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Factors Influencing Paternal Postpartum Depression: A Systematic

Review and Meta-Analysis

Dan Wang Master , Yi-Lu Li Master , Dan Qiu PhD ,

Shui-Yuan Xiao MD

PII: S0165-0327(21)00532-2
DOI: https://doi.org/10.1016/j.jad.2021.05.088
Reference: JAD 13403

To appear in: Journal of Affective Disorders

Received date: 21 July 2020

Revised date: 11 May 2021
Accepted date: 31 May 2021

Please cite this article as: Dan Wang Master , Yi-Lu Li Master , Dan Qiu PhD , Shui-Yuan Xiao MD ,
Factors Influencing Paternal Postpartum Depression: A Systematic Review and Meta-Analysis, Journal
of Affective Disorders (2021), doi: https://doi.org/10.1016/j.jad.2021.05.088

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 Highlights
 Influencing factors of paternal PPD can be classified into paternal,
maternal, infant and family characteristics.
 Paternal factors, such as unemployment (OR=2.59, 95%CI:1.42-4.74),
high social support(OR=0.95, 95%CI:0.93-0.97), negative life events
(OR=1.45, 95%CI:1.13-1.87), perceived stress(OR=1.08,
95%CI:1.03-1.12), financial strain(OR=2.07, 95%CI:1.13-3.81),
history of mental illness(OR=3.48, 95%CI:2.49-4.86) were associated
with paternal PPD.
 Maternal factors, such as parity (OR=1.36, 95%CI:1.13-1.65) and
maternal postnatal depression (OR=1.17, 95%CI:1.03-1.33) were
associated with paternal PPD.
 Family factors, such as low marital satisfaction (OR=1.40,
95%CI:1.22-1.61) was associated with paternal PPD.
Factors Influencing Paternal Postpartum Depression: A
Systematic Review and Meta-Analysis
Dan Wang1, Yi-Lu Li1, Dan Qiu1, Shui-Yuan Xiao1*

1 Department of Social Medicine and Health Management, Xiangya School of Public

Health, Central South University, Changsha 410078, Hunan, China
* Correspondence: E-mail: xiaosy@csu.edu.cn; Tel.: +86-0731-84-805-459

Dan Wang, Yi-Lu Li, Dan Qiu, Shui-Yuan Xiao*

Author name: Dan Wang (D.W.)

Preferred degree: Master
Affiliations: Department of Social Medicine and Health Management,
Xiangya School of Public Health, Central South University, Changsha,
Hunan, People’s Republic of China
Full address: 110 Xiangya Road, Changsha, Hunan, 410078, China
E-mail: 186911057@csu.edu.cn
Declarations of interest: none

Author name: Yi-Lu Li (Y.-L.L.)

Preferred degree: Master
Affiliations: Department of Social Medicine and Health Management,
Xiangya School of Public Health, Central South University, Changsha,
Hunan, People’s Republic of China
Full address: 110 Xiangya Road, Changsha, Hunan, 410078, China
E-mail: 176911065@csu.edu.cn
Declarations of interest: none

Author name: Dan Qiu (D.Q.)

Preferred degree: PhD
Affiliations: Department of Social Medicine and Health Management,
Xiangya School of Public Health, Central South University, Changsha,
Hunan, People’s Republic of China
Full address: 110 Xiangya Road, Changsha, Hunan, 410078, China
E-mail: qiudan@csu.edu.cn
Declarations of interest: none

Corresponding author: Shui-Yuan Xiao (S.-Y.X.)

Preferred degree: MD
Affiliations: Department of Social Medicine and Health Management,
Xiangya School of Public Health, Central South University, Changsha,
Hunan, People’s Republic of China
Full address: 110 Xiangya Road, Changsha, Hunan, 410078, China
Phone/Fax: +86-0731-84805459.
E-mail: shuiyuanxiao1503@163.com
Declarations of interest: none

