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CONTEXT:

The death of a child is devastating, and complicated grief adversely impacts parental physical and psychosocial well-being. Most research currently is centered on bereaved mothers, and the experiences of fathers remains underexplored.

OBJECTIVE:

We systematically reviewed the literature to characterize the grief and bereavement experiences of fathers after the death of a child.

DATA SOURCES:

We searched Medline, PsycInfo, Embase, and Cumulative Index to Nursing and Allied Health Literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

STUDY SELECTION:

Inclusion criteria encompassed English language articles published between 2007 and 2019 that evaluated the grief and bereavement experiences of fathers after the death of their child. We excluded studies describing paternal bereavement after the death of a child aged older than 21 years, stillbirth, miscarriage, or studies that did not specify age of death.

DATA EXTRACTION:

Extracted domains included study design, demographics, findings, and quality assessment.

RESULTS:

We screened 1848 deduplicated titles and abstracts and 139 full articles, yielding 21 articles for inclusion in this analysis. Fathers often avoided discussing their grief with others, returned to work earlier, and used goal-oriented tasks as coping strategies. Intense grief reactions and posttraumatic psychological sequelae diminished over time in mothers yet persisted in fathers.

LIMITATIONS:

Included studies were primarily descriptive in nature, without ability to ascertain causality. Limited paternal data exists in the literature compared with maternal data.

CONCLUSIONS:

Despite evolving gender roles, many fathers navigate loss through stoicism, self-isolation, and hard work. For some fathers, these coping mechanisms may be inadequate for navigating grief.

The death of a child is devastating and results in profound bereavement.1,2  Parents grieve not only the death of their child but also the loss of their future hopes and plans for the child and family. Parental bereavement adversely impacts psychological and physical well-being, with respect to heightened risks of anxiety, depression, and psychiatric admissions,35  diminished health-related quality of life,6  and increased mortality compared with parents who have not experienced the death of a child.7 

Historically, 75% of parents studied in pediatric palliative care research have been mothers,8  and the specific grief and bereavement experience of fathers remains underinvestigated. Researchers in several studies have evaluated differences in grief and bereavement between mothers and fathers, finding evidence to suggest briefer or less-intense grief reactions in fathers.911  Limited data suggest that fathers may repress or avoid discussion of their feelings and are less likely than mothers to reach out for social support.12  Differences in grief expression, intensity, and coping mechanisms may be rooted in Western sociocultural expectations of masculinity, with men expected to solve problems, refrain from expressing emotions, and be action oriented in the context of grief.13 

In recent years, sociocultural views on parental expectations and roles have shifted, with fathers increasingly involved in the care of their children.14,15  Yet the existing whole body of research on paternal grief and bereavement has not been recently synthesized. To address this deficit in the literature, we conducted a systematic review to critically assess current knowledge around the grief and bereavement experience of fathers after the death of a child.

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting our results.16  The driving question of our systematic review was: “What are the grief and bereavement experiences of fathers following the death of a child?” The Patient population, Intervention, Comparator, Outcome, Timing, Setting (PICOTS) and study eligibility criteria are presented in Table 1.17  Briefly, the targeted population comprised fathers who experienced the death of a child, and study inclusion necessitated evaluation of the grief and bereavement of fathers; mothers who experienced the death of a child could serve as comparators, but included articles specifically assessed paternal experiences independent of maternal ones. In included studies, researchers used quantitative or qualitative outcomes related to grief intensity, physical or psychological health impacts, tools for grief, or coping mechanisms. Articles were written in English and published between 2007 and 2019.

TABLE 1

PICOTS Question and Eligibility Criteria

PICOTS question: “What is the grief and bereavement experience of fathers following the death of a child?”
Population: fathers who have lost a child. 
Intervention: evaluation of the bereavement and grief experience of fathers who have lost a child. 
Comparator: mothers who have lost a child (although not essential for inclusion). 
Outcome(s): quantitative or qualitative articles related to the grief experience of fathers, addressing the general grief experience or more-specific outcomes such as grief intensity, physical or psychological health impacts, tools for grief, or coping mechanisms. 
Timing: 2007–2019. 
Setting(s): any environment. 
Inclusion criteria 
 Studies directly and specifically evaluating the bereavement and grief experience of fathers who have lost a child. 
 The researchers could study fathers alone or in comparison between genders, but the article must specifically assess the father’s experience. 
 Prospective or retrospective study design 
 Quantitative, qualitative, or mixed methodology. 
 Any outcomes related to the grief and bereavement experience of fathers. 
 Articles published in the English language. 
 Articles published between 2007 and 2019. 
Exclusion criteria 
 Single case reports or case series. 
 Narrative, scoping, or systematic literature reviews. 
 Articles without presentation of original data (eg, perspective articles, commentary, letters, studies describing methodology sans data). 
 Abstracts, non–peer-reviewed publications or other “gray literature.” 
 Studies that do not describe the father’s experience. 
 Any study with children who died age >21, were stillbirth or miscarriage, or did not specify ages of the patient at time of death. 
PICOTS question: “What is the grief and bereavement experience of fathers following the death of a child?”
Population: fathers who have lost a child. 
Intervention: evaluation of the bereavement and grief experience of fathers who have lost a child. 
Comparator: mothers who have lost a child (although not essential for inclusion). 
Outcome(s): quantitative or qualitative articles related to the grief experience of fathers, addressing the general grief experience or more-specific outcomes such as grief intensity, physical or psychological health impacts, tools for grief, or coping mechanisms. 
Timing: 2007–2019. 
Setting(s): any environment. 
Inclusion criteria 
 Studies directly and specifically evaluating the bereavement and grief experience of fathers who have lost a child. 
 The researchers could study fathers alone or in comparison between genders, but the article must specifically assess the father’s experience. 
 Prospective or retrospective study design 
 Quantitative, qualitative, or mixed methodology. 
 Any outcomes related to the grief and bereavement experience of fathers. 
 Articles published in the English language. 
 Articles published between 2007 and 2019. 
Exclusion criteria 
 Single case reports or case series. 
 Narrative, scoping, or systematic literature reviews. 
 Articles without presentation of original data (eg, perspective articles, commentary, letters, studies describing methodology sans data). 
 Abstracts, non–peer-reviewed publications or other “gray literature.” 
 Studies that do not describe the father’s experience. 
 Any study with children who died age >21, were stillbirth or miscarriage, or did not specify ages of the patient at time of death. 

