The impact of a subsequent pregnancy on grief and emotional adjustment following a perinatal loss

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    INFANT MENTAL HEALTH JOURNAL, Vol. 20(2), 175187 (1999)Q 1999 Michigan Association for Infant Mental Health CCC 0163-9641/99/020175-13

    A R T I C L E

    THE IMPACT OF A SUBSEQUENT PREGNANCY ON

    GRIEF AND EMOTIONAL ADJUSTMENT

    FOLLOWING A PERINATAL LOSS

    RENE E-LOUISE FRANCHEOttawa Hospital - General site, University of Ottawa & Carleton University

    CATHY BULOWDepartment of Psychology, Mississauga Queensway Hospital

    ABSTRACT: The present study examined the impact of a subsequent pregnancy on emotional adjustmentassociated with a previous perinatal loss and on the following components of parental griefactive grief,difficulty coping, despair. Participants included 25 women and 24 partners who were expecting a babyfor the first time since their loss and 25 women and 18 partners who were not expecting and had not hada child or pregnancy after their loss. Depressive symptomatology, anxiety, marital adjustment, as well asactive grief, despair, and difficulty coping were measured. Mothers who were not pregnant were expe-riencing significantly higher levels of despair and difficulty coping than pregnant mothers, independentlyfrom the effect of time elapsed since the loss. For the fathers, no significant group effect in emotionaldistress or intensity of grief was found. Women reported significantly higher levels of negative affectivitythan men. A new pregnancy may be associated with a beneficial effect on the mourning process of womenwith a previous perinatal loss, primarily by decreasing their despair and difficulty coping. However, inour sample, grief intensity remained high, suggesting that the mourning process may not be hindered bya subsequent pregnancy.

    RESUMEN: El presente estudio examina el impacto que un embarazo subsecuente tiene en cuanto al ajusteemocional asociado con una previa perdida perinatal, as como en los consiguientes componentes depena-pena activa, dificultad en el enfrentamiento con situaciones, y la desesperacon,

    Entre los participantes se encontraban 25 mujeres y 24 de sus parejas que esperaban un nino porprimera vez desde que haban experimentado la perdida, y 25 mujeres y 24 de sus parejas que no estabanesperando y no haban tenido ningun nino ni haban experimentado un embarazo despues de la perdida.Se midieron la sintomatologa depresiva, la ansiedad, el ajuste marital, as como la pena activa, la de-sesperacion y la dificultad de enfrentarse con situaciones,

    Las madres que no estaban embarazadas estaban experimentando niveles significativamente masaltos de desesperacion y dificultad de enfrentarse con situaciones que las madres embarazadas, indepen-dientemente del efecto del tiempo transcurrido desde la perdida. En cuanto a los padres, no se encontroningun efecto significativo como grupo en cuanto a trastornos emocionales o a la intensidad de la pena.Las mujeres reportaron niveles significativamente mas altos de afectividad negativa que los hombres.

    This study was funded by the Ministry of Health of Ontario and by the Ottawa General Hospital Research Foundation.We wish to thank the staff of the Ottawa General Hospital Perinatology and Obstetrics clinics for their cooperationin the recruitment of participants. Address correspondence to: Dr. Renee-Louise Franche, Department of Psychology,Ottawa Hospital-General site, 501 Smyth Road, Ottawa, ON, Canada, K1H 8L6.

  • 176 c R.-L. Franche and C. Bulow

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    cap heightbase of textUn nuevo embarazo pudiera estar asociado con un efecto beneficioso en el proceso de afliccion de

    las mujeres con una perdida perinatal prvia, sobretodo porque alivia su desesperacion y la dificultad deenfrentarse con situaciones. Sin embargo, en la muestra de este estudio, la intensidadde la pena permaneciosiendo alta, lo cual sugiere que el proceso de afliccion pudiera no ser afectado o entorpecido por unembarazo subsecuente.

