It has become widely accepted within the last decade (see McGreal 1997, Puddifoot and Johnson 1997, Volker and Striegel 1995, Kohn and Moffitt 1994) that attachment to an unborn baby begins before birth. The introduction of ultrasound scanning now enables parents to see and begin a bonding process with the unborn baby. It is as if the visual image provided by ultrasound scanning provides a material link from which a bonding process can develop. All the men in the study who experienced a stillbirth; two who experienced both miscarriage and stillbirth, and two who experienced a miscarriage (10 men), saw an ultrasound scan of their unborn baby. These fathers reported developing an awareness of the baby as a real living person and specifically described physical features, such as fingers and toes, they had observed, or believed they had observed. Sandelowski and Black (1994) suggest that by attending an ultrasound scan, men come to occupy the same position as their partner in terms of ‘knowing’ the baby. Research carried out by Johnson and Puddifoot (1996, 1997, 1998) found that experience of confirmatory imaging of the baby via routine ultrasound scan was a factor related to raised levels of grief and stress in male partners. This would appear to indicate that the representation of an image of the baby sparks off a strong emotional response from the male who then has a strong visual focus for his feelings. For example, in the present study, one father, Martin, had scanned the image of his baby onto his computer as a screen-saver and three weeks later his baby was stillborn. The presence of the image, continuously accessible, was said by Martin to be at first a strong source of comfort, and subsequently a terrible reminder of tragedy when the news of bereavement was received. This narration showed the capacity of the respondent to construct and express very different kinds of emotion elicited by an image recalled in different circumstances. This evidence suggests the importance of visualisation in understanding how the fathers came to construct their own meanings in relation to the anticipated birth. Research has shown (see Cecil 1994, Letherby 1993) that women who have experienced a pregnancy loss find support for their healing through oral communication with networks of friends. Men, generally, may not be able to avail themselves of equivalent support, but may make use of other modalities, such as use of visual and other material links or images, which afford opportunities for them to articulate to themselves their sense of loss, and to share their grief with others.
By contrast, four fathers, who had experienced early miscarriage, did not have the opportunity to see an ultrasound scan and did not report that they had visualised the babies. All reported that they had grieved deeply for a baby whose coming they had anticipated, but in view of the small sample of respondents interviewed and the absence of any relevant interview cues, it is not possible to infer more from the evidence. Nevertheless, fathers, in many cases, had generated visions of parenthood either implicitly or explicitly through their imaginings of the future being. These imaginings amounted to personal and social constructions of a lived being with individual characteristics. The fact that these constructions were attached to biological events that might not come under a scientific classification of what might be considered a lived life does not take away from the grief experienced by fathers. This aspect of pregnancy loss merits further research.
Most men in the study blamed themselves for the pregnancy loss. One father, Gary, noted: ‘I should have listened when she [partner] said she felt ill, I should have made her go to the hospital sooner’. Another father, Brian, stated: ‘if I had taken my wife to hospital instead of listening to our General Practitioner, who told us we were being over anxious, things may have been different’. Two fathers related how their experience with hospital staff had left them blaming themselves for the pregnancy loss. Eric, whose baby son was stillborn, stated: ‘they [hospital staff] just ignored us totally, we were a bit like a bad smell in the ward. Yes it's true to a certain extent that men are ignored, you feel you’re almost the bastard that caused all this’. Another father, Connor, stated: ‘it took me a long time to live with myself, never mind, you know because the hospital really done a hatchet job on me, they ruined me emotionally the hospital, done to me emotionally what nobody else could have done, they really put the hatchet in me, they left me in bits, they left me blaming myself, blaming God, blaming my family’. Connor cited lack of consideration for his partner's acute physical pain and inadequate information regarding his partner's health as the cause of his intense distress. Connor recognised that blaming himself for the loss was irrational, but, as he explained, his anger and feelings of helplessness were so intense that he blamed everyone, including himself, for the loss of his baby.
