Further Reading for Health Professionals - Another Baby?

1. Alexandre, M., Votino, C., De Noose, L., Cos Sanchez, T., Gaugue, J., & Jani, J. (2016). The Impact of Prior Medical Termination of Pregnancy on the Mother’s Early Relationship with a Subsequent Infant. The Journal of Maternal-Fetal & Neonatal Medicine: 29(8), 1238-1243. doi:10.3109/14767058.2015.1043260

Department of Clinical Child and Adolescent Psychology, Faculty of Psychology and Education Sciences , University of Mons , Mons , Belgium

Objective: There is insufficient research on the mother’s early relationship with a child born subsequent to a previous medical termination of pregnancy (TOP). This study explores mother-infant interactions following prior TOP and the impact on the infant’s development. Methods: Being an exploratory research comprising 12 mother-infant (6-7 months old) couples, following prior TOP, and five controls, this study uses a descriptive methodology and a qualitative approach. The Greenspan and Lieberman Observation Scale (GLOS) and the Stern’s “R”-Interview were employed to investigate the mother-infant relationship. We used the Brunet-Lézine’s Revised Scales (BL-R) and the Projective Kit for Early Childhood (PKEC) to assess the infant’s development. Grief resolution was taken into account (Perinatal Grief Scale, semi-structured interview). Results: The later the perinatal loss, the less likely children are to express their emotions and respond contingently (GLOS). Their psychomotor (BL-R) and emotional (PKEC) development remains adequate. Unresolved grief is associated with more pronounced disturbances: no dyadic exchange (GLOS), language disruptions (BL-R), and withdrawal from the environment (PKEC). Conclusions: This study suggests that mother-infant interactions following a prior late TOP could undergo disturbances, which do not lead systematically to pathogenic effect on the subsequent child. Nevertheless, unresolved grief could lead to adverse effects.

2. Power, A., & Rea, T. (2016). Clinicians in the Classroom: The Bereavement Midwife. British Journal of Midwifery, 24(3), 219-221.

Senior Lecturer (Midwifery), University of Northampton, UK

The aim of pre-registration midwifery education is to prepare the student for the demanding and complex role they aspire to, using a range of teaching, learning and assessment strategies both in theory and practice. This article is part of a series exploring the role of clinicians as facilitators of learning in the classroom environment. This article explores the role of the bereavement midwife and discusses a teaching session conducted by bereavement midwife Tracy Rea with second-year students on the 3-year pre-registration midwifery programme. The session included input from a couple who shared their experiences of the loss of their son and their subsequent pregnancy. The article concludes with student feedback on the session, demonstrating the deep and meaningful learning that took place and confirming the value of bringing the realities of practice into the classroom environment.

3. Baghdari, N. (2015). The Effect of Pregnancy-Adaptation Training Package on the Anxiety of Pregnant Women with a Prior History of Fetal or Neonatal Death. Journal of Midwifery and Reproductive Health, 3(2), 355-360. [full text]

School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran

Background & aim: One of the factors of affecting maternal anxiety is a history of fetal death or neonatal death. This anxiety affects fetal and maternal health. By consideration the impact of anxiety on fetal and maternal health and the lack of protective activities in this field, this study was done to determine the impact of adaptation with pregnancy educational package on anxiety and maternal fetal attachment in pregnant women with a history of baby loss. Methods:60 pregnant women were selected in two studying group with previous fetal death or neonatal death by convenience sampling and were randomly assigned to control and intervention groups. Educational package includes: teaching session’s adaptation with pregnancy in four 60- minutes, training booklet and CD, maternal educating was beginning from 23 week gestation. Maternal anxiety measured before and after the intervention in both groups using the Mann-Whitney and Kruskal-Wallis test and STAI anxiety questionnaire was compared. Results: visible and invisible Anxiety scores had not significant difference between two groups pre-intervention. Immediately after the intervention visible and invisible anxiety scores in the experimental group was better than the control group (P ≤ 0.05, P ≤ 0.05 vice versa). Conclusion: Adaptation with pregnancy educational package reduces anxiety in pregnant women with a history of fetal or neonatal death. So, due to reduce the damaging effects of anxiety on the mother and fetus in pregnancy, holding effective proceeding for reducing anxiety such as: holding training courses are recommended for pregnant women with a history of fetal or neonatal death.

