The Effects of Fatherhood on the Health of Men:
A Review of the Literature
Journal of Men’s Health and Gender
Volume 1, pp 159-169
Edward E. Bartlett, PhD
School of Public Health and Health Services
George Washington University
Washington, DC USA
This article reviews a wide-ranging literature with professional and theoretical perspectives. The methods
included case studies, qualitative interviews, surveys of selected clinic populations, prospective
epidemiological studies, and analyses of nationally representative databases. The review is organized by the
stage in the paternal lifecycle: pregnancy, labor and delivery, postpartum period, parenthood, and child
custody, with the following key findings:
Pregnancy: Recent research reveals that pregnancy induces detectable physiological changes in male
partners. Case studies indicate that some fathers-to-be experience a variety of physical symptoms that
mimic their partner's health changes, a phenomenon referred to as couvade. But empirical research does not
establish the existence of couvade on a wide-scale basis.
Labor and delivery: Research reveals that the labor and delivery experience is often a difficult time for the
father. Substantial percentages of men felt coerced, ill-prepared, ineffective, and/or psychologically
excluded from the event.
Postpartum period: Case studies and qualitative research indicate that the first year after childbirth is a time
of emotional upheaval for first-time fathers, who must adapt to the presence of an infant who commands
priority from his partner.
Parenthood: In the long-term, the weight of evidence indicates that fatherhood is beneficial to a man's
health. The health effects of fatherhood are probably mediated by a variety of other variables, including
number of children, role competency, and lifestyle.
Child custody: Fathers who lose custody were consistently found to be at greater risk for chronic health
conditions, psychological impairment, and death. Of particular concern is the suicide risk of divorced men
who become legally disenfranchised from their children.
Over the past 80 years, the health of mothers has enjoyed extensive attention from researchers, medical
practitioners, and policymakers . Less is known about the physical and psychological health of fathers
. This disparity is important because becoming a father is a major developmental milestone for men [3-
Several reviews have addressed the health of men in general but not specifically paternal health [6-8].
This review summarizes research on the physical and psychological effects of the fatherhood role on men.
Papers were located through Medline database searches for the years 1966-2002, using the descriptors
"fathers" and "fatherhood," and a review of previously-published articles cited in recent research. Only
English-language articles were considered. Most research has been done in North America, Europe, and
The literature has important methodological limitations. Many studies had small sample sizes and some
have no control group. Others are retrospective in design, thus introducing selection and recall biases.
Some use measures of unknown reliability and validity or use ethnographic methods, which can yield rich
personal insights, but have limited generalizability.
Furthermore, attributions of causation are problematic. For example, selection biases exist because men
who are healthier are more likely to marry and have children [9,10]. Additionally, interaction effects are
often operational among health, social class, social support, and marital status. Three caveats apply:
•The role of fathers varies substantially across social class and cultural context . Thus, findings
from individual studies need to be interpreted within their socio-economic context.
•The social construction of fatherhood is currently undergoing redefinition, which could affect
men's cognitive appraisal of and psychological reaction to the events of pregnancy, labor and
delivery, and fatherhood.
•Relationships might differ between first-time and experienced fathers, especially during the period
of pregnancy and the first year after childbirth .
Theoretical basis for this review
Fatherhood is a social role that has both a biological and cultural basis. Although fatherhood is predicated
on a biological act (procreation), the enactment of fatherhood is more social than biological [13, 14] and
has even been asserted as primarily a “social intervention” .
A consistent findings in the social science literature is that marriage is associated with improved health
and longevity, especially for husbands [16-22]. One explanation is that fatherhood expands, strengthens,
and formalizes a man's social network.
Scientific investigation into the link between social networks and health status goes back to the late 1800s,
when the French sociologist Emile Durkheim examined the effects of social integration and cohesion on
patterns of suicide risk. In 1976, epidemiologist Eric Cassel published his landmark article on the protective
effects of the social environment . Drawing from animal and human studies, Cassel posited that social
support serves as a protective factor that reduces individuals' vulnerability to the deleterious effects of
stress. The theoretical underpinnings for the burgeoning research on social support and health has been
summarized elsewhere .
Thus, concepts of social integration, social networks, and social support form the theoretical basis of this
review, which is organized around the lifecycle concept with five stages of fatherhood: pregnancy,labor
and delivery, postpartum period, parenthood and child custody.
The paternal experience of pregnancy was once described as "among the territories studied by the human
sciences...still a dark continent, a little known zone, particularly when attention is focused on that strange
binomial father-pregnancy" (quoted in ).
Lemmer  reviewed the nursing literature on the effects of pregnancy on fathers and identified some
common themes: fathers were often ambivalent during the early phase of pregnancy; in the third trimester,
the pregancy became "real" and fathers became more involved; and men were concerned about financial
security, changes in the marital and sexual relationship, and adequacy in the fathering role. A more recent
study of Australian men identified similar concerns.
