impact of perinatal loss on the subsequent pregnancy and self: women's experiences

JOGN N CLINICAL STUDIES

Impact of Perinatal Loss on the Subsequent Pregnancy and Self= Women’s Experiences Denise Cbte‘-Arsenault, RNC, PhD, Nomvuyo Mahlangu, SRN, M S

= Obiective: To describe the experience of a pregnancy after perinatal loss.

Design: Descriptive, open-ended responses to a self-completed questionnaire.

Setting: Questionnaires were distributed at a prenatal visit and completed in the office or at home.

Patiicipants: Seventy-two women who were 17 to 28 weeks pregnant, with a history of one or two perinatal losses.

Main outcome Measurn: Themes that emerged from the women’s responses to the questions.

Results: Three main dimensions, Past Pregnan- cy, Current Pregnancy, and Self constituted the overall framework for the themes of pregnancy anxiety, significant points in time, ways of coping, safe passage, social acceptance, binding-in, and grief and loss.

Conclusions: Pregnancy after perinatal loss i s characterized by guarded emotions, anxiety about this pregnancy, marking off the progress of the pregnancy in terms of fetal development and safety, and individual ways of coping to meet the tasks of pregnancy by seeking out or avoiding various behaviors. Women who have experienced perinatal loss would benefit from interventions to help them through these anxiety-filled pregnancies. IOGNN, 28,274-282; 1999.

Accepted: August 1 998

Early verification of conception, increased in vitro fertilization, and more expeditious diagnoses of impending miscarriage have raised estimates of perinatal loss to 20% or more of all pregnancies. Thus, more women are aware of their perinatal

274 JOGNN

losses now than in previous decades (Woods & Woods, 1997).

Perinatal loss, through miscarriage, stillbirth, or neonatal death, frequently is experienced as the death of a wished-for child. While intense grief often follows the event, 5 0 4 0 % of these women go on to become pregnant again (Cordle & Prettyman, 1994; Garel, Blondel, Lelong, Bonenfant, & Kaminski, 1994; Wolff, Nielson, & Schiller, 1970). Practitioners generally have been concerned with the resolution of grief before the undertaking of another pregnancy (Cuisinier, Janssen, de Graaw, Bakker, & Hoogduin, 1996; Davis, Stewart, & Harmon, 1989), but this view needs to be reexamined and expanded. The pregnancies that follow a loss are anecdotally described as anxiety-laden, with fear of a recur- ring loss, not as being dominated by grief over the previous loss. Women report that they have lost their innocence and blissful enjoyment of pregnancy; they worry more about their subsequent pregnancies (O’Leary & Thorwick, 1997). Research on pregnancy after perinatal loss is limited. This study was undertaken to gain insight into the experience of pregnancy after perinatal loss.

Literature Review Until recently, little research existed on preg-

nancy after perinatal loss. Some research has been conducted to study such pregnancies as part of longitudinal examinations of women’s responses to perinatal loss (Garel et al., 1994; Wolff et al., 1970). Davis et al. (1989) conducted a retrospective survey of advice given regarding the timing of

Volume 28, Number 3

subsequent pregnancy after perinatal loss. Other researchers have specifically investigated pregnancy after perinatal loss.

Phipps (1985) conducted a retrospective qualitative review of 15 couples’ recent pregnancy experiences. All had successfully completed pregnancies after previous losses. Phipps found evidence of a “suspension of commitment to pregnancy” (p. 248) and fear that dis- aster could strike at any minute. The couples were in a state of hypervigilance. Some made plans for the baby’s death, just in case. Phipps found evidence of self-protective and controlling behaviors, increased skepticism, and a lack of naivet6 about the pregnancy experience.

In another retrospective study, Wilson, Soule, and Fenton (1988) interviewed a convenience sample of 16 parents 2 years after the birth of their second children. They found that the group who had experienced still- births in first pregnancies prepared the baby’s room 1 month later in this most recent pregnancy than the comparison group who had just delivered their second healthy child. The parents who had experienced a stillbirth were more likely to report having been worried during their last pregnancies.

