Honey…..  I’m Pregnant Too!  : Couvade Syndrome

Honey…..  I’m Pregnant Too!  : Couvade Syndrome

 by Dave Hopwood for the Shiatsu practitioner Diploma course

Summary

 This essay presents a short analysis of the concept of “couvade.”  Research regarding both ritual couvade, as seen in primitive societies, and the attenuated modern version of couvade syndrome, in which partners of pregnant women may experience pregnancy-like symptoms, is explored.  Possible causes, symptoms, diagnoses and treatment of the latter are discussed.  Finally, the importance of the concept of couvade syndrome from a Shiatsu perspective is considered so that health needs of new and expectant fathers-to-be[1] may be met as well as those of mothers and babies.

Man’s rare syndrome leaves him with bloated tum, weight gain, hot flushes, exhaustion, cravings and morning sickness

 Tums-to-be … Amanda Bennett and Mike Dowdall

Exclusive

By JENNY FRANCIS

Last Updated: 08th September 2012

MISERABLE Mike Dowdall is enduring morning sickness, hot flushes, cravings and a swollen belly — all because girlfriend Amanda Bennett is pregnant. (an article in the Sun)

 

Do remember the breeding ritual of emperor penguins, immortalised in the documentary March of the Penguins?  After the penguins mate, Mother Penguin lays an egg and places it at the feet of Father Penguin who then incubates it over a two month period, all the while protecting it from predatory birds and the extremes of the Antarctic’s weather.  As a result, he loses nearly half his body weight.  A lot of people were moved to tears by the dedication and paternal instincts of Father penguin, but for some reason, the idea of fathers suffering like their pregnant counterparts is a strange phenomena for many people to comprehend.  Allow me to set the record straight: Blokes can have pregnancy symptoms, and there is even a clinical term for it – Couvade Syndrome – although most people are more familiar with the term sympathetic pregnancy.  My own interest in the concept of couvade was recently triggered when conducting a labour preparation class and one of the fathers-to-be asked why I thought he had gained weight as his partner’s pregnancy had progressed.  I suggested that it was probably because they shared the same diet and that he was perhaps being overly ‘supportive’ of her craving for cakes and sweet pastries.  As a result of his question I thought back on my own experiences as an expectant father of two and although I do not recollect putting on weight I was certainly more protective of my wife and very aware of her developing pregnancy.  I therefore began to research how prevalent such experiences were with other fathers-to-be and was surprised to find that it is actually rather common.  In fact, up to 90 percent of men experience at least one pregnancy-like symptom, according to a 2005 report filed by CNN chief medical correspondent Sanjay Gupta, M.D.  If one accepts this statistic then, as a Shiatsu practitioner, when caring for childbearing families, we have to be aware that the health needs of new fathers and fathers-to-be have also to be met as well as those of mothers and babies.  The problem is that there is a dearth of information in the Shiatsu literature regarding approaches to treating couvade.

 

Let’s be clear what we are discussing…

 

Definition

 

The term couvade was first used by the anthropologist E. B. Tylor in 1865 to describe certain father-hood rituals.[2]  The origin of the word probably comes from the French verb “couver” which means “brooding or hatching”.[3]  Couvade, according to Webster’s New International Dictionary is “a custom among primitive peoples in many parts of the world in accordance with which when a child is born the father takes to his bed as if he himself has suffered the pains of childbirth, cares for the child, or submits himself to fasting, purification, or various taboos”.[4]  Another definition states that “couvade is an involuntary disorder consisting of interrelated physical and psychological symptoms in the male partners of gestational (pregnant) women.[5]  Both of these examples exemplify the two main forms of the concept described in the literature: ritual couvade and the modern couvade syndrome.

 

 

Ritual Couvade

 

