The full length version of this article was originally published in the peer-reviewed journal "Social Science and Medicine" Vol. 38 No. 9, pp. 1193-1200, 1994.

Tables are not presented here. For the full article, please see the Pioneer Publishing Order Form in our resources section.

The Effects of Pregnancy Loss on Women's Health

Philip G. Ney MA, MD, FRCP(C), FRANZCP, Clinical Professor, Department of Family Practice, Faculty of Medicine, University of B.C.

Tak Fung PhD, Biostatistician, Academic Computing Service, University of Calgary

Adele Rose Wickett, BSN, Research Assistant

Carol Beaman-Dodd, BA, Research Assistant

Correspondence and reprint requests to:

Dr. Philip G. Ney, PO Box 27103, 750 Goldstream Avenue, Victoria, BC, V9B 5S4

Phone (250) 642-1848 / Fax (250) 642-1841

Abstract

     A survey of women patients in the practices of family physicians in Victoria, B.C. was undertaken to determine the factors associated with pregnancy losses and their effect on women's health.  Questionnaires returned by 1428 women with 2961 pregnancies showed that a higher number of losses, particularly abortions, correlates both with poor health and the need to obtain professional help in dealing with the loss(es).  Partner support appears to be one of the most important factors in maintaining a pregnancy.

KEY WORDS: Maternal Health, Mental Health, Abortion, Mother-Fetus Relationship, Pregnant Women.

Introduction

     We have known for a long time that loss affects humans as well as animals.  When pets lose their keepers or animals lose their mates they "pine away".  Emde, Polak, and Spitz (1) found that "anaclitic depression" occurs in children when they lose contact with their parents. Bowlby (2) described mourning in infants when they lost their parents.  Depression correlates with poor health in adults.  Sudden death of many kinds occurs in people who lose hope after the death of a loved one (3).  For this reason, Emmanuel Lewis and others (4,5) have emphasized the importance of mourning stillborn infants.

     The present study was conducted with the objective of determining the effect of all types of pregnancy loss on women's general health.

Literature Review

     Several researchers have documented maternal reactions to perinatal death as similar to symptoms of grief over any death (6 -19).  Kowalski noted that, "perinatal death encompasses each type of loss": loss of a significant person, loss of some aspect of the self, loss of external objects, loss of a stage of life (as defined by Peretz, 1970) (20,21), loss of a dream inherent in the parents' desire to have children (as studied by Schneiderman, 1979) (22), and loss of creation (23,24). Yet because the infant who dies through miscarriage, stillbirth, induced abortion, or as a newborn has not been seen and known, the death is often not considered worthy of recognition and mourning (9,12-14,19,24-31). Such ignorance of the significance of the loss on the part of society, friends, family and possibly even the mother herself, impedes the mother's bereavement process.  This in turn may lead to her development of pathological, chronic, or inappropriate grief responses (7,17,24,27,29,31-35).

     Acute or pathological grief threaten the mother's physical and psychological health. Dr. Erich Lindemann (36) catalogued the following symptoms of pathological grief:

(1) overactivity without a sense of loss;

(2) acquisition of the symptoms of the illness of the deceased;

(3) development of psychosomatic diseases such as ulcerative colitis, asthma, rheumatoid arthritis;

(4) irritability and social withdrawal;

(5) furious hostility;

(6) mannerisms resembling schizophrenia, due to repressed hostility;

(7) lost patterns of social interaction, involving inhibition of decision-making and initiative;

(8) activities detrimental to own social and economic existence;

(9) agitated depression, including insomnia, tension, agitation, low self-esteem, self-accusation, and even suicidal tendencies.

     Research has confirmed the presence of symptoms typical of both acute and prolonged grief in women who have suffered pregnancy loss (6,7,24,27,29,31,37).  Kennel also noted a preoccupation with the dead infant, the inability to function in a daily routine, and the loss of appetite (6).  Other researchers have recorded feelings of guilt and a sense of failure (27,29).  The acute grief phase generally lasts from six to twelve months (38,39) and possibly even as long as two years (28).

