THE RELATIONSHIP OF ATTACHMENT THEORY AND PERINATAL LOSS

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  • This article was downloaded by: [University of California, SanFrancisco]On: 19 August 2014, At: 09:25Publisher: RoutledgeInforma Ltd Registered in England and Wales RegisteredNumber: 1072954 Registered office: Mortimer House, 37-41Mortimer Street, London W1T 3JH, UK

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    THE RELATIONSHIP OFATTACHMENT THEORYAND PERINATAL LOSSMargaret Robinson, Lisa Baker, LarryNackerudPublished online: 11 Nov 2010.

    To cite this article: Margaret Robinson, Lisa Baker, Larry Nackerud(1999) THE RELATIONSHIP OF ATTACHMENT THEORY AND PERINATALLOSS, Death Studies, 23:3, 257-270, DOI: 10.1080/074811899201073

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  • ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` `

    THE RELATIONSHIP OF ATTACHMENT THEORYAND PERINATAL LOSS

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    MARGARET ROBINSON, LISA BAKER, and LARRY NACKERUD

    University of Georgia, Athens, GA, USA

    Perinatal loss has recently received attention in the literature that presents it asdierent f rom other types of losses. Perinatal loss, or the loss of an inf ant due tomiscarriage, stillbirth, or neonatal death, is a signi cant problem that may be bestunderstood when viewed through the f ramework of attachment theory. Recentadvances in medical technolog y, including prenatal diagnostic procedures andresulting decisions have inuenced issues of both perinatal attachment and loss, andhave provided challenges f or the clinician. This article presents a review of currenttheories and research on attachment and perinatal loss, and discusses how knowledg egained from this research may be integrated into clinical practice.

    The issue of perinatal loss and ways of intervening with familieswho are experiencing such a loss has recently received much atten-tion in professional literature ( Findeisen, 1993; Leon, 1992a;Madden, 1994; Malacrida, 1997; McDermott-Shaefer, 1992;Smith & Borgers, 1988; Theut, Pederson, Zaslow, & Rabinovich,1988; Zeunah, 1989) . Prior to 1970, there was little research on theissue of perinatal loss, and the knowledge base today, althoughgrowing, continues to be limited. Since the publication in 1969 ofAttachment, Separation, and Loss, by John Bowlby, there has been anincrease in the literature related to theories of attachment, or theemotional bond between parents and their child. Whereas much ofthe literature concentrates on the neonatal period, the perioddirectly after birth ( Bowlby, 1969 ; Klaus & Kennell, 1976;Peppers & Knapp, 1980; Sugarman, 1977) , attachment during

    Address correspondence to Dr. Margaret Robinson, 312 Tucker Hall, School of SocialWork, University of Georgia, Athens, GA 30602-7016.

    Death Studies, 23 : 257270, 1999Copyright 1999 Taylor & Francis

    0748-1187/99 $12.00 1 .00 257

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  • 258 M . Robinson et al.

    pregnancy, or prenatal attachment is also addressed (Cecil, 1996;Ganey, 1988; Kemp & Page, 1987; Mercer, Ferketich, May,DeJoseph, & Sollid, 1988; Muller, 1992; Rubin, 1975) . Thisarticle examines research on parent and child attachment as afoundation for understanding the relation between attachment andperinatal loss. It will be argued that knowledge on individualattachment can provide insight into the complexity of perinatalgrief reactions for families, thus guiding intervention. The impactof medical technology on attachment theory will also be discussed,along with recommendations for implementing knowledge ofattachment in clinical practice.

    Scope of Perinatal Loss

    Although it is difficult to nd exact numerical data on perinatalloss due to variances in operational de nitions, available statisticsdo provide a framework for understanding the scope of perinatalloss. Perinatal loss includes the loss of an infant due to miscarriage,stillbirth, or neonatal death. Malacrida ( 1997) enlarged this de ni-tion to include death of an infant from pregnancy complications,prematurity, stillbirth, or complications within the rst month oflife.

    In 1991, more than 35,900 perinatal deaths occurred in theUnited States alone, including fetal deaths occurring at 28 weeksgestation or later and infant deaths less than 7 days of age, with aperinatal mortality rate being as high as 17.5 per 1,000 live birthssince 1980 (Hoyert, 1995) . In addition, research shows that asmany as 20% of recognized pregnancies result in miscarriages,including pregnancies ending at less than 28 weeks of gestation(Chen, 1986; Madden, 1994) .

