Enduring to Gain New Perspective: A Grounded Theory Study of the Experience of Perinatal Bereavement in Black Adolescents

Abstract

Black adolescents in the US experience perinatal loss at a higher rate than other races and ethnicities. The experience of eight Black urban adolescents through the first three months after perinatal loss was studied using grounded theory. The process of “enduring to gain new perspective” began with “denying and hesitating” when surprised by unplanned pregnancy but led to “getting ready for this whole new life,” followed by shock of “suffering through the loss,” “all that pain for nothing,” and “mixed emotions going everywhere.” Over time, the adolescents began “reaching out for support” and eventually “preserving the memory and maintaining relationship,” “searching for meaning and asking why,” and gaining new perspective on life.” Parallels are noted to extant bereavement theory.

Perinatal bereavement has been defined as the experience of parents that follows the death of an infant through miscarriage, stillbirth, neonatal loss, or elective termination for fetal anomalies and is characterized by a complex emotional response (Fenstermacher & Hupcey, 2013). Perinatal loss has been described as one of the most stressful events a person can experience (Flenady & Wilson, 2008). It differs from other losses through death because it represents the loss of future hopes, dreams, and parenthood (Bartellas & Van Aerde, 2003).

In the United States, non-Hispanic Black women experience perinatal loss at a rate of 13.31 deaths per 1000 live births compared to rates of 5.63 for white women and a range of 4.75 to 9.22 for other racial and ethnic groups (Kochanek, Kirmeyer, Martin, Strobino & Guyer, 2012). The incidence of perinatal loss is particularly high in Black teenage mothers, given that non-Hispanic Black women under 20 experience an infant mortality rate of 13.79 compared to 9.59 for teenagers of all races and ethnicities (Mathews & MacDorman, 2012). Despite this disparity in birth outcomes, most perinatal bereavement research has concentrated on the experience of middle-class, adult White women (Kavanaugh & Hershberger, 2005), making the provision of evidence-based care challenging for nurses. The purpose of this grounded theory study was to describe the experience of bereavement after recent perinatal loss in Black adolescent women.

Two teams have reported on the experience of perinatal loss and bereavement in Black women (Kavanaugh & Hershberger, 2005; Van, 2001), but their studies had limited inclusion of adolescent participants. Van (2001) interviewed ten African American women, all over the age of 18, to determine healing strategies after pregnancy loss. Spirituality, avoidance, an inner voice of comfort, and finding purpose in the loss were reported as healing strategies. Kavanaugh and Hershberger (2005) used a phenomenological approach to study the experience of perinatal loss in 23 low-income African American parents with an age range of 19 to 34 years. The authors reported four themes: Recognizing problems and responding to the loss; dealing with stressful life events; creating and cherishing memories of their baby; and living with the loss. They recommended nursing assessment for concurrent stressors in bereaved parents along with the provision of a supportive environment and access to appropriate referrals, noting that standard referral to a hospital-based perinatal loss support group may not be a therapeutic intervention for low-income African American parents.

The expressed emotions and needs of an adolescent experiencing perinatal loss and bereavement may not be the same as those experienced by an adult. For example, the developmental challenges during adolescence, such as the emotional separation from parents and finding a sense of belonging with one’s peer group, affect the adolescent’s experience of loss and bereavement (Balk, 1996). Wheeler and Austin (2001), in a study of 164 adolescent girls, found that adolescents who experience early pregnancy loss may be at increased risk for depressive symptoms and display significant physical, emotional, social, and cognitive grief responses. Sefton (2007) examined the perinatal bereavement experiences of 14 Latina adolescents after a miscarriage and reported that the bereavement response ranged from minimal upset to long-term, unresolved grief. Sefton noted that adolescents are at higher risk for complicated grieving due to the often-sudden nature of the loss and the negative stigma associated with pregnancy.