     Pregnancy loss strains all of a woman's important relationships.  Her anger and need to focus blame alienate her from the medical staff serving her, her friends, her family, and her partner.  In particular, differences between her partner's and her own grieving behaviours can produce extreme conflict and stress in their relationship (7,9,13,14,18,24,27,29,31,38).  Any other children in the family will have special needs at such a time, to which their mother, distracted and physically exhausted by her ordeal, may not be able to attend (29,31,40).

     Pregnancies within five to six months after pregnancy loss, and later births, may exacerbate parents' trauma, causing inappropriate grief (25,27).  Phipps found that neither parent showed much pleasure in there being another pregnancy and less emotional attachment in subsequent pregnancies (41).  Forrest, Standish and Baum reported that mothers were unresponsive to their newborns (14).  Mandell and Wolfe described the "replacement child syndrome" in which parents hold unrealistic expectations for the next child (42).  As a result of evidence that both pregnancy and pregnancy loss leave an impact on not only the women, but entire families, hospitals have initiated family-centred caregiving programs, equipping medial staff, counsellors and friends to support bereaved couples and their families (24,31,43-46).  The supportive presence of their partners promotes the health of pregnant women or women suffering pregnancy loss (24).

     The key elements in facilitating the recovery of the mother and any partner or family member involved are:

(1) the bereaved's recognition of both the life and then the death of the infant (27,29,34);

(2) an ongoing, informed, and sympathetic social support network for the bereaved (27,29,34,48-50).

Both medical workers and researchers have stressed the importance of the mother's (or couple's) actually seeing and holding the dead infant (5,17,47,51).  Naming, baptizing, holding a funeral service, visiting the gravesite, and keeping mementos benefit the bereaved by acknowledging the individual for whom they mourn, and by drawing together a caring community (18,24,27,29,52-54).  Single women, both teen-aged and adult, frequently have less social support for their pregnancy and thus face greater hardship upon pregnancy loss.  Although pregnancy as a single woman is no longer taboo, it is not the norm, so the grieving mother lacks the aid of a partner and possibly even family and a larger social network (29).

     The options of seeing the baby, holding a funeral service, keeping mementos (e.g., lock of hair, footprint, photo, etc.) available to some parents suffering later natural pregnancy losses, are not available to those experiencing a loss through induced abortion.  Benfield and co-workers found that intensity of maternal grief was not correlated with positive feelings about being pregnant (55).  Although parents may not express regret over choosing to abort due to fetal abnormality, they still feel a sense of failure and frequently grieve intensely for a period of time longer than the typical duration of grief.  This may be due to conflict over the decision to end a wanted pregnancy (34) or from the deliberate decision to terminate the life of an unborn child.  Borg and Lasker learned that even when parents maintained that selective abortion was appropriate, they still felt "ambivalence", "terrible guilt", and grief, and were generally "shocked and overwhelmed" by the experience (29).  That decision is all the more poignant and painful because frequently by the time selective abortion is deemed necessary, the baby has already started to kick. Adler and Kushnick reported classic grief symptoms on the part of parents dealing with the midtrimester termination of pregnancy because of fetal abnormalities (16).

     There is evidence of guilt, regret, and psychological disturbance in cases of the termination of unwanted pregnancies as well.  Freeman, in a follow-up investigation four months after the abortion, reported that of his 106 patients, 39 percent were ambivalent, 14 percent showed symptoms of anxiety, and 13 percent showed symptoms of depression (56).  Ashton recorded that 5 percent suffered severe psychiatric sequelae for up to eight weeks following the abortion, while 10 percent sought help from their doctor for emotional problems (57). The Lane Committee report stated that 20 percent of women experience short term regret and self-reproach after abortion (58). Other studies confirm the common occurrence of distress soon after termination of pregnancy (59,60). Donnai, Charles and Harris observed that terminations later in the pregnancy disturb abortive women more than do earlier ones (61).  Figa-Talamanca reported that teens are more vulnerable to suffer distress after an abortion than adults (62).  Belsey, Greer, Lai, Lewis and Beard determined that conflicted or negative attitudes towards pregnancy termination or the pregnancy itself lead to problems after abortion (63). Additional research has revealed that guilt detected before an abortion will recur afterwards (60,63,64). The Lane Committee found that most women were uninformed and lacking in helpful counsel prior to termination (58). Dunlop produced a list of factors related to distress following abortion (65), which Shusterman augmented (66). Broome summarized with her statement that "in general terms the ambivalent woman who lacks social support or has previously had psychological difficulties is more likely to be at risk" (67).

