THE IMPACT OF FATHERHOOD ON MEN’S HEALTH AND DEVELOPMENT
Milton Kotelchuck, PhD, MPH
Harvard Medical School/MGH Fatherhood Project
This chapter, the second of a pair of related chapters, provides a broad overview, and new conceptualization, about the various ways in which fatherhood influences the health and development of men. [The first chapter explored the impact of father’s health on reproductive and infant health and development (Kotelchuck, 2019)]. Together these two deeply inter-related chapters endeavor to illuminate the here-to-fore under appreciated topic of men’s/father’s importance and necessary active involvement in the reproductive/perinatal health and health care period, including for his own health anddevelopment.
As noted in the previous Chapter, the traditional focus of my own MCH field (and closely aligned Obstetric, Pediatrics and Nursing fields) has been on the mother’s health and behavior and its impact on reproductive and infant health and development outcomes. Reproductive health and early parenting has been perceived as primarily, if not exclusively, the mother’s responsibility and her cultural domain; and to a significant extent, fathers and men have been excluded. Not surprisingly, as a result, the impact of fatherhood on men’s health and mental health, especially in the perinatal period, has not been the subject of much inquiry.
First, this chapter, for men/fathers, models and builds upon the current women’s preconception health perspectives in the MCH field, which simultaneously addresses the impact of the mother’s pregnancy/perinatal health on both infant’s health outcomes and on mother’s own life time health – an intergenerational approach that respects the integrity and health of both mothers and infants simultaneously, without valuing one’s life above the other (Wise 2005). These paired chapters adopt this same dual orientation; they explore both the father’s health contributions to infant health (in the previous chapter) and the impact of fatherhood on men’s own health – a virtually new topic in the MCH literature – in this chapter.
Second, this chapter attempts to create a new conceptual framework that can organize and document the multiple pathways by which perinatal fatherhood impacts on men’s own health and development. By comparison to the previous chapter, there is an even more limited and scattered set of research (and popular culture references) on this second theme; it is a very under-explored topic.
Third, this chapter, like the prior chapter, will also explore the perinatal roots of the impact of fatherhood on men’s health and development, or if not even earlier. Fatherhood research here-to-fore has primarily been supported by the large, well established developmental psychology literature demonstrating the positive impacts of fathers’ involvement on multiple facets of child development and family relationships (e.g. Yogman and Garfield, 2017; Lamb 1975, 2000; Yogman and Eppel, 2019). This chapter aims to more explicitly expand the understanding of men’s life course development, impact and responsibilities, as fathers, into earlier temporal periods before delivery.
Fourth, several of this chapter’s conceptual themes about the health impacts of fatherhood build upon similar themes from an earlier preconception health and fatherhood paper, especially paternal generativity and men’s primary health care needs (Kotelchuck and Lu, 2018). This chapter however moves beyond that essay’s more limited reproductive health time frame, explores additional new evolving paternal reproductive health themes, and separates the reproductive health impacts on infants from those on fathers. This chapter adopts a very broad holistic approach to men’s health – blending mental, physical, genetic, and social health dimensions -into a single comprehensive fatherhood framework.
Fifth, as noted in the initial associated chapter, this chapter’s focus on fatherhood and men’s health themes does not emerge in an ahistorical vacuum, but is linked to, and hopefully contributes to, numerous ongoing political and professional movements. In particular, this chapter is partially embedded in the larger evolving social and gender equity debates over roles and opportunities for women and men in society, especially given that many aspects of parenthood are socially determine and that fatherhood is transitioning from a traditional distant patriarchy model to a newer one based on greater parental equity and paternal engagement. The major economic, social, and child care work place transformations associated with the increasingly large numbers of women who have now entered into the paid labor market is undoubtedly hastening this conversation. This chapter also builds upon the IOM/NASEM-inspired multigenerational life-course movement to foster effective parenting and parenting health, but now expanded to explicitly include fathers (NASEM, 2019). And finally, this Chapter derives in part from the emerging men’s health movement, and emphasizes new reproductive/fatherhood health dimensions to that movement.
Sixth, as before, it is hoped that in articulating the multiple domains of fatherhood’s impact on men’s health and development, it will spur and guide more effective targeted father-oriented reproductive health interventions and policies, encouraging father’s earlier involvement in the perinatal health period, strengthening what they bring to and take from their fatherhood experiences, and improving their subsequent health and development throughout their life course. That is, to move this chapter’s conceptual research synthesis on this emerging fatherhood topic from theory to programmatic and policy action; to provide better guidance for further research, and to enhance the political will and advocacy for greater paternal perinatal involvement.
This chapter specifically provides the scientific evidence base for the impact of fatherhood on men’s health and development – that in turn should lead to healthier infants, families and communities.
THE IMPACT OF FATHERHOOD ON MEN’S HEALTH AND DEVELOPMENT
There are multiple pathways through which fatherhood and its associated experiences could impact men’s health and development during the perinatal and early parenting periods and over his life course. This Chapter will note and briefly explore six distinct pathways. These pathways, in turn, directly and indirectly influence reproductive and infant health and development, two sets of deeply inter-related topics. Specifically,
- Men’s physical health status during the perinatal period
- Impact of Fatherhood on Men’s physical health: Changes in men’s physical health during the perinatal period
- Impact of Fatherhood on Men’s Mental Health/Stress: Changes in men’s mental health/stress during the perinatal period
- Impact of Fatherhood on Men’s Social well-being: Changes in men’s social well-being/ SDOH
- Men’s Improved Capacity for Parenthood and Fatherhood: Psychological maturation of paternal generativity
- Men’s Life Course Development as Fathers. Life Course transformations in fatherhood
- Men’s physical health status during pregnancy and early parenthood.
Perhaps not surprisingly, in the United States, given men’s generally sub-optimal health status and health care utilization, men’s physical health status during perinatal period reveals substantial health problems and potential opportunities for their improvement.
Ascertaining men’s health status on a population-basis during their prime reproductive years has been methodologically challenging, and possibly here-to-fore of limited reproductive health interest. Although some broad longitudinal epidemiologic data exists for men of childbearing ages, they are their not usually stratified by parenting status; the NHANES survey, for example, appears to have no publications describing father’s health. Yet health status may differ for men between pre- and post-fatherhood years. In general though, fathers initially should be healthier than non-fathers, as men with a wide variety of health issues are less likely to achieve successful fertility (CDC 2019; Frey et al 2008).
Choiriyyah et al (2015) examined the 2006-2010 US National Survey of Family Growth, which suggested that 60% of men aged 15-44 were in need of preconception healthcare; 56% were overweight or obese; 58% binge drank in the last year; and 21% had high STI risk. Pre-pregnancy overweight and obesity is a more pervasive problem for men than for women (53% vs. 29%) (Edvarson et al 2013), which takes on added importance since men’s obesity is an independent predictor of childhood obesity (Freeman et al 2012). One might assume that fathers in the perinatal period would continue to still have a similar set of broad health risks. Smoking rates are highest among men during childbearing years; ~30% of men aged 20-24 and ~25 % of men aged 25-34 smoked in Canada (Canadian Tobacco Use Monitoring survey 2006).
MGH Obstetric Prenatal Fatherhood studies (See Chapter by Levy and Kotelchuck, 2019) reinforce some of the above pre-conception physical [and later mental] health findings: ~75% of men were overweight (25% obese), reflecting their self-reported high sedentary, low physical activity and extensive media usage levels; plus ~14% of men noted signs of infertility or delayed fertility.
Men are well known for their lesser use of health services than women, even adjusting for women’s reproductive health services usage (Bertakis et al 2000; Smith et al 2006). Perhaps due to their own social construction of masculinity, men differentially ignore screening and preventive health care and delay help seeking for symptoms (Smith et al 2006; Mahalik et al 2003). Yet the opportunity for care exists, as most men (~70%) in the US would appear to receive primary health care annually (Choiriyyah et al 2015; Levy and Kotelchuck 2019). However, too many receive no preconception health care at those visits; Choiriyyah et al (2015) reported very limited receipt of STD/HIV testing (<20 %) or counseling (<11 %) services.
These limited, one-time, self-reported assessments of men’s/father’s health during the preconception and antenatal periods suggest that there is much room for improvement in men’s own health status and health care utilization. Similar to women, the perinatal period could be an opportune time to address men’s health overall. There remains great need for more creative secondary epidemiological studies of men’s overall health status during his prime reproductive years, and specifically stratified by fatherhood status.
