The experience of men following stillbirth: the case of Israeli bereaved fathers

ABSTRACT

Purpose

This paper explores the impact of stillbirth among men in Israeli society, which is marked by strong pronatalist norms. It sought to evaluate the impact of perceived social expectations and interactions with family, friends, and healthcare providers on the experience of problematic levels of grief among men experiencing stillbirth.

Methods

Thirty men after stillbirth were interviewed using semi-structured interviews and transcripts, which were analysed using the phenomenological approach.

Results

Four core themes were identified. The first theme exposes the discrepancy between men’s pain on the one hand and the lack of awareness towards them on the other. The second theme found that not only is the attention of others directed almost exclusively towards their partners, men are expected to take on complex and demanding roles related to the loss. The lack of recognition, coupled with the need to perform the roles imposed upon them, seems to cause men to suppress their grief. The third theme was the lack of support from their parents, underlining their need for empathy and recognition in this family-oriented society. The fourth theme focused on the need for an emotional space of their own, in which they could be seen and listened to.

Conclusion

The findings demonstrate that many most interviewees (25 out of 30) focused on their spouse’s grief and recovery, diminishing their own remorse while receiving little recognition and support. Our findings may contribute to the overarching understanding of this particular kind of loss, and promote the creation of specially targeted interventions.

KEYWORDS:

• Men after stillbirth
• disenfranchised grief
• loss of a child
• trauma
• fathers

Introduction

Stillbirth, defined as foetal death at or after twenty weeks of pregnancy, is a taxing emotional experience that evokes feelings of grief and reactions consistent with posttraumatic stress in parents (Horesh et al., 2018). Stillbirth is an extremely unsettling experience in which death precedes the beginning of life. This experience turns what should have been a joyous event into a tragedy, and the anticipated feelings of happiness are suddenly replaced by severe loss and pain (Gensch & Midland, 2000; Harrigan et al., 1993; Knuppel & Drukker, 1987).

A growing body of research shows that pregnancy loss and stillbirth are associated with high levels of psychological distress (Westby et al., 2021). In one out of five parents, grief and psychological distress may become prolonged and last for months and even years (Cacciatore, 2013; Flenady et al., 2014; Koopmans et al., 2013; S. Murphy et al., 2014). Until recent years, the experience of men after the birth of their stillborn child has drawn scant research interest, and was almost absent from the social and professional discourse, thus maintaining a disregard for men’s experience of loss that may lead to disenfranchised grief (Doka, 1989).

Earlier studies have treated men who experienced the loss of a stillborn child as part of a couple, or have otherwise compared them to a control group of couples who delivered healthy babies (Menke & McClead, 1990; J. C. Vance et al., 1995), but rarely focused on men’s experience and feelings. Most (Conway & Russell, 2000) studies on couples after stillbirth reported a greater level of distress among women compared to men, who showed a tendency towards a faster recovery (Abboud & Liamputtong, 2003; Kong et al., 2010; S. Murphy et al., 2014; Rinehart & Kiselica, 2010). However, in recent years it has become evident that such comparative methods may not accurately assess the depth and complexities of men’s grief after stillbirth. Therefore, it has been suggested that men score lower on ‘active’ grief than women – not because they feel less, but because men are less likely to externalise their emotions and tend to suppress outward signs of grief (Armstrong, 2001; Avelin et al., 2013; Bonnette et al., 2011; Miron & Chapman, 1994; F. A. Murphy, 1998; Puddifoot & Johnson, 1997). It has also been shown that men are inclined to rely on avoidant-oriented coping strategies, including returning to work (Armstrong, 2001; Johnson & Baker, 2004) and increased substance use (Turton et al., 2006; J. Vance et al., 2002). In addition, due to normative gender expectations, disenfranchised grief may have a greater effect on men, as they are expected to take on the role of ‘supporter’ for their female partner and families (Basile & Thorsteinsson, 2015; McCreight, 2004).

A relatively small body of research has suggested that men often feel marginalised by healthcare professionals, family or friends (Bonnette et al., 2011; McCreight, 2004; F. A. Murphy & Hunt, 1997; Puddifoot & Johnson, 1997). A frequent lack of social recognition of men bereaved after pregnancy loss may also lead them to perceive limited options for adequate support tailored to cope with their grief (McCreight, 2004; Puddifoot & Johnson, 1997; Samuelsson et al., 2001).