A medical librarian in collaboration with M.J.M. developed an advanced Boolean logic search strategy using controlled subject headings and text words, as described in Supplemental Table 3. The following concepts were integrated: “parent or family emotions” and “child death”; “end-of-life care” and “family” and “pediatrics,” in conjunction with the Medical Subject Heading (MeSH) terms: “grief,” “bereavement,” “parent,” and “father.” We searched the databases Medline; PsycInfo; Embase; and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Additionally, we used a standard snowballing strategy of manually searching the references of relevant studies and review articles to identify other articles eligible for inclusion.18 

EndNote was used as the reference database to retrieve and screen records. Duplicate records were removed, and 2 reviewers (M.J.M. and I.S.) independently screened deduplicated titles and abstracts before conducting comprehensive full-text assessment of the remaining articles. Discrepancies were adjudicated through group discussion between all authors.

A standardized data abstraction tool was developed on the basis of a modified version of the Cochrane Review.16  M.J.M. and I.S. extracted data using a template form, shown in Supplemental Table 4. In the context of dual data extraction across 334 database cells, a total of 17 discrepancies were identified, resulting in high interrater reliability at 0.95. Discrepancies were resolved through adjudication until consensus was achieved.

Results from each identified study were synthesized narratively. Because of heterogeneity of content and interventions, lack of validated tools, and inconsistent use of comparisons, conducting a meta-analysis was not feasible.

The McGill Mixed Methods Appraisal Tool (MMAT; Version 2018)19  was used to evaluate methodologic quality and study bias. The MMAT allows for critical assessment of different methodologic approaches including qualitative, quantitative, and mixed methods studies. The tool encompasses 7 criteria including clarity of research question, whether the data collected adequately answer the research question, and 5 items specific to study design. For each criterion, individual appraisers (M.J.M. and I.S.) assessed whether the article met each quality criterion (“yes”), if it failed to meet the criterion (“no”), or if insufficient information was presented to adequately assess the specific criterion (“cannot tell”). Eleven discrepancies were identified out of 154 database cells, yielding high interrater reliability at 0.93; discrepancies were adjudicated by the research team to reach consensus. Studies with 0 to 1 MMAT deficits are considered to have good overall methodologic quality. The quality of studies with 2 to 3 deficits is considered medium-level, and the presence of ≥4 deficiencies is concerning for suboptimal methodologic quality.

Our search methods identified 1848 deduplicated articles. After screening abstracts for inclusion and exclusion criteria, 139 articles were identified for full-text assessment, and 21 unique articles ultimately met inclusion criteria. Figure 1 presents the PRISMA flowchart. Data abstracted from each included article are summarized in Table 2.2040 

FIGURE 1

PRISMA Flowchart. Presentation of PRISMA flowchart, including database sources, articles screened, full text assessment, rationale for excluded studies, and final studies included in this systematic review.

FIGURE 1

PRISMA Flowchart. Presentation of PRISMA flowchart, including database sources, articles screened, full text assessment, rationale for excluded studies, and final studies included in this systematic review.

