https://orcid.org/0000-0002-8251-8094
Abstract
Purpose
The study aims to investigate risk factors of paternal perinatal depression during the COVID-19 pandemic.
Methods
We conducted an online cross-sectional study of 473 prenatal fathers and 1246 postnatal fathers in August 2021. We applied a modified Poisson regression to estimate relative risk ratios of possible factors for paternal perinatal depression (measured by Edinburgh Postnatal Depression Scale), sequentially introducing the following factors into the model: individual factors, interpersonal factors, obstetric/pediatric factors, and service utilization factors.
Results
Prenatal fathers with the following risk factors were at an increased risk for having depressive symptoms: adverse childhood experiences (risk ratio; RR 1.61), past depression (RR 1.63), fear of COVID-19 (RR 2.09), lower social support (RR 1.91), low family resources (RR 1.95), and intimate partner violence (IPV) victimization (RR 1.29). Postnatal fathers having the following risk factors were at an increased risk for having depressive symptoms: past depression (RR 1.67), fear of COVID-19 (RR 1.26), low family resources (RR 1.85), IPV victimization. (RR 1.18), and preterm birth (RR 1.18).
Conclusion
The study showed risk factors such as past history of depression, high fear of COVID-19, low family functionality, and IPV victimization were associated with perinatal depressive symptoms. The findings should contribute to future directions of interventions for paternal perinatal mental health.
Introduction
Paternal perinatal depression (PPD) is defined as depressive symptoms occurring during a partner’s pregnancy and up to 1 year after a child’s birth, following the definition of maternal perinatal depression [Citation1]. Perinatal depression in fathers occurs as often as in mothers. A meta-analysis reported the prevalence of paternal prenatal depression and paternal postnatal depression in the first postpartum year as 9.8%, 8.8%, respectively [Citation2].
Paternal perinatal depression negatively influences the physical and mental health of fathers, mothers, and children. Previous studies showed that paternal perinatal depression has significant impacts on the emotional, behavioral, and developmental problems of their offspring [Citation3–6], and even depressive symptoms of their children at the age of 18 years [Citation7].
Given its high prevalence and long-lasting impact, research on risk factors of paternal perinatal depression has received increasing attention in recent years. These risk factors include individual factors such age, socioeconomic status, ethnicity, past depression, insomnia, parenting stress, criminal conviction, and substance abuse; interpersonal factors such as poor social support, marital dissatisfaction, and prenatal attachment; and community factors including exposure to racism and limited access to transportation and housing [Citation8–10]. However, several factors that have been shown to be important in maternal perinatal depression have not been well examined in relation to paternal perinatal depression.
Traumatic experiences such as adverse childhood experiences (ACEs) or intimate partner violence (IPV) are known as significant risk factors for maternal perinatal depression. Women having a higher number of ACEs are at an increased risk for prenatal depression [Citation11–13] and postnatal depression [Citation12–14]. Moreover, women who have been victimized by IPV showed an increased risk for perinatal depressive symptoms [Citation15,Citation16]. The American College of Obstetrics and Gynecology (ACOG) recommends screening all pregnant women for IPV in obstetric care to prevent adverse consequences [Citation17]. Although there are numerous studies showing the role of trauma and violence in association with maternal perinatal mental health, there is scarce literature concerning fathers. Only one study reported an association between paternal ACEs, IPV victimization, and postnatal depressive symptoms among fathers [Citation18]. Given that ACEs and IPV vary in frequency and magnitude of impact depending on racial, ethnic, and cultural attributes, we believe that further research is needed on fathers.
Clarifying potential risk and protective factors of paternal perinatal depression may lead to understanding the pathways, as well as informing directions for future interventions for paternal perinatal depression. The aim of the study is to investigate risk factors of paternal perinatal depression during the COVID-19 pandemic, using cross-sectional data of Japanese fathers. The findings of this study should contribute to understanding what attributes and factors make fathers a population in need of mental health support and what interventions should be implemented.
