Keywords

1 Introduction

In the Western World, the man’s role regarding pregnancy appeared, some decades ago, rather limited. After conception, the man barely got attention till the birth, and then, he was often portrayed as nervously waiting in the hallway. Nowadays, this has changed, with men participating in antenatal classes and parenting education courses in many Western countries, while this still might be different in other parts of the world. Despite wide variation across different contexts, globally identified barriers to men’s involvement in pregnancy and childbirth commonly include beliefs that men’s participation is unnecessary or that it’s inappropriate for them to participate. Besides, men are systematically not (actively) invited to attend services, consultations, etc.

This chapter will address various aspects of the male partner’s role, beyond just conception and childbirth or his role as a father-to-be. We will also look into the psychological and existential changes that men face before and throughout pregnancy, childbirth, and postpartum. Additionally, the chapter will address the possible physical (and even hormonal) changes that men can experience throughout these specific life events.

We will also elaborate on the man’s sexual life. Male partners can feel pressured to impregnate, be scared about the influence of sexual activity in pregnancy, and even fear that sex can cause miscarriage or premature birth. Without being adequately addressed by the midwives and other healthcare professionals (HCPs), these worries will not disappear. Another reason to pay a good amount of attention to this area is that—especially in the postpartum—the difference between the man’s and the woman’s sexual desire can become a hot topic and even a severe couple problem.

The fact that midwifery is a nearly complete female profession in many places asks for a touch of ‘male information’.

2 Physical and Hormonal Changes

Transition to parenthood or fatherhood can be a challenging time. For nearly all men, first fatherhood is accompanied by many emotional and physical consequences. Even the gonadal hormones, and their influence on sexuality, change in the course of pregnancy.

Although there is little recognised physiological basis, we should, in this context, mention the Couvade syndrome. This syndrome is a psychosomatic phenomenon affecting male partners mainly during the first and third trimesters of pregnancy and disappearing early in the postpartum period [1]. In first-time expectant fathers, the Couvade syndrome is linked to various physical and psychological changes. Physical symptoms might include changes in appetite, digestion problems, fatigue, nausea, food cravings, weight loss, and weight gain. One of the fathers we interviewed expressed: ‘I got lost in unhealthy food cravings and gained weight during my partners’ pregnancy’. Psychological symptoms can be insomnia, mood swings, irritability, and not being interested in usual activities. Since women and men often laugh at the syndrome, many men feel embarrassed admitting they have Couvade syndrome-related symptoms [2]. One interviewed father expressed: ‘I think the Couvade syndrome is somehow stigmatising, I would call this “sympathy pregnancy”, like in our case, e.g. situations where the partner sympathises with the partners’ increased appetite’. Another father we interviewed stated that these psychological changes in pregnancy are ‘Not evident to talk about, but I don’t want to burden my partner with this’.

Some men lose weight during their wife’s pregnancy, while some future fathers explain they want to be healthier to set a good example to their children. Yet, more men appear to gain weight during the transition to parenthood, and since men do not undergo the physical demands of pregnancy, the underlying mechanisms are multidimensional [3]. Using a biopsychosocial model to look at sexual health helps us to see how biological and hormonal mechanisms (testosterone and cortisol changes), social and behavioural mechanisms (sleep, physical activity, and diet), and psychological mechanisms (depression and stress) are identified as potentially influencing physical changes in fathers-to-be.

Several hormonal levels change in men. In the preconception phase, some men have hormonal changes. In couples trying to conceive, the men have monthly fluctuations in their testosterone levels [4]. On the other hand, men have lower testosterone and cortisol levels during their partners’ pregnancy, and some have higher oestrogen levels [5]. The low testosterone level could explain the diminished sexual interest found in many men at the end of the second trimester. Research indicates that pair-bonding and paternal care are associated with lower male testosterone levels, while searching and acquiring sex partners are associated with higher male testosterone levels [6].

3 Male Experiences in the Preconception Phase

When trying to conceive, couples undergo hormonal and psychological changes. In the first months after they stopped using contraception, many men experience more satisfactory and more frequent sexual intercourse. One of the interviewed fathers stated that he found the potential impregnation of his partner exciting and even animal-like. When the man is ambivalent about a possible pregnancy or a child, sexual problems might appear, with sometimes anxiety to ejaculate, low sexual desire, or erectile dysfunction. When conception does not take place, the function of sexuality usually shifts from having fun to ‘trying to conceive’ [7].

