JOGNN

RESEARCH

The Influence of Prior Perinatal Loss on

Parents Psychological Distress After
the Birth of a Subsequent Healthy Infant
Deborah S. Armstrong, Marianne H. Hutti, and John Myers

Correspondence
Deborah S. Armstrong, PhD,
RN, School of Nursing,
University of Louisville,
K-4043 Health Sciences
Campus, Louisville, KY
40292.
dsarms01@louisville.edu
Keywords
perinatal loss
posttraumatic stress
depressive symptoms
parent-infant attachment

ABSTRACT
Objective: To evaluate the long-term influence of a previous perinatal loss on parents psychological distress during
a subsequent childbearing experience.
Design and Sample: A cohort design was used to examine 36 couples with a history of prior perinatal loss. Data
were collected during the third trimester of pregnancy, 3 months postpartum, and again 8 months after birth.
Measures: Outcome measures included posttraumatic stress (The Impact of Event Scale), depressive symptoms
(Center for Epidemiologic Studies-Depression Scale), anxiety (Spielberger State-Trait Anxiety Inventory), and parental concerns and attitudes (Maternal/Paternal Attitudes Questionnaire).
Results: Levels of depressive symptoms (po.001), anxiety (po.001), and posttraumatic stress (p 5 .046) significantly decreased over time in this population. However, levels of posttraumatic stress remained in the moderate range
even at 8 months after birth. Depression was significantly correlated with posttraumatic stress at each time point. In
addition, depression was significantly related to posttraumatic stress, anxiety, and concerns parents had about their
infants well-being at T3.
Conclusion: While levels of anxiety and depressive symptoms decreased for parents who have experienced a
previous perinatal loss, posttraumatic stress levels remained moderately high. It is unclear how this compares to
parents without losses. These may be the unique symptoms and concerns these parents have about their new infant.
Parents with a history of prior loss should have assessments carefully tailored to their experiences to anticipate
continued psychological distress.

JOGNN, 38, 654-666; 2009. DOI: 10.1111/j.1552-6909.2009.01069.x

Accepted September 2009

Deborah S. Armstrong,
PhD, RN, is an associate
professor in the School of
Nursing, University of
Louisville, Louisville, KY.
Marianne H. Hutti, DNS,
WHNP-BC, is a professor
in the School of Nursing,
University of Louisville,
Louisville, KY.
John Myers, PhD, MSPH,
is an assistant professor in
the Department of
Bioinformatics and
Biostatistics, School of
Public Health and
Information Sciences,
University of Louisville,
Louisville, KY.

654

erinatal losses are traumatic events in the lives

of families and can have serious long-term
consequences for the psychological health of parents and any subsequent children (Armstrong,
2001, 2007; Franche & Mikail, 1999; Heller & Zeanah, 1999; Hutti, 1992; Swanson, 1999; Theut et al.,
1992). Perinatal loss includes fetal death (early or
late) or neonatal death within the rst 28 days of life.
The incidence of early fetal death (before 20 weeks
gestation) is conservatively estimated at one in six
pregnancies (Ventura, Mosher, Curtain, Abma, &
Henshaw, 1999). Bereavement of perinatal loss may
be dicult and complex for a number of reasons.
Death is occurring at a time when the joyful anticipation of a new life was expected. There may be no
visible child, memories, or shared life experiences
to mourn. Moreover, the death is usually sudden,
and there may be a lack of societal recognition of
the signicance of such a loss to the parents (Arm-

strong, 2002; Cote-Arsenault & Mahlangu, 1999;

Cote-Arsenault & Marshall, 2000; Rajan & Oakley,
1993). The purpose of this study was to evaluate
the long-term inuence of previous perinatal losses
on parents psychological distress during subsequent childbearing experiences.

Review of Literature
Depressive symptoms aect a womans ability to
function and have considerable adverse inuence
on family outcomes and maternal-child interactions
as well as on infant and child development
(Lundy, Field, & Pickens, 1996; Mandl, Tronick,
Brennan, Alpert, & Homer, 1999; Weinberg & Tronick, 1998a,1998b). However, depressive symptoms
are recognized and treated in as few as 10%
of those aected (Mandl et al.). Depressive
symptomology during pregnancy increases the risk

& 2009 AWHONN, the Association of Womens Health, Obstetric and Neonatal Nurses

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RESEARCH

Armstrong, D. S., Hutti, M. H. and Myers J.