Ritual couvade is a practice noted in historical, ethnographic and anthropological studies of numerous societies, since 60 B.C. in ancient Greece to the present in primitive societies.  Doja points out that the beliefs, rites and practices, the many genres and the other symbolic forms and collective representations of the traditions surrounding birth must be considered as a social strategy that serves to confer a symbolic value of recognition to the process of the construction of the person and the socialization of the individual as well as a way to formulate models of behaviour for varying groups in society, in this case pregnant women, newborns, new mothers, fathers, and kin.[6]  The rites are widespread and have been present in some form on almost every continent and seen in such diverse peoples as North and South American Indians, Africans, Indians, Basques of Spain and France, Chinese and in Papua New Guinea.[7]  Examples of ritual behaviour have included a man taking to his bed or dressing in his wife’s clothing during her labour and delivery, or observances by the new father of certain postpartum dietary and/or activity restrictions.[8]  Anthropological interpretations of couvade have changed over time generally reflecting the major theoretical standpoint of the era.  For example, in the 19th century, cultural evolutionists posited that primordial societies were matriarchal and suggested that couvade was a relic of the transition to patriarchy.  Early 20th-century functionalists on the other hand held that it was a method through which fathers publicly accepted the legitimacy of their children.  By the 1970s, psychological anthropologists were citing Freud suggesting that according to psychoanalytic theory, couvade is the husband’s envying his wife’s ability to produce a child.[9]  From the literature it is clear that the true reasons behind ritual couvade are only speculated at by anthropologists, et al, and are thought to have a number of possible purposes, depending on the specific culture.  These include:

 

• To draw the attention of evil spirits away from the mother to the father instead.
• To strengthen the emotional bond between father and child.
• To show that the man is the child’s biological father.
• To guide – some believe that the father has a stronger supernatural bond than the mother and so the ritual is used so that the father can guide the child into the world.
• To provide a form of anxiety relief for the man.
• To make the father’s role in pregnancy more profound than only the sex act nine months previously.

 

Even though ritualistic Couvade has still been reported during the twentieth century, in most parts of the modern western world these rituals are no longer observed.

 

Couvade Syndrome

 

Trethowan[10] first wrote in 1944 of a ‘modern version’ of couvade, which he called the “couvade syndrome,” in which husbands of pregnant women suffer pregnancy-like symptoms.  After Trethowan’s initial work, other researchers began investigating the incidence and variables associated with this modern version of couvade.  For example, Brennan[11] conducted a survey of 1439 Australian men in 2010.  His findings indicated an approximate incidence of 31% of Australian men afflicted with the couvade syndrome.  This compares to 25% incidence in the UK population.  Researchers at St George’s University, London, also carried out a study of 282 fathers-to-be.  Specialists monitored the men, aged between 19 and 55, whose partners attended St George’s Hospital during their pregnancy and compared the findings with a similar number of controls.  Fathers-to-be reported a range of symptoms, including cramps, back pain, mood swings, food cravings, morning sickness, fatigue, depression, fainting, insomnia and toothache.  In more extreme cases, men developed swollen stomachs that looked like a “baby bump”.  Eleven of the men went to their GP about their symptoms but no physical causes were found.  These findings are similar to Brennan’s who found that the most common symptoms were weight gain (26%), tiredness (45%), and “feeling stressed / anxious” (37%).  From these and other studies it is clear that the manifestations of the syndrome can vary widely, including:

 

• Variations in appetite
• Weight Gain
• Nausea
• Insomnia
• Indigestion
• Diarrhoea/Constipation
• Headaches
• Toothaches
• Mood swings
• Backache
• Itchy skin
• Food cravings
• Fainting
• Abdominal pain
• Cramps
• Tiredness

 

As stated earlier, as many as 90% of fathers-to-be can experience couvade syndrome in some form or other, although only a very few will display the more dramatic symptoms.[12]  Some have to cope with problems right up until the delivery, however, most symptoms disappear after the birth.[13]  Some researchers report that the syndrome is more common in first-time fathers, while others have found that it is equally likely to develop in men who already have children.  Brennan, in his study of 37 first-time fathers, found a positive relationship between paternal anxiety and the level of the man’s involvement with his unborn child as well as an increased susceptibility to developing couvade syndrome.[14]

 

The two features, which distinguish couvade from other syndromes, are its time course which commences in the 1st trimester, temporarily disappears in the 2nd trimester and emerges again with greater severity in the 3rd Trimester and the fact that it has no pathological basis (i.e. it is not caused by illness or injury).[15]  Once identified, the prognosis is clear, couvade syndrome almost always goes away after the baby is born.  However, herein lies a key issue because, despite the research, the actual diagnosis of couvade syndrome is difficult as some doctors are sceptical of male pregnancy symptoms, and do not recognise couvade syndrome as a medical condition.  Certainly, couvade syndrome is not listed as a diagnostic category in the American Diagnostic and Statistical Manual of Mental Disorders or the World Health Organisation’s International Classification of Diseases.  Nor is it described or discussed in many medical textbooks and is often referred to in passing as a condition of unknown origin.  Also, since most men with couvade syndrome have only mild symptoms, they are less likely to consult a doctor about the condition by itself and, in many cases, it is often confused with other ailments hence diagnosis is made more difficult because it is least expected.

