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Physical and emotional responses of expectant fathers throughout pregnancy and the early postpartum period
Ini. 1. Nun. Stud., Vol Printed m Great Bnrain
2A, No.
I. pp.
59-68,
1987. 0
002@7489/87 1987 Per~smon
s3.00 + 0.00 Journals Ltd.
Physical and emotional responses of expectant fathers throughout pregnancy and the early postpartum period * JACQUELINE F. CLINTON, Ph.D., RN, FAAN Center for Nursing Research and Evaluation, University of Wisconsin-Milwaukee, Box 413, Milwaukee, 53201, U.S.A.
Abstract-A comparative, repeated measures survey design was used to monitor the physical and emotional health of 81 expectant fathers and 66 non-expectant men over the course of a year at monthly intervals. A total of 877 monthly data collection episodes were completed. Compared to non-expectant men, expectant fathers were found to experience relatively similar patterns of both physical and emotional symptoms throughout the three trimesters of pregnancy. However, expectant fathers’ health was found to differ significantly from that of non-expectant men during the immediate postpartum period with a greater incidence of emotional discomforts as well as total number of symptoms, their duration and perceived seriousness. Included are recommendations for anticipatory health counseling to promote health in expectant fathers.
Compared to the research attention devoted exclusively to the female pregnancy experience, there is a scarcity of data based information about the health of expectant fathers throughout pregnancy and the early postpartum period. Osofsky (1982) argued that the reason for our lack of knowledge about expectant fathers’ health is a tendency to minimize the adjustments of normal males to the pregnancy experience. Yet the transition to fatherhood is a significant developmental event in the lives of men and, as such, should be expected to involve significant and detectable adaptations. The phenomenon of couvade refers to pregnancy related symptoms and behaviors of *This research was supported by a grant from the United States Department of Health and Human Services, Public Health Service, Division of Nursing awarded to the author (No. I ROl NUO0977). 59
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JACQUELINE F. CLINTON
expectant fathers. Anthropologists have documented the ritual form of couvade which appears almost exclusively in pre-industrial societies and consists of special observances and restrictions carried out by expectant fathers. Most commonly, these culturally sanctioned, learned behaviors involve special dress, social confinement, limitations on physical labor, sexual restraint, avoidance of polluting substances, mock labor and postpartum seclusion (Malinowski, 1927; Dawson, 1929; Mead, 1935; Webster, 1942; Read, 1952; Mead and Newton, 1967; Meigs, 1976; Munroe, 1980). Theoretical explanations for ritual couvade include: magico-religious protection for the vulnerable infant and mother; symbolic expression of the close physical and moral bond between father and unborn child; acceptance of a new social status of fatherhood; the claiming of paternity rights and social control over powerful feelings in men in response to birth (Howells, 1971; Munroe et al., 1973; Paige and Paige, 1973; Ginath, 1974; Gurwitt, 1976; Fishbein, 1981). In contrast to the ritual form of couvade, modern couvade or couvade syndrome has been observed primarily in industrial societies around the world and includes a wide array of physical and psychological symptoms experienced by men during their partners’ pregnancies. Altogether, 39 distinct symptoms have been linked to modern couvade in previous research. Symptoms reported include physical discomforts of musculoskeletal muscle and gastrointestinal systems and the skin; as well as behavioral manifestations and a host of indicators of emotional distress (Wapner, 1975; Wilson, 1977; Bittman and Zalk, 1978; Davis, 1978; Gerzi and Berman, 1981; Gabriel, 1982; Bogren, 1983; Brown, 1983). The documented incidence of modern couvade has varied considerably. In Great Britain the incidence has been reported to range from 11% (Trethowan and Conlon, 1965) to over 50% (Dickens and Trethowan, 1971). In North America, the documented prevalence ranges from 22 to 79% (Curtis, 1955; Liebenberg, 1969; Viesti, 1980; Lipkin and Lamb, 1982). Gabriel (1982) reasoned that modern couvade serves a similar function as ritual couvade in that both mark the passage from childless individual to the status of father. It has been observed that in cultures where ritual couvade is not practiced, a significant proportion of men suffer from numerous complaints during expectant fatherhood (Trethowan and Conlon, 1965). There have been only a few studies where symptomatology of expectant fathers was compared to a control group of non-expectant men and the findings are conflicting. Trethowan and Conlon (1965) found three symptoms that distinguished expectant fathers from men whose partners were not pregnant: anorexia, toothache and nausea. However, other investigators found that expectant fathers did not differ at all in symptomatology from non-expectant men (Fordor, 1981; Quill et al., 1984). There are also only a few studies where investigators focused on the couvade experience over time, usually over the course of pregnancy. There is general consensus in three studies that the occurrence of couvade symptoms are distributed in a U-shape curve over the course of pregnancy (Curtis, 1955; Lamb and Lipkin, 1982). That is, couvade symptoms are most prevalent at the end of the first trimester, decline during the second trimester and increase just prior to birth. Purpose and rationale
Critical review of previous studies reveals that couvade is a prevalent, but not well understood, experience of expectant fathers in Western societies. To better understand the developmental experiences of expectant fatherhood, there was a need to execute research
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that: (a) monitors multiple parameters of the expectant fatherhood experience over the entire course of pregnancy and the early postpartum period; (b) includes comparisons of expectant fathers to non-expectant men; and (c) uses a sample drawn from a larger population as opposed to only those individuals seeking treatment. Using the above criteria, this study was part of a larger project designed to expand knowledge of the physical and emotional events associated with expectant fatherhood. The specific aim of the study reported herein was to examine the incidence, duration and perceived seriousness of couvade symptoms experienced by expectant fathers throughout pregnancy and the early postpartum period compared to the same symptoms experienced by men who are not expectant fathers. Method
Design The design of the study was a comparative, repeated measures survey which allowed for: (a) the monitoring of the physical and emotional health of expectant fathers over the entire course of pregnancy and early postpartum period; and (b) comparison of health events of expectant fathers to those of non-expectant men at standardized time points. Data were collected on expectant fathers at lunar month intervals and coded according to expected date of confinement of each subject’s pregnant partner. One postpartum data collection point occurred at 6 weeks post-delivery. Assignment of lunar month codes to repeatedmeasures data collected for non-expectant controls was done in a fashion analogous to the lunar month sequence assigned to their matched expectant fathers. Sample The sample included 147 men residing in a large metropolitan area of the United States. Eighty-one were expectant fathers and 66 were non-expectant men who served as controls.* Participant age ranged from 18 to 44 years old (M for expectant fathers = 29.1, M for non-expectant controls = 30.2). Annual total family income ranged from below poverty level of less than $5000 to over $100,000. Modal income for each study group was $30,000 annually. Ethnic background of the sample included Anglo-European descent (expectant fathers = 91070, non-expectant controls = 94%), Black (expectant fathers = 5%, nonexpectant controls = 4Oro),Asian (expectant fathers = 2%, non-expectant controls = 1Vo) and Native American Indian (expectant fathers = 2%, non-expectant controls = 1%). The two study groups were not significantly different in regard to age (t[145] = 0.79, P = ns), education (t[145] = 79, P = ns), occupation (x’[9] = 2.03, P = ns) or ethnic background ($[9] = 1.03, P = ns). In terms of previous health history, the two study groups were healthy young men free of serious or chronic health conditions with no prior history of prolonged hospitalization for any physical or emotional problems. Setting The study was conducted at the University of Wisconsin-Milwaukee
School of Nursing
*Subject retention is particularly problematic in repeated measures designs that require participation of nearly a year’s period of time. Subjects included in the final analyses were those whose repeated measures data sets included time points in all three trimesters and postpartum. The drop out rate for expectant fathers was 9% compared to 13% for the control group. As anticipated, non-expectant men were not as interested or motivated by the study as expectant fathers. For a detailed exploration of subject retention and other human issues in conducting repeated measures research which evolved from this study see Clinton et 111.(1986).
