Pregnancy Subsequent to Perinatal Loss: Parental Anxiety and Depression

SUSAN K. THEUT, M.D., M.P.H., FRANK A. PEDERSEN, PH.D., MARTHA J. ZASLOW, PH.D., AND

BETH A. RABINOVICH, PH.D.

Abstract. Twenty-five expectant couples who had experienced a perinatal loss within the previous 2 yearswerecompared with 31 first-time expectantcouples usingthe Trait Scale (A-Trait) of the Spielberger State-TraitAnxiety Inventory,the Beck Depression Inventory (BOI), and the Pregnancy OutcomeQuestionnaire (POQ). ThePOQwasdesigned for this study to examine the hypothesis that during the subsequent pregnancy, parents with aprevious loss would exhibit anxiety that is specific to the pregnancy experience and not of a more generalizednature. The POQ significantly differentiated between the two groupsof mothers (p < 0.0 I); the A-Traitand BOIdid not. Fathers in the twogroupsdid not differsignificantly on the BOI,A-Trait, or the POQ.J. Am. Acad. ChildAdolesc. Psychiatry, 1988,27, 3:289-292. Key Words: perinatal loss, pregnancy, anxiety, depression.

The bereavement of parents following a perinatal loss hasbeen described in clinical reports (Bourne, 1983; Kennell etal., 1970; Leon, 1986; Lewis, 1979; Stack, 1980). The parentsmourn the lost child, and the process of mourning is analo­gous to that experienced when an adult dies. Clinicians havedescribed anxiety and depression during the pregnancy sub­sequent to a perinatal loss (Jolly, 1976; Lewis, 1983; Theut,1985). These descriptions of anxiety and depression duringthe subsequent pregnancy have been based on clinical judg­ments and a small number of cases. Empirical work to datehas not examined the nature and extent of anxiety anddepression in the subsequent pregnancy, nor whether suchreactions occur in all or most women who have experienceda pregnancy loss.

The attachment to the unborn child has usually been estab­lished by the latter part of pregnancy (Benedek, 1970; Klausand Kennell, 1982). Anxiety and depression of sufficientseverity can interfere with the parent's ability to focus on theprocess of the new pregnancy, the developing fetus, and thepsychological process involved in attachment. Thus, it isimportant to assess such reactions during a pregnancy subse­quent to perinatal loss. Are both anxiety and depressionsignificantly higher among mothers who had previously ex­perienced loss than among mothers with no history of loss?Does the evidence point to pervasive anxiety and/or depres­sion, with implications in many areas of functioning, or ratherto reactions specific to and focused on the course of thepregnancy itself?

Fathers, as well as mothers, emotionally invest in their

Accepted February 3, 1988.Dr. Theut is an Assistant Professor and Director of Bereavement

Research. Department of Psychiatry, Georgetown University Schoolof Medicine. Washington. D.C. She completed this study while aMedical StaffFellow in the Child & Family Research Section (CFRS),Laboratory of Comparative Ethology (LCE). National Institute ofChild Health and Human Development (NICHD). National InstitutesofHea/th (NIH). Dr. Pedersen is Chief ofthe CFRS, LCE. NICHD,NIH and Dr. Rabinovich is affiliated with the same Institute. Dr.Zaslow is with the Committee on Child Development Research andPublic Policy. National Research Council.

This project was approved by the Institutional Clinical Review­Subpanel of the National Institute ofChild Health & Human Devel­opment on January 16. 1986.

Presented at the Annual Meeting ofthe American Academy ofChildand Adolescent Psychiatry, October 24. 1987, Washington D.C.

Requests for reprints to Dr. Theut, Department of Psychiatry,Georgetown University School (if Medicine. 3800 Reservoir Road,N. w.. Washington. D.C. 20007.

0890-8567/88/2703-0289$02.00/0© 1988 by the American Acad­emy of Child and Adolescent Psychiatry.

289

babies during pregnancy (May and Perrin, 1985). Kennell etaI. (1970) recognized that fathers also grieve after a perinatalloss. The existing literature on perinatal loss has focusedalmost exclusively on mothers, with little attention given tofathers. It would be desirable to obtain more informationabout fathers' reactions to periatal loss. For example, dohusbands whose wives experience perinatal loss show height­ened anxiety and depression during their wives' subsequentpregnancy?

