angry at the baby, just the situation … He's angry at our life’. Another described her experience where ‘he gets very frustrated very easily’.
Other mothers reported changes including fathers' altered sleep patterns, weight loss, no longer exercising, low appetite, and overeating. They also described fathers' loss of sense of humour, feeling ‘stressed’, ‘overwhelmed’, ‘trapped’, and being ‘depressed’.These were marked changes from their partners' past characters:
‘It's not ‘him’, really … My partner is, or was, the most empathic, kind and thoughtful man I've ever been with, and does still show he has it in him from time to time … my partner is really not … like that.’
‘He was always hands-on before and supported my return for work. He knows there is no alternative, and he's not the type to cause a drama.’
Mothers also described their partners' ‘work stress’, stating the fathers were ‘stressed at work’, ‘struggling at work’ or ‘not performing well’. Based on all these changes, mothers suspected PND: ‘I think he's got depression’; and ‘I'm convinced he's suffering from postnatal depression’.
Mothers observe a lack of father–baby bond and feel let down by a lack of support
Another common experience was where mothers described fathers as being unable to bond with their infants. Some mothers had noticed this by watching their partners interact with their babies, observing, ‘He don't take much interest in her as in cooing over her, having cuddles’ or ‘He looked at our daughter with such a vacant expression and gets so easily annoyed with her’.
Another mother said similar:
‘Since our youngest has been born I have noticed he is not the same with her, there are no playful interactions, no kisses or cuddles, nothing at all’.
In other cases, fathers had told the mothers about their bonding difficulties during conversation: ‘He admitted to me he'd really struggled to bond with our baby’, and ‘He says he isn't enjoying him’. It is notable that three mothers used the word ‘admitted’ when describing how their partners shared their bonding and unhappiness, suggesting they were aware of this as potentially ‘unacceptable’ or shameful. A further emotion observed by the mothers was guilt, as a response to not being able to bond with their babies: ‘He'd really struggled to bond with our baby and he feels guilty/ashamed etc’.
There was evidence that mothers had thought in detail about these bonding difficulties. For instance, in one case, a mother had considered reasons for her partner's lack of bonding and deduced that it was not because the baby was particularly difficult: ‘The youngest is not a cryer or anything’. Another mother emphasised that her partner, despite lacking a bond, was making efforts to become closer to his baby, stating, ‘He's here he is trying with her’. Therefore, when perceiving PND in their partner, mothers noticed changed emotions, behaviour and character, and a lack of father–baby bond.
Theme 2: Women expect fathers to seek help when PND is suspected, with mothers feeling unsupported and in need of help
Mothers seek help from others about their situation
Following the birth of their babies, some mothers described needing some care and attention, and perceived the father's PND as denying them this: ‘It felt like the latest in a line of selfish behaviours’; ‘He couldn't even allow me the ability to be the person who might need help and support’; and ‘Yet again, it was all about him’. Thus, when mothers perceive PND in the father of their child, this may negatively affect their own motherhood experience.
Some mothers, therefore, directly appealed for help, often using the word ‘really’ to emphasise this: ‘Really looking for some help’; ‘I really need someone's perspective on this to help me through’; and ‘I'd be really grateful for any advice’. This demonstrates the anxieties they felt at the situation. Mothers also identified a feeling of helplessness at the situation: ‘I really don't know what to do’; ‘I don't know what to do’; ‘I just don't know how to sort things out’.
A lack of understanding around paternal PND
Some mothers sought clarification on whether PND was even a condition affecting men: ‘Is there a male-specific term for depression relating to the birth of a child?’, and ‘Can fathers suffer postnatal depression?’ In one case, a mother wanted to confirm her health visitor's suggestion: ‘I really feel he might have PND. My HV [health visitor] said that men can suffer from it too’.
Some posters did consider that fathers can experience PND, with some arguing that ‘he really can't help it, and he can't ‘pull himself together’, and another suggesting he was ‘trying his best’. In other cases, however, the fathers' depressive symptoms were minimised: ‘He does sound a bit low’; ‘He does sound very lazy, even if he is ill’.
Other posters rejected the idea PND affects men: ‘If you haven't given birth you're not postpartum, so though you may have depression it isn't postpartum depression?’; ‘Men can't have postnatal depression’; and ‘PND is the wrong word’. Paternal PND was considered an appropriation of a female condition: ‘Women aren't allowed to have anything specific to them’. Therefore, there were mixed views about whether paternal PND was a condition which affects men.
Women's expectations for men's help-seeking
There was a clear expectation that fathers should seek help, usually from their GP. This was included in advice across both Mumsnet and Netmums forums: ‘He should seek counselling, parenting support group, and/or medication – his GP is the first person he should call’; ‘He needs to see his GP’; ‘He really needs to see his GP and get some help’; and ‘If he is depressed I think his first step should be talking to his GP’.