    Maternal characteristics from within the groups of women expe-riencing a perinatal loss are varied. Perinatal loss a ects mothersand families of all demographic groups, from adolescent pregnancyto older mothers, from unplanned pregnancies to pregnancies as aresult of fertility treatment, from low socioeconomic to high socio-economic status. Expectations about parenthood and of the childincrease the sense of loss or failure. The increase in medical tech-nology has almost persuaded American women to believe that

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  • Attachment and Perinatal Loss 259

    their babies will not die. Therefore, they tend to begin the bondingprocess earlier, even prenatally ( Letherby, 1993) . Consequently, tofully understand the clinical implications of perinatal loss, it isimportant to rst obtain an understanding of the beginning ofattachment.

    Prenatal Attachment

    Peppers and Knapp ( 1980) provided a progression in the study ofmotherinfant attachment by initiating a discussion of not onlyneonatal attachment, but also prenatal attachment. They state thefollowing :

    What people do not realize is that for the mother, this infant has been apart of her since conception. She has come to know it in a way that no oneelse has . . . Maternal love, whatever its source, reaches deeply into the ear-liest stages of pregnancy and attaches itself rmly to the growing infant.( p. 29)

    There is a beginning knowledge base that clearly supports thetheory that attachment does not begin at birth, but long before.Peppers and Knapp ( 1980, p. 59) expounded on nine events thatcontribute to the formation of a mothers attachment to her infant :( a) planning the pregnancy, ( b) con rming the pregnancy, ( c)accepting the pregnancy, ( d) feeling fetal movement, ( e) acceptingthe fetus as an individual, ( f) giving birth, ( g) seeing the baby, ( h)touching the baby, and ( i) giving care to the baby. Although all ofthese events can be discussed in terms of their impact on attach-ment, it is signi cant to note that events ae occur prenatally.Moreover, event d, fetal movement, has been cited often in theliterature as a time of heightened attachment (Ga ney, 1988;Heidrich & Cranley, 1989 ; Klaus & Kennell, 1976; Lerum &LoBiondo-Wood, 1989; Peppers & Knapp, 1980) .

    Ganey ( 1988) reviewed the literature on prenatal attachmentto make recommendations for nursing interventions aimed at facili-tating motherinfant attachment, providing a comprehensive dis-cussion of literature that validates claims that attachment beginsprenatally. Although Ganey ( 1988) recommended that further

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  • 260 M . Robinson et al.

    research be conducted, and encouraged development of appropri-ate measures for attachment, she made a recommendation thatmaternal social supports be strengthened as much as possibleduring the prenatal period.

    Rubin ( 1975) outlined the maternal tasks of pregnancy. Theseare as follows : ( a) seeking safe passage for herself and her childthrough pregnancy, labor, and delivery ; ( b) ensuring the accep-tance of the child she bears by signi cant persons in the family ; ( c)binding-in to her unknown child ; and ( d) learning to give ofherself ( Rubin, 1970, p. 145) . The third task, binding-in, providesa clear understanding of the attachment that has already beenestablished. Rubin stated that :

    The bond between a mother and her child that is so apparent immediatelyat the birth of her child is developed and structured during pregnancy. Atbirth there is already a sense of knowing the child, within the limitations ofnot having had perceptions through the usual sensory modalities. At birththere is already a sense of shared experiences, shared history, and sharedtime on an intimate and exclusive plane. ( p. 149)

    Neonatal Attachment

    Bowlby ( 1969) discussed attachment theory related to childparentand adultadult interactions in great depth. Through his research,he developed a framework consisting of general principles of neo-natal attachment. The most relevant principle to the neonatalperiod is as follows :

    Most of the most intense emotions arise during the formation, the main-tenance, the disruption and the renewal of attachment relationships. Theformation of a bond is described as falling in love, maintaining a bond asloving someone . . . Similarly, the threat of loss arouses anxiety and actualloss gives rise to sorrow ( p. 40)

    Klaus and Kennell ( 1976) also spoke to the process of parentinfant attachment. They state that Perhaps the mothers attach-ment to her child is the strongest bond in the human. First, beforethe birth the infant gestates in the mothers body, and, second,after birth she ensures his survival ( p. 1) . Klaus and Kennell( 1976) continued to de ne attachment as a unique relationshipbetween two people that is speci c and endures through time

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  • Attachment and Perinatal Loss 261

    ( p. 2) . Although this de nition of attachment is generallyaccepted, clinicians should be aware that when attachment de ni-tions include an element of time there is the potential risk for mini-mization of a perinatal loss. It is important to note that eventhough a child has not been with the parent for a signi cant dura-tion of time, the loss itself is by no means less signi cant. It isincreasingly important to examine the elements of attachmentrather than simply its length.

