pregnancy after perinatal loss: association of grief, anxiety and attachment

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Pregnancy after perinatal loss:association of grief, anxiety andattachmentCaroline Gaudet a , Nathalène Séjourné a , Laure Camborieux a ,Rachel Rogers a & Henri Chabrol aa Université Toulouse II Le Mirail, Centre d'études et derecherches en Psychopathologie , Toulouse, FrancePublished online: 20 May 2010.

To cite this article: Caroline Gaudet , Nathalène Séjourné , Laure Camborieux , Rachel Rogers &Henri Chabrol (2010) Pregnancy after perinatal loss: association of grief, anxiety and attachment,Journal of Reproductive and Infant Psychology, 28:3, 240-251, DOI: 10.1080/02646830903487342

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Journal of Reproductive and Infant PsychologyVol. 28, No. 3, August 2010, 240–251

ISSN 0264-6838 print/ISSN 1469-672X online© 2010 Society for Reproductive and Infant PsychologyDOI: 10.1080/02646830903487342http://www.informaworld.com

Pregnancy after perinatal loss: association of grief, anxiety and attachment

Caroline Gaudet*, Nathalène Séjourné, Laure Camborieux, Rachel Rogers and Henri Chabrol

Université Toulouse II Le Mirail, Centre d’études et de recherches en Psychopathologie, Toulouse, France

Taylor and FrancisCJRI_A_449144.sgm (Received 10 January 2009; final version received 6 September 2009)10.1080/02646830903487342Journal of Reproductive and Infant Psychology0264-6838 (print)/1469-672X (online)Original Article2009Taylor & Francis0000000002010CarolineGaudetcaroline.gaudet@club-internet.fr

Objectives: The aim of this study was to explore the psychological experience ofpregnancy after a previous perinatal loss and to bring to light the risk factors ofpsychological distress and disorders in instituting antenatal attachment with thesubsequent child. Methods: 96 pregnant women, having experienced a previousperinatal loss answered several questionnaires which measured the feelings ofperinatal grief (PGS), anxio-depressive symptomatology (HADS), acceptance ofpregnancy, identification with the maternal role (PSEQ) and perinatal attachment(MAAS). The control group included 74 women with no experience of perinatalloss. Results: Women having suffered from perinatal loss reported significantlyhigher scores of grief and anxio-depressive symptoms compared to the controlgroup. These variables were significant predictors of prenatal attachment.Conclusion: Findings reveal the intense psychological distress during pregnancyfollowing a perinatal loss and underscore the need for psychosocial and clinicalcare when there is a perinatal loss, care that should be extended up to the birth ofthe subsequent child.

Keywords: perinatal grief; subsequent pregnancy; anxiety attachment; depression

Introduction

Perinatal losses affect on average 30% of pregnancies (abortions, therapeutic abor-tions, miscarriages, sudden infant death syndrome, foetal death) (Rousseau, 1998).Regardless of the circumstances in which the pregnancy ended, there is the loss of theobject of an antenatal emotional attachment. The immediate reactions to loss aremainly manifestations of stress, followed by emotional responses ranging fromtemporary disappointment to intense reactions, underlined by pronounced, persistentand severe psychological concerns (Zolese & Blacker, 1992), characterised by symp-toms of anxiety and depression. Certain longitudinal studies have shown significantclinical distress after 4 years for 34% of women confronted with these issues(Hunfeld, Wladimiroff & Passchier, 1997). Psychiatric morbidity varies from 13 to34% (Nichol, Tompkins, Campbell & Syme, 1986) and 25% of women report a stateof pathological grief (Rousseau & Fierens, 1994). The specificity of this grief mayaccount for these high rates: mother never get to know the object of her grief and thesudden loss also symbolises the loss of her maternal identity, an identity that isfurthermore not recognised by society.