The knowledge accumulated thus far suggests different reasons as to why men’s grief following stillbirth is ‘disenfranchised’. The consequences of a stillbirth are particularly salient and pronounced among men, as their relationship with the child is usually recognised only after the baby’s birth, and because some men’s manner and timing in relation to mourning deviate from the accepted norms (Bonnette et al., 2011). However, some of the reasons for men’s grief being ignored can relate to specific social norms, policies, and regulations. In this context, there are a number of specific reasons why, in Israel, men’s grief remains largely unacknowledged. First, according to Jewish tradition stillbirth is often not considered a death; therefore, the stillborn baby is not considered a living entity. As a result, no mourning customs or official burial customs are practiced. Thus, mothers and fathers who experience stillbirth may be in a confused state, as their own individual sorrow is not mediated through ritualised mourning customs because there are no formal (e.g. religious or medical) practices for working through the stillbirth-related grief (Neuman et al., 2006).

Another characteristic of Israeli society is related to the issue of birth encouragement. With an average of 3.0 children per woman, Israel ranks first among the developed countries in fertility rate (OECD, 2023). This reflects the strong pronatalist norms and the value of parenthood present in Israeli society, including all educational, socio-economic and religiosity levels (Weinreb et al., 2018). Being a ‘child-oriented’ society, Israeli couples are expected to raise children. Childless people are often perceived as having an ‘empty life’ (Lavee & Katz, 2003). Therefore, stillbirth – with an occurrence of 6.7 per 1,000 live births (Israel Central Bureau of Statistics, 2022) – may have particularly high emotional consequences for Israeli families. Israeli couples are also unique in their attitudes towards gender roles, ranging from the most egalitarian to the traditional. Although educational and occupational opportunities are largely equal for Israeli men and women, heterosexual couples still allocate their active time in accordance with traditional gender responsibilities (Lavee & Katz, 2003).

Women in Israel, along with men, are obliged to do compulsory military service at the age of 18, which is often presented as a symbol of gender equality (Azmon & Izraeli, 1993). However, in practice, the majority of women still occupy clerical and administrative positions in the military, while men are likely to serve in combat units. In fact, serving in a combat unit is still a central role model for men in Israeli-Jewish society (Gilbar et al., 2019; Lomsky-Feder & Rapoport, 2000; Sasson-Levy, 2008). This model is deeply rooted in Israeli society and culture, and strongly reflects the civic model of masculinity (Noy, 2007). Since its establishment in 1948, Israel has been involved in nine wars and numerous other kinds of attacks and reprisals as part of the long Arab – Israeli conflict. The traumatic discourse produces and reproduces social ranking of groups according to how they have suffered and been traumatised and consequently hierarchy of their legitimacy for voicing pain and distress. In this manner, non-combat ‘daily’ traumas among young men such as experiencing stillbirth, are marginalised (Lomsky-Feder & Rapoport, 2000).

Israel is a nation influenced by Western culture, which co-exists side-by-side with Orthodox religious values and practices (Lavee & Katz, 2003). In Judaism, men are commanded to ‘be fruitful and multiply’. This is, in fact, the first commandment mentioned in the Bible (Genesis 1:28). However, Jewish law does not recognise the dead foetus as an object deserving of mourning rituals (Hamama-Raz et al., 2014). This lack of religious legitimacy for bereavement experienced in the Jewish Orthodox religious culture may also contribute to disenfranchised grief among Israeli men following stillbirth.

Nonetheless, to the best of our knowledge, no studies to date have focused on Israeli men’s experiences after pregnancy loss. Therefore, the present study aimed to map Israeli men’s experiences after stillbirth, and the attitudes and interactions with their parents and family, friends, work colleagues, and healthcare providers towards their loss and distress. We also sought to evaluate the impact of perceived social expectations on levels of bereavement and voicing pain among men experiencing stillbirth.

Methods

Recruitment and participants

This study, which focused exclusively on men’s perspective of experiencing the loss of a stillborn child, was based on the phenomenological approach. This approach encourages the use of mapping to understand phenomena as perceived and presented by those who experience them. In order to allow as wide and diverse a range of interviewees as possible, the study employed criterion sampling, consisting of only two criteria: Hebrew-speaking men who experienced the loss of a stillborn child.

Semi-structured interviews were conducted among 30 men whose female partners had experienced a pregnancy loss. The interviewees included men from all over the country between the ages of 29 and 55 (M = 39.97, SD = 5.82 years). The study participants’ characteristics are presented in Table 1. The time elapsed since the loss of the child and the interview ranged between three weeks and 22 years.

Table 1. Study participants’ characteristics.

