Parenting paradox: Parenting after infant loss

doi:10.1016/j.midw.2010.02.004

Midwifery

Volume 27, Issue 5, October 2011, Pages e163-e169

https://doi.org/10.1016/j.midw.2010.02.004 Get rights and content

Abstract

Objective

to gain an in-depth understanding of the parenting experiences of bereaved parents in the years following an infant death.

Design

an exploratory qualitative study.

Setting

semi-structured interview in the participants’ homes. Data were collected over a five-month period in 2008 and analysed using thematic analysis.

Participants

a purposive sample of 13 bereaved parents (10 mothers and three fathers) was used. Parents who had accessed the support services offered by two bereavement support agencies were recruited. Participants were asked to describe their experiences of raising their subsequent child. Interviews were conducted when the next born child was at least three years of age.

Findings

the parents described a ‘paradoxical’ parenting style where they were trying to parent using two diametrically opposed unsustainable options. For example, they described trying to hold their subsequent child emotionally close but aloof at the same time.

Key conclusions and implications for practice

the results from this study indicate that the impact of a loss of an infant has far-reaching consequences on subsequent parenting. Support and early intervention at the time of the stillbirth and subsequent pregnancy are likely to be useful. However, further research is required to determine the extent to which early intervention can alter the tendency towards bereaved parents adopting a paradoxical parenting style. The impact of this style on mental health and the emotional health and well-being of the next born child/ren after perinatal loss should also be further examined.

Introduction

It is commonly reported that bereaved parents, in the pregnancy after the death of an infant, may delay emotional attachment to their coming baby for fear of another loss (Lewis, 1979; Armstrong and Hutti, 1998; Cote–Arsenault and Marshall, 2000; Lamb, 2002; O’Leary, 2004). Literature in this area also discusses the subsequent child in terms of being a ‘replacement’ (Cain and Cain, 1964; Anisfeld and Richards, 2000), ‘vulnerable’ (Green and Solnit, 1964; Sabbadini, 1988; Grout and Romanoff, 2000) and ‘penumbra’ (shadow) (Reid, 2003; Kempson et al., 2008), who may be subject to increased risk of psychopathology (Anisfeld and Richards, 2000) including attachment disorders (Sabbadini, 1988; Powell, 1995; Reid, 2007; O’Leary and Thorwick, 2008).

Furthermore, literature acknowledges that parents may be anxious when pregnant again (Armstrong and Hutti, 1998; Robertson and Kavanaugh, 1998; Warland, 2000) and in the postpartum period (Warland, 2000; O’Leary et al., 2006). This apprehension can extend into parenting subsequent infants (Theut et al., 1992; Lamb, 2002). This anxiety may have far-reaching consequences for both the bereaved parent and/or the subsequent child (Cote–Arsenault and Marshall, 2000), especially if parents become overprotective (Parker, 1983). Whilst there is considerable literature concerning parents’ experiences of loss of an infant at or around birth as well as during the subsequent pregnancy, the literature is almost silent on parents’ experiences of parenting after loss or the longer-term effect that the loss may have on parenting style. Such literature as exists on this topic is reviewed here.

Section snippets

Parental overprotection and anxiety

It is normal for all adults to protect their young from danger; however, bereaved parents have been described as more likely to be extra vigilant, with a rapid response to any sign of trouble or danger (Rosenblatt, 2000). Overprotection, defined as ‘behaviours beyond what most parents would do in similar circumstances’ (Thomasgard and Metz, 1993, p. 67), is also something to which bereaved parents can be more prone. For example, Pantke and Slade (2006) asked adolescents to recall their parents’

Subjects and methods

A qualitative approach was chosen as the most appropriate method of exploring families’ experiences of raising their subsequent child (Flick, 2009). Semi-structured interviews were used to enable the conversations to be purposively steered in the direction of the topic (Flick, 2009, p. 185).

Community organisations that offer support to the target population such as SANDS (Stillbirth And Neonatal Death Support) and ‘SIDS & Kids’ (Sudden Infant Death Support) were approached and agreed to

Sample

Thirteen bereaved parents (10 female and three male) participated in 11 interviews. There were eight mothers alone, two couples together and one father alone. Although only three fathers are included in this sample, it was felt important not to discount their comments, especially as there is a lack of research on fathering and we wanted to describe experiences of parents.

