Helping Fathers in the Perinatal Period: A Mapping Review of Paternal Mental Health Issues for Social Workers

Abstract

The absence of father-focused perinatal research and the prioritizing of child- and family-focused perinatal research is particularly noticeable within social work literature. While recent social work scholarship on research related to paternal mental health and the experience of fathers exists, it is sparse. Focused on what is currently known about helping fathers in the perinatal period, this mapping review was done to explore existing and relevant knowledge related to practices to better serve fathers and their families. Themes among the existing knowledge related to developmental change, traumatic birth, paternal mental health, interventions, neurobiology, and policy will be discussed before concluding with a focus on emerging focal points for future research related to nurturing fathers during perinatal care.

Keywords

fatherhood mental health perinatal paternal

Introduction

Significant research has examined fathers’ mental health from the perspectives of child development and family cohesion (Gere et al., 2013; Giallo et al., 2014; S. J. Lee et al., 2012; Wickersham et al., 2020) and improving father involvement (Henry et al., 2020). This research has drawn strong associations between paternal mental health struggles and negative child outcomes throughout their developmental lifespan. However, comparatively little is known about fathers’ perinatal experiences and how these experiences influence fathers’ psychosocial function. Fisher (2017) described paternal mental health as a “neglected” topic (p. 200), and Goldstein et al. (2020) similarly noted the “paucity of research” on paternal mental health interventions (p. 509).

While it is clear that struggling fathers impact their families, much remains to be clarified about how to help fathers. Understanding fathers’ experiences during the perinatal period (prenatal period through the first year of parenthood, per Singley & Edwards, 2015), is a crucial prerequisite to helping struggling fathers heal and thrive, and to advocate for any needed changes to systems or policies. Recent literature focused on paternal mental health has developed research and clinical parameters, etiological understanding, and next directions (Ansari et al., 2021; Habib, 2012). Most research has examined postnatal depression and anxiety, including prevalence, risk factors, outcomes, and interventions (Rodrigues et al., 2022). Additional research spans the perinatal spectrum and includes epidemiological, clinical, and policy areas. However, scholars agree that more research, advocacy, and clinician exposure to paternal concerns is warranted.

The absence of father-focused paternal perinatal research is particularly noticeable within social work. While recent social work research related to fathers exists (Johnson & Briggs, 2021; Trahan & Shafer, 2019; Walsh et al., 2014), it is comparatively sparse. A body of critical scholarship has suggested problematic conceptualizations of fatherhood within social work research, from deficit-based views to general exclusion (Greif & Bailey, 1990; Greif & Greif, 1997; Shapiro & Krysik, 2010; Strug & Wilmore-Schaeffer, 2003; Zanoni et al., 2013). Baum (2016) contended that “fathers’ emotions and needs have tended to go unrecognized and unacknowledged in social work literature and practice” (p. 1465). In a 2016 Social Work Research editorial, Shafer and Bellamy challenged the field to address its research and practice “disservice” to fathers and argued that social work has both an ethical responsibility and a uniquely effective ability to do so (p. 199).

Shafer & Bellamy’s (2016) challenge to provide ethical, equitable, and competent care to fathers remains unmet in the area of paternal mental health (Johnson & Briggs, 2021). As importantly, social workers can add to the literature in unique and substantial ways. Thus, it is crucial that social workers gain a thorough introduction to paternal mental health research and practice knowledge. This article seeks to contribute a mapping review of the literature to help social workers identify the breadth of useful clinical knowledge, and the gaps and challenges. In addition, this review fundamentally seeks to honor social work’s strengths-based orientation by encouraging workers to further the research and practice knowledge that can help fathers.

Methods

Mapping Review Aims and Objectives

Mapping reviews are a relatively new review methodology with good utility for conceptualizing a large and underexplored research area. Mapping reviews follow systematized search methods similar to systematic reviews; however, mapping reviews seek breadth instead of depth and do not include bias risk evaluation in their evidence selection. Like scoping reviews, mapping reviews aim to identify a topic’s parameters and key concepts. However, mapping reviews are more inductive, not guided by a PICO-type question, and are more appropriate for projects with >40 articles (Arksey & O’Malley, 2005; M. J. Grant & Booth, 2009; Miake-Lye et al., 2016). The mapping review’s chief functions are to categorize evidence production to “pinpoint specific knowledge gaps” and to “make vast bodies of literature accessible, digestible, and usable” (Miake-Lye et al., 2016, p. 4).

