2 Perinatal Attachment and Loss 35
brain development occurs rapidly in the last weeks before delivery and after
the birth, making developed and complex cognitions unlikely as the cortex
only develops over the last trimester of pregnancy and the first 3 months of the
neonatal period. As such, we cannot interpret how losses may be experienced
by a fetus, just as we suspect a fetus has no context for making interpretations
of changes/losses it experiences.
Loss of a Fetus as Experienced by Significant Others
Biological Changes Associated With Intrauterine Fetal Death
The experience of miscarriage, intrauterine fetal death (IUFD) or other preg-
nancy loss will lead to an abrupt change in the biological status of the preg-
nant woman. If labor must be induced, the experience of laboring to produce a
dead fetus/baby is physically and emotionally grueling. Hormone levels will
drop dramatically (www.childbirthconnection.org/article.asp?ck=10184) just
as with delivery of a live child. Prolactin release will signal oxytocin release
and the woman will have to cope with breast enlargement and milk produc-
tion until bound and unused breasts quit secreting milk. Endorphin levels are
high during late pregnancy and delivery to blunt the pain of labor but these
also drop off dramatically after delivery (www.nct.org.uk/birth/hormones-
labour). These hormonal and other metabolic changes happen regardless of
whether the fetus is born alive or not. It is assumed by most obstetricians and
perinatal observers that hormonal changes promote feelings of depression
ranging from “baby blues” to postpartum depression. The drop in hormone
levels creates a propensity toward depressive moods that a pregnancy loss
will exacerbate.
Women who lose a pregnancy often experience a sense of failure due to
their body’s inability to accomplish the task of pregnancy and body image is
likely to be affected (Bennett, Litz, Sarnoff Lee, & Maguen, 2005; Cacciatore,
2010). Women seem to interpret the inability to provide a “safe nest” as a fail-
ure of the body that brings into question future ability to sustain a pregnancy.
Clinical experience shows that women frequently comment on mistrusting
their body’s ability to sustain future pregnancy. They often generalize this into
a broad mistrust of their bodies. Certainly the medical language of perinatal
loss—“failed” in vitro fertilization (IVF) cycles, “mis” carriage, “incompetent”
cervix, and “elderly” primigravida (older first time mothers) all carry implica-
tions of fault.
Although not totally consistent, most studies have found higher levels
of grief associated with fetal death or stillbirth (after 20 weeks estimated age
of gestation [EGA]) as compared to those experiencing miscarriage (prior to
20 weeks EGA) (Cole, 1995; Goldbach, Dunn, Toedter, & Lasker, 1991). Yet,
the developers of the scale most commonly used to assess perinatal grief
(the Perinatal Grief Scale) have found that complicated, chronic, and delayed
grief responses are found most commonly in those who experienced early
pregnancy loss (Goldbach et al., 1991; Lasker & Toedter, 1991). A biological
interpretation that ties grief to gestational age might be based on the observa-
tion that hormonal drops may be less precipitous earlier in pregnancy (since