Theut, Pedersen, Zaslow, and Rabinovich (1988) conducted a prospective quantitative study of pregnancy after loss. In that study, a group of parents in their 8th month of pregnancy with a history of perinatal loss was compared with a group of first-time parents in their 8th month of pregnancy (no history of perinatal loss) on depression, trait anxiety, and anxiety specific to pregnancy concerns. The 21 couples who had experienced perinatal loss did not differ significantly on any vari- ables except for the anxiety specific to pregnancy (measured by their Pregnancy Outcome Questionnaire; POQ). Theut et al. concluded that heightened anxiety in pregnancy after loss is specific to concerns about the pregnancy, not general anxiety. A limitation of that study was the dissimilarity of the comparison group (first pregnancy) from the loss group (at least their second pregnancy).

A similar comparison group was used in Arm- strong and Hutti’s (1998) study in which the relationship between anxiety and prenatal attachment was examined in 16 women in the latter half of their pregnancies subsequent to late pregnancy losses. These women were compared with 15 primiparae at similar gestational age. Again, this comparison seems difficult to justify; however, statistically significant differences were found in pregnancy-specific anxiety, as measured by the POQ (Theut et al., 1988). The mothers who had experienced perinatal loss were found to have higher anxiety and lower prenatal attachment than the mothers in the comparison group. However, no relationship was found between anxiety and attachment in this small sample.

Statham and Green (1994) studied women with a history mostly of miscarriage who were in the early part of a pregnancy after perinatal loss. The sample ( n = 140) was divided into segments with no children, living children, and losses other than miscarriage. These women with loss were compared with primigravidae (n = 505) and multigravidae (n = 498) with only successful pregnancies; these large sample comparison groups were the greatest strength of Statham and Green’s study. All women without living children were found to have higher trait anxiety than those with children; however, no statistically significant difference was found in trait anxiety between primigravidae and those with successful pregnancies. Women with a history of miscarriage were as happy to be pregnant as those with no history of loss, but they had more worries about their pregnancies. They were also significantly less confident about their pregnancy. Women’s worries reflected their previous experiences. Length of time since an unsuccessful pregnancy (i.e., less than 1 year ago versus greater than 1 year ago) was not found to yield any overall differences in the amount or type of worries.

In an examination of the long-term consequences of miscarriage, Garel et al. (1994) found that 53% of the sample of 144 women who had just miscarried became pregnant again during the 18 months of the study. These pregnant women had as many depressive symptoms after their miscarriage as those who did not have a subsequent pregnancy, and length of time to new pregnancy did not alter depressive symptoms. Of the women who completed questionnaires after delivery, most described their subsequent pregnancy experiences as “bad.”

Hense (1994) interviewed 10 women during their last trimester and postpartum of pregnancies subsequent to having a stillbirth. The primary findings focused on the themes of reliving the previous loss, attempting to replace the lost child, fear of loss of this child, and mothering of a live child. Sub- themes during the subsequent pregnancy, under the broader heading of “Fearing Recurrence,” were anxiety, guilt, resisting attachment, and protecting the child. Hense presented a model of the maternal processes of live birth following stillbirth. The Hense study is the most comprehensive to date on pregnancy after perinatal loss; however, it focused only on the post-stillbirth experience and did not include other pregnancy losses.

The current study was designed to answer the following questions:

What are the experiences of women in pregnancies after perinatal loss? What are the effects of past pregnancy experiences on the current pregnancy?

MaylJune 1999 JOGNN 275

Method The current study was a qualitative component of

a larger quantitative comparison study (C6tC-Arsenault, 1995). Rubin’s (1984) first two tasks of pregnancy,

Feelings of concern surrounded the whole

pregnancy experience; women guarded their

emotions about the pregnancy and the baby.

ensuring safe passage and ensuring social acceptance, served as the conceptual framework for the study. The participants’ progress toward accomplishing these tasks was tapped through quantitative items on a questionnaire and follow-up questions to elicit the reason behind the previously given (quantitative) response (see Table 1). In addition, five questions were asked that had the participant compare the current pregnancy with previous pregnancies; open lines were provided for free responses. Space also was provided at the end of the questionnaire for additional comments. The textual data from these three areas are reported in this article. Not every participant responded to each question.