    RE SUME : Cette etude examine limpact dune grossesse subsequente sur lajustement emotionnel associea` une perte perinatale ayant precede et sur les composants suivants de deuil parentaldeuil actif, difficultea` faire face, desespoir. Les participants comprenaient 25 femmes et 24 partenaires qui attendaient un bebepour la premie`re fois depuis la perte et femmes et 18 partenaires qui nattendaient pas denfant et quinavaient pas eu denfant ni de grossesse apre`s leur perte. La symptomatologie depressive, lanxiete,lajustement conjugal, ainsi que le deuil actif, le desespoir et la difficulte a` faire face ont ete measures.Les me`res qui netaient pas enceintes avaient des niveaux de desespoir bien plus eleves et bien plus dedifficulte a` faire face que les me`res enceintes, independamment de leffet du temps ecoule depuis la perte.Pour les pe`res, aucun effet de groupe significatif de detresse emotionnelle ou dintensite de deuil na etetrouve. Les femmes ont fait etat de niveaux plus eleves daffectivite negative que les hommes. Unenouvelle grossesse peut etre associee a` un effet benefique sur le processus de deuil des femmes ayantsubi une perte perinatale, essentiellement en reduisant leur desespoir et leur difficulte a` faire face. Ce-pendant, dans notre echantillon, lintensite du deuil demeurait haute, suggerant que le processus de deuilpourrait ne pas etre gene par une grossesse subsequente.

    ZUSAMMENFASSUNG: Die vorliegende Studie untersuchte die Bedeutung einer weiteren Schwangerschaftauf die gefuhlsmaige Anpassung nach einem Verlust rund um die Geburt und auf die folgende Kom-ponenten der elterlichen Traueraktive Trauer, schwierige Bewaltigung, Verzweiflung.

    Es wurden 25 Frauen und 24 Partner, die nach einem Verlust zum ersten Mal ein Baby erwartetenund 25 Frauen und 18 Partner eingeschlossen, die weder ein Kind erwarteten, noch seit dem Verlust einBaby bekommen hatten, noch eine Schwangerschaft seither durchgemacht hatten, untersucht. Es wurdengemessen: depressive Symptomatologie, Angst, eheliche Anpassung, aktive Trauer, Verzweiflung unddie Schwierigkeiten der Bewaltigung. Unabhangig von der verstrichenen Zeit waren Mutter, die keinKind erwarteten verzweifelter und hatten mehr Schwierigkeiten der Bewaltigung, als die schwangerenFrauen. Bei den Vatern wurden keine Unterschiede bei der gefuhlsmaigen Belastung, oder der Intensitatder Trauer gefunden. Frauen hatten generell signifikant mehr negativen Gefuhle, als Manner.

    Eine neue Schwangerschaft kann einen positiven Effekt auf den Proze der Trauer nach einemvorangegangenen Verlust rund um die Geburt habenvor allem indem es die Verzweiflung und dieSchwierigkeiten der Bewaltigung reduziert. Jedoch war es in unserer Stichprobe so, da die Trauerintesitathoch blieb. Das weist darauf hin, da der Trauerproze durch eine folgende Schwangerschaft nicht be-hindert werden mu.

    * * *

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    cap heightbase of textIt is now well established that a perinatal loss constitutes a significant loss in ones life,

    frequently involving a period of mourning (Benfield, Leib, & Reuter, 1978; Kennell, Slyter,& Klaus, 1970; Lasker & Toedter, 1991; Peppers & Knapp, 1980). The mourning processassociated with a perinatal loss can be conceptualized as consisting of three factors; activegrief, difficulty coping, and despair (Lasker & Toedter, 1991). Despair and difficulty copingare less common reactions compared with active grief, and are associated with more disturbedand chronic reactions to perinatal loss (Potvin, Lasker, & Toedter, 1989). Higher levels ofdespair and difficulty coping at 2 months postloss have significantly predicted the presence ofhigher levels of grief 2 years after the loss (Lasker & Toedter, 1991).

    Perinatal loss also involves emotional distress. Bereaved parents can report depression(Garel, Blondel, Lelong, & Kaminski, 1994; Neugebauer et al., 1992), suicidal ideation (De-frain, Martens, Stork, & Stork, 1986), self-criticism (Giles, 1970; Herz, 1984), and anxiety(Cecil & Leslie, 1993; Thapar & Thapar, 1992).

    Several factors are related to the intensity of grief and emotional adjustment following aperinatal loss. Gender is related to grief intensity as women, compared to men, tend to reporthigher levels of grief, guilt, and personal responsibility (Goldbach, Dunn, Toedter, & Lasker,1991; Theut, Pedersen, Zaslow, & Rabinovich, 1988). However, it should be noted that in onestudy (Zeanah, Danis, Hirshberg, & Dietz, 1995), in 25% of participating couples, fathersreported more intense grief than mothers. Gestational age at the time of the loss is also relatedto the intensity of grief. Late losses are associated with more intense grief (Janssen, Cuisinier,de Graauw, & Hoogduin, 1997; Kirkley-Best, 1981; Lasker & Toedter, 1991; Theut et al.,1989; Toedter, Lasker, & Alhadeff, 1988) and more persistent active grief (Lasker & Toedter,1991) than early losses. In one study, however, no differences were found in grief intensity inlosses occurring after 20 weeks of gestation (Zeanah et al., 1995). Less intense grief has beenassociated with a strong marital relationship and sufficient social support (Lasker & Toedter,1991), good premorbid mental health status (Janssen, Cuisinier, Hoogduin, & de Graauw, 1997;Lasker & Toedter, 1991; Toedter et al., 1988), and parents positive perceptions of their ownphysical health (Toedter et al., 1988). One factor that has received little attention is whetheror not a subsequent pregnancy affects the mourning process.

