Sot. Sci. Med. Vol. 37, No. 8, PP. 1006-1010, Printed in Great Britain. All rights reserved

THE IMPACT

0277-9536/93 $6.00 + 0.00 Copyright 0 1993 Pergamon Press Ltd

1993

OF A CHILD DEATH ON MARITAL ADJUSTMENT

JAKE M. NAJMAN,’ JOHN C. VANCE,’ FRAN BOYLE,’ GARY EMBLETON,~ BILL FOSTERS and JOHN THEARLE’

‘Department of Social Medicine, Medical School, The University of Queensland, Queensland 4072, *Queensland University of Technology, GPO Box 2434, Brisbane, Queensland 4001 and ‘The Catholic

University, Brisbane, Australia

Abstract-One continuing concern in the sociological and psychological literature has been with the mental health consequences of stressful life events. Occasionally such stressful events have been linked to other outcomes such as a deterioration in the extent or quality of the relationship between a cohabiting (usually married) couple. This paper takes data from a longitudinal study of parents of an infant who has died (due to a Stillbirth, Neonatal Death or Sudden Infant Death), to determine whether the relationship between the parents is adversely affected. The follow-up data is available 2 months and 68 months after the infant death. The results indicate there is an increased marital break-up rate for parents whose infant has died. Further, shortly after the death there is evidence of a deterioration of the quality of the marital relationship between the partners whose relationship has remained intact. Both these consequences of an infant death are unlikely to be due to chance, but their magnitude is relatively modest. At the 6 month follow-up, there is evidence of a deterioration in the quality of the relationship for those partners whose infant survived, such that at 6 months there are no longer any marital adjustment differences between parents experiencing an infant death and parents whose infant survived.

Key words-stillbirth, neonatal death, sudden infant death, marital adjustment, stress

INTRODUCl’ION

Periodically scholars have reflected upon the impact of such major life events as the birth of a disabled child, or the death of a child on the relationship between the partners in a marriage. Essentially two possibilities have been noted. The first is that major stressful life events may negatively impact on the relationship between the partners, while the second is that such stressful life events may increase cohesion and improve the quality of the relationship. Curi- ously, it is difficult to find evidence which would enable one to determine which of the above is more prevalent nor is there much consideration of the possibility that even major stressful life events (like the death of a child) have relatively little impact on the survival or quality of a marital relationship. This paper uses data taken from a large scale longitudinal study of the impact of infant death on the parents, to determine whether an infant death has an impact on the duration or quality of the marital relationship.

BACKGROUND

Studies of the impact of stressful life events on family functioning and family cohesion are hard to find. Admittedly, there exist a series of studies from which it is possible to make an informed judgement about the family impact of various stressful events. For example, there is the consistent finding that those in lower socioeconomic status groups have higher rates of marital breakdown [1] a finding which might lead

to the conclusion that poverty entails a form of chro- nic stress which serves to damage many marriages.

Various theories and community based treatment programs have emerged to deal with the perceived health consequences of traumatic and stressful events. Perhaps the best known of these is crisis theory, developed by Gerald Caplan [2]. The thrust of these theories is to focus on the way individuals respond to the stress and factors which lead to what are inter- preted as adaptive and maladaptive responses. Among the maladaptive consequences of stress are feelings associated with mental health problems and an increasing degree of social disorganisation [3].

One category of event which is clearly of central importance to many parents and which, when associ- ated with an adverse outcome, could be unambigu- ously labelled as stressful, is the birth of a child. With a trend towards declining birthrates, it could be argued that each birth attains greater significance for the prospective parents. Thus, children born with chronic disabilities, or instances of infant death con- stitute a form of added stress likely to impact on parents for varying periods of time.

In evaluating the impact of an infant death on the relationship between the parents, three possibilities need to be considered. Firstly, time alone may lead to changes in the quality of the marital relationship, perhaps as a consequence of the partners simply becoming more familiar with each other. This may simply reflect a maturing and development in the character of their relationship. A change in marital

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1006 JAKE M. NAJMAN et al.

relationship which might appear to be a consequence of a stressful event might be confounded by ‘normal’ changes in the nature of the relationship over time. Secondly, it would be a mistake to assume that the live birth of a ‘normal’ child does not itself impose some stress on the parents. Children require a signifi- cant input of emotional and physical energy as well as financial resources. The advent or addition of a child is likely to change the content and style of interaction between the partners in ways that neither might have anticipated prior to the birth. While there has been little empirical documentation of the extent or prevalence of these changes, there is some evidence that there is an increase in the rate at which mothers report marital conflict in the 6 month period follow- ing the birth of their child [4].

