Abstract
Research exploring fathers’ experiences of using bereavement photography after perinatal loss is lacking. Using continuing bonds theory, this study aims to investigate fathers’experiences of bereavement photography and predictors of posttraumatic growth (PTG). Mixed methodology was employed with participants (n = 29). A hierarchical regression showed that there were no significant associations between continuing bonds and PTG, but time since death predicted PTG in bereaved fathers. Further, a t test indicated that there was no significant difference in PTG for mothers and fathers. A thematic analysis was conducted on the qualitative data from an open-ended survey question (n = 23) and semi-structured interviews (n = 3) with fathers. The qualitative analysis of fathers' responses showed themes relating to bonding/connection, capturing memories, recommendations to receive photography help with grieving, validation, memory-making and continuing bonds, and engagement with photos. Fathers valued bereavement photographs as it enabled them to integrate grief over time.
Keywords
Background
There are an estimated 4 million perinatal (including foetal, neonatal, and infant) deaths each year around the globe (Flenady et al., 2014; Jones et al., 2019). This encompasses miscarriage, early loss of pregnancy less than twenty weeks of gestation, stillbirth over 20 weeks of gestation, and neonatal loss (newborn through to 28 days of life) (Due et al., 2017; Jones et al., 2019). Perinatal bereavement can be associated with a range of negative sequelae such as depression, anxiety, substance abuse, posttraumatic stress disorder, poor physical outcomes, and loss of identity for the parents (Badenhorst et al., 2006; Hvidtjørn et al., 2018; Jones et al., 2019; Ramirez et al., 2019; Waugh et al., 2018).
Perinatal bereavement is a complex process that is situated within societal, clinical, and cultural conceptualisations of death, grief, parenthood, gender, and familial bonds (Blood & Cacciatore, 2014a; Cacciatore, 2010; Fenstermacher & Hupcey, 2013; Godel, 2007; Hvidtjørn et al., 2018). Whether the baby is considered a person by society, and if the fathers are recognised in their roles, has a large impact on fathers’ bereavement and the enfranchisement, or not, of their grief (Burden et al., 2016; Cholette, 2012; Due et al., 2017; Jones et al., 2019; Ramirez et al., 2019).
Gender, Perinatal and Neonatal Loss
Men’s experiences following pregnancy loss and neonatal death are relatively under-examined when compared to studies involving women (Obst et al., 2020). A systematic review investigating the impact of pregnancy loss on men’s health and well-being concluded that men tended to have less intense and prolonged grief and fewer enduring negative psychological outcomes than women (Jones et al., 2019). Fathers show varied responses to grief but are more likely to show externalising symptoms and compensatory behaviours such as substance use, and double disenfranchisement of grief. Conversely, qualitative research demonstrates that fathers report intense levels of distress and loss, along with an expectation of grief suppression (Aydin & Kabukcuoglu, 2020) and express a profound desire to have their loss and grief recognised (Bonnette & Broom, 2012; Due et al., 2017).There appears to be a conflict between a father’s outward expression of emotions, and his desire to be validated in grief and parenthood (Bonnette & Broom, 2012; Cholette, 2012; Due et al., 2017; Jones et al., 2019; Obst et al., 2020).
Posttraumatic Growth and Continuing Bonds
Research on positive sequalae following perinatal loss, such as Posttraumatic Growth (PTG) in relation to fathers is lacking. In their recent systematic review, Alvarez & Chaves (2023) examined perinatal loss and PTG, and identified that mothers comprised the vast majority of samples studied with only one study in the review recruiting 11 participant fathers (Cacciatore et al., 2012). PTG reportedly occurs when an individual experiences positive changes and growth in their life, despite a profound loss (Tedeschi et al., 2017; Waugh et al., 2018). Further, an enduring loss can potentially enable an individual to realise their strength and define what is important in their life, and with the passing of time resulting in increasing levels of PTG (Büchi et al., 2009; Cholette, 2012; Johnsen & Afgun, 2021; Polatinsky & Esprey, 2000; Scholtes & Browne, 2015; Tedeschi et al., 2017; Waugh et al., 2018). Tedeschi et al. (2017) explain that PTG can be facilitated through the bereaved “continuing their bond with their loved one and assimilating it [the loss] meaningfully into their life now” [p33].
