Are individual differences of attachment predicting bereavement outcome after perinatal loss? A prospective cohort study

OBJECTIVE

The purpose of this study was to examine the influence of attachment, social support and the quality of the current partnership on the outcome of bereavement after perinatal loss.

METHODS

In a prospective cohort design 33 women after perinatal loss were approached on admission to hospital and reassessed four weeks, four months and nine months later. The initial assessment included the Adult Attachment Interview and self-report questionnaires for social support and quality of the current partnership. Bereavement outcome was assessed using measures of grief (MTS), depression and anxiety (HADS), psychological distress (BSI), somatisation (BSI-SOM) and symptoms of PTSD (PDS).

RESULTS

All measures of outcome showed a significant improvement over time. Standardized effect sizes between the initial assessment and nine month follow-up ranged between .36 for anxiety (HADS) and 1.02 for grief (MTS). Social support, quality of the partnership and secure attachment correlated inversely, and insecure preoccupied attachment correlated positively with the outcome measures. Preoccupied attachment was included as a predictor in two multivariate statistical models of non-linear regression analysis, one with somatisation (adjusted R2=.698, P=.016), the other with posttraumatic stress symptoms at nine month follow-up (adjusted R2=.416, P=.002) as target variable. Initial assessment scores of psychological distress predicted the course of the respective measure during follow-up (adjusted R2=.432, P=.014).

CONCLUSION

Attachment, social support and the quality of the current partnership have an impact on the course of bereavement after perinatal loss. Secondary prevention after the event may focus on these factors in order to offer specific counselling and support.

Supporting bereaved parents: practical steps in providing compassionate perinatal and neonatal end-of-life care. A North American perspective

Providing compassionate bereavement support challenges care-givers in perinatal medicine. A practical and consistent approach tailored to individual families may increase the care-giver's ability to relieve parental grief. This approach includes: (1) clear and consistent communication compassionately delivered; (2) shared decision-making; (3) physical and emotional support; and (4) follow-up medical, psychological and social care. Challenges to providing comprehensive end-of-life care include care-giver comfort, consistency of care, cultural and legal barriers, and lack of adequate training.

Hospital Care for Parents After Perinatal Death

OBJECTIVE

To systematically review parent experiences with hospital care after perinatal death.

DATA SOURCES

An evaluation of more than 1,100 articles from 1966 to 2006 was performed to identify studies of fetal death in the second or third trimester and neonatal death in the first month of life.

METHODS OF STUDY SELECTION

Studies were limited to those that were in English, evaluated care in U.S. hospitals, and contained direct parent data or opinions.

TABULATION, INTEGRATION, AND RESULTS

Results were compiled on five aspects of recommended care: 1) obtaining photographs and memorabilia of the deceased infant, 2) seeing and holding the infant, 3) labor and delivery of the child, 4) autopsies, and 5) options for funerals or memorial services. Sixty eligible studies with over 6,200 patients were reviewed. In general, parents reported appreciating time and contact with their deceased infant, being given options about labor, delivery, and burial, receiving photographs and memorabilia, and having appropriate hospital follow-up after autopsy.

CONCLUSION

Although care after perinatal death often adheres to published guidelines, substantial room for improvement is apparent. Parents with perinatal losses report few choices during labor and delivery and inadequate communication about burial options and autopsy results. Hospitals, nurses, and doctors should increase parental choice about timing and location of delivery and postpartum care, encourage parental contact with the deceased infant, and facilitate provision of photos and memorabilia.

Psychological aspects of perinatal loss

After perinatal loss, parents experience painful grief. Fathers and mothers show the same pattern of symptoms, but generally mothers' distress is more intense. Grief should be sympathetically acknowledged by health professionals, and parents should be reassured that their feelings are normal and that recovery may take many months. Intense depression lasting more than 6 months may require psychological treatment. There is some evidence that delaying conception for a year may allow an easier pregnancy psychologically. The common practice of encouraging parents to have contact with a dead infant is not evidence-based and may have adverse effects, including inducing symptoms of post-traumatic stress disorder. A protocol of postnatal follow-up allows parents to get appropriate information about the loss, including possible problems and timing of another pregnancy. The subsequent pregnancy is stressful, and health professionals should recognize that parents may suffer significant anxiety.