Given the gap in knowledge about how perinatal loss and bereavement are experienced in Black adolescents, the overarching aim of this study was to generate a disclosive theory of perinatal bereavement in non-Hispanic Black adolescent females. Disclosive theory exposes the linkages between concepts and delimits the stages and phases of a process (Morse, 1997). The research question was: What is the process of perinatal bereavement in non-Hispanic Black adolescents who have experienced perinatal loss?

Methods

Grounded theory can be used to identify the nature of process, describe the interaction and emotion in response to a situation, and build theory (Corbin & Strauss, 2008). Grounded theory methods as explicated by Corbin and Strauss were used. Symbolic interactionism guided the study by informing the underlying assumption that the participants in the research study shared a common problem in the domain being studied (Wuest, 2007). The three major assumptions of symbolic interactionism are (1) human beings act toward things and people according to the meaning that things and people hold for them, (2) meaning is derived from social interaction, and (3) people modify the meanings of things through an interpretive process as they respond to experience (Blumer, 1969).

Participants

IRB approval was obtained from three large urban teaching hospitals in the Mid-Atlantic States before data were collected. Inclusion criteria were: 16–21 years old with a recent perinatal loss defined as miscarriage, stillbirth or neonatal loss within the first 28 days of life; race/ethnicity reported as non-Hispanic Black (African American); not married, given that single young women have received little attention in bereavement literature; English-speaking; able to read and understand consent form written at 6^th grade reading level; no extended hospital stay after the perinatal loss.

The eight Black urban adolescent female participants ranged in age from 18–21. Six reported being in relationships with boyfriends at the time of their loss, but only two of the relationships were still intact at the end of the 12-week study. The mean gestation of the pregnancies at the time of loss was 19.8 weeks (range 9–32 weeks).

Data Collection

The Perinatal Bereavement Coordinator at each participating hospital used a scripted letter to invite potential participants to hear more about the study. Interested women gave their permission for the researcher to make contact by telephone. Informed consent was obtained prior to the first interview. Each participant received a stipend of $10 US for each interview that was completed.

In-depth interviews were conducted at three points in the first 12 weeks of the bereavement experience: 1) as close to the loss as possible, 2) around six to nine weeks post-loss, and 3) around 12 weeks post-loss. The mean time interval between the time of loss and the first interview was five weeks. Four participants completed all three interviews; three participants completed the first two interviews, after which the researcher was unable to reach them by phone; and one participant withdrew from the study after the first interview due to illness. Thus, 19 interviews were conducted. All interviews were digitally recorded and conducted in private at a time and location convenient to the participants. Most interviews were conducted by telephone due to distance. Two participants were interviewed in their homes. Data collection took place between April 2010 and May 2011. Sampling continued until theoretical saturation of all analytic categories was reached, that is, no new or relevant data emerged and the categories were dense with well-established relationships between them (Strauss & Corbin, 1998). Analysis of the last interview with the eighth participant confirmed the categories and the linkages between the categories.

A semi-structured interview guide was used for each interview. Participants were encouraged to tell their story of their loss experience. Probes were aimed at eliciting a deeper understanding of the perspectives of the participants. The researcher, who differed in race and ethnicity from the participants, began each interview by expressing sympathy to the participant and (if in person) asking to see any mementos of the baby (i.e. photos, footprints, etc.) as a way to build trust and establish rapport. Interviews lasted approximately 45–50 minutes. A series of de-briefing questions was asked at the conclusion of each interview, such as “What was it like for you to talk with me about your loss?” and “How are you feeling now?” (Kavanaugh & Hershberger, 2005). Digital recordings were transcribed by a professional transcriptionist, de-identified, and verified against the original recordings for accuracy.

Data Analysis

Data were analyzed using constant comparative analysis. Each interview transcript was analyzed prior to collecting additional data from participants, thus the constant comparative analysis informed future data collection. As data were analyzed, theoretical sampling was used to further clarify and expand the conceptual findings according to the emerging categories in the data (Corbin & Strauss, 2008). For example, how did the experience of mothers with earlier losses compare with those with later gestational losses regarding preserving the memory, searching for meaning and support needs? After IRB amendment, participants who had experienced early losses were recruited. In addition, interview questions were refocused to gain more insights regarding emerging themes (Draucker, Martsolf, Ross, & Rusk, 2007).