• Changes in Men’s Physical Health during Pregnancy/ perinatal Health period
Pregnancy and early parenthood are associated with multiple changes in men’s physical health status.
Changes in paternal weight–Fatherhood, on a population basis, is associated with increased weight and BMI compared to comparable aged men who are not fathers. Using the American Changing Lives panel data, Umberson et al (2011), showed that fathers have more accelerated weight gain throughout their life course and weigh ~14 pounds more than non-parental males. Garfield et al (2016), using the National Longitudinal Study of Adolescent to Adult Health (ADD Health) data base, documented that the transition to fatherhood was association with an additional weight gain of 3.5-4.5 pounds more for residential fathers than for non-residential fathers or non-fathers. These paternal weight gains set the stage for their greater obesity morbidity throughout their lives (Umberson et al 2011; Saxbe et al 2018).
Moreover, popular literature has noted and commented extensively on the “Dad Bod” or “preg-MAN-cy weight”; i.e., weight gain among antenatal and new fathers. One widely cited informal British study estimates an 11 pound weight gain (Mary 2014), and speculates that fathers partake in their partner’s binge eating and finish up the left over foods, eat out more in restaurants and increase eating to respond to their own stress. Saxbe et al (2018) more formally assessed 7 possible behavioral, hormonal, psychological and partner mechanisms for the increased weight gain in fathers; the likely sources included decreased sleep, less exercise, less testosterone, more stress and partner effects (shared diets).
Specifically, the transition to fatherhood is associated with significant sleep disturbance and disruption (e.g. partnered men with young children sleep about 13 fewer minutes per night or approximately 80 fewer hours per year than single, childless men (Burgard & Ailshire, 2013)) and reduced time available for leisure and exercise (e.g. 5 hours/week decrease in physical activity with the first child and an additional 3.5 hours/week with a subsequent child (Hull et al., 2010)). Parenting-associated physical activity declines were more pronounced for men than for women. Fatherhood was not associated with changes in men’s diet (Saxbe et al 2018).
In many cultures, fathers experience “Couvade Syndrome” or “Sympathetic Pregnancy”, physical and psychological symptoms and behaviors that mimic the expectant mother’s during her pregnancy and post-partum period (Kazmierczak et al 2013). Physical symptoms can include insomnia, nausea, headaches, toothaches and abdominal pain, as well as increased stress and weight gain. Couvade is not a recognized (DSM5) mental illness or (ICD10) disease. Thus, the extent of couvade syndrome prevalence has been difficult to ascertain, and estimates (11-65%) vary widely depending on the symptoms and populations being assessed (Masoni et al 1994). Symptoms seem most common in the first and third trimesters, and most go away after the baby is born (Brennan et al 2007). The sources of couvade in men remain elusive, with extensive psychological and psychosomatic theorizing (e.g., empathetic responses to pregnancy; compensatory or even competitive symptoms; or shared hormonal changes (Kazmierczak et al 2013)). Traditionally called ‘primitive couvade”, it was associated with anthropologic studies of male pregnancy rituals, in which men refrained or partook in special pregnancy/birthing rituals thought to impact the spirit of the developing child. Couvade symptoms are associated with increased paternal health service utilization, though they are often un-recognized or associated with the partner’s pregnancy status (Lipkin and Lamb, 1982).
Men’s biologic adaption to fatherhood: hormonal and brain structure transformation– While it has long been noted that women’s hormones change or adapt as a function of motherhood (Fleming et al 1997; Edelstein et al 2013), there is also now growing evidence of men’s biologic adaptation to fatherhood (Edelstein et al 2013; Gettler et al 2011; Grebe et al 2019). Testosterone, which is important to male sexuality, mating and aggression, declines as men prepare to assume enhanced parental roles. Testosterone levels are lower among fathers than non-fathers (Grebbe et al 2019), decline over the course of pregnancy (Edelstein et al 2013), and further decrease among fathers who more actively provide infant care compared to men who provide little or no care (Grebe et al 2019), especially for the youngest infants (Gettler et al 2011). The synchronous decline in paternal and partner’s testosterone levels during pregnancy is associated with greater post-partum relationship investment (Saxbe et al 2017). The internal regulation of testosterone levels presents a biologic conflict between men’s mating and men’s caretaking characteristics in the ~6% of animal species where men participate in parenting activities; paternal caretaking increases the Darwinian survival of their children. Other paternal hormones: estradiol (Edelstein et al 2013); oxytocin (Gordon et l 2010); and prolactin (Hashemian et al 2016) also increase in men over the course of pregnancy and early post-partum period; and all are associated with increased child care, nurturing behaviors and engagement in both men and women.
The term “Dad Brain” has also gained prominence in the popular literature, perhaps inadvertently reflecting the new beginning exploration and documentation of the plasticity of men’s brain structure associated with parenting. There is growing evidence that fathers and mothers neurally process infant stimuli in similar manner (e.g. global parent caregiving neural network) (Abraham et al 2014). Paternal brain plasticity is associated with greater paternal caretaking involvement, especially in the social–cognitive pathway network (e.g. amygdala-superior temporal sulcus brain connectivity), which in part allows men to better infer infant mental states from their behavior (Abraham et al 2014). Fathers, like most mothers, can recognize and pick out their own infant’s crying, but only if they spend extensive time daily with them (Gutafsson et al 2013). Moreover, within the first four months postpartum, there are changes in the volume of gray matter in the regions of the paternal brain involved in motivation and decision-making (Kim et al 2013), further suggesting plasticity in father’s brain after becoming a parent. Additionally, there is an extensive and growing animal literature showing paternal brain structure changes with active fatherhood, especially among prairie volves (Rollin and Hascaro 2017)
Paternal longevity– And finally and positively, fathers live longer than men without children, even controlling for marital status (Modig et al 2017; Grundy and Kravdal 2008; Keizer et al 2011), similar to that reported for mothers. The longevity impact of parenthood is stronger for men than women (e.g. 2.0 versus 1.5 years greater life expectancy gap at 60 years of age (Modig et al 2017)), and for 2 or 3 children versus none (Grundy and Kravdal 2008; Keizer et al 2011). When older, fatherhood could be a source of deep emotional satisfaction, as well as companionship and non-isolation. This longevity finding may perhaps also reflect a confounding of healthier men have children being played out over their life courses.
Father’s physical health is much more profoundly affected by early fatherhood than perhaps most of the existing popular and professional literature here-to-fore would likely have assumed. During the perinatal period and likely beyond, father’s minds and bodies, like the mother’s, adapt biologically to their new parenting roles – perhaps preparing them for the physical and mental stresses, joys and requirements of parenthood. The impact of fatherhood on men’s physical health reinforces the need to insure physically healthy fathers and to attend to their changing physical health needs during the perinatal period and beyond, encouraging both greater health promotion and utilization of paternal reproductive and primary health services. Basic research on this topic is just beginning, as interest in father’s health in the perinatal period is increasing.
• Impact of Fatherhood on Men’s Mental Health/Stress.
Pregnancy and the onset of parenthood is a time of substantial mental health transition for men – as it is for women/mothers (Singley and Edwards 2015). There is greater awareness and recognition of fatherhood’s impact on men’s mental health than on his physical health, perhaps due to the growing awareness of maternal perinatal depression on women’s health and the increasing calls to similarly address paternal mental health by the family sociology, clinical psychology and nurse-midwifery communities [REF]]. Men’s mental health responses to fatherhood are very salient during pregnancy and early parenthood – both as sources of stress and of growth and love.
Pregnancy/parenthood, especially for first time fathers, is an unknown and unfamiliar event, out of men’s normal control (e.g. Baldwin et al 2018); a source of multiple potential perinatal stresses include changing relationship with the mother, added financial obligations, and concerns over ability to be a competent parent (Coleman & Karraker, 1998; Singley and Edwards 2015). Moreover, given limitations in sex/parenting education in schools and in gender role experiences developmentally, most men have limited or no understanding about pregnancy biology, perinatal health services or practical parenting skills; and they often feel helpless and lack knowledge about what to expect or do as they enter into fatherhood. And postnatally, fathers/men must confront additional new concerns about the physical well-being of the mother and baby, breastfeeding and bonding, restrictions and frustrations of new fatherhood roles, and more work-family balance conflicts; plus sleep deprivation and childcare logistics. Moreover, men often lack of social/peer support (beyond their partner) to help them adjust to their new fatherhood roles.