Materials and methods
Data setting
We conducted a cross-sectional study using the Japan COVID-19 and Society Internet Survey (JACSIS) database. The JACSIS database is a prospective internet cohort survey to investigate the impact of the COVID-19 pandemic on health and social conditions. The details of the study are described in the previous paper [Citation19]. A checklist for Reporting the Results of Internet E-Surveys (CHERRIES) is provided in Supplementary Table S1 [Citation20]. This study used data from a cross-sectional panel that was administered for perinatal fathers in August 2021.
Participants
Participants were males aged 15–69 years, registered individuals in the internet research company (Rakuten Insight) who had a pregnant or postpartum (within 1 year after a child’s birth) partner at the time of the survey in August 2021. Potential candidates were contacted and informed of the survey by e-mail, and those who agreed to participate in the study accessed the designated website. Participants received incentives (online points) for their participation in the survey. Participants who did not live with their partners during the perinatal period were excluded from the study. Participants who presented inconsistent responses in the screening questions were also excluded from the analysis. The inconsistent responses included the following conditions: (a) participants who marked invalid response for screening question (participants are instructed to select the second alternative from the bottom, but they have chosen other alternatives); (b) participants marked “yes” to all the items to the questions on drug use; and (c) marked “yes” for having all of the 16 underlying chronic diseases. The algorithms used to exclude inconsistent responses are described elsewhere.
Measures
Exposures
For exposure measures, we included factors that were reported in previous studies and added several factors that had not been investigated but were considered important. We categorized these factors into four groups: individual, interpersonal, obstetric, and pediatric, and social utilization factors based on social-ecological theory ().
Table 1. Risk factors for paternal perinatal depression included in analysis.
Individual factors included paternal age, educational attainment (junior high school or high school, junior college, college or above), equivalent household annual income (below the poverty line, above the poverty line), unplanned pregnancy, paternal adverse childhood experiences, paternal history of depression prior to pregnancy (yes/no), and fear of COVID-19. The equivalent household income per capita was computed by annual household income divided by the square root of number of household members. Fear of COVID-19 was measured by the Japanese version of the Fear of Coronavirus-19 Scale, which has been confirmed for validity and reliability [Citation21,Citation22], with a higher score suggesting higher fear of being infected by COVID-19.
Interpersonal factors included social support, family resources and functionality, and IPV victimization of fathers during the perinatal period. Social support was measured by the following question: “How many people can you talk to when you really need help?” Family resources and functionality were measured by the Japanese version of family APGAR [Citation23–25], with a higher score indicating higher family resources and functions. For IPV victimization, participants were asked if they have experienced any of the following events since January 2021: “Being physically abused by your partner, such as being hit, kicked having objects thrown at you, or being confined by my partner (spouse)”; “I have been physically harmed to the extent of sustaining injuries from fights with my partner (spouse)”; “I have been insulted or verbally abused by my partner (spouse)”; “My partner (spouse) has used or taken away my possessions, including my savings, without my consent”; “I have experienced non-consensual sexual acts from my partner (spouse)". IPV victimization was dichotomized as “none” or “any IPV”. Obstetric and pediatric factors included fertility treatment, parity (primipara, multipara), child sex (male, female), and preterm birth (<37 weeks, ≥37 weeks).
For service utilization factors, participants were asked if they had participated in paternal or parental class, used paternal leave, home visitation for newborn baby by health care nurses, consultation with a child guidance center on child or family issues, or consultation with a clinic or hospital on child or family issues. Each item was recorded as “Yes” or “No”.
Outcomes
We used paternal perinatal depressive symptoms for outcome variables, measured by Edinburgh Postnatal Depression Scale (EPDS) [Citation26] at the date of response. For prenatal fathers, the EPDS scores were recorded as prenatal depressive symptoms. For postnatal fathers, the EPDS scores were recorded as postnatal depressive symptoms. For a cutoff point, we used a score of 7/8, following a previous study on Japanese men for our main analysis [Citation27]. As a cutoff of 11/12 points is most commonly used in most countries, we used a cutoff of 11/12 points as sensitivity analysis [Citation10,Citation28].
