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114 https://oamjms.eu/index.php/mjms/index
Scientic Foundation SPIROSKI, Skopje, Republic of Macedonia
Open Access Macedonian Journal of Medical Sciences. 2022 Jan 03; 10(T8):114-121.
https://doi.org/10.3889/oamjms.2022.9502
eISSN: 1857-9655
Category: T8 –“APHNI: Health Improvement Strategies Post Pandemic Covid-19”
Section: Gynecology and Obstetrics
The Experience of Chronic Sorrow among Indonesian Mothers
Who have Suered Recent Perinatal Loss
Erni Samutri1*, Widyawati Widyawati2, Wenny Artanty Nisman2, Joel Gittelsohn3, Hamam Hadi4, Emma C. Lewis3,
Lia Endriyani1, Sofyan Indrayana1, Artha Mevia Ruly Ata1
1Department of Nursing, Faculty of Health Science, The University of Alma Ata, Yogyakarta, Indonesia; 2Department of Child
and Maternity Nursing, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia;
3Department of International Health, Center for Human Nutrition, Bloomberg School of Public Health, The Johns Hopkins
University, Baltimore, USA; 4Department of Public Health, Faculty of Health Science, The University of Alma Ata, Yogyakarta,
Indonesia
Abstract
BACKGROUND: Perinatal death results in physical loss of a child as well as symbolic loss (loss of self, hope, and
self-esteem) experienced by many parents. Loss is often expressed through a grief response that can develop into
chronic sorrow. Ineective coping strategies may increase susceptibility to complications associated with chronic
sorrow. These complications can include clinical depression, dysthymic disorder, post-traumatic stress disorder,
attachment disorder, drug dependence, psychosis, and suicidal ideation. Therefore, it is crucial to understand the
barriers and facilitators to chronic sorrow particularly among vulnerable populations.
AIM: This study aims to explore the experience of chronic sorrow among Indonesian women who have suered
perinatal loss.
METHODS: The present qualitative study utilized a descriptive phenomenological approach. Participants included
women who experienced chronic sorrow due to perinatal loss within the past 7 weeks–3 years. Maximum variation
sampling was used based on women’s current number of children. Data were collected using semi-structured
interviews and analyzed using a modied Stevick-Colaizzi-Keen method.
RESULTS: Three key themes emerged from the data: (1) Recurrent experiences of grief are common particularly
when exposed to certain triggers (memories from pregnancy and mementos); (2) adequate coping strategies and
emotional support are needed to help treat grief; and (3) specic characteristics of chronic sorrow are associated
with perinatal loss, such as grief that feels diminished and the presence of another child serving as both a cure and
a trigger of sorrow.
CONCLUSION: Chronic sorrow as a result of perinatal loss is experienced repeatedly when mothers face certain
triggers. We have identied two characteristics (diminished grief, having another child serve to both cure and trigger
sorrow) that are specic to the experience of chronic sorrow compared to that of general grief. It is important to
understand the experience of chronic sorrow and how coping strategies and a support system can help grieving
mothers to overcome their loss.
Edited by: Ksenija Bogoeva-Kostovska
Citation: Samutri E, Widyawati W, Nisman WA,
Gittelsohn J, Hadi H, Lewis EC, Endriyani L, Indrayana
S, Ata AMR. The Experience of Chronic Sorrow among
Indonesian Mothers Who have Suered Recent Perinatal
Loss. Open-Access Maced J Med Sci. 2022 Jan 03;
10(T8):114-121. https://doi.org/10.3889/oamjms.2022.9502
Keywords: Chronic sorrow; Perinatal loss; Grief; Child
loss
*Correspondence: Erni Samutri, Department of
Child and Maternity Nursing, Faculty of Health
Science, Universitas Alma Ata, Yogyakarta 55183,
Indonesia. E-mail: erni.samutri@almaata.ac.id
Received: 13-Oct-2021
Revised: 21-Nov-2021
Accepted: 02-Dec-2021
Copyright: © 2022 Erni Samutri, Widyawati Widyawati,
Wenny Artanty Nisman, Joel Gittelsohn, Hamam Hadi,
Emma C. Lewis, Lia Endriyani, Sofyan Indrayana,
Artha Mevia Ruly Ata
Funding: The research supported by Alma Ata University
and the Ministry of Education and Culture, Research
and Technology, and Higher Education, the Republic
of Indonesia through the World Class Professor grant
program (No: 2817/E4.1/KK.04.05/2021, 14 August 2021)
Competing Interest: The authors have declared that no
competing interest exists
Open Access: This is an open-access article distributed
under the terms of the Creative Commons Attribution-
NonCommercial 4.0 International License (CC BY-NC 4.0)
Introduction
Perinatal loss is an umbrella term which
encompasses the death of a child spanning from
fetal death as early as 20 weeks since gestation until
neonatal death up to 28 days in early life [1]. Over
the past few decades, the perinatal mortality rate
has generally decreased worldwide, although more
recently, it has tended to remain stable [1], [2]. This
trend is reected in Indonesia, where the neonatal
mortality rate was gradually decreasing until 2002 when
the rate of decrease slowed. According to Statistics
Indonesia, neonatal mortality was at 23 deaths/1000
live births in 2002, then remained at 19 deaths/1000
live births in 2007 and in 2012, and most recently
was 15 deaths/1000 live births in 2017 [3]. Neonatal
death is typically associated with high-risk pregnancy
and childbirth conditions (such as being pregnant at a
younger or older age, birth spacing of <2 years, and
living in rural areas) and with labor where there is no
health-care provider present [3].