Continuing bonds (CB), a construct developed by Klass et al. (1996) is defined as an ongoing connection between the bereaved person and the deceased loved one. Several studies have explored bereaved parents more generally and reported CB to affect grief outcomes and facilitate PTG (Scholtes & Browne, 2015; Tedeschi et al., 2017; Waugh et al., 2018). In their systematic review of 13 studies identifying aspects of PTG that may be experienced by bereaved parents, Waugh et al. (2018) reported the importance of CB as a facilitator of PTG, through meaning-making and mementos. Further, internalised CB expression was reported by bereaved parents and influenced grief expression (Scholtes & Browne, 2015). In addition, the time since death was related to CB, less grief intensity and more personal growth. However, the studies did not separate perinatal loss and parents whose children died later in life, further requiring an exploration of PTG experiences in perinatal bereavement populations due to its complexity, and the scarcity of literature (Waugh et al., 2018). Positive relationships have been reported between continuing bonds through a range of memory-making activities and mental health outcomes, primarily in a sample of mothers experiencing stillbirths (Jones et al., 2023). Further, a recent study found that most participants (nearly 90%) reported that bereavement photos facilitated strong continuing bonds with their deceased babies (Vivekananda et al., 2024).
Whilst Waugh et al. (2018) found that mothers may experience higher levels of PTG than fathers, this is contrasted by Michael and Cooper’s (2013) systematic review of 15 studies concluding no statistically significant gender difference in PTG. However, a failure to engage in meaning-making was associated with poorer grief outcomes (Michael & Cooper, 2013). Therefore, further study of PTG outcomes following perinatal loss in fathers is warranted. A recent study examining bereavement adaptation following still birth, reported time since death of baby, meaning making, legacy building activities and time spent in nature were positively linked to bereavement adaptation (Jones et al., 2023).
Perinatal Bereavement Photography
Over the past decade there has been accumulating research evidence for perinatal bereavement photography as a memory-making activity following perinatal loss that allows parents to enact parenting roles, create bonds with their deceased baby, and validate their experience (Vivekananda et al., 2024; Basile & Thorsteinsson, 2015; Flenady et al., 2014; Thornton et al., 2019). Earlier research showed bereavement photography provided a tangible resource in validation of the baby’s existence, legitimises mourning, facilitates bonding and memory-making, and allows the enactment of parenting rituals (Blood & Cacciatore, 2014a; Cacciatore & Flint, 2012; Cholette, 2012; Flenady et al., 2014; Hennegan et al., 2015; Koopmans et al., 2013). More recent mixed-methods research with a large sample of parents provided confirmation that professional perinatal bereavement photography was perceived as validating and enfranchised parental grief. Furthermore, bereavement photographs were perceived as facilitating strong continuing bonds by maintaining connections between parents and their babies and helped parents feel that their babies continued to be a part of the family. These ongoing connections extended to the broader family and social network as significant positive correlation was reported for continuing bonds and the sharing of bereavement photos with family and friends (Vivekananda et al., 2024).
Fathers and Bereavement Photography
In a qualitative study focusing on stillbirth experiences conducted with Australian fathers (n = 12), Bonnette and Broom (2012) found that they benefited from holding and taking photos with their baby, as this allowed them to reconcile the experience of loss, create memories with the baby, and confirm their identity as a father. Martel and Ives-Baine (2014) qualitatively analysed 10 interviews with parents (fathers n = 4) who received photography in a neonatal intensive care unit and reported that photography allowed parents to identify with their parenthood, whilst validating their child and family. However, fathers tend to be unrepresented in samples examining perinatal bereavement photography with limited research specifically on examining fathers’ experiences and perspectives.
Given the potential benefits of bereavement photography for parents, and the limited research on fathers’ experiences of bereavement photography, this study aims to investigate posttraumatic growth and continuing bonds in fathers who have experienced perinatal loss, whilst qualitatively exploring how bereavement photography contributes to their experience.
Method
Design
This study was part of a larger study investigating bereavement photography conducted by Monash University (MUHREC Reference #23165). A mixed-methods design was used for this study. An anonymous online survey was distributed to parents, and semi-structured interviews were then conducted with consenting participants. Parents were able to participate in a dyad interview if desired. As such, mothers, fathers and couples (same gender and heterosexual) were encouraged to respond as part of the larger study. This paper reports on data relevant to fathers.
Participants
Demographics of Fathers.
Questions were also asked about details of the deceased baby. The mean age of baby at birth, in gestational weeks, was 32.14 (Min. = 20, Max. = 41, SD = 6.51). The mean age of baby at death, in days, was 2.47 (Min. = 0, Max. = 28, SD = 6.12), where ‘0’ was indicated as stillborn. The median number of perinatal losses that parents experienced was 1 (Min. = 0, Max. = 22).
