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Brennan, A., Marshall-Lucette, S., Ayers, S. & Ahmed, H. (2007). A qualitative exploration of the
couvade syndrome in expectant fathers. Journal of Reproductive and Infant Psychology, 25(1), 18 -
39. doi: 10.1080/02646830601117142 <http://dx.doi.org/10.1080/02646830601117142>
City Research Online
Original citation: Brennan, A., Marshall-Lucette, S., Ayers, S. & Ahmed, H. (2007). A qualitative
exploration of the couvade syndrome in expectant fathers. Journal of Reproductive and Infant
Psychology, 25(1), 18 - 39. doi: 10.1080/02646830601117142
<http://dx.doi.org/10.1080/02646830601117142>
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1
A Qualitative Exploration of the Couvade Syndrome in Expectant
Fathers
A. Brennan, S. Marshall-Lucette, S. Ayers & H. Ahmed.
Please cite this paper as:
Brennan, A., Marshall-Lucette, S., Ayers, S., & Ahmed, H. (2007). A qualitative
exploration of the couvade syndrome in expectant fathers. Journal of Reproductive and
Infant Psychology, 25(1), 18-39.
2
Abstract
The aim of this qualitative study is to explore the nature and duration of male partners
somatic and psychological symptoms, across gestation and parturition, collectively called
the Couvade syndrome. Fourteen men with expectant partners aged 19-48 years from
diverse social and ethnic backgrounds were interviewed. The data was processed using
qualitative analytical software WinMAX Professional and the emerging themes and sub-
categories identified and analysed. The first was “Emotional Diversity in Response to
Pregnancy”, that varied with time and other factors and also included mixed and
polarised feelings such as excitement, pride, elation, worries, fears, shock and reluctance.
The second was “Nature, Management and Duration of Symptoms”, which revealed the
types and duration of physical and psychological symptoms experienced by men.
Attempts at managing these were influenced by social and cultural factors. Physical
symptoms were more common than psychological ones, and their time course
demonstrated trends similar to those reported for the Couvade syndrome. Although the
former were reported to their GPs, no definitive diagnosis was made despite medical
investigations being performed. The third theme, “Explanatory Attempts for Symptoms”
was influenced by cultural beliefs and conventions like religion, alternative medical
beliefs or through the enlightenment by health care professionals in the process. Some
participants were unable to find explanations for symptoms but some perceived that they
were related in some way to the altered physiology of their female partners during
pregnancy. These findings highlight the need for further research to acquire deeper
insight into men’s experiences of, and responses to, pregnancy as a way of explaining the
syndrome.
Key Words: Couvade syndrome, Modern Couvade, Sympathetic pregnancy, Pseudo-
pregnancy, Pseudocyesis.
3
Introduction
The Couvade Syndrome is a phenomenon which occurs in industrialised countries around
the world. It affects the male partners of pregnant women who experience a range of
physical and psychological symptoms with no pathological basis (Klein, 1991; Mason &
Elwood, 1995). However, one case study has reported a Couvade syndrome equivalent in
an African-American woman during both of her twin sister’s pregnancies (Budur ‘et al.’
2005). Conner & Denson (1990) identified 3 main groups of symptoms commonly
associated with the syndrome. The first group included the gastrointestinal symptoms
nausea, heartburn, abdominal pain, bloating, and appetite changes. The second group
comprised upper respiratory disturbances like colds, breathing difficulties and epistaxis,
in addition to pains like toothache, leg cramps, backache and urogenital irritations. In the
third category, psychological symptoms such as changes in sleeping patterns, anxiety and
worry, depression, reduced libido and restlessness were reported. The symptoms are
chronologically connected to pregnancy and their course appears to follow a U-shaped
pattern over the duration of gestation (Schodt, 1989), as the symptoms appear in the first
trimester, temporarily disappear in the second and reappear in the third trimester. This
has been confirmed by the timing of medical consultations for them (Lipkin & Lamb,
1982). The symptoms classically cease abruptly at birth or shortly within the postpartum
period.
Problems of Definition
Early accounts tended to medicalise the syndrome as a psychosomatic disorder
(Trethowan & Conlon 1965; Trethowan, 1968). Enoch ‘et al.’ (1967) refer to it as an
4
“uncommon psychiatric syndrome”. However, the syndrome does not appear in the
nosologies of the Diagnostic Statistical Manual of Mental Disorders: DSM-Version 1V,
(American Psychiatric Association 2000) or the International Classification of Diseases:
ICD-Version 10, (World Health Organisation 1993). The reason for this is not clear, but
the syndrome is idiopathic, and according to classic definitions, is not specifically related
to physical or psychological illnesses. Furthermore, Couvade symptoms are by definition
non-specific and transient, which hamper attempts to discriminate them from symptoms
that do have a pathophysiological basis. Its diagnosis is principally made by exclusion
(Schodt, 1989; Mason & Elwood, 1995). While these somatic symptoms are concurrent
with pregnancy the fact that they are not associated with disease may cause some to
question whether it is a syndrome at all. In 1991 Klein argued that the syndrome was a
poorly understood phenomenon which might be explained by problems of definition,
inconsistencies in its criteria and the use of multiple and varied measures across studies.
Moreover, the fact that the syndrome is an unconsciously and involuntarily determined
phenomenon (Klein 1991) may complicate efforts by physicians to explain it, and
attempts by those affected to understand it. Yet Mayer & Kapfhammer (1993); Magalini
& Magalini (1997) suggest that the syndrome is the man’s conscious imitation or
simulation of his partner’s symptoms during gestation. Those in the medical profession
may sometimes overlook lay narratives of the syndrome and its social context in their
efforts to medicalise it. Despite this, lay conceptions of the syndrome continue to be
influenced not only by medical knowledge but also by the lived and personal experience
5
of those affected by the symptoms. Likewise, Falkum & Larsen (1999) argue that
accounts of illness are based on existing knowledge and explanations which express
individualised views based on beliefs and experience. Thus, those who have Couvade
syndrome constitute a valuable resource when it comes to rationalising and making sense
of its symptoms. Moreover, this understanding is often influenced by their respective
socio-cultural contexts. All these factors were influential in deciding the qualitative
nature of this study.