TABLE 1 Examples of Questions Asked I

Questiorr

Have you asked to see your doctor/midwife more often than they usually suggest that pregnant women be seen?a

I avoid women who have had particular pregnancy or delivery experiences.a (VAS)

Have you asked for prenatal tests above and beyond what your care provider would usually do?a

List any dates or times that are or have been important milestones to you during this pregnancy or a gestational age you were glad to be past.a

List people who have or have not been supportive and open to you during this pregnancy.b

Sample The convenience sample consisted of 72 women who met the following criteria:

(a) 18 years of age or older; (b) able to read and write English; (c) currently pregnant, between 17 and 28 weeks

(d) have had at least one other pregnancy; (e) have no history of elective abortions; and (f) have experienced one or two perinatal losses

(miscarriage, stillbirth, or neonatal death).

gestation;

The sample ranged in age from 19 to 44 years (M = 32 years); the women were primarily middle class, white, well-educated, and married. Obstetric history ranged from gravida 2 to 6, with 0 to 4 living children, and a mean of 1.28 perinatal losses. The perinatal losses had occurred predominantly during the 1st trimester (82%), with 14% during the 2nd trimester, and 3% during the 3rd trimester; one woman had experienced a neonatal death. Sixty-five percent had not had a live birth since their most recent loss, and 35% had one to three live births since the loss. Time since the most recent loss averaged 3 years, with 51 % reporting that it had been 1 year since their loss (range = 1-12 years).

Follour-tip

If yes, why? (Two lines provided for response)

If yes, which experiences? (Two lines provided for response)

If yes, explain why. (Two lines provided for response)

Include why the date was important to you.

State their relationship to you and why you are or are not comfortable turning to them for support.

Note. Tasks of pregnancy tapped with question: asafe passage; bsocial acceptance; VAS = visual analogue scale.

276 JOGNN Volume 28, Number 3

Data Collection

Significant Pointsin Time -

Data were collected from women with appoint- ments in private obstetrician offices in a city in the northeastern United States. Women completed the questionnaire while they waited to be seen, or they took it home and returned it in the self-addressed, stamped envelope provided. They were paid $5.00 for their participation with the option of donating their money to the March of Dimes Birth Defects Foundation.

Waysof Safe Coping Passage Aooeptance In

- - -

Data Analysis Written responses were transcribed from the ques-

tionnaires, with the item number noted. Emphases, such as punctuation, upper-case letters, or underlining also were transcribed.

Each research team member read the complete transcript and independently noted major themes. Then the team reached agreement on three dimensions of the text and seven themes that emerged from the data. Each dimension was put into a separate file in Folio Views, a textbase manager computer program. Themes were then coded within each dimension separately. Signifi- cant words or statements were highlighted by theme. Parameters of each theme were discussed and agreed upon by the entire research team. Additional themes were named and defined as they emerged. This process is a blend of thematic analysis and question analysis as described by Morse and Field (1995).

Results The women spoke of their current pregnancy

experiences and their sense of self as having been affected by their past pregnancy experiences, which included perinatal loss. These effects were referred to within the dimensions of Past Pregnancy, Current Pregnancy, and Self. A fourth dimension, Pregnancy, was identified but not analyzed because it was not found relevant to the study questions.

Within the identified dimensions a number of themes emerged, several of which were found in two or more of the dimensions. Each theme is described with reference to the particular dimensions in which the theme was found. Themes emerged from the amalga- mated data, although the question numbers remained in the transcripts to provide context. Presence of a theme does not imply quantity, simply that the theme existed. Saturation was reached in nearly every theme (Powers & Knapp, 1995). See Figure 1 for a visual representa- tion of the dimensions and themes.

Past Pregnancy The expectation that past experiences may recur

when one returns to similar circumstances is a part of

the human experience. It is common for women to compare their current pregnancy experiences with their past pregnancy experiences. These women’s past experience included having a pregnancy end unsuc- cessfully, in the death of their baby. Some women shared their loss experiences in their responses to the questionnaire.