Data analysis
We used a modified Poisson regression using a robust error variance to estimate relative risk ratios of possible paternal perinatal factors for perinatal or postnatal depressive symptoms among fathers. A Poisson regression approach is an appropriate way to estimate the effect measure directly but presents a wide confidence interval for the relative risk. A modified Poisson regression using a robust error variance is an effective way to directly estimate relative risk and overcome variance overestimation [Citation29]. The study sequentially introduced different sets of factors into the model, first individual factors, second interpersonal factors, third obstetric and pediatric factors, and fourth service utilization factors, as these factors are known to be associated with paternal perinatal depressive symptoms. To compute a relative risk for paternal prenatal depression, we entered individual factors (age, educational attainment, equivalent household income, unplanned/unwanted pregnancy, paternal adverse childhood experiences, fear of COVID-19), interpersonal factors (social support, Family APGAR, IPV victimization), obstetric and pediatric factors (fertility treatment, parity), and service utilization factor (participation in paternal or parental class) in analysis. In addition to the factors entered for prenatal depression, we entered obstetric factors (child sex, preterm birth), and service utilization factors (use of paternal leave, home visitation for newborn baby, consultation to child guidance center, consultation to clinics or hospital) to compute a relative risk for postnatal depression. The study used variance inflation factors to evaluate multicollinearity possibly existing among perinatal risk factors. Factors that were important in the previous literature but were not statistically significant were excluded from the final model. Statistical analyses were conducted using STATA (StataCorp LLC, 4905 Lakeway Drive, College Station, TX 77845, USA).
Results
A total of 3436 registered individuals was considered as possible candidates for the study and were invited for participation in the study. Of these candidates, 1953 perinatal fathers participated in the study, with a participation rate of 56.8%. After removing the participants with inconsistent responses, 473 prenatal fathers and 1246 postnatal fathers were included in the analysis. presents the proportion of respondents presenting each individual factor by EPDS score stratum (EPDS < 8, EPDS ≥ 8, EPDS ≥ 12) The proportions of prenatal fathers with EPDS scores of ≥8, ≥ 12 were 40.7%, and 24.3%, respectively. The proportions of postnatal fathers with EPDS scores of ≥ 8, ≥ 12 were 37.7% and 20.5%, respectively.
Table 2. Number and proportion of individual factors in EPDS stratum.
shows the number and proportion of respondents with interpersonal, obstetric, and pediatric factors by EPDS score stratum. The proportion of respondents with IPV victimization during the COVID-19 pandemic was higher for the respondents with EPDS ≥ 8 or EPDS ≥ 12 than those with EPDS < 8.
Table 3. Number and proportion of interpersonal factors and obstetric and pediatric factors in EPDS stratum.
shows the number and proportion of respondents who reported using public or private services during the perinatal period by EPDS score stratum. The proportion of respondents who participated in paternal or parental class was higher among fathers with EPDS ≥ 8 or EPDS ≥ 12 than those with lower EPDS scores. The proportion of respondents who consulted the child guidance center about child or family issues was higher for the respondents with higher EPDS than those with lower EPDS.
Table 4. Number and proportion of service utilization factors in EPDS stratum.
shows the relative risk ratios of possible risk factors for paternal prenatal depressive symptoms with EPDS ≥ 8 and EPDS ≥ 12. After sequentially entering different sets of predictors, predictors that remained significant in Model 4 for prenatal depressive symptoms were as follows: paternal adverse childhood experiences (≥ 4; adjusted RR 1.63, 95% CI: 1.06–2.49); paternal depression prior to partner’s pregnancy (adjusted RR 1.57, 95% CI: 1.15–2.13); high fear of COVID-19 pandemic (adjusted RR 2.13, 95% CI: 1.52–2.98); low social support (adjusted RR 1.95, 95% CI: 1.28–2.97); lower family resources and function, (adjusted RR 1.96, 95% CI: 1.55–2.48); and paternal victimization of intimate partner violence during the COVID-19 pandemic (adjusted RR 1.28, 95% CI: 0.99–1.66). Participation in paternal or parental class presented an increased risk for prenatal depressive symptoms of EPDS ≥ 12 (adjusted RR 1.65, 95% CI: 1.23–2.23).