for depression in the postpartum period (Beck,

1996b; Carter, Garrity-Rokous, Chazan-Cohen, Little, & Briggs-Gowan, 2001). Prenatal anxiety also is
associated with the development of depressive symptoms after birth (Beck, 1996a). Mounting evidence
from a considerable succession of clinical studies
demonstrates the negative inuence of maternal
postpartum depressive symptoms on cognitive and
behavioral development of infants whose mothers
were diagnosed with this psychopathology (Carter et
al.; Field, 1998; Heller & Zeanah, 1999; Lundy et al.,
1999; Murray, Fiori-Cowley, Hooper, & Cooper,1996).
Both men and women are aected by perinatal loss
and may experience high levels of psychological
distress (Armstrong, 2001; Johnson & Puddifoot,
1996; Swanson, 1999). After perinatal loss, fathers
are both the comforter and the bereaved (Johnson
& Puddifoot). They may be caught between their
own grief and the needs of their partners. Fathers
may feel an expectation to oer support rather
than receive it (Wallerstedt, Lilley, & Baldwin, 2003).
Their responses to perinatal loss may correspond
with how they believe they should act as men,
rather than how they need to act to cope with and
resolve their grief (Cordell & Thomas, 1990; Menke
& McClead,1990; Wallerstedt & Higgins,1996).
Parents who have experienced a previous perinatal
loss enter their subsequent pregnancies with much
higher levels of psychological distress (Armstrong,
2002; Cote-Arsenault, Donato, & Earl, 2006;
Hughes, Turton, & Evans, 1999; Hughes, Turton,
Hopper, McGauley, & Fonagy, 2001; Janssen, Cuisinier, Hoogduin, & de Graauw, 1996; Statham &
Green,1994) and pregnancy-specic anxiety (Armstrong, 2002, 2004, Armstrong & Hutti, 1998; CoteArsenault & Marshall, 2000; Franche & Mikail,
1999), and may even develop symptoms of posttraumatic stress (PTS; Armstrong, 2002; OLeary &
Thornwick, 2006; Turton, Hughes, Evans, & Fainman, 2001). Several studies of mothers who have
had a previous loss show that they experience
higher levels of anxiety than do fathers (Armstrong,
2002, 2004; Franche & Bulow, 1999). Anxiety is pervasive in a subsequent pregnancy, resulting in
exaggerated arousal, heightened awareness, never
feeling safe, and a constant state of hypervigilance
(Armstrong, 2001; Cote-Arsenault, 2007; Cote-Arsenault & Marshall). Parents with a history of
previous perinatal loss report waiting much later to
prepare a room for the baby (Armstrong, 2001,
2002; Cote-Arsenault & Donato, 2007) and frequently report feeling worried, fearful, nervous, or
ambivalent with the new baby (Armstrong, 2001,
2002; Cote-Arsenault & Mahlangu, 1999; Cote-

JOGNN 2009; Vol. 38, Issue 6

Parents who have experienced a previous perinatal loss

enter subsequent pregnancies with much higher levels
of psychological distress.

Arsenault & Marshall; Rajan & Oakley, 1993; Statham & Green,1994).
Early research demonstrates an association between maternal unresolved loss or trauma as a
result of perinatal loss and the development of disordered attachment relationships between infants
and mothers. Heller and Zeanah (1999), in a study
of 19 mothers and their infants born 12 to 19 months
after a perinatal loss, evaluated the risk for disturbed attachment relationships. Forty-ve percent
of infants in this sample had disorganized attachment relationships with their mothers at 12 months
of age. This was substantially higher than the
expected prevalence of 15% for disordered attachment relationships in other middle-class samples. In
addition, Hughes et al. (2001) studied 53 infants
born subsequent to still birth (study group mothers)
and compared them to 53 infants of primigravida
mothers (comparison group mothers). Infants were
evaluated at 12 months postpartum for attachment
disturbances utilizing a process similar to Heller
and Zeanahs study. Thirty-six percent of the infants
of mother with prior losses demonstrated disturbed
attachment as compared to the infants whose
mothers had no history of loss. These early ndings
suggest the possible long-term inuence of a prior
perinatal loss on the relationship between mother
and infant as well as potential developmental problems for children born to those with a history of loss.
Other issues that warrant attention are parental
concerns about the vulnerability and well-being of
a subsequent child. Theut et al. (1992) examined
maternal attitudes toward a subsequent child after
prior perinatal loss in a group of 25 mothers with a
history of loss compared to 30 mothers with no such
history. At 16 months past birth, mothers who experienced a perinatal loss continued to express
anxiety about their childs physical well-being and
more concerns about dierentiating from their child
than mothers with no history of loss. These results
clearly show the eects of prior perinatal loss are
not temporary, but may persist as long a year or
more after the birth of another child.
Knowledge of the trajectory of parents psychological distress from the third trimester of a subsequent
pregnancy through the rst 6 to 8 months postpar-

655

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Perinatal Loss and Parents Psychological Distress

tum may provide the basis for identication

of parents at risk. Longitudinal follow-up evaluating
changes in parents levels of depressive symptoms,
anxiety, PTS, and parents self-evaluation of
their feelings about the well-being of their new
infant is important to identify those at risk for
continuing psychological distress. Examining the
patterns of this distress may allow a clearer
understanding of the continued inuence of
perinatal loss on parenting concerns, infant
development, and outcomes for these families
at risk. While other longitudinal studies have
been done, none have followed parents prospectively from late in a subsequent pregnancy through
two thirds of the infants rst year. This studys
ndings helped to address that gap in knowledge.
Therefore, the specic aim of this study was to
determine whether levels of PTS, depressive symptoms, anxiety, and parents concerns about and
investment in their infant dier over the course of
late pregnancy through the rst 6 to 8 months after
birth for mothers and fathers with a history of perinatal loss.