Incidence and Socio-Demographic Factors
The syndrome’s incidence has a wide international variation, and early reports from the
U.K. have a wide range of 11-50% (Trethowan & Conlon 1965; Dickens & Trethowan,
1971). Bogren (1984) found an incidence of 20% in Sweden. In the USA, Clinton (1987)
and Brown (1988) reported a much higher incidence of 94-97%. Khanobdee ‘et al.’
(1993) estimated an average incidence of 61% among Thai males; while Tsai & Chen
(1997) reported a similar incidence of 68% among Chinese men. The global incidence of
the syndrome has also been demonstrated by reports of its presence in France (Sizaret ‘et
al.’ 1991), South Africa (Chalmers & Meyer, 1996), Russia (Marilov, 1997) and Serbia
(Koić ‘et al.’ 2004). However, one country where the syndrome has sparsely been
reported is Australia (Condon, 1987), which might reflect reluctance to admit such
symptoms in what is perceived to be a “macho culture”. Its relationship with socio-
demographic factors such as age (Bogren, 1989), educational level (Lipkin & Lamb,
1982), social class (Strickland, 1987), number of previous children (Sizaret et al, 1991)
planned or unplanned pregnancy (Bogren, 1983, 1984; Clinton, 1986; Strickland, 1987)
6
all show inconsistent findings. The only exception is ethnicity where a higher incidence
among black men has been consistently reported (Munroe & Munroe, 1971, Munroe ‘et
al.’ 1973, Clinton, 1986). These disparate findings might be explained by problems of
sample size variation, cultural and age differences across studies, socio-economic class
variability and geographical distributions.
Theoretical Concepts
A plethora of theories have been put forward to account for the origin of the Couvade
syndrome. Psychoanalytical theories propose that it emanates from the man’s envy of the
woman’s procreative ability (Bohem, 1930; Rapheal-Leff, 1991). Another perspective
maintains that it occurs because pregnancy for the expectant man acts as a catalyst for the
resurgence of ambivalence and Oedipal conflicts (Gerzi & Berman, 1981; Barclay ‘et al’.
1996; Bartlett, 2004). Other psychoanalytical theories propose a relationship between the
syndrome and the man’s rivalry with his unborn child (Malthie ‘et al.’1980; Kapfhammer
& Mayer in Brahler and Unger 1996). It is not surprising, therefore, that those male
partners in such studies have often been referred to psychoanalysts or psychiatrists for
treatment given the idiopathic nature of the syndrome and its failure to be diagnosed by
physicians. Studies exploring a psychoanalytical basis for the syndrome are mainly case
reports, which might be prone to subjective interpretation and difficult to generalise.
Psychosocial theories propose that the syndrome is a reactive process to the
marginalisation of men during pregnancy (Mayer & Kapfhammer, 1993; Chandler &
Field, 1997). However the feminist perspective rejects this, and argues instead for the
increased and active participation of men during pregnancy and birth (Masoni ‘et al.’
1994; Polomeno, 1998). Psychosocial theories also propose that the syndrome arises
7
because of men’s transitional crisis to prospective parenthood (Jordan 1990; Imle, 1990;
Klein, 1991).
Paternal theories propose a relationship between men’s involvement in the pregnancy,
role preparation and the syndrome (Weaver & Cranley, 1983; Raphael-Leff, 1991; Drake
‘et al’. 1998). This might imply that a transitional crisis is less likely to occur if the male
partner is better prepared for his new role but the fact that he is, still predisposes him to
the syndrome, which contradicts psychosocial theories. Other paternal theories propose
an association between the syndrome and anxiety (Trethowan & Conlon, 1965;
Strickland, 1987; Brown, 1988). It is difficult, however, to determine whether anxiety is
the cause or consequence of the syndrome. The use of varied measures of anxiety across
studies further complicates the issue. To date only two studies by Storey ‘et al.’ (2000),
and Berg & Wynne-Edwards (2001) support a hormonal basis for the syndrome. The
findings of both indicated a significant increase in men’s hormonal levels of prolactin and
oestrogen but lower levels of testosterone and cortisol. These hormonal changes were
associated with the display of paternal behaviours as well as Couvade symptoms. These
findings support paternal theories which propose men’s involvement in pregnancy as an
antecedent of the syndrome. However, both investigations failed to assess the well
documented but confounding relationship between paternal stress and anxiety with
elevated levels of cortisol and the somatic symptoms of the syndrome. The literature
reveals a dearth of studies testing these theories except those examining the syndrome’s
relationship with pregnancy involvement, role preparation and anxiety.
8
Despite a predominance of literature on the syndrome during the 1980’s and 90’s, little
has been published between 2000 and 2006. This might reflect fluctuating interest over
the decades seen also with other subjects that do not receive significant scientific
attention from public and independent funding bodies that usually express more interest
in common health problems. The transient nature of the syndrome which affects
otherwise healthy males, and the relative ignorance about its exact definitions and
possible impact even in academic circles might also explain the deficit.
Rationale for Qualitative Approach
The rationale for using a qualitative approach to investigate the Couvade syndrome is
fourfold. Firstly, the fact that the syndrome continues to be poorly understood by those
affected and by the health care professionals they consult necessitates the need for an
independent and in-depth exploration of male partners own perceptions and experiences
of it. This approach is likely to reveal insights into the nature of the symptoms and their
relationship to pregnancy. Secondly, the qualitative approach could offer an alternative
perspective in understanding male partners perceptions of the syndrome, as opposed to
the currently predominant medical perspectives within the literature. Thirdly, it enables
exploration of the syndrome in a naturalised and holistic manner, making recourse to
individuals’ social and cultural contexts in the process, and whether these influence the
ways in which it is managed and explained. Fourthly, the approach is ideally suited to
allow further theoretical contributions to be made or existing ones to be confirmed or
developed.