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in a suite of offices specifically designated for the project which were easily accessible to subjects. A staff of seven registered nurses with graduate preparation collected the data.
Instruments The Expectant Father’s Preliminary Health Interview* contains 194 questions about demographic and cultural background, social history and health events prior to the partner’s pregnancy. For non-expectant control subjects, information was elicited for the time prior to admission to the study. The readability of the Expectant Father’s Preliminary Health Interview was tested and found to be at the 6th grade reading level using the Fry Readability Formula (Fry, 1968). Health-related items included in the Expectant Father’s Preliminary Health Interview were organized into nine conceptual categories: (a) early childhood relationships associated with couvade in previous studies; (b) health problems during past year; (c) health problems during lifetime; (d) symptoms experienced in past year; (e) symptoms experienced during lifetime; (f) physical and social role disabilities experienced in past year; (g) utilization of professional health resources in past year; (h) perceptions of pregnancy planning and convenience; and (i) satisfaction with own health in past year. With the exception of the area of early childhood experiences, all other areas of the Expectant Fathers’Preliminary Health Interview demonstrated sufficient internal consistency estimates ranging a = 0.77 to 0.91, N = 147. Test-retest reliability on a random subsample of 25 subjects ranged from r(23) = 0.88, P = 0.001 to r(23) = 0.94, P = 0.01. Predictive validity testing was conducted on the Preliminary Health Interview with data from a pilot study of 62 subjects prior to the current study. Correlations were found to be in the expected direction and vary in strength. For example, health problems occurring in the past year were positively associated with presence of symptoms of the past year (r[60] = 0.81, P = 0.002) as well as short term disabilities (r[60] = 0.63, P = 0.05), and negatively correlated with satisfaction with own health (r[60] = -0.42, P = 0.05). The Expectant Father’s Monthly Health Diary contains 280 items and was designed to elicit monthly information in eight conceptually related areas: (a) self-perceptions of physical and emotional status; (b) incidence, duration and perceived seriousness of 39 couvade discomforts; (c) perceived effectiveness of self-care actions; (d) professional health utilization; (e) physical and social role disabilities attributed to couvade discomforts; (f) work loss and salary dollar loss attributed to couvade discomforts; (g) affective and behavioral involvement in pregnancy; and (h) perceptions of partner’s difficulty with pregnancy and extent to which respondent felt he was able to help her. The readability of the Expectant Father’s Monthly Health Diary was determined to be at the 6th grade level using the Fry Readability Formula (Fry, 1968). Internal consistency of the Expectant Father’sMonthly Health Znterview was tested and found to be sufficient for each conceptually-related area of the instrument ranging from OL= 0.74 to 0.93, N = 147. Content validity was established for the couvade items which were derived from previous studies. Predictive validity testing was done on data from a pilot study of 62 subjects. Correlations were in the expected direction and varied in strength. For example, how healthy subjects felt emotionally was negatively associated with irritability (r[60] = -0.53, P = O.OOl),nervousness (r[60] = -0.48, P = O.OOl), depression *Completecopies of all instruments used in this study and administration obtained free of charge by writing the author.
can be found in Clinton (1985) or
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(r [60] = - 0.41, P = O.Ol), and inconvenience of pregnancy (r [60] = - 0.30, P = 0.009). Self-assessed physical health status was positively related to other satisfaction with health (r[60] = 0.48, P = 0.001). Men who reported disabilities in carrying out activities of daily living also reported more couvade discomforts (r[60] = 0.62, P = 0.03), emotional instability (r]60] = 0.50, P = 0.001) and a sense of declining physical health (r[60] = 0.61, P = 0.001). Total number of symptom days for expectant fathers corresponded positively with the use of professional health resources (r[60] = 0.61, P = 0.001). The Expectant Father’s Monthly Health Diary was also subjected to external criterion validity testing using the Ireton Personal Inventory (Ireton, 1980) which measures stress and worry and the Jalowiec Coping Scale (Jalowiec and Powers, 1981) which measures stress responses. Using a subsample of 199 subjects, correlations among theoretically linked items in all three instruments were in an expected direction and varied in strength. For example, total symptom days measured with the Eqectmt Father’s Monthly Health Diary corresponded positively to Ireton items of feeling stressed (r[l17] = 0.46, P = O.OOOl), worry about personal habits (r[117] = 0.46, P = O.OOOl), being unhappy (r[l17] = 0.48, P = 0.0001) and easily upset (r[117] = 0.43, P = 0.0001). Sadness measured with the Expectant Father’s Monthly Health Diary was positively associated with Jalowiec items on depression (r[117] = 0.65, P = OOOI),and resignation (r[117] = 0.52, P = 0.05).
Procedure Because of the need to recruit expectant fathers at the earliest possible time during their partners’ pregnancies, recruitment was broad in scope and highly visible to the general public. Recruitment procedures included regular use of the mass media (television, radio and newspapers) and poster announcements distributed throughout the community including industries and health service agencies who have contact with expectant fathers. Informed consent was obtained from all subjects prior to their admission to the study. Initial data collection was completed within 4 days of admission to the study and included the Expectant Father’s Monthly Health Interview. Repeated measures data collection was also begun at the initial interview and then every lunar month until the 6th week postdelivery. To standardize the data collection process, all data collection personnel were given written protocols and training. Each nurse was required to observe a trained data collector prior to collecting data alone. All instruments included a code identifying the data collector so that interviewer bias could be detected and controlled. No significant associations were found between interviewers and subject responses to any items on the instruments used. To control for the possible confounding influence of seasonal influences on dependent variables, data were collected concurrently on both study groups. In addition, the calendar of each interview was coded and entered on all computerized data sets to allow for the evaluation of seasonal variation, if any, using regressional analysis.
