Initial adaptation in mothers and fathers following perinatal loss

Depression, anxiety, PTSD, and OCD after stillbirth: a systematic review

BACKGROUND

This systematic review aimed to provide an updated summary of studies investigating depression, anxiety, post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD) in parents after stillbirth (from 20 weeks gestational age until birth).

METHODS

A literature search was conducted in the databases Web of Science and PsychINFO. Main inclusion criteria were 1) peer-reviewed, quantitative, English-language articles published from 1980; (2) studies investigating depression, anxiety, PTSD, or OCD among parents following stillbirth; and (3) studies defining stillbirth as equal to or after 20 weeks of gestation.

RESULTS

Thirteen quantitative, peer-reviewed articles were eligible for inclusion. Selected articles investigated depression, anxiety, and PTSD, while no studies on OCD met our inclusion criteria. The majority of studies investigated women, while only two studies included men. The results indicated heightened short- and long-term levels of depression, anxiety, and PTSD in parents after stillbirth compared to those of parents with live birth. Studies investigating predictors found that social support, marital status, negative appraisals, and variables related to care and management after stillbirth affected levels of symptoms.

CONCLUSIONS

Parents who experience stillbirth have a considerably higher risk of reporting symptoms of depression, anxiety, and PTSD compared with parents with live births. More longitudinal studies are needed to increase our knowledge of how symptoms develop over time, and more research on fathers, transgender, non-binary and gender fluid individuals is needed. Research on the association between stillbirth and OCD is also warranted. Knowledge of the severity of anxiety, depression, and PTSD after stillbirth, and predictors associated with symptom severity could provide healthcare professionals with valuable information on how to provide beneficial postpartum care.

Australian Heterosexual Men's Experiences of Pregnancy Loss: The Relationships Between Grief, Psychological Distress, Stigma, Help-Seeking, and Support

This study explores experiences of pregnancy loss via a questionnaire completed by a convenience sample of 48 Australian cisgender heterosexual men. The questionnaire included measures of support following pregnancy loss, recognition of loss, perceived utility of help-seeking, perceived stigma attached to help-seeking, perinatal grief, and depression and anxiety. The questionnaire also included open-ended questions focused on help-seeking and support. Higher levels of grief were related to higher levels of both depression and anxiety. Perceptions about stigma were related to the perceived utility of help-seeking. While a majority of participants had accessed formal support services, feeling supported was unrelated to either grief or depression. Participants emphasized the utility of men's groups where members have experienced pregnancy loss, though barriers to support were also identified in terms of the unavailability of support or the perceived need to focus on a partner's loss.

Care quality following intrauterine death in Spanish hospitals: results from an online survey

BACKGROUND

The objective of the study was to evaluate practices in Spanish hospitals after intrauterine death in terms of medical/ technical care and bereavement support care.

METHODS

A cross-sectional descriptive study using an online self-completion questionnaire. The population was defined as women who had experienced an intrauterine fetal death between sixteen weeks and birth, either through spontaneous late miscarriage/stillbirth or termination of pregnancy for medical reasons. Respondents were recruited through an online advertisement on a stillbirth charity website and social media. The analysis used Pearson's chi-squared (p ≤ 0.05) test of independence to cross-analyse for associations between objective measures of care quality and independent variables.

RESULTS

Responses from 796 women were analysed. Half of the women (52.9%) had postmortem contact with their baby. 30.4% left the hospital with a least one linking object or a photograph. In 35.8% of cases parents weren't given any option to recover the body/remains. 22.9% of births ≥26 weeks gestation were by caesarean, with a significant (p < 0.001) difference between public hospitals (16.8%) and private hospitals (41.5%). 29.3% of respondents were not accompanied during the delivery. 48.0% of respondents recalled being administered sedatives at least once during the hospital stay. The autopsy rate in stillbirth cases (≥ 20 weeks) was 70.5% and 44.4% in cases of termination of pregnancy (all gestational ages). Consistent significant (p < 0.05) differences in care practices were found based on gestational age and type of hospital (public or private), but not to other variables related to socio-demographics, pregnancy history or details of the loss/death. Intrauterine deaths at earlier gestational ages received poorer quality care.

CONCLUSIONS

Supportive healthcare following intrauterine death is important to women's experiences in the hospital and beneficial to the grief process. Many care practices that are standard in other high-income countries are not routine in Spanish hospitals. Providing such care is a relatively new phenomenon in the Spanish health system, the results provide a quality benchmark and identify a number of areas where hospitals could make improvements to care practices that should have important psychosocial benefits for women and their families.

