Adaptation following perinatal loss: a critical review

Angels in the Clouds: Stillbirth and Virtual Cemeteries on 50 YouTube Videos

Today every aspect of our life is published and shared online, including grief. The virtual cemeteries and social networks' use could be considered as a new modern mortuary ritual. Starting from the keyword stillbirth, 50 videos published on YouTube since 2008 have been analyzed qualitatively. The videos, 70% published by the mother, with an average length of 5.52 minutes, a mean of 2,429,576 views and 2,563 of comments, follow a sort of script: the second part with black and white photos, background music, and religious references. Could the continuous access to the child's technological grave encourage a complicated grief or be a support, given by the interaction with users, limiting the sense of isolation. The parent shows his or her own conceptions about death and, as a modern baptism, presents the child to the whole society. Videos keep child's memory alive and fuel a process of personalization and tenderness in the user.

Psychiatric Morbidity and Correlates in Postpartum Women in a Tertiary Care Hospital

BACKGROUND

A range of psychological disorders occur in women in the postpartum period apart from the traditional blues, postpartum depression and psychosis. These include obsession of infanticide, PTSD, morbid preoccupations regarding child birth and disorders of mother-infant relationships, though they are under emphasized.

METHODS

it is a cross-sectional study conducted in the tertiary maternity care hospital. A total of 152 study subjects were interviewed on MINI (Mini International Neuropsychiatric Inventory) and GAF (Global Assessment of Functioning) within 2 weeks after delivery.

RESULTS

The psychiatric morbidity was seen in 67 (44%) of the study subjects. About 26% of subjects had Depressive disorder NOS. Obsessive harm to the child, Panic disorder, Social phobia were the other disorders identified. There were no cases of Mania, Bipolar disorder, psychosis, post traumatic stress disorder or substance use disorder diagnosed across the sample. The Global Assessment of Functioning (GAF) score averaged 87.8. Statistically significant association was seen to be present between psychiatric illness and number of previous still births and dead children before this delivery (P = 0.045).

CONCLUSIONS

The study reveals that psychiatric co-morbidity is very common in the postpartum period and can be detected as early as first week after delivery. Social phobia identified as a common association is a new finding and needs further replication. It needs a larger sample with a prospective assessment to generalize the findings of our study.

Type of continuing bonds expression and its comforting versus distressing nature: implications for adjustment among bereaved mothers

This study investigated type of continuing bonds (CB) expression and its comforting versus distressing nature in relation to psychosocial adjustment among bereaved mothers. Twenty-eight mothers whose child had died within the previous five years participated in a CB interview in which they rated the extent they used each of 11 different types of CB expression during the past month and the degree to which they experienced each of the CB expressions as comforting and distressing. CB expressions involving illusions and hallucinations of the deceased child were predictive of greater distress whereas those involving belief that the deceased child was aware of the mother or communicating with her through dreams were not associated with symptoms, but instead linked to greater spirituality. Furthermore, mothers who reported CB as more comforting than distressing had lower symptom ratings. The implications of the findings for the attachment theory perspective on unresolved loss are discussed.

Cognitive schemata and processing among parents bereaved by infant death

The present prospective study examined cognitive schemata and processing among 93 parents bereaved by infant death. The Trauma Constellation Identification Scale (TCIS) was used to assess maladaptive cognitive schemata associated with the loss. The impact of pre-, peri-, and post-trauma factors on the TCIS scores was assessed. Compared to parents who had not lost an infant, bereaved parents displayed significantly higher TCIS scores. High TCIS scores were significantly associated with PTSD as well as general symptomatology. Although interesting gender differences were found, the variables most strongly related to TCIS scores were posttraumatic emotional coping and cognitive processing.

Psychological vulnerability in children next-born after stillbirth: a case-control follow-up study

BACKGROUND

Case studies and anecdotal accounts suggest that perinatal loss may impact upon other children in the family, including those born subsequent to loss. However, there is a dearth of systematically collected quantitative data on this potentially vulnerable group.

METHODS

Case-controlled follow-up of 52 mothers with history of stillbirth with their next-born children aged 6-8 years, and 51 control mother-child dyads. Previously reported baseline data included maternal antenatal and postnatal psychological assessment, and infant security of attachment at 12 months. Follow-up assessments included maternal psychiatric and socio-demographic data, mother and teacher-rated scales of the child's strengths and difficulties, child IQ, observer-rated mother-child interaction and maternal reports of child health.