Abstract
Background: Postpartum period is a critical time that requires
adjustments not only for mothers but also for fathers and may pose risk
for depression. Studies show that the prevalence of paternal postpartum
depression (PPD) is between 1.2% and 25.5%. PPD is an under-
recognized public health issue and its reported influencing factors are still
inconclusive.
Objective: The purpose of this paper is to extend the literature by
examining influencing factors that affect paternal PPD and describe the
strength their associations.
Methods: We conducted keyword search of Web of Science, PubMed,
Embase, the Cochrane Library and PsycARTICLES electronic databases
up to Jan 17, 2020, without language restrictions, for observational
studies investigating the factors influencing paternal PPD and its effects.
Fixed or random effect model was used to pool odds ratio (OR) and 95%
confidence intervals (CI) with Stata software 12.0. Heterogeneity
between studies was evaluated using Cochran’s chi-squared test
(Cochran’s Q) and I2 values.
Results: Nineteen cross-sectional studies and eighteen cohort studies
published from 1996 to 2019 were included in this review and seventeen
studies in the meta-analysis. Factors affecting paternal PPD can be
classified into paternal, maternal, infant and family factors. In Meta-
analysis, 9 of 17 influencing factors were revealed to be statistically
significant: 1) paternal factors: unemployment 2.59 (1.42-4.74), low
social support 1.05 (1.03-1.08), negative life events 1.45 (1.13-1.87),
perceived stress 1.08 (1.03-1.12), financial strain 2.07 (1.13-3.81), history
of mental illness 3.48 (2.49-4.86); 2) maternal factors: parity 1.36 (1.13-
1.65) and maternal postnatal depression 1.17 (1.03-1.33); 3) family
factors: low marital satisfaction 1.40 (1.22-1.61). No statistically
significant association with infant factors was found in the meta-analysis.
Limitations: There was publication bias since we only included English
studies. Samples were under-represented in low-and middle-income
countries. The meta-analysis results are subject to unobserved
confounding factors and cannot explain causality.
Conclusion: This overview of the evidence suggests a relationship
between paternal employment, psychological status, history of maternal
mental illness, first pregnancy, marital relationship and paternal PPD. The
low number of studies for some infant factors in meta-analysis leaves
gaps in knowledge that need to be addressed. The mechanisms underlying
the reported associations and their causal relationship still remain unclear.
The awareness of the serious long-term consequences of paternal PPD
should encourage better identification of those at risk and the
development of effective interventions to protect fathers from PPD.
Keywords: paternal postpartum depression, influencing factors,
systematic review, meta-analysis
1.Introduction
Postpartum depression (PPD) is a mental disorder that occurs for the
first time within four weeks after delivery, mainly characterized by
depressed mood and loss of pleasure in daily interested activities. The
prevalence, risk factors, and targeted intervention of PPD among new
mothers have received much attention, but research on paternal PPD are
rare . The incidence of paternal PPD may be nearly as high as the
known incidence of maternal PPD 3. According to a meta-analysis of
observational surveys until July 1,2018, the worldwide prevalence of
paternal depression was 8.75% within the first postpartum year4. During
the 3 to 6 months postpartum period, higher rate of paternal depression
was reported with a meta-estimate of 25.6% (95% CI:17.3%-
36.1%)5.Paternal PPD has many negative effects on couples and whole
family health. For fathers, it can bring a series of poor emotional
experiences and physical discomfort such as sadness, fatigue, insomnia,
loss of appetite and even worse, suicide. The quality of life and social
interaction may be impaired among fathers who are struggling with PPD.
Moreover, research has shown that paternal PPD will put mothers at
higher risk of depression7 and may even translate into violence against
mothers8. Besides, paternal PPD has an adverse influence on the
development of children's emotion, conduct, hyperactivity, and prosocial
behavior9. Furthermore, paternal PPD also affects family functioning,
the well-being of family members and marital satisfaction10.
Targeted intervention requires an understanding of the influencing factors.
Despite the increasing research on paternal PPD, risk factors of paternal
PPD remain relatively unclear11. Currently available evidence has shown
the following risk factors for paternal PPD: sociodemographic factors,
such as age, ethnicity, education level, marital status, monthly income [12-
13]
; psychological factors, such as history of depression, social support,
maternal prenatal anxiety, marital relationship satisfaction[14-15]; obstetric
and infant factors, undesired pregnancy, pregnancy with infertility
treatment, full-term pregnancy, mode of delivery and infant gender-17 ;
behavioral factors, smoking and alcohol use [18-19]. However, the current
studies on the influencing factors of paternal PPD have limitations such
as small sample size, inconsistent strength and direction of the association,
different screening tools, potential confounders, different measurement
cutoff values and time, etc.
Due to the scarce and controversial available evidence, we conducted the
current systematic review and meta-analysis to review the influencing
factors of paternal PPD worldwide and explore the strengths of such
associations. This paper aims to identify associations between paternal
PPD and influencing factors by quantitative synthesis. Considering the
multi-faceted characteristics of influencing factors of paternal PPD, this
paper described the influencing factors by category. The findings may
provide guidance for future research and intervention programs to
implement targeted interventions by finding out father-specific factors
and couple-shared factors.