These features make a mapping review ideal for a social work-focused exploration of extant paternal mental health research. The paternal mental health literature is broad and often not interdisciplinary: multiple aspects of paternal mental health are researched with infrequent coordinating or cross-referencing. This article’s primary aim is to identify the literature’s breadth to organize and contextualize cohesive findings for social workers. The first objective is to offer social workers a “digestible” global overview with sufficient detail to increase knowledge of key concepts and results. The second objective is to highlight relevant clinical implications. The secondary aim is to identify needs, gaps, and limitations to highlight research and practice needs and encourage social workers to bring our unique strengths and lenses to the topic.

Search Protocol

Three highly-populated databases were systematically searched to identify literature related to paternal mental health: Web of Science Core Collection, APA PsycArticles, and Academic Search Premier. The Web of Science Core Collection included six indices and over 21,000 peer-reviewed journals covering multiple academic disciplines. APA PsycArticles and Academic Search Premier were available institutional resources chosen specifically for comprehensiveness and overlap: APA PsycArticles includes access to all peer-reviewed APA journals and allied health fields; Academic Search Premier’s vast multidisciplinary database captures articles outside the allied health fields. Due to feasibility and duplicate article concerns, the search protocol excluded additional databases, gray literature, and other related non-research literature. Databases were searched in May 2023 using a Boolean rubric, for peer-reviewed, full-text, English-language articles from 2013 to 2023. To increase search results, search term fields remained unspecified; additionally, Academic Search Premier and APA PsycArticles searches were expanded to apply equivalent subjects, and the Web of Science Core Collection search was not limited by exact terms. Terms were constructed to capture articles related to fathers’ perinatal experiences and to control for the robust literature on maternal mental health:

Term: paternal mental health or father mental health or dad mental health

Term: father* AND “mental health”

Term: father* AND perinatal AND mental

Term: father* AND childbirth AND mental

The initial article search produced a total of 7,221 articles (161 APA PsycArticles; 1,586 Academic Search Premier; 5,474 Web of Science Core Collection). The first author manually assessed these results by article title for inclusion/exclusion criteria, with Figure 1 depicting the flowchart of the process. When needed for clarity, article abstracts were then also reviewed for inclusion/exclusion criteria. Articles were included for initial review if they measured, described, or otherwise focused on the mental health experiences and needs of fathers during the perinatal period (antenatal period through first year after birth). Articles were excluded from initial review if they focused on child development, maternal mental health, family/marriage outcomes, or if otherwise unrelated to paternal mental health. 360 articles met these initial criteria (16 APA PsycArticles; 88 Academic Search Premier; 256 Web of Science Core Collection). The first author reviewed these articles’ abstracts to further ensure adherence to inclusion/exclusion criteria. Articles were excluded if a detailed search of sample demographics and study methods noted that children were older than 1 year at the time of inclusion; conversely, articles were included if no child age was noted. Brief editorials and brief clinical opinion papers not describing unique data or distinct interventions were excluded. After this review, 300 articles met criteria (14 APA PsycArticles; 77 Academic Search Premier; 209 Web of Science Core Collection). Articles from all databases were then grouped together in Microsoft Excel for duplicate deletion. The final article set included 253 articles. The second author subsequently reviewed this search for agreement.

The final article set (253) was then analyzed and thematically categorized manually by the first author using methodology developed by Arksey and O’Malley (2005) and refined by Levac et al. (2010). This “charting” process first organized article characteristics with a preset data charting form (Microsoft Excel). Information included descriptors such as publication year, journal title, the journal’s academic discipline, study type, article focus, and perinatal phase. Articles were then categorized thematically into distinct research areas through an inductive, iterative, open coding process using standard thematic analysis (Arksey & O’Malley, 2005; Braun & Clarke, 2006) methods. The second author verified this analysis with investigator triangulation for accuracy and agreement. By examining the codes and themes from the initial analysis, this aided in the credibility of the study as the codes were in agreement or accurately reflective of the data (Farmer et al., 2006).

