Men's grief following pregnancy loss and neonatal loss: a systematic review and emerging theoretical model

BACKGROUND

Emotional distress following pregnancy loss and neonatal loss is common, with enduring grief occurring for many parents. However, little is known about men's grief, since the majority of existing literature and subsequent bereavement care guidelines have focused on women. To develop a comprehensive understanding of men's grief, this systematic review sought to summarise and appraise the literature focusing on men's grief following pregnancy loss and neonatal loss.

METHODS

A systematic review was undertaken with searches completed across four databases (PubMed, PsycINFO, Embase, and CINAHL). These were guided by two research questions: 1) what are men's experiences of grief following pregnancy/neonatal loss; and 2) what are the predictors of men's grief following pregnancy/neonatal loss? Eligible articles were qualitative, quantitative or mixed methods empirical studies including primary data on men's grief, published between 1998 and October 2018. Eligibility for loss type included miscarriage or stillbirth (by any definition), termination of pregnancy for nonviable foetal anomaly, and neonatal death up to 28 days after a live birth.

RESULTS

A final sample of 46 articles were identified, including 26 qualitative, 19 quantitative, and one mixed methods paper. Findings indicate that men's grief experiences are highly varied, and current grief measures may not capture all of the complexities of grief for men. Qualitative studies identified that in comparison to women, men may face different challenges including expectations to support female partners, and a lack of social recognition for their grief and subsequent needs. Men may face double-disenfranchised grief in relation to the pregnancy/neonatal loss experience.

CONCLUSION

There is a need to increase the accessibility of support services for men following pregnancy/neonatal loss, and to provide recognition and validation of their experiences of grief. Cohort studies are required among varied groups of bereaved men to confirm grief-predictor relationships, and to refine an emerging socio-ecological model of men's grief.

TRIALS REGISTRATION

PROSPERO registration number: CRD42018103981.

Parent Distress and the Decision to Have Another Child After an Infant's Death in the NICU

OBJECTIVE

To examine associations among parent perceptions of infant symptoms/suffering, parent distress, and decision making about having additional children after an infant's death in the NICU.

DESIGN

Mixed-methods pilot study incorporating mailed surveys and qualitative interviews.

SETTING

Midwestern Level IV regional referral NICU.

PARTICIPANTS

Participants were 42 mothers and 27 fathers whose infants died in the NICU.

METHODS

Parents reported on infant symptoms/suffering at end of life and their own grief and posttraumatic stress symptoms. Qualitative interviews explored decision making about having additional children.

RESULTS

Approximately two thirds of bereaved parents had another child after their infant's death (62% of mothers, 67% of fathers). Mothers who had another child reported fewer infant symptoms at end of life compared with mothers who did not (p = .002, d = 1.28). Although few mothers exceeded clinical levels of prolonged grief (3%) and posttraumatic stress symptoms (18%), mothers who had another child endorsed fewer symptoms of prolonged grief (p = .001, d = 1.63) and posttraumatic stress (p = .009, d = 1.16). Differences between fathers mirrored these effects but were not significant. Parent interviews generated themes related to decision making about having additional children, including Impact of Infant Death, Facilitators and Barriers, Timing and Trajectories of Decisions, and Not Wanting to Replace the Deceased Child.

CONCLUSION

Having another child after infant loss may promote resilience or serve as an indicator of positive adjustment among parents bereaved by infant death in the NICU. Prospective research is necessary to distinguish directional associations and guide evidence-based care.

A Unitary Healing Praxis Model for Women in Despair

The evolution of a unitary healing praxis model derived from three unitary appreciative inquiries of despair is described. Explication of unitary appreciative inquiry and how it informed and contributed to the development of the model is provided. The model is based on a conceptualization of healing as appreciating the inherent wholeness of life and provides knowledge specific to the individual lives of women in despair. The process of generative theorizing that led to the creation of the model is explicated. Unitary, appreciative, and participatory responses to despair are integrated in the model, praxis modalities are delineated, key concerns and perspectives of women in despair are addressed, and potentialities for healing are illustrated.

