Previous stress and acute psychological defence as predictors of perinatal grief--an exploratory study

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.

The loss of self: The effect of miscarriage, stillbirth, and child death on maternal self-esteem

A child's death augments how grieving parents view the world, the family, and the self. Using a representative sample of women ages 25-45 who have ever given birth, we assessed whether miscarriage, stillbirth, and child death impact self-esteem and whether this loss is moderated by maternal identity. We found that stillbirth and child death, but not miscarriage, negatively impacted self-esteem. For those who experienced a loss, the impact on self-esteem was moderated by maternal identity. Women who experienced a stillbirth were the only group who had significantly lower self-esteem after controlling for background characteristics and maternal identity variables.

Posttraumatic stress and posttraumatic stress disorder after termination of pregnancy and reproductive loss: a systematic review

Objective. The aims of this systematic review were to integrate the research on posttraumatic stress (PTS) and posttraumatic stress disorder (PTSD) after termination of pregnancy (TOP), miscarriage, perinatal death, stillbirth, neonatal death, and failed in vitro fertilisation (IVF). Methods. Electronic databases (AMED, British Nursing Index, CINAHL, MEDLINE, SPORTDiscus, PsycINFO, PubMEd, ScienceDirect) were searched for articles using PRISMA guidelines. Results. Data from 48 studies were included. Quality of the research was generally good. PTS/PTSD has been investigated in TOP and miscarriage more than perinatal loss, stillbirth, and neonatal death. In all reproductive losses and TOPs, the prevalence of PTS was greater than PTSD, both decreased over time, and longer gestational age is associated with higher levels of PTS/PTSD. Women have generally reported more PTS or PTSD than men. Sociodemographic characteristics (e.g., younger age, lower education, and history of previous traumas or mental health problems) and psychsocial factors influence PTS and PTSD after TOP and reproductive loss. Conclusions. This systematic review is the first to investigate PTS/PTSD after reproductive loss. Patients with advanced pregnancies, a history of previous traumas, mental health problems, and adverse psychosocial profiles should be considered as high risk for developing PTS or PTSD following reproductive loss.

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.

Impact of a child with congenital anomalies on parents (ICCAP) questionnaire; a psychometric analysis

Background

The objective of this study was to validate the Impact of a Child with Congenital Anomalies on Parents (ICCAP) questionnaire. ICCAP was newly designed to assess the impact of giving birth to a child with severe anatomical congenital anomalies (CA) on parental quality of life as a result of early stress.

Methods

At 6 weeks and 6 months after birth, mothers and fathers of 100 children with severe CA were asked to complete the ICCAP questionnaire and the SF36. The ICCAP questionnaire measures six domains: contact with caregivers, social network, partner relationship, state of mind, child acceptance, and fears and anxiety. Reliability (i.e. internal consistency and test-retest) and validity were tested and the ICCAP was compared to the SF-36.

Results

Confirmatory factor analysis resulted in 6 six a priori constructed subscales covering different psychological and social domains of parental quality of life as a result of early stress. Reliability estimates (congeneric approach) ranged from .49 to .92. Positive correlations with SF-36 scales ranging from .34 to .77 confirmed congruent validity. Correlations between ICCAP subscales and children's biographic characteristics, primary CA, and medical care as well as parental biographic and demographic variables ranged from -.23 to .58 and thus indicated known-group validity of the instrument. Over time both mothers and fathers showed changes on subscales (Cohen's d varied from .07 to .49), while the test-retest reliability estimates varied from .42 to .91.

Conclusion

The ICCAP is a reliable and valid instrument for clinical practice. It enables early signaling of parental quality of life as a result of early stress, and thus early intervention.

Affective state of women following a prenatal diagnosis: predictors of a negative psychological outcome

OBJECTIVE

The benefits of prenatal diagnostic procedures are well documented. However, the investigation of psychological consequences related to these procedures has remained a surprisingly neglected area of research. The main aim of the present study was to investigate the potential relationship between psychological outcome and associated (socio-demographic, psychological and obstetric) variables in women attending a tertiary referral center for prenatal diagnosis and therapy for ultrasound scanning (due to the suspicion of a fetal malformation raised by the gynecologist in private practice), amniocentesis or chorionic villus sampling.

METHODS

Affective state was assessed by means of standardized measures of anxiety and depression (State-Trait Anxiety Inventory; Mood Scale) in 77 consecutive, unselected women. A follow-up investigation, including an additional assessment of coping mechanisms, took place 6 months after the first contact. Given the considerable number of intervening and correlating factors, a path analysis was undertaken.