9
Study Approach, Aims and Objectives
A phenomenological approach was chosen for the study based on the lived experiences of
male partners with the Couvade syndrome. The aim is to explore the emotional, physical
and psychological characteristics of the syndrome and their explanations, as perceived by
men with pregnant partners. Its specific objectives are to:
• Explore male partners experiences of pregnancy, including their feelings and
aspects of involvement, to assess concurrence with current theoretical
propositions for the Couvade syndrome.
• Explore the nature and duration of male partners physical and psychological
symptoms experienced across the three trimesters of pregnancy and labour as
defining criteria of the syndrome.
• Explore male partners accounts of whether and how these symptoms are
investigated and managed making comparisons with the published literature.
• Identify the timing of symptoms and their cessation in male partners and compare
with those reported in published literature.
• Explore male partners explanatory attempts for their symptoms, to determine their
meanings and possible social and cultural influences.
10
Methods
Access and sampling
A purposive sample of 14 men were recruited from the Foetal Medicine Unit of a large
teaching hospital in London which serves a large Asian and Afro-Caribbean population.
The main investigator approached the men when they attended pre-scanning information
sessions with their partners around the tenth week of the pregnancy, which provided them
with details of the ultrasound scan procedure, potential pregnancy anomalies and details
of antenatal care. Prior to these sessions the investigator introduced himself to the couples
and provided an outline of the study and its purpose making no mention of the “Couvade
syndrome”, but rather “men’s health during their partners’ pregnancy”. Participants were
offered the opportunity to ask questions about the study and provide their contact details.
Thirteen male partners agreed to participate, six who had no children, five who had one
child each, and two who had two or more children each. Four other men who were first
time parents were also recruited from an Internet website specifically designed for the
study namely, www.pregnancyandfathers.com to reach a more heterogeneous group.
Inclusion and exclusion criteria were established to reduce the likelihood of confounding
symptoms. The inclusion criteria were:
• Over 18 years of age.
• Can read, speak and understand English at a level suitable for the full completion
of the interview.
11
• Partner has a confirmed pregnancy for which the recruited person is the
biological father.
• Be willing to be interviewed.
• Have experienced a minimum of 4 physical or psychological symptoms whose
onset coincided with the pregnancy.
The selection procedure involved completing short questionnaire requesting
information about male partners’ symptoms. A list of thirty-five symptoms (27
physical and 8 psychological) was developed from the literature on the Couvade
syndrome. The symptoms comprised 12 gastro-intestinal, 3 genito-urinary, 4
respiratory, 2 oral/dental, 2 generalised aches/pains and 4 other symptoms which did
not fall into these anatomical categories. There were also eight psychological
symptoms relating to sleep, mood, emotional affect, motivation, cognition and
coping. Men with four or more symptoms whose onset coincided with the pregnancy
were included.
The exclusion criteria were:
• Under 18 years of age.
• Unable to speak or write English at a level suitable for the full completion of the
interview.
• Receiving current treatment for illnesses that might produce physical symptoms
similar to those of the Couvade syndrome, e.g., inflammatory bowel disease, viral
infections like chronic fatigue syndrome, herpes, glandular fever, meningitis,
thyroid problems, any form of cancer, anaemia or relevant chronic disease.
12
• Receiving current treatment for any form of mental disorders that might produce
psychological symptoms similar to the Couvade syndrome, e.g. depression or
manic phases of affective disorder, anxiety disorders, schizophrenia and other
relevant psychoses or neuroses.
• Partner has confirmed medical problems with her pregnancy, e.g., gestational
diabetes, hypertension, pre-eclampsia or other relevant maternal disorders.
• Partner has a high-risk pregnancy, e.g., antenatal haemorrhage, foetal/maternal
blood group incompatibility and similar conditions.
Three men did not fulfil the study selection criteria because of language difficulties,
having less than 4 physical symptoms and a partner with a high-risk pregnancy and so
were excluded. Subsequently the selected number for the study was fourteen men. The
socio-demographic characteristics of the study population are summarised in the Table.
Ethical Considerations
Permission for the study was sought from the Local Research and Ethics Committee.
Men who indicated their interest and satisfied the study entry criteria were invited to
participate. They were provided with an information sheet and a written consent form for
audio-interview recordings to be performed in their own homes. It was made clear that
their decision to participate or opt out of the study would not affect the subsequent care
that they or their pregnant partners receive. Anonymity was preserved during the
interviews and other aspects of the research process, through the use of pseudonyms for
study participants and their partners if they referred to them by name. All forms of data
were kept on a computer protected by a security password. Tapes/magnetic discs and
13
other documents related to the interviews were stored in a locked cupboard in a secure
room. Data were treated with strict confidentiality.
Methods
Data Collection
Study participants were telephoned to arrange a suitable time for the interview. The
purpose of the study was described to participants whose aim was to explore their
feelings about the pregnancy, experience of physical and psychological symptoms and
accounts of how these were managed and attempts to understand their symptoms. Details
of the interview procedure were provided concerning its location, length of time, method
of recording, management of interruptions and instances where clarification was needed.
The interviews were conducted in the participants’ homes during the evening time and
lasted between 60-90 minutes. Female partners were requested not to be present lest this
affect male partners’ level of disclosure. A male researcher carried out all the interviews
to take account of potential gender interaction effects between the interviewer and
informants. This was in keeping with Levine & DeSimone’s (1991) observation that men
often confide more readily to an interviewer of the same gender and report less to
someone of the opposite sex. Moreover, the same researcher throughout also helps
promote consistency and uniformity across the interviews. Prior to data collection, the
researcher spent considerable time examining aspects of the pregnancy experience for
men to increase awareness of personal prejudices, viewpoints and assumptions. These
were then “bracketed” (Ashworth 1999) or set aside, so as not to influence the process
and maintain neutrality and objectivity. An open-ended conversational stance was used
14
along with field notes to capture the interview context. An interview guide piloted prior
to the interviews was also used for the systematic sequencing of topics or issues to be
explored as follows:
1. Participant’s feelings and emotions in response to and during each trimester
of pregnancy
• Men’s and partners’ feelings and emotions, whether positive, negative or
both, in relation to pregnancy.
• Male partner’s rationale for any identified feelings and emotions.
