The effect of attachment, attributions, maternal age, previous fetal loss and number of children on grief following spontaneous abortion

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Further reproduction prohibited without permission. THE EFFECT OF ATTACHMENT, ATTRIBUTIONS, MATERNAL AGE, PREVIOUS FETAL LOSS, AND NUMBER OF CHILDREN ON GRIEF FOLLOWING SPONTANEOUS ABORTION A dissertation submitted to the Kent State University Graduate School o f Education in partial fulfillment o f the requirements for the degree of Doctor o f Philosophy by Rebecca Johnson Heikkinen May, 1995 R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited w ithout p erm ission. UHI Number: 9536635 UMI Microform 9536635 Copyright 1995, by UMI Company. All rights reserved. This microform edition is protected against unauthorized copying under Title 17, United States Code. UMI 300 North Zeeb Road Ann Arbor, MI 48103 R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited without p erm ission. Dissertation written by Rebecca Johnson Heikkinen B.A., Wittenberg University, 1974 M.Ed., Kent State University, 1987 Ph.D., Kent State University, 1995 A -^ ^ 2 f*^Director, Doctoral Dissertation Committee Members, Doctoral Dissertation Committee C I cxA a l ftitA/tu D/ctanfe^'v Accepted by c/. Chairperson, Department o f Adult, Counseling, Health and Vocational Education Dean, Graduate School of Education ii R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited w ithout p erm ission. ACKNOWLEDGEMENTS I wish to extend grateful acknowledgment to my dissertation committee, including Dr. Claire Draucker who offered both encouragement and guidance with editing; Dr. Dan Sanders who gave patient support; and especially Dr. Tom Dowd for his motivation and generous gift of both time and mentorship. All o f the above individuals were instrumental in helping me to finish the long process leading up to this final milestone in my doctoral studies. I am grateful to my friends and colleagues, but most especially to my family for their acceptance o f the frequent disruptions caused by my extended tenure as a student. I am especially thankful for the on-going support afforded by my husband, Carl, who has carried many additional responsibilities in the family during my seven years o f graduate work. I would also like to thank my two sons, Matthew and Eric for their patience and good humor at times when my studies caused me to be unavailable to them. Finally, I wish to thank my parents, Nils and Janet Johnson, whose support for the pursuing of one’s dreams led to the vision o f the possibility o f obtaining a doctorate mid-life. iii R ep ro d u ced with p erm ission o f th e copyright ow ner. Further reproduction prohibited w ithout perm ission. TABLE OF CONTENTS Page ACKNOWLEDGEMENTS................................................................................................... iii LIST OF TA B LE S...................................................................................................................vi Chapter I. THE PROBLEM ......................................................................................................... Introduction.............................................................................................................. Description of the P ro b le m .................................................................................. Psychological Repercussions of Spontaneous A bortion.............................. A ttachm ent......................................................................................................... Causal Attributions ....................................................................................... Causal Attributions and Spontaneous Abortion ........................................ Previous Fetal L o s s ....................................................................................... Statement of the Problem .................................................................................. Operational Definitions ................................................................................ Scope of the S tu d y ............................................................................................... II. 1 1 3 3 7 10 13 14 15 16 17 REVIEW OF THE LITERATURE......................................................................... 19 Review of the Literature on the Problem Spontaneous A bortion.......................................................................................... 19 Definition of a Spontaneous Abortion ....................................................... 20 Psychological Repercussions of Spontaneous A b o rtio n ................................. 21 A tta ch m en t........................................................................................................... 24 Attributional T h e o ry ............................................................................................ 30 Spontaneous Abortion and Attributions .................................................... 34 Grief ..................................................................................................................... 41 III. M ETH O D O LO G Y .................................................................................................... Description of the S am p le .................................................................................. In stru m en ts........................................................................................................... Pregnancy Loss Attributional Questionnaire-Predictor Variable .......... Maternal-Fetal Attachment Scale-Predictor V ariable................................. Perinatal Grief Scale-Dependent V a ria b le .................................................. Design ................................................................................................................... Procedures ........................................................................................................... Statistical T reatm en t............................................................................................ iv R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited w ithout p erm ission. 45 45 48 48 49 53 56 57 59 IV. R E S U L T S................................................................................................................... Results for Hypothesis I ..................................................................................... Results for Hypothesis II .................................................................................. Results for Hypothesis I E .................................................................................. Results for Hypothesis I V .................................................................................. Results for Hypothesis V .................................................................................. 