Pregnancy continuation and organizational religious activity following prenatal diagnosis of a lethal fetal defect are associated with improved psychological outcome

Fatal fetal anomaly: Experiences of women and their partners

OBJECTIVE

This study explored the care experiences of parents whose pregnancy was diagnosed with a fatal fetal anomaly following the legalisation of termination of pregnancy in 2019 in Ireland.

METHODS

A qualitative study using in-depth semi-structured interviews and interpretative phenomenological analysis was undertaken. Purposeful sampling was used to recruit 10 parents, six women and four of their male partners. Parents recruited included those who terminated and continued the pregnancy.

RESULTS

Three superordinate themes were identified: 'Attachment and coping', 'There's no place for you in the pregnancy world' and 'Consistency of quality care'. Parents shared the different approaches and level of attachment to their baby that supported their coping. Regardless of the level of attachment, many parents benefited from the acts of remembrance. Parents expressed how they no longer felt they belonged in the 'pregnancy world' and described a need for healthcare professionals to recognise their loss and create a safe and supportive environment in which they could share their grief. Despite this, parents' accounts highlighted variations and inconsistencies in care and service provision.

CONCLUSION

Our study highlighted parents' need for consistent, well communicated, and comprehensive care, which encourages an individualised perinatal palliative care approach to meet parental needs.

"This pregnancy makes sense": Experiences of women who have decided to continue pregnancy after lethal fetal diagnosis

Lethal fetal diagnosis defines severe developmental disorders that lead to the death of a fetus or newborn. Using semi-structured interviews, we explored the experiences of women in Poland who actively decided to continue with the pregnancy after diagnosis. We thematically analyzed data collected from 10 women. We identified four themes: pregnancy as an experience of prenatal motherhood; the child as person; birth as encounter and farewell; and the mother experience in retrospect. This study was conducted while the termination of pregnancy due to the irreversible fetal abnormality was legal in Poland. Since October 2021, it is no longer legal.

The level of grief in women with pregnancy loss: a prospective evaluation of the first three months of perinatal loss

OBJECTIVE

To prospectively investigate perinatal grief in women with pregnancy loss.

METHODS

A total of 215 women (mean (SD) age: 30.7 (5.9) years) who experienced pregnancy loss were included. Data on sociodemographic, marital and obstetric characteristics and Perinatal Grief Scale (PGS) (first 48 h, 1 week, 1 month and 3 months after the loss) were recorded.

RESULTS

Active grief scores were lower (p ranged  < .05 to <.01), while difficulty coping (p < .05 for each) and despair (p < .05 for each) scores were higher in the 3rd month as compared with prior assessments. All PGS scores at the 48 h and 3rd month assessments were significantly higher in assisted and planned pregnancies (p < .01 for each). Maternal age was positively correlated with 48 h active grief (r = 0.19, p < .001), despair (r = 0.13, p < .05) and total PGS (r = 0.13, p < .05) scores. Parity and the number of children were negatively correlated (r ranged from -0.35 to -0.20, p < .01 for each) with all PGS scores.

CONCLUSION

Our findings revealed decrease in active grief levels, whereas gradual increase in difficulty coping and despair in women with pregnancy loss within the first 3 months of losing a child. Our finding indicate association of older maternal age, primiparity, assisted and planned pregnancies with regular antenatal follow up with higher total PGS scores as well as active grief, difficulty coping and despair scores in women regardless of the time of assessment within 3 months after the pregnancy loss.

Therapeutic termination of pregnancy and women's mental health: Determinants and consequences

The therapeutic termination of pregnancy (TToP) is an induced abortion following a diagnosis of medical necessity. TToP is applied to avoid the risk of substantial harm to the mother or in cases of fetal unviability. This type of induced abortion is provided after the second semester of gestation if fetal illness or the pregnancy cause physical danger or pathological mental distress to the mother. Socio-cultural and economic determinants could influence the desire for children and family planning in couples, as well as the use of effective contraception and the choice to perform an induced abortion. Also, pre-existing mental health problems could affect the decision between carrying on a problematic pregnancy or having TToP. Furthermore, the TToP is a reproductive event with an important traumatic burden, but also with an intrinsic therapeutic effect and it can produce different psychological and psychopathological effects on women and couples. The aim of this review is to evaluate what demographic, reproductive and psychopathological determinants are involved in the choice of undergoing a TToP in women. Also, we will examine both positive and negative consequences of this procedure on women's mental health, underlying which factors are related to a worse outcome in order to provide the best clinical support to vulnerable groups.