• The type and degree of men’s involvement in the pregnancy e.g.
attendance at scans, involvement with the unborn baby, attendance of
antenatal classes, practical, financial and emotional support for pregnant
partner.
2. Participants’ experience of symptoms during each trimester of pregnancy:
The nature and duration of symptoms, accounts of how these were assessed
and managed
• Nature and duration of physical symptoms.
• Nature and duration of psychological symptoms.
• Account of how symptoms were assessed and managed, and by whom.
• Cessation patterns for symptoms.
3. Explanations and meanings for symptoms
• Men’s explanations and meanings for individual symptoms and/or these as
a whole.
• Explanations and meanings for individual symptoms and/or these as a
whole by those consulted.
15
• Difficulties or failures in explaining symptoms, individually and/or as a
whole either by men themselves and/or by those consulted.
Data was collected until it reached a point of saturation and redundancy, where no new
information or insights seemed to emerge
Method of Analysis
An inductive approach based upon the analytic procedures of Colaizzi (1978) and
Boyatzis (1998) was used namely thematic content analysis which ran concurrently
alongside the process of data collection. A professional transcriber undertook
transcription of the tape-recorded interviews, and the interviewing male researcher
performed the analysis. The data was processed using the qualitative software package
WinMAX Professional (Udo Kuckartz, BSS, Berlin, Germany 1998). The individual
interviews were labelled M1-M14 (M1 = first interview, M14 = last interview). All the
transcripts were scanned line-by-line and potential labels describing respective data
segments were assigned manually and then later by the above programme. Categories and
sub-categories were generated based on participants’ recurrent words or phrases within
the data sets. Data segments were cross-indexed with the original interview transcripts
that were re-read and checked against field notes to ascertain the contextual meaning of
the data. Key categories and sub-categories with their appropriate data segments were
then organised in a meaningful sequence, reflecting the aim of the study. This was
followed with the identification of relevant concepts prior to establishing possible
relationships between these.
16
In this process, three key themes emerged, which were used to describe the participants’
accounts, supported with verbatim examples. This was followed by attempts at
interpretation of the meanings from the data sets. The personal meanings of participants’
experiences were interpreted using their “lived perspectives” to represent their reality and
seek possible justification. Conceptual meanings were interpreted by making reference to
individual participants’ social and cultural contexts as well as the pregnancy in explaining
their perceptions and experiences. Two independent researchers were invited to read the
interview transcripts in order to validate the sub-categories and themes. Three
participants also reviewed their transcripts to ensure trustworthiness, accuracy and
confirmability of the data prior to analysis.
Results
Three themes emerged from the data, namely “Emotional Diversity in Response to
Pregnancy”, “Nature, Duration and Management of Symptoms”, “Explanatory Attempts
for Symptoms”. The relationship between the analytic sub-categories and higher order
themes are illustrated in the Figure.
1. Emotional Diversity in Response to Pregnancy
Men’s experiences of the pregnancy from its announcement up to the birth were
demonstrated through their feelings, worries and concerns, response to demands and
involvement with partner and unborn child. A myriad of mixed feelings were expressed,
which varied in intensity over time. Twelve men indicated their sense of excitement at
the news of conception, especially in cases where it was their first child,
17
… Wow it was am-a-a-zing when I first heard that Sarah was pregnant as we’d
only been married for a short time. I remember announcing it in the pub to
all my friends the next evening that I was to become a new father I was really
elated. I was excited for about four weeks afterwards… (M: 2).
In addition, three men expressed ambivalence where the pregnancy was unplanned,
… Yeah well it was a delight and in a way horror as well... (M: 12).
Feelings of shock to unanticipated pregnancy and a transitory reluctance to accept it also
surfaced,
… It was a bit of a bombshell mate since we was using some prevention at the
time you know what I mean? Later on I took it on board I guess ... (M 8).
After the period of announcement the initial excitement gradually lessened. Nevertheless,
positive feelings continued for nine of the participants as the pregnancy progressed and
even intensified during the third trimester. Six men indicated that the pregnancy
precipitated feelings of closeness and intimacy with their partners especially during and
after the period of the first ultrasound scan,
…We actually got very close after that period my wife and I, we
hadn’t been married very long, and it sort of really brought us
that much closer…(M:13).
Men’s closeness to their pregnant partners was also displayed by their feelings of
protection which involved health precautions and environmental prohibitions,
…I tried to get Sarah out of the house a bit more but we kept out of
smoky pubs because of her condition at that time…(M: 2).
18
While the pregnancy generated positive feelings it also precipitated worries and concerns.
These were mainly in response to the demands of the pregnancy, what it signified in
terms of its potential effects on the health of the partner and unborn, its impact upon the
conjugal relationship and other siblings, financial commitment, accommodation space,
prospective parenthood, antenatal preparation and maternal care. The demands of
pregnancy were largely pragmatic, emotional and financial. Men’s practical support such
as shopping, lifting heavy items, care of siblings and housework increased as the
pregnancy progressed and the women’s physical capacity declined. Many men responded
empathetically and sensitively to their partners’ emotional state especially in cases where
they were tearful, anxious and vulnerable. Male partners also seemed to have a contextual
understanding of the woman’s emotional state,
...There were times when Eileen would start crying for
no reason and need a big hug from me and the boys to
cheer her up. I suppose that was her hormones tough
at the time…(M: 6).
While many men were responsive to demands demonstrating awareness of their partners
physical and mental stresses as the pregnancy progressed, their feelings were not always
congruent with their actions. For example, some men harboured feelings of resentment,
lack of patience and irritability although these were not expressed directly to their
partners,
…There was definitely ‘a shortness’, an anger, a lack of patience
and irritation because there’s too many things that I was thinking
that I had to do for her…(M: 13).
19
Another participant expressed his frustration with his partner’s increasing demands across
the stages of pregnancy and felt that she should be able to do more for herself despite her
condition.
Worries and concerns centred on the health of the partner and unborn child, whether the
pregnancy would go to term, prospective parenthood and its responsibilities, how other
siblings would react to the newborn child, insufficient accommodation space and
financial commitments especially among those whose salaries were low or who were
unemployed. Three participants expressed worries concerning the health of the unborn
based on their lay conceptions when the first ultrasound scan was performed,
…I was worried ‘cos I thought he wasn’t right he might be..what
ya’ call it..a Mongol or something…(M: 8).
