Paternal postpartum depression in Suzhou: An analysis of prevalence and risk factors

Abstract

BACKGROUND

Postpartum depression (PPD) in women has long been a focus of public health concern. With rapid societal changes, accelerated pace of life, two-child policy, and rising childcare costs, paternal PPD among new fathers is increasingly recognized. However, its incidence and associated factors in Suzhou remain understudied. We hypothesized that paternal PPD is prevalent in Suzhou and linked to specific sociodemographic and psychosocial factors.

AIM

To investigate the incidence and risk factors of paternal PPD among fathers in Suzhou.

METHODS

This was a cross-sectional, observational study conducted in five districts and counties of Suzhou. A total of 621 husbands of parturient were enrolled using convenience sampling. The Edinburgh Postnatal Depression Scale was adopted to assess their depressive status. Data on risk factors were collected using the participants’ general condition questionnaire, neonatal general condition questionnaire, parturient general condition questionnaire, Eysenck Personality Questionnaire, and Social Support Rating Scale. Statistical analyses were performed to identify the risk factors of paternal PPD.

RESULTS

Among 621 participants, the prevalence of paternal PPD was 13.69%. Univariate analysis showed significant associations of PPD with personal factors of husband such as place of birth, marital satisfaction and an urge to vent emotions towards the baby; with neonatal factors such as sex and congenital abnormalities; with spouse factors such as whether this pregnancy resulted in a fetus, living conditions, expectation regarding the baby’s sex, marital satisfaction and caregivers during pregnancy. Multivariate logistic regression analysis identified several significant independent factors associated with the outcome. These included place of residence, living condition, educational level, marital satisfaction, marital satisfaction of spouse, caregivers during pregnancy, pregnancy protection, expectation of baby’s sex, and subjective social support.

CONCLUSION

Paternal PPD has a moderate incidence in Suzhou. Its key risk factors require attention to formulate targeted preventive measures.

Key Words: Paternal postpartum depression; Incidence; Risk factors; Suzhou; Fathers; Cross-sectional study

Core Tip: Postpartum depression in fathers is a critical factor affecting perinatal family mental health, yet its prevalence and specific determinants among new fathers in Suzhou have not been fully clarified. This cross-sectional study enrolled 621 husbands of parturient from five districts and counties of Suzhou. We systematically investigated the incidence of paternal postpartum depression and its associated factors using standardized scales and statistical analyses. The study provided reliable evidence to guide the development of targeted prevention and intervention strategies, thereby helping to improve the mental health status of families during the perinatal period.

INTRODUCTION

Postpartum depression (PPD), as defined by the American Psychiatric Association, 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 incidence of paternal depression is relatively high during the period of 3 months to 6 months postpartum[1,2]. It includes both prenatal and PPD, affecting not only pregnant women but also their partners. In recent years, paternal PPD has gradually become a global public health concern. Paternal PPD is defined by analogy with maternal PPD, referring to depressive symptoms emerging in fathers during the postpartum period, which may persist and exert longterm adverse impacts on family function.

According to global research, paternal PPD is not a rare condition, but its prevalence varies widely across regions due to differences in socioeconomic status, cultural backgrounds, and research methodologies. A Finnish systematic review reported that 10% of fathers experienced depressive symptoms during the postpartum period[3]. Other studies have also documented considerable variability in paternal PPD prevalence: 28.3% in Pakistan, 13.6% in Saudi Arabia, and 19% in Northeast Ethiopia[3-5], reflecting the significant impact of regional contexts on paternal mental health.

In China, existing epidemiological studies have shown substantial heterogeneity in the prevalence of paternal PPD, with reported rates ranging from 4.1% to 24.3%[6-8]. As the main source of family support, fathers’ perinatal mental health is closely associated with maternal well-being, infant development, and family stability. However, current evidence on paternal PPD in China remains limited, especially in economically developed regions with unique social contexts such as Suzhou. Few studies have systematically explored the prevalence and risk factors of paternal PPD in this area, making it difficult to develop locally targeted prevention and intervention strategies.