Depression and socioeconomic stressors in expectant parents with fetal congenital anomalies

OBJECTIVE

Congenital anomalies are increasingly diagnosed before birth, which may lead to psychological distress in expectant parents. While the presence of significant symptoms of depression and stress in these parents is established, understanding their context within parents' other life stressors has not been fully investigated. We sought to characterize the socioeconomic profile and depression symptoms of expectant parents in a quaternary care academic hospital's fetal care clinic.

METHODS

This prospective observational study enrolled pregnant persons and their partners in our fetal care clinic. The Edinburgh Postpartum Depression Scale (EPDS), Tool Assessing Patient Stress (TAPS), and a sociodemographic survey were utilized to assess parent psychological distress and socioeconomic stressors. Results were analyzed by the severity of the fetal anomaly. EPDS was repeated at two weeks postpartum.

RESULTS

21.7% of pregnant subjects and 25.0% of co-parents had a positive screen on the EPDS at enrollment during their pregnancy. Mothers' EPDS scores correlated with the severity of the fetal anomaly. Many parents reported socioeconomic stressors including: living remotely from the medical center, low household income, food insecurity, unemployment, or other employment concerns, and difficulty affording living expenses. Most also reported factors that can mitigate psychological distress including social support and participation in a religion or faith.

CONCLUSIONS

Expectant parents with fetal anomalies should be screened for depression as well as social and economic risk factors that place them and their infants at higher risk for poor health outcomes. Further work is needed to determine the optimum interventions for addressing their depression symptoms and reducing socioeconomic stressors.

Factors contributing to men's grief following pregnancy loss and neonatal death: further development of an emerging model in an Australian sample

Background

Historically, men’s experiences of grief following pregnancy loss and neonatal death have been under-explored in comparison to women. However, investigating men’s perspectives is important, given potential gendered differences concerning grief styles, help-seeking and service access. Few studies have comprehensively examined the various individual, interpersonal, community and system/policy-level factors which may contribute to the intensity of grief in bereaved parents, particularly for men.

Methods

Men (N = 228) aged at least 18 years whose partner had experienced an ectopic pregnancy, miscarriage, stillbirth, termination of pregnancy for foetal anomaly, or neonatal death within the last 20 years responded to an online survey exploring their experiences of grief. Multiple linear regression analyses were used to examine the factors associated with men’s grief intensity and style.

Results

Men experienced significant grief across all loss types, with the average score sitting above the minimum cut-off considered to be a high degree of grief. Men’s total grief scores were associated with loss history, marital satisfaction, availability of social support, acknowledgement of their grief from family/friends, time spent bonding with the baby during pregnancy, and feeling as though their role of ‘supporter’ conflicted with their ability to process grief. Factors contributing to grief also differed depending on grief style. Intuitive (emotion-focused) grief was associated with support received from healthcare professionals. Instrumental (activity-focused) grief was associated with time and quality of attachment to the baby during pregnancy, availability of social support, acknowledgement of men’s grief from their female partner, supporter role interfering with their grief, and tendencies toward self-reliance.

Conclusions

Following pregnancy loss and neonatal death, men can experience high levels of grief, requiring acknowledgement and validation from all healthcare professionals, family/friends, community networks and workplaces. Addressing male-specific needs, such as balancing a desire to both support and be supported, requires tailored information and support. Strategies to support men should consider grief styles and draw upon father-inclusive practice recommendations. Further research is required to explore the underlying causal mechanisms of associations found.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-020-03514-6.

