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A critical literature review exploring the psychosocial experience of men

following the loss of their partner’s pregnancy

Word Count: 4970

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Abstract Introduction

Men are becoming increasingly involved in their partner’s pregnancy and emotionally

invested because advances in technology such as ultrasound and increased interaction help to

confirm the reality of the baby. This review is inspired by the experience of a family member,

and a gap in knowledge has been identified in the literature pertaining to the father’s

experience when pregnancy fails. Additionally a lack of guidelines and policies addressing

their needs have become apparent.

Methodology

A systematic approach was used in electronic database and hand searching. 10 articles were

retrieved and critically examined with an appraisal tool to determine their credibility and

value. Subsequently a content analysis was employed to determine key themes.

Results

Following appraisal, the literature retrieved was synthesised, interpreted and critiqued. The

studies retrieved were of high quality, with the exception of a few, although these did not

influence the findings. Four themes were identified as key psychosocial experiences:

‘Keeping occupied and caring for the partner is both beneficial and burdensome’; ‘validation

of fatherhood and the baby is required to support fathers’; ‘fathers struggle with pressures to

regulate emotions’ and finally, ‘making sense of the situation’.

Discussion and conclusions

This review has uncovered the complex struggle that fathers endure following the loss of

their partner’s pregnancy. There are internal and external variables which influence this

struggle, relating to societal pressures and perceptions of men, some of which are self-

imposed. The findings have revealed that recognition, support and information can make a

substantial difference to fathers’ overall well-being. This knowledge is needed to influence

guidelines, policies and approach to care. Nurses are amongst the first people encountered

following the loss and play a key role in how the loss is experienced, even years later, for it is

clear that the effect remains indefinitely if they fail to ‘care’.

Keywords: Pregnancy loss; father's experience; father's struggle; psychosocial experience;

father's loss

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Table of Contents Abstract ...................................................................................................................................... 2

List of Tables ............................................................................................................................. 3

Introduction ................................................................................................................................ 4

Review question ..................................................................................................................... 4

Aims and objectives ............................................................................................................... 4

Methodology .............................................................................................................................. 5

Critical appraisal .................................................................................................................... 5

Synthesis of findings .............................................................................................................. 6

Bias and limitations ................................................................................................................ 6

Results .................................................................................................................................... 6

Content analysis ......................................................................................................................... 9

Theme one: Keeping occupied and caring for the partner is both beneficial and burdensome

................................................................................................................................................ 9

Theme two: Validation of fatherhood and the baby is required to support fathers ................ 9

Theme three: Fathers struggle with pressures to regulate emotions ...................................... 9

Theme four: Making sense of the situation .......................................................................... 10

Discussion ................................................................................................................................ 10

Theme one ............................................................................................................................ 10

Theme two ............................................................................................................................ 11

Theme three .......................................................................................................................... 12

Theme four ........................................................................................................................... 13

Conclusion ............................................................................................................................... 14

Implications for practice....................................................................................................... 14

Areas requiring further research ........................................................................................... 14

List of Tables

Table 1 ....................................................................................................................................... 5

Table 2 ....................................................................................................................................... 6

Table 3: Summary of studies ..................................................................................................... 8

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Introduction

The National Institute for Health and Care Excellence (2014) defines miscarriage as the

spontaneous loss of a baby before 24 weeks of gestation, with approximately 15-20% of

recognised pregnancies ending this way. The World Health Organisation further classifies

miscarriage as the loss of a baby weighing 500 grams or less around this time period (Mehta

and Pattanayak 2013); after 24 weeks it is considered a stillbirth (Bensouilah 2011).For many

men, pregnancy is an exciting time which represents a new beginning (Rodriguez 2005).

Though they do not experience the physical transformation, they may anticipate the child and

become emotionally invested, particularly when the pregnancy is planned (Zeanah 2009).

When the partner’s pregnancy is lost due to miscarriage or stillbirth for example, the effects

can be devastating. Although mothers often receive support from friends and family, for

many the partner may be a significant source of support (Bensouilah 2011). However the

amount of support the partner can offer is dependent on how well they are able to cope

(Johnson and Baker 2004).