To help international readers understand family planning and reproductive decisionmaking in China, a brief overview of the twochild and three-child policies is helpful. China’s family planning policy has shifted from strict control to active encouragement. Before 2016, the one-child policy was implemented. In 2016, the universal two-child policy was introduced to mitigate population aging and low fertility. In June 2021, the three-child policy was formally adopted, allowing all couples to have three children, with restrictions such as social compensation fees abolished and supportive incentives introduced to improve fertility willingness. At present, the government actively encourages families to have three children rather than imposing a maximum limit of three children. Recent policies focus on reducing the burdens of childbirth, childcare, and education, including educational preferences, housing support, and employment protection for women of childbearing age. Social campaigns promote childfriendly environments, reduce fertility anxiety, and encourage shared parenting. This policy transition has reshaped family structure and parenting pressure, highlighting the urgency of understanding paternal mental health.

Accordingly, this study was designed to fill these knowledge gaps by investigating the prevalence and risk factors of paternal PPD among fathers in Suzhou. We aim to provide a scientific basis for developing targeted preventive measures and improving the mental health of perinatal families.

MATERIALS AND METHODS

Study design and participants

Questionnaire collection methods: (1) Face-to-face on-site investigation: All surveys were conducted in clinical settings (hospital outpatient clinics and community health service centers) with participants present in person, avoiding nonresponse from online or mail surveys; (2) Standardized investigator training: All researchers received rigorous training on survey administration and communication to guide participants to complete the questionnaire; (3) Immediate completeness check: Questionnaires were checked on site for missing or invalid answers, and researchers assisted participants in supplementing incomplete information immediately; and (4) Voluntary participation with clear informed consent: Participants were fully informed of the study purpose and procedures, with no coercion, and all agreed to participate without refusal or withdrawal.

Through convenience sampling, 621 husbands of postpartum women were recruited from Suzhou Science and Technology City Hospital and the Suzhou Youxin Street Community Health Service Center. The inclusion criteria were: (1) Husbands at 30-100 days postpartum[9]; and (2) Intact communication ability and voluntary participation. The exclusion criteria were: (1) Non-cooperation with the survey; and (2) Impairment of cognition or communication.

Definition and justification of key study variables

A total of 40 items of general information were collected using self-designed questionnaires, covering paternal, maternal, and neonatal characteristics. These variables were initially included as potential confounders based on clinical experience and preliminary epidemiological observations. After univariate and multivariate logistic regression screening, nine variables were identified as significant independent factors associated with paternal PPD. For each key variable, we provided a clear operational definition and justified its inclusion based on existing literature, as detailed below.

Place of residence: Defined by household registration. Rural residence was included as a potential risk factor due to limited mental health resources and higher economic pressure[10].

Educational level (primary school and below to college and above): Higher education was considered a protective factor, as it is associated with better health literacy and help-seeking behavior[11].

Marital satisfaction (1-5 scale): Poor marital satisfaction was justified as a core predictor of paternal PPD, as it exacerbates parenting stress and reduces emotional support[12].

Living conditions (good/moderate/poor): Defined by self-reported housing environment. Poor conditions were included due to their association with increased caregiving burden[13].

Marital satisfaction of spouse (1-5 scale): Maternal marital dissatisfaction was justified as a risk factor, as it may lead to family conflict and increased paternal stress[12].

Caregivers during pregnancy: Inadequate care support was included, as it increases paternal caregiving burden and anxiety[14].

Pregnancy protection: Defined as clinical interventions and care measures for threatened miscarriage or high-risk pregnancy. Inadequate protection elevates paternal anxiety about fetal safety, justifying its inclusion as a potential risk factor[15].

Expectation of baby’s sex: Influenced by Chinese traditional son-preference culture, inconsistent sex expectation increases paternal psychological pressure, justifying its inclusion as a potential risk factor[16].

Subjective social support: Sufficient perceived support was considered a protective factor, as it buffers against postpartum stress[17].

Ethics approval

This study was approved by the Ethics Committee of Suzhou Guangji Hospital, and participation was voluntary.

Crisis response protocol

Any participant with depressive symptoms [Edinburgh Postnatal Depression Scale (EPDS) ≥ 13] or suicidal thoughts was immediately referred to the Psychology Clinic of Suzhou Guangji Hospital for psychiatric evaluation and intervention. The research team-maintained follow-up with these participants for 3 months to ensure their mental health and safety. This protocol complied with clinical ethical standards.

