Similarities and differences in couples' grief reactions following a miscarriage: results from a longitudinal study

Perinatal loss and parental distress after the birth of a healthy infant

PURPOSE

Determine whether levels of depressive symptoms and current stress related to prior perinatal loss differ from similar prenatal evaluations after the birth of a subsequent healthy full-term infant and investigate differences in depressive symptoms in the postpartum period among parents with and without a history of perinatal loss.

PARTICIPANTS

Seventy-four of the original 206 parents who participated in an earlier prenatal study agreed to participate at follow-up and were divided into 2 groups (38 parents with a history of perinatal loss and 36 parents with no prior losses).

METHODS AND DESIGN

A 2-wave, 2-group comparative design was used. Both mothers and fathers were recruited for this study. Surveys were completed via telephone interviews. Data were analyzed using descriptive statistics, chi-square tests, t tests and Pearson correlations.

MAIN OUTCOME MEASURES

The Impact of the Event Scale (IES) is broadly used to evaluate the continuing influence of a past stressful life event. In the current study, the items were anchored to the traumatic event of perinatal loss. The IES contains 2 subscales: Intrusion and Avoidance. Cronbach's alphas for the current study were .80 (total scale), .85 (Intrusion subscale), and .69 (Avoidance subscale). The Center for Epidemiologic Studies-Depression Scale (CES-D) is used to identify the duration and frequency of depressive symptoms experienced by the respondent during the previous week. The Cronbach's alpha for the current study was .92.

PRINCIPLE RESULTS

There was a significant overall decrease in depressive symptoms after the birth of a healthy infant for fathers but not for mothers with prior perinatal losses. Nevertheless, approximately one third of the mothers with a history of loss continued to report CES-D scores that placed them at high risk for depression. There also was a significant decrease in stress related to the prior loss for both mother and fathers. The greater the stress associated with the prior loss, the greater were parents' depressive symptoms after birth. In contrast to the prenatal assessment, there were no significant differences in levels of depressive symptoms between the loss and nonloss groups at the postnatal assessment.

CONCLUSIONS

The stress associated with perinatal loss, although diminished after the subsequent birth of a healthy infant compared with that during pregnancy, remained high for many parents, especially mothers. Neonatal nurses need to continue to evaluate parents with a history of perinatal loss for ongoing psychological distress after the birth of a subsequent healthy infant.

The emotional burden of miscarriage for women and their partners: trajectories of anxiety and depression over 13 months

OBJECTIVE

To identify the trajectories of anxiety and depression in women and in their partners over 13 months after miscarriage.

DESIGN

A prospective study with follow up at 6 and 13 months after miscarriage.

SETTING

Three Scottish Early Pregnancy Assessment Units.

SAMPLE

Of the 1443 eligible individuals approached, 686 (48.3%) consented to participate (432 women; 254 men). Complete data were obtained from 273 women and 133 men at baseline, 6, and 13 months.

METHODS

On completion of the management of the index miscarriage, eligible and consenting women and men underwent an initial assessment comprising a semi-structured interview and a standardised self-report questionnaire. The latter was readministered at the follow-up assessments.

MAIN OUTCOME MEASURES

The hospital anxiety and depression scale (HADS), a reliable and valid measure of general psychopathology for use in nonpsychiatric samples.

RESULTS

Compared with depression, anxiety was overall the greater clinical burden. Over the 13-month period, women reported higher levels of anxiety and depression than men. Over time, a significantly greater level of adjustment was reported by women particularly with regards to the resolution of anxiety symptoms. The effect of time on HADS scores in either gender was similar between subgroups of socio-demographic and clinical factors.

CONCLUSIONS

These findings verify that early pregnancy loss represents a significant emotional burden for women, and to some extent for men, especially with regards to anxiety. For many, the detrimental effects of miscarriage are enduring and display a complex course of resolution. These findings are discussed in terms of their clinical implications for early identification and management.

Health concordance within couples: A systematic review

Research has consistently linked marriage and positive health outcomes. In addition, many researchers have found that couples often have similar or concordant health statuses. However, concordance research has been conducted in many fields for decades without a concise review of the literature, nor has one theory of health concordance been established. A systematic review was performed implementing rigorous identification strategies, and 103 health concordance research articles were identified and reviewed to understand what research has been conducted in mental health, physical health, and health behavior concordance among couples. The research overwhelmingly suggests evidence for concordant mental and physical health, as well as health behaviors among couples. Each area of health concordance research offers room for greater research and deeper understanding for the causes of health concordance.

