Planning a pregnancy after the death of baby is complex with many competing emotions. Couples’ experiences of their decision-making processes, with various influences, help us to understand this complex issue. New insights into men’s thinking about the decision to get pregnant after stillbirth are discussed.
Dr. Margaret Murphy is a Lecturer in Midwifery, School of Nursing and Midwifery, University College Cork, Ireland. She was awarded her doctoral degree in 2018 for her thesis which explored couples’ experiences of pregnancy following stillbirth using an Interpretative Phenomenological Analysis methodology. She was elected to the Board of the International Stillbirth Alliance in 2016 and as its Treasurer in 2017. She is a Registered Midwife, Registered General Nurse, and has senior clinical experience in Midwifery and Neonatal Intensive Care. She is co-author of the book Different Baby, Different Story: Pregnancy and Parenting after loss with Dr Joann O’Leary and Dr Jane Warland.
Dr. Murphy has disclosed that she does not have any real or perceived conflicts of interest in making this presentation.
Kathy Gardner: Dr. Margaret Murphy is a Lecturer in Midwifery, School of Nursing and Midwifery, University College Cork, Ireland. She was awarded her doctoral degree in 2018 for her thesis which explored couples’ experiences of pregnancy following stillbirth using an Interpretative Phenomenological Analysis methodology. She was elected to the Board of the International Stillbirth Alliance in 2016 and as its Treasurer in 2017. She is a Registered Midwife, Registered General Nurse, and has senior clinical experience in Midwifery and Neonatal Intensive Care. She is co-author of the book Different Baby, Different Story: Pregnancy and Parenting after loss with Dr. Joann O’Leary and Dr. Jane Warland. Dr. Murphy’s presentation is titled, Deciding on Pregnancy After Loss and Trying to Conceive: The Experiences of Couples in Pregnancy After Stillbirth.
Dr. Margaret Murphy: Hello, and thank you to Star Legacy for inviting me here to speak to you today on deciding and trying to conceive: the experiences of couples in pregnancy after stillbirth. Just to state at the outset that I have no conflicts of interest to declare and the findings that I would be talking to you today are from my own self-funded doctoral degree.
The learning objectives from today’s presentation are that you will be able to understand the influencing factors on decision making amongst couples in pregnancy after stillbirth, and that you may have an awareness of the gender differences that may be present in couples in pregnancy after stillbirth.
What we know globally is that around 2 million babies are stillborn annually with the greatest of these burdens remaining in low- and middle-income countries. However, in high income countries, an estimated 1 in 200 pregnancies will still end in stillbirth, and there are racial, ethnic, and socioeconomic disparities evident. These babies’ deaths have a profound and long-lasting effect on couples, on families, and on wider society.
Most couples do go on to have another pregnancy often within a very short timeframe, and large global studies have cited that about two thirds of couples are pregnant again within 12 months of the death of their first baby. What does that mean? That means that couples are trying to get pregnant again while they’re still actively grieving. The evidence would tell us that little is known about how couples negotiate this decision to get pregnant again. Or also that little is known about experiences of trying to get pregnant.
Following ethical approval from the Local Hospital’s Ethics Committee, my doctoral research aimed to examine and explore the lived experiences of couples undergoing a pregnancy following stillbirth. In order to answer this question, I conducted face to face in depth interviews with couples jointly together in the immediate pregnancy following the death of their baby. In total, eight heterosexual couples agreed to meet with me and to sit down and we discussed their lived experiences. These interviews lasted anywhere from 1 to 2 hours. Although not an exclusion criteria, it was only heterosexual couples who came forward and agreed to meet with me to discuss their experiences.
The following grid is an anonymized representation of the eight couples. What you might notice is that the majority of couples were in their 30s, the majority of couples were living together and they were either cohabiting or they were married. The majority of couples except one couple had living children prior to their experience of stillbirth, and some of the couples, their babies died due to expected causes.
