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Australian men's experiences of support following pregnancy loss: A qualitative study
Midwifery 70 (2019) 1–6
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Australian men’s experiences of support following pregnancy loss: A qualitative study Kate Louise Obst∗, Clemence Due School of Psychology, University of Adelaide, Adelaide, Australia
a r t i c l e
i n f o
Article history: Received 4 August 2018 Accepted 28 November 2018
Keywords: Men Pregnancy loss Miscarriage Stillbirth Grief Support
a b s t r a c t Background: Despite growing recognition of the potential psychological and emotional impacts of pregnancy loss on expecting parents, the majority of the literature and subsequent care guidelines focus largely on women’s experiences. Currently, there is limited research pertaining solely to men’s health and psychological outcomes, especially in the Australian context. Objective: This study aimed to explore Australian men’s experiences of both formal and informal supports received following a female partner’s pregnancy loss. Methods: Using a qualitative research design, eight South Australian men were interviewed about their experiences of support following pregnancy loss. Findings: Thematic analysis returned six themes, categorised into three sections based on the aims of the study. Overall, findings indicated that fathers require emotional support following a loss, however these supports need to be flexible. Although some men may find support groups and individual counselling helpful, others may benefit from informal support options, such as having another trusted man to confide in, or the opportunity to ‘give back’ and help others. Additionally, while participants who accessed support services were largely satisfied, others were unaware of services, perceiving a lack of appropriate support options. Conclusion: There is a need for more active recognition of men throughout the pregnancy journey and early in their grief following a loss, especially in the hospital setting. In addition to experiencing grief, our findings suggest that male-specific challenges also exist, and future research is required to further explore and extend existing theories of men’s grief. © 2018 Elsevier Ltd. All rights reserved.
Introduction In Australia, a stillbirth is defined as a death in-utero from at least 20 weeks’ gestation or over 400 g in weight, and occurs in approximately one in every 170 births (Australian Bureau of Statistics, 2017). Miscarriage is defined as a loss occurring at less than 20 weeks’ gestation, and is estimated to occur for around 15– 20% of all recognised pregnancies (Brier, 2008). Over the last three decades, research has acknowledged the potential negative psychological and emotional impacts of pregnancy loss. High levels of psychological distress are common immediately following the loss, and enduring psychological distress and grief occur for approximately one in five parents (Cacciatore, 2013; Flenady et al., 2014; Koopmans et al., 2013; Murphy et al., 2014). Pregnancy loss can also lead to disenfranchised grief (Doka, 1999), particularly given the frequent lack of social recognition for the unborn baby as a
∗
Corresponding author. E-mail address: [email protected] (K.L. Obst).
https://doi.org/10.1016/j.midw.2018.11.013 0266-6138/© 2018 Elsevier Ltd. All rights reserved.
living individual, and an absence of prescribed norms and rituals surrounding mourning (Brier, 2008; Collins et al., 2014; Lang et al., 2011; Mulvihill and Walsh, 2014). Despite increasing recognition concerning the impact of pregnancy loss on psychological outcomes, the majority of previous research has focussed on heterosexual women’s experiences of pregnancy loss, with men typically considered as a comparative to their female partner’s experiences (Due et al., 2017; Kong et al., 2010). While most studies comparing heterosexual couples’ levels of distress following pregnancy loss suggest that men do experience grief, women’s responses have usually been more intense and enduring (Abboud and Liamputtong, 2008; Kong et al., 2010; Murphy et al., 2014; Rinehart and Kiselica, 2010). However, other studies have found similar grief responses between men and women (Bonnette and Broom, 2011; Puddifoot and Johnson, 1997), with one study suggesting higher grief responses in men (Conway and Russell, 20 0 0). Importantly, some researchers have suggested that existing research fails to capture the complexities of men’s grief following pregnancy loss, since men may downplay or suppress their outward grief reactions
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(Avelin et al., 2013; Bonnette and Broom, 2011). For example, men have reported that they are less likely to externalise their grief, instead relying on avoidant-oriented coping strategies. These include returning to work (Armstrong, 20 01; Johnson and Baker, 20 09), or turning to substance use to help suppress their grief (Turton et al., 20 06; Vance et al., 20 02). Research also suggests that men typically experience a struggle between expressing and suppressing their grief to take on the role of a ‘supporter’ for their female partner (Armstrong, 2001; Miron and Chapman, 1994; Murphy, 1998; Puddifoot and Johnson, 1997), potentially due to normative gender expectations (McCreight, 2004). A frequent lack of social recognition for men’s emotional needs may also lead men who have experienced pregnancy loss to perceive limited options for support. A small body of available studies has identified that men often feel marginalised by healthcare staff, family or friends (Basile and Thorsteinsson, 2015; Bonnette and Broom, 2011; McCreight, 2004; Murphy and Hunt, 1997; Puddifoot and Johnson, 1997). Although support services including self-help groups have increased in availability over recent years in a number of countries, past research (e.g., McCreight, 2004) notes that the majority of these are attended largely by couples or women. In addition, although positive informal support networks were available for men in one study (Armstrong, 2001), most research has found that men lack both formal and informal support options tailored to their needs (McCreight, 2004; Puddifoot and Johnson, 1997; Samuelsson et al., 2001). In relation to support following pregnancy loss in Australia specifically, no studies have aimed to examine men’s experiences. Of the Australian pregnancy loss support research, one study explored men’s experiences of miscarriage support alongside their female partners’ experiences (Abboud and Liamputtong, 2005), and the second provided a quantitative evaluation of stillbirth support in 96 Australian hospitals; however only six participants (3.2%) were men (Basile and Thorsteinsson, 2015). A recent third paper also reported on experience of care and follow-up after stillbirth in Sydney hospitals, however all of the participants were mothers (Bond et al., 2017). Overall, findings from these studies in the Australian context support international research, with parents reporting mixed experiences of satisfaction with healthcare system, a general lack of information provision, and varied support from family and friends. In Abboud and Liamputtong (2005) study, male participants felt as though their primary role was that of a supporter to their female partner. More generally, a number of guidelines for perinatal healthcare professionals have been produced to inform quality care practices following pregnancy loss (e.g., Flenady et al., 2018; Koopmans et al., 2013; Peters et al., 2014; Schott and Henley, 2007). However, many bereaved parents have continued to report receiving inconsistent or inadequate support (Basile and Thorsteinsson, 2015; Downe et al., 2013; Lang et al., 2011). Although many of the recommendations provided by guidelines are applicable to both miscarriage, stillbirth, and parents’ support needs generally, the majority focus primarily on support for loss experiences associated with more advanced gestational age. Men’s voices have also been frequently under-represented in informing such guidelines, especially in the Australian context. Only two previous Australian studies have explored men’s experiences of grief following pregnancy loss; one with men as a comparison to their female partners (Abboud and Liamputtong, 2008; Bonnette and Broom, 2011). To address this research gap, the present study aimed to explore Australian men’s experiences of support following pregnancy loss, through the following research questions:
(1) How do men experience grief following a pregnancy loss? (2) What supports are available to men following their female partner’s pregnancy loss and are these are perceived as adequate?