Many years back in Western societies, fathers’ had limited involvement during pregnancy

and the birthing process, however after the feminist movement demanded equality, men were

invited to become more involved with the pregnancy and began to develop a connection with

the baby at an early stage (Tropp 2013). Furthermore, since the introduction of technological

aids such as ultrasound to visualise the baby and devices to hear the heart beat, fathers’ are

able to develop intense relationships with the unborn baby. Collectively, fathers are

considerably involved in pregnancy and it only stands to reason that this is reflected in the

heartbreak experienced when pregnancy fails. A systematic review conducted by Badenhorst

et al (2006) demonstrates this by confirming that fathers do experience grief at this time.

Much of the literature surrounding pregnancy loss focuses on the mother, however there is

limited research dedicated to how fathers are affected. Furthermore, following a search of

British organisations such as the National Institute of Health and Care Excellence and the

Department of Health, the absence of guidelines and policy pertaining to care of the father

following pregnancy loss suggests a gap of knowledge in this area. Understanding of the

fathers experience can improve nursing practice by necessitating an extension on patient

centred care by also promoting fathers well-being, as is part of nursing conduct (Nursing and

Midwifery Council 2008).

Review question “What are the psychosocial experiences of men following loss of their partner’s pregnancy?”

Aims and objectives The aim of this literature review is to explore and critically appraise relevant research articles

relating to the psychosocial experiences of men following the loss of pregnancy and to

consider how an understanding of this can contribute to promotion of overall well-being.

Psychosocial characteristics involve the interrelationship between psychological and social

aspects of the experience (Hamber and Gallagher 2015). It is noted here that only

psychosocial issues will be examined and not isolated psychological aspects relating to the

topic such as levels of depression, grief or suffering in men.

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Methodology

A systematic search of the literature published from the year 2000 onwards was carried out to

identify existing research into the psychosocial experience of fathers following the loss of

their partner’s pregnancy, for which it was observed there is a small body of research.

Keywords were identified in a preliminary search and through creative thinking. Five

databases were searched in a systematic manner to reduce bias (Burns and Grove 2010)

(Medline, PsycINFO, ProQuest Nursing and Allied Health Resources, Applied Social

Sciences Index and Abstracts (ASSIA) and Cumulative Index to Nursing and Allied Health

Literature (CINAHL) Plus), and this concluded when data saturation was achieved.

Subsequent snowball sampling of selected articles and relevant journals identified data which

did not appear on the database searches.

The title and abstract of 1036 search results were screened against inclusion and exclusion

criteria detailed in Table 1 for suitability and relevance to the research question. This

produced 24 prospective articles which were read and re-read and screened again for

suitability. Of these, 14 met exclusion criteria, which left 10 articles appropriate for this

review.

Table 1

Inclusion criteria Exclusion criteria

Published literature Unpublished and grey literature

Primary source Secondary source

Date of publication 2000-current Date of publication before 2000

English language Language other than English

Focus on men Focus on women’s, couples or shared experiences

where men’s perspectives are not isolated

Psychosocial focus Psychological focus

Qualitative data Quantitative data

Academic source/study Planned termination of the pregnancy

Critical appraisal The Critical Appraisal Skills Programme (CASP 2013) qualitative appraisal tool was used to analyse all of the

analyse all of the retrieved articles as questions were specific to the type of research conducted. This tool facilitated

conducted. This tool facilitated an in-depth examination of the strengths, weaknesses and limitations of the articles to

limitations of the articles to systematically assess them for quality, rigor, credibility and relevance. The full use of the

relevance. The full use of the tool was used to do this, hence each article was scrutinised against the 10 questions

against the 10 questions detailed in

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Table 2.

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Table 2

1. Was there a clear statement of the aims of the research?

2. Is a qualitative methodology appropriate?

3. Was the research design appropriate to address the aims of the research?

4. Was the recruitment strategy appropriate to the aims of the research?

5. Was the data collected in a way that addressed the research issue?

6. Has the relationship between researcher and participants been adequately considered?

7. Have ethical issues been taken into consideration?

8. Was the data analysis sufficiently rigorous?

9. Is there a clear statement of findings?

10. How valuable is the research?

Synthesis of findings

Syntheses of findings were guided by suggestions made by Aveyard (2010). Meta-

ethnography was used to examine, interpret and explore differences in the retrieved articles.

Content analysis was used to derive meaning from the data. Similar codes were combined to

form 17 categories and again to produce 4 themes which were compared to the original data

for accuracy.