60 65 65 66 66 66 V. SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS....................... Summary .............................................................................................................. Purpose................................................................................................................... M eth o d................................................................................................................... Results and D iscu ssio n ....................................................................................... Hypothesis I .................................................................................................... Hypothesis II ................................................................................................. Hypothesis I E ................................................................................................. Hypothesis I V ................................................................................................. Hypothesis V ................................................................................................. Limitations ........................................................................................................... Conclusions and Recommendations for Future R e searc h .............................. 67 67 67 69 70 70 74 76 79 81 82 84 APPENDDCES ................................................................................................................... 88 REFERENCES .................................................................................................................. v R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited w ithout p erm ission. 100 LIST OF TABLES Table Page 1. Estimations o f Internal Consistency for the Maternal-Fetal Attachment Scale and Five Subscales 53 2. Correlation Matrix: Maternal-Fetal Attachment Scale and Subscales 55 3. Sample Items and Alpha Coefficients for Grief Subscales 59 4. Descriptive Statistics for all Measures 65 5. ANOVAS for Planned Comparisons 67 6. Correlation Coefficients 68 7. Stepwise Multiple Regression Statistics 69 vi R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited without p erm ission. CHAPTER I THE PROBLEM Introduction When a pregnancy ends in a spontaneous abortion, the mother typically experiences grief similar to the grief experienced after the loss o f a significant other (Kennel, Slyter, & Klaus, 1970; Peppers & Knapp, 1980). The level o f grief following spontaneous abortion is most likely influenced by a variety of variables, although few have been identified in the literature. By being able to isolate factors that may influence the level o f grief experienced, individuals who are most at risk for experiencing pathological grief reactions can be identified and given support soon after the loss in an attempt to resolve grief expeditiously. The World Health Organization (1970) defined spontaneous abortion as a spontaneous fetal loss occurring between conception and twenty-eight weeks o f gestation. The term "miscarriage" is synonymous with spontaneous abortion. Buehler (1983) stated the percentage of pregnant women in the United States who realize they are pregnant and then lose the fetus is about 10%-14%, while Cavanagh and Comas (1982) placed the rate at 20%. "Attachment" is an emotional bond which is established between mother and fetus 1 R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited w ithout p erm ission . and can be measured in terms o f the behaviors the mother engages in which represent interaction and affiliation with the fetus (Kemp & Page, 1987). Although attachment was originally believed to occur after birth, it is now described as one of the developmental stages that occurs during pregnancy (Cranley, 1981). "For five months or longer (the mother) has had a physical and kinesthetic awareness of the fetus, and for even longer she has had intellectual knowledge of her child" (Cranley, 1981, p. 281). Attachment has been found to be related to the intensity of emotion experienced after miscarriage (Madden, 1986). The causal explanations that people place on life events have often been found to influence their psychological adjustment and ability to cope following those life events (Abramson, Seligman, & Teasdale, 1978; Bulman & Wortman, 1977; Janoff-Bulman, 1979; Seligman, 1975; Silver & Wortman, 1980; Wortman, 1976; Wortman & Brehm, 1975). O f particular interest are the explanations that people provide following a negative life event, especially when this event is in reality beyond their control. Even in situations where it is evident that a change o f actions would not have resulted in a different outcome, it is not unusual for people to attempt to find a causal link. Attribution theory suggests that our cognitions, expectations, and actions are based on a mastery of the causal network of the environment. A "causal attribution" is an assignment o f perceived causation to one or more factors in an attempt to understand events that one observes around oneself, including one’s own actions or the actions taken by others (Harvey & Smith, 1977). Unlike a prediction, an attribution is made following an event, although it may influence future events. Causal attributions are R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited w ithout p erm ission . thought to affect the emotional path that one experiences following the event, so that different causal attributions lead to different emotions (Weiner et al., 1971). One negative life event that is usually beyond the control o f the persons involved is a spontaneous abortion. When a woman plans a pregnancy, she may or may not think about the level of control she may have on its eventual outcome. Once a woman experiences a fetal loss, whether it is caused by a spontaneous abortion, a stillbirth, or a neonatal death, she is apt to pay more attention to this issue. As the number o f losses mount, it is probable that a woman feels less able to control the outcome of any future pregnancy. In this study, the emotional aftermath of spontaneous abortion will be viewed in terms o f level o f grief. "Grief' will be considered in terms of active grief, difficulty coping and despair as measured by these factors on the Perinatal Grief Scale. Description o f the Problem Psychological Repercussions o f Spontaneous Abortion Until recent years, spontaneous abortion, which has been estimated to occur in about one-fourth o f all pregnancies, has been almost neglected as a subject of social science research. Since 1969 a few investigations have been conducted, but for the most part they have been lacking in methodological sophistication, have been filled with statistical errors and design insufficiencies, and have been based on very little data (Kirkley-Best & Kellner, 1982; Peppers & Knapp, 1980a). Reinharz (1988) commented that "the most striking aspects of the experiential literature on miscarriage R ep ro d u ced with p erm ission o f th e copyright ow ner. Further reproduction prohibited w ithout perm ission. are its sparseness and its persistent complaints about the silence with which miscarriage is surrounded" (p. 85). The literature on spontaneous abortion is largely unsystematic and is