Denise Côté-Arsenault

Women's emotions and concerns during pregnancy following perinatal loss.

Purpose To determine the specific emotions and concerns of women who are pregnant following a perinatal loss. Study Design and Methods Data were collected through a mailed questionnaire using an open response format. The sample consisted of 73 women on the membership mailing lists from two pregnancy-after-loss support groups. A content analysis was conducted on women’s self-reports; five primary emotions and five main concerns were expressed during their pregnancies. Results “Anxious,” “nervous,” and “scared” were the most frequent emotions reported by these women. However, most women also included a positive emotion in their list, indicating the mixed emotions of their pregnancy experience. Eight categories of profound concerns were identified: “losing another baby,” “overall health of the baby,” “emotional stability of self,” “impact of another loss on my future,” “lack of support from others,” “fear of bad news,” “own impact on the baby,” and “worries never end.” Responses of currently pregnant women as compared with women retrospectively reporting on their last pregnancy experiences were essentially similar. Clinical Implications Women pregnant after a previous perinatal loss are skeptical about pregnancy. Clinicians should be cognizant of the constellation of concerns and the simultaneous contrasting emotions experienced by these women in order to provide supportive prenatal care. Because the women’s concerns are ongoing, responsive care should include asking about specific concerns throughout the pregnancy.

The Influence of Perinatal Loss on Anxiety in Multigravidas

OBJECTIVE To compare multigravid women with and without a history of perinatal loss on state anxiety, pregnancy anxiety, and optimism. DESIGN Comparative descriptive; cross-sectional. SETTING Private obstetric offices in a small northeastern city in the United States. PARTICIPANTS The sample included 160 women who were between 17 and 28 weeks gestation: 96 multigravidas with no history of loss and 74 women with a history of one or two losses. MAIN OUTCOME MEASURES State anxiety, pregnancy anxiety, optimism, and perinatal loss history. RESULTS No group differences were found on demographic variables, state anxiety, or optimism. However, pregnancy anxiety was higher in women with a history of perinatal loss. Pregnancy anxiety was also correlated with desire to see care provider more often and number of phone calls between visits, and was not correlated with the number of living children. CONCLUSION Women experiencing pregnancy subsequent to perinatal loss have greater pregnancy anxiety: That is, they are more concerned about their pregnancies and their babies than women without a history of perinatal loss. State anxiety and optimism do not differentiate these two groups. This heightened anxiety should be acknowledged and more frequent contact with the care provider should be offered.

MATERNAL ASSIGNMENT OF FETAL PERSONHOOD TO A PREVIOUS PREGNANCY LOSS: RELATIONSHIP TO ANXIETY IN THE CURRENT PREGNANCY

The degree of personhood a mother assigns to her dead fetus (i.e., whether she felt she lost a pregnancy or a baby) may help explain the meaning of a perinatal loss and the amount of anxiety experienced in a subsequent pregnancy. This descriptive study of 72 multigravidas with a history of one or two perinatal losses was conducted to understand the relationships between the assignment of fetal personhood and the influence of that assignment on state anxiety and pregnancy anxiety in a subsequent pregnancy. Assignment of personhood was significantly related to pregnancy anxiety and to the gestational age of the first loss but not to state anxiety. Understanding and responding to womens perceptions of perinatal losses and their significance for women may be one way to support them in subsequent pregnancies.

Support Groups Helping Women Through Pregnancies after Loss

Pregnancies following perinatal loss are full of fears and anxieties. Standards of care or interventions are not generally available, however support groups exist across the country. This study explored several pregnancy-after-loss support groups. Data were collected through participant observation of meetings, individual interviews, questionnaires, and artifacts. Five paradoxes were identified reflecting conflicts between common cultural expectations and the women’s own perspectives about pregnancy: birth/death, pregnancy equals/does not equal baby, head/heart, public/private, and hope/fear. According to participants, the groups helped members recognize their commonalities, remember their earlier babies who died, develop caring relationships, and learn new coping skills. Key outcomes included “making it through” their pregnancies, finding ways to reconcile the cultural paradoxes, and relating better with their current, live babies.

