Grief reactions to perinatal death--a follow-up study

Added value of chromosomal microarray analysis over conventional karyotyping in stillbirth work-up: systematic review and meta-analysis

OBJECTIVE

To assess the added value of chromosomal microarray analysis (CMA) over conventional karyotyping to assess the genetic causes in stillbirth.

METHODS

To identify relevant studies, published in English or Spanish and without publication time restrictions, we performed a systematic search of PubMed, SCOPUS and ISI Web of Science databases, The Cochrane Library and the PROSPERO register of systematic reviews, for case series of fetal loss ≥ 20 weeks of gestation, with normal or suspected normal karyotype, undergoing CMA and with at least five subjects analyzed. To investigate quality, two reviewers evaluated independently the risk of bias using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. For the meta-analysis, the incremental yield of CMA over karyotyping was assessed by single-proportion analysis using a random-effects model (weighting by inverse variance). We assessed heterogeneity between studies and performed a sensitivity analysis and a subgroup analysis of structurally abnormal (malformed or growth-restricted) and normal fetuses.

RESULTS

Included in the meta-analysis were seven studies involving 903 stillborn fetuses which had normal karyotype. The test success rate achieved by conventional cytogenetic analysis was 75%, while that for CMA was 90%. The incremental yield of CMA over conventional karyotyping based on the random-effects model was 4% (95% CI, 3-5%) for pathogenic copy-number variants (pCNVs) and 8% (95% CI, 4-17%) for variants of unknown significance. Subgroup analysis showed a 6% (95% CI, 4-10%) incremental yield of CMA for pCNVs in structurally abnormal fetuses and 3% (95% CI, 1-5%) incremental yield for those in structurally normal fetuses. The pCNV found most commonly was del22q11.21.

CONCLUSIONS

CMA, incorporated into the stillbirth work-up, improves both the test success rate and the detection of genetic anomalies compared with conventional karyotyping. To achieve a genetic diagnosis in stillbirth is particularly relevant for the purpose of counseling regarding future pregnancies. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

The presence and predictors of complicated grief symptoms in perinatally bereaved mothers from a bereavement support organization

The present study investigated the presence and possible predictors of complicated grief symptoms in perinatally bereaved mothers (N = 121) up to 5 years postbereavement. The presence of complicated grief scores in the clinical range was 12.4%, which is higher than in many other bereaved populations, and the presence of other living children may protect against the development of complicated grief symptoms. The majority of the women were able to negotiate a perinatal loss without developing complicated grief; however, there remains an important group of women who up to 5 years later score in the clinical range for complicated grief symptoms.

Providing meaningful care for families experiencing stillbirth: a meta-synthesis of qualitative evidence

OBJECTIVE

The objective of this study was to explore the meaningfulness of non-pharmacological care experienced by families throughout the experience of stillbirth from diagnosis onwards.

STUDY DESIGN

A comprehensive systematic review was conducted. Multiple sources were searched for relevant studies including gray literature. Studies were included if they reported the experiences of families with the care they received throughout the experience of stillbirth, from diagnosis onwards. Studies were assessed for methodological quality prior to inclusion. Qualitative findings were extracted from included studies and pooled using a meta-aggregative approach. This paper reports the results of one meta-synthesis from the systematic review.

RESULTS

Ten qualitative studies of moderate to high quality informed this meta-synthesis. The meta-aggregative synthesis included 69 findings that informed the development of 10 categories and one final, synthesized finding. Emerging themes that underpinned the meaningfulness of care provided to parents experiencing stillbirth included: information provision, the need for emotional support and appropriate maternity ward environments and systems.

CONCLUSION

The results of this meta-synthesis revealed the elements of care that were experienced as meaningful from the perspective of parents who had experienced stillbirth. Exploration of these elements has provided important detail to underpin a growing understanding of how parents experience care and what may help or hinder parents' experience of distress, anxiety and grief throughout the experience of stillbirth.

Women's experiences in relation to stillbirth and risk factors for long-term post-traumatic stress symptoms: a retrospective study

OBJECTIVES

(1) To investigate the experiences of women with a previous stillbirth and their appraisal of the care they received at the hospital. (2) To assess the long-term level of post-traumatic stress symptoms (PTSS) in this group and identify risk factors for this outcome.

DESIGN

A retrospective study.

SETTING

Two university hospitals.