Methods and Procedures

Study Design and Sample
A longitudinal cohort study design was used to
collect data from expectant mothers and fathers
during the third trimester of pregnancy (T1), 2
to 3 months postpartum (T2), and again 6 to
8 months after birth (T3). The sample consisted of
72 expectant parents (36 couples). Preliminary pilot
data obtained by Armstrong (2007) yielded correlations of .67 between Center for Epidemiologic
Studies-Depression Scale (CES-D) and Impact
of Event Scale (IES) scores at baseline and .63 at
follow-up for females, and .57 at baseline and .38
at follow-up for males. Assuming that these correlations accurately represent the population values,
a sample size of N 5 80 (40 couples) will yield
95% power for detecting correlations of this magnitude using a signicance level of .05. Only couples
who completed all three study interviews were used
in the nal analysis reported here. As a result
of attrition across the study timeframe, a nal
sample size of 36 couples (n 5 72 participants) was
obtained.
Participants were recruited and enrolled in the current study in their third trimester of pregnancy.
Couples were eligible for the current study if they
had experienced a previous pregnancy that resulted in a perinatal loss (early or late fetal or
neonatal death).

656

Recruitment and Screening

The volunteer sample was recruited from prenatal
clinics, prenatal education classes, and private
obstetric practices in a southeastern state. Perinatal
loss support groups and newsletters nationwide such as SHARE, Helping Hands, and RTS
Bereavement Services also served as recruitment sites. Notices about the study were posted on
Internet message boards focusing on perinatal
loss as well as general pregnancy boards, and
interested parents were recruited from those responding. Both the mother and father from each
couple were recruited. Participants were 18 years of
age or older and were able to read and understand
English.

Measures
All questionnaires were written at a fourth-to sixthgrade reading level. Each study interview took approximately 30 to 45 minutes.
Subjective Stress Related to a Past Traumatic Life
Event (Perinatal Loss)
The IES (Horowitz, Wilner, & Alvarez, 1979) was developed to broadly measure the current subjective
distress an individual was experiencing in relation
to a specic traumatic life event. The wording
may be adapted to indicate any stressful life event.
In the current study, the items were anchored to
the traumatic event of their previous perinatal
loss as the named stressor. The IES contains two
subscales: Intrusion and Avoidance. Unbidden
thoughts, images, troubled dreams, strong emotions, and repetitive behavior exemplify the
Intrusion subscale. The Avoidance subscale is
characterized by denial of the meaning and consequences of the event, emotional numbness, and
behavioral inhibitions. Acceptable internal consistency reliability has been demonstrated with
Cronbachs as of .95 (total scale), .78 (Intrusion),
and .82 (Avoidance), as well as test-retest reliabilities of .87 (total scale); .89 (Intrusion), and .79
(Avoidance; Horowitz et al.). Validity was supported
by frequent endorsement of items by a population seeking help for PTS disorder (Horowitz et al.).
This instrument is broadly used in a variety of
populations and circumstances to evaluate the
continuing inuence of a past stressful life event.
The questionnaires easy adaptability to a specically named stressor and its wide use make it
an acceptable instrument to measure the continuing inuence of a previous perinatal loss on
parents psychological distress. Cronbach as for
the current study were .83 (total scale), .90 (Intrusion), and .80 (Avoidance).

JOGNN, 38, 654-666; 2009. DOI: 10.1111/j.1552-6909.2009.01069.x

http://jognn.awhonn.org

RESEARCH

Armstrong, D. S., Hutti, M. H. and Myers J.

Depressive Symptoms
The CES-D (Radlo,1977) is a self-report scale used to
identify the duration and frequency of depressive
symptoms experienced by the respondent during the
previous week. It was developed to evaluate depressive symptoms in the general population and to
identify individuals at high risk for clinical depression
(Radlo). The CES-D is applicable across age and sociodemographic groups (Radlo). Scores of16 or more
indicate a high level of depressive symptoms (Weissman, Sholomskas, Pottenger, Pruso, & Locke, 1977).
The CES-D has demonstrated high internal consistency with Cronbachs as ranging from .85 to .91 and
good test-retest reliability in a wide range of community,
clinical, pregnant, and postpartum samples (Armstrong, 2001, 2002; Comstock & Helsing, 1976; Hall,
Kotch, Browne, & Rayens, 1996; Logsdon, McBride, &
Birkimer, 1994; Radlo). The validity of the CES-D was
supported by its ability to dierentiate among a community sample, clinically depressed inpatients, and
those with other psychiatric conditions (Weissman et
al.). The CES-D is widely used in pregnant and parenting research. Because of its broad use both in
expectant and parenting mothers and fathers, its decreased response burden (only 20 items), and its
ability to be used without adaptation for both males
and females, the CES-D was chosen for use in this
study. Cronbachs a for the current study was .89.

