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ORIGINAL RESEARCH |
From the Institute for Work & Health and University of Toronto, Toronto, Ontario, Canada.
Address reprint requests to: Renée-Louise Franche, PhD Institute for Work & Health 250 Bloor Street East, Suite 702 Toronto, ON M4W 1E6 Canada E-mail: rfranche{at}iwh.on.ca
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Abstract |
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Methods: Participants included 60 pregnant women with previous miscarriages or perinatal deaths, and 50 of their partners. Participants completed a package of psychometric instruments between the tenth and 19th week of gestation. Predictors of grief (active grief, difficulty coping, despair) included (1) psychologic factors: marital adjustment and self-criticism; (2) demographic factors: age and number of living children; and (3) obstetric factors: gestational age at time of loss, number of losses, and time between loss and subsequent conception.
Results: Stepwise regression analyses were conducted for each grief component for women and men. For women, active grief was significantly associated with high self-criticism and later losses (R2 = 0.31). Later losses and longer time between loss and conception were significantly associated with difficulty coping (R2 = 0.55) and despair (R2 = 0.44). In men, active grief was associated with high self-criticism and later losses (R2 = 0.28), difficulty coping (R2 = 0.18), and despair (R2 = 0.25) with high self-criticism. A trend was found for poor marital adjustment to be associated with higher levels of difficulty coping and despair in men.
Conclusion: High levels of self-criticism and later gestational age at time of loss are predictors of increased grief during a pregnancy after a miscarriage or perinatal death. Increased time between loss and subsequent conception is also predictive of increased grief for women. For men, low levels of marital adjustment are predictive of increased grief. These results may be helpful in counselling couples considering pregnancy after a loss.
More than half of women who experience miscarriage or perinatal death are pregnant with another child within 22 months after the loss.1 It is well established that a more advanced gestational age at the time of loss is associated with more intense grief,2–4 and that women tend to report more intense initial symptoms of perinatal grief than men.4,5 However, few studies have examined predictors of grief and psychologic adjustment during a pregnancy after a miscarriage or perinatal death,1,6 and little is known about the role of psychologic variables as predictors of grief after such a loss.
The purpose of the current study was to determine if the psychologic constructs of self-criticism and marital adjustment, considered jointly with obstetric and demographic factors, are significant predictors of grief during a pregnancy after a miscarriage or perinatal death. Obstetric factors included gestational age at time of loss, number of losses, and time between loss and conception. Demographic factors included age and number of living children.
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Materials and Methods |
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Two previous studies had been conducted on separate halves of the sample used in the current study. The outcome variables and main research questions in those two studies differed from those in the current study. In the first study,7 the focus was on comparing 31 pregnant women and 28 of their partners with a history of miscarriage or perinatal death with 31 pregnant women and 23 of their partners without a history of loss on levels and predictors of depressive symptomatology and anxiety. In the second study,5 the impact of a subsequent pregnancy after a loss was assessed by comparing 25 pregnant women and 24 partners with previous losses with 25 nonpregnant women and 18 partners with a previous loss on measures of psychological adjustment and grief.
Announcements concerning the study were posted in obstetric and perinatal clinics of a university-affiliated hospital in a metropolitan community of 600,000. Eligible women were asked by health care staff if they were interested in the study. Interested patients immediately met with a research assistant who explained what participation involved. Partners were encouraged to participate, either by direct contact or through the woman (if the partner was not present at the visit). Participants were asked to complete a battery of questionnaires when they were between 10 and 19 weeks of gestation. It is typically around the 20th week of gestation that all ultrasound and routine prenatal testing are completed and that fetal movement has been perceived. It is believed that, as a result of confirmation of good fetal health, visualization of the fetus, and of quickening, prenatal attachment grows more rapidly. Couples completed the questionnaires at home and returned them by mail. They were then called by the research assistant for debriefing and to offer emotional support if appropriate. Eligible partners included husbands, common-law partners, and boyfriends who had fathered the baby. The study was approved by the hospital’s research ethics board.