4. Brooten, D., Youngblut, J. M., Hannan, J., Caicedo, C., Roche, R., & Malkawi, F. (2015). Infant and Child Deaths: Parent Concerns about Subsequent Pregnancies. Journal of the American Association of Nurse Practitioners, 27(12), 690-697. doi: 10.1002/2327-6924.12243

Nicole Wertheim College of Nursing & Health Sciences, Florida International University, Miami, FL, USA

Purpose Examine parents’ concerns about subsequent pregnancies after experiencing an infant or child death (newborn to 18 years). Data sources Thirty-nine semistructured parent (white, black, Hispanic) interviews 7 and 13 months post infant/child death conducted in English and/or Spanish, audio-recorded, transcribed, and content analyzed. Mothers’ mean age was 31.8 years, fathers’ was 39 years; 11 parents were white, 16 black, and 12 Hispanic. Conclusions Themes common at 7 and 13 months: wanting more children; fear, anxiety, scared; praying to God/God’s will; thinking about/keeping the infant’s/child’s memory and at 7 months importance of becoming pregnant for family members; and at 13 months happy about a new baby. Parents who lost a child in neonatal intensive care unit (NICU) commented more than those who lost a child in pediatric intensive care unit (PICU). Black and Hispanic parents commented more on praying to God and subsequent pregnancies being God’s will than white parents. Implications for practice Loss of an infant/child is a significant stressor on parents with documented negative physical and mental health outcomes. Assessing parents’ subsequent pregnancy plans, recognizing the legitimacy of their fears about another pregnancy, discussing a plan should they encounter problems, and carefully monitoring the health of all parents who lost an infant/child is an essential practitioner role.

5. Côté-Arsenault, D., & O’Leary, J. (2015). Understanding the Experience of Pregnancy Subsequent to a Perinatal Loss. In Black, B. P., Wright, P. M. & Limbo, R. K. (eds.). Perinatal and Pediatric Bereavement in Nursing and Other Health Professions. New York: Springer. 159. [Find in an Australian library]

6. Hutti, M. H., Armstrong, D. S., Myers, J. A., & Hall, L. A. (2015). Grief Intensity, Psychological Well‐Being, and the Intimate Partner Relationship in the Subsequent Pregnancy after a Perinatal Loss. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 44(1), 42-50. doi: 10.1111/1552-6909.12539


To examine the construct validity of the Perinatal Grief Intensity Scale (PGIS) and the associations of grief intensity with psychological well-being and the quality of intimate partner relationships of women in the subsequent pregnancy after perinatal loss. The consequences of intense grief due to perinatal loss may include significant couple relationship issues, depression, anxiety, and post-traumatic stress that may extend into the subsequent healthy pregnancy.

Design and Setting

A correlational, descriptive research design was used to collect survey data in this cross-sectional, web-based study.


Participants were 227 currently pregnant women who experienced perinatal loss in their immediate past pregnancies.


Instruments included the Pregnancy Outcome Questionnaire (pregnancy-specific anxiety), Impact of Event Scale (post-traumatic stress), Center for Epidemiologic Studies-Depression Scale (depression symptoms), the Autonomy and Relatedness Inventory (quality of the intimate partner relationship), and the Perinatal Grief Intensity Scale (perinatal grief intensity).


As hypothesized, greater grief intensity was associated with higher pregnancy-specific anxiety, depression symptoms, and post-traumatic stress as well as poorer quality of the intimate partner relationship.


Support for the construct validity of the PGIS was demonstrated by its significant associations in the expected directions with pregnancy-specific anxiety, depression symptoms, post-traumatic stress, and the quality of the intimate partner relationship. The scale may be useful to health care providers in identifying mothers in need of follow-up for intense grief and other clinically relevant symptoms after perinatal loss.

7. Kinsey, C. B., Baptiste-Roberts, K., Zhu, J., & Kjerulff, K. H. (2015). Effect of Previous Miscarriage on Depressive Symptoms during Subsequent Pregnancy and Postpartum in the First Baby Study. Maternal and Child Health Journal, 19(2), 391-400. doi: 10.1007/s10995-014-1521-0

College of Nursing, The Pennsylvania State University, University Park, PA, USA

Our objective was to test the hypothesis that nulliparous women with a history of miscarriage have an increased risk of depression during late pregnancy, and at 1, 6, and 12 months postpartum compared to women without a history of miscarriage. We conducted secondary analysis of a longitudinal cohort study, the First Baby Study, and compared 448 pregnant women with a history of miscarriage to 2,343 pregnant women without a history of miscarriage on risk of probable depression (score >12 on the Edinburgh Postnatal Depression Scale). Logistic regression models were used to estimate odds ratios at each time point and generalized estimating equations were used to obtain estimates in longitudinal analysis. Women with a history of miscarriage were not more likely than woman without a history of miscarriage to score in the probable depression range during the third trimester or at 6 or 12 months postpartum but were more likely at 1 month postpartum, after adjustment for sociodemographic factors (OR 1.66, 95 % CI 1.03–2.69). Women with a history of miscarriage may be more vulnerable to depression during the first month postpartum than women without prior miscarriage, but this effect does not appear to persist beyond this time period. We support the promotion of awareness surrounding this issue and recommend that research is planned to identify risk factors that may position a woman with a history of miscarriage to be at higher risk for depression.