     Growing evidence indicates that any phenomenon which may intervene in the early attachment of the mother to the child may be an important contributor to the pathogenesis of child abuse.  The establishment of the mother-infant bond is a delicate business and can be easily influenced by subtle changes in the mother or infant.  Any stress, the death of a close friend, an earlier abortion or loss of previous children may delay preparation for the infant and retard bond formation (68).  Though longer and more intense mourning was seen in mothers for whom pregnancy was a positive experience, the mothers grieved whether an infant lived one hour or twelve days, whether he weighed 3,000 grams or a non-viable 580 grams and whether the pregnancy was planned or unplanned (69).  There is a significant association between a previous induced abortion and depression during pregnancy (70).  The mother's wanting or not wanting the child during the pregnancy does not seem to have an effect on bond formation or rates of child abuse and neglect (71).  The shakeup in pregnancy can be seen as an alarm reaction, readying the circuits and preparing the mother for new attachments (72).

Method

     In this study, conducted in conjunction with the College of Family Physicians, a request was made of the family physicians of British Columbia, Canada to hand out questionnaires to the first thirty women of child bearing age or older who walked into their practice on a particular week.  Each questionnaire began with assurances of confidentiality and proper treatment regardless of the subject's participation, together with an explanation of how to respond to the questions.

     The questionnaire consisted of seven visual analog scales asking questions about health.  There was also a grid in which subjects indicated the outcome of up to nine pregnancies, the presence of a supportive partner and questions regarding age, number of living children, marital status, and total number of pregnancies. While the patients waited to see their doctors, the receptionists gave them questionnaires with brief instructions.

     To validate the patients' estimate of their own health, we checked a sub-sample.  Without seeing the patients' answers both her own doctor and a researcher made independent estimates of each patient's physical and emotional health.  The researcher's estimate was based on a perusal of the patient's chart.  Each estimate was rated on a 9-point scale. Correlations were used to estimate the amount of agreement.  In 84% of the cases, the researcher's estimate was within 2 points of the patient's.  The doctor made a rating within 1 point of the patient's in 44% of the cases.  While any scale rating of health will necessarily be subjective, these data indicate that there is a reasonable correlation between the patient's estimate of health and the estimate of an outside observer.

Results

    Of the 238 family physicians to whom requests were sent, 69 physicians provided useful questionnaires.  These doctors appeared to be representative and without any dominant bias or style of practice.  Of the 1428 women in this sample, 1167 women had 2961 pregnancies.  Figure 1 shows the distribution of responses on the visual analog scale in answer to the question, "My present health is ..." , together with responses to the questions, "My family life is...", "I enjoy being a parent...", and "My partner is supportive...".  Each of these shows a similar distribution, roughly a reversed J-shaped curve.

     Using demographic data from Statistics Canada, it appears this sample is representative of the general population of women (Table 1).  There is a slight preponderance of married people in our sample, but there were more teenage pregnancies than the national average.

     Table 2  indicates there is a correlation between the age of the patient and the outcome of her first pregnancy. Approximately 27% of pregnant women 14 to 19 years have abortions.  Of these, 22% have a second abortion.  If aborted pregnancies are not included in the calculation, it appears that the 14 to 19 year old group has as many full term, normal birthweight pregnancies as older mothers.  That is, 77.2% of the unaborted teenage mothers in our sample gave birth to full-term, normal birthweight babies, as compared to 78.0%, 75.8%. and 73.8% of the unaborted mothers in the older age groups.  The miscarriage rate in young women is 12.5% for first pregnancies, and climbs steadily after age 25.

