Article ID: hco-17297524 Processed by Minitex on: 03/30/2015 10:00 AM Central Daylight Time This material comes to you from the University of Minnesota collection or another participating library of the Minitex Library Information Network. Patrons, please contact your library for questions about this document. Libraries, for more information, visit: http://minitex.umn.edu If you have any questions about this service, please email [email protected] or call: Kyle Triska: 612-625-0886 or Carol Nelson: 612-624-7879 NOTICE CONCERNING COPYRIGHT RESTRICTIONS: The copyright law of the United States [Title 17, United StatesCode] governs the making of photocopies or other reproductions of copyrighted materials. Under certain conditions specified in the law, libraries and archives are authorized to furnish a photocopy or other reproduction. One of these specific conditions is that the photocopy is not to be "used for any purpose other than private study, scholarship, or research." If a user makes a request for, or later uses, a photocopy or reproduction for purposes in excess of "fair use," that user may be liable for copyright infringement. This institution reserves the right to refuse to accept a copying order if, in its judgement, fulfillment of that order would involve violation of copyright law. EVIDENCE FOR HEALING INTERVENTIONS WITH PERINATAL BEREAVEMENT Kathleen Leask Capitulo, DNSc, RN, FACCE ABSTRACT The purpose of this article is to explore the concept of perinatal grief and evidence-based healing interventions for it. The loss of a pregnancy or death of an infant causes profound grief, yet society has long minimized or ignored this grief, which is among the most painful of bereavement experiences. Throughout the last century, research on grief and the special needs of bereaved parents has changed the context of professional intervention from protec- tive to supportive. The central focus of bereavement interventions is to assist families in healing by helping them make meaning of their losses. The use of symbols, spirituality, and rituals has been shown to help bring meaning. Research has shown that memories are key to healing, and that gender, age, and relationships bring different grief expressions and experiences. While children’s understanding of loss and grief differs with developmental age, they should also be given the opportunity to participate in grief rituals and practices. Professionals who care for bereaved parents have a unique opportunity to offer support by validating their grief, facilitating rituals, providing mementos, and letting the bereaved tell their stories. While no intervention can bring back their beloved children, appropriate intervention can promote healing. Key Words: Bereavement; Perinatal; Grief. November/December 2005 MCN 389 iscarriage, stillbirth, infant death, and child death after miscarriage has long been underestimated. The litera- continue to be significant topics of concern for ture has now shown us that miscarriage is a life-changing Mperinatal and pediatric nurses in the 21st century. event, leading to feelings of emptiness, dread, guilt, and Although rates of infant mortality have decreased recently, grief (Freda, Devine, Semelsberger, 2003). Côté-Arsenault annual reports of deaths in the United States include and Morrison-Beedy (2001) have shown that women who 54,964 perinatal deaths (Centers for Disease Control, have miscarriages have an increased need for support and 2004) and 28,371 infant deaths (Public Health Advisory experience many fears about their future childbearing. Board, 2001). In addition, 15% to 20% of pregnancies end Studies have also shown that women have elevated depres- in miscarriage, most during the first trimester of pregnancy sion and anxiety scores for up to 1 year after the miscar- (Infertility Tutorials, 2005). Yet, infant deaths and pregnan- riage (Lee & Slade, 1996; Prettyman, Cordle, & Cook, cy losses have often been invisible to society. This article 1993; Slade, 1994), and can also develop post-traumatic will explore perinatal grief and describe the evidence in the stress disorder after miscarriage (Englehard, van den Hout, literature that can assist nurses in providing healing inter- & Arntz, 2001). It is essential, therefore, that nurses vali- ventions in caring for bereaved families. date the loss that women feel after a miscarriage and en- courage them to tell their stories. Grief In the case of stillbirth or infant death, lack of validation Grief is now considered a normal, healthy, dynamic, uni- of that loss (by discouraging parents from seeing their de- versal, and individual response to loss. Grief enables the ceased child or denying mourning rites) can disenfranchise bereaved to heal and integrate the loss into their life (An- grief. The