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Division of Mental Health, St George’s University of London, London, UK
Correspondence: Dr Penelope Turton, Division of Mental Health, St George’s University of London, London SW17 0RE, UK. E-mail: pturton{at}sgul.ac.uk
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...REFERENCES |
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Aims To assess the psychological morbidity of fathers in the pregnancy and post-partum year subsequent to a stillbirth, to test within-couple effects and to identify risk factors.
Method This was a community-based cohort study of 38 pregnant couples whose previous pregnancy had ended in stillbirth, and 38 pair-matched controls. Psychological assessments took place antenatally and at 6 weeks, 6 months and 1year postnatally.
Results Fathers in the index group experienced significant levels of anxiety and post-traumatic stress disorder antenatally, but all of their symptoms remitted postnatally (after the birth of a live baby). Fathers’ symptom levels were lower than those of mothers at all time points. In contrast to mothers, fathers experienced greater anxiety when a subsequent pregnancy (following stillbirth) was delayed.
Conclusions The vulnerability of fathers to psychological distress during the pregnancy after a stillbirth needs to be recognised.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...REFERENCES |
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This paper reports a systematic investigation of the psychological effects of stillbirth on fathers, and aims to address some of the limitations of the existing literature. We have restricted our focus to a specific type of loss, namely stillbirth, to avoid conflation with other pregnancy or child losses. We assessed parents in the pregnancy following a stillbirth, as we had postulated that this would be a reactivating stressor for all parents, irrespective of the time that had elapsed since their loss.
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METHOD |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...REFERENCES |
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Assessments
Antenatal (third-trimester) assessment (current successful pregnancy)
Observer-rated questionnaire in two parts. The first part of the
questionnaire elicited the parents’ socio-economic and medical history
(age, ethnicity, level of education, employment status, income, obstetric
history, history of previous physical and mental illness). The second part
focused on the stillbirth (gestational age, time since the loss, level of
family and partner support, clinical and social management of the
stillbirth).
Assessment of depression. Depression in fathers was assessed with the Beck Depression Inventory (BDI; Beck et al, 1961), using the conventional cut-off score of 10/11 (Metcalfe & Goldman, 1965).
Depression in mothers was assessed by means of the Edinburgh Postnatal Depression Scale (EPDS; Cox et al, 1987), a 10-item self-report scale that was developed and validated to assess postnatal depression, and which is extensively used in the UK. The instrument has now been validated for use during pregnancy (Murray & Cox, 1990), employing a cut-off score of 14/15 for dichotomous analysis because of the high levels of dysphoria that occur in pregnancy.
Assessment of anxiety. The Spielberger State–Trait Inventory (Spielberger et al, 1970) was used. This 40-item questionnaire measures anxiety at the time of testing (state) and general tendency to anxiety (trait).
Assessment of PTSD. The PTSD–I Interview (Watson et al, 1991) was used. This interview shows close correspondence with DSM–III–R (American Psychiatric Association, 1987) standards and correlates strongly with parallel Diagnostic Interview Schedule criteria and with the PTSD subscale of the Minnesota Multiphasic Personality Inventory (MMPI; Keane et al, 1984). The PTSD–I Interview has been shown to have substantial reliability and validity, with very high internal consistency and test–retest reliability. It provides binary present/absent and continuous severity/frequency outputs on each symptom and symptom cluster, and on the entire syndrome.
Assessment of marital satisfaction. The Golombok Rust Inventory of Marital Satisfaction (GRIMS; Rust et al, 1988) was used.
Assessment 6 weeks and 6 months after a recent successful pregnancy
The following instruments were used:
Assessment 12 months after a recent successful pregnancy
The following instruments were used:
Analysis
All analyses were performed using the Statistical Package for the Social
Sciences version 10.0 for Windows and SAS version 8.1 for SunOS. In univariate
analyses the 
2-test or Fisher’s exact test was used to
look for associations between two categorical variables. Independent-samples
t-tests were used to compare the mean scores between two groups, and
Pearson correlations were used to look for an association between two
continuous variables. Paired t-tests were used for the within-couple
analysis.
