The Impact of Pregnancy Loss on Men's Health and Wellbeing

Due et al. BMC Pregnancy and Childbirth (2017) 17:380 DOI 10.1186/s12884-017-1560-9

RESEARCHARTICLE Open Access The impact of pregnancy loss on men’s health and wellbeing: a systematic review Clemence Due1* , Stephanie Chiarolli1 and Damien W. Riggs2

Abstract Background: 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. Methods: 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. Results: 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. Conclusions: 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. Keywords: Men, Pregnancy loss, Miscarriage, Stillbirth, Ectopic pregnancy, Systematic review

Background women who experience a pregnancy loss, and how Pregnancy loss affects many people every year, with such women can be best supported [6–9]. However, miscarriage occurring in approximately 15–50% of as pregnancy is still arguably considered primarily a all pregnancies [1], the majority of which occur be- ‘women’s issue’ [10], fewer studies have considered fore a pregnancy is formally recognised [2]. In the impact of pregnancy loss on the health and well- addition, in 2015 an estimated 2.6 million babies being of men. Furthermore, the literature on men were stillborn [3]. Miscarriage is defined as the unin- tends to focus almost exclusively on heterosexual cis- tended termination of pregnancy resulting in foetal gender men, with research on the impact of preg- death that occurs prior to 20 weeks of gestation, and nancy loss on gay and/or transgender men lacking. stillbirth is the death of the foetus after 20 weeks or This lack of research is particularly problematic since after reaching 400 g in weight [4]. Ectopic pregnancy available research details a range of potential health is a pregnancy in which the fertilised ovum implants impacts for men following pregnancy loss, including outside the uterine cavity [5]. disenfranchised grief, anxiety, depression, and a ten- There are a significant body of studies detailing dency to resort to avoidance behaviours such as alco- health and wellbeing outcomes for heterosexual hol and drug use [1, 7]. Taken together, men’s experience of pregnancy loss is a key area of concern- * Correspondence: [email protected] ing for healthcare professionals working with men 1School of Psychology, The University of Adelaide, Adelaide, South Australia 5005, Australia and their families. Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Due et al. BMC Pregnancy and Childbirth (2017) 17:380 Page 2 of 13

The present paper provides a systematic review of Table 1 PsycINFO search strategy research findings from all empirical research designs Pregnancy loss/miscarriage Men’s health outcomes with regard to men and pregnancy loss. It aims to Spontaneous abortion.sh human males.sh describe the nature and characteristics of current re- OR OR search into the impact of pregnancy loss on men, spontaneous abortion*.mp husbands.sh OR OR and in so doing provides a solid base for future em- Pregnancy loss*.mp spouses.sh pirical research that addresses gaps in the literature. OR OR miscarriage*.mp husband*.mp OR OR Method Perinatal loss*.mp Men.mp Preferred Reporting Items for Systematic Reviews OR OR and Meta-Analyses (PRISMA) [11] and Joanna Briggs Stillbirth*.mp Male.mp OR Institute(JBI)methods[12]weredrawnuponinthe Males.mp collection and analysis of articles, as well as qualita- OR tive data synthesis and analysis processes from the father*.mp OR Social Care Institute for Excellence (SCIE) System- paternal.mp atic Research Review Guidelines [13]. The * acts as a truncation symbol, whereby the search includes all possible endings for the term Inclusion criteria Any peer-reviewed study published in English be- identified could be accessed by the authors without tween 1995 and 2016 was included for review in contact with individual researchers. The final date order to capture all recent research. Inclusion cri- for inclusion was end of July 2016. teria were that studies 1) aimed to investigate the The initial search of PsycINFO, PubMed, CINAHL impact of pregnancy loss on men’s health and wellbeing and Scopus generated 3976 results. After reviewing with pregnancy loss referring to miscarriage, stillbirth and all abstracts, 108 articles were retrieved by the first author, ectopic pregnancy (studies which focused on perinatal loss and the full texts of these articles were reviewed by all au- in the early neonatal period were excluded), 2) included thors. The primary reason for exclusion of the remaining either a focus on men or included men’s voices separately 3868 articles was a focus on women’s medical and gynaeco- (i.e., in studies that focused on both men and women), 3) logical issues of pregnancy loss, rather than men’shealth were empirical, involving primary data collection. The outcomes. Studies were also excluded if they reported on search also identified a number of studies that focused on women’s perceptions of the impact of pregnancy loss on the impact of pregnancy loss on men’s health and well- men, rather than specifically including men as study partici- being in the context of a subsequent pregnancy, and these pants. Of the 108 articles retrieved for full-text examin- papers were assessed as meeting the inclusion criteria and ation, 27 met all inclusion criteria and were agreed upon by were therefore included in the review. Studies which in- all three authors. A further two articles were retrieved from vestigated the impact of both elective termination and ter- Google Scholar after reviewing reference lists, both of mination due to foetal abnormality were excluded as which met the inclusion criteria, giving a total sample of 29 previous research suggests that these may be experienced articles. Three of these studies were mixed methods in de- differently to an unplanned pregnancy loss [14, 15]. sign, and for synthesis purposes, these were incorporated

Search strategy and data extraction Table 2 PubMed search strategy An initial search of PsycINFO was undertaken to Pregnancy loss/miscarriage Men’s health outcomes identify subject headings and potential keywords. Abortion, habitual [mh] Men’s health [mh] OR OR The subject headings and potential keywords identi- Abortion, spontaneous [mh] Fathers/psychology [mh] fied in this initial search were: spontaneous abortion, OR OR Stillbirth/psychology [mh] Spouse*[tiab] pregnancy loss, miscarriage, perinatal loss and still- OR OR birth along with human males, husbands, spouses, Miscarriage/psychology [mh] husband*[tiab] OR OR men, males, fathers and paternal. A second search miscarriage*[tiab] Men [tiab] was then undertaken in PsycINFO using these key- OR OR Perinatal loss*[tiab] Male [tiab] words, subject headings and index terms. The search OR OR was then undertaken in PubMed, Scopus, CINAHL, Stillbirth*[tiab] Males [tiab] OR and Google Scholar, and reference lists selected for Father*[tiab] OR full text review were searched for articles of rele- Paternal [tiab] vance. Example search strategies from PsycINFO and The * acts as a truncation symbol, whereby the search includes all PubMed are outlined in Tables 1 and 2. All studies possible endings for the term Due et al. BMC Pregnancy and Childbirth (2017) 17:380 Page 3 of 13

