Grief reactions to perinatal death: an exploratory study

A systematic review of instruments measuring grief after perinatal loss and factors associated with grief reactions

OBJECTIVE

Expectant parents who live through perinatal loss experience intense grief, which is not always acknowledged or accepted. A screening tool to detect bereaved parents' grief reactions can guide professionals, including perinatal palliative care teams, to provide follow-up for those in need. This review's goal is to identify and synthesize the international published literature on existent instruments specifically measuring the grieving process after any perinatal loss and to identify factors that could moderate grief reactions.

METHOD

Systematic review (PROSPERO # CRD42018092555) with critical synthesis. PUBMED, Cochrane, and PsycINFO databases were searched in English language articles using the keywords "perinatal" AND ("grief" OR "bereavement" OR mourning) AND ("scale" OR "questionnaire" OR "measure" OR "assessment") up to May 2018. Eligibility criteria included every study using a measure to assess perinatal grief after all kinds of perinatal losses, including validations and translations to other languages and interventions designed to alleviate grief symptoms.

RESULTS

A total of 67 papers met inclusion criteria. Seven instruments measuring perinatal grief published between 1984 and 2002 are described. The Perinatal Grief Scale (PGS) was used in 53 of the selected studies. Of those, 39 analyzed factors associated with grief reactions. Six articles used PGS scores to evaluate pre- and post-bereavement interventions. Studies in English language only might have limited the number of articles.

SIGNIFICANCE OF RESULTS

The PGS is the most used standardized measures to assess grief after perinatal loss. All parents living through any kind of perinatal loss should be screened.

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.

Perinatal bereavement: a principle-based concept analysis

AIM

To report an analysis of the concept of perinatal bereavement.

BACKGROUND

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

DESIGN

Concept Analysis.

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSIONS

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

Recurrent perinatal loss: a case study

To date, investigators have not demonstrated a clear relationship between a parent's history of prior perinatal losses and intensity of grief response following a subsequent perinatal loss. Examining this relationship for low-income, African-American parents is important because they are a vulnerable population due to the high incidence of perinatal mortality in Blacks and their other life stressors that can impact on grief response and caring needs. The purpose of this case study was to examine the impact of recurrent perinatal loss on a low-income African-American parent. The research design for this study was case report, using interview data collected from a mother who had recently experienced her fourth perinatal loss, which occurred at twenty-five weeks of gestation. Transcripts from two open-ended interviews were analyzed. The theoretical framework used to guide analysis of this case study was Lazarus and Folkman's stress and coping theory. Results demonstrated that the prior perinatal losses did not appear as critical components of the way the mother responded to her most recent loss. Instead, perception of the care she received from healthcare providers and how that care related to her experiences with her one living child who was born at the same gestational age was an important determinant in how she responded to her loss. The results of this case study demonstrate the importance assessing a person's perception of their experience and those factors which contribute to the way they respond.

Depressive symptoms in a sample of women following perinatal loss

OBJECTIVE

The aim of the study is to identify variables associated with depressive symptoms among women shortly after perinatal loss.

METHOD

Respondents who agreed to participate in the study were interviewed, and sociodemographic data were obtained from them. The Hospital Anxiety and Depression Scale and the Edinburgh Postnatal Depression Scale (EDPS) were thereafter administered on each respondent.

RESULTS

Respondents with perinatal loss had high rate of depressive symptoms (52% on EDPS), the rate was significantly higher, when compared with the control group (chi2 = 10.16, P=0.001). Factors significantly associated with depressive symptoms included previous perinatal losses, poor support from husband and occurrence of antenatal complications.

CONCLUSION

Depressive reaction following perinatal loss is very common. Programs need to be designed to help these women cope with their loss and to reduce subsequent psychological morbidity.

Psychological morbidity following miscarriage

Emerging evidence has suggested that miscarriage could be associated with significant and possibly enduring psychological consequences. As many as 50% of miscarrying women suffer some form of psychological morbidity in the weeks and months after loss. About 40% of miscarrying women were found to be suffering from symptoms of grief shortly after miscarriage, and pathological grief can follow. Elevated anxiety and depressive symptoms are common, and major depressive disorder has been reported in 10-50% after miscarriage. Psychological symptoms could persist for 6 months to 1 year after miscarriage. The underlying risk factors predisposing a miscarrying woman to psychological morbidity include a history of psychiatric illness, childlessness, lack of social support or poor marital adjustment, prior pregnancy loss, and ambivalence toward the fetus. In addition, care-givers should be aware of the possible moderating effect of clinical practices such as surgical treatment and ultrasound findings on the psychological impact on a miscarrying woman. Unlike in postpartum depression, simple and effective screening measures of psychological morbidity in the context of miscarriage have not been well established. While studies have highlighted that psychological follow-up was highly desired by miscarrying women, and that psychological intervention was potentially beneficial, there is a substantial lack of randomized controlled intervention studies in this area.