When it came to prospective parenthood and its anticipated responsibilities eight men
expressed mixed feelings. These included positive anticipation and longing for
fatherhood, a realisation of its responsibilities and the sense of meaning it created in their
lives,
…Becoming a father I think of many responsibilities I have for wife
and child, it also give meaning to my life. I knew that have child
change everything for me and family…(M: 9).
Conversely, prospective fatherhood led to feelings of worry, uncertainty and
apprehension for others who were expecting their first child,
…Well I guess I was worried about becoming a dad…it’s a lot of
responsibility ya’ know what I’m sayin’…(M: 8).
20
The majority of men participated in antenatal preparation such as attending ultrasound
scans and antenatal classes but the feelings that these invoked were again mixed and
seemingly influenced by cultural expectancies on some occasions. On one hand there
were those who actively and willingly participated in antenatal classes with their pregnant
partners but on the other hand there were those who seemed reluctant to do so because of
the impact on their feelings. Others questioned their relevance and even led to a sense of
empathic distance from the pregnancy,
…Oh ‘yeh’ I went to a few of those mother classes as well. I mean they
‘was getting’ me to do some exercises that Hope was ‘doin’. I just felt
like a bit of a plonker man. I mean it wasn’t ME ‘havin’ the kid was
it? …(M: 3).
On some occasions antenatal classes were perceived as not being inclusive for the man,
…The focus of antenatal classes in my view is always on the woman
and not on the man…(M: 10).
Men also contrasted their position with that of their pregnant partner when it came to
antenatal care and felt their feelings were overlooked in the process,
… I did feel a bit of an outsider at the time…I mean it’s not as if I felt I
should be the centre of things then but I sometimes wondered if people
really know what its like for the other half when a baby comes along … (M: 2).
The feelings of the twelve men who attended the ultrasound scans varied and were
sometimes influenced by cultural expectancies. For three men the scan unveiled the
reality of the unborn baby through direct visual confirmation. For others it created
feelings of apprehension about whether the health of the unborn was “normal”. Other
men reported that it drew them closer to their partners. Not all men wished to know the
21
gender of the baby but those who did displayed contrasting feelings when it was
confirmed. This was classically illustrated by two Asian participants where a boy was
confirmed in one case and a girl in the other. The former stated,
…I felt very exhilarated when it was confirmed that we were going to
have a boy…(M: 7).
The other indicated,
…Well if I’m honest with you I felt a little disappointed since I was
hoping for a boy…(M:10).
Men’s emotional responses were sometimes linked to aspects of their involvement with
the pregnancy and/or their unborn child. Their involvement in both took a number of
forms which included commitment to demands, attendance and participation in antenatal
care, preparation for the baby and choosing names, seeking confirmation of the unborn
baby and evidence of paternal-foetal attachment. Men’s involvement with, and vicarious
confirmation of, the unborn mainly occurred through the ultrasound scans and when they
felt or listened to their partner’s abdomen for evidence of the baby kicking. Both the
reality of the unborn baby and prospective parenthood were reinforced in such instances.
For one participant the audible evidence of his partner’s “quickening” early in the second
trimester confirmed,
…I used to try and listen to the baby in Sarah’s tummy. What I do remember
is feeling the kicking …am-a-a-a-zing and it really brought home to me
that I was a dad or would be very soon …(M: 2).
22
2. Nature, Management and Duration of Symptoms
This theme centred on the men’s experiences of physical and psychological symptoms
and their time course over the pregnancy, with accounts of the ways in which they were
managed and by whom in addition to their cessation patterns. The identification of
symptoms by men revealed insights into the ways in which these were experienced and
their reality, intensity and level of distress. The most commonly reported physical
symptoms were gastrointestinal, genitourinary, and musculo-skeletal and some other
symptoms which could not be classified anatomically. Gastrointestinal symptoms
included stomach pains/cramps (n-13) vomiting (n-7) and appetite disturbances (n-6).
Men described their stomach pains as distressing and varying in intensity from an “ache”
or initially “mild” to getting progressively “stronger” or severer,
…My stomach pains were very much like a build up of a
woman’s contractions as she’s giving birth, they start mild
and then get stronger and stronger and stronger. That’s exactly
what these stomach pains were like for me, you know they started
mild and got stronger and stronger and stronger… (M: 13).
Vomiting mainly occurred in the mornings and on some occasions was also displayed
concurrently by pregnant partners,
…I was throwing up and retching a lot and couldn’t keep anything down both
Beverly and me… (M: 8).
Appetite disturbances took the form of either increased or decreased appetite with some
participants experiencing both alternatively. Some indicated that their appetite was
insatiable and that hunger continued no matter what had been eaten. Occasionally,
increased appetite and specific food cravings were linked,
23
…I was constantly hungry all the time and had an unstoppable craving for
chicken kormas and poppadams. Even in the early hours of the morning
I would get up and prepare myself one. It was strange to say the least… (M: 14).
The most common genitiourinary symptom was difficulty with micturition (n-5). Men
reported that it took them a long time to urinate especially at night and that it was painful,
…Another thing, going for a piss was really hard…it was evil man! (M: 3).
The most commonly reported musculo-skeletal symptom was back pain (n-5). Among the
other symptoms was tiredness (n-10), which some men described as disabling and
accounted for their lethargy,
…I was tired all the time day and night it took all my strength to
do anything… (M: 4).
Less commonly reported symptoms were gastrointestinal including abdominal distension
(n-3), diarrhoea and constipation (n-3), food cravings (n-2). Musculo-skeletal comprised
leg cramps (n-1). Upper respiratory symptoms such as sore throat (n-3), colds (n-1),
cough (n-1) and epsitaxis (n-1). Oral-dental symptoms were toothache (n-3) and sore
gums (n-2). Other symptoms included lethargy (n-4), weight loss (n-4), weight gain (n-2),
fainting (n-1).