Table 3 Characteristics of the quantitative and mixed methods studies Number of studiesa Year of publication 1995–2000 11 2001–2005 3 2006–2010 4 2011–2016 1 Sample size of males includedb <30 5 30–60 6 60–100 2 101–300 4 301–400 2 Region of study Australia 3 Europe/United Kingdom 6 Canada/United States 6 Asia 2 Recruitment Hospitals/clinics 11 Private Practices/General Practitioners 2 Education classes 1 Pregnancy loss support group 1 Pregnancy loss clinic 2 Other 4 Time since pregnancy loss 0–8 weeks 6 8 weeks-6 months 6 6 months-1 year 4 1 year-2 years 5 2 years + 3 Time of gestation at which loss occurred 5–12 weeks 5 13–20 weeks 6 21 weeks–30 weeks 3 31 weeks–40 weeks 1 > 40 weeks 1 a If numbers total more or less than 18 then the characteristics of a study were unknown or were relevant in more than one category b The sample size for studies assessing couples is halved so that the results for men only are displayed into the reporting of the quantitative studies as the study of studies that met the inclusion criteria. The follow- designs were primarily quantitative. The details of all 29 in- ing section contains discussion of overall risk of bias in cluded studies are outlined in Appendix. this body of research. Finally, a formal meta-analysis of the Overall quality and risk of bias was assessed using quantitative studies was not conducted due to the hetero- the Cochrane Collaboration’s tool for assessing bias. geneity of studies in terms of design, study populations and The second and third authors reviewed the studies outcome measures. and reached consensus, however no study was ex- The first author extracted important characteristics of cluded on the basis of quality given the low number the studies using a predesigned table. This information Due et al. BMC Pregnancy and Childbirth (2017) 17:380 Page 4 of 13

included: country where the research was conducted, 60. Time since the pregnancy loss occurred and when date of publication, study design, number and character- the men participated in the research varied, but the istics of participants, and psychological and physical majority of studies (n=6) interviewed participants health outcome measures. This information was cross- within 8 weeks of the pregnancy loss occurring. The checked by the second author. time of gestation at which the pregnancy loss occurred ranged from five to 44 weeks, and was be- Results tween 5 and 20 weeks in the majority of studies. As noted above, 29 studies were included in this re- Table 4 provides details of the psychological instru- view from 108 reviewed full-texts and 3976 search ments used to measure outcomes in the quantitative and results. Sixteen of the included articles were quanti- mixed methods studies. The psychological variables that tative, 10 qualitative, and three used a mixed were measured most often were depression, anxiety and methodsdesign.Twoofthestudiesutilisedthe grief. The most commonly used instruments were the same data and population but reported on different Beck Depression Inventory (BDI) [19], the State-Trait aspects of the findings, so they were both included. Anxiety Inventory (STAI) [20], the Perinatal Grief Scale Fifteen studies examined the impact of a pregnancy (PGS) [21] and the Impact of Event Scale (IES) [22]. loss on both men and women, and aimed to identify any differences and similarities in their experiences. Outcomes of quantitative and mixed methods studies Nine of the studies solely attempted to identify the All of the studies which compared men’sandwomen’spsy- impact on men, and a further four studies aimed to chological experiences found a difference in response pat- explore the experience of a subsequent pregnancy terns. It was generally found that while men reported many for men after experiencing a prior pregnancy loss, of the same feelings of grief, depression, stress and anxiety with two of those studies investigating both men as women, they tended to have less intense and less endur- and women. ing levels of these psychological outcomes than did women [7, 23–30]. The studies which examined men whose part- Description of quantitative and mixed methods studies ners were pregnant following a loss indicated similar results, Table 3 provides details of the key characteristics of in that anxiety and depressive symptoms tended to be high the 19 quantitative and mixed methods studies. All antenatally but these were likely to subside postnatally [31– of the male participants were heterosexual and cis- 33]. Kagami et al. [25] found that women showed signifi- gender. Of the 16 solely quantitative studies, 12 cantly higher levels of depression and anxiety following a aimed to compare heterosexual couples’ psycho- pregnancy loss compared to men, and this was significantly logical experiences of a pregnancy loss, while four associated with poor quality of the marital relationship. aimed to measure only men’s psychological reactions. Similarly to previous research concerning women, how- Four of these studies involved men whose partners ever, gestational age at time of loss was not related to the were currently pregnant following a prior loss. health or wellbeing outcomes of men [26, 28, 29, 31, 32]. In- The three studies that used a mixed methods design were stead, and again similarly to research with women, whether primarily based on a self-administered quantitative question- or not a pregnancy was planned or welcomed was found to naire that also incorporated a small number of open-ended be a key indicator of levels of psychological distress [26]. questions [16, 17]. One mixed methods study utilised a self- Some of the quantitative studies reported that men were administered questionnaire which was supplemented with typically hesitant to disclose their feelings, had elevated re- semi-structured interviews with 10 out of 126 male partici- sults on avoidance scales, had difficulty accessing support, pants [18]. The aims of each of these studies were relatively and utilised varying coping strategies, including focusing on different: one investigated grief responses of couples follow- work as a distraction [23–25, 33–36]. However, and in con- ing a pregnancy loss and the adequacy of support; one trast to other quantitative studies, men in Johnson and aimed to examine the emotional, social and physical effects Puddifoot’s [18] mixed methods study scored high in grief of a pregnancy loss on families; and one examined the psy- similar to that expected for women (that is, the entire sam- chological impact of a pregnancy loss on males. ple of both men and women had a high mean grief score). Most of the quantitative or mixed methods studies Also supporting this were the results of Conway and Rus- were undertaken in the European Union (EU; n=6) sell’s [16] mixed methods study, where men scored signifi- or Canada or the United States (US; n = 6), and par- cantly higher than their female partners on the three ticipants were most commonly recruited through re- subscales and overall scores on the Perinatal Grief Scale. ferrals from hospitals or clinics (n=11), meaning Similar to other studies on grief [37], however, men scored that they were convenience samples. Sample sizes of lower in ‘active’ grief than women – incorporating sadness, male participants included in the studies ranged from missing the baby and crying for the baby – further support- 17 to 332 but were most commonly between 30 and ing the idea that men tend to suppress outward signs of Due et al. BMC Pregnancy and Childbirth (2017) 17:380 Page 5 of 13

