Grief
Both quantitative and qualitative studies revealed the highly varied and individual nature of men’s grief. Although men’s grief was less intense compared to women’s in some quantitative studies [
23,
67,
76,
88,
91,
93,
94,
96], qualitative studies identified the significant impact of loss on men. Given grief is a normal and expected process following a loss, it is unsurprising that some men experienced such significant effects. In contrast to stereotypes that men intellectualise or rationalise their grief, studies also found that men do grieve on an emotional level. They may also oscillate between problem-focused coping and emotional expressions of grief, as reflected in the dual-process model of coping [
31]. However, men’s experiences also appeared to be consistent with the theory of disenfranchised grief [
5], with a general silence surrounding pregnancy loss contributing to feelings of isolation and worsened grief. Compared to women overall, men may also face different challenges that can worsen grief. This finding is consistent with previous research on gender and grieving which suggests that grief can be impacted by, but is not dependent on, gender [
100].
Predictors of grief
A wide range of factors have the potential to influence men’s grief. At an individual level there are mixed findings relating to demographic factors, suggesting that these have not been well-explored. Similarly, personality constructs may play a key role in predicting grief [
24,
88,
90], although further research is required to confirm causality. However, in contrast to early assumptions that men only develop an attachment to the developing baby as gestation increases, results suggest that attachment at any level is an important predictor of grief [
58,
62,
79,
81,
82].
Men’s interactions with others seem to play a pivotal role in how they experience grief. The quality of the couple relationship contributed to either a positive source of support that helped the grief process, or a negative source of added stress which increased the impact of the loss [
55,
57,
59‐
62,
70,
71,
74,
81]. Grief was eased when friends and family were available to support men, and were understanding of their loss [
56,
57,
59,
61,
75,
79,
81,
82]. Furthermore, a positive experience with the healthcare system led to both reduced grief and increased support group participation [
60], whereas insensitive treatment led to psychological distress and worsened grief [
64].
These findings relating to individual and interpersonal factors are similar to studies focused on women’s experiences of grief following pregnancy/neonatal loss. For example, findings on demographic factors have also been inconsistent. Involvement in religious activity and strength of religious faith have been inversely associated with grief in some studies [
101,
102] but not others [
103]. Similarly, maternal age both has [
23,
101], and has not [
24,
104], been found to be a significant predictor of grief. However, while the impact of cultural diversity is yet to be explored in men, cross-cultural studies with women highlight a range of culturally-specific understandings and practices relating to the loss of a baby that can impact upon grief [
105‐
109]. Finally, social support and experiences with the healthcare system have been linked to both immediate grief and long-term psychological health for women [
1,
110‐
113].
Alongside the potential for mixed styles of grieving, individual-level supports should consider these factors to provide tailored and appropriate support options to suit men’s individual needs. For example, individual counselling or support groups may not be appealing to all men. Rather, previous research has recommended creative options including activity-based supports, evidence-based online supports, opportunity for peer contact, or including male support workers in hospitals [
21,
46,
47]. Joint couple bereavement counselling could also be considered where necessary. As a minimum, it is important to provide explanations to bereaved parents about incongruent grieving between partners, and skills to navigate potential issues. There is an ongoing need for healthcare professionals to provide sensitive and empathetic care to both members of a couple relationship. This includes adopting appropriate, jargon-free language, providing explanations relating to the cause of loss when available, and follow-up calls specifically to men in the weeks or months following a loss. Practical information on how best to support their partner, alongside recognising and managing their own grief, was also desired by men [
46,
62,
72].
Community attitudes concerning the legitimacy of parents’ grief following pregnancy/neonatal loss, along with gendered expectations relating to how men should behave in the face of loss, are important in shaping men’s experience. A lack of recognition for grief following pregnancy/neonatal loss resulted in disenfranchisement [
5], with men frequently reporting a feeling of being overlooked as grieving fathers [
46,
58,
61,
66,
82]. Policies relating to woman-centred care and bereavement leave in the workplace also impacted grief. Where pregnancy was seen as an issue relating exclusively to women, and men consequently felt excluded from the loss experience at the hospital, their grief was worsened [
46,
61,
81]. A small number of studies also suggested that men were frequently not afforded adequate workplace leave to manage their grief following a loss [
61,
66,
80]. In line with recent investigations which have highlighted similar social and economic consequences of stillbirth [
27,
114], there is potential to re-examine current paternity and bereavement leave policies [
66,
80].