    THE IMPACT OF A SUBSEQUENT PREGNANCY ONTHE EXPERIENCE OF MOURNING

    Parents often wish to have another pregnancy soon after their loss (Cuisinier, Janssen, deGraauw, Bakker, & Hoogduin, 1996) and they express dissatisfaction with advice to wait,citing pressing concerns such as maternal age, infertility issues, and preferred spacing of chil-dren (in age) as reasons not to wait (Davis, Stewart, & Harmon, 1989). While a perinatal losscan impact upon a subsequent pregnancy causing it to be considered a stressful and joylesstask of keeping the baby (Franche & Mikail, 1999; Phipps, 1985; Theut et al., 1989), it ispossible that a reciprocal relationship exists in that a subsequent pregnancy also impacts uponthe experience of mourning (Lin & Lasker, 1996; Theut et al., 1989).

    It has been suggested that a speedy pregnancy can cause the mourning process to bediscontinued or thwarted, possibly leading to problems in attachment to the subsequent baby(Bourne & Lewis, 1984; Lewis, 1979; Lewis & Page, 1978). Difficulties hypothesized to berelated to chronic, unresolved grief include (1) the 0vulnerable child syndrome0 (Green &Solnit, 1964), where the couple may become overprotective of the subsequent baby possiblyresulting in separation/ individualization issues, infantilization, and/or preoccupation with so-matic concerns (Phipps, 1985) and (2) the 0replacement child syndrome0 (Cain & Cain, 1964;Poznanski, 1972), where the parents perceive the subsequent child as a replacement for thebaby lost. These syndromes are based primarily on clinical observations.

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    cap heightbase of textTheut and colleagues (Theut, Pedersen, Zaslow, et al., 1988) hold a somewhat alternative

    position. They suggest that a subsequent pregnancy may contribute to the resolution of perinatalgrief by improving self-concept. For a woman, 0pregnancy is an opportunity to mitigate hernarcissistic loss and to assuage her guilt over the previous loss0 (Theut et al., 1988, p. 291).

    Few empirical studies have considered the impact of a subsequent pregnancy on thecouples grief and emotional adjustment. In one study (Theut et al., 1989), participants com-pleted the Perinatal Bereavement Scale during the eighth month of the pregnancy and 6 weekspostnatally. Results suggested that the birth of a healthy baby was a significant factor in theresolution of grief for couples with early or late losses.

    In a recent longitudinal study (Cuisinier et al., 1996), 227 women who lost a baby earlyin their pregnancy were asked to complete the Perinatal Grief Scale at 2.5, 6, 12, and 18 monthspostloss. In this sample, 87% of the women had lost their baby within the first 16 weeks ofgestation. The conception of a child and the birth of a living child following a perinatal losswere associated with a significant decrease in the total level of grief reported. Furthermore, asubsequent pregnancy decreased the severity of grief to the equivalent of the passage of 8months of time after a loss. A speedy new pregnancy was seldomly found to be harmful.

    Finally, Lin and Lasker (1996) followed 194 bereaved parents (138 women and 56 men)over a period of 2 years. The Perinatal Grief Scale was administered at 3 months, 1 year, and2 years following the loss. Variables related to a significant decrease in total grief intensityincluded subsequent birth, subsequent pregnancy, and the presence of other children. Thesethree studies suggest that a subsequent pregnancy does reduce perinatal grief. However, it isunclear which aspects of grief are most significantly reduced. The present study was designedto examine the impact of a subsequent pregnancy on grief, emotional adjustment, and maritaladjustment following a perinatal loss. Of particular interest was the impact of a subsequentpregnancy on the different components of grief. This study extends the literature as it is, to ourknowledge, the first study that examines active grief, difficulty coping, and despair in associ-ation with subsequent pregnancy. Previous studies have examined the total score only of thePerinatal Grief Scale (Cuisinier et al., 1996; Lin & Lasker, 1996) or used a unidimensionalmeasure of grief (Theut et al., 1989). Understanding the impact of a subsequent pregnancy onspecific aspects of grief and emotional distress can help professionals address patients concernsin a more precise fashion.

