EFFECTS OF MARITAL SATISFACTION AND RITUAL UTILITY ON BEREAVEMENT EXPERIENCE IN ABORTION

ABSTRACT

Objective:

The present study analyzed the effects of the use and perceived usefulness of bereavement rituals and marital satisfaction on perinatal bereavement.

Method:

74 Portuguese women who attended a public hospital in Porto - Portugal, after experiencing one or more abortions in 2019, responded to a self-report survey. The effects of ritual utility and marital satisfaction on bereavement experience, as well as interaction effects, were analyzed.

Results:

With adjustment to bereavement after pregnancy loss as the dependent variable, a negative effect of marital satisfaction (b=.33) and a positive effect of ritual utility (b =.46) were observed. No significant moderation effect was observed.

Conclusion:

This study highlights the importance of addressing bereavement rituals and conjugality in providing emotional support for the loss, with the figure of the nurse being paramount in the contexts of abortion and neonatal loss.

DESCRIPTORS:
Abortion; Bereavement; Reproductive Health; Conjugal Relationship; Maternal Bereavement.

RESUMO

Objetivo:

O presente estudo analisou os efeitos da utilização e da percepção de utilidade dos rituais de luto e da satisfação conjugal no luto perinatal.

Método:

Responderam a um inquérito de autorrelato, 74 mulheres portuguesas que recorreram a um hospital público no Porto - Portugal, após vivenciarem um ou mais abortamentos em 2019. Foram analisados os efeitos da utilidade dos rituais e da satisfação conjugal na vivência do luto, bem como os efeitos de interação.

Resultados:

Tendo o ajustamento ao luto após a perda gestacional como variável dependente, observou-se um efeito negativo da satisfação conjugal (b=.33) e um efeito positivo da utilidade dos rituais (b =.46). Não foi observado um efeito significativo de moderação.

Conclusão:

Este estudo vem realçar a importância da abordagem dos rituais de luto e da conjugalidade no apoio emocional à perda, sendo primordial a figura do enfermeiro nos contextos do aborto e da perda neonatal.

DESCRITORES:
Abortamento; Luto; Saúde Reprodutiva; Relacionamento Conjugal; Luto Materno.

RESUMEN

Objetivo:

El presente estudio examinó los efectos del uso y la utilidad percibida de los rituales de duelo y la satisfacción marital en el duelo perinatal.

Método:

74 mujeres portuguesas que acudieron a un hospital público en Oporto - Portugal, después de experimentar uno o más abortos en 2019, respondieron a una encuesta de autoinforme. Se analizaron los efectos de la utilidad ritual y la satisfacción marital en la experiencia del duelo, así como los efectos de interacción.

Resultados:

Con la adaptación al duelo tras la pérdida del embarazo como variable dependiente, se observó un efecto negativo de la satisfacción marital (b=.33) y un efecto positivo de la utilidad ritual (b=.46). No se observó ningún efecto de moderación significativo.

Conclusión:

Este estudio pone de manifiesto la importancia de abordar los rituales del duelo y la conyugalidad en el apoyo emocional a la pérdida, siendo la figura de la enfermera primordial en los contextos del aborto y la pérdida neonatal.

DESCRIPTORES:
Aborto; Aflicción; Salud Reproductiva; Matrimonio; Duelo Materno.

INTRODUCTION

Just half a century ago, abortion was invisible, minimized and undervalued in society¹. However, scientific interest in the abortion experience has been emerging, especially in the last 20 years, and it has been associated with long-lasting psychological consequences².

Abortion constitutes a stressful life experience characterized by the unexpected loss of a desired child³. Etiologically, it is classified as spontaneous abortion when it occurs naturally and without deliberate interference, or as medical termination when it is voluntarily induced⁴. According to the World Health Organization (WHO), abortion is the termination of pregnancy before the beginning of the perinatal period, which begins after 28 completed weeks of gestation.

Abortion can be early or late depending on the gestational time or age, the time being expressed in weeks since the last menstrual period. This classification varies considerably, and the American College of Obstetricians and Gynecologists6 defines early abortion as that which occurs in the first 12 weeks of pregnancy, while the WHO classifies abortion as early when it occurs before 13 weeks of pregnancy, and late when it occurs between 13 and 22 weeks.