These findings imply that beyond individual and interpersonal supports, there is also a need to educate the community about the impact of pregnancy/neonatal loss on men, as well as promoting their strengths to seek and accept, rather than avoid, support. More generally, similar recommendations have been made in the men’s physical and mental health literature, where stigma surrounding male help-seeking frequently serves as a barrier to accessing appropriate health-related supports [
34‐
36]. Strategies are also needed to develop male-inclusive healthcare practices, and promote the meaningful engagement of men as equal partners throughout pregnancy and childbirth. In the broader postnatal health context, engagement of fathers has demonstrated improved long-term physical and mental health outcomes for women, men and babies [
115,
116].
Limitations and future research
Although inconsistencies concerning grief between quantitative and qualitative studies highlight the varied nature of men’s experiences, some authors have questioned the ecological validity of current grief measures [
23,
84,
89,
95]. The PGS, for example, was initially developed and validated in a sample of mainly bereaved mothers (women
n = 138 and men
n = 56) [
117]. As such, some of the items and subscales have been criticised for measuring more traditionally ‘feminine’ (or intuitive) expressions of grief, which may under-recognise more ‘masculine’ (or instrumental) expressions and responses. Across included studies that provided separate subscale analyses of grief, the greatest differences between men and women occurred on the Active Grief subscale. This reflects outward expressions of grief and emotions, which men often display less frequently than women [
25,
91,
95,
96], and may indicate a selection bias in qualitative studies toward men with more extreme grief responses. However, some men in qualitative studies also expressed less extreme reactions to the loss, indicating representation of a range of experiences [
56,
61,
69,
71‐
75,
78,
79]. Given the correlational nature of findings on viewing an ultrasound [
25], it also remains unclear as to whether viewing an ultrasound results in more intense grief, or whether men who were already more attached to their baby were more likely to attend the ultrasound appointment. This concept requires further investigation.
Overall, quantitative studies seem to have captured part of the picture about grief, focusing predominately on individual and interpersonal factors as key contributors to the grief experience. Further studies are needed to explore the unique facets of men’s grief following pregnancy/neonatal loss (e.g., helplessness, marginalisation, and the expectation to ‘be strong’), as well as the broader sociocultural and public policy factors. This might include a more comprehensive measure of attachment to the baby and workplace functioning, or quantitative measures of marginalisation from the healthcare system, and the expectation to ‘be strong’ and conform to masculine norms. Once these factors are well understood, there will be scope to develop and validate a grief measure with increased sensitivity toward these elements, as well as the more instrumental-orientated grief styles [
23,
80,
84].
None of the included studies focused exclusively on men’s grief following neonatal loss. Furthermore, those which did include men experiencing neonatal loss did not specifically identify disenfranchisement as a contributing factor. This may be due to increased recognition for the baby’s life, given survival outside of the womb. However, in studies on neonatal loss not eligible for inclusion [
4,
118,
119], parents reported feelings similar to those following miscarriage or stillbirth. These included loneliness and isolation from friends and family, as well as a profound “silence concerning the death” [
4]. There is a need for updated research to explore men’s experiences of grief following neonatal loss, and to identify any unique factors impacting grief.
Finally, participants in the included studies were predominately Caucasian, heterosexual males. As ever, there is a need for research among diverse samples of men. This includes gay and transgender men whose pregnancy and loss experiences may involve unique or added challenges [
120,
121], single and separated men who experience relationship breakdown following a loss, and culturally and socio-demographically diverse men. The emerging socio-ecological model of men’s grief following pregnancy/neonatal loss also requires refinement and confirmation through cohort studies which includes these diverse populations. A comprehensive longitudinal study following men throughout pregnancy, and then during and following a pregnancy/neonatal loss, would also be useful to explore the causal pathways for risk and protective factors of grief.