Perinatal Grief in Latino Parents

Abstract

Extensive research exists that describes the meaning of perinatal loss to some parents, but the experience of loss from the perspective of Latino parents is not clearly understood. Additionally, current perinatal bereavement practices used often to facilitate memory-making for parents (such as viewing or holding the baby, taking photographs, or collecting mementos) are based upon research done primarily with non-Latino families. Are these common practices appropriate for this population? Because there is a paucity of research on this topic, this article describes what has been written over the past 30 years on the topic of grief and perinatal loss in Latino culture.

Introduction

Perinatal loss, defined as any pregnancy loss and/or neonatal death up to one month of age, continues to be a common occurrence even though major advances have taken place in perinatal health care. In 2005, there were approximately 25,000 fetal deaths with a rate of 6.22 per 1000 births (Heron et al., 2010). Hispanic or Latina women experience higher rates of perinatal death (loss of any pregnancy greater than 20 weeks and neonatal death) varying by country of origin, and according to one study are at one and a half times greater risk for experiencing perinatal loss (Healy, et al., 2006; Mathews & MacDorman, 2010). Despite the increased risk of perinatal loss with Latina women, little has been written about perinatal grief in Latino parents. Although authors have provided data on parental perceptions of perinatal care practices after pregnancy loss in recent review articles (Bennett, et al., 2005; Gold, et al., 2007), the participants in the studies have been predominantly white (Gold et al., 2007). In their review of hospital care practices in over 1,000 articles on the topic, Gold, et al., reported that although interventions appeared to be well-received by parents, parents were given few choices, and had minimal communication with providers about what was available.

The prevalence of perinatal loss and the lack of data on Latino experiences means that nurses have little research evidence to guide them in appropriately caring for this population. This article was written, therefore, to summarize what is known about perinatal grief in Latino parents, and to discuss implications for practice and research. For the purposes of this article, Latina is defined as women of Latin American descent living in the United States (whether born abroad or within the United States), and includes individuals of Mexican, Puerto Rican, Cuban, and Central or South American descent. This definition is consistent with the term Hispanic, the classification used in vital statistics. For clarity, the term Latina will be used except where the original authors have used the term Hispanic. We recognize that there are differences within each of these cultural groups, and that no one description completely accounts for the variation seen among them.

Risk Factors in Latina Women

Compared to non-Hispanic women, Latina women have been shown to have multiple risk factors for perinatal loss:

• a higher teen birth ratio (81.7 per 1000 versus 27.2);

• more births to unmarried mothers (51.3 per 1000 births versus 27.8), and

• twice the likelihood of receiving late care (beginning in the third trimester of pregnancy) or no care (Heron et al, 2010).

Latino Grief Responses

There is a dearth of literature on Latina grief. For this reason, we have included studies done 30 years ago in this article in order to be complete in our review of this topic. We do know, however, that there are well-documented cultural differences in the way people grieve. There are also differences between grief reactions within ethnic groups; for instance, one cannot generalize Latino grief responses because there are variations between the different Latino cultures and religious practices (Chichester, 2005; Hardy-Bougere, 2008;;York & Stichler, 1985 ). Also, there may be generational differences based upon levels of acculturation, with first generation immigrants generally grieving in traditional ways common to their countries of origin, and subsequent generations beginning to incorporate the dominant Anglo culture’s customs (Clements et al., 2003; Cutliffe, 2002). In one study of Mexican-American grief (duelo), it was found that both emotional and physical grieving were common, and had two commonalities: both dolor (pain) and peña (worry) (Candelaria & Adkins, 1994). Many Hispanic families believe in a spiritual and psychological continuity with the dead which takes the form of a continuous relationship; this is nurtured via prayer, and is manifested in actions such as shrines in the home, lighting candles, gravesite visits and formal mourning (Clements et al., 2003). In Hispanic cultures, open expression of grief such as crying are viewed as healthy and are encouraged (Hardy-Bougere, 2008).

Investigators have found that there are many differences in the ways that Latinos express grief as compared to white populations. In one study of Mexican-American and Anglo college students who had experienced the death of someone close to them, the results demonstrated an increase in overt expressions of grief and increased somatization among the Mexican-American students (Oltjenbruns, 1998). There were no statistically significant differences between the groups in other responses to grief such as despair, anger, guilt, social isolation, rumination, depersonalization, or death anxiety.