Men, especially first time fathers, are further challenged to creating a new internal fatherhood identity for themselves (Baldwin et al 2018); and there may be deeper conflicting fatherhood gender role identity expectations at play (Singley and Edwards, 2015). Many men today had been raised in an era of more traditional male gender roles and now are being confronted with expectations for greater engagement with their infants and more equity in caretaking, and perhaps even perceiving these roles as feminine or weak: a fatherhood generation gap. Overall, a potent brew of men’s mental health challenges in the perinatal period.
Paternal Stress, Anxiety and Depression:
Given the formidable parental role transformations associated with fatherhood, not surprisingly, there are numerous reports of substantial elevated paternal stress associated with pregnancy and early parenthood. A review article by Philpott et al 2017 found 18 studies on paternal stress in the antenatal period, with XX% rates of elevated paternal stress reported. They report that paternal stress increases continuously throughout antenatal period, peaks at birth and then declines afterwards. The principle factors identified that contribute to paternal stress included negative feelings about the pregnancy, role restrictions related to becoming a father, fear of childbirth, and feelings of incompetence related to infant care. Higher stress levels negatively impact father’s health and mental health, contributing to increased anxiety, depression, psychological distress and fatigue (Philpott et al 2017).
The MGH Obstetric Prenatal Fatherhood studies (Levy and Kotelchuck 2019) reinforce these observations antenatally; ~56% men endorsed the observation that pregnancy is associated with high levels of paternal stress; with concerns focused on financial issues (44%), ability to care for the baby (29%), less time for self (20%), changing relationship with mother (15%), and not repeating their father’s mistakes (14%). Further, 35% of men reported not having any place or person to go to for fatherhood support, which likely further added to their stress symptoms.
Paternal Anxiety: Substantial clinical anxiety disorders are found among men during the perinatal period. A recent systematic review by Leach et al (2016) reported the prevalence rates of anxiety disorders in men ranged between 4.1%–16.0% during the prenatal period and 2.4%–18.0% during the postnatal period. [As compared to a 13.0% rate in general population of men (McLean et al 2011)]. Anxiety disorders increase steadily throughout antenatal period and then decline after birth (Philpott et al 2019). Factors contributing to anxiety disorders included lower income levels, less co-parent support, fewer social supports, work-family conflict, partner’s anxiety and depression, and paternal anxiety history during a previous birth. Higher anxiety levels contribute to paternal stress, depression, fatigue and lower self-efficacy (Philpott et al 2019). The few clinical trials to reduce paternal anxiety, to date, have all been successful (Philpott et al 2019).
Paternal depression: There are numerous reports of elevated levels of depression associated with fatherhood. A meta-analysis of the prevalence of men’s depression in the perinatal period (Paulson and Bazemore 2010) showed higher rates of paternal depression (10.4%) than in similar aged men in the general population (4.8% over 12 month period) (Kessler et al 2003). Garfield et al 2014, using the ADD Health data, documented that new father’s were 1.68 times more likely to be depressed compared to comparable aged men without children, and that resident father’s depression symptoms increased from before pregnancy through the pregnancy and beyond.
Paulson and Brazemore (2010) analysis documented substantial rates of paternal depression throughout the pregnancy; 11% in first and second trimester and 12% in third trimester; and then varied rates throughout the first year post-partum: 8% at 1-3 months, peaking at 26% at 3-6 months, and then 9% from 6-12 months. When stratified by country, paternal depression rates are higher in the US (14.1%) than in the rest of the developed world (perhaps associated with our lack of childcare support and paid parental leave in the US (Glass et al 2016)). Paternal depression is strongly correlated (r= ~.30) with maternal depression (Ramchanandi et al 2008; Paulson and Bazemore, 2010), though prevalence rates are consistently higher for mothers. In the MGH Obstetric Prenatal Fatherhood studies, 26% of the antenatal fatherhood sample endorsed at least one of the two PHQ-2 depression screener symptoms, with 8% reporting more severe/frequent symptoms (Levy and Kotelchuck 2019). A wide variety of risk factors have been linked to paternal depression: prior mental health/depression experiences, changing paternal hormones, lack of social supports, maternal depression, and poor relationship satisfaction (Singley and Edwards 2015; Gemayal et 2018).
Paternal post-partum depression: Increasingly, there has been a heightened awareness that post-partum depression (PPD) is not restricted to only women, that men also experience PPD (Kim and Swain 2007; Ramchanandi et al 2008; Singley and Edwards 2015). Paternal PPD is increasingly recognized as a chronic condition, with the10% prevalence rate from the Paulson and Brazemore (2010) meta-analysis widely quoted. Ramchanandani et al 2008, using the Avon Longitudinal study (ALSPAC) found the highest predictors of paternal PPD to be high prenatal anxiety, high prenatal depression, and a history of severe depression; findings consistent with a more recent meta-analysis (Gemayel et al 2018).
Other paternal mental health disorders: Beyond depression, there is only a very thin literature on other men’s perinatal mood and anxiety disorders. Singley & Edwards (2015) posited rates of 0-4.7% for post-partum PTSD; 4.4-9.7% for post-partum anxiety disorders; 3.4% 3rd trimester and 1.8% post-partum OCD rates; and they noted that among depressed fathers, 42% also experienced co-morbid manic episodes. It is hard to assess if these prevalence rates are primarily attributable to the new pregnancy, as comparable non-pregnancy data generally doesn’t exist.
Behavioral and externalizing mental health impacts of fatherhood. The mental health consequences of fatherhood aren’t only manifested internally, but also through externalizing behaviors. Men often express their depression, stress or anxiety through “self-medicating” drinking, over-eating, interpersonal anger, or physical/residential absence. IPV, for example, is known to be markedly elevated after conception and again after delivery (Nannini et al 2011). Singley & Edwards (2015) note that many new fathers retreat to over-working at their employment (the traditional model of fathers as providers) to withdraw more from the family/infant involvement and associated stresses. Theoretically, many negative paternal perinatal health behaviors can be interpreted as mental health linked. In general, however, there is little or no systematic, population-based, longitudinal research on the changes in men’s mental health and health-related behaviors attributable to the pregnancy and post-partum period.
Positive mental health impacts of fatherhood. While fatherhood is a time of much emotional stress, it is also a time of deep joy, happiness, and satisfaction for most men. While most qualitative studies of men’s mental health during the perinatal period acknowledge positive emotional responses, few have explored them in detail. Baldwin et al’s (2018) systematic review concluded “Fathers who were involved with their child and bonded with them over time found the experience to be rewarding. Those who recognized the need for change, adjusted better to the new role, especially when they worked together with their partners.” Satisfaction resulted from achieving mastery, confidence and pleasure over the reality of dealing with a newborn, becoming a competent father, and doing it in a constructive way with one’s partner. [[The family planning literature also explores men’s happiness with the pregnancy conception as its core outcome measure]] Moreover, some men, like many women, improve their mental health-influenced health behaviors as they move into their new parental roles. In the Fragile Families and Child Well Being Study, for example, among low-income urban fathers, fatherhood was associated with, more healthy behaviors and decreased substance use (Garfield et al 2010). In the subsequent section (1.5), the (positive) impact of fatherhood on men’s psychological development and generativity is further explored.
Perinatal/infant specific sources of paternal depression. The post-partum mental health impact of fatherhood has bi-directional roots; it can be and is influenced by the infant’s health and behavior characteristics, not just his own psychological responses to the pregnancy and new paternal and family roles.
Fatherhood and pregnancy loss: While there is a robust literature on the impact of fetal loss on mothers’ mental health, the equivalent literature for fathers is very limited; a summary review by Due et al (2017) identified only 29 articles on paternal responses to fetal loss versus 3868 articles on maternal responses. They concluded that fathers primarily feel the need to be supporters of their partners, and that they receive less recognition for their own responses to the loss, feeling overlooked and marginalized. Like the mothers, fathers experience a loss of parental identity and of parental hopes and dreams for their deceased infant, though less enduring levels of negative emotions. I am unaware of any informational brochures about fetal loss specifically directed towards fathers.
Fatherhood and prematurity. Fathers of premature or LBW infants are more likely than mothers to experience post-partum depressive symptoms; this takes on added significance since paternal depression is also an independent predictor of subsequent child development (Cheng et al 2017). Interventions to address parental mental health needs (including depression) of infants in NICUs are increasing, but only some are directed at both parents (Garfield et al 2014).