News of his partner's pregnancy evokes a broad range of emotions, from euphoria and pride, to anxiety
about expanded financial responsibilities . Reflecting these stresses, numerous case reports have
appeared in the psychiatric literature about pregnancies that precipitated mental illness in fathers [28-32].
Medical and anthropological case reports have shown fathers-to-be can experience the physical effects of
their partner's pregnancy, a phenomenon referred to as "couvade" [27, 33]. Unfortunately, this literature
lacks standardization in definition, measurement, and research design and detecting the effects of
pregnancy on men is difficult because of the high background prevalence in the general population of
symptoms such as nausea, vomiting, and anxiety. Therefore, this review is restricted only to those studies
that included a historical or concurrent control group. These articles are arranged chronologically.
Trethowan and Conlon  did a retrospective survey of 327 English fathers shortly after the delivery of
their babies, and 221 control group husbands whose wives had not been pregnant during the previous nine
months. They reported that 55.7% of "pregnant" fathers suffered from symptoms associated with pregnancy
such as loss of appetite, nausea, and vomiting, compared with 43.4% among the control group, a
statistically significant difference. Mostly these symptoms occurred among younger fathers, began in the
third or fourth month of pregnancy, and were associated with the father's anxiety.
Lipkin and Lamb  cross-matched a systematic sample of Rochester, NY Health Maintenance
Organization (HMO) obstetrical hospital admission lists with ambulatory visit records to identify 267
husbands who sought medical attention during the course of their partner's pregnancy. Using a
retrospective chart review, they compared the mens' symptoms recorded in their charts at three points in
time: the 6 months before, during, and the 6 months after the pregnancy. Couvade was diagnosed if the
husband had any couvade symptoms during pregnancy, but not before or afterwards. They found that
22.5% of the fathers had sought care for symptoms that met their strict criteria of couvade. Those men also
had a twofold increase in the number of visits.
Seeking to validate these findings, the same team retrospectively analyzed the care-seeking patterns of 212
fathers-to-be enrolled in the same HMO . To control for selection biases, the investigators added 212
non-expectant concurrent control group fathers who were matched for marital status, age, and number of
prior children. Over the 21-month review period, the expectant fathers were found to have had a
significantly lower outpatient visit rate than the non-expectant fathers, thus tending to disprove the couvade
hypothesis. The telling observation was also made that "The fact that pregnancy or expectant fatherhood
was recorded in the chart only 4.5% of the expectant fathers' visits suggest that such psychosocial
information is not being sought, or is not felt to be important or relevant".
Clinton  used a prospective, repeat-measures design to survey a convenience sample of 81 expectant
fathers in the Milwaukee area, compared with a group of 66 non-expectant men. Physical health was
assessed on a monthly basis using interviews and health diaries that measured health problems, symptoms,
and disabilities. Compared with controls, expectant fathers were more likely to experience colds and
irritability in the first trimester, and weight gain, insomnia, and restlessness in the third trimester. Although
these differences reached statistically significant levels, the differences were not large.
Condon  retrospectively surveyed the male partners of 165 pregnant women attending obstetrical
clinics in a large general hospital in Australia. Fathers-to-be experienced the following symptoms as
“severe” or “very severe” during the 2 previous weeks, compared with the fathers’ pre-expectant state:
sleep disturbance (11%),lack of energy (9%),decreased sexual drive (9%) aches/pains (5%) and appetite
Masoni and coworkers  surveyed 73 Italian husbands of pregnant women in their last month of
pregnancy, compared with a control group of husbands of non-pregnant women. They found that husbands
of pregnant women reported a lower overall rate of symptoms than the reference husbands, at a statistically
significant level. The one exception to this finding was nausea, which was experienced by fathers-to-be
Two Canadian studies analyzed the hormonal changes in men over the course of their wives' pregnancies.
They found that "pregnant" men experience elevations in cortisol and other hormones that, to a lesser
degree, mimicked the physiological changes in their pregnant partners [39, 40]. Although the mechanisms
remain unknown, these studies reveal that pregnancy can trigger measurable physiological changes in
Labor and delivery
Childbirth is a social milestone for fathers . Anecdotal reports indicate that the birth of a child can
cause fathers to take stock of life commitments and establishes new priorities.
Even as late as the 1970s, controversy persisted in the United States whether involving fathers in the birth
process interferes with rigid obstetrical routines . But advocates of "natural childbirth" sought to
involve fathers in the process to promote paternal-infant bonding [42-44].
Some studies have gauged the effects of participating in childbirth on fathers. Typically qualitative in
design and conducted on small convenience samples shortly after childbirth, they have reported four
•Many men felt initially coerced to participate in the labor and delivery process .
•Many were uncomfortable in their role as a labor "coach" , especially younger and first-time
•Some felt excluded and/or relegated to an ancillary role [48, 49].
