The experiences of men following recurrent miscarriage in an Irish tertiary hospital: A qualitative analysis

Abstract Introduction Miscarriage is one of the most common complications of pregnancy, and recurrent miscarriage affects approximately 1% of couples. The psychological impact of early pregnancy loss on women has been well documented in the literature; however, the burden of miscarriage on men remains largely unexplored. Methods This qualitative research involved semi‐structured interviews with five men whose partners had experienced at least two consecutive miscarriages. Participants were recruited through an early pregnancy loss clinic in a large, tertiary maternity hospital. Interviews were recorded and transcribed verbatim and analysed thematically. Results Recurrent miscarriage had a pronounced psychological impact on all the men interviewed, which worsened with each successive miscarriage. Three primary themes were developed from the data: (1) the deeply emotional experiences of men following recurrent miscarriage; (2) frustrations experienced during the provision of support following recurrent miscarriage; and (3) a sense of feeling unimportant. Lack of timely provision of information about miscarriage as well as lack of access to services were highlighted as deficiencies in the quality of care provided after recurrent miscarriage. Conclusion The experiences of men after recurrent miscarriage are based largely on their assumed role as the protector and supporter of their partner, which often results in neglect of their own psychological needs. The support required by men is similar to that required by women, and greater access to information and services is needed to improve the experiences of men following recurrent miscarriage. Patient Contribution Participants were recruited through the Pregnancy Loss Clinic at Cork University Maternity Hospital and were identified by specialist midwives. Participants were approached and interviewed by one of the researchers. Participation was voluntary and the men received no financial contribution for their time.


| INTRODUCTION
Miscarriage is one of the most common complications of pregnancy, and in Ireland, it is defined as the loss of pregnancy before 24 weeks of gestation. 1 Recurrent miscarriage, where two or more consecutive pregnancies end in loss, affects approximately 1% of the reproductive-age population. [2][3][4] The need for familial and social support has been highlighted previously, given the deeply emotional and distressing experiences that can be associated with pregnancy loss. 5,6 The often profound emotional distress associated with recurrent miscarriage is experienced by both the couple as a unit as well as by partners individually. An extensive body of research has explored the psychological burden as well as the health and wellbeing outcomes of women who have experienced miscarriage, 4,[7][8][9] and in recent years, some academic interest has been demonstrated regarding the impact that pregnancy loss has on male partners. 5,10 However, the experiences of men, particularly in the setting of recurrent miscarriage, remain largely underevaluated.
A heightened awareness of the psychological impact that pregnancy loss has on bereaved parents has led to increased research interest in this area in recent years. 11,12 Parents who have experienced a miscarriage often feel an overwhelming sense of grief that is coupled with a sense of loneliness in coping with this loss, as they are often excluded from the normal grieving processes that would occur in other cases of death that are considered less ambiguous and more legitimate. 13 Such experiences can lead to a disenfranchized experience of loss, a maladaptive grieving and bereavement process and may incur strain on familial relationships. 14 Evaluation of the psychological morbidity associated with miscarriage in women has led to the development of a number of supports to address their needs. 15 However, few interventions are tailored specifically for men despite the potentially negative impact of the experience on their well-being.
It has been reported that although men show different response patterns after the event of a miscarriage, in general, the emotions experienced are similar to those felt by women: grief, anxiety, stress and depression. 10 Some quantitative data suggest that men are just as likely to experience as high or higher levels of grief as their female partners 16 ; however, following pregnancy loss, men are more likely to engage in active-avoidance coping mechanisms and resulting maladaptive compensatory behaviours such as smoking and increased alcohol consumption. 10,17 Men are more likely to internalize their emotions, which may be attributable to the lack of recognition of their loss as well as the societal perception and pressure on men to be strong and supportive of their partners during a time of significant loss. 10 Men who internalize these grief emotions are less likely to engage with or seek out health services, which can impact negatively on their intimate relationships. 18 When men were perceived by their partners to be open about their feelings and engaging with caring behaviours, they were less likely to experience negative outcomes in their intimate relationships than those who were not. 18 The need for support following miscarriage for men has been acknowledged and the literature to date emphasizes that men are deeply emotionally affected by their loss of role as a father, manifesting as grief and frustration. 5 Due et al. 10 Koert et al. 21 was the first to address the needs of couples experiencing recurrent pregnancy loss and highlighted the apparent disconnect between the couple's needs and their experience of medical care after recurrent miscarriage. Furthermore, these authors suggest that the isolated examination of the experiences of men is grossly unexplored.
The aim of this paper is to address a gap in the current literature by analysing, through interviews, the experiences of men following their partner's recurrent first-trimester miscarriage. Following this, we hope to determine the necessary supports and/or interventions that are required to support men in their bereavement and grief journey.

