impact of prior perinatal loss on subsequent pregnancies

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November/December 2004 JOGNN 765

CLINICAL RESEARCH

Impact of Prior Perinatal Loss onSubsequent PregnanciesDeborah S. Armstrong

Objective: To evaluate the influence of previousperinatal loss on depressive symptoms, pregnancy-specific anxiety, and prenatal attachment for parentsduring subsequent pregnancies.

Design: Cross-sectional, survey design.Participants: Forty expectant couples who expe-

rienced a prior perinatal loss.Measures: Influence of loss (Impact of Event

Scale [IES]), depressive symptoms (Center for Epi-demiologic Studies–Depression Scale [CES-D]),pregnancy-specific anxiety (Pregnancy OutcomeQuestionnaire [POQ]), and prenatal attachment (Pre-natal Attachment Inventory [PAI]).

Results: Mothers reported higher levels ofdepressive symptoms, pregnancy-specific anxiety,and prenatal attachment than fathers did. Forty-fivepercent of mothers and 23% of fathers had CES-Dscores greater than or equal to 16 indicating high riskfor depression. Eighty-eight percent of mothers and90% of fathers reported elevated stress related to theprior loss (IES scores greater than or equal to 19).The impact of the previous perinatal loss was moder-ately correlated with depressive symptoms as well aspregnancy-specific anxiety. There was no relationshipbetween the psychological distress in pregnancy afterperinatal loss and prenatal attachment.

Conclusions: The extent to which the impact ofthe prior loss increased parents’ stress in the currentpregnancy influenced their psychological distress.These findings should heighten awareness of the mix-ture of hope and fear expectant parents experienceduring pregnancies subsequent to perinatal loss.JOGNN, 33, 765-773; 2004. DOI: 10.1177/0884217504270714

Keywords: Anxiety—Depression—Perinatalloss—Pregnancy—Prenatal attachment

Accepted: July 2003

Perinatal loss includes fetal death (early, late, orstillbirth) and neonatal death within the first 28 daysof life. The incidence of early fetal death (before 20weeks gestation) is conservatively estimated at 1 in 6pregnancies (Ventura, Mosher, Curtin, Abma, &Henshaw, 1999). In 1999, late fetal and neonataldeath was reported at 11.4 per 1,000 live births(National Center for Health Statistics, 2002).

Perinatal loss is a distressing event for parents andcan have serious long-term effects (Franche &Mikail, 1999; Hutti, 1992; Swanson, 1999; Vance,Boyle, Najman, & Therale, 1995). Bereavement ofthis type may be difficult and complex for a numberof reasons. Death occurs at a time when new life isexpected, and there may be no visible child, memo-ries, or shared life experiences to mourn. Moreover,death is usually sudden, and society may not recog-nize the significance of such a loss to the parents(Brost & Kenney, 1992; Cote-Arsenault &Mahlangu, 1999; Rajan & Oakley, 1993).

Researchers have described symptoms consistentwith increased psychological distress in parents witha history of perinatal loss (Armstrong & Hutti,1998; Franche & Mikail, 1999; Johnson & Puddi-foot, 1996; Vance et al., 1995). Research on theimpact of miscarriage as a traumatic event describesdifficulties with emotional adjustment after loss.Increased levels of anxiety and depressive symptomshave been demonstrated in women after miscarriage

(Prettyman, Cordle, & Cook, 1993; Thapar & Thapar,1992). Two weeks after pregnancy loss, women were 3.4times more likely to have depressive symptoms than werepregnant women and 4 times more likely to have depres-sive symptoms than a community sample (Neugebauer etal., 1992). At 6 weeks and 6 months, the prevalence ofdepression was 3 times that of the general community. Ina 2-year follow-up study related to distress and decisionmaking in pregnancy, Cordle and Prettyman (1994) foundthat 68% of the women were still upset about their mis-carriage, and 64% indicated the miscarriage had affecteddecisions about subsequent pregnancies.

