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Perinatal Loss and Adult Development.
Another factor that complicates mourning perinatal loss is that it is a developmental “crisis within a crisis” for parents (Leon, 1990). Pregnancy itself is the first crisis, involving regression and changes in self- concept. This crisis is resolved through the birth of a viable child. When a perinatal loss occurs, however, there is no longer a child. Then, a second crisis unfolds: the loss itself. Without the child, the adult is not able to enter parenthood, an adult developmental phase that pregnancy has facilitated. Thus, in many cases, when there is a perinatal loss, adults lose the opportunity to actualize their parental identity and further develop their own adult identity (Leon, 1990).
The birth of a baby also facilitates the third-separation individuation (Colarusso, 1990). The third separation-individuation is a phase of adulthood where adults further separate from their own parents in part by creating a family of procreation. Perinatal loss can interfere with the entrance to parenthood, preventing further separation from one s own parents and the consolidating of one s own adult identity (Colarusso, 1990).
Psychological Reactions to Perinatal Loss.
A variety of psychological reactions to perinatal loss among mothers have been described in the literature (Frost & Condon, 1996; Klock, Chang, Hiley, & Hill, 1997; Lee & Slade, 1996; Madden, 1994). Commonly, they have symptoms of shock, disbelief, somatic distress, insomnia, anhedonia, sexual dysfunction, anorexia, time confusion, emotional lability, weakness, dreams of the baby, preoccupation with the lost baby, and an inability to return to normal activities. Simultaneously, feelings of inadequacy, sadness, guilt, anger, and irritability are experienced (Frost & Condon, 1996; Peppers & Knapp, 1980).
To date, there are many studies that report that depression is a significant reaction to perinatal loss in women (Condon, 1986; Dyregrove & Mattieson, 1987; Lee & Slade, 1996; Madden, 1994; Vance et al., 1995). Although the majority of these studies report only depressive symptomatology, there is some evidence that many women actually develop depressive disorders. For instance, Neugebauer et al. (1997) assessed the risk for major depressive disorder among women six months following a miscarriage. The study found that Major Depressive Disorder, as measured by the Diagnostic Interview Scale (DIS), occurred in 10% of the women who miscarried, which was two times as much as the general population of women. Furthermore, they found that women who miscarried and did not have previous children were at a higher risk for depression.
In an attempt to look at depression, Klock et al. (1997) gave questionnaires that assessed psychological distress to 57 women who had experienced recurrent miscarriages (average of 3 miscarriages). Clinical depression, as measured by the Beck Depression Inventory (BDI), was found in 32% of the women in the study.
Indeed, these studies demonstrate that clinical depression often occurs after perinatal loss, although, they ignore other emotions or behaviors that women experience (Madden, 1994). These emotions include anxiety, guilt, increased substance use, and/or pathological grief, which will be discussed in the following paragraphs.
Anxiety is a common reaction women have to reproductive loss (Dyregrove & Mattieson, 1987; Lee & Slade, 1996; Vance et al., 1991). In fact, in a study of early responses to Sudden Infant Death Syndrome (SIDS), stillbirth, and neonatal death, Vance et al. (1991) found that symptoms of anxiety were reported more frequently than symptoms of depression. In another study, the psychological responses of women who had experienced multiple miscarriages were examined. Using the State-Trait Anxiety Scale, they found that these women had overall high levels of anxiety (Klock et al., 1997). Although studies have found that anxiety is very high among mothers after perinatal loss, the majority of research merely examines depression. Clearly, more research is needed to assess anxiety in mothers after perinatal loss.
Guilt is another common emotion seen in mothers following reproductive loss (Condon, 1986; Frost & Condon, 1996; Lewis, 1979, Phipps, 1981). Although there is controversy over where it stems from, two main sources are typically identified in the literature. First, the mother is extremely aware that the fetus is entirely dependent on her. Therefore, when the baby is lost, the mother feels entirely responsible. Second, the mother often may have mixed feelings about the pregnancy. She may feel like she is giving up her physical well-being, figure, social activity, career, and concept of self as a child. She may also worry about injury or death at delivery, coping with parenthood, and eventual loss of two-person marital relationship. Therefore, the mother may conclude that the loss was a result of her own forbidden wishes to not have a child (Condon, 1986). These feelings of guilt may still be present despite the fact that she is cognitively aware that she did not cause the death (Phipps, 1981).
There is evidence that drug usage increases in women following perinatal loss. Vance et al. (1994) examined pain medicine, prescription tranquilizer, and alcohol use two months after the loss of an infant through stillbirth, neonatal death, and SIDS. Using a self-made questionnaire and an interview, this study had several findings. First, no increase in the use of pain medicine was found. Second, more prescribed tranquilizers were taken among all bereaved mothers, and were four times likely to be taken among. mothers who lost infants to SIDS than by the control group. Third, bereaved mothers were not found to ingest more alcohol than non-bereaved mothers. However, it is possible that these participants underreported their alcohol use because it is not socially desirable for women to drink, while accurately reporting prescription drug use because it is more socially acceptable to take medicine that is prescribed by doctors.
The above study is useful in that it illustrates the degree that substances are used to numb the emotional pain of perinatal loss. Indeed, this knowledge is essential because it is likely that substance use suppresses grief, causing individuals to appear as if they are not grieving. Therefore, it is possible that grief has been under reported in previous research. However, the results of the above study should be interpreted cautiously because it was conducted in Australia, and there are cultural differences in style, acceptability, and traditions in both and alcohol and prescription drug use.