4 Male Experiences in Pregnancy

A systematic review of the literature examining sexuality among couples during pregnancy and postpartum demonstrates that the sexual experiences of the male partner have been largely neglected [8]. Most studies of sex during pregnancy and postpartum have focused on women. Moreover, past research mainly focused on vaginal intercourse, while other aspects of sexuality were ignored or not considered [9]. Therefore, we know little about the influence of pregnancy on male sexuality. The consideration of men’s emotional, physical, and sexual experience in the perinatal period is limited [9], although the minds of expecting men and young fathers are influenced by various hormonal, physical, emotional, existential, and relational causes [9]. According to the limited studies, becoming a father can greatly impact how sexuality is experienced and expressed [10]. Some men have fears and anxieties about their sexuality during pregnancy and postpartum [11].

While describing various aspects of male partner behaviour, we need to acknowledge that there is much variance among men. Throughout pregnancy and postpartum, sexual activity for individuals is highly variable [9]. Yet, both average sexual interest and coital activity decline slightly in the first trimester of pregnancy, show variable patterns in the second trimester, and decrease sharply in the third trimester. Overall, there is a significant difference in mean scores for sexual activity between females and males. In the PASSION study (Pregnancy and Sexual Relationships Study Involving wOmen and meN), partners reported less frequent intercourse during pregnancy than before pregnancy [12]. Fathers-to-be acknowledge the declined sexual frequency as an important issue between them and their partners. Although some feel guilty to admit they expect more from their partners, while she suffers from many pregnancy-related symptoms. But not only the frequency of intercourse determines sexual satisfaction in expectant fathers. If there is decreased sexual activity in pregnancy, increased affection can often compensate for this [13].

Most men acknowledge that other aspects of sexuality become more important in pregnancy. Male masturbation tends to remain stable throughout the progressing pregnancy and postpartum. For many men, masturbation functions as a backup when intercourse with their partner is not desirable or possible [5]. Some men have problems adapting when their partner’s role changes from a sexual partner to a future mother [13]. While some find the pregnant woman’s changing body desirable and attractive, others do not. One of our interviewed fathers described sex during pregnancy as disgusting or awkward. Both situations have effects on sexual desire in men. Moreover, men often reported fear of hurting the foetus as one of the main reasons they refrained from having intercourse during pregnancy [14]. Other reasons for men not to have sexual intercourse during pregnancy are concerns about inducing labour [9, 15] and fear of harming their partner [8]. Especially in late pregnancy, men are willing to sacrifice sexuality with their partner for the good of mother and baby. Affection and tenderness through kissing, hugging, and non-genital, non-orgasmic caressing can continue and are highly encouraged, reinforcing the emotional connection between both partners [13].

5 Male Experience of Childbirth

Despite the near-universal attendance of fathers at childbirth in affluent Western countries, there is comparatively little research on men’s experience of this event. In addition, there is scant focus on men during childbirth education and labour [16].

Most fathers are willing to attend labour and birth yet express feelings of fear and helplessness during the event due to unrealistic expectations, deficiency in antenatal preparation, or lack of midwives’ guidance [17]. The most challenging for men is the pain experienced by their partner and being unable to help or alleviate the pain [18]. Some men are confused about their role during childbirth [14]. Men often feel helpless if they do not have a clear role during labour, such as helping their partner cope with contractions through massage techniques. Some expecting fathers do not know where to sit, what to do, and what to say. Some do not recognise their partner because she is in pain like never before. That is why most men find childbirth both wonderful and distressing at the same time. Especially young fathers and those expecting their first baby reported feeling uncomfortable during childbirth more frequently than others [18]. Through their lack of knowledge and perceived control, they struggle to find a role here [19]. Midwifery support, the midwife’s presence, and sufficient information about labour progress are important aspects of a father’s positive birth experience. When the (male) partner is present during childbirth, the process of birth can be a complex choreography for each party. During childbirth, the midwife’s role is important to the father, and respecting his individual needs will enhance a positive birth experience [20]. Meeting the father’s needs will result in a calm father-to-be, which will reflect positively on the partner giving birth, whereas a father-to-be that feels lost or stressed might be a factor that could negatively impact the mindset of the partner giving birth.