| METHODS
Qualitative methods were used in this study. Qualitative research can be used to better understand complex social processes, to capture essential aspects of a phenomenon from the perspective of study participants, and to uncover beliefs, values and motivations towards the quality of care and service provision. 22,23 Qualitative methods have previously been used extensively to evaluate outcomes in the field of pregnancy loss and effectively capture the lived experiences of women and men after miscarriage and pregnancy loss. 5,9,24,25 This helps to inform clinical practice with regard to the identification of deficiencies in the quality of care provided and how, as clinicians, we can better improve the experiences of couples and families at a particularly distressing time in their lives. Qualitative methods can effectively capture patterns of meaning from the richness of data that are required to best understand the experiences of men affected by recurrent miscarriage.

| Ethical approval
Ethical approval was sought and granted from the Clinical Research Ethics Committee of the Cork Teaching Hospitals (CREC) on 9 February 2019. A distress protocol was in place should any participant become overtly upset during the interview process; however, this was not required.

| Recruitment
Men were recruited through a pregnancy loss clinic in an Irish tertiary maternity hospital. A purposive sample of nine men was approached by the specialist midwives in bereavement and loss with an invitation to participate in the study. Inclusion criteria were that the participants were partners of women who had been cared for in the study hospital and had experienced two or more first trimester miscarriages, were over 18 years old and had not previously indicated that they did not wish to be contacted by the hospital for study purposes. Men were excluded if they did not have English as their first spoken language. The rationale for recurrent first trimester miscarriage was informed by the literature and the lack of focus on this particular cohort.
Once deemed eligible for the study, men were issued with an invitation to participate in the study and asked to contact the primary interviewer, following which an appointment for a semi-structured interview was made to take place at the study hospital.
Semi-structured interviews were conducted by one of the researchers. Semi-structured interviews ensure uniformity in the content of the interview, while also providing an additional opportunity to capture the lived experienced of the individual's experience. 26 The interview process was supported by two specialist midwives in bereavement and loss with experience in the provision of care to couples who experience pregnancy loss, whose purpose in this study was to identify men from the pregnancy loss clinic and refer them to the interviewer. The specialist midwives were not present during the interview. However, they were available as part of the distress protocol, should it be required.

| Data analysis
Phenomenological methods were used in this study. The aim of phenomenology is to describe the meaning of an experience, both in terms of what happened and how it was experienced. 30 Using this method, we provide detailed examinations of the men's lived experiences in their own terms rather than a predetermined theoretical approach, with the aim of understanding the depth of experience of each man following recurrent miscarriage, before making more generalized claims. The data generated from the interview process were analysed using a close interpretive reading of the transcripts, and notes were translated into themes using an iterative thematic approach to provide a rich understanding of the phenomenon of recurrent miscarriage for men. 31 Each transcript was reviewed by the researcher, M. T., multiple times. Inductive methods were used to develop thematic patterns from the data to capture the meanings associated with recurrent miscarriage experiences for the participants. These themes were coded accordingly. A coding framework was developed, and coded text was collated and analysed for similarities and differences. The data were handled and analysed manually. The researcher was aware of the importance of self-reflexivity in the process of engaging with the data, recognizing areas of personal identification with the stories of participants, areas of divergence and the interpretation of the data in the development of the themes. Of particular note was the personal experience and history of miscarriage for the researcher and an awareness of the reflexive importance of this experience alongside the experiences of participants.
Themes, defined as a piece of information that captures something important about the data in relation to the research question and represents some level of patterned response or meaning within the data set, 31 were identified. Following this, the data were reviewed and further classified into subthemes. A second researcher, D. N., reviewed the manuscript transcriptions for accuracy, and the authors reached consensus on the final interpretation of the data.

