Perinatal bereavement
Perinatal bereavement or perinatal grief refers to the emotions of the family following a perinatal death, defined as the demise of a fetus or newborn infant. Perinatal loss affects one in every ten women across the globe with the worldwide perinatal death rate at approximately 2.7 million deaths per year. Perinatal death is recognized as a traumatic life event as it is often sudden, unexpected, and devastating to parents who have had little to no direct life experiences with their child before their death.
Perinatal bereavement, while sharing similarities with grief for other loved ones, is unique due to its nature as the loss of an idealized future relationship. Parents often experience grief over the loss of their sense of self and role, which can complicate the grieving process. This type of grief may lead to prolonged or severe symptoms, including complicated grief or psychiatric illnesses like depression, making it critical to differentiate between normal and complicated grief.
Types of perinatal loss
Miscarriage
A miscarriage, or spontaneous abortion, is defined as a "natural pregnancy loss before 20 weeks of gestation." According to The American College of Obstetricians and Gynecologists, miscarriage is the most frequent type of pregnancy loss. Approximately 15% of all pregnancies result in a miscarriage, with one in every four women experiencing a miscarriage at some point in their life. 50% of all miscarriages result from chromosomal abnormalities, while the remaining cases could be a mixture of physical, hormonal, environmental, and lifestyle factors. Risk factors for miscarriage include advanced maternal age, history of previous miscarriages, obesity, autoimmune disorders, substance use, and more. Despite recommendations of bed rest, administrations of hormones such as β-hCG and prophylactic progesterone, uterine relaxants, and other therapies, there are no effective means of preventing a miscarriage.Common symptoms of miscarriage include vaginal bleeding and lower abdominal cramping. However, these symptoms are not definitive of a miscarriage occurring. To distinguish a miscarriage from other pregnancy complications, a thorough evaluation of a patient's medical history, as well as a physical examination, transvaginal ultrasound, and blood tests are recommended.
Stillbirth
Pregnancy loss that occurs after 20 weeks of gestation is referred to as a stillbirth. Stillbirth involves the delivery of a fetus that has passed away before or during birth. Almost 1.9 million stillbirths occur each year, with unexplained stillbirths accounting for 76% of cases across the globe. Risk factors for stillbirth include placental abnormalities, advanced maternal age, diabetes, substance use, hypertension, previous stillbirths, and more. However, it is often difficult to assess the cause of stillbirth if systematic investigations into the cause of death are not undertaken.Neonatal mortality
refers to the death of an infant within the first 28 days after birth. 75% of all neonatal deaths occur during the first seven days of life, with the main causes of neonatal death being preterm birth, congenital malformations, perinatal asphyxia or trauma, neonatal infections, and other birth disorders. Approximately 2.4 million neonatal deaths occur each year, with the majority of deaths taking place in low- and middle-income countries. In 2020, almost half of all deaths in children under the age of five occurred during the newborn period.History
Women have documented their experiences of perinatal bereavement since at least the 19th century. However, modern research into the effects of this type of loss began in the 1960s, led by a small number of psychoanalysts. One of the first to recognize miscarriage as a traumatic event was psychoanalyst A.C. Cain in 1964. Cain explored the impact of child loss on siblings and described the profound emotions women often face after a miscarriage, including fear, grief, anger, and despair. In 1970, Kennell, Slyter, and Klaus conducted seminal research on the mourning response of parents to the death of a newborn infant, providing the first empirical evidence that women experience a profound mourning process following such a loss.Before the 1970s, the medical community often dismissed perinatal loss classifying it as insignificant, resulting in little recognition of perinatal bereavement. Over time, three key factors contributed to the acknowledgment of perinatal bereavement as a legitimate experience:
- Emergence of Attachment Theory: Research on maternal bonding during pregnancy, highlighting the deep emotional connections formed between mothers and their unborn babies.
- Shifting Social Perspectives: Changing societal attitudes allowed women to voice their grief and advocate for recognition of their suffering after perinatal loss.