Some babies died following a prenatal diagnosis of a fetal anomaly, and some babies had an unexpected death that was presented with either premature prolonged rupture of membranes, or their mothers presented with reduced fetal movements and they were told that their babies had died unexpectedly in utero. Some babies died in the mid trimester of their mother’s pregnancies, and more in the third trimester.
What you’ll also notice is that most of the interviews occurred with the couples in the late second trimester or most commonly in the third trimester of the subsequent pregnancy. So while the couples were still pregnant again. Again, you can see that the time from the time when they lost their first babies to the time when they were being interviewed varied greatly from 11 months in some instances, so some people were very newly bereaved, up to 33 months in the case of Valerie and Tim.
As part of the research process, the interviews were rigorously analyzed using qualitative research design, and two major themes emerged from the data analysis. One was looking at the journey of loss that these couples undertook, and the second was, they’re hoping for a born alive baby in this subsequent pregnancy.
One of the themes that informed that subordinate theme was trying to conceive, which is what I will be discussing in this presentation here today. You can see there that this subordinate theme of trying to conceive was informed by these sub themes of reaching a decision, intimacy being a functional act, difficulty waiting, and the impact that trying to conceive had on the couple’s relationship. These are the subheadings that I will be discussing in this presentation today.
Just to give you an overview of the findings that I’ll be talking about, what I found was that couples jointly negotiated their decision to get pregnant again. That agreement on this decision was important for them, both as individuals, but also for their ongoing relationship. Their baby’s death and their subsequent efforts to try to conceive placed a great strain upon their relationship with one another. They talked about that in their joint interviews. Although the couples shared a common event, which was the death of their baby, they often had very different experiences of that event, and indeed of the subsequent pregnancy.
The first theme that I will talk about was about deciding on the pregnancy itself. That was affected really by couples whether they knew that their baby’s death was anticipated or whether their baby’s death was sudden. It’s highlighted here by a comment one of the fathers made when he said, “It probably would’ve ended up with us having more arguments in 10 years’ time if we didn’t try it again,” it meaning trying to have another baby.
What I found was that couples who knew prenatally that their babies had life limiting conditions and who were unlikely to survive outside of the womb, they talked about waiting longer to get pregnant again compared to couples whose babies died unexpectedly. Likewise, couples whose babies died as a result of congenital anomalies, discussed the need to wait until they had the results of all investigations before contemplating trying to conceive again. This theme was particularly important, more for the men in the relationship than the women. It was expressed more commonly by the men.
It was couples whose babies died suddenly, and whose babies had no obvious congenital anomalies, those were the couples who actually had the shortest inter pregnancy interval. Those were the couples who tended to commit and to begin a subsequent pregnancy the quickest.
The next sub theme was around intimacy and intimacy being a functional act. This quote from Adam exemplifies this where he talks about their sexual act of sexual intimacy, and he talks about how his wife in this instance was chastising him during their sexual intercourse because he was kissing her and he said, “She chastised me one time,” and said to him, “What’s wrong with you??” He said, “Seriously, it was like homework.” He was describing it as being very, very functional, something that he felt he had to do in order to satisfy her desire for pregnancy. Sexual intimacy therefore became less about emotional connection and more were about a means to an end about achieving a pregnancy.
Couples who were able to discuss their feelings with one another appeared to find this challenge easier to deal with. Trying to conceive a pregnancy impacted their couple relationship, and it was men who spoke commonly about the emotional disconnection. These thoughts of being used to functionally perform was a theme that was actually raised mostly by men while women discussed their fear of bodily failure more when they spoke about intimacy.
This informs the next theme, which talks about the difficulty in waiting to achieve a pregnancy. Jill’s comment here really exemplifies that where she was talking about the difficulty in waiting to get pregnant. She said, “Every time I got my period, oh, I was like a mad woman.” Women talked about menstrual periods being particularly stressful for them and many likened these periods to losing their baby again. They voiced fears even that a successful pregnancy may not be possible for them. That there may be actually something physically wrong with them as women and physically wrong with their female bodies that not only had they lost their baby, but now they couldn’t conceive another baby in a subsequent pregnancy.