Although few studies have evaluated the traumaticimpact of fetal death on expectant fathers, they too seemaffected by perinatal loss. Within a convenience sample of126 expectant fathers whose partners experienced a fetaldeath before 25 weeks gestation, Johnson and Puddifoot(1996) evaluated the level of grieving and the impact ofthe perinatal loss within 8 weeks of the loss event. Themajority of the fathers demonstrated considerable psy-chological impact. The number of previous fetal deaths orliving children did not influence the level of grieving orthe impact of the loss. However, the duration of the preg-nancy was an important factor, and fathers who saw anultrasound scan reported greater distress.

People who are subjected to traumatic events oftendemonstrate a pattern of psychological and physiologicalreactions such as anxiety, depression, restlessness, irri-tability, excessive fatigue, sleep disturbance, and concen-tration difficulties (Horowitz, 1974). Denial and repres-sion of feelings may lead to an increased chance of poorhealth outcomes and costly disorders such as post-traumatic stress disorder. This condition is characterizedby reexperiencing the traumatic event, avoiding stimuliassociated with the trauma, and experiencing impairedfunctioning and increased arousal (Mason & Rowlands,1997). Post-traumatic stress disorder has been diagnosedin individuals having undergone an event outside therange of normal experience, and the experience of perina-tal loss may be traumatic enough to cause post-traumaticstress disorder–like symptoms.

Despite considerable research describing increasedanxiety and depressive symptoms after perinatal loss, lessis known about the consequences of continued psycho-logical distress on future pregnancies. The decision toattempt another pregnancy often causes conflicting emo-tions (Brost & Kenney, 1992; Cote-Arsenault & Mar-shall, 2000). Cote-Arsenault and Mahlangu (1999)reported the experience of pregnancy after loss for 72women in their 2nd trimester of a subsequent pregnancy.These women reported high levels of anxiety anddescribed marking their progress through pregnancy interms of fetal development and safety. They guarded theiremotions. Expectant fathers in Armstrong’s (2001) quali-

tative study described similar emotions. Regardless of thetiming of the loss or investment in the previous baby, allexpectant fathers expressed a high level of anxiety duringthe subsequent pregnancy. Fathers described a heightenedsense of risk and a greater vigilance about the course ofthe current pregnancy than at any time before the loss.

In pregnancies after perinatal loss, parents may experi-ence many negative effects such as high levels of anxietyand depression, which could increase health care costs.Some health care providers may overlook the profoundeffect that a previous loss can have on a subsequent preg-nancy. Even publications that serve as standards of prac-tice for obstetricians fail to note the potential impact ofprevious pregnancy loss (American College of Obstetricsand Gynecology, 2001).

It is important to continue to evaluate the impact ofperinatal loss on families both at the time of the loss andduring future pregnancies. Understanding the effect ofpregnancy loss on couples may lead to the design and test-ing of interventions to reduce their psychological distress.Evaluating whether the trauma of perinatal loss is anevent that could trigger a post-traumatic stress–like disor-der in a subsequent pregnancy is a first step in examiningthis problem.

The purpose of this study was to evaluate the influenceof previous perinatal loss on depressive symptoms,pregnancy-specific anxiety, and prenatal attachment forexpectant parents in a subsequent pregnancy. This pur-pose was addressed with the following research questions:(a) Do expectant mothers and fathers differ in their levelof depressive symptoms, pregnancy-specific anxiety, andprenatal attachment during a subsequent pregnancy? and(b) What is the influence of a history of prior perinatalloss on levels of depressive symptoms, pregnancy-specificanxiety, and prenatal attachment of expectant parentsduring a subsequent pregnancy?