Table 5. Risk ratios of possible risk factors by categories for paternal prenatal depressive symptoms (EPD ≥ 8, EPDS ≥ 12).
shows the relative risk ratios of possible risk factors for paternal postnatal depressive symptoms (EPDS ≥ 8, EPDS ≥ 12). Among individual factors, paternal depression prior to the partner’s pregnancy and fear of COVID-19 showed a significantly higher risk for paternal postnatal depressive symptoms (adjusted RR1.68, 95% CI: 1.37–2.06, and adjusted RR 2.08, 95% CI: 1.69–2.57, respectively). Among interpersonal factors, low family resources and functionality, and paternal victimization for IPV were associated with paternal postnatal depressive symptoms (adjusted RR 1.85, 95% CI: 1.59–2.15, and adjusted RR 1.18, 95% CI: 1.00–1.39, respectively). Preterm birth of a child was also associated with paternal postnatal depressive symptoms (adjusted RR 1.27, 95% CI: 1.09–1.49). Among service utilization factors, participation in a paternal class was associated with a higher risk of depressive symptoms (adjusted RR 1.18, 95% CI: 1.02–1.36). Consultation about child or family issues with a child guidance center (child protection service) was associated with higher depressive symptoms among fathers (adjusted RR 1.41, 95% CI:1.09–1.83). Consultation about child or family issues with a medical service was associated with lower depressive symptoms with a cutoff of EPDS ≥ 12 among postnatal fathers (adjusted RR 0.65, 95% CI: 0.48–0.87) but did not show significance with a cutoff point of EPDS ≥ 8.
Table 6. Risk ratios of possible risk factors by categories for paternal postnatal depressive symptoms (EPD ≥ 8, EPDS ≥ 12).
Discussion
Our study reported the prevalence of fathers having prenatal and postnatal depressive symptoms during the COVID-19 pandemic and investigated risk factors for prenatal and postnatal depression of fathers. We found that the prevalence of fathers having prenatal depressive symptoms with an EPDS score ≥ 8 was 40.6%, and with an EPDS score ≥ 12 was 24.3%, respectively. The prevalence of fathers having postnatal depressive symptoms with an EPDS score ≥ 8 and with an EPDS score ≥ 12 was 37.5% and 20.4%, respectively. Previous studies reported the prevalence of fathers having perinatal depression was approximately 8%–10%, yet this study reported a much higher prevalence for both prenatal and postnatal depression among fathers. The high prevalence of both prenatal and postnatal depression among fathers might have resulted from stressful situations due to the COVID-19 pandemic, especially as the survey was conducted in August 2021, the time when a state of emergency had been declared in many prefectures in Japan [Citation30]. People were forced to change their daily lives, and many of them had to deal with fears of infection or an unstable economy, not excluding fathers and fathers to be.
We showed that paternal prenatal conditions such as paternal depression prior to the partner’s pregnancy, fear of COVID-19, low social support, poor family functionality, and paternal victimization to IPV during the pandemic were associated with higher depressive symptoms among prenatal fathers. Our findings were consistent with the previous studies on paternal risk factors for prenatal depression including depression prior to partner’s pregnancy, low social support, and family functionality [Citation8,Citation9,Citation31,Citation32]. Moreover, our study added to the existing literature that fathers with high fears of COVID-19 or fathers who have experienced ACEs or IPV victimization during the pandemic as risk factors for paternal prenatal depression. Health care providers who have opportunities to support prenatal fathers should be aware of the factors associated with paternal depression, screen for paternal depression, and provide support when needed. IPV is a serious public health problem affecting the physical and psychological health of both men and women. Although the U.S. Preventive Services Task Force recommends IPV screening for all women at childbearing age [Citation33], IPV screening is not generally conducted for men. Our finding on paternal victimization rings a bell that expected fathers may also be subjected to victimization for IPV, leading to prenatal depression.