(3) What are the barriers and facilitators to accessing supports for men, including future support options? Method Participants Semi-structured interviews were completed with eight South Australian men whose female partners had recently experienced a pregnancy loss. They were aged between 33 and 45 (M = 39 years), and time since loss was between six months and five years ago (M = 2.5 years; see Table 1 for further details). Procedure The study was approved by the University of Adelaide Human Research Ethics Committee on 13th of April 2017. Participants were recruited through local pregnancy loss support organisations and passive snowball sampling. Individual interviews took a semi-structured approach, given the exploratory aims of the research. Questions were developed based on previous studies from across the pregnancy loss literature (e.g., Basile and Thorsteinsson, 2015; Bonnette and Broom, 2011; Due et al., 2017; McCreight, 2004; Rinehart and Kiselica, 2010). Examples include: “Could you share a little about your experience(s) with pregnancy loss?” and “Can you tell me about the supports you received at the time of the loss?” A pilot interview was conducted with a father who had recently experienced a pregnancy loss. This was used to judge the appropriateness and clarity of the proposed interview schedule. Following the interview, it was decided that only one additional question was required, concerning whether or not men felt that there were any significant differences between support needs for men and women. Therefore, this pilot interview was included in the final sample and analysis. Interviews were an average of 38 min (range 20–63 min), with data saturation achieved by the seventh interview. To ensure this, one additional interview was completed (Guest et al., 2006). Interviews were audio-recorded with participants’ permission and transcribed verbatim by the first author using an orthographic method (Braun and Clarke, 2006,2013). Confidentiality and anonymity were maintained by allocating each participant a pseudonym, and removing all names and identifying features from the transcripts. To enhance methodological rigour (Tracy’s 2010), criteria for excellence in qualitative research were followed. An ongoing Audit Trail was kept to facilitate data analysis by noting and conceptualising emerging themes, reflecting on the quality of the interview process, and making decisions about future interview modifications. All participants were offered the opportunity to read their transcripts (Tracy, 2010) following their interview. Six participants did so, however no changes were requested. Self-reflexivity is the process of engaging in an honest and transparent self-awareness that leads to more sincere research (Tracy, 2010). The first author has no personal experience with pregnancy loss, and does not have any children of her own. She completed the interviews, and thus her experience may have influenced the way in which the fathers responded to questions. However, a number of men stated during the interviews that they were keen to discuss their experiences for the purposes of the research, as they hoped that by sharing they could help men to be better supported in future. For a number of participants, it was also their first time speaking to someone about their experiences, and they expressed appreciation in being able to do so. The second author has three children and experiences of pregnancy loss. As such, the authors were able to approach the data analysis from their respective positions as women with and without children and pregnancy loss experiences.
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Table 1 Participant characteristics.
∗
Participant name∗
Age
Number of losses
Gestational age
Time since loss
Cultural background
Level of education
Aaron Simon Rob Chris Adam Jason Sam John
33 42 38 44 42 38 48 33
1 Several miscarriages, 1 stillbirth 1 stillbirth, 1 miscarriage 1 1 1 2 2
22 weeks 20 weeks and multiple early miscarriages 1 stillbirth, 1 miscarriage 21 weeks 25 weeks 27 weeks 10 weeks and 9 weeks 25 weeks
8 3 5 4 3 3 2 6
Caucasian Caucasian Caucasian Caucasian Caucasian Caucasian Caucasian Caucasian
Tertiary Tertiary Tertiary Tertiary Secondary Tertiary Tertiary Tertiary
months years years and 4 years years years years years and 1 year months
Note: Participant names are pseudonyms.