Results A total of 877 lunar month interviews were completed with the 147 participants. The study design predicted a total of 1470 repeated measures interviews. However, complete lunar month data sets were not possible to obtain for every subject for several reasons: (a) few expectant father subjects entered the study prior to the first 2 months of their partners’ pregnancies because they were unaware or unsure of pregnancy; (b) some subjects
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Table 1. Distribution of subjects by trimester and group Trimester
Group Expectant fathers Non-expectant controls Total
I 48 38
II
86
III
PP
80
76
50
64
54
38
144
130
88
missed data collection appointments due to busy work schedules and when they returned, pregnancy had progressed to the next lunar month; (c) occasionally, extreme weather conditions, which are notorious in the geographic region where the study was conducted, rendered transportation to the study site nearly impossible. Because complete lunar month data sets were not possible for every subject, data were condensed into trimesters to generate sufficient N for analysis purposes .* These procedures yielded a distribution of subjects as shown on Table 1. Overview Over the 11 months during their participation in the study, the vast majority of expectant fathers (93.7-97.0%) and non-expectant men (92.0-96.6%) reported they experienced at least one symptom in a typical month during each trimester. Very few subjects were symptom free for nearly a year time span. The duration of each couvade symptom was measured in days and ranged from less than 1 day to 2% days per month in both groups. Total duration of all symptoms did not differ for expectant fathers and non-expectant men during trimester I (t[l28] = 0.38, P = ns), trimester II (t[142] = 0.12, P = ns), or trimester III (t[128] = 0.58, P = ns). However, during the immediate postpartum period, expectant fathers tended to have a greater number of symptom days than non-expectant men (t[86] = 1.69, P = 0.09). Using a IO-point Likert scale, all subjects were asked how serious their symptoms were to them. A score of 1 meant not all serious and a score of 10 meant very serious. Total seriousness of symptom scores were calculated for each group by trimester. Perceived seriousness of couvade symptoms was not significantly different between the two groups during the three trimesters of pregnancy (trimester I = t[84] = 0.27, P = ns; trimester II = t[142] = 0.03, P = ns; trimester III = t[128] = 0.04, P = ns). During the postpartum period, however, expectant fathers reported greater total seriousness of symptoms w51 = 4.61, P = 0.001). Inferential comparisons between the two study groups were conducted on each couvade symptom to discover the specifics of how and when expectant fathers’ health deviates from that of non-expectant men. These findings are presented below and are organized by trimester. Trimester I Compared to non-expectant men during the first trimester of pregnancy, expectant fathers experienced a higher incidence of colds (t[84] = 2.17, P = 0.04) which lasted longer (t[84] = 3.60, P = 0.001) and a higher incidence of irritability (t[84] = 3.16, P = 0.002) which tended to be longer in duration (t[84] = 1.78, P = 0.08). Total perceived seriousness *Detailed exploration of data management/analysis issues and decision making in repeated measures nursing research can be found in Clinton (1985) and is also forthcoming in: Clinton (1987).
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of symptoms was similar in both groups (t[84] = 0.27, P = ns). Expectant fathers were no different from non-expectant controls on all other symptomatology during this time.
Trimester II During the months of trimester II, couvade symptomatology of expectant fathers was virtually indistinguishable from that of non-expectant men. No significant differences in incidence, duration, or perceived seriousness for any of the 39 couvade symptoms were detected.
Trimester III By the third trimester, the health profile of expectant fathers was found to deviate slightly from that of non-expectant controls. Unintentional weight gain was found to be more serious (?[128] = 3.42, P = 0.001). Insomnia was found to be more prevalent in expectant fathers (?[128] = 3.24, P = 0.002) and also lasted longer (t[l28] = 2.75, P = 0.01) and was perceived as more serious (t[l28] = 2.76, P = 0.01). Restlessness was also a problem found to last longer in expectant fathers (t[l28] = 2.01, P = 0.05). Expectant fathers were no different from non-expectant controls on all other symptomatology during this time.
Early postpartum period The health of expectant fathers was found to differ most from non-expectant men during the immediate postpartum period particularly in regard to seven different symptoms (Fig. 1). Nervousness was significantly more prevalent (t[86] = 2.32, P = 0.09, more serious Mean Symptom
0
02 I
frequency 04 I
of appearance 06 I
/ I
08 I
Fatigue
t(86)=4
irritability
-
fBW2.2i,p=0.03
Headache
-
t(86) / 2.21 , p =0.03
Difficulty concentrating
Insomnia
Nervousness
B
-
Q86)=3.56
I2 I 86,p=.0001
1p =0.02
tB6)=2.32,p=0.02
1(86)=22O,p*O.O3
Backache
Restlessness
Depression
086)=0.57,p=ns
Colds
t(86)=134,p=ns
-
Expectant
fathers
Controts
Fig. 1. Comparison of expectant fathers and controls on top ten ranked couvade symptoms during the postpartum period.
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(t[86] = 2.31, P = 0.05) and lasted longer (t[86] = 2.50, P = 0.05) for expectant fathers. Difficulty in concentrating was also more prevalent (t[86] = 2.50, P = 0.05), more serious (t[86] = 2.82, P = 0.004) and longer in duration (t[86] = 2.64, P = 0.02) among expectant fathers. Excessive fatigue was more frequent (t[86] = 4.86, P = 0.0001) in expectant fathers, as well as more serious (t[86] = 3.76, P = O.OOOl),and tended to be longer in duration (t[86] = 1.87, P = 0.08). Insomnia was more evident (t[86] = 2.23, P = 0.05), more serious (t[86] = 2.52, P = 0.02) and lasted longer (t[86] = 3.11, P = 0.003) in expectant fathers. Higher incidences of restlessness (?[86] = 1.99, P = 0.05), headaches (r[86] = 2.23, P = 0.05) and irritability (t[86] = 2.21, P = 0.05) were detected among expectant fathers. The postpartum period is the time when the overall incidence of all symptoms combined was found to be greater among expectant fathers (t[86] = 5.13, P = 0.001) as well as the overall seriousness of symptoms in general (t[86] = 4.61, P = 0.0001).
Discussion
In reference to the expectant father group only, the prevalence of four physical symptoms reported by subjects in this study are similar to those identified in previous research. These were colds, backaches, stomachaches, and unintentional weight gain. Compared to nonexpectant men, expectant fathers experienced a higher incidence and duration of colds during trimester I and great unintentional weight gain which was perceived as more serious during trimester III. However, expectant fathers were found to be no different from non-expectant men relative to the incidence, duration, and perceived seriousness of all other physical symtpoms at all time points. With the exception of colds and unintentional weight gain, the overall similarity of physical symptomatology between expectant fathers and nonexpectant men observed in this study confirms earlier findings reported in studies that incorporated a comparative non-expectant control group (Fordor, 198 1; Quill et al., 1984). In general, however, there were very few physical symptoms that differed significantly between the two study groups and these differences did not reflect a consistent pattern over time. Expectant fathers were found to most distinguishable from non-expectant men in terms of emotional health particularly during the immediate postpartum period. This include a wide array of symptoms including irritability, nervousness, inability to concentrate, headaches, restlessness, fatigue and insomnia. This is the developmental period when new fathers experience the greatest stress and are most vulnerable to psychological discomforts. The emotional manifestations observed postpartum in this study are similar to those attributed to couvade in other studies (Curtis, 1955; Soule et al., 1979; Gerzi and Berman, 1981; Bogren, 1983; Brown, 1983). The finding on emotional responses that deviates from other studies concerns depression. Both Brown (1983) and Davis (1978) reported a high prevalence of depression among expectant fathers. However, when expectant fathers were compared to non-expectant men in this study, depression did not appear to be particularly prevalent nor serious for expectant fathers. The findings of this study serve to inform clinicians about the health needs of men during the developmental transition to fatherhood. The most prevalent couvade symptoms experienced by expectant fathers have been identified in detail as well as the time these symptoms are most likely to deviate in incidence, duration and seriousness compared to non-expectant men.