based for the most part on case studies or on very small-scale studies usually involving married, middle-class couples (e.g., Drotar & Irevin, 1979; Turco, 1981). Both types of literature have reported emotional trauma and often intense depression on the part o f these women. Many authors have stated that this depression has not been supported by others, either in the lay public or by professionals. More complete information about the psychological repercussions of this type o f perinatal loss is needed in order to provide support for victims (Brody, 1980; Holland, 1982; Jimenez, 1982; Pizer & Palinski, 1980). The studies that venture beyond the case-study approach frequently use unstructured interviews to assess the level of grief (e.g., Rowe et al., 1978; Wolff, Nielson, & Schiller, 1970). A few researchers have been more systematic and have used the work of Kennell, Slyter, and Klaus (1970) to measure perinatal grief, while including other variables o f interest. In 1988, Toedter, Lasker, and Alhadeff developed the Perinatal Grief Scale, providing the first reliable and well-validated measure of this grief construct. The studies that have looked at perinatal grief indicate that maternal grief is very similar to the reaction o f grief generally experienced with the death o f an older loved one (Kennell et al., 1970; Peppers & Knapp, 1980). However, Leon (1987) listed six reasons that perinatal loss is particularly difficult for women. The first is related to the narcissistic nature o f the loss experience. Losing a fetus is like losing a part o f R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited w ithout p erm ission. one’s own body, which can be more difficult to mourn than a separate person (Furman, 1978). In order to mourn a perinatal loss, the fetus must be viewed as a separate individual who has died. The second reason is related to the self-blame that is typically felt by the mother as she looks for a cause in her own behavior during the pregnancy. This will be discussed in more detail in the section dealing with attributions. The third reason is that with perinatal loss there is usually no opportunity to anticipate the death, which makes the shock much greater. Parkes (1975) stated that when advance warning is short and the death is sudden a much greater impact is felt than with deaths that take place following a warning with the life terminating more gradually. Sudden death results in greater and more long-lasting disorganization in the life o f the survivor. The speed o f change has been shown to compound the effects stemming from negative life events (Lauer, 1974). With perinatal loss a woman’s status can often change from pregnant to no-longer pregnant in one day. Pizer and Palinski (1980) agreed that the stark contrast o f being in the process o f fulfilling a dream one day and experiencing a devastating loss the next day is a reason spontaneous abortion is so difficult to handle. The fourth reason Leon (1987) listed is a lack o f concrete memories or objects with which to remember the child. The fifth reason is the prospective nature of the grief; that is, fantasies o f future interactions that might have taken place with the child need to be mourned. Finally, as already mentioned, there is a lack of social support by the medical profession and the community at large. R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited w ithout p erm ission. Hutti (1992) stated that participants in her study o f miscarriage had no schema model, or set o f expectations, for what a miscarriage is like because they had no prior miscarriage experience personally or from anyone close to them. Because the experience in not generally openly discussed, the women did not have a framework to view their own experience from, and therefore stated that they did not know what to expect o f themselves or from the experience. Developmentally, Rubin (1975) described pregnancy as a time o f heightened sensory perceptivity. The pregnant woman turns inward with the realization that others cannot share these sensory experiences. This leads to a heightened sense of uniqueness and estrangement, which can serve to isolate the pregnant woman. This isolation is exacerbated when the pregnancy is suddenly ended due to a spontaneous abortion, often leading to feelings that no one can really understand. Another difficulty in dealing with a spontaneous abortion is that traditionally there has been no ritual that accompanies the loss. Burr, Leigh, Day, and Constantine (1979) talked about the high levels o f family disorganization that can result when there are no specific rituals used to help people make transitions. Kohn and Moffitt (1992) and Broner (1982) advocated the use o f rituals to symbolize the loss of pregnancy. Beil (1992) pointed out that since so many pregnancies end in miscarriage, many women who are in therapy will have been through this type o f loss. Reproductiverelated events may well be related to depression in women, but the biopsychosocial factors which may contribute to this depression are poorly understood by both therapists and the women themselves. The women themselves may be unaware of the R ep ro d u ced with p erm ission o f th e copyright ow ner. Further reproduction prohibited w ithout perm ission. impact that past losses may have on their current level o f functioning. Few empirical studies have examined the psycho-social aspects o f spontaneous abortion. As Beil (1992) stated, "the study o f the internal experience o f miscarriage has been largely neglected" (p. 62). Variables that have been studied include the relationship between grief following spontaneous abortion and future incidence of spontaneous abortion (Dunbar, 1963; Peppers & Knapp, 1980), pregnancy used as a grief resolution strategy (Horowitz, 1979), and the incidence o f pathological grief following spontaneous abortion (Stack, 1980, 1984). More recently, Madden (1986) has studied the emotional aftermath o f spontaneous abortion. She found that respondents remembered mainly negative reactions right after the spontaneous abortion, but often felt more positive four months later. Attachment "Attachment" is defined as the affectional tie that develops between a mother and her child from conception on, causing the mother to maintain proximity to that child following birth. Attachment theory suggests that this response is programmed in the species in order to ensure the survival o f the infant by establishing proximity of mother and child in case o f threat or danger (Ainsworth, Blehar, Waters, & Wall, 1978; Bowlby, 1969). Attachment that develops over the first two years of a child’s life has been studied as it relates to various aspects of developmental functioning. Because it has variously correlated with the child’s exploration and problem-solving ability, curiosity, sociability, and control, it has been seen as a critical developmental issue (Egeland & R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited w ithout p erm ission. 