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Autonomy and Social Norms in a Three

Factor Grief Model Predicting Perinatal
Grief in India
a

Lisa R. Roberts & Jerry W. Lee

School of Nursing , Loma Linda University , Loma Linda ,

California , USA
b

Department of Health Promotion and Education, School of Public

Health , Loma Linda University , Loma Linda , California , USA
Accepted author version posted online: 13 May 2013.Published
online: 18 Jul 2013.

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To cite this article: Lisa R. Roberts & Jerry W. Lee (2014) Autonomy and Social Norms in a Three
Factor Grief Model Predicting Perinatal Grief in India, Health Care for Women International, 35:3,
285-299, DOI: 10.1080/07399332.2013.801483
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Health Care for Women International, 35:285299, 2014

Copyright Taylor & Francis Group, LLC
ISSN: 0739-9332 print / 1096-4665 online
DOI: 10.1080/07399332.2013.801483

Autonomy and Social Norms in a Three Factor

Grief Model Predicting Perinatal Grief in India
LISA R. ROBERTS
School of Nursing, Loma Linda University, Loma Linda, California, USA

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JERRY W. LEE
Department of Health Promotion and Education, School of Public Health, Loma Linda
University, Loma Linda, California, USA

Perinatal grief following stillbirth is a significant social and mental health burden. We examined associations among the following latent variables: autonomy, social norms, self-despair, strained
coping, and acute griefamong poor, rural women in India who
experienced stillbirth. A structural equation model was built and
tested using quantitative data from 347 women of reproductive age
in Chhattisgarh. Maternal acceptance of traditional social norms
worsens self-despair and strained coping, and increases the autonomy granted to women. Greater autonomy increases acute grief.
Greater despair and acute grief increase strained coping. Social
and cultural factors were found to predict perinatal grief in India.
Stillbirth is a significant global public health problem with multiple etiologies.
Perinatal grief following stillbirth is a significant social and mental health burden. Therefore, in India, where stillbirth rates are high, perinatal grief affects
the day-to-day life of many women (Roberts, Anderson, Lee, & Montgomery,
2012a; Roberts, Montgomery, Lee, & Anderson, 2012b).
Our objective in this study was to examine associations among latent
variables of perinatal grief among poor, rural women of central India who
had experienced stillbirth. A structural equation model was built and tested
using quantitative data from women of reproductive age. We were compelled
to better understand predictors of perinatal grief within the cultural context
so that appropriate interventions may be undertaken in the future.

Received 15 July 2012; accepted 24 April 2013.

Address correspondence to Lisa R. Roberts, School of Nursing, Loma Linda University,
11262 Campus Street, West Hall, Loma Linda, CA 92350-0001, USA. E-mail: lroberts@llu.edu
285

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L. R. Roberts and J. W. Lee

While perinatal grief predictors are well documented in Western countries, this study adds to the limited literature on perinatal grief in non-Western
countries.

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BACKGROUND
Stillbirth is a significant global public health problem with multiple etiologies (Kramer, 2003; Lawn et al., 2009b; Rubens, Gravett, Victora, & Nunes,
2010). In addition to medical causes, indirect casual factors include lack of
antenatal care (Di Mario, Say, & Lincetto, 2007), poverty (Lawn et al., 2009a),
and social norms facilitating gender discrimination. Gender discrimination in
India results in disparity of female education (Korde-Nayak Vaishali & Gaikwad Pradeep, 2008), early marriage (Croll, 2000), and low female autonomy
(Lee et al., 2009; Yesudian, 2009), each of which are known risk factors for
stillbirth (Lawn et al., 2009b).
Therefore, maternal coping with stillbirth cannot be studied without
necessarily considering womens status. As stated by Lee Jong-Wook, former
Director-General of the World Health Organization (WHO), Mothers, the
newborn, and children represent the well-being of society and its potential
for the future (WHO, 2005, p. xi). Womens status in India is a summation of
a number of factors including education, economic activity, decision-making
authority, personal freedom of movement, control over economic resources,
reproductive rights, land ownership, age at marriage, spousal age difference, joint family residence, socialization of secondary status, and health
(Jejeebhoy & Sathar, 2001; Mathur, 2008). Womens autonomy is generally
acknowledged to be low in developing nations, and specifically in India
(Barua & Kurz, 2001; Clarke & Clarke, 2009; Croll, 2000; Mistry, Galal, & Lu,
2009; Yesudian, 2009). Bloom, Wypij, and Gupta (2001) define womens autonomy in India as interpersonal control, characterized by a womans ability
to control or make decisions regarding concerns in her life, even though
family members may oppose her wishes.
Womens autonomy, however, cannot be understood outside of the
overarching social norms in India. India is a patriarchal society in which
women are transferred between patrilines at the time of marriage and live
with affinal kin (Bloom et al., 2001, p. 68). In other words, upon marriage
women leave their natal kin to live with their husbands family. Their autonomy, therefore, must be understood within this social context. After marriage
a woman is no longer considered a member of her natal kins family. Her
status in her new family is determined by her fertility, her ability to produce
at least one son, and her age in relationship to her sisters-in-law. At the
beginning of her marriage, as the newest member of the household, she has
the lowest social status within the household hierarchy (Bloom et al., 2001;
Croll, 2000).
Predictors of poor coping with perinatal grief in Western societies
have included emotion-focused coping strategies, maladaptive coping skills,