Table 4 Instruments used to measure outcomes in the quantitative and mixed methods studies Number of studiesa Grief 8 The Grief Experience Inventory-Loss Version 1 Munich Grief Scale 1 Perinatal Grief Scale 6 Grief Experience Inventory-Perinatal 1 Depression 10 Center for Epidemiological Studies-Depression Scale 1 Von Zerssen Depression Scale 1 Beck Depression Inventory 6 Anxiety 8 Stait-Trait Anxiety Inventory 5 Hospital Anxiety and Depression Scaleb 2 Pregnancy Outcome Questionnaire 1 Delusions Symptoms State Inventoryb 1 Stress 5 PTSD-I Interview 1 Impact of Event Scale 4 Coping 2 Coping Response Inventory 1 The Coping Scale for Adults 1 Marital Satisfaction/Relationship 4 Quality Marital Index 1 Golombok Rust Inventory of Marital Satisfaction 1 Intimate Relationship Scale 1 Partnership Questionnaire 1 Dyadic Adjustment Scale 1 Other 6 Prenatal Attachment Inventory 1 The Complaints List 1 General Health Questionnaire 1 Ego Strength Scale 1 Life Experiences Survey 1 a If numbers total more or less than 18 then the characteristics of a study were unknown or were relevant in two groups b This instrument is listed under ‘anxiety’ but is also counted under ‘depression’ grief. Also consistent with other studies were themes that seven out of 38 fathers reported they had used prescribed emerged from the analysis of open-ended questions, includ- medication to enable them to cope, and three fathers re- ing the perceptions of others minimizing the loss, active- ported that they had used illegal drugs. DeFrain et al. [17] avoidance as a coping strategy, and the meaning generated also examined the social and physical effects of pregnancy by being able to view ultrasound images which was associ- loss in their mixed methods study. They found that drug ated with higher levels of grief. and alcohol use had increased in 7% of households (n = 12), Only two quantitative or mixed methods studies touched and that family violence related to the loss occurred in 3% on non-psychological impacts of pregnancy loss. Vance et al. of households (n = 5). They also found that 6% of parents (n [38] examined patterns of alcohol use following a pregnancy = 10) moved from their homes or communities to escape loss, and found that 7–12.3% of bereaved fathers met the from the painful memories and/or friends or relatives who criterion for heavy alcohol usage compared to 4.7–5.8% of they felt were insensitive to their loss. non-bereaved fathers. Turton et al. [32] assessed the psychological morbidity of fathers during a pregnancy subsequent Description of qualitative studies to a stillbirth, and found that nine out of 34 fathers who Table 5 provides details of the key characteristics of the ten were non-drinkers reported increased alcohol consumption, qualitative studies. In contrast to the quantitative studies, Due et al. BMC Pregnancy and Childbirth (2017) 17:380 Page 6 of 13

only three of the ten qualitative studies aimed to compare Table 5 Characteristics of the qualitative studies couples’ experiences, while the remaining seven focussed Number of a solely on men’s perspectives (two of these involved men studies whose partners were currently pregnant following a prior Year of publication loss). Most studies were published between 2001 and 2005 1995–2000 1 (n=6), which may indicate attempts to address gaps that 2001–2005 6 were uncovered in earlier quantitative studies. Most of the 2006–2010 2 studies were undertaken in the EU (n=4) or Australia (n= 2011–2016 1 3), and participants were most commonly recruited through Sample size of males includedb n= snowball sampling ( 5) and through referrals from hospi- 1–53 n= tals and general practitioners ( 6). 6–93 Sample sizes of male participants included in the 10–14 4 studies ranged from four to 14, but were most com- Region of study monly between 10 and 14. Time since the pregnancy Australia 3 loss occurred and when they participated in the research varied, but was most commonly between 8 Europe/UK 4 weeks and 6 months. The time of gestation that the US 2 pregnancy loss occurred was most commonly be- Middle-East 1 tween 13 and 20 weeks. Seven of the studies adopted Recruitment a phenomenological approach using thematic ana- Hospitals/clinics 3 lysis, in which the researchers undertook semi or Private Practices/GPs 3 unstructured interviews with each participant. Two Pregnancy loss support group 2 of the studies had an interpretive narrative design, Pregnancy loss clinic 1 whileonestudywasaself-reported questionnaire of Newspapers 1 open-ended questions. Community locations (noticeboards, libraries, centres, 2 pharmacies, shops) Outcomes of qualitative studies Snowball sampling/word of mouth 5 ’ Seven studies which aimed to describe men sexperi- Time since pregnancy loss ences of pregnancy loss either in the context of an- 0–8 weeks 4 other pregnancy or as an occurrence in itself 8 weeks-6 months 6 reported similar themes, particularly that of men 6 months-1 year 5 feeling that their role was primarily as a ‘supporter’ to 1 year-2 years 3 their female partner [10, 39–44]. These studies examined – the normative social expectation that males ought to be 2 years 3 years 2 caretakers and sources of strength, together with the associ- > 3 years 1 ated outcome of feeling unable to express their emotions Time of gestation at which loss occurred due to the expectation that they maintain control of the 6–12 weeks 3 situation and be a comfort to their female partner. These 13–20 weeks 4 studies found that while many men would make the effort 21 weeks–30 weeks 2 to appear overtly ‘strong’ and return to their regular life as a 31 weeks–40 weeks 3 coping strategy, they nevertheless experienced in- > 40 weeks 3 ternal feelings of stress and vulnerability which in- a If numbers total more or less than 10 then the characteristics of a study were tensified their role of ‘protector’ in subsequent unknown or were relevant in two groups b The sample size for studies assessing couples is halved so that the results for pregnancies following a previous loss. Furthermore, men men only are displayed often reported feeling unable to respond to their female partners with emotional support, preferring instead to re- experience and whose pain was more visible [10, 39, spond with instrumental support by absorbing practical 43–45]. Studies also focused on different expres- strain such as paying the bills, in the hope of maintaining sions of male grief when compared to their female routine and ‘protecting’ their female partners. partners, in that while male participants expressed Five qualitative studies also identified the lack of feelings that are typical of the grief and bereave- social recognition that many men felt in dealing ment process such as sadness and uncertainty, they with a pregnancy loss, describing feeling overlooked, tended to report less intense feelings that lasted a alienated and marginalised in comparison to their shorter amount of time. Furthermore, the predomin- female partners who had suffered the physical ant emotions reported by men were those of Due et al. BMC Pregnancy and Childbirth (2017) 17:380 Page 7 of 13