Bias and limitations

The question for this review was derived from the researcher’s private life, which may

introduce bias; however the systematic approach taken reduces the impact of this (Burns and

Grove 2010). A short time frame was a limitation and skills in database searching are new,

however each database was checked for appropriate truncation. Publication bias may have

been introduced as it is beyond the reviewer’s capabilities to locate grey literature.

Results All of the studies followed a qualitative design, five of which were specifically

phenomenological, providing an in-depth exploration (Polit and Beck 2010) (Table 3).

O’Leary and Thorwick (2006) specified that descriptive phenomenology was used. However

the remaining four studies did not identify their school of thought but are suggestive of an

even mixture of interpretive and descriptive. The auto-ethnographic design used by Weaver-

Hightower (2011) captures an intimate experience, although is subjective in nature and prone

to bias (Adams et al 2015). The use of a systematic approach did however reduce the impact

of this (Burns and Grove 2010).

A mixture of convenience or purposive sampling is suggestive in eight of the studies,

although not directly specified. Data collected by Cacciatore et al (2013) is however subject

to interpretation due to anonymity in recruitment, thus bias is a possibility but there may be

honesty in the results. Four studies additionally use snowball sampling, effective in

identifying participants missed. A combination of 3 recruitment techniques are used by

Bonnette and Broom (2012), which is most effective in producing information rich data.

Sample sizes in the majority of the studies are appropriately small. Cacciatore et al (2013)

however recruited 135 men, preventing in-depth exploration (Burns and Grove 2010). This

study may have been more credible with random purposive sampling (Patton 2002).

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Most of the studies conducted interviews and observations with some consideration for

researcher involvement for their data collection although not all indicate the structure and two

used questionnaires; findings are specified in Table 3: Summary of studies. Weaver-

Hightower (2011) utilised multiple auto-ethnographic methods of data collection, enriching

the study.

Data analysis methods are identified in all studies except Khan et al (2004), where it is

absent. The studies mainly use some form of thematic or content analysis, involving coding.

Bonnette and Broom (2012) utilise Charmaz’s approach, which is suited to grounded theory

but is not specified in the design, thus leaving some uncertainty regarding the methodology of

the study. Although thematic analysis would have been more beneficial given that they

sought to understand experiences of the participants (Polit and Beck 2010). Computer

software is helpful in assisting experienced researchers in the management of data during

analysis (Holland and Rees 2010) and is used by McCreight (2004).

Abboud and Liamputtong (2003; 2005) appear to have performed a secondary analysis due to

this reviewer’s observation of identical sampling strategies and participant characteristics.

Although acceptable, it should be specified. The majority of the studies were judged to be

ethically sound, although there is uncertainty in the lack of declaration of institutional

approval/informed consent in McCreight (2004), Khan et al (2001) and Samuelsson et al

(2001). However all studies used pseudonyms to protect participant identity.

Member checking in some studies and data collection/investigator triangulation utilised by all

studies increase validity of the findings presented in Table 3: Summary of studies. While

most of the studies recognise that their findings cannot be generalised, descriptive data

provided in several of the studies can aid in evaluating transferability (Polit and Beck 2010).

Overall the majority of the studies are of high quality, with others considered less reliable by

the reviewer (Cacciatore et al 2013; Khan et al 2004).

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Table 3: Summary of studies

Author (date) Country Design Recruitment Findings (Of relevance)

Abboud and

Liamputtong

(2003)

Australia Phenomenology Snowball/ GP Stoicism, social and personal pressures, concern for partner. Most were accepting and blamed no one;

small talk preferred and moving forward.

Abboud and

Liamputtong

(2005)

Australia Phenomenology Snowball/ GP Distraction is beneficial, acceptance, helping partner important, received less support and information

Armstrong

(2001)

America Phenomenology Medical

practices/ clinics

in 2 cities

Satisfied with support, identify as fathers. Recognition of baby’s existence is important, interaction

and rituals are beneficial. The partner is the priority, fathers display a supportive role and are the care

takers.

Bonnette and

Broom

(2012)

Australia Qualitative Purposive/

snowball/

advertisements/

newsletters

Men develop their identity as a father early on and due to a stoic persona, are lacking in recognition.

Their identity remains and is ongoing post pregnancy loss.

Cacciatore et

al (2013)

Sweden Qualitative Online

advertisement

The majority of fathers were supported and given information. Fatherhood was validated and the

baby was recognised. The remainder reported lack of sensitivity from staff.