    METHOD

    Participants

    Women and their partners who had suffered a perinatal loss within the last 3 years wererecruited to participate in the study. They were either pregnant for the first time since the loss(Pregnant Loss group) or were not pregnant and had not been expecting again since their loss(Loss group). Exclusion criteria included previous or current psychotic disorder, current sub-stance abuse, and inability to speak or read English.

    Procedure

    Announcements concerning the study were posted in obstetrical clinics in a large Canadianuniversity hospital. Recruitment for the Pregnant Loss group occurred between the 10th and19th week of gestation, while recruitment for the Loss group occurred at their 6th week post-partum visit. Eligible women were asked by health-care staff if they were interested to learnmore about the study. If interest was expressed, they immediately met with a research assistantwho explained what participation involved. Partners were then encouraged, either by direct

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    cap heightbase of textcontact or through the woman (if the partner was not present at the visit), to participate. Women

    and partners willing to participate were asked to complete a battery of questionnaires. Couplestypically chose to complete the questionnaires at home and returned them by mail. They werethen called by the research assistant for debriefing and to offer emotional support if appropriate.Eligible partners included husbands, common-law partners, and boyfriends, who were the fatherof the baby. All participants were able to contact the main investigator or the research assistantif they had any questions.

    Of the patients who were approached, the acceptance rate was 88 and 100% for the Preg-nant Loss and the Loss groups, respectively. Some participants from the Loss group, however,asked to be called several months later after the initial contact as they did not feel ready toparticipate. After consenting to participate, three couples in the Pregnant Loss group and fivecouples in the Loss group did not return the questionnaires. Some of them expressed that theyfound it too painful or unpleasant to think about their perinatal loss. The final sample consistedof 25 women in each group, 24 men in the Pregnant Loss group, and 18 men in the Loss group.Final participation rate of approached female patients was 78 and 83% for the Pregnant Lossgroup and the Loss group, respectively. For the men (who were eligible only if their wives/partners initially consented to participate), the participation rate was 86 and 60% for the Preg-nant Loss group and the Loss group, respectively.

    Participating men and nonparticipating men were compared using Chi-Square or t-tests(adjusted for unequal sample size) with respect to the following demographic and obstetricalvariables: education, marital status, length of marital or common-law relationship, birthplace,family income, language spoken, number of losses, gestational age at time of loss, number ofliving children, and length of time since the loss. No significant differences were found. Ma-ternal reports of marital adjustment, depressive symptomatology, grief symptoms, and anxietywere also examined. Couples in which the man did not participate had maternal reports ofmarital adjustment that were significantly poorer than couples in which both parents partici-pated (t 5 3.24, p , .011).

    Sample Characteristics

    The age of the participants ranged from 20 years to 41 years for mothers (M 5 31.48,SD 5 4.95), and 26 years to 51 years for fathers (M 5 34.67, SD 5 6.27). Participants werehomogeneous with respect to ethnicity and spoken language; 96% were born in Canada, 42%spoke English only, and 50% spoke English and French. Eighty-two percent of the coupleswere married and 18% were living common-law. None of the female participants were singlein this study. Total annual household income for 68% of the sample exceeded $40,000 (CAN).Length of maternal formal education ranged from 9 to 18 years (M 5 14.44, SD 5 2.60 ) andlength of paternal education ranged from 12 to 18 years (M 5 15.60, SD 5 1.85).

    Characteristics of the Pregnant Loss GroupThe mean gestational age at which the pregnant group lost their child was 25.24 weeks(SD 5 9.92, range 5 10 weeks to 41 weeks). Eighty-eight percent of the couples lost theirbaby after 15 weeks of gestation. The mean duration of time since the pregnancy loss was13.28 months (SD 5 8.85, range 5 4 to 36 months). The mean time between the loss andsubsequent conception was 9.55 months (SD 5 8.90, range 5 1 to 31.5 months). Eighty-eightpercent of the couples noted that their current pregnancy was planned.