Influence of Religiosity on Situational Coping Scores in Women with Malformed Fetuses

In clinical care settings, religiosity may serve as an important source of support for coping with the prenatal diagnosis of fetal abnormalities. This study evaluated the influence of religiosity on the situational coping of 28 pregnant women with fetal abnormalities. The study was approved by the institutional research ethics committee, and the informed consent document was obtained from all participants included in this study. Validated measures of religiosity and situational coping were used to evaluate data collected. Practical religiosity but not intrinsic religiosity correlated positively and significantly with coping scores. However, the severity of the fetal malformations did not correlate significantly with the scores of maternal coping. The results showed that religious practices were associated with improved coping in women diagnosed with fetal abnormalities and should be encouraged in care settings.

A systematic review of instruments measuring grief after perinatal loss and factors associated with grief reactions

OBJECTIVE

Expectant parents who live through perinatal loss experience intense grief, which is not always acknowledged or accepted. A screening tool to detect bereaved parents' grief reactions can guide professionals, including perinatal palliative care teams, to provide follow-up for those in need. This review's goal is to identify and synthesize the international published literature on existent instruments specifically measuring the grieving process after any perinatal loss and to identify factors that could moderate grief reactions.

METHOD

Systematic review (PROSPERO # CRD42018092555) with critical synthesis. PUBMED, Cochrane, and PsycINFO databases were searched in English language articles using the keywords "perinatal" AND ("grief" OR "bereavement" OR mourning) AND ("scale" OR "questionnaire" OR "measure" OR "assessment") up to May 2018. Eligibility criteria included every study using a measure to assess perinatal grief after all kinds of perinatal losses, including validations and translations to other languages and interventions designed to alleviate grief symptoms.

RESULTS

A total of 67 papers met inclusion criteria. Seven instruments measuring perinatal grief published between 1984 and 2002 are described. The Perinatal Grief Scale (PGS) was used in 53 of the selected studies. Of those, 39 analyzed factors associated with grief reactions. Six articles used PGS scores to evaluate pre- and post-bereavement interventions. Studies in English language only might have limited the number of articles.

SIGNIFICANCE OF RESULTS

The PGS is the most used standardized measures to assess grief after perinatal loss. All parents living through any kind of perinatal loss should be screened.

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.

Perinatal Palliative Care: A qualitative study evaluating the perspectives of pregnancy counselors

BACKGROUND

A prenatal diagnosis of a life-limiting disease raises complex ethical, emotional, and medical issues. Studies suggest that 40%-85% of parents decide to continue the pregnancy if given the option of Perinatal Palliative Care. However, structured Perinatal Palliative Care programs are missing in many European countries. In Germany, parents have the right to free psychosocial support from pregnancy counseling services after the prenatal diagnosis of a life-limiting disease.

AIM

We aimed to investigate whether German professional pregnancy counselors perceive the need for structured Perinatal Palliative Care and if so, how it should be conceived.

DESIGN

This is a qualitative interview study with purposeful sampling. The interviews were analyzed with the coding method of Saldaña.

SETTING/PARTICIPANTS

A total of 10 professionals from three different pregnancy counseling services participated in the study.

RESULTS

The main topics raised by the professionals were as follows: (1) counseling and parental support during the decision-making process; (2) fragmented or missing support infrastructure for parents; and (3) challenges, hesitations, and barriers, particularly from the different stakeholders, regarding a Perinatal Palliative Care framework. They highlighted the importance of the integration of Perinatal Palliative Care in existing structures, a multi-professional approach, continuous coordination of care and education for all healthcare providers involved.

CONCLUSION

A structured Perinatal Palliative Care program is considered as necessary by the pregnancy counselors. Future research should focus on (1) needs reported by concerned parents; (2) attitude and role of all healthcare providers involved; (3) strategies to include stakeholders in the development of Perinatal Palliative Care networks; and (4) outcome parameters for evaluation of Perinatal Palliative Care frameworks.

Recurrent anencephalic stillbirths: A rare case presentation

Anencephaly is one of the three major lethal fetal anomalies. Termination of pregnancy is offered for all prenatally diagnosed cases, but some parents choose to continue with pregnancy with full obstetric intervention. I describe the case of a woman who had two pregnancies with anencephalic stillbirths in the third trimester. There is a paucity of well-defined standards of care and management for pregnancies that are carried to the third trimester with this malformation. This case raises important practical questions: Management strategies of recurrent pregnancies with anencephaly, best supportive care during, and after birth and counseling the expectant parents.