*Email: [email protected]

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Journal of Reproductive and Infant Psychology 241

According to Cuisinier, Janssen, Degraauw, Bakker and Ogduin (1996), 86% ofwomen became pregnant again within 18 months after perinatal loss, which leads oneto question the relationship between the coexisting sense of grief and the bonds withthe child during this new pregnancy. During pregnancy, the young woman often accom-plishes a ‘true psychological journey itinerary’ in her object relations with the child.Numerous studies uphold the idea that maternal attachment processes are establishedwell before birth. According to Cranley (1981), prenatal attachment can be translatedinto different maternal behaviours such as the differentiation of self and the foetus, theinteractions with the foetus, attributing characteristics and intentions to the foetus,forgetting oneself in favour of the pregnancy and the fact of seeing oneself as a mother.A lack of consensus is to be found in the literature as to the role and consequences ofa new pregnancy in the prenatal grief process. Some studies suggest an emerging accep-tance of the initial loss as well as a decrease of the symptoms of grief and guilty feelingsas positive effects due to the subsequent pregnancy (Lin & Lasker, 1996; Theut,Zaslow, Rabinovich, Bartko & Morihisa, 1990). O’Leary (2004) warns against theseimmediate benefits since they are all signs that can hide the presence of unresolvedgrief. Indeed, other research brings forward the inhibitive role of a pregnancy in thegrief process (Lewis, 1979) by the superposition of identities and the hope of renewingwith the absentee through the awaited child (Côte-Arsenault, 1995; O’Leary, 2004).

Many recent studies underline that the experience of perinatal loss has the resultantrisk of high levels of anxiety during the next pregnancy (Armstrong, 2002; Côte-Arsenault & Dombeck, 2001; Hughes, Turton & Evans, 1999). This anxiety ischaracterised by the imminent fear of a recurrence (Armstrong, 2002) and the parentstend to reject any favourable outcome of the pregnancy. Fear, anxiety, anger, insecurityand an interpretative tendency with regards to the symptoms of pregnancy predominate(Côte-Arsenault, Donato & Earl, 2007), therefore leading the parents to a constant needto have everything under control and to an averred hypervigilance. While some authorsconsider that this anxiety is at the root of a prenatal bonding issue with the child (Rille-stone & Hutchinson, 2001; Wallerstedt, Lilley & Baldwin, 2003), other researchdemonstrates the opposite (Avant, 1981). Thus, some authors interpret the increasedanxiety as a sign of the creation of an emotional link with their child (Brazelton &Keefer, 1982). According to the study of Figueiredo, Costa, Pacheco, Conde and Teix-eira (2007), after a perinatal loss 26.4% of pregnant women report symptoms of anxi-ety, 28.4% symptoms of depression and both negatively interfere in the emotionalinvestment in the child during pregnancy. Due to the lack of consensus in scientificliterature, some questions are left unanswered: What is the anxio-depressive risk of thispregnancy? What role does the feeling of loss and grief have in this pregnancy? Canthese emotions interfere with the creation of an emotional link with the child to be? Inconsequence, our research explores the psychological experience of a pregnancy aftera perinatal loss and attempts to determine possible links between the symptoms of peri-natal grief, anxio-depressive symptoms, acceptance of pregnancy, identification withthe maternal role and perinatal attachment among women having experienced perinatalloss compared to those with no experience of perinatal loss.

Method

Participants

The sample included 96 pregnant women who had experienced one or several perina-tal losses: termination of pregnancy, miscarriage, therapeutic abortion, in utero death

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242 C. Gaudet et al.

and early neonatal death (average age 29.8, SD=4.01, 24–41 years). For this group,the inclusion criteria for the study were: the present state of pregnancy and the previ-ous experience of one or several perinatal losses. The study conducted in France withFrench women met via midwives offices (N=8) or through an online questionnaire(N=88). For this last sample, women are living in France or for a minority someoutside French-speaking countries.

The socio-demographic characteristics of the sample and the data concerning peri-natal loss and the present pregnancy are presented on Table 1. At the time of thisstudy, women were on average at 22.4 weeks of amenorrhea (SD=10.24) and 59% ofthem were primiparous. The participants were separated in accordance with thenumber and type of loss experienced in the past. The average in weeks of amenorrheaat which a loss occurred is indicated with regards to each type of loss. Termination ofpregnancy is an abortion induced by medication or carried out surgically to a non-pathological pregnancy by request of the patient with up to 14 weeks of amenorrhoea(N=8; M=7.63; SD=2.2); miscarriage is a natural or accidental termination of preg-nancy (N=27 M=12.48; SD=7.54); therapeutic abortion is an induced abortion done atany time in France during pregnancy when an illness or a handicap of the child ormother has been diagnosed (N=36; M=24.56; SD=7.14); in utero death is the death ofthe child in its mother’s womb without a medical intervention (N=17; M=26.59;SD=7.12) and early neonatal death includes all deaths of children from birth to 6 daysold (N=8; on average, birth and loss had occurred at 36.63 weeks of amenorrhoea;SD=5.99). Following the loss, the women benefited from various follow ups: medical

Table 1. General characteristics of the perinatal loss group (N=96).