Khan et al

(2004)

Ireland Qualitative

(Pilot)

Clinic Uncertainty and lack of information. Father’s ignored their feelings, seeking distraction. Support was

received from family and friends but more was needed from health professionals.

McCreight

(2004)

Northern

Ireland

Qualitative Self-help

groups/ 10

hospitals

Techno-mediated bonding such as ultrasound and doppler. Self-blame, uncertainty around identity

and the future. Recognition, validation and collection of memorabilia. Significant lack of support and

understanding; loss was devalued. Lack of information. Practical/social aspects fall under the father’s

responsibility, supporting partner. Support groups are helpful but male participation is desired.

O'Leary and

Thorwick

(2006)

Unknown Descriptive

phenomenology

Snowball/

newsletter/

Perinatal centre

Lack of recognition, stoicism, preoccupation, burden, support needed, suppression

Samuelsson

et al (2001)

Sweden Phenomenology Written

invitation

Open and discreet emotional displays observed. Received support and information; baby was

recognised. Protected partner but carried burden. Medical jargon was frustrating, as was lack of

control. Interaction and collecting tokens was beneficial. Adjustment was difficult but moving

forward was important.

Weaver-

Hightower

(2011)

America Evocative Auto-

ethnography

Self reflection Support is invaluable, there was a need to avoid emotional expression, recognising the baby and

collecting memorabilia was important.

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Content analysis

Theme one: Keeping occupied and caring for the partner is both beneficial

and burdensome In six studies many fathers prioritised their partner as it was comforting and they wanted to

support her, whereas for some others there is a societal pressure arising from gender

differences in grief. It is noted in Samuelsson et al (2001) that the role of a carer can be

burdensome as they too are distressed but gives them meaning. There is a trend for fathers to

take on social and physical responsibilities following the loss of a baby and a tendency to

keep busy in order to establish normality (Abboud and Liamputtong 2005; Khan et al 2004;

O’Leary and Thorwick 2006). This may also be therapeutic, allowing time to think (Weaver-

Hightower 2011). O’Leary and Thorwick (2006) emphasise the exhaustion the

responsibilities elicits, some tasks such as organising the funeral are overwhelming

(McCreight 2004).

Theme two: Validation of fatherhood and the baby is required to support

fathers Father’s identity develops early during pregnancy due to increased involvement and

developments in technology, providing visual and aural representations of the baby,

additionally supplemented through sensual interaction. These all contribute to an embodied

relationship which extends beyond the baby’s death, through rituals and interactions which

further validating fatherhood and the baby’s existence. However in McCreight (2004), one

baby was not recognised by a physician and was subsequently presented in an undignified

manner, intensifying grief. It is important to fathers that the baby is treated with dignity and

respect, as though alive. Six studies describe an on-going relationship through creation of

memories by collecting tokens and celebrating anniversaries which are important in

confirming the father’s identity.

Recognition as a father and as someone who is grieving is one of the biggest issues faced in

seven of the studies, with many desiring to be acknowledged. They experience problems

relating to marginalisation, disenfranchisement and acknowledgement, leading to intensified

emotions. The amount of recognition links to the level of support received (and self conduct,

explained in theme three). Many fathers receive some form of support through friends, family

or hospital staff, through conversation or help with everyday duties. Although many state that

consideration for emotional wellbeing still focuses on the partner, as fathers are presumed to

be coping. It is however evident only in McCreight (2004) that there is lack of support from

hospital staff, reflected in the insensitive nature and lack of compassion, which is exhibited in

a small amount of participants in Cacciatore et al (2012). Similarly O’Leary and Thorwick

(2006) describe lack of support from friends and family in general.

Theme three: Fathers struggle with pressures to regulate emotions The way many of the fathers in the studies describe their self conduct reflects a stoic persona,

made worse by societal and self imposed pressures to be strong, and in some cases it is for

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the partners sake (Abboud and Liamputtong 2003; Bonnette and Broom 2012). Consequently

fathers are generally less expressive, several described crying in isolation or on the inside,

finding it difficult to talk to others, preferring time alone to think. However there is conflict

between this conduct and inner distress; they contradict each other.

There is active negotiation about what it means to be a man/masculine, as is described in

Bonnette and Broom (2012), O’Leary and Thorwick (2006) and Weaver-Hightower (2011).