Method

Research Design and SampleThe research being reported here is part of a larger

study that compared emotional distress during pregnancyfor expectant parents (both mothers and fathers) with andwithout a history of prior perinatal loss (Armstrong,2002). A cross-sectional survey design was used to collectdata during a single telephone interview in which bothmothers and fathers independently responded to the studyquestionnaire. Study procedures were explained, and ver-bal consent was given before data collection. Participantswere recruited from prenatal clinics and private obstetricpractices, prenatal education classes, perinatal loss sup-port groups, Web sites, and newsletters. Notices about thestudy were posted on Internet message boards focusing on

766 JOGNN Volume 33, Number 6

perinatal loss as well as general pregnancy sites, and inter-ested parents were recruited from those responding. Thestudy sample consisted of 40 couples who, in a previouspregnancy, suffered a perinatal loss at any gestational ageand were currently pregnant in the 2nd trimester of themothers’ subsequent pregnancy. Both mothers and fatherswere recruited for this study. Participants were 18 years ofage or older and read and understood English. Parentswere excluded from the study if they had experienced asuccessful delivery of a healthy infant in a pregnancy sub-sequent to the loss. Participants were in a coupled rela-tionship, as they defined it.

Measures

Impact of loss. The Impact of Event Scale (IES;Horowitz, Wilner, & Alverez, 1979) was developed tobroadly measure current subjective distress related to aspecific traumatic life event. In this study, the items wereanchored to the traumatic event of previous perinatal lossas the named stressor. The IES is a 15-item scale withresponse options ranging from 0 (not at all) to 5 (often).An overall score of 19 or greater indicates high impact ofthe traumatic event on current emotions. The IES con-tains two subscales. Unbidden thoughts, images, troubleddreams, strong emotions, and repetitive behavior exem-plify the Intrusion subscale. The Avoidance subscale ischaracterized by denial of the meaning and consequencesof the event, emotional numbness, and behavioral inhibi-tions. Acceptable internal consistency reliability has beendemonstrated with Cronbach’s alphas of .95 (total scale),.78 (Intrusion), and .82 (Avoidance), as well as test-retestreliabilities of .87 (total scale), .89 (Intrusion), and .89(Avoidance) (Horowitz et al., 1979). Cronbach’s alpha of.86 for both mothers and fathers for Intrusion and .68 formothers and .73 for fathers for Avoidance were foundduring the current study.

Depressive symptoms. The Center for EpidemiologicStudies–Depression Scale (CES-D; Radloff, 1977) is a 20-item self-report scale developed to identify the durationand frequency of depressive symptoms. Respondentsrated each symptom experienced during the previousweek on a 4-point scale ranging from 0 (rarely) to 3 (allthe time). Overall scores of 16 or greater indicate a highlevel of depressive symptoms. The CES-D has shown highinternal consistency reliability with Cronbach’s alphas of.84 to .91 and good test-retest reliability (Comstock &Helsing, 1976; Hall, Kotch, Browne, & Rayens, 1996;Radloff, 1977). This scale has been used frequently toidentify the presence of depressive symptoms in pregnantand parenting women (Hall et al., 1996; Logsdon & Usui,2001; Lutenbacher & Hall, 1998; Sachs, Hall, Luten-bacher, & Rayens, 1999). Cronbach’s alphas in this studywere .91 for the mothers and .85 for the fathers, indicat-ing acceptable internal reliability.

Pregnancy-specific anxiety. The Pregnancy OutcomeQuestionnaire (POQ; Theut, Pederson, Zaslow, & Rabi-novich, 1988) is a measure of anxiety about the outcomeof the current pregnancy. The 15-item POQ examinesconcerns related to the course of pregnancy. Responsesare scored on a 4-point Likert-type scale with responseoptions ranging from 1 (almost never) to 4 (almostalways). Evidence of content and concurrent validity wasevaluated during the development of the POQ by com-parisons with other measures of anxiety (SpeilbergerState-Trait Anxiety Inventory; Speilberger, Gorsuch, &Luschene, 1984) and depression (Beck Depression Inven-tory; Beck, Ward, Mendleson, Mock, & Erbaugh, 1961).Internal consistency reliability has been reported withalphas ranging from .80 to .89 (Armstrong & Hutti,1998; Theut et al., 1988). Cronbach’s alphas for thisstudy were .88 for mothers and .77 for fathers.