Women were also very conscious logically that their actions did not appear to be rational even to themselves. They knew logically and they discussed logically that they were appearing like a mad woman as Jill said, but they were also unable to help themselves, which again, created more stress for them within their relationship.
All of these issues had an impact upon the couple relationship. This quote from this couple here exemplified that beautifully. “We had to decide how, how much more we could put up with,” was what the woman said. Her husband said, “Yes, how much we could endure mentally and physically.” This was a couple who had two stillbirths one year after another. For them, it was about trying for a pregnancy after two successive losses.
What men talked about was their anxiety around protecting the time they saw as belonging to their deceased baby. The men in this study were very anxious to have the opportunity to parent their baby who had died. For them, they wished to wait until after their babies’ anniversaries had passed to begin to think about a subsequent pregnancy.
That may be to do with the fact that for men, their transition to fatherhood may not truly be cemented until their babies are actually born and until they have a physical relationship with their babies. This was certainly true for the men in this study. For them, honoring and protecting that time with their babies was very important to them.
The women in this study certainly physically were often more willing to try to conceive much quicker than their partners. Many of them expressed a desire to actually be pregnant again for the anniversaries of their baby’s death or for the anniversaries of their baby’s due dates. These differences between the couples often created challenges within their relationships that they struggle sometimes to negotiate. If they were able to have a dialogue, and if they were able to discuss these issues, the couples that were able to do that seemed to negotiate these challenges much better than the couples who did not have the language and were not able to talk about these issues.
What were the implications for these couples? Well, couples’ experiences of stillbirth, the reasons for their baby’s deaths, and their relationship to their deceased baby, all played a role in their decision making and their negotiation of pregnancy after stillbirth within this study cohort. We gained new insights into, particularly, men’s thinking about decision making to get pregnant again after stillbirth, and we were able to see gender differences. That may be explained by the desire of the men in this study to fully parent the babies who had died before reaching a decision about a subsequent pregnancy.
Now, the limitations of this study are that it is a small group, only eight participants, done in a small area of the world. The couples themselves were fairly homogenous, meaning they’re very similar. Similar education, similar age group, similar ethnic background, similar racial background. While the findings may not be generalizable to the entire pregnancy after loss population, it does give us some new insights into this group or this population.
What recommendations, if any, can we make from what we’ve discovered from these parents’ stories? Well, I think it’s important to say that discussions about sexuality and subsequent pregnancy need to form part of any bundle of care around stillbirth, because couples are thinking about pregnancy after loss very soon after the death of their baby. Couples need to be supported to be able to communicate with one another about intimacy and about differences that may occur in their wants and needs in the aftermath of stillbirth.
I think while sometimes clinicians may be very good at providing physical care to couples, I think it’s important that we also look at addressing people’s psychological and their intimacy needs as well. Individual counseling may be beneficial to couples in addition to maybe couples counseling, because certainly within the couples that I interviewed, sometimes I think there may be challenges for individuals that they may need to discuss on a one-to-one basis with counselors or with support people that may be useful to think through before discussing them as part of a couple diode.
Finally, I think there’s no universal approach to providing the support. I think it needs to be provided in a tailored individual way, rather than ascribing a one size fits all approach.
I would just like to offer some words of thanks to you all for listening to me today, but in particular to the couples who shared their experiences with me and their babies and their stories with me, and also just to my co-authors Professor Eileen Savage, Professor Keelin O’Donoghue, Dr. Joann O’Leary, and Professor Patricia Leahy-Warren.
If you are looking for any further information, we have published a paper in this area and Dr. O’Leary and Dr. Warland and I have published a book on pregnancy and parenting after loss called Different Baby, Different Story, which is based on this and our own research in this area. I’m also available on email or on Twitter, and I’d be very happy to discuss this and any further aspects of my research with you. I hope you enjoy the rest of the conference. Thank you so much. Goodbye.
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