Some felt able to discuss their loss and feelings, but only in two studies was this in depth

(Samuelsson et al 2001; Weaver-Hightower 2011). Very few expressed feelings of freedom

to cry, with the exception of some participants in Samuelsson et al (2001). This is

contradictory to the general impression from the other studies. The variable noted is the

levels of support and validation of fatherhood and loss. However the study lacked rigour and

credibility, so the results do not influence the general findings.

Theme four: Making sense of the situation One thing noted in some of the studies was way language was used. Fathers in Abboud and

Liamputtong (2005) and McCreight (2004) assert that some comments devalued the loss and

others were insensitive (Cacciatore et al 2012). Similarly medical jargon and ambiguity in

death notification reduced understanding. Fathers in Abboud and Liamputtong (2003) and

Samuelsson et al (2001) describe occasional satisfaction with information given. This is only

unanimous in Cacciatore et al (2012), perhaps due to the increased support and recognition.

There is overall a desire for more information to prepare fathers for the delivery of a stillborn

baby and surrounding subsequent events as most felt uncertain or frightened. Many fathers

display signs of accepting their loss. However it is evident in McCreight (2004) and Weaver-

Hightower (2011) that such a loss can in some cases challenge father’s spiritual beliefs.

Discussion Coding and categorisation carried out during content analysis helped to produce four themes.

This discussion will attempt to interpret these themes and relate them to the wider context by

considering existing knowledge (Aveyard 2010). As themes overlap and influence each other,

this discussion will adopt an integrated approach.

Theme one Theme one demonstrates that fathers work through grief by engaging in activities, therefore

establishing normality. This is considered a coping mechanism, which Folkman and

Moskowitz (2004) define as ‘the thoughts and behaviours used to manage the internal and

external demands of situations that are appraised as stressful’ (Pg 745). Fathers preoccupied

themselves in various activities as a form of a problem and emotion focused coping

mechanism. This involved seeking out information and taking action, whereas the emotional

focus involved avoidance, blame and humour in order to improve and control the situation.

The prevalence of either mechanism is however dependent on how the loss is appraised

(Folkman and Lazarus 1980).

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An issue which became apparent in Weaver-Hightower (2011)’s autoethnography is that his

partner did not understand his preoccupation with projects in their garage in isolation instead

of talking to her more. It is theorised that this father was employing an emotional strategy of

distancing, having concluded that nothing will change what happened, the baby died

(Folkman and Moskowitz 2004). Abboud and Liamputtong (2005) note that some fathers

used humour to cope, which was responded to by shock and horror by others, they thought it

odd to be laughing and joking about the death of a baby. Due to the nature of the strategies

used in these two studies, misunderstanding about the way fathers deal with their grief can

occur. Overall in the other studies, the problem focused strategy of keeping busy (taking

action) is not interpreted negatively.

In most of the studies many fathers want to support their partner, it is a key aspect in

achieving emotional comfort and brings them meaning, as observed in Samuelsson et al

(2001) and Armstrong (2001)’s studies. However it is not a universally desired role, the

reviewed literature suggests that some fathers feel morally obliged to put their partner first

and overall in the studies, exhaustion occurs over time as they too are distressed. This notion

is supported in a study by Puddifoot and Johnson (1997), noting particular pressure from

female family members to perform the role.

Theme two The dilemma observed between the father’s role and their anguish above implies that there

are internal and external social pressures to take control. The social role theory brings insight

into this; gender specific characteristics/behaviours become stereotypical traits which are

governed by society, where men are seen as dominant leaders and self-regulating, for

example (Eckes and Trautner 2000). The evidence from the reviewed literature suggests that

it is becoming more difficult to maintain this role in the modern day because the involvement

of men during pregnancy is significantly increasing, thanks to techno-mediated interactions

such as ultrasound. Their parenting identity is realised almost as early as the mothers and is

be on-going after the loss (Abboud and Liamputtong 2003; Armstrong 2001; Bonnette and

Broom 2012; Cacciatore 2012; Samuelsson et al 2001).