frustration and helplessness. This finding reflected of loss. Many studies made no mention of culture or ethni- that of the quantitative studies, as discussed above. city at all [10, 16, 17, 32, 34, 36, 43–45], or included a ma- Another theme identified from the qualitative studies was jority of Caucasian participants or those who spoke English theideaofalossofidentityduetowhatthepregnancyhad [28, 31]. This method of recruitment and subsequent sam- come to mean to men who had experienced pregnancy loss. ple may present issues for data collection concerning the The studies found that most men anticipated a healthy preg- retrospective health impacts of the loss. Similarly, the fact nancy, so participants in three studies reported a struggle in that the majority of the studies were conducted in middle recognising their transition into fatherhood, and questioned to high income countries also presents a bias in the evi- if they had the right to the ‘father’ title following a loss [41, dence base, given that 98% of all stillbirths occur in either 43, 46]. Male participants described a deep sense of loss for low or middle income countries [3]. the hopes and dreams they had visualised for their baby, and also the hopes they had invested in the prospect of be- Discussion ing a parent, particularly after bonding with images of their Overall, this review found several common themes across baby through ultrasound, gaining a sense of their physical studies that have explored men’s experiences of pregnancy features, and becoming ‘mentally engaged’ with the idea of loss. Specifically, findings indicated that men typically feel as being a father. Participants in Murphy’s [45] study, for ex- though they need to take on a ‘supporter’ role for their fe- ample, explained that having children was viewed as being male partner, which may come at the expense of their own ‘normal’ in society, so miscarriage therefore threatened the health and wellbeing [10, 39–44]. In addition, the existing process of becoming a father and having a family. body of research indicates that pregnancy loss may lead to a A common coping mechanism that was also described in loss of identity related to both the anticipated father role, nine of the studies was that of active-avoidance, whereby and the grief and loss associated with the changes which men withdrew emotionally and/or physically by choosing may come after a pregnancy loss [41, 43, 46]. Finally, exist- to return to work early and immersing themselves in their ing research mirrors that with women in finding that preg- work as a distraction. Khan et al. [47] touched on a health nancy loss and associated grief lack social recognition, impact of pregnancy loss when they found that four of the leading to disenfranchised grief for men, as well as chal- nine men in their study tried to ignore their feelings by fo- lenges accessing support and often negative impacts upon cusing on other distractions such as smoking. Participants relationships [10, 39, 43–45]. in O’Leary and Thorwick’s [10] study also touched on phys- While the results of this review indicate that the feelings ical health issues when they described feeling both physic- associated with pregnancy loss are often very similar be- ally and emotionally exhausted following a miscarriage, tween men and women, the manifestations of these feelings which they attempted to manage by keeping busy and go- are typically different, indicating that men’s health and well- ing to work. In some studies, men stated that while work being is an important research area in itself. The lack of was a temporary distraction, the combination of both knowledge of these issues amongst some health providers household and work pressures wore them down [10]. and family and friends of couples who have experienced a loss can lead to helplessness, marginalisation and the feeling Quality and bias of being alone in their grief [10, 17, 24, 28, 39]. The overall quality of the studies was impacted by several Many studies focussing on heterosexual cisgender men issues relating to participant selection, and the final partici- have tended to infer behaviour and emotions from the fe- pant sample – issues which are likely to impact knowledge male partner’s reports, due in part to a socio-cultural belief in relation to men’s health outcomes following pregnancy that men may be less willing to communicate and that loss. In particular, almost all of the quantitative studies [7, pregnancy loss has a greater impact on women [33]. There 16–18, 23–35, 37, 38] and a smaller number of the qualita- are also some methodological issues in previous research tive studies [39, 40, 46] primarily included men as part of a concerning men’s experience of pregnancy loss. For ex- heterosexual couple, with men often recruited through ample, men have tended to be interviewed as part of a their female partners. Indeed, several studies specifically couple, and those studies which are solely from the man’s only included men in order to compare outcomes with perspective tend to be in the context of a subsequent preg- their female partners [7, 23, 30, 40]. While these studies nancy and/or have some issues with generalisability due to certainly contribute to literature in this area, they are lim- population, sampling, and response bias. Moreover, most ited in terms of what they can tell us specifically in relation qualitative studies of men’s experiences have small sample to men’s individual responses, and offer little insight into sizes, are often case-studies, and have often used conveni- the experiences of men who are single or gay (as discussed ence/snowball sampling to obtain participants through further below). Relatively few quantitative [18, 25, 27, 32, means of recruitment via health centres or self-help groups. 33, 35] or qualitative studies [10, 42–45, 47] recruited only This may indicate that the men interviewed already have a fathers, or aimed specifically to explore men’s experiences vested interest in their health and wellbeing following the Due et al. BMC Pregnancy and Childbirth (2017) 17:380 Page 8 of 13