Psychological morbidity following miscarriage

Emerging evidence has suggested that miscarriage could be associated with significant and possibly enduring psychological consequences. As many as 50% of miscarrying women suffer some form of psychological morbidity in the weeks and months after loss. About 40% of miscarrying women were found to be suffering from symptoms of grief shortly after miscarriage, and pathological grief can follow. Elevated anxiety and depressive symptoms are common, and major depressive disorder has been reported in 10-50% after miscarriage. Psychological symptoms could persist for 6 months to 1 year after miscarriage. The underlying risk factors predisposing a miscarrying woman to psychological morbidity include a history of psychiatric illness, childlessness, lack of social support or poor marital adjustment, prior pregnancy loss, and ambivalence toward the fetus. In addition, care-givers should be aware of the possible moderating effect of clinical practices such as surgical treatment and ultrasound findings on the psychological impact on a miscarrying woman. Unlike in postpartum depression, simple and effective screening measures of psychological morbidity in the context of miscarriage have not been well established. While studies have highlighted that psychological follow-up was highly desired by miscarrying women, and that psychological intervention was potentially beneficial, there is a substantial lack of randomized controlled intervention studies in this area.

Infertility treatment and marital relationships: a 1-year prospective study among successfully treated ART couples and their controls

BACKGROUND

Evidence about the effects of infertility and assisted reproduction technique (ART) on marital relationships is discrepant. Here, we examined the impact of ART on marital relationships. The roles of life stressors, infertility and treatment characteristics in predicting marital relations were also evaluated.

METHODS

SUBJECTS

367 couples with singleton IVF/ICSI pregnancies.

CONTROLS

379 couples with spontaneous singleton pregnancies. Women and men were assessed when the child was 2 months (T2) and 12 months old (T3). They further reported stressful life events at T2 and depression in pregnancy.

RESULTS

No between-group differences were found in marital satisfaction and dyadic cohesion. Dyadic consensus deteriorated from T2 to T3 only among control women. Sexual affection was low among control men at T2 and stressful life events decreased it further. Depression during pregnancy predicted deteriorated marital relations only in control couples. Several unsuccessful treatment attempts were associated with good dyadic consensus and cohesion among ART women. Spontaneous abortions and multiple parity predicted poor marital satisfaction in ART women, whereas long duration of infertility and multiple parity predicted poor marital relations in ART men.

CONCLUSIONS

Successful ART does not constitute a risk for marital adjustment. The shared stress of infertility may even stabilize marital relationships.

Recurrent miscarriage: psychological and relational consequences for couples

Recurrent miscarriage is a rare condition that has been described as a traumatic event for couples. Although symptoms of depression, anxiety and lowered self-esteem have been related after recurrent miscarriage, little is known about its impact on couple sexuality and on gender differences in attitude and the grief that follow. The objectives of this study are to describe the consequences of recurrent pregnancy loss for the couple's relationship, and explore gender differences in attitudes and grief intensity toward this kind of reproductive failure. Each member of 30 couples with at least 3 recurrent miscarriages answered a set of questionnaires, including the Impact of Events Scale (Horowitz, Wilnwe, & Alvarez, 1979), the Perinatal Grief Scale (Toedter, Lasker, & Qlhadeff, 1988), the Partnership Questionnaire (Hahlweg, 1979) and the Intimate Relationship Scale (Hetherington & Soeken, 1990). Results showed that men do grieve, but less intensely than their partners. Although the couple's relationship seemed to not be adversely affected by recurrent miscarriage, couples described sexual changes after those events. Grief was related to the quality of communication in the couple for women, and to the quality of sex life for men.

Remembered parenting style and psychological well-being in young adults whose parents had experienced early child loss

BACKGROUND

Pre-, peri-, or postnatal childloss can have devastating consequences for bereaved families. This study explored the long-term sequelae of these experiences for the young adult siblings' psychological well-being and the perceived quality of parenting received during participants' first 16 years of life.

METHODS

A bereaved group of young adult siblings was compared to a non-bereaved group on the Parent Bonding Instrument, the Rosenberg Self-esteem Scale and the Mental Health Index-5.

