Abortion constitutes a stressful life experience characterized by the unexpected loss of a desired child. Etiologically, it is classified as spontaneous abortion when it occurs naturally and without deliberate interference, or as medical termination when it is voluntarily induced. 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 time. 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 persistence.
Parity or the presence of children may be an important predictor of bereavement intensity after a miscarriage (abortion). Several studies confirm that childless women report higher levels of bereavement after an abortion compared to women who already have children, a result identical to that found for depressive symptoms. Age at the time of abortion may also be an important predictor in grief, as younger women reported higher levels of bereavement. 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 symptoms.
Despite scant research, some studies claim that gestation time is not a predictor of adult psychosocial adjustment, while others support the idea of gestational age being important in adjustment after an abortion. 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 trimester. 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 Franche, 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 individual. 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 grieved. 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 difficulties.
One of the strategies to deal with the loss is using bereavement rituals, 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 them. 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/her. 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 life. In addition, rituals are beneficial because they create the opportunity to recognize and legitimize the emotional change, validate the loss, and accept the separation from the loved one. 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 impact.
Another factor that mitigates the impact of pregnancy loss is the quality of the couple’s relationship and the support provided by their partners, and the low quality of the marital relationship is associated with compromised psychological adjustment in women who suffered recurrent pregnancy loss. Along with other studies 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.
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