Fathers describe the moment the baby enters the World as the best experience ever. Directly after childbirth, most fathers experience pride related to fatherhood and love towards their partner and the newborn [21]. Some new fathers experience pride for their partner for what she has accomplished. Many fathers describe the birth as the beginning of fatherhood. Fathers who were present during childbirth reported that their attendance resulted in a closer emotional bond with their partner and newborn [22].

6 Male Experiences in the Postpartum

The frequency of most shared sexual activities declines during pregnancy, reaches almost zero in the first 3 months postpartum, and then begins to increase [23]. At 6–12 months after birth, sexual responsiveness is reduced in about 20% of the fathers [9]. Most couples do not practice intercourse for about 2 months after childbirth [9]. A meta-analysis of 59 studies found no significant correlations between birth complications, the severity of birth pain and forceps assistance, and postpartum coital activity, sexual interest, enjoyment, or responsiveness [8]. Though men are concerned about hurting their partner, the first time they have intercourse [13]. Men reported fear of harming and expressed concerns about the healing of her lacerations and stressed that it was important that the woman felt comfortable again before trying to resume sexual intercourse [11]. Additionally, fathers have commented that tiredness and disruptions with the baby and waiting for the six-week postpartum check-up affected sexual activity [9]. Some men experience this as an embargo period they were put on.

In studies on men’s sexual experiences during their partners’ pregnancy and postpartum, the focus had been predominantly on the frequency of sexuality during that period. Often both partners are dissatisfied with the frequency, the women because it was ‘too often’ and the men because it was ‘too seldom’ [9]. In a longitudinal study, at 6 months, 4 years, and 8 years postpartum, the mothers had a lower sexual desire than the fathers on all three occasions of measurement [24]. Most studies confirmed a decrease in sexual activity due to a lack of time and energy [10]. Several men expressed that unfinished tasks and household duties made their partners less interested in having sex. So, negotiating sex in this situation was bound to be unsuccessful [11]. Too significant desire differences may threaten the relationship, sometimes decreasing intimacy and sliding down to emotional and physical detachment.

Many assume that parents do not prioritise the sensual and sexual aspects of their relationship during this intensive period of their life. New fathers focused on the baby and were prepared to postpone sex until both parties were ready for that [11]. After having a child, fathers experience that sexuality becomes tailored according to circumstances [10]. The relationship with one’s partner is frequently reported as the most important determinant of sexual satisfaction, with a unique role for mutual closeness [14]. A new form of togetherness can evolve between the partners after having a baby. As in late pregnancy, men can focus on other ways of expressing sexuality and prioritise showing love, affection, and consideration in the postpartum period [10]. The fathers’ perceptions of sexual life extended to include all kinds of closeness and touching, deviating from the stereotype of male sexuality [11]. Most of the fathers’ satisfaction with their sexuality after having a baby can be related to judging the situation as a transient phenomenon, but some question if the relation and sexual life will ever be the same as before.

The metanalysis of von Sydow (1999) found between 4% and 23% of young fathers have an extramarital affair postpartum [8]. For 15% of the men, the affairs developed before the pregnancy. There are various explanations for these extramarital affairs; the medical advice for prolonged coital abstinence, the need to prove his male independence, or dealing with confusing emotions of becoming a father. When a man is not used to masturbation, his inability to masturbate could also lead to male extramarital sex around childbirth [5]. This might be context or cultur-driven.

Like some of their female partners, some men also experience postpartum depression. Paternal postpartum depression (PPD) within the first postpartum year is estimated to occur in 4–25% of new fathers [25] and can affect sexual health. The definition of PPD used in many studies is that paternal PPD is depression that occurs within the first 12 months postpartum. The highest rates are found at 3–6 months postpartum, while mothers’ onset of postpartum depression is generally in the early postpartum period. The most significant risk factor of paternal PPD is postpartum depression in the mother. Some speculate that paternal PPD is related to a decrease in the father’s testosterone level. Although the link between low testosterone levels and depression is not clear in the literature, there is a clear link between low testosterone levels and a decline in sexual desire. Research indicates that paternal PPD can also lead to a loss of interest in sex. Education of both parents by childbirth professionals is vital to increase awareness of the condition and decrease stigmas associated with PPD and the combination of PPD and sexual health issues.

