Abstract
Historically, African American women have faced racial disparities in perinatal and neonatal mortality rates. There is limited research on the sustained stress and amplified emotional and psychological strain that African American women undergo during perinatal loss. Studies are even scarcer concerning the heightened emotional and psychological difficulties during pregnancies subsequent to loss. Semi-structured interviews were carried out with 22 African American women who had experienced perinatal loss and were either pregnant or had given birth after their loss. Descriptive coding and thematic analysis revealed three main themes: life stressors, mental health complexities, and coping strategies. The results showed a potential pattern of increased risk of adverse perinatal outcomes due to social determinants, including income, access to healthcare, and housing. Furthermore, participants described experiences of systemic racism that appeared to exacerbate psychological distress after perinatal loss, often manifesting as depression and anxiety. The study reveals the urgent need to dismantle systemic racism in maternity and mental healthcare to boost perinatal outcomes for African American women. It provides essential insights for developing effective support programs.
Perinatal loss, which often has a significant impact on women, is typically characterized as an unintentional or sudden termination of pregnancy. Perinatal loss can occur due to a miscarriage (before 20 weeks of gestation), stillbirth (after 20 weeks), or the death of a newborn within the first 28 days of its life (Fenstermacher & Hupcey, 2013). Racial and ethnic disparities can influence obstetrical outcomes in minoritized populations. These disparities are deeply rooted in maternal health behaviors, physical and social environments, genetics, and access to healthcare and quality resources (Bryant et al., 2010). African American women may be unduly affected by the psychological impacts of chronic stress. The health disparities associated with chronic stressors, including housing instability, neighborhood violence, family and daily stress, environmental and maternal stress, as well as racism and discrimination, may contribute to poor health outcomes (Djuric et al., 2008).
Background
Approximately 26% of all pregnancies in the United States (U.S.) result in a miscarriage each year, and up to 10% of clinically acknowledged pregnancies result in a loss (Dugas & Slane, 2022). In addition, one in every 10 infants in the U.S. is born prematurely at fewer than 37 completed weeks gestation (March of Dimes, 2019). According to the data collected in 2022, the provisional number of U.S. births stood at 3,661,220 (Hamilton et al., 2023). The data also demonstrated that preterm birth rates consistently showed notable variation when categorized by race and ethnicity (Centers for Disease Control and Prevention [CDC], 2023). For instance, the premature birth rate among African American women was reported as 14.6%, which was significantly higher compared to the 9.4% rate seen among White women (Hamilton et al., 2023).
In 2021, there were approximately 20,948 fetal deaths in the U.S., which reflected an overall fetal mortality rate of 5.7 fetal deaths per 1000 live births (Gregory et al., 2023). The fetal mortality rate for African American women, more specifically, was 9.8 per 1000 live births, which was greater than twice the rate of White women at 4.8 per 1000 live births (Gregory et al., 2023). In 2020, the infant mortality rate among African American infants was 10.6 for every 1000 live births (Murphy et al., 2021). The difference (or disparity) in infant mortality between African American women and White women has more than doubled over the past decade.
Understanding how social factors relate to stress equips clinicians and researchers with the ability to engage with communities to reduce the Black-White perinatal mortality gap. Several studies have reported relationships between racism, stress, and pregnancy-related outcomes, including preterm birth and low infant birthweight (Dominguez, 2008; Gadson et al., 2017; Slaughter-Acey et al., 2019). Low birthweight (LBW) is a weight under 2500 g, and very low birthweight (VLBW) signifies a weight under 1500 g (Osterman et al., 2023). In 2021, 3,664,292 births were recorded in the U.S. There was a 3% increase in LBW, and VLBW rose to 1.4% in the same year (Osterman et al., 2023). Moreover, African American infants experienced higher rates of LBW and VLBW at 14.7% and 2.9%, respectively, compared to White infants at 7% and 1% (Osterman et al., 2023).
Disparities in social determinants of health (SDOH) may also lead to profound stress that is responsible for poor pregnancy, birth, and health outcomes in African American women. In an overarching context of historical and structural inequity, researchers and clinicians need to acknowledge the role racism and stress have on racial disparities in maternal healthcare (Gadson et al., 2017; Louis et al., 2015). In African American women, chronic stress, fueled by racism and discrimination, has been associated with higher levels of cortisol (Shapiro et al., 2013) that may influence an epigenetic process that prepares the fetus for life in a high-stress environment outside the womb (Goosby et al., 2018).
The theory of allostatic load suggests that exposure to chronic psychological stressors, such as racism and discrimination, can create cumulative risk and psychological imbalance, leading to poor health outcomes (Edes & Crews, 2017). Allostasis describes the link between stress and physiological functioning, outlining the body’s response to chronic stress through homeostasis regulation (McEwen, 1998). The hypothalamic-pituitary-adrenal (HPA) axis modifies the body’s internal state in response to changes in the environment by leveraging pathways sensitive to glucocorticoids, equipping itself to manage both anticipated and unanticipated environmental stressors (McEwen & Stellar, 1993). However, the persistent over-activation and chronic divergence of glucocorticoids from their balanced state can result in allostatic load (Agorastos et al., 2019; Seeman et al., 1997). Despite the body’s natural ability to adapt to stress, long-term stress can significantly “wear down” the body over time, eventually leading to a dysfunction in various physiological systems (e.g., cardiovascular, metabolic, inflammatory, and neuroendocrine) and a decline in functionality, potentially resulting in disease development or exacerbation, and ultimately, death (James et al., 1992; McEwen, 1998; McLean et al., 2020; Schoendorf et al., 1992).
Similarly, elevated cortisol levels may hasten aging in African American women, heightening their susceptibility to stress-related complications in pregnancy (Geronimus, 1992; Giurgescue et al., 2013). The “weathering” concept, introduced by Geronimus (1992), suggests that the impact of social inequality on population health may intensify with age. This weathering could lead to an expanding health status disparity between young and middle adulthood that could affect fetal health. Collins et al. (2004) found that lifetime experiences of racism have served as a chronic stressor for African American women, posing an independent risk factor for poor health outcomes, including VLBW infants. Elevated cortisol and norepinephrine are the natural hormones that trigger premature labor and preterm births (Lu & Halfon, 2003). When exposing a fetus to high cortisol levels, it disrupts vital hormone receptors (Wadhwa, 2005). This exposure may trigger an epigenetic process, preparing the fetus for a stressful external environment after birth (Goosby et al., 2018).
