Perinatal Grief: Symptoms, Phases, and Treatment
Grief is an adaptive process that people go through after a significant loss. When this is triggered by a perinatal death, that is, by the death of a child that was gestating, then we speak of perinatal grief.
According to a study by Pía López (2011), between approximately 15 and 25% of pregnancies end in miscarriage. That is, almost 1 in 4 women will go through this traumatic situation.
In addition, if this process isn’t treated properly, it can lead to pathological grief. In relation to this, international studies, cited in Neira (2017), affirm that the prevalence of pathological grief in perinatal grief varies between 20-40%.
Perinatal grief: What is it?
Grief is the emotional reaction to a significant loss in our life. It’s the completely normal and adaptive process that emerges after this loss.
When we speak of losses, we refer, for example, to the loss of a loved one due to death, a breakup, the loss of a job, a skill, moving to a new city, etc.
In the case of perinatal grief, we’re talking about a very specific type of grief, which emerges after the loss that occurred at any time during gestation through to a baby’s first month of life. Therefore, it’s the process after the death of a child, which occurs for different reasons:
- Spontaneous or induced abortions.
- Ectopic pregnancies (when a fertilized egg implants and grows outside the main cavity of the uterus).
- Selective reduction (the induced abortion of one or more fetuses in a multiple pregnancy).
- The death of a twin in gestation.
- A dead fetus in utero or during delivery.
- Premature or newborn death.
- Giving a child up for adoption.
Grief for the child and the expectations of a new life
Perinatal grief is a natural response for parents and family members who go through a perinatal loss. And the fact of the matter is that the death of a child not only implies mourning for that death but also for the loss of other related aspects, which make this grief somewhat more complex.
We’re talking about facing future expectations or a truncated life project, the loss of a projected child, the loss of a stage of life, and the loss of one’s identity as a mother/father, grief over infertility, the loss of sharing experiences with an environment that has or expects children, etc.
Symptoms
It’s true that each person will manifest a series of specific symptoms in their perinatal grief process. But it’s also true that there are some symptoms that appear frequently in many people (especially women).
We’re talking about symptoms such as the following:
- Denial (especially in the initial stages)
- Feeling of emptiness
- Deep sadness
- Guilty feeling
- Irritability
- Anhedonia or loss of enjoyment
- Apathy or loss of interest
- Emotional incontinence
- Depressed mood
- Anxiety
- Anger and rage
Perinatal Grief Disorders
Perinatal grief can lead to significant psychological disorders, including the following:
Depressive disorders
According to studies by Neugebauer et al. (1997) and Friedman et al. (1989), between 10 and 48% of women who go through perinatal bereavement will manifest depressive disorders.
These types of disorders are more frequent in women with a depressive or psychiatric history in general or in those who’ve had previous miscarriages.
Perinatal depression
More recent studies affirm that 1 in 6 women will suffer perinatal depression during a perinatal grief process.
In relation to this, Jésica Rodríguez Czaplicki, perinatal psychologist and president of the Spanish Association of Perinatal Psychology, maintains that “2 out of 10 women will suffer perinatal mental health disorders, and of these, 2.5% will suffer perinatal depression.”
However, she adds that the figures vary slightly in each country. It’s important to differentiate here the symptoms of depression (a disorder), from the symptoms of grief (an adaptive and normal process).
“To weep is to make less the depth of grief.”
-William Shakespeare-
Anxiety disorders
Anxiety disorders (or anxiety in general) are another possible perinatal grief symptom.
According to a study by Prettyman et al. (1993), these types of disorders increase after a miscarriage and decrease after 12 weeks, but come back in the face of the possibility of a new pregnancy.
Therefore, women who become pregnant after a miscarriage tend to experience fear and, in many cases, anxiety (out of fear that it will happen again).
Post-traumatic stress disorder (PTSD)
According to a study by Ayers (2003), between 2 and 5% of women who go through an instrumental delivery or a cesarean section will develop PTSD.
At the same time, according to Brier (2004), up to 25% of women will suffer from this disorder in the month after the loss, and 7% four months later.