Watching & Worrying: Early Pregnancy after Loss Experiences

PurposeTo describe womens early pregnancy after loss experiences (up to 25 weeks gestation), to document the timing and frequency of their common discomforts and events, and to explore changes in these over time. Study DesignLongitudinal, qualitative descriptive, and triangulated (data, methods, analyses). MethodsQualitative data were collected from 82 women pregnant after a past perinatal loss, who were followed through their 25th week gestation. Field notes were taken on all women; 75 women recorded events of their pregnancy through text and stickers on an investigator-supplied calendar. Thematic analysis was done from field notes and hand-written calendar entries; content analysis was conducted on sticker-entered events and symptoms. ResultsThemes identified in the data were Growing Confident, Fluctuating Worry, Interpreting Signs, Managing Pregnancy, and Having Dreams. The first four themes comprise the see-saw nature of these pregnancies. Managing Pregnancy includes the subthemes of Being Hypervigilant, Seeking Reassurance, and Relying on Internal Beliefs. The theme of Having Dreams was a serendipitous finding, in the sense that women reported their dreams without prompting, but the data did not reach saturation. Future research in this area is suggested. Calendar stickers indicate that fatigue and headaches are the most commonly reported discomforts. Fetal movement, felt by all the women by 25 weeks gestation, was very reassuring. Clinical ImplicationsNurses should understand that women who have experienced a previous pregnancy loss have omnipresent worry and anxiety during a subsequent pregnancy, and seek reassurance that their pregnancy and baby are okay. Therefore, the frequent calls and visits to healthcare providers from these women represent their most common and comforting way of coping with their worry.

Emotional cushioning in pregnancy after perinatal loss

Women pregnant again after prior perinatal loss fear another loss and thus protect their emotions and avoid prenatal bonding. This phenomenon, emotional cushioning, appears to be a complex self‐protective mechanism and is proposed here as a unique combination of circumstances and responses used by women to cope with the anxiety, uncertainty, and sense of vulnerability experienced in these subsequent pregnancies. Related literature is reviewed to clarify and circumscribe what emotional cushioning is. In this mixed‐methods study, a convenience sample of women pregnant after perinatal loss (N=63) completed the Pregnancy Anxiety Scale during and following pregnancy and responded to questions regarding ‘holding back their emotions’ in pregnancy. The purpose was to describe the range and prevalence of emotional cushioning, to compare pre‐ and post‐natal reports of emotional cushioning, and to examine relationships between emotional cushioning and pregnancy anxiety pre‐ and post‐natally. The majority of women (58.7%) reported some emotional cushioning. Emotional cushioning questions were significantly and positively correlated with pregnancy anxiety. Clinical and research implications are discussed.

Weaving Babies Lost in Pregnancy Into the Fabric of the Family

During four qualitative research studies on pregnancy after perinatal loss, parents spoke of their dead babies and various ways they remembered them. Thus, they were a continued part of their lives. A secondary analysis was done of all relevant data and is reported here. The overall finding was that parents weave remembered babies into the fabric of their families in multiple ways. Specifically, the following five themes of ways babies were remembered and incorporated into family life emerged from the data: rituals, symbols, visible presence, holding a place in the family, and lifelong impressions. Clinical implications focus on recognizing the excellent care these families received that enabled them to heal and grow after the death of their babies so that such care can be expanded to other families in need. Parents could be encouraged to find their own ways of honoring their deceased babies.

Provision of Services in Perinatal Palliative Care: A Multicenter Survey in the United States