Loss and Grief. Previous pregnancy losses and grief were referred to within the three dimensions studied. Some women shared experiences from their past pregnancies: “I must have been in shock or denial (or it was the drugs); but when it was happening I never real- izedacknowledged that I was losing a baby. . . . I was never asked if I wanted to see or hold him. . . . My heal- ing has been much harder as a result.”

Reference also was made to the impact of the loss: “The stillborn experience has robbed me of ‘pregnancy bliss.’ None of your questions ask about anger. I have a lot of anger about having to live the rest of my life with this pain.” Another woman wrote: “The miscarriages were painful both physically and emotionally. After the miscarriage I was depressed and unsure of myself.”

The impact of the pregnancy loss went beyond grief and a sense of loss for the baby. It affected the current pregnancy in numerous ways. Women’s concerns often focused on how to get through this pregnancy

FORMER SELF

1 1 1

PAST PREGNANCY

PRE6T.IANCY Loss

CHANGED SELF

1 CURRENT PREGNANCY

Mayl’une 1999 JOGNN 277

with a healthy self and a healthy baby, as described below.

Current Pregnancy Early in the data analysis there emerged a broad

answer to the research question, “What is the woman’s experience of pregnancy after perinatal loss?” These women found themselves to be more guarded with their emotions about the pregnancy and the baby. The pregnancies were seen as more precarious and unsure, and the women remained skeptical and cautious. The causal link was made by these women. For example, one woman wrote, “This pregnancy, especially the early weeks, has left me more precarious, and I knew what losing it would mean to me emotionally.” Another woman wrote, “The preconceived notion that pregnancy, birth, and motherhood is easy and carefree and com- pletely within our control just isn’t so. I adore babies, but because of past experiences, pregnancy for me is a very stressful time.”

Other women referred to their past loss as well as other concerns for their current pregnancy. When asked what they would like to avoid in this pregnancy, one woman responded, “My last year’s miscarriage I would certainly like to avoid. As for my births-the deliveries went pretty much the same except for the second, I had Stadol in the IV and with the first I went natural.” For

A b s e n t from the list of those helpful and

supportive during these pregnancies were

nurses and physicians.

this woman, avoiding another loss was paramount, but it was not her only issue.

Pregnancy Anxiety. Like a black cloud hovering, concern for the baby’s well-being and the outcome of the pregnancy was expressed as always being there; this theme was labeled pregnancy anxiety. Previous pregnancy experiences had taught these women that pregnancy is not always normal and babies do not always survive. They were aware that what went wrong in the past could go wrong again. Therefore, feelings of concern overshadowed the whole pregnancy experience. This pregnancy anxiety made the women protect themselves by maintaining a more distant emotional attachment in the current pregnancy. One woman wrote, “Having any number of miscarriages is traumatic and it takes away from each pregnancy because you are always ‘on guard.’ ” Another woman explained, “This

pregnancy I seem to think about all the things that could go wrong; in a way I have left room for the idea of losing this baby as well, just in case.”

Significant Points in Time. The women seemed to balance events or milestones achieved in this pregnancy against their questions about the future of the pregnancy and fetal well-being. Pregnancy anxiety seemed to be temporarily relieved or accelerated depending on the positive or negative interpretation of a significant event. All of these women noted that there were significant points in time in their pregnancies. Commonly men- tioned milestones were making it past the gestational age of the previous loss, the end of the 1st trimester due to its high threat of miscarriage, the first detection of fetal movement around 17-20 weeks, and the times when a heartbeat was seen on a sonogram or heard in the health care provider’s office. Each event signaled the progress in or status of the pregnancy and offered infor- mation about the safety and health of the pregnancy and fetus.