Demographic information and clinical data

General information questionnaire: The self-designed general questionnaire for husbands of postpartum women included 8 items: Age, place of birth, place of residence, only-child status, educational level, marital status, marital satisfaction, and an urge to vent emotions towards the baby. General maternal information included 20 items: Age, method of medical payment, place of birth, place of residence, only-child status, whether the pregnancy resulted in live birth, expectation regarding the baby’s sex, pregnancy complications, caregivers during pregnancy, mode of delivery, pregnancy protection, postnatal caregivers, educational level, annual family income, marital status, marital satisfaction, mother-in-law/daughter-in-law relationship, whether this was the first pregnancy, whether this pregnancy resulted in childbirth, and living conditions. Newborn general information included 4 items: Sex, congenital abnormalities, current health status, and night-time caregivers.

EPDS: Currently, no scale has been developed specifically to assess PPD among the husbands of postpartum women. Therefore, we used the EPDS, which was developed in 1978 for PPD screening. Previous studies have shown that the EPDS is suitable for postpartum women and can also screen for depression among their husbands. The EPDS has good reliability, with a Cronbach’s α of 0.81 and a split-half reliability of 0.78[18]. In this study, the Cronbach’s α coefficient for this sample was 0.89, with a split-half reliability of 0.84. The scale included 10 items: Fun, mood, self-blame, anxiety, fear, coping ability, insomnia, sadness, crying, and self-injury. Each item was scored on a four-point scale (0-3; 0 = least severe, 3 = most severe). Studie have reported that husbands of parturient with EPDS scores ≥ 9 were classified as depressive, while those with scores < 9 were considered non-depressive, demonstrating high sensitivity (89.5%) and specificity (78.2%) of the scale[19]. Scores of 0-8 indicated no obvious depressive symptoms; 9-12 suggested possible PPD; 13-20 indicated clear PPD, warranting evaluation and intervention by professional medical staff; and 21-30 indicated severe PPD, requiring professional medical evaluation.

Eysenck Personality Questionnaire: The Eysenck Personality Questionnaire (EPQ) included four dimensions: Extraversion/introversion, neuroticism, psychoticism, and lie (social desirability), with 88 items[20]. For forward-scored items, “yes” = 1 point; for reverse-scored items, “yes” = 0 points. Standard T scores were derived using sex-specific and age-specific norms to characterize participants’ personality profiles. In this study, the Cronbach’s α coefficient of the EPQ for this sample was 0.87, showing satisfactory internal consistency.

Social support rating scale: This scale was comprised three dimensions[21]: Subjective social support, objective social support, and support utilization. The scale contained 10 items; eight of which were single-choice questions. Single-choice items were scored 1-4 points, and two were multiple choice. The total scores ranged from 13 to 70. Higher scores indicated better social support. The scale demonstrated good reliability, with a Cronbach’s α coefficient of 0.88.

Statistical analysis

All data entry and statistical analyses were performed using SPSS 21.0, and prior to formal testing, data quality was checked for missing values, outliers, and adherence to statistical method assumptions to ensure reliability and reproducibility. Descriptive statistics were selected based on variable type. Continuous variables (age, and EPQ and Social Support Rating Scale scores) were presented as mean ± SD (justified by normal distribution via Shapiro-Wilk test, P > 0.05, and homogeneous variances via Levene’s test, P > 0.05). Categorical variables (birthplace, education, and marital status) were summarized as frequencies/percentages. Univariate analyses were conducted to screen potential paternal PPD risk factors (with PPD defined by the EPDS as the dependent variable). Independent samples t tests were used for continuous variables (given the dichotomous PPD outcome and met normality/homogeneity assumptions). Pearson’s χ² test was used for categorical variables (with Fisher’s exact test substituted when expected cell frequencies were < 5). A two-tailed P < 0.05 was considered statistically significant. Multivariable logistic regression was used to identify independent PPD risk factors (justified by the binary PPD outcome), with all 31 factors significant in univariate analyses included to avoid confounding (aligning with the study’s aim); the entry method used for variable inclusion; model fit assessed via the Hosmer-Lemeshow test; and a two-tailed P < 0.05 used to determine the final independent risk factors.