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Model Predicting Perinatal Grief in India

287

perceived lack of social support, and intense emotionality at the time of

stillbirth (Bennett, Litz, Maguen, & Ehrenreich, 2008; Cacciatore, Schnebly,
& Froen, 2009; Engler & Lasker, 2000). The dearth of data pertaining to
Indian womens perinatal grief limits our understanding of factors that
predict their coping with the loss. Social norms, however, may influence
perinatal grief in this setting. Examples of social norms pertaining to birthing
practices in India can be found in the literature: a strict code of practices and
expected behaviors during the postpartum period for women (Ramakrishna,
Ganapathy, Matthews, Mahendra, & Kilaru, 2008), social consequences for
women without children include divorce or shunning (Joshi, Dhapola, &
Pelto, 2008), prohibition from being present at the babys burial due to
religious beliefs (Gatrad, Ray, & Sheikh, 2004), and conferral of blessings
only for the birth of a son (Garg & Nath, 2008); furthermore, women
who suffer stillbirth are stigmatized (Sather, Fajon, Zaentz, & Rubens,
2010).
While the Indian medical society has not traditionally acknowledged
perinatal grief as a significant problem (Mehta & Verma, 1990), more recent
studies have shown that perinatal grief is not a Western phenomenon (Mammen, 1995) and perinatal grief is indeed a significant problem and social
burden in India (Roberts et al., 2012b) that can negatively impact womens
health.
The purpose of this study was to examine associations among autonomy
(womens freedom of movement without permission), acceptance of social
norms regarding stillbirth, self-despair (helplessness and hopelessness),
strained coping (difficulty with everyday life and social interactions), and
acute grief (anguish regarding the stillborn baby) by examining causal pathways to perinatal grief among poor, rural women of central India who had
experienced stillbirth. A conceptual model was theoretically developed;
structural equation modeling (SEM) was then used to explore the model
fitness. We hypothesized that (a) women with lower autonomy would
have higher perinatal grief scores due to a lack freedom to exercise any
practical coping, thereby relying heavily on emotion focused coping which
is associated with increased perinatal grief (Engler & Lasker, 2000), and
that (b) women with traditional views toward social norms would have
greater perinatal grief due to inhibited expression of grief proscribed by
social expectations and the stigma and blame attached to stillbirth (Sather
et al., 2010; Stanton, Lawn, Rahman, Wilczynska-Ketende, & Hill, 2006).
Additionally, the internationally validated Perinatal Grief Scale (PGS) was
expected to perform reliably in our study population. Toedter, Lasker, and
Janssen (2001) reviewed 22 studies in four Western countries to validate the
PGS in widely varying samples. As a result, the authors state that PGS has
excellent reliability and generalizability. The authors also found remarkable
similarities of grief predictors among these studies done with samples in
three European countries and the United States.

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L. R. Roberts and J. W. Lee

METHODS
Participants and Procedures

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These data were gathered from a cohort of 355 poor, rural women of central India (see Table 1) as part of a larger mixed-methods study exploring
womens perceptions of stillbirth and factors that inhibit or enhance coping
with perinatal grief (Roberts et al., 2012a; Roberts et al., 2012b). Structured
interviews were used to collect demographics as well as measure acceptance
of social norms pertaining to expectations of womens response to stillbirth,
perceived social provision of support, intrinsic religiosity, coping methods,
autonomy, and perinatal grief. Cases with any missing data on the variables
used in this analysis were excluded, reducing the cohort to 347.