Anxiety
The State-Trait Anxiety Inventory (STAI ; Spielberger
& Vagg, 1984) is a self-report questionnaire designed to measure two dimensions of anxiety: how
the respondent feels right now (state) and how the
individual generally feels (trait). The essential qualities measured by the State subscale (STAI-S) are
current feelings of apprehension, tension, nervousness, and worry. Scores on this subscale increase
in response to physical danger and immediate psychological stress. The Trait subscale (STAI-T) has
been widely used for assessing clinical anxiety and
screening for anxiety problems (Spielberger &
Vagg). The STAI has been used with a wide range
of clinical and community samples, with both males
and females, and in all age groups. Excellent internal consistency reliability has been demonstrated in
a wide range of samples (working adults, highschool and college students, and military recruits)
and age groups (Cronbachs as range from .86 to
.95 for the STAI-S and .89 to .91 for the STAI-T subscale; Spielberger & Vagg). Alphas for the current
study were acceptable at .92 for both the STAI-S
and the STAI-T. This instrument was chosen because of its broad use in a variety of gender, age
groups, and samples. It also has been used in a

JOGNN 2009; Vol. 38, Issue 6

number of studies during pregnancy and with parenting women and men (Armstrong, 2007; Carter,
Baker, & Brownell, 2000; Da Costa, Larouche, Dritsa, & Brender, 2000).

Parental Concerns and Investment in Infant

The Maternal/Paternal Attitudes Questionnaire
(MAQ; Theut et al., 1990; Theut et al., 1992) was developed to examine a mothers attitudes toward her
infant/toddler. This instrument is intended to evaluate maternal attitudes, and to examine whether
mothers who had a history of prior perinatal loss
would express more concerns about a subsequent
childs health, more investment in the child, and
heightened concerns about maternal-child dierentiation/separation compared to mothers without
a history of loss. The MAQ was designed to be used
with mothers of infants who are 16 months of age. It
is a 46-item instrument with three subscales: concerns about the childs health, how invested the
mother is with her child, and the dierentiation from
self. The dierentiation subscale deals with the diculties of psychological separation between
mother and child. This subscale was designed to
evaluate the anxieties mothers may have as their infant becomes less dependent on them and more
independent. Adequate internal consistency was
demonstrated in prior research with Cronbachs as
of .78 (total scale), .80 (Health Concerns subscale),
and .70 (Investment subscale), but somewhat questionable with a .60 on the Dierentiation subscale
(Theut et al.). While no gender adjustment was
needed, this was the rst time the questionnaire
was used with fathers or infants less than 1 year of
age. In addition, two items were deleted related to
the infant needing the parent more when the infant
was younger (Item 18) and walking (Item 37) because they were inappropriate for a younger infant.
Cronbach as for the current study were .75 (total
scale), .69 (Health Concerns subscale), .67 (Investment subscale), and an unacceptability low .28
(Dierentiation subscale). This low reliability makes
any conclusions based on this subscale tentative at
best and may possibly be the result of the fact that
this instrument was designed for use with an older
child.
Concurrent validity of the original MAQ was supported by correlations with another measure of
maternal separation anxiety (Maternal Separation
Anxiety Scale, Hock, McBride, & Gnezda, 1989).
Construct validity was supported by derivation of
items from interviews with mothers of infants and
toddlers who had experienced a prior perinatal
loss and those with no history of loss as well as fac-

657

RESEARCH

Perinatal Loss and Parents Psychological Distress

tor analysis (Theut et al., 1992). This instrument was

used only at the T3 assessment and evaluated
dierences in parental concerns about and investment in their 6- to 8-month-old infant.

Procedure
After review and approval by the Universitys IRB,
prospective participants were recruited via prenatal
clinics and private practices or were identied by
their primary health care provider and gave permission to be contacted to discuss the study. Others
were self-selected by responding directly as a result
of recruitment at prenatal classes. Participants who
were recruited via yers contacted the study investigators by telephone or e-mail and indicated their
interest in participating. In addition, those recruited
via the Internet responded by e-mail to express their
interest. Potential participants were then contacted
by telephone by a member of the research team
and given detailed information about the study purposes and procedures. Signed informed consent to
participate was obtained, and a time convenient for
each participant to complete the initial prenatal interview was arranged.
The prenatal interview was planned for a time when
expectant mothers were between 28 to 40 weeks
(7-9 months) of the current pregnancy. Quantitative
questionnaires evaluating depressive symptoms
(CES-D), general anxiety (STAI), impact of the prior
perinatal loss on current emotions (IES), and their
concerns about and investment in their infant
(MAQ at T3 only), the questionnaires were read
and participants answers recorded. An interview
procedure was decided upon as compared with
mailed questionnaires so that participants could offer qualitative comments after the interview was
nished. Each participant completed their interviews privately; however, data collected from one
member of the couple was paired with their partner
using a predetermined identication number. At the
conclusion of the prenatal interview (T1), a tentative
appointment for the 2 month postpartum interview
(T2) based on the mothers estimated date of birth
was made. Parents who gave birth prematurely or
who suered a perinatal loss in the current pregnancy were excluded from the study. None were
excluded as a result of perinatal loss or preterm
birth during the current pregnancy. The same data
collection procedure was repeated to complete all
interviews.