Data analysis Thematic Analysis (TA) was used to analyse the data from a realist ontological position, whereby reality is assumed to be independent from human knowledge and understanding (Braun and Clarke, 2006,2013). Participants’ interview data was therefore analysed and interpreted as a direct reflection of their lived experiences. Initially, a deductive approach was used to examine the data according to the research questions (specifically, in relation to experiences of grief and experiences of support). Following this, an inductive approach was taken, whereby additional themes were identified from the data itself. The first author transcribed the interviews and completed initial coding. These codes and initial themes were then discussed with the second author. Following discussions and refinement, a final thematic structure was reached and agreed upon by both authors. Results A total of six themes were identified across the interviews, categorised into three overarching sections. Nature of grief for men Highly individualised experience Men described varied experiences with grief, noting that “everybody’s experience is different” (Adam). Some men developed a strong bond with their unborn baby(ies) and a lasting sense of grief, while others did not. Importantly, the experience of grief was not related to the gestational age of the baby(ies). Lack of recognition for men’s grief In line with the theory of disenfranchised grief (Doka, 1999), many men described how a lack of recognition for their grief made the grieving process harder, as they felt they had to suppress their feelings. For example: “every time I’d get a text from my friends the text was like how’s [partner]? […] but you know, the father is just as upset even though he doesn’t necessarily show it in the same way” – John. Many men also downplayed their own grief experiences in relation to that experienced by women, given that their female partners had endured the physical component of the pregnancy and loss. For example: “I think it’s definitely the case that men do need support […] and they do suffer the loss just as much, but because women have to bear the brunt of it and actually go through the whole […] childbirth after a loss, it’s more emotional for them, it’s more taxing” - Rob
In general, then, men expressed varied grief reactions. However, for those men whose grief was significant, there was a lack of societal recognition which made psychological recovery difficult. In addition, normative gendered expectations surrounding grief and recovery following pregnancy loss meant that both broader society and the men themselves focussed on their female partners, rather than their own emotional experiences. Support experiences Given that men had highly individualised grief experiences, the supports they received or sought out were also highly varied. Captured by the following two themes, support was dependent both on men’s individual experiences of loss and grief, and also the level of recognition they received from their social networks. Men’s support needs vary based on their experiences of loss and level of grief Previous research (e.g., Due et al., 2018) has indicated that the initial hospital experience is a crucial source of support where subsequent support options can be established following a pregnancy loss. For the men in this study, there were inconsistent experiences of support in the hospital setting. While some men reported leaving hospital with a good understanding of their support options, others felt dissatisfied with a lack of information or follow-up. A few men described how they felt as though they “barely existed” (Chris). Participants also noted differences in the support following a miscarriage as compared to stillbirth. For example, Rob described how “the support was a fair bit less” for his partner’s miscarriage compared to later term loss, since miscarriages typically receive less formal medical care. Given previous research concerning the lack of evidence of the impact of gestational age on grief outcomes, this is potentially problematic. Outside the hospital system, some men didn’t utilise formal support options because they were not aware of them, or “didn’t feel I needed to” (Adam). Furthermore, many participants felt that the activities and supports on offer from support organisations were “very much geared to women” (Aaron). Others also avoided formal options such as group settings because they were uncomfortable. For example: “Seeing people sitting in a circle can be a little bit confronting because it then makes you feel like you’re going to have to stand up and talk to people about something that’s incredibly personal. And I don’t know that that’s something that men are particularly good at.” – Simon. Despite this, the fathers who did attend a support group found it helpful to their grieving process, and mixed support groups were also helpful for some men. Given that group settings were often undesirable, others described the usefulness of individual counselling. However, the perceived efficacy of counselling depended
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on the type of counsellor, with many men stating a preference for grief counsellors rather than general psychological services.
two themes seen in the data concerning appropriate support options for men.
Support requires social recognition Despite experiences of focusing on women’s grief as noted in the previous section, the majority of men recounted positive experiences of support with family members or friends, especially in the earliest stages following the loss. For example, Chris described how having a few good friends to catch up informally was helpful for him:
Male-specific, informal supports Many of the men discussed a desire for male-specific, informal support opportunities, such as catching up with another trusted man who understood their situation. In the hospital setting, many men expressed a desire to be approached by a male support worker. These ideas were especially appealing among the men who found formal support settings uncomfortable. For example:
And we didn’t really talk specifically about that, I sort of raised it over a few things and they were pretty good about it […] the appropriate response to anything that they say is, yeah that sucks man […] And that’s all I wanted to hear.” – Chris. However, consistent with the theory of disenfranchised grief, other men described how family and friends were “pretty useless” (Sam), because they didn’t understand their grief or avoided talking about it. This lack of acknowledgement of grief from social groups led to men reporting few support options, and worse grief outcomes. Given that family and friends weren’t always a positive source of support, many men relied on their female partner as a support mechanism. However, relying on this relationship was complicated. Although some reported a strengthening of the partner relationship, others experienced strain due to differences in grieving styles or a lack of communication. Many of the men also mentioned a feeling of primarily being a ‘supporter’ to their female partner and children; a role which served as a barrier to seeking support for themselves. For example: “why […] have [I] never sought help? […] I think the main reason was that feeling of that need to look after my family […] it’s a stereotype that you feel like you just have to keep things going and […] just [keep] the wheels in motion and [keep] everyone else kind of supported.” – Jason. Within this supporter role, participants also identified unspoken pressures, using terms such as the perceived need to be “strong” (Aaron, Chris, Jason and John), “tough” (Adam), or “blokey” (Adam and Jason). Finally, given that many men reported returning to work early following their loss, support in the workplace was important. Some workplaces offered extended paid leave, or sessions with a psychologist or counsellor. However, not all workplace policies were appropriate, with one father describing his disappointment with the amount of leave offered by his workplace in comparison to parents whose were babies are born healthily. Some work colleagues were described as helpful and supportive, whereas others were less so, due to a lack of understanding or difficulties handling emotional issues. In these instances, the grief response and demands of work were more difficult for men. In sum, most men in the study reported relying on informal supports, including family and friends, and perceived a lack of formal support options either from support organisations, hospitals or workplaces. This was typically due to a lack of recognition of grief following pregnancy loss, exacerbated by gendered expectations of men’s experiences of pregnancy loss and subsequent need for support. Facilitators and future supports The final aim of the research was to consider support services for fathers, and ways to facilitate these. This section summarises