 

The diagnosis debate is further complicated because the varying research statistics and lack of hard evidence has led health professionals to debate whether couvade syndrome is even a medical condition at all, or if it is a psychiatric one.  In an attempt to clarify current debate, I have summarised the main research approaches to explaining the syndrome under the following headings:

 

• Couvade is a physiological condition. Fathers-to-be, worried about the massive impending life change, eat to comfort themselves, or simply eat more because their partner is eating more.  Any mood swings could be connected to the weight gain.[16]  “When you gain weight, you have more fat tissue, which converts testosterone into estrogen,” explains Hakakha.  “The increased levels of estrogen may be responsible for mood swings and nausea.”  Insomnia may be the result of sleep deprivation (which also contributes to being irritable and moody). “If there’s a pregnant woman in the house, you won’t sleep well if she’s not sleeping well.  This can lead to more stress and more symptoms.”[17]  Fleeting emotional symptoms like depression, irritability, and mood swings are all considered normal behaviour, but during a partner’s pregnancy, they could seem more profound or distressing than usual, prompting the men to seek help.

 

• Couvade is rooted in biology. Some studies have shown that men with pregnant partners tend to have higher levels of female hormones, like estradiol, in their blood.  While the studies’ implications are inconclusive, they seem to suggest that bonding and preparing for the arrival of a baby could trigger the release of hormones meant to create a stronger father-child relationship.  Canadian researchers, Wynne-Edwards and Storey, looked at hormone levels of men at various intervals during their partners’ pregnancies.  They found high levels of estradiol, prolactin, and cortisol in the men, which are low in men who are not expectant fathers.  These hormones are associated with stress response and aggression.  The researchers hypothesise that these elevated hormones give expectant fathers the drive and endurance to protect and nurture.  Disruptions to behavioural, physiological, and biochemical functions may be enough to cause male pregnancy symptoms.  In some cases these symptoms are not just confined to pregnancy.  Men have been known to feel bloated, lethargic and irritable when their wives are menstruating.  It is already known that women living together synchronise their menstrual cycles due to this effect, but no studies have yet been done to prove this where couvade is concerned.  It seems that the closer the man is to the woman emotionally, the more likely he is to exhibit symptoms.  Brennan states male pregnancy symptoms are involuntary, and the men are so in tune with their partners that they start to develop the same symptoms.[18]  Thus, pregnancy can not only be an emotionally as well as physically charged time for women…but for men as well.

 

• Couvade syndrome is psychosomatic. Psychosomatic symptoms are the main characteristic of the syndrome, as it is defined today.[19]  Over 39 symptoms, directly or indirectly related to expectant fatherhood, can be found in the literature.[20]  Many “psychology-based theories” cite physical manifestations seen with couvade as a subconscious means to adjust to pregnancy, for the man to identify with his partner, bond with the unborn baby, emphasise his fatherhood, or regain his partner’s attention.[21]  Some psychiatrists, especially those who specialise in psychoanalysis, claim that couvade syndrome is an expression of a man’s anxiety or ambivalence about his partner’s pregnancy.  This type of explanation appears more common among European than American physicians.  The Journal of Reproductive and Infant Psychology states that the symptoms may be “a consequence of the man’s envy of the woman’s procreative ability,” while others maintain that they result from male guilt over impregnating the woman or to sibling rivalry – that is, the husband regards the wife as a competitor that he must try to outperform.

 

• Couvade is a psychiatric disorder.[22] While a few instances of the syndrome developing into full-blown psychosis (loss of contact with reality) have been reported in European medical journals, such cases appear extremely rare.

 

• Couvade is a reaction to a changed social role; that is, the syndrome is one way that some men “work through” their feelings about assuming the social expectations and responsibilities associated with fatherhood. Brennan supports this view insisting that couvade syndrome is real and is becoming more common in the western world due, in part, to the social changes that have taken place in the last thirty years that now allow the man to take a more active and caring role in pregnancy and childcare.[23]  What better way for a man to show that he is supportive and nurturing than to experience the uncomfortable effects of pregnancy right along with his partner?