Mixed models (using PROC MIXED in SAS) were employed to investigate depression and anxiety scores for all assessments, examining whether they differed between the index and control groups (group effects), whether they changed over time (time effects), or whether there was a group x time interaction (where any difference between the groups is not constant over time). This methodology was used so that all of the data collected could be utilised. More standard methods such as repeated-measures analysis of variance would have deleted a participant from the analysis if they had data missing for any assessment. This does not occur in PROC MIXED.
Multivariate analysis of variance (MANOVA) was used to ascertain what factors (all dichotomous) were associated with psychological morbidity (depression, state and trait anxiety and PTSD symptom severity) at the antenatal assessment in the index group of fathers.
Recruitment of the index group
Of 105 mothers who appeared to meet the study criteria on the basis of
screening of case records, 16 mothers were subsequently excluded because we
found that they had started a relationship with a new partner since the
stillbirth. In the case of a further 16 couples the baby was born before they
could be interviewed antenatally, either because the birth occurred a few
weeks early, or because of difficulty in arranging a meeting. We excluded
these couples because important baseline data would be missing. However,
towards the end of the recruitment period, when the difficulty in enrolling
couples who met the study criteria was more fully appreciated, the inclusion
criteria were relaxed and we decided to include data for four couples who
asked to be interviewed only after the safe arrival of their baby. Another 32
couples declined to participate, more often owing to refusal by the father
than by the mother. Three couples proved impossible to contact despite
repeated efforts.
A total of 38 couples (52.1% of the 73 couples who were not excluded) had an initial assessment, of whom 34 were interviewed during pregnancy and 4 had their initial assessment postnatally. In total, 15 stillborn infants (40.5%) had been born in the second trimester (20–27 weeks, mean gestational age 21.8 weeks) and 23 (59.5%) had been born in the third trimester (28–41 weeks, mean gestational age 35.8 weeks). The time lapse between stillbirth and the expected date of delivery ranged from 11 to 44 months (mean=18.8, 18.8, s.d.=8.7). In total, 26 mothers (68.4%) conceived within 1 year of a stillbirth.
Subsequent to the initial assessment, 1 couple was excluded because the mother had another stillbirth, 2 couples dropped out and attributed this to major marital difficulties, 2 couples moved abroad and 1 couple dropped out without giving a reason. We here report the 6-week follow-up data for 35 couples, the 6-month follow-up data for 33 couples and the 1-year follow-up data for 32 couples.
Recruitment of the control group
In total, 110 couples were matched from antenatal records to the index
group. Of these, 51 couples (46.4%) consented to participate in the study but,
as with the index group, some couples (13 in total) had their baby before they
could be interviewed antenatally, and were therefore excluded. A total of 38
couples (39.2% of the 97 couples who were not excluded) entered the study, 43
couples declined to take part and 16 couples proved impossible to contact
despite repeated efforts. Again it was nearly always the fathers who refused
to take part in the study or were impossible to contact.
Subsequent to the antenatal assessment, one couple dropped out before the 6-month assessment without giving a reason. At the 6-week assessment data were not available for one family because the baby was ill and the family did not want a visit, and at the 6-month assessment data were unavailable for another family who refused a visit because they were moving house. We here report the 6-week follow-up data for 37 couples, the 6-month follow-up data for 36 couples and the 1-year follow-up data for 37 couples.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...REFERENCES |
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£20 000).
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Representativeness of the sample
Only limited data from antenatal records (for maternal age, ethnicity,
gestation of lost baby and the presence of live children in the family) were
available for those couples who refused to take part in the study or who did
not meet the inclusion criteria. We found that among the couples who refused
to take part or who were excluded the mothers were slightly younger (mean age
30.0 
32.7 years; t112=2.308, P=0.023) and
were significantly more likely to be from a Black or minority ethnic group
(60.3% 27.6%; 2 test: P=0.001). There were no
significant differences with regard to the presence of children in the family,
problem pregnancies other than stillbirth, or gestation of lost pregnancy.
Data on income and education for couples who refused to take part in the study
were insufficiently complete to allow valid comparisons.