8 Farber, 1984). Recently, attachment has been viewed as something that may develop prior to the birth of the child. Psychoanalysts have suggested that the mother-infant bond is initiated with intrauterine movements (stated in Klaus & Kennel, 1982), but Cranley (1981) suggested that this bond develops even earlier for the mother, sometimes from the time she first becomes aware of her pregnancy. Cranley believed this attachment is the result of both psychological and physiological events. Kemp and Page (1987) defined this prenatal attachment as "the extent to which the woman engages in behaviors that represent affiliation and interaction with her unborn fetus" (p. 179). Developmental theory provides a basic framework for understanding attachment in terms of the tasks or stages o f pregnancy. A developmental task is defined as "the growth responsibility that arises at a certain time in the course of development, successful achievement o f which leads to satisfaction and success with later tasks" (Kemp & Page, 1987). Rubin (1975) described pregnancy as a period o f identity reformulation and personality maturation with tasks to be completed at different levels. Three of the major tasks o f pregnancy that a woman must accomplish include: 1. Seeking safe passage from conception through delivery for herself and her baby; 2. Attempting to secure the infant’s acceptance by significant family members; 3. Attaching or binding-in with her child. Rubin (1975) stated that during the first trimester, the woman’s method o f seeking safe passage relates more to herself than the baby. Her only early clue concerning her pregnant status is a non-event, namely amenorrhea. This can signify the presence of R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited w ithout p erm ission. cancer or another serious disease or dysfunction, thus Rubin felt that pregnancy represents a better alternative to the woman. It is better to be pregnant than to have cancer or another serious medical problem. Rubin felt that attachment to the child develops after the first trimester, when tactile, visual, and kinesthetic cues first appear. It is the attachment to and awareness o f the child that causes the woman to seek prenatal care in an attempt to protect the child from being damaged. This help can take many forms including media (books, magazines, television), medical professionals, or laywomen considered experts in childbearing. Along with seeking safe passage for herself and her baby, a woman has the task of securing acceptance o f that child by significant others. Especially during the first trimester, the woman as childbearer must assure not only for physical accommodation of the child into the family, but also for the psychosocial accommodation o f that child. Securing acceptance involves loosening relationship bonds o f intimacy and exclusiveness and realigning these bonds in preparation for the addition o f a child. The acceptance process begins during pregnancy as a conceptual one. If acceptance is conditional on the child’s sex or health status, the acceptance is not considered complete. "Conditional acceptance involves implicit rejection" (Rubin, 1975. p. 148). The rejection o f the child is tied to a rejection of the self. Cranley (1981) believed that the development o f the mother-fetal relationship is integral to the consideration of both the woman’s identity and the identity of the developing fetus. Leifer (1977) stated that maternal involvement with the fetus can be seen in prenatal attachment behaviors, such as talking to the fetus, calling it by a pet name or R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited without p erm ission. 10 maneuvering the fetus in an effort to allow the husband to observe the movement. These behaviors are evidence o f what Rubin (1975) termed binding-in or attaching to the fetus as person, the third developmental task of pregnancy. It is not known exactly when these attachment behaviors begin or whether the level o f attachment effects the level o f grief experienced following the severing of this attachment via spontaneous abortion. Causal Attributions Recently there has been much interest in understanding how people cope with negative life events, and in particular, in determining what factors place individuals "at risk" for negative psychological outcomes. Seligman and his associates’ research dealing with learned helplessness and depression (Abramson, Seligman, & Teasdale, 1978; Seligman, 1975), as well as the work o f Wortman and Janoff-Bulman on coping with uncontrollable negative life events (Bulman & Wortman, 1977; Janoff-Bulman, 1979; Silver & Wortman, 1980; Wortman, 1976; Wortman & Brehm, 1975), have been influential in this sphere. Peterson and Seligman (1984) stated that people have characteristic explanatory styles. If reality is ambiguous enough, a person will project and impose his habitual style in the form o f an explanation or attribution for the event. There are two things that influence what particular explanation is chosen. The first factor is the reality of the bad event, which is the environmental stressor in a diathesis-stress model. The second factor is that of explanatory style, which is sometimes seen as a risk factor, but will only come into play in the event o f some precursor. R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited w ithout p erm ission. Janoff-Bulman (1979) looked at causal attributions in terms o f predicting coping and Abramson and Martin (1981) in terms of predicting depression. Other theorists have noted the tendency o f groups o f people to place blame on themselves for negative life events that are in actuality beyond their control. Examples of such groups have included concentration camp prisoners (Bettelheim, 1943), parents o f children with leukemia (Chodoff, Friedman, & Hamburg, 1964), rape victims (Burgess & Holmstrom, 1974a, 1974b, 1976), and victims of freak accidents (Bulman & Wortman, 1977: see Wortman, 1976, for a review). There has been a controversy among authors as to whether this tendency for self­ blame has played an adaptive or maladaptive role in terms of the coping process. Beck (1967) viewed self-blame as a maladaptive and self-deprecating symptom of depression; Abrams and Finesinger (1953), stated that self blame was maladaptive; Weisman (1976) also found self-blame to be a counter-productive response. From the other perspective, self-blame is seen as an adaptive coping response as the assignment of self-blame implies a sense o f personal control over outcomes (Janoff-Bulman, 1979). Perceived control over one’s outcomes is thought to be related to adjustment and health. Janoff-Bulman (1979), in an attempt to reconcile these different findings, proposed two distinguishable types of self-blame; self-behavior blame, an attribution to a controllable or modifiable aspect of the self; and self-character blame, an attribution to uncontrollable aspects o f the self. Because o f the lack of control postulated over characterological blame, it is seen as a self-deprecating response. Abramson and his R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited w ithout p erm ission. associates, in