Interestingly, the majority of these women referred to gestational age in weeks, rather than in the lay lan- guage of months of pregnancy. The women appeared to mark off the pregnancy in weekly increments, and certain weeks held particular significance. Women wrote, “I breathe a sigh of relief to get through another week, our baby is that much bigger.” “Six weeks-first sonogram, saw heartbeat, big relief!” “It was important to reach 10 weeks because of my previous miscarriages.” “At 16 weeks-I feel confident that this time I will have the baby.”

Ways of Coping. Women coped with the reality of their past losses in their current pregnancy in various ways. Each woman used her past experiences to deter- mine her current behavior. The women coped by choosing what behaviors to do and what to avoid. What some would seek out, others might shun. For example, some women responded to the news that they were pregnant this time with excitement and others chose to remain silent about the present pregnancy. One woman described her previous loss disclosure experience as being “. . . too painful ‘untelling’ people.” Another woman said that “because of what happened the last time, I didn’t want hopes to be built up again.” Some women waited to disclose this pregnancy, and they were selective in choosing which friends and relatives to tell. “After my premature baby and the miscarriages, I need- ed the support and understanding of others who shared similar experiences.”

The women varied in their health care practices in these pregnancies after loss. For example, some women altered their diet and exercise in this pregnancy and others gave up any sense that what they did made a difference. “My last pregnancy ended in tragedy. I felt like I did all the right things [during the]


last pregnancy and it didn’t matter.” References to “ways of coping” also were embedded in the themes of safe passage, social acceptance, and binding-in and were found in descriptions of past pregnancies, most often reflecting and comparing the current pregnancy with past pregnancies.

Safe Passage. “Although the physician said that all my activities had nothing to do with the stillbirth of our daughter, many friends and family felt that I was ‘working too much.’ I don’t want them to be able to blame me if there are problems this time.” In trying to avoid the blame that others loaded on her, this woman followed self-care practices during the current pregnancy that were influenced by her past pregnancy experiences. “Actually I feel like I’m less ‘strict’ with my diet-but somewhat more careful with my activities during this pregnancy. I felt like I did all the right things [during the] last pregnancy and it didn’t matter!” Another woman wrote, “I stopped drinking coffee [during the] 1st trimester because I felt it had contributed to past miscarriage.”

Some women made changes they hoped would make a difference in the current pregnancy, but they were not convinced that they had control over the outcome. Their efforts to ensure safe passage for themselves and their babies were manifested in their behaviors and seemed to be influenced by pregnancy anxiety.

Accessing prenatal care and deciding from whom, how much, and how often to solicit care was another means of trying to ensure safe passage. Some stayed with a previously responsive health care provider; others sought new providers who would better meet their needs. Many women wanted to be seen more frequently than is routine. Seeking out knowledge, through books, videos, or people with knowledge or experience, was another approach to ensuring safe passage. The women wrote that they focused on their nutrition, drug use, and activity levels. These were areas in which women felt they had some control. “To give the best possible outcome for this baby, I’ll do anything they tell me to if it will give my child a better chance.”

“For my second pregnancy (child lived) I took all the AFP [alpha-fetoprotein] tests, level 2 sonogram, and amnio. It was a horrifying experience, and I spent most of my pregnancy in fear. Actually, almost all of it because I worried about losing the baby again. . . . The risk of losing the baby with amnio they say is small but any risk is too high for me, isn’t worth it to me. I’m confident I’m doing the best I can to ensure I give birth to a healthy child.”

Binding-In. The mother’s connection to her fetus and the interplay between mother and baby was named binding-in, as described by Rubin (1984). Binding-in with these mothers had an objective and a subjective

component. The mothers wrote that objective indica- tors of their baby’s presence, such as fetal growth and movement or hearing the heartbeat, made the baby more real. The subjective component was their sense of closeness to the baby and how that made them feel. “I guess I feel a bit distant from this pregnancy, worried about getting too excited or overconfident. It is getting better now that my uterus is growing and I’m beginning to show.” “I never got to feel close to my baby before I had my miscarriage. This time I feel close to him because I know he is there kicking me, messing around.”

Although no question was asked about bonding or attaching to their unborn child, many of these women referred to this process. Whether it was the holding back of bonding or the realization that attachment was occurring, these women were aware that this process was an issue for them.