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It is particularly noteworthy that all symptoms found to be problematic for expectant fathers are highly amendable to nursing influence. From a psychological perspective, this study confirms that the psychological transition to fatherhood is a dramatic as that to motherhood. It is therefore recommended that the expectant father be routinely monitored throughout pregnancy along with his pregnant partner. Anticipatory health counseling done by nurses or other health professionals should include several approaches that are routine. First, the expectant father should be assessed periodically over the course of pregnancy relative to emotional health status and events in daily life that contribute to feelings of stress. Second, during the latter months of pregnancy, the nurse should periodically explore the expectant father’s expectations about anticipated stressors during the early postpartum period. Prior to delivery, health promotion counseling should include exploration of ways to cope with new fatherhood responsibilities. Third, at all points in time when the nurse interacts with the expectant father, information and instruction should be offered to him about relationships between life transition, emotional status and physical health. Because the postpartum period is a time when new fathers are especially vulnerable to emotional turmoil, it is recommended that public health nursing home visits to mothers and infants be scheduled at a time when the new father is also present so that his needs can be assessed and treated when appropriate. In all instances, the expectant father should be encouraged to express his needs and experiences without feeling as though it takes time or the nurse’s attention away from his partner. This can be accomplished by tending to the new mother and baby first and then giving undivided attention to the new father.
References Bittman, S. and Zalk, S. (1978). Expecton? Futhers. Ballantine Books, New York. Bogren, L. Y. (1983). Couvade. Acta Psychiat. neuroi. 68, 55-65. Brown, M. A. (1983). Social support and support symptomatology: A study of first time expectant parents. Doctoral dissertation, University of Washington, 1983. Diss. Abstr. Int. 44, 1118. Clinton, J. (1985). Couvade: patterns and predictors. United States Department of Health and Human Services, Division of Nursing. Funded 1983-85. Technical Report No. ROl-NUOC977. Clinton, J. (1987). Conceptual and technical issues in using time-series methodology in nursing research. Adw. Nurs. Sci. In press. Clinton, J., Radjenovic, D., Taylor, L., Westlake, S. and Wilson, S. (1986). Time-series designs and clinical nursing research: Human issues. Nurs. Rex 35, 188-191. Curtis, J. L. (1955). A psychiatric study of 55 expectant fathers. U.S. arm. Forces med. J. 6, 937-950. Davis, 0. S. (1978). Mood and symptoms of expectant fathers during the course of pregnancy: a study of the crisis perspective of expectant fatherhood. Doctorial dissertation, University of North Carolina at Greensboro, 1977. Diss. Abstr. Int. 38, 5741A. Dawson, W. (1929). The Custom of Couvude. Manchester University Press, Manchester, U.K. Dickens, J. and Trethowan, W. A. (1971). Cravings and aversions during pregnancy. J. Psychosomot. Res. 15, 259-268. Fishbein, E. G. (1981). The couvade: a review. Journal of Obstetric, Gynecologic and Neonatal Nursing, 10, 356-359. Fordor, H. E. (1981). The transition to parenthood: Life change and continuity in two phases of the family life cycle. Unpublished doctoral dissertation. University of Michigan. Fry, E. (1968). A readability formula that saves time. Journuf of Reading, 11, 513-516, 575-577. Gabriel, A. (1982). On changes in weight of expectant fathers. In 77re Use andAbuse of Medicine. M. W. deVries, R. L. Berg and M. Lipkin, Jr. (Eds.) pp. 118-122. Praeger, New York. Gerzi, S. and Berman, E. (1981). Emotional reactions of expectant fathers to their wives’ first pregnancy. Br. J. Med. Psych. 54, 259-265. Ginath, Y. (1974). Psychoses in males in relation to their wives’ pregnancy and childbirth. IsraelAnn. Psych&. reiat. Discip. 12, 227-237.
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Gurwitt, A. R. (1976). Aspects of prospective fatherhood: a case report. Psychoanal. Study Child 31.237-271. Howells, J. G. (1971). Fathering. In Modem Perspectives in International Child Psychiatry. J. G. Howells (Ed.), pp. 125-156. Brunner 8t Mazel, New York. Ireton, H. R. (1980). A personal inventory. J. Family Pratt. 11, 137-140. Jalowiec, A. and Powers, M. J. (1981). Stress and coping in hypertensive and emergency room patients. Nurs. Res. 30, 10-15. Lamb, G. S. and Lipkin, M.. Jr. (1982). Somatic symptoms of expectant fathers. Am. J. Maternal Child Nurs. 7, 110-113, 115. Liebenberg, B. (1969). Expectant fathers. Child Family 8, 265-278. Lipkin, M., Jr. and Lamb, G. S. (1982). The couvade syndrome: an epidemiologic study. Ann. int. Med. 96, 509-511. Malinowski, B. (1927). Sex and Repression in Savage Society. Harcourt Brace, New York. Maltie, A. A. Cavenar, J. O., O’Shanick, G. J. and Volow, M. R. (1980). A couvade syndrome variant: Case report. N. Carol. med. J. 41, 90-92. Mead, M. (1935). Sex and Temperament. Marrow, New York. Mead, M. and Newton, N. (1967). Cultural patterning of peminatal behavior. In Childbearing-Its Social and Psychological Aspects. Richardson, S. and Guttmacher, A. (Eds.), pp. 142-224. Wiiams & Wilkins, Baltimore. Meigs. A. S. (1976). Male pregnancy and the reduction of sexual opposition in a New Guinea highlands society. Eihnoiogy,‘ 15, i93-407. Munroe, R. L., Munroe, R. H. and Whiting, J. W. (1973). The couvade: a psychological analysis. Ethos 1,30-74. Munroe. R. L. (1980). Male transvestism and the couvade: a nsycho-cultural analysis. Ethos 8. 49-59. Osofsky; H. (1982). Expectant and new fatherhood as a developmental crisis. Bull. Menninger Clin. 46.209-230. Paige, K. E. and Paige, J. M. (1973). The politics of bii practices: a strategies analysis. Am. Sot. Rev. 38.663-677. Quill, T. E., Lipkin, M. and Lamb, G. S. (1984). Health-care seeking by men in their spouse’s pregnancy. Psychosom. Med. 46, 227-283. Read, K. E. (1952). Nama cult of central highlands of New Guinea. S Wes. J. Antrop. 10, l-43. Some, B., Standley, K. and Copans, S. A. (1979). Father identity. Psychiatry 42, 255-263. Trethowan, W. H. and Conlon, M. F. (1965). The couvade syndrome. Br. J. Psychiat. 111, 57-66. Viesti, C. R. (1980). An exploration of the psychological experience of expectant fatherhood. Diss. Abstr. Int. 41, 715B. (University Microfilms No. 80-17, 900). Wapner, J. H. (1975). An empirical approach to the attitudes, feelings and behaviors of expectant fathers. Diss. Abstr. Int. 36, 3633B-3634B. (University Microfilms No. 75-29, 777). Webster, H. (1942). Taboo: A Sociological Study. Stanford University Press, Stanford, U.S.A. Wilson, L. G. (1977). The couvade syndrome. Am. Famiiy Physician 15, 157-160. (Received 1 August 1985; accepted for publication 4 September 1986)
2A, No.