Both theories highlight the necessity of identifying and scrutinizing various stress-related factors that could potentially lead to adverse pregnancy and health outcomes (Louis et al., 2015; Woods-Giscombe, 2010). Chronic stress has been connected to shorter telomere length in adults (Chae et al., 2014) and in the placenta of newborns whose mothers endured chronic stress during pregnancy (Jones et al., 2019). As a result, African American women who experience continued exposure to high-stress levels during pregnancy might have a higher likelihood of suffering from elevated blood pressure, LBW, VLBW, and increased risk of preterm births (Goosby et al., 2018; Shapiro et al., 2013).
Theoretical Framework
The theoretical frameworks used for this study were Black feminist thought alongside a life-course perspective. These frameworks give prominence to how African American women’s complex challenges occur within a sociopolitical context that obstructs access to healthcare and quality resources. Black feminism refers to power structures that significantly differentiate the positioning of African American women from their White counterparts (Combahee River Collective, 2015). This framework is used to strengthen the researchers’ understanding of the social conditions of African American women throughout their life course that may potentially impact their health and pregnancy (Anderson, 2002). Through a life-course perspective, researchers can explore how the places in which individuals are born, grow up in, work, and age influence their health outcomes (Jones et al., 2019). According to Lu and Halfon (2003), disparities in pregnancy and birth outcomes are the consequences of early life experiences and cumulative allostatic load throughout the life course. This perspective allows healthcare providers, public health officials, and researchers to link health and wellness across the lifespan. Through an intersectional lens, Black feminist thought alongside a life-course perspective allows for a deeper understanding of the complexity and situatedness of the identity of African American women.
Purpose of Study
There exists a considerable gap in research focusing on the continuous stress and escalated emotional and psychological distress that African American women experience during perinatal loss. Furthermore, studies that have explored the increased emotional and psychological struggles during subsequent pregnancies following perinatal loss are scarce. This study centers on chronic stress factors, which may influence the journey through perinatal loss and pregnancy subsequent to loss. Considering that 80% of miscarriages happen in the first trimester (March of Dimes, 2023), we zeroed in on losses occurring from the second trimester (starting at 14 weeks gestation) up to the first 28 days of life. This focus aims to encapsulate those pregnancies that have been clinically diagnosed (Dugas & Slane, 2022). Thus, the purpose of this study was to examine the lived experiences of African American women and their chronic psychological stressors, which include race-based disparities, to understand better how these stressors may have an impact on perinatal loss and a pregnancy subsequent to loss.
Method
Participants
Participants were 22 African American women aged between 18 and 48 (M = 34.2, SD = 8.3), who had experienced perinatal loss and were either pregnant, or had given birth after their loss. There were several eligibility criteria. Participants were required to (a) identify as African American and to be 18 years or older. They also had to speak and read English. Maternity requirements were as follows: They had to have experienced the death of a fetus/baby through miscarriage, stillbirth, or neonatal death between 14 weeks gestation through 28 days of life; they had to be pregnant with a subsequent pregnancy or having given birth after their loss, and they had encountered stress-related situations during perinatal loss and/or leading up to and throughout a pregnancy subsequent to loss.
The distribution of women spanned across different areas of the U.S., with the highest number (n = 10) residing in the Midwest. The rest were from the Northeast (n = 3), Central (n = 1), West (n = 2), and South (n = 6).
The average income for women was $41,500 annually, although this varied significantly. Seven women earned less than $20,000 annually, and six earned over $80,000. Employment status varied among participants. Sixteen women were employed, five were unemployed, and one was a full-time student. Regarding their educational level, one woman had not completed high school, four were high school graduates, eight had some college education, and nine held college degrees. In terms of relationship status, nine women identified as married, seven identified as single, four reported being divorced, one being in a relationship, and one being engaged. The women's housing arrangements varied; some owned homes (n = 9), while others rented (n = 13).
Demographic Characteristics of Participants.
Note: Participants’ names are pseudonyms. The mean age of the participants was 34.2 years.
Research Design
The researchers conducted this study using a descriptive and interpretive phenomenological design. This qualitative approach aims to understand how individuals interpret their experiences and situations (Sandelowski, 2000). Through inductive data analysis, the research team produced descriptive results. This approach helped the researchers extract meaningful insights from the participants’ experiences, structure them into identifiable patterns, and articulate the results into themes aligned with the study’s aim and context (Sundler et al., 2019).
Interview Protocol
Interview Guide.
Participant Recruitment
The researchers obtained ethical approval for this study from their university’s Institutional Review Board. Throughout the United States, the research team recruited participants through snowball sampling from clinics where women received care, were involved in perinatal loss support groups, in community centers, churches, and hair salons, and were on social media. Flyers were posted and distributed to potential participants at recruitment sites. The primary researcher requested that interested participants send an email expressing their desire to participate in the study. After receiving the emails, the primary researcher evaluated their study eligibility. Eligible participants received instructions to complete an electronic informed consent form before their interview. The primary researcher scheduled each interview. Before the interview, the primary researcher informed each participant about the study’s process, possible risks, and their freedom to withdraw from the study at any time. Additionally, the primary researcher provided the participants with information about the audio-recording of the interview. Each participant received a series of demographic questions before the start of the interview. These questions aimed to gather information on age, gender, state of residence, education level, annual income, employment situation, relationship status, housing arrangements, and healthcare coverage.
The primary researcher conducted the interviews in person or through communication platforms like Skype, FaceTime, or the telephone. Each interview was conducted at the prearranged time using the medium that the participant preferred. At the start of the interview, researchers gave each participant a pseudonym. This name allowed them to link demographic information with the interview, while ensuring the data remained de-identified and maintaining participant confidentiality. These interviews were audio-recorded and, on average, lasted 50 minutes. After the interview, as a token of appreciation, women were gifted a $25 gift card.
Data Collection
The researchers collected data for this study using semi-structured one-on-one interviews. The researchers prompted participants with open-ended questions and made subsequent inquiries based on their responses. This method allowed the researchers to diverge from the pre-established interview guide when required to better comprehend and frame participants’ narratives (Jamshed, 2014; Rabionet, 2011).