Social Acceptance. The respondents’ kin and friendship network provided an emotionally supportive environment for these women. Of most importance, in rank order, were mothers, husbands, friends, sisters, and co-workers. Women felt that these family members and friends were supportive because they were interest- ed, concerned, good listeners, “there through all emotions,” had had perinatal losses or other commonalities with the woman, or shared a family relationship.

All the women listed five people important to them that they could talk to about this pregnancy, but many were not able to list five people whom they felt would not be supportive. Those listed as not supportive were in-laws, their father, or friends. Indications of non- support for these women were the following: not understanding the woman in general, a poor relationship, poor communication, or failure to understand about the losses the woman had experienced.

Self The third dimension, Self, was an unexpected

dimension affected by the loss experience and included the responses that explicated the feelings about what and how the previous loss had changed the woman’s inner self: who she had been, who she had become, and her attitude and beliefs. “I have developed a progres- sively deeper trust in the Lord. I have gained greater trust in my abilities as a wife and mother. I have an even wider and stronger support system for my values and lifestyle,” wrote one participant.

Ways of Coping. Women described ways in which they coped differently in pregnancy and in life in general now, after their perinatal loss: “If I hear of a friend who has recently experienced a miscarriage or stillbirth, I call to listen, console, or help in any way I can since I have been there.” In contrast another woman wrote, “While I do not avoid women who have had miscar-

May/June 1999 JOGNN 279

riages, it raises fears within me to talk about it.” Some women turn to others for support in new ways, “My faith in God has enabled me to get through the fear and unknown in this pregnancy without being a basket case. It allows me to keep going with a primarily positive attitude.”

Impressions of the Loss. Women were left with impressions of their loss that are now a part of who they are. “I feel that loss will always be with me,” wrote one woman. Another wrote, “With this pregnancy I do not think ‘if I have a child to bring home,’ it’s ‘when the baby comes home.’ ” “I did not see the baby, and out of everything that happened, not seeing the baby has been one thing I cannot get over.” Their losses were not for- gotten as they moved on into a subsequent pregnancy.

Competence as Biologic Woman. The women’s perceptions of self also included their ability to be successful at pregnancy. “I’m thrilled to be pregnant again with no complications because it somehow diminishes the idea that I am a failure at being pregnant.” At 17 weeks, this woman stopped her progesterone injections and “. . . felt much better as a biologically competent woman able to take over the job myself.” For these women, the self-perception of being competent was at stake in the current pregnancy.

Maturity. When asked why they thought this pregnancy might differ from past pregnancies, some women wrote that it was because they were older and had experienced pregnancy before. “I am older and quite confident” or “Being older, in my 30s, during the second pregnancy is much more comfortable for me emotionally.”

Self-worth. Some women attributed their differing experiences to their own change in self-knowledge and their feelings that they need to participate in their pregnancy care. As one woman explained, “I am now more willing to speak up about my desires and opinions regarding my care. With my first babies I felt more like a bystander than a participant.” For others there was a new sense of self-worth, “I have learned to trust my instincts about how I am feeling.” Experiencing an unsuccessful pregnancy changed their self-perceptions and their role in their future care.

Discussion The dimensions of Past Pregnancy, Current Preg-

nancy, and Self within which women framed their pregnancy experiences are reflective of the areas affected by a previous perinatal loss. Rubin’s tasks of pregnancy- safe passage and social acceptance-provided a useful framework for this study, with the women’s responses also encompassing the task of binding-in.

The themes identified in the current study are similar to those described by Hense (1994) with women

pregnant after having a stillbirth. Women in the current study had perinatal losses at varying points in pregnancy, but primarily during the 1st trimester, and data were collected only at one time, between 17 and 28 weeks gestation. Similar to Hense’s findings are the impressions that the loss made on the current pregnancy experience, the significance of particular dates or times in the pregnancy, and the ever-present anxiety and fear of another loss, called pregnancy anxiety in this article. A finding of the current study is the reference women made to changes within themselves. According to Rubin, “there are qualitative changes in the personality of a woman” across childbearing (p. 69, 1984). Health care providers need to understand that the impact of perinatal loss on women may continue beyond the childbearing years.