2.Method
2.1 Literature Search Strategy
Five electronic databases--Web of Science, PubMed, Embase, the
Cocharane library and EBSCO PsycARTICLES were searched to identify
relevant available articles up to Jan 17, 2020 without any restriction.
Search terms included ‘paternal’ (or ‘spouse’ or ‘husband’ or ‘partner’ or
‘mate’ or ‘companion’ or ’father’), ‘maternal’ ( or ‘puerperal’ or
‘parturient’ or ‘lying-in woman’ or ‘delivery woman’), ‘postnatal
depression’ (or ‘postpartum depression’ or ‘puerperal depression’ or
‘depression after delivery’ or ‘depression after childbirth’ or ‘depression’
or ‘depressive’ ) and ‘factor’ (or ‘risk’ or ‘influence’). Search strategies
are slightly different for each electronic database (See Appendix I for
details). The reference lists from included articles were also reviewed to
ensure that additional relevant articles are not missed.
2.2 Selection Criteria
Studies that reported possible influencing factors of paternal PPD were
selected based on these inclusion criteria: (1) observational study (case
control, cohort or cross-sectional study); (2) measurement time of PPD
from birth to one year after delivery; (3) original research with clear study
time and sample. Studies were excluded if they were: (1) duplicate
literature; (2) without full text in English; (3) case reports, reviews,
conference abstracts, qualitative studies, etc. In addition, studies that
directly reported OR value and 95% CI or provided multivariate logistic
regression coefficient estimates (β) and standard errors (SE) were
included in the meta-analysis.
2.3 Quality Assessment
We used the Newcastle-Ottawa Scale (NOS) and the evaluation criteria of
America Agency for Healthcare Research and Quality (AHRQ) to
determine the validity of included studies. NOS contains eight items
which is used for cohort and case-control studies, categorized into three
dimensions: selection, comparability, and outcome (cohort studies) or
exposure (case-control studies). The NOS uses semi-quantitative star
system to assess study quality, which ranges from 0 up to 9 stars. Studies
with a score of less than 5 are identified as low quality, with 6-7 as
medium quality and 8-9 as high quality[20]. The criteria recommended by
AHRQ for cross-sectional study included 11 items, with "yes", "no" and
"unclear" as answers respectively. The scoring criteria were as follows:0-
3 as low quality, 4-7 as medium quality, and 8-11 as high quality[21].
2.4 Data extraction
Data from the studies included in this systematic review and meta-
analysis were extracted from two authors independently by a standard
data extraction form according to guidelines recommended by the
Preferred Reporting Items for Systematic reviews and Meta-Analyses for
Protocols (PRISMA-2015)[22]. The third author was invited to extract the
data for inconsistent results between the first two authors until all authors
reached a consensus after discussion. Priorities on information extraction
were as follows: title, first author, journal name, year of publication,
country, study type, measure time of PPD, study instrument, cutoff value
of scale, sample size, influencing factors and measures of effect (OR and
95%CI, β and SE).
2.5 Data Synthesis and Statistical Analysis
Stata12.0 software was used to analyze all data. First of all, we
summarized all influencing factors of articles that meet the inclusion
criteria. To settle disputes and better describe factors, at least three OR
values with the same factor should be included in meta-analysis. Apart
from the commonly repeated factors evaluated, other factors with
insufficient OR were listed in a table. Heterogeneity was evaluated using
Cochran Q and I2 statistics, which is reported as chi-square (2), P value
and percentage. Heterogeneity is one of the main contents of the meta-
analysis report. When P≤0.10 and I2>50%, it indicates that there is
significant heterogeneity between studies, and it is necessary to use a
random effect model to combine OR and 95%CI. If not, we used fixed
effect model to analyze. Subgroup analysis and sensitivity analysis were
performed to explore possible reasons for the significant heterogeneity
and address the effects of important factors. We divided the data into
smaller groups based on geographic location (developed country versus
developing country), study type (cohort versus cross-sectional) and study
quality (medium versus high), and then compared across subgroups.
Additionally, leave- one- out method was used to examine the robustness
of a single study by sequentially removing each study in turn and
reanalyzing the remaining data sets.
3.Results
3.1 Identification of Studies
A detailed flow diagram of the literature screening was presented in
Figure 1. 20,290 potential articles were identified initially. After deleting
duplicates, there were 15,821 articles left. Using the search function
provided by EndnoteX9, systematic review and meta-analysis (n=552)
and non-English articles (n=402) were preliminarily excluded. Based on
the title and keywords, altogether 15,447 articles that are obviously
irrelevant to PPD were excluded. Our criteria for exclusion are: 1)
Duplicate and non-English articles(n=3913); 2) The research population
is not a maternal spouse(n=5806); 3) Qualitative articles such as reviews,
conference abstracts, and bulletins(n=1479); 4) Randomized control trail
and other experimental articles(n=574); 5) The outcome of the study is
not postpartum depression(n=1146); 6) Only the incidence/prevalence is
reported, no influencing factors reported(n=2529). Through abstract
screening, 303 articles were excluded with the following reasons:
qualitative studies (n=34), maternal PPD (n=196), the measure time of
PPD beyond a year postpartum period (n=46) and unreported influencing
factors (n=27). Therefore, a full-text of 71 studies were retrieved for
further assessment and 37 studies were excluded because of the above-
mentioned reasons. Additionally, three articles were identified by
reference list of the left 34 full-text articles. Finally, 37 articles were
retained for this systematic review. Among them, 17 articles reporting
ORs and 95% CIs were included in the meta-analysis.
3.2 Description of Studies
The basic characteristics of 37 included articles were shown in Table 1[24-
60]
. All studies were published between 1996 to 2019. Of the included
articles, 19 are cross-sectional and 18 are cohort studies. 30 studies were
conducted in the developed countries (America, England, Sweden,
Australia, Germany, Canada, Spain, Italy, Portugal, New Zealand, Ireland,
Denmark, Japan) and 7 in developing countries (China, Nigeria, Iran,
Saudi Arabia). Moreover, sample size for each study ranges from 42 to
12,396. The combined sample size of the 37 studies was 35,677. 28 of 37
studies used the Edinburgh Postpartum Depression Scale (EPDS) tool to
measure PPD symptoms. It is a widely used 10-item scale compiled by
Cox et al. in 1987 and has been validated for new mothers and
fathers. Besides, depressive symptoms were also measured by the
Center of Epidemiological Studies-Depression Scale (CES-D), Rutter’s 9-
item Malaise Inventory (RMI-9), Structured Clinical Interview for DSM
IV axis I disorder (SCID-IV), semi-structured clinical interview
(Schedule for Affective Disorders, SADS) and 9-item Patient Health
Questionnaire (PHQ-9). Regarding the quality score, NOS score of all
cohort studies ranges between 4 to 8, with 3 defined as low quality, 12 as
medium quality and 3 as high quality. All cross-sectional studies are of
medium quality with scores ranging from 4 to 7(See Appendix II).
3.3 The Influencing Factors of Paternal PPD