The impact of pregnancy loss on men's health and wellbeing: a systematic review

Background

Research indicates that men’s psychological and physical health outcomes after pregnancy loss differ from those of women. Our goal was to identify all literature with a focus on men’s experiences of pregnancy loss in order to outline current evidence concerning men’s wellbeing.

Methods

A systematic review of literature on men and pregnancy loss was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), Joanna Briggs Institute (JBI) and Social Care Institute for Excellence (SCIE) guidelines. Literature was sourced from PsycINFO, PubMed, Scopus, CINAHL, and Google Scholar. Inclusion criteria were 1) studies that focused on pregnancy loss (including miscarriage, stillbirth, and ectopic pregnancy, 2) that men’s voices were specifically represented, and 3) that studies were of primary data.

Results

A final sample of 29 articles was identified, of which 16 were quantitative, 10 qualitative, and 3 mixed methods. Quantitative and mixed methods studies indicated that while men tended to have less intense and less enduring levels of negative psychological outcomes than women, they are more likely to engage in compensatory behaviours, such as increased alcohol consumption. Qualitative studies indicated that men often feel that their role is primarily as a ‘supporter’ to their female partner, and that this precludes recognition of their own loss. These studies also reported that men may feel overlooked and marginalised in comparison to their female partners, whose pain is typically more visible.

Conclusions

Further research is needed on men’s experiences of pregnancy loss, focusing on cultural differences. The experience of gay and/or transgender men who face pregnancy loss is overlooked in the literature to date.

Losing Thomas & Ella: A Father's Story (A Research Comic)

"Losing Thomas & Ella" presents a research comic about one father's perinatal loss of twins. The comic recounts Paul's experience of the hospital and the babies' deaths, and it details the complex grieving process afterward, including themes of anger, distance, relationship stress, self-blame, religious challenges, and resignation. A methodological appendix explains the process of constructing the comic and provides a rationale for the use of comics-based research for illness, death, and grief among practitioners, policy makers, and the bereaved.

Meaning-making after neonatal death: narratives of Xhosa-speaking women in South Africa

The death of a neonate can be traumatic for mothers, resulting in profound grief which ruptures their sense of coherence and identity. A narrative approach was used to explore how six Xhosa-speaking women tell stories about the death of their baby to help them understand the significance of the loss. They struggled to establish a sense of their baby as a person to be mourned, to redefine their own identity, and to find reasons for the death. Their meaning-making was influenced by the baby's father, older women in their community, and the context of deprivation in which they live.

Recurrent perinatal loss: a case study

To date, investigators have not demonstrated a clear relationship between a parent's history of prior perinatal losses and intensity of grief response following a subsequent perinatal loss. Examining this relationship for low-income, African-American parents is important because they are a vulnerable population due to the high incidence of perinatal mortality in Blacks and their other life stressors that can impact on grief response and caring needs. The purpose of this case study was to examine the impact of recurrent perinatal loss on a low-income African-American parent. The research design for this study was case report, using interview data collected from a mother who had recently experienced her fourth perinatal loss, which occurred at twenty-five weeks of gestation. Transcripts from two open-ended interviews were analyzed. The theoretical framework used to guide analysis of this case study was Lazarus and Folkman's stress and coping theory. Results demonstrated that the prior perinatal losses did not appear as critical components of the way the mother responded to her most recent loss. Instead, perception of the care she received from healthcare providers and how that care related to her experiences with her one living child who was born at the same gestational age was an important determinant in how she responded to her loss. The results of this case study demonstrate the importance assessing a person's perception of their experience and those factors which contribute to the way they respond.

Negative self-conscious emotion and grief: an actor-partner analysis in couples bereaved by stillbirth or neonatal death

OBJECTIVES

The purpose of the present study was to examine the intrapersonal (actor) and interpersonal (partner) relationships of personality proneness to negative self-conscious emotion (shame and guilt) to grief in couples 13 months after a perinatal death.

DESIGN

A cohort study using self-report questionnaire measures of grief, shame, and guilt.

METHODS

The participants were 63 Australian couples bereaved by stillbirth (N= 31) or neonatal death (N= 32). The actor and partner relationships of chronic shame (Personal Feelings Questionnaire-2), situational shame (Test of Self-Conscious Affect-2), and survivor guilt and omnipotence guilt (Interpersonal Guilt Questionnaire-67) to grief (Perinatal Grief Scale-33) were explored using the Actor-Partner Interdependence Model (APIM) method of dyadic analysis.

RESULTS

The correlations between the self-conscious emotions and grief were invariably larger in men compared with women. Chronic shame had a significant actor relationship with grief in women and men and a non-significant partner relationship in both sexes. Situational shame and survivor guilt had significant actor relationships with grief in men and significant partner relationships in women. Omnipotence guilt had a significant linear actor relationship with grief in men and a significant U-shaped quadratic actor relationship in women.