Phases of grief
Experts usually speak of the 5 phases or stages of grief. It was the psychiatrist Elisabeth Kübler-Ross who first described these 5 phases, which can also be applied to perinatal grief:
- The denial and isolation phase: The person denies what’s happened to them, is in shock, and can’t assimilate the situation.
- Anger: Strong feelings of anger appear, added to a feeling of injustice about the situation. The person asks “why me?”
- Negotiation: The pain of the loss of the child begins to pass. The objective here is to process the emotional burden that comes after this experience.
- Sadness: The first emotions of sadness and a lot of pain are triggered.
- Acceptance: The loss has been processed; a certain relief appears and the experience is integrated as part of the individual’s personal history.
Perinatal grief: A cyclical process
Women who go through perinatal grief usually go through these 5 phases, although not all of them have to go through all the phases, nor do they do it in the same order.
In addition, grief is a cyclical process, so it’s very normal to go from one phase to the other, “go back” to the previous one, return to the initial one, and so on. In this cyclical process, significant “lows” can appear, where sadness overflows, and this doesn’t mean that progress isn’t being made.
“Grief is a process, not a state.”
-Anne Grant-
Treatment
Rather than referring to the treatment of perinatal grief, we should speak of an emotional approach or accompaniment. Why? Because perinatal grief isn’t a sickness or a mental disorder.
It is, we insist, a normal reaction to a traumatic experience such as the loss of a child. This doesn’t not mean that grief symptoms shouldn’t be addressed, as emotional monitoring by a specialized professional (perinatal psychologist) is of great importance in these cases.
At the same time, we know that grief can get complicated and end up leading to other disorders. In these cases, it’ll be essential to address all the symptoms.
The importance of emotional accompaniment
When the grief isn’t complicated, that is, when the woman (or the father of the child who’s died) goes through the normal stages in this process, a professional may accompany the person in the following ways:
- Emotional validation: Recognizing your emotions as valid, and never judging them. Normalizing the feeling.
- Active listening: Listening to what the person has to say, as well as their non-verbal language, offering feedback and support from an empathetic and understanding stance.
- Offer effective techniques to reduce anxiety levels: Relaxation techniques, breathing…
It’s important for the woman to feel heard and understood, and for her to be able to go through the different phases of perinatal grief, without pressure–allowing herself to feel. At the same time, it’ll be important to address the feelings of guilt and fear that appear many times in these types of experiences.
A long process that can manifest itself in several ways
Perinatal grief, although it’s a normal and adaptive process in the face of a loss as painful as that of a developing child, it can become complicated if the symptoms aren’t adequately treated.
One of the most frequent complications is perinatal depression, which, according to experts, is underdiagnosed, and which isn’t related to the number of children that the mother or father may have.
It’s important to become aware, as a society, of these types of situations that can lead to grief in order to make perinatal grief visible and normalize it.
It’s also important to accompany women who suffer this experience (as well as men) with empathy and respect, and never judge whether what they’re feeling is right or wrong.
- Ayers, S. (2003). Post-traumatic stress following childbirth: a review of the emerging literature and directions for research and practice: commentary. Psychol Health Med, 8: 169-171.
- Brier, N. (2004). Anxiety After Miscarriage: A Review of the Empirical Literature and Implications for Clinical Practice. Birth. 31: 138-42.
- Fernández M, Cruz F, Pérez N, Robles H. Factores psicológicos implicados en el duelo perinatal. Index Enferm., 21(1-2): 48-52.
- Friedman, T. et al. (1989). The psychiatric consequences of spontaneous abortion. Br J Psychiatry, 155: 810-3.
- Kübler-Ross, E. (2006): Sobre el duelo y el dolor. Luciérnaga.
- Neimeyer, R. (2001). Aprender de la pérdida. Una guía para afrontar el duelo. Paidós.
- Neugebauer, R. et al. (1997). Major depressive disorder in the 6 months after miscarriage. JAMA, 277: 383-8.
- Pía López, A. (2011). Duelo perinatal: un secreto dentro de un misterio. Asociación Española Neuropsiquiatría, 31(109): 53-70.
- Prettyman, R.J. et al. (1993). A three-month follow-up of psychological morbidity after early miscarriage. Br J Med Psychol, 66: 363-72.