I. pp.
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1987. 0
002@7489/87 1987 Per~smon
s3.00 + 0.00 Journals Ltd.
Physical and emotional responses of expectant fathers throughout pregnancy and the early postpartum period * JACQUELINE F. CLINTON, Ph.D., RN, FAAN Center for Nursing Research and Evaluation, University of Wisconsin-Milwaukee, Box 413, Milwaukee, 53201, U.S.A.
Abstract-A comparative, repeated measures survey design was used to monitor the physical and emotional health of 81 expectant fathers and 66 non-expectant men over the course of a year at monthly intervals. A total of 877 monthly data collection episodes were completed. Compared to non-expectant men, expectant fathers were found to experience relatively similar patterns of both physical and emotional symptoms throughout the three trimesters of pregnancy. However, expectant fathers’ health was found to differ significantly from that of non-expectant men during the immediate postpartum period with a greater incidence of emotional discomforts as well as total number of symptoms, their duration and perceived seriousness. Included are recommendations for anticipatory health counseling to promote health in expectant fathers.
Compared to the research attention devoted exclusively to the female pregnancy experience, there is a scarcity of data based information about the health of expectant fathers throughout pregnancy and the early postpartum period. Osofsky (1982) argued that the reason for our lack of knowledge about expectant fathers’ health is a tendency to minimize the adjustments of normal males to the pregnancy experience. Yet the transition to fatherhood is a significant developmental event in the lives of men and, as such, should be expected to involve significant and detectable adaptations. The phenomenon of couvade refers to pregnancy related symptoms and behaviors of *This research was supported by a grant from the United States Department of Health and Human Services, Public Health Service, Division of Nursing awarded to the author (No. I ROl NUO0977). 59
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expectant fathers. Anthropologists have documented the ritual form of couvade which appears almost exclusively in pre-industrial societies and consists of special observances and restrictions carried out by expectant fathers. Most commonly, these culturally sanctioned, learned behaviors involve special dress, social confinement, limitations on physical labor, sexual restraint, avoidance of polluting substances, mock labor and postpartum seclusion (Malinowski, 1927; Dawson, 1929; Mead, 1935; Webster, 1942; Read, 1952; Mead and Newton, 1967; Meigs, 1976; Munroe, 1980). Theoretical explanations for ritual couvade include: magico-religious protection for the vulnerable infant and mother; symbolic expression of the close physical and moral bond between father and unborn child; acceptance of a new social status of fatherhood; the claiming of paternity rights and social control over powerful feelings in men in response to birth (Howells, 1971; Munroe et al., 1973; Paige and Paige, 1973; Ginath, 1974; Gurwitt, 1976; Fishbein, 1981). In contrast to the ritual form of couvade, modern couvade or couvade syndrome has been observed primarily in industrial societies around the world and includes a wide array of physical and psychological symptoms experienced by men during their partners’ pregnancies. Altogether, 39 distinct symptoms have been linked to modern couvade in previous research. Symptoms reported include physical discomforts of musculoskeletal muscle and gastrointestinal systems and the skin; as well as behavioral manifestations and a host of indicators of emotional distress (Wapner, 1975; Wilson, 1977; Bittman and Zalk, 1978; Davis, 1978; Gerzi and Berman, 1981; Gabriel, 1982; Bogren, 1983; Brown, 1983). The documented incidence of modern couvade has varied considerably. In Great Britain the incidence has been reported to range from 11% (Trethowan and Conlon, 1965) to over 50% (Dickens and Trethowan, 1971). In North America, the documented prevalence ranges from 22 to 79% (Curtis, 1955; Liebenberg, 1969; Viesti, 1980; Lipkin and Lamb, 1982). Gabriel (1982) reasoned that modern couvade serves a similar function as ritual couvade in that both mark the passage from childless individual to the status of father. It has been observed that in cultures where ritual couvade is not practiced, a significant proportion of men suffer from numerous complaints during expectant fatherhood (Trethowan and Conlon, 1965). There have been only a few studies where symptomatology of expectant fathers was compared to a control group of non-expectant men and the findings are conflicting. Trethowan and Conlon (1965) found three symptoms that distinguished expectant fathers from men whose partners were not pregnant: anorexia, toothache and nausea. However, other investigators found that expectant fathers did not differ at all in symptomatology from non-expectant men (Fordor, 1981; Quill et al., 1984). There are also only a few studies where investigators focused on the couvade experience over time, usually over the course of pregnancy. There is general consensus in three studies that the occurrence of couvade symptoms are distributed in a U-shape curve over the course of pregnancy (Curtis, 1955; Lamb and Lipkin, 1982). That is, couvade symptoms are most prevalent at the end of the first trimester, decline during the second trimester and increase just prior to birth. Purpose and rationale
Critical review of previous studies reveals that couvade is a prevalent, but not well understood, experience of expectant fathers in Western societies. To better understand the developmental experiences of expectant fatherhood, there was a need to execute research
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that: (a) monitors multiple parameters of the expectant fatherhood experience over the entire course of pregnancy and the early postpartum period; (b) includes comparisons of expectant fathers to non-expectant men; and (c) uses a sample drawn from a larger population as opposed to only those individuals seeking treatment. Using the above criteria, this study was part of a larger project designed to expand knowledge of the physical and emotional events associated with expectant fatherhood. The specific aim of the study reported herein was to examine the incidence, duration and perceived seriousness of couvade symptoms experienced by expectant fathers throughout pregnancy and the early postpartum period compared to the same symptoms experienced by men who are not expectant fathers. Method
Design The design of the study was a comparative, repeated measures survey which allowed for: (a) the monitoring of the physical and emotional health of expectant fathers over the entire course of pregnancy and early postpartum period; and (b) comparison of health events of expectant fathers to those of non-expectant men at standardized time points. Data were collected on expectant fathers at lunar month intervals and coded according to expected date of confinement of each subject’s pregnant partner. One postpartum data collection point occurred at 6 weeks post-delivery. Assignment of lunar month codes to repeatedmeasures data collected for non-expectant controls was done in a fashion analogous to the lunar month sequence assigned to their matched expectant fathers. Sample The sample included 147 men residing in a large metropolitan area of the United States. Eighty-one were expectant fathers and 66 were non-expectant men who served as controls.* Participant age ranged from 18 to 44 years old (M for expectant fathers = 29.1, M for non-expectant controls = 30.2). Annual total family income ranged from below poverty level of less than $5000 to over $100,000. Modal income for each study group was $30,000 annually. Ethnic background of the sample included Anglo-European descent (expectant fathers = 91070, non-expectant controls = 94%), Black (expectant fathers = 5%, nonexpectant controls = 4Oro),Asian (expectant fathers = 2%, non-expectant controls = 1Vo) and Native American Indian (expectant fathers = 2%, non-expectant controls = 1%). The two study groups were not significantly different in regard to age (t[145] = 0.79, P = ns), education (t[145] = 79, P = ns), occupation (x’[9] = 2.03, P = ns) or ethnic background ($[9] = 1.03, P = ns). In terms of previous health history, the two study groups were healthy young men free of serious or chronic health conditions with no prior history of prolonged hospitalization for any physical or emotional problems. Setting The study was conducted at the University of Wisconsin-Milwaukee
School of Nursing
*Subject retention is particularly problematic in repeated measures designs that require participation of nearly a year’s period of time. Subjects included in the final analyses were those whose repeated measures data sets included time points in all three trimesters and postpartum. The drop out rate for expectant fathers was 9% compared to 13% for the control group. As anticipated, non-expectant men were not as interested or motivated by the study as expectant fathers. For a detailed exploration of subject retention and other human issues in conducting repeated measures research which evolved from this study see Clinton et 111.(1986).