“…maybe if I’d had some guy come ‘round says look you want to have a chat? Have a beer and a chat? You know I reckon maybe that would’ve been good. Just so just have somebody sitting there and […] just basically go, ‘yeah man that sucks’. You know who was a stranger because you know, with your friends its sort of, you talk about it and stuff, but sometimes it’s easier to talk to a stranger […] it couldn’t have been a woman though, for me at least, I’d want to speak to another bloke because […] even though there’s no difference or whatever, there is in my head.” – Chris. Re-framing the language of support Many participants initiated discussions about the language of support, including the need to use language that provides a more active offering of support options rather than a “wishy-washy” (Chris) approach that requires fathers to reach out and proactively ask for support themselves. For example, one participant suggested advertising opportunities such as fundraising events for men to participate in, as this would allow fathers to support others and connect with other men. Indeed, a number of men described how they happily attended support organisation events with their families, and found these helpful: “I think personally the way to reach out to men and make them connect with [support] is to frame the proposition completely differently. And not make it about support. I think it honestly would be better to tap into what they’re probably thinking themselves, and that’s about supporting other people. And through that you actually support them.” – Jason. Discussion Supporting previous research on both typical grief responses and grief following pregnancy loss (e.g., Brier, 2008; Lang et al., 2011; McCreight, 2004), the findings of this study suggest that men’s grief responses and subsequent support needs following pregnancy loss were highly individualised, and not related to the gestational age of their baby(ies). Regardless of the severity of men’s grief, a widespread lack of recognition of men as grieving fathers from both the healthcare system and their social circles worsened their psychological recovery. These findings are consistent with the theory of disenfranchised grief (Doka, 1999), and replicate previous research findings concerning expectations for men to take on the ‘supporter role’ that prescribes expectations to suppress their own emotions (Abboud and Liamputtong, 2008; Armstrong, 2001; Bonnette and Broom, 2011; McCreight, 2004). As previously suggested, this lack of recognition for themselves as a griever in need of support is likely driven by a wider lack of social recognition for men’s role in pregnancy and childbirth (Bonnette and Broom, 2011; McCreight, 2004). While some men reported positive hospital experiences and caring healthcare professionals, others described inconsistent experiences. Again, this finding echoes previous research on the hospital experience (Basile and Thorsteinsson, 2015; Downe et al., 2013),
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suggesting that established guidelines are not being consistently followed. While some men required informal grief management tools such as grief literature, information or practical advice, others desired emotive, formal strategies including individual counselling or access to support groups. However, overall, and as in (McCreight’s, 2004) study, many of the men in this study reported discomfort in the idea of formal supports. Instead, they relied on family and friends for support, although these relationships remain complicated and are not always readily available (Puddifoot and Johnson, 1997; Samuelsson et al., 2001). Reflecting previous research, many men also reported returning to work soon following a loss (Armstrong, 2001; Johnson and Baker, 2009). However, in many instances, workplace policies were inadequate, with participants expressing a desire for increased opportunities to take leave or connect with confidential workplace support services. Currently, care regarding pregnancy and the support activities on offer following a pregnancy loss are heavily focussed on, or delivered by, women. To reduce the widespread sense of marginalisation that men have experienced across the research literature, participants in this study expressed a desire for male-specific, informal support options. Finally, although previous research and current guidelines address the importance of sensitive, jargonfree and empathetic doctor-patient communication to discuss pregnancy loss with bereaved parents (e.g., Flenady et al., 2018; JonasSimpson and McMahon, 2005), this study also identified the importance of appropriately framing the language of support to increase receptivity among men. There is a need to adopt language that is more inclusive of men, especially in the hospital environment. Limitations and future research While this study found that men’s grief responses and support experiences were highly varied, it is important to note that the male participants fell in a similar age range, were well-educated and Caucasian, which may indicate a selection bias. Future research would ideally include samples of men with broader ages, socioeconomic and cultural backgrounds. Importantly, it is also essential for future research to explore and understand the experiences of gay, bisexual and/or transgender men following a pregnancy loss, who may experience unique or added challenges, particularly in relation to accessing appropriate support (Due et al., 2017; Ellis et al., 2015; Ziv and Freund-Eschar, 2015). Conclusion This is the first Australian study to examine men’s experiences of support following miscarriage and stillbirth, providing a much needed contribution to the currently limited pregnancy loss literature for men. Practically, the findings demonstrate a clear need for more male-specific and flexible support options following pregnancy loss, along with more active recognition of men throughout the pregnancy journey and early in their grief. The findings also provide further support for theories regarding complex loss and disenfranchised grief following a pregnancy loss (Cacciatore et al., 2008; Doka, 1999; Lang et al., 2011), and indicate that additional male-specific challenges may also exist. Conflict of interest None declared. Ethical approval This study was approved by the University of Adelaide Human Research Ethics Committee on the 13th of April 2017 (approval number H-2017-049).