RESULTS

Demographic and clinical characteristics

The participants were aged 21-53 years (31.81 ± 4.63 years). Among the participants, 305 (49.1%) were Suzhou natives, and 316 (50.9%) were not. A total of 265 (42.7%) lived in urban areas, 133 (21.4%) in towns/townships, and 223 (35.9%) in rural areas. Overall, 340 (54.8%) had an only-child status, and 281 (45.2%) did not. The educational levels were: Primary school or below, 18 (2.9%); junior high school, 55 (8.9%); high school/secondary school, 52 (8.4%); college, 147 (23.7%); undergraduate, 284 (45.7%); and graduate, 65 (10.5%). In total, 29 (4.7%) reported a history of mental disorders, whereas 592 (95.3%) did not. Marital status was unmarried, 9 (1.4%); first marriage, 591 (95.2%); remarried, seven (1.1%); and divorced, five (0.8%). Marital satisfaction was reported as: Extremely dissatisfied, three (0.5%); very dissatisfied, four (0.6%); somewhat dissatisfied, 10 (1.6%); average, 126 (20.3%); satisfied, 23 (3.7%); very satisfied, 267 (43.0%); and extremely satisfied, 188 (30.3%). A total of 600 (96.6%) participants reported an urge to vent emotions towards the baby, whereas 21 (3.4%) did not.

Prevalence of paternal PPD

Among the participants, 536 (86.31%) scored 0-8 on the EPDS, 55 (8.86%) scored 9-12, 29 (4.67%) scored 13-20, and 1 (0.16%) scored 21-30. Three fathers (0.48%) in the PPD group reported mild suicidal thoughts (no suicidal plans or attempts), and no suicidal thoughts were reported in the nondepressed group. Therefore, the prevalence of paternal PPD (EPDS ≥ 9) was 13.69% (Figure 1).

Figure 1 Prevalence of paternal postpartum depression in Suzhou. Donut chart showing the distribution of paternal postpartum depression among 621 participants in Suzhou (China). The depressive group (n = 85) accounted for 1369% of the total sample, while the non-depressive group (n = 536) accounted for 8631%. Postpartum depression was assessed using the Edinburgh Postnatal Depression Scale.

Univariate analysis

Among the 32 categorical variables, 10 were significantly associated with paternal PPD prevalence: Husband’s birthplace (χ² = 33.401, P < 0.001); marital satisfaction (χ² = 28.636, P < 0.001); venting emotions towards the baby (χ² = 4.076, P = 0.044); maternal marital satisfaction (χ² = 18.834, P = 0.002); whether the pregnancy resulted in live birth (χ² = 5.844, P = 0.016), living conditions (χ² = 6.274, P = 0.043); caregivers during pregnancy (χ² = 11.260, P = 0.024); expectations regarding the baby’s sex (χ² = 8.040, P = 0.018); neonatal sex (χ² = 3.689, P = 0.045); and presence of birth abnormalities (χ² = 7.059, P = 0.016). Among the eight continuous variables, neuroticism (t = -2.625, P = 0.010) and objective social support (t = 3.590, P = 0.007) were significantly associated with paternal PPD (Tables 1 and 2).

Table 1 Univariate analysis of postpartum depression categorical variables among postpartum women’s husbands.

Variables	No depression	Depression	χ2	P value
Personal factors
Place of birth			33.401	< 0.001
Suzhou natives	288	17
Non-Suzhou natives	248	68
Marital satisfaction			28.636	< 0.001
Extremely dissatisfied	2	1
Very dissatisfied	4	0
Somewhat dissatisfied	7	3
Average	94	32
Satisfied	17	6
Very satisfied	240	27
Extremely satisfied	172	16
Venting emotions to the baby			4.076	0.044
Yes	521	79
No	15	6
Spouse factors
Marital satisfaction			18.834	0.002
Extremely dissatisfied	0	0
Very dissatisfied	6	1
Somewhat dissatisfied	12	2
Average	125	33
Satisfied	45	14
Very satisfied	242	23
Extremely satisfied	106	12
Whether this pregnancy resulted in a fetus			5.844	0.016
Yes	157	36
No	379	49
Living conditions			6.274	0.043
Renting room	92	24
Own room	435	59
Others	9	2
Caregivers during pregnancy			11.260	0.024
Husband	494	73
Parents	45	14
Wife’s parents	58	11
Nurse	4	2
None	7	4
Expectation of baby’s sex during pregnancy			8.040	0.018
Boy	12	4
Girl	31	11
Indifferent	493	70
Neonatal gender
Sex			3.689	0.045
Male	283	35
Female	246	48
Congenital abnormalities			7.059	0.016
Yes	23	46
No	484	68

Table 2 Univariate analysis of continuous postpartum depression variables among postpartum women’s husbands, mean ± SD.

