Ž .International Journal of Gynecology & Obstetrics 62 1998 149]153

Article

Depression in women suffering perinatal loss

L. Carreraa, J. Dıez-Domingob, V. Montananaa, J. Monleon Sanchoc,´ ˜ ´J. Minguezc, J. Monleonc,U´

a Obstetrics Department, Lluıs Alcanyıs Xati a Hospital, Valencia, Spain´ ´ ´bPediatrics Department, Lluıs Alcanyıs Xati a Hospital, Valencia, Spain´ ´ ´

cObstetrics Department, La Fe Uni ersitario Hospital, Valencia, Spain´

Received 6 June 1997; received in revised form 17 March 1998; accepted 20 March 1998

Abstract

Objecti e: To analyze depression in women who have suffered perinatal loss in the present study. Methods: TheŽ .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. TheBDI was recorded immediately after delivery and at 6 and 12 months postpartum. A third group of women withperinatal 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

Žwomen 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 scoredvery similar to the live-birth group. Conclusion: Women who experience perinatal loss endorse more depressivesymptoms than mothers of live-births, and these depressive symptoms can be ameliorated by a psychologicalintervention. Q 1998 International Federation of Gynecology and Obstetrics

Keywords: Perinatal loss; Psychological support; Depression

U Corresponding author. Tel.: q34 6 3868774; fax: q34 6 3868702.

0020-7292r98r$19.00 Q 1998 International Federation of Gynecology and ObstetricsŽ .P I I S 0 0 2 0 - 7 2 9 2 9 8 0 0 0 5 9 - 9

( )L. Carrera et al. r International Journal of Gynecology & Obstetrics 62 1998 149]153150

1. Introduction

Pregnancy is an important event in a woman’slife. When the time of delivery approaches thereis a certain degree of apprehension due to fear of

w xthe unknown 1 . Parents feel hopeful and excitedabout the arrival of their baby, and have evenmade plans for its future, yet all hopes are trun-cated when death in the perinatal period occurs.

Until recently it was believed that although thedeath of a baby before or shortly after birthconstituted a loss, it carried less emotional weight

w xthan other forms of death 2 . However, since thew xfirst publications of Bruce and McLenaham 3 in

w x1962, various authors 4]8 have established thatboth parents suffer a period of intense mourningfollowing a perinatal death, and even endorse

w xdepressive symptoms 9 .It has been suggested that some psychological

support to the families, starting soon after deliv-w xery, could improve depressive symptoms 10]18 .

The objective of this study is twofold: to ana-lyze depression and its evolution in mothers whoexperience a perinatal loss, and the effect of 1year psychological intervention on these women.

2. Materials and method

Ninety-four women agreed to take part in theŽ .study. They were divided in three groups: 1 The

live-birth group consisted of 37 women who hadgiven birth to a healthy child after a completegestation, regardless of the method of deliveryand independent of their socioeconomic, family

Ž .or cultural circumstances. 2 The interventiongroup were 23 women who suffered a perinatalloss. Of these, 21 had single gestations, and twohad twin gestations where both fetuses were still-born. This group received psychological interven-

Ž .tion as described later. 3 The no interventiongroup was formed by 34 women who had suffereda perinatal loss 12 months ago, and received nointervention.

ŽThe average age of the patients was 28 S.D.. Ž .s4 in the live-birth group, 30 S.D.s4 in the

Ž .intervention, and 28 S.D.s4 in the no interven-tion group. There was no statistical differenceamong the three groups studied in the marriage

status, in the ruralrurban residence, the numberof multiple pregnancies, and in obstetricsparameters as the number of previous pregnan-cies, and the way of delivery.

The psychometric appraisal was carried outthrough a personal interview during which the

Ž .Beck Depression Inventory BDI was appliedw x19,20 . This is a validated test that allows thestudy of depression levels and its changes with

Ž .time. Normal non-depressed people scored 0]9,and an increase in the score reflects worse de-pressive symptoms.

Both the live-birth and the intervention groupreceived the BDI test immediately after delivery,and at 6 and 12 months postpartum. The nointervention group only had the BDI test once, at12 months postpartum in order to obtain a com-plete absence of intervention.