In sum, the perinatal period is a time of significant mental health transition for fathers, especially first time fathers, as they address the multiple new challenges of fatherhood. Fatherhood is associated with both substantially elevated levels of stress, anxiety and depression, as well as joy, pride and emotional maturation. Interest in men’s perinatal mental health derives heavily from the increasing appreciation of maternal depression and its impact on reproductive and child outcomes. Paternal mental health has been the main initial focus of interest in the exploration of the impact of fatherhood on men’s health. Moreover, men’s perinatal mental health represents an important cultural crossover theme, necessarily dealing with such broad issues as contemporary masculinity, family gender roles, as well as the realities of parenthood. Only recently has there begun to be any even slight professional recognition of men’s own mental health needs in the perinatal period, and virtually no mental health services are directed at them. Fathers’ mental health, however, in turn, has a major impact on maternal reproductive and parenting heath and on infant health and development.
The impact of fatherhood on men’s social well-being. The social impacts of fatherhood
Fatherhood doesn’t only influence men’s physical and mental health, but also his social well-being; that is, his social capacities and characteristics, as an employee, as a family and community member, and as an economic provider. Different professional communities have focused on different aspects of fatherhood’s impact on men’s social well-being.
Fathers as better and more stressed employees.
There is a growing recognition within the business communities, especially their human resources professionals, that more family (and father) friendly workplaces are associated with higher productivity and profits than traditional work places [possibly through more motivated, loyal and skilled employees, with less staff turn over and burn out (Ladge 2019). [As women increasingly enter the paid labor force, family child caretaking /employment conflicts have gained greater salience, and in a more gender equity awareness era, their impact on fathers as employees is being examined more.]
First, in general, parenthood, including fatherhood, is associated with positive contributions to their work/employment capacities. Father’s psychological development and maturity make them better employees; the skills of parenthood carry over into the work place – better self-managerial skills, enhanced time management, focus, patience, responsibility, and leadership (Ladge 2019). Fathers at work are perceived as more kind, compassionate and mature (Humbred et al 2015), and builders of social connections and bonds (Ladge 2019). Among men with the similar skill levels and CV’s, fathers are more likely to be offered a position (Correl et al 2007). In some employment situations fatherhood is associated with a “fatherhood premium” (i.e., increased wages to be able to support their families) (Correl et al 2007).
Second, fatherhood has the potential to add to men’s work-family stress. Fathers often experience added conflicts about the competing demands of work and family life [which may not have existed pre-fatherhood] (Baldwin 2018). In general, men increase work hours post-delivery, perhaps to meet in part the growing family economic needs (Budig 2014). Work challenges may heighten the conflicting internal/cultural views over nature of fatherhood; men sense of masculinity is closely linked to employment and occupational career (Neuman and Mennser, 2017). Younger men trying to achieve the new dual caring father/successful breadwinner fatherhood ideal feel more pressured by the conflicting roles (Harrington 201X). [NYT article] Involved fathers who work in family friendly environments have greater job satisfaction, less work-family conflict, and less likely to think about quitting their job, though they also may have weaker career identity (Ladge 2016).
Third, paternal paid leave is an opportunity for men’s psychological and practical growth as fathers (i.e., paternal generativity). Fathers who take 2 or more weeks of leave are more involved in direct childcare at 9 months (Nepomnyaschy and Waldfogel 2007). While the value of paternal leaves for their partner’s health and wealth has been studied (Rossin-Slater 2019; Bartel et al 2015), its benefits for the father are less well researched. Short or no paternal newborn leaves, in general, are associated with difficulties establishing sense of paternal identity, paternal confidence and competence in caregiving, and more work-family stress (Harrington et al 2014).
Subsequent chapters in this book (e.g. Chapters X, Y, and Z) examine the challenges that working new fathers experience in trying to achieve a healthier work life balance, and the employment and social welfare practices and policies that could help reduce the social developmental burdens.
Fathers as better family and community members assuming societal parental roles and responsibilities
Fatherhood, for most men, increases their sense family responsibility and commitment, and draws them into family life ever more tightly. Men, encouraged by cultural and religious norms, their own sense of paternal generativity, and governmental policy, generally adopted the social welfare expectations of fatherhood [no matter what their perspectives are on the nature of fatherhood] This topic is often presented from a negative father-absent family, deadbeat dads, perspective; but will be consider here from a more positive fatherhood social well-being prospective. [
The first social responsibility of men as fathers is the acknowledgement of his paternity. Historically, acknowledgement of paternity was related to infant legitimacy and inheritance, and was closely tied to the marital status of the father and mother. [Despite increases in births to unmarried parents (~40 % of US births, with substantially higher rates in younger, Black and Latinx populations (Birth 2018)), the vast majority of men embrace and acknowledge their paternity, and the rate appears to be increasing]. [In the US, for each birth to an unmarried mother, there is a legally mandated effort to establish an “Acknowledgement of Paternity” (AOP).] Almond and Rossin-Slater (2013) documented that over nearly 15 years in Michigan, rates of acknowledgement of paternity among unmarried mothers rose substantially, from 26% to 62%, and among all births lack of paternal acknowledgement declined from 25% to 15%, despite stabilized rates of unmarried birth (~35%). Birth outcomes (and maternal social characteristics) among unmarried but acknowledged paternity births were intermediate between births to married women and to women unmarried without paternity acknowledgement (Almond and Rossin-Slater 2013.)
A second social welfare responsibility or social impact of fatherhood is the decision to reside with and support their families (financially and emotionally) during the perinatal period and beyond. The vast majority of men do accept this social responsibility, (though obviously a partnered decision); but over time the extent of their financially, emotionally and child engaged involvement does decline. In Great Britain in 2013, 15% of families are unmarried at birth, rising to 23% by one year of age. In the US, paternal involvement decreases as children age (REF/Census 2017); among fragile families with unmarried couples at birth, 50% are still living together at the child’s first birthday, and 63% are separated by the child’s fifth birthday (McLanahan, 20XX). Married marital status, per se, conveys social and developmental benefits for the father and his children (McLanahan 20XX), though it is increasingly a marker of higher social classes (Census 2017). Men’s continued presence in the family can be viewed, in part, as a bi-directional impact of fatherhood on men’s social well-being –a behavioral response to stresses and joys of parenthood and his relationship with the child’s mother.
Even among non-residential fathers, fatherhood can serve as a source of engagement (social well being) for themselves and their children. In the Fragile Families Study, the majority of non-resident fathers at one year of age saw their children, provided informal and in-kind support (McLanahan et al 2019), and fatherhood gave meaning to their lives (Garfield et al 2010). Both governmental and community-based fatherhood programs are trying to encourage more positive non-residential father emotional and financial involvement with their children (e.g., Yogman and Eppel, 2019).
The impact of fatherhood on men’s social well-being, especially for poor and minority men, is heavily influenced by federal and state government social welfare policies that both encourage and discourage paternal involvement with their families –perhaps reflecting the ambivalence towards low income fathers who do not conform to the traditional roles of fatherhood, as well as their partners (mothers). Many US social benefits are structure to penalize or limit benefits (in housing, food, welfare) for single men and non-residential non-married fathers. Aggressive federal and state child support enforcement agency efforts, while perhaps enhancing mother’s income, often decrease father’s family involvement, especially for very poor men with limited education, skills, and employment opportunities, and past incarceration (Tollestrup 2018), by further burdening them with high child support interest rates, asset seizures and possible incarceration (Boggess et al 2014). Older welfare and Medicaid eligibility regulations restricted support to mothers without residential male partners, which are still widely and incorrectly believed to be true today. The federal Healthy Marriage and Responsible Fatherhood Initiative is theoretically a more positive motivational and skill-based approach to engage fathers with their families {and perhaps also diminish government expenditures on poor families}, though its initial evaluations are quite mixed (Knox et al 2011); [its limited programs may be insufficient to overcome the structural realities for poor men in the US]. Other countries provide more positive supports for the social welfare consequences of fatherhood – such as family allowances.