Data Analysis
A descriptive analysis of demographics as well as
each of the outcomes at baseline was performed

658

stratied by gender. Dierences in categorical variables between the mothers and the fathers were
tested using chi-square techniques, while dierences in continuous variables between mothers
and fathers were tested using paired t-tests techniques. For each outcome separate two-factor
repeated measures analysis of variance (ANOVA)
models were developed. The main eects in the
model included time point (T1, T2, and T3), gender,
and the potential interaction eect between time
and gender. Bonferroni post hoc comparisons were
employed when main eects were signicant
(po.05) to determine specic mean dierences.
Correlations were completed to evaluate relationships among the variables by gender.

Findings
As seen in Table 1, at baseline fathers graduated
from vocational/technical schools more often
(8.7% vs. 0.0%, p 5 .001), had less depressive
symptoms (9.11 vs.15.08, p 5 .0048), and had less intrusive thoughts (13.17 vs. 20.75, p 5 .0029) when
compared to mothers. In addition, in this mostly
White, middle to upper income, highly educated
sample of participants there were no gender dierences identied in mean age, ethnicity, income
levels, marital status, and number of living children.
Further, no dierences were found at baseline for
anxiety levels, IES total scores and IES avoidance
scores between fathers and mothers.
The results from the repeated measures ANOVA
models (Table 2) present many interesting ndings.
Depressive symptoms (po.001), anxiety scores
(po.001 for both STAI subscales), and overall PTS
levels (po.001, measured by IES total scores) signicantly decreased over time, while intrusive
thoughts (IES Intrusion subscale) signicantly increased over time (po.001). Avoidance of thoughts
about the loss, as measured by the IES Avoidance
subscale, remained unchanged over time. The only
gender eect identied in the current study was for
the PTS outcome of intrusive thoughts; mothers
consistently experienced more intrusive thoughts
when compared to fathers (p 5 .026). An interaction
eect existed for the CES-D scores (p 5 .009) and
STAI-T scores (p 5 .02) between gender and time.
That is, the dierence between mothers and fathers
is present at baseline and absent at T3 (see Table 2
and Figures 1^6).
On the MAQ evaluated at T3 only, there were signicant gender dierences regarding concerns
about their childs health with mothers reporting
higher levels of health concerns than fathers

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Armstrong, D. S., Hutti, M. H. and Myers J.

Table 1: Participant Demographic

Characteristics at Baseline Stratified
by Gender
Variable

Male

Age

32.04 (4.80) 30.58 (4.39)

Female

Table 2: Repeated Measures Analysis of

Variance of Depressive Symptoms, State
and Trait Anxiety, and Past Traumatic
Event Stress From the Third Trimester of
Pregnancy to 6 to 8 Months Postpartum

.1962
Outcome

Predictors

CES-D

Time

22.60

o.001 

Gender

2.20

.144

Gender Time

7.34

.009 

29.40

o.001 

Ethnicity
Black

2.7%

2.7%

.999

White

95.5%

95.5%

.999

Hispanic

1.8%

0.9%

.412
STAI-State

Other

0.0%

0.9%

Time

.387

Education
Primary

0.0%

2.8%

.302

High school

2.8%

0.0%

.117

Vocational

8.7%

0.0%

.001 

College

30.6%

19.4%

.417

STAI-Trait

IES total
Masters

38.9%

47.2%

.084

Doctoral

16.7%

27.8%

.289

Professional

2.8%

2.8%

.999
IES Avoidance

Gender

2.71

.12

Gender Time

1.12

.29

25.82

o.001 

Gender

1.42

.24

Gender Time

5.69

.02 

Time

0.558

o.001 

Gender

0.762

.39

Gender Time

0.651

.12

Time

0.558

.34

Gender

0.762

.18

Gender Time

0.651

.23

Time

0.558

o.001 

Gender

0.762

.026 

Gender Time

0.651

.71

Time

Income
Less than $50,000 16.7%

11.1%

.516

$50,000-$99,999

80.6%

.623

72.2%

IES Intrusion
Greater than

11.1%

8.3%

.211

$100,000
Married

96.4%

96.4%

.999

Living children

0.62 (0.80)

0.59 (0.80)

.804

Previous pregnancies

2.06 (1.12)

2.06 (1.12)

.999

Baseline CES-D

9.11 (8.40) 15.08 (8.98)

.0048 

Baseline STAI-State

37.36 (11.25) 41.64 (11.03)

.1078

Baseline STAI-Trait

36.25 (9.93)