RESULTS

There were no significant between-group differences in child cognitive or health assessments, or in teacher-rated child difficulties. However, mothers with history of stillbirth (the index group) reported increased child difficulties, in particular peer problems, and more adverse interaction was observed in respect of higher levels of maternal criticism of the child's actions, more overall controlling behaviour by the mother, a less harmonious emotional atmosphere and a lower level of maternal engagement with the child. Some of these effects appeared to be mediated by maternal perinatal psychological symptoms and family breakdown.

CONCLUSIONS

This study provides no evidence to suggest that siblings born after stillbirth are clinically at risk but does lend empirical support to clinical reports that such children are seen by their mothers as having problems and that they are exposed to less optimal interaction with their mothers. Possible interpretations of these findings are discussed in the context of theoretical accounts of 'replacement child' and 'vulnerable child' syndromes.

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.

Effectiveness of bereavement interventions in neonatal intensive care: a review of the evidence

The provision of bereavement care is an important part of neonatal intensive care. This systematic review of the effectiveness of interventions to support families and facilitate emotional adjustment following the death of a baby suggests that, while these are largely appreciated by parents who have participated in research, there has been little rigorous evaluation of their effectiveness. This review reflects on possible reasons for this; for example: NICU-led bereavement care is changing, the effectiveness of bereavement care is difficult to measure, concepts of effectiveness are not static, and ethical concerns complicate experimental research. Bereavement interventions are compassion-led and generally considered to be beneficial. New research questions and new methodological challenges are discussed with reference to two examples of evolving practice: bereavement photography and the use of ritual. Future research using innovative and sensitive RCTs and consensus amongst relevant stakeholders is suggested.

[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.

Unexpected diagnosis of fetal abnormality: women's encounters with caregivers

BACKGROUND

It is acknowledged that health professionals have difficulty with breaking bad news. However, relatively little research has been conducted on the experiences of women who have had a fetal anomaly detected at the routine pregnancy ultrasound examination. The study objective was to explore women's experiences of encounters with caregivers after the diagnosis of fetal anomaly at the routine second trimester ultrasound scan.

METHODS

The theoretical perspective of symbolic interactionism guided this study design. A purposive sample of 38 women, at low risk of fetal abnormality, who received a diagnosis of a fetal abnormality in a tertiary referral center in Ireland, were recruited to participate. An in-depth interview was conducted within 4-6 weeks of the diagnosis. Data were collected between April 2004 and August 2005 and analyzed using the constant comparative method.

RESULTS

Six categories in relation to women's encounters with caregivers emerged: information sharing, timing of referral, getting to see the expert, describing the anomaly, availability of written information, and continuity of caregiver. Once an anomaly was suspected, women wanted information quickly, including prompt referral to the fetal medicine specialist for confirmation of the diagnosis. Supplementary written information was seen as essential to enhance understanding and to assist women in informing significant others. Continuity of caregiver and empathy from staff were valued strongly.

CONCLUSIONS

The way in which adverse diagnoses are communicated to parents leaves room for improvement. Health professionals should receive specific education on how to break bad news sensitively to a vulnerable population. A specialist midwifery or nursing role to provide support for parents after diagnosis is recommended.

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.

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSION

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

Factors associated with the unresolved classification of the Adult Attachment Interview in women who have suffered stillbirth

The "unresolved" state of mind with respect to loss or trauma as assessed in the Adult Attachment Interview is common in clinical and forensic groups, as well as in mothers whose infants are classified as disorganized in their attachment relationship to them. However, questions remain about what the unresolved state represents and what factors predict the unresolved state. This case controlled study reports on 64 women who had suffered stillbirth and who were pregnant with their next child. The study explores attachment, psychiatric, and social factors associated with the unresolved state or higher unresolved scores with respect to stillbirth. Women who had experienced stillbirth were more likely to be unresolved than control women. Although a similar number of stillbirth and control women had experienced childhood trauma, only women who had experienced stillbirth were unresolved with respect to this trauma, suggesting the unresolved state may be evoked or reevoked by subsequent traumatic loss. Higher unresolved scores in relation to stillbirth were predicted by childhood trauma, poor support from family after the loss, and having a funeral for the infant. The results are discussed in terms of the woman's sense of being causal in the loss.

Interconceptional counseling after perinatal and infant loss

Historically, preconceptional health promotion has been recommended for all prospective parents to improve perinatal outcomes. Preconceptional health promotion and interconceptional counseling may be even more beneficial for parents who have had previous perinatal losses. Perinatal loss can be devastating, with long-term effects on subsequent pregnancies and children. A theoretical framework for interconceptional counseling after perinatal loss needs to be developed. Interconceptional counseling can give couples important information to improve outcomes, acknowledge fears and anxieties, evaluate genetic risks, facilitate grieving, and explore attachment and parenting issues.