Perinatal mortality results in the experience of
physical loss of the child coupled with symbolic loss that
can be felt by parents due to the disparity between the
current reality and the desired reality [4], [5]. This loss is
expressed through a grief response, which can involve
periodic and non-resolution characteristics [6], [7], [8].
Periodic characteristics of grief refer to the cyclical and
continual process of re-experiencing grief when facing
triggers of the loss, which, in turn, can result in non-
resolution of grief when the disparity between current
and desired realities remains. The term “chronic sorrow”
was originally coined by Olsansky in 1962 based on his
observation of the particular grief response experienced
Samutri et al. Chronic Sorrow Experience of Mothers with Perinatal Loss
Open Access Maced J Med Sci. 2022 Jan 03; 10(T8):114-121. 115
by parents caring for their disabled children. The
concept of chronic sorrow was later expanded upon by
Eakes, Burke, and Hainsworth in 1998 wherein it was
described as a response to signicant loss characterized
by pervasive, periodic, permanent, and potentially
progressive sadness [5]. Chronic sorrow is now widely
understood to be a normal response to signicant loss [5].
However, ineective coping strategies and inadequate
support for those experiencing chronic sorrow may
increase susceptibility to complications such as clinical
depression [9], [10], [11], dysthymic disorder [12], post-
traumatic stress disorder, attachment disorder [13],
drug dependence, psychosis, and suicidal ideation [14].
Chronic sorrow has been identied as a
response to experiencing many conditions in addition to
signicant loss: Disabilities, autism, neurodegenerative
disease, cerebral palsy, sickle cell disease, neural tube
defects, multiple sclerosis, preterm birth, type 1 diabetes,
and drug addiction [9], [15]. Several studies examining
chronic sorrow among parents who have lost a child have
shown that the sorrow continues to be experienced over
the course of the lifespan [16], [17], [18]. A quantitative
study [10] compared chronic sorrow among infertile
participants and perinatal loss participants, and found
that chronic sorrow was signicantly higher among
those who had suered perinatal loss. However, a
gap in the literature remains regarding an in-depth
understanding of chronic sorrow due to perinatal loss
and virtually no research has been done in this area
among the Indonesian population. The present study
sought to explore the experience of chronic sorrow
among Indonesian mothers who have recently suered
perinatal loss. Our research questions were as follows:
1. What is the experience of chronic sorrow
among Indonesian mothers who have recently
experienced perinatal loss? and
2. What is the role of the healthcare provider in
caring for mothers who have suered perinatal
loss?
Methods
Participants
We conducted a qualitative study using a
descriptive phenomenological approach [19]. We chose
this approach for its exibility in leveraging participants’
perceptions of the experience of chronic sorrow.
Participants were identied using perinatal mortality
records collected between 2015 and 2017 at two
Community Health Centers in Yogyakarta, Indonesia.
Purposive sampling was used to select participants.
The inclusion criteria consisted of: (a) Being a mother
with chronic sorrow experience due to perinatal
loss, (b) meeting variations of the current number of
children (a mother who is pregnant and/or already has
other child; a mother who is not pregnant and has no
children), and (c) having suered the perinatal loss
between 7 weeks and 3 years ago. Mothers were
excluded if their perinatal loss was accompanied by
a severe mental disorder (such as major depression,
severe physical disorders, chronic illness, or surgery)
determined by the perinatal mortality record.
The shortest duration since perinatal loss
was chosen to be 7 weeks because the crisis of acute
grief generally ends 6 weeks after experiencing a
loss [20], [21], therefore, parents may enter chronic
sorrow experience after this point [22]. The longest
duration was chosen to be 3 years because parents
who have suered from child loss tend to begin to
move on with their lives after 3 years since their child’s
death [13], [16]. Therefore, we chose this timeframe
to most accurately explore the current experience
of chronic sorrow and to minimize recall bias. It is
important to note that data saturation was reached on
the ninth participant.