Measures
Control variables. Initial analyses showed demographic variables such
as education and age, were unrelated to our five primary constructs and
therefore were not included as control variables.
Latent constructs. Our structural equation model (SEM) was designed
around five constructs: social norms, autonomy, despair, difficulty coping,
TABLE 1 Sample Demographics (N = 355): Comparing Participants With a History of Stillbirth and Those Without a History of Stillbirth
Item
Scheduled tribe (ST)
Scheduled castes (SC)
Other backward castes (OBC)
Hindu
Women of reproductive age with no
education
Birth intervals < 2 years
Report of domestic violence
Ever had a sonogram
Women reporting no health problems
Tobacco and/or paan used
Mean age at first delivery
Birth control pill use among rural women of
reproductive age
No form of contraceptive used
Total fertility rate
p

Had stillbirth
(n = 178)

No stillbirth
(n = 177)

14.6% (N = 26)
31.5% (N = 56)
46.6% (N = 83)
100% (N = 178)
53.9% (N = 96)

6.2% (N = 11)
35.0% (N = 62)
49.7% (N = 88)
98.9% (N = 175)
41.8% (N = 74)

81.4% (N = 144)
20.3% (N = 36)
43.3% (N = 77)
63.5% (N = 113)
25.3% (N = 45)
19.01 (2.17)
0.6% (N = 1)

78.3% (N = 137)
13.6% (N = 24)
29.4% (N = 52)
81.9% (N = 145)
13.6% (N = 24)
18.74 (2.28)
1.1% (N = 2)

86.0% (N = 153)
4.6

83.6% (N = 148)
2.7

< .05, p < .01.

Note: ST, SC, OBC are people groups at the bottom of the Indian social stratification system and have
previously been known by such designations as untouchables, harijans, outcastes, and depressed classes
and are currently also known as dalits (Sachchidananda, 1993). Paan is a chewing mixture of areca nut
and lime wrapped in a betel leaf or a similar variation (Gandhi, Kaur, & Sharma, 2005).

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Model Predicting Perinatal Grief in India

289

and active grief. Each construct was formed from three to seven manifest
variables as described below. All Cronbachs statistics were calculated on
our full sample of women.
Demographics. Independent variables included age, ethnicity, and religion, and additional pertinent information such as maternal age at first
delivery, education level, socioeconomic status, household position (head of
household/widow, wife, daughter-in-law, or daughter), gender roles, contraceptive use, family composition, and history of domestic violence.
Autonomy. An autonomy scale was derived from questions in a previous study done in India (Mistry et al., 2009). The authors defined autonomy
as a womans freedom to exercise her own judgment in order to act in her
own interest and extracted data from the 19981999 National Family Health
Survey-2 for married, rural women ages 15 to 49 who had at least one
singleton birth.
Initially all six questions used by Mistry and colleagues (2009) were
used in this study as an autonomy; scale with a summed index score with
higher scores indicating greater autonomy; however, the Cronbach alpha
was abysmal (.14). Therefore, two items were droppedspecifically two
items regarding decision making as it pertains to buying a major household
item and going to stay at natal kinswhich resulted in a much improved
Cronbach alpha (.54). The women in our study were very poor, and buying
a major household item was not something they could relate to very wellit
simply is not within the realm of their realty to even consider this. Likewise,
once married, our sample women live with their husbands family and rarely
leave their homes. As expressed by a mother-in-law in phase one of our
study, She came here after marriage; now she should live here and she
should die here. Always she should be here, her husband her only focus.
Therefore, the item regarding staying with natal kin did not track well with
our study population. Thus, while the initial autonomy scale was also developed in an Indian context, further contextualization to our target women
was required due to the vast diversity of India that, taken as a whole, hides
the variance of many subgroups and their unique cultures, languages, and
traditions.
Social norms. The acceptance of social norms scale was designed to
measure womens attitudes toward social norms on a continuum of agreement with traditional social norms to disagreement with traditional social
norms. The social norms questions were derived from the literature and
included (a) expectations regarding the appropriate age for women to be
married (Croll, 2000), (b) mothers-in-law expectations for offspring within a
year of marriage (Barua & Kurz, 2001), (c) expression of grief after a baby is
lost (Mehta & Verma, 1990), (d) shame after stillbirth, (e) being blamed by
others for the stillbirth (Sather et al., 2010), and (f) preference for a son (Garg
& Nath, 2008; Gatrad et al., 2004). Two items dealt with son preference; one

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L. R. Roberts and J. W. Lee

to elicit maternal attitude and one to elicit repercussions of having a male

versus female stillbirth. Womens acceptance of social norms was ascertained using seven questions with a 3-point Likert-type scale (agree, neutral,
disagree). Social norm questions were represented by an index score as a
continuous variable, with low scores indicating traditional views and higher
scores indicating progressive views. The 7-item scale, summed for an index
score of 0 to 14, had a Cronbach alpha of .50.
Perinatal grief. The internationally validated (Toedter, Lasker, &
Janssen, 2001) PGS-33 is a reliable measure of maternal grief with three
factor-analyzed 11-item subscales measuring active grief, difficulty coping,
and despair with a 5-point Likert scale, ranging from 1 (strongly disagree)
to 5 (strongly agree) (Potvin, Lasker, & Toedter, 1989). For scoring, all items
were summed, so that higher scores reflect more severe grief. An index score
(33 to 165) represented perinatal grief as a continuous variable (Cronbachs
alpha = .91).

