The grief of late pregnancy loss

Incidence of Infertility and Pregnancy Complications in US Female Surgeons

Importance

While surgeons often delay pregnancy and childbearing because of training and establishing early careers, little is known about risks of infertility and pregnancy complications among female surgeons.

Objective

To describe the incidence of infertility and pregnancy complications among female surgeons in the US and to identify workplace factors associated with increased risk compared with a sociodemographically similar nonsurgeon population.

Design, Setting, and Participants

This self-administered survey questionnaire was electronically distributed and collected from November 2020 to January 2021 through multiple surgical societies in the US and social media among male and female attending and resident surgeons with children. Nonchildbearing surgeons were asked to answer questions regarding the pregnancies of their nonsurgeon partners as applicable.

Exposures

Surgical profession; work, operative, and overnight call schedules.

Main Outcomes and Measures

Descriptive data on pregnancy loss were collected for female surgeons. Use of assisted reproductive technology was compared between male and female surgeons. Pregnancy and neonatal complications were compared between female surgeons and female nonsurgeon partners of surgeons.

Results

A total of 850 surgeons (692 women and 158 men) were included in this survey study. Female surgeons with female partners were excluded because of lack of clarity about who carried the pregnancy. Because the included nonchildbearing population was therefore made up of male individuals with female partners, this group is referred to throughout the study as male surgeons. The median (IQR) age was 40 (36-45) years. Of 692 female surgeons surveyed, 290 (42.0%) had a pregnancy loss, more than twice the rate of the general population. Compared with male surgeons, female surgeons had fewer children (mean [SD], 1.8 [0.8] vs 2.3 [1.1]; P < .001), were more likely to delay having children because of surgical training (450 of 692 [65.0%] vs 69 of 158 [43.7%]; P < .001), and were more likely to use assisted reproductive technology (172 of 692 [24.9%] vs 27 of 158 [17.1%]; P = .04). Compared with female nonsurgeon partners, female surgeons were more likely to have major pregnancy complications (311 of 692 [48.3%] vs 43 of 158 [27.2%]; P < .001), which was significant after controlling for age, work hours, in vitro fertilization use, and multiple gestation (odds ratio [OR], 1.72; 95% CI, 1.11-2.66). Female surgeons operating 12 or more hours per week during the last trimester of pregnancy were at higher risk of major pregnancy complications compared with those operating less than 12 hours per week (OR, 1.57; 95% CI, 1.08-2.26). Compared with female nonsurgeon partners, female surgeons were more likely to have musculoskeletal disorders (255 of 692 [36.9%] vs 29 of 158 [18.4%]; P < .001), nonelective cesarean delivery (170 of 692 [25.5%] vs 24 of 158 [15.3%]; P = .01), and postpartum depression (77 of 692 [11.1%] vs 9 of 158 [5.7%]; P = .04).

Conclusions and Relevance

This national survey study highlighted increased medical risks of infertility and pregnancy complications among female surgeons. With an increasing percentage of women representing the surgical workforce, changing surgical culture to support pregnancy is paramount to reducing the risk of major pregnancy complications, use of fertility interventions, or involuntary childlessness because of delayed attempts at childbearing.

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.

Experiences of fathers having faced with termination of pregnancy for foetal abnormality

The development of medical ultrasound techniques and progress in prenatal diagnosis allows foetus malformations to be discovered during pregnancy. These outcomes may force parents to be faced with the decision of termination of pregnancy for foetal abnormality (TOP). According to the literature, some parents will develop somatic or psychological troubles during and after the TOP, differently depending on sex. Moreover, fathers feel sometimes isolated during TOP. It seems important to propose a specific support for fathers throughout this event. Aim of this qualitative study is to describe how fathers perceive the TOP, their feelings about caregivers and their strategies for coping. Our study was performed in the Maternity Department of the Nancy University Hospital, between April and December 2016 and concerns TOP beyond 22 weeks of amenorrhea. Semi-structured interview was offered to the father the day after the TOP. These semi-structured interviews were transcribed, and text thus obtained were subjected to inductive thematic analysis. Eight men agreed to participate in this study. Results show that fathers have gone through intense emotional strain throughout the TOP. They experienced a fear of losing their partner, feelings of anger, loneliness and exclusion. They used internalisation, minimisation and avoidance by distraction. In addition, they all insisted on their desire to be beside their partners throughout the TOP. As found in recent literature, the midwives and other caregivers have a role to play in supporting the couple: during the TOP and after the procedure, because consequences may appear after several months.