Coping With Stillbirth Among Ultraorthodox Jewish Women

Stillbirth is a traumatic prenatal loss with personal, familial, and social implications. We explored the meaning of stillbirth for ultraorthodox Israeli women for whom grieving for prenatal loss derived from the power of faith. We conducted semistructured interviews with ten ultraorthodox women, ages 26 to 55, in a qualitative study that was focused on thematic content analysis and influenced by the phenomenological-hermeneutic tradition. The loss of the fetus was experienced as a test to the women's belief in God, and was perceived as a way to experience God's love. The women's faith became stronger and provided relief, calm, and confidence in God as benefactor. The meanings they attributed to their losses enabled them to move on. Findings are discussed in the context of research and theoretical literature on coping, bereavement, and mourning processes, and meaning for pregnancy-related losses. Awareness of ethnic meanings of stillbirth promotes implementation of culture-sensitive psychosocial interventions.

Reproductive performance in the next pregnancy for nulliparous women with history of first trimester spontaneous abortion

OBJECTIVE

To determine whether interpregnancy interval after the first spontaneous abortion has an effect on reproductive performance of women in their next pregnancy.

METHOD

A prospective cohort study was conducted on 4,619 women with history of spontaneous abortion in their first pregnancy. Of them 2,422 (52.4 %) conceived within 6 months of the miscarriage (group A) and 2,197 47.6 % after 12 months (group B). The primary outcome was abortion, live birth, termination, or ectopic pregnancy in the next pregnancy. Secondary outcomes were preterm delivery, low birth weight infants, caesarean section rate and occurrence of preeclampsia, placental abruption and induced labour in the second pregnancy.

RESULTS

Women who conceived again within 6 months were less likely to have another abortion, termination, or ectopic pregnancy compared with women with interpregnancy interval more than 12 months. Women with an interpregnancy interval more than 12 months were less likely to have live birth in the second pregnancy and more likely to have a caesarean section, preterm delivery, or infant of low birth weight compared with women who conceived again within 6 months.

CONCLUSIONS

Women who conceive within 6 months after their first spontaneous abortion have better reproductive outcomes and the lowest complication rates in their subsequent pregnancy.

Psychological effects of stillbirth

Despite the high prevalence globally, the death of a baby to stillbirth is an often misunderstood and disenfranchised loss. Mothers, fathers, and families struggle to cope with the immediate and long-lasting effects of a baby's death which can last for years and sometimes decades. In addition, providers can be adversely affected by stillbirth, particularly when met with experiential avoidance and a sense of guilt and failure. There is little evidence on intervention efficacy in acute grief following perinatal death; however, there is a growing body of scientific literature on the efficacy of mindfulness-based interventions in treating anxiety, depression, and other biopsychosocial maladies as well as improving patient satisfaction with psychosocial care. This paper explores one such intervention model, ATTEND (attunement, trust, therapeutic touch, egalitarianism, nuance, and death education), as a means to improve psychosocial care during both acute and chronic states of bereavement. Whereas the death of a baby to stillbirth is the ultimate paradox for providers and patients - the convergence of life and death and the fundamental contradiction it represents - with proper care and compassion, families stand a better chance in the face of such indescribable loss and they need not suffer alone.

National survey of obstetrician attitudes about timing the subsequent pregnancy after perinatal death

OBJECTIVE

After stillbirth or early infant death, parents often query when they can try for another pregnancy. We conducted a national survey of US obstetricians to assess attitudes about optimal timing of next pregnancy and advice given to parents.

STUDY DESIGN

The study was an anonymous mail survey of 1500 randomly selected US obstetricians asking about physician experiences with perinatal death.

