Psychological Distress following Miscarriage and Stillbirth: An Examination of Grief, Depression and Anxiety in Relation to Gestational Length, Women’s Attributions, Perception of Care and Provision of Information A Thesis Submitted to the Faculty of Drexel University by Danielle Kerns Clauss in partial fulfillment of the requirements for the degree of Doctor of Philosophy January 2009 ii Dedications This work is dedicated to my family for their tireless support and encouragement throughout my academic career. I have the great fortune to have a family who believed in me from the start and shared in my joy as I pursued my dream of becoming a psychologist. My mother in particular has provided unwavering support and unbridled enthusiasm at every turn in my life. For this, I am forever grateful. I am indebted to my twin sister, Julia, for her constant supportive presence in my life. I suspect that my love of the field of psychology may partly have to do with being a living embodiment of the nurture/nature debate. I am convinced that whatever the contribution of genes and environment to our make-up, my life would not be near as rich without her. iii Acknowledgments This project is the culmination of many individuals’ willingness to share their knowledge and expertise. I am grateful to my dissertation chair, Pamela A. Geller, Ph.D., for the mentorship, encouragement, guidance and support that she provided throughout my graduate career. I would like to thank my committee members for the meaningful feedback and assistance they provided in the development and implementation of this study. I am grateful for the responsiveness they demonstrated in response to the real-life challenges faced during data collection. I would also like to acknowledge the lab members who assisted with this project, in particular, Christina Psaros, Sara Levine Kornfield, Anne Vorndran, Tiffany Richardson, Alexa Bonacquisti and Karni Kissil. They provided not only their assistance but also camaraderie during the process. I am most grateful to my family and friends for their unending support throughout this project. To Meghan Butryn, Julia Kerns and Heather Murray, I owe my eternal gratitude for enriching not only my graduate school career and dissertation process, but my life. As they have done in all areas of my life, these three women provided consistent support, encouragement and well-timed levity throughout the writing of this dissertation. And finally, I would like to thank my husband, Ricky Clauss, for embracing and supporting my goals and being the kind of partner who makes me excited to grow old with him. iv Table of Contents LIST OF TABLES ............................................................................................................ vii LIST OF FIGURES ......................................................................................................... viii ABSTRACT ....................................................................................................................... ix 1. INTRODUCTION ..........................................................................................................1 1.1 Grief ..........................................................................................................................1 1.2 Reproductive Loss ....................................................................................................4 1.3 Perinatal Loss as a Bereavement Event ....................................................................8 1.4 Reproductive Loss and Psychopathology ...............................................................16 1.5 Correlates of Distress following Reproductive Loss ..............................................29 1.6 Rationale for Current Study ....................................................................................39 1.7 Original Specific Aims of Study .............................................................................40 1.8 Original Hypotheses to Be Tested ..........................................................................41 1.9 Modifications to the Original Proposal ...................................................................43 1.10 New Specific Aims of Study.................................................................................45 1.11 New Hypotheses to Be Tested ..............................................................................47 2. METHODS ...................................................................................................................50 2.1 Participants ...............................................................................................................50 2.2 Measures ..................................................................................................................50 2.3 Procedure .................................................................................................................55 2.4 Statistical Analyses ..................................................................................................57 3. RESULTS .....................................................................................................................59 3.1 Sample Description ..................................................................................................59 v 3.2 Primary Analyses .....................................................................................................61 4. DISCUSSION ...............................................................................................................64 4.1 Psychological Distress ..............................................................................................64 4.2 Gestational Length and Psychological Distress ........................................................71 4.3 Attributions ...............................................................................................................73 4.4 Perception of Care .....................................................................................................76 4.5 Provision of Information ...........................................................................................77 4.6 Limitations ................................................................................................................78 4.7 Future Research ........................................................................................................82 LIST OF REFERENCES ...................................................................................................91 APPENDIX A: RECRUITMENT BROCHURE ...........................................................106 APPENDIX B: RECRUITMENT FLIER ......................................................................107 APPENDIX C: WEBSITE RECRUITMENT ................................................................108 APPENDIX D: DEMOGRAPHICS QUESTIONNAIRE ..............................................109 APPENDIX E: PERINATAL GRIEF SCALE ...............................................................113 APPENDIX F: CENTER FOR EPIDEMIOLOGIC STUDIES DEPRESSION SCALE ..................................................................................................116 APPENDIX G: STATE TRAIT ANXIETY INVENTORY – TRAIT SCALE .............117 APPENDIX H: IMPACT OF EVENTS SCALE - REVISED .......................................118 APPENDIX I: ATTRIBUTIONAL QUESTIONNAIRE ...............................................122 APPENDIX J: INTERPERSONAL ASPECTS OF CARE SCALE ..............................125 APPENDIX K: PROVISION OF INFORMATION QUESTIONNAIRE .....................127 APPENDIX L: STUDY SUMMARY SHEET ...............................................................128 APPENDIX M: RESOURCE INFORMATION SHEET ...............................................129 vi APPENDIX N: STUDY INSTRUCTIONS SHEET ......................................................132 VITA ................................................................................................................................134 vii List of Tables 1. Scores on Psychological Distress Measures ..........................................................84 2. Psychological Distress by Loss Cohort..................................................................85 3. Independent Samples T-Tests - Comparison of Psychological Distress by Loss Cohort ............................................................................................................86 4. Correlations between Attributional Questionnaire and Distress Measures ...........87 5. Correlations between Interpersonal Aspects of Care Scale and Distress Measures ................................................................................................................88 6. Correlations between Provision of Information Questionnaire and Distress Measures ................................................................................................................89 viii List of Figures 1. PGS Total Scale Scores by Time since Loss and Gestational Length ...................90 ix Abstract Psychological Distress following Miscarriage and Stillbirth: An Examination of Grief, Depression and Anxiety in Relation to Gestational Length, Women’s Attributions, Perception of Care and Provision of Information Danielle Kerns Clauss, M.S. Pamela A. Geller, Ph.D. Over half a million women in the United States experience a miscarriage or stillbirth annually. Research suggests that miscarriage and stillbirth are loss events associated with grief and an increased risk for psychological morbidity.