Cognitive predictors and risk factors of PTSD following stillbirth: a short-term longitudinal study

This short-term longitudinal study investigated cognitive predictors and risk factors of posttraumatic stress disorder (PTSD) in mothers following stillbirth. After a stillbirth at ≥ 24 weeks gestational age, 65 women completed structured clinical interviews and questionnaires assessing PTSD symptoms, cognitive predictors (appraisals, dysfunctional strategies), and risk factors (perceived social support, trauma history, obstetric history) at 3 and 6 months. PTSD symptoms decreased between 3 and 6 months (Cohen's d ranged .34-.52). Regression analyses also revealed a specific positive relationship between Rumination and concurrent frequency of PTSD symptoms (β = .45). Negative Self-View and Negative World-View related positively and Self-Blame related negatively to concurrent number of PTSD symptoms (β = .48, .44, -.45, respectively). Suppression and Distraction predicted a decrease and Numbing predicted an increase in time-lagged number of PTSD symptoms (β = -.33, -.28, .30, respectively). Risk factors for PTSD symptoms were younger age (β = -.25), lower income (β = -.29), fewer previous pregnancies (β = -.31), and poorer perceived social support (β = -.26). Interventions addressing negative appraisals, dysfunctional strategies, and social support are recommended for mothers with PTSD following stillbirth. Knowledge of cognitive predictors and risk factors of PTSD may inform the development of a screening instrument.

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.

Perinatal bereavement: a principle-based concept analysis

AIM

To report an analysis of the concept of perinatal bereavement.

BACKGROUND

The concept of perinatal bereavement emerged in the scientific literature during the 1970s. Perinatal bereavement is a practice-based concept, although it is not well-defined in the scientific literature and is often intermingled with the concepts of mourning and grief.

DESIGN

Concept Analysis.

DATA SOURCES

Using the term 'perinatal bereavement' and limits of only English and human, Pub Med and CINAHL were searched to yield 278 available references dating from 1974-2011. Articles specific to the experience of perinatal bereavement were reviewed. The final data set was 143 articles.

REVIEW METHODS

The methods of principle-based concept analysis were used. Results reveal conceptual components (antecedents, attributes and outcomes) which are delineated to create a theoretical definition of perinatal bereavement.

RESULTS

The concept is epistemologically immature, with few explicit definitions to describe the phenomenon. Inconsistency in conceptual meaning threatens the construct validity of measurement tools for perinatal bereavement and contributes to incongruent theoretical definitions. This has implications for both nursing science (how the concept is studied and theoretically integrated) and clinical practice (timing and delivery of support interventions).

CONCLUSIONS

Perinatal bereavement is a multifaceted global phenomenon that follows perinatal loss. Lack of conceptual clarity and lack of a clearly articulated conceptual definition impede the synthesis and translation of research findings into practice. A theoretical definition of perinatal bereavement is offered as a platform for researchers to advance the concept through research and theory development.

Psychosocial aspects of preconception consultation in primary care: lessons from our experience in clinical genetics

To date, little is known about the psychosocial aspects of preconception consultation (PCC) in primary care. PCC in primary care is appropriate for couples and individuals with a reproductive wish. In PCC, non-genetic and genetic risk factors may be identified. Focusing on non-genetic and genetic risk factors in PCC requires the use of different counselling strategies and tools in optimizing the outcome of pregnancy. Addressing lifestyle alterations requires directive counselling, whereas addressing increased genetic risk and its subsequent reproductive options requires non-directiveness. When an increased genetic risk is detected, couples should be informed about their possibilities for not passing on a disease allele. Depending upon the various modes of inheritance and reproductive options, couples may face a variety of psychosocial challenges. This paper aims to provide insights into the psychosocial impact of the genetic aspects of PCC by drawing upon literature and clinical experience in the Clinical Genetics department. Furthermore, this paper provides consideration for future developments regarding preconception genetic screening.