    Characteristics of the loss group. The mean gestational age at which the nonpregnant grouplost their child was 27.72 weeks (SD 5 9.29, range 5 10 weeks to 42 weeks). Ninety-six

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    cap heightbase of textpercent of the couples lost their baby after 15 weeks of gestation. The mean duration of time

    since the pregnancy loss was 5.76 months (SD 5 4.82, range 2 to 19 months).Participants were asked to complete the following questionnaires:

    Beck Depression Inventory (BDI; Beck, Steer, & Garbin, 1988). The total score of this 21item measure of depressive symptomatology was used. Beck and colleagues (1988)reported an internal consistency of .86 and test-retest reliability ranging from .48 to.86 for varying time intervals. The BDI demonstrates moderate to good correlationswith several other scales assessing depression (Dobson, 1985).

    State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, & Lushene, 1984). The STAIis a self-report measure of state and trait anxiety levels. Only the State Anxiety subs-cale (STAIS) was used in the current study. The STAIS has a high degree of internalconsistency, ranging from .83 to .92 (Spielberger et al., 1984).

    Abbreviated Dyadic Adjustment Scale (ADAS; Sharpley & Rogers, 1984). The ADAS isa seven-item questionnaire assessing marital adjustment. Internal consistency was re-ported to be 0.76 (Spanier, 1976). The ADAS adequately discriminates between per-sons who in their perception were happy with their relationship and those who werenot, as well as between married and divorced couples (Sharpley & Rogers, 1984).

    Perinatal Grief Scaleshort form version (PGS; Potvin et al., 1989; Toedter et al., 1988).The PGS scale was designed to assess general symptoms of grief as well as symptomsthought to be especially relevant to a perinatal loss. The three factors of Active Grief(PGS-AG), Difficulty Coping (PGS-DC), and Despair (PGS-D) are derived from afactor analysis of descriptors of perinatal grief generated by 194 bereaved parents(Lasker & Toedter, 1991). The short form version consists of three 11-item subscalescorresponding to the three grief components. The total scale internal consistency co-efficient is 0.95; for the subscales of Active Grief, Difficulty Coping, and Despair, thealpha coefficients are 0.92, 0.91, and 0.86, respectively. The three subscales also showadequate discriminant validity (Lasker & Toedter, 1991).

    All participants completed a personal information form assessing basic demographics,circumstances of perinatal loss, and, if applicable, of present pregnancy.

    RESULTS

    Preliminary Analyses

    Dependent variables were examined for potential multicollinearity. The three PGS subscales werehighly correlated, however, they were kept in the analyses as they are meant to be examinedjointly despite high intercorrelation (Potvin et al., 1988; Toedter et al., 1988) (see Table 1).

    TABLE 1. Correlations Between Active Grief,Difficulty Coping, and Despair

    Active Grief Difficulty Coping Despair

    Active grief .74(p 5 .000)

    .69(p 5 .000)

    Difficulty coping .84(p 5 .000)

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    TABLE 2. Groups (Pregnant Loss vs. Loss) by Gender Means and StandardDeviations for the Dependent Variables

    Mothers

    Pregnant Loss M(SD) Loss M(SD)Fathers

    Pregnant Loss M(SD) Loss M(SD)

    Depressive Symptoms (BDI)10.00 (6.36) 14.00 (8.66) 7.75 (7.43) 6.44 (4.57)

    State-Trait Anxiety Inventory-State (STAIS)43.32 (14.48)(70th percentile)

    46.76 (13.30)(83rd percentile)

    39.63 (14.27)(52nd percentile)

    36.28 (11.33)(33rd percentile)

    Dyadic Adjustment (ADAS)24.48 (5.15) 25.52 (7.50) 24.71 (4.78) 26.00 (2.75)

    Perinatal Grief Scale-Active Grief (PGS-AG)36.32 (8.64) 39.64 (8.04) 32.09 (7.47) 32.22 (5.26)

    Perinatal Grief Scale-Difficulty Coping (PGS-DC)25.56 (10.20) 29.88 (10.42) 22.61 (7.64) 23.39 (6.57)

    Perinatal Grief Scale-Despair (PGS-D)21.76 (7.68) 25.72 (8.63) 19.96 (6.30) 19.50 (5.48)

    Standard deviations are in brackets in all tables.

    One-way analysis of variance (ANOVA) and Chi-square analyses were conducted to de-termine whether the two groups differed on variables that have been found to influence grieflevels. A Chi-square analysis showed no group differences in marital status. One-way ANOVAsrevealed no significant group differences in gestational age at the time of the loss, number ofliving children, income level, age of mother and father, and number of previous losses. How-ever, a significant group difference was observed for the duration of time elapsed since theloss (F 5 28.12, p , .001). The Loss group, compared with the Pregnant Loss group, had losttheir baby more recently. As this variable may contribute to the intensity of emotional distressand grief, it was entered as a covariate, where applicable, in the main analyses examining groupdifferences.