To solve the problem of different expressions of numerous factors, we
summarized the influencing factors in the following categories as shown
in in Table 2 and described as following:
3.3.1 Spouse Factors
Sociodemographic characteristics of paternal PPD were widely studied. A
total of 13 articles have studied the relationship between age and paternal
PPD. Only 2 studies have shown that age was associated with paternal
PPD. One study showed that older fathers are more susceptible to PPD,
while the other study showed the opposite result. Education level was
investigated in 15 studies, of which 4 studies showed significant
association between education and paternal PPD. Nine out of 12 studies
showed positive association between unemployment and paternal PPD.
Three articles showed no association between ethnicity and PPD. Two
other articles explored the impact of social class (primarily based on
occupational status) and immigration (with or without migration
background) on paternal PPD, but found no correlation. Two studies
found that spouses’ monthly income was not related to PPD.
There are 5 studies investigating the association between work-related
characteristics and PPD. Three studies argued that work hours are not
related to PPD. Two other articles study the relationship between work
efficiency (balancing the relationship between work and family or a sense
of control at work) and PPD and one study suggested an association.
There were extensive researches on psychological characteristics of
paternal PPD. Studies found that spouses who had neurotic personality
and felt financial strain were more likely to suffer from PPD. Only one
study reported the relationship between social adjustment and PPD, but
found no association. Two studies investigating psychological distress
showed that high levels of pregnancy- and birth-related distress was
strongly related to PPD. Psychosocial resilience resources [63]such as
social support, self-esteem, and coping approach style were revealed by
16 studies. Ten articles have concluded that lower level of social support,
avoidant coping and poor self-esteem were associated with PPD. Three of
9 articles consistently showed that negative life events were significantly
associated with PPD. Perceived stress was significantly associated with
paternal PPD in 7 of 11 studies. There are 18 articles exploring the
relationship between history of mental health disorders (mainly
depression and anxiety before and during pregnancy) and paternal PPD.
As a result, 12 articles suggested that spouses who have had mental
illness were more likely to suffer from PPD.
Some studies considered health and lifestyle characteristics. Three studies
consistently showed that fathers with poor sleep quality and health status
were susceptible to paternal PPD. Any cigarette or marijuana use was
found to be related to paternal PPD, while alcohol consumption was not.
Several studies have investigated other factors associated with paternal
PPD. Only one article found that experiences of racism after the infant’s
birth was significantly associated with greater depressive symptoms. Two
of 3 articles suggested that spouses who didn’t have their own home were
prone to paternal PPD, while another article did not find such a
correlation. One study concluded that spouse not attending the delivery of
infant was associated with paternal PPD, while another article found no
correlation between accompanied delivery and paternal PPD. Adverse
childhood experience was studied by two articles. Separation from
parents as a child was associated with paternal PPD, but history of
violence during childhood was not. Additionally, only one study found
that fathers who had experienced intimate partner violence were more
likely to be depressed after childbirth. The negative experience of
becoming a father, enough knowledge of infant care, and parenting style
were all factors affecting PPD after the birth of a baby.
3.3.2 Maternal Factors
Most data on paternal PPD came from a simultaneous survey of couples.
Being the spouse’s intimate partner and co- caregiver of the baby, the
mother has a significant effect on paternal PPD. Two of 7 articles
reported that parity (e.g. for second-born or later-born vs. first-born) was
related to paternal PPD. Specifically, spouse of the multipara was more
likely to be depressed during postpartum period than the spouse of the
primipara. Undesired pregnancy was examined in 9 studies to determine
its relationship with paternal PPD. Only two studies reported undesired
pregnancy was associated with paternal PPD. In 1 of 3 studies, the
correlation between pregnancy with infertility treatment and paternal PPD
was verified. Partners of women who were pregnant through assisted
reproduction were more likely to have paternal PPD. As for the mode of
delivery, one of the three articles showed that cesarean section was an
influencing factor of paternal PPD. Maternal depression as an influencing
factor was investigated in 24 studies. In 17 studies, maternal depression
has been consistently shown to be associated with paternal PPD, either
prenatally or postnatally. Only one study showed significant association
between maternal prenatal anxiety and sexual abuse with paternal PPD.
No association was found between maternal postpartum healthcare and
complications during childbirth with paternal PPD.
3.3.3 Infant Factors
Nine studies reported eight infant-related factors. Four articles explored
the association between infant gender and paternal PPD. A Chinese study
indicated that the preference for a male baby was associated with high
EPDS scores of fathers. Number of newborn babies (singleton, twins or
more) and infant week age was assessed by 2 studies, but no correlation
was found. One of two studies reported full-term infants were related to
paternal PPD, but the other showed no association. Two out of the 3
studies on infant temperament showed significant association between
difficult infant temperament and paternal PPD. Two studies showed
infant behavior as a predictor of paternal PPD. Infant feeding behaviors
(such as spill, vomit or refusing milk) were also associated with paternal
PPD. However, this correlation was not found in sleeping behaviors. One
of 2 studies showed that poor infant health status was associated with
paternal PPD.
3.3.4 Family Factors
In addition to the paternal factors, family factors are the most studied.
Two of 4 empirical studies suggested that region was associated with
paternal PPD. One of 2 studies showed that religion was related to
paternal PPD. One of six studies on the marital status found that being
unmarried was associated with paternal PPD. The most commonly
studied family factor of paternal PPD was marital relationship satisfaction,
with 13 out of 20 studies showing that marital satisfaction is negatively
correlated with paternal PPD. Three of seven studies reported that fathers
from high-income families were more prone to PPD, but another study
showed the opposite conclusion. In 2 of 6 studies, the number of children
excluding the newborns was found to independently influence paternal
PPD. Two of three articles showed difficult parent-infant interaction was
associated with paternal PPD. Two of four articles identified family
history of mental illness as an influencing factor of paternal PPD. No
correlations were identified between paternal PPD and family setup (joint
vs. nucleus), family type (monogamy or polygamy), marriage or
relationship length (years), family and external environment (defined as
family support and neighborhood relations) and separation of couples
after childbirth.

