The Influence of Prior Perinatal Loss on Parents' Psychological Distress After the Birth of a Subsequent Healthy Infant

doi:10.1111/j.1552-6909.2009.01069.x

Journal of Obstetric, Gynecologic & Neonatal Nursing

Volume 38, Issue 6, November–December 2009, Pages 654-666

https://doi.org/10.1111/j.1552-6909.2009.01069.x Get rights and content

ABSTRACT

Objective

To evaluate the long-term influence of a previous perinatal loss on parents' psychological distress during a subsequent childbearing experience.

Design and Sample

A cohort design was used to examine 36 couples with a history of prior perinatal loss. Data were collected during the third trimester of pregnancy, 3 months postpartum, and again 8 months after birth.

Measures

Outcome measures included posttraumatic stress (The Impact of Event Scale), depressive symptoms (Center for Epidemiologic Studies-Depression Scale), anxiety (Spielberger State-Trait Anxiety Inventory), and parental concerns and attitudes (Maternal/Paternal Attitudes Questionnaire).

Results

Levels of depressive symptoms (p<.001), anxiety (p<.001), and posttraumatic stress (p=.046) significantly decreased over time in this population. However, levels of posttraumatic stress remained in the moderate range even at 8 months after birth. Depression was significantly correlated with posttraumatic stress at each time point. In addition, depression was significantly related to posttraumatic stress, anxiety, and concerns parents had about their infant's well-being at T3.

Conclusion

While levels of anxiety and depressive symptoms decreased for parents who have experienced a previous perinatal loss, posttraumatic stress levels remained moderately high. It is unclear how this compares to parents without losses. These may be the unique symptoms and concerns these parents have about their new infant. Parents with a history of prior loss should have assessments carefully tailored to their experiences to anticipate continued psychological distress.

Section snippets

Review of Literature

Depressive symptoms affect a woman's ability to function and have considerable adverse influence on family outcomes and maternal-child interactions as well as on infant and child development (Lundy et al., 1996, Mandl et al., 1999, Weinberg and Tronick 1998, Weinberg and Tronick 1998). However, depressive symptoms are recognized and treated in as few as 10% of those affected (Mandl et al.). Depressive symptomology during pregnancy increases the risk for depression in the postpartum period (Beck

Study Design and Sample

A longitudinal cohort study design was used to collect data from expectant mothers and fathers during the third trimester of pregnancy (T1), 2 to 3 months postpartum (T2), and again 6 to 8 months after birth (T3). The sample consisted of 72 expectant parents (36 couples). Preliminary pilot data obtained by Armstrong (2007) yielded correlations of .67 between Center for Epidemiologic Studies-Depression Scale (CES-D) and Impact of Event Scale (IES) scores at baseline and .63 at follow-up for

Findings

As seen in Table 1, at baseline fathers graduated from vocational/technical schools more often (8.7% vs. 0.0%, p=.001), had less depressive symptoms (9.11 vs. 15.08, p=.0048), and had less intrusive thoughts (13.17 vs. 20.75, p=.0029) when compared to mothers. In addition, in this mostly White, middle to upper income, highly educated sample of participants there were no gender differences identified in mean age, ethnicity, income levels, marital status, and number of living children. Further,

Discussion

Mothers' level of depressive symptoms indicated a potential risk for depression during pregnancy similar to previous research (Armstrong 2002, Armstrong 2004, Armstrong and Hutti 1998, Cote-Arsenault and Mahlangu 1999). In addition, mothers' levels of depressive symptoms and anxiety were higher than fathers during pregnancy; however, there was no significant difference between their levels of PTS. This also is similar to that found in other studies (Armstrong 2002, Armstrong 2004). Mothers

Implications for Clinical Practice

Clinicians who work with families with a history of prior perinatal loss should be aware of the potential for continued distress. Becoming pregnant again may not “make everything better” for these parents. The current study as well as previous research demonstrates that mothers in particular may experience significant levels of depressive symptoms and anxiety in the subsequent pregnancy, some potentially to the level of clinical depression (Armstrong 2002, Armstrong 2004, Armstrong 2007,

Limitations

The small sample size and its homogeneity are limitations of this preliminary research. While every effort was made to recruit more diverse study participants, because the study relied on a volunteer sample, this was not possible. In future studies greater attention to recruiting in areas with more diverse populations may help.

Limited confidence in results from the MAQ's differentiation subscale is needed because of its low Cronbach's α, which may be related to the design of this instrument for

Future Directions for Research

Different, more specific instruments to measure the threats or vulnerabilities that parents may experience related to their prior perinatal losses are needed. The generalized psychological distress that the questionnaires evaluated in this study may not focus on the specific anxieties and stress parents with a history of loss are dealing with when they parent a subsequent child. Replication of the current study or similar ones with different, more specific questionnaires related to the

Acknowledgment

Funded by National Institute of Nursing Research Grant 1-R-15 NR08492-01.