Variables	No depression	Depression	t	P value
Internal and external	31.49 ± 4.24	32.31 ± 3.20	0.659	0.144
Neuroticism	35.52 ± 6.63	39.08 ± 4.65	1.851	0.030
Mental quality	35.25 ± 2.27	37.00 ± 3.32	2.379	0.087
Disguise	30.60 ± 4.12	33.30 ± 4.60	1.900	0.698
Total score of social support	49.22 ± 5.84	43.00 ± 7.80	2.273	0.658
Objective social support	17.33 ± 2.59	9.69 ± 1.11	10.409	0.003
Subjective social support	25.97 ± 3.70	21.00 ± 4.32	3.142	0.632
Support utilization	8.46 ± 2.18	8.03 ± 1.70	0.787	0.084

Multivariate analysis

All 40 factors were included in the logistic regression analysis. The participants’ age, score of the EPQ in all dimensions, social support scores in all dimensions, and the total scores were inputted according to the original values. The values of the other independent variables are shown in Table 3. Nine factors were significantly associated with the prevalence of PPD among the participants: Place of residence, living conditions, educational level, marital satisfaction of both spouses, caregivers during pregnancy, pregnancy protection; expectations of the baby’s sex, and subjective social support. These findings are summarized in Table 4 and illustrated in Figure 2.

Figure 2 Forest plot of binary logistic regression analysis for paternal postpartum depression. Odds ratios and 95% confidence intervals for significant predictors of paternal postpartum depression in the multivariate binary logistic regression model. Significant protective factors include place of residence, living conditions, education level, and marital satisfaction, while caregivers during pregnancy was a significant risk factor. OR: Odds ratio; CI: Confidence interval.

Table 3 Independent variable assignment method for risk factors of postpartum depression.

Item	Assignment
Only child or not	Non-only child status = 0, only-child status = 1
Educational level	Primary school and below = 1, junior high schools = 2, high school or secondary school = 3, colleges = 4, undergraduates = 5, graduates = 6
Marital status	Unmarried = 1, first marriage = 2, remarried = 3, divorced = 4, others = 5
Marital satisfaction/relationship satisfaction between mother-in-law and daughter-in-law	Extremely dissatisfied = 1, very dissatisfied = 2, somewhat dissatisfied = 3, average = 4, satisfied = 5, very satisfied = 6, extremely satisfied = 7
Venting emotions towards the baby	No = 0, yes = 1
Medical payment method	Medical insurance = 1, commercial insurance = 2, self-payment = 3, others = 4
Annual family income	Less than 50 thousand = 1, 50-150 thousand = 2, 150-300 thousand = 3, 300-500 thousand = 4, more than 500 thousand = 5
First pregnancy	No = 0, yes = 1
Pregnancy protection	No = 0, yes = 1
Living conditions	Renting room = 1, own room = 2, others = 3
Caregivers during pregnancy	Husband = 1, parents = 2, wife’s parents = 3, nurse = 4, none = 5
Type of delivery	Abdominal delivery = 0, vaginal delivery = 1
Abnormality in delivery	No = 0, yes = 1
Whether the pregnancy resulted in live birth?	No = 0, yes = 1
Expectation of baby’s sex	Boy = 1, girl = 2, indifferent = 3
Pregnancy complications	No =0, diabetes = 1, gestational hypertension = 2, others = 3
Neonatal sex	Boy = 1, girl = 2
Neonatal health status	Good = 1, general = 2, poor = 3, bad = 4
Night-time caregivers	Self = 1, husband = 2, couple = 3, parents = 4, wife’s parents = 5, nurse = 6
Congenital abnormalities	No = 0, yes = 1

Table 4 Binary logistic regression analysis of postpartum depression of the participants.

Variable	P value	OR	95%CI
Place of residence	0.000	0.458	0.311-0.673
Living condition	0.035	0.578	0.348-0.962
Educational level	0.006	0.747	0.608-0.919
Marital satisfaction	0.000	0.674	0.566-0.802
Marital satisfaction of spouse	0.001	0.736	0.610-0.886
Caregivers during pregnancy	0.010	1.333	1.072-1.657
Pregnancy protection	0.017	0.564	0.353-0.901
Expectation of baby’s sex	0.000	0.090	0.045-0.182
Subjective social support	0.026	0.598	0.290-1.012

OR: Odds ratio; CI: Confidence interval.