Our findings on risk factors for paternal postnatal depression were somewhat similar to those for prenatal depression, with several exceptions. Consistent with previous studies, a history of depression prior to a partner’s pregnancy and low family functioning [Citation8,Citation9,Citation31,Citation32,Citation34,Citation35] were associated with postnatal depressive symptoms among fathers, but the study added new findings that high fear of COVID-19 and fathers’ victimization of IPV were associated with postnatal depressive symptoms. Health care providers who support perinatal fathers need to be aware that there is a need for more mental health support for fathers with these pasts. It is also important to consider that mental health can deteriorate more easily in cases of high fear of COVID-19. We found that several factors such as ACEs and low social support had a higher impact on prenatal depression than on postnatal depression. No study examined the association between paternal ACEs and depressive symptoms across the perinatal period, but a meta-analysis on perinatal women showed that ACEs had a slightly higher effect size for postnatal depression than for prenatal depression [Citation12]. In our study, low social support presented an association with paternal prenatal symptoms, but not with paternal postnatal symptoms. The finding was not in line with the previous studies reporting an association between social support and depressive symptoms in both prenatal and postnatal periods [Citation10,Citation32,Citation34,Citation36]. Investigation on the mechanism is left for future research, but as the current study was conducted during the COVID-19 pandemic, fathers without ACEs or fathers who previously had stable relationships with families or friends may have been more likely to have more communication and receive psychological support through online contact even in the pandemic. On the other hand, fathers with ACEs or fathers with fewer relationships with others may have been even more isolated and less likely to get psychological support. The extent to which ACEs and low social support impact depressive symptoms may be greater in the prenatal period than in the postnatal period, because during the postnatal period, fathers with ACEs or less social support may have more opportunities for mental health support through home visitation programs, infant health checkups, or local community services than in the prenatal period. Moreover, the birth of a child brings about significant changes in the father’s circumstances, shifting the focus toward the care and nurturing of the newborn. Factors associated with postnatal depressive symptoms may become more diverse, possibly differing from those observed during the prenatal period. As for postnatal factors, preterm infants were shown to be significantly associated with postnatal depressive symptoms in fathers, consistent with the findings of several prior studies [Citation37,Citation38]. The fathers of preterm infants are expected to be anxious about the health status of their children, and also engage in a lot of childcare, suggesting the importance of support for fathers of preterm infants.
Furthermore, as service utilization factors in this study, participation in father or parent classes and consultation with a child guidance center regarding child and family problems were significantly associated with postnatal depressive symptoms in fathers. On the other hand, consultation with a medical institution regarding family and child problems was negatively associated with postnatal depressive symptoms with an EPDS cutoff score of 12 or higher. Fathers who were anxious about pregnancy, childbirth, and childcare may have voluntarily participated in paternal or parent classes or were encouraged to do so by their surroundings, which may have been significantly associated with postnatal depressive symptoms in fathers. In Japan, paternal classes often provide information on childbirth, child-rearing methods, and mental health care for mothers, but the importance of fathers’ own mental health care should also be conveyed. In cases where fathers consulted with the child guidance center about their children and family problems, there is a possibility that the fathers were anxious and worried about child rearing, which may have contributed to the positive association between postnatal depression and the fathers’ symptoms. This suggests the need to pay attention to the father’s mental health when consulting with the child guidance center.
On the one hand, fathers’ medical consultations on child or family issues were negatively associated with fathers’ postnatal depressive symptoms, and it is recommended that fathers’ consultations at hospitals or clinics may be effective in reducing depressive symptoms. On the other hand, it is possible that fathers who are aware of their illness and cases with few barriers to medical consultation may have sought medical consultation, and the results should be interpreted with caution.
Several limitations of the study should be noted. First, the study was conducted using an internet survey. The findings of our study may not be applied to the whole population. Second, our study is a cross-sectional study, and our findings should be confirmed using longitudinal data. Third, we relied on the self-report of participants for assessing prenatal and postanal depressive symptoms. Forth, the assessment of participants’ prenatal or postnatal depressive symptoms was conducted at the time of survey response, and the timing of the EPDS evaluation varied among participants. Finally, we only evaluated the aspects of perinatal fathers, and the influence of their partners was not considered in the current study. Future studies should investigate the impact of social factors on paternal perinatal depression after considering maternal factors.
Conclusion
In summary, the study showed certain risk factors such as paternal past history of depression, high fear of COVID-19, low family functionality, and paternal victimization of IPV were significantly associated with prenatal and postnatal depressive symptoms. The study also showed that fathers with preterm babies may be at potential risk for postnatal depression. Future studies should explore protective factors that alleviate the effect of risk factors on paternal perinatal depressive symptoms, as well as interventions for preventing paternal perinatal depression.
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References
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