The men in the study also questioned their identity as fathers, uncertain as to their right to the term ‘father’ and equally unclear as to whether the pregnancy outcome was to be understood as a baby. The pregnancy loss has impacted on the future of the men; several perceive their visions of family life to have disintegrated. When a pregnancy ends there is not only the loss of the baby, but also a loss of future hopes and dreams. Thomas, whose baby had been stillborn five years before the study, stated: ‘I feel I have lost my future, no Fathers’ Day celebrations, no Christmas presents, no birthday cards’. Thomas did not have any other living children and this may have been a factor in considering the extent of his grief relating to what he perceived as his future role and identity. Men who have gone on to father a child may still, however, have ambivalence in relation to identity; Dave expressed his dilemma when asked how many children he had. He did not know whether to describe himself as a father of four children, or a father of one, since three children had been stillborn. It was not possible from the data to draw any definite conclusions relating to long-term grief since all fathers appeared to have suffered irrespective of the time lapse since the bereavement had occurred. It should, however, be noted that three men who had suffered long-term grief had become group facilitators, suggesting that the grief had profoundly affected their lives. The study also found that several men who had experienced multiple losses attended group meetings over a long period of time. Equally, three fathers who had experienced a single loss still attended group meetings five and two years after the loss. Differences in impact of grief between men who had experienced stillbirth, or both stillbirth and miscarriage, and men who had experienced miscarriage only, could not be adequately investigated, however, owing to the small number of men in the sample.
The results from this research clearly indicate that, where pregnancy loss is approached as a social event, which requires reflection, explanation and the development of an appropriate ritual, there is increased opportunity for parents to articulate their own interpretation of the experience. It is clear that ritual is used to signal life events of key importance, and in particular birth and death. For example, when a baby is stillborn, that is, where a baby dies after 23 weeks gestation, a stillbirth certificate is required, which serves as a ritualistic affirmation that bereavement has taken place. Fathers, however, who are not married to the mother, are excluded from registering the stillbirth. One father in the study expressed how his grief was heightened when he tried to register his stillborn daughter only to find that, since he was not married to the mother he was unable, legally, to register the stillbirth, although the parents and siblings of the mother (as well as the mother) are able to do so. Such men are thereby prevented from having their experience of death validated through customary social procedures and their status as parents acknowledged. A baby born under the age of legal viability does not require any documentation, is classified as non-viable, has no legal status and is termed a miscarriage. Six fathers in the study were not given the opportunity to bury the remains (where remains existed) of their miscarried baby, although, five fathers had expressed a wish to do so. Miscarriage can, therefore, be considered as an intangible loss with no formal mechanism in Western societies that allows the expression of grief through the formal ritual of burial.
Fathers’ reports on hospital staff
The study demonstrated that several men tended to be marginalised by hospital staff, despite the fact that the men often had onerous responsibilities at the time of the loss, through, for example, being the first family member to see the remains of the baby. Furthermore, it is usually the role of the father to inform relatives, friends and work colleagues of the loss. The men in the study also had the overwhelming task of arranging a funeral. All the fathers expressed the view that they were not prepared for this practicality. For several men this was their first experience of death and most expressed the feeling of helplessness and despair surrounding the ambiguity of burial arrangements for a stillborn or miscarried baby. The haphazard approach to burial arrangements adopted by some hospital staff may add to the feelings of isolation and distress expressed by the fathers. The following narrative from Connor illustrates this point:
We had a funeral, it was the mortician who helped us arrange it, he said ‘don’t worry about the coffin I’ll get that sorted out’ so we didn’t have to worry about that. He picked us the most beautiful coffin. He came to me and said ‘you know you can get your baby christened, the hospital doesn’t have to deal with it, you can deal with it’. Not one of the doctors, nurses or midwives came to us and told us that. You know I have so much respect for that man it's unbelievable. He got out of his bed in the middle of the night and came up to talk to me, showed respect, put on a black tie and shirt, you know I wouldn’t of cared if he had come up in his pyjamas, it was just somebody to talk to, because they [hospital staff]) were just leaving me sitting there. He came in and talked to me like I was a human being who was hurting, it wouldn’t have hurt any of those nurses to do that.