Variable	N	%
Gender (men)	30	100%
Age, years (M, SD)	39.97	5.82
Marital Status
Married	29
Divorced	1
Pregnancy Week of Loss, Range (SD)	22–40	6
Time from loss
<1 year	7	23%
1–2 years	7	23%
2–5 years	8	27%
5+ years	8	27%
Level of religiosity
Orthodox	2	7%
Religious	4	13%
Secular	24	80%
Type of Stillbirth
Natural	16	53%
Feticide	14	47%
Number of children at the time of the interview
0	4	13%
1–2 children	15	50%
3–5 children	11	37%
Number of pregnancies
First	14	47%
Other	16	53%

Procedure

The study was approved by the Bar-Ilan University School of Social Work Institutional Ethics Committee on 3/2017 (#031707). Participants were recruited via advertising on social networks (Facebook interest group) and provided an informed consent to participate in the study.

Individual interviews – lasting between one to three hours – took a semi-structured approach. Face-to-face interviews were conducted in Hebrew and were based on an interview protocol, but also allowed for free-flowing and in-depth conversation about the experience of loss following the stillbirth, from the interviewee’s point of view. All interviews were conducted by the first author. Questions were developed based on previous studies in the research area (Basile & Thorsteinsson, 2015; Bonnette et al., 2011; Due et al., 2018; McCreight, 2004; Rinehart & Kiselica, 2010). Examples include: ‘Could you share something about your experience(s) regarding the pregnancy loss from your perspective? You may begin from any point in time’ and ‘Can you please tell me about coping with your partner after experiencing stillbirth, with family, friends, and colleagues at work?’. Interviews were audio-recorded with participants’ permission. Field notes were transcribed verbatim immediately after each interview by the first author. Each participant was given a pseudonym in order to maintain privacy. Participants were allowed the opportunity to read their transcripts upon request. Among those participants who did so, no changes were requested.

Data analysis

We used a deductive approach to examine the interview transcripts in relation to participants’ self-reported experiences of grief and perspectives of interpersonal relationships with family, friends and other social circles. Additionally, the inductive approach was used to allow for any unexpected themes to develop during the process. An ongoing thematic analysis was performed using Narralizer software (http://www.narralizer.com). Analysed themes were then discussed and refined over several iterations with the second author to construct a final, full thematic structure.

The quality of the research was ensured in several ways by: openly and explicitly reporting on all phases of the research (transparency), setting aside prior knowledge and biases of the researcher (bracketing), and continuously referring to the researcher’s epistemological position as a woman questioning men about a phenomenon that is still widely regarded as ‘feminine’. In addition, both the research in general and the analysis of the interviews in particular, were accompanied by self-observation, which included an examination of the researcher’s attitudes and sensibilities, and by ongoing and in-depth professional dialogues with the second author.

Results

Over the course of five months, 30 interviews were conducted with 30 participants. One of the preliminary observations that emerged, prior even to the analysis of the interviews, was the men’s rapid and eager response to the invitation to be interviewed. Within 48 hours of posting the invitation to take part in the study on social media, 30 men had already applied. They shared their experience from their point of view. Most of them (18 out of 30) said they were sharing their full story for the first time. These reactions, which were surprising and touching, revealed the sense of loneliness that accompanies the loss experienced by men after a child’s stillbirth.

Four major themes were identified across all 30 interviews.

Men’s emotional distress and perceived hierarchy of loss

The first theme exposes the discrepancy between men’s reports of a difficult, painful and even life-changing event on one hand, and the little or, in some cases, complete absence of awareness regarding their loss, grief and emotional vulnerability on the other.

All study participants used the term ‘trauma’ to describe their loss and ‘being post traumatic’ to capture the magnitude of their experience and the intensity of their reactions. They often faced with an array of difficulties and challenges in their daily lives. Symptoms included flashbacks to the moments of the loss. Triggers for symptoms were mentioned in 20 interviews. They were often related to encounters with pregnant women, parenthood (e.g. seeing a father pushing a stroller), encounters with children at the same age their lost child would have been, as well as emotional events around the loss anniversary.

The vast majority of the interviewees (25 out of 30) used the word ‘child’ as the object of the loss. The use of this emotionally-charged term may illustrate their need to project a certain meaning onto the lost figure, and underscores its contrast to the lack of recognition with which their grief was met.