In contrast to physical symptoms, psychological ones were less common, and included
insomnia (n-12), feelings of depression (n-6) and irritability (n-3). Men described their
insomnia as difficulty in getting off to sleep coupled with nocturnal restlessness and short
intermittent sleep,
…Oh sure my sleep was terrible, I could never seem to get off.
24
I’d be tossing and turning in the bed all the time… (M: 6).
Insomnia appeared to be linked to other symptoms such as tiredness and lethargy, or
pregnancy-related worries and demands while feelings of depression were related to
irritability,
…Well I suppose I felt quite low about the problems with my health … (M: 14).
Less commonly reported psychological symptoms included those related to sleep, mood
disturbance, emotional affect, motivation, cognition and coping ability. One unexpected
result was that a mere three men reported anxiety each within one of the trimesters of
pregnancy only.
Symptoms were managed by men themselves and/or by those whom they consulted. In
addition to visiting their doctors six men initiated self-management of their physical
symptoms, four of whom sought advice or treatment remedies from their local high street
pharmacy. One Chinese participant initiated his own dietary remedy which appeared to
be in keeping with his cultural beliefs,
…My appetite was very bad and it was very important to have hot food
to make the dampness go away… (M: 9).
Men only requested help in relation to their physical but not psychological symptoms.
The people consulted were health professionals (general practitioners (GP) and/or
dentists), one complimentary therapist (Chinese Herbalist) and one church minister. A
total of eleven men consulted their GPs during the first and third trimesters for symptoms
such as stomach pains, painful micturition, episodic fainting and respiratory problems
and their dentists for toothache (n-3). Participants perceived that their GPs took their
symptoms seriously, as indicated by the thorough assessment and the number and type of
25
investigations performed. Assessment included physical examinations, blood or/or urine
tests, blood pressure monitoring, computerised tomography (CT) scan and
electroencephalography (EEG) to check brain activity. Management strategies included
medical advice, referral to a counsellor and prescriptions, mainly in the form of
analgesics. In each case no underlying pathology for symptoms was found and hence no
definitive diagnosis made. One participant illustrates the idiopathic nature of his
symptom of episodic fainting despite a multitude of investigations,
…He did an examination and a blood test and referred me to the hospital for a number of
other tests. I had some done on my head, for one of these
I had a scan of my brain but when the results came back they were all
clear and my doctor seemed quite puzzled… (M: 14).
For men who had dental examinations a similar trend was evident causing one participant
to temporarily doubt the reality of his symptom,
…I had a lot of pain in one of my back teeth. I thought it was the one
where I had a filling so I went to my dentist and she told me that
my tooth was OK and did not need any work doing on it. When this
happened I begun to think I was imagining everything but I know I
didn’t imagine it and I was very frustrated that no one thought that
anything was wrong with me except myself…(M: 5).
In relation to the time course of symptom development, the onset of physical symptoms
was mainly in the first trimester of pregnancy. Many of these symptoms temporarily
disappeared in the second trimester and re-emerged again in the third trimester often with
greater intensity. The symptoms seemed to cease temporarily during the second trimester,
26
and permanently at birth or shortly in the postpartum period as reported by eleven men.
One of these confirmed the abrupt cessation of his stomach pains at the moment of his
partner’s delivery,
…It went, literally. The baby had started to come and that was the point
where I had to leave the delivery room and I couldn’t have walked more
than 10 or 15 yards and it just went totally, like someone turning the
light off, the pain just went. I thought it was very strange because it had
just gone, so I went back into the delivery room and I had a son… (M: 13).
However, three other men developed symptoms for the first time in the second trimester.
Two of them acknowledged that tiredness did not permanently cease in the immediate
postpartum period. Psychological symptoms displayed a similar time course of start /
cessation pattern, although a greater number of symptoms either commenced in or
persisted during the second trimester. Some symptoms, e.g., insomnia and early morning
waking, persisted well into the postpartum period.
3. Explanatory Attempts for Symptoms
Men’s attempts in making sense of their symptoms and acquiring meaning were
illustrated in the explanations they provided, sometimes influenced by cultural beliefs and
conventions like religion, alternative medicine or through the enlightenment by health
care professionals in the process. All the men interviewed provided explanations for their
symptoms referring to them individually and generally. Some men revealed insights into
the contextual meaning of their symptoms, as did their partners,
…Well the stomach pains were like aching especially in the
mornings. There was me and Marcel comforting each other
27
about our tummy pains and you know what she said to me
one time, ‘which one of us is pregnant you or me’?…(M:4).
Men also reflected on the onset of their symptoms and acknowledged these as coinciding
with their partners’ pregnancy. In one case a participant made a comparison between the
periods before and during pregnancy in assessing the onset of his symptoms,
…Yes I had a lot of things wrong with me then. I just
couldn’t understand what was happening to me at the time
I mean I had none of these problems before and then they
all seem to come at once during my wife’s pregnancy…(M: 5).
Other men acknowledged their symptoms arose as a consequence of the worries and
concerns which the pregnancy generated and in some instances being “in sympathy” with
their partners. Men perceived that symptoms such as food cravings, abdominal pains and
insomnia, arose because their partners had also experienced them,
…She was a devil at night because she she’s be turning in the
bed all the time so I didn’t get much sleep myself either…(M: 6).
In other cases male partners drew analogies between their abdominal pains with those of
their pregnant partners during the pregnancy and labour. In doing so one participant
attempted to make sense of this symptom by comparing its intensity with that of his
partner and attributing its transfer from her to him,
…I think I was in more pain than she was. It seemed like my pain
was worse. It was almost as if she was transferring the pain on
to me that sort of transferral thing you get sometimes. It was
very much like that because she was in pain, her contractions
were fairly strong but she couldn’t push and as that was happening
28
my stomach pain was building up and up and getting worse and
worse… (M: 13)
On another occasion a participant resorted to his religious beliefs to explain the meaning
of his symptoms. He subsequently attempted to verify his spiritual perceptions with his
church minister, who subsequently prayed for him and his partner,
…I have often tried very hard to think why all these things happened to
me. When I look back I think that the problems with my health came
about because of the forces of the enemy (Satanic) attacking
us and making me sick. Satan hates Christian families you know!… (M: 4).