| FINDINGS
Five men consented to participate in the semi-structured interviews.
The remaining four invitees were either unavailable or declined to participate in the study. This small sample size reflects the availability of participants within this specific study population, and is comparable to similar studies, 32,33 as the challenges of recruiting men for reproductive research are acknowledged. 34 Details pertaining to the number of miscarriages experienced by each participant are described in Table 1. Interviews were conducted between May and July 2019 and ranged in duration from 40 min to 2 h and 10 min. The mean interview time was 65 min. Direct quotes are used in this paper to support the results and represent the themes identified in the interviews.
Three main themes were developed from the data set: (1) the deeply emotional experiences of men following recurrent miscarriage; (2) frustrations experienced during the provision of support following It is clear from these excerpts that visualizing the foetal heartbeat offers an overwhelming sense of hope to these men that this pregnancy may be the one that is successful, a feeling that has been built on the previous experience of pregnancies ending in miscarriage. Furthermore, Participant 1 highlighted that the feeling of loss with their second miscarriage was far more profound, having been offered this apparent sense of hope after seeing their child's beating heart, a phenomenon that had not occurred during this couple's first pregnancy.You could see a tiny…….little circle ………it made it more connected actually…….the nurse asked when we were leaving if we find anything do you want us to contact you or will we bury it and like neither myself or [partner] are religious so my initial reaction was no, we will take care of it, which made me feel a bit more connected to it then. (Participant 3) Here, Participant 3 is also referring to burying foetal tissue that may be identified on laboratory analysis of the miscarried products of conception.
Having something physical to hold onto and grieve by burying clearly promotes a deep emotional response in this man.
3. Perceived role as protector for their partners following miscarriage(s) All men addressed their role in supporting their partner after miscarriage. It was clear from each interview that the men viewed this as an essential role to support and protect their partners through the miscarriage process and, in some sense, to 'fix' the situation. One man felt the need for himself to be 'calm' to 'keep it together' for his partner (Participant 1). Notably, it became more difficult for the men to maintain this role as supporter for their partners with each successive loss. One of the men in this study spoke of the cumulative nature of the losses and how, with each miscarriage, remaining positive and protective of their partner became increasingly difficult.
Theme 2: Frustrations experienced during the provision of support following recurrent miscarriage Some men identified the specific support provided by the specialist midwives in bereavement and loss as the only beneficial support that they experienced following their partners' recurrent miscarriages. Overall, the quality of this service was deemed to be excellent. Admittedly, these men did not meet with the specialist midwives until after they had already experienced one miscarriage, and in some cases, it was not until after several miscarriages that the men met with this specialist support service. Furthermore, meetings with the specialist pregnancy loss team and midwives were aimed at the couple as a single unit, and not at the man individually. Some of the participants mentioned that their partners were offered information about the availability of miscarriage support groups; however, they admitted that none of the same support was offered to them individually, as men.

Practical and logistical aspects of the service provided that influenced their experience
The majority of the men expressed frustration at logistical aspects of the service provision in this tertiary maternity hospital.
Grievances were voiced about some of the practicalities relating to the service and how, at times, it impacted negatively on their experience.
The men felt unsupported as a result of challenges that were inherent to the system in which the service was provided. reflects their primary concern relating to their role as supporter of their partner through loss.