     Table 3 shows that the woman's present health is negatively affected by miscarriages, abortions, and low birthweight babies.  In response to the question, "My present health is ...", it appears that age is not a significant factor but the number of abortions and the support of the family is (Table 4).  Table 5 indicates that there is a progressive impact on the mother's present health by an increasing numbers of losses.

     Table 6 indicates a more negative effect on the mother's present health by the abortions of the second and third pregnancy.  That may be partly due to immediacy and ability to recall the more remote effect or a natural tendency of people to heal.  Table 7 indicates that there is a greater correlation between negative health effects and the loss of the latest pregnancy than with previous pregnancies.  Approximately 50% of the women who lose a pregnancy indicate their health is affected by that loss.  Twenty-five percent estimate their health is adversely affected a great deal by their most recent pregnancy loss.

     Table 8 indicates that a woman's health is affected by a previous loss through abortion to a greater extent than through a miscarriage.  Table 9 shows that more than 20% of the women feel from moderately to a great deal that they need professional help to resolve a loss, particularly in the most recent pregnancy.

     When a multiple regression analysis is performed on the 44 factors we considered relating to "My present health ...", the most important factors are quality of family life, previous pregnancy loss and whether the partner is supportive (Table 10).  Lack of partner support was a significant contributor to higher rates of abortion and miscarriage.  In the first pregnancy, if a partner is present and not supportive, the miscarriage rate is more than double and the abortion rate four times greater than if he is present and supportive (Table 11).  If the partner is absent the abortion rate is six times greater.  The most important factors, determined by logistic regression, of those considered as affecting the mother's decision to abort her first pregnancy were the lack of partner support (Table 12).

Discussion

     The hypothesis that pregnancy losses negatively affect a woman's health appears to be supported by the data in this study.  There are a number of possible mechanisms:

(1) It is possible that a pregnancy loss results in a psychological conflict that consumes a mother's energy and leaves less strength available to deal with the exigencies of life.

(2) If a woman is distracted by the internal conflict of prolonged mourning she may be more likely to misinterpret information that provides critical input for decision making that affects her health.

(3) If she is preoccupied with internal conflict and grief there is less opportunity to think rationally and freely about other aspects of her life, health and personal relationships.

(4) If losses are not mourned, depression (and consequently poor physical and mental health) is more likely to occur, (73,74).  There is evidence that depression interferes with the functioning of the immune system.  Irwin, Daniels, Bloom, Smith and Weiner (75) found the severity of depressive symptoms in women was associated with an impairment of the natural killer cell activity, an absolute loss of suppressor/cytotoxic cells, and increase in the ratio of T-helper to T-suppressor/ cytotoxic cells.  Kiecolt-Glazer, Fisher, Ogrocki and Stout (76) found poor marital quality to be associated with greater depression and a poorer response of immune function among separated or divorced women.  More recent losses, and greater attachment to the ex-spouse, were associated with poorer immune function and greater depression.

     Anxiety and depression are more likely to occur after the birth of a second child if the first one is aborted (77). The mother's disturbed psychological state may interfere with bonding to children following an unresolved pregnancy loss (78), and also with breast-feeding.  The poor bonding following abortion appears to increase the likelihood of child abuse and neglect (79).

     Although all pregnancy losses appear to adversely affect a woman's health, abortions seem to have a greater impact than do a similar number of miscarriages, even though the miscarried pregnancy was usually longer than the one terminated by an induced abortion.  This finding agrees with that of Berkeley and Humphreys (80), who studied the number of visits by women to their family physician for a year prior to and a year following abortions.  After the termination of pregnancy, they found there was an 80% increase in women visiting their doctor for all reasons, and 180% increase for psychosocial reasons.  It could be argued that the women who undergo abortions are less well to begin with.  This does not accord with our results that show women attribute a worsening of their health to a pregnancy loss.