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TABLE 2

Study Design, Analysis, Findings, and Limitations

Article, Year, CountryStudy DesignParticipantsQualitative Data Analysis and Study ToolsKey FindingsMMAT Assessment/Study Limitations
Fathers Only      
Qualitative      
 Aho et al20  2009 Finland Open-ended questionnaire with interview 8 fathers whose children died of various conditions before age 3. 100% white Inductive qualitative analysis Support networks for fathers included either just the spouse or the spouse and other people. The fathers experienced social isolation but also deliberately isolated themselves. MMAT assessment: good; deficiencies: none 
 Edwards et al21  2009 New Zealand In-person open-ended interviews 9 fathers whose children died of SIDS. 100% Maori Thematic discourse analysis Strong perception by the fathers that they needed to be stoic for themselves and family. Unemployed fathers likely to use alcohol as a coping strategy. MMAT assessment: good deficiencies: none 
 Proulx et al22  2016 Canada Individual, semistructured interviews 13 fathers whose children died of various conditions. 100% white Interpretative phenomenological analysis Fathers needed to push forward and “keep busy” with work and other activities. Fathers needed to keep the child present in everyday life. Fathers needed to find meaning in their experience of grief. MMAT assessment: good; deficiencies: none 
Mothers and Fathers      
Qualitative      
 Alam et al23  2012 Canada Individual, semistructured interviews 31 parents (18 mothers and 13 fathers) whose children died of cancer. 74% white Conventional content analysis Majority of fathers continued to work full-time after diagnosis and death. Mothers expressed more intense grief reactions that lessened over time. Mothers used more family-focused strategies, fathers used more task-focused and legacy building. MMAT assessment: good; deficiencies: none 
 Armentrout et al24  2009 United States Narrative interviews 15 parents (11 mothers and 4 fathers) whose children died in the NICU. 86.6% white, 6.7% Hispanic, 6.7% African American Grounded theory Emphasis on the outward expression versus inward expression. “Keeping busy.” Undertaking household projects and returning to work was described by fathers in the study as their “grief work.” MMAT assessment: medium; deficient criteria: 1.4. Is the interpretation of results sufficiently substantiated by data? 1.5. Is there coherence between qualitative data sources, collection, analysis and interpretation? 
 Brooten et al25  2019 United States Open-ended questionnaire 104 parents (81 mothers and 23 fathers) whose children died of various conditions in NICU or PICU. 32% white, 27% Hispanic, 43% African American Conventional content analysis: Caring for themselves was the main coping strategy for both mothers and fathers after the child’s death. Fathers seemed ready to move forward and return to work sooner than mothers who were heavily focused on remembering the child. MMAT assessment: good; deficient criteria: 1.5. Is there coherence between qualitative data sources, collection, analysis and interpretation? 
 Caicedo et al26  2019 United States Open-ended questionnaire 96 parents (70 mothers, 26 fathers) whose children died of various conditions in NICU or PICU. 24% white, 33% Hispanic, 41% African American Conventional content analysis: Fathers wished most to have spent more time with the child. MMAT assessment: Good
Deficient criteria:
1.5. Is there coherence between qualitative data sources, collection, analysis and interpretation? 
 Foster et al27  2011 United States and Canada Semistructured interview 60 (36 mothers, 24 fathers) and 39 siblings whose children died of cancer. 83% of fathers were white Conventional content analysis Mothers communicated with the deceased, thought about the deceased, and did things that the deceased child would have liked more often than fathers. MMAT assessment: good; deficiencies: None 
 Gilmer et al28  2012 United States and Canada Semistructured interviews of both parents and siblings 60 parents (36 mothers, 24 fathers) and 39 siblings whose children died of cancer. 83% of fathers were white Conventional content analysis Mothers reported feeling more sadness while no fathers reported feeling sad. Mothers more likely to have a change in their work with some having an increase in work but most having a decrease. Similar changes in perspective and religious or spiritual beliefs. MMAT assessment: good; deficiencies: none 
Quantitative      
 Brooten et al29  2018 United States Longitudinal cohort 249 parents (176 mothers, 73 fathers) whose children died of various conditions in NICU or PICU. 26% white, 48% Hispanic, 26% African American. Survey developed by study team Fathers reported 104 acute illnesses (colds or flu and headaches) and 9 hospitalizations, less than that of mothers. MMAT assessment: medium; deficiencies: 4.2. Is the sample representative of the target population? 4.4. Is the risk of nonresponse bias low? 
 Hawthorne et al30  2016 United States Longitudinal cohort 165 parents (114 mothers, 51 fathers) whose children died of various conditions in the NICU or PICU. 22% white, 28% Hispanic, 40% African American BDI HGRC SCS Impact of Events Scale Fathers’ use of spiritual activities was related to less-severe symptoms of depression at both 1 and 3 mo. Use of religious activities was related to less-severe symptoms of depression at 1 mo for fathers’ after their infant or child’s death. MMAT assessment: medium; deficiencies: 4.2. Is the sample representative of the target population? 4.4. Is the risk of nonresponse bias low? 
 Hawthorne et al31  2017 United States Longitudinal cohort 165 parents (114 mothers, 51 fathers) whose children died of various conditions in NICU or PICU. 22% white, 28% Hispanic, 40% African American SCS At time 1, mothers reported significantly greater use of religious, but not spiritual, coping practices than fathers. At time 2, mothers had significantly higher scores for religious and spiritual coping practices than fathers. Protestant fathers reported significantly greater use of spiritual coping practices than those in the “other” religion group at time 1. MMAT assessment: medium; deficiencies: 4.2. Is the sample representative of the target population? 4.4. Is the risk of nonresponse bias low? 
 Ljungman et al32  2015 Sweden Longitudinal cohort 37 bereaved parents (17 mothers and 20 fathers) whose children died of cancer. Race and ethnicity were not provided PTSD Checklist (PCL-30) Bereavement was associated with a high level of PTSS and risk of PTSD. The prevalence of PTSD decreased among mothers over time but not among fathers. MMAT assessment: good; deficiencies: 4.4. Is the risk of nonresponse bias low? 
 Lykke et al33  2019 Denmark Cross-sectional questionnaire 193 parents (136 mothers and 57 fathers) whose children died of various conditions. Race and ethnicity were not provided CES-D VDS There were no statistically significant differences in anxiety between mothers and fathers. Furthermore, there was no significant difference between parent sex and depression. MMAT assessment: good; deficiencies: 4.4. Is the risk of nonresponse bias low? 
 Morris et al34  2016 United States Cross-sectional questionnaire 88 parents (60 mothers, 28 fathers) and 62 siblings whose children died of various conditions. 89.3% white, 3.6% Hispanic, 3.6% African American PTSD Checklist (PCL-30) Prolonged Grief Disorder (PG-13) Maternal, but not paternal, symptoms of PTSD and PGD were directly associated with sibling outcomes. Paternal symptoms were associated with sibling symptoms indirectly, through parenting behaviors (ie, via decreasing positive parenting). MMAT assessment: medium; deficiencies: 4.3. Are the measurements appropriate? 4.4. Is the risk of nonresponse bias low? 4.5. Is the statistical analysis appropriate to answer the research question? 