Additionally, the primary researcher compiled field notes before, during, and after each interview and consistently across the entire research process. These notes played a pivotal role in offering insights and assisting researchers to gain a deeper understanding of how the women perceived the stress they faced during their perinatal loss and in the period before and throughout a subsequent pregnancy. Field notes are fundamental to robust qualitative research as they augment the collected data and offer an in-depth context for the following analysis (Phillippi & Lauderdale, 2018).
Data Analysis
A professional transcription service accurately transcribed all audio recordings verbatim. After transcribing, the researchers checked the transcriptions against the original audio files for accuracy and made corrections as necessary. All transcripts were de-identified for confidentiality and analyzed using QSR International’s NVivo 12 software to interpret qualitative data.
The analysis process entailed both descriptive coding and thematic analysis. Descriptive coding summarizes data segments with words or brief phrases that encapsulate the core topic (Saldańa, 2021). Additionally, thematic analysis facilitates the recognition of dominant themes that arise from the data (Braun & Clarke, 2006). This process was repeated with each transcript, facilitating the identification of themes and subthemes. For this study, we primarily focused on the data related to key themes such as life stressors, complexities of mental health, and coping strategies. This analysis method paved the way for an in-depth exploration of the participants’ experiences. To validate the findings, the research team regularly convened by ZOOM to examine each code and determine its pertinence. The team carefully evaluated each theme and subtheme, leading to the formulation of comprehensive overarching themes.
Rigor
The research team used several strategies to ensure trustworthiness during the data collection and analysis process of this study. The research team strengthened confirmability by dictating in a reflective journal throughout the research process. The primary researcher’s assumptions and viewpoints documented in the journal entries aimed to promote openness and reduce researcher bias in data collection. The second author regularly examined these entries to discuss any potential influence of personal assumptions and perspectives on bias. After data collection, the research team solidified credibility by implementing member checking. This process involved asking participants to verify the authenticity and accuracy of their transcripts. The primary researcher sent each participant their transcript via secure email. Twelve participants verified the accuracy of their transcribed data, while 10 did not respond. The second author’s expertise was regularly utilized throughout the data analysis process to verify the authenticity of the identified themes and subthemes. The researchers convened weekly to biweekly via ZOOM to evaluate and discuss the data. The research team established triangulation by using field notes to confirm the authenticity of the findings. The research team ensured transferability by using detailed demographic data of the participants. This data helped to contextualize their stories and describe the research setting, the role of the researchers, and research assumptions. Last, the research team enhanced dependability by conducting an audit trail to document the research process.
Results
Definitions, Examples of Themes, and Subthemes (N = 22).
Life Stressors
Women reported experiencing multiple life stressors before, during, and after their loss experiences and at the time of a subsequent pregnancy to a loss. Racism, race-based disparities, and the challenges of living in a hostile environment intensified these stressors. Women’s descriptions of stressors could be divided into three subthemes: (a) not in a good place, (b) not being heard, and (c) feeling alone. Women reported one or more of these stressors present at the time of their perinatal loss and into their subsequent pregnancy to their loss.
Not in a good place
Generally, the women reported feeling they were not in a good place before or during their perinatal loss. Some women also identified not being in a good place during a subsequent pregnancy to the loss. Many women identified significant life stressors such as housing instability, neighborhood stress, and intimate partner violence as contributors to their chronic psychological stress. The women described that these stressors complicated their loss experience, making it difficult for them to focus on their healing. Other women reported that their living situations added to their existing stress, which intensified their anxiety and worry about having another loss. Some women reported that one or more of their stressors directly contributed to their perinatal loss. One participant shared her experience of her volatile relationship with her ex-husband, stating: I wasn't in a good relationship. My oldest two children, their father was really, really abusive and, he beat me. And I ended up going to the emergency room the day before, bleeding... so, the next morning I woke up and my water bag broke. And, I went in the bathroom, and I had him there.
This participant expressed that she did not attend prenatal care regularly due to her abusive situation, which created additional stress for her. At times, she indicated avoiding her healthcare provider when she had physical signs of abuse, such as multiple bruises on her body, due to fear of being judged. Another participant shared the intense emotional distress she experienced before, during, and after her perinatal loss. Several women believed their partners’ violent behaviors emerged or worsened during their pregnancy.
Other women reported similar episodes of physical violence from partners, while others indicated that the abuse came in the form of financial control. One participant described her stress when her partner took her money or made her account for her spending. Some women reported that their partners controlled their financial spending and denied them opportunities to seek employment. For these women, this stressor proceeded into their subsequent pregnancy to their loss.
Women also reported housing instability as a significant stressor during their perinatal loss experience. Some women indicated being homeless at some point during their pregnancy. One participant reported experiencing a house fire, leaving her and her partner to find shelter while learning she was pregnant. She stated: We had a house fire and were displaced and homeless... then I found out I was pregnant like two weeks later. Oh my god, and then we lost it.
Some women experienced a lack of housing because family members displaced them due to becoming pregnant, and having a lack of social networks, which compounded the stress of being homeless. One participant described the stress experienced while being pregnant and homeless in her junior year in high school. For women who experienced housing instability, many reported limited resources, while others expressed that resources were difficult to obtain.
Most women also identified neighborhood stress as a constant factor in their lives. Some women reported residing in low-income, high-crime neighborhoods where they grew up and felt unsafe. Participants who lived in neighborhoods with high crime rates described feeling hypervigilant about their safety. One participant described this hypervigilance as always locking her doors and never walking in her neighborhood because of potential violence. Other women resided in actively violent communities where they reported constant fear and stress. One participant expressed how neighborhood violence had a direct impact on her home. She reported: We lost our home in a storm last summer, so we had to find another house, like, really, really quickly. I actually have bullet holes, like, in my living room and through my kitchen. Yeah, it's pretty bad.
Women’s experiences of neighborhood stress stemmed from a lack of other available resources within their community. Women reported having limited access to healthcare facilities and transportation. One participant shared that the nearest hospital was more than a 30-minute drive from her home, which led to her giving birth at 17 weeks at a local urgent care facility. Others reported not having access to healthy and affordable foods during their pregnancies. This situation was common as many women expressed limited access to healthcare, transportation, and healthy foods, which complicated their ability to have a healthy pregnancy and may have contributed to their perinatal loss.