     For all pregnancy losses, at least 25% of the women feel that they need professional help.  Often this need is unrecognized and unresolved mourning goes untreated. It may be that women do not feel that they should report or complain about loss through a miscarriage or abortion. Because they are not supposed to miss an early loss, they may feel awkward in talking to anyone about it.  The collusion of denial prolongs the mourning and incomplete grieving is more likely to end in depression.

     Abortions may be more difficult to mourn because abortion is considered too controversial to talk about. Possibly the public media's depiction of abortion as being hardly an important event makes women believe it is abnormal to grieve an aborted fetus.  Because it is an abortion, patients are often too embarrassed to broach the subject with their families.  Professionals may not be skilled enough or may be disinclined to deal with this type of loss.

     Abortions may result in more intense psychological conflict, partly because there may have been pressure to terminate her pregnancy which went against the woman's desire to have a child.  Conflict also occurs as she realizes that she has contributed to the loss.  The greater ambivalence and many complicated factors regarding the choice, make counselling for these kind of losses difficult.  With the pressure to abort early in a pregnancy, there is seldom time to deal with each of the many aspects which must be considered before a rational choice can be made.  The lack of partner support appears to contribute to a greater tendency to both miscarry and voluntarily abort a pregnancy.  The mother's hurt and anger at being neglected and/or rejected by her partner may be displaced onto the fetus.  There are also complex neurohormonal factors that may contribute to the rejection of the infant.  This and related findings will be discussed in a subsequent article.

Conclusion

     It appears that pregnancy losses of all types have a deleterious effect on women's health.  Although there is increasing attention paid to the effect of pregnancy losses, some receive more consideration than others. Women who miscarry or abort their pregnancies are less likely to obtain professional help than those with stillbirths.  This is most true of abortions, which may be most difficult to grieve, partly because of the intensity of the conflict, and partly because there are few people available who will help mothers deal with that kind of pregnancy loss.  Our results indicate that over 25% of women who have had pregnancy losses feel they need professional help.  Aborted women appear to require more and more sophisticated grief counselling than those who suffer other types of pregnancy loss.  They should not be neglected just because many professionals think the loss of an unborn child through termination is of little consequence.

     To maintain health and prevent illnesses related to immune dysfunction, it is important for health professionals to facilitate grieving all pregnancy losses, particularly those more intensely conflicted.  To prevent pregnancy losses, physicians should encourage partner support.  Whenever that is impossible, the physicians may be able to increase the rates of full term pregnancies by providing more support and encouragement themselves.

References

1. Emde R.N., Polak P.R. and Spitz R.A. "Anaclitic Depression In An Infant Raised In An Institution", J Am Acad Child Adolesc Psychiatry 4, 545-53, 1965.

2. Bowlby J. "Grief And Mourning In Infancy And Early Childhood", Psychoanal Study Child 15, 9-52, 1968.

3. Engel G.L. "Homeostasis, Behavioral Adjustment And The Concept Of Health And Disease." In Midcentury Psychiatry. (Edited by Grinker, R.R.) p.33-59. Thomas, Charles C., Springfield Illinois, 1953.

4. Lewis E. "Failure To Mourn A Stillbirth: An Overlooked Catastrophe", Brit J Med Psychol 51, 237-41, 1978.

5. Lewis E. "Mourning By The Family After A Stillbirth Or Neonatal Death", Arch Dis Child 54, 303-6, 1979.

6. Kennell J.H., Slyter H. and Klaus M.H. "The Mourning Response Of Parents To The Death Of A Newborn", N Engl J Med 283, 344-9, 1970.

7. Cullberg J. "Mental Reactions Of Women To Perinatal Death." In Proceedings of Psychosomatic Medicine in Obstetrics and Gynaecology, Third International Congress. Basel: Karger, 326-9, 1972.