Prenatal attachment. The Prenatal Attachment Inven-tory (PAI; Muller, 1993) was designed to measure theemotional attachment between mother and child beforebirth. The 21-item questionnaire has no subscales and isscored on a 4-point Likert-type scale with responseoptions of 1 (almost never) to 4 (almost always). Internalconsistency of the PAI has been demonstrated in priorresearch with alphas ranging from .81 to .93 (Armstrong& Hutti, 1998; Muller, 1993; Muller, 1996). In this study,Cronbach’s alpha for mothers was .87.

The PAI was modified for fathers (PAI-F). Items werereworded to reflect gender differences. The PAI-F has 22items and is scored on a Likert-type scale similar to thePAI for mothers. Expectant fathers and a panel of expertswho work with these fathers evaluated the items of thePAI-F and provided support for content validity. Priorsupport for the internal consistency of the modified PAI-F was demonstrated (alpha of .87). In the current study,the Cronbach’s alpha for the fathers was .82.

Personal information. Data on sociodemographiccharacteristics of age, race, education, marital status, andannual household income were collected. The number ofprevious pregnancies, number of living children orstepchildren, and gestational age of the current pregnan-cy at the time of the interview were requested. In addition,the number of previous losses as well as the timing andgestational age at loss were collected.

ProcedureUniversity Institutional Review Board approval was

granted before implementation of this study. To ensureuniformity of data collection related to the length of ges-tation of the current pregnancy, each parent participatedin one structured interview completed during the 15th to32nd week of the mother’s pregnancy. Data collectedfrom one member of the couple were paired with data


from their partner using a predetermined identificationnumber.

Data Analysis PlanResearch Question 1 was analyzed using t tests to eval-

uate gender differences between expectant mothers andfathers on levels of depressive symptoms (CES-D scores),pregnancy-specific anxiety (POQ scores), prenatal attach-ment (PAI scores), and impact of the loss on current lev-els of stress (IES scores). Research Question 2 was evalu-ated using Pearson’s correlations to determine theassociation of continuous variables of CES-D scores,POQ scores, and PAI scores with IES scores. In addition,three separate multiple regression equations were used todetermine the best predictive model for depressive symp-toms, pregnancy-specific anxiety, and prenatal attach-ment with independent variables of IES scores, parentgender, and their interaction.

FindingsParticipants experienced an average of two prior peri-

natal losses (range = 1–7) with a mean gestational age of22.6 weeks (SD = 12.3) at the time of the loss. Twenty-nine percent of the losses occurred in the 1st trimester.Approximately 35% of the losses were in the 2ndtrimester, and the remaining 36% were late pregnancylosses beyond 28 weeks gestation at the time of the loss.Approximately one third of the parents attended sometype of perinatal loss support group. In addition, aboutone quarter of the parents continued to attend a supportgroup or were part of some supportive networking at thetime of the interview. There were significant differencesfor depressive symptoms (attended support group: M =17.3, SD = 9.9; did not attend: M = 9.9, SD = 7.8; t78 =3.7, p < .001) and pregnancy-specific anxiety (attendedsupport group: M = 35.7, SD = 7.7; did not attend: M =29.3, SD = 6.9; t78 = 3.9, p < .001) during the currentpregnancy between parents who attended a supportgroup after the loss and those who did not.

Sixty percent of this study’s participants had no otherliving children. Differences between parents with andwithout other children were assessed on the major studyvariables. No differences were found for level of depres-sive symptoms or prenatal attachment. However, motherswith no other living children reported significantly higherpregnancy-specific anxiety (M = 37.7, SD = 6.8) than didthose with living children (M = 30.9, SD = 9.2; t38 = 2.7,p = .01).

Mothers had higher levels of depressive symptoms,anxiety about the outcome of the current pregnancy, andprenatal attachment than did fathers (see Table 1). Near-ly half the mothers (45%) and a quarter of the fathers(23%) had depressive scores of 16 or greater, indicatinghigh risk for depression. The mean IES scores for bothmothers (M = 31.7, SD = 10.8) and fathers (M = 30.2,

SD = 9.1) were considerably higher than the cut point of19, indicating high levels of continuing stress related totheir prior perinatal loss. Eighty-eight percent of themothers and 90% of the fathers scored in the high-stressrange. There was no significant difference between moth-ers and fathers on their overall IES scores. However, therewere significant differences between parents’ scores onthe IES subscales. Mothers scored significantly higher onAvoidance, and fathers scored higher on Intrusion (seeTable 2).

