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Table 6 Studies included from systematic searches

From: The impact of pregnancy loss on men’s health and wellbeing: a systematic review

Author Research Aims Participants/Setting Method/Design Results/Conclusions
1. Quantitative studies
 Alderman et al. [23] To study the psychological experience of a miscarriage and to determine if women and their partners experience the loss differently 19 Caucasian married couples (10 experienced a miscarriage in their first pregnancy), recruitment unknown but undertaken in the US Questionnaires using psychological instruments: The Grief Experience Inventory-Loss Version and the Impact of Event Scale Men and women’s overall response patterns were different. Men reported less grief and stress than their partners and men were less willing to admit their feelings. Men had elevated results on the Avoidance scale.
 Armstrong [31] To evaluate the association between previous perinatal loss and parents’ levels of depression, anxiety and prenatal attachment 103 couples in their second trimester (40 had a prior perinatal loss, 33 first time pregnancy, 30 with a history of successful pregnancies), prenatal clinics, education classes, private medical practices and internet message boards in the US Structured questionnaires in person or over the telephone measured depressive symptoms (Center for Epidemiological Studies-Depression Scale), anxiety (Pregnancy Outcome Questionnaire) and prenatal attachment (Prenatal Attachment Inventory) Couples with a history of perinatal loss had higher depressive symptoms and pregnancy-specific anxiety (Fathers reported less mothers). Perinatal attachment did not differ between groups (Fathers had lower levels of prenatal attachment than mothers).
 Beutel et al. [24] To ascertain similarities and differences in couples’ grief and depressive reactions following a miscarriage 56 couples from Germany (mean age of men was 33), experienced a spontaneous abortion between 6 and 16 weeks (M = 10), 48% had other children, 18% of women had previous miscarriages Controlled follow-up study at 6 and 12 months after a miscarriage using standardised questionnaires measuring depression (von Zerssen Depression Scale), physical complaints (The Complaint List), anxiety (State-Trait Anxiety Inventory) and grief (Munich Grief Scale) Men were found to grieve less intensely and less enduringly then women, the manner in which grief is experienced is similar however men cry less and feel less need to talk about it, men feel burdened by their partners grief, conflicting reactions affect couple interactions
 Cumming et al. [7] To examine the emotional burden of miscarriage for women and their partners, measuring anxiety and depression over 13 months Complete data from 133 men and 273 women from three Scottish Early Pregnancy Assessment Units Prospective study with follow up at 6 and 13 months after miscarriage, the hospital anxiety and depression scale (HADS) was the main outcome measure Anxiety was a higher overall clinical burden than depression and men reported lower levels of anxiety and depression than women, a greater level of adjustment over time was reported by women
 Daly et al. [36] To determine the psychological morbidity among the male partners of women who had miscarried 25 men whose female partners had miscarried within the previous 6 weeks. Recruited from a miscarriage clinic in Dublin, Ireland where they were attending with their partners Structured interviews including the Hospital Anxiety and Depression Scale which measures anxiety and depressive symptoms 50% of males had evidence of significant psychological morbidity following miscarriage, only 32% of men were able to find support for themselves
 Franche & Mikail [30] To compare emotional adjustment of men and women with and without pregnancy loss (in context of current pregnancy). Comparisons included between men and women in response to pregnancy loss. 28 men whose female partners have experienced pregnancy loss and were not pregnancy gain. Recruited from hospital and physicians in Canada. Quantitative cross sectional design, using measures of depression (Beck Depression Inventory) and anxiety (State-Trait Anxiety Inventory). Women scored higher on depression measures than did their male partners.