Semi-structured telephone interviews were conducted using an interview schedule that included 6 open-ended questions regarding the experience of receiving the photographs, perceived impact of the photographs on grieving, how fathers have used the photographs, and learnings from their bereavement photography experience. The interviews were recorded via Zoom and lasted between 25 minutes to 1 hour. Only the interviews that were conducted with fathers’ present were included for analysis in this study.
Materials
Survey
The online survey was developed using Qualtrics. The survey consisted of 31 questions which were a mix of multiple-choice and short response. Questions comprised of 10 participant demographic questions (see Table 1) such as age, gender, marital status, and level of education. There were 5 demographic questions about the baby, including the age of the baby at birth (gestational weeks), the age of the baby when they died (days since birth), the time since baby died, and the number of stillbirths/perinatal losses experienced. Open-ended questions were asked about parents' general satisfaction with bereavement photography services.
Continuing Bonds (CB)
The Continuing Bonds (CB) questions was adapted from a questionnaire as developed by Jones (2020) to ensure relevance to the bereavement photography experience. The participants were asked to rate their agreement to statements such as “I feel Heartfelt photos helped me to feel connected to my baby” on a 7-point Likert scale, with 1 = Strongly Agree, to 7 = Strongly Disagree. A factor analysis was conducted showing that all 8 questions loaded onto one factor and Cronbach’s alpha for the 8 items was .92.
Posttraumatic Growth Inventory- Short Form (PTGI-SF)
The PTGI-SF is a ten-item, self-report questionnaire that measures growth after loss. It loads on to five factors: I) Relating to Others, II) New Possibilities, III) Personal Strength, IV) Spiritual Change, and V) Appreciation of Life. Participants were asked to rate their experience, with 0 being “I did not experience this change as a result of losing my baby”, to 5 being “I experienced this change to a very great degree as a result of losing my baby”.
The PTGI-SF was adapted from the original Posttraumatic Growth Inventory (PTGI) and was evaluated by Cann et al. (2010) as having good internal validity and consistency. It is comparable to the full version of the PTGI and was also tested on bereaved parents. The Cronbach’s alpha for the current sample was .84.
Analysis
Quantitative Analysis
The data from Qualtrics was exported to IBM SPSS Statistics 26 for data analysis Quantitative Analysis. Descriptive statistics were calculated for all variables. A t test was conducted to compare Post-Traumatic Growth Inventory (PTGI) of mothers and fathers. Further, a regression was conducted to assess whether CB predicts levels of posttraumatic growth (PTGI-SF).
Qualitative Analysis
The recordings of interviews were transcribed using transcription software. These recordings were then analysed for accuracy by listening to the recordings while checking the transcription output. The process recommended by Braun and Clarke (2006) was followed for thematic analysis of the interviews (n = 3). In the first stage, researchers independently analysed interviews for themes. Once this was completed, the researchers conferred on the themes that were identified during individual analysis. The themes were scanned for consistency and appropriateness. To ensure reliability, the themes were cross-checked by the research team.
The answers to the open-ended questions in the survey were collated and analysed using frequency tables and Word Clouds as suggested by Braun and Clarke (2006) in the third phase of their process for thematic analysis. Only fathers’ (n = 23) responses were included in this paper. To validate findings, data triangulation was sought by involving multiple researchers in the qualitative thematic analyses, as well as methodological triangulation through using both interviews and a questionnaire to collect data from parents (Noble & Heale, 2019).
Results
Quantitative Analysis
Descriptive Statistics
Descriptive Statistical Analysis of PTGI and CB.
Note. PTGI = Posttraumatic Growth Inventory, CB = Continuing Bonds.
A missing values analysis was conducted. No variable had more than 5% missing values, so the expectation maximisation method was determined to be appropriate to replace missing values. Values were only replaced if participants had completed more than a third of a scale. Any participant who was missing more than a third of a scale was recorded as incomplete and values for that scale were not replaced.
Table 2 above reports Means and Standard Deviations for PTGI and CB measures for the sample of fathers. Fathers reported moderate to high levels of PTG.
T test Sample of Parents
An independent-measures t test was conducted to compare PTGI of mothers and fathers. There were many more mothers (N = 455) than fathers (N = 29) in the analysis, but equality of variance was established, so a t test was appropriate. There was no significant difference in PTGI scores between mothers and fathers, t (483) = 0.25, p = .81.