Men’s explanations for their symptoms were also influenced by their cultural beliefs and
dietary patterns. For example, a Chinese participant attributed his poor appetite to
ingesting too many “damp foods”. He consulted an herbalist who confirmed the same and
suggested that he should include more “hot or spicy foods” in his diet. On another
occasion an Asian participant explained his indigestion and diarrhoea by eating too many
chillies the evening before.
Causal explanations for physical symptoms were most common where one symptom
gave rise to another. In this context, weight gain was interpreted as resulting from
increased appetite while weight loss occurring from decreased appetite. Symptoms were
also perceived as arising from common viruses and infections such as breathlessness
from colds and stomach pains from a transient viral infection or food poisoning.
Sometimes health professionals shared participant’s explanations for these symptoms but
without confirmatory evidence. However, dentists consistently based their failure to
29
provide explanations for toothache on their dental examinations all of which confirmed
no underlying cause.
While participants did not consult for psychological symptoms they still tried to make
sense of them which they perceived as arising from the financial, physical and emotional
demands of pregnancy as well as concerns about the health of their partner and unborn
baby during gestation. Other participants perceived that psychological symptoms
occurred because of physical ones and seemed preoccupied with their impact on general
health. Feelings of depression, anxiety, preoccupation and irritability were all explained
in this way. Only in one case did a health professional interpret physical symptoms as
having a psychological basis by a suggested referral which appeared to negate the
participant’s experience,
…He said there was nothing else he could do and suggested
that he could arrange for me to see a counsellor. This made me
REALLY angry. It was as if he did not believe that I had all these
problems with my stomach and getting sick…(M: 14).
Six men showed difficulty in their attempts to understand their symptoms, as did the
health professionals they consulted. In these instances men often resorted to supposition
or conjecture in the process,
…As I’ve already said they might have had something to do with
my wife’s pregnancy but I don’t know what exactly… (M: 7).
For some men their symptoms still constituted a sense of “mystery”, “confusion” and
“puzzlement” when considered in hindsight,
30
…I don’t know mate it’s still a mystery to me…(M: 3).
In these cases they continued searching for answers and even sought enlightenment from
the interviewer in doing so,
…Well I’ll tell you now I am baffled by the whole thing, I mean if
you or my doctor couldn’t tell me, who could… (M: 6).
Those GPs who were unable to definitively diagnose or explain symptoms often made
broad or generalised, non-descript diagnostic statements instead such as, “you’re run
down”, “you’re stressed” or “you’re generally under the weather”.
Discussion
Pregnancy triggered a mixed range of emotions for the men in the study especially at the
news of their partners’ conception. Men expecting their first child unsurprisingly
exhibited initial feelings of excitement but others displayed ambivalence, feelings of
shock and reluctance precipitated by an unexpected or unplanned pregnancy. Lewis
(1982) acknowledges this diverse display by proposing that news of the partner’s
pregnancy often evokes a broad range of emotions in men. As the pregnancy progressed
so too did its reality, significance and impact on the conjugal relationship, its physical
and emotional demands, the realisation of prospective parenthood triggered by different
aspects of its care and related health concerns. These unsurprisingly led to a myriad of
different feelings and opposing emotional responses some of which men kept covert from
their partners. Men may have felt that by expressing these openly they would have caused
their partners further distress at a time when they were emotionally labile. Pregnancy-
31
related financial demands generated worries for those men who were unemployed or on
low salaries.
Men’s varied feelings about prospective parenthood, its roles, responsibilities and
demands, were most likely influenced by first-time parenthood (n-8) or previous
parenting experience (n-6). Certainly those who were first-time parents were more
apprehensive and uncertain but whether this made them more susceptible to a transitional
crisis and thereafter the syndrome as psychosocial theories suggest (Jordan 1990; Klein
1991), is unclear. Nevertheless, it was curious that all men displayed known features of
the syndrome despite their parenthood status.
Men did not always feel that antenatal preparation was inclusive for them but one needs
to carefully consider the evidence to determine whether this arose out of choice or fact.
During antenatal classes some felt marginalised because of the attention their partners
received, or felt on the periphery because of what they perceived as a specific gender
focus on women, while others showed a reluctance to participate in them. Exclusion out
of choice probably reflected cultural or traditional expectancies of gender roles and
caused some men to question and curtail their participation accordingly. These feelings of
exclusion for whatever reasons, may have contributed men’s susceptibility to the
syndrome as some psychoanalytical theories suggest (Mayer and Kapfhammer 1993;
Masoni ‘et al.’1994).
32
Men’s feelings to the ultrasound scans were mixed for a variety of reasons but those in
relation to the gender confirmation of the unborn appeared to be the result of cultural
pressures or expectancies. For a number of men ultrasound confirmed the reality of their
baby where previously this was vicarious. The ultrasound scans also unveiled men’s
innermost concerns about the health of the unborn. Indeed, their degree of attachment to
the unborn may have conditionally rested on this confirmation through ultrasound,
although there was no direct evidence for this in the study. Weaver and Cranley (1983)
have acknowledged this as part of the process where men through technological
visualisation attempt to make contact with their unborn child which in itself constitutes a
significant indicator of paternal attachment and involvement. Men’s involvement as well
as the reality of imminent fatherhood was also demonstrated when they attempted to
listen for signs of the unborn baby’s kicking during the period of the woman’s
“quickening”. Since the majority of men demonstrated involvement and varying degrees
of attachment to their unborn these may have been related to the onset of the Couvade
syndrome as Weaver and Cranley (1983) have shown.
Many of the physical symptoms which men experienced were identical to those of the
Couvade syndrome confirmed in a number of investigations (Chalmers and Meyer 1996;
Tsai and Chen 1997; Thomas and Upton, 2000). Men’s stomach pains and vomiting in
particular, commonly compares with those most prominently displayed by pregnant
women. Evidence for their concurrence between both partners seems suggestive of men’s
attunement to, or identification with, their partner’s display of them (Mayer &
Kapfhammer 1993; Magalini & Magalini 1997). Alternatively, men’s vomiting might
33
simply have occurred because of smelling or hearing the sound of their partners vomiting
which caused them do likewise. This is feasible in the first trimester but it would not
explain its persistence in the third when the pregnant woman’s morning sickness ceases.