A third consideration which needs to be discussed when evaluating the impact of stressful events on the relationship between the parents has to do with other changes occasioned by stress, particularly those which relate to the mental and emotional state of the parents. Stressful life events have been associated with anxiety and depression, and with a range of physiological changes and physical health problems [S]. It follows that stressful life events may act to trigger a variety of emotional changes in the marital partners, and that any observed impact on the marital relationship may follow either from the stress itself or, more likely, from the emotional and other changes manifested by the parents.

PREVIOUS RESEARCH

While there have been very few empirical studies which permit an assessment of the prevalence of the sequence suggested above, some relevant evidence is available. Firstly it is clear that the loss of a child can have major effects on the mental health of the mother leading to anxiety and depression [6,7] accompanied perhaps by feelings of guilt and hostility. It has been further suggested that the bereaved may manifest significant personality changes [6] and that parents may blame each other for the death of their child [8].

The second type of evidence is however more equivocal, raising questions about the rate at which a child death is characteristically followed by marital conflict or marital breakdown. Thus, in one study, some 1.5% of women and 3% of men reported divorcing following a stillbirth, while 4% of parents who lost a child from SIDS reported a divorce followed the death of their child [9]. These rates are not likely to be much greater than the percent of parents divorcing following the birth and survival of their child. In another study of 44 SIDS couples, only three separated or divorced following the death [8], a rate again likely to be broadly comparable to the marital break-up rate for parents whose children survive. In one of the few control studies, Lehman et al. [lo] found higher break-up 4-7 yr after the death of an older child.

The third type of evidence is derived from studies of chronically ill children on the basis that the stress experienced by such parents might be expected to have a similar impact (though clearly these are differ- ent types of events) to the stress experienced by parents whose child has died. Such studies, for example, of parents of children with Cystic Fibrosis [ 1 l] Spina Bifida [12] or kidney disease [ 131 are consistent in indicating that the decline in quality of the marital relationship [12] and the rate of marital separation or break-up [l l] is broadly the same as that experienced by groups which do not have a disabled child.

In perhaps the best controlled study of this type, Nixon [14] has examined the impact of a child born with a major congenital abnormality on subsequent marital break-up and marital conflict. The data was taken from the Mater-University of Queensland Study of Pregnancy (MUSP). It involved 8556 con- secutive pregnancies, with 82 surviving children born with a severe congenital abnormality, selected as the main comparison group. A matched group (on par- ental characteristics) of healthy children provided the controls. This was a longitudinal study with data obtained prior to and on three occasions after the birth (334 days, 6-8 months, 5 yr). Thus, data on marital adjustment and marital status were available for the comparison and control groups, prior and subsequent to the birth of a child with a severe congenital abnormality. The results of this study indicate no decline in marital quality nor an increase in marital break-up following the birth of a child with a severe congenital abnormality, when compared to families having a normal child. There was however some evidence of a decline in marital cohesion follow- ing the birth of a child, whether the child was normal or born with a congenital abnormality.

This paper is concerned with the impact of a child death on the relationship between the parents. Based upon previous research, there is reason to anticipate that a child death will produce a variety of emotional and other changes in the parents, and that these-as well as the death itself-may reduce the quality or duration of the relationship. There are few well controlled studies which have examined this possi- bility and the existing data are equivocal and, at best, suggestive.

METHODS

Data for this analysis are taken from the Family and Child Health Study (FACHS), more complete details of which are in Vance et al. [I. Briefly, almost all hospitals in a defined geographic area (South East Queensland, Australia) agreed to participate in a study of the impact of a child death on the family. Three categories of death were selected, neonatal death (NND), stillbirth (SB) and Sudden Infant Death Syndrome (SIDS). About 85% of cases of death were approached and 53% of SIDS, 68% of

Child death impact on marital adjustment 1007

Table 1. Characteristics of parents lost to follow-up at 6 Table 2. Changes in marital status of parents of children from first months to second interview (only for parents still in study at follow-up)

% Loss to follow-up CHISQ

Initial interview Follow-up (6 months)

Married 88 89 Living together 8 7 Divorced/separated 1 2 Single

,L, (809) 2

* (809)

Respondents age I 5-24 25-34 35 +

Type of case SIDS NND SB SIDS-control NND-control SB-control

Parent responding Mother Father

Employment status Employed Housewife Unemployed

Marital status Married Living together Div/se.p/single

(174) 16

(603) 9 (135) 10

(912)

(95) 14 (194) 9 (180) 16

(SO) 5 (206) 9 (179) 10

(934)