their reformulated model of learned helplessness, go beyond a simple internal-external attributional distinction. They add two additional dimensions: the degree to which attributions are both stable versus unstable and specific versus global (Abramson, Seligman, & Teasdale, 1978). Both models agree on the importance o f distinguishing attributions that are characterological (internal, stable, and global) from those that are behavioral (internal, unstable, and specific). If the characteristic explanatory style attributes internal, stable and global causes (characterological attributions) the person tends to become depressed or to cope more poorly when bad events occur because of the decrease in self-esteem and lack of control that exists with this attributional style. Therefore, those attributions involving characterological blame should be negatively related to coping but positively related to depression. Those that make behavioral attributions assume the ability to exercise some control and make changes to prevent reoccurrence. Therefore, a behavioral attributional style should be positively related to coping but negatively related to depression. External attributions imply causation due to an outside force, which may be stable or unstable, and specific or global. This type o f attribution results in the perception of lack of control. However, what distinguishes between this type of attributional style and either type o f internal attributional style is the exemption o f personal responsibility. When an external source is found to be accountable for a negative life event, one is personally exonerated from causation, and there is not a decrease in self­ esteem as is found with characterological attributions. Therefore, making an external R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited without p erm ission. 13 attribution should be positively related to coping and negatively related to depression. Causal Attributions and Spontaneous Abortion Spontaneous abortion or miscarriage can be viewed as a negative life event that is normally out o f the control of the woman experiencing the event. Cavanagh and Comas (1982) stated one reason spontaneous abortions in particular can be so traumatic is that a cause is not often identifiable. Uterine infection or chromosomal abnormalities can only rarely be isolated as the cause o f a spontaneous abortion. This ambiguity leaves the door open for the woman to attribute any cause she may choose for the loss. It is not unusual for an attribution to take the form o f self-blame (internal characterological or internal behavioral attributions), because the culture emphasizes the need for pregnant women to be responsible for their unborn children’s health. Especially in recent years, both the medical profession and the culture at large have emphasized that a woman’s behavior during pregnancy has the potential to impact her baby’s health. Warnings about smoking and drugs and admonitions to eat well and exercise moderately are examples of this. With the experience o f a spontaneous abortion it becomes difficult to reconcile this idea of responsibility for the health of the fetus with the fact that some losses cannot be prevented with even the best prenatal care (Reinharz, 1988). There are two common myths that may affect the attribution made by the victim (Stack, 1984). One is the idea that either physical exertion or an accidental injury are common causes o f the loss of a fetus. There is no medical evidence linking physical R ep ro d u ced with p erm ission o f th e copyright ow ner. Further reproduction prohibited w ithout perm ission. 14 activity or trauma and spontaneous abortions (Cavanagh & Comas, 1982). Although most physicians impart this information to their patients (Stack, 1984), many women still attribute causation to something they did (e.g., Pizer & Palinski, 1980). The second myth is that anxiety can cause spontaneous abortion. Although there are psychoanalytic clinical reports that claim to identify psychological causes of spontaneous abortion, there has not been such a link from larger, more systematic studies. Despite the reassurance of doctors, some women continue to think that the fact that they are nervous or under a lot o f strain might have contributed to their loss (Madden, 1988; Pizer & Palinski, 1980). Previous Fetal Loss Control over future losses is one reason why it is important for individuals to make a causal attribution. If one can attribute the cause to something that is modifiable, the individual believes that chances are the event will not be repeated once a specific change is made. Control is also important in terms of the number o f losses a woman has experienced in the past and her confidence about being able to successfully accomplish pregnancy and birth o f a healthy baby in the future. With a second or third loss, the woman begins to look for variables that were the same during every pregnancy. I f the first loss was thought to occur due to a modifiable factor and that factor is changed, yet a subsequent pregnancy also ends in spontaneous abortion, it should become more difficult to believe future losses will be controlled. One attempts to find commonalities between the losses and place a new cause o f blame that fits both instances, but control seems less possible as the number o f losses mount. For this R e p r o d u c e d with p erm ission o f th e copyright ow ner. Further reproduction prohibited without perm ission. 15 reason it is thought that level o f grief will be higher for those who have experienced more than one fetal loss (spontaneous abortion, stillbirth or neonatal death). Statement of the Problem It is important to be able to identify who might be at risk for negative psychological consequences following a spontaneous abortion so that interventions can be implemented early in the grief process. It is proposed that higher levels of attachment to the fetus will increase the level of grief. "Attachment" is defined as an affectiona! tie that helps to bind individuals together. Thus it is felt that the more tied to the fetus one has become, the more difficult the loss of that "individual" will be. Further, it is proposed that an attribution for the spontaneous abortion that is assigned as an aspect o f one’s character as opposed to being attributed to either one’s behavior or some external cause, would have a negative effect on an individual’s level of grief following the loss of a pregnancy. This study will look at maternal attachment to the fetus during pregnancy, attributions o f the cause o f a spontaneous abortion, number o f previous fetal losses, number o f living children, and maternal age as predictors of level of grief following spontaneous abortion for previously expectant females. From previous studies that have been done it is possible to theorize several factors that might have an impact on level of grief following spontaneous abortion. The following hypotheses were addressed in this study: 1. Level o f grief will be significantly impacted by level of attachment. R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited w ithout p erm ission. 