pregnancy loss, and may not be representative of the general including grey literature as well as literature in languages population of men who are experiencing the impact of a other than English. The scope of the review was necessarily pregnancy loss. broad which reflects the paucity of the current literature As discussed previously, a common theme evident in base on the subject. Due to this fact, a quality screening seven studies involving men and pregnancy loss is one of was not undertaken and a meta-analysis was not done due being a supporter and ‘remaining strong’ inthefaceofloss. to the heterogeneity among studies. Future studies may be Therefore, there may also be a social desirability bias inher- able to utilise meta-analysis to examine psychological im- ent in some men’s responses, in that they may not fully dis- pacts in particular in more depth. close 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 coun- Conclusions tries and different cultures including the UK, the US, Japan, Future empirical research would benefit from longitudinal Australia, Israel and Portugal that explore pregnancy loss studies with less of a focus on measurable psychological as- from a male perspective, they do not explore how reactions pects of pregnancy loss on men and an increased focus on to a loss may be attributed to cultural differences (for ex- other aspects of health and wellbeing that may be affected ample in understandings of what loss and grieving means, by such a loss, for example physical health. Most studies death rituals, and cultural constructions of relationship that encompass different characteristics of health tend to meaning within families and parents) [48]. be qualitative. The development or use of a psychometric- Another gap in the literature pertains to gay and/or trans- ally valid measure which incorporates non-psychological gender men’s experiences of pregnancy loss. Exceptions to aspects of health and can be used to measure a larger sam- this include the work of Ziv and Freund-Eschar [49] who ple would be beneficial in capturing information that may conducted in-depth interviews with eight gay couples from be more generalisable. It is important to acknowledge the Tel-Aviv expecting a baby through surrogacy in either the impact that avoidance and coping behaviours may have on United States or India. As part of their analysis, Ziv and men and their partners as a result of a pregnancy loss. Freund-Eschar touched on the impact of pregnancy loss in These behaviours may include focusing on work as a dis- describing one participant’s frustration and anxiety with re- traction, and increasing risk behaviours such as excessive gard to the ways in which surrogacy clinic practices did not alcohol consumption, smoking and drug. These avoidance allow for emotions to be expressed in regards to a miscar- and coping behaviours may exacerbate the experience of riage, with the participant reporting disappointment over the loss and lead to relationship breakdowns and prolonged time wasted. Riggs, Due and Power [50] also conducted in- grief. terviews with 12 gay men who had undertaken surrogacy ar- Studies that include a larger sample of men from rangements in India. A key issue that arose in the interviews varying cultural and religious backgrounds to show was the lack of sensitivity shown by clinics following a preg- how the impact of a pregnancy loss may differ in re- nancy loss. One participant described the initial response of lation to culture and context may also be beneficial. the clinic as talking about finding another surrogate who Culture can strongly influence and define grieving had a high success rate, rather than acknowledging their processes, and provides a framework within which grief and assisting in organising the funeral. Finally, in human relationships vary and are given meaning [3]. regards to transgender men, Ellis, Wojnar and Pettinato [51] The process of acculturation whereby people move reported on a qualitative study of eight trans or gender di- to a different cultural setting may also influence the verse men who had undertaken a pregnancy. Half of these role of culture as findings may be similar to those men had experienced at least one miscarriage, with one who had always lived in that particular cultural set- participant reporting that they felt betrayed by their body ting. With this in mind, it is important to under- as a result of a miscarriage. This small number of papers stand how men from varying cultures are impacted suggests the importance of future research that focuses upon by grief following a pregnancy loss, and how specifically on the health and psychological impacts of they deal with this grief in their specific cultural pregnancy loss for gay and/or transgender men, however contexts. It is also vital to explore pregnancy loss none met the inclusion criteria for this paper with respect from the perspective of non-heterosexual non- to a specific focus on pregnancy loss. cisgender men, as research with these populations is There are no previous systematic reviews which aim to lacking. Approaching men’s experiences of pregnancy describe the nature and characteristics of pregnancy loss as loss from a biopsychosocial perspective may lead to experienced by men with a specific focus on health and a better understanding in health care of how preg- wellbeing. The search strategy only included peer-reviewed nancy loss may impact on men both physically and studies that were written in English, so this may be consid- mentally, which may influence the development of ered as a source of bias and future studies may benefit from improved practices and resources. Due et al. BMC Pregnancy and Childbirth (2017) 17:380 Page 9 of 13