Another indication of a strong emotional attachment to the unborn baby was evident by the use of the words ‘son’ (Oded) or ‘daughter’(David). Similarly, some participants referred to themselves as ‘bereaved fathers’. ‘I lost a child, too’, ‘This was my daughter who was born, I held her[…] My daughter is dead’ (David); ‘I buried my son with my own hands. He’s mine. He’s a part of me … It was a real child. A very small one, but a baby”. (Yuval)

In contrast with their deep attachment towards the soon-to-be born child, men often reported being treated in a manner that devalued their grief and loss – first by the medical personnel (24 out of 30) and later by their family and friends (23 out of 30). The sense of disenfranchised grief appeared early after the loss. Interviewees encountered this lack of awareness soon after arriving at the hospital. In ‘When we arrived at the hospital … ’ said Eli ‘ I remember that feeling. No one turned to me or asked me anything – as if I didn’t exist. In 13 out of 30 interviews, the men testified to feeling a sense of exclusion from the hospital staff. ‘I called the social worker to speak with us; I felt we needed her help to adjust. She came, and we started walking towards the room [where my wife was, and she left me standing out in the hospital hallway. Of all the things we’d been through, this was the most annoying, upsetting and humiliating experience. I felt left out, isolated and irrelevant’. (Menahem)

The majority of the study participants (25 out of 30) expressed awareness and empathy towards their partner’s difficult and complex experience, which was often recognised as being more profound than their own. Nonetheless, while this hierarchy in the level of emotional distress allowed them to recognise the relativity of the loss, others’ complete lack of awareness regarding their grief was disheartening, to say the least. ‘It was obvious that her (their partner) experience was much worse than mine … She had undergone something. She’d had to kill what was in her womb’. (Arnon) ‘My wife really did experience a greater trauma than I had, because for her it was also physical. It wasn’t only the delivery itself … her trauma was bigger’. (Or) ‘I didn’t experience that. I can’t really understand what it means. I didn’t have this kind of bonding – like the bonding between a mother and a baby’ (Avshalom). ‘Mika has gone through something worse. It’s true she went through more, but it’s also true that I’m experiencing the same level of difficulty’. (David)

Men’s role as supporters

Initial hospital support was shown to have a major role in fostering positive emotional outcomes for women experiencing a pregnancy loss (Due et al., 2018). However, the perceived quality and availability of support in the hospital setting in our study was inconsistent. Not only was the attention of the surrounding society directed almost exclusively on the women, men were also explicitly or implicitly expected to take on complex and demanding roles related to the loss as describe by more than 50% of the men that took place in the research (17 out of 30).

Perceived lack of recognition and empathy while at the hospital was predominant in 13 out of 30 men’s narratives. ‘At the hospital, they don’t look at the fathers at all, they see you merely as the patient’s companion’. (Yogev) ‘I remember feeling that very clearly. I wasn’t considered a part of the event, no one asked me anything … no one directly addressed me’. (Eli) Alongside the lack attention of the healthcare staff, men also reported the clear expectation to ‘support’ their female partner and family. Supporter roles are common after having a baby; however, after stillbirth, being a supporter becomes emotionally difficult, and sometimes, even unbearable. “From the minute we got to the hospital, it was very intense. [My wife] was devastated and I struggled to keep her sane, to be there for her. I totally removed myself from the equation and switched into operation mode.

The ‘supporter role’, and the expectation to be strong, was described in 17 of 30 interviews as the most obvious and initial role expected from the surrounding environment – both in the hospital, and then later, among the family. ‘I cry, sit on the floor and cry… and everyone around me tells me I have to cheer her up, [they say I] must be strong for her’. (Zohar) In most cases (23 out of 30), these expectations were accompanied by participants feeling incapable of meeting friends and family members, as they’d had no preparation for such an unexpected and traumatic loss, and no prior knowledge on how to handle a deceased baby and other related arrangements. ‘Everyone said I need to take care of her [my wife], and that in fact she is the one facing a crisis … and I was marginalised. People were taking me aside and saying: “You need to take care of her … and be there for her”. I didn’t know what to do; just like she didn’t know what to do’. (Shai) While some (10 out of 30) men described the supporter role as a burden, others said it provided them with a sense of purpose and self-esteem during the bereavement period.

In addition to the supporter role, study interviewees reported taking on two additional onerous responsibilities. One was being the first to inform the family, work colleagues and friends about the loss (8 out of 30); the second was related to the bureaucratic tasks regarding the funeral, autopsy and other decisions (12 out of 30). None of these decisions and tasks are purely technical. ‘I called my parents and told them about the baby… It was so difficult to explain that the baby had been born dead. It was so hard to say it, and it was the first time these words came out of my mouth. It was painful to hear them cry’. (Ahikam) some fathers (8 out of 30) said they simply texted a short message. ‘It’s over. We will begin everything, all over again’ (Harel). They sent this message, again and again, making small changes in accordance with the recipient…

The third responsibility was dealing with administrative tasks while at the hospital that was mentioned by 12 participants. ‘I was sent to bring the pathology report. Obviously, they didn’t ask the physicians to get it and explain it to us. I opened it up and realised that our daughter had been cut into pieces … that were weighed one by one … do you really give such a document to the parents to read?!’ (Ehud) A trivial task becomes a dreadful experience that could have been easily avoided had the hospital staff been more attentive and sensitive.