(511) 10 (423) 11

(934)

(514) 10 (318) 9

(85) 20

(917)

(809) 9 (80) 19 (45) 29

P = 0.02

NS

NS

P = 0.01

P < O.OOI

NND and 63% of SB parents agreed to participate in the study. The birth registers of the relevant hospitals were accessed and three potential control children (live births) were selected and matched on a range of sociodemographic criteria. Second and third control families were approached in turn if a family refused to participate in the study. Some 65% of control families approached agreed to participate in the study. There were no major sociodemographic differences between the control and case groups, although there were some differences between parents who chose or decided not to participate in the study. Responders more often had a male infant, were older mothers and tended to be initially contacted by phone. There were no significant differences between responders and non-responders in parents’ occu- pations or the age of the infant at death. Because the control groups for NND, SB and SIDS were identical in all important respects, they have been aggregated into a single control group for the purposes of the following analysis.

Marital status was determined by the response to a pre-coded question at the 2 month and 6-8 month points of data collection. Included in both phases of data collection were seven items from the Spanier [ 151 Dyadic Adjustment Scale* and an additional global marital satisfaction item. These items focus largely on the level of disagreement/conflict in the relationship. Five items are negatively phrased [e.g. “Do you ever

l Dyadic here refers to a relationship in which two people are living together irrespective of whether they have for- mally married.

regret that you married (or lived together?)] and three are presented in a positive form. Except for the final item (4 point index), the other seven are scored on a l-5 point scale. The negative items were reverse scored, and then all the items were correlated with each other. Reliability coefficients (Cronbach Alpha) for the first phase were 0.82, and for the second phase 0.83. Both scales (Dyadic Adjustment phases A and B) are skewed towards a good quality of dyadic adjustment.

RESULTS

In total 934 parents were enrolled in the study. Of these 98 (10.4%) were lost to the 6-8 month follow- up, although some respondents provided incomplete information on some variables. Table 1 documents this attrition according to the parents relevant initial characteristics. All types of death were equally likely to be lost to follow-up. Mothers and fathers were also equally likely not to remain in the study. Not surpris- ingly younger parents who described themselves as unemployed and parents not married were less likely to be followed up. As the major analyses are re- stricted to persons married or living together, and as there are few unemployed in the study, this pattern of selective attrition is unlikely to influence subsequent results.

Table 2 (and subsequent tables) is limited to those persons who responded to the second interview (N = 809). Simple comparisons of the membership of various marital status groups from initial interview to follow-up suggest that there has been little change (Table 2). This is broadly confirmed by Table 3. Table 3 is limited to those parents married or living together at entry into the study and provides frequen- cies of divorce/separation or being single at the 6-8 month follow-up. Some 13 respondents reported that their marriage had broken up by the 6-8 month follow-up. Analysis is presented separately for each parent. Of the 10 women reporting their marriage dissolved, nine came from the group who had lost a child.? Such a difference could occur by chance less than one time in 100. A closer inspection of the data suggests that those mothers who describe themselves as “living together” were the main group which contributed disproportionately to the broken mar- riages. Of the three men who reported their marriage

$See footnote Table 3.

1008 JAKE M. NAJMAN et al.

Table 3. Marital status of parents at 6 month follow-up visit Table 5. Dyadic adjustment at first interview by whether parent is (onlv for oarents married at first visit) a case (death) or control

Mothers Case (death) Control

Married/living together 191 216 Divorced/separated/single 1

211 Pearson x> 6.78.1 df, P < 0.01

Fathers Case (death) Control

Married/livina together Divorced/sep&atEd/single

Pearson Y *NS

*The data in Table 3 are taken from the self reports in the questionnaire, administered almost 2 months after the death. Closer inspection of the detailed questionnaires indicates that 4 mothers separated from their partners after the death of their child, but before the first interview. Two mothers in the control group also separated before the first interview. Recalculating the x’ for these figures does not materially affect the results (x2 7.14,1 df, P <O.l).

dissolved, two came from the group that had lost a child. This difference could arise by chance. It ap- pears that in marriages which dissolved, fathers were much more likely to be lost to follow-up.

Subsequent analyses are limited to those parents who were living with a partner at both the initial interview and the 68 month follow-up. These analy- ses are directed to the specific issue of whether the quality of the relationship between the partners dete- riorated in the group of parents who lost a child. For the following analyses, the dyadic adjustment scales have been dichotomised to distinguish those respon- dents who report some (usually) or a lot of disagree- ment or conflict with their partner, from those who report little or no disagreement or conflict. As the three control groups are similar they have been aggregated into a single control group.