 

From the above it can be seen that researchers are divided as to the causes of couvade syndrome.  In some ways it does not matter whether one views the syndrome as a physical response to the psychological stresses of imminent fatherhood, as an expression of the close bond between the expectant couple or as a somatic expression of normal anxiety experienced by the father-to-be, because while researchers argue the existence and causes of the syndrome, the manifestation of symptoms and the physical discomfort caused appear quite real to those experiencing them.  What is important, therefore, is recognising and understanding that the syndrome really does exist and that it is simply a basic human reaction to the pregnancy.

 

Conclusions

 

From the foregoing it can be seen that, at this time, there does not appear to be a consensus of opinion as to whether couvade syndrome is a positive, adaptive behaviour in expectant fathers or a maladaptive one.  It may be a socially acceptable way for the father to act out involvement in pregnancy and birth and may result in increased closeness as the husband identifies with the wife.  On the other hand, it could cause a strain in family relationships if the husband is more concerned with his own somatic and psychological symptoms than in providing support for his wife.  There is general agreement, however, that expectant fatherhood is a significant event for men.  Pregnancy is a crucial period for fathers-to-be as well as their mates, a time when physical symptoms may occur as an expression of deep psychological stress as they anticipate the births of their children.  Frequently, little attention is given to fathers-to-be and inadequate concern is shown for relieving their anxieties and physical symptoms.

 

Conventional Treatment

There is no standard mainstream treatment recommended for couvade syndrome because of the continuing debate over what it is.  That said, it is important for couples, and especially future fathers-to-be, to know that the symptoms of couvade syndrome are real and that a significant number of men whose partners are pregnant genuinely experience them.  Doctors and psychologists agree that couples should speak frequently about their baby’s future to soothe any fears men feel over becoming a parent.  Salvadoran psychologist Melisa Villeda says, “Communication between couples is key.  Each one must express how they’re living the experience of becoming parents, since this will inevitably change their lives and they must learn to deal with it as well as possible.  If psychological or medical help is necessary because a patient’s symptoms are overwhelming, each case must be evaluated and treated with either therapy or medication to alleviate the discomfort.”  Experts agree that the most effective treatment is to make the man feel he is an active and vital part of the process, whether by participating in childbirth classes or providing support during delivery.  Taking the time to prepare for birth and parenthood can help them avoid feelings of anxiety and fear.  Some things that fathers-to-be can do to help include:

 

• Becoming more involved in their partner’s pregnancy
• Cope with any anxiety regarding the baby
• Face the fears associated with impending fatherhood
• Establish a deeper bond with their partner
• Share their feelings with their partner
• Discuss symptoms with a doctor

 

If nothing seems to alleviate the symptoms, fathers-to-be can be assured they will go away but only after the birth of the baby.

 

Implications for Shiatsu Practice

 

By becoming familiar with the characteristics, possible underlying meanings, and variables with which couvade syndrome is associated, Shiatsu practitioners can more effectively anticipate needs and problems of fathers-to-be and assist them in working through this challenging time.  However, from my researches on the web and various university library catalogues, there does not appear to be any reference to couvade syndrome in Chinese medicine or Shiatsu literature.  How then can the ‘energetics’ of this syndrome be diagnosed and assessed in a meaningful way to allow us, as Shiatsu practitioners, to work with and address the needs of fathers-to-be?  Solve et coagula say the masters – ‘Concentrate and disperse your energies according to the situation.’[24]  To do this I believe that we should go back to first principles and using our diagnostic tools of looking, asking, listening, smelling and most importantly touching (hara and pulse).  An additional diagnostic assumption is that the father-to-be may be reflecting and/or empathising with the ‘energy’ patterns of his pregnant partner.  Factoring everything together we can then build up a picture of our fathers-to-be constitution and condition so that we can deduce the underlying cause of their disharmony and decide upon the optimum mode of treatment.

 

Brennan’s research on the time course of couvade syndrome suggests that practitioners should focus their attentions on fathers-to-be reflecting their partner’s energy changes and patterns in the 1st trimester, less so in the 2nd trimester and then again as the syndrome emerges again with greater severity in the 3rd trimester.  Yates et al[25] have documented these energy changes and patterns across the trimesters providing a useful frame of reference and energetic focus on a trimester by trimester basis to support diagnosis and any treatment for specific presenting symptoms.  They also draw the practitioner’s attention to the importance of the Eight Extra Ordinary Vessels.  For example the Penetrating Vessel (PV) is very important during the 1st trimester.  Yates notes that rising PV energy during this period may drain Kidney energy leading to it becoming depleted in the lower burner area and manifesting as tiredness and weakness in this area.  Additionally, if the Stomach energy is weak the upward movement of the PV is aggravated creating feelings of nausea and sickness.  If the PV is unsettled it can also lead to feeling emotionally ‘all over the place’.  In effect, what is good for the goose is good for the gander, so as practitioners we need to be aware of the importance of the Eight Extra Ordinary Vessels not just for the pregnant partner but also for the father-to-be.