Included in the questionnaire package: was the Perinatal Grief Scale—short form version.8 This scale assesses general symptoms of grief and symptoms specific to miscarriage and perinatal death. The mourning process associated with a miscarriage or perinatal death is conceptualized as consisting of three factors: active grief, difficulty coping, and despair. Active grief refers to the outward expression of distress. Difficulty coping is the difficulty an individual has in dealing with normal activities and with other people. Despair addresses a self-blaming and hopeless attitude conducive to depression. The three factors of active grief, difficulty coping, and despair are derived from a factor analysis of descriptors of perinatal grief generated by 194 bereaved parents. The three subscales show adequate discriminant validity and internal consistency. Each subscale has a range of 11–55, based on a five-point Likert scale format.
Also included in the questionnaire package was the Depressive Experiences Questionnaire—Self-criticism subscale.9 This total scale comprises three subscales: dependency, self-criticism, and self-efficacy. Test–retest reliability and internal consistency were adequate. The scale was given in its entirety; however, for the purposes of this study, only results pertaining to the self-criticism subscale are reported. The self-criticism subscale has a range of 15–105, based on a seven-point Likert scale.
The last questionnaire was the Abbreviated Dyadic Adjustment Scale.10 This scale assesses marital adjustment. Internal consistency and discriminant validity were adequate. It has a range of 0–35, based on a five-point Likert scale format.
Participants completed a personal information form assessing basic demographics, circumstances of miscarriage or perinatal death, and of current pregnancy.
Statistical analyses included variables examined for potential multicollinearity. To identify any possible confounding variable, participating and nonparticipating men were compared with respect to the main demographic, obstetric and psychologic variables. Normality of distribution of dependent variables was examined to ensure that assumptions for regressions were met. Stepwise regressions were conducted to investigate the predictors of each grief subscale for men and women. In stepwise regression, independent variables are added one at a time if they meet statistical criteria, but they may also be deleted at any step where they no longer contribute significantly to regression. Stepwise regression is considered the surest path to the best prediction equation.11 Seven predictor variables were included: gestational age at time of loss, number of months between loss and conception of subsequent pregnancy, number of losses, number of living children, age, marital adjustment, and self-criticism. Sample size was adequate as it is recommended that the number of participants be five to 10 times the number of variables included in the analyses.12
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Results |
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Mean gestational age at time of loss was of 17.5 weeks (± 11.1), with a median of 12 weeks and a range of 4–42 weeks. Thirty-one (51%) women reported having a loss within the first trimester, 17 (29%) in the second trimester, nine (15%) in the third trimester, and three (5%) had neonatal deaths within the first 4 days of life. Mean total number losses was of 2.2 losses (± 1.8) with a median of two, and a range of 1–12. Thirty-one (51%) of women had at least two previous losses. Average time since the loss was of 15.1 months (± 9.9), with a median of 13 months, and a range of 4–48 months. For 58 (97%) couples, time lapsed since the loss was 36 months or less.
Mean gestational age for the current pregnancy was 14.7 weeks (± 2.23), with a median of 14 weeks, and a range of 10–19 weeks. Average amount of time between the miscarriage/perinatal death and conception for the new pregnancy was 11.4 months (± 9.8), with a median of 8.5 months, and a range of 1–35.5 months. Fifty-six (93%) women had conceived within 2.5 years following their loss. Ninety-one (83%) participants reported that the current pregnancy had been planned.
Despite moderately high correlations between the subscales of the Perinatal Grief Scale (Tables 1
and 2), these scales were retained for analysis as they reflect closely the expected correlations based on the validation study of the Perinatal Grief Scale.3 Concerning the degree of multicollinearity between independent and dependent variables, high correlations between dependent and independent variables are optimal in regression analyses.11
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2 analysis was performed on marital status of participating and nonparticipating men and was nonsignificant.
Distribution of the dependent variables was examined by plotting their expected normal values against their actual normal values with a Q-Q plot. Normality was supported for the three Perinatal Grief subscale scores for each gender.11 Stepwise regression showed that for women (Table 3), higher levels of all three grief components were significantly associated with higher levels of self-criticism and later gestational age at time of loss. Difficulty coping and despair were associated with time between loss and subsequent conception, in that the longer the period of time, the more intense the grief. In men (Table 4), higher levels of active grief were associated with higher levels of self-criticism and later losses. Difficulty coping was associated with high self-criticism with a trend for poor marital adjustment. Despair was associated with poor marital adjustment, with a trend for high self-criticism.