The lack of recognition, coupled with the need to perform the roles imposed upon them seem to cause men to inhibit their grief. Consequently, the blatant lack of societal recognition made psychological recovery difficult, with some men (n = 6) airing their grievances only at a much later stage – weeks, months and even years after the loss, often accompanied by intense emotional distress. ‘I went back to work as usual, but a few months later my productivity decreased, I couldn’t help thinking about it, yet no one noticed. I felt I just can’t deal anymore with the growing inner pressure’ (Eli).

Perceived lack of support from parents and family

The third theme that emerged from most of the interviews with even greater frequency was the support, or lack thereof, which the men received from their parents. In sharp contrast to the recognition, compassion and support that other bereaved fathers receive, study men reported being avoided by friends and even family members. They expressed the feeling of being left out, and the utter lack of practical and/or emotional support. Regarding this aspect, they described feelings of loneliness, a deep disappointment, and feeling shattered as a result of their parents’ lack of emotional presence, which in some instances led to the men’s temporary or even prolonged estrangement from them. Only in a few cases was their support noted as ‘adequate’, ‘appropriate’, or ‘sensitive’.

All of the study participants expected to receive support and strength from their parents and family. The perceived significance of family support underlines the men’s need for empathy and recognition of their grief shortly after the loss and during the weeks, months and sometimes years which followed the loss. Conversely, lack of empathy and recognition of the loss had a negative impact on 23 of the study participants. ‘Just after the delivery, my brother texted me. He wrote “this is the time to acknowledge what you have, and to move forward”. The (dead) newborn was still in my arms when he texted me! Why would someone say such a thing?! While I was still holding my dead baby?’. (Oded) At the time of the interview, Oded held his new baby – born a year after the loss, and a few weeks before the interview – on his lap. ‘This is the right order of things,’ he says, looking at his baby, and smiling. A similar experience was reported by another interviewee: ’September 12th is the anniversary of our loss … it is a day that we always remember. It happened three years ago. This date has never held any significance for my family. So much so, that my brother planned a wedding on this date, which created a very big family crisis […] they rescheduled it, but it clearly reflects just how detached they are from what we feel’. (Rotem)

The subject of parental support was also addressed by Oria. He reported that when he and his wife returned home from the hospital, their parents’ support included mostly practical help, which deflected any internal recognition of his grief and distress. ‘The mothers were really helpful … but I was asked to do a lot of practical tasks, like: “go buy this, bring that, give [so-and-so] a ride”. They didn’t give much thought to either my feelings or my experience. My father even said once “forget it, it’s not on you, it’s mostly on the wife”’(Oria). In some cases, 14 out of 30, the level of disappointment resulting from the family’s lack of empathy and emotional support was so high, that it caused irreversible damage to the relationships. ’I used to think that whenever we’d need support, we’d always have our parents…[But] they were unable to understand, there was tension between us. I really wanted my parents to feel like they had lost a grandchild … that the anniversary of the loss would be a day they would remember, but they showed no empathy. Come to visit! Show some recognition of our loss! That’s all we need’. (Rotem)

It was as if the ability to contain their feelings and manage their lives without support from others enabled some (10 out of 30) of the men to maintain an inward sense of manliness. Yet, for others, the lack of social support and acknowledgement of their grief led to worsening grief outcomes. ‘I felt so alone, I had to cope with it alone, with no family or friends, as if I had nobody, as if it were nothing,’ said Ohad in his interview.

In cases where on-going support was given, it was perceived as valuable and fostered a faster recovery and grief resolution process. Even simple emotional support was considered important. ‘Our families texted us and said they were thinking of us and sent their love. It might seem trivial, but it was exactly what we needed at the time’. (Ohad). Perceived lack of support from parents and family was recorded in men across varying time from the loss, and level of religious beliefs.