Regression
Regression predicting Total Posttraumatic Growth With Time Since Death (months) and Continuing Bonds.
Note. **p < .001, CB = Continuing Bonds.
Model 1 analysed how well Time Since Death predicted PTG in fathers. This model gave a significant prediction of PTG, R2 = 0.19, F (1, 28) = 6.44, p = .017. Adding Continuing Bonds into the model did not significantly improve the model, Fchange = 1.21, p = .28, though the final model was significant, R 2 = .17, F (2, 28) = 3.85, p = .034.
In this model, Continuing bonds did not significantly contribute to the prediction. However, both models indicate that time since death is a positive predictor of PTG.
Qualitative Analysis
A thematic analysis was undertaken for the semi-structured interviews and the short-answer question from the survey.
Open Ended Survey Responses
Open Ended Survey Responses.
Semi-structured Interviews
A total of three interviews involving fathers were analysed. Although there were interviews where mothers spoke substantially about fathers, these were excluded as they were reflective of mothers perceptions of the fathers experience and may not have accurately reflected the fathers’ experiences or opinions. Pseudonyms have been given to participants to protect confidentiality.
Theme One: Validation
Fathers spoke about how the photographs validated their baby’s existence and provided a means to induct the baby in their families and lives. John said, “I think the opportunity to have photos taken supported the fact that we can go, this is [baby], this is where she was, and she’s our child and we love her.” John continued, “She’s here… not to be ignored or forgotten about, or for dismissal of the thing. So, I think it, [the photography] is a very helpful and powerful tool to start pushing that with families and friends."
Similarly, photographs also provided validation for fathers’ grief experiences. Another father, Brad said, "It validated her existence, especially in conversations with other people. And having her just as validated also validated our feelings. It wasn't just feeling like crap for no reason.”
Theme Two: Memory Making
Bereavement photographs facilitated making of memories, or otherwise providing a memento of the memories. As this father said, “It just felt like the right step for us to be able to have the memories… the experience made it a lot more of a natural process.” In his interview, Brad also explained, “The photos, it makes us grateful we have the memory.”
Like memory-making, having ongoing bonds with the baby was important. In his interview, Tom said, “How we deal with what she could have been, and how we carried that forward, I think being offered the photographs was a way of carrying her forward.” About the importance of the photographs, he also said:
“It allows you to tap into the memories from the time… it’s as normal and as powerful as any other photograph we have, which is pretty much the ideal outcome of [baby] in our lives, that she is present and powerful.”
Theme Three: Sharing with Others
Parents were asked to reflect on the experience of sharing bereavement photographs with others. Tom spoke about the online photographs being “a good way to engage family and friends that were overseas, as well as provide conversation.” Tom also spoke of having the photograph displayed on the desk in his office, where colleagues were able to comment on it, and said “it’s important to reflect that the photos have been really powerful, they’re really helpful, they provide access, but they’ve also provided a lot of humour and normality to what is a very different and stressful situation.” In the same interview, Tom explained the photographs served different purposes, that there were some for them to just connect with, or “pictures that we could put out that were definitely of [baby], but gentle enough for other people to observe and engage with.”
The concept of some photos feeling appropriate to share, and others not, was common reported. Brad said, “Because of the confronting photos, I wouldn’t show…my male friends.” He also explained how he only showed one close friend the photographs.
In both the surveys and open-ended responses, common themes were the recommendation to get the photography despite being unsure, memory making, validation of baby, and sharing.
Discussion
The purpose of this study was to investigate the relationship between bereavement photography, CB, and PTG for fathers who have experienced perinatal loss. We also aimed to investigate how fathers respond and interact with their bereavement photography. This is the first study, to our knowledge, to examine PTG in an exclusive sample of fathers receiving bereavement photography and provides encouraging findings regarding the experiences of fathers. Most importantly in our study, fathers report similar levels of PTG as mothers. Furthermore, our finding concurs with the moderate to high levels of PTG reported by samples of mothers experiencing stillbirth in the 11 studies reviewed by Oxlad et al. (2023).