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Discussion |
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Better perceived marital adjustment was associated with less difficulty coping and less despair for men, whereas for women marital adjustment was not a significant predictor. This finding is consistent with previous research in which a positive marital relationship was found to be associated with decreased grief reactions after a loss.2,3
Taken together, these results suggest that a miscarriage or perinatal death may be most relevant to women’s self-concept and to men’s perceived marital adjustment. Given women’s physical and psychologic relationship to the fetus, women may interpret a loss as a personal failure, whereas men may be more sensitive to the effects of the loss on their relationship with their partner. Of the pregnancy-related and demographic variables considered in this study, only gestational age at time of loss and time between loss and conception were significant predictors of grief levels. Age, number of previous losses, and number of living children, when considered in conjunction with psychologic variables, were not significantly associated with grief levels.
Gestational age at time of loss was a significant predictor of all three grief components for women, and of only active grief for men. These results are consistent with previous research conducted with women: gestational age has been found to be a significant predictor of the three grief components at 2 months post-loss for women and men,15 up to 18 months post-loss for women only,2 up to 30 months post-loss for women and men,5 and of total grief scores 6–8 weeks post-loss for women and men.3 For men, the absence of a significant association between gestational age and despair and difficulty coping suggests that marital adjustment and self-criticism play pivotal roles in the development of the more problematic aspects of grieving. These two psychologic variables had not been included in previous studies examining the three components of grief in men.
The finding that women who conceive later after the loss experience more despair and difficulty coping than women who conceive earlier after the loss is perplexing as it contradicts a recent study in which a speedy pregnancy was found to be associated with higher levels of depression and anxiety.6 Our findings can be interpreted only tentatively, as intention to become pregnant was not assessed in our participants. It is possible that women who are more distressed may spontaneously delay their next conception to avoid experiencing negative emotions during their pregnancy. Alternatively, women who are grieving intensely may have more difficulty conceiving than those experiencing less grief due to psychophysiological factors16 or might engage less frequently in sexual activity.
The cross-sectional design of the study limits the conclusions that can be made regarding causality of relationships between independent and dependent variables. Most importantly, we cannot eliminate the possibility that only couples who were experiencing lower levels of grief after a loss were willing or able to conceive. Prospective, longitudinal designs, assessing intention to become pregnant, would shed light on the factors contributing to adjustment over the course of the subsequent pregnancy. Future studies should incorporate a standardized assessment of previous psychopathology, especially depression. It is likely that mental health history, particularly a history of depression, would be associated with higher self-criticism. In addition, cultural and religious factors were not assessed in this study and their impact on the mourning process may be important.
Although there was a high participation rate in the study, 72% of the participating women reported an annual family income of over $40,000 (Canadian) and few participants born outside of Canada were recruited. The fact that participants were recruited in a teaching hospital may have biased the sample toward one with more frequent high-risk pregnancies. Finally, it is possible that individuals who dropped out of the study or refused to participate were more distressed, as compared with individuals in the study sample. In a previous study on perinatal death, participants tended to be psychologically healthier than those refusing to participate.17 The homogeneity of the sample, the potential sampling bias, and the potential "healthy participant" effect restrict the generalizability of results.
The results of the current study highlight the importance of providing interventions specifically oriented to decrease a woman’s self-critical attitudes about a miscarriage or perinatal death. Interventions that may be helpful include providing reassurance that she was not responsible for the loss, informing her about the possible physical causes of the loss, and assisting the patient in seeing and holding her deceased fetus for later losses, which can increase positive feelings toward the fetus. Clearly, these interventions should be assessed in future studies in terms of their effectiveness in alleviating patients’ self-criticism.
