Grief in fars and turkmen women experiencing perinatal loss

Abstract

Introduction

Perinatal grief is one of the most stressful events in women’s lives and can be influenced by various factors, such as cultural and ethnic background. Gorgan City in Golestan province is populated by two main ethnic groups, Fars and Turkmen, with differences in various dimensions such as language, clothing, and customs. The study aimed to compare grief among Fars and Turkmen women who experienced perinatal loss in Gorgan − 2020–2021.

Materials and methods

The present cross-sectional study was conducted among 860 Fars and Turkmen mothers with a history of PL. A convenience sampling method was used. Participants with inclusion criteria completed the questionnaire, including demographic information and the Persian version of the Perinatal Grief Scale. A chi-square test, univariate and multiple logistic regressions were used via SPSS 16.

Results

Fars women experienced severe grief more than Turkmen women (26% vs. 18.4%, p = 0.009). The univariate logistic regression showed that the variables of ethnicity, women’s education level, and number of living children were significantly associated with the intensity of grief. After controlling for the covariates, multiple logistic regression showed that only the number of live children had a significant effect on the intensity of perinatal grief. In other words, the risk of severe grief was 79%, 77%, and 76% lower in women with one, two, and three or more children than women with no children, respectively.

Conclusion

The frequency of severe grief was higher in Fars women than in Turkmen. The severe grief was also associated with childlessness. It is suggested that the above differences be taken into account in providing care services to bereaved mothers.

Background

Perinatal loss (PL), including spontaneous abortion, stillbirth, and infant death [1], is a common public health problem in different societies; one in 10 women will experience PL during their lifetime [2]. The death of a child is not part of the natural order of life, as children are not expected to die before their parents. And the complex identity shift it brings for parents can make their grieving process a unique experience [3].

Following the loss of a fetus or baby, most women experience normal (non-pathological) grief reactions, such as crying, confusion, anxiety, regret, fear and a temporary impairment in the ability to function daily, seen in the avoidance of social activities. About 25–30% of them may experience intense and long-term reactions, known as complicated grief. It is a serious problem for people’s physical and mental health [4], with more destructive, pervasive or prolonged symptoms than a normal grief reaction [5], including social withdrawal [6], post-traumatic stress disorder [7], as well as suicidal thoughts and behaviors [8].

A high degree of grief (referred to in this study as severe grief) can be considered to reflect a high vulnerability to developing further and more complicated grief. It is therefore essential to identify individuals with severe grief so that they can receive special attention and support if needed [9].

In Iran, some family members who care for a bereaved mother believe that she should not even think about her lost child. Others, due to their lack of knowledge about the grieving process, ask the mother not to cry and consider it inappropriate to cry for the fetus. In the health system of Iran, grieving mothers receive only the same care as mothers who have given birth to a living child [10]. The psychological advice given to bereaved mothers is often based on staff experiences and can sometimes lack scientific grounding [11]. Therefore, due to the lack of any formal training, care and support for bereaved mothers is the missing link in the system [10, 12]. It seems that healthcare providers are unable to properly communicate with bereaved parents and provide the emotional and psychological support they need. Some participants reported that healthcare providers disregarded their dignity and maternal feelings by saying that they did not even know who their doctor was [12].

Although grief is a universal phenomenon and people experience common dimensions or similar cultural rituals surrounding loss, individuals’ widespread manifestations and responses can be influenced by their backgrounds and cultural beliefs [13]. Cultures and religions have their unique ways of coping with the death of a loved one. From funeral customs to mourning practices, many different rituals are observed, depending on the child age, parent choice, culture and religion [14].

There is limited literature on the rituals following the death of a newborn or child. There are variations in the ceremonies carried out for babies and children compared to those performed for adults. These ceremonies are usually shorter, fewer prayers are offered, and the attendance of family and friends is often less [15]. Some parents perform activities such as lighting candles, listening to music, and releasing balloons or butterflies at the funeral or other memorial event [14]. In some cultures, parents struggle with the silence and taboo surrounding perinatal loss and do not have a social space to legitimize and express their feelings [16]. Therefore, cultural norms can help or hinder people in grieving and coping methods, and affect the intensity of grief [17, 18].