Andrew had lost two babies in 1980 and 1984. The first baby, Grace, had been born at 23 weeks gestation, the second baby, Stephen, at 27 weeks gestation. Grace and Stephen had both been defined as miscarriages as they had been born under the age of viability which was, at that time, 28 weeks. Andrew had asked if he could see his first baby. He stated:
She was a perfectly formed baby girl; however, it wasn’t a question of wrapping the baby up and seeing her dressed, she was presented to me lying in a kidney dish covered in a green paper towel, I remember that and that will stick with me more than anything. Grace was probably incinerated, she was just taken away and we thought we’d get an answer for her death, but we didn’t and the hospital never brought her back to us. We didn’t know to ask if we could have her back, it wasn’t the done thing then.
The study found that most hospitals in Northern Ireland now encourage parents to see their deceased baby, take photographs, a lock of hair [usually in the case of a stillborn baby], and to hold a funeral, although not every parent is offered this opportunity. Robert, who had lost his baby at 12 weeks gestation, had not been offered the opportunity to take the remains of his baby home for burial. Another father, James, related how when he had asked hospital staff if he could bring his 14 week gestation baby home to bury it, he was told that they [hospital staff] did not know where the remains were. James stated: ‘I think it was up in the lab just like a bit of tissue thrown about, I think they would have thrown it in the bin if I hadn’t asked, you know they don’t have any compassion’. The study also showed that miscarriage and stillbirth are deeply personal experiences and the way in which the decease of the baby is socially constructed is crucial to enabling the parents to come to terms with their grief. The present research strongly suggests that the procedures adopted within hospitals for handling the remains should be as similar as possible to those used in relation to the death of a lived person, in terms of recognising the sensibilities involved. The following narratives from the men in the study clearly indicate that there are occasions when the procedures would appear to suggest to parents that the event is not accorded the value that would be expected when a bereavement has occurred.
Connor had lost his baby daughter Sinead in 1998 at 41 weeks gestation; she weighed 10lb 2oz. Connor stated:
When I saw Sinead she shocked me, the hospital staff did not inform me that there might be a bit of skin loss. They handed me my baby in a basket and the skin had ripped off her face and from under her arms. The skin ripped off her head with the force of the vacuum and forceps and they didn’t warn me about it. I held her and I was afraid, I was actually petrified, my own flesh and blood and I was petrified to see her, she shocked me, they handed me 10lb 2oz of meat, it was freezing cold in a basket with no skin.
Connor went on to relate: ‘I haven’t grieved yet, I can’t because I’m still so angry with the hospital staff. If even one of the hospital staff had said, “Connor, I’m sorry, you know you’re a Dad and you feel pain as well”, it would have helped, but I was constantly pushed aside’.
Daniel lost his baby son Michael in 1995 at 25 weeks gestation. The hospital put Michael in a moses basket for his parents to take home for burial. On the morning of the funeral, however, the hospital rang Daniel and requested that the moses basket be brought back as they needed it for another baby who had died. Daniel states: ‘I had to lift the baby out of the moses basket and put him into a casket. I felt a terrible sense of loss then, at that particular moment’. Another father, James, lost three babies at 12, 14 and 24 weeks gestation. He explained how, when he had lost his baby at 12 weeks gestation, one consultant had commented: ‘it didn’t have a chance, it wasn’t really a baby, it was a product of conception’. James went on to state that ‘it had wee arms and wee legs and it's amazing, something so small and they don’t class it as a baby’. The devaluation of loss expressed in the doctor's remarks was clearly being resisted in James’ recollection of feelings engendered at the time.
William, whose baby daughter had been stillborn, recalled how when he was in a side room waiting for his baby to be born, the consultant had come in and said ‘Mum is doing fine, but we’ve lost baby’. William stated: ‘it didn’t register with me what he was telling me and I thought well, like I mean, how? That's very careless surely you can look for it, it can’t be that big a room and baby can’t move, and then the consultant said “I’m so sorry” and it slowly registered with me that he was telling me something more serious than he had just misplaced the child’. This incident demonstrates that the use of a particular form of language can disadvantage men who may not, generally, be familiar with specific modes of expression found in doctor-patient interaction. The narration of his interpretation enabled William to articulate the mechanisms through which his grief was amplified, albeit unintentionally, by the consultant.