Analysis
We used Amos and SPSS 20 to generate data sets for SEM and run descriptive
statistics. Exploratory factor analysis was utilized to eliminate items based
on principal component analysis. Models were built for autonomy, social
norms, self-despair, strained coping, and acute grief. Then structural equation modeling was performed using Amos 20 to examine the causal relationships among the latent variables. Root mean square error of approximation
(RMSEA) and comparative fit index (CFI) were utilized to judge how well
the model fit the data.

RESULTS
To explore how autonomy, social norms, and perinatal grief related to one an
other and with demographics and pregnancy-related variables simple linear
regressions were performed with autonomy, social norms, and perinatal grief
as the dependent variables. The results are shown in Table 2.

Predictors of Autonomy
Only education and social norms predicted autonomy in the simple linear
regressions. When multiple regression was used to regress autonomy on
all the variables in Table 2, again, only education and response to social
norms were significant predictors of autonomy (p = .033 and .003, respectively), and very little of the variance (R 2 = .07) in autonomy was explained.

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Model Predicting Perinatal Grief in India

TABLE 2 Simple Linear Regression of Autonomy, Social Norms, and Perinatal Grief on Each
Demographic, and on Each Other, Among All Study Participants (N = 355)
Autonomy

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Item
Age
Ethnicity
Household position
Victim of domestic violence
Contraceptive use
Number of living sons
Number of living daughters
Education
Comparative SES
Maternal age at 1st delivery
Number of pregnancies
Ever had a sonogram
Number of stillbirths
Social norms
Autonomy
Note. p < .05,

0.05
0.01
0.02
0.06
0.06
0.07
0.06
0.16
0.03
0.07
0.01
0.07
0.01
0.18

p
.373
.856
.680
.236
.272
.161
.250
.002
.552
.208
.866
.171
.885
.001

Social norms

Perinatal grief

0.11
0.06
0.05
0.11
0.11
0.14
0.10
0.18
0.03
0.15
0.22
0.06
0.13

.049
.235
.391
.048
.033
.009
.071
.001
.562
.004
.000
.277
.014

0.18

.001

0.04
0.07
0.01
0.08
0.10
0.06
0.01
0.14
0.01
0.14
0.15
0.03
0.21
0.50
0.09

.492
.186
.987
.148
.059
.286
.926
.009
.880
.010
.004
.552
.000
.000
.086

< .01

Predictors of Social Norms

Age, history of domestic violence, contraceptives, number of living sons,
education, age at first delivery, number of pregnancies, number of stillbirths,
and autonomy were significant predictors of response to social norms (see
Table 2). When the social norms variable was regressed on all of the independent variables, however, only contraceptives, number of pregnancies,
and autonomy were significant (p = .014, .019, .003, respectively), and only
a small amount of variance was explained (R 2 = .13).

Predictors of Perinatal Grief

In simple linear regressions, education, age at first delivery, number of pregnancies, number of stillbirths, and social norms were significant predictors
of perinatal grief (see Table 2). Perinatal grief was then regressed on all
the other variables jointly and only one variablesocial normwas highly
significant (p < .01). Finally, perinatal grief was regressed on the variables
that had been significant on the above multiple linear regressions (MLRs);
namely, contraceptives, education, number of pregnancies, autonomy, and
social norms. Once again, only social norms was significant (p < .01), with
moderate variance explained (R 2 = .26).

Factor Analysis
Exploratory factor analysis was applied to reduce variables of autonomy, social norms, and perinatal grief, and principal component analysis was used

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L. R. Roberts and J. W. Lee

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to obtain the main factors among the variables. Table 3 shows the variables kept for each factor extracted. Of note, three factors were confirmed
for perinatal grief; however, the items correlated differently for our cohort
than that described by Potvin and colleagues (1989). There was some degree of overlap between our factors and Potvin and colleagues factors, and
while representing the same essence of their factors, we felt it necessary
to rename our factors. Thus, we titled our three factors of perinatal grief
self-despair, strained coping, and acute grief. For comparison to Potvin and
colleagues factors (despair, difficulty coping, and active grief), please see
Table 3.