Perinatal loss is one of the most emotionally challenging experiences women encounter, and reactions to death, along with expressions of grief, vary significantly across cultures [17]. Furthermore, Gorgan is a multicultural city where two ethnic groups, Fars and Turkmen, coexist with their distinct customs and traditions [19]. However, no studies have examined the differences in perinatal grief between Fars and Turkmen women. Consequently, this study was designed and conducted to investigate the intensity of perinatal grief among these two ethnic groups: Fars and Turkmen.

Method

Participants and procedure

The present cross-sectional-analytical study with “Ethics approval number: IR.GOUMS.REC.1398.342” was conducted among 860 Fars (n = 430) and Turkmen (n = 430) women who had a history of PL (miscarriage, stillbirth, and infant death) in one year before in Gorgan City. The number of each type of perinatal loss was exactly the same in both groups (Table 2).

The study used the convenience sampling method. According to the official correspondence, a list of women who had experienced perinatal loss (up to one year before the start of sampling) was obtained from the Nab¹ system of the health dean of Gorgan University of Medical Sciences. In this system, the health files of households are electronically registered. This list included the contact numbers and the centers where the women were covered. After obtaining the written informed consent forms from the participants, they were asked to complete the demographic form and the Persian version of the perinatal grief scale (PGS-P) [20].

Data analysis

Data were analyzed using SPSS Ver.16 software. The normality of data distribution was confirmed by Shapiro-Wilk’s test. Analytical analyses for quantitative variables were reported via mean and standard deviation but descriptive statistics of the qualitative variables were presented through frequency and percentage. A chi-square test was also run to compare qualitative variables between the two study groups. Logistic regression was employed to adjust the effect of the demographic variables (ethnicity, education level, spouse’s education, pregnancy status, and the number of living children) on the intensity of grief.

Measures

Demographic form

This form included the participants’ ethnicity, place of residence, length of residence, age, education level (of the mother and her husband), occupation (of the mother and her husband), length of marriage, and fertility information including gestational age at the time of loss, previous pregnancies, previous pregnancy losses, the time since the loss, and the number of children.

Persian version of the perinatal grief scale

The original American Perinatal Grief Scale was designed by Toedter and colleagues with 104 items with responses on a 5-point Likert scale [21]. It was then modified to a 33-item measure with three subscales [22]. The PGS-P is a 32-item instrument including three domains of active grief (11 items), adjustment problems (11 items), and hopelessness (10 items). This instrument was translated into Persian and its validity and reliability were evaluated and confirmed. Cronbach’s alpha coefficient was 0.95 for the whole scale and ranged from 0.84 to 0.89 for its subscales [20]. The attainable total scores range from 32 to 160; a higher score shows that the respondent is experiencing greater levels of grief. A score of ˃ 82 can be considered as the clinical attention point for screening those who have severe grief [9].

Results

In the present study, there was no statistically significant difference in the average age and duration of marriage of women in two ethnic groups (Table 1).

Table 1 Mean comparison of qualitative demographic characteristics in two ethnic groups of women with a history of PL

The results showed significant statistical differences between the two groups on women’s education, spouse’s education, pregnancy and the number of living children (Table 2).

Table 2 Frequency comparison of qualitative demographic characteristics in two ethnic groups of women with a history of PL

The mean and standard deviation of the total PL grief scores were 75.75 ± 15.67 and 71.49 ± 15.01 for the Fars and Turkmen ethnic groups, respectively (p = 0.001).

A significant difference in experiencing severe grief was observed between Fars and Turkmen women. The results show that Fars women are more prone to suffering from severe grief than Turkmen women (Table 3).

Table 3 Comparison of the frequency of severe grief in women of two ethnicities with a history of PL

To control for the effect of demographic variables (ethnicity, women’s education level, spouse’s education level, pregnancy status, and the number of living children) on the intensity of grief, univariate and multiple logistic regressions were run. In the univariate logistic regression model, the variables of ethnicity, women’s education level, and number of living children were significantly associated with the intensity of grief. In other words, the risk of severe grief was about 60% higher in Fars than in Turkmen women (OR = 1.61(CI: 1.05, 2.46), p = 0.02) and about 83% higher in women with higher education than in those with low education (OR = 1.83(CI: 1.10, 3.03), p = 0.01). However, the risk of severe grief was 80%, 79%, and 78% lower in women with one child (OR = 0.20 (CI: 0.12, 0.35), p < 0.001), two children (OR = 0.21(CI: 0.12, 0.37), p < 0.001), and three children and more (OR = 0.22 (CI: 0.10, 0.50), p < 0.001) compared to women with no children, respectively. After running the multiple logistic regression and controlling for the covariates, the findings corroborated that only having the living child had a significant effect on the intensity of PL grief so that the risk of severe grief compared to non-severe grief was 79%, 77%, and 76% lower in women with one child, two children, and three and more children than in women without child (Table 4).