Many participants wrote about their experiences surrounding attachment to their fetus, although no questions referred specifically to attachment or bonding. Included as a task of pregnancy by Rubin (1984) and Cranley (1981), binding-in is described as an unconscious process, with the gradual recognition of the fetus as separate from self, rather than as a cognitive process of which pregnant women are aware. However, the women in the current study who referred to binding-in were aware of the process. Armstrong and Hutti (1998) note similar comments from women in their study. Hense’s (1994) study offers insight into the women’s resistance to attaching with the baby, both during pregnancy and after delivery. It may be a self- protective response from having a perinatal loss; these women do not want to be hurt again.

Pregnancy anxiety was a common theme for women pregnant after perinatal loss. This fear of recurrence of loss is related to the guarding of their emotions. Relationships also were noted between the themes of pregnancy anxiety and significance of specific points in time. With the passage of time and the experience of success at making it to certain milestones, such as the time of a previous loss or feeling fetal movement, pregnancy anxiety was qualitatively decreased for the participants. This relationship was noted by the participants and deserves further study.

The current study was limited by the nature of the data collection. No direct contact was made with the participants to promote participation, clarify questions, or provide answers regarding the study, although a phone number was provided. The study results are directly related to the questions that were asked on the questionnaire and the women’s willingness to explain their responses and write about their experiences.

This study only begins to describe the experience of pregnancy after perinatal loss. The findings from this study should be used to inform the design of further research on women’s experiences and theory develop-


ment. Future studies can explore the perspectives of the spouse and health care provider as well as investigate what women find to be helpful and supportive in pregnancies after perinatal loss.

Implications for Practice As previously described (Leon, 1992; Ryan, CBtt-

Arsenault, & Sugarman, 1991), supportive care needs to be provided after perinatal loss. Women’s impressions of the loss and the care that they received stay with them and affect their future pregnancies and their view of themselves. Absent from the list of helpful and supportive people that women felt they could turn to were nurses or physicians. Health care providers should be empathetic both after a loss and during subsequent pregnancies. Because reactions are individual, health care providers must listen to each woman’s perception of her experience and respond to her individual needs.

This study found that certain milestones are significant to women pregnant after perinatal loss and are used as gauges with which the women measure their

Rubin ‘s tasks of pregnancy served as a

framework for the concerns of women

pregnant after perinatal loss.

progression through the current pregnancy. Practition- ers need to communicate physical findings clearly to their patients, whether they are indicative of the normal progress of pregnancy or aberrations. Women may want to participate actively in their care or to come in more frequently than is customary to be reassured that all is well. The effect of pregnancy anxiety on pregnancy outcome is unknown, but it is known that women feel better after receiving reassuring progress reports.

Because women are making decisions about their behaviors during pregnancy, nurses can help by identifying those behaviors and assist women to process or interpret the impact that behaviors may have on the pregnancy outcome. Women in this study made judgments based on past experiences; therefore, a review and discussion of the current recommendations would be helpful.

Women pregnant after perinatal loss are concerned that their current pregnancy may not be successful. It is also likely that their significant others have similar concerns, although their needs have received little attention (Phipps, 1985; Theut et al., 1988). Previous pregnancy losses should not be ignored, but should be explored and incorporated into a holistic approach to care of the childbearing family.

REFERENCES

Armstrong, D., & Hutti, M. (1998). Pregnancy after perinatal loss: The relationship between anxiety and prenatal anxiety. Journal of Obstetric, Gynecologic, and Neona- tal Nursing, 27, 183-189.

Cordle, C.J., & Prettyman, R.J. (1994). A 2-year follow-up of women who have experienced early miscarriage. Journal of Reproductive and Infant Psychology, 12, 37-43.

CGtC-Arsenault, D.Y. (1995). Tasks of pregnancy and anxiety in pregnancy after perinatal loss: A descriptive study. Dissertation Abstracts International, 56-12, 6669.

