- Research article
- Open Access
- Open Peer Review
The impact of pregnancy loss on men’s health and wellbeing: a systematic review
BMC Pregnancy and Childbirthvolume 17, Article number: 380 (2017)
Research indicates that men’s psychological and physical health outcomes after pregnancy loss differ from those of women. Our goal was to identify all literature with a focus on men’s experiences of pregnancy loss in order to outline current evidence concerning men’s wellbeing.
A systematic review of literature on men and pregnancy loss was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), Joanna Briggs Institute (JBI) and Social Care Institute for Excellence (SCIE) guidelines. Literature was sourced from PsycINFO, PubMed, Scopus, CINAHL, and Google Scholar. Inclusion criteria were 1) studies that focused on pregnancy loss (including miscarriage, stillbirth, and ectopic pregnancy, 2) that men’s voices were specifically represented, and 3) that studies were of primary data.
A final sample of 29 articles was identified, of which 16 were quantitative, 10 qualitative, and 3 mixed methods. Quantitative and mixed methods studies indicated that while men tended to have less intense and less enduring levels of negative psychological outcomes than women, they are more likely to engage in compensatory behaviours, such as increased alcohol consumption. Qualitative studies indicated that men often feel that their role is primarily as a ‘supporter’ to their female partner, and that this precludes recognition of their own loss. These studies also reported that men may feel overlooked and marginalised in comparison to their female partners, whose pain is typically more visible.
Further research is needed on men’s experiences of pregnancy loss, focusing on cultural differences. The experience of gay and/or transgender men who face pregnancy loss is overlooked in the literature to date.
Pregnancy loss affects many people every year, with miscarriage occurring in approximately 15–50% of all pregnancies , the majority of which occur before a pregnancy is formally recognised . In addition, in 2015 an estimated 2.6 million babies were stillborn . Miscarriage is defined as the unintended termination of pregnancy resulting in foetal death that occurs prior to 20 weeks of gestation, and stillbirth is the death of the foetus after 20 weeks or after reaching 400 g in weight . Ectopic pregnancy is a pregnancy in which the fertilised ovum implants outside the uterine cavity .
There are a significant body of studies detailing health and wellbeing outcomes for heterosexual women who experience a pregnancy loss, and how such women can be best supported [6,7,8,9]. However, as pregnancy is still arguably considered primarily a ‘women’s issue’ , fewer studies have considered the impact of pregnancy loss on the health and wellbeing of men. Furthermore, the literature on men tends to focus almost exclusively on heterosexual cisgender men, with research on the impact of pregnancy loss on gay and/or transgender men lacking. This lack of research is particularly problematic since available research details a range of potential health impacts for men following pregnancy loss, including disenfranchised grief, anxiety, depression, and a tendency to resort to avoidance behaviours such as alcohol and drug use [1, 7]. Taken together, men’s experience of pregnancy loss is a key area of concerning for healthcare professionals working with men and their families.
The present paper provides a systematic review of research findings from all empirical research designs with regard to men and pregnancy loss. It aims to describe the nature and characteristics of current research into the impact of pregnancy loss on men, and in so doing provides a solid base for future empirical research that addresses gaps in the literature.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)  and Joanna Briggs Institute (JBI) methods  were drawn upon in the collection and analysis of articles, as well as qualitative data synthesis and analysis processes from the Social Care Institute for Excellence (SCIE) Systematic Research Review Guidelines .
Any peer-reviewed study published in English between 1995 and 2016 was included for review in order to capture all recent research. Inclusion criteria were that studies 1) aimed to investigate the impact of pregnancy loss on men’s health and wellbeing with pregnancy loss referring to miscarriage, stillbirth and ectopic pregnancy (studies which focused on perinatal loss in the early neonatal period were excluded), 2) included either a focus on men or included men’s voices separately (i.e., in studies that focused on both men and women), 3) were empirical, involving primary data collection. The search also identified a number of studies that focused on the impact of pregnancy loss on men’s health and wellbeing in the context of a subsequent pregnancy, and these papers were assessed as meeting the inclusion criteria and were therefore included in the review. Studies which investigated the impact of both elective termination and termination due to foetal abnormality were excluded as previous research suggests that these may be experienced differently to an unplanned pregnancy loss [14, 15].