 Johnson & Baker [33] To examine if men’s coping response during pregnancy, childbirth and or miscarriage predict psychological outcomes at the time of childbirth/miscarriage or 1 year later and establish any changes in coping repertoire 332 expectant fathers (68 pregnancies ended due to miscarriage between 6 and 24 weeks gestation and 100 couples had suffered a miscarriage previously). Unclear of recruitment processes or setting Longitudinal design: Measures of stress (Impact of Event Scale), anxiety (State-Trait Anxiety Inventory), depression (Beck Depression Inventory) and coping (Coping Response Inventory) during pregnancy, following childbirth or miscarriage and 1 year later All psychological outcomes increased at childbirth/miscarriage compared with pregnancy, then decreased at 1 year. Approach-oriented strategies e.g. problem solving and support seeking are used less following a negative pregnancy outcome, higher avoidance coping following miscarriage
 Kagami et al. [25] To examine the effects of recurrent pregnancy loss on the psychological adjustment and psychosocial stress on couples 76 couples in Japan who visited the outpatient clinic of a tertiary hospital (Keio University Hospital) Self-administered questionnaires assessing recurrent pregnancy loss associated stress, quality of the marital relationship (Quality Marital Index), depression (Beck Depression Index) and anxiety (State-Trait Anxiety Inventory) Men showed significantly lower levels of depression, anxiety and stress compared with women, depressed and anxious women more likely to be unsatisfied with partner’s support, men reluctant to exhibit their negative feelings, men showed increased active-avoidance coping (e.g., returning to work)
 Kong et al. [26] To explore men’s psychological reaction following their female partner’s miscarriage and investigate similarities and differences 83 couples who had been admitted to a university-affiliated tertiary referral hospital in Hong Kong with a miscarriage over a 1 year recruitment period Prospective 1 year longitudinal observational study: psychological reactions assessed immediately and at 3, 6 and 12 months after miscarriage using the 12 item General Health Questionnaire (GHQ-12) and the Beck Depression Inventory (BDI). Questionnaires were completed independently A large amount of men scored high in the GHQ-12 and 16.9% scored high in the BDI immediately after miscarriage (associated with a planned pregnancy) but this strongly decreased in the first 3 months and then plateaued, men scored significantly lower than women 1 year after miscarriage, psychological impact was less enduring for men
 Lin & Lasker [27] To explore the patterns of grief reaction following a pregnancy loss to see if patterns were different than those commonly noted in the literature 138 women and 56 of their male partners in Pennsylvania, USA who had experienced a pregnancy loss, recruited from a non-hospital based midwifery centre, ob/gyn private practices, four hospital ob/gyn clinics, a city health bureau and a social service agency Longitudinal: three waves of the Perinatal Grief Scale over the course of 2 years (2 months, 1 year and 2 years after the loss) Large variety of grief patterns found, which were more complicated than had previously been described in the literature, men experienced lower levels of grief after pregnancy loss than women, women show greater distress than men shortly after the loss but there is no change in adjustment after 1 year between men and women
 McGreal et al. [34] To examine whether male and female partners had different coping behaviours following perinatal death 17 males and 35 females who had approached the Bonnie Babes Association in Australia for assistance in coping with the stress of pregnancy loss. Time since the pregnancy loss varied from less than 12 months to 5 years Self-administered questionnaire about coping behaviours (The Coping Scale for Adults). This was completed individually and in confidence. Results suggested gender differences in coping strategies; the highest coping strategies for men were work hard, problem solve, use friendships, indulge in wishful thinking, worry, focus on the positive, tension reduction and keep to oneself; the lowest were spiritual support, social action and physical recreation
 Puddifoot & Johnson [35] To measure characteristics of male response following their partner’s miscarriage 323 male partners of women who miscarried within 8 weeks of the study. Recruited from north-east England and the Midlands. Self-administered Perinatal Grief Scale Men scored similar to female cohorts on the grief scale, characteristic differences in the way grief was handled e.g. less immediate active grief, duration of the pregnancy and seeing the ultrasound increased levels of grief
 Serrano & Lima [29] To describe the consequences of recurrent pregnancy loss on couples’ relationships and explore gender differences in attitudes and grief intensity 30 couples with at least 3 recurrent miscarriages and no living children, time interval between pregnancy loss and data collection was at least 3 months, most had losses prior to 13 weeks gestation, 2 couples were Black, 28 couples were Caucasian and all were recruited at the Recurrent Miscarriage Clinic in Lisbon, Portugal. Self-administered questionnaires assessing psychological and relational impact (Impact of Events Scale and Perinatal Grief Scale) and measuring the quality of the couple’s relationship (Intimate Relationship Scale and Partnership Questionnaire). Members of each couple answered the questionnaires separately Men grieve less intensely, relationships were not usually adversely affected by miscarriage but couples described sexual changes with grief being related to the quality of their sex life for men and quality of communication for women