Rates of psychological symptoms in fathers
Table 2 shows that fathers
in the index group experienced higher levels of depression than controls
across all assessments (except for the mean score at the 6-week follow-up,
which was fractionally higher in the control group). However, the mixed-model
analysis did not show a significant effect of group
(F73=0.42, P=0.517), although there was a
significant time effect (F60=3.36, P=0.025), with
levels of depression falling postnatally. At the antenatal assessment, 5 out
of 34 men (14.7%) in the index group compared with 2 out of 36 men (5.6%) in
the control group reached case threshold levels for depression (Fisher’s
exact test: P=0.253). These rates fell to 3 (9.7%) v. 2
(5.9%) by the 1-year follow-up. For both anxiety outcomes there were
significant group (state: F73=5.28, P=0.024;
trait: F73=5.45, P=0.022) and time (state:
F65=8.20, P=0.006; trait:
F62=5.35, P=0.024) effects, indicating that
levels of anxiety differed both between the groups and over time. For state
anxiety there was also evidence of a group x time interaction
(F65=5.50, P=0.022) (i.e. the difference between
the two groups was not constant over the two assessment times).
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PTSD
We cannot report group effects for stillbirth-related PTSD because the
control group had not experienced comparable trauma. However, we have already
established that stillbirth is a category A stressor for PTSD in mothers, and
that mothers experience high levels of PTSD in the pregnancy subsequent to a
stillbirth (Turton et al,
2001). We found similar levels of stillbirth-related PTSD in
fathers. At the antenatal assessment, five fathers (15.6%) met the criteria
for a current diagnosis of PTSD, and six fathers (18.8%) met the criteria for
a lifetime diagnosis. As was found for mothers, PTSD symptoms remitted rapidly
after the birth of a live baby. At the 6-week post-partum assessment, none of
the fathers still had case-level symptoms, and this remained true at all of
the remaining assessments.
We also assessed PTSD in relation to other stressors in all of the participants. With regard to non-stillbirth-related trauma, there was no difference between the groups in the prevalence of PTSD (lifetime or current) or in the overall symptom severity score. Only one father in the control group and none of the fathers in the index group reached case threshold level at the antenatal assessment, and none of the fathers in either group reached case threshold level at the 1-year assessment.
Fathers’ marital satisfaction
Two couples in the index group dropped out during the course of the study
and cited marital difficulties as a reason for this, whereas none of the
control couples dropped out for this reason. However, there was no real
evidence of a higher prevalence of marital problems in the index group.
Although fathers in the index group had a slightly higher mean score on the
GRIMS (indicating lower levels of marital satisfaction) at both the antenatal
assessment and the 1-year post-partum assessment, these differences were not
significant, and the scores generally indicated high levels of marital
satisfaction.
Fathers’ coping strategies
Fathers retrospectively reported that they had used various coping
strategies to try to come to terms with their loss. Out of the 34 fathers who
were not non-drinkers, 9 (26.5%) reported increased alcohol consumption after
the loss. Out of 38 fathers 7 (18.4%) reported that they had used prescribed
drugs specifically to enable them to cope after the stillbirth. Three fathers
(7.9%) reported using illegal drugs. Nearly half of the fathers (47.4%) had
received some form of professional help from hospital counsellors, ministers
of religion or other healthcare professionals, and five fathers (13.2%) had
been in contact with the voluntary self-help group Stillbirth and Neonatal
Death Society (SANDS). A substantial proportion of the fathers (39.5% of
fathers 42.1% of mothers) would have welcomed some form of further
support (other than that of family and friends) after the stillbirth.
Levels of psychological symptoms in mothers
As in our previous study (Hughes et
al, 1999), mothers who had experienced a stillbirth had
significantly higher levels of depression and anxiety than controls across all
assessments and at all time points, with the exception of depression scores at
the 6-month assessment. We also replicated the finding of noteworthy levels of
stillbirth-related PTSD in mothers. The prevalence of PTSD in response to the
stillbirth was similar for fathers and mothers at both the antenatal
assessment and the 1-year follow-up. Six of the mothers (18.8%) met the
criteria for current PTSD during pregnancy but, as with the fathers, symptoms
had remitted in all but one mother by 1 year post-partum following the birth
of a live baby.