Anencephaly; the maternal experience of continuing with the pregnancy. Incompatible with life but not with love

OBJECTIVE

As advances in prenatal diagnosis increasingly enable detection of life-limiting conditions, end-of-life care may start before birth. Termination of these pregnancies may have been default management, but in the Republic of Ireland, where termination is not a legal option, skilled experience in caring for mothers who continue their pregnancies has developed. This study examines the lived experience of four such mothers.

METHOD

A qualitative study was designed using interpretive phenomenological analysis, which examined the maternal experience of continuing pregnancy with a prenatal diagnosis of anencephaly. Four mothers participated in semi-structured interviews on their experience of pregnancy and delivery of a baby with anencephaly.

RESULTS

A profoundly emotional journey represented an adaptive grieving process, which culminated in rich experiences of transformative growth for all the parents. The parents' relationship with their caregivers facilitated this process and the development of a meaningful parenting relationship with their babies. This positive finding coexists alongside a parallel experience of ongoing deep sense of loss and sadness.

CONCLUSION

Perinatal palliative care for those with a prenatal lethal diagnosis is a positive life experience for some mothers. The role of relationship with healthcare professionals is vital to the process and consideration must be given to a comprehensive multi-disciplinary team approach.

“Love Is a Choice”: Couple Responses to Continuing Pregnancy With a Lethal Fetal Diagnosis

While it is known that couples experience pregnancy differently from one another, the circumstance of continuing pregnancy after learning of a lethal fetal diagnosis has received little attention. This longitudinal, naturalistic study of 16 mothers and 14 spouses/partners aimed to describe pregnant couples’ responses and relationships in continued pregnancy with lethal fetal diagnosis and to examine similarities and differences within those couple responses. Individual and joint interviews with parents were conducted across pregnancy, birth, and death of the baby. Within and across couple analysis was performed. Three categories emerged (Pregnant vs. Not Pregnant; Individual Responses to Adversity; Strength of the Couple Relationship) with 12 themes. Findings indicate that individual responses to these stressful pregnancies were inherent in who was physically pregnant, choosing whether to love and embrace the unborn baby, personal characteristics, and the strength of the couple relationship. Care providers should assess couple dynamics. Couples with committed relationships, shared decision-making, and mutual support fared the best in the aftermath of their baby’s death.

Effectiveness of medical self-experience counseling in pregnant women after echocardiographic detection of a suspected fetal heart anomaly: A longitudinal study

AIM

The purpose of this longitudinal study was to assess maternal psychological responses after echocardiographic detection of a suspected fetal heart anomaly and to evaluate a medical self-experience counseling intervention in improving psychological responses.

METHODS

A total of 751 women were referred to Shandong Provincial Hospital, Jinan during May 2014 and April 2015. To analyze the psychological impact on the mothers, the groups were divided into mild, intermediate and severe, according to heart defect severity. State-Trait Anxiety Inventory (STAI) and Beck Depression Inventory II (BDI-II) questionnaires were distributed in three steps: first evaluation, after the diagnostic examination; second evaluation, two weeks after step one, both study and control groups underwent routine psychological counseling; third evaluation, two weeks after step two, study groups underwent self-experience counseling and controls underwent routine counseling. Anxiety and depression scores and above clinical cut-off percentages in the subgroups were calculated and compared.

RESULTS

The severity of anxiety and depression was not significantly relieved with the alleviative type of suspicious heart abnormality. State-STAI and BDI-II scores and above clinical cut-off percentages were statistically different between steps 2 and 3 in intermediate and mild mothers. Women in control groups did not exhibit obvious relief of anxiety and depression.

CONCLUSION

Women pregnant with fetuses with mild or intermediate fetal heart abnormalities presented heightened levels of depression and anxiety when compared with mothers pregnant with fetuses with severe heart disease. Medical self-experience counseling played an important role in relieving anxiety and depression in these mothers.