•Overall, a substantial gap exists between what men were prepared for and the reality of childbirth
These qualitative findings were confirmed in a recent study  that surveyed a convenience sample of 53
British men whose partner had undergone a normal delivery. The survey, completed within 60 hours after
delivery to minimize selective recall effects, revealed that of the men:
•57% had felt under pressure to be present at birth
•56% stated their most overwhelming memory was the pain being endured by their partner
•38% did not believe they had been effective in supporting their partner
•56% were made to feel "in the way" during the delivery
•22% did not wish to be present at a future birth.
The arrival of the newborn is a major developmental challenge to the first-time father . But the
emotional adjustment of fathers during the postpartum period has attracted less scientific attention than the
psychological changes of mothers. "Unfortunately, studies of the psychology of new parents often. . .
exclude fathers altogether" . "It is puzzling that equivalent psychiatric and psychodynamic
investigations of fatherhood have not been forthcoming".
Qualitative interviews of first-time fathers in the United States, Canada, and Britain showed similiarities.
Fathers reported feelings of disruption, discomfort, and even exclusion during the first few weeks of the
infant's life . They felt recognized as helpmates and breadwinners, but struggled to receive recognition
as a parent by their mate, coworkers, friends, and society . Role strain associated with playing multiple,
sometimes conflicting roles, was noted in one report .
A common theme was that fathers had no role models for their new role as active and involved fathers
[12, 55]. Some fathers felt "irrelevant" to the infant-nurturing process . Despite initially-positive
expectations, most men found the early months of fatherhood more uncomfortable than rewarding .
Numerous case reports in the psychiatric literature document that in extreme cases, the birth of a child can
trigger paternal psychosis or other mental illness [57-60].
Five quantitative studies were located, all of which examined psychological changes during the
Rees and Lutkins  assessed depression rates (using the Beck Depression Inventory) in a convenience
sample of 61 British married couples who had delivered their baby within the prior 12 months. Of the
postnatal fathers 13% experienced mild, moderate, or severe depression against 10% in the same group of
men during their wives' pregnancies.
Clinton  as described above interviewed 50 fathers 6 weeks post-delivery using an Expectant Father's
Monthly Health Interview. She found that during the postpartum period, newfound fathers reported
significantly higher levels of nervousness, difficulty in concentrating, fatigue, insomnia, restlessness,
headaches, and irritability than the 38 men in the control group.
Ferketich and Mercer  surveyed 147 men in Arizona at four times after delivery: a few days afterwards,
and at 1, 4, and 8 months. The fathers' health was measured using the State-Trait Anxiety Inventory, the
Center for Epidemiological Studies Depression Scale, and the General Health Index. The General Health
Index assesses perceived health status, including current health and health worry/concern. Although a
significant decline in general health status was seen, no significant changes in psychological health were
noted (Table 1).
Raskin and coworkers  recruited 86 married couples, most of whom were white (85%) and college-
educated, attending a childbirth preparation class in Chicago. All couples were experiencing their first
pregnancy. They measured depression using the Center for Epidemiologic Studies Depression Scale. Eight
weeks after childbirth, the prevalence of depressed mood was 21% among fathers compared with 18.7%
among the same group of men at 34 weeks pregnancy.
Ballard and coworkers  measured postnatal depression in fathers whose partners had recently delivered
in a hospital in England. Fathers were screened with a mailed questionnaire, then interviewed using the
Psychiatric Assessment Schedule. Depression prevalence rates were 9.0% at 6 weeks postpartum, and 5.4%
at 6 months.
What is the association between fatherhood and a man's long-term morbidity and mortality experience?
Seven studies have investigated this intriguing question.
Verbrugge  studied 302 white men participating in the Health in Detroit Study. The survey examined the
relationships among marriage, parenthood, employment, and physical health. Health was measured by self-
rated health status, symptoms and conditions, healthcare usage, and medication usage. Data were collected
by an initial interview and a daily health record maintained for a 6-week period. Parenthood was associated
with higher levels of health status among men but the association was weaker than the effects of
employment or marriage.
Haynes and coworkers  prospectively examined the effects of number of children on fathers' risk of
developing coronary heart disease (CHD) over a 10-year period. The 269 married men, participants in the
Framingham Heart Study, were 45-64 years old at the inception of the study. The incidence of heart disease
(based on a review of clinical and physical examination data) was 7.9% among married men with no
children, 15.4% among fathers with 1-2 children, and 18.5% among men with three or more children. This
trend did not reach normal levels of statistical significance (p=0.07), even after controlling for the man's
coronary risk factors and the wife's occupational status.
Clark and coworkers  analyzed data from a national sample of 4,809 adults, with oversampling of low-
income adults. They looked at "domestic position" (a composite measure of a person's age, sex, marital
status, and presence of children) on self-reported health status and illness or injury that required staying in
bed. Among married men 40 years old and younger, the presence of children was associated with poorer
health status, as measured by self-rated health status and number of bed days (Table 2). But among married
men 41-64 years old, the opposite pattern emerged. Unfortunately no tests of statistical significance were
Thus, the recent arrival of children can be a highly stressful event to the father and possibly detrimental to
his health. But as family size stabilizes and he gains competence in his paternal role, the presence of
children can be associated with higher levels of paternal health.