 Turton et al. [32] To assess the psychological morbidity of fathers in a pregnancy subsequent to a stillbirth, test within-couple effects and identify risk factors 38 pregnant couples whose previous pregnancy had ended in stillbirth and 38 pair matched controls, antenatal clinics in 3 general hospitals in the UK Psychological assessments antenatally and at 6 weeks, 6 months and 1 year postnatally: antenatal questionnaire about medical history, socio-economic status and stillbirth; Beck Depression Inventory; Spielberger State-Trait Inventory (anxiety measure); PTSD-I Interview; and Golombok Rust Inventory of Marital Satisfaction Fathers in the index group experienced significant levels of anxiety and PTSD antenatally but all symptoms subsided postnatally. Fathers experienced greater anxiety when a subsequent pregnancy following stillbirth was delayed. Fathers may be vulnerable to psychological distress during a pregnancy following a stillbirth
 Vance et al. [38] To examine patterns of anxiety, depression and alcohol use in couples following stillbirth, neonatal death or sudden infant death syndrome 138 bereaved and 156 non-bereaved couples. Bereaved couples were referred by seven obstetric hospitals in south-east Queensland, Australia and they were matched with non-bereaved couples recruited through the same hospitals Prospective study: Couples completed standardised interviews at 2, 8, 15 and 30 months post-loss that measured self-reported distress (Delusions Symptoms State Inventory to measure anxiety and depression, questions about frequency and quantity of alcohol consumption to measure alcohol use and seven items from the satisfaction subscale of the Spanier Dyadic Adjustment Scale to measure marital satisfaction) Both partners were rarely distressed in either group, father only distress ranged from 7% to 15% peaking at 30 months, distress more common feature in bereaved couples, fathers less likely to be distressed, 7%–12.3% of bereaved fathers met the criterion for heavy alcohol usage compared to 4.7%–5.8% for non-bereaved fathers
 Zeanah et al. [28] To investigate factors that may influence mothers’ and fathers’ adaptation following perinatal loss and the differences between them 82 mothers and 47 of their male partners who had experienced a perinatal loss 2 months previously and were between 20 and 44 weeks gestation, recruited from a single tertiary referral hospital in New England, USA. Assessments conducted by researchers in the family’s home: Ego Strength Scale (parental personality), Nethelp, Dyadic Adjustment Scale, Life Experiences Survey (parental social characteristics), Beck Depression Inventory, Grief Experience Inventory-perinatal, Perinatal Grief Scale (grief and affective symptoms). Members of each couple answered the questionnaires separately Fathers had lower levels of grief than mothers in 75% of the sample population; fathers with less ego strength, less social support and more stressful live events had higher levels of grief; personality characteristics were the strongest predictors of grief intensity
2. Qualitative studies
 Abboud & Liamputtong [39] To examine the means by which women and their partners cope with a miscarriage Six women and their partners from ethnic backgrounds (Middle-East and Philippines) living in Melbourne, Australia. All Christian, recruited via snowballing and one couple from a GP referral Phenomenological approach using thematic analysis: 40–90 min in-depth interviews in participant’s homes, both members of each couple interviewed separately All men mentioned their role was to support, coped by trying not to make it a big issue and returning to ‘normal’, men described family members as assisting partners but not themselves, most men did not believe talking to others would help so they did not
 Abboud & Liamputtong [40] To examine the experiences and perceptions of women and their partners who have suffered a miscarriage Six women and their partners from ethnic backgrounds (Middle-East and Philippines) living in Melbourne, Australia. All Christian, recruited via snowballing and one couple from a GP referral Phenomenological approach using thematic analysis: Unstructured in-depth interviews in participant’s homes, both members of each couple interviewed separately Men experienced less intense feelings for a shorter period of time than women, men stated that their role was to support and encourage and they had to consider their partner first, most men stated they were happy and no longer though about the miscarriage
 Armstrong [41] To explore fathers’ experiences of pregnancy after a prior perinatal loss Four men whose wives were currently pregnant following a previous loss in the second or third trimester, recruited through healthcare providers at medical practices in two US cities Phenomenological: 45–90 min unstructured and semi-structured in-depth interviews (initial interview about the loss and experience of current pregnancy and second interview 3–4 weeks later for ongoing analysis All fathers expressed anxiety and a heightened sense of risk about the outcome of the subsequent pregnancy. Themes included: intensity of the experience, dealing with grief, supporting their partner, replacement of the loss and importance of milestones
 Bonnette & Broom [42] To explore men’s experiences of stillbirth and how they experienced fathering and grief 12 men who were recruited over a 6 month period by purposive and snowball sampling via posters on community noticeboards, libraries, community centres, pharmacies and shops throughout regional New South Wales, Australia. Qualitative in-depth 45 min to 2.5 h interviews Identify as fathers in complex ways, expressing grief in the context of the ‘male role’ is problematic, fathering and grief are situated in a gendered dynamic
 Hamama-Raz [46] To examine the meaning of abortion amongst religious Jewish couples and how this meaning is expressed Five couples: 3 Haredi (ultraorthodox) and 2 Dati-Leumi (national-religious representing the Zionist movement), had experienced a spontaneous abortion between the 10th and 18th week of pregnancy after a previous successful pregnancy, recruited in Israel via snowballing Interpretive narrative study: 2 h semi-structured interviews by a female Hebrew social worker in their homes, both members of each couple interviewed separately Both experienced spontaneous abortion as some kind of loss but expressed it differently (men saw is as a loss of potential), themes emerged: meaning of relationship with the foetus; doubts about parenthood; and crisis in faith.