3.4 Meta-analysis of Pooled OR and Heterogeneity Test

Table 3 showed 17 influencing factors included in the meta-analysis
about spouse, maternal and family (See Appendix III for forest plots).
After combining OR, 9 factors are statistically significant. For spouse
factors, unemployment (OR=2.59; 95%CI:1.42-4.74), low social support
(OR=1.05; 95%CI:1.03-1.08), negative life events (OR=1.45; 95%CI:
1.13-1.78), perceived stress (OR=1.08; 95%CI: 1.03-1.12), financial
strain (OR=2.07; 95%CI: 1.13-3.81), and history of mental illness
(OR=3.48; 95%CI: 2.49-4.86) were associated with PPD. However, age,
educational level, and postnatal smoking were not correlated with
paternal PPD. On maternal factors, parity (OR=1.36; 95%CI 1.13-1.65)
and maternal postnatal depression (OR=1.17; 95%CI 1.03-1.33) increased
the prevalence of experiencing elevated paternal PPD. Moreover,
unexpected pregnancy) and maternal prenatal depression were not found
to be associated with paternal PPD. On family factors, low marital
relationship satisfaction (OR=1.40; 95%CI 1.22-1.61) were related with
paternal PPD. Married status, close relatives with depression and low
household income were not found to be associated with paternal PPD.
In addition to the factors noted above, some other influencing factors with
OR value but less than three numbers were listed in the Appendix IV.
Further study is needed to confirm the relationship between these factors
and paternal PPD.