Structural Equation Modeling

Our causal model included 20 manifest variables as shown in Figure 1.
Direct effects. Initially we ran the causal model shown in Figure 1 with
direct paths from education to autonomy, autonomy to social norms, and
social norms to perinatal grief. These direct pathways did not meet our statistical significance criterion, and the model was modified. Education was
dropped and direct paths from autonomy to social norms, social norms to
perinatal grief, and autonomy to perinatal grief were explored. Perinatal
grief was then modeled according to the three factorsself-despair, strained
coping, and acute griefreplacing a unitary perinatal grief factor in the
model. The following direct paths did not meet statistical significance and
were dropped from the model: autonomy to self-despair, autonomy to
strained coping, and social norms to acute grief. Additionally, modification indices suggested several logical connections in the error variances
of items; for example, several questions used the phrase since the baby
died or since he or she died, which might have contributed to the correlated error variance. Also, a direct connection was suggested between
the blame myself question and the family ashamed of me due to stillbirth question, which seemed a reasonable connection and it was added.
This resulted in the final model with goodness of fit statistics as shown in
Figure 1.
Acceptance of social norms was positively associated with self-despair
and strained coping, while negatively associated with autonomy. Autonomy
was positively associated with acute grief. Self-despair and acute grief were
both positively associated with strained coping.
Indirect effects. Causal pathways from one variable to another can
be affected by an intervening variable. Note in Figure 1, for example,
that social norms is indirectly connected with acute grief through autonomy. In this respect, an increase in acceptance of social norms was associated with decrease in acute grief, but it did not reach significance
(p = .059).

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TABLE 3 Three Factors of Perinatal Grief

Potvin et al.

Our model

Active grief
I feel depressed.
I feel empty inside.
I feel a need to talk about the baby.
I am grieving for the baby.
I am frightened.
I very much miss the baby.
It is painful to recall memories of the loss.
I get upset when I think about him/her.
I cry when I think about him/her.
Time passes so slowly since the baby died.
I feel so lonely since he/she died.

Acute grief
I feel depressed.

Difficulty coping
I find it hard to get along with certain
people.
I cant keep up with my usual activities.
I have considered suicide since the loss.
I feel I have adjusted well to the loss.R
I have let peole down since the baby died.
I get cross at my friends/relatives more than
I should.
Sometimes I feel like I need a professional
counselor to help me get my life together
again.
I feel as though I am just existing and not
really living since he/she died.
I feel somewhat apart and remote even
among friends.
I find it difficult to make decisions since the
baby died.
It feels great to be alive.R

Strained coping
I find it hard to get along with certain people.

Despair
I take medicine for my nerves.
I feel guilty when I think about the baby.
I feel physically ill when I think about the
baby.
I feel unprotected in a dangerous world
since he/she died.
I try to laugh but nothing seems funny
anymore.
The best part of me died with the baby.
I blame myself for the babys death.
I feel worthless since he/she died.
It is safer not to love.
I worry about what my future will be.
Being a bereaved parent means being a
second class citizen.

Self-despair
I feel my nerves are bad.
I feel guilty when I think about the baby.
I feel physically ill when I think about the baby.

I feel a need to talk about the baby.

I am grieving for the baby.
I very much miss the baby.
It is painful to recall memories of the loss.
I get upset when I think about him/her.
I cry when I think about him/her.

I cannot keep up with my usual activities.

I get cross at my friends/relatives more than I

should.

It is safer not to love.

I feel empty inside.
I am frightened.

I feel unprotected in a dangerous world since

he/she died.
I try to laugh but nothing seems funny anymore.
The best part of me died with the baby.
I blame myself for the babys death.
I feel worthless since he/she died.
Because of the stillbirth I feel like an outcast.
I have considered suicide since the loss.
I feel so lonely since he/she died.
I find it hard to concentrate since the baby died.
I feel alone even among friends/family.
I have let people down since the baby died.
I feel as though I am just existing and not really
living since he/she died.
Time passes so slowly since the baby died.

Note: The items are not in the order in which they have been used. = indicates that in our study this item
loaded on a different factor than in Potvin et al. R = Items reverse coded before analysis. Italics indicate
wording of item changed from original wording to accommodate cultural understanding/translation.

294

FIGURE 1 Final causal model on sample with no missing data (n = 347). Standardized regression coefficients from structural equation model are
shown. X 2 = 336.2, df = 159, p < .001, RMSEA = .057 (.048, 0.65), CFI = .935. Numbers on arrows are standardized path coefficients. SB =
stillbirth (color figure available online).