Frequency Percentage

Age Less than 26 years 10 10Mean age=29.81 Between 26 and 30 years 49 51(SD= 4.01) Between 31and 35years 28 29

More than 36 years 9 9Marital status Married 48 50

Common-law marriage 11 11Cohabitation 37 38

Employment status Executive, intellectual profession 8 8Intermediate profession 28 29Employed 33 34Worker 1 1Unemployed 24 25No enquired 2 2

Number of loss One loss 67 70Average number=1.46 Two losses 19 20(SD=.857) Three losses 10 10Stage of actual pregnancy First trimester 28 29

Second trimester 40 41Third trimester 28 29

Time since loss Less than a year 49 51Mean time=19.25 Between 1 and 2 years 23 24(SD=18.20) More than 2 years 24 25

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(N=22), psychological (N=9), medical and psychological (N=39) and there was nofollow up for 26 women. At the present date, 31 participants are being followed-up ina psychological setting.

The control group comes from a parallel study conducted at the same time andusing the same procedures. A control group of 74 pregnant women who had notsuffered perinatal loss (inclusion criteria) was constituted (average age: 27 years;SD=4.07; range 20–36). These women were on mean at 26.9 weeks of amenorrhoea(SD=9.35) and 60% of the sample was childless.

Measures

Women who had experienced a perinatal loss completed four scales so as to evaluateanxio-depressive symptomatology (HADS), prenatal attachment (MAAS), post perin-atal grief symptoms (PSG), identification with the maternal role and acceptance ofpregnancy (PSEQ). Women of the control group only completed the first two scales.For all scales used, the observed internal consistency in this study is given in paren-thesis (Cronbach’s α).

The Hospital Anxiety and Depression Scale (HADS) (Lepine, Godchau, Brun &Lemperiere, 1985) assesses present anxio-depressive symptomatology (α=.83). Thisscale is composed of 14 items, 7 of which evaluate anxiety symptomatology (‘I feeltense or stressed out’) and 7 of which evaluate depressive symptomatology (‘I feel likeI’m living in slow motion’). Each answer is rated from 0 to 3 on a scale assessing theintensity of the symptom during the past week. A score above or equal to 8 on eachsubscale indicates the presence of anxiety or depressive symptomatology rangingfrom moderate to severe. The choice of this instrument is based on its psychometricproperties (good internal consistency, test–retest reliability, convergent and predictivevalidity) and the availability of a validated French translation: the validation study ofthe HADS has been conducted with a community sample of hospitalised patients anddepressed subjects. We did not therefore use specific maternal anxiety scales, since,to our knowledge, there exists no French validation and they do not assess maternalanxiety symptomatology but only anxiety related to the pregnancy (such as fear ofchildbirth).

The maternal prenatal attachment scale (MAAS) (Cranley, 1981; French transla-tion: Camborieux & Callahan, submitted for publication) assesses the mother–childattachment during the prenatal period (α=.85). The French validation has beenconducted with a community of women whose pregnancies ranged from the first tothe last trimester and both validations showed a good internal consistency and conver-gent validity. It is composed of 21 items rated on a 5-point scale, with total scoresranging from 21 to 105. The scores provide two dimensions of prenatal attachment:the quality of the attachment (regarding the affective experience: ‘During the last twoweeks, my feelings towards the expected child were: …Very positive, (…) Very nega-tive’) and the intensity of the attachment (evaluating the importance of preoccupationwith the foetus: ‘when I spoke or when I thought of the child I am expecting, theemotions I have felt were: very weak or nonexistent (…) or very strong’).

