Grief and Bereavement in Fathers After the Death of a Child: A Systematic Review

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.

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.^20–40 

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.^{25,26,29–31,36}  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.^{25,26,29–31,36}  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).^20–22  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.^20–22  (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,^23,25–28  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.^30,32–36  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.^29–32,36  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.^20–24,38  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.^{20–24,28,38,39}  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.^{22–24,27,38}  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,^{22–24,27,38}  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,^45–47  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.

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