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Model Predicting Perinatal Grief in India

295

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DISCUSSION
Acceptance of traditional social norms was associated with increased selfdespair and strained coping. Acceptance of social norms apparently decreased autonomy. Increased autonomy was accompanied by more acute
grief. Greater self-despair and acute grief was associated with increased
strained coping, which suggests how these three aspects of perinatal grief
might be related.
While we had anticipated greater autonomy to have a protective effect
in terms of perinatal grief, we found the opposite to be true. Our hypothesis was that women with increased autonomy would be less isolated and
have greater opportunity for fulfillment through means other than fertility.
Additionally, we hypothesized that those with more autonomy would be
less accepting of traditional social norms and possibly have a wider network
of social supportboth of which were found to have a protective effect
in terms of perinatal grief outcomes in our previous study (Roberts et al.,
2012b). It is possible that the reason autonomy, instead, was associated with
increased acute grief in this context is that with greater autonomy there is
some freedom of choice, which may make it harder to simply accept the stillbirth as ones fate. In traditional Indian society fatalism is pervasive (Lawn
et al., 2009a).
Traditional Indian society is also collectivistic in nature, however, giving
autonomy a different connotation than in Western society. Further consideration of the quality of autonomy measured in our study population boiled
down to whether or not women needed to seek permission to go to the market or visit relatives/friends, which would or would not be granted by her
affinal kin. Our assertion that womens autonomy and social norms in India
are correlated entities was confirmed by this SEM. Maternal acceptance of
traditional social norms may be associated with decreased autonomy simply
because she would never think or dare to go to the market or visit natal kin/friends without seeking permission from her affinal kin. This would
explain why increased acceptance of social norms would be negatively associated with autonomy and at the same time autonomy was associated with
increased acute grief.
Acceptance of social norms affects each of the three factors of perinatal griefself-despair and strained coping directly and acute grief indirectly
through autonomyindicating that maternal acceptance of traditional social norms is associated with perinatal grief. The high acceptance of social
norms involves increased self-despair and strained coping, however, through
decreased autonomy, decreased acute grief.
Yet the increased acute grief associated with increased autonomy may
be protective in the long run. Acute grief following stillbirth could be considered normal (Potvin et al., 1989) and while consensus is lacking as to
the appropriate duration for normal grieving (Woof & Carter, 1997), it does

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resolve spontaneously (Kim & Jacobs, 1991). Complicated grief, an intensification of the normal grief response, however, is characterized by the presence of intrusive thoughts, pangs of severe emotion, distressing yearnings,
feeling excessively alone and empty, excessively avoiding tasks reminiscent
of the deceased, unusual sleep disturbances, and maladaptive levels of loss
of interest in personal activities, present more than a year after the loss event,
are indicative of complicated grief disorder (Horowitz et al., 2003). Perinatal
loss creates a propensity for complicated grief (Bennett, Litz, Lee, & Maguen,
2005), and the characteristics of complicated grief thematically map on to the
self-despair and strained coping variables of our study very well. Similarly,
Potvin and colleagues (1989) indicated more severe grief associated with the
progression from active grief to difficulty coping to despair. Therefore, it may
be that acceptance of social norms, associated with self-despair and strained
coping, results in worsened perinatal grief compared with the acute grief associated with increased autonomy among women who are less accepting of
social norms. In essence, acute grief may result in better long-term outcomes.
Longitudinal studies are needed to further investigate this possibility.
Predicting perinatal grief is clearly different in this context than
what is documented in the literature for Western women. Understanding
perinatal grief predictors according to cultural context is important for the
design of future investigations as well as the development of appropriate
interventions. A tailored approach is made possible by careful analysis of
the data.

Strengths and Limitations

This data analysis contributes to the limited literature available on perinatal
grief in India and the social norms and autonomy factors affecting perinatal
grief in the context of poor, rural women. The vast variation of people
groups, religious beliefs, and traditions within India limit generalizability.
Enhanced understanding of the predictors of perinatal grief gained through
this factor analysis and structural equation modeling however, is particularly
helpful when considering possible interventions.

Conclusion
The importance of social norms in this context cannot be ignored. Not only
do traditional social norms contribute to the high levels of grief experienced
in the daily lives of these women (likely by sustaining systematic gender
discrimination), the particular social norms of disparity in female health and
education, son preference, low autonomy, and early marriage and childbearing are risk factors for stillbirth; yet for these women their very identity

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and worth are determined by fertility. Therefore, perinatal grief adds tremendously to their already high levels of grief.
Future interventions aimed at reducing mental health and social sequelae resulting from perinatal grief must also address the underlying social
norms that form the backdrop of the lives of Indian women. Until traditional
social norms are challenged, the daily lives of these women will continue to
be burdened with grief. If, on the other hand, these women are encouraged
to adopt progressive attitudes and social norms are addressed within their
families and villages through community education, the women will fare
better if stillbirth does occur.
Additionally, as social norms are addressed through community education, families may be more likely to access antenatal care and facility
deliveries as offered through government and private programs, thus reducing the future incidence of stillbirth, and, at the same time, when stillbirth
does occur families may be more understanding of maternal grief.
Women who are currently grieving may also be more likely to recover
if the pressure of social norms to produce children, particularly sons, is
reduced. These interventions would also likely help lower the general grief
that is so much a part of womens lives in India.
The results of this study add to the limited literature on perinatal grief
among Indian women and other non-Western women whose fertility is
paramount and whose culture perpetuates systematic gender discrimination.
Whether these women are encountered in their countries of origin or as immigrants in Western countries, understanding their cultural paradigm is vital.
Only with an informed approach can we effectively predict perinatal grief
and offer appropriate intervention.