 Werthmann et al35  2010 Denmark Retrospective cohort 21 062 parents (11 221 mothers, 9841 fathers) whose children died of various conditions. Race and ethnicity were not provided Retrospective assessment of civil registry data Bereaved parents who had lost a child of the same sex had similar overall mortality as bereaved parents who had lost a child of the opposite sex. MMAT assessment: good; deficiencies: none 
 Youngblut et al36  2017 United States Longitudinal cohort 182 parents (130 mothers and 52 fathers) whose children died of various conditions in NICU or PICU. 23.1% white, 48.1% Hispanic, 28.8% African American HGRC Grief decreased from 3 to 13 mo for mothers and from 3 to 6 mo for fathers. For fathers, grief despair scores decreased significantly from 3 to 6 mo. MMAT assessment: good; deficiencies: 4.4. Is the risk of nonresponse bias low? 
Mixed methods      
 Barrera et al37  2007 Canada Cross-sectional Study 20 (13 mothers and 7 fathers) whose children died of various conditions. 90% white with 10% Asian Canadian and African Canadian Qualitative: grounded theory. quantitative: BDI, Grief Measurement Scale The majority of parents (65%) presented uncomplicated, integrated grief. 5 mothers were consumed by grief, but no fathers Having surviving children, social support, and being active appeared to help to integrate grief into daily life. MMAT assessment: good; deficiency: 5.2. Are the different components of the study effectively integrated to answer the research question? 
 Bergstraesser et al38  2015 Switzerland Cross-sectional study 46 married parents (23 couples) whose children died of various conditions. Race and ethnicity were not provided. Qualitative: reconstructive hermeneutical approach; conventional content analysis; quantitative: CES-D, TRIG-D Mothers were more prone to share their feelings and thoughts with others. Fathers preferred not to talk about their feelings with others. Aspects of common dyadic coping, helped the parents work through their grief as a couple but also individually. MMAT assessment: good; deficiencies: none 
 Donovan et al39  2019 Australia Cross-sectional study 119 parents (91 mothers, 28 fathers) whose children had died of cancer. Race and ethnicity were not provided. Qualitative: deductive thematic analysis; quantitative: survey developed by study team Fathers appeared more likely than mothers to continue working throughout their child’s sickness. Mothers described frustration that their partners avoided the reality of the situation by seeking refuge in work or exercise in the lead up to their child’s death. MMAT assessment: good; deficiency: 5.4. Are divergences and inconsistencies between quantitative and qualitative results adequately addressed? 
 Keim et al40  2017 United States Cross-sectional study 69 parents (42 mothers and 27 fathers) whose children died of various conditions in the NICU. 85% of fathers were white Qualitative: conventional content analysis; quantitative: PG-13 Although not statistically significant, large effects were observed such that fathers who had additional children reported lower PTSS and prolonged grief scores. MMAT assessment: suboptimal; deficiencies: 5.1. Is there an adequate rationale for using a mixed methods design to address the research question? 5.2. Are the different components of the study effectively integrated to answer the research question? 5.3. Are the outputs of the integration of qualitative and quantitative components adequately interpreted? 5.4. Are divergences and inconsistencies between quantitative and qualitative results adequately addressed?
5.5. Do the different components of the study adhere to the quality criteria of each tradition of the methods involved? 
Article, Year, CountryStudy DesignParticipantsQualitative Data Analysis and Study ToolsKey FindingsMMAT Assessment/Study Limitations
Fathers Only      
Qualitative      
 Aho et al20  2009 Finland Open-ended questionnaire with interview 8 fathers whose children died of various conditions before age 3. 100% white Inductive qualitative analysis Support networks for fathers included either just the spouse or the spouse and other people. The fathers experienced social isolation but also deliberately isolated themselves. MMAT assessment: good; deficiencies: none 
 Edwards et al21  2009 New Zealand In-person open-ended interviews 9 fathers whose children died of SIDS. 100% Maori Thematic discourse analysis Strong perception by the fathers that they needed to be stoic for themselves and family. Unemployed fathers likely to use alcohol as a coping strategy. MMAT assessment: good deficiencies: none 
 Proulx et al22  2016 Canada Individual, semistructured interviews 13 fathers whose children died of various conditions. 100% white Interpretative phenomenological analysis Fathers needed to push forward and “keep busy” with work and other activities. Fathers needed to keep the child present in everyday life. Fathers needed to find meaning in their experience of grief. MMAT assessment: good; deficiencies: none 
Mothers and Fathers      
Qualitative      
 Alam et al23  2012 Canada Individual, semistructured interviews 31 parents (18 mothers and 13 fathers) whose children died of cancer. 74% white Conventional content analysis Majority of fathers continued to work full-time after diagnosis and death. Mothers expressed more intense grief reactions that lessened over time. Mothers used more family-focused strategies, fathers used more task-focused and legacy building. MMAT assessment: good; deficiencies: none 
 Armentrout et al24  2009 United States Narrative interviews 15 parents (11 mothers and 4 fathers) whose children died in the NICU. 86.6% white, 6.7% Hispanic, 6.7% African American Grounded theory Emphasis on the outward expression versus inward expression. “Keeping busy.” Undertaking household projects and returning to work was described by fathers in the study as their “grief work.” MMAT assessment: medium; deficient criteria: 1.4. Is the interpretation of results sufficiently substantiated by data? 1.5. Is there coherence between qualitative data sources, collection, analysis and interpretation? 
 Brooten et al25  2019 United States Open-ended questionnaire 104 parents (81 mothers and 23 fathers) whose children died of various conditions in NICU or PICU. 32% white, 27% Hispanic, 43% African American Conventional content analysis: Caring for themselves was the main coping strategy for both mothers and fathers after the child’s death. Fathers seemed ready to move forward and return to work sooner than mothers who were heavily focused on remembering the child. MMAT assessment: good; deficient criteria: 1.5. Is there coherence between qualitative data sources, collection, analysis and interpretation? 
 Caicedo et al26  2019 United States Open-ended questionnaire 96 parents (70 mothers, 26 fathers) whose children died of various conditions in NICU or PICU. 24% white, 33% Hispanic, 41% African American Conventional content analysis: Fathers wished most to have spent more time with the child. MMAT assessment: Good
Deficient criteria:
1.5. Is there coherence between qualitative data sources, collection, analysis and interpretation? 
 Foster et al27  2011 United States and Canada Semistructured interview 60 (36 mothers, 24 fathers) and 39 siblings whose children died of cancer. 83% of fathers were white Conventional content analysis Mothers communicated with the deceased, thought about the deceased, and did things that the deceased child would have liked more often than fathers. MMAT assessment: good; deficiencies: None 
