Explanatory model of health in bereaved parents post-fetal/infant death
Introduction
The death of a fetus/infant has a significant impact on many aspects of the health of bereaved couples. Researchers have tended to focus on the deleterious outcomes of the physical and psychological health and well-being of each spouse (Smith and Borgers, 1989; Theut et al., 1989) and on present and future family relationships (Gilbert, 1989; Schwab, 1992). Parental grief is particularly severe, long lasting, and complicated with symptoms that fluctuate over time (Rando, 1986; Zeanah et al., 1995). One of the most difficult aspects of parental bereavement is that the death strikes both partners in the marital dyad simultaneously and confronts them with an overwhelming sense of loss.
There is suggestive evidence that the differences in the way husbands and wives grieve and perceive the situation can result in misunderstandings. These misunderstandings can affect their family functioning as well as the couple's marital relationship and thus decrease each other's ability to be a primary source of support for the other (Gilbert, 1989; Gottlieb et al., 1996; Lang and Gottlieb, 1991; Mekosh-Rosenbaum and Lasker, 1995). This difficult situation has temporal implications in that the bereavement process and the deleterious consequences of the loss will be felt throughout the parents’ lifetime. Yet in contrast, some parents report that they were able to make sense of their own existence following such a tragedy. Their loss had brought them closer together and strengthened their marital relationship (Gilbert, 1989; Gottlieb et al., 1994). The persistent question of why some family systems endure and sometimes even thrive when faced with normative transitions or situational stressors, while other family units seem to deteriorate and disintegrate under similar circumstances is quintessential to nursing.
The contextual model of family stress (CMFS) (Boss, 2002) is a dynamic and useful theoretical framework for family research and theory development in times of significant stress or important life transitions. This middle-range theory identifies variables such as individual and family resources and emphasizes the importance of perceptions and meaning of the situation as determinants of health (Fig. 1). Health is a multidimensional concept that has been defined and measured in a number of ways. From a nursing perspective of health promotion, health is intimately connected to the family system, which is recognized as the context in which individuals learn about health and as such, is considered the unit of nursing intervention (Feeley and Gottlieb, 2000). In order to predict the health of bereaved parents following the death of their fetus/infant this study empirically tested the relationships between resources both internal (hardiness) and external (marital and social support), perception of the event, and health following a perinatal loss, based on the CMFS and displayed in Fig. 2.
Section snippets
Literature review
In Canada, the cumulative annual incidence of stillbirths and perinatal deaths is 10.1 per 1000 births (Statistics Canada, 2001). There are no published statistics on the demise of fetuses prior to 20 weeks gestation or who weigh less than 500 g even though it is estimated that 15–20% of pregnancies end in miscarriage (Johnson and Puddifoot, 1996; Seibel and Graves, 1980).
Empirical studies have revealed the deleterious effects that the death of a fetus/infant can have on the health of parents
Hypotheses
H1: Bereaved parents who score higher on hardiness, are more satisfied with their marital and social support, and have a more positive appraisal of the situation have a higher health index.
H2: Bereaved parents who score higher on hardiness at baseline (T1), are more satisfied with their marital and social supports at T2/T3, and have a more positive appraisal of the situation at T2/T3 have a higher health index at T2/T3.
H3: There are differences between the models of health for bereaved mothers
Method
With a power of 0.80 and a 0.05 risk of Type I error and assuming a moderate effect size (r⩾0.30) and the number of independent variables, the sample size required was 107 couples (Cohen, 1992). In all, 110 couples participated at T1 (2 months post-loss). With great effort, attrition was relatively low (Dyregrov and Dyregrov, 1999; Hayslip et al., 1999) with only 13% (n=96) at T2 and a final 21% attrition resulting in 87 couples remaining at T3. Despite this rate of attrition, power in this
Measures
All of the instruments in this study were available to participants in either French or English.
Hypothesis 1
A statistical model was built using MRs. As seen from Fig. 2, part of this explanatory model of health relates to the relationships among resources, both internal (hardiness) and external (marital and social support) and perception of the event (situational appraisal). Hence, prior to running the analyses on the complete model with Factor X (health) as the outcome variable, separate regressions were run on Factor B and Factor C of the model. With the exception of underscoring that in general
Discussion
The Explanatory Model of Health in Bereaved Parents Post-Fetal/Infant Death provides empirical support for Boss’ (2002) CFMS. It is a model that focuses on individual and couple strengths rather than on the deleterious consequences of such a loss, which have predominantly been the emphasis of previous studies. However, in contrast to the CMFS that propounds perception of the event as the key variable, resources, both internal (hardiness) and external (marital and social support), emerged as the
Conclusion
This study heightens understanding of the role that a personal resource such as hardiness, in relation to marital and social support as well as appraisal of the situation, can have on the health protection and promotion of bereaved parents. It provides empirical support for the explanatory model of health, over time for bereaved parents, both as individuals and as a couple following perinatal loss. Greater understanding of the complexity of the relationships between these variables is required
Acknowledgements
This study was supported in part by the Jewish General Hospital, Fonds de la Recherche en Santé du Québec, Bourse Guy-Sauvageau de la Faculté des Infirmières at l’Université of Montréal, and La Fondation Appui enfance-famille et le Conseil de développement de la recherche sur la famille du Québec. The authors would like to thank all of the nurses who made the initial contact with the families. A special thanks is also extended to the families who participated by opening their homes and hearts
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