by Anna Machin
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 see
m 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, f
ather-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.