Intercouple correlations examined the potential influ-ence of one member’s psychological distress on his or herpartner. There were significant associations between part-ners’ reports of depressive symptoms (r = .40, p < .05),pregnancy-specific anxiety (r = .36, p < .05), and prenatalattachment (r = .40, p < .05). There also was a moderate-ly strong relationship between couples’ reports of theimpact of the loss during the current pregnancy (r = .54,p < .001).

The impact of the previous perinatal loss was moder-ately correlated with depressive symptoms and pregnancy-specific anxiety for both mothers and fathers (see Table3). As their stress related to the previous loss heightened,


Mothers Fathers

Characteristic M SD M SD

Education (years) 16.1 2.1 15.9 3.3Age (years) 32.6 4.6 33.7 5.9

Mothers FathersCharacteristic (%) (%)

RaceWhite 95 90Other 5 10

Employment statusEmployed 72 97Unemployed 28 3

Marital statusMarried 95 95Not married 5 5

Annual household income<$29,999 11 10$30,000 to $59,999 26 28$60,000 to $89,999 34 33>$90,000 29 30

Attended loss support groupAfter loss 23 14At present 13 9

TABLE 1Sociodemographic Characteristics of Mothersand Fathers (N = 80)

their depressive symptoms and anxiety about the outcomeof the current pregnancy increased. For fathers, theimpact of the loss also was positively correlated with theirdeveloping relationship with their unborn infant. Thisrelationship was nonsignificant for mothers. However,mothers’ level of prenatal anxiety was negatively relatedto their prenatal attachment. As their concerns about theoutcome of the current pregnancy rose, their prenatalattachment decreased. For fathers, this relationship wasnonsignificant.

For the regression of depressive symptoms on gender,IES scores, and their interaction, backward stepwise elim-ination was used to determine the best predictive model.This model demonstrated significant standardized betasfor gender and IES scores and accounted for 35% of thevariance in depressive symptoms (see Table 4). The posi-tive relationship between the impact of loss and depres-sive symptoms indicated that the greater the impact of theloss on parents, the greater their depressive symptoms.The significant relationship between parent gender anddepressive symptoms indicated parent gender contributedto the variance in depressive symptoms.

Pregnancy-specific anxiety was regressed onto IESscores, parent gender, and their interaction. This modelaccounted for approximately 30% of the variance in pre-natal anxiety (see Table 5). There was a positive relation-ship between impact of the loss and pregnancy-specificanxiety, indicating that parents who expressed a greaterimpact of their prior perinatal loss also reported a greateranxiety about the outcome of the current pregnancy. Inaddition, there was a significant association between gen-der and prenatal anxiety indicating that parent genderalso accounted for some of the variance in pregnancy-specific anxiety.

When prenatal attachment was regressed onto IESscores, parent gender, and their interaction, there was anonsignificant relationship between the influence of theprior loss and prenatal attachment in the current preg-nancy for either parent.

Discussion

Perinatal loss is a traumatic event in the lives of fami-lies, and 1 in 4 childbearing couples will experience sometype of pregnancy loss. This study adds to the growingbody of knowledge on this topic by describing parents’

experience of pregnancy after prior perinatal loss. Thesefindings challenge the belief that once a new pregnancy isachieved, concerns and grieving decrease. In contrast, thepsychological distress demonstrated in this study was sig-nificant.