The participants were bereaved through stillbirth, neonatal death, SIDS or sudden death in infancy. They were all recruited

Discussion

The results of this study both confirm and support previous research findings, and suggest several new paths for future exploration.

The only other published study which has examined parenting after perinatal loss reported mothers needing constant reassurance regarding the physical health of their subsequent child, and fearing failure to notice a medical problem might mean the child would die (Theut et al., 1992, p. 164). Our findings suggest that these fears and anxieties not only occur when

Conclusions

The results from this study indicate that loss of an infant has far-reaching consequences on subsequent parenting. This research shows that bereaved parents can adopt a paradoxical parenting style when parenting after a perinatal or early infant loss. There is a need for research into the effect of this on not only the emotional development of the subsequent child, but also other children already in the family, and the mental health status of the bereaved parents. Further research is required

Conflict of interest statement

All authors declare no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Acknowledgement

We thank the study participants.

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Trying to conceive: An interpretive phenomenological analysis of couples’ experiences of pregnancy after stillbirth
2021, Women and Birth
Citation Excerpt :
Pregnancy after stillbirth poses the potential for psychological harm to mothers, partners and the subsequent children born after perinatal loss. These include increased rates of anxiety, depression and disorganised attachment to babies conceived after loss [2–9]. Couples are adjusting to a new pregnancy and attempting to bond with a new baby while still actively grieving the loss of their previous baby and have reported difficulties in attaching to their new baby as a protective means of coping, not wanting to bond to the new baby in case it too should die [10,11].
Stillbirth affects 1:200 pregnancies in high income countries. Most women are pregnant again within 12 months. Little is known about how couples negotiate a subsequent pregnancy. This paper presents findings from a study exploring the experiences of couples’ in pregnancy after stillbirth.
Qualitative, interpretive phenomenological analysis was used to conduct in-depth interviews with eight heterosexual couples in the immediate pregnancy after stillbirth. Couples were interviewed together to explore their dyadic, lived experiences of stillbirth and the pregnancy that follows.
Hoping for a born alive baby was one superordinate theme and Trying to conceive one of its subordinate themes, is presented here. Couples jointly negotiated their decision to get pregnant again, varying upon their individual circumstances, including their experiences of stillbirth. Gender differences were apparent in a couple’s agreement to pursue a pregnancy after stillbirth and may be explained by the desire of men to fully parent the baby who died before reaching a decision about a subsequent pregnancy. Sexual intercourse often became less about emotional connection and more about a means to achieve a pregnancy.
Couples spoke of the need for each partner to be in agreement with the decision for a pregnancy. The experiences of trying to conceive after stillbirth impacted the couple relationships. Couples who were able to discuss their feelings with one another appeared more cohesive than those who experienced communication challenges in the aftermath of loss. New insights into men’s thinking about the decision to get pregnant after stillbirth were revealed.
History of perinatal loss: A study of psychological outcomes in mothers and fathers after subsequent healthy birth
2021, Journal of Affective Disorders
The loss of an expected child is a psychologically difficult and potentially traumatic life event. While most women will become pregnant again within a year following the loss, data are limited regarding the mental health of parents with a history of perinatal loss, especially in the period following the birth of a subsequent healthy child. This study, therefore, investigated the relation between perinatal loss and mothers’ and fathers’ psychological symptoms and parenting stress 6-months after the birth of a healthy child.
A community sample of 92 mother-father dyads living in a Canadian city and having a 6-month-old biological infant were asked to complete questionnaires measuring their history of perinatal losses (55 parents reporting at least one loss) and their psychological symptoms and parenting stress.
Mothers and fathers who have experienced a perinatal loss reported more psychological symptoms and parenting stress. Mothers were more likely to report psychological symptoms and parenting stress compared to fathers, but the magnitude of the relation between perinatal losses and psychological outcomes were comparable for mothers and fathers.