    Main Analyses

    A series of multivariate analyses of variance (MANCOVAs) and univariate tests were con-ducted to compare the levels of emotional adjustment and grief between the Pregnant Lossgroup and the Loss group. The analyses were conducted separately for men and women. Aseries of MANOVAs were then performed examining gender differences across the two groupsfor emotional adjustment and grief levels. Significant multivariate analyses were followed byunivariate analyses using the Bonferroni correction. The mean scores and standard deviationsfor the BDI, STAIS, ADAS, and PGS for both groups are presented in Table 2.

    Group differences for women. To examine group differences in emotional adjustment in moth-ers, a MANCOVA was performed using scores on the ADAS, BDI, STAIS as dependentmeasures, with the effect of the time elapsed since the loss covaried out. A significant multi-variate group effect was found (F 5 2.79, p , .05). Using the Bonferroni correction (level ofsignificance, p 5 0.017), univariate tests did not reveal any significant group difference in BDI,

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    TABLE 3. Summary of MANCOVA and Univariate Tests Examining Perinatal Grief of Women with aPrevious Loss Occurring at or after 20 Weeks of Gestation, with Time Since the Loss as a Covariate

    MANCOVADependent Variables F (p)

    PGS-Active griefPGS-Difficulty copingPGS-Despair 2.24 0.10

    Univariate F-TestsDependent Variables Pregnant Loss Adjusted Means Loss Adjusted Means F (p)

    PGS-Active grief 36.62 41.02 2.27 nsPGS-Difficulty coping 24.88 33.01 4.90 .033PGS-Despair 20.87 28.47 7.00 .012

    STAIS, or ADAS scores. However, a trend (F 5 4.47, p , .04) was found for the Loss groupto have higher scores on the BDI than the Pregnant Loss group. It should be noted howeverthat levels of depressive symptomatology remained low for both groups. The mean BDI scorefor the Pregnant Loss group was within normal limits according to recommended guidelines(Beck et al., 1988), while the mean BDI score for the Loss group was in the minimal to moderaterange of depressive symptomatology. As well, the ADAS scores for all groups were within 1standard deviation of the mean for married couples (Sharpley & Rogers, 1984).

    A second MANCOVA compared levels of grief of mothers in both groups using scoreson the PGS subscales as dependent variablesActive Grief, Difficulty Coping, and Despair.The effect of the time elapsed since the loss was partialed out. A significant multivariate groupeffect was found (F 5 2.91, p , .05). Univariate tests (significance level, p 5 0.017) revealedthat scores were significantly higher for the Loss group as compared to the Pregnant Loss groupon the Despair (F 5 8.58, p , .005) and Difficulty Coping (F 5 7.76, p , .008) subscales.A trend (F 5 4.33, p , .04) in the same direction was found for the Active Grief subscale.

    Given that later losses are typically associated with more intense and persistent grief, apost hoc analysis was conducted to determine whether the above group differences in despairand difficulty coping would remain significant in women with late losses. The MANCOVAwas repeated in women whose losses had occurred at or after 20 weeks of gestation. Therewere 20 women in the Pregnant Loss group and 22 women in the Loss group. Despite theabsence of a significant multivariate group effect, univariate tests were interpreted due to theexploratory nature of the analysis (Tabachnik & Fidell, 1983, pp. 250251) and without theuse of Bonferroni correction due to the small number of participants involved. Despair andDifficulty Coping subscales remained significant (see Table 3).

    Group differences for men. For the fathers, two MANCOVAS were performed examininggroup differences in levels of grief and emotional adjustment. No significant group effects inemotional adjustment or intensity of grief were found.

    Gender differences. Differences in emotional adjustment between women and men were ex-amined using a MANOVA, with scores on the ADAS, BDI, and STAIS as the dependentmeasures. Results of the analysis revealed a significant multivariate gender effect (F 5 4.83,

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    cap heightbase of textp , .004). Univariate tests (significance level, p 5 0.017) revealed that women, compared to

    men, reported significantly higher levels of depression (F 5 12.23, p , .001) and state anxiety(F 5 7.02, p , .009).