Effectiveness of group psychotherapy for adult outpatients traumatized by abuse, neglect, and/or pregnancy loss: a multiple-site, pre-post-follow-up, naturalistic study

The New Experience for Survivors of Trauma (NEST) is a group psychotherapy intervention for clients traumatized by consequences of abuse, neglect, and pregnancy loss. This multiple site study is the first investigation of its effectiveness. Ninety outpatients from a naturalistic setting completed the Symptom Checklist and the Sense of Coherence questionnaire at baseline, end of treatment, and one-year follow-up. Effectiveness was tested with statistical significance, effect size, and clinical significance. Clients from the total sample as well as from the abortion subsample showed improvement at the end of treatment and at follow-up. Lack of a control group is balanced to some extent by the high ecological validity. The findings suggest that the NEST treatment may be beneficial for traumatized clients and call for further research.

Affirming motherhood: validation and invalidation in women's perinatal hospice narratives

BACKGROUND

Perinatal hospice is an option for women who learn during pregnancy that their fetuses are affected by terminal conditions and choose to continue their affected pregnancies. These women face emotional pain and the impending loss of their fetuses or infants. The aims of this study were to explore the experiences of perinatal hospice mothers, to gather knowledge useful to health professionals, and to guide future research.

METHODS

  Narrative analysis was performed using the personal stories of 15 women who continued pregnancies affected by lethal fetal anomalies.

RESULTS

The participants identified themselves as mothers and their fetuses or newborns as babies. Mothers valued caring for and interacting with their babies. Health professionals who affirmed their status as mothers, the value of their babies, and the significance of their losses were perceived as supportive. Invalidating attitudes and behavior caused significant distress among mothers.

CONCLUSIONS

Optimal care of perinatal hospice mothers supports the development of maternal identity and contact between mothers and newborns when desired. Professionals who care for perinatal hospice mothers can affirm their motherhood through their behavior and attitudes.

Silenced voices: Israeli mothers' experience of feticide

The study is a qualitative analysis of 13 interviews with Israeli women who experienced feticide by injection at a late stage of their pregnancy due to fetus abnormality. Neither the public nor health care professionals are fully aware of the implications and significance of feticide to the mother. The goal of this study which was conducted from May 2008 until October 2009 was to understand and give voice to the women's experience. Three themes were discovered: (a) difficult decision making process and outcomes; (b) the unbearable experience of feticide; and (c) feticide as an unspoken experience. Feticide was revealed to incorporate both social and psychological layers; thus, the findings highlight the interface between a personal experience and a social phenomenon. The women's experience is discussed within the Israeli social context, where feticide is a relatively common yet unspoken procedure.

Doing, Being, and Becoming: A Family’s Journey Through Perinatal Loss

Occupational therapists are encouraged to reflect on doing, being, and becoming not only as it relates to the development of their profession but also in their own lives (Wilcock 1999). This article is a description of that process for me and my family in our journey through perinatal loss. This autoethnography uses a personally situated account of perinatal death. This article is a form of self-narrative that places me and my family in social context through the lens of an occupational therapist. This article aims to convey the meanings attached to the experience of grief and loss in the context of participation in everyday occupations. By sharing a perspective on the lived experience and connecting it to the literature on grief and occupation, readers will be able to decide if the connection holds as valid from a theoretical and clinical perspective.

Depression among Nigerian women following pregnancy loss

OBJECTIVE

To determine the level of depression in Nigerian women following spontaneous pregnancy loss and the coping strategies used.