2. Level o f grief will be significantly impacted by type o f attribution made. 3. Level o f grief will be significantly impacted by the number o f previous fetal losses. 4. Level o f grief will be significantly impacted by the number o f living children. 5. Level o f grief will be significantly impacted by maternal age. Operational Definitions 1. Maternal attachment: The mean score on Maternal Fetal Attachment scale. The greater the sum, the greater is the inferred attachment to the lost fetus. 2. Attribution of cause o f the spontaneous abortion: The raw score total o f items answered in the keyed direction on the Pregnancy Loss Attributional Questionnaire subscales (External, Behavioral, and Characterological attributions). 3. Number o f Fetal Losses: The total number o f losses from spontaneous abortion, stillbirth, or neonatal death experienced previous to the current miscarriage by the previously expectant mother. 4. Number o f Living Children: The number o f surviving children who were born to or adopted by the subject. 5. Maternal Age: The self-reported age of the subject. 6. Perinatal grief: The total score on the Perinatal Grief Scale. The larger the score, the greater is the inferred level of grief. R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited w ithout p erm ission. 17 Scope o f the Study This study is limited to an examination of maternal attachment to the fetus, the attribution o f cause o f the spontaneous abortion, number of previous fetal losses, number of living children, and maternal age as predictors of level of grief for females who have spontaneously aborted. Attachment was previously seen as beginning following the birth of a baby as an inborn trait that served the purpose of keeping parent and child close to each other for the sake of protection. It has been shown that most women become attached to the fetus prior to birth, at some time during the pregnancy. Since this attachment occurs at different stages during the pregnancy and develops at different levels, it is hypothesized that this difference may affect level o f grief. Similarly, since people are known to spontaneously make attributions for the cause of negative life events, it is postulated that the type of attribution made for the spontaneous abortion may affect level o f grief. The issue of control over future losses is important in terms of the number o f losses one has experienced. Women who have experienced more than one loss are likely to experience greater levels of grief because they may have attempted to change behaviors after an initial loss, yet experienced the same outcome. It is hypothesized that they will feel less control following subsequent losses, and therefore should exhibit higher levels o f grief. Women who already have at least one child have a history o f successfully completing a pregnancy in the past. Besides knowing that they have been able to conceive and carry a pregnancy to term, they also have the consolation o f knowing R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited without p erm ission. 18 that they already have a child. This should impact the level o f grief that they experience following spontaneous abortion. Older women should be aware that it is more difficult to become pregnant as they age, since both men and women are most fertile in their mid-twenties. Fertility for women starts to decline slowly after the mid-twenties, until at about age thirty-five, it begins to decline rapidly. Younger women have statistically better chances o f conceiving. Therefore, it is felt that there will be a difference in level o f grief due to maternal age. R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited w ithout p erm ission. CHAPTER II REVIEW OF THE LITERATURE Review o f the Literature on the Problem Spontaneous Abortion Women who have suffered a spontaneous abortion have traditionally not been supported psychologically through their time of grieving by either the medical or the mental health community (Leon, 1987). Along with the lack of understanding and concern on the part of these professionals, the lay public has also tended to belittle the concerns o f those who experience a spontaneous abortion. There is a silence that pervades the whole issue of perinatal loss - as if the mention of the possibility may bring about the occurrence (Reinharz, 1988). This silence begins very early in the pregnancy cycle and in the case of one experiencing a pregnancy loss, is most often resumed immediately following the loss. This unvoiced, superstitious belief serves to contribute to the fact that couples are both uninformed about and unprepared for pregnancy loss. Literature addressing the nature of spontaneous abortion and the factors that have been found to predispose individuals to pathological outcomes following these losses is reviewed. One result o f the shroud of silence that has been found to surround the issue of 19 with p erm ission o f th e copyright ow ner. Further reproduction prohibited w ithout perm ission. 20 pregnancy loss is the idea that people assume that the whole reproductive process is a simple linkage between desire and accomplishment, a fait accompli. As Reinharz (1988) stated when conception is assumed to be the simple outcome o f the choice to conceive and when pregnancy and a baby are assumed to be the natural outcomes o f conception, an exaggerated notion of control has been introduced into our view of reproduction. People speak o f the choice to have or not to have children. Unfortunately, the very notion of choice hides the fact that the only thing about which women have some choice is not to reproduce, (p. 86) The fact that most couples are led to believe that with modern medical care pregnancy leads to a healthy baby has led to an assumption that they are more in control o f the outcome than in actuality they are. Therefore, a spontaneous abortion is not only shocking since the silence surrounding loss has kept them unaware of the commonality o f the occurrence, but jolts them to realize that control o f reproduction is not in their hands alone. Definition o f a Spontaneous Abortion For the purposes o f this paper a spontaneous abortion (miscarriage) is classified as a spontaneous (as opposed to induced) pregnancy loss occurring between conception and twenty eight weeks gestation. There are approximately 600,000 to 800,000 spontaneous abortions in the U.S. alone annually (Beil, 1992). The collection of epidemiological data is controversial because o f methodological problems. Often spontaneous abortions are not recognized by the women who have them, and some, although recognized, require no medical intervention, and therefore go unreported. Some statisticians place the spontaneous abortion rate as high as one in four R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited w ithout p erm ission. 