by Joann O’Leary
This article is a brief overview of my work over the last 25 years with families pregnant after a pregnancy or infant loss and why I believe relationship- based prenatal intervention needs to begin during pregnancy. A case study of one adult child will be presented to illustrate this belief.
The loss of a baby during pregnancy or the new-born period never just involves the bereaved parents, but children alive at the time and those that follow. Most families go on to have another pregnancy. In spite of family, friends and health care providers hoping parents’ grief will subside when they enter a new pregnancy, they are still bereaved parents. When my colleagues and I began presenting our work and showing our video, After Loss: Journey of the Next Pregnancy, at conference, both in the U.S. and England, participants from the audience would approach us with glazed eyes, saying, “I was that child. I understand now why my relationship with my parents was so confusing”. This happened with such frequency that I sought approval to research adults who were the child in their family born after loss. The findings published thus far show these adults bear a variety of experiences, some deep wounds (O’Leary and Gaziano, 2011a; O’Leary et al., 2006).
To begin, I think it is important to understand the state of mind of parents who experience a loss and then enter a new pregnancy. Gudmundsdottir (2009) writes that a body in grief has been considered inconsequential, even bizarre, thus, has largely been silenced as it does not fit the dominant story of grief as psychological. Similar to a body in illness, their grieving body suffers from the pain, manifested through behaviors that often appear odd to others (Goffman, 1963). This research supports why the parents’ embodied ways of being in the world call for different responses in the pregnancy that follows. Fear of another loss can be so strong, some parents will appropriately shut down to survive, putting the unborn baby at risk for attachment issues with parents. Without therapeutic educational intervention that can begin during pregnancy, there can be a life-long impact of being carried in the womb of a grieving mother and her bereaved father/partner. This is illustrated in the following story of one adult subsequent child.
Anne was a 40-year-old woman when I interviewed her. She was born after the loss of her parents’ first child, a brother born with Anencephaly. His life and death were not hidden from her and, growing up, she felt very treasured by her parents. Only as an adult did she become aware she had gender issues of rejecting her feminine side.
I started realizing I tried to be a boy to my dad. I was like a girl and a boy and he could have cared less [sic]. I had to ask about baseball and needing to learn about that stuff and the technical stuff; not that it’s only boy stuff but I really pursued that. Maybe it’s also because I was very close to my dad. It’s just now that I’m feeling like I’m coming to terms with what it is to be feminine, even like in a relationship.
Whether to have children was something she thought about but never felt drawn to explore until meeting a man she felt she would want to have children with. She had been going to an acupuncturist who was into energy and, during a session, became drawn to the emotional part of Anne’s body, saying, “I’m just getting this sense of questioning or need to have children but there’s something holding you back; it’s as if you had a brother and the brother is telling you it’s okay to not worry”. Because he also treated her mother, Anne asked if he knew about the brother born before her, but he did not know the story. He said, “It’s almost like you’re carrying the pain… the pain of the loss from your mother, like the fear or whatever went to you. It’s wrapped up in you, not necessarily meaning that you need to have or not have children, but you need to think about it and become okay with the idea. Maybe it’s come up because you’ve met this man that you’re very attracted to and you’re comfortable and it feels really right, that now it’s kind of coming to the surface more”.
Anne shared this information with her mother, who was totally shocked. When the feelings did not go away, Anne went to another woman who helped her explore these feelings through visualizations. The purpose was not necessarily to connect with this brother but with how she felt about having children.
I ended up feeling like I was drawn into this dark, deep, dank pit. I just kept seeing it. It’s cold, it’s gross. I feel okay but it’s really kind of scary and depressing. It feels like death, I’m pulled into this thing. It was like being stuck in the muck in the bottom of this dark well almost. It’s wet, it’s damp, like a womb. It was like a horror movie but I wasn’t scared. It just felt gross, it was freakish. I just felt that dampness and darkness. I never felt scared which was also interesting because if you’re in the womb then you’re protected by another body, by your mother. But it doesn’t mean that there isn’t something icky there. Then there was someone in there and we were talking and it was like embracing that and then being able to just let go of it. I came back out and I felt relieved. Ever since, it hasn’t come up anymore. So it was almost like being aware of his death that was pulling at me and now being okay with it and whatever happens, happens in terms of having children.