Fatherhood increases/decreases men’s own social or economic welfare
The impact of fatherhood on men’s own social and economic welfare, his lived SDOH, has only just begun to emerge as a topic in the MCH [reproductive health] community with its growing attention to SDOH and the father’s importance in its determination (Kotelchuck 2019). This topic, however, has historically drawn the attention of economists and social welfare policy analysts focused on gender pay equity and women’s employment/wages over her life course (e.g. Hodges and Budig 2014).
Fatherhood, in part, allows for the potential transformation in men’s own social and economic well-being. Fathers are eligible for societal benefits that favor families relative to single or married men without children; the latter are often restricted from (or last to receive) societal social welfare benefits, a positive discrimination in favor of fathers. There are specific father-targeted programs that non-fathers are not eligible for, such as paid paternity leave or family allowances. Tax benefits, in general, also favor families (and therefore fathers with children), such as child tax credits, child and dependent care tax credits and EITC (for employed families). Whether these benefits are merely compensation for the extra costs of child rearing or improve father’s lived SDOH can be debated, but they do increase father’s social and economic well being.
Economists have documented a fatherhood pay bonus. In adjusted analyses, fathers earn 6% more salary than non-fathers (Hodges 2014). Moreover, the wage gaps between employed men and women increases substantially for parenthood; non-parent women earn 93% of non-parent men’s salary, whereas, mothers earn only 76% of father’s wages (Hodges 2014); plus further reinforcing social disparities, the wage gap is even greater for low-income fathers and mothers. This paternal pay bonus may be due in part to higher salaries for married men (who are perceived as better workers), an increase in men’s work hours to compensate for increased family financial needs, and a positive selection bias for father’s employment (Correll et al 2007). However, as noted previously, fatherhood can also limit or harm men’s social and financial status, especially for low income, non-residential fathers,
In sum, fatherhood impacts on men’s own social well-being – in employment, family commitment and social and economic resources. Fathers (relative to non-fathers) may socially benefit from their fatherhood status, though the evidence for the poorest fathers is less clear. While health professionals have not explored this theme, as father’s health has not heretofore been an important focus, other business, social welfare/government policy, and economic professionals have focused on different aspects of this theme. The business community, in particular, has a critical role in shaping the family-related employment benefits and experiences of fatherhood. The impact of fatherhood on men’s social well-being may be culturally specific, and depend on the unique policies and practices within each country. The United States, in particular, has weak and often punitive social welfare policies that substantially impact on fathers, especially low income fathers. The reproductive health community must be cognizant of the changing social realities for new fathers and their families.
Men’s Psychological Development/Growth of Paternal Generativity: Men’s Improved Capacity for Parenthood and Fatherhood
Fatherhood can be a major influence on men’s own adult psychological development and maturation, especially during his initial pregnancy experiences and early parenthood. This transformation represents one of most important health impacts of fatherhood. Virtually all men can biologically procreate children, but it takes more than just sperm to become a father. Having children is a powerful biologic urge that can profoundly affect men and women’s psychological maturation. Many fathers, similar to most mothers, go through substantial psychological transformations and growth during the perinatal period. Fatherhood can be viewed as an adult psychological developmental stage of life.
In reviews of men’s psychological transition to fatherhood studies, Genesoni and Tallandini (2009) found pregnancy to be the most demanding period for the father’s psychological reorganization of self, and labor and birth to be the most emotional moments. Baldwin et al (2018) characterized some of the most salient features of the positive psychological transition into their new fatherhood identity: “Becoming a father gave men a new identity, which made them feel like they were fulfilling their role as men, with a recognition of changed priorities and responsibility and expanded vision; however they worried about being a good father and getting it right…. Fathers who were involved with their child and bonded with them over time found the experience to be rewarding. Those who recognized the need for change, adjusted better to the new role, especially when they worked together with their partners.”
Beyond the predominantly qualitative literature, describing men’s psychological transition to fatherhood, this developmental concept is perhaps best noted in a series of movies and television shows that captures the profound paternal transformation of men as a result of parenthood (e.g., Kramer vs. Kramer; Mrs. Doubtfire; Three Men and a Baby; Marriage Story). This transition has been well documented in the popular media, in religious communities, and occasionally in the professional literature.
As fathers are increasingly attending their partner’s birth, there is a growing literature on its transformative effects on his psychological development (Johansson et al 2015). His presence allows him to share the joy and miracle of birth, to be supportive of his partner, to be involved in the well-being of his new family, and possibly to demonstrate his assumption of greater paternal-maternal equity in childcare responsibilities. But his roles and responsibilities in the delivery room are often unclear, he may not know what is happening obstetrically or feel anxious and uncomfortable (Shibli-Kometiani and Maria 2012). The responsiveness of the delivery staff towards the accompanying fathers is quite mixed, and they are not always treated in a supportive way (e.g., “not patient, not visitor” (Steen et al 2012); [Pol and Koh 2014]). Yet for many men delivery is deeply emotional and psychological transformative moment (Genesoni and Talladini, 2009). And only now are efforts beginning to be undertaken to enhance father’s contributions and engagement during delivery to foster a more positive family-forming health event and to support his own psychological development as a father (Pol and Koh 2014; Johansson et al 2015).
There are numerous different terms used to describe this developmental transformation in men from biological procreation to responsible fatherhood. For many, it is commonly and best discussed in terms of life fulfillment or even of religious or spiritual goals; e.g., “Fatherhood as the highest calling in life”. I prefer to use the psychological term of “generativity”, to describe this transformation; it is a term coined by Dr. Erik Erikson (1973) and defined as “establishing and guiding the next generation, with a capacity for love and sense of optimism about humanity”, (i.e. successfully nurturing the next generation). Hawkins and Dollohite (1997) and Hawkins et al (1997) have expanded on this concept and coined the term “generative fathering”, a perspective on fathering rooted in the ethical obligations for fathers to meet the needs of the next generation. They conceptualize fathering as generative work rather than as a social role embedded in a changing socio-historical context from which both fathers and children benefit and grow. Singley and Edwards (2015) interpret the term generative fathering to describe the type of parenting used by fathers who respond readily and consistently to their child’s development needs over time, a key element of Erik Erikson’s adult development rooted in broadening the sense of self to include the next generation. The generative fathering perspective highlights a clear way that men can focus their instinct to protect and to provide their children in a strengths-based way – by being involved and responsive to their children’s needs even from their earliest (antenatal) age. Men themselves are the agents of their own psychological transformation.
This fatherhood psychological transition is not universal. Generative or responsible fathers don’t just happen but reflect a gradual transformative process; men can be helped along in this transformation. [Beyond the previously noted federal Healthy Marriage and Responsible Fatherhood Initiative, which primary emphasizes men’s social roles in child development/engagement and family financial support and less his own psychological transformation and motivations,] Community-based, non-profit social service and welfare, advocacy and religious groups have taken the initiative to emphasize and develop men and fatherhood responsibility and generativity programs. These efforts have primarily emerged within the Black community’s parenting, men’s, and religious organizations (e.g. Concerned Black Men of America, Colorlines, etc.), backed up by national fatherhood resource and training organizations (e.g. The Fatherhood Project, the National Fatherhood Initiative, Mr. Dad, etc.). These non-governmental organizations, which are not restricted to the narrower federal political perspectives on family structure and marriage, try to emphasize the father’s own social and psychological health and development, and the need for his moral, spiritual, and psychological engagement with his children and family, as well as his financial support. These organizations explicitly counter the debilitating myths of Black men’s non-involvement with their children.
The Healthy Start Initiative was the first and currently is the principal U.S. national MCH perinatal program to actively incorporate a positive mandate to address Fatherhood and Male Engagement (REF/HRSA HSI; Harris 2018). Its Dads Matter Initiative, with its Dads and Diamonds are Forever curriculum, and an annual Fatherhood Conference, emphasizes father’s “inclusion, involvement, investment and integration” across the life course, enhancing men’s sense of value to himself, his children, the mothers of his children and his community (i.e. generative fathering) (Harris 2018). Several other MCH programs serving low income communities, such as MIECHV/home visiting, Head Start and WIC programs, also have begun to target and address father’s needs, though not as systematically as Healthy Start (Davidson et al 2018).
Even for the most marginalized fathers, creating and nurturing life is perceived as one of the most meaningful statement about one’s presence on earth and contribution to life (Edin and Nelson 2013). In the Fragile Families and Child Well Being Study, fatherhood was associated with being present for their child’s future (Garfield et al 2010). From a parallel perspective, Roubinov et al (2015; 2017) describe “familism” in Latino (Chicano) communities as a father’s deep ethical and cultural commitment to nurturing their children and family, even if also deeply imbued with a “machismo” social roles perspective. And the Black women’s reproductive justice movements are now beginning to recognize the importance of economic and reproductive justice for their poor Black male partners as well {REF}.