 Gilmer et al28  2012 United States and Canada Semistructured interviews of both parents and siblings 60 parents (36 mothers, 24 fathers) and 39 siblings whose children died of cancer. 83% of fathers were white Conventional content analysis Mothers reported feeling more sadness while no fathers reported feeling sad. Mothers more likely to have a change in their work with some having an increase in work but most having a decrease. Similar changes in perspective and religious or spiritual beliefs. MMAT assessment: good; deficiencies: none 
Quantitative      
 Brooten et al29  2018 United States Longitudinal cohort 249 parents (176 mothers, 73 fathers) whose children died of various conditions in NICU or PICU. 26% white, 48% Hispanic, 26% African American. Survey developed by study team Fathers reported 104 acute illnesses (colds or flu and headaches) and 9 hospitalizations, less than that of mothers. MMAT assessment: medium; deficiencies: 4.2. Is the sample representative of the target population? 4.4. Is the risk of nonresponse bias low? 
 Hawthorne et al30  2016 United States Longitudinal cohort 165 parents (114 mothers, 51 fathers) whose children died of various conditions in the NICU or PICU. 22% white, 28% Hispanic, 40% African American BDI HGRC SCS Impact of Events Scale Fathers’ use of spiritual activities was related to less-severe symptoms of depression at both 1 and 3 mo. Use of religious activities was related to less-severe symptoms of depression at 1 mo for fathers’ after their infant or child’s death. MMAT assessment: medium; deficiencies: 4.2. Is the sample representative of the target population? 4.4. Is the risk of nonresponse bias low? 
 Hawthorne et al31  2017 United States Longitudinal cohort 165 parents (114 mothers, 51 fathers) whose children died of various conditions in NICU or PICU. 22% white, 28% Hispanic, 40% African American SCS At time 1, mothers reported significantly greater use of religious, but not spiritual, coping practices than fathers. At time 2, mothers had significantly higher scores for religious and spiritual coping practices than fathers. Protestant fathers reported significantly greater use of spiritual coping practices than those in the “other” religion group at time 1. MMAT assessment: medium; deficiencies: 4.2. Is the sample representative of the target population? 4.4. Is the risk of nonresponse bias low? 
 Ljungman et al32  2015 Sweden Longitudinal cohort 37 bereaved parents (17 mothers and 20 fathers) whose children died of cancer. Race and ethnicity were not provided PTSD Checklist (PCL-30) Bereavement was associated with a high level of PTSS and risk of PTSD. The prevalence of PTSD decreased among mothers over time but not among fathers. MMAT assessment: good; deficiencies: 4.4. Is the risk of nonresponse bias low? 
 Lykke et al33  2019 Denmark Cross-sectional questionnaire 193 parents (136 mothers and 57 fathers) whose children died of various conditions. Race and ethnicity were not provided CES-D VDS There were no statistically significant differences in anxiety between mothers and fathers. Furthermore, there was no significant difference between parent sex and depression. MMAT assessment: good; deficiencies: 4.4. Is the risk of nonresponse bias low? 
 Morris et al34  2016 United States Cross-sectional questionnaire 88 parents (60 mothers, 28 fathers) and 62 siblings whose children died of various conditions. 89.3% white, 3.6% Hispanic, 3.6% African American PTSD Checklist (PCL-30) Prolonged Grief Disorder (PG-13) Maternal, but not paternal, symptoms of PTSD and PGD were directly associated with sibling outcomes. Paternal symptoms were associated with sibling symptoms indirectly, through parenting behaviors (ie, via decreasing positive parenting). MMAT assessment: medium; deficiencies: 4.3. Are the measurements appropriate? 4.4. Is the risk of nonresponse bias low? 4.5. Is the statistical analysis appropriate to answer the research question? 
 Werthmann et al35  2010 Denmark Retrospective cohort 21 062 parents (11 221 mothers, 9841 fathers) whose children died of various conditions. Race and ethnicity were not provided Retrospective assessment of civil registry data Bereaved parents who had lost a child of the same sex had similar overall mortality as bereaved parents who had lost a child of the opposite sex. MMAT assessment: good; deficiencies: none 
 Youngblut et al36  2017 United States Longitudinal cohort 182 parents (130 mothers and 52 fathers) whose children died of various conditions in NICU or PICU. 23.1% white, 48.1% Hispanic, 28.8% African American HGRC Grief decreased from 3 to 13 mo for mothers and from 3 to 6 mo for fathers. For fathers, grief despair scores decreased significantly from 3 to 6 mo. MMAT assessment: good; deficiencies: 4.4. Is the risk of nonresponse bias low? 
Mixed methods      
 Barrera et al37  2007 Canada Cross-sectional Study 20 (13 mothers and 7 fathers) whose children died of various conditions. 90% white with 10% Asian Canadian and African Canadian Qualitative: grounded theory. quantitative: BDI, Grief Measurement Scale The majority of parents (65%) presented uncomplicated, integrated grief. 5 mothers were consumed by grief, but no fathers Having surviving children, social support, and being active appeared to help to integrate grief into daily life. MMAT assessment: good; deficiency: 5.2. Are the different components of the study effectively integrated to answer the research question? 
 Bergstraesser et al38  2015 Switzerland Cross-sectional study 46 married parents (23 couples) whose children died of various conditions. Race and ethnicity were not provided. Qualitative: reconstructive hermeneutical approach; conventional content analysis; quantitative: CES-D, TRIG-D Mothers were more prone to share their feelings and thoughts with others. Fathers preferred not to talk about their feelings with others. Aspects of common dyadic coping, helped the parents work through their grief as a couple but also individually. MMAT assessment: good; deficiencies: none 
 Donovan et al39  2019 Australia Cross-sectional study 119 parents (91 mothers, 28 fathers) whose children had died of cancer. Race and ethnicity were not provided. Qualitative: deductive thematic analysis; quantitative: survey developed by study team Fathers appeared more likely than mothers to continue working throughout their child’s sickness. Mothers described frustration that their partners avoided the reality of the situation by seeking refuge in work or exercise in the lead up to their child’s death. MMAT assessment: good; deficiency: 5.4. Are divergences and inconsistencies between quantitative and qualitative results adequately addressed? 
 Keim et al40  2017 United States Cross-sectional study 69 parents (42 mothers and 27 fathers) whose children died of various conditions in the NICU. 85% of fathers were white Qualitative: conventional content analysis; quantitative: PG-13 Although not statistically significant, large effects were observed such that fathers who had additional children reported lower PTSS and prolonged grief scores. MMAT assessment: suboptimal; deficiencies: 5.1. Is there an adequate rationale for using a mixed methods design to address the research question? 5.2. Are the different components of the study effectively integrated to answer the research question? 5.3. Are the outputs of the integration of qualitative and quantitative components adequately interpreted? 5.4. Are divergences and inconsistencies between quantitative and qualitative results adequately addressed?
5.5. Do the different components of the study adhere to the quality criteria of each tradition of the methods involved? 