Her mother had been on bed rest during the pregnancy; telling Anne she “just wanted to get out, I was anxious to get out”. In spite of her parents always being open, rational, comfortable and clear about her brother, Anne felt like her mother’s grief was somehow planted in her during the pregnancy, so her mother didn’t have it.
She didn’t do it knowingly, maybe it’s during the birthing process, whenever. There’s like this exchange of energy, however you want to look at it. It’s just sort of this seed was planted. I don’t think it was verbal and I don’t think it was when they were being open and telling me about everything. But it was always this sort of unknown thing that I didn’t know was unknown.
This story is an illustration of why “keeping the baby in mind” (Slade, 2002) during a pregnancy following loss is a complex developmental process, encompassing diverse and shifting feelings. Today, we realize that prenatal development – all that happens in the interdependent life of the womb – has a significant impact on the type of people we become later in life. Even before we are born, we are already embedded in a web of relationships, which remains the primary context of our lives until the day we die (O’Murchu, 1998:84). Pre- and perinatal traumas are encoded, not as learned knowledge, but as ingrained personality traits that are difficult to uncover and can be resistant to change (Findeisen, 1992) and can have a lifelong impact if not resolved when they are followed by reinforcing conditions (Emerson, 1998).
While there are many who still hold to the belief that grief needs to be set aside during a pregnancy following loss, my nurse colleagues and I saw the importance of working with both the parents’ feelings of grief for their deceased baby while attaching to the new unborn child. The focus of our intervention drew on the work of Selma Fraiberg’s belief that no baby can wait for parents to resolve their neuroses, neuroses that can impede development (Fraiberg et al ., 1980). Her model places the baby at the centre of intervention, thus, in collaboration with my colleague nurses and my background in early childhood, a prenatal attachment relationship- based intervention was developed (O’Leary and Parker, 2009; O’Leary and Thorwick, 2008). This model affirmed their role as parents; learning they did not have to ‘give up’ their love and loyalty to the deceased baby to attach to the new unborn baby who needed their attention now. We drew on the research in pre- and perinatal psychology, as well as the research supporting the unborn’s competencies (DiPietro, 2010; Thompson, 2007), helping parents understand that the unborn baby already knew their fears and anxieties as well as their struggle to attach. In one-to-one intervention, as well as a weekly group setting, we encouraged parents to give the unborn baby the words for their feelings, teaching that the baby already heard the words and felt the parents’ emotion they were absorbing. This also validated theorist Fraiberg’s belief that giving words to a situation helps healing as one lets go of secrets (Fraiberg et al., 1980).
Education and support for families during their subsequent pregnancy does make a difference. It is a great relief when parents are helped to accept their extreme fear, distrust, anxiety and anger as normal, given their obstetrical history. The powerful impact of parents sharing their struggle in one-to-one support or with other bereaved pregnant parents in a group setting cannot be denied. Feelings are validated as normal and a space is provided to process their emotions while learning information about the clinical and emotional implications of the pregnancy in relation to the prior pregnancy.
The idea that a baby who died many years ago can continue to be a major influence in one’s personality is important to keep in mind in working with patients. Not knowing the story of a missing sibling can leave a profound impact on siblings alive at the time of loss as well; some unwilling to attach to children that followed and who continue to have attachment issues into adulthood (O’Leary and Gaziano, 2011b). These adult siblings shared uniquely different behaviors than what my colleague and I heard from siblings whose parents had support in knowing how to involve their children (O’Leary and Thorwick, 2006; O’Leary, 2007; O’Leary, Warland, 2012, Warland et. al, 2010). At the same time, we have found there can be gifts of being the child born after loss (O’Leary et al., 2011; O’Leary and Warland, 2012), also something to be explored with these subsequent adults.