Comparison between mothers’ and fathers’ symptom levels in the index group
When we compared mothers’ and fathers’ symptom levels within
samples on the same measures (BDI depression scores at 1-year follow-up,
Spielberger state and trait anxiety scores both antenatally and at 1-year
follow-up, and PTSD symptom severity score antenatally), we found that mothers
had higher levels of psychological symptoms than fathers at every assessment,
although the difference did not reach the level of significance (see
Table 3). We also wanted to
determine whether there was any correlation between partners’ (i.e.
mothers’ and fathers’) scores – that is, whether both
partners within a couple responded in similar ways to their trauma, or whether
within-couple scores were unrelated. In fact, within-pair correlations were
not strong, only reaching significance in relation to antenatal PTSD symptom
severity scores and Spielberger state anxiety scores (see
Table 3).
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Factors associated with psychological morbidity in fathers in the index group
As with mothers, there was no association between fathers’ levels of
psychological symptoms in the pregnancy following stillbirth and
socio-demographic factors (age, ethnicity, income or level of education).
There was also no association with the presence of other children in the
family.
Using MANOVA, we then looked at two sets of dichotomous factors. First, we examined background factors that have been identified as being associated with poorer outcome in mothers (history of treatment for psychological symptoms, time period between loss and becoming pregnant again (<12 months or >12 months), whether or not the father felt that he received emotional support from his partner and family). Secondly, we examined factors connected with the loss itself (the gestation of the lost pregnancy (second or third trimester), whether or not the father had seen the dead infant). Possibly because of the small numbers in each group, none of these independent variables in fathers were found to be significantly associated with depression, anxiety or PTSD symptom scores at the antenatal assessment. However, Table 4 shows a consistent trend towards findings being similar in fathers to those that have been reported in mothers, with a worse outcome occurring if fathers had a history of treatment for psychological symptoms, if they had not felt well supported by their partner and family at the time of the loss, if the loss had occurred in the third trimester, or if they had seen their dead infant. Interestingly, the finding in relation to the time interval between a stillbirth and conceiving again showed a trend in the opposite direction in fathers, with higher depression and anxiety scores occurring where there had been a longer delay (more than 1 year). The Pearson correlation between the time interval in months and antenatal trait anxiety in fathers was 0.455 (P=0.007). For mothers in the present study, again there was a slight trend towards higher trait anxiety and PTSD scores if the pregnancy under investigation (i.e. that following a stillbirth) had been delayed. This finding runs counter to the results of other reports.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...REFERENCES |
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When we reviewed the original data in the literature specific to the psychological effects of perinatal death (stillbirth or neonatal death) on fathers, we found that the published studies vary both in their emphasis and in quality of design, and most of them have serious methodological weaknesses. Many studies had to be excluded because they conflate different types of loss (e.g. miscarriage, stillbirth, neonatal death and sudden infant death syndrome) without separating the results by loss category. The studies also vary in the time interval since the loss (e.g. 2 months in Zeanah et al, 1995, and between 2 months and 5 years in Worth, 1997). Many studies (both qualitative and quantitative) have problems with generalisability arising from population bias, sampling bias and response bias. For example, Theut et al (1989, 1990), Worth (1997) and DeFrain et al (1991) used volunteer samples, and one American group (Hughes & Page-Liberman, 1989) identified some of their sample from support groups. This is important because, as Toedter et al (2001) have reported, significantly higher grief scores were found in studies that recruited participants from support groups and self-selected populations rather than from medical sources. Two studies (Dyregrov & Matthiesen, 1987; Samuelsson et al, 2001) systematically excluded individuals on the basis of adverse social or family situations (which were not described). Social class is an important area of potential bias, and is relevant in studies where researchers have deliberately included only a homogenous group (Helmrath & Steinitz, 1978), or where responders are demographically different from non-responders. Most of the papers that have addressed such demographic differences have not considered social class, with the exception of a study by Zeanah et al (1995), who found that non-responders were significantly more likely to be from a lower social class. Small sample size also limits generalisability. The majority of the papers that we reviewed did not report power calculations for their sample sizes. The exception was the series of papers by Vance, Foster, Najman and colleagues (Vance et al, 1991, 1994, 1995a,b; Najman et al, 1993), in which adequate sample sizes were recorded. However, a large proportion of the participants in that cohort dropped out or were lost to follow-up at 6 months and 8 months, and were excluded from the analysis (Najman et al, 1993; Vance et al, 1995a), thus potentially skewing the reported findings.