.0999

Baseline IES total

27.28 (16.83) 32.53 (16.63)

Baseline IES

14.11 (9.83)

40.19 (10.15)

11.78 (10.91)

.1875
.3439

Avoidance
Baseline IES Intrusion 13.17 (10.41) 20.75 (10.43)

.0029 

MAQ Dierentiation

41.79 (3.30) 43.31 (3.11)

.0020 

MAQ Investment

78.60 (6.43) 85.02 (4.05) o.001 

MAQ Health

24.99 (4.38) 27.22 (4.25)

.0010 

Concerns
Note. CES-D 5 Center for Epidemiologic Studies-Depression Scale;
IES 5 Impact of Event Scale; MAQ 5 Maternal/Paternal Attitudes
Questionnaire; STAI 5 State-Trait Anxiety Inventory.
po.001.

JOGNN 2009; Vol. 38, Issue 6

Note. CES-D 5 Center for Epidemiologic Studies-Depression Scale;

IES 5 Impact of Event Scale; MAQ 5 Maternal/Paternal Attitudes
Questionnaire; STAI 5 State-Trait Anxiety Inventory.
p 5 .01.

(M mother 5 27.22 vs. M father 5 24.99, p 5 .001). In

their report of investment in their infant, mothers reported greater investment than fathers (M mothers 5
85.02 vs. M fathers 5 78.60, po.001). Parents also
demonstrated disparity in their dierentiation
of self from their infants (M mother 5 43.31 vs.
M father 5 41.79, p 5 .0020; see Table 1).
For mothers, there was a positive moderate correlation between PTS and anxiety only during
pregnancy (T1: r 5 .571, po.001). Findings demonstrated moderate relationships between fathers
trait anxiety with PTS at each assessment point in
time (T1: r 5 .571, p 5 .001; T2: r 5 .515, p 5 .002). At
all time points there were signicant positive correlations between depressive symptoms and PTS for
fathers (T1: r 5 .520, p 5 .001; T2: r 5 .574, po.001),
but for mothers their depressive symptoms and

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Perinatal Loss and Parents Psychological Distress

Findings indicate that depressive symptoms and anxiety

decreased over time, but parents level of posttraumatic
stress still remain in the moderately high range.

PTS were moderately correlated only during pregnancy (r 5 .534, p 5 .001) and at T3 (see Table 3 for
all T3 correlations).

Discussion
Mothers level of depressive symptoms indicated a
potential risk for depression during pregnancy similar to previous research (Armstrong, 2002, 2004;
Armstrong & Hutti, 1998; Cote-Arsenault & Mahlangu, 1999). In addition, mothers levels of
depressive symptoms and anxiety were higher than
fathers during pregnancy; however, there was no
signicant dierence between their levels of PTS.
This also is similar to that found in other studies
(Armstrong, 2002, 2004). Mothers experienced decreased levels of depressive symptoms and anxiety,
as well as psychological distress after the birth of
their healthy infant. However, the amount of intrusive thoughts signicantly increased over time. In
addition, while mothers scores during pregnancy
came close to those that might indicate clinical levels of depression, levels of depressive symptoms
after birth were in a low range indicating less concern for the possibility of postpartum depression.
Fathers depressive symptoms and anxiety were in
the low range at each point in time. While these ndings indicate that depressive symptoms and anxiety
decreased over time after birth, parents level of PTS
still remained in the moderately high range. In addition, there was a signicant relationship between

higher IES scores and those who reported higher

levels of depressive symptoms and anxiety.
Relationships between PTS, depressive symptoms,
and anxiety at T3 with parents scores on the MAQ
demonstrated that mothers reported moderate positive associations between their PTS scores and their
investment in this infant. Higher levels of intrusive
thoughts on the IES may be one cause of this association. In addition, mothers reported a moderate
positive correlation between their depressive symptoms with investment in and concerns about the
health of their new infant. As their depressive symptoms increased, their concerns about and
investment in their infant also increased. Anxiety
and subscales on the MAQ demonstrated a positive
relationship between mothers state anxiety and
concerns about the health of their infant also raising
concerns about those mothers with higher anxiety
and their parent-infant relationships.
Mothers with higher levels of PTS expressed signicant relationships between this type of stress and
investment in and health concerns about their child
at 6 to 8 months after birth. These maternal concerns have been shown to result in increased
phone calls and visits to the health care provider in
one study (Cote-Arsenault, 2002) but not in another
(Garel, Blondel, Lelong, Bonenfant, & Kaminski,
1994). The possibility of this increased health care
utilization may be a concern because of the potential for increased health care costs.
For fathers, there also were signicant relationships
between their PTS and health concerns about their
infant. In addition, there also was a moderate asso-

16
15.1
14
12
9.3

10
9.1
8

6.8

8.9

Mothers
Fathers

6.8

4
2
0

Figure 1. Depressive symptoms from third trimester of pregnancy to 6 to 8 months postpartum stratified by gender.
Note. Depressive symptoms (Center for Epidemiologic Studies-Depression scores): 1 5 means at prenatal assessment;
2 5 means at assessment at 2 to 3 months; 3 5 means at assessment at 6 to 8 months.

