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March/April 2004 JOGNN 155

Author’s Response

I appreciate this opportunity to have a dialogue aboutperinatal loss, subsequent pregnancies, and the state ofour science in these areas. The writer thoughtfully ques-tions several important points inherent in my study(reported in September/October 2003 JOGNN).

Definitions of perinatal loss vary in scope and breadth,depending on the context in which the definition will beused. Not everyone agrees with any one particular defini-tion. Of utmost importance is the need to provide a cleardefinition so that judgments can be made about the com-parability of information, or in this case, the generaliz-ability of the findings. Most people would agree that thereis a difference between a spontaneous perinatal loss (mis-carriage, ectopic pregnancy, stillbirth, or neonatal death)and an elective termination of pregnancy (ETP) (electiveabortion, selective termination). This is not to say thatETP is not difficult, or is not experienced as a loss. How-ever, there are differences in the circumstances that lead tothe loss, especially regarding decision making.

For this reason, the sample criteria for my studyincluded only spontaneous loss so that the roots of theanxiety in pregnancy after loss could be as clearly isolat-ed as possible. It was imperative for the loss groups andno-loss groups to be as similar as possible (see my letterto the editor, January/February 1999 JOGNN). Thus, thewomen in both groups should have obstetric histories asalike as possible, so that any differences found could beattributed to the perinatal loss (the primary differencebetween groups).

Indeed, exclusion of women with a history of electiveabortion does limit the generalizability of the findings. Iwas remiss in not stating this additional study limitationin my report. Clinical practice and research methods donot always match, due to necessary decisions regarding

designs for internal (control) and external validity (gener-alizability). These research decisions generally increaseone type of validity as they decrease the other. Therefore,judgments must be made by the researcher to design thestrongest study possible, given the inherent limitations ofsample size, methodology, and other factors. Because ourempirical knowledge of pregnancy after perinatal loss isstill limited, our studies must be carefully planned so as tolearn as much as possible from each of them.

Although I agree that we need to know what pregnan-cies after elective abortions are like, we are still trying tounderstand what pregnancies after spontaneous loss arelike. I believe that these two kinds of pregnancy need tobe studied both separately and together. In the studyunder discussion here, I chose to limit my sample as I didto minimize confounding variables and thus clarify inter-pretation of the results.

More research is clearly needed to expand our inquiryand understanding. I am pleased to say that my currentlongitudinal study on pregnancy after perinatal loss mayanswer questions the writer has asked. All participants inthe current study have had spontaneous loss and somealso have had elective abortions; I hope to look for simi-larities and differences within and between the partici-pants across their pregnancies. I agree that researchersand clinicians need to understand all pregnancy situationsso that we can provide optimal care. This requires thecareful and systematic testing of questions and the build-ing of knowledge. Validation, evidence building, and care-ful interpretation of findings will all contribute to ourknowledge of pregnancy experiences in our diversesociety.

Denise Côté-Arsenault, RNC, PhDSyracuse UniversitySyracuse, NY