RESULTS

We found that all women in our sample experienced acute distress, not only those with proven fetal malformations, genetic disorders or intrauterine fetal death, but also those with the diagnosis of a sonographic sign. At baseline (i.e. immediately after the diagnostic procedure), mood and anxiety scores in our sample were found to be comparable to those of patients with a major depressive episode. A high trait anxiety level, implementation of negative coping strategies and loss of the child during pregnancy were found to be predictive of a negative psychological outcome at follow-up. Socio-demographic variables did not have a significant predictive function for the psychological outcome.

CONCLUSIONS

We assume that a considerable number of women undergoing prenatal diagnostic procedures experience psychological distress, which may be underestimated by workers in prenatal care. Establishment of interdisciplinary treatment settings, in which access to psychological support is facilitated, may be extremely beneficial for women following a prenatal diagnosis.

[Opinions of couples on care during medical termination of pregnancy]

OBJECTIVES

To study the medical care, staff attitudes and patients' satisfaction from the decision to the post-intervention medical visit for termination of pregnancy for fetal abnormalies.

PATIENTS AND METHODS

All patients and their spouses having a termination of pregnancy at the "Unite de Medecine Foetale" in Port-Royal Hospital between November 1996 and July 1997 were contacted for the study. A self-administered questionnaire was mailed six to eight weeks after intervention. Forty seven women and 42 men returned a completed questionnaire, the response rates were respectively 68% and 61%.

RESULTS

The patients and their spouses rated globally very high their satisfaction about the care received. The delay before intervention, the length and pain of labour were rated less positively. The factors associated with satisfaction were the quality of the relationship with the staff, and of information. Positive feelings about delivery were linked with the consideration and relief of pain. Most respondents mentioned that their physical and psychological state has improved at the moment of the survey but the psychological distress subsisted or has increased in one fourth of the cases. On the whole the answers made within the couples were correlated.

CONCLUSION

The positive results should be moderated by the number of non-respondents. In a context of very high rates of satisfaction, psychological distress is still present for one respondent out of four, six to eight weeks after termination of pregnancy for fetal abnormalies.

Role of major lifetime stressors in patients' and spouses' reactions to cancer

This study examined the role of number of major lifetime stressors (e.g., rape, abuse), and the perceived resolution of those stressors, in cancer patients' (n = 54) and spouses' (n = 30) appraisals and current mood. We hypothesized that a high number of lifetime stressors, and low resolution ratings, would be associated with more distress and more negative appraisals of the cancer. Hierarchical regression analyses showed that number of lifetime stressors was a positive predictor of patients' ratings of the cancer's threat, and a positive predictor of their spouses' anger. Mean resolution ratings were a significant positive predictor of spouses' positive affect. The findings suggest that experience with previous stressors affects an individual's reactions to cancer.

Follow-up of Parents who Experience a Perinatal Loss: Facilitating Grief and Assessing for Grief Complicated by Depression

The importance of providing follow-up support to parents who have experienced a perinatal loss has been described in the literature. Anecdotal reports demonstrate that many health care professionals provide some type of telephone follow-up contact to bereaved parents in the weeks following the loss. Yet, limited information exists to guide the way that follow-up telephone calls are made, especially for assessing complicated grief. Health care professionals are often challenged as they attempt to identify parents at risk, especially when contacts are provided over the telephone. While it is never easy to talk to a parent during the very painful adjustment at home, guidelines for follow-up telephone calls can assist professionals in providing sensitive, individualized follow-up care.

Quality of life and anxiety in pregnancies after late pregnancy loss: a case-control study

Pregnant women with (n = 24) and without (n = 26) a previous pregnancy loss (> 16 weeks) due to congenital anomalies were compared on quality of life and anxiety. Pregnant women with a previous loss were divided into those with and those without a normal livebirth since the loss [cases+ (n = 6) and cases- (n = 18), respectively]. Psychological measurements were carried out before and after an ultrasound scan in the second trimester of the pregnancy. Women with a previous loss who had not delivered a healthy infant between the loss and the present pregnancy showed a lower quality of life as revealed by feelings of social isolation, negative emotional reactions, and pain than the other groups. In addition, they showed more pregnancy-related anxiety. The negative emotions were particularly present just before the anomaly scan. Feelings of social isolation, negative emotional reactions, pain, and pregnancy-related anxiety were significantly positively related to trait anxiety, irrespective of having experienced late pregnancy loss. The implications of this study are that the referring gynaecologist, physician, or midwife should be aware of the strong emotions and major concerns of women in a pregnancy subsequent to a late pregnancy loss. In addition, they should offer these women the opportunity to express their emotional distress.