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Armstrong, D. S., Hutti, M. H. and Myers J.

45
40

41.6

36.2

37.4

32.5

35
34.6

30

30.6

25
Mothers

20

Fathers
15
10
5
0

Figure 2. State anxiety from third trimester of pregnancy to 6 to 8 months postpartum stratified by gender.
Note. State anxiety (State-Trait Anxiety Inventory, State subscale scores): 1 5 means at prenatal assessment; 2 5 means at
assessment at 2 to 3 months ; 3 5 means at assessment at 6 to 8 months.

ciation between this stress and dierentiation of self

from their infant. Similar to PTS, there was a signicant relationship between their trait anxiety and
dierentiation of self and concerns about their
infants health. As their PTS and trait anxiety increased, concerns about the health and wellbeing of their infant and dierentiation of self from
the infant also increased. Their greater anxiety may
be the cause of more concerns about the health of
their infant again creating concerns about parentinfant relationships. There were no signicant relationships between their depressive symptoms and
any of the MAQ subscales for fathers.
Fathers with continuing moderate levels of PTS
showed a greater distancing of themselves from
their child compared to mothers. These dierences
could be related to dierences that mothers and

fathers expressed on the dierent subscales of the

IES. Scores for mothers demonstrated higher levels
of intrusive thoughts about their previous loss,
whereas fathers expressed more avoidance of
thoughts about the loss. These dierences may
cause mothers to have more concerns and investment in their current infant whereas fathers
avoidance may cause more distancing and therefore dierentiation of himself from his new infant
when his PTS is higher. However, any conclusions
drawn from ndings dealing with the dierentiation
subscale should be evaluated with caution because of the low internal reliability for the subscale
in this study.
It is uncertain how the ndings of this research inuence parenting or the long-term cognitive and
behavior development of the infant. It is well docu-

42
40

40.2

38
36

35.8

36.2

Mothers
33.8
35.2

34

Fathers

33.5
32
30

Figure 3. Trait anxiety from third trimester of pregnancy to 6 to 8 months postpartum stratified by gender.
Note. Trait Anxiety Inventory (State-Trait Anxiety Inventory,Trait subscale scores): 1 5 means at prenatal assessment; 2 5 means
at assessment at 2 to 3 months; 3 5 means at assessment at 6 to 8 months.

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Perinatal Loss and Parents Psychological Distress

35
32.5
30

26.3

27.3

33.8

25
25.6
20

33.5
Mothers

15

Fathers

10
5
0

Figure 4. Posttrauma stress from third trimester of pregnancy to 6 to 8 months postpartum stratified by gender.
Note. Posttrauma stress (Impact of Event Scale total scores): 1 5 means at prenatal assessment; 2 5 means at assessment
at 2 to 3 months; 3 5 means at assessment at 6 to 8 months.

mented that postpartum depression in mothers can

inuence the growth and development of their infants (Carter et al., 2001; Field, 1998; Lundy et al.,
1999). Does an increased level of PTS related to
their previous loss act in a similar manner? It remains unclear how these relationships between
PTS and attachment might continue over time and
inuence the childs development. For fathers with
a history of loss, does the relationship between increased PTS and dierentiation of themselves from
their infant result in decreased attachment during
later parenting?
The current research may give clues as to the
decreasing levels of depressive symptoms and
generalized anxiety experienced by parents with a

20

Implications for Clinical Practice

Clinicians who work with families with a history of
prior perinatal loss should be aware of the potential
for continued distress. Becoming pregnant again
may not make everything better for these parents.
The current study as well as previous research demonstrates that mothers in particular may experience
signicant levels of depressive symptoms and anxi-

17.9

18
16

history of loss after the birth of a healthy infant.

However, it is unknown what inuence the continued high levels of PTS related to their previous
perinatal loss may have on parenting as well as
the growth and development of their subsequent
infants.

18.8
15.8

14
12
10

10.3

11.7

12.7

Mothers
Fathers

6
4
2
0

Figure 5. Posttrauma stressintrusive thoughts from third trimester of pregnancy to 6 to 8 months postpartum
stratified by gender.
Note. Posttrauma stressintrusive thoughts (Impact of Event Scale Intrusion subscale): 1 5 means at prenatal assessment;
2 5 means at assessment at 2 to 3 months; 3 5 means at assessment at 6 to 8 months.