Initial steps of analysis included open coding to identify and label broad concepts. As data collection and analysis continued, initial codes were collapsed into broader axial codes. Linkages between concepts were identified to connect categories and subcategories at a conceptual level, as well as to identify the core category that was central to the experience. Supportive data were linked to the categories as further empirical verification. A schematic model was developed to illustrate the theorized relationships between the final selective codes and the core category.

Trustworthiness was optimized through field notes and memos of theoretical insights. An audit trail was maintained of decisions about revisions of interview questions, insights and reflections of the researcher, and emerging codes and categories. A team of three qualitative nurse researchers reviewed the theoretical findings. In member checking with two of the participants, after explaining the theoretical model and findings and asking them, “Do these results ring true for you?” participants responded that the researcher was “right on target” or “got it exactly right.”

Results

For these eight young women, the process of “enduring to gain new perspective” began prior to the loss. The core category of the experience was “enduring the loss.”

Surprised by Unintended Pregnancy: “Denying and Hesitating”

None of the participants were planning to become pregnant, and each one reported disbelief, surprise, and shock at the news of the pregnancy, accompanied by a time of denial and hesitancy about what to do next.

Well, I kind of figured I was pregnant. I just hesitated. I was in denial for like the first month and a half. Like my breasts were sore and stuff and I wasn’t getting my period. So I was like wow…I thought about it and I finally called the doctor.

Something was telling me, ‘cause my period was late and I just didn’t feel right. I really didn’t believe it at first. I took a pregnancy test and I was like oh my God. It was a complete shocker.

I was confused about what to do about the situation, so waited a couple of months and then I finally decided to keep it.

Accepting the Pregnancy: “Getting Ready for this Whole New Life”

In the social interaction of family and friends and making the pregnancy known to others, participants came to accept the pregnancy and plan for the baby’s arrival.

Well my mom and my grandmother were very upset and I cried too, but after a while you start to get used to it and you start to plan for the baby that’s coming.

My friends were happy because they all have kids. I was the only person out of all of them that didn’t have kids.

All of the mothers in this study spoke about forming a bond with their baby and anticipating motherhood, regardless of how long they were pregnant before the loss occurred. For example, one mother who experienced a very early loss said:

I had 21 days of heaven knowing I was pregnant and it was one of the best times in my life…it was just exciting to know that I was carrying something that was mine and that I had made. I wrote a letter to the baby saying I can’t wait to meet you, I love you…

Mothers expressed feeling a closer connection to the baby after seeing the baby on ultrasound, hearing the baby’s heartbeat, seeing their growing abdomen, and feeling movement.

When I had my ultrasound, I actually got to see the baby move. My first initial reaction was I don’t know if I’m going to be able to keep the baby. Once I seen the baby move, I changed my whole idea of thinking. When I first seen the first heart beat, I was like I don’t know how I’m going to be able to do this but that’s someone growing inside of you, furthermore it’s my child.

They demonstrated their connection to the baby and planning for the future through choosing the baby’s name, writing letters to the baby, and dreaming about motherhood:

You connect, you bond, you know? Like you’re getting ready for this whole new life. We talked about it every day, what our plans were and you know, if it was a boy or girl what we would name it; we were thinking of names and everything.

Suffering Through the Loss: “All that Pain for Nothing”

Living through the loss at the hospital was described in vivid detail. The young women suffered both emotional and physical pain. Many of the participants misread the cues of preterm labor as “not feeling well” or as a “stomachache from something I ate” and therefore did not seek medical attention immediately. Several participants reported delivery experiences that were characterized as a time of extreme physical pain with no reward.