CONCLUSIONS

Negative self-conscious emotions had intrapersonal relationship with grief in men and both intrapersonal and interpersonal relationships with grief in women. A moderate level of omnipotence guilt was associated with lower grief in women. APIM dyadic analysis furthers understanding of the relationship between personality and parental grief following a perinatal death.

How Couples Cope With the Death of a Twin or Higher Order Multiple

Fifty-two Australian couples who had experienced the death of at least one member of a multiple birth (twin or higher order), with at least one survivor of that birth, were interviewed about their experiences at the time of the death, and since. This study compared parents' coping after the twins' deaths using the Beck Depression Inventory II, Perinatal Grief Scale, and unstructured interviews with some structured queries. Parents provided information on the influence of family, community and medical staff. According to retrospective reports, mothers experienced significantly more depression and grief than fathers at the time of loss. Both parents found the death of their twins grievous, but fathers, unlike mothers, were not encouraged to express their emotions. Although parents generally agreed about what helped them cope, fathers believed that they should be able to cope regardless of their grief. The strength of parents' spiritual beliefs had increased significantly since their loss, and there was some evidence that depressed and grieving mothers turned to spiritual support. Parents whose children died earlier reported levels of depression similar to those reported by parents whose children died later. To date, this is the largest study of grief in couples who have experienced the death of a twin and who have a surviving twin or higher order multiple.

Evaluating a bereavement follow-up intervention for grieving fathers and their experiences of support after the death of a child--a pilot study

This article describes a study designed to evaluate the effectiveness of an intervention program for bereaved fathers and their experiences of it in a sample of intervention (n = 62) and control (n = 41) fathers. Data were collected by 3 scales: the Hogan Grief Reactions Checklist, a scale for measuring received social support, and a scale for measuring fathers' experiences of the intervention program. Assessment at 6 months after leaving the hospital showed that intervention fathers reported lower grief reaction scores and stronger personal growth. Intervention fathers reported the most emotional support from both health care personnel and peer supporters. The support received was perceived as helpful in coping, and fathers rated the intervention favorably. The findings support the continuation of the intervention.

Perinatal loss and parental grief: the challenge of ambiguity and disenfranchised grief

Following perinatal loss, a type of ambiguous loss, bereaved couples struggle with and experience distress due to various forms of ambiguity. Moreover, the juxtaposition of their grief with society's minimization often disenfranchises them from traditional grieving processes. The purpose of this study was to explore sources of ambiguity and disenfranchised grief related to perinatal loss. Audio-taped interviews with 13 bereaved couples at 2, 6, and 13 months following the death of their fetus or infant were analyzed. Several categories of ambiguity and disenfranchised grief emerged, pertaining to: (a) the viability of the pregnancy; (b) the physical process of pregnancy loss; (c) making arrangements for the remains; and (d) sharing the news. This study uncovers the many sources of ambiguity and disenfranchised grief that bereaved couples face in interactions with family, friends, society, and healthcare professionals. These insights may inform healthcare professionals in their attempts to ease distress related to perinatal loss.

Validation of the Perinatal Grief Scale for use in Chinese women who have experienced recent reproductive loss

The primary objective of this research was to validate the short version of the Perinatal Grief Scale (SVPGS) in the Chinese population. The Chinese SVPGS was administered to a sample of Chinese women who had experienced recent reproductive loss (N = 314). The results of the confirmatory factor analysis rejected the original 3-factor model delineated by Potvin (1989). A follow-up exploratory factor analysis suggested an alternative 3-factor model, consisting of a 12-item Sense of Worthlessness subscale, a 7-item Social Detachment subscale, and a 7-item Painful Recollection subscale. Further analysis showed that both the original and Chinese SVPGS demonstrated good internal consistency. Cronbach's alpha equaled .86, .83, .90, and .95, respectively, for the three subscales of Active Grief, Difficulty Coping, and Despair, and the total original SVPGS, and .85, .93, .91, and .95, respectively, for the new subscales of Sense of Worthlessness, Social Detachment, and Painful Recollection, and the total Chinese SVPGS. Both versions demonstrated satisfactory correlations with the participants' psychological distress and spousal emotional support. The authors suggest that both versions are useful in measuring the responses of Chinese women to reproductive loss; the original SVPGS should be used for cross-cultural studies, whereas the Chinese SVPGS should be used for local studies.