8. Kint, E. L. (2015) Women’s Experiences of Pregnancy Loss: An Interpretative Phenomenological Analysis. Ph.D. Thesis, Edith Cowan University, WA, Australia [full text]

Over the past three decades, research has proliferated on the incidence of grief severity following pregnancy loss, with many research studies citing the existence of ‘complicated’ and ‘unresolved’ grief. It is argued that this emphasis on grief severity has overshadowed other aspects of the bereavement experience that might differ from grief as it has been defined. Understanding the experience of loss in pregnancy instead of categorising it, would allow for new and varied understandings of the meaning women attribute to their experience of losing a baby. Furthermore, paying attention to women’s interpretations and understandings of pregnancy loss provides valuable insight into care that is perceived as meaningful and supportive. Utilising interpretative phenomenological analysis (IPA), a qualitative research method, the current study explored the experience of pregnancy loss among nineteen bereaved women with a history of miscarriage or stillbirth. The findings revealed that bereaved women struggle with a unique, complex and pervasive bereavement experience, that is largely unacknowledged and misunderstood. Women conveyed a strong desire for others to acknowledge and validate their loss, and to facilitate rather than suppress their grief. In addition, women identified a need to remain connected to their deceased baby, and for others to recognise the profound and enduring nature of their grief. Perceptions of support were identified as a critical catalyst in determining women’s bereavement experiences, and revealed both positive and negative attributions of professional and social support. In particular, women identified a need for increased public awareness of pregnancy loss, more sensitive and empathic care, continued support to facilitate contact with the baby, improved continuity of care to support grieving, and enhanced support in the subsequent pregnancy to assist with anxiety management. The implications of these findings for future research and practice are discussed. The study provides a context within which women’s experiences can not only be recognised as widespread and rational emotional processes following pregnancy loss, but that those suffering can also receive appropriate, specialised professional support and social acceptance by the wider community.

Particularly: Psychological Distress in the Subsequent Pregnancy. | Chapter 6: The Subsequent Pregnancy

9. McCarthy, F. P., Moss‐Morris, R., Khashan, A. S., North, R. A., Baker, P. N., Dekker, G., ... & O’Donoghue, K. (2015). Previous Pregnancy Loss has an Adverse Impact on Distress and Behaviour in Subsequent Pregnancy. BJOG:.doi: 10.1111/1471-0528.13233

The Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork University Maternity Hospital, Wilton, Cork, Ireland

Objective To investigate whether women with previous miscarriages or terminations have higher levels of anxiety, depression, stress, and altered behaviours in a subsequent pregnancy. Design A retrospective analysis of 5575 women recruited into the Screening for Pregnancy Endpoints (SCOPE) study, a prospective cohort study. Setting Auckland, New Zealand, Adelaide, Australia, Cork, Ireland, and Manchester, Leeds, and London, UK. Population Healthy nulliparous women with singleton pregnancies. Methods Outcomes were recorded at 15 and 20 weeks of gestation. Main outcome measures Short-form State–Trait Anxiety Inventory (STAI) score, Perceived Stress Scale score, Edinburgh Postnatal Depression Scale score, and pregnancy-related behaviour measured using behavioural responses to pregnancy score. Results Of the 5465 women included in the final analysis, 559 (10%) had one and 94 (2%) had two previous miscarriages, and 415 (8%) had one and 66 (1%) had two previous terminations of pregnancy. Women with one previous miscarriage had increased anxiety (adjusted mean difference 1.85; 95% confidence interval, 95% CI 0.61–3.09), perceived stress (adjusted mean difference 0.76; 95% CI 0.48–1.03), depression (adjusted odds ratio, aOR 1.26; 95% CI 1.08–1.45), and limiting/resting behaviour in pregnancy (adjusted mean difference 0.80; 95% CI 0.62–0.97). In women with two miscarriages, depression was more common (aOR 1.65; 95% CI 1.01–2.70) and they had higher scores for limiting/resting behaviour in pregnancy (adjusted mean difference 1.70; 95% CI 0.90–2.53) at 15 weeks of gestation. Women with one previous termination displayed elevated perceived stress (adjusted mean difference 0.65; 95% CI 0.08–1.23) and depression (aOR 1.25; 95% 1.08–1.45) at 15 weeks of gestation. Women with two previous terminations displayed increased perceived stress (adjusted mean difference 1.43; 95% CI 0.00–2.87) and depression (aOR 1.67; 95% 1.28–2.18). Conclusions This study highlights the psychological implications of miscarriage and termination of pregnancy.