Table 4 The effect of demographic and ethnicity factors on severe grief using univariate and multiple logistic regression in women of two ethnicities with a history of PL

Discussion

This study aimed to compare grief among Fars and Turkmen women who experienced perinatal loss in Gorgan City. The findings showed that Fars women experience more severe grief than Turkmen women. Limited studies have examined PL grief among different ethnic groups, and no study in this field was found in Iran; one of the reasons for this could be that the PGS-P scale has only been translated and validated in recent years [9, 20].

Similar studies in other countries are also limited. A descriptive-analytical study noted that severe grief in Brazilian women was significantly higher than that of Canadian women. The high prevalence of severe grief in Brazilian women was mainly attributed to the lack of professional support in dealing with grief in addition to lower levels of education, marital satisfaction, and religious practices [23]. According to the above findings and the present study findings, it seems that PL grief can be influenced by cultural and ethnic differences [23].

Cowles and Rogers theorized that different cultures have specific grief norms. Each cultural group has its belief system about death, which is related to the rituals or behavioral styles as well as the expected social and cultural behaviors in response to loss and grief [24]. Similarly, Egesi also concluded that women’s response to PL grief depends on the cultural resources available in society [13].

The findings also showed that not having children has a significant impact on the frequency of severe grief. The desire to have children and the appropriate number of children are different in women of varied ethnicities in Iran. The Turkmen people prefer to have more children. Fewer than a quarter of Turkmen women are satisfied with one or two children, so the preference for one child among them is only about 1%, while Kurdish and Turkish ethnic groups prefer one or two children [25]. Therefore, this variety in vulnerability to severe grief can be attributed not only to ethnicity but also to different reproductive preference attitudes of the Fars and Turkmen groups. In other words, having more children buffers the impact of perinatal loss. Therefore, reduces the likelihood of experiencing severe grief. In line with the results of the present study, some researchers indicated that the number of living children had a significant negative relationship with the total score of grief after loss [26]. Women without children had significantly higher active grief than women with children [27]. Three months after perinatal loss, the grief score mean was higher in women who did not have another living child [28]. The number of living children was reported to be the best predictor of reducing women’s perinatal grief scores and contributing to their psychological well-being [29]. The above-mentioned findings, in the same line with the current research, indicate that having a living child plays a crucial role in reducing the grief score after birth so that not having a living child increases the possibility of a person facing a higher degree of grief [26].

It is important to emphasize that this finding relates to having a living child at the time of loss, not having a child after the loss. Therefore, social pressure to get pregnant again after a loss not only is not a protective factor but also may even be a risk factor for complicated grief [3]. It was reported that women who gave birth to another child shortly after the loss, and those who planned to replace their previous child with the current one, have been shown to have significantly higher levels of grief. This result supports the idea that although most families may resort to another pregnancy to cope with their grief, a new pregnancy may disrupt women’s grieving process and make them more susceptible to severe or chronic grief [30].

Given the role of ethnicity on the severity of grief in this study, and the fact that ethnicity as a social and cultural construct, plays a decisive role in the formation of childbearing behaviors [31], ethnic differences in reproductive preferences and behaviors can be attributed to the influence of ethnic values ​​and norms. However, the reasons for these differences are unclear. It indicates the need for further research [32].

This study was one of the few studies on the topic of perinatal grief, especially in two ethnic groups in Iran. Given the importance of women’s health as a vulnerable group in the priorities of the health system of each region, focusing on women was one of the limitations of the present study.

Conclusion

The frequency of severe grief was higher in Fars women than in Turkmen. The severe grief was also associated with childlessness. Although ethnic values ​​and norms can explain the differences in childbearing between the two ethnicities, the reasons for the differences in values ​​require further studies. It is suggested that the above differences be taken into account in providing care services to bereaved mothers.