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Funding sources None declared. Acknowledgements The authors would like to sincerely thank the participants who so generously gave their time to participate in interviews and share their experiences. References Abboud, L., Liamputtong, P., 2005. When pregnancy fails: coping strategies, support networks and experiences with health care of ethnic women and their partners. J. Reprod. Infant Psychol. 23 (1), 3–18. doi:10.1080/02646830512331330974. Abboud, L., Liamputtong, P., 2008. Pregnancy loss: what it means to women who miscarry and their partners. Soc. Work Health Care 36 (3), 37–62. doi:10.1300/ J010v36n03_03. Armstrong, D., 2001. Exploring fathers’ experiences of pregnancy after a prior perinatal loss. Am. J. Matern./Child Nurs. 26 (3), 147–153. doi:10.1097/ 0 0 0 05721-20 01050 0 0-0 0 012. Australian Bureau of Statistics. (2017). Causes of Death, Australia, 2016. (3303.0) Canberra: Commonwealth of Australia. Avelin, P., Rådestad, I., Säflund, K., Wredling, R., Erlandsson, K., 2013. Parental grief and relationships after the loss of a stillborn baby. Midwifery 668–673. doi:10. 1016/j.midw.2012.06.007. Basile, M.L., Thorsteinsson, E.B., 2015. Parents’ evaluation of support in Australian hospitals following stillbirth. Peer J. 3, e1049. doi:10.7717/peerj.1049. Bonnette, S., Broom, A., 2011. On grief, fathering and the male role in men’s accounts of stillbirth. J. Sociol. 48 (3), 248–265. doi:10.1177/1440783311413485. Braun, V., Clarke, V., 2006. Using thematic analysis in psychology. Qual. Res. Psychol. 3, 77–101. doi:10.1191/1478088706qp063oa. Braun, V., Clarke, V., 2013. Successful Qualitative Research: A Practical Guide for Beginners. SAGE Publications, London, UK. Brier, N., 2008. Grief following miscarriage: a comprehensive review of the literature. J. Women’s Health 17 (3), 451–464. doi:10.1089/jwh.2007.0505. Cacciatore, J., 2013. Psychological effects of stillbirth. Semin. Fetal Neonatal Med. 18 (2), 76–82. doi:10.1016/j.siny.2012.09.001. Cacciatore, J., DeFrain, J., Jones, K.L.C., 2008. When a baby dies: ambiguity and stillbirth. Marriage Fam. Rev. 44 (4), 439–454. doi:10.1080/01494920802454017. Collins, C., Due, C., Riggs, D.W., 2014. The impact of pregnancy loss on women’s adult relationships. Grief Matters 17 (2), 44–50. Conway, K., Russell, G., 20 0 0. Couples’ grief and experience of support in the aftermath of miscarriage. Br. J. Med. Psychol. 73 (4), 531–545. doi:10.1348/ 0 0 071120 0160714. Doka, K.J., 1999. Disenfranchised grief. Bereave. Care 18 (3), 37–39. doi:10.1080/ 02682629908657467. Downe, S., Schmidt, E., Kingdon, C., Heazell, A.E.P., 2013. Bereaved parents’ experience of stillbirth in UK hospitals: a qualitative interview study. Biomed. J. Open 3 (2), e002237. doi:10.1136/bmjopen- 2012- 002237. Due, C., Chiarolli, S., Riggs, D.W., 2017. The impact of pregnancy loss on men’s health and wellbeing: a systematic review. BMC Pregnancy Childbirth 17 (1), 380. doi:10.1186/s12884- 017- 1560- 9. Due, C., Obst, K., Riggs, D.W., Collins, C., 2018. Australian heterosexual women’s experiences of healthcare provision following a pregnancy loss. Women Birth 31 (4), 331–338. doi:10.1016/j.wombi.2017.11.002. Ellis, S.A., Wojnar, D.M., Pettinato, M., 2015. Conception, pregnancy, and birth experiences of male and gender variant gestational parents: it’s how we could have a family. J. Midwifery Women’s Health 60 (1), 62–69. doi:10.1111/jmwh.12213. Flenady, V., Boyle, F., Koopmans, L., Wilson, T., Stones, W., Cacciatore, J., 2014. Meeting the needs of parents after a stillbirth or neonatal death. BJOG 121, 137–140. doi:10.1111/1471-0528.13009. Flenady, V., Oats, J., Gardener, G., Masson, V., McCowan, L., Kent, A., Khong, Y., 2018. Perinatal Society of Australia and New Zealand clinical practice guideline for care around stillbirth and neonatal death. Perinatal Society of Australia and New Zealand, 3 ed., pp. 56–72. Guest, G., Bunce, A., Johnson, L., 2006. How many interviews are enough? An experiment with data saturation and variability. Field Methods 18 (1), 59–82. doi:10.1177/1525822X05279903. Johnson, M.P., Baker, L., 2009. Implications of coping repertoire as predictors of men’s stress, anxiety and depression following pregnancy, childbirth and miscarriage: a longitudinal study. J. Psychosom. Obstet. Gynecol. 25 (2), 87–98. doi:10.1080/01674820412331282240. Jonas-Simpson, C., McMahon, E., 2005. The language of loss when a baby dies prior to birth: cocreating human experience. Nurs. Sci. Q. 18 (2), 124–130. doi:10.1177/0894318405275861. Kong, G.W.S., Chung, T.K.H., Lai, B.P.Y., Lok, I.H., 2010. Gender comparison of psychological reaction after miscarriage—a 1-year longitudinal study. BJOG 117 (10), 1211–1219. Koopmans, L., Wilson, T., Cacciatore, J., Flenady, V., 2013. Support for mothers, fathers and families after perinatal death. Cochrane Database Syst. Rev. 6. doi:10. 10 02/14651858.CD0 0 0452.pub3.
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Australian men’s experiences of support following pregnancy loss: A qualitative study Kate Louise Obst∗, Clemence Due School of Psychology, University of Adelaide, Adelaide, Australia
a r t i c l e
i n f o
Article history: Received 4 August 2018 Accepted 28 November 2018
Keywords: Men Pregnancy loss Miscarriage Stillbirth Grief Support
a b s t r a c t Background: Despite growing recognition of the potential psychological and emotional impacts of pregnancy loss on expecting parents, the majority of the literature and subsequent care guidelines focus largely on women’s experiences. Currently, there is limited research pertaining solely to men’s health and psychological outcomes, especially in the Australian context. Objective: This study aimed to explore Australian men’s experiences of both formal and informal supports received following a female partner’s pregnancy loss. Methods: Using a qualitative research design, eight South Australian men were interviewed about their experiences of support following pregnancy loss. Findings: Thematic analysis returned six themes, categorised into three sections based on the aims of the study. Overall, findings indicated that fathers require emotional support following a loss, however these supports need to be flexible. Although some men may find support groups and individual counselling helpful, others may benefit from informal support options, such as having another trusted man to confide in, or the opportunity to ‘give back’ and help others. Additionally, while participants who accessed support services were largely satisfied, others were unaware of services, perceiving a lack of appropriate support options. Conclusion: There is a need for more active recognition of men throughout the pregnancy journey and early in their grief following a loss, especially in the hospital setting. In addition to experiencing grief, our findings suggest that male-specific challenges also exist, and future research is required to further explore and extend existing theories of men’s grief. © 2018 Elsevier Ltd. All rights reserved.
Introduction In Australia, a stillbirth is defined as a death in-utero from at least 20 weeks’ gestation or over 400 g in weight, and occurs in approximately one in every 170 births (Australian Bureau of Statistics, 2017). Miscarriage is defined as a loss occurring at less than 20 weeks’ gestation, and is estimated to occur for around 15– 20% of all recognised pregnancies (Brier, 2008). Over the last three decades, research has acknowledged the potential negative psychological and emotional impacts of pregnancy loss. High levels of psychological distress are common immediately following the loss, and enduring psychological distress and grief occur for approximately one in five parents (Cacciatore, 2013; Flenady et al., 2014; Koopmans et al., 2013; Murphy et al., 2014). Pregnancy loss can also lead to disenfranchised grief (Doka, 1999), particularly given the frequent lack of social recognition for the unborn baby as a
∗
Corresponding author. E-mail address: [email protected] (K.L. Obst).
https://doi.org/10.1016/j.midw.2018.11.013 0266-6138/© 2018 Elsevier Ltd. All rights reserved.