METHODS

A questionnaire survey of 202 Nigerian women who had involuntary pregnancy loss over a 1-year period. The Zung Self-Rating Depression Scale was used to assess the women.

RESULTS

Two-thirds of the pregnancy losses occurred before 20 weeks of gestation and one-third occurred after 20 weeks. The majority of respondents (74.3%) had minimal depressive symptoms (scoring 50-59 on the depression scale), 3% had moderate symptoms (scoring 60-69), and 13.9% had severe symptoms (scoring 70-80). Risk factors for moderate to severe depression included being married, previous pregnancy loss, loss of a male fetus, childlessness, and losses after 20 weeks (P<0.05). Presence of a woman's husband, children, parents and relatives, friends, and religious observance were identified as positive coping strategies.

CONCLUSION

Most Nigerian women suffer some level of depression following pregnancy loss, with no living children and losses after 20 weeks being the most significant risk factors.

[A subsequent pregnancy after a termination of pregnancy because of fetal anomaly--all forgotten and a new beginning?]

There is a lack of profound research on the experiences of a new pregnancy following a subsequent late termination of pregnancy (TOP). Results from late pregnancy losses indicate that women do grieve even during a new pregnancy and therefore the process of bonding can be affected. 56 women were investigated within the project "psychosocial counselling in the context of prenatal diagnosis," which recruited 512 patients. Results on the experience of a new pregnancy after late TOP will be presented. In general women experienced a normal level of bereavement 2 years after TOP (PGS), but 11-21% showed significant symptoms of distress (BSI). 50% were aware of the terminated pregnancy furthermore and they felt an emotional distance to their unborn child. This is remarkable because most subsequent pregnancies were planned and desired. Many patients showed feelings of fear, worries and uncertainties. Time since TOP and new conception was not predictive of feelings during pregnancy. If a pregnant woman had a TOP because of fetal anomaly in the preceding pregnancy this should be taken into account during medical care. If symptoms of distress are persisting there is an indication for additional care. The intention is to release the patient and to support a sound relationship between mother and child.

Psychological outcome in women undergoing termination of pregnancy for ultrasound-detected fetal anomaly in the first and second trimesters: a pilot study

OBJECTIVE

To ascertain and compare psychological morbidity following first- and second-trimester termination for fetal anomaly.

METHODS

This was a cohort study of 30 women aged 20-40 years in a north London teaching hospital, 14 of whom had had a first-trimester termination and 16 a second-trimester termination for fetal anomaly. The main outcome measures were questionnaire data (General Health Questionnaire-28, Beck Depression Inventory, Perinatal Grief Scale, Impact of Event Scale (IES)) at 6 weeks, 6 months and 12 months after termination.

RESULTS

There were high levels of psychological distress in both groups at each time point, and for the combined group the mean total scores on the IES remained above the cut-off for the entire study period. Those having second-trimester terminations had a significantly higher level of post-traumatic stress symptomatology 6 weeks after termination (14/16 vs. 6/14; odds ratio = 9.3; 95% CI, 1.5-57.7).

CONCLUSIONS

Psychological morbidity following termination of pregnancy for fetal anomaly is prevalent and persistent. Our data suggest that in the short term (as assessed at a 6-week follow-up), second-trimester termination may be more stressful compared with first-trimester termination.

Parents' experiences of midwife-managed care following the loss of a baby in a previous pregnancy

AIMS OF THE STUDY

This article reports on research that explored the impact of the Special Delivery Service, a midwife-managed intervention, developed as an addition to routine care to support and educate high-risk pregnant women and their partners subsequent to the death of a baby in a previous pregnancy.

BACKGROUND

Approximately 40,000 families suffer the trauma of a neonatal death* annually in the USA, while statistics for Canada and Australia give similar numbers relative to population. Since many more babies die than those accounted for in these statistics, through stillbirth, miscarriage and Sudden Infant Death Syndrome, more than the above-cited 2% of childbearing couples will face the trauma of the loss of a baby.

