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A Qualitative Study Examining Fathers Experiencing a Perinatal Loss.
Hughes and Page-Lieberman (1989) conducted a qualitative study on the experience of bereavement in fathers following a perinatal loss. Given that their study is very similar to this dissertation, a thorough review of the article will be covered in this literature review. The purpose of this study was to thoroughly interpret fathers’ perceptions of their experiences of perinatal loss. More specifically, the researchers focused on three areas of study: the fathers’ perceptions of the losses, their closeness to the fetus prenatally, their experiences with others during the grieving period, and their intensity, nature, and duration of bereavement.
The study used a retrospective, exploratory design, which took place six months to two years after the loss, and included an interview and the Grief Experience Inventory (GEI). An interview guide was created and included both open-ended and close-ended questions. A panel of experts piloted, reviewed, and modified this guide. The questions focused on the father’s description of the events, their feelings, and the people involved with the death event. Three individuals were trained to conduct the interviews.
For analysis, all of the interview data was taped and transcribed. Two independent raters coded both the manifest and the latent level of content of the interviews. Fourteen coding categories were created. They were developed from the interview data, the pilot, and the literature. These categories included: pregnancy health, centrality, death even, death preventable, shock feelings, sadness, anger, family’s involvement, men-women differences, OB physician relationships, nurse relationships, effect on marital dyad, guilt, and job performance. The fourteen items had 90% interrater reliability.
This study used the Grief Experience Inventory (GEI) as an objective measure of the intensity and nature of their grief process. This instrument has 135 true-false questions and takes thirty minutes to complete. The authors reported that the GEI has a “satisfactory” level of interrater reliability and test-retest reliability, as well as having criterion and construct validity. Unfortunately, the investigators did not provide specific levels of reliability and validity.
The sample included 51 fathers who were recruited from support groups and hospital lists of individuals who experienced a perinatal loss. To be included in the study, the fathers had to experience the loss of an infant from twenty-eight weeks gestation of the neonatal period, have lost the infant six months to two years prior to the interview, and to be married at the time of birth.
To analyze the data, the researchers compared the scales to a normed bereavement group. They used a t-test to measure the intensity and the nature of the fathers’ grief.
Several themes emerged. The fathers in this study described the event of the death as a very active time. They spent their time managing the mother's emotional condition while notifying their friends and family. Simultaneously, they had to deal with their own feelings about the death. When asked about how close they felt to the fetus, almost one-half (45%) reported that they felt close, but not as close as their wife did to the fetus. Despite the fact that fathers are understood to attach less to the unborn fetus than mothers are, most of the fathers (80%) reported that they felt attached to the baby.
The results of this study indicated that the way an individual perceived the preventability of a death often led to either self-scrutiny or anger toward another. Forty- one percent of the fathers did not think that the death was preventable, 39% had mixed feelings on whether the death was preventable, and 18% believed that the death was preventable. If the father thought that the death was preventable, he often criticized himself. In addition, 50% of the time he also blamed the physician or medical management for the loss.
Other findings of this study indicate that 78% of the fathers described sadness, but reported that this sadness was not "intensely overpowering or debilitating". Twenty percent viewed their sadness as "more intense, enduring, or debilitating." Although, the fathers acknowledged anger less often than sadness, 51% of them expressed this emotion. Over one-half (57%) of the fathers expressed guilt over the loss. Additionally, an important finding, especially to this dissertation was that only 37% of the fathers reported typical grief symptoms (fatigue, decreased appetite, and change of sleep pattern). This finding leads one to speculate that other factors in grieving may be at work.
This study also documented some changes in work habits of the fathers. Thirty- one percent of the men decreased their hours of work, and 14% increased the hours they worked. One-fourth of the fathers reported that they used their work to "heal" or as a "diversionary" factor. Furthermore, fathers reported a short duration of grief. However, other data indicated that there was a decrease in family functioning over time related to the loss. Unfortunately, the researchers did not elaborate on how the family’s functioning decreased.
Although this study was rich in data, it is based on a father s memory of what happened. Furthermore, the study may also have a self-selection bias. Fathers who were less able to talk about their feelings or who had more severe reactions to the loss may not have volunteered for the study. Additionally, this study only looked at the conscious experiences of these fathers. Those fathers who were more defended against or who were not ready to talk about the loss may not have expressed their feelings about it. Therefore, it would behoove of researchers to look at the unconscious experiences of fathers after perinatal loss. Instead of using instruments that takes just a snapshot of one point in time of their conscious experiences, the present study will take a more open-ended, in-depth approach.
Clearly, more research is needed on men s grief following a perinatal loss. Currently, there is a lack of validated instruments to measure the men s grief. Before valid instruments can be created, more research is necessary to understand men’s grief reactions following perinatal loss.
Mitigating Factors that Influence Men’s Experiences of Perinatal Loss
The Influence of Ultrasound Scans on Grief.
Many theorists believe the use of ultrasound scans during pregnancy accelerates a father s attachment to a fetus, and may increase his level of grief following a perinatal loss. In a study of fathers grief responses to miscarriage, Johnson and Puddifoot (1996) found that fathers who have seen an ultrasound scan of their baby experienced higher levels of grief than those fathers who did not see an ultrasound. In a subsequent exploratory study, Puddifoot and Johnson (1997) interviewed 20 fathers following a miscarriage, discovering three effects of ultrasound scans: (1) they increase the reality of the existence of the baby; (2) they allowed fathers to become more involved with the pregnancy; and (3) they increased the levels of grief when a miscarriage occurred. Although this study is useful in that it gathered first-hand experience reported by the fathers, it had a small sample size. Therefore, the generalizability of these results is limited. Beutal et al. (1996) conducted a study looking at the similarities and differences between couples grief reactions following ultrasounds. He found that while mothers were more attached to babies, fathers were not as strongly influenced by seeing an ultrasound.