10. Üstündağ-Budak, A. M., Larkin, M., Harris, G., & Blissett, J. (2015). Mothers’ Accounts of their Stillbirth Experiences and of their Subsequent Relationships with their Living Infant: An Interpretative Phenomenological Analysis. BMC Pregnancy and Childbirth, 15, 263. doi: 10.1186/s12884-015-0700-3 [full text]

The School of Psychology, Bahçeşehir University, Istanbul, Turkey

BACKGROUND: Due to contradictory findings regarding the effects of seeing and holding stillborn infants on women’s worsening mental health symptoms, there is a lack of clear of guidance in stillbirth bereavement care. Although some current research examines this phenomenon we are still not certain of the meaning of such experiences to women and what effects there may be on her subsequent parenting. Thus the present study focuses on the meaning of the stillbirth experience to women and its influence on the subsequent pregnancy and subsequent parenting from the mothers’ own experiences.

METHODS: A purposive sample of six women who experienced a stillbirth during their first pregnancy and who then went on to give birth to a living child after a further pregnancy, took part in email interviews, providing rich and detailed experiential narratives about both the stillbirth itself, and their relationship with their living child. An Interpretive Phenomenological Analysis was carried out in order to focus on mothers making sense of such experiences.

RESULTS: Analysis of written accounts led to the development of three overarching themes. In ‘Broken Canopy’, ‘How This Happened’ and ‘Continuing Bonds’, their accounts revealed an ongoing process where women accepted a new ‘unsafe’ view of the world, re-evaluated their view of self and others, and established relationships with both the deceased and the living infant.

CONCLUSIONS: This study provided an insight into the stillbirth experience of mothers and its meaning to them with an existential focus. Typically the mother struggled with the contradictory process of accepting the existence of her deceased baby (this baby once lived) while being aware of the nonexistence (this baby). Meeting the dead baby was a crucial point at which the mother started processing her grief. The importance of individual differences in dealing with stressful situations was highlighted in terms of attachment strategies. Subsequent parenting experiences of mothers were very much influenced by their own previous experiences. Although some mothers managed to integrate this trauma into their life some remained very concerned and anxious about future and this anxiety then translated into their parenting experiences.

11. Campbell-Jackson, L., Bezance, J., & Horsch, A. (2014). “A renewed sense of purpose”: mothers’ and fathers’ experience of having a child following a recent stillbirth. BMC Pregnancy and Childbirth, 14, 423. doi: 10.1186/s12884-014-0423-x [full text]

Oxford Institute of Clinical Psychology Training, Isis Education Centre, Warneford Hospital, Oxford, UK

BACKGROUND: Most research has focused on mothers’ experiences of perinatal loss itself or on the subsequent pregnancy, whereas little attention has been paid to both parents’ experiences of having a child following late perinatal loss and the experience of parenting this child. The current study therefore explored mothers’ and fathers’ experiences of becoming a parent to a child born after a recent stillbirth, covering the period of the second pregnancy and up to two years after the birth of the next baby. METHOD: In depth interviews were conducted with 7 couples (14 participants). Couples were eligible if they previously had a stillbirth (after 24 weeks of gestation) and subsequently had another child (their first live baby) who was now under the age of 2 years. Couples who had more than one child after experiencing a stillbirth and those who were not fluent in English were excluded. Qualitative analysis of the interview data was conducted using Interpretive Phenomenological Analysis. RESULTS: Five superordinate themes emerged from the data: Living with uncertainty; Coping with uncertainty; Relationship with the next child; The continuing grief process; Identity as a parent. Overall, fathers’ experiences were similar to those of mothers’, including high levels of anxiety and guilt during the subsequent pregnancy and after the child was born. Coping strategies to address these were identified. Differences between mothers and fathers regarding the grief process during the subsequent pregnancy and after their second child was born were identified. Despite difficulties with bonding during pregnancy and at the time when the baby was born, parents’ perceptions of their relationship with their subsequent child were positive. CONCLUSIONS: Findings highlight the importance of tailoring support systems not only according to mothers’ but also to fathers’ needs. Parents’, and particularly fathers’, reported lack of opportunities for grieving as well as the high level of anxiety of both parents about their baby’s wellbeing during pregnancy and after birth implies a need for structured support. Difficulties experienced in bonding with the subsequent child during pregnancy and once the child is born need to be normalised.