Search strategy and data extraction
An initial search of PsycINFO was undertaken to identify subject headings and potential keywords. The subject headings and potential keywords identified in this initial search were: spontaneous abortion, pregnancy loss, miscarriage, perinatal loss and stillbirth along with human males, husbands, spouses, men, males, fathers and paternal. A second search was then undertaken in PsycINFO using these keywords, subject headings and index terms. The search was then undertaken in PubMed, Scopus, CINAHL, and Google Scholar, and reference lists selected for full text review were searched for articles of relevance. Example search strategies from PsycINFO and PubMed are outlined in Tables 1 and 2. All studies identified could be accessed by the authors without contact with individual researchers. The final date for inclusion was end of July 2016.
The initial search of PsycINFO, PubMed, CINAHL and Scopus generated 3976 results. After reviewing all abstracts, 108 articles were retrieved by the first author, and the full texts of these articles were reviewed by all authors. The primary reason for exclusion of the remaining 3868 articles was a focus on women’s medical and gynaecological issues of pregnancy loss, rather than men’s health outcomes. Studies were also excluded if they reported on women’s perceptions of the impact of pregnancy loss on men, rather than specifically including men as study participants. Of the 108 articles retrieved for full-text examination, 27 met all inclusion criteria and were agreed upon by all three authors. A further two articles were retrieved from Google Scholar after reviewing reference lists, both of which met the inclusion criteria, giving a total sample of 29 articles. Three of these studies were mixed methods in design, and for synthesis purposes, these were incorporated into the reporting of the quantitative studies as the study designs were primarily quantitative. The details of all 29 included studies are outlined in Appendix.
Overall quality and risk of bias was assessed using the Cochrane Collaboration’s tool for assessing bias. The second and third authors reviewed the studies and reached consensus, however no study was excluded on the basis of quality given the low number of studies that met the inclusion criteria. The following section contains discussion of overall risk of bias in this body of research. Finally, a formal meta-analysis of the quantitative studies was not conducted due to the heterogeneity of studies in terms of design, study populations and outcome measures.
The first author extracted important characteristics of the studies using a predesigned table. This information included: country where the research was conducted, date of publication, study design, number and characteristics of participants, and psychological and physical health outcome measures. This information was cross-checked by the second author.
As noted above, 29 studies were included in this review from 108 reviewed full-texts and 3976 search results. Sixteen of the included articles were quantitative, 10 qualitative, and three used a mixed methods design. Two of the studies utilised the same data and population but reported on different aspects of the findings, so they were both included. Fifteen studies examined the impact of a pregnancy loss on both men and women, and aimed to identify any differences and similarities in their experiences. Nine of the studies solely attempted to identify the impact on men, and a further four studies aimed to explore the experience of a subsequent pregnancy for men after experiencing a prior pregnancy loss, with two of those studies investigating both men and women.
Description of quantitative and mixed methods studies
Table 3 provides details of the key characteristics of the 19 quantitative and mixed methods studies. All of the male participants were heterosexual and cisgender. Of the 16 solely quantitative studies, 12 aimed to compare heterosexual couples’ psychological experiences of a pregnancy loss, while four aimed to measure only men’s psychological reactions. Four of these studies involved men whose partners were currently pregnant following a prior loss.
The three studies that used a mixed methods design were primarily based on a self-administered quantitative questionnaire that also incorporated a small number of open-ended questions [16, 17]. One mixed methods study utilised a self-administered questionnaire which was supplemented with semi-structured interviews with 10 out of 126 male participants . The aims of each of these studies were relatively different: one investigated grief responses of couples following a pregnancy loss and the adequacy of support; one aimed to examine the emotional, social and physical effects of a pregnancy loss on families; and one examined the psychological impact of a pregnancy loss on males.