    Klaus and Kennell ( 1976) carefully studied the period directlyafter the birth, which they label the maternal sensitive period. Theystate that it is during this enigmatic period that complex inter-actions between mother and infant help to lock them together.Further, events that occur during this time, such as holding, touch-ing, and watching the baby, have been found to have a lastinge ect on the future development of the family ( Peppers & Knapp,1980) . Attachment thus begins before birth but is solidi ed whenphysical contact with the infant can be made.

    The basic premise of theories on maternal attachment is fairlystraightforward. Attachment is a process that occurs to establish abond between a parent and child. However, the underlyingassumptions about the process are far more complex. Attachmentdoes not only refer to the period directly after birth, where themother is seeing the infant for the rst time and begins the processof learning about the infant. The process has already been initiatedprior to this period, prenatally. Maternal attachment consists of acomplex set of events that include not only tangible events, such asfetal movement, but also events such as preparation and adjust-ment to the pregnancy that begin the relationship. Prior to birth,the mother has been able to conceptualize the infant and to projectthe way the presence of the infant will contribute to the life of thefamily. It is in the more subtle aspects of attachment that we ndthe deep beginnings of the parentchild bond.

    Medical Technology, Attachment and Loss

    Recent advances in medical technology have had a profound e ecton issues of prenatal attachment and perinatal loss ( Black, 1990;Heidrich & Cranley, 1989 ; Kolker & Burke, 1993) . The now fre-quent use of ultrasound has in uenced prenatal attachment by

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    providing parents an opportunity to visually bond with theirinfant, although the extent of the relationship does not appear tobe as signi cant as quickening, or the point of fetal movement( Fletcher & Evans, 1983; Heidrich & Cranley, 1989) . Prenataldiagnosis, including the use of ultrasound, amniocentesis, and cho-rionic villus sampling, has also had an impact on the issue of peri-natal loss ( Black, 1990; I les & Gath, 1993; Kolker & Burke, 1993) .Families are often dealing with greater feelings of guilt when theyare now given an active part in decision making regarding the lifeor death of their infant when an abnormality is discovered. Green-feld, Diamond, and DeCherney ( 1988) even commented on thegrief reactions of women following failed in-vitro fertilization ( IVF)treatment, stating that the grief response can be predicted byobserving the degree of the IVF patients attachment to theexpected pregnancy ( p. 169) .

    Kemp and Page ( 1987) also substantiated prenatal attachmentearlier in their discussion of maternal attachment in normal andhigh risk pregnancies. They stated that the results of their studysupport theoretical perspectives of prenatal attachment . . . mater-nal affiliation with the fetus seems to be a task that is accomplishedduring pregnancy regardless of whether the pregnancy is threat-ened ( p. 182) .

    Moulder ( 1994) provided a framework for understanding preg-nancy loss using integration of the models of attachment and loss.His integration of some of the above theories, discussed by Klausand Kennell ( 1976) , suggests a more sophisticated frameworkbased on attachment.

    It is suggested that the key factors in explaining a womans reactions to theloss of her pregnancy are the extent of the attachment to the baby and thedegree of investment in the pregnancy and although they may be in u-enced by, they are not necessarily determined by gestational age . . . attach-ment and investment are separate but linked processes that develop atdi erent rates for di erent women . . . Attachment is concerned with thedevelopment of feelings for the baby, whereas investment is a more activeprocess of involvement in the pregnancy. ( p. 66)

    Moulder ( 1994) reiterated the basic assumptions of attachmenttheory in his views on loss. The assumptions are that time alone is

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  • Attachment and Perinatal Loss 263

    not necessarily an indicator of the level or degree of attachment,nor is the physical presence of the infant after birth. Attachmenttheories stand on assumptions that attachment is an individualprocess that occurs not only after birth, but also before birth, in theprenatal experience. The sophisticated model of Moulder takesinto account the subtle di erences that contribute to attachmentand suggest that the process begins early in the pregnancy.