The way women react after a loss is seen as a continuous process that reveals emotional reactions over time⁴. In this sense, the authors verified that women reveal higher levels of stress immediately after the loss. However, they also indicate that after six, 16, and 52 weeks, these feelings persist moderately. There is a significant percentage of women who suffer psychological disorders after miscarriage (abortion) and, although their incidence decreases with time, it maintains a prolonged persistence³.

Parity or the presence of children may be an important predictor of bereavement intensity after a miscarriage (abortion)⁴. Several studies confirm that childless women report higher levels of bereavement after an abortion compared to women who already have children⁷, a result identical to that found for depressive symptoms⁸. Age at the time of abortion may also be an important predictor in grief, as younger women reported higher levels of bereavement⁹. Age may be inversely associated with abortion bereavement, as maturity is associated with better coping strategies. Thus, it is a predictor of bereavement as higher age is a protective factor against depressive and bereavement symptoms⁸.

Despite scant research, some studies claim that gestation time is not a predictor of adult psychosocial adjustment¹⁰, while others support the idea of gestational age being important in adjustment after an abortion⁷, ⁹, ¹¹. Recent evidence has shown that couples with early miscarriage showed less distress than couples with late miscarriages in the first trimester, as well as couples who suffered a fetal death in the second trimester², ⁹. In addition, couples who experienced a late loss reported higher levels of guilt and isolation when compared to those who experienced an early loss. These results are congruent with the study by Franche¹¹, who revealed a late loss as a predictor in the difficulty in coping with loss, being associated with increased psychological distress. Such finding justifies considering gestational age as a predictor in miscarriage, since the literature is neither recent nor consensual.

Bereavement is a normal, healthy, dynamic, universal, and individual response to the loss of an individual¹². In the case of an abortion, bereavement can be a complex and difficult task, representing an unexpected death when a new life is expected. And although there is no visible child, the memories and desired experiences are equally grieved¹³. The impact of an abortion, seen as a traumatic incident, entails difficulties in adjustment. Especially in one’s emotional adjustment, including bereavement and depression. Thus, couples go through a grieving (bereavement) process. This grieving, although normative, compromises personal and affective functioning, causing reactions of anxiety, restlessness, irritability, depression, sleep disturbances, and concentration difficulties¹³.

One of the strategies to deal with the loss is using bereavement rituals¹⁴, defined as an intentional and purposeful action whose objective is to make the individual acknowledge a loss. Bereavement rituals are any activity - sacred, public, or private, repeated, or one-time - that includes symbolic expressions of a combination of emotions, thoughts, and beliefs, with special meaning for those practicing them¹⁵. In many cases the practice of these rituals involves the use of objects, such as photographs, letters, gifts, clothes, jewelry, or other symbols that allow the bereaved parents to represent the baby or their relationship with him/her¹⁶. Rituals can be important psychological factors in the bereavement process because they provide a separative function - becoming aware of the death, and an integrative function - guiding the person to reorganize his or her life¹⁷. In addition, rituals are beneficial because the’y create the opportunity to recognize and legitimize the emotional change, validate the loss, and accept the separation from the loved one¹⁶. Despite the gaps identified in the literature, some studies refer that the adjustment to mourning may be facilitated by the performance of post-funeral rituals and that the accomplishment of these can have a significant beneficial impact¹⁵.

Another factor that mitigates the impact of pregnancy loss is the quality of the couple’s relationship and the support provided by their partners¹⁸, and the low quality of the marital relationship is associated with compromised psychological adjustment in women who suffered recurrent pregnancy loss¹⁹. Along with other studies¹¹, ²⁰, it was also found that women with lower marital satisfaction presented higher levels of anxiety and depression.

The present study aimed to: (a) to verify differences in the use and usefulness of rituals and in the experience of mourning after abortion according to relevant socio-demographic factors, such as gestational age, chronological age, parity and academic qualifications; (b) to verify the existence of significant associations between the usefulness of rituals, marital satisfaction and the experience of bereavement after abortion; and c) to verify if the relationship between rituals usefulness and perinatal bereavement is moderated by marital satisfaction, that is, if the relationship between rituals usefulness and bereavement adjustment ceases to be significant for those who perceive a high marital satisfaction.