Most of the quantitative or mixed methods studies were undertaken in the European Union (EU; n = 6) or Canada or the United States (US; n = 6), and participants were most commonly recruited through referrals from hospitals or clinics (n = 11), meaning that they were convenience samples. Sample sizes of male participants included in the studies ranged from 17 to 332 but were most commonly between 30 and 60. Time since the pregnancy loss occurred and when the men participated in the research varied, but the majority of studies (n = 6) interviewed participants within 8 weeks of the pregnancy loss occurring. The time of gestation at which the pregnancy loss occurred ranged from five to 44 weeks, and was between 5 and 20 weeks in the majority of studies.
Table 4 provides details of the psychological instruments used to measure outcomes in the quantitative and mixed methods studies. The psychological variables that were measured most often were depression, anxiety and grief. The most commonly used instruments were the Beck Depression Inventory (BDI) , the State-Trait Anxiety Inventory (STAI) , the Perinatal Grief Scale (PGS)  and the Impact of Event Scale (IES) .
Outcomes of quantitative and mixed methods studies
All of the studies which compared men’s and women’s psychological experiences found a difference in response patterns. It was generally found that while men reported many of the same feelings of grief, depression, stress and anxiety as women, they tended to have less intense and less enduring levels of these psychological outcomes than did women [7, 23,24,25,26,27,28,29,30]. The studies which examined men whose partners were pregnant following a loss indicated similar results, in that anxiety and depressive symptoms tended to be high antenatally but these were likely to subside postnatally [31,32,33]. Kagami et al.  found that women showed significantly higher levels of depression and anxiety following a pregnancy loss compared to men, and this was significantly associated with poor quality of the marital relationship.
Similarly to previous research concerning women, however, gestational age at time of loss was not related to the health or wellbeing outcomes of men [26, 28, 29, 31, 32]. Instead, and again similarly to research with women, whether or not a pregnancy was planned or welcomed was found to be a key indicator of levels of psychological distress .
Some of the quantitative studies reported that men were typically hesitant to disclose their feelings, had elevated results on avoidance scales, had difficulty accessing support, and utilised varying coping strategies, including focusing on work as a distraction [23,24,25, 33,34,35,36]. However, and in contrast to other quantitative studies, men in Johnson and Puddifoot’s  mixed methods study scored high in grief similar to that expected for women (that is, the entire sample of both men and women had a high mean grief score). Also supporting this were the results of Conway and Russell’s  mixed methods study, where men scored significantly higher than their female partners on the three subscales and overall scores on the Perinatal Grief Scale. Similar to other studies on grief , however, men scored lower in ‘active’ grief than women – incorporating sadness, missing the baby and crying for the baby – further supporting the idea that men tend to suppress outward signs of grief. Also consistent with other studies were themes that emerged from the analysis of open-ended questions, including the perceptions of others minimizing the loss, active-avoidance as a coping strategy, and the meaning generated by being able to view ultrasound images which was associated with higher levels of grief.
Only two quantitative or mixed methods studies touched on non-psychological impacts of pregnancy loss. Vance et al.  examined patterns of alcohol use following a pregnancy loss, and found that 7–12.3% of bereaved fathers met the criterion for heavy alcohol usage compared to 4.7–5.8% of non-bereaved fathers. Turton et al.  assessed the psychological morbidity of fathers during a pregnancy subsequent to a stillbirth, and found that nine out of 34 fathers who were non-drinkers reported increased alcohol consumption, seven out of 38 fathers reported they had used prescribed medication to enable them to cope, and three fathers reported that they had used illegal drugs. DeFrain et al.  also examined the social and physical effects of pregnancy loss in their mixed methods study. They found that drug and alcohol use had increased in 7% of households (n = 12), and that family violence related to the loss occurred in 3% of households (n = 5). They also found that 6% of parents (n = 10) moved from their homes or communities to escape from the painful memories and/or friends or relatives who they felt were insensitive to their loss.