PARTICIPANTS

The study population comprised 379 women with a verified diagnosis of stillbirth (≥23 gestational weeks or birth weight ≥500 g) in a singleton or twin pregnancy 5-18 years previously. 101 women completed a comprehensive questionnaire in two parts.

PRIMARY AND SECONDARY OUTCOME MEASURES

The women's experiences and appraisal of the care provided by healthcare professionals before, during and after stillbirth. PTSS at follow-up was assessed using the Impact of Event Scale (IES).

RESULTS

The great majority saw (98%) and held (82%) their baby. Most women felt that healthcare professionals were supportive during the delivery (85.6%) and showed respect towards their baby (94.9%). The majority (91.1%) had received some form of short-term follow-up. One-third showed clinically significant long-term PTSS (IES ≥ 20). Independent risk factors were younger age (OR 6.60, 95% CI 1.99 to 21.83), induced abortion prior to stillbirth (OR 5.78, 95% CI 1.56 to 21.38) and higher parity (OR 3.46, 95% CI 1.19 to 10.07) at the time of stillbirth. Having held the baby (OR 0.17, 95% CI 0.05 to 0.56) was associated with less PTSS.

CONCLUSIONS

The great majority saw and held their baby and were satisfied with the support from healthcare professionals. One in three women presented with a clinically significant level of PTSS 5-18 years after stillbirth. Having held the baby was protective, whereas prior induced abortion was a risk factor for a high level of PTSS.

TRIAL REGISTRATION

The study was registered at http://www.clinicaltrials.gov, with registration number NCT 00856076.

Bereaved parents' experience of stillbirth in UK hospitals: a qualitative interview study

OBJECTIVE

To obtain the views of bereaved parents about their interactions with healthcare staff when their baby died just before or during labour.

DESIGN

Qualitative in-depth interview study, following an earlier national survey. All interviews took place during 2011, either face-to-face or on the telephone. Data analysis was informed by the constant comparative technique from grounded theory.

SETTING

Every National Health Service (NHS) region in the UK was represented.

PARTICIPANTS

Bereaved parents who had completed an e-questionnaire, via the website of Sands (Stillbirth and Neonatal Death Society). Of the 304 survey respondents who gave provisional consent, 29 families were approached to take part, based on maximum variation sampling and data saturation.

RESULTS

22 families (n=25) participated. Births took place between 2002 and 2010. Specific practices were identified that were particularly helpful to the parents. Respondents talked about their interactions with hospital staff as having profound effects on their capacity to cope, both during labour and in the longer term. The data generated three key themes: 'enduring and multiple loss': 'making irretrievable moments precious'; and the 'best care possible to the worst imaginable'. The overall synthesis of findings is encapsulated in the meta-theme 'One chance to get it right.' This pertains to the parents and family themselves, clinical and support staff who care for them directly, and the NHS organisations that indirectly provide the resources and governance procedures that may (or may not) foster a caring ethos.

CONCLUSIONS

Positive memories and outcomes following stillbirth depend as much on genuinely caring staff attitudes and behaviours as on high-quality clinical procedures. All staff who encounter parents in this situation need to see each meeting as their one chance to get it right.

Stillbirths: why they matter

In this first paper of The Lancet's Stillbirths Series we explore the present status of stillbirths in the world-from global health policy to a survey of community perceptions in 135 countries. Our findings highlight the need for a strong call for action. In times of global focus on motherhood, the mother's own aspiration of a liveborn baby is not recognised on the world's health agenda. Millions of deaths are not counted; stillbirths are not in the Global Burden of Disease, nor in disability-adjusted life-years lost, and they are not part of the UN Millennium Development Goals. The grief of mothers might be aggravated by social stigma, blame, and marginalisation in regions where most deaths occur. Most stillborn babies are disposed of without any recognition or ritual, such as naming, funeral rites, or the mother holding or dressing the baby. Beliefs in the mother's sins and evil spirits as causes of stillbirth are rife, and stillbirth is widely believed to be a natural selection of babies never meant to live. Stillbirth prevention is closely linked with prevention of maternal and neonatal deaths. Knowledge of causes and feasible solutions for prevention is key to health professionals' priorities, to which this Stillbirths Series paper aims to contribute.