12. Gong, X., Hao, J., Tao, F., Zhang, J., Wang, H., & Xu, R. (2013). Pregnancy loss and anxiety and depression during subsequent pregnancies: data from the C-ABC study. European Journal of Obstetrics & Gynecology and Reproductive Biology, 166(1), 30-36. doi:10.1016/j.ejogrb.2012.09.024

Department of Child and Maternal Health Care, Anhui Medical University, Hefei, PR China

Objective Previous studies have shown that pregnancy loss may affect the mental health of women in subsequent pregnancies. The China Anhui Birth Defects and Child Development cohort study therefore aimed to investigate the influence of pregnancy loss on anxiety and depression in subsequent pregnancies. Study design In total, 20,308 pregnant women provided written informed consent and completed the study questionnaire. The Self-rating Anxiety Scale and Center for Epidemiologic Studies–Depression Scale were used to evaluate anxiety and depression in pregnant women. Pearson’s χ2 test and binary logistic regression were used for statistical analyses. Results Of 20,308 pregnant women, 1495 (7.36%) had a history of miscarriage and 7686 (37.85%) had a history of induced abortion. The binary logistic regression model found that pregnant women with a history of miscarriage had a significantly higher risk of anxiety and depression in the first trimester than primigravidae after stratified analysis according to the timing of the first prenatal visit (p < 0.05). Compared with pregnant women with no history of miscarriage, women who had a history of miscarriage and an interpregnancy interval of less than 6 months had increased risk of anxiety symptoms (p < 0.05) and depression symptoms (p < 0.05) during the first trimester. Women with an interpregnancy interval of 7–12 months had a 2.511-fold higher risk of depression (p < 0.05) than women with no history of miscarriage. These findings were not changed after adjustment for maternal age, maternal education, family income, place of residence and pre-pregnancy body mass index. Conclusions Women with a history of miscarriage experienced significant anxiety and depression during their next pregnancy. A short interpregnancy interval and the first trimester are risk factors for adverse mental health.

13. Hutti, M. H., Armstrong, D. S., & Myers, J. (2013). Evaluation of the Perinatal Grief Intensity Scale in the Subsequent Pregnancy after Perinatal Loss. Journal of Obstetric, Gynecologic, and Neonatal Nursing: JOGNN / NAACOG, 42(6), 697–706. doi: 10.1111/1552-6909.12249

University of Louisville School of Nursing, Louisville, KY, USA

OBJECTIVES: To evaluate the reliability and validity of the Perinatal Grief Intensity Scale (PGIS) for identifying a woman’s grief intensity in the immediate subsequent pregnancy after a miscarriage, stillbirth, or neonatal death. DESIGN/SETTING/PARTICIPANTS: A web-based approach was used to collect data from 227 pregnant women after each woman had experienced a perinatal loss in her previous pregnancy. METHODS: Participants completed a demographic information form and the 14-item PGIS. RESULTS: Cronbach’s alphas for the PGIS total scale and subscales were high: 0.75 (PGIS total), 0.80 (Reality), 0.82 (Confront Others), and 0.80 (Congruence), which indicated good internal consistency reliability. Validity was supported by factor analysis of the PGIS, which accounted for 66.94% of the total variance. Mothers in the neonatal death group experienced more intense grief, as measured by the PGIS, when compared with mothers in the miscarriage or stillbirth groups. CONCLUSIONS: Data from this study provided initial support for the reliability and validity of the PGIS in women in their immediate subsequent pregnancies after perinatal loss as well as the concepts of the grief intensity theoretical framework.

14. Lee, L., McKenzie‐McHarg, K., & Horsch, A. (2013). Women’s Decision Making and Experience of Subsequent Pregnancy following Stillbirth. Journal of Midwifery & Women’s Health, 58(4), 431-439. doi: 10.1111/jmwh.12011

Clinical Psychologist, Central and Northwest London NHS Foundation Trust (UK).

Introduction This study sought to increase understanding of women’s thoughts and feelings about decision making and the experience of subsequent pregnancy following stillbirth (intrauterine death after 24 weeks’ gestation). Methods Eleven women were interviewed, 8 of whom were pregnant at the time of the interview. Modified grounded theory was used to guide the research methodology and to analyze the data. Results A model was developed to illustrate women’s experiences of decision making in relation to subsequent pregnancy and of subsequent pregnancy itself. Discussion The results of the current study have significant implications for women who have experienced stillbirth and the health professionals who work with them. Based on the model, women may find it helpful to discuss their beliefs in relation to healing and health professionals to provide support with this in mind. Women and their partners may also benefit from explanations and support about the potentially conflicting emotions they may experience during this time.

Last reviewed: 19/5/24