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.

Perinatal Bereavement Grief Scale: distinguishing grief from depression following miscarriage

The study evaluated the Perinatal Bereavement Grief Scale (PBGS), the first scale designed to measure grieffollowing reproductive loss in terms of yearning for the lost pregnancy and lost baby. Participants included 304 women interviewed by telephone I to 3 times within 6 months aftermiscarriage. The PBGS had high internal consistency and test-retest reliability. It showed convergent validity with measures of attachment and investment in the child and divergent validity against measures of social desirability and depressive symptoms, supporting the conceptual distinction between grief and depression. Cross-cultural validity was acceptable whether tested by language (Spanish vs. English) or ethnicity (Hispanic vs. other). This measure of yearning enables study of the epidemiology and prognostic value of this key feature of mourning.

Maternal assignment of fetal personhood to a previous pregnancy loss: relationship to anxiety in the current pregnancy

The degree of personhood a mother assigns to her dead fetus (i.e., whether she felt she lost a pregnancy or a baby) may help explain the meaning of a perinatal loss and the amount of anxiety experienced in a subsequent pregnancy. This descriptive study of 72 multigravidas with a history of one or two perinatal losses was conducted to understand the relationships between the assignment of fetal personhood and the influence of that assignment on state anxiety and pregnancy anxiety in a subsequent pregnancy. Assignment of personhood was significantly related to pregnancy anxiety and to the gestational age of the first loss but not to state anxiety. Understanding and responding to women's perceptions of perinatal losses and their significance for women may be one way to support them in subsequent pregnancies.

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.

Follow up care of bereaved parents after treatment withdrawal from newborns

OBJECTIVE

To explore parents' experiences of bereavement care after withdrawal of newborn intensive care.

DESIGN

Face to face interviews with 108 parents of 62 babies born over two calendar years in the East of Scotland.

RESULTS

Only 22% were seen by six weeks after the death, 10% were not recalled before 6-11 months, and 8% were not seen at all in the first year. All except one couple saw the neonatologist who had cared for their baby. Only 33% remembered a neonatal nurse being present. Most (88%) were seen in the study hospital. Parents highlighted a number of specific needs. Appointments should be: (a) scheduled soon after the death of the baby and certainly within two months of the death irrespective of whether or not autopsy results are available; (b) with the named neonatologist; (c) in a setting away from the hospital if possible. Parents value: (a) efforts to find out how they are coping; (b) full frank information given sensitively to enable them to build up a cohesive picture of what happened and assess their future risks; (c) reassurance where possible, but half truths, false reassurances, and broken promises are unacceptable.

CONCLUSIONS

Follow up care is a crucial part of the management of families from whose babies treatment has been withdrawn. Resources devoted to it should be re-examined to provide a service more in tune with parental need. In choosing the place, timing, and conduct of the meeting, staff should be sensitive to the expressed wishes of the parents themselves.

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.

Prenatal diagnosis of fetal abnormality: psychological effects on women in low-risk pregnancies

When given an adverse prenatal diagnosis, parents are deeply shocked and experience acute grief. This review considers the psychological outcomes for parents whether they opt to terminate the pregnancy or continue, either through choice or because termination is not an option. It covers the full spectrum of malformation from treatable, through those carrying a risk of significant handicap, to lethal. It draws on two types of studies: those that are retrospective and qualitative, describing feelings and aspects of care, and those that are prospective and assess psychological state with standardized measures of grief, anxiety and depression. The relationship between psychological outcome and possible associated variables, such as individual characteristics, nature of the abnormality and obstetric factors is described and evaluated. In addition, the authors draw on both scientific and support group literature to summarize good practice for the care of parents receiving an unexpected diagnosis of fetal abnormality.

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.

Predictors of Maternal Grief in the Year after a Newborn Death

Existing interventions to assist mothers following newborn death are implemented once manifestations of distress are present. Preventive measures could be instituted if predictors of grief were defined. The objective of this study was to investigate the value of perceived support, relationship satisfaction, emotion-focused coping, problem-focused coping, and mixed coping in predicting maternal grief in the year after a newborn death. The sample consisted of seventy-five bereaved mothers. Measures used included the Perinatal Grief Scale, Short Version; the Ways of Coping Scale, Revised; the Personal Resources Questionnaire 85, Part II; the Relationship Satisfaction Questionnaire; and the Demographic Data Sheet. Perceived support and emotion-focused coping accounted for a significant proportion of variance in total grief (43 percent), demonstrating that these two variables together can predict maternal grief. Programs to help bereaved mothers mobilize perceived support and use different ways of coping could be beneficial following the death of a newborn.