Description of qualitative studies
Table 5 provides details of the key characteristics of the ten qualitative studies. In contrast to the quantitative studies, only three of the ten qualitative studies aimed to compare couples’ experiences, while the remaining seven focussed solely on men’s perspectives (two of these involved men whose partners were currently pregnant following a prior loss). Most studies were published between 2001 and 2005 (n = 6), which may indicate attempts to address gaps that were uncovered in earlier quantitative studies. Most of the studies were undertaken in the EU (n = 4) or Australia (n = 3), and participants were most commonly recruited through snowball sampling (n = 5) and through referrals from hospitals and general practitioners (n = 6).
Sample sizes of male participants included in the studies ranged from four to 14, but were most commonly between 10 and 14. Time since the pregnancy loss occurred and when they participated in the research varied, but was most commonly between 8 weeks and 6 months. The time of gestation that the pregnancy loss occurred was most commonly between 13 and 20 weeks. Seven of the studies adopted a phenomenological approach using thematic analysis, in which the researchers undertook semi or unstructured interviews with each participant. Two of the studies had an interpretive narrative design, while one study was a self-reported questionnaire of open-ended questions.
Outcomes of qualitative studies
Seven studies which aimed to describe men’s experiences of pregnancy loss either in the context of another pregnancy or as an occurrence in itself reported similar themes, particularly that of men feeling that their role was primarily as a ‘supporter’ to their female partner [10, 39,40,41,42,43,44]. These studies examined the normative social expectation that males ought to be caretakers and sources of strength, together with the associated outcome of feeling unable to express their emotions due to the expectation that they maintain control of the situation and be a comfort to their female partner. These studies found that while many men would make the effort to appear overtly ‘strong’ and return to their regular life as a coping strategy, they nevertheless experienced internal feelings of stress and vulnerability which intensified their role of ‘protector’ in subsequent pregnancies following a previous loss. Furthermore, men often reported feeling unable to respond to their female partners with emotional support, preferring instead to respond with instrumental support by absorbing practical strain such as paying the bills, in the hope of maintaining routine and ‘protecting’ their female partners.
Five qualitative studies also identified the lack of social recognition that many men felt in dealing with a pregnancy loss, describing feeling overlooked, alienated and marginalised in comparison to their female partners who had suffered the physical experience and whose pain was more visible [10, 39, 43,44,45]. Studies also focused on different expressions of male grief when compared to their female partners, in that while male participants expressed feelings that are typical of the grief and bereavement process such as sadness and uncertainty, they tended to report less intense feelings that lasted a shorter amount of time. Furthermore, the predominant emotions reported by men were those of frustration and helplessness. This finding reflected that of the quantitative studies, as discussed above.
Another theme identified from the qualitative studies was the idea of a loss of identity due to what the pregnancy had come to mean to men who had experienced pregnancy loss. The studies found that most men anticipated a healthy pregnancy, so participants in three studies reported a struggle in recognising their transition into fatherhood, and questioned if they had the right to the ‘father’ title following a loss [41, 43, 46]. Male participants described a deep sense of loss for the hopes and dreams they had visualised for their baby, and also the hopes they had invested in the prospect of being a parent, particularly after bonding with images of their baby through ultrasound, gaining a sense of their physical features, and becoming ‘mentally engaged’ with the idea of being a father. Participants in Murphy’s  study, for example, explained that having children was viewed as being ‘normal’ in society, so miscarriage therefore threatened the process of becoming a father and having a family.
A common coping mechanism that was also described in nine of the studies was that of active-avoidance, whereby men withdrew emotionally and/or physically by choosing to return to work early and immersing themselves in their work as a distraction. Khan et al.  touched on a health impact of pregnancy loss when they found that four of the nine men in their study tried to ignore their feelings by focusing on other distractions such as smoking. Participants in O’Leary and Thorwick’s  study also touched on physical health issues when they described feeling both physically and emotionally exhausted following a miscarriage, which they attempted to manage by keeping busy and going to work. In some studies, men stated that while work was a temporary distraction, the combination of both household and work pressures wore them down .