METHOD

Cross-sectional study conducted in Porto, Portugal. Participation had the following inclusion criteria: a) age 18 years or older; b) consent to participate voluntarily; c) living in a marital relationship (marriage or stable union) for at least two years; d) having experienced at least one miscarriage or neonatal death, spontaneous or for medical reasons, in the last 24 months. Seventy-nine women completed the questionnaire; five were excluded for not being in a marital relationship. The final sample consisted of 74 women whose sociodemographic characteristics are presented in Table 1.

The questionnaire used was developed in an online platform and disclosed through the website https://perdagestacional.fpce.up.pt/ Besides a sociodemographic questionnaire, containing data such as age, marital status, time in a relationship, income, nationality, profession, and academic qualifications, the following measurement instruments were used.

The Bereavement Activities Questionnaire¹⁵,²¹ quantifies the usefulness of grief rituals through 68 items, assessed on a five-point Likert scale and organized into three subscales: the activities/rituals that the subjects participated in to help them deal with their bereavement process; the aspects of the rituals that they considered useful in the bereavement process and the positive results of participating in these rituals. For adaptation to the context of pregnancy loss, 15 items from the activities’ subscale and 18 from the positive outcomes’ subscale were used. This version required a validation on the structure of the questionnaire, entitled “Perinatal Bereavement Rituals and Resignification Questionnaire” (Appendix I). Exploratory factor analysis revealed a solution consisting of three factors explaining 50% of the variance: ‘Bereavement Rituals/Activities’, referring to the performance and usefulness of commonly used grief rituals in situations of gestational loss or fetal death (α = 0.90), ; ‘Loss Resignification’, assessing the effects of acceptance of the loss (α = 0.78); and ‘Individual Resignification’, accessing the positive effects of grief on individual psychological adjustment (α = 0.88).

The Relationship Assessment Scale²²-²³ is composed of seven items whose objective is to assess marital relationship satisfaction. Each item is rated on a five-point Likert-type scale, where the higher the score, the greater the satisfaction with their marital relationship. The scale presents a high level of internal consistency (α = 0.86), and in our sample this value was 0.92.

The short version of the Perinatal Grief Scale²⁴-²⁵ was developed specifically to assess the grief of a perinatal loss. It is composed of 33 items, clustered in three dimensions (Active Grief, Coping Difficulties, and Hopelessness), and with a four-point Likert-type response format (zero = strongly disagree, four = strongly agree). In its original version (TOEDTER, LASKER, and ALHADEFF, 1988) the scale has 84 items and a highly satisfactory construct validity revealing a high level of internal consistency (α = 0.97). In this study, this scale revealed a Cronbach’s Alpha value of 0.97, with good internal consistency in the dimensions of Active Grief (α = 0.89), Coping Difficulties (α = 0.93) and Despair (α = 0.93).

For the statistical analysis of data, the Statistical Package for Social Sciences - SPSS, version 26 software was used. The normality of the data distribution was verified (|Sk| < 3 and |Ku| < 8-10; as well as the existence of outliers, and no extreme values were observed. Student’s t-tests for independent samples were used for differences between groups (p. ≤ .05). Finally, to verify the existence of moderation, a PROCESS, version 3.5²⁵ macro analysis was performed.

The procedures of the present study respected the Declaration of Helsinki and were approved by the Committee of the Faculty of Psychology and Education Sciences of the University of Porto [Ref. 2018-11-1]. Collection occurred between November 2019 and April 2020.

RESULTS

Table 1 shows the sociodemographic characteristics of the sample. The participants had a mean age of 35 years (M = 35.72; SD = 7.09), ranging from 23 to 54 years. About 60 participants (82.4%) were of Portuguese nationality, with the remaining being of Brazilian nationality. Fifty women were married (67.6%), and 49 had attended college (66.2%). Sixty-nine pregnancies occurred spontaneously (90%), and only 5 (6.8%) were the result of medically assisted reproduction techniques. Forty-six participants (62.2%) experienced one gestational loss, 16 (21.6%) experienced two losses, and 12 (16.3%) experienced recurrent gestational losses (≥ three miscarriages). Gestational and perinatal losses occurred between three and 41 weeks (M = 14.07; SD = 9.92).

