IJCP Volume 20 • Issue 3 • Autumn 2020 Practitioner Perspective Perinatal Grief – A Profound and Complex Process By Cathy Quinn This article provides an overview of the multiple facets of perinatal grief and the grieving process. It explores the key concepts of continuing bonds and the complexity of disenfranchised grief. It also reflects briefly on the significance of creating a safe empathetic space. Perinatal death in perspective In the past, the predominant culture of maternity hospitals and society in general tended to minimise or even ignore the existence of perinatal grief. Today compassionate approaches to care are slowly but positively transforming the landscape and culture of how we care for this umerous studies demonstrate that grief following vulnerable group of parents, for Na baby’s death is frequently minimised and may example the introduction of the go unacknowledged by society. These findings challenge National Standards for Bereavement Care following Pregnancy Loss and us not only to grasp the significant impact of the Perinatal Death (Health Service sociocultural dynamics woven into perinatal grief but Executive (HSE), 2016). also to create an empathetic therapeutic relationship, In 2016, a total of 227 babies were stillborn and 124 babies wherein bereaved parents are truly understood died within the first week of life in Ireland (Healthcare Pricing “When you are understood, you are born alive but dies within the first Office & HSE, 2018). Miscarriage at home. Understanding nourishes week of life. The profound grief occurs in approximately one- belonging. When you really feel experienced by parents following fifth of pregnancies equating to understood, you feel free to miscarriage or the death of their approximately 14,000 miscarriages release your self into the trust and baby is considered a complex per year in Ireland (Poulose, shelter of the other person’s soul” emotional response (Fenstermacher Richardson, Ewings & Fox, 2006). (O’Donohue, 1997, p. 13-14) & Hupcey, 2013). However, the Concealed in these statistics are majority of bereaved parents will an enormous number of bereaved Introduction experience a normal grief reaction parents and their families who erinatal grief embraces the grief with the support of family and undeniably will require empathetic Pexperienced by parents following friends (McSpedden, Mullan, care and support. miscarriage, following a diagnosis Sharpe, Breen, & Lobb, 2017). during pregnancy of a baby with Additional support may be sought Multiple facets of perinatal grief a life-limiting condition, when a from advocacy groups, while some To empathise fully with bereaved baby is stillborn or when a baby is parents may attend counselling. parents’ experience of perinatal 14 Irish Association for Counselling and Psychotherapy Volume 20 • Issue 3 • Autumn 2020 IJCP grief, the counsellor needs to impact of their baby’s death recognise the multiple facets of nforming parents of the on their relationship; they may perinatal death that are woven Iindividuality of grief is struggle to find the emotional into the tapestry of grief and helpful; although they are resilience to help each other undoubtedly impact the parents’ both grieving as parents of while they are individually coping grief response. the same baby, each parent with their own grief. Studies have Perinatal grief is unique given may grieve differently and shown that parents who share that most mourning is retrospective and communicate their grief whereas perinatal grief is are rarely synchronised in report less severe grief reactions prospective mourning i.e. parents their grief and greater partner satisfaction have to relinquish hopes, wishes (Cacciatore et al. 2008; Buchi and dreams about a future together et al. 2009; Avelin, Radestad, with their anticipated baby (Leon, and anxiety symptoms following S¨aflund, Wredling, & Erlandsson, 1990). They grieve for what might perinatal death (Blackmore et al. 2013). In contrast, other studies have been, a future with their baby 2011; Cheung, Hoi-yan, & Hung-yu, have identified perinatal death suddenly vanishes when unfulfilled 2013; Christiansen, Elklit, & Olff, as a risk factor for relationship dreams and expectations are 2013; McSpedden et al. 2017). break-down (Gold, Sen, & Hayward, crushed. Seeing live healthy babies of 2010; Shreffler, Hill, & Cacciatore, A baby’s death goes against family and friends may be difficult 2012). Informing parents of the the natural sequence of life for parents; particularly in the early individuality of grief is helpful; events, is frequently unexpected stages of grief; they may struggle although they are both grieving as and the cause of death may be to cope with painful feelings or parents of the same baby, each unexplained. Furthermore, there