    Frameworks such as Moulders ( 1994) provide a foundationthrough which attachment theory may be used to understand peri-natal loss, thus integrating the two to provide a comprehensiveframework. Given the conceptualization of loss after attachment,the issues of perinatal loss become one of degree rather than one ofexistence. Klaus and Kennell ( 1976) and Sugarman ( 1977) provid-ed suggestions for interventions during this period that provide theoptimum opportunity for attachment. Interventions on the part ofinvolved professionals center around decreasing unnecessarymedical protocols and restructuring practices to be sensitive tofamily attachment to the infant. Social workers, nurses, physicians,and other caregivers are encouraged to return to the naturalcontext of birth and de-emphasize the technological context when-ever possible. Attention to this critical period highlights the impor-tance of facilitating attachment by providing the optimalenvironment for attachment to occur. However, the psychologicalimportance of the neonatal period does not suggest that attach-ment has not already been occurring prenatally.

    Perinatal Loss

    A baby can represent hope for the future, hope of a better life, andhope of greater opportunities. A baby can represent the potentialfor ful lling dreams, a way of starting over, another chance to alterthe course of a lifetime. A baby can embody dreams and fantasies( Arnold & Gemma, 1994) .

    Arnold and Gemma ( 1994) eloquently described why so often aperinatal loss holds great signi cance for the parents. The loss of anadult is the loss of the past ; the loss of a baby is the loss of thefuture. The nature of a perinatal loss is often sudden and unex-pected, as pregnancy complications result in a miscarriage, still-birth, or neonatal death. Klass ( 1988) refered to the loss both of

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  • 264 M . Robinson et al.

    self and of competence and power through guilt. The childbecomes a part of the parents identity, and that part of the iden-tity is lost. Smith and Borgers ( 1988) also alluded to the issue ofguilt when they stated that the predominant media messagesconvey the impression that perinatal death can be avoided withgood medical care and good health habits ( p. 211) , clarifyinglater that those assumptions are false. Unfortunately perinatal lossoccurs in spite of good health habits and proper medical attention.It is no surprise then that perinatal loss often results in increasedanxiety in subsequent pregnancy ( Theut et al., 1988) and feelingsof guilt.

    Leon ( 1992b) cautioned that although much has been learnedabout perinatal loss, it is still often compared to the loss of anadult, despite its unique qualities. Using a psychoanalytic frame-work, Leon concluded that perinatal loss has other implications aswell for a parents self-esteem, developmental goals, and ability tocope with earlier con icts ( p. 1470) .

    Turco ( 1981) provided a case report in which the loss of aninfant resulted in unresolved grief, discussing a sense of helplessnesswithin the client, along with a reemergence of a sense of self thatis inadequate to cope with circumstances, accompanied by theemergence of a strong sense of guilt ( p. 503) . Unresolved griefoften carries over into subsequent pregnancies, as mentionedbefore, and can a ect attachment. Janssen, Cuisinier, Hoogduin,and Kees ( 1996) , in their study on mental health of women follow-ing a pregnancy loss, concluded that although the majority ofwomen are able to recover without psychiatric treatment, preg-nancy loss is a stressful life event that can cause marked deterio-ration in a womans mental health. Although pregnancy loss didnot contribute to long-term psychological problems, the problemwas signi cant in the absence of additional mental disorders. It istherefore important when considering the varying elements inattachment theory and perinatal grief, to consider their implica-tions for clinical practice.

    Implications for Clinical Practice

    In the specialty of perinatal clinical work, issues like perinatal lossare confronted frequently. Perinatal loss is evidenced in prenatal

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  • Attachment and Perinatal Loss 265

    clinics, hospitals, primary care clinics, and family planningagencies, to mention some sites. However, the issue of perinatal lossmay also surface in any agency setting that deals with femaleclients or families, including drug and alcohol treatment centers,general hospital settings, and mental health clinics. Therefore, forcompetent clinical practice, a basic understanding of perinatal lossis indicated, not only for social workers, but for other mentalhealth and medical care professionals as well.

    It has been found that during pregnancy, physical and psycho-logical processes are taking place that facilitate early attachmentand suggest that, while individualized, attachments formed at aprenatal level may be evident in some degree with every woman( Bowlby, 1969; Peppers & Knapp, 1980; Rubin, 1975; Sugarman,1977) . One of the crucial beginning points in clinical practice is tobe able to accurately assess the level of attachment. Individualassessments need to take into consideration the possibility of avariety of emotions (Madden, 1994) . Assumptions cannot be madeon factors such as gestational age alone. For example, the degree ofattachment for a teenage mother in the rst trimester and a motherwho has been having difficulty conceiving, at the same gestationalpoint, may be very di erent. Although some degree of attachmentmay be evident for both mothers, the scope and intensity of theattachment and possible loss may be very di erent, taking intoconsideration their social situation, readiness to accept the preg-nancy, implications of having a child, and expectations. Accurateassessment of degree of attachment is a critical factor.