Heterogeneity tests were carried out on all studies and we found high
heterogeneity for most pooled estimates (Table3). Factors with less
heterogeneity (PQ> 0.05 and I2 <50.0%) were age, social support,
negative life events, parity, unexpected pregnancy and close relatives
with depression, of which a fixed effect model was used to pool
ORs(95%CI). Besides, the test of heterogeneity was highly significant for
the remaining 11 factors (I² ranged from 64.9 to 97.9).
3.5 Subgroup Analysis
The results of a subgroup analysis of 11 factors with significant
heterogeneity were shown in Appendix V. Regrettably, no heterogeneity
was explained by geographic location, study type, or quality score. For all
comparisons, the heterogeneity of research in developed countries was
greater than that in developing countries, mainly because of the large
number of studies in developed countries, resulting in poor internal
consistency. Comparing the subgroups of study design, we find that OR
values of cross-sectional studies were larger, and the confidence intervals
were also wider. Subgroup analysis of study quality reduced the
heterogeneity of meta-analysis data to a certain extent, but it did not
prove that it was the source of heterogeneity.
3.6 Sensitivity Analysis
Sensitivity analysis was done to assess the impact of each study on the
overall effect size using the leave-one-out method (Figure 2). Generally,
except for maternal postnatal depression and marital relationship
satisfaction, the combined values of other factors fall within the 95%
interval of the total pooled effect. For maternal postnatal depression and
paternal, after the study of Selina Nath (2016) [45] was omitted, the results
of the remaining 5 studies showed no statistical significance. Among the
6 studies on maternal postnatal depression, the study of Selina Nath (2016)
[45]
had the largest sample size, so it had the largest weight in the analysis.
Additionally, two studies influenced the robustness of meta-analytic
findings about marital relationship satisfaction and paternal PPD.
Removing the study of Deborah Da Costa (2019) [56], OR value of total
effect lied out of the 95% confidence interval and the confidence interval
became wider after deleting the study of Selina Nath (2016) [45], but
obviously, the statistical significance of the effect value did not change
4.Discussion & Conclusions
To the best of our knowledge, this is the first systematic review and meta-
analysis summarizing the influencing factors of paternal PPD in first
postpartum year. In this paper, we comprehensively explored a range of
influencing factors on paternal PPD from spouse, maternal, infant and
family aspects, including sociodemographic, psychological, social
environment, health and lifestyle characteristics. In meta-analyses, more
details were given to specific significant factors under each category.
Nine influencing factors for paternal PPD were identified: unemployment,
low social support, negative life events, perceived stress, financial strain,
history of mental illness, parity, maternal postnatal depression and lower
marital relationship satisfaction. A medium effect size (OR≥2) was seen
for the factors unemployment, financial strain and history of mental
illness. A small effect size (OR<2) was observed for the other 6 factors
apart from the three factors of the father noted above.
History of mental illness had the largest effect size on paternal PPD and
studies examining the association between them were the most frequently
reported(n=15). Fathers who have suffered from mental illness are more
psychologically vulnerable. Maternal pregnancy and childbirth may
exacerbate the symptoms of previous mental illness and affect the mental
health of fathers during the perinatal period. Unemployment and paternal
PPD was also found to be positively correlated in this meta-analysis.
However, in a previous study of Japanese fathers at one month
postpartum, employment status was strongly correlated with paternal
PPD [31]. To confirm the association between paternal PPD and
employment, researchers need to recruit more employed and unemployed
fathers and consider the influence of background cultures. It is certain
that unemployment will inevitably lead to a decrease in income, while the
increase in the cost of raising a child will make the father feel financially
strained. Besides, having a baby is most likely to add new responsibilities
and parenting stress on new fathers. The continuous sense of stress within
perinatal period may cause fathers to feel melancholic and lead to
depression [32]. Concurrently, if the father is feeling depressed in the
prenatal period, the stressors related to childbirth and a new baby may
aggravate the symptoms of PPD[64]. The association between negative life
event and paternal PPD further supports the findings by Vicenta Escriba`-
Agu¨ir et al. (2011) [33] and Pamela Massoudi et al. (2016) [43]. Negative
life events such as conflicts within family, serious illness or injury of
close family member, traffic accidents and loss of significant others can
lead to negative emotional problems. Notably, more negative life events,
were more likely to cause obvious and persistent threat to people and
damage their physical and mental health. The result of the current meta-
analysis shows that lack of affective and confidant social support will
increase the risk of PPD for fathers. This is because the support and
understanding of relatives and friends can weaken the negative effects of
psychological stress.
An interactive relationship between the mental health of the fathers and
mothers has been noted previously[64-65].Many factors are interrelated.
The mother's depression prevents father from telling her about the
difficulties he faced with his fatherhood, which is more likely to lead to
marital crisis. In addition, depressed mothers cannot take care of their
babies better, which makes fathers feel more stressful. Maternal
depression and reduced baby care may also lead to deterioration of the
marital relationship satisfaction between mother and father. This, in turn,
may cause distress to the father, leading to depression [14]. Parity was
calculated as the number of a woman's live births (excluding miscarriages
and stillbirths) prior to delivery. It should be noted that biological
children with another partner or step children aren’t included. The same
father and mother with more than one live birth before the investigated
gestation were defined as experienced parents(parity ≥2). The effect of
parity was evident in fathers. Higher depression risk throughout the
postpartum period was observed among experienced fathers than among
first-time ones. Multiparity easily leads to greater parenting burden and
psychological distress. If the father is not able to receive parental
competence, they are more likely to develop PPD.
In order to better understand the causes of paternal PPD and inform
prevention efforts, some important issues remain to be clarified in future
research.
First of all, paternal PPD is a mental disorder resulting from a
combination of vulnerability factors and couple-based factors rather than
a single condition. It is noted that many of these factors are similar with
previous studies about maternal PPD[66], such as economic status, social
support, history of depression, the quality of marriage and whether
planned pregnancy. There is a correlation between the influencing factors
of paternal PPD and maternal PPD. Some other authors have suggested
that maternal depression may play causal role in paternal depression[67-68].
In our meta-analysis, correlation between maternal postnatal depression
and paternal PPD was significant. Maternal PPD is an adverse health
outcome and a strong predictor of paternal PPD. However, additional
evidence is needed to draw firm conclusions about maternal prenatal
depression and paternal PPD. Therefore, researchers should pay attention
to the interaction among factors shared by couples.
Secondly, infant factors remain under-investigated in this meta-analysis.
Because only a small number of researchers focus on infant factors of
paternal PPD and few single studies reported effect values, future studies
are needed to establish those associations. Additionally, the results of
infant factors on paternal PPD in included studies are controversial. For
example, the study of Hidekazu Nishigori (2019) [59] identified newborn
health status as a risk factor for paternal PPD, while the study of Naila A.
Shaheen (2019) [58] demonstrated that it wasn’t associated with paternal
PPD. Given this difference, more evidence is needed.
Thirdly, it's an innovation to accommodate both time-dependent and
time-independent covariates. Some influencing factors were dynamic, but
findings from this study only provided information about a slice of time
in the first postnatal year. Time effect has an unignored impact on
paternal PPD. Vicenta Escriba`- Agu¨ir (2011) [33]and Heather L. Sipsma
(2016) [42] highlighted the association between time and PPD at different
postpartum period. As time goes on, it is important to emphasize factors
of change. For example, a spouse who experienced a change of financial
situation from good to poor may be more likely to have PPD than a
spouse with a poor financial situation all along. Therefore, it may be more
valuable to consider factors that change over time, especially the
transition to parenthood.
Finally, the mechanisms underlying associations between influencing
factors and paternal PPD should be clarified. First, relevant confounding
factors might account for observed associations. Our meta-analysis didn’t
adjust crude associations, therefore the pooled ORs might have
overestimated the association between paternal, maternal and family
factors and PPD risk. Second, this review involved many factors, but the
number and sample size of a single study is limited, the extrapolation and
representativeness of the results are still questionable. Third, factors may
be internally related. For example, unemployment may lead to financial
strain, negative life events may give rise to perceived stress, history of
mental illness and lack of social support contribute additional risk for
worsen mental health. Fourth, causation cannot be established because of
cross-sectional design and unmeasured factors[69]. Future studies need to
determine whether a factor is a protective factor or a risk factor.
Therefore, understanding these mechanisms is essential because they may
inform preventive interventions of paternal PPD.
4.1 Limitations
This study provided a relatively complete picture of the multidimensional
influencing factors of paternal PPD in 37 included articles, and combined
the factors with ORs (95%CI). To identify the small study effect and the
risk of heterogeneity, we employed subgroup analysis with regard to
geographic location, study type and quality score. At the same time, all
influencing factors were discussed separately by paternal, maternal, infant
and family categories. The medium and high quality of included studies
in meta-analysis was another advantage of this study. Nevertheless, there
are several limitations in this paper. First, our meta-analysis only reported
crude associations. Since individuals cannot be randomly allocated to
case groups, there are still many unobserved confounders that can’t be
discussed, such as infant health status, paternal sleep quality, smoking
and drinking, maternal complications during childbirth, which need
further research. Therefore, the pooled ORs might have overestimated the
association between influencing factors and paternal PPD risk because of
inadequate adjustment for confounding. Second, there were 19 cross-
sectional studies and 18 cohort studies among this review, a specific time
point (cross-sectional design) or during a certain follow-up time period
(cohort design) cannot be fully evaluated. It can only be said that the
meaningful factors found are associated factors, because the causal
relationship between the outcome and the independent variables can’t be
completely determined. Thus, it needs to be cautious about this result.
Third, since most studies used self-reporting questionnaires to assess PPD
without standardized diagnosis, we can only describe factors that affect
depressive symptoms. And various PPD measures and cut off scores were
used in various studies. This lack of standardization of outcome variables
makes interpretation of results across studies difficult. Forth, most of the
included studies came from high-income countries, especially from the
United States, there is under-representation of low-income and middle-
income countries. Representation of respondents may be limited because
the investigated associations might be different in other socioeconomic
contexts. Finally, publishing biases have been introduced because of non-
published data, unavailable database and papers published in languages
other than English.
4.2 Conclusions
This review and meta-analysis suggest associations between paternal,
maternal, infant, family factors and PPD. Most of the influencing factors
of paternal PPD were in keeping with previous studies[70] and similar as
those of maternal PPD. This suggests that we should carry out joint
intervention for both paternal and maternal PPD. Our study demonstrated
aggregate quantitative effects of the 17 correlations, to our knowledge for
the first time. Future research could examine the causative factors that
contribute to paternal PPD. In conclusion, influencing factors of paternal
PPD are multiple and complex, prevention targeted to the fathers alone is
not enough. Identifying relevant influencing factors will facilitate the
screening of perinatal depression, as well as provision of differential
mental health services. Specific interventions can then be designed to fit
the profile of influencing factors for each individual father. Paternal
postpartum health plan should be strengthened and integrated in primary
health care to prevent PPD. Moreover, it is imperative that epidemiology
and public health approaches should be taken to prevent PPD from both
personal and family perspectives.
 Author Statement
Contributors
D.W., Y.-L.L., D.Q. and S.-Y.X. conceived and designed the study. D.W.,
Y.-L.L. searched the literature and extracted data. D.W. and D.Q.
performed the statistical analysis. D.W. drafted the manuscript while Y.-
L.L., D.Q. and S.-Y.X. critically appraised it and revised it. All authors
read and approved the final manuscript.