The intervention group received a 1-year psy-w xchological support, based on Lake et al. 11 . This

basically consisted of three items: first recogniz-ing the dead baby as part of the family, thenparents were encouraged to see and touch thebaby, give it a name, and have a proper burial,after a postmortem study. Second the mourningprocess was explained and couples were encour-aged to avoid a new pregnancy in the year fol-lowing the death in order to avoid the ‘replace-ment baby’. Third, parents were encouraged toexpress their feelings and freely talk about theirchild.

2.1. Statistics

w xThe plots of Box and Wisker 21 were used toshow the BDI results. To compare the resultsamong the groups, the Wilcoxon test or the statis-tical Z-test were used.

3. Results

Ž .At the time of delivery Fig. 1 women of thelive-birth group had lower scores in the BDI than

Ž .in the intervention group Table 1 , meaning thatin the latter group there were more depressive

Ž .symptoms P-0.001 . Six months after delivery,the live-birth group scored very similar to itsprevious test. The intervention group scored lower

( )L. Carrera et al. r International Journal of Gynecology & Obstetrics 62 1998 149]153 151

Fig. 1. Comparative analysis of Beck results at birth.

than at delivery, but continued to endorse milddepression and therefore scored higher than the

Ž .live-birth group Ps0.05; Fig. 2 . At 12 monthspostpartum the intervention group scored signifi-

Ž .cantly lower that they did at birth P-0.001 ,reaching the same result in the BDI than thelive-birth group. However, the no interventiongroup presented higher BDI scores, i.e. endorsedmore depressive symptoms, than the live-birth

Ž .group P-0.01; Fig. 3 .

4. Discussion

Women with perinatal loss endorsed more de-pressive symptoms than those with a live-birth.After the aforementioned psychological interven-tion administered for 1 year, the BDI falls in theloss group to match scores in live-birth mothers,though at 6 months mothers with perinatal loss

Table 1Beck Depression Inventory scores by group and time of study

Beck IC Birth 6 months 12 months

Live-birth 4.2]8.2 4.4]7.9 4.2]7.0Intervention 13.2]20.0 6.4]11.2 3.7]8.0No intervention } } 8.5]15.5

Note. 95% confidence interval of the mean.

Fig. 2. Comparative analysis of Beck results at 6 months.

still show higher depression levels. If no interven-tion is given, depression at the end of the firstyear is still present in women who lost theirbabies.

Ž .The intervention given had three objectives: 1Ž .to give the needed human support; 2 to encour-

Ž .age expression of emotion; and 3 to encourageŽmothers to complete the cycle of mourning dis-

belief, yearning, disorganization and reorganiza-. w xtion 11 . With this intervention we noted that

Fig. 3. Comparative analysis of Beck results at 12 months.

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depressive symptoms improved throughout thefirst year postpartum, and at its end patient scoreswere within the normal range. Women withoutintervention were more depressed at the end ofthe first year postpartum, and three of these hadmoderate to severe depression, while no one inthe intervention group was symptomatic, includ-ing two women who had hysterectomy after theirfirst pregnancy.

w xLa Roche 9 carried out a prospective study inwomen with perinatal loss and showed a certaindegree of depression at 3 months postpartum,that disappeared by 1 year postpartum if inter-

w xvention was given 22 .w xOther authors 23 compared two groups of

women with perinatal loss, one received somepsychological intervention and the other did not.At 6 months their intervention group had lesspsychological symptoms, but at 12 months post-partum both groups scored equally.

All these studies lack a control group, i.e.women with a live-birth baby, therefore they couldnot conclude if the intervention used was usefulin the perinatal death group to get the samescores as mothers with live-birth babies. Clarkew x24 used a control group to compare the evolu-tion of depression in the first 6 months postpar-tum. They noted that at the end of this periodwomen with perinatal loss endorsed more depres-sive symptoms that the control group. No inter-vention was used.

Our results show that psychological interven-tion is useful in helping women with perinatal lossto normalize their depressed state.

Our no intervention group were studied only at12 months. This could bias the study as we do notknow their initial mood status. However, wethought that showing an interest in their psycho-logical status, and spending some hours with themexplaining the study and having the tests donecould be some way of psychological intervention.This may have occurred in the control group of

w xForrest 23 where they equalled the results of thetest with the intervention group.

In conclusion, it seems that our interventionfor 1 year allowed women with perinatal loss toscore, at the end of the period, very similar tomothers with a live-birth baby, and much better

than women who did not receive any psychologi-cal support.

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