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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  • 262 M . Robinson et al.

    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 state...