Results

Article analysis and thematic categorization generated six distinct research areas of paternal mental health research. Each research area is summarized and details additional information including key clinical and research points, unique studies and emerging areas of interest. Randomized controlled trials (RCTs), current systematic reviews, and current meta-analyses are highlighted. Each section also identifies and critically explores clinical and research gaps and needs (Arksey & O’Malley, 2005; M. J. Grant & Booth, 2009; Miake-Lye et al., 2016). The objectives are to map and describe pertinent clinical practice knowledge and potential implications for practice.

Research Area 1: Fatherhood Identity Shifts (23/253 Articles)

Summary

This research area concentrated on the experiences of preparing for fatherhood, becoming a father, and beginning the postpartum period. Papers identified a similar process of emotional and identity transition over time, with multiple phases and what Lagarto & Duaso (2022) described as a “trigger moment” culminating in positive change. A particular strength of these papers is the normalization of negative, “taboo” (Solberg et al., 2023) emotions and related difficulties during the perinatal period.

Key Clinical and Research Findings

Multiple researchers used phased transition concepts to describe the process of creating a successful fathering identity. Each described a period of stress and disequilibrium followed by new homeostasis and sense of mastery. Kowlessar et al. (2015) likened the process to rituals and rites of passage: separation, transition, and eventual incorporation. Study participants frequently reported significant negative emotion and cognitions during this process: fear and insecurity, resentment, anger, helplessness, jealousy, and exhaustion (des Robert et al., 2021; Kowlessar et al., 2015; Solberg et al., 2023). In one mixed-methods analysis, half of the 871-father sample reported struggling prior to childbirth (Johansson et al., 2015). However, studies normalized these experiences and confirmed them as predictable aspects of identity change, which reliably culminated in feelings of mastery around being a new father. Several researchers also explored the identity change process for various marginalized fathers, including fathers who had entered foster care after suffering childhood trauma, adolescent, low-SES, Latinx fathers (Recto & Lesser, 2020), teenage males struggling with delinquency, and African American fathers (Dilworth-Bart et al., 2022). Resources and factors aiding the identity development process include contact with midwives during the postpartum period (Brunstad et al., 2020), fostering father-inclusive provider norms (Kothari et al., 2023), robust and father-inclusive antenatal education programs (Kowlessar et al., 2015), and paternal connection to the mental concept of a fetus via ultrasounds, physical sensation, and nursery preparation (Lagarto & Duaso, 2022).

Gaps and Future Needs

Missing from this literature is a discussion on clinically supporting fathers and intervening early in the change process. Although the literature suggests overall that the process reliably resolves in favor of a prepared fatherhood identity, this outcome is certainly variable. Scoping the psychoanalytic/psychodynamic literature for ideas on supporting prenatal anxiety and helping expectant fathers with internal conflicts could be informative. Studying the use of mentalization and attachment concepts as prenatal psychoeducation might be worthwhile.

There are not enough published or easily accessible papers on the experiences of marginalized fathers, especially in the context of systematic racism. Relatedly, very little is known about how to help support marginalized fathers if they present with prenatal distress. Cooper et al.’s (2021) research suggests Black fathers do not internalize systemic racism around their fathering identities and navigate this process quite skillfully with their children. However, the intersection of economic resources with race, ethnicity, and other marginalized identities likely influences these outcomes, and needs more study.

Research Area 2: Traumatic Birth (24/253 Articles)

Summary

This research area focused on fathers’ traumatic birthing experiences: witnessing birth trauma, miscarriage and stillbirth, preterm birth, and infant neonatal intensive care unit (NICU) admission. Researchers consistently noted the lack of research on these experiences (Miller et al., 2019). Factors include policy/practice issues in health systems (Shafey et al., 2022) and the tendencies of fathers to, “Be Quiet and Man Up” (Daniels et al., 2020) in the face of birthing trauma. The research included qualitative accounts of fathers’ needs and experiences, and quantitative data on outcomes. Research Area 2 brings attention to what the knowledge base considers a salient experience for fathers; thus, a major focal point for practitioners.