Acknowledgements
The authors would also like to thank Dr. Wei Zhou of Hunan University
for the advice on the study design, PhD. Lu Niu of Central South
University and PhD. Yu Yu of Yale School of Medicine for revise
opinion.

Funding
This research was supported by the Ministry of Science and Technology
of China (Grant NO: 2016YFC0900802).

Conflict of Interest
The authors have no conflict of interest to declare.
Figure 1 PRISMA flow diagram about the process of study selection.
Figure 2 Forest plots of the sensitivity analysis of the associations
between each factor and paternal PPD
Table 1 Descriptive information for 37 studies included in systematic review and
meta- analysis
First Y Publication Co Stu Me Cuto Meas Sam Q Wheth
Autho e un dy as ff ure ple u er
r a try Ty ur Time Size al Includi
r pe e Valu of it ng OR
To e PPD y
ol S
c
o
r
e
M.E.G 1 British Journal of Po Co SA / 3-12 42 Mediu Yes
. 9 Psychiatry rtu hor
DS month m
AREI 9 gal t /E s
A [24] 6 PD
S
LEAT 1 Journal of US Cro CE / 6 10 Mediu No
HERS, 9 Nervous and A ss- S- month 8 m
SONY 9 Mental Disease sect D s
A J. 7 ion
[25]
al
Sonya 2 American US Cro CE 16 4 12 Mediu No
J. 0 Journal of A ss- S- month 4 m
Leathe 0 Orthopsychiatry sect D s
rs [26] 0 ion
al
MICH 2 Journal of Au Cro EP EPD 6 19 Mediu No
AEL 0 Reproductive and str ss- DS S≥ month 3 m
DUDL 0 Infant ali sect /B 12; s
[27]
EY 1 Psychology a ion DI/ BDI
al G ≥10;
H GHQ
Q ≥5
M. 2 Archives of Sw Cro EP 9/10 1 10 Mediu No
Edhbo 0 Women's Mental ed ss- DS week 6 m
rg [28] 0 Health en sect and 2
5 ion month
al s
Paul 2 Journal of the U Co EP 12 8 83 Mediu Yes
G. 0 American K hor DS weeks 32 m
Ramch 0 Academy of t
andani 8 Child and
[29]
Adolescent
Psychiatry
JANIC 2 Infant Mental US Cro EP 10 2and3 12 Mediu No
E H. 0 Health Journal A ss- DS month 8 m
GOOD 0 sect s
MAN 8 ion
[30]
al
Akiko 2 Nursing and Ja Cro CE CES- 4 13 Mediu Yes
Nishi 0 Health Sciences pa ss- S- D≥1 weeks 3 m
mura 1 n sect D/ 6;
[31]
0 ion EP EPD
al DS S ≥8
Qing 2 Journal of Ch Cro EP 13 6-8 37 Mediu No
Mao 0 Clinical Nursing ina ss- DS weeks 6 m
[32]
1 sect
0 ion
al
Vicent 2 J Epidemiol Sp Co EP 11 3and1 66 High Yes
a 0 Community ain hor DS 2 9
Escrib 1 Health t month
a`- 1 s
Agu¨ir
[33]

Bárbar 2 Journal of Po Cro EP / 3 26 Mediu No

a 0 Affective rtu ss- DS month 0 m
Figueir 1 Disorders gal sect s
edo [34] 1 ion
al
Terrini 2 Journal of Black US Cro CE 16 6 59 Mediu No
ekaT. 0 Psychology A ss- S- weeks m
Willia 1 sect D
ms [35] 2 ion
al
Daniel 2 Journal of US Co EP 10 15and 92 Mediu No
le 0 Affective A hor DS 21wee m
S.Rou 1 Disorders t ks
binov 3
[36]

Wende 2 Journal of Au Cro EP / 0-24 21 Mediu No

ll D 0 Psychosomatic str ss- DS weeks 9 m
Cocks 1 Obstetrics & ali sect
haw 4 Gynecology a ion
[37]
al
Fei- 2 Journal of Ch Co G 4/5 6 20 Mediu No
Wan 0 Psychosomatic ina hor H month 0 m
Ngai 1 Research t Q s
[38]
4
Y. W. 2 Depression Ch Cro EP 12/1 6 62 Mediu No
Koh 0 Research and ina ss- DS 3 weeks 2 m
[39]
1 Treatment sect
4 ion
al
Akiko 2 BMC Pregnancy Ja Cro EP 8 4 80 Mediu Yes
Nishi 0 and Childbirth pa ss- DS month 7 m
mura 1 n sect s
[40]
5 ion
al
Maria 2 Pediatric Reports ItaCro EP 5/6 1 75 Mediu No
Stella 0 ly ss- DS month m
Epifan 1 sect
io [41] 5 ion
al
Heathe 2 Matern Child US Co CE 13 12 18 High Yes
r L. 0 Health J A hor S- month 9
Sipsm 1 t D s
a [42] 6
Pamel 2 Scandinavian Sw Cro EP 12 3 88 Mediu Yes
a 0 Journal of Public ed ss- DS month 2 m
Masso 1 Health en sect s
udi [43] 6 ion
al
Maiko 2 Research in Ja Co EP 8 3 21 Mediu Yes
Suto 0 Nursing & pa hor DS month 5 m
[44]
1 Health n t s
6
Selina 2 BMC public U Co R / 9 12 Low Yes
Nath 0 health K hor MI month 39
[45]
1 t -9 s 6
6
Jana 2 Journal of Ge Co EP 12 2 27 Low No
Eos 0 Affective rm hor DS weeks 6
Andin 1 Disorders an t
g [46] 6 y
Laura 2 Frontiers in Ita Co EP 8/9 3-6 18 Mediu No
Vismar 0 Psychology ly hor DS month 1 m
a [47] 1 t s
6
Yin- 2 Midwifery Ch Co EP 9/10 3days, 18 Low No
Ping 0 ina hor DS 2week 0
Zhang 1 t s and
[48]
6 6week
s
Olajid 2 Cultural US Co EP 9 1and1 30 Mediu No
e N. 0 Diversity and A hor DS 2 6 m
Bamis 1 Ethnic Minority t month
higbin 6 Psychology s
[49]

Lisa 2 JAMA Ne Co PH 9 9 35 High Yes

Under 0 Psychiatry w hor Q- month 23
wood 1 Ze t 9 s
[50]
7 ala
nd
Brenda 2 Community Ca Co EP 9 3 10 Mediu Yes
M. Y. 0 mental health na hor DS month 43 m
Leung 1 journal da t s
[51]
7
Olatun 2 Journal of Ni Co SC / 6 33 Mediu No
de 0 Psychosomatic ger hor ID weeks 1 m
Ayinde 1 Obstetrics & ia t
[52]
7 Gynecology
Magda 2 American Sw Cro EP 10/1 3 ~6 25 Mediu Yes
lena 0 Journal of Men’s ed ss- DS 2 month 8 m
Carlbe 1 Health en sect s
rg [53] 8 ion
al
Lloyd 2 Midwifery Ire Cro EP 1 12 10 Mediu Yes
Frank 0 lan ss- DS month 0 m
Philpot 1 d sect s
t [54] 8 ion
al
Azam 2 Psychiatry Ira Cro EP 10 8 40 Mediu No
Maleki 0 Research n ss- DS weeks 3 m
[55]
1 sect
8 ion
al
Debor 2 Journal of Ca Co EP 10 2 and 48 Mediu Yes
ah Da 0 Affective na hor DS 6 7 m
Costa 1 Disorders da t month
[56]
9 s
Chen 2 Journal of Ch Co EP 9/10 12 53 Mediu Yes
Yi- 0 Affective ina hor DS month 1 m
Han 1 Disorders t s
[57]
9
Naila 2 American Sa Cro EP 9 6 29 Mediu Yes
A. 0 Journal of Men’s udi ss- DS month 0 m
Shahee 1 Health Ar sect / s
n [58] 9 abi ion DS
a al M-
5
Hideka 2 The Journal of Ja Co EP 8 1and 13 Mediu Yes
zu 0 Maternal-Fetal & pa hor DS 6 30 m
Nishig 1 Neonatal n t month
ori [59] 9 Medicine
HANN 2 Journal of Social De Cro EP 10 10 21 Mediu No
E 0 and Clinical nm ss- DS month 1 m
NØRR 1 Psychology ark sect s
FENT 9 ion
Z [60] al
Table 2 Influencing factors of paternal PPD in 37 studies
Maternal Infant
Paternal Factors Family Factors
Factors Factors