Some of the Hispanic cultural imperatives which have an influence on their reactions to perinatal bereavement include respeto and familismo. The concept of Respeto, or respect, involves a family hierarchal structure based upon age and gender, with males dominant to females (Clements et al., 2003; Hardy-Bougere, 2008). Respeto, religion and spirituality are essential components of Latino culture, and as such, influence grief reactions. For instance, since many Hispanics are Catholic (Hardy-Bougere, 2008), baptism may be an important ritual for them, as has been shown in the literature on this topic since the 1980s (Hardy-Bougere, 2008; Chichester, 2005; York & Stichler, 1985). Familismo, or the value of support from family, is of paramount importance for Hispanic families experiencing grief. Traditionally, in Latino society, bereaved individuals receive most of their support from their families.

Another study (done 30 years ago) which compared Mexican-American and Anglo college students ( Fierro, 1980) found that Mexican-Americans had more pervasive thoughts about death and were more concerned with death than their Anglo counterparts, but there was no correlation with maladjustment to death or positive or negative adjustment to death. The investigator concluded that orientation toward, and adjustment to, death are shaped by a combination of culture, age and gender, and thereby necessitates an understanding of the individual’s worldview.

Relevant Theories of Grief

Many theories on grief and the grieving process exist. Latino grief response is similar to the Social Developmental Model of Family Bereavement, in which grief is resolved by the adaptation and life-long revision of the relationship between the deceased and the living (Shapiro, 1995). This differs from some of the traditional Western/Anglo grief theories proposed by theorists such as Freud (Mourning and Melancholia), Kubler-Ross (Five Stages of Grief), and Parkes (Theory of Bereavement), all of which promote detachment from the deceased as an expression of acceptance and, hence, healthy grieving (Cutcliffe, 2002; Shapiro, 1995;). According to Shapiro, the Western/Anglo medical model of mental health has had a negative impact on how we define normal grief since it continues to place an emphasis on severing ties to the deceased, accepting the finality of death, and expecting grief to be a process that is both private and finite. Despite the culturally diverse population of North America, the dominance of Western/Anglo culture and practices within this context is apparent and can lead to labeling those with different grief responses as pathologic.

If the majority of those of providing care subscribe to a theory of grief work which emphasizes “letting go” and accepting death, and our patients are Latina women who believe in the importance of maintaining connections with the dead, we will find ourselves practicing nursing care which is incongruent with the culture of our patients. It becomes essential, therefore, for us to understand how our patients feel about grieving, and what will satisfy their needs rather than our needs.

Perinatal Grief in Latino Parents

Very few research studies exist that explore Latino grief as it concerns perinatal loss. Much of the available literature is limited to review articles that compare grief expression and rituals amongst several different cultural groups (Chichester, 2005)York & Stichler, 1985). There has been much in the literature about perinatal grief response (Bennett et al., 2005; Gold et al., 2007), but very limited number of investigators included any Latino parents as research participants. We reviewed over 200 studies of perinatal loss for this article and found that Latinos were only mentioned as research participants in 13 studies, with some dating back 30 years, and for greater than half of these, less than 15% of the sample was Latino and all but two were women (Armstrong, Hutti, & Myers, 2009; Bradshaw, 1985; Clyman, Green, Rowe, Mikkelsen, & Ataide, 1980; Cohen, Zilkha, Middleton, & O’Donnohue, 1978; DiMarco, Menke, & McNamara, 2001; Graham, Thompson, Estrada, & Yonekura, 1987; Leppert, & Pahlka, 1984; Lin & Lasker, 1996; Neugebauer, et al., 1997; Ritsher & Neugebauer, 2002; Sefton, 2007; Swanson, Chen, Graham, Wojnar, & Petras, 2009; Zaccardi, Abbott, & Koziol-McLain, 1993). Only one investigator included an exclusively Latina population. For the other studies, there were no findings that could be attributed directly to ethnicity or race or which described specific needs of Latino parents. However, in one study, the investigators demonstrated cross-cultural validity of the Perinatal Bereavement Grief Scale with Latina populations in both English and Spanish (Ritsher & Neugebauer, 2002).

Findings from two of these 13 studies are noteworthy because of the numbers of Latina participants (Graham et al., 1987; Sefton, 2007). In the first study, Sefton (2007) interviewed 14 Latina adolescents who had an early pregnancy loss prior to 16 weeks gestation (mean gestational age of 8.57 weeks). The results demonstrated that adolescents who experienced early pregnancy loss had varying emotional responses to the loss (similar to adults), and that most resolved their grief with evidence of psychosocial growth. Of the fourteen young women in the sample, six demonstrated signs of prolonged grief such as depression, and two required referrals for counseling. The author suggests that Latino cultural characteristics may affect the grieving process, and that specifically, the view that the miscarriage represented a “loss of life” may have increased the emotional impact of both the loss and the subsequent grieving process.