living individual, and an absence of prescribed norms and rituals surrounding mourning (Brier, 2008; Collins et al., 2014; Lang et al., 2011; Mulvihill and Walsh, 2014). Despite increasing recognition concerning the impact of pregnancy loss on psychological outcomes, the majority of previous research has focussed on heterosexual women’s experiences of pregnancy loss, with men typically considered as a comparative to their female partner’s experiences (Due et al., 2017; Kong et al., 2010). While most studies comparing heterosexual couples’ levels of distress following pregnancy loss suggest that men do experience grief, women’s responses have usually been more intense and enduring (Abboud and Liamputtong, 2008; Kong et al., 2010; Murphy et al., 2014; Rinehart and Kiselica, 2010). However, other studies have found similar grief responses between men and women (Bonnette and Broom, 2011; Puddifoot and Johnson, 1997), with one study suggesting higher grief responses in men (Conway and Russell, 20 0 0). Importantly, some researchers have suggested that existing research fails to capture the complexities of men’s grief following pregnancy loss, since men may downplay or suppress their outward grief reactions
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(Avelin et al., 2013; Bonnette and Broom, 2011). For example, men have reported that they are less likely to externalise their grief, instead relying on avoidant-oriented coping strategies. These include returning to work (Armstrong, 20 01; Johnson and Baker, 20 09), or turning to substance use to help suppress their grief (Turton et al., 20 06; Vance et al., 20 02). Research also suggests that men typically experience a struggle between expressing and suppressing their grief to take on the role of a ‘supporter’ for their female partner (Armstrong, 2001; Miron and Chapman, 1994; Murphy, 1998; Puddifoot and Johnson, 1997), potentially due to normative gender expectations (McCreight, 2004). A frequent lack of social recognition for men’s emotional needs may also lead men who have experienced pregnancy loss to perceive limited options for support. A small body of available studies has identified that men often feel marginalised by healthcare staff, family or friends (Basile and Thorsteinsson, 2015; Bonnette and Broom, 2011; McCreight, 2004; Murphy and Hunt, 1997; Puddifoot and Johnson, 1997). Although support services including self-help groups have increased in availability over recent years in a number of countries, past research (e.g., McCreight, 2004) notes that the majority of these are attended largely by couples or women. In addition, although positive informal support networks were available for men in one study (Armstrong, 2001), most research has found that men lack both formal and informal support options tailored to their needs (McCreight, 2004; Puddifoot and Johnson, 1997; Samuelsson et al., 2001). In relation to support following pregnancy loss in Australia specifically, no studies have aimed to examine men’s experiences. Of the Australian pregnancy loss support research, one study explored men’s experiences of miscarriage support alongside their female partners’ experiences (Abboud and Liamputtong, 2005), and the second provided a quantitative evaluation of stillbirth support in 96 Australian hospitals; however only six participants (3.2%) were men (Basile and Thorsteinsson, 2015). A recent third paper also reported on experience of care and follow-up after stillbirth in Sydney hospitals, however all of the participants were mothers (Bond et al., 2017). Overall, findings from these studies in the Australian context support international research, with parents reporting mixed experiences of satisfaction with healthcare system, a general lack of information provision, and varied support from family and friends. In Abboud and Liamputtong (2005) study, male participants felt as though their primary role was that of a supporter to their female partner. More generally, a number of guidelines for perinatal healthcare professionals have been produced to inform quality care practices following pregnancy loss (e.g., Flenady et al., 2018; Koopmans et al., 2013; Peters et al., 2014; Schott and Henley, 2007). However, many bereaved parents have continued to report receiving inconsistent or inadequate support (Basile and Thorsteinsson, 2015; Downe et al., 2013; Lang et al., 2011). Although many of the recommendations provided by guidelines are applicable to both miscarriage, stillbirth, and parents’ support needs generally, the majority focus primarily on support for loss experiences associated with more advanced gestational age. Men’s voices have also been frequently under-represented in informing such guidelines, especially in the Australian context. Only two previous Australian studies have explored men’s experiences of grief following pregnancy loss; one with men as a comparison to their female partners (Abboud and Liamputtong, 2008; Bonnette and Broom, 2011). To address this research gap, the present study aimed to explore Australian men’s experiences of support following pregnancy loss, through the following research questions:
(1) How do men experience grief following a pregnancy loss? (2) What supports are available to men following their female partner’s pregnancy loss and are these are perceived as adequate?
(3) What are the barriers and facilitators to accessing supports for men, including future support options? Method Participants Semi-structured interviews were completed with eight South Australian men whose female partners had recently experienced a pregnancy loss. They were aged between 33 and 45 (M = 39 years), and time since loss was between six months and five years ago (M = 2.5 years; see Table 1 for further details). Procedure The study was approved by the University of Adelaide Human Research Ethics Committee on 13th of April 2017. Participants were recruited through local pregnancy loss support organisations and passive snowball sampling. Individual interviews took a semi-structured approach, given the exploratory aims of the research. Questions were developed based on previous studies from across the pregnancy loss literature (e.g., Basile and Thorsteinsson, 2015; Bonnette and Broom, 2011; Due et al., 2017; McCreight, 2004; Rinehart and Kiselica, 2010). Examples include: “Could you share a little about your experience(s) with pregnancy loss?” and “Can you tell me about the supports you received at the time of the loss?” A pilot interview was conducted with a father who had recently experienced a pregnancy loss. This was used to judge the appropriateness and clarity of the proposed interview schedule. Following the interview, it was decided that only one additional question was required, concerning whether or not men felt that there were any significant differences between support needs for men and women. Therefore, this pilot interview was included in the final sample and analysis. Interviews were an average of 38 min (range 20–63 min), with data saturation achieved by the seventh interview. To ensure this, one additional interview was completed (Guest et al., 2006). Interviews were audio-recorded with participants’ permission and transcribed verbatim by the first author using an orthographic method (Braun and Clarke, 2006,2013). Confidentiality and anonymity were maintained by allocating each participant a pseudonym, and removing all names and identifying features from the transcripts. To enhance methodological rigour (Tracy’s 2010), criteria for excellence in qualitative research were followed. An ongoing Audit Trail was kept to facilitate data analysis by noting and conceptualising emerging themes, reflecting on the quality of the interview process, and making decisions about future interview modifications. All participants were offered the opportunity to read their transcripts (Tracy, 2010) following their interview. Six participants did so, however no changes were requested. Self-reflexivity is the process of engaging in an honest and transparent self-awareness that leads to more sincere research (Tracy, 2010). The first author has no personal experience with pregnancy loss, and does not have any children of her own. She completed the interviews, and thus her experience may have influenced the way in which the fathers responded to questions. However, a number of men stated during the interviews that they were keen to discuss their experiences for the purposes of the research, as they hoped that by sharing they could help men to be better supported in future. For a number of participants, it was also their first time speaking to someone about their experiences, and they expressed appreciation in being able to do so. The second author has three children and experiences of pregnancy loss. As such, the authors were able to approach the data analysis from their respective positions as women with and without children and pregnancy loss experiences.