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Stillbirth occurs in every 3.5 of 1000 pregnancies in Ireland and is a devastating event for a family. Women who have a pregnancy after stillbirth require increased antenatal support.
This study aimed to determine maternal and fetal outcomes and to quantify health service utilization in pregnancy after stillbirth.
A retrospective cohort study of all pregnancies after stillbirth was conducted from 2011 to 2017 in a large tertiary referral university maternity teaching hospital with approximately 8000 births annually.
There were 222 stillbirths from 2011 to 2017. Two-thirds of women (145 of 222 [64.3%]) had a pregnancy after stillbirth. Almost one-fifth of these women (28 of 145 [19.3%]) had a miscarriage, but 16 of 28 women (57.1%) had a subsequent live birth, giving an overall live birth rate of 90.3% (131/145). The average interval from index loss to booking in the next pregnancy was 13 months, with almost half of the women (72 of 145 [49.7%]) booking within 1 year. The average number of antenatal appointments was twice than expected (10; range, 2–27), and the average number of ultrasound scans was 5 times higher than expected (5; range, 0–29). Rates of induction of labor (63 of 131 [48.1%]) and cesarean delivery (53 of 131 [40.5%]) were significantly higher than national rates for multiparous women. Almost two-thirds of women (40 of 63 [63.5%]) cited previous history of stillbirth as the indication for induction. There was a significantly higher rate of preterm delivery (30 of 131 [22.9%]). Moreover, 1 in 4 babies (35 of 137 [25.5%]) required admission to the neonatal intensive care unit, more than twice the number expected (median gestation, 37 0/7 weeks; range, 25 4/7 to 39 2/7 weeks).
Pregnancy after stillbirth was associated with increased surveillance and intervention. The women in this study had higher rates of cesarean delivery, induction of labor, and preterm delivery than the general multiparous population. Decision-making for intervention was often based on previous history of stillbirth. Clinicians should be cognizant of additional supports required for this population and focus on evidence-based interventions that improve maternal well-being and perinatal outcomes in pregnancy after stillbirth.
Trying to conceive: An interpretive phenomenological analysis of couples’ experiences of pregnancy after stillbirth
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Stillbirth affects 1:200 pregnancies in high income countries. Most women are pregnant again within 12 months. Little is known about how couples negotiate a subsequent pregnancy. This paper presents findings from a study exploring the experiences of couples’ in pregnancy after stillbirth.
Qualitative, interpretive phenomenological analysis was used to conduct in-depth interviews with eight heterosexual couples in the immediate pregnancy after stillbirth. Couples were interviewed together to explore their dyadic, lived experiences of stillbirth and the pregnancy that follows.
Hoping for a born alive baby was one superordinate theme and Trying to conceive one of its subordinate themes, is presented here. Couples jointly negotiated their decision to get pregnant again, varying upon their individual circumstances, including their experiences of stillbirth. Gender differences were apparent in a couple’s agreement to pursue a pregnancy after stillbirth and may be explained by the desire of men to fully parent the baby who died before reaching a decision about a subsequent pregnancy. Sexual intercourse often became less about emotional connection and more about a means to achieve a pregnancy.
Couples spoke of the need for each partner to be in agreement with the decision for a pregnancy. The experiences of trying to conceive after stillbirth impacted the couple relationships. Couples who were able to discuss their feelings with one another appeared more cohesive than those who experienced communication challenges in the aftermath of loss. New insights into men’s thinking about the decision to get pregnant after stillbirth were revealed.
History of perinatal loss: A study of psychological outcomes in mothers and fathers after subsequent healthy birth
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The loss of an expected child is a psychologically difficult and potentially traumatic life event. While most women will become pregnant again within a year following the loss, data are limited regarding the mental health of parents with a history of perinatal loss, especially in the period following the birth of a subsequent healthy child. This study, therefore, investigated the relation between perinatal loss and mothers’ and fathers’ psychological symptoms and parenting stress 6-months after the birth of a healthy child.
A community sample of 92 mother-father dyads living in a Canadian city and having a 6-month-old biological infant were asked to complete questionnaires measuring their history of perinatal losses (55 parents reporting at least one loss) and their psychological symptoms and parenting stress.
Mothers and fathers who have experienced a perinatal loss reported more psychological symptoms and parenting stress. Mothers were more likely to report psychological symptoms and parenting stress compared to fathers, but the magnitude of the relation between perinatal losses and psychological outcomes were comparable for mothers and fathers.
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The results suggest that the experience of a perinatal loss might have negative consequences on the psychological wellbeing of parents even after the birth of a healthy child.
Anxiety in fathers in the perinatal period: A systematic review
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Citation Excerpt :
The third trimester has been identified as a key time point for elevated paternal anxiety, and this may be the most applicable time to provide information, and implement programmes that reduce anxiety. The findings from this systematic review indicate that experience anxiety which increases from the antenatal period to the time of birth, with a decrease in anxiety from the time of birth to the later postnatal period (Keeton et al., 2008; Castle et al., 2008; Armstrong et al., 2009; Vismara et al., 2016; Figueiredo and Conde, 2011a,b). An increase in anxiety from the antenatal period to the time of birth, was followed by a decrease in anxiety from the time of birth to the later postnatal period.
fatherhood in the perinatal period can be a time of great excitement, happiness and joy. However, a growing body of literature indicates that fathers are at risk for elevated levels of anxiety symptoms during the perinatal period.
the purpose of this systematic review is to determine the prevalence and levels of anxiety in fathers during the perinatal period, identify the risk factors and impact of anxiety, and establish if there are effective interventions that reduce father's anxiety.
Systematic review.
A systematic review protocol was developed and registered with PROSPERO (reference number: CRD42017073760). The review was guided by the PRISMA reporting process. Electronic databases Medline, CINAHL, Embase, the Cochrane Library, PsycARTICLES, PsycINFO, and Psychology were searched to identify eligible studies. Studies that researched fathers during the perinatal period were included if anxiety was the primary focus of the research or was an outcome or dependent variable. Data were extracted and presented in narrative form including tables and figures.
Thirty-four studies met the inclusion criteria. Findings from these studies indicate that fathers experience anxiety in the perinatal period, particularly at the time of birth. Anxiety increased from the antenatal period to the time of birth, with a decrease in anxiety from the time of birth to the later postnatal period. The prevalence of anxiety ranged between 3.4% and 25.0% during the antenatal period and 2.4% and 51.0% during the postnatal period. Factors contributing to anxiety included lower education levels, lower income levels, lower co-parenting support, lower social support, work-family conflict, a partner’ anxiety and depression, and being present during a previous birth. Anxiety had a negative impact on fathers’ mental health, physical health, social relationships and parenting skills. Anxiety contributed to stress, depression, fatigue and lower paternal self-efficacy. Five studies reported on interventions to reduce anxiety and all the studies found that anxiety significantly decreased following the intervention.
Fathers experience increased anxiety from the antenatal period to the time of birth, with a decrease in anxiety from the time of birth to the later postnatal period. Anxiety during the perinatal period that can impact negatively on fathers physical and mental health, and social relationships.