Table 4 examines the association between the type of death experienced by mothers and fathers and the percentage of parents who report that their relation- ship is characterised by some (and a lot) of disagree- ment or conflict. This reports data from the first interview, approx. 2 months after the death of the child. Between 12 and 16.7% of mothers who have experienced a child death, report that their relation- ship with their partner is less than satisfactory, compared to 6.5% of mothers who feel this is the case in the control group. Fathers of children who have died from SIDS also appear to more often report that their marital relationship is less satisfactory.

Table 5 aggregates the three groups @IDS, NND and SB) who have experienced a child death and

Table 4. Dyadic adjustment at first interview by category of child death

Dyadic adjustment SIDS NND SB Control

%Reporting some + % reporting some + disagreement/conflict disagreement/conflict Mothers x2 16.7 (36) 16.3 (SO) 12.0 (75) 6.5 (214) Mothers x2 22.2 (36) 15.6 (77) 14.7 (75) 14.9 (215) P=O.O4 P=NS Fathers x2 18.2 (33) 8.0 (75) 8.0 (63) 5.0 (173) Fathers x2 12.1 (33) 12.2 (74) 11.3 (62) 7.0 (172) P = 0.05 P=NS

Death Control

% Reporting some Mother, 14.7 (191) 6.5 (214) + disagreement/conflict P < 0.01

Father, 9.9 (171) 4.6 (173) P = 0.06

Odds ratio of experiencing Mother 2.5 1.0 some + (1.25-4.82) disagreement/conflict Father 2.1 1.0 (brackets 95% confidence (0.95-4.85) limits)

compares them with the control group. Both the percentages of persons having a less satisfactory relationship are reported, as well as the odds of having a less satisfactory relationship. Mothers in the group who have experienced a child death are, on average, 2.5 times more likely to report that their relationship with their partner is less satisfactory (95% confidence limits 1.254.82). The data for males is similar, but the difference is not statistically signifi- cant. This is because, as Table 4 indicated, the differences between the NND and SB fathers, and the control fathers, were relatively minor.

Table 6 considers data taken from the 68 month follow-up. There are no longer any significant differ- ences between the dyadic adjustment scores of the mothers in the case (death) and control groups. Curiously, this is not because the quality of the dyadic relationship has improved in the cases (of a child death), but because mothers with a 68 month old child report a lower dyadic adjustment than mothers with a new baby. For the fathers, the SIDS group is no longer less satisfied with their partner, at the 6-8 month follow-up.

Table 7 compares aggregate data for the cases (all deaths together) and the controls. Once again there are no significant differences, suggesting that the quality of the relationship between the partners, 68 months after the death of a child, is similar to the quality of the relationship reported by parents who have not lost a child.

DISCUSSION

This study has been concerned with the impact of an infant death on the duration and quality of the relationship between partners who are living to- gether, or married at the time of the death. A

Table 6. Dyadic adjustment at second interview by category of child death

Dyadic adjustment

SIDS NND SB Control

Child death impact on marital adjustment 1009

Table 7. Dyadic adjustment at second interview by whether parent is a case (death) or control

Death Control

%Reporting Mother, 16.5 (188) 14.9 (215) some + P=NS disagreement Father, 11.8 (169) 7.0 (172) /conflict P=NS Odds ratio of Mother 1.11 1.0 experiencing (0.70-I .74) some + disagreement Father 1.70 1.0 /conflict (0.86-3.36) (brackets 95% confidents limits)

matched control group of parents whose infant sur- vived, provides the comparison group for detecting adverse outcomes.

The first set of results indicate that parents of an infant who has died are more likely to experience a marital break-up than parents whose infant survived. Only about 54% of marriages in the cases (with an infant death) dissolved, compared to OS-1.5% in the controls. The interpretation of this finding needs to be tempered by three considerations. Firstly, it is not clear to what extent a child death “brings forward” a marital breakup which would have occurred any- way in the future. Secondly, on a population basis, a doubling or tripling of the divorce rate may have substantial implications. Thirdly, some parents move to have another child as quickly as possible after the death, and this may partly account for low break-up rate in these cases. It needs to be further noted that a small number of parents whose relationship had dissolved by the 6-8 month interview, subsequently reconciled with their partner. Overall it would seem accurate to suggest that there is a slightly increased rate of marital break-up resulting from an infant death, and that those marriages in which the partners are ‘living together’ are the ones most likely to subsequently dissolve. It is possible that some of the ‘living together’ group might have decided to do so because a child was expected and that the child death has severed this bond. It seems more likely that the decision to ‘live together’ reflects the fact that the marital relationship was more tenuous in the first instance.