RESULTS

The loss group reported their mothers, but not their fathers, to have been more protective/controlling than non-bereaved participants. No differences between the loss group and the comparison group were found for parental care, their own mental health or self-esteem. Those participants whose siblings died during the peri/post-natal period perceived their parents as more controlling than the miscarriage group as well as the non-bereaved group. Higher protection scores were evident among those born subsequent to the loss than those who were born before. Lower levels of protection were associated with better mental health across all groups. In the non-bereaved group lower levels of protection were associated with better self-esteem, but in the bereaved group a different even opposite pattern was shown.

CONCLUSIONS

Young adults who lost a sibling when they themselves were under 5 recall their mothers as more protective/controlling than non-bereaved groups, although they do not report less care nor differ in mental health nor self-esteem. Higher levels of parental protection/control were found where the child was born subsequent to loss and for peri/post-natal loss rather than miscarriage. While high protection was associated with poorer mental health regardless of loss this may not be necessarily disadvantageous to the child's self-esteem. Differences with regard to parent gender were found.

Fathers’ Perspectives During Pregnancy, Postperinatal Loss

OBJECTIVE

To present information about the father's perspective during the experience of a pregnancy following perinatal loss.

DESIGN

Descriptive phenomenology.

SETTING

Interviews were done in a venue chosen by fathers (home, clinic).

PARTICIPANTS

Ten fathers who had experienced a loss within the prior year and were currently with that partner in a subsequent pregnancy. FOUR THEMES EMERGED: Recognition, preoccupation, stoicism, and support.

CONCLUSIONS

Participants describe the need to be recognized by others. The orderly conduct of their daily lives is disrupted by preoccupation with the pregnancy. They feel unable to share their own anxiety and fear because they want to protect the mothers. Societal pressure to "be strong" and the belief that "men don't share" appear to inhibit fathers from getting support. Strategies to assess and support fathers emotionally at the time of loss and in the subsequent pregnancy need to be explored.

Psychological consequences of termination of pregnancy for fetal anomaly: similarities and differences between partners

OBJECTIVE

We examined the psychological responses to termination of pregnancy (TOP) for fetal anomaly from both men and women. The aim was to find risk factors for poor psychological outcome both for the individuals and for the couple.

METHODS

A cross-sectional study was performed in 151 couples 2-7 years after TOP. We used standardized and validated questionnaires to investigate grief, symptoms of posttraumatic stress, somatic complaints, anxiety, and depression.

RESULTS

Most couples adapted well to their loss, although several patients had pathological scores on posttraumatic stress symptoms and depression. Differences between men and women were slight. Higher education, good partner support, earlier gestational age, and life-incompatibility of the disorder positively influenced the outcomes, more for women than for men. Men and women with pathological scores rarely had such scores simultaneously.

CONCLUSION

We emphasize the importance of equally involving both parents in the counselling because the outcomes of grief and posttraumatic stress symptoms between men and women only moderately differ and post-TOP psychopathology occurs in men as well. Good adjustment to TOP in women seems dependent on the level of support that they perceive from their partners. The intracouple results of the study suggest a mutual influence in the process of grieving between the partners.

Anxiety following miscarriage and the subsequent pregnancy: a review of the literature and future directions

OBJECTIVE

This is the first comprehensive review to summarize the research literature regarding anxiety symptomatology and disorders following miscarriage.

METHODS

Both "controlled" and "uncontrolled" designs are considered, with the inferential limitations of studies lacking comparison groups highlighted.

RESULTS

The limited research available suggests that miscarrying women are at increased risk for anxiety symptoms immediately following miscarriage and continuing until approximately 4 months post-loss. Beyond 4 months, reports are inconsistent. There is evidence to suggest increased risk for some anxiety disorders in the 6 months following loss; however, studies using larger sample sizes and comparison groups are needed.

CONCLUSIONS

This is the first review to consider the incidence of anxiety disorders following miscarriage, as well as the psychological impact of loss on the pregnancy subsequent to miscarriage, and the impact on partners of miscarrying women. Areas warranting further study are noted and are intended to guide future investigation.