Effects of a program of intervention on parental distress following infant death

A longitudinal study of 144 parents (65 fathers, 79 mothers) was conducted to evaluate the effectiveness of a program of intervention in relieving the psychological distress of parents affected by infant death. Participants were assessed in terms of their psychiatric disturbance, depression, anxiety, physical symptoms, dyadic adjustment, and coping strategies. The experimental group (n = 84) was offered an intervention program comprising the use of specially designed resources and contact with a trained grief worker. A control group (n = 60) was given routine community care. Parental reactions were assessed at four to six weeks postloss (prior to the implementation of the intervention program), at six months postloss, and at 15 months postloss. A series of multivariate analyses of variance revealed that the intervention was effective in reducing the distress of parents, particularly those assessed prior to the intervention as being at high-risk of developing mourning difficulties. Effects of the intervention were noted in terms of parents' overall psychiatric disturbance, marital quality, and paternal coping strategies.

The myth of the replacement child: parents' stories and practices after perinatal death

Parents bereaved by perinatal death adapt to their losses in different ways. When bereaved parents give birth to a child or children subsequent to a perinatal death, their constructions of the family necessarily change. The subsequent child is thought to be at risk of psychopathology (the replacement child syndrome) if parents have not sufficiently grieved their losses. This qualitative interview study examines the family stories told by bereaved parents, with particular attention to how parents represent the dead child and subsequent children in the current family structure. We categorized parents' stories as those which suggested that parents replaced the loss by an emphasis on parenting subsequent children, or maintained a connection to the dead child through storytelling and ritual behavior. The two ways in which parents maintained the connection were to preserve the space in the family that the dead child would have inhabited, or to create an on-going relationship with the dead child for themselves and their subsequent children. There seem to be multiple paths to parenting through bereavement. The place of rituals and memorial behavior is also examined.

The relationship of attachment theory and perinatal loss

Perinatal loss has recently received attention in the literature that presents it as different from other types of losses. Perinatal loss, or the loss of an infant due to miscarriage, stillbirth, or neonatal death, is a significant problem that may be best understood when viewed through the framework of attachment theory. Recent advances in medical technology, including prenatal diagnostic procedures and resulting decisions have influenced issues of both perinatal attachment and loss, and have provided challenges for the clinician. This article presents a review of current theories and research on attachment and perinatal loss, and discusses how knowledge gained from this research may be integrated into clinical practice.

Trait anxiety, negative emotions, and the mothers' adaptation to an infant born subsequent to late pregnancy loss: a case-control study

Women with (n = 27) a history of late pregnancy loss (> or = 20 weeks) due to congenital anomalies who had completed the subsequent pregnancy with a live-birth were compared with a group of mothers with newborns without such a history (n = 29) at 4 and 16 weeks post-partum. The following aspects were assessed; depression, anxiety, psychological distress, and mother-infant adaptation. The women with a previous pregnancy loss showed significantly more negative emotions than the women without such a history. In addition, they considered that their healthy baby experienced more problems with sleeping, crying, eating, and acquiring a regular pattern of this behaviour than the average baby. They also perceived their baby as being less ideal than the women without a previous pregnancy loss. These problems were particularly present 4 weeks post-partum and were significantly positively related to trait anxiety. The implications of this study are that in women with a history of late pregnancy loss, family physicians and welfare officers should be made aware of possible problems in the mother and in mother-infant adaptation shortly after a normal live-birth, particularly in those with high trait anxiety. They will then be able to arrange psychological support at an early stage.

The grief of late pregnancy loss

We studied 46 women who had an ultrasound diagnosis of a lethal fetal anomaly (gestational age > or = 24 weeks). Shortly after the diagnosis, 45% of these 46 women showed severe psychological instability established by a consensus diagnosis. Three months later, this percentage had diminished significantly to 22%. The total GHQ-28 score revealed that after 4 years, 11 out of the 29 remaining participants (38%) had a score of 5 or more, which indicated a clinically significant degree of general psychological distress. Depression and despair measured with the Perinatal Grief scale, did not decrease significantly over the 4-year period. Women with a strong disposition towards feelings of inadequacy or 'neuroticism', measured with the Dutch Personality Questionnaire, displayed significantly more intense grief reactions than women without such a strong disposition. The implications of our study are that in the face of (threatened) late pregnancy loss, medical care should include (i) paying attention to the need for medical information and emotional support and (ii) performing psychosocial screening of women identified as showing signs of inadequacy.