Materials and procedure
Materials
The present study utilized two instruments to
(1) screen for chronic sorrow and (2) explore the chronic
sorrow experience. First, the chronic sorrow screening
tool was developed based on the Nursing Diagnoses
Denition and Classication and the Burke/Eakes
Chronic Sorrow Assessment Tool [23]. This screening
tool consisted of four questions selected to assess
the duration since perinatal loss and the presence of
characteristics indicative of chronic sorrow.
Second, the interview instrument was
developed based on the Burke/Eakes Chronic Sorrow
Assessment tool [24]. This instrument consisted of
six questions: (1) “How did you experience fetal/baby
death?” (2) “How did you feel when you found out
that your fetus/baby had died?” (3) “How do you feel
right now when you recall the events of your fetal/
baby death?” (4) “When do those feelings reappear?”
(5) “What situations might remind you of your loss?” and
(6) “What actions do you take to overcome the feelings
when you remember your loss?” Probing questions
were used based on the participants’ answers. Field
notes were taken to record nonverbal responses during
the interview.
Procedure
Data collection was conducted from January
2018 to February 2018. The research team and
cadres (community health volunteers) visited eligible
participants in their homes to obtain informed consent
and administer the chronic sorrow screening tool.
Each participant was interviewed at 2 time points. The
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rst interview was used to explore the chronic sorrow
experience, and the second interview was conducted
3–8 days later to perform member checking and
triangulation. Member checking was completed by
asking the participant about the accuracy of the data
collected from the rst interview during the second
interview. The triangulation techniques we chose to
use were included data triangulation and method
triangulation. Data triangulation was conducted by
administering an interview to the participant’s husband,
participant’s mother, and the researcher’s colleague
who had perinatal loss, while method triangulation
was conducted by collecting eld note observations
of participant’s non-verbal responses during the
interviews. The duration of each interview lasted, on
average, 60 min and 35 min, respectively. During the
interview process, one participant refused to answer a
screening question and withdrew from the study.
Data analysis
Our data analysis approach used a modied
Stevick-Colaizzi-Keen method. This method involves six
sequential steps of data analysis [25], [26], [27], including:
(1) Bracketing by writing reective journals about the
researcher’s perception before and after the interview, (2)
identifying signicant statements from the transcribed data,
(3) grouping the signicant statements into meaningful
groups, (4) arranging a textual description of participants’
experiences through theme formulation, (5) arranging
a structural description from the textual explanation
of participants’ experiences, and (6) constructing a
composite description incorporating both the textual and
structural descriptions to represent the overall essence
of one’s experience. This process was repeated for
each participant until no new information was obtained.
The process of translating codes into nal themes was
conducted through discussion among the research team.
Ethical consideration
The present study was approved by the
ethics committee of Universitas Gadjah Mada (KE/
FK/1244/EC/2017). The participants were informed
of the research objectives, data condentiality, data
publication, and their right to withdraw from the study at
any time. The chronic sorrow screening was conducted
immediately after written consent was obtained. The
researcher present oered access to psychological
counselors at the Community Health Center for
participants due to the sensitivity of the questions being
asked, however, all participants stated that they did not
need a psychological counselor.
Rigor
Trustworthiness of qualitative data is assessed
by credibility, dependability, conrmability, transferability,
and authenticity [28]. In the present study, credibility
was conrmed by member checking, triangulation, and
reective journal writing. Dependability was conrmed
by member checking and triangulation. Member
checking was conducted by checking the accuracy
of data collected with participants, while triangulation
was done through data triangulation and method
triangulation. Conrmability was assessed using an
inquiry audit procedure. The inquiry audit was completed
by consulting the transcript and analysis process with
the research advisor. Transferability and authenticity
were strived for by collecting a thick description of the
entire study process and citing participant quotations to
support the conclusions made by the research team.
Results
Participants (n = 9) ranged from 23 to 43 years
old and included mothers who currently had other children
(n = 6), who already had children and were currently
pregnant with another child (n = 1), and who were neither
pregnant nor had any children (n = 2). Researcher-
generated codes were used to identify participants.
Mothers were identied using P1, P2, P3, and so on
(Table 1). Participants used for data triangulation were
identied using T1 for P5’s husband, T2 for P9’s mother,
and T3 for the researcher’s colleagues.
The present study identied three key themes
describing the experience of chronic sorrow among
mothers who had suered perinatal loss. Each theme
was comprised of 2–4 subthemes based on what was
shared in the interview (Table 2).