Key Clinical and Research Findings

Fathers experiencing traumatic birth scenarios most often complained of poor communication and poor support from medical and clinical staff (Vallin et al., 2019). Per the literature, clinicians tend to “push aside” fathers during crises and not reconnect with them (Elmir & Schmied, 2022; Jarneid et al., 2020). Elmir & Schmied (2022) reported that antenatal psychoeducational preparation is a helpful solution. Vallin et al. (2019) reported that “valuable actions” by clinicians included keeping fathers informed verbally, sharing digital pictures of childbirth, and offering support. When fathers experience the trauma of miscarriage/stillbirth, they tend to report fewer symptoms but engage in more avoidance-based coping including minimizing feelings and alcohol abuse (Jones et al., 2019). Per Miller et al. (2019), fathers avoid their own feelings because they view their job as supporting their partner.

For preterm birth, the most commonly cited issue is reactive postpartum hypervigilance, which can significantly affect fathers’ ability to self-soothe and bond with their infant (O’Donovan & Nixon, 2019; Premji et al., 2020). O’Donovan and Nixon (2019) recommended trauma-informed postpartum care for fathers of preterm infants. Fronheiser et al. (2023) recommended cognitive processing and narrative therapy interventions, and showed that these interventions matched with saliva-measured cortisol reductions. Ozdemir & Alemdar (2017) showed that encouraging fathers to visit and interact with their NICU infants significantly reduced fathers’ stress measures. Shafey et al. (2022) created a father-specific NICU program that has shown promise in supporting, educating, and empowering fathers.

Gaps and Future Needs

Clinical information on postpartum posttraumatic stress disorder (PPTSD) and subclinical symptoms is a significant need. Although one study measured traumatic witnessing stress by fathers (Zacher et al., 2023), more information on prevalence, symptom presentation, and fathers’ experiences is needed. It is likely that fathers underreport these experiences and related symptoms. Ayers’ group previously developed the City Birth Trauma Scale (CBTS) for mothers, and has begun validation work for the CBTS-partner version (Webb et al., 2021).

Fathers’ experiences of obstetric racism is another area where little to no research exists. Clinicians and researchers have become more aware of crisis-level disparities in maternal care and outcomes between white women and women of color. These issues include care access, marginalization during care, perinatal adverse events, and infant/mother mortality—Black women, for example, have higher rates of pregnancy-related deaths than any other population (Taylor, 2020). Davis (2019) coined the term “obstetric racism” to capture this cluster of issues. Research is needed on fathers’ experiences of witnessing, navigating, preventing, and coping with obstetric racism throughout the perinatal period.

Research Area 3: Paternal Mental Health Diagnoses (130/253 Articles)

Summary

This research area claimed the majority of literature. This section’s articles focused on quantitatively measuring prevalence rates of various paternal mental health disorders and the related risk/protective factors, and qualitatively describing fathers’ needs, beliefs, and experiences. Of note, the majority of these articles examined postpartum depression. Relatively few papers explored anxiety, and several disorders were left unexplored.

Key Clinical and Research Findings

Prevalence data on paternal depression and anxiety is available from recently updated and highly rigorous meta-analyses. Leiferman et al. (2021) calculated perinatal anxiety rates at 10.69%, and noted this rate is higher than WHO-based non-perinatal male anxiety rates (2.2%–3.8%). Rao et al. (2020) calculated perinatal depression rates worldwide and found the average prenatal rate was 9.76%, with the prevalence at one-year postpartum averaging 8.75% The authors also calculated average rates at various perinatal timepoints, noting the highest rate at between 3 and 6 months after birth (9.23%). Gray et al.’s (2018) cohort study measured postpartum depression in a huge sample of 3,425 new Jamaican fathers and calculated a similar prevalence rate of 9.1%. No meta-analyses or significant current quantitative father-focused studies have been done on postpartum PTSD, obsessive-compulsive disorder (OCD), psychosis, or substance abuse.