The Perinatal Grief Scale (PGS) (Potvin, Lasker & Toedter, 1989; French transla-tion De Tychey & Dollander, 2000) aims to assess the emotional distress of womenafter perinatal grief (α=.94). The validation study of the PGS has been conducted witha community of bereaved parents after different perinatal losses (Potvin et al., 1989).The PGS showed good psychometric properties (internal consistency, test–retest

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reliability and convergent validity). The scale includes 33 items split up into 3subscales that evaluate the different dimensions inherent to perinatal grief: active grief(‘I cry when I think of him/her’), difficulties with coping (‘I think that I have notadapted myself well to the loss’), despair and a feeling of worthlessness (‘I feel emptyinside’). All items are graded on a 5-point scale, with total scores ranging from 33 to165. A high score indicates intense psychological suffering due to the loss.

The Prenatal Self-Evaluation Questionnaire (PSEQ) (Lederman, 1996) measuresseven dimensions of maternal prenatal development and adaptation to the psycho-social changes induced by the pregnancy (α=.91). A validation study has beenconducted in a community of women whose pregnancies ranged from the first to thelast trimester (Lederman, 1996). The PSEQ showed good internal consistency, test–retest reliability and convergent validity. Each subscale is composed of 10–15 itemsgraded according to the Likert scale depending on their agreement with each of theproposed affirmations. Only two subscales were used in this study: pregnancyacceptance (‘I’m having a hard time adapting to this pregnancy’) and identificationwith the maternal role (‘I have doubts as to my capacity of being a good mother’).

Procedure

The study took place between January and May 2008. Women having experiencedperinatal loss were approached in midwives’ offices, on websites and specialisedinternet forums (French chat forums on pregnancy and associations’ forums on perin-atal death) so as to participate in a clinical study on ‘the experience of a pregnancyafter a perinatal loss’. The women of the control group were approached via the samespecial internet forum. For both groups, the internet link to the questionnaire was putonline on a website, thereby enabling participants to answer anonymously and confi-dentially. At first, it explained the aims of the study, its method as well as the rightsof the participants (anonymity, confidentiality, the right to refuse or rectify the data,as well as the right to have additional information from the researcher). All gave theirconsent to participate and filled in the questionnaire which followed.

Results

Post-hoc power analysis for Student’s t-test showed that observed power was 0.68.The subjects-to-predictors ratio was adequate for multiple regression analysis as it wasaround the traditional guideline of at least ten variables per predictors (Howell, 1997).Post-hoc power analysis was conducted for regression analyses.

Comparison between groups

Table 2 represents average scores in response to the questionnaires and the compari-sons of averages between the two groups (t-test). Table 3 represents the frequencycomparison of the anxio-depressive symptomatology between the two groups (χ2

tests). Significantly more women having experienced a perinatal loss had a higheranxiety symptomatology than in the control group (72% (N=70) versus 29% (N=22)for scores above or equal to 8 on the anxiety scale of HADS). There was no significantdifference between the number of women having a moderate to severe depressivesymptomatology.

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Comparisons in the perinatal loss group

Amongst women who had experienced perinatal loss in the past, those who wereaware of the gender of the child reported higher scores of prenatal attachment (t(94)= −2.42; p<.05) as did those who participated in preparation to childbirth compared tothose who did not (t(73)= −3.00; p<.01). Women had a stronger attachment the furtheralong they were in their pregnancies (F(2,93)=5.39; p<.01). Furthermore, comparativeanalysis demonstrated significantly higher intensity of attachment among primiparouswomen (t(94)=2.6; p<.05). In contrast, we noticed no significant differences betweenthe two groups with regard to the quality of prenatal attachment (t(62.07)=1.91;p>.05), feelings of grief (t(94)=.90; p>.05), anxio-depressive symptomatology(t(94)=.12; p>.05), acceptance of pregnancy (t(94)=.60; p>.05) and identification withthe maternal role (t(94)= −.86; p>.05).