 Khan et al. [47] To assess the emotional response of males whose female partners had suffered early pregnancy loss and establish if sufficient support services are provided (provide recommendations if necessary) Nine Caucasian men attending a specialised Early Pregnancy Loss Clinic with their partners at Rotunda Hospital in Dublin, Ireland. Pregnancy loss occurred before 20 weeks gestation and the questionnaires were completed while in the waiting room 6–8 weeks following the pregnancy loss Close and open-ended questionnaire Men expressed feelings typical of grief and bereavement process such as sadness and uncertainty. Acceptance and depression were reported later. Pregnancy loss may represent a failure for men
 McCreight [43] To describe the experiences of men whose partner had experienced pregnancy loss 14 men who attended pregnancy loss self-help groups in Northern Ireland (range of gestational stage when pregnancy loss occurred was 7 weeks to 40 weeks and period since the loss ranged from 3 months to 20 years). Also 32 midwives and nurses to examine attitudes towards bereaved fathers Observation and in-depth semi-structured interviews of a narrative nature (observation took place once a month over 3 years and interviews with 14 volunteers took place over those 3 years also). Most interviews took place in their homes. Themes uncovered: self-blame, loss of identity, need to be appear strong, grief and anger. The perception of men as having the supportive role is unjustified, lack of legal recognition and institutional validation posed problems for their identity
 Murphy [45] To describe the experience of early miscarriage from a male perspective Five men whose partners miscarried early more than 2 years prior to the interview. Snowballing used to find participants located in the UK. Phenomenological approach: 30–60 min unstructured interviews Themes emerged: feelings, loss, differences between men and women, staff action and attitudes, what to do, coping and time. Predominant feelings were frustration, helplessness and loneliness. Avoidance/ignoring was a common coping strategy
 O’Leary & Thorwick [10] To present information about fathers’ perspectives during the experience of a pregnancy following a prior perinatal loss 10 fathers who had experienced a loss within the prior year and were with the same partner in a subsequent pregnancy, obtained through friends of parents who had been involved in a pregnancy loss support group; notice in a bereavement newsletter; and staff at a perinatal centre Descriptive phenomenology: 60–90 min one-on-one interviews in venues chosen by the fathers (i.e. home or clinic) Four themes emerged: recognition-fathers need to be recognized by others, pre-occupation-conduct of their daily lives in disrupted, stoicism-unable to share fear and anxiety as they want to protect their partners, and support-societal pressure to be strong.
 Samuelsson et al. [44] To describe how fathers experienced losing a child as a result of intrauterine death 11 men whose offspring died between weeks 29 and 42 of pregnancy. Recruited in Sweden and interviewed 5 to 27 months after the loss Phenomenological approach: 25 min to 2 h interviews mostly in their homes and some in a hospital Strong feelings of frustration and helplessness, found meaning and relief in supporting their partner, the most important comfort was a good relationship with their partner, important to be able to grieve in their own way
3. Mixed methods studies
 Conway & Russell [16] To investigate the grief responses of women and their partners following a miscarriage and discover if support received met their needs 39 women and 32 of their male partners who had experienced a pregnancy loss between 5 and 16 weeks gestation. Recruitment was from four major obstetrics hospitals and one district hospital in Sydney, Australia (an accurate participation rate was only obtained from one hospital), 11 GPs also approached patients after a miscarriage Prospective study: Self-administered initial questionnaire including the Perinatal Grief Scale which was completed within 3 weeks of the miscarriage to minimise retrospectivity (80% of the questions were closed questions), follow-up self-administered questionnaire including the Perinatal Grief Scale 2–4 months after the miscarriage (48% of the questions were open-ended) On the initial questionnaire, men scored significantly higher on the Perinatal Grief Scale than women, they were also higher on the follow-up questionnaire but not significantly, high attrition rate between initial and follow-up, the greatest difference was on the active-grief subscale (men tend to suppress outward signs of grief)
 DeFrain et al. [17] To examine the emotional, social and physical effects of miscarriage on family members and suggest implications for health professionals 21 fathers and 272 mothers who had experienced a miscarriage between 1 month and 42 years prior to completing the study (M = 5.4 years), recruited through 30 newspapers in the U.S. (people in 32 states participated) A 23 page questionnaire was developed after 20 pilot interviews were conducted (63% of the questions were quantitative, 37% were qualitative) Many fathers and mothers reported flashbacks and nightmares, they turned to each other for support, themes included: guilt and blame; reactions to crisis and pain; perceptions of others minimizing the miscarriage; and returning to normal
 Johnson & Puddifoot [18] To examine the psychological impact on the male partners of women who have miscarried 126 men in Britain whose partners had suffered a spontaneous abortion prior to the start of the 25th week of pregnancy. Recruited via referrals from gynaecological wards of general hospitals in the north-east of England Opportunity sample survey supplemented by 10 semi-structured interviews with volunteers from the sample (42 volunteered). Two standard scales were used: the Perinatal Grief Scale and the Impact of Events Scale. Participants completed the questionnaires in their own time High levels of grief were found that were felt strongly in the short term which affected their daily lives and relationship, the duration of the pregnancy and experience of ultrasound images were associated with higher levels of grief and stress, scores on the avoidance subscale were considerably high.