    A MANOVA was also conducted comparing levels of grief between women and men,with scores on the PGS-AG, PGS-D, and PGS-DC as dependent variables. Results of theMANOVA revealed a significant multivariate gender effect (F 5 5.15, p , .05). Univariatetests (significance level, p 5 0.017) showed that women reported higher levels of grief thanmen on the three PGS subscales and significantly so for Active Grief (F 5 15.94, p , .000)and Difficulty Coping (F 5 8.04, p , .006). There was a trend in the same direction forDespair (F 5 4.99, p , .028).

    DISCUSSION

    Pregnant women with a previous perinatal loss experienced less despair and difficulty copingin their grief reactions than women who had a perinatal loss and had not subsequently becomepregnant. In contrast, expecting bereaved fathers did not report lower levels of grief intensity,anxiety, or depressive symptomatology that those who were not expecting. Furthermore, moth-ers, compared with fathers, experienced higher levels of active grief, difficulty coping relatedto the grief, anxiety, and depressive symptomatology.

    Lower levels of despair and difficulty coping are known to predict less chronic grief, bettercoping skills and improved self-esteem (Lasker & Toedter, 1991). Our findings suggest that anew pregnancy may be associated with a restorative effect for women with a previous perinatalloss. Indeed, a subsequent pregnancy may help to improve a womans perception of herself bymoderating the narcissistic injury and despair. However, due to the studys cross-sectionaldesign, we cannot eliminate the possibility that women with initially lower grief intensity feltmore ready to attempt a new pregnancy or, for psychophysiological reasons, were more phys-ically able to conceive.

    Results concerning women with losses occurring after 20 weeks suggest that the potentialbeneficial effects of a subsequent pregnancy also hold true for women with late losses. How-ever, these results need to be considered with caution, as more relaxed criteria of interpretationwere applied.

    A common apprehension among professionals working with bereaved parents is that asubsequent pregnancy could lead to a suspension or discontinuation of the grieving processand to the development of a subsequent maladaptive parentchild relationship. The presentdata suggests that grief does continue despite a subsequent pregnancy. In pregnant motherswith a previous loss, although we observed a decrease in active grief, the grief remained high.Moreover, the additive score of the mean of the three PGS subscales remained above 60 (ona scale with a minimal score of 33) for both parents in both groups, which has been consideredindicative of continued mourning (Lin & Lasker, 1996). Consequently, the grief process didnot appear to be hindered by a subsequent pregnancy.

    It is important to consider our results concerning couples in which the man chose not toparticipate: they suggest that these couples may have been less well adjusted than coupleswhere both partners participated. One cannot eliminate the possibility that for a small groupof parents, possibly those who choose not to participate to studies on perinatal loss, a subsequentpregnancy could represent a significant obstacle to continued mourning. In a previous studyon perinatal loss, participants tended to be psychologically healthier than those refusing toparticipate (Zeanah et al., 1995).

    A subsequent pregnancy was not associated with significant changes in levels of depressive

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    cap heightbase of textsymptoms and state anxiety of bereaved parents. Women and men in both groups reported low

    levels of depressive symptoms. Women in both groups reported high levels of state anxiety.The severity of this anxiety response in pregnant and nonpregnant bereaved women may bedue to the unexpected impact of their griefthey may feel overwhelmed by the magnitude oftheir reaction.

    Despite similar levels of maternal state anxiety, the sources of that anxiety may vary. Theanxiety of bereaved mothers who are not pregnant may be related to the fear of not becomingpregnant again. In contrast, studies have shown that following a perinatal loss pregnant be-reaved mothers report more anxiety specifically concerning the outcome of their pregnancythan pregnant women with an unremarkable obstetrical history (Franche & Mikail, in press;Theut et al., 1988). However, in these studies, no significant differences were observed betweenpregnant women with and without a previous loss in terms of their high levels of state anxiety,measured between the 10th and 24th week of gestation (Franche & Mikail, in press) and traitanxiety, measured at 8-month gestation (Theut et al., 1988). These findings point to the distinctconcepts captured by state-, trait-, and pregnancy-specific anxiety that may have very differentrelationships among each other in expecting, expecting and bereaved, and bereaved popula-tions.