8. Peppers L.G. and Knapp R.J. "Maternal Reactions To Involuntary Fetal/Infant Death", Psychiatry 43, 155-9, 1980.

9. Peppers L.G. and Knapp R.J.  Motherhood And Mourning. Praeger, New York, 1980.

10. Wolff J., Nelson P. and Schiller P. "The Emotional Reaction To A Stillbirth", Am J Obstet Gynecol 108, 73-6, 1970.

11. Giles P.F.H. "Reactions Of Women To Perinatal Death", Aust NZ Obstet Gynecol 10, 207-10, 1970.

12. Benfield D.G., Leib S.A. and Vollman J.H. "Grief Response Of Parents To Neonatal Death And Parent Participation In Deciding Care", Pediatrics 62, 171-7, 1978.

13. Clyman R.I., Green C., Rowe J., Mikkelson C. and Ataide L. "Issues Concerning Parents After The Death Of Their Newborn", Crit Care Med 8, 215-18, 1980.

14. Forrest G.C., Standish E., Baum J.D. "Support After Perinatal Death: A Study Of Support And Counseling After Perinatal Bereavement", Br Med J 285, 1475-9, 1982.

15. Leppert P.C. and Pahlka B.S. "Grieving Characteristics After Spontaneous Abortion: A Management Approach", Obstet Gynecol 64, 119-22, 1984.

16. Adler B. and Kushnick T. "Genetic Counseling In Prenatally Diagnosed Trisomy 18 and 21: Psychosocial Aspects", Pediatrics 69, 94-9, 1982. 

17. LaRoche C., Lalinec-Michaud M., Engelsmann F., Fuller N., Copp M. and Vasilevsky K. "Grief Reactions To Perinatal Death: An Exploratory Study", Psychosomatics 23, 510-11,514,516-18, 1982.

18. LaRoche C., Lalinec-Michaud M., Engelsmann F., et al. "Grief Reactions To Perinatal Death: A Follow-up Study", Can J Psychiatry 29, 14-19, 1984.

19. Wilson A.L., Fenton L.J., Stevens D.C. and Soule D.J. "The Death Of A Newborn Twin: An Analysis Of Parental Bereavement", Pediatrics 70, 587-91, 1982.

20. Peretz D. "Development, Object-relationships and Loss".  In Loss And Grief: Psychological Management In Medical Practice (Edited by Schoenbery, A.C., Karr D., Peretz D. and Kutscher A.H.), Columbia University Press, New York, 1970.

21. Peretz D. "Reaction To Loss".  In Loss And Grief: Psychological Management In Medical Practice (Edited by Schoenberg B., Karr A.C., Peretz D. and Kutscher A.H.),Columbia University Press, New York, 1970.

22. Schneiderman G. Coping With Death In The Family. Chimo Publishing, Toronto, 1979.

23. Kowalski K. "A Bereaved Parents Group: An Ethnographic Study", unpublished comprehensive examination paper. Boulder: University of Colorado, 1983.

24. Kowalski K. "Perinatal Loss And Bereavement", In Women's Health Vol. 3: Crisis And Illness In Childbearing. (Edited by Sonstegard L., Kowalski K. and Jennings B.), Grune and Stratton, a subsidiary of Harcourt, Brace, Jovanovich, New York, 1987.

25. Rowe J., Clyman R., Green C., Mikkelson C., Haight J. and Ataide L. "Follow Up Of Families Who Experience A Perinatal Death", Pediatrics 62, 166-70, 1978.

26. Lovell A. "Some Questions Of Identity: Late Miscarriage, Stillbirth And Perinatal Loss". Soc Sci Med 11, 755-61, 1983.

27. Stierman, E.D. (1987). "Emotional Aspects Of Perinatal Death", Clin Obstet Gynecol 30(2):352-61.

28. Kennell, J.H. Foreword in Borg, S. and Lasker, J. When Pregnancy Fails: Families Coping With Miscarriage, Stillbirth And Infant Death. Beacon Press, Boston, 1981.

29. Borg S. and Lasker J. When Pregnancy Fails: Families Coping With Miscarriage, Stillbirth And Infant Death. Beacon Press, Boston, 1981.

30. Ouimette J.  Perinatal Nursing: Care Of High Risk Mother And Infant. Jones and Bartlett, Boston, 1986.

31. Hawkins J.W., Gorvine B., Currier-Dagrosa C., Fleming P. and Schiffman R.F.  Postpartum Nursing: Health Care Of Women. Springer, New York, 1985.