RESULTS

In all, 804 of 1500 obstetricians completed the survey for a 54% usable response rate. Two-thirds of respondents endorsed a waiting time <6 months for parents bereaved by stillbirth who desired another pregnancy.

CONCLUSION

Physicians in this national survey supported very short interpregnancy intervals for parents bereaved by perinatal death. Responses may reflect efforts to support parents emotionally while recognizing individuals vary in coping and clinical circumstances. However, this is a provocative finding since short intervals may confer greater fetal risks for poor outcome.

The influence of prior perinatal loss on parents' psychological distress after the birth of a subsequent healthy infant

OBJECTIVE

To evaluate the long-term influence of a previous perinatal loss on parents' psychological distress during a subsequent childbearing experience.

DESIGN AND SAMPLE

A cohort design was used to examine 36 couples with a history of prior perinatal loss. Data were collected during the third trimester of pregnancy, 3 months postpartum, and again 8 months after birth.

MEASURES

Outcome measures included posttraumatic stress (The Impact of Event Scale), depressive symptoms (Center for Epidemiologic Studies-Depression Scale), anxiety (Spielberger State-Trait Anxiety Inventory), and parental concerns and attitudes (Maternal/Paternal Attitudes Questionnaire).

RESULTS

Levels of depressive symptoms (p<.001), anxiety (p<.001), and posttraumatic stress (p=.046) significantly decreased over time in this population. However, levels of posttraumatic stress remained in the moderate range even at 8 months after birth. Depression was significantly correlated with posttraumatic stress at each time point. In addition, depression was significantly related to posttraumatic stress, anxiety, and concerns parents had about their infant's well-being at T3.

CONCLUSION

While levels of anxiety and depressive symptoms decreased for parents who have experienced a previous perinatal loss, posttraumatic stress levels remained moderately high. It is unclear how this compares to parents without losses. These may be the unique symptoms and concerns these parents have about their new infant. Parents with a history of prior loss should have assessments carefully tailored to their experiences to anticipate continued psychological distress.

Stepping back to gain perspective: pregnancy loss history, depression, and parenting capacity in the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B)

Previous empirical studies of pregnancy loss have predominantly focused on complex grief response and emergent problems associated with future parenting in self-selected samples of bereaved women. This article presents findings from a retrospective secondary data analysis conducted with a racially and ethnically diverse sample of currently parenting women in the United States (N = 10,688) that examined the relationships among pregnancy loss history, current maternal depressive symptoms, and mother-infant interaction with the enrolled child. Study findings underscore a racial-ethnic disparity in pregnancy loss history for African American women, whereas current maternal depressive symptoms remain fairly constant across racial-ethnic groups. Multiple loss history is associated with a slight elevation in overall symptoms of depression, but there is no relationship between pregnancy loss history and current mother-infant interaction in the study sample. An important limitation in this study is that the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B) data does not allow for inferences specific to the type of loss, gestational age of fetus, time since loss, or whether the loss was spontaneous or induced. However, study findings highlight areas of incongruity between clinical and population-based research that deserve further investigation. Ultimately, the findings from this population-based research contribute to a wider perspective regarding maternal response to reproductive loss that can inform future research and targeted bereavement support.

Relation between grief and subsequent pregnancy status 13 months after perinatal bereavement

AIMS

The present longitudinal study sought to explore the relationship between parental grief following perinatal bereavement and subsequent pregnancy, according to the particular facets of grief and pregnancy state being considered.

METHOD

The study participants were 63 couples who had been bereaved by stillbirth (n = 31) or neonatal death (n = 32). The relationship of self-reported grief (Perinatal Grief Scale-33 Active Grief, Difficulty Coping and Despair) 1 month and 13 months after the loss to subsequent pregnancy status (Pregnant, n = 20, Live Baby, n = 10, Trying, n = 11, Not Trying, n = 22) at 13 months was investigated with repeated measures analysis of variance.