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Table 1 Participant characteristics.
∗
Participant name∗
Age
Number of losses
Gestational age
Time since loss
Cultural background
Level of education
Aaron Simon Rob Chris Adam Jason Sam John
33 42 38 44 42 38 48 33
1 Several miscarriages, 1 stillbirth 1 stillbirth, 1 miscarriage 1 1 1 2 2
22 weeks 20 weeks and multiple early miscarriages 1 stillbirth, 1 miscarriage 21 weeks 25 weeks 27 weeks 10 weeks and 9 weeks 25 weeks
8 3 5 4 3 3 2 6
Caucasian Caucasian Caucasian Caucasian Caucasian Caucasian Caucasian Caucasian
Tertiary Tertiary Tertiary Tertiary Secondary Tertiary Tertiary Tertiary
months years years and 4 years years years years years and 1 year months
Note: Participant names are pseudonyms.
Data analysis Thematic Analysis (TA) was used to analyse the data from a realist ontological position, whereby reality is assumed to be independent from human knowledge and understanding (Braun and Clarke, 2006,2013). Participants’ interview data was therefore analysed and interpreted as a direct reflection of their lived experiences. Initially, a deductive approach was used to examine the data according to the research questions (specifically, in relation to experiences of grief and experiences of support). Following this, an inductive approach was taken, whereby additional themes were identified from the data itself. The first author transcribed the interviews and completed initial coding. These codes and initial themes were then discussed with the second author. Following discussions and refinement, a final thematic structure was reached and agreed upon by both authors. Results A total of six themes were identified across the interviews, categorised into three overarching sections. Nature of grief for men Highly individualised experience Men described varied experiences with grief, noting that “everybody’s experience is different” (Adam). Some men developed a strong bond with their unborn baby(ies) and a lasting sense of grief, while others did not. Importantly, the experience of grief was not related to the gestational age of the baby(ies). Lack of recognition for men’s grief In line with the theory of disenfranchised grief (Doka, 1999), many men described how a lack of recognition for their grief made the grieving process harder, as they felt they had to suppress their feelings. For example: “every time I’d get a text from my friends the text was like how’s [partner]? […] but you know, the father is just as upset even though he doesn’t necessarily show it in the same way” – John. Many men also downplayed their own grief experiences in relation to that experienced by women, given that their female partners had endured the physical component of the pregnancy and loss. For example: “I think it’s definitely the case that men do need support […] and they do suffer the loss just as much, but because women have to bear the brunt of it and actually go through the whole […] childbirth after a loss, it’s more emotional for them, it’s more taxing” - Rob
In general, then, men expressed varied grief reactions. However, for those men whose grief was significant, there was a lack of societal recognition which made psychological recovery difficult. In addition, normative gendered expectations surrounding grief and recovery following pregnancy loss meant that both broader society and the men themselves focussed on their female partners, rather than their own emotional experiences. Support experiences Given that men had highly individualised grief experiences, the supports they received or sought out were also highly varied. Captured by the following two themes, support was dependent both on men’s individual experiences of loss and grief, and also the level of recognition they received from their social networks. Men’s support needs vary based on their experiences of loss and level of grief Previous research (e.g., Due et al., 2018) has indicated that the initial hospital experience is a crucial source of support where subsequent support options can be established following a pregnancy loss. For the men in this study, there were inconsistent experiences of support in the hospital setting. While some men reported leaving hospital with a good understanding of their support options, others felt dissatisfied with a lack of information or follow-up. A few men described how they felt as though they “barely existed” (Chris). Participants also noted differences in the support following a miscarriage as compared to stillbirth. For example, Rob described how “the support was a fair bit less” for his partner’s miscarriage compared to later term loss, since miscarriages typically receive less formal medical care. Given previous research concerning the lack of evidence of the impact of gestational age on grief outcomes, this is potentially problematic. Outside the hospital system, some men didn’t utilise formal support options because they were not aware of them, or “didn’t feel I needed to” (Adam). Furthermore, many participants felt that the activities and supports on offer from support organisations were “very much geared to women” (Aaron). Others also avoided formal options such as group settings because they were uncomfortable. For example: “Seeing people sitting in a circle can be a little bit confronting because it then makes you feel like you’re going to have to stand up and talk to people about something that’s incredibly personal. And I don’t know that that’s something that men are particularly good at.” – Simon. Despite this, the fathers who did attend a support group found it helpful to their grieving process, and mixed support groups were also helpful for some men. Given that group settings were often undesirable, others described the usefulness of individual counselling. However, the perceived efficacy of counselling depended
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on the type of counsellor, with many men stating a preference for grief counsellors rather than general psychological services.
two themes seen in the data concerning appropriate support options for men.