Age
Infant
[29,31,37,40,44 Parity
Intimate Partner Gender Region
- [31,34,40,44,49,
Violence [42] [32,37,45,4 [49,50,53]
46,48,50,52,53, 50,57]
8]
55,56]

Education
Desired
Level Number of
Adverse Childhood Pregnancy
[27,29,31,37,43 Newborns Religion [36,52]
Experience [46,60] [31,39-
-46,48-50,52- [58]
41,44,50,58,60]
54,58]

Pregnancy with
Full-Term
Ethnicity Paternal Infertility
Infant Family Setup [58]
[45,50,56] Neuroticism [27] Treatment
[31,54]
[31,40,58]

Mode of Infant Age

Experiences of Poor Social Family Type
Delivery (Weeks)
Racism [49] Adjustment [24] [52,58]
[28,48,58] [37]

Infant
Complications
Social Class Psychological Temperam Marital Status
During
[24] Distress [46,59] ent [49,50,52-54,58]
Childbirth [58]
[27,37,45]

Maternal
Prenatal or
Psychosocial
Postpartum
Resilience Infant Marriage/Relatio
Depression
Immigration Resources Sleep nship Length
[24,27-
[46] [25,26,32,33,35,37- Behaviors (Years)
30,32,33,36,38-
39,42- [37,54] [52,55,60]
41,43-
44,46,49,51,54,58]
47,50,52,56,58-
60]

Marital
Employment Relationship
Infant
Status Negative Life Event Maternal Satisfaction
Feeding
[31,36,40,43,45 [24,31,33,37,43,46,4 Prenatal Anxiety
Behaviors
,48,50,52,56,58 9,51,58] [29] [26,27,30,33,35,3
[37]
-60] 6,38-40,42-46,48-
50,56,58,60]

Perceived Stress Household

Infant
Working Hours [30,32,35, Maternal Sexual Income
Health
[43,44,58] 38,41,46,47,49,50,5 Abuse [27] [44,45,51,55,58,5
[58,59]
6,60] 9]

Working History of Mental Postpartum Care Separation of

Efficacy Health Disorders [54,58] Couples After
[25,39] [24,26,28,29,31,33,3 Childbirth [58]
5,38,43,44,46,47,50,
51,54,55,59,60]

Number of
Monthly Knowledge of Infant
Children
Income [48,53] Care [48]
[29,43,52,53,58]

Parents–Infant
Financial Strain Parenting Style
Interaction
[40,54,56,60] [27,37]
[28,30,46]

Positive Parental Family History of

Sleep Quality
Experience Mental Disorder
[48,56]
[25,46,48] [29,40,58,60]

Family and
Health Status Cigarette Use External
[50] [42,50,51] Environment
[38,49,50]

Accommodatio
Alcohol
n Owner
Consumption [50]
[45,54,58]

Accompanied
Any Marijuana Use
Delivery
[42]
[27,58]
Table 3 Results of Meta-analysis and Heterogeneity test
Te
st For
Eff
Variance ect 95 Overa
N Sampl Between Mo Poole % ll
Factors o. e Size Studies del d OR CI Effect

I2 (P
(% Val
P(Q) ) ue)
Paternal
Factors

0.99-
Older Age 8 26139 0.136 36.8 FE* 1.01 1.04 0.233

High
Educational RE* 0.46-
Level 7 25685 0.000 84.5 * 0.72 1.14 0.161

Unemployme 1.42-
nt 6 18564 0.010 66.7 RE 2.59 4.74 0.002

Low Social 1.03-

Support 9 2587 0.045 49.4 FE 1.05 1.08 0.000

Negative Life 1.13-

Events 3 2403 0.167 44.1 FE 1.45 1.87 0.004

Perceived 1.03-
Stress 3 4385 0.057 65.0 RE 1.08 1.12 0.001

Financial 1.13-
Strain 4 1382 0.008 74.9 RE 2.07 3.81 0.019

History of 2.49-
Mental Illness 15 46110 0.000 73.7 RE 3.48 4.86 0.000

Postnatal 0.51-
Smoking 4 8276 0.002 80.1 RE 1.08 2.32 0.835

Maternal
Factors

Parity (2+Vs. 1.13-

1) 5 10765 0.164 38.5 FE 1.36 1.65 0.002

4 4670 0.268 23.8 FE 1.36 0.102

Unexpected 0.94-
 Pregnancy 1.97

Maternal
Prenatal 0.99-
Depression 5 12566 0.022 64.9 RE 1.86 3.49 0.054

Maternal
Postnatal 1.03-
Depression 6 18796 0.003 71.6 RE 1.17 1.33 0.015

Family
Factors

0.28-
Married 3 479 0.024 73.2 RE 1.36 6.70 0.707

Lower Marital
Relationship 1 1.22-
Satisfaction 0 19641 0.000 97.9 RE 1.40 1.61 0.000

Close
Relatives with 0.91-
Depression 3 16954 0.339 7.5 FE 1.18 1.53 0.211

Lower
Household 0.93-
Income 6 15056 0.002 73.0 RE 1.36 1.98 0.111

*Fixed effect model ** Random effect model

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