«A COMPARISON OF GRIEF AS RELATED TO MISCARRIAGE AND TERMINATION FOR FETAL ABNORMALITY KATHLEEN KEEFE-COOPERMAN, PSY.D. Long Island University, ...»
OMEGA, Vol. 50(4) 281-300, 2004-2005
A COMPARISON OF GRIEF AS RELATED TO
MISCARRIAGE AND TERMINATION FOR
KATHLEEN KEEFE-COOPERMAN, PSY.D.
Long Island University, Orangeburg, New York
This study proposed that maternal bereavement in women who experienced miscarriage and women who terminated for fetal abnormality would differ related to the existence of a grief reaction, and to identify the factors that differentiated the two groups. There were no significant grief differences between the miscarriage group and termination group. The groups were then combined to analyze within group factors. Six fixed variables were found to be related to vulnerability for a grief reaction. Factors included: time since the most recent loss; intervention of counseling; employment outside the home;
feeling responsible for the perinatal loss; age of the mother as related to guilt;
and gestational length of pregnancy.
The loss of a wanted pregnancy in the second trimester because of miscarriage or termination for fetal abnormality causes a woman to mourn for both the possibly malformed baby she was carrying and the perfect baby she mentally anticipated.
Perinatal loss is unique and troubling because there is usually no visible child to mourn, and no memories of shared life experiences. The death is sudden and often coupled with a lack of recognition by relatives and friends regarding the significance of the loss (Lee & Slade, 1996). Personal stories of women who miscarry or terminate a wanted pregnancy for fetal abnormality reverberate with feelings of loss and emptiness. In addition, women who terminate cite the added emotional pain of guilt for choosing to end a life. This guilt enters into and permeates the woman’s mourning process.
281 Ó 2005, Baywood Publishing Co., Inc.
282 / KEEFE-COOPERMAN Each trimester of a pregnancy includes psychological tasks that are part of the bonding process between mother and infant. The first trimester involves suspicion and confirmation, resolving initial ambivalence, accepting the pregnancy, and reviewing of one’s childhood and changing feelings regarding body image and sexuality. During the second trimester, the mother begins to realize the fetus is a separate individual, and bonding is facilitated by the quickening (fetal movement) and viewing the fetus via ultrasound. She begins to picture the ideal child (Benkendorf, Corson, Allen, & Ilse, 1990). In the third trimester, the mother establishes a caretaking relationship with the fetus, and mentally prepares for labor and delivery (Bliss-Holtz, 1991).
Following perinatal death, the mother begins to process the meaning of the loss. Grief has been defined as “a painful, complex emotional state that changes with time and a process of confronting the loss (e.g., by yearning for and repeatedly reliving the lost relationship) in the service of gradual detachment from the lost person or object” (Beutel, Deckardt, Von Rad, & Weiner, 1995, p. 518). Normal grief is accompanied by a multitude of symptoms impacting feelings, cognitions, and physical sensations (Worden, 1991). Difficulty in grieving has been found to persevere at least six months. With uncomplicated grief, these feelings wane in intensity and the person slowly returns to a subdued interest in and ultimately a zest for life. A grief disorder is characterized by intrusive images, extreme feelings of emotion, denial of the importance of the loss to the self, and a general neglect of necessary adaptive actions both in the workforce and at home (Horowitz, Siegal, Holen, Bonnanno, Milbrath, & Stinson, 1997).
The loss of the infant during the second trimester because of miscarriage or termination often results in grief as the mother may have completed many of the psychological tasks, including accepting the pregnancy and bonding with the child (Benkendorf et al., 1990). She mourns the death of the idealized baby but may not receive sufficient emotional support because of a lack of social recognition of the loss (White-Van Mourik, Connor, & Ferguson-Smith, 1992).
When applying current bereavement theory to perinatal loss, several factors must be considered. A pregnancy is confirmed much sooner in today’s society than in earlier times due to medical advances. This, combined with first trimester sonograms, leads to an earlier bonding with the fetus in utero and the development of a mental representation of the child. Also, lower infant mortality rates have led to greater expectations regarding the success of pregnancy (Cecil, 1994).
Consequently, many women are not prepared for pregnancy failure. The process of miscarriage and termination for fetal abnormality both contain factors including a sense of biological failure, isolated grieving, a possible lack of perceived support and no time for anticipatory grieving. The factors related to the two types of pregnancy loss may either combine with other risk factors, or alone be detrimental enough to increase susceptibility to a short-term grief reaction leading to a grief disorder.
COMPARISON OF GRIEF IN PERINATAL LOSS / 283
A loss of moral self-esteem may occur in women terminating for fetal abnormality. The female might personally confront her own morality in causing death (White-Van Mourik et al., 1992). The woman is aware of her own decision to end her child’s life, which may result in guilt. This feeling may be possible in other types of loss such as miscarriage, where the mother may blame her own inappropriate behavior such as excessive exercise (Mander, 1999). In terminating a pregnancy, however, there is no doubt as to how the life was ended.
One study found women who experienced miscarriage had more feelings of loss and grief, while women who had an induced abortion for reasons other than fetal abnormality had greater feelings of relief, guilt, and shame (Broen, Moum, Bodtker, & Ekeberg, 2004). Though the pregnancies in this study were terminated for fetal abnormalities, the act of abortion may still cause feelings of guilt which necessitates exploration of its impact on the grief process. Women who terminate often speak in support groups of the additional burden of guilt, as compared to the focus on the feelings of loss by women who miscarried (Magi, personal communication, 1999).