Not being heard
In addition to situational vulnerability, women described their stress and frustration because they were not listened to during and after their perinatal loss. Although most participants reported they established early prenatal care to help ensure a healthy pregnancy, many women believed their healthcare provider ignored or dismissed their symptoms before, during, or after their perinatal loss. One participant shared the interaction with her healthcare provider: She didn’t listen to anything that I said, really. It was like, “Well, how are you feeling?” Like, she was just asking me, and not even paying attention to my answer, just going through the motion.
Women expressed ongoing stress over growing concerns about their pregnancy. Most women sought care or called their healthcare provider with symptoms that included “bleeding,” “spotting,” “stomach pains,” “cramps,” or “didn’t feel the baby move,” but did not feel heard. One participant reported these concerns to her healthcare provider on multiple occasions and explained: I think I was 14 weeks when I went in, and they told me that my cervix was six centimeters. Before then, I had already told them I was cramping. I told them that I was spotting. I told them that I had back pain... but they just kept telling me that's normal.
Most women believed that racial biases were the root cause for providers not listening to their concerns or taking their complaints seriously. Other women reported that their health insurance coverage influenced the care received at the time of their perinatal loss. Women who had state and federal insurance coverage did not believe that their healthcare providers put forth the same effort to listen to their concerns if they had private insurance. Women indicated being treated differently based on the “color of their skin” because they were African American. This complexity seemed to add to their loss experience and a persistent source of psychological stress. One participant believed that her race influenced the questions asked of her following her perinatal loss. She stated: I had the worst doctor ever, to the point that I had to call and report. He'd ask me questions that they would only ask African American people, I'm pretty sure. He asked, “Well, did you do drugs with this baby?” or “Well, did you smoke any tobacco with this child?” Just things like that...
Women also reported experiencing racial discrimination about their healthcare. Experiences of racism appeared to have a negative impact on patient-provider communication for these women. One participant expressed that her provider failed to evaluate her symptoms of preterm labor as thoroughly as someone from another race. She shared: You know, the doctors and nurses are more likely to pay attention to Caucasians or different races other than people of color. Like, when they tell you, “Oh, my back hurts,” or “Oh, my stomach hurts,” or something is hurting, they just kind of tell us, like, “Oh, chalk it off,” whereas a different person, a different race, they're more like, “Oh, well, let me look into it,” you know?
Most women spoke of the need to advocate for themselves when the healthcare provider did not address their concerns. Often, women indicated changing healthcare providers as a means of advocacy for themselves and their fetus. One participant sought care from three different healthcare providers during the pregnancy, where she experienced her perinatal loss and moved to a fourth provider with the pregnancy that occurred after her loss. Women showed assertiveness by advocating for themselves and persistently pursuing their desired care.
Feeling alone
Although many women felt connected to social networks consisting of close family and friends, they still felt isolated and alone after their loss and at the time of their subsequent pregnancy. Some women reported having limited to no social networks to turn to for support following their perinatal loss. Often, the central aspect of women’s isolation was their experience of feeling alone in their loss and the perception that others “did not understand” their circumstances. Some women noted making the conscious choice to isolate themselves. Women seemed to internalize feelings of sadness and grief, which seemed to add to their loneliness. One participant felt isolated from the physical sense of loss. She explained: It was really defeating. And my husband is a phenomenal support...but I think I felt very isolated at that point because it wasn't his body that had gone through that.
Having family, friends, and healthcare providers acknowledge perinatal loss was significant for women. Some women indicated that their healthcare provider did not provide adequate follow-up care after their perinatal loss. This lack of attention seemed to have a negative influence, extending their emotional distress into subsequent pregnancies. For others, having family and friends who did not acknowledge their loss made them feel as though their child did not exist.
Mental Health Complexities
The feelings experienced following their loss negatively appeared to impact the mental health of many women. They recounted a period filled with intense emotional distress as they grappled with their perinatal loss. Additionally, this emotional turmoil was prominent when they were preparing for or transitioning through pregnancy subsequent to loss. The central theme of mental health complexities included three subthemes: (a) feelings of anxiety and depression, (b) lack of peace, and (c) failure as a woman.
Feelings of anxiety and depression
Women expressed experiencing anxiety and depression when faced with the realities of perinatal loss and pregnancies subsequent to loss. Some women described feelings of walking on eggshells, while others reported living in a perpetual state of fear as they anticipated the loss of their fetus. Many women were fearful during a subsequent pregnancy as they feared another loss. Feelings of isolation and smaller social networks compounded women’s depressive symptoms. Over half of the women reported recurrent feelings of anxiety and depression throughout their perinatal loss and pregnancy subsequent to loss.
One participant described how the daily uncertainty she felt during her twin pregnancy created persistent anxiety. Women expressed feeling hypervigilant during their pregnancies, and for some, these feelings were present during the pregnancy after their perinatal loss. Most women reported hypervigilant behavior because they felt a sense of impending doom and were fearful of experiencing another loss. One participant reported that listening to the heartbeat of her fetus multiple times each day was the only way she could decrease her excessive worry. Some women created daily rituals to help them cope with pregnancy-related anxiety. One participant stated: You know, just really, a lot of looking into underwear constantly. Walking around with essentially an emergency miscarriage package if you will. Just yank my teeth out. I can take it much easier than the panic, the worry.
Many women felt traumatized after their perinatal loss, either directly from the loss or trauma from the actual birth. One participant experienced trauma from the emergency cesarean section to deliver her stillborn son. Four women reported a history or a diagnosis of posttraumatic stress disorder (PTSD) after their perinatal loss. Other women indicated burying their feelings as they were too painful to remember. One participant revealed that after undergoing extensive therapy, she could now recall and manage her emotions regarding the stillbirth of her child.
Lack of peace
Some women reported constant worry and fear leading to a lack of peace, as they feared experiencing another perinatal loss during subsequent pregnancies. One participant’s fear took over when she began having complications early in her pregnancy; she was unable to experience any joy of being pregnant. Once some women passed the point in their pregnancy where their previous loss occurred or they received reassurance from an event like an ultrasound, their fear decreased. However, many women experienced fear throughout their pregnancy. One participant “kept waiting for the other shoe to drop,” while another felt she was “walking on pins and needles” her entire pregnancy. While many women consistently reported feeling fearful, the majority still held onto optimism, hoping for the best outcome.