The finding of a an alternative occurrence of increased and decreased appetite for some
men replicates a similar trend reported by Conner and Denson (1990) and Khanobdee ‘et
al.’ (1993). Some men indicated that their increased appetite was linked to food cravings
while decreased appetite might have arisen because of vomiting and anxiety. The less
commonly reported symptom of abdominal distension especially in the third trimester
coincided with a time when women are most heavily pregnant but weight gain was the
most probable cause. Alternatively, it might have indicated pseudocyesis or “phantom
pregnancy” which includes a progressive swelling of the abdomen and whose presence
has been linked to the Couvade syndrome (Mayer and Kapfhammer 1993; Koić ‘et al.
2004).
The most commonly reported psychological symptom was insomnia which men
explained resulted from worries and anxieties concerning their physical symptoms and
the pregnancy itself. Its reoccurrence in the third trimester may have been additionally
affected by their partner’s nocturnal restlessness due to being heavily pregnant at that
time. Feelings of depression are difficult to compare or contrast with other work given
the dearth of literature on antenatal paternal depression. However, there was some
evidence to suggest that the number and distress of men’s physical symptoms were the
cause. Few men reported anxiety which was surprising as this finding contrasts with other
studies confirming its prominence and relationship with the syndrome (Strickland 1987;
34
Brown, 1988). Overall, the physical and psychological symptoms which men experienced
closely identified with those of the Couvade syndrome reported in the literature. In
addition, their presence across a heterogeneous and culturally diverse but rather small
sample was confirmed.
Consultation and accounts of symptom management were partially influenced by socio-
cultural and religious beliefs. The fact that many men consulted their G.P.’s suggests that
they perceived their physical symptoms as serious and/or distressing. The fact that none
consulted for psychological symptoms does not mean that they were perceived less so but
most likely reflected reticence to admit them because of social or cultural taboos. The
timing of consultations mainly in the first and third trimesters confirmed similar trends
for those of the Couvade syndrome in the Lipkin and Lamb (1982) study. The failure to
specifically diagnose or show a physiological basis for physical symptoms is consistent
with the defining criteria of the syndrome identified in other studies (Klein, 1991; Mason
and Elwood 1995). Their onset and cessation periods demonstrate the same (Trethowan
and Conlon 1965; Clinton, 1987). However, the persistence of sleeping problems and
tiredness for some men into the postpartum was unsurprising given the likelihood of the
newborn baby’s nocturnal crying.
The findings show that male partner’s attempts to explain and provide meanings for their
symptoms were influenced by lay, cultural and religious beliefs which have not been
considered in other studies. A number of men possessed contextual insights concerning
the relationship of their symptoms to pregnancy or made attempts to understand them in
35
this way. Men’s inability to explain their symptoms and those whom they consulted
likewise confirms the widely acknowledged idiopathic nature of the Couvade syndrome
(Klein 1991).
Limitations
The main limitations of the study were its small sample size and generalisibility of
findings given the unique nature of the data. Men may have reported more symptoms
because they volunteered for the study while those less commonly reported may simply
have arisen within one of the sample’s sub-groups. Demographic influences such as
culture, social class and reproductive history on symptom reporting were likely to be
influential and in some cases may have led to underreporting. Selective recall of
distressing symptoms is also likely to have affected reporting, a common methodological
problem in symptom reporting research, acknowledged by Pennebaker (1982). The
study’s results are compared with literature on the Couvade syndrome some of which is
dated for reasons mentioned earlier. The interpretations of the findings, which at times
may be speculative, also uses supporting evidence confirming the syndrome in these men.
The nature, time course, consultation outcomes and explanations for symptoms compare
favourably with those documented for the Couvade syndrome and its criteria, but others
might cast doubt on this, implicating men’s normal responses to pregnancy instead.
Conclusion
This was the first phase of a three-part study exploring pregnancy-related symptoms of
the Couvade syndrome among a highly heterogeneous but small group of men within the
36
U.K. Using an inductive analytic approach, the findings of the study demonstrated men’s
mixed display of emotional responses to pregnancy and different aspects of their
involvement within it. Men identified a range of physical and psychological symptoms
including their reality, intensity, duration and cessation many of which closely resembled
those of the Couvade syndrome. Patterns of men’s consultation were influenced by socio-
cultural factors and religious beliefs. Men’s accounts of how symptoms were managed
confirmed that health professionals treated them seriously but failed to definitely
diagnose or find a pathological basis for them as confirmed in previous reports of the
syndrome. Explanatory attempts for symptoms revealed that some men had contextual
insights into their relationship with pregnancy while others resorted to lay, cultural and
religious beliefs in making sense of them. There were those who experienced difficulties
in explaining them and resorted to supposition or conjecture in the process. Health
professionals showed similar difficulties.
From a theoretical standpoint the feelings that men experienced in response to and during
pregnancy highlights their emotional vulnerability during this period. The event of
pregnancy signals many changes in men’s lives some of which are perceived
apprehensively. Health professions need to be mindful of the socio-cultural and
emotional contexts of antenatal care for male partners where they may be confronted with
the reality of prospective fatherhood including concerns about its roles and
responsibilities and gender of the unborn. If men’s emotions are overlooked in antenatal
care this might contribute to or exacerbate somatic symptoms as suggested by
psychoanalytic and psychosocial theories. Men’s active involvement in the pregnancy
37
does not necessarily serve as a protective factor but may make them equally susceptible
to those less involved. Expectant men’s physical and psychological health needs need to
be addressed in current antenatal care provision. A greater awareness of the syndrome is
warranted given its physical and emotional consequences not only for the man but also
his pregnant partner. Future attempts to understand, explain and manage the syndrome
may be best served if socio-cultural and psychological contexts are considered as they
have in this study. Future clinical interventions should aim toward increasing men’s
understanding of the transitory nature of symptoms and their spontaneous disappearance
despite their distress.
38
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