Limitations of the study include the use of a small community sample with low generalizability and low levels of psychological symptoms and stress.
The results suggest that the experience of a perinatal loss might have negative consequences on the psychological wellbeing of parents even after the birth of a healthy child.
N<sup>o</sup> 369 - Prise en charge de la grossesse aprés une mortinaissance
2018, Journal of Obstetrics and Gynaecology Canada
Citation Excerpt :
Les parents apprécient que les fournisseurs évaluent leurs besoins et leurs préférences uniques82, et leur demandent ce qui les aiderait ou les rassurerait14. Il est important de s'appuyer sur les forces de la famille, de bâtir sa résilience et de prendre des choix éclairés pour la mère et la famille14, 32, 66, 68, 75, 80. Selon un sondage Web récent mené auprès de 2 716 parents provenant de 40 pays à revenu moyen ou élevé, les options de soins qui favorisent le bien-être psychologique et psychosocial – comme l'accès au numéro de téléphone d'un fournisseur de soins nommé, les cours prénataux spécialisés, les consultations de soins prénataux supplémentaires, la prise de décisions conjointe et le fait de consacrer assez de temps à écouter les inquiétudes des parents et à y répondre – varient grandement d'un fournisseur de soins à l'autre et, dans l'ensemble, sont insuffisantes lors des grossesses suivant une mortinaissance42.
L'objectif principal de la présente déclaration de consensus est d’élaborer des énoncés de consensus qui guideront la pratique clinique et des recommandations pour les soins prénataux et les soins intrapartum, et les considérations psychosociales dont il faut tenir compte pour prendre soin des femmes enceintes ayant des antécédents de mortinaissance.
Les cliniciens participant à la prise en charge obstétrique des femmes ayant des antécédents de mortinaissance ou d'autres formes de décès périnatal.
Les femmes et les familles recevant des soins après une grossesse s’étant soldée par une mortinaissance ou une autre forme de décès périnatal.
La présente directive clinique résume la littérature publiée et énonce un consensus général sur la prise en charge des grossesses suivant une mortinaissance ou un décès périnatal. Nous avons interrogé les bases de données MEDLINE, Embase et Cochrane au moyen des mots-clés : « previous stillbirth », « perinatal loss » et « subsequent pregnancy ». Nous avons ensuite étudié les résultats et lu les articles pertinents. Nous avons également consulté les références des articles retenus et les documents citant des études pertinentes. Les données ont ensuite été présentées pendant une réunion de consensus, et les énoncés ont été formulés. En raison du manque de données probantes, nous avons également consulté les cheminements de soins de cliniques spécialisées.
Le contenu et les lignes directrices ont été élaborés par les auteurs principaux en consultation avec les participants à la rencontre. Le Conseil d'administration de la Société des obstétriciens et gynécologues du Canada a approuvé la version finale avant publication. La qualité des données probantes a été évaluée au moyen des critères de l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation) [tableau 1]. L'interprétation des recommandations solides et conditionnelles est décrite dans le tableau 2. Le résumé des conclusions peut être fourni sur demande.
Nous avons exploré une approche multidisciplinaire de prestation des soins prénataux et intrapartum aux femmes et aux familles ayant des antécédents de mortinaissance ou de décès périnatal. Bien qu'il manque de données probantes dans ce domaine, certains membres du groupe de travail fournissent ces soins à des femmes et à des familles dans plusieurs pays et nous ont fait part de leurs connaissances et de leurs expériences dans le but de guider les soins.
Une revue des données probantes sera menée cinq ans après la publication de la présente directive clinique afin d’évaluer si une mise à jour complète ou partielle s'impose. Cependant, si de nouvelles données probantes importantes sont publiées avant la fin du cycle de cinq ans, le processus pourrait être accéléré afin que certaines recommandations soient mises à jour rapidement.
La présente directive clinique a été élaborée à l'aide de ressources financées par la Société des obstétriciens et gynécologues du Canada et le Programme pour les femmes et les bébés du Centre Sunnybrook des sciences et la santé tableau 1,2.
- 1
  Le principal facteur de risque de mortinaissance récurrente est le fait d'avoir des antécédents de mortinaissance. Le risque de récurrence des femmes peut être stratifié en fonction de la cause connue de la mortinaissance initiale et des autres facteurs de risque maternels connus (qualité des preuves : élevée).