REFERENCES
Barua, A., & Kurz, K. (2001). Reproductive health-seeking by married adolescent
girls in Maharashtra. In M. Koenig, S. Jejeebhoy, J. Cleland, & B. Ganatra (Eds.),
Reproductive health in India: New evidence (pp. 3246). New Delhi, India:
Rawat.
Bennett, S. M., Litz, B. T., Lee, B. S., & Maguen, S. (2005). The scope and impact
of perinatal loss: Current status and future directions. Professional Psychology:
Research and Practice, 36, 180187. doi:10.1037/0735-7028.36.2.180
Bennett, S. M., Litz, B. T., Maguen, S., & Ehrenreich, J. T. (2008). An exploratory
study of the psychological impact and clinical care of perinatal loss. Journal of
Loss & Trauma, 13, 485510.
Bloom, S. S., Wypij, D., & Gupta, M. D. (2001). Dimensions of womens autonomy
and the influence on maternal health care utilization in a North Indian City.
Demography, 38(1), 6778.
Cacciatore, J., Schnebly, S., & Froen, J. F. (2009). The effects of social support on
maternal anxiety and depression after stillbirth. Health & Social Care in the
Community, 17, 167176. doi:10.1111/j.1365-2524.2008.00814.x

Downloaded by [University of Veracruzana] at 11:10 20 August 2015

298

L. R. Roberts and J. W. Lee

Clarke, P., & Clarke, P. B. (2009). The Oxford handbook of the sociology of religion.
New York, NY: Oxford University Press.
Croll, E. (2000). Endangered daughters: Discrimination and development in Asia.
London, England: Routledge.
Di Mario, S., Say, L., & Lincetto, O. (2007). Risk factors for stillbirth in developing
countries: A systematic review of the literature. Sexually Transmitted Diseases,
34(7), S11S21. doi:10.1097/01.olq.0000258130.07476.e3
Engler, A. I., & Lasker, J. N. (2000). Predictors of maternal grief in the year after a
newborn death. Illness, Crisis & Loss, 8, 227243.
Gandhi, G., Kaur, R., & Sharma, S. (2005). Chewing pan masala and/or betel
quidFashionable attributes and/or cancer menaces? Journal of Human Ecology, 17, 161166.
Garg, S., & Nath, A. (2008). Female feticide in India: Issues and concerns. Journal
of Postgraduate Medicine, 54, 276279.
Gatrad, A. R., Ray, M., & Sheikh, A. (2004). Hindu birth customs. Archives of Disease
in Childhood, 89, 10941097. doi:10.1136/adc.2004.050591
Horowitz, M. J., Siegel, B., Holen, A., Bonanno, G. A., Milbrath, C., & Stinson, C. H.
(2003). Diagnostic criteria for complicated grief disorder. Focus, 1, 290298.
Jejeebhoy, S. J., & Sathar, Z. A. (2001). Womens autonomy in India and Pakistan:
The influence of religion and region. Population and Development Review, 27,
687712.
Joshi, A., Dhapola, M., & Pelto, P. J. (2008). Gynaecological problems: Perceptions
and treatment-seeking behaviors of rural Gujarati women. In M. Koenig, S.
Jejeebhoy, J. Cleland, & B. Ganatra (Eds.), Reproductive health in India: New
evidence (pp. 133158). New Delhi, India: Rawat.
Kim, K, & Jacobs, S. (1991). Pathologic grief and its relationship to other psychiatric
disorders. Journal of Affective Disorders, 21, 257263.
Korde-Nayak Vaishali, N., & Gaikwad Pradeep, R. (2008). Causes of stillbirth. The
Journal of Obstetrics and Gynecology of India, 58, 314318.
Kramer, M. S. (2003). The epidemiology of adverse pregnancy outcomes: An
overview. Journal of Nutrition, 133, 1592S1596S.
Lawn, J., Kinney, M., Lee, A., Chopra, M., Donnay, F., Paul, V., . . . Darmstadt, G.
(2009a). Reducing intrapartum-related deaths and disability: Can the health system deliver? International Journal of Gynecology & Obstetrics, 107, S123S142.
doi:10.1016/j.ijgo.2009.07.021
Lawn, J., Yakoob, M., Haws, R., Soomro, T., Darmstadt, G., & Bhutta, Z. (2009b).
3.2 million stillbirths: Epidemiology and overview of the evidence review. BMC
Pregnancy and Childbirth, 9(Suppl. 1), S2. doi:10.1186/1471-2393-9-S1-S2
Lee, A. C. C., Lawn, J. E., Cousens, S., Kumar, V., Osrin, D., Bhutta, Z. A., . . .
Darmstadt, G. L. (2009). Linking families and facilities for care at birth: What
works to avert intrapartum-related deaths? International Journal of Gynecology
& Obstetrics, 107, S65S88. doi:10.1016/j.ijgo.2009.07.012
Mammen, O. K. (1995). Womens reaction to perinatal loss in India: An exploratory,
descriptive study. Infant Mental Health Journal, 16, 94101.
Mathur, K. (2008). Body as space, body as site: Bodily integrity and womens empowerment in india. Economic and Political Weekly, 43(17), 54.
Mehta, L., & Verma, I. C. (1990). Helping parents to face perinatal loss. Indian
Journal of Pediatrics, 57, 607609.