lack of visible rituals following loss makes the drews, 1995; Cowles, 1996; Cowles & Rodgers, 1991). tragedy a “nonevent” and the loss a “nondeath” (Kay, Ro- Grief is a kaleidoscope through which each individual man, & Schulte, 1997). Disenfranchised grief can lead to views the world; a healing process that evolves from surviv- exacerbated anger, psychiatric disorders, and perpetual sad- ing and continuing to live; and a transformational process ness. According to Kroth et al. (2004), mothers who had of learning to live without the deceased, but instead with not seen their deceased infants reported dreams that their memories. Grief does not require severing of emotional babies were monsters. Others who were never told the dis- bonds, is not in stages, and is not only death related position of their stillborn infants reported dreams in which (Arnold, 1995). The experience of grief, while universal, is they were searching for their babies. Dreams seem to enable dynamic and individual (Reed, 2003). the bereaved to express their feelings and also provide cues for professionals to facilitate thera- peutic interventions; they may help in the grief recovery process (Kroth INTERVENTIONS SHOULD et al., 2004). The broad spectrum of symp- FOCUS ON HELPING FAMILIES toms exhibited after perinatal loss include physical, psychosocial, MAKE MEANING OF THEIR LOSS- emotional, and cognitive expres- ES, LETTING THEM TELL THE sions (Table 1). As one mother said, “Grief is like a roller coaster” STORIES OF THEIR PREGNANCY, and comes in waves (Capitulo, 2004); it may be overlapping and THEIR CHILD’S LIFE, AND THEIR interconnecting in no particular or- CHILD’S DEATH REPEATEDLY. der or time frame. Gender and Grief Men and women express feelings of grief differently (Peppers & Dreams of the deceased are common in grief. Parents Knapp, 1985). Men in the American culture may quickly may dream of their deceased babies, providing a connec- return to their jobs and “normalcy,” being less expressive tion between them and their babies. Dreams may include of their feelings and declining to participate in support memories, symbols, and metaphors, and may reflect obsta- groups. Women are generally more expressive, cry, need to cles to grief’s expressions (Blowey, 2002). Dreams can, talk about their feelings, and are more likely to participate however, also be an expression of disenfranchised grief (a in support groups (Capitulo, 2004; Leming & Dickenson, form of grief that is not publicly recognized or validated; its 1998). According to Noppe (2004), women’s experiences expressions are thwarted or prohibited). Grief following with death are a reflection of their biologic propensity to miscarriage or infant death is particularly susceptible to be- live longer than men, and also reflect their capacities for ing disenfranchised, as only parents may have known the giving life (birth) and death (miscarriage, abortion). These baby, felt it move, or seen it through ultrasound. The grief differences can cause incongruent grieving, resulting in 390 VOLUME 30 | NUMBER 6 November/December 2005 problems in communication and relationships (Pep- Table 1: pers & Knapp, 1985). Women may perceive their partners as uncaring and emotionally distant, and SYMPTOMS AND EXPRESSIONS OF GRIEF misunderstand their lack of grief expression (Capitu- lo, 2004). Nurses should understand that helping Physical/somatic Head, stomach, and arm aches couples identify differences in grieving can improve Changes in heart and breathing patterns the couple’s communication, facilitate grief, and sup- Throat tightness port the couple’s relationship (DeFrain, 1991). Gen- Decreased appetite der differences are found in children’s grief as well. Difficulty sleeping Researchers studying children found that girls ex- Lack of energy pressed more emotion and guilt and an increased Generalized malaise desire to continue a relationship with the deceased Tiredness (Moss, Resch, & Moss, 1997). Crying Given their different needs, women and men should be allowed to grieve differently. Nurses Psychological/social Isolation should counsel them to express their feelings, being Withdrawal cognizant of gender differences in expressions. For Difficulty with activities of daily living example, a man may not support a woman’s need to express sadness and cry, and may appear to be pro- tective by blocking her efforts to grieve. This might Emotional Anger disenfranchise her grief and actually cause her more Denial pain and suffering. If affected couples are counseled Guilt about this, bereaved women might feel more com- Resentment fortable in seeking and finding support outside of Failure their relationship, in support groups that are face to Sadness face, or online (Capitulo, 2004; Noppe, 2004). Preoccupation