RESULTS

There were statistically significant main effects for Active Grief and Difficulty Coping in women and men and Despair in women, but not in men. There was a statistically significant Active Grief by pregnancy status interaction in women (F(3, 59) = 2.89, P = 0.04), but not in men. Simple main effects analysis indicated a statistically significant decrease in Active Grief in women who were pregnant (F(1, 59) = 52.8, P < 0.0005), women who were not pregnant and not trying to conceive (F(1, 59) = 27.5, P < 0.0005), and women who had had a live baby (F(1, 59) = 9.62, P = 0.003). There was no statistically significant decrease in Active Grief in women who were not pregnant but trying to conceive (F(1, 59) = 3.44, P = 0.07). The Difficulty Coping in women and men and Despair in women by pregnancy status interactions were not statistically significant. None of the between-subjects main effects for pregnancy status was statistically significant in women or men.

CONCLUSION

The relation between grief and subsequent pregnancy differed with the sex of the parent and the particular facets of grief and pregnancy state being considered. Subsequent pregnancy was related to Active Grief in women, but not to Difficulty Coping or Despair that are known to be predictors of chronic grief.

Social and Professional Support Needs of Families After Perinatal Loss

Perinatal loss has been associated with depression, anxiety, obsessive-compulsive disorder, suicide, marital conflict, and post-traumatic stress disorder. Nurses may provide professional support through teaching, role modeling, encouragement, counseling, problem solving, and other interventions. Nurses also may encourage more effective social support by helping significant others to provide willing, well-intentioned action that will produce a positive response in the bereaved couple. Interventions to increase professional and social support after perinatal loss are described.

Transforming loss: Taiwanese women's adaptation to stillbirth

AIM

To explore the experiences of Taiwanese mothers of stillborn babies, their coping strategies, and the ways in which their subsequent human interactions are shaped by Taiwanese culture.

BACKGROUND

Giving birth to a male family heir is still considered an important responsibility for Taiwanese women. The ideology of continuity is still at the centre of Chinese family life in which women are expected to deliver babies that will continue their husbands' family lines. Research on the connection between this responsibility and women's reaction to stillbirth in a cultural context is limited. Understanding Taiwanese women's experiences with stillbirth will add to the body of nursing knowledge, especially in terms of giving culturally competent nursing care.

METHODS

Interpretive ethnographic procedures were used to locate coping strategies. Twenty mothers who had stillbirth experiences were interviewed periodically during the 2 years following their losses. Following Agar's example, data were analysed to identify themes representing coping strategies.

FINDINGS

The four major themes identified were (a) transforming the meaning of death, (b) doing something for the deceased, (c) anticipating another pregnancy, and (d) rebuilding a social fabric.

CONCLUSION

The processes that the mothers of stillborn babies experience represent transformations that involve engagement with cultural expectations for woman. The authors suggest that these cultural impacts should be incorporated into nursing assessment and treatment practices.

One foot in-one foot out: weathering the storm of pregnancy after perinatal loss

Pregnancies after perinatal loss are oftentimes anxiety-laden and lacking in joy. This may lead to potential negative obstetrical and parenting outcomes. The purpose of this qualitative inquiry was to gain insights into women's pregnancy after perinatal loss experiences, including major features and helpful provider responses. Thirteen women, at varying points surrounding pregnancy after perinatal loss, participated in either a focus group or interview. An overall metaphor of "One Foot In-One Foot Out" and seven themes within four contexts emerged from the data. Women found themselves living within the contexts of (a) reliving the past, (b) trying to find a balance in the present, (c) recognizing their changed reality, and (d) living with wavering expectations. Seven themes characterized their navigation of the pregnancy: (1) setting the stage, (2) weathering the storm, (3) gauging where I am, (4) honoring each baby, (5) expecting the worst, (6) supporting me where I am, and (7) realizing how I've changed. Trying to stay balanced is the major challenge in pregnancy after perinatal loss.