Cranley, M. (1981). Development of a tool for the measure- ment of maternal attachment during pregnancy. Nurs- ing Research, 30(5), 281-257.

Cuisinier, M., Janssen, H., de Graaw, C., Bakker, S., & Hoog- . duin, C. (1996). Pregnancy following miscarriage:

Course of grief and some determining factors. Journal of Psychosomatics in Obstetrics and Gynaecology, 17,

Davis, D.L., Stewart, M., & Harmon, R.J. (1989). Postponing pregnancy after perinatal death: Perspectives on doctor advice. Journal of American Academy of Child and Adolescent Psychiatry, 28(3), 481-487.

Garel, M., Blondel, B., Lelong, N., Bonenfant, S., & Kamins- ki, M. (1994). Long-term consequences of miscarriage: The depressive disorders and the following pregnancy. Journal of Reproductive and Infant Psychology, 12, 233-240.

Hense, A.L. (1994). Livebirth following stillbirth. In P.A. Field & P.B Marck (Eds.), Uncertain motherhood (pp. 163-194). Thousand Oaks, CA: Sage.

Leon, I.G. (1992). Perinatal loss: A critique of current hospi- tal practices. Clinical Pediatrics, 31, 366-374.

Morse, J.M., & Field, P.A. (1995). Qualitative research meth- ods for health professionals (2nd ed.). Thousand Oaks, CA: Sage.

O’Leary, J.M., & Thorwick, C. (1997). Impact of pregnancy loss on subsequent pregnancy. In J.R. Woods & J.L.E. Woods (Eds.), Loss during pregnancy or in the newborn period (pp. 43 1-45 1). Pitman, NJ: Jannetti Publica- tions.

Phipps, S. (1985). The subsequent pregnancy after stillbirth: Anticipatory parenthood in the face of uncertainty. International Journal of Psychiatry in Medicine, 15( 3),

Powers, B.A., & Knapp, T.R. (1995). A dictionary of nursing theory and research (2nd ed.). Thousand Oaks, CA: Sage.

Rubin, R. (1984). Maternal identity and the maternal experience. New York: Springer Publishing.

Ryan, P.F., C6t&Arsenault, D.Y., & Sugarman, L.L. (1991). Facilitating care after perinatal loss: A comprehensive checklist. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 20, 385-397.

Statham, H., & Green, J.M. (1994). The effects of miscarriage and other ‘unsuccessful’ pregnancies on feelings early in a subsequent pregnancy. Journal of Reproductive and Infant Psychology, 12, 45-54.

168-174.

243-264.

May/June 1999 JOGNN 281

Theut, S.K., Pedersen, F.A., Zaslow, M.J., & Rabinovich, B.A. (1988). Pregnancy subsequent to perinatal loss: Parental anxiety and depression. Journal of the American Acad- emy of Child and Adolescent Psychiatry, 27(3),

Wilson, A.L., Soule, D.J., & Fenton, L.J. (1988). The next baby: Parents’ responses to perinatal experiences subsequent to a stillbirth. Journal of Perinatology, 8(3),

Wolff, J.R., Nielson, P.E., & Schiller, P. (1970). The emotional reaction to stillbirth. American Journal of Obstetrics and Gynecology, 2 08( l), 73-77.

Woods, J.R., & Woods, J.L.E. (1997). Loss during pregnancy

28 9-292.

188-192.

or in the newborn period. Pitman, NJ: Jannetti Publica- tions.

Denise CGtb-Arsenault is an associate professor at Syracuse University’s College of Nursing in Syracuse, NY Nomvuyo Mahlangu is a faculty member at the Depavtment of Nursing Science Faculty of Medicine at the University of Zimbabwe in Harare, Zimbabwe. She was a graduate stu- dent at Syracuse University’s College of Nursing at the time of this study. Address for correspondence: Denise CGtb-Arsenault, RNC, PhD, Syracuse University, College of Nursing, 426 Ostrom Ave., Syracuse, NY 13244.


impact of perinatal loss on the subsequent pregnancy and self: women's experiences

Documents