The perinatal period for many men, as for women, is also a period of marked openness for behavioral, social and health changes (Mahalik et al 2003). Fatherhood imperatives can trump masculine stereotypes. Mental health, relational, and fathering skills can be taught (MGH Obstetric Prenatal Fatherhood Project; Tollestrup 2018; Knox et al 2011). The transition from traditional fatherhood expectations to a more equitable childcare taking partnership may also free fathers from other gendered sex role stereotypes that harm their psychological capacities to experience and express emotions and health needs, and treat their partners more respectfully. Father’s developmental transitions during the perinatal period however are not generally recognized or appreciated by most reproductive and primary health care professionals (Pol and Kuh 2014), and they are not usually given the institutional support for their psychological development as generative fathers – a few fatherhood books and two week post-partum leave not withstanding. Moreover, from a life-course perspective, the earlier the paternal involvement with the responsibilities and joys of parenthood, the stronger and longer lasting the subsequent child and family attachments (Redshaw and Henderson 2013) and the more positive his own adult psychological growth and development as a generative father. Much more research is needed to understand what facilitates the growth of men’s paternal generativity, and even how to measure it
Similar to women, men’s adult psychological developmental as a more generative parent is one of most important positive mental health impacts of pregnancy and early fatherhood, especially for the first time fathers. Paternal generativity doesn’t just happen. While the momentum for paternal generativity must ultimately come from and be empowered by each man himself, all MCH and father-involving programs must consciously engage with and support his developmental maturation. Culturally and professionally, we must create the paternal expectations and opportunities, beyond the federal emphasis on his financial and marital responsibilities, to help men celebrate the joys and deep satisfactions of fatherhood. Most fathers make the successful adult psychological transition to generative parenting and are happy to have accomplished that transition.
Men’s Life Course Development as Fathers.
Generative responsible fathers don’t just happen, but reflect a gradual longitudinal developmental process that has its roots long prior to the pregnancy conception and continues long after the delivery; and it can be helped and hindered all along the way. Paternal generativity is both personal and intergenerational. The perinatal period, the focus of this essay, is one of its principle sensitive periods of accelerated growth.
Drs. Kotelchuck and Lu (2018) in their publication on men and preconception health graphically highlight several key conceptual features about the growth of men’s paternal generativity over the life course. To quote from that article “First, as with women’s reproductive life course, it [this graph] encourages us to view men’s health and development longitudinally, recognizing that the impact of his health and generativity transcends the moment of pregnancy conception, and appreciate the intergenerational continuity and the bi-directionality of men’s health. Father’s reproductive health and generativity is not a fixed; each stage of life/health builds on both prior and current life/health experiences and evolves over the life course (Fine and Kotelchuck, 2010). This new MCH fatherhood life course graphic acknowledges that some men have more negative or positive life experiences (prior and currently); that the root causes of men’s reproductive health and paternal generativity reflects both the negative and positive social determinants influencing his health –including his adverse childhood and adolescent experiences, sexual health education and socialization, current and past poverty, employment, and environmental and occupational exposures, etc. The men’s/father’s MCH life course model thus reflects both a resiliency and a deficit perspective. One’s reproductive potential is not immutable. We can and must help build boy’s and men’s resiliency to achieve both the biology and paternal generativity of fatherhood, and thereby optimize both their own and their children’s health [and development]. The men’s reproductive health life course graphic also reminds us that there are multiple times and places to intervene to enhance (or diminish) men’s health and paternal generativity.”
And although this graph focuses on men’s individual generativity, efforts to encourage his shared responsibility for healthy parenthood and for equitable parental childcare and involvement must start earlier than conception with his shared responsibility for sexuality and family planning. Further, men’s development as generative fathers must also necessarily address his pre-fatherhood adolescent social and gender norms, perhaps beginning with parenting, sexuality and gender-role training programs in schools. The preconception time period for paternal generativity must be pushed backwards in developmental ontological time.
Additionally, men’s paternal generativity is not a simple linear age trend, but is embedded within our larger human biologic development. The roots of men’s intergenerational and epigenetic generativity starts before birth, and has at least two special sensitive periods of growth: puberty and the initial antenatal and early postnatal transition to fatherhood. The latter is perhaps the most sensitive transformational life course period for men’s psychosocial development and maturation as a father (Genesoni and Tallandini (2009)); it may perhaps also reflect a new paternal biological sensitive period due to his changing perinatal hormones and brain structure. The experiences and health consequences of fatherhood are then further filtered through and modified by the men’s pre-existing life course health that he bring into the pregnancy/perinatal period, similar to that of pregnant women.
The developmental roots of paternal generativity are not restricted only to the perinatal period but build off of men’s prior life course health and experiences. Paternal generativity can even be viewed as an intergenerational and epigenetic phenomenon, building off of prior generations and building towards future generations. The perinatal period is a critical sensitive period for paternal generativity transformation. The momentum for paternal generativity, for fatherhood, with all its benefits and stresses, must be empowered by each man himself; but it is embedded in the larger developmental world in which his reproductive potential grows and thrives or is stunted and unachieved. A fatherhood life course perspective allows us to see that there are multiple places and time points in which positive and negative experiences and interventions can help influence men’s paternal generativity. Paternal generativity is not fixed, but malleable. Paternal generativity, the essence of fatherhood, is critical for the health and development of his infant, his family and himself; it is shaped over his life course.
Discussion: The significance of this chapter
Fatherhood profoundly impacts men’s health and development. It impacts his physical, mental and social health, and his sense of paternal generativity, both immediately and over his life course. These, in turn, impact his infant’s, partner’s, and family’s health. Indeed, fatherhood can be viewed as a risk or resiliency factor for men’s subsequent health across his life course. The focus on men’s changing health as a consequence of fatherhood is an important new perspective for the MCH reproductive health field, which has historically focused on the mother and her health.
This chapter on the impact of fatherhood on men’s health is one of a pair of inter-related chapters that parallel for fathers the dual approach of the current women’s preconception health framework, which simultaneously addresses the impact of the mother’s perinatal health both on the infant’s health outcomes and on the mother’s own subsequent lifetime health. Both topics are critical and intractably bound. Father’s health is similarly a bi-directional, intertwined and inter-generational topic.
To date, there is only a very limited and scattered MCH perinatal fatherhood health literature, especially exploring the impacts of fatherhood on men’s health and development. [And despite a growing recognition that parent’s health is a key contributor for ensuring and optimizing infant and child health (NASEM, 2016, 2019); it’s bi-directional inverse, that infant and child health impact parent’s health, remains a relatively understudied subject, especially concerning fathers.] No broad, systematic effort, as far as I know, has explored this topic across the full range of its potential impacts.
This chapter reflects an effort to create a new broad encompassing conceptual framework to understand and organize the multiple potential pathways by which fatherhood influences men’s health and development. It moves beyond a generic overall assertion that fatherhood impacts men’s health to emphasize six distinct conceptual pathways -men’s pre-existing health, his perinatal changed physical, mental, and social health and development, his generativity, and his life-course experiences. The six specific pathways are written to try to isolate and better articulate them, but many of them likely overlap and are synergistic. Hopefully, these six pathways will provide a useful organizing framework to guide future research, practice and policy on father’s perinatal and life course health and development. A couple of themes merit further comment.
First, this essay, in particular, emphasized and explored the impact of fatherhood on men’s psychological maturation into more generative, healthy and engaged fathers, a much less well-articulated fatherhood topic, especially antenatally. The psychological development of men as fathers has not been a focus of professional MCH or prenatal health services – though a large popular ‘Advice for new Dads” literature exists, which may at times touch on this theme. The psychological empowerment of fathers requires, in part, that our current health service systems (and the men themselves) overcome culturally derived, internalized sexist assumptions about men’s supposedly limited roles and needs during pregnancy and early childhood, and explicitly attend to their developmental needs. The concept of generativity, or generative fathering, adds an internal motivational and moral dimension to men’s ongoing psychological transformation in becoming fathers, a sense of paternal agency.
