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.

Postponing pregnancy after perinatal death: perspectives on doctor advice.

The Perinatal Loss Interview was administered to 24 mothers who had experienced perinatal loss and were raising a child born subsequent to the loss; mothers were asked about postponing subsequent pregnancy, including what their doctors advised. Mothers were dissatisfied with doctor advice, reporting that the timing of a subsequent pregnancy was a personal decision and many factors influenced their decision. Furthermore, regardless of timing, most mothers reported overprotective and replacement feelings toward the subsequent child. These results imply that physicians may be most effective by educating mothers about advantages and disadvantages of postponing pregnancy so that an informed decision can be made.

Predicting adjustment to perinatal death.

One hundred and thirty parents who had experienced a perinatal death completed a self-administered questionnaire that examined the demographic characteristics of parents, factors associated with the loss, and their levels of satisfaction with the amount of support they received. In addition, they completed scales measuring current levels of depression, self-esteem and psychological well-being. Comparisons with available norms revealed that, while parents were more depressed than general members of the community, they showed fewer symptoms of depression than did depressed patients. In addition, results revealed that less depressed parents were more satisfied with the level of support and comfort they received from doctors and nurses after the loss of their infant. Greater satisfaction with the support from hospital staff also predicted higher levels of self-esteem, as did being satisfied with opportunities to be with the baby. Being more pleased with support from hospital staff and partners also predicted higher levels of psychological well-being. Parents who reported higher well-being were more likely to have experienced a neonatal death, and were satisfied with the opportunities they had had to create special memories of their baby. In the case of happier parents more time had elapsed since the loss of the child.

Litter deficits of socially stressed and low status hamster dams.

The effects of maternal social stress, induced by pairing pregnant females, and social status, measured by agonistic behavior within pairs, on pup development was investigated in hamsters. Using litters from untreated first pregnancies as a control, 40 dams were housed either alone or paired with another dam during their second pregnancy. Within a pair, the dam with more aggressive and fewer defensive responses than the other was considered dominant. Compared to their first unpaired litters, second litters of paired dams were smaller in number. Comparisons among second litters showed that paired dams, especially submissive dams, had fewer pups than unpaired dams. It was concluded that both maternal social stress and low status increase intrauterine mortality.

Psychological effects and management of perinatal loss.

Serious short-term and long-term psychological sequelae may result from unresolved loss. It is now recognized that perinatal loss presents a situation where the early activation of the grief process may be prevented by the circumstances of the loss. Some theoretical aspects of the management of perinatal loss are considered together with a description of a program that has been set up to try to help to create some reality out of an unreal situation. The possible sequelae of unresolved loss are briefly reviewed.

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.

Do parents utilize physician follow-up after death of their newborn?

Numerous authors have advocated appropriate physician-patient counseling following a perinatal death. We examined, in a prospective manner, how many families utilized physician follow-up when such follow-up was offered. Seventy-six percent of the 108 families who experienced a neonatal death chose to have physician follow-up in the weeks after the death. A family's utilization of subsequent physician contact was not related to the distance they lived from the medical center, the duration of survival of the infant, or the racial background of the mother. Parents utilized follow-up visits whether or not an autopsy was performed or an interpreter was needed. Certain features distinguished the parents who did not utilize the physician follow-up service: parents were less likely to utilize the service if they were not married, the mother was a teenager, the head of the household was unemployed, or there was no phone at home.

Doctor-patient relationships in fetal/infant death encounters.

A study of concerns of 100 middle-class mothers and fathers who had lost infants revealed that the death of an infant or fetus (through miscarriage) was viewed as devastating because of inadequate community recognition of the loss. The impact of these deaths and the lack of community support forces the parents to turn to their physicians from whom they attempt to seek counsel and comfort. Many physicians, unfortunately, are unable to meet the parent's needs because they cannot deal with death on the personal level, and/or their training militates against their accepting a shift in responsibility from "healer" to "counselor-consoler." Thus, an impasse often is reached in which the expectations of parents exceed the service that the physician is able or willing to render. This detracts from the physician's ability to fulfill adequately his role of provider of total care.

Depression in women after perinatal death.

Post-partum depression was studied with the Beck inventory during a 6-month period in two groups of over 300 women. The difference in prevalence of depression between women who had had live births and women whose babies were stillborn or died in the first 7 days of life was influenced by age. At 6 months, post-partum depression was just as common in women aged under 24 whose babies had survived as in women of the same age whose babies had died.