Appendix

Table 6 Studies included from systematic searches Author Research Aims Participants/Setting Method/Design Results/Conclusions 1. Quantitative studies Alderman To study the psychological 19 Caucasian married couples (10 Questionnaires using psychological Men and women’s overall response et al. [23] experience of a miscarriage and to experienced a miscarriage in their instruments: The Grief Experience patterns were different. Men determine if women and their first pregnancy), recruitment Inventory-Loss Version and the Im- reported less grief and stress than partners experience the loss unknown but undertaken in the US pact of Event Scale their partners and men were less differently willing to admit their feelings. Men had elevated results on the Avoidance scale. Armstrong To evaluate the association between 103 couples in their second Structured questionnaires in person Couples with a history of perinatal [31] previous perinatal loss and parents’ trimester (40 had a prior perinatal or over the telephone measured loss had higher depressive levels of depression, anxiety and loss, 33 first time pregnancy, 30 with depressive symptoms (Center for symptoms and pregnancy-specific prenatal attachment a history of successful pregnancies), Epidemiological Studies-Depression anxiety (Fathers reported less prenatal clinics, education classes, Scale), anxiety (Pregnancy Outcome mothers). Perinatal attachment did private medical practices and Questionnaire) and prenatal attach- not differ between groups (Fathers internet message boards in the US ment (Prenatal Attachment had lower levels of prenatal attach- Inventory) ment than mothers). Beutel et To ascertain similarities and 56 couples from Germany (mean Controlled follow-up study at 6 and Men were found to grieve less al. [24] differences in couples’ grief and age of men was 33), experienced a 12 months after a miscarriage using intensely and less enduringly then depressive reactions following a spontaneous abortion between 6 standardised questionnaires measur- women, the manner in which grief miscarriage and 16 weeks (M = 10), 48% had ing depression (von Zerssen Depres- is experienced is similar however other children, 18% of women had sion Scale), physical complaints (The men cry less and feel less need to previous miscarriages Complaint List), anxiety (State-Trait talk about it, men feel burdened by Anxiety Inventory) and grief (Munich their partners grief, conflicting Grief Scale) reactions affect couple interactions Cumming To examine the emotional burden Complete data from 133 men and Prospective study with follow up at Anxiety was a higher overall clinical et al. [7] of miscarriage for women and their 273 women from three Scottish Early 6 and 13 months after miscarriage, burden than depression and men partners, measuring anxiety and Pregnancy Assessment Units the hospital anxiety and depression reported lower levels of anxiety and depression over 13 months scale (HADS) was the main outcome depression than women, a greater measure level of adjustment over time was reported by women Daly et al. To determine the psychological 25 men whose female partners had Structured interviews including the 50% of males had evidence of [36] morbidity among the male partners miscarried within the previous Hospital Anxiety and Depression significant psychological morbidity of women who had miscarried 6 weeks. Recruited from a Scale which measures anxiety and following miscarriage, only 32% of miscarriage clinic in Dublin, Ireland depressive symptoms men were able to find support for where they were attending with themselves their partners Franche & To compare emotional adjustment 28 men whose female partners have Quantitative cross sectional design, Women scored higher on Mikail [30] of men and women with and experienced pregnancy loss and using measures of depression (Beck depression measures than did their without pregnancy loss (in context were not pregnancy gain. Recruited Depression Inventory) and anxiety male partners. of current pregnancy). Comparisons from hospital and physicians in (State-Trait Anxiety Inventory). included between men and women Canada. in response to pregnancy loss. Johnson & To examine if men’s coping 332 expectant fathers (68 Longitudinal design: Measures of All psychological outcomes Baker [33] response during pregnancy, pregnancies ended due to stress (Impact of Event Scale), increased at childbirth/miscarriage childbirth and or miscarriage predict miscarriage between 6 and anxiety (State-Trait Anxiety compared with pregnancy, then psychological outcomes at the time 24 weeks gestation and 100 couples Inventory), depression (Beck decreased at 1 year. Approach- of childbirth/miscarriage or 1 year had suffered a miscarriage Depression Inventory) and coping oriented strategies e.g. problem solv- later and establish any changes in previously). Unclear of recruitment (Coping Response Inventory) during ing and support seeking are used coping repertoire processes or setting pregnancy, following childbirth or less following a negative pregnancy miscarriage and 1 year later outcome, higher avoidance coping following miscarriage Kagami et To examine the effects of recurrent 76 couples in Japan who visited the Self-administered questionnaires Men showed significantly lower al. [25] pregnancy loss on the psychological outpatient clinic of a tertiary hospital assessing recurrent pregnancy loss levels of depression, anxiety and adjustment and psychosocial stress (Keio University Hospital) associated stress, quality of the stress compared with women, on couples marital relationship (Quality Marital depressed and anxious women Index), depression (Beck Depression more likely to be unsatisfied with Index) and anxiety (State-Trait partner’s support, men reluctant to Anxiety Inventory) exhibit their negative feelings, men showed increased active-avoidance coping (e.g., returning to work) Kong et al. To explore men’s psychological 83 couples who had been admitted Prospective 1 year longitudinal A large amount of men scored high [26] reaction following their female to a university-affiliated tertiary refer- observational study: psychological in the GHQ-12 and 16.9% scored partner’s miscarriage and investigate ral hospital in Hong Kong with a reactions assessed immediately and high in the BDI immediately after similarities and differences miscarriage over a 1 year recruitment at 3, 6 and 12 months after miscarriage (associated with a period miscarriage using the 12 item planned pregnancy) but this strongly General Health Questionnaire decreased in the first 3 months and (GHQ-12) and the Beck Depression then plateaued, men scored significantly lower than women 1 year Due et al. BMC Pregnancy and Childbirth (2017) 17:380 Page 10 of 13

Table 6 Studies included from systematic searches (Continued) Author Research Aims Participants/Setting Method/Design Results/Conclusions Inventory (BDI). Questionnaires were after miscarriage, psychological im- completed independently pact was less enduring for men Lin & To explore the patterns of grief 138 women and 56 of their male Longitudinal: three waves of the Large variety of grief patterns found, Lasker [27] reaction following a pregnancy loss partners in Pennsylvania, USA who Perinatal Grief Scale over the course which were more complicated than to see if patterns were different than had experienced a pregnancy loss, of 2 years (2 months, 1 year and 2 had previously been described in those commonly noted in the recruited from a non-hospital based years after the loss) the literature, men experienced literature midwifery centre, ob/gyn private lower levels of grief after pregnancy practices, four hospital ob/gyn loss than women, women show clinics, a city health bureau and a so- greater distress than men shortly cial service agency after the loss but there is no change in adjustment after 1 year between men and women McGreal et To examine whether male and 17 males and 35 females who had Self-administered questionnaire Results suggested gender al. [34] female partners had different coping approached the Bonnie Babes about coping behaviours (The differences in coping strategies; the behaviours following perinatal death Association in Australia for assistance Coping Scale for Adults). This was highest coping strategies for men in coping with the stress of completed individually and in were work hard, problem solve, use pregnancy loss. Time since the confidence. friendships, indulge in wishful pregnancy loss varied from less than thinking, worry, focus on the 12 months to 5 years positive, tension reduction and keep to oneself; the lowest were spiritual support, social action and physical recreation Puddifoot To measure characteristics of male 323 male partners of women who Self-administered Perinatal Grief Men scored similar to female & Johnson response following their partner’s miscarried within 8 weeks of the Scale cohorts on the grief scale, [35] miscarriage study. Recruited from north-east characteristic differences in the way England and the Midlands. grief was handled e.g. less immediate active grief, duration of the pregnancy and seeing the ultrasound increased levels of grief Serrano & To describe the consequences of 30 couples with at least 3 recurrent Self-administered questionnaires Men grieve less intensely, Lima [29] recurrent pregnancy loss on couples’ miscarriages and no living children, assessing psychological and relationships were not usually relationships and explore gender time interval between pregnancy relational impact (Impact of Events adversely affected by miscarriage differences in attitudes and grief loss and data collection was at least Scale and Perinatal Grief Scale) and but couples described sexual intensity 3 months, most had losses prior to measuring the quality of the changes with grief being related to 13 weeks gestation, 2 couples were couple’s relationship (Intimate the quality of their sex life for men Black, 28 couples were Caucasian Relationship Scale and Partnership and quality of communication for and all were recruited at the Questionnaire). Members of each women Recurrent Miscarriage Clinic in couple answered the questionnaires Lisbon, Portugal. separately Turton et To assess the psychological 38 pregnant couples whose previous Psychological assessments Fathers in the index group al. [32] morbidity of fathers in a pregnancy pregnancy had ended in stillbirth antenatally and at 6 weeks, experienced significant levels of subsequent to a stillbirth, test and 38 pair matched controls, 6 months and 1 year postnatally: anxiety and PTSD antenatally but all within-couple effects and identify antenatal clinics in 3 general antenatal questionnaire about symptoms subsided postnatally. risk factors hospitals in the UK medical history, socio-economic sta- Fathers experienced greater anxiety tus and stillbirth; Beck Depression In- when a subsequent pregnancy ventory; Spielberger State-Trait following stillbirth was delayed. Inventory (anxiety measure); PTSD-I Fathers may be vulnerable to Interview; and Golombok Rust Inven- psychological distress during a tory of Marital Satisfaction pregnancy following a stillbirth Vance et To examine patterns of anxiety, 138 bereaved and 156 non-bereaved Prospective study: Couples Both partners were rarely distressed al. [38] depression and alcohol use in couples. Bereaved couples were re- completed standardised interviews in either group, father only distress couples following stillbirth, neonatal ferred by seven obstetric hospitals in at 2, 8, 15 and 30 months post-loss ranged from 7% to 15% peaking at death or sudden infant death south-east Queensland, Australia and that measured self-reported distress 30 months, distress more common syndrome they were matched with non- (Delusions Symptoms State Inven- feature in bereaved couples, fathers bereaved couples recruited through tory to measure anxiety and depres- less likely to be distressed, 7%–12.3% the same hospitals sion, questions about frequency and of bereaved fathers met the criterion quantity of alcohol consumption to for heavy alcohol usage compared measure alcohol use and seven to 4.7%–5.8% for non-bereaved items from the satisfaction subscale fathers of the Spanier Dyadic Adjustment Scale to measure marital satisfaction) Zeanah et To investigate factors that may 82 mothers and 47 of their male Assessments conducted by Fathers had lower levels of grief al. [28] influence mothers’ and fathers’ partners who had experienced a researchers in the family’s home: Ego than mothers in 75% of the sample adaptation following perinatal loss perinatal loss 2 months previously Strength Scale (parental personality), population; fathers with less ego and the differences between them and were between 20 and 44 weeks Nethelp, Dyadic Adjustment Scale, strength, less social support and gestation, recruited from a single Life Experiences Survey (parental more stressful live events had higher tertiary referral hospital in New social characteristics), Beck levels of grief; personality England, USA. Depression Inventory, Grief characteristics were the strongest Experience Inventory-perinatal, Peri- predictors of grief intensity natal Grief Scale (grief and affective symptoms). Members of each couple answered the questionnaires separately Due et al. BMC Pregnancy and Childbirth (2017) 17:380 Page 11 of 13