Kotler and Wingard  analyzed data on 3,700 participants enrolled in the Alameda County Study to
study the effects of multiple parental, familial, and occupational roles on all-cause mortality. Participants in
the Human Population Laboratory cohort aged 35-64 years completed a comprehensive health and
psychosocial questionnaire in 1965, and their mortality experience was tracked until 1982. Using multiple
logistic regression analysis which controlled for a variety of factors related to mortality, they found that the
18-year mortality risk of men and of women was unaffected by either the presence or number (0, 1-3, or
4+) of children.
Hibbard and Pope  prospectively followed a cohort of 997 men who were HMO members in the Pacific
Northwest over a 15-year period. The men were interviewed to assess the amount of time they spent with
their children, satisfaction with their parental role, and degree to which they worried about their children.
None of these three variables were found to influence men's subsequent risk of death, or their diagnosis of
heart disease, stroke, or cancer.
Smith and Zick  examined data from the Panel Study of Income Dynamics, a nationally representative
sample of more than 5,000 households in the United States conducted over a 20-year period. They
examined couples who were married and in which the husband was between the ages of 35 and 64 years
during the 1968-1969 period. The couples had an average of 3.15 children ever born. Using a paired-hazard
rate model, they found that husbands experienced a lower mortality risk with an increase in the number of
children ever born.
Hemström  linked national health and demographic databases to analyze the effects of the presence of
children on the mortality of 44,000 Swedes who had died between 1981 and 1986. In 1970, all were
married and between the ages of 20-49 years. At the time of death, 80.3% of the men were still married.
The effects of having children on the mortality of divorced men were that men who had no children had a
higher relative mortality ratio than men who had one or more children (Fig. 1). The results for men are
however unstable due to the smaller numbers of men with children in the divorced group.
Lawlor  retrospectively analyzed heart disease morbidity among 4,252 British men aged 60-79 years
old and observed a J-shaped association between number of children and risk of developing coronary heart
disease. Men with two children had a significantly lower risk of developing heart disease than men with
one or no children. With each additional child after two, men's risk of heart disease increased by 12%.
Statistical adjustment for obesity and metabolic risk factors (high-density lipoprotein and cholesterol)
attenuated this relationship. Changes in diet and exercise patterns appear to explain as least part of the
changes in coronary heart disease risk among fathers.
Divorce is known to exert a range of deleterious health effects on men [9,18, 22, 71-74]. This is of
concern because divorce is so common (the American divorce rate was 48.8% in 1997 .
The average divorce decree spells out custody arrangements for an average of 0.9 children . Custody
of children is usually awarded to the mother. In the United States, there were 3.1 million children in 1998
who lived with their father only, representing 15.3% of all children living with just one parent .
The next two sections review the association between child custody and the physical and psychological
health of fathers.
Four studies examined the effects of child custody awards on the physical health of fathers.
Clark and coworkers  analyzed data from a national sample of 4,809 adults (methodology described
earlier in this article). For men 41-64 years old, single fathers with children present experienced the best
health, and single fathers with no children present the worst health (Table 3). The differentials are
especially pronounced in the areas of illness requiring bed rest and medical care visits.
Popay and Jones  used data from the 1980-82 British General Household Survey (an annual population
survey) to analyze data collected from 150 single fathers, of whom approximately equal percentages were
widowed, divorced, or separated. Overall, single fathers fared worse than married fathers for chronic illness
and self-reported health status (Table 4).
A small Swedish study  surveyed 27 men aged 35-49 years 5 years after they had divorced. Twenty-
two of the men had had children during the marriage, and only seven had gained child custody. Men who
had custody of children or lived in a stable relationship had fewer medical and social problems than those
Benzeval  compared information on 157 single fathers and fathers living in a couple relationship from
the 1992-1995 rounds of the British General Household Survey. Standardized to all parents between the
ages of 16 and 64 years, she found that single fathers were in worse health (Table 5).
Numerous case studies and clinical observations have reported on the psychological health of non-
custodial fathers. Findings included that postdivorce visits with children "can lead to depression and sorrow
in men who love their children"  and many divorced fathers are "overwhelmed by feelings of failure
and self-hatred," and as a result are "disengaging from a family that is no longer really theirs" . As a
result of the sense of failure that these fathers experience, these men "exhibit substantially higher rates of
psychological distress and alcohol consumption than do married men" associated with their parental role
strain . Contacts with a convenience sample of non-custodial fathers described that "These men are
very angry. Indeed, their white-hot sense of injustice can sometimes produce in them the phenomenon of
pressured speech, in which emotional intensity derails normal conversational rhythms" . There are also
anecdotal reports of the effects of loss of child custody on paternal suicide risk [85,86].
