Pregnancy & Infant Loss Awareness Month
New Assessment Tool for Grief After Reproductive Loss: A Review
By: Jeanmarie Petersen, DO
Director’s Note: Although research and resources continue to evolve for couples experiencing miscarriage, a more integrated approach to patient care is needed in this setting. We conclude our 3-week series with a study that highlights the importance of addressing grief after miscarriage. In a summary of research published by Buskmiller et al [1] titled, “Validation of a Brief Measure for Complicated Grief Specific to Reproductive Loss,” FACTS elective student Jeanmarie Villata emphasizes the value of listening to these patients. She also discusses the complexity of assessing patients for grief and effective screening methods to support mental health.
Introduction
The topic of complicated grief after reproductive loss has been neglected in research. Complicated grief is a pathological grief that causes anxiety, depression, and other symptoms that affect daily living. Long term, complicated grief can increase the risk of cardiovascular disease, weight gain, and suicide. [1] Currently, the Edinburg Postpartum Depression Screening (EPDS) is used to screen for mental health concerns after reproductive loss. Yet, this screening tool does not address the intricacy of complicated grief that often accompanies loss. The Perinatal Grief Scale (PGS) is another instrument used for perinatal loss but the lengthy questionnaire limits its clinical applications. [1] This study aims to address the lack of proper screening questionnaires for complicated grief after reproductive loss by modifying a validated brief grief questionnaire to adapt it specifically to reproductive loss.
Methodology
A group comprised of two physicians, a nurse, and a patient advocate modified the Brief Grief Questionnaire (BGQ) to create a 5-item questionnaire with more inclusive language related to grief after miscarriage, stillbirth, neonatal death, infant death, selective reduction or termination of pregnancy. This 5-question tool is referred to as the reproductive grief screen (RGS).
“The Brief Grief Questionnaire (was modified) to create a 5-item questionnaire with more inclusive language related to grief after miscarriage, stillbirth, neonatal death, infant death, selective reduction or termination of pregnancy.”
A total of 140 women from the University of Texas were recruited in person and via social media to validate the questionnaire alongside validated surveys for anxiety (7-item Panic Disorder Severity Scale, PDSS), trauma (22-item Impact of Events Scale), and reproductive grief and depressive symptoms (33-item Perinatal Grief Scale, PGS). The questionnaire assessed symptoms such as interference with daily life, avoidance of daily life, reminders of loss, and trouble connecting with support. Data analysis involved chi square tests, t-tests, Mann-Whitney U test, the root mean square error of approximation (RMSEA), comparative fit index (CFI), and standardized root mean squared residuals (SRMR). These statistical data were used to assess the validity of the new questionnaire.
Results
Most women were recruited for the study via social media (65%), and the average age of those enrolled was 35 years. The study participants had a reproductive loss within 2 years of the study; 81% of them experienced the loss prior to delivery. Over half of respondents (51%) had a score > 4, which is a positive screen for the BGQ.
Regarding the RGS, scores and item means did not differ by race, a supportive religion or culture, or the loss of more than one embryo or fetus. Reproductive loss after delivery was associated with an increase in reminder symptoms as well as a higher RGS score. Participants with a subsequent pregnancy after loss had a lower RGS score, though suboptimal timing of a subsequent pregnancy was associated with higher RGS scores. Participants who reported more reminder symptoms were associated with treatment with psychiatric medication.
“Reproductive loss after delivery was associated with an increase in reminder symptoms as well as a higher reproductive grief screen score.”
Although the RGS was correlated with measuring comparable items as the PGS, it did not assess nonspecific anxiety or inadequate support as the PGS does. This met the Fornell-Larcker criterion which verifies the discriminant validity of investigator-designed survey instruments.
Discussion
This study helped to develop a more targeted screening tool for patients with complicated grief after reproductive loss. The 5-question survey met the criteria for discriminant validity while assessing various symptoms associated with other mood disorders. The results suggest this could be a valuable tool to screen patients after reproductive loss. In a population where grief is so prevalent, proper screening can lead to much better outcomes. Yet, to implement the study questionnaire within a larger population, the reliability, sensitivity, and specificity of the RGS need to improve. Further research could be done to refine the PGS within the RGS to address support and non-specific anxiety in this setting.
“This study helped to develop a more targeted screening tool for patients with complicated grief after reproductive loss … (which) can lead to much better outcomes.”
This pilot study has significant implications for the use of screening tools to assess mental health in the reproductive loss community. A strength of this research was using different questionnaires to validate as well as detect flaws within the questionnaire. This tool not only has potential to assess mental health concerns among people who have experienced reproductive loss but could also be a resource in post-treatment evaluation. This research provides valuable contributions to further promote mental health evaluation in women’s health.
References
[1] Buskmiller, C., Grauerholz, K. R., Bute, J., Brann, M., Fredenburg, M., & Refuerzo, J. S. (2023). Validation of a Brief Measure for Complicated Grief Specific to Reproductive Loss. Cureus, 15(4), e37884. doi:10.7759/cureus.37884
ABOUT THE AUTHOR
Jeanmarie Petersen, DO
Jeanmarie Petersen, DO is a first year family medicine resident at Atlanticare Regional Medical Center in Atlantic City, NJ. She completed her undergraduate education at the University of Scranton in Scranton, PA and her medical education at Rowan-Virtua SOM in Stratford, NJ. She enrolled in the FACTS elective to gain a better understanding of natural family planning methods to better counsel patients on their reproductive health choices.