Miscarriage effects on couples' interpersonal and sexual relationships during the first year after loss: women's perceptions

OBJECTIVES

To describe inductively women's perceptions of the effects of miscarriage on their interpersonal and sexual couple relationships (IR and SR); and, guided by the Lazarus Emotions and Adaptation Model, to compare IR and SR patterns 1 year after loss for differences in backgrounds, contexts, appraisals, reappraisals, and emotions.

METHODS

This was a secondary analysis of data gathered at 1, 6, 16, and 52 weeks postmiscarriage from 185 women. Text data were content-analyzed. Relationship differences were examined using MANCOVA with Bonferroni adjusted pairwise comparisons.

RESULTS

There were three relationship patterns: closer, as it was, and more distant. At 1 year, women whose IR (44%) was as it was (vs. closer [23%] or more distant [32%]) or whose SR (55%) was as it was (vs. more distant [39%]) coped less passively and appraised less miscarriage impact. Women whose IR or SR was as it was (vs. closer) were more likely to have children and (vs. more distant), miscarried at an earlier gestation, conceived again, and experienced fewer negative events. Those whose IR was closer or as it was and whose SR was as it was (vs. IR or SR more distant) had less disturbed emotions, more emotional strength, and partners who performed more caring acts. Women whose IR was closer and whose SR was as it was (vs. more distant) had partners who engaged in more mutual sharing.

CONCLUSIONS

Women differed in perceptions of how miscarriage affected their IR and SR. The Lazarus Model helped explain those differences.

Women's Perceptions of Partner Support in the Context of Pregnancy Loss(es)

Misunderstandings concerning expected and perceived support and expectations about how to grieve at the time of pregnancy loss have the potential to create stress within a partner dyad. Audio-recorded, semi-structured interviews, with eight women from varying contexts, were transcribed and analysed using Charmaz' grounded theory in this qualitative study. Voices of these participants express their perceptions regarding the support they feel they did, or did not receive at this time. Some women were unable to turn to their partners due to existing relationship problems. Many women were able to turn to their partners, but some found that support was not sustained. Women appear to want emotional support from their male partners. When this is not forthcoming, they may perceive their partners' support as negative or lacking. Potential areas of conflict are highlighted and suggestions are made regarding helpful informational support from health professionals.

Pregnancy loss: what it means to women who miscarry and their partners

This paper reports results from six women who had miscarried and their partners in Melbourne. A qualitative approach, namely in-depth semi-structured interviews, was utilised to obtain information. Several themes emerged from the data. The findings of this study show that women and men experienced a variety of feelings in reaction before, during and after the miscarriage. These feelings varied in type, intensity, and duration in which the men generally experienced less intense feelings for a shorter period of time as compared to the women. We argue that support and counselling be provided not only for women who miscarry, but also for their male partner, as the men may have fewer means to express their grief due to the "social expectation" of male roles.

Coping with grief after involuntary pregnancy loss: perspectives of African American women

OBJECTIVE

To present the coping strategies used by African American women following their miscarriages, ectopic pregnancies, fetal deaths, and still-births, which the authors have termed involuntary pregnancy losses or IPLs.

DESIGN

Semistructured audiotaped interviews; grounded theory methods used to collect and analyze the data.

SETTING

Urban community-based sites in the Western United States.

PARTICIPANTS

20 African American adult women who reported a history of involuntary pregnancy loss within 3 years of interview.

RESULTS

In this study, the women's responses to their IPL were grouped into four areas. They coped with personal reactions, reactions of others, memories of the baby, and subsequent pregnancies.

CONCLUSION

The women in this study used inner resources to develop self-help strategies to cope with reactions following IPL. Nurses are challenged to harness the influence of family, friends, religion, and cultural traditions to assist women in processing the cognitive, emotional, and social traumas associated with IPL. Educating women to recognize grief responses after IPL and to manage these responses effectively may prevent adverse outcomes to their physical and mental health. A culturally sensitive framework of clinical assessment and intervention for African American women experiencing IPL has been developed.

Effects of an Educational Bereavement Program on Health Care Professionals' Perceptions of Perinatal Loss

BACKGROUND

The purpose of this study was to examine the differences in health care professionals' perceptions of perinatal loss situations before and after an educational program on perinatal bereavement.

METHOD

A quasi-experimental design was used in a pretest and posttest format.