Table 6 Studies included from systematic searches (Continued) Author Research Aims Participants/Setting Method/Design Results/Conclusions 2. Qualitative studies Abboud & To examine the means by which Six women and their partners from Phenomenological approach using All men mentioned their role was to Liamputtong women and their partners cope with ethnic backgrounds (Middle-East and thematic analysis: 40–90 min in- support, coped by trying not to [39] a miscarriage Philippines) living in Melbourne, depth interviews in participant’s make it a big issue and returning to Australia. All Christian, recruited via homes, both members of each ‘normal’, men described family snowballing and one couple from a couple interviewed separately members as assisting partners but GP referral not themselves, most men did not believe talking to others would help so they did not Abboud & To examine the experiences and Six women and their partners from Phenomenological approach using Men experienced less intense Liamputtong perceptions of women and their ethnic backgrounds (Middle-East and thematic analysis: Unstructured in- feelings for a shorter period of time [40] partners who have suffered a Philippines) living in Melbourne, depth interviews in participant’s than women, men stated that their miscarriage Australia. All Christian, recruited via homes, both members of each role was to support and encourage snowballing and one couple from a couple interviewed separately and they had to consider their GP referral partner first, most men stated they were happy and no longer though about the miscarriage Armstrong To explore fathers’ experiences of Four men whose wives were Phenomenological: 45–90 min All fathers expressed anxiety and a [41] pregnancy after a prior perinatal loss currently pregnant following a unstructured and semi-structured in- heightened sense of risk about the previous loss in the second or third depth interviews (initial interview outcome of the subsequent trimester, recruited through about the loss and experience of pregnancy. Themes included: healthcare providers at medical current pregnancy and second inter- intensity of the experience, dealing practices in two US cities view 3–4 weeks later for ongoing with grief, supporting their partner, analysis replacement of the loss and importance of milestones Bonnette To explore men’s experiences of 12 men who were recruited over a Qualitative in-depth 45 min to 2.5 h Identify as fathers in complex ways, & Broom [42] stillbirth and how they experienced 6 month period by purposive and interviews expressing grief in the context of fathering and grief snowball sampling via posters on the ‘male role’ is problematic, community noticeboards, libraries, fathering and grief are situated in a community centres, pharmacies and gendered dynamic shops throughout regional New South Wales, Australia. Hamama- To examine the meaning of Five couples: 3 Haredi Interpretive narrative study: 2 h Both experienced spontaneous Raz [46] abortion amongst religious Jewish (ultraorthodox) and 2 Dati-Leumi semi-structured interviews by a fe- abortion as some kind of loss but couples and how this meaning is (national-religious representing the male Hebrew social worker in their expressed it differently (men saw is expressed Zionist movement), had experienced homes, both members of each as a loss of potential), themes a spontaneous abortion between couple interviewed separately emerged: meaning of relationship the 10th and 18th week of preg- with the foetus; doubts about nancy after a previous successful parenthood; and crisis in faith. pregnancy, recruited in Israel via snowballing Khan et al. To assess the emotional response of Nine Caucasian men attending a Close and open-ended questionnaire Men expressed feelings typical of [47] males whose female partners had specialised Early Pregnancy Loss grief and bereavement process such suffered early pregnancy loss and Clinic with their partners at Rotunda as sadness and uncertainty. establish if sufficient support services Hospital in Dublin, Ireland. Acceptance and depression were are provided (provide Pregnancy loss occurred before reported later. Pregnancy loss may recommendations if necessary) 20 weeks gestation and the represent a failure for men questionnaires were completed while in the waiting room 6– 8 weeks following the pregnancy loss McCreight To describe the experiences of men 14 men who attended pregnancy Observation and in-depth semi- Themes uncovered: self-blame, loss [43] whose partner had experienced loss self-help groups in Northern structured interviews of a narrative of identity, need to be appear pregnancy loss Ireland (range of gestational stage nature (observation took place once strong, grief and anger. The percep- when pregnancy loss occurred was a month over 3 years and interviews tion of men as having the support- 7 weeks to 40 weeks and period with 14 volunteers took place over ive role is unjustified, lack of legal since the loss ranged from 3 months those 3 years also). Most interviews recognition and institutional valid- to 20 years). Also 32 midwives and took place in their homes. ation posed problems for their nurses to examine attitudes towards identity bereaved fathers Murphy To describe the experience of early Five men whose partners miscarried Phenomenological approach: 30– Themes emerged: feelings, loss, [45] miscarriage from a male perspective early more than 2 years prior to the 60 min unstructured interviews differences between men and interview. Snowballing used to find women, staff action and attitudes, participants located in the UK. what to do, coping and time. Predominant feelings were frustration, helplessness and loneliness. Avoidance/ignoring was a common coping strategy O’Leary & To present information about 10 fathers who had experienced a Descriptive phenomenology: 60– Four themes emerged: recognition- Thorwick [10] fathers’ perspectives during the loss within the prior year and were 90 min one-on-one interviews in fathers need to be recognized by with the same partner in a others, pre-occupation-conduct of Due et al. BMC Pregnancy and Childbirth (2017) 17:380 Page 12 of 13