Zoja and Martin (1997) discuss the polar opposites of abortion within the United States culture. Diametrically opposed positions are fostered: pro-choice or pro-life. In reality, however, there is much overlap and middle ground. The woman who terminates may feel emotional pain generated by the controversy surrounding abortion and its implied immorality. Women may later dwell upon the decision or experience guilt (Ilse, 1995).
A loss of social self-esteem is also associated with perinatal death, as compared to the elevated social status often accorded to pregnant women (White-Van Mourik et al., 1992). Society does not attach great importance to pregnancy loss and does not encourage open grieving for this type of death. One indication of the lack of validity is that funeral observances are limited. No set grieving process within society for a perinatal loss exists. The female experiences a loss of self-esteem engendered by the lack of recognition by society of the importance of the death. This results in possible isolating tendencies. Successful completion of the grieving process is dependent upon resolution of factors associated with perinatal loss. Key factors include a sense of biological failure, feelings of isolation, and a perceived lack of support.
284 / KEEFE-COOPERMAN The three areas of loss of self-esteem—biological self-esteem, moral selfesteem, and social self-esteem—permit the factors associated with the experience of miscarriage and termination for fetal abnormality to be viewed in a concrete manner. The resultant breakdown analysis allows for the determination of which variables are most associated with a greater susceptibility for a grief reaction, while identifying variables that facilitate the grief process.
HYPOTHESIS ONEThis study proposed that maternal bereavement in women who experienced miscarriage and women who terminated a wanted pregnancy as a result of fetal abnormality should be examined and compared to determine if a difference in susceptibility to a grief reaction existed, to identify the factors that differentiated the two groups, and to address the needs of women in both circumstances.
HYPOTHESIS TWOThe second hypothesis of this study speculated that a greater number of variables would be significantly related to grief scores, and would attempt to identify those factors. Some examples of variables include number of living children, prior losses, and psychological interventions.
In this study, contributing factors were considered in conjunction with WhiteVan Mourik et al.’s (1992) concept of the three areas of loss (biological selfesteem, social self-esteem, and moral self-esteem) in order to evaluate the variables in a quantifiable manner. Variables associated with biological self-esteem included the age of the mother, previous pregnancy losses, length of the pregnancy and the presence of a fetal abnormality. Variables associated with social selfesteem included limited or no family or social support. Lastly, the variable associated with moral self-esteem was guilt.
It was hypothesized that females who terminated a wanted pregnancy would experience a greater vulnerability for emotional problems as evidenced by a depressive reaction (Beutel et al., 1995). The loss of moral self-esteem was theorized to have a greater negative effect upon women who terminated a wanted pregnancy than women who miscarried.
Subject Recruitment Questionnaire results were gathered through four different venues: 1) clinician participation in recruiting patients (3.5% of subjects); 2) New York based hospital support groups (23.5% of subjects); 3) World Wide Web support groups, Website
COMPARISON OF GRIEF IN PERINATAL LOSS / 285messages, and World Wide Web listserv recruitment (64.7% of subjects); and
4) advertisements in national perinatal support newsletters (8.2% of subjects).
Data collection began in August 1999 and ended in March 2000. The desired number of subjects for the miscarriage group (n = 50) was not obtained because of a lack of response from miscarriage participants. The researcher attempted to enlarge the cohort base, because the specificity of requiring second trimester loss participants narrowed the subject pool considerably. The resultant 23 valid questionnaire response sets allow for hypothesis one to be addressed.
A total number of 23 women who experienced miscarriage and 62 women who terminated for fetal anomaly correctly completed the set of questionnaires. This totaled 85 participants.
The target period was up to two years post loss, with the majority of the women having experienced the loss less than one year prior to filling out the questionnaire. Consequently, longitudinal and short-term effects were addressed.
Participants were gathered from different pools. Patients who experienced miscarriages and terminations at Westchester County Medical Center (WCMC) in Valhalla, New York were administered the series of questionnaires. The questionnaire was mailed to the participants with a short cover letter asking for cooperation and two self-addressed stamped envelopes (SASEs) included. One letter regarded confidentiality and informed consent, and was returned by the participant separately to ensure anonymity. Each responder’s returned questionnaire was assigned an identification number to guarantee anonymity.
A World Wide Web listserv was also used for both groups from which equal numbers of participants were targeted. This was a moderated newsgroup where members posted messages that others read via e-mail and invited responses. As a closed list designed to protect privacy, a person sent a brief note to the monitor describing her experience and why she wanted to be on the list. The monitor screened each individual for his or her suitability for the group and authenticity of experience, thus attempting to ensure the truthfulness of each member (www.aheartbreakingchoice.com). Hygeia (www.hygeia.org), a Website dedicated to perinatal loss, posted a notice regarding the study, allowing selection from an even greater population.
The perinatal bereavement coordinator at Good Samaritan Hospital in Suffern, New York agreed to solicit the participation of women who miscarried in their hospital setting, women who participated in their support groups, and women who were referred to them for follow-up (P. Magi, personal communication, April 24, 1999). The same procedures as above were followed for questionnaire administration. Additional advertisements were placed in perinatal bereavement newsletters to solicit participants.
286 / KEEFE-COOPERMAN Coding ensured the results would differentiate between the internet participants, the support group participants, and the WCMC participants. Equal numbers of participants were targeted for both the miscarriage and the termination groups, allowing for monitoring of differences between each group.
Questionnaires To accurately assess the three areas of loss experienced by the two populations, measures were used that looked at grief factors through the use of self-report questionnaires.