Finally, given that many men (19 out of 30), reported returning to work early following their loss, support in the workplace should be addressed. In six interviews, the men describe their colleagues as being supportive and helpful, while eleven men felt that nobody at their workplace gave the slightest thought to the loss they had experienced. For those study participants who expected to continue to work as usual, gaps between their expectations and the actual received support made dealing with the loss more difficult, and in some cases even unbearable. Eyal’s return to work is described as a very difficult time. After several months he resigned. ”I couldn’t concentrate at work; it was really a case of disenfranchised grief. Maybe part of it was my fault, I didn’t take enough time out, but … I felt that this was what society expected of me: ‘It’s okay man, you weren’t a part of it, anyway’. Family, colleagues … no one said: ‘Come on, slow down, stop for a second, stay home for another day or two’ … ’. (Eyal)

Men who shared their loss with their co-workers were more likely to report on a supportive response. Amir described how calling his boss and asking him to let the people in his office know about his loss before returning to the office helped him cope. ‘I told him: “You should know that I don’t want it to be a secret, I want people to ask”. He probably told them and explained the situation because many of my colleagues approached me and said they were sorry about what I’d experienced’. (Amir)Sharing the information in advance prior to returning to work was also helpful for David; ’I sent a message to my friend from work and told him to let the others know what had happened, that we’d had a stillbirth, and that for me, I’d lost a daughter. I wanted people to ask how I am or say that they’re sorry. I wanted them to be able to send me a message, and share my grief … All I remember from that time is my workplace and my boss… I will never forget how attentive and thoughtful they were. I remember one of the moments that moved me the most that month when I stayed home with [my wife] … [My boss] called me and said he would pay me a full salary, for the whole month, and that I should be calm and be with my wife as much as we needed. When I talk about it now, it makes me cry more than anything else. It is so simple and moving. That is the workplace and that boss I cherish most – on an emotional and social level’. (Gal)

Perceived lack of recognition from society and healthcare personnel

A total of 28 of the 30 interviewees reported receiving no support or too little support regarding their grief. The need for social recognition, visibility and acceptance were mentioned by all participants. Some of these needs were relatively basic and easy to provide.

After leaving the hospital, men said they often wished to be acknowledged by the healthcare system and referred for counselling, to be acknowledged as being in need, and eligible for support or emotional therapy, as is reflected in the following quote: ‘I wish someone would sit next to me and ask me if I want to talk about it, that’s all’. (Yogev) Some men asked to be approached, even via text messaging. ‘What I really wanted was a hug. I wish I had someone to talk to or to meet or write to’. It was made clear that the interviewees wanted personal recognition and support, and not only to be seen as the partner of the grieving mother. ’I wanted attention. It may sound childish, but I felt that all the attention was given to [my wife][…] I understand that dealing with the fathers is a great effort, but I think it should be an integral part of the process – to give me a call and ask me how I’m doing, and not only how [my wife] is doing. This happened so many times’. (Oded)

The data indicates that in the context of stillbirth, many men need and expect personal attention and recognition of their loss. Almost all of the men attributed precedence to recognition of their pain, agony and lost fatherhood. ‘I needed the recognition. At the cemetery, someone addressed me as “the father”. He said that the decision regarding what to call the baby was mine … and that [recognition] was all I needed’. (Rotem) Men’s undefined fatherhood status was often confusing to them, along with their families and friends. ‘I needed to have a clear understanding of the situation. Should we have a “shiva” or not? My wife had many visitors and I also needed my friends near me. It took me a while to realise that’. (Ohad)

Five participants mentioned that they were contacted personally by hospital staff. In most cases, this was done only to ask about their partners. ’As soon as they started talking to me, it was only to ask about [my wife]’ (Oded). ‘I was nothing. They asked: “How is [your wife] doing, how is she coping? It must be very difficult for her”. In most cases I just ignored them, and answered briefly. But it was the same thing, over and over again … as if I had no part in it, as if I weren’t hurting too, as if nothing had happened to me’. (Rotem) In only two cases, participants did reference positive and personal sympathy from staff members. They expressed this as being meaningful and extremely moving. ‘After the birth, the male midwife came and hugged me, and I felt so grateful. I didn’t feel transparent or like a fly on the wall. I was being noticed’. (Yuval) Study interviewees also mentioned simple needs. At the hospital, and also after coming home or returning to work, they all said they needed people to ask questions, approach them and recognise them as being a part of the loss.