RESULTS

Scores were significantly higher (p = .000) on each of the posttest vignettes. Overall scores were lowest for the miscarriage pretest, whereas scores for the pretest vignettes for the stillbirth and neonatal loss were similar. A similar pattern occurred in the posttest vignette scores.

CONCLUSION

Health care professionals' perceptions of the emotional care needs of families experiencing perinatal loss were significantly increased after an educational program. The miscarriage vignette had the largest change score and the lowest mean scores on the pretest and posttest, which indicates professionals do not view miscarriage as significant a loss as stillbirth and neonatal loss.

Evaluating a Support Group for Perinatal Loss

PURPOSE

This study attempted to determine if a support group intervention makes a difference in grief reactions of parents who have experienced a perinatal loss, and describes what parents perceived as being helpful and not helpful in handling the loss.

DESIGN

A cross-sectional, retrospective, two-group research design was used. The independent variable was having attended or not having attended a perinatal loss support group.

METHODS

A convenience sample of 121 participants (n = 67 in support groups; n = 51 not in support groups) was obtained from a mail survey to families who were on a perinatal loss support newsletter mailing list. The participants completed the Hogan Grief Reactions Checklist and a demographic questionnaire.

RESULTS

There were no statistically significant differences in parents' grief reaction scores between the two groups, but there were some differences in grief scores by gender and ethnicity. In both groups, the parents perceived their spouse, their extended families, and their friends as "most helpful." Physicians were perceived as "least helpful."

CLINICAL IMPLICATIONS

Grief is very individual, and not all individuals may benefit from a support group. When suggesting a support group or any intervention, timing and a caring approach are essential.

Exploring Fathers’ Experiences of Pregnancy After a Prior Perinatal Loss

PURPOSE

To explore fathers' experiences of pregnancy after a prior perinatal loss.

STUDY DESIGN AND METHODS

This phenomenological study used unstructured, in-depth interviews with four men whose wives were currently pregnant subsequent to previous perinatal loss in the second or third trimester.

RESULTS

Regardless of the timing of the loss or their investment in the previous pregnancy, fathers expressed anxiety about the outcome of the subsequent pregnancy, a heightened sense of risk, and a need for increased vigilance. Themes concerning the intensity of the loss experience, dealing with grief, spirituality, supporting their spouse, influence of the previous loss, replacement of the loss, the importance of milestones, and change in world view were described.

CLINICAL IMPLICATIONS

This study can provide insight for nurses into the needs of these families during a subsequent pregnancy and can help nurses to better support fathers during this critical time.

The Impact of Postpregnancy Loss Services on Grief Outcome: Integrating Research and Practice in the Design of Perinatal Bereavement Programs

A national sample of 249 bereaved mothers and 114 of their male partners was investigated retrospectively, using a mailed questionnaire and the Perinatal Grief Scale, to determine the impact of postpregnancy loss services on grief outcome. Participants ranged in age from eighteen to forty-seven and experienced from one to twelve pregnancy losses with gestational age of two to forty-two weeks. A three-stage multiple regression analysis determined that predictors differed by gender and that services contributed to the prediction of grief outcome above and beyond demographic variables. Significant predictors for mothers were months since loss, attending counseling, and attending support group; significant predictors for fathers were length of pregnancy, talking with friends, and timing of talking with family. A large-scale longitudinal study that controls for service variables could inform the development of future perinatal bereavement programming in addressing the unique needs of bereaved mothers and fathers.

A Loss of Innocence and a Gain in Vulnerability: Subsequent Pregnancy after a Loss

Each year in the United States, there are 650,000 miscarriages, 30,000 stillbirths, and 30,000 newborn deaths. Many of the families who suffer these losses will become pregnant again; however, the crisis of loss and grief responses leave the family feeling more vulnerable to the unexpected during the next pregnancy. For most families, the next pregnancy is fraught with anxiety and fear. Health care professionals need to be aware of these families' responses to loss, concerns, and needs for support during the next pregnancy. Therefore, the purpose of this article is to provide an understanding of the impact of early pregnancy loss, perinatal loss, and subsequent pregnancy loss, based on research findings. Interventions, based on the research findings, that health care professionals might use in offering anticipatory guidance, information, and support during this time are also offered.