Two men in the study felt that they had been treated well by hospital staff. William recalled how the anaesthetist had come after the event to say she was sorry for the loss of his baby; another father, Thomas, related how the midwives had cried along with him and had offered him emotional support. Several of the men, however, expressed anger and dissatisfaction with hospital care. Eric described the time he had spent in hospital with his partner as ‘not a good experience’. He notes that, except for one particular ward sister, his experience would have been totally unbearable:
While they addressed my partner's medical needs, to say they didn’t address her emotional needs doesn’t even start to describe it, they never addressed her as a human being, they never spoke to her, they never came to see her, she was abandoned. I was even less a consideration.
Hospital practices after pregnancy loss have changed considerably over the past decade, yet they have not been well evaluated (Lasker and Toedter 1994). Interviews were carried out in the present study with nurses and midwives throughout Northern Ireland, in order to determine the attitude of staff towards a male partner and the nature of the care provided. Hospital practices for dealing with the remains of babies were also investigated. The Stillbirth and Neonatal Death Society: guidelines for professionals’ (SANDS 1991, 1995) offer guidance for health professionals on the emotional and practical care of parents who have experienced a pregnancy loss. In a study of midwives’ perceptions of dealing with miscarriage, stillbirth and neonatal death in Northern Ireland, Devlin (1998) found that while midwives reportedly perceived these guidelines as being an invaluable source of information, nevertheless, a number of midwives in her study had not read the guidelines.
During the 20th century, experiences of death have been mediated through the intervention of professionals, for example, medical staff or undertakers, and the personal care which people of previous generations would have accorded their deceased relatives has been superseded by standardised and externally-provided services. The professionalisation of the protocols surrounding the death process has distanced relatives from an experience which, in the past, would have been handled by the community directly, including the clergy, and would have made use of a range of informal and semi-informal rituals. It has been suggested by James (1989: 20) that ‘it is health care professionals in hospitals who are most likely to set the tone immediately after a death, although they appear to be poorly equipped to do so’. From an emotion management perspective, Hochschild (1979: 551) argues that emotion is often subject to acts of management and that ‘the individual often works on inducing or inhibiting feelings so as to render them “appropriate” to a situation’. In the context of a strong, sometimes overpowering institutional context, such as a hospital, men who have suffered loss may well submit to forms of emotion management which may operate not through direct manipulation, but through latent, inhibiting qualities of a milieu in which it seems inappropriate to release certain feelings, particularly when the hospital culture does not accord recognition to men's unexpressed emotional needs.
Most of the nursing and midwifery staff in the interviews felt they addressed the needs of the male partner, such as by providing a bed, thus enabling him to spend the night with his partner and deceased baby. Sara, a midwife, however, commented:
I’m sure we don’t really focus on men at all; they get explanations, but it's funny you don’t even think of them, well I don’t. Men come to the labour ward and they sit beside their partner and they participate in the event, but nobody really ever thinks to say, are you all right unless you look at them and they’re pale and you think they might fall over and get in the way.
Norma, a staff nurse in a gynaecology ward, had had experience of research for a post-graduate degree in health promotion and she took a reflective approach to the issues under consideration. It was noticeable that she began by focusing on communication and feelings, stating that she would encourage the woman to talk to her partner. Norma also commented that she would explain things fully to the male partner.
Anna, a midwife, stressed that she was very aware of the feelings of the male partner and always asked the male how he was coping. Anna goes on to state:
The men very often try and put on a brave face, for their partners sake obviously; they maybe don’t discuss their feeling as much as they should. Most of the time they are putting on a good front and being supportive, outside the room, however, they would be very upset but inside they don’t want to show their feelings to their partners.