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in a suite of offices specifically designated for the project which were easily accessible to subjects. A staff of seven registered nurses with graduate preparation collected the data.
Instruments The Expectant Father’s Preliminary Health Interview* contains 194 questions about demographic and cultural background, social history and health events prior to the partner’s pregnancy. For non-expectant control subjects, information was elicited for the time prior to admission to the study. The readability of the Expectant Father’s Preliminary Health Interview was tested and found to be at the 6th grade reading level using the Fry Readability Formula (Fry, 1968). Health-related items included in the Expectant Father’s Preliminary Health Interview were organized into nine conceptual categories: (a) early childhood relationships associated with couvade in previous studies; (b) health problems during past year; (c) health problems during lifetime; (d) symptoms experienced in past year; (e) symptoms experienced during lifetime; (f) physical and social role disabilities experienced in past year; (g) utilization of professional health resources in past year; (h) perceptions of pregnancy planning and convenience; and (i) satisfaction with own health in past year. With the exception of the area of early childhood experiences, all other areas of the Expectant Fathers’Preliminary Health Interview demonstrated sufficient internal consistency estimates ranging a = 0.77 to 0.91, N = 147. Test-retest reliability on a random subsample of 25 subjects ranged from r(23) = 0.88, P = 0.001 to r(23) = 0.94, P = 0.01. Predictive validity testing was conducted on the Preliminary Health Interview with data from a pilot study of 62 subjects prior to the current study. Correlations were found to be in the expected direction and vary in strength. For example, health problems occurring in the past year were positively associated with presence of symptoms of the past year (r[60] = 0.81, P = 0.002) as well as short term disabilities (r[60] = 0.63, P = 0.05), and negatively correlated with satisfaction with own health (r[60] = -0.42, P = 0.05). The Expectant Father’s Monthly Health Diary contains 280 items and was designed to elicit monthly information in eight conceptually related areas: (a) self-perceptions of physical and emotional status; (b) incidence, duration and perceived seriousness of 39 couvade discomforts; (c) perceived effectiveness of self-care actions; (d) professional health utilization; (e) physical and social role disabilities attributed to couvade discomforts; (f) work loss and salary dollar loss attributed to couvade discomforts; (g) affective and behavioral involvement in pregnancy; and (h) perceptions of partner’s difficulty with pregnancy and extent to which respondent felt he was able to help her. The readability of the Expectant Father’s Monthly Health Diary was determined to be at the 6th grade level using the Fry Readability Formula (Fry, 1968). Internal consistency of the Expectant Father’sMonthly Health Znterview was tested and found to be sufficient for each conceptually-related area of the instrument ranging from OL= 0.74 to 0.93, N = 147. Content validity was established for the couvade items which were derived from previous studies. Predictive validity testing was done on data from a pilot study of 62 subjects. Correlations were in the expected direction and varied in strength. For example, how healthy subjects felt emotionally was negatively associated with irritability (r[60] = -0.53, P = O.OOl),nervousness (r[60] = -0.48, P = O.OOl), depression *Completecopies of all instruments used in this study and administration obtained free of charge by writing the author.
can be found in Clinton (1985) or
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(r [60] = - 0.41, P = O.Ol), and inconvenience of pregnancy (r [60] = - 0.30, P = 0.009). Self-assessed physical health status was positively related to other satisfaction with health (r[60] = 0.48, P = 0.001). Men who reported disabilities in carrying out activities of daily living also reported more couvade discomforts (r[60] = 0.62, P = 0.03), emotional instability (r]60] = 0.50, P = 0.001) and a sense of declining physical health (r[60] = 0.61, P = 0.001). Total number of symptom days for expectant fathers corresponded positively with the use of professional health resources (r[60] = 0.61, P = 0.001). The Expectant Father’s Monthly Health Diary was also subjected to external criterion validity testing using the Ireton Personal Inventory (Ireton, 1980) which measures stress and worry and the Jalowiec Coping Scale (Jalowiec and Powers, 1981) which measures stress responses. Using a subsample of 199 subjects, correlations among theoretically linked items in all three instruments were in an expected direction and varied in strength. For example, total symptom days measured with the Eqectmt Father’s Monthly Health Diary corresponded positively to Ireton items of feeling stressed (r[l17] = 0.46, P = O.OOOl), worry about personal habits (r[117] = 0.46, P = O.OOOl), being unhappy (r[l17] = 0.48, P = 0.0001) and easily upset (r[117] = 0.43, P = 0.0001). Sadness measured with the Expectant Father’s Monthly Health Diary was positively associated with Jalowiec items on depression (r[117] = 0.65, P = OOOI),and resignation (r[117] = 0.52, P = 0.05).
Procedure Because of the need to recruit expectant fathers at the earliest possible time during their partners’ pregnancies, recruitment was broad in scope and highly visible to the general public. Recruitment procedures included regular use of the mass media (television, radio and newspapers) and poster announcements distributed throughout the community including industries and health service agencies who have contact with expectant fathers. Informed consent was obtained from all subjects prior to their admission to the study. Initial data collection was completed within 4 days of admission to the study and included the Expectant Father’s Monthly Health Interview. Repeated measures data collection was also begun at the initial interview and then every lunar month until the 6th week postdelivery. To standardize the data collection process, all data collection personnel were given written protocols and training. Each nurse was required to observe a trained data collector prior to collecting data alone. All instruments included a code identifying the data collector so that interviewer bias could be detected and controlled. No significant associations were found between interviewers and subject responses to any items on the instruments used. To control for the possible confounding influence of seasonal influences on dependent variables, data were collected concurrently on both study groups. In addition, the calendar of each interview was coded and entered on all computerized data sets to allow for the evaluation of seasonal variation, if any, using regressional analysis.