Mothers reported higher depressive symptoms andincreased anxiety about the outcome of the current preg-nancy when compared to fathers. The extent to which theimpact of the prior loss increased parents’ stress in thecurrent pregnancy influenced their psychological distress.Nearly half the mothers and one quarter of the fathersreported a high level of depressive symptoms, placingthem at high risk for depression. These results are similar


TABLE 2t Tests for Differences in Means on DepressiveSymptoms, Pregnancy-Specific Anxiety, PrenatalAttachment, and Impact of Loss (N = 80)

Mothers Fathers

Variable M SD M SD t78

Depressive symptoms 16.48 9.7 10.20 8.3 –3.10**

Pregnancy-specific anxiety 34.98 8.5 29.56 6.4 –3.23**

Prenatal attachment 56.53 12.2 51.85 9.1 1.94

Overall Impact of Event Scale 31.7 10.8 30.2 9.1 0.69

Avoidance 20.8 7.9 15.8 8.3 –2.17*Intrusion 11.0 7.1 14.4 7.7 2.95**

*p ≤ .05. **p ≤ .01.

Depressive Prenatal PrenatalVariable/Parent Symptoms Anxiety Attachment

Prenatal anxietyMothers .53****Fathers .58****

Prenatal attachmentMothers –.01 –.33*Fathers .26 .08

Impact of lossMothers .50**** .57**** –.03Fathers .57**** .32* .34*

*p ≤ .05. ****p ≤ .0001.

TABLE 3Intercorrelations Among the Study Variables byGender of the Parent (N = 80)

Mothers reported higher depressivesymptoms and increased anxiety

than did fathers.

to those reported by Franche and Mikail (1999), whofound mothers and fathers with a history of perinatal lossdemonstrated increased depressive symptoms in subse-quent pregnancies. In their study of parents after perina-tal or sudden infant death, Vance et al. (1995) reportedthat there was a gradual decrease in depressive symptomsand anxiety over time, but even at 30 months after theloss, bereaved mothers and fathers continued to demon-strate almost twice the level of psychological distress asthose in the comparison groups did. For most parents inthe current study, the loss occurred within the previous 2years.

There also were gender differences in levels of pregnancy-specific anxiety. These findings are consistent with thoseof Armstrong and Hutti (1998), who reported higherpregnancy-specific anxiety for expectant mothers in preg-

nancies subsequent to perinatal loss, and Franche andMikail (1999), who found increased prenatal anxiety forboth expectant mothers and fathers in a pregnancy afterloss. The current findings were, however, in contrast tothose of Theut and colleagues (1988), who found no dif-ference in levels of pregnancy-specific anxiety for expec-tant fathers with prior losses compared to those withouta history of loss. The conflict between study findingscould be a result of the difference in timing of the datacollection. Theut et al. evaluated parents in the 8th monthof their pregnancy when differences in anxiety about theoutcome of the current pregnancy may be decreasing andtherefore not significantly different from those without previ-ous losses.

When evaluating the influence of their experience ofloss on their present emotions, parents’ IES scores were


TABLE 5Multiple Regression for the Effects of Parent Gender and Impact of Previous Perinatal Loss on Pregnancy-Specific Anxiety (N = 80)

Standardized Betas

Step/Variable in Model Step 1 Step 2 t Adjusted R2 F of Equation

Step 1 .31 12.56(3,79)**Impact of Loss (Impact of Event Scale) .56*** 4.52

Gender .13 .42Gender × Impact of Event Scale –.46 –1.46

Step 2 .30 17.561(2,79)****Impact of Event Scale .44**** 4.67Gender –.31** –3.26

**p ≤ .01. ***p ≤ .001. ****p ≤ .0001.

TABLE 4Multiple Regression of the Effects of Parent Gender and Impact of Previous Perinatal Loss on DepressiveSymptoms (N = 80)

Standardized Betas

Step/Variable in Model Step 1 Step 2 t Adjusted R2 F of Equation

Step 1 .34 14.48(3,79)****Gender –.40 –1.30Impact of loss (Impact of Event Scale) .48**** 3.94

Gender × Impact of Event Scale .11 .37

Step 2 .35 21.90(2,79)****Gender –.29** –3.20Impact of Event Scale .50**** 5.53

**p ≤ .01. ****p ≤ .0001.

compared to the cut point of 19 or greater for high-impact scores established by Horowitz and colleagues(1979). Eighty-eight percent of the mothers and 90% ofthe fathers had IES scores at or greater than 19. This indi-cates a considerable influence of prior perinatal loss(es)on parents during subsequent pregnancies.