Theme 1: Recurrent grief experience and
triggers
Theme 1 describes the grief experience of
perinatal loss as being felt repeatedly and recurring
when the mother encounters meaningful situations or
triggers. There are four subthemes within this theme
based on events shared by mothers during their
interviews:
Grief experience at the event of fetal/baby death
The event of perinatal loss caused mothers
deep feelings of grief. They mentioned feeling shocked,
angry, guilty, regretful, and empty. One mother in
particular revealed her shock and that she could not
accept the fact that her baby was dead:
“…I feel so sad, shocked, I can’t believe it. At
rst I was excited to get pregnant, but why do
it again? I’m really mad, but with who?” (P7,
4 months after perinatal loss)
Samutri et al. Chronic Sorrow Experience of Mothers with Perinatal Loss
Open Access Maced J Med Sci. 2022 Jan 03; 10(T8):114-121. 117
Her response was validated by her husband,
who shared that:
“…Back then, she did not want to wake up and
kept crying. She even stated that “The baby is
crying, why you don’t want to carry the baby”, I
said “What are you talking about? The baby is
dead but you keep crying.” (T1, 50 years old)
Table 2: Themes and sub-themes of chronic sorrow
Themes Sub-Themes
Recurrent grief experience and
triggers
Grief experience at the event of fetal/baby death
Adapting to loss
Recurrent and unforgettable grief experience
The trigger of recurrent grief experience
Coping strategies and emotional
support to treat feelings of grief
Adaptive coping strategies
Emotional support from various sources
Maladaptive coping strategies
Specic characteristics of chronic
sorrow due to perinatal loss
Grief that feels diminished
The presence of another child can be a cure as well
as a grief trigger
Adapting to loss by focusing on other children
Mothers reported adapting to their loss but that
they could not accept it. Certain life stressors inuenced
mothers’ ability to adapt to and accept their loss. One
mother who had a child with special needs reported
being physical abused by her husband and subsequently
experienced two perinatal losses; yet she felt that she
had to stay positive. This mother tried to convince herself
to accept the losses as soon as the babies were buried:
“ I had two losses, the rst one (the rst baby)
and this one (the fourth baby). I feel so sad but
I can handle it. The 1st day after the baby was
buried, I thought “OK, maybe I should focus on
my other children. I think that was my destiny,
I should receive it and look at the bright side.”
(P6, 19 months after perinatal loss)
Similarly, a mother who had twin births during
which one died forced herself to focus on caring for her
living baby:
“…During labor, the living baby was brought
to the NICU. I kept thinking about it. One of
them was already dead and I have to let it go.
I forced myself though it was dicult. I kept
struggling.” (P4, 22 months after perinatal loss)
Recurrent and unforgettable grief experience
Mothers who have adapted to their loss often
return to their normal routine. However, grief can recur
when a meaningful situation is encountered. When this
happened, mothers reported feeling sorrow, fear, and
trauma, which often led to emotional ups and downs.
This type of sorrow can be described as a cycle between
triggering events, grief, and coping strategies (Figure 1).
DISPARITY
LOSS EXPERIENCE
Perinatal loss due to
perinatal death
CHRONIC SORROW
Pervasive
Permanent
Periodic
ADAPTIVE COPING
- Keep busy with another child
- Being thankful for the current pregnancy
- Share stories
- Get closer to God
INCREASED
COMFORT
TRIGGER EVENTS
- Looking at other baby
- Interaction with the baby while alive
- The pregnancy memories the memorable days
- The mementos
- The siblings
- Sharing the sadness
Figure 1: The process of experiencing chronic sorrow after perinatal loss
One mother who had no children after the loss
of her baby revealed that the trauma and fear of losing
another had stopped her from planning to become
pregnant again.
In addition, it was felt that the memory of
mothers’ babies would never be lost even if they had
never spent time together. Some mothers believed that
their deceased baby would help them in the next life.
Regardless, one mother explained:
“…But the trauma is still there, persists. I am
still afraid. I want to hold a baby, have a baby.