Significant differences in the PGS were found according to type of loss(F(4,91)=3.45; p<.05) and the trimester of loss (F(2,93)=4.26; p<.01). Women whohad experienced a neonatal loss had significantly higher mean scores on the depres-sion subscale (t(94)=−3.18; p<.01) and the PGS (t(94)=−2.06; p<.05) and lower scoresfor prenatal attachment intensity (t(94)=−2.09; p<.05) than those who had experienceda loss during pregnancy. Women who had moderate to severe depressive symptomsas well as those who had moderate to severe anxiety symptoms had significant lowermean MAAS scores (respectively, t(94)=2.39; p<.05; t(94)=.59; p>.05) and PSEQscores (t(94)=3.37; p<.01; t(94)=−2.21; p<.05), and higher PGS scores (t(94)=−5.99;p<.01; t(94)=−3.89; p<.01).

Women who had not had a follow-up (neither medical nor psychological) at thetime of the loss had greater difficulty than others in facing up to the loss(F(3,92)=3.04; p<.05) and in the prenatal attachment to the subsequent child(F(3,92)=2.79; p<.05). Women who had had a psychological follow-up during their

Table 3. Frequencies of anxio-depressive symptomatology (score above or equal to 8 on eachsubscale of HADS).

Perinatal loss group (N=96) Control group (N=74)

Frequency Percentage Frequency Percentage χ2 test

Anxiety N=70 72 N=22 29 χ2 =31.38 ; Df=1; p<.001Depression N=22 29 N=26 27 χ2 = .04 ; Df=1; p>.05

Table 2. Mean scores for study variables.

Group having had a perinatal loss (N=96) Control group (N=74) Student’s t

PGS 86.49 (SD= 23.15) – –PSEQ 101.59 (SD=11.71) – –MASS - Total 63.96 (SD=10.90) 64.08 (SD=7.36) t(165.3)=.87; p>.05

– Quality 35.96 (SD=5.50) 37.14 (SD=3.69) t(168)=1.58; p>.05 – Intensity 24.57 (SD=6.03) 23.55 (SD=4.76) t(168)= −1.19; p>.05

HADS - Anxiety 10.33 (SD=3.77) 6.32 (SD=3.23) t(168)= −7.31; p<.01 – Depression 5.84 (SD=4.16) 5.49 (SD=3.23) t(168)= −.60; p>.05

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pregnancy reported significantly higher levels of grief compared to those who had nothad a psychological follow-up (t(94)=−2.63; p<.01).

Correlation and regression analyses among the perinatal loss group

The correlations between the different scales are shown in Table 4. Prenatal attach-ment correlated significantly and negatively with perinatal grief (r=.31; p<.01) anddepressive symptomatology (r=−.36; p<.01). With regard to the subscales, the ‘qual-ity’ of prenatal attachment was significantly and negatively correlated with all thePGS subscales (active grief, difficulties with coping, despair and a feeling of worth-lessness) (r=−.40; p<.01) and the ‘depression’ subscale of the HADS (r=−.48; p<.01);however, the ‘intensity’ of the attachment was significantly and negatively correlatedwith anxiety symptoms (r=−.21; p<.05). The feelings of grief appeared to be signifi-cantly and positively correlated with the number of perinatal losses experienced(r=.23; p<.05) and the stage of pregnancy at the time of the loss (r=.31; p<.01). Thedata analysis also revealed that the more the present pregnancy in progress was early,the more the grief (r=–.26; p<.05) and anxio-depressive symptomatology was high(r=.22; p<.05). Moreover, as women went beyond the pregnancy stage at which theyhad experienced a loss, their reports of high scores of perinatal grief symptomatology(r=−.27; p<.01) tended to diminish, and prenatal attachment to the child increased(respectively, r=.37; p<.01).

Two multiple regression analyses were conducted the results of which are presentedin Table 5. The first regression analysis aimed to determine if the HADS variables(anxiety and depression), PSEQ (acceptance of pregnancy, identification with thematernal role), PGS and the stage of pregnancy, improved the prediction of the qualityof prenatal attachment, entered as a dependant variable. Results showed that this modelexplained 51.6% of the variance in the quality of prenatal attachment (F(5,90)=19.18;p<.0001; R2=.52). Given an alpha level of .05, the number of predictors, the observedR2, and the sample size, post-hoc power analysis showed that the observed power was1. Anxiety and perinatal grief syndromes were non-significant. Pregnancy acceptanceand identifying with the maternal role, depressive symptomatology and pregnancystage significantly contributed to the quality of prenatal attachment.