The findings of this study showed that from the use of bereavement photography, CB did not predict PTG in fathers, but time since death certainly predicted PTG, despite moderately high CB scores. Previous research has found that CB is associated with PTG (Scholtes & Browne, 2015; Tedeschi et al., 2017; Waugh et al., 2018) and the expression of continuing bonds is particularly apparent in bereaved parents experiencing the death of older children. It is possible that age of child at the time of death may influence CB connection with PTG. It is also possible that mechanisms of post-traumatic growth may differ for fathers, and bereavement photography may not contribute to PTG through CB in this sample. Indeed, the current research shows that time since death predicted post-traumatic growth, and there was no significant difference between posttraumatic growth scores between mother and fathers. This is consistent with previous research that shows that as time passes since the death of a child, the greater the opportunity for parents to identify opportunities for personal growth (Büchi et al., 2009; Johnsen & Afgun, 2021; Jones et al., 2019; Waugh et al., 2018). Both fathers and mothers in our sample received the bereavement photography intervention and were mainly recruited from an online community dedicated to bereavement photography. It is possible, therefore, that the photos provided a means to engage with their partners and share the experience of grief thus resulting in higher PTGI scores. The qualitative analysis ‘sharing with others’ emerged as a theme as fathers talked about how the photographs became a means to engage others in conversations about the deceased baby. The process of sharing one’s grief appears to enfranchises grief through opportunities to discuss it openly thereby eliciting social support which is a known correlate of post-traumatic growth (Hogan & Schmidt, 2002).
While CB did not significantly predict post-traumatic growth, fathers reported high mean CB scores. The qualitative analysis demonstrated fathers’ rich descriptions about their experiences with bereavement photography which appears to allow them to continue bonds with their baby through enacting parenting rituals and integrating the loss into their lives, which they found helpful in their grieving. Fathers’ reported that photographs allowed positive integration of their baby as part of their family and identity of fatherhood despite the loss. This positive integration allowed for the baby to be a continuing part of the family and affirmed their parenthood. In alignment with previous research, the qualitative analysis indicates that provision of bereavement photography appears to facilitate continuing bonds via memory making thereby bringing about healing (Blood & Cacciatore, 2014a; Paraíso Pueyo et al., 2021; Thornton et al., 2019). For some fathers in this study, the photography appeared to facilitate dialectical thinking, whereby they can have memories of their baby at the time of their death, whilst also bringing their bond and existence into the future, thereby encouraging CB. This is reflected by Tedeschi et al. (2017) who posit that dialectical thinking about the loss is important for PTG.
Thematic analysis provided further insight into the quantitative results. Fathers reported that bereavement photography supported their grieving, created valued memories, and integrated the memory of their baby into their family thereby facilitating ongoing connections and a means to continue bonds with their baby. Fathers valued the experiences facilitated by photos of their baby as they emphasised the importance of having tangible reminders of their baby, recommending bereavement photography to other perinatally bereaved parents. Fathers reflected that photography sessions allowed for moments of parenting and interacting with their baby that would not otherwise have been possible. These results reflect more broadly the experiences of all parents reported by Ramirez et al. (2019) and Blood and Cacciatore (2014b) and highlight the importance of bereavement photography for parents experiencing perinatal loss as a way in which to promote CB and to support PTG.
Strengths and Limitations
The mixed-method nature of this study was a strength, as it allowed for the triangulation of data, and researchers could gain richer perspectives from fathers. Although this study included 29 fathers, which is large in this area of research, there was still a heavy sample bias toward mothers. Thus, future research should make further efforts to recruit more fathers. Similarly, future research may also attempt to recruit fathers who did not receive photography to compare PTG to those fathers who did and did not receive photography. Further, participants were also recruited from a bereavement photography Facebook group, an implication of which is that it can be expected that those who engage with the group still positively engage with their photographs. Future research may attempt to recruit from other sources. The limitations of biases from self-report data needs to be acknowledged as does the limitations of cross-sectional survey design that do not allow for causal inferences in the data.
Perinatal bereavement is a complex experience, with research showing that fathers need to be given the opportunity to be validated in their role as fathers, and to create and share memories of their babies. Qualitative findings indicate that fathers experiencing perinatal bereavement benefit from receiving quality bereavement photography to support and validate their grieving and facilitate growth from their profound loss. The results of this study emphasise that fathers too gain important benefits from having their grief validated and supported, their identity as fathers recognised and being given opportunities for both memory-making and meaning-making. Our findings can be incorporated into perinatal bereavement guidelines so as to encourage fathers to participate in bereavement photography when they are experiencing unfathomable grief and loss.
Footnotes
Acknowledgements
The authors would like to acknowledge the contribution of Kayleigh Knipe, Charlotte McMaster, Fatima Rahimi, and Mia Richards to this study. Further, we would like to extend our gratitude and acknowledgements to Gavin Blue and Heartfelt for their assistance.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
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