Table 1
Sociodemographic characterization of the sample (n = 74). Porto, Portugal, 2019 - 2020

Variables	n	%
Age <35	42	56.8
Age >35	32	43.2
Nationality
Portuguese	61	82.4
Brazilian	13	17.6
Marital Status
Married	50	67.6
Fact Union	24	32.4
<12th year	25	33.8
>12th year	49	66.2
Type of pregnancy
Spontaneous Pregnancy	69	93.2
Treatments	5	6.8
Type of gestational loss
First trimester spontaneous abortion	62	83.8
Neonatal death after 23 weeks	12	16.2
Neonatal loss in the first 7 days after birth	4	5.4
Neonatal loss at 28 days after birth	2	2.7
Authorized medical termination	2	2.7
Voluntary termination of pregnancy (due to fetal anomaly)	19	25.7
Total gestational losses
1 loss	46	62.2
2 losses	16	21.6
>3 losses (recurrent abortion)	12	16.3
Parity
Nulliparous	40	54.1
Single/multiparous	34	45.9
Having Children in a Current Relationship
The fruit of the current relationship	32	43.2
From a previous relationship	2	2.7
From the partner’s previous relationship	2	2.7

Source: Authors (2022)

Table 2 shows the descriptive statistics and Pearson’s correlations in relation to the subscales used. Although there was a positive and very low correlation between Resignation of loss and Bereavement (p = > 0.05), between Individual Resignation and Marital Satisfaction (p = > 0.05), and between Rituals and Individual Resignation (p = > 0.05), these results were not significant. Contrarily, there was a significant correlation between Loss Resignation and Marital Satisfaction (p = < 0.01). A positive and low correlation was also observed between Rituals and Resignification of loss (p = < 0.01) and between individual Resignification and Bereavement, (p = < 0.05). On the other hand, positive and moderate correlations were found between Rituals and Bereavement (p = < 0.01) and between Resignification of loss and Individual Resignification (p = < 0.01). In contrast, a negative and very low correlation was found between Rituals and Marital Satisfaction, (p = > 0.05), and a negative and moderate correlation between Marital Satisfaction and Bereavement, (p = < 0.01).

Table 2
Pearson’s correlations and descriptive statistics for the RAS and PGS scales and for the BAQ and PGS dimensions (n= 74). Porto, Portugal, 2019

	1	2	3	4	5	6	7	8
Rituals (BAQ)	-
Resignification of loss (BAQ)	0.309**	-
Individual resignation (BAQ)	0.141	0.427**	-
Marital satisfaction (score total)	-0.107	0.053	0.170	-
Bereavement (score total)	0.455**	0.089	-0.254*	-0.431**	-		.
Active bereavement	0.397**	0.093	-0.194	-0.381**	0.918**	-
Coping difficulties	0.458**	0.108	-0.281*	-0.444**	0.964**	0.823**	-
Despair	0.433**	0.053	-0.241*	-0.394**	0.958**	0.806**	0.905**	-
Average	1.34	3.69	3.37	4.24	1.79	2.46	1.51	1.39
Standard Deviation	1.19	0.67	0.76	0.88	1.02	0.97	1.15	1.11

^*p
• ^**
  são p < 0,01;
^*p
• ^**
  are p < 0.01;
Source: Authors (2022)

Experience of perinatal mourning and grief rituals: parity, level of education and gestational and chronological age of the woman

The results (Table 3) reveal that there are no statistically significant differences (p >.05) in the way the grief rituals are reported by parity, level of education, gestational age, and chronological age (p >.05). As regards the way mourning for abortion is experienced, no statistically significant differences were found in the sociodemographic variables (p >.05).