Failure as a woman
For many women, the inability to successfully carry a pregnancy to viability created a feeling of failure and inadequacy, which interrupted their ideal of womanhood and strained relationships with their partners. One participant expressed difficulty as she attempted to re-establish intimacy with her partner while trying to move past her feelings from her loss. She explained: It’s such a blow to whatever you’re identifying or pinning onto your womanhood.
Women searched to find a reason for their perinatal loss. The women often indicated deserving the blame; many believed their age, “broken” bodies, and lack of self-esteem hindered their ability to sustain a pregnancy.
Coping Strategies
Women found ways to cope after their perinatal loss to manage their fear and anxiety during pregnancy subsequent to loss. Women described coping strategies that were classified into two subthemes. These subthemes were (a) talking with others and (b) relying on faith.
Talking to others
Most women looked to family and friends for support after they experienced perinatal loss. Social networks were identified as an essential component to help women cope. Establishing a strong social circle allowed women to confide in others and to feel that they were not alone. One participant explained: I think just knowing that I wasn't alone ... made a big difference to cope with my loss.
Most women reported finding support through perinatal loss support groups or speaking at local and national perinatal loss conferences. Women also expressed that sharing about their loss was one way to honor their child. Sharing the loss and honoring their child became a form of therapy and a way to promote self-healing after the loss. For women with small or no social networks, professional counseling allowed them to work through the pain and even family or cultural expectations. One participant, encouraged by her mother to seek the help of a therapist to help manage her feelings, stated: I also ended up going to an outpatient program, it was one of the best decisions... Black people, or people of color, in general, and mental health is not something that's discussed often.
Consequently, for some women, the ability to cope fluctuated. One participant expressed that there were days she could cope with her loss and days she could not “function past it,” despite having a strong support system. Even women who found difficulty coping identified how important it was to have individuals they could trust to share their perinatal loss experience.
Relying on faith
Faith was central to most women’s experiences of being resilient as they navigated through the complex realities of loss and apprehension, embarking on a pregnancy subsequent to loss. Women reported coping with their loss and navigating the experience of a subsequent pregnancy by finding solace in religious and spiritual practices. Many women who were not religious reported seeking solace in a “higher power” to cope. One participant spoke of praying, even though she was not religious, hoping for a better outcome to her pregnancy.
For some women, faith was a conduit between self-forgiveness and self-blame, as one participant explained: I thought that I had killed my baby. I thought that I had stressed myself out to the point where I stopped my baby’s heartbeat, and shortly after that, the doctors told me, no, that’s not possible; that’s not a thing, you know. I’m a very spiritual woman, so my spirituality played a lot into me dealing with it… I know that it wasn’t my fault, but you know, sometimes I still think, that what if all that stress did stop the baby’s heartbeat? What if all that stress did make me reject my pregnancy?
Faith provided a framework through which women could make meaning of realities, seek comfort, and cope, often using several strategies. For many of these women, their strategy included prayer, church attendance, and involvement in bible study groups. Some found reassurance in the belief that their baby was resting in heaven. For others, therapy provided a comforting supplement to their spiritual beliefs. One participant expressed realizing it was “okay to have Jesus and a counselor” through her healing process.
Discussion
The aim of this qualitative study was to delve deeper into the lived experiences of African American women, with a particular focus on their ongoing race-related psychological stress. The goal was to better understand how these stressors had an impact on perinatal loss and pregnancies subsequent to loss. Through the lens of Black feminist thought and a life-course perspective, we contextualized African American women’s perinatal loss experience and resultant mental health symptoms within a sociopolitical landscape that continually imposes reproductive disadvantage. Individual interviews revealed three dominant themes: Life Stressors, Mental Health Complexities, and Coping Strategies. These African American women reported experiencing significant stressors during their perinatal loss and extending into a pregnancy subsequent to loss, which have important implications for mental well-being. These findings support the need, as identified in other pregnancy outcome studies, to evaluate experiences of racism and health disparities across various life domains to understand how women cope with these experiences (Alhusen et al., 2016; Thompson & Suter, 2020). In a study by Nuru-Jeter et al. (2009), women reported experiences of racism throughout different parts of their lives, with childhood incidents leaving incredibly profound and enduring effects.
Similarly, Thomas et al. (2008) revealed that African American women perceived a sense of disrespect due to their racial and gender identity, leading to behavioral and emotional responses. Our findings indicate that gender-based racism seem to profoundly impact the mental well-being of African American women and retain its influence even when coping strategies are in place. Given these insights, acquiring cultural understanding and sensitivity becomes a significant priority among the requisite skills for providers and public health practitioners. It is crucial to equip those serving traditionally marginalized and medically underserved populations better to foster a healthcare approach that is both inclusive and equitable, effectively addressing the diverse socio-cultural dynamics impacting patient experiences (George et al., 2014).
This research also demonstrates the self-advocacy among African American women and their resilient approach toward stress management, where they utilize their faith and social connections as pillars of support. Existing literature highlights a frequent presence of self-advocacy among African American women, even though the levels of advocacy and their effects on health outcomes can vary (Molina et al., 2015, 2016; Wiltshire et al., 2006). While earlier studies view such self-advocacy positively as a tool for better health outcomes and addressing health disparities (Molina et al., 2015), others suggest self-advocacy serves as a reflexive survival strategy against racism and discrimination (Treder et al., 2022). Historical adversities, such as slavery, coerced childbearing, and unethical medical studies have profoundly impacted African American women’s identities (hooks, 1981; Washington, 2007) yet have also fostered resilience (Lekan, 2009). Conversely, Treder et al. (2022) make the argument that these strategies, seen as self-reliant survival tactics, may be linked to the continued poor health outcomes and inequities among African American women.