DISCUSSION

The prevalence of paternal PPD was 13.69%, and an additional 8.9% were likely to have symptoms. Furthermore, 4.7% warranted evaluation and intervention by professional medical staff, and one participant (0.2%) required professional diagnostic assessment and treatment. The prevalence was comparable to estimates reported in China (4.1%-24.3%)[6,8] and other countries (10%-28.3%)[3,5]; however, it exceeded the upper boundary of some international estimates (1.2%-11.9%)[22,23]. Suzhou has a developed economy. The participants included registered patients from a tertiary grade A hospital and a community health service center. The sample was broad and comprehensive, reflecting the situation in Suzhou region. Previous studies conducted in tertiary grade A hospitals in Beijing and Guangzhou Province reported paternal PPD prevalence rates of 10.8% and 7.4%, respectively[24,25]; both of which were lower than those in the present study. We included participants from community health service centers. Most lived in towns and villages and had fewer ways to address PPD, which may explain the higher prevalence of paternal PPD.

Binary logistic regression revealed nine factors retained in the model, including place of residence, living conditions, marital satisfaction, and objective social support. The prevalence of PPD was low among participants who were Suzhou-born, lived in urban areas, and owned their homes. Previous studies have shown that the living environment is a key determinant of PPD, with rural incidence rates substantially higher than those in towns and cities[26,27]. In this study, 50.9% were non-Suzhou natives, and 57.3% resided in towns or villages. The prevalence of depression among home renters was 20.7%, which was markedly higher than that among homeowners (11.9%). Prior research has indicated that housing satisfaction is an important indicator of public service quality, and housing issues among low- and middle-income groups remain a critical concern[28,29]. With rapid economic development in southern Jiangsu Province, Suzhou has gradually become a regional economic hub. As housing prices soar and the number of migrant workers increases, many people remain without housing or are dissatisfied with their living conditions. The implementation of the national two-child policy has further increased economic and psychological pressure on husbands as head of household.

In this study, 89.8% of the participants had a college degree or above. The highest prevalence of PPD occurred among those with a high school or technical secondary education (25%), followed by those with a graduate degree (16.92%) and those with a primary school education or below (16.67%). A possible explanation is that individuals with high school or technical secondary education were mostly middle-aged or older, often with less stable employment, lower income, and an older child-rearing age. In addition, those with postgraduate degrees may have higher material expectations and face greater work pressure, making work-life balance difficult[30]. Although only 2.9% had a primary school education or below, their PPD prevalence was high; likely because of limited educational background and a lack of professional knowledge and life skills. Therefore, education level is a risk factor for PPD. Marital satisfaction strongly influenced the occurrence of paternal PPD and was negatively correlated with it. Stressful life events increase the incidence of PPD. The birth of a baby profoundly affects family role allocation and emotional dynamics. PPD can only be reduced with sufficient marital satisfaction and mutual tolerance, and reducing or avoiding negative life events.

Paternal PPD prevalence was higher when the mother’s caregiver was a nanny (33.33%) or when she was unattended (36.36%) than when she was cared for by parents-in-law or parents (23.73%) or her husband (12.67%). Paternal PPD prevalence was higher when the mother received pregnancy protection (16.9%) than when she did not (10.94%). Paternal PPD prevalence exceeded 25% when pregnant women had specific expectations regarding the baby’s sex, whereas it was 12.43% when they were indifferent. Therefore, conditions related to the spouse during pregnancy had a major influence on the husband’s risk of PPD.

Objective social support differed significantly between the depressed and nondepressed groups. Higher objective social support scores were associated with a lower likelihood of PPD, which is consistent with previous studies[25]. One study has suggested that limited social support and restricted interpersonal networks are important contributors to paternal PPD[31] and that a lack of family support increases PPD risk. Because family support is a component of objective social support, insufficient family support and family conflict are important reasons for husbands to develop PPD[32]. Husbands are traditionally viewed as the primary economic pillar of the family, bearing greater responsibilities and more prominent social roles. In practice, the level of objective social support substantially influences men’s sense of self-worth and is closely linked to psychological pressure.

