SEEING AND HOLDING THE BABY

MEMENTOS

A. PHOTOGRAPHS

Many families also cherish Ultrasound Images. When I started working in the field, these images were unique and exciting, but you needed a cartographer to read them or tell what part of the baby you were seeing in utero! Today with computer enhancement and advanced technology, these images can be quite realistic and distinct: families often cherish their ultrasounds of a son or daughter who died. When no photo is available post-partum, an ultrasound image may be the only tangible picture to remember a child by.

B. FOOTPRINTS/HANDPRINTS

C. OTHER MEMENTOS

CHOICES OF CREMATION VS BURIAL IN THE HOSPITAL

THE FUNERAL

THE AUTOPSY

REACTIONS OF OTHERS

OTHER VARIABLES AFFECTING THE OUTCOME OF PERINATAL BEREAVEMENT

There is a difference when one is given word before a baby is born that it has died: what some call 'magical' thinking may occur in which parents hold out all hope against what doctors say and still believe, even with conclusive evidence, that the baby may still be born alive or even more dramatic, may come back to life. One cannot really gauge which is the more difficult grief: both are difficult in their own way: comparisons are more harmful than productive. When a death occurs at birth or shortly before, the key factor is a radical reversal of expectation accompanied by overwhelming sorrow and pain. When a death occurs before birth, and there is still time until the due date: the reality of the death is hard to synthesize: parents hold out every last hope. Additionally, decisions must be made which most people dread the thought of ever confronting: if an infant dies before birth and is not shortly delivered, it becomes hazardous to the mother's health to continue to carry to term since septicemia and other conditions may set in. Parents who are strongly pro-life meet with agonizing choices of inducing labor or waiting, not knowing the outcome. Likewise, the 'psychological' effect of carrying a deceased infant still in utero is extremely difficult, especially in parents with increased death-threat anxiety: confusion, pain and suffering are intense, and unlike a death which occurs at birth, virtually nothing can be done: one might discuss funeral arrangements, but there is too much uncertainty, parents are left to wait for a dreadful outcome. Most labor begins naturally within a week or so of a diagnosis of in utero demise, but not always. The best a physician or health care professional can do in such circumstances, is to provide out-of-the-way support: more and more hospitals now who encounter death in the Ob-Gyn ward have built-in mechanisms for crisis counseling and dealing with the deaths which even physicians feel inept at dealing with.

The most important factor for the physician and healthcare professional when a death occurs in utero, is support and liberty for the parents: they are not dealing with an event any of us would be adept at handling: they feel ostracized, odd, and morbid: like anyone else they just want the troubling event to end. More than even a perinatal death which occurs without warning, the events for this grief require careful counseling including making information and choices clear, and then not persuading parents to do what the physician or worker would do in this case. Giving parents liberty and comfort and supporting the decision-making process may very well avoid litigation and blame later.

Number of living children, and the order into which the child is born, most certainly affect the intensity of a parent's grief. One qualification must always be kept in mind: any parent can be different and well within the normal range. After years of research, I came the the conclusion that most psychological research at its best, is a careful and ordered way of making an observation. While parents may vary from the norms, psychological 'research' at its best falls short of prediction and control and is best assigned the rubric of 'systematic' description. A keen and empathic counselor or listener who is mature may come to the same conclusion, and both research and the careful observer may occasionally 'miss the mark'. Given that , though, in general, a first child which is stillborn, when there are not other living children, may be even more emotionally threatening and the mourning more intense, than if the child is stillborn late in life and parity, and would, for example have been the last child of 5 or 6. This in no way denigrates the importance or significance of the death to the family or mother. Griefs cannot be well compared. It is simply that when mothers have other living children, there is a necessity and investment in them emotionally which requires daily attention: grief still occurs, and often quite intensely, but it is different than losing one's only child, where the role of mothering is lost also, and expectations about the way the world is is often turned upside down. One may probably better say, that the griefs are slightly different, rather than to disparage the degree of loss felt by either.

A first child which dies, has its own parameters: it is as mentioned, the loss of motherhood, expectation of parenting, a world view as well as the child. It has the greatest propensity for overturning a person emotionally. Bereavement in many forms challenges a person's faith, but the loss of a baby when he or she is a firstborn, is coupled by the event often happening at a young age, when expectations about the world have not totally formed, may often be the first personal encounter with death, and may completely unsettle a person's emotional stability. Mourning as a 'task' is hard enough when one has maturity and has experienced loss, but mourning when joy is expected, and when death is a distant 'topic' steals the ground out from under most young parents. The most critical factor is to help the parent experiencing a first loss to identify the child, name the child, and value the child as their firstborn. Attempts to 'replace' this child with another shortly and try to foist the identity of firstborn on the next is not only problematic but can be damaging to the child. (See

A Critical Factor which may be easily surmized is the PROXIMITY of the last birth, if there was one. Certainly parity in general is a key factor in how grief will be experienced and lived out, and unfortunately often in what kind of support an individual may receive after the death. The primary determinant is whether the mother already has a living child, or possibly has had another child who was stillborn or died later. A previous living child most would assume would make the loss more tolerable, although this cannot be established in all cases, as many factors such as marital status, support and age may interact. In Kirkley-Best (1981) in a study of mothers at the time of delivery and a 4 to 6 week follow-up, parity was one of the three factors accounting for the greatest amount of variance [greatest predictive power] on measures of intensity of grieving responses. While there were those who fell outside the norm, in general, mothers who experience a first child loss, have a greater risk for problems and report more intense reactions than mothers who have other children. The reason most likely is that a first loss represents not only the loss of the child, but of the complete role of motherhood as well. A mother may be aided emotionally in being helped to understand this small complexity, and to own the the role of motherhood anyway, only one of a grieving mother: it helps define and articulate her relationship to the infant who has died.

One must be careful however not to fall into the cruel habit of 'comparing griefs' as though they were gradations or diagnostic categories. Griefs share some characteristics but we do a horrible disservice to mourning parents if we try. But parity is not the discussion per se in this section, it is PROXIMITY, or the nearness to the last birth. When an infant dies, following the birth of another very closely, ambivalent grief becomes an issue, in which one continues to care for the infant which was born before, while grieving the loss of another. Distance allows for cognitive [although often not emotional] separation, as a child born years before has distinct identification to the parents, whereas a child born immediately following the birth of another child presents complex emotional problems, with :

This pattern also occurs in the loss of a twin where one twin survives and one does not: parents sometimes even report feeling guilty for positive feelings about the living child, or guilt over negative feelings which may be played out on the living child. Some of these issues are covered under the heading "Replacement Children" or "Vulnerable Child" [syndrome*]

©1981, 2004 Elizabeth Kirkley Best PhD

Title taken from "The Forgotten Grief"

published in American Journal of Orthopsychiatry, 1982.

*The Author prefers to steer away from 'medical models' and syndromes and diagnostic categories: even professionals when facing grief of their own find such terms and practices disheartening and not comforting.