Quality and bias
The overall quality of the studies was impacted by several issues relating to participant selection, and the final participant sample – issues which are likely to impact knowledge in relation to men’s health outcomes following pregnancy loss. In particular, almost all of the quantitative studies [7, 16,17,18, 23,24,25,26,27,28,29,30,31,32,33,34,35, 37, 38] and a smaller number of the qualitative studies [39, 40, 46] primarily included men as part of a heterosexual couple, with men often recruited through their female partners. Indeed, several studies specifically only included men in order to compare outcomes with their female partners [7, 23, 30, 40]. While these studies certainly contribute to literature in this area, they are limited in terms of what they can tell us specifically in relation to men’s individual responses, and offer little insight into the experiences of men who are single or gay (as discussed further below). Relatively few quantitative [18, 25, 27, 32, 33, 35] or qualitative studies [10, 42,43,44,45, 47] recruited only fathers, or aimed specifically to explore men’s experiences of loss. Many studies made no mention of culture or ethnicity at all [10, 16, 17, 32, 34, 36, 43,44,45], or included a majority of Caucasian participants or those who spoke English [28, 31]. This method of recruitment and subsequent sample may present issues for data collection concerning the retrospective health impacts of the loss. Similarly, the fact that the majority of the studies were conducted in middle to high income countries also presents a bias in the evidence base, given that 98% of all stillbirths occur in either low or middle income countries .
Overall, this review found several common themes across studies that have explored men’s experiences of pregnancy loss. Specifically, findings indicated that men typically feel as though they need to take on a ‘supporter’ role for their female partner, which may come at the expense of their own health and wellbeing [10, 39,40,41,42,43,44]. In addition, the existing body of research indicates that pregnancy loss may lead to a loss of identity related to both the anticipated father role, and the grief and loss associated with the changes which may come after a pregnancy loss [41, 43, 46]. Finally, existing research mirrors that with women in finding that pregnancy loss and associated grief lack social recognition, leading to disenfranchised grief for men, as well as challenges accessing support and often negative impacts upon relationships [10, 39, 43,44,45].
While the results of this review indicate that the feelings associated with pregnancy loss are often very similar between men and women, the manifestations of these feelings are typically different, indicating that men’s health and wellbeing is an important research area in itself. The lack of knowledge of these issues amongst some health providers and family and friends of couples who have experienced a loss can lead to helplessness, marginalisation and the feeling of being alone in their grief [10, 17, 24, 28, 39].
Many studies focussing on heterosexual cisgender men have tended to infer behaviour and emotions from the female partner’s reports, due in part to a socio-cultural belief that men may be less willing to communicate and that pregnancy loss has a greater impact on women . There are also some methodological issues in previous research concerning men’s experience of pregnancy loss. For example, men have tended to be interviewed as part of a couple, and those studies which are solely from the man’s perspective tend to be in the context of a subsequent pregnancy and/or have some issues with generalisability due to population, sampling, and response bias. Moreover, most qualitative studies of men’s experiences have small sample sizes, are often case-studies, and have often used convenience/snowball sampling to obtain participants through means of recruitment via health centres or self-help groups. This may indicate that the men interviewed already have a vested interest in their health and wellbeing following the pregnancy loss, and may not be representative of the general population of men who are experiencing the impact of a pregnancy loss.
As discussed previously, a common theme evident in seven studies involving men and pregnancy loss is one of being a supporter and ‘remaining strong’ in the face of loss. Therefore, there may also be a social desirability bias inherent in some men’s responses, in that they may not fully disclose their feelings and the challenges they face as they do not want to appear weak or vulnerable. In terms of a cultural bias, while there are some studies from different countries and different cultures including the UK, the US, Japan, Australia, Israel and Portugal that explore pregnancy loss from a male perspective, they do not explore how reactions to a loss may be attributed to cultural differences (for example in understandings of what loss and grieving means, death rituals, and cultural constructions of relationship meaning within families and parents) .