Downloaded by [University of Veracruzana] at 11:10 20 August 2015

Model Predicting Perinatal Grief in India

299

Mistry, R., Galal, O., & Lu, M. (2009). Womens autonomy and pregnancy care
in rural India: A contextual analysis. Social Science & Medicine, 69, 926933.
doi:10.1016/j.socscimed.2009.07.008
Potvin, L., Lasker, J., & Toedter, L. (1989). Measuring grief: A short version of the
Perinatal Grief Scale. Journal of Psychopathology and Behavioral Assessment,
11(1), 2945. doi:10.1007/bf00962697
Ramakrishna, J., Ganapathy, S., Matthews, Z., Mahendra, S., & Kilaru, A. (2008).
Health, illness and care in the obstetric period: A prospective study of women
in Rural Karnataka. In M. Koenig, S. Jejeebhoy, J. Cleland, & B. Ganatra (Eds.),
Reproductive health in India: New evidence (pp. 86115). New Delhi, India:
Rawat.
Roberts, L. R., Anderson, B. A., Lee, J. W., & Montgomery, S. (2012a). Grief and
women: Stillbirth in the social context of India. International Journal of Childbirth, 2, 187198. doi:http://dx.doi.org/10.1891/2156-5287.2.3.187
Roberts, L. R., Montgomery, S., Lee, J. W., & Anderson, B. A. (2012b). Social and
cultural factors associated with perinatal grief in Chhattisgarh, India. Journal of
Community Health, 37, 572582. doi:10.1007/s10900-011-9485-0
Rubens, C., Gravett, M., Victora, C., & Nunes, T. (2010). Global report on preterm
birth and stillbirth (7 of 7): Mobilizing resources to accelerate innovative solutions (Global Action Agenda). BMC Pregnancy and Childbirth, 10(Suppl. 1),
S7. doi: 10.1186/1471-2393-10-S1-S7
Sachchidananda. (1993). Political culture of scheduled castes and tribes: A study
in change. In S. B. Roy & A. K. Ghosh (Eds.), People of India: Bio-cultural
dimensions (pp. 113125). New Delhi, India: Inter-India Publications.
Sather, M., Fajon, A. V., Zaentz, R., & Rubens, C. (2010). Global report on preterm
birth and stillbirth (5 of 7): Advocacy barriers and opportunities. BMC Pregnancy
and Childbirth, 10(Suppl. 1), S5. doi:10.1186/1471-2393-10-S1-S5
Stanton, C., Lawn, J. E., Rahman, H., Wilczynska-Ketende, K., & Hill, K. (2006). Stillbirth rates: Delivering estimates in 190 countries. Lancet, 367(9521), 14871494.
Toedter, L. J., Lasker, J. N., & Janssen, H. M. (2001). International comparison of
studies using the Perinatal Grief Scale: A decade of research on pregnancy loss.
Death Studies, 25, 205228. doi:10.1080/074811801750073251
Woof, W. R., & Carter, Y. H. (1997). The grieving adult and the general practitioner:
A literature review in two parts (Part 2). The British Journal of General Practice,
47(421), 509514.
World Health Organization (WHO). (2005). World Health Report 2005: Make every
mother and child count. Geneva, Switzerland: Author.
Yesudian, P. P. (2009). Synergy between womens empowerment and maternal
and peri-natal care utilization. Retrieved from http://iussp2009.princeton.edu/
download.aspx?submissionId=92156