In another study, conducted more than 20 years ago, the sample was comprised of 28 women (96% were Hispanic and Spanish speaking) who had experienced an intrauterine fetal death(Graham, et al., 1987). The average time of loss was 36 weeks gestation. The investigators collected interview data and administered the Depression Symptom Checklist (SCR-90). In this study, women with children at home experienced lower rates of depression than did nulliparous women. They also found a significant negative correlation between depression and women who attributed the death of their baby to God’s will, as opposed to women who blamed themselves or others for the demise; women who blamed themselves had more depression. The investigators also described a number of findings related to memory-making (Graham et al., 1987). Women who received pictures of their infant were significantly less depressed than women who did not. In addition, women who were allowed to view or hold the infant were less depressed than those who did not. Finally, those women who declined the opportunity to view also had lower rates of depression compared to those who were denied the opportunity. The investigators concluded that pictures and the opportunity to view the baby should be offered to women, but that those who decline also cope well. They also noted that the religiosity of the sample perhaps influenced results because of the high rate of women who attributed the loss to God (31%) and the negative correlation with depression. Given the relatively large number of adult Latinas within this study sample, this is perhaps the most compelling evidence thus far. It is, however, important to note that the sample size is only 28 women and therefore cannot be generalized to all Latina women.

Implications for Practice

While the common practices and rituals that nurses use to help parents who have experienced a perinatal loss (viewing or holding the baby, taking photographs, or collecting mementos) are based upon research done primarily with non-Latino parents, there is some limited research supporting these interventions with Latino families. Furthermore, these practices appear to be consistent with Latino traditions surrounding death such as holding, naming and baptizing the baby (Chichester, 2005).

Regardless, in practice, nurses should talk to parents to determine which rituals would comfort them at the time of the loss (Kobler, Limbo, & Kavanaugh, 2007). Open and caring communication could include describing the practices that are currently used in the institution, and asking the parents if there are different, or other practices they would prefer. Parents need to be asked if they want to view the body, take photographs or keep mementos. In cases where language barriers exist, the assistance of a translator or translation service should always be sought. Also, since it is clear that religion and spirituality are two common cultural imperatives for Latino parents, nurses should ask if a meeting with pastoral staff or clergy for prayer, support or a blessing for the infant are desired. If the facility does not have pastoral care services, nurses may offer to contact the patient’s clergy.

In practice settings where access to social workers, psychologists or other mental health specialists are available, nurses can act as liaisons to insure that Latina patients have an introduction to support services. Remembering the familismo imperative for the Latino culture, nurses should be sensitive to the fact that many family members might be in attendance for support.

Implications for Research

The paucity of recent research with Latino participants who have experienced a perinatal loss represents a lack of knowledge about this population and should be addressed in new nursing research. Better understanding of this culture’s needs and desires after a perinatal loss will lead to the opportunity to develop more holistic interventions.

Because Hispanics have been shown to have higher risk for perinatal loss, it is imperative that nurses learn more about how to help this population at a time of great need in their lives. Learning more about this cultural group should be high on the list of future research that is needed. Studies on Latino fathers, siblings and the family in general should also be done. Also, the role of religious beliefs and practices within Latino communities and their impact on the experience of perinatal loss is a potential area for more research. Additionally, studies that focus on investigating the meaningfulness of the current interventions after perinatal loss which are practiced in hospital environments are needed.

Conclusion

While there is limited research evidence about this population’s needs after a perinatal loss, there is unlimited opportunity for nurses to study every aspect of this problem. The potential to expand the body of knowledge regarding the needs of Latino parents experiencing perinatal loss is large indeed. We suggest that nurses interested in this topic do more research and publish high quality studies in order to help all clinical nurses provide the best nursing care for a population which needs our help in healing.

Suggested Clinical Implications.

When working with Hispanic families who are experiencing a perinatal loss, nurses should:

• Talk to the parents to determine which practices or rituals they wish to participate in, such as viewing or holding the baby, taking photographs, or collecting mementos.

• Explain what practices are common in that institution, but make it clear that if their culture dictates a different practice, it will be allowed.

• Always use a translation service or a translator if the family’s primary language is different from the nurse’s language.

• Ask the parents what interventions they specifically want and work toward helping them attain them, even if the tradition is not usual in the facility

• Offer parents an opportunity to meet with pastoral staff or clergy for prayer, support and/or a blessing for the infant

• Offer to contact the family’s own clergy person

• In practice settings where access to social workers, psychologists or other mental health specialists are available, nurses can act as a liaison to insure that Latina patients have an introduction to after care services that might be available