BDI, Beck Depression Inventory; BDI, Beck Depression Inventory; CES-D, Center for Epidemiologic Studies Depression scale; HGRC, Hogan Grief Reaction Checklist; PCL-30, PTSD Checklist; PG-13, Prolonged Grief Disorder; SCS, Spiritual coping Scale; SIDS, sudden infant death syndrome; TRIG-D, Texas Revised Grief Inventory; VDS, Visual Digital Scale.

Of the 21 included studies, 14 (66.7%) were published after 2015. Six studies (28.6%) included a majority multiracial population including bereaved Black and Hispanic parents.25,26,2931,36  No researchers evaluated the bereavement experience of fathers in low- and middle-income countries, although researchers in 1 study evaluated an indigenous population (Maori) in New Zealand.21  Researchers in 5 studies evaluated grief and bereavement after the child died of cancer,23,27,28,32,39  and those in 1 study targeted grief and bereavement after the death of a child from sudden infant death syndrome.21  Researchers in 6 studies evaluated grief after a child died either in the PICU or NICU with mode of death described as brain death, unsuccessful cardiopulmonary resuscitation, or withdrawal of life sustaining measures.25,26,2931,36  Two studies were specific to children who died in the NICU.24,40  In other studies, researchers included a variety of causes of death, such as malignancy, trauma, congenital heart defects, and infection.20,22,30,31,33,34  Researchers in 1 study did not specify cause of death, simply differentiating between “natural” versus “unnatural” death.35  A total of 427 fathers were studied, with a median of 24 fathers per study. Researchers in 3 articles (14.3%) studied only fathers (Table 2).2022  Of those studies that included both mothers and fathers in their analysis, 31.1% of the parents were fathers (427 of 1374). Two studies (9.1%) had equal participation between fathers and mothers.32,38 

Study methodologies comprised qualitative (n = 9), quantitative (n = 8), and mixed methodologic (n = 4) approaches. The primary study objective endorsed in all qualitative studies was a general evaluation of grief. Researchers in the 3 studies that exclusively evaluated fathers relied on qualitative methods.2022  (Table 2) Multiple strategies were used to collect qualitative data, ranging from in-depth interviews conducted via telephone, in the clinic, or in the participant’s home,20,21,23,24,27,28  and open-ended questions on surveys.25,26  Analytic methods also varied, with reported use of inductive qualitative content analysis,20  conventional content analysis,23,2528  thematic discourse analysis,21  interpretive phenomenological analysis,22  and grounded theory study (Table 2).24 

All included quantitative studies were descriptive in nature (Table 2). Quantitative objectives included a general assessment of the grief experience,36  the physical health impacts of grief,29,35  assessments on the psychological impact of grief,30,32,33  religion or spirituality and its role in the grief experience,30,31  and parental grief and its impact on surviving siblings.34  Most quantitative studies used self-reported questionnaires (7 of 8, 87.5%) incorporating a range of survey tools to assess posttraumatic stress symptoms (PTSS) and posttraumatic stress disorder (PTSD), depression, prolonged grief, and spiritual coping.30,3236  Different survey tools were used to assess features such as grief, depression, and PTSD, as summarized in Table 2.

Regarding formal study design, 5 of the 8 quantitative studies (66.7%) were longitudinal cohort studies following bereaved parents across time.2932,36  One study comprised a retrospective cohort study of civil registry data.35  Authors of 4 articles presented mixed method studies via cross-sectional designs (Table 2). Mixed method study objectives varied broadly in assessment of the general grief experience,37,39  grief and its impact on siblings,40  and dyadic coping.38  Mixed methods studies often used a combination of quantitative self-reported questionnaires followed by either semistructured or open-ended interviews to supplement survey data.

Several key topics and themes were identified as integral to the grief and bereavement of experience of fathers after the death of a child.