RATIONALE

The resultant threat that this situation may pose to the health of the mother has been extensively documented in the literature. However, despite the recent growth in knowledge about the impact of perinatal loss and bereavement, few interventions are specifically designed to support Australian and Canadian women and their partners during a pregnancy following the loss of a baby.

METHODOLOGY

This phenomenological study explored women's and their partners' experiences of grief and loss and the support offered to them through the Special Delivery Service programme.

RESULTS & DISCUSSION

In the face of funding and organizational changes to both the Australian and Canadian health care systems that have eliminated or reduced some services, this research reinforced the need for individualized, compassionate midwifery care and the urgent need for genuinely empathic and supportive health care services for these women and their partners. It also emphasized the need for couples to be informed and supported so that gender differences in grieving do not become a divisive element in the relationship.

CONCLUSIONS

The findings have implications for both nurses and midwives in their practice in countries where optimum care of this vulnerable population is not routinely available. The research supports midwife-managed models of care to ensure women and their families are appropriately supported in crisis. The findings provide insight also into the diverse grief response among couples and the difficulties experienced in a pregnancy following the loss of a baby.

Attitudes of parents and health care professionals toward active treatment of extremely premature infants

OBJECTIVES

To compare the attitudes of neonatologists, neonatal nurses, the parents of extremely low birth weight (ELBW) children, and the parents of normal birth weight children toward saving infants of borderline viability and who should be involved in the decision-making process and to compare physicians' and nurses' estimates of the proportion of infants who are born at various gestational ages with regard to survival, morbidity, and treatment.

METHODS

A questionnaire was given to 169 parents of ELBW children and 123 parents of term children, who were part of a longitudinal study of the outcome of ELBW infants. A similar questionnaire was completed by 98 Canadian neonatologists and 99 neonatal nurses.

RESULTS

Physicians tended to be more optimistic than nurses regarding the probability of survival and freedom from serious disabilities and would recommend to parents life-saving interventions for their child at earlier gestational ages. A significant majority of parents believed that attempts should be made to save all infants, irrespective of condition or weight at birth, compared with only 6% of health professionals who endorsed this. In contrast to parents, health professionals believed that economic costs to society should be a factor in deciding whether to save an ELBW infant. However, health professionals did not believe that the economic status of the parents should be a factor, although the stress of raising an infant with disabilities should be. Most respondents believed that the parents and physicians should make the final decision but that other bodies, such as ethics committees or the courts, should not.

CONCLUSION

Health care professionals must recognize that their attitudes toward saving ELBW infants differ from those of parents. Parents, whether of term or extremely premature children, are more in favor of intervening to save the infant irrespective of its weight or condition at birth than are professionals. It therefore is imperative that there be joint decision making, combining the knowledge of the physician with the wishes of the parents.

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.

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.

Preimplantation genetic diagnosis as an alternative to amniocentesis and chorionic villus sampling: psychosocial and ethical aspects

Social and ethical considerations play an increasing role in decisions about the use of diagnostic technologies. In this article expert opinions of a medical-biological and a social-ethical panel on psychosocial, ethical and social aspects of preimplantation genetic diagnosis (PGD) are discussed. PGD is a new diagnostic technology for identifying chromosomal or single gene defects, which is now available as a medical treatment in several western countries. In contrast to traditional technologies like amniocentesis and chorionic villus sampling PGD offers the possibility for diagnosis before pregnancy. The panels expected PGD to be chosen only in serious situations. IVF was considered to be a barrier for PGD but less so in more serious situations. Destruction of pre-embryos was thought more acceptable than selective abortion, but only marginally. Finally a substantial decrease was expected in the acceptance of handicapped people in society as a consequence of the possibilities of technologies like PGD. Although PGD offers new possibilities for couples at risk of having a child with a genetic defect, it is important that couples are counseled in a way that emphasizes both the advantages and disadvantages of the technology. The general public should be informed about possibilities and impossibilities of preventive diagnosis and the right of future parents not to use genetic diagnosis.