Receiving complete and detailed information for best decision making was mentioned by 13 study participants. ’ If only they [the hospital staff] had told us about the burial and about how important it is to see the baby, and the emotional needs that may develop after such a loss. We didn’t have a clue what might happen if we didn’t bury the baby or say goodbye … we only did it because they explained it to us. This was one of the most important things they told us about, and it made all the difference in the world’. (Yoav)

Discussion

Our study among Israeli men after stillbirth identified several themes. Overall, despite divergent circumstances, personal background and time from the event, we found relatively little variation in participants’ loss experiences. Similar to a previous study of Israeli fathers after foeticide (Leichtentritt & Weinberg-Kurnik, 2016), men’s grief manifestation after the loss of an unborn child is heavily influenced by social constructs, leaving little room for personal variation. One such prevalent construct was that men are expected to take on a ‘supporter’ role for their female partner, which precludes recognition of their own loss from both medical personnel and family. Moreover, many interviewees often reported being asked to carry out two emotionally challenging tasks, while ignoring their bereavement: to inform the family about the loss and arranging the funeral. These implicit and explicit social expectations to inhibit their grief response are consistent with the theory of disenfranchised grief (Doka, 1989).

Such expectations from men might be particularly strong in Israeli society and relate to its unique ideals of masculinity. According to Connell’s relational model (Connell & Messerschmidt, 2005), social perspectives about masculinity are embedded within communal structures with multiple, hierarchical configurations dominated by a leading position of hegemonic masculinity. Thus, the brave, warrior type was reported as the dominant civic model of masculinity in Israeli society (Noy, 2007). This is often explained by the excessive presence of the army within Israeli daily life (Lomsky-Feder & Rapoport, 2000). While these ideals do not necessarily describe the actual ideal of Israeli masculinity, they do represent a model type which Israeli men strive to achieve.

The results gleaned from this study contribute to the overarching understanding that men’s experience of having a stillborn child consists of deep feelings of loss, pain and grief. However, stillbirth is often not considered a death, and mourning rituals are therefore absent (Collins et al., 2014; Lang et al., 2011). This lack tends to become amplified in the Israeli Jewish society, where none of the traditional mourning rituals are relevant in the case of a stillbirth. Van Gennep (1960) described rituals as liminal for allowing the bereaved to cross a threshold from one identity or status to another (Van Gennep, 1960). Rituals provide structure and one such important practice is Shiva (from the Hebrew word for seven) – a seven-day mourning period. It provides an opportunity to contain and express emotion with wide social circles and build up the narrative of the loss. In contrast, men and women after stillbirth have no specific rituals to help them through this difficult period. In Judaism, all of the mourning customs are absent in the case of stillbirth and neonatal death. Unlike men, women have some platforms where they can express themselves or share their loss. Men have fewer options when it comes to addressing the matter. This may explain why many of the study participants (18 out of 30, as described at the results section) mentioned that the study interview was their first opportunity to tell their story from beginning to end.

These men could probably benefit from more professional emotional support, to enable them to share their thoughts and feelings and tell their narratives concerning the loss. In a previous research bereaving men felt unseen by medical and social services, and indicated that they wanted to be approached directly with a special tailored support to meet their special needs (Obst et al., 2020). Similar needs were also expressed in the current study.

Most narratives emphasised the lack of community acknowledgement and understanding regarding men’s grief following pregnancy loss, lack of legitimacy for externalised emotional reactions, and consequent efforts to suppress feelings of grief. Experiences of disenfranchisement included vagueness related to the stillborn baby being perceived as a child, and the man as a father. Lack of tangible mementos further limited empathy from family and friends. In addition, grief-related reactions are further diminished by hurtful and insensitive responses from family and friends.

Results provide important insights into the role of men’s parents and the ways in which they cope with their sons’ experience. Little is known in the literature on parents’ supporting role of their son after pregnancy loss (Laakso & Paunonen-Ilmonen, 2002). Parents can offer a sense of stability, and provide intergenerational acknowledgement of the ongoing relationship with the deceased child (O’Leary et al., 2011).

Men’s experiences of support from their parents varied greatly. Often, parents were the only family members with whom men felt the need to share their grief. For some, open discussions with their parents were an immense comfort. However, in line with previous literature (Rinehart & Kiselica, 2010), many participants reported on a lack of support or even negative interactions with their parents. Findings indicated that grandparents frequently avoided talking about the loss in general, and failed to recognise the stillborn as their own grandchild. As a result, men were left with the feeling that their parents were not emotionally available, due to a lack of understanding and acknowledgement.

Professionals attention for men after stillbirth can therefore benefit from exploring grief characteristics. Guidance may help both parents and grandparents establish intergenerational communication, and to ensure awareness of the emotional pain resulting from a stillborn. This may subsequently prevent a sense of disenfranchised grief in families, and allow others to perceive the deceased baby as a recognised family member.