Psychosomatic approaches to obstetrics, gynaecology and andrology--a review

This review aims to clarify the scope and clinical importance of psychosomatic approaches to obstetrics, gynaecology and andrology. This gradually expanding sub-specialty covers a wide domain of complex disease conditions that can be managed more effectively if the various biological, psychological and social aspects are recognised at the start and concurrent treatment initiated. The current need to practise biopsychosocial management of disease conditions is highlighted along with a description of what this would involve. The nine-field psychosomatic approach, which can be applied to everyday clinical encounters, has been illustrated. Clinical applications of the psychosomatic approach are discussed for various conditions including chronic pelvic pain, eating disorders, tokophobia, post-traumatic stress disorder, depression, menstrual disorders, infertility, bereavement and testicular cancer. Cultural considerations and the need for further research are also briefly discussed.

Fathers' experience of social support after the death of a child

The aims of this study were to describe fathers' social networks and their experience of social support after the death of a child. The sample consisted of 8 fathers who had lost a child under the age of 3. The data were collected with open-ended questions and interviews. Data analysis used qualitative content analysis. The fathers' social support networks varied over time and between fathers. The support networks included either just the spouse or the spouse and other people. Social relationships broke down and new relationships formed in their place. The fathers experienced social isolation but also deliberately isolated themselves from human relationships. The support the fathers received was felt to be both positive and negative. Peer support was only positive. Support from professionals was reported to be important but was also criticized. In particular better family care, informal support, and systematic support after leaving the hospital were expected.

Psychological aspects of perinatal loss

After perinatal loss, parents experience painful grief. Fathers and mothers show the same pattern of symptoms, but generally mothers' distress is more intense. Grief should be sympathetically acknowledged by health professionals, and parents should be reassured that their feelings are normal and that recovery may take many months. Intense depression lasting more than 6 months may require psychological treatment. There is some evidence that delaying conception for a year may allow an easier pregnancy psychologically. The common practice of encouraging parents to have contact with a dead infant is not evidence-based and may have adverse effects, including inducing symptoms of post-traumatic stress disorder. A protocol of postnatal follow-up allows parents to get appropriate information about the loss, including possible problems and timing of another pregnancy. The subsequent pregnancy is stressful, and health professionals should recognize that parents may suffer significant anxiety.

The psychological effects of stillbirth and neonatal death on fathers: systematic review

OBJECTIVE

To review the available evidence on the psychological effects of perinatal death on fathers.

METHOD

Electronic search of CINAHL, MEDLINE and PsycINFO databases from 1966-2005.

INCLUSION CRITERIA

papers describing at least one psychological outcome for fathers who had experienced stillbirth or neonatal death.

EXCLUSION CRITERIA

papers not in English, dissertations, reviews, books without original data, intervention studies, studies of parents without separate results for fathers, studies where perinatal loss was not distinguished from other losses, first person accounts of a single experience, studies reporting on fewer than five fathers. Seventy-seven potential papers were obtained and screened by two authors. Seventeen studies were included. Study quality was rated using a checklist and main findings were summarized.

RESULTS

Quality of methodology varied. Qualitative studies described classical grief responses, but less guilt than mothers. Fathers described experiences related to their social role and potential conflict between grieving couples. Quantitative research reported symptoms of anxiety and depression, but at a lower level than mothers. Fathers may develop post-traumatic stress disorder following stillbirth.

DISCUSSION

Case prevalence of psychological disorders is unknown. More good quality research is needed. The social role of fathers as carers for their partners needs recognition when planning care for bereaved families.

Psychological impact of stillbirth on fathers in the subsequent pregnancy and puerperium

BACKGROUND

Approximately 1 in 200 UK pregnancies ends in stillbirth. Although serious psychological effects of stillbirth on mothers are well established, much less is known about the impact of such loss on fathers.

AIMS

To assess the psychological morbidity of fathers in the pregnancy and post-partum year subsequent to a stillbirth, to test within-couple effects and to identify risk factors.

METHOD

This was a community-based cohort study of 38 pregnant couples whose previous pregnancy had ended in stillbirth, and 38 pair-matched controls. Psychological assessments took place antenatally and at 6 weeks, 6 months and 1 year postnatally.

RESULTS

Fathers in the index group experienced significant levels of anxiety and post-traumatic stress disorder antenatally, but all of their symptoms remitted postnatally (after the birth of a live baby). Fathers' symptom levels were lower than those of mothers at all time points. In contrast to mothers, fathers experienced greater anxiety when a subsequent pregnancy (following stillbirth) was delayed.

CONCLUSIONS

The vulnerability of fathers to psychological distress during the pregnancy after a stillbirth needs to be recognised.

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.