There is recognition, therefore, among some hospital staff, that men's different approach to the expression of feelings belies the depth of their emotional response and may often conceal the fact that they are grieving.
Hospital burial arrangements
Hospital staff in Northern Ireland now encourage parents to take possession of their stillborn baby and to hold a funeral. In the case of miscarriage, however, arrangements for possession and burial are variable and depend on individual hospital practices, as well as the knowledge and sensitivity of the medical and nursing staff involved. Furthermore, not all hospital staff were aware of the method of burial in their particular unit. The study found that it was no longer acceptable in many hospitals for the remains of miscarried babies to be disposed of in hospital incinerators. Nine hospitals in the study have a ritual procedure for dealing with the remains of miscarried babies. One hospital, however, did not have any common burial plot for the remains of the miscarried babies, although the parents were given the opportunity to bury their baby themselves. According to one staff nurse: ‘they [the hospital] were to get a common burial plot for all denominations, but they didn’t. A lot of parents think that you do have a burial plot and then when they find out you don’t, you know what the next question is going to be, “well what do you do with the baby?” and it doesn’t even bear thinking about, you have to be honest and it's just, you know incinerated’. While hospital staff cannot take away parents’ grief, they nevertheless need to create a climate for dialogues that addresses burial arrangements in an informative and sensitive environment.
Acknowledgement of loss by wider community
All fathers indicated that they frequently felt their loss had been devalued by the wider community. Feelings of loss may have been exacerbated by the modes of language and discourse used in discussions with fathers or in informing them of the bereavement. Opportunities for validating the loss, however, are of particular importance in facilitating a healthy grieving process (e.g. see Robinson et al. 1999), and the use of appropriate language is necessary if the men are to be enabled to come to terms with their loss.
All the fathers noted how ‘well meaning’ remarks from the wider community, for example, ‘never mind, you can always have another baby’, led to feelings of anger and despair. As Corr et al. (1997) point out, no individual child ever is or should be a replacement for another child. One father, Patrick, lost his first baby Sean through stillbirth in 1994 and his second baby was lost through miscarriage in 1995. Patrick, stated how ‘communication and understanding are very important, some people did not understand’. He noted how one woman commented, ‘I know how you feel, it nearly happened to us’. Another commented, ‘I know how you feel, I lost my dog last year’. Patrick also related how ‘when the phone rang it was always the same question, “how is Maria [partner], how is she coping?” At one stage I wanted to scream, what about me? No-one ever asked how I was’. He goes on to state:
It was hard because all the time when you’re growing up you’re told ‘you’re a big boy now’, when you fell in the playground you were told ‘big boys don’t cry, boys are strong’, you’re always fighting those emotions really, but when you lose your baby, it sort of confuses you, you want to tell some-one how you feel, but yet you think ‘I’m a man, I shouldn’t be feeling like this.
This account suggests that the father has profound emotions and that he has not attempted to intellectualise the grief; rather, his concealment of some of the obvious indicators of emotion may have led others to underestimate the impact of his experience.
Another father, Eric, also commented on reactions from the wider community. One individual commented to Eric: ‘it could be worse, he could have lived for an hour and died; he could have come home and suffered a cot death; he could have been six years old and run down by a car. Now wouldn’t that have been far worse?’ His rejection of attempts by others to rationalise his loss demonstrates how Eric has struggled to resist the depersonalisation of his experience.
The men also noted how many people, including family, reacted by avoiding talking about their loss. Patrick recalled how when he tried to talk to his mother about the loss of his baby, she told him ‘now don’t you think its time you stopped the crying; you’ve cried long enough’. A study carried out by Cecil (1996) found how pregnancy loss in rural Ireland in the 1940s, 1950s and 1960s was embedded in secrecy. The author notes how the evidence suggests that information about pregnancy loss was not passed from one generation to another. Several men in the present study related how it only came to light when they lost their own baby that their sisters, aunts and even their parents had lost babies many years before. In Ireland, therefore, families and communities may have failed to develop appropriate rituals for the validation and sustenance of perinatal bereavement so that individuals are bereft of coping strategies. This would be particularly true in the case of the men.