32. Maddison D. "Relevance Of Conjugal Bereavement For Preventive Psychiatry", Br J Med Psychol 42, 223, 1968.

33. Parkes C.M. Bereavement: Studies Of Grief In Adult Life. International Universities Press, New York, 1972. 

34. Parkes C.M. "Bereavement", Brit J Psychiatry 146, 11-17, 1985.

35. Vachon M.L. "Grief And Bereavement Following The Death Of A Spouse", Can Psych A J 21, 35, 1976.

36. Lindemann E. "Symptomatology And Management Of Acute Grief", Am J Psychiatry 101, 141-48, 1944.

37. Kim M.J. "Classification Of Nursing Diagnoses", Proceedings of the Third and Fourth National Conferences. McGraw-Hill, New York, 1982.

38. Helmrath T.A. and Steinitz E.M. "Death Of An Infant: Parental Grieving And The Failure Of Social Support", J Fam Prac 6(4), 785-90, 1978.

39. Stringham J.G., Riley J.H. and Ross A. "Silent Birth: Mourning A Stillborn Baby", Soc Work 27(4), 322-27, 1982.

40. Vancouver Women's Health Collective. Miscarriage: You Are Not Alone.  Women's Reproductive Health Project, Vancouver, British Columbia, 1988.

41. Phipps S. "The Subsequent Pregnancy After Stillbirth: Anticipatory Parenthood In The Face Of Uncertainty", Int J Psychiatry Med 15, 243-64, 1985-86.

42. Mandell F. and Wolfe L.C. "Sudden Infant Death Syndrome And Subsequent Pregnancy", Pediatrics 56, 774-76, 1975.

43. Harmon R.T., Glicken A.D. and Siegel R.E. "Neonatal Loss In The Intensive Care Nursery: Effects On Maternal Grieving And A Program For Intervention", J Am Acad Child Psychiatry 23, 68-71, 1983.

44. Haire D. and Haire J.  Implementing Family-centered Maternity Care Nursing.  International Childbirth Education Association, Milwaukee, 1975.

45. Interprofessional Task Force on Health Care of Women and Children. Development Of Family-centered Maternity/newborn Care In Hospitals.  The National Foundation/March of Dimes, White Plains, 1978.

46. Sonstegard L.J., Kowalski K.M. and Jennings B. Women's Health, Vol. 2: Childbearing.  Grune and Stratton, a subsidiary of Harcourt, Brace Jovanovich, New York, 1987.

47. Klaus M. and Kennell J. Maternal-Infant Bonding. C.V. Mosby, St. Louis, 1976.

48. Kowalski K. Perinatal Death: An Ethnomethodological Study Of Factors Influencing Parental Bereavement. Unpublished doctoral dissertation. Boulder: University of Colorado, 1984.

49. Kowalski K. and Osborn M. "Helping Mothers Of Stillborn Infants To Grieve", MCN: A J Mat Child Nurs 2, 29-32, 1977.

50. Swanson-Kaufman K. The Unborn One: A Profile Of The Human Experience Of Miscarriage. Unpublished doctoral dissertation. Denver: University of Colorado, 1983.

51. Kellner K.R., Donnelly W.H. and Gould S.D. "Parental Behaviour After Perinatal Death: Lack Of Predictive Demographic And Obstetric Variables", Obstet Gynecol 63, 809-14, 1984.

52. vanGennep A. The Rites Of Passage. University of Chicago Press, Chicago, 1960.

53. Mandelbaum D.E. "Social uses of funeral rites", In Meaning of Death. (Edited by Feifel H.) McGraw-Hill, New York, 1959.

54. Kowalski K. "Managing Perinatal Loss", Clin Obst Gynecol 23, 1113-23, 1980.

55. Benfield D.G., Leib S.A. and Vollman G.H. "Grief Responses Of Parents To Neonatal Death And Parent Participation In Deciding Care", Pediatrics 62, 171-7, 1978.