But, why this feeling is still here” (P7, 4 months
after perinatal loss)
Triggers of recurrent grief experience
Recurrent grief seemed to be most often triggered
by seeing a baby of similar age to mothers’ deceased
babies. Other typical triggers included interacting with the
lost baby while alive, pregnancy memories, meaningful
days (i.e., the baby’s birthday), mementos (i.e., baby
clothes, photos), sibling’s sadness, and talking about
their own sadness (Figure 1). One mother said:
“…When I remember and share about it, I feel
hurt, sad…” (P5, 2 months after perinatal loss)
Theme 2. Coping strategies and emotional
support to treat the grief feeling
Mothers tend to use adaptive coping strategies
and emotional support to help restore their emotional
stability. However, sometimes, they reported using
Table 1: Chronic sorry study participant characteristics
Code Age (years) Education level Religion Age of perinatal death Number of children Duration of perinatal loss (months) Cause of perinatal loss
P1 31 High school Islam 6 h 1 and pregnant 8 Asphyxia
P2 40 Elementary school Islam 3 days 17 Low birth weight
P3 23 High school Islam 3 days 0 8 Death on arrival
P4 27 High school Islam IUFD 122 Intrauterine fetal death
P5 43 High school Islam 3 days 2 2 Congenital heart disease
P6 39 Elementary school Islam 6 h 2 19 Meconium aspiration
P7 32 High school Islam 3 days 0 4Premature
P8 27 University Hindu 12 days 125 Congenital heart disease
P9 30 High school Islam IUFD 126 Mother with eclampsia
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maladaptive coping strategies that resulted in a worsening
of their grief. This theme encompasses three subthemes:
Adaptive coping strategies
Coping strategies such as keeping busy with
another child, being thankful for a current pregnancy,
sharing stories, and getting closer to God, have all been
reported by mothers as aiding in the management of
grief (Figure 1). Mothers with other children especially
leaned on those surviving children to help them cope:
“…I still do my daily activity and my cure is my
child (pointed her living child).” (P4, 22 months
after perinatal loss)
In addition, turning to religion seemed to help
mothers develop positive thoughts related to their loss.
Those who shared religious sentiments often shared
that they had chosen to remain patient, restore all
things to God’s will, accept the destiny of their lives,
and think positively:
“…Yes I have to be patient, be patient. If we
continue to obey our ego, we don’t move
forward, we must think positively.” (P3,
8 months after perinatal loss)
“When the memory of the baby came back,
the sadness came again. When the arrival of a
baby has been expected for a long time, then
suddenly God takes it back, it hurts. But, again,
I have to be patient. Because everything is
destiny, humans only hope, but God determines
everything. I am sure there will be a better one.”
(P9, 26 months after perinatal loss)
“…the experience of losing this baby is the
most valuable life lesson, right (P7 starts to cry).
Basically I have to be sincere, patient. I always
remember that when God gives diculties, it
means that God still loves his people.” (P7,
4 months after perinatal loss)
Emotional support from others can be positive
or negative
Mothers received emotional support from
various sources. Their parent’s support, such as
encouragement to rise from sadness, made them feel
more comfortable. On the other hand, husbands tended
to cause the mother to feel burdened. One mother’s
husband exclaimed:
“…I said, “It is better if you pray and do not
remember that loss again”. I have given more
advice to her, but she still remembers it.” (S5,
50 years old)
Maladaptive coping strategies
In certain situations, the coping strategies
developed by mothers led to discomfort. Maladaptive
coping strategies, such as questioning God’s destiny,
only made these mothers fall deeper into grief. Eorts
to suppress grief often did not help:
“…Now, I can hold my grief. It’s not relieved.
But, it can disappear when my other child
come.” (P5, 2 months after perinatal loss)
Theme 3. Specic characteristics of
chronic sorrow on perinatal loss
Two specic subthemes that were identied
from our interviews with mothers spoke specically to
the characteristics of chronic sorrow and subsequently
shaped this third theme:
Grief that feels diminished
The rst subtheme describes how mothers
have tried to control their feelings and move on from
their loss but the result is often a feeling of diminished
grief. This sentiment was shared by all nine participants.
One mother with a history of three perinatal losses said:
“…As time goes by, it used to be felt often, but
the longer, it got smaller. So as time goes by, I
start a little bit to adapt.” (P9, 26 months after
perinatal loss)
The presence of another child can be a cure
as well as a grief trigger
The second subtheme pertains to participants
who have other children besides the baby that was lost.
The mothers who felt that their other child(ren) was a
cure for the grief shared that:
“…My cure is my child (pointed her living
child).”(P4, 22 months after perinatal loss)
“…My children make me feel entertained.” (P5,
2 months after perinatal loss)
Although, sometimes, their children’s questions
about the deceased baby triggered grief:
“…If they say, “let’s go to my sister’s cemetery,
mom!”, I feel shocked and it triggers me to cry.
But I hold it because they are my children.”(P5,
2 months after perinatal loss)
One pregnant mother also experienced
a similar situation wherein she believed that her
pregnancy was a positive substitute for her loss as well
as a source of concern.
Overall, seven out of nine participants showed
emotional responses such as crying (across a spectrum
ranging from glazed to tearful eyes). Crying often
occurred when they talked about the event of the baby’s
death and their grief afterward. This was supported
by information provided by their family members who
claimed that they typically saw the participants crying
when they had remembered the memories of their lost
babies.