Another gap in the literature pertains to gay and/or transgender men’s experiences of pregnancy loss. Exceptions to this include the work of Ziv and Freund-Eschar  who conducted in-depth interviews with eight gay couples from Tel-Aviv expecting a baby through surrogacy in either the United States or India. As part of their analysis, Ziv and Freund-Eschar touched on the impact of pregnancy loss in describing one participant’s frustration and anxiety with regard to the ways in which surrogacy clinic practices did not allow for emotions to be expressed in regards to a miscarriage, with the participant reporting disappointment over time wasted. Riggs, Due and Power  also conducted interviews with 12 gay men who had undertaken surrogacy arrangements in India. A key issue that arose in the interviews was the lack of sensitivity shown by clinics following a pregnancy loss. One participant described the initial response of the clinic as talking about finding another surrogate who had a high success rate, rather than acknowledging their grief and assisting in organising the funeral. Finally, in regards to transgender men, Ellis, Wojnar and Pettinato  reported on a qualitative study of eight trans or gender diverse men who had undertaken a pregnancy. Half of these men had experienced at least one miscarriage, with one participant reporting that they felt betrayed by their body as a result of a miscarriage. This small number of papers suggests the importance of future research that focuses specifically on the health and psychological impacts of pregnancy loss for gay and/or transgender men, however none met the inclusion criteria for this paper with respect to a specific focus on pregnancy loss.
There are no previous systematic reviews which aim to describe the nature and characteristics of pregnancy loss as experienced by men with a specific focus on health and wellbeing. The search strategy only included peer-reviewed studies that were written in English, so this may be considered as a source of bias and future studies may benefit from including grey literature as well as literature in languages other than English. The scope of the review was necessarily broad which reflects the paucity of the current literature base on the subject. Due to this fact, a quality screening was not undertaken and a meta-analysis was not done due to the heterogeneity among studies. Future studies may be able to utilise meta-analysis to examine psychological impacts in particular in more depth.
Future empirical research would benefit from longitudinal studies with less of a focus on measurable psychological aspects of pregnancy loss on men and an increased focus on other aspects of health and wellbeing that may be affected by such a loss, for example physical health. Most studies that encompass different characteristics of health tend to be qualitative. The development or use of a psychometrically valid measure which incorporates non-psychological aspects of health and can be used to measure a larger sample would be beneficial in capturing information that may be more generalisable. It is important to acknowledge the impact that avoidance and coping behaviours may have on men and their partners as a result of a pregnancy loss. These behaviours may include focusing on work as a distraction, and increasing risk behaviours such as excessive alcohol consumption, smoking and drug. These avoidance and coping behaviours may exacerbate the experience of the loss and lead to relationship breakdowns and prolonged grief.
Studies that include a larger sample of men from varying cultural and religious backgrounds to show how the impact of a pregnancy loss may differ in relation to culture and context may also be beneficial. Culture can strongly influence and define grieving processes, and provides a framework within which human relationships vary and are given meaning . The process of acculturation whereby people move to a different cultural setting may also influence the role of culture as findings may be similar to those who had always lived in that particular cultural setting. With this in mind, it is important to understand how men from varying cultures are impacted upon by grief following a pregnancy loss, and how they deal with this grief in their specific cultural contexts. It is also vital to explore pregnancy loss from the perspective of non-heterosexual non-cisgender men, as research with these populations is lacking. Approaching men’s experiences of pregnancy loss from a biopsychosocial perspective may lead to a better understanding in health care of how pregnancy loss may impact on men both physically and mentally, which may influence the development of improved practices and resources.
Joanna Briggs Institute
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
Social Care Institute for Excellence
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The second author received funds from the University of Adelaide via a Vice Chancellor’s aware for Excellence in Research to support the open access fees. The third author was funded by an Australian Research Council Future Fellowship, FT130100087.
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