- 2
  Au moment de la mortinaissance, des tests devraient être menés selon le tableau clinique. Tous les parents devraient se voir offrir une autopsie ou un examen équivalent, un examen pathologique du placenta, un dépistage génétique de source fœtale et une recherche d'hémorragie fœto-maternelle (qualité des preuves : moyenne).
- 3
  Les femmes ayant des antécédents de mortinaissance présentent aussi un risque accru d'autres issues défavorables de la grossesse, comme l'accouchement prématuré, le poids insuffisant à la naissance et le décollement placentaire (qualité des preuves : moyenne).
- 4
  Lors de la visite initiale, si la mortinaissance précédente n'a pas fait l'objet d'une investigation adéquate, il convient de noter qu'aucun test universel n'est recommandé. Les antécédents cliniques et les examens au moment de la mortinaissance devraient guider les tests au cas par cas (qualité des preuves : moyenne).
- 5
  L’évaluation biochimique de la fonction placentaire et l'examen Doppler de l'artère utérine systématiques ne sont pas universellement recommandés en raison de leur faible valeur prédictive et de leur inutilité dans l'ajustement de la stratification du risque, puisque le risque de récurrence est déjà élevé (qualité des preuves : moyenne).
- 6
  L'aspirine à faible dose peut réduire le risque de décès périnatal chez les femmes à risque d'insuffisance placentaire. Certaines femmes ayant des antécédents de mortinaissance peuvent se trouver dans cette catégorie (qualité des preuves : élevée).
- 7
  Les femmes ayant des antécédents de mortinaissance peuvent être à risque de retard de croissance fœtal durant la grossesse subséquente et peuvent tirer avantage d’échographies répétées pour mesurer la croissance (qualité des preuves : élevée). Bien qu'il y ait peu de données probantes appuyant les examens systématiques du profil biophysique, la surveillance accrue peut être bénéfique pour certaines femmes et leurs familles, mais elle peut causer de l'anxiété chez d'autres. La fréquence et le calendrier de surveillance fœtale devraient être déterminés en fonction des antécédents médicaux, des circonstances entourant la mortinaissance initiale et des préférences des parents (qualité des preuves : moyenne).
- 8
  Les décisions quant au moment de l'accouchement devraient tenir compte des circonstances entourant la mortinaissance précédente, du tableau clinique de la grossesse en cours et de l’état émotionnel de la femme et de sa famille, ainsi que des inconvénients connus de l'accouchement avant 39 semaines. Dans certains cas précis, l'accouchement à terme précoce (de 37 à 39 semaines) peut être pertinent. Il n'existe pas de données probantes appuyant l'accouchement avant 37 semaines pour le facteur de risque de mortinaissance seulement (qualité des preuves : moyenne).
- 9
  Les familles sont particulièrement touchées par une mortinaissance antérieure. Cet événement change leur vie, et entraîne des coûts psychologiques, physiques et sociaux continus qui persistent durant la grossesse subséquente et par la suite. Les besoins psychosociaux des familles sont accrus durant les grossesses suivant une mortinaissance. Les systèmes et processus actuels de prise en charge de la grossesse devraient chercher à bien répondre à ces besoins (qualité des preuves : élevée).
- 10
  La prestation adéquate des soins comprend du soutien des soins et des services médicaux et psychosociaux cohérents et prodigués en temps opportun par des équipes de soins compétentes et connues des familles qui connaissent bien les conséquences persistantes d'une mortinaissance sur les grossesses subséquentes. Tous les soins offerts aux familles ayant vécu une mortinaissance devraient être axés sur la protection et la promotion de la santé de la femme et de sa famille, et sur les choix éclairés (qualité des preuves : élevée).
- 11
  Le soutien par les pairs est souvent bénéfique pour les parents qui vivent une grossesse après une mortinaissance. Les fournisseurs de soins devraient discuter des options de soutien par les pairs et les encourager à s'en prévaloir (qualité des preuves : moyenne).
- 12
  Les femmes et les familles qui ont vécu une mortinaissance sont très susceptibles d'avoir besoin de soutien émotionnel, et toute la famille devrait se voir offrir des possibilités de soutien durant la grossesse et la période postpartum. De nombreuses séquelles psychologiques sont associées aux grossesses suivant une mortinaissance, notamment la dépression, le stress post-traumatique et l'anxiété. Chez certaines personnes, des taux élevés de symptômes d'anxiété et de dépression sont présents tout au long de la grossesse et après la naissance. Les réactions au deuil sont aussi variées et devraient être reconnues. Les fournisseurs de soins devraient faire valoir les forces de la famille et offrir un dépistage psychosocial, un suivi ciblé, des aiguillages et un traitement, au besoin (qualité des preuves : élevée).