Taken together, the fathers who participated in these studies tended to grieve more in isolation than in public. In several studies, authors described paternal isolation during the grief process but also stated that this may be a deliberate choice. Many fathers attempted to avoid discussing their feelings of grief, in contrast to more open communication by mothers.2024,38  Fathers also attempted to deflect attention from their suffering in an effort to prioritize support for their partners.39  Nevertheless, fathers emphasized the importance of communication with their spouses and peers; although fathers were less likely to seek out conversation, they still described communication about their loss as important for processing their grief.20,38 

Paternal grief was shown to have a significant impact on fathers’ relationships with their partners and children. Differences in communication styles between mothers and fathers at times led to increased frustration between partners.20,22,38,39  However, fathers also reported that their spouse was their primary source of support during bereavement as well as an integral aspect of their recovery process after the death of a child.20,22,38  Researchers in 1 study evaluated dyadic coping, showing no increased risk of divorce in bereaved couples after the death of their child.38  Researchers in another study demonstrated that a mother’s, but not a father’s, symptoms of PTSD and prolonged grief were associated with surviving children’s psychological outcomes, including PTSD, prolonged grief, and depression.34 

Fathers appeared more likely than mothers to work at their occupation and on projects in the home as a way to “keep busy,” using goal-oriented tasks as a coping mechanism to manage grief.2024,28,38,39  Although most bereaved parents came from dual-income households, in all but 1 case, mothers served as the primary caregivers. At the time of their child’s cancer diagnosis, the majority of fathers continued working full-time, whereas the majority of mothers either reduced their work schedule or took time off work to care for the child. After the death of their child, the majority of mothers focused on caring for their surviving children and deprioritized work obligations. The majority of fathers, comparatively, returned to work shortly after the death of their child.23,25,28  Fathers who were unemployed reported increased psychological distress in the setting of inability to provide for their families or distract themselves with work, and several reported abusing substances as a negative coping mechanism.21  However, in follow-up interviews, many fathers reported loss of fulfillment and satisfaction in their work and were actively seeking alternative meaningful activities to sustain their child’s legacy.23  The biggest regret reported by fathers after the death of a child was a wish that they had spent more time with the child.26 

Fathers also described the importance of rituals to maintain a relationship with their deceased child as an important aspect of their grief process. Rituals included visiting the gravesite, speaking or writing to their child, and keeping their room or toys and/or clothing as remembrances. These practices were followed by father individually as well as in conjunction with their partners and other family members.2224,27,38  In addition to rituals, fathers also relied on legacy building activities as a way to honor their child’s life.22,23,27  Such practices included creating a charity or fundraiser in their child’s honor, building projects in the house or community, and participating in their child’s favorite sporting events or other activities.

Religion and spirituality were also evaluated in the grief experience of fathers.22,24,30,31  Researchers in 1 study suggested that fathers experienced personal growth at 1 and 3 months with increased use of spiritual and religious activities across time. Spiritual activities were defined as activities oriented toward the relationship with self, others, and the environment whereas religious activities were defined as activities oriented toward religion and belief in God. Increased participation in spiritual activities was associated with lower symptoms of grief and depression, but not posttraumatic stress in fathers. Engagement in organized religion activities was also related to decreased severity of depression at 1 month for fathers after the death of their child.30 

With respect to physical morbidities, fathers experienced an increase in acute illnesses, medication changes, and hospitalizations in the first 6 months after the death of a child, which declined in months 7 to 12 but again increased at month 13.29  Although rates of anxiety in fathers appear to decrease over time after the death of a child, self-reported depression in fathers remained constant even 3 to 5 years after a child’s death.33  Additionally, initial PTSS and PTSD scores in 1 study were higher in mothers than fathers after the death of a child, but over time the rates of PTSS and PTSD declined significantly in mothers but not in fathers.32  Although not statistically significant, fathers with additional children also reported lower PTSS and prolonged grief scores as compared with fathers who with no additional children.40 

Several researchers investigated the intensity of grief experienced by bereaved parents. No one standardized metric was used to measure grief intensity. Authors in 1 article stratified grief intensity as integrated grief, minimal grief expression, or consumed by grief.37  Within this construct, mothers and fathers demonstrated equivalent degrees of integrated or minimal expression, whereas only mothers were consumed by grief.37  Another study also identified more intense grief in mothers compared with fathers, including panic, disorganization, and despair; however, these findings revealed that mothers’ grief intensity diminished over time, whereas fathers’ grief remained relatively constant after a child’s death.36 

The included studies were primarily descriptive in nature, without ability to ascertain causality. Fewer father participants compared with mother participants adversely impacted study capacity to compare and contrast parental grief and bereavement experiences. Small sample sizes affected study ability to query statistical significance or generalize findings to other populations. Within longitudinal studies, attrition rates further reduced power. Participant cohorts with predominantly white parents and relatively higher socioeconomic statuses than the general population further precluded generalizability.25,26,29,31,36  MMAT assessments and deficiencies are presented in Table 2.

The relationship between a parent and their child is unique and powerful, making the death of a child particularly profound and devastating for a parent. In this review, we systematically synthesize the existing literature on the grief and bereavement experience of fathers after the death of a child, identifying key features of paternal grief and bereavement experience that warrant further exploration.

All of the identified articles included in this review were published within the last 11 years, representing a more-recent sociocultural era in which fathers play a more involved and engaged role in their children’s lives compared with several decades ago.14  Yet synthesis of the limited literature suggests ongoing gender-based differences between maternal and paternal grief and bereavement experiences. Cultural beliefs that fathers should be more stoic and not discuss their feelings persist,22,23,39  along with self-isolating behaviors.12,41  Notably, the described attitudes and behaviors are specific to predominantly Western contexts, and further research is needed to explore the impact of sociocultural expectations on paternal grief in multiracial, non-Western populations. Further investigation is also warranted to parse out perceived advantages and disadvantages of gender normative grief expectations. For example, some fathers perceived self-distancing as beneficial; others described social isolation as harmful to their grief journeys.20,23,27,39  Additional efforts are needed to explore how coping mechanisms are shaped and guided by external pressures. Given variability in the coping strategies of different fathers, high quality provision of bereavement care necessitates an individualized approach in synergy with listening, validating, and normalizing each parent’s unique experiences and preferred coping styles.