A grief ignored: narratives of pregnancy loss from a male perspective

This paper, utilising a narrative approach, aims to describe the experiences of men whose partner had experienced pregnancy loss, based on data from Northern Ireland. The methodology was based upon observation within pregnancy loss self-help groups and in-depth interviews with 14 men who attended the groups. The study also included interviews with 32 midwives and nurses, with the intention of examining attitudes within the medical context towards bereaved fathers. The impact of pregnancy loss on male partners has been largely overlooked in academic research. When a baby dies before birth the loss can be devastating for fathers yet, very often, the world that surrounds them tends to discount their loss, and emotional support and cultural rituals that are normally available to other bereaved individuals are often absent for this group of men. Previous research has shown that men are expected to be emotionally strong in order to support their partner. The present study will show that the perception that men have only a supportive role in pregnancy loss is unjustified, as it ignores the actual life-world experiences of the men, and the meanings they attach to their loss, in what may be a very personal emotional tragedy for them where they have limited support available. The study uncovered several recurring themes including self-blame; loss of identity; and the need to appear strong and hide feelings of grief and anger. There is consideration of the need for hospital staff and the wider community to acknowledge the male partner's grief as being a valid response to the bereavement suffered.

Communicating with Parents who Experience a Perinatal Loss

The importance of communicating with parents who experience a perinatal loss has been documented repeatedly in the research. Yet, parents do not consistently receive adequate information when they experience a loss. Effective communication with parents who have experienced a loss requires ongoing dialogue throughout all phases of care, starting well before the loss of an infant. To communicate effectively, clinicians need to know the type of information to give, how and when to give the information, and how to assess parents' understanding of the information. Professionals who are skilled at communicating with and caring for parents who experience a loss should serve as mentors for their colleagues to ensure the ongoing availability of competent clinicians.

Posttraumatic stress disorder after pregnancy loss

This prospective longitudinal study investigated the prevalence of posttraumatic stress disorder (PTSD) in response to pregnancy loss. About 1,370 women were recruited in the early stages of pregnancy and 113 of them had a subsequent pregnancy loss. One and four months after pregnancy loss, they were assessed for PTSD with the Posttraumatic Symptom Scale. Depression was also assessed. The majority had an early loss, i.e., within 20 weeks. At one month, the prevalence of PTSD was 25%, and the symptom-severity was similar to other traumatized populations. Women with PTSD had increased risk of depression: 34% of PTSD cases and 5% of non-cases reported depression. At four months, 7% met the criteria for PTSD, of which half were chronic. In contrast, rates for depression had not declined. The results indicate that pregnancy loss is potentially traumatic, putting women at risk of developing PTSD. In most cases, the disorder is immediate and persists for several months.

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

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

The Impact of Postpregnancy Loss Services on Grief Outcome: Integrating Research and Practice in the Design of Perinatal Bereavement Programs

A national sample of 249 bereaved mothers and 114 of their male partners was investigated retrospectively, using a mailed questionnaire and the Perinatal Grief Scale, to determine the impact of postpregnancy loss services on grief outcome. Participants ranged in age from eighteen to forty-seven and experienced from one to twelve pregnancy losses with gestational age of two to forty-two weeks. A three-stage multiple regression analysis determined that predictors differed by gender and that services contributed to the prediction of grief outcome above and beyond demographic variables. Significant predictors for mothers were months since loss, attending counseling, and attending support group; significant predictors for fathers were length of pregnancy, talking with friends, and timing of talking with family. A large-scale longitudinal study that controls for service variables could inform the development of future perinatal bereavement programming in addressing the unique needs of bereaved mothers and fathers.

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.

Unresolved loss due to miscarriage: an addition to the Adult Attachment Interview

Parental unresolved loss as assessed in the Adult Attachment Interview (AAI; George, Kaplan, & Main, 1985) is significantly associated with infant disorganized attachment. Lapses in the monitoring of both reasoning and discourse and reports of extreme behavioural reactions are evidence of the continuing presence of unresolved responses to loss. (Main, DeMoss, & Hesse, 1994). The original format of the AAI does not include a separate question concerning the experience of miscarriage. We added questions on this subject because, for many parents, miscarriage represents a significant loss. The questions and follow-up probes closely followed the format of the questions in the AAI about loss and were asked immediately after these questions. Answers to the questions about miscarriage were rated with the current classification system for unresolved loss. In a sample of 85 middle-class, non-clinical mothers of 1-year-old infants, thirty mothers (35%) reported that they had experienced a miscarriage. Scores on the 9-point rating scale for unresolved loss due to miscarriage were related to infant disorganized attachment behaviour, r(30) = .30, p = .05. Mothers' unresolved loss was not related to the amount of time that had passed since they had a miscarriage. Unresolved loss due to miscarriage was, however, related to the duration of the pregnancy before miscarriage, r(30) = .56, p = .004. Thus, including a question on miscarriage in the AAI may yield theoretically and clinically important information.