In Johnson and Puddifoot’s (1996) study, fathersscored higher on the Avoidance subscale (M = 24.0, SD =8.6) than the Intrusion subscale (M = 17.5, SD = 8.0).These results were similar to the current findings, withfathers’ Avoidance scores slightly higher than Intrusionscores. Mothers’ Avoidance scores were significantlyhigher than were fathers’, whereas their Intrusion scoreswere lower. Differences between parents’ subscale scoresmay indicate that for mothers, there is a greater emotion-al numbness or denial of the meaning of the previous lossin order to attempt to remain hopeful about the currentpregnancy, whereas for fathers, unintended thoughtsabout their previous loss may occur.

There was a moderately strong relationship betweencouples’ reports of the impact of the loss during the cur-rent pregnancy. The impact of the experience of perinatalloss on these couples may increase the association of theirpsychological distress. This seems to make sense whenone considers the trauma of the event they share. Formembers of some couples, their partner may be their pri-mary, or only, source of support and comfort.

Intercorrelations among the study variables demon-strated significant relationships between depressive symp-toms, prenatal anxiety, and impact of the loss on currentpsychological stress. The inverse correlation betweenpregnancy-specific anxiety and prenatal attachment formothers indicated that as their prenatal anxiety increased,their prenatal attachment in the current pregnancydecreased. This may be in part a self-protective measurefor mothers with prior losses that allows them to distancethemselves from the hurt or trauma of another loss. Pre-vious research supports this finding. In their study,Armstrong and Hutti (1998) found increased pregnancy-specific anxiety and decreased prenatal attachment forexpectant mothers in a pregnancy subsequent to priorperinatal loss. In the current study, there was no signifi-cant relationship between fathers’ prenatal anxiety andprenatal attachment. Interestingly, for fathers, the greaterthe impact of their previous loss, the greater their prena-tal attachment to the current infant.

Significant correlations between IES scores and depres-sive symptoms as well as pregnancy-specific anxiety forparents with a history of perinatal loss indicate an associ-ation between the influence of the loss and parents’ psy-chological distress during the current pregnancy. Thesefindings are similar to previous research indicating thatthe experience of perinatal loss influences parents’ depres-sive symptoms and pregnancy-specific anxiety in subse-

quent pregnancies (Cote-Arsenault & Marshall, 2000;Franche & Mikail, 1999; Theut et al., 1988; Vance et al.,1995).

LimitationsMore diverse samples in future research will provide a

better understanding of the influence of previous loss forparents with different ethnic or cultural backgrounds.Recruiting participants with lower annual income willallow analysis of the trauma of pregnancy loss for fami-lies dealing with additional socioeconomic stressors.Including parents not in partnered relationships willallow the evaluation of couple support in mediatingstressful pregnancies. The volunteer sample who self-selected into the study may not be representative of allparents with a history of perinatal loss. Therefore, thefindings may reflect only the experiences of those parentswho are most affected by their losses or interested in shar-ing their stories, which diminishes the generalizability ofthese findings.

Implications for Future ResearchPrior research describing the influence of stress during

pregnancy on poor birth outcomes highlights an associa-tion between maternal stress during pregnancy and lowerbirth weight and decreased gestational age at birth (Wad-hwa, Sandman, Porto, Dunkel-Schetter, & Garite, 1993).The current study’s findings underscore additional con-cerns for those caring for parents in stressful pregnancies.Other traumatic events such as termination of pregnancydue to fetal anomalies, severe prematurity in other chil-dren, infertility, and sudden infant death syndrome deathsmay all affect parents’ anxiety and stress in a subsequentpregnancy. Future research with parents suffering thesetraumas will allow evaluation of the long-term conse-quences of any type of stressful pregnancy.