A second multiple regression analysis of was conducted so as to determine if thesame variables improved the prediction of attachment intensity. This model explained32.6% of the variance of prenatal intensity attachment (F(5,90)=8.68; p<.0001;R2=.33). Observed power was .99. Depressive symptoms and perinatal symptoms ofgrief were non-significant. Acceptance of pregnancy and identification with thematernal role, anxiety symptomatology and stage of pregnancy significantly contrib-uted to the intensity of attachment.

Table 4. Correlations between study variables in the perinatal loss group.

PGS HADS MAAS PSEQ

PGS –HADS .69**MAAS −.31** −.21*PSEQ −.27** −.31** .55** –

Significant correlations for *p < .05, **p < .001.

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Discussion

The aim of our study was to explore the psychological experience of pregnancy aftera perinatal loss and to bring forward psychological distress risk factors that couldinterfere with the development of an antenatal relationship with the subsequent child.The psychological distress of these women is revealed by frequent severe symptomsof anxiety and co-occurring high levels of grief. Our results show that the grouphaving experienced parental loss suffers from significantly higher levels of anxio-depressive symptomatology than the control group. The frequency of anxiety reportedin our sample is higher that reported in other studies. Although, firm comparisons aredifficult to draw from a single measurement of anxiety among a group of women atdifferent stages of pregnancy, these findings confirm the importance of anxiety duringthese pregnancies highlighted by previous studies (Armstrong, 2002; Côte-Arsenault& Dombeck, 2001; Hughes et al., 1999).

Our findings suggest that early conception following grief, the stage of the priorpregnancy before the loss, the experience of a late loss and the high number of lossesappear to be risk factors for grief symptomatology, high anxiety and weak prenatalattachment. Therefore, going beyond the stage at which women experienced loss, andconsequently the progress of the pregnancy, are reassuring elements and they enablewomen to invest themselves progressively in the pregnancy and to bond with the child.Even if the size of the sub-groups is small, results reveal that pregnancy following theloss of a child in the early neonatal period is accompanied by intense feelings of griefand a significant anxio-depressive risk. These findings are in line with those of theliterature, namely that the later the loss occurred during pregnancy, the more womenexpress a significant state of distress. In a longitudinal study conducted by Vance et al.(1995) among 220 parents (not specifically during the subsequent pregnancy) who hadlost a child, at 8 months anxiety and depressive disorders were multiplied by 5 follow-ing sudden infant death syndrome, by 3 for parents whose children were stillborn andby 4 for perinatal deaths with comorbid paternal alcohol abuse.

We have chosen to include primiparous as well as multiparous women to the studybecause comparison of the two different groups appears interesting in order to explore

Table 5. Multiple standard regression results for the perinatal loss group aiming to predict thequality and intensity of the prenatal attachment.

β t p

Quality of prenatal attachmentAnxiety .00 .00 .99Depression −.22 −2.10 <.05PSEQ .53 6.54 <.001Feelings of grief −.04 −.42 .67Stage of pregnancy .24 3.28 <.01

Intensity of attachmentAnxiety .32 3.32 <.01Depression −.05 −.45 .66PSEQ .36 3.74 <.001Feelings of grief −.14 −1.11 .27Stage of pregnancy .28 3.21 <.01

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risk factors for distress and consequently, the women’s potential need of psychosocialas well as clinical care. Primiparous women displayed a higher intensity of attachmentand higher levels of preoccupation with their foetus compares to the multiparousgroup. However, being primiparous did not represent a risk factor with regard to theother aspects studied here.

In accordance with other studies (Armstrong & Hutti, 1998; Wallerstedt et al.,2003), one possible explanation might be that the high levels of anxio-depressivesymptomatology interfere with the prenatal attachment to the child. If our results donot enable us to fully grasp the complexity of this relationship, they do contribute toour understanding of this phenomenon. Thus, it seems that anxiety interferes with theintensity of attachment (represented by the time spent thinking about the baby, talkingabout it, touching it or dreaming about it), meanwhile feelings of grief and depressivesyndromes interfere with the quality of the prenatal attachment to the subsequent child(tenderness, proximity, or the pleasure of interacting with the child). Difficulties ininvesting emotionally in the pregnancy and the attachment with the child to be bornappear to be the result of a defensive process, the aim of which is to protect oneselfagainst all possibilities of an eventual loss. This mechanism is perceived by Côte-Arsenault and Mahlangu (1999) as a resistance to preparing physically, emotionallyand socially for the coming child. The longitudinal study conducted by Côte-Arsenault and Dombeck (2001) during pregnancy up until the birth of the next childsimilarly revealed the link between anxiety during a pregnancy and previous loss, andsuggested that the anxiety was associated with the importance placed upon the loss,the degree of personification of the deceased child and attachment to the child.