Although clinicians' judgments that mothers who haveexperienced a pregnancy loss are at risk for heightened anxietyand depression during a subsequent pregnancy appears rea­sonable, an important conceptual issue is the pervasivenessof such reactions. Anxiety, for example, can be expressed ina variety of responses: somatic symptoms, subjective distress,or uncertainty as to appropriate behavior. It is possible thatpregnancy loss may result in selective concerns that are fo­cused upon the mother's reproductive efficacy itself. In addi­tion to addressing the question of whether generalized meas­ures of anxiety and depression are elevated in expectantmothers who have experienced a previous loss, this researchsought to measure a highly selective component of anxiety:concerns about the course of the pregnancy. Toward this end,a specialized measure was developed to contrast with existinggeneralized measures of anxiety and depression.

In summary, the research to be described in this paper hasboth methodological and substantive aims. The methodolog­ical purposes ofthis paper are: (I) to describe the developmentof a new measure to evaluate anxiety specific to the course ofthe subsequent pregnancy; (2) to evaluate the internal con­sistency of this measure; (3) to examine how it correlates withstandardized psychometric measures of anxiety and depres­sion. The substantive purposes of this paper are: (I) to assesswhether anxiety and depression are heightened in mothers aswell as fathers who have experienced a pregnancy loss relativeto parents with no history of loss; and (2) to determine whetherthe anxiety and depression, if they are heightened, are gener­alized or focused.

Method

Measure Development

The Pregnancy Outcome Questionnaire (POQ) was devel­oped as part of a larger study to examine the anxiety of first­time expectant parents and of parents who had experienced aperinatal loss. Before the development of the POQ, a series ofinterviews was conducted with seven women, and three of

290 THEUT ET AL.

their husbands, who had experienced a perinatal loss. Theitems of the PDQ were derived from these interviews, basedupon areas of concern expressed by these subjects. Each itemwas intended to apply to first-time expectant parents as wellas parents who had a previous pregnancy.

The PDQ consists of 15 items. (See Appendix for thecomplete questionnaire for mothers). Responses are scoredon four-point Likert scales that range from "Almost Never"to "Almost all the Time." Items appear in both the positiveand negative directions to minimize acquiescent response sets.Parallel items were used for fathers with wording appropriatefor men. A summary score was obtained for each participantby adding each of the individual scores. Both the individualscores and the summary scores were recorded and used forthe data analysis. The PDQ requires approximately 15 min­utes to complete.

Sample

The sample of 56 middle-class, expectant, married couples(55 were Caucasian and one was minority) was obtained inthe Washington, D.C. metropolitan area through announce­ments in local newspapers, medical centers, and childbirthclasses. The mean maternal age was 31.3 years (range 20.00to 40.00 years). Each mother in the sample had graduatedfrom high school. The mean maternal number of years ofeducation beyond high school was 6.8 years (range 0 to 9years). The mean number of hours per week that mothersworked outside the home was 32.7 (range 0 to 55 hours perweek). The mean paternal age was 33.5 years (range 23 to 46years). Each father in the sample had graduated from highschool. The mean paternal number of years of educationbeyond high school was 7.5 years (range 0 to II years). Yearsmarried in the sample averaged 3.2 (range I to 8 years).

Twenty-five of these couples had experienced a perinatalloss within the previous 2 years. The average number of weeksbetween perinatal loss and the subsequent conception was34.8 weeks. Sixteen of the couples with a history of perinatalloss had experienced a miscarriage (pregnancy loss up to 20weeks of gestation), seven couples had experienced a stillbirth(pregnancy loss of 20 weeks gestation or longer), and twocouples had experienced a neonatal death (both infants diedwithin 3 days of birth). The other 31 couples comprised acomparison group of first-time expectant parents. Two of thewomen in the miscarriage group had had elective abortionsbefore the perinatal loss. The groups of loss and nonlosscouples did not differ significantly on background variables(maternal age, years married, maternal education, and mater­nal employment). Subsequent to the study, all parents gavebirth to viable children.

Procedure

During the 8th month of pregnancy, the men and womenin each couple visited the laboratory of the Child and FamilyResearch Section, Laboratory ofComparative Ethology of theNational Institute ofChild Health and Human Development.During this visit, husbands and wives received a descriptionof the project and signed consent forms. Each then completedthe Beck Depression Inventory (BDI) (Beck et al., 1961), the

Trait Scale (A-Trait) of the Spielberger State-Trait AnxietyInventory (STAI) (Spielberger et al., 1970) (widely used meas­ures of depression and anxiety, respectively) and the PDQ.The session also included additional questionnaires and inter­view measures not considered here. Husbands and wivescompleted the questionnaires in separate rooms and wereasked not to consult with each other. The expectant parentswere assured of the confidentiality of their responses.