A critical extension of the present study lies in contrasting its findings with qualitative results from western countries, which highlights the profound influence of cultural and social systems on paternal PPD. The core risk factors identified in this Suzhou-based study - particularly the national two-child policy and housing conditions - are distinctly rooted in China’s social and economic context, whereas western studies (predominantly from the United States and Europe) prioritize work-family balance and paternal leave policies as key determinants of paternal PPD.

In China, implementation of the two-child policy has significantly altered family dynamics and increased paternal responsibilities. In the present study, the policy exacerbated economic and psychological pressure on husbands as primary household breadwinners. This contrasts with western countries, where fertility policies are typically less restrictive, and paternal PPD research often focuses on the availability and duration of paid paternal leave. For example, in Sweden (which has generous parental leave policies, including 90 days of exclusive paternity leave) longer paternal leave is associated with lower PPD risk, as it enables fathers to better adapt to their new role and reduces work-family conflict[33]. In the United States, by comparison, the lack of mandatory paid paternal leave leads to heightened work pressure and limited time for childcare, which is a dominant risk factor for paternal PPD[34]. This contrasts with China where policy-driven fertility changes and associated economic burdens are more prominent.

Housing conditions, another key risk factor in the present study (with home renters showing a significantly higher PPD prevalence than homeowners), also reflect China’s unique socioeconomic landscape. Suzhou’s rapid economic development and soaring housing prices have created substantial housing insecurity, particularly among migrant workers and low- to middle-income groups, which amplifies paternal stress. In western countries, while housing costs can be a concern in major cities, they are less frequently identified as a dominant risk factor for paternal PPD compared to work-related stressors. For instance, in Germany, job insecurity, long working hours, and difficulty reconciling work and childcare are more strongly associated with paternal PPD than housing conditions[35], reflecting a societal emphasis on individual work achievement and work-life balance.

Cultural differences in family structure and social support further explain the divergence in risk factors. In China, extended family support (e.g., care from parents or parents-in-law for the postpartum mother) is a common coping mechanism, and the absence of such support (e.g., reliance on nannies or no care) is associated with higher paternal PPD in this study. This aligns with China’s collectivist cultural values that prioritize family interdependence. In contrast, western cultures (characterized by individualism) place greater emphasis on nuclear family units, and paternal PPD risk is more closely linked to spousal support and community resources rather than extended family involvement[36,37].

These cross-cultural differences emphasize that paternal PPD is not a universally homogeneous phenomenon but is shaped by context-specific social, economic, and cultural factors. The present study’s focus on China-specific factors (fertility policy and housing insecurity) complements western research, enhancing the global context of paternal PPD research and improving cross-cultural interpretability. It also suggests that targeted interventions for paternal PPD must be tailored to the cultural and social context. In China, interventions may need to address economic pressures associated with fertility policies and housing, whereas in western countries, policies promoting paid paternal leave and work-family balance may be more effective. Strengthening medical staff training, enhancing prenatal health education, and providing psychological care can help address paternal PPD[38] and reduce related risk factors.

The present study had some limitations that should be considered when interpreting its findings. This was a cross-sectional survey, and an observational study would be more suitable for determining the patterns of PPD occurrence, its risk factors, and causal relationships. This study was unable to establish causal relationships between the identified risk factors and paternal PPD, and a prospective cohort study is therefore needed for verification. Additionally, the study population was recruited using convenience sampling from two medical institutions in Suzhou, which limits its representativeness for the entire Chinese population. The use of self-report questionnaires may have introduced social desirability bias, potentially affecting the accuracy of the collected data. Finally, the findings were analyzed within the cultural and social context of Eastern China (Suzhou); therefore, their transferability to other regions or countries needs to be evaluated in conjunction with local cultural characteristics. We further discuss the implications of these limitations for future research, which greatly enhances the rigor and transparency of the manuscript for international readers.

CONCLUSION

The PPD should be used for paternal depression management, and the PPD incidence rate remains high, with screening threshold values posing significant challenges. However, to better implement the national three-child policy, it is recommended that governments at all levels, social organizations, medical institutions, healthcare professionals, and social workers adopt targeted and effective interventions on the basis of various risk factors. These measures should provide greater understanding and attention to this group, promote positive psychological adjustment, and facilitate role transition.

ACKNOWLEDGEMENTS

We thank all the participants and staff involved in this research.