The effects of social support on maternal anxiety and depression after stillbirth

While most births result in a live baby, stillbirth (the birth of a dead baby) occurs in nearly 1 in 110 pregnancies. This study examined whether levels of maternal anxiety and depression are lower amongst mothers who received social support after stillbirth. Using non-probability sampling, data were collected from 769 mothers residing within the USA who experienced a stillbirth within the past 18 months and for whom we have complete data. The study Maternal Observations and Memories of Stillbirth and the website http://www.momstudy.com containing the questionnaire were open in the period 8 February 2004-15 September 2005. Congruent with the family stress and coping theory, mothers of stillborn babies who perceived family support in the period after stillbirth experienced levels of anxiety and depression that were notably lower than those of their counterparts. Nurses, physicians and support groups also were important sources of support after a stillbirth; however, these sources of support alone were not statistically significant in reducing anxiety and depression in grieving mothers. Community interventions should focus on the grieving mother and her family system, including her partner and surviving children.

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.

Depressive symptoms at two months after miscarriage: interpreting study findings from an epidemiological versus clinical perspective

We identify two study designs used to investigate psychiatric symptoms following reproductive loss. One design examines psychiatric outcomes in a single cohort of bereaved women; the other compares psychiatric outcomes in bereaved and non-bereaved cohorts. We employ the findings from one study of depressive symptoms following miscarriage to exemplify these designs and inferential differences in causal inferences that can be drawn. We interviewed a cohort of 114 women at 6-8 weeks after miscarriage and a cohort of 318 community women not recently pregnant. Depressive symptoms were assessed with the Center for Epidemiologic Studies Depression (CES-D) Scale. Among miscarrying women, the mean level of depressive symptoms was substantially elevated above that in the community cohort (adjusted difference in means between cohorts, 4.9, 95% confidence interval [CI] 2.3-7.4). Among miscarrying women, 20.2% were highly symptomatic (CES-D 30+), as compared with 10.1% among community women (adjusted odds ratio [OR] 2.8, 95% CI 1.4-5.6). However, in contrast to findings from the same study concerning depressive reactions at 2 weeks after loss, the impact of miscarriage on depressive symptoms at 6-8 weeks was markedly greater for younger women and possibly for women with a history of prior reproductive loss, but otherwise did not vary with number of living children, marital status, ethnicity or educational level. We conclude that miscarrying women first seen at their 6- to 8-week post miscarriage gynecologic visit are likely to be more depressed on average than otherwise comparable women who have not experienced a recent reproductive loss. Factors that moderate the impact of miscarriage may vary with time since loss. Enhanced recognition of the implications of study design for research inferences may help bring greater clarify and uniformity to findings from future investigations in this field.

Motherhood as a vulnerability factor in major depression: the role of negative pregnancy experiences

Adverse pregnancy experiences were examined retrospectively in relation to adult lifetime experience of clinical depression to see whether such experience conferred long-term risk for women. The sample consisted of just under 200 community-based women, half of whom were selected for high depressive-risk on the basis of adverse childhood experience. Over two-thirds of these women had experienced pregnancy. Adverse pregnancies were classified either in terms of loss (adverse non-live pregnancy/births) or in terms of live births in difficult circumstances (adverse live pregnancy/births). Intensive life history interviews collected details of all pregnancies, childhood neglect/abuse, marital adversity and a history of episodes of clinical depression. Both adverse non-live and live pregnancy experiences were significantly related to lifetime depression. The relationship remained for depression in different time periods and for those episodes unrelated to maternity experience. Both types of adverse pregnancy/birth experiences were associated with increased rates of marital problems. While adverse live pregnancy/births related to prior childhood neglect/abuse, this did not hold for those non-live. Logistic regression showed that only adverse non-live pregnancy/births together with marital adversity and childhood neglect/abuse provided the best model for lifetime depression. The findings are discussed in terms of lifetime trajectories linking difficult environments, close relationships and issues of loss.

Couple distress after sudden infant or perinatal death: a 30-month follow up

OBJECTIVE

To examine, using a 30-month prospective study, patterns of anxiety, depression and alcohol use in couples following stillbirth, neonatal death or sudden infant death syndrome.

METHODOLOGY

One hundred and thirty-eight bereaved and 156 non-bereaved couples completed standardized interviews at 2, 8, 15 and 30 months post-loss.

RESULTS

At all interviews, bereaved couples were significantly more likely than non-bereaved couples to have at least one distressed partner. Rarely were both partners distressed in either group. For bereaved couples, 'mother only' distress declined from 21% to 10% during the study. 'Father only' distress ranged from 7% to 15%, peaking at 30 months. Bereaved mothers who were distressed at 2 months reported significantly lower marital satisfaction at 30 months.