Table 3
Means and standard deviations of differences between groups at parity level, educational attainment, gestational age, and age of the woman. Porto, Portugal, 2019

	Rituals (SD)	Test T (p-value)	Resignification of loss (SD)	Test T (p-value)	Individual Resignification ( SD)	Test T (p-value)	Bereavement ( SD)	Test T (p-value)
Parity
Nulliparous	1.32 (1.22)	0.19 (0.85)	3.76 (0.64)	-0.99 (0.32)	3.38 (0.79)	-0.20 (0.84)	1.89 (1.00)	-0.93 (0.35)
Uniparous/multiparous	1.37 (1.17)		3.60 (0.70)		3.35 (0.76)		1.67 (1.04)
Academic qualifications
<12º grade	1.29 (1.05)	-0.26 (0.80)	3.65 (0.63)	-0.31 (0.76)	3.35 (0.66)	-0.12 (0.91)	1.70 (0.85)	-0.52 (0.61)
>12º grade	1.37 (1.27)		3.70 (0.70)		3.37 (0.83)		1.83 (1.10)
Gestational Age
<12 weeks	1.13 (1.10)	-1.92 (0.06)	3.66 (0.60)	-0.44 (0.62)	3.31 (0.79)	-0.73 (0.47)	1.67 (0.95)	-1.28 (0.21)
>12 weeks	1.67 (1.26)		3.73 (0.77)		3.45 (0.76)		1.98 (1.11)
Age
<35 years old	1.15 (1.06)	-1.58 (0.12)	3.66 (0.66)	-0.41 (0.68)	3.34 (0.76)	-0.28 (0.78)	1.79 (1.04)	0.02 (0.99)
>35 years old	1.59 (1.32)		3.72 (0.70)		3.40 (0.81)		1.79 (1.01)

Source: Authors (2022)

Efeitos da satisfação conjugal e da utilidade de rituais na vivência do luto

A Satisfação conjugal e a Utilidade de rituais de luto explicaram 35% da variância da vivência do luto (R² = 0,35). Foi encontrado um efeito significativo e positivo da utilidade de rituais na vivência do luto (b = 0,33, s.e. = 0,08; CI 95% [0,17, 0,50]; p = 0,00) e um efeito significativo e negativo da satisfação conjugal na vivência do luto (b = -0,46, s.e. = 0,11; CI 95% [-68, -0,23]; p = 0,00). Já o efeito de interação não se verificou significativo na predição da vivência do luto (R²△ = 0,01; b = 0,09, s.e. = 0,11; CI 95% [-0,14, 0,31]; p = > 0,05), tal como representado na Figura 1. Estes resultados indicam que a satisfação conjugal revelou-se um preditor do luto perinatal, sendo que quanto menor for a satisfação conjugal, maiores são os níveis de luto. Ademais, verificou-se que a utilidade dos rituais de luto revela-se um fator de risco no luto perinatal e que a satisfação conjugal não interfere na relação entre a vivência do luto e a utilidade dos rituais de luto.

Effects of Marital Satisfaction and Usefulness of Rituals on Bereavement Experiences

Marital satisfaction and Bereavement ritual utility explained 35% of the variance of bereavement experience (R² = 0.35). A significant and positive effect of ritual utility on grief experience was found (b = 0.33, s.e. = 0.08; 95% CI [0.17, 0.50]; p = 0.00) and a significant and negative effect of marital satisfaction on bereavement experience (b = -0.46, s.e. = 0.11; 95% CI [-68, -0.23]; p = 0.00). In contrast, the interaction effect was not significant in predicting grief experience (R²△ = 0.01; b = 0.09, s.e. = 0.11; 95% CI [-0.14, 0.31]; p = > 0.05), as depicted in Figure 1. These results indicate that marital satisfaction was found to be a predictor of perinatal bereavement, with the lower the marital satisfaction, the higher the levels of bereavement. Furthermore, it was found that the usefulness of bereavement rituals is a risk factor for perinatal bereavement and that marital satisfaction does not interfere in the relationship between the experience of bereavement and the usefulness of bereavement rituals.