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Open Access Maced J Med Sci. 2022 Jan 03; 10(T8):114-121. 119
Discussion
The nature of grief experienced due to
perinatal loss among Indonesian women is in line
with the characteristics of chronic sorrow proposed by
Eakes et al. [5] where the grief felt is pervasive and
periodically recurrent. The present study identied
specic characteristics of chronic sorrow among
mothers who have suered perinatal loss which help
to dierentiate the experience from other forms of grief
and sorrow: (1) That the grief often feels diminished
and (2) the presence of another child in the home can
serve as both a positive cure and a negative trigger.
First, diminished grief refers to the notion that
the grief felt when facing a trigger is no more severe
than the grief felt at the time of the loss event. This
nding supports the chronic sorrow concept analysis
conducted by Teel et al. [21], in which it was found that
although chronic sorrow due to signicant loss has
no resolution, eective coping strategies can help to
make the intensity of the grief felt diminish over time.
Adaptive coping strategies such as being thankful for a
current pregnancy, and being grateful for the presence
of another child or other positive thoughts, have helped
women adapt to loss and minimize the recurrence of
their chronic sorrow. This nding is also in line with that
of the previous studies [28], [29], [30].
Second, the presence of another child can
serve as both a cure and a trigger of feelings of grief.
Mothers who had a surviving child typically felt that
the presence of their child helped to remedy their grief
experience. On the other hand, when children asked
about the whereabouts of their deceased siblings,
events like this made mothers recall their loss and
triggered grief. This nding is consistent with Üstündağ-
Budak et al. [30] which revealed that mothers interpreted
their living child as a reection of their deceased child.
They were happy to have a living child, but could not
deny that they were still grieving their loss. In particular,
pregnancy after perinatal loss can cause mothers to
feel a mixture of emotions, such as happiness and
concern [28], [31]. These conicting emotions can
mean that the pregnancy is both supportive as well as
triggering.
In the present study, mothers’ adaptation to loss
was not accompanied by the resolution of grief. This is
consistent with other previous research [5], [10], [17]
that has found that the outcome of chronic sorrow is not
a resolution, but rather a continuous adaptation.
One mother who had suered two perinatal
losses, a history of domestic violence, and had a child
with special needs, immediately convinced herself
that she needed to adapt to her loss and move on.
Adaptive coping strategies have helped mothers to
keep functioning. This is in line with the case study
proposed by Bettle and Latimer (2009) [32] where it was
determined that mothers often try to nd the strength to
adapt to loss to maintain their family role. This coping
strategy is known as the strength-based approach [32].
It is important to consider culture in this context.
All of the mothers in the present study were Javanese.
Therefore, their response to experiencing loss may have
been inuenced by the life principles instilled in them as
a part of the Javanese culture. The life principles cover
eling (remembering), sabar (being patient), and nrimo
(being submissive). Mothers of this culture typically
believe that their loss is the destiny of God and that
their deceased baby will be the mother’s helper to the
next life (hereafter). This nding is in line with one of the
Javanese life principles of eling (remembering), which
refers to the notion that humans should restore all things
to God’s will and believe in God’s power [33]. Sabar
(being patient) [34] pertains to mothers’ endurance in
facing their loss and attempts to hold back their sadness.
In the present study, mothers mentioned developing
positive thoughts to help control their grief. In addition,
mothers also sought to hold back their overowing
sadness when interacting with their other children. Nrimo
(being submissive) can help individuals accept the reality
of their lives and develop eective coping strategies
that prevent them from experiencing trauma [35], [36].
In the present study, even though the mothers who
participated had not yet accepted their loss, they tried to
adapt nevertheless, particularly when attempting to feel
gratitude for a current living child or current pregnancy.
There are a few strengths of the present study
worth noting. Our identication of specic characteristics
of chronic sorrow after perinatal loss can help to enrich
the understanding of chronic sorrow in this particular
context. Our ndings also provide important data for the
planning of eective interventions in this area of work.
The main limiting factor of the present study
was the small sample size and the homogeneity of
participant characteristics. Many eligible mothers
refused to participate because they did not want to
relive the loss and grief. The majority of participants
were Islamic and all came from a Javanese background.
For this reason, the ndings from the present study are
not necessarily representative of the chronic sorrow
experiences among women of other religious or ethnic
backgrounds. Religion and ethnicity both shape how
people approach loss and express their grief. Therefore,
research exploring the grief experiences of women
while considering dierent participant’s spiritual beliefs
and ethnic backgrounds should be conducted to help
better understand loss and grief in other settings and
contexts [29], [37], [38].
Conclusion
To the best of our knowledge, this is the rst study
of its kind to explore the experience of chronic sorrow in
T8 –“APHNI: Health Improvement Strategies Post Pandemic Covid-19” Gynecology and Obstetrics
120 https://oamjms.eu/index.php/mjms/index
the wake of perinatal loss among Indonesian mothers.
