BUFFALO, N.Y. -- Pregnancy for most women means joyous anticipation of the birth of a baby, day-dreaming about the child, preparing the nursery, accepting congratulations from friends.
For some pregnant women, however, feeling joy is a psychological luxury they can't afford. These are women who after one, sometimes many, miscarriages, stillbirths or newborn deaths, are pregnant again.
To protect themselves from another potential crushing emotional blow, it is easier to think of their pregnancy as an impersonal biological condition. They are not, in fact, "expecting a baby." There are no joyous baby showers. Mainly there is anxiety.
Denise Côté-Arsenault, Ph.D., an associate professor in the University at Buffalo School of Nursing, is one of the few researchers to study the field of pregnancy after perinatal loss. She uses the metaphor "One Foot In -- One Foot Out" to characterize the state of being for these women.
" 'One Foot In -- One Foot Out' describes women's sense that the pregnancy is uncertain, so they steel themselves emotionally by acknowledging that the pregnancy may not end with the birth of a live baby," says Côté-Arsenault. "They cushion themselves against attaching to the new baby.
"For most of these women, carefree enjoyment of a pregnancy is not possible. Instead, it is a balancing act between trying to insure safe passage of the baby while maintaining emotional stability."
A nurse specializing in the care of childbearing families, Côté-Arsenault is the first to develop a pregnancy anxiety scale that can be used to determine if a woman in this situation could benefit from extra emotional support.
"When a woman becomes pregnant after a loss, that pregnancy is a very different experience," says Cote-Arsenault, "but the care she receives isn't necessarily different. These women are in a very different place. Most are emotionally guarded. Many experience high anxiety and stress. There is a loss of innocence and a sense of skepticism."
Studies by other researchers have shown that experiences such as this can influence the obstetrical outcome and can have a negative impact on mother-child bonding and parenting.
When she decided to pursue a doctorate and teach in academia, Côté-Arsenault chose the topic of pregnancy after perinatal loss for her doctoral thesis. She was shocked by the lack of sensitivity among care givers to the issue of miscarriage as a maternity nurse in the '80s and the topic became her passion. To her astonishment, she found only five studies on the subject. That was in 1994. Since then she has contributed more than twice that number to the field.
Her investigations have involved both data from questionnaires and deeply emotional reflections of women who are pregnant again after an unsuccessful pregnancy and who participated in focus groups. One of her studies recounts a poignant episode told by a woman who had a miscarriage at 19 weeks and now was pregnant again.
"Second time, I didn't have nearly the vivid pictures of what this baby was going to be like…I knew that I was pregnant, but I didn't think that I was going to have a baby. Six weeks before the due date someone sent me a baby present and I said, 'They think I'm having a baby.' And my husband said 'I think you are, too.' I started crying because I hadn't let myself think that at all."
Côté-Arsenault's research addresses several concerns: the primary emotions experienced by these women; the degree of personhood assigned by the mother to a lost fetus; the amount of anxiety experienced in a current pregnancy; the impact of fetal loss on the woman's concept of self, and the role of support groups in helping women through a pregnancy after a loss.
One of her studies, published in 2003 in the Journal of Obstetric, Gynecologic and Neonatal Nursing, on the influence of perinatal loss on anxiety in women with more than one pregnancy -- those with and without a previous loss -- provided novel insight into the emotional states of the two groups. The results showed that women in both groups were equally optimistic and had similar outlooks on life, but women in the perinatal-loss group had higher pregnancy anxiety.
"It's important to measure pregnancy anxiety, not simply generalized anxiety," said Côté-Arsenault, "because generalized measures don't address the specific concerns of women in pregnancy.
Having other living children did not result in lower pregnancy anxiety, results showed, nor did gestational age at the time of the loss. "In this sample, losses were primarily in the first trimester, while most of the women in the loss group were past that point in their current pregnancy," said Côté-Arsenault. "But, the loss group still had higher anxiety.
"This contradicts the common assumptions that a first-trimester miscarriage isn't significant or important, and that once women get past the point when their miscarriage occurred, everything is fine."
Since these findings were limited by the study's snapshot" design -- measuring anxiety at one point in the pregnancy -- Côté-Arsenault is following 82 women with a prior loss throughout their current pregnancies. The women are keeping pregnancy calendars to record their emotional ups and downs during their pregnancies and are completing questionnaires at three points across their pregnancies, once in each trimester.
Côté-Arsenault is interested particularly in the women's emotional states at various times, appraisal of the threat to their pregnancy and how they are coping with the pregnancy.
"The knowledge gained from this study will help clinicians in the future know when women who are pregnant after losing a baby might need emotional support the most, and what kind of support will be most helpful," she said.
At the very least, women should be asked key questions that would invite them to talk about any concerns they may be harboring, she noted. "Key questions to be asked would be: 'Are you anxious or worried about this pregnancy?' 'Are you worried about bringing this pregnancy to term?' 'What do you feel you lost in past pregnancies?' 'Are you expecting the worst to happen in this pregnancy?'"
In Japan, acknowledging a miscarriage or stillbirth is ingrained in the culture, said Côté-Arsenault. There are gardens of baby statues, where mothers who have lost babies can place a tiny knit cap on a statue and mourn publicly.
"It would be wonderful if pregnancy losses were acknowledged openly in our culture too," she said, "but at least hospitals in this country have gotten better about helping women acknowledge a lost baby," noted Côté -Arsenault. "When a baby dies, giving the mother the baby's photo, footprints and handprints is much more routine. We have made progress. Now we need to recognize the impact of perinatal loss on subsequent pregnancies."
The University at Buffalo is a premier research-intensive public university, the largest and most comprehensive campus in the State University of New York.
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