Second, this essay also tries to illuminate the topic of the impact of fatherhood on men’s social health and well-being. This pathway may be a difficult to appreciate for reproductive health clinicians, if they even focusing on the health of fathers, as it links more broadly to the larger SDOH roles of men in families; and that men’s SDOH/social well-being characteristics may partially transform with parenthood is yet another step removed from clinicians usual reproductive health concerns. Yet social welfare policies for single-parent families, paternal work-family balance and father’s employment/incomes directly affect the health and mental health of mothers and children (and their fathers). Moreover, these topics (and the achievement of gender equity across multiple domains of life) directly and necessarily link the clinical health professions to similar concerns and interventions in other business, social and government policy, and economics professions (all represented at this multi-professional Fatherhood conference). This essay represents an initial discussion about this important but still emerging paternal social well-being pathway.
Third, this chapter further builds upon the growing recognition that fathers are a key vector for the social well-being/SDOH of their families (Kotelchuck 2018). Beyond simply considering the father’s presence and economic contributions to the family as a direct fixed risk factor for reproductive and child health, his own social well-being/SDOH can further indirectly modulate the father’s own mental, physical, social and generative health, and therefore its impact on his family. In addition to the objective added financial burdens of parenthood, father’s historical life course SDOH experiences (childhood poverty, childhood ACES, etc.) may increase his initial physical and mental health vulnerabilities to the challenges of fatherhood; his current SDOH/social-well being realities (such as being poor) may further exacerbate his reactions to the new psychological stresses of parenthood; and his capacity to actively engage with his child (and perhaps challenge traditional gender roles expectations) may be undercut by inflexible employment work schedules and leave practices, especially among lower income fathers. And while paternal generativity is not principally determined by social class, but poverty does make it harder for some men. Fathers however do have some personal agency in determining their own and family’s social well-being, and often feel strongly about that responsibility; but ultimately, father’s social well-being is not simply a personal responsibility. His social class, race and employment are not fully paternal “reproductive health” choices, but primarily reflect the accident of his birth. The father’s historical and current SDOH/social well-being can diminish his positive health responses to fatherhood and limit his fullest and healthiest participation in the perinatal period and beyond.
Fourth, the positive or negative impact of fatherhood on men’s physical, mental, social or generative health and development is not ordained, and often is both. This essay (reflecting the limited existing literature) predominantly noted negative paternal physical health and especially mental health/stress impacts of fatherhood. Where appropriate, those were balanced with more positive health experiences (e.g. mental health focus on joy, happiness and satisfaction; adult psychological maturation/generative fatherhood; enhanced employee characteristics; greater primary care motivations, etc.). The impact of fatherhood on men’s mental health, to date, is the most widely examined topic; and policies and programs to prevent or mitigate father absence are the most widespread targeted fatherhood interventions with federal/state governmental support.
Fifth, this chapter documents that the impact of fatherhood on men’s health begins before delivery (i.e., the perinatal roots of men’s/father’s health); it strongly reinforces the initial chapter’s parallel efforts to push the time frame for the impact of men’s health on reproductive and infant health and development back into the antenatal period. This essay emphasizes not merely the perinatal impact of fatherhood on men’s health, but an even longer life course perspective on father’s health. The health of men and their paternal generative characteristics start early, long before conception; though like for women, the experiences during the perinatal and early parenthood period seem to be a biologically sensitive period of impact. Moreover, the preconception health and social well-being that men bring into the pregnancy not only directly influences the mother’s and infant’s health, but also indirectly modulates the men’s fatherhood experiences and his health consequences. Fatherhood/paternal generativity must be conceptualized across the life course; fatherhood is not simply a sperm and post-partum parenting. A life course perspective additionally suggests that there are multiple places, timing and synergy for potential paternal interventions to enhance men’s/father’s health.
Sixth, much of this essay’s discussion and the MCH research literature are written as if fathers are a relatively homogeneous group. This is clearly not true. Different subgroups of fathers may experience the health and developmental challenges of fatherhood differently, based on their own historical and current life course experiences, both personal and social – whether the groups of fathers are characterized by first time/experienced status, race/ethnicity, socio-economic status, disability status, planned/unplanned pregnancies, residential status, or any other unique fatherhood groupings (including teenage, incarcerated or military fathers). The extensive documentation of the risk factors (often fatherhood sub-groups) associated with men’s mental health responses to fatherhood further demonstrates men’s heterogeneous experiences. In particular, some fatherhood advocates have emphasized the often negative and unintended consequences of public social welfare and clinical policies on low income and minority fathers, especially non-residential fathers; they have tried to counter the myths of Deadbeat Dads and encourage all fathers, irrespective of residency status, to actively engage in their children’s lives, for the children and themselves (Yogman and Eppel, 2019; Garfield and Yogman 2017; Bond et al 2015). Future research, practice and policy papers examining the impact of fatherhood on men’s health should perhaps stratify their major findings by important fatherhood sub-groups.
Seventh, this chapter [and the prior chapter] disputes the prevailing view that mothers and their health/well-being alone are principally responsible for positive reproductive and infant outcomes and that they are the only or primary ones affected by parenthood. If men assume, or are allowed, to participate in the joys and responsibilities of reproductive and infant care; they will become more generative fathers, and in turn could help free up women and men from overly prescribed gendered parental roles. This chapter, while a self-contained and innovative MCH theme, is also inspired by and hopefully contributes to the larger social gender equity movement; to the growing men’s health movement; and to the cultural efforts to rebalance the traditional maternal/paternal parental role expectations.
Hopefully, this chapter and the prior chapter have demonstrated that a focus on father’s health should be a more formal and important perinatal health research, practice and policy topic. These chapters begin to open up a new positive empirical developmental science policy rationale to support greater and earlier paternal perinatal involvement: for enhanced reproductive and infant health and for men’s own health, based on an ever-stronger empirical and theoretical rationale.
Clearly the core public health action message of this essay is that there should be greater paternal involvement in the perinatal period, in order to improve reproductive and infant health and development, and father’s own health and development. This essay should add to the momentum for more targeted and effective father-oriented perinatal health interventions and policies to enhance the impact of fatherhood on men’s health and development. Many of this Chapter’s themes call out for doable ameliorative actions and interventions. The fatherhood life course perspective suggests that there are many places and times to intervene to enhance father’s health throughout his life course. The six pathways presented in substantial detail in this Chapter[our current Scientific Knowledge Base] should provide a useful organizing framework.Without an over-arching framework to synthesize the growing fatherhood literature, it is ultimately difficult to develop effective targeted fatherhood interventions (Programmatic/Policy Social Strategies) or to create more effective and scientifically justified fatherhood advocacy efforts (Political Will) for their implementations (Richmond and Kotelchuck, 1984). To improve father’s health, I believe requires three inter-related and synergistic domains of interventions: paternal clinical health care; social welfare and employment policies; and men’s agency initiatives–but sadly, there is little professional recognition of men’s unique perinatal health needs – and even less health, social welfare or generativity/agency services directed at them. [The three sets of inter-related intervention domains are discussed fully in the next section.]
Fatherhood is a life course developmental achievement. Fatherhood is not a singular point in the life course– but a profoundly human experience that occurs over time and across generations. The developmental trajectory of fatherhood starts long before conception and impacts him and his children and family throughout their lives, long after conception and inter-generationally.
Men’s fatherhood health interventions/practices recommendations.
While this essay primarily focused on describing and organizing the current knowledge base about the impact of fatherhood on men’s health, many of its theme’s call out for ameliorative actions and interventions to address the added challenges of fatherhood on men’s health and hopefully ensure a more optimal healthy life course development of men (and enhanced paternal generativity) – which should also improve the health and development of his children and family.
While the intent of this chapter was not to present a menu of the needed preventative or ameliorative interventions and policies to ensure greater healthy paternal involvement in the perinatal period [for himself and his children, family and community]; I do wish to briefly highlight three broad distinct sets of interventions needed to address the six [multi-sectorial] pathways identified in this Chapter: namely, paternal health care services reform; improved paternal social welfare and employment policy; and enhanced paternal sense of agency (or generativity) initiatives. No single domain alone can influence fathers’ health and development; all sectors must be synergistically involved.