I pushed the baby out, like that was the worst pain ever in my life. Like a thousand hurts put together. I thought the worst part about pushing the baby out is that the baby is not going to survive and going through all that pain for nothing….a whole bunch of pain for no reason. Cause the baby wasn’t going to live anyway.

Most participants felt they didn’t receive enough information about what was happening once they reached the hospital. One young woman said,

I told my boyfriend something is not right. I was bleeding real bad. Then when I got to the hospital they were checking for his heart beat. They didn’t tell me nothing, they just took me upstairs. But when you see doctors whispering you know there’s something wrong.

Some participants described being in such a state of shock that they could not cry, even though they knew others expected them to cry. They described an underlying fear of sensing things were not okay but still hoping and praying for a miracle.

He (doctor) gave me some medicine for me to start contracting and he said it could take all day or you could deliver in a couple of hours. I thought she was still going to make it. I thought some miracle was going to happen. He never really said. He had it on his face, but he never really came out and said she wouldn’t make it.

Participants told their stories in graphic sequence, with great attention to detail.

So when they took her out they cut the umbilical cord and I asked my boyfriend what the sex of the baby was. He said it was a girl. Then they laid her down and you could see her chest moving up and down and her gasping for air and I saw her chest moving up and down. And like the only hard part was to watch her chest move up and down fast and like watch her slowly die and her chest just kept going slower and slower.

After discharge, several of the young women were surprised when they began to produce breast milk, as they had not been informed that this would happen. Although some had received anticipatory guidance about lactation, it was always worse than they expected. Participants described the pain of lactation as “horrific” and the “worst pain ever.”

Emotional Turmoil: “Mixed Emotions Going Everywhere”

In the time that followed, emotional turmoil was manifested both outwardly and internally, by crying, anger, depression, jealousy, and disappointment.

It was just a pain I couldn’t understand…a lot of crying; mixed emotions going everywhere.

The pain felt so bad I was crying so much I couldn’t breathe. I would never wish that pain on my worst enemy. It’s just like I can’t even explain. I’m talking like about the pain of losing the baby…the emotional pain.

Like all of my happiness is turned upside down because I lost the baby. It’s like we did something wrong to lose the baby. I was so happy and then like the next day my stomach was so flat.

Jealousy, depression, sadness, and anger were triggered by seeing other pregnant friends or women with babies in real life or in TV and movies. Participants felt left out and sad about their lost dreams of motherhood.

One of my other friends got pregnant around the same time I was. I’m always rubbing her belly. And it makes me sad because I don’t have a belly to rub. So it gets kind of sad then…deep down inside, I cry on my insides cause I wish it was me.

It kills me seeing pregnant women that I know. A lot of girls in my town just make babies to make babies and it makes me mad. I’m not looking down on them, it just frustrates me.

Reaching Out for Support

Almost immediately after the loss, the young women actively looked for support from their partners, girlfriends, and older women. Many expressed looking to God as a source of strength through prayer. They informed others of their loss by phone, texting, or Facebook while still in the hospital. Although participants expected that their friends would be supportive, they described being disappointed.

Like after I lost the baby, I was calling people and sending them pictures of him, my friends weren’t there for me at the time I needed them. You know how they say they’ll be here when you call them and you’re crying about your baby and stuff. Then they don’t answer your phone calls or come to your house, they said they would, but they didn’t come.

One participant reported seeking out a support group offered by the hospital and attending with her boyfriend. She felt out of place because she was the only young, single Black woman. She said, “I just felt kind of different.” Some participants sought out support from other Black women who had experienced perinatal loss, often an older woman in the family or church. Almost every young woman described her major source of support as the women of the family, most often her mother or grandmother. If participants were partnered, they received support from their boyfriends, although these young men demonstrated a wide range of responses to the loss according to the participants’ accounts.

Participants also welcomed support they received without having to seek it out. For example, the hospital bereavement nurses provided standardized bereavement care to all of the participants. This support varied according to the gestational age of the baby and the resources, scope, and creativity of the hospital programs, but most included tangible items such as a memory box, footprints, hat, blanket, and photographs, as well as bereavement pamphlets and phone calls after discharge. All of the participants described these interventions as helpful.