CONCLUSIONS

At the couple level, the experience of a baby's death is multifaceted. Gender differences are common and partners' needs may change over time. Early recognition of these differences may facilitate longer-term adjustment for both partners.

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.

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.

Depression in women suffering perinatal loss

OBJECTIVE

To analyze depression in women who have suffered perinatal loss in the present study.

METHODS

The level of depression was studied, by means of the Beck Depression Inventory (BDI), in two groups of women, mothers who suffered perinatal loss and received psychological intervention for 1 year and mothers with live-birth babies. The BDI was recorded immediately after delivery and at 6 and 12 months postpartum. A third group of women with perinatal loss who received no intervention were studied only 12 months postpartum.

RESULTS

At the time of delivery, women who suffered perinatal loss showed higher levels of depression, as measured by higher scores on the BDI than women experiencing a live-birth. At 6 months postpartum the intervention group showed improvement (lower BDI scores), but as a group they endorsed more depressive symptoms than the live-birth group. At 12 months the perinatal loss group who received the 1-year intervention was less depressed than the group who did not, and scored very similar to the live-birth group.

CONCLUSION

Women who experience perinatal loss endorse more depressive symptoms than mothers of live-births, and these depressive symptoms can be ameliorated by a psychological intervention.

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.

The mental health impact of stillbirth, neonatal death or SIDS: prevalence and patterns of distress among mothers

Although stressful events have long been implicated in the onset of psychological disorder, available data suggest that the majority of individuals appear to escape serious impairment even following highly traumatic events. Related to this is the question of chronicity and whether those who do become impaired develop mental health problems of an ongoing nature. This paper documents the psychological adjustment of 194 women following a highly stressful event-the death of an infant due to stillbirth, neonatal death or SIDS. Anxiety and depression were measured on four occasions-at 2, 8, 15 and 30 months post-loss--using the Delusions Symptoms States Inventory (DSSI/sAD). For comparative purposes, the mental health of 203 mothers of a surviving infant was similarly assessed. The results demonstrate that bereaved mothers, as a group, manifest significantly higher rates of psychological distress than mothers of living infants for at least 30 months after their loss. Their impairment may be either acute or chronic in form. The majority of bereaved mothers appear not be develop serious mental health problems in response to the loss or experience psychological impairment that is usually self-limiting. For a smaller group of women, the death of a baby may herald serious and ongoing distress. Bereaved mothers who were not distressed soon (2 months) after the loss were unlikely to become so later, but those who were still distressed at 8 months were likely to remain so subsequently.

Psychological complications after stillbirth--influence of memories and immediate management: population based study

OBJECTIVE

To identify factors that may predict long term psychological complications among women who have had a stillborn child.

DESIGN

Nationwide population based study using epidemiological methods.

SUBJECTS

380 subjects and 379 controls who had had a stillborn or non-deformed live child in Sweden in 1991.

RESULTS

Information was provided by 636 (84%) women. The ratio (95% confidence interval) of proportions of women with symptoms related to anxiety above the 90th centile for women who had had a stillborn child compared with those who had not was 2.1 (1.2 to 3.9). An interval of 25 hours or more from the diagnosis of death in utero to the start of delivery gave a ratio of 4.8 (1.5 to 15.9). The ratio was 2.3 (1.1 to 5.3) for not seeing the child as long as the mother had wished and 3.1 (1.6 to 6.0) for no possession of a token of remembrance.

CONCLUSION

It is advisable to induce the delivery as soon as feasible after the diagnosis of death in utero. A calm environment for the woman to spend as much time as she wants with her stillborn child is beneficial, and tokens of remembrance should be collected.

Grief following the loss of a newborn twin compared to a singleton

This study, involving five level III neonatal intensive care units, investigated whether there are any differences between parental grief following the death of a newborn twin and parental grief following the death of a newborn singleton. A total of 142 parents were examined using the Perinatal Grief Scale (PGS): 72 who had lost a newborn twin and 70 matched controls who had lost a newborn singleton 0.5-3.5 years previously. We found that bereaved twin parents did not differ in grief reactions from bereaved singleton parents (PGS: F = 0.00, p = 0.962). This held true both for the short and the long term (F = 0.13, p = 0.721). Mothers showed more grief than fathers (F = 8.16, p = 0.005). In conclusion, grief in bereaved twin parents should be taken as seriously as grief in bereaved singleton parents. The present guidelines regarding care for the latter ought to be adapted to meet the needs of the former.

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.