Several papers discussed and evaluated paternal mental health screening instruments. The most prolific screening instrument is the Edinburgh Postnatal Depression Scale (EPDS), developed by Cox et al. (1987) to detect maternal postpartum depression, and subsequently validated for use with fathers. Since its adoption, the EPDS has become a standard inclusion criterion in systematic reviews and meta-analyses of paternal postpartum depression (Ansari et al., 2021; Goldstein et al., 2020). However, subsequent research has continued to call validity and reliability into question, especially around scoring cutoff: the standard cutoff of 12 does not pick up on “minor” depression or anxiety and other distress (Matthey, 2021). Kennedy & Munyan’s (2021) systematic review reports current best practice: using the EPDS with a cutoff score of 10, and following up with the Patient Health Questionnaire (PHQ-9) and individualized assessment.

A particular strength of this research area is the qualitative and quantitative work on risk and protective factors, especially for paternal depression and anxiety. Although recent meta-analyses are not in complete agreement, they all note primary risk factors: maternal depression, unemployment and financial strain, marital strain, previous mental health struggle, high levels of life stressors, low levels of support (Ansari et al., 2021; Chhabra et al., 2020; Wang et al., 2021). Giallo et al. (2013b) identified lack of job control (hours, leave, flexibility) as a critically important subfactor of financial strain. Also reported as risk factors were fear/worry, inadequacy feelings, unmet perinatal expectations, and relationship strain (Shorey & Chan, 2020). Recto & Champion (2020) used a psychosocial-ecological lens and reported a host of micro, mezzo, and macro-level factors. Unique factors included identifying as African American or Latinx, relationship with parents, racism, inadequate housing and transportation access, and maladaptive coping styles. Multiple studies also reported approach-based and avoidance-based coping as a significant strength or risk factor, respectively (Bamishigbin et al., 2017; Livingston et al., 2021; Paredes & Parchment, 2021; Seymour et al., 2014).

Gaps and Future Needs

The experiences of fathers with significant childhood trauma needs more research. While poor outcomes from abuse history are well-established generally, less is known about fathering outcomes. This area is important as stigma and shame likely contribute to fathers’ underreporting and difficulties asking for help. Two studies noted links between traumatic history and fathering difficulties. Skjothaug et al.’s (2015) Norwegian cohort study found higher anxiety and depression scores throughout the perinatal period from fathers who reported high adverse childhood events (ACEs) scores. Doi et al. (2022) measured the association between high ACEs scores and postpartum depression in a Japanese cohort and found a strong association in the first weeks postpartum that weakened significantly by the third month postpartum.

Research Area 4: Interventions (44/253 Articles)

Summary

Interventions for paternal perinatal mental health struggles are an unmet priority in paternal mental health research. While a strong literature base describes the risks, prevalence, and experiences of paternal perinatal struggles, effective intervention data remain elusive. This research area includes data on interventions and on a group of papers that examine support-seeking and needs assessment. Due to the lack of successful clinical interventions, support-seeking activities are important to explore. Needs assessment additionally informs intervention possibilities and likelihood of success.

Systematic Review Findings

Wee et al.’s (2013) review noted a lack of paternal mental health intervention research, including the near-total absence of RCTs. Subsequent high-quality systematic reviews found RCTs with pre/post data on paternal perinatal depression, anxiety, and stress (M. L. Fisher et al., 2022; Goldstein et al., 2020; Rodrigues et al., 2022; Rominov et al., 2016). Although each systematic review has advanced the intervention literature, the small pool of available studies has led to incremental additions and similar conclusions in each review. M. L. Fisher et al. (2022) was the only review to report low bias risk and low methodological concerns in their study sample. Previous reviews (Goldstein et al., 2020; Rodrigues et al., 2022; Rominov et al., 2016) noted methodological flaws in their samples, including studies using depression and anxiety scores from fathers who do not meet criteria for either disorder.