    Expecting and nonexpecting bereaved parents reported levels of marital adjustment thatwere within the normal range. However, the generalizability of these results is limited by thefact that fathers who did not participate were in couples where maternal rating of maritaladjustment was significantly lower than in couples where both partners participated. Partici-pation of fathers was also much lower in the Loss group than in the Pregnant Loss group,suggesting that there may be differences in marital adjustment between expecting and nonex-pecting parents, which the study did not capture. Current literature indicates that marital ad-justment may be a relatively stable phenomenon, best predicted by previous marital adjustment.Previous research also indicates that perinatal loss is not a greater risk factor for marital distressthan having a live healthy birth (Mekosh-Rosenbaum & Lasker, 1995) and that the best pre-dictor of marital adjustment following a perinatal loss is the level of marital adjustment im-mediately prior to the loss (Gottlieb, Lang, & Amsel, 1996; Lang, Gottlieb, & Amsel, 1996).However, these studies may have suffered from the same bias as the one of the current studyand couples who were distressed about their marital life may have been less likely to participate.

    The finding that the subsequent pregnancy was not associated with any changes in thegrief intensity of men, as it was for women, suggests that there are gender differences in howthe subsequent pregnancy is perceived. It has been suggested that the lost baby is perceivedby the mother as part of herself (Furman, 1978) and that grief is unique for a mother in thatshe is mourning part of herself. In contrast, for a father, the separateness of the baby fromoneself is possibly more clearly distinguished (Furman, 1978; Leon, 1992; Theut et al., 1988).Accordingly, a new pregnancy may not restore mens perception of self in the same way as itdoes for women (Theut et al., 1988).

    Gender differences in levels of overall grief have been attributed to the different courseof prenatal attachment to the baby in women and men. It is proposed that fathers attachmentlags slightly behind mothers earlier during pregnancy and that the gap is gradually reducedas birth approaches (Goldbach et al., 1991; Peppers & Knapp, 1980). Gender differences havebeen documented in self-reported prenatal attachment (Weaver & Cranley, 1983; Zeanah, 1989)as well as in reported prenatal ability to interact with the fetus (Stainton, 1985).

    Gender differences may be related to differences in socially sanctioned expressions of grieffor women and men. The active expression of grief, such as crying about the loss, is moresocially acceptable for women than for men. Men may tend to suppress or deny their grief(Zeanah, 1989), especially in the presence of their grieving partner. It is interesting that in our

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    cap heightbase of textstudy, the most salient gender differences were for active grief and difficulty coping. These

    components of grief may be thought of as more readily observable components of perinatalgrief than the despair component that refers to more covert beliefs.

    Men may not express grief in the same manner as women. A previous study found thatsalient grief symptoms for mothers included sleep problems, depression, anorexia, weight loss,social withdrawal, guilt/anger/hostility, morbid preoccupation with baby, and psychosomaticsymptoms; salient symptoms of grief for fathers included an inability to work, guilt, anger,hostility, denial of death, alcohol abuse, and social withdrawal (Tudehope, Iredell, Rodgers, &Gunn, 1986).

    Gender differences may also be related to the limited availability of perinatal grief mea-sures. The PGS was developed and validated on a sample comprised mainly of women (women,n 5 138; men, n 5 56), thereby limiting its sensitivity to mens experiences of grief . Thedegree to which fathers lower grief scores after a loss are due to differences in attachmentand/or to gender related differences in the expression of grief should therefore be furtherexplored using a grief measure developed and validated on a larger sample of men.

    Several shortcomings of this study require mention. The sample size was small, limitingthe number of variables that could be considered for each analysis. The homogeneity of par-ticipants with respect to socioeconomic level, the relatively lower rates of participation in theLoss group, as well as the documented difference in marital adjustment of participants versusnonparticipants, limit the generalizability of the findings.

    In addition, some of the measures used in this study limited the interpretations of thefindings. The BDI, similar to other measures of depressive symptomatology, includes severalitems of somatic symptoms that can be signs of depression and normal physical changes as-sociated with pregnancy. As well, norms for the PGS at this time are limited. Interpretation ofscores on this scale would be improved by norms for gestational age at loss, time since loss,and gender.

    The studys cross-sectional design limited the ability to establish direction of effects be-tween emotional health and ability or choice to conceive. Only a prospective longitudinaldesign, where intent and attempt to conceive were monitored, could provide additional insightinto these questions.

    The impact of a subsequent pregnancy following a perinatal loss remains an importantissue in obstetrical care. The results of this study support the idea that, for most women, asubsequent pregnancy could have a significant positive impact on psychological adjustment,by helping to reduce grief intensity. While pregnant mothers continue to grieve their loss, asubsequent pregnancy is associated with lower levels of despair and difficulty coping, thecomponents of grief associated with a more chronic and complicated form of grief. This in-formation, offered to couples considering or beginning a pregnancy after a loss, may help toalleviate their anxieties about their level of readiness for a subsequent pregnancy and their fearof not adequately mourning the lost pregnancy.

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