Miscarriages, stillbirths, and neonatal losses are unexpected and unfortunate events that can occur during a parent’s life. While these terms may seem synonymous to each other, there are small differences that characterize each event. Miscarriage is the loss of a fetus before 20 weeks of pregnancy, while stillbirth is the loss of a fetus after 20 weeks of pregnancy. Neonatal loss is defined as the death of a newborn baby within the first 28 days of its life. With miscarriages occurring in about 1 in 4 pregnancies, and stillbirths occurring in 1 in 160, these events are more common than people realize. When it comes to neonatal loss, about 2.8 million babies die within their first week of life (Fig. 1). These events are extremely devastating and difficult for parents and their extended families to go through.

Pregnancy and neonatal related loss have been garnering increased research interest, specifically on the psychological and/or emotional effects on the parents. However, a lot of discussions focused mainly on the maternal effects instead of both maternal and paternal effects. This is not to say that paternal grief has not been researched; it has but to a much lesser extent.

A study conducted by Kate Louise Obst sought to identify how men experienced grief and the factors that contributed to its intensity. The study also proposed possible solutions that can help men properly express grief without fear of invalidation. The researchers used a methodical literature search, also known as a systematic review, throughout four online databases to find studies that discussed paternal grief and/or the factors that contribute to it and analyzed the results (Fig. 2).

The Perinatal Grief Scale (PGS) was used to measure grief in literature studies utilizing quantitative, or numerical, data. Normal responses indicated that scores above 91 show a high degree of grief, but men did not score in this range. Men, in general, scored significantly lower than women with other grief measurements such as the Revised Impact of Miscarriage Scale (RIMS). Obst found that some literature studies argued that these assessments were invalid for men since there is a potential difference between how men and women grieve. Furthermore, grief measurements, including the PGS, were initially made to measure maternal grief, so these examinations and resulting scores would not apply to men.

In studies that used qualitative, or non-numerical, data, it was shown that men are less likely to show emotion due to social expectations of male behavior and grieve in silence or privacy. The theory of disenfranchised grief, which refers to grief that is invalidated or not accepted by society, explains this phenomenon very well. Furthermore, the grief measurements previously mentioned showed that men scored on the higher end of the devastating event, the denial and social desirability, and the avoidance scales, leading to the idea that men tend to hide their grief from the public. Due to this, they may have a harder time seeking help through the grieving process, which may harm their overall health and wellbeing. Additionally, it was shown that men experienced a range of challenges, for example, helplessness and other responsibilities, that worsened their grief. Furthermore, most men used “active” or “problem-focused” coping strategies in an attempt to distract them from their feelings. However, distraction is not always the best tool to use when dealing with intense emotions because it allows a person to run away from the situation and ineffectively move through the grieving process.

Obst’s literature study showed that there are four factors related to how men experience grief. The first factor is individual, which includes an attachment to the baby and previous losses. It has been shown that a strong attachment can be formed during ultrasound appointments or any other doctor’s visits, the strength of these attachments can increase the intensity of grief. Men who experienced previous pregnancy or neonatal losses showed a variety of results in grief intensity. Some reported no change in grief or the same level of grief continued, while others reported worsening grief.

The second factor is the quality of the relationship with the partner and support and acknowledgment from family, friends, and healthcare professionals, also known as interpersonal. It has been shown that the partner can be the main source of support. A better quality relationship would help the couple move more effectively through the grieving process, and it could also strengthen their relationship. A lack of support, however, from family and friends worsened grief. Healthcare professionals could also add to this grief by being obscure with the situation surrounding the loss. For example, they would use medical terminology to describe how or why the loss occurred, and not properly explain it in a way that makes it easier for parents to understand and process.

The third factor is the community, which encompasses the theory of disenfranchised grief previously mentioned. The lack of community acknowledgment and understanding worsened men’s grief, which also led to increased distress and feelings of isolation. There is also a pressure for men to conform to the masculine role society expects of them, effectively controlling how, and if, they should grieve outwardly.

The final factor is public policies that center on women’s care. In general, society tends to focus more on women’s grief since pregnancy or neonatal loss is considered a “woman’s experience”. One study suggests that this causes men to feel overlooked or ignored. Furthermore, men were not given the same opportunity as women in the workplace to take time off to grieve, which can lead to physical and emotional exhaustion.

Some issues came up in the literature study, which is the lack of diversity and inclusivity, leading to a lack of generalizability. A majority of the participants were Caucasian, heterosexual men, so there was limited discussion as to whether cultural or ethnic backgrounds can be considered a factor in how men experience grief. Obst’s article also calls for gay and transgender men to be included in further studies since they may face unique challenges. Furthermore, most of the studies were conducted in high-income countries, disregarding the likelihood of economic instability being a factor in grief.

Bronfenbrenner’s Ecological System Theory states that an individual’s development is impacted by the microsystem (the immediate environment), the mesosystem (the settings in which we actively participate), the exosystem (the wider social setting), and the macrosystem (culture and belief systems)$^{5}$. With Bronfenbrenner’s ecological system theory in mind, Obst proposed a new model stating that grief does not exist in isolation, rather it is shaped by a complex system of interacting factors. In this suggested model, men’s grief should not be viewed as an individual response but as a part of a wider socio-ecological process. The new model of men’s grief showed new multi-level strategies that will allow men to grieve properly and uniquely. Society itself needs to learn about how pregnancy or neonatal loss affects men. Some ways this can be done is through public health campaigns to change the attitudes toward grief and loss and to create policies that validate their feelings. Obst hopes that their literature review created a solid foundation to assist future research in men’s experience and the factors that contribute to their grief after pregnancy or neonatal loss.

References

1. World Health Organization. Stillbirths.
2. Obst KL, Due C, Oxlad M, et. al. Men’s grief following pregnancy loss and neonatal loss: a systemic review and emerging theoretical model. BMC Pregnancy and Childbirth. 2020;20(1).
3. Toedter LJ, Lasker JN, et. al. The perinatal grief scale: development and initial validation. Am J Orthopsychiatry. 1988;58(3):435-49.
4. O’Leary J, Thorwick C. Fathers’ perspectives during pregnancy, postperinatal loss. J Obstet Neonatal Nurs. 2006;35(1):78-86.
5. Bronfenbrenner U. The ecology of human development: experiments by nature and design. Cambridge: Harvard University Press; 1979.