These systematic reviews have drawn similar conclusions about intervention efficacy and meaningful clinical results. Behavioral skills including infant and partner massage and infant bathing (Rominov et al., 2016), physical fitness and nutrition programming (Goldstein et al., 2020), and relaxation training (M. L. Fisher et al., 2022) were all shown to be the most effective interventions to date. This was further confirmed in a study using group exercise for fathers (Giallo et al., 2022) which reported significant reductions in depression, anxiety, and stress scores maintained 3 months’ postpartum. In addition, antenatal education was shown to be effective, and superior to postnatal education (M. L. Fisher et al., 2022; Goldstein et al., 2020; Rodrigues et al., 2022; Rominov et al., 2016). Interestingly, couples-based interventions were consistently shown to be ineffective (M. L. Fisher et al., 2022; Goldstein et al., 2020; Rominov et al., 2016). M. L. Fisher et al. (2022) hypothesized that couples’ classes triggered male role expectations and hindered fathers’ access to their own feelings and needs, which matches cohort report data from Ghaleiha et al. (2022). Review authors consistently advocated for the future development of CBT-based interventions. However, a pilot study by Tandon et al. (2021) using a 12-session CBT framework had no significant effects on depression or anxiety. The authors reported that significant adherence/attendance difficulties informed results.

Support Seeking and Needs Assessment

A group of papers explored fathers’ preferences for nonexpert, mutually supportive online communities, and online information sources (Eriksson & Salzmann-Erikson, 2013; Giallo et al., 2017; Ndzi & Holmes, 2022; Rominov et al., 2018; Wade et al., 2022). Giallo et al. (2017) and Ndzi and Holmes (2022) reported that factors related to online preference include control needs, emotion minimizing, and adherence to stoicism values. Studies exploring Facebook communities noted high levels of mutual support, reported fathering improvement, and a means to normalize experiences (Mancini et al., 2023; McLeod, 2020). Da Costa et al. (2017) found that fathers’ top online searches included infant care, relationship management, sleep concerns, and stress management.

Gaps and Future Needs

More and better-quality research on interventions is sorely needed. Systematic reviews have so far only been able to evaluate studies with fathers who have subclinical pre/post depression, anxiety, and stress screening scores. RCT’s specifically focused on treating postpartum paternal disorders are necessary. There is a specific need for perinatal substance abuse interventions: multiple studies reported substance use as a common paternal externalizing symptom (Giusto et al., 2021; Goldstein et al., 2020; Jones et al., 2019; Livingston et al., 2021).

More research on peer mentoring and mutual aid relationships are needed. Peer mentoring interventions might successfully resolve the contradiction between fathers’ reports of wanting anonymity (Isacco et al., 2016) and their reports of feeling ignored. Fletcher et al. (2017) reported that asking Aboriginal elders and leaders to help develop a text and app support system for Australian Aboriginal fathers led to high rates of app use, adherence, community pride, and engagement. Similarly, Giusto et al. (2021) asked a cohort of local Kenyan fathers to train in behavioral activation and motivational interviewing and serve as peer mentors to new fathers with problem drinking behaviors. The authors reported high intervention success rates, and also high fidelity to treatment models.

Research Area 5: Neurobiology (5/253 Articles)

Summary

The neurobiology research area is a small but unique literature base focusing on understanding fundamental and generalizable changes in response to fatherhood instead of distress, symptoms, and treatment. The research implications are exciting and potentially important in studying paternal mental health. To date, the most intriguing work has been on neuroplasticity and hormonal actions in service of social fatherhood functions.

Key Clinical and Research Findings

Evidence for paternal neuroplasticity is significant (Kim & Swain, 2007), and has important clinical implications. Magnetic resonance imaging (MRI)-based research has found that brain volume changes in response to pregnancy and childbirth; these changes support better relating, child care, and infant developmental needs. Researchers have termed these brain areas the “global human caregiving network” (Feldman et al., 2019) and suggest this network reliably develops in response to infant care. Fathers experience gray matter increases in the prefrontal cortex, anterior cingulate cortex, and amygdala, and decreases in the orbitofrontal cortex (OFC). These changes improve emotional comprehension and relational ability, and are protective against anxiety, depression, and related threat hyperfocus. Fathers’ unique OFC decreases are directly associated with increased physical play/stimulation, which aids infants’ ability to develop regulation. Fathers also experience unique changes to their superior temporal sulcus (STS), which fosters mentalizing and related cognitive processing of non-verbal infants (Swain et al., 2014). Feldman et al. (2019) further reported that daily child interaction increased amygdala-STS connectivity, suggesting that improved neural coherence can be actively enhanced.