We found that chronic sorrow is recurrent and is most
often exacerbated when confronted with triggers that
remind mothers of their loss. Two specic characteristics
of chronic sorrow resulting from perinatal loss were
identied: (1) Diminished grief and (2) the presence of
another child serving as both a cure and a grief trigger.
Although chronic sorrow often consists of feelings of
non-resolution, adaptive coping strategies and positive
emotional support can assist those suering to regain their
happiness and reduce their level of perceived disparity in
the realities of their loss. This conceptualization of chronic
sorrow is crucial for health-care providers to understand
so that they can deliver eective care to patients dealing
with chronic sorrow and loss.
Our study ndings lay the groundwork for
providing evidence-based recommendations. First,
health-care providers should be given the tools to
understand the various concepts of grief, including
acute grief, the grieving phases, and chronic sorrow,
to best understand what mothers are going through.
Second, it is crucial for nurses to be able to assess life
stressors as inuences of mothers’ ability to adapt to
their loss. Third and nally, helping to correctly identify
coping strategies could help mothers to better handle
their experience with loss and the grieving process. By
providing adequate support during the acute grief phase,
mothers may be better equipped to avoid experiencing
chronic sorrow and pathological grief in the wake of
perinatal loss, lessening their risk of comorbid and life-
altering physical, mental, and emotional consequences.
References
1. MacDorman MF, Gregory EC. Fetal and Perinatal Mortality:
United States, 2013. Natl Vital Stat Rep. 2015;64(8):1-24.
PMid:26222771
2. Paris GF, Montigny F, Pelloso SM. Factors associated with the
grief after stillbirth: A comparative study between Brazilian and
Canadian women. Rev Esc Enferm USP. 2016;50(4):546-53.
https://doi.org/10.1590/S0080-623420160000500002
PMid:27680038
3. Statistics Indonesia. Neonatal Death Rate And Infant Mortality
Rate Per 1000 Birth By Province. 2021. Available from: https://
www.bps.go.id/subject/30/kesehatan.html#subjekViewTab3
[Last accessed on 2022 Jan 30].
4. Guidelines for Health Care Professionals Supporting Families
Experiencing a Perinatal Loss, in Paediatrics and Child Health.
Canada: Pulsus Group Inc.; 2001. p. 469.
5. Eakes GG, Burke MA, Hainsworth MA. Middle-range theory of
chronic sorrow. Image J Nurs Sch. 1998;30(2):179-84. https://
doi.org/10.1111/j.1547-5069.1998.tb01276.x
PMid:9775562
6. Daitchman R. Perinatal Loss. Canada: Jewish General
Hospital; 2012.
7. Puia DM, Lewis CT, Beck CT. Experiences of obstetric nurses who
are present for a perinatal loss. J Obstet Gynecol Neonatal Nurs.
2013;42(3):321-31. https://doi.org/10.1111/1552-6909.12040
PMid:23682697
8. Samutri E, Widyawati W, Nisman WA. Acute grief: Grief
experience of the mothers with perinatal loss. Dinamika
Kesehatan J Kebidanan Keperawatan. 2020;10(1):132-45.
9. Roos S. Chronic Sorrow A Living Loss. The Saries in Death,
Dying, and Bereavement. 2nd ed. New York: Routledge; 2018.
10. Casale A. Distinguishing the Concept of Chronic Sorrow From
Standard Grief: An Empirical Study of Infertile Couples, in
New York University School of Social Work. New York; New York
University School of Social Work; 2009.
11. Gordon J. An evidence-based approach for supporting parents
experiencing chronic sorrow. Pediatr Nurs. 2009;35(2):115-9.
PMid:19472675
12. Borkon DA. Is Chronic Sorrow Present in Maternal Caregivers.
Minnesota: Alfred Adler Graduate School; 2008.
13. Murphy SA, Johnson LC, Wu L, Fan JJ, Lohan J. Bereaved
parents’ outcomes 4 to 60 months after their children’s
deaths by accident, suicide, or homicide: A comparative study
demonstrating dierences. Death Stud. 2003;27(1):39-61.
https://doi.org/10.1080/07481180302871
PMid:12508827
14. Weingarten K. Sorrow: A therapist’s reection on the inevitable
and the unknowable. Fam Process. 2012;51(4):440-55. https://
doi.org/10.1111/j.1545-5300.2012.01412.x
PMid:23230977
15. Yugistyowati A. Phenomenological study: Grieving process and
coping of mothers with premature infant in neonatal intensive
care unit. J Ners Dan Kebidanan Indones. 2018;7(3):160-7.