Most of the studies (Kimble, 1991; Worth, 1997) did not have a control group, although some researchers compared different types of loss, or compared the effects on fathers with those on mothers. The outcome measures varied. Where a qualitative approach was used, fathers reported feelings of grief and described their role as being a social support to their partner. With the exception of the study by Worth (1997), these research findings were limited by a lack of measures to ensure reliability. Quantitative studies tend to measure grief responses, depression and anxiety. To our knowledge, no studies to date have measured the development of PTSD in fathers. Other possible limitations of such research include the use of instruments not commonly employed to measure the outcomes under investigation (for example, Vance and colleagues used sub-scales of the Delusions Symptoms States Inventory to measure affective symptoms; Foulds & Bedford, 1978), and a tendency not to report P values or confidence intervals.
Despite these limitations, the consistency of certain findings and observations suggests that many fathers do experience grief after a perinatal loss, including feelings of shock, anger, emptiness, helplessness and loneliness (e.g. Kimble, 1991; Zeanah et al, 1995; Worth, 1997; Samuelsson et al, 2001). Symptoms of depression and anxiety have also been described (Vance et al, 1995a,b). The expected social role of fathers as a support to their partner (Helmrath & Steinitz, 1978) may partly explain the observation that the grief reactions of fathers tend to be less intense than those of mothers. Levels of marital dissatisfaction are reported to be higher in bereaved fathers than in controls (Najman et al, 1993), but there are no data on whether relationships survive intact in the wake of the loss.
This paper forms part of a series in which our research group is investigating the effects of a previous stillbirth on families. As noted above, we have already investigated psychological symptoms in mothers (Hughes et al, 1999; Turton et al, 2001). We have also reported that unresolved mourning for the lost infant is prevalent in mothers during the next pregnancy (Hughes et al, 2004), and that this is associated with an increase in insecure disorganised attachment in infants born subsequent to a stillbirth (Hughes et al, 2001). We have also reported on the association between the psychosocial management of stillbirth and adverse outcome for the mother and the next-born child (Hughes et al, 2002). We are currently writing up a 7-year follow-up study of mothers and next-born children after a stillbirth.
In the present case–control cohort study we compared fathers whose partners’ previous pregnancy had ended in stillbirth with both their partners and non-bereaved fathers. The index group consisted of couples who were expecting a child and whose last pregnancy had ended in spontaneous loss after 20 weeks’ gestation. Although our primary interest was in fathers, it would have been insensitive to exclude mothers from a study of the psychological impact of previous stillbirth on the next pregnancy. We chose a 20-week cut-off point because clinicians generally regard a loss in the second half of pregnancy as representing the loss of a child to the parents. All of the parents were over 20 years of age, had a singleton pregnancy and spoke enough English for them to be interviewed. The control group consisted of couples who had not experienced a stillbirth but who were otherwise pair-matched (from the mothers’ obstetric records) as closely as possible with regard to age, ethnicity, obstetric history, presence of children in the family, and socio-economic status according to occupation. We excluded couples antenatally if either parent was currently receiving treatment for acute physical or mental illness.
Difficulties with recruitment of male participants
We experienced many more recruitment problems in this study than in our
previous investigation of the psychological effects of a stillbirth on
mothers, in which 86% of mothers consented to take part. Although it was not
always possible to identify the reason or individual responsible for a
couple’s refusal to participate, it was our strong impression that
fathers were much more likely to refuse to take part than mothers. This was
not simply attributable to the difficulty in finding a suitable appointment
time (we were always ready to make appointments at times convenient to
participants, including evenings and weekends). It seemed that we were caught
up in a more widespread problem in recruiting men to psychological or social
research, which has been noted previously
(Lewis et al, 1989).