 

As noted earlier, Brennan has highlighted the most common symptoms or manifestations presented by fathers-to-be which are weight gain (26%), tiredness (45%), and “feeling stressed/anxious” (37%).  Practitioners could use this data and other research to provide themselves with an energetic ‘recipe book’ of acupressure and bodywork techniques to alleviate these and other common symptoms.  Taking the 1st trimester and the most common symptom of tiredness as an example –  tiredness is often due to depletion of Ki, Blood or Essence.  Treatment should therefore entail working the Kidney-Uterus, Governing, Conception and Penetrating Vessels, balancing points along the Bladder (Yu), Stomach (36) and Liver (13) channels.  There are also potentially many benefits of bodywork, however, given the tiredness, relaxation-style work may be more appropriate.  Breathing and visualisation techniques and a review of exercise routines are also excellent ancillary options.

 

Following the more conventional approach, it may be helpful to provide information about couvade syndrome to the father-to-be.  Men are not as likely as women to compare and share feelings and symptoms with other expectant fathers, and a man experiencing “morning sickness” during his partner’s pregnancy may think he is the only one to have such signs.  He may also be too embarrassed to mention his problems.  With information about possible couvade symptoms, he may feel more comfortable voicing his concerns and getting his needs met.  Providing the father-to-be with the skills and tools to play an active and vital part in his partner’s pregnancy, whether by participating in childbirth classes or providing support during delivery is also another successful strategy.  As Shiatsu practitioners we can teach them some basic techniques such as back massage, working with breath and exercises to ease tense muscles and help their partners relax.  I have taught fathers-to-be to massage their pregnant partner’s abdomen’ focusing on making contact with the baby.  Towards the end of the 3rd trimester I teach techniques for pain relief and labour focus points.  Postnatally, I teach fathers baby massage and simple Shiatsu routines to relieve colic, constipation or to help their baby sleep.  This gives them an active and useful role from early on in their new family.

 

In summary, when caring for childbearing families, it is important that Shiatsu practitioners focus on the physical and psychological well-being of fathers-to-be and new fathers, as well as those of mothers and infants.  After assessing fathers’ needs, practitioners should suggest interventions to promote wellness and active participation in their partner’s developing pregnancy.  Armed with an understanding of the variety of responses normally experienced by men during their partners’ pregnancies, Shiatsu practitioners will be better able to provide the education and support necessary for fathers to work through this challenging growth process and to make a real contribution to the health and well-being of new fathers and their families.

 

Afternote

 

So, for any fathers-to-be who, for some reason, may read this essay, know that you are not alone, and that you have the Shiatsu community backing you up.  Eat some crackers, get out of bed slowly, drink some ginger tea and try to get a bit of rest and know that birth is right around the corner.

 

General Resources

Books

 

Hauser, P.M. Fathers-To-Be Handbook. Creative Life Systems Ltd, 2007.

Reed, Richard K. Birthing Fathers: The Transformation of Men in American Rites of Birth. Piscataway, NJ: Rutgers University Press, 2005.

 

 

Web

 

Wikipedia: Couvade
User-edited article about Couvade syndrome.
www.wikipedia.org/wiki/Couvade

 

About.com: Couvade Syndrome
Article about pregnancy-like symptoms among expectant fathers.
pregnancy.about.com/library/weekly/aa033197.htm

Couvade and the Cloud of Unknowing
Essay about the personal experience of a father and historical precedents.

 

[1] This terminology is commonly used throughout the literature and, in the context of this essay, incorporates both husbands and opposite sex partners.  I did not find any research pertaining to same sex partners.

[2] Doja, A. 2005. Rethinking the Couvade. University of Limerick & University College London,  Anthropological Quarterly, vol. 78 (4),pp. 917–950.

[3] Trethowan, W., and M. Conlon. 1965. The couvade syndrome. British Journal of Psychiatry. 3:57-66.