Explanatory model of health in bereaved parents post-fetal/infant death

In order to identify which features contribute to attenuating or intensifying the deleterious consequences of a perinatal loss such that some family systems endure and sometimes even thrive when faced with such a situational stressor, while other family units seem to deteriorate and disintegrate under similar circumstances, an explanatory model of health was tested. The purpose of this longitudinal study was to examine how the relationships between the elements in the model namely: resources both internal (hardiness) and external (marital and social supports), as well as appraisal of the situation, predicted the health of 110 bereaved couples (husbands and wives).

Lang and Goulet Hardiness Scale: development and testing on bereaved parents following the death of their fetus/infant

The process of development and testing of the Lang and Goulet Hardiness Scale (LGHS), a self-report instrument designed to measure hardiness in bereaved parents following the death of their fetus/infant, is presented. Hardiness is a personal resource, composed of 3 interdependent components that are characterized by a sense of personal control over the outcome of life events and hardships such as the death of a fetus/infant, an active orientation toward meeting the challenges brought on by the loss, and a belief in the ability to make sense of one's own existence following such a tragedy. The concept of hardiness has been studied by various disciplines and in a multitude of settings to understand its ability to lessen potentially negative effects of life stress. However, it has never been studied within the context of parental bereavement. The LGHS was developed systematically, originating from a concept analysis. A panel of 15 experts was used to establish content validity.A pretest was conducted on 73 bereaved individuals to assess convergent and discriminant validity of the LGHS. Subsequently, a validation study on 220 bereaved parents who had experienced the death of their fetus/infant 2 months previously was conducted including a retest 6 months after the loss with 192 of the remaining participants. Analyses reveal that the LGHS is a valid and reliable instrument for measuring hardiness and that it is sensitive enough to detect changes in the construct over time.

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.

Weathering the storm of perinatal bereavement via hardiness

Hardiness is a personal resource that can potentially diminish negative effects of life stress. To increase understanding of the role that it can have on the health protection and promotion of bereaved parents following a perinatal loss, this article uses J. Wilson's (1969) method to present a concept analysis of hardiness. This analysis provides not only a fresh perspective for understanding the experience of perinatal loss but has also induced the development of a hardiness instrument. Knowledge development in this area is paramount for professionals interested in enabling bereaved parents to draw on and develop their hardiness, not only to transcend the experience but ultimately to gain a sense of personal growth following their loss.

International comparison of studies using the perinatal grief scale: a decade of research on pregnancy loss

The Perinatal Grief Scale (PGS) has been used in many studies of loss in pregnancy, including miscarriage, stillbirth, induced abortion, neonatal death, and relinquishment for adoption. This article describes 22 studies from 4 countries that used the PGS with a total of 2485 participants. Studies that report Cronbach's alpha for their own samples give evidence of very high internal consistency reliability. Evidence for the validity of the PGS is also reviewed, such as convergent validity seen in its association with measures of mental health, social support, and marital satisfaction. The standard errors of the means for the total scale and for the subscales reveal fairly consistent scores, in spite of very different samples and types of loss; computation of means and standard deviations for the studies as a whole permits us to establish normal score ranges. Significantly higher scores were found in studies that recruited participants from support groups and self-selected populations rather than from medical sources, and from U.S. studies compared with those in Europe.

Predicting Outcomes after Pregnancy Loss: Results from Studies Using the Perinatal Grief Scale

There are widely diverse findings in the literature on the types of variables that best predict grief following a pregnancy loss. This article compares the results from twenty-two studies, carried out in four countries, which all used the Perinatal Grief Scale as their outcome measure. Results of the comparison support the value of the measure for such investigations and indicate strong commonalities among the findings. Specifically, lower grief scores are consistently related to male gender, older age, shorter pregnancy, passage of more time since the loss, mental health, good marital relationship and social support, and a subsequent pregnancy. Conclusions suggest the need for studies that include more diverse populations and evaluate the impact of attributions, coping, and interventions following a loss.

Long-term impact of sudden infant death: a 12- to 15-year follow-up

To understand parents' subjective feelings, experiences, and understanding connected to the loss of a child over time, the authors chose semi-structured, in-depth interviews as the method of examination in a study of 26 parents who lost a child to sudden infant death syndrome (SIDS) between 1981 and 1984. In addition, parents were asked to complete different inventories to compare their present responses (1996) with their responses to the same inventories in 1981-1984. Most parents still viewed the death of their child as affecting their daily life in important ways. Inventory data show that gender differences have diminished 12-15 years after the loss, and few parents are psychologically at risk in 1996. The study clearly shows the benefit of method triangulation in providing a total picture of the parent's experiences.