In McCreight (2004) there was uncertainty regarding whether they have the right to the title

‘father’ and how many children they are father to, and this may be because of the

inconsiderate approach taken by the hospital staff. For participants in Armstrong (2001) and

Weaver-Hightower (2011), recognition was shown through naming the babies and interacting

with them, whereas in Samuelsson et al (2001) fatherhood was endorsed through societal

recognition of the baby. By observing the outcomes of the above studies, a connection is

evident between recognition of the baby and validity of fatherhood. This is particularly

important in a healthcare setting because as expressed in Cacciatore et al (2012), recognition

of the baby as a real person legitimised fatherhood, whereas when this was not apparent,

fathers’ suffering increased.

Bonnette and Broom (2012), McCreight (2004), Samuelsson et al (2001), O’Leary and

Thorwick (2006), Khan et al (2001), Cacciatore et al (2012) and Weaver-Hightower 2011

identified recognition as a father and as someone who is grieving is one of the biggest issues

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faced. Many fathers express that they felt marginalised as the overall concern was directed at

the partner and they were often presumed to be coping, with the exception in the study by

Cacciatore et al (2011) due to higher levels of recognition and compassion. It is noted that

fathers do not imply that their partners suffering is less valid, but that their suffering is not

legitimised; an experience illustrated by Anonymous (2000) shares this notion.

Weaver-Hightower (2011) and McCreight (2004) describe experiences of disenfranchised

grief, in which unmarried fathers were unable to register the stillbirth, further intensifying

their suffering. Furthermore the denial of burial due to the unknown location of the baby

noted in McCreight (2004) made the loss intangible and an experience described by Callanan

(2005) mimics this feeling. It is evident that society is yet to catch up to the changing

psychological variables surrounding fathers’ grief, in which there is a greater demand for

recognition, but a theory relating to why there is a struggle with recognition is discussed in

theme three.

Theme three The social role theory suggests pressures from society to enact stereotyped characteristics, as

previously explained. Stoicism and limited expression are frequently described in the studies,

in which fathers are more inclined to hide their anguish due to social pressures, as identified

in Abboud and Liamputtong (2005), or to support their partner, sometimes for fear of a

worsened outcome (Bonnette and Broom 2006). However internal pressures to be stoic are

also evident in fathers’ struggle to talk in depth about feelings, as noted in Abboud and

Liamputtong (2003;2005), Samuelsson et al (2001) and O’Leary and Thorwick (2006).

Weaver-Hightower (2011) felt able to talk in depth, but emotional expression was prohibited

by perceived societal pressures. This behaviour may cloud other peoples’ perception of the

fathers, giving a false impression that their grief is not as great as the mothers and thus

require minimal consideration.

As a result the amount of support received is negatively affected, such as in Bonnette and

Broom (2006), O’leary and Thorwick (2006) and McCreight (2004) where there is a repeated

relationship between low levels of recognition, high incidence of stoicism and insufficient

support. In contrast, participants in Samuelsson et al (2001) and Cacciatore et al (2012) are

recognised and receive lots of support, but stoicism is not discussed. As most of the studies

were of high quality, it is reasonable to deduce that recognition of the grieving father is

fundamental in achieving a supportive and positive outcome. However collectively in all of

the studies, variables aside, there is an even mixture between sufficient and insufficient

support, this may be due to difference in culture.

Furthermore, Badenhorst et al (2006) confirm in their systematic review that fathers do in

fact grieve. It is therefore important to understand the differences in the way grief is

experienced and expressed by fathers in order to recognise it. It is often a silent process with

many fathers crying in isolation, although a small amount of men were openly expressive

about their sorrow. This reviewer theorises that fathers’ individual perception of manliness

and masculinity influences self conduct, the definition of what it means to be a man is

however widely debated (McKay and McKay 2011). Additionally it is evident that there is

14

ongoing conflict between masculinity and the need to express sorrow; the line between these

are becoming increasingly blurred as fathers’ emotions are becoming more intense due to

increased involvement and investment prior to the loss.

The above is an important consideration in support groups as the literature suggests that

groups are not adapted to male expressions of grief, are too feminine and lack male members.

Some fathers’ expressed the desire for one to one support and male only groups (O’Leary and

Thorwick 2006). Weaver-Hightower (2011) benefitted from a mixed support group but

indicated the significance of one to one interactions. Fathers’ would benefit from support

groups which are adapted to provide a safe environment for expression.