Table 6 Studies included from systematic searches (Continued) Author Research Aims Participants/Setting Method/Design Results/Conclusions experience of a pregnancy following subsequent pregnancy, obtained venues chosen by the fathers (i.e. their daily lives in disrupted, a prior perinatal loss through friends of parents who had home or clinic) stoicism-unable to share fear and been involved in a pregnancy loss anxiety as they want to protect their support group; notice in a partners, and support-societal pres- bereavement newsletter; and staff at sure to be strong. a perinatal centre To describe how fathers experienced 11 men whose offspring died Phenomenological approach: 25 min Strong feelings of frustration and Samuelsson losing a child as a result of between weeks 29 and 42 of to 2 h interviews mostly in their helplessness, found meaning and et al. [44] intrauterine death pregnancy. Recruited in Sweden and homes and some in a hospital relief in supporting their partner, the interviewed 5 to 27 months after the most important comfort was a good loss relationship with their partner, important to be able to grieve in their own way 3. Mixed methods studies Conway & To investigate the grief responses of 39 women and 32 of their male Prospective study: Self-administered On the initial questionnaire, men Russell [16] women and their partners following partners who had experienced a initial questionnaire including the scored significantly higher on the a miscarriage and discover if support pregnancy loss between 5 and Perinatal Grief Scale which was com- Perinatal Grief Scale than women, received met their needs 16 weeks gestation. Recruitment was pleted within 3 weeks of the miscar- they were also higher on the follow- from four major obstetrics hospitals riage to minimise retrospectivity up questionnaire but not signifi- and one district hospital in Sydney, (80% of the questions were closed cantly, high attrition rate between Australia (an accurate participation questions), follow-up self- initial and follow-up, the greatest dif- rate was only obtained from one administered questionnaire including ference was on the active-grief sub- hospital), 11 GPs also approached the Perinatal Grief Scale 2–4 months scale (men tend to suppress patients after a miscarriage after the miscarriage (48% of the outward signs of grief) questions were open-ended) DeFrain et To examine the emotional, social 21 fathers and 272 mothers who A 23 page questionnaire was Many fathers and mothers reported al. [17] and physical effects of miscarriage had experienced a miscarriage developed after 20 pilot interviews flashbacks and nightmares, they on family members and suggest between 1 month and 42 years prior were conducted (63% of the turned to each other for support, implications for health professionals to completing the study (M = questions were quantitative, 37% themes included: guilt and blame; 5.4 years), recruited through 30 were qualitative) reactions to crisis and pain; newspapers in the U.S. (people in 32 perceptions of others minimizing states participated) the miscarriage; and returning to normal Johnson & To examine the psychological 126 men in Britain whose partners Opportunity sample survey High levels of grief were found that Puddifoot impact on the male partners of had suffered a spontaneous abortion supplemented by 10 semi-structured were felt strongly in the short term [18] women who have miscarried prior to the start of the 25th week of interviews with volunteers from the which affected their daily lives and pregnancy. Recruited via referrals sample (42 volunteered). Two stand- relationship, the duration of the from gynaecological wards of ard scales were used: the Perinatal pregnancy and experience of general hospitals in the north-east of Grief Scale and the Impact of Events ultrasound images were associated England Scale. Participants completed the with higher levels of grief and stress, questionnaires in their own time scores on the avoidance subscale were considerably high.

Abbreviations Ethics approval and consent to participate EU: European Union; JBI: Joanna Briggs Institute; PRISMA: Preferred Reporting Not applicable Items for Systematic Reviews and Meta-Analyses; SCIE: Social Care Institute for Excellence; UK: United Kingdom; US: United States Consent for publication Not applicable Acknowledgements Not applicable Competing interests The authors declare that they have no competing interests. Funding 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 Publisher sNote fees. The third author was funded by an Australian Research Council Future Springer Nature remains neutral with regard to jurisdictional claims in Fellowship, FT130100087. published maps and institutional affiliations.

Author details Availability of data and materials 1School of Psychology, The University of Adelaide, Adelaide, South Australia Data included in the systematic review are listed in Appendix. 5005, Australia. 2School of Social and Policy Studies, Flinders University, GPO Box 2100, Adelaide, South Australia 5001, Australia. Authors’ contributions DR and CD identified the topic and conducted initial literature searches. SC Received: 23 September 2016 Accepted: 3 November 2017 undertook the systematic review and drafted the paper. CD reviewed a subset of abstracts (10%) and all full texts identified by SC. CD and DR confirmed the systematic review findings, and edited the draft. DR prepared References the manuscript for journal submission. All authors read and approved the 1. Rinehart MS, Kiselica MS. Helping men with the trauma of miscarriage. final manuscript. Psychother Theor Res. 2010;47:288–95. Due et al. BMC Pregnancy and Childbirth (2017) 17:380 Page 13 of 13

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