    Understanding of a healthy grieving process and parameters forperinatal grief are also important clinical considerations (Davis,Stewart, & Harmon, 1988; Horowitz, 1978; Klass, 1988) . It isimportant for the clinician to be aware that the length of the preg-nancy may not be the only indicator of length or intensity of thegrieving process (Hutti, 1988; Moulder, 1994) . Again, di erentaspects of attachment should be taken into consideration, alongwith individual di erences, before a diagnosis of pathological orunresolved grief is made.

    Although the literature and research on perinatal loss is limited,it does provide some guidelines for clinical intervention, especiallyin the medical setting (Brown, 1993; Davis et al., 1988; Harr &Thistlethwaite, 1990; Hutti, 1988; Leon, 1992a; McDermott-

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    Shaefer, 1992) . Hutti provided a review of the literature discussingfour types of interventions : ( a) those that reduce the trauma of thehospitalization period, ( b) those that validate the loss, ( c) thosethat make the loss more real, and ( d) those that teach.

    Reducing the Trauma of the Hospitalization Period

    The period surrounding a perinatal loss is oftentimes a period ofcrisis. Complications resulting in a miscarriage or problematicdelivery frequently arise suddenly, requiring emergency high-techintervention. Once the medical situation is stabilized, interventionsaimed at reducing trauma may be implemented. Such interven-tions include allowing families time alone to spend with theirinfant, providing an opportunity to begin the grieving process.Allowing a woman an opportunity to recover on a unit besides thepostpartum unit if desired is also helpful initially to eliminate theconstant reminder of successful pregnancies. I f the woman remainsin the postpartum area, subtle signs such as a teddy bear or oweroutside the door can alert the sta that the family has experienceda loss, preventing inadvertent questions regarding the status orlocation of the infant.

    Validating the Loss

    Validation of the loss is of particular importance to facilitate ahealthy grieving process. Allowing families the opportunity to viewtheir dead infant and to hold the infant if desired contribute tovalidation of the loss. Pictures or mementos, including footprints,handprints, locks of hair, and receiving blankets, con rm that thepregnancy did exist. It is important to prepare families for whatthey will be seeing when the infant is extremely premature or hassome congenital malformation or other deformity. In the authorsexperience, families who are prepared in advance for any unusualcharacteristics are very accepting of the way their infant appearsand are able to look past any negative characteristics to nd posi-tive attributes. Additionally, the importance of taking photographscannot be stressed enough. Although families initially may statethat they do not wish photographs, many nd great relief in that

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  • Attachment and Perinatal Loss 267

    fact that photos were held in the le and could be received at alater date.

    Making the Loss More Real

    There are many opportunities for families to make the loss morereal through rituals and remembrances. Funeral options should bediscussed with families shortly after the loss, if appropriate. Manystates require burials or cremation for infants born after 2021weeks gestation or with a heartbeat. It is important for the clini-cian to be familiar with the laws of the state to advise families.Memorial services are another way for families to express theirgrief. Often hospitals will have yearly remembrance services forlosses within that year. Long-term remembrances, such as plantinga tree or making a charitable donation, provide familiesopportunity for ongoing memories. One family in the authorspractice would place a rose in the corner of the yearly familypicture in memory of an infant that had died.

    Teaching

    Teaching provided to families around the grieving process andemotional expectations is helpful, and can help to normalize feel-ings and reactions. Providing written materials after discussion onthe grieving process is preferred so that families have anopportunity to return to the materials as needed.

    In addition to the above interventions, follow-up support andreferral for ongoing counseling should always be provided as neces-sary ( Brown, 1993; Davis et al., 1988; Hutti, 1988) . Although theliterature does provide speci c interventions as a guideline forpractice, Leon ( 1992a) also cautioned against the institutional-ization of bereavement and reiterates that interventions be sensi-tive to the individual di erences of grieving families. The need foreducation and validation regarding the loss also requires an accu-rate assessment of the needs of the family.

    The emergence of recent literature on perinatal loss is prom-ising, however there is still more research to be done. Qualitativemethodologies have provided a solid foundation to further research

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    that provides a more representative view of perinatal loss and takesinto account di erences due to maternal age and cultural diversity.However, there still remains a need for research to assess under-lying issues related to attachment and perinatal loss using quanti-tative methods to provide a strong empirical foundation to guidecompetent clinical practice.

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