The current findings indicated no relationship betweenthe psychological distress of parents in pregnancy afterperinatal loss and their developing relationship with theirunborn infant. However, qualitative comments in otherresearch suggest an effort by some parents to delayattachment to their current baby (Armstrong, 2001; Arm-strong & Hutti, 1998; Cote-Arsenault & Marshall, 2000;Rillstone & Hutchinson, 2001). It remains important toevaluate early development of parent-infant relationshipsto identify what, if any, effect previous pregnancy loss orother traumatic experiences in prior pregnancies mayhave on future attachment relationships. Heller andZeanah (1999), investigating prior perinatal loss and dis-ordered attachment with subsequent infants, reported45% of these children had disturbed attachment relation-ships. This was substantially higher than the expectedprevalence of 15% for disordered attachment relation-ships in other middle-class samples. Replicating studies


such as this will help health care providers comprehendthe association between past traumatic experiences andparent-infant attachment relationships.

Clinical Significance

Health care practitioners working with expectant cou-ples planning a pregnancy subsequent to perinatal lossshould counsel them to anticipate the possible increase inemotional distress a new pregnancy may bring. Memoriesof their past traumatic pregnancy loss may resurfaceunexpectedly. Reassurance and understanding are impor-tant at this time. In addition, short assessment tools suchas those used in this study may help to identify those par-ents particularly stressed and in need of further counsel-ing or treatment.

Methods to reduce psychological distress should betested in future research. The development and testing ofinterventions to decrease anxiety and depressive symp-toms is important for families as they go through the bit-tersweet experience of subsequent pregnancies. For healthcare practitioners working with expectant families, thisstudy’s findings stress the importance of evaluating priorobstetric history to examine the influence of past trau-matic experiences on anxiety and depressive symptoms insubsequent pregnancies. Support and referrals for mentalhealth services may be needed. Practitioners need to cre-ate an environment in which parents feel free to discusstheir fears, to validate their loss, and to begin to separatetheir past experience from the current pregnancy. In addi-tion, the effectiveness of support groups and networksduring pregnancy requires further evaluation. It may benecessary to continue to tailor this type of support to thespecial needs of expectant parents during subsequentpregnancies after loss.

Encouraging parental control over available choices isimportant. A thorough discussion of procedures used dur-ing subsequent pregnancies and sensitivity to the concernsthat any prenatal testing may generate is needed. Promot-ing parental choice assists parents in retaining some nor-malcy in the current pregnancy.

Health care providers need to support and encourageexpectant fathers to play an active role during pregnancy.Nurses should be aware of differences between mothersand fathers in grieving the previous loss as well as theexperience of a subsequent pregnancy. Although mothers’experiences of the loss and subsequent pregnancy aremore physical and less abstract, fathers struggle with theirmultiple roles. The current findings as well as previousresearch (Armstrong, 2001, 2002; Franche & Mikail,1999; Johnson & Puddifoot, 1996) support the influenceof prior pregnancy loss on expectant fathers. While theygrieve the loss of a wished-for child, fathers also may feelpowerless to support and protect their families. Hyper-

vigilance in subsequent pregnancies and a heightenedinvolvement may be ways fathers can attempt to maintainsome control. Providing information for fathers andinvolvement during the course of the current pregnancycan address fathers’ own concerns as well as his ability tobe supportive to his partner.

Understanding the emotions that parents experienceduring a pregnancy after perinatal loss can provide insightinto the needs of these families at this critical time. Thefindings of this research should heighten health care pro-fessionals’ awareness and deepen their understanding ofthe mixture of hope and fear expectant parents experienceduring pregnancies subsequent to perinatal loss. Address-ing this psychological distress may influence the course ofthe current pregnancy as well as future parent-infant rela-tionships.

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Deborah S. Armstrong, PhD, RN, is an assistant professor inthe School of Nursing at the University of Louisville, Kentucky.

Address for correspondence: Deborah S. Armstrong, PhD, RN,School of Nursing, University of Louisville, Louisville, KY40292. E-mail: [email protected].


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