Long-term impact of sudden infant death: a 12- to 15-year follow-up

To understand parents' subjective feelings, experiences, and understanding connected to the loss of a child over time, the authors chose semi-structured, in-depth interviews as the method of examination in a study of 26 parents who lost a child to sudden infant death syndrome (SIDS) between 1981 and 1984. In addition, parents were asked to complete different inventories to compare their present responses (1996) with their responses to the same inventories in 1981-1984. Most parents still viewed the death of their child as affecting their daily life in important ways. Inventory data show that gender differences have diminished 12-15 years after the loss, and few parents are psychologically at risk in 1996. The study clearly shows the benefit of method triangulation in providing a total picture of the parent's experiences.

A study of miscarriage: development and validation of the Perinatal Grief Intensity Scale

OBJECTIVE

This article outlines the development of the Perinatal Grief Intensity Scale (PGIS). It is based on a theoretical model developed to predict intensity of grief response to early pregnancy loss.

DESIGN

Participants completed the PGIS by mail and made an overall assessment of their grief intensity by completing a single Likert-type item.

PARTICIPANTS

A convenience sample of 186 women who had experienced a miscarriage before 16 weeks gestation in the previous 12-18 months.

RESULTS

Fourteen items were retained after factor analyses, loading at .4 or greater. The 14 items loaded on a three-factor solution as predicted and accounted for 65% of the variance. Three factors were found to influence intensity of grieving: Reality of the pregnancy and baby within (Reality), congruence between the actual miscarriage experience and the woman's standard of the desirable (Congruence), and the ability of parents to make decisions or act in ways to increase this congruence (Confront Others). Chronbach's alpha for the entire instrument was .82, with subscale reliability scores of .89 (Reality), .84 (Confront Others), and .71 (Congruence).

CONCLUSION

The PGIS demonstrates acceptable beginning reliability and validity in predicting grief intensity. Further testing of the instrument is needed with all types of pregnancy losses. The level of score needed to predict intense responses also needs to be determined.

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.

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.

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.

The lived experience of grieving the loss of an important other

The purpose of this study was to uncover the structure of the lived experience of grieving the loss of an important other using Parse's research methodology. Parse's theory of human becoming provided the nursing perspective for the study. Five participants described their experience of grieving the loss of an important other through dialogical engagement with the researcher. The researcher dwelled with the transcribed descriptions and through the processes of extraction-synthesis uncovered the structure of the lived experience of grieving the loss of an important other as an anguished suffering in devastating void amidst consoling movements away from and together with the lost one and others while confidently moving beyond personal doubts. Linked to the major concepts of Parse's theory through heuristic interpretation, the structure was abstracted as valuing the connecting-separating in transforming. The study adds to knowledge about grieving and expands Parse's theory of nursing. Recommendations for practice and further research are offered.

Maternal views of the management of foetal remains following early miscarriage

Objective:Recommendations for the sensitive management of perinatal and late pregnancy deaths are now widely applied. This study assessed management experiences and preferences of women who had an early miscarriage to ascertain if current practices are acceptable to these women.Method:Women who had experienced a first trimester miscarriage in the previous year and had attended hospital were identified from hospital and GP records. They were interviewed using a semi-structural format (N=27) and asked about their own experiences and opinions regarding viewing the foetus following miscarriage and making burial arrangements.Results:Most women did not see their miscarried foetus (85%) or know what burial arrangements had been made for the foetus (92%). Preferences regarding these issues were varied but all women felt that parents should be consulted.Conclusions:Recommendations on specific arrangements for the viewing of and disposal of remains following early miscarriage may be secondary to the provision of choice for the parents involved.

Perinatal loss. A critique of current hospital practices

Dramatic improvements in the hospital management of perinatal loss have taken place in the past 20 years. However, there has been no critical examination of current approaches. Four possible hazards of current hospital practice are described: 1) Institutionalization of bereavement: Instead of offering parents an empathic awareness of the unique dimensions of their perinatal loss, caregivers often interact according to detailed behavioral protocols. 2) Idealization of contact with the dead baby: This approach may equate actual physical contact with the dead child with the more complicated and variable process of mourning. 3) Homogenization of grief: Counselors tend to denigrate different grief responses by focusing on a preconceived grief reaction. Thus, they may mistakenly label many such reactions pathologic if they deviate from the rigidly prescribed "norm." 4) Lecturing the bereaved: Telling parents the "right" thing to do may deprive them of a crucial aspect of the process that empowers parents after they experience the helplessness associated with perinatal loss--that of making their own decisions. These problems are illustrated by a clinical vignette, and alternative approaches are explored.

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.

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.

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

Thirty mothers who experienced a perinatal death were offered crisis intervention aimed at facilitating their grief process at a few days, 3 weeks and 3 months after the loss. Evaluation of maternal grief reactions and their general psychological adjustment took place at these 3 early contacts and 1 to 2 years later. This last assessment included a semi-structured clinical interview and a number of self-rating scales (Life Events Schedule, Beck Depression Inventory (BDI) and a Mourning Scale). Six of the 30 mothers showed inappropriate grief reactions at the 3 week and 3 month assessment. By the long term follow up only 1 of these 6 displayed depression or other psychiatric disorder. Three other women not identified as high risk candidates by the 3 month evaluation developed high BDI scores and clinical depressions at the 1 to 2 year assessment. Variables associated with abnormal grief and depression such as social support systems, communication between the parents, maternal dreams, and hospital practices were examined and discussed indicating possibilities for future research.