The second set of results indicate that, at the first interview in the marriages which remain apparently intact, parents whose infant has died are more likely to express dissatisfaction with the relationship with their partner, than parents whose infant survived. We have previously found [7l that the mental health of both mothers and fathers whose infant has died is poorer at the first interview. It could be suggested that the emotional changes which result from the infant death also serve to negatively influence the relationship between the partners.

Again, however, these results must be interpreted with caution. Thus at the 6-8 month follow-up, there is no difference in marital satisfaction scores between

those parents who have lost an infant, and those parents whose infant survived. This appears to be because the quality of the marital relationship be- tween parents whose child survived, has deteriorated; and not because of an improvement in the relation- ship between parents whose infant died. Of course some parents of a deceased infant are now awaiting the outcome of a subsequent pregnancy. (The rate of subsequent pregnancies is lower in the control group.) In any event, it must be noted that only a small minority of parents in the cases and control group report dissatisfaction with their marriage, ei- ther at the first or second interviews.

These results have both theoretical and practical relevance. Theoretically they contribute to our under- standing of the likely impact of various life stresses on the duration and quality of a marriage. The death of an infant constitutes perhaps the major of the acute stresses likely to confront a marriage. While such stresses appear to have the capacity to affect nega- tively a small number of marriages, the evidence suggests that the overwhelming proportion of mar- riages survive such an event. Marriages, it would appear, are resilient entities as far as major acute stresses are concerned.

At a practical level, there may be concerns with the marital counselling needs of parents whose infant has died. The results indicate that only a small minority of parents manifest marital changes of a kind likely to be relevant to counselling. Here the difficult but necessary task would seem to be to identify the small number of marriages affected, and the even smaller number likely to benefit from services if they are available. Certainly the total counselling needs of parents whose infant has died are likely to be modest, and to place only some strains on the existing demand for services. The task then is to design such services so that they are easily accessible, and become known and available to those in need.

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REFERENCES

Glenn N. D. and Supancic M. The Social and demo- graphic correlates of divorce and separation in the United States: An update and reconsideration. J. Marriage Family 46(3), 563-575, 1984. Caplan G., Mason E. A. and Kaplan D. M. Four studies of crisis in parents of prematures. Communify Menfal Hlth J. l(2). 149-161. 1965. . _, Lindsay R. Crisis Theory: A critical Overview. Depart- ment of Social Work, University of Western Australia, 1975. Belsky J. and Pensky E. Marital change across the transition to parenthood. In Transitions to Parenthood (Edited by Palkovitz R. and Sussman M. B.). Haworth Press, New York, 1985. Mirowsky J. and Ross C. E. Social Causes of Psvcho- logical Distress. Aldine de Gruyter, New York. _ Rubin S. S. Maternal attachment and child death: On adjustment, relationship and resolution. OMEGA 15(4), 347-352, 1984. Vance et al. Early parental responses to Sudden Infant Death, Stillbirth or Neonatal Death. Med. J. Aust. lSS,(Sept 2), 292-297, 1991.

1010 JAKE M. NAJMAN et al.

8. Williams R. A. and Nilolaisen S. M. Sudden Infant 12. Death Syndrome: Parents’ perceptions and responses to the loss of their infant. Res. Nursing Hlth 5,561, 1982.

9. Defrain J. Learning about grief from normal families: SIDS, Stillbirth and Miscarriage. J. Marital Family 13. Therapy 17(3), 215-23, 1991. -

10. Lehman D. R.. Wortman C. B. and Williams A. F. Long-term effects of losing a spouse or child in a motor 14. vehicle crash. J. Pers. Sot. Psychol. 52, 218-231, 1987.

11. Begleiter M. L., Burry V. F. and Harris D. J. Prevalence of divorce among parents of children with cystic fibrosis 15. and other chronic diseases. Sot. Biol. 23(3), 260-264, 1976.

Tew B. J., Payne H., Lawrence K. M. and Rawnsley K. Psychological testing: Reactions of parents of physically handicapped and normal children. Deu. Med. Child Neurolo&. 16, 501-600, 1974. Vance et al. Effects of Neuhrotic Syndrome on the family: A controlled study. -Pediatrics 65(s), 948-955, 1980. Nixon. Family Cohesion in Families with an Impaired Child, Ph.D. Thesis, University of Queens- land, 1988. Spanier G. B. Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads”. J. Marriage Family 38, 15-28, 1976.