Mothers advised to seek support from their health visitor
Regarding the men's help-seeking, mothers were advised to support fathers, but to also seek advice through their own routes. Whereas the general practitioner (GP) was most often suggested by mothers for men's help-seeking, Mumsnet mothers were directed to their health visitor instead: ‘Could you maybe mention it to a health visitor and see what they suggest? If he's refusing to seek professional guidance then I'm not sure what else you can do…’; ‘Could you reconnect with your HV?’ Women were also signposted to their health visitor by the Netmums moderators: ‘It could help to speak to your health visitor about how this is affecting you’; and ‘Have you had a chance to talk to your health visitor?’ This indicates that seeking health visitor support is recommended for women who ask others for advice. Thus, among women there is a lack of agreement about whether PND is experienced by men. However, women expect fathers to seek help for their mental health postnatally if they are experiencing difficulties. Fathers are expected to visit their GP, while mothers are advised to talk to their health visitor.
Discussion
To date, paternal PND has only been explored in qualitative research through the lens of fathers (Dallos and Nokes, 2011; Edhborg et al, 2016; Eddy et al, 2019; Pedersen et al, 2021; Davenport and Swami, 2023a; 2023b) and professionals, including child centre health nurses (Hammarlund et al, 2015) and health visitors (Davenport and Swami, 2023c). This study offers a unique insight into mothers' perspectives towards fathers' help-seeking for PND.
Mothers' expectations of paternal help-seeking
In both original and responding posts, help-seeking was considered a necessary action for fathers, who were considered to lack responsibility if they refused to do so. In one study, fathers declared that they would seek help if they believed that their partners or children were being affected by their mental health struggles (Schuppan et al, 2019). Indeed, fathers not understanding their partner's emotional needs is considered a source of relationship strain (Darwin et al, 2017).
Here, mothers sought help out of a sense of helplessness and having waited unsuccessfully for the situation to change, at times because the father had not done so. Other research highlights that when fathers seek help for their mental health, their symptoms are ‘marked’ (Darwin et al, 2017). This study shows that women approaching their health visitor for support may have been advised to do so from someone else, and feel helpless about their situation.
Paternal anger, ‘postnatal depression’ and safeguarding
Another point arises from a small number of mothers' descriptions of fathers as angry or easily frustrated with the child. Paternal PND is characterised by emotions including anger in other qualitative studies (Eddy et al, 2019; Pedersen et al, 2021; Davenport and Swami, 2023a). While this study in no way suggests that a father poses a risk to his family individually, in the context of broader safeguarding findings, assessment of fathers' mental health, particularly changed emotions and behaviours, requires further consideration. For example, in ‘The Myth of Invisible Men’, a Child Safeguarding Practice Review Panel (2021) report on non-accidental harm by fathers and male carers to babies, problems with emotional regulation and anger were described by the men, with two highlighting that the baby crying was a trigger for their anger. There is a need to screen fathers for mental health difficulties, including changed character, behaviour and emotions which present throughout the perinatal period. This is particularly pertinent given the findings in this study where fathers were described by mothers as reluctant to seek help.
Notably, the data here comes from mothers who suspect paternal PND. The data does not confirm that fathers described here are diagnosed or even clinically depressed. Therefore, when considering these findings, the most significant point lies in the mothers' understandings. That is, we cannot ascertain from online descriptions what PND ‘symptoms’ might be. What we can determine is that when fathers experience changed emotions, behaviours, a change in character or a difficulty bonding with their baby, this causes the mothers to suspect PND. This is pertinent for health visitors, and demonstrates that asking mothers about how their partner has coped with new fatherhood, his mental health, or about the bond between father and baby, are likely to be successful in identifying a possible mental health difficulty in fathers.
Moreover, this screening is necessary because it is quite possible that the causes of changed behaviour or bonding are not related to paternal PND at all. Currently, this is not possible to discern, because services do not currently routinely fathers, meaning that risk is not clear in the current system (CSPRP, 2021). This is especially pertinent given that domestic abuse increases during pregnancy and in the postnatal period (Finnbogadottir and Dykes, 2016; NHS, 2021).
The blurred boundaries between mental health symptoms and domestic abusive behaviours is perpetuated by a lack of routine screening of men's mental health. Unfortunately, this has the potential to reinforce fear in men with PND, stigmatising their experiences and impeding their help-seeking. However, the situation still requires a specific professional assessment and support. Professionally, given their safeguarding role responsibilities, health visitors should routinely and directly ask about fathers' emotions and behaviours when paternal PND is suspected by the mother, considering the wellbeing of the whole family.
Limitations
Limitations of this study were both clinical and methodological. First, it is important to note that the study focused on mothers' perceptions of paternal PND and their experiences of living with what they believed was a depressed father. As such, their partners may not have been experiencing a clinical condition; however, it does demonstrate what behaviours and emotional changes mothers understand to be a symptom of paternal PND.
Second, the authors were unable to ascertain that participants were all mothers, given the online anonymous format. However, as we were unable to recruit mothers for interviews due to lack of responses, the online accounts were as close as possible to the original design.
Finally, a more robust methodology is required to examine women's experiences of men's emotions in the postnatal period, as well as a large study into the symptomology of paternal PND to inform diagnosis in men.
Conclusion
Overall, this study has produced new insight into the maternal experiences of presumed paternal PND. Mothers observe behavioural, emotional and character changes in their partner which make them suspect PND, alongside a lack of father–child bond. Research into health visitors' communications with mothers who report changed father behaviours following birth, particularly given the lack of clinical diagnosis of paternal PND, is recommended. This study highlights that mothers suspect paternal PND following changes in fathers' behaviour, emotions, and character. This requires assessment and support by health visitors, and a routine screening of fathers' mental health postnatally.