Theme four Communication was acceptable for most fathers but when there were lapses, the outcome was

intensified. In McCreight (2004) and Weaver-Hightower (2011), when death notification was

ambiguous through use of terms such as ‘couldn’t find a heart beat’ or ‘lost the baby’,

fathers’ initial reaction was wondering where their baby was. Likewise, when friends and

relatives expressed that they could try for another baby or found light of the situation, the loss

was devalued; they wanted ‘that’ baby (Abboud and Liamputtong 2005; McCreight 2004).

However in Samuelsson et al (2001) communication was good, with only some confusion

noted around medical jargon.

Many of the fathers expressed the need for information in the studies in order to understand

what is going on and feel prepared. It is only suggested in Cacciatore et al (2012) and

Samuelsson et al (2001) that fathers’ were content with information received, perhaps due to

the amount of support available; whereas in Abbound and Liamputtong (2005), McCreight

(2004) and Khan et al (2001) the opposite is evident, leaving some fathers feeling

marginalised. It is important that fathers’ are given information in order to improve the

experience, reducing the anxiety and fright experienced when encountering the deceased

baby in person for the first time, as is evident in McCreight (2004). The benefits of

preparation were very much reflected in Weaver-Hightower (2011), who was able to find

closure.

Information and support, mentioned earlier, impacted the way fathers’ moved through the

stages of grief (Basavanthappa 2004). Ambiguity in notification prolongs the stage of denial,

although this occurred regardless in Weaver-Hightower (2011) when he refused an autopsy

for fear of harming the baby. Few fathers exhibited signs of the anger stage by blaming

themselves or others (McCreight 2004). Weaver-Hightower (2011) and some fathers in

McCreight (2004) challenged the existence of God. But this was conflicted because if there

was not such a thing, it was inconceivable that they would meet their baby again. No fathers

appear to have entered the bargaining phase but many went through the depression phase

before finally reaching acceptance, many wishing to move on having concluding they can’t

change what has happened and some such as in O’leary and Thorwick (2006) tried for

another child.

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Conclusion In conclusion, the psychosocial experience of men following the loss of their partner’s

pregnancy is complex, the systematic process of obtaining high quality literature helped to

bring insight into this. The results showed that there are many variables determining how this

experience is shaped, what is most important at such a difficult time is that a positive

outcome is achieved through a good support system. While supporting the partner gives

fathers meaning and is something they want to do, the increased involvement during

pregnancy causes them to develop their identity as a father at an early stage and at the time of

loss, many are considerably invested in the baby and exhibit deep sorrow.

The literature shows that society is yet to recognise these changing dynamics as fathers’

struggle greatly with recognition; much more understanding must be shown to the silent and

often hidden grief that fathers experience and that they are in fact very much affected. Some

of the ways identified in the literature which are useful for supporting the fathers experience

is conveying considerate comments; ask fathers ‘Are you ok? How are you personally

coping?’ It is paramount that fathers are never assumed to be coping, because as evident in

this review, a stoic persona often masks the torment felt. Finally, this review fills in a gap in

research, providing a valuable contribution to existing knowledge. Society must catch up with

the new gendered dynamics around pregnancy loss and facilitate fathers grieving, let them

know it is ok to cry and display their sorrow, as is one of the biggest hardships faced today.

Implications for practice The implications that this review has on practice relates to the holistic approach which is

universally strived for in nursing practice (Hogston and Marjoram 2011). As the evidence

suggests, many fathers are excluded from receiving adequate care in the absence of a physical

condition experienced by them; further to this, their emotional wellbeing is misinterpreted

and nurses need to be able to understand the differences in the way fathers’ experience grief

and hardship; this extends to any situation causing significant stress of loss. As identified in

the review, nurses can use the knowledge that providing detailed information and

uncompromised support can make a huge difference in fathers’ emotional wellbeing, in

addition to a kind, considerate and empathetic approach, free from the influence of societal

stereotype and judgement. As can be seen in Cacciatore et al (2012), when this is

incorporated into practice, the outcome is much improved.

Areas requiring further research This literature review gives insight into the current knowledge regarding the psychosocial

experience of fathers, but is unable to build the full picture. The evidence base is small, but

originates for several countries, suggesting that the experiences are shared globally and thus

is relevant to practice in the United Kingdom. It became evident that in addition to

psychosocial aspects, cultural characteristics may also have an influence on the way fathers’

experience loss of their partner’s pregnancy. Therefore it is recommended that further

research investigates this aspect, whether or not it influences one of the biggest obstacles in

male recognition, self-regulation.

16

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