It has been suggested (Miller 2000) that people make sense of what is happening to them in relation to the past and to future expectations and in relation to other actors. If men are not offered opportunities to understand past events and do not have access to appropriate discourses in which to articulate and express their interpretations and feelings, they may be less able to prepare for their future lives. The evidence from the men, therefore, suggests that the discourses of grief are predominantly gendered through a customary and habitual focus on the grief of women, and a need arises for professional carers to attend to the construction of forms of discourse that can assist men to comprehend and reflect on their experiences within an established tradition of knowledge.
Role of pregnancy loss self-help groups
Lang et al. (1996) point out that couples who are able to reach out early on and maintain a common social network are better able to progress in their ‘grief work’. Three men in the study gave talks to the medical profession and wider community on their experiences. Three men also facilitated a self-help group, along with their partner. The men expressed the view that belonging to a social network, where they were able to share the grief of others, also helped them come to terms with their own grief. The self-help groups also afforded to the men an opportunity to grieve through rituals and remembrance services. For example, many self-help groups organise communal memorial services during which bereaved parents are invited to enter their baby's name in a book of remembrance, lay a flower, light candles, recite poems and sing songs. These developments have shown the need to devise rituals that can serve the purpose of signalling that an important event has taken place, one that sanctions grieving processes and shows to parents that their sorrow has been recognised. Kuller and Katz (1994) note that the social acceptance of grieving through ritual assists in the progression and resolution of the grief. Yet for most men, when a baby dies before birth, the world that surrounds them tends to belittle, or at least discount, their loss and the emotional support and cultural rituals that are normally available to other bereaved individuals are often unavailable for men. Rando (1984) asserts that social support reflects the degree to which the deceased individual is valued by members of society at large. In the case of pregnancy loss, where the status of the baby is not valued, few traditional gestures that accompany a ‘social death’ will be made. The absence of rituals and rites marking pregnancy loss denies men an opportunity to mourn within a traditional ambience of comfort and support provided by significant others. Men mourning the loss of a baby suffer the additional burden of disenfranchised grief (Doka 1989); they do not have a socially recognised right to grieve because the loss is not considered a ‘social death’.
Participants in self-help groups cannot be taken to represent all individuals who have experienced a pregnancy loss; they have, however, the potential to contribute to change in hospital practices through helping to encourage the provision of rituals such as annual services for bereaved parents. It is important also to consider that many fathers will not have access to a self-help group and may, therefore, be distanced from sources of support available to mothers.
Writing in 1990, Layne noted that in the previous 15 years, organisations had sprung up throughout the United States in protest at the cultural denial of perinatal loss and had sought to define the pregnancy loss as a legitimate source of grief. The author noted that ‘SHARE’ (source of help in airing and resolving experiences), the largest national directory of support groups for perinatal loss, lists almost five hundred such groups in urban, suburban, and rural settings around the country, as well as groups in Canada, Australia, Israel, Italy, England, West Germany, South Africa and the Virgin Islands. Layne (1997) conducted ethnographic research with pregnancy loss support groups in the New York/New Jersey area of the United States and found that although some women and an occasional man attended group meetings on their own, most support groups were attended by couples. The present study found that where a group was facilitated by both partners, as in the case of three SANDS groups, the group was attended by both partners. It was notable, however, that where a woman alone facilitated the group, as in the case of the Miscarriage Support Group and one SANDS group, men rarely attended the group. All the men expressed the view that having another male present was a source of support. Most fathers stated how they felt relief at sharing their grief and anger, in a context which was viewed as normal and acceptable. One father, Brian, expressed how he attended the group but felt uncomfortable at being the only male there. Brian stated: ‘I felt like it was sort of a woman's group’. The results from this study are important as they indicate that the needs of the male partner may remain ignored if they are unable to find an outlet for their grief. Moreover, most of the men in the study noted how they were unable to talk to family or work colleagues about their experience. Further research with male partners who do not attend self-help groups is needed, therefore, in order to locate the determinants of their grief and understand their experiences more fully.