56. Freeman E.W. "Abortion: Subjective Attitudes And Feelings", Fam Plann Persp 10, 150-55, 1978.

57. Ashton J.R. "Psychological Outcome Of Induced Abortion", Br J Ostet Gynecol 87, 1115-122, 1980.

58. Lane. Report of the Committee on the Working of the Abortion Act, Vol. 1. Report. CMND, London: 55-79, HMSO 1974.

59. Rovinsky J.J. "Abortion Recidivism", J Obstet Gynecol 39(5), 649-59, 1972.

60. Osofsky J.D. and Osofsky H.J. "Teenage Pregnancy: Psychological Considerations", Clin Obstet Gynecol 21(4), 1161-1173, 1978.

61. Donnai P., Charles N. and Harris R. "Attitudes Of Patients After Genetic Termination Of Pregnancy", Br Med J 282, 621-22, 1981.

62. Figa-Talamanca I. "Abortion And Mental Health" In Abortion And Sterilization: Medical And Social Aspects. (Edited by Hodgson J.E.) Academic Press, London, 1981.

63. Belsey E.M., Greer H.S., Lai S., Lewis S.C. and Beard R.W. "Predictive Factors In Emotional Response To Abortion; Kings Termination Study", Social Sci and Med 11:71-82, 1977.

64.  Jacobs D., Gacia C.R., Rickels S.K., Preucel R.W. "A prospective study of the psychological effects of therapeutic abortion". Comparative Psychiatry 15, 324-34, 1974.

65. Dunlop J.Z. "Counselling patients requesting an abortion". Practitioner 220, 847-52, 1978.

66. Shusterman L.R. "Predicting the psychological consequences of abortion". Soc Sci Med 96, 683-89, 1979.

67. Broome A. "Termination of pregnancy". In Psychology and gynaecological problems(Edited by Broome A. and Wallace L.) Tavistock, London, 1984.

68. Colman A.D., Colman L.L.  Pregnancy: The Psychological Experience, Herder and Herder, New York, 1971.

69. Klaus M.H., Kennell J.H. Maternal Infant Bonding. C.V. Mosby Co., St. Louis, 1976.

70. Kumar R., Robson K. "Previous induced abortion and ante-natal depression in primiparae: A preliminary report of a survey of mental health in pregnancy".  Psychol. Med., 8, 711-715, 1978.

71. Ney P.G., Moore C., McPhee J., Trought P. "Child abuse: a study of the child's perspective".  J Child Abuse Neglect, 10,  510-8, 1986.

72. Brazelton T.B. "Effect of maternal expectations on early infant behaviour".  Early Child Dev Care, 2, 259-273, 1973.

73. Siegel J.M. and Kuykendall D.H. "Loss, widowhood and psychological distress among the elderly".  J Consult Clin Psychol 58, 519-24, 1990.

74. Harris T.O., Brown G.W., Bifulco A.T. "Depression and situational helplessness/mastery in a sample selected to study childhood parental loss".  J Affective Disord 20, 27-41, 1990.

75. Irwin M., Daniels M., Bloom E.T., Smith T.L. and Weiner H.     "Life events, depressive symptoms and immune function".  Am J Psychiatry 144, 437-41, 1987.

76. Kiecolt-Glaser J.K., Fisher L.D., Ogrocki P., Stout J.C. et al. "Marital quality, marital disruption and immune function".  Psychosom Med 49, 13-34, 1987.

77. Bradley C.F. "Abortion and subsequent pregnancy".  Can J Psychiatry 29, 494-8, 1984.

78. Klaus M.H., Kennell J.H. Maternal-Infant Bonding. CV Mosby, St. Louis, 1976.

79. Ney P.G., Fung T. and Wickett A.R.  "The relationship between induced abortion and child abuse and neglect: four studies".  In press.  Pre & Peri-Natal Psychology Journal, vol. No.1, June 1993.

80. Berkeley D., Humphreys P.L., Davidson D. "Demands made on general practice by women before and after an abortion".  J Royal Coll Gen Pract 34, 310-5, 1984.