The women in our interviews expressed the existence of stress before and throughout their perinatal loss experience and expanding into pregnancies subsequent to their losses. Similar to findings by other researchers, psychosocial and environmental stressors have been identified as contributors to stress patterns (Dove-Medows et al., 2020; Giurgescu et al., 2012; Mayne et al., 2018). For example, Giurgescu et al. (2012) linked the environment of an African American women’s neighborhood and their experiences of racial discrimination to psychological distress, which could potentially heighten the likelihood of preterm birth. Similarly, African American women participating in a study by Dove-Medows et al. (2020) indicated that a woman’s residential area could have an impact on her pregnancy.
The heightened likelihood of African American women developing mental health issues like anxiety and depression due to stress emphasizes the need for targeted interventions (Braig et al., 2015; Pryce & Fuchs, 2017). Seib et al. (2018) further underscores this, linking life stressors to such symptoms, with past events playing a role in women’s ability to navigate challenges. Addressing these specific challenges is crucial to reduce health inequities. This effort could involve bolstering community-wide resources, such as businesses fostering financial literacy, mental health services, and nutritional advocacy in economically disadvantaged neighborhoods (Robinette et al., 2021). Considering the significant influence of neighborhood conditions on health outcomes, it is essential to foster collaborative relationships between healthcare providers and various stakeholders to shape health policies that would improve living conditions.
In addition, psychosocial and environmental stressors may contribute to adverse pregnancy outcomes directly by increasing cortisol levels that may trigger preterm birth or restricting fetal growth (Giurgescu et al., 2013; Shaikh et al., 2013). In their study, Giurgescu et al. (2013) discovered that all women in the high-stress response group experienced heightened levels of depression, anxiety, and reduced psychological well-being. In addition, these women presented irregular cervical remodeling at one or both data collection points. Life stressors appeared to heighten their emotional stress responses, potentially leading to abnormal reduction and fluctuations in cervical length measurements. Conversely, findings by Doktorchik et al. (2018) reported that although women with increased anxiety scores were at an increased risk of premature birth, chronic stress did not modify the relationship between anxiety and preterm birth. Moreover, increasing research suggests that when women find themselves in highly threatening situations, they may exhibit emotional and physiological changes due to stress, leading to mental and physical health consequences. (Conway et al., 2016; Epel et al., 2018; Tafet & Nemeroff, 2016), including poor pregnancy, birth, and health outcomes (Dadi et al., 2020; Woods et al., 2010).
Women in the study heavily emphasized their mental health challenges within their narratives. Consistent with previous studies, they reported experiencing depression and anxiety following their loss and described feelings of fear, guilt, and anxiety in their next pregnancy. (Cote-Arsenault et al., 2001; Farren et al., 2020; Hunter et al., 2017; Van & Meleis, 2003). Van and Meleis (2003) reported that African American women refrained from confronting their grief due to multiple reasons. These included avoiding the physical and emotional distress tied to remembrances of the loss, having inadequate support for grieving, feelings of guilt, and having the concurrent presence of other life struggles. In addition, women with recurrent perinatal loss experiences expressed significant anxiety and depressive symptoms. For example, He et al. (2019) reported that women who experienced one or more losses had a significantly higher level of anxiety and depression.
Many women reported feeling, after their perinatal loss, siloed due to cultural constraints. Due to this siloed experience, African American women may be more vulnerable to depressive symptoms associated with stress and anxiety (Donovan & West, 2015). Researchers have recognized mental health issues as potential contributors to maternal morbidity and mortality (Burch et al., 2012). In a recent study Shorter et al. (2021) found that approximately one in four women faced an elevated risk of experiencing severe depression within a month following perinatal loss. They notably classified African American women who have suffered perinatal loss as a high-risk group. As depression is a treatable medical condition, it is crucial to identify individuals who are at risk. African American women experiencing perinatal loss necessitate the availability of reliable mental health services and intervention initiatives. Catering to the needs of these high-risk groups requires healthcare providers who are structurally adept and culturally knowledgeable to fully address the needs of African American women (Shorter et al., 2021).
Participants in this study reported feelings of isolation, which seemed to impede them from discussing their loss experience, which appeared to increased their anxiety and depressive symptoms and, ultimately, may have impacted their mental well-being. Women reported that in African American families, there was usually an avoidance of discussions regarding perinatal loss, as well as a suppression of emotions connected to these losses. They also mentioned that conversations related to the anxieties and fears tied to pregnancies following a loss were often not undertaken. For example, Donovan and West (2015) highlighted that African American women are often socialized and reared to be strong Black women.
The “Strong Black Woman” (SBW) persona, deeply embedded with race and gender nuances, sets culturally specific expectations for African American women, such as steadfast strength, multitasking roles, and caring for others (Beauboeuf-Lafontant, 2007; Settles et al., 2008). Although the SBW may serve as an adaptive response to validate the uniqueness of the Black female narrative, this construct overemphasizes strengths and resilience and may fail to fully encompass the breadth of African American women’s diverse experiences (Robinson, 1983; Wallace, 1990). Additionally, some skeptics perceive the SBW schema as a simplified distortion that does not entirely reflect the historical resilience exhibited by African American women amidst adversities (Beauboeuf-Lafontant, 2009). Despite the seemingly empowering image this stereotype projects, there is potential harm if it leads women to believe they can bear all of life’s hardships without seeking support or acknowledging psychological distress (Mitchell & Herring, 1998). Consequently, this cultural narrative of the SBW could influence how African American women perceive stress and choose to adopt coping strategies, thereby shaping their overall methods to manage adversity. For instance, Graham et al. (2022) demonstrated a relationship where an increased adherence to the SBW narrative corresponded with escalated stress levels among African American female participants. They stressed the concept of collective coping, suggesting that some women, under the influence of SBW beliefs, mitigate stress by leaning on family and social networks for support.
Women experienced a lack of healthcare provider contact and follow-up care after their perinatal loss. Similarly, Nynas et al. (2015) reported in their study that women who did not have the opportunity to express their feelings during a follow-up visit or telephone call after their loss experienced an increase in anxiety. In addition, the timing of follow-up care can play an important role in psychiatric symptoms. Women reported the need for follow-up contact from their provider two to three days after their loss due to the increase in depression, anxiety, and guilt. According to Nynas et al. (2015), due to immediate emotional distress after a loss, provider contact and initial counseling should begin within one week after the loss. For many women, lack of contact from their healthcare provider was an indicator that they should quietly and quickly move forward, leaving some women to develop symptoms of self-harm.