Some women have extreme difficulty coping with reproductive loss and develop pathological grief. According to Condon (1986), pathological grief can take two forms: absence of grief or prolonged grief. The absence of grief occurs when there is no evidence of grief in the first two weeks following the loss. Later, as a result of unresolved grief, other neurotic symptoms may be present, including: phobias, compulsive behaviors, somatiform disorders, psychosexual dysfunction, depression, and difficulty in bonding to a subsequent child. Conversely, prolonged grief is a reaction that initially appears to be normal grief, but continues for longer than typical or does not abate over time.
Similarly, Lin and Lasker (1996) divide pathological grief into two categories: chronic grief and delayed grief. Chronic grief, as in prolonged grief, is when grief is protracted or excessively intense (Lin & Lasker, 1996, p. 263). Symptoms of chronic grief include: excessive anger, guilt, self-blame, or ongoing depression. Delayed grief is when there is no obvious grief immediately following the loss. Instead, the grief manifests itself later as over-activity, hostility against others, alienation, or severe depression. Because these depressive symptoms are quite common in grief following perinatal loss, they make it difficult to differentiate from pathological mourning (Condon, 1986).
Although these theories of pathological grief are useful in that they help to identify when women are struggling with grief, it is difficult to classify individuals into two categories. Wide individual variations are to be expected in the grief experience.
Indeed more research is needed on the psychological reactions to reproductive loss. Many of the studies are retrospective in design, and participants may not accurately remember their reactions during the study. Another weakness in this research is the high attrition rate in grief studies. Moreover, participants in these studies may be at a different stage of grief, thus reporting different symptomatology.
Differences Among Various Types of Perinatal Loss.
Very few studies have explored the variations in psychological reactions to stillbirth, miscarriage, and Sudden Infant Death Syndrome (SIDS). There is some existing debate on the differences in intensity among the losses. Peppers and Knapp (1980) compared the impact that neonatal death, stillbirth, and miscarriage had on 65 mothers. Because, at the time, no scale had been developed to measure grief responses to perinatal loss, the researchers developed their own scale. This Likert-Type scale measured sadness, loss of appetite, inability to sleep, irritability, preoccupation, inability to return to normal activities, difficulty in concentration, anger, guilt, failure to accept reality, time confusion, exhaustion, lack of strength, depression, and repetitive dreams of the lost child. The results indicated that there were no differences in the intensity of grief between the three losses. The findings from this study provide solid support, that the length of the maternal/infant bond is not necessarily proportionate to the intensity of the experienced grief. However, the study was weakened by several factors. First, the sample size was small, consisting of only 65 individuals. Second, the participants included volunteers, which suggests a self-selection bias, where more distressed individuals may not have volunteered for the study, lowering one or more of the scores in the groups. Third, the investigator’s grief instrument had never been validated. It is possible that their measure did not capture the type of grief reactions that occur after perinatal loss.
Vance et al. (1991) examined the early responses to SIDS, stillbirth, and neonatal death. Measuring both anxiety and depressive symptoms, this study found that parents who had a baby die from SIDS had the strongest grief reaction. However, this study only measured anxiety and depression. Perhaps symptoms of anxiety and depression do not adequately measure the complete reactions to these three losses, causing parents who lost a child to neonatal death and stillbirth to appear as if they are grieving less than parents who lost a baby to SIDS.
Although little quantitative research has examined the differences in the experience among the various types of perinatal loss, speculations could be made based on the unique situation that surrounds each loss. For instance, miscarriage has been considered a traumatic event because it happens very suddenly, and often involves considerable pain, loss of blood, and an invasive medical procedure. Frequently, at the time of the miscarriage, women are alone without anyone to help them. In addition, a miscarriage entails losing a pregnancy, requiring the mother to mourn both the loss of a baby and the loss of her pregnancy (Lee & Slade, 1996). Furthermore, the mother cannot see or hold the deceased infant. Without this tangible evidence of the baby, the facilitation of mourning is difficult (Condon, 1986; Frost & Condon, 1996).
On the other hand, stillbirth occurs in the hospital when the birth of a viable baby is expected. Parents have had a longer time to attach to the baby as well as have had more time to fantasize about what the baby will be like. Unlike miscarriage, by the time a stillbirth occurs, friends, family, and acquaintances are aware that a baby is expected, so parents must face many people who ask about the baby. Mourning in parents is generally easier to facilitate after a stillbirth than after a miscarriage, because the loss is more tangible, allowing for the mother to hold the baby and have a burial for it.
In both Sudden Infant Death Syndrome and neonatal death, parents have had time to get to know the baby before the death. They have attached to the baby, who is already born, as well as had a chance to say “goodbye” to the baby after he dies. Although the opportunity to say “goodbye” often works to facilitate mourning, the more intense attachment associated with the longer life of the baby can make it difficult to mourn the loss. In addition, unlike with stillbirth and miscarriage, this loss involves both prospective and retrospective mourning. In other words, the parents must mourn both past experiences and future fantasies associated with the baby. Furthermore, the situation of Sudden Infant Death Syndrome involves putting an apparently healthy baby to sleep in a crib and later finding him dead, creating another trauma. Unfortunately, physicians usually do not have an explanation for the death even after an autopsy, leaving many parents confused about the loss (Defrain, 1991).
Because fathers’ experiences are somewhat different from those of mothers, the perinatal loss literature based on mothers does not necessarily apply to fathers in all aspects. First, mothers have a biological component to pregnancy, while fathers do not. Second, fathers may experience attachment to babies a little later than mothers do, therefore, this loss may affect fathers in a different way. Third, fathers are often coping with their wives’ reactions, which may be physical illness, psychological grief reactions, or hormonal changes after the loss.
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