Results A total of 877 lunar month interviews were completed with the 147 participants. The study design predicted a total of 1470 repeated measures interviews. However, complete lunar month data sets were not possible to obtain for every subject for several reasons: (a) few expectant father subjects entered the study prior to the first 2 months of their partners’ pregnancies because they were unaware or unsure of pregnancy; (b) some subjects
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Table 1. Distribution of subjects by trimester and group Trimester
Group Expectant fathers Non-expectant controls Total
I 48 38
II
86
III
PP
80
76
50
64
54
38
144
130
88
missed data collection appointments due to busy work schedules and when they returned, pregnancy had progressed to the next lunar month; (c) occasionally, extreme weather conditions, which are notorious in the geographic region where the study was conducted, rendered transportation to the study site nearly impossible. Because complete lunar month data sets were not possible for every subject, data were condensed into trimesters to generate sufficient N for analysis purposes .* These procedures yielded a distribution of subjects as shown on Table 1. Overview Over the 11 months during their participation in the study, the vast majority of expectant fathers (93.7-97.0%) and non-expectant men (92.0-96.6%) reported they experienced at least one symptom in a typical month during each trimester. Very few subjects were symptom free for nearly a year time span. The duration of each couvade symptom was measured in days and ranged from less than 1 day to 2% days per month in both groups. Total duration of all symptoms did not differ for expectant fathers and non-expectant men during trimester I (t[l28] = 0.38, P = ns), trimester II (t[142] = 0.12, P = ns), or trimester III (t[128] = 0.58, P = ns). However, during the immediate postpartum period, expectant fathers tended to have a greater number of symptom days than non-expectant men (t[86] = 1.69, P = 0.09). Using a IO-point Likert scale, all subjects were asked how serious their symptoms were to them. A score of 1 meant not all serious and a score of 10 meant very serious. Total seriousness of symptom scores were calculated for each group by trimester. Perceived seriousness of couvade symptoms was not significantly different between the two groups during the three trimesters of pregnancy (trimester I = t[84] = 0.27, P = ns; trimester II = t[142] = 0.03, P = ns; trimester III = t[128] = 0.04, P = ns). During the postpartum period, however, expectant fathers reported greater total seriousness of symptoms w51 = 4.61, P = 0.001). Inferential comparisons between the two study groups were conducted on each couvade symptom to discover the specifics of how and when expectant fathers’ health deviates from that of non-expectant men. These findings are presented below and are organized by trimester. Trimester I Compared to non-expectant men during the first trimester of pregnancy, expectant fathers experienced a higher incidence of colds (t[84] = 2.17, P = 0.04) which lasted longer (t[84] = 3.60, P = 0.001) and a higher incidence of irritability (t[84] = 3.16, P = 0.002) which tended to be longer in duration (t[84] = 1.78, P = 0.08). Total perceived seriousness *Detailed exploration of data management/analysis issues and decision making in repeated measures nursing research can be found in Clinton (1985) and is also forthcoming in: Clinton (1987).
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of symptoms was similar in both groups (t[84] = 0.27, P = ns). Expectant fathers were no different from non-expectant controls on all other symptomatology during this time.
Trimester II During the months of trimester II, couvade symptomatology of expectant fathers was virtually indistinguishable from that of non-expectant men. No significant differences in incidence, duration, or perceived seriousness for any of the 39 couvade symptoms were detected.
Trimester III By the third trimester, the health profile of expectant fathers was found to deviate slightly from that of non-expectant controls. Unintentional weight gain was found to be more serious (?[128] = 3.42, P = 0.001). Insomnia was found to be more prevalent in expectant fathers (?[128] = 3.24, P = 0.002) and also lasted longer (t[l28] = 2.75, P = 0.01) and was perceived as more serious (t[l28] = 2.76, P = 0.01). Restlessness was also a problem found to last longer in expectant fathers (t[l28] = 2.01, P = 0.05). Expectant fathers were no different from non-expectant controls on all other symptomatology during this time.
Early postpartum period The health of expectant fathers was found to differ most from non-expectant men during the immediate postpartum period particularly in regard to seven different symptoms (Fig. 1). Nervousness was significantly more prevalent (t[86] = 2.32, P = 0.09, more serious Mean Symptom
0
02 I
frequency 04 I
of appearance 06 I
/ I
08 I
Fatigue
t(86)=4
irritability
-
fBW2.2i,p=0.03
Headache
-
t(86) / 2.21 , p =0.03
Difficulty concentrating
Insomnia
Nervousness
B
-
Q86)=3.56
I2 I 86,p=.0001
1p =0.02
tB6)=2.32,p=0.02
1(86)=22O,p*O.O3
Backache
Restlessness
Depression
086)=0.57,p=ns
Colds
t(86)=134,p=ns
-
Expectant
fathers
Controts
Fig. 1. Comparison of expectant fathers and controls on top ten ranked couvade symptoms during the postpartum period.
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(t[86] = 2.31, P = 0.05) and lasted longer (t[86] = 2.50, P = 0.05) for expectant fathers. Difficulty in concentrating was also more prevalent (t[86] = 2.50, P = 0.05), more serious (t[86] = 2.82, P = 0.004) and longer in duration (t[86] = 2.64, P = 0.02) among expectant fathers. Excessive fatigue was more frequent (t[86] = 4.86, P = 0.0001) in expectant fathers, as well as more serious (t[86] = 3.76, P = O.OOOl),and tended to be longer in duration (t[86] = 1.87, P = 0.08). Insomnia was more evident (t[86] = 2.23, P = 0.05), more serious (t[86] = 2.52, P = 0.02) and lasted longer (t[86] = 3.11, P = 0.003) in expectant fathers. Higher incidences of restlessness (?[86] = 1.99, P = 0.05), headaches (r[86] = 2.23, P = 0.05) and irritability (t[86] = 2.21, P = 0.05) were detected among expectant fathers. The postpartum period is the time when the overall incidence of all symptoms combined was found to be greater among expectant fathers (t[86] = 5.13, P = 0.001) as well as the overall seriousness of symptoms in general (t[86] = 4.61, P = 0.0001).
Discussion
In reference to the expectant father group only, the prevalence of four physical symptoms reported by subjects in this study are similar to those identified in previous research. These were colds, backaches, stomachaches, and unintentional weight gain. Compared to nonexpectant men, expectant fathers experienced a higher incidence and duration of colds during trimester I and great unintentional weight gain which was perceived as more serious during trimester III. However, expectant fathers were found to be no different from non-expectant men relative to the incidence, duration, and perceived seriousness of all other physical symtpoms at all time points. With the exception of colds and unintentional weight gain, the overall similarity of physical symptomatology between expectant fathers and nonexpectant men observed in this study confirms earlier findings reported in studies that incorporated a comparative non-expectant control group (Fordor, 198 1; Quill et al., 1984). In general, however, there were very few physical symptoms that differed significantly between the two study groups and these differences did not reflect a consistent pattern over time. Expectant fathers were found to most distinguishable from non-expectant men in terms of emotional health particularly during the immediate postpartum period. This include a wide array of symptoms including irritability, nervousness, inability to concentrate, headaches, restlessness, fatigue and insomnia. This is the developmental period when new fathers experience the greatest stress and are most vulnerable to psychological discomforts. The emotional manifestations observed postpartum in this study are similar to those attributed to couvade in other studies (Curtis, 1955; Soule et al., 1979; Gerzi and Berman, 1981; Bogren, 1983; Brown, 1983). The finding on emotional responses that deviates from other studies concerns depression. Both Brown (1983) and Davis (1978) reported a high prevalence of depression among expectant fathers. However, when expectant fathers were compared to non-expectant men in this study, depression did not appear to be particularly prevalent nor serious for expectant fathers. The findings of this study serve to inform clinicians about the health needs of men during the developmental transition to fatherhood. The most prevalent couvade symptoms experienced by expectant fathers have been identified in detail as well as the time these symptoms are most likely to deviate in incidence, duration and seriousness compared to non-expectant men.