7 What Can Midwives Do? The Role of Midwives Within a Biopsychosocial Sexology Approach

Medical staff rarely discuss sexual issues with their patients during pregnancy or the postpartum period [8]. In fathers’ encounters with perinatal care professionals, they want to be acknowledged and involved as a partner and a parent-to-be. Yet, their experience of maternity care services is as a ‘non-patient’ and a ‘non-visitor’. One of our interviewed fathers stated: ‘You are like an informal caregiver, not the patient. I was somewhat involved, but … clearly on the side-line’. This situates men in an interstitial and undefined place (both emotionally and physically) with the risk that many will feel excluded and fearful [26]. Although men emphasised the need to support their partner and protect their partnership as central to the successful navigation of fatherhood, fathers questioned their entitlement to support, noting that services should be focused on mothers [27].

It seems imperative to provide information to both partners about postpartum sexuality, both during prenatal and postnatal care [10]. HCPs should invite men to share their concerns during pregnancy and offer a chance to voice them [9]. For instance, using the ICE model (see Chap. 26) to address both partners’ ideas, concerns, and expectations concerning their sex life as new parents. They need their sexual changes acknowledged and normalised. Midwives and other HCPs need to understand how new fathers look upon their sexual relationship during the transition to parenthood [11] and to take care not to make culturally charged assumptions like men wishing to have more sex and women less.

There is consensus in the literature that discussing sexuality should begin early in pregnancy and that each subsequent prenatal visit should keep the discussion ongoing [11]. Midwives have to develop the skills and acquire the confidence to talk to couples about sexuality during pregnancy and parenthood, assisting the couples in their transition into parenthood. Midwives can inform men, and their pregnant partners that talking about sexuality is a part of their job. We recommend asking men and their pregnant partners for permission to speak about the subject, making them aware that their opinion matters and that they are in control. Midwives can refer to (fictional) couples and situations or existing research to start talking about the subject. Besides addressing sexuality in prenatal visits, the perinatal education classes or workshops should encourage men to discuss sexual changes [13]. We suggest asking dads questions such as: ‘how do you experience sexuality during pregnancy?’ or ‘how do you experience intimacy since you are a father?’

It appears valuable that new fathers meet and exchange experiences. Men need reassurance and information to feel connected to the new family situation [11]. Daddy’s classes are now more common in several Western countries. That could be an interesting method for distributing this information [12]. In most cases, 90% of the challenge is information giving, followed by reassurance in normalising their feelings and concerns [13]. Young fathers benefit from better communication skills that include the role of sexuality and sensuality during the transition to parenthood and beyond.

Sharing the right information at the right time will help men and their partners gain new knowledge and bring comfort and reassurance [13]. Midwives must be aware that, after having a child, sexuality can be expressed in many different ways and that it deserves a biopsychosocial approach. Midwives need to be cautious to not only include information about sexual activities [10]. Addressing only sexual function without the aspect of intimacy can be as harmful as not addressing sexuality at all.

In most sexuality studies, participants are white, educated middle class, married, and selected from antenatal classes [15]. Culture-specific trends in sexual activity can explain differences found in research. For instance, Europeans claim more sexual experience than North Americans [23]. The wide cultural variation encompasses sexual taboos before and after birth, lasting for different periods [15]. Additional research is needed to explore the variability between fathers of different cultures and backgrounds. Be also aware of reporting bias with data on men’s sexuality, often relying on self-report. This is true for the bulk of research on human sexuality and a reason for interpreting the findings with caution. By concentrating on sexual functioning, activity, and satisfaction, studies of men’s postpartum sexuality tend not to use a biopsychosocial approach [10]. Besides, the quantitative nature of most research does not allow to articulate and hear individual experiences [9]. We have to develop sociocultural-sensitive interventions within a tailor-made approach to facilitate a smoother transition to fatherhood [28].

Some health professionals are comfortable talking about sexuality while others avoid the subject [13]. Still, every midwife needs to develop the communication skills necessary to put the subject on the table. Today’s HCPs must be aware of the fathers’ needs and the impact gender aspects have on their professional support, as counselling or parent classes mostly address women’s needs, making it doubtful if the fathers benefit from participation [29]. HCPs need to be aware that midwifery care can only be good care when the couple’s sexuality is adequately addressed. Men’s sexual and other needs during pregnancy and postpartum deserve more attention.