Research has also shown hormones coordinate with these neurological changes. Testosterone decreases in response to pregnancy and childbirth and again in response to child care and play, which contributes to family investment. Vasopressin, prolactin, and oxytocin levels also increase (plasma oxytocin increases significantly postpartum), which increases infant play, touch, care, attention, and protection; and inhibits paternal aggression (Abraham & Feldman, 2022; Feldman et al., 2019; Saxbe et al., 2018; Swain et al., 2014). These changes appear to reliably begin during pregnancy, which potentially suggests an evolutionary basis for fathering behavior (Saxbe et al., 2017).

Gaps and Future Needs

Papers in this study sample readily acknowledged that much research is needed to better understand paternal neurobiology. Generally, the opportunity exists to go beyond psychological theory and observation in understanding fatherhood dynamics and function. Researchers are particularly interested in exploring vasopressin’s role in facilitating paternal neuroplasticity and understanding whether testosterone reduction is static or more a dynamic response to environment. Factors limiting research conclusions include small sample sizes in MRI-based research, the difficulty in isolating causation, and the complex ecological context in fathering (Abraham & Feldman, 2022; Feldman et al., 2019; Kim & Swain, 2007; Swain et al., 2014). Another important area is the potential interactions between disorders and the global human caregiving network, particularly whether disorders blunt network development.

Research Area 6: Policy and Advocacy (27/253 Articles)

Summary

This research area focuses on systems and policies, and disparities and marginalization ripe for advocacy work. This section’s small portion of articles is notable given that this section does not focus on a single policy, system, or aspect of marginalization. The relative paucity of articles is indicative of significant unmet needs within paternal mental health research. Thirteen papers focused on systemic barriers for fathers, 11 focused on specific disparities and marginalization experiences, and three focused on paid family leave policy.

Key Clinical and Research Findings

Studies conceptualized fathers as marginalized generally in the context of perinatal health systems. Multiple papers explored paternal marginalization and exclusion in perinatal practice (Baran & Sawrikar, 2023; Campbell et al., 2015; Culley et al., 2013; S. Fisher et al., 2021; Gervais et al., 2016; Venning et al., 2021). In addition, Lee et al.’s (2018) systematic review on father-inclusive perinatal education programs called the literature “poor” overall, with few interventions, an insufficient evidence base, and inconclusive efficacy.

Studies also focused on ways fatherhood intersects with additional marginalization. Several papers focused on the experiences of fathers of color, including the multiple burdens of systemic racism on Black fathers (Assini-Meytin et al., 2019; D. Grant, 2020), and strengths-based lenses to measure potential “resilience resources” in low-SES white, Latinx, and African American fathers (Wilson et al., 2021). One paper focused on the experience of Canadian Indigenous fathers (Waddell et al., 2021). Several studies explored the experiences of fathers who identified as gay or queer, including surrogacy dynamics (Van Rijn et al., 2018), family function through the lens of minority stress theory (Grigoropoulos, 2023) and a qualitative study on the experience of working-class gay fathers (Mather & McWhirter, 2023). Of note, no papers in this study explored the experience of trans fathers.

Gaps and Future Needs

Much more research is needed on the impact of paid family leave. Saxbe et al. (2018) argued that improved family leave policies and funding are key to reducing perinatal disorders and related disparities. Yet, the studies in this review were broadly inconclusive around outcomes (Heshmati et al., 2023; B. C. Lee et al., 2020). Current laws and guidelines disqualify many from the Family Medical and Leave Act (FMLA) guidelines, and other workers cannot afford the lost income even if they qualify. Relatedly, Petts et al. (2020) noted the significant disparity between high-income workers who can afford time off and tend to work for companies offering generous family leave, and low-income workers who have neither. Research showing strong justifications for paid paternal leave is needed to bolster advocacy.