[4] Gove, P.B., ed. 1968. Webster’s new international dictionary. Springfield, MA: G. & C. Merriam Co.

[5] Brennan, A., Ayers, S., Marshall-Lucette, S., Ahmed, H. (2007): ‘A Critical Review of the Couvade Syndrome: The Pregnant Male’. Journal of Reproductive and Infant Psychology, 25 (3), pp.173-189.

Brennan, A., Marshall-Lucette, S., Ayers, S., Ahmed, H. (2007): ‘A Qualitative Exploration of the Couvade Syndrome in Expectant Fathers’. Journal of Reproductive and Infant Psychology, 25 (1), pp.18-39.

Klein, H. (1991): ‘Couvade Syndrome: Male Counterpart to Pregnancy’. International Journal of Psychiatry in Medicine, 21 (1), pp.57-69.

Miller, B., and C. Keane (eds). 1987. Saunders encyclopaedia and dictionary of medicine, nursing, and allied health. Philadelphia: W.B. Saunders Co.

Trethowan, W. H. and Conlon, M. F. (1965): ‘The Couvade Syndrome’. British Journal of Psychiatry, 111, pp. 57-66.

[6] Doja, A., Ibid.

[7] Tylor, E. 1965. Researches into the early history of mankind. P. Bohannan, ed. Chicago: The University of Chicago Press.

[8] Murphy, R.L. 1992. Couvade: the pregnant male. Journal of Perinatal Education. 1(2) 113-8.

[9] Monroe, R., R. Monroe, and J. Whiting. 1973. The couvade: A psychological analysis. Ethos. 1:30-74.

[10] Trethowan, W., and M. Conlon. 1965. The couvade syndrome. British Journal of Psychiatry. 3:57-66.

[11] Brennan, A. 2010. Couvade Syndrome in Australian Men: A National Survey, 2010.

[12] Murphy, R.L. Ibid.

[13] Brennan, A., Marshall-Lucette, S., Ayers, S. and Ahmed, H. 2007. A qualitative exploration of the Couvade syndrome in expectant fathers.  Journal of Reproductive and Infant Psychology, 25(1), pp. 18-39.

[14] Brennan, A. (1997): ‘A Correlational Study of the Relationship between Attitudes to Ultrasound, Paternal/Maternal-foetal Attachment and Anxiety among Fist-time Mothers and Fathers’. Unpublished MSc Study, University of Surrey.

[15] Brennan, A. 2010. Ibid.

[16] Mason, C., and Elwood, R. 1995. “Is There a Physiological Basis for the Couvade and Onset of Paternal Care?” International Journal of Nursing Studies 32 (April): 137-148.

[17] Men Get Pregnancy Symptoms Too
Offers a historical perspective and a discussion of couvade in the modern world.
www.paternityangel.com/Articles_zone/Couvade/CouvadeIntro.htm

[18] Brennan, A. and Marshall-Lucette, S. 2009. The Couvade Syndrome: implications of the “pregnant” male from a global perspective. International Nursing Research Congress: Focusing on evidence based practice; 13 – 17 Jul, Vancouver, Canada.

[19] Masoni, S., A., Maio, G. Trimarchi, et al. 1994. “The Couvade Syndrome.” Journal of Psychosomatic Obstetrics and Gynecology 15 (September): 125-131.

[20] Budur, K. and Mathews, M. 2005. “Couvade Syndrome Equivalent?” Psychosomatics 46 (January): 71-72.

[21] It is a set of psychosomatic symptoms that is within the range of normal experience and does not indicate mental illness.

[22] Tenyi, T., Trixler, M. and Jadi F. 1996. “Psychotic Couvade: 2 Case Reports.” Psychopathology 29: 252-254.

[23] Brennan, A., Ayers, S., Ahmed, H. and Marshall-Lucette, S. 2007.  A critical review of the Couvade syndrome: the pregnant male. Journal of Reproductive and Infant Psychology, 25(3), pp. 173-189.

[24] Coelho, P. 2002. Manual of the Warrior of Light, Harper Collins.

[25] Yates, S. and Anderson, T. 2003. Shiatsu for Midwives, BfM Books for Midwives, Elsevier Science Ltd.

Yates, S. 2010. Pregnancy and Childbirth, A holistic approach to massage and bodywork, Churchhill Livingstone, Elsevier Science Ltd.