Perceived lack of social recognition for their loss was reported as a major source of distress among most of the study participants. Instead, due to the normative expectations, Israeli men were expected to take on a supporting role and focus on their spouse’s grief and recovery, rather than their own sense of loss, pain and remorse.

There was a very wide range in the time elapsed since the stillbirth from three weeks to 22 years. Since the emotional effects of experiencing a stillbirth often ease with time, interpretation of interviews taken at one point of time should be done cautiously. Nonetheless, the emotional distress and the perceived lack of support from family was common across varying times from the loss. Similar to previous reports (Christiansen et al., 2013), the psychological needs of father did not tend to cease over time, as feelings of isolation by health-care professionals can persist.

In a meta-analysis (Heyne et al., 2022) of 154 studies on birth-related posttraumatic stress among parents in relation to the traumatic event of childbirth, the pooled prevalence rate of PTSD among fathers (1.2%) was significantly lower compared to mothers (4.7%). Dyregrov (1990) has suggested four reasons for gender differences in reaction to perinatal death: (a) differences in attachment to the lost child, (b) in methods of coping, (c) in social situation following the loss, and (d) lower acknowledgement of feelings among men (Dyregrov, 1990). The lack of recognition, coupled with the need to perform the roles imposed upon them, seem to cause men to suppress their grief uncovered in our study alongside strong feelings of attachment towards the soon-to-be born child. This is corroborated with previous research on men’s prenatal attachment that suggests that men develop a caregiving bond to the unborn child during pregnancy (Johnson & Puddifoot, 1996; McCreight, 2004; Rinehart & Kiselica, 2010). Our results indicate that Dyregrov’s hypothesised reasons are intertwined. Men who display greater attachment to the unborn child may experience a lack acknowledgement and little social support, and therefore bound to cope differently with their grief. The unique interlocking of characteristics associated with unacknowledged grief leaves men isolated in their own pain, without a space in which they can share their experience. This combination of elements further intensifies the experience of loss and has far-reaching implications for the men’s personal, marital, and family lives.

Israeli women are entitled to a 15-week maternity-leave, while men have no official leave of their own. Taking longer time to return to work, the void left by the absence of a baby within a home might be greater for mothers. This exposes women to more reminders, intrusive thoughts (Christiansen et al., 2013) and may also contribute to their greater likelihood of PTSD. Our results indicate that while some men found returning to work to be a helpful distraction, others found it emotionally difficult. In one study, sharing information about the loss with co-workers prior to returning to work led to receiving recognition and understanding, and aided in their return-to-work process (Obst et al., 2021). In line with the present study, those who reported to their workplace in advance perceived the workplace as a pleasant space in which they were seen and recognised. However, those who did not receive such treatment found returning to work very difficult. Six participants even left their workplace after many years of employment. Allowing fathers an option to receive professional support and guidance and to take leave before returning to work may help bereaved men and women better cope with their grief.

There were some limitations in this study. The convenience nature of sampling is open to potential selection bias in that participants may have been unique from other men who chose not to participate. In addition, participants were also recruited through Social Networks related loss in stillbirth and neonatal death support. This recruitment approach could constitute a sampling bias in that men who were not connected to these emotional issues would not have had access to the information to participate. This study relied on retrospective accounts of grief that might be affected by recall bias, especially for the losses which had occurred long time ago. Although we found no substantial differences in grief scores according to time since loss in our sample, changes in individual, community and health system/policy level support over time are likely to shape men’s grief outcomes.

In this study, the complex concept of ‘disenfranchised grief’ experienced by

Israeli men following a child’s stillbirth was systematically explored for the first time by affording them a discursive space. Study results may help raise awareness of the event’s many facets, and of the way these men experience their loss. Ideally, our findings will also promote the creation of specially targeted interventions for men who have experienced this particular kind of loss, and for those surrounding them. Healthcare professionals should recognise the unique grief experiences of fathers and encourage open communication with partners, grandparents and other family members as well as with friends and work colleagues. Specifically, in working with fathers after stillbirth, we recommend that clinicians provide them with guidance about the legitimacy to grieve and to receive social support during bereavement, and to encourage them to spend more time with their partners and to engage in meaningful experiences.

In sum, most participants mentioned a lack of formal support and recognition of their pain, agony and lost fatherhood from hospital personnel and from their parents, family, friends and work colleagues. This was further exacerbated by the absence of normative religious mourning customs in the case of stillbirth.

Disclosure statement

No potential conflict of interest was reported by the author(s).