We are linked through the power of relationships. Sense of self for adults begins during their intrauterine life. When one is conceived and carried in wombs of mothers who, one can only speculate, carried fears and anxieties for the safety of their unborn child, as the fathers likely did, as well, the emotions of grief can unknowingly be embedded. In working with adults who may be struggling with symptoms of anxiety, fear to form intimate relationships, or depression, it is important to ask about their own pregnancy and loss history in the family. Many times people are not aware such losses can have a direct link to the problems they face today. The parents I have been honored to work with have given me much information on why, regardless of the outcome, parenting and children’s development begins during pregnancy. Thus, understanding of one’s prenatal history, both in ourselves and in those we work with, is an important component in healing.
Joann O’Leary has been working with families who have experienced an unexpected outcome of pregnancy for the last 40 years. Her specific interest is the pregnancy that follows loss and its impact on parenting children. She is a field faculty member for the Center for Early Education and Development at the University of Minnesota where she teaches an on-line course on relationship based-intervention during pregnancy. http://cehd.umn.edu/ceed/ profdev/onlinecourses/prenatal.htm).
DiPietro, J.A. (2010). ‘Psychological and psychophysiological considerations regarding the maternal-fetal relationship’. Infant and Child Development. 19(1): 27-38.
Emerson, W. (1998). ‘The vulnerable infant’. The International Journal of Prenatal and Perinatal Psychology and Medicine. 10(1): 5-17.
Findesisen, B. (1992). ‘The long term psychological impact of pre- and perinatal experiences’. The International Journal of Prenatal and Perinatal Studies. 4(1): 14.
Fraiberg, S., Adelson, E., Shapiro, V. (1980). ‘Ghost in the nursery:
A psychoanalytic approach to the problems of impaired infant-mother relationships’ in S. Fraiberg (Ed.) Clinical studies in infant mental health: The first year of life, pp.164-106. London: Tavistock.
Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice-Hall.
Gudmundsdottir, M. (2009). ‘Bereaved parents’ narratives of their suffering body’. Omega. 59: 263-269.
O’Leary, J. (2007). ‘Pregnancy and Infant Loss: Supporting parents and their children’. Zero to Three. 27(6): 42-49.
O’Leary, J., Gaziano, C. (2011a). ‘The experience of adult siblings born after loss’. Attachment, 5(3): 246-272.
O’Leary, J., Gaziano, C. (2011b). ‘Sibling grief after perinatal loss’. Journal of Pre- and Perinatal Psychology and Health. 25(3): 173-193.
O’Leary, J., Gazanio, C., Thorwick, C (2006). ’Born after Loss: The invisible child in adulthood’. Journal of Pre- and Perinatal Psychology and Health.21(1): 3-23.
O’Leary, J., Gaziano, C., Warland, J. (2011). ‘Gifts from the Deceased Sibling to Siblings Born After Loss’. International Journal Prenatal and Perinatal Psychology and Medicine. 23 (1/2): 415-429.
O’Leary, J., Parker, L. (2009). Parenting before birth: A manual for professionals working with parents prenatally. C. Thorwick (Ed.). O’Leary self published. Minneapolis, MN. Available at www.aplacetoremember. com.
O’Leary, J., Thorwick, C. (2006). When pregnancy follows a loss: Preparing for the birth of your new baby. Self-published booklet for parents.
O’Leary, J., Thorwick, C. (2008).’ Maternal-Paternal representation of pregnancy and attachment to the unborn child during pregnancy following loss’. Attachment. 2(3): 292-320.
O’Leary, J., Warland, J. (2012). ‘ Intentional Parenting of Children Born After a Perinatal Loss’. Journal of Loss and Trauma. 17(2): 137-157.
O’Murchu, D. (1998). Quantum Theology. New York: Crossroads. Slade, A. (2002).’ Keeping the baby in mind: a critical factor in perinatal mental health’. Zero to Three. 22(6): 10-16.
Thomson, P. (2007).’ Down will come baby: Prenatal stress, primitive defenses and gestational dysregulation’. Journal of Trauma and Dissociation., 8(3): 85-113.
Warland, J., O’Leary, J., McCutcheon, H. (2010). Born after a loss: The experiences of subsequent children. Midwifery e-pub ahead of print 16th August 2010.