No. 369-Management of Pregnancy Subsequent to Stillbirth
2018, Journal of Obstetrics and Gynaecology Canada
Citation Excerpt :
Parents appreciate an assessment of their unique needs and preferences74,82 and when providers ask what would be helpful and reassuring.14 Supporting existing family strengths, building resiliency, and making informed maternal and family choice should be emphasized.14,32,66,68,75,80 A recent web-based survey of 2716 parents from 40 high- and middle-income countries found that care options that support psychological and psychosocial well-being, such as access to the phone number of a named care provider, specialist antenatal classes, additional antenatal care visits, joint decision making, and sufficient time spent listening to addressing concerns from parents, vary widely among care providers and, overall, are lacking in current pregnancy care after stillbirth.42
The primary objective of this consensus statement is to develop consensus statements to guide clinical practice and recommendations for antenatal care, intrapartum care, and the psychosocial considerations necessary in the care of pregnant women with a history of stillbirth.
Clinicians involved in the obstetric management of women with a history of stillbirth or other causes of perinatal loss
Women and families presenting for care following a pregnancy affected by stillbirth or other causes perinatal loss
This document presents a summary of the literature and a general consensus on the management of pregnancies subsequent to stillbirth and perinatal loss. Medline, EMBASE, and Cochrane databases were searched using the following key words: previous stillbirth, perinatal loss, subsequent pregnancy. The results were then studied, and relevant papers were reviewed. The references of the reviewed studies were also searched, as were documents citing pertinent studies. The evidence was then presented at a consensus meeting, and statements were developed. Due to lack of evidence, care pathways of specialty clinics were consulted.
The content and guidelines were developed by the primary authors in consultation with the meeting attendees. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework (Table 1). The interpretation of strong and weak recommendations is described in Table 2. The Summary of Findings is available upon request.
A multidisciplinary approach in the provision of antenatal and intrapartum care to women and families with a history of stillbirth and perinatal loss was explored. While there is a lack of evidence in this area, members of the working group are providing care to women and families around the world and are sharing their knowledge and experience to help guide care.
Evidence will be reviewed 5 years after publication to evaluate whether all or part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations.
This guideline was developed with resources funded by the Society of Obstetricians and Gynaecologists of Canada and the Women and Babies Program at Sunnybrook Health Sciences Centre.
- 1
  The single most important risk factor for recurrent stillbirth is the history of previous stillbirth. Women's recurrence risk can be stratified based on the known cause of index stillbirth and other known maternal risk factors (GRADE: high).
- 2
  At the time of stillbirth, tests should be conducted in accordance with the clinical picture. All parents should be offered an autopsy or equivalent, placental pathology, genetic testing from fetal source, and testing for feto-maternal hemorrhage (GRADE: moderate).
- 3
  Women with a history of stillbirth are at higher risk of other adverse pregnancy outcomes, such as preterm birth, low birth weight, and placental abruption (GRADE: moderate).
- 4
  At the initial booking visit, if the previous stillbirth was not adequately investigated, it should be noted that no universal tests are recommended. Clinical history and workup at the time of stillbirth should be used to guide testing on a case-by-case basis (GRADE: moderate).
- 5
  Routine biochemical assessment of placental function and routine uterine artery Doppler are not universally recommended due to poor predictive value and absence of their roles in adjusting the risk stratification, given there is already a high risk of recurrence (GRADE: moderate).
- 6
  Low-dose aspirin may reduce the risk of perinatal death in women at risk for placental insufficiency. Some women with a history of stillbirth may fall into this category (GRADE: high).
- 7
  Women with a history of stillbirth may be at risk for fetal growth restriction in the subsequent pregnancy and may benefit from serial growth ultrasound (GRADE: high). While there is limited evidence supporting routine biophysical profile studies, some women and their families may benefit from increased surveillance, while others will find the increased monitoring to contribute to their anxiety. Fetal surveillance frequency and schedules should be determined with consideration for medical history, the circumstances surrounding the index stillbirth, and parental preferences (GRADE: moderate).