16. Arnold J, Gemma PB. The continuing process of parental
grief. Death Stud. 2008;32(7):658-73. https://doi.
org/10.1080/07481180802215718
PMid:18924293
17. Buckley CJ. When sorrow never stops. Chronic sorrow after the
death of a child. J Christ Nurs. 2016;33(1):22-5.
PMid:26817366
18. Arnold J, Gemma PB, Cushman LF. Exploring parental grief:
Combining quantitative and qualitative measures. Arch
Psychiatr Nurs. 2005;19(6):245-55. https://doi.org/10.1016/j.
apnu.2005.07.008
PMid:16308124
19. Streubert H, Carpenter D. Qualitative Research in Nursing
Advancing the Humanistic Imperative. 5th ed. China: Wolters
Kluwer Health, Lippincott Williams & Wilkins; 2011.
20. Swanson KM. Research-based practice with women who
have had miscarriages. Image J Nurs Sch. 1999;31(4):339-45.
https://doi.org/10.1111/j.1547-5069.1999.tb00514.x
PMid:10628100
21. Teel CS. Chronic sorrow: Analysis of the concept. J Adv Nurs.
1992;6(1):27-40.
PMid:1585085
22. Eakes GG, Burke ML, Hainsworth MA. Chronic sorrow: The
experiences of bereaved individuals. Illness Crisis Loss.
1999;7(2):172-82.
23. Herdman T, Kamitsuru SL, Lopes C. NANDA International
Nursing Diagnoses Denitions and Classication 2021-2023.
United States: Thieme Medical Publishers Inc.; 2021.
24. Burke ML, Hainsworth MA, Eakes GG, Lindgren CL. Current
knowledge and research on chronic sorrow: A foundation for
inquiry. Death Studies. 1992;16(3):231-45.
25. Moustakas C. Phenomenological Research Methods. United
States: Sage Publications; 1994.
26. Creswell JW. Qualitative Inquiry and Research Design:
Choosing among Five Approaches. 2nd ed. United States: Sage
Samutri et al. Chronic Sorrow Experience of Mothers with Perinatal Loss
Open Access Maced J Med Sci. 2022 Jan 03; 10(T8):114-121. 121
Publications; 2007.
27. Polit DF, Beck CT. Nursing Research Generating and Assessing
Evidence for Nursing Practice. 9th ed.United States: Wolters
Kluwer Health, Lippincott Williams & Wilkins; 2012.
28. DeBackere KJ, Hill KL, Kavanaugh KL. The parental
experience of pregnancy after perinatal loss. J Obstet
Gynecol Neonatal Nurs. 2008;37(5):525-37. https://doi.
org/10.1111/j.1552-6909.2008.00275.x
PMid:18811772
29. Sutan R, Miskam HM. Psychosocial impact of perinatal loss
among Muslim women. BMC Womens Health; 2012;12:15.
https://doi.org/10.1186/1472-6874-12-15
PMid:22708998
30. Üstündağ-Budak AM, Larkin M, Harris G, Blissett J. Mothers’
accounts of their stillbirth experiences and of their subsequent
relationships with their living infant: An interpretative
phenomenological analysis. BMC Pregnancy Childbirth.
2015;15:263. https://doi.org/10.1186/s12884-015-0700-3
PMid:26463456
31. O’Leary J. Grief and its impact on prenatal attachment in the
subsequent pregnancy. Arch Womens Ment Health. Arch
Womens Ment Health. 2004;7(1):7-18. https://doi.org/10.1007/
s00737-003-0037-1
PMid:14963728
32. Bettle AM, Latimer MA. Maternal coping and adaptation: A case
study examination of chronic sorrow in caring for an adolescent
with a progressive neurodegenerative disease. Can J Neurosci
Nurs. 2009;31(4):15-21.
PMid:20085116
33. Siswayanti N. Javanese ethical values in Tafsir Al-Huda. Analisa.
2013;20:207.
34. Subandi S. A psychological concept. J Psikol UGM.
2011;38(2):7654.
35. Yuniarti KW. The magical strength of nrimo and gotong-royong
a quick response report following the May 27, 2006 Earthquake
in Yogyakarta. Anima Indones Psychol J. 2009;24(3):201-6.
36. Sudirman SA, Suud FM, Rouzi KS, Sari DP. Forgiveness
and hapiness through resilience. Al-Qalb J Psikol Islam.
2019;10(2):113-32.
37. Allahdadian M, Irajpour A. The role of religious beliefs in
pregnancy loss. J Educ Health Promot. 2015;4:99. https://doi.
org/10.4103/2277-9531.171813
PMid:27462641
38. Wright PM. Perinatal loss and spirituality. Illness Crisis Loss
2017;28(2):99-118.