Aiming to further explore the influence of ultrasound scans, Johnson and Puddifoot (1998) conducted another study to see if the vividness of visual imagery is a mediating factor in fathers’grief responses. In other words, they wanted to find out if seeing an ultrasound scan of their baby during pregnancy influenced the vividness of the visual imagery of their baby. Did men who had more vivid visual images of their baby had higher grief reactions to miscarriage? The rationale behind looking at the visual imagery of the fathers is that previous research has documented that more vivid images of the baby after an ultrasound scan is associated with a stronger bond with the baby (Puddifoot & Johnson, 1997). Using the Baby Vividness of Visual Imagery Questionnaire and the Perinatal Grief Scale, the results of this study supported the authors’ hypotheses that the men who had seen an in utero ultrasound scan of their baby were more likely to have more vivid visual images of their baby, and those men with more vivid visual images exhibited significantly higher levels of grief.
This study is useful in that it emphasizes the influence that ultrasound scans have on the visual images men have of their baby, and how these visual images impact the degree of grief after a miscarriage. However, this study took place in the United Kingdom; thus the cultural uniqueness of these men, as well as the different health care systems must be considered in terms of being able to generalize these findings. Additionally, it could be speculated that the types of men who are willing to see an ultrasound scan are men who are more interested in their babies, and therefore might have higher grief reactions to their miscarriages even if they did not see the ultrasound scan. Finally, the majority of studies that look at the influence of seeing ultrasound scans on grief only look at miscarriages. The influence of ultrasound scans on grief of stillbirths, and Sudden Infant Death Syndrome are largely ignored. One might speculate that these losses might be even more devastating for fathers if they began to attach earlier through ultrasound scans. More research is needed on the influence of seeing ultrasound scans on grief following perinatal loss.
Men and Their Role as Supporters.
It has been reported that support networks are beneficial in facilitating grief subsequent to perinatal loss (Cordell & Thomas, 1990; Dyregrove & Mattieson, 1987; Mandel, McAnulty, & Reece, 1980). Parents have a greater need for support following perinatal loss as such experiences increase their vulnerability and decrease their coping resources (Leon, 1992). Without support, they have higher psychological morbidity (Lee & Slade, 1996) and higher levels of grief (Zeanah, 1995).
The literature on perinatal loss has emphasized the impact that perinatal loss has on mothers and the need for husbands to support their wives. Fathers have not been seen as individuals who mourn the loss, but as supporters to their wives following the loss (Johnson & Puddifoot, 1996).
This lack of recognition of fathers begins long before a perinatal loss occurs. From the beginning of pregnancy, fathers are not considered a significant part of the childbirth process. The father is often given subtle messages from his peers and family that he is not as credible as his wife as a parent (Shapiro, 1995). An ongoing message to men is that their role is to protect and support their wives (Jordan, 1990). While men often turn to their wives for support during pregnancy (Shapiro, 1995), their wives may be preoccupied with their own needs, such as a changing body and new emotions about becoming a parent. Even at the birth of their child, fathers often take a passive role as a protector and supporter (May & Perrin, 1985). In a study looking at the experience of expectant and new fathers, many fathers felt unrecognized as a parent, felt that health care workers only considered their wife and baby, and felt excluded from parenting their child (Jordan, 1990).
Summary and Conclusions
Within the literature, there is debate about how fathers grieve after a perinatal loss. Some researchers believe that fathers grieve little and less than mothers do, because they have less of an attachment to the fetus. Other researchers believe that they have different ways of coping and expressing their emotions about the loss. For instance, they may fail to express their emotions, underreport their symptoms, struggle to acknowledge that they have any grief, or be “Minimizers” and not be consciously grieving. Furthermore, fathers may also intellectualize their grief, increase their alcohol consumption to numb their grief, or take a managerial role to avoid their own feelings about the loss (i.e. take care of wife s needs).
Much of the existing literature has failed to take into account the unique ways fathers have of coping with reproductive loss. The measures used tap into overt grief, anxiety, and depression. However, they may not be capturing the full experience of grief for fathers. Thus, it is possible that fathers have more intense grief reactions to perinatal loss than is documented in the literature.
To understand how fathers grieve a perinatal loss, several issues must be considered. First, because the construct used to measure fathers grief may be inaccurate, new ways of measurement need to be applied to the research. Second, perinatal loss is a unique type of loss because it involves losing someone who is the part of oneself, and requires the parents to grieve for someone who they have no or few clear memories of. Thus, grieving can be difficult. Third, perinatal loss often occurs in the context of new or expectant fatherhood, which has been documented to be a time when men regress and rework object relations. Hence, the loss of their baby occurs in an already regressed state, causing a crisis within a crisis .
The problems with the current research as well as the complicated nature of perinatal loss suggests the need to explore this phenomenon more fully. This study will use a broad approach in examining fathers grief, focusing on their conscious and unconscious experiences. By using a qualitative design, this dissertation will attempt to future quantitative research.
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