Two empirical papers examined the psychological health of non-custodial fathers.
Tepp  recruited a convenience sample of 26 white non-custodial fathers who remained involved in their
childrens' lives and interviewed them at 1 and 3 years after the divorce. Paternal role competence, degree of
involvement in child rearing 1 year after divorce, and ease in being able to see their children were
associated with fathers' greater participation at 3 years. The report documented widespread paternal
feelings of loss and dysphoria. Many fathers described feeling shut out of parenting functions, decreased
feelings of being special, a sense of displacement, and a sense of confusion and difficulty about their role as
Kposowa  used the National Longitudinal Mortality Study, a large, nationally-representative sample, to
analyze the effects of marital status on suicide risk. He found that divorced men were more than twice as
likely to commit suicide as married men, and almost 10 times more likely to kill themselves as divorced
women . Although Kposowa could not directly analyze the link between loss of child custody and
suicide risk, the widespread award of child custody to mothers is strongly suggestive of an association.
Of the pregnancy studies reviewed, the Clinton study  used the most robust research design and
instrumentation to assess the effects of pregnancy on health of men. Clinton reported small increases in
selected symptoms during the first and third trimesters, but not during the second trimester. Condon 
documented modest effects on men's sleep disturbance, lack of energy, and other variables.
The importance of study design is revealed in the Lipkin and Lamb study , which restricted the study
sample to a group of self-selected men who had sought medical attention. His team’s 1984 study 
analyzed all expectant fathers enrolled in the HMO during the study period, and included a non-expectant
control group. These two studies, conducted at the same medical facility, reveal how an initially-promising
result is not always confirmed by a more rigorous design.
Numerous case studies attest to news of an impending childbirth triggering couvade symptoms and even
psychiatric difficulties. Possible physiological mechanisms for these physical symptoms have been
suggested [39, 40]. This body of literature indicates that pregnancy induces physiological changes in
expectant men, and a subset of experience modest increases in certain physical and psychological
symptoms. No good evidence however supports these symptoms being severe enough to trigger an increase
in seeking medical care.
With regard to father participation in childbirth although proponents of advocate the concept in idealistic
terms , research reveals a very different experience for many. Many fathers feel ill-prepared, helpless in
the face of their partner's pain, and are sometimes made to feel unwelcome by nursing staff. Clearly, a large
difference exists between the ideal and the reality.
Findings from qualitative research and psychiatric case studies suggest that the psotpartum experience of
fatherhood can be difficult, especially for first-time fathers. Some felt irrelevant, neglected, and
marginalized during the first year after childbirth. These qualitative findings were supported by Clinton
, who found that compared with the control group, fathers were significantly more likely to report a
variety of emotional symptoms during the first 6 weeks after childbirth.
In four quantitative studies, fathers served as their own controls over the course of the study. Similar rates
of depression in fathers were reported before and after the birth  with essentially no changes in the
prevalence of paternal depression over the first 6-8 months postpartum [53, 62, 63].
These mixed findings should be interpreted in the light of possible confounding variables. For example,
one study revealed that fathers' postpartum psychological adaptation is often influenced by how well the
couple coped with the pregnancy itself . In addition, evidence exists that marital satisfaction declines
with the addition of a new child [12, 89, 90]. Thus, the findings might partly reflect events that occurred
during the pregnancy itself, or marital changes after childbirth.
Research on parenthood consists of population-based studies that examined the effects of presence and
number of children on a variety of measures of paternal health. Five drew upon national samples, and three
were prospective in design. Some studies found a positive association between fatherhood and health status
[2, 68], but that certain variables may potentiate, attenuate, or even reverse this association.
The number of children seems an important explanatory variable, although evidence on the direction of
this effect is unclear. One study  concludes that having one or more children decreases overall mortality
risk among divorced men, and another  that 3 or more children increases CHD risk and further suggests
that this association was mediated by increased paternal obesity. Another study suggested an interaction
between temporal factors, role competency, and health benefits . Paternal competency increases over time
augmenting the health benefits of fatherhood .
The three studies that did not report a positive association between fatherhood and improved health status
[64, 66, 67] had smaller sample sizes and were probably inadequately powered to detect predictors of
mortality risk, which is a relatively rare outcome among men in this age group.
Thus, the preponderance of evidence suggests that fatherhood in itself can be beneficial to a man's health.
Evidence regarding the effects of the number of children, however, is mixed. Other variables such as
lifestyle risk factors and paternal role competency could be important mediating factors.
Almost all studies of the physical health of fathers following award of child custody relied on large
national samples. Collectively, the studies used a variety of outcome indicators of paternal health. All
studies reported that loss of child custody was associated with a variety of adverse consequences for the
physical health of fathers. Echoing this finding were numerous case reports and two empirical studies that
examined the psychological sequelae of paternal loss of child custody. These studies reveal a troubling
pattern of high psychological morbidity. Loss of child custody may be associated with substantially higher
Recommendations for research and practice
Research on fatherhood lags behind that on maternal health, a disparity has been called "one of the
significant gaps in family research and theory" .