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RESEARCH

Armstrong, D. S., Hutti, M. H. and Myers J.

ety in the subsequent pregnancy, some potentially

to the level of clinical depression (Armstrong, 2002,
2004, 2007; Cote-Arsenault, 2002, 2007; Cote-Arsenault & Marshall, 2000; Cote-Arsenault et al.,
2006). Mothers should be monitored throughout
the subsequent pregnancy for symptoms of PTS,
depressive symptoms, and anxiety and oered
counseling and other treatments as appropriate.
While more research is needed, this preliminary
study suggests that families should be followed
carefully after birth to determine any long-term inuence of PTS on attachment issues. Increased
levels of health concerns or abnormal attachment
for mothers or distancing of themselves from their
infant for fathers may be cause for concern in the
growth and development of their subsequent child.
Expression of these concerns may indicate a need
for further observation of these families at risk. Referral to the familys pediatric health care provider
regarding these concerns would be an appropriate
starting point for continued monitoring of the parent-child relationship.

Limitations
The small sample size and its homogeneity are limitations of this preliminary research. While every
eort was made to recruit more diverse study participants, because the study relied on a volunteer
sample, this was not possible. In future studies
greater attention to recruiting in areas with more diverse populations may help.
Limited condence in results from the MAQs dierentiation subscale is needed because of its low

Families should be followed carefully after birth to

determine any long-term influence of posttraumatic stress
on attachment issues.

Cronbachs a, which may be related to the design

of this instrument for use with older children. This
particular subscale was designed to test psychological separation anxiety parents may experience
when their child starts to become less dependent
on the parent. This typically happens at a later age
than 8 months. Therefore, ndings related to dierentiation of the child from the parent in the current
research may not be as useful or dependable as
studies with older infants when using this subscale
of the MAQ.
In addition, the instruments utilized, while widely
used in other research, may not be the most appropriate for these parents with very specic
psychological distress. Questions about their feelings of threat and vulnerability remain and may not
have been captured when using the current studys
questionnaires. In future studies, dierent measures
of these threats and vulnerabilities will help to test
these questions.

Future Directions for Research

Dierent, more specic instruments to measure the
threats or vulnerabilities that parents may experience related to their prior perinatal losses are
needed. The generalized psychological distress
that the questionnaires evaluated in this study may

16
13.9
14
12
11.2
10
9.2

18.8

Mothers
8.4

Fathers

6
12.7
4
2
0

Figure 6. Posttrauma stressavoidance of thoughts from third trimester of pregnancy to 6 to 8 months postpartum
stratified by gender.
Note. Posttrauma stressavoidance of thoughts (Impact of Event Scale Avoidance subscale): 1 5 means at prenatal assessment; 2 5 means at assessment at 2 to 3 months; 3 5 means at assessment at 6 to 8 months.

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Perinatal Loss and Parents Psychological Distress

Table 3: Pearsons Correlations Among Nine Variables at 6 to 8 Month Postpartum (T3)

CES-D r 2 (P)

IES r 2 (P)

Mother

1.0

.436 (.013)

.252 (.163)

.375 (.034)

Father

1.0

.381 (.031)

.404 (.022)

.113 (.54)

Mother

0.250 (.168)

.194 (.288)

.415 (.018)

.106 (.565)

Father

0.244 (.179)

.419 (.017)

.226 (.214)

.390 (027)

Mother

0.393 (.026)

.457 (.009)

.428 (.014)

.246 (.175)

Father

0.068 (.713)

.079 (.669)

.100 (.585)

.198 (.277)

Mother

0.449 (.010)

.203 (.265)

.090 (.624)

.199 (.274)

Father

0.345 (.053)

.638 (o.001)

.431 (.014)

.516 (.003)

Mother

0.682 (o.001)

.158 (.387)

.205 (.261)

.034 (.852)

Father

0.680 (o.001)

.250 (.167)

.437 (.012)

.032 (.861)

Mother

0.575 (.001)

.199 (.276)

.064 (.728)

.217 (.233)

Father

0.804 (o.001)

.406 (.021)

.472 (.006)

.155 (.398)

Variable

IES Avoidance r 2 (P)

IES Intrusion r 2 (P)

CES-D

Dierentiation

Investment

Health

STAI-State

STAI-Triate

Note. CES-D 5 Center for Epidemiologic Studies-Depression Scale; Dierentiation (Maternal Attitudes Scale dierentiation from infant
subscale); Health (Maternal Attitudes Scale; MAQ health concerns about infant subscale); IES 5 Impact of Event Scale; Investment
(Maternal/Paternal Attitudes Questionnaire; MAQ investment in infant subscale; STAI 5 State-Trait Anxiety Inventory.

not focus on the specic anxieties and stress parents with a history of loss are dealing with when
they parent a subsequent child. Replication of the
current study or similar ones with dierent, more
specic questionnaires related to the concerns
parents with a history of loss may have is important
to further examine the current ndings.
Exploration of biochemical and physiological as
well as developmental outcomes for infants resulting from ongoing stress during a pregnancy
associated with prior perinatal losses will allow the
evaluation of any long-term inuence on child development. In addition, parent-infant attachment
diculties that may result from continued PTS after
the birth of a healthy infant require further study.

and promote early parent-infant attachment relationships that can help to provide improved
outcomes and quality of life for families at risk.

Acknowledgment
Funded by National Institute of Nursing Research
Grant 1-R-15 NR08492-01.

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