Management of anxiety and depressive symptoms after perinatal loss is essential for a woman’s future well-being (Nynas et al., 2015). Wool and Catlin (2018) recommend emphasizing education and training to equip healthcare providers with the necessary skills for effectively communicating with grieving parents. It is important to ensure care is family-centered and in tune with the family’s cultural context using suitable communication methods considering the potential for anxiety and depression. Healthcare providers must integrate a systematic follow-up plan as an essential component to ensure continuity in mental health support.
Similar to current research, many women in our study reported anxiety and depression that extended into pregnancies subsequent to loss (McCarthy et al., 2015; Robertson Blackmore et al., 2011; Ustundag-Budak et al., 2015). For example, Bergner et al. (2008) conducted a study and discovered that in pregnancies following a perinatal loss, women displayed considerable pregnancy-specific anxiety throughout the first trimester. During a pregnancy subsequent to loss, it was also common for grief and hope to occupy the same space. For example, Bailey et al. (2019) reported a new pregnancy after loss can be a traumatic time filled with uncertainty and emotional chaos. Women in the current study reported feeling cautiously optimistic during a pregnancy subsequent to a loss. For example, allowing time to enjoy small milestones such as experiencing fetal kicks, having ultrasounds, or surpassing the gestational age of a previous loss helped to decrease anxiety and give a sense of optimism. Awaiting confirmation of an ongoing pregnancy after perinatal loss can be a difficult period marked by an intense struggle between optimism and despair, hypervigilance of pregnancy symptoms, and bracing for another loss (Bailey et al., 2019). For example, Bailey et al. (2019) reported that women labeled the waiting period in pregnancy after experiencing a loss as distressing, a time filled with hopeful anticipation yet marred by pessimistic expectations.
Women also experienced hypervigilance during pregnancies subsequent to their prior losses. A pregnancy subsequent to loss can be a time of hypervigilance and constant pregnancy treatment appraisal (Cote-Arsenault, 2007). Women may experience high anxiety (Armstrong et al., 2009), depression (Hutti et al., 2011), and increased healthcare use during pregnancy subsequent to a loss (Hutti et al., 2011; Robson et al., 2010). Similar to findings by Nowak and Stevens (2011), women in this study did everything possible for the welfare of the fetus despite stress, healthcare inequity, and income. In addition, Hutti et al. (2011) noted that women in their study had a higher frequency of telephone interactions and unscheduled office visits and underwent more diagnostic procedures during pregnancy following a loss. The findings revealed that concerns for the baby led to escalated depressive symptoms among the women. Furthermore, Robertson Blackmore et al. (2011) reported that stress, depression, and anxiety remained constant across both the prenatal and postnatal periods, indicating that the impact of previous loss did not diminish significantly after the birth of a healthy newborn.
Women in this study also spoke of a taboo in announcing their pregnancy before the 12-week gestation as they feared this to be a time when miscarriage was most likely to occur. Most women preferred to withhold their pregnancy announcement until they were beyond the 12-week gestation mark. These findings are similar to current research studies (Lou et al., 2017; Ross, 2015). For example, Lou et al. (2017) reported that women kept their pregnancy a secret during the first 12 weeks of gestation due to a higher rate of miscarriage. In the same study, women anticipated reaching certain milestones, such as screenings or ultrasounds, to mark a new and more certain phase of their pregnancy. Similarly, Ross (2015) reported that women withheld announcing their pregnancy until they felt the risk of a perinatal loss had decreased. Moreover, women in the same study reported that the delay in announcing their pregnancy was a form of self-preservation in the event an early perinatal loss was to occur.
In our study, women used self-help strategies to cope with their perinatal loss by connecting with their social networks and with religious and spiritual beliefs and practices. Similarly, Athan et al. (2015) reported that women who practiced religious and spiritual practices had better scores on anxiety, depression, stress, and social networks. These same strategies are reflected in the results from a study by Van and Meleis (2003) on African American women and in other studies where one or more of the strategies were used by women of other races and ethnicities (Allahdadian et al., 2015; Fernandez-Basanta et al., 2019; Marin-Morales et al., 2012). For example, Van and Meleis (2003) suggest that personal relationships, along with religious, spiritual, and cultural beliefs, are crucial elements that could shape the experiences of African American women after perinatal loss. Similarly, Fernandez-Basanta et al. (2019) found that cultural, social, and personal aspects shaped parents’ strategies to manage a perinatal loss. Healthcare providers must recognize the value of coping strategies amid perinatal loss. Such understanding significantly promotes attendance at regular preventive health services and early disease intervention among African American women (Pullen et al., 2014). Greater insight into these coping strategies by healthcare workers could lead to substantial advancements in patient care.
Women in this study relied on individuals in their small social circles to help them cope through receiving emotional support. The findings revealed that women who experienced perinatal loss or who were pregnant after perinatal loss appeared to have reduced psychological distress and improved well-being when they received significant social support. This status was especially true among African American women who reported experiences of racism and discrimination, including those that occurred in healthcare settings, as they typically leaned on friends, family, and support groups for comfort (Jacob et al., 2023). Conversely, Giurgescu et al. (2017) reported a relationship between increased experiences of racial discrimination among African American women and decreased levels of social support and psychological well-being. Interestingly, even with the existence of social support, it did not lessen the adverse impact that racial discrimination had on their mental health.
Some women reported going outside their social networks and looked to support groups for comfort. Most women preferred participating in online loss support groups for ease and privacy. For example, Gold et al. (2012) found that women who used online message boards felt less isolated in their loss and grief and appreciated the convenience, access, and anonymity. Some women in the current study even reported that participating was a form of support because they did not have access to other resources for therapeutic listening.
Finally, results from our women’s narratives indicated that racism and discrimination may contribute to African American women’s race-related stress burden. Women in the study reported feeling discriminated against and treated differently by their healthcare providers. Women expressed feeling “ignored,” being “not taken seriously,” or receiving less than quality care by their healthcare providers during their perinatal loss. In addition, some women expressed that these experiences extended into their pregnancies subsequent to their losses. These findings are similar to those reported by Attanasio and Hardeman (2019), who found that women reported receiving inadequate treatment due to race, insurance status, or a difference of opinion with a healthcare provider.