Preserving the Memory and Maintaining Relationship

The young mothers preserved the memory of their babies through tangibles such as the memory box and photographs, and intangibles such as dreaming about what the baby would have been like. “I think about him a lot, like every day. Wishing he was here and what would he be like…” Some devoted a special place in their home to display their mementos: “I put the memory box on my dresser. I put a wreath right there and a little teddy bear. I printed out a bunch of her pictures and I have them in a special frame.” Their actions indicated desire to foster continuing bonds with the baby and maintain a relationship through remembering the baby rather than just “getting over it.”

Maintaining a relationship was manifested in repeatedly looking through the memory box, visiting the gravesite, or in the words of one participant, “Sometimes I just open the memory box and I smell his hat, I look at his ultrasound….” Many participants described holding the deceased baby a number of times or keeping the baby in the hospital room for as long as possible. One participant who had had an early loss got a tattoo of angel wings as a more permanent reminder of her brief pregnancy. Others described getting a necklace to wear the ashes, journaling letters to the baby, or holding a memorial service.

They gave me this box. It’s got everything…it has the pictures of his feet, his little feet, a little blanket and the outfit he had on and the little hat. I thought it was one of the best gifts because I’m so glad I have it. It’s something I can always remember him by.

Searching for Meaning and Asking Why

All of the participants asked “why?” and “why me?” After some time had passed, some participants sought out a medical reason for the loss. Some blamed themselves. Although most participants did not attend church regularly, they all referred to God as they searched for meaning and asked why the loss had happened to them: “I pray and I know that everything happens for a reason and that he (God) knows best.”

God took him for a reason. Maybe he didn’t think I was ready yet and he probably wanted me to finish school.

There was a reason that I wasn’t meant to be a mother yet. God had a reason. God wouldn’t give me anything I can’t handle. I truly believe that. I was raised to believe that. So there was a reason why this happened and I’m searching for it. Maybe I just have to come at peace with it.

At first I didn’t want to believe in God no more. Like why did this happen to me? I’m not a bad person. Like I don’t have no criminal record. Like I’m about to graduate. Like all these people who do drugs and all this bad stuff and nothing ever happens to them. But that’s how things work. That’s how God do things.

Gaining New Perspective on Life

As participants endured the loss over time, they gained new perspective on the situation of the loss, the bereavement experience, and their future life. They described a resolve to do better, do more, and get “back on track,” make a fresh start and stay focused on their goals. “It just made me want to start over completely. Just redo everything. Well I’m starting over, I’m not done…I’m in progress.”

They felt stronger and somehow motivated to change by the experience of losing the baby. One participant who was failing in school at the time of her loss of twins said,

I felt like this was my wake up call. I always felt like I wanted more for myself, but I was just too lazy to act on it. Now I don’t feel like I have to do it for myself, I have to do it for my babies.

As they endured, with the passing of time, they were able to reflect on how the experience had affected them.

My whole outlook on life has changed. Just cherish every moment you have with your family and with your friends.

Everything I went through, I swear, it makes me a stronger person than I’ve ever been. This whole experience has humbled me in so many ways. I don’t even know where to begin by saying that. No I’m not the same. I would probably go on for hours talking about how it humbled me.

The Role of Time

The influence of the passage of time and the experience of bereavement as a process were both evident as participants described enduring the loss. In the words of one participant, “I’m still in the middle of it, you know? I’ve accepted it and I’m trying to move forward with it, but it’s still so fresh. Yeah, it can be a transforming experience. I’m still in the process. That’s the word…it’s a process.”

Time was integral to the bereavement process. The young women described how the passing of time softened the emotional pain and helped them be able to talk about their loss. For example, one participant offered at the 12-week interview: “Like at this point in time, I can talk about it with other people and not cry. So I’m doing a lot better.” Another stated, “As the weeks and months go by I feel a lot better. I used to cry every day but it’s less now.”