Our results equally seem to point to the risks of early conception following perin-atal loss and therefore contradict research concluding to the beneficial effects of anearly conception after the loss (Lewis, 1979; Theut et al., 1990). For some authors,pregnancy is seen as a hindrance to working out the loss and which aims to eliminatethe guilt induced by the naturally conflicting and ambivalent feelings at work in themourning process. According to Mazet and Lebovici (1998, pp. 76–77), ‘The inhibi-tion of attachment to the new child could also be the consequence at the same time ofits non-existence as an imaginary child, since it is the departed that is replaced, andthe fear of a new loss’. If our study did not reveal feelings of grief as a sufficiently‘strong’ predictor to contribute to the explained variance of antenatal attachment, itdid, nevertheless, demonstrate their relationship in the development of a prenatalbond. The high scores on PGS also unveil the difficulties of disinvesting the deceasedchild and the psychological distress attached.

If one refers to the studies demonstrating the continuity of the attachment bond(Avant, 1981; Caccia, Johnson, Robinson & Barna, 1991) and the predictive value ofanxiety and depression in the quality of mother-child interactions during a pregnancy(Ammaniti, Candelori, Pola & Tambelli, 1999), this study raises the question of the‘replacement child syndrome’. Early bonding disorders associated with this syndromecould start as early as the premises of the emotional link with the child, meaningduring pregnancy. For this reason, it would be especially interesting to study the conti-nuity of the pre and postnatal emotional link and to investigate the evolution of thispsychological distress through a longitudinal study from conception to the birth of thenext child. In the present study, group sizes when organised according to the type ofgrief were insufficient to test for significant differences. If numerous studies(Armstrong & Hutti, 1998) have demonstrated a significantly higher level of distressaccording to the stage of loss, this preliminary study shows the need to further

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investigate this distress and to thoroughly analyse the experience of these pregnancieswith regard to the different types of perinatal losses with more homogenous and largergroups. Lastly, in this study, we used a generalised anxiety measurement; it would beuseful, in future research, to use additional specific pregnancy measurements in orderto investigate this distress and better understand women’s overall pregnancy experi-ence after a perinatal loss.

If some studies (Côte-Arsenault & Freije, 2004) suggest the benefits of psycho-logical follow-up during pregnancy after a perinatal loss, our results show a signifi-cantly higher level of distress among those who have had such a follow-up. Theseresults could be explained by the fact that the women who benefited from the follow-up were the most distressed initially. Meanwhile, the experience of pregnancy seemsto depend on the proposed follow-up after a loss, thus underlining the necessity togive support to women, not only to help them face up to the loss, but also to favourthe proper unfolding of the next pregnancy. Therefore, the continuity of the proposedfollow-up at the time of the loss right up to birth of the subsequent child at minimumseems particularly important. The latter must not only take into account the experi-ence of the present pregnancy, but also grief, its development, the significance of theloss and its place in the maternal history in addition to its involvement in the institut-ing of an emotional link with the subsequent child. When faced with a loss, all themedical care team can be supportive through empathetic listening and its warm pres-ence. As a preventive goal, the latter can also inform women of the need to leavethemselves a bit of time before planning another pregnancy, this in spite of the painof absence, so that they can work out the loss of the baby and the associated feelings.During pregnancy, it is essential that they find a place where they can feel free toexpress their distress, anxiety, fears, their sometimes ambivalent feelings betweenexpecting a child and grieving for the previous child. Methods have to be found tohelp them face up to all their anxieties so as to bring them progressively to discoverand invest themselves emotionally in this new pregnancy and new child in everythingthey specifically represent.

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pregnancy after perinatal loss: association of grief, anxiety and attachment

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