Stress and Grief of a Perinatal Loss: Integrating Qualitative and Quantitative Methods

Based on family stress theory, this study examined the question of how parents grieve the loss of a baby through miscarriage or stillbirth. Using a combination of qualitative and quantitative research methods, we interviewed twenty-six couples two weeks after a perinatal loss. The couples filled out questionnaires measuring individual variables including bereavement, depression and stress, and couple variables including cohesion, adaptability, communication, satisfaction, and partner support. Then they participated in a three-hour semi-structured interview. Ethnographic content analysis revealed twelve themes closely related to the resources, the meaning of the stressful event, and the coping strategies of Hill's ABC-X stress model. The quantitative analysis of the individual and couple variables supported the qualitative findings in that most couples had excellent coping strategies derived from within the couple relationship.

Parents' Coping and Communication following Their Infant'S Death

The purpose of this study was: 1) to examine whether mothers and fathers utilize similar or different coping strategies to deal with the death of their infant, and 2) to explore whether discordant parental coping was associated with communication difficulties.

Twenty-seven couples who had experienced a stillbirth, neonatal death, or Sudden Infant Death within the previous six to twenty-seven months were asked to participate. Two constructs were measured: (a) Coping was assessed with the Ways of Coping Checklist and the Coping with the Death of a Child instrument and (b) Communication was measured with the Marital Communication Inventory. Mothers and fathers independently completed these three questionnaires.

Mothers and fathers differed in their use of only three of the fourteen coping strategies examined. Thus, mothers' and fathers' coping strategies, six to twenty-seven months post-loss, were more concordant than discordant. Mothers used seeking social support, escape-avoidance strategies, and preoccupation to a significantly greater extent than did fathers. Important predictors of mothers' coping strategies were the infant's age and time since the death, while for fathers the important predictors were the infant's gender and the family income level.

For couples whose coping was discordant, mothers perceived higher levels of conflict in their communication with their spouses as compared to couples whose coping was concordant.

The effects of pregnancy loss on women's health

A survey of women patients in the practices of family physicians in Victoria, B.C. was undertaken to determine the factors associated with pregnancy losses and their effect on women's health. Questionnaires returned by 1428 women with 2961 pregnancies showed that a higher number of losses, particularly abortions, correlates both with poor health and the need to obtain professional help in dealing with the loss(es). Partner support appears to be one of the most important factors in maintaining a pregnancy.

Miscarriage and stillbirth: time since the loss, grief intensity and satisfaction with care

In this paper we discuss the results of a study, conducted in the Netherlands, involving 143 women who experienced a miscarriage or stillbirth (response of 69%). The main questions were: how women with a fetal loss before the 20th week (miscarriage) versus women with a loss later in pregnancy (stillbirth) coped with the death of their baby; how the lapse of time since the loss related to grief intensity; and how satisfied women were with the professional care and support. The relationship between some other variables and grief intensity was also examined. It was found that grief intensity was greater and there was more satisfaction with professional care when gestational age was longer. With regard to the care, we concluded that some aspects needed improvement, especially the professional support for women who miscarry and the coordination of care for all women after discharge from hospital.

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.

Depressive symptoms in women in the six months after miscarriage

This study, the first systematic investigation of the psychiatric impact of miscarriage, tests whether miscarriage markedly increases depressive symptoms in the 6 months after loss. We interviewed 382 miscarrying women entering the study at 2 weeks, 6 weeks, or 6 months after loss and, for comparison, 283 pregnant women and 318 community women not recently pregnant. Among women interviewed 2 weeks after miscarriage the proportion highly symptomatic on the Center for Epidemiologic Studies-Depression scale was 3.4 times that of pregnant women (95% confidence limits 2.0 and 5.0) and 4.3 times that of community women (95% confidence limits 3.0 and 5.8). Among women first interviewed 6 weeks and 6 months after miscarriage the proportion highly symptomatic was three times that of the community women. Women reinterviewed at 6 weeks and 6 months did not have elevated symptom levels, a result attributed to the unintended therapeutic and test effects of study interviews. Interviews were fully structured, readily administered by telephone by nonmedical personnel. The possibility that such interviews afford miscarrying women substantial psychologic benefits merits future investigation.

Facilitating care after perinatal loss. A comprehensive checklist

Each year, one out of five women suffers the loss of a pregnancy. Such losses are more than statistics: to many mothers, they represent the death of a longed-for child. While increasing attention has been directed toward meeting the needs of these women, the services provided are often fragmented. The use of a comprehensive checklist for providing care facilitates continuity and consistency of care and offers structure and direction for the caregiver. In this manner, vital aspects of care are not omitted as the bereaved woman moves through the health-care delivery system.