There is a pressing need for such research in low-income and minority populations and in less-developed
countries. In addition, the health status of never-married fathers has received limited scientific attention.
And the mediating role of a variety of social and psychological factors needs to be established.
The psychological transition to fatherhood is as dramatic as that to motherhood . Nonetheless, the
medical and social services designed to help men cope with the myriad challenges of fatherhood have been
minimal or even non-existent. The reason for this neglect is probably a tendency to minimize the
adjustments that men make .
Policy makers, program planners, and care providers need to assure that prenatal classes address the
specific issues and concerns that fathers experience. Doctors and nurses need to assure that fathers feel
welcomed during labor and delivery.
Attention to the needs of fathers is important during the postnatal period, as well. For example, the British
National Health Service has recently begun to offer postnatal counseling services designed specifically for
men (The Telegraph, 24 August, 2003).
It is the plight of non-custodial fathers, however, that warrants greatest concern. The loss of child custody
places fathers at substantially higher risk of physical and psychological morbidity and mortality. Given that
so many fall in this category, it is surprising that so few services are available to this high-risk population.
In 1921, the United States Congress passed the Sheppard-Towner Act, a far-reaching law that was
designed to address the unmet needs of maternal health. More than 80 years later, research documents the
important needs of paternal health, needs that remain largely unattended.
In 1987, Lemmer argued, "the needs and expectations of men during this time of their lives cannot be
ignored or discounted" . It is high time that we pay attention to the physical and psychological needs of
fathers, those men who play a crucial role in fostering the health and well-being of children.
1. Wallace HM, Nelson RP, Sweeney PJ (eds.). Maternal and Child Health Practices. Oakland, CA: Third
Party Publishing, 1994.
2. Verbrugge LM. Multiple roles and physical health of women and men. J Health Soc Behavior 1983; 24:
3. Osofsky H. Expectant and new fatherhood as a developmental crisis. Bull Menninger Clinic 1982; 46:
4. Lemmer C. Becoming a father: A review of nursing research on expectant fatherhood. Matern Child
Nurs J 1987; 16: 261-275.
5. Lamb ME (ed.): The Role of the Father in Child Development. New York: Wiley, 1997.
6. O'Dowd T, Jewell D (eds.): Men's Health. Oxford: Oxford University Press, 1998.
7. Courtenay WH. Engendering health: A social constructionist examination of men's health beliefs and
behaviors. Psychology of Men and Masculinity 2000a; 1: 4-15.
8. Courtenay WH. Behavioral factors associated with disease, injury, and death among men: Evidence and
implications for prevention. J Men's Studies 2000b; 9: 81-142.
9. Rosengren A, Wedel H, Wilhelmsen L. Marital status and mortality in middle-aged Swedish men. Am J
Epidemiology 1989; 129: 54-64.
10. Goldman N. Marriage selection and mortality patterns: Inferences and fallacies. Demography 1993; 30:
11. Anthony EJ. Fatherhood and fathering: An overview. In Cath SH, Gurwitt AR, Ross JM (eds.): Father
and Child: Development and Clinical Perspectives. Boston: Little Brown and Co., 1982.
12. Grossman FK, Eichler LS, Winickoff SA. Pregnancy, Birth, and Parenthood. San Francisco: Jossey-
Bass, 1980, Chapter 8.
13. Lancaster JB, Altmann J, Rossi AS et al (eds.): Parenting across the Lifespan: Biosocial Dimensions.
New York: Aldine de Gruyter 1987.
14. Russell G, Radojevic M. The changing role of fathers? Current understanding and future directions for
research and practice. Infant Mental Health J 1992; 13: 296-311.
15. Mead M. Male and Female: A Study of the Sexes in a Changing World. New York: Dell, 1969.
16. Gove WR. Sex, marital status, and mortality. Am J Sociology 1973; 79: 45-67.
17. Kobrin FE, Hendershot GE. Do family ties reduce mortality? Evidence from the United States, 1966-
1968. J Marriage and Family 1977; 39: 737-745.
18. Verbrugge LM. Marital status and health. J Marriage and the Family 1979; 41: 267-285.
19. Chandra V, Szklo M, Goldberg R, et al. The impact of marital status on survival after an acute
myocardial infarct. Am J Epidemiology 1983; 117: 34-42.
20. House J, Landis K, Umberson D. Social relations and health. Science 1988; 241: 540-545.
21. Gove WR, Style CB, Hughes M. The effect of marriage on the well-being of adults: A theoretical
analysis. J Family Issues 1990; 11: 4-35.