Furthermore, Attanasio et al.(2018) found that women from socially marginalized groups showed a lower likelihood of engaging in shared decision-making during childbirth. This situation was even more pronounced for African American women who gave birth by cesarean section, as their participation in shared decision-making was particularly low. Moreover, McLemore et al. (2018) reported that African American women often found their prenatal healthcare treatment to be a stressful and negative experience. This perception was perceived to potentially impact both their health and their infant’s well-being. Key issues identified included having unsatisfactory patient-provider relationships, having an overreliance on trainees for care provision, and feeling disrespected by their healthcare providers. These health system issues are indicative of the negative aspects African American women face in their healthcare experiences (McLemore et al., 2018).
Limitations
There were limitations to this study. Many of the women interviewed were from the Midwestern and Eastern parts of the U.S. The complex and diverse experiences of African American women living in the southern regions of the U.S., influenced by varying sociopolitical climates across the nation, may not have been completely captured. Nevertheless, patterns of stress and their relationship to pregnancy should be similar across various geographic regions of the U.S.
Another potential limitation was that 13 interviews took place over the phone. The inability of the researcher to pick up on non-verbal cues or record observational notes during these phone interviews might have limited the depth of the data obtained from these participants. However, data from in-person interviews corroborated findings compared to those interviews obtained over the phone.
Future Research
Future empirical research would benefit from recruiting more diverse participants, including adolescents, same-sex couples, transgender birthing people, and African American fathers. Researchers should consider using Black feminist thought to share the voices of African American women who have experienced perinatal loss. African American women’s voices must play an essential role in influencing effective healthcare interventions. These interventions need to be firmly based on the realities that African American women experience daily. Additionally, more extensive studies need to be conducted that highlight the negative health consequences of racism and social inequality on pregnancy and childbearing. Researchers and healthcare providers need to take a more comprehensive and holistic approach to African American women to address chronic psychological stress and its role in adverse pregnancy and birth outcomes. Future research should examine how African American culture influences the grieving process after perinatal loss and how that grief may impact subsequent pregnancies.
Implications for Practice
The findings of this study highlight the profound effect of racial discrimination and race-based disparities on the perinatal loss experiences of African American women, intensifying their stress levels and influencing future pregnancies. They highlight the urgent need to scrutinize the roles of healthcare providers and organizations in perpetuating implicit bias and structural racism. Grasping the complexities of racism and discrimination is crucial for the development of equitable, inclusive, and scientifically based healthcare for historically marginalized populations. Structural racism, identified as societal structures, norms, practices, and policies, creates an imbalance in access to societal goods, services, and opportunities based on race (Jones, 2002). In healthcare, such discrimination obstructs access to critical health-promoting determinants. These include access to safe, stable housing, healthcare and insurance, and community resources, resulting in poor pregnancy, birth, and overall health outcomes for African American women (Wallace et al., 2017).
The pervasive nature of implicit bias calls for an extensive exploration and deconstruction to tackle its intricate systemic underpinnings and societal consequences. Such an undertaking necessitates a change in individual healthcare provider behaviors and sweeping policy reforms across diverse healthcare domains and additional social institutions. Addressing personal biases, educating the public, and devising culturally congruent interventions can construct safe environments where quality healthcare can thrive (Williams & Cooper, 2019).
A recommendation to emerge from this study is the integration of personalized reproductive life planning into female care plans to enhance pregnancy and birth results. This approach allows healthcare providers to specifically address every African American woman’s unique health, socioeconomic, and cultural concerns. It allows for identifying those most susceptible to poor health, pregnancy, and birth outcomes. Reproductive life planning facilitates a holistic approach to preconception, interconception, and prenatal care throughout a woman’s reproductive years (Malnory & Johnson, 2011).
The women in this study reported continual stress linked to precarious housing conditions, inadequate community resources, and insecure living environments. Addressing these issues is essential as it directly impacts and dictates health conditions (Williams & Cooper, 2019). Enhancing the state of housing and neighborhoods of underserved communities can improve health outcomes, alleviate disparities, and ultimately stimulate positive economic growth, improve safety, and foster overall physical and mental wellness (Hall & Boulware, 2023).
Mental health requires close attention, mainly as women in this study reported periods of untreated anxiety and depression following their perinatal loss and during subsequent pregnancies. This finding highlights the urgent need for healthcare systems to provide equal and culturally appropriate services. Expanding screening services could provide a pathway for increased diagnoses, referrals, treatment options, and effective strategies to manage stress (Dolibier et al., 2013). Healthcare providers must provide high-quality and accessible mental healthcare to overcome barriers like stigma and communication issues (Dwight-Johnson et al., 2001).
Finally, the study we emphasized the importance of emotional support in the narratives of African American women. We highlighted the need for ongoing assessment and follow-up care for women who have experienced perinatal loss. It is necessary for healthcare providers to immediately initiate follow-up services post-loss via telephone or telehealth to improve the well-being of women. When empathetic healthcare providers offer specialized bereavement support services attuned to the cultural needs of African American women, they actively contribute to helping them navigate perinatal loss (Hutti & Limbo, 2019).
Conclusion
Healthcare providers and systems must recognize and address racism as a vital and underlying factor. Understanding this factor is crucial in grasping the larger context driving the disparity in health outcomes among different racial groups (Dominguez, 2011). African American women are at an increased risk of psychological distress due to systemic racism within healthcare systems. Such experiences can result in sustained high-stress levels, negatively affecting pregnancy, birth, and overall health outcomes (Alhusen et al., 2016; Li et al., 2018). Women in the study associated their stress levels with social inequality, racism, and discrimination they experienced from healthcare providers during their perinatal loss and into subsequent pregnancies. As a result, it is imperative to prioritize the dismantling of structural racism in healthcare systems to mitigate the health disparities African American women encounter during perinatal loss or subsequent pregnancies. Recognizing racism as a fundamental factor is crucial to understanding the broader contextual factors that contribute to the health outcome differences across various racial groups (Dominguez, 2011). The narratives of these women offer valuable insights to healthcare professionals, public health officials, and other advocates. These insights can help identify culturally specific resources and support programs to reduce the stress experienced by African American women during perinatal loss and beyond.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