Support requires social recognition Despite experiences of focusing on women’s grief as noted in the previous section, the majority of men recounted positive experiences of support with family members or friends, especially in the earliest stages following the loss. For example, Chris described how having a few good friends to catch up informally was helpful for him:
Male-specific, informal supports Many of the men discussed a desire for male-specific, informal support opportunities, such as catching up with another trusted man who understood their situation. In the hospital setting, many men expressed a desire to be approached by a male support worker. These ideas were especially appealing among the men who found formal support settings uncomfortable. For example:
And we didn’t really talk specifically about that, I sort of raised it over a few things and they were pretty good about it […] the appropriate response to anything that they say is, yeah that sucks man […] And that’s all I wanted to hear.” – Chris. However, consistent with the theory of disenfranchised grief, other men described how family and friends were “pretty useless” (Sam), because they didn’t understand their grief or avoided talking about it. This lack of acknowledgement of grief from social groups led to men reporting few support options, and worse grief outcomes. Given that family and friends weren’t always a positive source of support, many men relied on their female partner as a support mechanism. However, relying on this relationship was complicated. Although some reported a strengthening of the partner relationship, others experienced strain due to differences in grieving styles or a lack of communication. Many of the men also mentioned a feeling of primarily being a ‘supporter’ to their female partner and children; a role which served as a barrier to seeking support for themselves. For example: “why […] have [I] never sought help? […] I think the main reason was that feeling of that need to look after my family […] it’s a stereotype that you feel like you just have to keep things going and […] just [keep] the wheels in motion and [keep] everyone else kind of supported.” – Jason. Within this supporter role, participants also identified unspoken pressures, using terms such as the perceived need to be “strong” (Aaron, Chris, Jason and John), “tough” (Adam), or “blokey” (Adam and Jason). Finally, given that many men reported returning to work early following their loss, support in the workplace was important. Some workplaces offered extended paid leave, or sessions with a psychologist or counsellor. However, not all workplace policies were appropriate, with one father describing his disappointment with the amount of leave offered by his workplace in comparison to parents whose were babies are born healthily. Some work colleagues were described as helpful and supportive, whereas others were less so, due to a lack of understanding or difficulties handling emotional issues. In these instances, the grief response and demands of work were more difficult for men. In sum, most men in the study reported relying on informal supports, including family and friends, and perceived a lack of formal support options either from support organisations, hospitals or workplaces. This was typically due to a lack of recognition of grief following pregnancy loss, exacerbated by gendered expectations of men’s experiences of pregnancy loss and subsequent need for support. Facilitators and future supports The final aim of the research was to consider support services for fathers, and ways to facilitate these. This section summarises
“…maybe if I’d had some guy come ‘round says look you want to have a chat? Have a beer and a chat? You know I reckon maybe that would’ve been good. Just so just have somebody sitting there and […] just basically go, ‘yeah man that sucks’. You know who was a stranger because you know, with your friends its sort of, you talk about it and stuff, but sometimes it’s easier to talk to a stranger […] it couldn’t have been a woman though, for me at least, I’d want to speak to another bloke because […] even though there’s no difference or whatever, there is in my head.” – Chris. Re-framing the language of support Many participants initiated discussions about the language of support, including the need to use language that provides a more active offering of support options rather than a “wishy-washy” (Chris) approach that requires fathers to reach out and proactively ask for support themselves. For example, one participant suggested advertising opportunities such as fundraising events for men to participate in, as this would allow fathers to support others and connect with other men. Indeed, a number of men described how they happily attended support organisation events with their families, and found these helpful: “I think personally the way to reach out to men and make them connect with [support] is to frame the proposition completely differently. And not make it about support. I think it honestly would be better to tap into what they’re probably thinking themselves, and that’s about supporting other people. And through that you actually support them.” – Jason. Discussion Supporting previous research on both typical grief responses and grief following pregnancy loss (e.g., Brier, 2008; Lang et al., 2011; McCreight, 2004), the findings of this study suggest that men’s grief responses and subsequent support needs following pregnancy loss were highly individualised, and not related to the gestational age of their baby(ies). Regardless of the severity of men’s grief, a widespread lack of recognition of men as grieving fathers from both the healthcare system and their social circles worsened their psychological recovery. These findings are consistent with the theory of disenfranchised grief (Doka, 1999), and replicate previous research findings concerning expectations for men to take on the ‘supporter role’ that prescribes expectations to suppress their own emotions (Abboud and Liamputtong, 2008; Armstrong, 2001; Bonnette and Broom, 2011; McCreight, 2004). As previously suggested, this lack of recognition for themselves as a griever in need of support is likely driven by a wider lack of social recognition for men’s role in pregnancy and childbirth (Bonnette and Broom, 2011; McCreight, 2004). While some men reported positive hospital experiences and caring healthcare professionals, others described inconsistent experiences. Again, this finding echoes previous research on the hospital experience (Basile and Thorsteinsson, 2015; Downe et al., 2013),
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suggesting that established guidelines are not being consistently followed. While some men required informal grief management tools such as grief literature, information or practical advice, others desired emotive, formal strategies including individual counselling or access to support groups. However, overall, and as in (McCreight’s, 2004) study, many of the men in this study reported discomfort in the idea of formal supports. Instead, they relied on family and friends for support, although these relationships remain complicated and are not always readily available (Puddifoot and Johnson, 1997; Samuelsson et al., 2001). Reflecting previous research, many men also reported returning to work soon following a loss (Armstrong, 2001; Johnson and Baker, 2009). However, in many instances, workplace policies were inadequate, with participants expressing a desire for increased opportunities to take leave or connect with confidential workplace support services. Currently, care regarding pregnancy and the support activities on offer following a pregnancy loss are heavily focussed on, or delivered by, women. To reduce the widespread sense of marginalisation that men have experienced across the research literature, participants in this study expressed a desire for male-specific, informal support options. Finally, although previous research and current guidelines address the importance of sensitive, jargonfree and empathetic doctor-patient communication to discuss pregnancy loss with bereaved parents (e.g., Flenady et al., 2018; JonasSimpson and McMahon, 2005), this study also identified the importance of appropriately framing the language of support to increase receptivity among men. There is a need to adopt language that is more inclusive of men, especially in the hospital environment. Limitations and future research While this study found that men’s grief responses and support experiences were highly varied, it is important to note that the male participants fell in a similar age range, were well-educated and Caucasian, which may indicate a selection bias. Future research would ideally include samples of men with broader ages, socioeconomic and cultural backgrounds. Importantly, it is also essential for future research to explore and understand the experiences of gay, bisexual and/or transgender men following a pregnancy loss, who may experience unique or added challenges, particularly in relation to accessing appropriate support (Due et al., 2017; Ellis et al., 2015; Ziv and Freund-Eschar, 2015). Conclusion This is the first Australian study to examine men’s experiences of support following miscarriage and stillbirth, providing a much needed contribution to the currently limited pregnancy loss literature for men. Practically, the findings demonstrate a clear need for more male-specific and flexible support options following pregnancy loss, along with more active recognition of men throughout the pregnancy journey and early in their grief. The findings also provide further support for theories regarding complex loss and disenfranchised grief following a pregnancy loss (Cacciatore et al., 2008; Doka, 1999; Lang et al., 2011), and indicate that additional male-specific challenges may also exist. Conflict of interest None declared. Ethical approval This study was approved by the University of Adelaide Human Research Ethics Committee on the 13th of April 2017 (approval number H-2017-049).
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