The passing of time was also associated with gaining strength: “Not that I don’t think about it every day, it’s just that it has made me stronger as every day goes by.” Another participant shared: “As time went past, that’s when I was able to finally do other things, as time moved along.”

Model of the Process of Enduring to Gain New Perspective

The theoretical model represents the conceptual relationships between the categories of the theory (See Figure 1). It is situated on a time axis to indicate that bereavement was a process that occurred over time, but it is not to be interpreted as linear, prescriptive, or limited with respect to time. The arrow indicating the passing of time reflects continuing on, or enduring. The phases were dynamic and without distinct beginning and ending points but rather were fluid and responsive to each other in the young women’s context and social interactions.

Figure 1.

The dotted lines connecting the three “enduring” activities indicate the fluid nature of these concepts and the dynamic relationship between them. The bi-directional wavy arrow connecting “gaining new perspective” to the other categories illustrates the nature of bereavement as a phenomenon that may be characterized by “ups and downs.” The future is indicated by a dotted line extending forward, illustrating absence of a defined end point.

Discussion

The findings of this study add to the existing literature of perinatal bereavement and inform practice for nurses and other disciplines concerned with providing evidence-based care for bereaved mothers. Importantly, this study gives voice to young Black women who have previously not been adequately represented in perinatal bereavement research. The perinatal bereavement experience of Black adolescents has many parallels to theory derived from the study of perinatal loss in other races and ethnicities. The theoretical model generated from these data supports the non-linear, fluid and dynamic experience of bereavement, suggesting that there is no prescribed end point or mutually exclusive phases of grief.

The young women in this study were all between the ages of 18 and 21, in “late adolescence” (Balk, 1996). They were in the midst of the developmental tasks connected with late adolescence and its transitions: graduating from high school, planning to go to college, or working to save money to move out on their own. Thus, it not surprising that the news of the pregnancy was a disruptive event that initially created shock and disbelief, consistent with earlier research (Dyson & While, 1998; McCreight, 2008; Murphy & Merrell, 2009; Sefton, 2007). The adolescents’ sadness, jealousy, or anger when seeing other pregnant women in person or on television is also consistent with findings of other qualitative researchers (Kavanaugh & Hershberger, 2005; Sefton, 2007). Participants gave detailed accounts of the loss event, beginning with the moment they first sensed trouble. Many of them misread the cues of preterm labor as a stomach ache or as a normal part of pregnancy and as a result did not seek immediate medical attention, similar to findings of Kavanaugh and Hershberger (2005).

Most participants turned to the women in their family circle for support. Other researchers who have studied bereavement in African Americans confirmed the support of kinship during a loss experience (Laurie & Neimeyer, 2008; Van & Meleis, 2003). Laurie and Neimeyer (2008) posited that when kinship is strong, bereaved individuals are less likely to seek professional services for support. Participants in this study sought support from other women who had experienced perinatal loss, as found in a qualitative study of the culture of an online support group (Capitulo, 2004). Similarly, Van and Meleis (2003) reported that adult African American women after pregnancy loss wanted to talk with women of their own culture, their family, and their close friends for support. Few participants in that study attended formal bereavement support groups because they felt constrained and perceived support groups to be for wealthier White women.

Other researchers have reported that bereaved mothers maintain a sense of attachment and relationship to the baby even months and years after the loss, refuting the belief that bereavement has a specific endpoint. The notion of continuing the ties to the deceased person through maintaining relationship has been empirically supported by other contemporary bereavement theorists and reflects the current direction of bereavement theory (Davies, 2004; Florczak, 2008; Lindstrom, 2002). Other qualitative researchers have noted the connection to spirituality among African American women after perinatal loss, including searching for a reason in order to find meaning (Kavanaugh & Hershberger, 2005) and feeling that God does everything for a reason (Van & Meleis, 2003).