DataAnalysis

Cronbach's alpha (Cronbach, 1951) was computed sepa­rately on the data from mothers and fathers to examine theinternal consistency of the PDQ. T tests were performed onthe scores of the BDI, the A-Trait, and the PDQ between theloss and nonloss groups. Correlations were performed for thePDQ, the BDI, and the A-Trait for the mothers and fatherswithin each of the two groups.

Results

Pregnancy OutcomeQuestionnaire as a Measure

The alpha coefficients for the PDQ were 0.80 for themothers and 0.80 for the fathers, indicating acceptable inter­nal consistency.

Table I presents the intercorrelations of the three measuresused to assess anxiety and depression. The PDQ was positivelyand significantly correlated with the A-Trait measure for allgroups except fathers in the loss group. The PDQ did notcorrelate significantly with the BDI for any of the groups.

Between Group Differences

The A-Trait and the BDI, the generalized measures ofanxiety and depression, respectively, did not significantlydifferentiate between the expectant mothers who had experi­enced a perinatal loss and those who had not. However, thePDQ, measuring anxiety specific to the current pregnancy,did significantly differentiate between the two groups of moth­ers (t(54) = 3.32, p < 0.0 I). Fathers in the two groups did notdiffer significantly on the BDI, A-Trait, or the PDQ. Table 2presents the means, S.D. and t tests values for the threemeasures.

Discussion

The results of the present study point to the usefulness ofthe PDQ in assessing parental anxiety in a pregnancy subse-

TABLE I. Correlations ofthe POQ with the BDI and the A-Trait forthe Loss and Nonloss Groups ofMothers and Fathers

CorrelationsParent Groups

801 A-Trait

NonlossMothers POQ 0.30 0.47--Fathers POQ 0.29 0.48--

LossMothers POQ 0.36 0.59--Fathers POQ 0.39 0.32

-- p < 0.01.

Mothers8D!A-TraitPOQ

Fathers8D!A-TraitPOQ

**p < 0.01.

Loss Group(N= 25)

X (S.D.)

10.04 (6.15)39.16 (6.39)32.84 (6.65)

8.04 (5.74)35.13 (6.96)30.21 (7.19)

NonlossGroup

(N= 31)

X (S.D.)

9.77 (3.87)36.77 (6.16)27.81 (4.68)

6.65 (5.19)37.23 (8.43)27.23 (5.46)

3.32**

291

quent to a perinatal loss. This study indicat~s t~at the PC?Qhas adequate internal consistency, correlates significantly Withthe A-Trait for all groups except fathers whose wives hadexperienced a previous pregnancy loss, and ditTerentiates be­tween mothers who had and had not experienced perinatalloss.

The results of this study corroborate clinical reports thatdescribe increased maternal anxiety in a pregnancy subse­quent to a perinatal loss. The finding that mothers in the twogroups ditTered on the POQ but not trait anxiety indicat~s

that perinatal loss in a middle-class sample of mothers IS

associated with specific rather than generalized anxiety duringa subsequent pregnancy. Thus, intervention by clinicianswould most appropriately address issues concerning the pre­vious loss and concerns about carrying the present pregnancyto term, rather than more general issues. If persistent anxietyand depression are present, clinicians should consider otherpsychological stressors as primary contributors.

The fathers in the loss and nonloss groups in the presentstudy did not ditTer significantly on the POQ, the BDI, or theA-Trait. Further, the POQ was not significantly correlatedwith the A-Trait for fathers in the loss group, although it wasin the nonloss group. Perhaps the fathers in the loss group areless influenced by perinatal loss during a subsequent preg­nancy. Alternatively, their reactions may be expressed in waysother than those assessed in the present study, or they may bedenying their emotional reactions. It is possible that fathersdeny their emotional reactions to a pregnancy loss in orderto be supportive of their wives. Perhaps this initial reaction issustained through the subsequent pregnancy and is reflectedby the present results.

The finding of the group ditTerence in the present studybetween mothers but not fathers according to perinatal historycan be understood through the psychodynamic literature ofpregnancy and perinatal loss. This literature raise~ the possi­bility that the early stages of attachment formation dunngpregnancy ditTerfor men and women.