Despite cultural shifts in dual-income households and parenting roles, mothers continue to perform the bulk of child-rearing responsibilities, including care of a child during progressive illness.23  Although fathers have tripled the time spent with their children, they still spend half as much time in child-rearing activities as mothers.42  Paternal reliance on continuing work, use of work as distraction, and returning to work after the death of a child as a coping mechanism for grief are notable and likely a manifestation of ongoing gender disparities. Fathers also use household projects such as yardwork, reorganization, or other goal-oriented tasks and physical labor as coping tools,2224,27,38  with equivocal findings to suggest whether “staying busy” and “distracting themselves” were healthy or harmful to their grief and bereavement journeys. We advocate for grief research programs to incorporate qualitative father-specific studies to gain a more-nuanced understanding of the ways that bereaved fathers seek and sustain resilience during bereavement.

Interestingly, although grief intensity was found to be higher in mothers immediately after the death of a child, intense grief reactions, PTSS, and PTSD diminished over time in mothers yet persisted in fathers.37  We hypothesize that, for some fathers, gendered coping mechanisms (eg, isolation, stoicism, work ethic) are insufficient strategies for processing grief across time; further research is needed to explore this hypothesis. Additionally, the definition of grief intensity remains poorly defined and variable between studies, with most features of grief intensity reported as outward expressions of grief. Given data to suggest that fathers self-isolate themselves and avoid visible features of grief, these metrics may underestimate the true grief intensity experienced by fathers, and new metrics may be needed to capture the depth of paternal grief.

The perinatal grief and bereavement experiences of fathers also represent a profound and understudied area of research deserving of further attention. Paternal perinatal stressors may exacerbate complicated bereavement and related mental health disorders. A systematic review of 144 studies found that stillbirth was associated with parental depression, anxiety disorder, social phobia, PTSD, and suicidal ideation.43  Specifically, studies of fathers demonstrated grief suppression or avoidance, employment difficulties, financial debt, and increased substance use.43  Another systematic review on stillbirth suggested that the prevalence of PTSD in grieving fathers may be underrepresented, because current PTSD measures may not fully capture paternal grief and fathers may not consistently vocalize grief.44  Increased paternal participation in bereavement research is needed to better understand the unique grief experiences of fathers across different loss experiences. Deeper knowledge on paternal grief will enable the development of more-nuanced measures and interventions to assess for and mitigate complicated grief and other related mental health disorders, respectively.

Several limitations may influence this analysis. First, we excluded studies assessing the grief experience of fathers after stillbirth or miscarriage; in the context of a growing literature on paternal perinatal mental health disorders,4547  we believe that these unique experiences warrant a separate and focused analysis. Second, we excluded studies of bereaved parents of young adults >21 years, opting to focus on the experiences of parents who lose a child; however, we acknowledge the value in future research to broaden our knowledge of the bereaved father experience in the context of the death of a young adult. Third, we excluded non-English articles, which may have resulted in missed data and a lack of cultural diversity, impacting our aggregated impressions. Fourth, fewer fathers participated in grief and bereavement research compared with mothers, limiting our ability to compare and contrast grief across genders and potentially skewing findings to focus on heightened maternal or paternal behavioral responses to grief.

Synthesis of available literature suggests that clinicians should recognize the unique grief experiences and needs of fathers and encourage open communication with partners and health professionals. Specifically, we recommend that clinicians provide individualized anticipatory guidance about regret and support opportunities for fathers to engage in meaningful experiences with their ailing child before death and with their partners and surviving siblings after death. In addition, we encourage longitudinal, relationship-based support throughout the illness trajectory and bereavement. The provision of financial and other social supports across the illness course and extending into bereavement also may enable fathers to spend more time with their children and family, mitigating decisional regret in the context of a lessened fiscal burden. Finally, we advocate for additional research to better understand the grief experience of fathers, using data to inform the development and investigation of interventions to better support fathers after the death of a child. Successful research platforms will necessitate intentional recruitment of fathers to balance the typical maternal-heavy cohorts, as well as studies that include participants from racially and ethnically diverse populations as well as participants from outside of Western cultural contexts.

The grief experience of fathers appears to be unique and is likely influenced by the cultural, societal, and religious contexts within their respective lived experiences. Despite evolving gender roles across the past several decades, many fathers remain anchored to the belief that men should deal with loss through stoicism, a “stiff upper lip,” self-isolation, and hard work. Yet the literature suggests that, for some fathers, these coping mechanisms may be inadequate for navigating their grief. Better understanding of paternal grief and bereavement has the potential to lead directly to clinical improvements in the care and support of fathers after the death of a child.

Dr McNeil conceptualized and designed the systematic review, coordinated and supervised the data collection, drafted the initial manuscript, and reviewed and revised the manuscript; Mr Snyder assisted in the data collection and reviewed and revised the manuscript; Drs Baker, and Rosenberg helped in the conceptualization and design of the systematic review and reviewed and revised the manuscript; Dr Kaye coordinated and supervised the systematic review, and critically reviewed the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

     
  • CINAHL

    Cumulative Index to Nursing and Allied Health Literature

  •  
  • MeSH

    Medical Subject Headings

  •  
  • MMAT

    McGill Mixed Methods Appraisal Tool

  •  
  • PICOTS

    Patient population, Intervention, Comparator, Outcome, Timing, Setting

  •  
  • PRISMA

    Preferred Reporting Items for Systematic Reviews and Meta-Analyses

  •  
  • PTSS

    posttraumatic stress symptoms

  •  
  • PTSD

    posttraumatic stress disorder

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data