are avoid situations, which can lead to parent may grieve differently and no formal funeral or burial rituals isolation. are rarely synchronised in their for babies usually associated with Parents may also be fearful and grief. Encouraging parents to share other deaths which may limit social doubt their ability to have a live their feelings may help them to acknowledgement and support. healthy baby in the future. Well- understand each other’s unique Consistent feelings of guilt, meaning family and friends and reactions and ultimately avert or shame and failure, combined society in general may sometimes lessen tensions that may develop with self-blame and low self- assume that a subsequent in their relationship. Open, honest, esteem, may dominate the pregnancy will instantly heal communication with their surviving parents’ landscape of grief (Barr the parents’ grief, resulting in children is also encouraged. & Cacciatore, 2007; Wonch Hill, diminished opportunities for Grieving the death of a baby of a Cacciatore, Shreffler, & Pritchard, parents to share their true feelings multiple birth is a complex process 2017). A study conducted by (Markin, 2016; Meaney et al. 2017) for families (Richards, Graham, Meaney, Everard, Gallagher and In the midst of the parents’ Embleton, Campbell, & Rankin, O’Donoghue, (2017) revealed that grief, the focus of support may 2015). Parents often experience bereaved parents experienced a be directed solely towards the a rollercoaster of conflicting sense of failure which battered mother’s needs which may emotions: grief for the baby who their self-esteem and mothers in lead to the father’s grief going has died, as well as hopes and particular felt guilty and blamed unacknowledged by society. Fathers fears for their vulnerable baby/ themselves for their baby’s death. may feel they have to be stoic babies who survive. Parents may These complex, intrusive feelings and society may dictate this. In keep their emotions on hold while of shame, failure and guilt may a study by Meaney et al. (2017) caring for the surviving baby and a impede the grieving process and fathers reported that they had to be strong grief reaction may emerge damage a vulnerable self-esteem, strong emotionally, at times putting weeks, months or even years later thereby increasing the risk of their own grief on hold in order to (Richards et al. 2015) complicated grief (Markin, 2017). support their partner. Validation Early and late miscarriage may be Counsellors should be alert to and acknowledgement of the experienced as a highly traumatic pathological symptoms of grief father’s grief experiences and his loss for many women, yet it may be that may arise as several studies fatherhood is essential (Cacciatore, minimised and go unacknowledged have reported elevated levels of DeFrain, Jones, & Jones, 2008). by society (Gerber-Epstein, complicated grief, post-traumatic Another challenge that bereaved Leichtentritt, & Benyamini, 2009; stress disorder, depression parents have to negotiate is the Murphy & Merrell, 2009; Sejourne, Irish Association for Counselling and Psychotherapy 15 IJCP Volume 20 • Issue 3 • Autumn 2020 Callahan, & Chabrol, 2010). Lack grief reaction and an obstacle to of tangible mementos, especially he deceased baby successful grief resolution (Klass, in early pregnancy loss, limited Tis both present and Silverman, & Nickman, 1996). The empathy and support from family absent; there is a physical general consensus among grief and friends with few opportunities letting go of the deceased theorists echoed a belief that in to engage in culturally recognised baby but at the same order to resolve their grief, it was mourning rituals, which may lead to time keeping hold of the necessary for the bereaved to sever social isolation and disenfranchised bonds by detaching themselves grief (Kersting, & Wagner, 2012; connection or the bond emotionally from the deceased Bellhouse, Temple-Smith, & Bilardi, person. 2018). with the changes that occur as a It was Klass (1988) who first Parents who decide to terminate consequence of the baby’s death. reported that bereaved parents their pregnancy when their baby They are faced with the challenges maintained a bond with their is diagnosed with a life-limiting of readjusting to their changed deceased baby. However, he condition may experience higher world without their baby; learning did caution that it may not be levels of self-blame, guilt, and to live with the death in the face of representative of all bereaved social isolation (Maguire, 2015). bereavement and rebuilding their parents (Klass, 2006). He They may seek counselling, feeling lives by creating a new normal. supported the theory that a baby’s unsupported or stigmatised and Oscillation between the two types