More research is needed on the needs, experiences, and outcomes of significantly marginalized fathers. Of the 253 articles in this study sample, only 21 (8.3%) focused on fathers with marginalized identities. The limited research on fathers marginalized by race, ethnicity, gender/sexuality, or other experiences, and the related implicit biases is by the far the biggest overall literature gap. While this gap is perhaps unsurprising, it remains an urgent unmet research priority. As these intersections often increase stress from stigma, socioeconomic disparity, and systemic racism, paternal mental health needs are likely particularly relevant to these fathers. For example, Ishak et al.’s (2022) outcomes study on non-English speaking (NES) fathers in Australian health systems found that newborn nursery admissions rates doubled for NES fathers, and that 31% of NES fathers (compared with 19% of ES fathers) reported postdelivery psychological struggles.

Discussion

Mapping review results confirm a significant breadth of research data on paternal mental health with clinical utility. Results also show that these data are disparate and segmented, making this mapping review uniquely cohesion-building. Ascertaining social workers’ awareness of paternal mental health was beyond this study’s scope; however, future research would be useful. Perhaps more importantly, this review also identified significant research gaps and opportunities for social workers to contribute. There are countless needs and opportunities; here we have outlined several.

First, social workers have the skill, flexibility, and presence to lead culture change on elevating paternal mental health needs in clinical and policy spaces. Second, social workers have the creativity to use systems thinking and clinical acumen to fundamentally shift screening away from reactive postpartum assessment of discrete disorders to robust antenatal assessment based on a matrix of established risk and protective factors. Third, social workers can take the lead on developing much-needed paternal mental health interventions by relying on pragmatism, ability to operationalize theory with empathy for clients’ situations, and strengths-based orientation.

By cataloging a topic, mapping reviews also capture an impression of that topic as it is developing. Issues around marginalization are a primary concern. In addition to the issues noted throughout this article, the available studies themselves highlight problematic processes. A significant number of studies reported sample participant demographics weighted toward heterosexual, cisgender, white participants, and repeatedly noted as a limitation the overrepresentation of white, mid- to high-SES fathers. In addition, indications of implicit biases within the research include heteronormative assumptions and deficit-view assumptions of non-white fathers. It is important that paternal mental health research does not become a “worried well” concern focused on the economically-advantaged, but instead addresses the needs of the most vulnerable fathers.

This mapping review has both strengths and limitations. The focus on breadth bolstered exploration of multiple research aspects. The use of social work perspectives is another strength. Material was analyzed and integrated using systems and ecological lenses, a strengths-based perspective, and social work values and ethics. Another strength was the dual focus on clinical and research knowledge to empower both clinicians and researchers. Although breadth is a study strength, it also limited study feasibility, information management, and depth of topic exploration. Hopefully this review will encourage more targeted research on the presented research areas. Second, although the search protocol was comprehensive, it is impossible to capture all possible articles. Indeed, the sample articles referenced several important papers not captured in the search. Nomenclature, specifically within neurobiology, potentially influenced these results. Regarding the inclusion criteria of some articles, those that did not mention the age of a child were included. The choice to avoid gray literature also added limitations around accessing potentially important materials in an emerging topic. In addition, this study’s choice of search terms are a potentially significant limitation. While database searches were constructed to apply equivalent subjects and not limit to exact terms, more or different search terms (e.g., “behavioral” and “emotion”) might yield additional results. Discrete diagnoses were intentionally left out of the search protocol to capture the experience of fathers who do not identify with a diagnostic label, and because the literature is already saturated with postpartum anxiety and depression studies. Yet, adding additional terms would aid comprehensiveness goals and would benefit future studies. However, this study’s article sample is a quality representation of the paternal mental health literature and adds to the social work knowledge base.

Conclusion

This mapping review sought to identify and organize paternal mental health research for social workers. This review focused on mapping parameters, identifying relevant clinical knowledge, and highlighting the research concerns around father-focused care. It is hoped that this mapping review will contribute to the process of knowledge creation and encourage social workers to bring their unique strengths to the challenges of paternal mental health care. The opportunity for fathers to have a positive perinatal experience—and to have effective solutions and care when overwhelmed—are important social needs. Working to remove the biological, psychological, or socio-economic/ecological barriers to that experience is an ethical obligation for social workers and an opportunity to make important clinical and research contributions.

Footnotes

Disposition editor: Cristina Mogro-Wilson

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Curtis Davis

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