Parents' experience surrounding the death of a newborn whose birth is at the margin of viability

OBJECTIVE

To describe the experience of parents surrounding the death of a newborn weighing less than 500 g at birth.

DESIGN

Descriptive, using an eidetic phenomenologic approach.

SETTING

Interviews were conducted in the parents' homes or by telephone between 4 and 15 weeks after the loss.

PARTICIPANTS

Eight parents (five mothers and three of their husbands) who had experienced the death of a newborn weighing less than 500 g at birth.

MAIN OUTCOME MEASURES

The lived parental experience of the death of a newborn consists of a number of parental processes, responses, and activities that occur over time.

RESULTS

Five themes were generated from the data: (a) realization that the loss is occurring; (b) initial response to the loss; (c) decision making at the time of the loss; (d) components of supportive relationships with others; and (e) the adjustment at home.

CONCLUSIONS

The findings demonstrate the unique experience of having a newborn who is born at the margin of viability and support the need for individualized, caring-based interventions for parents.

Pregnancy following miscarriage: course of grief and some determining factors

This prospective study aimed to investigate the impact of both (the speediness of) a subsequent pregnancy and the birth of a viable child on grief arising from a previous pregnancy loss. Data were collected from a series of written questionnaires. Of the 2140 pregnant women who participated in the study, 227 lost a baby by miscarriage (85%) or perinatal death (15%). In 221 women, the loss concerned a singleton. At each of four post-loss assessments, these women completed the Perinatal Grief Scale. They also indicated whether they had conceived again and, if they had, related how they felt about that. Data were analyzed by means of hierarchical multiple regression. Both conceiving again and the birth of a living child lessened grief. A speedy new pregnancy was only rarely found to be detrimental. It is suggested that parents, at least following miscarriage, no longer be advised to wait a specific time before conceiving again. Preferably their individual situation should be discussed with them in order to help them make their own informed decision concerning the subsequent pregnancy.

Facilitating perinatal grieving between the mother and the father

Society often expects mothers and fathers to share equally in the perinatal grief process because the child was a common bond between them. Unfortunately, in perinatal grief, this is not always the case. The mother and the father can experience incongruent grieving and use discordant coping mechanisms. It is important to evaluate these differences to facilitate communication between the distraught parents. Improved communication can in turn facilitate the grieving process.

A Critical Review of the Concept of Pathological Grief following Pregnancy Loss

It has often been suggested in the literature on pregnancy loss, that parents run a high risk of complicated or pathological grief as a result of the specific characteristics of such loss. What confuses the issue is that pathological grief has been defined in various ways. In the interest of improving professional care, it is important to ascertain how pathological grief manifests itself and which parents are most likely to have problems coping with pregnancy loss and therefore develop pathological grief reactions. Given the lack of clarity regarding the concept of pathological grief following pregnancy loss, this article reviews empirical studies on pathological grief following pregnancy loss according to four subtypes derived from general bereavement literature: chronic grief, delayed grief, masked grief, and exaggerated grief. It can be concluded that in the first six months following pregnancy loss, psychological complaints, behavioral changes, and somatic complaints are fairly common responses. Approximately 10-to-15 percent of the women develop a psychiatric disorder during the first two years following such loss, and less than 10 percent seek specific psychiatric care. Parents often mourn the loss of their baby for more than a year; one in five women is unable to accept pregnancy loss after approximately two years. A delayed grief reaction occurs in about 4 percent of parents and seems to occur most often in men. It is suggested that developing pathological grief following pregnancy loss may be more uncommon than had previously been thought, and the long-held idea that parents run a higher risk of pathological grief following pregnancy loss seems partly to result from flaws in the empirical studies in this field. A large majority of women seem to be able to recover from pregnancy loss in due time, drawing on their own strength.