- Advances in Neonatal Care: Innovations in neonatal technology, including the regionalization of neonatal intensive care
Measurement
The most widely used measure for perinatal grief is the Perinatal Grief Scale, developed by Lori J. Toedter, Judith N. Lasker and Janice M. Alhadeff in 1988. PGS is used both by researchers to understand perinatal grief and by psychiatrists as a testing instrument to assess a patient experiencing perinatal bereavement. The PGS consists of 33 statements regarding feelings following perinatal loss and a scale of answers ranging from "strongly agree" to "strongly disagree." The 33 statements are categorized into three subscales, each consisting of 11 items:- Active Grief: emotions such as sadness, longing for the baby, and crying;
- Difficulty Coping: behaviors like withdrawal and symptoms of depression;
- Despair: feelings of worthlessness and hopelessness.
Critics of the Perinatal Grief Scale argue that it places excessive emphasis on emotions specifically related to the loss of the baby, while neglecting other grief-related feelings. Additionally, the scale has been criticized for overlapping significantly with indicators of depression. Despite the development of other perinatal grief instruments, the PGS remains the most consistent and reliable means of assessing perinatal grief for clinicians and researchers. It has been instrumental in gauging grief responses in patients, assessing related psychological and social factors, and evaluating the effectiveness of bereavement interventions. The widespread use of the Perinatal Grief Scale may be attributed to its ease of application, quick analysis, and successful validation across various languages and cultures, reinforcing its utility as both a clinical and research tool.
Factors Influencing Severity
The Perinatal Grief Scale has been instrumental in helping researchers identify key factors associated with perinatal grief reactions. A scoping review identified four primary factors commonly examined for their influence on grief responses: sociodemographic characteristics, support systems, reproductive history, and mental health status.Among these factors, support consistently emerged as the strongest predictor of lower grief scores. Higher levels of marital satisfaction, social support, participation in professional support groups, and religiosity were all associated with reduced grief as measured by PGS scores.
Conversely, mental health status was the factor most consistently associated with higher grief scores. Individuals with pre-existing mental health issues were more likely to report elevated levels of grief following a perinatal loss.
The influence of other factors, including sociodemographics and reproductive history, yielded mixed or conflicting results. The lack of consensus among researchers can be attributed to variations in study designs, sample populations, and the diverse measures used to evaluate grief.
Psychological impact
The loss of a child, regardless of their age, is a profoundly painful event for any parent to experience. Perinatal death is especially traumatic as it is rarely anticipated and can defy parents' expectations of the natural order of life. The grieving process involved in a sudden perinatal death further includes the loss of future dreams, experiences, and expectations associated with their child's future.Reactions to perinatal loss can vary widely depending on one's personal, cultural, and situational factors. In a typical grieving process, the intensity of grief gradually lessens over the course of a year after the loss. In several longitudinal studies, Perinatal Grief Scale scores, as expected, decrease over the two years following a loss among bereaved parents as a whole. However, for a majority of parents experiencing perinatal loss, varying patterns of persistent and unresolved grief remain after two years of the loss. For example, around 20% of women continue to experience clinically significant symptoms even a year after the loss.
Perinatal death can have profound emotional consequences for parents, families, and communities. For mothers, the consequences of perinatal loss can be physical and psychological. Approximately one in five women who go through perinatal loss develop depression or post-traumatic stress disorder. Over the course of their lives, the likelihood of experiencing PTSD linked to perinatal loss is estimated at 29%. For fathers, feelings of pain, sadness, inadequacy, and helplessness may be masked to assume the responsibility of supporting their partners during the grieving process. Furthermore, as bereavement care guidelines tend to be female-focused, bereaved fathers may feel overlooked and marginalized by medical professionals, workplace policies, and community support programs, leading to unresolved grief. Complicated grief, or prolonged grief disorder, can develop following a perinatal death due to a lack of social support, poor marital relations, fertility struggles, pre-existing mental health conditions, and/or the absence of other children. A lack of acknowledgement and support from society and healthcare professionals of the emotional impact of perinatal loss can further lead to parents experiencing disenfranchised grief, which may result in secretive mourning and heightened feelings of guilt and self-blame. Maladaptive coping mechanisms, such as avoidance, emotional suppression, or self-blame for the loss, are often linked to negative outcomes.