Predicting depressive symptoms after miscarriage: a path analysis based on the Lazarus paradigm

Twenty percent of all pregnancies end in miscarriage. Findings are mixed about who is most at risk for a depressive response. The purpose of this study was to develop and test a theory-based path model that would enable prediction of the intensity of women's depressive symptoms at 4 months and at 1 year after miscarriage. The model is based on Lazarus's theory of emotions and adaptation. Model constructs examined included stage I contextual variables (gestational age, number of miscarriages, number of children, maternal age, perceived provider caring at the time of loss, and family income), stage II interceding variables (perceived social support, emotional strength, and subsequent pregnancy/birth), stage III primary appraisal of meaning (personal significance of miscarrying), stage IV secondary appraisal (active or passive coping), and stage V emotional response (depressive symptoms). Path analysis employing a series of stepwise, multiple regression equations was used to test the hypothesized model. The sample consisted of 174 women whose pregnancies ended prior to 20 weeks gestation (mean = 10.51, SD = 3.32). The model accounted for 63% of the variance in women's depressive symptoms at 4 months and 54% at 1 year. Findings support the utility of the Lazarus model and confirm that women most at risk for increased depressive symptoms after miscarriage are those who attribute high personal significance to miscarriage, lack social support, have lower emotional strength, use passive coping strategies, have lower incomes, and do not conceive or give birth by 1 year after loss.

Risk factors and interventions for psychological sequelae in women after miscarriage

Spontaneous abortion occurs in about one in five pregnancies, and for many women can lead to significant psychological sequelae. This article reviews the literature on the psychological morbidities after pregnancy loss, their risk factors, differences in partner's reactions, potential screening tools and interventions for physicians. The most common reactions women experienced after pregnancy loss were grief, depression, and anxiety, with rates cited of approximately 40%, 12-50%, and 22-41%, respectively. Risk factors for these reactions include having a past psychiatric history, poor social support, no living children, lack of knowledge about miscarriages, and having no explanation for the event. Women's partners also show grief reactions after pregnancy loss, but they grieve less intensely and for a briefer time than women. Men also tend to talk less about their feelings. Women consistently express a desire to have follow-up appointments after a miscarriage, and have a high (75%) show rate when physicians offer them follow-up appointments. The 30-item General Health Questionnaire has good sensitivity and specificity in detecting psychological morbidity after miscarriage. Based on our review we recommend that ob/gyns offer women a follow-up appointment two to three weeks after miscarriage. By using a screening tool such as the General Health Questionnaire and asking about potential risk factors, ob/gyns should be able to effectively identify and refer high risk women to a psychiatric consultant.

Research-based practice with women who have had miscarriages

PURPOSE

To summarize a research-based description of what it is like to miscarry and to recommend an empirically tested theory of caring for women who have experienced miscarriage.

DESIGN

The research program included three phases: interpretive theory generation, descriptive survey and instrument development, and experimental testing of a theory-based intervention.

METHODS

Research methods included interpretive phenomenology, factor analysis, and ANCOVA.

FINDINGS

A theory of caring and a model of what it is like to miscarry were generated, refined, and tested. A case study shows one woman's response to miscarrying and illustrates clinical application of the caring theory.

CONCLUSIONS

The Miscarriage Model is a useful framework for anticipating the variety of responses women have to miscarrying. The caring theory is an effective and sensitive guide to clinical practice with women who miscarry.

Effects of caring, measurement, and time on miscarriage impact and women's well-being

BACKGROUND

Responses to miscarriage range from relief to devastation, yet there have been no randomized controlled studies that demonstrate significant effects of counseling with women who miscarry.

OBJECTIVE

To test the effects of caring-based counseling, measurement, and time on the integration of loss (miscarriage impact) and women's emotional well-being (moods and self-esteem) in the first year after miscarrying.

METHOD

ANCOVA was used in this randomized, longitudinal Solomon four-group experimental investigation. Enrolled were 242; 185 completed. Outcomes included: self-esteem, overall emotional disturbance, anger, depression, anxiety, confusion, overall miscarriage impact, personal significance, devastating event, lost baby, and isolated.

RESULTS

During the first year after loss (a) caring was effective in reducing overall emotional disturbance, anger, and depression; and (b) time passing led to increased self-esteem and decreased anxiety, depression, anger, confusion, and personal significance of loss.

CONCLUSION

Caring, measurement, and time had some positive and significant effects on the integration of loss and enhancement of well-being in the first year subsequent to miscarrying.