Multifetal pregnancy reduction: psychodynamic implications

New reproductive technologies, such as advanced infertility treatments, may have significant implications for women's psychological experience of pregnancy and motherhood. This paper examines some of the psychodynamic implications of multifetal pregnancy reduction, a medical procedure in which some of the fetuses in a multiple pregnancy are aborted while other fetuses are carried to term. Forty-four women who had undergone pregnancy reductions were interviewed about their emotional experience of this medical intervention and their subsequent pregnancies. A qualitative analysis of their experience was conducted from five psychoanalytically-informed vantage points: drive theory, ego psychology, object relations theory, self psychology and a developmental perspective. Women experienced having to abort some of their fetuses as a stressful and distressing life event, and a fourth of the women experienced bereavement reactions which impaired their functioning for at least two weeks. Conscious and unconscious responses to the procedure included ambivalence, guilt, and a sense of narcissistic injury, increasing the complexity of their attachment to the remaining babies. However, the achievement of the developmental goal of parenting healthy birth children helped most women feel that they had made the right decision for themselves and their families. Further research is indicated, including interviews before the reduction and long-term follow-up of mothers and surviving children.

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

We evaluated whether the emotional reactions of women at 2-6 weeks after the prenatal diagnosis of a lethal anomaly and at 3 months after perinatal loss might be predicted by previous stress and acute psychological defence reactions to the diagnosis. Previous stress was defined objectively as a history of major life event(s) and having received professional mental health treatment in the past, and subjectively as the disposition for feelings of inadequacy and anxiety. Forty-one women were interviewed and completed measures on their history of major life events, whether they had received professional mental health treatment in the past, inadequacy, acute psychological defence reactions and perinatal grief. Regression analyses showed that inadequacy was the most strongly positive predictor of perinatal grief shortly after receiving the unfavourable diagnosis and three months after perinatal loss. In addition to inadequacy, having received professional mental health treatment in the past led to significantly more intense grief, but only shortly after receiving the unfavourable diagnosis. Previous life events intensified grief three months after perinatal death. The grieving process was significantly moderated by the defence of 'principalization' while it was significantly intensified by 'turning aggression against oneself', but only shortly after receiving the unfavourable diagnosis. These effects were not contaminated by relationships with pregnancy-related variables. Our findings imply that psychological support for women with perinatal loss should particularly be offered to those who have been identified as generally anxious, who have reported previous major life events and have received professional mental health treatment in the past.

Psychosocial needs of women during miscarriage or ectopic pregnancy

The woman who experiences a miscarriage or ectopic pregnancy may express her grief with many different responses. Perioperative nurses can enable the woman and her family members to adequately grieve the loss of pregnancy and the baby by using sensitive communication, therapeutic listening, and empathy skills and by coordinating follow up.

Preterm labour and delivery: psychological sequelae

The psychological care of preterm babies and their families is challenging and at least as demanding for staff as the technical aspects of care. There is growing evidence for the effectiveness of therapeutic interventions in this area, thus ensuring the optimum outcome for the baby, the family and the staff.

Emotional reactions in women in late pregnancy (24 weeks or longer) following the ultrasound diagnosis of a severe or lethal fetal malformation

We studied the emotional reactions of 41 women in late pregnancy shortly after they had been informed of the diagnosis of 'severe or lethal fetal malformations' and 3 months after delivery. In addition, situational variables were explored as determinants of grieving. While grief did not diminish during the study period, psychological instability was less pronounced at 3 months after delivery. More grief reactions were evoked by self-reported easily versus self-reported not easily initiated pregnancy, gestational age between 24 and 34 weeks versus beyond 34 weeks, multiparity versus primiparity, and viewing versus not viewing the baby.

Determinants of depressive symptoms in the early weeks after miscarriage

OBJECTIVES

We tested whether and under what conditions miscarriage increases depressive symptoms in the early weeks following loss.

METHODS

We interviewed 232 women within 4 weeks of miscarriage and 283 pregnant women and 318 community women who had not recently been pregnant. Depressive symptoms were measured with the Center for Epidemiologic Studies Depression (CES-D) Scale.

RESULTS

Among women who had miscarried, the proportion who were highly symptomatic on the CES-D was 3.4 times that of pregnant women and 4.3 times that of community women. Among childless women, the proportion of women who had miscarried who were highly symptomatic was 5.7 times that of pregnant women and 11.0 times that of community women. Women who had miscarried were equally depressed regardless of length of gestation; among pregnant women, depressive symptoms declined with length of gestation. Among women who had miscarried, symptom levels did not vary with attitude toward the pregnancy; among pregnant women, depressive symptoms were elevated in those with unwanted pregnancies. Prior reproductive loss and advanced maternal age (35+ years) were not associated with symptom levels in any cohort.

CONCLUSIONS

Depressive symptoms are markedly increased in the early weeks following miscarriage. This effect is substantially modified by number of living children, length of gestation at loss, and attitude toward pregnancy.