This difficulty may explain why other studies of parents have involved far
fewer fathers than mothers (DeFrain et
al, 1991; Zeanah et
al, 1995), and it may reflect a cultural belief that men are
less willing to talk about their feelings than women. This belief may have
been exacerbated in a study related to pregnancy, where men identify
themselves as less involved, and by the common assumption that a pregnancy
loss has a greater impact on mothers because of their physical involvement in
carrying the baby (Theut et al,
1988). Whatever the reason, the difficulty with recruitment of
male participants is a problem in psychological research involving men, and
further work is needed to identify the factors that impede collaboration and
to find ways of overcoming those factors.
The importance and neglect of fathers in stillbirth research
This study has confirmed that the pregnancy following a stillbirth is a
particularly stressful time for parents, and that although fathers show lower
levels of psychological morbidity than their partners, they are still
vulnerable to significant levels of distressing symptoms, particularly anxiety
and PTSD. Reassuringly, it appears that these symptoms largely remit after the
birth of a live child, although mothers continue to be more vulnerable than
fathers to ongoing psychological morbidity. This finding is consistent with
some previous research, but runs counter to the results of other studies which
have suggested that although mothers’ grief may be more intense in the
short term, fathers’ scores do not decline as much as the scores of
mothers over time (Stinson et al,
1992).
Our findings also suggest that there is a tendency for parents’ levels of symptoms to run in tandem rather than for one of the partners to ‘carry’ the burden of symptomatic distress for both parents, or for one of the partners (typically the father) to feel that they have to deny their grief in order to remain strong in the face of the other’s distress.
Factors that have a protective effect and factors that increase risk
Previous research has identified factors that appear to be associated with
a more adverse outcome in mothers, in particular psychiatric symptoms before
the loss (Janssen et al,
1997), early subsequent pregnancy
(Hughes et al, 1999),
longer gestation (Theut et al,
1989) less support from partners or family
(Turton et al, 2001),
and physical contact with the dead infant
(Hughes et al, 2002). This study extends and provides some additional support for these findings.
The finding that parental contact with the dead infant appears to increase
risk is sensitive. Not only does it run counter to existing models of
‘good practice’, but also our interviews with parents confirmed
that those parents who did have such contact greatly valued the opportunity
they had to spend time with their dead infant, and would not willingly have
foregone the experience. It is possible that such contact intensifies an
attachment that no parent could regret. However, given the evidence which
suggests that parents who do have such contact are more rather than less
vulnerable to distressing symptoms in their next pregnancy, we believe that
clinicians should be cautious about advocating its benefits. The parents in
our study who did not see their dead infant had no regrets either. The
solution that is usually proposed for this problem is ‘parental
choice’. However, the choice of whether or not to see and hold their
dead infant takes place in a social and cultural context that currently
emphasises the importance of acknowledging and confronting feelings (even
negative ones) rather than suppressing or avoiding them. In such a culture it
may be difficult for parents to decline the invitation to spend time with
their dead infant. Perhaps both society and parents believe that some degree
of psychological morbidity is a price worth paying for such a highly valued
experience. Further research on this important topic in a broader cultural
context is urgently needed.
It is interesting that, for the fathers in our study, there was a trend for better outcome to be associated with conceiving again within a year of the stillbirth, contrary to previous research findings in relation to mothers (Theut et al, 1990; Hughes et al, 1999; Rich, 2000). It is possible that these are chance findings, but it is also possible that fathers and mothers have different needs in relation to this decision. Whereas mothers need time to mourn and recover before becoming pregnant again, fathers’ levels of depression and anxiety may increase as more time elapses before there is a real prospect of becoming a parent again. If this is the case, then there are implications for the advice that parents should be given about the timing of a subsequent pregnancy in the best interests of both partners.
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Clinical Implications and Limitations |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...REFERENCES |
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LIMITATIONS
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...REFERENCES |
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Received for publication June 15, 2004. Revision received March 4, 2005. Accepted for publication March 14, 2005.
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