BACKGROUND Congenital anomalies account for 20% of neonatal and infant deaths in the United States. Perinatal palliative care is a recent addition to palliative care and is meant to meet the needs of families who choose to continue a pregnancy affected by a life-limiting diagnosis. OBJECTIVE To examine characteristics of programs and services provided, assess alignment with the National Consensus Project domains of care, and identify providers and disciplines involved in programs. DESIGN A cross-sectional survey design included 48 items addressing funding and domains of quality care. SUBJECTS Program representatives from 30 states (n = 75). PRINCIPAL RESULTS Perinatal palliative care programs are housed in academic medical centers, regional or community hospitals, local hospices, or community-based organizations. Significant differences by program setting were observed for type of fetal diagnoses seen, formal training in communicating bad news to parents, mechanisms to ensure continuity of care, and reimbursement mechanisms. One hundred percent of programs provided attention to spiritual needs and bereavement services; 70% of programs are less than 10 years old. Follow-up with parents to assess whether goals were met occurs at 43% of the perinatal palliative care programs. Formal measures of quality assessment were articulated in 38% of programs. CONCLUSION This study dramatically adds to the literature available on perinatal palliative care program settings, types, and domains of care. It is clear that there are a variety of types of programs and that the field is still developing. More work is needed to determine which quality measures are needed to address perinatal care needs in this population.

Evidence-based Intervention with Women Pregnant after Perinatal Loss

Purpose:To test the feasibility and acceptability of a caring-based nurse home visit intervention for women pregnant after perinatal loss (PAL), the goal of which was to provide a safe, supportive environment, normalize the pregnancy after loss, reduce anxiety and depression through stress reduction skills, and facilitate prenatal attachment. Study Design and Methods:This mixed methods study was conducted in two phases: Phase I, to determine the components of the intervention, and Phase II, a randomized trial that used the revised intervention components. Pregnant women with a history of at least one perinatal loss (9 in Phase I and 24 in Phase II) were recruited from obstetrical practices. Phase II sample size was adequate to detect group differences. Background measures of demographics, obstetrical history, and meaning of past losses were collected at baseline. Measured at three points across pregnancy were threat appraisal of pregnancy; and emotional states: anxiety (pregnancy, state, trait), depression, self mastery, prenatal attachment, and satisfaction with social support. The caring-based nurse home visit intervention included activities aimed to reduce anxiety and promote prenatal attachment. The control group were sent pregnancy information booklets that coincided with their gestational age. Qualitative and quantitative evaluations were obtained. Results:In Phase I, 8 women received the intervention; in Phase II, 13 received the intervention and 11 were in the control group. No baseline between-group differences were found. The intervention group had significantly higher satisfaction with social support over time. Womens evaluations were very positive; home visits were rated most liked and helpful. They appreciated a knowledgeable nurse who knew their story, listened, normalized the PAL experience, and was there with nonjudgmental support. Clinical Implications:The intervention is both feasible and acceptable. Most women felt that they could reduce their own anxiety using the tools and skills they were provided. Healthcare providers should consider past historys impact on current pregnancy experiences and incorporate process and content of the intervention into their practice.

Evaluating Schwartz Center Rounds in an urban hospital center.

PURPOSE Schwartz Center Rounds (SCRs) bring multidisciplinary caregivers together to discuss authentic patient cases from the social and emotional perspective. The monthly sessions provide a forum to share personal thoughts and feelings. The purpose of this paper is to learn why people attend SCR, understand what is gained from the experience, and identify key elements to use in measuring the programs effectiveness. DESIGN/METHODOLOGY/APPROACH This qualitative descriptive study used four focus groups and three telephone interviews for data collection. Purposive sampling resulted in a multidisciplinary sample of 30 participants. Thematic analysis was conducted with complete transcripts by all researchers. FINDINGS All parties viewed SCR as beneficial. Six themes emerged during data analysis: culture change, exposing emotions, walking in anothers shoes, inequality of topics, influence of rules and boundaries, and personal impact. Institutional culture was positively influenced through SCR. RESEARCH LIMITATIONS/IMPLICATIONS Limitations include a single institution and restricted data gathered from physicians. Future research should focus on identifying outcome measures to evaluate the long-term impact of SCR on healthcare organizations. PRACTICAL IMPLICATIONS This study confirms that the SCR program should be continued at the study organization, and expanded to increase availability to all staff. The growth of this program in healthcare organizations across the country is encouraged. ORIGINALITY/VALUE This research provides support for healthcare organizations to offer SCR and highlights how the emotional aspects of patient care can be acknowledged, explored, and discussed.