Figure 1
Graphical representation of the interaction effect of marital satisfaction and ritual utility in the experience of bereavement. Porto, Portugal, 2019-20

Note: independent variable - bereavement (Mean Bereavement); dependent variable - bereavement rituals (Ritu_BAQ); moderator variable - marital satisfaction (RelC_RAS)

DISCUSSION

The main purpose of the present study was to analyze the effects of the use and perceived usefulness of bereavement rituals and marital satisfaction on perinatal bereavement, creating a link between two major themes still little explored in the literature: the usefulness of bereavement rituals when experiencing a pregnancy loss.

According to the results found, there were no significant differences in the usefulness of the bereavement rituals by parity, education, and age of the participants, suggesting that the use and weighting of the usefulness of the bereavement rituals may be independent of education, age and the existence, or not, of children. Differences in relation to the woman’s gestational age at last abortion were also analyzed and were not statistically significant. This result is thus an addition to the future clarification of the existing controversy regarding the effects of gestational age, with several studies pointing to a lack of significance¹⁰. Thus, defending abortion as a loss like any loved one, it is expected that there are no differences regardless of gestation time. In fact, they consider that grief related to the death of a child may not be dependent on the child’s age or the reason for the loss, but on the loss itself²⁷.

Regarding the experience of grief, no statistically significant differences were found regarding parity, education, gestational age, and chronological age of the woman. These results are not consistent with the existing literature that indicates the possibility of attenuation in mourning by women with a previous existence of children, revealing that childless women report higher levels of mourning⁷. Gestational age and the woman’s age are also predictors of adjustment to perinatal mourning⁸, ⁹, ¹¹, and the lower the gestational age and the higher the woman’s age, the experience of mourning becomes less intense, contrary to the results found in this study. The fact that the results found are not consistent with the literature may be related to the sample size, making the variables not very broad for data analysis. In addition, the time between the loss and the performance of this study (last 24 months) is longer in relation to the studies performed in the same scope (last six months), thus possibly explaining the absence of differences.

There was a significantly positive correlation between the usefulness of the bereavement rituals and the resignification of the loss, this indicates to us that the greater the perceived usefulness of the rituals, the greater the levels of resignification of the loss. However, no significant association was found between rituals and individual resignification. Furthermore, a negative correlation was found between marital satisfaction and perinatal bereavement. These results are consistent with the literature, which indicates that the better the marital satisfaction, the lower the levels of bereavement²⁸. This result reveals the coherence and linearity of this significant relationship with the already known research in this field, reinforcing that a good quality of marital relationship stands out as an important factor in the process of bereavement due to abortion¹¹, ²⁰. On the other hand, we observed a positive correlation between the experience of bereavement and the usefulness of bereavement rituals, meaning that the higher the levels of perinatal bereavement, the higher the usefulness of bereavement rituals. This result is in line with previous studies, since bereavement rituals are an important factor in the bereavement process and contribute to a better adjustment to perinatal bereavement¹², ¹⁵.

The relationship between marital satisfaction and the dimensions of the Perinatal Bereavement Rituals and Resignification Questionnaire (rituals, resignification of loss, and individual resignification) was not found to be significant and may indicate that the usefulness of rituals and individual and loss resignification are not dependent on marital satisfaction to be useful in the acceptance of miscarriage loss. Interestingly, a positive and significant correlation was not found between bereavement and resignification of loss, but rather between bereavement and individual resignification. These results indicate that the higher the levels of bereavement, the greater the individual resignification. However, the same is not true for loss resignification, revealing that loss resignification is not assumed to be a protective factor in the intensity of bereavement experienced by abortion.

The results derived from the predictive value reinforced those obtained in terms of the association between variables, and the usefulness of rituals revealed a positive effect on the experience of bereavement. This result is not as expected since the usefulness of rituals was revealed as a potential risk factor for the experience of bereavement. However, the absence of longitudinal data does not allow us to make inferences about the causality of the data, and it is possible that a higher level of bereavement suffering leads to a higher perceived usefulness of bereavement rituals. Furthermore, the fact that these two variables were not measured at the longitudinal level-with months apart as is analyzed in the literature regarding perinatal bereavement-29, 30 may also have compromised the results obtained. A longitudinal analysis in this study could provide indicators of this relationship, in the sense of understanding if the usefulness of rituals proves to be a protective factor for long-term bereavement. Moreover, these results can be justified by several reasons: the sample of this study is small and selected by convenience, which may have influenced the results; moreover, the fact that it is still a little studied and valued topic in society, may lead to the fact that people bereaved by abortion do not know the necessary means to deal with bereavement - in this case through the use of bereavement rituals - and do not use them, or because the use of these rituals was so unconscious and natural that they did not recognize their use and usefulness. Also, the fact that one of the inclusion criteria for the sample was not controlled (‘having had an abortion, preferably, in the last 24 months’) may have led to the fact that the period from the loss to the completion of the questionnaire was so long that the usefulness of the rituals was somewhat devalued, even if they were used.