Lack of acknowledgement for grief of recurrent miscarriage
Several of the men discussed that as a couple, they felt under- Male partners' anticipated role as supporters for the partners has been reported extensively in the literature to date. 9,10,32,38 All the men in this study discussed their duty to act as a supporter for their partner, and in doing so, often neglected and undervalued their own needs. This seems an unsurprising finding when masculine roles and identities are explored in a societal context. 39  The men reported a deficiency in the timely provision of supportive information, a lack of appreciation of their role as a father who is also grieving and their frustrations towards some aspects of the care provided throughout the miscarriage. Men often feel like they are 'in the way' during the miscarriage process, 42 and the results from this study highlight a need to promote inclusivity for men and provide them with an appropriate level of understanding for them to achieve a sense of ownership of their rightful place during the grievance process.
Nearly all the men identified with the feeling of being just another number, which can be interpreted as an expression of feeling both inconsequential and belonging to part of a process. These experiences could also be compounded by the reality of disenfranchized grief for men. Notably, one man independently suggested that being given an information leaflet at the initial stage would have signalled to him that he was important and included in this situation.
A lack of provision of sufficient and timely information about the miscarriage process to men and details about how to access to services was highlighted as a major shortcoming during these men's experience. Public perceptions of miscarriage can often be erroneous, and the general population can have misconstrued beliefs regarding the incidence of miscarriage and its potential causes. [43][44][45] Most men interviewed felt that judicious provision of important information regarding miscarriages would have offered significant support to them as partners, particularly in the context of recurrent miscarriage.
Knowledge pertaining to miscarriage incidence and aetiologies, had it been provided in a timely manner from the first miscarriage, may have provided significant support and understanding to these men during subsequent losses. This information is pivotal in the planning of a support intervention for men.
Significant frustrations were expressed by the men regarding service provision. A lack of access to emergency services, such as the emergency medical and midwifery number, at critical times during the miscarriages as well as prolonged waiting times at clinics and in the emergency department were some of the grievances voiced.
Parents' perception of care at a traumatic time is shaped by the environment of care around them and has considerable impact on the grieving process. 33 The participating men appeared to interpret these shortcomings as a failure in the provision of adequate care for themselves and their partners.
The results from this study will be used to help establish a support service for men who have experienced a miscarriage in the study hospital. This will be an adjunct service to the early pregnancy loss clinic that runs in this hospital and will aim to provide men with psychological support in their journey through bereavement and loss. The support required by men is similar to that needed for women as cited in the literature: acknowledgement of loss and provision of personalized information and follow-up care, 46,47 which begs the following question: should we consider the 'patient' in the setting of recurrent miscarriage as the couple rather than the man and the woman individually? Results from a recent qualitative study by Koert et al. 21 found that couples who had experienced recurrent pregnancy loss desired a 'couple-focused' approach to medical care. This includes early access to investigations for both the man and the woman and personalized supportive and psychological care that is tailored to the couple. This concept of 'couple-focused' care is particularly relevant in the setting of recurrent miscarriage, which presents unique challenges to healthcare provision, given the cumulative effect of multiple losses and the toll that this takes on both partners. The data from our study highlight the importance of identifying and responding to the needs of men as part of the 'couple'.
Future research may extend the inclusion criteria to men who have experienced first and second trimester miscarriage to deepen our understanding of the supports required by a wider audience of men following recurrent miscarriage.

| STRENGTHS AND LIMITATIONS
To our knowledge, this is the first study of its kind to specifically examine in detail the lived experiences of men following their partners' recurrent miscarriages. This study provides an in-depth account of the experiences of men and the associated interpretations related to recurrent miscarriage for male partners. These results provide maternity care clinicians with important insights about parents experiencing recurrent miscarriage, which should be used to improve the quality of care provided for men and couples going forward.
The conduct of interviews by an interviewer who is not inherently involved with the service provision is a strength of this study. It allowed the participants to discuss in detail and with honesty some of the limitations and flaws related to the quality of care provided and service provision as the interviewer was distinguishable from clinicians who may have previously dealt with the men during the miscarriage process.
All men in this study were recruited through a pregnancy loss clinic in a single Irish tertiary maternity centre. It would be useful for future studies to analyse the experiences of men recruited from a broader range of services and locations.
The sample size reflects the acknowledged challenges of recruiting men into studies in pregnancy loss. 34,48 However, the data do contribute important information to the body of knowledge concerning this distinctive loss of recurrent first trimester miscarriage from the perspective of men.

| CONCLUSION
This valuable piece of research involved inquiry that generated knowledge and affirmed existing viewpoints regarding some of the experiences of men going through pregnancy loss. It is imperative that men's loss as a father is adequately recognized and acknowledged by clinicians and that adequate support such as the timely provision of appropriate information is made available to help men and their partners, eventually ending the stigma surrounding miscarriage. Men experiencing recurrent miscarriage run the risk of being doubly disenfranchised, with neither their unique experience as men nor their cumulative losses being recognized.