The clinician can gain valuable information about a patient’s future adjustment to a subsequent pregnancy by assessing her typical level of self-criticism. Patients are usually well aware of their inclination to engage in self-critical thinking and a simple question such as "Are you usually hard on yourself or do you often blame yourself for things that happen?" can be helpful in opening the discussion on this topic. If a patient appears to be highly self-critical, a referral to a mental health professional may be appropriate in order to provide therapy that specifically targets self-critical attitudes.
Men may benefit from discussions of the impact of the loss and the subsequent pregnancy on marital life. Although a miscarriage or perinatal death can bring couples closer emotionally, couples can sometimes experience a desynchrony in their grief experience and feel distressed by this discrepancy. Normalization of occasional desynchrony and encouragement of open communication can be beneficial. A recent study suggested that during a pregnancy after a loss, couples in fact benefit from increased mutual dependency.7 Future studies should attempt to clarify the predictors and the phenomenology of marital distress after a miscarriage or perinatal death.
It seems premature to give specific guidelines concerning the length of time couples should wait before attempting a future pregnancy. Rather than focussing on the duration of time per se, it may be more advisable and clinically sound to direct the couple’s attention toward optimizing psychologic and marital functioning. Such a patient-centered approach may offer a more realistic reflection of individual differences in adjustment to a pregnancy after a loss.
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Footnotes |
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The author thanks Dr Douglas Black and Ms Janet Belzile for facilitating recruitment of participants.
Received May 22, 2000. Received in revised form December 5, 2000. Accepted December 7, 2000.
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References |
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2. Janssen HJ, Cuisinier MC, de Graauw KP, Hoogduin KA. A prospective study of risk factors predicting grief intensity following pregnancy loss. Arch Gen Psychiatry 1997;54:56–61.[Abstract]
3. Toedter L, Lasker J, Alhadeff J. The perinatal grief scale: Development and initial validation. Am J Orthopsychiatry 1988;58:435–49.[Medline]
4. Goldbach KR, Dunn DS, Toedter LJ, Lasker JN. The effects of gestational age and gender on grief after pregnancy loss. Am J Orthopsychiatry 1991;61:461–7.[Medline]
5. Franche RL, Bulow C. The impact of a subsequent pregnancy on grief and emotional adjustment following perinatal loss. Infant Ment Health J 1999;20:175–87.
6. Hughes PM, Turton P, Evans CDH. Stillbirth as risk factor for depression and anxiety in the subsequent pregnancy: Cohort study. BMJ 1999;318:1721–4.
7. Franche RL, Mikail S. The impact of perinatal loss on adjustment to subsequent pregnancy. Soc Sci Med 1999;48:1613–23.
8. Potvin L, Lasker J, Toedter L. Measuring grief: A short form version of the perinatal grief scale. J Psychopathol Behav Assess 1989;11:29–45.
9. Zuroff D, Moskowitz DS, Wielgus MS, Powers TA, Franko DL. Construct validation of the dependency and self-criticism scales of the depressive experiences questionnaire. J Res Personal 1983;17: 226–41.
10. Sharpley CF, Rogers HJ. Preliminary validation of the Abbreviated Spanier Dyadic Adjustment Scale: Some psychometric data regarding a screening test of marital adjustment. Educ Psychol Meas 1984;44:1045–9.[Abstract]
11. Tabachnick BG, Fidell LS. Using multivariate statistics 1996. New York: Harper Collins, 1996.
12. Norman GR, Streiner DL. Biostatistics: The bare essentials. Hamilton, Ontario, Canada: Decker Inc., 1998.
13. Rando TA. Treatment of complicated mourning. Champaign, IL: Research Press, 1993.
14. Graham MA, Thompson SC, Estrada M, Yonekura ML. Factors affecting psychological adjustment to fetal death. Am J Obstet Gynecol 1987;157:254–7.[Medline]
15. Lasker JN, Toedter LJ. Acute versus chronic grief: The case of pregnancy loss. Am J Orthopsychiatry 1991;61:510–22.[Medline]
16. Sander KA, Bruce NW. A prospective study of psychosocial stress and fertility in women. Hum Reprod 1997;12:2324–9.
17. Zeanah C, Danis B, Hirshberg L, Dietz L. Initial adaptation in mothers and fathers following perinatal loss. Infant Ment Health J 1995;16:80–93.
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