21 conceptions. Buehler (1983) stated the percentage o f pregnant women in the United States who are cognizant o f their pregnancy and then abort the fetus is about 10%14%, while others place this rate at 20% (Cavanagh & Comas, 1982). When a study of 221 women who were attempting to conceive employed highly sensitive pregnancy detection methods, 22% of the 198 pregnancies ended prior to the pregnancy being detected clinically. Another 31% of the pregnancies in this study were lost after clinical deteciion (Wilcox et al., 1988). Psychological Repercussions of Spontaneous Abortion There has not been much research conducted in the area o f psychological repercussions o f spontaneous abortion. Those studies that have been done have consisted primarily of case studies with a very small number o f subjects. The literature has reported emotional trauma and often intense depression on the part of the women experiencing spontaneous abortions. Many women have stated that this depression has not been supported by others, either in the lay public or by medical or mental health professionals. In order to provide emotional support for victims, more complete information about the psychological repercussions o f perinatal loss is needed (Brody, 1980; Holland, 1982; Jimenez, 1982; Pizer & Palinski, 1980). One study that dealt with the emotions experienced following spontaneous abortion was conducted by Madden (1986). Sixty-five women were asked to describe their emotions and coping strategies following miscarriage. Sadness following the spontaneous abortion was by far the most common emotion reported by the women. This emotion was reported by 88.6 percent of the participants. Following this were R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited without p erm ission. 22 frustration (35.4%), disappointment (35.5%), and anger towards themselves (28%). All respondents reported experiencing a sense of loss that was very intense, and all reported crying afterward. However, what was perceived as lost varied for the women. Immediately following the spontaneous abortion, emotions were more intense for those women who had time to become attached, held themselves more responsible for the loss and were unable to talk to anyone about the loss. Madden (1986) concluded that miscarriage is clearly a disturbing experience, but that there seems to be a wider range o f reactions to it than has been indicated in case studies. Seibel and Graves (1980) administered a self-report questionnaire with both forcedchoice and open-ended questions to 93 patients who presented for a dilation and curettage (D&C) following an incomplete spontaneous abortion. A checklist o f 16 adjectives, including 4 positive and 12 representing depression, anxiety, and hostility, was used. Two thirds o f their subjects were either single, separated, divorced, or widowed, and 72% of the pregnancies were unplanned. Therefore, it was not surprising that at least one positive adjective was checked by 29.3% o f the patients and 13.4% checked two or more. However, even with this population, negative feelings were much more common, with 44% checking either unhappy or very unhappy. Only 11% checked no negative affect adjective, while 89% checked at least one and 23.1% checked four or more. In a study looking at psychological outcome following spontaneous abortion, Friedman and Gath (1989) interviewed sixty-seven women who were admitted to a hospital for complete or threatened abortion treated by evacuation o f the uterus. Semi- R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited w ithout p erm ission. 23 structured interviews were completed within four weeks o f having had the spontaneous abortion. Along with the interviews, each woman’s mental state was assessed using the Present State Examination (PSE; Wing, Cooper, & Sartorius, 1974). The women also completed self-rating scales, including the Beck Depression Inventory (BDI; Beck, 1967); the Eysenck Personality Questionnaire (EPQ; Eysenck & Eysenck, 1975); the Maudsley Marital Questionnaire (MMQ; Crowe, 1978); and the Modified Social Adjustment Scale (SAS-M; Cooper, Osborn & Gath, 1982). Levels of emotional distress were found to be high during the four week period following the spontaneous abortion. As determined by the PSE, 32 o f the 67 women were determined to have major psychiatric disorders, which is four times higher than would be expected in the normal population. In every case, the diagnosis was depressive disorder. Although this diagnosis was confirmed by the scores on three depression rating scales, the relatively mild level o f depression indicated that many of the women were already beginning to recover. Depressive symptoms were significantly associated with a history o f previous spontaneous abortions. Childlessness was also significantly associated with depressive symptoms, although less so than history of previous abortions. In an attempt to predict short and long-term grief following perinatal loss (i.e., spontaneous abortion, ectopic pregnancy, fetal and neonatal death), Lasker and Toedter (1990) measured the levels o f grief experienced by one hundred ninety-four bereaved parents at three intervals. The subjects were referred from a variety of private practices and hospital clinics, and grief scores were calculated at two months, one year, R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited w ithout p erm ission. and two years post-loss. Variables fit into one of five categories: individual characteristics, characteristics of the loss, coping resources, other stressful life conditions, and expectancy for the success o f a subsequent pregnancy. The research team found that contrary to their hypothesis, those women who had no history of fertility problems and who had expectations for a subsequent successful pregnancy were likely to experience higher grief scores. At two months post loss all variables in the model were significant in predicting grief, except other stressful life conditions. The only variables found to predict grief throughout the two years post loss were characteristics o f the loss, particularly length of the pregnancy, and coping resources, specifically mental health. This was contrary to the hypothesis that individual characteristics would be important for long-term grief. To summarize the literature, sadness, a sense o f loss, and depression tend to be the hallmarks of the psychological repercussions following spontaneous abortion. What is perceived as loss evidently varies for individual women. Levels of sadness and depression appear to be at higher levels immediately following the loss, with fewer characteristics having long-term predictability in terms of level o f grief. Length o f the pregnancy and coping resources have been found to predict grief levels two years after the loss. Attachment The relationship between the gestational age of the fetus at the time of the loss and maternal grief has been investigated. Kirkley-Best (1981) reported a strong positive relationship between gestational age and grief (r=.39, pc iso m th is m iscarriage w ould have liap|>cin:d. I1’. If I liad Ixrcn able to elim inate so m e stressors in m y life by changing my behaviors, this m iscarriage m ight not have hapixm cd. "(I. O