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ResearchThe Influence of Prior Perinatal Loss on Parents' Psychological Distress After the Birth of a Subsequent Healthy Infant

ABSTRACT

Objective

Design and Sample

Measures

Results

Conclusion

Section snippets

Review of Literature

Study Design and Sample

Findings

Discussion

Implications for Clinical Practice

Limitations

Future Directions for Research

Acknowledgment

Journal of Obstetric, Gynecologic, & Neonatal Nursing

Journal of Obstetric, Gynecologic, & Neonatal Nursing

Journal of the American Academy of Child and Adolescent Psychiatry

Journal of Obstetric, Gynecologic, & Neonatal Nursing

Journal of Obstetric, Gynecologic, & Neonatal Nursing

Journal of Affective Disorders

Preventive Medicine

Social Science and Medicine

Infant Behavior and Development

Infant Behavior and Development

Advances in Pediatrics

Journal of Obstetric, Gynecologic, & Neonatal Nursing

Journal of the American Academy of Child and Adolescent Psychiatry

Journal of Obstetric, Gynecologic, & Neonatal Nursing

Journal of Obstetric, Gynecologic, & Neonatal Nursing

Exploring fathers' experiences of pregnancy after a prior perinatal loss

The American Journal of Maternal/Child Nursing

Emotional distress and prenatal attachment in pregnancy after perinatal loss

Journal of Nursing Scholarship

After the birth of a healthy infant

Advances in Neonatal Care

A meta-analysis of predictors of postpartum depression

Nursing Research

Postpartum depressed mothers' experiences interacting with their children

Nursing Research

Body mass index, eating attitudes, and symptoms of depression and anxiety in pregnancy and the postpartum period

Psychosomatic Medicine

Symptoms of depression in two communities

Psychological Medicine

Fathers and grieving

Journal of Perinatology

The influence of perinatal loss on anxiety in multigravidas

Journal of Obstetric, Gynecologic, & Neonatal Nursing

Threat appraisal, coping, and emotions across pregnancy subsequent to perinatal loss

Nursing Research

Watching and worrying

Maternal Child Nursing

Research
The Influence of Prior Perinatal Loss on Parents' Psychological Distress After the Birth of a Subsequent Healthy Infant