Furman (1978) described the uniqueness of the mother­baby relationship and provided a basis for exploring themother's attachment to the baby. She noted that the baby isa part of the mother's body during gestation and is "invested

Appendix

Pregnancy Outcome Questionnaire (Mother)

Directions: The statements below have been made by women whoare pregnanl. After reading each statement. decide which response

292 THEUT ET AL.

best describes your present feelings. Then circle the appropriateletter next to each statement.

ReferencesBeck, A. T., Ward, C. H., Mendelson, M., Mock, J. E. & Erbaugh, J.

(1961), An inventory for measuring depression. Arch. Gen. Psy­chiatry, 4:561-571.

Benedek, T. (1970), The psychobiologic approach to parenthood. In:Parenthood-Its Psychology and Psychopathology, Part III, ed. E.J. Anthony & T. Benedek. Boston: Little, Brown, pp. 109-206.

Benfield, D. G., Leib, S. & Vollman, J. (1978), Grief response ofparents to neonatal death and parent participation in deciding care.Pediatrics, 62: 171-177.

Bourne, S. (1983), Psychological impact of stillbirth. The Practitioner,227:53-58.

Cronbach, L. J. (1951), Coefficient alpha and the internal structureof tests. Psychometrika, 16:297-334.

Furman, E. P. (1978), Death of a newborn: care of the parents. Birthand the Family Journal, 5:214-218.

Jolly, H. (1976), Family reactions to stillbirth. Proceedings RoyalSociety ofMedicine, 69:835-837.

Kennell, J. H., Slyter, H. & Klaus, M. H. (1970), The mourningresponse of parents to the death of a newborn infant. N. Engl. J.Med., 283:344-349.

Klaus, M. H. & Kennell, J. H. (1982), Parent-Infant Bonding, 2ndEd. St. Louis: C. V. Mosby.

Leon, L. G. (1986), Psychodynamics of perinatal loss. Psychiatry,49:312-323.

Lewis, E. (1979), Mourning by the family after a stillbirth or neonataldeath. Arch. Dis. Child., 54:303-306.

-- (1983). Psychological consequences and strategies of manage­ment. In: Advances in Perinatal Medicine, Vol. 3, ed. A. Milunsky& E. Fiedmen. London: Plenum, pp, 205-245.

May, K. A. & Perrin, S. P. (1985), Prelude: pregnancy and birth. In:Dimensions ofFatherhood, ed. S. H. Hansen & F. W. Saga. BeverlyHills, Cal.: Sage Press, pp. 64-91.

Spielberger, C. D., Gorsuch, R. L. & Lushene, R. E. (1970), STAIManual. Palo Alto, Cal.: Consulting Psychologists Press.

Stack, J. (1980), Spontaneous abortion and grieving. Am. Fam.Physician, 21:99-102.

Theut, S. K. (1985), Pregnancy after a fetal loss. Paper presented atthe American Orthopsychiatry Association meeting, New YorkCity.

I. I feel confident that my preg­nancy will proceed withoutany special problems.

2. I worry about whether mynervousness over this preg­nancy will have some effecton the outcome.

3. I feel worried about thehealth of my new baby.

4. During this pregnancy, Ihave been preoccupied aboutthe outcome.

5. I have hesitated to tell othersabout my pregnancy.

6. I feel that I am able to copewith the anxieties that havearisen from this pregnancy.

7. I am concerned aboutwhether my present preg­nancy will be normal.

8. I worry about whether I willbe able to bring this preg­nancy to term.

9. I feel overwhelmed becauseof the anxieties related to thispregnancy.

10. I worry about being able totake care of my new baby.

II. I feel confident that I havesome control regarding theoutcome of this pregnancy.

12. I am preoccupied thinkingabout my labor and delivery.

13. I feel assured that my babywill be healthy.

(4)AlmostAll TheTime

A

A

A

A

A

A

A

A

A

A

A

A

A

(3)Fre­

quent­Iy

B

B

B

B

B

B

B

B

B

B

B

B

B

(2)Occa­sion­ally

C

C

C

C

C

C

C

C

C

C

C

C

C

(I)

AlmostNever

D

D

D

D

D

D

D

D

D

D

D

D

D

14. I am cautious about makingpreparations for the newbaby (room, supplies, birthannouncement, etc.)

15. I have been extremely dili­gent about precautions dur­ing this pregnancy, e.g., withweight, sex, smoking, drink­ing, activity, diet.

A

A

B

B

C

C

D

D