thers had m ine contiol over th e outcom e o f this pregnancy Ilian I did. ? I. Som e of m y ow n physical p io h lcm s m ight have been partly to blam e for the m iscarriage. R ep ro d u ced with p erm ission of the copyright ow ner. Further reproduction prohibited w ithout p erm ission. A P P E N D IX F PERINATAL GRIEF SCALE P e r i n a t a l C r i e f S c a l e , L . T o e d t a r , Mor avian C o l l e g e 6 J . U a k e r , l e h l g h U n i v e r s i t y SHORT FORK PRESENT TH0UCI1TS AND TEELIHCS ADOUT TOUR I.OSS Each of t h e I t e m s l a a s t a t e m e n t o f t h o u g h t s and f e e l i n g s w h ich some people hays c o n c e r n i n g a l a s s , su c h a s y o u r s , T hera a r e no r i g h t o r wrong r e s p o n s e s to t h a s a etateaerita. For e a c h i t e m , c i r c l e t h a number w h i c h b e s t i n d i c a t e * t h a e a t a n t t o which you a g r e e o r d l e a g r e a w i t h I t c t th e p r e s e n t t i m e . I f you a r a n o t c e r t a i n , use t h a "neither*' c a te g o r y . P l e a s * t r y to u s e t h i s c a t e g o r y o n l y when y o u t r u l y h av a no opinion. N either Agraa Strongly Agree nor Agree D isagree D isa gree 1. (2.) 1 f e a l depressed. 2 3 4 2. ( 3 .) I f in d i t hard to get along w ith c e r t a i n people. 2 3 4 3. ( ( . ) S trongly D isagree 3 I f e e l empty i n s i d e , A. ( 1 0 .) I c a n ' t k e e p up w i t h a.7 n o rm al a c t i v i t i e s . 3 5. ( 1 1 . ) I f e e l a n e e d t o t a l k a b o u t t h e b ab y . 6. ( 1 1 . ) I am g r i e v i n g f o r th e baby. 7. ( 1 3 . ) 1 am f r i g h t e n e d . 8. ( 1 9 .) 1 hay* c o n s i d e r e d s u i c i d e since tha lo s s . '9 . 10. ( 2 3 . ) 1 t a k a m e d i c i n e f o r my nerves. ( 2 1 . ) I v e r y much m iss the baby. 11. ( 2 5 .) 1 f e e l I have a d j u s t e d w ell to th e lo ss . 12. (32.) I t I s p a i n f u l to r e c a l l mem ories o f the l o a s . 1 13. ( 3 3 . ) I g e e u p a c c when I t h i n k a b o u t t il* b a b y . 1 4. ( 3 6 .) I c r y when I t h l n k ' a b o u t h im /her. 1 13. ( 4 1 . ) I f e e l g u i l t y whan 1 t h i n k a b o u t th e baby. 1 16. ( 4 3 .) 1 f a e l p h y s i c a l l y i l l when 1 t h i n k about th a baby. 98 R ep ro d u ced with p erm ission o f the copyright ow ner. Further reproduction prohibited w ithout p erm ission. 5 N either A gre e Stro o g ly Agree nor D isa g ree D laagree Strongly Disagree 17. (4*[...]... negative effect on an individual’s level of grief following the loss of a pregnancy This study will look at maternal attachment to the fetus during pregnancy, attributions o f the cause o f a spontaneous abortion, number o f previous fetal losses, number o f living children, and maternal age as predictors of level of grief following spontaneous abortion for previously expectant females From previous studies... ithout p erm ission 17 Scope o f the Study This study is limited to an examination of maternal attachment to the fetus, the attribution o f cause o f the spontaneous abortion, number of previous fetal losses, number of living children, and maternal age as predictors of level of grief for females who have spontaneously aborted Attachment was previously seen as beginning following the birth of a baby as... f the Literature on the Problem Spontaneous Abortion Women who have suffered a spontaneous abortion have traditionally not been supported psychologically through their time of grieving by either the medical or the mental health community (Leon, 1987) Along with the lack of understanding and concern on the part of these professionals, the lay public has also tended to belittle the concerns o f those... than in actuality they are Therefore, a spontaneous abortion is not only shocking since the silence surrounding loss has kept them unaware of the commonality o f the occurrence, but jolts them to realize that control o f reproduction is not in their hands alone Definition o f a Spontaneous Abortion For the purposes o f this paper a spontaneous abortion (miscarriage) is classified as a spontaneous (as opposed... attachment to the lost fetus 2 Attribution of cause o f the spontaneous abortion: The raw score total o f items answered in the keyed direction on the Pregnancy Loss Attributional Questionnaire subscales (External, Behavioral, and Characterological attributions) 3 Number o f Fetal Losses: The total number o f losses from spontaneous abortion, stillbirth, or neonatal death experienced previous to the current... to control the outcome of any future pregnancy In this study, the emotional aftermath of spontaneous abortion will be viewed in terms o f level o f grief "Grief' will be considered in terms of active grief, difficulty coping and despair as measured by these factors on the Perinatal Grief Scale Description o f the Problem Psychological Repercussions o f Spontaneous Abortion Until recent years, spontaneous. .. conceptual one If acceptance is conditional on the child’s sex or health status, the acceptance is not considered complete "Conditional acceptance involves implicit rejection" (Rubin, 1975 p 148) The rejection o f the child is tied to a rejection of the self Cranley (1981) believed that the development o f the mother -fetal relationship is integral to the consideration of both the woman’s identity and. .. known to spontaneously make attributions for the cause of negative life events, it is postulated that the type of attribution made for the spontaneous abortion may affect level o f grief The issue of control over future losses is important in terms of the number o f losses one has experienced Women who have experienced more than one loss are likely to experience greater levels of grief because they may... Further reproduction prohibited without p erm ission 13 attribution should be positively related to coping and negatively related to depression Causal Attributions and Spontaneous Abortion Spontaneous abortion or miscarriage can be viewed as a negative life event that is normally out o f the control of the woman experiencing the event Cavanagh and Comas (1982) stated one reason spontaneous abortions... by the previously expectant mother 4 Number o f Living Children: The number o f surviving children who were born to or adopted by the subject 5 Maternal Age: The self-reported age of the subject 6 Perinatal grief: The total score on the Perinatal Grief Scale The larger the score, the greater is the inferred level of grief R ep ro d u ced with p erm ission o f the copyright ow ner Further reproduction ... permission of the copyright owner Further reproduction prohibited without permission THE EFFECT OF ATTACHMENT, ATTRIBUTIONS, MATERNAL AGE, PREVIOUS FETAL LOSS, AND NUMBER OF CHILDREN ON GRIEF FOLLOWING. .. REVIEW OF THE LITERATURE 19 Review of the Literature on the Problem Spontaneous A bortion 19 Definition of a Spontaneous Abortion 20 Psychological Repercussions of Spontaneous. .. abortion, number o f previous fetal losses, number o f living children, and maternal age as predictors of level of grief following spontaneous abortion for previously expectant females From previous