Parental grief following the death of an infant--a follow-up over one year

The course of parental bereavement during the first year following an infant's death was investigated. Also, the differences in mothers' and fathers' reactions, the differences according to the mothers' occupational role, and the similarities in couples' reactions were studied. From a total sample of 59 families, 13 families answered their questionnaires at all three time points (1, 6 and 13 months), 22 families responded at two time points, and 37 families responded at some point following the loss. Measures relating to anxiety, depression, bodily discomfort, general well being and impact of event were used at the three time points. The results showed that grief, as measured by the different inventories, decreased over time. The decrease was most evident from 6 to 13 months, and most prominent in women. A considerable number of the parents were still actively dealing with the loss all through the first year of bereavement. In most couples the mother reported most distress. Mothers were significantly more depressed than fathers at all time points, and mothers also had significantly higher anxiety and lower general health at 1 and 13 months, and intrusive scores of 1 and 6 months. Women at home evidenced more grief at all three time points than women employed outside the home. A high or low score in one spouse was more strongly correlated with a similar score in the other at 1 and 13 months, than at 6 months. The implications for counselling of parents, with special emphasis on the employment situation of the mother, is emphasized.

Parental reactions to the loss of an infant child: a review

This article examines methodological problems, and describes and evaluates commonly explored variables regarding research on the effect of an infant's death on the family. The components of parents' and siblings' grief reactions, and the similarities and differences in parental grief are reviewed. The research shows marked differences between mothers' and fathers' reactions--the grief reactions in mothers being stronger and more prolonged. Different explanations for this are put forward. The effect of different types of loss as well as the effect of the child's life span before death are also reviewed and discussed. Further knowledge is needed to single out the influence of these factors' on the families' reactions. It is concluded that the death of an infant makes the family prone to develop short-term and/or long-term problems in their adaptation to the loss. An integrated effort by health professionals is needed to develop systematic ways of helping families to cope with the death of a child.

A 1 and 6 month follow-up of prenatal diagnosis patients who lost pregnancies

This paper reports results of an exploratory study of prenatal diagnosis patients who experienced voluntary terminations of pregnancy following the detection of an abnormality or spontaneous miscarriages. The 121 participants were part of the national collaborative Chorionic Villus Sampling and Amniocentesis Study. They completed semi-structured telephone interviews and mailed questionnaires at 1 month and 6 months after the pregnancy losses. Scores on the Profile of Mood States showed that mood levels improved significantly over time. However, there were some declines in loss-related support from partners and others. The persisting distress and difficulties of a minority highlight the variability in women's responses to pregnancy losses. Women who lost pregnancies later in gestation, showed the greatest mood disturbances at initial assessments, used professional mental health assistance after the loss, or reported less satisfactory loss-related support from significant others showed the greatest levels of mood disturbance at the six-month assessment. Follow-up contacts with patients who lose pregnancies should be used to inform women about the variation in possible grief reactions, to assess the extent of support the women are receiving from their partners and significant others, and to provide additional follow-up or referral of those experiencing the greatest distress.

Adaptation following perinatal loss: a critical review

Parental adaptation following perinatal loss has received increasing attention in the past 20 years. From early anecdotal accounts to recent more rigorous investigations, it is clear that perinatal loss in the developed world is a significant psychological trauma for parents. Major immediate consequences are likely for virtually all affected families, and long-term sequelae are likely for some. Despite widespread attention to the experience of families who lose a stillborn or newborn infant, including major changes in hospital practices regarding management of these families, many important questions remain unanswered. We know little, for instance, about which parents are at greatest risk for disordered mourning or what additional measures might minimize their psychological morbidity. In fact, because of a tendency to focus exclusively on affective symptomatology following the loss, other important features of the process of mourning have been overlooked or examined unsystematically. Suggestions for specific and general directions for further research are discussed.

Prevention in high risk children of depressed parents

Opportunities for prevention of psychopathology in children and families are often overlooked in the treatment of the depressed adult patient. Research and clinical findings are reviewed which highlight the impact on children and the family of depressed parents. They range from illness serious enough to require hospitalization to cases in which depression has not yet been diagnosed. These findings are used as guidelines for the development of preventive and therapeutic interventions for all family members.