MCH life course Paternal Reproductive Health Policy Triangle/Model
Optional, as visualized in the graph above, modeled on/derived from the MCH Life Course Reproductive Health Policy triangle discussed in (Kotelchuck and Lu 2017,)
Health Service reforms;
Clinically addressing and enhancing men’s health before, during, after pregnancy and while parenting in early childhood is an obvious critical intervention pathway to respond to the [changing] health impacts of fatherhood, both prevention and treatment. Currently, however, reproductive health clinical services don’t generally address men’s perinatal health issues, nor do men’s primary health care health, address his new developmental health needs as a father.
In the previous Chapter, four ways that existing clinical perinatal, primary care and mental health services could be enhanced were briefly discuss – both to improve men’s current perinatal physical and mental health status and to be aware of and begin to address the changes in men’s health and development due to his new fatherhood status and its associated experiences: 1) Reorient reproductive health services to be more father/family inclusive; 2) Expanded men’s (or family) health care during existing mother-focused reproductive and pediatric services; 3) Encourage more and more enhanced approaches to reproductive primary health care for men; and 4) Increased mental health care for men in the perinatal period. These four health care interventions apply as importantly to address this Chapter’s health consequences of fatherhood as to the existing father’s health impacts on reproductive and infant health in the prior chapter.
The longitudinal roots of men’s health and fatherhood generativity would suggest that preconception health care (both pediatric and adolescent health care) would be important loci for preventive clinical services and enhanced gender role guidance. The MCH life course perspective emphasizes the continuity and impact on men’s health across the perinatal time frame.
Ultimately however, paternal health is only marginally impacted by the health/medical care sector; it is also more deeply influenced directly and indirectly by SDOH and employment policies directed at men – which are briefly discussed next and in other Chapters of this book.
Fatherhood Social Welfare and Employment (SDOH) Policy Recommendations:
There are a wide range of social welfare and employment policies and practices that could positively modulate the impact of fatherhood on men’s health. This domain mostly reflects the traditional population-based [non-clinical/medical model] public health/social policy approaches to enhance the health and social welfare of men and their families. Specifically,
Social welfare/SDOH and employment policies could directly enhance the current financial status and social realities (SDOH) of poor and working class fathers; through 1) poverty reduction/income enhancement initiatives such as family/childhood allowances, higher minimum wages, enhanced jobs opportunities, and family tax benefits (EITC, child credits); 2) Enhanced family friendly employment practices/policies that reduce the inevitable work family balance stresses of parenthood, and enhance paternal availability for needed family engagement and bonding (paid family leave, flex time); 3) social welfare/public health policies that address the derivative consequences of poverty –environmental injustice, poorer housing, poorer access to nutritious foods, poor education quality and opportunities – and other broad community development initiatives; 4) social justice reforms, including criminal justice and child support enforcement, that diminish the ability of low income fathers to be active, present and financially supportive of their families; and 5) health care/health insurance policies (especially in the US) that insure access to high quality clinical care and equitable distribution of needed health care resources (such as ACA/Obamacare; Medicaid). Unfortunately, given our highly partisan political divide in the US today, most national social welfare and economic policies will be contested.
A second set of social welfare/SDOH and employment policies could attempt to mitigate the historical life-course social realities (SDOH) of currently poor and working class children; and therefore change the [subsequent] pre-existing health and mental health characteristics that they will bring to their future fatherhood experiences and that will modulates their adaptive or maladaptive responses to fatherhood’s health challenges. Most of the prior adult –oriented social policy initiatives would apply equally well to the current generation of children. For example: 1) family income policy enhancements would additionally need to address the unjust/unequal socio-economic and racism-based eligibility criteria (for mothers and fathers) that too often fosters childhood poverty and ACES; or 5) health care policy issues would also have to particularly address improved access to child and adolescent pediatric health care (including mental and behavioral health care); or new 6) educational reform policies that would increase access to Pre-K education, quality schools and higher education, influencing future employment/career opportunities, as well as increase access to more scientific sexuality and gender education and contraceptive availability]. The impact of these proposed social welfare (and educational) policies will only have positive influences on children’s (and especially boys for this essay) early life health and well-being, who will grow into the next generation of fathers
Social welfare and employment policies are (directly and indirectly) important to fatherhood health, though they are not usually characterized as (paternal) perinatal public health programs – but should be. (See later chapters for more detailed discussion of social and employment practices that influence more adaptive fatherhood experiences)
Paternal sense of health agency.
Beyond health services and social/employment policy interventions, the father’s own volition, his agency, his sense of responsibility can play an important role in modulating how fatherhood impacts on men’s health and development. Interventions in this third domain empower men during the perinatal period to be able to assume greater direct responsibility for their child’s, family’s and own health, and to more effectively handle the new health challenges that arise from fatherhood. That is, to help fathers consciously effectuate their own initiatives and activities to enhance reproductive and infant outcomes and to enhance their own fatherhood health. This domain also encourages fathers to address their own psychological limitations as fathers, such as internalized sexism or internalized male marginality, and to struggle against traditional male/female parental role identity expectations, both of which limit father’s engagement with their children. This domain’s core concept is most closely related to the development of a sense of paternal generativity.
Programmatically, this domain covers a wide range of interventions, an effort to move beyond the traditional medical model vs. public health approaches to addressing health outcomes. They roughly fall in four broad groupings.
1) Interventions to enhance father’s knowledge and skills to deal with his newborn/infant (an increased sense of parental efficacy) – such as perinatal knowledge and skills training; fatherhood information provision; childbirth education classes.
2) Interventions to enhance men’s capacity to address his own sense of fatherhood – such as family planning; male sexuality and sex-role parenting education; and relational skills training; fatherhood support groups
3) Interventions to provide fathers with the tools needed to handle and advance SDOH/social well-being of his family — such as job training; financial empowerment programs; executive functioning training
And 4) Interventions to help father’s directly address and enhance his own paternal health and well-being – such as internalized health promotion/disease prevention capacities; yoga, stress-reduction activities, smoking cessation; resiliency coaching.
And fathers needn’t be alone in addressing these systemic barriers and promoters of perinatal and fatherhood health [healthy fatherhood] Community-based fatherhood programs and support groups are a powerful means to enhance men’s sense of agency or develop paternal generativity (such as Healthy Start fatherhood programs, Black fatherhood empowerment groups, or self-help groups). The sum of individual agency is collective or community agency, the empowerment to demand political (policy and programmatic) actions to address the men’s/father’s needs (e.g. Teitler 2001).
These agency enhancing efforts encompass having the internal psychological skills and external political/cultural supports and skills to be able to respond positively to the health and developmental opportunities and challenges of fatherhood, and to successfully mature into a healthy, competent and engaged father. At the heart of this domain is an enhanced sense of his paternal generativity, a transformation of his consciousness as a responsible, loving parent.
Summary/Conclusion:
Fatherhood directly and substantially impacts men’s physical, mental and social health, and his sense of paternal generativity, which in turn impacts his infant’s, partner’s, and family’s health, both currently and intergenerationally. The systematic exploration of men’s changing health as a consequence of fatherhood is a new focus for the MCH field; though it does parallel a similar evolution in the women’s preconception health field, which focuses both on the mother’s health as a predictor of pregnancy outcomes and now as a consequence of the pregnancy. This Chapter pulls together a here-to-fore scattered fatherhood literature and articulates 6 broad pathways through which fatherhood could potentially positively or negatively impact men’s health and development – [men’s pre-existing health, his perinatal changed physical, mental, and social health, his generativity, and his life-course experiences]. This emerging conceptual framework encompasses the father’s entire life course, but focuses here especially on the perinatal time period, a time frame not usually thought of as impacting on men’s health. Father’s health is bi-directional and intergenerational, synergistically intertwined with reproductive and infant health. Hopefully, this essay provides a firmer scientific knowledge base and rationale to encourage and support new, targeted fatherhood perinatal health programs, policies and research [that encourage men’s early and continuing involvement in the perinatal period]. The goals of enhanced father’s health, like for women’s preconception health, should be to both improve reproductive and infant health outcomes, and also to improve men’s own health across the life course. Together, these should lead to a healthier, more engaged fatherhood for men and for their families and communities.
These aspirations will require a major cultural shift – and this Conference is part of that shift – with necessary changes in health care systems, social policies and employment practices, and society’s/men’s own conceptions of their paternal roles (agency/generativity). This Fatherhood Conference begins to provide some of the emerging science-based evidence and to generate political will (and coordination of cross-sector policy) to ensure the success of enhanced fatherhood efforts. And we can do something about it –Healthy men/fathers help insures healthy children, healthy families, healthy workforce and healthy communities.