- 8
  Decisions around timing of birth should incorporate the circumstances surrounding the previous stillbirth, the clinical picture of the current pregnancy, and the emotional state of the woman and her family, while taking into account the known drawbacks of birth prior to 39 weeks. In select cases, there may be a role for early term (37–39 weeks) birth. There is no evidence for delivery before 37 weeks based on the risk factor of stillbirth alone (GRADE: moderate).
- 9
  Families are uniquely impacted by prior stillbirth. Stillbirth is a life-changing event for families, with ongoing psychological, physical, and social costs that carry into a subsequent pregnancy and beyond. Families have increased psychosocial needs in pregnancies after stillbirth. Current pregnancy management systems and processes should strive to adequately address these needs (GRADE: high).
- 10
  Adequate care provision includes consistent and timely medical and psychosocial care, services, and support by skilled and familiar care teams knowledgeable about the pervasive impact of stillbirth on the subsequent pregnancy and beyond. All care for families with prior stillbirth should be focused on protecting and promoting the health of the woman and her family, as well as informed choice (GRADE: high).
- 11
  Peer support is often beneficial for parents in pregnancies after stillbirth. Care providers should discuss and promote peer support options (GRADE: moderate).
- 12
  Women and families who undergo prior stillbirth are very likely to need emotional support, and the entire family should be provided with opportunities for support during pregnancy and postpartum. Numerous adverse psychological sequelae are associated with pregnancies after stillbirth, including depression, post-traumatic stress, and anxiety. In some people, elevated rates of anxiety and depressive symptoms are shown throughout pregnancy and the postnatal period. Diverse grief reactions are also displayed and should be acknowledged. Care providers should promote family strengths and provide psychosocial screening, targeted follow-up, referrals, and treatment as appropriate (GRADE: high).
Predicting grief intensity after recent perinatal loss
2017, Journal of Psychosomatic Research
The Perinatal Grief Intensity Scale (PGIS) was developed for clinical use to identify and predict intense grief and need for follow-up after perinatal loss. This study evaluates the validity of the PGIS via its ability to predict future intense grief based on a PGIS score obtained early after a loss.
A prospective observational study was conducted with 103 international, English-speaking women recruited at hospital discharge or via the internet who experienced a miscarriage, stillbirth, or neonatal death within the previous 8 weeks. Survey data were collected at baseline using the PGIS and the Perinatal Grief Scale (PGS). Follow-up data on the PGS were obtained 3 months later. Data analysis included descriptive statistics, Cronbach's alpha, receiver operating characteristic curve analysis, and confirmatory factor analysis.
Cronbach's alphas were ≥ 0.70 for both instruments. PGIS factor analysis yielded three factors as predicted, explaining 57.7% of the variance. The optimal cutoff identified for the PGIS was 3.535. No difference was found when the ability of the PGIS to identify intense grief was compared to the PGS (p = 0.754). The PGIS was not inferior to the PGS (AUC = 0.78, 95% CI 0.68–0.88, p < 0.001) in predicting intense grief at the follow-up. A PGIS score ≥ 3.53 at baseline was associated with increased grief intensity at Time 2 (PGS: OR = 1.97, 95% CI 1.59–2.34, p < 0.001).
The PGIS is comparable to the PGS, has a lower response burden, and can reliably and validly predict women who may experience future intense grief associated with perinatal loss.
The Effects of Nursing Care Based on Watson's Theory of Human Caring on the Mental Health of Pregnant Women After a Pregnancy Loss
2017, Archives of Psychiatric Nursing
Citation Excerpt :
In a study, which was conducted to determine the effectiveness of such groups, and a determination was made of the recovery, progress, sharing and learning possibilities which these groups provided to the women (Cote-Arsenault & Freije, 2004). Studies have shown that families who join support groups feel better and bond better to the new-born baby (O'Leary & Warland, 2011; Warland, O'Leary, & McCutcheon, 2011; Warland, O'Leary, McCutcheon, & Williamson, 2011). In the literature there is also discussion of child birth education courses for women who become pregnant again after a pregnancy loss (Wright, 2005).

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