As participants in this study endured the loss experience, they gained a new perspective on life, on their loss, and on the future. Many of them resolved to reach their goals and to “do better”. They credited the experience of perinatal loss as the impetus for change. Several expressed a desire to help other young women through the experience of perinatal loss and bereavement. They viewed their participation in this study as one way to reach out to help others. As the crisis of bereavement challenges the adolescent’s assumptions about life and the meaning of human existence, spiritual change may be triggered. Leighton (2008) suggested that as adolescents mature, they continually reflect on the crisis of loss and reconstruct their views about the loss in a way that results in new perspective.

Strengths and Limitations

A design strength of the study was its longitudinal approach, enabling study of bereavement as a process over time. Data collection began soon after the loss and moved through the first three months of the bereavement experience.

Limitations include that all of the participants received perinatal bereavement support in the hospital and after discharge, so it is not known what the experience is like for those without available perinatal bereavement support. There was no match in race or ethnicity between the researcher and the participants, which may have limited participants’ full disclosure and transparency in talking about their experiences. Unreliability of the participants’ cell phones (dropped calls, cell phones not charged, cell numbers changed) created challenges in data collection, and only two participants were interviewed in person due to distance constraints.

Nevertheless, participants who were interviewed via telephone spoke candidly and openly about their experiences. All participants expressed appreciation that they were invited to be a part of a research study. One participant said, “I feel like I got to speak my mind openly without being judged and that somebody listens and cares.”

Recommendations

Communication and emotional support from nurses and physicians during the loss experience and then in the immediate post-partum period is a critical component of perinatal bereavement support in the hospital setting. Adolescents need accurate and timely information delivered in a nonjudgmental approach to explain what is happening in terms they can understand. Adolescents who experience perinatal loss need to be informed about the physical changes they will experience, such as fatigue and lactation.

Participants often turned to the women in their family circle, to women in their church, and to prayer for support, thus, an early assessment to identify the presence of family members and church members who will offer guidance and care after discharge is important. Partners or boyfriends provided different levels of support. Although support groups were not valued by the participants, current perinatal bereavement program offerings, such as holding the baby, taking photographs, and collecting memorabilia, were very helpful. As few adolescents could afford funerals, perinatal bereavement nurses can offer annual events to commemorate the infants who died in the past year, as a way for parents to memorialize their infants.

Research is needed on the cultural impact of perinatal bereavement both in adolescents and adult Black women. Comparisons of the perinatal loss and bereavement experience across racial and ethnic groups would be helpful to better understand the cultural nuances of the bereavement experience, in particular for nurses working in urban settings with diverse patient populations.

As diagnostic technology continues to provide earlier detection of lethal fetal anomalies, perinatal palliative care and its impact on bereavement is a growing area for nursing research. Thanatologist Balk (2008) asserted that when bereavement is anticipated, outcomes from the crisis of loss are better than when bereavement is unexpected.

Interdisciplinary research with colleagues from psychology, social work, and medicine has great potential for strengthening collaborative care to bereaved families. Research is needed to develop and test bereavement support interventions across a variety of types of losses, age ranges, socioeconomic groups, and cultures.

Conclusions

Perinatal loss and the bereavement experience that follows were important and often transforming life events in the lives of these young women. The theory discovered in this research corresponded in many ways to what other perinatal bereavement researchers have found, but its manifestations in these Black adolescents’ experience differed due to their age and culture.

Perinatal bereavement was interpreted by these adolescents in relation to the meaning they ascribed to their pregnancy and motherhood. The experience of perinatal loss was shaped in interaction with partners, family and friends, taking cues from their cultural norms and inherent value systems. Over time, as they endured the loss, through seeking and receiving support, preserving the memory and maintaining relationship with the baby, and searching for a reason for the loss, the adolescents gained new perspective on what mattered in life, how they had been changed, and how the experience would shape their futures. In the poignant and profound words of one participant, “It taught me life.”