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It is particularly noteworthy that all symptoms found to be problematic for expectant fathers are highly amendable to nursing influence. From a psychological perspective, this study confirms that the psychological transition to fatherhood is a dramatic as that to motherhood. It is therefore recommended that the expectant father be routinely monitored throughout pregnancy along with his pregnant partner. Anticipatory health counseling done by nurses or other health professionals should include several approaches that are routine. First, the expectant father should be assessed periodically over the course of pregnancy relative to emotional health status and events in daily life that contribute to feelings of stress. Second, during the latter months of pregnancy, the nurse should periodically explore the expectant father’s expectations about anticipated stressors during the early postpartum period. Prior to delivery, health promotion counseling should include exploration of ways to cope with new fatherhood responsibilities. Third, at all points in time when the nurse interacts with the expectant father, information and instruction should be offered to him about relationships between life transition, emotional status and physical health. Because the postpartum period is a time when new fathers are especially vulnerable to emotional turmoil, it is recommended that public health nursing home visits to mothers and infants be scheduled at a time when the new father is also present so that his needs can be assessed and treated when appropriate. In all instances, the expectant father should be encouraged to express his needs and experiences without feeling as though it takes time or the nurse’s attention away from his partner. This can be accomplished by tending to the new mother and baby first and then giving undivided attention to the new father.
References Bittman, S. and Zalk, S. (1978). Expecton? Futhers. Ballantine Books, New York. Bogren, L. Y. (1983). Couvade. Acta Psychiat. neuroi. 68, 55-65. Brown, M. A. (1983). Social support and support symptomatology: A study of first time expectant parents. Doctoral dissertation, University of Washington, 1983. Diss. Abstr. Int. 44, 1118. Clinton, J. (1985). Couvade: patterns and predictors. United States Department of Health and Human Services, Division of Nursing. Funded 1983-85. Technical Report No. ROl-NUOC977. Clinton, J. (1987). Conceptual and technical issues in using time-series methodology in nursing research. Adw. Nurs. Sci. In press. Clinton, J., Radjenovic, D., Taylor, L., Westlake, S. and Wilson, S. (1986). Time-series designs and clinical nursing research: Human issues. Nurs. Rex 35, 188-191. Curtis, J. L. (1955). A psychiatric study of 55 expectant fathers. U.S. arm. Forces med. J. 6, 937-950. Davis, 0. S. (1978). Mood and symptoms of expectant fathers during the course of pregnancy: a study of the crisis perspective of expectant fatherhood. Doctorial dissertation, University of North Carolina at Greensboro, 1977. Diss. Abstr. Int. 38, 5741A. Dawson, W. (1929). The Custom of Couvude. Manchester University Press, Manchester, U.K. Dickens, J. and Trethowan, W. A. (1971). Cravings and aversions during pregnancy. J. Psychosomot. Res. 15, 259-268. Fishbein, E. G. (1981). The couvade: a review. Journal of Obstetric, Gynecologic and Neonatal Nursing, 10, 356-359. Fordor, H. E. (1981). The transition to parenthood: Life change and continuity in two phases of the family life cycle. Unpublished doctoral dissertation. University of Michigan. Fry, E. (1968). A readability formula that saves time. Journuf of Reading, 11, 513-516, 575-577. Gabriel, A. (1982). On changes in weight of expectant fathers. In 77re Use andAbuse of Medicine. M. W. deVries, R. L. Berg and M. Lipkin, Jr. (Eds.) pp. 118-122. Praeger, New York. Gerzi, S. and Berman, E. (1981). Emotional reactions of expectant fathers to their wives’ first pregnancy. Br. J. Med. Psych. 54, 259-265. Ginath, Y. (1974). Psychoses in males in relation to their wives’ pregnancy and childbirth. IsraelAnn. Psych&. reiat. Discip. 12, 227-237.
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Gurwitt, A. R. (1976). Aspects of prospective fatherhood: a case report. Psychoanal. Study Child 31.237-271. Howells, J. G. (1971). Fathering. In Modem Perspectives in International Child Psychiatry. J. G. Howells (Ed.), pp. 125-156. Brunner 8t Mazel, New York. Ireton, H. R. (1980). A personal inventory. J. Family Pratt. 11, 137-140. Jalowiec, A. and Powers, M. J. (1981). Stress and coping in hypertensive and emergency room patients. Nurs. Res. 30, 10-15. Lamb, G. S. and Lipkin, M.. Jr. (1982). Somatic symptoms of expectant fathers. Am. J. Maternal Child Nurs. 7, 110-113, 115. Liebenberg, B. (1969). Expectant fathers. Child Family 8, 265-278. Lipkin, M., Jr. and Lamb, G. S. (1982). The couvade syndrome: an epidemiologic study. Ann. int. Med. 96, 509-511. Malinowski, B. (1927). Sex and Repression in Savage Society. Harcourt Brace, New York. Maltie, A. A. Cavenar, J. O., O’Shanick, G. J. and Volow, M. R. (1980). A couvade syndrome variant: Case report. N. Carol. med. J. 41, 90-92. Mead, M. (1935). Sex and Temperament. Marrow, New York. Mead, M. and Newton, N. (1967). Cultural patterning of peminatal behavior. In Childbearing-Its Social and Psychological Aspects. Richardson, S. and Guttmacher, A. (Eds.), pp. 142-224. Wiiams & Wilkins, Baltimore. Meigs. A. S. (1976). Male pregnancy and the reduction of sexual opposition in a New Guinea highlands society. Eihnoiogy,‘ 15, i93-407. Munroe, R. L., Munroe, R. H. and Whiting, J. W. (1973). The couvade: a psychological analysis. Ethos 1,30-74. Munroe. R. L. (1980). Male transvestism and the couvade: a nsycho-cultural analysis. Ethos 8. 49-59. Osofsky; H. (1982). Expectant and new fatherhood as a developmental crisis. Bull. Menninger Clin. 46.209-230. Paige, K. E. and Paige, J. M. (1973). The politics of bii practices: a strategies analysis. Am. Sot. Rev. 38.663-677. Quill, T. E., Lipkin, M. and Lamb, G. S. (1984). Health-care seeking by men in their spouse’s pregnancy. Psychosom. Med. 46, 227-283. Read, K. E. (1952). Nama cult of central highlands of New Guinea. S Wes. J. Antrop. 10, l-43. Some, B., Standley, K. and Copans, S. A. (1979). Father identity. Psychiatry 42, 255-263. Trethowan, W. H. and Conlon, M. F. (1965). The couvade syndrome. Br. J. Psychiat. 111, 57-66. Viesti, C. R. (1980). An exploration of the psychological experience of expectant fatherhood. Diss. Abstr. Int. 41, 715B. (University Microfilms No. 80-17, 900). Wapner, J. H. (1975). An empirical approach to the attitudes, feelings and behaviors of expectant fathers. Diss. Abstr. Int. 36, 3633B-3634B. (University Microfilms No. 75-29, 777). Webster, H. (1942). Taboo: A Sociological Study. Stanford University Press, Stanford, U.S.A. Wilson, L. G. (1977). The couvade syndrome. Am. Famiiy Physician 15, 157-160. (Received 1 August 1985; accepted for publication 4 September 1986)