22. Rogers RG. Marriage, sex, and mortality. J Marriage and the Family 1995; 57: 515-526.
23. Cassel J. The contribution of the social environment to host resistance. Am J Epidemiol 1976; 104:
24. Berkman LF, Glass T, Brissette I, Seeman TE. From social integration to health: Durkheim in the new
millennium. Soc Sci Med 2000; 51: 843-857.
25. Masoni S, Maio A, Trimarchi G et al. The couvade syndrome. J Psychosomatic Obstet Gynec 1994; 15:
26. Donovan J. The process of analysis during a grounded theory study of men during their partners'
pregnancies. J Adv Nurs 1995; 21: 708-715.
27. Lewis C. 'A feeling you can't scratch': The effect of pregnancy and birth on married men. In Beail N
and McGuire J, eds: Fathers: Psychological Perspectives. London: Junction Books, 1982.
28. Zilboorg G. Depressive reactions related to parenthood. Am J Psychiatr 1931; 10: 927-962.
29. Freeman T. Pregnancy as a precipitant of mental illness in men. Brit J Med Psychol 1951; 24: 49.
30. Towne RD, Afterman J. Psychosis in males related to parenthood. Bull Menninger Clin 1955; 19: 19.
31. Retterstol N and Opjordsmoen S. Fatherhood, impeding or newly-established, precipitating delusional
disorders. Long-term course and outcome. Psychopathology 1991; 24: 232-237.
32. Benvenuti P, Marchetti G, Niccheri C, et al. The psychosis of
fatherhood: A clinical study. Psychopathology 1995; 28: 78-84.
Benzeval M. The self-reported health status of lone parents. Soc Sci Med 1998; 46; 1337-1353.
33. Clinton JF. Expectant fathers at risk for couvade. Nurs Res 1986; 35: 290-295.
34. Trethowan WH, Conlon MF. The couvade syndrome. Brit J Psychiatr 1965;
35. Lipkin M and Lamb GS. The couvade syndrome: An epidemiologic study. Ann Int Med 1982; 96: 509-
36. Quill TE, Lipkin M, Lamb GS. Health-care seeking by men in their spouse's pregnancy. Psychosom
Med 1984; 46: 277-283.
37. Clinton JF. Physical and emotional responses of expectant fathers throughout pregnancy and the early
postpartum period. Int J Nurs Stud 1987; 24: 59-68.
38. Condon JT. Psychological and physical symptoms during pregnancy: A comparison of male and female
expectant parents. J Reproductive and Infant Psychol 1987; 5: 207-219.
39. Wynne-Edwards KE, Reburn CJ. Behavioral endocrinology of mammalian fatherhood. Trends Ecol
Evol 2000; 15: 464-468.
40. Storey AE, Walsh CJ, Quinton RL et al. Hormonal correlates of paternal responsiveness in new and
expectant fathers. Evolution and Human Behav 2000; 21: 79-95.
41. Tanzer D, Block JL. Why Natural Childbirth? Garden City, NY: Doubleday, 1972. Telegraph. Men to
get NHS counseling for "postnatal depression." August 24, 2003.
42. Klaus et al. Maternal attachment: Importance of the first post-partum days. N Engl J Med 1972; 286:
43. Kinney W. Paternal attachment. N Engl J Med. 1972 Nov 2; 287: 939.
44. Eakins PS. The American Way of Birth. Philadelphia: Temple University Press, 1986.
45. Antle-May K and Perrin SP. Prelude, pregnancy, and birth. In Hanson SMH and Bozett FW (eds.):
Dimensions of Fatherhood. Beverly Hills: Sage. 1985.
46. Berry LM. Realistic expectations of the labor coach. J Obstet Gyn Neonatal Nurs 1988; 17: 354-355.
47. Vehvilainen-Julkunen K, Liukkonen A. Fathers' experiences of childbirth. Midwifery 1998; 14: 10-17.
48. Jordan PL. Laboring for relevance: Expectant and new fatherhood. Nurs Res 1990; 39: 11-16.
49. Chandler S, Field PA. Becoming a father. First-time fathers' experience of labor and delivery. J Nurse
Midwifery 1997; 42: 17-24.
50. Chalmers B and Meyer D. What men say about pregnancy, birth, and parenthood. J Psychos Obstet
Gynec 1996; 17: 47-52.
51. Steinberg S, Kruckman L, Steinberg S. Reinventing fatherhood in Japan and Canada. Soc Sci Med
2000; 50: 1257-1272.
52. Johnson MP. An exploration of men's experience and role at childbirth. J Men's Studies 2002; 10: 165-
53. Raskin JD, Richman JA, Gaines C. Patterns of depressive symptoms in expectant and new parents. Am
J Psychiatr 1990; 147: 658-660.
54. Marks M and Lovestone S. The role of the father in parental postnatal mental health. Brit J Med
Psychol 1995; 68: 157-168.
55. Henderson AD and Brouse AJ. The experience of new fathers during the first three weeksk of life. J
Adv Nurs 1991; 16: 293-298.