As expected, marital satisfaction proved to be a predictor of perinatal bereavement, and it was found that the lower the marital satisfaction, the higher the levels of grief. The bereavement process is complex and often severe. However, with good social support, namely at the marital level, the process is attenuated¹¹,²⁸. This result substantiates what science has highlighted about the harmful role of low marital satisfaction in the bereavement process after abortion, since low marital satisfaction is associated to impaired psychological adjustment in women¹¹, ¹⁹, ²⁸.

Marital satisfaction did not prove to be a moderator of the relationship between the experience of perinatal bereavement and bereavement rituals, meaning that, regardless of the levels of marital satisfaction, there is a positive relationship between the two, and that the greater the experience of bereavement, the greater the usefulness of the bereavement rituals. It can be stated, then, that marital satisfaction does not interfere in this relationship, a phenomenon explained by the fact that marital satisfaction is a positive predictor of women’s bereavement adjustment¹⁹ and not a variable that influences their maladjustment. However, this result may also be compromised due to the lack of control of the time variable, and it would be possible to verify if marital satisfaction could predict a better adjustment in perinatal bereavement only with a longitudinal investigation.

Although this research has not revealed statistically significant results in general, these results are relevant because they show how the use and usefulness of bereavement rituals are not interdependent with certain individual or relational characteristics of the participants. These results consolidate the certainty that the use and usefulness of bereavement rituals when experiencing an abortion is independent and reveals itself as a predictor for a better adjustment to perinatal bereavement. The figure of the nurse being paramount in the contexts of abortion and neonatal loss. And most of the times, the first and main figure of contact with the patients. This study also highlights the importance of addressing the possibility of bereavement rituals in the emotional support for the loss that is part of the nurse’s care.

Among the limitations of the study are the sample size stands out as being small, compromising the results. A larger sample would provide more comprehensive data for the analysis of results. Moreover, several questionnaires were incomplete, not ruling out the possibility of fatigue and giving up on completing them due to their length, which consequently had repercussions on the final sample. Of the scales used in this study, two were neither validated nor adapted to the Portuguese population, which is also a limitation due to their reliability. It is important to mention that the results may also have been influenced by uncontrolled variables, such as the time between the loss and the completion of the questionnaire.

FINAL CONSIDERATIONS

Studies on abortion experiences are scarce. Thus, the relevance of this study is justified by the need to understand this experience and analyze the influence of the use and usefulness of bereavement rituals in this context. Thus, this study stands out for its innovative character, since it bridges the gap in research on the use of bereavement rituals in cases of abortion, both in Portugal and in other countries.

In view of this balance, we consider it important to replicate the study to confirm the results in a larger sample and, preferably, with couples. This need arises from the fact that the literature points to significant gender differences regarding mourning for abortion, so it would be relevant to verify eventual differences regarding the use and usefulness of bereavement rituals. Furthermore, it is necessary to investigate the variable of the woman’s gestational age to understand its influence on bereavement in this area. Finally, it would be pertinent to conduct longitudinal research to understand the trajectory of this variable temporally from the moment of the loss.

The role of the nurse is to provide psychosocial counseling and promote well-being, and this study shows that it can be important, in a preventive logic, to address with the couple the importance of marital adjustment and the usefulness of rituals for a successful bereavement.

REFERÊNCIAS

• ¹
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Edited by

Associate editor: Dra. Tatiane Trigueiro

Publication Dates

• Publication in this collection
  16 Dec 2022
• Date of issue
  2022

History

• Received
  01 Sept 2021
• Accepted
  13 July 2022