56. Barclay L, Lupton D. The experience of new fatherhood: A socio-cultural analysis. J Adv Nurs 1999;
57. Jarvis W. Some effects of pregnancy and childbirth on men. J Am Psychoanalytic Assn 1962; 10: 689-
58. Wainright W. Fatherhood as a precipitant of mental illness. Am J Psychiatry 1966; 123: 40-44.
59. LaCoursiere RB. Fatherhood and mental illness: A review and new material. Psychiatric Quarterly
1972; 46: 109-124.
60. Shapiro S, Nass J. Postpartum psychosis in the male. Psychopathology 1986; 19: 138-142.
61. Rees WD, Lutkins SG. Parental depression before and after childbirth. J Royal College of Gen
Practitioners 1971; 21: 26-31.
62. Ferketich SL, Mercer RT. Men's health status during pregnancy and early parenthood. Research Nurs
and Health 1989; 12: 137-148.
63. Ballard CG, Davis R, Cullen PC et al. Prevalence of postnatal psychiatric morbidity in mothers and
fathers. Brit J Psychiatr 1994; 164:782-788.
64. Haynes S, Eaker E, Feinleib M. Spouse behavior and coronary heart disease in men: Prospective results
from the Framingham Heart Study. I. Concordance of risk factors and the relationship of psychosocial
status to coronary incidence. Am J Epidemiology 1983; 118: 1-22.
65. Clark W, Freeman H, Kane R et al. The influence of domestic position on health status. Soc Sci Med
1987; 24: 501-506.
66. Kotler P, Wingard DL. The effect of occupational, marital, and parental roles on mortality: The
Alameda County Study. Am J Public Health 1989;
67. Hibbard JH. Pope CR. Quality of social roles as predictors of morbidity and mortality. Soc Sci Med
1993; 36: 217-225.
68. Smith KR, Zick CD. Linked lives, dependent demise? Survival analysis of husbands and wives.
Demography 1994; 31: 81-93.
69. Hemström O. Is marriage dissolution linked to differences in mortality
risks for men and women? Journal of Marriage and the Family 1996; 58;
70. Lawlor D et al. Is the association between parity and coronary heart disease due to biological effects of
pregnancy or adverse lifestyle risk factors associated with child-rearing? Findings from the British
Women's Heart and Health Study and the British Regional Heart Study. Circulation 2003; 107:1260-1264.
71. Gove WR. The relationship between sex, marital status, and suicide. J Health Soc Behavior 1972; 13:
72. Bloom BL, Asher SJ, White SW. Marital disruption as a stressor: A review and analysis. Psychol Bull
1978; 85: 867-894.
73. Gove WR, Shin HC. The psychological well-being of divorced and widowed men and women. J Family
Issues 1989; 10: 122-144.
74. Kposowa AJ Marital status and suicide in the National Longitudinal Mortality Study. J Epidemiol
Comm Health 2000; 54: 254-261.
75. Brunner B (ed.): Time Almanac 1999. Boston: Information Please LLC, 1998, p. 803.
76. U.S. Bureau of Census. Statistical Abstract of the United States, 1999. Washington, DC, 1999, Table
77. U.S. Bureau of Census. Marital Status and Living Arrangements. Current Population Reports, Series
P20-514, March 1998, Table CH-6.
78. Popay J, Jones G. Patterns of health and illness amongst lone parents. J Soc Policy 1990; 19: 499-534.
79. Hallberg H. Life after divorce--A five-year follow-up study of divorced middle-aged men in Sweden.
Fam Pract 1992; 9: 49-56.
80. Benzeval 1998
81. Wallerstein JS, Blakeslee S. Second Chances: Men, Women, and Children a Decade after Divorce. New
York: Ticknor and Fields, 1989, p. 235.
82. Ross JM. The Male Paradox. New York: Simon and Schuster, 1992, pp. 154-157.
83. Umberson D, Williams CL. Divorced fathers: Parental role strain and psychological distress. J Family
Issues 1993; 14: 385-378.
84. Blankenhorn D. Fatherless America: Confronting our Most Urgent Social Problem. New York:
HarperPerennial. 1995, p. 161.
85. Campbell D. Suicide: When hope is gone. Everyman May/June, 2000, p. 9.
86. Vorsteveld T. Suicide: When hope is gone. Everyman 2000 (May/June): No. 43, p. 9.
87. Tepp AV. Divorced fathers: Predictors of continued paternal involvement. Am J Psychiatr 1983; 140:
88. Farrell W. Father and Child Reunion. New York: Jeremy Tarcher, 2001, p. 259, footnote 13.
89. Moss P, Bolland G, Foxman R et al. Marital relations during the transition to parenthood J Reprod Inf
Psychol 1986; 4: 57-67.
90. Wilkinson RB. Changes in psychological health and the marital relationship through childbearing:
Transition or process as stressor? Austr J Psychol 1995; 47: 86-92.